MARKETPLACEMARKETPLACE PLANPLAN Drug FormularyFormulary Indiana

IN-EXCM-0854b-V.11 CareSource is a Qualified Health Plan issuer in the INTRODUCTION

We are pleased to provide the 2021 CareSource Drug Formulary. The Drug Formulary is a list of the drugs covered by CareSource.

This document is divided into three parts:

1. The Introduction – Provides important facts about the CareSource prescription drug benefit. This section explains terms, such as network pharmacy, prior authorizations, quantity limits, step therapy, therapeutic interchange and exceptions.

2. The Drug Formulary – Lists the drugs we cover.

3. The Index – Lists all of the covered drugs in alphabetical order. You can find the Index in the back of this document.

PRESCRIPTION DRUG COVERAGE DETAILS

Best Medical Practices

We want to make sure our members get the safest, most cost-effective drugs for their needs. We use evidence-based guidelines to make sure our Formulary meets best medical practices.

Network Pharmacies

CareSource provides coverage for prescription drugs and some prescription medical supplies.

CareSource contracts with pharmacies in order to provide members with a full range of prescription benefits. Members may choose and receive prescriptions from any pharmacy that is contracted with CareSource. These are often referred to as network pharmacies. It is important that members receive prescriptions from network pharmacies because prescriptions received from non-network pharmacies are generally not reimbursable or covered by CareSource, except as otherwise required by applicable federal and state law and your Evidence of Coverage. Accordingly, members may be responsible for the entire amount charged by a non-network pharmacy.

Network pharmacies can include local pharmacies, mail-order pharmacies or specialty pharmacies. To find a network pharmacy, use our online Find a Pharmacy tool under “Quick Links” at CareSource.com/marketplace.

CareSource may also cover drugs administered in the member’s home, such as medicines given through a home health agency. Cost Sharing

Members may pay part of the costs of some drugs and supplies. These cost-sharing amounts are called deductibles, copays and/or coinsurance. For some drugs, members may pay coinsurance. Coinsurance is a percent of a drug's cost.

The Drug Formulary shows drugs in different levels or tiers. Drugs are grouped into tiers based on the amounts that members pay.

Tiered Medications

The CareSource Formulary has up to six levels or tiers, including tiers 0, 1, 2, 3, 4 and 5. Some benefit designs only have five tiers. If a benefit design only has five tiers anything shown in this document as a tier 5 drug will process under the tier 4 price structure. In general, the higher the cost-sharing tier number, the higher the cost for the drug. In general, the copay amount increases as the tier number increases. All deductibles, coinsurance and copay amounts paid count toward members’ maximum out-of-pocket amount.

To find tier levels for drugs, go to the drug list section of this document.

Prior Authorizations

CareSource may require health partners (doctors or other providers) to send us information about why a drug or a certain amount is needed. This is called a prior authorization request. CareSource must approve the request before a member can get the drug. Theabbreviation “PA” is used in the Drug Formulary toshowthat a priorauthorization is needed.

Here are some reasons for a prior authorization:

• A generic or alternative drug is available. • The drug can be misused or abused. • The drug requires special handling, monitoring or is available from limited shipping locations. • There are other drugs that must be tried first.

Prior Authorization Requests

Health partners may make prior authorization requests by phone or fax. Please call the Provider Services telephone number for your state and follow the prompts, or fax to the Medical Management provider fax number for your state.

We may not approve a prior authorization request for a drug. If we don't, we will send the member information about how to appeal our decision.

ii Quantity Limits

Some drugs have limits on how much can be given to a member at one time. The abbreviation “QL” is used in the Drug Formulary to show there is a quantity limit.

Quantity limits are based on the drug makers’ recommended dosing frequencies. Patient safety is also considered.

Therapy with opioid analgesics may have quantity limits based on drug makers' recommended dosing frequencies and/or state regulations.

Step Therapy

Members may need to try one drug before taking another. This is called Step Therapy. A member must first try one medicine on the Formulary before another Formulary drug would be approved for use.

CareSource will cover certain drugs only if Step Therapy is used. The abbreviation “ST” is used in the Drug Formulary to show when Step Therapy is required.

Generic Substitution and Therapeutic Interchange

A pharmacy may provide a generic drug in place of a brand-name drug. This is called generic substitution. Members and health partners can expect the generic to produce the same effect and have the same safety profile as the brand-name drug. This is known as therapeutic interchange.

Generic drugs usually cost less than their brand-name equivalents.

Note to Health Partners: Generic drugs should be considered the first line of prescribing, subject to applicable rules. Prescription generic drugs are:

• Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the same strict standards that apply to brand-name drugs.

• Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different from the brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drugs.

• Manufactured in the same strength and dosage form as the brand-name drugs.

In most instances, a brand-name drug for which a generic product becomes available will become non-Formulary, with the generic product covered in its place, upon release of the generic product onto the market. However, the Formulary document is subject to state- specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate. Choosing a

iii brand drug when there is a generic available may cost you more. When a generic is available and you choose the brand name drug, you may be responsible to pay the cost difference between the two in addition to your copay or coinsurance. Or you could be responsible for the entire cost of the brand.

Tell Us the Medical Reasons for Exceptions

Sometimes a member may have a drug allergy or intolerance. Or, a certain drug may not be effectivefor a member.Inthese cases, thememberorthe member’s representative may ask for an exception to a drug listed on the Drug Formulary. The member or member’s representative must call Member Services to make the request. The member services telephone number for your state is listed on the back of the member ID card.

CareSource then contacts the appropriate health partner. CareSource may ask the health partner to provide written clinical documentation about why the member needs an exception. Health partners must provide this information.

Typically, our Drug Formulary includes more than one drug for treating a condition. These medicines are called “alternative” drugs. CareSource will generally not approve the request for an exception if an alternative drug would be just as effective as the drug requested and would not cause other health problems.

Specialty Pharmacy

CareSource works with Accredo Pharmacy to supply specialty medications that health partners may prescribe. Accredo Pharmacy can:

• H elp members get prescriptions filled or moved to Accredo Pharmacy from another p harmacy • D eliver members’ specialty medicines to their homes, workplaces or their doctors’ offices • H elp members learn about their specialty medications and give them support from s pecially-trained health care professionals

For more information, call Accredo Pharmacy at 1-866-231-3520. Hours are Monday through Friday from 8 a.m. to 11 p.m. Eastern Standard Time (EST).

Mail Order Medications

CareSource works with Express Scripts Pharmacy to supply prescription medicines to members’ homes. This could change a member’s copay amount. Express Scripts Pharmacy can: • Help members get prescriptions filled or moved to Express Scripts Pharmacy from another pharmacy • Deliver prescriptions to members’ homes, workplaces or doctors' offices. For more information, call CareSource Member Services at 877-806-9284. Hours are Monday through Friday from 7 a.m. to 7 p.m. EST.

Members may also access the express-scripts.com website through the CareSource

iv member portal to manage prescription refills for their specialty and mail order medications and to check coverage. To create an account on the CareSource Member Portal, go to my.caresource.com.

Other Medical Supplies and Durable Medical Equipment (DME)

To support members, other medical supplies can continue to be filled by the CareSource Pharmacy Benefit Manager (PBM) through a retail pharmacy for a limited period of time until a DME provider can be contacted. This may include wound care supplies and enteral feeds.

Medications Administered in the Health Partner Setting

Medications that are administered in a health partner setting will be billed to the health plan under your medical benefit. Such settings include a physician office, hospital outpatient department, clinic, dialysis center, or infusion center. Prior authorization requirements now exist for many injectable medicines.

Medication Therapy Management Program

CareSource offers a Medication Therapy Management (MTM) program for all members. MTM services allow local pharmacists to work with doctors and other prescribers to enhance quality of care, improve medication compliance, address medication needs, and provide health care to patients in a cost-effective manner. Members and health partners may be contacted by a pharmacist to discuss medications. We encourage members to talk with their pharmacists about their medications. This can help members to get the best results from the medications they are taking.

HOW TO USE THIS DOCUMENT Go to the Index to look up a drug by name. Drugs are listed in alphabetical order. The Index will show the page number on which the drug is found in the Drug Formulary. Turn to that page number to get details about the drug.

Note to Health Partners: The CareSource Drug Formulary is organized by sections. Each section is divided by therapeutic drug class, primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable dosage forms and strengths of the drug cited are included in the document.

v ADDITIONAL INFORMATION FOR HEALTH PARTNERS

The drugs represented have been reviewed by a National Pharmacy and Therapeutics (P&T) Committee and then approved by a local Pharmacy, Therapeutics and Technology (PT&T) Committee for inclusion. The document is reflective of current medical practice as of the date of review.

The information contained in this document and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This document is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in the document is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.

The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

National guidelines can be found on the National Guideline Clearinghouse site at www.guideline.gov.

CARESOURCE ONLINE FORMULARY SEARCH TOOLS AVAILABLE

CareSource has easy-to-use online drug formulary tools that can help you save time by quickly looking up medications to make sure they are covered by CareSource. Also, you can check for generic alternatives, prior authorization requirements, and any restrictions or limits that may apply. To start using the tool, visit CareSource.com, and visit the Pharmacy page of the appropriate line of business, and select Formulary Search Tool. You can also find CareSource policies on CareSource.com Health Partner Policies page.

PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of an independent National Pharmacy and Therapeutics (P&T) Committee are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of experts from across the United States. The P&T Committee’s voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee, but no employee may vote on issues before the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

vi In addition to the National P&T Committee review, the CareSource Pharmacy Therapeutics and Technology (PT&T) Committee makes formulary recommendations based upon the needs of regional member demographics. The CareSource PT&T Committee is comprised of the Plan’s Medical Directors, Pharmacy staff and representatives from the medical community.

DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms on the document are covered, we have provided examples below. The general principles shown in the examples can usually be extended to other entries in the document.

When a strength, dosage or different formulation is specified, only that specific strength, dosage or formulation may be covered. Other strengths/dosages/formulations, including injectable dosage forms of the reference product, are not covered.

Extended-release and delayed-release products require their own entry. metformin Glucophage

The immediate-release product listing of Glucophage alone would not include the extended-release product Glucophage XR. metformin ext-rel Glucophage XR

A separate entry for Glucophage XR confirms that the extended-release product is on the document.

Dosage forms on the document will be consistent with the category and use where listed. neomycin/polymyxin B/hydrocortisone Cortisporin

Since Cortisporin is listed only in the OTIC section, it is limited to the OTIC solution and suspension. From this entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the DERMATOLOGY section of the document.

PLAN DESIGN The document represents a closed formulary plan design. The medications listed on the document are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits, etc.); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a Formulary exception may be requested for coverage. Medical necessity or Formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria.

vii NOTICE

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers.

Please be advised that this document is updated periodically and changes may appear prior to their effective date to allow for member notification.

While we make every effort to ensure that our Drug Formulary is up-to-date, this list may have changed since printing. For the most up-to-date information, you must use the “Find My Prescriptions” tool on CareSource.com/marketplace, or contact Member Services at the toll-free telephone number on your ID card to confirm the accuracy of the information in this copy of the Drug Formulary.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.

©2018 All rights reserved.

viii Table of Contents

ANTI - INFECTIVES ...... 3 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ...... 16 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH...... 24 CARDIOVASCULAR, HYPERTENSION & LIPIDS...... 52 DERMATOLOGICALS/TOPICAL THERAPY...... 67 DIAGNOSTICS & MISCELLANEOUS AGENTS...... 82 EAR, NOSE & THROAT MEDICATIONS...... 86 ENDOCRINE/DIABETES ...... 88 GASTROENTEROLOGY ...... 101 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ...... 111 MUSCULOSKELETAL & RHEUMATOLOGY...... 119 OBSTETRICS & GYNECOLOGY...... 122 OPHTHALMOLOGY ...... 134 RESPIRATORY, ALLERGY, COUGH & COLD...... 144 UROLOGICALS...... 152 VITAMINS, HEMATINICS & ELECTROLYTES ...... 154 Index ...... 164

1 List of Abbreviations

ACA: Affordable Care Act.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.

