MICHILD – CHILDREN’S SPECIAL HEALTH CARE SERVICES (CSHCS) FORMULARY Effective July 2015

Provided by EnvisionRxOptions

Introduction

The Total Health Care (THC) MIChild – Children’s Special Health Care Services (CSHCS) Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management.

Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications.

Notice

The information contained in this formulary is provided by THC, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature.

This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes 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.

How to Read the Formulary

Drug Name

All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. The brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any drug not found in this Formulary listing shall be considered a non-formulary drug.

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Requirements/Limits

This field includes potential limitations to the formulary drug. It also may contain additional information about the coverage of the drug such as applicable quantity limits (QL). For certain agents within the MIChild-CSHCS Formulary, a recommended prescribing guideline may apply.

Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include:

Prior Authorization Drug requires prior authorization through a specific physician request Required (PA) process.

Over the Counter Drugs Drug coverage is available for drugs that are available OTC with an (OTC) authorized prescription from your provider.

Specialty Drugs (SP) Drug requires processing through THC’s contracted specialty pharmacy, Diplomat Specialty Pharmacy.

Quantity Limit (QL) Drug coverage may be limited to specific quantities per prescription and/or time period.

Age Limit (AL) Drug coverage may depend on patient age.

Gender Restriction (GR) Drug coverage may depend on patient gender.

Step Therapy Required Drug coverage requires that an alternative or trial of another drug be (ST) used before the medication is covered.

Custom (C) Drug coverage has unique restrictions.

Benefit Coverage and Limitations

This formulary does not define benefit coverage and limitations. Members should contact Total Health Care at 1-800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year.

Prior Authorization (PA)

Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-877-503-7231. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health

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Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request.

Non-Formulary Agents

Drugs not found on the Total Health Care MIChild - CSHCS Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non- formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review:

. The patient has failed an appropriate trial of formulary or preferred agents. . The use of preferred or formulary agent is contraindicated in the patient. . The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety.

If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action.

Common Drug Exclusions

The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverage may include, but are not limited to:

. Drug products used for cosmetic purposes. . Drug products for erectile dysfunction. . Drug products for infertility treatment. . Experimental drug products or any drug product used in an experimental manner. . Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).

MICHILD - CSHCS Fee-For-Service Carve Out List

The State of Michigan has a carve-out list for the CSHCS formulary. The carve-out drugs include HIV/AIDS, Oncology, Hemophilia and other miscellaneous drugs that have been added to the State's 100% carve-out list. These drugs must be billed directly by the pharmacies at point-of-sale to the Michigan Department of Community Health's contracted Pharmacy Benefits Manager (PBM). A list of the carve-out drugs can be found at https://michigan.fhsc.com/Providers/DrugInfo.asp.

Mandated Generic Substitution

Total Health Care advocates the use of cost-effective generic drugs where FDA- approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted as “generic” wherever an FDA- approved generic drug product is available. The brand names listed in the formulary are for reference only.

Total Health Care Pharmacy and Therapeutics (P&T) Committee

Total Health Care’s Pharmacy & Therapeutic Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians,

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pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel.

Product Selection Criteria

The primary goal of the THC Pharmacy & Therapeutic Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862.

Diabetic Testing Supplies

Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933.

Specialty Bio-Pharmaceutical Pharmacy Program

Total Health Care works with Diplomat Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Diplomat Specialty Pharmacy.

A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRxOptions at 1- 877-503-7231 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com.

Once the order is received, EnvisionRxOptions obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Diplomat Specialty Pharmacy. Then, the Diplomat Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRxOptions at 1-844-222- 5584 or Diplomat Specialty Pharmacy at 1-877-977-9118.

Contact Information

The Total Health Care MIChild-CSHCS formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at 1-800-826-2862.

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Medication Limitations

Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of therapy.

Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit.

Gender Restrictions Gender restrictions are indicated with a “GR” on the formulary and require the member to be a specific gender for coverage.

Step Therapy Criteria Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled.

Step-Therapy Criteria Therapy Class First Line Second Line Step Therapy Criteria

Antibiotics Amoxicillin, Cefadroxil, Prior use of Amoxicillin, Ampicillin, Cefaclor, Ampicillin, Amoxicillin & Amoxicillin & Cefprozil Clavulanate, Cefpodoxime, Clavulanate, Cefdinir, Cefuroxime, Cefpodoxime, Cephalexin, Ciprofloxacin, Cefdinir, Clindamycin, Dicloxacillin, Cefuroxime, Doxycycline, Erythromycin, Cephalexin, Penicillin, Ciprofloxacin, Sulfamethoxazole- Clindamycin, Trimethoprim or Dicloxacillin, Tetracycline in the last 30 Doxycycline, days Erythromycin, Penicillin, Sulfamethoxazole- Trimethoprim, Tetracycline Antidiabetic Agents Metformin Januvia, Prior use of Metformin in Janumet the last 90 days Attention Amphetamine Immediate- Amphetamine Prior use of Amphetamine Deficit/Hyperactivity Release Extended-Release Immediate-Release for 60 days within the last 90 days Antipsychotic Agents Risperidone Quetiapine Prior use of Quetiapine Immediate-Release within the last 90 days. Benign Prostatic Doxazosin Immediate- Alfuzosin Prior use of Doxazosin Hypertrophy agents Release, Immediate-Release, v

Finasteride, Finasteride, Tamsulosin or Tamsulosin, Terazosin in the last 90 days Terazosin Glucocorticoid Inhaler Qvar Dulera, Prior use of Qvar within the Symbicort, last 90 days. Advair Diskus 100/50 Pediculicides Lice-B-Gone Kit, Malathion Lotion Prior use of Lice-B-Gone Lice-B-Gone Shampoo, Kit, Lice-B-Gone Shampoo, Pyrethrins-Piperonyl Pyrethrins-Piperonyl Butoxide Liquid, Butoxide Liquid, Permethrin Permethrin Spray & Spray & Pyrethins- Pyrethins-Piperonyl Piperonyl Butoxide Butoxide Shampoo Kit Shampoo Kit in the last 30 days Urinary Antispasmodics Oxybutynin, Oxybutynin Prior use of Oxytrol OTC or Oxybutynin Syrup, Extended -Release, Oxybutynin/Oxybutynin Oxytrol OTC Tolterodine, Syrup in the last 90 days. Tolterodine Extended-Release

*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRxOptions. The presence of a medication on this formulary list does not guarantee coverage.

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LIST OF COVERED PRESCRIPTION MEDICATIONS

DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ANALGESICS (PAIN, INFLAMMATION, MUSCLE, JOINT CONDITIONS DRUGS)

Nonsteroidal Anti-inflammatory Drugs (PAIN, ANTI-INFLAMMATORY DRUGS)

diclofenac potassium tab 50 mg diclofenac sodium tab delayed release 25 mg diclofenac sodium tab delayed release 50 mg diclofenac sodium tab delayed release 75 mg diclofenac sodium tab sr 24hr 100 mg diflunisal tab 500 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg FENOPROFEN CALCIUM TAB 600 MG fenoprofen calcium flurbiprofen tab 100 mg flurbiprofen tab 50 mg ibuprofen susp 100 mg/5ml ibuprofen tab 200 mg ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg indomethacin cap 25 mg indomethacin cap 50 mg ketoprofen cap 50 mg

ketoprofen cap 75 mg QL 120 / 30 days

ketorolac tromethamine tab 10 mg QL 20 / 5 days

PAGE 7 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS MECLOFENAMATE SODIUM CAP 50 MG meclofenamate sodium meloxicam tab 15 mg meloxicam tab 7.5 mg

nabumetone tab 500 mg QL 120 / 30 days

nabumetone tab 750 mg QL 60 / 30 days

naproxen sodium tab 220 mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml NAPROXEN SUSPENSION 125 MG/5ML naproxen naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg naproxen tab ec 375 mg oxaprozin tab 600 mg piroxicam cap 10 mg piroxicam cap 20 mg sulindac tab 150 mg sulindac tab 200 mg Opioid Analgesics, Long-acting (NARCOTIC PAIN RELIEVERS)

QL 10 / 30 days fentanyl td patch 72hr 100 mcg/hr PA

QL 10 / 30 days fentanyl td patch 72hr 12 mcg/hr PA

QL 10 / 30 days fentanyl td patch 72hr 25 mcg/hr PA

QL 10 / 30 days fentanyl td patch 72hr 50 mcg/hr PA

QL 10 / 30 days fentanyl td patch 72hr 75 mcg/hr PA

PAGE 8 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS methadone hcl soln 10 mg/5ml methadone hcl soln 5 mg/5ml METHADONE HCL SOLUTION 10 MG/5ML methadone hcl METHADONE HCL SOLUTION 5 MG/5ML methadone hcl

methadone hcl tab 10 mg QL 240 / 30 days

methadone hcl tab 5 mg MORPHINE SULFATE TAB 15 MG QL 180 / 30 days morphine sulfate MORPHINE SULFATE TAB 30 MG QL 180 / 30 days morphine sulfate

morphine sulfate tab cr 100 mg QL 90 / 30 days

morphine sulfate tab cr 15 mg QL 90 / 30 days

morphine sulfate tab cr 30 mg QL 90 / 30 days

morphine sulfate tab cr 60 mg QL 90 / 30 days

Opioid Analgesics, Short-Acting ( NARCOTIC PAIN RELIEVERS)

acetaminophen w/ codeine soln 120-12 mg/5ml

acetaminophen w/ codeine tab 300-15 mg QL 390 / 30 days

acetaminophen w/ codeine tab 300-30 mg QL 390 / 30 days

acetaminophen w/ codeine tab 300-60 mg QL 390 / 30 days

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg codeine sulfate tab 30 mg CODEINE SULFATE TAB 30 MG codeine sulfate codeine sulfate tab 60 mg CODEINE SULFATE TAB 60 MG codeine sulfate

hydrocodone-acetaminophen soln 10-325 mg/15ml QL 900 / 90 days

hydrocodone-acetaminophen soln 7.5-325 mg/15ml QL 900 / 90 days

HYDROCODONE-ACETAMINOPHEN SOLUTION 10-325 MG/15ML QL 900 / 90 days hydrocodone-acetaminophen

PAGE 9 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

hydrocodone-acetaminophen tab 10-325 mg QL 180 / 30 days

hydrocodone-acetaminophen tab 10-500 mg hydrocodone-acetaminophen tab 10-650 mg hydrocodone-acetaminophen tab 10-660 mg hydrocodone-acetaminophen tab 2.5-500 mg

hydrocodone-acetaminophen tab 5-325 mg QL 360 / 30 days

hydrocodone-acetaminophen tab 5-500 mg

hydrocodone-acetaminophen tab 7.5-325 mg QL 180 / 30 days

hydrocodone-acetaminophen tab 7.5-500 mg HYDROCODONE-ACETAMINOPHEN TAB 7.5-500 MG hydrocodone-acetaminophen hydrocodone-acetaminophen tab 7.5-650 mg HYDROCODONE-ACETAMINOPHEN TAB 7.5-650 MG hydrocodone-acetaminophen hydrocodone-acetaminophen tab 7.5-750 mg HYDROCODONE-ACETAMINOPHEN TAB 7.5-750 MG hydrocodone-acetaminophen

hydromorphone hcl tab 2 mg QL 240 / 30 days

hydromorphone hcl tab 4 mg QL 240 / 30 days

hydromorphone hcl tab 8 mg QL 240 / 30 days

LORTAB ELIXIR 10-300 MG/15ML QL 900 / 90 days hydrocodone-acetaminophen morphine sulfate (concentrate) oral soln 20 mg/ml MORPHINE SULFATE (CONCENTRATE) SOLUTION 20 MG/ML morphine sulfate morphine sulfate oral soln 10 mg/5ml morphine sulfate oral soln 20 mg/5ml oxycodone hcl soln 5 mg/5ml OXYCODONE HCL SOLUTION 5 MG/5ML oxycodone hcl

oxycodone hcl tab 15 mg QL 180 / 30 days

oxycodone hcl tab 30 mg QL 180 / 30 days

PAGE 10 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

oxycodone hcl tab 5 mg QL 180 / 30 days

oxycodone w/ acetaminophen tab 10-325 mg QL 180 / 30 days

oxycodone w/ acetaminophen tab 10-650 mg

oxycodone w/ acetaminophen tab 5-325 mg QL 360 / 30 days

oxycodone w/ acetaminophen tab 7.5-325 mg QL 180 / 30 days

oxycodone w/ acetaminophen tab 7.5-500 mg oxycodone-aspirin tab 4.8355-325 mg ROXICET TAB 5-500 MG oxycodone w/ acetaminophen

tramadol hcl tab 50 mg QL 240 / 30 days

ZAMICET SOLUTION 10-325 MG/15ML QL 900 / 90 days hydrocodone-acetaminophen Anesthetics

LOCAL ANESTHETICS (LOCAL NUMBING DRUGS)

lidocaine hcl cream 3% QL 85 / 30 days

lidocaine hcl gel 2% lidocaine hcl laryngotracheal soln 4% lidocaine hcl local inj 4% lidocaine hcl soln 4% lidocaine hcl viscous soln 2%

lidocaine-prilocaine cream 2.5-2.5% QL 30 / 30 days

Anti-Addiction/Substance Abuse Treatment Agents (NERVE CONDITIONS DRUGS)

Smoking Cessation Agents (DEPRESSION DRUGS)

bupropion hcl (smoking deterrent) tab sr 12hr 150 mg QL 180 / 365 days

QL 60 / 30 days

CHANTIX CONTINUING MONTH PAK TAB 1 MG PA varenicline tartrate C 90 days of coverage per year

QL 60 / 30 days

CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1 MG X 42 PA varenicline tartrate C 90 days of coverage per year

PAGE 11 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

QL 60 / 30 days

CHANTIX TAB 0.5 MG PA varenicline tartrate C 90 days of coverage per year

QL 60 / 30 days

CHANTIX TAB 1 MG PA varenicline tartrate C 90 days of coverage per year NICOTROL NS SOLUTION 10 MG/ML C 90 days of coverage nicotine per year Antibacterials (INFECTION FIGHTING DRUGS)

Aminoglycosides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))

GENTAMICIN SULFATE CREAM 0.1 % gentamicin sulfate (topical) gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% GENTAMICIN SULFATE OINTMENT 0.1 % gentamicin sulfate (topical) gentamicin sulfate ophth oint 0.3% gentamicin sulfate ophth soln 0.3% neomycin sulfate tab 500 mg tobramycin ophth soln 0.3% Antibacterials, Other (MISCELLANEOUS INFECTION FIGHTING DRUGS)

BACITRACIN OINTMENT 500 UNIT/GM bacitracin (ophthalmic) bacitracin-polymyxin b ophth oint bacitracin-polymyxin-neomycin-hc ophth oint 1% CLEOCIN SUPPOS 100 MG clindamycin phosphate vaginal clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin hcl cap 75 mg clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) clindamycin phosphate vaginal cream 2%

PAGE 12 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS CURITY ALCOHOL PREPS PAD 70 % alcohol swabs MACRODANTIN CAP 25 MG nitrofurantoin macrocrystal methenamine hippurate tab 1 gm METHENAMINE MANDELATE TAB 0.5 GM methenamine mandelate methenamine mandelate tab 1 gm metronidazole cream 0.75% metronidazole gel 0.75% metronidazole lotion 0.75% metronidazole tab 250 mg metronidazole tab 500 mg metronidazole vaginal gel 0.75% mupirocin calcium cream 2% mupirocin oint 2% neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml NEOMYCIN-POLYMYXIN-HC SUSPENSION 3.5-10000-1 neomycin-polymyxin-hc (ophth)

nitrofurantoin macrocrystalline cap 100 mg QL 60 / 30 days

nitrofurantoin macrocrystalline cap 50 mg QL 60 / 30 days

nitrofurantoin monohydrate macrocrystalline cap 100 mg QL 60 / 30 days

polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% silver sulfadiazine cream 1%

trimethoprim tab 100 mg QL 60 / 30 days

vancomycin hcl for inj 10 gm vancomycin hcl for inj 1000 mg vancomycin hcl for inj 500 mg vancomycin hcl for inj 5000 mg VANCOMYCIN HCL RECON SOLN 750 MG vancomycin hcl

PAGE 13 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS Beta-lactam, Cephalosporins (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))

cefaclor cap 250 mg ST

cefaclor cap 500 mg ST

CEFACLOR RECON SUSP 125 MG/5ML ST cefaclor CEFACLOR RECON SUSP 250 MG/5ML ST cefaclor CEFACLOR RECON SUSP 375 MG/5ML ST cefaclor

QL 40 / 10 days cefadroxil cap 500 mg ST

cefadroxil for susp 250 mg/5ml ST

cefadroxil for susp 500 mg/5ml ST

QL 20 / 10 days cefadroxil tab 1 gm ST

cefdinir cap 300 mg

cefdinir for susp 125 mg/5ml AL Up to 11 yrs old

cefdinir for susp 250 mg/5ml AL Up to 11 yrs old

cefpodoxime proxetil for susp 100 mg/5ml cefpodoxime proxetil for susp 50 mg/5ml

cefpodoxime proxetil tab 100 mg QL 60 / 30 days

cefpodoxime proxetil tab 200 mg QL 60 / 30 days

cefprozil for susp 125 mg/5ml ST

cefprozil for susp 250 mg/5ml ST

QL 60 / 30 days cefprozil tab 250 mg ST

QL 60 / 30 days cefprozil tab 500 mg ST

ceftriaxone sodium for inj 1 gm QL 10 / 30 days

ceftriaxone sodium for inj 250 mg QL 10 / 30 days

PAGE 14 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

ceftriaxone sodium for inj 500 mg QL 10 / 30 days

ceftriaxone sodium for iv soln 1 gm QL 10 / 30 days

cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5ml cephalexin for susp 250 mg/5ml Beta-lactam, Other (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))

DORIBAX RECON SOLN 250 MG doripenem DORIBAX RECON SOLN 500 MG doripenem Beta-lactam, Penicillins (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))

amoxicillin & k clavulanate chew tab 200-28.5 mg amoxicillin & k clavulanate chew tab 400-57 mg amoxicillin & k clavulanate for susp 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 400-57 mg/5ml amoxicillin & k clavulanate for susp 600-42.9 mg/5ml

amoxicillin & k clavulanate tab 250-125 mg QL 42 / 14 days

amoxicillin & k clavulanate tab 500-125 mg QL 28 / 14 days

amoxicillin & k clavulanate tab 875-125 mg QL 28 / 14 days

amoxicillin (trihydrate) cap 250 mg amoxicillin (trihydrate) cap 500 mg amoxicillin (trihydrate) chew tab 250 mg amoxicillin (trihydrate) for susp 125 mg/5ml amoxicillin (trihydrate) for susp 200 mg/5ml amoxicillin (trihydrate) for susp 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml amoxicillin (trihydrate) tab 500 mg amoxicillin (trihydrate) tab 875 mg

PAGE 15 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS AMOXICILLIN CHEW TAB 125 MG amoxicillin AMOXICILLIN CHEW TAB 250 MG amoxicillin ampicillin cap 250 mg ampicillin cap 500 mg BICILLIN C-R 900/300 SUSPENSION 900000-300000 UNIT/2ML QL 4 / 28 days penicillin g benzathine & procaine BICILLIN C-R SUSPENSION 1200000 UNIT/2ML QL 4 / 28 days penicillin g benzathine & procaine dicloxacillin sodium cap 250 mg dicloxacillin sodium cap 500 mg penicillin v potassium for soln 125 mg/5ml penicillin v potassium for soln 250 mg/5ml penicillin v potassium tab 250 mg penicillin v potassium tab 500 mg Macrolides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))

azithromycin for susp 100 mg/5ml azithromycin for susp 200 mg/5ml

azithromycin tab 250 mg QL 12 / 30 days

azithromycin tab 500 mg QL 6 / 30 days

azithromycin tab 600 mg QL 60 / 30 days

clarithromycin for susp 125 mg/5ml clarithromycin for susp 250 mg/5ml clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab sr 24hr 500 mg erythromycin gel 2% erythromycin ophth oint 5 mg/gm erythromycin soln 2% erythromycin-sulfisoxazole for susp 200-600 mg/5ml

PAGE 16 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS Quinolones (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))

ciprofloxacin hcl ophth soln 0.3% ciprofloxacin hcl tab 250 mg (base equiv) ciprofloxacin hcl tab 500 mg (base equiv) ciprofloxacin hcl tab 750 mg (base equiv)

levofloxacin tab 250 mg QL 14 / 14 days

levofloxacin tab 500 mg QL 14 / 14 days

levofloxacin tab 750 mg QL 14 / 14 days

ofloxacin ophth soln 0.3% ofloxacin otic soln 0.3%

ofloxacin tab 200 mg QL 60 / 30 days

ofloxacin tab 300 mg QL 60 / 30 days

ofloxacin tab 400 mg QL 60 / 30 days

OFLOXACIN TAB 400 MG QL 60 / 30 days ofloxacin Sulfonamides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))

BLEPHAMIDE S.O.P. OINTMENT 10-0.2 % sulfacetamide sod-prednisolone BLEPHAMIDE SUSPENSION 10-0.2 % sulfacetamide sod-prednisolone sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% SULFADIAZINE TAB 500 MG sulfadiazine sulfamethoxazole-trimethoprim susp 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 mg sulfamethoxazole-trimethoprim tab 800-160 mg Tetracyclines (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))

doxycycline hyclate cap 100 mg doxycycline hyclate cap 50 mg doxycycline hyclate tab 100 mg doxycycline monohydrate for susp 25 mg/5ml

PAGE 17 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS minocycline hcl cap 100 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg Anticonvulsants (NERVE CONDITIONS DRUGS)

Anticonvulsants, Other (SEIZURE CONTROL DRUGS)

levetiracetam oral soln 100 mg/ml

levetiracetam tab 1000 mg QL 90 / 30 days

levetiracetam tab 250 mg

levetiracetam tab 500 mg QL 180 / 30 days

levetiracetam tab 750 mg QL 120 / 30 days

phenobarbital elixir 20 mg/5ml phenobarbital tab 100 mg PHENOBARBITAL TAB 100 MG phenobarbital phenobarbital tab 15 mg PHENOBARBITAL TAB 15 MG phenobarbital phenobarbital tab 16.2 mg phenobarbital tab 30 mg PHENOBARBITAL TAB 30 MG phenobarbital phenobarbital tab 32.4 mg phenobarbital tab 60 mg PHENOBARBITAL TAB 60 MG phenobarbital phenobarbital tab 64.8 mg phenobarbital tab 97.2 mg Calcium Channel Modifying Agents (SEIZURES CONTROL DRUGS)

ethosuximide cap 250 mg ethosuximide soln 250 mg/5ml

zonisamide cap 100 mg QL 180 / 30 days

zonisamide cap 25 mg QL 30 / 30 days

PAGE 18 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

zonisamide cap 50 mg QL 30 / 30 days

Gamma-aminobutyric Acid (GABA) Augmenting Agents (SEIZURES CONTROL DRUGS)

clonazepam tab 0.5 mg clonazepam tab 1 mg clonazepam tab 2 mg DIAZEPAM GEL 2.5 MG QL 2 / 30 days diazepam (anticonvulsant) divalproex sodium cap sprinkle 125 mg divalproex sodium tab delayed release 125 mg divalproex sodium tab delayed release 250 mg divalproex sodium tab delayed release 500 mg divalproex sodium tab sr 24 hr 250 mg divalproex sodium tab sr 24 hr 500 mg gabapentin cap 100 mg gabapentin cap 300 mg gabapentin cap 400 mg gabapentin oral soln 250 mg/5ml gabapentin tab 600 mg gabapentin tab 800 mg primidone tab 250 mg primidone tab 50 mg valproate sodium syrup 250 mg/5ml (base equiv) Glutamate Reducing Agents (SEIZURES CONTROL DRUGS)

lamotrigine tab 100 mg lamotrigine tab 150 mg lamotrigine tab 200 mg lamotrigine tab 25 mg lamotrigine tab chewable dispersible 25 mg lamotrigine tab chewable dispersible 5 mg topiramate sprinkle cap 15 mg topiramate sprinkle cap 25 mg

PAGE 19 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS topiramate tab 100 mg topiramate tab 200 mg topiramate tab 25 mg topiramate tab 50 mg Sodium Channel Agents (SEIZURES CONTROL DRUGS)

carbamazepine cap sr 12hr 300 mg carbamazepine chew tab 100 mg carbamazepine susp 100 mg/5ml carbamazepine tab 200 mg carbamazepine tab sr 12hr 200 mg carbamazepine tab sr 12hr 400 mg fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) oxcarbazepine tab 150 mg oxcarbazepine tab 300 mg oxcarbazepine tab 600 mg phenytoin chew tab 50 mg phenytoin sodium extended cap 100 mg

phenytoin susp 125 mg/5ml QL 750 / 30 days

Antidepressants (NERVE CONDITIONS DRUGS)

Antidepressants, Other (DEPRESSION DRUGS)

bupropion hcl tab 100 mg bupropion hcl tab 75 mg bupropion hcl tab sr 12hr 100 mg bupropion hcl tab sr 12hr 150 mg bupropion hcl tab sr 12hr 200 mg bupropion hcl tab sr 24hr 150 mg bupropion hcl tab sr 24hr 300 mg mirtazapine tab 15 mg mirtazapine tab 30 mg mirtazapine tab 45 mg

PAGE 20 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS trazodone hcl tab 100 mg trazodone hcl tab 150 mg trazodone hcl tab 300 mg trazodone hcl tab 50 mg Monoamine Oxidase Inhibitors (DEPRESSION DRUGS)

phenelzine sulfate tab 15 mg

tranylcypromine sulfate tab 10 mg PA

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor (DEPRESSION)

citalopram hydrobromide tab 10 mg (base equiv) QL 51 / 30 days

citalopram hydrobromide tab 20 mg (base equiv) QL 51 / 30 days

citalopram hydrobromide tab 40 mg (base equiv)

duloxetine hcl enteric coated pellets cap 20 mg QL 30 / 30 days

duloxetine hcl enteric coated pellets cap 30 mg QL 30 / 30 days

duloxetine hcl enteric coated pellets cap 60 mg QL 30 / 30 days

escitalopram oxalate tab 10 mg (base equiv) QL 45 / 30 days

escitalopram oxalate tab 20 mg (base equiv) QL 30 / 30 days

escitalopram oxalate tab 5 mg (base equiv) QL 45 / 30 days

fluoxetine hcl cap 10 mg fluoxetine hcl cap 20 mg fluoxetine hcl cap 40 mg fluoxetine hcl solution 20 mg/5ml fluoxetine hcl tab 10 mg fluoxetine hcl tab 20 mg fluvoxamine maleate tab 100 mg fluvoxamine maleate tab 25 mg fluvoxamine maleate tab 50 mg paroxetine hcl tab 10 mg paroxetine hcl tab 20 mg paroxetine hcl tab 30 mg

PAGE 21 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS paroxetine hcl tab 40 mg sertraline hcl tab 100 mg sertraline hcl tab 25 mg sertraline hcl tab 50 mg venlafaxine hcl cap sr 24hr 150 mg (base equivalent) venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) venlafaxine hcl cap sr 24hr 75 mg (base equivalent) venlafaxine hcl tab 100 mg venlafaxine hcl tab 25 mg venlafaxine hcl tab 37.5 mg venlafaxine hcl tab 50 mg venlafaxine hcl tab 75 mg Tricyclics (DEPRESSION DRUGS)

amitriptyline hcl tab 10 mg amitriptyline hcl tab 100 mg amitriptyline hcl tab 150 mg amitriptyline hcl tab 25 mg amitriptyline hcl tab 50 mg amitriptyline hcl tab 75 mg AMOXAPINE TAB 100 MG amoxapine AMOXAPINE TAB 150 MG amoxapine AMOXAPINE TAB 25 MG amoxapine AMOXAPINE TAB 50 MG amoxapine clomipramine hcl cap 75 mg imipramine hcl tab 10 mg imipramine hcl tab 25 mg imipramine hcl tab 50 mg nortriptyline hcl cap 10 mg nortriptyline hcl cap 25 mg

PAGE 22 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS nortriptyline hcl cap 50 mg nortriptyline hcl cap 75 mg nortriptyline hcl soln 10 mg/5ml NORTRIPTYLINE HCL SOLUTION 10 MG/5ML nortriptyline hcl trimipramine maleate cap 100 mg trimipramine maleate cap 25 mg trimipramine maleate cap 50 mg Antiemetics (BOWEL, INSTESTINE, AND STOMACH CONDITIONS DRUGS)

ANTIEMETICS, Other (NAUSEA AND VOMITING DRUGS)

meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg meclizine hcl tab 32 mg

promethazine hcl suppos 12.5 mg QL 28 / 14 days

promethazine hcl suppos 25 mg QL 28 / 14 days

promethazine hcl suppos 50 mg QL 28 / 14 days

promethazine hcl syrup 6.25 mg/5ml promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg trimethobenzamide hcl cap 300 mg Emetogenic Therapy Adjuncts (NAUSEA AND VOMITING DRUGS)

dronabinol cap 10 mg PA

dronabinol cap 2.5 mg PA

dronabinol cap 5 mg PA

ondansetron hcl oral soln 4 mg/5ml QL 50 / 30 days

ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron orally disintegrating tab 4 mg ondansetron orally disintegrating tab 8 mg

PAGE 23 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ANTIFUNGALS (FUNGUS INFECTION DRUGS)

*nystatin topical powder**

ciclopirox solution 8% QL 6.6 / 30 days

clotrimazole soln 1% clotrimazole troche 10 mg econazole nitrate cream 1% fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml

fluconazole tab 100 mg QL 30 / 30 days

fluconazole tab 150 mg QL 4 / 30 days

fluconazole tab 200 mg QL 30 / 30 days

fluconazole tab 50 mg QL 30 / 30 days

griseofulvin microsize susp 125 mg/5ml griseofulvin microsize tab 500 mg griseofulvin ultramicrosize tab 125 mg griseofulvin ultramicrosize tab 250 mg ketoconazole cream 2% ketoconazole shampoo 2% ketoconazole tab 200 mg MICONAZOLE 3 SUPPOS 200 MG miconazole nitrate vaginal miconazole nitrate vaginal suppos 100 mg nystatin cream 100000 unit/gm nystatin oint 100000 unit/gm NYSTATIN POWDER nystatin (topical) nystatin susp 100000 unit/ml nystatin tab 500000 unit nystatin-triamcinolone cream 100000-0.1 unit/gm-% nystatin-triamcinolone oint 100000-0.1 unit/gm-% terbinafine hcl tab 250 mg

PAGE 24 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS terconazole vaginal cream 0.4% terconazole vaginal cream 0.8% terconazole vaginal suppos 80 mg Antigout Agents (GOUT DRUGS)

allopurinol tab 100 mg allopurinol tab 300 mg COLCHICINE TAB 0.6 MG QL 20 / 30 days colchicine colchicine w/ probenecid tab 0.5-500 mg probenecid tab 500 mg Antimigraine Agents (NERVE CONDITIONS DRUGS)

Prophylactic (MIGRAINE DRUGS)

TIMOLOL MALEATE TAB 10 MG timolol maleate TIMOLOL MALEATE TAB 20 MG timolol maleate TIMOLOL MALEATE TAB 5 MG timolol maleate valproic acid cap 250 mg Serotonin (5-HT) 1b/1d Receptor Agonists (MIGRAINE DRUGS)

sumatriptan succinate tab 100 mg QL 9 / 30 days

sumatriptan succinate tab 25 mg QL 9 / 30 days

sumatriptan succinate tab 50 mg QL 9 / 30 days

Antimycobacterials (INFECTION FIGHTING DRUGS)

Antimycobacterials, Other (MISCELLANEOUS INFECTION FIGHTING DRUGS)

DAPSONE TAB 100 MG dapsone DAPSONE TAB 25 MG dapsone Antituberculars

ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg

PAGE 25 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS isoniazid tab 100 mg isoniazid tab 300 mg pyrazinamide tab 500 mg rifampin cap 150 mg rifampin cap 300 mg RIFATER TAB 50-120-300 MG isoniazid-rifampin w/ pyrazinamide TRECATOR TAB 250 MG ethionamide ANTINEOPLASTICS (CANCER DRUGS)

ALKYLATING AGENTS (CHEMOTHERAPY DRUGS)

CYCLOPHOSPHAMIDE TAB 25 MG cyclophosphamide CYCLOPHOSPHAMIDE TAB 50 MG cyclophosphamide HEXALEN CAP 50 MG PA altretamine LEUKERAN TAB 2 MG PA chlorambucil LOMUSTINE CAP 10 MG PA lomustine LOMUSTINE CAP 100 MG PA lomustine LOMUSTINE CAP 40 MG PA lomustine MATULANE CAP 50 MG PA procarbazine hcl Antiandrogens (CANCER DRUGS)

bicalutamide tab 50 mg

flutamide cap 125 mg PA

Antiestrogens/Modifiers (CANCER DRUGS)

PA

tamoxifen citrate tab 10 mg (base equivalent) GL Female

AL At least 35 yrs old

PAGE 26 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

PA

tamoxifen citrate tab 20 mg (base equivalent) GL Female

AL At least 35 yrs old

ANTIMETABOLITES (CHEMOTHERAPY DRUGS)

hydroxyurea cap 500 mg mercaptopurine tab 50 mg TABLOID TAB 40 MG PA thioguanine Antineoplastics, Other (CANCER DRUGS)

CYCLOPHOSPHAMIDE CAP 25 MG cyclophosphamide CYCLOPHOSPHAMIDE CAP 50 MG cyclophosphamide LEUCOVORIN CALCIUM TAB 15 MG leucovorin calcium leucovorin calcium tab 25 mg leucovorin calcium tab 5 mg MENEST TAB 0.3 MG GL Female esterified estrogens MENEST TAB 0.625 MG GL Female esterified estrogens MENEST TAB 1.25 MG GL Female esterified estrogens MENEST TAB 2.5 MG GL Female esterified estrogens Aromatase Inhibitors, 3rd Generation (HORMONAL CHEMOTHERAPY DRUGS)

anastrozole tab 1 mg GL Female

QL 30 / 30 days letrozole tab 2.5 mg AL At least 18 yrs old

Retinoids (CANCER DRUGS)

tretinoin cap 10 mg PA

PAGE 27 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ANTIPARASITICS (INFECTION FIGHTING DRUGS)

Antiprotozoals (MALARIA DRUGS)

atovaquone susp 750 mg/5ml QL 210 / 18 days

chloroquine phosphate tab 250 mg PA

DARAPRIM TAB 25 MG QL 6 / 30 days pyrimethamine hydroxychloroquine sulfate tab 200 mg

mefloquine hcl tab 250 mg QL 5 / 30 days

PRIMAQUINE PHOSPHATE TAB 26.3 MG QL 14 / 30 days primaquine phosphate quinine sulfate cap 324 mg Pediculicides/Scabicides (SCABIES DRUGS)

EURAX CREAM 10 % QL 120 / 365 days crotamiton EURAX LOTION 10 % QL 120 / 365 days crotamiton lindane lotion 1% lindane shampoo 1%

malathion lotion 0.5% ST

OVIDE LOTION 0.5 % ST malathion

permethrin cream 5% QL 120 / 30 days

Antiparkinson Agents (NERVE CONDITIONS DRUGS)

'Dopamine Agonists (PARKINSON'S DISEASE DRUGS)'

pramipexole dihydrochloride tab 0.125 mg Antipsychotics (NERVE CONDITIONS DRUGS)

1st Generation/Typical (MOOD DISORDER DRUGS)

chlorpromazine hcl tab 10 mg chlorpromazine hcl tab 100 mg chlorpromazine hcl tab 200 mg chlorpromazine hcl tab 25 mg

PAGE 28 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS chlorpromazine hcl tab 50 mg FLUPHENAZINE HCL CONC 5 MG/ML fluphenazine hcl FLUPHENAZINE HCL ELIXIR 2.5 MG/5ML fluphenazine hcl FLUPHENAZINE HCL SOLUTION 2.5 MG/ML fluphenazine hcl fluphenazine hcl tab 1 mg fluphenazine hcl tab 10 mg fluphenazine hcl tab 2.5 mg fluphenazine hcl tab 5 mg haloperidol decanoate im soln 100 mg/ml haloperidol tab 0.5 mg haloperidol tab 1 mg haloperidol tab 10 mg haloperidol tab 2 mg haloperidol tab 20 mg haloperidol tab 5 mg loxapine succinate cap 10 mg loxapine succinate cap 25 mg loxapine succinate cap 5 mg loxapine succinate cap 50 mg perphenazine tab 16 mg perphenazine tab 2 mg perphenazine tab 4 mg perphenazine tab 8 mg prochlorperazine maleate tab 10 mg (base equivalent) prochlorperazine maleate tab 5 mg (base equivalent)

prochlorperazine suppos 25 mg QL 60 / 30 days

thiothixene cap 1 mg thiothixene cap 10 mg thiothixene cap 2 mg

PAGE 29 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS thiothixene cap 5 mg trifluoperazine hcl tab 1 mg trifluoperazine hcl tab 10 mg trifluoperazine hcl tab 2 mg trifluoperazine hcl tab 5 mg 2nd Generation/Atypical (MOOD DISORDER DRUGS)

quetiapine fumarate tab 100 mg ST

quetiapine fumarate tab 200 mg ST

quetiapine fumarate tab 25 mg ST

quetiapine fumarate tab 300 mg ST

quetiapine fumarate tab 400 mg ST

quetiapine fumarate tab 50 mg ST

risperidone tab 0.25 mg risperidone tab 0.5 mg risperidone tab 1 mg risperidone tab 2 mg risperidone tab 3 mg risperidone tab 4 mg

ziprasidone hcl cap 20 mg ST

ziprasidone hcl cap 40 mg ST

ziprasidone hcl cap 60 mg ST

ziprasidone hcl cap 80 mg ST

Treatment-Resistant (MOOD DISORDER DRUGS)

clozapine tab 100 mg clozapine tab 200 mg clozapine tab 25 mg clozapine tab 50 mg

PAGE 30 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS Antispasticity Agents (MUSCLE AND JOINT DRUGS)

baclofen tab 10 mg baclofen tab 20 mg

tizanidine hcl tab 2 mg QL 90 / 30 days

tizanidine hcl tab 4 mg QL 90 / 30 days

Antivirals (INFECTION FIGHTING DRUGS)

Anti-hepatitis B (HBV) Agents (VIRUS INFECTION DRUGS)

INTRON A RECON SOLN 10000000 UNIT PA interferon alfa-2b INTRON A RECON SOLN 18000000 UNIT PA interferon alfa-2b INTRON A RECON SOLN 50000000 UNIT PA interferon alfa-2b INTRON A SOLUTION 10000000 UNIT/ML PA interferon alfa-2b INTRON A SOLUTION 6000000 UNIT/ML PA interferon alfa-2b Anti-hepatitis C (HCV) Agents (VIRUS INFECTION DRUGS)

PEG-INTRON KIT 120 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON KIT 150 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON KIT 50 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON KIT 80 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON REDIPEN KIT 120 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON REDIPEN KIT 150 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON REDIPEN KIT 50 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON REDIPEN KIT 80 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON REDIPEN PAK 4 KIT 120 MCG/0.5ML PA peginterferon alfa-2b

PAGE 31 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS PEG-INTRON REDIPEN PAK 4 KIT 150 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON REDIPEN PAK 4 KIT 50 MCG/0.5ML PA peginterferon alfa-2b PEG-INTRON REDIPEN PAK 4 KIT 80 MCG/0.5ML PA peginterferon alfa-2b PEGINTRON KIT 120 MCG/0.5ML PA peginterferon alfa-2b PEGINTRON KIT 150 MCG/0.5ML PA peginterferon alfa-2b PEGINTRON KIT 50 MCG/0.5ML PA peginterferon alfa-2b PEGINTRON KIT 80 MCG/0.5ML PA peginterferon alfa-2b

ribavirin cap 200 mg PA

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) (RETROVIRUS INFECTION DRUGS)

EPIVIR HBV SOLUTION 5 MG/ML QL 1800 / 30 days lamivudine (hbv) Anti-influenza Agents (VIRUS INFECTION DRUGS)

amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5ml RELENZA DISKHALER AER POW BA 5 MG/BLISTER QL 20 / 5 days zanamivir rimantadine hydrochloride tab 100 mg TAMIFLU CAP 30 MG QL 10 / 5 days oseltamivir phosphate TAMIFLU CAP 45 MG QL 10 / 5 days oseltamivir phosphate TAMIFLU CAP 75 MG QL 10 / 5 days oseltamivir phosphate Antiherpetic Agents

acyclovir cap 200 mg

acyclovir susp 200 mg/5ml AL Up to 12 yrs old

acyclovir tab 400 mg acyclovir tab 800 mg

PAGE 32 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS trifluridine ophth soln 1% Anxiolytics (NERVE CONDITIONS DRUGS)

Anxiolytics, Other (ANXIETY DRUGS)

buspirone hcl tab 10 mg buspirone hcl tab 15 mg buspirone hcl tab 30 mg buspirone hcl tab 5 mg buspirone hcl tab 7.5 mg doxepin hcl cap 10 mg doxepin hcl cap 100 mg doxepin hcl cap 150 mg doxepin hcl cap 25 mg doxepin hcl cap 50 mg DOXEPIN HCL CAP 75 MG doxepin hcl doxepin hcl conc 10 mg/ml Benzodiazepines (ANXIETY DRUGS)

alprazolam tab 0.25 mg alprazolam tab 0.5 mg alprazolam tab 1 mg alprazolam tab 2 mg

alprazolam tab sr 24hr 0.5 mg PA

alprazolam tab sr 24hr 1 mg PA

alprazolam tab sr 24hr 2 mg PA

alprazolam tab sr 24hr 3 mg PA

clorazepate dipotassium tab 15 mg clorazepate dipotassium tab 3.75 mg clorazepate dipotassium tab 7.5 mg DIAZEPAM SOLUTION 1 MG/ML diazepam DIAZEPAM SOLUTION 5 MG/ML diazepam

PAGE 33 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS diazepam tab 10 mg diazepam tab 2 mg diazepam tab 5 mg lorazepam tab 0.5 mg lorazepam tab 1 mg lorazepam tab 2 mg oxazepam cap 10 mg oxazepam cap 15 mg oxazepam cap 30 mg temazepam cap 15 mg temazepam cap 30 mg Bipolar Agents (NERVE CONDITIONS DRUGS)

Mood Stabilizers (MISCELLANEOUS NERVE CONDITIONS DRUGS)

lithium carbonate cap 150 mg LITHIUM CARBONATE CAP 150 MG lithium carbonate lithium carbonate cap 300 mg lithium carbonate cap 600 mg LITHIUM CARBONATE CAP 600 MG lithium carbonate lithium carbonate tab 300 mg lithium carbonate tab cr 300 mg lithium carbonate tab cr 450 mg Blood Glucose Regulators (HORMONE AND DIABETIC DRUGS)

ANTIDIABETIC AGENTS (BLOOD SUGAR PRODUCTS)

acarbose tab 100 mg acarbose tab 25 mg acarbose tab 50 mg BYDUREON RECON SUSP 2 MG PA exenatide glimepiride tab 1 mg glimepiride tab 2 mg

