Preferred Drug List

Pharmacy Program

Louisiana Healthcare Connections is committed to providing appropriate, high quality, and cost effective drug therapy to all Louisiana Healthcare Connections members. Louisiana Healthcare Connections works with providers and pharmacists to ensure medications used to treat a variety of conditions and diseases are covered. Louisiana Healthcare Connections covers prescription medications and certain over-the-counter (OTC) medications when ordered by a practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage and maximum quantities.

Preferred Drug List

The Louisiana Healthcare Connections Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The Louisiana Healthcare Connections PDL is continually evaluated by the Louisiana Healthcare Connections Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is comprised of the Louisiana Healthcare Connections Medical Director, Louisiana Healthcare Connections Pharmacy Director and several Louisiana physicians, pharmacists, dentists and specialists. (Click HERE if you have trouble opening the PDL.)

Pharmacy Benefit Manager

Louisiana Healthcare Connections works with Envolve Pharmacy Solutions to process all pharmacy claims for prescribed drugs. Some drugs on the Louisiana Healthcare Connections PDL require PA, and Envolve Pharmacy Solutions is responsible for administering this process. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager.

Specialty Drugs

Louisiana Healthcare Connections contracts with a number of specialty pharmacies to ensure members have adequate access to the specialty drugs they require. All specialty drugs, such as biopharmaceuticals and injectable drugs require PA to be approved for payment by Louisiana Healthcare Connections. PA requirements are programmed specific to the drug.

For providers wishing to have a specialty drug distributed by a specialty pharmacy that is contracted with Louisiana Healthcare Connections, the listing of specialty medications requiring PA can be found on the PDL.

Dispensing Limits

Drugs may be dispensed up to a maximum of thirty (30) day supply for each new prescription or refill. A total of 85% of the 30 day supply must have elapsed before the prescription can be refilled for most drugs.

Appropriate Use and Safety Edits

The health and safety of the member is a priority for Louisiana Healthcare Connections. One of the ways we address member safety is through point-of sale (POS) edits when a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

Additional information about the drugs that are part of these edits can be found in the Appropriate Use and Safety Edits document.

Prior Authorizations

Some medications listed on the Louisiana Healthcare Connections PDL may require PA. The information should be submitted by the practitioner or pharmacist to Envolve Pharmacy Solutions on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document is located on the Louisiana Healthcare Connections website at www .louisianahealthconnect.com.

Louisiana Healthcare Connections will cover the medication if:

1. There is a medical reason the member needs the specific medication 2. Depending on the medication, other medications on the PDL have not worked

All reviews are performed by a licensed clinical pharmacist using the criteria established by the Louisiana Healthcare Connections P&T Committee. If the request is approved, Envolve Pharmacy Solutions notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Louisiana Healthcare Connections will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Step Therapy

Some medications listed on the Louisiana Healthcare Connections PDL may require specific medications to be used before the member can receive the step therapy medication. If Louisiana Healthcare Connections has a record that the required medication was tried first, the step therapy medications are automatically covered. If Louisiana Healthcare Connections does not have a record that the required medication was tried, the member's practitioner may be required to provide additional information. If Louisiana Healthcare Connections does not grant PA, we will notify the member and their practitioner and provide information regarding the appeal process.

Quantity Limits

Louisiana Healthcare Connections may limit how much medication a member can get at one time. If the practitioner has a medical reason for increasing the amount of medication a member receives, a PA may be requested. If Louisiana Healthcare Connections does not grant PA, we will notify the member and his or her practitioner and provide information regarding the appeal process.

Age Limits

Some medications on the Louisiana Healthcare Connections PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Medical Necessity Requests

If the member requires a medication that does not appear on the PDL, the member's practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare, and PDL medications will be appropriate to treat the vast majority of medical conditions. Louisiana Healthcare Connections requires the following:  Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or  Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or  Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.

All reviews are performed by a licensed clinical pharmacist using the criteria established by the Louisiana Healthcare Connections P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication, Louisiana Healthcare Connections will notify the member and his or her practitioner of alternatives and provide information regarding the appeal process.

Compounded Prescriptions Compounded prescriptions are not listed on Louisiana Healthcare Connections PDL. However, compounded prescriptions may be covered through the prior authorization process. The member’s practitioner can request a prior authorization for the compounded prescription. If there is a medical reason that a member needs a Compounded prescription, the provider or pharmacist should submit documentation and information on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions at 1- 866-399-0929.

72 Hour Emergency Supply Policy

State and Federal laws require that a pharmacy dispense a 72 hour (3 day) supply of medication to any member awaiting PA determination .The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call Envolve Pharmacy Solutions at 1-888-929-3790 for a prescription override to submit the 72 hour medication supply for payment.

Exclusions

The following drug categories are not part of the Louisiana Healthcare Connections PDL and are not covered by the 72 hour emergency supply policy:  Drugs that are considered experimental  Drug Efficacy Study and Implementation (DESI) drugs  Drugs prescribed for weight loss (with the exception of orlistat)  Drugs prescribed for infertility  Drugs prescribed for erectile dysfunction  Drugs prescribed for cosmetic purposes or hair growth  Cough and cold preparations

Newly Approved Products

Louisiana Healthcare Connections reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If Louisiana Healthcare Connections does not grant PA, we will notify the member and his or her practitioner and provide information regarding the appeal process.

Over-the-Counter (OTC) Medications

The Louisiana Healthcare Connections PDL covers a variety of OTC medications. A list of covered OTC medications can be found in the Over-the-Counter Medication Section of the Comprehensive Preferred Drug List. These OTCs are covered when the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

Tobacco Cessation Medications

The following types of tobacco cessation medications will be covered by Louisiana Healthcare Connections for members over the age of 18 and participating in an approved smoking cessation program: generic replacement products (gum,

lozenges, and patches) and SR (Zyban). A prescription will be required for all tobacco cessation medications.

Louisiana Healthcare Connections authorizes benefits for tobacco cessation medications for the purpose of supporting members who are trying to quit tobacco use with the temporary assistance of nicotine replacement therapy. It is expected that utilization of these products will be in accordance with medical standards of practice, FDA guidelines and manufacturers' recommendations which generally limit product use to approximately 12 weeks.

Generic Drugs

When generic drugs are available, the brand-name drug will not be covered without PA. Generic drugs have the same active ingredient, work the same as brand-name drugs and have lower co-payments. If the member or practitioner feels a brand-name drug is medically necessary, the practitioner can request the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason for the member needing the particular brand-name drug. If Louisiana Healthcare Connections does not grant PA, we will notify the member and his or her practitioner and provide information regarding the appeal process.

The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-Thyroxine, , Phenytoin, Procainamide, Theophylline, Thyroid, Valproic Acid and Warfarin.

Drug Efficacy Study and Implementation (DESI) Drugs

DESI products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by Louisiana Healthcare Connections.

Filling a Prescription

A member can have prescriptions filled at a Louisiana Healthcare Connections network pharmacy. If the member decides to have a prescription filled at a network pharmacy, the member can locate a pharmacy near them by contacting Louisiana Healthcare Connections Member Services. At the pharmacy, the member will need to provide the pharmacist with the prescription and a Louisiana Healthcare Connections ID card.

Copayments

The table below lists the copayment for the drugs according to the actual cost of the prescript ion. Actual Cost of Prescription Member Copayment Less than $10.01 $0.50 Between $10.01 and $25.00 $1.00 Between $25.01 and $50.00 $2.00 More than $50.01 $3.00

Copayments are not required for:

 children under the age of 21  pregnant women  family planning supplies  members in the hospital or a nursing home

 Alaskan Eskimo or American Indian members  Preventative medications which includes: Aspirin 81mg Vitamin D 400IU Folic Acid 0.4mg and 0.8mg Breast Cancer preventive medications (Tamoxifen and Raloxifene only) Tobacco cessation pharmacotherapy Oral Fluoride Supplementation (Children <21 years old) Gonorrhea prophylactic medication in newborns (Erythromycin eye ointment)

Contact Information

Louisiana Healthcare Connections Provider Services 1-866-595-8133 Fax:1- 866-768-9374

Prior Authorizations 1-888-929-3790 Fax: 1-866-399-0929

Envolve Pharmacy Solutions Help Desk 1-877-690-9330

Tier Definition:

Drug Tier Tier Definition 1 Preferred Generic 2 Preferred Brand 9 Non-formulary F Formulary NF Non-formulary VC $0 Copay

Legend Description AL Age Limit Drug is limited to specific age. Max Daily MDD Dose A limit on the number of times the drug can be taken per day. Max Package MPL Limit A limit on the amount of drug covered per prescription. MFL Max Fill Limit There is a limit on the number of times this drug can be refilled. Max Days’ MDS Supply There is a limit on the amount of this drug that is covered. Prior PA Authorization Prior Authorization required before prescription can be filled. There is a limit on the amount of drug covered per prescription, or within a QL Quantity Limit specific time frame. Rx/OTC Rx/OTC Product has both Rx and OTC National Drug Codes. Requires trial and failure of one or more preferred products prior to ST Step Therapy coverage.

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- ST; Try generic OBESITY/ANOREXIANTS - Drugs to Treat Adderall XR, ADHD, Sleep and Eating Disorders Concerta, Metadate CD or Ritalin SR VYVANSE CAPS F ADDERALL TABS (Use QL(2 ea daily); first;QL(1 ea - NF AL(At least 3 daily); AL(At Dextroamphetamine) yrs old) least 6 yrs old - ADDERALL XR CP24 (Use QL(1 ea daily); Up to 18 yrs Amphetamine- NF AL(At least 6 old) Dextroamphetamine) yrs old) ST; Try generic amphetamine- QL(1 ea daily); Adderall XR, dextroamphetamine cp24 AL(At least 6 Concerta, 5mg-5mg-5mg-5mg, yrs old) Metadate CD 2.5mg-2.5mg-2.5mg- VYVANSE CHEW F or Ritalin SR first;QL(1 ea 2.5mg, 7.5mg-7.5mg- F 7.5mg-7.5mg, 1.25mg- daily); AL(At 1.25mg-1.25mg-1.25mg, least 6 yrs old - 3.75mg-3.75mg-3.75mg- Up to 18 yrs 3.75mg, 6.25mg-6.25mg- old) 6.25mg-6.25mg Analeptics amphetamine- QL(2 ea daily); caffeine citrate soln or 20 F QL(90 ml per dextroamphetamine tabs AL(At least 3 mg/ml, 60 mg/3ml 30 days retail) 5mg-5mg-5mg-5mg, yrs old) 2.5mg-2.5mg-2.5mg- Attention-Deficit/Hyperactivity Disorder (ADHD) 2.5mg, 7.5mg-7.5mg- hcl (adhd) tb12 F 7.5mg-7.5mg, 1.25mg- 0.1 mg 1.25mg-1.25mg-1.25mg, F QL(1 ea daily); 3.75mg-3.75mg-3.75mg- hcl (adhd) tb24 F AL(At least 6 3.75mg, 1.875mg- yrs old) 1.875mg-1.875mg- 1.875mg, 3.125mg- QL(1 ea daily); INTUNIV TB24 (Use NF 3.125mg-3.125mg- Guanfacine HCl (ADHD)) AL(At least 6 3.125mg yrs old) DEXEDRINE CP24 10 MG, QL(2 ea daily); KAPVAY TB12 (Use NF Clonidine HCl (ADHD)) 15 MG (Use NF AL(At least 6 Dextroamphetamine yrs old) Stimulants - Misc. Sulfate) CONCERTA TBCR 18 MG, QL(1 ea daily); DEXEDRINE CP24 5 MG QL(1 ea daily); 27 MG, 54 MG (Use NF AL(At least 6 (Use Dextroamphetamine NF AL(At least 6 Methylphenidate HCl) yrs old) Sulfate) yrs old) QL(2 ea daily); QL(2 ea daily); CONCERTA TBCR 36 MG NF AL(At least 6 dextroamphetamine sulfate F AL(At least 6 (Use Methylphenidate HCl) cp24 10 mg, 15 mg yrs old) yrs old) dexmethylphenidate hcl F AL(At least 6 QL(1 ea daily); tabs 5 mg, 10 mg, 2.5 mg yrs old) dextroamphetamine sulfate F AL(At least 6 cp24 5 mg FOCALIN TABS (Use NF AL(At least 6 yrs old) Dexmethylphenidate HCl) yrs old) QL(3 ea daily); dextroamphetamine sulfate F AL(At least 3 tabs 5 mg, 10 mg yrs old) Louisiana Healthcare Connections Updated April 1, 2019

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); TOBRAMYCIN NEBU IN F PA METADATE CD CPCR NF AL(At least 6 (Use Methylphenidate HCl) 300 MG/5ML yrs old) tobramycin nebu in 300 F PA methylphenidate hcl cpcr or QL(1 ea daily); mg/5ml 10 mg, 20 mg, 30 mg, 40 F AL(At least 6 TOBRAMYCIN SULFATE PA mg, 50 mg, 60 mg yrs old) SOLN IJ 10 MG/ML, 40 F QL(3 ea daily); MG/ML methylphenidate hcl tabs or F AL(At least 3 10 mg, 20 mg tobramycin sulfate soln ij PA yrs old) 40 mg/ml, 80 mg/2ml, 1.2 F QL(6 ea daily); gm/30ml methylphenidate hcl tabs or F AL(At least 3 5 mg tobramycin sulfate solr ij F PA yrs old) 1.2 gm QL(2 ea daily); methylphenidate hcl tbcr or F AL(At least 6 - ANTI-INFLAMMATORY - Drugs 10 mg, 36 mg yrs old) to Treat Pain, Swelling, Muscle and Joint Conditions methylphenidate hcl tbcr or QL(1 ea daily); 18 mg, 20 mg, 27 mg, 54 F AL(At least 6 Anti-TNF-alpha - Monoclonal Antibodies mg yrs old) HUMIRA PEDIATRIC PA METHYLPHENIDATE QL(1 ea daily); CROHNS DISEASE F STARTER PACK PSKT HYDROCHLORIDE ER F AL(At least 6 TB24 18 MG, 27 MG, 54 yrs old) HUMIRA PEN PNKT F PA MG METHYLPHENIDATE QL(2 ea daily); HUMIRA PEN-CD/UC/HS F PA HYDROCHLORIDE ER F AL(At least 6 STARTER PNKT TB24 36 MG yrs old) HUMIRA PEN-PS/UV F PA RITALIN TABS 10 MG, 20 QL(3 ea daily); STARTER PNKT MG (Use Methylphenidate NF AL(At least 3 HUMIRA PSKT 10 PA HCl) yrs old) MG/0.1ML, 20 MG/0.2ML, F QL(6 ea daily); 20 MG/0.4ML, 40 RITALIN TABS 5 MG (Use NF MG/0.4ML, 40 MG/0.8ML Methylphenidate HCl) AL(At least 3 yrs old) Antirheumatic Antimetabolites ALTERNATIVE METHOTREXATE TABS F OR Alternative - M's Nonsteroidal Anti-inflammatory Agents (NSAIDs) tabs or 3 mg, 5 F QL(1 ea daily) mg ADVIL TABS (Use NF Ibuprofen) AMINOGLYCOSIDES - Drugs to Treat Bacterial ALEVE ARTHRITIS TABS NF QL(2 ea daily) Infections (Use Naproxen Sodium) Aminoglycosides ALEVE TABS (Use NF QL(2 ea daily) Naproxen Sodium) KITABIS PAK NEBU 300 F PA MG/5ML ANAPROX DS TABS (Use NF Naproxen Sodium) neomycin sulfate tabs or F CELEBREX CAPS (Use NF PA; QL(2 ea Celecoxib) daily) TOBI NEBU (Use NF PA Tobramycin) celecoxib caps or 50 mg, F PA; QL(2 ea 100 mg, 200 mg, 400 mg daily)

Louisiana Healthcare Connections Updated April 1, 2019

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHILDRENS ADVIL SUSP NF RX/OTC QL(20 ea per (Use Ibuprofen) ketorolac tromethamine F 30 days retail); tabs or 10 mg AL(At least 17 CHILDRENS MOTRIN NF RX/OTC SUSP (Use Ibuprofen) yrs old) LODINE TABS (Use DAYPRO TABS (Use NF NF Oxaprozin) Etodolac) meloxicam tabs or 15 mg, diclofenac potassium tabs F F 50 mg 7.5 mg MOBIC TABS (Use diclofenac sodium tb24 or F NF 100 mg Meloxicam) MOTRIN INFANTS diclofenac sodium tbec or F 25 mg, 50 mg, 75 mg DROPS SUSP (Use NF Ibuprofen) EC-NAPROSYN TBEC NF QL(2 ea daily) (Use Naproxen) nabumetone tabs or 500 F mg, 750 mg EC-NAPROXEN TBEC NF QL(2 ea daily) (Use Naproxen) NAPROSYN SUSP (Use NF Naproxen) etodolac caps F NAPROSYN TABS (Use NF Naproxen) etodolac tabs F naproxen sodium tabs or F QL(2 ea daily) 220 mg etodolac tb24 F naproxen sodium tabs or F FELDENE CAPS (Use NF 275 mg, 550 mg Piroxicam) naproxen susp or 125 F flurbiprofen tabs or 50 mg, F mg/5ml 100 mg naproxen tabs or 250 mg, F ibuprofen chew or 100 mg F 375 mg, 500 mg naproxen tbec or 375 mg, F QL(2 ea daily) ibuprofen susp or 100 F RX/OTC 500 mg mg/5ml oxaprozin tabs 600 mg F ibuprofen susp or 40 F mg/ml, 50 mg/1.25ml piroxicam caps or 10 mg, F ibuprofen tabs or 200 mg, F 20 mg 400 mg, 600 mg, 800 mg sulindac tabs or 150 mg, F indomethacin caps or 25 F 200 mg mg, 50 mg TOLMETIN SODIUM F indomethacin cpcr or 75 F CAPS mg TOLMETIN SODIUM TABS F INFANTS ADVIL SUSP NF (Use Ibuprofen) Pyrimidine Synthesis Inhibitors ketoprofen caps or 50 mg, F ARAVA TABS (Use NF QL(1 ea daily) 75 mg Leflunomide) KETOPROFEN CAPS OR F leflunomide tabs or 10 mg, F QL(1 ea daily) 50 MG, 75 MG 20 mg KETOPROFEN ER CP24 F Soluble Tumor Necrosis Factor Receptor Agents

Louisiana Healthcare Connections Updated April 1, 2019

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENBREL MINI SOCT F PA acetaminophen tabs or 325 F mg, 500 mg PA ENBREL SOLR F NORTEMP INFANTS F SUSP ENBREL SOSY F PA TYLENOL CHILDRENS CHEWABLES/PAIN + NF ENBREL SURECLICK F PA FEVER CHEW (Use SOAJ Acetaminophen) ANALGESICS - NonNarcotic - Drugs to Treat TYLENOL CHILDRENS Pain, Muscle and Joint Conditions SUSP (Use NF Combinations Acetaminophen) TYLENOL EXTRA butalbital-acetaminophen F tabs 325mg-50mg STRENGTH TABS (Use NF Acetaminophen) butalbital-acetaminophen- QL(4 ea daily) caffeine caps 325mg- F TYLENOL INFANTS 50mg-40mg PAIN+FEVER SUSP (Use NF Acetaminophen) butalbital-acetaminophen- QL(4 ea daily) caffeine tabs 325mg-50mg- F TYLENOL INFANTS SUSP NF 40mg (Use Acetaminophen) TYLENOL TABS (Use butalbital-aspirin-caffeine F QL(4 ea daily) NF caps 50mg-40mg-325mg Acetaminophen) BUTALBITAL/ASPIRIN/CA Salicylates FFEINE TABS 50MG- F aspirin buffered (cal carb- F 40MG-325MG mag carb-mag oxide) tabs ESGIC TABS (Use QL(4 ea daily) aspirin chew or 81 mg VC Butalbital-Acetaminophen- NF Caffeine) QL(12 ea per aspirin supp re 300 mg F fill retail) FIORINAL CAPS (Use NF QL(4 ea daily) Butalbital-Aspirin-Caffeine) ASPIRIN SUPP RE 300 F QL(12 ea per MG fill retail) TENCON TABS 325MG- F 50MG ASPIRIN SUPP RE 600 F Analgesics Other MG acetaminophen chew or 80 F aspirin supp re 600 mg F mg, 160 mg aspirin tabs or 325 mg F acetaminophen elix or 160 F mg/5ml, 80 mg/2.5ml aspirin tbec or 324 mg, 325 F acetaminophen liqd or 160 F mg, 500 mg mg/5ml acetaminophen soln or 160 aspirin tbec or 81 mg VC mg/5ml, 650 mg/20.3ml, F BUFFERIN TABS (Use 325 mg/10.15ml Aspirin Buffered (Cal Carb- NF acetaminophen supp re F QL(12 ea per Mag Carb-Mag Oxide)) 120 mg, 325 mg, 650 mg fill retail) choline & mag salicylate F acetaminophen susp or liqd 160 mg/5ml, 80 mg/0.8ml, F 80 mg/2.5ml diflunisal tabs F

Louisiana Healthcare Connections Updated April 1, 2019

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ECOTRIN MAXIMUM sulfate soln or 10 F QL(500 ml per STRENGTH TBEC (Use NF mg/5ml, 20 mg/5ml fill retail) Aspirin) morphine sulfate soln or 20 F QL(240 ml per ECOTRIN REGULAR mg/ml, 100 mg/5ml fill retail) STRENGTH TBEC (Use NF MORPHINE SULFATE QL(24 ea per Aspirin) SUPP RE 5 MG, 10 MG, F fill retail) salsalate tabs or 500 mg, F 20 MG, 30 MG 750 mg MORPHINE SULFATE F QL(6 ea daily) ANALGESICS - - Drugs to Treat Pain, TABS OR 15 MG, 30 MG Muscle and Joint Conditions morphine sulfate tbcr or 15 QL(3 ea daily) mg, 30 mg, 60 mg, 100 mg, F Opioid 200 mg CODEINE SULFATE TABS F QL(2 ea daily) 15 MG, 60 MG MS CONTIN TBCR (Use NF QL(3 ea daily) Morphine Sulfate) CODEINE SULFATE TABS QL(2 ea daily) 30 MG (Use Codeine NF oxycodone hcl caps or 5 F QL(6 ea daily) Sulfate) mg oxycodone hcl conc or 100 QL(6 ml daily) codeine sulfate tabs 30 mg, F QL(2 ea daily) F 60 mg mg/5ml OXYCODONE HCL ER QL(2 ea daily) DEMEROL TABS OR 100 NF QL(6 ea daily) F MG (Use Meperidine HCl) T12A DILAUDID TABS OR 2 QL(8 ea daily) oxycodone hcl soln or 5 F MG, 4 MG, 8 MG (Use NF mg/5ml Hydromorphone HCl) oxycodone hcl tabs or 5 QL(6 ea daily) mg, 10 mg, 15 mg, 20 mg, F DOLOPHINE TABS 10 MG NF QL(10 ea daily) (Use Methadone HCl) 30 mg ROXICODONE TABS (Use QL(6 ea daily) DOLOPHINE TABS 5 MG NF QL(4 ea daily) NF (Use Methadone HCl) Oxycodone HCl) 20 per hcl tabs or 50 mg F QL(8 ea daily) DURAGESIC PT72 (Use NF Fentanyl) month;QL(0.67 ea daily) ULTRAM TABS (Use NF QL(8 ea daily) Tramadol HCl) fentanyl pt72 12 mcg/hr, 25 20 per mcg/hr, 50 mcg/hr, 75 F month;QL(0.67 Opioid Combinations mcg/hr, 100 mcg/hr ea daily) acetaminophen w/ codeine F QL(30 ml daily) soln 120mg/5ml-12mg/5ml HYDROMORPHONE HCL F QL(12 ea per SUPP RE 3 MG fill retail) acetaminophen w/ codeine QL(6 ea daily) tabs 300mg-15mg, 300mg- F hydromorphone hcl tabs or F QL(8 ea daily) 2 mg, 4 mg, 8 mg 30mg, 300mg-60mg butalbital-acetaminophen- QL(4 ea daily) MEPERIDINE HCL SOLN F QL(500 ml per OR 50 MG/5ML fill retail) caffeine w/ codeine caps F 325mg-50mg-40mg-30mg meperidine hcl tabs or 50 F QL(6 ea daily) mg, 100 mg butalbital-aspirin-caffeine QL(4 ea daily) w/cod caps 50mg-40mg- F methadone hcl tabs or 10 F QL(10 ea daily) mg 30mg-325mg FIORINAL/CODEINE #3 QL(4 ea daily) methadone hcl tabs or 5 F QL(4 ea daily) mg CAPS (Use Butalbital- NF Aspirin-Caffeine w/Cod)

Louisiana Healthcare Connections Updated April 1, 2019

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocodone- QL(180 ml buprenorphine hcl- PA; QL(1 ea acetaminophen soln daily) naloxone hcl dihydrate film F daily) 2.5mg/5ml-108mg/5ml, F 4mg-1mg, 2mg-0.5mg 5mg/10ml-217mg/10ml, buprenorphine hcl- PA; QL(2 ea 7.5mg/15ml-325mg/15ml naloxone hcl dihydrate film F daily) hydrocodone- QL(6 ea daily) 8mg-2mg, 12mg-3mg acetaminophen tabs 10mg- F SUBOXONE FILM 12MG- PA; QL(2 ea 325mg 3MG (Use Buprenorphine NF daily) hydrocodone- QL(12 ea daily) HCl-Naloxone HCl acetaminophen tabs 5mg- F Dihydrate) 325mg SUBOXONE FILM 4MG- PA; QL(1 ea hydrocodone- QL(8 ea daily) 1MG, 2MG-0.5MG (Use NF daily) acetaminophen tabs F Buprenorphine HCl- 7.5mg-325mg Naloxone HCl Dihydrate) NORCO TABS 10MG- QL(6 ea daily) SUBOXONE FILM 8MG- PA; QL(2 ea NF 325MG (Use Hydrocodone- 2MG (Use Buprenorphine F daily) Acetaminophen) HCl-Naloxone HCl NORCO TABS 5MG- QL(12 ea daily) Dihydrate) 325MG (Use Hydrocodone- NF ANDROGENS-ANABOLIC - Drugs to Regulate Acetaminophen) Hormones NORCO TABS 7.5MG- QL(8 ea daily) 325MG (Use Hydrocodone- NF Androgens Acetaminophen) ANDRODERM PT24 F QL(1 ea daily) oxycodone w/ QL(6 ea daily) ANDROXY TABS F acetaminophen tabs 5mg- F 325mg, 10mg-325mg, 7.5mg-325mg DEPO-TESTOSTERONE SOLN 200 MG/ML (Use NF oxycodone-aspirin tabs F QL(6 ea daily) Testosterone Cypionate) METHITEST TABS 10 MG F OXYCODONE/ACETAMIN F QL(30 ml daily) OPHEN SOLN TESTOSTERONE PERCOCET TABS 5MG- QL(6 ea daily) CYPIONATE SOLN IM 200 F 325MG, 10MG-325MG, MG/ML 7.5MG-325MG (Use NF Oxycodone w/ testosterone cypionate soln F Acetaminophen) im 200 mg/ml ANORECTAL AGENTS - Rectal Drugs to Treat tramadol-acetaminophen F QL(4 ea daily) tabs 37.5mg-325mg Pain, Swelling and Itching TYLENOL/CODEINE #3 QL(6 ea daily) Intrarectal Steroids TABS (Use Acetaminophen NF CORTENEMA ENEM (Use QL(420 ml per w/ Codeine) Hydrocortisone NF fill retail) TYLENOL/CODEINE #4 QL(6 ea daily) (Intrarectal)) TABS (Use Acetaminophen NF hydrocortisone (intrarectal) F QL(420 ml per w/ Codeine) enem 100 mg/60ml fill retail) ULTRACET TABS (Use NF QL(4 ea daily) Tramadol-Acetaminophen) Rectal Combinations -shark F QL(12 ea per Opioid Partial Agonists oil-cocoa butter supp fill retail)

Louisiana Healthcare Connections Updated April 1, 2019

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits phenylephrine-shark liver QL(60 gm per TUMS LASTING EFFECTS oil-mineral oil-petrolatum F fill retail) CHEW (Use Calcium NF oint Carbonate (Antacid)) Rectal Local Anesthetics Antacids - Magnesium Salts pramoxine hcl (rectal) foam F QL(15 gm per magnesium oxide tabs 400 F 1 % fill retail) mg PROCTOFOAM FOAM QL(15 gm per ANTHELMINTICS - Drugs to Treat Worm (Use Pramoxine HCl NF fill retail) Infections (Rectal)) Anthelmintics Rectal Steroids QL(1 ea per fill EMVERM CHEW 100 MG F ANUSOL-HC CREA (Use NF QL(30 gm per retail) Hydrocortisone (Rectal)) fill retail) QL(60 ml per pyrantel pamoate susp or F hydrocortisone (rectal) crea F QL(30 gm per fill retail) 2.5 % fill retail) REESES PINWORM F QL(16 ea per ANTACIDS MEDICINE TABS fill retail) ANTI-INFECTIVE AGENTS - MISC. - Drugs to Antacid Combinations Treat Bacterial Infections alum & mag hydrox- Anti-infective Agents - Misc. simethicone liqd F 200mg/5ml-20mg/5ml- FLAGYL TABS 250 MG, 200mg/5ml 500 MG (Use NF alum & mag hydrox- Metronidazole) simethicone susp metronidazole tabs or 250 F 200mg/5ml-20mg/5ml- mg, 500 mg 200mg/5ml, 200mg/5ml- F trimethoprim tabs or 100 F 200mg/5ml-20mg/5ml- mg 20mg/5ml-200mg/5ml- 200mg/5ml Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Antacids - Aluminum Salts Sulfamethoxazole- NF ALUMINUM HYDROXIDE F Trimethoprim) SUSP OR BACTRIM TABS (Use Antacids - Bicarbonate Sulfamethoxazole- NF Trimethoprim) sodium bicarbonate F (antacid) tabs sulfamethoxazole- trimethoprim susp or F Antacids - Calcium Salts 40mg/5ml-200mg/5ml calcium carbonate F (antacid) chew 500 mg sulfamethoxazole- trimethoprim tabs or 80mg- F calcium carbonate QL(500 ml per 400mg, 160mg-800mg (antacid) susp 1250 F fill retail) mg/5ml Glycopeptides QL(300 ml per TUMS CHEW (Use FIRVANQ SOLR F Calcium Carbonate NF fill retail) (Antacid)) VANCOCIN HCL CAPS QL(4 ea daily) 125 MG (Use Vancomycin NF HCl)

Louisiana Healthcare Connections Updated April 1, 2019

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VANCOCIN HCL CAPS QL(8 ea daily) isosorbide mononitrate F QL(1 ea daily) 250 MG (Use Vancomycin NF tb24 30 mg, 60 mg, 120 mg HCl) NITRO-BID OINT F vancomycin hcl caps or F QL(4 ea daily) 125 mg NITRO-DUR PT24 0.1 MG/HR, 0.2 MG/HR, 0.4 vancomycin hcl caps or F QL(8 ea daily) NF 250 mg MG/HR, 0.6 MG/HR (Use Nitroglycerin) vancomycin hcl solr iv 1 F QL(14 ea per gm, 1000 mg fill retail) nitroglycerin cpcr or 9 mg, F 2.5 mg, 6.5 mg vancomycin hcl solr iv 500 F QL(14 ea per mg 30 days retail) nitroglycerin pt24 td 0.1 mg/hr, 0.2 mg/hr, 0.4 F Leprostatics mg/hr, 0.6 mg/hr dapsone tabs or 25 mg, F nitroglycerin subl sl 0.3 mg, F 100 mg 0.4 mg, 0.6 mg Lincosamides NITROSTAT SUBL (Use NF CLEOCIN CAPS OR 150 Nitroglycerin) MG, 300 MG (Use NF Clindamycin HCl) ANTIANXIETY AGENTS - Drugs to Treat CLEOCIN PEDIATRIC Antianxiety Agents - Misc. GRANULES SOLR (Use NF hcl tabs or 10 F QL(6 ea daily) Clindamycin Palmitate mg Hydrochloride) buspirone hcl tabs or 15 F QL(4 ea daily) clindamycin hcl caps or F mg 150 mg, 300 mg buspirone hcl tabs or 30 F QL(3 ea daily) clindamycin palmitate mg, 7.5 mg hydrochloride solr 75 F mg/5ml buspirone hcl tabs or 5 mg F Oxazolidinones hydroxyzine hcl syrp or 10 F mg/5ml SIVEXTRO TABS F PA; QL(6 ea per fill retail) hydroxyzine hcl tabs or 10 F AGENTS - Drugs to Treat Chest mg, 25 mg, 50 mg Pain HYDROXYZINE PAMOATE CAPS OR 100 F Nitrates MG ISORDIL TITRADOSE hydroxyzine pamoate caps TABS 5 MG (Use NF F Isosorbide Dinitrate) or 25 mg, 50 mg tabs F ISOSORBIDE DINITRATE F ER TBCR VISTARIL CAPS (Use NF ISOSORBIDE DINITRATE F Hydroxyzine Pamoate) TABS 30 MG isosorbide dinitrate tabs 5 F mg, 10 mg, 20 mg, 30 mg tabs or 0.25 F QL(4 ea daily) mg, 0.5 mg, 1 mg, 2 mg isosorbide mononitrate F QL(2 ea daily) tabs 10 mg, 20 mg ATIVAN TABS OR 0.5 MG, NF QL(3 ea daily) 2 MG (Use )