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

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

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

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

2 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ANTI - INFECTIVES ketoconazole oral 1 tablet 200 mg ANTIFUNGAL AGENTS NOXAFIL ORAL 2 PA clotrimazole mucous 1 SUSPENSION 200 membrane troche 10 MG/5 ML (40 mg MG/ML) DIFLUCAN ORAL 3 nystatin oral 1 SUSPENSION FOR suspension 100,000 RECONSTITUTIO unit/ml N 10 MG/ML, 40 MG/ML nystatin oral tablet 1 500,000 unit DIFLUCAN ORAL 3 TABLET 100 MG, ORAVIG BUCCAL 3 200 MG, 50 MG MUCO-ADHESIVE BUCCAL TABLET DIFLUCAN ORAL 3 QL 50 MG TABLET 150 MG posaconazole oral 1 PA fluconazole oral 1 tablet,delayed suspension for release (dr/ec) 100 reconstitution 10 mg mg/ml, 40 mg/ml SPORANOX ORAL 3 fluconazole oral 1 SOLUTION 10 tablet 100 mg, 200 MG/ML mg, 50 mg SPORANOX 3 QL fluconazole oral 1 QL PULSEPAK ORAL tablet 150 mg CAPSULE 100 MG griseofulvin 1 terbinafine hcl oral 1 microsize oral tablet 250 mg suspension 125 mg/5 ml VFEND ORAL 3 PA SUSPENSION FOR griseofulvin 1 RECONSTITUTIO microsize oral tablet N 200 MG/5 ML (40 500 mg MG/ML) griseofulvin 1 VFEND ORAL 3 PA ultramicrosize oral TABLET 200 MG, tablet 125 mg, 250 50 MG mg voriconazole oral 1 PA itraconazole oral 1 QL suspension for capsule 100 mg reconstitution 200 itraconazole oral 1 mg/5 ml (40 mg/ml) solution 10 mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits voriconazole oral 1 PA BIKTARVY ORAL 2 tablet 200 mg, 50 mg TABLET 50-200-25 MG ANTIVIRALS CIMDUO ORAL 2 abacavir oral 1 TABLET 300-300 solution 20 mg/ml MG abacavir oral tablet 1 COMBIVIR ORAL 3 300 mg TABLET 150-300 abacavir-lamivudine 1 MG oral tablet 600-300 DESCOVY ORAL 2 mg TABLET 200-25 abacavir- 1 MG lamivudine- didanosine oral 1 zidovudine oral capsule,delayed tablet 300-150-300 release(dr/ec) 250 mg mg, 400 mg acyclovir oral 1 DOVATO ORAL 2 capsule 200 mg TABLET 50-300 acyclovir oral 1 MG suspension 200 mg/5 EDURANT ORAL 2 ml TABLET 25 MG acyclovir oral tablet 1 efavirenz oral 1 400 mg, 800 mg capsule 200 mg, 50 adefovir oral tablet 1 mg 10 mg efavirenz oral tablet 1 amantadine hcl oral 1 600 mg capsule 100 mg efavirenz- 1 amantadine hcl oral 1 emtricitabin-tenofov solution 50 mg/5 ml oral tablet 600-200- amantadine hcl oral 1 300 mg tablet 100 mg efavirenz-lamivu- 1 APTIVUS ORAL 2 tenofov disop oral CAPSULE 250 MG tablet 400-300-300 mg, 600-300-300 mg atazanavir oral 1 capsule 150 mg, 200 emtricitabine oral 1 mg, 300 mg capsule 200 mg BARACLUDE 2 ORAL SOLUTION 0.05 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits emtricitabine- 1 famciclovir oral 1 QL tenofovir (tdf) oral tablet 125 mg, 250 tablet 100-150 mg, mg, 500 mg 133-200 mg, 167- FLUMADINE 3 250 mg ORAL TABLET emtricitabine- 0 100 MG tenofovir (tdf) oral fosamprenavir oral 1 tablet 200-300 mg tablet 700 mg EMTRIVA ORAL 3 FUZEON 2 CAPSULE 200 MG SUBCUTANEOUS EMTRIVA ORAL 2 RECON SOLN 90 SOLUTION 10 MG MG/ML GENVOYA ORAL 2 entecavir oral tablet 1 TABLET 150-150- 0.5 mg, 1 mg 200-10 MG EPCLUSA ORAL 4 PA; QL HARVONI ORAL 4 PA; QL TABLET 200-50 PELLETS IN MG, 400-100 MG PACKET 33.75-150 EPIVIR HBV 2 MG, 45-200 MG ORAL SOLUTION HARVONI ORAL 4 PA; QL 25 MG/5 ML (5 TABLET 45-200 MG/ML) MG, 90-400 MG EPIVIR HBV 3 HEPSERA ORAL 3 ORAL TABLET TABLET 10 MG 100 MG INTELENCE ORAL 3 EPIVIR ORAL 3 TABLET 100 MG, SOLUTION 10 200 MG MG/ML INTELENCE ORAL 2 EPIVIR ORAL 3 TABLET 25 MG TABLET 150 MG, INVIRASE ORAL 2 300 MG TABLET 500 MG EPZICOM ORAL 3 ISENTRESS HD 2 TABLET 600-300 ORAL TABLET MG 600 MG etravirine oral tablet 1 ISENTRESS ORAL 2 100 mg, 200 mg POWDER IN EVOTAZ ORAL 3 PACKET 100 MG TABLET 300-150 ISENTRESS ORAL 2 MG TABLET 400 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ISENTRESS ORAL 2 nevirapine oral 1 TABLET,CHEWAB tablet extended LE 100 MG, 25 MG release 24 hr 100 JULUCA ORAL 2 mg, 400 mg TABLET 50-25 MG NORVIR ORAL 2 KALETRA ORAL 3 POWDER IN SOLUTION 400- PACKET 100 MG 100 MG/5 ML NORVIR ORAL 2 KALETRA ORAL 2 SOLUTION 80 TABLET 100-25 MG/ML MG, 200-50 MG NORVIR ORAL 3 lamivudine oral 1 TABLET 100 MG solution 10 mg/ml ODEFSEY ORAL 2 lamivudine oral 1 TABLET 200-25-25 tablet 100 mg, 150 MG mg, 300 mg oseltamivir oral 1 QL lamivudine- 1 capsule 30 mg, 45 zidovudine oral mg, 75 mg tablet 150-300 mg oseltamivir oral 1 QL LEXIVA ORAL 2 suspension for SUSPENSION 50 reconstitution 6 MG/ML mg/ml LEXIVA ORAL 3 PREZISTA ORAL 2 TABLET 700 MG SUSPENSION 100 MG/ML lopinavir-ritonavir 1 oral solution 400- PREZISTA ORAL 2 100 mg/5 ml TABLET 150 MG, 600 MG, 75 MG, lopinavir-ritonavir 1 800 MG oral tablet 100-25 mg, 200-50 mg RELENZA 3 QL DISKHALER MAVYRET ORAL 5 PA; QL INHALATION TABLET 100-40 BLISTER WITH MG DEVICE 5 nevirapine oral 1 MG/ACTUATION suspension 50 mg/5 RETROVIR ORAL 3 ml CAPSULE 100 MG nevirapine oral 1 RETROVIR ORAL 3 tablet 200 mg SYRUP 10 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits REYATAZ ORAL 3 SYMTUZA ORAL 2 CAPSULE 150 MG, TABLET 800-150- 200 MG, 300 MG 200-10 MG REYATAZ ORAL 2 TAMIFLU ORAL 3 QL POWDER IN CAPSULE 30 MG, PACKET 50 MG 45 MG, 75 MG ribavirin inhalation 1 TAMIFLU ORAL 3 QL recon soln 6 gram SUSPENSION FOR rimantadine oral 1 RECONSTITUTIO tablet 100 mg N 6 MG/ML ritonavir oral tablet 1 TEMIXYS ORAL 2 100 mg TABLET 300-300 MG SELZENTRY 2 ORAL SOLUTION tenofovir disoproxil 1 20 MG/ML fumarate oral tablet 300 mg SELZENTRY 2 ORAL TABLET TIVICAY ORAL 2 150 MG, 25 MG, TABLET 10 MG, 25 300 MG, 75 MG MG, 50 MG SOVALDI ORAL 5 PA; QL TIVICAY PD 2 PELLETS IN ORAL TABLET PACKET 150 MG, FOR SUSPENSION 200 MG 5 MG SOVALDI ORAL 5 PA; QL TRIUMEQ ORAL 2 TABLET 200 MG, TABLET 600-50- 400 MG 300 MG stavudine oral 1 TRIZIVIR ORAL 3 capsule 15 mg, 20 TABLET 300-150- mg, 40 mg 300 MG SUSTIVA ORAL 3 TYBOST ORAL 3 CAPSULE 200 MG, TABLET 150 MG 50 MG valacyclovir oral 1 QL SUSTIVA ORAL 3 tablet 1 gram, 500 TABLET 600 MG mg SYMFI LO ORAL 2 VALCYTE ORAL 3 TABLET 400-300- RECON SOLN 50 300 MG MG/ML SYMFI ORAL 2 VALCYTE ORAL 3 TABLET 600-300- TABLET 450 MG 300 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 7 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits valganciclovir oral 1 XOFLUZA ORAL 3 QL recon soln 50 mg/ml TABLET 20 MG, 40 valganciclovir oral 1 MG tablet 450 mg XOFLUZA ORAL 3 VEMLIDY ORAL 2 TABLET 80 MG TABLET 25 MG ZEPATIER ORAL 4 PA; QL VIEKIRA PAK 5 PA; QL TABLET 50-100 ORAL MG TABLETS,DOSE ZIAGEN ORAL 3 PACK 12.5 MG-75 SOLUTION 20 MG -50 MG/250 MG/ML MG ZIAGEN ORAL 3 VIRACEPT ORAL 2 TABLET 300 MG TABLET 250 MG, zidovudine oral 1 625 MG capsule 100 mg VIRAMUNE ORAL 3 zidovudine oral 1 SUSPENSION 50 syrup 10 mg/ml MG/5 ML zidovudine oral 1 VIRAMUNE XR 3 tablet 300 mg ORAL TABLET EXTENDED ZOVIRAX ORAL 3 RELEASE 24 HR SUSPENSION 200 400 MG MG/5 ML VIRAZOLE 3 CEPHALOSPORINS INHALATION cefaclor oral capsule 1 RECON SOLN 6 250 mg, 500 mg GRAM cefaclor oral 1 VIREAD ORAL 2 suspension for POWDER 40 reconstitution 125 MG/SCOOP (40 mg/5 ml, 250 mg/5 MG/GRAM) ml, 375 mg/5 ml VIREAD ORAL 2 cefaclor oral tablet 1 TABLET 150 MG, extended release 12 200 MG, 250 MG hr 500 mg VIREAD ORAL 3 cefadroxil oral 1 TABLET 300 MG capsule 500 mg VOSEVI ORAL 4 PA; QL TABLET 400-100- 100 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits cefadroxil oral 1 cephalexin oral 1 suspension for capsule 250 mg, 500 reconstitution 250 mg, 750 mg mg/5 ml, 500 mg/5 cephalexin oral 1 ml suspension for cefadroxil oral tablet 1 reconstitution 125 1 gram mg/5 ml, 250 mg/5 cefdinir oral capsule 1 ml 300 mg cephalexin oral 1 cefdinir oral 1 tablet 250 mg, 500 suspension for mg reconstitution 125 KEFLEX ORAL 3 mg/5 ml, 250 mg/5 CAPSULE 750 MG ml SPECTRACEF 3 cefditoren pivoxil 1 ORAL TABLET oral tablet 200 mg, 400 MG 400 mg SUPRAX ORAL 3 cefixime oral 1 CAPSULE 400 MG capsule 400 mg SUPRAX ORAL 3 cefixime oral 1 SUSPENSION FOR suspension for RECONSTITUTIO reconstitution 100 N 100 MG/5 ML, mg/5 ml, 200 mg/5 200 MG/5 ML, 500 ml MG/5 ML cefpodoxime oral 1 SUPRAX ORAL 3 suspension for TABLET,CHEWAB reconstitution 100 LE 100 MG, 200 mg/5 ml, 50 mg/5 ml MG cefpodoxime oral 1 ERYTHROMYCINS & OTHER tablet 100 mg, 200 MACROLIDES mg azithromycin oral 1 cefprozil oral 1 packet 1 gram suspension for reconstitution 125 azithromycin oral 1 mg/5 ml, 250 mg/5 suspension for ml reconstitution 100 mg/5 ml, 200 mg/5 cefprozil oral tablet 1 ml 250 mg, 500 mg azithromycin oral 1 cefuroxime axetil 1 tablet 250 mg, 500 oral tablet 250 mg, mg, 600 mg 500 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 9 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clarithromycin oral 1 ERY-TAB ORAL 3 suspension for TABLET,DELAYE reconstitution 125 D RELEASE mg/5 ml, 250 mg/5 (DR/EC) 500 MG ml erythrocin (as 1 clarithromycin oral 1 stearate) oral tablet tablet 250 mg, 500 250 mg mg erythromycin 1 clarithromycin oral 1 ethylsuccinate oral tablet extended suspension for release 24 hr 500 mg reconstitution 200 DIFICID ORAL 3 QL mg/5 ml, 400 mg/5 SUSPENSION FOR ml RECONSTITUTIO erythromycin 1 N 40 MG/ML ethylsuccinate oral DIFICID ORAL 3 QL tablet 400 mg TABLET 200 MG erythromycin oral 1 e.e.s. 400 oral tablet 1 capsule,delayed 400 mg release(dr/ec) 250 mg E.E.S. GRANULES 3 ORAL erythromycin oral 1 SUSPENSION FOR tablet 250 mg, 500 RECONSTITUTIO mg N 200 MG/5 ML erythromycin oral 1 ERYPED 200 3 tablet,delayed ORAL release (dr/ec) 250 SUSPENSION FOR mg, 333 mg, 500 mg RECONSTITUTIO ZITHROMAX 3 N 200 MG/5 ML ORAL PACKET 1 ERYPED 400 3 GRAM ORAL ZITHROMAX 3 SUSPENSION FOR ORAL RECONSTITUTIO SUSPENSION FOR N 400 MG/5 ML RECONSTITUTIO ery-tab oral 1 N 100 MG/5 ML, tablet,delayed 200 MG/5 ML release (dr/ec) 250 ZITHROMAX 3 mg, 333 mg ORAL TABLET 250 MG, 500 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZITHROMAX TRI- 3 chloroquine 1 PAK ORAL phosphate oral TABLET 500 MG tablet 250 mg, 500 ZITHROMAX Z- 3 mg PAK ORAL CLEOCIN HCL 3 TABLET 250 MG ORAL CAPSULE 150 MG, 300 MG, MISCELLANEOUS 75 MG ANTIINFECTIVES CLEOCIN 3 AEMCOLO ORAL 3 QL PEDIATRIC ORAL TABLET,DELAYE RECON SOLN 75 D RELEASE MG/5 ML (DR/EC) 194 MG clindamycin hcl oral 1 albendazole oral 1 QL capsule 150 mg, 300 tablet 200 mg mg, 75 mg ALBENZA ORAL 3 QL clindamycin 1 TABLET 200 MG pediatric oral recon ALINIA ORAL 2 QL soln 75 mg/5 ml SUSPENSION FOR CYCLOSERINE 3 RECONSTITUTIO ORAL CAPSULE N 100 MG/5 ML 250 MG ALINIA ORAL 2 QL dapsone oral tablet 1 TABLET 500 MG 100 mg, 25 mg atovaquone oral 1 DARAPRIM ORAL 4 PA suspension 750 mg/5 TABLET 25 MG ml EMVERM ORAL 2 QL atovaquone- 1 QL TABLET,CHEWAB proguanil oral tablet LE 100 MG 250-100 mg, 62.5-25 mg ethambutol oral 1 tablet 100 mg, 400 BENZNIDAZOLE 2 QL mg ORAL TABLET 100 MG, 12.5 MG FLAGYL ORAL 3 CAPSULE 375 MG BETHKIS 4 PA; QL INHALATION FLAGYL ORAL 3 SOLUTION FOR TABLET 500 MG NEBULIZATION hydroxychloroquine 1 300 MG/4 ML oral tablet 200 mg isoniazid oral 1 solution 50 mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 11 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits isoniazid oral tablet 1 NEBUPENT 2 QL 100 mg, 300 mg INHALATION ivermectin oral 1 QL RECON SOLN 300 tablet 3 mg MG KITABIS PAK 4 PA; QL neomycin oral tablet 1 INHALATION 500 mg SOLUTION FOR nitazoxanide oral 1 QL NEBULIZATION tablet 500 mg 300 MG/5 ML PASER ORAL 3 linezolid oral 1 PA GRANULES DR suspension for FOR SUSP IN reconstitution 100 PACKET 4 GRAM mg/5 ml pentamidine 1 QL linezolid oral tablet 1 PA inhalation recon 600 mg soln 300 mg MALARONE 3 QL PRETOMANID 3 PA ORAL TABLET ORAL TABLET 250-100 MG 200 MG MALARONE 3 QL PRIFTIN ORAL 2 PEDIATRIC ORAL TABLET 150 MG TABLET 62.5-25 primaquine oral 1 QL MG tablet 26.3 mg mefloquine oral 1 QL pyrazinamide oral 1 tablet 250 mg tablet 500 mg MEPRON ORAL 3 pyrimethamine oral 4 PA SUSPENSION 750 tablet 25 mg MG/5 ML QUALAQUIN 3 QL metronidazole oral 1 ORAL CAPSULE capsule 375 mg 324 MG metronidazole oral 1 quinine sulfate oral 1 QL tablet 250 mg, 500 capsule 324 mg mg rifabutin oral 1 MYAMBUTOL 3 capsule 150 mg ORAL TABLET 400 MG rifampin oral 1 capsule 150 mg, 300 MYCOBUTIN 3 mg ORAL CAPSULE 150 MG STROMECTOL 3 QL ORAL TABLET 3 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tinidazole oral tablet 1 QL amoxicillin oral 1 250 mg, 500 mg tablet 500 mg, 875 TOBI PODHALER 4 PA; QL mg INHALATION amoxicillin oral 1 CAPSULE, tablet,chewable 125 W/INHALATION mg, 250 mg DEVICE 28 MG amoxicillin-pot 1 tobramycin in 0.225 4 PA; QL clavulanate oral % nacl inhalation suspension for solution for reconstitution 200- nebulization 300 28.5 mg/5 ml, 250- mg/5 ml 62.5 mg/5 ml, 400- tobramycin 4 PA; QL 57 mg/5 ml, 600- inhalation solution 42.9 mg/5 ml for nebulization 300 amoxicillin-pot 1 mg/4 ml clavulanate oral TOBRAMYCIN 5 PA; QL tablet 250-125 mg, WITH NEBULIZER 500-125 mg, 875- INHALATION 125 mg SOLUTION FOR amoxicillin-pot 1 NEBULIZATION clavulanate oral 300 MG/5 ML tablet extended TRECATOR ORAL 3 release 12 hr 1,000- TABLET 250 MG 62.5 mg XENLETA ORAL 3 amoxicillin-pot 1 TABLET 600 MG clavulanate oral tablet,chewable 200- XIFAXAN ORAL 2 QL 28.5 mg, 400-57 mg TABLET 200 MG, 550 MG AUGMENTIN 2 ORAL PENICILLINS SUSPENSION FOR amoxicillin oral 1 RECONSTITUTIO capsule 250 mg, 500 N 125-31.25 MG/5 mg ML amoxicillin oral 1 AUGMENTIN 3 suspension for ORAL reconstitution 125 SUSPENSION FOR mg/5 ml, 200 mg/5 RECONSTITUTIO ml, 250 mg/5 ml, 400 N 250-62.5 MG/5 mg/5 ml ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 13 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AUGMENTIN XR 3 BACTRIM DS 3 ORAL TABLET ORAL TABLET EXTENDED 800-160 MG RELEASE 12 HR BACTRIM ORAL 3 1,000-62.5 MG TABLET 400-80 dicloxacillin oral 1 MG capsule 250 mg, 500 sulfadiazine oral 1 mg tablet 500 mg MOXATAG ORAL 3 sulfamethoxazole- 1 TABLET, ER trimethoprim oral MULTIPHASE 24 suspension 200-40 HR 775 MG mg/5 ml penicillin v 1 sulfamethoxazole- 1 potassium oral recon trimethoprim oral soln 125 mg/5 ml, tablet 400-80 mg, 250 mg/5 ml 800-160 mg penicillin v 1 sulfatrim oral 1 potassium oral tablet suspension 200-40 250 mg, 500 mg mg/5 ml QUINOLONES TETRACYCLINES CIPRO ORAL 3 ACTICLATE 3 ST TABLET 250 MG, ORAL TABLET 500 MG 150 MG, 75 MG ciprofloxacin hcl 1 AVIDOXY DK KIT 3 ST oral tablet 100 mg, 100 MG-2 % -SPF 250 mg, 500 mg, 750 30 mg avidoxy oral tablet 1 FACTIVE ORAL 3 100 mg TABLET 320 MG coremino oral tablet 1 ST levofloxacin oral 1 extended release 24 solution 250 mg/10 hr 135 mg, 45 mg, ml 90 mg levofloxacin oral 1 demeclocycline oral 1 tablet 250 mg, 500 tablet 150 mg, 300 mg, 750 mg mg moxifloxacin oral 1 DORYX MPC 3 ST tablet 400 mg ORAL ofloxacin oral tablet 1 TABLET,DELAYE 300 mg, 400 mg D RELEASE (DR/EC) 120 MG SULFA'S & RELATED AGENTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 14 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DORYX ORAL 3 ST minocycline oral 1 ST TABLET,DELAYE tablet extended D RELEASE release 24 hr 105 (DR/EC) 200 MG, mg, 115 mg, 135 mg, 50 MG 45 mg, 55 mg, 65 doxycycline hyclate 1 mg, 80 mg, 90 mg oral capsule 100 mg, MINOLIRA ER 3 ST 50 mg ORAL TABLET, IR doxycycline hyclate 1 - ER, BIPHASIC oral tablet 100 mg, 24HR 105 MG, 135 20 mg MG doxycycline hyclate 1 ST mondoxyne nl oral 1 oral tablet 150 mg, capsule 100 mg, 75 50 mg, 75 mg mg doxycycline hyclate 1 ST MONODOX ORAL 3 ST oral tablet,delayed CAPSULE 100 MG, release (dr/ec) 100 50 MG, 75 MG mg, 150 mg, 200 mg, MORGIDOX 1X 50 3 ST 50 mg, 75 mg KIT 50 MG doxycycline 1 MORGIDOX 2X100 3 ST monohydrate oral KIT 100 MG capsule 100 mg, 50 morgidox oral 1 mg, 75 mg capsule 100 mg doxycycline 1 ST NUZYRA ORAL 3 QL monohydrate oral TABLET 150 MG capsule 150 mg ORACEA ORAL 3 ST doxycycline 1 CAPSULE,IR - monohydrate oral DELAY suspension for REL,BIPHASE 40 reconstitution 25 MG mg/5 ml SEYSARA ORAL 3 ST doxycycline 1 TABLET 100 MG, monohydrate oral 150 MG, 60 MG tablet 100 mg, 150 mg, 50 mg, 75 mg SOLODYN ORAL 3 ST TABLET minocycline oral 1 EXTENDED capsule 100 mg, 50 RELEASE 24 HR mg, 75 mg 105 MG, 115 MG, minocycline oral 1 55 MG, 65 MG, 80 tablet 100 mg, 50 MG mg, 75 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 15 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TARGADOX 3 ST nitrofurantoin 1 ORAL TABLET 50 monohyd/m-cryst MG oral capsule 100 mg tetracycline oral 1 nitrofurantoin oral 1 capsule 250 mg, 500 suspension 25 mg/5 mg ml VIBRAMYCIN 3 ST PRIMSOL ORAL 3 ORAL CAPSULE SOLUTION 50 100 MG MG/5 ML VIBRAMYCIN 3 ST trimethoprim oral 1 ORAL tablet 100 mg SUSPENSION FOR VANCOMYCIN RECONSTITUTIO N 25 MG/5 ML VANCOCIN ORAL 3 PA; QL CAPSULE 125 MG, VIBRAMYCIN 3 ST 250 MG ORAL SYRUP 50 MG/5 ML vancomycin oral 1 PA; QL capsule 125 mg, 250 URINARY TRACT AGENTS mg FURADANTIN 3 vancomycin oral 1 QL ORAL recon soln 50 mg/ml SUSPENSION 25 MG/5 ML ANTINEOPLASTIC & MACROBID ORAL 3 IMMUNOSUPPRESSANT CAPSULE 100 MG DRUGS MACRODANTIN 3 ADJUNCTIVE AGENTS ORAL CAPSULE 100 MG, 25 MG, 50 leucovorin calcium 1 MG oral tablet 10 mg, 15 mg, 25 mg, 5 mg methenamine 1 hippurate oral tablet MESNEX ORAL 2 1 gram TABLET 400 MG methenamine 1 ANTINEOPLASTIC & mandelate oral IMMUNOSUPPRESSANT DRUGS tablet 0.5 g, 1 gram ABECMA 5 PA nitrofurantoin 1 INTRAVENOUS macrocrystal oral SUSPENSION capsule 100 mg, 25 300X10EXP6 TO mg, 50 mg 460X10EXP6 CELL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 16 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits abiraterone oral 4 PA; QL ASTAGRAF XL 3 ST tablet 250 mg, 500 ORAL mg CAPSULE,EXTEN ADAKVEO 4 PA DED RELEASE INTRAVENOUS 24HR 0.5 MG, 1 SOLUTION 10 MG, 5 MG MG/ML AYVAKIT ORAL 5 PA; QL AFINITOR 4 PA TABLET 100 MG, DISPERZ ORAL 200 MG, 300 MG TABLET FOR AYVAKIT ORAL 5 PA SUSPENSION 2 TABLET 25 MG, 50 MG, 3 MG, 5 MG MG AFINITOR ORAL 4 PA AZASAN ORAL 3 TABLET 10 MG TABLET 100 MG, AFINITOR ORAL 5 PA 75 MG TABLET 2.5 MG, 5 azathioprine oral 1 MG, 7.5 MG tablet 50 mg ALECENSA ORAL 4 PA; QL BALVERSA ORAL 4 PA CAPSULE 150 MG TABLET 3 MG, 4 ALKERAN ORAL 3 MG, 5 MG TABLET 2 MG BELRAPZO 5 PA ALUNBRIG ORAL 4 PA; QL INTRAVENOUS TABLET 180 MG, SOLUTION 25 30 MG, 90 MG MG/ML ALUNBRIG ORAL 4 PA; QL BENDEKA 4 PA TABLETS,DOSE INTRAVENOUS PACK 90 MG (7)- SOLUTION 25 180 MG (23) MG/ML anastrozole oral 0 bexarotene oral 4 PA tablet 1 mg capsule 75 mg AROMASIN ORAL 3 bicalutamide oral 1 TABLET 25 MG tablet 50 mg ASPARLAS 5 PA BOSULIF ORAL 4 PA; QL INTRAVENOUS TABLET 100 MG, SOLUTION 750 400 MG, 500 MG UNIT/ML BRAFTOVI ORAL 5 PA; QL CAPSULE 50 MG, 75 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 17 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BREYANZI 5 PA COTELLIC ORAL 4 PA; QL INTRAVENOUS TABLET 20 MG SUSPENSION 1.5 cyclophosphamide 1 X TO 70 X 10EXP6 oral capsule 25 mg, CELL/ML 50 mg BRUKINSA ORAL 5 PA CYCLOPHOSPHA 3 CAPSULE 80 MG MIDE ORAL CABOMETYX 4 PA; QL TABLET 25 MG, 50 ORAL TABLET 20 MG MG, 40 MG, 60 MG cyclosporine 1 capecitabine oral 4 modified oral tablet 150 mg, 500 capsule 100 mg, 25 mg mg, 50 mg CAPRELSA ORAL 4 PA; QL cyclosporine 1 TABLET 100 MG, modified oral 300 MG solution 100 mg/ml CASODEX ORAL 3 cyclosporine oral 1 TABLET 50 MG capsule 100 mg, 25 CELLCEPT ORAL 3 mg CAPSULE 250 MG DANYELZA 5 PA CELLCEPT ORAL 3 INTRAVENOUS SUSPENSION FOR SOLUTION 4 RECONSTITUTIO MG/ML N 200 MG/ML DARZALEX 5 PA CELLCEPT ORAL 3 FASPRO TABLET 500 MG SUBCUTANEOUS SOLUTION 1,800 COMETRIQ ORAL 4 PA MG-30,000 CAPSULE 100 UNIT/15 ML MG/DAY(80 MG X1-20 MG X1), 140 DAURISMO ORAL 5 PA; QL MG/DAY(80 MG TABLET 100 MG, X1-20 MG X3), 60 25 MG MG/DAY (20 MG X DROXIA ORAL 2 3/DAY) CAPSULE 200 MG, COPIKTRA ORAL 5 PA; QL 300 MG, 400 MG CAPSULE 15 MG, ELZONRIS 4 PA 25 MG INTRAVENOUS COSELA 5 PA SOLUTION 1,000 INTRAVENOUS MCG/ML RECON SOLN 300 EMCYT ORAL 2 MG CAPSULE 140 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 18 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ENHERTU 5 PA GILOTRIF ORAL 4 PA; QL INTRAVENOUS TABLET 20 MG, 30 RECON SOLN 100 MG, 40 MG MG GLEOSTINE ORAL 2 ENSPRYNG 4 PA CAPSULE 10 MG, SUBCUTANEOUS 100 MG, 40 MG SYRINGE 120 HYDREA ORAL 3 MG/ML CAPSULE 500 MG ERIVEDGE ORAL 4 PA; QL hydroxyurea oral 1 CAPSULE 150 MG capsule 500 mg erlotinib oral tablet 4 PA; QL IBRANCE ORAL 4 PA; QL 100 mg, 150 mg, 25 CAPSULE 100 MG, mg 125 MG, 75 MG etoposide oral 1 IBRANCE ORAL 4 PA; QL capsule 50 mg TABLET 100 MG, everolimus 4 PA 125 MG, 75 MG (antineoplastic) oral ICLUSIG ORAL 4 PA; QL tablet 2.5 mg, 5 mg, TABLET 10 MG, 15 7.5 mg MG, 30 MG, 45 MG everolimus 1 IDHIFA ORAL 4 PA; QL (immunosuppressive TABLET 100 MG, ) oral tablet 0.25 mg, 50 MG 0.5 mg, 0.75 mg imatinib oral tablet 4 PA; QL exemestane oral 0 100 mg, 400 mg tablet 25 mg IMURAN ORAL 3 FARYDAK ORAL 5 PA; QL TABLET 50 MG CAPSULE 10 MG, 15 MG, 20 MG INLYTA ORAL 4 PA; QL TABLET 1 MG, 5 FEMARA ORAL 3 MG TABLET 2.5 MG IRESSA ORAL 4 PA; QL flutamide oral 1 TABLET 250 MG capsule 125 mg JAKAFI ORAL 4 PA; QL GAVRETO ORAL 4 PA; QL TABLET 10 MG, 15 CAPSULE 100 MG MG, 20 MG, 25 gengraf oral capsule 1 MG, 5 MG 100 mg, 25 mg JEMPERLI 5 PA gengraf oral solution 1 INTRAVENOUS 100 mg/ml SOLUTION 50 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 19 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits KANJINTI 4 PA MATULANE 4 INTRAVENOUS ORAL CAPSULE RECON SOLN 150 50 MG MG, 420 MG megestrol oral 1 KOSELUGO ORAL 5 PA suspension 400 CAPSULE 10 MG, mg/10 ml (40 25 MG mg/ml), 625 mg/5 ml lapatinib oral tablet 4 PA; QL (125 mg/ml) 250 mg megestrol oral tablet 1 LENVIMA ORAL 4 PA 20 mg, 40 mg CAPSULE 10 MEKINIST ORAL 4 PA; QL MG/DAY (10 MG X TABLET 0.5 MG, 2 1), 12 MG/DAY (4 MG MG X 3), 14 MEKTOVI ORAL 5 PA; QL MG/DAY(10 MG X TABLET 15 MG 1-4 MG X 1), 18 MG/DAY (10 MG X melphalan oral 1 1-4 MG X2), 20 tablet 2 mg MG/DAY (10 MG X mercaptopurine oral 1 2), 24 MG/DAY(10 tablet 50 mg MG X 2-4 MG X 1), 4 MG, 8 MG/DAY methotrexate sodium 1 (4 MG X 2) (pf) injection recon soln 1 gram letrozole oral tablet 1 2.5 mg methotrexate sodium 1 (pf) injection LEUKERAN ORAL 2 solution 25 mg/ml TABLET 2 MG methotrexate sodium 1 LORBRENA ORAL 4 PA; QL injection solution 25 TABLET 100 MG, mg/ml 25 MG methotrexate sodium 1 LYNPARZA ORAL 4 PA; QL oral tablet 2.5 mg TABLET 100 MG, 150 MG MONJUVI 5 PA INTRAVENOUS LYSODREN ORAL 4 RECON SOLN 200 TABLET 500 MG MG MARGENZA 5 PA MVASI 4 PA INTRAVENOUS INTRAVENOUS SOLUTION 25 SOLUTION 25 MG/ML MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 20 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits mycophenolate 1 NINLARO ORAL 4 PA; QL mofetil oral capsule CAPSULE 2.3 MG, 250 mg 3 MG, 4 MG mycophenolate 1 NUBEQA ORAL 4 PA; QL mofetil oral TABLET 300 MG suspension for ODOMZO ORAL 4 PA; QL reconstitution 200 CAPSULE 200 MG mg/ml PADCEV 5 PA mycophenolate 1 INTRAVENOUS mofetil oral tablet RECON SOLN 20 500 mg MG, 30 MG mycophenolate 1 PEMAZYRE ORAL 5 PA; QL sodium oral TABLET 13.5 MG, tablet,delayed 4.5 MG, 9 MG release (dr/ec) 180 mg, 360 mg PEPAXTO 5 PA INTRAVENOUS MYFORTIC ORAL 3 RECON SOLN 20 TABLET,DELAYE MG D RELEASE (DR/EC) 180 MG, POLIVY 5 PA 360 MG INTRAVENOUS RECON SOLN 140 MYLERAN ORAL 2 MG, 30 MG TABLET 2 MG PROGRAF ORAL 3 NEORAL ORAL 3 CAPSULE 0.5 MG, CAPSULE 100 MG, 1 MG, 5 MG 25 MG PROGRAF ORAL 2 NEORAL ORAL 3 GRANULES IN SOLUTION 100 PACKET 0.2 MG, 1 MG/ML MG NERLYNX ORAL 4 PA PURIXAN ORAL 4 TABLET 40 MG SUSPENSION 20 NEXAVAR ORAL 4 PA; QL MG/ML TABLET 200 MG RAPAMUNE 3 NILANDRON 3 PA ORAL SOLUTION ORAL TABLET 1 MG/ML 150 MG RAPAMUNE 3 nilutamide oral 1 PA ORAL TABLET 0.5 tablet 150 mg MG, 1 MG, 2 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 21 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RETEVMO ORAL 5 PA; QL SOLTAMOX 0 $0 for ages 35 CAPSULE 40 MG, ORAL SOLUTION and older 80 MG 20 MG/10 ML ROMIDEPSIN 5 PA SPRYCEL ORAL 4 PA; QL INTRAVENOUS TABLET 100 MG, SOLUTION 5 140 MG, 20 MG, 50 MG/ML MG, 70 MG, 80 MG ROZLYTREK 4 PA; QL STIVARGA ORAL 4 PA; QL ORAL CAPSULE TABLET 40 MG 100 MG, 200 MG SUTENT ORAL 4 PA; QL RUBRACA ORAL 4 PA; QL CAPSULE 12.5 TABLET 200 MG, MG, 25 MG, 37.5 250 MG, 300 MG MG, 50 MG RUXIENCE 4 PA TABRECTA ORAL 4 PA INTRAVENOUS TABLET 150 MG, SOLUTION 10 200 MG MG/ML tacrolimus oral 1 RYDAPT ORAL 4 PA capsule 0.5 mg, 1 CAPSULE 25 MG mg, 5 mg SANDIMMUNE 3 TAFINLAR ORAL 4 PA; QL ORAL CAPSULE CAPSULE 50 MG, 100 MG, 25 MG 75 MG SANDIMMUNE 2 TAGRISSO ORAL 4 PA; QL ORAL SOLUTION TABLET 40 MG, 80 100 MG/ML MG SARCLISA 5 PA TALZENNA ORAL 4 PA; QL INTRAVENOUS CAPSULE 0.25 SOLUTION 20 MG, 1 MG MG/ML tamoxifen oral tablet 0 $0 for ages 35 SIGNIFOR 4 PA 10 mg, 20 mg and older SUBCUTANEOUS TARCEVA ORAL 5 PA; QL SOLUTION 0.3 TABLET 100 MG, MG/ML (1 ML), 0.6 150 MG, 25 MG MG/ML (1 ML), 0.9 MG/ML (1 ML) TARGRETIN 4 PA TOPICAL GEL 1 % sirolimus oral 1 solution 1 mg/ml TASIGNA ORAL 4 PA; QL CAPSULE 150 MG, sirolimus oral tablet 1 200 MG, 50 MG 0.5 mg, 1 mg, 2 mg TAZVERIK ORAL 5 PA TABLET 200 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 22 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TECARTUS 5 PA TUKYSA ORAL 5 PA; QL INTRAVENOUS TABLET 150 MG, SUSPENSION 50 MG 2X10EXP6 TO TURALIO ORAL 5 PA; QL 2X10EXP8 CELL CAPSULE 200 MG TEMODAR 4 TYKERB ORAL 4 PA; QL INTRAVENOUS TABLET 250 MG RECON SOLN 100 MG UKONIQ ORAL 5 PA; QL TABLET 200 MG TEMODAR ORAL 5 PA CAPSULE 100 MG, VENCLEXTA 4 PA 140 MG, 180 MG, ORAL TABLET 10 250 MG MG, 100 MG, 50 MG temozolomide oral 4 PA capsule 100 mg, 140 VENCLEXTA 4 PA; QL mg, 180 mg, 20 mg, STARTING PACK 250 mg, 5 mg ORAL TABLETS,DOSE TIBSOVO ORAL 4 PA PACK 10 MG-50 TABLET 250 MG MG- 100 MG toremifene oral 1 VERZENIO ORAL 4 PA; QL tablet 60 mg TABLET 100 MG, TRAZIMERA 4 PA 150 MG, 200 MG, INTRAVENOUS 50 MG RECON SOLN 150 VITRAKVI ORAL 4 PA; QL MG, 420 MG CAPSULE 100 MG, TREANDA 4 PA 25 MG INTRAVENOUS VITRAKVI ORAL 4 PA; QL RECON SOLN 100 SOLUTION 20 MG, 25 MG MG/ML tretinoin 1 VIZIMPRO ORAL 4 PA; QL (antineoplastic) oral TABLET 15 MG, 30 capsule 10 mg MG, 45 MG TREXALL ORAL 3 VOTRIENT ORAL 4 PA; QL TABLET 10 MG, 15 TABLET 200 MG MG, 5 MG, 7.5 MG XALKORI ORAL 4 PA; QL TRODELVY 5 PA CAPSULE 200 MG, INTRAVENOUS 250 MG RECON SOLN 180 MG XELODA ORAL 5 TABLET 150 MG, 500 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 23 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits XOSPATA ORAL 4 PA carbamazepine oral 1 TABLET 40 MG suspension 100 mg/5 ZEJULA ORAL 4 PA; QL ml, 200 mg/10 ml CAPSULE 100 MG carbamazepine oral 1 ZELBORAF ORAL 4 PA; QL tablet 200 mg TABLET 240 MG carbamazepine oral 1 ZEPZELCA 5 PA tablet extended INTRAVENOUS release 12 hr 100 RECON SOLN 4 mg, 200 mg, 400 mg MG carbamazepine oral 1 ZIRABEV 4 PA tablet,chewable 100 INTRAVENOUS mg SOLUTION 25 CARBATROL 3 MG/ML ORAL CAPSULE, ZOLINZA ORAL 4 PA ER MULTIPHASE CAPSULE 100 MG 12 HR 100 MG, 200 MG, 300 MG ZORTRESS ORAL 2 TABLET 0.25 MG, CELONTIN ORAL 2 0.5 MG, 0.75 MG, 1 CAPSULE 300 MG MG clobazam oral 1 PA ZYDELIG ORAL 4 PA; QL suspension 2.5 TABLET 100 MG, mg/ml 150 MG clobazam oral tablet 1 PA ZYKADIA ORAL 4 PA; QL 10 mg, 20 mg TABLET 150 MG clonazepam oral 1 tablet 0.5 mg, 1 mg, AUTONOMIC & CNS DRUGS, 2 mg NEUROLOGY & PSYCH clonazepam oral 1 ANTICONVULSANTS tablet,disintegrating 0.125 mg, 0.25 mg, BANZEL ORAL 2 PA 0.5 mg, 1 mg, 2 mg SUSPENSION 40 MG/ML DEPAKOTE ER 3 ST ORAL TABLET BANZEL ORAL 3 PA EXTENDED TABLET 200 MG, RELEASE 24 HR 400 MG 250 MG, 500 MG carbamazepine oral 1 DEPAKOTE ORAL 3 ST capsule, er TABLET,DELAYE multiphase 12 hr D RELEASE 100 mg, 200 mg, 300 (DR/EC) 125 MG, mg 250 MG, 500 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 24 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DEPAKOTE 3 ST divalproex oral 1 SPRINKLES ORAL tablet extended CAPSULE, release 24 hr 250 DELAYED REL mg, 500 mg SPRINKLE 125 MG divalproex oral 1 DIACOMIT ORAL 4 PA tablet,delayed CAPSULE 250 MG, release (dr/ec) 125 500 MG mg, 250 mg, 500 mg DIACOMIT ORAL 4 PA EPIDIOLEX ORAL 4 PA POWDER IN SOLUTION 100 PACKET 250 MG, MG/ML 500 MG epitol oral tablet 200 1 DIASTAT 3 mg ACUDIAL EQUETRO ORAL 3 RECTAL KIT 12.5- CAPSULE, ER 15-17.5-20 MG, 5- MULTIPHASE 12 7.5-10 MG HR 100 MG, 200 DIASTAT RECTAL 3 MG, 300 MG KIT 2.5 MG ethosuximide oral 1 diazepam rectal kit 1 capsule 250 mg 12.5-15-17.5-20 mg, ethosuximide oral 1 2.5 mg, 5-7.5-10 mg solution 250 mg/5 ml DILANTIN 3 felbamate oral 1 EXTENDED ORAL suspension 600 mg/5 CAPSULE 100 MG ml DILANTIN 3 felbamate oral tablet 1 INFATABS ORAL 400 mg, 600 mg TABLET,CHEWAB LE 50 MG FELBATOL ORAL 3 SUSPENSION 600 DILANTIN ORAL 2 MG/5 ML CAPSULE 30 MG FELBATOL ORAL 3 DILANTIN-125 3 TABLET 400 MG, ORAL 600 MG SUSPENSION 125 MG/5 ML gabapentin oral 1 capsule 100 mg, 300 divalproex oral 1 mg, 400 mg capsule, delayed rel sprinkle 125 mg gabapentin oral 1 solution 250 mg/5 ml, 300 mg/6 ml (6 ml)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 25 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits gabapentin oral 1 lamotrigine oral 1 tablet 600 mg, 800 tablet disintegrating, mg dose pk 25 mg (21) - GABITRIL ORAL 3 50 mg (7), 25 TABLET 12 MG, 16 mg(14)-50 mg (14)- MG, 2 MG, 4 MG 100 mg (7), 50 mg (42) -100 mg (14) GRALISE ORAL 3 ST TABLET lamotrigine oral 1 EXTENDED tablet extended RELEASE 24 HR release 24hr 100 mg, 300 MG, 600 MG 200 mg, 25 mg, 250 mg, 300 mg, 50 mg KLONOPIN ORAL 3 TABLET 0.5 MG, 1 lamotrigine oral 1 MG, 2 MG tablet, chewable dispersible 25 mg, 5 LAMICTAL XR 3 ST mg STARTER (BLUE) ORAL TABLET lamotrigine oral 1 EXTENDED tablet,disintegrating REL,DOSE PACK 100 mg, 200 mg, 25 25 MG (21) -50 MG mg, 50 mg (7) lamotrigine oral 1 LAMICTAL XR 3 ST tablets,dose pack 25 STARTER mg (35), 25 mg (42) (GREEN) ORAL -100 mg (7), 25 mg TABLET (84) -100 mg (14) EXTENDED levetiracetam oral 1 REL,DOSE PACK solution 100 mg/ml, 50 MG(14)-100MG 500 mg/5 ml (5 ml) (14)-200 MG (7) levetiracetam oral 1 LAMICTAL XR 3 ST tablet 1,000 mg, 250 STARTER mg, 500 mg, 750 mg (ORANGE) ORAL levetiracetam oral 1 TABLET tablet extended EXTENDED release 24 hr 500 REL,DOSE PACK mg, 750 mg 25MG (14)-50 MG (14)-100MG (7) MYSOLINE ORAL 3 TABLET 250 MG, lamotrigine oral 1 50 MG tablet 100 mg, 150 mg, 200 mg, 25 mg ONFI ORAL 3 PA SUSPENSION 2.5 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 26 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ONFI ORAL 3 PA pregabalin oral 1 TABLET 10 MG, 20 solution 20 mg/ml MG pregabalin oral 1 ST oxcarbazepine oral 1 tablet extended suspension 300 mg/5 release 24 hr 165 ml (60 mg/ml) mg, 330 mg, 82.5 mg oxcarbazepine oral 1 primidone oral 1 tablet 150 mg, 300 tablet 250 mg, 50 mg mg, 600 mg QUDEXY XR 2 ST OXTELLAR XR 3 ST ORAL ORAL TABLET CAPSULE,SPRINK EXTENDED LE,ER 24HR 100 RELEASE 24 HR MG, 150 MG, 200 150 MG, 300 MG, MG, 25 MG, 50 MG 600 MG roweepra oral tablet 1 phenobarbital oral 1 1,000 mg, 500 mg, elixir 20 mg/5 ml (4 750 mg mg/ml) rufinamide oral 1 PA phenobarbital oral 1 suspension 40 mg/ml tablet 100 mg, 15 rufinamide oral 1 PA mg, 16.2 mg, 30 mg, tablet 200 mg, 400 32.4 mg, 60 mg, 64.8 mg mg, 97.2 mg SPRITAM ORAL 3 ST PHENYTEK ORAL 3 TABLET FOR CAPSULE 200 MG, SUSPENSION 300 MG 1,000 MG, 250 MG, phenytoin oral 1 500 MG, 750 MG suspension 100 mg/4 subvenite oral tablet 1 ml, 125 mg/5 ml 100 mg, 150 mg, 200 phenytoin oral 1 mg, 25 mg tablet,chewable 50 subvenite starter 1 mg (blue) kit oral phenytoin sodium 1 tablets,dose pack 25 extended oral mg (35) capsule 100 mg, 200 subvenite starter 1 mg, 300 mg (green) kit oral pregabalin oral 1 tablets,dose pack 25 capsule 100 mg, 150 mg (84) -100 mg mg, 200 mg, 225 mg, (14) 25 mg, 300 mg, 50 mg, 75 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 27 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits subvenite starter 1 valproic acid (as 1 (orange) kit oral sodium salt) oral tablets,dose pack 25 solution 250 mg/5 mg (42) -100 mg (7) ml, 500 mg/10 ml SYMPAZAN ORAL 3 PA (10 ml) FILM 10 MG, 20 valproic acid oral 1 MG, 5 MG capsule 250 mg TEGRETOL ORAL 3 VALTOCO NASAL 3 QL SUSPENSION 100 SPRAY,NON- MG/5 ML AEROSOL 10 TEGRETOL ORAL 3 MG/SPRAY (0.1 TABLET 200 MG ML), 15 MG/2 SPRAY (7.5/0.1ML TEGRETOL XR 3 X 2), 20 MG/2 ORAL TABLET SPRAY EXTENDED (10MG/0.1ML X2), RELEASE 12 HR 5 MG/SPRAY (0.1 100 MG, 200 MG, ML) 400 MG VIMPAT ORAL 2 tiagabine oral tablet 1 SOLUTION 10 12 mg, 16 mg, 2 mg, MG/ML 4 mg VIMPAT ORAL 2 topiramate oral 1 TABLET 100 MG, capsule, sprinkle 15 150 MG, 200 MG, mg, 25 mg 50 MG topiramate oral 1 ST XCOPRI 3 QL capsule,sprinkle,er MAINTENANCE 24hr 100 mg, 150 PACK ORAL mg, 200 mg, 25 mg, TABLET 50 mg 250MG/DAY(150 topiramate oral 1 MG X1-100MG tablet 100 mg, 200 X1), 350 MG/DAY mg, 25 mg, 50 mg (200 MG X1- 150MG X1) TROKENDI XR 3 ST ORAL XCOPRI ORAL 3 QL CAPSULE,EXTEN TABLET 100 MG, DED RELEASE 150 MG, 200 MG, 24HR 100 MG, 200 50 MG MG, 25 MG, 50 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 28 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits XCOPRI 3 QL carbidopa-levodopa 1 TITRATION PACK oral ORAL tablet,disintegrating TABLETS,DOSE 10-100 mg, 25-100 PACK 12.5 MG mg, 25-250 mg (14)- 25 MG (14), carbidopa-levodopa- 1 150 MG (14)- 200 entacapone oral MG (14), 50 MG tablet 12.5-50-200 (14)- 100 MG (14) mg, 18.75-75-200 ZARONTIN ORAL 3 mg, 25-100-200 mg, CAPSULE 250 MG 31.25-125-200 mg, ZARONTIN ORAL 3 37.5-150-200 mg, SOLUTION 250 50-200-200 mg MG/5 ML COMTAN ORAL 3 zonisamide oral 1 TABLET 200 MG capsule 100 mg, 25 entacapone oral 1 mg, 50 mg tablet 200 mg ANTIPARKINSONISM AGENTS INBRIJA 4 PA; QL INHALATION AZILECT ORAL 3 ST CAPSULE, TABLET 0.5 MG, 1 W/INHALATION MG DEVICE 42 MG benztropine oral 1 KYNMOBI 2 PA; QL tablet 0.5 mg, 1 mg, SUBLINGUAL 2 mg FILM 10 MG, 15 bromocriptine oral 1 MG, 20 MG, 25 capsule 5 mg MG, 30 MG bromocriptine oral 1 LODOSYN ORAL 3 PA tablet 2.5 mg TABLET 25 MG carbidopa oral 1 PA MIRAPEX ER 3 tablet 25 mg ORAL TABLET carbidopa-levodopa 1 EXTENDED oral tablet 10-100 RELEASE 24 HR mg, 25-100 mg, 25- 0.375 MG, 0.75 MG, 250 mg 1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 carbidopa-levodopa 1 MG oral tablet extended release 25-100 mg, NOURIANZ ORAL 5 PA; QL 50-200 mg TABLET 20 MG, 40 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 29 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OSMOLEX ER 5 PA; QL selegiline hcl oral 1 ORAL TABLET, IR tablet 5 mg - ER, BIPHASIC SINEMET ORAL 3 24HR 129 MG, 193 TABLET 10-100 MG, 258 MG, 322 MG, 25-100 MG MG/DAY(129 MG X1-193MG X1) STALEVO 100 3 ORAL TABLET 25- PARLODEL ORAL 3 100-200 MG CAPSULE 5 MG STALEVO 125 3 PARLODEL ORAL 3 ORAL TABLET TABLET 2.5 MG 31.25-125-200 MG pramipexole oral 1 STALEVO 150 3 tablet 0.125 mg, 0.25 ORAL TABLET mg, 0.5 mg, 0.75 mg, 37.5-150-200 MG 1 mg, 1.5 mg STALEVO 200 3 pramipexole oral 1 ORAL TABLET 50- tablet extended 200-200 MG release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, STALEVO 50 3 2.25 mg, 3 mg, 3.75 ORAL TABLET mg, 4.5 mg 12.5-50-200 MG rasagiline oral tablet 1 STALEVO 75 3 0.5 mg, 1 mg ORAL TABLET 18.75-75-200 MG ropinirole oral tablet 1 0.25 mg, 0.5 mg, 1 TASMAR ORAL 3 PA mg, 2 mg, 3 mg, 4 TABLET 100 MG mg, 5 mg tolcapone oral tablet 1 PA ropinirole oral tablet 1 100 mg extended release 24 trihexyphenidyl oral 1 hr 12 mg, 2 mg, 4 elixir 0.4 mg/ml mg, 6 mg, 8 mg trihexyphenidyl oral 1 RYTARY ORAL 3 tablet 2 mg, 5 mg CAPSULE, EXTENDED MIGRAINE & CLUSTER RELEASE 23.75-95 HEADACHE THERAPY MG, 36.25-145 MG, almotriptan malate 1 QL 48.75-195 MG, oral tablet 12.5 mg, 61.25-245 MG 6.25 mg selegiline hcl oral 1 AMERGE ORAL 3 ST; QL capsule 5 mg TABLET 1 MG, 2.5 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 30 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CAFERGOT ORAL 3 MIGRANAL 3 ST; QL TABLET 1-100 MG NASAL D.H.E.45 3 SPRAY,NON- INJECTION AEROSOL 0.5 SOLUTION 1 MG/PUMP ACT. (4 MG/ML MG/ML) dihydroergotamine 1 naratriptan oral 1 QL injection solution 1 tablet 1 mg, 2.5 mg mg/ml NURTEC ODT 3 PA; QL dihydroergotamine 1 ST; QL ORAL nasal spray,non- TABLET,DISINTE aerosol 0.5 mg/pump GRATING 75 MG act. (4 mg/ml) ONZETRA XSAIL 3 ST; QL eletriptan oral tablet 1 QL NASAL AEROSOL 20 mg, 40 mg POWDR BREATH ACTIVATED 11 EMGALITY PEN 2 PA; QL MG SUBCUTANEOUS PEN INJECTOR RELPAX ORAL 3 ST; QL 120 MG/ML TABLET 20 MG, 40 MG EMGALITY 2 PA; QL SYRINGE REYVOW ORAL 3 PA; QL SUBCUTANEOUS TABLET 100 MG, SYRINGE 120 50 MG MG/ML, 300 MG/3 rizatriptan oral 1 QL ML (100 MG/ML X tablet 10 mg, 5 mg 3) rizatriptan oral 1 QL ERGOMAR 3 tablet,disintegrating SUBLINGUAL 10 mg, 5 mg TABLET 2 MG sumatriptan nasal 1 QL ergotamine-caffeine 1 spray,non-aerosol oral tablet 1-100 mg 20 mg/actuation, 5 FROVA ORAL 3 ST; QL mg/actuation TABLET 2.5 MG sumatriptan 1 QL frovatriptan oral 1 QL succinate oral tablet tablet 2.5 mg 100 mg, 25 mg, 50 mg migergot rectal 1 suppository 2-100 sumatriptan 1 QL mg succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 31 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sumatriptan 1 QL dalfampridine oral 4 PA; QL succinate tablet extended subcutaneous pen release 12 hr 10 mg injector 4 mg/0.5 ml, donepezil oral tablet 1 6 mg/0.5 ml 10 mg, 5 mg sumatriptan 1 QL donepezil oral tablet 1 ST succinate 23 mg subcutaneous solution 6 mg/0.5 ml donepezil oral 1 tablet,disintegrating sumatriptan 1 QL 10 mg, 5 mg succinate subcutaneous EVRYSDI ORAL 5 PA; QL syringe 6 mg/0.5 ml RECON SOLN 0.75 MG/ML TOSYMRA NASAL 3 ST; QL SPRAY,NON- EXELON PATCH 3 ST AEROSOL 10 TRANSDERMAL MG/ACTUATION PATCH 24 HOUR 13.3 MG/24 HOUR, UBRELVY ORAL 3 PA; QL 4.6 MG/24 HOUR, TABLET 100 MG, 9.5 MG/24 HOUR 50 MG galantamine oral 1 ZEMBRACE 3 ST; QL capsule,ext rel. SYMTOUCH pellets 24 hr 16 mg, SUBCUTANEOUS 24 mg, 8 mg PEN INJECTOR 3 MG/0.5 ML galantamine oral 1 solution 4 mg/ml zolmitriptan oral 1 QL tablet 2.5 mg, 5 mg galantamine oral 1 tablet 12 mg, 4 mg, 8 zolmitriptan oral 1 QL mg tablet,disintegrating 2.5 mg, 5 mg HORIZANT ORAL 3 ST TABLET ZOMIG NASAL 2 ST; QL EXTENDED SPRAY,NON- RELEASE 300 MG, AEROSOL 2.5 MG, 600 MG 5 MG INGREZZA 5 PA; QL MISCELLANEOUS INITIATION PACK NEUROLOGICAL THERAPY ORAL ARICEPT ORAL 3 ST CAPSULE,DOSE TABLET 10 MG, 23 PACK 40 MG (7)- MG, 5 MG 80 MG (21)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 32 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits INGREZZA ORAL 5 PA; QL rivastigmine tartrate 1 CAPSULE 40 MG, oral capsule 1.5 mg, 60 MG, 80 MG 3 mg, 4.5 mg, 6 mg memantine oral 1 rivastigmine 1 capsule,sprinkle,er transdermal patch 24hr 14 mg, 21 mg, 24 hour 13.3 mg/24 28 mg, 7 mg hour, 4.6 mg/24 memantine oral 1 hour, 9.5 mg/24 solution 2 mg/ml hour memantine oral 1 RUZURGI ORAL 4 PA tablet 10 mg, 5 mg TABLET 10 MG MEMANTINE 3 TEGSEDI 4 ORAL SUBCUTANEOUS TABLETS,DOSE SYRINGE 284 PACK 5-10 MG MG/1.5 ML NAMENDA ORAL 3 ST tetrabenazine oral 4 PA; QL TABLET 10 MG, 5 tablet 12.5 mg, 25 MG mg NAMENDA 3 MUSCLE RELAXANTS & TITRATION PAK ANTISPASMODIC THERAPY ORAL baclofen oral tablet 1 TABLETS,DOSE 10 mg, 20 mg, 5 mg PACK 5-10 MG carisoprodol-aspirin 1 NAMENDA XR 3 oral tablet 200-325 ORAL mg CAP,SPRINKLE,ER 24HR DOSE PACK carisoprodol- 1 7-14-21-28 MG aspirin-codeine oral tablet 200-325-16 NUEDEXTA ORAL 2 PA mg CAPSULE 20-10 MG chlorzoxazone oral 1 tablet 250 mg, 375 NULIBRY 5 PA mg, 500 mg, 750 mg INTRAVENOUS RECON SOLN 9.5 cyclobenzaprine oral 1 MG capsule,extended release 24hr 15 mg, RAZADYNE ER 3 ST 30 mg ORAL CAPSULE,EXT cyclobenzaprine oral 1 REL. PELLETS 24 tablet 10 mg, 5 mg, HR 16 MG, 24 MG, 7.5 mg 8 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 33 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DANTRIUM ORAL 3 pyridostigmine 1 CAPSULE 25 MG, bromide oral tablet 50 MG extended release 180 dantrolene oral 1 mg capsule 100 mg, 25 SKELAXIN ORAL 3 mg, 50 mg TABLET 800 MG FEXMID ORAL 3 ST tizanidine oral 1 TABLET 7.5 MG capsule 2 mg, 4 mg, LORZONE ORAL 3 ST 6 mg TABLET 375 MG, tizanidine oral tablet 1 750 MG 2 mg, 4 mg metaxalone oral 1 ZANAFLEX ORAL 3 tablet 400 mg, 800 CAPSULE 2 MG, 4 mg MG, 6 MG methocarbamol oral 1 ZANAFLEX ORAL 3 tablet 500 mg, 750 TABLET 4 MG mg NARCOTIC ANALGESICS NORGESIC FORTE 3 acetaminophen-caff- 1 ORAL TABLET 50- dihydrocod oral 770-60 MG capsule 320.5-30-16 orphenadrine citrate 1 mg oral tablet extended acetaminophen-caff- 1 release 100 mg dihydrocod oral orphenadrine-asa- 1 tablet 325-30-16 mg caffeine oral tablet acetaminophen- 1 50-770-60 mg codeine oral solution orphengesic forte 1 120-12 mg/5 ml, 300 oral tablet 50-770- mg-30 mg /12.5 ml 60 mg acetaminophen- 1 pyridostigmine 1 codeine oral tablet bromide oral syrup 300-15 mg, 300-30 60 mg/5 ml mg, 300-60 mg PYRIDOSTIGMINE 3 ACTIQ BUCCAL 3 PA; QL BROMIDE ORAL LOZENGE ON A TABLET 30 MG HANDLE 1,200 pyridostigmine 1 MCG, 1,600 MCG, bromide oral tablet 200 MCG, 400 60 mg MCG, 600 MCG, 800 MCG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 34 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ALLZITAL ORAL 3 ST butalbital- 1 TABLET 25-325 acetaminophen-caff MG oral capsule 50-300- ascomp with codeine 1 40 mg, 50-325-40 oral capsule 30-50- mg 325-40 mg butalbital- 1 BELBUCA 2 PA; QL acetaminophen-caff BUCCAL FILM 150 oral tablet 50-325- MCG, 300 MCG, 40 mg 450 MCG, 600 butalbital-aspirin- 1 MCG, 75 MCG, 750 caffeine oral capsule MCG, 900 MCG 50-325-40 mg buprenorphine hcl 1 butalbital-aspirin- 1 sublingual tablet 2 caffeine oral tablet mg, 8 mg 50-325-40 mg buprenorphine 1 PA codeine sulfate oral 1 transdermal patch tablet 15 mg, 30 mg, weekly 10 mcg/hour, 60 mg 15 mcg/hour, 20 codeine-butalbital- 1 mcg/hour, 5 asa-caff oral capsule mcg/hour, 7.5 30-50-325-40 mg mcg/hour DILAUDID ORAL 3 butalbital compound 1 LIQUID 1 MG/ML w/codeine oral capsule 30-50-325- DILAUDID ORAL 3 40 mg TABLET 2 MG, 4 MG, 8 MG butalbital- 1 acetaminop-caf-cod diskets oral 1 PA oral capsule 50-300- tablet,soluble 40 mg 40-30 mg, 50-325- DSUVIA 3 40-30 mg SUBLINGUAL butalbital- 1 TABLET IN acetaminophen oral APPLICATOR 30 capsule 50-300 mg MCG butalbital- 1 dvorah oral tablet 1 acetaminophen oral 325-30-16 mg tablet 25-325 mg, endocet oral tablet 1 50-300 mg, 50-325 10-325 mg, 2.5-325 mg mg, 5-325 mg, 7.5- 325 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 35 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ESGIC ORAL 3 ST hydrocodone- 1 CAPSULE 50-325- acetaminophen oral 40 MG solution 10-325 ESGIC ORAL 3 ST mg/15 ml(15 ml), TABLET 50-325-40 7.5-325 mg/15 ml MG hydrocodone- 1 fentanyl citrate 1 PA; QL acetaminophen oral buccal lozenge on a tablet 10-300 mg, handle 1,200 mcg, 10-325 mg, 5-300 1,600 mcg, 200 mcg, mg, 5-325 mg, 7.5- 400 mcg, 600 mcg, 300 mg, 7.5-325 mg 800 mcg hydrocodone- 1 fentanyl transdermal 1 PA; QL ibuprofen oral tablet patch 72 hour 100 10-200 mg, 5-200 mcg/hr, 12 mcg/hr, mg, 7.5-200 mg 25 mcg/hr, 37.5 hydromorphone oral 1 mcg/hour, 50 liquid 1 mg/ml mcg/hr, 62.5 hydromorphone oral 1 mcg/hour, 75 tablet 2 mg, 4 mg, 8 mcg/hr, 87.5 mg mcg/hour hydromorphone oral 1 PA; QL FIORICET ORAL 3 ST tablet extended CAPSULE 50-300- release 24 hr 12 mg, 40 MG 16 mg, 32 mg, 8 mg FIORICET WITH 3 hydromorphone 1 CODEINE ORAL rectal suppository 3 CAPSULE 50-300- mg 40-30 MG HYSINGLA ER 2 PA; QL hydrocodone 1 PA; QL ORAL bitartrate oral TABLET,ORAL capsule, oral only, ONLY,EXT.REL.24 er 12hr 10 mg, 15 HR 100 MG, 120 mg, 20 mg, 30 mg, MG, 20 MG, 30 40 mg, 50 mg MG, 40 MG, 60 hydrocodone 1 PA; QL MG, 80 MG bitartrate oral levorphanol tartrate 1 tablet,oral oral tablet 2 mg, 3 only,ext.rel.24 hr mg 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, LORTAB ELIXIR 3 60 mg, 80 mg ORAL SOLUTION 10-300 MG/15 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 36 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits methadone oral 1 PA morphine rectal 1 concentrate 10 suppository 10 mg, mg/ml 20 mg, 30 mg, 5 mg methadone oral 1 PA MS CONTIN ORAL 3 PA; QL solution 10 mg/5 ml, TABLET 5 mg/5 ml EXTENDED methadone oral 1 PA RELEASE 100 MG, tablet 10 mg, 5 mg 15 MG, 200 MG, 30 MG, 60 MG methadone oral 1 PA tablet,soluble 40 mg NALOCET ORAL 3 TABLET 2.5-300 methadose oral 1 PA MG concentrate 10 mg/ml OXAYDO ORAL 3 TABLET, ORAL methadose oral 1 PA ONLY 5 MG, 7.5 tablet,soluble 40 mg MG morphine 1 oxycodone oral 1 concentrate oral capsule 5 mg solution 100 mg/5 ml (20 mg/ml) oxycodone oral 1 concentrate 20 morphine oral 1 PA; QL mg/ml capsule, er multiphase 24 hr oxycodone oral 1 120 mg, 30 mg, 45 solution 5 mg/5 ml mg, 60 mg, 75 mg, oxycodone oral 1 90 mg tablet 10 mg, 15 mg, morphine oral 1 PA; QL 20 mg, 30 mg, 5 mg capsule,extend.relea oxycodone- 1 se pellets 10 mg, 100 acetaminophen oral mg, 20 mg, 30 mg, tablet 10-325 mg, 40 mg, 50 mg, 60 2.5-300 mg, 2.5-325 mg, 80 mg mg, 5-325 mg, 7.5- morphine oral 1 325 mg solution 10 mg/5 ml, OXYCONTIN 2 PA; QL 20 mg/5 ml (4 ORAL mg/ml) TABLET,ORAL morphine oral tablet 1 ONLY,EXT.REL.12 15 mg, 30 mg HR 10 MG, 15 MG, 20 MG, 30 MG, 40 morphine oral tablet 1 PA; QL MG, 60 MG, 80 MG extended release 100 mg, 15 mg, 200 mg, oxymorphone oral 1 30 mg, 60 mg tablet 10 mg, 5 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 37 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxymorphone oral 1 PA; QL ANAPROX DS 3 tablet extended ORAL TABLET release 12 hr 10 mg, 550 MG 15 mg, 20 mg, 30 ARTHROTEC 50 3 ST mg, 40 mg, 5 mg, 7.5 ORAL mg TABLET,IR,DELA prolate oral tablet 1 YED 10-300 mg, 5-300 REL,BIPHASIC 50- mg, 7.5-300 mg 200 MG-MCG ROXICODONE 3 ARTHROTEC 75 3 ST ORAL TABLET 15 ORAL MG, 30 MG, 5 MG TABLET,IR,DELA SUBLOCADE 4 YED SUBCUTANEOUS REL,BIPHASIC 75- SOLUTION, 200 MG-MCG EXTENDED REL aspirin low dose 0 covered at $0 SYRINGE 100 oral tablet,delayed for ages 69 and MG/0.5 ML, 300 release (dr/ec) 81 younger; OTC MG/1.5 ML mg tencon oral tablet 1 aspirin oral tablet 0 covered at $0 50-325 mg 325 mg for ages 69 and VANATOL LQ 3 ST younger; OTC ORAL SOLUTION aspirin oral 0 covered at $0 50-325-40 MG/15 tablet,chewable 81 for ages 69 and ML mg younger; OTC VANATOL S 3 ST aspirin oral 0 covered at $0 ORAL SOLUTION tablet,delayed for ages 69 and 50-325-40 MG/15 release (dr/ec) 325 younger; OTC ML mg, 81 mg vtol lq oral solution 1 aspir-trin oral 0 covered at $0 50-325-40 mg/15 ml tablet,delayed for ages 69 and zebutal oral capsule 1 release (dr/ec) 325 younger; OTC 50-325-40 mg mg bayer aspirin oral 0 covered at $0 NON-NARCOTIC ANALGESICS tablet 325 mg for ages 69 and adult aspirin 0 covered at $0 younger; OTC regimen oral for ages 69 and buprenorphine- 1 tablet,delayed younger; OTC naloxone sublingual release (dr/ec) 81 film 12-3 mg mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 38 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits buprenorphine- 1 QL DAYPRO ORAL 3 ST naloxone sublingual TABLET 600 MG film 2-0.5 mg, 4-1 diclofenac potassium 1 mg, 8-2 mg oral tablet 50 mg buprenorphine- 1 QL diclofenac sodium 1 naloxone sublingual oral tablet extended tablet 2-0.5 mg release 24 hr 100 mg buprenorphine- 1 diclofenac sodium 1 naloxone sublingual oral tablet,delayed tablet 8-2 mg release (dr/ec) 25 butorphanol 1 mg, 50 mg, 75 mg injection solution 1 diclofenac- 1 mg/ml, 2 mg/ml misoprostol oral butorphanol nasal 1 QL tablet,ir,delayed spray,non-aerosol rel,biphasic 50-200 10 mg/ml mg-mcg, 75-200 mg- CAMBIA ORAL 3 ST; QL mcg POWDER IN diflunisal oral tablet 1 PACKET 50 MG 500 mg cataflam oral tablet 1 DISALCID ORAL 3 50 mg TABLET 500 MG, celecoxib oral 1 ST 750 MG capsule 100 mg, 200 DUEXIS ORAL 3 ST mg, 400 mg, 50 mg TABLET 800-26.6 children's aspirin 0 covered at $0 MG oral tablet,chewable for ages 69 and EC-NAPROSYN 3 ST 81 mg younger; OTC ORAL choline,magnesium 1 TABLET,DELAYE salicylate oral liquid D RELEASE 500 mg/5 ml (DR/EC) 375 MG, 500 MG CONZIP ORAL 3 ST; QL CAPSULE,ER ecotrin low strength 0 covered at $0 BIPHASE 24 HR oral tablet,delayed for ages 69 and 17-83 300 MG release (dr/ec) 81 younger; OTC mg CONZIP ORAL 3 ST; QL CAPSULE,ER ecotrin oral 0 covered at $0 BIPHASE 24 HR tablet,delayed for ages 69 and 25-75 100 MG, 200 release (dr/ec) 325 younger; OTC MG mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 39 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits etodolac oral 1 indomethacin oral 1 capsule 200 mg, 300 capsule 25 mg, 50 mg mg etodolac oral tablet 1 indomethacin oral 1 400 mg, 500 mg capsule, extended etodolac oral tablet 1 release 75 mg extended release 24 ketoprofen oral 1 ST hr 400 mg, 500 mg, capsule 25 mg 600 mg ketoprofen oral 1 EUFLEXXA 4 PA capsule 50 mg, 75 INTRA- mg ARTICULAR ketoprofen oral 1 ST SYRINGE 10 capsule,ext rel. MG/ML(MW 2.4 - pellets 24 hr 200 mg 3.6 MILLION) LICART 2 ST; QL FELDENE ORAL 3 ST TRANSDERMAL CAPSULE 10 MG, PATCH 24 HOUR 20 MG 1.3 % fenoprofen oral 1 ST LODINE ORAL 3 ST tablet 600 mg TABLET 400 MG FLECTOR 2 ST; QL meclofenamate oral 1 TRANSDERMAL capsule 100 mg, 50 PATCH 12 HOUR mg 1.3 % mefenamic acid oral 1 flurbiprofen oral 1 capsule 250 mg tablet 100 mg meloxicam oral 1 ibu oral tablet 400 1 tablet 15 mg mg, 600 mg, 800 mg meloxicam oral 1 QL ibuprofen oral 1 tablet 7.5 mg suspension 100 mg/5 ml meloxicam 1 ST submicronized oral ibuprofen oral tablet 1 capsule 10 mg 400 mg, 600 mg, 800 mg meloxicam 1 ST; QL submicronized oral INDOCIN ORAL 3 ST capsule 5 mg SUSPENSION 25 MG/5 ML MOBIC ORAL 3 ST TABLET 15 MG INDOCIN RECTAL 3 SUPPOSITORY 50 MOBIC ORAL 3 ST; QL MG TABLET 7.5 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 40 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nabumetone oral 1 NAPROXEN 3 ST tablet 500 mg, 750 SODIUM ORAL mg TABLET, ER NALFON ORAL 3 ST MULTIPHASE 24 TABLET 600 MG HR 750 MG naloxone injection 1 naproxen- 1 ST solution 0.4 mg/ml esomeprazole oral tablet,ir,delayed naloxone injection 1 rel,biphasic 375-20 syringe 0.4 mg/ml, 1 mg, 500-20 mg mg/ml NARCAN NASAL 2 QL naltrexone oral 1 SPRAY,NON- tablet 50 mg AEROSOL 4 NAPRELAN CR 3 ST MG/ACTUATION ORAL TABLET, NUCYNTA ER 3 PA; QL ER MULTIPHASE ORAL TABLET 24 HR 375 MG, 500 EXTENDED MG, 750 MG RELEASE 12 HR NAPROSYN ORAL 3 ST 100 MG, 150 MG, SUSPENSION 125 200 MG, 250 MG, MG/5 ML 50 MG NAPROSYN ORAL 3 ST ORTHOVISC 4 PA TABLET 500 MG INTRA- ARTICULAR naproxen oral 1 ST SYRINGE 30 MG/2 suspension 125 mg/5 ML ml oxaprozin oral tablet 1 naproxen oral tablet 1 600 mg 250 mg, 375 mg, 500 mg pentazocine- 1 naloxone oral tablet naproxen oral 1 50-0.5 mg tablet,delayed release (dr/ec) 375 piroxicam oral 1 mg, 500 mg capsule 10 mg, 20 mg naproxen sodium 1 oral tablet 275 mg, RELAFEN ORAL 3 ST 550 mg TABLET 500 MG, 750 MG naproxen sodium 1 ST oral tablet, er salsalate oral tablet 1 multiphase 24 hr 500 mg, 750 mg 500 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 41 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits st joseph aspirin 0 covered at $0 tramadol- 1 QL oral tablet,chewable for ages 69 and acetaminophen oral 81 mg younger; OTC tablet 37.5-325 mg st. joseph aspirin 0 covered at $0 ULTRACET ORAL 3 QL oral tablet,delayed for ages 69 and TABLET 37.5-325 release (dr/ec) 81 younger; OTC MG mg ULTRAM ORAL 3 QL sulindac oral tablet 1 TABLET 50 MG 150 mg, 200 mg VIMOVO ORAL 3 ST tolmetin oral capsule 1 ST TABLET,IR,DELA 400 mg YED tolmetin oral tablet 1 REL,BIPHASIC 200 mg 375-20 MG, 500-20 MG tolmetin oral tablet 1 ST 600 mg VIVITROL 4 INTRAMUSCULA TRAMADOL 3 ST; QL R ORAL SUSPENSION,EXT CAPSULE,ER ENDED REL BIPHASE 24 HR RECON 380 MG 17-83 300 MG ZUBSOLV 2 QL TRAMADOL 3 ST; QL SUBLINGUAL ORAL TABLET 0.7-0.18 CAPSULE,ER MG, 1.4-0.36 MG, BIPHASE 24 HR 2.9-0.71 MG, 5.7- 25-75 100 MG, 200 1.4 MG, 8.6-2.1 MG MG ZUBSOLV 2 TRAMADOL 3 SUBLINGUAL ORAL TABLET TABLET 11.4-2.9 100 MG MG tramadol oral tablet 1 QL PSYCHOTHERAPEUTIC DRUGS 50 mg ABILIFY MYCITE 3 QL tramadol oral tablet 1 PA; QL MAINTENANCE extended release 24 KIT ORAL hr 100 mg, 200 mg, TABLET WITH 300 mg SENSOR AND tramadol oral tablet, 1 PA; QL STRIP 10 MG, 15 er multiphase 24 hr MG, 2 MG, 20 MG, 100 mg, 200 mg, 300 30 MG, 5 MG mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 42 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ABILIFY MYCITE 3 QL ADZENYS XR- 3 ST ORAL TABLET ODT ORAL WITH SENSOR TABLET,DISINTE AND PATCH 10 G ER BIPHASE MG, 15 MG, 2 MG, 24H 12.5 MG, 15.7 20 MG, 30 MG, 5 MG, 18.8 MG, 3.1 MG MG, 6.3 MG, 9.4 ABILIFY MYCITE 3 QL MG STARTER KIT alprazolam intensol 1 ORAL TABLET oral concentrate 1 WITH SENSOR, mg/ml STRIP, POD 10 alprazolam oral 1 MG, 15 MG, 2 MG, tablet 0.25 mg, 0.5 20 MG, 30 MG, 5 mg, 1 mg, 2 mg MG alprazolam oral 1 ADASUVE 3 tablet extended INHALATION release 24 hr 0.5 mg, AEROSOL POWDR 1 mg, 2 mg, 3 mg BREATH ACTIVATED 10 alprazolam oral 1 MG tablet,disintegrating 0.25 mg, 0.5 mg, 1 ADDERALL XR 3 ST mg, 2 mg ORAL CAPSULE,EXTEN amitriptyline oral 1 DED RELEASE tablet 10 mg, 100 24HR 10 MG, 15 mg, 150 mg, 25 mg, MG, 20 MG, 25 50 mg, 75 mg MG, 30 MG, 5 MG amitriptyline- 1 ADHANSIA XR 3 ST chlordiazepoxide ORAL CAPSULE, oral tablet 12.5-5 ER BIPHASIC 20- mg, 25-10 mg 80 25 MG, 35 MG, amoxapine oral 1 45 MG, 55 MG, 70 tablet 100 mg, 150 MG, 85 MG mg, 25 mg, 50 mg ADZENYS ER 3 ST amphetamine sulfate 1 ORAL SUSPEN, IR oral tablet 10 mg, 5 - ER, BIPHASIC mg 24HR 1.25 MG/ML ANAFRANIL 3 ORAL CAPSULE 25 MG, 50 MG, 75 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 43 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits APLENZIN ORAL 3 ST; QL BUPROPION HCL 3 ST; QL TABLET ORAL TABLET EXTENDED EXTENDED RELEASE 24 HR RELEASE 24 HR 174 MG, 348 MG, 450 MG 522 MG bupropion hcl oral 1 QL APTENSIO XR 3 ST tablet sustained- ORAL CAP,ER release 12 hr 100 SPRINKLE,BIPHA mg, 150 mg, 200 mg SIC 40-60 10 MG, buspirone oral tablet 1 15 MG, 20 MG, 30 10 mg, 15 mg, 30 MG, 40 MG, 50 mg, 5 mg, 7.5 mg MG, 60 MG chlorpromazine oral 1 aripiprazole oral 1 tablet 10 mg, 100 solution 1 mg/ml mg, 200 mg, 25 mg, aripiprazole oral 1 QL 50 mg tablet 10 mg, 15 mg, citalopram oral 1 2 mg, 20 mg, 30 mg, solution 10 mg/5 ml 5 mg citalopram oral 1 QL aripiprazole oral 1 QL tablet 10 mg, 20 mg, tablet,disintegrating 40 mg 10 mg, 15 mg clomipramine oral 1 armodafinil oral 1 ST; QL capsule 25 mg, 50 tablet 150 mg, 200 mg, 75 mg mg, 250 mg, 50 mg clonidine hcl oral 1 asenapine maleate 1 QL tablet extended sublingual tablet 10 release 12 hr 0.1 mg mg, 2.5 mg, 5 mg clorazepate 1 ATIVAN ORAL 3 dipotassium oral TABLET 0.5 MG, 1 tablet 15 mg, 3.75 MG, 2 MG mg, 7.5 mg atomoxetine oral 1 clozapine oral tablet 1 capsule 10 mg, 100 100 mg, 200 mg, 25 mg, 18 mg, 25 mg, mg, 50 mg 40 mg, 60 mg, 80 mg clozapine oral 1 bupropion hcl oral 1 tablet,disintegrating tablet 100 mg, 75 mg 100 mg, 12.5 mg, bupropion hcl oral 1 QL 150 mg, 200 mg, 25 tablet extended mg release 24 hr 150 mg, 300 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 44 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CLOZARIL ORAL 3 dexmethylphenidate 1 TABLET 100 MG, oral capsule,er 200 MG, 25 MG, 50 biphasic 50-50 10 MG mg, 15 mg, 20 mg, COTEMPLA XR- 3 ST 25 mg, 30 mg, 35 ODT ORAL mg, 40 mg, 5 mg TABLET,DISINTE dexmethylphenidate 1 G ER BIPHASE oral tablet 10 mg, 24H 17.3 MG, 25.9 2.5 mg, 5 mg MG, 8.6 MG dextroamphetamine 1 DAYTRANA 2 ST oral capsule, TRANSDERMAL extended release 10 PATCH 24 HOUR mg, 15 mg, 5 mg 10 MG/9 HR, 15 dextroamphetamine 1 MG/9 HR, 20 MG/9 oral solution 5 mg/5 HR, 30 MG/9 HR ml DAYVIGO ORAL 3 ST; QL dextroamphetamine 1 TABLET 10 MG, 5 oral tablet 10 mg, 5 MG mg desipramine oral 1 dextroamphetamine- 1 tablet 10 mg, 100 amphetamine oral mg, 150 mg, 25 mg, capsule,extended 50 mg, 75 mg release 24hr 10 mg, DESOXYN ORAL 3 15 mg, 20 mg, 25 TABLET 5 MG mg, 30 mg, 5 mg DESVENLAFAXIN 3 ST; QL dextroamphetamine- 1 E ORAL TABLET amphetamine oral EXTENDED tablet 10 mg, 12.5 RELEASE 24 HR mg, 15 mg, 20 mg, 100 MG, 50 MG 30 mg, 5 mg, 7.5 mg desvenlafaxine 1 ST; QL diazepam intensol 1 succinate oral tablet oral concentrate 5 extended release 24 mg/ml hr 100 mg, 25 mg, diazepam oral 1 50 mg solution 5 mg/5 ml DEXEDRINE 3 ST (1 mg/ml) SPANSULE ORAL diazepam oral tablet 1 CAPSULE, 10 mg, 2 mg, 5 mg EXTENDED RELEASE 10 MG, 15 MG, 5 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 45 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits doxepin oral capsule 1 EVEKEO ODT 3 10 mg, 100 mg, 150 ORAL mg, 25 mg, 50 mg, TABLET,DISINTE 75 mg GRATING 10 MG, doxepin oral 1 15 MG, 20 MG, 5 concentrate 10 MG mg/ml EVEKEO ORAL 3 doxepin oral tablet 3 1 ST; QL TABLET 10 MG, 5 mg, 6 mg MG duloxetine oral 1 QL FANAPT ORAL 3 QL capsule,delayed TABLET 1 MG, 10 release(dr/ec) 20 MG, 12 MG, 2 MG, mg, 30 mg, 60 mg 4 MG, 6 MG, 8 MG duloxetine oral 1 ST; QL FANAPT ORAL 3 QL capsule,delayed TABLETS,DOSE release(dr/ec) 40 mg PACK 1MG(2)- 2MG(2)- 4MG(2)- DYANAVEL XR 2 ST 6MG(2) ORAL SUSPEN, IR - ER, BIPHASIC FETZIMA ORAL 2 ST; QL 24HR 2.5 MG/ML CAPSULE,EXT REL 24HR DOSE EDLUAR 3 ST; QL PACK 20 MG (2)- SUBLINGUAL 40 MG (26) TABLET 10 MG, 5 MG FETZIMA ORAL 2 ST; QL CAPSULE,EXTEN EMSAM 3 DED RELEASE 24 TRANSDERMAL HR 120 MG, 20 PATCH 24 HOUR MG, 40 MG, 80 MG 12 MG/24 HR, 6 MG/24 HR, 9 fluoxetine oral 1 QL MG/24 HR capsule 10 mg, 40 mg ergoloid oral tablet 1 1 mg fluoxetine oral 1 capsule 20 mg escitalopram oxalate 1 oral solution 5 mg/5 fluoxetine oral 1 QL ml capsule,delayed release(dr/ec) 90 mg escitalopram oxalate 1 QL oral tablet 10 mg, 20 fluoxetine oral 1 mg, 5 mg solution 20 mg/5 ml (4 mg/ml) eszopiclone oral 1 QL tablet 1 mg, 2 mg, 3 fluoxetine oral tablet 1 ST; QL mg 10 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 46 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluoxetine oral tablet 1 ST HETLIOZ LQ 5 PA; QL 20 mg, 60 mg ORAL fluphenazine hcl oral 1 SUSPENSION 4 concentrate 5 mg/ml MG/ML fluphenazine hcl oral 1 HETLIOZ ORAL 5 PA; QL elixir 2.5 mg/5 ml CAPSULE 20 MG fluphenazine hcl oral 1 imipramine hcl oral 1 tablet 1 mg, 10 mg, tablet 10 mg, 25 mg, 2.5 mg, 5 mg 50 mg flurazepam oral 1 QL imipramine pamoate 1 capsule 15 mg, 30 oral capsule 100 mg, mg 125 mg, 150 mg, 75 mg fluvoxamine oral 1 ST; QL capsule,extended INVEGA ORAL 3 QL release 24hr 100 mg, TABLET 150 mg EXTENDED RELEASE 24HR fluvoxamine oral 1 QL 1.5 MG, 3 MG, 6 tablet 100 mg, 25 MG, 9 MG mg, 50 mg JORNAY PM 3 ST FORFIVO XL 3 ST; QL ORAL ORAL TABLET CAPSULE,DEL EXTENDED REL,EXT REL RELEASE 24 HR SPRINK 100 MG, 450 MG 20 MG, 40 MG, 60 GEODON ORAL 3 QL MG, 80 MG CAPSULE 20 MG, KAPVAY ORAL 3 ST 40 MG, 60 MG, 80 TABLET MG EXTENDED guanfacine oral 1 RELEASE 12 HR tablet extended 0.1 MG release 24 hr 1 mg, 2 KETAMINE 3 mg, 3 mg, 4 mg SUBLINGUAL haloperidol lactate 1 TROCHE 100 MG oral concentrate 2 LATUDA ORAL 2 QL mg/ml TABLET 120 MG, haloperidol oral 1 20 MG, 40 MG, 60 tablet 0.5 mg, 1 mg, MG, 80 MG 10 mg, 2 mg, 20 mg, lithium carbonate 1 5 mg oral capsule 150 mg, 300 mg, 600 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 47 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lithium carbonate 1 methylphenidate hcl 1 oral tablet 300 mg oral capsule, er lithium carbonate 1 biphasic 30-70 10 oral tablet extended mg, 20 mg, 30 mg, release 300 mg, 450 40 mg, 50 mg, 60 mg mg methylphenidate hcl 1 LITHOBID ORAL 3 oral capsule,er TABLET biphasic 50-50 10 EXTENDED mg, 20 mg, 30 mg, RELEASE 300 MG 40 mg, 60 mg lorazepam intensol 1 methylphenidate hcl 1 oral concentrate 2 oral solution 10 mg/ml mg/5 ml, 5 mg/5 ml lorazepam oral 1 methylphenidate hcl 1 concentrate 2 mg/ml oral tablet 10 mg, 20 mg, 5 mg lorazepam oral 1 tablet 0.5 mg, 1 mg, methylphenidate hcl 1 2 mg oral tablet extended release 10 mg, 20 loxapine succinate 1 mg oral capsule 10 mg, 25 mg, 5 mg, 50 mg methylphenidate hcl 1 oral tablet extended maprotiline oral 1 release 24hr 18 mg, tablet 25 mg, 50 mg, 27 mg, 36 mg, 54 mg 75 mg METHYLPHENID 3 ST MARPLAN ORAL 3 ATE HCL ORAL TABLET 10 MG TABLET methamphetamine 1 EXTENDED oral tablet 5 mg RELEASE 24HR 72 MG METHYLIN ORAL 3 SOLUTION 10 methylphenidate hcl 1 MG/5 ML, 5 MG/5 oral tablet,chewable ML 10 mg, 2.5 mg, 5 mg methylphenidate hcl 1 ST midazolam oral 1 oral cap,er syrup 2 mg/ml sprinkle,biphasic 40- mirtazapine oral 1 60 10 mg, 15 mg, 20 tablet 15 mg, 30 mg, mg, 30 mg, 40 mg, 45 mg, 7.5 mg 50 mg, 60 mg mirtazapine oral 1 tablet,disintegrating 15 mg, 30 mg, 45 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 48 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MKO 3 olanzapine- 1 (MIDAZOLAM- fluoxetine oral KETAMINE- capsule 12-25 mg, ONDAN) 12-50 mg, 3-25 mg, SUBLINGUAL 6-25 mg, 6-50 mg TROCHE 3-25-2 oxazepam oral 1 MG capsule 10 mg, 15 modafinil oral tablet 1 ST; QL mg, 30 mg 100 mg, 200 mg paliperidone oral 1 QL molindone oral 1 tablet extended tablet 10 mg, 25 mg, release 24hr 1.5 mg, 5 mg 3 mg, 6 mg, 9 mg MYDAYIS ORAL 2 ST PAMELOR ORAL 3 CAPSULE, ER CAPSULE 10 MG, TRIPHASIC 24 HR 25 MG, 50 MG, 75 12.5 MG, 25 MG, MG 37.5 MG, 50 MG PARNATE ORAL 3 NARDIL ORAL 3 TABLET 10 MG TABLET 15 MG paroxetine hcl oral 1 QL nefazodone oral 1 tablet 10 mg, 20 mg, tablet 100 mg, 150 30 mg, 40 mg mg, 200 mg, 250 mg, paroxetine hcl oral 1 ST; QL 50 mg tablet extended NORPRAMIN 3 release 24 hr 12.5 ORAL TABLET 10 mg, 25 mg, 37.5 mg MG, 25 MG paroxetine 1 ST; QL nortriptyline oral 1 mesylate(menop.sym capsule 10 mg, 25 ) oral capsule 7.5 mg, 50 mg, 75 mg mg nortriptyline oral 1 PAXIL CR ORAL 3 ST; QL solution 10 mg/5 ml TABLET olanzapine oral 1 QL EXTENDED tablet 10 mg, 15 mg, RELEASE 24 HR 2.5 mg, 20 mg, 5 mg, 12.5 MG, 25 MG, 7.5 mg 37.5 MG olanzapine oral 1 QL PAXIL ORAL 3 ST tablet,disintegrating SUSPENSION 10 10 mg, 15 mg, 20 MG/5 ML mg, 5 mg PAXIL ORAL 3 ST; QL TABLET 10 MG, 20 MG, 30 MG, 40 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 49 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits perphenazine oral 1 RELEXXII ORAL 3 ST tablet 16 mg, 2 mg, 4 TABLET mg, 8 mg EXTENDED perphenazine- 1 RELEASE 24HR 72 amitriptyline oral MG tablet 2-10 mg, 2-25 REMERON ORAL 3 mg, 4-10 mg, 4-25 TABLET 15 MG, 30 mg, 4-50 mg MG phenelzine oral 1 REMERON 3 tablet 15 mg SOLTAB ORAL pimozide oral tablet 1 TABLET,DISINTE 1 mg, 2 mg GRATING 15 MG, 30 MG, 45 MG procentra oral 1 solution 5 mg/5 ml RESTORIL ORAL 3 QL CAPSULE 15 MG, protriptyline oral 1 22.5 MG, 30 MG, tablet 10 mg, 5 mg 7.5 MG quetiapine oral 1 QL RISPERDAL ORAL 3 tablet 100 mg, 200 SOLUTION 1 mg, 25 mg, 300 mg, MG/ML 400 mg, 50 mg RISPERDAL ORAL 3 QL quetiapine oral 1 QL TABLET 0.5 MG, 1 tablet extended MG, 2 MG, 3 MG, 4 release 24 hr 150 MG mg, 200 mg, 300 mg, 400 mg, 50 mg risperidone oral 1 solution 1 mg/ml QUILLICHEW ER 2 ST ORAL risperidone oral 1 QL TABLET,CHEW,IR tablet 0.25 mg, 0.5 - mg, 1 mg, 2 mg, 3 ER.BIPHASIC24HR mg, 4 mg 20 MG, 30 MG, 40 risperidone oral 1 QL MG tablet,disintegrating QUILLIVANT XR 2 ST 0.25 mg, 0.5 mg, 1 ORAL mg, 2 mg, 3 mg, 4 SUSPENSION,EXT mg REL 24HR,RECON RITALIN LA 3 ST 5 MG/ML (25 MG/5 ORAL ML) CAPSULE,ER ramelteon oral tablet 1 QL BIPHASIC 50-50 10 8 mg MG, 20 MG, 30 MG, 40 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 50 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits RITALIN ORAL 3 trazodone oral tablet 1 TABLET 10 MG, 20 100 mg, 150 mg, 300 MG, 5 MG mg, 50 mg seconal sodium oral 1 QL trifluoperazine oral 1 capsule 100 mg tablet 1 mg, 10 mg, 2 SECUADO 3 QL mg, 5 mg TRANSDERMAL trimipramine oral 1 PATCH 24 HOUR capsule 100 mg, 25 3.8 MG/24 HOUR, mg, 50 mg 5.7 MG/24 HOUR, TRINTELLIX 3 ST; QL 7.6 MG/24 HOUR ORAL TABLET 10 sertraline oral 1 MG, 20 MG, 5 MG concentrate 20 venlafaxine oral 1 QL mg/ml capsule,extended sertraline oral tablet 1 QL release 24hr 150 mg, 100 mg, 25 mg, 50 37.5 mg, 75 mg mg venlafaxine oral 1 QL SILENOR ORAL 3 ST; QL tablet 100 mg, 25 TABLET 3 MG, 6 mg, 37.5 mg, 50 mg, MG 75 mg SUNOSI ORAL 2 ST; QL venlafaxine oral 1 ST; QL TABLET 150 MG, tablet extended 75 MG release 24hr 150 mg, SYMBYAX ORAL 3 225 mg, 37.5 mg, 75 CAPSULE 3-25 mg MG, 6-25 MG VERSACLOZ 3 temazepam oral 1 QL ORAL capsule 15 mg, 22.5 SUSPENSION 50 mg, 30 mg, 7.5 mg MG/ML thioridazine oral 1 VYLEESI 5 PA; QL tablet 10 mg, 100 SUBCUTANEOUS mg, 25 mg, 50 mg AUTO-INJECTOR 1.75 MG/0.3 ML thiothixene oral 1 capsule 1 mg, 10 mg, WAKIX ORAL 5 ST; QL 2 mg, 5 mg TABLET 17.8 MG, 4.45 MG TRANXENE T- 3 TAB ORAL XYREM ORAL 4 PA; QL TABLET 7.5 MG SOLUTION 500 MG/ML tranylcypromine 1 oral tablet 10 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 51 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits XYWAV ORAL 4 PA; QL ZYPREXA ZYDIS 3 QL SOLUTION 0.5 ORAL GRAM/ML TABLET,DISINTE zaleplon oral 1 QL GRATING 10 MG, capsule 10 mg, 5 mg 15 MG, 20 MG, 5 MG zenzedi oral tablet 1 10 mg, 5 mg CARDIOVASCULAR, ZENZEDI ORAL 3 HYPERTENSION & LIPIDS TABLET 15 MG, ANTIARRHYTHMIC AGENTS 2.5 MG, 20 MG, 30 MG, 7.5 MG amiodarone oral 1 tablet 100 mg, 200 ziprasidone hcl oral 1 QL mg, 400 mg capsule 20 mg, 40 mg, 60 mg, 80 mg BETAPACE AF 3 ST ORAL TABLET zolpidem oral tablet 1 QL 120 MG, 160 MG, 10 mg, 5 mg 80 MG zolpidem oral 1 QL BETAPACE ORAL 3 ST tablet,ext release TABLET 120 MG, multiphase 12.5 mg, 160 MG, 240 MG, 6.25 mg 80 MG zolpidem sublingual 1 QL disopyramide 1 tablet 1.75 mg, 3.5 phosphate oral mg capsule 100 mg, 150 ZOLPIMIST ORAL 3 ST; QL mg SPRAY,NON- dofetilide oral 1 AEROSOL 5 capsule 125 mcg, MG/SPRAY (0.1 250 mcg, 500 mcg ML) flecainide oral tablet 1 ZULRESSO 4 PA 100 mg, 150 mg, 50 INTRAVENOUS mg SOLUTION 5 MG/ML mexiletine oral 1 capsule 150 mg, 200 ZYPREXA ORAL 3 QL mg, 250 mg TABLET 10 MG, 15 MG, 2.5 MG, 20 NORPACE CR 3 MG, 5 MG, 7.5 MG ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 52 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NORPACE ORAL 3 ACCUPRIL ORAL 3 CAPSULE 100 MG, TABLET 10 MG, 20 150 MG MG, 40 MG, 5 MG pacerone oral tablet 1 ACCURETIC 3 100 mg, 200 mg, 400 ORAL TABLET 10- mg 12.5 MG, 20-12.5 propafenone oral 1 MG, 20-25 MG capsule,extended acebutolol oral 1 release 12 hr 225 capsule 200 mg, 400 mg, 325 mg, 425 mg mg propafenone oral 1 ADALAT CC 3 ST tablet 150 mg, 225 ORAL TABLET mg, 300 mg EXTENDED quinidine gluconate 1 RELEASE 30 MG, oral tablet extended 60 MG, 90 MG release 324 mg ALDACTAZIDE 3 quinidine sulfate 1 ORAL TABLET 25- oral tablet 200 mg, 25 MG, 50-50 MG 300 mg ALDACTONE 3 RYTHMOL SR 3 ORAL TABLET ORAL 100 MG, 25 MG, 50 CAPSULE,EXTEN MG DED RELEASE 12 aliskiren oral tablet 1 HR 225 MG, 325 150 mg, 300 mg MG, 425 MG ALTACE ORAL 3 sorine oral tablet 1 CAPSULE 1.25 120 mg, 160 mg, 240 MG, 10 MG, 2.5 mg, 80 mg MG, 5 MG sotalol af oral tablet 1 amiloride oral tablet 1 120 mg, 160 mg, 80 5 mg mg amiloride- 1 sotalol oral tablet 1 hydrochlorothiazide 120 mg, 160 mg, 240 oral tablet 5-50 mg mg, 80 mg amlodipine oral 1 SOTYLIZE ORAL 2 tablet 10 mg, 2.5 mg, SOLUTION 5 5 mg MG/ML ANTIHYPERTENSIVE THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 53 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits amlodipine- 1 BIDIL ORAL 3 benazepril oral TABLET 20-37.5 capsule 10-20 mg, MG 10-40 mg, 2.5-10 bisoprolol fumarate 1 mg, 5-10 mg, 5-20 oral tablet 10 mg, 5 mg, 5-40 mg mg amlodipine- 1 bisoprolol- 1 olmesartan oral hydrochlorothiazide tablet 10-20 mg, 10- oral tablet 10-6.25 40 mg, 5-20 mg, 5- mg, 2.5-6.25 mg, 5- 40 mg 6.25 mg amlodipine- 1 bumetanide oral 1 valsartan oral tablet tablet 0.5 mg, 1 mg, 10-160 mg, 10-320 2 mg mg, 5-160 mg, 5-320 mg CALAN SR ORAL 3 ST TABLET amlodipine- 1 EXTENDED valsartan-hcthiazid RELEASE 120 MG, oral tablet 10-160- 180 MG, 240 MG 12.5 mg, 10-160-25 mg, 10-320-25 mg, candesartan oral 1 5-160-12.5 mg, 5- tablet 16 mg, 32 mg, 160-25 mg 4 mg, 8 mg atenolol oral tablet 1 candesartan- 1 100 mg, 25 mg, 50 hydrochlorothiazid mg oral tablet 16-12.5 mg, 32-12.5 mg, 32- atenolol- 1 25 mg chlorthalidone oral tablet 100-25 mg, captopril oral tablet 1 50-25 mg 100 mg, 12.5 mg, 25 mg, 50 mg benazepril oral 1 tablet 10 mg, 20 mg, captopril- 1 40 mg, 5 mg hydrochlorothiazide oral tablet 25-15 mg, benazepril- 1 25-25 mg, 50-15 mg, hydrochlorothiazide 50-25 mg oral tablet 10-12.5 mg, 20-12.5 mg, 20- CARDIZEM CD 3 25 mg, 5-6.25 mg ORAL CAPSULE,EXTEN betaxolol oral tablet 1 DED RELEASE 10 mg, 20 mg 24HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 54 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CARDIZEM LA 3 CATAPRES-TTS-3 3 QL ORAL TABLET TRANSDERMAL EXTENDED PATCH WEEKLY RELEASE 24 HR 0.3 MG/24 HR 120 MG, 180 MG, chlorthalidone oral 1 240 MG, 300 MG, tablet 25 mg, 50 mg 360 MG, 420 MG clonidine hcl oral 1 CARDIZEM ORAL 3 tablet 0.1 mg, 0.2 TABLET 120 MG, mg, 0.3 mg 30 MG, 60 MG clonidine 1 QL CARDURA ORAL 3 ST; QL transdermal patch TABLET 1 MG, 2 weekly 0.1 mg/24 hr, MG, 4 MG, 8 MG 0.2 mg/24 hr, 0.3 CARDURA XL 3 ST; QL mg/24 hr ORAL TABLET CONSENSI ORAL 3 EXTENDED TABLET 10-200 RELEASE 24HR 4 MG, 2.5-200 MG, 5- MG, 8 MG 200 MG CAROSPIR ORAL 3 ST COREG CR ORAL 3 ST SUSPENSION 25 CAPSULE, ER MG/5 ML MULTIPHASE 24 cartia xt oral 1 HR 10 MG, 20 MG, capsule,extended 40 MG, 80 MG release 24hr 120 mg, CORGARD ORAL 3 ST 180 mg, 240 mg, 300 TABLET 20 MG, 40 mg MG, 80 MG carvedilol oral tablet 1 DEMSER ORAL 2 PA 12.5 mg, 25 mg, CAPSULE 250 MG 3.125 mg, 6.25 mg DIBENZYLINE 3 PA carvedilol phosphate 1 ORAL CAPSULE oral capsule, er 10 MG multiphase 24 hr 10 mg, 20 mg, 40 mg, diltiazem hcl oral 1 80 mg capsule,ext.rel 24h degradable 120 mg, CATAPRES-TTS-1 3 QL 180 mg, 240 mg TRANSDERMAL PATCH WEEKLY diltiazem hcl oral 1 0.1 MG/24 HR capsule,extended release 12 hr 120 CATAPRES-TTS-2 3 QL mg, 60 mg, 90 mg TRANSDERMAL PATCH WEEKLY 0.2 MG/24 HR You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 55 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits diltiazem hcl oral 1 enalapril- 1 capsule,extended hydrochlorothiazide release 24 hr 180 oral tablet 10-25 mg, mg, 240 mg, 300 mg, 5-12.5 mg 360 mg, 420 mg eplerenone oral 1 diltiazem hcl oral 1 tablet 25 mg, 50 mg capsule,extended eprosartan oral 1 release 24hr 120 mg, tablet 600 mg 180 mg, 240 mg, 300 mg, 360 mg ethacrynic acid oral 1 tablet 25 mg diltiazem hcl oral 1 tablet 120 mg, 30 felodipine oral tablet 1 mg, 60 mg, 90 mg extended release 24 hr 10 mg, 2.5 mg, 5 diltiazem hcl oral 1 mg tablet extended release 24 hr 180 fosinopril oral tablet 1 mg, 240 mg, 300 mg, 10 mg, 20 mg, 40 mg 360 mg, 420 mg fosinopril- 1 dilt-xr oral 1 hydrochlorothiazide capsule,ext.rel 24h oral tablet 10-12.5 degradable 120 mg, mg, 20-12.5 mg 180 mg, 240 mg furosemide oral 1 DIURIL ORAL 3 solution 10 mg/ml, SUSPENSION 250 40 mg/5 ml (8 MG/5 ML mg/ml) doxazosin oral tablet 1 QL furosemide oral 1 1 mg, 2 mg, 4 mg, 8 tablet 20 mg, 40 mg, mg 80 mg DYRENIUM ORAL 3 guanfacine oral 1 CAPSULE 100 MG, tablet 1 mg, 2 mg 50 MG hydralazine oral 1 EDARBI ORAL 2 ST tablet 10 mg, 100 TABLET 40 MG, 80 mg, 25 mg, 50 mg MG hydrochlorothiazide 1 EDECRIN ORAL 3 oral capsule 12.5 mg TABLET 25 MG hydrochlorothiazide 1 enalapril maleate 1 oral tablet 12.5 mg, oral tablet 10 mg, 25 mg, 50 mg 2.5 mg, 20 mg, 5 mg indapamide oral 1 tablet 1.25 mg, 2.5 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 56 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits INSPRA ORAL 3 LOTENSIN HCT 3 TABLET 25 MG, 50 ORAL TABLET 10- MG 12.5 MG, 20-12.5 irbesartan oral 1 MG, 20-25 MG tablet 150 mg, 300 LOTENSIN ORAL 3 mg, 75 mg TABLET 10 MG, 20 irbesartan- 1 MG, 40 MG hydrochlorothiazide matzim la oral tablet 1 oral tablet 150-12.5 extended release 24 mg, 300-12.5 mg hr 180 mg, 240 mg, isradipine oral 1 300 mg, 360 mg, 420 capsule 2.5 mg, 5 mg mg labetalol oral tablet 1 MAXZIDE ORAL 3 100 mg, 200 mg, 300 TABLET 75-50 MG mg MAXZIDE-25MG 3 LASIX ORAL 3 ORAL TABLET TABLET 20 MG, 40 37.5-25 MG MG, 80 MG methyldopa oral 1 lisinopril oral tablet 1 tablet 250 mg, 500 10 mg, 2.5 mg, 20 mg mg, 30 mg, 40 mg, 5 methyldopa- 1 mg hydrochlorothiazide lisinopril- 1 oral tablet 250-15 hydrochlorothiazide mg, 250-25 mg oral tablet 10-12.5 metolazone oral 1 mg, 20-12.5 mg, 20- tablet 10 mg, 2.5 mg, 25 mg 5 mg LOPRESSOR 3 ST metoprolol succinate 1 ORAL TABLET oral tablet extended 100 MG, 50 MG release 24 hr 100 losartan oral tablet 1 mg, 200 mg, 25 mg, 100 mg, 25 mg, 50 50 mg mg metoprolol tartrate 1 losartan- 1 oral tablet 100 mg, hydrochlorothiazide 25 mg, 37.5 mg, 50 oral tablet 100-12.5 mg, 75 mg mg, 100-25 mg, 50- metyrosine oral 1 PA 12.5 mg capsule 250 mg MINIPRESS ORAL 3 CAPSULE 1 MG, 2 MG, 5 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 57 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits minoxidil oral tablet 1 olmesartan- 1 10 mg, 2.5 mg amlodipin-hcthiazid moexipril oral tablet 1 oral tablet 20-5-12.5 15 mg, 7.5 mg mg, 40-10-12.5 mg, 40-10-25 mg, 40-5- nadolol oral tablet 1 12.5 mg, 40-5-25 mg 20 mg, 40 mg, 80 mg olmesartan- 1 nadolol- 1 hydrochlorothiazide bendroflumethiazide oral tablet 20-12.5 oral tablet 80-5 mg mg, 40-12.5 mg, 40- nicardipine oral 1 25 mg capsule 20 mg, 30 ORENITRAM 5 PA mg ORAL TABLET nifedipine oral 1 EXTENDED capsule 10 mg, 20 RELEASE 0.125 mg MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG nifedipine oral tablet 1 extended release perindopril 1 24hr 30 mg, 60 mg, erbumine oral tablet 90 mg 2 mg, 4 mg, 8 mg nifedipine oral tablet 1 phenoxybenzamine 1 PA extended release 30 oral capsule 10 mg mg, 60 mg, 90 mg pindolol oral tablet 1 nimodipine oral 1 10 mg, 5 mg capsule 30 mg prazosin oral 1 nisoldipine oral 1 capsule 1 mg, 2 mg, tablet extended 5 mg release 24 hr 17 mg, PRINIVIL ORAL 3 20 mg, 25.5 mg, 30 TABLET 20 MG mg, 34 mg, 40 mg, 8.5 mg PROCARDIA XL 3 ST ORAL TABLET NYMALIZE ORAL 3 EXTENDED SOLUTION 60 RELEASE 24HR 30 MG/10 ML MG, 60 MG, 90 MG NYMALIZE ORAL 3 propranolol oral 1 SYRINGE 30 MG/5 capsule,extended ML, 60 MG/10 ML release 24 hr 120 olmesartan oral 1 mg, 160 mg, 60 mg, tablet 20 mg, 40 mg, 80 mg 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 58 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits propranolol oral 1 taztia xt oral 1 solution 20 mg/5 ml capsule,extended (4 mg/ml), 40 mg/5 release 24 hr 120 ml (8 mg/ml) mg, 180 mg, 240 mg, propranolol oral 1 300 mg, 360 mg tablet 10 mg, 20 mg, TEKTURNA HCT 2 40 mg, 60 mg, 80 mg ORAL TABLET propranolol- 1 150-12.5 MG, 150- hydrochlorothiazid 25 MG, 300-12.5 oral tablet 40-25 mg, MG, 300-25 MG 80-25 mg telmisartan oral 1 quinapril oral tablet 1 tablet 20 mg, 40 mg, 10 mg, 20 mg, 40 80 mg mg, 5 mg telmisartan- 1 quinapril- 1 amlodipine oral hydrochlorothiazide tablet 40-10 mg, 40- oral tablet 10-12.5 5 mg, 80-10 mg, 80- mg, 20-12.5 mg, 20- 5 mg 25 mg telmisartan- 1 ramipril oral 1 hydrochlorothiazid capsule 1.25 mg, 10 oral tablet 40-12.5 mg, 2.5 mg, 5 mg mg, 80-12.5 mg, 80- 25 mg spironolactone oral 1 tablet 100 mg, 25 TENORMIN ORAL 3 ST mg, 50 mg TABLET 25 MG spironolacton- 1 terazosin oral 1 QL hydrochlorothiaz capsule 1 mg, 10 mg, oral tablet 25-25 mg 2 mg, 5 mg SULAR ORAL 3 ST tiadylt er oral 1 TABLET capsule,extended EXTENDED release 24 hr 120 RELEASE 24 HR mg, 180 mg, 240 mg, 17 MG, 34 MG, 8.5 300 mg, 360 mg, 420 MG mg TARKA ORAL 3 TIAZAC ORAL 3 TABLET, IR - ER, CAPSULE,EXTEN BIPHASIC 24HR 2- DED RELEASE 24 240 MG HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 59 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits timolol maleate oral 1 valsartan- 1 tablet 10 mg, 20 mg, hydrochlorothiazide 5 mg oral tablet 160-12.5 torsemide oral tablet 1 mg, 160-25 mg, 320- 10 mg, 100 mg, 20 12.5 mg, 320-25 mg, mg, 5 mg 80-12.5 mg trandolapril oral 1 VASERETIC ORAL 3 tablet 1 mg, 2 mg, 4 TABLET 10-25 MG mg VASOTEC ORAL 3 trandolapril- 1 TABLET 10 MG, verapamil oral 2.5 MG, 20 MG, 5 tablet, ir - er, MG biphasic 24hr 1-240 verapamil oral 1 mg, 2-180 mg, 2-240 capsule, 24 hr er mg, 4-240 mg pellet ct 100 mg, 200 triamterene oral 1 mg, 300 mg capsule 100 mg, 50 verapamil oral 1 mg capsule,ext rel. triamterene- 1 pellets 24 hr 120 mg, hydrochlorothiazid 180 mg, 240 mg, 360 oral capsule 37.5-25 mg mg verapamil oral tablet 1 triamterene- 1 120 mg, 40 mg, 80 hydrochlorothiazid mg oral tablet 37.5-25 verapamil oral tablet 1 mg, 75-50 mg extended release 120 UPTRAVI ORAL 4 PA mg, 180 mg, 240 mg TABLET 1,000 VERELAN ORAL 3 ST MCG, 1,200 MCG, CAPSULE,EXT 1,400 MCG, 1,600 REL. PELLETS 24 MCG, 200 MCG, HR 120 MG, 180 400 MCG, 600 MG, 240 MG, 360 MCG, 800 MCG MG UPTRAVI ORAL 4 PA VERELAN PM 3 ST TABLETS,DOSE ORAL CAPSULE, PACK 200 MCG 24 HR ER PELLET (140)- 800 MCG CT 100 MG, 200 (60) MG, 300 MG valsartan oral tablet 1 ZESTORETIC 3 160 mg, 320 mg, 40 ORAL TABLET 10- mg, 80 mg 12.5 MG, 20-12.5 MG, 20-25 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 60 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZESTRIL ORAL 3 BRILINTA ORAL 2 TABLET 10 MG, TABLET 60 MG, 90 2.5 MG, 20 MG, 30 MG MG, 40 MG, 5 MG CABLIVI 4 PA ZIAC ORAL 3 ST INJECTION KIT 11 TABLET 10-6.25 MG MG, 2.5-6.25 MG, cilostazol oral tablet 1 5-6.25 MG 100 mg, 50 mg CARDIAC GLYCOSIDES clopidogrel oral 1 digitek oral tablet 1 tablet 300 mg, 75 mg 125 mcg (0.125 mg), dipyridamole oral 1 250 mcg (0.25 mg) tablet 25 mg, 50 mg, digox oral tablet 125 1 75 mg mcg (0.125 mg), 250 DOPTELET (15 4 PA; QL mcg (0.25 mg) TAB PACK) ORAL digoxin oral solution 1 TABLET 20 MG 50 mcg/ml (0.05 EFFIENT ORAL 3 mg/ml) TABLET 10 MG, 5 digoxin oral tablet 1 MG 125 mcg (0.125 mg), ELIQUIS DVT-PE 2 PA 250 mcg (0.25 mg) TREAT 30D LANOXIN ORAL 3 START ORAL TABLET 125 MCG TABLETS,DOSE (0.125 MG), 250 PACK 5 MG (74 MCG (0.25 MG), TABS) 62.5 MCG (0.0625 ELIQUIS ORAL 2 PA MG) TABLET 2.5 MG, 5 COAGULATION THERAPY MG ARIXTRA 5 enoxaparin 4 SUBCUTANEOUS subcutaneous SYRINGE 10 solution 300 mg/3 ml MG/0.8 ML, 2.5 enoxaparin 4 MG/0.5 ML, 5 subcutaneous MG/0.4 ML, 7.5 syringe 100 mg/ml, MG/0.6 ML 120 mg/0.8 ml, 150 aspirin-dipyridamole 1 mg/ml, 30 mg/0.3 ml, oral capsule, er 40 mg/0.4 ml, 60 multiphase 12 hr 25- mg/0.6 ml, 80 mg/0.8 200 mg ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 61 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fondaparinux 4 heparin (porcine) 1 subcutaneous injection solution syringe 10 mg/0.8 1,000 unit/ml, ml, 2.5 mg/0.5 ml, 5 10,000 unit/ml, mg/0.4 ml, 7.5 20,000 unit/ml, mg/0.6 ml 5,000 unit/ml hep flush-10 (pf) 1 heparin (porcine) 1 intravenous solution injection syringe 10 unit/ml 5,000 unit/ml HEPARIN 3 heparin 1 (PORCINE) IN flush(porcine)- 0.9% NACL 0.9nacl intravenous INTRAVENOUS kit 100 unit/ml PARENTERAL heparin lock flush 1 SOLUTION 2,500 (porcine) UNIT/500 ML (5 intravenous solution UNIT/ML), 30,000 10 unit/ml, 100 UNIT/1,000 ML, unit/ml 5,000 UNIT/1,000 ML, 5,000 heparin 1 UNIT/500 ML (10 lockflush(porcine)(pf UNIT/ML) ) intravenous syringe 100 unit/ml heparin (porcine) in 1 5 % dex intravenous HEPARIN(PORCIN 3 parenteral solution E) IN 0.45% NACL 20,000 unit/500 ml INTRAVENOUS (40 unit/ml), 25,000 PARENTERAL unit/250 ml(100 SOLUTION 12,500 unit/ml), 25,000 UNIT/250 ML unit/500 ml (50 heparin(porcine) in 1 unit/ml) 0.45% nacl heparin (porcine) in 1 intravenous nacl (pf) intravenous parenteral solution parenteral solution 25,000 unit/250 ml, 1,000 unit/500 ml, 25,000 unit/500 ml 2,000 unit/1,000 ml heparin, porcine (pf) 1 heparin (porcine) 1 injection solution injection cartridge 1,000 unit/ml, 5,000 5,000 unit/ml (1 ml) unit/0.5 ml heparin, porcine (pf) 1 injection syringe 5,000 unit/0.5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 62 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HEPARIN, 3 vitamin k injection 1 PORCINE (PF) solution 1 mg/0.5 ml INJECTION vitamin k1 injection 1 SYRINGE 5,000 solution 10 mg/ml UNIT/ML warfarin oral tablet 1 heparin, porcine (pf) 1 1 mg, 10 mg, 2 mg, intravenous solution 2.5 mg, 3 mg, 4 mg, 100 unit/ml (1 ml) 5 mg, 6 mg, 7.5 mg heparin, porcine (pf) 1 XARELTO DVT-PE 2 PA intravenous syringe TREAT 30D 1 unit/ml, 10 unit/ml, START ORAL 100 unit/ml TABLETS,DOSE HEPARIN, 3 PACK 15 MG (42)- PORCINE (PF) 20 MG (9) SUBCUTANEOUS XARELTO ORAL 2 PA SYRINGE 5,000 TABLET 10 MG, 15 UNIT/0.5 ML MG, 2.5 MG, 20 jantoven oral tablet 1 MG 1 mg, 10 mg, 2 mg, ZONTIVITY ORAL 3 PA 2.5 mg, 3 mg, 4 mg, TABLET 2.08 MG 5 mg, 6 mg, 7.5 mg LIPID/CHOLESTEROL LOWERING MEPHYTON 3 QL ORAL TABLET 5 AGENTS MG ANTARA ORAL 3 ST pentoxifylline oral 1 CAPSULE 30 MG, tablet extended 90 MG release 400 mg atorvastatin oral 0 $0 for ages 40- phytonadione 1 tablet 10 mg, 20 mg 75 years; QL (vitamin k1) atorvastatin oral 1 QL injection solution 10 tablet 40 mg, 80 mg mg/ml cholestyramine (with 1 PHYTONADIONE 2 sugar) oral powder (VITAMIN K1) 4 gram INJECTION cholestyramine (with 1 SYRINGE 1 MG/0.5 sugar) oral powder ML in packet 4 gram phytonadione 1 QL cholestyramine light 1 (vitamin k1) oral oral powder 4 gram tablet 5 mg cholestyramine light 1 prasugrel oral tablet 1 oral powder in 10 mg, 5 mg packet 4 gram You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 63 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits colesevelam oral 1 fenofibrate oral 1 ST powder in packet tablet 120 mg, 40 mg 3.75 gram fenofibrate oral 1 colesevelam oral 1 tablet 160 mg, 54 mg tablet 625 mg fenofibric acid 1 COLESTID 3 ST (choline) oral FLAVORED ORAL capsule,delayed PACKET 7.5 release(dr/ec) 135 GRAM mg, 45 mg COLESTID ORAL 3 ST fenofibric acid oral 1 GRANULES 5 tablet 105 mg, 35 mg GRAM FENOGLIDE 3 ST COLESTID ORAL 3 ST ORAL TABLET PACKET 5 GRAM 120 MG, 40 MG COLESTID ORAL 3 ST FIBRICOR ORAL 3 ST TABLET 1 GRAM TABLET 105 MG, colestipol oral 1 35 MG granules 5 gram FLOLIPID ORAL 3 ST; QL colestipol oral 1 SUSPENSION 20 packet 5 gram MG/5 ML (4 MG/ML), 40 MG/5 colestipol oral tablet 1 ML (8 MG/ML) 1 gram fluvastatin oral 0 $0 for ages 40- EVKEEZA 5 PA capsule 20 mg, 40 75 years; QL INTRAVENOUS mg SOLUTION 150 MG/ML fluvastatin oral 0 $0 for ages 40- tablet extended 75 years; QL ezetimibe oral tablet 1 ST release 24 hr 80 mg 10 mg gemfibrozil oral 1 fenofibrate 1 tablet 600 mg micronized oral capsule 130 mg, 134 icosapent ethyl oral 1 PA mg, 200 mg, 43 mg, capsule 1 gram 67 mg LESCOL XL ORAL 3 ST; QL fenofibrate 1 TABLET nanocrystallized EXTENDED oral tablet 145 mg, RELEASE 24 HR 48 mg 80 MG FENOFIBRATE 3 ST LIPOFEN ORAL 2 ST ORAL CAPSULE CAPSULE 150 MG, 150 MG, 50 MG 50 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 64 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LIVALO ORAL 2 ST; QL prevalite oral 1 TABLET 1 MG, 2 powder in packet 4 MG, 4 MG gram LOPID ORAL 3 QUESTRAN 3 ST TABLET 600 MG LIGHT ORAL lovastatin oral tablet 0 $0 for ages 40- POWDER 4 GRAM 10 mg, 20 mg, 40 mg 75 years; QL QUESTRAN ORAL 3 ST LOVAZA ORAL 3 PA POWDER 4 GRAM CAPSULE 1 GRAM QUESTRAN ORAL 3 ST NEXLETOL ORAL 2 PA POWDER IN TABLET 180 MG PACKET 4 GRAM NEXLIZET ORAL 2 PA REPATHA 2 PA; QL TABLET 180-10 PUSHTRONEX MG SUBCUTANEOUS WEARABLE niacin oral tablet 1 INJECTOR 420 500 mg MG/3.5 ML niacin oral tablet 1 REPATHA 2 PA; QL extended release 24 SURECLICK hr 1,000 mg, 500 SUBCUTANEOUS mg, 750 mg PEN INJECTOR NIACOR ORAL 3 140 MG/ML TABLET 500 MG REPATHA 2 PA; QL NIASPAN 3 SYRINGE EXTENDED- SUBCUTANEOUS RELEASE ORAL SYRINGE 140 TABLET MG/ML EXTENDED rosuvastatin oral 0 $0 for ages 40- RELEASE 24 HR tablet 10 mg, 5 mg 75 years; QL 1,000 MG, 500 MG, 750 MG rosuvastatin oral 1 QL tablet 20 mg, 40 mg omega-3 acid ethyl 1 PA esters oral capsule 1 ROSZET ORAL 3 PA; QL gram TABLET 10-10 MG, 10-20 MG, 10- pravastatin oral 0 $0 for ages 40- 40 MG, 10-5 MG tablet 10 mg, 20 mg, 75 years; QL 40 mg, 80 mg simvastatin oral 0 $0 for ages 40- tablet 10 mg, 20 mg, 75 years; QL prevalite oral 1 40 mg, 5 mg powder 4 gram simvastatin oral 1 QL tablet 80 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 65 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TRILIPIX ORAL 3 ST ISORDIL ORAL 3 CAPSULE,DELAY TABLET 40 MG ED ISORDIL 3 RELEASE(DR/EC) TITRADOSE 135 MG, 45 MG ORAL TABLET 5 VASCEPA ORAL 2 PA MG CAPSULE 0.5 isosorbide dinitrate 1 GRAM, 1 GRAM oral tablet 10 mg, 20 ZYPITAMAG 3 ST; QL mg, 30 mg, 40 mg, 5 ORAL TABLET 2 mg MG, 4 MG isosorbide 1 MISCELLANEOUS mononitrate oral CARDIOVASCULAR AGENTS tablet 10 mg, 20 mg ENTRESTO ORAL 2 QL isosorbide 1 TABLET 24-26 mononitrate oral MG, 49-51 MG, 97- tablet extended 103 MG release 24 hr 120 mg, 30 mg, 60 mg ranolazine oral 1 tablet extended MINITRAN 3 release 12 hr 1,000 TRANSDERMAL mg, 500 mg PATCH 24 HOUR 0.1 MG/HR, 0.2 VERQUVO ORAL 2 QL MG/HR, 0.4 TABLET 10 MG, MG/HR, 0.6 2.5 MG, 5 MG MG/HR VYNDAMAX 4 PA nitro-bid 1 ORAL CAPSULE transdermal 61 MG ointment 2 % VYNDAQEL 4 PA NITRO-DUR 3 ORAL CAPSULE TRANSDERMAL 20 MG PATCH 24 HOUR NITRATES 0.1 MG/HR, 0.2 MG/HR, 0.3 DILATRATE-SR 2 MG/HR, 0.4 ORAL CAPSULE, MG/HR, 0.6 EXTENDED MG/HR, 0.8 RELEASE 40 MG MG/HR GONITRO 3 nitroglycerin 1 SUBLINGUAL sublingual tablet 0.3 POWDER IN mg, 0.4 mg, 0.6 mg PACKET 400 MCG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 66 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nitroglycerin 1 calcipotriene topical 1 QL transdermal patch ointment 0.005 % 24 hour 0.1 mg/hr, calcipotriene- 1 QL 0.2 mg/hr, 0.4 betamethasone mg/hr, 0.6 mg/hr topical ointment nitroglycerin 1 0.005-0.064 % translingual calcipotriene- 1 QL spray,non-aerosol betamethasone 400 mcg/spray topical suspension NITROLINGUAL 3 0.005-0.064 % TRANSLINGUAL calcitriol topical 1 SPRAY,NON- ointment 3 AEROSOL 400 mcg/gram MCG/SPRAY DOVONEX 3 QL NITROMIST 3 TOPICAL CREAM TRANSLINGUAL 0.005 % AEROSOL,SPRAY 400 MCG/SPRAY ENSTILAR 2 QL TOPICAL FOAM NITROSTAT 3 0.005-0.064 % SUBLINGUAL TABLET 0.3 MG, EPIFOAM 3 ST 0.4 MG, 0.6 MG TOPICAL FOAM 1- 1 % nitro-time oral 1 capsule, extended hydrocortisone- 1 ST release 2.5 mg, 6.5 pramoxine topical mg, 9 mg cream 2.5-1 % DERMATOLOGICALS/TOPICA OVACE PLUS 3 SHAMPOO L THERAPY TOPICAL ANTIPSORIATIC / SHAMPOO 10 % ANTISEBORRHEIC OVACE PLUS 3 acitretin oral 1 TOPICAL capsule 10 mg, 17.5 CLEANSER 10 % mg, 25 mg OVACE PLUS 3 ANALPRAM-HC 3 ST TOPICAL CREAM TOPICAL LOTION 10 % 2.5-1 % OVACE PLUS 3 calcipotriene scalp 1 QL TOPICAL FOAM solution 0.005 % 9.8 % calcipotriene topical 1 QL cream 0.005 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 67 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OVACE PLUS 3 SORIATANE 3 TOPICAL LOTION ORAL CAPSULE 9.8 % 10 MG, 25 MG OVACE PLUS 3 SORILUX 3 QL WASH TOPICAL TOPICAL FOAM CLEANSER, GEL 0.005 % 10 % STELARA 5 PA OVACE TOPICAL 3 INTRAVENOUS CLEANSER 10 % SOLUTION 130 PRAMOSONE 3 ST MG/26 ML TOPICAL CREAM STELARA 4 PA; QL 1-1 %, 2.5-1 % SUBCUTANEOUS PRAMOSONE 3 ST SOLUTION 45 TOPICAL LOTION MG/0.5 ML 1-1 %, 2.5-1 % STELARA 4 PA; QL PRAMOSONE 3 ST SUBCUTANEOUS TOPICAL SYRINGE 45 OINTMENT 1-1 %, MG/0.5 ML, 90 2.5-1 % MG/ML selenium sulfide 1 sulfacetamide 1 topical lotion 2.5 % sodium topical cleanser 10 % selenium sulfide 1 topical shampoo sulfacetamide 1 2.25 %, 2.3 % sodium topical cleanser, gel 10 % SELRX TOPICAL 3 SHAMPOO 2.3 % sulfacetamide 1 sodium topical SKYRIZI 4 PA; QL shampoo 10 % SUBCUTANEOUS PEN INJECTOR TACLONEX 3 QL 150 MG/ML TOPICAL OINTMENT 0.005- SKYRIZI 4 PA; QL 0.064 % SUBCUTANEOUS SYRINGE 150 TACLONEX 2 QL MG/ML TOPICAL SUSPENSION SKYRIZI 4 PA; QL 0.005-0.064 % SUBCUTANEOUS SYRINGE KIT 150MG/1.66ML(75 MG/0.83 ML X2)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 68 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TALTZ 4 PA; QL INOVA 8-2 3 ST AUTOINJECTOR TOPICAL COMBO (2 PACK) PACK 2-8-5 % SUBCUTANEOUS MISCELLANEOUS AUTO-INJECTOR 80 MG/ML DERMATOLOGICALS TALTZ 4 PA; QL ammonium lactate 1 AUTOINJECTOR topical cream 12 % (3 PACK) ammonium lactate 1 SUBCUTANEOUS topical lotion 12 % AUTO-INJECTOR CANTHARIDIN IN 3 80 MG/ML ACETONE TALTZ 4 PA; QL TOPICAL AUTOINJECTOR SOLUTION 0.7 % SUBCUTANEOUS CONDYLOX 3 QL AUTO-INJECTOR TOPICAL GEL 0.5 80 MG/ML % TALTZ SYRINGE 4 PA; QL CORTANE-B 3 SUBCUTANEOUS TOPICAL LOTION SYRINGE 80 1-1-0.1 % MG/ML EFUDEX TOPICAL 3 TERSI FOAM 3 CREAM 5 % TOPICAL FOAM 2.25 % FLUOROPLEX 3 TOPICAL CREAM VECTICAL 3 1 % TOPICAL OINTMENT 3 fluorouracil topical 1 MCG/GRAM cream 5 % BURN THERAPY fluorouracil topical 1 solution 2 %, 5 % SILVADENE 3 TOPICAL CREAM iodine-sodium iodide 1 1 % topical tincture 2 % silver sulfadiazine 1 IODOFLEX 3 topical cream 1 % TOPICAL PADS, MEDICATED 0.9 % ssd topical cream 1 1 % IODOSORB 3 TOPICAL GEL 0.9 KERATOLYTICS % INOVA 4-1 3 ST TOPICAL COMBO PACK 1-4-5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 69 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits methoxsalen oral 1 ABSORICA ORAL 3 ST capsule,liqd- CAPSULE 10 MG, filled,rapid rel 10 20 MG, 25 MG, 30 mg MG, 35 MG, 40 MG methyl salicylate oil 1 accutane oral 1 methyl salicylate 1 capsule 20 mg, 30 topical liquid mg, 40 mg PANRETIN 3 ACZONE 3 ST TOPICAL GEL 0.1 TOPICAL GEL 5 % % ACZONE 3 ST pimecrolimus topical 1 ST; QL TOPICAL GEL cream 1 % WITH PUMP 7.5 % podofilox topical 1 adapalene topical 1 solution 0.5 % cream 0.1 % PROTOPIC 3 ST; QL adapalene topical 1 TOPICAL gel 0.3 % OINTMENT 0.03 adapalene topical 1 %, 0.1 % gel with pump 0.3 % QBREXZA 3 PA ADAPALENE 3 ST TOPICAL TOPICAL LOTION TOWELETTE 2.4 0.1 % % adapalene topical 1 SCENESSE 5 PA solution 0.1 % SUBCUTANEOUS adapalene topical 1 IMPLANT 16 MG swab 0.1 % tacrolimus topical 1 ST; QL adapalene-benzoyl 1 ointment 0.03 %, 0.1 peroxide topical gel % with pump 0.1-2.5 % TOLAK TOPICAL 3 AKLIEF TOPICAL 3 PA CREAM 4 % CREAM 0.005 % VALCHLOR 4 PA ALTRENO 3 PA TOPICAL GEL TOPICAL LOTION 0.016 % 0.05 % wintergreen oil oil 1 amnesteem oral 1 THERAPY FOR ACNE capsule 10 mg, 20 mg, 40 mg ABSORICA LD 3 ST ORAL CAPSULE AMZEEQ 2 ST 16 MG, 24 MG, 32 TOPICAL FOAM 4 MG, 8 MG %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 70 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ARAZLO 3 PA BENZEPRO 3 ST TOPICAL LOTION (MICROSPHERES) 0.045 % TOPICAL AVAR LS 3 ST CLEANSER 7 % TOPICAL benzepro topical 1 CLEANSER 10-2 % towelette 6 % AVAR LS 3 ST benzoyl peroxide 1 TOPICAL FOAM topical cleanser 7 % 10-2 % benzoyl peroxide 1 AVAR LS 3 ST topical foam 9.8 % TOPICAL PADS, bp 10-1 topical 1 ST MEDICATED 10-2 cleanser 10-1 % % claravis oral capsule 1 avar topical cleanser 1 10 mg, 20 mg, 30 10-5 % (w/w) mg, 40 mg AVAR TOPICAL 3 ST CLEOCIN T 3 ST; QL PADS, TOPICAL LOTION MEDICATED 9.5-5 1 % % CLINDACIN ETZ 3 ST AVAR-E GREEN 3 ST TOPICAL KIT 1 % TOPICAL CREAM 10-5 % (W/W) clindacin p topical 1 swab 1 % AVAR-E LS 3 ST TOPICAL CREAM CLINDACIN PAC 3 ST 10-2 % TOPICAL KIT 1 % avita topical cream 1 PA clindamycin 1 QL 0.025 % phosphate topical foam 1 % AVITA TOPICAL 3 PA GEL 0.025 % clindamycin 1 QL phosphate topical azelaic acid topical 1 gel 1 % gel 15 % clindamycin 1 QL AZELEX TOPICAL 3 ST phosphate topical CREAM 20 % lotion 1 % BENZACLIN 3 ST clindamycin 1 QL PUMP TOPICAL phosphate topical GEL WITH PUMP solution 1 % 1-5 % clindamycin 1 BENZACLIN 3 ST phosphate topical TOPICAL GEL 1-5 swab 1 % % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 71 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clindamycin-benzoyl 1 FABIOR TOPICAL 3 PA peroxide topical gel FOAM 0.1 % 1-5 %, 1.2 %(1 % FINACEA 2 ST base) -5 % TOPICAL FOAM clindamycin-benzoyl 1 15 % peroxide topical gel FINACEA 3 ST with pump 1-5 %, TOPICAL GEL 15 1.2-2.5 % % clindamycin- 1 PA INOVA TOPICAL 3 ST tretinoin topical gel COMBO PACK 4-5 1.2-0.025 % %, 8-5 % dapsone topical gel 1 isotretinoin oral 1 5 % capsule 10 mg, 20 dapsone topical gel 1 mg, 25 mg, 30 mg, with pump 7.5 % 35 mg, 40 mg DIFFERIN 3 ST ivermectin topical 1 QL TOPICAL CREAM cream 1 % 0.1 % METROCREAM 3 ST DIFFERIN 3 ST TOPICAL CREAM TOPICAL GEL 0.75 % WITH PUMP 0.3 % METROGEL 3 ST DIFFERIN 3 ST TOPICAL GEL 1 % TOPICAL LOTION metronidazole 1 0.1 % topical cream 0.75 ENZOCLEAR 3 ST % TOPICAL FOAM metronidazole 1 9.8 % topical gel 0.75 %, 1 ery pads topical 1 % swab 2 % metronidazole 1 erygel topical gel 2 1 topical gel with % pump 1 % erythromycin with 1 metronidazole 1 ethanol topical gel 2 topical lotion 0.75 % % myorisan oral 1 erythromycin with 1 capsule 10 mg, 20 ethanol topical mg, 30 mg, 40 mg solution 2 % NEUAC KIT 3 ST EVOCLIN 3 ST; QL TOPICAL COMBO TOPICAL FOAM 1 PACK,CREAM % AND GEL 1.2-5 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 72 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits neuac topical gel 1.2 1 RETIN-A TOPICAL 3 PA %(1 % base) -5 % GEL 0.01 %, 0.025 NORITATE 3 ST % TOPICAL CREAM rosadan topical 1 1 % cream 0.75 % ONEXTON 2 ST rosadan topical gel 1 TOPICAL GEL 0.75 % WITH PUMP 1.2 ROSADAN 3 ST %(1 % BASE) -3.75 TOPICAL KIT, % CLEANSER AND PACNEX TOPICAL 3 ST GEL 0.75 % CLEANSER 7 % ROSADAN 3 ST PLEXION 3 ST TOPICAL CLEANSING KIT,CLEANSER CLOTHS TOPICAL AND CREAM 0.75 PADS, % MEDICATED 9.8- ROSANIL 3 ST 4.8 % TOPICAL PLEXION 3 ST CLEANSER 10-5 % TOPICAL (W/W) CLEANSER 9.8-4.8 rosula cleansing 1 % cloths topical pads, PLEXION 3 ST medicated 10-5 % TOPICAL CREAM ROSULA TOPICAL 3 ST 9.8-4.8 % CLEANSER 10-4.5 PLEXION 3 ST % TOPICAL LOTION SOOLANTRA 3 ST; QL 9.8-4.8 % TOPICAL CREAM PR BENZOYL 3 ST 1 % PEROXIDE sss 10-5 topical 1 TOPICAL cream 10-5 % (w/w) CLEANSER 7 % sss 10-5 topical 1 RETIN-A MICRO 3 PA foam 10-5 % PUMP TOPICAL GEL WITH PUMP sulfacetamide 1 0.06 %, 0.08 % sodium-sulfur topical cleanser 10-2 RETIN-A TOPICAL 3 PA %, 10-5 % (w/w), 9- CREAM 0.025 %, 4 %, 9-4.5 %, 9.8- 0.05 %, 0.1 % 4.8 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 73 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sulfacetamide 1 SUMAXIN 3 ST sodium-sulfur TOPICAL topical cream 10-2 CLEANSER 9-4 % %, 10-5 % (w/w), SUMAXIN 3 ST 9.8-4.8 % TOPICAL PADS, sulfacetamide 1 MEDICATED 10-4 sodium-sulfur % topical lotion 10-5 SUMAXIN TS 3 ST % (w/v), 10-5 % TOPICAL (w/w), 9.8-4.8 % SUSPENSION 8-4 sulfacetamide 1 % sodium-sulfur tazarotene topical 1 PA topical pads, cream 0.1 % medicated 10-4 %, 9.8-4.8 % TAZORAC 2 PA TOPICAL CREAM sulfacetamide 1 0.05 % sodium-sulfur topical suspension TAZORAC 2 PA 10-5 %, 8-4 % TOPICAL GEL 0.05 %, 0.1 % sulfacetamide- 1 sulfur-cleansr23 tretinoin 1 PA topical kit 9-4.5 % microspheres topical gel 0.04 %, 0.1 % sulfacleanse 8-4 1 ST topical suspension 8- tretinoin 1 PA 4 % microspheres topical gel with pump 0.04 SUMADAN 3 ST %, 0.1 % TOPICAL CLEANSER 9-4.5 tretinoin topical 1 PA % cream 0.025 %, 0.05 %, 0.1 % SUMADAN 3 ST TOPICAL KIT 9-4.5 tretinoin topical gel 1 PA % 0.01 %, 0.025 %, 0.05 % SUMADAN XLT 3 ST TOPICAL COMBO TRETIN-X CREAM 3 PA PACK,CLEANSER KIT TOPICAL AND CREAM 9 %- COMBO PACK 4.5 % -SPF 25 0.025 %, 0.05 %, 0.1 % SUMAXIN CP 3 ST TOPICAL KIT 10-4 TRETIN-X 3 PA % TOPICAL CREAM 0.075 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 74 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VANOXIDE-HC 3 ST lidocaine-prilocaine 1 QL TOPICAL topical cream 2.5- SUSPENSION 5-0.5 2.5 % % lidocort topical 1 zenatane oral 1 cream 3-0.5 % capsule 10 mg, 20 lta pre-attached 1 mg, 30 mg, 40 mg laryngotracheal ZIANA TOPICAL 3 ST solution 4 % GEL 1.2-0.025 % ZTLIDO TOPICAL 2 PA ZILXI TOPICAL 3 ST ADHESIVE FOAM 1.5 % PATCH,MEDICAT ED 1.8 % TOPICAL ANESTHETICS glydo mucous 1 QL TOPICAL ANTIBACTERIALS membrane jelly in CENTANY AT 3 ST; QL applicator 2 % TOPICAL lidocaine hcl 1 OINTMENT KIT 2 laryngotracheal % solution 4 % CENTANY 3 ST; QL lidocaine hcl mucous 1 QL TOPICAL membrane jelly 2 % OINTMENT 2 % lidocaine hcl mucous 1 QL gentamicin topical 1 QL membrane jelly in cream 0.1 % applicator 2 % gentamicin topical 1 QL lidocaine hcl mucous 1 ointment 0.1 % membrane solution 4 KLARON 3 ST % (40 mg/ml) TOPICAL lidocaine hcl- 1 SUSPENSION 10 % hydrocortison ac lugols topical 1 topical cream 3-0.5 solution 5-10 % % mafenide acetate 1 lidocaine topical 1 PA topical packet 50 adhesive gram patch,medicated 5 % mupirocin calcium 1 ST; QL lidocaine topical 1 QL topical cream 2 % ointment 5 % mupirocin topical 1 QL lidocaine viscous 1 ointment 2 % mucous membrane solution 2 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 75 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NEO-SYNALAR 3 ciclopirox-ure- 1 KIT TOPICAL camph-menth-euc CREAM 0.5 % (0.35 topical solution 8 % % BASE)-0.025 % clotrimazole topical 1 QL strong iodine topical 1 cream 1 % solution 5-10 % clotrimazole topical 1 QL sulfacetamide 1 solution 1 % sodium (acne) clotrimazole- 1 QL topical suspension betamethasone 10 % topical cream 1-0.05 SULFAMYLON 2 % TOPICAL CREAM clotrimazole- 1 QL 85 MG/G betamethasone SULFAMYLON 3 topical lotion 1-0.05 TOPICAL PACKET % 50 GRAM econazole topical 1 QL TOPICAL ANTIFUNGALS cream 1 % CICLODAN KIT 3 ERTACZO 3 QL TOPICAL COMBO TOPICAL CREAM PACK 0.77 % 2 % CICLODAN KIT 3 ST EXELDERM 3 QL TOPICAL TOPICAL CREAM SOLUTION 8 % 1 % ciclodan topical 1 QL EXELDERM 3 QL cream 0.77 % TOPICAL SOLUTION 1 % ciclodan topical 1 solution 8 % EXTINA TOPICAL 3 QL FOAM 2 % ciclopirox topical 1 QL cream 0.77 % ketoconazole topical 1 QL cream 2 % ciclopirox topical 1 QL gel 0.77 % ketoconazole topical 1 QL foam 2 % ciclopirox topical 1 QL shampoo 1 % ketoconazole topical 1 QL shampoo 2 % ciclopirox topical 1 solution 8 % ketodan kit topical 1 combo pack 2 % ciclopirox topical 1 QL suspension 0.77 % ketodan topical foam 1 QL 2 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 76 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LOPROX (AS 3 QL nystatin topical 1 QL OLAMINE) ointment 100,000 TOPICAL CREAM unit/gram 0.77 % nystatin topical 1 QL LOPROX (AS 3 QL powder 100,000 OLAMINE) unit/gram TOPICAL nystatin- 1 QL SUSPENSION 0.77 triamcinolone % topical cream LOPROX KIT 3 QL 100,000-0.1 unit/g- TOPICAL COMBO % PACK 0.77 % nystatin- 1 QL LOPROX KIT 3 QL triamcinolone TOPICAL KIT, topical ointment SUSPENSION AND 100,000-0.1 CLEANSER 0.77 % unit/gram-% LOPROX TOPICAL 3 QL nystop topical 1 QL SHAMPOO 1 % powder 100,000 LUZU TOPICAL 3 QL unit/gram CREAM 1 % oxiconazole topical 1 QL MENTAX 3 QL cream 1 % TOPICAL CREAM OXISTAT 3 QL 1 % TOPICAL CREAM MICONAZOLE 3 QL 1 % NITRATE-ZINC OXISTAT 3 QL OX-PET TOPICAL TOPICAL LOTION OINTMENT 0.25- 1 % 15-81.35 % VUSION TOPICAL 3 QL naftifine topical 1 QL OINTMENT 0.25- cream 1 %, 2 % 15-81.35 % naftifine topical gel 1 QL TOPICAL ANTIVIRALS 1 % acyclovir topical 1 PA; QL NAFTIN TOPICAL 3 QL cream 5 % GEL 1 %, 2 % acyclovir topical 1 PA; QL nyamyc topical 1 QL ointment 5 % powder 100,000 DENAVIR 3 unit/gram TOPICAL CREAM nystatin topical 1 QL 1 % cream 100,000 XERESE TOPICAL 3 unit/gram CREAM 5-1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 77 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ZOVIRAX 3 PA; QL betamethasone 1 TOPICAL CREAM valerate topical 5 % lotion 0.1 % TOPICAL CORTICOSTEROIDS betamethasone 1 valerate topical ala-cort topical 1 ointment 0.1 % cream 1 % betamethasone, 1 ALA-SCALP 3 ST augmented topical TOPICAL LOTION cream 0.05 % 2 % betamethasone, 1 alclometasone 1 augmented topical topical cream 0.05 gel 0.05 % % betamethasone, 1 alclometasone 1 augmented topical topical ointment lotion 0.05 % 0.05 % betamethasone, 1 amcinonide topical 1 ST augmented topical cream 0.1 % ointment 0.05 % amcinonide topical 1 ST BRYHALI 3 ST lotion 0.1 % TOPICAL LOTION apexicon e topical 1 ST 0.01 % cream 0.05 % CAPEX TOPICAL 3 ST beser topical lotion 1 ST SHAMPOO 0.01 % 0.05 % clobetasol scalp 1 QL betamethasone 1 solution 0.05 % dipropionate topical clobetasol topical 1 QL cream 0.05 % cream 0.05 % betamethasone 1 clobetasol topical 1 ST; QL dipropionate topical foam 0.05 % lotion 0.05 % clobetasol topical 1 QL betamethasone 1 gel 0.05 % dipropionate topical ointment 0.05 % clobetasol topical 1 ST; QL lotion 0.05 % betamethasone 1 valerate topical clobetasol topical 1 QL cream 0.1 % ointment 0.05 % betamethasone 1 ST clobetasol topical 1 ST; QL valerate topical shampoo 0.05 % foam 0.12 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 78 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits clobetasol topical 1 ST; QL DESONATE 3 ST spray,non-aerosol TOPICAL GEL 0.05 0.05 % % clobetasol-emollient 1 QL desonide topical 1 topical cream 0.05 cream 0.05 % % desonide topical gel 1 ST clobetasol-emollient 1 ST; QL 0.05 % topical foam 0.05 % desonide topical 1 ST CLOBEX TOPICAL 3 ST; QL lotion 0.05 % SHAMPOO 0.05 % desonide topical 1 CLOBEX TOPICAL 3 ST; QL ointment 0.05 % SPRAY,NON- DESOWEN 3 ST AEROSOL 0.05 % TOPICAL LOTION CLODAN KIT 3 ST 0.05 % TOPICAL desoximetasone 1 ST KIT,SHAMPOO topical cream 0.05 AND CLEANSER %, 0.25 % 0.05 % desoximetasone 1 ST clodan topical 1 ST; QL topical gel 0.05 % shampoo 0.05 % desoximetasone 1 ST CLODERM 3 ST topical ointment TOPICAL CREAM 0.05 %, 0.25 % 0.1 % desoximetasone 1 ST CUTIVATE 3 ST topical spray,non- TOPICAL CREAM aerosol 0.25 % 0.05 % desrx topical gel 1 ST CUTIVATE 3 ST 0.05 % TOPICAL LOTION 0.05 % diflorasone topical 1 ST; QL cream 0.05 % DERMA- 3 ST SMOOTHE/FS diflorasone topical 1 ST; QL BODY OIL ointment 0.05 % TOPICAL OIL 0.01 DIPROLENE 3 ST % (AUGMENTED) DERMA- 3 ST TOPICAL SMOOTHE/FS OINTMENT 0.05 % SCALP OIL SCALP DUOBRII 3 ST; QL OIL 0.01 % TOPICAL LOTION 0.01-0.045 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 79 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluocinolone and 1 HALOBETASOL 3 ST shower cap scalp oil PROPIONATE 0.01 % TOPICAL FOAM fluocinolone topical 1 0.05 % cream 0.01 %, 0.025 halobetasol 1 % propionate topical fluocinolone topical 1 ointment 0.05 % oil 0.01 % HALOG TOPICAL 3 ST fluocinolone topical 1 CREAM 0.1 % ointment 0.025 % HALOG TOPICAL 3 ST fluocinolone topical 1 OINTMENT 0.1 % solution 0.01 % HALOG TOPICAL 3 ST fluocinonide topical 1 QL SOLUTION 0.1 % cream 0.05 % hydrocortisone 1 QL fluocinonide topical 1 ST; QL butyrate topical cream 0.1 % cream 0.1 % fluocinonide topical 1 QL hydrocortisone 1 ST; QL gel 0.05 % butyrate topical lotion 0.1 % fluocinonide topical 1 QL ointment 0.05 % hydrocortisone 1 ST butyrate topical fluocinonide topical 1 QL ointment 0.1 % solution 0.05 % hydrocortisone 1 ST; QL fluocinonide-e 1 QL butyrate topical topical cream 0.05 solution 0.1 % % hydrocortisone 1 QL fluticasone 1 butyr-emollient propionate topical topical cream 0.1 % cream 0.05 % hydrocortisone 1 fluticasone 1 ST topical cream 1 %, propionate topical 2.5 % lotion 0.05 % hydrocortisone 1 fluticasone 1 topical lotion 2.5 % propionate topical ointment 0.005 % hydrocortisone 1 topical ointment 1 halcinonide topical 1 ST %, 2.5 % cream 0.1 % hydrocortisone 1 halobetasol 1 valerate topical propionate topical cream 0.2 % cream 0.05 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 80 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydrocortisone 1 SCALACORT DK 3 ST valerate topical TOPICAL COMBO ointment 0.2 % PACK 2-2-2 % IMPOYZ TOPICAL 3 ST; QL scalacort topical 1 CREAM 0.025 % lotion 2 % KENALOG 3 ST; QL SERNIVO 3 ST TOPICAL TOPICAL SPRAY AEROSOL 0.147 WITH PUMP 0.05 MG/GRAM % LEXETTE 3 ST SYNALAR 3 ST TOPICAL FOAM CREAM KIT 0.05 % TOPICAL CREAM LUXIQ TOPICAL 3 ST 0.025 % FOAM 0.12 % SYNALAR 3 ST mometasone topical 1 OINTMENT KIT cream 0.1 % TOPICAL COMBO PACK,OINTMENT mometasone topical 1 AND CREAM 0.025 ointment 0.1 % % mometasone topical 1 SYNALAR 3 ST solution 0.1 % TOPICAL CREAM NUCORT 3 ST 0.025 % TOPICAL LOTION SYNALAR 3 ST 2 % TOPICAL OLUX TOPICAL 3 ST; QL OINTMENT 0.025 FOAM 0.05 % % OLUX-E TOPICAL 3 ST; QL SYNALAR 3 ST FOAM 0.05 % TOPICAL SOLUTION 0.01 % PANDEL TOPICAL 3 ST CREAM 0.1 % SYNALAR TS 3 ST TOPICAL KIT 0.01 prednicarbate 1 % topical cream 0.1 % TEMOVATE 3 ST; QL prednicarbate 1 TOPICAL CREAM topical ointment 0.1 0.05 % % TEMOVATE 3 ST; QL PROCTOCORT 3 ST TOPICAL TOPICAL CREAM OINTMENT 0.05 % 1 % TEXACORT 3 ST TOPICAL SOLUTION 2.5 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 81 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TOPICORT 3 ST tritocin topical 1 ST TOPICAL CREAM ointment 0.05 % 0.05 %, 0.25 % ULTRAVATE 3 ST TOPICORT 3 ST TOPICAL LOTION TOPICAL GEL 0.05 0.05 % % TOPICAL SCABICIDES / TOPICORT 3 ST PEDICULICIDES TOPICAL OINTMENT 0.05 crotan topical lotion 1 %, 0.25 % 10 % tovet emollient 1 ST; QL ELIMITE TOPICAL 3 topical foam 0.05 % CREAM 5 % triamcinolone 1 ST; QL EURAX TOPICAL 3 acetonide topical CREAM 10 % aerosol 0.147 EURAX TOPICAL 3 mg/gram LOTION 10 % triamcinolone 1 ivermectin topical 1 acetonide topical lotion 0.5 % cream 0.025 %, 0.1 lindane topical 1 %, 0.5 % shampoo 1 % triamcinolone 1 malathion topical 1 acetonide topical lotion 0.5 % lotion 0.025 %, 0.1 % OVIDE TOPICAL 3 LOTION 0.5 % triamcinolone 1 acetonide topical permethrin topical 1 ointment 0.025 %, cream 5 % 0.1 %, 0.5 % SKLICE TOPICAL 3 triamcinolone 1 ST LOTION 0.5 % acetonide topical spinosad topical 1 ointment 0.05 % suspension 0.9 % trianex topical 1 ST ointment 0.05 % DIAGNOSTICS & MISCELLANEOUS AGENTS triderm topical 1 cream 0.1 % IRRIGATING SOLUTIONS triderm topical 1 ST lactated ringers 1 cream 0.5 % irrigation solution TRIDESILON 3 ST TOPICAL CREAM 0.05 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 82 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits neomycin-polymyxin 1 aqua care sodium 1 b gu irrigation chloride irrigation solution 40 mg- solution 0.9 % 200,000 unit/ml aqua care sterile 1 PHYSIOLYTE 3 water irrigation IRRIGATION solution SOLUTION 140-5- caffeine citrate oral 1 3-98 MEQ/L solution 60 mg/3 ml PHYSIOSOL 3 (20 mg/ml) IRRIGATION CARNITOR 3 IRRIGATION (SUGAR-FREE) SOLUTION 140-5- ORAL SOLUTION 3-98 MEQ/L 100 MG/ML ringer's irrigation 1 CARNITOR ORAL 3 solution SOLUTION 100 SORBITOL 3 MG/ML IRRIGATION CARNITOR ORAL 3 SOLUTION 3 % TABLET 330 MG SORBITOL- 3 cevimeline oral 1 MANNITOL capsule 30 mg TRANSURETHRA L SOLUTION 2.7- deferiprone oral 4 PA 0.54 GRAM/100 tablet 500 mg ML disulfiram oral 1 tis-u-sol pentalyte 1 tablet 250 mg, 500 irrigation irrigation mg solution 800-40-20- droxidopa oral 4 PA 8.75- 6.25 mg/100 capsule 100 mg, 200 ml mg, 300 mg MISCELLANEOUS AGENTS EVOXAC ORAL 3 acamprosate oral 1 CAPSULE 30 MG tablet,delayed FERRIPROX ORAL 4 PA release (dr/ec) 333 SOLUTION 100 mg MG/ML acetic acid irrigation 1 FERRIPROX ORAL 4 PA solution 0.25 % TABLET 1,000 MG AGRYLIN ORAL 3 FERRIPROX ORAL 5 PA CAPSULE 0.5 MG TABLET 500 MG anagrelide oral 1 capsule 0.5 mg, 1 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 83 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FERRLECIT 3 PA SALAGEN 3 INTRAVENOUS (PILOCARPINE) SOLUTION 62.5 ORAL TABLET 5 MG/5 ML MG GIVLAARI 5 PA sodium chloride 0.9 1 SUBCUTANEOUS % (flush) injection SOLUTION 189 syringe MG/ML sodium chloride 0.9 1 GLEOLAN ORAL 3 % injection solution RECON SOLN 30 sodium chloride 0.9 1 MG/ML % intravenous INFASURF 3 parenteral solution INTRATRACHEAL sodium chloride 0.9 1 SUSPENSION 35 % intravenous MG/ML piggyback levocarnitine (with 1 sodium chloride 1 sugar) oral solution injection syringe 0.9 100 mg/ml % levocarnitine oral 1 sodium ferric 1 PA solution 100 mg/ml gluconat-sucrose levocarnitine oral 1 intravenous solution tablet 330 mg 62.5 mg/5 ml LITHOSTAT ORAL 3 SURVANTA 3 TABLET 250 MG INTRATRACHEAL METOPIRONE 3 SUSPENSION 25 ORAL CAPSULE MG/ML 250 MG THIOLA EC ORAL 5 PA midodrine oral 1 TABLET,DELAYE tablet 10 mg, 2.5 mg, D RELEASE 5 mg (DR/EC) 100 MG, 300 MG pilocarpine hcl oral 1 tablet 5 mg THIOLA ORAL 5 PA TABLET 100 MG RILUTEK ORAL 3 PA TABLET 50 MG TIGLUTIK ORAL 3 PA SUSPENSION 50 riluzole oral tablet 1 PA MG/10 ML 50 mg tiopronin oral tablet 4 PA risedronate oral 1 QL 100 mg tablet 30 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 84 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits water for irrigation, 1 NICORETTE 0 $0 for ages 18 sterile irrigation BUCCAL and older for solution LOZENGE 2 MG, 4 first 180 days; ZOKINVY ORAL 5 PA; ST; QL MG OTC CAPSULE 50 MG, NICORETTE 0 $0 for ages 18 75 MG BUCCAL MINI and older for LOZENGE 2 MG, 4 first 180 days; SMOKING DETERRENTS MG OTC bupropion hcl 0 $0 for ages 18 nicotine (polacrilex) 0 $0 for ages 18 (smoking deter) oral and older for buccal gum 2 mg, 4 and older for tablet extended first 180 days mg first 180 days; release 12 hr 150 mg OTC CHANTIX 0 $0 for ages 18 nicotine (polacrilex) 0 $0 for ages 18 CONTINUING and older for buccal lozenge 2 mg, and older for MONTH BOX first 180 days 4 mg first 180 days; ORAL TABLET 1 OTC MG nicotine (polacrilex) 0 $0 for ages 18 CHANTIX ORAL 0 $0 for ages 18 buccal mini lozenge and older for TABLET 0.5 MG, 1 and older for 2 mg, 4 mg first 180 days; MG first 180 days OTC CHANTIX 0 $0 for ages 18 nicotine transdermal 0 $0 for ages 18 STARTING and older for patch 24 hour 14 and older for MONTH BOX first 180 days mg/24 hr, 21 mg/24 first 180 days; ORAL hr, 7 mg/24 hr OTC TABLETS,DOSE PACK 0.5 MG (11)- nicotine transdermal 0 $0 for ages 18 1 MG (42) patch, td daily, and older for sequential 21-14-7 first 180 days; NICODERM CQ 0 $0 for ages 18 mg/24 hr OTC TRANSDERMAL and older for PATCH 24 HOUR first 180 days; NICOTROL 0 $0 for ages 18 14 MG/24 HR, 21 OTC INHALATION and older for MG/24 HR, 7 CARTRIDGE 10 first 180 days MG/24 HR MG NICORETTE 0 $0 for ages 18 NICOTROL NS 0 $0 for ages 18 BUCCAL GUM 2 and older for NASAL and older for MG first 180 days; SPRAY,NON- first 180 days OTC AEROSOL 10 MG/ML nicorette buccal gum 0 $0 for ages 18 4 mg and older for quit 2 buccal gum 2 0 $0 for ages 18 first 180 days; mg and older for OTC first 180 days; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 85 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits quit 2 buccal 0 $0 for ages 18 EPISIL MUCOUS 3 lozenge 2 mg and older for MEMBRANE GEL first 180 days; FORMING OTC SOLUTION quit 4 buccal gum 4 0 $0 for ages 18 fluoride (sodium) 1 mg and older for dental cream 1.1 % first 180 days; fluoride (sodium) 1 OTC dental gel 1.1 % quit 4 buccal 0 $0 for ages 18 fluoride (sodium) 1 lozenge 4 mg and older for dental paste 1.1 % first 180 days; OTC fluoride (sodium) 1 dental solution 0.2 stop smoking aid 0 $0 for ages 18 % buccal lozenge 2 mg, and older for 4 mg first 180 days; FLUORIDEX 3 OTC DAILY DEFENSE DENTAL PASTE VARENICLINE 0 1.1 % ORAL TABLET 0.5 MG, 1 MG FLUORIDEX 3 SENSITIVITY EAR, NOSE & THROAT RELIEF DENTAL MEDICATIONS PASTE 1.1-5 % MISCELLANEOUS AGENTS GELCLAIR 3 MUCOUS azelastine nasal 1 QL MEMBRANE GEL aerosol,spray 137 IN PACKET mcg (0.1 %) GELX MUCOUS 3 azelastine nasal 1 MEMBRANE GEL spray,non-aerosol 205.5 mcg (0.15 %) ipratropium bromide 1 QL nasal spray,non- chlorhexidine 1 aerosol 21 mcg (0.03 gluconate mucous %), 42 mcg (0.06 %) membrane mouthwash 0.12 % MUGARD 3 MUCOUS CLINPRO 5000 3 MEMBRANE DENTAL PASTE SOLUTION 1.1 % olopatadine nasal 1 QL denta 5000 plus 1 spray,non-aerosol dental cream 1.1 % 0.6 % dentagel dental gel 1 oralone dental paste 1 1.1 % 0.1 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 86 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ORAMAGICRX 3 PREVIDENT 5000 3 MUCOUS SENSITIVE MEMBRANE DENTAL PASTE MOUTHWASH 1.1-5 % paroex oral rinse 1 PREVIDENT 3 mucous membrane DENTAL GEL 1.1 mouthwash 0.12 % % PATANASE 3 QL PREVIDENT 3 NASAL DENTAL SPRAY,NON- SOLUTION 0.2 % AEROSOL 0.6 % PROTHELIAL 5 PERIDEX 3 MUCOUS MUCOUS MEMBRANE MEMBRANE PASTE 1 GRAM/10 MOUTHWASH ML 0.12 % SALAGEN 3 periogard mucous 1 (PILOCARPINE) membrane ORAL TABLET 7.5 mouthwash 0.12 % MG pilocarpine hcl oral 1 sf 5000 plus dental 1 tablet 7.5 mg cream 1.1 % PREVIDENT 5000 3 sf dental gel 1.1 % 1 BOOSTER PLUS sodium fluoride 1 DENTAL PASTE 5000 dry mouth 1.1 % dental gel 1.1 % PREVIDENT 5000 3 sodium fluoride 1 DRY MOUTH 5000 plus dental DENTAL GEL 1.1 cream 1.1 % % sodium fluoride-pot 1 PREVIDENT 5000 3 nitrate dental paste ENAMEL 1.1-5 % PROTECT DENTAL PASTE triamcinolone 1 1.1-5 % acetonide dental paste 0.1 % PREVIDENT 5000 3 ORTHO DEFENSE MISCELLANEOUS OTIC DENTAL PASTE PREPARATIONS 1.1 % acetic acid otic (ear) 1 PREVIDENT 5000 3 solution 2 % PLUS DENTAL CREAM 1.1 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 87 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ciprofloxacin hcl 1 neomycin- 1 otic (ear) polymyxin-hc otic dropperette 0.2 % (ear) solution 3.5- DERMOTIC OIL 3 10,000-1 mg/ml- OTIC (EAR) unit/ml-% DROPS 0.01 % ENDOCRINE/DIABETES flac otic oil otic 1 ADRENAL HORMONES (ear) drops 0.01 % CORTEF ORAL 3 fluocinolone 1 TABLET 10 MG, 20 acetonide oil otic MG, 5 MG (ear) drops 0.01 % decadron oral tablet 1 hydrocortisone- 1 0.5 mg acetic acid otic (ear) drops 1-2 % dexabliss oral 1 ST tablets,dose pack 1.5 ofloxacin otic (ear) 1 mg (39 tabs) drops 0.3 % dexamethasone 1 OTIC STEROID / ANTIBIOTIC intensol oral drops 1 CIPRO HC OTIC 3 mg/ml (EAR) dexamethasone oral 1 DROPS,SUSPENSI elixir 0.5 mg/5 ml ON 0.2-1 % dexamethasone oral 1 CIPRODEX OTIC 2 solution 0.5 mg/5 ml (EAR) DROPS,SUSPENSI dexamethasone oral 1 ON 0.3-0.1 % tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 ciprofloxacin- 1 mg, 4 mg, 6 mg dexamethasone otic (ear) dexamethasone oral 1 ST drops,suspension tablets,dose pack 1.5 0.3-0.1 % mg (21 tabs), 1.5 mg (35 tabs), 1.5 mg (51 CORTISPORIN-TC 3 tabs) OTIC (EAR) DROPS,SUSPENSI DXEVO ORAL 3 ST ON 3.3-3-10-0.5 TABLETS,DOSE MG/ML PACK 1.5 MG (39 TABS) neomycin- 1 polymyxin-hc otic fludrocortisone oral 1 (ear) tablet 0.1 mg drops,suspension hidex oral 1 ST 3.5-10,000-1 mg/ml- tablets,dose pack 1.5 unit/ml-% mg (21 tabs) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 88 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydrocortisone oral 1 prednisolone sodium 1 tablet 10 mg, 20 mg, phosphate oral 5 mg tablet,disintegrating MEDROL (PAK) 3 10 mg, 15 mg, 30 mg ORAL prednisone intensol 1 TABLETS,DOSE oral concentrate 5 PACK 4 MG mg/ml MEDROL ORAL 3 prednisone oral 1 TABLET 16 MG, 2 solution 5 mg/5 ml MG, 32 MG, 4 MG, prednisone oral 1 8 MG tablet 1 mg, 10 mg, methylprednisolone 1 2.5 mg, 20 mg, 5 mg, oral tablet 16 mg, 32 50 mg mg, 4 mg, 8 mg prednisone oral 1 methylprednisolone 1 tablets,dose pack 10 oral tablets,dose mg, 5 mg pack 4 mg RAYOS ORAL 3 ST millipred dp oral 1 TABLET,DELAYE tablets,dose pack 5 D RELEASE mg (21 tabs), 5 mg (DR/EC) 1 MG, 2 (48 tabs) MG, 5 MG millipred oral tablet 1 TAPERDEX ORAL 3 ST 5 mg TABLETS,DOSE ORAPRED ODT 3 PACK 1.5 MG (21 ORAL TABS), 1.5 MG (27 TABLET,DISINTE TABS), 1.5 MG (49 GRATING 10 MG, TABS) 15 MG, 30 MG TRIESENCE (PF) 3 prednisolone oral 1 INTRAOCULAR solution 15 mg/5 ml SUSPENSION 40 MG/ML prednisolone sodium 1 phosphate oral ZCORT ORAL 3 ST solution 10 mg/5 ml, TABLETS,DOSE 15 mg/5 ml (3 PACK 1.5 MG (25 mg/ml), 20 mg/5 ml TABS) (4 mg/ml), 25 mg/5 ANTITHYROID AGENTS ml (5 mg/ml), 5 mg methimazole oral 1 base/5 ml (6.7 mg/5 tablet 10 mg, 5 mg ml) propylthiouracil oral 1 tablet 50 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 89 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits SSKI ORAL 3 AEROTRACH 2 SOLUTION 1 PLUS SPACER GRAM/ML AEROVENT PLUS 2 TAPAZOLE ORAL 3 SPACER TABLET 10 MG, 5 BREATHERITE 2 MG MDI SPACER BLOOD GLUCOSE MONITORING SPACER DEVICES & SUPPLIES COMPACT SPACE 2 FREESTYLE 2 OTC CHAMBER INSULINX STRIP SPACER FREESTYLE 2 OTC EASIVENT 2 INSULINX TEST HOLDING STRIPS STRIP CHAMBER SPACER FREESTYLE LITE 2 OTC STRIPS STRIP FLEXICHAMBER 2 SPACER FREESTYLE TEST 2 OTC STRIP GLUCAGEN 2 DIAGNOSTIC KIT ONETOUCH 2 OTC INJECTION ULTRA TEST RECON SOLN 1 STRIP MG/ML ONETOUCH 2 OTC GLUCAGON HCL 3 VERIO TEST INJECTION STRIPS STRIP RECON SOLN 1 PRECISION XTRA 2 OTC MG/ML TEST STRIP INSPIRACHAMBE 2 DIABETES, SUPPLIES, & DURABLE R SPACER MEDICAL EQUIPMENT INSULIN 3 ACE AEROSOL 2 SYRINGE- CLOUD NEEDLE U-100 ENHANCER SYRINGE 0.5 ML SPACER 29 GAUGE X 1/2" AEROCHAMBER 2 LITEAIRE MDI 2 MINI SPACER CHAMBER SPACER AEROCHAMBER 2 PLUS FLOW-VU MICROCHAMBER 2 SPACER SPACER AEROCHAMBER 2 MICROSPACER 2 PLUS Z STAT SPACER SPACER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 90 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits OPTICHAMBER 2 GLUCAGON 2 QL DIAMOND VHC (HCL) SPACER EMERGENCY KIT POCKET 2 INJECTION CHAMBER RECON SOLN 1 SPACER MG PRIMEAIRE 2 glucagon emergency 1 QL SPACER kit (human) injection recon soln 1 mg PROCHAMBER 2 SPACER GVOKE HYPOPEN 2 QL 2-PACK RITEFLO 2 SUBCUTANEOUS AEROCHAMBER AUTO-INJECTOR SPACER 0.5 MG/0.1 ML, 1 SPACE CHAMBER 2 MG/0.2 ML SPACER GVOKE PFS 2- 2 QL TRIJARDY XR 2 ST PACK SYRINGE ORAL TABLET, IR SUBCUTANEOUS - ER, BIPHASIC SYRINGE 0.5 24HR 10-5-1,000 MG/0.1 ML, 1 MG, 12.5-2.5-1,000 MG/0.2 ML MG, 25-5-1,000 PROGLYCEM 2 MG, 5-2.5-1,000 ORAL MG SUSPENSION 50 VORTEX 2 MG/ML HOLDING ZEGALOGUE 2 QL CHAMBER AUTOINJECTOR SPACER SUBCUTANEOUS GLUCOSE ELEVATING AGENTS AUTO-INJECTOR 0.6 MG/0.6 ML BAQSIMI NASAL 2 QL SPRAY,NON- ZEGALOGUE 2 QL AEROSOL 3 SYRINGE MG/ACTUATION SUBCUTANEOUS SYRINGE 0.6 diazoxide oral 1 MG/0.6 ML suspension 50 mg/ml INSULIN GLUCAGEN 2 QL SYRINGES/MISCELLANEOUS HYPOKIT DURABLE MEDICAL EQU INJECTION RECON SOLN 1 AT HOME A1C 3 OTC MG DEVICE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 91 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AUTOJECT 2 2 OTC DEXCOM G6 2 INJECTION RECEIVER DEVICE DEXCOM G6 2 QL SUBCUTANEOUS SENSOR DEVICE INSULIN PEN DEXCOM G6 2 QL AUTOPEN 1 TO 21 2 OTC TRANSMITTER UNITS DEVICE SUBCUTANEOUS INSULIN PEN DEXCOM 2 RECEIVER BD INTEGRA 2 NEEDLE NEEDLE EASY TOUCH 3 OTC 23 GAUGE X 1" BLU CTRL SOLN- L1,L3 SOLUTION BD 2 OTC MICROTAINER ECLIPSE NEEDLE 3 LANCET 30 NEEDLE 27 GAUGE GAUGE X 1/2" BD SPECIALTY 2 ENLITE SYSTEM 3 USE NEEDLES EVERSENSE 3 NEEDLE 30 SENSOR-HOLDER GAUGE X 1/2" SUBCUTANEOUS BD ULTRA FINE 2 OTC DEVICE LANCETS 33 FORA GTEL 3 OTC GAUGE MULTI-FUNCTN BD ULTRA-FINE 2 OTC MONITOR NANO PEN DEVICE NEEDLE NEEDLE FORA TN'G 3 OTC 32 GAUGE X 5/32" ADVANCE PRO CEQUR 3 MONITOR SIMPLICITY DEVICE DEVICE 2 UNIT FREESTYLE 2 OTC DEXCOM G4 2 FREEDOM KIT RECEIVER FREESTYLE 2 OTC DEXCOM G4 2 QL FREEDOM LITE TRANSMITTER KIT DEVICE FREESTYLE 2 OTC DEXCOM G5 2 INSULINX RECEIVER FREESTYLE 2 DEXCOM G5-G4 2 QL LIBRE 14 DAY SENSOR DEVICE READER