PAGE 34 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS glimepiride tab 4 mg glipizide tab 10 mg glipizide tab 5 mg

glipizide tab sr 24hr 10 mg QL 60 / 30 days

glipizide tab sr 24hr 2.5 mg QL 60 / 30 days

glipizide tab sr 24hr 5 mg QL 60 / 30 days

glyburide micronized tab 1.5 mg glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg GLYBURIDE TAB 1.25 MG glyburide glyburide tab 2.5 mg GLYBURIDE TAB 2.5 MG glyburide glyburide tab 5 mg GLYBURIDE TAB 5 MG glyburide glyburide-metformin tab 1.25-250 mg glyburide-metformin tab 2.5-500 mg glyburide-metformin tab 5-500 mg

JANUMET TAB 50-1000 MG QL 60 / 30 days sitagliptin-metformin hcl ST

JANUMET TAB 50-500 MG QL 60 / 30 days sitagliptin-metformin hcl ST

JANUVIA TAB 100 MG QL 30 / 30 days sitagliptin phosphate ST

JANUVIA TAB 25 MG QL 30 / 30 days sitagliptin phosphate ST

JANUVIA TAB 50 MG QL 30 / 30 days sitagliptin phosphate ST

PAGE 35 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS metformin hcl tab 1000 mg metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab sr 24hr 500 mg metformin hcl tab sr 24hr 750 mg

nateglinide tab 120 mg QL 90 / 30 days

nateglinide tab 60 mg QL 90 / 30 days

pioglitazone hcl tab 15 mg (base equiv) QL 30 / 30 days

pioglitazone hcl tab 30 mg (base equiv) QL 30 / 30 days

pioglitazone hcl tab 45 mg (base equiv) QL 30 / 30 days

pioglitazone hcl-metformin hcl tab 15-500 mg QL 60 / 30 days

pioglitazone hcl-metformin hcl tab 15-850 mg QL 60 / 30 days

GLYCEMIC AGENTS (LOW BLOOD GLUCOSE DRUGS)

GLUCAGON EMERGENCY KIT 1 MG glucagon (rdna) Insulins (INJECTABLE DIABETES, BLOOD SUGAR DRUGS)

APIDRA SOLUTION 100 UNIT/ML insulin glulisine LANTUS SOLUTION 100 UNIT/ML insulin glargine LEVEMIR SOLUTION 100 UNIT/ML insulin detemir NOVOLIN 70/30 RELION SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin isophane & reg (human) NOVOLIN N RELION SUSPENSION 100 UNIT/ML insulin isophane (human) NOVOLIN N SUSPENSION 100 UNIT/ML insulin isophane (human) NOVOLIN R RELION SOLUTION 100 UNIT/ML insulin regular (human) NOVOLIN R SOLUTION 100 UNIT/ML insulin regular (human)

PAGE 36 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML insulin aspart protamine & aspart (human) Blood Products/Modifiers/Volume Expanders (BLOOD DISORDER DRUGS)

ANTICOAGULANTS (BLOOD THINNERS)

PA enoxaparin sodium inj 100 mg/ml GL Female

PA enoxaparin sodium inj 120 mg/0.8ml GL Female

PA enoxaparin sodium inj 150 mg/ml GL Female

PA enoxaparin sodium inj 30 mg/0.3ml GL Female

PA enoxaparin sodium inj 300 mg/3ml GL Female

PA enoxaparin sodium inj 40 mg/0.4ml GL Female

PA enoxaparin sodium inj 60 mg/0.6ml GL Female

PA enoxaparin sodium inj 80 mg/0.8ml GL Female

heparin sodium (porcine) inj 1000 unit/ml heparin sodium (porcine) inj 10000 unit/ml heparin sodium (porcine) inj 20000 unit/ml heparin sodium (porcine) inj 5000 unit/ml heparin sodium (porcine) pf inj 5000 unit/0.5ml HEPARIN SODIUM (PORCINE) SOLUTION 2000 UNIT/ML heparin sodium (porcine) warfarin sodium tab 1 mg warfarin sodium tab 10 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg

PAGE 37 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg

XARELTO TAB 10 MG QL 35 / 35 days rivaroxaban PA

Blood Formation Modifiers (BLOOD FORMATION DRUGS)

anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg EPOGEN SOLUTION 10000 UNIT/ML PA epoetin alfa EPOGEN SOLUTION 2000 UNIT/ML PA epoetin alfa EPOGEN SOLUTION 3000 UNIT/ML PA epoetin alfa EPOGEN SOLUTION 4000 UNIT/ML PA epoetin alfa NEUPOGEN SOLUTION 300 MCG/0.5ML PA filgrastim NEUPOGEN SOLUTION 300 MCG/ML PA filgrastim NEUPOGEN SOLUTION 480 MCG/0.8ML PA filgrastim NEUPOGEN SOLUTION 480 MCG/1.6ML PA filgrastim PROCRIT SOLUTION 10000 UNIT/ML PA epoetin alfa PROCRIT SOLUTION 2000 UNIT/ML PA epoetin alfa PROCRIT SOLUTION 3000 UNIT/ML PA epoetin alfa PROCRIT SOLUTION 4000 UNIT/ML PA epoetin alfa PROCRIT SOLUTION 40000 UNIT/ML PA epoetin alfa

PAGE 38 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS Platelet Modifying Agents (BLOOD THINNERS)

cilostazol tab 100 mg cilostazol tab 50 mg

clopidogrel bisulfate tab 300 mg (base equiv) QL 5 / 90 days

clopidogrel bisulfate tab 75 mg (base equiv) QL 30 / 30 days

dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg EFFIENT TAB 10 MG PA prasugrel hcl EFFIENT TAB 5 MG PA prasugrel hcl ticlopidine hcl tab 250 mg Cardiovascular Agents (HEART AND CIRCULATION CONDITIONS DRUGS)

Alpha-adrenergic Agonists (HEART AND CIRCULATION CONDITIONS DRUGS)

clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg methyldopa tab 250 mg methyldopa tab 500 mg

midodrine hcl tab 10 mg QL 120 / 30 days

midodrine hcl tab 2.5 mg QL 30 / 30 days

midodrine hcl tab 5 mg QL 240 / 30 days

Alpha-adrenergic Blocking Agents (BLOOD PRESSURE DRUGS)

prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg

PAGE 39 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ANGIOTENSIN II RECEPTOR ANTAGONISTS (BLOOD PRESSURE DRUGS)

losartan potassium & hydrochlorothiazide tab 100-12.5 mg QL 30 / 30 days

losartan potassium & hydrochlorothiazide tab 100-25 mg QL 30 / 30 days

losartan potassium & hydrochlorothiazide tab 50-12.5 mg QL 30 / 30 days

losartan potassium tab 100 mg QL 30 / 30 days

losartan potassium tab 25 mg QL 30 / 30 days

losartan potassium tab 50 mg QL 30 / 30 days

Angiotensin-converting Enzyme (ACE) Inhibitors (BLOOD PRESSURE DRUGS)

benazepril & hydrochlorothiazide tab 10-12.5 mg QL 30 / 30 days

benazepril & hydrochlorothiazide tab 20-12.5 mg QL 30 / 30 days

benazepril & hydrochlorothiazide tab 20-25 mg QL 30 / 30 days

benazepril & hydrochlorothiazide tab 5-6.25 mg QL 30 / 30 days

benazepril hcl tab 10 mg QL 30 / 30 days

benazepril hcl tab 20 mg QL 30 / 30 days

benazepril hcl tab 40 mg

benazepril hcl tab 5 mg QL 30 / 30 days

captopril & hydrochlorothiazide tab 25-15 mg QL 30 / 30 days

captopril & hydrochlorothiazide tab 25-25 mg QL 30 / 30 days

captopril & hydrochlorothiazide tab 50-15 mg QL 30 / 30 days

captopril & hydrochlorothiazide tab 50-25 mg QL 30 / 30 days

captopril tab 100 mg

captopril tab 12.5 mg QL 90 / 30 days

captopril tab 25 mg QL 90 / 30 days

captopril tab 50 mg QL 90 / 30 days

CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 25-15 MG QL 30 / 30 days captopril & hydrochlorothiazide CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 25-25 MG QL 30 / 30 days captopril & hydrochlorothiazide

PAGE 40 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 50-15 MG QL 30 / 30 days captopril & hydrochlorothiazide CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 50-25 MG QL 30 / 30 days captopril & hydrochlorothiazide

enalapril maleate & hydrochlorothiazide tab 10-25 mg QL 30 / 30 days

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg QL 30 / 30 days

enalapril maleate tab 10 mg QL 30 / 30 days

enalapril maleate tab 2.5 mg QL 30 / 30 days

enalapril maleate tab 20 mg

enalapril maleate tab 5 mg QL 30 / 30 days

fosinopril sodium tab 10 mg QL 30 / 30 days

fosinopril sodium tab 20 mg QL 30 / 30 days

fosinopril sodium tab 40 mg

lisinopril & hydrochlorothiazide tab 10-12.5 mg QL 30 / 30 days

lisinopril & hydrochlorothiazide tab 20-12.5 mg QL 30 / 30 days

lisinopril & hydrochlorothiazide tab 20-25 mg QL 30 / 30 days

lisinopril tab 10 mg QL 30 / 30 days

lisinopril tab 2.5 mg QL 30 / 30 days

lisinopril tab 20 mg QL 30 / 30 days

lisinopril tab 30 mg QL 30 / 30 days

lisinopril tab 40 mg

lisinopril tab 5 mg QL 30 / 30 days

moexipril hcl tab 15 mg

moexipril hcl tab 7.5 mg QL 30 / 30 days

quinapril hcl tab 10 mg QL 30 / 30 days

quinapril hcl tab 20 mg QL 30 / 30 days

quinapril hcl tab 40 mg

quinapril hcl tab 5 mg QL 30 / 30 days

PAGE 41 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

quinapril-hydrochlorothiazide tab 10-12.5 mg QL 30 / 30 days

quinapril-hydrochlorothiazide tab 20-12.5 mg QL 30 / 30 days

quinapril-hydrochlorothiazide tab 20-25 mg QL 30 / 30 days

ramipril cap 1.25 mg QL 30 / 30 days

ramipril cap 10 mg

ramipril cap 2.5 mg QL 30 / 30 days

ramipril cap 5 mg QL 30 / 30 days

trandolapril tab 1 mg QL 30 / 30 days

trandolapril tab 2 mg QL 30 / 30 days

trandolapril tab 4 mg ANTIARRHYTHMICS (HEART REGULATION DRUGS)

amiodarone hcl tab 200 mg disopyramide phosphate cap 100 mg disopyramide phosphate cap 150 mg flecainide acetate tab 100 mg flecainide acetate tab 150 mg flecainide acetate tab 50 mg NORPACE CR CAP ER 12H 100 MG QL 60 / 30 days disopyramide phosphate NORPACE CR CAP ER 12H 150 MG QL 120 / 30 days disopyramide phosphate propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg quinidine gluconate tab cr 324 mg quinidine sulfate tab 200 mg QUINIDINE SULFATE TAB 200 MG quinidine sulfate quinidine sulfate tab 300 mg sotalol hcl (afib/afl) tab 120 mg sotalol hcl (afib/afl) tab 160 mg

PAGE 42 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS sotalol hcl (afib/afl) tab 80 mg sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg sotalol hcl tab 80 mg Beta-adrenergic Blocking Agents (BLOOD PRESSURE DRUGS)

acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg atenolol & chlorthalidone tab 100-25 mg atenolol & chlorthalidone tab 50-25 mg atenolol tab 100 mg atenolol tab 25 mg atenolol tab 50 mg bisoprolol & hydrochlorothiazide tab 10-6.25 mg bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25 mg bisoprolol fumarate tab 10 mg bisoprolol fumarate tab 5 mg BYSTOLIC TAB 10 MG PA nebivolol hcl BYSTOLIC TAB 2.5 MG PA nebivolol hcl BYSTOLIC TAB 20 MG PA nebivolol hcl BYSTOLIC TAB 5 MG PA nebivolol hcl carvedilol tab 12.5 mg carvedilol tab 25 mg carvedilol tab 3.125 mg carvedilol tab 6.25 mg labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg

PAGE 43 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS metoprolol & hydrochlorothiazide tab 100-25 mg metoprolol & hydrochlorothiazide tab 100-50 mg metoprolol & hydrochlorothiazide tab 50-25 mg

metoprolol succinate tab sr 24hr 100 mg QL 30 / 30 days

metoprolol succinate tab sr 24hr 200 mg QL 30 / 30 days

metoprolol succinate tab sr 24hr 25 mg QL 30 / 30 days

metoprolol succinate tab sr 24hr 50 mg QL 30 / 30 days

metoprolol tartrate tab 100 mg metoprolol tartrate tab 25 mg metoprolol tartrate tab 50 mg nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg pindolol tab 10 mg pindolol tab 5 mg propranolol hcl cap sr 24hr 120 mg propranolol hcl cap sr 24hr 160 mg propranolol hcl cap sr 24hr 60 mg propranolol hcl cap sr 24hr 80 mg propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg PROPRANOLOL-HCTZ TAB 40-25 MG QL 30 / 30 days propranolol & hydrochlorothiazide PROPRANOLOL-HCTZ TAB 80-25 MG QL 30 / 30 days propranolol & hydrochlorothiazide Calcium Channel Blocking Agents (BLOOD PRESSURE DRUGS)

amlodipine besylate tab 10 mg QL 30 / 30 days

amlodipine besylate tab 2.5 mg QL 30 / 30 days

PAGE 44 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

amlodipine besylate tab 5 mg QL 30 / 30 days

amlodipine besylate-benazepril hcl cap 10-20 mg QL 30 / 30 days

amlodipine besylate-benazepril hcl cap 10-40 mg QL 30 / 30 days

amlodipine besylate-benazepril hcl cap 2.5-10 mg QL 30 / 30 days

amlodipine besylate-benazepril hcl cap 5-10 mg QL 30 / 30 days

amlodipine besylate-benazepril hcl cap 5-20 mg QL 30 / 30 days

amlodipine besylate-benazepril hcl cap 5-40 mg QL 30 / 30 days

AZOR TAB 10-20 MG QL 30 / 30 days amlodipine besylate-olmesartan medoxomil PA

AZOR TAB 10-40 MG QL 30 / 30 days amlodipine besylate-olmesartan medoxomil PA

AZOR TAB 5-20 MG QL 30 / 30 days amlodipine besylate-olmesartan medoxomil PA

AZOR TAB 5-40 MG QL 30 / 30 days amlodipine besylate-olmesartan medoxomil PA

diltiazem hcl cap sr 12hr 120 mg QL 60 / 30 days

diltiazem hcl cap sr 12hr 60 mg QL 60 / 30 days

diltiazem hcl cap sr 12hr 90 mg QL 60 / 30 days

diltiazem hcl cap sr 24hr 120 mg QL 30 / 30 days

diltiazem hcl cap sr 24hr 180 mg QL 30 / 30 days

diltiazem hcl cap sr 24hr 240 mg QL 30 / 30 days

diltiazem hcl coated beads cap sr 24hr 120 mg QL 30 / 30 days

diltiazem hcl coated beads cap sr 24hr 180 mg QL 30 / 30 days

diltiazem hcl coated beads cap sr 24hr 240 mg QL 30 / 30 days

diltiazem hcl coated beads cap sr 24hr 300 mg QL 30 / 30 days

diltiazem hcl coated beads cap sr 24hr 360 mg QL 30 / 30 days

diltiazem hcl coated beads tab sr 24hr 180 mg QL 30 / 30 days

PAGE 45 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

diltiazem hcl coated beads tab sr 24hr 240 mg QL 30 / 30 days

diltiazem hcl coated beads tab sr 24hr 300 mg QL 30 / 30 days

diltiazem hcl coated beads tab sr 24hr 360 mg QL 30 / 30 days

diltiazem hcl coated beads tab sr 24hr 420 mg QL 30 / 30 days

diltiazem hcl extended release beads cap sr 24hr 360 mg QL 30 / 30 days

diltiazem hcl tab 120 mg diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg

QL 30 / 30 days felodipine tab sr 24hr 10 mg ST

QL 30 / 30 days felodipine tab sr 24hr 2.5 mg ST

QL 30 / 30 days felodipine tab sr 24hr 5 mg ST

nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg nifedipine cap 10 mg nifedipine cap 20 mg

nifedipine tab sr 24hr 30 mg QL 30 / 30 days

nifedipine tab sr 24hr 60 mg QL 30 / 30 days

nifedipine tab sr 24hr 90 mg QL 30 / 30 days

nifedipine tab sr 24hr osmotic 30 mg QL 30 / 30 days

nifedipine tab sr 24hr osmotic 60 mg QL 30 / 30 days

nifedipine tab sr 24hr osmotic 90 mg QL 30 / 30 days

verapamil hcl cap sr 24hr 100 mg QL 30 / 30 days

verapamil hcl cap sr 24hr 120 mg QL 30 / 30 days

verapamil hcl cap sr 24hr 180 mg QL 30 / 30 days

PAGE 46 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

verapamil hcl cap sr 24hr 200 mg QL 30 / 30 days

verapamil hcl cap sr 24hr 240 mg QL 30 / 30 days

verapamil hcl cap sr 24hr 300 mg QL 30 / 30 days

verapamil hcl cap sr 24hr 360 mg QL 30 / 30 days

verapamil hcl tab 120 mg VERAPAMIL HCL TAB 40 MG verapamil hcl verapamil hcl tab 80 mg

verapamil hcl tab cr 120 mg QL 30 / 30 days

verapamil hcl tab cr 180 mg QL 30 / 30 days

verapamil hcl tab cr 240 mg QL 30 / 30 days

Cardiovascular Agents, Other (MISCELLANEOUS HEART AND CIRCULATION DRUGS)

digoxin tab 125 mcg (0.125 mg) digoxin tab 250 mcg (0.25 mg)

pentoxifylline tab cr 400 mg QL 90 / 30 days

Diuretics, Carbonic Anhydrase Inhibitors (BLOOD PRESSURE DRUGS (WATER PILLS))

ACETAZOLAMIDE TAB 125 MG acetazolamide acetazolamide tab 250 mg methazolamide tab 25 mg methazolamide tab 50 mg DIURETICS, LOOP (BLOOD PRESSURE DRUGS (WATER PILLS))

bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg furosemide inj 10 mg/ml furosemide oral soln 10 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg

PAGE 47 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS torsemide tab 10 mg torsemide tab 100 mg torsemide tab 20 mg torsemide tab 5 mg Diuretics, Potassium-sparing (BLOOD PRESSURE DRUGS (WATER PILLS))

amiloride & hydrochlorothiazide tab 5-50 mg amiloride hcl tab 5 mg spironolactone & hydrochlorothiazide tab 25-25 mg spironolactone tab 100 mg spironolactone tab 25 mg spironolactone tab 50 mg triamterene & hydrochlorothiazide cap 37.5-25 mg triamterene & hydrochlorothiazide tab 37.5-25 mg triamterene & hydrochlorothiazide tab 75-50 mg TRIAMTERENE-HCTZ CAP 50-25 MG triamterene & hydrochlorothiazide DIURETICS, THIAZIDE (BLOOD PRESSURE DRUGS (WATER PILLS))

chlorothiazide tab 250 mg CHLOROTHIAZIDE TAB 250 MG chlorothiazide chlorothiazide tab 500 mg CHLORTHALIDONE TAB 25 MG chlorthalidone CHLORTHALIDONE TAB 50 MG chlorthalidone hydrochlorothiazide cap 12.5 mg hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg METHYCLOTHIAZIDE TAB 5 MG methyclothiazide metolazone tab 10 mg

PAGE 48 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS metolazone tab 2.5 mg metolazone tab 5 mg Dyslipidemics, Fibric Acid Derivatives (CHOLESTEROL DRUGS)

fenofibrate micronized cap 134 mg fenofibrate micronized cap 200 mg fenofibrate micronized cap 67 mg

fenofibrate tab 160 mg QL 30 / 30 days

fenofibrate tab 54 mg QL 30 / 30 days

gemfibrozil tab 600 mg Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium tab 10 mg (base equivalent) QL 30 / 30 days

atorvastatin calcium tab 20 mg (base equivalent) QL 30 / 30 days

atorvastatin calcium tab 40 mg (base equivalent) QL 30 / 30 days

atorvastatin calcium tab 80 mg (base equivalent) QL 30 / 30 days

lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg

simvastatin tab 10 mg QL 30 / 30 days

simvastatin tab 20 mg QL 30 / 30 days

simvastatin tab 40 mg QL 30 / 30 days

simvastatin tab 5 mg QL 30 / 30 days

Dyslipidemics, Other (CHOLESTEROL DRUGS)

cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm colestipol hcl granule packets 5 gm

PAGE 49 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS colestipol hcl granules 5 gm colestipol hcl tab 1 gm NIACOR TAB 500 MG niacin (antihyperlipidemic) Vasodilators, Direct-acting Arterial (MISCELLANEOUS HEART AND CIRCULATION DRUGS)

hydralazine hcl tab 10 mg hydralazine hcl tab 100 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg minoxidil tab 10 mg minoxidil tab 2.5 mg Vasodilators, Direct-acting Arterial/Venous (CHEST PAIN DRUGS)

isosorbide dinitrate tab 10 mg isosorbide dinitrate tab 20 mg isosorbide dinitrate tab 30 mg ISOSORBIDE DINITRATE TAB 30 MG isosorbide dinitrate isosorbide dinitrate tab 5 mg isosorbide dinitrate tab cr 40 mg isosorbide mononitrate tab 20 mg isosorbide mononitrate tab sr 24hr 120 mg isosorbide mononitrate tab sr 24hr 30 mg isosorbide mononitrate tab sr 24hr 60 mg NITRO-BID OINTMENT 2 % nitroglycerin nitroglycerin td patch 24hr 0.1 mg/hr nitroglycerin td patch 24hr 0.2 mg/hr nitroglycerin td patch 24hr 0.4 mg/hr nitroglycerin td patch 24hr 0.6 mg/hr NITROSTAT SL TAB 0.3 MG nitroglycerin NITROSTAT SL TAB 0.4 MG nitroglycerin

PAGE 50 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS NITROSTAT SL TAB 0.6 MG nitroglycerin CENTRAL NERVOUS SYSTEM AGENTS (NERVE CONDITIONS DRUGS)

Attention Deficit Hyperactivity Disorder Agents, Amphetamines (ADHD DRUGS)

QL 30 / 30 days

amphetamine-dextroamphetamine cap sr 24hr 10 mg ST

AL 6 to 17 yrs old

QL 30 / 30 days amphetamine-dextroamphetamine cap sr 24hr 15 mg AL 6 to 17 yrs old

QL 30 / 30 days amphetamine-dextroamphetamine cap sr 24hr 20 mg AL 6 to 17 yrs old

QL 30 / 30 days amphetamine-dextroamphetamine cap sr 24hr 25 mg AL 6 to 17 yrs old

QL 30 / 30 days amphetamine-dextroamphetamine cap sr 24hr 30 mg AL 6 to 17 yrs old

QL 30 / 30 days

amphetamine-dextroamphetamine cap sr 24hr 5 mg ST

AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 10 mg AL 6 to 17 yrs old

ST amphetamine-dextroamphetamine tab 12.5 mg AL 6 to 17 yrs old

ST amphetamine-dextroamphetamine tab 15 mg AL 6 to 17 yrs old

ST amphetamine-dextroamphetamine tab 20 mg AL 6 to 17 yrs old

ST amphetamine-dextroamphetamine tab 30 mg AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 5 mg AL 6 to 17 yrs old

amphetamine-dextroamphetamine tab 7.5 mg AL 6 to 17 yrs old

ST dextroamphetamine sulfate cap sr 24hr 10 mg AL 6 to 17 yrs old

PAGE 51 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

ST dextroamphetamine sulfate cap sr 24hr 15 mg AL 6 to 17 yrs old

ST dextroamphetamine sulfate cap sr 24hr 5 mg AL 6 to 17 yrs old

ST dextroamphetamine sulfate tab 10 mg AL 6 to 17 yrs old

dextroamphetamine sulfate tab 5 mg AL 6 to 17 yrs old

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines (ADHD DRUGS)

dexmethylphenidate hcl tab 10 mg AL 6 to 17 yrs old

dexmethylphenidate hcl tab 2.5 mg AL 6 to 17 yrs old

dexmethylphenidate hcl tab 5 mg AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl cap cr 10 mg AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl cap cr 20 mg AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl cap cr 30 mg AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl cap cr 40 mg AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl cap cr 50 mg AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl cap cr 60 mg AL 6 to 17 yrs old

METHYLPHENIDATE HCL ER TAB ER 10 MG QL 30 / 30 days methylphenidate hcl AL 6 to 17 yrs old

QL 180 / 30 days methylphenidate hcl tab 10 mg AL 6 to 17 yrs old

QL 90 / 30 days methylphenidate hcl tab 20 mg AL 6 to 17 yrs old

PAGE 52 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

QL 90 / 30 days methylphenidate hcl tab 5 mg AL 6 to 17 yrs old

QL 30 / 30 days methylphenidate hcl tab cr 10 mg AL 6 to 17 yrs old

QL 90 / 30 days methylphenidate hcl tab cr 20 mg AL 6 to 17 yrs old

Central Nervous System, Other (MISCELLANEOUS NERVE CONDITIONS DRUGS)

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg MULTIPLE SCLEROSIS AGENTS (MULTIPLE SCLEROSIS DRUGS)

AVONEX KIT 30 MCG PA interferon beta-1a BETASERON KIT 0.3 MG PA interferon beta-1b COPAXONE SOLN PRSYR 20 MG/ML PA glatiramer acetate EXTAVIA KIT 0.3 MG PA interferon beta-1b Dental and Oral Agents (DRUGS FOR THE MOUTH)

chlorhexidine gluconate soln 0.12% pilocarpine hcl tab 5 mg triamcinolone acetonide dental paste 0.1% Dermatological Agents

alclometasone dipropionate cream 0.05% alclometasone dipropionate oint 0.05%

betamethasone dipropionate augmented cream 0.05% QL 100 / 30 days

betamethasone dipropionate cream 0.05% QL 90 / 30 days

betamethasone dipropionate lotion 0.05% QL 120 / 30 days

betamethasone dipropionate oint 0.05% QL 90 / 30 days

betamethasone valerate cream 0.1% QL 90 / 30 days

betamethasone valerate lotion 0.1% QL 120 / 30 days

betamethasone valerate oint 0.1% QL 90 / 30 days

PAGE 53 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS clindamycin phosphate lotion 1% clindamycin phosphate soln 1% clindamycin phosphate swab 1%

clobetasol propionate cream 0.05% QL 120 / 30 days

clobetasol propionate oint 0.05% QL 120 / 30 days

clobetasol propionate soln 0.05% QL 100 / 30 days

DERMA-SMOOTHE/FS BODY OIL 0.01 % QL 120 / 30 days fluocinolone acetonide DERMA-SMOOTHE/FS SCALP OIL 0.01 % QL 120 / 30 days fluocinolone acetonide

desonide oint 0.05% QL 120 / 30 days

fluocinolone acetonide cream 0.01% QL 120 / 30 days

fluocinolone acetonide cream 0.025% QL 120 / 30 days

fluocinolone acetonide oint 0.025% QL 120 / 30 days

fluocinonide cream 0.05% QL 120 / 30 days

fluocinonide emulsified base cream 0.05% QL 120 / 30 days

fluocinonide gel 0.05% QL 120 / 30 days

fluocinonide oint 0.05% QL 120 / 30 days

fluocinonide soln 0.05% QL 120 / 30 days

fluorouracil cream 5% fluorouracil soln 2% fluorouracil soln 5%

fluticasone propionate cream 0.05% QL 120 / 30 days

fluticasone propionate oint 0.005% QL 120 / 30 days

GAUZE SPONGE PAD 4"X4" QL 60 / 30 days gauze pads & dressings

halobetasol propionate cream 0.05% QL 100 / 30 days

halobetasol propionate oint 0.05% QL 100 / 30 days

hydrocortisone cream 0.5% QL 60 / 30 days

PAGE 54 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

hydrocortisone cream 1% QL 120 / 30 days

hydrocortisone cream 2.5% QL 90 / 30 days

hydrocortisone lotion 1% QL 240 / 30 days

hydrocortisone lotion 2.5% QL 120 / 30 days

hydrocortisone oint 0.5% QL 60 / 30 days

hydrocortisone oint 1% QL 60 / 30 days

hydrocortisone oint 2.5% QL 90 / 30 days

hydrocortisone rectal cream 2.5%

hydrocortisone valerate cream 0.2% QL 120 / 30 days

hydrocortisone valerate oint 0.2% QL 120 / 30 days

lactic acid (ammonium lactate) cream 12% lactic acid (ammonium lactate) lotion 10% lactic acid (ammonium lactate) lotion 12%

lactic acid (ammonium lactate) lotion 5% QL 226 / 30 days

mometasone furoate cream 0.1% QL 60 / 30 days

mometasone furoate oint 0.1% QL 60 / 30 days

mometasone furoate solution 0.1% (lotion) QL 60 / 30 days

podofilox soln 0.5%

prednicarbate oint 0.1% QL 60 / 30 days

SANTYL OINTMENT 250 UNIT/GM QL 60 / 30 days collagenase selenium sulfide lotion 2.5% sulfacetamide sodium lotion 10% (acne) SURGICAL DRESSING PAD 5"X9" QL 60 / 30 days gauze pads & dressings

QL 45 / 30 days tretinoin cream 0.025% AL Up to 29 yrs old

QL 45 / 30 days tretinoin cream 0.05% AL Up to 29 yrs old

PAGE 55 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

QL 45 / 30 days tretinoin cream 0.1% AL Up to 29 yrs old

QL 45 / 30 days tretinoin gel 0.01% AL Up to 29 yrs old

QL 45 / 30 days tretinoin gel 0.025% AL Up to 29 yrs old

triamcinolone acetonide cream 0.025% QL 160 / 30 days

triamcinolone acetonide cream 0.1% QL 160 / 30 days

triamcinolone acetonide cream 0.5% QL 60 / 30 days

triamcinolone acetonide lotion 0.025% QL 120 / 30 days

triamcinolone acetonide lotion 0.1% QL 120 / 30 days

triamcinolone acetonide oint 0.025% QL 160 / 30 days

triamcinolone acetonide oint 0.1% QL 160 / 30 days

TRIAMCINOLONE ACETONIDE OINTMENT 0.5 % QL 60 / 30 days triamcinolone acetonide (topical) Enzyme Replacement/Modifiers (ENZYME DEFICIENCY DRUGS)

CREON CP DR PART 12000 UNIT pancrelipase (lipase-protease-amylase) CREON CP DR PART 24000 UNIT pancrelipase (lipase-protease-amylase) CREON CP DR PART 3000-9500 UNIT pancrelipase (lipase-protease-amylase) CREON CP DR PART 36000 UNIT pancrelipase (lipase-protease-amylase) CREON CP DR PART 6000 UNIT pancrelipase (lipase-protease-amylase) PANCREAZE CP DR PART 10500 UNIT pancrelipase (lipase-protease-amylase) PANCREAZE CP DR PART 16800 UNIT pancrelipase (lipase-protease-amylase) PANCREAZE CP DR PART 21000 UNIT pancrelipase (lipase-protease-amylase) PANCREAZE CP DR PART 4200 UNIT pancrelipase (lipase-protease-amylase)

PAGE 56 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS PANCRELIPASE (LIP-PROT-AMYL) CP DR PART 5000 UNIT pancrelipase (lipase-protease-amylase) PERTZYE CP DR PART 16000 UNIT pancrelipase (lipase-protease-amylase) PERTZYE CP DR PART 8000 UNIT pancrelipase (lipase-protease-amylase) ULTRESA CP DR PART 13800 UNIT pancrelipase (lipase-protease-amylase) ULTRESA CP DR PART 20700 UNIT pancrelipase (lipase-protease-amylase) ULTRESA CP DR PART 23000 UNIT pancrelipase (lipase-protease-amylase) VIOKACE TAB 10440 UNIT pancrelipase (lipase-protease-amylase) VIOKACE TAB 20880 UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR PART 10000 UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR PART 15000 UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR PART 20000 UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR PART 25000 UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR PART 3000-10000 UNIT pancrelipase (lipase-protease-amylase) ZENPEP CP DR PART 5000 UNIT pancrelipase (lipase-protease-amylase) GASTROINTESTINAL Agents (BOWEL, INSTESTINE, AND STOMACH CONDITIONS DRUGS)

ANTISPASMODICS, GASTROINTESTINAL (BOWEL TREATMENT DRUGS)

dicyclomine hcl cap 10 mg dicyclomine hcl tab 20 mg glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg Gastrointestinal Agents, Other (MISCELLANEOUS DIGESTIVE SYSTEM DRUGS)

diphenoxylate w/ atropine tab 2.5-0.025 mg

PAGE 57 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS DIPHENOXYLATE-ATROPINE LIQUID 2.5-0.025 MG/5ML diphenoxylate w/ atropine loperamide hcl cap 2 mg loperamide hcl tab 2 mg metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) metoclopramide hcl tab 10 mg metoclopramide hcl tab 5 mg ursodiol cap 300 mg Histamine2 (H2) Receptor Antagonists (ULCER AND STOMACH ACID DRUGS)

cimetidine hcl soln 300 mg/5ml cimetidine tab 200 mg cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg famotidine inj 20 mg/2ml famotidine inj 200 mg/20ml famotidine inj 40 mg/4ml FAMOTIDINE SOLUTION 500 MG/50ML famotidine famotidine tab 10 mg famotidine tab 20 mg famotidine tab 40 mg ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ranitidine hcl tab 150 mg ranitidine hcl tab 300 mg LAXATIVES (CONSTIPATION DRUGS)

COLYTE WITH FLAVOR PACKS 240 GM QL 4000 / 365 days peg 3350-kcl-sod bicarb-sod chloride-sod sulfate AL 50 to 75 yrs old

COLYTE WITH FLAVOR PACKS RECON SOLN 240 GM QL 4000 / 365 days peg 3350-kcl-sod bicarb-sod chloride-sod sulfate AL 50 to 75 yrs old

GOLYTELY RECON SOLN 236 GM QL 4000 / 365 days peg 3350-kcl-sod bicarb-sod chloride-sod sulfate AL 50 to 75 yrs old

PAGE 58 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS lactulose solution 10 gm/15ml

NULYTELY WITH FLAVOR PACKS RECON SOLN 420 GM QL 4000 / 365 days peg 3350-potassium chloride-sod bicarbonate-sod chloride AL 50 to 75 yrs old

QL 4000 / 365 days

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm PA

AL 50 to 75 yrs old

QL 4000 / 365 days

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm PA

AL 50 to 75 yrs old

QL 4000 / 365 days peg 3350-kcl-sod bicarb-nacl for soln 420 gm AL 50 to 75 yrs old

polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder PROTECTANTS (MISCELLANEOUS DIGESTIVE SYSTEM DRUGS)

misoprostol tab 100 mcg misoprostol tab 200 mcg sucralfate tab 1 gm PROTON PUMP INHIBITORS (ULCER AND STOMACH ACID DRUGS)

lansoprazole cap delayed release 15 mg QL 60 / 30 days

lansoprazole cap delayed release 30 mg QL 30 / 30 days

omeprazole cap delayed release 20 mg QL 60 / 30 days

omeprazole cap delayed release 40 mg QL 30 / 30 days

pantoprazole sodium ec tab 20 mg (base equiv) QL 30 / 30 days

pantoprazole sodium ec tab 40 mg (base equiv) QL 60 / 30 days

Genitourinary Agents (BLADDER, GENITAL, AND KIDNEY CONDITIONS DRUGS)

Antispasmodics, Urinary (BLADDER MUSCLE RELAXANTS)

oxybutynin chloride syrup 5 mg/5ml oxybutynin chloride tab 5 mg oxybutynin chloride tab sr 24hr 10 mg

PAGE 59 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS oxybutynin chloride tab sr 24hr 15 mg oxybutynin chloride tab sr 24hr 5 mg OXYTROL FOR WOMEN PATCH TW 3.9 MG/24HR oxybutynin OXYTROL PATCH TW 3.9 MG/24HR oxybutynin

tolterodine tartrate cap sr 24hr 2 mg ST

tolterodine tartrate cap sr 24hr 4 mg ST

tolterodine tartrate tab 1 mg ST

tolterodine tartrate tab 2 mg ST

BENIGN PROSTATIC HYPERTROPHY AGENTS (PROSTATE DRUGS)

alfuzosin hcl tab sr 24hr 10 mg ST

doxazosin mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg finasteride tab 5 mg terazosin hcl cap 1 mg terazosin hcl cap 10 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg Genitourinary Agents, Other (MISCELLANEOUS BLADDER, GENITAL, AND KIDNEY CONDITIONS DRUGS)

bethanechol chloride tab 10 mg bethanechol chloride tab 25 mg bethanechol chloride tab 5 mg bethanechol chloride tab 50 mg PHOSPHATE BINDERS (PHOSPHATE REMOVING DRUGS)

calcium acetate (phosphate binder) cap 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 667 mg ELIPHOS TAB 667 MG calcium acetate (phosphate binder)

PAGE 60 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

clotrimazole w/ betamethasone cream 1-0.05% QL 90 / 24 days

clotrimazole w/ betamethasone lotion 1-0.05% QL 60 / 24 days

CORTISONE ACETATE TAB 25 MG cortisone acetate dexamethasone elixir 0.5 mg/5ml DEXAMETHASONE INTENSOL CONC 1 MG/ML dexamethasone dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg DEXAMETHASONE TAB 2 MG dexamethasone dexamethasone tab 4 mg dexamethasone tab 6 mg fludrocortisone acetate tab 0.1 mg hydrocortisone rectal cream 1% hydrocortisone rectal cream 2.5% hydrocortisone tab 10 mg hydrocortisone tab 20 mg hydrocortisone tab 5 mg methylprednisolone tab 4 mg methylprednisolone tab 4 mg dose pack methylprednisolone tab 8 mg prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) prednisolone syrup 15 mg/5ml (usp solution equivalent) PREDNISONE (PAK) TAB 10 MG prednisone PREDNISONE (PAK) TAB 5 MG prednisone PREDNISONE SOLUTION 5 MG/5ML prednisone prednisone tab 1 mg

PAGE 61 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS prednisone tab 10 mg prednisone tab 10 mg dose pack prednisone tab 2.5 mg prednisone tab 20 mg prednisone tab 5 mg prednisone tab 5 mg dose pack PREDNISONE TAB 50 MG prednisone Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

desmopressin acetate nasal spray soln 0.01% desmopressin acetate nasal spray soln 0.01% (refrigerated) desmopressin acetate tab 0.1 mg desmopressin acetate tab 0.2 mg Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

ANDROGENS (MALE HORMONE DRUGS)

PA testosterone cypionate im inj in oil 100 mg/ml GL Male

PA testosterone cypionate im inj in oil 200 mg/ml GL Male

ESTROGENS (HORMONE REPLACEMENT/MODIFYING DRUGS)

QL 37.5 / 28 days

desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg PA

GL Female

QL 37.5 / 28 days

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg PA

GL Female

ESTRACE CREAM 0.1 MG/GM estradiol vaginal

estradiol tab 0.5 mg GL Female

estradiol tab 1 mg GL Female

estradiol tab 2 mg GL Female

PAGE 62 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

QL 8 / 28 days estradiol td patch twice weekly 0.025 mg/24hr GL Female

QL 8 / 28 days estradiol td patch twice weekly 0.0375 mg/24hr GL Female

QL 8 / 28 days estradiol td patch twice weekly 0.05 mg/24hr GL Female

QL 8 / 28 days estradiol td patch twice weekly 0.075 mg/24hr GL Female

QL 8 / 28 days estradiol td patch twice weekly 0.1 mg/24hr GL Female

QL 4 / 21 days estradiol td patch weekly 0.025 mg/24hr GL Female

QL 4 / 21 days estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) GL Female

QL 4 / 21 days estradiol td patch weekly 0.05 mg/24hr GL Female

QL 4 / 21 days estradiol td patch weekly 0.06 mg/24hr GL Female

QL 4 / 21 days estradiol td patch weekly 0.075 mg/24hr GL Female

QL 4 / 21 days estradiol td patch weekly 0.1 mg/24hr GL Female

QL 21 / 28 days estropipate tab 0.75 mg GL Female

QL 21 / 28 days estropipate tab 1.5 mg GL Female

QL 21 / 28 days estropipate tab 3 mg GL Female

ESTROPIPATE TAB 3 MG QL 21 / 28 days estropipate GL Female

PAGE 63 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

PA ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg GL Female

QL 91 / 91 days levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg GL Female

QL 37.5 / 28 days

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg PA

GL Female

QL 37.5 / 28 days

levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg PA

GL Female

QL 37.5 / 28 days

levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg PA

GL Female

NECON 10/11 (28) TAB 35 MCG QL 37.5 / 28 days norethindrone-eth estradiol (biphasic) PA

QL 37.5 / 28 days

norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg PA

GL Female

QL 37.5 / 28 days

norethindrone & ethinyl estradiol tab 1 mg-35 mcg PA

GL Female

QL 28 / 28 days norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg GL Female

QL 28 / 28 days norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg GL Female

QL 37.5 / 28 days

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg PA

GL Female

QL 37.5 / 28 days

norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg PA

GL Female

PAGE 64 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

QL 37.5 / 28 days norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) PA

QL 28 / 28 days norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg GL Female

QL 21 / 28 days norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg GL Female

QL 37.5 / 28 days

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg PA

GL Female

QL 37.5 / 28 days

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg PA

GL Female

QL 37.5 / 28 days

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg PA

GL Female

QL 37.5 / 28 days

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg PA

GL Female

PREMARIN TAB 0.3 MG QL 30 / 30 days estrogens, conjugated GL Female

PREMARIN TAB 0.45 MG QL 30 / 30 days estrogens, conjugated GL Female

PREMARIN TAB 0.625 MG QL 30 / 30 days estrogens, conjugated GL Female

PREMARIN TAB 0.9 MG QL 30 / 30 days estrogens, conjugated GL Female

PREMARIN TAB 1.25 MG QL 30 / 30 days estrogens, conjugated GL Female

PREMPHASE TAB 0.625-5 MG QL 30 / 30 days conjugated estrogens-medroxyprogesterone acetate GL Female

PAGE 65 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

PREMPRO TAB 0.3-1.5 MG QL 30 / 30 days conjugated estrogens-medroxyprogesterone acetate GL Female

PREMPRO TAB 0.45-1.5 MG QL 30 / 30 days conjugated estrogens-medroxyprogesterone acetate GL Female

PREMPRO TAB 0.625-2.5 MG QL 30 / 30 days conjugated estrogens-medroxyprogesterone acetate GL Female

PREMPRO TAB 0.625-5 MG QL 30 / 30 days conjugated estrogens-medroxyprogesterone acetate GL Female

ZOVIA 1/50E (28) TAB 1-50 MG-MCG QL 37.5 / 28 days ethynodiol diacet & eth estrad PA

PROGESTINS (HORMONE REPLACEMENT/MODIFYING DRUGS)

DEPO-PROVERA SUSPENSION 150 MG/ML QL 1 / 90 days medroxyprogesterone acetate (contraceptive) GL Female

furosemide inj 10 mg/ml magnesium sulfate inj 50% MAGNESIUM SULFATE SOLUTION 40 MG/ML magnesium sulfate MAGNESIUM SULFATE SOLUTION 80 MG/ML magnesium sulfate