Louisiana Healthcare Connections Updated April 1, 2019

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ATIVAN TABS OR 1 MG NF QL(4 ea daily) flecainide acetate tabs F (Use Lorazepam) QL(4 ea daily) hcl tabs 150 F hcl caps F mg, 225 mg, 300 mg dipotassium F QL(3 ea daily) Antiarrhythmics Type III tabs amiodarone hcl tabs or 200 F SOLN OR 5 F QL(500 ml per mg MG/5ML fill retail) dofetilide caps F diazepam tabs or 2 mg, 5 F QL(4 ea daily) mg, 10 mg TIKOSYN CAPS (Use NF lorazepam tabs or 0.5 mg, F QL(3 ea daily) Dofetilide) 2 mg ANTIASTHMATIC AND BRONCHODILATOR lorazepam tabs or 1 mg F QL(4 ea daily) AGENTS - Drugs to Treat Lung Conditions Anti-Inflammatory Agents caps 10 mg, 15 F QL(4 ea daily) mg, 30 mg cromolyn sodium nebu in F QL(240 ml per 20 mg/2ml fill retail) OXAZEPAM CAPS 30 MG F QL(4 ea daily) Bronchodilators - TRANXENE T TABS (Use QL(3 ea daily) NF ATROVENT HFA AERS F QL(26 gm per Clorazepate Dipotassium) fill retail) VALIUM TABS (Use NF QL(4 ea daily) QL(1 ea daily) Diazepam) INCRUSE ELLIPTA AEPB F XANAX TABS (Use QL(4 ea daily) NF ipratropium soln in F QL(375 ml per Alprazolam) 0.02 % fill retail) ANTIARRHYTHMICS - Drugs to treat abnormal TUDORZA PRESSAIR F QL(1 ea per 30 heart rhythms AEPB days retail) Antiarrhythmics Type I-A Leukotriene Modulators montelukast sodium chew QL(1 ea daily) disopyramide phosphate F F caps or 4 mg, 5 mg montelukast sodium pack QL(1 ea daily) NORPACE CAPS (Use F F Disopyramide Phosphate) or 4 mg montelukast sodium tabs or QL(1 ea daily) NORPACE CR CP12 150 F F MG 10 mg SINGULAIR CHEW (Use QL(1 ea daily) gluconate tbcr or F NF 324 mg Montelukast Sodium) QUINIDINE SULFATE SINGULAIR PACK (Use NF QL(1 ea daily) TABS OR 200 MG, 300 F Montelukast Sodium) MG SINGULAIR TABS (Use NF QL(1 ea daily) Antiarrhythmics Type I-B Montelukast Sodium) Steroid Inhalants mexiletine hcl caps 150 F mg, 200 mg, 250 mg QL(0.3 gm AEROSPAN AERS F daily,8.9 gm MEXILETINE HCL CAPS F 150 MG, 200 MG, 250 MG per fill retail) Antiarrhythmics Type I-C

Louisiana Healthcare Connections Updated April 1, 2019

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 ml daily); PROAIR HFA AERS (Use NF budesonide (inhalation) F AL(At least 1 Albuterol Sulfate) susp yrs old - Up to SEREVENT DISKUS F QL(2 ea daily) 8 yrs old) AEPB FLOVENT DISKUS AEPB QL(2 ea daily) SYMBICORT AERO F QL(11 gm per 100 MCG/BLIST, 250 F fill retail) MCG/BLIST sulfate tabs or 5 F FLOVENT DISKUS AEPB F QL(60 ea per mg, 2.5 mg 50 MCG/BLIST fill retail) QL(36 gm per FLOVENT HFA AERO 110 QL(12 gm per F VENTOLIN HFA AERS NF fill retail,36 gm MCG/ACT, 220 MCG/ACT fill retail) (Use Albuterol Sulfate) per 30 days FLOVENT HFA AERO 44 F QL(11 gm per retail) MCG/ACT fill retail) QL(16 gm per PULMICORT FLEXHALER F QL(1 ea per 25 VENTOLIN HFA AERS NF fill retail,16 gm AEPB days retail) (Use Albuterol Sulfate) per 30 days QL(4 ml daily); retail) PULMICORT SUSP (Use NF AL(At least 1 VOSPIRE ER TB12 (Use NF Budesonide (Inhalation)) yrs old - Up to Albuterol Sulfate) 8 yrs old) Xanthines Sympathomimetics aminophylline soln 25 F albuterol sulfate aers in F mg/ml 108 mcg/act ELIXOPHYLLIN ELIX F ALBUTEROL SULFATE F ER TB12 THEO-24 CP24 F albuterol sulfate nebu in F QL(2 ml daily) 0.5 % theophylline soln 80 F QL(475 ml per albuterol sulfate nebu in QL(375 ml per mg/15ml fill retail) 0.63 mg/3ml, 0.083 %, 1.25 F fill retail) theophylline tb12 100 mg, F mg/3ml 200 mg, 300 mg, 450 mg theophylline tb24 400 mg, albuterol sulfate syrp or 2 F F mg/5ml 600 mg albuterol sulfate tabs or 2 F ANTICOAGULANTS - Blood Thinners mg, 4 mg Coumarin Anticoagulants albuterol sulfate tb12 or 4 F mg, 8 mg COUMADIN TABS (Use F Warfarin Sodium) COMBIVENT RESPIMAT F QL(4 gm per fill AERS retail) warfarin sodium tabs F QL(13 gm per DULERA AERO F fill retail) Direct Factor Xa Inhibitors QL(12 ml daily) ipratropium-albuterol soln F ELIQUIS STARTER PACK F QL(4 ea daily) TABS METAPROTERENOL QL(30 ml daily) QL(4 ea daily) SULFATE SYRP OR 10 F ELIQUIS TABS F MG/5ML XARELTO TABS 10 MG, F QL(1 ea daily) METAPROTERENOL 20 MG SULFATE TABS OR 10 F MG, 20 MG Louisiana Healthcare Connections Updated April 1, 2019

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XARELTO TABS 15 MG F QL(2 ea daily) QL(1 ea per fill diazepam (anticonvulsant) F retail); AL(At gel Heparins And Heparinoid-Like Agents least 2 yrs old) enoxaparin sodium soln ij QL(42 ml per QL(1 ea per fill F DIAZEPAM GEL RE 20 F 300 mg/3ml fill retail) MG, 2.5 MG retail); AL(At least 2 yrs old) enoxaparin sodium soln sc F QL(14 ml per 100 mg/ml, 150 mg/ml fill retail) QL(1 ea per fill DIAZEPAM RECTAL GEL F retail); AL(At GEL enoxaparin sodium soln sc F QL(5 ml per fill least 2 yrs old) 30 mg/0.3ml retail) KLONOPIN TABS (Use NF QL(4 ea daily) enoxaparin sodium soln sc F QL(6 ml per fill ) 40 mg/0.4ml retail) Anticonvulsants - Misc. enoxaparin sodium soln sc F QL(9 ml per fill 60 mg/0.6ml retail) carbamazepine chew or F 100 mg enoxaparin sodium soln sc F QL(12 ml per 80 mg/0.8ml, 120 mg/0.8ml fill retail) carbamazepine susp or F 100 mg/5ml heparin sodium (porcine) F soln carbamazepine tabs or 200 F LOVENOX SOLN IJ 300 QL(42 ml per mg MG/3ML (Use Enoxaparin NF fill retail) carbamazepine tb12 or 100 F Sodium) mg, 200 mg, 400 mg LOVENOX SOLN SC 100 QL(14 ml per caps or 100 F QL(9 ea daily) MG/ML, 150 MG/ML (Use NF fill retail) mg, 300 mg, 400 mg Enoxaparin Sodium) gabapentin soln or 250 F LOVENOX SOLN SC 30 QL(5 ml per fill mg/5ml, 300 mg/6ml MG/0.3ML (Use NF retail) QL(6 ea daily) Enoxaparin Sodium) gabapentin tabs or 600 mg F LOVENOX SOLN SC 40 QL(6 ml per fill gabapentin tabs or 800 mg F QL(4 ea daily) MG/0.4ML (Use NF retail) Enoxaparin Sodium) KEPPRA SOLN OR 100 QL(30 ml daily) LOVENOX SOLN SC 60 QL(9 ml per fill MG/ML (Use NF MG/0.6ML (Use NF retail) Levetiracetam) Enoxaparin Sodium) KEPPRA TABS OR 1000 NF LOVENOX SOLN SC 80 QL(12 ml per MG (Use Levetiracetam) MG/0.8ML, 120 MG/0.8ML NF fill retail) KEPPRA TABS OR 250 QL(4 ea daily) (Use Enoxaparin Sodium) MG, 750 MG (Use NF Levetiracetam) ANTICONVULSANTS - Drugs to Treat Seizures KEPPRA TABS OR 500 NF QL(6 ea daily) Anticonvulsants - Benzodiazepines MG (Use Levetiracetam) KEPPRA XR TB24 (Use ST clonazepam tabs or 0.5 F QL(4 ea daily) NF mg, 1 mg, 2 mg Levetiracetam) QL(1 ea per fill LAMICTAL CHEWABLE DIASTAT ACUDIAL GEL F retail); AL(At DISPERSIBLE CHEW (Use NF least 2 yrs old) Lamotrigine) QL(1 ea per fill LAMICTAL TABS (Use NF DIASTAT PEDIATRIC GEL F retail); AL(At Lamotrigine) least 2 yrs old)

Louisiana Healthcare Connections Updated April 1, 2019

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL XR TB24 25 ST TOPAMAX SPRINKLE QL(8 ea daily) MG, 50 MG, 100 MG, 200 NF CPSP 25 MG (Use NF MG, 250 MG, 300 MG (Use Topiramate) Lamotrigine) TOPAMAX TABS 100 MG NF QL(4 ea daily) lamotrigine chew or 5 mg, F (Use Topiramate) 25 mg TOPAMAX TABS 200 MG NF QL(3 ea daily) lamotrigine tabs or 25 mg, F (Use Topiramate) 100 mg, 150 mg, 200 mg TOPAMAX TABS 25 MG, NF QL(6 ea daily) lamotrigine tb24 or 25 mg, ST 50 MG (Use Topiramate) 50 mg, 100 mg, 200 mg, F QL(6 ea daily) 250 mg, 300 mg topiramate cpsp or 15 mg F levetiracetam soln or 100 F QL(30 ml daily) topiramate cpsp or 25 mg F QL(8 ea daily) mg/ml, 500 mg/5ml QL(4 ea daily) levetiracetam tabs or 1000 F topiramate tabs or 100 mg F mg QL(3 ea daily) levetiracetam tabs or 250 F QL(4 ea daily) topiramate tabs or 200 mg F mg, 750 mg topiramate tabs or 25 mg, QL(6 ea daily) levetiracetam tabs or 500 F QL(6 ea daily) F mg 50 mg TRILEPTAL SUSP (Use levetiracetam tb24 or 500 F ST NF mg, 750 mg Oxcarbazepine) TRILEPTAL TABS (Use MYSOLINE TABS (Use NF NF Primidone) Oxcarbazepine) NEURONTIN CAPS 100 QL(9 ea daily) ZONEGRAN CAPS (Use NF MG, 300 MG, 400 MG (Use NF Zonisamide) Gabapentin) zonisamide caps or 25 mg, F 50 mg, 100 mg NEURONTIN SOLN 250 NF MG/5ML (Use Gabapentin) NEURONTIN TABS 600 NF QL(6 ea daily) felbamate susp F MG (Use Gabapentin) NEURONTIN TABS 800 NF QL(4 ea daily) felbamate tabs F MG (Use Gabapentin) FELBATOL SUSP (Use NF oxcarbazepine susp F Felbamate) FELBATOL TABS (Use NF oxcarbazepine tabs F Felbamate) primidone tabs or 50 mg, F GABA Modulators 250 mg GABITRIL TABS (Use NF TEGRETOL SUSP (Use F HCl) Carbamazepine) tiagabine hcl tabs F TEGRETOL TABS (Use F Carbamazepine) Hydantoins TEGRETOL-XR TB12 (Use F Carbamazepine) DILANTIN CAPS 100 MG (Use Phenytoin Sodium F TOPAMAX SPRINKLE QL(6 ea daily) Extended) CPSP 15 MG (Use NF Topiramate) Louisiana Healthcare Connections Updated April 1, 2019

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DILANTIN CAPS 30 MG F Alpha-2 Receptor Antagonists (Tetracyclics) tabs or 15 mg F QL(3 ea daily) DILANTIN INFATABS F ) CHEW (Use Phenytoin QL(1.5 ea mirtazapine tabs or 30 mg F DILANTIN-125 SUSP (Use F daily) Phenytoin) mirtazapine tabs or 45 mg, F QL(1 ea daily) phenytoin chew or 50 mg F 7.5 mg mirtazapine tbdp or 15 mg F QL(3 ea daily) phenytoin sodium extended F caps 100 mg QL(1.5 ea mirtazapine tbdp or 30 mg F phenytoin susp or 125 F daily) mg/5ml mirtazapine tbdp or 45 mg F QL(1 ea daily) Succinimides REMERON SOLTAB TBDP QL(3 ea daily) ethosuximide caps or 250 F NF mg 15 MG (Use Mirtazapine) REMERON SOLTAB TBDP QL(1.5 ea ethosuximide soln or 250 F NF mg/5ml 30 MG (Use Mirtazapine) daily) REMERON SOLTAB TBDP QL(1 ea daily) ZARONTIN CAPS (Use F NF Ethosuximide) 45 MG (Use Mirtazapine) REMERON TABS 15 MG QL(3 ea daily) ZARONTIN SOLN (Use F NF Ethosuximide) (Use Mirtazapine) Valproic Acid REMERON TABS 30 MG NF QL(1.5 ea (Use Mirtazapine) daily) DEPAKENE CAPS (Use F Valproic Acid) REMERON TABS 45 MG NF QL(1 ea daily) (Use Mirtazapine) DEPAKENE SOLN 250 MG/5ML (Use Valproate F - Misc. Sodium) bupropion hcl tabs or 75 F QL(3 ea daily) mg, 100 mg DEPAKOTE ER TB24 (Use NF Divalproex Sodium) bupropion hcl tb12 or 100 F QL(4 ea daily) DEPAKOTE SPRINKLES mg CSDR (Use Divalproex NF bupropion hcl tb12 or 150 F QL(3 ea daily) Sodium) mg DEPAKOTE TBEC (Use NF bupropion hcl tb12 or 200 F QL(2 ea daily) Divalproex Sodium) mg divalproex sodium csdr F bupropion hcl tb24 or 150 F QL(3 ea daily) mg divalproex sodium tb24 F bupropion hcl tb24 or 300 F QL(1 ea daily) mg divalproex sodium tbec F HCL TABS F valproate sodium soln or F WELLBUTRIN SR TB12 QL(4 ea daily) 250 mg/5ml 100 MG (Use Bupropion NF valproic acid caps or F HCl) WELLBUTRIN SR TB12 QL(3 ea daily) ANTIDEPRESSANTS - Drugs to Treat 150 MG (Use Bupropion NF Depression HCl)

Louisiana Healthcare Connections Updated April 1, 2019

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WELLBUTRIN SR TB12 QL(2 ea daily) QL(4 ea daily); NF hcl caps or 40 F AL(At least 7 200 MG (Use Bupropion mg HCl) yrs old) WELLBUTRIN XL TB24 QL(3 ea daily) QL(600 ml per 150 MG (Use Bupropion NF fluoxetine hcl soln or 20 F 30 days retail); HCl) mg/5ml AL(At least 7 WELLBUTRIN XL TB24 QL(1 ea daily) yrs old) 300 MG (Use Bupropion NF QL(1 ea daily); HCl) fluoxetine hcl tabs or 10 mg F AL(At least 7 yrs old) Monoamine Oxidase Inhibitors (MAOIs) fluoxetine hcl tabs or 20 mg F QL(4 ea daily) NARDIL TABS (Use NF Sulfate) maleate tabs F QL(3 ea daily) PARNATE TABS (Use NF 100 mg Tranylcypromine Sulfate) fluvoxamine maleate tabs F QL(2 ea daily) phenelzine sulfate tabs or F 25 mg, 50 mg 15 mg LEXAPRO TABS 10 MG NF QL(2 ea daily) tranylcypromine sulfate F (Use Oxalate) tabs 10 mg LEXAPRO TABS 20 MG NF QL(1 ea daily) Selective Reuptake Inhibitors (SSRIs) (Use Escitalopram Oxalate) CELEXA TABS 10 MG QL(4 ea daily) LEXAPRO TABS 5 MG NF QL(4 ea daily) (Use NF (Use Escitalopram Oxalate) Hydrobromide) hcl tabs 10 mg F QL(6 ea daily) CELEXA TABS 20 MG QL(2 ea daily) (Use Citalopram NF QL(3 ea daily) Hydrobromide) paroxetine hcl tabs 20 mg F CELEXA TABS 40 MG QL(1 ea daily) paroxetine hcl tabs 30 mg, F QL(2 ea daily) (Use Citalopram NF 40 mg Hydrobromide) paroxetine hcl tb24 25 mg, F 12.5 mg, 37.5 mg citalopram hydrobromide F QL(8 ml daily) soln 10 mg/5ml PAXIL CR TB24 (Use NF Paroxetine HCl) citalopram hydrobromide F QL(4 ea daily) tabs 10 mg PAXIL SUSP 10 MG/5ML F QL(40 ml daily) citalopram hydrobromide F QL(2 ea daily) tabs 20 mg PAXIL TABS 10 MG (Use NF QL(6 ea daily) Paroxetine HCl) citalopram hydrobromide F QL(1 ea daily) tabs 40 mg PAXIL TABS 20 MG (Use NF QL(3 ea daily) Paroxetine HCl) escitalopram oxalate tabs F QL(2 ea daily) 10 mg PAXIL TABS 30 MG, 40 NF QL(2 ea daily) MG (Use Paroxetine HCl) escitalopram oxalate tabs F QL(1 ea daily) 20 mg PROZAC CAPS 10 MG, 20 NF QL(4 ea daily) MG (Use Fluoxetine HCl) escitalopram oxalate tabs 5 F QL(4 ea daily) mg QL(4 ea daily); PROZAC CAPS 40 MG NF AL(At least 7 fluoxetine hcl caps or 10 F QL(4 ea daily) (Use Fluoxetine HCl) mg, 20 mg yrs old) hcl conc or 20 F QL(10 ml daily) mg/ml

Louisiana Healthcare Connections Updated April 1, 2019

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sertraline hcl tabs or 100 F QL(2 ea daily) PRISTIQ TB24 25 MG, 50 QL(1 ea daily) mg MG (Use Desvenlafaxine NF Succinate) sertraline hcl tabs or 25 F QL(4 ea daily) mg, 50 mg hcl cp24 150 F QL(2 ea daily) mg ZOLOFT CONC 20 MG/ML NF QL(10 ml daily) (Use Sertraline HCl) venlafaxine hcl cp24 37.5 F QL(4 ea daily) mg ZOLOFT TABS 100 MG NF QL(2 ea daily) (Use Sertraline HCl) venlafaxine hcl cp24 75 mg F QL(5 ea daily) ZOLOFT TABS 25 MG, 50 NF QL(4 ea daily) MG (Use Sertraline HCl) venlafaxine hcl tabs 25 mg, 50 mg, 75 mg, 100 mg, F Serotonin Modulators 37.5 mg HCL TABS F venlafaxine hcl tb24 225 F QL(1 ea daily) 100 MG, 150 MG mg, 37.5 mg nefazodone hcl tabs 50 F venlafaxine hcl tb24 75 mg, F mg, 250 mg 150 mg NEFAZODONE F HYDROCHLORIDE TABS Agents hcl tabs or 10 hcl tabs or 300 F QL(2 ea daily) mg mg, 25 mg, 50 mg, 75 mg, F 100 mg, 150 mg trazodone hcl tabs or 50 F mg, 100 mg, 150 mg TABS F QL(1 ea daily); ANAFRANIL CAPS 75 MG NF TRINTELLIX TABS F AL(At least 18 (Use HCl) yrs old) clomipramine hcl caps or F VIIBRYD TABS F PA; QL(1 ea 75 mg daily) hcl tabs or 10 Serotonin- Reuptake Inhibitors mg, 50 mg, 75 mg, 100 mg, F QL(1 ea daily); 150 mg CYMBALTA CPEP (Use NF AL(At least 7 HCl) desipramine hcl tabs or 25 F QL(2 ea daily) yrs old) mg desvenlafaxine succinate F QL(4 ea daily) hcl caps or 10 mg, tb24 100 mg 25 mg, 50 mg, 75 mg, 100 F mg, 150 mg desvenlafaxine succinate F QL(1 ea daily) tb24 25 mg, 50 mg DOXEPIN HCL CAPS OR F QL(1 ea daily); 150 MG duloxetine hcl cpep or 20 F AL(At least 7 mg, 30 mg, 60 mg doxepin hcl conc or 10 F yrs old) mg/ml EFFEXOR XR CP24 150 QL(2 ea daily) NF ELAVIL TABS (Use NF MG (Use Venlafaxine HCl) Amitriptyline HCl) EFFEXOR XR CP24 37.5 QL(4 ea daily) NF hcl tabs or 10 F MG (Use Venlafaxine HCl) mg, 25 mg, 50 mg EFFEXOR XR CP24 75 QL(5 ea daily) NF NORPRAMIN TABS 10 MG NF MG (Use Venlafaxine HCl) (Use Desipramine HCl) PRISTIQ TB24 100 MG QL(4 ea daily) NORPRAMIN TABS 25 MG NF QL(2 ea daily) (Use Desvenlafaxine NF (Use Desipramine HCl) Succinate) Louisiana Healthcare Connections Updated April 1, 2019

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hcl caps or 10 F GLUCOPHAGE TABS 500 NF QL(5 ea daily) mg, 25 mg, 50 mg, 75 mg MG (Use Metformin HCl) nortriptyline hcl soln or 10 F QL(20 ml daily) GLUCOPHAGE TABS 850 NF QL(3 ea daily) mg/5ml MG (Use Metformin HCl) NORTRIPTYLINE HCL F QL(20 ml daily) GLUCOPHAGE XR TB24 QL(4 ea daily) SOLN OR 10 MG/5ML 500 MG (Use Metformin NF HCl) PAMELOR CAPS (Use NF Nortriptyline HCl) GLUCOPHAGE XR TB24 QL(2 ea daily) 750 MG (Use Metformin NF TOFRANIL TABS (Use NF Imipramine HCl) HCl) metformin hcl tabs or 1000 F QL(2 ea daily) ANTIDIABETICS - Drugs to Regulate Blood mg Sugar metformin hcl tabs or 500 F QL(5 ea daily) Antidiabetic - Amylin Analogs mg PA; QL(11 ml metformin hcl tabs or 850 F QL(3 ea daily) SYMLINPEN 120 SOPN F per 30 days mg retail) metformin hcl tb24 or 500 F QL(4 ea daily) PA; QL(6 ml mg SYMLINPEN 60 SOPN F per 30 days retail) metformin hcl tb24 or 750 F QL(2 ea daily) mg Antidiabetic Combinations Diabetic Other ACTOPLUS MET TABS QL(2 ea daily) QL(50 ea per (Use Pioglitazone HCl- NF BD GLUCOSE CHEW F Metformin HCl) 30 days retail) CVS GLUCOSE CHEW 4 QL(50 ea per alogliptin-metformin hcl F PA; QL(2 ea F tabs daily) GM 30 days retail) PA; QL(1 ea DEX4 QUICK DISSOLVE QL(50 ea per alogliptin-pioglitazone tabs F F daily) GLUCOSE CHEW 30 days retail) GLUCAGEN HYPOKIT F glipizide-metformin hcl tabs F SOLR GLUCAGON QL(1 ea per fill GLUCOVANCE TABS (Use NF F Glyburide-Metformin) EMERGENCY KIT KIT retail) GLUCOSE CHEW 4 GM F QL(50 ea per glyburide-metformin tabs F 30 days retail) PA; QL(2 ea GNP GLUCOSE CHEW 4 F QL(50 ea per GM 30 days retail) F daily); AL(At JENTADUETO TABS least 18 yrs GNP QUICK DISSOLVE F QL(50 ea per old) GLUCOSE CHEW 30 days retail) pioglitazone hcl-metformin F QL(2 ea daily) LEADER QUICK QL(50 ea per hcl tabs DISSOLVE GLUCOSE F 30 days retail) CHEW SEGLUROMET TABS F ST; QL(2 ea daily) SM GLUCOSE CHEW 4 F QL(50 ea per Biguanides GM 30 days retail) GLUCOPHAGE TABS QL(2 ea daily) WALGREENS GLUCOSE F QL(50 ea per 1000 MG (Use Metformin NF CHEW 4 GM 30 days retail) HCl) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

Louisiana Healthcare Connections Updated April 1, 2019

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea HUMALOG MIX 50/50 QL(30 ml per alogliptin benzoate tabs F F daily) KWIKPEN SUPN 30 days retail) PA; QL(1 ea HUMALOG MIX 50/50 F QL(40 ml per F daily); AL(At SUSP 30 days retail) TRADJENTA TABS least 18 yrs HUMALOG MIX 75/25 F QL(30 ml per old) KWIKPEN SUPN 30 days retail) Incretin Mimetic Agents (GLP-1 Receptor HUMALOG MIX 75/25 F QL(40 ml per PA; QL(3.4 ml SUSP 30 days retail) BYDUREON BCISE AUIJ F per 28 days HUMULIN 70/30 KWIKPEN F QL(30 ml per retail) SUPN 30 days retail) PA; QL(4 ea HUMULIN 70/30 SUSP F QL(40 ml per per 30 days 30 days retail) BYDUREON PEN PEN F retail); AL(At HUMULIN N KWIKPEN F QL(40 ml per least 18 yrs SUPN 30 days retail) old) HUMULIN N SUSP F QL(40 ml per PA; QL(4 ea 30 days retail) per 30 days QL(40 ml per BYDUREON SRER F retail); AL(At HUMULIN R SOLN F least 18 yrs 30 days retail) old) HUMULIN R U-500 F QL(30 ml per PA; QL(2 ml (CONCENTRATED) SOLN 30 days retail) per 30 days NOVOLIN 70/30 FLEXPEN F QL(30 ml per BYETTA SOPN 10 F retail); AL(At RELION SUPN 30 days retail) MCG/0.04ML least 18 yrs NOVOLIN 70/30 FLEXPEN F QL(30 ml per old) SUPN 30 days retail) PA; QL(1 ml NOVOLIN 70/30 RELION F QL(40 ml per per 30 days SUSP 30 days retail) BYETTA SOPN 5 F retail); AL(At MCG/0.02ML NOVOLIN 70/30 SUSP F QL(40 ml per least 18 yrs 30 days retail) old) NOVOLIN N RELION F QL(40 ml per VICTOZA SOPN F QL(0.3 ml SUSP 30 days retail) daily) NOVOLIN N SUSP F QL(40 ml per Insulin Sensitizing Agents 30 days retail) ACTOS TABS (Use QL(1 ea daily) NF NOVOLIN R RELION F QL(40 ml per Pioglitazone HCl) SOLN 30 days retail) QL(1 ea daily) AVANDIA TABS F NOVOLIN R SOLN F QL(40 ml per 30 days retail) pioglitazone hcl tabs F QL(1 ea daily) NOVOLOG MIX 70/30 QL(30 ml per PREFILLED FLEXPEN F 30 days retail) Insulin SUPN ADMELOG SOLN 100 QL(40 ml per F NOVOLOG MIX 70/30 F QL(40 ml per UNIT/ML 30 days retail) SUSP 30 days retail) ADMELOG SOLOSTAR F QL(30 ml per Meglitinide Analogues SOPN 100 UNIT/ML 30 days retail) nateglinide tabs F QL(3 ea daily) BASAGLAR KWIKPEN F QL(30 ml per SOPN 100 UNIT/ML 30 days retail) STARLIX TABS (Use NF QL(3 ea daily) Nateglinide) Louisiana Healthcare Connections Updated April 1, 2019

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Sodium-Glucose Co-Transporter 2 (SGLT2) PEPTO-BISMOL TO-GO CHEW (Use Bismuth NF JARDIANCE TABS F PA; QL(1 ea Subsalicylate) daily) ST; QL(1 ea Antiperistaltic Agents STEGLATRO TABS F daily) diphenoxylate w/ F tabs Sulfonylureas DIPHENOXYLATE/ATROP F AMARYL TABS 1 MG, 2 NF QL(4 ea daily) INE LIQD MG (Use Glimepiride) IMODIUM A-D CAPS 2 MG NF QL(8 ea daily); AMARYL TABS 4 MG (Use NF QL(2 ea daily) ) Glimepiride) (Use Loperamide HCl RX/OTC glimepiride tabs 1 mg, 2 QL(4 ea daily) IMODIUM A-D TABS 2 MG NF QL(8 ea daily) F (Use Loperamide HCl) mg QL(2 ea daily) LOMOTIL TABS (Use NF glimepiride tabs 4 mg F Diphenoxylate w/ Atropine) loperamide hcl caps or 2 QL(8 ea daily); glipizide tabs or 5 mg, 10 F F mg mg RX/OTC loperamide hcl liqd or 1 QL(40 ml daily) glipizide tb24 or 5 mg, 10 F F mg, 2.5 mg mg/5ml loperamide hcl tabs or 2 QL(8 ea daily) GLUCOTROL TABS (Use NF F Glipizide) mg GLUCOTROL XL TB24 NF PAREGORIC TINC F (Use Glipizide) glyburide micronized tabs F ANTIDOTES AND SPECIFIC ANTAGONISTS Antidotes - Chelating Agents glyburide tabs or 5 mg, 2.5 F mg, 1.25 mg CHEMET CAPS F GLYNASE TABS (Use NF Glyburide Micronized) JADENU TABS F PA ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea Antidotes and Specific Antagonists Antidiarrheal/Probiotic Agents - Misc. SM IPECAC SYRUP SYRP F bismuth subsalicylate chew F or 262 mg VISTOGARD PACK F bismuth subsalicylate susp F Opioid Antagonists or 525 mg/15ml QL(0.023 ml PEPTO-BISMOL CHEW naloxone hcl soln ij 0.4 F daily,2 ml per mg/ml 262 MG (Use Bismuth NF 90 days retail) Subsalicylate) QL(0.023 ml PEPTO-BISMOL naloxone hcl soln ij 4 F daily,40 ml per mg/10ml INSTACOOL CHEW (Use NF 90 days retail) Bismuth Subsalicylate) NALOXONE HCL SOSY IJ F QL(4 ml per 90 PEPTO-BISMOL MAX 2 MG/2ML days retail) STRENGTH SUSP (Use NF Bismuth Subsalicylate) naltrexone hcl tabs or F

Louisiana Healthcare Connections Updated April 1, 2019

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6 ea daily) NARCAN LIQD F QL(2 ea per 90 nystatin tabs 500000 unit F days retail) PA; QL(1 ea QL(1 ea terbinafine hcl tabs or 250 F daily,90 ea per per 30 days mg retail); AL(At 120 days retail) VIVITROL SUSR F least 18 yrs old -Related Antifungals - Up to 999 yrs old) DIFLUCAN SUSR 10 QL(70 ml per MG/ML, 40 MG/ML (Use NF fill retail) - Drugs to Treat and Fluconazole) Vomiting DIFLUCAN TABS 100 MG NF QL(1 ea daily) 5-HT3 Receptor Antagonists (Use Fluconazole) DIFLUCAN TABS 150 MG QL(2 ea per fill hcl soln or 4 F QL(50 ml per NF mg/5ml fill retail) (Use Fluconazole) retail) DIFLUCAN TABS 200 MG QL(2 ea daily) ondansetron hcl tabs or 24 F QL(1 ea per 14 NF mg days retail) (Use Fluconazole) DIFLUCAN TABS 50 MG QL(7 ea per fill ondansetron hcl tabs or 4 F QL(2 ea daily) NF mg, 8 mg (Use Fluconazole) retail) QL(2 ea daily) fluconazole susr or 10 F QL(70 ml per ondansetron tbdp F mg/ml, 40 mg/ml fill retail) ZOFRAN ODT TBDP (Use NF QL(2 ea daily) fluconazole tabs or 100 mg F QL(1 ea daily) Ondansetron) QL(2 ea per fill ZOFRAN SOLN 4 MG/5ML NF QL(50 ml per fluconazole tabs or 150 mg F (Use Ondansetron HCl) fill retail) retail) ZOFRAN TABS 4 MG, 8 QL(2 ea daily) fluconazole tabs or 200 mg F QL(2 ea daily) MG (Use Ondansetron NF QL(7 ea per fill HCl) fluconazole tabs or 50 mg F retail) Antiemetics - caps or 100 F PA; QL(1 ea hcl chew or 25 F mg daily) mg SPORANOX CAPS 100 NF PA; QL(1 ea meclizine hcl tabs or 25 F RX/OTC MG (Use Itraconazole) daily) mg, 12.5 mg SPORANOX PULSEPAK NF PA; QL(1 ea ANTIFUNGALS - Drugs to Treat Fungal Infections CAPS (Use Itraconazole) daily) Antifungals - Drugs to Treat GRIS-PEG TABS (Use NF Antihistamines - Alkylamines Griseofulvin Ultramicrosize) CHLOR-TRIMETON SYRP QL(60 ml daily) griseofulvin microsize susp F 2 MG/5ML (Use NF Chlorpheniramine Maleate) griseofulvin microsize tabs F CHLOR-TRIMETON TABS QL(120 ea per 4 MG (Use NF fill retail) griseofulvin ultramicrosize F tabs Chlorpheniramine Maleate) QL(1 ea chlorpheniramine maleate F QL(60 ml daily) LAMISIL TABS (Use NF syrp or 2 mg/5ml Terbinafine HCl) daily,90 ea per 120 days retail) chlorpheniramine maleate F QL(120 ea per tabs or 4 mg fill retail)

Louisiana Healthcare Connections Updated April 1, 2019

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEXCHLORPHENIRAMIN F QL(480 ml per hcl syrp 1 mg/ml, F fill retail); E MALEATE SYRP OR 5 mg/5ml RX/OTC RYCLORA SYRP F cetirizine hcl tabs 5 mg, 10 F QL(1 ea daily) Antihistamines - Ethanolamines mg QL(4 ea daily) CLARITIN QL(240 ml per ALER-DRYL TABS F CHILDRENS SYRP (Use NF fill retail) BENADRYL ALLERGY QL(4 ea daily) ) CAPS (Use NF CLARITIN REDITABS HCl) TBDP 10 MG (Use NF BENADRYL ALLERGY QL(240 ml per Loratadine) CLARITIN SYRP 5 QL(240 ml per CHILDRENS LIQD 12.5 NF fill retail) NF MG/5ML (Use MG/5ML (Use Loratadine) fill retail) Diphenhydramine HCl) CLARITIN TABS 10 MG NF BENADRYL ALLERGY QL(4 ea daily) (Use Loratadine) TABS (Use NF hcl tabs or F QL(1 ea daily) Diphenhydramine HCl) 180 mg fumarate tabs QL(2 ea daily) F fexofenadine hcl tabs or 60 F QL(2 ea daily) or 1.34 mg mg diphenhydramine hcl caps F QL(4 ea daily) RX/OTC or 25 mg, 50 mg dihydrochloride tabs or 5 F QL(240 ml per mg diphenhydramine hcl elix or F fill retail); QL(240 ml per 12.5 mg/5ml loratadine soln or 5 mg/5ml F RX/OTC fill retail) diphenhydramine hcl liqd or QL(240 ml per QL(240 ml per loratadine syrp or 5 mg/5ml F 25 mg/10ml, 50 mg/20ml, F fill retail) fill retail) 12.5 mg/5ml loratadine tabs or 10 mg F diphenhydramine hcl tabs F QL(4 ea daily) or 25 mg loratadine tbdp or 10 mg F QL(240 ml per SILPHEN COUGH SYRP F fill retail) XYZAL ALLERGY 24HR RX/OTC TAVIST ALLERGY TABS QL(2 ea daily) TABS (Use Levocetirizine NF (Use Clemastine NF Dihydrochloride) Fumarate) XYZAL TABS 5 MG (Use RX/OTC Antihistamines - Non-Sedating Levocetirizine NF Dihydrochloride) ALLEGRA ALLERGY QL(1 ea daily) TABS 180 MG (Use NF ZYRTEC ALLERGY TABS NF QL(1 ea daily) Fexofenadine HCl) (Use Cetirizine HCl) ALLEGRA ALLERGY QL(2 ea daily) ZYRTEC CHILDRENS QL(480 ml per TABS 60 MG (Use NF ALLERGY SOLN (Use NF fill retail); Fexofenadine HCl) Cetirizine HCl) RX/OTC Antihistamines - cetirizine hcl chew 5 mg, F QL(1 ea daily) 10 mg hcl soln or F AL(At least 2 QL(480 ml per 6.25 mg/5ml yrs old) cetirizine hcl soln 1 mg/ml, F fill retail); 5 mg/5ml promethazine hcl supp re F AL(At least 2 RX/OTC 25 mg, 50 mg, 12.5 mg yrs old)