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 92 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FREESTYLE 2 QL ONETOUCH 2 OTC LIBRE 14 DAY VERIO FLEX SENSOR KIT METER FREESTYLE 2 ONETOUCH 2 OTC LIBRE 2 READER VERIO IQ METER FREESTYLE 2 ONETOUCH 2 OTC LIBRE 2 SENSOR VERIO METER KIT ONETOUCH 2 OTC FREESTYLE LITE 2 OTC VERIO REFLECT METER KIT METER GENTEEL 3 OTC PEN NEEDLE, 3 OTC VACUUM DIABETIC LANCING DEVICE NEEDLE 29 COMBO PACK GAUGE X 1/2" GOJJI MULTI- 3 OTC PRECISION XTRA 2 OTC FUNCTIONAL KETONE- METER KIT GLUCOSE KIT INPEN (FOR 3 PRECISION XTRA 2 OTC HUMALOG) MONITOR SUBCUTANEOUS SAFE-CLIP BY 2 OTC INSULIN PEN MAIL DEVICE INPEN (FOR 3 V-GO 20 DEVICE 2 NOVOLOG OR FIASP) V-GO 30 DEVICE 2 SUBCUTANEOUS V-GO 40 DEVICE 2 INSULIN PEN INSULIN THERAPY LANCETS 33 2 OTC GAUGE BASAGLAR 3 KWIKPEN U-100 LANCING DEVICE 2 OTC INSULIN MEDISENSE 2 OTC SUBCUTANEOUS GLUCOSE INSULIN PEN 100 KETONE COMBO UNIT/ML (3 ML) PACK HUMALOG 2 NOVOPEN ECHO 3 JUNIOR KWIKPEN SUBCUTANEOUS U-100 INSULIN PEN SUBCUTANEOUS INSULIN PEN, ONETOUCH 2 OTC HALF-UNIT 100 ULTRA2 METER UNIT/ML ONETOUCH 2 OTC ULTRAMINI KIT You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 93 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HUMALOG 2 HUMULIN 70/30 2 KWIKPEN U-100 INSULIN INSULIN SUBCUTANEOUS SUBCUTANEOUS SUSPENSION 100 INSULIN PEN 100 UNIT/ML (70-30) UNIT/ML, 200 HUMULIN 70/30 2 UNIT/ML (3 ML) U-100 KWIKPEN HUMALOG MIX 2 SUBCUTANEOUS 50-50 INSULN U- INSULIN PEN 100 100 UNIT/ML (70-30) SUBCUTANEOUS HUMULIN N NPH 2 SUSPENSION 100 INSULIN UNIT/ML (50-50) KWIKPEN HUMALOG MIX 2 SUBCUTANEOUS 50-50 KWIKPEN INSULIN PEN 100 SUBCUTANEOUS UNIT/ML (3 ML) INSULIN PEN 100 HUMULIN N NPH 2 UNIT/ML (50-50) U-100 INSULIN HUMALOG MIX 2 SUBCUTANEOUS 75-25 KWIKPEN SUSPENSION 100 SUBCUTANEOUS UNIT/ML INSULIN PEN 100 HUMULIN R 2 UNIT/ML (75-25) REGULAR U-100 HUMALOG MIX 2 INSULN 75-25(U- INJECTION 100)INSULN SOLUTION 100 SUBCUTANEOUS UNIT/ML SUSPENSION 100 HUMULIN R U-500 2 UNIT/ML (75-25) (CONC) INSULIN HUMALOG U-100 2 SUBCUTANEOUS INSULIN SOLUTION 500 SUBCUTANEOUS UNIT/ML CARTRIDGE 100 HUMULIN R U-500 2 UNIT/ML (CONC) KWIKPEN HUMALOG U-100 2 SUBCUTANEOUS INSULIN INSULIN PEN 500 SUBCUTANEOUS UNIT/ML (3 ML) SOLUTION 100 UNIT/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 94 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LANTUS 2 SOLIQUA 100/33 2 QL SOLOSTAR U-100 SUBCUTANEOUS INSULIN INSULIN PEN 100 SUBCUTANEOUS UNIT-33 MCG/ML INSULIN PEN 100 TOUJEO MAX U- 2 UNIT/ML (3 ML) 300 SOLOSTAR LANTUS U-100 2 SUBCUTANEOUS INSULIN INSULIN PEN 300 SUBCUTANEOUS UNIT/ML (3 ML) SOLUTION 100 TOUJEO 2 UNIT/ML SOLOSTAR U-300 LEVEMIR 2 INSULIN FLEXTOUCH U- SUBCUTANEOUS 100 INSULN INSULIN PEN 300 SUBCUTANEOUS UNIT/ML (1.5 ML) INSULIN PEN 100 TRESIBA 2 UNIT/ML (3 ML) FLEXTOUCH U- LEVEMIR U-100 2 100 INSULIN SUBCUTANEOUS SUBCUTANEOUS INSULIN PEN 100 SOLUTION 100 UNIT/ML (3 ML) UNIT/ML TRESIBA 2 LYUMJEV 2 FLEXTOUCH U- KWIKPEN U-100 200 INSULIN SUBCUTANEOUS SUBCUTANEOUS INSULIN PEN 200 INSULIN PEN 100 UNIT/ML (3 ML) UNIT/ML TRESIBA U-100 2 LYUMJEV 2 INSULIN KWIKPEN U-200 SUBCUTANEOUS INSULIN SOLUTION 100 SUBCUTANEOUS UNIT/ML INSULIN PEN 200 XULTOPHY 2 QL UNIT/ML (3 ML) 100/3.6 LYUMJEV U-100 2 SUBCUTANEOUS INSULIN INSULIN PEN 100 SUBCUTANEOUS UNIT-3.6 MG /ML SOLUTION 100 (3 ML) UNIT/ML MISCELLANEOUS HORMONES