QL 1 / 90 days

medroxyprogesterone acetate im susp 150 mg/ml PA

GL Female

QL 30 / 30 days medroxyprogesterone acetate tab 10 mg GL Female

QL 28 / 28 days medroxyprogesterone acetate tab 2.5 mg GL Female

QL 120 / 30 days medroxyprogesterone acetate tab 5 mg GL Female

megestrol acetate susp 40 mg/ml PA

megestrol acetate tab 20 mg PA

PAGE 66 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

megestrol acetate tab 40 mg PA

QL 60 / 30 days norethindrone acetate tab 5 mg GL Female

QL 21 / 28 days

norethindrone tab 0.35 mg PA

GL Female

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium tab 100 mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levothyroxine sodium tab 137 mcg levothyroxine sodium tab 150 mcg levothyroxine sodium tab 175 mcg levothyroxine sodium tab 200 mcg levothyroxine sodium tab 25 mcg levothyroxine sodium tab 300 mcg levothyroxine sodium tab 50 mcg levothyroxine sodium tab 75 mcg levothyroxine sodium tab 88 mcg Hormonal Agents, Suppressant (Parathyroid) (DRUGS TO TREAT HIGH CALCIUM)

SENSIPAR TAB 30 MG PA cinacalcet hcl SENSIPAR TAB 60 MG PA cinacalcet hcl Hormonal Agents, Suppressant (Pituitary) (HORMONE AND DIABETIC DRUGS)

ELIGARD KIT 22.5 MG PA leuprolide acetate (3 month) ELIGARD KIT 30 MG PA leuprolide acetate (4 month) ELIGARD KIT 45 MG PA leuprolide acetate (6 month) ELIGARD KIT 7.5 MG PA leuprolide acetate

PAGE 67 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS LUPRON DEPOT KIT 11.25 MG PA leuprolide acetate (3 month) LUPRON DEPOT KIT 22.5 MG PA leuprolide acetate (3 month) LUPRON DEPOT KIT 3.75 MG PA leuprolide acetate LUPRON DEPOT KIT 30 MG PA leuprolide acetate (4 month) LUPRON DEPOT KIT 7.5 MG PA leuprolide acetate LUPRON DEPOT-PED KIT 11.25 MG PA leuprolide acetate (cpp) LUPRON DEPOT-PED KIT 15 MG PA leuprolide acetate (cpp) LUPRON DEPOT-PED KIT 7.5 MG PA leuprolide acetate (cpp) Hormonal Agents, Suppressant (Thyroid) (HORMONE AND DIABETIC DRUGS)

Antithyroid Agents (THYROID DRUGS)

methimazole tab 10 mg methimazole tab 5 mg propylthiouracil tab 50 mg Immunological Agents (DRUGS AFFECTING THE IMMUNE SYSTEM)

Immune Suppressants (IMMUNE SYSTEM DRUGS)

azathioprine tab 50 mg CELLCEPT RECON SUSP 200 MG/ML PA mycophenolate mofetil cyclosporine cap 100 mg cyclosporine cap 25 mg cyclosporine modified cap 100 mg cyclosporine modified cap 25 mg CYCLOSPORINE MODIFIED CAP 50 MG cyclosporine modified (for microemulsion) cyclosporine modified oral soln 100 mg/ml methotrexate sodium tab 2.5 mg (base equiv) mycophenolate mofetil cap 250 mg

PAGE 68 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

mycophenolate mofetil for oral susp 200 mg/ml PA

mycophenolate mofetil tab 500 mg tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg Immunomodulators (IMMUNE SYSTEM DRUGS)

leflunomide tab 10 mg leflunomide tab 20 mg SYNAGIS SOLUTION 100 MG/ML PA palivizumab SYNAGIS SOLUTION 50 MG/0.5ML PA palivizumab VACCINES (VACCINES)

ZOSTAVAX RECON SOLN 19400 UNT/0.65ML AL At least 60 yrs old zoster vaccine live Inflammatory Bowel Disease Agents (BOWEL, INSTESTINE, AND STOMACH CONDITIONS DRUGS)

Aminosalicylates (BOWEL TREATMENT DRUGS)

APRISO CAP ER 24H 0.375 GM QL 120 / 30 days mesalamine balsalazide disodium cap 750 mg

mesalamine enema 4 gm QL 1800 / 30 days

SFROWASA ENEMA 4 GM/60ML QL 1800 / 30 days mesalamine Glucocorticoids (BOWEL TREATMENT DRUGS)

hydrocortisone enema 100 mg/60ml Sulfonamides (BACTERIAL INFECTION DRUGS (ANTIBIOTICS))

sulfasalazine tab 500 mg sulfasalazine tab delayed release 500 mg Metabolic Bone Disease Agents (HORMONE AND BONE DRUGS)

alendronate sodium tab 10 mg alendronate sodium tab 35 mg ALENDRONATE SODIUM TAB 40 MG alendronate sodium

PAGE 69 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS alendronate sodium tab 5 mg

alendronate sodium tab 70 mg QL 4 / 28 days

calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg Miscellaneous Therapeutic Agents (Miscellaneous Drug Products)

1ST CHOICE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1ST CHOICE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS MISC 29G X 12MM QL 100 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS PLUS MISC 29G X 12MM QL 100 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS PLUS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle 1ST TIER UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle ADVOCATE INSULIN PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle ADVOCATE INSULIN PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle ADVOCATE INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ADVOCATE INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 70 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ADVOCATE INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ADVOCATE INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ADVOCATE INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ADVOCATE INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ADVOCATE INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ADVOCATE INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ADVOCATE INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ANTI-STICK INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ASSURE ID INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ASSURE ID INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 AURORA PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle AURORA PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle AURORA PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle AURORA UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle AURORA UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle BD AUTOSHIELD DUO MISC 30G X 5 MM QL 100 / 30 days insulin pen needle BD AUTOSHIELD MISC 29G X 12MM QL 100 / 30 days insulin pen needle BD AUTOSHIELD MISC 29G X 5MM QL 100 / 30 days insulin pen needle BD AUTOSHIELD MISC 29G X 8MM QL 100 / 30 days insulin pen needle BD INSULIN SYR ULTRAFINE II MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 71 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS BD INSULIN SYR ULTRAFINE II MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE HALF-UNIT MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MICROFINE MISC 27G X 5/8" 1 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MICROFINE MISC 28G X 1/2" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MICROFINE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MICROFINE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 25G X 1" 1 ML QL 200 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 25G X 5/8" 1 ML QL 200 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 26G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 27G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 30G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 72 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 1 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 BD INSULIN SYRINGE ULTRAFINE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 BD INTEGRA INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 BD INTEGRA SYRINGE MISC 25G X 1" 1 ML QL 200 / 30 days insulin syringe/needle u-100 BD PEN NEEDLE MINI U/F MISC 31G X 5 MM QL 200 / 30 days insulin pen needle BD PEN NEEDLE NANO U/F MISC 32G X 4 MM QL 200 / 30 days insulin pen needle BD PEN NEEDLE SHORT U/F MISC 31G X 8 MM QL 200 / 30 days insulin pen needle BD PEN NEEDLE ULTRAFINE MISC 29G X 12.7MM QL 100 / 30 days insulin pen needle BD SAFETY-LOK INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 BD SAFETYGLIDE INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 CAREFINE PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle CAREFINE PEN NEEDLES MISC 30G X 8 MM QL 100 / 30 days insulin pen needle CAREFINE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle CAREFINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle CAREFINE PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle CAREFINE PEN NEEDLES MISC 32G X 5 MM QL 200 / 30 days insulin pen needle

PAGE 73 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS CAREFINE PEN NEEDLES MISC 32G X 6 MM QL 200 / 30 days insulin pen needle CAREONE ULTIGUARD INSULIN SYR MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 CAREONE ULTIGUARD INSULIN SYR MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 CAREONE ULTIGUARD INSULIN SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 CAREONE ULTIGUARD INSULIN SYR MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 CAREONE ULTIGUARD INSULIN SYR MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 CAREONE ULTIGUARD INSULIN SYR MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 CAREONE UNIFINE PENTIPS MISC 29G X 12MM QL 100 / 30 days insulin pen needle CAREONE UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle CAREONE UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle CAREONE UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle CAREONE UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle CAREONE UNIFINE PENTIPS PLUS MISC 29G X 12MM QL 100 / 30 days insulin pen needle CAREONE UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle CAREONE UNIFINE PENTIPS PLUS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle CAREONE UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle CAREONE UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle CLICKFINE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle CLICKFINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle CLICKFINE PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle

PAGE 74 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS COMFORT EZ INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 COMFORT EZ PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle COMFORT EZ PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle COMFORT EZ PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle COMFORT EZ PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle CVS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 CVS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 CVS INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 75 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS CVS INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 DRUG MART ULTRA COMFORT SYR MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 DRUG MART ULTRA COMFORT SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 DRUG MART ULTRA COMFORT SYR MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 DRUG MART ULTRA COMFORT SYR MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 DRUG MART ULTRA COMFORT SYR MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 DRUG MART ULTRA COMFORT SYR MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 DRUG MART ULTRA COMFORT SYR MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 DRUG MART UNIFINE PENTIPS MISC 29G X 12MM QL 100 / 30 days insulin pen needle DRUG MART UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle DRUG MART UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle DRUG MART UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle DRUG MART UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle DRUG MART UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle DUANE READE UNIFINE PENTIPS MISC 29G X 12MM QL 100 / 30 days insulin pen needle DUANE READE UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle DUANE READE UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle EASY COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 76 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EASY COMFORT PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle EASY COMFORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle EASY COMFORT PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle EASY TOUCH INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SAFETY SYR MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 27G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 27G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 77 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS EASY TOUCH INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EASY TOUCH PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle EASY TOUCH PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle EASY TOUCH PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle EASY TOUCH PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle EASY TOUCH PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle EASY TOUCH PEN NEEDLES MISC 32G X 5 MM QL 200 / 30 days insulin pen needle EASY TOUCH PEN NEEDLES MISC 32G X 6 MM QL 200 / 30 days insulin pen needle EQL INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 EQL INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EQL INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EQL INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 EQL INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EQL INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EQL INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 EQL INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EQL INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EQL SHORT PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle EQL ULTRA COMFORT INSULIN SYR MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EQL ULTRA COMFORT INSULIN SYR MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 78 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS EQL ULTRA SHORT PEN NEEDLE MISC 31G X 6 MM QL 200 / 30 days insulin pen needle EXCEL COMFORT POINT PEN NEEDLE MISC 29G X 12MM QL 100 / 30 days insulin pen needle EXCEL COMFORT POINT PEN NEEDLE MISC 31G X 6 MM QL 200 / 30 days insulin pen needle EXCEL COMFORT POINT PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle EXEL COMFORT POINT INSULIN SYR MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 EXEL COMFORT POINT INSULIN SYR MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 FIFTY50 PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle FIFTY50 PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 FREDS PHARMACY UNIFINE PENTIP+ MISC 31G X 5 MM QL 200 / 30 days insulin pen needle FREDS PHARMACY UNIFINE PENTIP+ MISC 31G X 8 MM QL 200 / 30 days insulin pen needle FREDS PHARMACY UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle

PAGE 79 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS FREESTYLE PRECISION INS SYR MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 FREESTYLE PRECISION INS SYR MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 FREESTYLE PRECISION INS SYR MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 FREESTYLE PRECISION INS SYR MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL EASE INJECT PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle GLOBAL EASE INJECT PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle GLOBAL EASE INJECT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle GLOBAL EASE INJECT PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle GLOBAL INJECT EASE INSULIN SYR MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GLOBAL INJECT EASE INSULIN SYR MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 80 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS GLOBAL INJECT EASE INSULIN SYR MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GLUCOPRO INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GLUCOPRO INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GLUCOPRO INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GLUCOPRO INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GLUCOPRO INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GLUCOPRO INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GLUCOPRO INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GLUCOPRO INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GNP CLICKFINE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle GNP CLICKFINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle GNP INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GNP INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 GNP INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GNP INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GNP INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GNP INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GNP INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GNP INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GNP INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 81 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS GNP INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GNP INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 GNP ULTRA COM INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 H-E-B INCONTROL PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle H-E-B INCONTROL PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle H-E-B INCONTROL PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle H-E-B INCONTROL PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle H-E-B INCONTROL PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle HEALTHWISE MINI PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle HEALTHWISE PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle

PAGE 82 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS HEALTHWISE SHORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle HEALTHWISE UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle HEALTHY ACCENTS UNIFINE PENTIP MISC 29G X 12MM QL 100 / 30 days insulin pen needle HEALTHY ACCENTS UNIFINE PENTIP MISC 31G X 5 MM QL 200 / 30 days insulin pen needle HEALTHY ACCENTS UNIFINE PENTIP MISC 31G X 6 MM QL 200 / 30 days insulin pen needle HEALTHY ACCENTS UNIFINE PENTIP MISC 31G X 8 MM QL 200 / 30 days insulin pen needle HEALTHY ACCENTS UNIFINE PENTIP MISC 32G X 4 MM QL 200 / 30 days insulin pen needle INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 29G X 1" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 83 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS INSULIN SYRINGE/NEEDLE MISC 27G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE/NEEDLE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 INSULIN SYRINGE/NEEDLE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 INSUPEN PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle INSUPEN SENSITIVE MISC 32G X 6 MM QL 200 / 30 days insulin pen needle INSUPEN SENSITIVE MISC 32G X 8 MM QL 100 / 30 days insulin pen needle INSUPEN ULTRAFIN MISC 29G X 12MM QL 100 / 30 days insulin pen needle INSUPEN ULTRAFIN MISC 30G X 8 MM QL 100 / 30 days insulin pen needle INSUPEN ULTRAFIN MISC 31G X 6 MM QL 200 / 30 days insulin pen needle INSUPEN ULTRAFIN MISC 31G X 8 MM QL 200 / 30 days insulin pen needle KINRAY INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 KINRAY INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 KINRAY INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 KINRAY INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 KROGER INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 KROGER INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 KROGER INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 KROGER INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 KROGER INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 KROGER INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 84 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS KROGER INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 KROGER INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 KROGER INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 KROGER PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle KROGER PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle KROGER PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle LEADER INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 LEADER UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle LEADER UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle LEADER UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle

PAGE 85 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS LEADER UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle LEADER UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle LITE TOUCH PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle LITETOUCH INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 LITETOUCH PEN NEEDLES MISC 29G X 12.7MM QL 100 / 30 days insulin pen needle LITETOUCH PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle LITETOUCH PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle LIVE BETTER PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle LIVE BETTER PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle LIVE BETTER PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle

PAGE 86 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS LONGS INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MAGELLAN INSULIN SAFETY SYR MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MAGELLAN INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MAGELLAN INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 MAGELLAN INSULIN SAFETY SYR MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MAGELLAN INSULIN SAFETY SYR MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MAGELLAN INSULIN SAFETY SYR MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MEDICINE SHOPPE PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle MEDICINE SHOPPE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle MEDICINE SHOPPE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle MEIJER PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle MEIJER PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle MEIJER PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle methylergonovine maleate tab 0.2 mg MONOJECT INSULIN SYRINGE MISC 25G X 5/8" 1 ML QL 200 / 30 days insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 27G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100

PAGE 87 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS MONOJECT INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MONOJECT ULTRA COMFORT SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MOORE MONO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MOORE MONO INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 MOORE MONO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MOORE MONO INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 88 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS MS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MS INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 MS INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MS INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MS INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 MS INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 MS INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 MS INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 NOVOFINE AUTOCOVER MISC 30G X 8 MM QL 100 / 30 days insulin pen needle NOVOFINE MISC 30G X 8 MM QL 100 / 30 days insulin pen needle NOVOFINE MISC 32G X 6 MM QL 200 / 30 days insulin pen needle NOVOFINE PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle NOVOTWIST MISC 30G X 8 MM QL 100 / 30 days insulin pen needle NOVOTWIST MISC 32G X 5 MM QL 200 / 30 days insulin pen needle ORSINI INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ORSINI INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ORSINI INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 PC UNIFINE PENTIPS MISC 29G X 12MM QL 100 / 30 days insulin pen needle PC UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle

PAGE 89 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS PC UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle PC UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle PEN NEEDLES 1/2" MISC 29G X 12MM QL 100 / 30 days insulin pen needle PEN NEEDLES 3/16" MISC 31G X 5 MM QL 200 / 30 days insulin pen needle PEN NEEDLES 5/16" MISC 30G X 8 MM QL 100 / 30 days insulin pen needle PEN NEEDLES 5/16" MISC 31G X 8 MM QL 200 / 30 days insulin pen needle PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle PRECISION SURE-DOSE SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 PRECISION SURE-DOSE SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 PRECISION SURE-DOSE SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 PRECISION SURE-DOSE SYRINGE MISC 30G X 3/8" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 PRECISION SURE-DOSE SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 PRECISION SUREDOSE PLUS SYR MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 PRECISION SUREDOSE PLUS SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 90 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS PREFERRED PLUS INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 PREFERRED PLUS INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 PREFERRED PLUS UNIFINE PENTIPS MISC 29G X 12MM QL 100 / 30 days insulin pen needle PREFERRED PLUS UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle PREFERRED PLUS UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle PREFERRED PLUS UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle PREFERRED PLUS UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle PRODIGY INSULIN PEN NEEDLES MISC 29G X 13MM QL 100 / 30 days insulin pen needle PRODIGY INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 PRODIGY INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 PRODIGY INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 PRODIGY MINI PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle PRODIGY SHORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle PX EXTRA SHORT PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle PX INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 PX INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 PX INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 PX INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 PX INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 91 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS PX MINI PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle PX PEN NEEDLE MISC 29G X 12MM QL 100 / 30 days insulin pen needle PX PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle QC INSULIN SYRINGE MISC 29G 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 QC INSULIN SYRINGE MISC 29G 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 QC INSULIN SYRINGE MISC 29G 1 ML QL 200 / 30 days insulin syringe/needle u-100 QC INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 QC INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 QC INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 QC INSULIN SYRINGE MISC 30G 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 QC INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 QC INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 QC PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle QC PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle QC PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle QC UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle RA INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 RA INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 RA INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 RA INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 92 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS RA PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle RA PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle RELI-ON INSULIN SYRINGE MISC 29G 0.3 ML QL 200 / 30 days insulin syringe/needle u-100 RELI-ON INSULIN SYRINGE MISC 29G 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 RELI-ON INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 RELION INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 RELION INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 RELION INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 RELION INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 RELION INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 RELION INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 RELION INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 RELION INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 RELION INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 RELION MINI PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle RELION PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle RELION PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle RELION PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle RELION SHORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle SAFESNAP INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100

PAGE 93 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS SAFESNAP INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SAFESNAP INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SAFESNAP INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SAFESNAP INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SAFETY-GLIDE SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SB INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SB INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SB INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SB INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SB INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SCHNUCKS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SCHNUCKS INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SHOPKO UNIFINE PENTIPS MISC 29G X 12MM QL 100 / 30 days insulin pen needle SHOPKO UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle SHOPKO UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle SHOPKO UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle SM INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SM INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 SM INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SM INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 94 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS SM INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SM INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SM INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SM INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SM INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SM INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SM INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 sodium chloride irrigation soln 0.9% SURE COMFORT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SURE COMFORT INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 95 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS SURE COMFORT PEN NEEDLES MISC 29G X 12.7MM QL 100 / 30 days insulin pen needle SURE COMFORT PEN NEEDLES MISC 30G X 8 MM QL 100 / 30 days insulin pen needle SURE COMFORT PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle SURE COMFORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle SURE COMFORT PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle SURE-FINE PEN NEEDLES MISC 29G X 12.7MM QL 100 / 30 days insulin pen needle SURE-FINE PEN NEEDLES MISC 31G X 5 MM QL 200 / 30 days insulin pen needle SURE-FINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle SURE-JECT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 SURE-JECT INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 27G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 96 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS TERUMO INSULIN SYRINGE MISC 27G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 30G X 3/8" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO INSULIN SYRINGE MISC 30G X 3/8" 1 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO SURGUARD INSULIN SYR MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO SURGUARD INSULIN SYR MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 TERUMO SURGUARD INSULIN SYR MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO SURGUARD INSULIN SYR MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TERUMO SURGUARD INSULIN SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 30G X 3/8" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 30G X 3/8" 1 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 97 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS THINPRO INSULIN SYRINGE MISC 31G X 3/8" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 31G X 3/8" 0.5 ML QL 200 / 30 days insulin syringe/needle u-100 THINPRO INSULIN SYRINGE MISC 31G X 3/8" 1 ML QL 200 / 30 days insulin syringe/needle u-100 TODAYS HEALTH MINI PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle TODAYS HEALTH PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle TODAYS HEALTH SHORT PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle TOPCARE CLICKFINE PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle TOPCARE CLICKFINE PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle TOPCARE ULTRA COMFORT INS SYR MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TOPCARE ULTRA COMFORT INS SYR MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 98 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS TRUEPLUS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 TRUEPLUS INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 30G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 99 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ULTICARE INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTICARE MICRO PEN NEEDLES MISC 32G X 4 MM QL 200 / 30 days insulin pen needle ULTICARE MINI PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle ULTICARE PEN NEEDLES MISC 29G X 12.7MM QL 100 / 30 days insulin pen needle ULTICARE PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle ULTICARE SHORT PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle ULTILET INSULIN SYRINGE MISC 29G X 7/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTILET INSULIN SYRINGE MISC 29G X 7/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTILET INSULIN SYRINGE SHORT MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTILET PEN NEEDLE MISC 31G X 8 MM QL 200 / 30 days insulin pen needle ULTRA COMFORT INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA COMFORT INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100

PAGE 100 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ULTRA COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA COMFORT INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA COMFORT INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-COMFORT INSULIN SYRINGE MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 ULTRA-THIN II INS SYR SHORT MISC 31G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 UNIFINE PENTIPS MISC 29G X 12MM QL 100 / 30 days insulin pen needle UNIFINE PENTIPS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle

PAGE 101 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle UNIFINE PENTIPS PLUS MISC 29G X 12MM QL 100 / 30 days insulin pen needle UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle UNIFINE PENTIPS PLUS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle V-R MONO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 V-R MONO INSULIN SYRINGE MISC 28G X 1/2" 1 ML QL 200 / 30 days insulin syringe/needle u-100 V-R MONO INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 V-R MONO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 V-R MONO INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 VALUE HEALTH INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 VALUE HEALTH INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 VALUMARK PEN NEEDLES MISC 29G X 12MM QL 100 / 30 days insulin pen needle VALUMARK PEN NEEDLES MISC 31G X 6 MM QL 200 / 30 days insulin pen needle VALUMARK PEN NEEDLES MISC 31G X 8 MM QL 200 / 30 days insulin pen needle VANISHPOINT INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 VANISHPOINT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 VIDA MIA UNIFINE PENTIPS MISC 29G X 12MM QL 100 / 30 days insulin pen needle VIDA MIA UNIFINE PENTIPS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle

PAGE 102 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS VIDA MIA UNIFINE PENTIPS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle VIDA MIA UNIFINE PENTIPS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle VP INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 water for irrigation, sterile irrigation soln WD MEDIC INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 WD MEDIC INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 WD MEDIC INSULIN SYRINGE MISC 29G X 1/2" 1 ML QL 100 / 30 days insulin syringe/needle u-100 WD MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML QL 100 / 30 days insulin syringe/needle u-100 WD MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML QL 100 / 30 days insulin syringe/needle u-100 WD MEDIC INSULIN SYRINGE MISC 30G X 5/16" 1 ML QL 100 / 30 days insulin syringe/needle u-100 WEGMANS UNIFINE PENTIPS PLUS MISC 31G X 5 MM QL 200 / 30 days insulin pen needle WEGMANS UNIFINE PENTIPS PLUS MISC 31G X 6 MM QL 200 / 30 days insulin pen needle WEGMANS UNIFINE PENTIPS PLUS MISC 31G X 8 MM QL 200 / 30 days insulin pen needle WEGMANS UNIFINE PENTIPS PLUS MISC 32G X 4 MM QL 200 / 30 days insulin pen needle OPHTHALMIC AGENTS (EYE MEDICATIONS)

Ophthalmic Agents, Other (MISCELLANEOUS EYE MEDICATIONS)

*artificial tear ophth ointment*** *artificial tear ophth solution*** neomycin-polymyxin-dexamethasone ophth oint 0.1% neomycin-polymyxin-dexamethasone ophth susp 0.1% proparacaine hcl ophth soln 0.5% Ophthalmic Anti-allergy Agents (ALLERGY EYE MEDICATIONS)

azelastine hcl ophth soln 0.05%

PAGE 103 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS cromolyn sodium ophth soln 4% Ophthalmic Anti-inflammatories (INFLAMMATION EYE MEDICATIONS)

dexamethasone sodium phosphate ophth soln 0.1% diclofenac sodium ophth soln 0.1% FLAREX SUSPENSION 0.1 % fluorometholone acetate flurbiprofen sodium ophth soln 0.03% FML FORTE SUSPENSION 0.25 % fluorometholone (ophth) FML OINTMENT 0.1 % fluorometholone (ophth) ketorolac tromethamine ophth soln 0.4% ketorolac tromethamine ophth soln 0.5% prednisolone acetate ophth susp 1%

tobramycin-dexamethasone ophth susp 0.3-0.1% QL 5 / 10 days

Ophthalmic Antiglaucoma Agents (GLAUCOMA MEDICATIONS)

acetazolamide cap sr 12hr 500 mg atropine sulfate ophth soln 1% betaxolol hcl ophth soln 0.5% brimonidine tartrate ophth soln 0.2% carteolol hcl ophth soln 1% dorzolamide hcl ophth soln 2% dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml levobunolol hcl ophth soln 0.5% metipranolol ophth soln 0.3% METIPRANOLOL SOLUTION 0.3 % metipranolol timolol maleate ophth soln 0.25% timolol maleate ophth soln 0.5% Ophthalmic Prostaglandin and Prostamide Analogs (GLAUCOMA MEDICATIONS)

latanoprost ophth soln 0.005% QL 5 / 30 days

PAGE 104 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS OTIC AGENTS (EAR DRUGS)

acetic acid otic soln 2% hydrocortisone w/ acetic acid otic soln 1-2% neomycin-polymyxin-hc otic soln 1% neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% Respiratory Tract/Pulmonary Agents (ALLERGIES, COUGH, COLD AND LUNG CONDITION DRUGS)

Anti-inflammatories, Inhaled Corticosteroids (ASTHMA/LUNG DRUGS)

ADVAIR DISKUS AER POW BA 100-50 MCG/DOSE QL 60 / 30 days fluticasone-salmeterol ST

BREO ELLIPTA AER POW BA 100-25 MCG/INH QL 60 / 30 days fluticasone furoate-vilanterol

budesonide inhalation susp 0.25 mg/2ml AL Up to 8 yrs old

budesonide inhalation susp 0.5 mg/2ml AL Up to 8 yrs old

DULERA AEROSOL 100-5 MCG/ACT QL 13 / 30 days mometasone furoate-formoterol fumarate dihydrate ST

DULERA AEROSOL 200-5 MCG/ACT QL 13 / 30 days mometasone furoate-formoterol fumarate dihydrate ST

FLOVENT DISKUS AER POW BA 100 MCG/BLIST QL 60 / 30 days fluticasone propionate (inhalation) AL 4 to 11 yrs old

FLOVENT DISKUS AER POW BA 50 MCG/BLIST QL 60 / 30 days fluticasone propionate (inhalation) AL 4 to 11 yrs old

FLOVENT HFA AEROSOL 44 MCG/ACT QL 10.6 / 30 days fluticasone propionate hfa AL 4 to 11 yrs old

flunisolide nasal soln 25 mcg/act (0.025%) QL 50 / 30 days

FLUNISOLIDE SOLUTION 25 MCG/ACT (0.025%) QL 50 / 30 days flunisolide (nasal) FLUNISOLIDE SOLUTION 29 MCG/ACT (0.025%) QL 50 / 30 days flunisolide (nasal)

fluticasone propionate nasal susp 50 mcg/act QL 16 / 30 days

NASACORT ALLERGY 24HR AEROSOL 55 MCG/ACT triamcinolone acetonide (nasal)

PAGE 105 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS QVAR AERO SOLN 40 MCG/ACT QL 8.7 / 30 days beclomethasone dipropionate QVAR AERO SOLN 80 MCG/ACT QL 8.7 / 30 days beclomethasone dipropionate

SYMBICORT AEROSOL 160-4.5 MCG/ACT QL 10.2 / 30 days budesonide-formoterol fumarate dihydrate ST

SYMBICORT AEROSOL 80-4.5 MCG/ACT QL 10.2 / 30 days budesonide-formoterol fumarate dihydrate ST

ANTIHISTAMINES (ALLERGY DRUGS)

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) cyproheptadine hcl syrup 2 mg/5ml cyproheptadine hcl tab 4 mg hydroxyzine hcl syrup 10 mg/5ml hydroxyzine hcl tab 10 mg hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg HYDROXYZINE PAMOATE CAP 100 MG hydroxyzine pamoate hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg Antileukotrienes (ASTHMA/LUNG DRUGS)

montelukast sodium chew tab 4 mg (base equiv) montelukast sodium chew tab 5 mg (base equiv) montelukast sodium tab 10 mg (base equiv) Bronchodilators, Anticholinergic (ASTHMA/LUNG DRUGS)

ATROVENT HFA AERO SOLN 17 MCG/ACT QL 12.9 / 30 days ipratropium bromide hfa ipratropium bromide inhal soln 0.02%

ipratropium bromide nasal soln 0.03% (21 mcg/spray) QL 30 / 30 days

ipratropium bromide nasal soln 0.06% (42 mcg/spray) QL 15 / 30 days

TUDORZA PRESSAIR AER POW BA 400 MCG/ACT QL 1 / 30 days aclidinium bromide

PAGE 106 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS Bronchodilators, Sympathomimetic (ASTHMA/LUNG DRUGS)

ADRENACLICK SOLN A-INJ 0.3 MG/0.3ML QL 2 / 90 days epinephrine albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) albuterol sulfate soln nebu 0.5% (5 mg/ml) albuterol sulfate syrup 2 mg/5ml

ANORO ELLIPTA AER POW BA 62.5-25 MCG/INH QL 60 / 30 days umeclidinium-vilanterol PA

AUVI-Q SOLN A-INJ 0.3 MG/0.3ML epinephrine EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML QL 2 / 90 days epinephrine EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML QL 2 / 90 days epinephrine EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML epinephrine EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML epinephrine EPIPEN SOLN A-INJ 0.3 MG/0.3ML epinephrine FORADIL AEROLIZER CAP 12 MCG QL 60 / 30 days formoterol fumarate metaproterenol sulfate syrup 10 mg/5ml METAPROTERENOL SULFATE SYRUP 10 MG/5ML metaproterenol sulfate SEREVENT DISKUS AER POW BA 50 MCG/DOSE QL 120 / 30 days salmeterol xinafoate terbutaline sulfate tab 2.5 mg terbutaline sulfate tab 5 mg TWINJECT SOLN A-INJ 0.3 MG/0.3ML epinephrine VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT QL 18 / 25 days albuterol sulfate Cystic Fibrosis Agents (ALLERGIES, COUGH, COLD AND LUNG CONDITION DRUGS)

PULMOZYME SOLUTION 1 MG/ML PA dornase alfa

PAGE 107 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS Phosphodiesterase Inhibitors, Airways Disease (ALLERGIES, COUGH, COLD AND LUNG CONDITION DRUGS)

ELIXOPHYLLIN ELIXIR 80 MG/15ML theophylline LUFYLLIN TAB 200 MG dyphylline LUFYLLIN TAB 400 MG dyphylline theophylline tab sr 12hr 100 mg theophylline tab sr 12hr 200 mg theophylline tab sr 12hr 300 mg theophylline tab sr 12hr 450 mg Respiratory Tract Agents, Other (MISCELLANEOUS RESPIRATORY DRUGS)

acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% promethazine & phenylephrine syrup 6.25-5 mg/5ml PROMETHAZINE VC PLAIN SYRUP 6.25-5 MG/5ML promethazine & phenylephrine Skeletal Muscle Relaxants (MUSCLE AND JOINT DRUGS)

chlorzoxazone tab 500 mg cyclobenzaprine hcl tab 10 mg cyclobenzaprine hcl tab 5 mg methocarbamol tab 500 mg methocarbamol tab 750 mg Sleep Disorder Agents (SLEEP CONDITIONS DRUGS)

GABA Receptor Modulators (SEDATION AND SLEEP DRUGS)

zaleplon cap 10 mg zaleplon cap 5 mg

zolpidem tartrate tab 10 mg QL 30 / 30 days

zolpidem tartrate tab 5 mg QL 30 / 30 days

PAGE 108 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS Therapeutic Nutrients/Minerals/Electrolytes (MULTIVITAMINS AND REPLACEMENT SOLUTIONS)

ELECTROLYTE/MINERAL MODIFIERS (ANTIDOTES/PROTECTANTS)

*sodium polystyrene sulfonate powder** ELECTROLYTE/MINERAL REPLACEMENT (ELECTROLYTES REPLACEMENTS)

KLOR-CON M15 TAB ER 15 MEQ potassium chloride microencapsulated crystals cr potassium chloride cap cr 10 meq potassium chloride cap cr 8 meq POTASSIUM CHLORIDE ER TAB ER 8 MEQ potassium chloride potassium chloride microencapsulated crys cr tab 10 meq potassium chloride microencapsulated crys cr tab 20 meq potassium chloride tab cr 10 meq potassium chloride tab cr 8 meq (600 mg) sodium chloride flush iv soln 0.9% sodium chloride inj 0.9% sodium chloride iv soln 0.9% Uncategorized

Unclassified

*b-complex w/ c & calcium tab*** *b-complex w/ c & e + zn tab*** *b-complex w/ c & folic acid cap 1 mg*** *b-complex w/ c & folic acid tab*** *b-complex w/ c tab** *iron combination cap*** *lactobacillus acidophilus-pectin cap** *multiple vitamin tab** *multiple vitamins w/ iron tab** *multiple vitamins w/ minerals cap** *multiple vitamins w/ minerals chew tab** *multiple vitamins w/ minerals tab cr**

PAGE 109 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS *multiple vitamins w/ minerals tab** *neomycin-bacitracin-polymyxin oint*** *neomycin-bacitracin-polymyxin w/ lidocaine oint 4%*** *nit remover - gel*** *nystatin oral powder* *oral electrolyte tab*** *pe-apap cap & doxylamine-pe-apap cap therapy pack***

*pediatric multiple vitamin liq** AL Up to 9 yrs old

*pediatric multiple vitamin w/ c & fa chew tab** AL Up to 9 yrs old

*pediatric multiple vitamin w/ c soln 35 mg/ml** AL Up to 9 yrs old

*pediatric multiple vitamin w/ extra c & fa chew tab** AL Up to 9 yrs old

*pediatric multiple vitamin w/ minerals & c chew tab 30 mg** AL Up to 9 yrs old

*pediatric multiple vitamin w/ minerals & c chew tab 60 mg** AL Up to 9 yrs old

*pediatric multiple vitamin w/ minerals & c chew tab** AL Up to 9 yrs old

*pediatric multiple vitamin w/ minerals & c drops 45 mg/ml** AL Up to 9 yrs old

*pediatric multiple vitamins w/ iron chew tab 15 mg** AL Up to 9 yrs old

*pediatric multiple vitamins w/ iron drops 10 mg/ml** AL Up to 9 yrs old

*pediatric vitamins acd w/ fluoride soln 0.25 mg/ml*** AL Up to 9 yrs old

*pediatric vitamins acd w/ fluoride soln 0.5 mg/ml*** AL Up to 9 yrs old

*soft contact lens products - solution*** *white petrolatum-mineral oil ophth ointment*** ABREVA CREAM 10 % docosanol ACCU-CHEK TENDER 1 INFUSION KIT QL 100 / 30 days iv sets/tubing ACEROLA C 500 WAFER 500 MG ascorbic acid acetaminophen cap 500 mg acetaminophen chew tab 80 mg acetaminophen elixir 160 mg/5ml

PAGE 110 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS acetaminophen liquid 160 mg/5ml acetaminophen soln 100 mg/ml acetaminophen suppos 120 mg acetaminophen suppos 325 mg acetaminophen susp 80 mg/0.8ml acetaminophen tab 325 mg acetaminophen tab 500 mg acetaminophen tab cr 650 mg acetaminophen w/ dm liq 1000-30 mg/30ml acetaminophen w/ dm liq 160-5 mg/5ml acetaminophen-guaifenesin tab 325-200 mg acetaminophen-guaifenesin tab 650-400 mg ACETIC ACID-ALUMINUM ACETATE SOLUTION 2 % acetic acid-aluminum acetate ACETONE SOLUTION acetone ACIDOPHILUS PLUS PECTIN TAB lactobacillus acidophilus-pectin ACIDOPHILUS/CITRUS PECTIN TAB lactobacillus acidophilus-pectin ACNE MEDICATION LOTION 10 % benzoyl peroxide ACTIPHYTE OF LEMONGRASS LIQUID lemongrass (bulk) ADMINISTRATION SET MISC QL 200 / 30 days iv sets/tubing ADULT ACNOMEL CREAM 2-8 % resorcinol-sulfur

ADULT ASPIRIN LOW STRENGTH TAB DISP 81 MG QL 30 / 30 days aspirin AL 40 to 79 yrs old

ADVIL ALLERGY & CONGESTION TAB 4-10-200 MG chlorpheniramine-phenylephrine-ibuprofen ADVIL ALLERGY SINUS TAB 2-30-200 MG chlorpheniramine-pseudoephedrine-ibuprofen ADVIL COLD & SINUS LIQUI-GELS CAP 30-200 MG pseudoephedrine-ibuprofen

PAGE 111 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

AFLURIA PRESERVATIVE FREE SUSP PRSYR 0.5 ML QL 0.5 / 365 days influenza virus vaccine split preservative free PA

AFLURIA SUSPENSION QL 0.5 / 365 days influenza virus vaccine split PA

AGORAL MAXIMUM STRENGTH LIQUID 25 MG/15ML sennosides AIMSCO LUBRICATED MISC QL 12 / 30 days condoms latex lubricated - male AIR ELIMINATING TPN IV SET MISC QL 200 / 30 days iv sets/tubing ALA-HIST PE TAB 2-10 MG dexbrompheniramine-phenylephrine ALAMAG CHEW TAB 300-150 MG aluminum & magnesium hydroxide ALBATUSSIN NN LIQUID phenyleph-dm-pyril-pot guai-sod cit-citric acid ALCOHOL (RUBBING) SOLUTION 70 % alcohol, rubbing ALCOHOL DENATURED SOLUTION 95 % alcohol, rubbing

PA ALER-DRYL TAB 50 MG diphenhydramine hcl C Covered up to age 65, then PA required ALKA-SELTZER HEARTBURN EFFER TAB 1940-1000 MG sodium bicarbonate-citric acid ALKA-SELTZER PLS ALLERGY & CGH CAP 5-6.25-10-325 MG phenylephrine-doxylamine-dextromethorphan-acetaminophen ALKA-SELTZER PLS NIGHT CLD/FLU CAP 5-6.25-10-325 MG phenylephrine-doxylamine-dextromethorphan-acetaminophen ALKA-SELTZER PLUS COLD & COUGH CAP 5-2-10-325 MG phenylephrine-chlorpheniramine-dm w/ apap ALKA-SELTZER PLUS COLD & COUGH EFFER TAB 7.8-2-10-325 MG phenylephrine-chlorpheniramine-dm-aspirin ALKA-SELTZER PLUS COLD & FLU EFFER TAB 5-2-10-250 MG phenylephrine-chlorpheniramine-dm w/ apap ALKA-SELTZER PLUS DAY/NIGHT MISC phenylephrine-doxylamine-dextromethorphan-aspirin

PAGE 112 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ALKA-SELTZER PLUS NIGHT COLD EFFER TAB 7.8-6.25-10-500 MG phenylephrine-doxylamine-dextromethorphan-aspirin ALKA-SELTZER PLUS SINUS EFFER TAB 7.8-325 MG phenylephrine-aspirin alum & mag hydroxide-simethicone chew tab 200-200-25 mg alum & mag hydroxide-simethicone susp 200-200-20 mg/5ml alum & mag hydroxide-simethicone susp 400-400-40 mg/5ml aluminum hydroxide-magnesium carbonate chew tab 160-105 mg aluminum hydroxide-magnesium carbonate susp 95-358 mg/15ml aluminum hydroxide-magnesium trisilicate chew tab 80-20 mg AMBI 60PSE/400GFN/20DM TAB 60-400-20 MG pseudoephedrine w/ dm-gg AMMONIUM LACTATE SOLUTION 70 % ammonium lactate AMPICILLIN RECON SUSP 125 MG/5ML ampicillin AMPICILLIN RECON SUSP 250 MG/5ML ampicillin ANESTHESIA EXTENSION TUBING MISC QL 200 / 30 days iv sets/tubing ANTACID CHEW TAB 1177 MG calcium carbonate (antacid) ANTACID CHEW TAB 350-150 MG calcium carbonate-mag hydrox antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) APATATE FORTE LIQUID multiple vitamins w/ minerals ARGYLE EXTENSION TUBE 20" MISC QL 200 / 30 days iv sets/tubing ARMOUR THYROID TAB 120 MG thyroid ARMOUR THYROID TAB 15 MG thyroid ARMOUR THYROID TAB 180 MG thyroid ARMOUR THYROID TAB 240 MG thyroid

PAGE 113 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ARMOUR THYROID TAB 300 MG thyroid ascorbic acid cap cr 500 mg ascorbic acid chew tab 100 mg ascorbic acid chew tab 250 mg ascorbic acid chew tab 500 mg ascorbic acid inj 500 mg/ml ascorbic acid liquid 500 mg/5ml ascorbic acid lozenge 60 mg ascorbic acid syrup 500 mg/5ml ascorbic acid tab 100 mg ascorbic acid tab 1000 mg ascorbic acid tab 250 mg ascorbic acid tab 500 mg ascorbic acid tab cr 1000 mg ascorbic acid tab cr 1500 mg ascorbic acid tab cr 500 mg

QL 30 / 30 days

aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg PA

AL 40 to 79 yrs old

QL 30 / 30 days aspirin buffered tab 325 mg AL 40 to 79 yrs old

QL 60 / 30 days

aspirin chew tab 81 mg PA

AL 40 to 79 yrs old

ASPIRIN LOW DOSE TAB 81 MG QL 60 / 30 days aspirin AL 40 to 79 yrs old

aspirin suppos 300 mg aspirin suppos 600 mg

QL 30 / 30 days

aspirin tab 325 mg PA

AL 40 to 79 yrs old

PAGE 114 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS aspirin tab 500 mg