Louisiana Healthcare Connections Updated April 1, 2019

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits promethazine hcl syrp or F AL(At least 2 FENOFIBRATE TABS OR F QL(1 ea daily) 6.25 mg/5ml yrs old) 160 MG promethazine hcl tabs or F AL(At least 2 fenofibrate tabs or 54 mg F QL(3 ea daily) 25 mg, 50 mg, 12.5 mg yrs old) Antihistamines - Piperidines gemfibrozil tabs or 600 mg F QL(2 ea daily) hcl syrp or F LOFIBRA CAPS (Use NF QL(1 ea daily) 2 mg/5ml Fenofibrate Micronized) cyproheptadine hcl tabs or F LOPID TABS (Use NF QL(2 ea daily) 4 mg Gemfibrozil) ANTIHYPERLIPIDEMICS - Drugs to Treat High QL(1 ea daily) Cholesterol TRIGLIDE TABS F Bile Acid Sequestrants HMG CoA Reductase Inhibitors cholestyramine light pack F $0 copay for atorvastatin calcium tabs or Generic only, 10 mg, 20 mg, 40 mg, 80 F age 40 to cholestyramine light powd F mg 75;QL(1 ea daily); PV cholestyramine pack or 4 F gm ST; Try atorvastatin, cholestyramine powd or 4 F gm/dose simvastatin, CRESTOR TABS (Use NF COLESTID FLAVORED Rosuvastatin Calcium) pravastatin, or GRAN 5 GM (Use NF lovastatin Colestipol HCl) first;QL(1 ea daily) COLESTID GRAN 5 GM NF (Use Colestipol HCl) $0 copay for Generic only, COLESTID TABS 1 GM LIPITOR TABS (Use NF NF ) age 40 to (Use Colestipol HCl) Atorvastatin Calcium 75;QL(1 ea colestipol hcl gran 5 gm F daily); PV $0 copay for colestipol hcl tabs 1 gm F Generic only, lovastatin tabs 10 mg, 20 F age 40 to mg QUESTRAN LIGHT POWD NF 75;QL(1 ea (Use Cholestyramine Light) daily); PV QUESTRAN PACK (Use NF $0 copay for Cholestyramine) Generic only, lovastatin tabs 40 mg F age 40 to QUESTRAN POWD (Use NF Cholestyramine) 75;QL(2 ea daily); PV Fibric Acid Derivatives $0 copay for fenofibrate micronized caps F QL(1 ea daily) Generic only, 134 mg, 200 mg MEVACOR TABS (Use NF Lovastatin) age 40 to fenofibrate micronized caps F QL(2 ea daily) 75;QL(2 ea 67 mg daily); PV fenofibrate tabs or 160 mg F QL(1 ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits $0 copay for enalapril maleate tabs or 5 F QL(2 ea daily) Generic only, mg, 10 mg, 20 mg, 2.5 mg PRAVACHOL TABS (Use NF ) age 40 to Pravastatin Sodium 75;QL(1 ea EPANED SOLR F daily); PV fosinopril sodium tabs F QL(1 ea daily) $0 copay for Generic only, QL(1 ea daily) pravastatin sodium tabs F age 40 to lisinopril tabs or 2.5 mg F 75;QL(1 ea lisinopril tabs or 5 mg, 10 F QL(2 ea daily) daily); PV mg, 20 mg, 30 mg, 40 mg ST; Try LOTENSIN TABS 10 MG, QL(1 ea daily) atorvastatin, 20 MG (Use Benazepril NF simvastatin, HCl) rosuvastatin calcium tabs F pravastatin, or lovastatin LOTENSIN TABS 40 MG NF QL(2 ea daily) first;QL(1 ea (Use Benazepril HCl) daily) PRINIVIL TABS (Use NF QL(2 ea daily) $0 copay for Lisinopril) Generic only, quinapril hcl tabs F QL(1 ea daily) simvastatin tabs or 5 mg, F age 40 to 10 mg, 20 mg, 40 mg 75;QL(1 ea ramipril caps F QL(2 ea daily) daily); PV $0 copay for trandolapril tabs 1 mg, 2 F QL(1 ea daily) ZOCOR TABS 5 MG, 10 Generic only, mg MG, 20 MG, 40 MG (Use NF age 40 to trandolapril tabs 4 mg F QL(2 ea daily) Simvastatin) 75;QL(1 ea daily); PV VASOTEC TABS (Use NF QL(2 ea daily) Nicotinic Acid Derivatives Enalapril Maleate) ZESTRIL TABS 2.5 MG QL(1 ea daily) niacin (antihyperlipidemic) F NF tbcr (Use Lisinopril) ZESTRIL TABS 5 MG, 10 QL(2 ea daily) NIACOR TABS F MG, 20 MG, 30 MG, 40 MG NF (Use Lisinopril) NIASPAN TBCR (Use NF Niacin (Antihyperlipidemic)) Angiotensin II Receptor Antagonists ANTIHYPERTENSIVES - Drugs to Treat High ST; Try Blood Pressure ATACAND TABS (Use NF losartan, Candesartan Cilexetil) irbesartan, or ACE Inhibitors valsartan first ACCUPRIL TABS (Use QL(1 ea daily) NF AVAPRO TABS (Use NF QL(1 ea daily) Quinapril HCl) Irbesartan) ALTACE CAPS (Use NF QL(2 ea daily) ST; Try Ramipril) BENICAR TABS (Use NF losartan, Olmesartan Medoxomil) irbesartan, or benazepril hcl tabs or 40 F QL(2 ea daily) mg valsartan first benazepril hcl tabs or 5 QL(1 ea daily) ST; Try F losartan, mg, 10 mg, 20 mg candesartan cilexetil tabs F irbesartan, or captopril tabs or 25 mg, 50 F QL(3 ea daily) mg, 100 mg, 12.5 mg valsartan first

Louisiana Healthcare Connections Updated April 1, 2019

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COZAAR TABS (Use NF QL(1 ea daily) hcl caps F Losartan Potassium) DIOVAN TABS (Use NF QL(1 ea daily) hcl caps F Valsartan) Try losartan, Antihypertensive Combinations EDARBI TABS F irbesartan, or ACCURETIC TABS 10MG- QL(3 ea daily) valsartan first 12.5MG (Use Quinapril- NF ST; Try Hydrochlorothiazide) EPROSARTAN F losartan, ACCURETIC TABS 20MG- QL(4 ea daily) MESYLATE TABS irbesartan, or 12.5MG (Use Quinapril- NF valsartan first Hydrochlorothiazide) irbesartan tabs F QL(1 ea daily) ACCURETIC TABS 20MG- QL(2 ea daily) 25MG (Use Quinapril- NF losartan potassium tabs F QL(1 ea daily) Hydrochlorothiazide) amlodipine besylate- F QL(1 ea daily) ST; Try benazepril hcl caps losartan, ST MICARDIS TABS ( irbesartan, or amlodipine besylate- F Use NF olmesartan medoxomil tabs Telmisartan) valsartan first;QL(1 ea amlodipine besylate- F ST daily) valsartan tabs ST; Try amlodipine-valsartan- F ST losartan, hydrochlorothiazide tabs olmesartan medoxomil tabs F irbesartan, or ST; Try valsartan first ATACAND HCT TABS losartan hctz, ST; Try (Use Candesartan Cilexetil- NF irbesartan hctz, losartan, Hydrochlorothiazide) or valsartan irbesartan, or hctz first telmisartan tabs F valsartan & chlorthalidone F QL(1 ea daily) first;QL(1 ea tabs daily) AVALIDE TABS (Use QL(1 ea daily) valsartan tabs F QL(1 ea daily) Irbesartan- NF Hydrochlorothiazide) Antiadrenergic Antihypertensives AZOR TABS (Use ST Amlodipine Besylate- NF CARDURA TABS (Use NF Mesylate) Olmesartan Medoxomil) benazepril & QL(1 ea daily) CATAPRES TABS (Use NF F Clonidine HCl) hydrochlorothiazide tabs ST; Try clonidine hcl tabs or 0.1 F mg, 0.2 mg, 0.3 mg BENICAR HCT TABS (Use losartan hctz, Olmesartan Medoxomil- NF irbesartan hctz, doxazosin mesylate tabs or F Hydrochlorothiazide) or valsartan 1 mg, 2 mg, 4 mg, 8 mg hctz first guanfacine hcl tabs F & F QL(1 ea daily) hydrochlorothiazide tabs tabs F

MINIPRESS CAPS (Use NF Prazosin HCl) Louisiana Healthcare Connections Updated April 1, 2019

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; Try QL(1 ea daily) losartan hctz, candesartan cilexetil- SUCCINATE F F irbesartan hctz, ER/HYDROCHLOROTHIA hydrochlorothiazide tabs or valsartan ZIDE TB24 hctz first METOPROLOL/HYDROCH F QL(2 ea daily) CAPTOPRIL/HYDROCHL F QL(2 ea daily) LOROTHIAZIDE TABS OROTHIAZIDE TABS MICARDIS HCT TABS QL(1 ea daily) DIOVAN HCT TABS (Use QL(1 ea daily) (Use Telmisartan- NF Valsartan- NF Hydrochlorothiazide) Hydrochlorothiazide) olmesartan medoxomil- ST DUTOPROL TB24 F QL(1 ea daily) amlodipine- F hydrochlorothiazide tabs enalapril maleate & F QL(2 ea daily) ST; Try hydrochlorothiazide tabs losartan hctz, olmesartan medoxomil- F irbesartan hctz, EXFORGE HCT TABS ST hydrochlorothiazide tabs (Use Amlodipine-Valsartan- NF or valsartan Hydrochlorothiazide) hctz first EXFORGE TABS (Use ST /HYDROC F QL(2 ea daily) Amlodipine Besylate- NF HLOROTHIAZIDE TABS Valsartan) quinapril- QL(3 ea daily) hydrochlorothiazide tabs F fosinopril sodium & F QL(1 ea daily) hydrochlorothiazide tabs 10mg-12.5mg HYZAAR TABS (Use QL(1 ea daily) quinapril- QL(4 ea daily) Losartan Potassium & NF hydrochlorothiazide tabs F Hydrochlorothiazide) 20mg-12.5mg quinapril- QL(2 ea daily) irbesartan- F QL(1 ea daily) hydrochlorothiazide tabs hydrochlorothiazide tabs F lisinopril & QL(2 ea daily) 20mg-25mg TARKA TBCR (Use hydrochlorothiazide tabs F 10mg-12.5mg, 20mg- Trandolapril-Verapamil NF 12.5mg HCl) lisinopril & QL(1 ea daily) telmisartan-amlodipine tabs F hydrochlorothiazide tabs F 20mg-25mg telmisartan- F QL(1 ea daily) LOPRESSOR HCT TABS QL(2 ea daily) hydrochlorothiazide tabs (Use Metoprolol & NF TENORETIC 100 TABS QL(1 ea daily) Hydrochlorothiazide) (Use Atenolol & NF Chlorthalidone) losartan potassium & F QL(1 ea daily) hydrochlorothiazide tabs TENORETIC 50 TABS QL(1 ea daily) LOTENSIN HCT TABS QL(1 ea daily) (Use Atenolol & NF (Use Benazepril & NF Chlorthalidone) Hydrochlorothiazide) trandolapril-verapamil hcl F LOTREL CAPS (Use QL(1 ea daily) tbcr Amlodipine Besylate- NF TRANDOLAPRIL/VERAPA F Benazepril HCl) MIL HCL ER TBCR metoprolol & F QL(2 ea daily) hydrochlorothiazide tabs

Louisiana Healthcare Connections Updated April 1, 2019

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRIBENZOR TABS (Use ST PRIMAQUINE Olmesartan Medoxomil- NF PHOSPHATE TABS (Use NF Amlodipine- Primaquine Phosphate) Hydrochlorothiazide) primaquine phosphate tabs F TWYNSTA TABS (Use NF 26.3 mg Telmisartan-Amlodipine) ANTIMYASTHENIC/CHOLINERGIC AGENTS valsartan- F QL(1 ea daily) hydrochlorothiazide tabs Antimyasthenic/Cholinergic Agents VASERETIC TABS (Use QL(2 ea daily) MESTINON TABS 60 MG Enalapril Maleate & NF (Use Pyridostigmine NF Hydrochlorothiazide) Bromide) ZESTORETIC TABS QL(2 ea daily) MESTINON TIMESPAN 10MG-12.5MG, 20MG- NF TBCR (Use Pyridostigmine NF 12.5MG (Use Lisinopril & Bromide) Hydrochlorothiazide) pyridostigmine bromide F ZESTORETIC TABS QL(1 ea daily) tabs or 60 mg 20MG-25MG (Use NF Lisinopril & pyridostigmine bromide tbcr F Hydrochlorothiazide) or 180 mg ANTIMYCOBACTERIAL AGENTS - Drugs to ZIAC TABS (Use Bisoprolol NF QL(1 ea daily) & Hydrochlorothiazide) Treat Tuberculosis (Bacterial Infections) Vasodilators Antimycobacterial Agents ethambutol hcl tabs or 100 hydralazine hcl tabs or 10 F F mg, 25 mg, 50 mg, 100 mg mg, 400 mg ISONIAZID SYRP OR 50 minoxidil tabs or 10 mg, 2.5 F F mg MG/5ML ANTIMALARIALS - Drugs to Treat Malaria isoniazid tabs or 100 mg, F (Parasitic Infections) 300 mg MYAMBUTOL TABS (Use NF Antimalarial Combinations Ethambutol HCl) COARTEM TABS F QL(24 ea per fill retail) pyrazinamide tabs or F Antimalarials RIFADIN CAPS OR 150 CHLOROQUINE QL(2 ea daily) MG, 300 MG (Use NF PHOSPHATE TABS OR F Rifampin) 250 MG rifampin caps or 150 mg, F 300 mg chloroquine phosphate F QL(8 ea per 56 tabs or 500 mg days retail) TRECATOR TABS F hydroxychloroquine sulfate F tabs or 200 mg ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer MEFLOQUINE HCL TABS F Alkylating Agents mefloquine hcl tabs F ALKERAN TABS OR 2 MG NF (Use Melphalan) PLAQUENIL TABS (Use Hydroxychloroquine NF cyclophosphamide caps or F Sulfate) 25 mg, 50 mg

Louisiana Healthcare Connections Updated April 1, 2019

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CYCLOPHOSPHAMIDE megestrol acetate susp or F CAPS OR 25 MG, 50 MG NF 40 mg/ml, 400 mg/10ml (Use Cyclophosphamide) megestrol acetate tabs or F LEUKERAN TABS F 20 mg, 40 mg tamoxifen citrate tabs or 10 VC melphalan tabs 2 mg F mg, 20 mg toremifene citrate tabs 60 F PA MYLERAN TABS 2 MG F mg Antimetabolites Antineoplastic Enzyme Inhibitors PA mercaptopurine tabs or F COTELLIC TABS F methotrexate sodium soln ij NINLARO CAPS F PA 1 gm/40ml, 50 mg/2ml, 250 F mg/10ml Antineoplastics Misc. METHOTREXATE HYDREA CAPS (Use NF SODIUM SOLN IJ 250 F Hydroxyurea) MG/10ML hydroxyurea caps or 500 F mg methotrexate sodium tabs F or 2.5 mg Chemotherapy Rescue/Antidote Agents PURIXAN SUSP F LEUCOVORIN CALCIUM F TABS OR 10 MG, 15 MG TREXALL TABS F leucovorin calcium tabs or F 5 mg, 25 mg Antineoplastic - Hormonal and Related Agents ANTIPARKINSON AND RELATED THERAPY anastrozole tabs or 1 mg F AGENTS - Drugs to Treat Parkinson's Disease Antiparkinson Adjuvants ARIMIDEX TABS (Use NF Anastrozole) carbidopa tabs or 25 mg F ST; Try AROMASIN TABS (Use NF Exemestane) anastrozole or LODOSYN TABS (Use NF letrozole first Carbidopa) bicalutamide tabs 50 mg F QL(1 ea daily) Antiparkinson Anticholinergics benztropine mesylate tabs F CASODEX TABS (Use NF QL(1 ea daily) or 0.5 mg, 1 mg, 2 mg Bicalutamide) ST; Try trihexyphenidyl hcl elix F exemestane tabs 25 mg F anastrozole or letrozole first trihexyphenidyl hcl tabs F FARESTON TABS (Use NF PA Toremifene Citrate) Antiparkinson hcl caps or 100 FEMARA TABS (Use NF F Letrozole) mg amantadine hcl syrp or 50 F flutamide caps F mg/5ml mesylate F letrozole tabs or 2.5 mg F caps or 5 mg

Louisiana Healthcare Connections Updated April 1, 2019

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bromocriptine mesylate F LITHIUM CARBONATE tabs or 2.5 mg CAPS OR 150 MG, 600 F carbidopa-levodopa tabs MG (Use Lithium 10mg-100mg, 25mg- F Carbonate) 100mg, 25mg-250mg lithium carbonate tabs or F carbidopa-levodopa tbcr 300 mg 25mg-100mg, 50mg- F lithium carbonate tbcr or F 200mg 300 mg, 450 mg MIRAPEX TABS (Use QL(3 ea daily); LITHIUM SOLN F NF AL(At least 18 Dihydrochloride) yrs old) LITHOBID TBCR (Use F Lithium Carbonate) PARLODEL CAPS (Use NF Bromocriptine Mesylate) - Misc. PARLODEL TABS (Use NF GEODON CAPS OR 20 QL(2 ea daily); Bromocriptine Mesylate) MG, 40 MG, 60 MG, 80 MG NF AL(At least 18 pramipexole QL(3 ea daily); (Use HCl) yrs old) dihydrochloride tabs 0.125 F AL(At least 18 PA; QL(1 ea mg, 0.25 mg, 0.75 mg, 0.5 yrs old) LATUDA TABS 20 MG, 40 F daily); AL(At mg, 1 mg, 1.5 mg MG, 60 MG, 120 MG least 10 yrs REQUIP TABS 0.25 MG, 3 QL(6 ea daily) old) MG, 4 MG (Use NF PA; QL(2 ea Hydrochloride) F daily); AL(At REQUIP TABS 0.5 MG, 1 QL(3 ea daily) LATUDA TABS 80 MG least 10 yrs MG, 2 MG, 5 MG (Use NF old) Ropinirole Hydrochloride) PA; QL(1 ea NUPLAZID CAPS 34 MG F ropinirole hydrochloride F QL(6 ea daily) daily) tabs 0.25 mg, 3 mg, 4 mg NUPLAZID TABS 17 MG F QL(2 ea daily) ropinirole hydrochloride QL(3 ea daily) tabs 0.5 mg, 1 mg, 2 mg, 5 F QL(2 ea daily); mg ziprasidone hcl caps F AL(At least 18 yrs old) SINEMET CR TBCR (Use NF Carbidopa-Levodopa) Benzisoxazoles SINEMET TABS (Use NF PA; QL(1 ea Carbidopa-Levodopa) per 28 days Antiparkinson Monoamine Oxidase Inhibitors PERSERIS PRSY F retail); AL(At least 18 yrs ELDEPRYL CAPS (Use NF Selegiline HCl) old) RISPERDAL CONSTA F PA selegiline hcl caps or 5 mg F SUSR QL(2 ea daily); selegiline hcl tabs or 5 mg F RISPERDAL M-TAB TBDP NF (Use ) AL(At least 5 yrs old) ANTIPSYCHOTICS/ANTIMANIC AGENTS - Drugs to Treat Mood Disorders QL(4 ml daily); RISPERDAL SOLN 1 NF AL(At least 5 MG/ML (Use Risperidone) Antimanic Agents yrs old) lithium carbonate caps or F 150 mg, 300 mg, 600 mg

Louisiana Healthcare Connections Updated April 1, 2019

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RISPERDAL TABS 0.25 QL(4 ea daily); succinate caps F QL(4 ea daily) MG, 0.5 MG, 1 MG, 2 MG, NF AL(At least 5 3 MG, 4 MG (Use yrs old) QL(2 ea daily); Risperidone) tabs or 10 mg, F AL(At least 10 7.5 mg QL(1 ea daily); yrs old) RISPERIDONE ODT TBDP F AL(At least 5 QL(1 ea daily); yrs old) olanzapine tabs or 15 mg, F AL(At least 10 20 mg QL(4 ml daily); yrs old) risperidone soln 1 mg/ml F AL(At least 5 QL(4 ea daily); yrs old) olanzapine tabs or 5 mg, F AL(At least 10 2.5 mg risperidone tabs 0.25 mg, QL(4 ea daily); yrs old) 0.5 mg, 1 mg, 2 mg, 3 mg, F AL(At least 5 fumarate tabs QL(4 ea daily); 4 mg yrs old) 25 mg, 50 mg, 100 mg, 200 F AL(At least 10 QL(1 ea daily); mg yrs old) risperidone tbdp 0.25 mg F AL(At least 5 QL(2 ea daily); yrs old) quetiapine fumarate tabs F AL(At least 10 300 mg, 400 mg QL(2 ea daily); yrs old) risperidone tbdp 0.5 mg, 1 F AL(At least 5 mg, 2 mg, 3 mg, 4 mg SEROQUEL TABS 25 MG, QL(4 ea daily); yrs old) 50 MG, 100 MG, 200 MG NF AL(At least 10 Butyrophenones (Use Quetiapine Fumarate) yrs old) HALDOL DECANOATE SEROQUEL TABS 300 QL(2 ea daily); 100 SOLN (Use NF MG, 400 MG (Use NF AL(At least 10 Decanoate) Quetiapine Fumarate) yrs old) HALDOL DECANOATE 50 ZYPREXA TABS OR 10 QL(2 ea daily); SOLN (Use Haloperidol NF MG, 7.5 MG (Use NF AL(At least 10 Decanoate) Olanzapine) yrs old) ZYPREXA TABS OR 15 QL(1 ea daily); soln F im 50 mg/ml, 100 mg/ml MG, 20 MG (Use NF AL(At least 10 Olanzapine) yrs old) haloperidol lactate conc or F 2 mg/ml ZYPREXA TABS OR 5 QL(4 ea daily); MG, 2.5 MG (Use NF AL(At least 10 haloperidol tabs or 0.5 mg, F QL(3 ea daily) Olanzapine) yrs old) 1 mg, 10 mg Dihydroindolones haloperidol tabs or 2 mg, 5 F mg, 20 mg QL(4 ea daily) HYDROCHLORIDE TABS F Dibenzapines 10 MG QL(9 ea daily); tabs 100 mg F AL(At least 18 Phenothiazines yrs old) hcl tabs or F QL(10 ea daily) QL(3 ea daily); 10 mg clozapine tabs 25 mg, 50 F AL(At least 18 chlorpromazine hcl tabs or QL(3 ea daily) mg, 200 mg yrs old) 25 mg, 50 mg, 100 mg, 200 F QL(9 ea daily); mg CLOZARIL TABS 100 MG NF AL(At least 18 decanoate (Use Clozapine) F yrs old) soln ij QL(3 ea daily); fluphenazine hcl tabs or 1 F CLOZARIL TABS 25 MG NF AL(At least 18 mg, 5 mg, 10 mg, 2.5 mg (Use Clozapine) yrs old) Louisiana Healthcare Connections Updated April 1, 2019

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tabs or 2 mg, F QL(4 ea daily) 4 mg, 8 mg, 16 mg ANTIVIRALS - Drugs to Treat Viral Infections maleate F Antiretrovirals tabs or 5 mg, 10 mg abacavir sulfate soln 20 F QL(30 ml daily) prochlorperazine supp F mg/ml abacavir sulfate tabs 300 F QL(2 ea daily) hcl tabs or 10 F QL(3 ea daily) mg mg, 25 mg, 50 mg, 100 mg abacavir sulfate-lamivudine F QL(1 ea daily) hcl tabs F QL(3 ea daily) tabs 600mg-300mg abacavir sulfate- QL(2 ea daily) Quinolinone Derivatives lamivudine-zidovudine tabs F 300mg-150mg-300mg ABILIFY MAINTENA PRSY F SP 300 MG, 400 MG APTIVUS CAPS 250 MG F QL(4 ea daily) ABILIFY TABS ( QL(1 ea daily); Use NF APTIVUS SOLN 100 QL(10 ml daily) ) AL(At least 6 F yrs old) MG/ML PA; QL(25 ml atazanavir sulfate caps F QL(2 ea daily) aripiprazole soln 1 mg/ml F daily); AL(At least 6 yrs old) ATRIPLA TABS F QL(1 ea daily) aripiprazole tabs 2 mg, 5 QL(1 ea daily); mg, 10 mg, 15 mg, 20 mg, F AL(At least 6 BIKTARVY TABS F QL(1 ea daily) 30 mg yrs old) PA; QL(1 ea CIMDUO TABS F QL(1 ea daily) aripiprazole tbdp 10 mg, 15 F daily); AL(At mg least 6 yrs old) COMBIVIR TABS (Use NF QL(2 ea daily) PA; 1 rtl pack Lamivudine-Zidovudine) lmt amt,548 rtl COMPLERA TABS F QL(1 ea daily) ARISTADA INITIO PRSY F pack lmt 675 MG/2.4ML day(s),; AL(At CRIXIVAN CAPS 200 MG F QL(9 ea daily) least 18 yrs old) CRIXIVAN CAPS 400 MG F QL(6 ea daily) DELSTRIGO TABS F QL(1 ea daily) THIOTHIXENE CAPS 1 F QL(3 ea daily) MG DESCOVY TABS F QL(1 ea daily) thiothixene caps 1 mg, 2 F QL(3 ea daily) mg, 5 mg, 10 mg didanosine cpdr F QL(1 ea daily) ANTISEPTICS & DISINFECTANTS EDURANT TABS F QL(1 ea daily) Antiseptics & Disinfectants caps 200 mg F QL(1 ea daily) formaldehyde soln 10%, 10 F QL(90 ml per % fill retail) efavirenz caps 50 mg F QL(2 ea daily) Chlorine Antiseptics QL(1 ea daily) chlorhexidine gluconate F efavirenz tabs 600 mg F liqd ex 4 % QL(1 ea daily) HIBICLENS LIQD (Use NF EMTRIVA CAPS 200 MG F Chlorhexidine Gluconate)

Louisiana Healthcare Connections Updated April 1, 2019

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMTRIVA SOLN 10 F QL(24 ml daily) lamivudine-zidovudine tabs F QL(2 ea daily) MG/ML 150mg-300mg EPIVIR SOLN 10 MG/ML NF QL(30 ml daily) LEXIVA SUSP 50 MG/ML F QL(56 ml daily) (Use Lamivudine) LEXIVA TABS 700 MG QL(4 ea daily) EPIVIR TABS 150 MG NF QL(2 ea daily) (Use Lamivudine) (Use Fosamprenavir NF EPIVIR TABS 300 MG QL(1 ea daily) Calcium) NF QL(160 ml per (Use Lamivudine) lopinavir-ritonavir soln F EPZICOM TABS (Use QL(1 ea daily) fill retail) Abacavir Sulfate- NF nevirapine susp 50 mg/5ml F QL(40 ml daily) Lamivudine) QL(2 ea daily) EVOTAZ TABS F QL(1 ea daily) nevirapine tabs 200 mg F QL(4 ea daily) nevirapine tb24 100 mg, F QL(1 ea daily) fosamprenavir calcium tabs F 400 mg QL(12 ea daily) FUZEON SOLR F NORVIR CAPS 100 MG F

GENVOYA TABS F QL(1 ea daily) NORVIR PACK 100 MG F QL(15 ml daily) INTELENCE TABS 200 F QL(2 ea daily) NORVIR SOLN 80 MG/ML F MG NORVIR TABS 100 MG QL(12 ea daily) INTELENCE TABS 25 MG, F QL(4 ea daily) NF 100 MG (Use Ritonavir) QL(1 ea daily) INVIRASE CAPS 200 MG F QL(10 ea daily) ODEFSEY TABS F QL(1 ea daily) INVIRASE TABS 500 MG F QL(4 ea daily) PIFELTRO TABS F QL(1 ea daily) ISENTRESS CHEW 100 F QL(6 ea daily) PREZCOBIX TABS F MG PREZISTA SUSP 100 F QL(12 ml daily) ISENTRESS CHEW 25 MG F QL(12 ea daily) MG/ML QL(3 ea daily) ISENTRESS PACK 100 F QL(2 ea daily) PREZISTA TABS 150 MG F MG PREZISTA TABS 75 MG, F QL(2 ea daily) ISENTRESS TABS 400 F QL(2 ea daily) 600 MG MG PREZISTA TABS 800 MG F QL(1 ea daily) JULUCA TABS F RESCRIPTOR TABS 100 F QL(12 ea daily) KALETRA SOLN QL(160 ml per MG 400MG/5ML-100MG/5ML NF fill retail) (Use Lopinavir-Ritonavir) RESCRIPTOR TABS 200 F QL(6 ea daily) MG KALETRA TABS 100MG- F QL(4 ea daily) 25MG, 200MG-50MG RETROVIR CAPS 100 MG NF QL(6 ea daily) (Use Zidovudine) lamivudine soln 10 mg/ml F QL(30 ml daily) RETROVIR IV INFUSION F SOLN lamivudine tabs 150 mg F QL(2 ea daily) RETROVIR SYRP 50 NF QL(60 ml daily) MG/5ML (Use Zidovudine) lamivudine tabs 300 mg F QL(1 ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REYATAZ CAPS 150 MG, QL(2 ea daily) TRUVADA TABS 150MG- 200 MG, 300 MG (Use NF 100MG, 200MG-133MG, F Atazanavir Sulfate) 250MG-167MG REYATAZ PACK 50 MG F QL(6 ea daily) TRUVADA TABS 300MG- F QL(1 ea daily) 200MG ritonavir tabs F QL(12 ea daily) QL(1 ea daily); TYBOST TABS F AL(At least 18 SELZENTRY TABS 150 F QL(2 ea daily) yrs old) MG QL(1 ea daily) QL 2 per VIDEX EC CPDR 125 MG F SELZENTRY TABS 25 F day;SL(2 ea MG, 75 MG VIDEX EC CPDR 200 MG, QL(1 ea daily) daily) 250 MG, 400 MG (Use NF Didanosine) SELZENTRY TABS 300 F QL(4 ea daily) MG VIDEXPEDIATRIC SOLR F QL(20 ml daily) stavudine caps F QL(2 ea daily) VIRACEPT TABS 250 MG F QL(9 ea daily) STRIBILD TABS F QL(1 ea daily) VIRACEPT TABS 625 MG F QL(4 ea daily) SUSTIVA CAPS 200 MG NF QL(1 ea daily) (Use Efavirenz) VIRAMUNE SUSP 50 NF QL(40 ml daily) MG/5ML (Use Nevirapine) SUSTIVA CAPS 50 MG NF QL(2 ea daily) (Use Efavirenz) VIRAMUNE TABS 200 MG NF QL(2 ea daily) (Use Nevirapine) SUSTIVA TABS 600 MG NF QL(1 ea daily) (Use Efavirenz) VIRAMUNE XR TB24 (Use NF QL(1 ea daily) Nevirapine) SYMFI LO TABS F QL(1 ea daily) VIREAD POWD 40 MG/GM F QL(8 gm daily) SYMFI TABS F QL(1 ea daily) VIREAD TABS 150 MG, F QL(1 ea daily) SYMTUZA TABS F QL(1 ea daily) 200 MG, 250 MG VIREAD TABS 300 MG QL(1 ea daily) tenofovir disoproxil F QL(1 ea daily) (Use Tenofovir Disoproxil NF fumarate tabs Fumarate) TIVICAY TABS 10 MG F QL(10 ea daily) ZERIT CAPS 15 MG, 20 QL(2 ea daily) MG, 30 MG, 40 MG (Use NF TIVICAY TABS 25 MG F QL(4 ea daily) Stavudine) ZERIT SOLR 1 MG/ML F QL(80 ml daily) TIVICAY TABS 50 MG F QL(2 ea daily) ZIAGEN SOLN 20 MG/ML NF QL(30 ml daily) QL(1 ea daily); (Use Abacavir Sulfate) TRIUMEQ TABS F AL(At least 18 ZIAGEN TABS 300 MG NF QL(2 ea daily) yrs old) (Use Abacavir Sulfate) TRIZIVIR TABS (Use QL(2 ea daily) QL(6 ea daily) Abacavir Sulfate- NF zidovudine caps 100 mg F Lamivudine-Zidovudine) zidovudine syrp 50 mg/5ml F QL(60 ml daily) TROGARZO SOLN F zidovudine tabs 300 mg F QL(2 ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CMV Agents TAMIFLU CAPS 30 MG QL(20 ea per (Use Oseltamivir NF 30 days retail) VALCYTE TABS 450 MG NF QL(2 ea daily) Phosphate) (Use Valganciclovir HCl) TAMIFLU CAPS 45 MG, 75 QL(10 ea per valganciclovir hcl tabs 450 QL(2 ea daily) F MG (Use Oseltamivir NF 30 days retail) mg Phosphate) Hepatitis Agents TAMIFLU SUSR 6 MG/ML QL(120 ml per NF MAVYRET TABS F PA; QL(3 ea (Use Oseltamivir 30 days retail) daily) Phosphate) Herpes Agents BETA BLOCKERS - Drugs to Treat High Blood QL(50 ea per Pressure acyclovir caps or 200 mg F 30 days retail) Alpha-Beta Blockers acyclovir susp or 200 F QL(400 ml per QL(1 ea daily) mg/5ml 30 days retail) phosphate cp24 F QL(2 ea daily) acyclovir tabs or 400 mg F carvedilol tabs 12.5 mg, F QL(3 ea daily) 6.25 mg, 3.125 mg QL(50 ea per acyclovir tabs or 800 mg F QL(4 ea daily) 30 days retail) carvedilol tabs 25 mg F famciclovir tabs or 125 mg, F COREG CR CP24 (Use NF QL(1 ea daily) 250 mg, 500 mg Carvedilol Phosphate) valacyclovir hcl tabs or 1 F COREG TABS 12.5 MG, QL(3 ea daily) gm, 1000 mg 6.25 MG, 3.125 MG (Use NF Carvedilol) valacyclovir hcl tabs or 500 F QL(2 ea daily) mg COREG TABS 25 MG (Use NF QL(4 ea daily) Carvedilol) VALTREX TABS 1 GM NF (Use Valacyclovir HCl) hcl tabs or 100 mg F QL(3 ea daily) VALTREX TABS 500 MG NF QL(2 ea daily) (Use Valacyclovir HCl) labetalol hcl tabs or 200 mg F QL(6 ea daily) ZOVIRAX CAPS OR 200 NF QL(50 ea per MG (Use Acyclovir) 30 days retail) labetalol hcl tabs or 300 mg F QL(8 ea daily) ZOVIRAX SUSP OR 200 NF QL(400 ml per MG/5ML (Use Acyclovir) 30 days retail) Beta Blockers Cardio-Selective hcl caps or 200 ZOVIRAX TABS OR 400 NF QL(2 ea daily) F MG (Use Acyclovir) mg, 400 mg atenolol tabs or 25 mg, 50 QL(2 ea daily) ZOVIRAX TABS OR 800 NF QL(50 ea per F MG (Use Acyclovir) 30 days retail) mg, 100 mg QL(1 ea daily) Influenza Agents bisoprolol fumarate tabs F oseltamivir phosphate caps F QL(20 ea per LOPRESSOR TABS 100 QL(4.5 ea or 30 mg 30 days retail) MG (Use Metoprolol NF daily) oseltamivir phosphate caps F QL(10 ea per Tartrate) or 45 mg, 75 mg 30 days retail) LOPRESSOR TABS 50 QL(4 ea daily) oseltamivir phosphate susr F QL(120 ml per MG (Use Metoprolol NF or 6 mg/ml 30 days retail) Tartrate) QL(20 ea per metoprolol succinate tb24 QL(2 ea daily) RELENZA DISKHALER F fill retail); AL(At F AEPB 200 mg least 5 yrs old) Louisiana Healthcare Connections Updated April 1, 2019