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 95 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ANDRODERM 2 PA; QL DDAVP NASAL 2 TRANSDERMAL SOLUTION 0.1 PATCH 24 HOUR 2 MG/ML MG/24 HOUR, 4 (REFRIGERATE) MG/24 HR DDAVP ORAL 3 cabergoline oral 1 QL TABLET 0.1 MG, tablet 0.5 mg 0.2 MG calcitonin (salmon) 1 DEPO- 3 PA injection solution TESTOSTERONE 200 unit/ml INTRAMUSCULA calcitonin (salmon) 1 R OIL 100 MG/ML, nasal spray,non- 200 MG/ML aerosol 200 desmopressin nasal 1 unit/actuation spray,non-aerosol calcitriol 1 10 mcg/spray (0.1 intravenous solution ml) 1 mcg/ml desmopressin oral 1 calcitriol oral 1 tablet 0.1 mg, 0.2 mg capsule 0.25 mcg, doxercalciferol oral 1 ST 0.5 mcg capsule 0.5 mcg, 1 calcitriol oral 1 mcg, 2.5 mcg solution 1 mcg/ml FORTESTA 3 PA; QL CHORIONIC 3 PA TRANSDERMAL GONADOTROPIN, GEL IN HUMAN METERED-DOSE INJECTION PUMP 10 MG/0.5 RECON SOLN GRAM 12,000 UNIT, 6,000 /ACTUATION UNIT MENOPUR 4 CHORIONIC 5 QL SUBCUTANEOUS GONADOTROPIN, RECON SOLN 75 HUMAN UNIT INTRAMUSCULA METHITEST 2 R RECON SOLN ORAL TABLET 10 10,000 UNIT MG cinacalcet oral 1 PA methyltestosterone 1 tablet 30 mg, 60 mg, oral capsule 10 mg 90 mg MIACALCIN 3 danazol oral capsule 1 INJECTION 100 mg, 200 mg, 50 SOLUTION 200 mg UNIT/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 96 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits NATESTO NASAL 2 PA; QL ROCALTROL 3 ST GEL IN ORAL CAPSULE METERED-DOSE 0.25 MCG, 0.5 PUMP 5.5 MCG MG/0.122 ROCALTROL 3 ST GRAM/ACTUATIO ORAL SOLUTION N 1 MCG/ML NOCDURNA 3 PA; QL SOMAVERT 4 PA (MEN) SUBCUTANEOUS SUBLINGUAL RECON SOLN 10 TABLET,DISINTE MG, 15 MG, 20 GRATING 55.3 MG, 25 MG, 30 MG MCG SYNAREL NASAL 2 PA; ST NOCDURNA 3 PA; QL SPRAY,NON- (WOMEN) AEROSOL 2 SUBLINGUAL MG/ML TABLET,DISINTE GRATING 27.7 TEPEZZA 5 PA MCG INTRAVENOUS RECON SOLN 500 NOVAREL 4 QL MG INTRAMUSCULA R RECON SOLN testosterone 1 PA 10,000 UNIT, 5,000 cypionate UNIT intramuscular oil 100 mg/ml, 200 ORILISSA ORAL 2 PA; QL mg/ml TABLET 150 MG, 200 MG testosterone 1 PA enanthate OVIDREL 4 intramuscular oil SUBCUTANEOUS 200 mg/ml SYRINGE 250 MCG/0.5 ML testosterone 1 PA; QL transdermal gel 50 oxandrolone oral 1 mg/5 gram (1 %) tablet 10 mg, 2.5 mg testosterone 1 PA; QL paricalcitol 1 transdermal gel in intravenous solution metered-dose pump 2 mcg/ml, 5 mcg/ml 10 mg/0.5 gram paricalcitol oral 1 ST /actuation, 12.5 mg/ capsule 1 mcg, 2 1.25 gram (1 %), mcg, 4 mcg 20.25 mg/1.25 gram (1.62 %)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 97 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits testosterone 1 PA; QL ZEMPLAR ORAL 3 ST transdermal gel in CAPSULE 1 MCG, packet 1 % (25 2 MCG mg/2.5gram), 1 % NON-INSULIN HYPOGLYCEMIC (50 mg/5 gram), 1.62 % (20.25 AGENTS mg/1.25 gram), 1.62 acarbose oral tablet 1 % (40.5 mg/2.5 100 mg, 25 mg, 50 gram) mg testosterone 1 PA; QL ACTOPLUS MET 3 ST; QL transdermal solution ORAL TABLET 15- in metered pump 500 MG, 15-850 w/app 30 MG mg/actuation (1.5 ACTOS ORAL 3 ST; QL ml) TABLET 15 MG, 30 VOGELXO 3 PA; QL MG, 45 MG TRANSDERMAL ALOGLIPTIN 1 ST; QL GEL 50 MG/5 ORAL TABLET GRAM (1 %) 12.5 MG, 25 MG, VOGELXO 3 PA; QL 6.25 MG TRANSDERMAL AMARYL ORAL 3 GEL IN TABLET 1 MG, 2 METERED-DOSE MG, 4 MG PUMP 12.5 MG/ 1.25 GRAM (1 %) CYCLOSET ORAL 3 TABLET 0.8 MG VOGELXO 3 PA; QL TRANSDERMAL DUETACT ORAL 3 ST; QL GEL IN PACKET 1 TABLET 30-2 MG, % (50 MG/5 30-4 MG GRAM) FARXIGA ORAL 2 ST; QL XYOSTED 3 PA; QL TABLET 10 MG, 5 SUBCUTANEOUS MG AUTO-INJECTOR glimepiride oral 1 100 MG/0.5 ML, 50 tablet 1 mg, 2 mg, 4 MG/0.5 ML, 75 mg MG/0.5 ML glipizide oral tablet 1 ZEMPLAR 3 10 mg, 5 mg INTRAVENOUS SOLUTION 2 glipizide oral tablet 1 MCG/ML, 5 extended release MCG/ML 24hr 10 mg, 2.5 mg, 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 98 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits glipizide-metformin 1 JARDIANCE 2 ST; QL oral tablet 2.5-250 ORAL TABLET 10 mg, 2.5-500 mg, 5- MG, 25 MG 500 mg metformin oral 1 ST GLUCOTROL 3 solution 500 mg/5 ml ORAL TABLET 10 metformin oral 1 MG tablet 1,000 mg, 500 GLUCOTROL XL 3 mg, 850 mg ORAL TABLET metformin oral 1 QL EXTENDED tablet extended RELEASE 24HR 10 release 24 hr 500 MG, 2.5 MG, 5 MG mg, 750 mg glyburide 1 miglitol oral tablet 1 micronized oral 100 mg, 25 mg, 50 tablet 1.5 mg, 3 mg, mg 6 mg nateglinide oral 1 glyburide oral tablet 1 tablet 120 mg, 60 mg 1.25 mg, 2.5 mg, 5 mg OZEMPIC 2 PA; QL SUBCUTANEOUS glyburide-metformin 1 PEN INJECTOR oral tablet 1.25-250 0.25 MG OR 0.5 mg, 2.5-500 mg, 5- MG(2 MG/1.5 ML), 500 mg 1 MG/DOSE (2 GLYNASE ORAL 3 MG/1.5 ML), 1 TABLET 1.5 MG, 3 MG/DOSE (4 MG/3 MG, 6 MG ML) GLYXAMBI ORAL 2 ST; QL pioglitazone oral 1 QL TABLET 10-5 MG, tablet 15 mg, 30 mg, 25-5 MG 45 mg JANUMET ORAL 2 ST; QL pioglitazone- 1 QL TABLET 50-1,000 glimepiride oral MG, 50-500 MG tablet 30-2 mg, 30-4 JANUMET XR 2 ST; QL mg ORAL TABLET, pioglitazone- 1 QL ER MULTIPHASE metformin oral 24 HR 100-1,000 tablet 15-500 mg, MG, 50-1,000 MG, 15-850 mg 50-500 MG PRECOSE ORAL 3 JANUVIA ORAL 2 ST; QL TABLET 100 MG, TABLET 100 MG, 25 MG, 50 MG 25 MG, 50 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 99 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits repaglinide oral 1 TRULICITY 2 PA; QL tablet 0.5 mg, 1 mg, SUBCUTANEOUS 2 mg PEN INJECTOR repaglinide- 1 QL 0.75 MG/0.5 ML, metformin oral 1.5 MG/0.5 ML, 3 tablet 1-500 mg, 2- MG/0.5 ML, 4.5 500 mg MG/0.5 ML RIOMET ER ORAL 3 ST XIGDUO XR 2 ST; QL SUSPENSION,EXT ORAL TABLET, IR ENDED REL - ER, BIPHASIC RECON 500 MG/5 24HR 10-1,000 MG, ML 10-500 MG, 2.5- 1,000 MG, 5-1,000 RIOMET ORAL 3 ST MG, 5-500 MG SOLUTION 500 MG/5 ML THYROID HORMONES RYBELSUS ORAL 2 PA; QL ARMOUR 2 TABLET 14 MG, 3 THYROID ORAL MG, 7 MG TABLET 120 MG, 15 MG, 180 MG, STEGLUJAN 2 ST; QL 240 MG, 30 MG, ORAL TABLET 15- 300 MG, 60 MG, 90 100 MG, 5-100 MG MG SYMLINPEN 120 2 PA; QL euthyrox oral tablet 1 SUBCUTANEOUS 100 mcg, 112 mcg, PEN INJECTOR 125 mcg, 137 mcg, 2,700 MCG/2.7 ML 150 mcg, 175 mcg, SYMLINPEN 60 2 PA; QL 200 mcg, 25 mcg, 50 SUBCUTANEOUS mcg, 75 mcg, 88 mcg PEN INJECTOR levo-t oral tablet 100 1 1,500 MCG/1.5 ML mcg, 112 mcg, 125 SYNJARDY ORAL 2 ST; QL mcg, 137 mcg, 150 TABLET 12.5-1,000 mcg, 175 mcg, 200 MG, 12.5-500 MG, mcg, 25 mcg, 300 5-1,000 MG, 5-500 mcg, 50 mcg, 75 MG mcg, 88 mcg SYNJARDY XR 2 ST; QL levothyroxine oral 1 ORAL TABLET, IR tablet 100 mcg, 112 - ER, BIPHASIC mcg, 125 mcg, 137 24HR 10-1,000 MG, mcg, 150 mcg, 175 12.5-1,000 MG, 25- mcg, 200 mcg, 25 1,000 MG, 5-1,000 mcg, 300 mcg, 50 MG mcg, 75 mcg, 88 mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 100 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits levoxyl oral tablet 1 unithroid oral tablet 1 100 mcg, 112 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 200 mcg, 25 mcg, mcg, 75 mcg, 88 mcg 300 mcg, 50 mcg, 75 liothyronine oral 1 mcg, 88 mcg tablet 25 mcg, 5 westhroid oral tablet 1 mcg, 50 mcg 130 mg, 195 mg, np thyroid oral 1 32.5 mg, 65 mg, 97.5 tablet 120 mg, 15 mg mg, 30 mg, 60 mg, GASTROENTEROLOGY 90 mg ANTIDIARRHEALS & SYNTHROID 3 ANTISPASMODICS ORAL TABLET 100 MCG, 112 anaspaz oral 1 MCG, 125 MCG, tablet,disintegrating 137 MCG, 150 0.125 mg MCG, 175 MCG, belladonna 1 200 MCG, 25 MCG, alkaloids-opium 300 MCG, 50 MCG, rectal suppository 75 MCG, 88 MCG 16.2-30 mg, 16.2-60 THYROLAR-1 3 mg ORAL TABLET chlordiazepoxide- 1 12.5-50 MCG clidinium oral THYROLAR-1/2 3 capsule 5-2.5 mg ORAL TABLET dicyclomine oral 1 6.25-25 MCG capsule 10 mg THYROLAR-1/4 3 dicyclomine oral 1 ORAL TABLET solution 10 mg/5 ml 3.1-12.5 MCG dicyclomine oral 1 THYROLAR-2 3 tablet 20 mg ORAL TABLET 25- 100 MCG diphenoxylate- 1 atropine oral liquid THYROLAR-3 3 2.5-0.025 mg/5 ml ORAL TABLET 37.5-150 MCG diphenoxylate- 1 atropine oral tablet 2.5-0.025 mg ed-spaz oral 1 tablet,disintegrating 0.125 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 101 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hyoscyamine sulfate 1 methscopolamine 1 oral drops 0.125 oral tablet 2.5 mg, 5 mg/ml mg hyoscyamine sulfate 1 NULEV ORAL 3 oral elixir 0.125 TABLET,DISINTE mg/5 ml GRATING 0.125 hyoscyamine sulfate 1 MG oral tablet 0.125 mg opium tincture oral 1 hyoscyamine sulfate 1 tincture 10 mg/ml oral tablet extended (morphine) release 12 hr 0.375 oscimin oral tablet 1 mg 0.125 mg hyoscyamine sulfate 1 oscimin sl sublingual 1 oral tablet 0.125 mg tablet,disintegrating oscimin sr oral 1 0.125 mg tablet extended hyoscyamine sulfate 1 release 12 hr 0.375 sublingual tablet mg 0.125 mg phenobarb-hyoscy- 1 hyosyne oral drops 1 atropine-scop oral 0.125 mg/ml tablet 16.2-0.1037 - hyosyne oral elixir 1 0.0194 mg 0.125 mg/5 ml SYMAX DUOTAB 3 LEVBID ORAL 3 ORAL TABLET TABLET,EXT EXTENDED RELEASE RELEASE 12 HR MULTIPHASE 0.375 MG 0.125 MG-0.25 MG (0.375 MG) LEVSIN ORAL 3 TABLET 0.125 MG symax fastabs oral 1 tablet,disintegrating LEVSIN/SL 3 0.125 mg SUBLINGUAL TABLET 0.125 MG symax-sl sublingual 1 tablet 0.125 mg LOMOTIL ORAL 3 TABLET 2.5-0.025 symax-sr oral tablet 1 MG extended release 12 hr 0.375 mg loperamide oral 1 capsule 2 mg MISCELLANEOUS GASTROINTESTINAL AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 102 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AKYNZEO 3 QL AVSOLA 5 PA (NETUPITANT) INTRAVENOUS ORAL CAPSULE RECON SOLN 100 300-0.5 MG MG alophen (bisacodyl) 0 covered at $0 AZULFIDINE EN- 3 oral tablet,delayed for ages 50-75 TABS ORAL release (dr/ec) 5 mg years; OTC TABLET,DELAYE alosetron oral tablet 1 D RELEASE 0.5 mg, 1 mg (DR/EC) 500 MG alvimopan oral 1 AZULFIDINE 3 capsule 12 mg ORAL TABLET 500 MG ANA-LEX KIT 3 RECTAL KIT 2-2 % balsalazide oral 1 capsule 750 mg ANALPRAM-HC 3 RECTAL CREAM bisacodyl oral 0 covered at $0 1-1 % tablet,delayed for ages 50-75 release (dr/ec) 5 mg years; OTC ANALPRAM-HC 3 ST RECTAL CREAM bisa-lax (bisacodyl) 0 covered at $0 2.5-1 % oral tablet,delayed for ages 50-75 release (dr/ec) 5 mg years; OTC ANALPRAM-HC 3 SINGLES RECTAL BONJESTA ORAL 3 QL CREAM 2.5-1 % TABLET,IR,DELA (4G) YED REL,BIPHASIC 20- anucort-hc rectal 1 20 MG suppository 25 mg budesonide oral 1 aprepitant oral 1 QL capsule,delayed,exte capsule 125 mg, 40 nd.release 3 mg mg, 80 mg budesonide oral 1 aprepitant oral 1 QL tablet,delayed and capsule,dose pack ext.release 9 mg 125 mg (1)- 80 mg (2) calcium 1 QL acetate(phosphat APRISO ORAL 3 bind) oral capsule CAPSULE,EXTEN 667 mg DED RELEASE 24HR 0.375 GRAM calcium 1 QL acetate(phosphat AURYXIA ORAL 3 bind) oral tablet 667 TABLET 210 MG mg IRON CHENODAL ORAL 4 PA TABLET 250 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 103 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits citrate of magnesia 0 covered at $0 CREON ORAL 2 oral solution for ages 50-75 CAPSULE,DELAY years; OTC ED citroma oral solution 0 covered at $0 RELEASE(DR/EC) for ages 50-75 12,000-38,000 - years; OTC 60,000 UNIT, 24,000-76,000 - clearlax oral powder 0 covered at $0 120,000 UNIT, 17 gram/dose for ages 50-75 3,000-9,500- 15,000 years; OTC UNIT, 36,000- clearlax oral powder 0 covered at $0 114,000- 180,000 in packet 17 gram for ages 50-75 UNIT, 6,000-19,000 years; OTC -30,000 UNIT CLENPIQ ORAL 0 $0 for ages 50- cromolyn oral 1 SOLUTION 10 MG- 75 years concentrate 100 3.5 GRAM -12 mg/5 ml GRAM/160 ML DIPENTUM ORAL 3 COLAZAL ORAL 3 CAPSULE 250 MG CAPSULE 750 MG doxylamine- 1 QL COMPAZINE 3 pyridoxine (vit b6) ORAL TABLET 10 oral tablet,delayed MG, 5 MG release (dr/ec) 10-10 mg COMPAZINE 3 RECTAL dronabinol oral 1 PA SUPPOSITORY 25 capsule 10 mg, 2.5 MG mg, 5 mg compro rectal 1 dulcolax 0 OTC suppository 25 mg (magnesium hydroxide) oral constulose oral 1 suspension 400 mg/5 solution 10 gram/15 ml ml ENTEREG ORAL 3 CORTENEMA 3 CAPSULE 12 MG RECTAL ENEMA 100 MG/60 ML ENTOCORT EC 3 ORAL CAPSULE,DELAY ED,EXTEND.RELE ASE 3 MG enulose oral solution 1 10 gram/15 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 104 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GASTROCROM 3 hydrocortisone 1 ORAL topical cream with CONCENTRATE perineal applicator 1 100 MG/5 ML %, 2.5 % GATTEX 30-VIAL 5 PA hydrocortisone- 1 SUBCUTANEOUS pramoxine rectal KIT 5 MG cream 1-1 %, 2.5-1 gavilax oral powder 0 covered at $0 %, 2.5-1 % (4g) 17 gram/dose for ages 50-75 KRISTALOSE 3 years; OTC ORAL PACKET 10 generlac oral 1 GRAM, 20 GRAM solution 10 gram/15 lactulose oral packet 1 ml 10 gram gentle laxative 0 covered at $0 lactulose oral 1 (bisacodyl) oral for ages 50-75 solution 10 gram/15 tablet,delayed years; OTC ml, 20 gram/30 ml release (dr/ec) 5 mg laxaclear oral 0 covered at $0 gentlelax oral 0 covered at $0 powder 17 for ages 50-75 powder 17 for ages 50-75 gram/dose years; OTC gram/dose years; OTC laxative (bisacodyl) 0 covered at $0 glycolax oral 0 covered at $0 oral tablet 5 mg for ages 50-75 powder 17 for ages 50-75 years; OTC gram/dose years; OTC laxative (bisacodyl) 0 covered at $0 granisetron hcl oral 1 QL oral tablet,delayed for ages 50-75 tablet 1 mg release (dr/ec) 5 mg years; OTC healthylax oral 0 covered at $0 laxative peg 3350 0 covered at $0 powder in packet 17 for ages 50-75 oral powder 17 for ages 50-75 gram years; OTC gram/dose years; OTC hemmorex-hc rectal 1 lidocaine hcl- 1 suppository 25 mg hydrocortison ac hydrocortisone 1 rectal cream 3-0.5 % acetate rectal LIDOCAINE HCL- 3 suppository 25 mg, HYDROCORTISO 30 mg N AC RECTAL hydrocortisone 1 GEL 3 %-2.5 % (7 rectal enema 100 GRAM) mg/60 ml lidocaine hcl- 1 hydrocortison ac rectal kit 2 %-2 % (7 gram), 3-0.5 %, 3-1 % (7 gram) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 105 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lidocaine- 1 metoclopramide hcl 1 hydrocortisone-aloe oral tablet 10 mg, 5 rectal gel 2.8-0.55 % mg lidocaine- 1 metoclopramide hcl 1 hydrocortisone-aloe oral rectal kit 3-2.5 % (7 tablet,disintegrating gram) 10 mg, 5 mg magnesium citrate 0 covered at $0 milk of magnesia 0 covered at $0 oral solution for ages 50-75 concentrated oral for ages 50-75 years; OTC suspension 2,400 years; OTC MARINOL ORAL 3 PA mg/10 ml CAPSULE 10 MG, milk of magnesia 0 covered at $0 2.5 MG, 5 MG oral suspension 400 for ages 50-75 meclizine oral tablet 1 mg/5 ml years; OTC 12.5 mg, 25 mg miralax oral powder 0 covered at $0 mesalamine oral 1 in packet 17 gram for ages 50-75 capsule (with del rel years; OTC tablets) 400 mg MOTEGRITY 3 QL mesalamine oral 1 ORAL TABLET 1 capsule,extended MG, 2 MG release 24hr 0.375 MOVANTIK ORAL 2 QL gram TABLET 12.5 MG, mesalamine oral 1 25 MG tablet,delayed natura-lax oral 0 covered at $0 release (dr/ec) 1.2 powder 17 for ages 50-75 gram, 800 mg gram/dose years; OTC mesalamine rectal 1 NULYTELY 0 enema 4 gram/60 ml LEMON-LIME mesalamine rectal 1 ORAL RECON suppository 1,000 SOLN 420 GRAM mg ondansetron hcl oral 1 QL mesalamine with 1 solution 4 mg/5 ml cleansing wipe ondansetron hcl oral 1 QL rectal enema kit 4 tablet 4 mg, 8 mg gram/60 ml ondansetron oral 1 QL metoclopramide hcl 1 tablet,disintegrating oral solution 5 mg/5 4 mg, 8 mg ml oral saline laxative 0 covered at $0 oral liquid 7.2-2.7 for ages 50-75 gram/15 ml years; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 106 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ORTIKOS ORAL 3 PHOSLYRA ORAL 2 QL CAPSULE, SOLUTION 667 EXTENDED MG (169 MG RELEASE 6 MG, 9 CALCIUM)/5 ML MG phosphate laxative 0 covered at $0 PANCREAZE 2 oral liquid 7.2-2.7 for ages 50-75 ORAL gram/15 ml years; OTC CAPSULE,DELAY polyethylene glycol 0 covered at $0 ED 3350 oral powder 17 for ages 50-75 RELEASE(DR/EC) gram/dose years; OTC 10,500-35,500- 61,500 UNIT, polyethylene glycol 0 covered at $0 16,800-56,800- 3350 oral powder in for ages 50-75 98,400 UNIT, 2,600- packet 17 gram years; OTC 8,800- 15,200 UNIT, powderlax oral 0 covered at $0 21,000-54,700- powder 17 for ages 50-75 83,900 UNIT, gram/dose years; OTC 37,000-97,300- 149,900 UNIT, powderlax oral 0 covered at $0 4,200-14,200- powder in packet 17 for ages 50-75 24,600 UNIT gram years; OTC peg 3350- 0 prochlorperazine 1 electrolytes oral maleate oral tablet recon soln 236- 10 mg, 5 mg 22.74-6.74 -5.86 prochlorperazine 1 gram rectal suppository 25 peg3350-sod sul- 0 mg nacl-kcl-asb-c oral PROCORT 3 powder in packet RECTAL CREAM 100-7.5-2.691 gram 1.85-1.15 % peg-electrolyte soln 0 $0 for ages 50- PROCTOCORT 3 ST oral recon soln 420 75 years RECTAL gram SUPPOSITORY 30 peg-prep oral kit 5- 0 $0 for ages 50- MG 210 mg-gram 75 years procto-med hc 1 PENTASA ORAL 2 topical cream with CAPSULE, perineal applicator EXTENDED 2.5 % RELEASE 250 MG, procto-pak topical 1 500 MG cream with perineal applicator 1 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 107 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits proctosol hc topical 1 sevelamer carbonate 1 QL cream with perineal oral tablet 800 mg applicator 2.5 % sevelamer hcl oral 1 QL proctozone-hc 1 tablet 400 mg, 800 topical cream with mg perineal applicator SFROWASA 3 2.5 % RECTAL ENEMA 4 purelax oral powder 0 covered at $0 GRAM/60 ML 17 gram/dose for ages 50-75 smoothlax oral 0 covered at $0 years; OTC powder 17 for ages 50-75 purelax oral powder 0 covered at $0 gram/dose years; OTC in packet 17 gram for ages 50-75 smoothlax oral 0 covered at $0 years; OTC powder in packet 17 for ages 50-75 RECTIV RECTAL 2 gram years; OTC OINTMENT 0.4 % sodium polystyrene 1 (W/W) sulfonate oral REGLAN ORAL 3 powder TABLET 10 MG, 5 sps (with sorbitol) 1 MG oral suspension 15- RENVELA ORAL 3 QL 20 gram/60 ml POWDER IN sps (with sorbitol) 1 PACKET 0.8 rectal enema 30-40 GRAM, 2.4 GRAM gram/120 ml RENVELA ORAL 3 QL SUCRAID ORAL 4 PA TABLET 800 MG SOLUTION 8,500 ROWASA RECTAL 3 UNIT/ML ENEMA KIT 4 sulfasalazine oral 1 GRAM/60 ML tablet 500 mg SANCUSO 3 QL sulfasalazine oral 1 TRANSDERMAL tablet,delayed PATCH WEEKLY release (dr/ec) 500 3.1 MG/24 HOUR mg scopolamine base 1 SYNDROS ORAL 3 PA transdermal patch 3 SOLUTION 5 day 1 mg over 3 MG/ML days trilyte with flavor 0 $0 for ages 50- sevelamer carbonate 1 QL packets oral recon 75 years oral powder in soln 420 gram packet 0.8 gram, 2.4 gram trimethobenzamide 1 oral capsule 300 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 108 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits UCERIS ORAL 3 ZENPEP ORAL 2 TABLET,DELAYE CAPSULE,DELAY D AND ED EXT.RELEASE 9 RELEASE(DR/EC) MG 10,000-32,000 - UCERIS RECTAL 2 42,000 UNIT, FOAM 2 15,000-47,000 - MG/ACTUATION 63,000 UNIT, 20,000-63,000- URSO 250 ORAL 3 84,000 UNIT, TABLET 250 MG 25,000-79,000- URSO FORTE 3 105,000 UNIT, ORAL TABLET 3,000-10,000 - 500 MG 14,000-UNIT, 40,000-126,000- ursodiol oral 1 168,000 UNIT, capsule 300 mg 5,000-17,000- ursodiol oral tablet 1 24,000 UNIT 250 mg, 500 mg ZOFRAN ORAL 3 QL VARUBI ORAL 2 QL TABLET 4 MG TABLET 90 MG ZUPLENZ ORAL 3 QL VIOKACE ORAL 2 FILM 4 MG, 8 MG TABLET 10,440- ULCER THERAPY 39,150- 39,150 UNIT, 20,880- amoxicil- 1 QL 78,300- 78,300 clarithromy- UNIT lansopraz oral combo pack 500- women's gentle 0 covered at $0 500-30 mg laxative(bisac) oral for ages 50-75 tablet,delayed years; OTC CARAFATE ORAL 3 release (dr/ec) 5 mg SUSPENSION 100 MG/ML women's laxative 0 covered at $0 (bisacodyl) oral for ages 50-75 CARAFATE ORAL 3 tablet 5 mg years; OTC TABLET 1 GRAM women's laxative 0 covered at $0 cimetidine hcl oral 1 (bisacodyl) oral for ages 50-75 solution 300 mg/5 ml tablet,delayed years; OTC cimetidine oral 1 release (dr/ec) 5 mg tablet 200 mg, 300 ZELNORM ORAL 3 mg, 400 mg, 800 mg TABLET 6 MG CYTOTEC ORAL 3 TABLET 100 MCG, 200 MCG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 109 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DEXILANT ORAL 3 ST; QL lansoprazole oral 1 ST CAPSULE,BIPHAS tablet,disintegrat, E DELAYED delay rel 30 mg RELEAS 30 MG misoprostol oral 1 DEXILANT ORAL 3 ST tablet 100 mcg, 200 CAPSULE,BIPHAS mcg E DELAYED nizatidine oral 1 RELEAS 60 MG capsule 150 mg, 300 esomeprazole 1 QL mg magnesium oral nizatidine oral 1 capsule,delayed solution 150 mg/10 release(dr/ec) 20 mg ml esomeprazole 1 OMECLAMOX- 3 QL magnesium oral PAK ORAL capsule,delayed COMBO PACK 20 release(dr/ec) 40 mg MG-500 MG- 500 esomeprazole 1 ST; QL MG (40) magnesium oral omeprazole oral 1 QL granules dr for susp capsule,delayed in packet 10 mg, 20 release(dr/ec) 10 mg mg omeprazole oral 1 esomeprazole 1 ST capsule,delayed magnesium oral release(dr/ec) 20 granules dr for susp mg, 40 mg in packet 40 mg omeprazole-sodium 1 ST; QL famotidine oral 1 bicarbonate oral suspension 40 mg/5 capsule 20-1.1 mg- ml (8 mg/ml) gram famotidine oral 1 omeprazole-sodium 1 ST tablet 20 mg, 40 mg bicarbonate oral lansoprazole oral 1 QL capsule 40-1.1 mg- capsule,delayed gram release(dr/ec) 15 mg omeprazole-sodium 1 ST; QL lansoprazole oral 1 bicarbonate oral capsule,delayed packet 20-1,680 mg release(dr/ec) 30 mg omeprazole-sodium 1 ST lansoprazole oral 1 ST; QL bicarbonate oral tablet,disintegrat, packet 40-1,680 mg delay rel 15 mg pantoprazole oral 1 ST granules dr for susp in packet 40 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 110 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits pantoprazole oral 1 QL NIVESTYM 4 PA tablet,delayed INJECTION release (dr/ec) 20 SOLUTION 300 mg MCG/ML, 480 pantoprazole oral 1 MCG/1.6 ML tablet,delayed NIVESTYM 4 PA release (dr/ec) 40 SUBCUTANEOUS mg SYRINGE 300 PEPCID ORAL 3 MCG/0.5 ML, 480 TABLET 20 MG, 40 MCG/0.8 ML MG NYVEPRIA 4 PA; QL rabeprazole oral 1 SUBCUTANEOUS tablet,delayed SYRINGE 6 MG/0.6 release (dr/ec) 20 ML mg REBLOZYL 5 PA sucralfate oral 1 SUBCUTANEOUS suspension 100 RECON SOLN 25 mg/ml MG, 75 MG sucralfate oral tablet 1 RETACRIT 4 PA 1 gram INJECTION SOLUTION 10,000 TALICIA ORAL 2 QL UNIT/ML, 2,000 CAPSULE,IR - UNIT/ML, 20,000 DELAY UNIT/2 ML, 20,000 REL,BIPHASE 10- UNIT/ML, 3,000 250-12.5 MG UNIT/ML, 4,000 IMMUNOLOGY, VACCINES & UNIT/ML, 40,000 UNIT/ML BIOTECHNOLOGY ZARXIO 4 PA BIOTECHNOLOGY DRUGS INJECTION FULPHILA 4 PA; QL SYRINGE 300 SUBCUTANEOUS MCG/0.5 ML, 480 SYRINGE 6 MG/0.6 MCG/0.8 ML ML ZIEXTENZO 4 PA MACRILEN ORAL 5 QL SUBCUTANEOUS RECON SOLN 0.5 SYRINGE 6 MG/0.6 MG/ML ML MOZOBIL 4 GROWTH HORMONES SUBCUTANEOUS EGRIFTA SV 4 PA SOLUTION 24 SUBCUTANEOUS MG/1.2 ML (20 RECON SOLN 2 MG/ML) MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 111 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits GENOTROPIN 4 PA AUBAGIO ORAL 4 PA; QL MINIQUICK TABLET 14 MG, 7 SUBCUTANEOUS MG SYRINGE 0.2 BAFIERTAM 4 PA; QL MG/0.25 ML, 0.4 ORAL MG/0.25 ML, 0.6 CAPSULE,DELAY MG/0.25 ML, 0.8 ED MG/0.25 ML, 1 RELEASE(DR/EC) MG/0.25 ML, 1.2 95 MG MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 BETASERON 4 PA; QL MG/0.25 ML, 1.8 SUBCUTANEOUS MG/0.25 ML, 2 KIT 0.3 MG MG/0.25 ML COPAXONE 5 PA; QL GENOTROPIN 4 PA SUBCUTANEOUS SUBCUTANEOUS SYRINGE 20 CARTRIDGE 12 MG/ML, 40 MG/ML (36 MG/ML UNIT/ML), 5 dimethyl fumarate 4 PA; QL MG/ML (15 oral capsule,delayed UNIT/ML) release(dr/ec) 120 NORDITROPIN 4 PA mg, 120 mg (14)- FLEXPRO 240 mg (46), 240 mg SUBCUTANEOUS GILENYA ORAL 4 PA; QL PEN INJECTOR 10 CAPSULE 0.5 MG MG/1.5 ML (6.7 MG/ML), 15 glatiramer 4 PA; QL MG/1.5 ML (10 subcutaneous MG/ML), 30 MG/3 syringe 20 mg/ml, 40 ML (10 MG/ML), 5 mg/ml MG/1.5 ML (3.3 glatopa 4 PA; QL MG/ML) subcutaneous SEROSTIM 4 syringe 20 mg/ml, 40 SUBCUTANEOUS mg/ml RECON SOLN 4 MAVENCLAD (10 5 PA; QL MG, 5 MG, 6 MG TABLET PACK) ZORBTIVE 5 ORAL TABLET 10 SUBCUTANEOUS MG RECON SOLN 8.8 MAVENCLAD (4 5 PA; QL MG TABLET PACK) INTERFERONS ORAL TABLET 10 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 112 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MAVENCLAD (5 5 PA; QL PLEGRIDY 4 PA; QL TABLET PACK) SUBCUTANEOUS ORAL TABLET 10 PEN INJECTOR MG 125 MCG/0.5 ML, MAVENCLAD (6 5 PA; QL 63 MCG/0.5 ML- 94 TABLET PACK) MCG/0.5 ML ORAL TABLET 10 PLEGRIDY 4 PA; QL MG SUBCUTANEOUS MAVENCLAD (7 5 PA; QL SYRINGE 125 TABLET PACK) MCG/0.5 ML, 63 ORAL TABLET 10 MCG/0.5 ML- 94 MG MCG/0.5 ML MAVENCLAD (8 5 PA; QL POMALYST ORAL 4 PA TABLET PACK) CAPSULE 1 MG, 2 ORAL TABLET 10 MG, 3 MG, 4 MG MG PONVORY 14- 4 PA; QL MAVENCLAD (9 5 PA; QL DAY STARTER TABLET PACK) PACK ORAL ORAL TABLET 10 TABLETS,DOSE MG PACK 2 MG (2) - 10 MG (3) MAYZENT ORAL 4 PA; QL TABLET 0.25 MG, PONVORY ORAL 4 PA; QL 2 MG TABLET 20 MG MAYZENT 4 PA REBIF REBIDOSE 4 PA; QL STARTER PACK SUBCUTANEOUS ORAL PEN INJECTOR 22 TABLETS,DOSE MCG/0.5 ML, 44 PACK 0.25 MG (12 MCG/0.5 ML TABS) REVLIMID ORAL 4 PA; QL PEGASYS 4 PA; QL CAPSULE 10 MG, SUBCUTANEOUS 15 MG, 2.5 MG, 20 SOLUTION 180 MG, 25 MG, 5 MG MCG/ML ribavirin oral 4 PA PEGASYS 4 PA; QL capsule 200 mg SUBCUTANEOUS ribavirin oral tablet 4 PA SYRINGE 180 200 mg MCG/0.5 ML PLEGRIDY 4 PA; QL INTRAMUSCULA R SYRINGE 125 MCG/0.5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 113 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TECFIDERA ORAL 4 PA; QL imiquimod topical 1 CAPSULE,DELAY cream in packet 3.75 ED %, 5 % RELEASE(DR/EC) VACCINES & MISCELLANEOUS 120 MG, 120 MG (14)- 240 MG (46), IMMUNOLOGICALS 240 MG ACTHIB (PF) 0 $0 for ages 1 VUMERITY ORAL 4 PA; QL INTRAMUSCULA month and CAPSULE,DELAY R RECON SOLN 10 older ED MCG/0.5 ML RELEASE(DR/EC) ADACEL(TDAP 0 $0 for ages 7 231 MG ADOLESN/ADULT and older ZEPOSIA ORAL 4 PA; QL )(PF) CAPSULE 0.92 MG INTRAMUSCULA R SUSPENSION 2 ZEPOSIA 4 PA; QL LF-(2.5-5-3-5 STARTER KIT MCG)-5LF/0.5 ML ORAL CAPSULE,DOSE ADACEL(TDAP 0 $0 for ages 7 PACK 0.23-0.46- ADOLESN/ADULT and older 0.92 MG )(PF) INTRAMUSCULA ZEPOSIA 4 PA; QL R SYRINGE 2 LF- STARTER PACK (2.5-5-3-5 MCG)- ORAL 5LF/0.5 ML CAPSULE,DOSE PACK 0.23 MG (4)- AFLURIA QD 0 0.46 MG (3) 2021-22(3YR UP)(PF) INTERLEUKINS INTRAMUSCULA ACTIMMUNE 4 PA R SYRINGE 60 SUBCUTANEOUS MCG (15 MCG X SOLUTION 100 4)/0.5 ML MCG/0.5 ML AFLURIA QD 0 ALDARA 3 2021-22(6- TOPICAL CREAM 35MO)(PF) IN PACKET 5 % INTRAMUSCULA R SYRINGE 30 ALFERON N 2 MCG (7.5 MCG X INJECTION 4)/0.25 ML SOLUTION 5 MILLION UNIT/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 114 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits AFLURIA QUAD 0 ENGERIX-B (PF) 0 2021-2022(6MO INTRAMUSCULA UP) R SUSPENSION 20 INTRAMUSCULA MCG/ML R SUSPENSION 60 ENGERIX-B (PF) 0 MCG (15 MCG X INTRAMUSCULA 4)/0.5 ML R SYRINGE 20 ASCENIV 5 PA MCG/ML INTRAVENOUS ENGERIX-B 0 SOLUTION 10 % PEDIATRIC (PF) BCG VACCINE, 0 INTRAMUSCULA LIVE (PF) R SYRINGE 10 PERCUTANEOUS MCG/0.5 ML SUSPENSION FOR FLUAD QUAD 0 RECONSTITUTIO 2021-22(65Y N 50 MG UP)(PF) BEXSERO 0 $0 for ages 10 INTRAMUSCULA INTRAMUSCULA years and older R SYRINGE 60 R SYRINGE 50-50- MCG (15 MCG X 50-25 MCG/0.5 ML 4)/0.5 ML BIOTHRAX 0 FLUARIX QUAD 0 INTRAMUSCULA 2021-2022 (PF) R SUSPENSION 0.5 INTRAMUSCULA ML/DOSE R SYRINGE 60 BOOSTRIX TDAP 0 $0 for ages 7 MCG (15 MCG X INTRAMUSCULA and older 4)/0.5 ML R SUSPENSION FLUBLOK QUAD 0 2.5-8-5 LF-MCG- 2021-2022 (PF) LF/0.5ML INTRAMUSCULA BOOSTRIX TDAP 0 $0 for ages 7 R SYRINGE 180 INTRAMUSCULA and older MCG (45 MCG X R SYRINGE 2.5-8-5 4)/0.5 ML LF-MCG-LF/0.5ML FLUCELVAX 0 DAPTACEL (DTAP 0 $0 for ages 1- QUAD 2021-2022 PEDIATRIC) (PF) 12 months old (PF) INTRAMUSCULA INTRAMUSCULA R SUSPENSION R SYRINGE 60 15-10-5 LF-MCG- MCG (15 MCG X LF/0.5ML 4)/0.5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 115 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits FLUCELVAX 0 GARDASIL 9 (PF) 0 $0 for ages 9- QUAD 2021-2022 INTRAMUSCULA 26 years old INTRAMUSCULA R SYRINGE 0.5 ML R SUSPENSION 60 HAVRIX (PF) 0 $0 for ages 1 MCG (15 MCG X INTRAMUSCULA year and older 4)/0.5 ML R SUSPENSION FLULAVAL QUAD 0 1,440 ELISA 2021-2022 (PF) UNIT/ML INTRAMUSCULA HAVRIX (PF) 0 $0 for ages 1 R SYRINGE 60 INTRAMUSCULA year and older MCG (15 MCG X R SYRINGE 1,440 4)/0.5 ML ELISA UNIT/ML, FLUZONE 0 720 ELISA HIGHDOSE QUAD UNIT/0.5 ML 21-22 PF HEPLISAV-B (PF) 0 $0 for ages 18 INTRAMUSCULA INTRAMUSCULA and older R SYRINGE 240 R SYRINGE 20 MCG/0.7 ML MCG/0.5 ML FLUZONE QUAD 0 HIBERIX (PF) 0 2021-2022 (PF) INTRAMUSCULA INTRAMUSCULA R RECON SOLN 10 R SUSPENSION 60 MCG/0.5 ML MCG (15 MCG X 4)/0.5 ML IMOVAX RABIES 0 VACCINE (PF) FLUZONE QUAD 0 INTRAMUSCULA 2021-2022 (PF) R RECON SOLN INTRAMUSCULA 2.5 UNIT R SYRINGE 60 MCG (15 MCG X INFANRIX (DTAP) 0 $0 for ages 1- 4)/0.5 ML (PF) 12 months old INTRAMUSCULA FLUZONE QUAD 0 R SYRINGE 25-58- 2021-2022 10 LF-MCG- INTRAMUSCULA LF/0.5ML R SUSPENSION 60 MCG (15 MCG X IPOL INJECTION 0 4)/0.5 ML SUSPENSION 40-8- 32 UNIT/0.5 ML GARDASIL 9 (PF) 0 $0 for ages 9- INTRAMUSCULA 26 years old IXIARO (PF) 0 R SUSPENSION 0.5 INTRAMUSCULA ML R SYRINGE 6 MCG/0.5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 116 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits JANSSEN COVID- 0 PEDVAX HIB (PF) 0 $0 for ages 1 19 VACCINE INTRAMUSCULA month and (EUA) R SOLUTION 7.5 older INTRAMUSCULA MCG/0.5 ML R SUSPENSION 0.5 PENTACEL (PF) 0 $0 for ages 1-6 ML INTRAMUSCULA years KINRIX (PF) 0 $0 for ages 4-6 R KIT 15 LF UNIT- INTRAMUSCULA years old 20 MCG-5 LF/0.5 R SYRINGE 25 LF- ML 58 MCG-10 LF/0.5 PENTACEL (PF) 0 ML INTRAMUSCULA MENACTRA (PF) 0 $0 for ages 9 R KIT 15LF- INTRAMUSCULA months and 48MCG-62DU -10 R SOLUTION 4 older MCG/0.5ML MCG/0.5 ML PENTACEL 0 $0 for ages 1-6 MENQUADFI (PF) 0 ACTHIB years INTRAMUSCULA COMPONENT (PF) R SOLUTION 10 INTRAMUSCULA MCG/0.5 ML R RECON SOLN 10 MENVEO A-C-Y- 0 $0 for ages 2 MCG/0.5 ML W-135-DIP (PF) months and PFIZER COVID-19 0 INTRAMUSCULA older VACCINE (EUA) R KIT 10-5 INTRAMUSCULA MCG/0.5 ML R SUSPENSION M-M-R II (PF) 0 $0 for ages 6 FOR SUBCUTANEOUS months and RECONSTITUTIO RECON SOLN older N 30 MCG/0.3 ML 1,000-12,500 PNEUMOVAX-23 0 $0 for ages 2 TCID50/0.5 ML INJECTION years an older MODERNA 0 SOLUTION 25 COVID-19 MCG/0.5 ML VACCINE (EUA) PNEUMOVAX-23 0 $0 for ages 2 INTRAMUSCULA INJECTION years an older R SUSPENSION SYRINGE 25 100 MCG/0.5 ML MCG/0.5 ML PEDIARIX (PF) 0 $0 for ages 1- PREVNAR 13 (PF) 0 $0 for ages 1 INTRAMUSCULA 12 months old INTRAMUSCULA month and R SYRINGE 10 R SYRINGE 0.5 ML older MCG-25LF-25 MCG-10LF/0.5 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 117 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PROQUAD (PF) 0 $0 for ages 1 SHINGRIX (PF) 0 $0 for ages 50 SUBCUTANEOUS year and older INTRAMUSCULA years and older SUSPENSION FOR R SUSPENSION RECONSTITUTIO FOR N 10EXP3-4.3-3- RECONSTITUTIO 3.99 TCID50/0.5 N 50 MCG/0.5 ML QUADRACEL (PF) 0 $0 for ages 4-6 STAMARIL (PF) 0 INTRAMUSCULA years old SUBCUTANEOUS R SUSPENSION 15 SUSPENSION FOR LF-48 MCG- 5 LF RECONSTITUTIO UNIT/0.5ML N 1,000 UNIT/0.5 RABAVERT (PF) 0 ML INTRAMUSCULA TDVAX 0 $0 for ages 7 R SUSPENSION INTRAMUSCULA and older FOR R SUSPENSION 2- RECONSTITUTIO 2 LF UNIT/0.5 ML N 2.5 UNIT TENIVAC (PF) 0 $0 for ages 7 RECOMBIVAX HB 0 INTRAMUSCULA and older (PF) R SUSPENSION 5 INTRAMUSCULA LF UNIT- 2 LF R SUSPENSION 10 UNIT/0.5ML MCG/ML, 40 TENIVAC (PF) 0 $0 for ages 7 MCG/ML, 5 INTRAMUSCULA and older MCG/0.5 ML R SYRINGE 5-2 LF RECOMBIVAX HB 0 UNIT/0.5 ML (PF) TETANUS,DIPHTH 0 $0 for ages 1- INTRAMUSCULA ERIA TOX 12 months old R SYRINGE 10 PED(PF) MCG/ML, 5 INTRAMUSCULA MCG/0.5 ML R SUSPENSION 5- ROTARIX ORAL 0 $0 for ages 1-9 25 LF UNIT/0.5 ML SUSPENSION FOR months TRUMENBA 0 $0 for ages 10 RECONSTITUTIO INTRAMUSCULA years and older N 10EXP6 R SYRINGE 120 CCID50/ML MCG/0.5 ML ROTATEQ 0 $0 for ages 1-9 TWINRIX (PF) 0 $0 for ages 18 VACCINE ORAL months INTRAMUSCULA years and older SOLUTION 2 ML R SYRINGE 720 ELISA UNIT- 20 MCG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 118 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TYPHIM VI 0 XEMBIFY 4 PA INTRAMUSCULA SUBCUTANEOUS R SOLUTION 25 SOLUTION 1 MCG/0.5 ML GRAM/5 ML (20 TYPHIM VI 0 %), 10 GRAM/50 INTRAMUSCULA ML (20 %), 2 R SYRINGE 25 GRAM/10 ML (20 MCG/0.5 ML %), 4 GRAM/20 ML (20 %) VAQTA (PF) 0 $0 for ages 1 INTRAMUSCULA year and older YF-VAX (PF) 0 R SUSPENSION 25 SUBCUTANEOUS UNIT/0.5 ML, 50 SUSPENSION FOR UNIT/ML RECONSTITUTIO N 10 EXP4.74 VAQTA (PF) 0 $0 for ages 1 UNIT/0.5 ML INTRAMUSCULA year and older R SYRINGE 25 ZOSTAVAX (PF) 0 $0 for ages 60 UNIT/0.5 ML, 50 SUBCUTANEOUS years an older UNIT/ML SUSPENSION FOR RECONSTITUTIO VARIVAX (PF) 0 $0 for ages 1 N 19,400 UNIT/0.65 SUBCUTANEOUS year and older ML SUSPENSION FOR RECONSTITUTIO MUSCULOSKELETAL & N 1,350 UNIT/0.5 RHEUMATOLOGY ML GOUT THERAPY VARIZIG 0 INTRAMUSCULA allopurinol oral 1 R SOLUTION 125 tablet 100 mg, 300 UNIT/1.2 ML mg VAXELIS (PF) 3 colchicine oral 1 INTRAMUSCULA tablet 0.6 mg R SUSPENSION 15 febuxostat oral 1 ST UNIT-5 UNIT- 10 tablet 40 mg, 80 mg MCG/0.5 ML GLOPERBA ORAL 3 VAXELIS (PF) 3 SOLUTION 0.6 INTRAMUSCULA MG/5 ML R SYRINGE 15 MITIGARE ORAL 2 UNIT-5 UNIT- 10 CAPSULE 0.6 MG MCG/0.5 ML probenecid oral 1 tablet 500 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 119 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits probenecid- 1 risedronate oral 1 QL colchicine oral tablet 150 mg, 35 tablet 500-0.5 mg mg, 5 mg ZYLOPRIM ORAL 3 risedronate oral 1 QL TABLET 100 MG tablet,delayed release (dr/ec) 35 OSTEOPOROSIS THERAPY mg ACTONEL ORAL 3 ST; QL TYMLOS 4 PA; QL TABLET 150 MG, SUBCUTANEOUS 35 MG PEN INJECTOR 80 alendronate oral 1 QL MCG (3,120 solution 70 mg/75 ml MCG/1.56 ML) alendronate oral 1 QL OTHER RHEUMATOLOGICALS tablet 10 mg, 35 mg, 5 mg, 70 mg ACTEMRA 4 PA; QL ACTPEN ATELVIA ORAL 3 ST; QL SUBCUTANEOUS TABLET,DELAYE PEN INJECTOR D RELEASE 162 MG/0.9 ML (DR/EC) 35 MG ACTEMRA 4 PA BINOSTO ORAL 3 ST; QL INTRAVENOUS TABLET, SOLUTION 200 EFFERVESCENT MG/10 ML (20 70 MG MG/ML), 400 BONIVA ORAL 3 ST; QL MG/20 ML (20 TABLET 150 MG MG/ML), 80 MG/4 ML (20 MG/ML) EVISTA ORAL 3 TABLET 60 MG ACTEMRA 4 PA; QL SUBCUTANEOUS FOSAMAX ORAL 3 ST; QL SYRINGE 162 TABLET 70 MG MG/0.9 ML FOSAMAX PLUS 3 ST; QL ARAVA ORAL 3 QL D ORAL TABLET TABLET 10 MG, 20 70 MG- 2,800 MG UNIT, 70 MG- 5,600 UNIT BENLYSTA 4 PA INTRAVENOUS ibandronate oral 1 QL RECON SOLN 120 tablet 150 mg MG, 400 MG raloxifene oral tablet 0 $0 for ages 35 BENLYSTA 4 PA; QL 60 mg and older SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 120 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BENLYSTA 4 PA; QL HUMIRA PEN 4 PA; QL SUBCUTANEOUS SUBCUTANEOUS SYRINGE 200 PEN INJECTOR MG/ML KIT 40 MG/0.8 ML DEPEN 2 PA HUMIRA 4 PA; QL TITRATABS ORAL SUBCUTANEOUS TABLET 250 MG SYRINGE KIT 40 ENBREL MINI 4 PA; QL MG/0.8 ML SUBCUTANEOUS HUMIRA(CF) PEDI 4 PA; QL CARTRIDGE 50 CROHNS MG/ML (1 ML) STARTER ENBREL 4 PA; QL SUBCUTANEOUS SUBCUTANEOUS SYRINGE KIT 80 RECON SOLN 25 MG/0.8 ML, 80 MG (1 ML) MG/0.8 ML-40 MG/0.4 ML ENBREL 4 PA; QL SUBCUTANEOUS HUMIRA(CF) PEN 4 PA; QL SOLUTION 25 CROHNS-UC-HS MG/0.5 ML SUBCUTANEOUS PEN INJECTOR ENBREL 4 PA; QL KIT 80 MG/0.8 ML SUBCUTANEOUS SYRINGE 25 HUMIRA(CF) PEN 4 PA MG/0.5 ML (0.5), PEDIATRIC UC 50 MG/ML (1 ML) SUBCUTANEOUS PEN INJECTOR ENBREL 4 PA; QL KIT 80 MG/0.8 ML SURECLICK SUBCUTANEOUS HUMIRA(CF) PEN 4 PA; QL PEN INJECTOR 50 PSOR-UV-ADOL MG/ML (1 ML) HS SUBCUTANEOUS HUMIRA PEN 4 PA; QL PEN INJECTOR CROHNS-UC-HS KIT 80 MG/0.8 ML- START 40 MG/0.4 ML SUBCUTANEOUS PEN INJECTOR HUMIRA(CF) PEN 4 PA; QL KIT 40 MG/0.8 ML SUBCUTANEOUS PEN INJECTOR HUMIRA PEN 4 PA; QL KIT 40 MG/0.4 ML PSOR-UVEITS- ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 121 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits HUMIRA(CF) 4 PA; QL SAVELLA ORAL 2 ST; QL SUBCUTANEOUS TABLET 100 MG, SYRINGE KIT 10 12.5 MG, 25 MG, 50 MG/0.1 ML, 20 MG MG/0.2 ML, 40 SAVELLA ORAL 2 ST; QL MG/0.4 ML TABLETS,DOSE leflunomide oral 1 QL PACK 12.5 MG (5)- tablet 10 mg, 20 mg 25 MG(8)-50 OTEZLA ORAL 4 PA; QL MG(42) TABLET 30 MG SIMPONI ARIA 5 PA OTEZLA 4 PA; QL INTRAVENOUS STARTER ORAL SOLUTION 12.5 TABLETS,DOSE MG/ML PACK 10 MG (4)- SIMPONI 4 PA; QL 20 MG (4)-30 MG SUBCUTANEOUS (47) PEN INJECTOR penicillamine oral 1 ST 100 MG/ML capsule 250 mg SIMPONI 4 PA; QL penicillamine oral 1 PA SUBCUTANEOUS tablet 250 mg SYRINGE 100 MG/ML RASUVO (PF) 2 ST SUBCUTANEOUS XELJANZ ORAL 4 PA; QL AUTO-INJECTOR SOLUTION 1 10 MG/0.2 ML, 12.5 MG/ML MG/0.25 ML, 15 XELJANZ ORAL 4 PA; QL MG/0.3 ML, 17.5 TABLET 10 MG, 5 MG/0.35 ML, 20 MG MG/0.4 ML, 22.5 XELJANZ XR 4 PA; QL MG/0.45 ML, 25 ORAL TABLET MG/0.5 ML, 30 EXTENDED MG/0.6 ML, 7.5 RELEASE 24 HR MG/0.15 ML 11 MG, 22 MG RIDAURA ORAL 2 CAPSULE 3 MG OBSTETRICS & GYNECOLOGY RINVOQ ORAL 4 PA; QL TABLET DIAPHRAGMS AND OTHER NON- EXTENDED ORAL CONTRACEPTIVES RELEASE 24 HR 15 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 122 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CAYA 0 CLIMARA 3 QL CONTOURED TRANSDERMAL VAGINAL PATCH WEEKLY DIAPHRAGM 65- 0.025 MG/24 HR, 80 MM 0.0375 MG/24 HR, FC2 FEMALE 0 OTC 0.05 MG/24 HR, CONDOM 0.06 MG/24 HR, 0.075 MG/24 HR, FEMCAP 0 0.1 MG/24 HR VAGINAL DEVICE 22 MM COMBIPATCH 2 TRANSDERMAL WIDE-SEAL 0 PATCH DIAPHRAGM 60 SEMIWEEKLY VAGINAL 0.05-0.14 MG/24 DIAPHRAGM 60 HR, 0.05-0.25 MM MG/24 HR ESTROGENS & PROGESTINS covaryx h.s. oral 1 ACTIVELLA 3 tablet 0.625-1.25 mg ORAL TABLET 1- covaryx oral tablet 1 0.5 MG 1.25-2.5 mg ALORA 3 QL deblitane oral tablet 0 TRANSDERMAL 0.35 mg PATCH DELESTROGEN 3 SEMIWEEKLY INTRAMUSCULA 0.025 MG/24 HR, R OIL 10 MG/ML, 0.05 MG/24 HR, 20 MG/ML, 40 0.075 MG/24 HR, MG/ML 0.1 MG/24 HR DEPO-ESTRADIOL 2 amabelz oral tablet 1 INTRAMUSCULA 0.5-0.1 mg, 1-0.5 mg R OIL 5 MG/ML ANGELIQ ORAL 3 DEPO-PROVERA 0 QL TABLET 0.25-0.5 INTRAMUSCULA MG, 0.5-1 MG R SUSPENSION AYGESTIN ORAL 3 150 MG/ML TABLET 5 MG DEPO-PROVERA 0 QL camila oral tablet 0 INTRAMUSCULA 0.35 mg R SYRINGE 150 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 123 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DEPO-SUBQ 3 QL estradiol 1 QL PROVERA 104 transdermal patch SUBCUTANEOUS weekly 0.025 mg/24 SYRINGE 104 hr, 0.0375 mg/24 hr, MG/0.65 ML 0.05 mg/24 hr, 0.06 dotti transdermal 1 QL mg/24 hr, 0.075 patch semiweekly mg/24 hr, 0.1 mg/24 0.025 mg/24 hr, hr 0.0375 mg/24 hr, estradiol vaginal 1 0.05 mg/24 hr, 0.075 cream 0.01 % (0.1 mg/24 hr, 0.1 mg/24 mg/gram) hr estradiol vaginal 1 DUAVEE ORAL 2 tablet 10 mcg TABLET 0.45-20 estradiol valerate 1 MG intramuscular oil 20 eemt hs oral tablet 1 mg/ml, 40 mg/ml 0.625-1.25 mg estradiol- 1 eemt oral tablet 1 norethindrone acet 1.25-2.5 mg oral tablet 0.5-0.1 ENDOMETRIN 4 mg, 1-0.5 mg VAGINAL INSERT estrogens- 1 100 MG methyltestosterone errin oral tablet 0.35 0 oral tablet 0.625- mg 1.25 mg, 1.25-2.5 mg ESTRACE ORAL 3 TABLET 0.5 MG, 1 FEMHRT LOW 3 MG, 2 MG DOSE ORAL TABLET 0.5-2.5 estradiol oral tablet 1 MG-MCG 0.5 mg, 1 mg, 2 mg fyavolv oral tablet 1 estradiol 1 QL 0.5-2.5 mg-mcg, 1-5 transdermal patch mg-mcg semiweekly 0.025 mg/24 hr, 0.0375 heather oral tablet 0 mg/24 hr, 0.05 0.35 mg mg/24 hr, 0.075 incassia oral tablet 0 mg/24 hr, 0.1 mg/24 0.35 mg hr jencycla oral tablet 0 0.35 mg jinteli oral tablet 1-5 1 mg-mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 124 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits lyleq oral tablet 0.35 0 norlyda oral tablet 0 mg 0.35 mg lyllana transdermal 1 QL PREFEST ORAL 3 patch semiweekly TABLET 1 MG 0.025 mg/24 hr, (15)/1 MG- 0.09 MG 0.0375 mg/24 hr, (15) 0.05 mg/24 hr, 0.075 PREMARIN 2 mg/24 hr, 0.1 mg/24 VAGINAL CREAM hr 0.625 MG/GRAM lyza oral tablet 0.35 0 progesterone 1 mg micronized oral medroxyprogesteron 0 QL capsule 100 mg, 200 e intramuscular mg suspension 150 PROMETRIUM 3 mg/ml ORAL CAPSULE medroxyprogesteron 0 QL 100 MG, 200 MG e intramuscular PROVERA ORAL 3 syringe 150 mg/ml TABLET 10 MG, medroxyprogesteron 1 2.5 MG, 5 MG e oral tablet 10 mg, sharobel oral tablet 0 2.5 mg, 5 mg 0.35 mg MENOSTAR 3 QL tulana oral tablet 0 TRANSDERMAL 0.35 mg PATCH WEEKLY 14 MCG/24 HR yuvafem vaginal 1 tablet 10 mcg mimvey oral tablet 1 1-0.5 mg MISCELLANEOUS OB/GYN nora-be oral tablet 0 CLEOCIN 3 0.35 mg VAGINAL CREAM 2 % norethindrone 0 (contraceptive) oral CLEOCIN 3 tablet 0.35 mg VAGINAL SUPPOSITORY 100 norethindrone 1 MG acetate oral tablet 5 mg clindamycin 1 phosphate vaginal norethindrone ac-eth 1 cream 2 % estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 CLINDESSE 3 mg-mcg VAGINAL CREAM,EXTENDE D RELEASE 2 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 125 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits eluryng vaginal ring 0 ORIAHNN ORAL 2 PA 0.12-0.015 mg/24 hr CAPSULE, etonogestrel-ethinyl 0 SEQUENTIAL 300- estradiol vaginal 1-0.5MG(AM) /300 ring 0.12-0.015 MG(PM) mg/24 hr RELAGARD 3 fem ph vaginal gel 1 VAGINAL GEL 0.9-0.025 % 0.9-0.025 % GYNAZOLE-1 3 terconazole vaginal 1 VAGINAL CREAM cream 0.4 %, 0.8 % 2 % terconazole vaginal 1 gynol ii vaginal gel 3 0 OTC suppository 80 mg % TODAY 0 OTC INTRAROSA 3 CONTRACEPTIVE VAGINAL INSERT SPONGE 6.5 MG VAGINAL CONTRACEPTIVE isoxsuprine oral 1 SPONGE 1,000 MG tablet 10 mg, 20 mg tranexamic acid oral 1 LYSTEDA ORAL 3 tablet 650 mg TABLET 650 MG TRIMO-SAN 2 METROGEL 3 JELLY VAGINAL VAGINAL GEL 0.025-0.01 % VAGINAL GEL 0.75 % vandazole vaginal 1 gel 0.75 % metronidazole 1 vaginal gel 0.75 % VCF 2 OTC CONTRACEPTIVE miconazole-3 1 FILM VAGINAL vaginal suppository FILM 28 % 200 mg VCF 2 OTC NUVARING 0 CONTRACEPTIVE VAGINAL RING GEL VAGINAL 0.12-0.015 MG/24 GEL 4 % HR xulane transdermal 0 NUVESSA 3 patch weekly 150-35 VAGINAL GEL 1.3 mcg/24 hr % zafemy transdermal 0 patch weekly 150-35 mcg/24 hr