QL 60 / 30 days

aspirin tab 81 mg PA

AL 40 to 79 yrs old

QL 30 / 30 days

aspirin tab delayed release 325 mg PA

AL 40 to 79 yrs old

QL 60 / 30 days aspirin tab delayed release 81 mg AL 40 to 79 yrs old

aspirin-acetaminophen-caffeine tab 250-250-65 mg ASSURE DOSE CONTROL SOLUTION NORMAL blood glucose calibration ATABEX CHEW TAB 18-0.8 MG prenatal without a vit w/ iron carbonyl-folic acid ATABEX EC TAB DR 29-1 MG prenatal vit w/ docusate-iron carbonyl-folic acid ATABEX TAB 65-1 MG prenatal vit w/ iron carbonyl-folic acid ATROPINE SULFATE OINTMENT 1 % atropine sulfate (ophthalmic) AUTOJECT 2 MISC QL 100 / 30 days injection device AUTOPEN DEVICE QL 200 / 30 days injection device for insulin AZOLEN TINCTURE SOLUTION 2 % miconazole nitrate (topical) B-NATAL LOZ HANDLE 25 MG pyridoxine hcl B-NATAL LOZENGE 25 MG pyridoxine hcl B1 NATURAL TAB 250 MG thiamine mononitrate bacitracin oint 500 unit/gm bacitracin zinc oint 500 unit/gm BD ANGIOCATH AUTOGUARD MISC QL 200 / 30 days iv catheter

PAGE 115 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS BD ECLIPSE SYRINGE MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml BD FIRST MIDCATH 18G/4FRX20CM KIT QL 100 / 30 days iv catheter BD FIRST MIDCATH 18G/4FRX20CM MISC QL 200 / 30 days iv catheter BD FIRST MIDCATH 20G/3FRX20CM KIT QL 100 / 30 days iv catheter BD FIRST MIDCATH 20G/3FRX20CM MISC QL 200 / 30 days iv catheter BD FIRST PICC 16G/5FRX65CM KIT QL 100 / 30 days iv catheter BD FIRST PICC 16G/5FRX65CM MISC QL 200 / 30 days iv catheter BD FIRST PICC 18G/4FRX65CM KIT QL 100 / 30 days iv catheter BD FIRST PICC 18G/4FRX65CM MISC QL 200 / 30 days iv catheter BD FIRST PICC 20G/3FRX65CM KIT QL 100 / 30 days iv catheter BD FIRST PICC 20G/3FRX65CM MISC QL 200 / 30 days iv catheter BD FIRST PICC 22G/2.8FRX50CM MISC QL 200 / 30 days iv catheter BD FIRST PICC 26G/1.9FRX50CM KIT QL 100 / 30 days iv catheter BD FIRST PICC 26G/1.9FRX50CM MISC QL 200 / 30 days iv catheter BD INSULIN SYRINGE MISC U-100 1 ML QL 200 / 30 days insulin syringes (disposable) BD INSULIN SYRINGE U-40 MISC 25G X 5/8" 1 ML QL 100 / 30 days insulin syringe/needle u-40 BD INTEGRA SYRINGE MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml BD L-CATH 16G/5FR KIT QL 100 / 30 days iv catheter BD L-CATH 16G/5FRX60CM MISC QL 200 / 30 days iv catheter BD L-CATH 18G/3.5FR KIT QL 100 / 30 days iv catheter

PAGE 116 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS BD L-CATH 18G/3.5FRX60CM MISC QL 200 / 30 days iv catheter BD L-CATH 20G/2.6FR KIT QL 100 / 30 days iv catheter BD L-CATH 20G/2.6FRX60CM MISC QL 200 / 30 days iv catheter BD L-CATH 20G/3FR KIT QL 100 / 30 days iv catheter BD L-CATH 20G/3FRX60CM MISC QL 200 / 30 days iv catheter BD L-CATH 28G/1.2FRX25CM KIT QL 100 / 30 days iv catheter BD L-CATH MIDLINE 18G/3.5FRX20 KIT QL 100 / 30 days iv catheter BD L-CATH MIDLINE 18G/3.5FRX20 MISC QL 200 / 30 days iv catheter BD L-CATH MIDLINE 20G/3FRX20CM MISC QL 200 / 30 days iv catheter BD LUER-LOK SYRINGE MISC 20G X 1" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml BD LUER-LOK SYRINGE MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml BD NEXIVA 18GX1.25" MISC QL 200 / 30 days iv catheter BD NEXIVA 18GX1.75" MISC QL 200 / 30 days iv catheter BD NEXIVA 20GX1" MISC QL 200 / 30 days iv catheter BD NEXIVA 20GX1.25" MISC QL 200 / 30 days iv catheter BD NEXIVA 20GX1.75" MISC QL 200 / 30 days iv catheter BD NEXIVA 22GX1" MISC QL 200 / 30 days iv catheter BD NEXIVA 24GX0.56" MISC QL 200 / 30 days iv catheter BD NEXIVA 24GX0.75" MISC QL 200 / 30 days iv catheter BD SAF-T E-Z SET MISC QL 200 / 30 days iv sets/tubing

PAGE 117 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS BD SAF-T-INTIMA 18G X 1" KIT QL 100 / 30 days iv catheter BD SAF-T-INTIMA 20GX1" MISC QL 200 / 30 days iv catheter BD SAF-T-INTIMA 22G X 0.75" KIT QL 100 / 30 days iv catheter BD SAF-T-INTIMA 22GX3/4" MISC QL 200 / 30 days iv catheter BD SAF-T-INTIMA 24G X 0.75" KIT QL 100 / 30 days iv catheter BD SAF-T-INTIMA 24GX3/4" MISC QL 200 / 30 days iv catheter BD SAFETY-LOK SET MISC QL 200 / 30 days iv sets/tubing BD SAFETY-LOK VACUTAINER SET MISC QL 200 / 30 days iv sets/tubing BD SYRINGE/NEEDLE MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml BD SYRINGE/NEEDLE SLIP TIP MISC 26G X 5/8" 1 ML QL 200 / 30 days syringe/needle (disp) 1 ml BD VACUTAINER SET MISC QL 200 / 30 days iv sets/tubing BENFOTIAMINE CAP 150 MG benfotiamine BENFOTIAMINE-V CAP 150 MG benfotiamine benzocaine dental gel 10% benzocaine dental gel 20% benzocaine dental gel 7.5% benzocaine dental liquid 20% benzocaine dental paste 20% benzocaine dental soln 20% benzocaine dental swab 20% benzocaine-docusate sodium rectal enema 20-283 mg benzonatate cap 100 mg benzonatate cap 200 mg

PAGE 118 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS benzoyl peroxide cleanser 3.5% benzoyl peroxide cream 10% benzoyl peroxide cream 2.5% benzoyl peroxide creamy wash 4% & cleanser lotion kit benzoyl peroxide creamy wash 8% & cleanser lotion kit benzoyl peroxide gel 10% BENZOYL PEROXIDE GEL 2.5 % benzoyl peroxide benzoyl peroxide gel 5% benzoyl peroxide liq 10% benzoyl peroxide liq 2.5% benzoyl peroxide liq 5% benzoyl peroxide lotion 6% BENZYL ALCOHOL LIQUID benzyl alcohol BENZYL BENZOATE LIQUID benzyl benzoate (bulk) BICARSIM FORTE TAB 125 MG simethicone BICARSIM TAB 80 MG simethicone BICLORA LIQUID 12.5-12.5 MG/5ML chlophedianol-chlorcyclizine BICLORA TAB 25-25 MG chlophedianol-chlorcyclizine BICLORA-D LIQUID 30-12.5-12.5 MG/5ML pseudoephedrine-chlorcyclizine-chlophedianol BICLORA-D TAB 60-25-25 MG pseudoephedrine-chlorcyclizine-chlophedianol BIOBRON SF SYRUP 10-15-350 MG/5ML phenylephrine w/ dm-gg BIODESP DM SYRUP 5-15-100 MG/5ML phenylephrine w/ dm-gg BIONATUSS DXP LIQUID 10-2-20 MG/5ML phenylephrine-dexbrompheniramine-dextromethorphan BIONEL LIQUID 30-15-200 MG/5ML pseudoephedrine w/ dm-gg

PAGE 119 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS BIONEL PEDIATRIC LIQUID 15-5-50 MG/5ML pseudoephedrine w/ dm-gg BIOSPEC DMX LIQUID 15-25 MG/5ML dextromethorphan-guaifenesin BIOSUPP LIQUID multiple vitamins w/ minerals BIOTECT PLUS LIQUID multiple vitamins w/ minerals biotin cap 2.5 mg biotin cap 5 mg BIOTIN TAB 10 MG biotin biotin tab 1000 mcg biotin tab 2.5 mg biotin tab 300 mcg biotin tab 5 mg BIOTIN TAB 7500 MCG biotin biotin tab 800 mcg BIOTIN ULTRA STRENGTH CAP 10 MG biotin BIOVOL SYRUP multiple vitamins w/ minerals bisacodyl suppos 10 mg bisacodyl tab delayed release 5 mg bismuth subsalicylate chew tab 262 mg bismuth subsalicylate susp 262 mg/15ml bismuth subsalicylate susp 525 mg/15ml bismuth subsalicylate tab 262 mg BLACK DRAUGHT CHEW TAB 10 MG sennosides BLINK TEARS GEL 0.25 % polyethylene glycol 400 (ophth) BLINK TEARS SOLUTION 0.25 % polyethylene glycol 400 (ophth)

PAGE 120 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS BONE MEAL TAB bone meal w/ vitamin d BP CLEANSING LOTION 4 % benzoyl peroxide BP CLEANSING WASH EMULSION 10-4 % sulfacetamide sodium-sulfur in urea vehicle BPO GEL 4 % benzoyl peroxide BRAINSTRONG PRENATAL MISC 33-0.8 & 350 MG prenatal mv & min w/fe carbonyl-fa-dha BRASIVOL PASTE aluminum oxide BROHIST D TAB 4-10 MG brompheniramine & phenyleph brompheniramine & phenylephrine elixir 1-2.5 mg/5ml brompheniramine & phenylephrine liqd 4-10 mg/5ml brompheniramine & phenylephrine susp 6-10 mg/5ml brompheniramine & pseudoephedrine elixir 1-15 mg/5ml BRONCOTRON PED DROPS LIQUID 2.5-5-100 MG/ML phenylephrine w/ dm-gg BRONCOTRON-D SUSPENSION 10-40-400 MG/10ML phenylephrine w/ dm-gg BRONCOTRON-S LIQUID 20-400 MG/5ML dextromethorphan-guaifenesin BRONKAID TAB 25-400 MG ephedrine-guaifenesin BRONKIDS LIQUID 1.5-0.6-2.75 MG/ML phenylephrine-chlorphen-dm BRONKIDS LIQUID 10-4-10 MG/5ML phenylephrine-chlorphen-dm BRONTUSS DX LIQUID 10-20-200 MG/5ML phenylephrine w/ dm-gg BROVEX PSB DM LIQUID 20-4-20 MG/5ML pseudoephed-bromphen-dm BROVEX PSB LIQUID 4-20 MG/5ML brompheniramine & pseudoeph BUBBLE GUM SYRUP oral vehicles

PAGE 121 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS BUFFERED VITAMIN C CAP 1000 MG ascorbic acid buffered

BUFFERIN TAB 325 MG QL 30 / 30 days aspirin buffered (cal carb-mag carb-mag oxide) AL 40 to 79 yrs old

BURIED TREASURE ACTIVE 55 PLUS LIQUID multiple vitamins w/ minerals butalbital-acetaminophen tab 50-325 mg butalbital-acetaminophen-caffeine tab 50-325-40 mg butalbital-acetaminophen-caffeine tab 50-500-40 mg butalbital-aspirin-caffeine cap 50-325-40 mg cal carb & mag hydrox-simethicone chew tab 675-135-60 mg CAL-MAG CHELA-MAX CAP 70-83 MG calcium w/ magnesium CAL-QUICK LIQUID 500-400 MG-UNT/5ML calcium carbonate-cholecalciferol CAL/MAG TAB 200-100 MG calcium w/ magnesium CALCET CREAMY BITES CHEW TAB 500-400 MG-UNIT calcium citrate-vitamin d calcium carbonate (antacid) chew tab 1000 mg calcium carbonate (antacid) chew tab 400 mg calcium carbonate (antacid) chew tab 420 mg calcium carbonate (antacid) chew tab 500 mg calcium carbonate (antacid) chew tab 600 mg calcium carbonate (antacid) chew tab 750 mg CALCIUM CARBONATE ANTACID TAB 648 MG calcium carbonate (antacid) calcium carbonate susp 1250 mg/5ml (500 mg/5ml elemental ca) calcium carbonate tab 1250 mg (500 mg elemental ca) calcium carbonate-cholecalciferol tab 500 mg-125 unit calcium carbonate-cholecalciferol tab 500 mg-200 unit calcium carbonate-cholecalciferol tab 500 mg-400 unit calcium carbonate-cholecalciferol tab 500 mg-600 unit calcium carbonate-cholecalciferol tab 600 mg-200 unit

PAGE 122 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS calcium carbonate-cholecalciferol tab 600 mg-400 unit calcium carbonate-mag hydroxide chew tab 550-110 mg calcium carbonate-mag hydroxide chew tab 675-135 mg calcium carbonate-mag hydroxide chew tab 700-300 mg calcium carbonate-mag hydroxide susp 400-135 mg/5ml calcium carbonate-simethicone chew tab 1000-60 mg calcium carbonate-vitamin d cap 600 mg-200 unit calcium carbonate-vitamin d tab 250 mg-125 unit calcium carbonate-vitamin d tab 500 mg-125 unit calcium carbonate-vitamin d tab 500 mg-200 unit calcium carbonate-vitamin d tab 500 mg-400 unit calcium carbonate-vitamin d tab 600 mg-125 unit calcium carbonate-vitamin d tab 600 mg-200 unit calcium carbonate-vitamin d tab 600 mg-400 unit CALCIUM CHEW TAB 500-100 MG-UNIT calcium carbonate-cholecalciferol CALCIUM CHEW TAB 600-400 MG-UNIT calcium carbonate-cholecalciferol CALCIUM CITRATE GRANULES 760 MG/3.5GM calcium citrate CALCIUM CITRATE MALATE-VIT D TAB 250-100 MG-UNIT calcium citrate malate-cholecalciferol calcium citrate tab 200 mg calcium citrate tab 950 mg (200 mg elemental ca) calcium citrate-vitamin d tab 250 mg-200 unit (elemental ca) CALCIUM CITRATE-VITAMIN D TAB 250-50 MG-UNIT calcium citrate-vitamin d calcium citrate-vitamin d tab 315 mg-200 unit (elemental ca) CALCIUM CITRATE-VITAMIN D3 LIQUID 1000-400 calcium citrate-vitamin d CALCIUM PANTOTHENATE TAB 100 MG calcium pantothenate CALCIUM PLUS VITAMIN D CAP 300-100 MG-UNIT calcium carbonate-vitamin d

PAGE 123 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS calcium polycarbophil tab 625 mg calcium w/ magnesium tab 250-125 mg calcium w/ vitamin d tab 500 mg-125 unit calcium w/ vitamin d tab 600 mg-200 unit CALCIUM-MAGNESIUM TAB 750-465 MG calcium w/ magnesium CALCIUM-VITAMIN D3 CAP 600-400 MG-UNIT calcium carbonate-cholecalciferol CALCIUM/VITAMIN D3 GUMMIES CHEW TAB 200-200 MG-UNIT calcium phosphate-cholecalciferol camphor inhalant liquid 6.2% CAMPHOR SPIRIT SPIRIT camphor spirit CAPCOF SYRUP 5-2-10 MG/5ML phenylephrine-chlorpheniramine w/ codeine

capecitabine tab 150 mg PA

capecitabine tab 500 mg PA

CAPMIST DM TAB 60-15-400 MG pseudoephedrine w/ dm-gg CAPRON DM LIQUID 7.5-7.5 MG/5ML dextromethorphan-pyrilamine capsaicin cream 0.025% capsaicin cream 0.075% capsaicin cream 0.1% CAPZASIN LIQUID 0.15 % capsaicin carbamide peroxide 6.5% otic soln CARBAPHEN 12 LIQUID 10-4-27.5 MG/5ML phenylephrine-chlorpheniramine-carbetapentane CARBAPHEN CH SUSPENSION 10-4-24 MG/5ML phenylephrine-chlorpheniramine-chlophedianol CARBAPHEN PED CH SUSPENSION 2.5-1.25-8 MG/ML phenylephrine-chlorpheniramine-chlophedianol carboxymethylcellulose sodium ophth gel 1% carboxymethylcellulose sodium ophth soln 0.5%

PAGE 124 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS carboxymethylcellulose-glycerin ophth soln 0.5-0.9% CCP CAFFEINE FREE TAB 325-200-10 MG phenylephrine-acetaminophen-guaifenesin CEFTIN RECON SUSP 250 MG/5ML AL Up to 11 yrs old cefuroxime axetil

cefuroxime axetil for susp 125 mg/5ml AL Up to 11 yrs old

CENTRUM SPECIALIST PRENATAL MISC 27-0.8 & 200 MG prenatal mv & min w/fe fumarate-fa-dha CERALYTE 70 SOLUTION oral electrolytes CERASPORT EX1 SOLUTION oral electrolytes CERASPORT SOLUTION oral electrolytes CERTUSS-D TAB 60-25-400 MG pseudoephedrine-chlophedianol-guaifenesin cetirizine hcl tab 10 mg cetirizine hcl tab 5 mg cetirizine-pseudoephedrine tab sr 12hr 5-120 mg CHERRY CONCENTRATE SYRUP cherry syrup CHERRY SYRUP cherry syrup CHLO TUSS EX LIQUID 12.5-100 MG/5ML chlophedianol-guaifenesin CHLO TUSS LIQUID 30-1-12.5 MG/5ML pseudoephedrine-dexbrompheniramine-chophedianol CHLO TUSS LIQUID 5-1-12.5 MG/5ML phenylephrine-dexbrompheniramine-chlophedianol CHLOPHED LIQUID 5-12.5-100 MG/5ML phenylephrine-chlophedianol-guaifenesin chlordiazepoxide hcl cap 10 mg chlordiazepoxide hcl cap 25 mg chlordiazepoxide hcl cap 5 mg chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg CHLORHEXIDINE GLUCONATE SOLUTION chlorhexidine gluconate (bulk)

PAGE 125 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS CHLOROFORM SOLUTION chloroform chlorphen-pe-apap tab 2-5-325 mg & pe-apap tab 5-325 mg pack chlorphen-phenylephrine w/ apap effer tab 2-5-250 mg chlorphen-phenylephrine w/ apap susp 1-2.5-160 mg/5ml chlorphen-phenylephrine w/ apap tab 2-5-325 mg chlorphen-phenylephrine w/ apap tab 4-10-650 mg chlorphen-pseudoephedrine w/ apap cap 2-30-325 mg chlorphen-pseudoephedrine w/ apap liquid 1-15-160 mg/5ml chlorpheniramine & phenylephrine liquid 1-2 mg/ml chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml chlorpheniramine & phenylephrine liquid 4-10 mg/5ml chlorpheniramine & phenylephrine tab 4-10 mg chlorpheniramine & pseudoephedrine syrup 1-15 mg/5ml chlorpheniramine & pseudoephedrine tab 4-60 mg CHLORPHENIRAMINE MALEATE POWDER chlorpheniramine maleate chlorpheniramine maleate syrup 2 mg/5ml chlorpheniramine maleate tab 4 mg chlorpheniramine maleate tab cr 12 mg chlorpheniramine w/ codeine liquid 2-10 mg/5ml chlorpheniramine-acetaminophen tab 2-325 mg chlorpheniramine-dm liquid 1-5 mg/5ml chlorpheniramine-dm liquid 2-15 mg/5ml chlorpheniramine-dm tab 4-30 mg chlorpheniramine-phenylephrine-asa effer tab 2-7.8-325 mg CHLORPROPAMIDE TAB 100 MG chlorpropamide CHLORPROPAMIDE TAB 250 MG chlorpropamide

cholecalciferol cap 400 unit AL At least 65 yrs old

cholecalciferol tab 1000 unit

PAGE 126 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

QL 60 / 30 days cholecalciferol tab 400 unit AL At least 65 yrs old

cholecalciferol tab 5000 unit choline & magnesium salicylates liq 500 mg/5ml choline & magnesium salicylates tab 1000 mg CIPROFLOXACIN HCL SOLUTION 0.2 % ciprofloxacin hcl (otic) CITROCARBONATE GRAN EFFER 0.78-1.82 GM/DOSE sodium bicarbonate-sodium citrate CITRUS SYRUP SYRUP oral vehicles CLARITIN REDITABS TAB DISP 5 MG loratadine CLASSIC PRENATAL TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid CLEAR EYES FOR DRY EYES SOLUTION 1-0.25 % carboxymethylcellulose-glycerin CLEARCANAL EAR WAX REMOVAL KIT 6.5 % carbamide peroxide & saline CLEMASTINE FUMARATE SYRUP 0.67 MG/5ML clemastine fumarate clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq) clemastine fumarate tab 1.34 mg (1 mg base equiv) clemastine fumarate tab 2.68 mg CLINICAL NUTRIENTS PRENATAL TAB 7.5-0.2 MG prenatal vitamins w/ ferrous succinate-folic acid CLINIPUR 27G INFUSION SET 10MM MISC QL 200 / 30 days iv sets/tubing CLINIPUR 27G INFUSION SET 6MM MISC QL 200 / 30 days iv sets/tubing CLINIPUR 27G INFUSION SET 8MM MISC QL 200 / 30 days iv sets/tubing CLOFERA LIQUID 12.5-30 MG/5ML chlophedianol-pseudoephedrine clotrimazole cream 1% clotrimazole vaginal cream 1%

PAGE 127 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS clotrimazole vaginal cream 2% CLUSIMAR SYRUP multiple vitamins w/ minerals CO-NATAL FA TAB prenatal vit w/ ferrous fumarate-folic acid CODAR AR LIQUID 2-8 MG/5ML chlorpheniramine w/ codeine CODAR D LIQUID 30-8 MG/5ML pseudoephedrine w/ codeine CODITUSS DM SYRUP 5-8.33-10 MG/5ML phenylephrine-pyrilamine-dm

QL 270 / 30 days COMMIT 2 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days COMMIT 4 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days COMMIT LOZENGE 2 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days COMMIT LOZENGE 4 MG nicotine polacrilex C 90 days of coverage per year COMPLETE FORMULATION PEDIATRIC SOLUTION 45 MG/0.5ML AL Up to 9 yrs old pediatric multiple vitamin w/ minerals & c COMPLETE NATAL DHA MISC 29-1-200 & 250 MG prenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 COMPLETE NUTRITIONAL DRINK POWDER nutritional supplements COMPLETE PRENATAL/DHA MISC 30-0.975 & 300 MG prenatal without a w/ fe bisglycinate-fa-dha COMPLETE SINUS RELIEF TAB 2-10-500 MG dexbrompheniramine-phenylephrine-acetaminophen COMPLETENATE CHEW TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid CONCEPTIONXR MOTILITY SUPPORT MISC multiple vitamins w/ minerals CONDOMS MISC QL 12 / 30 days condoms - male

PAGE 128 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS CONEX COLD/ALLERGY SOLUTION 1-30 MG/5ML dexbrompheniramine & pseudoephedrine CONEX COLD/ALLERGY TAB 2-60 MG dexbrompheniramine & pseudoephedrine CONTAC COLD+FLU MAX ST TAB 2-5-500 MG chlorpheniramine-phenylephrine-acetaminophen CONTAC COLD/FLU DAY & NIGHT MISC 2-5-500 & 5-500 MG chlorpheniramine-phenylephrine-acetaminophen CONTAC COLD/FLU DAY & NIGHT TAB 2-5-500 MG chlorpheniramine-phenylephrine-acetaminophen CONTAC COLD/FLU MAX ST TAB 2-5-500 MG chlorpheniramine-phenylephrine-acetaminophen COOL MIST HUMIDIFIER MISC humidifiers CORICIDIN HBP DAY/NIGHT COLD MISC 10-20 &15-200-2 MG dextromethorphan-guaifenesin-chlorpheniramine-acetaminophen CORICIDIN NIGHTTIME COLD-COUGH LIQUID 12.5-325 MG/15ML diphenhydramine-acetaminophen CORNWALL METAL PIPETTING MISC QL 100 / 30 days injection device CORRECTOL HERBAL TEA MISC 30 MG senna COTTONSEED OIL cottonseed oil (bulk) COTTONSEED OIL OIL cottonseed oil (bulk) CPB WC LIQUID 10-1.3-6.3 MG/5ML pseudoephedrine-brompheniramine-codeine cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) CRYOSERV SOLUTION dimethyl sulfoxide (bulk) CULTURELLE CAP lactobacillus rhamnosus (gg) CULTURELLE DIGESTIVE HEALTH CAP lactobacillus-inulin CULTURELLE DIGESTIVE HEALTH CHEW TAB lactobacillus-inulin CULTURELLE HEALTH & WELLNESS CAP lactobacillus-inulin

PAGE 129 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS CULTURELLE IMMUNITY SUPPORT CAP lactobacillus rhamnosus (gg) CVS CHEST CONGESTION CHILDRENS PACKET 100 MG guaifenesin CVS DIABETES HEALTH SUPPORT MISC multiple vitamins w/ minerals CVS EAR WAX CLEANSING SYSTEM KIT 6.5 % carbamide peroxide & saline CVS ETHYL ALCOHOL SOLUTION 70 % alcohol, usp CVS ISOPROPYL ALCOHOL SOLUTION 70 % isopropyl alcohol CVS ISOPROPYL ALCOHOL SOLUTION 91 % isopropyl alcohol CVS ISOPROPYL RUBBING ALCOHOL SOLUTION 70 % isopropyl alcohol CVS NATURAL FIBER SUPPLEMENT PACKET 58.6 % psyllium CVS PRENATAL GUMMY CHEW TAB 0.4-113.5 MG prenatal multivitamins & minerals w/ folic acid-fish oil CVS PRENATAL MULTI+DHA CAP 27-0.8-250 MG prenatal mv & min w/fe fumarate-fa-dha CVS PRENATAL TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid CVS VITAMIN C CHEW TAB 1000 MG ascorbic acid CVS WOMENS PRENATAL+DHA MISC 28-0.975 & 200 MG prenatal mv & min w/fe fumarate-fa-dha cyanocobalamin inj 1000 mcg/ml cyanocobalamin tab 1000 mcg cyclopentolate hcl ophth soln 1% CYTRA-3 SYRUP 550-500-334 MG/5ML pot & sod citrates w/citric ac DAILY ENERGY ENFUSION POWDER multiple vitamins w/ minerals DAILY HEART HEALTH SUPPORT MISC multiple vitamins w/ minerals DAILY PAK MAXIMUM MULTIVITAMIN MISC multiple vitamins w/ minerals

PAGE 130 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS DALLERGY LIQUID 1-2.5 MG/ML chlorpheniramine & phenylephrine DALLERGY TAB 1-5 MG dexbrompheniramine-phenylephrine DALLERGY TAB 25-10 MG chlorcyclizine-phenylephrine DAYTIME COLD MEDICINE LIQUID 325-15 MG/15ML acetaminophen w/ dm DECON-A ELIXIR 2-5 MG/5ML brompheniramine & phenyleph DECON-A LIQUID 2-5 MG/ML brompheniramine & phenyleph DECON-G LIQUID 2-1-40 MG/ML phenylephrine-brompheniramine-guaifenesin DELTUSS DP LIQUID 1-30 MG/5ML dexchlorpheniramine & pseudoephedrine DELZICOL CAP DR 400 MG QL 180 / 30 days mesalamine DENTURE ADHESIVE CREAM QL 60 / 30 days denture care products DESGEN DM SYRUP 5-15-100 MG/5ML phenylephrine w/ dm-gg DESPEC DM SYRUP 5-15-100 MG/5ML phenylephrine w/ dm-gg DESPEC-DM TAB 40-30-400 MG pseudoephedrine w/ dm-gg DEWEES CARMINATIVE LIQUID 6-250 magnesium oxide-asafoetida DEX-TUSS LIQUID 300-10 MG/5ML guaifenesin-codeine DEXAMETHASONE SOLUTION 0.5 MG/5ML dexamethasone dexbrompheniramine & pseudoephedrine tab sr 12hr 6-120 mg DEXCHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML dexchlorpheniramine maleate DEXPAK 10 DAY TAB 1.5 MG dexamethasone DEXPAK 13 DAY TAB 1.5 MG dexamethasone

PAGE 131 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS DEXPAK 6 DAY TAB 1.5 MG dexamethasone dextromethorphan hbr syrup 15 mg/5ml dextromethorphan-apap-chlorpheniramine susp 5-160-1 mg/5ml dextromethorphan-apap-chlorpheniramine tab 15-500-2 mg dextromethorphan-doxylamine-apap cap 15-6.25-325 mg dextromethorphan-doxylamine-apap liquid 15-6.25-325 mg/15ml dextromethorphan-doxylamine-apap liquid 30-12.5-1000 mg/30ml dextromethorphan-guaifenesin cap 10-200 mg dextromethorphan-guaifenesin liquid 10-100 mg/5ml dextromethorphan-guaifenesin liquid 10-200 mg/15ml dextromethorphan-guaifenesin liquid 10-200 mg/5ml dextromethorphan-guaifenesin liquid 20-300 mg/5ml dextromethorphan-guaifenesin liquid 30-200 mg/5ml dextromethorphan-guaifenesin liquid 5-100 mg/5ml dextromethorphan-guaifenesin syrup 10-100 mg/5ml dextromethorphan-guaifenesin tab 20-400 mg dextromethorphan-guaifenesin tab sr 12hr 30-600 mg dextromethorphan-guaifenesin tab sr 12hr 60-1200 mg dextromethorphan-phenylephrine-apap cap 10-5-325 mg dextromethorphan-phenylephrine-apap liqd 10-5-325 mg/15ml dextromethorphan-phenylephrine-apap powd pack 20-10-650 mg dextromethorphan-phenylephrine-apap tab 10-5-325 mg DI-GEL CHEW TAB 280.8-128-20 MG cal carb & mag hydrox-simeth DI-GEL SUSPENSION 282-87-25 MG/5ML alum & mag hydrox-simethicone DIABETES HEALTH MISC multiple vitamins w/ minerals DIABETES SUPPORT MISC multiple vitamins w/ minerals DIABETIC TUSSIN COLD & FLU LIQUID 10-12.5-325 MG/5ML dextromethorphan-diphenhydramine-acetaminophen

PAGE 132 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS DIABETIC TUSSIN NIGHT COLD/FLU LIQUID 10-12.5-325 MG/5ML dextromethorphan-diphenhydramine-acetaminophen DIALYVITE SUPREME D TAB 3 MG multiple vitamins w/ minerals & folic acid DICEL CD LIQUID 30-2-12.5 MG/5ML pseudoephedrine-brompheniramine-chlophedianol DIMENHYDRINATE SOLUTION 50 MG/ML dimenhydrinate dimenhydrinate tab 50 mg DIMETAPP COLD/ALLERGY CHEW TAB 1-2.5 MG brompheniramine & phenyleph DIMETAPP LONG ACT COUGH/COLD SYRUP 1-7.5 MG/5ML chlorpheniramine-dm DIMETHYL SULFOXIDE SOLUTION dimethyl sulfoxide (bulk) DIMETHYL SULFOXIDE SOLUTION 100 % dimethyl sulfoxide (bulk) DINO-LIFE W/IRON-ZINC CHEW TAB 30-200-3 AL Up to 9 yrs old pediatric multiple vitamins w/ iron diphenhydramine hcl (sleep) cap 25 mg diphenhydramine hcl (sleep) cap 50 mg diphenhydramine hcl (sleep) liquid 50 mg/30ml diphenhydramine hcl (sleep) tab 25 mg diphenhydramine hcl (sleep) tab 50 mg diphenhydramine hcl (sleep) tab disp 25 mg

PA diphenhydramine hcl cap 25 mg C Covered up to age 65, then PA required

PA diphenhydramine hcl cap 50 mg C Covered up to age 65, then PA required

PA diphenhydramine hcl chew tab 12.5 mg C Covered up to age 65, then PA required

PA diphenhydramine hcl elixir 12.5 mg/5ml C Covered up to age 65, then PA required

PAGE 133 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

PA diphenhydramine hcl liquid 12.5 mg/5ml C Covered up to age 65, then PA required

PA diphenhydramine hcl syrup 12.5 mg/5ml C Covered up to age 65, then PA required

PA diphenhydramine hcl tab 25 mg C Covered up to age 65, then PA required

PA diphenhydramine hcl tab disp 12.5 mg C Covered up to age 65, then PA required diphenhydramine-acetaminophen tab 12.5-325 mg diphenhydramine-acetaminophen tab 12.5-500 mg diphenhydramine-acetaminophen tab 25-500 mg diphenhydramine-acetaminophen tab 25-500 mg (sleep) diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml diphenhydramine-phenylephrine soln 12.5-5 mg/5ml diphenhydramine-phenylephrine tab 25-10 mg diphenhydramine-phenylephrine-apap liq 12.5-5-325 mg/10ml diphenhydramine-phenylephrine-apap liq 12.5-5-325 mg/15ml diphenhydramine-phenylephrine-apap liq 6.25-2.5-160 mg/5ml diphenhydramine-phenylephrine-apap packet 25-10-650 mg diphenhydramine-phenylephrine-apap susp 12.5-2.5-160 mg/5ml diphenhydramine-phenylephrine-apap tab 12.5-5-325 mg diphenhydramine-phenylephrine-apap tab 25-10-650 mg diphenhydramine-phenylephrine-apap tab 25-5-325 mg diphenhydramine-pse w/ apap tab 12.5-30-500 mg

DIURIL SUSPENSION 250 MG/5ML QL 600 / 30 days chlorothiazide AL Up to 12 yrs old

docusate calcium cap 240 mg docusate sodium cap 100 mg docusate sodium cap 250 mg

PAGE 134 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS docusate sodium cap 50 mg docusate sodium enema 283 mg docusate sodium liquid 150 mg/15ml docusate sodium syrup 60 mg/15ml docusate sodium tab 100 mg DOCUSOL KIDS ENEMA 100 MG/5ML docusate sodium DOLOGEN TAB 2-650 MG dexbrompheniramine-acetaminophen DOLOMITE TAB 130-78 MG dolomite DOMETUSS-DA/CHILDREN LIQUID 1-2.5 MG/5ML chlorpheniramine & phenylephrine doxylamine-dm 6.25-15 mg/15ml & dm 15 mg/15ml liqd ther pack doxylamine-dm liquid 6.25-15 mg/15ml doxylamine-phenylephrine-apap cap 6.25-5-325 mg DRAMAMINE CHEW TAB 50 MG dimenhydrinate DULCOLAX BOWEL PREP KIT KIT bisacodyl DURAVENT PE TAB 10-395 MG phenylephrine-guaifenesin dyphylline-guaifenesin liqd 100-100 mg/5ml dyphylline-guaifenesin tab 200-200 mg E-Z-GAS II PACKET 2.21-1.53-0.04 GM sodium bicarb-citric acid w/ simethicone EAR WAX CLEANSING KIT 6.5 % carbamide peroxide & saline EASIVENT MASK LARGE MISC QL 2 / 365 days spacer/aerosol-holding chambers EASIVENT MASK MEDIUM MISC QL 2 / 365 days spacer/aerosol-holding chambers EASIVENT MASK SMALL MISC QL 2 / 365 days spacer/aerosol-holding chambers EASIVENT MISC QL 2 / 365 days spacer/aerosol-holding chambers

PAGE 135 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS EASY TOUCH FLURINGE MISC 25G X 1" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml EASY TOUCH FLURINGE MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml EASY TOUCH SAFETY SYRINGE MISC 25G X 1" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml EASY TOUCH SAFETY SYRINGE MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml

ECOTRIN TAB DR 325 MG QL 30 / 30 days aspirin AL 40 to 79 yrs old

ED CHLORPED D LIQUID 2-5 MG/ML chlorpheniramine & phenylephrine ED CHLORPED LIQUID 2 MG/ML chlorpheniramine maleate ED-CHLOR-TAN TAB 8 MG chlorpheniramine tannate EFFACLAR DUO SOLUTION 5.5 % benzoyl peroxide ELDERTONIC ELIXIR multiple vitamins w/ minerals ELEXA NATURAL FEEL MISC QL 12 / 30 days condoms latex lubricated - male ELEXA STIMULATING MISC QL 12 / 30 days condoms latex lubricated - male ELEXA ULTRA SENSITIVE MISC QL 12 / 30 days condoms latex lubricated - male ELITE IRON TAB 15 MG ferrous bisglycinate chelate ELLIS TONIC ELIXIR multiple vitamins w/ minerals ENDACON SYRUP 10-20-100 MG/5ML phenylephrine w/ dm-gg ENERGY BOOSTER PACKET multiple vitamins w/ minerals ENFALYTE SOLUTION oral electrolytes ENFAMIL ENFALYTE SOLUTION oral electrolytes

PAGE 136 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ENFAMIL EXPECTA MISC 28-0.8 & 200 MG prenatal mv & min w/fe fumarate-fa-dha ENTEX LQ LIQUID 10-100 MG/5ML phenylephrine-guaifenesin ENTEX T TAB 60-375 MG pseudoephedrine-guaifenesin ENTRE-COUGH TANNATE SUSPENSION 30-15-175 MG/5ML pseudoephedrine hcl-dextromethorphan hbr-guaifenesin tannate ephedrine-guaifenesin tab 12.5-200 mg EQL CALCIUM/VITAMIN D CAP 600-100 MG-UNIT calcium carbonate-cholecalciferol EQL ETHYL ALCOHOL (RUBBING) SOLUTION 70 % alcohol, rubbing EQL INFANTS DECONGESTANT/COUGH SOLUTION 7.5-2.5 MG/0.8ML pseudoephedrine-dm EQL ISOPROPYL ALCOHOL SOLUTION 91 % isopropyl alcohol EQL NATURAL FIBER POWDER 92 % psyllium EQL PRENATAL FORMULA TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid EQL SUPER ENERGY BOOSTER PACKET multiple vitamins w/ minerals EQL VITAMIN D-3 HIGH POTENCY TAB 115-2000 MG-UNIT calcium phosphate-cholecalciferol EQUALACTIN CHEW TAB 625 MG calcium polycarbophil

ergocalciferol cap 50000 unit QL 4 / 28 days

estazolam tab 1 mg estazolam tab 2 mg

QL 21 / 28 days esterified estrogens & methyltestosterone tab 0.625-1.25 mg GL Female

QL 21 / 28 days esterified estrogens & methyltestosterone tab 1.25-2.5 mg GL Female

ETHER SOLUTION ether

PAGE 137 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ETHYL ALCOHOL (RUBBING) SOLUTION 70 % alcohol, rubbing ETHYL ALCOHOL SOLUTION 95 % alcohol, rubbing ETHYL ALCOHOL SOLUTION 95 % alcohol, usp EUGENOL SOLUTION eugenol (bulk) EVAC-U-GEN CHEW TAB 10 MG sennosides EZFE FORTE CAP 155-1 MG prenatal without vit a w/ iron polysaccharide complex-fa FAMOTIDINE PREMIXED SOLUTION 20-0.9 MG/50ML-% famotidine in nacl FANTASY LUBRICATED MISC QL 12 / 30 days condoms latex lubricated - male FANTASY LUBRICATED/SPERMICIDE MISC QL 12 / 30 days condoms latex lubricated - male FATHER JOHNS MEDICINE PLUS SOLUTION 10-4-10 MG/30ML phenylephrine-chlorphen-dm fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg FENESIN DM IR TAB 15-400 MG dextromethorphan-guaifenesin

FER-IN-SOL SOLUTION 75 (15 FE) MG/ML PA ferrous sulfate AL Up to 12 yrs old

FERATE TAB 256 (28 FE) MG ferrous gluconate FERRETTS IPS SOLUTION 40 MG/15ML iron succinyl-protein complex FERRIMIN 150 TAB 150 MG ferrous fumarate FERROUS FUMARATE TAB 29 MG ferrous fumarate ferrous fumarate tab 325 mg (106 mg elemental fe) FERROUS FUMARATE TAB 90 MG ferrous fumarate

PAGE 138 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS FERROUS GLUCONATE TAB 225 (27 FE) MG ferrous gluconate ferrous gluconate tab 240 mg (27 mg elemental fe) ferrous gluconate tab 324 mg (37.5 mg elemental iron) ferrous gluconate tab 325 mg (36 mg elemental fe) ferrous sulfate dried tab 200 mg (65 mg elemental fe) ferrous sulfate dried tab cr 160 mg (50 mg fe equivalent) ferrous sulfate dried tab cr 45 mg (fe equivalent)

PA ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) AL Up to 12 yrs old

FERROUS SULFATE GRANULES ferrous sulfate

PA ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) AL Up to 12 yrs old

FERROUS SULFATE SYRUP 300 (60 FE) MG/5ML AL Up to 12 yrs old ferrous sulfate ferrous sulfate tab 134 mg (27 mg elemental fe) ferrous sulfate tab 27 mg (elemental fe) ferrous sulfate tab 325 mg (65 mg elemental fe) ferrous sulfate tab cr 142 mg (45 mg fe equivalent) ferrous sulfate tab cr 47.5 mg (elemental fe) ferrous sulfate tab ec 325 mg (65 mg fe equivalent) ferrous sulfate-vit c-folic acid tab cr 105-500-0.8 mg fexofenadine hcl tab 180 mg FIRST-LANSOPRAZOLE SUSPENSION 3 MG/ML QL 150 / 30 days lansoprazole FIRST-OMEPRAZOLE SUSPENSION 2 MG/ML QL 150 / 30 days omeprazole FIRST-PROGESTERONE VGS 100 SUPPOS 100 MG progesterone (vaginal) FIRST-PROGESTERONE VGS 200 SUPPOS 200 MG progesterone (vaginal) FIRST-PROGESTERONE VGS 25 SUPPOS 25 MG progesterone (vaginal)

PAGE 139 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS FIRST-PROGESTERONE VGS 400 SUPPOS 400 MG progesterone (vaginal) FIRST-PROGESTERONE VGS 50 SUPPOS 50 MG progesterone (vaginal) FIRST-VANCOMYCIN 25 SOLUTION 25 MG/ML QL 300 / 15 days vancomycin hcl FIRST-VANCOMYCIN 50 SOLUTION 50 MG/ML QL 150 / 15 days vancomycin hcl FLAVOR BLEND SUSPENSION oral vehicles FLAVOR PLUS LIQUID oral vehicles FLAVOR SWEET SYRUP oral vehicles FLAVOR SWEET-SF LIQUID oral vehicles FLEET BISACODYL ENEMA 10 MG/30ML bisacodyl FLU & SORE THROAT PACKET 20-10-650 MG pheniramine-phenylephrine-acetaminophen FLUARIX QUADRIVALENT SUSP PRSYR 0.5 ML QL 0.5 / 365 days influenza virus vaccine split quadrivalent

FLUARIX SUSP PRSYR 0.5 ML QL 0.5 / 365 days influenza virus vaccine split preservative free PA

FLUCELVAX SUSP PRSYR 0.5 ML QL 0.5 / 365 days influenza virus vaccine tissue-cultured subunit PA