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metoprolol succinate tb24 F QL(4 ea daily) CALCIUM CHANNEL BLOCKERS - Drugs to 25 mg, 50 mg, 100 mg Treat High Blood Pressure metoprolol tartrate tabs or QL(4.5 ea F Calcium Channel Blockers 100 mg daily) ADALAT CC TB24 30 MG, NF QL(1 ea daily) metoprolol tartrate tabs or F QL(4 ea daily) 90 MG (Use Nifedipine) 25 mg, 50 mg ADALAT CC TB24 60 MG NF QL(2 ea daily) TENORMIN TABS (Use NF QL(2 ea daily) (Use Nifedipine) Atenolol) amlodipine besylate tabs or F QL(1 ea daily) TOPROL XL TB24 200 MG NF QL(2 ea daily) 5 mg, 10 mg, 2.5 mg (Use Metoprolol Succinate) CALAN SR TBCR (Use NF QL(2 ea daily) TOPROL XL TB24 25 MG, QL(4 ea daily) Verapamil HCl) 50 MG, 100 MG (Use NF Metoprolol Succinate) CALAN TABS (Use NF QL(3 ea daily) Verapamil HCl) ZEBETA TABS (Use NF QL(1 ea daily) Bisoprolol Fumarate) CARDIZEM CD CP24 120 QL(1 ea daily) MG, 180 MG, 300 MG (Use NF Beta Blockers Non-Selective Diltiazem HCl Coated Beads) BETAPACE AF TABS (Use NF QL(2 ea daily) HCl (AFIB/AFL)) CARDIZEM CD CP24 240 QL(2 ea daily) MG (Use Diltiazem HCl NF BETAPACE TABS (Use NF QL(2 ea daily) Sotalol HCl) Coated Beads) CARDIZEM TABS (Use QL(3 ea daily) CORGARD TABS (Use NF QL(2 ea daily) NF ) Diltiazem HCl) HEMANGEOL SOLN F PA diltiazem hcl coated beads QL(1 ea daily) cp24 120 mg, 180 mg, 300 F mg INDERAL LA CP24 (Use NF QL(2 ea daily) Propranolol HCl) diltiazem hcl coated beads F QL(2 ea daily) cp24 240 mg nadolol tabs or 20 mg, 40 F QL(2 ea daily) mg, 80 mg diltiazem hcl cp12 or 60 F QL(2 ea daily) mg, 90 mg, 120 mg tabs F diltiazem hcl cp24 or 120 F QL(1 ea daily) propranolol hcl cp24 or 60 QL(2 ea daily) mg, 180 mg mg, 80 mg, 120 mg, 160 F diltiazem hcl cp24 or 240 F QL(2 ea daily) mg mg PROPRANOLOL HCL diltiazem hcl extended F QL(1 ea daily) SOLN OR 20 MG/5ML, 40 F release beads cp24 MG/5ML diltiazem hcl tabs or 30 mg, F QL(3 ea daily) propranolol hcl tabs or 10 60 mg, 90 mg, 120 mg mg, 20 mg, 40 mg, 60 mg, F 80 mg felodipine tb24 F QL(1 ea daily) sotalol hcl (afib/afl) tabs F QL(2 ea daily) nicardipine hcl caps or 20 F mg, 30 mg sotalol hcl tabs 240 mg F nifedipine caps or 10 mg, F QL(4 ea daily) 20 mg sotalol hcl tabs 80 mg, 120 F QL(2 ea daily) mg, 160 mg nifedipine tb24 or 30 mg, F QL(1 ea daily) 90 mg MALEATE TABS F OR 5 MG, 10 MG, 20 MG Louisiana Healthcare Connections Updated April 1, 2019

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nifedipine tb24 or 60 mg F QL(2 ea daily) LANOXIN TABS OR 125 MCG, 250 MCG (Use F Digoxin) NORVASC TABS (Use NF QL(1 ea daily) Amlodipine Besylate) CEPHALOSPORINS - Drugs to Treat Bacterial PROCARDIA CAPS (Use NF QL(4 ea daily) Infections Nifedipine) Cephalosporins - 1st Generation PROCARDIA XL TB24 30 QL(1 ea daily) MG, 90 MG (Use NF cefadroxil caps 500 mg F Nifedipine) QL(100 ml per PROCARDIA XL TB24 60 QL(2 ea daily) NF F fill retail); MG (Use Nifedipine) cefadroxil susr 250 mg/5ml AL(Up to 12 yrs TIAZAC CP24 (Use QL(1 ea daily) old ) Diltiazem HCl Extended NF Release Beads) cefadroxil susr 500 mg/5ml F verapamil hcl cp24 or 100 QL(2 ea daily) mg, 120 mg, 180 mg, 200 F cefadroxil tabs 1 gm F mg, 240 mg cephalexin caps 250 mg, F verapamil hcl cp24 or 300 F QL(1 ea daily) 500 mg mg cephalexin susr 125 F VERAPAMIL HCL SR F QL(1 ea daily) mg/5ml, 250 mg/5ml CP24 KEFLEX CAPS 250 MG, NF verapamil hcl tabs or 40 F 500 MG (Use Cephalexin) mg Cephalosporins - 2nd Generation verapamil hcl tabs or 80 F QL(3 ea daily) mg, 120 mg cefaclor caps 250 mg, 500 F mg verapamil hcl tbcr or 120 F QL(2 ea daily) mg, 180 mg, 240 mg CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML, F VERELAN CP24 120 MG, QL(2 ea daily) 375 MG/5ML 180 MG, 240 MG (Use NF Verapamil HCl) cefoxitin sodium solr iv 1 F gm, 2 gm QL(1 ea daily) VERELAN CP24 360 MG F CEFOXITIN SODIUM VERELAN PM CP24 100 QL(2 ea daily) SOLR IV 1GM-4%, 2GM- F MG, 200 MG (Use NF 2.2% QL(100 ml per Verapamil HCl) cefprozil susr 125 mg/5ml F VERELAN PM CP24 300 QL(1 ea daily) fill retail) NF AL(Up to 12 yrs MG (Use Verapamil HCl) cefprozil susr 250 mg/5ml F old ) CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm cefprozil tabs 250 mg, 500 F QL(20 ea per mg fill retail) Cardiac Glycosides QL(100 ml per DIGOXIN SOLN OR 0.05 F CEFTIN SUSR 125 F fill retail); MG/ML MG/5ML AL(Up to 12 yrs digoxin tabs or 0.125 mg, old ) 0.25 mg, 125 mcg, 250 F mcg

Louisiana Healthcare Connections Updated April 1, 2019

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(200 ml per ethynodiol diacet & eth VC QL(1 ea daily) CEFTIN SUSR 250 F fill retail); estrad tabs 1mg-35mcg MG/5ML AL(Up to 12 yrs ethynodiol diacet & eth VC old ) estrad tabs 1mg-50mcg QL(20 ea per cefuroxime axetil tabs F FEMCON FE CHEW (Use fill retail) Norethindrone & Ethinyl VC Cephalosporins - 3rd Generation Estradiol-Fe) QL(20 ea per GENERESS FE CHEW cefdinir caps 300 mg F fill retail) (Use Norethindrone & VC ) QL(100 ml per Ethinyl Estradiol-Fe cefdinir susr 125 mg/5ml F fill retail) levonorgestrel & eth VC QL(1 ea daily) QL(200 ml per estradiol tabs cefdinir susr 250 mg/5ml F fill retail) levonorgestrel-eth estradiol VC QL(1 ea daily) (triphasic) tabs ceftriaxone sodium solr ij 1 F QL(3 ea per fill gm, 250 mg, 500 mg retail) QL(1 ea levonorgestrel-ethinyl VC daily,91 day(s) ceftriaxone sodium solr ij 2 estradiol (91-day) tabs F limit) gm LOESTRIN 1.5/30-21 ceftriaxone sodium solr iv 1 QL(1 ea daily) F TABS (Use Norethindrone VC gm, 2 gm Acet & Eth Estra) CONTRACEPTIVES - Drugs to Prevent LOESTRIN 1/20-21 TABS QL(1 ea daily) Pregnancy (Use Norethindrone Acet & VC Combination Contraceptives - Oral Eth Estra) PA LOESTRIN FE 1.5/30 QL(1 ea daily) BALCOLTRA TABS VC TABS (Use Norethin Acet & VC BREVICON-28 TABS (Use QL(1 ea daily) Estrad-Fe) Norethindrone & Eth VC LOESTRIN FE 1/20 TABS QL(1 ea daily) Estradiol) (Use Norethin Acet & VC CYCLESSA TABS (Use QL(1 ea daily) Estrad-Fe) Desogestrel-Ethinyl VC MIRCETTE TABS (Use QL(1 ea daily) Estradiol (Triphasic)) Desogestrel-Ethinyl VC DESOGEN TABS (Use QL(1 ea daily) Estradiol (Biphasic)) Desogestrel & Ethinyl VC NECON 1/50-28 TABS VC QL(1 ea daily) Estradiol) QL(1 ea daily) desogestrel & ethinyl VC QL(1 ea daily) NECON 10/11-28 TABS VC estradiol tabs norethin acet & estrad-fe QL(1 ea daily) desogestrel-ethinyl VC QL(1 ea daily) VC estradiol (biphasic) tabs tabs norethindrone & eth QL(1 ea daily) desogestrel-ethinyl VC QL(1 ea daily) VC estradiol (triphasic) tabs estradiol tabs norethindrone & ethinyl drospirenone-ethinyl VC QL(1 ea daily) VC estradiol tabs estradiol-fe chew ESTROSTEP FE TABS norethindrone acet & eth VC QL(1 ea daily) estra tabs (Use Norethindrone VC Acetate-Ethinyl Estradiol- norethindrone acetate- VC Fe) ethinyl estradiol-fe tabs

Louisiana Healthcare Connections Updated April 1, 2019

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norethindrone-eth estradiol VC QL(1 ea daily) Combination Contraceptives - Transdermal (triphasic) tabs 3/28 days;QL(3 norgestimate-ethinyl VC XULANE PTWK VC ea per 28 days estradiol (triphasic) tabs retail) norgestimate-ethinyl VC QL(1 ea daily) Combination Contraceptives - Vaginal estradiol (triphasic) tabs NUVARING RING VC norgestimate-ethinyl VC QL(1 ea daily) estradiol tabs Copper Contraceptives - IUD norgestrel & ethinyl VC QL(2 ea daily) estradiol tabs PARAGARD INTRAUTERINE COPPER NORINYL 1+35 TABS (Use QL(1 ea daily) VC VC CONTRACEPTIVE T380A Norethindrone & Eth IUD Estradiol) Emergency Contraceptives OGESTREL TABS VC QL(1 ea daily) QL(4 ea per ELLA TABS VC ORTHO TRI-CYCLEN LO 365 days retail) TABS (Use Norgestimate- VC levonorgestrel (emergency VC QL(1 ea per 21 Ethinyl Estradiol oc) tabs days retail) (Triphasic)) PLAN B ONE-STEP TABS QL(1 ea per 21 ORTHO TRI-CYCLEN QL(1 ea daily) (Use Levonorgestrel VC days retail) TABS (Use Norgestimate- VC (Emergency OC)) Ethinyl Estradiol (Triphasic)) Progestin Contraceptives - IUD ORTHO-CYCLEN TABS QL(1 ea daily) KYLEENA IUD VC (Use Norgestimate-Ethinyl VC Estradiol) LILETTA IUD VC ORTHO-NOVUM 1/35 QL(1 ea daily) TABS (Use Norethindrone VC MIRENA IUD VC & Eth Estradiol) ORTHO-NOVUM 7/7/7 QL(1 ea daily) SKYLA IUD VC TABS (Use Norethindrone- VC Eth Estradiol (Triphasic)) Progestin Contraceptives - Implants OVCON-35 TABS (Use QL(1 ea daily) NEXPLANON IMPL VC Norethindrone & Eth VC Estradiol) Progestin Contraceptives - Injectable SEASONIQUE TABS (Use QL(1 ea DEPO-PROVERA Levonorgestrel-Ethinyl VC daily,91 day(s) CONTRACEPTIVE SUSP VC Estradiol (91-Day)) limit) (Use Medroxyprogesterone TRI-NORINYL 28 TABS QL(1 ea daily) Acetate (Contraceptive)) (Use Norethindrone-Eth VC DEPO-PROVERA Estradiol (Triphasic)) CONTRACEPTIVE SUSY VC YASMIN 28 TABS (Use QL(1 ea daily) (Use Medroxyprogesterone Drospirenone-Ethinyl VC Acetate (Contraceptive)) Estradiol) DEPO-SUBQ PROVERA VC YAZ TABS (Use QL(1 ea daily) 104 SUSY Drospirenone-Ethinyl VC medroxyprogesterone Estradiol) acetate (contraceptive) VC susp Louisiana Healthcare Connections Updated April 1, 2019

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits medroxyprogesterone MILLIPRED TABS 5 MG F acetate (contraceptive) VC susy PEDIAPRED SOLN (Use Progestin Contraceptives - Oral Prednisolone Sodium NF Phosphate) norethindrone VC QL(1 ea daily) (contraceptive) tabs prednisolone sodium QL(240 ml per phosphate soln or 15 F fill retail) ORTHO MICRONOR QL(1 ea daily) mg/5ml TABS (Use Norethindrone VC (Contraceptive)) prednisolone sodium QL(150 ml per phosphate soln or 20 F fill retail) CORTICOSTEROIDS - Steroid Hormone Drugs to mg/5ml Treat Systemic Swelling Conditions prednisolone sodium Glucocorticosteroids phosphate soln or 5 F mg/5ml CORTEF TABS (Use NF Hydrocortisone) PREDNISOLONE SOLN F OR CORTISONE ACETATE F TABS OR 25 MG prednisolone soln or F elix or 0.5 F mg/5ml prednisolone syrp or F DEXAMETHASONE F PREDNISONE INTENSOL F INTENSOL CONC CONC QL(0.167 ml dexamethasone sodium PREDNISONE SOLN OR 5 F F daily,150 ml MG/5ML phosphate soln ij 20 per 30 days mg/5ml retail) prednisone tabs or 1 mg, 5 F mg, 10 mg, 20 mg, 2.5 mg dexamethasone sodium QL(1 ml daily) phosphate soln ij 4 mg/ml, F PREDNISONE TABS OR F 120 mg/30ml 50 MG PREDNISONE TBPK OR 5 DEXAMETHASONE SOLN F F OR 0.5 MG/5ML MG, 10 MG dexamethasone tabs or VERIPRED 20 SOLN (Use QL(150 ml per 0.75 mg, 0.5 mg, 4 mg, 6 F Prednisolone Sodium NF fill retail) mg, 1.5 mg Phosphate) Mineralocorticoids DEXAMETHASONE TABS F OR 1 MG, 2 MG fludrocortisone acetate tabs F or 0.1 mg hydrocortisone tabs or 5 F mg, 10 mg, 20 mg COUGH/COLD/ALLERGY - Drugs to Treat MEDROL DOSEPAK TBPK NF Cough, Cold and Allergy Symptoms (Use Methylprednisolone) Antitussives MEDROL TABS 4 MG, 8 MG (Use NF dextromethorphan hbr liqd F QL(240 ml per Methylprednisolone) or 7.5 mg/5ml fill retail) TRIAMINIC LONG ACTING QL(240 ml per methylprednisolone tabs or F 4 mg, 8 mg COUGH LIQD 7.5 MG/5ML NF fill retail) (Use Dextromethorphan methylprednisolone tbpk or F HBr) 4 mg Cough/Cold/Allergy Combinations Louisiana Healthcare Connections Updated April 1, 2019

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVIL COLD & SINUS DIMETAPP LONG ACTING QL(240 ml per TABS (Use NF COUGH PLUS COLD F fill retail) - SYRP Ibuprofen) LOHIST-D LIQD F QL(240 ml per QL(240 ml per 30MG/5ML-2MG/5ML fill retail) BIOSPEC DMX LIQD F fill retail) loratadine & QL(2 ea daily) & QL(120 ml per pseudoephedrine tb12 F phenyleph elix 1mg/5ml- fill retail) 5mg-120mg 2.5mg/5ml, 1mg/5ml- F loratadine & QL(1 ea daily) 1mg/5ml-2.5mg/5ml- pseudoephedrine tb24 F 2.5mg/5ml 10mg-240mg, 10mg-10mg- brompheniramine & QL(120 ml per 240mg-240mg pseudoeph elix 1mg/5ml- F fill retail) QL(240 ml per phenylephrine-dm liqd F 15mg/5ml fill retail) brompheniramine & QL(120 ml per QL(240 ml per phenylephrine-dm soln F pseudoeph liqd 1mg/5ml- F fill retail) fill retail) 15mg/5ml promethazine & F BROTAPP DM LIQD QL(240 ml per phenylephrine soln 1MG/5ML-15MG/5ML- F fill retail) 5MG/5ML promethazine-dm syrp F cetirizine-pseudoephedrine QL(2 ea daily) F PROMETHAZINE/PHENYL F tb12 EPHRINE SYRP CLARITIN-D 12 HOUR QL(2 ea daily) pseudoephedrine w/ QL(240 ml per TB12 (Use Loratadine & NF codeine-gg soln 30mg/5ml- F fill retail) Pseudoephedrine) 100mg/5ml-10mg/5ml-70% CLARITIN-D 24 HOUR QL(1 ea daily) pseudoephedrine w/ dm-gg QL(240 ml per TB24 (Use Loratadine & NF liqd 10mg/5ml-30mg/5ml- F fill retail) Pseudoephedrine) 100mg/5ml DECON-A ELIX F pseudoephedrine- F QL(240 ml per chlorphen-dm liqd fill retail) DECON-A LIQD F pseudoephedrine- QL(240 ml per syrp 30mg/5ml- F fill retail) dextromethorphan- QL(240 ml per 100mg/5ml guaifenesin liqd 5mg/5ml- fill retail) pseudoephedrine-ibuprofen 100mg/5ml, 10mg/5ml- F F 200mg/5ml, 20mg/10ml- tabs 200mg-30mg 400mg/10ml, 20mg/20ml- ROBITUSSIN PEAK COLD QL(240 ml per 400mg/20ml COUGH+ CHEST fill retail) dextromethorphan- QL(240 ml per CONGESTION DM MAX NF guaifenesin syrp fill retail) STRENGTH LIQD (Use 10mg/5ml-100mg/5ml, F Dextromethorphan- 10mg/5ml-10mg/5ml- Guaifenesin) 100mg/5ml-100mg/5ml ROBITUSSIN PEAK COLD QL(240 ml per DIMETAPP COLD & QL(120 ml per DM SYRP (Use NF fill retail) ALLERGY ELIX 1MG/5ML- fill retail) Dextromethorphan- 2.5MG/5ML (Use NF Guaifenesin) Brompheniramine & QL(240 ml per SCOT-TUSSIN DM LIQD F Phenyleph) fill retail)

Louisiana Healthcare Connections Updated April 1, 2019

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SCOT-TUSSIN SENIOR F QL(240 ml per BENZOYL PEROXIDE F LIQD fill retail) GEL EX 2.5 % TRIAMINIC COLD & QL(240 ml per benzoyl peroxide gel ex 5 F COUGH DAY TIME F fill retail) % CHILDRENS SOLN benzoyl peroxide liqd ex 4 F TRIAMINIC COLD & QL(240 ml per % COUGH DAY TIME F fill retail) benzoyl peroxide liqd ex 5 F RX/OTC CHILDRENS SYRP %, 10 % ZYRTEC-D QL(2 ea daily) benzoyl peroxide lotn ex 6 F ALLERGY/CONGESTION NF % TB12 (Use Cetirizine- Pseudoephedrine) CLEAN & CLEAR ADVANTAGE 3-IN-1 F Expectorants EXFOLIATING CLEANSER guaifenesin liqd or 100 QL(240 ml per LOTN mg/5ml, 200 mg/10ml, 400 F fill retail) CLEOCIN-T LOTN (Use QL(60 ml per mg/20ml Clindamycin Phosphate NF fill retail) guaifenesin soln or 100 QL(240 ml per (Topical)) mg/5ml, 200 mg/10ml, 300 F fill retail) CLEOCIN-T SOLN (Use mg/15ml Clindamycin Phosphate NF (Topical)) guaifenesin syrp or 100 F QL(240 ml per mg/5ml, 200 mg/10ml fill retail) clindamycin phosphate F QL(60 ml per Misc. Respiratory Inhalants (topical) lotn 1 % fill retail) clindamycin phosphate sodium chloride (inhalant) F QL(240 ml per F aers 0.9 % fill retail) (topical) soln 1 % DESQUAM-X WASH LIQD RX/OTC sodium chloride (inhalant) F NF nebu 0.9 %, 3 %, 10 % (Use Benzoyl Peroxide) ERYGEL GEL (Use NF QL(60 gm per Mucolytics Erythromycin (Acne Aid)) fill retail) acetylcysteine soln in 10 F erythromycin (acne aid) gel F QL(60 gm per %, 20 % 2 % fill retail) DERMATOLOGICALS - Drugs to Treat Skin erythromycin (acne aid) F Conditions soln 2 % Acne Products QL(2 ea daily); isotretinoin caps or 10 mg, F AL(At least 12 ACNE MEDICATION 10 F 20 mg, 40 mg LOTN yrs old) KLARON LOTN (Use QL(120 ml per ACNE MEDICATION 5 F LOTN Sulfacetamide Sodium NF fill retail) (Acne)) BENZAC AC WASH LIQD NF RX/OTC (Use Benzoyl Peroxide) PANOXYL-4 CREAMY WASH LIQD (Use Benzoyl NF benzoyl peroxide bar ex 10 F Peroxide) % QL(45 gm per BENZOYL PEROXIDE F RETIN-A CREA (Use NF fill retail); CLEANSER LOTN 6 % Tretinoin) AL(Up to 35 yrs benzoyl peroxide gel ex 10 F RX/OTC old ) %

Louisiana Healthcare Connections Updated April 1, 2019

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(45 gm per QL(60 gm per mupirocin oint ex 2 % F RETIN-A GEL (Use NF fill retail); fill retail) Tretinoin) AL(Up to 35 yrs neomycin-bacitracin- F QL(454 gm per old ) polymyxin oint fill retail) SODIUM QL(60 gm per neomycin-polymyxin w/ QL(30 gm per SULFACETAMIDE/SULFU F fill retail) pramoxine crea F fill retail) R LOTN 5%-10% 10000unit/gm-3.5mg/gm- SODIUM QL(30 gm per 10mg/gm SULFACETAMIDE/SULFU F fill retail) NEOSPORIN ORIGINAL QL(454 gm per R SUSP 5%-10% OINT (Use Neomycin- NF fill retail) sulfacetamide sodium F QL(120 ml per Bacitracin-Polymyxin) (acne) lotn 10 % fill retail) NEOSPORIN PLUS PAIN QL(30 gm per QL(45 gm per RELIEF MAXIMUM fill retail) NF tretinoin crea ex 0.025 %, F fill retail); STRENGTH CREA (Use 0.05 %, 0.1 % AL(Up to 35 yrs Neomycin-Polymyxin w/ old ) Pramoxine) QL(45 gm per Antifungals - Topical tretinoin gel ex 0.025 %, F fill retail); QL(90 gm per 0.01 % AL(Up to 35 yrs clotrimazole (topical) crea 1 F fill retail); old ) % RX/OTC Anti-inflammatory Agents - Topical QL(60 ml per QL(6.68 gm clotrimazole (topical) soln 1 F fill retail); diclofenac sodium (topical) F % gel 1 % daily) RX/OTC VOLTAREN GEL (Use QL(6.68 gm clotrimazole w/ QL(45 gm per Diclofenac Sodium NF daily) betamethasone crea 1%- F fill retail) (Topical)) 0.05% Antibiotics - Topical clotrimazole w/ QL(30 ml per betamethasone lotn 1%- F fill retail) BACIGUENT OINT (Use NF QL(30 gm per 0.05% Bacitracin (Topical)) fill retail) QL(90 gm per bacitracin (topical) oint 500 QL(30 gm per econazole nitrate crea ex 1 F F % fill retail) unit/gm fill retail) QL(60 gm per bacitracin zinc oint ex 500 QL(30 gm per ketoconazole (topical) crea F F fill retail) unit/gm fill retail) QL(120 ml per BACTROBAN CREA (Use QL(30 gm per ketoconazole (topical) F sham fill retail) Mupirocin Calcium NF fill retail) (Topical)) LAMISIL AT CREA (Use NF QL(42 gm per Terbinafine HCl (Topical)) fill retail) CENTANY OINT 2 % F QL(60 gm per fill retail) LAMISIL AT JOCK QL(42 gm per NF QL(30 gm per CREA (Use Terbinafine fill retail) gentamicin sulfate (topical) F HCl (Topical)) crea 0.1 % fill retail) gentamicin sulfate (topical) QL(30 gm per LOTRIMIN AF CREA 1 % QL(90 gm per F (Use Clotrimazole NF fill retail); oint 0.1 % fill retail) (Topical)) RX/OTC mupirocin calcium (topical) QL(30 gm per F LOTRIMIN AF FOR HER QL(90 gm per crea 2 % fill retail) CREA (Use Clotrimazole NF fill retail); MUPIROCIN CREA EX 2 F QL(30 gm per (Topical)) RX/OTC % fill retail)

Louisiana Healthcare Connections Updated April 1, 2019

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOTRIMIN AF JOCK ITCH QL(90 gm per FLUOROURACIL CREA F QL(30 gm per CREA (Use Clotrimazole NF fill retail); EX 0.5 % fill retail) (Topical)) RX/OTC FLUOROURACIL SOLN F LOTRISONE CREA (Use QL(45 gm per EX 2 %, 5 % Clotrimazole w/ NF fill retail) Betamethasone) - Topical camphor & menthol lotn QL(222 ml per MICATIN CREA (Use QL(60 ml per F 0.5%-0.5% fill retail) Miconazole Nitrate NF fill retail) (Topical)) SARNA LOTN (Use NF QL(222 ml per Camphor & Menthol) fill retail) miconazole nitrate (topical) F QL(60 ml per crea 2 % fill retail) Antipsoriatics QL(200 ml per QL(60 gm per NIZORAL A-D SHAM F calcipotriene crea ex 0.005 F fill retail) % fill retail) NIZORAL SHAM (Use NF QL(120 ml per calcipotriene soln ex 0.005 F QL(60 ml per Ketoconazole (Topical)) fill retail) % fill retail) QL(30 gm per DOVONEX CREA ( QL(60 gm per nystatin (topical) crea F Use NF fill retail) Calcipotriene) fill retail) QL(30 gm per DRITHO-CREME HP nystatin (topical) oint F F fill retail) CREA 1 % QL(60 gm per QL(60 gm per nystatin (topical) powd F fill retail) fill retail); tazarotene crea ex F QL(60 gm per AL(Up to 21 yrs nystatin-triamcinolone crea F fill retail) old ) QL(60 gm per QL(100 gm per nystatin-triamcinolone oint F fill retail) F fill retail); TAZORAC CREA 0.05 % AL(Up to 21 yrs terbinafine hcl (topical) F QL(42 gm per old ) crea 1 % fill retail) QL(60 gm per TINACTIN CREA (Use QL(30 gm per NF TAZORAC CREA 0.1 % NF fill retail); Tolnaftate) fill retail) (Use Tazarotene) AL(Up to 21 yrs TINACTIN JOCK ITCH NF QL(30 gm per old ) CREA (Use Tolnaftate) fill retail) QL(3.3 gm QL(30 gm per TAZORAC GEL 0.05 %, F tolnaftate crea ex 1 % F 0.1 % daily); AL(Up to fill retail) 21 yrs old ) Antihistamines-Topical Antiseborrheic Products diphenhydramine hcl F HEAD & SHOULDERS (topical) crea 2 % 2IN1 CLASSIC NF ITCH RELIEF CREA 2 % F CLEAN/NORMAL SHAM (Use Pyrithione Zinc) Antineoplastic or Premalignant Lesion Agents - HEAD & SHOULDERS CLASSICCLEAN/NORMAL CARAC CREA F QL(30 gm per NF fill retail) SHAM (Use Pyrithione Zinc) EFUDEX CREA (Use NF Fluorouracil (Topical)) HEAD & SHOULDERS DRY SCALP 2 IN 1 SHAM NF fluorouracil (topical) crea F (Use Pyrithione Zinc)

Louisiana Healthcare Connections Updated April 1, 2019

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OVACE PLUS WASH LIQD QL(480 ml per betamethasone QL(50 gm per (Use Sulfacetamide NF fill retail) dipropionate augmented F fill retail) Sodium) crea 0.05 % OVACE WASH LIQD (Use NF QL(480 ml per betamethasone valerate F QL(15 gm per Sulfacetamide Sodium) fill retail) crea ex 0.1 % fill retail) pyrithione zinc sham 1 % F betamethasone valerate F QL(60 ml per lotn ex 0.1 % fill retail) selenium sulfide lotn ex 1 QL(240 ml per F betamethasone valerate F QL(45 gm per % fill retail) oint ex 0.1 % fill retail) selenium sulfide lotn ex 2.5 QL(120 ml per F clobetasol propionate crea F QL(60 gm per % fill retail) ex 0.05 % fill retail) selenium sulfide sham ex 1 QL(240 ml per F clobetasol propionate F QL(60 gm per % fill retail) emollient base crea 0.05 % fill retail) SELSUN BLUE DAILY QL(240 ml per clobetasol propionate gel F QL(60 gm per LOTN (Use Selenium NF fill retail) ex 0.05 % fill retail) Sulfide) clobetasol propionate oint F QL(60 gm per SELSUN BLUE LOTN (Use NF QL(240 ml per ex 0.05 % fill retail) Selenium Sulfide) fill retail) clobetasol propionate soln F QL(50 ml per SELSUN BLUE QL(240 ml per ex 0.05 % fill retail) MEDICATED LOTN (Use NF fill retail) DERMATOP CREA (Use NF QL(60 gm per Selenium Sulfide) Prednicarbate) fill retail) SELSUN BLUE QL(240 ml per DERMATOP OINT (Use NF QL(60 gm per MOISTURIZING LOTN NF fill retail) Prednicarbate) fill retail) (Use Selenium Sulfide) desonide crea ex 0.05 % F QL(2 gm daily) sulfacetamide sodium liqd F QL(480 ml per ex 10 % fill retail) desonide oint ex 0.05 % F QL(2 gm daily) Antivirals - Topical QL(5 gm per fill DESOWEN CREA (Use QL(2 gm daily) acyclovir topical crea 5 % F NF retail) Desonide) QL(30 gm per desoximetasone crea ex QL(105 gm per acyclovir topical oint 5 % F F fill retail) 0.05 % fill retail) DIFLORASONE QL(60 gm per ZOVIRAX CREA EX 5 % NF QL(5 gm per fill F (Use Acyclovir Topical) retail) DIACETATE CREA fill retail) QL(60 gm per ZOVIRAX OINT EX 5 % NF QL(30 gm per diflorasone diacetate oint F (Use Acyclovir Topical) fill retail) fill retail) Burn Products DIPROLENE AF CREA QL(50 gm per (Use Betamethasone NF fill retail) SILVADENE CREA (Use NF QL(325 gm per Dipropionate Augmented) Silver Sulfadiazine) fill retail) ELOCON CREA (Use NF QL(50 gm per silver sulfadiazine crea ex F QL(325 gm per Mometasone Furoate) fill retail) 1 % fill retail) ELOCON OINT (Use NF QL(45 gm per Corticosteroids - Topical Mometasone Furoate) fill retail) APEXICON E CREA F QL(60 gm per fill retail) EPIFOAM FOAM 1%-1% F QL(120 gm per betamethasone 1 rtl pack lmt fluocinonide crea ex 0.05 % F dipropionate (topical) crea F amt,30 rtl pack fill retail) 0.05 % lmt day(s), Louisiana Healthcare Connections Updated April 1, 2019