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 126 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ORAL CONTRACEPTIVES & aurovela 1/20 (21) 0 RELATED AGENTS oral tablet 1-20 mg- mcg afirmelle oral tablet 0 0.1-20 mg-mcg aurovela 24 fe oral 0 tablet 1 mg-20 mcg AFTERA ORAL 0 OTC; QL (24)/75 mg (4) TABLET 1.5 MG aurovela fe 1.5/30 0 altavera (28) oral 0 (28) oral tablet 1.5 tablet 0.15-0.03 mg mg-30 mcg (21)/75 alyacen 1/35 (28) 0 mg (7) oral tablet 1-35 mg- aurovela fe 1-20 0 mcg (28) oral tablet 1 alyacen 7/7/7 (28) 0 mg-20 mcg (21)/75 oral tablet 0.5/0.75/1 mg (7) mg- 35 mcg aviane oral tablet 0 amethia oral 0 0.1-20 mg-mcg tablets,dose pack,3 ayuna oral tablet 0 month 0.15 mg-30 0.15-0.03 mg mcg (84)/10 mcg (7) azurette (28) oral 0 amethyst (28) oral 0 tablet 0.15-0.02 tablet 90-20 mcg mgx21 /0.01 mg x 5 (28) balziva (28) oral 0 apri oral tablet 0.15- 0 tablet 0.4-35 mg- 0.03 mg mcg aranelle (28) oral 0 BEYAZ ORAL 0 ST tablet 0.5/1/0.5-35 TABLET 3-0.02- mg-mcg 0.451 MG (24) (4) ashlyna oral 0 blisovi 24 fe oral 0 tablets,dose pack,3 tablet 1 mg-20 mcg month 0.15 mg-30 (24)/75 mg (4) mcg (84)/10 mcg (7) blisovi fe 1.5/30 (28) 0 aubra eq oral tablet 0 oral tablet 1.5 mg-30 0.1-20 mg-mcg mcg (21)/75 mg (7) aubra oral tablet 0 blisovi fe 1/20 (28) 0 0.1-20 mg-mcg oral tablet 1 mg-20 aurovela 1.5/30 (21) 0 mcg (21)/75 mg (7) oral tablet 1.5-30 briellyn oral tablet 0 mg-mcg 0.4-35 mg-mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 127 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits camrese lo oral 0 daysee oral 0 tablets,dose pack,3 tablets,dose pack,3 month 0.10 mg-20 month 0.15 mg-30 mcg (84)/10 mcg (7) mcg (84)/10 mcg (7) camrese oral 0 desog- 0 tablets,dose pack,3 e.estradiol/e.estradio month 0.15 mg-30 l oral tablet 0.15- mcg (84)/10 mcg (7) 0.02 mgx21 /0.01 mg caziant (28) oral 0 x 5 tablet 0.1/.125/.15- desogestrel-ethinyl 0 25 mg-mcg estradiol oral tablet charlotte 24 fe oral 0 0.15-0.03 mg tablet,chewable 1 dolishale oral tablet 0 mg-20 mcg(24) /75 90-20 mcg (28) mg (4) drospirenone- 0 chateal (28) oral 0 e.estradiol-lm.fa tablet 0.15-0.03 mg oral tablet 3-0.02- chateal eq (28) oral 0 0.451 mg (24) (4), 3- tablet 0.15-0.03 mg 0.03-0.451 mg (21) (7) cryselle (28) oral 0 tablet 0.3-30 mg- drospirenone-ethinyl 0 mcg estradiol oral tablet 3-0.02 mg, 3-0.03 cyclafem 1/35 (28) 0 mg oral tablet 1-35 mg- mcg econtra ez oral 0 OTC; QL tablet 1.5 mg cyclafem 7/7/7 (28) 0 oral tablet 0.5/0.75/1 econtra one-step 0 OTC; QL mg- 35 mcg oral tablet 1.5 mg cyred eq oral tablet 0 elinest oral tablet 0 0.15-0.03 mg 0.3-30 mg-mcg cyred oral tablet 0 ELLA ORAL 0 QL 0.15-0.03 mg TABLET 30 MG dasetta 1/35 (28) 0 emoquette oral 0 oral tablet 1-35 mg- tablet 0.15-0.03 mg mcg enpresse oral tablet 0 dasetta 7/7/7 (28) 0 50-30 (6)/75-40 oral tablet 0.5/0.75/1 (5)/125-30(10) mg- 35 mcg enskyce oral tablet 0 0.15-0.03 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 128 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits estarylla oral tablet 0 jasmiel (28) oral 0 0.25-35 mg-mcg tablet 3-0.02 mg ethynodiol diac-eth 0 jolessa oral 0 estradiol oral tablet tablets,dose pack,3 1-35 mg-mcg, 1-50 month 0.15 mg-30 mg-mcg mcg (91) falmina (28) oral 0 juleber oral tablet 0 tablet 0.1-20 mg- 0.15-0.03 mg mcg junel 1.5/30 (21) 0 fayosim oral 0 oral tablet 1.5-30 tablets,dose pack,3 mg-mcg month 0.15 mg-20 junel 1/20 (21) oral 0 mcg/ 0.15 mg-25 tablet 1-20 mg-mcg mcg junel fe 1.5/30 (28) 0 femynor oral tablet 0 oral tablet 1.5 mg-30 0.25-35 mg-mcg mcg (21)/75 mg (7) gemmily oral 0 junel fe 1/20 (28) 0 capsule 1 mg-20 oral tablet 1 mg-20 mcg (24)/75 mg (4) mcg (21)/75 mg (7) hailey 24 fe oral 0 junel fe 24 oral 0 tablet 1 mg-20 mcg tablet 1 mg-20 mcg (24)/75 mg (4) (24)/75 mg (4) hailey fe 1.5/30 (28) 0 kaitlib fe oral 0 oral tablet 1.5 mg-30 tablet,chewable mcg (21)/75 mg (7) 0.8mg-25mcg(24) hailey fe 1/20 (28) 0 and 75 mg (4) oral tablet 1 mg-20 kalliga oral tablet 0 mcg (21)/75 mg (7) 0.15-0.03 mg hailey oral tablet 0 kariva (28) oral 0 1.5-30 mg-mcg tablet 0.15-0.02 iclevia oral 0 mgx21 /0.01 mg x 5 tablets,dose pack,3 kelnor 1/35 (28) oral 0 month 0.15 mg-30 tablet 1-35 mg-mcg mcg (91) kelnor 1-50 (28) oral 0 isibloom oral tablet 0 tablet 1-50 mg-mcg 0.15-0.03 mg kurvelo (28) oral 0 jaimiess oral 0 tablet 0.15-0.03 mg tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 129 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits l norgest/e.estradiol- 0 levonorgestrel- 0 e.estrad oral ethinyl estrad oral tablets,dose pack,3 tablet 0.1-20 mg- month 0.10 mg-20 mcg, 0.15-0.03 mg, mcg (84)/10 mcg (7), 90-20 mcg (28) 0.15 mg-20 mcg/ levonorgestrel- 0 0.15 mg-25 mcg, ethinyl estrad oral 0.15 mg-30 mcg tablets,dose pack,3 (84)/10 mcg (7) month 0.15 mg-30 larin 1.5/30 (21) 0 mcg (91) oral tablet 1.5-30 levonorg-eth estrad 0 mg-mcg triphasic oral tablet larin 1/20 (21) oral 0 50-30 (6)/75-40 tablet 1-20 mg-mcg (5)/125-30(10) larin 24 fe oral 0 levora-28 oral tablet 0 tablet 1 mg-20 mcg 0.15-0.03 mg (24)/75 mg (4) lillow (28) oral 0 larin fe 1.5/30 (28) 0 tablet 0.15-0.03 mg oral tablet 1.5 mg-30 lojaimiess oral 0 mcg (21)/75 mg (7) tablets,dose pack,3 larin fe 1/20 (28) 0 month 0.10 mg-20 oral tablet 1 mg-20 mcg (84)/10 mcg (7) mcg (21)/75 mg (7) loryna (28) oral 0 larissia oral tablet 0 tablet 3-0.02 mg 0.1-20 mg-mcg low-ogestrel (28) 0 layolis fe oral 0 oral tablet 0.3-30 tablet,chewable mg-mcg 0.8mg-25mcg(24) lo-zumandimine (28) 0 and 75 mg (4) oral tablet 3-0.02 mg leena 28 oral tablet 0 lutera (28) oral 0 0.5/1/0.5-35 mg-mcg tablet 0.1-20 mg- lessina oral tablet 0 mcg 0.1-20 mg-mcg marlissa (28) oral 0 levonest (28) oral 0 tablet 0.15-0.03 mg tablet 50-30 (6)/75- merzee oral capsule 0 40 (5)/125-30(10) 1 mg-20 mcg (24)/75 levonorgestrel oral 0 OTC; QL mg (4) tablet 1.5 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 130 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits mibelas 24 fe oral 0 noreth-ethinyl 0 tablet,chewable 1 estradiol-iron oral mg-20 mcg(24) /75 tablet,chewable mg (4) 0.4mg-35mcg(21) microgestin 1.5/30 0 and 75 mg (7), (21) oral tablet 1.5- 0.8mg-25mcg(24) 30 mg-mcg and 75 mg (4) microgestin 1/20 0 norethindrone ac-eth 0 (21) oral tablet 1-20 estradiol oral tablet mg-mcg 1-20 mg-mcg, 1.5-30 mg-mcg MICROGESTIN 24 0 ST FE ORAL TABLET norethindrone- 0 1 MG-20 MCG e.estradiol-iron oral (24)/75 MG (4) capsule 1 mg-20 mcg (24)/75 mg (4) microgestin fe 1.5/30 0 (28) oral tablet 1.5 norethindrone- 0 mg-30 mcg (21)/75 e.estradiol-iron oral mg (7) tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 microgestin fe 1/20 0 mg-30 mcg (21)/75 (28) oral tablet 1 mg (7) mg-20 mcg (21)/75 mg (7) norethindrone- 0 e.estradiol-iron oral mili oral tablet 0.25- 0 tablet,chewable 1 35 mg-mcg mg-20 mcg(24) /75 mono-linyah oral 0 mg (4) tablet 0.25-35 mg- norgestimate-ethinyl 0 mcg estradiol oral tablet my choice oral tablet 0 OTC; QL 0.18/0.215/0.25 mg- 1.5 mg 25 mcg, 0.18/0.215/0.25 mg- my way oral tablet 0 OTC; QL 35 mcg (28), 0.25-35 1.5 mg mg-mcg necon 0.5/35 (28) 0 nortrel 0.5/35 (28) 0 oral tablet 0.5-35 oral tablet 0.5-35 mg-mcg mg-mcg new day oral tablet 0 OTC; QL nortrel 1/35 (21) 0 1.5 mg oral tablet 1-35 mg- nikki (28) oral tablet 0 mcg (21) 3-0.02 mg nortrel 1/35 (28) 0 oral tablet 1-35 mg- mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 131 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits nortrel 7/7/7 (28) 0 setlakin oral 0 oral tablet 0.5/0.75/1 tablets,dose pack,3 mg- 35 mcg month 0.15 mg-30 nylia 7/7/7 (28) oral 0 mcg (91) tablet 0.5/0.75/1 mg- simliya (28) oral 0 35 mcg tablet 0.15-0.02 nymyo oral tablet 0 mgx21 /0.01 mg x 5 0.25-35 mg-mcg simpesse oral 0 ocella oral tablet 3- 0 tablets,dose pack,3 0.03 mg month 0.15 mg-30 mcg (84)/10 mcg (7) opcicon one-step 0 OTC; QL oral tablet 1.5 mg sprintec (28) oral 0 tablet 0.25-35 mg- option-2 oral tablet 0 OTC; QL mcg 1.5 mg sronyx oral tablet 0 orsythia oral tablet 0 0.1-20 mg-mcg 0.1-20 mg-mcg syeda oral tablet 3- 0 philith oral tablet 0 0.03 mg 0.4-35 mg-mcg TAKE ACTION 0 OTC; QL pimtrea (28) oral 0 ORAL TABLET 1.5 tablet 0.15-0.02 MG mgx21 /0.01 mg x 5 tarina 24 fe oral 0 pirmella oral tablet 0 tablet 1 mg-20 mcg 0.5/0.75/1 mg- 35 (24)/75 mg (4) mcg, 1-35 mg-mcg tarina fe 1/20 (28) 0 PLAN B ONE-STEP 0 OTC; QL oral tablet 1 mg-20 ORAL TABLET 1.5 mcg (21)/75 mg (7) MG tilia fe oral tablet 1- 0 portia 28 oral tablet 0 20(5)/1-30(7) /1mg- 0.15-0.03 mg 35mcg (9) previfem oral tablet 0 tri femynor oral 0 0.25-35 mg-mcg tablet reclipsen (28) oral 0 0.18/0.215/0.25 mg- tablet 0.15-0.03 mg 35 mcg (28) rivelsa oral 0 tri-estarylla oral 0 tablets,dose pack,3 tablet month 0.15 mg-20 0.18/0.215/0.25 mg- mcg/ 0.15 mg-25 35 mcg (28) mcg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 132 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits tri-legest fe oral 0 tri-vylibra lo oral 0 tablet 1-20(5)/1- tablet 30(7) /1mg-35mcg 0.18/0.215/0.25 mg- (9) 25 mcg tri-linyah oral tablet 0 tri-vylibra oral 0 0.18/0.215/0.25 mg- tablet 35 mcg (28) 0.18/0.215/0.25 mg- tri-lo-estarylla oral 0 35 mcg (28) tablet tydemy oral tablet 3- 0 0.18/0.215/0.25 mg- 0.03-0.451 mg (21) 25 mcg (7) tri-lo-marzia oral 0 velivet triphasic 0 tablet regimen (28) oral 0.18/0.215/0.25 mg- tablet 0.1/.125/.15- 25 mcg 25 mg-mcg tri-lo-mili oral tablet 0 vestura (28) oral 0 0.18/0.215/0.25 mg- tablet 3-0.02 mg 25 mcg vienva oral tablet 0 tri-lo-sprintec oral 0 0.1-20 mg-mcg tablet viorele (28) oral 0 0.18/0.215/0.25 mg- tablet 0.15-0.02 25 mcg mgx21 /0.01 mg x 5 tri-mili oral tablet 0 volnea (28) oral 0 0.18/0.215/0.25 mg- tablet 0.15-0.02 35 mcg (28) mgx21 /0.01 mg x 5 tri-nymyo oral tablet 0 vyfemla (28) oral 0 0.18/0.215/0.25 mg- tablet 0.4-35 mg- 35 mcg (28) mcg tri-previfem (28) 0 vylibra oral tablet 0 oral tablet 0.25-35 mg-mcg 0.18/0.215/0.25 mg- 35 mcg (28) wera (28) oral tablet 0 0.5-35 mg-mcg tri-sprintec (28) oral 0 tablet wymzya fe oral 0 0.18/0.215/0.25 mg- tablet,chewable 35 mcg (28) 0.4mg-35mcg(21) and 75 mg (7) trivora (28) oral 0 tablet 50-30 (6)/75- YAZ (28) ORAL 0 ST 40 (5)/125-30(10) TABLET 3-0.02 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 133 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits zarah oral tablet 3- 0 ciprofloxacin hcl 1 0.03 mg ophthalmic (eye) zovia 1/35e (28) oral 0 drops 0.3 % tablet 1-35 mg-mcg erythromycin 1 zumandimine (28) 0 ophthalmic (eye) oral tablet 3-0.03 mg ointment 5 mg/gram (0.5 %) OXYTOCICS gatifloxacin 1 methergine oral 1 ST; QL ophthalmic (eye) tablet 0.2 mg drops 0.5 % methylergonovine 1 ST; QL gentak ophthalmic 1 oral tablet 0.2 mg (eye) ointment 0.3 % (3 mg/gram) OPHTHALMOLOGY gentamicin 1 ANTIBIOTICS ophthalmic (eye) ak-poly-bac 1 drops 0.3 % ophthalmic (eye) levofloxacin 1 ointment 500-10,000 ophthalmic (eye) unit/gram drops 0.5 % AZASITE 2 MOXEZA 3 OPHTHALMIC OPHTHALMIC (EYE) DROPS 1 % (EYE) DROPS, bacitracin 1 VISCOUS 0.5 % ophthalmic (eye) MOXIFLOXACIN 3 ST ointment 500 (PF)-BSS unit/gram INTRAVITREAL bacitracin- 1 SOLUTION 1 polymyxin b MG/ML ophthalmic (eye) moxifloxacin 1 ointment 500-10,000 ophthalmic (eye) unit/gram drops 0.5 % BETADINE 3 moxifloxacin 1 OPHTHALMIC ophthalmic (eye) PREP drops, viscous 0.5 % OPHTHALMIC (EYE) SOLUTION 5 % CILOXAN 3 OPHTHALMIC (EYE) DROPS 0.3 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 134 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits MOXIFLOXACIN- 3 ST ofloxacin ophthalmic 1 SOD (eye) drops 0.3 % CHLOR,ISO(PF) polycin ophthalmic 1 INTRAOCULAR (eye) ointment 500- SOLUTION 0.8 10,000 unit/gram MG/0.8 ML, 4 MG/0.8 ML, 5 polymyxin b sulf- 1 MG/ML trimethoprim ophthalmic (eye) MOXIFLOXACIN- 3 ST drops 10,000 unit- 1 SOD mg/ml CHLOR,ISO(PF) INTRAOCULAR POLYTRIM 3 SYRINGE 0.3 OPHTHALMIC MG/0.3 ML, 1.6 (EYE) DROPS MG/ML 10,000 UNIT- 1 MG/ML NATACYN 2 OPHTHALMIC tobramycin 1 (EYE) ophthalmic (eye) DROPS,SUSPENSI drops 0.3 % ON 5 % TOBREX 3 neomycin- 1 OPHTHALMIC bacitracin- (EYE) DROPS 0.3 polymyxin % ophthalmic (eye) TOBREX 3 ointment 3.5-400- OPHTHALMIC 10,000 mg-unit- (EYE) OINTMENT unit/g 0.3 % neomycin- 1 VIGAMOX 3 polymyxin- OPHTHALMIC gramicidin (EYE) DROPS 0.5 ophthalmic (eye) % drops 1.75 mg- 10,000 unit- ZYMAXID 3 0.025mg/ml OPHTHALMIC (EYE) DROPS 0.5 neo-polycin 1 % ophthalmic (eye) ointment 3.5-400- ANTIVIRALS 10,000 mg-unit- trifluridine 1 unit/g ophthalmic (eye) OCUFLOX 3 drops 1 % OPHTHALMIC ZIRGAN 3 (EYE) DROPS 0.3 OPHTHALMIC % (EYE) GEL 0.15 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 135 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits BETA-BLOCKERS ATROPINE 3 OPHTHALMIC betaxolol ophthalmic 1 (EYE) DROPS, (eye) drops 0.5 % EMULSION 0.01 % BETOPTIC S 3 CYCLOGYL 3 OPHTHALMIC OPHTHALMIC (EYE) (EYE) DROPS 0.5 DROPS,SUSPENSI %, 1 %, 2 % ON 0.25 % cyclopentolate 1 carteolol ophthalmic 1 ophthalmic (eye) (eye) drops 1 % drops 0.5 %, 1 %, 2 levobunolol 1 % ophthalmic (eye) CYCLOPEN- 3 drops 0.5 % TROPIC- timolol maleate (pf) 1 PHENYLEPH- ophthalmic (eye) WATR dropperette 0.5 % OPHTHALMIC timolol maleate 1 (EYE) DROPS 1-1- ophthalmic (eye) 2.5 % drops 0.25 %, 0.5 % CYCLOPENT- 3 timolol maleate 1 TROPIC-PHEN- ophthalmic (eye) KETR-WAT drops, once daily 0.5 OPHTHALMIC % (EYE) DROPS 1 %- 1 %-10 %- 0.5 %, 1 timolol maleate 1 %-1 %-2.5 %- 0.5 % ophthalmic (eye) gel forming solution CYCLOP-TROP- 3 0.25 %, 0.5 % PROPA-PHEN- KET-WAT TIMOPTIC 3 OPHTHALMIC OPHTHALMIC (EYE) DROPS 1 %- (EYE) DROPS 0.25 1 %-0.1 %- 2.5 %- %, 0.5 % 0.4 % TIMOPTIC-XE 3 homatropaire 1 OPHTHALMIC ophthalmic (eye) (EYE) GEL drops 5 % FORMING SOLUTION 0.25 %, MYDRIACYL 3 0.5 % OPHTHALMIC (EYE) DROPS 1 % CYCLOPLEGIC MYDRIATICS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 136 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PAREMYD 3 ALOMIDE 3 ST OPHTHALMIC OPHTHALMIC (EYE) DROPS 1- (EYE) DROPS 0.1 0.25 % % PHENYLEPH- 3 altacaine ophthalmic 1 TROPICAMIDE IN (eye) drops 0.5 % WATER ALTAFLUOR 3 OPHTHALMIC BENOX (EYE) DROPS 2.5-1 OPHTHALMIC % (EYE) DROPS 0.25- tropicamide 1 0.4 % ophthalmic (eye) azelastine 1 drops 0.5 %, 1 % ophthalmic (eye) DIRECT ACTING MIOTICS drops 0.05 % ISOPTO CARPINE 3 BEOVU 5 PA OPHTHALMIC INTRAVITREAL (EYE) DROPS 1 %, SOLUTION 6 2 %, 4 % MG/0.05 ML MIOCHOL-E 3 bepotastine besilate 1 INTRAOCULAR ophthalmic (eye) KIT 1 % (10 drops 1.5 % MG/ML) BEPREVE 3 ST pilocarpine hcl 1 OPHTHALMIC ophthalmic (eye) (EYE) DROPS 1.5 drops 1 %, 2 %, 4 % % MISCELLANEOUS CEQUA 3 PA OPHTHALMOLOGICS OPHTHALMIC (EYE) AKTEN (PF) 3 DROPPERETTE OPHTHALMIC 0.09 % (EYE) GEL 3.5 % cromolyn 1 ALCAINE 3 ophthalmic (eye) OPHTHALMIC drops 4 % (EYE) DROPS 0.5 % CYCLOSPORINE 3 IN KLARITY ALOCRIL 3 ST OPHTHALMIC OPHTHALMIC (EYE) DROPS 0.1- (EYE) DROPS 2 % 0.25 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 137 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits DEXAMET- 3 lidocaine- 1 MOXIFL- phenylephrn in KETORO- water intraocular NACL(PF) solution 1-1.5 % INTRAOCULAR MYDRIATIC4(TRO 3 SOLUTION 1-0.5- P-PROP-PE- 0.4 MG/ML KTRLC) epinastine 1 OPHTHALMIC ophthalmic (eye) (EYE) DROPS 1- drops 0.05 % 0.5-2.5-0.5 % FLUORESCEIN- 3 olopatadine 1 BENOXINATE ophthalmic (eye) OPHTHALMIC drops 0.1 %, 0.2 % (EYE) DROPS 0.3- PREDNISOL ACE- 3 0.4 % GATIFLOX- KLARITY-A 3 BROMFEN (AZITHRO- OPHTHALMIC CHONDR)(PF) (EYE) OPHTHALMIC DROPS,SUSPENSI (EYE) DROPS 1- ON 1-0.5-0.075 % 0.25 % PREDNISOLN SP- 3 KLARITY-B 3 GATIFLOX- (BETAMETH- BROMFEN CHOND)(PF) OPHTHALMIC OPHTHALMIC (EYE) DROPS 1- (EYE) DROPS 0.1- 0.5-0.075 % 0.25 % PREDNISOLN SP- 3 KLARITY-L 3 MOXIFLOX- (LOTEPRED- BROMFEN CHOND)(PF) OPHTHALMIC OPHTHALMIC (EYE) DROPS 1- (EYE) DROPS 0.2- 0.5-0.075 % 0.25 %, 0.5-0.25 % PREDNISOLONE 3 LACRISERT 3 ST ACETATE- OPHTHALMIC NEPAFENAC (EYE) INSERT 5 OPHTHALMIC MG (EYE) LIDOCAINE- 3 DROPS,SUSPENSI PHENYLEPHRIN- ON 1-0.1 % BSS(PF) INTRAOCULAR SYRINGE 1-1.5 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 138 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PREDNISOLONE- 3 ZERVIATE 2 ST MOXIFLO- OPHTHALMIC NEPAFENAC (EYE) OPHTHALMIC DROPPERETTE (EYE) 0.24 % DROPS,SUSPENSI NON-STEROIDAL ANTI- ON 1-0.5-0.1 % INFLAMMATORY AGENTS PREDNISOLONE- 3 MOXIFLOX- ACULAR LS 3 BROMFEN OPHTHALMIC OPHTHALMIC (EYE) DROPS 0.4 (EYE) % DROPS,SUSPENSI ACULAR 3 ON 1-0.5-0.075 % OPHTHALMIC RACEPINEPH- 3 (EYE) DROPS 0.5 LIDOCAINE-BSS % 7(PF) bromfenac 1 INTRAOCULAR ophthalmic (eye) SOLUTION 0.025- drops 0.09 % 0.75 % diclofenac sodium 1 RESTASIS 2 PA; QL ophthalmic (eye) MULTIDOSE drops 0.1 % OPHTHALMIC flurbiprofen sodium 1 (EYE) DROPS 0.05 ophthalmic (eye) % drops 0.03 % RESTASIS 2 PA; QL ILEVRO 3 OPHTHALMIC OPHTHALMIC (EYE) (EYE) DROPPERETTE DROPS,SUSPENSI 0.05 % ON 0.3 % TETRACAINE 3 ketorolac 1 HCL (PF) ophthalmic (eye) OPHTHALMIC drops 0.4 %, 0.5 % (EYE) DROPS 0.5 % PROLENSA 3 OPHTHALMIC tetracaine hcl 1 (EYE) DROPS 0.07 ophthalmic (eye) % drops 0.5 % ORAL DRUGS FOR GLAUCOMA acetazolamide oral 1 capsule, extended release 500 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 139 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits acetazolamide oral 1 DORZOLAMIDE- 3 tablet 125 mg, 250 TIMOLOL (PF) mg OPHTHALMIC methazolamide oral 1 (EYE) DROPS 2-0.5 tablet 25 mg, 50 mg % dorzolamide-timolol 1 OTHER GLAUCOMA DRUGS ophthalmic (eye) AZOPT 3 drops 22.3-6.8 OPHTHALMIC mg/ml (EYE) LATANOPROST 3 DROPS,SUSPENSI (PF) ON 1 % OPHTHALMIC bimatoprost 1 PA (EYE) DROPS ophthalmic (eye) 0.005 % drops 0.03 % latanoprost 1 PA BRIMONIDINE- 3 ophthalmic (eye) DORZOLAMIDE drops 0.005 % (PF) LUMIGAN 2 ST OPHTHALMIC OPHTHALMIC (EYE) DROPS 0.15- (EYE) DROPS 0.01 2 % % brinzolamide 1 miostat intraocular 1 ophthalmic (eye) solution 0.01 % drops,suspension 1 % SIMBRINZA 3 OPHTHALMIC COMBIGAN 2 (EYE) OPHTHALMIC DROPS,SUSPENSI (EYE) DROPS 0.2- ON 1-0.2 % 0.5 % TIMOL-BRIMON- 3 DORZOLAMIDE 3 DORZO- (PF) LATANOP(PF) OPHTHALMIC OPHTHALMIC (EYE) DROPS 2 % (EYE) DROPS 0.5 dorzolamide 1 %-0.15 %- 2 %- ophthalmic (eye) 0.005 % drops 2 % TIMOLOL- 3 dorzolamide-timolol 1 BRIMONIDI- (pf) ophthalmic (eye) DORZOLAM(PF) dropperette 2-0.5 % OPHTHALMIC (EYE) DROPS 0.5- 0.15-2 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 140 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TIMOLOL- 3 neomycin- 1 DORZOLAMID- bacitracin-poly-hc LATANOP(PF) ophthalmic (eye) OPHTHALMIC ointment 3.5-400- (EYE) DROPS 0.5- 10,000 mg-unit/g- 2-0.005 % 1% TIMOLOL- 3 neomycin-polymyxin 1 LATANOPROST(P b-dexameth F) OPHTHALMIC ophthalmic (eye) (EYE) DROPS 0.5- drops,suspension 0.005 % 3.5mg/ml-10,000 travoprost 1 PA unit/ml-0.1 % ophthalmic (eye) neomycin-polymyxin 1 drops 0.004 % b-dexameth TRUSOPT 3 ophthalmic (eye) OPHTHALMIC ointment 3.5 mg/g- (EYE) DROPS 2 % 10,000 unit/g-0.1 % ZIOPTAN (PF) 2 ST neomycin- 1 OPHTHALMIC polymyxin-hc (EYE) ophthalmic (eye) DROPPERETTE drops,suspension 0.0015 % 3.5-10,000-10 mg- unit-mg/ml STEROID-ANTIBIOTIC neo-polycin hc 1 COMBINATIONS ophthalmic (eye) DEXAMETH- 3 ointment 3.5-400- MOXIFLOX(PF)- 10,000 mg-unit/g- NACL,ISO 1% INTRAOCULAR PRED-G 3 SOLUTION 1-5 OPHTHALMIC MG/ML (EYE) MAXITROL 3 DROPS,SUSPENSI OPHTHALMIC ON 0.3-1 % (EYE) PRED-G S.O.P. 3 DROPS,SUSPENSI OPHTHALMIC ON 3.5MG/ML- (EYE) OINTMENT 10,000 UNIT/ML- 0.3-0.6 % 0.1 % MAXITROL 3 OPHTHALMIC (EYE) OINTMENT 3.5 MG/G-10,000 UNIT/G-0.1 % You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 141 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PREDNISOLONE 3 ALREX 3 ST ACET- OPHTHALMIC GATIFLOXACIN (EYE) OPHTHALMIC DROPS,SUSPENSI (EYE) ON 0.2 % DROPS,SUSPENSI dexamethasone 1 ON 1-0.5 % sodium phosphate PREDNISOLONE 3 ophthalmic (eye) SOD PH- drops 0.1 % MOXIFLOX DEXTENZA 3 OPHTHALMIC INTRACANALICU (EYE) DROPS 1-0.5 LAR INSERT 0.4 % MG PREDNISOLONE- 3 DEXYCU (PF) 3 MOXIFLOXACIN INTRAOCULAR HCL SUSPENSION 9 % OPHTHALMIC (EYE) DUREZOL 3 DROPS,SUSPENSI OPHTHALMIC ON 1-0.5 % (EYE) DROPS 0.05 % TOBRADEX 3 OPHTHALMIC EYSUVIS 3 PA; ST; QL (EYE) OPHTHALMIC DROPS,SUSPENSI (EYE) ON 0.3-0.1 % DROPS,SUSPENSI ON 0.25 % TOBRADEX 2 OPHTHALMIC fluorometholone 1 (EYE) OINTMENT ophthalmic (eye) 0.3-0.1 % drops,suspension 0.1 % tobramycin- 1 dexamethasone FML LIQUIFILM 3 ophthalmic (eye) OPHTHALMIC drops,suspension (EYE) 0.3-0.1 % DROPS,SUSPENSI ON 0.1 % TRIAMCINOLON- 3 MOXIFLOX- INVELTYS 2 WATR(PF) OPHTHALMIC INTRAOCULAR (EYE) SUSPENSION 9 DROPS,SUSPENSI MG-0.6 MG /0.6 ON 1 % ML STEROIDS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 142 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits LOTEMAX 2 prednisolone sodium 1 OPHTHALMIC phosphate (EYE) DROPS,GEL ophthalmic (eye) 0.5 % drops 1 % LOTEMAX 3 STEROID-SULFONAMIDE OPHTHALMIC COMBINATIONS (EYE) DROPS,SUSPENSI BLEPHAMIDE 3 ON 0.5 % OPHTHALMIC (EYE) LOTEMAX 2 DROPS,SUSPENSI OPHTHALMIC ON 10-0.2 % (EYE) OINTMENT 0.5 % BLEPHAMIDE 3 S.O.P. LOTEMAX SM 2 OPHTHALMIC OPHTHALMIC (EYE) OINTMENT (EYE) DROPS,GEL 10-0.2 % 0.38 % sulfacetamide- 1 loteprednol 1 prednisolone etabonate ophthalmic (eye) ophthalmic (eye) drops 10 %-0.23 % drops,gel 0.5 % (0.25 %) loteprednol 1 SULFONAMIDES etabonate ophthalmic (eye) BLEPH-10 3 drops,suspension 0.5 OPHTHALMIC % (EYE) DROPS 10 % PRED FORTE 3 sulfacetamide 1 OPHTHALMIC sodium ophthalmic (EYE) (eye) drops 10 % DROPS,SUSPENSI sulfacetamide 1 ON 1 % sodium ophthalmic PREDNISOLONE 3 (eye) ointment 10 % ACETATE (PF) SYMPATHOMIMETICS OPHTHALMIC (EYE) ALPHAGAN P 2 DROPS,SUSPENSI OPHTHALMIC ON 1 % (EYE) DROPS 0.1 % prednisolone acetate 1 ophthalmic (eye) ALPHAGAN P 3 drops,suspension 1 OPHTHALMIC % (EYE) DROPS 0.15 %