FLUID ADMINISTRATION SET MISC QL 200 / 30 days iv sets/tubing

FLULAVAL SUSPENSION QL 0.5 / 365 days influenza virus vaccine split PA

flurazepam hcl cap 15 mg FLURAZEPAM HCL CAP 15 MG flurazepam hcl flurazepam hcl cap 30 mg FLURAZEPAM HCL CAP 30 MG flurazepam hcl

PAGE 140 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

FLUVIRIN PRESERVATIVE FREE SUSP PRSYR 0.5 ML QL 0.5 / 365 days influenza virus vaccine types a & b preservative free PA

FLUVIRIN SUSP PRSYR 0.5 ML QL 0.5 / 365 days influenza virus vaccine types a & b surface antigen PA

FLUVIRIN SUSPENSION QL 0.5 / 365 days influenza virus vaccine types a & b surface antigen PA

FLUZONE PEDIATRIC PF SUSP PRSYR 0.25 ML QL 0.25 / 365 days influenza virus vaccine split preservative free PA

FLUZONE PRESERVATIVE FREE SUSP PRSYR 0.5 ML QL 0.5 / 365 days influenza virus vaccine split preservative free PA

FLUZONE PRESERVATIVE FREE SUSPENSION QL 0.5 / 365 days influenza virus vaccine split preservative free PA

FLUZONE QUADRIVALENT SUSP PRSYR 0.5 ML QL 0.5 / 365 days influenza virus vaccine split quadrivalent FLUZONE QUADRIVALENT SUSPENSION 0.5 ML QL 0.5 / 365 days influenza virus vaccine split quadrivalent

FLUZONE SUSP PEN 9 MCG/STRAIN QL 0.1 / 365 days influenza virus vaccine split PA

FLUZONE SUSPENSION QL 0.5 / 365 days influenza virus vaccine split PA

FOLGARD OS TAB 500-1.1 MG QL 30 / 30 days multiple vitamins w/ minerals & calcium-folic acid AL 14 to 50 yrs old

folic acid tab 1 mg

QL 30 / 30 days

PA folic acid tab 400 mcg GL Female

AL 14 to 50 yrs old

QL 30 / 30 days

PA folic acid tab 800 mcg GL Female

AL 14 to 50 yrs old

PAGE 141 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS FORTAVIT LIQUID multiple vitamins w/ minerals FREESTYLE CONTROL SOLUTION LIQUID blood glucose calibration FREESTYLE LITE TEST STRIP PA glucose blood FREESTYLE TEST STRIP PA glucose blood FUNGOID TINCTURE SOLUTION 2 % miconazole nitrate (topical) G-DOLOGEN TAB 2-650 MG dexbrompheniramine-acetaminophen G-P-TUSS DXP LIQUID 10-2-20 MG/5ML phenylephrine-dexbrompheniramine-dextromethorphan G-TRON PEDIATRIC DROPS LIQUID 2.5-5-100 MG/ML phenylephrine w/ dm-gg G-TUSICOF LIQUID 10-20-400 MG/5ML phenylephrine w/ dm-gg G-ZYNCOF SYRUP 20-400 MG/5ML dextromethorphan-guaifenesin GAS-X CHILDRENS STRIP 40 MG simethicone GAS-X EXTRA STRENGTH STRIP 62.5 MG simethicone GAS-X WITH MAALOX EX ST CHEW TAB 500-125 MG calcium carbonate-simethicone GAVISCON CHEW TAB 80-14.2 MG aluminum hydroxide-mag trisil GAVISCON EXTRA RELIEF FORMULA SUSPENSION 508-475 MG/10ML aluminum hydroxide-mag carb GENTEAL GEL 0.25-0.3 % carboxymethylcellulose-hypromellose GENTEAL SEVERE GEL 0.3 % hypromellose (ophth) GILTUSS PED-C LIQUID 2.5-3-50 MG/ML phenylephrine w/ codeine-gg GILTUSS TR CAP 7-14-288 MG phenylephrine w/ dm-gg GLUCOCARD EXPRESSION CONTROL SOLUTION blood glucose calibration

PAGE 142 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS GLUCOCARD EXPRESSION TEST STRIP glucose blood GLUCOCARD VITAL TEST STRIP glucose blood glucose gel 40% GLYCERIN LIQUID glycerin (bulk) GLYCERIN SOLUTION glycerin (bulk) glycerin suppos 1 gm glycerin suppos 1.2 gm glycerin suppos 2 gm glycerin suppos 2.1 gm glycerin suppos 80.7% glycerin topical liquid glycerin-hypromellose-peg 400 ophth soln 0.2-0.2-1% GLYCERINE LIQUID glycerin (bulk) GLYCEROL FORMAL LIQUID glycerin (bulk) GLYCEROL LIQUID glycerin (bulk) GLYCINE SOYA EXTRACT SOLUTION soybean (bulk) GLYCINE SOYA PROTEIN SOLUTION soybean protein (bulk) GNP ALCOHOL DENATURED SOLUTION alcohol, rubbing GNP CAPSAICIN LIQUID 0.15 % capsaicin GNP DAILY PRENATAL MISC 28-0.8 & 440 MG prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids GNP ETHYL ALCOHOL SOLUTION 70 % alcohol, usp GNP ETHYL RUBBING ALCOHOL SOLUTION 70 % alcohol, usp GNP FLU & SORE THROAT PACKET 20-10-650 MG pheniramine-phenylephrine-acetaminophen

PAGE 143 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS GNP ISOPROPYL ALCOHOL SOLUTION 70 % isopropyl alcohol GNP ISOPROPYL ALCOHOL SOLUTION 91 % isopropyl alcohol GNP PEPPERMINT SPIRIT SPIRIT peppermint spirit GNP PRENATAL TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid GNP PRENATAL VITAMINS TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid GNP RI-MAG PLUS SUSPENSION 540-40 MG/5ML magaldrate w/ simethicone GNP SODIUM SILICATE SOLUTION sodium silicate GONIOVISC SOLUTION 2 % hypromellose (ophth) GOODSENSE PRENATAL VITAMINS TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid GRAPE SYRUP SYRUP oral vehicles GUAIACOL SOLUTION guaiacol guaifenesin liquid 100 mg/5ml guaifenesin liquid 200 mg/5ml GUAIFENESIN POWDER guaifenesin guaifenesin syrup 100 mg/5ml guaifenesin tab 200 mg guaifenesin tab 400 mg guaifenesin tab sr 12hr 600 mg guaifenesin-codeine liquid 225-7.5 mg/5ml guaifenesin-codeine soln 100-10 mg/5ml guaifenesin-codeine soln 100-6.3 mg/5ml GYNAZOLE-1 CREAM 2 % butoconazole nitrate (one dose) H 468L TUBING MISC QL 200 / 30 days iv sets/tubing

PAGE 144 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS HC DERMAPAX LIQUID 0.5-0.5 % hydrocortisone-diphenhydramine hcl HEALTHY MAMA BE WELL ROUNDED THER PACK 28-0.8 & 450 MG prenatal vit w/ fe bisglycinate-folic acid-omega 3 fatty acd HERBAL EXPEC LIQUID 150 MG/15ML guaifenesin HIGH POTENCY IRON CAP 86 (27 FE) MG ferrous fumarate HISTEX-DM SYRUP 10-2.5-20 MG/5ML phenylephrine-triprolidine-dextromethorphan HISTEX-PE SYRUP 2.5-10 MG/5ML triprolidine-phenylephrine HM ETHYL RUBBING ALCOHOL SOLUTION 70 % alcohol, usp HM ISOPROPYL ALCOHOL SOLUTION 70 % isopropyl alcohol HM ISOPROPYL ALCOHOL SOLUTION 91 % isopropyl alcohol HM ONE DAILY PRENATAL MISC 28-0.8 & 440 MG prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids HM PRENATAL TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid homatropine hbr ophth soln 5% HONEY BEARS W/IRON-ZINC CHEW TAB 30-200-3 AL Up to 9 yrs old pediatric multiple vitamins w/ iron HUBER INFUSION SET MISC QL 200 / 30 days iv sets/tubing HUMAPEN LUXURA HD DEVICE QL 200 / 30 days injection device for insulin HUMAPEN MEMOIR DEVICE QL 200 / 30 days injection device for insulin HUMATROPEN FOR 12MG DEVICE QL 100 / 30 days injection device HUMATROPEN FOR 24MG DEVICE QL 100 / 30 days injection device HUMATROPEN FOR 6MG DEVICE QL 100 / 30 days injection device HYDROCIL PACKET 95 % psyllium

PAGE 145 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml hydrocodone w/ homatropine syrup 5-1.5 mg/5ml hydrocodone w/ homatropine tab 5-1.5 mg

hydrocortisone acetate cream 1% QL 60 / 30 days

hydrocortisone acetate oint 1% QL 60 / 30 days

hydrocortisone acetate suppos 25 mg QL 28 / 14 days

hydrocortisone acetate suppos 30 mg QL 28 / 14 days

hydrocortisone gel 1% QL 60 / 30 days

hydrocortisone soln 1% QL 90 / 30 days

hydrocortisone-aloe vera cream 0.5% QL 90 / 30 days

hydrocortisone-aloe vera cream 1% QL 90 / 30 days

HYDROXYPROGESTERONE CAPROATE POWDER hydroxyprogesterone caproate (bulk) hyoscyamine sulfate elixir 0.125 mg/5ml hyoscyamine sulfate soln 0.125 mg/ml hyoscyamine sulfate tab 0.125 mg hyoscyamine sulfate tab disp 0.125 mg hyoscyamine sulfate tab sl 0.125 mg hyoscyamine sulfate tab sr 12hr 0.375 mg HYPERRHO S/D SOLN PRSYR 1500 UNIT rho d immune globulin (human) hypromellose gonioscopic soln 2.5% hypromellose ophth soln 0.3% hypromellose ophth soln 0.4% ibuprofen cap 200 mg ibuprofen-diphenhydramine citrate tab 200-38 mg IMMUNE SUPPORT VITAMIN C PACKET multiple vitamins w/ minerals IMODIUM A-D CHEW TAB 2 MG loperamide hcl INATAL ADVANCE TAB prenatal vit w/ docusate-iron carbonyl-folic acid

PAGE 146 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS INATAL GT TAB prenatal vit w/ docusate-iron carbonyl-folic acid INATAL ULTRA TAB prenatal vit w/ docusate-iron carbonyl-folic acid INFERGEN INJECTABLE 15 MCG/0.5ML PA interferon alfacon-1 INFERGEN INJECTABLE 9 MCG/0.3ML PA interferon alfacon-1 INFUSION SET 23" COMFORT MISC QL 200 / 30 days iv sets/tubing INFUSION SET MISC QL 200 / 30 days iv sets/tubing INJECT-EASE AUTOMATIC INJECTOR MISC QL 100 / 30 days injection device INJECT-EASE MISC QL 100 / 30 days injection device INSUFLON MISC 25G X 0.71" QL 200 / 30 days subcutaneous soft cannula INSYTE AUTOGUARD 14GX1.75" MISC QL 200 / 30 days iv catheter INSYTE AUTOGUARD 18GX1.16" MISC QL 200 / 30 days iv catheter INSYTE AUTOGUARD 20GX1" MISC QL 200 / 30 days iv catheter INSYTE AUTOGUARD 20GX1.16" MISC QL 200 / 30 days iv catheter INSYTE AUTOGUARD 22GX1" MISC QL 200 / 30 days iv catheter INSYTE AUTOGUARD 24GX3/4" MISC QL 200 / 30 days iv catheter INTERLINK INJECT SITE/LUER LOC MISC QL 200 / 30 days iv sets/tubing INVOKANA TAB 100 MG PA canagliflozin INVOKANA TAB 300 MG PA canagliflozin IONIL SHAMPOO 2-0.2 % salicylic acid-benzalkonium chloride IRON (FERROUS GLUCONATE) TAB 256 (28 FE) MG ferrous gluconate

PAGE 147 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS iron polysacch complex-vit b12-fa cap 150-0.025-1 mg IRON UP LIQUID 15 MG/0.5ML polysaccharide iron complex ISONIAZID SYRUP 50 MG/5ML isoniazid ISOPROPANOL SOLUTION 70 % isopropyl alcohol ISOPROPYL ALCOHOL SOLUTION isopropyl alcohol ISOPROPYL ALCOHOL SOLUTION 50 % isopropyl alcohol ISOPROPYL ALCOHOL SOLUTION 70 % isopropyl alcohol ISOPROPYL ALCOHOL SOLUTION 91 % isopropyl alcohol ISOPROPYL ALCOHOL WIPES MISC 70 % isopropyl alcohol (skin cleanser) ISOPROPYL PALMITATE LIQUID isopropyl palmitate ISOPTO TEARS SOLUTION 0.5 % hypromellose (ophth) isosorbide dinitrate sl tab 2.5 mg ISOSORBIDE DINITRATE SL TAB 2.5 MG isosorbide dinitrate K-PHOS NO 2 TAB 305-700 MG potassium & sodium acid phosphates K-PHOS TAB 500 MG potassium phosphate monobasic KALA TAB lactobacillus acidophilus-pectin KAMELEON LUBRICATED MISC QL 12 / 30 days condoms latex lubricated - male KANGAROO BURETTE SET MISC QL 200 / 30 days iv sets/tubing KETOSTIX STRIP acetone (urine) test

ketotifen fumarate ophth soln 0.025% (base equiv) QL 5 / 30 days

KIMONO MICRO THIN MISC QL 12 / 30 days condoms latex non-lubricated - male

PAGE 148 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS KIMONO MICRO THIN PLUS MISC QL 12 / 30 days condoms latex lubricated - male KIMONO MISC QL 12 / 30 days condoms latex lubricated - male KIMONO PLUS MISC QL 12 / 30 days condoms latex lubricated - male KIMONO PS MISC QL 12 / 30 days condoms latex lubricated - male KIMONO PS PLUS MISC QL 12 / 30 days condoms latex lubricated - male KIMONO SENSATION MISC QL 12 / 30 days condoms latex lubricated - male KIMONO SENSATION PLUS MISC QL 12 / 30 days condoms latex lubricated - male KMART VALU INSULIN SYRINGE 29G MISC U-100 0.5 ML QL 200 / 30 days insulin syringes (disposable) KMART VALU INSULIN SYRINGE 29G MISC U-100 1 ML QL 200 / 30 days insulin syringes (disposable) KMART VALU INSULIN SYRINGE 30G MISC U-100 0.3 ML QL 100 / 30 days insulin syringes (disposable) KMART VALU INSULIN SYRINGE 30G MISC U-100 0.5 ML QL 200 / 30 days insulin syringes (disposable) KMART VALU INSULIN SYRINGE 30G MISC U-100 1 ML QL 200 / 30 days insulin syringes (disposable) KNEE STABILIZER/ELASTIC/SM/MED MISC elastic bandages & supports KONSYL PACKET 100 % psyllium KONSYL PACKET 28.3 % psyllium KONSYL PACKET 60.3 % psyllium KONSYL POWDER 60.3 % psyllium KONSYL POWDER 71.67 % psyllium KONSYL-D POWDER 52.3 % psyllium KP PRENATAL MULTIVITAMINS TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid

PAGE 149 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS KPN PRENATAL TAB 0.1 MG prenatal multivit-min w/fe-fa L606 TUBING MISC QL 200 / 30 days iv sets/tubing L609 TUBING MISC QL 200 / 30 days iv sets/tubing lactic acid w/ vitamin e cream 10%-3500 unit/30gm

QL 2 / 30 days LEVONORGESTREL TAB 0.75 MG PA levonorgestrel (emergency oc) GL Female

QL 2 / 30 days

levonorgestrel tab 0.75 mg PA

GL Female

QL 2 / 30 days

levonorgestrel tab 1.5 mg PA

GL Female

LICE B GONE CAP SATURATED KIT vegetable extract LICE B GONE KIT vegetable extract LICE B GONE SHAMPOO vegetable extract LICIDE TREATMENT KIT pyrethrins-piperonyl butoxide LIFE PACK MENS MISC multiple vitamins w/ minerals LIFESTYLES ASSORTED COLORS MISC QL 12 / 30 days condoms - male LIFESTYLES EXTRA STRENGTH MISC QL 12 / 30 days condoms - male LIFESTYLES FORM FITTING MISC QL 12 / 30 days condoms - male LIFESTYLES LUBRICATED MISC QL 12 / 30 days condoms - male LIFESTYLES RIBBED MISC QL 12 / 30 days condoms - male

PAGE 150 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS LIFESTYLES SKYN ORIGINAL MISC QL 12 / 30 days condoms - male LIFESTYLES SPERMICIDAL LUBE MISC QL 12 / 30 days condoms - male LIFESTYLES STUDDED MISC QL 12 / 30 days condoms - male LIFESTYLES ULTRA SENSITIVE MISC QL 12 / 30 days condoms - male LIFESTYLES VIBRA-RIBBED MISC QL 12 / 30 days condoms - male LIFESTYLES XTRA PLEASURE MISC QL 12 / 30 days condoms - male LIQUIMAT LOTION 5 % sulfur LITTLE REMEDIES FOR COLDS LIQUID 2.5-1.25-80 MG/ML dextromethorphan-phenylephrine-acetaminophen LODRANE D CAP 4-60 MG brompheniramine & pseudoeph LOHIST-D LIQUID 2-30 MG/5ML chlorpheniramine & pseudoeph loperamide hcl liq 1 mg/5ml (0.2 mg/ml) loperamide hcl liq 1 mg/7.5ml loratadine & pseudoephedrine tab sr 12hr 5-120 mg loratadine & pseudoephedrine tab sr 24hr 10-240 mg loratadine rapidly-disintegrating tab 10 mg loratadine syrup 5 mg/5ml loratadine tab 10 mg LORTUSS DM LIQUID 30-6.25-15 MG/5ML pseudoephedrine-doxylamine-dextromethorphan LORTUSS EX LIQUID 22.5-10-100 MG/5ML pseudoephedrine w/ codeine-gg LORTUSS LQ LIQUID 6.25-30 MG/5ML doxylamine-pseudoephedrine LOZI-FLUR LOZENGE 2.2 (1 F) MG sodium fluoride LTXF PRIM CNV PIN MICRODRIP MISC QL 200 / 30 days iv sets/tubing

PAGE 151 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS LTXF PRIM IV SET/CNVT PIN MISC QL 200 / 30 days iv sets/tubing LTXF SECONDARY/CNV PIN/32INC MISC QL 200 / 30 days iv sets/tubing

LURIDE CHEW TAB 1.1 (0.5 F) MG QL 30 / 30 days sodium fluoride AL Up to 10 yrs old

LURIDE CHEW TAB 2.2 (1 F) MG QL 30 / 30 days sodium fluoride AL Up to 10 yrs old

LURIDE SOLUTION 1.1 (0.5 F) MG/ML QL 30 / 30 days sodium fluoride AL Up to 10 yrs old

LUSAIR LIQUID 7.5-200 MG/5ML phenylephrine-guaifenesin M-END DMX LIQUID 20-0.667-10 MG/5ML pseudoephedrine-dexbrompheniramine-dextromethorphan M-END MAX D LIQUID 20-0.667-6 MG/5ML pseudoephedrine-dexbrompheniramine-codeine M-END PE LIQUID 3.33-1.33-6.33 MG/5ML phenylephrine-brompheniramine w/ codeine M-VIT TAB prenatal vit w/ ferrous fumarate-folic acid M2 POTASSIUM CAP 60 MG potassium aminobenzoate MAALOX JUNIOR PLUS ANTIGAS CHEW TAB 400-24 MG calcium carbonate-simethicone MAG-AL LIQUID 200-200 MG/5ML aluminum & magnesium hydroxide MAG-TAB SR TAB ER 84 MG (7MEQ) magnesium lactate MAGINEX DS PACKET 1230 MG magnesium aspartate hydrochloride MAGINEX TAB DR 615 MG magnesium aspartate hydrochloride MAGNESIUM CAP 300 MG magnesium MAGNESIUM CARBONATE HEAVY POWDER magnesium carbonate MAGNESIUM CARBONATE POWDER magnesium carbonate

PAGE 152 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS MAGNESIUM CHLORIDE CRYSTALS magnesium chloride MAGNESIUM CHLORIDE POWDER magnesium chloride magnesium chloride tab cr 535 mg (64 mg elemental mg) magnesium citrate soln MAGNESIUM CITRATE TAB 100 MG magnesium citrate (mg supplement) MAGNESIUM GLUCONATE TAB 250 MG magnesium gluconate MAGNESIUM GLUCONATE TAB 30 MG magnesium gluconate magnesium gluconate tab 500 mg magnesium gluconate tab 500 mg (27 mg elemental mg) MAGNESIUM GLUCONATE TAB 550 MG magnesium gluconate MAGNESIUM OXIDE CAP 400 MG magnesium oxide MAGNESIUM OXIDE POWDER magnesium oxide MAGNESIUM OXIDE POWDER magnesium oxide (mg supplement) magnesium oxide tab 250 mg magnesium oxide tab 250 mg (mg supplement) magnesium oxide tab 400 mg magnesium oxide tab 400 mg (240 mg elemental mg) magnesium oxide tab 400 mg (241.3 mg elemental mg) magnesium oxide tab 420 mg magnesium tab 100 mg magnesium tab 200 mg magnesium tab 250 mg MAGNESIUM TAB 30 MG magnesium MAGNESIUM TAB 400 MG magnesium

PAGE 153 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS MAGNESIUM TAB 500 MG magnesium MAGONATE LIQUID 1000 (54 MG) MG/5ML magnesium gluconate MAR-COF BP LIQUID 30-2-7.5 MG/5ML pseudoephedrine-brompheniramine-codeine MAXIMIN PACK PACKET multiple vitamins w/ minerals MAXX MISC QL 12 / 30 days condoms latex lubricated - male MAXX PLUS MISC QL 12 / 30 days condoms latex lubricated - male meclizine hcl chew tab 25 mg MECLIZINE HCL POWDER meclizine hcl MEDI-GRAINE TAB 500-75-5 MG phenylephrine-apap-caffeine MEDI-JECTOR VISION ADAPTERS MISC QL 100 / 30 days injection device needle-free for insulin MEDI-JECTOR VISION MISC QL 100 / 30 days injection device needle-free for insulin MEDSAVER SYRINGE MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml MEGA BIOTIN CAP 10 MG biotin MEGA MULTIVITAMIN POWDER multiple vitamins w/ minerals meperidine hcl tab 100 mg meperidine hcl tab 50 mg METAMUCIL MULTIHEALTH FIBER POWDER 63 % psyllium METAMUCIL SMOOTH TEXTURE PACKET 28 % psyllium METAMUCIL WAFER psyllium METAPROTERENOL SULFATE TAB 10 MG metaproterenol sulfate METAPROTERENOL SULFATE TAB 20 MG metaproterenol sulfate

PAGE 154 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS methadone hcl conc 10 mg/ml methadone hcl tab for oral susp 40 mg METHADOSE CONC 10 MG/ML methadone hcl METHADOSE SUGAR-FREE CONC 10 MG/ML methadone hcl METHANOL SOLUTION methyl alcohol METHANOL SOLUTION 99 % methyl alcohol METHYL ALCOHOL SOLUTION methyl alcohol methylcellulose powder laxative MH MACULAR HEALTH MISC multiple vitamins w/ minerals miconazole nitrate aerosol 2% miconazole nitrate aerosol pow 2% miconazole nitrate cream 2% miconazole nitrate ointment 2% miconazole nitrate powder 2% miconazole nitrate vaginal cream 2% miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit MIRANEL AF SOLUTION 2 % miconazole nitrate (topical) MISSION PRENATAL FA TAB prenatal vit w/ ferrous gluconate-folic acid MISSION PRENATAL HP TAB prenatal vit w/ ferrous gluconate-folic acid MISSION PRENATAL TAB prenatal vit w/ ferrous gluconate-folic acid MONOJECT INSULIN SYRINGE MISC U-100 1 ML QL 200 / 30 days insulin syringes (disposable) MONOJECT LIFESHIELD SYRINGE MISC 18G X 1" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml MONOJECT MAGELLAN SYRINGE MISC 23G X 1" 1 ML QL 200 / 30 days syringe/needle (disp) 1 ml

PAGE 155 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS MONOJECT MAGELLAN SYRINGE MISC 25G X 1" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml MONOJECT MAGELLAN SYRINGE MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml MUCINEX CHILD MS DAY-NIGHT CLD MISC phenylephrine-diphenhydramine-dm-guaifenesin-apap MUCINEX COUGH FOR KIDS PACKET 5-100 MG dextromethorphan-guaifenesin MUCINEX D TAB ER 12H 120-1200 MG pseudoephedrine-guaifenesin MUCINEX D TAB ER 12H 60-600 MG pseudoephedrine-guaifenesin MUCINEX FAST-MAX CONGEST COUGH TAB 5-10-200 MG phenylephrine w/ dm-gg MUCINEX FAST-MAX DAY/NIGHT MISC phenylephrine-diphenhydramine-dm-guaifenesin-apap MUCINEX FOR KIDS PACKET 100 MG guaifenesin MUCINEX FOR KIDS PACKET 50 MG guaifenesin MUCINEX MAXIMUM STRENGTH TAB ER 12H 1200 MG guaifenesin MUCINEX SINUS-MAX DAY/NIGHT MISC phenylephrine-diphenhydramine-gg w/ apap MULTI FOR HER PACKET multiple vitamins w/ minerals MULTI FOR HIM PACKET multiple vitamins w/ minerals MULTI PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid MYKIDZ IRON 10 SUSPENSION 15 MG/1.5ML iron MYLANTA ULTIMATE STRENGTH SUSPENSION 500-500 MG/5ML aluminum & magnesium hydroxide MYLERAN TAB 2 MG PA busulfan MYNATAL ADVANCE TAB prenatal vit w/ docusate-iron carbonyl-folic acid MYNATAL CAP prenatal multivit-min w/fe-fa

PAGE 156 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS MYNATAL PLUS TAB prenatal vit w/ ferrous fumarate-folic acid MYNATAL TAB 90-1 MG prenatal vit w/ docusate-iron carbonyl-folic acid MYNATAL-Z TAB prenatal vit w/ ferrous fumarate-folic acid MYNATE 90 PLUS TAB ER prenatal vit w/ docusate-fe fumarate-folic acid NANOVM T/F LIQUID AL Up to 9 yrs old pediatric multiple vitamin w/ minerals NAPHAZOLINE HCL SOLUTION 0.1 % naphazoline hcl naphazoline w/ pheniramine ophth soln 0.025-0.3% naphazoline w/ pheniramine ophth soln 0.027-0.315% naphazoline-glycerin ophth soln 0.012-0.2% naphazoline-glycerin ophth soln 0.012-0.25% naphazoline-glycerin ophth soln 0.03-0.5% naphazoline-hypromellose ophth soln 0.03-0.5% naphazoline-polyethylene glycol 300 ophth soln 0.012-0.2% NAPRELAN TAB ER 24H 375 MG naproxen sodium NAPRELAN TAB ER 24H 500 MG naproxen sodium NAPRELAN TAB ER 24H 750 MG naproxen sodium naproxen sodium cap 220 mg NAPROXEN SODIUM POWDER naproxen sodium NASAL DECONGESTANT LIQUID 30 MG/5ML pseudoephedrine hcl NASAL DECONGESTANT SYRUP 30 MG/5ML pseudoephedrine hcl NASOPEN LIQUID 9.375-30 MG/5ML chlorcyclizine & pseudoephedrine NASOPEN PE LIQUID 50-10 MG/15ML thonzylamine-phenylephrine NAT-RUL PRENATAL VITAMINS TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid

PAGE 157 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS NATAL-V RX TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid NATALVIT TAB prenatal vit w/ ferrous fumarate-folic acid NATRUL-100 TAB ER multiple vitamins w/ minerals NATURAL SENNA LAXATIVE TAB 64.8-324 MG senna NATURE-THROID TAB 130 MG thyroid NATURE-THROID TAB 195 MG thyroid NATURE-THROID TAB 260 MG thyroid NATURE-THROID TAB 32.5 MG thyroid NATURE-THROID TAB 325 MG thyroid NATURE-THROID TAB 48.75 MG thyroid NATURE-THROID TAB 65 MG thyroid NATURE-THROID TAB 97.5 MG thyroid

QL 37.5 / 28 days NECON 1/50 (28) TAB 1-50 MG-MCG PA norethindrone & mestranol GL Female

NEEDLE-FREE INSULIN SYRINGE A MISC QL 100 / 30 days injection device needle-free for insulin NEEDLE-FREE INSULIN SYRINGE B MISC QL 100 / 30 days injection device needle-free for insulin NEEDLE-FREE INSULIN SYRINGE C MISC QL 100 / 30 days injection device needle-free for insulin NEEDLE-FREE SYRINGE KIT A KIT QL 100 / 30 days injection device needle-free for insulin NEEDLE-FREE SYRINGE KIT B KIT QL 100 / 30 days injection device needle-free for insulin NEEDLE-FREE SYRINGE KIT C KIT QL 100 / 30 days injection device needle-free for insulin

PAGE 158 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS NEOSPORIN ESSENTIALS TRIAL PK KIT 1 & 1 % hydrocortisone & colloidal oatmeal & body wash NEOTUSS PLUS LIQUID 7.5-4-30 MG/5ML phenylephrine-chlorphen-dm NEOTUSS-D LIQUID 30-2-30-200 MG/5ML pseudoephedrine-chlorpheniramine w/ dm-gg NEOTUSS-D LIQUID 7.5-30-200 MG/5ML phenylephrine w/ dm-gg NERIA 29G INFUSION SET 10MM MISC QL 200 / 30 days iv sets/tubing NERIA 29G INFUSION SET 6MM MISC QL 200 / 30 days iv sets/tubing NERIA 29G INFUSION SET 8MM MISC QL 200 / 30 days iv sets/tubing NERIA MULTI 27G 2X10MM MISC QL 200 / 30 days iv sets/tubing NERIA MULTI 27G 3X10MM MISC QL 200 / 30 days iv sets/tubing NERIA MULTI 27G 4X12MM MISC QL 200 / 30 days iv sets/tubing NERIA SOFT 25G INFUSION 13MM MISC QL 200 / 30 days iv sets/tubing NERIA SOFT 25G INFUSION 17MM MISC QL 200 / 30 days iv sets/tubing NEXIUM 24HR CAP DR 20 MG QL 60 / 30 days esomeprazole magnesium niacin cap cr 250 mg niacin cap cr 500 mg NIACIN ER TAB ER 1000 MG niacin niacin tab 100 mg niacin tab 250 mg niacin tab 50 mg niacin tab 500 mg niacin tab cr 250 mg niacin tab cr 500 mg niacin tab cr 750 mg

PAGE 159 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS niacinamide tab 100 mg niacinamide tab 500 mg NIACINAMIDE TAB ER 500 MG niacinamide NICODERM CQ PATCH 24HR 14 MG/24HR C 90 days of coverage nicotine per year NICODERM CQ PATCH 24HR 21 MG/24HR C 90 days of coverage nicotine per year NICODERM CQ PATCH 24HR 7 MG/24HR C 90 days of coverage nicotine per year

QL 270 / 30 days NICORETTE GUM 2 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days NICORETTE GUM 4 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days NICORETTE LOZENGE 2 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days NICORETTE LOZENGE 4 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days NICORETTE MINI LOZENGE 2 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days NICORETTE MINI LOZENGE 4 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days NICORETTE REFILL GUM 2 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days NICORETTE REFILL GUM 4 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days NICORETTE STARTER KIT GUM 2 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days NICORETTE STARTER KIT GUM 4 MG nicotine polacrilex C 90 days of coverage per year

PAGE 160 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

QL 90 / 365 days

NICOTINE KIT 21-14-7 MG/24HR PA nicotine C 90 days of coverage per year

QL 270 / 30 days NICOTINE MINI LOZENGE 2 MG nicotine polacrilex C 90 days of coverage per year

QL 270 / 30 days

nicotine polacrilex gum 2 mg PA

C 90 days of coverage per year

QL 270 / 30 days

nicotine polacrilex gum 4 mg PA

C 90 days of coverage per year

QL 270 / 30 days

nicotine polacrilex lozenge 2 mg PA

C 90 days of coverage per year

QL 270 / 30 days

nicotine polacrilex lozenge 4 mg PA

C 90 days of coverage per year

QL 90 / 365 days

nicotine td patch 24hr 14 mg/24hr PA

C 90 days of coverage per year

QL 90 / 365 days

nicotine td patch 24hr 21 mg/24hr PA

C 90 days of coverage per year

QL 90 / 365 days

nicotine td patch 24hr 7 mg/24hr PA

C 90 days of coverage per year NICOTROL INHALER 10 MG C 90 days of coverage nicotine per year NITE-TIME COLD/FLU RELIEF LIQUID 5-6.25-15-500 MG/15ML phenylephrine-doxylamine-dextromethorphan-acetaminophen

PAGE 161 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS nitroglycerin cap cr 2.5 mg nitroglycerin cap cr 6.5 mg nitroglycerin cap cr 9 mg NORDIPEN 5 INJECTION DEVICE MISC QL 100 / 30 days injection device NORDIPEN DELIVERY SYSTEM MISC QL 100 / 30 days injection device NOREL AD TAB 4-10-325 MG chlorpheniramine-phenylephrine-acetaminophen NOREL CS LIQUID 10-4-12.5 MG/5ML phenylephrine-chlorphen-dm NORTUSS-EX LIQUID 20-200 MG/5ML dextromethorphan-guaifenesin NOVAFERRUM PEDIATRIC DROPS LIQUID 15 MG/ML polysaccharide iron complex NOVOPEN 3 MISC QL 200 / 30 days injection device for insulin NOVOPEN 3 PENMATE MISC QL 200 / 30 days injection device for insulin NOVOPEN ECHO DEVICE QL 200 / 30 days injection device for insulin NOVOPEN JR (GREEN) MISC QL 200 / 30 days injection device for insulin NOVOPEN JR (YELLOW) MISC QL 200 / 30 days injection device for insulin O-CAL FA TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid O-CAL PRENATAL TAB prenatal vit w/ ferrous fumarate-folic acid OBSTETRIX DHA MISC 29-1 & 387 MG prenatal w/fe carbonyl-fa-dss-omega 3 fatty acids OBSTETRIX EC TAB 29-1 MG prenatal vit w/ docusate-iron carbonyl-folic acid OBTREX DHA MISC 29-1 & 387 MG prenatal w/fe carbonyl-fa-dss-omega 3 fatty acids OBTREX TAB prenatal vit w/ docusate-iron carbonyl-folic acid OC8 GEL 7 % benzoyl peroxide

PAGE 162 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS OMEPRAZOLE+SYRSPEND SF ALKA SUSPENSION 2 MG/ML QL 150 / 30 days omeprazole

omeprazole-sodium bicarbonate cap 20-1100 mg QL 60 / 30 days

omeprazole-sodium bicarbonate cap 40-1100 mg QL 60 / 30 days

QL 1 / 365 days OMNIFLEX DIAPHRAGM DIAPHRAGM PA diaphragms GL Female

OMNITROPE PEN 10 INJ DEVICE MISC QL 100 / 30 days injection device OMNITROPE PEN 5 INJ DEVICE MISC QL 100 / 30 days injection device ONE-A-DAY WOMENS PRENATAL MISC 28-0.8 & 223 MG prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids ONE-A-DAY WOMENS PRENATAL MISC 28-0.8 & 440 MG prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids ONETOUCH ULTRA CONTROL SOLUTION blood glucose calibration ONSET FORTE TAB 162-2-5 MG chlorpheniramine-phenylephrine-acetaminophen OPIUM TINCTURE (PAREGORIC) TINCTURE 2 MG/5ML paregoric OPTIONS GYNOL II CONTRACEPTIVE GEL 3 % nonoxynol-9 ORA-BLEND SF SUSPENSION oral vehicles ORA-BLEND SUSPENSION oral vehicles ORA-FILM STRIP 6 % benzocaine (dental) ORA-PLUS LIQUID oral vehicles ORA-SWEET SF SYRUP oral vehicles ORA-SWEET SYRUP oral vehicles ORACIT SOLUTION 490-640 MG/5ML sodium citrate & citric acid

PAGE 163 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ORAL MIX LIQUID oral vehicles ORAL MIX SF LIQUID oral vehicles ORAL SUSPEND LIQUID oral vehicles ORAL SYRUP LIQUID oral vehicles ORAL SYRUP SF LIQUID oral vehicles ORAZINC TAB 110 MG zinc sulfate

QL 1 / 365 days ORTHO DIAPHRAGM ALL-FLEX DIAPHRAGM 65 MM PA diaphragm arc-spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM ALL-FLEX DIAPHRAGM 70 MM PA diaphragm arc-spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM ALL-FLEX DIAPHRAGM 75 MM PA diaphragm arc-spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM ALL-FLEX DIAPHRAGM 80 MM PA diaphragm arc-spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM COIL KIT 100 MM PA diaphragm coil spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM COIL KIT 105 MM PA diaphragm coil spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM COIL KIT 50 MM PA diaphragm coil spring GL Female

PAGE 164 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

QL 1 / 365 days ORTHO DIAPHRAGM FLAT KIT 55 MM PA diaphragm flat spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM FLAT KIT 60 MM PA diaphragm flat spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM FLAT KIT 65 MM PA diaphragm flat spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM FLAT KIT 70 MM PA diaphragm flat spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM FLAT KIT 75 MM PA diaphragm flat spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM FLAT KIT 80 MM PA diaphragm flat spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM FLAT KIT 85 MM PA diaphragm flat spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM FLAT KIT 90 MM PA diaphragm flat spring GL Female

QL 1 / 365 days ORTHO DIAPHRAGM FLAT KIT 95 MM PA diaphragm flat spring GL Female

OSTEO-PORETICAL TAB 600-1000 MG-UNIT calcium carbonate-cholecalciferol OXYCODONE HCL CONC 100 MG/5ML oxycodone hcl oxycodone hcl conc 100 mg/5ml (20 mg/ml)

PAGE 165 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS oxycodone w/ acetaminophen cap 5-500 mg oxymetazoline hcl nasal soln 0.05% OYSTER SHELL CALCIUM/D TAB 250-250 MG-UNIT calcium carbonate-cholecalciferol PA MENS 50 PLUS VITAPAK MISC multiple vitamins w/ minerals PA MENS VITAPAK MISC multiple vitamins w/ minerals PA PRENATAL FORMULA TAB 9-0.5 MG prenatal vit w/ selenium-fe fumarate-folic acid PA WOMENS 50 PLUS VITAPAK MISC multiple vitamins w/ minerals PA WOMENS VITAPAK MISC multiple vitamins w/ minerals PABA TAB 100 MG para-aminobenzoic acid (paba) PANATUSS DXP LIQUID 10-2-20 MG/5ML phenylephrine-dexbrompheniramine-dextromethorphan PANATUSS DXP PEDIATRIC LIQUID 2-0.5-5-50 MG/ML phenylephrine-dexbrompheniramine-dm-guaifenesin PANATUSS PED DROPS LIQUID 15-0.5-6.25 MG/ML pseudoephedrine-dexchlorpheniramine-chlophedianol PANATUSS PED LIQUID 60-2-25 MG/5ML pseudoephedrine-dexchlorpheniramine-chlophedianol PARVA-CAL TAB 250-100 MG-UNIT calcium-ergocalciferol PARVA-CAL TAB 500-200 MG-UNIT calcium-ergocalciferol PCCA SWEET-SF SYRUP oral vehicles PCCA SYRUP VEHICLE SYRUP oral vehicles PCCA-PLUS SUSPENSION oral vehicles pe-dm-apap & pe-cpm-dm-apap tab day/night therapy pack pe-dm-apap cap & doxylamine-dm-apap cap day/night ther pack pe-dm-apap liq & doxylamine-dm-apap liq day/night ther pack

PAGE 166 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS pe-dm-gg-apap tab & pe-diphenhyd-apap tab therapy pack PECGEN DMX LIQUID 15-125 MG/5ML dextromethorphan-guaifenesin PEDIA-LAX LIQUID 50 MG/15ML docusate sodium PEDIA-LAX SUPPOS 2.8 GM glycerin (laxative) PEPCID AC MAXIMUM STRENGTH CHEW TAB 20 MG famotidine PEPPERMINT SPIRIT SPIRIT peppermint spirit PERFECT IRON TAB 25 MG carbonyl iron permethrin aerosol 0.5% permethrin creme rinse 1%

permethrin lotion 1% QL 120 / 30 days

permethrin spray & pyrethins-piperonyl butoxide shamp kit PERRY PRENATAL CAP 13.5-0.4 MG prenatal vit w/ ferrous fumarate-folic acid phenazopyridine hcl tab 100 mg phenazopyridine hcl tab 200 mg phenazopyridine hcl tab 95 mg phenyleph-chlorphen-dm w/apap liquid 2.5-1-5-160 mg/5ml phenyleph-chlorphen-dm w/apap susp 2.5-1-5-160 mg/5ml phenyleph-chlorphen-dm w/apap tab 5-2-10-325 mg phenylephrine w/ acetaminophen cap 5-325 mg phenylephrine w/ acetaminophen powd pack 10-650 mg phenylephrine w/ acetaminophen tab 5-325 mg phenylephrine w/ acetaminophen tab 5-500 mg phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml phenylephrine w/ dm-gg liqd 2.5-5-100 mg/5ml phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml

PAGE 167 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS phenylephrine w/ dm-gg liqd 2.5-5-75 mg/5ml phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml phenylephrine w/ dm-gg liqd 5-10-100 mg/5ml phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml phenylephrine w/ dm-gg liquid 10-15-350 mg/5ml phenylephrine w/ dm-gg syrup 5-10-100 mg/5ml phenylephrine w/ dm-gg tab 10-15-380 mg phenylephrine w/ dm-gg tab 10-20-400 mg phenylephrine-apap-gg liqd 10-650-400 mg/20ml phenylephrine-apap-gg tab 10-650-400 mg phenylephrine-apap-gg tab 5-325-200 mg phenylephrine-brompheniramine-dm elixir 2.5-1-5 mg/5ml phenylephrine-brompheniramine-dm liquid 10-4-20 mg/5ml phenylephrine-brompheniramine-dm liquid 2.5-1-5 mg/5ml phenylephrine-brompheniramine-dm liquid 7.5-4-15 mg/5ml phenylephrine-brompheniramine-dm syrup 5-2-10 mg/5ml PHENYLEPHRINE-CHLORPHEN-DM LIQUID 1.75-0.75-2.75 MG/ML phenylephrine-chlorphen-dm phenylephrine-chlorphen-dm liquid 10-2-15 mg/5ml phenylephrine-chlorphen-dm liquid 10-4-15 mg/5ml phenylephrine-chlorphen-dm liquid 3.5-1-3 mg/ml phenylephrine-dm soln 2.5-5 mg/5ml phenylephrine-dm-gg w/ apap liq 5-10-200-325 mg/10ml phenylephrine-dm-gg w/ apap liq 5-10-200-325 mg/15ml phenylephrine-dm-gg w/ apap tab 5-10-100-325 mg phenylephrine-dm-gg w/ apap tab 5-10-200-325 mg phenylephrine-dm-gg w/ apap tab 5-15-200-325 mg phenylephrine-doxylamine-dm-apap liq 5-6.25-10-325 mg/15ml phenylephrine-guaifenesin liqd 2.5-100 mg/5ml phenylephrine-guaifenesin liqd 5-100 mg/5ml phenylephrine-guaifenesin syrup 5-200 mg/5ml