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluocinonide emulsified QL(60 gm per F PSORCON CREA F QL(60 gm per base crea fill retail) fill retail) QL(60 gm per fluocinonide gel ex 0.05 % F TEMOVATE CREA (Use NF QL(60 gm per fill retail) Clobetasol Propionate) fill retail) QL(60 gm per fluocinonide oint ex 0.05 % F TEMOVATE E CREA (Use QL(60 gm per fill retail) Clobetasol Propionate NF fill retail) QL(60 ml per Emollient Base) fluocinonide soln ex 0.05 % F fill retail) TEMOVATE OINT (Use NF QL(60 gm per Clobetasol Propionate) fill retail) fluticasone propionate crea F QL(2 gm daily) ex 0.05 % TOPICORT CREA 0.05 % NF QL(105 gm per (Use Desoximetasone) fill retail) fluticasone propionate oint F QL(60 gm per ex 0.005 % fill retail) triamcinolone acetonide F QL(160 gm per (topical) crea 0.025 % fill retail) hydrocortisone (topical) F QL(30 gm per crea 0.5 %, 2.5 % fill retail) triamcinolone acetonide F QL(90 gm per QL(454 gm per (topical) crea 0.1 % fill retail) hydrocortisone (topical) F fill retail); QL(15 gm per crea 1%, 1 % triamcinolone acetonide F RX/OTC (topical) crea 0.5 % fill retail) hydrocortisone (topical) F QL(120 ml per triamcinolone acetonide QL(60 ml per lotn 1 %, 2.5 % fill retail) (topical) lotn 0.025 %, 0.1 F fill retail) QL(60 gm per % hydrocortisone (topical) F fill retail); QL(80 gm per oint 1 % triamcinolone acetonide RX/OTC (topical) oint 0.025 %, 0.1 F fill retail) % hydrocortisone (topical) F QL(1 gm daily) oint 2.5 % triamcinolone acetonide F QL(15 gm per (topical) oint 0.5 % fill retail) hydrocortisone butyrate F QL(60 ml per soln 0.1 % fill retail) TRIDESILON CREA (Use NF QL(2 gm daily) Desonide) hydrocortisone-aloe vera F QL(60 gm per crea 1% fill retail) Emollient/Keratolytic Agents LOCOID SOLN (Use NF QL(60 ml per QL(210 gm per Hydrocortisone Butyrate) fill retail) urea crea ex 40 % F fill retail); RX/OTC mometasone furoate crea F QL(50 gm per ex 0.1 % fill retail) QL(240 ml per urea lotn ex 40 % F fill retail) mometasone furoate oint F QL(45 gm per ex 0.1 % fill retail) Emollients mometasone furoate soln QL(60 ml per F A + D PERSONAL CARE F ex 0.1 % fill retail) LOTION LOTN MONISTAT SOOTHING QL(454 gm per ALOE AFTERSUN F CARE ITCH RELIEF CREA NF fill retail); LOTION LOTN (Use Hydrocortisone RX/OTC (Topical)) AQUA GLYCOLIC HAND & F BODYLOTION LOTN PREDNICARBATE CREA F QL(60 gm per 0.1 % fill retail) AQUA LACTEN LOTN F QL(60 gm per prednicarbate crea 0.1 % F fill retail) AQUADERM TREATMENT/MOISTURIZ F PREDNICARBATE OINT F QL(60 gm per ER LOTN 0.1 % fill retail)

Louisiana Healthcare Connections Updated April 1, 2019

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AQUAMED LOTN F COCOA BUTTER HAND & F BODYLOTION LOTN AVEENO ACTIVE COCOA BUTTER LOTN F NATURALS DAILY F EX MOISTURIZING BODY CVS DAILY ULTRA F YOGURT LOTN MOISTURELOTION LOTN AVEENO ACTIVE DERMAL THERAPY NATURALS DAILY F EXTRA STRENGTH BODY F MOISTURIZING BODY LOTION LOTN YOGURT/APRICO LOTN DERMAL THERAPY FACE AVEENO DAILY CAREMOISTURIZING F MOISTURIZINGSPF 15 F LOTION LOTN LOTN DERMAL THERAPY FOOT F AVEENO POSITIVELY MASSAGE LOTN AGELESSFIRMING BODY F LOTN DERMAL THERAPY HAND ELBOW & KNEE CREAM F AVEENO POSITIVELY F LOTN RADIANT LOTN DERMAL THERAPY HEEL F AVEENO STRESS RELIEF F CARE LOTN MOISTURIZING LOTN DIABETIDERM HAND & F BETA CARE LOTN F BODY LOTN

CAM LOTN F DIABETIDERM LOTN F

CERAVE AM SPF 30 F EMOLLIA-LOTION LOTN F LOTN emollient lotn 1.25 %, F CERAVE LOTN F EPILYT LOTN F CERAVE PM LOTN F EQL ADVANCED CERAVE SA RENEWING F RECOVERY SKIN CARE F LOTN LOTN CETAPHIL DAILY EQL ULTRA ADVANCE ULTRA F MOISTURIZING DAILY F HYDRATING LOTN LOTION LOTN CETAPHIL DAILY FACIAL F MOISTURIZER LOTN EUCERIN BABY LOTN F CETAPHIL EUCERIN DAILY DERMACONTROL F PROTECTION/SPF 30 F MOISTURIZER/SPF 30 LOTN LOTN EUCERIN INTENSIVE F CETAPHIL F REPAIR LOTN MOISTURIZING LOTN EUCERIN LOTN F CETAPHIL F RESTORADERM LOTN EUCERIN ORIGINAL CLN FACIAL HEALINGSOOTHING F MOISTURIZER F REPAIR LOTN NOURISHING LOTN Louisiana Healthcare Connections Updated April 1, 2019

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EUCERIN PLUS LOTN F KERI ADVANCED 5%-5% MOISTURE THERAPY F EUCERIN LOTN PROFESSIONAL REPAIR F KERI BASIC ESSENTIALS F RICH FEEL LOTN LOTN EUCERIN SMOOTHING KERI NOURISHING SHEA F REPAIRADVANCED F BUTTER LOTN FORMULA LOTN KERI ORIGINAL LOTN F FORMULA 405 F MOISTURIZING LOTN KERI OVERNIGHT LOTN F GNP ADVANCED F RECOVERY LOTN KERI RENEWAL MILK F GOLD BOND MEDICATED BODY LOTN BODYLOTION EXTRA F KERI RENEWAL SKIN F STRENGTH LOTN FIRMING LOTN KERI RENEWAL GOLD BOND MEDICATED F BODYLOTION LOTN STRETCH MARK F GOLD BOND ULTIMATE MINIMIZER LOTN DIABETICS DRY SKIN F KERI SENSITIVE SKIN F RELIEF LOTN LOTN GOLD BOND ULTIMATE LAC-HYDRIN CREA (Use QL(140 gm per DIABETICS' DRY RELIEF F Lactic Acid (Ammonium NF fill retail); LOTN Lactate)) RX/OTC LAC-HYDRIN LOTN (Use QL(255 ml per GOLD BOND ULTIMATE F HEALING LOTN Lactic Acid (Ammonium NF fill retail); Lactate)) RX/OTC GOLD BOND ULTIMATE F LOTN LAC-HYDRIN TWELVE QL(255 ml per LOTN (Use Lactic Acid NF fill retail); GOLD BOND ULTIMATE F OVERNIGHT LOTN (Ammonium Lactate)) RX/OTC GOLD BOND ULTIMATE QL(140 gm per F lactic acid (ammonium F fill retail); PROTECTION LOTN lactate) crea 12 % RX/OTC GOLD BOND ULTIMATE F RESTORING LOTN QL(255 ml per lactic acid (ammonium F fill retail); lactate) lotn 12 % GOLD BOND ULTIMATE RX/OTC SHEERRIBBONS F PEARLRADIANCE LOTN LUBRIDERM ADVANCED F THERAPY LOTN GOLD BOND ULTIMATE SHEERRIBBONS F LUBRIDERM DAILY SILKSOFTNESS LOTN MOISTURE/NORMAL TO F DRY SKIN LOTN GOLD BOND ULTIMATE F SOFTENING LOTN LUBRIDERM DAILY MOISTURESHEA + F GOLD BOND ULTIMATE F CALMING LAVENDER SOOTHING LOTN JASMINE LOTN GRX VITAMIN E LOTN F LUBRIDERM INTENSE F SKIN REPAIR LOTN HYDRAZONE LOTION F LOTN Louisiana Healthcare Connections Updated April 1, 2019

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LUBRIDERM LOTN F RA DAYLOGIC HEALING DRY SKIN THERAPY F LOTN LUBRIDERM MENS 3-IN-1 F LOTN RA RENEWAL DRY SKIN F THERAPY LOTN LUBRIDERM SERIOUSLY F SENSITIVE LOTN RADIAGUARD F LUBRIDERM SKIN ADVANCED LOTN NOURISHINGWITH SHEA F AND COCOA BUTTERS RESTA LITE LOTN F LOTN ROC DEEP WRINKLE F LUBRISOFT LOTN F SERUM LOTN ROSE MILK LOTN F MAXAM LOTN F SKIN REPAIR LOTN F MEDERMA AG HAND & F BODY LOTION LOTN SOOTHE & COOL MOTHERS FRIEND LOTN F MOISTURIZING BODY F LOTION WITH ALOE MSM SKIN LOTION LOTN F LOTN ST IVES SWISS NEUTROGENA BODY FORMULA 24HOUR F LIGHT SESAME F MOISTURE LOTN FORMULA LOTN STUDIO 35 EXTRA NEUTROGENA HEALTHY F MOISTURIZING LOTION F SKIN FACE SPF 15 LOTN LOTN NEUTROGENA THERABETIC SKIN CARE F MOISTURE SENSITIVE F LOTN SKIN LOTN THERAPLEX F NIVEA EXTRA ENRICHED F HYDROLOTION LOTN LOTION LOTN VANICREAM LITE LOTN F NIVEA EXTRA ENRICHED F LOTN WIBI LOTN F NIVEA GENTLE BODY F EXFOLIATOR LOTN Immunomodulating Agents - Topical NIVEA LIGHT LOTN F ALDARA CREA (Use NF QL(48 ea per Imiquimod) 180 days retail) NIVEA LOTN F QL(48 ea per imiquimod crea ex 5 % F 180 days retail) NIVEA ORIGINAL LOTN F Immunosuppressive Agents - Topical NIVEA ORIGINAL F PA; QL(30 gm MOISTURE LOTN ELIDEL CREA (Use NF per fill retail); Pimecrolimus) AL(At least 2 NIVEA VISAGE LOTN F yrs old) PA; QL(30 gm NUTRADERM ADVANCED F FORMULA LOTN F per fill retail); pimecrolimus crea 1 % AL(At least 2 NUTRADERM LOTN 2.5%- F 2.5%-2.5%-2.5%-2.5% yrs old) Louisiana Healthcare Connections Updated April 1, 2019

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(30 gm CASTIVA WARMING F QL(120 gm per PROTOPIC OINT 0.03 % NF per fill retail); LOTN fill retail) (Use Tacrolimus (Topical)) AL(At least 2 QL(60 gm per dibucaine oint ex F yrs old) fill retail) PA; QL(30 gm QL(45 gm per lidocaine crea ex 4 % F PROTOPIC OINT 0.1 % NF per fill retail); fill retail) (Use Tacrolimus (Topical)) AL(At least 16 yrs old) QL(90 gm per lidocaine hcl crea ex 3 % F fill retail); PA; QL(30 gm RX/OTC tacrolimus (topical) oint per fill retail); F QL(45 ml per 0.03 % AL(At least 2 lidocaine hcl crea ex 4 % F yrs old) fill retail) PA; QL(30 gm QL(120 ml per lidocaine hcl gel ex 2 % F fill retail); tacrolimus (topical) oint 0.1 F per fill retail); % AL(At least 16 RX/OTC PA; QL(30 ea yrs old) lidocaine ptch ex 5 % F per fill retail) Keratolytic/Antimitotic Agents lidocaine-prilocaine crea F QL(30 gm per CONDYLOX SOLN (Use NF QL(4 ml per fill 2.5%-2.5% fill retail) Podofilox) retail) LIDODERM PTCH (Use NF PA; QL(30 ea DERMAREST PSORIASIS F QL(30 ml per Lidocaine) per fill retail) GEL 3 % fill retail) LMX 4 CREA (Use NF QL(45 gm per KERALYT GEL 3 % F QL(30 ml per Lidocaine) fill retail) fill retail) PREDATOR CREA (Use NF QL(45 ml per KERALYT GEL 6 % (Use NF QL(240 gm per Lidocaine HCl) fill retail) Salicylic Acid) fill retail) QL(4 ml per fill Misc. Topical podofilox soln ex 0.5 % F retail) AMEDA TRIPLE ZERO F QL(240 gm per LANOLIN CREA salicylic acid gel ex 6 % F fill retail) DRYSOL SOLN 20 % F QL(60 ml per fill retail) Local Anesthetics - Topical lanolin (topical) crea F ARTHRITIS PAIN F QL(60 gm per RELIEVING CREA fill retail) QL(170 gm per CAPSAGEL EXTRA QL(60 gm per F F fill retail,340 gm STRENGTH GEL fill retail) OFF DEEP WOODS AERO per 30 days QL(60 gm per retail) CAPSAGEL GEL F fill retail) QL(113 gm per OFF DEEP WOODS DRY fill retail,226 gm CAPSAGEL MAXIMUM F QL(30 gm per F STRENGTH GEL fill retail) AERO per 30 days retail) capsaicin crea ex 0.025 % F QL(170 gm per QL(60 gm per ULTRATHON INSECT fill retail,340 gm capsaicin crea ex 0.1 % F F fill retail) REPELLENT 8 AERO per 30 days retail) CAPZASIN-HP CREA (Use NF QL(60 gm per Capsaicin) fill retail) QL(57 gm per QL(43 gm per ULTRATHON INSECT F fill retail,114 gm CAPZASIN-P CREA F REPELLENT LOTN per 30 days fill retail) retail) Louisiana Healthcare Connections Updated April 1, 2019

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(60 gm per QL(60 gm per zinc oxide (topical) oint 20 F permethrin crea ex 5 % F % fill retail) fill retail) Pigmenting-Depigmenting Agents permethrin liqd ex 1 % F hydroquinone crea ex 4 % F QL(120 ml per permethrin lotn ex 1 % F fill retail) Rosacea Agents pyrethrins-piperonyl F QL(240 ml per METROCREAM CREA QL(45 gm per butoxide liqd 0.33%-4% fill retail) (Use Metronidazole NF fill retail) (Topical)) pyrethrins-piperonyl butoxide liqd 1.2%-0.3%- F METROLOTION LOTN 0.3%-2.4%-3% (Use Metronidazole NF (Topical)) pyrethrins-piperonyl butoxide sham 0.3%- F metronidazole (topical) F QL(45 gm per 0.33%-4%, 0.33%-4% crea 0.75 % fill retail) pyrethrins-piperonyl F QL(240 ml per metronidazole (topical) gel F QL(45 gm per butoxide sham 0.33%-4% fill retail) 0.75 % fill retail) pyrethrins-piperonyl metronidazole (topical) lotn F butoxide-permethrin-nit F 0.75 % remover kit 0.5%-0.33%- Scabicides & Pediculicides 4% QL(60 gm per RA LICE SOLUTION KIT crotamiton lotn ex 10 % F F fill retail) KIT RID AERO XX 0.5 % (Use ELIMITE CREA (Use NF QL(60 gm per NF Permethrin) fill retail) Permethrin) RID COMPLETE LICE EURAX CREA 10 % F QL(60 gm per fill retail) ELIMINATION KIT (Use Pyrethrins-Piperonyl NF EURAX LOTN (Use NF QL(60 gm per ) Butoxide-Permethrin-Nit Crotamiton fill retail) Remover) KLOUT SHAM F RID ESSENTIAL LICE F ELIMINATION KIT KIT LICEMD GEL F RID LIQD EX 0.33%-4% QL(240 ml per (Use Pyrethrins-Piperonyl NF fill retail) LICIDE TREATMENT KIT F KIT Butoxide) QL(59 ml per SCHOOLTIME SHAMPOO malathion lotn 0.5 % F F fill retail) SHAM QL(120 ml per QL(120 ml per fill retail,240 ml F fill retail,240 ml SPINOSAD SUSP F NATROBA SUSP per 30 days per 30 days retail) retail) Tar Products NIX CREME RINSE LIQD NF (Use Permethrin) coal tar extract sham 0.5 % F OVIDE LOTN (Use NF QL(59 ml per Malathion) fill retail) DHS TAR GEL SHAM (Use NF Coal Tar Extract) permethrin aero xx 0.5 % F DHS TAR SHAM (Use Coal NF Tar Extract)

Louisiana Healthcare Connections Updated April 1, 2019

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEUTROGENA T/GEL TRUETEST BLOOD F QL(5 ea daily); SHAM (Use Coal Tar NF GLUCOSE TEST STRP RX/OTC Extract) TRUETEST STRIPS STRP F QL(5 ea daily); NEUTROGENA T/GEL RX/OTC STUBBORN ITCH NF TRUETRACK BLOOD F QL(5 ea daily); CONTROL SHAM (Use GLUCOSE TEST STRP RX/OTC Coal Tar Extract) QL(5 ea daily); TRUETRACK TEST STRP F DIAGNOSTIC PRODUCTS RX/OTC DIGESTIVE AIDS - Drugs to Treat Low Digestive Diagnostic Drugs Enzymes GLUCAGEN DIAGNOSTIC F SOLR Digestive Enzymes Diagnostic Tests CREON CPEP F CHEK-STIX CONTROL F PANCREAZE CPEP STRP 14200UNIT-4200UNIT- 2 packages / 24600UNIT, 35500UNIT- 30 CHEMSTRIP-K STRP F 10500UNIT-61500UNIT, F days;QL(6.67 54700UNIT-21000UNIT- ea daily) 83900UNIT, 56800UNIT- IGLUCOSE BLOOD RX/OTC 16800UNIT-98400UNIT GLUCOSE TEST STRIPS F DIURETICS - Drugs to Treat Heart, Circulation STRP Conditions and Blood Pressure 2 packages / 30 Carbonic Anhydrase Inhibitors KETOCARE STRP F days;QL(6.67 acetazolamide cp12 or 500 F ea daily) mg acetazolamide tabs or 125 KETONE TEST STRIPS F F STRP mg, 250 mg DIAMOX CP12 (Use NF KETOSTIX STRP F Acetazolamide) NOVA MAX PLUS QL(30 ea per methazolamide tabs or 25 F KETONE TESTSTRIPS F fill retail) mg, 50 mg STRP NEPTAZANE TABS (Use NF Methazolamide) PRECISION XTRA STRP F QL(30 ea per VI fill retail) Diuretic Combinations PTS PANELS KETONE F QL(30 ea per ALDACTAZIDE TABS TEST STRP fill retail) 25MG-25MG (Use NF TRUE METRIX BLOOD QL(5 ea daily); Spironolactone & GLUCOSETEST STRIPS F RX/OTC Hydrochlorothiazide) STRP amiloride & F QL(1 ea daily) TRUE METRIX SELF QL(5 ea daily); hydrochlorothiazide tabs MONITORING BLOOD F RX/OTC DYAZIDE CAPS (Use QL(1 ea daily) GLUCOSE STRIPS STRP Triamterene & NF TRUETEST BLOOD QL(5 ea daily); Hydrochlorothiazide) GLUCOSE TEST STRIPS F RX/OTC MAXZIDE TABS (Use QL(1 ea daily) STRP Triamterene & NF Hydrochlorothiazide) Louisiana Healthcare Connections Updated April 1, 2019

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAXZIDE-25 TABS (Use hydrochlorothiazide caps or F Triamterene & NF 12.5 mg Hydrochlorothiazide) hydrochlorothiazide tabs or F spironolactone & 25 mg, 50 mg, 12.5 mg hydrochlorothiazide tabs F 25mg-25mg indapamide tabs F triamterene & QL(1 ea daily) metolazone tabs F hydrochlorothiazide caps F 37.5mg-25mg MICROZIDE CAPS (Use NF triamterene & Hydrochlorothiazide) hydrochlorothiazide tabs F ENDOCRINE AND METABOLIC AGENTS - 37.5mg-25mg MISC. - Drugs to Treat Bone Disease and triamterene & QL(1 ea daily) Regulate Hormones hydrochlorothiazide tabs F 75mg-50mg Bone Density Regulators PA; QL(4 ea Loop Diuretics ACTONEL TABS 35 MG NF per 28 days (Use Risedronate Sodium) bumetanide tabs or 0.5 mg, F retail) 1 mg, 2 mg ACTONEL TABS 5 MG, 30 PA; QL(1 ea BUMEX TABS (Use NF MG (Use Risedronate NF daily) Bumetanide) Sodium) DEMADEX TABS (Use QL(1 ea daily) NF ALENDRONATE SODIUM F QL(10.8 ml Torsemide) SOLN 70 MG/75ML daily) furosemide soln or 10 F alendronate sodium tabs F QL(0.15 ea mg/ml 35 mg, 70 mg daily) FUROSEMIDE SOLN OR 8 F ALENDRONATE SODIUM F QL(1 ea daily) MG/ML TABS 40 MG furosemide tabs or 20 mg, F alendronate sodium tabs 5 F QL(1 ea daily) 40 mg, 80 mg mg, 10 mg LASIX TABS (Use QL(4 ml per 30 NF calcitonin (salmon) soln F Furosemide) days retail) QL(1 ea daily) torsemide tabs F FOSAMAX TABS (Use NF QL(0.15 ea Alendronate Sodium) daily) Potassium Sparing Diuretics MIACALCIN SOLN IJ 200 F QL(2 ml per 30 UNIT/ML days retail) ALDACTONE TABS (Use NF Spironolactone) MIACALCIN SOLN NA 200 QL(4 ml per 30 QL(4 ea daily) UNIT/ACT (Use Calcitonin NF days retail) amiloride hcl tabs or 5 mg F (Salmon)) spironolactone tabs or 25 F PA; QL(4 ea mg, 50 mg, 100 mg risedronate sodium tabs 35 F per 28 days mg retail) Thiazides and Thiazide-Like Diuretics risedronate sodium tabs 5 PA; QL(1 ea CHLOROTHIAZIDE TABS F QL(2 ea daily) F 250 MG mg, 30 mg daily) Growth Hormones chlorothiazide tabs 500 mg F QL(4 ea daily) NORDITROPIN FLEXPRO PA chlorthalidone tabs F SOLN 30 MG/3ML, 10 F MG/1.5ML, 15 MG/1.5ML

Louisiana Healthcare Connections Updated April 1, 2019

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NORDITROPIN FLEXPRO F PA; SP JYNARQUE TBPK F PA SOLN 5 MG/1.5ML OMNITROPE SOLN 10 F PA ESTROGENS - Hormone Replacement/Modifying MG/1.5ML Drugs Hormone Receptor Modulators Estrogen Combinations EVISTA TABS (Use VC QL(1 ea daily) ACTIVELLA TABS (Use QL(1 ea daily) Raloxifene HCl) Estradiol & Norethindrone NF Acetate) raloxifene hcl tabs VC QL(1 ea daily) QL(8 ea per 28 COMBIPATCH PTTW F Metabolic Modifiers days retail) estradiol & norethindrone QL(1 ea daily) calcitriol caps or 0.25 mcg, F F 0.5 mcg acetate tabs CARNITOR SF SOLN (Use QL(30 ml daily) FEMHRT LOW DOSE Levocarnitine (Metabolic NF TABS (Use Norethindrone NF Modifiers)) Acetate-Ethinyl Estradiol) CARNITOR SOLN OR 1 QL(30 ml daily) norethindrone acetate- F ethinyl estradiol tabs GM/10ML (Use NF Levocarnitine (Metabolic PREMPHASE TABS F QL(1 ea daily) Modifiers)) CARNITOR TABS OR 330 QL(3 ea daily); PREMPRO TABS F QL(1 ea daily) MG (Use Levocarnitine NF RX/OTC (Metabolic Modifiers)) Estrogens levocarnitine (metabolic QL(30 ml daily) F ALORA PTTW F QL(0.29 ea modifiers) soln 1 gm/10ml daily) levocarnitine (metabolic QL(3 ea daily); F CLIMARA PTWK (Use NF QL(12 ea per modifiers) tabs 330 mg RX/OTC Estradiol) 84 days retail) ROCALTROL CAPS 0.25 ESTRACE TABS OR 0.5 MCG, 0.5 MCG (Use NF MG, 1 MG, 2 MG (Use NF Calcitriol) Estradiol) Posterior Pituitary Hormones estradiol pttw td 0.0375 QL(0.29 ea mg/24hr, 0.025 mg/24hr, daily) DDAVP SOLN NA 0.01 % F QL(5 ml per fill F retail) 0.075 mg/24hr, 0.05 mg/24hr, 0.1 mg/24hr DDAVP SOLN NA 0.01 % QL(5 ml per fill (Use Desmopressin NF retail) estradiol ptwk td 0.025 QL(12 ea per Acetate Spray) mg/24hr, 0.075 mg/24hr, 84 days retail) 0.05 mg/24hr, 0.06 F DDAVP TABS OR 0.1 MG, QL(6 ea daily) mg/24hr, 0.1 mg/24hr, 37.5 0.2 MG (Use NF mcg/24hr Desmopressin Acetate) estradiol tabs or 0.5 mg, 1 F desmopressin acetate F QL(5 ml per fill mg, 2 mg spray refrigerated soln retail) ESTROPIPATE TABS 0.75 F QL(1 ea daily) desmopressin acetate F QL(5 ml per fill MG, 1.5 MG spray soln 0.01 % retail) ESTROPIPATE TABS 3 F QL(2 ea daily) desmopressin acetate tabs F QL(6 ea daily) MG or 0.1 mg, 0.2 mg MINIVELLE PTTW (Use NF QL(0.29 ea Vasopressin Receptor Antagonists Estradiol) daily)

Louisiana Healthcare Connections Updated April 1, 2019

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMARIN TABS OR QL(1 ea daily) URSO 250 TABS (Use NF QL(7 ea daily) 0.625 MG, 0.45 MG, 0.3 F Ursodiol) MG, 0.9 MG, 1.25 MG ursodiol caps or 300 mg F QL(3 ea daily) VIVELLE-DOT PTTW (Use NF QL(0.29 ea Estradiol) daily) ursodiol tabs or 250 mg F QL(7 ea daily) FLUOROQUINOLONES - Drugs to Treat Bacterial Infections Gastrointestinal Stimulants Fluoroquinolones hcl soln or F 5 mg/5ml, 10 mg/10ml CIPRO TABS 250 MG, 500 MG (Use NF metoclopramide hcl tabs or F HCl) 5 mg, 10 mg REGLAN TABS (Use CIPROFLOXACIN HCL F QL(6 ea per fill NF TABS OR 100 MG retail) Metoclopramide HCl) Inflammatory Bowel Agents ciprofloxacin hcl tabs or F 250 mg, 500 mg, 750 mg AZULFIDINE EN-TABS NF TBEC (Use Sulfasalazine) LEVAQUIN TABS (Use NF QL(1 ea daily) Levofloxacin) AZULFIDINE TABS (Use NF Sulfasalazine) levofloxacin tabs or 250 F QL(1 ea daily) mg, 500 mg, 750 mg balsalazide disodium caps F QL(9 ea daily) 750 mg OFLOXACIN TABS 300 F QL(56 ea per MG fill retail) COLAZAL CAPS (Use NF QL(9 ea daily) QL(56 ea per Balsalazide Disodium) ofloxacin tabs 400 mg F fill retail) LIALDA TBEC (Use NF GASTROINTESTINAL AGENTS - MISC. - Mesalamine) Miscellaneous Gastrointestinal Drugs mesalamine enem re 4 gm F QL(60 ml daily) Antiflatulents mesalamine tbec or 1.2 gm F GAS-X CHEW (Use NF Simethicone) mesalamine tbec or 800 F QL(3 ea daily) MYLICON INFANTS GAS QL(30 ml per mg RELIEF SUSP (Use NF fill retail) Simethicone) SFROWASA ENEM F MYLICON SUSP (Use QL(30 ml per NF sulfasalazine tabs or 500 F Simethicone) fill retail) mg simethicone chew or 80 mg F sulfasalazine tbec or 500 F mg simethicone liqd or 20 F QL(30 ml per mg/0.3ml, 40 mg/0.6ml fill retail) Intestinal Acidifiers lactulose (encephalopathy) simethicone susp or 20 F QL(30 ml per F mg/0.3ml, 40 mg/0.6ml fill retail) soln Bile Acid Synthesis Disorder Agents Phosphate Binder Agents calcium acetate (phosphate CHOLBAM CAPS F PA; QL(5 ea F daily) binder) caps 667 mg Gallstone Solubilizing Agents GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive ACTIGALL CAPS (Use NF QL(3 ea daily) Organs and Urinary System Ursodiol) Louisiana Healthcare Connections Updated April 1, 2019

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Alkalinizers F QL(6 ea per fill colchicine tabs or 0.6 mg retail) potassium citrate QL(6 ea per fill (alkalinizer) tbcr 540 mg, F COLCRYS TABS 0.6 MG F 1080 mg retail) ZYLOPRIM TABS (Use potassium citrate-citric acid F NF pack 3300mg-1002mg Allopurinol) sodium citrate & citric acid F RX/OTC Uricosurics soln probenecid tabs F UROCIT-K 10 TBCR (Use Potassium Citrate NF HEMATOLOGICAL AGENTS - MISC. - Drugs to (Alkalinizer)) Treat Blood Disorders UROCIT-K 5 TBCR (Use Potassium Citrate NF Complement Inhibitors (Alkalinizer)) SOLIRIS SOLN F Genitourinary Irrigants Hematorheologic Agents sodium chloride (gu F irrigant) soln pentoxifylline tbcr or F Agents Platelet Aggregation Inhibitors QL(3 ea daily) ELMIRON CAPS F BRILINTA TABS F QL(2 ea daily) Prostatic Hypertrophy Agents cilostazol tabs F QL(2 ea daily) finasteride tabs or 5 mg F QL(1 ea daily) clopidogrel bisulfate tabs F QL(1 ea daily) 75 mg FLOMAX CAPS (Use NF QL(2 ea daily) HCl) dipyridamole tabs or 25 F mg, 50 mg, 75 mg PROSCAR TABS (Use NF QL(1 ea daily) Finasteride) EFFIENT TABS (Use NF QL(1 ea daily) tamsulosin hcl caps 0.4 mg F QL(2 ea daily) Prasugrel HCl) PLAVIX TABS 75 MG (Use NF QL(1 ea daily) Urinary Analgesics Clopidogrel Bisulfate) QL(1 ea daily) phenazopyridine hcl tabs or F prasugrel hcl tabs F 100 mg, 200 mg HEMATOPOIETIC AGENTS - Drugs to Treat PYRIDIUM TABS (Use NF Phenazopyridine HCl) Blood Disorders GOUT AGENTS - Drugs to Treat Gout Agents for Sickle Cell Anemia Gout Agent Combinations DROXIA CAPS F colchicine w/ probenecid F Cobalamins tabs cyanocobalamin soln ij F Gout Agents 1000 mcg/ml allopurinol tabs or 100 mg, F Folic Acid/Folates 300 mg folic acid tabs or 1 mg F RX/OTC COLCHICINE TABS OR F QL(6 ea per fill 0.6 MG retail)

Louisiana Healthcare Connections Updated April 1, 2019

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits folic acid tabs or 400 mcg, VC QL(1 ea daily) QL(30 ea per 5 800 mcg LYSTEDA TABS (Use NF days retail); Tranexamic Acid) AL(At least 12 Hematopoietic Growth Factors yrs old) ZARXIO SOSY F PA QL(30 ea per 5 tranexamic acid tabs or 650 F days retail); Hematopoietic Mixtures mg AL(At least 12 ferrous fumarate-fa-b QL(1 ea daily) yrs old) complex-c-zn-mg-mn-cu F //SLEEP DISORDER tabs AGENTS Iron Hypnotics FER-IN-SOL SOLN (Use QL(3.4 ml NF diphenhydramine hcl F Ferrous Sulfate) daily) (sleep) caps 50 mg FERRETTS TABS F QL(2 ea daily) diphenhydramine hcl F QL(1 ea daily) (sleep) tabs 25 mg ferrous fumarate tabs or F QL(2 ea daily) 324 mg diphenhydramine hcl F (sleep) tabs 50 mg ferrous gluconate tabs or F 27 mg, 240 mg succinate F (sleep) tabs 25 mg FERROUS GLUCONATE F TABS OR 324 MG NYTOL MAXIMUM STRENGTH TABS (Use NF ferrous sulfate dried tbcr F Diphenhydramine HCl 160 mg (Sleep)) ferrous sulfate elix or 220 F QL(16 ml daily) UNISOM SLEEPGELS mg/5ml CAPS (Use NF ferrous sulfate soln or 15 F QL(3.4 ml Diphenhydramine HCl mg/ml daily) (Sleep)) ferrous sulfate tabs or 28 F UNISOM SLEEPTABS mg, 65 mg, 325 mg TABS (Use Doxylamine NF Succinate (Sleep)) FERROUS SULFATE F TBEC OR 324 MG Hypnotics ferrous sulfate tbec or 325 F elix or 20 F mg mg/5ml HEMOCYTE TABS (Use QL(2 ea daily) NF phenobarbital soln or 20 F Ferrous Fumarate) mg/5ml IRON CHEWS PEDIATRIC F phenobarbital tabs or 15 CHEW 15 MG mg, 30 mg, 60 mg, 100 mg, F polysaccharide iron F QL(1 ea daily) 16.2 mg, 32.4 mg, 64.8 mg, complex caps 150 mg 97.2 mg HEMOSTATICS - Drugs to Stop Bleeding/Treat Non-Barbiturate Hypnotics Blood Disorders AMBIEN TABS (Use NF QL(1 ea daily) Hemostatics - Systemic Tartrate) QL(1 ea daily) AMICAR TABS 500 MG NF QL(24 ea per HCL CAPS F (Use Aminocaproic Acid) fill retail) HALCION TABS (Use QL(1 ea daily) aminocaproic acid tabs or F QL(24 ea per NF 500 mg fill retail) ) Louisiana Healthcare Connections Updated April 1, 2019