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 143 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits apraclonidine 1 clemastine oral 1 ophthalmic (eye) tablet 2.68 mg drops 0.5 % cyproheptadine oral 1 brimonidine 1 syrup 2 mg/5 ml ophthalmic (eye) cyproheptadine oral 1 drops 0.15 %, 0.2 % tablet 4 mg IOPIDINE 3 desloratadine oral 1 QL OPHTHALMIC tablet 5 mg (EYE) DROPPERETTE 1 desloratadine oral 1 QL % tablet,disintegrating 2.5 mg, 5 mg VASOCONSTRICTOR DECONGESTANTS dexchlorpheniramin 1 e maleate oral CYCLOMYDRIL 3 solution 2 mg/5 ml OPHTHALMIC (EYE) DROPS 0.2-1 DIPHEN ORAL 3 % ELIXIR 12.5 MG/5 ML phenylephrine hcl 1 ophthalmic (eye) epinephrine 1 QL drops 10 %, 2.5 % injection auto- injector 0.15 mg/0.3 RESPIRATORY, ALLERGY, ml, 0.3 mg/0.3 ml COUGH & COLD EPIPEN 2-PAK 2 ST; QL ANTIHISTAMINE & INJECTION AUTO- INJECTOR 0.3 ANTIALLERGENIC AGENTS MG/0.3 ML carbinoxamine 1 EPIPEN JR 2-PAK 2 ST; QL maleate oral liquid 4 INJECTION AUTO- mg/5 ml INJECTOR 0.15 carbinoxamine 1 MG/0.3 ML maleate oral tablet 4 hydroxyzine hcl oral 1 mg solution 10 mg/5 ml carbinoxamine 1 ST hydroxyzine hcl oral 1 maleate oral tablet 6 tablet 10 mg, 25 mg, mg 50 mg cetirizine oral 1 hydroxyzine 1 solution 1 mg/ml pamoate oral CLARINEX ORAL 3 QL capsule 100 mg, 25 TABLET 5 MG mg, 50 mg clemastine oral 1 syrup 0.5 mg/5 ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 144 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits KARBINAL ER 3 ST brompheniramine- 1 ORAL pseudoeph-dm oral SUSPENSION,EXT syrup 2-30-10 mg/5 ENDED REL 12 HR ml 4 MG/5 ML CAPCOF ORAL 3 levocetirizine oral 1 LIQUID 2-5-10 solution 2.5 mg/5 ml MG/5 ML levocetirizine oral 1 QL CLARINEX-D 12 3 QL tablet 5 mg HOUR ORAL promethazine oral 1 TABLET, ER syrup 6.25 mg/5 ml MULTIPHASE 12 HR 2.5-120 MG promethazine oral 1 tablet 12.5 mg, 25 codeine-guaifenesin 1 mg, 50 mg oral liquid 10-100 mg/5 ml promethazine rectal 1 suppository 12.5 mg, CODITUSSIN AC 3 25 mg ORAL LIQUID 10- 200 MG/5 ML promethegan rectal 1 suppository 12.5 mg, CODITUSSIN DAC 3 25 mg, 50 mg ORAL LIQUID 30- 10-200 MG/5 ML RYCLORA ORAL 3 SOLUTION 2 MG/5 g tussin ac oral 1 ML liquid 10-100 mg/5 ml RYVENT ORAL 3 ST TABLET 6 MG guaiatussin ac oral 1 liquid 10-100 mg/5 SYMJEPI 2 QL ml INJECTION SYRINGE 0.15 HISTEX-AC ORAL 3 MG/0.3 ML, 0.3 SYRUP 2.5-10-10 MG/0.3 ML MG/5 ML VISTARIL ORAL 3 HYCODAN (WITH 3 CAPSULE 25 MG, HOMATROPINE) 50 MG ORAL SYRUP 5- 1.5 MG/5 ML COUGH & COLD THERAPY hydrocodone- 1 benzonatate oral 1 homatropine oral capsule 100 mg, 150 syrup 5-1.5 mg/5 ml mg, 200 mg hydrocodone- 1 BROMFED DM 3 homatropine oral ORAL SYRUP 2- tablet 5-1.5 mg 30-10 MG/5 ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 145 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits hydromet oral syrup 1 RESPA-AR ORAL 3 5-1.5 mg/5 ml TABLET MAR-COF CG 3 EXTENDED ORAL LIQUID 7.5- RELEASE 12 HR 8- 225 MG/5 ML 90-0.24 MG maxi-tuss ac oral 1 TESSALON 3 liquid 10-100 mg/5 PERLES ORAL ml CAPSULE 100 MG MAXI-TUSS CD 3 TUSSICAPS ORAL 3 ST ORAL LIQUID 4- CAPSULE,EXTEN 10-10 MG/5 ML DED RELEASE 12 HR 10-8 MG m-clear wc oral 1 liquid 6.3-100 mg/5 TUZISTRA XR 3 ST ml ORAL SUSPENSION,EXT M-END PE ORAL 3 ENDED REL 12 HR LIQUID 1.33-3.33- 14.7-2.8 MG/5 ML 6.33 MG/5 ML virtussin ac oral 1 NINJACOF-XG 3 liquid 10-100 mg/5 ORAL LIQUID 8- ml 200 MG/5 ML virtussin dac oral 1 POLY-TUSSIN AC 3 syrup 30-10-100 ORAL LIQUID 4- mg/5 ml 10-10 MG/5 ML PULMONARY AGENTS promethazine- 1 codeine oral syrup ACCOLATE ORAL 3 6.25-10 mg/5 ml TABLET 10 MG, 20 MG promethazine-dm 1 oral syrup 6.25-15 acetylcysteine 1 mg/5 ml solution 100 mg/ml (10 %), 200 mg/ml promethazine- 1 (20 %) phenyleph-codeine oral syrup 6.25-5-10 ADEMPAS ORAL 4 PA mg/5 ml TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, promethazine- 1 2.5 MG phenylephrine oral syrup 6.25-5 mg/5 ADRENALIN 3 ml NASAL SOLUTION 1 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 146 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ADVAIR DISKUS 3 PA; QL alyq oral tablet 20 4 PA; QL INHALATION mg BLISTER WITH ambrisentan oral 4 PA DEVICE 100-50 tablet 10 mg, 5 mg MCG/DOSE, 250-50 MCG/DOSE, 500-50 ANORO ELLIPTA 2 QL MCG/DOSE INHALATION BLISTER WITH ADVAIR HFA 2 PA; QL DEVICE 62.5-25 INHALATION HFA MCG/ACTUATION AEROSOL INHALER 115-21 arformoterol 1 QL MCG/ACTUATION inhalation solution , 230-21 for nebulization 15 MCG/ACTUATION mcg/2 ml , 45-21 ARNUITY 2 QL MCG/ACTUATION ELLIPTA albuterol sulfate 1 QL INHALATION inhalation hfa BLISTER WITH aerosol inhaler 90 DEVICE 100 mcg/actuation MCG/ACTUATION , 200 albuterol sulfate 1 MCG/ACTUATION inhalation solution , 50 for nebulization 0.63 MCG/ACTUATION mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml ASMANEX HFA 2 QL (0.083 %), 2.5 INHALATION HFA mg/0.5 ml, 5 mg/ml AEROSOL INHALER 100 albuterol sulfate oral 1 MCG/ACTUATION syrup 2 mg/5 ml , 200 albuterol sulfate oral 1 MCG/ACTUATION tablet 2 mg, 4 mg , 50 albuterol sulfate oral 1 MCG/ACTUATION tablet extended release 12 hr 4 mg, 8 mg ALVESCO 3 QL INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION , 80 MCG/ACTUATION

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 147 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ASMANEX 2 QL BROVANA 3 QL TWISTHALER INHALATION INHALATION SOLUTION FOR AEROSOL POWDR NEBULIZATION BREATH 15 MCG/2 ML ACTIVATED 110 budesonide 1 QL MCG/ inhalation ACTUATION (30), suspension for 220 MCG/ nebulization 0.25 ACTUATION (120), mg/2 ml, 0.5 mg/2 220 MCG/ ml, 1 mg/2 ml ACTUATION (14), 220 MCG/ COMBIVENT 2 QL ACTUATION (30), RESPIMAT 220 MCG/ INHALATION ACTUATION (60) MIST 20-100 MCG/ACTUATION ATROVENT HFA 3 QL INHALATION HFA cromolyn inhalation 1 AEROSOL solution for INHALER 17 nebulization 20 mg/2 MCG/ACTUATION ml azelastine- 1 ST; QL CUROSURF 3 fluticasone nasal INTRATRACHEAL spray,non-aerosol SUSPENSION 120 137-50 mcg/spray MG/1.5 ML, 240 MG/3 ML bosentan oral tablet 4 PA 125 mg, 62.5 mg DULERA 2 PA; QL INHALATION HFA BREO ELLIPTA 2 PA; QL AEROSOL INHALATION INHALER 100-5 BLISTER WITH MCG/ACTUATION DEVICE 100-25 , 200-5 MCG/DOSE, 200-25 MCG/ACTUATION MCG/DOSE , 50-5 BREZTRI 2 QL MCG/ACTUATION AEROSPHERE DYMISTA NASAL 2 ST; QL INHALATION HFA SPRAY,NON- AEROSOL AEROSOL 137-50 INHALER 160-9- MCG/SPRAY 4.8 MCG/ACTUATION ELIXOPHYLLIN 3 ORAL ELIXIR 80 MG/15 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 148 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits epinephrine hcl 1 INCRUSE 2 QL nasal solution 1 ELLIPTA mg/ml INHALATION FLOVENT DISKUS 2 QL BLISTER WITH INHALATION DEVICE 62.5 BLISTER WITH MCG/ACTUATION DEVICE 100 ipratropium bromide 1 MCG/ACTUATION inhalation solution , 250 0.02 % MCG/ACTUATION ipratropium- 1 QL , 50 albuterol inhalation MCG/ACTUATION solution for FLOVENT HFA 2 QL nebulization 0.5 mg- INHALATION HFA 3 mg(2.5 mg base)/3 AEROSOL ml INHALER 110 KALYDECO ORAL 4 PA; QL MCG/ACTUATION GRANULES IN , 220 PACKET 25 MG, 50 MCG/ACTUATION MG, 75 MG , 44 MCG/ACTUATION KALYDECO ORAL 4 PA; QL TABLET 150 MG fluticasone 1 QL propionate nasal levalbuterol hcl 1 spray,suspension 50 inhalation solution mcg/actuation for nebulization 0.31 mg/3 ml, 0.63 mg/3 fluticasone propion- 1 PA; QL ml, 1.25 mg/0.5 ml, salmeterol 1.25 mg/3 ml inhalation blister with device 100-50 LONHALA 3 QL mcg/dose, 250-50 MAGNAIR REFILL mcg/dose, 500-50 INHALATION mcg/dose SOLUTION FOR NEBULIZATION formoterol fumarate 1 QL 25 MCG/ML inhalation solution for nebulization 20 LONHALA 3 QL mcg/2 ml MAGNAIR STARTER HYPER-SAL 3 INHALATION INHALATION SOLUTION FOR SOLUTION FOR NEBULIZATION NEBULIZATION 25 MCG/ML 3.5 % metaproterenol oral 1 syrup 10 mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 149 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits mometasone nasal 1 ST; QL ORLADEYO ORAL 5 PA spray,non-aerosol CAPSULE 110 MG, 50 mcg/actuation 150 MG montelukast oral 1 PERFOROMIST 2 QL granules in packet 4 INHALATION mg SOLUTION FOR montelukast oral 1 NEBULIZATION tablet 10 mg 20 MCG/2 ML montelukast oral 1 pulmosal inhalation 1 tablet,chewable 4 solution for mg, 5 mg nebulization 7 % nebusal inhalation 1 PULMOZYME 4 PA solution for INHALATION nebulization 3 % SOLUTION 1 MG/ML NEBUSAL 3 INHALATION QVAR 2 QL SOLUTION FOR REDIHALER NEBULIZATION 6 INHALATION HFA % AEROSOL BREATH NUCALA 4 PA; QL ACTIVATED 40 SUBCUTANEOUS MCG/ACTUATION AUTO-INJECTOR , 80 100 MG/ML MCG/ACTUATION NUCALA 4 PA; QL REVATIO ORAL 5 PA; QL SUBCUTANEOUS SUSPENSION FOR SYRINGE 100 RECONSTITUTIO MG/ML N 10 MG/ML OFEV ORAL 4 PA; QL REVATIO ORAL 5 PA; QL CAPSULE 100 MG, TABLET 20 MG 150 MG sildenafil 4 PA; QL OPSUMIT ORAL 4 PA (pulm.hypertension) TABLET 10 MG oral suspension for ORKAMBI ORAL 4 PA; QL reconstitution 10 GRANULES IN mg/ml PACKET 100-125 sildenafil 4 PA; QL MG, 150-188 MG (pulm.hypertension) ORKAMBI ORAL 4 PA; QL oral tablet 20 mg TABLET 100-125 SINUVA SINUS 5 MG, 200-125 MG IMPLANT 1,350 MCG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 150 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits sodium chloride 1 THEO-24 ORAL 3 inhalation solution CAPSULE,EXTEN for nebulization 0.9 DED RELEASE %, 10 %, 3 %, 7 % 24HR 100 MG, 200 SPIRIVA 2 QL MG, 300 MG, 400 RESPIMAT MG INHALATION theophylline oral 1 MIST 1.25 elixir 80 mg/15 ml MCG/ACTUATION theophylline oral 1 , 2.5 solution 80 mg/15 ml MCG/ACTUATION theophylline oral 1 SPIRIVA WITH 2 QL tablet extended HANDIHALER release 12 hr 300 INHALATION mg, 450 mg CAPSULE, W/INHALATION theophylline oral 1 DEVICE 18 MCG tablet extended release 24 hr 400 STIOLTO 2 QL mg, 600 mg RESPIMAT INHALATION TRACLEER ORAL 5 PA MIST 2.5-2.5 TABLET 125 MG, MCG/ACTUATION 62.5 MG SYMBICORT 2 PA; QL TRACLEER ORAL 4 PA INHALATION HFA TABLET FOR AEROSOL SUSPENSION 32 INHALER 160-4.5 MG MCG/ACTUATION TRELEGY 2 QL , 80-4.5 ELLIPTA MCG/ACTUATION INHALATION SYMDEKO ORAL 4 PA; QL BLISTER WITH TABLETS, DEVICE 100-62.5- SEQUENTIAL 100- 25 MCG, 200-62.5- 150 MG (D)/ 150 25 MCG MG (N), 50-75 MG TRIKAFTA ORAL 4 PA; QL (D)/ 75 MG (N) TABLETS, tadalafil (pulm. 4 PA; QL SEQUENTIAL 100- hypertension) oral 50-75 MG(D) /150 tablet 20 mg MG (N) terbutaline oral 1 TRIKAFTA ORAL 4 PA tablet 2.5 mg, 5 mg TABLETS, SEQUENTIAL 50- 25-37.5 MG (D)/75 MG (N) You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 151 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits TYVASO 4 PA YUPELRI 2 QL INHALATION INHALATION SOLUTION FOR SOLUTION FOR NEBULIZATION NEBULIZATION 1.74 MG/2.9 ML 175 MCG/3 ML (0.6 MG/ML) zafirlukast oral 1 TYVASO REFILL 4 PA tablet 10 mg, 20 mg KIT INHALATION zileuton oral tablet, 1 ST SOLUTION FOR er multiphase 12 hr NEBULIZATION 600 mg 1.74 MG/2.9 ML (0.6 MG/ML) ZYFLO ORAL 3 ST TABLET 600 MG TYVASO 4 PA STARTER KIT UROLOGICALS INHALATION SOLUTION FOR ANTICHOLINERGICS & NEBULIZATION ANTISPASMODICS 1.74 MG/2.9 ML darifenacin oral 1 wixela inhub 1 PA; QL tablet extended inhalation blister release 24 hr 15 mg, with device 100-50 7.5 mg mcg/dose, 250-50 DITROPAN XL 3 ST mcg/dose, 500-50 ORAL TABLET mcg/dose EXTENDED XHANCE NASAL 3 ST; QL RELEASE 24HR 10 AEROSOL MG, 5 MG BREATH flavoxate oral tablet 1 ACTIVATED 93 100 mg MCG/ACTUATION GELNIQUE 2 ST; QL XOPENEX 3 TRANSDERMAL CONCENTRATE GEL IN PACKET INHALATION 10 % (100 SOLUTION FOR MG/GRAM) NEBULIZATION 1.25 MG/0.5 ML GEMTESA ORAL 3 ST TABLET 75 MG XOPENEX 3 INHALATION oxybutynin chloride 1 SOLUTION FOR oral syrup 5 mg/5 ml NEBULIZATION oxybutynin chloride 1 0.31 MG/3 ML, 0.63 oral tablet 5 mg MG/3 ML, 1.25 MG/3 ML

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 152 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits oxybutynin chloride 1 finasteride oral 1 oral tablet extended tablet 5 mg release 24hr 10 mg, FLOMAX ORAL 3 ST 15 mg, 5 mg CAPSULE 0.4 MG OXYTROL 3 ST; QL JALYN ORAL 3 ST TRANSDERMAL CAPSULE, ER PATCH MULTIPHASE 24 SEMIWEEKLY 3.9 HR 0.5-0.4 MG MG/24 HR PROSCAR ORAL 3 ST solifenacin oral 1 TABLET 5 MG tablet 10 mg, 5 mg silodosin oral 1 tolterodine oral 1 capsule 4 mg, 8 mg capsule,extended release 24hr 2 mg, 4 tadalafil oral tablet 1 QL mg 2.5 mg, 5 mg tolterodine oral 1 tamsulosin oral 1 tablet 1 mg, 2 mg capsule 0.4 mg TOVIAZ ORAL 2 ST CHOLINERGIC STIMULANTS TABLET bethanechol chloride 1 EXTENDED oral tablet 10 mg, 25 RELEASE 24 HR 4 mg, 5 mg, 50 mg MG, 8 MG MISCELLANEOUS UROLOGICALS trospium oral 1 capsule,extended CYSTAGON ORAL 4 PA release 24hr 60 mg CAPSULE 150 MG, 50 MG trospium oral tablet 1 20 mg ELMIRON ORAL 2 CAPSULE 100 MG BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY hyophen oral tablet 1 81.6-0.12-10.8 mg alfuzosin oral tablet 1 extended release 24 K-PHOS NO 2 3 hr 10 mg ORAL TABLET 305-700 MG dutasteride oral 1 ST capsule 0.5 mg K-PHOS 2 ORIGINAL ORAL dutasteride- 1 ST TABLET,SOLUBL tamsulosin oral E 500 MG capsule, er multiphase 24 hr methen-sod phos- 1 0.5-0.4 mg meth blue-hyos oral tablet 81.6-40.8-0.12 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 153 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits ORACIT ORAL 3 ustell oral capsule 1 SOLUTION 490- 120-0.12 mg 640 MG/5 ML utira-c oral tablet 1 OXLUMO 5 81.6-10.8-40.8 mg SUBCUTANEOUS URINARY ANESTHETICS SOLUTION 94.5 MG/0.5 ML phenazopyridine 1 oral tablet 100 mg, phosphasal oral 1 200 mg tablet 81.6-10.8-40.8 mg PYRIDIUM ORAL 3 TABLET 100 MG, potassium citrate 1 200 MG oral tablet extended release 10 meq VITAMINS, HEMATINICS & (1,080 mg), 15 meq, ELECTROLYTES 5 meq (540 mg) URELLE ORAL 3 ELECTROLYTES TABLET 81-10.8- effer-k oral tablet, 1 40.8 MG effervescent 25 meq uretron d-s oral 1 GALZIN ORAL 3 tablet 81.6-10.8-40.8 CAPSULE 25 MG mg (ZINC), 50 MG URIBEL ORAL 3 (ZINC) CAPSULE 118-10- klor-con 10 oral 1 40.8-36 MG tablet extended urimar-t oral tablet 1 release 10 meq 120-0.12-10.8 mg klor-con 8 oral 1 uro-458 oral tablet 1 tablet extended 81-10.8-40.8 mg release 8 meq urogesic-blue oral 1 klor-con m10 oral 1 tablet 81.6-40.8-0.12 tablet,er mg particles/crystals 10 meq uro-mp oral capsule 1 118-10-40.8-36 mg klor-con m15 oral 1 tablet,er UROQID-ACID 3 particles/crystals 15 NO.2 ORAL meq TABLET 500-500 MG klor-con m20 oral 1 tablet,er uryl oral tablet 81.6- 1 particles/crystals 20 40.8-0.12 mg meq

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 154 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits klor-con oral packet 1 b complex 1 (with 0 Covered for $0 20 meq folic acid) oral for ages 50 and klor-con/ef oral 1 tablet 0.4 mg younger; OTC tablet, effervescent b complex-vitamin 0 covered at $0 25 meq b12 oral tablet for ages 50 K-TAB ORAL 3 years and TABLET younger; OTC EXTENDED b complex-vitamin c- 0 covered at $0 RELEASE 10 MEQ, folic acid oral tablet for ages 50 20 MEQ 400 mcg years and k-tab oral tablet 1 younger; OTC extended release 8 balanced b-100 0 covered at $0 meq complex oral tablet for ages 50 lugols oral solution 1 extended release 100 years and 5 % mg younger; OTC POTABA ORAL 3 balanced b-100 oral 0 covered at $0 CAPSULE 500 MG tablet 0.4 mg for ages 50 years and potassium chloride 1 younger; OTC oral liquid 20 meq/15 ml, 40 balanced b-50 oral 0 covered at $0 meq/15 ml tablet for ages 50 years and potassium chloride 1 younger; OTC oral packet 20 meq BAL-CARE DHA 3 potassium chloride 1 ESSENTIAL ORAL oral tablet extended COMBO release 10 meq, 20 PACK,TABLET meq, 8 meq AND CAP,DR 27 potassium chloride 1 MG IRON-1 MG - oral tablet,er 374 MG particles/crystals 10 bal-care dha oral 1 meq, 20 meq combo pack,tablet strong iodine oral 1 and cap,dr 27-1-430 solution 5 % mg MISCELLANEOUS VITAMINS, b-complex with 0 covered at $0 HEMATINICS, & ELECTROLYTES vitamin c oral tablet for ages 50 , 400-500 mcg-mg years and DOJOLVI ORAL 5 younger; OTC LIQUID 8.3 KCAL/ML VITAMINS & HEMATINICS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 155 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits CITRANATAL B- 3 DRISDOL ORAL 3 CALM (FE GLUC) CAPSULE 1,250 ORAL TABLETS, MCG (50,000 SEQUENTIAL 20 UNIT) MG IRON-1 MG - DUET DHA 3 25 MG/25 MG BALANCED ORAL classic prenatal oral 0 covered at $0 COMBO PACK 25 tablet 28 mg iron- for ages 50 MG IRON-1 MG - 800 mcg years and 267 MG-233 MG younger; OTC DUET DHA WITH 3 c-nate dha oral 1 OMEGA-3 ORAL capsule 28 mg iron- COMBO PACK 25 1 mg -200 mg MG IRON-1 MG - complete natal dha 1 400 MG oral combo pack 29- elite-ob oral tablet 1 1-250-200 mg 50 mg iron- 1.25 mg complex b-100 oral 0 covered at $0 ENBRACE HR 3 tablet extended for ages 50 ORAL release years and CAPSULE,IR - younger; OTC DELAY CONCEPT DHA 3 REL,BIPHASE 1.5 ORAL CAPSULE MG IRON- 8.73 35-1-200 MG MG-6.4 MG CONCEPT OB 3 ergocalciferol 1 ORAL CAPSULE (vitamin d2) oral 85-1 MG capsule 1,250 mcg (50,000 unit) cyanocobalamin 1 (vitamin b-12) FERAHEME 2 PA injection solution INTRAVENOUS 1,000 mcg/ml SOLUTION 510 MG/17 ML (30 DERMACINRX 3 MG/ML) PRENATRYL ORAL TABLET 27 FLORIVA 3 OTC MG IRON- 1 MG (FLUORIDE- VITAMIN D3) dialyvite 800 oral 0 covered at $0 ORAL DROPS 0.25 tablet 0.8 mg for ages 50 MG (0.55 MG)-400 years and UNIT/ML younger; OTC fluoride (sodium) 0 covered at $0 oral drops 0.5 mg for ages 1-16 (1.1 mg years; OTC sod.fluorid)/ml

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 156 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits fluoride (sodium) 0 covered at $0 KOSHER 3 oral tablet,chewable for ages 1-16 PRENATAL PLUS 0.25 mg(0.55 mg years; OTC IRON ORAL sod. fluoride), 0.5 TABLET 30 MG mg (1.1 mg sodium IRON- 1 MG fluorid), 1 mg (2.2 kpn oral tablet 0 covered at $0 mg sod. fluoride) for ages 50 folic acid injection 1 years and solution 5 mg/ml younger; OTC folic acid oral tablet 1 ludent fluoride oral 0 covered at $0 1 mg tablet,chewable 0.25 for ages 1-16 folic acid oral tablet 0 covered at $0 mg(0.55 mg sod. years; OTC 400 mcg, 800 mcg for ages 50 fluoride), 0.5 mg years and (1.1 mg sodium younger; OTC fluorid), 1 mg (2.2 mg sod. fluoride) folivane-ob oral 1 capsule 85-1 mg MARNATAL-F 3 ORAL CAPSULE foltabs 800 oral 0 covered at $0 60 MG IRON-1 MG tablet 0.8-10-115 for ages 50 mg-mg-mcg years and MECOBALAMIN 3 younger; OTC (VITAMIN B12) INJECTION full spectrum b- 0 covered at $0 RECON SOLN vitamin c oral tablet for ages 50 10,000 MCG 0.8 mg years and younger; OTC m-natal plus oral 1 tablet 27 mg iron- 1 hydroxocobalamin 1 mg intramuscular solution 1,000 multi-vitamin with 0 covered at $0 mcg/ml fluoride oral drops for ages 1-16 0.25 mg/ml, 0.5 years; OTC INFED INJECTION 2 PA mg/ml SOLUTION 50 MG/ML multi-vitamin with 0 covered at $0 fluoride oral for ages 1-16 INJECTAFER 3 PA tablet,chewable 0.25 years; OTC INTRAVENOUS mg, 0.5 mg, 1 mg SOLUTION 50 IRON MG/ML multivitamins with 0 covered at $0 fluoride oral for ages 1-16 kobee oral tablet 0.4 0 covered at $0 tablet,chewable 0.25 years; OTC mg for ages 50 mg, 0.5 mg, 1 mg years and younger; OTC mvc-fluoride oral 0 covered at $0 tablet,chewable 0.25 for ages 1-16 mg, 0.5 mg, 1 mg years; OTC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 157 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits mynatal oral capsule 1 NESTABS ABC 3 65 mg iron- 1 mg ORAL COMBO mynatal plus oral 1 PACK 32 MG tablet 65 mg iron- 1 IRON-1 MG -120 mg MG-180 MG mynatal-z oral tablet 1 NESTABS DHA 3 65 mg iron- 1 mg ORAL COMBO PACK 32 MG NASCOBAL 2 QL IRON- 1,000 MCG- NASAL 230MG SPRAY,NON- AEROSOL 500 NESTABS ONE 3 MCG/SPRAY ORAL CAPSULE 38-1-225 MG NATACHEW (FE 3 BIS-GLYCINATE) NESTABS ORAL 3 ORAL TABLET 32-1,000 TABLET,CHEWAB MG-MCG LE 28 MG IRON -1 newgen oral tablet 1 MG 32-1,000 mg-mcg natural b-100 0 covered at $0 OB COMPLETE 3 complex oral tablet for ages 50 ONE ORAL 100 mg years and CAPSULE 40-10-1- younger; OTC 300 MG NEEVODHA 3 OB COMPLETE 3 (WITH ALGAL ORAL TABLET 50 OIL) ORAL MG IRON- 1.25 MG CAPSULE 27 MG OB COMPLETE 3 IRON-1.13 MG- PETITE ORAL 581.92 MG CAPSULE 35 MG NEONATAL 3 IRON-5 MG IRON- COMPLETE ORAL 1 MG TABLET 29-1 MG OB COMPLETE 3 NEONATAL FE 3 PREMIER ORAL ORAL TABLET 90 TABLET 30-20-1 MG-120 MG-12 MG MCG-1,000 MCG OB COMPLETE 3 NEONATAL-DHA 3 WITH DHA ORAL ORAL COMBO CAPSULE 30 MG PACK 29-1-200-500 IRON-10 MG MG IRON-1 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 158 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits one daily prenatal 0 covered at $0 prena1 true oral 1 oral combo pack 28- for ages 50 combo pack 30 mg 800-440 mg-mcg-mg years and iron- 1.4 mg-300 mg younger; OTC PRENATA ORAL 3 perry prenatal oral 0 covered at $0 TABLET,CHEWAB capsule 13.5-0.4 mg for ages 50 LE 29 MG IRON- 1 years and MG younger; OTC prenatabs fa oral 1 pnv 29-1 oral tablet 1 tablet 29-1 mg 29 mg iron- 1 mg prenatabs rx oral 1 pnv-dha oral capsule 1 tablet 29 mg iron- 1 27 mg iron-1 mg - mg 300 mg prenatal complete 0 covered at $0 pnv-omega oral 1 oral tablet 14 mg for ages 50 capsule 28-1-300 mg iron- 400 mcg years and pnv-select oral tablet 1 younger; OTC 27-1 mg prenatal multi-dha 0 covered at $0 pr natal 400 ec oral 1 (algal oil) oral for ages 50 combo pack,tablet capsule 27mg iron- years and and cap,dr 29-1-400 800 mcg-250 mg younger; OTC mg prenatal 0 covered at $0 pr natal 400 oral 1 multivitamins oral for ages 50 combo pack 29-1- tablet 28 mg iron- years and 400 mg 800 mcg younger; OTC pr natal 430 ec oral 1 prenatal one daily 0 covered at $0 combo pack,tablet oral tablet 27 mg for ages 50 and cap,dr 29-1-430 iron- 800 mcg years and mg younger; OTC pr natal 430 oral 1 prenatal oral tablet 0 covered at $0 combo pack 29 mg 28 mg iron- 800 mcg for ages 50 iron-1 mg -430 mg years and younger; OTC prena1 chew oral 1 tablet,chew,ir - prenatal plus 1 dr,biphase 1.4 mg (calcium carb) oral tablet 27 mg iron- 1 prena1 pearl oral 1 mg capsule,ir - delay rel,biphase 30-1.4- PRENATAL PLUS 3 200 mg DHA ORAL COMBO PACK 27 MG IRON-1 MG - 312 MG-250 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 159 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits prenatal plus oral 1 PRENATE 3 tablet 29 mg iron- 1 ENHANCE ORAL mg CAPSULE 28 MG prenatal vitamin 0 OTC IRON- 1 MG-400 oral tablet 27 mg MG iron- 0.8 mg PRENATE 3 prenatal vitamin 1 ESSENTIAL(IRON- plus low iron oral ASP-GL) ORAL tablet 27 mg iron- 1 CAPSULE 18 MG mg IRON- 1 MG-300 MG prenatal vitamin 0 covered at $0 with minerals oral for ages 50 PRENATE MINI 3 tablet 28 mg iron- years and (FERR ASP 800 mcg younger; OTC GLYCIN) ORAL CAPSULE 18-1-350 prenatal vits96-iron 0 covered at $0 MG fum-folic oral tablet for ages 50 27 mg iron- 800 mcg years and PRENATE PIXIE 3 younger; OTC ORAL CAPSULE 10 MG IRON- 1 prenatal-u oral 1 MG-200 MG capsule 106.5-1 mg PRENATE 3 PRENATE AM 3 RESTORE ORAL ORAL TABLET 1- CAPSULE 27 MG 500 MG IRON- 1 MG-400 PRENATE 3 MG CHEWABLE PRENATE STAR 3 ORAL ORAL TABLET 20 TABLET,CHEWAB MG IRON- 1 MG LE 1 MG preplus oral tablet 1 PRENATE DHA 3 27 mg iron- 1 mg (FERR ASP GLYCIN) ORAL pretab oral tablet 1 CAPSULE 18 MG 29-1 mg IRON-1 MG -300 PRIMACARE 3 MG ORAL CAPSULE PRENATE ELITE 3 30-1-300 MG (IRON ASP GLYC) PROVIDA OB 3 ORAL TABLET 20 ORAL CAPSULE MG IRON- 1 MG 40 MG IRON- 1.25 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 160 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits PUREFE OB PLUS 3 stress formula with 0 covered at $0 ORAL CAPSULE iron(sulf) oral tablet for ages 50 106 MG IRON- 1 500 mg-400 mcg- 27 years and MG mg iron younger; OTC rena-vite oral tablet 0 covered at $0 super b complex- 0 covered at $0 0.8 mg for ages 50 vitamin c oral tablet for ages 50 years and years and younger; OTC younger; OTC R-NATAL OB 3 super b maxi 0 covered at $0 ORAL CAPSULE complex oral tablet for ages 50 20 MG IRON- 1 0.4 mg years and MG-320 MG younger; OTC SELECT-OB 3 super quints b-50 0 covered at $0 (FOLIC ACID) oral tablet for ages 50 ORAL years and TABLET,CHEWAB younger; OTC LE 29 MG IRON- 1 super quints oral 0 covered at $0 MG tablet 0.4 mg for ages 50 SELECT-OB + 3 years and DHA ORAL younger; OTC COMBO PACK 29 taron-c dha oral 1 MG IRON-1 MG - capsule 35-1-200 mg 250 MG THRIVITE RX 3 SELECT-OB ORAL 3 ORAL TABLET 29 TABLET,CHEWAB MG IRON- 1 MG LE 29 MG IRON- 1 MG TRICARE ORAL 3 TABLET 27 MG se-natal 19 chewable 1 IRON- 1 MG oral tablet,chewable 29 mg iron- 1 mg TRIFERIC 3 HEMODIALYSIS se-natal-19 oral 1 SOLUTION 27.2 tablet 29 mg iron- 1 MG IRON/5 ML mg trinatal rx 1 oral 1 stress formula oral 0 covered at $0 tablet 60 mg iron-1 tablet for ages 50 mg years and younger; OTC trinate oral tablet 28 1 mg iron- 1 mg stress formula with 0 covered at $0 iron oral tablet 500 for ages 50 TRISTART DHA 3 mg-400 mcg- 18 mg years and ORAL CAPSULE iron younger; OTC 31 MG IRON- 1 MG-200 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 161 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits triveen-duo dha oral 1 VITAFOL-OB 3 combo pack 29-1- ORAL TABLET 65- 400 mg 1 MG tri-vitamin with 0 covered at $0 VITAFOL- 3 fluoride oral drops for ages 1-16 OB+DHA ORAL 0.25 mg fluor. (0.55 years; OTC COMBO PACK 65- mg)/ml, 0.5 mg 1-250 MG fluoride (1.1 mg)/ml VITAFOL-ONE 3 VENOFER 2 PA ORAL CAPSULE INTRAVENOUS 29 MG IRON- 1 SOLUTION 100 MG-200 MG MG IRON/5 ML, VITAMED MD 3 200 MG IRON/10 ONE RX ORAL ML, 50 MG CAPSULE 30 MG IRON/2.5 ML IRON-1MG -200 virt-c dha oral 1 MG capsule 35-1-200 mg VITAMEDMD 3 virt-nate dha oral 1 REDICHEW RX capsule 28 mg iron- ORAL 1 mg -200 mg TABLET,CHEW,IR virt-pn dha oral 1 - DR,BIPHASE 1.4 capsule 27 mg iron- MG 1 mg -300 mg vitamin b complex 0 covered at $0 virt-pn plus oral 1 oral tablet for ages 50 capsule 28-1-300 mg years and younger; OTC VITAFOL FE PLUS 3 ORAL CAPSULE vitamin b complex- 0 covered at $0 90 MG IRON- 1 folic acid oral tablet for ages 50 MG-200 MG 0.4 mg years and younger; OTC VITAFOL 3 GUMMIES ORAL vitamins a,c,d and 0 covered at $0 TABLET,CHEWAB fluoride oral drops for ages 1-16 LE 3.33 MG IRON- 0.25 mg fluor. (0.55 years; OTC 0.33 MG mg)/ml, 0.5 mg fluoride (1.1 mg)/ml VITAFOL NANO 3 ORAL TABLET 18 VITAPEARL 3 MG IRON- 1 MG ORAL CAPSULE,IR - VITAFOL ULTRA 3 DELAY ORAL CAPSULE REL,BIPHASE 30- 29 MG IRON- 1 1.4-200 MG MG-200 MG