PAGE 168 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS phenylephrine-guaifenesin tab 10-380 mg phenylephrine-guaifenesin tab 10-400 mg phenylephrine-guaifenesin tab 5-200 mg phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml PHENYLHISTINE DH LIQUID 30-2-10 MG/5ML pseudoeph-chlorphen w/ cod PHLEXY-VITS POWDER multiple vitamins w/ minerals phytonadione tab 100 mcg PINE TAR LIQUID pine tar (bulk)

PLAN B ONE-STEP TAB 1.5 MG QL 2 / 30 days levonorgestrel (emergency oc) GL Female

PLAN B TAB 0.75 MG QL 2 / 30 days levonorgestrel (emergency oc) GL Female

PLASTIC ADAPTER MISC QL 100 / 30 days injection device PLASTIC ADAPTER MISC 1 ML QL 200 / 30 days injection device PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid PNV FOLIC ACID + IRON TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid PNV TABS 29-1 TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid PNV-VP-U CAP 106.5-1 MG prenatal without a vit w/ fe fumarate-folic acid POLY HIST FORTE TAB 7.5-10 MG doxylamine-phenylephrine POLY-HIST DM LIQUID 5-25-10 MG/5ML phenylephrine-thonzylamine-dextromethorphan POLY-HIST PD LIQUID 6.25-6.25 MG/ML thonzylamine-chlophedianol POLY-TUSSIN AC LIQUID 10-4-10 MG/5ML phenylephrine-brompheniramine w/ codeine

PAGE 169 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS POLY-TUSSIN D LIQUID 10-30-9.375 MG/5ML codeine-pseudoephedrine-chlorcyclizine POLY-TUSSIN LIQUID 10-9.375 MG/5ML codeine-chlorcyclizine POLY-VENT DM TAB 60-20-380 MG pseudoephedrine w/ dm-gg POLY-VENT IR TAB 60-380 MG pseudoephedrine-guaifenesin POLYETHYLENE GLYCOL 3350 POWDER polyethylene glycol 3350 (bulk) polyethylene glycol-propylene glycol ophth soln 0.4-0.3% POLYSORBATE 20 SOLUTION polysorbate 20 POLYSORBATE 40 SOLUTION polysorbate 40 POLYSORBATE 60 LIQUID polysorbate 60 POLYSORBATE 80 LIQUID polysorbate 80 polyvinyl alcohol-povidone ophth soln 1.4-0.6% polyvinyl alcohol-povidone ophth soln 5-6 mg/ml (0.5-0.6%) pot bicarbonate & chloride effer tab 25 meq pot phos monobasic w/sod phos di & monobas tab 155-852-130mg POTABA CAP 500 MG potassium aminobenzoate POTABA TAB 500 MG potassium aminobenzoate potassium bicarbonate effer tab 25 meq potassium chloride oral liq 10% (20 meq/15ml) potassium chloride powder packet 20 meq potassium citrate & citric acid powder pack 3300-1002 mg potassium citrate & citric acid soln 1100-334 mg/5ml povidone-iodine douche soln 10% POVIDONE-IODINE PAD 10 % povidone-iodine povidone-iodine soln 10%

PAGE 170 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS PR NATAL 400 MISC 29-1-200 & 400 MG prenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 PR NATAL 430 MISC 29-1-200 & 430 MG prenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 pramox-pe-glycerin-petrolatum rectal cream 1-0.25-14.4-15% pramoxine-calamine lotion 1-8% PRE-NATAL FORMULA TAB prenatal multivit-min w/fe-fa PRECISION XTRA KETONE STRIP ketone blood test PREMIUM CONDOMS LUBRICATED MISC QL 12 / 30 days condoms latex lubricated - male PREMIUM PACKETS MISC multiple vitamins w/ minerals PRENAPLUS TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid PRENATA CHEW TAB 29-1 MG prenatal without a vit w/ fe fumarate-folic acid PRENATABS FA TAB prenatal vit w/ ferrous fumarate-folic acid PRENATABS RX TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid PRENATAL 19 CHEW TAB prenatal vit w/ ferrous fumarate-folic acid PRENATAL 19 CHEW TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL 19 TAB prenatal vit w/ docusate-fe fumarate-folic acid PRENATAL 19 TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid PRENATAL AD TAB prenatal vit w/ docusate-iron carbonyl-folic acid PRENATAL COMPLETE TAB 14-0.4 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL FORMULA A-FREE TAB 9-0.267 MG prenatal without a vit w/ fe fumarate-folic acid PRENATAL FORMULA CAP 28-0.8-235 MG prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids

PAGE 171 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS PRENATAL FORMULA TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL LOW IRON TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL LOW IRON TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL MULTI +DHA CAP 27-0.8-228 MG prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids PRENATAL MULTIVITAMIN + DHA MISC 28-0.8 & 200 MG prenatal mv & min w/fe fumarate-fa-dha PRENATAL ONE DAILY TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL PLUS DHA TAB 7-0.4-100 MG prenatal mv & min w/fe carbonyl-fa-dha PRENATAL PLUS IRON TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid PRENATAL PLUS TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL TAB 6.75-0.2 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL VITAMINS PLUS TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL VITAMINS TAB 0.8 MG prenatal multivit-min w/fe-fa PRENATAL VITAMINS TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid PRENATAL+DHA MISC 28-0.975 & 200 MG prenatal mv & min w/fe fumarate-fa-dha PRENATAL-U CAP 106.5-1 MG prenatal without a vit w/ fe fumarate-folic acid PRENATAL/IRON TAB prenatal multivit-min w/fe-fa PRENATAL/OMEGA-3/FA/IRON CAP 28-0.8-530 MG prenatal vit w/ ferrous fumarate-fa-fish oil

PAGE 172 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS PREPLUS TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid PRESCRIPTIVE FORMULAS MENS MISC multiple vitamins w/ minerals PRESCRIPTIVE FORMULAS WOMENS MISC multiple vitamins w/ minerals PRETAB TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid PRETZ SOLUTION 10 % glycerin (bulk) PRILOSEC OTC TAB DR 20 MG QL 60 / 30 days omeprazole magnesium PRIMSOL SOLUTION 50 MG/5ML QL 600 / 30 days trimethoprim hcl PRO-CHLO LIQUID 5-12.5-12.5 MG/5ML phenylephrine-pyrilamine-chlophedianol PRO-CLEAR AC SYRUP 9-8.33 MG/5ML codeine-pyrilamine PRO-RED AC SYRUP 5-1-9 MG/5ML phenylephrine-dexchlorpheniramine-codeine PROFE FORTE CAP 155-1 MG prenatal without vit a w/ iron polysaccharide complex-fa PROFERRIN ES TAB 12 MG iron heme polypeptide PROMETHAZINE VC/CODEINE SYRUP 6.25-5-10 MG/5ML phenyleph-promethazine w/ cod promethazine w/ codeine syrup 6.25-10 mg/5ml promethazine-dm syrup 6.25-15 mg/5ml PROPANTHELINE BROMIDE TAB 15 MG propantheline bromide PROPRANOLOL HCL SOLUTION 20 MG/5ML propranolol hcl PROPRANOLOL HCL SOLUTION 40 MG/5ML propranolol hcl propylene glycol-glycerin ophth soln 1-0.3% PROTECT PLUS LIQUID multiple vitamins w/ minerals PROTECT PLUS NF LIQUID multiple vitamins w/ minerals

PAGE 173 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS pseudoeph-chlorphen-dm w/ apap cap 30-2-10-325 mg pseudoeph-chlorphen-dm w/ apap pack 60-4-30-1000 mg pseudoeph-chlorphen-dm w/ apap syrup 15-1-5-160 mg/5ml pseudoeph-chlorphen-dm w/ apap tab 30-2-15-325 mg pseudoeph-chlorphen-dm w/ apap tab 30-2-15-500 mg pseudoeph-doxylamine-dm w/ apap cap 30-6.25-15-325 mg pseudoeph-doxylamine-dm w/apap liq 60-12.5-30-1000 mg/30ml pseudoephed-bromphen-dm elixir 15-1-5 mg/5ml pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml pseudoephed-chlorphen-dm liq 15-1-5 mg/5ml pseudoephed-chlorphen-dm liq 15-1-7.5 mg/5ml pseudoephed-chlorphen-dm liq 15-2-15 mg/5ml pseudoephed-dexchlorphen-chlophedianol liqd 30-1-12.5 mg/5ml pseudoephedrine hcl liq 15 mg/5ml pseudoephedrine hcl tab 30 mg pseudoephedrine hcl tab 60 mg pseudoephedrine hcl tab abuse deter 30 mg pseudoephedrine hcl tab sr 12hr 120 mg pseudoephedrine w/ acetaminophen tab 30-500 mg pseudoephedrine w/ apap-dm cap 30-325-15 mg pseudoephedrine w/ apap-dm liq 30-325-15 mg/15ml pseudoephedrine w/ apap-dm tab 30-500-15 mg pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml pseudoephedrine w/ dm-gg cap 30-10-200 mg pseudoephedrine w/ dm-gg liquid 30-10-100 mg/5ml pseudoephedrine w/ dm-gg liquid 30-15-175 mg/5ml pseudoephedrine-bromphen-codeine liq 10-1.33-6.33 mg/5ml pseudoephedrine-chlophedianol-gg liqd 30-12.5-100 mg/5ml pseudoephedrine-dexchlorpheniramine-dm liqd 30-1-15 mg/5ml pseudoephedrine-dm liqd 15-7.5 mg/5ml

PAGE 174 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS pseudoephedrine-dm syrup 30-15 mg/5ml pseudoephedrine-dm-gg w/ apap tab 30-15-200-325 mg pseudoephedrine-guaifenesin cap 30-200 mg pseudoephedrine-guaifenesin syrup 30-100 mg/5ml pseudoephedrine-guaifenesin tab 40-400 mg pseudoephedrine-guaifenesin tab 60-400 mg pseudoephedrine-ibuprofen susp 15-100 mg/5ml pseudoephedrine-ibuprofen tab 30-200 mg pseudoephedrine-naproxen sodium tab sr 12hr 120-220 mg psyllium cap 0.52 gm psyllium powder 100% psyllium powder 28.3% psyllium powder 30% psyllium powder 30.9% psyllium powder 33% psyllium powder 48.57% psyllium powder 58.6% psyllium powder 68% psyllium powder 95% PUREFE OB PLUS CAP 162-115.2-1 MG prenatal without a vit w/ fe fum-iron polysacch complex -fa PX PRENATAL MULTIVITAMINS TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv) pyreth-piperonyl butox sham-permeth aero-nit remover gel kit pyrethrins-piperonyl butoxide liq 0.3-3% pyrethrins-piperonyl butoxide liq 0.33-4% pyrethrins-piperonyl butoxide shampoo 0.33-4% pyridoxine hcl tab 100 mg pyridoxine hcl tab 200 mg pyridoxine hcl tab 25 mg pyridoxine hcl tab 250 mg

PAGE 175 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS pyridoxine hcl tab 50 mg pyridoxine hcl tab 500 mg pyridoxine hcl tab cr 200 mg PYRIL DM SUSPENSION 5-16-15 MG/5ML phenylephrine-pyrilamine-dm pyrilamine mal-phenylephrine hcl tann susp 16-5 mg/5ml pyrilamine-phenylephrine tab 25-10 mg QC ISOPROPYL RUBBING ALCOHOL SOLUTION 91 % isopropyl alcohol QC PRENATAL TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid RA ACNE MAXIMUM PAD 2 % salicylic acid in alcohol RA CALCIUM HI-CAL/VITAMIN D TAB 500-200 MG-UNIT calcium-cholecalciferol RA CALCIUM-BORON TAB 500-1.5 MG calcium-boron RA EAR WAX CLEANSING SYSTEM KIT 6.5 % carbamide peroxide & saline RA ESSENCE-C PACKET multiple vitamins w/ minerals RA ETHYL ALCOHOL SOLUTION 70 % alcohol, usp RA LOTION LOTION resorcinol-alcohol RA ONE DAILY MISC 28-0.8 & 440 MG prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids RA PRENATAL FORMULA TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid RA PRENATAL TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid RAPID-FILL TUBE SET MISC QL 200 / 30 days iv sets/tubing REALITY LATEX/ULTRA TEXTURED DEVICE QL 12 / 30 days condoms latex lubricated - male REALITY LATEX/ULTRA THIN DEVICE QL 12 / 30 days condoms latex lubricated - male

PAGE 176 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS REFRESH OPTIVE ADVANCED SOLUTION 0.5-1-0.5 % carboxymethylcellulose-glycerin-polysorbate 80 REFRESH REDNESS RELIEF SOLUTION 0.12-1.4 % phenylephrine-polyvinyl alcohol RENAGEL TAB 400 MG PA sevelamer hcl RENAGEL TAB 800 MG PA sevelamer hcl RESCON DM SYRUP 30-2-10 MG/5ML pseudoephedrine-chlorphen-dm RESPAIRE-30 CAP 30-150 MG pseudoephedrine-guaifenesin RETAINE MGD EMULSION 0.5-0.5 % light mineral oil-mineral oil REZAMID LOTION 2-5 % resorcinol-sulfur RHOGAM ULTRA-FILTERED PLUS SOLN PRSYR 1500 UNIT rho d immune globulin (human) RIBOFLAVIN CAP 100 MG riboflavin RIBOFLAVIN CAP 50 MG riboflavin riboflavin tab 25 mg RIBOFLAVIN TAB 400 MG riboflavin riboflavin tab 50 mg RID ESSENTIAL LICE ELIMINATION KIT 0.33-4 % pyrethrins-piperonyl butoxide RIGHT STEP PRENATAL TAB 27-0.8 MG prenatal vit w/ ferrous fumarate-folic acid ROBITUSSIN CHILD COUGH/COLD CF LIQUID 2.5-5-50 MG/5ML phenylephrine w/ dm-gg ROBITUSSIN CHILD COUGH/COLD LA LIQUID 1-7.5 MG/5ML chlorpheniramine-dm ROBITUSSIN COUGH/COLD D LIQUID 30-15-200 MG/5ML pseudoephedrine w/ dm-gg ROBITUSSIN DAY/NIGHT VALUE PAK MISC phenylephrine-diphenhydramine-dm-gg

PAGE 177 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ROBITUSSIN NIGHTTIME COUGH DM LIQUID 12.5-30 MG/10ML doxylamine-dm ROBITUSSIN PK COLD DAY/NGHT DM MISC phenylephrine-diphenhydramine-dm-guaifenesin-apap ROBITUSSIN PK COLD DAY/NGHT MS MISC phenylephrine-diphenhydramine-dm-guaifenesin-apap RU-HIST D TAB 4-10 MG brompheniramine & phenyleph RU-HIST-D LIQUID 30-10 MG/5ML pyrilamine-phenylephrine RU-HIST-D TAB 30-10 MG pyrilamine-phenylephrine RYDEX G TAB 38.5-398 MG pseudoephedrine-guaifenesin RYMED TAB 2-10 MG dexchlorpheniramine-phenylephrine SAFE TUSSIN PM LIQUID 3.125-7.5 MG/5ML doxylamine-dm SAFELET IV CATHETER MISC QL 200 / 30 days iv sets/tubing salicylic acid & sulfur shampoo 2-2% salicylic acid pad 40%

saline nasal spray 0.65% QL 90 / 30 days

salsalate tab 500 mg salsalate tab 750 mg SASTID SOAP BAR 3-5 % salicylic acid & sulfur (soap) SCALP VEIN SET MISC QL 200 / 30 days iv sets/tubing SCHOOLTIME SHAMPOO SHAMPOO nit remover SCOT-TUSSIN SENIOR LIQUID 15-200 MG/5ML dextromethorphan-guaifenesin SCOT-TUSSIN SUGAR-FREE LIQUID pheniramine-pe w/ sod salicylate & caffeine citrate SE-NATAL 19 CHEW TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid

PAGE 178 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS SE-NATAL 19 TAB 29-1 MG prenatal vit w/ docusate-fe fumarate-folic acid SE-NATAL 90 TAB ER 90-1 MG prenatal vit w/ docusate-fe fumarate-folic acid SE-NATAL ONE TAB 60-1 MG prenatal vit w/ ferrous fumarate-folic acid SEBASORB LOTION 2-10 % salicylic acid-attapulgite SENNA LEAVES LEAVES senna SENNA SYRUP 176 MG/5ML senna sennosides cap 8.6 mg sennosides chew tab 15 mg sennosides syrup 8.8 mg/5ml sennosides tab 15 mg sennosides tab 17.2 mg sennosides tab 25 mg sennosides tab 8.6 mg SETONET MISC 29-1-200 & 430 MG prenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 SEVELAMER CARBONATE TAB 800 MG PA sevelamer carbonate simethicone cap 125 mg simethicone cap 180 mg simethicone chew tab 125 mg simethicone chew tab 80 mg simethicone liquid 40 mg/0.6ml simethicone susp 40 mg/0.6ml SIMILAC PRENATAL EARLY SHIELD MISC 27-0.8 & 200 MG prenatal mv & min w/fe fumarate-fa-dha SINADRIN PE COMPLETE SINUS REL TAB 2-10-650 MG dexbrompheniramine-phenylephrine-acetaminophen SKIN BEAUTY & WELLNESS PACKET multiple vitamins w/ minerals

PAGE 179 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS SM CAMPHOR SPIRIT SPIRIT camphor spirit SM ETHYL ALCOHOL (RUBBING) SOLUTION 70 % alcohol, usp SM IPECAC SYRUP SYRUP ipecac SM ISOPROPYL ALCOHOL SOLUTION 50 % isopropyl alcohol SM ISOPROPYL ALCOHOL SOLUTION 70 % isopropyl alcohol SM ISOPROPYL ALCOHOL SOLUTION 91 % isopropyl alcohol SM ONE DAILY PRENATAL MISC 28-0.8 & 440 MG prenatal vit w/ ferrous fumarate-fa-omega 3 fatty acids SM PRENATAL VITAMINS TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid SODIUM ASCORBATE GRANULES sodium ascorbate SODIUM BICARBONATE POWDER sodium bicarbonate (antacid) SODIUM BICARBONATE POWDER sodium bicarbonate (bulk) sodium bicarbonate tab 325 mg sodium bicarbonate tab 650 mg sodium chloride aero soln 0.9% sodium chloride hypertonic ophth oint 5% sodium chloride hypertonic ophth soln 5% sodium chloride soln nebu 0.9% sodium chloride tab 1 gm sodium citrate & citric acid soln 500-334 mg/5ml

QL 30 / 30 days

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) PA

AL Up to 10 yrs old

QL 30 / 30 days

sodium fluoride chew tab 1 mg f (from 2.2 mg naf) PA

AL Up to 10 yrs old

PAGE 180 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS sodium fluoride cream 1.1%

QL 30 / 30 days sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) AL Up to 10 yrs old

SODIUM POLYSTYRENE SULFONATE POWDER sodium polystyrene sulfonate (bulk) SODIUM SILICATE SOLUTION sodium silicate SODIUM SILICATE SOLUTION 40 % sodium silicate SOLUTION ADMINISTRATION SET MISC QL 200 / 30 days iv sets/tubing SOLUTION TRANSFER DEVICE MISC QL 200 / 30 days iv sets/tubing SOURCECF PEDIATRIC LIQUID AL Up to 9 yrs old pediatric multiple vitamin w/ minerals SPAN 20 SOLUTION polysorbate 20 SPATONE PUR-ABSORB IRON LIQUID 5 MG/20ML AL Up to 12 yrs old ferrous sulfate STAHIST AD LIQUID 25-60 MG/5ML chlorcyclizine & pseudoephedrine STAHIST AD TAB 25-60 MG chlorcyclizine & pseudoephedrine stannous fluoride conc 0.63% stannous fluoride gel 0.4% starch suppositories 51% STATUSS GREEN LIQUID 9-30-12.5 MG/5ML codeine-pseudoephedrine-chlorcyclizine STEP 2 SOLUTION 8 % formic acid (nit removal) STERILE LUBRICANT LIQUID 0.7 % carboxymethylcellulose sodium (ophth) STROVITE FORTE SYRUP multiple vitamins w/ minerals & folic acid STUART ONE CAP 27-0.8-200 MG prenatal mv & min w/fe carbonyl-fa-dha STUART PRENATAL TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid

PAGE 181 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS SUDAFED 24 HOUR TAB ER 24H 240 MG pseudoephedrine hcl SUDAFED PE DAY & NIGHT MISC 25-10 & 10 MG diphenhydramine-phenylephrine SUDAFED TRIPLE ACTION TAB 30-325-200 MG pseudoephedrine-acetaminophen-guaifenesin sulfacetamide sodium w/ sulfur cleanser 10-2% sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% sulfacetamide sodium w/ sulfur emulsion 10-5% sulfacetamide sodium w/ sulfur susp 8-4% sulfacetamide sodium w/ sulfur wash 9-4% sulfacetamide sodium w/ sulfur wash 9-4.5% sulfacetamide sodium-sulfur in urea emulsion 10-4% sulfur bar 5% SUPER NU-THERA POWDER multiple vitamins w/ minerals SUPERVITE EC TAB DR 1 MG multiple vitamins w/ minerals & folic acid SUPPORT LIQUID multiple vitamins w/ minerals SUPRESS A PEDIATRIC LIQUID 5-1-10 MG/ML phenylephrine-dexbrompheniramine-dextromethorphan SUPRESS DM PEDIATRIC LIQUID 5-50 MG/ML dextromethorphan-guaifenesin SUPRESS-PE PEDIATRIC LIQUID 2.5-50 MG/ML phenylephrine-guaifenesin SURE-T INFUSION SET 18" MISC QL 200 / 30 days subcutaneous infusion set SURE-T INFUSION SET 23" MISC QL 200 / 30 days subcutaneous infusion set SURE-T INFUSION SET 32" MISC QL 200 / 30 days subcutaneous infusion set SYNAGEX CAP 1.25 MG multiple vitamins w/ minerals & folic acid SYNATEK CAP 1.25 MG multiple vitamins w/ minerals & folic acid SYNDION LIQUID multiple vitamins w/ minerals

PAGE 182 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS SYNDION-SF LIQUID multiple vitamins w/ minerals SYRINGE LUER SLIP MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml SYRINGE LUER SLIP MISC 26G X 3/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml SYRPALTA (RED) SYRUP oral vehicles SYRPALTA SYRUP oral vehicles SYRSPEND SF LIQUID oral vehicles SYSTANE BALANCE SOLUTION 0.6 % propylene glycol (ophth) SYSTANE OVERNIGHT THERAPY GEL 0.3 % hypromellose (ophth)

TAMIFLU RECON SUSP 6 MG/ML QL 120 / 10 days oseltamivir phosphate AL Up to 12 yrs old

TANDEM OB CAP 162-115.2-1 MG prenatal without a vit w/ fe fum-iron polysacch complex -fa TARON-BC MISC 20-1 & 25 (2) MG prenatal without vit a w/ iron carbonyl-folic acid & vit b6 TEARS AGAIN NIGHT & DAY GEL 2-0.1 % artificial tear gel terbinafine hcl cream 1% TERPIN HYDRATE MONOHYDRATE POWDER terpin hydrate TERPIN HYDRATE POWDER terpin hydrate TERUMO SURGUARD2 SYRINGE MISC 25G X 5/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml TERUMO SURGUARD2 SYRINGE MISC 26G X 3/8" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml tetrahydrozoline hcl ophth soln 0.05% tetrahydrozoline w/ polyethylene glycol ophth soln 0.05-1% tetrahydrozoline w/ zinc sulfate ophth soln 0.05-0.25% TG 45PSE/400GFN/15DM TAB 45-400-15 MG pseudoephedrine w/ dm-gg

PAGE 183 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS TGQ 15DM/5PEH/2CPM SYRUP 15-5-2 MG/5ML phenylephrine-chlorphen-dm TGQ 30PSE/150GFN/15DM SYRUP 30-150-15 MG/5ML pseudoephedrine w/ dm-gg TGQ 30PSE/3BRM/15DM SYRUP 30-3-15 MG/5ML pseudoephed-bromphen-dm TGQ 50PSE/3BRM/30DM SYRUP 50-3-30 MG/5ML pseudoephed-bromphen-dm TH PRENATAL VITAMINS TAB 28-0.8 MG prenatal vit w/ ferrous fumarate-folic acid THEO-24 CAP ER 24H 100 MG theophylline THEO-24 CAP ER 24H 200 MG theophylline THEO-24 CAP ER 24H 300 MG theophylline THERACOF PLUS COUGH/COLD REL LIQUID 5-10-100-325 MG/5ML phenylephrine-dm-gg w/ apap THERAFLU COLD & COUGH PACKET 10-20-20 MG phenylephrine-pheniramine-dm THERAFLU COLD & SORE THROAT PACKET 20-10-325 MG pheniramine-phenylephrine-acetaminophen THERAFLU COLD/COUGH DAYTIME STRIP 10-20 MG phenylephrine-dm THERAFLU FLU & SORE THROAT PACKET 20-10-650 MG pheniramine-phenylephrine-acetaminophen THERAFLU FLU/CHEST CONGESTION PACKET 1000-400 MG acetaminophen-guaifenesin THERAFLU MAX-D COLD & FLU PACKET 60-30-400-1000 MG pseudoephedrine-dm-gg w/ apap THERAFLU SEVERE COLD & COUGH MISC PACKET phenylephrine-diphenhydramine-dm w/ apap THERAFLU SEVERE COLD DAYTIME TAB 15-5-325 MG dextromethorphan-phenylephrine-acetaminophen THERAFLU SINUS & COLD PACKET 20-10-325 MG pheniramine-phenylephrine-acetaminophen THERAFLU WARMING COLD & CHEST LIQUID 5-325-200 MG/15ML phenylephrine-acetaminophen-guaifenesin THERANATAL COMPLETE MISC 27-1 & 300 MG prenatal mv & min w/fe fumarate-fa-dha

PAGE 184 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS THERANATAL CORE NUTRITION TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid THERANATAL LACTATION SUPPORT MISC multiple vitamins w/ minerals THERANATAL PLUS MISC 27-1 & 300 MG prenatal mv & min w/fe fumarate-fa-dha THERAPEUTIC LIQUID SOLUTION multiple vitamins w/ minerals thiamine hcl tab 100 mg thiamine hcl tab 50 mg TITRALAC PLUS CHEW TAB 420-21 MG calcium carbonate-simethicone

TL G-FOL OS TAB 500-1.1 MG QL 30 / 30 days multiple vitamins w/ minerals & calcium-folic acid AL 14 to 50 yrs old

TREXBROM LIQUID 10-4-25 MG/5ML phenylephrine-brompheniramine-chlophedianol TRIACTIN CHEST CONGESTION SOLUTION 50 MG/5ML guaifenesin TRIADVANCE TAB 90-1 MG prenatal vit w/ docusate-iron carbonyl-folic acid TRIAMINIC CHEST/NASAL CONGEST LIQUID 2.5-50 MG/5ML phenylephrine-guaifenesin TRIAMINIC CHEST/NASAL CONGEST SYRUP 2.5-50 MG/5ML phenylephrine-guaifenesin TRIAMINIC COLD/ALLERGY CHILD SYRUP 1-2.5 MG/5ML chlorpheniramine & phenylephrine TRIAMINIC COLD/COUGH DAY TIME SOLUTION 2.5-5 MG/5ML phenylephrine-dm TRIAMINIC COLD/COUGH DAY TIME SYRUP 2.5-5 MG/5ML phenylephrine-dm TRIAMINIC COLD/COUGH DAYTIME STRIP 2.5-5 MG phenylephrine-dm TRIAMINIC COLD/COUGH MISC 2.5-5 &2.5-6.25 MG/5ML phenylephrine-diphenhydramine-dextromethorphan TRIAMINIC COLD/COUGH NIGHTTIME STRIP 12.5-5 MG diphenhydramine-phenylephrine TRIAMINIC COUGH & SORE THROAT SYRUP 160-5 MG/5ML acetaminophen w/ dm

PAGE 185 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS TRIAMINIC COUGH/RUNNY NOSE CHEW TAB 1-5 MG chlorpheniramine-dm

PA TRIAMINIC COUGH/RUNNY NOSE STRIP 12.5 MG diphenhydramine hcl C Covered up to age 65, then PA required TRIAMINIC COUGH/SORE THROAT CHEW TAB 160-5 MG acetaminophen w/ dm TRIAMINIC FLU COUGH & FEVER SYRUP 7.5-160-1 MG/5ML dextromethorphan-acetaminophen-chlorpheniramine TRIAMINIC FLU/COUGH/FEVER LIQUID 7.5-160-1 MG/5ML dextromethorphan-acetaminophen-chlorpheniramine TRIAMINIC MULTI-SYMPTOM FEVER SYRUP 7.5-160-1 MG/5ML dextromethorphan-acetaminophen-chlorpheniramine TRIAMINIC NIGHT TIME COLD/CGH SYRUP 6.25-2.5 MG/5ML diphenhydramine-phenylephrine TRIAMINIC-D SYRUP 15-1-7.5 MG/5ML pseudoephedrine-chlorphen-dm triazolam tab 0.125 mg triazolam tab 0.25 mg TRICARE TAB prenatal vit w/ ferrous fumarate-folic acid TRICODE AR LIQUID 30-2-8 MG/5ML pseudoeph-chlorphen w/ cod TRICODE GF LIQUID 30-8-200 MG/5ML pseudoephedrine w/ codeine-gg TRIGOFEN DM LIQUID 2-1-3 MG/ML phenylephrine-chlorphen-dm TRINATAL GT TAB 90-1 MG prenatal vit w/ docusate-iron carbonyl-folic acid TRINATAL RX 1 TAB 60-1 MG prenatal vit w/ ferrous fumarate-folic acid TRINATAL ULTRA TAB 90-1 MG prenatal vit w/ docusate-iron carbonyl-folic acid triprolidine & pseudoephedrine liquid 0.938-10 mg/ml triprolidine & pseudoephedrine syrup 1.25-30 mg/5ml triprolidine & pseudoephedrine tab 2.5-60 mg TRISPEC DMX LIQUID 10-187 MG/5ML dextromethorphan-guaifenesin

PAGE 186 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS TRISPEC DMX LIQUID 15-125 MG/5ML dextromethorphan-guaifenesin TRISPEC DMX LIQUID 15-25 MG/5ML dextromethorphan-guaifenesin TRISPEC DMX PEDIATRIC LIQUID 15-25 MG/5ML dextromethorphan-guaifenesin TRISPEC PSE LIQUID 30-15-125 MG/5ML pseudoephedrine w/ dm-gg TRISPEC PSE PEDIATRIC LIQUID 30-15-125 MG/5ML pseudoephedrine w/ dm-gg TRIVEEN-DUO DHA MISC 29-1-200 & 400 MG prenatal mv & min w/fe bisglyc-fe prot succ-fa-ca-omega 3 TRIVEEN-U CAP 106.5-1 MG prenatal without a vit w/ fe fumarate-folic acid TROJAN MAGNUM WARM SENSATIONS DEVICE QL 12 / 30 days condoms latex lubricated - male TROJAN NATURALAMB/SPERMICIDE MISC QL 12 / 30 days condoms - male TROJAN SUPRAS SPERMICIDAL DEVICE QL 12 / 30 days condoms latex lubricated - male TROJAN TWISTED PLEASURE DEVICE QL 12 / 30 days condoms latex lubricated - male tropicamide ophth soln 0.5% tropicamide ophth soln 1% TRUSTEX COLOR CONDOMS + LUBE MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX LUB/RIBBED/STUDDED MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX LUB/SPERMICIDE EX ST MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX LUB/SPERMICIDE XL MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX LUBRICATED EX LARGE MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX LUBRICATED EXTRA ST MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX LUBRICATED MISC QL 12 / 30 days condoms latex lubricated - male

PAGE 187 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS TRUSTEX LUBRICATED/SPERMICIDE MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX NATURAL CONDOMS + LUBE MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX NON-LUBRICATED MISC QL 12 / 30 days condoms latex non-lubricated - male TRUSTEX RIA LUB/SPERMICIDE MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX RIA LUBRICATED MISC QL 12 / 30 days condoms latex lubricated - male TRUSTEX RIA NON-LUBRICATED MISC QL 12 / 30 days condoms latex non-lubricated - male TRUSTEX-NONOXYNOL-9/RIB/STUD MISC QL 12 / 30 days condoms latex lubricated - male

trypsin w/ castor oil & peruvian balsam oint QL 60 / 30 days

trypsin w/ castor oil & peruvian balsam spray QL 60 / 30 days

TURPENTINE LIQUID turpentine TUSICOF LIQUID 10-20-400 MG/5ML phenylephrine w/ dm-gg TUSNEL CAP 2-15-200 MG brompheniramine w/ dm-gg TUSNEL LIQUID 30-15-200 MG/5ML pseudoephedrine w/ dm-gg TUSNEL PEDIATRIC LIQUID 15-5-50 MG/5ML pseudoephedrine w/ dm-gg TUSSAFEX-A LIQUID 6-2-15 MG/5ML phenylephrine-chlorphen-dm TYLENOL CHILDRENS COLD/STUFFY SUSPENSION 2.5-160 MG/5ML phenylephrine w/ acetaminophen TYLENOL CHILDRENS PLUS CLD/CGH SUSPENSION 5-2.5-160 MG/5ML dextromethorphan-phenylephrine-acetaminophen TYLENOL SINUS SEVERE CONGEST TAB 30-325-200 MG pseudoephedrine-acetaminophen-guaifenesin ULTICARE SYRINGE MISC 22G X 1-1/2" 1 ML QL 200 / 30 days syringe/needle (disp) 1 ml ULTRA MENS PACK MISC multiple vitamins w/ minerals

PAGE 188 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ULTRA WOMENS PACK MISC multiple vitamins w/ minerals UNDECYLENIC ACID LIQUID undecylenic acid (bulk) UPCAL D PACKET 500-500 MG-UNIT calcium citrate-vitamin d UPCAL D POWDER 500-500 MG-UNT/5GM calcium citrate-vitamin d urea cream 40% URO-MAG CAP 140 MG magnesium oxide VACUTAINER TUBING MISC QL 200 / 30 days iv sets/tubing VANACOF APE LIQUID 10-50-25 MG/15ML phenylephrine-thonzylamine-chlophedianol VANACOF CD LIQUID 5-1-10 MG/5ML phenylephrine-dexchlorpheniramine-codeine VANACOF DM LIQUID 10-18-200 MG/15ML phenylephrine w/ dm-gg VANACOF G LIQUID 25-200 MG/5ML chlophedianol-guaifenesin VANACOF GPE LIQUID 10-25-200 MG/15ML phenylephrine-chlophedianol-guaifenesin VANACOF-8 LIQUID 25-50 MG/15ML chlophedianol-pyrilamine VANATAB DX TAB 30-12.5-200 MG pseudoephedrine-chlophedianol-guaifenesin VANISHPOINT 18GX1-1/4" FEP MISC QL 200 / 30 days iv catheter VANISHPOINT 18GX1-1/4" PUR MISC QL 200 / 30 days iv catheter VANISHPOINT 20GX1-1/4" FEP MISC QL 200 / 30 days iv catheter VANISHPOINT 20GX1-1/4" PUR MISC QL 200 / 30 days iv catheter VANISHPOINT 22GX1" FEP MISC QL 200 / 30 days iv catheter VANISHPOINT 22GX1" PUR MISC QL 200 / 30 days iv catheter

PAGE 189 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS VANISHPOINT 24GX3/4" FEP MISC QL 200 / 30 days iv catheter VANISHPOINT 24GX3/4" PUR MISC QL 200 / 30 days iv catheter VANISHPOINT SYRINGE MISC 25G X 1" 1 ML QL 100 / 30 days syringe/needle (disp) 1 ml VENATAL-FA TAB 29-1 MG prenatal vit w/ ferrous fumarate-folic acid VERSAFREE SYRUP oral vehicles VERSAPLUS SYRUP oral vehicles VIBRAMYCIN SYRUP 50 MG/5ML doxycycline calcium VICKS NATURE FUSION COLD & FLU LIQUID 30-7.5-650 MG/30ML dextromethorphan-doxylamine-acetaminophen VICKS NATURE FUSION CONGEST LIQUID 20-200 MG/30ML dextromethorphan-guaifenesin VICKS NYQUIL CHILDRENS CLD/CGH LIQUID 2-15 MG/15ML chlorpheniramine-dm VICKS NYQUIL COLD & FLU NIGHT LIQUID 30-650-4 MG/30ML dextromethorphan-acetaminophen-chlorpheniramine VINATE AZ EXTRA TAB 29-1 MG prenatal vit w/ fe bisglycinate chelate-folic acid VINATE CALCIUM TAB 27-1 MG prenatal vit w/ iron carbonyl-fe gluconate-folic acid VINATE GT TAB 90-1 MG prenatal vit w/ docusate-iron carbonyl-folic acid VINATE IC CAP 162-115.2-1 MG prenatal without a vit w/ fe fum-iron polysacch complex -fa VINATE II TAB 29-1 MG prenatal vit w/ fe bisglycinate chelate-folic acid VINATE M TAB 27-1 MG prenatal vit w/ selenium-fe fumarate-folic acid VINATE ONE TAB 60-1 MG prenatal vit w/ ferrous fumarate-folic acid VINATE ULTRA TAB prenatal vit w/ docusate-iron carbonyl-folic acid VIRT-ADVANCE TAB 90-1 MG prenatal vit w/ docusate-iron carbonyl-folic acid

PAGE 190 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS VIRT-VITE GT TAB 90-1 MG prenatal vit w/ docusate-iron carbonyl-folic acid VITAFOL-OB TAB prenatal vit w/ ferrous fumarate-folic acid VITAFOL-PN TAB prenatal vit w/ ferrous fumarate-folic acid VITALINE BUFFERED ZINC-220 TAB ER 220 (50 ZN) MG zinc sulfate VITAMENT PACKET multiple vitamins w/ minerals VITAMIN C (CALCIUM ASCORBATE) RECON SOLN calcium ascorbate VITAMIN C-ELECTROLYTES PACKET multiple vitamins w/ minerals vitamin e cap 400 unit VITAMINS TO GO MAXIMUM MISC multiple vitamins w/ minerals VITAMINS TO GO MEN MISC multiple vitamins w/ minerals VITAMINS TO GO WOMEN MISC multiple vitamins w/ minerals VIVA DROPS SOLUTION 1 % polysorbate 80 (ophth) VOL-PLUS TAB 27-1 MG prenatal vit w/ ferrous fumarate-folic acid VOL-TAB RX TAB 29-1 MG prenatal vit w/ iron carbonyl-folic acid WAL-FLU SEVERE COLD NIGHT TIME PACKET 20-10-650 MG pheniramine-phenylephrine-acetaminophen WARM MIST VAPORIZER MISC vaporizers WEGMANS COMPLETE PRENATAL+DHA MISC 28-0.975 & 200 MG prenatal mv & min w/fe fumarate-fa-dha WESTHROID TAB 130 MG thyroid WESTHROID TAB 195 MG thyroid WESTHROID TAB 260 MG thyroid

PAGE 191 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS WESTHROID TAB 32.5 MG thyroid WESTHROID TAB 325 MG thyroid WESTHROID TAB 48.75 MG thyroid WESTHROID TAB 65 MG thyroid WESTHROID TAB 97.5 MG thyroid WESTHROID-P TAB 130 MG thyroid WESTHROID-P TAB 32.5 MG thyroid WESTHROID-P TAB 48.75 MG thyroid WESTHROID-P TAB 65 MG thyroid WESTHROID-P TAB 97.5 MG thyroid

QL 1 / 365 days WIDE-SEAL DIAPHRAGM 60 DIAPHRAGM 2 % PA diaphragm wide seal GL Female

QL 1 / 365 days WIDE-SEAL DIAPHRAGM 65 DIAPHRAGM 2 % PA diaphragm wide seal GL Female

QL 1 / 365 days WIDE-SEAL DIAPHRAGM 70 DIAPHRAGM 2 % PA diaphragm wide seal GL Female

QL 1 / 365 days WIDE-SEAL DIAPHRAGM 75 DIAPHRAGM 2 % PA diaphragm wide seal GL Female

QL 1 / 365 days WIDE-SEAL DIAPHRAGM 80 DIAPHRAGM 2 % PA diaphragm wide seal GL Female

PAGE 192 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS

QL 1 / 365 days WIDE-SEAL DIAPHRAGM 85 DIAPHRAGM 2 % PA diaphragm wide seal GL Female

QL 1 / 365 days WIDE-SEAL DIAPHRAGM 90 DIAPHRAGM 2 % PA diaphragm wide seal GL Female

WIDE-SEAL DIAPHRAGM 95 DIAPHRAGM 2 % QL 1 / 365 days diaphragm wide seal WP THYROID TAB 130 MG thyroid WP THYROID TAB 32.5 MG thyroid WP THYROID TAB 48.75 MG thyroid WP THYROID TAB 65 MG thyroid WP THYROID TAB 97.5 MG thyroid YOUR LIFE MULTI PRENATAL CAP 28-0.8-530 MG prenatal vit w/ ferrous fumarate-fa-fish oil Z-TUSS AC LIQUID 2-9 MG/5ML chlorpheniramine w/ codeine Z-TUSS E LIQUID 30-9-200 MG/5ML pseudoephedrine w/ codeine-gg ZINC 15 TAB 66 MG zinc sulfate ZINC SULFATE GRANULES zinc sulfate ZINC SULFATE SOLUTION 1 MG/ML zinc sulfate ZINC SULFATE SOLUTION 5 MG/ML zinc sulfate ZODRYL AC 25 SUSPENSION 0.333-1 MG/ML chlorpheniramine w/ codeine ZODRYL AC 30 SUSPENSION 0.286-1 MG/ML chlorpheniramine w/ codeine ZODRYL AC 35 SUSPENSION 0.25-1 MG/ML chlorpheniramine w/ codeine

PAGE 193 LAST UPDATED 07/2015 DRUG DESCRIPTION (RX) LIMITS & RESTRICTIONS ZODRYL AC 40 SUSPENSION 0.222-1 MG/ML chlorpheniramine w/ codeine ZODRYL DAC 25 SUSPENSION 5-0.333-1 MG/ML pseudoeph-chlorphen w/ cod ZODRYL DAC 30 SUSPENSION 4.286-0.286-1 MG/ML pseudoeph-chlorphen w/ cod ZODRYL DAC 35 SUSPENSION 3.75-0.25-1 MG/ML pseudoeph-chlorphen w/ cod ZODRYL DAC 40 SUSPENSION 3.333-0.222-1 MG/ML pseudoeph-chlorphen w/ cod ZODRYL DEC 25 SUSPENSION 5-1-20 MG/ML pseudoephedrine w/ codeine-gg ZODRYL DEC 30 SUSPENSION 4.286-1-20 MG/ML pseudoephedrine w/ codeine-gg ZODRYL DEC 35 SUSPENSION 3.75-1-20 MG/ML pseudoephedrine w/ codeine-gg ZODRYL DEC 40 SUSPENSION 3.333-1-20 MG/ML pseudoephedrine w/ codeine-gg ZYNCOF SYRUP 20-400 MG/5ML dextromethorphan-guaifenesin