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hcl soln ij 5 METAMUCIL POWD 48.57 NF mg/ml, 2 mg/2ml, 5 % (Use Psyllium) mg/5ml, 10 mg/2ml, 25 F psyllium caps 0.52 gm, 520 F mg/5ml, 10 mg/10ml, 50 mg mg/10ml psyllium powd 30 %, 33 %, QL(1 ea daily); 68 %, 100 %, 28.3 %, 30.9 F RESTORIL CAPS 15 MG, NF 30 MG (Use ) AL(At least 18 %, 58.6 %, 48.57 %, yrs old) ST; Try Laxative Combinations zolpidem COLYTE-FLAVOR PACKS QL(4000 ml per SOLR (Use PEG 3350-KCl- fill retail) SONATA CAPS (Use NF first;QL(1 ea NF ) daily); AL(At Sod Bicarb-Sod Chloride- least 18 yrs Sod Sulfate) old) GOLYTELY SOLR 236GM- QL(4000 ml per QL(1 ea daily); 22.74GM-5.86GM-2.97GM- fill retail) temazepam caps 15 mg, F AL(At least 18 6.74GM (Use PEG 3350- NF 30 mg yrs old) KCl-Sod Bicarb-Sod Chloride-Sod Sulfate) QL(1 ea daily) triazolam tabs F NULYTELY/FLAVOR QL(4000 ml per ST; Try PACKS SOLR (Use PEG fill retail) zolpidem 3350-Potassium Chloride- NF Sod Bicarbonate-Sod F first;QL(1 ea zaleplon caps daily); AL(At Chloride) least 18 yrs peg 3350-kcl-sod bicarb- QL(4000 ml per old) sod chloride-sod sulfate F fill retail) solr zolpidem tartrate tabs or 5 F QL(1 ea daily) mg, 10 mg peg 3350-potassium QL(4000 ml per chloride-sod bicarbonate- F fill retail) LAXATIVES - Bowel Treatment Drugs sod chloride solr 420gm- 11.2gm-1.48gm-5.72gm Bulk Laxatives sennosides-docusate F QL(4 ea daily) calcium polycarbophil tabs F QL(10 ea daily) sodium tabs 625 mg SENOKOT S TABS (Use QL(4 ea daily) EVAC POWD (Use NF Sennosides-Docusate NF Psyllium) Sodium) FIBERCON TABS (Use NF QL(10 ea daily) Calcium Polycarbophil) Laxatives - Miscellaneous KONSYL DAILY FIBER glycerin (laxative) supp 2 F POWD 100 % (Use NF gm Psyllium) GLYCERIN ADULT SUPP NF KONSYL ORIGINAL (Use Glycerin (Laxative)) FORMULADAILY FIBER NF lactulose soln 10 gm/15ml, F POWD (Use Psyllium) 20 gm/30ml MIRALAX PACK (Use RX/OTC METAMUCIL CAPS 0.52 NF NF GM (Use Psyllium) Polyethylene Glycol 3350) METAMUCIL ORIGINAL MIRALAX POWD (Use NF QL(34 gm TEXTURE POWD (Use NF Polyethylene Glycol 3350) daily); RX/OTC Psyllium) polyethylene glycol 3350 F RX/OTC pack or Louisiana Healthcare Connections Updated April 1, 2019

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits polyethylene glycol 3350 F QL(34 gm docusate sodium caps or F powd or daily); RX/OTC 50 mg SORBITOL SOLN OR 70 F docusate sodium liqd or 50 F % mg/5ml, 150 mg/15ml Saline Laxatives docusate sodium syrp or 60 F mg/15ml FLEET ENEMA ENEM NF (Use Sodium Phosphates) docusate sodium tabs or F QL(3 ea daily) 100 mg FLEET ENEMA SIX PACK ENEM (Use Sodium NF MACROLIDES - Drugs to Treat Bacterial Phosphates) Infections FLEET PEDIATRIC ENEM NF Azithromycin (Use Sodium Phosphates) AZITHROMYCIN PACK F magnesium citrate soln or OR 1 GM 1.745gm/30ml, 1.745 F gm/30ml, azithromycin susr or 100 F mg/5ml, 200 mg/5ml magnesium hydroxide susp azithromycin tabs or 250 QL(6 ea per fill or 7.75 %, 400 mg/5ml, F F 1200 mg/15ml, 2400 mg retail) mg/30ml, azithromycin tabs or 500 F QL(4 ea daily) sodium phosphates enem mg re 16gm/133ml-6gm/133ml, azithromycin tabs or 600 F QL(8 ea per 28 mg days retail) 19gm/118ml-7gm/118ml, F 9.5gm/59ml-3.5gm/59ml, ZITHROMAX PACK OR 1 F 19gm/118ml-19gm/118ml- GM 7gm/118ml-7gm/118ml ZITHROMAX SUSR OR Stimulant Laxatives 100 MG/5ML, 200 MG/5ML NF QL(12 ea per (Use Azithromycin) bisacodyl supp re 10 mg F fill retail) ZITHROMAX TABS OR NF QL(6 ea per fill 250 MG (Use Azithromycin) retail) bisacodyl tbec or 5 mg F QL(1 ea daily) ZITHROMAX TABS OR NF QL(4 ea daily) 500 MG (Use Azithromycin) DULCOLAX SUPP RE 10 NF QL(12 ea per MG (Use Bisacodyl) fill retail) ZITHROMAX TABS OR NF QL(8 ea per 28 600 MG (Use Azithromycin) days retail) DULCOLAX TBEC OR 5 NF QL(1 ea daily) MG (Use Bisacodyl) ZITHROMAX TRI-PAK NF QL(4 ea daily) TABS (Use Azithromycin) sennosides tabs 8.6 mg F ZITHROMAX Z-PAK TABS NF QL(6 ea per fill (Use Azithromycin) retail) SENOKOT TABS (Use NF Sennosides) Clarithromycin Surfactant Laxatives BIAXIN TABS (Use NF QL(28 ea per Clarithromycin) fill retail) COLACE CAPS (Use NF QL(3 ea daily) Docusate Sodium) clarithromycin susr or 125 F QL(100 ml per mg/5ml fill retail) COLACE CLEAR CAPS NF (Use Docusate Sodium) CLARITHROMYCIN SUSR F QL(100 ml per OR 125 MG/5ML fill retail) docusate sodium caps or F QL(3 ea daily) 100 mg, 250 mg CLARITHROMYCIN SUSR F QL(200 ml per OR 250 MG/5ML fill retail)

Louisiana Healthcare Connections Updated April 1, 2019

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clarithromycin susr or 250 F QL(200 ml per BAND-AID GAUZE PADS F RX/OTC mg/5ml fill retail) LARGE4" X 4" PADS clarithromycin tabs or 250 F QL(28 ea per BAND-AID GAUZE PADS F mg, 500 mg fill retail) MEDIUM 3" X 3" PADS clarithromycin tb24 or 500 F QL(14 ea per BAND-AID GAUZE PADS F RX/OTC mg fill retail) SMALL2" X 2" PADS Erythromycins BAND-AID MIRASORB RX/OTC GAUZE SPONGES F E.E.S. 400 TABS F LARGE 4" X 4" PADS E.E.S. GRANULES SUSR BIATAIN ADHESIVE RX/OTC (Use Erythromycin NF FOAM DRESSING 4"X4" F Ethylsuccinate) PADS BIATAIN FOAM F RX/OTC ERY-TAB TBEC F DRESSING 4"X4" PADS ERYPED 200 SUSR (Use BIOGUARD GAUZE RX/OTC Erythromycin NF SPONGE 2"X2" 8 PLY F Ethylsuccinate) PADS ERYPED 400 SUSR (Use BIOGUARD GAUZE RX/OTC Erythromycin NF SPONGES 4"X4" 12 PLY F Ethylsuccinate) PADS BORDERED GAUZE RX/OTC ERYTHROCIN STEARATE F F TABS PADS CARRASMART FOAM F RX/OTC erythromycin base cpep F PADS erythromycin base tabs F CARRASMART PADS XX F RX/OTC erythromycin COPA ISLAND RX/OTC ethylsuccinate susr or 200 F BORDERED FOAM F mg/5ml, 400 mg/5ml DRESSING 4"X4" PADS ERYTHROMYCIN COPA PLUS RX/OTC ETHYLSUCCINATE TABS F HYDROPHILIC FOAM F OR 400 MG DRESSING 4"X4" PADS PCE TBEC F COVRSITE COVER F RX/OTC DRESSING PADS MEDICAL DEVICES AND SUPPLIES COVRSITE PLUS RX/OTC COMPOSITE DRESSING F Bandages-Dressings-Tape PADS CURITY ALL PURPOSE RX/OTC ALLEVYN PLUS CAVITY F RX/OTC PADS XX SPONGES 2"X2" 4PLY F PADS ALLEVYN THIN PADS F RX/OTC CURITY ALL PURPOSE F RX/OTC SPONGES 2"X2" PADS AMD FOAM DRESSING F RX/OTC 4"X4" PADS CURITY ALL PURPOSE AMD FOAM RX/OTC SPONGES 3"X3" 4PLY F DRESSING/TOPSHEET F PADS 4"X4" PADS CURITY ALL PURPOSE F RX/OTC SPONGES 4 PLY PADS

Louisiana Healthcare Connections Updated April 1, 2019

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY ALL PURPOSE RX/OTC CURITY GAUZE RX/OTC SPONGES 4"X4" 4PLY F SPONGES 4"X4" 12 PLY F PADS PADS CURITY ALL PURPOSE RX/OTC CURITY GAUZE RX/OTC SPONGES 4"X4" F SPONGES 4"X4" 8 PLY F 4PLY/SOFT POUCH PADS PADS CURITY ALL PURPOSE F RX/OTC CURITY NON-ADHERENT F SPONGES 4"X4" PADS STRIPS 3"X3" PADS CURITY AMD RX/OTC CURITY RX/OTC F ANTIMICROBIALGAUZE F SPONGES/CELLULOSEFI SPONGES 2"X2" 8 PLY LLED/2"X2" PADS PADS CURITY RX/OTC CURITY AMD RX/OTC SPONGES/CELLULOSEFI F ANTIMICROBIALGAUZE F LLED/4"X4" PADS SPONGES 4"X4" 12 PLY CVS GAUZE PAD 3"X3" F PADS PADS CURITY COVER SPONGE RX/OTC F CVS GAUZE PADS 2"X2" F RX/OTC 4"X4" PADS 12-PLY PADS CURITY COVER F CVS GAUZE PADS 4"X4" F RX/OTC SPONGES 3"X3" PADS 12-PLY PADS CURITY COVER F RX/OTC CVS GAUZE PADS RX/OTC SPONGES 4"X4" PADS STERILE 4"X4" 12-PLY F CURITY DRESSING RX/OTC PADS SPONGES 4"X4" 6 PLY F DERMACEA DRAIN F RX/OTC PADS SPONGES 4"X4" PADS CURITY GAUZE PADS F RX/OTC DERMACEA GAUZE RX/OTC 2"X2" 12 PLY PADS SPONGE 2"X2" 12 PLY F CURITY GAUZE PADS F RX/OTC PADS 2"X2" PADS DERMACEA GAUZE RX/OTC CURITY GAUZE PADS F SPONGE 2"X2" 8 PLY F 3"X3" PADS PADS CURITY GAUZE PADS F RX/OTC DERMACEA GAUZE 4"X4" 12 PLY PADS SPONGE 3"X3" 12 PLY F PADS CURITY GAUZE SPONGE F RX/OTC 2"X2" 8 PLY PADS DERMACEA GAUZE SPONGE 3"X3" 8 PLY F CURITY GAUZE SPONGE F RX/OTC 2"X2"12 PLY PADS PADS DERMACEA GAUZE RX/OTC CURITY GAUZE SPONGE F 3"X3" 12 PLY PADS SPONGE 4"X4" 12 PLY F PADS CURITY GAUZE SPONGE F RX/OTC 4"X4" 12 PLY PADS DERMACEA GAUZE RX/OTC SPONGE 4"X4" 16 PLY F CURITY GAUZE SPONGE F RX/OTC PADS 4"X4" 16 PLY PADS DERMACEA GAUZE RX/OTC CURITY GAUZE SPONGE F RX/OTC SPONGE 4"X4" 8 PLY F 4"X4" 8 PLY PADS PADS CURITY GAUZE SPONGE F RX/OTC 4"X4"16 PLY PADS Louisiana Healthcare Connections Updated April 1, 2019

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA I.V. DRAIN F RX/OTC EQL GAUZE PADS F RX/OTC SPONGES 2"X2" PADS 4"X4"/LARGE PADS DERMACEA I.V. DRAIN F RX/OTC EQL GAUZE STERILE F SPONGES 4"X4" PADS PADS 3"X3" PADS DERMACEA I.V. F RX/OTC EXCILON AMD RX/OTC SPONGES 2"X2" PADS ANTIMICROBIALDRAIN F DERMACEA NON-WOVEN RX/OTC SPONGES 4"X4" 6 PLY SPONGES 2"X2" 4 PLY F PADS PADS EXCILON AMD RX/OTC DERMACEA NON-WOVEN ANTIMICROBIALNON- F SPONGES 3"X3" 4 PLY F WOVEN SPONGES 4"X4" PADS 6 PLY PADS DERMACEA NON-WOVEN RX/OTC EXCILON DRAIN F RX/OTC SPONGES 4"X4" 4 PLY F SPONGE 4"X4" PADS PADS EXCILON DRAIN RX/OTC DERMACEA NON-WOVEN RX/OTC SPONGES 4"X4" 6 PLY F SPONGES 4"X4" 6 PLY F PADS PADS EXCILON I.V. SPONGES F RX/OTC DERMACEA TYPE VII RX/OTC 2"X2" 6 PLY PADS F GAUZE 2"X2" 12 PLY GAUZE DRESSING 4"X4" F RX/OTC PADS PADS DERMACEA TYPE VII F RX/OTC GAUZE PADS 2"X2" PADS F RX/OTC GAUZE 2"X2" 8 PLY PADS DERMACEA TYPE VII GAUZE PADS 3"X3" PADS F GAUZE 3"X3" 12 PLY F PADS GAUZE PADS 4"X4" 12 F RX/OTC DERMACEA TYPE VII PLY PADS GAUZE 3"X3" 12PLY F GAUZE PADS 4"X4" PADS F RX/OTC PADS DERMACEA TYPE VII RX/OTC GAUZE SPONGE TYPE RX/OTC GAUZE 4"X4" 12 PLY F VII MEDI-PAK 2"X2" 8PLY F PADS PADS DERMACEA TYPE VII RX/OTC GAUZE SPONGES 4"X4" F RX/OTC GAUZE 4"X4" 16 PLY F 12 PLY PADS PADS GNP STERILE PADS F 3"X3" PADS DERMACEA TYPE VII F RX/OTC GAUZE 4"X4" 8 PLY PADS HM STERILE PADS 2"X2" F RX/OTC DERMACEA X-RAY RX/OTC PADS SPONGES 4"X4" 16 PLY F HM STERILE PADS PADS F RX/OTC PADS DERMALEVIN ADHESIVE RX/OTC HYDROCELL ADHESIVE F RX/OTC FOAMDRESSING 4"X4" F DRESSING 4"X4" PADS PADS HYDROCELL DRESSING F RX/OTC 4"X4" PADS DRYMAX EXTRA PADS F RX/OTC J & J GAUZE 2"X2" 8 PLY F RX/OTC PADS EQL GAUZE PADS F RX/OTC 2"X2"/SMALL PADS

Louisiana Healthcare Connections Updated April 1, 2019

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits J & J GAUZE 4"X4" 12 PLY F RX/OTC POLYMEM NON- F RX/OTC PADS ADHESIVE PAD PADS J & J GAUZE 4"X4" 8 PLY F RX/OTC QC ALL PURPOSE F RX/OTC PADS DRESSINGS4"X4" PADS J & J GAUZE SPONGES F RX/OTC QC BORDER ISLAND F RX/OTC 12-PLY 4" X 4" MISC GAUZE PAD 2"X2" PADS J & J GAUZE SPONGES F RX/OTC QC STERILE PADS PADS F 16-PLY 4" X 4" MISC RX/OTC J & J GAUZE SPONGES F RX/OTC QC STERILE PADS PADS F 8-PLY4" X 4" MISC KENDALL HYDROPHILIC RX/OTC RA ALL PURPOSE F RX/OTC FOAMDRESSING 2"X2" F DRESSINGS4"X4" PADS PADS RA DRESSING SPONGES F RX/OTC KENDALL HYDROPHILIC 4"X4" PADS FOAMDRESSING 3"X3" F RA GAUZE SPONGES F RX/OTC PADS 4"X4" PADS KENDALL HYDROPHILIC RX/OTC RA STERILE PADS 2"X2" F RX/OTC FOAMDRESSING 4"X4" F PADS PADS RA STERILE PADS 3"X3" F KENDALL HYDROPHILIC RX/OTC PADS FOAMPLUS DRESSING F RA STERILE PADS 4"X4" F RX/OTC 2"X2" PADS PADS KENDALL HYDROPHILIC RAY-TEC X-RAY RX/OTC FOAMPLUS DRESSING F DETECTABLESPONGES F 3"X3" PADS 4" X 4" 16 PLY MISC KERLIX SPONGES 4" X 4" F RX/OTC RESTORE CONTACT RX/OTC 12 PLY PADS LAYER/NON-ADHERENT F 2"X2" PADS KERLIX SPONGES 4" X 4" F RX/OTC 16 PLY PADS RESTORE FOAM RX/OTC DRESSING BORDERED F MIRASORB SPONGES 2" F RX/OTC X 2" MISC 4"X4" PADS RESTORE FOAM RX/OTC MIRASORB SPONGES 4" F RX/OTC X 4" MISC DRESSING NON- F BORDERED 4"X4" PADS NU GAUZE 4PLY 4"X4" F RX/OTC PADS RESTORE ODOR RX/OTC NU GAUZE GENERAL- RX/OTC ABSORBING DRESSING F USE SPONGES 4"X4" 4 F 4"X4" PADS PLY MISC RESTORE TRIO RX/OTC ABSORBENT DRESSING F OPTIFOAM PADS F 3"X3" PADS SM GAUZE PADS 2"X2" RX/OTC POLYMEM DRESSING/3" F F X 3" PADS PADS SM GAUZE PADS 3"X3" POLYMEM DRESSING/4" F RX/OTC F X 4" PADS PADS SM GAUZE PADS 4"X4" RX/OTC POLYMEM FILM DOT F RX/OTC F PADS PADS

Louisiana Healthcare Connections Updated April 1, 2019

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SM STERILE PADS 2"X2" F RX/OTC ATLAS LUBRICATED QL(36 ea per PADS CONDOM/SPERMICIDE VC fill retail) DEVI SM STERILE PADS PADS F RX/OTC CLASS ACT LUBRICATED VC QL(36 ea per SOF-WICK 4"X4" PADS F RX/OTC MISC fill retail) DUREX EXTRA VC QL(36 ea per STERILE GAUZE PADS F RX/OTC SENSITIVE DEVI fill retail) 2"X2" PADS ELEXA NATURAL FEEL VC QL(36 ea per STERILE GAUZE PADS F MISC fill retail) 3"X3" PADS ELEXA STIMULATING VC QL(36 ea per STERILE PADS 2"X2" F RX/OTC MISC fill retail) PADS ELEXA ULTRA SENSITIVE VC QL(36 ea per STERILE PADS 3"X3" F MISC fill retail) PADS EXTRA SENSITIVE VC QL(36 ea per STERILE PADS 4"X4" F RX/OTC SPERMICIDAL DEVI fill retail) PADS FANTASY LUBRICATED VC QL(36 ea per SURGICAL GAUZE F RX/OTC MISC fill retail) SPONGE PADS FANTASY QL(36 ea per TEGADERM FOAM F RX/OTC LUBRICATED/SPERMICID VC fill retail) DRESSING 2"X2" PADS E MISC TEGADERM FOAM RX/OTC F HIGH SENSATION VC QL(36 ea per DRESSING 4"X4" PADS SPERMICIDAL DEVI fill retail) RX/OTC THERAGAUZE PADS F INTENSE SENSATION VC QL(36 ea per DEVI fill retail) TOPPER DRESSING RX/OTC F KAMELEON LUBRICATED VC QL(36 ea per SPONGES 4"X4" MISC MISC fill retail) VERSIVA XC 3" X 3" QL(36 ea per KIMONO COLORS DEVI VC FOAM F fill retail) DRESSING/HYDROFIBER TECHNOLOGY PADS KIMONO LUBRICATED VC QL(36 ea per MISC fill retail) VERSIVA XC 4" X 4" RX/OTC KIMONO MICRO THIN QL(36 ea per FOAM F VC DRESSING/HYDROFIBER MISC fill retail) TECHNOLOGY PADS KIMONO MICRO THIN QL(36 ea per PLUS SPERMICIDE VC fill retail) Contraceptives LUBRICATED MISC AIMSCO LUBRICATED VC QL(36 ea per KIMONO PLUS QL(36 ea per MISC fill retail) SPERMICIDE VC fill retail) ATLAS COLORED QL(36 ea per LUBRICATED MISC CONDOM/SPERMICIDE VC fill retail) KIMONO PLUS QL(36 ea per DEVI SPERMICIDE/LUBRICATE VC fill retail) ATLAS COLORED QL(36 ea per D MISC LUBRICATEDCONDOM VC fill retail) KIMONO PS LUBRICATED VC QL(36 ea per DEVI MISC fill retail) ATLAS LUBRICATED VC QL(36 ea per KIMONO PS PLUS QL(36 ea per CONDOM DEVI fill retail) SPERMICIDE/LUBRICATE VC fill retail) D MISC

Louisiana Healthcare Connections Updated April 1, 2019

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO SENSATION VC QL(36 ea per TROJAN SHARED QL(36 ea per LUBRICATED MISC fill retail) SENSATION/LUBRICATE VC fill retail) KIMONO SENSATION QL(36 ea per D DEVI VC PLUS SPERMICIDE fill retail) TROJAN SUPRAS VC QL(36 ea per LUBRICATED MISC SPERMICIDAL DEVI fill retail) QL(36 ea per TROJAN TWISTED QL(36 ea per KIMONO SPECIAL DEVI VC VC fill retail) PLEASURE DEVI fill retail) QL(36 ea per TROJAN ULTRA QL(36 ea per MAXX LUBRICATED MISC VC fill retail) PLEASURE/LUBRICATED VC fill retail) DEVI MAXX PLUS SPERMICIDE VC QL(36 ea per LUBRICATED MISC fill retail) TROJAN VERY QL(36 ea per SENSITIVE LUBRICATED VC fill retail) PREMIUM CONDOMS VC QL(36 ea per LUBRICATED MISC fill retail) MISC REALITY LATEX QL(36 ea per TROJAN VERY QL(36 ea per CONDOMS/LUBRICATED VC fill retail) SENSITIVE SPERMICIDAL VC fill retail) MISC LUBRICANT MISC TROJAN VERY THIN QL(36 ea per REALITY LATEX/ULTRA VC QL(36 ea per VC TEXTURED DEVI fill retail) LUBRICATED MISC fill retail) TROJAN VERY THIN QL(36 ea per REALITY LATEX/ULTRA VC QL(36 ea per THIN DEVI fill retail) SPERMICIDAL VC fill retail) LUBRICANT MISC TROJAN ASSORTMENT VC QL(36 ea per PACK MISC fill retail) TROJAN-ENZ LUBRICANT VC QL(36 ea per MISC fill retail) TROJAN EXTENDED QL(36 ea per PLEASURE/LUBRICATED VC fill retail) TROJAN-ENZ VC QL(36 ea per DEVI LUBRICATED MISC fill retail) TROJAN-ENZ QL(36 ea per TROJAN EXTRA VC QL(36 ea per VC STRENGTH MISC fill retail) W/SPERMICIDAL MISC fill retail) TRUSTEX COLOR QL(36 ea per TROJAN MAGNUM MISC VC QL(36 ea per VC fill retail) CONDOMS + LUBE MISC fill retail) TRUSTEX LUBRICATED QL(36 ea per TROJAN MAGNUM WARM VC QL(36 ea per VC SENSATIONS DEVI fill retail) EXTRALARGE MISC fill retail) TRUSTEX LUBRICATED QL(36 ea per TROJAN MAGNUM XL VC QL(36 ea per VC LUBRICATED DEVI fill retail) EXTRASTRENGTH MISC fill retail) TRUSTEX LUBRICATED QL(36 ea per TROJAN MISC VC QL(36 ea per VC fill retail) MISC fill retail) TROJAN PLEASURE QL(36 ea per TRUSTEX QL(36 ea per MESH/SPERMICIDAL VC fill retail) LUBRICATED/RIBBED/ST VC fill retail) DEVI UDDED MISC TRUSTEX QL(36 ea per TROJAN PLUS MISC VC QL(36 ea per fill retail) LUBRICATED/SPERMICID VC fill retail) E EXTRA LARGE MISC TROJAN REGULAR MISC VC QL(36 ea per fill retail) TRUSTEX QL(36 ea per LUBRICATED/SPERMICID fill retail) QL(36 ea per VC TROJAN RIBBED MISC VC E EXTRA STRENGTH fill retail) MISC TROJAN RIBBED VC QL(36 ea per W/SPERMICIDAL MISC fill retail)

Louisiana Healthcare Connections Updated April 1, 2019

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX QL(36 ea per AQUA LANCE QL(1 ea per LUBRICATED/SPERMICID VC fill retail) ADJUSTABLE LANCING F 180 days retail) E MISC DEVICE DEVI TRUSTEX NATURAL QL(36 ea per 200 / 30 CONDOMS fill retail) AURORA LANCET SUPER F VC THIN30G MISC days;QL(6.67 +LUBE/LUBRICATED ea daily) MISC 200 / 30 TRUSTEX NON- QL(36 ea per AURORA LANCET THIN F VC 23G MISC days;QL(6.67 LUBRICATED MISC fill retail) ea daily) TRUSTEX WITH QL(36 ea per QL(1 ea per AUTO-LANCET MINI MISC F NONOXYNOL- VC fill retail) 180 days retail) 9/RIBBED/STUDDED QL(1 ea per AUTO-LANCET MISC F MISC 180 days retail) TRUSTEX/RIA QL(36 ea per VC AUTOLET IMPRESSION F QL(1 ea per LUBRICATED MISC fill retail) LANCING DEVICE MISC 180 days retail) TRUSTEX/RIA QL(36 ea per AUTOLET LANCING F QL(1 ea per LUBRICATED VC fill retail) DEVICE MISC 180 days retail) SPERMICIDE MISC AUTOLET MINI MISC F QL(1 ea per TRUSTEX/RIA QL(36 ea per 180 days retail) LUBRICATED/SPERMICID VC fill retail) E MISC AUTOLET PLUS MISC F QL(1 ea per 180 days retail) TRUSTEX/RIA NON- VC QL(36 ea per LUBRICATED MISC fill retail) BAYER MICROLET 2 F QL(1 ea per LANCING DEVICE MISC 180 days retail) ULTIMATE FEELING DEVI VC QL(36 ea per fill retail) 200 / 30 BD LANCET ULTRAFINE F 30G MISC days;QL(6.67 Diabetic Supplies ea daily) 1ST TIER UNILET 200 / 30 CARDIOCOM LANCING F QL(1 ea per COMFORTOUCH F days;QL(6.67 DEVICE MISC 180 days retail) LANCETS 28G MISC ea daily) CAREONE ADVANCED F QL(1 ea per 1ST TIER UNILET 200 / 30 LANCINGDEVICE MISC 180 days retail) COMFORTOUCH F days;QL(6.67 200 / 30 LANCETS 30G MISC ea daily) CAREONE LANCET THIN F days;QL(6.67 MISC ADJUSTABLE LANCING F QL(1 ea per ea daily) DEVICE MISC 180 days retail) 200 / 30 200 / CAREONE LANCET F days;QL(6.67 ADVANCED MOBILE F month;QL(6.67 ULTRA THIN MISC LANCET 30G MISC ea daily) ea daily) CARETOUCH LANCING QL(1 ea per ADVOCATE LANCING F QL(1 ea per DEVICEWITH EJECTOR F 180 days retail) DEVICE MISC 180 days retail) MISC ADVOCATE RAPID-SAFE F QL(1 ea per 200 / 30 LANCING DEVICE MISC 180 days retail) CLEANLET LANCETS 28G F days;QL(6.67 MISC 200 / 30 ea daily) AGAMATRIX ULTRA-THIN F days;QL(6.67 LANCETS 33G MISC CLOSERCARE MISC F QL(1 ea per ea daily) 180 days retail) ALTERNATE SITE F QL(1 ea per COMFORT ASSURED 200 / 30 LANCING DEVICE MISC 180 days retail) LANCETS SUPER THIN F days;QL(6.67 28G MISC ea daily) Louisiana Healthcare Connections Updated April 1, 2019