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 162 Drug Name Drug Requirements Drug Name Drug Requirements Tier / Limits Tier / Limits VITATRUE ORAL 3 westgel dha oral 1 COMBO PACK 30 capsule 31 mg iron- MG IRON- 1.4 MG- 1 mg-200 mg 300 MG zatean-pn dha oral 1 VP-PNV-DHA 3 capsule 27 mg iron- ORAL CAPSULE 1 mg -300 mg 28 MG IRON- 1 zatean-pn plus oral 1 MG-200 MG capsule 28-1-300 mg westab plus oral 1 zingiber oral tablet 1 tablet 27 mg iron- 1 1.2 mg-40 mg- 124.1 mg mg-100 mg

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 163 Index

A ADACEL(TDAP ALBENZA ...... 11 abacavir ...... 4 ADOLESN/ADULT)(PF) albuterol sulfate ...... 147 abacavir-lamivudine ...... 4 ...... 114 ALCAINE...... 137 abacavir-lamivudine- ADAKVEO ...... 17 alclometasone ...... 78 zidovudine ...... 4 ADALAT CC ...... 53 ALDACTAZIDE...... 53 ABECMA...... 16 adapalene ...... 70 ALDACTONE...... 53 ABILIFY MYCITE...... 43 ADAPALENE ...... 70 ALDARA ...... 114 ABILIFY MYCITE adapalene-benzoyl peroxide .70 ALECENSA ...... 17 MAINTENANCE KIT.....42 ADASUVE...... 43 alendronate ...... 120 ABILIFY MYCITE ADDERALL XR...... 43 ALFERON N...... 114 STARTER KIT ...... 43 adefovir...... 4 alfuzosin ...... 153 abiraterone...... 17 ADEMPAS...... 146 ALINIA ...... 11 ABSORICA...... 70 ADHANSIA XR...... 43 aliskiren ...... 53 ABSORICA LD ...... 70 ADRENALIN...... 146 ALKERAN ...... 17 acamprosate...... 83 adult aspirin regimen ...... 38 allopurinol...... 119 acarbose...... 98 ADVAIR DISKUS ...... 147 ALLZITAL...... 35 ACCOLATE...... 146 ADVAIR HFA ...... 147 almotriptan malate ...... 30 ACCUPRIL ...... 53 ADZENYS ER ...... 43 ALOCRIL...... 137 ACCURETIC ...... 53 ADZENYS XR-ODT ...... 43 ALOGLIPTIN ...... 98 accutane...... 70 AEMCOLO ...... 11 ALOMIDE...... 137 ACE AEROSOL CLOUD AEROCHAMBER MINI .....90 alophen (bisacodyl) ...... 103 ENHANCER ...... 90 AEROCHAMBER PLUS ALORA ...... 123 acebutolol ...... 53 FLOW-VU...... 90 alosetron ...... 103 acetaminophen-caff- AEROCHAMBER PLUS Z ALPHAGAN P...... 143 dihydrocod...... 34 STAT ...... 90 alprazolam ...... 43 acetaminophen-codeine...... 34 AEROTRACH PLUS...... 90 alprazolam intensol...... 43 acetazolamide ...... 139, 140 AEROVENT PLUS...... 90 ALREX...... 142 acetic acid...... 83, 87 AFINITOR ...... 17 altacaine...... 137 acetylcysteine ...... 146 AFINITOR DISPERZ ...... 17 ALTACE ...... 53 acitretin...... 67 afirmelle...... 127 ALTAFLUOR BENOX...... 137 ACTEMRA ...... 120 AFLURIA QD 2021-22(3YR altavera (28)...... 127 ACTEMRA ACTPEN...... 120 UP)(PF) ...... 114 ALTRENO ...... 70 ACTHIB (PF)...... 114 AFLURIA QD 2021-22(6- ALUNBRIG ...... 17 ACTICLATE...... 14 35MO)(PF) ...... 114 ALVESCO...... 147 ACTIMMUNE ...... 114 AFLURIA QUAD 2021- alvimopan ...... 103 ACTIQ...... 34 2022(6MO UP)...... 115 alyacen 1/35 (28) ...... 127 ACTIVELLA ...... 123 AFTERA ...... 127 alyacen 7/7/7 (28) ...... 127 ACTONEL ...... 120 AGRYLIN ...... 83 alyq ...... 147 ACTOPLUS MET...... 98 AKLIEF...... 70 amabelz...... 123 ACTOS...... 98 ak-poly-bac...... 134 amantadine hcl...... 4 ACULAR ...... 139 AKTEN (PF) ...... 137 AMARYL...... 98 ACULAR LS...... 139 AKYNZEO (NETUPITANT) ambrisentan...... 147 acyclovir...... 4, 77 ...... 103 amcinonide ...... 78 ACZONE...... 70 ala-cort...... 78 AMERGE ...... 30 ALA-SCALP...... 78 amethia ...... 127 albendazole...... 11 amethyst (28) ...... 127 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 164 amiloride...... 53 ARAZLO...... 71 AUTOJECT 2 INJECTION amiloride-hydrochlorothiazide arformoterol...... 147 DEVICE ...... 92 ...... 53 ARICEPT ...... 32 AUTOPEN 1 TO 21 UNITS 92 amiodarone...... 52 aripiprazole...... 44 avar ...... 71 amitriptyline ...... 43 ARIXTRA ...... 61 AVAR...... 71 amitriptyline-chlordiazepoxide armodafinil ...... 44 AVAR LS ...... 71 ...... 43 ARMOUR THYROID ...... 100 AVAR-E GREEN...... 71 amlodipine...... 53 ARNUITY ELLIPTA...... 147 AVAR-E LS ...... 71 amlodipine-benazepril...... 54 AROMASIN...... 17 aviane...... 127 amlodipine-olmesartan...... 54 ARTHROTEC 50 ...... 38 avidoxy ...... 14 amlodipine-valsartan ...... 54 ARTHROTEC 75 ...... 38 AVIDOXY DK...... 14 amlodipine-valsartan-hcthiazid ASCENIV...... 115 avita ...... 71 ...... 54 ascomp with codeine ...... 35 AVITA...... 71 ammonium lactate ...... 69 asenapine maleate...... 44 AVSOLA...... 103 amnesteem...... 70 ashlyna...... 127 AYGESTIN ...... 123 amoxapine ...... 43 ASMANEX HFA ...... 147 ayuna...... 127 amoxicil-clarithromy-lansopraz ASMANEX TWISTHALER AYVAKIT...... 17 ...... 109 ...... 148 AZASAN...... 17 amoxicillin...... 13 ASPARLAS...... 17 AZASITE ...... 134 amoxicillin-pot clavulanate..13 aspirin ...... 38 azathioprine ...... 17 amphetamine sulfate...... 43 aspirin low dose...... 38 azelaic acid ...... 71 AMZEEQ ...... 70 aspirin-dipyridamole ...... 61 azelastine ...... 86, 137 ANAFRANIL...... 43 aspir-trin ...... 38 azelastine-fluticasone ...... 148 anagrelide ...... 83 ASTAGRAF XL...... 17 AZELEX...... 71 ANA-LEX KIT ...... 103 AT HOME A1C ...... 91 AZILECT ...... 29 ANALPRAM-HC...... 67, 103 atazanavir...... 4 azithromycin ...... 9 ANALPRAM-HC SINGLES ATELVIA...... 120 AZOPT ...... 140 ...... 103 atenolol ...... 54 AZULFIDINE ...... 103 ANAPROX DS ...... 38 atenolol-chlorthalidone...... 54 AZULFIDINE EN-TABS ..103 anaspaz ...... 101 ATIVAN...... 44 azurette (28)...... 127 anastrozole...... 17 atomoxetine ...... 44 B ANDRODERM ...... 96 atorvastatin ...... 63 b complex 1 (with folic acid) ANGELIQ ...... 123 atovaquone...... 11 ...... 155 ANORO ELLIPTA ...... 147 atovaquone-proguanil...... 11 b complex-vitamin b12...... 155 ANTARA ...... 63 ATROPINE ...... 136 b complex-vitamin c-folic acid anucort-hc...... 103 ATROVENT HFA ...... 148 ...... 155 apexicon e...... 78 AUBAGIO...... 112 bacitracin ...... 134 APLENZIN ...... 44 aubra ...... 127 bacitracin-polymyxin b...... 134 apraclonidine ...... 144 aubra eq ...... 127 baclofen ...... 33 aprepitant...... 103 AUGMENTIN...... 13 BACTRIM...... 14 apri...... 127 AUGMENTIN XR ...... 14 BACTRIM DS...... 14 APRISO...... 103 aurovela 1.5/30 (21) ...... 127 BAFIERTAM...... 112 APTENSIO XR...... 44 aurovela 1/20 (21) ...... 127 balanced b-100...... 155 APTIVUS...... 4 aurovela 24 fe ...... 127 balanced b-100 complex.....155 aqua care sodium chloride....83 aurovela fe 1.5/30 (28) ...... 127 balanced b-50...... 155 aqua care sterile water...... 83 aurovela fe 1-20 (28) ...... 127 bal-care dha ...... 155 aranelle (28)...... 127 AURYXIA...... 103 BAL-CARE DHA ARAVA...... 120 ESSENTIAL...... 155

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 165 balsalazide ...... 103 BETAPACE AF ...... 52 brompheniramine-pseudoeph- BALVERSA...... 17 BETASERON ...... 112 dm...... 145 balziva (28)...... 127 betaxolol ...... 54, 136 BROVANA ...... 148 BANZEL ...... 24 bethanechol chloride...... 153 BRUKINSA...... 18 BAQSIMI ...... 91 BETHKIS ...... 11 BRYHALI ...... 78 BARACLUDE ...... 4 BETOPTIC S...... 136 budesonide...... 103, 148 BASAGLAR KWIKPEN U- bexarotene ...... 17 bumetanide ...... 54 100 INSULIN...... 93 BEXSERO...... 115 buprenorphine...... 35 bayer aspirin ...... 38 BEYAZ...... 127 buprenorphine hcl...... 35 BCG VACCINE, LIVE (PF) bicalutamide ...... 17 buprenorphine-naloxone.38, 39 ...... 115 BIDIL ...... 54 bupropion hcl...... 44 b-complex with vitamin c...155 BIKTARVY ...... 4 BUPROPION HCL ...... 44 BD INTEGRA NEEDLE .....92 bimatoprost...... 140 bupropion hcl (smoking deter) BD MICROTAINER BINOSTO...... 120 ...... 85 LANCET ...... 92 BIOTHRAX ...... 115 buspirone ...... 44 BD SPECIALTY USE bisacodyl...... 103 butalbital compound w/codeine NEEDLES ...... 92 bisa-lax (bisacodyl) ...... 103 ...... 35 BD ULTRA FINE LANCETS bisoprolol fumarate...... 54 butalbital-acetaminop-caf-cod ...... 92 bisoprolol-hydrochlorothiazide ...... 35 BD ULTRA-FINE NANO ...... 54 butalbital-acetaminophen .....35 PEN NEEDLE...... 92 BLEPH-10...... 143 butalbital-acetaminophen-caff BELBUCA ...... 35 BLEPHAMIDE ...... 143 ...... 35 belladonna alkaloids-opium101 BLEPHAMIDE S.O.P...... 143 butalbital-aspirin-caffeine.....35 BELRAPZO ...... 17 blisovi 24 fe...... 127 butorphanol...... 39 benazepril ...... 54 blisovi fe 1.5/30 (28) ...... 127 C benazepril-hydrochlorothiazide blisovi fe 1/20 (28) ...... 127 cabergoline ...... 96 ...... 54 BONIVA ...... 120 CABLIVI...... 61 BENDEKA...... 17 BONJESTA ...... 103 CABOMETYX...... 18 BENLYSTA...... 120, 121 BOOSTRIX TDAP...... 115 CAFERGOT ...... 31 BENZACLIN ...... 71 bosentan...... 148 caffeine citrate ...... 83 BENZACLIN PUMP ...... 71 BOSULIF ...... 17 CALAN SR ...... 54 benzepro ...... 71 bp 10-1...... 71 calcipotriene ...... 67 BENZEPRO BRAFTOVI ...... 17 calcipotriene-betamethasone 67 (MICROSPHERES)...... 71 BREATHERITE MDI calcitonin (salmon) ...... 96 BENZNIDAZOLE ...... 11 SPACER...... 90 calcitriol...... 67, 96 benzonatate...... 145 BREO ELLIPTA ...... 148 calcium acetate(phosphat bind) benzoyl peroxide ...... 71 BREYANZI...... 18 ...... 103 benztropine...... 29 BREZTRI AEROSPHERE.148 CAMBIA ...... 39 BEOVU ...... 137 briellyn...... 127 camila ...... 123 bepotastine besilate ...... 137 BRILINTA ...... 61 camrese ...... 128 BEPREVE ...... 137 brimonidine ...... 144 camrese lo...... 128 beser ...... 78 BRIMONIDINE- candesartan ...... 54 BETADINE OPHTHALMIC DORZOLAMIDE (PF)...140 candesartan-hydrochlorothiazid PREP ...... 134 brinzolamide...... 140 ...... 54 betamethasone dipropionate.78 BROMFED DM ...... 145 CANTHARIDIN IN betamethasone valerate ...... 78 bromfenac...... 139 ACETONE ...... 69 betamethasone, augmented...78 bromocriptine ...... 29 CAPCOF...... 145 BETAPACE ...... 52 capecitabine ...... 18

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 166 CAPEX...... 78 cephalexin...... 9 citrate of magnesia...... 104 CAPRELSA ...... 18 CEQUA ...... 137 citroma...... 104 captopril...... 54 CEQUR SIMPLICITY...... 92 claravis...... 71 captopril-hydrochlorothiazide cetirizine ...... 144 CLARINEX...... 144 ...... 54 cevimeline ...... 83 CLARINEX-D 12 HOUR ..145 CARAFATE...... 109 CHANTIX ...... 85 clarithromycin...... 10 carbamazepine...... 24 CHANTIX CONTINUING classic prenatal...... 156 CARBATROL...... 24 MONTH BOX...... 85 clearlax ...... 104 carbidopa ...... 29 CHANTIX STARTING clemastine ...... 144 carbidopa-levodopa ...... 29 MONTH BOX...... 85 CLENPIQ ...... 104 carbidopa-levodopa- charlotte 24 fe...... 128 CLEOCIN...... 125 entacapone...... 29 chateal (28) ...... 128 CLEOCIN HCL...... 11 carbinoxamine maleate...... 144 chateal eq (28) ...... 128 CLEOCIN PEDIATRIC...... 11 CARDIZEM...... 55 CHENODAL ...... 103 CLEOCIN T ...... 71 CARDIZEM CD ...... 54 children's aspirin...... 39 CLIMARA...... 123 CARDIZEM LA...... 55 chlordiazepoxide-clidinium 101 CLINDACIN ETZ...... 71 CARDURA ...... 55 chlorhexidine gluconate ...... 86 clindacin p ...... 71 CARDURA XL...... 55 chloroquine phosphate...... 11 CLINDACIN PAC ...... 71 carisoprodol-aspirin...... 33 chlorpromazine...... 44 clindamycin hcl ...... 11 carisoprodol-aspirin-codeine 33 chlorthalidone...... 55 clindamycin pediatric ...... 11 CARNITOR ...... 83 chlorzoxazone...... 33 clindamycin phosphate .71, 125 CARNITOR (SUGAR-FREE) cholestyramine (with sugar) .63 clindamycin-benzoyl peroxide ...... 83 cholestyramine light ...... 63 ...... 72 CAROSPIR ...... 55 choline,magnesium salicylate clindamycin-tretinoin ...... 72 carteolol...... 136 ...... 39 CLINDESSE...... 125 cartia xt...... 55 CHORIONIC CLINPRO 5000...... 86 carvedilol...... 55 GONADOTROPIN, clobazam...... 24 carvedilol phosphate...... 55 HUMAN...... 96 clobetasol...... 78, 79 CASODEX...... 18 ciclodan ...... 76 clobetasol-emollient ...... 79 cataflam ...... 39 CICLODAN KIT...... 76 CLOBEX ...... 79 CATAPRES-TTS-1...... 55 ciclopirox...... 76 clodan ...... 79 CATAPRES-TTS-2...... 55 ciclopirox-ure-camph-menth- CLODAN KIT...... 79 CATAPRES-TTS-3...... 55 euc ...... 76 CLODERM...... 79 CAYA CONTOURED...... 123 cilostazol...... 61 clomipramine...... 44 caziant (28)...... 128 CILOXAN ...... 134 clonazepam ...... 24 cefaclor...... 8 CIMDUO...... 4 clonidine ...... 55 cefadroxil...... 8, 9 cimetidine ...... 109 clonidine hcl ...... 44, 55 cefdinir ...... 9 cimetidine hcl ...... 109 clopidogrel...... 61 cefditoren pivoxil ...... 9 cinacalcet ...... 96 clorazepate dipotassium...... 44 cefixime...... 9 CIPRO ...... 14 clotrimazole ...... 3, 76 cefpodoxime...... 9 CIPRO HC...... 88 clotrimazole-betamethasone .76 cefprozil...... 9 CIPRODEX ...... 88 clozapine...... 44 cefuroxime axetil...... 9 ciprofloxacin hcl.....14, 88, 134 CLOZARIL ...... 45 celecoxib...... 39 ciprofloxacin-dexamethasone c-nate dha...... 156 CELLCEPT ...... 18 ...... 88 codeine sulfate ...... 35 CELONTIN...... 24 citalopram...... 44 codeine-butalbital-asa-caff ...35 CENTANY...... 75 CITRANATAL B-CALM (FE codeine-guaifenesin...... 145 CENTANY AT ...... 75 GLUC)...... 156 CODITUSSIN AC...... 145

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 167 CODITUSSIN DAC...... 145 cyclafem 7/7/7 (28) ...... 128 DELESTROGEN ...... 123 COLAZAL ...... 104 cyclobenzaprine...... 33 demeclocycline ...... 14 colchicine ...... 119 CYCLOGYL ...... 136 DEMSER...... 55 colesevelam ...... 64 CYCLOMYDRIL...... 144 DENAVIR ...... 77 COLESTID ...... 64 cyclopentolate...... 136 denta 5000 plus...... 86 COLESTID FLAVORED ....64 CYCLOPEN-TROPIC- dentagel...... 86 colestipol ...... 64 PHENYLEPH-WATR....136 DEPAKOTE ...... 24 COMBIGAN ...... 140 CYCLOPENT-TROPIC- DEPAKOTE ER...... 24 COMBIPATCH...... 123 PHEN-KETR-WAT ...... 136 DEPAKOTE SPRINKLES...25 COMBIVENT RESPIMAT148 cyclophosphamide ...... 18 DEPEN TITRATABS ...... 121 COMBIVIR...... 4 CYCLOPHOSPHAMIDE ....18 DEPO-ESTRADIOL ...... 123 COMETRIQ...... 18 CYCLOP-TROP-PROPA- DEPO-PROVERA...... 123 COMPACT SPACE PHEN-KET-WAT ...... 136 DEPO-SUBQ PROVERA 104 CHAMBER ...... 90 CYCLOSERINE ...... 11 ...... 124 COMPAZINE ...... 104 CYCLOSET ...... 98 DEPO-TESTOSTERONE....96 complete natal dha...... 156 cyclosporine...... 18 DERMACINRX complex b-100...... 156 CYCLOSPORINE IN PRENATRYL...... 156 compro...... 104 KLARITY ...... 137 DERMA-SMOOTHE/FS COMTAN ...... 29 cyclosporine modified ...... 18 BODY OIL ...... 79 CONCEPT DHA...... 156 cyproheptadine ...... 144 DERMA-SMOOTHE/FS CONCEPT OB ...... 156 cyred ...... 128 SCALP OIL ...... 79 CONDYLOX ...... 69 cyred eq ...... 128 DERMOTIC OIL...... 88 CONSENSI ...... 55 CYSTAGON ...... 153 DESCOVY ...... 4 constulose...... 104 CYTOTEC...... 109 desipramine...... 45 CONZIP ...... 39 D desloratadine...... 144 COPAXONE ...... 112 D.H.E.45...... 31 desmopressin ...... 96 COPIKTRA...... 18 dalfampridine...... 32 desog-e.estradiol/e.estradiol COREG CR...... 55 danazol...... 96 ...... 128 coremino...... 14 DANTRIUM ...... 34 desogestrel-ethinyl estradiol CORGARD ...... 55 dantrolene ...... 34 ...... 128 CORTANE-B...... 69 DANYELZA ...... 18 DESONATE ...... 79 CORTEF ...... 88 dapsone...... 11, 72 desonide...... 79 CORTENEMA...... 104 DAPTACEL (DTAP DESOWEN...... 79 CORTISPORIN-TC ...... 88 PEDIATRIC) (PF)...... 115 desoximetasone...... 79 COSELA ...... 18 DARAPRIM...... 11 DESOXYN ...... 45 COTELLIC...... 18 darifenacin ...... 152 desrx ...... 79 COTEMPLA XR-ODT ...... 45 DARZALEX FASPRO ...... 18 DESVENLAFAXINE ...... 45 covaryx...... 123 dasetta 1/35 (28) ...... 128 desvenlafaxine succinate ...... 45 covaryx h.s...... 123 dasetta 7/7/7 (28) ...... 128 dexabliss ...... 88 CREON ...... 104 DAURISMO...... 18 dexamethasone ...... 88 cromolyn...... 104, 137, 148 DAYPRO...... 39 dexamethasone intensol...... 88 crotan...... 82 daysee ...... 128 dexamethasone sodium cryselle (28)...... 128 DAYTRANA...... 45 phosphate...... 142 CUROSURF...... 148 DAYVIGO ...... 45 DEXAMETH- CUTIVATE...... 79 DDAVP ...... 96 MOXIFLOX(PF)- cyanocobalamin (vitamin b-12) deblitane ...... 123 NACL,ISO...... 141 ...... 156 decadron ...... 88 DEXAMET-MOXIFL- cyclafem 1/35 (28) ...... 128 deferiprone...... 83 KETORO-NACL(PF).....138

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 168 dexchlorpheniramine maleate DILAUDID ...... 35 droxidopa...... 83 ...... 144 diltiazem ...... 55, 56 DSUVIA ...... 35 DEXCOM G4 RECEIVER ..92 dilt-xr...... 56 DUAVEE...... 124 DEXCOM G4 dimethyl fumarate...... 112 DUET DHA BALANCED .156 TRANSMITTER...... 92 DIPENTUM ...... 104 DUET DHA WITH OMEGA-3 DEXCOM G5 RECEIVER ..92 DIPHEN ...... 144 ...... 156 DEXCOM G5-G4 SENSOR 92 diphenoxylate-atropine...... 101 DUETACT ...... 98 DEXCOM G6 RECEIVER ..92 DIPROLENE DUEXIS ...... 39 DEXCOM G6 SENSOR ...... 92 (AUGMENTED) ...... 79 dulcolax (magnesium DEXCOM G6 dipyridamole...... 61 hydroxide)...... 104 TRANSMITTER...... 92 DISALCID ...... 39 DULERA...... 148 DEXCOM RECEIVER...... 92 diskets...... 35 duloxetine ...... 46 DEXEDRINE SPANSULE..45 disopyramide phosphate ...... 52 DUOBRII ...... 79 DEXILANT...... 110 disulfiram...... 83 DUREZOL ...... 142 dexmethylphenidate ...... 45 DITROPAN XL ...... 152 dutasteride...... 153 DEXTENZA...... 142 DIURIL ...... 56 dutasteride-tamsulosin...... 153 dextroamphetamine ...... 45 divalproex...... 25 dvorah...... 35 dextroamphetamine- dofetilide...... 52 DXEVO ...... 88 amphetamine ...... 45 DOJOLVI ...... 155 DYANAVEL XR ...... 46 DEXYCU (PF) ...... 142 dolishale...... 128 DYMISTA...... 148 DIACOMIT...... 25 donepezil ...... 32 DYRENIUM...... 56 dialyvite 800...... 156 DOPTELET (15 TAB PACK) E DIASTAT...... 25 ...... 61 e.e.s. 400...... 10 DIASTAT ACUDIAL...... 25 DORYX...... 15 E.E.S. GRANULES...... 10 diazepam...... 25, 45 DORYX MPC ...... 14 EASIVENT HOLDING diazepam intensol...... 45 dorzolamide ...... 140 CHAMBER ...... 90 diazoxide ...... 91 DORZOLAMIDE (PF)...... 140 EASY TOUCH BLU CTRL DIBENZYLINE ...... 55 dorzolamide-timolol ...... 140 SOLN-L1,L3 ...... 92 diclofenac potassium...... 39 dorzolamide-timolol (pf) ....140 ECLIPSE NEEDLE...... 92 diclofenac sodium ...... 39, 139 DORZOLAMIDE-TIMOLOL EC-NAPROSYN ...... 39 diclofenac-misoprostol ...... 39 (PF)...... 140 econazole ...... 76 dicloxacillin...... 14 dotti...... 124 econtra ez...... 128 dicyclomine ...... 101 DOVATO ...... 4 econtra one-step...... 128 didanosine...... 4 DOVONEX ...... 67 ecotrin...... 39 DIFFERIN...... 72 doxazosin...... 56 ecotrin low strength ...... 39 DIFICID ...... 10 doxepin ...... 46 EDARBI ...... 56 diflorasone...... 79 doxercalciferol...... 96 EDECRIN...... 56 DIFLUCAN...... 3 doxycycline hyclate...... 15 EDLUAR...... 46 diflunisal...... 39 doxycycline monohydrate ....15 ed-spaz...... 101 digitek...... 61 doxylamine-pyridoxine (vit b6) EDURANT ...... 4 digox...... 61 ...... 104 eemt ...... 124 digoxin...... 61 DRISDOL...... 156 eemt hs...... 124 dihydroergotamine ...... 31 dronabinol...... 104 efavirenz ...... 4 DILANTIN...... 25 drospirenone-e.estradiol-lm.fa efavirenz-emtricitabin-tenofov DILANTIN EXTENDED ....25 ...... 128 ...... 4 DILANTIN INFATABS ...... 25 drospirenone-ethinyl estradiol efavirenz-lamivu-tenofov disop DILANTIN-125 ...... 25 ...... 128 ...... 4 DILATRATE-SR ...... 66 DROXIA ...... 18 effer-k ...... 154

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 169 EFFIENT...... 61 enulose...... 104 ethacrynic acid...... 56 EFUDEX ...... 69 ENZOCLEAR ...... 72 ethambutol ...... 11 EGRIFTA SV...... 111 EPCLUSA ...... 5 ethosuximide...... 25 eletriptan...... 31 EPIDIOLEX ...... 25 ethynodiol diac-eth estradiol ELIMITE...... 82 EPIFOAM ...... 67 ...... 129 elinest ...... 128 epinastine...... 138 etodolac...... 40 ELIQUIS ...... 61 epinephrine ...... 144 etonogestrel-ethinyl estradiol ELIQUIS DVT-PE TREAT epinephrine hcl ...... 149 ...... 126 30D START ...... 61 EPIPEN 2-PAK ...... 144 etoposide...... 19 elite-ob...... 156 EPIPEN JR 2-PAK...... 144 etravirine...... 5 ELIXOPHYLLIN...... 148 EPISIL...... 86 EUFLEXXA ...... 40 ELLA...... 128 epitol...... 25 EURAX ...... 82 ELMIRON...... 153 EPIVIR ...... 5 euthyrox...... 100 eluryng...... 126 EPIVIR HBV...... 5 EVEKEO ...... 46 ELZONRIS ...... 18 eplerenone ...... 56 EVEKEO ODT...... 46 EMCYT...... 18 eprosartan ...... 56 everolimus (antineoplastic) ..19 EMGALITY PEN ...... 31 EPZICOM ...... 5 everolimus EMGALITY SYRINGE...... 31 EQUETRO ...... 25 (immunosuppressive) ...... 19 emoquette ...... 128 ergocalciferol (vitamin d2).156 EVERSENSE SENSOR- EMSAM ...... 46 ergoloid...... 46 HOLDER...... 92 emtricitabine...... 4 ERGOMAR ...... 31 EVISTA...... 120 emtricitabine-tenofovir (tdf)...5 ergotamine-caffeine...... 31 EVKEEZA...... 64 EMTRIVA...... 5 ERIVEDGE ...... 19 EVOCLIN...... 72 EMVERM ...... 11 erlotinib ...... 19 EVOTAZ ...... 5 enalapril maleate ...... 56 errin ...... 124 EVOXAC ...... 83 enalapril-hydrochlorothiazide ERTACZO...... 76 EVRYSDI...... 32 ...... 56 ery pads...... 72 EXELDERM ...... 76 ENBRACE HR...... 156 erygel...... 72 EXELON PATCH ...... 32 ENBREL ...... 121 ERYPED 200 ...... 10 exemestane ...... 19 ENBREL MINI ...... 121 ERYPED 400 ...... 10 EXTINA ...... 76 ENBREL SURECLICK .....121 ery-tab...... 10 EYSUVIS ...... 142 endocet ...... 35 ERY-TAB...... 10 ezetimibe...... 64 ENDOMETRIN ...... 124 erythrocin (as stearate) ...... 10 F ENGERIX-B (PF) ...... 115 erythromycin ...... 10, 134 FABIOR ...... 72 ENGERIX-B PEDIATRIC erythromycin ethylsuccinate.10 FACTIVE ...... 14 (PF)...... 115 erythromycin with ethanol....72 falmina (28) ...... 129 ENHERTU ...... 19 escitalopram oxalate...... 46 famciclovir...... 5 ENLITE SYSTEM ...... 92 ESGIC ...... 36 famotidine...... 110 enoxaparin ...... 61 esomeprazole magnesium...110 FANAPT...... 46 enpresse ...... 128 estarylla ...... 129 FARXIGA ...... 98 enskyce...... 128 ESTRACE ...... 124 FARYDAK...... 19 ENSPRYNG...... 19 estradiol ...... 124 fayosim ...... 129 ENSTILAR ...... 67 estradiol valerate...... 124 FC2 FEMALE CONDOM .123 entacapone...... 29 estradiol-norethindrone acet febuxostat ...... 119 entecavir ...... 5 ...... 124 felbamate ...... 25 ENTEREG...... 104 estrogens-methyltestosterone FELBATOL...... 25 ENTOCORT EC ...... 104 ...... 124 FELDENE ...... 40 ENTRESTO ...... 66 eszopiclone ...... 46 felodipine...... 56

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 170 fem ph...... 126 fluconazole ...... 3 FORTESTA...... 96 FEMARA ...... 19 fludrocortisone...... 88 FOSAMAX...... 120 FEMCAP...... 123 FLULAVAL QUAD 2021- FOSAMAX PLUS D...... 120 FEMHRT LOW DOSE ...... 124 2022 (PF)...... 116 fosamprenavir ...... 5 femynor ...... 129 FLUMADINE ...... 5 fosinopril...... 56 fenofibrate ...... 64 fluocinolone...... 80 fosinopril-hydrochlorothiazide FENOFIBRATE...... 64 fluocinolone acetonide oil ....88 ...... 56 fenofibrate micronized ...... 64 fluocinolone and shower cap 80 FREESTYLE FREEDOM....92 fenofibrate nanocrystallized .64 fluocinonide...... 80 FREESTYLE FREEDOM fenofibric acid ...... 64 fluocinonide-e...... 80 LITE ...... 92 fenofibric acid (choline) ...... 64 FLUORESCEIN- FREESTYLE INSULINX ...90, FENOGLIDE ...... 64 BENOXINATE ...... 138 92 fenoprofen ...... 40 fluoride (sodium)..86, 156, 157 FREESTYLE INSULINX fentanyl...... 36 FLUORIDEX DAILY TEST STRIPS ...... 90 fentanyl citrate...... 36 DEFENSE ...... 86 FREESTYLE LIBRE 14 DAY FERAHEME ...... 156 FLUORIDEX SENSITIVITY READER ...... 92 FERRIPROX...... 83 RELIEF ...... 86 FREESTYLE LIBRE 14 DAY FERRLECIT...... 84 fluorometholone ...... 142 SENSOR...... 93 FETZIMA ...... 46 FLUOROPLEX ...... 69 FREESTYLE LIBRE 2 FEXMID ...... 34 fluorouracil ...... 69 READER ...... 93 FIBRICOR ...... 64 fluoxetine...... 46, 47 FREESTYLE LIBRE 2 FINACEA ...... 72 fluphenazine hcl ...... 47 SENSOR...... 93 finasteride...... 153 flurazepam...... 47 FREESTYLE LITE METER93 FIORICET...... 36 flurbiprofen...... 40 FREESTYLE LITE STRIPS 90 FIORICET WITH CODEINE flurbiprofen sodium...... 139 FREESTYLE TEST ...... 90 ...... 36 flutamide...... 19 FROVA...... 31 flac otic oil...... 88 fluticasone propionate ..80, 149 frovatriptan ...... 31 FLAGYL ...... 11 fluticasone propion-salmeterol full spectrum b-vitamin c....157 flavoxate...... 152 ...... 149 FULPHILA...... 111 flecainide ...... 52 fluvastatin ...... 64 FURADANTIN ...... 16 FLECTOR ...... 40 fluvoxamine...... 47 furosemide ...... 56 FLEXICHAMBER...... 90 FLUZONE HIGHDOSE FUZEON ...... 5 FLOLIPID ...... 64 QUAD 21-22 PF...... 116 fyavolv...... 124 FLOMAX...... 153 FLUZONE QUAD 2021-2022 G FLORIVA (FLUORIDE- ...... 116 g tussin ac ...... 145 VITAMIN D3) ...... 156 FLUZONE QUAD 2021-2022 gabapentin...... 25, 26 FLOVENT DISKUS ...... 149 (PF)...... 116 GABITRIL ...... 26 FLOVENT HFA...... 149 FML LIQUIFILM ...... 142 galantamine...... 32 FLUAD QUAD 2021-22(65Y folic acid...... 157 GALZIN ...... 154 UP)(PF) ...... 115 folivane-ob...... 157 GARDASIL 9 (PF)...... 116 FLUARIX QUAD 2021-2022 foltabs 800 ...... 157 GASTROCROM ...... 105 (PF)...... 115 fondaparinux...... 62 gatifloxacin...... 134 FLUBLOK QUAD 2021-2022 FORA GTEL MULTI- GATTEX 30-VIAL ...... 105 (PF)...... 115 FUNCTN MONITOR ...... 92 gavilax ...... 105 FLUCELVAX QUAD 2021- FORA TN'G ADVANCE PRO GAVRETO ...... 19 2022...... 116 MONITOR ...... 92 GELCLAIR ...... 86 FLUCELVAX QUAD 2021- FORFIVO XL...... 47 GELNIQUE...... 152 2022 (PF)...... 115 formoterol fumarate...... 149 GELX ...... 86

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 171 gemfibrozil ...... 64 granisetron hcl ...... 105 HETLIOZ LQ...... 47 gemmily...... 129 griseofulvin microsize ...... 3 HIBERIX (PF)...... 116 GEMTESA...... 152 griseofulvin ultramicrosize.....3 hidex ...... 88 generlac ...... 105 guaiatussin ac ...... 145 HISTEX-AC...... 145 gengraf...... 19 guanfacine ...... 47, 56 homatropaire...... 136 GENOTROPIN ...... 112 GVOKE HYPOPEN 2-PACK HORIZANT...... 32 GENOTROPIN MINIQUICK ...... 91 HUMALOG JUNIOR ...... 112 GVOKE PFS 2-PACK KWIKPEN U-100 ...... 93 gentak ...... 134 SYRINGE...... 91 HUMALOG KWIKPEN gentamicin ...... 75, 134 GYNAZOLE-1...... 126 INSULIN ...... 94 GENTEEL VACUUM gynol ii...... 126 HUMALOG MIX 50-50 LANCING DEVICE ...... 93 H INSULN U-100 ...... 94 gentle laxative (bisacodyl) .105 hailey ...... 129 HUMALOG MIX 50-50 gentlelax ...... 105 hailey 24 fe ...... 129 KWIKPEN...... 94 GENVOYA ...... 5 hailey fe 1.5/30 (28) ...... 129 HUMALOG MIX 75-25 GEODON...... 47 hailey fe 1/20 (28) ...... 129 KWIKPEN...... 94 GILENYA ...... 112 halcinonide ...... 80 HUMALOG MIX 75-25(U- GILOTRIF...... 19 halobetasol propionate...... 80 100)INSULN ...... 94 GIVLAARI...... 84 HALOBETASOL HUMALOG U-100 INSULIN glatiramer ...... 112 PROPIONATE ...... 80 ...... 94 glatopa ...... 112 HALOG ...... 80 HUMIRA...... 121 GLEOLAN...... 84 haloperidol...... 47 HUMIRA PEN ...... 121 GLEOSTINE...... 19 haloperidol lactate ...... 47 HUMIRA PEN CROHNS-UC- glimepiride ...... 98 HARVONI...... 5 HS START ...... 121 glipizide...... 98 HAVRIX (PF) ...... 116 HUMIRA PEN PSOR- glipizide-metformin...... 99 healthylax ...... 105 UVEITS-ADOL HS ...... 121 GLOPERBA...... 119 heather ...... 124 HUMIRA(CF) ...... 122 GLUCAGEN DIAGNOSTIC hemmorex-hc...... 105 HUMIRA(CF) PEDI KIT ...... 90 hep flush-10 (pf)...... 62 CROHNS STARTER .....121 GLUCAGEN HYPOKIT .....91 heparin (porcine) ...... 62 HUMIRA(CF) PEN...... 121 GLUCAGON (HCL) HEPARIN (PORCINE) IN HUMIRA(CF) PEN EMERGENCY KIT ...... 91 0.9% NACL...... 62 CROHNS-UC-HS...... 121 glucagon emergency kit heparin (porcine) in 5 % dex 62 HUMIRA(CF) PEN (human) ...... 91 heparin (porcine) in nacl (pf)62 PEDIATRIC UC...... 121 GLUCAGON HCL ...... 90 heparin flush(porcine)-0.9nacl HUMIRA(CF) PEN PSOR- GLUCOTROL...... 99 ...... 62 UV-ADOL HS...... 121 GLUCOTROL XL ...... 99 heparin lock flush (porcine) .62 HUMULIN 70/30 U-100 glyburide...... 99 heparin lockflush(porcine)(pf) INSULIN ...... 94 glyburide micronized...... 99 ...... 62 HUMULIN 70/30 U-100 glyburide-metformin ...... 99 heparin(porcine) in 0.45% nacl KWIKPEN...... 94 glycolax ...... 105 ...... 62 HUMULIN N NPH INSULIN glydo...... 75 HEPARIN(PORCINE) IN KWIKPEN...... 94 GLYNASE ...... 99 0.45% NACL...... 62 HUMULIN N NPH U-100 GLYXAMBI ...... 99 heparin, porcine (pf) ...... 62, 63 INSULIN ...... 94 GOJJI MULTI-FUNCTIONAL HEPARIN, PORCINE (PF) .63 HUMULIN R REGULAR U- METER ...... 93 HEPLISAV-B (PF)...... 116 100 INSULN ...... 94 GONITRO...... 66 HEPSERA ...... 5 HUMULIN R U-500 (CONC) GRALISE ...... 26 HETLIOZ ...... 47 INSULIN ...... 94

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 172 HUMULIN R U-500 (CONC) IMPOYZ...... 81 ISORDIL TITRADOSE ...... 66 KWIKPEN ...... 94 IMURAN...... 19 isosorbide dinitrate ...... 66 HYCODAN (WITH INBRIJA...... 29 isosorbide mononitrate ...... 66 HOMATROPINE) ...... 145 incassia ...... 124 isotretinoin...... 72 hydralazine ...... 56 INCRUSE ELLIPTA...... 149 isoxsuprine...... 126 HYDREA ...... 19 indapamide ...... 56 isradipine ...... 57 hydrochlorothiazide...... 56 INDOCIN ...... 40 itraconazole...... 3 hydrocodone bitartrate...... 36 indomethacin ...... 40 ivermectin ...... 12, 72, 82 hydrocodone-acetaminophen36 INFANRIX (DTAP) (PF)...116 IXIARO (PF)...... 116 hydrocodone-homatropine .145 INFASURF...... 84 J hydrocodone-ibuprofen ...... 36 INFED ...... 157 jaimiess...... 129 hydrocortisone...... 80, 89, 105 INGREZZA ...... 33 JAKAFI ...... 19 hydrocortisone acetate...... 105 INGREZZA INITIATION JALYN ...... 153 hydrocortisone butyrate...... 80 PACK ...... 32 JANSSEN COVID-19 hydrocortisone butyr-emollient INJECTAFER ...... 157 VACCINE (EUA) ...... 117 ...... 80 INLYTA ...... 19 jantoven ...... 63 hydrocortisone valerate ..80, 81 INOVA ...... 72 JANUMET ...... 99 hydrocortisone-acetic acid....88 INOVA 4-1...... 69 JANUMET XR...... 99 hydrocortisone-pramoxine ..67, INOVA 8-2...... 69 JANUVIA...... 99 105 INPEN (FOR HUMALOG) .93 JARDIANCE...... 99 hydromet...... 146 INPEN (FOR NOVOLOG OR jasmiel (28)...... 129 hydromorphone ...... 36 FIASP)...... 93 JEMPERLI ...... 19 hydroxocobalamin...... 157 INSPIRACHAMBER...... 90 jencycla...... 124 hydroxychloroquine ...... 11 INSPRA...... 57 jinteli...... 124 hydroxyurea...... 19 INSULIN SYRINGE- jolessa ...... 129 hydroxyzine hcl...... 144 NEEDLE U-100 ...... 90 JORNAY PM...... 47 hydroxyzine pamoate ...... 144 INTELENCE...... 5 juleber...... 129 hyophen ...... 153 INTRAROSA ...... 126 JULUCA...... 6 hyoscyamine sulfate ...... 102 INVEGA...... 47 junel 1.5/30 (21) ...... 129 hyosyne ...... 102 INVELTYS ...... 142 junel 1/20 (21) ...... 129 HYPER-SAL...... 149 INVIRASE ...... 5 junel fe 1.5/30 (28) ...... 129 HYSINGLA ER ...... 36 iodine-sodium iodide...... 69 junel fe 1/20 (28) ...... 129 I IODOFLEX ...... 69 junel fe 24...... 129 ibandronate...... 120 IODOSORB...... 69 K IBRANCE ...... 19 IOPIDINE...... 144 kaitlib fe...... 129 ibu...... 40 IPOL ...... 116 KALETRA ...... 6 ibuprofen ...... 40 ipratropium bromide.....86, 149 kalliga ...... 129 iclevia ...... 129 ipratropium-albuterol...... 149 KALYDECO ...... 149 ICLUSIG ...... 19 irbesartan ...... 57 KANJINTI...... 20 icosapent ethyl...... 64 irbesartan-hydrochlorothiazide KAPVAY ...... 47 IDHIFA ...... 19 ...... 57 KARBINAL ER ...... 145 ILEVRO ...... 139 IRESSA ...... 19 kariva (28) ...... 129 imatinib ...... 19 ISENTRESS ...... 5, 6 KEFLEX...... 9 imipramine hcl...... 47 ISENTRESS HD ...... 5 kelnor 1/35 (28) ...... 129 imipramine pamoate...... 47 isibloom...... 129 kelnor 1-50 (28)...... 129 imiquimod ...... 114 isoniazid...... 11, 12 KENALOG...... 81 IMOVAX RABIES VACCINE ISOPTO CARPINE...... 137 KETAMINE ...... 47 (PF)...... 116 ISORDIL ...... 66 ketoconazole ...... 3, 76

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 173 ketodan ...... 76 lamotrigine...... 26 levora-28...... 130 ketodan kit...... 76 LANCETS ...... 93 levorphanol tartrate...... 36 ketoprofen...... 40 LANCING DEVICE ...... 93 levo-t...... 100 ketorolac...... 139 LANOXIN...... 61 levothyroxine...... 100 KINRIX (PF)...... 117 lansoprazole...... 110 levoxyl ...... 101 KITABIS PAK ...... 12 LANTUS SOLOSTAR U-100 LEVSIN...... 102 KLARITY-A (AZITHRO- INSULIN ...... 95 LEVSIN/SL ...... 102 CHONDR)(PF) ...... 138 LANTUS U-100 INSULIN ..95 LEXETTE...... 81 KLARITY-B (BETAMETH- lapatinib...... 20 LEXIVA ...... 6 CHOND)(PF) ...... 138 larin 1.5/30 (21)...... 130 LICART...... 40 KLARITY-L (LOTEPRED- larin 1/20 (21)...... 130 lidocaine ...... 75 CHOND)(PF) ...... 138 larin 24 fe...... 130 lidocaine hcl...... 75 KLARON ...... 75 larin fe 1.5/30 (28)...... 130 lidocaine hcl-hydrocortison ac KLONOPIN ...... 26 larin fe 1/20 (28)...... 130 ...... 75, 105 klor-con ...... 155 larissia...... 130 LIDOCAINE HCL- klor-con 10 ...... 154 LASIX ...... 57 HYDROCORTISON AC105 klor-con 8 ...... 154 latanoprost ...... 140 lidocaine viscous ...... 75 klor-con m10 ...... 154 LATANOPROST (PF) ...... 140 lidocaine-hydrocortisone-aloe klor-con m15 ...... 154 LATUDA...... 47 ...... 106 klor-con m20 ...... 154 laxaclear...... 105 LIDOCAINE- klor-con/ef ...... 155 laxative (bisacodyl) ...... 105 PHENYLEPHRIN-BSS(PF) kobee ...... 157 laxative peg 3350...... 105 ...... 138 KOSELUGO ...... 20 layolis fe ...... 130 lidocaine-phenylephrn in water KOSHER PRENATAL PLUS leena 28...... 130 ...... 138 IRON ...... 157 leflunomide...... 122 lidocaine-prilocaine ...... 75 K-PHOS NO 2...... 153 LENVIMA...... 20 lidocort...... 75 K-PHOS ORIGINAL ...... 153 LESCOL XL...... 64 lillow (28) ...... 130 kpn...... 157 lessina ...... 130 lindane ...... 82 KRISTALOSE ...... 105 letrozole...... 20 linezolid ...... 12 k-tab...... 155 leucovorin calcium ...... 16 liothyronine...... 101 K-TAB...... 155 LEUKERAN ...... 20 LIPOFEN...... 64 kurvelo (28)...... 129 levalbuterol hcl ...... 149 lisinopril...... 57 KYNMOBI...... 29 LEVBID ...... 102 lisinopril-hydrochlorothiazide L LEVEMIR FLEXTOUCH U- ...... 57 l norgest/e.estradiol-e.estrad 100 INSULN ...... 95 LITEAIRE MDI CHAMBER ...... 130 LEVEMIR U-100 INSULIN 95 ...... 90 labetalol ...... 57 levetiracetam ...... 26 lithium carbonate ...... 47, 48 LACRISERT ...... 138 levobunolol...... 136 LITHOBID ...... 48 lactated ringers ...... 82 levocarnitine ...... 84 LITHOSTAT ...... 84 lactulose...... 105 levocarnitine (with sugar).....84 LIVALO ...... 65 LAMICTAL XR STARTER levocetirizine ...... 145 LODINE ...... 40 (BLUE)...... 26 levofloxacin...... 14, 134 LODOSYN ...... 29 LAMICTAL XR STARTER levonest (28) ...... 130 lojaimiess...... 130 (GREEN)...... 26 levonorgestrel ...... 130 LOMOTIL ...... 102 LAMICTAL XR STARTER levonorgestrel-ethinyl estrad LONHALA MAGNAIR (ORANGE)...... 26 ...... 130 REFILL...... 149 lamivudine...... 6 levonorg-eth estrad triphasic LONHALA MAGNAIR lamivudine-zidovudine...... 6 ...... 130 STARTER ...... 149