PAGE 194 LAST UPDATED 07/2015 Index of covered drugs Agoral Maximum Strength 112 1 Aimsco Lubricated 112 1st Choice Pen Needles 70 Air Eliminating TPN IV Set 112 1st Tier Unifine Pentips 70 Ala-Hist PE 112 1st Tier Unifine Pentips Plus 70 Alamag 112 Albatussin NN 112 A Albuterol Sulfate 107 Abreva 110 Alclometasone Dipropionate 53 Acarbose 34 Alcohol (Rubbing) 112 Accu-Chek Tender 1 Infusion 110 Alcohol Denatured 112 Acebutolol HCl 43 Alcohol Swabs 13 Acerola C 500 110 Alcohol, Rubbing 112,137,138,143 Acetaminophen 110,111 Alcohol, USP 130,138,143,145,176,180 Acetaminophen w/ Codeine 9 Alendronate Sodium 69,70 Acetaminophen w/ DM 111,131,185,186 Aler-Dryl 112 Acetaminophen-Guaifenesin 111,184 Alfuzosin HCl 60 Acetazolamide 47,104 Alka-Seltzer Heartburn 112 AcetaZOLAMIDE 47 Alka-Seltzer Pls Allergy & Cgh 112 Acetic Acid (Otic) 105 Alka-Seltzer Pls Night Cld/Flu 112 Acetic Acid-Aluminum Acetate 111 Alka-Seltzer Plus Cold & Cough 112 Acetone 111 Alka-Seltzer Plus Cold & Flu 112 Acetone (Urine) Test 148 Alka-Seltzer Plus Day/Night 112 Acetylcysteine 108 Alka-Seltzer Plus Night Cold 113 Acidophilus Plus Pectin 111 Alka-Seltzer Plus Sinus 113 Acidophilus/Citrus Pectin 111 Allopurinol 25 Aclidinium Bromide 106 Alprazolam 33 Acne Medication 111 Altretamine 26 Actiphyte of Lemongrass 111 Alum & Mag Hydrox-Simethicone 113,132 Acyclovir 32 Aluminum & Magnesium Hydroxide 112,152,156 Administration Set 111 Aluminum Hydroxide-Mag Carb 113,142 Adrenaclick 107 Aluminum Hydroxide-Mag Trisil 113,142 Adult Acnomel 111 Aluminum Oxide 121 Adult Aspirin Low Strength 111 Amantadine HCl 32 Advair Diskus 105 AMBI 60PSE/400GFN/20DM 113 Advil Allergy & Congestion 111 Amiloride & Hydrochlorothiazide 48 Advil Allergy Sinus 111 Amiloride HCl 48 Advil Cold & Sinus Liqui-Gels 111 Amiodarone HCl 42 Advocate Insulin Pen Needles 70 Amitriptyline HCl 22 Advocate Insulin Syringe 70,71 Amlodipine Besylate 44,45 Afluria 112 Amlodipine Besylate-Benazepril HCl 45 Afluria Preservative Free 112 Amlodipine Besylate-Olmesartan Medoxomil 45

PAGE 195 LAST UPDATED 07/2015 Ammonium Lactate 113 Aurora Unifine Pentips 71 Amoxapine 22 Autoject 2 115 Amoxicillin 15,16 Autopen 115 Amoxicillin & Pot Clavulanate 15 Auvi-Q 107 Amphetamine-Dextroamphetamine 51 Avonex 53 Ampicillin 16,113 Azathioprine 68 Anagrelide HCl 38 Azelastine HCl (Ophth) 103 Anastrozole 27 Azithromycin 16 Anesthesia Extension Tubing 113 Azolen Tincture 115 Anoro Ellipta 107 Azor 45 Antacid 113 Anti-Stick Insulin Syringe 71 B Antipyrine-Benzocaine 113 B Complex w/ C 109 Apatate Forte 113 B-Complex w/ C & Calcium 109 Apidra 36 B-Complex w/ C & E + Zn 109 Apriso 69 B-Complex w/ C & Folic Acid 109 Argyle Extension Tube 20" 113 B-natal 115 Armour Thyroid 113,114 B1 Natural 115 Artificial Tear Gel 183 Bacitracin 12 Artificial Tear Ointment 103 Bacitracin (Ophthalmic) 12 Artificial Tear Solution 103 Bacitracin (Topical) 115 Ascorbic Acid 110,114,130 Bacitracin Zinc 115 Ascorbic Acid Buffered 122 Bacitracin-Poly-Neomycin-HC 12 Aspirin 111,114,115,136 Bacitracin-Polymyxin B (Ophth) 12 Aspirin Buffered 114 Baclofen 31 Aspirin Buffered (Cal Carb-Mag Carb-Mag Balsalazide Disodium 69 Oxide) 114,122 BD Angiocath Autoguard 115 Aspirin Low Dose 114 BD AutoShield 71 Aspirin-Acetaminophen-Caffeine 115 BD AutoShield Duo 71 Assure Dose Control 115 BD Eclipse Syringe 116 Assure ID Insulin Safety Syr 71 BD First Midcath 18G/4FRx20cm 116 Atabex 115 BD First Midcath 20G/3FRx20cm 116 Atabex EC 115 BD First PICC 16G/5FRx65cm 116 Atenolol 43 BD First PICC 18G/4FRx65cm 116 Atenolol & Chlorthalidone 43 BD First PICC 20G/3FRx65cm 116 Atorvastatin Calcium 49 BD First PICC 22G/2.8FRx50cm 116 Atovaquone 28 BD First PICC 26G/1.9FRx50cm 116 Atropine Sulfate 115 BD Insulin Syr Ultrafine II 71,72 Atropine Sulfate (Ophthalmic) 104,115 BD Insulin Syringe 72,116 Atrovent HFA 106 BD Insulin Syringe Half-Unit 72 Aurora Pen Needles 71 BD Insulin Syringe MicroFine 72

PAGE 196 LAST UPDATED 07/2015 BD Insulin Syringe U-40 116 BD Vacutainer Set 118 BD Insulin Syringe Ultrafine 72,73 Beclomethasone Dipropionate 106 BD Integra Insulin Syringe 73 Benazepril & Hydrochlorothiazide 40 BD Integra Syringe 73,116 Benazepril HCl 40 BD L-Cath 16G/5FR 116 Benfotiamine 118 BD L-Cath 16G/5FRx60cm 116 Benfotiamine-V 118 BD L-Cath 18G/3.5FR 116 Benzocaine (Dental) 118,163 BD L-Cath 18G/3.5FRx60cm 117 Benzocaine-Docusate Sodium 118 BD L-Cath 20G/2.6FR 117 Benzonatate 118 BD L-Cath 20G/2.6FRx60cm 117 Benzoyl Peroxide 111,119,121,136,162 BD L-Cath 20G/3FR 117 Benzoyl Peroxide w/ Cleanser 119 BD L-Cath 20G/3FRx60cm 117 Benzyl Alcohol 119 BD L-Cath 28G/1.2FRx25cm 117 Benzyl Benzoate 119 BD L-Cath Midline 18G/3.5FRx20 117 Benzyl Benzoate (Bulk) 119 BD L-Cath Midline 20G/3FRx20cm 117 Betamethasone Dipropionate (Topical) 53 BD Luer-Lok Syringe 117 Betamethasone Dipropionate Augmented 53 BD Nexiva 18Gx1.25" 117 Betamethasone Valerate 53 BD Nexiva 18Gx1.75" 117 Betaseron 53 BD Nexiva 20Gx1" 117 Betaxolol HCl (Ophth) 104 BD Nexiva 20Gx1.25" 117 Bethanechol Chloride 60 BD Nexiva 20Gx1.75" 117 Bicalutamide 26 BD Nexiva 22Gx1" 117 Bicarsim 119 BD Nexiva 24Gx0.56" 117 Bicarsim Forte 119 BD Nexiva 24Gx0.75" 117 Bicillin C-R 16 BD Pen Needle Mini U/F 73 Bicillin C-R 900/300 16 BD Pen Needle Nano U/F 73 Biclora 119 BD Pen Needle Short U/F 73 Biclora-D 119 BD Pen Needle Ultrafine 73 Biobron SF 119 BD Saf-T E-Z Set 117 Biodesp DM 119 BD Saf-T-Intima 18G x 1" 118 Bionatuss DXP 119 BD Saf-T-Intima 20Gx1" 118 Bionel 119 BD Saf-T-Intima 22G x 0.75" 118 Bionel Pediatric 120 BD Saf-T-Intima 22Gx3/4" 118 Biospec DMX 120 BD Saf-T-Intima 24G x 0.75" 118 Biosupp 120 BD Saf-T-Intima 24Gx3/4" 118 Biotect Plus 120 BD Safety-Lok Insulin Syringe 73 Biotin 120,154 BD Safety-Lok Set 118 Biotin Ultra Strength 120 BD Safety-Lok Vacutainer Set 118 Biovol 120 BD SafetyGlide Insulin Syringe 73 Bisacodyl 120,135,140 BD Syringe/Needle 118 Bismuth Subsalicylate 120 BD Syringe/Needle Slip Tip 118 Bisoprolol & Hydrochlorothiazide 43

PAGE 197 LAST UPDATED 07/2015 Bisoprolol Fumarate 43 Butalbital-Aspirin-Caffeine 122 Black Draught 120 Butalbital-Aspirin-Caffeine w/Cod 9 Blephamide 17 Butoconazole Nitrate (One Dose) 144 Blephamide S.O.P. 17 Bydureon 34 Blink Tears 120 Bystolic 43 Blood Glucose Calibration 115,142,163 Bone Meal 121 C Bone Meal w/ Vitamin D 121 Cal Carb & Mag Hydrox-Simeth 122,132 BP Cleansing 121 Cal-Mag Chela-Max 122 BP Cleansing Wash 121 Cal-Quick 122 BPO 121 Cal/Mag 122 BrainStrong Prenatal 121 Calcet Creamy Bites 122 Brasivol 121 Calcitriol 70 Breo Ellipta 105 Calcium 123 Brimonidine Tartrate 104 Calcium Acetate (Phosphate Binder) 60 Brohist D 121 Calcium Ascorbate 191 Brompheniramine & Phenyleph 121,131,133,178 Calcium Carbonate 122 Brompheniramine & Pseudoeph 121,151 Calcium Carbonate (Antacid) 113,122 Brompheniramine w/ DM-GG 188 Calcium Carbonate Antacid 122 Broncotron PED Drops 121 Calcium Carbonate- Broncotron-D 121 Cholecalciferol 122,123,124,137,165,166 Broncotron-S 121 Calcium Carbonate-Mag Hydrox 113,123 Bronkaid 121 Calcium Carbonate-Simethicone 123,142,152,185 Bronkids 121 Calcium Carbonate-Vitamin D 123 Brontuss DX 121 Calcium Citrate 123 BroveX PSB 121 Calcium Citrate Malate-Cholecalciferol 123 BroveX PSB DM 121 Calcium Citrate Malate-Vit D 123 Bubble Gum 121 Calcium Citrate-Vitamin D 122,123,189 Budesonide (Inhalation) 105 Calcium Citrate-Vitamin D3 123 Budesonide-Formoterol Fumarate Dihydrate 106 Calcium Pantothenate 123 Buffered Vitamin C 122 Calcium Phosphate-Cholecalciferol 124,137 Bufferin 122 Calcium Plus Vitamin D 123 Bumetanide 47 Calcium Polycarbophil 124,137 Bupropion HCl 20 Calcium w/ Magnesium 122,124 Bupropion HCl (Smoking Deterrent) 11 Calcium w/ Vitamin D 124 Buried Treasure Active 55 Plus 122 Calcium-Boron 176 Buspirone HCl 33 Calcium-Cholecalciferol 176 Busulfan 156 Calcium-Ergocalciferol 166 Butalbital-Acetaminophen 122 Calcium-Magnesium 124 Butalbital-Acetaminophen-Caffeine 122 Calcium-Vitamin D3 124 Butalbital-Acetaminophen-Caffeine w/ Codeine 53 Calcium/Vitamin D3 Gummies 124

PAGE 198 LAST UPDATED 07/2015 Camphor (Inhalant) 124 CeraLyte 70 125 Camphor Spirit 124,180 CeraSport 125 Canagliflozin 147 CeraSport EX1 125 CapCof 124 Certuss-D 125 Capecitabine 124 Cetirizine HCl 106,125 Capmist DM 124 Cetirizine-Pseudoephedrine 125 Capron DM 124 Chantix 12 Capsaicin 124,143 Chantix Continuing Month Pak 11 Captopril 40 Chantix Starting Month Pak 11 Captopril & Hydrochlorothiazide 40,41 Cherry 125 Captopril-Hydrochlorothiazide 40,41 Cherry Concentrate 125 Capzasin 124 Cherry Syrup 125 Carbamazepine 20 Chlo Tuss 125 Carbamide Peroxide & Saline 127,130,135,176 Chlo Tuss EX 125 Carbamide Peroxide (Otic) 124 Chlophed 125 Carbaphen 12 124 Chlophedianol-Chlorcyclizine 119 Carbaphen CH 124 Chlophedianol-Guaifenesin 125,189 Carbaphen Ped CH 124 Chlophedianol-Pseudoephedrine 127 Carbonyl Iron 167 Chlophedianol-Pyrilamine 189 Carboxymethylcellulose Sodium (Ophth) 124,181 Chlorambucil 26 Carboxymethylcellulose-Glycerin 125,127 Chlorcyclizine & Pseudoephedrine 157,181 Carboxymethylcellulose-Glycerin-Polysorbate 80 177 Chlorcyclizine-Phenylephrine 131 Carboxymethylcellulose-Hypromellose 142 Chlordiazepoxide HCl 125 CareFine Pen Needles 73,74 Chlordiazepoxide HCl-Clidinium Bromide 125 CareOne UltiGuard Insulin Syr 74 Chlorhexidine Gluconate 125 CareOne Unifine Pentips 74 Chlorhexidine Gluconate (Bulk) 125 CareOne Unifine Pentips Plus 74 Chlorhexidine Gluconate (Mouth-Throat) 53 Carteolol HCl (Ophth) 104 Chloroform 126 Carvedilol 43 Chloroquine Phosphate 28 CCP Caffeine Free 125 Chlorothiazide 48,134 Cefaclor 14 Chlorpheniramine & Cefadroxil 14 Phenylephrine 126,131,135,136,185 Cefdinir 14 Chlorpheniramine & Pseudoeph 126,151 Cefpodoxime Proxetil 14 Chlorpheniramine Maleate 126,136 Cefprozil 14 Chlorpheniramine Tannate 136 Ceftin 125 Chlorpheniramine w/ Codeine 126,128,193,194 Ceftriaxone Sodium 14,15 Chlorpheniramine-Acetaminophen 126 Cefuroxime Axetil 15,125 Chlorpheniramine-DM 126,133,177,186,190 CellCept 68 Chlorpheniramine-Phenylephrine- Centrum Specialist Prenatal 125 Acetaminophen 126,129,162,163 Cephalexin 15 Chlorpheniramine-Phenylephrine-ASA 126

PAGE 199 LAST UPDATED 07/2015 Chlorpheniramine-Phenylephrine-Ibuprofen 111 Clomipramine HCl 22 Chlorpheniramine-Pseudoephedrine- Clonazepam 19 Acetaminophen 126 Clonidine HCl 39 Chlorpheniramine-Pseudoephedrine-Ibuprofen 111 Clopidogrel Bisulfate 39 Chlorpromazine HCl 28,29 Clorazepate Dipotassium 33 Chlorpropamide 126 Clotrimazole 24 ChlorproPAMIDE 126 Clotrimazole (Topical) 24,127 Chlorthalidone 48 Clotrimazole Vaginal 127,128 Chlorzoxazone 108 Clotrimazole w/ Betamethasone 61 Cholecalciferol 126,127 Clozapine 30 Cholestyramine 49 Clusimar 128 Choline & Mag Salicylate 127 Co-Natal FA 128 Ciclopirox 24 Codar AR 128 Cilostazol 39 Codar D 128 Cimetidine 58 Codeine Sulfate 9 Cimetidine HCl 58 Codeine-Chlorcyclizine 170 Cinacalcet HCl 67 Codeine-Pseudoephedrine-Chlorcyclizine 170,181 Ciprofloxacin HCl 17,127 Codeine-Pyrilamine 173 Ciprofloxacin HCl (Ophth) 17 Codituss DM 128 Ciprofloxacin HCl (Otic) 127 Colchicine 25 Citalopram Hydrobromide 21 Colchicine w/ Probenecid 25 Citrocarbonate 127 Colestipol HCl 49,50 Citrus Syrup 127 Collagenase 55 Clarithromycin 16 Colyte with Flavor Packs 58 Claritin Reditabs 127 Comfort EZ Insulin Syringe 75 Classic Prenatal 127 Comfort EZ Pen Needles 75 Clear Eyes for Dry Eyes 127 Commit 128 Clearcanal Ear Wax Removal 127 Complete Formulation Pediatric 128 Clemastine Fumarate 127 Complete Natal DHA 128 Cleocin 12 Complete Nutritional Drink 128 Clickfine Pen Needles 74 Complete Prenatal/DHA 128 Clindamycin HCl 12 Complete Sinus Relief 128 Clindamycin Palmitate Hydrochloride 12 CompleteNate 128 Clindamycin Phosphate (Topical) 54 ConceptionXR Motility Support 128 Clindamycin Phosphate Vaginal 12 Condoms 128 Clinical Nutrients Prenatal 127 Condoms - Male 128,150,151,187 Clinipur 27G Infusion Set 10mm 127 Condoms Latex Lubricated - Clinipur 27G Infusion Set 6mm 127 Male 112,136,138,148,149,154,171,176,187,188 Clinipur 27G Infusion Set 8mm 127 Condoms Latex Non-Lubricated - Male 148,188 Clobetasol Propionate 54 Conex Cold/Allergy 129 Clofera 127

PAGE 200 LAST UPDATED 07/2015 Conjugated Estrogens-Medroxyprogesterone Cyclophosphamide 26,27 Acetate 65,66 Cyclosporine 68 Contac Cold+Flu Max St 129 CycloSPORINE Modified 68 Contac Cold/Flu Day & Night 129 Cyclosporine Modified (For Microemulsion) 68 Contac Cold/Flu Max St 129 Cyproheptadine HCl 106 Cool Mist Humidifier 129 Cytra-3 130 Copaxone 53 Coricidin HBP Day/Night Cold 129 D Coricidin Nighttime Cold-Cough 129 Daily Energy Enfusion 130 Cornwall Metal Pipetting 129 Daily Heart Health Support 130 Correctol Herbal Tea 129 Daily Pak Maximum Multivitamin 130 Cortisone Acetate 61 Dallergy 131 Cottonseed Oil 129 Dapsone 25 Cottonseed Oil (Bulk) 129 Daraprim 28 CPB WC 129 Daytime Cold Medicine 131 Creon 56 Decon-A 131 Cromolyn Sodium (Nasal) 129 Decon-G 131 Cromolyn Sodium (Ophth) 104 Deltuss DP 131 Crotamiton 28 Delzicol 131 Cryoserv 129 Denture Adhesive 131 Culturelle 129 Denture Care Products 131 Culturelle Digestive Health 129 Depo-Provera 66 Culturelle Health & Wellness 129 Derma-Smoothe/FS Body 54 Culturelle Immunity Support 130 Derma-Smoothe/FS Scalp 54 Curity Alcohol Preps 13 Desgen DM 131 CVS Chest Congestion Childrens 130 Desmopressin Acetate 62 CVS Diabetes Health Support 130 Desmopressin Acetate Spray 62 CVS Ear Wax Cleansing System 130 Desmopressin Acetate Spray Refrigerated 62 CVS Ethyl Alcohol 130 Desogestrel & Ethinyl Estradiol 62 CVS Insulin Syringe 75,76 Desogestrel-Ethinyl Estradiol (Triphasic) 62 CVS Isopropyl Alcohol 130 Desonide 54 CVS Isopropyl Rubbing Alcohol 130 Despec DM 131 CVS Natural Fiber Supplement 130 Despec-DM 131 CVS Prenatal 130 Dewees Carminative 131 CVS Prenatal Gummy 130 Dex-Tuss 131 CVS Prenatal Multi+DHA 130 Dexamethasone 61,131,132 CVS Vitamin C 130 Dexamethasone Intensol 61 CVS Womens Prenatal+DHA 130 Dexamethasone Sodium Phosphate (Ophth) 104 Cyanocobalamin 130 Dexbrompheniramine & Pseudoephedrine 129,131 Cyclobenzaprine HCl 108 Dexbrompheniramine-Acetaminophen 135,142 Cyclopentolate HCl 130 Dexbrompheniramine-Phenylephrine 112,131

PAGE 201 LAST UPDATED 07/2015 Dexbrompheniramine-Phenylephrine- Diclofenac Sodium 7 Acetaminophen 128,179 Diclofenac Sodium (Ophth) 104 Dexchlorpheniramine & Pseudoephedrine 131 Dicloxacillin Sodium 16 Dexchlorpheniramine Maleate 131 Dicyclomine HCl 57 Dexchlorpheniramine-Phenylephrine 178 Diflunisal 7 Dexmethylphenidate HCl 52 Digoxin 47 DexPak 10 Day 131 Diltiazem HCl 45,46 DexPak 13 Day 131 Diltiazem HCl Coated Beads 45,46 DexPak 6 Day 132 Diltiazem HCl Extended Release Beads 46 Dextroamphetamine Sulfate 51,52 Dimenhydrinate 133,135 Dextromethorphan HBr 132 DimenhyDRINATE 133 Dextromethorphan-Acetaminophen- Dimetapp Cold/Allergy 133 Chlorpheniramine 132,186,190 Dimetapp Long Act Cough/Cold 133 Dextromethorphan-Diphenhydramine- Dimethyl Sulfoxide 133 Acetaminophen 132,133 Dimethyl Sulfoxide (bulk) 129,133 Dextromethorphan-Doxylamine- Dino-Life w/Iron-Zinc 133 Acetaminophen 132,190 Diphenhydramine HCl 112,133,134,186 Dextromethorphan- Diphenhydramine HCl (Sleep) 133 Guaifenesin 120,121,132,138,142,156,162,167,178,18 Diphenhydramine-Acetaminophen 129,134 2,186,187,190,194 Diphenhydramine-Acetaminophen (sleep) 134 Dextromethorphan-Guaifenesin-Chlorpheniramine- Diphenhydramine-Phenylephrine 134,182,185,186 Acetaminophen 129 Diphenhydramine-Phenylephrine-Acetaminophen 134 Dextromethorphan-Phenylephrine- Diphenhydramine-Pseudoephedrine- Acetaminophen 132,151,184,188 Acetaminophen 134 Dextromethorphan-Pyrilamine 124 Diphenoxylate w/ Atropine 57,58 Dextrose (Diabetic Use) 143 Diphenoxylate-Atropine 58 Di-Gel 132 Dipyridamole 39 Diabetes Health 132 Disopyramide Phosphate 42 Diabetes Support 132 Diuril 134 Diabetic Tussin Cold & Flu 132 Divalproex Sodium 19 Diabetic Tussin Night Cold/Flu 133 Docosanol 110 Dialyvite Supreme D 133 Docusate Calcium 134 Diaphragm Arc-Spring 164 Docusate Sodium 134,135,167 Diaphragm Coil Spring 164 DocuSol Kids 135 Diaphragm Flat Spring 165 Dologen 135 Diaphragm Wide Seal 192,193 Dolomite 135 Diaphragms 163 Dometuss-DA/Children 135 Diazepam 19,33,34 Doribax 15 Diazepam (Anticonvulsant) 19 Doripenem 15 Dicel CD 133 Dornase Alfa 107 Diclofenac Potassium 7 Dorzolamide HCl 104

PAGE 202 LAST UPDATED 07/2015 Dorzolamide HCl-Timolol Maleate 104 Ed-Chlor-Tan 136 Doxazosin Mesylate 60 Effaclar Duo 136 Doxepin HCl 33 Effient 39 Doxycycline (Monohydrate) 17 Elastic Bandages & Supports 149 Doxycycline Calcium 190 Eldertonic 136 Doxycycline Hyclate 17 Elexa Natural Feel 136 Doxylamine-DM 135,178 Elexa Stimulating 136 Doxylamine-Phenylephrine 169 Elexa Ultra Sensitive 136 Doxylamine-Phenylephrine-Acetaminophen 110,135 Eligard 67 Doxylamine-Pseudoephedrine 151 Eliphos 60 Dramamine 135 Elite Iron 136 Dronabinol 23 Elixophyllin 108 Drug Mart Ultra Comfort Syr 76 Ellis Tonic 136 Drug Mart Unifine Pentips 76 Enalapril Maleate 41 Drug Mart Unifine Pentips Plus 76 Enalapril Maleate & Hydrochlorothiazide 41 Duane Reade Unifine Pentips 76 Endacon 136 Dulcolax Bowel Prep Kit 135 Energy Booster 136 Dulera 105 Enfalyte 136 Duloxetine HCl 21 Enfamil Enfalyte 136 Duravent PE 135 Enfamil Expecta 137 Dyphylline 108 Enoxaparin Sodium 37 Dyphylline-Guaifenesin 135 Entex LQ 137 Entex T 137 E Entre-Cough Tannate 137 E-Z-Gas II 135 Ephedrine-Guaifenesin 121,137 Ear Wax Cleansing 135 Epinephrine 107 EasiVent 135 EPINEPHrine 107 EasiVent Mask Large 135 EpiPen 107 EasiVent Mask Medium 135 EpiPen 2-Pak 107 EasiVent Mask Small 135 EpiPen Jr 107 Easy Comfort Insulin Syringe 76,77 EpiPen Jr 2-Pak 107 Easy Comfort Pen Needles 77 Epivir HBV 32 Easy Touch Fluringe 136 Epoetin Alfa 38 Easy Touch Insulin Safety Syr 77 Epogen 38 Easy Touch Insulin Syringe 77,78 EQL Calcium/Vitamin D 137 Easy Touch Pen Needles 78 EQL Ethyl Alcohol (Rubbing) 137 Easy Touch Safety Syringe 136 EQL Infants Decongestant/Cough 137 Econazole Nitrate 24 EQL Insulin Syringe 78 Ecotrin 136 EQL Isopropyl Alcohol 137 Ed ChlorPed 136 EQL Natural Fiber 137 Ed ChlorPed D 136 EQL Prenatal Formula 137

PAGE 203 LAST UPDATED 07/2015 EQL Short Pen Needle 78 Famotidine Premixed 138 EQL Super Energy Booster 137 Fantasy Lubricated 138 EQL Ultra Comfort Insulin Syr 78 Fantasy Lubricated/Spermicide 138 EQL Ultra Short Pen Needle 79 Father Johns Medicine Plus 138 EQL Vitamin D-3 High Potency 137 Fe Fumarate-Vitamin C-Vitamin B12-Folic Acid 138 Equalactin 137 Felodipine 46 Ergocalciferol 137 Fenesin DM IR 138 Erythromycin (Acne Aid) 16 Fenofibrate 49 Erythromycin (Ophth) 16 Fenofibrate Micronized 49 Erythromycin-Sulfisoxazole 16 Fenoprofen Calcium 7 Escitalopram Oxalate 21 Fentanyl 8 Esomeprazole Magnesium 159 Fer-In-Sol 138 Estazolam 137 Ferate 138 Esterified Estrogens 27 Ferretts IPS 138 Esterified Estrogens & Methyltestosterone 137 Ferrimin 150 138 Estrace 62 Ferrous Bisglycinate Chelate 136 Estradiol 62,63 Ferrous Fumarate 138,145 Estradiol Vaginal 62 Ferrous Fumarate w/ B12-Vit C-FA-IFC 138 Estrogens, Conjugated 65 Ferrous Gluconate 138,139,147 Estropipate 63 Ferrous Sulfate 138,139,181 Ethambutol HCl 25 Ferrous Sulfate Dried 139 Ether 137 Ferrous Sulfate-Vitamin C-Folic Acid 139 Ethionamide 26 Fexofenadine HCl 139 Ethosuximide 18 Fifty50 Pen Needles 79 Ethyl Alcohol 138 Fifty50 Superior Comfort Syr 79 Ethyl Alcohol (Rubbing) 138 Filgrastim 38 Ethynodiol Diacet & Eth Estrad 64,66 Finasteride 60 Etodolac 7 First-Lansoprazole 139 Eugenol 138 First-Omeprazole 139 Eugenol (Bulk) 138 First-Progesterone VGS 100 139 Eurax 28 First-Progesterone VGS 200 139 Evac-U-Gen 138 First-Progesterone VGS 25 139 Excel Comfort Point Pen Needle 79 First-Progesterone VGS 400 140 Exel Comfort Point Insulin Syr 79 First-Progesterone VGS 50 140 Exenatide 34 First-Vancomycin 25 140 Extavia 53 First-Vancomycin 50 140 EzFe Forte 138 Flarex 104 Flavor Blend 140 F Flavor Plus 140 Famotidine 58,167 Flavor Sweet 140 Famotidine in NaCl 138 Flavor Sweet-SF 140

PAGE 204 LAST UPDATED 07/2015 Flecainide Acetate 42 FML Forte 104 Fleet Bisacodyl 140 Folgard OS 141 Flovent Diskus 105 Folic Acid 141 Flovent HFA 105 Foradil Aerolizer 107 Flu & Sore Throat 140 Formic Acid (Nit Removal) 181 Fluarix 140 Formoterol Fumarate 107 Fluarix Quadrivalent 140 Fortavit 142 Flucelvax 140 Fosinopril Sodium 41 Fluconazole 24 Fosphenytoin Sodium 20 Fludrocortisone Acetate 61 Freds Pharmacy Unifine Pentip+ 79 Fluid Administration Set 140 Freds Pharmacy Unifine Pentips 79 Flulaval 140 FreeStyle Control Solution 142 Flunisolide 105 FreeStyle Lite Test 142 Flunisolide (Nasal) 105 FreeStyle Precision Ins Syr 80 Fluocinolone Acetonide 54 FreeStyle Test 142 Fluocinonide 54 Fungoid Tincture 142 Fluocinonide Emulsified Base 54 Furosemide 47,66 Fluorometholone (Ophth) 104 Fluorometholone Acetate 104 G Fluorouracil (Topical) 54 G-Dologen 142 Fluoxetine HCl 21 G-P-Tuss DXP 142 Fluphenazine HCl 29 G-Tron Pediatric Drops 142 FluPHENAZine HCl 29 G-Tusicof 142 Flurazepam HCl 140 G-Zyncof 142 Flurbiprofen 7 Gabapentin 19 Flurbiprofen Sodium 104 Gas-X Childrens 142 Flutamide 26 Gas-X Extra Strength 142 Fluticasone Furoate-Vilanterol 105 Gas-X with Maalox Ex St 142 Fluticasone Propionate 54 Gauze Pads & Dressings 54,55 Fluticasone Propionate HFA 105 Gauze Sponge 54 Fluticasone Propionate (Inhalation) 105 Gaviscon 142 Fluticasone Propionate (Nasal) 105 Gaviscon Extra Relief Formula 142 Fluticasone-Salmeterol 105 Gemfibrozil 49 Fluvirin 141 Gentamicin Sulfate 12 Fluvirin Preservative Free 141 Gentamicin Sulfate (Ophth) 12 Fluvoxamine Maleate 21 Gentamicin Sulfate (Topical) 12 Fluzone 141 GenTeal 142 Fluzone Pediatric PF 141 GenTeal Severe 142 Fluzone Preservative Free 141 Giltuss Ped-C 142 Fluzone Quadrivalent 141 Giltuss TR 142 FML 104 Glatiramer Acetate 53

PAGE 205 LAST UPDATED 07/2015 Glimepiride 34,35 Golytely 58 Glipizide 35 Goniovisc 144 Global Ease Inject Pen Needles 80 GoodSense Prenatal Vitamins 144 Global Inject Ease Insulin Syr 80,81 Grape Syrup 144 Glucagon (rDNA) 36 Griseofulvin Microsize 24 Glucagon Emergency 36 Griseofulvin Ultramicrosize 24 Glucocard Expression Control 142 Guaiacol 144 Glucocard Expression Test 143 Guaifenesin 130,144,145,156,185 Glucocard Vital Test 143 GuaiFENesin 144 GlucoPro Insulin Syringe 81 Guaifenesin-Codeine 131,144 Glucose Blood 142,143 Guanfacine HCl 39 Glyburide 35 Gynazole-1 144 GlyBURIDE 35 Glyburide Micronized 35 H Glyburide-Metformin 35 H 468L Tubing 144 Glycerin 143 H-E-B inControl Pen Needles 82 Glycerin (Bulk) 143,173 Halobetasol Propionate 54 Glycerin (Laxative) 143,167 Haloperidol 29 Glycerin (Topical) 143 Haloperidol Decanoate 29 Glycerin-Hypromellose-Polyethylene Glycol 400 143 HC DermaPax 145 Glycerine 143 HealthWise Mini Pen Needles 82 Glycerol 143 HealthWise Pen Needles 82 Glycerol Formal 143 HealthWise Short Pen Needles 83 Glycine Soya Extract 143 HealthWise Unifine Pentips 83 Glycine Soya Protein 143 Healthy Accents Unifine Pentip 83 Glycopyrrolate 57 Healthy Mama Be Well Rounded 145 GNP Alcohol Denatured 143 Heparin Sodium (Porcine) 37 GNP Capsaicin 143 Herbal Expec 145 GNP Clickfine Pen Needles 81 Hexalen 26 GNP Daily Prenatal 143 High Potency Iron 145 GNP Ethyl Alcohol 143 Histex-DM 145 GNP Ethyl Rubbing Alcohol 143 Histex-PE 145 GNP Flu & Sore Throat 143 HM Ethyl Rubbing Alcohol 145 GNP Insulin Syringe 81,82 HM Isopropyl Alcohol 145 GNP Isopropyl Alcohol 144 HM One Daily Prenatal 145 GNP Peppermint Spirit 144 HM Prenatal 145 GNP PreNatal 144 Homatropine HBr 145 GNP Prenatal Vitamins 144 Honey Bears w/Iron-Zinc 145 GNP Ri-Mag Plus 144 Huber Infusion Set 145 GNP Sodium Silicate 144 HumaPen LUXURA HD 145 GNP Ultra Com Insulin Syringe 82 HumaPen MEMOIR 145

PAGE 206 LAST UPDATED 07/2015 HumatroPen for 12mg 145 iNatal Advance 146 HumatroPen for 24mg 145 Inatal GT 147 HumatroPen for 6mg 145 iNatal Ultra 147 Humidifiers 129 Indapamide 48 Hydralazine HCl 50 Indomethacin 7 Hydrochlorothiazide 48 Infergen 147 Hydrocil 145 Influenza Virus Vaccine Split 112,140,141 Hydrocodone Polistirex-Chlorpheniramine Influenza Virus Vaccine Split Preservative Polistirex 146 Free 112,140,141 Hydrocodone w/ Homatropine 146 Influenza Virus Vaccine Split Quadrivalent 140,141 Hydrocodone-Acetaminophen 9,10,11 Influenza Virus Vaccine Tissue-Cultured Subunit 140 Hydrocortisone 61 Influenza Virus Vaccine Types A & B Preservative Hydrocortisone & Colloidal Oatmeal & Body Wash 159 Free 141 Hydrocortisone (Intrarectal) 69 Influenza Virus Vaccine Types A & B Surface Hydrocortisone (Rectal) 55,61 Antigen 141 Hydrocortisone (Topical) 54,55,146 Infusion Set 147 Hydrocortisone Acetate (Rectal) 146 Infusion Set 23" Comfort 147 Hydrocortisone Acetate (Topical) 146 Inject-Ease 147 Hydrocortisone Valerate 55 Inject-Ease Automatic Injector 147 Hydrocortisone w/Acetic Acid 105 Injection Device 115,129,145,147,162,163,169 Hydrocortisone-Aloe Vera 146 Injection Device for Insulin 115,145,162 Hydrocortisone-Diphenhydramine HCl 145 Injection Device Needle-Free for Insulin 154,158 Hydromorphone HCl 10 Insuflon 147 Hydroxychloroquine Sulfate 28 Insulin Aspart Protamine & Aspart (Human) 37 Hydroxyprogesterone Caproate 146 Insulin Detemir 36 Hydroxyprogesterone Caproate (Bulk) 146 Insulin Glargine 36 Hydroxyurea 27 Insulin Glulisine 36 Hydroxyzine HCl 106 Insulin Isophane & Reg (Human) 36 Hydroxyzine Pamoate 106 Insulin Isophane (Human) 36 HydrOXYzine Pamoate 106 Insulin Pen Hyoscyamine Sulfate 146 Needle 70,71,73,74,75,76,77,78,79,80,81,82,83,84,85, HyperRHO S/D 146 86,87,89,90,91,92,93,94,96,98,100,101,102,103 Hypromellose (Gonioscopic) 146 Insulin Regular (Human) 36 Hypromellose (Ophth) 142,144,146,148,183 Insulin Syringe 83 Insulin Syringe/Needle 84 I Insulin Syringe/Needle U- Ibuprofen 7,146 10070,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,8 Ibuprofen-Diphenhydramine Citrate 146 6,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102 Imipramine HCl 22 ,103 Immune Support Vitamin C 146 Insulin Syringe/Needle U-40 116 Imodium A-D 146 Insulin Syringes (Disposable) 116,149,155

PAGE 207 LAST UPDATED 07/2015 Insupen Pen Needles 84 IV Insupen Sensitive 84 Sets/Tubing 110,111,112,113,117,118,127,140,144,14 Insupen Ultrafin 84 5,147,148,150,151,152,159,176,178,181,189 Insyte Autoguard 14Gx1.75" 147 Insyte Autoguard 18Gx1.16" 147 J Insyte Autoguard 20Gx1" 147 Janumet 35 Insyte Autoguard 20Gx1.16" 147 Januvia 35 Insyte Autoguard 22Gx1" 147 Insyte Autoguard 24Gx3/4" 147 K Interferon Alfa-2B 31 K-Phos 148 Interferon alfacon-1 147 K-Phos No 2 148 Interferon Beta-1a 53 Kala 148 Interferon Beta-1b 53 Kameleon Lubricated 148 InterLink Inject Site/Luer Loc 147 Kangaroo Burette Set 148 Intron A 31 Ketoconazole 24 Invokana 147 Ketoconazole (Topical) 24 Ionil 147 Ketone Blood Test 171 Ipecac 180 Ketoprofen 7 Ipratropium Bromide 106 Ketorolac Tromethamine 7 Ipratropium Bromide (Nasal) 106 Ketorolac Tromethamine (Ophth) 104 Ipratropium Bromide HFA 106 Ketostix 148 Iron 156 Ketotifen Fumarate (Ophth) 148 Iron (Ferrous Gluconate) 147 Kimono 149 Iron Combinations 109 Kimono Micro Thin 148 Iron Heme Polypeptide 173 Kimono Micro Thin Plus 149 Iron Polysaccharide Complex-Vit B12-Folic Acid 148 Kimono Plus 149 Iron Succinyl-Protein Complex 138 Kimono PS 149 Iron Up 148 Kimono PS Plus 149 Isoniazid 26,148 Kimono Sensation 149 Isoniazid-Rifampin w/ Pyrazinamide 26 Kimono Sensation Plus 149 Isopropanol 148 Kinray Insulin Syringe 84 Isopropyl Alcohol 130,137,144,145,148,176,180 Klor-Con M15 109 Isopropyl Alcohol (Skin Cleanser) 148 Kmart Valu Insulin Syringe 29G 149 Isopropyl Alcohol Wipes 148 Kmart Valu Insulin Syringe 30G 149 Isopropyl Palmitate 148 Knee Stabilizer/Elastic/Sm/Med 149 Isopto Tears 148 Konsyl 149 Isosorbide Dinitrate 50,148 Konsyl-D 149 Isosorbide Mononitrate 50 KP Prenatal Multivitamins 149 IV Catheter 115,116,117,118,147,189,190 KPN Prenatal 150 Kroger Insulin Syringe 84,85 Kroger Pen Needles 85

PAGE 208 LAST UPDATED 07/2015 Licide Treatment 150 L Lidocaine HCl 11 L606 Tubing 150 Lidocaine HCl (Local Anesth.) 11 L609 Tubing 150 Lidocaine HCl (Mouth-Throat) 11 Labetalol HCl 43 Lidocaine-Prilocaine 11 Lactic Acid (Ammonium Lactate) 55 Life Pack Mens 150 Lactic Acid w/ Vitamin E 150 LifeStyles Assorted Colors 150 Lactobacillus Acidophilus-Pectin 109,111,148 LifeStyles Extra Strength 150 Lactobacillus Rhamnosus (GG) 129,130 LifeStyles Form Fitting 150 Lactobacillus-Inulin 129 LifeStyles Lubricated 150 Lactulose 59 LifeStyles Ribbed 150 Lamivudine (HBV) 32 LifeStyles Skyn Original 151 Lamotrigine 19 LifeStyles Spermicidal Lube 151 Lansoprazole 59,139 LifeStyles Studded 151 Lantus 36 LifeStyles Ultra Sensitive 151 Latanoprost 104 LifeStyles Vibra-Ribbed 151 Leader Insulin Syringe 85 LifeStyles Xtra Pleasure 151 Leader Unifine Pentips 85 Light Mineral Oil-Mineral Oil 177 Leader Unifine Pentips Plus 85,86 Lindane 28 Leflunomide 69 Liquimat 151 Lemongrass (Bulk) 111 Lisinopril 41 Letrozole 27 Lisinopril & Hydrochlorothiazide 41 Leucovorin Calcium 27 Lite Touch Pen Needles 86 Leukeran 26 Litetouch Insulin Syringe 86 Leuprolide Acetate 67,68 Litetouch Pen Needles 86 Leuprolide Acetate (3 Month) 67,68 Lithium Carbonate 34 Leuprolide Acetate (4 Month) 67,68 Little Remedies for Colds 151 Leuprolide Acetate (6 Month) 67 Live Better Pen Needles 86 Leuprolide Acetate (CPP) 68 Lodrane D 151 Levemir 36 LoHist-D 151 Levetiracetam 18 Lomustine 26 Levobunolol HCl 104 Longs Insulin Syringe 87 Levofloxacin 17 Loperamide HCl 58,146,151 Levonorgestrel 150 Loratadine 127,151 Levonorgestrel & Eth Estradiol 64 Loratadine & Pseudoephedrine 151 Levonorgestrel (Emergency OC) 150,169 Lorazepam 34 Levonorgestrel-Eth Estradiol (Triphasic) 64 Lortab 10 Levonorgestrel-Ethinyl Estradiol (91-Day) 64 Lortuss DM 151 Levothyroxine Sodium 67 Lortuss EX 151 Lice B Gone 150 Lortuss LQ 151 Lice B Gone Cap Saturated 150 Losartan Potassium 40