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT LANCETS 200 / 30 200 / 30 F days;QL(6.67 E-Z JECT LANCETS 21G F days;QL(6.67 MISC MISC ea daily) ea daily) 200 / 30 200 / 30 CVS LANCETS 21G MISC F days;QL(6.67 E-Z JECT LANCETS F COLOR MISC days;QL(6.67 ea daily) ea daily) CVS LANCETS MICRO 200 / 30 200 / 30 F days;QL(6.67 E-Z JECT LANCETS MISC F days;QL(6.67 THIN 33G MISC ea daily) ea daily) CVS LANCETS ORIGINAL 200 / 30 200 / 30 F days;QL(6.67 E-Z JECT LANCETS F days;QL(6.67 MISC SUPER THIN 30G MISC ea daily) ea daily) CVS LANCETS THIN 26G 200 / 30 200 / 30 F days;QL(6.67 E-Z JECT LANCETS THIN F days;QL(6.67 MISC 26G MISC ea daily) ea daily) CVS LANCETS ULTRA 200 / 30 200 / 30 F days;QL(6.67 E-ZJECT LANCETS F days;QL(6.67 THIN 30G MISC MICRO-THIN 33G MISC ea daily) ea daily) CVS LANCING DEVICE F QL(1 ea per EASY MINI EJECT F QL(1 ea per MISC 180 days retail) LANCING DEVICE MISC 180 days retail) CVS ULTRA THIN 200 / 30 EASY MINI LANCING F QL(1 ea per F days;QL(6.67 DEVICE MISC 180 days retail) LANCETS MISC ea daily) 200 / 30 DIATHRIVE LANCING QL(1 ea per EASY TOUCH LANCETS F F 26G/PULL-TOP MISC days;QL(6.67 DEVICE MISC 180 days retail) ea daily) DROPLET LANCETS 200 / 30 200 / 30 F days;QL(6.67 EASY TOUCH LANCETS F days;QL(6.67 ULTRA THIN 30G MISC 26G/TWIST MISC ea daily) ea daily) DROPLET LANCING QL(1 ea per F EASY TOUCH LANCETS 200 / 30 DEVICE MISC 180 days retail) F days;QL(6.67 28G/PULL-TOP MISC DRUG MART QL(1 ea per ea daily) ADJUSTABLE LANCING F 180 days retail) EASY TOUCH LANCETS 200 / 30 DEVICE MISC F days;QL(6.67 28G/TWIST MISC 200 / 30 ea daily) DRUG MART LANCETS F days;QL(6.67 THIN MISC EASY TOUCH LANCETS 200 / 30 ea daily) F days;QL(6.67 30G/PULL-TOP MISC DRUG MART UNILET 200 / 30 ea daily) LANCETSSUPER THIN F days;QL(6.67 EASY TOUCH LANCETS 200 / 30 30G MISC ea daily) F days;QL(6.67 30G/TWIST MISC DRUG MART UNILET 200 / 30 ea daily) LANCETSULTRA THIN F days;QL(6.67 EASY TOUCH LANCETS 200 / 30 28G MISC ea daily) F days;QL(6.67 32G/PULL-TOP MISC DRUG MART UNILET 200 per 30 ea daily) MICRO THIN LANCETS F days;QL(6.67 200 / 30 33G MISC ea daily) EASY TOUCH LANCETS F 32G/TWIST MISC days;QL(6.67 ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS 200 / 30 FREDS PHARMACY QL(1 ea per F days;QL(6.67 AUTOLET LANCING F 180 days retail) 33G/TWIST MISC ea daily) DEVICE MISC EASY TOUCH LANCING F QL(1 ea per FREDS PHARMACY 200 / 30 DEVICE/EJECTOR MISC 180 days retail) UNILET LANCETS SUPER F days;QL(6.67 THIN 30G MISC ea daily) EASYTEST II LANCETS 200 / 30 F days;QL(6.67 FREDS PHARMACY 200 / 30 MISC ea daily) UNILET LANCETS ULTRA F days;QL(6.67 THIN 28G MISC ea daily) EASYTEST LANCETS 200 / 30 F days;QL(6.67 GENTEEL LANCING QL(1 ea per MISC ea daily) DEVICE/BUFF BLACK F 180 days retail) MISC EQL COLOR LANCETS 200 / 30 F days;QL(6.67 GENTEEL LANCING QL(1 ea per 21G MISC ea daily) DEVICE/BUTTERFLY F 180 days retail) BLUE MISC EQL COLOR LANCETS 200 / 30 F days;QL(6.67 GENTEEL LANCING QL(1 ea per MICRO THIN 33G MISC ea daily) DEVICE/GLORIOUS F 180 days retail) GOLD MISC EQL SUPER THIN 200 / 30 F days;QL(6.67 GENTEEL LANCING QL(1 ea per LANCETS 30G MISC ea daily) DEVICE/PLAYFUL F 180 days retail) PURPLE MISC EQL THIN LANCETS 26G 200 / 30 F days;QL(6.67 GENTEEL LANCING QL(1 ea per MISC ea daily) DEVICE/PRECIOUS F 180 days retail) EZ SMART BLOOD 200 / 30 PLATINUM MISC GLUCOSE LANCETS F days;QL(6.67 GENTEEL LANCING QL(1 ea per MISC ea daily) DEVICE/PRINCESS PINK F 180 days retail) MISC EZ-LETS LANCETS 23G 200 / 30 F days;QL(6.67 GENTEEL LANCING QL(1 ea per MISC ea daily) DEVICE/STATELY SILVER F 180 days retail) MISC EZ-LETS LANCETS 26G 200 / 30 F days;QL(6.67 GENTEEL LANCING QL(1 ea per SUPER-SOFT MISC ea daily) DEVICE/WILLOWY WHITE F 180 days retail) 200 / 30 MISC EZ-LETS LANCETS 28G F ULTRA-SOFT MISC days;QL(6.67 200 / 30 ea daily) GENTLE-LET GP F LANCETS MISC days;QL(6.67 ea daily) EZ-LETS LANCETS 30G 200 / 30 F days;QL(6.67 GENTLE-LET LANCETS 200 / 30 MISC ea daily) GENERAL PURPOSE F days;QL(6.67 200 / 30 STYLE/FINE POINT MISC ea daily) FORA LANCETS MISC F days;QL(6.67 GENTLE-LET LANCETS 200 / 30 ea daily) GENERAL PURPOSE F days;QL(6.67 STYLE/MEDIUM POINT ea daily) FORA LANCING DEVICE F QL(1 ea per MISC 180 days retail) MISC GENTLE-LET LANCETS 200 / 30 FORA LANCING F QL(1 ea per DEVICE/CLEARCAP MISC 180 days retail) SAFETY STYLE/FINE F days;QL(6.67 POINT MISC ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTLE-LET LANCETS 200 / 30 GOODSENSE LANCING F QL(1 ea per SAFETY STYLE/MEDIUM F days;QL(6.67 DEVICE MISC 180 days retail) POINT MISC ea daily) H-E-B INCONTROL QL(1 ea per GLOBAL LANCING F QL(1 ea per ADVANCEDLANCING F 180 days retail) DEVICE MISC 180 days retail) DEVICE MISC GLUCOSOURCE LANCET F QL(1 ea per H-E-B INCONTROL 200 / 30 DEVICE MISC 180 days retail) LANCETS MICRO THIN F days;QL(6.67 33G MISC ea daily) GLUCOSOURCE 200 / 30 F days;QL(6.67 H-E-B INCONTROL 200 / 30 LANCETS MISC ea daily) LANCETS SUPER THIN F days;QL(6.67 200 / 30 30G MISC ea daily) GNP LANCETS 21G MISC F days;QL(6.67 H-E-B INCONTROL 200 / 30 ea daily) LANCETS ULTRA THIN F days;QL(6.67 28G MISC ea daily) GNP LANCETS MICRO 200 / 30 F days;QL(6.67 HEALTH CARE LANCING QL(1 ea per THIN 33G MISC F ea daily) DEVICE MISC 180 days retail) 200 / 30 HEALTHWISE LANCING F QL(1 ea per GNP LANCETS MISC F days;QL(6.67 PEN MISC 180 days retail) ea daily) HEALTHY ACCENTS QL(1 ea per F GNP LANCETS SUPER 200 / 30 AUTOLET IMPRESSION 180 days retail) F days;QL(6.67 LANCING DEVICE MISC THIN 30G MISC ea daily) HEALTHY ACCENTS 200 / 30 F GNP LANCETS THIN 26G 200 / 30 UNILET LANCETS SUPER days;QL(6.67 F days;QL(6.67 THIN 30G MISC ea daily) MISC ea daily) 200 / 30 F GNP LANCETS THIN 200 / 30 HY-VEE LANCETS MISC days;QL(6.67 F days;QL(6.67 ea daily) MISC ea daily) 200 / 30 200 / 30 HY-VEE THIN LANCETS F days;QL(6.67 GNP MICRO THIN F MISC LANCETS 33G MISC days;QL(6.67 ea daily) ea daily) IN TOUCH LANCING F QL(1 ea per 200 / 30 DEVICE MISC 180 days retail) GNP SUPER THIN F days;QL(6.67 LANCETS/30G MISC 200 / 30 ea daily) KINNEY LANCETS MISC F days;QL(6.67 GOODSENSE COLOR 200 per 30 ea daily) LANCETS MICRO-THIN F days;QL(6.67 200 / 30 33G UNIVERSAL MISC ea daily) KINNEY THIN LANCETS F MISC days;QL(6.67 GOODSENSE LANCETS 200 per 30 ea daily) MICRO-THIN 33G F days;QL(6.67 200 / 30 UNIVERSAL MISC ea daily) KROGER LANCETS 21G F MISC days;QL(6.67 GOODSENSE LANCETS 200 per 30 ea daily) ULTRA-THIN 26G F days;QL(6.67 200 / 30 UNIVERSAL MISC ea daily) KROGER LANCETS F MICRO THIN33G MISC days;QL(6.67 GOODSENSE LANCETS 200 per 30 ea daily) ULTRA-THIN 30G F days;QL(6.67 200 / 30 UNIVERSAL MISC ea daily) KROGER LANCETS MISC F days;QL(6.67 ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KROGER LANCETS 200 / 30 200 / 30 F days;QL(6.67 LANCETS ULTRA THIN F days;QL(6.67 SUPER THIN MISC MISC ea daily) ea daily) 200 / 30 LANCING DEVICE QL(1 ea per KROGER LANCETS THIN F F 26G MISC days;QL(6.67 ADJUSTABLE MISC 180 days retail) ea daily) LANCING DEVICE MISC F QL(1 ea per 200 / 30 180 days retail) KROGER LANCETS THIN F days;QL(6.67 MISC LANZO MISC F QL(1 ea per ea daily) 180 days retail) 200 / 30 LEADER ADVANCED QL(1 ea per KROGER LANCETS F F ULTRATHIN30G MISC days;QL(6.67 LANCING DEVICE MISC 180 days retail) ea daily) LIBERTY MINI LANCING F QL(1 ea per KROGER LANCING F QL(1 ea per DEVICE MISC 180 days retail) DEVICE MISC 180 days retail) LITE TOUCH LANCING F QL(1 ea per LANCET DEVICE F QL(1 ea per PEN MISC 180 days retail) ADJUSTABLE MISC 180 days retail) LIVE BETTER ADVANCED F QL(1 ea per LANCET DEVICE WITH F QL(1 ea per LANCING DEVICE MISC 180 days retail) EJECTOR MISC 180 days retail) 200 / 30 200 / 30 LIVE BETTER LANCET F days;QL(6.67 LANCETS 26G TWIST F SUPERTHIN 30G MISC TOP MISC days;QL(6.67 ea daily) ea daily) 200 / 30 200 / 30 LIVE BETTER LANCET F ULTRATHIN 28G MISC days;QL(6.67 LANCETS 28G MISC F days;QL(6.67 ea daily) ea daily) 200 / 30 200 / 30 LONGS LANCETS F STANDARD MISC days;QL(6.67 LANCETS 30G MISC F days;QL(6.67 ea daily) ea daily) 200 / 30 200 / 30 LONGS LANCETS THIN F MISC days;QL(6.67 LANCETS MISC F days;QL(6.67 ea daily) ea daily) 200 / 30 200 / 30 MEDISENSE THIN F days;QL(6.67 LANCETS SAFETY SEAL F LANCETS MISC 21G MISC days;QL(6.67 ea daily) ea daily) MEIJER COLOR 200 / 30 200 / 30 LANCETS UNIVERSAL F days;QL(6.67 LANCETS SAFETY SEAL F 26G MISC days;QL(6.67 33G MISC ea daily) ea daily) 200 / 30 200 / 30 MEIJER LANCETS MISC F days;QL(6.67 LANCETS SAFETY SEAL F 28G MISC days;QL(6.67 ea daily) ea daily) 200 / 30 200 per 30 MEIJER LANCETS THIN F days;QL(6.67 LANCETS SUPER THIN F MISC 28G MISC days;QL(6.67 ea daily) ea daily) 200 / 30 200 / 30 MEIJER LANCETS F UNIVERSAL21G MISC days;QL(6.67 LANCETS THIN MISC F days;QL(6.67 ea daily) ea daily) 200 / 30 MEIJER LANCETS F UNIVERSAL30G MISC days;QL(6.67 ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEIJER LANCETS 200 / 30 200 / 30 F days;QL(6.67 PRECISION ULTRA F days;QL(6.67 UNIVERSAL33G MISC LANCET MISC ea daily) ea daily) MEIJER SUPER THIN 200 / 30 PREFERRED PLUS 200 / 30 F days;QL(6.67 LANCETS COLORED 21G F days;QL(6.67 LANCETS MISC ea daily) MISC ea daily) QL(1 ea per PREFERRED PLUS 200 / 30 MICROLET NEXT MISC F 180 days retail) LANCETS SUPER THIN F days;QL(6.67 30G MISC ea daily) MINI LANCING DEVICE F QL(1 ea per MISC 180 days retail) 200 / 30 PREFERRED PLUS F days;QL(6.67 MM LANCING DEVICE F QL(1 ea per LANCETS THIN 26G MISC MISC 180 days retail) ea daily) 200 / 30 PRODIGY LANCING F QL(1 ea per MONOLET LANCETS F DEVICE MISC 180 days retail) MISC days;QL(6.67 ea daily) 200 / 30 PRODIGY TWIST TOP F days;QL(6.67 200 / 30 LANCETS MISC MONOLET OPD LANCETS F ea daily) MISC days;QL(6.67 ea daily) 200 / 30 PSS SELECT GP F days;QL(6.67 MULTI-LANCET DEVICE F QL(1 ea per LANCETS MISC MISC 180 days retail) ea daily) 200 / 30 200 / 30 PSS SELECT SAFETY NOVA SUREFLEX F F days;QL(6.67 LANCETS MISC days;QL(6.67 LANCETS MISC ea daily) ea daily) PX ADVANCED LANCING QL(1 ea per NOVA SUREFLEX F QL(1 ea per F LANCING DEVICE MISC 180 days retail) DEVICE MISC 180 days retail) PX LANCET AUTO QL(1 ea per ON CALL LANCING F QL(1 ea per F DEVICE MISC 180 days retail) INJECTOR MISC 180 days retail) PX LANCETS ULTRA ON CALL PLUS LANCING F QL(1 ea per F DEVICE MISC 180 days retail) THIN 28G MISC ONETOUCH DELICA QL(1 ea per 200 / 30 F PX LANCETS ULTRA F LANCING DEVICE MISC 180 days retail) THIN MISC days;QL(6.67 ea daily) 200 / 30 PC LANCETS SUPER F QC ADVANCED LANCING QL(1 ea per THIN 30G MISC days;QL(6.67 F ea daily) DEVICE MISC 180 days retail) 200 / 30 200 / 30 QC LANCETS SUPER PERFECT LANCETS 30G F F days;QL(6.67 MISC days;QL(6.67 THIN MISC ea daily) ea daily) 200 / 30 200 / 30 QC LANCETS ULTRA PHARMACY COUNTER F F days;QL(6.67 LANCETS MISC days;QL(6.67 THIN MISC ea daily) ea daily) 200 / 30 200 / 30 QC UNILET LANCETS PRECISION THIN F F days;QL(6.67 LANCETS MISC days;QL(6.67 33G/MICRO THIN MISC ea daily) ea daily) 200 / 30 RA E-ZJECT COLOR 200 / 30 PRECISION THINS GP F LANCETSMICRO-THIN F days;QL(6.67 LANCET MISC days;QL(6.67 ea daily) 33G MISC ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA E-ZJECT LANCETS 200 / 30 RIGHTEST GD500 F QL(1 ea per F days;QL(6.67 LANCING DEVICE MISC 180 days retail) 28G MISC ea daily) 200 / 30 RIGHTEST GL300 F RA E-ZJECT LANCETS 200 / 30 days;QL(6.67 F days;QL(6.67 LANCETS MISC ea daily) THIN 26G MISC ea daily) 200 / 30 SAFETY SEAL LANCETS F RA E-ZJECT LANCETS 200 / 30 days;QL(6.67 F days;QL(6.67 28G MISC ea daily) THIN 28G MISC ea daily) 200 / 30 SAFETY SEAL LANCETS F RA E-ZJECT LANCETS 200 / 30 days;QL(6.67 F days;QL(6.67 30G MISC ea daily) ULTRATHIN 30G MISC ea daily) 200 / 30 RA LANCING DEVICE F QL(1 ea per SB LANCETS THIN MISC F days;QL(6.67 MISC 180 days retail) ea daily) 200 / 30 200 / 30 REALITY LANCETS MISC F days;QL(6.67 SB LANCETS ULTRA F THIN MISC days;QL(6.67 ea daily) ea daily) RELION 2-IN-1 LANCING F QL(1 ea per SELECT-LITE LANCING F QL(1 ea per DEVICE 25G MISC 180 days retail) DEVICE MISC 180 days retail) RELION 2-IN-1 LANCING F QL(1 ea per SHOPKO AUTOLET F QL(1 ea per DEVICE 30G MISC 180 days retail) LANCING DEVICE MISC 180 days retail) RELION LANCETS 200 / 30 SHOPKO UNILET 200 / 30 F days;QL(6.67 LANCETS SUPER THIN F days;QL(6.67 MICRO-THIN33G MISC ea daily) 30G MISC ea daily) RELION LANCETS 200 / 30 SHOPKO UNILET 200 / 30 F days;QL(6.67 LANCETS ULTRA THIN F days;QL(6.67 STANDARD 21G MISC ea daily) 28G MISC ea daily) RELION LANCETS THIN 200 / 30 SIMPLE DIAGNOSTICS F QL(1 ea per F days;QL(6.67 LANCING DEVICE MISC 180 days retail) 26G MISC ea daily) 200 / 30 200 / 30 SM MICRO THIN F days;QL(6.67 RELION LANCETS F LANCETS 33G MISC ULTRA-THIN30G MISC days;QL(6.67 ea daily) ea daily) SM TRUEDRAW LANCING F QL(1 ea per RELION LANCING F QL(1 ea per DEVICE MISC 180 days retail) DEVICE MISC 180 days retail) SMART DIABETES QL(1 ea per F RELION ULTRA THIN 200 / 30 VANTAGE LANCING 180 days retail) F days;QL(6.67 DEVICE MISC LANCETS30G MISC ea daily) SMART SENSE COLOR 200 / 30 RELION ULTRA THIN 200 / 30 LANCETS UNIVERSAL F days;QL(6.67 PLUS LANCETS 32G F days;QL(6.67 33G MISC ea daily) MISC ea daily) SMART SENSE 200 / 30 RELION ULTRA THIN 200 / 30 STANDARD LANCETS F days;QL(6.67 PLUS LANCETS 33G F days;QL(6.67 UNIVERSAL 21G MISC ea daily) MISC ea daily) SMART SENSE SUPER 200 / 30 200 / 30 THIN LANCETS F days;QL(6.67 REXALL LANCETS ULTRA F THIN MISC days;QL(6.67 UNIVERSAL 30G MISC ea daily) ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SMART SENSE THIN 200 / 30 200 / 30 LANCETSUNIVERSAL F days;QL(6.67 TODAYS HEALTH SUPER F THINLANCETS 30G MISC days;QL(6.67 26G MISC ea daily) ea daily) SOLUS V2 LANCING QL(1 ea per F TODAYS HEALTH ULTRA 200 / 30 DEVICE MISC 180 days retail) F days;QL(6.67 THINLANCETS 28G MISC 200 / 30 ea daily) STERILANCE TL MISC F days;QL(6.67 1/90 TRUE METRIX CONTROL ea daily) F days;QL(0.02 SOLUTION LEVEL 1 ea daily,90 200 / 30 SOLN SUPER THIN LANCETS F day(s) limit) MISC days;QL(6.67 ea daily) 1/90 TRUE METRIX CONTROL days;QL(0.02 SURE COMFORT F QL(1 ea per SOLUTION LEVEL 2 F LANCING PEN MISC 180 days retail) SOLN ea daily,90 day(s) limit) QL(1 ea per SURE-PEN MISC F 1/90 180 days retail) TRUE METRIX CONTROL F days;QL(0.02 200 / 30 SOLUTION LEVEL 3 ea daily,90 SURELITE LANCETS F SOLN MISC days;QL(6.67 day(s) limit) ea daily) 1/90 200 / 30 TRUECONTROL days;QL(0.02 TECHLITE AST LANCETS F days;QL(6.67 GLUCOSE CONTROL F MISC LEVEL 0 LIQD ea daily,90 ea daily) day(s) limit) 200 / 30 1/90 TECHLITE LANCETS 30G F TRUECONTROL MISC days;QL(6.67 days;QL(0.02 ea daily) GLUCOSE CONTROL F LEVEL 1 LIQD ea daily,90 200 / 30 day(s) limit) TECHLITE LANCETS F days;QL(6.67 MISC TRUEDRAW LANCING F QL(1 ea per ea daily) DEVICE MISC 180 days retail) 200 / 30 TGT LANCET MICRO 200 / 30 F days;QL(6.67 TRUEPLUS LANCETS F THIN 33G MISC 26G MISC days;QL(6.67 ea daily) ea daily) 200 / 30 TGT LANCET THIN 26G 200 / 30 F days;QL(6.67 TRUEPLUS LANCETS F MISC 28G MISC days;QL(6.67 ea daily) ea daily) 200 / 30 TGT LANCET ULTRA 200 / 30 F days;QL(6.67 TRUEPLUS LANCETS F days;QL(6.67 THIN 30G MISC 28G SUPER THIN MISC ea daily) ea daily) TGT LANCING DEVICE F QL(1 ea per 200 / 30 MISC 180 days retail) TRUEPLUS LANCETS F 30G MISC days;QL(6.67 200 / 30 ea daily) THINLETS GP LANCETS F days;QL(6.67 MISC 200 / 30 ea daily) TRUEPLUS LANCETS F 30G ULTRA THIN MISC days;QL(6.67 200 / 30 ea daily) THINLETS LANCET MISC F days;QL(6.67 200 / 30 ea daily) TRUEPLUS LANCETS F 33G MISC days;QL(6.67 TODAYS HEALTH QL(1 ea per ea daily) ADVANCED LANCING F 180 days retail) DEVICE MISC

Louisiana Healthcare Connections Updated April 1, 2019

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1/90 200 / 30 TRUETEST GLUCOSE days;QL(0.02 UNILET LANCETS F F ULTRA-THIN 28G MISC days;QL(6.67 CONTROLLEVEL 1 LIQD ea daily,90 ea daily) day(s) limit) 200 / 30 1/90 UNILET SUPERLITE F days;QL(6.67 LANCET MISC TRUETEST GLUCOSE F days;QL(0.02 ea daily) CONTROLLEVEL 2 LIQD ea daily,90 200 / 30 day(s) limit) UNIVERSAL 1 LANCETS F THIN26G MISC days;QL(6.67 1/90 ea daily) TRUETEST GLUCOSE F days;QL(0.02 200 / 30 CONTROLLEVEL 3 LIQD ea daily,90 UNIVERSAL 1 LANCETS F ULTRA THIN 30G MISC days;QL(6.67 day(s) limit) ea daily) ULTI-LANCE AUTOMATIC/ F QL(1 ea per 200 / 30 CLEAR TIP MISC 180 days retail) VALUE PLUS LANCETS F STANDARD 21G MISC days;QL(6.67 200 / 30 ea daily) ULTILET CLASSIC F days;QL(6.67 LANCETS MISC 200 / 30 ea daily) VALUE PLUS LANCETS F SUPERTHIN 30G MISC days;QL(6.67 ULTILET SAFETY ea daily) LANCETS 21G X 2.2MM F 200 / 30 MISC VALUE PLUS LANCETS F THIN 26G MISC days;QL(6.67 200 / 30 ea daily) UNILET COMFORTOUCH F days;QL(6.67 LANCET MISC VALUE PLUS LANCING F QL(1 ea per ea daily) DEVICE MISC 180 days retail) 200 / 30 200 / 30 UNILET EXCELITE II MISC F days;QL(6.67 VALUMARK LANCET F SUPER THIN 30G MISC days;QL(6.67 ea daily) ea daily) 200 / 30 200 / 30 UNILET EXCELITE MISC F days;QL(6.67 VALUMARK LANCET F ULTRA THIN 28G MISC days;QL(6.67 ea daily) ea daily) 200 / 30 VIDA MIA AUTOLET QL(1 ea per UNILET G.P. LANCET F F MISC days;QL(6.67 LANCINGDEVICE MISC 180 days retail) ea daily) VIDA MIA UNILET 200 / 30 200 / 30 LANCETS SUPER THIN F days;QL(6.67 UNILET G.P. SUPERLITE F LANCET MISC days;QL(6.67 30G MISC ea daily) ea daily) VIDA MIA UNILET 200 / 30 200 / 30 LANCETS ULTRA THIN F days;QL(6.67 UNILET GP 28 ULTRA F THIN MISC days;QL(6.67 28G MISC ea daily) ea daily) 200 / 30 200 / 30 W&F LANCETS 26G MISC F days;QL(6.67 UNILET LANCET MISC F days;QL(6.67 ea daily) ea daily) 200 / 30 200 / 30 W&F LANCETS F days;QL(6.67 UNILET LANCETS F COLORED 21G MISC MICRO-THIN33G MISC days;QL(6.67 ea daily) ea daily) WALGREENS COMFORT 200 / 30 200 / 30 ASSUREDLANCETS F days;QL(6.67 UNILET LANCETS F SUPER-THIN30G MISC days;QL(6.67 MICRO THIN/33G MISC ea daily) ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WALGREENS COMFORT 200 / 30 RA SWABS F RX/OTC ASSUREDLANCETS F days;QL(6.67 PADS SUPER THIN/28G MISC ea daily) REALITY SWABS PADS F RX/OTC 200 / 30 WALGREENS THIN F days;QL(6.67 LANCETS MISC RELION ALCOHOL F RX/OTC ea daily) SWABS PADS Misc. Devices SB ALCOHOL PREP F RX/OTC PADS PADS ALCOH-WIPE 12" X 12" F SHEE SHOPKO ALCOHOL F RX/OTC SWABS PADS ALCOHOL PREP PADS F RX/OTC PADS SM ALCOHOL PREP F RX/OTC PADS PADS ALCOHOL PREPS PADS F RX/OTC TGT ALCOHOL SWABS F RX/OTC PADS ALCOHOL SWABS PADS F RX/OTC ULTICARE ALCOHOL F RX/OTC ALCOHOL WIPES PADS F RX/OTC SWABS PADS WEBCOL ALCOHOL RX/OTC BD SWABS SINGLE USE F RX/OTC PREP LARGE 1 PLY F BUTTERFLY PADS PADS BD SWABS SINGLE USE F RX/OTC WEBCOL ALCOHOL RX/OTC PADS PREP LARGE 2 PLY F CURITY ALCOHOL RX/OTC PADS PREPS/MEDIUM 2 PLY F WEBCOL ALCOHOL RX/OTC PADS PREP MEDIUM 2 PLY F PADS CURITY ALCOHOL F RX/OTC SWABS PADS Parenteral Therapy Supplies CVS PREP PADS PADS F RX/OTC 1ST TIER UNIFINE QL(5 ea daily); PENTIPS/MINI/31GX5MM F RX/OTC EASY TOUCH ALCOHOL RX/OTC MISC PREP PADS/MEDIUM F PADS 1ST TIER UNIFINE QL(5 ea daily); PENTIPS29GX12MM F RX/OTC EQL ALCOHOL SWABS F RX/OTC MISC PADS 1ST TIER UNIFINE F QL(5 ea daily); FIFTY50 ALCOHOL PREP F RX/OTC PENTIPS31GX6MM MISC RX/OTC PADS PADS 1ST TIER UNIFINE F QL(5 ea daily); GNP ALCOHOL SWABS F RX/OTC PENTIPS31GX8MM MISC RX/OTC PADS 1ST TIER UNIFINE F QL(5 ea daily); H-E-B INCONTROL F RX/OTC PENTIPS32GX4MM MISC RX/OTC ALCOHOL PADS PADS 1ST TIER UNIFINE QL(5 ea daily); HM STERILE ALCOHOL F RX/OTC PENTIPSPLUS 31GX8MM F RX/OTC PREP PADS PADS MISC MEIJER ALCOHOL RX/OTC 1ST TIER UNIFINE QL(5 ea daily); SWABS EXTRA-THICK F PENTIPSPLUS 32GX4MM F RX/OTC PADS MISC QC ALCOHOL SWABS F RX/OTC 1ST TIER UNIFINE QL(5 ea daily); PADS PENTIPSPLUS/MINI/31GX F RX/OTC 5MM MISC Louisiana Healthcare Connections Updated April 1, 2019

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1ST TIER UNIFINE QL(5 ea daily); ANTI-STICK INSULIN QL(5 ea daily); PENTIPSPLUS/ORIGINAL/ F RX/OTC SYRINGE/U- F RX/OTC 29GX12MM MISC 100/0.5ML/28G X 1/2" 1ST TIER UNIFINE QL(5 ea daily); MISC PENTIPSPLUS/ULTRA F RX/OTC ANTI-STICK INSULIN QL(5 ea daily); SHORT/31GX6MM MISC SYRINGE/U- F RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily); 100/0.5ML/29G X 1/2" NEEDLES 29GX12.7MM F RX/OTC MISC MISC ANTI-STICK INSULIN QL(5 ea daily); ADVOCATE INSULIN PEN QL(5 ea daily); SYRINGE/U-100/1ML/29G F RX/OTC NEEDLES 31GX5MM F RX/OTC X 1/2" MISC MISC ASSURE ID INSULIN QL(5 ea daily); ADVOCATE INSULIN PEN QL(5 ea daily); SAFETYSYRINGE/U- F RX/OTC NEEDLES 31GX8MM F RX/OTC 100/0.5ML/29G X 1/2" MISC MISC ASSURE ID INSULIN QL(5 ea daily); ADVOCATE INSULIN PEN F QL(5 ea daily) NEEDLES MISC SAFETYSYRINGE/U- F RX/OTC 100/1ML/29G X 1/2" MISC ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC ASSURE ID SAFETY PEN QL(5 ea daily) 100/0.3ML/29GX1/2" MISC NEEDLES 30G X 5/16" F MISC ADVOCATE INSULIN QL(5 ea daily); ASSURE ID SAFETY PEN QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.3ML/30GX5/16" NEEDLES 31G X 3/16" F RX/OTC MISC MISC ADVOCATE INSULIN QL(5 ea daily) AURORA PEN NEEDLES F QL(5 ea daily); 29GX12MM MISC RX/OTC SYRINGE/U- F 100/0.3ML/31GX5/16" AURORA PEN NEEDLES F QL(5 ea daily); MISC 31G X6MM MISC RX/OTC ADVOCATE INSULIN QL(5 ea daily); AURORA PEN NEEDLES F QL(5 ea daily); SYRINGE/U- F RX/OTC 31G X8MM MISC RX/OTC 100/0.5ML/29GX1/2" MISC AURORA UNIFINE F QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); PENTIPS/32GX5/32" MISC RX/OTC SYRINGE/U- F RX/OTC AURORA UNIFINE QL(5 ea daily); 100/0.5ML/30GX5/16" PENTIPS/MINI/31GX3/16" F RX/OTC MISC MISC ADVOCATE INSULIN QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) SYRINGE/U- F ULTRAFINE II/0.3ML/31G F 100/0.5ML/31GX5/16" X 5/16" MISC MISC B-D INSULIN SYRINGE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); ULTRAFINE II/0.5ML/31G F SYRINGE/U- F RX/OTC X 5/16" MISC 100/1ML/29GX1/2" MISC B-D INSULIN SYRINGE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); ULTRAFINE II/1ML/31G X F SYRINGE/U- F RX/OTC 5/16" MISC 100/1ML/30GX5/16" MISC B-D INSULIN SYRINGE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily) ULTRAFINE/0.3ML/30G X F SYRINGE/U- F 1/2" MISC 100/1ML/31GX5/16" MISC

Louisiana Healthcare Connections Updated April 1, 2019

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/30G X F ULTRA-FINE/1/2 F 1/2" MISC UNIT/0.3ML/31G X 8MM BD LO-DOSE INSULIN QL(5 ea daily); MISC SYRINGE MICROFINE F RX/OTC BD INSULIN SYRINGE QL(5 ea daily) IV/0.5ML/28G X 1/2" MISC ULTRA-FINE/1ML/30G X F BD INSULIN SYRINGE QL(5 ea daily); 12.7MM MISC LUER-LOK/U-100/1ML F RX/OTC BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRA-FINE/1ML/31G X F BD INSULIN SYRINGE QL(5 ea daily); 8MM MISC MICROFINE IV/U- F RX/OTC BD INSULIN SYRINGE QL(5 ea daily) 100/0.5ML/28G X 1/2" ULTRAFINE/0.5ML/30G X F MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- F ULTRAFINE/0.5ML/31G X F 100/1ML/27G X 5/8" MISC 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- F RX/OTC ULTRAFINE/1ML/30G X F 100/1ML/28G X 1/2" MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); MICROFINE/U- RX/OTC F ULTRAFINE/U- F RX/OTC 100/0.5ML/28G X 1/2" 100/0.3ML/29G X 1/2" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); MICROFINE/U- F ULTRAFINE/U- F RX/OTC 100/1ML/27G X 5/8" MISC 100/0.5ML/29G X 1/2" BD INSULIN SYRINGE QL(5 ea daily); MISC MICROFINE/U- F RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/1ML/28G X 1/2" MISC ULTRAFINE/U- F RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/1ML/29G X 1/2" MISC SAFETYGLIDE/1ML/29G X F RX/OTC BD INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/29G X F RX/OTC 12.7MM MISC BD INSULIN SYRINGE F QL(5 ea daily); SLIP TIP/U-100/1ML MISC RX/OTC BD INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/0.5ML/29G X F RX/OTC ULTRA-FINE/0.3ML/30G X F 12.7MM MISC 12.7MM MISC BD INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/1ML/27G X F RX/OTC ULTRA-FINE/0.3ML/31G X F 12.7MM MISC 8MM MISC BD INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/1ML/29G X F RX/OTC ULTRA-FINE/0.5ML/30G X F 12.7MM MISC 12.7MM MISC BD INSULIN QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/DETACHABLE F ULTRA-FINE/0.5ML/31G X F NEEDLE/U-100/1ML/25G 8MM MISC X 1" MISC

Louisiana Healthcare Connections Updated April 1, 2019

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN QL(5 ea daily) BD VEO INSULIN QL(5 ea daily) SYRINGE/DETACHABLE F SYRINGE ULTRA- F NEEDLE/U-100/1ML/25G FINE/1ML/31G X 6MM X 5/8" MISC MISC BD INSULIN QL(5 ea daily) CAREFINE PEN NEEDLE F QL(5 ea daily); SYRINGE/DETACHABLE F 32GX4MM MISC RX/OTC NEEDLE/U-100/1ML/26G CAREFINE PEN F QL(5 ea daily); X 1/2" MISC NEEDLES 29GX1/2" MISC RX/OTC BD INSULIN SYRINGE/U- F QL(5 ea daily); CAREFINE PEN QL(5 ea daily) 100/1ML/27G X 1/2" MISC RX/OTC NEEDLES 30GX5/16" F BD PEN QL(5 ea daily) MISC NEEDLE/MICRO/ULTRA- F CAREFINE PEN QL(5 ea daily); FINE/32G X 6MM MISC NEEDLES 31GX6MM F RX/OTC BD PEN QL(5 ea daily); MISC NEEDLE/MINI/ULTRA- F RX/OTC CAREFINE PEN QL(5 ea daily); FINE/31G X 5MM MISC NEEDLES 31GX8MM F RX/OTC BD PEN QL(5 ea daily); MISC NEEDLE/NANO/ULTRA- F RX/OTC CAREFINE PEN QL(5 ea daily); FINE/32G X 4MM MISC NEEDLES 32GX5MM F RX/OTC BD PEN QL(5 ea daily); MISC NEEDLE/ORIGINAL/ULTR F RX/OTC CAREFINE PEN QL(5 ea daily) A-FINE/29G X 12.7MM NEEDLES 32GX6MM F MISC MISC BD PEN QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) NEEDLE/SHORT/ULTRA- F RX/OTC SYRINGES/0.3ML/30G X F FINE/31G X 8MM MISC 1/2" MISC BD SAFETY-GLIDE QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) INSULIN F RX/OTC SYRINGES/0.3ML/31G X F SYRINGE/0.5ML/29G X 5/16" MISC 1/2" MISC CAREONE INSULIN QL(5 ea daily) BD SAFETY-LOK INSULIN QL(5 ea daily); SYRINGES/0.5ML/30G X F SYRINGE/PERM F RX/OTC 1/2" MISC NEEDLE/UF/1ML/29G X 1/2" MISC CAREONE INSULIN QL(5 ea daily) SYRINGES/0.5ML/31G X F BD SAFETYGLIDE QL(5 ea daily); 5/16" MISC INSULIN F RX/OTC SYRINGE/0.3ML/29G X CAREONE INSULIN QL(5 ea daily) 1/2" MISC SYRINGES/1ML/30G X F 1/2" MISC BD SAFETYGLIDE QL(5 ea daily) CAREONE INSULIN QL(5 ea daily) INSULIN F SYRINGE/0.3ML/31G X SYRINGES/1ML/31GX5/16 F 5/16" MISC " MISC BD SAFETYGLIDE QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily); PENTIPS 29GX12MM F RX/OTC INSULIN F RX/OTC SYSYRINGE/0.5ML/30G X MISC 5/16" MISC CAREONE UNIFINE F QL(5 ea daily); PENTIPS 31GX5MM MISC RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREONE UNIFINE F QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) PENTIPS 31GX6MM MISC RX/OTC COMFORT EZINSULIN F PEN NEEDLES 33GX4MM CAREONE UNIFINE F QL(5 ea daily); PENTIPS 31GX8MM MISC RX/OTC MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS PEN NEEDLES F RX/OTC COMFORT EZINSULIN F RX/OTC 32GX4MM MISC SYRINGE/0.3ML/29G X 1/2" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) PENTIPS PLUS PEN F RX/OTC NEEDLES 29GX12MM COMFORT EZINSULIN F MISC SYRINGE/0.3ML/30G X 1/2" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS PLUS PEN F RX/OTC NEEDLES 31GX5MM COMFORT EZINSULIN F RX/OTC MISC SYRINGE/0.3ML/30G X 5/16" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) PENTIPS PLUS PEN F RX/OTC NEEDLES 31GX6MM COMFORT EZINSULIN F MISC SYRINGE/0.3ML/31G X 5/16" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS PLUS PEN F RX/OTC NEEDLES 31GX8MM COMFORT EZINSULIN F RX/OTC MISC SYRINGE/0.5ML/28G X 1/2" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS PLUS PEN F RX/OTC NEEDLES 32GX4MM COMFORT EZINSULIN F RX/OTC MISC SYRINGE/0.5ML/29G X 1/2" MISC CARETOUCH PEN QL(5 ea daily); NEEDLES 31G X 6 MM F RX/OTC CLEVER CHOICE QL(5 ea daily) MISC COMFORT EZINSULIN F SYRINGE/0.5ML/30G X CARETOUCH PEN QL(5 ea daily); 1/2" MISC NEEDLES 31GX 5MM F RX/OTC MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN F RX/OTC CARETOUCH PEN QL(5 ea daily); SYRINGE/0.5ML/30G X NEEDLES 31GX 8MM F RX/OTC 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CARETOUCH PEN QL(5 ea daily); COMFORT EZINSULIN F NEEDLES 32GX 4MM F RX/OTC SYRINGE/0.5ML/31G X MISC 5/16" MISC CARETOUCH PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) NEEDLES 32GX 5MM F RX/OTC COMFORT EZINSULIN F MISC SYRINGE/1.0ML/30G X CLEVER CHOICE QL(5 ea daily); 1/2" MISC COMFORT EZINSULIN F RX/OTC CLEVER CHOICE QL(5 ea daily); PEN NEEDLES 31GX8MM COMFORT EZINSULIN F RX/OTC MISC SYRINGE/1ML/28G X 1/2" MISC