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 174 loperamide...... 102 mafenide acetate ...... 75 mefloquine...... 12 LOPID ...... 65 magnesium citrate...... 106 megestrol ...... 20 lopinavir-ritonavir ...... 6 MALARONE ...... 12 MEKINIST...... 20 LOPRESSOR ...... 57 MALARONE PEDIATRIC .12 MEKTOVI...... 20 LOPROX...... 77 malathion ...... 82 meloxicam ...... 40 LOPROX (AS OLAMINE)..77 maprotiline...... 48 meloxicam submicronized....40 LOPROX KIT ...... 77 MAR-COF CG ...... 146 melphalan ...... 20 lorazepam ...... 48 MARGENZA ...... 20 memantine ...... 33 lorazepam intensol...... 48 MARINOL ...... 106 MEMANTINE...... 33 LORBRENA ...... 20 marlissa (28) ...... 130 MENACTRA (PF)...... 117 LORTAB ELIXIR...... 36 MARNATAL-F...... 157 M-END PE ...... 146 loryna (28)...... 130 MARPLAN ...... 48 MENOPUR...... 96 LORZONE ...... 34 MATULANE...... 20 MENOSTAR ...... 125 losartan ...... 57 matzim la ...... 57 MENQUADFI (PF)...... 117 losartan-hydrochlorothiazide 57 MAVENCLAD (10 TABLET MENTAX ...... 77 LOTEMAX ...... 143 PACK) ...... 112 MENVEO A-C-Y-W-135-DIP LOTEMAX SM ...... 143 MAVENCLAD (4 TABLET (PF)...... 117 LOTENSIN ...... 57 PACK) ...... 112 MEPHYTON...... 63 LOTENSIN HCT ...... 57 MAVENCLAD (5 TABLET MEPRON ...... 12 loteprednol etabonate ...... 143 PACK) ...... 113 mercaptopurine ...... 20 lovastatin ...... 65 MAVENCLAD (6 TABLET merzee...... 130 LOVAZA ...... 65 PACK) ...... 113 mesalamine ...... 106 low-ogestrel (28) ...... 130 MAVENCLAD (7 TABLET mesalamine with cleansing loxapine succinate ...... 48 PACK) ...... 113 wipe ...... 106 lo-zumandimine (28)...... 130 MAVENCLAD (8 TABLET MESNEX...... 16 lta pre-attached ...... 75 PACK) ...... 113 metaproterenol...... 149 ludent fluoride ...... 157 MAVENCLAD (9 TABLET metaxalone...... 34 lugols ...... 75, 155 PACK) ...... 113 metformin ...... 99 LUMIGAN...... 140 MAVYRET ...... 6 methadone...... 37 lutera (28) ...... 130 MAXITROL...... 141 methadose ...... 37 LUXIQ ...... 81 maxi-tuss ac...... 146 methamphetamine...... 48 LUZU ...... 77 MAXI-TUSS CD...... 146 methazolamide...... 140 lyleq...... 125 MAXZIDE...... 57 methenamine hippurate ...... 16 lyllana...... 125 MAXZIDE-25MG...... 57 methenamine mandelate ...... 16 LYNPARZA...... 20 MAYZENT ...... 113 methen-sod phos-meth blue- LYSODREN...... 20 MAYZENT STARTER PACK hyos...... 153 LYSTEDA...... 126 ...... 113 methergine ...... 134 LYUMJEV KWIKPEN U-100 m-clear wc ...... 146 methimazole ...... 89 INSULIN...... 95 meclizine ...... 106 METHITEST...... 96 LYUMJEV KWIKPEN U-200 meclofenamate...... 40 methocarbamol ...... 34 INSULIN...... 95 MECOBALAMIN (VITAMIN methotrexate sodium ...... 20 LYUMJEV U-100 INSULIN B12)...... 157 methotrexate sodium (pf) .....20 ...... 95 MEDISENSE GLUCOSE methoxsalen...... 70 lyza ...... 125 KETONE ...... 93 methscopolamine...... 102 M MEDROL ...... 89 methyl salicylate...... 70 MACRILEN...... 111 MEDROL (PAK) ...... 89 methyldopa ...... 57 MACROBID ...... 16 medroxyprogesterone ...... 125 methyldopa- MACRODANTIN...... 16 mefenamic acid...... 40 hydrochlorothiazide...... 57

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 175 methylergonovine...... 134 miostat ...... 140 MYCOBUTIN...... 12 METHYLIN...... 48 miralax...... 106 mycophenolate mofetil ...... 21 methylphenidate hcl ...... 48 MIRAPEX ER...... 29 mycophenolate sodium...... 21 METHYLPHENIDATE HCL mirtazapine ...... 48 MYDAYIS ...... 49 ...... 48 misoprostol ...... 110 MYDRIACYL...... 136 methylprednisolone ...... 89 MITIGARE ...... 119 MYDRIATIC4(TROP-PROP- methyltestosterone...... 96 MKO (MIDAZOLAM- PE-KTRLC)...... 138 metoclopramide hcl ...... 106 KETAMINE-ONDAN) ....49 MYFORTIC ...... 21 metolazone ...... 57 M-M-R II (PF)...... 117 MYLERAN ...... 21 METOPIRONE ...... 84 m-natal plus ...... 157 mynatal ...... 158 metoprolol succinate ...... 57 MOBIC...... 40 mynatal plus...... 158 metoprolol tartrate...... 57 modafinil ...... 49 mynatal-z ...... 158 METROCREAM...... 72 MODERNA COVID-19 myorisan ...... 72 METROGEL ...... 72 VACCINE (EUA) ...... 117 MYSOLINE ...... 26 METROGEL VAGINAL...126 moexipril ...... 58 N metronidazole...... 12, 72, 126 molindone...... 49 nabumetone...... 41 metyrosine ...... 57 mometasone...... 81, 150 nadolol ...... 58 mexiletine...... 52 mondoxyne nl ...... 15 nadolol-bendroflumethiazide58 MIACALCIN ...... 96 MONJUVI ...... 20 naftifine...... 77 mibelas 24 fe ...... 131 MONODOX ...... 15 NAFTIN ...... 77 MICONAZOLE NITRATE- mono-linyah...... 131 NALFON...... 41 ZINC OX-PET ...... 77 montelukast ...... 150 NALOCET ...... 37 miconazole-3 ...... 126 morgidox ...... 15 naloxone ...... 41 MICROCHAMBER...... 90 MORGIDOX 1X 50 ...... 15 naltrexone ...... 41 microgestin 1.5/30 (21) ...... 131 MORGIDOX 2X100 ...... 15 NAMENDA...... 33 microgestin 1/20 (21) ...... 131 morphine...... 37 NAMENDA TITRATION MICROGESTIN 24 FE...... 131 morphine concentrate ...... 37 PAK ...... 33 microgestin fe 1.5/30 (28) ..131 MOTEGRITY ...... 106 NAMENDA XR ...... 33 microgestin fe 1/20 (28) .....131 MOVANTIK ...... 106 NAPRELAN CR ...... 41 MICROSPACER...... 90 MOXATAG...... 14 NAPROSYN...... 41 midazolam ...... 48 MOXEZA...... 134 naproxen ...... 41 midodrine ...... 84 moxifloxacin...... 14, 134 naproxen sodium ...... 41 migergot ...... 31 MOXIFLOXACIN (PF)-BSS NAPROXEN SODIUM...... 41 miglitol ...... 99 ...... 134 naproxen-esomeprazole...... 41 MIGRANAL ...... 31 MOXIFLOXACIN-SOD naratriptan...... 31 mili ...... 131 CHLOR,ISO(PF)...... 135 NARCAN ...... 41 milk of magnesia ...... 106 MOZOBIL...... 111 NARDIL ...... 49 milk of magnesia concentrated MS CONTIN ...... 37 NASCOBAL...... 158 ...... 106 MUGARD ...... 86 NATACHEW (FE BIS- millipred ...... 89 multi-vitamin with fluoride 157 GLYCINATE)...... 158 millipred dp ...... 89 multivitamins with fluoride 157 NATACYN...... 135 mimvey...... 125 mupirocin...... 75 nateglinide ...... 99 MINIPRESS...... 57 mupirocin calcium...... 75 NATESTO...... 97 MINITRAN...... 66 MVASI ...... 20 natural b-100 complex...... 158 minocycline ...... 15 mvc-fluoride ...... 157 natura-lax...... 106 MINOLIRA ER...... 15 my choice ...... 131 NEBUPENT ...... 12 minoxidil ...... 58 my way ...... 131 nebusal...... 150 MIOCHOL-E ...... 137 MYAMBUTOL...... 12 NEBUSAL...... 150

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 176 necon 0.5/35 (28)...... 131 nifedipine...... 58 nortriptyline ...... 49 NEEVODHA (WITH ALGAL nikki (28) ...... 131 NORVIR...... 6 OIL)...... 158 NILANDRON ...... 21 NOURIANZ ...... 29 nefazodone ...... 49 nilutamide...... 21 NOVAREL ...... 97 neomycin ...... 12 nimodipine...... 58 NOVOPEN ECHO ...... 93 neomycin-bacitracin-poly-hc NINJACOF-XG...... 146 NOXAFIL...... 3 ...... 141 NINLARO ...... 21 np thyroid...... 101 neomycin-bacitracin- nisoldipine ...... 58 NUBEQA ...... 21 polymyxin ...... 135 nitazoxanide...... 12 NUCALA ...... 150 neomycin-polymyxin b gu ...83 nitro-bid...... 66 NUCORT...... 81 neomycin-polymyxin b- NITRO-DUR...... 66 NUCYNTA ER ...... 41 dexameth ...... 141 nitrofurantoin...... 16 NUEDEXTA ...... 33 neomycin-polymyxin- nitrofurantoin macrocrystal ..16 NULEV...... 102 gramicidin...... 135 nitrofurantoin monohyd/m- NULIBRY ...... 33 neomycin-polymyxin-hc .....88, cryst ...... 16 NULYTELY LEMON-LIME 141 nitroglycerin ...... 66, 67 ...... 106 NEONATAL COMPLETE 158 NITROLINGUAL ...... 67 NURTEC ODT...... 31 NEONATAL FE ...... 158 NITROMIST ...... 67 NUVARING...... 126 NEONATAL-DHA ...... 158 NITROSTAT...... 67 NUVESSA...... 126 neo-polycin...... 135 nitro-time ...... 67 NUZYRA ...... 15 neo-polycin hc...... 141 NIVESTYM ...... 111 nyamyc ...... 77 NEORAL...... 21 nizatidine ...... 110 nylia 7/7/7 (28) ...... 132 NEO-SYNALAR KIT...... 76 NOCDURNA (MEN)...... 97 NYMALIZE ...... 58 NERLYNX...... 21 NOCDURNA (WOMEN) ....97 nymyo ...... 132 NESTABS ...... 158 nora-be...... 125 nystatin ...... 3, 77 NESTABS ABC...... 158 NORDITROPIN FLEXPRO nystatin-triamcinolone...... 77 NESTABS DHA ...... 158 ...... 112 nystop ...... 77 NESTABS ONE...... 158 noreth-ethinyl estradiol-iron NYVEPRIA...... 111 neuac...... 73 ...... 131 O NEUAC KIT ...... 72 norethindrone (contraceptive) OB COMPLETE ...... 158 nevirapine...... 6 ...... 125 OB COMPLETE ONE ...... 158 new day ...... 131 norethindrone acetate ...... 125 OB COMPLETE PETITE ..158 newgen ...... 158 norethindrone ac-eth estradiol OB COMPLETE PREMIER NEXAVAR ...... 21 ...... 125, 131 ...... 158 NEXLETOL...... 65 norethindrone-e.estradiol-iron OB COMPLETE WITH DHA NEXLIZET...... 65 ...... 131 ...... 158 niacin ...... 65 NORGESIC FORTE ...... 34 ocella...... 132 NIACOR ...... 65 norgestimate-ethinyl estradiol OCUFLOX ...... 135 NIASPAN EXTENDED- ...... 131 ODEFSEY ...... 6 RELEASE ...... 65 NORITATE ...... 73 ODOMZO...... 21 nicardipine...... 58 norlyda...... 125 OFEV...... 150 NICODERM CQ...... 85 NORPACE ...... 53 ofloxacin...... 14, 88, 135 nicorette...... 85 NORPACE CR ...... 52 olanzapine...... 49 NICORETTE...... 85 NORPRAMIN...... 49 olanzapine-fluoxetine ...... 49 nicotine...... 85 nortrel 0.5/35 (28)...... 131 olmesartan...... 58 nicotine (polacrilex) ...... 85 nortrel 1/35 (21)...... 131 olmesartan-amlodipin- NICOTROL...... 85 nortrel 1/35 (28)...... 131 hcthiazid ...... 58 NICOTROL NS ...... 85 nortrel 7/7/7 (28) ...... 132

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 177 olmesartan- ORLADEYO ...... 150 PARLODEL ...... 30 hydrochlorothiazide...... 58 orphenadrine citrate...... 34 PARNATE...... 49 olopatadine ...... 86, 138 orphenadrine-asa-caffeine ....34 paroex oral rinse ...... 87 OLUX...... 81 orphengesic forte ...... 34 paroxetine hcl ...... 49 OLUX-E...... 81 orsythia ...... 132 paroxetine OMECLAMOX-PAK ...... 110 ORTHOVISC ...... 41 mesylate(menop.sym)...... 49 omega-3 acid ethyl esters .....65 ORTIKOS...... 107 PASER...... 12 omeprazole ...... 110 oscimin ...... 102 PATANASE ...... 87 omeprazole-sodium oscimin sl...... 102 PAXIL ...... 49 bicarbonate ...... 110 oscimin sr ...... 102 PAXIL CR ...... 49 ondansetron ...... 106 oseltamivir ...... 6 PEDIARIX (PF) ...... 117 ondansetron hcl ...... 106 OSMOLEX ER...... 30 PEDVAX HIB (PF)...... 117 one daily prenatal ...... 159 OTEZLA ...... 122 peg 3350-electrolytes...... 107 ONETOUCH ULTRA TEST OTEZLA STARTER...... 122 peg3350-sod sul-nacl-kcl-asb-c ...... 90 OVACE ...... 68 ...... 107 ONETOUCH ULTRA2 OVACE PLUS ...... 67, 68 PEGASYS ...... 113 METER ...... 93 OVACE PLUS SHAMPOO.67 peg-electrolyte soln ...... 107 ONETOUCH ULTRAMINI 93 OVACE PLUS WASH...... 68 peg-prep...... 107 ONETOUCH VERIO FLEX OVIDE...... 82 PEMAZYRE...... 21 METER ...... 93 OVIDREL ...... 97 PEN NEEDLE, DIABETIC .93 ONETOUCH VERIO IQ oxandrolone...... 97 penicillamine ...... 122 METER ...... 93 oxaprozin...... 41 penicillin v potassium...... 14 ONETOUCH VERIO METER OXAYDO...... 37 PENTACEL (PF)...... 117 ...... 93 oxazepam...... 49 PENTACEL ACTHIB ONETOUCH VERIO oxcarbazepine...... 27 COMPONENT (PF) ...... 117 REFLECT METER...... 93 oxiconazole...... 77 pentamidine ...... 12 ONETOUCH VERIO TEST OXISTAT...... 77 PENTASA ...... 107 STRIPS...... 90 OXLUMO ...... 154 pentazocine-naloxone...... 41 ONEXTON...... 73 OXTELLAR XR ...... 27 pentoxifylline...... 63 ONFI ...... 26, 27 oxybutynin chloride....152, 153 PEPAXTO ...... 21 ONZETRA XSAIL ...... 31 oxycodone ...... 37 PEPCID ...... 111 opcicon one-step...... 132 oxycodone-acetaminophen...37 PERFOROMIST...... 150 opium tincture ...... 102 OXYCONTIN ...... 37 PERIDEX ...... 87 OPSUMIT ...... 150 oxymorphone...... 37, 38 perindopril erbumine ...... 58 OPTICHAMBER DIAMOND OXYTROL...... 153 periogard...... 87 VHC ...... 91 OZEMPIC ...... 99 permethrin...... 82 option-2 ...... 132 P perphenazine...... 50 ORACEA ...... 15 pacerone...... 53 perphenazine-amitriptyline...50 ORACIT...... 154 PACNEX ...... 73 perry prenatal...... 159 oral saline laxative...... 106 PADCEV ...... 21 PFIZER COVID-19 oralone...... 86 paliperidone...... 49 VACCINE (EUA) ...... 117 ORAMAGICRX ...... 87 PAMELOR...... 49 phenazopyridine ...... 154 ORAPRED ODT ...... 89 PANCREAZE ...... 107 phenelzine...... 50 ORAVIG ...... 3 PANDEL ...... 81 phenobarb-hyoscy-atropine- ORENITRAM ...... 58 PANRETIN ...... 70 scop...... 102 ORIAHNN ...... 126 pantoprazole ...... 110, 111 phenobarbital ...... 27 ORILISSA...... 97 PAREMYD ...... 137 phenoxybenzamine ...... 58 ORKAMBI...... 150 paricalcitol ...... 97 phenylephrine hcl ...... 144

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 178 PHENYLEPH- portia 28...... 132 PREDNISOLONE- TROPICAMIDE IN posaconazole ...... 3 MOXIFLOXACIN HCL 142 WATER...... 137 POTABA ...... 155 PREDNISOLONE- PHENYTEK...... 27 potassium chloride...... 155 MOXIFLOX-BROMFEN phenytoin...... 27 potassium citrate...... 154 ...... 139 phenytoin sodium extended..27 powderlax ...... 107 prednisone...... 89 philith ...... 132 PR BENZOYL PEROXIDE.73 prednisone intensol...... 89 PHOSLYRA...... 107 pr natal 400...... 159 PREFEST ...... 125 phosphasal ...... 154 pr natal 400 ec ...... 159 pregabalin ...... 27 phosphate laxative...... 107 pr natal 430...... 159 PREMARIN ...... 125 PHYSIOLYTE ...... 83 pr natal 430 ec ...... 159 prena1 chew...... 159 PHYSIOSOL IRRIGATION83 pramipexole ...... 30 prena1 pearl ...... 159 phytonadione (vitamin k1) ...63 PRAMOSONE ...... 68 prena1 true...... 159 PHYTONADIONE prasugrel ...... 63 PRENATA...... 159 (VITAMIN K1)...... 63 pravastatin ...... 65 prenatabs fa...... 159 pilocarpine hcl...... 84, 87, 137 prazosin ...... 58 prenatabs rx ...... 159 pimecrolimus...... 70 PRECISION XTRA prenatal ...... 159 pimozide...... 50 KETONE-GLUCOSE ...... 93 prenatal complete...... 159 pimtrea (28)...... 132 PRECISION XTRA prenatal multi-dha (algal oil) pindolol ...... 58 MONITOR ...... 93 ...... 159 pioglitazone ...... 99 PRECISION XTRA TEST...90 prenatal multivitamins ...... 159 pioglitazone-glimepiride ...... 99 PRECOSE ...... 99 prenatal one daily ...... 159 pioglitazone-metformin...... 99 PRED FORTE ...... 143 prenatal plus...... 160 pirmella...... 132 PRED-G...... 141 prenatal plus (calcium carb)159 piroxicam...... 41 PRED-G S.O.P...... 141 PRENATAL PLUS DHA...159 PLAN B ONE-STEP...... 132 prednicarbate ...... 81 prenatal vitamin ...... 160 PLEGRIDY ...... 113 PREDNISOL ACE- prenatal vitamin plus low iron PLEXION...... 73 GATIFLOX-BROMFEN138 ...... 160 PLEXION CLEANSING PREDNISOLN SP- prenatal vitamin with minerals CLOTHS ...... 73 GATIFLOX-BROMFEN138 ...... 160 PNEUMOVAX-23...... 117 PREDNISOLN SP- prenatal vits96-iron fum-folic pnv 29-1 ...... 159 MOXIFLOX-BROMFEN ...... 160 pnv-dha...... 159 ...... 138 prenatal-u...... 160 pnv-omega...... 159 prednisolone ...... 89 PRENATE AM...... 160 pnv-select ...... 159 prednisolone acetate ...... 143 PRENATE CHEWABLE...160 POCKET CHAMBER ...... 91 PREDNISOLONE ACETATE PRENATE DHA (FERR ASP podofilox ...... 70 (PF)...... 143 GLYCIN)...... 160 POLIVY ...... 21 PREDNISOLONE ACETATE- PRENATE ELITE (IRON ASP polycin...... 135 NEPAFENAC ...... 138 GLYC)...... 160 polyethylene glycol 3350 ...107 PREDNISOLONE ACET- PRENATE ENHANCE ...... 160 polymyxin b sulf-trimethoprim GATIFLOXACIN ...... 142 PRENATE ...... 135 PREDNISOLONE SOD PH- ESSENTIAL(IRON-ASP- POLYTRIM ...... 135 MOXIFLOX...... 142 GL) ...... 160 POLY-TUSSIN AC ...... 146 prednisolone sodium phosphate PRENATE MINI (FERR ASP POMALYST ...... 113 ...... 89, 143 GLYCIN)...... 160 PONVORY ...... 113 PREDNISOLONE- PRENATE PIXIE...... 160 PONVORY 14-DAY MOXIFLO-NEPAFENAC PRENATE RESTORE ...... 160 STARTER PACK ...... 113 ...... 139 PRENATE STAR...... 160

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 179 preplus ...... 160 promethazine-phenyleph- R pretab...... 160 codeine...... 146 RABAVERT (PF) ...... 118 PRETOMANID...... 12 promethazine-phenylephrine rabeprazole ...... 111 prevalite...... 65 ...... 146 RACEPINEPH-LIDOCAINE- PREVIDENT...... 87 promethegan ...... 145 BSS 7(PF)...... 139 PREVIDENT 5000 BOOSTER PROMETRIUM ...... 125 raloxifene...... 120 PLUS ...... 87 propafenone...... 53 ramelteon ...... 50 PREVIDENT 5000 DRY propranolol ...... 58, 59 ramipril ...... 59 MOUTH ...... 87 propranolol-hydrochlorothiazid ranolazine ...... 66 PREVIDENT 5000 ENAMEL ...... 59 RAPAMUNE...... 21 PROTECT ...... 87 propylthiouracil ...... 89 rasagiline...... 30 PREVIDENT 5000 ORTHO PROQUAD (PF)...... 118 RASUVO (PF)...... 122 DEFENSE ...... 87 PROSCAR...... 153 RAYOS...... 89 PREVIDENT 5000 PLUS....87 PROTHELIAL ...... 87 RAZADYNE ER ...... 33 PREVIDENT 5000 PROTOPIC...... 70 REBIF REBIDOSE ...... 113 SENSITIVE...... 87 protriptyline...... 50 REBLOZYL ...... 111 previfem ...... 132 PROVERA ...... 125 reclipsen (28) ...... 132 PREVNAR 13 (PF) ...... 117 PROVIDA OB...... 160 RECOMBIVAX HB (PF)...118 PREZISTA ...... 6 pulmosal ...... 150 RECTIV...... 108 PRIFTIN...... 12 PULMOZYME...... 150 REGLAN...... 108 PRIMACARE ...... 160 PUREFE OB PLUS...... 161 RELAFEN ...... 41 primaquine...... 12 purelax...... 108 RELAGARD ...... 126 PRIMEAIRE ...... 91 PURIXAN ...... 21 RELENZA DISKHALER ...... 6 primidone ...... 27 pyrazinamide ...... 12 RELEXXII...... 50 PRIMSOL ...... 16 PYRIDIUM ...... 154 RELPAX...... 31 PRINIVIL...... 58 pyridostigmine bromide ...... 34 REMERON...... 50 probenecid ...... 119 PYRIDOSTIGMINE REMERON SOLTAB ...... 50 probenecid-colchicine ...... 120 BROMIDE...... 34 rena-vite...... 161 PROCARDIA XL ...... 58 pyrimethamine...... 12 RENVELA ...... 108 procentra...... 50 Q repaglinide ...... 100 PROCHAMBER ...... 91 QBREXZA ...... 70 repaglinide-metformin...... 100 prochlorperazine...... 107 QUADRACEL (PF) ...... 118 REPATHA PUSHTRONEX 65 prochlorperazine maleate ...107 QUALAQUIN...... 12 REPATHA SURECLICK ....65 PROCORT ...... 107 QUDEXY XR...... 27 REPATHA SYRINGE ...... 65 PROCTOCORT ...... 81, 107 QUESTRAN...... 65 RESPA-AR...... 146 procto-med hc...... 107 QUESTRAN LIGHT...... 65 RESTASIS...... 139 procto-pak...... 107 quetiapine ...... 50 RESTASIS MULTIDOSE..139 proctosol hc ...... 108 QUILLICHEW ER...... 50 RESTORIL ...... 50 proctozone-hc...... 108 QUILLIVANT XR ...... 50 RETACRIT...... 111 progesterone micronized ....125 quinapril...... 59 RETEVMO...... 22 PROGLYCEM ...... 91 quinapril-hydrochlorothiazide RETIN-A ...... 73 PROGRAF ...... 21 ...... 59 RETIN-A MICRO PUMP ....73 prolate...... 38 quinidine gluconate ...... 53 RETROVIR ...... 6 PROLENSA ...... 139 quinidine sulfate ...... 53 REVATIO...... 150 promethazine ...... 145 quinine sulfate ...... 12 REVLIMID...... 113 promethazine-codeine ...... 146 quit 2...... 85, 86 REYATAZ ...... 7 promethazine-dm...... 146 quit 4...... 86 REYVOW...... 31 QVAR REDIHALER ...... 150 ribavirin ...... 7, 113

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 180 RIDAURA...... 122 RYVENT...... 145 SIMPONI...... 122 rifabutin ...... 12 S SIMPONI ARIA...... 122 rifampin ...... 12 SAFE-CLIP BY MAIL ...... 93 simvastatin...... 65 RILUTEK...... 84 SALAGEN (PILOCARPINE) SINEMET...... 30 riluzole...... 84 ...... 84, 87 SINUVA ...... 150 rimantadine...... 7 salsalate ...... 41 sirolimus ...... 22 ringer's ...... 83 SANCUSO ...... 108 SKELAXIN ...... 34 RINVOQ ...... 122 SANDIMMUNE ...... 22 SKLICE ...... 82 RIOMET ...... 100 SARCLISA...... 22 SKYRIZI ...... 68 RIOMET ER ...... 100 SAVELLA...... 122 smoothlax ...... 108 risedronate ...... 84, 120 scalacort...... 81 sodium chloride ...... 84, 151 RISPERDAL ...... 50 SCALACORT DK ...... 81 sodium chloride 0.9 %...... 84 risperidone...... 50 SCENESSE ...... 70 sodium chloride 0.9 % (flush) RITALIN...... 51 scopolamine base...... 108 ...... 84 RITALIN LA...... 50 seconal sodium ...... 51 sodium ferric gluconat-sucrose RITEFLO AEROCHAMBER SECUADO ...... 51 ...... 84 ...... 91 SELECT-OB ...... 161 sodium fluoride 5000 dry ritonavir ...... 7 SELECT-OB (FOLIC ACID) mouth...... 87 rivastigmine...... 33 ...... 161 sodium fluoride 5000 plus ....87 rivastigmine tartrate...... 33 SELECT-OB + DHA...... 161 sodium fluoride-pot nitrate...87 rivelsa ...... 132 selegiline hcl...... 30 sodium polystyrene sulfonate rizatriptan ...... 31 selenium sulfide...... 68 ...... 108 R-NATAL OB...... 161 SELRX ...... 68 solifenacin...... 153 ROCALTROL...... 97 SELZENTRY ...... 7 SOLIQUA 100/33 ...... 95 ROMIDEPSIN ...... 22 se-natal 19 chewable ...... 161 SOLODYN ...... 15 ropinirole ...... 30 se-natal-19 ...... 161 SOLTAMOX...... 22 rosadan ...... 73 SERNIVO...... 81 SOMAVERT ...... 97 ROSADAN ...... 73 SEROSTIM ...... 112 SOOLANTRA...... 73 ROSANIL ...... 73 sertraline ...... 51 SORBITOL...... 83 ROSULA...... 73 setlakin...... 132 SORBITOL-MANNITOL....83 rosula cleansing cloths ...... 73 sevelamer carbonate ...... 108 SORIATANE ...... 68 rosuvastatin...... 65 sevelamer hcl...... 108 SORILUX...... 68 ROSZET...... 65 SEYSARA...... 15 sorine ...... 53 ROTARIX ...... 118 sf 87 sotalol ...... 53 ROTATEQ VACCINE ...... 118 sf 5000 plus ...... 87 sotalol af ...... 53 ROWASA ...... 108 SFROWASA ...... 108 SOTYLIZE ...... 53 roweepra...... 27 sharobel ...... 125 SOVALDI...... 7 ROXICODONE ...... 38 SHINGRIX (PF)...... 118 SPACE CHAMBER...... 91 ROZLYTREK ...... 22 SIGNIFOR...... 22 SPECTRACEF ...... 9 RUBRACA ...... 22 sildenafil (pulm.hypertension) spinosad ...... 82 rufinamide ...... 27 ...... 150 SPIRIVA RESPIMAT...... 151 RUXIENCE...... 22 SILENOR ...... 51 SPIRIVA WITH RUZURGI ...... 33 silodosin...... 153 HANDIHALER...... 151 RYBELSUS ...... 100 SILVADENE...... 69 spironolactone...... 59 RYCLORA...... 145 silver sulfadiazine...... 69 spironolacton-hydrochlorothiaz RYDAPT...... 22 SIMBRINZA...... 140 ...... 59 RYTARY ...... 30 simliya (28)...... 132 SPORANOX...... 3 RYTHMOL SR ...... 53 simpesse...... 132 SPORANOX PULSEPAK .....3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 181 sprintec (28)...... 132 SULFAMYLON...... 76 tacrolimus ...... 22, 70 SPRITAM ...... 27 sulfasalazine ...... 108 tadalafil ...... 153 SPRYCEL ...... 22 sulfatrim...... 14 tadalafil (pulm. hypertension) sps (with sorbitol)...... 108 sulindac...... 42 ...... 151 sronyx...... 132 SUMADAN...... 74 TAFINLAR ...... 22 ssd...... 69 SUMADAN XLT ...... 74 TAGRISSO...... 22 SSKI ...... 90 sumatriptan ...... 31 TAKE ACTION ...... 132 sss 10-5...... 73 sumatriptan succinate .....31, 32 TALICIA ...... 111 st joseph aspirin...... 42 SUMAXIN ...... 74 TALTZ AUTOINJECTOR ..69 st. joseph aspirin...... 42 SUMAXIN CP ...... 74 TALTZ AUTOINJECTOR (2 STALEVO 100...... 30 SUMAXIN TS...... 74 PACK) ...... 69 STALEVO 125...... 30 SUNOSI...... 51 TALTZ AUTOINJECTOR (3 STALEVO 150...... 30 super b complex-vitamin c .161 PACK) ...... 69 STALEVO 200...... 30 super b maxi complex...... 161 TALTZ SYRINGE ...... 69 STALEVO 50...... 30 super quints...... 161 TALZENNA...... 22 STALEVO 75...... 30 super quints b-50 ...... 161 TAMIFLU ...... 7 STAMARIL (PF) ...... 118 SUPRAX ...... 9 tamoxifen...... 22 stavudine...... 7 SURVANTA ...... 84 tamsulosin...... 153 STEGLUJAN ...... 100 SUSTIVA ...... 7 TAPAZOLE ...... 90 STELARA...... 68 SUTENT...... 22 TAPERDEX ...... 89 STIOLTO RESPIMAT ...... 151 syeda...... 132 TARCEVA ...... 22 STIVARGA...... 22 SYMAX DUOTAB...... 102 TARGADOX...... 16 stop smoking aid...... 86 symax fastabs ...... 102 TARGRETIN ...... 22 stress formula ...... 161 symax-sl...... 102 tarina 24 fe...... 132 stress formula with iron...... 161 symax-sr ...... 102 tarina fe 1/20 (28) ...... 132 stress formula with iron(sulf) SYMBICORT...... 151 TARKA ...... 59 ...... 161 SYMBYAX ...... 51 taron-c dha...... 161 STROMECTOL ...... 12 SYMDEKO ...... 151 TASIGNA...... 22 strong iodine...... 76, 155 SYMFI...... 7 TASMAR ...... 30 SUBLOCADE...... 38 SYMFI LO ...... 7 tazarotene...... 74 subvenite...... 27 SYMJEPI...... 145 TAZORAC ...... 74 subvenite starter (blue) kit....27 SYMLINPEN 120 ...... 100 taztia xt ...... 59 subvenite starter (green) kit..27 SYMLINPEN 60 ...... 100 TAZVERIK ...... 22 subvenite starter (orange) kit 28 SYMPAZAN...... 28 TDVAX ...... 118 SUCRAID ...... 108 SYMTUZA...... 7 TECARTUS ...... 23 sucralfate ...... 111 SYNALAR ...... 81 TECFIDERA ...... 114 SULAR...... 59 SYNALAR CREAM KIT ....81 TEGRETOL ...... 28 sulfacetamide sodium...68, 143 SYNALAR OINTMENT KIT TEGRETOL XR...... 28 sulfacetamide sodium (acne) 76 ...... 81 TEGSEDI ...... 33 sulfacetamide sodium-sulfur73, SYNALAR TS ...... 81 TEKTURNA HCT...... 59 74 SYNAREL...... 97 telmisartan ...... 59 sulfacetamide-prednisolone 143 SYNDROS ...... 108 telmisartan-amlodipine ...... 59 sulfacetamide-sulfur-cleansr23 SYNJARDY ...... 100 telmisartan-hydrochlorothiazid ...... 74 SYNJARDY XR...... 100 ...... 59 sulfacleanse 8-4...... 74 SYNTHROID...... 101 temazepam...... 51 sulfadiazine...... 14 T TEMIXYS ...... 7 sulfamethoxazole-trimethoprim TABRECTA...... 22 TEMODAR ...... 23 ...... 14 TACLONEX ...... 68 TEMOVATE ...... 81

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 182 temozolomide...... 23 TIMOLOL- TRECATOR ...... 13 tencon ...... 38 LATANOPROST(PF) ....141 TRELEGY ELLIPTA...... 151 TENIVAC (PF) ...... 118 TIMOPTIC ...... 136 TRESIBA FLEXTOUCH U- tenofovir disoproxil fumarate.7 TIMOPTIC-XE ...... 136 100 ...... 95 TENORMIN...... 59 tinidazole ...... 13 TRESIBA FLEXTOUCH U- TEPEZZA...... 97 tiopronin ...... 84 200 ...... 95 terazosin ...... 59 tis-u-sol pentalyte ...... 83 TRESIBA U-100 INSULIN .95 terbinafine hcl...... 3 TIVICAY...... 7 tretinoin...... 74 terbutaline...... 151 TIVICAY PD ...... 7 tretinoin (antineoplastic)...... 23 terconazole ...... 126 tizanidine ...... 34 tretinoin microspheres ...... 74 TERSI FOAM ...... 69 TOBI PODHALER ...... 13 TRETIN-X...... 74 TESSALON PERLES...... 146 TOBRADEX ...... 142 TRETIN-X CREAM KIT.....74 testosterone...... 97, 98 tobramycin...... 13, 135 TREXALL...... 23 testosterone cypionate ...... 97 tobramycin in 0.225 % nacl..13 tri femynor ...... 132 testosterone enanthate ...... 97 TOBRAMYCIN WITH triamcinolone acetonide..82, 87 TETANUS,DIPHTHERIA NEBULIZER...... 13 TRIAMCINOLON- TOX PED(PF)...... 118 tobramycin-dexamethasone 142 MOXIFLOX-WATR(PF) tetrabenazine...... 33 TOBREX ...... 135 ...... 142 tetracaine hcl ...... 139 TODAY CONTRACEPTIVE triamterene...... 60 TETRACAINE HCL (PF)..139 SPONGE ...... 126 triamterene-hydrochlorothiazid tetracycline ...... 16 TOLAK ...... 70 ...... 60 TEXACORT...... 81 tolcapone ...... 30 trianex...... 82 THEO-24...... 151 tolmetin...... 42 TRICARE ...... 161 theophylline...... 151 tolterodine...... 153 triderm ...... 82 THIOLA...... 84 TOPICORT ...... 82 TRIDESILON...... 82 THIOLA EC...... 84 topiramate...... 28 TRIESENCE (PF) ...... 89 thioridazine...... 51 toremifene...... 23 tri-estarylla...... 132 thiothixene...... 51 torsemide ...... 60 TRIFERIC ...... 161 THRIVITE RX...... 161 TOSYMRA ...... 32 trifluoperazine...... 51 THYROLAR-1...... 101 TOUJEO MAX U-300 trifluridine...... 135 THYROLAR-1/2...... 101 SOLOSTAR ...... 95 trihexyphenidyl...... 30 THYROLAR-1/4...... 101 TOUJEO SOLOSTAR U-300 TRIJARDY XR ...... 91 THYROLAR-2...... 101 INSULIN ...... 95 TRIKAFTA ...... 151 THYROLAR-3...... 101 tovet emollient...... 82 tri-legest fe...... 133 tiadylt er...... 59 TOVIAZ ...... 153 tri-linyah ...... 133 tiagabine ...... 28 TRACLEER ...... 151 TRILIPIX ...... 66 TIAZAC ...... 59 tramadol...... 42 tri-lo-estarylla ...... 133 TIBSOVO ...... 23 TRAMADOL ...... 42 tri-lo-marzia...... 133 TIGLUTIK ...... 84 tramadol-acetaminophen ...... 42 tri-lo-mili ...... 133 tilia fe...... 132 trandolapril ...... 60 tri-lo-sprintec ...... 133 TIMOL-BRIMON-DORZO- trandolapril-verapamil ...... 60 trilyte with flavor packets...108 LATANOP(PF) ...... 140 tranexamic acid...... 126 trimethobenzamide ...... 108 timolol maleate...... 60, 136 TRANXENE T-TAB...... 51 trimethoprim...... 16 timolol maleate (pf)...... 136 tranylcypromine...... 51 tri-mili...... 133 TIMOLOL-BRIMONIDI- travoprost...... 141 trimipramine ...... 51 DORZOLAM(PF) ...... 140 TRAZIMERA...... 23 TRIMO-SAN JELLY ...... 126 TIMOLOL-DORZOLAMID- trazodone ...... 51 trinatal rx 1 ...... 161 LATANOP(PF) ...... 141 TREANDA...... 23 trinate...... 161

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 183 TRINTELLIX...... 51 urogesic-blue ...... 154 VENOFER...... 162 tri-nymyo...... 133 uro-mp ...... 154 verapamil ...... 60 tri-previfem (28)...... 133 UROQID-ACID NO.2...... 154 VERELAN ...... 60 tri-sprintec (28)...... 133 URSO 250 ...... 109 VERELAN PM...... 60 TRISTART DHA ...... 161 URSO FORTE...... 109 VERQUVO...... 66 tritocin ...... 82 ursodiol...... 109 VERSACLOZ...... 51 TRIUMEQ...... 7 uryl...... 154 VERZENIO ...... 23 triveen-duo dha...... 162 ustell ...... 154 vestura (28)...... 133 tri-vitamin with fluoride.....162 utira-c...... 154 VFEND...... 3 trivora (28)...... 133 V V-GO 20 ...... 93 tri-vylibra...... 133 valacyclovir ...... 7 V-GO 30 ...... 93 tri-vylibra lo...... 133 VALCHLOR ...... 70 V-GO 40 ...... 93 TRIZIVIR...... 7 VALCYTE ...... 7 VIBRAMYCIN ...... 16 TRODELVY ...... 23 valganciclovir ...... 8 VIEKIRA PAK...... 8 TROKENDI XR...... 28 valproic acid ...... 28 vienva ...... 133 tropicamide...... 137 valproic acid (as sodium salt) VIGAMOX...... 135 trospium...... 153 ...... 28 VIMOVO...... 42 TRULICITY...... 100 valsartan...... 60 VIMPAT...... 28 TRUMENBA ...... 118 valsartan-hydrochlorothiazide VIOKACE ...... 109 TRUSOPT ...... 141 ...... 60 viorele (28) ...... 133 TUKYSA...... 23 VALTOCO...... 28 VIRACEPT...... 8 tulana ...... 125 VANATOL LQ ...... 38 VIRAMUNE...... 8 TURALIO ...... 23 VANATOL S ...... 38 VIRAMUNE XR ...... 8 TUSSICAPS...... 146 VANCOCIN...... 16 VIRAZOLE ...... 8 TUZISTRA XR...... 146 vancomycin ...... 16 VIREAD ...... 8 TWINRIX (PF) ...... 118 vandazole...... 126 virt-c dha...... 162 TYBOST ...... 7 VANOXIDE-HC...... 75 virt-nate dha...... 162 tydemy...... 133 VAQTA (PF)...... 119 virt-pn dha ...... 162 TYKERB...... 23 VARENICLINE ...... 86 virt-pn plus...... 162 TYMLOS ...... 120 VARIVAX (PF) ...... 119 virtussin ac...... 146 TYPHIM VI ...... 119 VARIZIG...... 119 virtussin dac...... 146 TYVASO...... 152 VARUBI...... 109 VISTARIL...... 145 TYVASO REFILL KIT .....152 VASCEPA...... 66 VITAFOL FE PLUS...... 162 TYVASO STARTER KIT .152 VASERETIC...... 60 VITAFOL GUMMIES ...... 162 U VASOTEC...... 60 VITAFOL NANO ...... 162 UBRELVY...... 32 VAXELIS (PF)...... 119 VITAFOL ULTRA...... 162 UCERIS...... 109 VCF CONTRACEPTIVE VITAFOL-OB ...... 162 UKONIQ ...... 23 FILM ...... 126 VITAFOL-OB+DHA ...... 162 ULTRACET...... 42 VCF CONTRACEPTIVE GEL VITAFOL-ONE ...... 162 ULTRAM...... 42 ...... 126 VITAMED MD ONE RX ..162 ULTRAVATE...... 82 VECTICAL ...... 69 VITAMEDMD REDICHEW unithroid ...... 101 velivet triphasic regimen (28) RX...... 162 UPTRAVI ...... 60 ...... 133 vitamin b complex ...... 162 URELLE...... 154 VEMLIDY...... 8 vitamin b complex-folic acid uretron d-s ...... 154 VENCLEXTA ...... 23 ...... 162 URIBEL ...... 154 VENCLEXTA STARTING vitamin k...... 63 urimar-t...... 154 PACK ...... 23 vitamin k1...... 63 uro-458 ...... 154 venlafaxine ...... 51 vitamins a,c,d and fluoride .162

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 184 VITAPEARL...... 162 XELJANZ ...... 122 ZEPATIER ...... 8 VITATRUE...... 163 XELJANZ XR...... 122 ZEPOSIA...... 114 VITRAKVI...... 23 XELODA...... 23 ZEPOSIA STARTER KIT .114 VIVITROL...... 42 XEMBIFY ...... 119 ZEPOSIA STARTER PACK VIZIMPRO ...... 23 XENLETA...... 13 ...... 114 VOGELXO...... 98 XERESE...... 77 ZEPZELCA ...... 24 volnea (28)...... 133 XHANCE ...... 152 ZERVIATE...... 139 voriconazole ...... 3, 4 XIFAXAN ...... 13 ZESTORETIC ...... 60 VORTEX HOLDING XIGDUO XR...... 100 ZESTRIL ...... 61 CHAMBER ...... 91 XOFLUZA ...... 8 ZIAC...... 61 VOSEVI ...... 8 XOPENEX ...... 152 ZIAGEN ...... 8 VOTRIENT...... 23 XOPENEX CONCENTRATE ZIANA...... 75 VP-PNV-DHA ...... 163 ...... 152 zidovudine ...... 8 vtol lq ...... 38 XOSPATA...... 24 ZIEXTENZO...... 111 VUMERITY...... 114 xulane ...... 126 zileuton ...... 152 VUSION...... 77 XULTOPHY 100/3.6 ...... 95 ZILXI...... 75 vyfemla (28) ...... 133 XYOSTED ...... 98 zingiber...... 163 VYLEESI ...... 51 XYREM...... 51 ZIOPTAN (PF)...... 141 vylibra...... 133 XYWAV...... 52 ziprasidone hcl...... 52 VYNDAMAX ...... 66 Y ZIRABEV...... 24 VYNDAQEL...... 66 YAZ (28) ...... 133 ZIRGAN ...... 135 W YF-VAX (PF)...... 119 ZITHROMAX ...... 10 WAKIX ...... 51 YUPELRI ...... 152 ZITHROMAX TRI-PAK .....11 warfarin ...... 63 yuvafem...... 125 ZITHROMAX Z-PAK ...... 11 water for irrigation, sterile....85 Z ZOFRAN ...... 109 wera (28) ...... 133 zafemy ...... 126 ZOKINVY...... 85 westab plus ...... 163 zafirlukast ...... 152 ZOLINZA...... 24 westgel dha...... 163 zaleplon ...... 52 zolmitriptan...... 32 westhroid ...... 101 ZANAFLEX...... 34 zolpidem ...... 52 WIDE-SEAL DIAPHRAGM zarah ...... 134 ZOLPIMIST ...... 52 ...... 123 ZARONTIN...... 29 ZOMIG ...... 32 wintergreen oil...... 70 ZARXIO...... 111 zonisamide...... 29 wixela inhub ...... 152 zatean-pn dha...... 163 ZONTIVITY...... 63 women's gentle laxative(bisac) zatean-pn plus...... 163 ZORBTIVE ...... 112 ...... 109 ZCORT...... 89 ZORTRESS ...... 24 women's laxative (bisacodyl) zebutal ...... 38 ZOSTAVAX (PF) ...... 119 ...... 109 ZEGALOGUE zovia 1/35e (28)...... 134 wymzya fe ...... 133 AUTOINJECTOR ...... 91 ZOVIRAX ...... 8, 78 X ZEGALOGUE SYRINGE ...91 ZTLIDO...... 75 XALKORI...... 23 ZEJULA ...... 24 ZUBSOLV...... 42 XARELTO ...... 63 ZELBORAF ...... 24 ZULRESSO...... 52 XARELTO DVT-PE TREAT ZELNORM...... 109 zumandimine (28)...... 134 30D START ...... 63 ZEMBRACE SYMTOUCH.32 ZUPLENZ ...... 109 XCOPRI ...... 28 ZEMPLAR ...... 98 ZYDELIG...... 24 XCOPRI MAINTENANCE zenatane ...... 75 ZYFLO ...... 152 PACK ...... 28 ZENPEP ...... 109 ZYKADIA...... 24 XCOPRI TITRATION PACK zenzedi...... 52 ZYLOPRIM...... 120 ...... 29 ZENZEDI ...... 52 ZYMAXID ...... 135

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 185 ZYPITAMAG ...... 66 ZYPREXA...... 52 ZYPREXA ZYDIS...... 52

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 186 If you, or someone you’re helping, have questions about CareSource, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-877-806-9284 TTY:711.

ARABIC HINDI यदि आपके , या आप जिसकी मिि कर रहे हℂ उसके CareSource إذا كان لديك، أو لدى أي شخص تساعده، أية استفسارات के बारे मᴂ कोई सवाल ह ℂ तो आपके पास बगैर दकसी लागत के अपनी بخصوص CareSource، فيحق لك الحصول على مساعدة भाषा मᴂ सहायता और िानकारी ꥍाप्त करने का अजिकार ह।ै एक िभाजषएु से बात करने के जलए कॉल कर,ᴂ 1-877-806-9284 ومعلومات مجانًا وباللغة التي تتحدث بها. للتحدث إلى أحد .TTY:711 المترجمين الفوريين، اتصل على .TTY:711 1-877-806-9284 AMHARIC ITALIAN እርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ CareSource ጥያቄ Se Lei, o qualcuno che Lei sta aiutando, ha domande su ካላችሁ፣ ያለ ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት CareSource, ha il diritto di avere supporto e informazioni አላችሁ። ከአስተርጓሚ ጋር ለመነጋገር፣ 1-877-806-9284 TTY:711 nella propria lingua senza alcun costo. Per parlare con ይደውሉ። un interprete, chiami il 1-877-806-9284 TTY:711. BURMESE JAPANESE CareSource အေၾကာင္း သင္ သို႔မဟုတ္ ご本人様、または身の回りの方で、CareSource に関 するご質問がございましたら、ご希望の言語でサポー သင္အကူအညီေပးေနသူ တစ္စံုတစ္ေယာက္က トを受けたり、情報を入手したりすることができます ေမးျမန္းလာပါက သင္ေျပာဆိုေသာ ဘာသာစကားျဖင့္ （無償）。 通訳をご利用の場合は、1-877-806-9284 အကူအညီႏွင့္ အခ်က္အလက္မ်ားအား အခမဲ့ ရယူႏိင္ရန္ TTY:711 にご連絡ください。 အခြင့္အေရး႐ွိပါသည္။ ဘာသာျပန္တစ္ဦးအား စကားေျပာဆိုရန္ KOREAN 1-877-806-9284 TTY:711 ဤတြင္ နံပါတ္ျဖည့္သြင္းပါ] သို႔ 귀하 본인이나 귀하께서 돕고 계신 분이 CareSource에 ေခၚဆိုပါ။ 대해 궁금한 점이 있으시면, 원하는 언어로 별도 비용 없이 도움을 받으실 수 있습니다. 통역사가 필요하시면 CHINESE 다음 번호로 전화해 주십시오: 1-877-806-9284 TTY:711. 如果您或者您在帮助的人对 CareSource 存有疑问，您 有权免费获得以您的语言提供的帮助和信息。 如果您需 PENNSYLVANIA DUTCH 要与一位翻译交谈，请致电 1-877-806-9284 TTY:711。 Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut CareSource, hoscht du es Recht fer Hilf un Information in deinre eegne CUSHITE – OROMO Schprooch griege, un die Hilf koschtet nix. Wann du Isin yookan namni biraa isin deeggartan CareSource mit me Interpreter schwetze witt, kannscht du 1-877- irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala 806-9284 TTY:711 uffrufe. ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa RUSSIAN Если у Вас или у кого-то, кому Вы помогаете, есть 1-877-806-9284 TTY:711 tiin bilbilaa. вопросы относительно CareSource, Вы имеете право бесплатно получить помощь и информацию DUTCH на Вашем языке. Для разговора с переводчиком, Als u, of iemand die u helpt, vragen heeft over позвоните по номеру 1-877-806-9284 TTY:711. CareSource, hebt u het recht om kosteloos hulp en informatie te ontvangen in uw taal. Als u wilt spreken SPANISH met een tolk, bel dan naar 1-877-806-9284 TTY:711. Si usted o alguien a quien ayuda tienen preguntas sobre CareSource, tiene derecho a recibir esta FRENCH (CANADA) información y ayuda en su propio idioma sin costo. Des questions au sujet de CareSource? Vous ou Para hablar con un intérprete, llame al 1-877-806-9284 la personne que vous aidez avez le droit d’obtenir TTY:711. gratuitement du soutien et de l’information dans votre langue. Pour parler à un interprète, veuillez téléphoner UKRAINIAN au 1-877-806-9284 TTY:711. Якщо у вас, чи в особи, котрій ви допомагаєте, виникнуть запитання щодо CareSource, ви GERMAN маєте право безкоштовно отримати допомогу Wenn Sie, oder jemand dem Sie helfen, eine Frage zu та інформацію вашою мовою. Щоб замовити CareSource haben, haben Sie das Recht, kostenfrei перекладача, зателефонуйте за номером in Ihrer eigenen Sprache Hilfe und Information zu 1-877-806-9284 TTY:711. bekommen. Um mit einem Dolmetscher zu sprechen, rufen Sie die Nummer 1-877-806-9284 TTY:711 an. VIETNAMESE Nếu bạn hoặc ai đó bạn đang giúp đỡ, có thắc mắc GUJARATI જો તમે અથવા તમે કોઇને મદદ કરી રહ્ાાં તેમ ાંથી કોઇને về CareSource, bạn có quyền được nhận trợ giúp và CareSource વવશે પ્રશનો હોર્ તો તમને મદદ અને મ હહતી મેવિવ નો thông tin bằng ngôn ngữ của mình miễn phí. Để nói અવવક ર છે. તે ખર㚯 વવન તમ રી ભ ષ મ ાં પ્ર પત કરી શક ર્ છે. દ ભ વષર્ો વ chuyện với một thông dịch viên, vui lòng gọi số ત કરર મ ટે,આ 1-877-806-9284 TTY:711 પર કોલ કરો. 1-877-806-9284 TTY:711.

IN-EXCM-0429 © 2016 CareSource. All Rights Reserved Notice of Non-Discrimination

CareSource complies with applicable state and federal civil rights laws and does not discriminate on the basis of age, gender, gender identity, color, race, disability, national origin, marital status, sexual preference, religious affiliation, health status, or public assistance status. CareSource does not exclude people or treat them differently because of age, gender, gender identity, color, race, disability, national origin, marital status, sexual preference, religious affiliation, health status, or public assistance status.

CareSource provides free aids and services to people with disabilities to communicate effectively with us, such as: (1) qualified sign language interpreters, and (2) written information in other formats (large print, audio, accessible electronic formats, other formats). In addition, CareSource provides free language services to people whose primary language is not English, such as: (1) qualified interpreters, and (2) information written in other languages. If you need these services, please contact CareSource at 1-877-806-9284 TTY:711.

If you believe that CareSource has failed to provide the above mentioned services to you or discriminated in another way on the basis of age, gender, gender identity, color, race, disability, national origin, marital status, sexual preference, religious affiliation, health status, or public assistance status, you may file a grievance, with:

CareSource Attn: Civil Rights Coordinator P.O. Box 1947, Dayton, Ohio 45401 1-844-539-1732, TTY: 711 Fax: 1-844-417-6254

[email protected]

You can file a grievance by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You may also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office of Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. CareSource.com/marketplace

INb -V.11 © 2018 CareSource.CareSource. AllAll Rights Rights Reserved. Reserved.