PAGE 209 LAST UPDATED 07/2015 Losartan Potassium & Hydrochlorothiazide 40 Malathion 28 Lovastatin 49 Mar-cof BP 154 Loxapine Succinate 29 Matulane 26 Lozi-Flur 151 Maximin Pack 154 LTXF Prim CNV Pin Microdrip 151 Maxx 154 LTXF Prim IV Set/CNVT Pin 152 Maxx Plus 154 LTXF Secondary/CNV Pin/32INC 152 Meclizine HCl 23,154 Lufyllin 108 Meclofenamate Sodium 8 Lupron Depot 68 Medi-Graine 154 Lupron Depot-Ped 68 Medi-Jector Vision 154 Luride 152 Medi-Jector Vision Adapters 154 Lusair 152 Medic Insulin Syringe 87 Medicine Shoppe Pen Needles 87 M Medroxyprogesterone Acetate 66 M-End DMX 152 Medroxyprogesterone Acetate (Contraceptive) 66 M-END MAX D 152 MedSaver Syringe 154 M-End PE 152 Mefloquine HCl 28 M-Vit 152 Mega Biotin 154 M2 Potassium 152 Mega MultiVitamin 154 Maalox Junior Plus Antigas 152 Megestrol Acetate 66,67 Macrodantin 13 Meijer Pen Needles 87 Mag-Al 152 Meloxicam 8 Mag-Tab SR 152 Menest 27 Magaldrate w/ Simethicone 144 Meperidine HCl 154 Magellan Insulin Safety Syr 87 Mercaptopurine 27 Maginex 152 Mesalamine 69,131 Maginex DS 152 Metamucil 154 Magnesium 152,153,154 Metamucil MultiHealth Fiber 154 Magnesium Aspartate Hydrochloride 152 Metamucil Smooth Texture 154 Magnesium Carbonate 152 Metaproterenol Sulfate 107,154 Magnesium Carbonate Heavy 152 Metformin HCl 36 Magnesium Chloride 153 Methadone HCl 9,155 Magnesium Citrate 153 Methadose 155 Magnesium Citrate (Mg Supplement) 153 Methadose Sugar-Free 155 Magnesium Gluconate 153,154 Methanol 155 Magnesium Lactate 152 Methazolamide 47 Magnesium Oxide 153,189 Methenamine Hippurate 13 Magnesium Oxide (Mg Supplement) 153 Methenamine Mandelate 13 Magnesium Oxide-Asafoetida 131 Methimazole 68 Magnesium Sulfate 66 Methocarbamol 108 Magonate 154 Methotrexate Sodium 68

PAGE 210 LAST UPDATED 07/2015 Methyclothiazide 48 Morphine Sulfate (Concentrate) 10 Methyl Alcohol 155 MS Insulin Syringe 89 Methylcellulose (Laxative) 155 Mucinex Child MS Day-Night Cld 156 Methyldopa 39 Mucinex Cough For Kids 156 Methylergonovine Maleate 87 Mucinex D 156 Methylphenidate HCl 52,53 Mucinex Fast-Max Congest Cough 156 Methylphenidate HCl ER 52 Mucinex Fast-Max Day/Night 156 Methylprednisolone 61 Mucinex For Kids 156 Metipranolol 104 Mucinex Maximum Strength 156 Metoclopramide HCl 58 Mucinex Sinus-Max Day/Night 156 Metolazone 48,49 Multi For Her 156 Metoprolol & Hydrochlorothiazide 44 Multi For Him 156 Metoprolol Succinate 44 Multi Prenatal 156 Metoprolol Tartrate 44 Multiple Vitamin 109 Metronidazole 13 Multiple Vitamins w/ Iron 109 Metronidazole (Topical) 13 Multiple Vitamins w/ Metronidazole Vaginal 13 Minerals 109,110,113,120,122,128,130,132,136,137,14 MH Macular Health 155 2,146,150,154,155,156,158,166,169,171,173,176,179, Miconazole 3 24 182,183,185,188,189,191 Miconazole Nitrate (Topical) 115,142,155 Multiple Vitamins w/ Minerals & Calcium-Folic Miconazole Nitrate Vaginal 24,155 Acid 141,185 Midodrine HCl 39 Multiple Vitamins w/ Minerals & Folic Acid 133,181,182 Minocycline HCl 18 Mupirocin 13 Minoxidil 50 Mupirocin Calcium (Topical) 13 Miranel AF 155 Mycophenolate Mofetil 68,69 Mirtazapine 20 MyKidz Iron 10 156 Misoprostol 59 Mylanta Ultimate Strength 156 Mission Prenatal 155 Myleran 156 Mission Prenatal FA 155 Mynatal 156,157 Mission Prenatal HP 155 Mynatal Advance 156 Moexipril HCl 41 Mynatal Plus 157 Mometasone Furoate 55 Mynatal-Z 157 Mometasone Furoate-Formoterol Fumarate Mynate 90 Plus 157 Dihydrate 105 Monoject Insulin Syringe 87,88,155 N Monoject LifeShield Syringe 155 Nabumetone 8 Monoject Magellan Syringe 155,156 Nadolol 44 Monoject Ultra Comfort Syringe 88 NanoVM t/f 157 Montelukast Sodium 106 Naphazoline HCl 157 Moore Mono Insulin Syringe 88 Naphazoline w/ Pheniramine 157 Morphine Sulfate 9,10 Naphazoline-Glycerin 157

PAGE 211 LAST UPDATED 07/2015 Naphazoline-Hypromellose 157 Neria Multi 27G 3x10mm 159 Naphazoline-Polyethylene Glycol 300 157 Neria Multi 27G 4x12mm 159 Naprelan 157 Neria Soft 25G Infusion 13mm 159 Naproxen 8 Neria Soft 25G Infusion 17mm 159 Naproxen Sodium 8,157 Neupogen 38 Nasacort Allergy 24HR 105 Nexium 24HR 159 Nasal Decongestant 157 Niacin 159 NasOpen 157 Niacin (Antihyperlipidemic) 50 NasOpen PE 157 Niacin ER 159 Nat-Rul Prenatal Vitamins 157 Niacinamide 160 Natal-V RX 158 Niacor 50 Natalvit 158 Nicardipine HCl 46 Nateglinide 36 Nicoderm CQ 160 Natrul-100 158 Nicorette 160 Natural Senna Laxative 158 Nicorette Mini 160 Nature-Throid 158 Nicorette Refill 160 Nebivolol HCl 43 Nicorette Starter Kit 160 Necon 1/50 (28) 158 Nicotine 12,160,161 Necon 10/11 (28) 64 Nicotine Mini 161 Needle-Free Insulin Syringe A 158 Nicotine Polacrilex 128,160,161 Needle-Free Insulin Syringe B 158 Nicotrol 161 Needle-Free Insulin Syringe C 158 Nicotrol NS 12 Needle-Free Syringe Kit A 158 Nifedipine 46 Needle-Free Syringe Kit B 158 Nit Remover 110,178 Needle-Free Syringe Kit C 158 Nite-Time Cold/Flu Relief 161 Neomycin Sulfate 12 Nitro-Bid 50 Neomycin-Bacitracin Zn-Polymyxin 13 Nitrofurantoin Macrocrystal 13 Neomycin-Bacitracin-Polymyxin 110 Nitrofurantoin Monohyd Macro 13 Neomycin-Bacitracin-Polymyxin w/ Lidocaine 110 Nitroglycerin 50,51,162 Neomycin-Polymy-Dexameth 103 Nitrostat 50,51 Neomycin-Polymyxin-Gramicidin 13 Nonoxynol-9 163 Neomycin-Polymyxin-HC 13 Nordipen 5 Injection Device 162 Neomycin-Polymyxin-HC (Ophth) 13 Nordipen Delivery System 162 Neomycin-Polymyxin-HC (Otic) 105 Norel AD 162 Neosporin Essentials Trial Pk 159 Norel CS 162 NeoTuss Plus 159 Norethin Acet & Estrad-Fe 64,65 NeoTuss-D 159 Norethindrone & Eth Estradiol 64 Neria 29G Infusion Set 10mm 159 Norethindrone & Mestranol 158 Neria 29G Infusion Set 6mm 159 Norethindrone (Contraceptive) 67 Neria 29G Infusion Set 8mm 159 Norethindrone Acet & Eth Estra 64 Neria Multi 27G 2x10mm 159 Norethindrone Acetate 67

PAGE 212 LAST UPDATED 07/2015 Norethindrone Acetate-Ethinyl Estradiol 65 Ofloxacin 17 Norethindrone-Eth Estradiol (Biphasic) 64 Ofloxacin (Ophth) 17 Norethindrone-Eth Estradiol (Triphasic) 65 Ofloxacin (Otic) 17 Norgestimate-Ethinyl Estradiol 65 Omeprazole 59,139,163 Norgestimate-Ethinyl Estradiol (Triphasic) 65 Omeprazole Magnesium 173 Norgestrel & Ethinyl Estradiol 65 Omeprazole+Syrspend SF Alka 163 Norpace CR 42 Omeprazole-Sodium Bicarbonate 163 Nortriptyline HCl 22,23 Omniflex Diaphragm 163 Nortuss-Ex 162 Omnitrope Pen 10 Inj Device 163 NovaFerrum Pediatric Drops 162 Omnitrope Pen 5 Inj Device 163 NovoFine 89 Ondansetron 23 NovoFine Autocover 89 Ondansetron HCl 23 NovoFine Plus 89 One-A-Day Womens Prenatal 163 NovoLIN 70/30 36 OneTouch Ultra Control 163 NovoLIN 70/30 ReliOn 36 Onset Forte 163 NovoLIN N 36 Opium Tincture (Paregoric) 163 NovoLIN N ReliOn 36 Options Gynol II Contraceptive 163 NovoLIN R 36 Ora-Blend 163 NovoLIN R ReliOn 36 Ora-Blend SF 163 NovoLOG Mix 70/30 37 Ora-film 163 Novopen 3 162 Ora-Plus 163 Novopen 3 Penmate 162 Ora-Sweet 163 NovoPen Echo 162 Ora-Sweet SF 163 Novopen Jr (Green) 162 Oracit 163 Novopen Jr (Yellow) 162 Oral Electrolytes 110,125,136 NovoTwist 89 Oral Mix 164 Nulytely with Flavor Packs 59 Oral Mix SF 164 Nutritional Supplements 128 Oral Suspend 164 Nystatin 24,110 Oral Syrup 164 Nystatin (Mouth-Throat) 24 Oral Syrup SF 164 Nystatin (Topical) 24 Oral Vehicles 121,127,140,144,163,164,166,183,190 Nystatin-Triamcinolone 24 Orazinc 164 Orsini Insulin Syringe 89 O Ortho Diaphragm All-Flex 164 O-Cal FA 162 Ortho Diaphragm Coil 164 O-Cal Prenatal 162 Ortho Diaphragm Flat 165 Obstetrix DHA 162 Oseltamivir Phosphate 32,183 Obstetrix EC 162 Osteo-Poretical 165 Obtrex 162 Ovide 28 Obtrex DHA 162 Oxaprozin 8 OC8 162 Oxazepam 34

PAGE 213 LAST UPDATED 07/2015 Oxcarbazepine 20 Pediatric Multiple Vitamin w/ Minerals 157,181 Oxybutynin 60 Pediatric Multiple Vitamin w/ Minerals & C 110,128 Oxybutynin Chloride 59,60 Pediatric Multiple Vitamins 110 Oxycodone HCl 10,11,165 Pediatric Multiple Vitamins w/ Iron 110,133,145 OxyCODONE HCl 10,165 Pediatric Vitamins ACD w/ Fluoride 110 Oxycodone w/ Acetaminophen 11,166 PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Oxycodone-Aspirin 11 Sulfate 58,59 Oxymetazoline HCl 166 PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Oxytrol 60 Chloride 59 Oxytrol For Women 60 Peg-Intron 31 Oyster Shell Calcium/D 166 Peg-Intron Redipen 31 Peg-Intron Redipen Pak 4 31,32 P Peginterferon alfa-2b 31,32 PA Mens 50 Plus Vitapak 166 PegIntron 32 PA Mens Vitapak 166 Pen Needles 90 PA Prenatal Formula 166 Pen Needles 1/2" 90 PA Womens 50 Plus Vitapak 166 Pen Needles 3/16" 90 PA Womens Vitapak 166 Pen Needles 5/16" 90 PABA 166 Penicillin G Benzathine & Procaine 16 Palivizumab 69 Penicillin V Potassium 16 Panatuss DXP 166 Pentoxifylline 47 Panatuss DXP Pediatric 166 Pepcid AC Maximum Strength 167 Panatuss PED 166 Peppermint Spirit 144,167 Panatuss PED Drops 166 Perfect Iron 167 Pancreaze 56 Permethrin 28,167 Pancrelipase (Lip-Prot-Amyl) 57 Permethrin & Pyrethrins-Piperonyl Butoxide 167 Pancrelipase (Lipase-Protease-Amylase) 56,57 Perphenazine 29 Pantoprazole Sodium 59 Perry Prenatal 167 Para-Aminobenzoic Acid (PABA) 166 Pertzye 57 Paregoric 163 Phenazopyridine HCl 167 Paroxetine HCl 21,22 Phenelzine Sulfate 21 Parva-Cal 166 Pheniramine-PE w/ Sod Salicylate & Caffeine PC Unifine Pentips 89,90 Citrate 178 PCCA Sweet-SF 166 Pheniramine-Phenylephrine- PCCA Syrup Vehicle 166 Acetaminophen 140,143,184,191 PCCA-Plus 166 Phenobarbital 18 Pecgen DMX 167 PHENobarbital 18 Pedia-Lax 167 Phenyleph-DM-Pyril-Pot Guai-Sod Cit-Citric Acid 112 Pediatric Multiple Vitamin w/ C 110 Phenyleph-Promethazine w/ Cod 169,173 Pediatric Multiple Vitamin w/ C & FA 110 Phenylephrine w/ Acetaminophen 167,188 Pediatric Multiple Vitamin w/ Extra C & FA 110 Phenylephrine w/ Codeine-GG 142

PAGE 214 LAST UPDATED 07/2015 Phenylephrine w/ DM- Phenylephrine- GG 119,121,131,136,142,156,159,167,168,177,188,18 Guaifenesin 135,137,152,168,169,182,185 9 Phenylephrine-Pheniramine-DM 184 Phenylephrine-Acetaminophen- Phenylephrine-Polyvinyl Alcohol 177 Guaifenesin 125,168,184 Phenylephrine-Pyrilamine-Chlophedianol 173 Phenylephrine-APAP-Caffeine 154 Phenylephrine-Pyrilamine-DM 128,176 Phenylephrine-Aspirin 113 Phenylephrine-Thonzylamine-Chlophedianol 189 Phenylephrine-Brompheniramine w/ Codeine 152,169 Phenylephrine-Thonzylamine-Dextromethorphan 169 Phenylephrine-Brompheniramine-Chlophedianol 185 Phenylephrine-Triprolidine-Dextromethorphan 145 Phenylephrine-Brompheniramine-DM 168 Phenylhistine DH 169 Phenylephrine-Brompheniramine-Guaifenesin 131 Phenytoin 20 Phenylephrine-Chlophedianol-Guaifenesin 125,189 Phenytoin Sodium Extended 20 Phenylephrine-Chlorphen- Phlexy-Vits 169 DM 121,138,159,162,168,184,186,188 Phytonadione 169 Phenylephrine-Chlorpheniramine w/ Codeine 124 Pilocarpine HCl (Oral) 53 Phenylephrine-Chlorpheniramine-Carbetapentane 124 Pindolol 44 Phenylephrine-Chlorpheniramine-Chlophedianol 124 Pine Tar 169 Phenylephrine-Chlorpheniramine-DM w/ Pine Tar (Bulk) 169 APAP 112,166,167 Pioglitazone HCl 36 Phenylephrine-Chlorpheniramine-DM-Aspirin 112 Pioglitazone HCl-Metformin HCl 36 Phenylephrine-Dexbrompheniramine- Piroxicam 8 Chlophedianol 125 Plan B 169 Phenylephrine-Dexbrompheniramine- Plan B One-Step 169 Dextromethorphan 119,142,166,182 Plastic Adapter 169 Phenylephrine-Dexbrompheniramine-DM- PNV Fe Fum/Docusate/Folic Acid 169 Guaifenesin 166 PNV Folic Acid + Iron 169 Phenylephrine-Dexchlorpheniramine-Codeine 173,189 PNV Prenatal Plus Multivitamin 169 Phenylephrine-Diphenhydramine- PNV Tabs 29-1 169 Dextromethorphan 185 PNV-VP-U 169 Phenylephrine-Diphenhydramine-DM w/ APAP 184 Podofilox 55 Phenylephrine-Diphenhydramine-DM-GG 177 Poly Hist Forte 169 Phenylephrine-Diphenhydramine-DM-Guaifenesin- Poly-Hist DM 169 APAP 156,167,178 Poly-Hist PD 169 Phenylephrine-Diphenhydramine-GG w/ APAP 156 Poly-Tussin 170 Phenylephrine-DM 168,184,185 Poly-Tussin AC 169 Phenylephrine-DM-GG w/ APAP 168,184 Poly-Tussin D 170 Phenylephrine-Doxylamine-Dextromethorphan- Poly-Vent DM 170 Acetaminophen 112,161,166,168 Poly-Vent IR 170 Phenylephrine-Doxylamine-Dextromethorphan- Polyethylene Glycol 3350 59,170 Aspirin 112,113 Polyethylene Glycol 3350 (Bulk) 170 Polyethylene Glycol 400 (Ophth) 120

PAGE 215 LAST UPDATED 07/2015 Polyethylene Glycol-Propylene Glycol (Ophth) 170 Prednisone 61,62 Polymyxin B-Trimethoprim 13 PredniSONE 61,62 Polysaccharide Iron Complex 148,162 PredniSONE (Pak) 61 Polysorbate 20 170,181 Preferred Plus Insulin Syringe 90,91 Polysorbate 40 170 Preferred Plus Unifine Pentips 91 Polysorbate 60 170 Premarin 65 Polysorbate 80 170 Premium Condoms Lubricated 171 Polysorbate 80 (Ophth) 191 Premium Packets 171 Polyvinyl Alcohol-Povidone (Ophth) 170 Premphase 65 Pot & Sod Citrates w/Citric Ac 130 Prempro 66 Pot Phosphate Monobasic w/ Sod Phosphate Dibasic PrenaPlus 171 & Monobasic 170 PreNata 171 Potaba 170 Prenatabs FA 171 Potassium & Sodium Acid Phosphates 148 Prenatabs Rx 171 Potassium Aminobenzoate 152,170 Prenatal 172 Potassium Bicarb & Chloride 170 Prenatal 19 171 Potassium Bicarbonate 170 Prenatal AD 171 Potassium Chloride 109,170 Prenatal Complete 171 Potassium Chloride ER 109 Prenatal Formula 171 Potassium Chloride Microencapsulated Crystals PreNatal Formula 172 CR 109 Prenatal Formula A-Free 171 Potassium Citrate-Citric Acid 170 Prenatal Low Iron 172 Potassium Phosphate Monobasic 148 Prenatal Multi +DHA 172 Povidone-Iodine 170 Prenatal Multivit-Min w/Fe-FA 150,156,171,172 Povidone-Iodine Vaginal 170 Prenatal Multivitamin + DHA 172 PR Natal 400 171 Prenatal Multivitamins & Minerals w/ Folic Acid-Fish PR Natal 430 171 Oil 130 Pramipexole Dihydrochloride 28 Prenatal MV & Min w/Fe Bisglyc-Fe Prot Succ-FA-CA- Pramoxine-Calamine 171 Omega 3 128,171,179,187 Pramoxine-Phenylephrine-Glycerin-Petrolatum 171 Prenatal MV & Min w/Fe Carbonyl-FA- Prasugrel HCl 39 DHA 121,172,181 Pravastatin Sodium 49 Prenatal MV & Min w/Fe Fumarate-FA- Prazosin HCl 39 DHA 125,130,137,172,179,184,185,191 Pre-Natal Formula 171 Prenatal One Daily 172 Precision Sure-Dose Syringe 90 Prenatal Plus 172 Precision SureDose Plus Syr 90 Prenatal Plus DHA 172 Precision Xtra Ketone 171 Prenatal Plus Iron 172 Prednicarbate 55 Prenatal Vit w/ Docusate-Fe Fumarate-Folic Prednisolone 61 Acid 157,169,171,179 Prednisolone Acetate (Ophth) 104 Prenatal Vit w/ Docusate-Iron Carbonyl-Folic Prednisolone Sodium Phosphate 61 Acid 115,146,147,156,157,162,171,185,186,190,191

PAGE 216 LAST UPDATED 07/2015 Prenatal Vit w/ Fe Bisglycinate Chelate-Folic Acid 190 PriLOSEC OTC 173 Prenatal Vit w/ Fe Bisglycinate-Folic Acid-Omega 3 Primaquine Phosphate 28 Fatty Acd 145 Primidone 19 Prenatal Vit w/ Ferrous Fumarate-FA-Fish Oil 172,193 Primsol 173 Prenatal Vit w/ Ferrous Fumarate-FA-Omega 3 Fatty Pro-Chlo 173 Acids 143,145,163,171,172,176,180 Pro-Clear AC 173 Prenatal Vit w/ Ferrous Fumarate-Folic Pro-Red AC 173 Acid127,128,130,137,144,145,149,152,156,157,158,16 Probenecid 25 2,167,169,171,172,173,175,176,177,178,179,180,181, Procarbazine HCl 26 184,185,186,190,191 Prochlorperazine 29 Prenatal Vit w/ Ferrous Gluconate-Folic Acid 155 Prochlorperazine Maleate 29 Prenatal Vit w/ Iron Carbonyl-Fe Gluconate-Folic Procrit 38 Acid 190 Prodigy Insulin Pen Needles 91 Prenatal Vit w/ Iron Carbonyl-Folic Prodigy Insulin Syringe 91 Acid 115,158,169,171,172,191 Prodigy Mini Pen Needles 91 Prenatal Vit w/ Selenium-Fe Fumarate-Folic Prodigy Short Pen Needles 91 Acid 166,190 ProFe Forte 173 Prenatal Vitamins 172 Proferrin ES 173 PreNatal Vitamins Plus 172 Progesterone (Vaginal) 139,140 Prenatal Vitamins w/ Ferrous Succinate-Folic Acid 127 Promethazine & Phenylephrine 108 Prenatal w/Fe Carbonyl-FA-DSS-Omega 3 Fatty Promethazine HCl 23 Acids 162 Promethazine VC Plain 108 Prenatal without A Vit w/ Fe Fum-Iron Polysacch Promethazine VC/Codeine 173 Complex -FA 175,183,190 Promethazine w/Codeine 173 Prenatal without A Vit w/ Fe Fumarate-Folic Promethazine-DM 173 Acid 169,171,172,187 Propafenone HCl 42 Prenatal without A Vit w/ Iron Carbonyl-Folic Acid 115 Propantheline Bromide 173 Prenatal without A w/ Fe Bisglycinate-FA-DHA 128 Proparacaine HCl 103 Prenatal without Vit A w/ Iron Carbonyl-Folic Acid & Vit Propranolol & Hydrochlorothiazide 44 B6 183 Propranolol HCl 44,173 Prenatal without Vit A w/ Iron Polysaccharide Complex- Propranolol-HCTZ 44 FA 138,173 Propylene Glycol (Ophth) 183 Prenatal+DHA 172 Propylene Glycol-Glycerin 173 Prenatal-U 172 Propylthiouracil 68 Prenatal/Iron 172 Protect Plus 173 Prenatal/Omega-3/FA/Iron 172 Protect Plus NF 173 PrePLUS 173 Pseudoeph-Chlorphen w/ Cod 169,186,194 Prescriptive Formulas Mens 173 Pseudoeph-CPM-DM w/APAP 174 Prescriptive Formulas Womens 173 Pseudoephed-Bromphen-DM 121,174,184 PreTAB 173 Pseudoephed-Doxyl-DM w/APAP 174 Pretz 173 Pseudoephedrine HCl 157,174,182

PAGE 217 LAST UPDATED 07/2015 Pseudoephedrine HCl-Dextromethorphan HBr- PX Pen Needle 92 Guaifenesin Tannate 137 PX Prenatal Multivitamins 175 Pseudoephedrine w/ Codeine 128 Pyrantel Pamoate 175 Pseudoephedrine w/ Codeine-GG151,174,186,193,194 Pyrazinamide 26 Pseudoephedrine w/ DM- Pyrethrins-Piperonyl Butoxide 150,175,177 GG 113,119,120,124,131,170,174,177,183,184,187,18 Pyrethrins-Piperonyl Butoxide-Permethrin-Nit 8 Remover 175 Pseudoephedrine-Acetaminophen 174 Pyridoxine HCl 115,175,176 Pseudoephedrine-Acetaminophen- Pyril DM 176 Dextromethorphan 174 Pyrilamine Maleate-Phenylephrine HCl Tannate 176 Pseudoephedrine-Acetaminophen-Guaifenesin182,188 Pyrilamine-Phenylephrine 176,178 Pseudoephedrine-Brompheniramine-Chlophedianol133 Pyrimethamine 28 Pseudoephedrine-Brompheniramine- Codeine 129,154,174 Q Pseudoephedrine-Chlophedianol- QC Insulin Syringe 92 Guaifenesin 125,174,189 QC Isopropyl Rubbing Alcohol 176 Pseudoephedrine-Chlorcyclizine-Chlophedianol 119 QC Pen Needles 92 Pseudoephedrine-Chlorphen-DM 174,177,186 QC Prenatal 176 Pseudoephedrine-Chlorpheniramine w/ DM-GG 159 QC Unifine Pentips 92 Pseudoephedrine-Dexbrompheniramine- Quetiapine Fumarate 30 Chophedianol 125 Quinapril HCl 41 Pseudoephedrine-Dexbrompheniramine-Codeine 152 Quinapril-Hydrochlorothiazide 42 Pseudoephedrine-Dexbrompheniramine- Quinidine Gluconate 42 Dextromethorphan 152 Quinidine Sulfate 42 Pseudoephedrine-Dexchlorpheniramine- QuiNIDine Sulfate 42 Chlophedianol 166,174 Quinine Sulfate 28 Pseudoephedrine-Dexchlorpheniramine- Qvar 106 Dextromethorphan 174 Pseudoephedrine-DM 137,174,175 R Pseudoephedrine-DM-GG w/ APAP 175,184 RA Acne Maximum 176 Pseudoephedrine-Doxylamine-Dextromethorphan 151 RA Calcium Hi-Cal/Vitamin D 176 Pseudoephedrine- RA Calcium-Boron 176 Guaifenesin 137,156,170,175,177,178 RA Ear Wax Cleansing System 176 Pseudoephedrine-Ibuprofen 111,175 RA Essence-C 176 Pseudoephedrine-Naproxen Sodium 175 RA Ethyl Alcohol 176 Psyllium 130,137,145,149,154,175 RA Insulin Syringe 92 Pulmozyme 107 RA Lotion 176 PureFe OB Plus 175 RA One Daily 176 PX Extra Short Pen Needles 91 RA Pen Needles 93 PX Insulin Syringe 91 RA Prenatal 176 PX Mini Pen Needles 92 RA Prenatal Formula 176

PAGE 218 LAST UPDATED 07/2015 Ramipril 42 Rydex G 178 Ranitidine HCl 58 Rymed 178 Rapid-Fill Tube Set 176 Reality Latex/Ultra Textured 176 S Reality Latex/Ultra Thin 176 Safe Tussin PM 178 Refresh Optive Advanced 177 Safelet IV Catheter 178 Refresh Redness Relief 177 SafeSnap Insulin Syringe 93,94 Relenza Diskhaler 32 Safety-Glide Syringe 94 Reli-On Insulin Syringe 93 Salicylic Acid 178 ReliOn Insulin Syringe 93 Salicylic Acid & Sulfur 178 ReliOn Mini Pen Needles 93 Salicylic Acid & Sulfur (Soap) 178 ReliOn Pen Needles 93 Salicylic Acid in Alcohol 176 ReliOn Short Pen Needles 93 Salicylic Acid-Attapulgite 179 Renagel 177 Salicylic Acid-Benzalkonium Chloride 147 Rescon DM 177 Saline 178 Resorcinol-Alcohol 176 Salmeterol Xinafoate 107 Resorcinol-Sulfur 111,177 Salsalate 178 Respaire-30 177 Santyl 55 Retaine MGD 177 SAStid Soap 178 Rezamid 177 SB Insulin Syringe 94 Rho D Immune Globulin (Human) 146,177 Scalp Vein Set 178 RhoGAM Ultra-Filtered Plus 177 Schnucks Insulin Syringe 94 Ribavirin (Hepatitis C) 32 SchoolTime Shampoo 178 Riboflavin 177 Scot-Tussin Senior 178 RID Essential Lice Elimination 177 Scot-Tussin Sugar-Free 178 Rifampin 26 Se-Natal 19 178,179 Rifater 26 Se-Natal 90 179 Right Step Prenatal 177 Se-Natal ONE 179 Rimantadine Hydrochloride 32 Sebasorb 179 Risperidone 30 Selenium Sulfide 55 Rivaroxaban 38 Senna 129,158,179 Robitussin Child Cough/Cold CF 177 Senna Leaves 179 Robitussin Child Cough/Cold LA 177 Sennosides 112,120,138,179 Robitussin Cough/Cold D 177 Sensipar 67 Robitussin Day/Night Value Pak 177 Serevent Diskus 107 Robitussin Nighttime Cough DM 178 Sertraline HCl 22 Robitussin Pk Cold Day/Nght DM 178 SetonET 179 Robitussin Pk Cold Day/Nght MS 178 Sevelamer Carbonate 179 Roxicet 11 Sevelamer HCl 177 Ru-Hist D 178 SfRowasa 69 Ru-Hist-D 178 Shopko Unifine Pentips 94

PAGE 219 LAST UPDATED 07/2015 Silver Sulfadiazine 13 Spacer/Aerosol-Holding Chambers 135 Simethicone 119,142,179 Span 20 181 Similac Prenatal Early Shield 179 Spatone pur-Absorb Iron 181 Simvastatin 49 Spironolactone 48 Sinadrin PE Complete Sinus Rel 179 Spironolactone & Hydrochlorothiazide 48 Sitagliptin Phosphate 35 Stahist AD 181 Sitagliptin-Metformin HCl 35 Stannous Fluoride 181 Skin Beauty & Wellness 179 Starch (topical) 181 SM Camphor Spirit 180 Statuss Green 181 SM Ethyl Alcohol (Rubbing) 180 Step 2 181 SM Insulin Syringe 94,95 Sterile Lubricant 181 SM Ipecac Syrup 180 Strovite Forte 181 SM Isopropyl Alcohol 180 Stuart One 181 SM One Daily Prenatal 180 Stuart Prenatal 181 SM Prenatal Vitamins 180 Subcutaneous Infusion Set 182 Sodium Ascorbate 180 Subcutaneous Soft Cannula 147 Sodium Bicarb-Citric Acid w/ Simethicone 135 Sucralfate 59 Sodium Bicarbonate 180 Sudafed 24 Hour 182 Sodium Bicarbonate (Antacid) 180 Sudafed PE Day & Night 182 Sodium Bicarbonate (Bulk) 180 Sudafed Triple Action 182 Sodium Bicarbonate-Citric Acid 112 Sulfacetamide Sod-Prednisolone 17 Sodium Bicarbonate-Sodium Citrate 127 Sulfacetamide Sodium (Acne) 55 Sodium Chloride 109,180 Sulfacetamide Sodium w/ Sulfur 182 Sodium Chloride (GU Irrigant) 95 Sulfacetamide Sodium-Sulfur in Urea Vehicle 121,182 Sodium Chloride (Inhalant) 180 Sulfadiazine 17 Sodium Chloride Flush 109 SulfADIAZINE 17 Sodium Chloride Hypertonic 180 Sulfamethoxazole-Trimethoprim 17 Sodium Citrate & Citric Acid 163,180 Sulfasalazine 69 Sodium Fluoride 151,152,180,181 Sulfur 151,182 Sodium Fluoride (Dental) 181 Sulindac 8 Sodium Polystyrene Sulfonate 109,181 Sumatriptan Succinate 25 Sodium Polystyrene Sulfonate (Bulk) 181 Super Nu-Thera 182 Sodium Silicate 144,181 Supervite EC 182 Soft Lens Products 110 Support 182 Solution Administration Set 181 Supress A Pediatric 182 Solution Transfer Device 181 Supress DM Pediatric 182 Sotalol HCl 43 Supress-PE Pediatric 182 Sotalol HCl (AFIB/AFL) 42,43 Sure Comfort Insulin Syringe 95 SourceCF Pediatric 181 Sure Comfort Pen Needles 96 Soybean (Bulk) 143 Sure-Fine Pen Needles 96 Soybean Protein (Bulk) 143 Sure-Ject Insulin Syringe 96

PAGE 220 LAST UPDATED 07/2015 Sure-T Infusion Set 18" 182 Tetrahydrozoline w/ Zinc Sulfate 183 Sure-T Infusion Set 23" 182 TG 45PSE/400GFN/15DM 183 Sure-T Infusion Set 32" 182 TGQ 15DM/5PEH/2CPM 184 Surgical Dressing 55 TGQ 30PSE/150GFN/15DM 184 Symbicort 106 TGQ 30PSE/3BRM/15DM 184 Synagex 182 TGQ 50PSE/3BRM/30DM 184 Synagis 69 TH Prenatal Vitamins 184 SynaTek 182 Theo-24 184 Syndion 182 Theophylline 108,184 Syndion-SF 183 Theracof Plus Cough/Cold Rel 184 Syringe Luer Slip 183 Theraflu Cold & Cough 184 Syringe/Needle (Disp) 1 Theraflu Cold & Sore Throat 184 ML 116,117,118,136,154,155,156,183,188,190 Theraflu Cold/Cough Daytime 184 Syrpalta 183 Theraflu Flu & Sore Throat 184 Syrpalta (Red) 183 Theraflu Flu/Chest Congestion 184 SyrSpend SF 183 Theraflu Max-D Cold & Flu 184 Systane Balance 183 Theraflu Severe Cold & Cough 184 Systane Overnight Therapy 183 Theraflu Severe Cold Daytime 184 Theraflu Sinus & Cold 184 T Theraflu Warming Cold & Chest 184 Tabloid 27 TheraNatal Complete 184 Tacrolimus 69 TheraNatal Core Nutrition 185 Tamiflu 32,183 TheraNatal Lactation Support 185 Tamoxifen Citrate 26,27 TheraNatal Plus 185 Tandem OB 183 Therapeutic Liquid 185 Taron-Bc 183 Thiamine HCl 185 Tears Again Night & Day 183 Thiamine Mononitrate 115 Temazepam 34 Thinpro Insulin Syringe 97,98 Terazosin HCl 60 Thioguanine 27 Terbinafine HCl 24 Thiothixene 29,30 Terbinafine HCl (Topical) 183 Thonzylamine-Chlophedianol 169 Terbutaline Sulfate 107 Thonzylamine-Phenylephrine 157 Terconazole Vaginal 25 Thyroid 113,114,158,191,192,193 Terpin Hydrate 183 Ticlopidine HCl 39 Terpin Hydrate Monohydrate 183 Timolol Maleate 25 Terumo Insulin Syringe 96,97 Timolol Maleate (Ophth) 104 Terumo SurGuard Insulin Syr 97 Titralac Plus 185 Terumo SurGuard2 Syringe 183 Tizanidine HCl 31 Testosterone Cypionate 62 TL G-Fol OS 185 Tetrahydrozoline HCl (Ophth) 183 Tobramycin (Ophth) 12 Tetrahydrozoline w/ Polyethylene Glycol 183 Tobramycin-Dexamethasone 104

PAGE 221 LAST UPDATED 07/2015 Todays Health Mini Pen Needles 98 Tricode GF 186 Todays Health Pen Needles 98 Trifluoperazine HCl 30 Todays Health Short Pen Needle 98 Trifluridine 33 Tolterodine Tartrate 60 Trigofen DM 186 TopCare Clickfine Pen Needles 98 Trimethobenzamide HCl 23 TopCare Ultra Comfort Ins Syr 98 Trimethoprim 13 Topiramate 19,20 Trimethoprim HCl 173 Torsemide 48 Trimipramine Maleate 23 Tramadol HCl 11 Trinatal GT 186 Trandolapril 42 Trinatal Rx 1 186 Tranylcypromine Sulfate 21 Trinatal Ultra 186 Trazodone HCl 21 Triprolidine & Pseudoephedrine 186 Trecator 26 Triprolidine-Phenylephrine 145 Tretinoin 55,56 Trispec DMX 186,187 Tretinoin (Chemotherapy) 27 Trispec DMX Pediatric 187 Trexbrom 185 Trispec PSE 187 Triactin Chest Congestion 185 Trispec PSE Pediatric 187 TriAdvance 185 Triveen-Duo DHA 187 Triamcinolone Acetonide 56 Triveen-U 187 Triamcinolone Acetonide (Mouth) 53 Trojan Magnum Warm Sensations 187 Triamcinolone Acetonide (Nasal) 105 Trojan Naturalamb/Spermicide 187 Triamcinolone Acetonide (Topical) 56 Trojan Supras Spermicidal 187 Triaminic Chest/Nasal Congest 185 Trojan Twisted Pleasure 187 Triaminic Cold/Allergy Child 185 Tropicamide 187 Triaminic Cold/Cough 185 TRUEplus Insulin Syringe 98,99 Triaminic Cold/Cough Day Time 185 Trustex Color Condoms + Lube 187 Triaminic Cold/Cough Daytime 185 Trustex Lub/Ribbed/Studded 187 Triaminic Cold/Cough NightTime 185 Trustex Lub/Spermicide Ex St 187 Triaminic Cough & Sore Throat 185 Trustex Lub/Spermicide XL 187 Triaminic Cough/Runny Nose 186 Trustex Lubricated 187 Triaminic Cough/Sore Throat 186 Trustex Lubricated Ex Large 187 Triaminic Flu Cough & Fever 186 Trustex Lubricated Extra St 187 Triaminic Flu/Cough/Fever 186 Trustex Lubricated/Spermicide 188 Triaminic Multi-Symptom Fever 186 Trustex Natural Condoms + Lube 188 Triaminic Night Time Cold/Cgh 186 Trustex Non-Lubricated 188 Triaminic-D 186 Trustex Ria Lub/Spermicide 188 Triamterene & Hydrochlorothiazide 48 Trustex Ria Lubricated 188 Triamterene-HCTZ 48 Trustex Ria Non-Lubricated 188 Triazolam 186 Trustex-Nonoxynol-9/Rib/Stud 188 TriCare 186 Trypsin w/ Castor Oil & Peruvian Balsam 188 Tricode AR 186 Tudorza Pressair 106

PAGE 222 LAST UPDATED 07/2015 Turpentine 188 Valproic Acid 25 Tusicof 188 Value Health Insulin Syringe 102 Tusnel 188 ValuMark Pen Needles 102 Tusnel Pediatric 188 Vanacof APE 189 Tussafex-A 188 Vanacof CD 189 Twinject 107 Vanacof DM 189 Tylenol Childrens Cold/Stuffy 188 Vanacof G 189 Tylenol Childrens Plus Cld/Cgh 188 Vanacof GPE 189 Tylenol Sinus Severe Congest 188 Vanacof-8 189 Vanatab DX 189 U Vancomycin HCl 13,140 UltiCare Insulin Safety Syr 99 VanishPoint 18Gx1-1/4" FEP 189 UltiCare Insulin Syringe 99,100 VanishPoint 18Gx1-1/4" PUR 189 UltiCare Micro Pen Needles 100 VanishPoint 20Gx1-1/4" FEP 189 UltiCare Mini Pen Needles 100 VanishPoint 20Gx1-1/4" PUR 189 UltiCare Pen Needles 100 VanishPoint 22Gx1" FEP 189 UltiCare Short Pen Needles 100 VanishPoint 22Gx1" PUR 189 UltiCare Syringe 188 VanishPoint 24Gx3/4" FEP 190 Ultilet Insulin Syringe 100 VanishPoint 24Gx3/4" PUR 190 Ultilet Insulin Syringe Short 100 VanishPoint Insulin Syringe 102 Ultilet Pen Needle 100 VanishPoint Syringe 190 Ultra Comfort Insulin Syringe 100,101 Vaporizers 191 Ultra Mens Pack 188 Varenicline Tartrate 11,12 Ultra Womens Pack 189 Vegetable Extract 150 Ultra-Comfort Insulin Syringe 101 Venatal-FA 190 Ultra-Thin II Ins Syr Short 101 Venlafaxine HCl 22 Ultresa 57 Ventolin HFA 107 Umeclidinium-Vilanterol 107 Verapamil HCl 46,47 Undecylenic Acid 189 VersaFree 190 Undecylenic Acid (Bulk) 189 VersaPlus 190 Unifine Pentips 101,102 Vibramycin 190 Unifine Pentips Plus 102 Vicks Nature Fusion Cold & Flu 190 UPCal D 189 Vicks Nature Fusion Congest 190 Urea 189 Vicks NyQuil Childrens Cld/Cgh 190 Uro-Mag 189 Vicks NyQuil Cold & Flu Night 190 Ursodiol 58 Vida Mia Unifine Pentips 102,103 Vinate AZ Extra 190 V Vinate Calcium 190 V-R Mono Insulin Syringe 102 Vinate GT 190 Vacutainer Tubing 189 Vinate IC 190 Valproate Sodium 19 Vinate II 190

PAGE 223 LAST UPDATED 07/2015 Vinate M 190 Vinate One 190 X Vinate Ultra 190 Xarelto 38 Viokace 57 Virt-Advance 190 Y Virt-Vite GT 191 Your Life Multi Prenatal 193 Vitafol-OB 191 Vitafol-PN 191 Z Vitaline Buffered Zinc-220 191 Z-Tuss AC 193 VitaMent 191 Z-Tuss E 193 Vitamin C (Calcium Ascorbate) 191 Zaleplon 108 Vitamin C-Electrolytes 191 Zamicet 11 Vitamin E 191 Zanamivir 32 Vitamins To Go Maximum 191 Zenpep 57 Vitamins To Go Men 191 Zinc 15 193 Vitamins To Go Women 191 Zinc Sulfate 164,191,193 Viva Drops 191 Ziprasidone HCl 30 Vol-Plus 191 Zodryl AC 25 193 Vol-Tab Rx 191 Zodryl AC 30 193 VP Insulin Syringe 103 Zodryl AC 35 193 Zodryl AC 40 194 W Zodryl DAC 25 194 Wal-Flu Severe Cold Night Time 191 Zodryl DAC 30 194 Warfarin Sodium 37,38 Zodryl DAC 35 194 Warm Mist Vaporizer 191 Zodryl DAC 40 194 Water For Irrigation, Sterile 103 Zodryl DEC 25 194 WD Medic Insulin Syringe 103 Zodryl DEC 30 194 Wegmans Complete Prenatal+DHA 191 Zodryl DEC 35 194 Wegmans Unifine Pentips Plus 103 Zodryl DEC 40 194 Westhroid 191,192 Zolpidem Tartrate 108 Westhroid-P 192 Zonisamide 18,19 White Petrolatum-Mineral Oil 110 Zostavax 69 Wide-Seal Diaphragm 60 192 Zoster Vaccine Live 69 Wide-Seal Diaphragm 65 192 Zovia 1/50E (28) 66 Wide-Seal Diaphragm 70 192 Zyncof 194 Wide-Seal Diaphragm 75 192 Wide-Seal Diaphragm 80 192 Wide-Seal Diaphragm 85 193 Wide-Seal Diaphragm 90 193 Wide-Seal Diaphragm 95 193 WP Thyroid 193

PAGE 224 LAST UPDATED 07/2015