Louisiana Healthcare Connections Updated April 1, 2019

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN NEEDLE F QL(5 ea daily); COMFORT EZINSULIN F RX/OTC 32GX5/32" MISC RX/OTC SYRINGE/1ML/29G X 1/2" CLICKFINE PEN NEEDLE QL(5 ea daily); MISC UNIVERSAL/31GX1/4" F RX/OTC CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN F RX/OTC CLICKFINE PEN NEEDLE QL(5 ea daily); SYRINGE/1ML/30G X UNIVERSAL/31GX5/16" F RX/OTC 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLICKFINE PEN QL(5 ea daily); COMFORT EZINSULIN F NEEDLES 31G X 8MM F RX/OTC SYRINGE/U- MISC 100/1ML/31GX5/16" MISC CLICKFINE PEN F QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); NEEDLES/31GX1/4" MISC RX/OTC COMFORT EZPEN F RX/OTC NEEDLES 29GX12MM CLICKFINE PEN QL(5 ea daily); MISC NEEDLES/31GX5/16" F RX/OTC MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE UNIVERSAL QL(5 ea daily); COMFORT EZPEN F RX/OTC NEEDLES 31GX5MM PEN NEEDLES 31GX5/16" F RX/OTC MISC MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); INSULIN SYRINGE F RX/OTC COMFORT EZPEN F RX/OTC NEEDLES 31GX6MM 0.3ML/29G X 1/2" MISC MISC COMFORT ASSIST QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); INSULIN F RX/OTC SYRINGE/0.3ML/30G X COMFORT EZPEN F RX/OTC NEEDLES 31GX8MM 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily) CLEVER CHOICE QL(5 ea daily); INSULIN F SYRINGE/0.3ML/31G X COMFORT EZPEN F RX/OTC NEEDLES 32GX4MM 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); INSULIN F RX/OTC SYRINGE/0.5ML/29G X COMFORT EZPEN F RX/OTC NEEDLES 32GX5MM 1/2" MISC MISC COMFORT ASSIST QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) INSULIN F RX/OTC SYRINGE/0.5ML/30G X COMFORT EZPEN F NEEDLES 32GX6MM 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) INSULIN F SYRINGE/0.5ML/31G X COMFORT EZPEN F NEEDLES 32GX8MM 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) INSULIN F RX/OTC SYRINGE/1ML/29G X 1/2" COMFORT EZPEN F NEEDLES 33GX4MM MISC MISC

Louisiana Healthcare Connections Updated April 1, 2019

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) INSULIN F RX/OTC SYRINGE U-100/1ML/30G F SYRINGE/1ML/30G X X 1/2" MISC 5/16" MISC DROPLET INSULIN QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) SYRINGE U-100/1ML/30G F RX/OTC INSULIN F X 5/16" MISC SYRINGE/1ML/31G X DROPLET INSULIN QL(5 ea daily) 5/16" MISC SYRINGE U-100/1ML/31G F COMFORT EZ INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/U- F DROPLET INSULIN QL(5 ea daily) 100/0.5ML/31G X 5/16" SYRINGE/U- F MISC 100/0.3ML/31G X 5/16" COMFORT EZ INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G F DROPLET INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/U- F COMFORT EZ F QL(5 ea daily); 100/0.5ML/30G X 1/2" MICRO/32G X 4MM MISC RX/OTC MISC COMFORT EZ F QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) SHORT/31G X 8MM MISC RX/OTC SYRINGE/U- F 100/0.5ML/31G X 5/16" COMFORT EZ/31G X 5MM F QL(5 ea daily); MISC RX/OTC MISC DROPLET INSULIN QL(5 ea daily) COMFORT EZ/31G X 6MM F QL(5 ea daily); MISC RX/OTC SYRINGE/U-100/1ML/30G F X 1/2" MISC DROPLET INSULIN QL(5 ea daily) SYRINGE U-100/0.3/31G F DROPLET INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/U-100/1ML/31G F X 5/16" MISC DROPLET INSULIN QL(5 ea daily) DROPLET PEN NEEDLES QL(5 ea daily); SYRINGE U- F F 100/0.3ML/30G X 1/2" 29GX12MM MISC RX/OTC MISC DROPLET PEN NEEDLES F QL(5 ea daily); DROPLET INSULIN QL(5 ea daily); 31GX5MM MISC RX/OTC SYRINGE U- F RX/OTC DROPLET PEN NEEDLES F QL(5 ea daily); 100/0.3ML/30G X 5/16" 31GX6MM MISC RX/OTC MISC DROPLET PEN NEEDLES F QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) 31GX8MM MISC RX/OTC SYRINGE U- F DROPLET PEN NEEDLES F QL(5 ea daily) 100/0.5ML/30G X 1/2" 32G X 1/4" MISC MISC DROPLET PEN NEEDLES F QL(5 ea daily); DROPLET INSULIN QL(5 ea daily); 32G X 3/16" MISC RX/OTC SYRINGE U- F RX/OTC 100/0.5ML/30G X 5/16" DROPLET PEN NEEDLES F QL(5 ea daily) MISC 32G X 5/16" MISC DROPLET INSULIN QL(5 ea daily) DROPLET PEN NEEDLES F QL(5 ea daily); 32G X 5/32" MISC RX/OTC SYRINGE U- F 100/0.5ML/31G X 5/16" DROPLET PEN NEEDLES F QL(5 ea daily); MISC 32GX4MM MISC RX/OTC DROPLET PEN NEEDLES F QL(5 ea daily); 32GX5MM MISC RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET PEN NEEDLES F QL(5 ea daily) EASY COMFORT PEN F QL(5 ea daily); 32GX6MM MISC NEEDLES31GX3/16" MISC RX/OTC DROPLET PEN NEEDLES F QL(5 ea daily) EASY COMFORT PEN F QL(5 ea daily); 32GX8MM MISC NEEDLES31GX5/16" MISC RX/OTC DROPSAFE SAFETY PEN QL(5 ea daily); EASY COMFORT PEN F QL(5 ea daily); NEEDLES/31G X 5/16" F RX/OTC NEEDLES32GX5/32" MISC RX/OTC MISC EASY GLIDE PEN QL(5 ea daily) DROPSAFE SAFTEY PEN QL(5 ea daily); NEEDLES 33G X 5/32" F NEEDLES/31G X 1/4" F RX/OTC MISC MISC EASY TOUCH 32GX5MM F QL(5 ea daily); DRUG MART UNIFINE F QL(5 ea daily); MISC RX/OTC PENTIPS 31GX5MM MISC RX/OTC EASY TOUCH 32GX6MM F QL(5 ea daily) DRUG MART UNIFINE QL(5 ea daily); MISC PENTIPS29G X 12MM F RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily); MISC SAFETY INSULIN F RX/OTC DRUG MART UNIFINE F QL(5 ea daily); SYRINGE 1ML/29GX1/2" PENTIPS31GX6MM MISC RX/OTC MISC DRUG MART UNIFINE F QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily) PENTIPS31GX8MM MISC RX/OTC SAFETY INSULIN F SYRINGE 1ML/30GX1/2" DRUG MART UNIFINE F QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC MISC DRUG MART UNIFINE QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily); PENTIPSPLUS 32GX4MM F RX/OTC SAFETY INSULIN F RX/OTC MISC SYRINGE 1ML/30GX5/16" MISC EASY COMFORT INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily) 5/16" MISC SAFETY INSULIN F SYRINGE 1ML/31GX5/16" EASY COMFORT INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X F 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X F RX/OTC EASY COMFORT INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/30G X F RX/OTC 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X F EASY COMFORT INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/1ML/31G X F 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X F RX/OTC EASY COMFORT INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- F 100/0.5ML/30G X 1/2" EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G F EASY TOUCH INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/1ML/30G X F RX/OTC 5/16" MISC EASY COMFORT PEN F QL(5 ea daily); NEEDLES31GX1/4" MISC RX/OTC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/SAFETY/U- F RX/OTC 100/0.5ML/29G X 1/2" MISC Louisiana Healthcare Connections Updated April 1, 2019

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

Louisiana Healthcare Connections Updated April 1, 2019

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELITE-THIN INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/U- F RX/OTC INSULIN PEN NEEDLES F RX/OTC 100/0.5ML/28G X 1/2" 29G X 12MM MISC MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) INSULIN PEN NEEDLES F RX/OTC SYRINGE/U- F 31G X 6MM MISC 100/0.5ML/31G X 5/16" EXEL COMFORT POINT QL(5 ea daily); MISC INSULIN PEN NEEDLES F RX/OTC ELITE-THIN INSULIN QL(5 ea daily); 31G X 8MM MISC SYRINGE/U-100/1ML/28G F RX/OTC EXEL COMFORT POINT QL(5 ea daily); X 1/2" MISC INSULIN F RX/OTC ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X SYRINGE/U-100/1ML/29G F RX/OTC 1/2" MISC X 1/2" MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) INSULIN F RX/OTC SYRINGE/U-100/1ML/31G F SYRINGE/0.3ML/30G X X 5/16" MISC 5/16" MISC EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/0.3ML/29G X F RX/OTC INSULIN F RX/OTC 1/2" MISC SYRINGE/0.5ML/28G X EQL INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/30G X F RX/OTC EXEL COMFORT POINT QL(5 ea daily); 5/16" MISC INSULIN F RX/OTC EQL INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X SYRINGE/0.3ML/31G X F 1/2" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); EQL INSULIN QL(5 ea daily); INSULIN F RX/OTC SYRINGE/0.5ML/29G X F RX/OTC SYRINGE/0.5ML/30G X 1/2" MISC 5/16" MISC EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC INSULIN F RX/OTC 5/16" MISC SYRINGE/1ML/28G X 1/2" MISC EQL INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F EXEL COMFORT POINT QL(5 ea daily); 5/16" MISC INSULIN F RX/OTC SYRINGE/1ML/29G X 1/2" EQL INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" F RX/OTC MISC EXEL COMFORT POINT QL(5 ea daily); INSULIN F RX/OTC EQL INSULIN QL(5 ea daily); SYRINGE/1ML/30G X SYRINGE/1ML/30G X F RX/OTC 5/16" MISC 5/16" MISC FIFTY50 PEN NEEDLES F QL(5 ea daily); EQL INSULIN QL(5 ea daily) 31G X3/16" (5MM) MISC RX/OTC SYRINGE/1ML/31G X F 5/16" MISC FIFTY50 PEN NEEDLES F QL(5 ea daily); 31G X5/16" (8MM) MISC RX/OTC EXCEL COMFORT POINT QL(5 ea daily) INSULIN PEN NEEDLES F FIFTY50 PEN NEEDLES F QL(5 ea daily); 31G X 4MM MISC 31GX5MM MISC RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

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

Louisiana Healthcare Connections Updated April 1, 2019

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN SYRINGE/U- F RX/OTC SYRINGE/U- F 100/0.5ML/30G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F SYRINGE/U- F RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/30G X 5/16" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) F INSULIN SYRINGE/U- RX/OTC SYRINGE/U- F 100/1ML/28G X 1/2" MISC 100/0.5ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 100/1ML/29G X 1/2" MISC SYRINGE/U-100/1ML/30G F GLOBAL INJECT EASE QL(5 ea daily) X 1/2" MISC INSULIN SYRINGE/U- F GLUCOPRO INSULIN QL(5 ea daily); 100/1ML/30G X 1/2" MISC SYRINGE/U-100/1ML/30G F RX/OTC GLOBAL INJECT EASE QL(5 ea daily); X 5/16" MISC INSULIN SYRINGE/U- F RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 100/1ML/30G X 5/16" SYRINGE/U-100/1ML/31G F MISC X 5/16" MISC GLOBAL INJECT EASE QL(5 ea daily) GNP CLICKFINE PEN QL(5 ea daily); INSULIN SYRINGE/U- F NEEDLEUNIVERSAL/31G F RX/OTC 100/1ML/31G X 5/16" X5/16" MISC MISC GNP CLICKFINE QL(5 ea daily); GLOBAL INSULIN QL(5 ea daily) UNIVERSAL PEN F RX/OTC SYRINGE/U- F NEEDLES 31GX1/4" MISC 100/0.3ML/30G X 1/2" GNP CLICKFINE QL(5 ea daily); MISC UNIVERSAL PEN F RX/OTC GLOBAL INSULIN QL(5 ea daily); NEEDLES 31GX5/16" SYRINGES/U- F RX/OTC MISC 100/0.3ML/30GX5/16" GNP INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/29G X F RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- F GNP INSULIN QL(5 ea daily); 100/0.3ML/30G X 1/2" SYRINGE/0.3ML/30G X F RX/OTC MISC 5/16" MISC GLUCOPRO INSULIN QL(5 ea daily); GNP INSULIN QL(5 ea daily) SYRINGE/U- F RX/OTC SYRINGE/0.3ML/31G X F 100/0.3ML/30G X 5/16" 5/16" MISC MISC GNP INSULIN QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) SYRINGE/0.5ML/28G X F RX/OTC SYRINGE/U- F 1/2" MISC 100/0.3ML/31G X 5/16" MISC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X F RX/OTC 1/2" MISC

Louisiana Healthcare Connections Updated April 1, 2019

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); F SYRINGE/0.5ML/30G X RX/OTC INSULIN F RX/OTC 5/16" MISC SYRINGE/1ML/28G X 1/2" GNP INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X F GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN F RX/OTC GNP INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" SYRINGE/1ML/28G X 1/2" F RX/OTC MISC MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN F RX/OTC SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/1ML/30G X MISC 5/16" SHORT MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily) SYRINGE/1ML/30G X F RX/OTC INSULIN F 5/16" MISC SYRINGE/1ML/31G X 5/16" SHORT MISC GNP INSULIN QL(5 ea daily) SYRINGE/1ML/31G X F GOODSENSE CLICKFINE QL(5 ea daily); 5/16" MISC SAFETY PEN F RX/OTC NEEDLE/31G X 3/16" GNP ULTRA COMFORT QL(5 ea daily); MISC INSULIN F RX/OTC SYRINGE/0.3ML/29G X GOODSENSE PEN QL(5 ea daily); 1/2" MISC NEEDLE/PENFINE F RX/OTC CLASSIC/31G X 3/16" GNP ULTRA COMFORT QL(5 ea daily); MISC INSULIN F RX/OTC SYRINGE/0.3ML/30G X GOODSENSE PEN QL(5 ea daily); 5/16" SHORT MISC NEEDLE/PENFINE F RX/OTC CLASSIC/31G X 5/16" GNP ULTRA COMFORT QL(5 ea daily) MISC INSULIN F SYRINGE/0.3ML/31G X GOODSENSE PEN QL(5 ea daily) 5/16" SHORT MISC NEEDLE/PENFINE F CLASSIC/32G X 1/4" MISC GNP ULTRA COMFORT QL(5 ea daily); GOODSENSE PEN QL(5 ea daily); INSULIN F RX/OTC SYRINGE/0.5ML/28G X NEEDLE/PENFINE F RX/OTC 1/2" MISC CLASSIC/32G X 5/32" MISC GNP ULTRA COMFORT QL(5 ea daily); H-E-B IN CONTROL PEN QL(5 ea daily); INSULIN F RX/OTC SYRINGE/0.5ML/29G X NEEDLES 31GX5MM F RX/OTC 1/2" MISC MISC GNP ULTRA COMFORT QL(5 ea daily); H-E-B IN CONTROL PEN QL(5 ea daily); NEEDLES 31GX6MM F RX/OTC INSULIN F RX/OTC SYRINGE/0.5ML/30G X MISC 5/16" SHORT MISC H-E-B IN CONTROL PEN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily) NEEDLES 31GX8MM F RX/OTC MISC INSULIN F SYRINGE/0.5ML/31G X H-E-B IN CONTROL PEN QL(5 ea daily); 5/16" SHORT MISC NEEDLES/NANO/32GX4M F RX/OTC M MISC

Louisiana Healthcare Connections Updated April 1, 2019

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B IN CONTROL QL(5 ea daily); HEALTHWISE SHORT QL(5 ea daily); UNIFINEPENTIPS PLUS F RX/OTC PEN NEEDLES/31G X F RX/OTC 31GX5MM MISC 5/16" MISC H-E-B IN CONTROL QL(5 ea daily); HEALTHWISE UNIFINE QL(5 ea daily); UNIFINEPENTIPS PLUS F RX/OTC PENTIPS PEN NEEDLES F RX/OTC 32GX4MM MISC 32GX4MM MISC H-E-B INCONTROL PEN QL(5 ea daily); HEALTHY ACCENTS QL(5 ea daily); F NEEDLES 29GX12MM RX/OTC UNIFINE PENTIPS PEN F RX/OTC MISC NEEDLES 29GX12MM HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC HEALTHY ACCENTS QL(5 ea daily); 100/0.3ML/30G X 5/16" UNIFINE PENTIPS PEN F RX/OTC MISC NEEDLES 31GX5MM HEALTHWISE INSULIN QL(5 ea daily) MISC SYRINGE/U- F HEALTHY ACCENTS QL(5 ea daily); 100/0.3ML/31G X 5/16" UNIFINE PENTIPS PEN F RX/OTC MISC NEEDLES 31GX6MM HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC HEALTHY ACCENTS QL(5 ea daily); 100/0.5ML/30G X 5/16" UNIFINE PENTIPS PEN F RX/OTC MISC NEEDLES 31GX8MM HEALTHWISE INSULIN QL(5 ea daily) MISC SYRINGE/U- F HEALTHY ACCENTS QL(5 ea daily); 100/0.5ML/31G X 5/16" UNIFINE PENTIPS PEN F RX/OTC MISC NEEDLES 32GX4MM HEALTHWISE INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G F RX/OTC HM ULTICARE INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/1ML/30G X 1/2" F HEALTHWISE INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G F HM ULTICARE INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE/U- F HEALTHWISE MICRON QL(5 ea daily); 100/0.3ML/31G X 5/16" PEN NEEDLES/32G X F RX/OTC MISC 5/32" MISC HM ULTICARE SHORT QL(5 ea daily); HEALTHWISE MINI PEN QL(5 ea daily); PEN NEEDLES 31GX8MM F RX/OTC NEEDLES 31GX6MM F RX/OTC MISC MISC INSULIN QL(5 ea daily) HEALTHWISE PEN QL(5 ea daily); SYRINGE/0.3ML/29G X 1" F NEEDLES 29GX12MM F RX/OTC MISC MISC INSULIN QL(5 ea daily); HEALTHWISE SHORT QL(5 ea daily); SYRINGE/0.3ML/29G X F RX/OTC PEN NEEDLES 31GX8MM F RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily); HEALTHWISE SHORT QL(5 ea daily); SYRINGE/0.3ML/30G X F RX/OTC PEN NEEDLES/31G X F RX/OTC 5/16" MISC 3/16" MISC INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X F 5/16" MISC

Louisiana Healthcare Connections Updated April 1, 2019

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/27G X F 100/0.3ML/29G X 1/2" F RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/28G X F RX/OTC 100/0.5ML/28G X 1/2" F RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/30G X F 100/0.5ML/29G X 1/2" F RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC 100/1ML/28G X 1/2" MISC RX/OTC 5/16" MISC INSULIN SYRINGE/U- F QL(5 ea daily); INSULIN QL(5 ea daily) 100/1ML/29G X 1/2" MISC RX/OTC SYRINGE/0.5ML/31G X F INSULIN SYRINGE/U- QL(5 ea daily); 5/16" MISC 100/1ML/30G X 5/16" F RX/OTC INSULIN QL(5 ea daily); MISC SYRINGE/1ML/28G X 1/2" F RX/OTC INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" F INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" F RX/OTC INSULIN QL(5 ea daily) MISC SYRINGES/0.5ML/27GX1/ F INSULIN QL(5 ea daily); 2" MISC SYRINGE/1ML/30G X F RX/OTC INSULIN QL(5 ea daily); 5/16" MISC SYRINGES/0.5ML/28GX1/ F RX/OTC INSULIN QL(5 ea daily); 2" MISC SYRINGE/NEEDLE F RX/OTC INSULIN QL(5 ea daily); 0.3ML/30G X 5/16" MISC SYRINGES/0.5ML/29GX1/ F RX/OTC INSULIN QL(5 ea daily) 2" MISC SYRINGE/NEEDLE F INSULIN QL(5 ea daily); 0.3ML/31G X 5/16" MISC SYRINGES/0.5ML/30GX5/ F RX/OTC INSULIN QL(5 ea daily); 16" MISC SYRINGE/NEEDLE F RX/OTC INSULIN QL(5 ea daily) 0.5ML/29G X 1/2" MISC SYRINGES/0.5ML/31GX F INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/NEEDLE F RX/OTC INSULIN QL(5 ea daily) 0.5ML/30G X 5/16" MISC SYRINGES/0.5ML/31GX5/ F INSULIN QL(5 ea daily) 16" MISC SYRINGE/NEEDLE F INSULIN QL(5 ea daily); 0.5ML/31G X 5/16" MISC SYRINGES/1ML/27GX/1/2" F RX/OTC INSULIN QL(5 ea daily); MISC SYRINGE/NEEDLE F RX/OTC INSULIN QL(5 ea daily); 1ML/29G X 1/2" MISC SYRINGES/1ML/27GX1/2" F RX/OTC INSULIN QL(5 ea daily); MISC SYRINGE/NEEDLE F RX/OTC INSULIN QL(5 ea daily); 1ML/30G X 5/16" MISC SYRINGES/1ML/28GX1/2" F RX/OTC INSULIN QL(5 ea daily) MISC SYRINGE/NEEDLE F 1ML/31G X 5/16" MISC Louisiana Healthcare Connections Updated April 1, 2019

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

Louisiana Healthcare Connections Updated April 1, 2019

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN PEN QL(5 ea daily); SYRINGE/0.3ML/30G X F RX/OTC NEEDLES/32G X F RX/OTC 5/16" MISC 4MM/MINI MISC LEADER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X F SYRINGE/0.3ML/29G X F RX/OTC 5/16" MISC 1/2" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/28G X F RX/OTC SYRINGE/0.3ML/30G X F RX/OTC 1/2" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X F RX/OTC SYRINGE/0.3ML/31G X F 1/2" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F SYRINGE/0.5ML/31G X F 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" F RX/OTC SYRINGE/1ML/30G X F RX/OTC MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/U- F RX/OTC MISC 100/0.3ML/30G X 5/16" LEADER INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X F RX/OTC LITETOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- F LEADER INSULIN QL(5 ea daily) 100/0.3ML/31G X 5/16" SYRINGE/1ML/31G X F MISC 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" PENTIPS F RX/OTC PLUS/MINI/31GX3/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" PENTIPS F RX/OTC PLUS/SHORT/31GX5/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U- F RX/OTC PENTIPS/MINI/31GX3/16" F RX/OTC 100/0.5ML/30G X 5/16" MISC MISC LEADER UNIFINE QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) PENTIPS/NANO/32GX5/32 F RX/OTC SYRINGE/U- F " MISC 100/0.5ML/31G X 5/16" MISC LEADER UNIFINE QL(5 ea daily); PENTIPS/PLUS/32GX5/32 F RX/OTC LITETOUCH INSULIN QL(5 ea daily); " MISC SYRINGE/U-100/1ML/28G F RX/OTC X 1/2" MISC

Louisiana Healthcare Connections Updated April 1, 2019

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

Louisiana Healthcare Connections Updated April 1, 2019

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

Louisiana Healthcare Connections Updated April 1, 2019

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(5 ea daily) MS INSULIN QL(5 ea daily) COMFORT INSULIN F SYRINGE/1ML/31G X F SYRINGE/0.3ML/31G X 5/16" MISC 5/16" MISC NOVOFINE 30GX8MM F QL(5 ea daily) MONOJECT ULTRA QL(5 ea daily); MISC COMFORT INSULIN RX/OTC F NOVOFINE 32GX6MM F QL(5 ea daily) SYRINGE/0.5ML/28G X MISC 1/2" MISC NOVOFINE AUTOCOVER F QL(5 ea daily) MONOJECT ULTRA QL(5 ea daily); 30GX8MM MISC COMFORT INSULIN F RX/OTC SYRINGE/0.5ML/29G X NOVOFINE PLUS F QL(5 ea daily); 1/2" MISC 32GX4MM MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); NOVOTWIST 32GX5MM F QL(5 ea daily); MISC RX/OTC COMFORT INSULIN F RX/OTC SYRINGE/0.5ML/30G X PC UNIFINE PENTIPS F QL(5 ea daily); 5/16" MISC 29G X1/2" MISC RX/OTC MONOJECT ULTRA QL(5 ea daily) PC UNIFINE PENTIPS F QL(5 ea daily); 31G X5MM MINI MISC RX/OTC COMFORT INSULIN F SYRINGE/0.5ML/31G X PC UNIFINE PENTIPS QL(5 ea daily); 5/16" MISC 31G X6MM ULTRA F RX/OTC MONOJECT ULTRA QL(5 ea daily); SHORT MISC COMFORT INSULIN RX/OTC F PC UNIFINE PENTIPS F QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 31G X8MM SHORT MISC RX/OTC MISC PEN NEEDLES 29G X F QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 12MM MISC RX/OTC COMFORT INSULIN RX/OTC F PEN NEEDLES 29GX1/2" F QL(5 ea daily); SYRINGE/1ML/29G X 1/2" MISC RX/OTC MISC PEN NEEDLES 30GX5/16" F QL(5 ea daily) MOORE MED MONOJECT QL(5 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" PEN NEEDLES 30GX8MM F QL(5 ea daily) MISC MISC MOORE MED MONOJECT QL(5 ea daily); PEN NEEDLES 31G X 1/4" F QL(5 ea daily); SHORT MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" PEN NEEDLES 31G X F QL(5 ea daily); MISC 3/16" MISC RX/OTC MOORE MED MONOJECT QL(5 ea daily); PEN NEEDLES 31G X F QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC 5MM MISC RX/OTC 100/1ML/28G X 1/2" MISC PEN NEEDLES 31G X F QL(5 ea daily); MOORE MED MONOJECT QL(5 ea daily); 6MM MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC PEN NEEDLES 31G X F QL(5 ea daily); 100/1ML/29G X 1/2" MISC 8MM MISC RX/OTC MS INSULIN QL(5 ea daily) PEN NEEDLES 31GX5/16" F QL(5 ea daily); SYRINGE/0.3ML/31G X F MISC RX/OTC 5/16" MISC PEN NEEDLES 31GX6MM F QL(5 ea daily); MS INSULIN QL(5 ea daily) (1/4") MISC RX/OTC SYRINGE/0.5ML/31G X F PEN NEEDLES 31GX8MM F QL(5 ea daily); 5/16" MISC (5/16") MISC RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

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

Louisiana Healthcare Connections Updated April 1, 2019

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

Louisiana Healthcare Connections Updated April 1, 2019

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); F SYRINGE/1ML/29G X 1/2" RX/OTC SYRINGE/U- F RX/OTC MISC 100/0.5ML/30G X 5/16" RA INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/0.5ML/30G X 5/16" F RX/OTC RELION INSULIN QL(5 ea daily) MISC SYRINGE/U- F RA INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/31G X 5/16" 100/1 ML/30G X 5/16" F RX/OTC MISC MISC RELION INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G F RX/OTC RA PEN NEEDLES 31G X F QL(5 ea daily); 5MM3/16" MISC RX/OTC X 5/16" MISC RELION INSULIN QL(5 ea daily) RA PEN NEEDLES 31G X F QL(5 ea daily); 8MM5/16" MISC RX/OTC SYRINGE/U-100/1ML/31G F X 5/16" MISC REALITY INSULIN QL(5 ea daily); RELION MINI PEN QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" NEEDLES 31GX6MM F RX/OTC MISC MISC REALITY INSULIN QL(5 ea daily); RELION PEN NEEDLES F QL(5 ea daily); 29GX12MM MISC RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" RELION PEN NEEDLES F QL(5 ea daily); MISC 31GX6MM MISC RX/OTC REALITY INSULIN QL(5 ea daily); RELION PEN NEEDLES F QL(5 ea daily); SYRINGE/U-100/1ML/28G F RX/OTC 31GX8MM MISC RX/OTC X 1/2" MISC RELION PEN NEEDLES F QL(5 ea daily); REALITY INSULIN QL(5 ea daily); 32GX4MM MISC RX/OTC SYRINGE/U-100/1ML/29G F RX/OTC RELION SHORT PEN F QL(5 ea daily); X 1/2" MISC NEEDLES31GX8MM MISC RX/OTC RELION INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/U-00/1ML/29G F RX/OTC SYRINGE/0.3ML/30G X F RX/OTC X 1/2" MISC 5/16" MISC RELION INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC SYRINGE/0.5ML/29G X F RX/OTC 100/0.3ML/29G X 1/2" 1/2" MISC MISC SAFESNAP INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/U- F RX/OTC 5/16" MISC 100/0.3ML/30G X 5/16" MISC SAFESNAP INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" F RX/OTC RELION INSULIN QL(5 ea daily) MISC SYRINGE/U- F 100/0.3ML/31G X 5/16" SAFESNAP INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" F RX/OTC MISC RELION INSULIN QL(5 ea daily); SAFETY INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" SYRINGES F RX/OTC MISC 0.5ML/29GX1/2" MISC

Louisiana Healthcare Connections Updated April 1, 2019

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY INSULIN QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); F SYRINGES RX/OTC PENTIPS PEN F RX/OTC 0.5ML/30GX5/16" MISC NEEDLES/SHORT/31GX8 SAFETY INSULIN QL(5 ea daily); MM MISC SYRINGES 1ML/27GX1/2" F RX/OTC SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PLUS PEN F RX/OTC SAFETY INSULIN QL(5 ea daily); NEEDLES/MICRO/REMOV SYRINGES 1ML/29GX1/2" F RX/OTC R/32GX4MM MISC MISC SHOPKO UNIFINE QL(5 ea daily); SAFETY INSULIN QL(5 ea daily) PENTIPS PLUS PEN F RX/OTC SYRINGES 1ML/30GX1/2" F NEEDLES/MINI/REMOVE MISC R/31GX5MM MISC SB INSULIN SYRINGE/U- QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); 100/0.5ML/29G X 1/2" F RX/OTC PENTIPS PLUS PEN F RX/OTC MISC NEEDLES/REMOVER/29G X12MM MISC SB INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/30G X 5/16" F RX/OTC SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PLUS PEN F RX/OTC NEEDLES/SHORT/REMO SB INSULIN SYRINGE/U- F QL(5 ea daily); VR/31GX8MM MISC 100/1ML/29G X 1/2" MISC RX/OTC SM INSULIN QL(5 ea daily) SB INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/1ML/31G X F 100/1ML/30G X 5/16" F RX/OTC 5/16" MISC MISC SURE COMFORT QL(5 ea daily); SB INSULIN SYRINGE/U- QL(5 ea daily) INSULIN SYRINGE/U- F RX/OTC 100/1ML/31G X 5/16" F 100/0.3ML/29G X 1/2" MISC MISC SCHNUCKS INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily) SYRINGEULTI-FINE/U- RX/OTC F INSULIN SYRINGE/U- F 100/0.5ML/29G X 1/2" 100/0.3ML/30G X 1/2" MISC MISC SCHNUCKS INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily); SYRINGEULTI-FINE/U- RX/OTC F INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" 100/0.3ML/30G X 5/16" MISC MISC SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily) PENTIPS PEN RX/OTC F INSULIN SYRINGE/U- F NEEDLES/MICRO/32GX4 100/0.3ML/31G X 5/16 MM MISC MISC SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily) PENTIPS PEN RX/OTC F INSULIN SYRINGE/U- F NEEDLES/MINI/31GX5MM 100/0.3ML/31G X 5/16" MISC MISC SHOPKO UNIFINE QL(5 ea daily); SURE COMFORT QL(5 ea daily); PENTIPS PEN RX/OTC F INSULIN SYRINGE/U- F RX/OTC NEEDLES/ORIGINAL/29G 100/0.5ML/28G X 1/2" X12MM MISC MISC

Louisiana Healthcare Connections Updated April 1, 2019

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

Louisiana Healthcare Connections Updated April 1, 2019

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-JECT INSULIN QL(5 ea daily) TECHLITE PEN NEEDLES F QL(5 ea daily); SYRINGE/U-100/1ML/31G F 29GX 12 MM MISC RX/OTC X 5/16" MISC TECHLITE PEN NEEDLES F QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); 31GX 5MM MISC RX/OTC SYRINGEU- F RX/OTC TECHLITE PEN QL(5 ea daily); 100/0.3ML/29G X 1/2" NEEDLES/31GX 5MM F RX/OTC MISC MISC TECHLITE INSULIN QL(5 ea daily) TECHLITE PEN QL(5 ea daily); SYRINGEU- F NEEDLES/31GX 6 MM F RX/OTC 100/0.3ML/30G X 1/2" MISC MISC TECHLITE PEN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); NEEDLES/31GX 8MM F RX/OTC SYRINGEU- F RX/OTC MISC 100/0.3ML/30G X 5/16" MISC TECHLITE PEN QL(5 ea daily); NEEDLES/32GX 4MM F RX/OTC TECHLITE INSULIN QL(5 ea daily) MISC SYRINGEU- F 100/0.3ML/31G X 5/16" TECHLITE PEN QL(5 ea daily) MISC NEEDLES/32GX 6MM F MISC TECHLITE INSULIN QL(5 ea daily); TECHLITE PEN QL(5 ea daily) SYRINGEU- F RX/OTC 100/0.5ML/29G X 1/2" NEEDLES/32GX 8MM F MISC MISC TECHLITE INSULIN QL(5 ea daily) TODAYS HEALTH MINI QL(5 ea daily); PEN NEEDLES 31G X 1/4" F RX/OTC SYRINGEU- F 100/0.5ML/30G X 1/2" MISC MISC TODAYS HEALTH QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); ORIGINAL PEN NEEDLES F RX/OTC 29G X 1/2" MISC SYRINGEU- F RX/OTC 100/0.5ML/30G X 5/16" TODAYS HEALTH SHORT QL(5 ea daily); MISC PEN NEEDLES 31G X F RX/OTC TECHLITE INSULIN QL(5 ea daily) 5/16" MISC TOPCARE CLICKFINE QL(5 ea daily); SYRINGEU- F 100/0.5ML/31G X 5/16" UNIVERSAL PEN EEDLES F RX/OTC MISC 31GX1/4" MISC TECHLITE INSULIN QL(5 ea daily); TOPCARE CLICKFINE QL(5 ea daily); SYRINGEU-100/1ML/29G F RX/OTC UNIVERSAL PEN EEDLES F RX/OTC X 1/2" MISC 31GX5/16" MISC TECHLITE INSULIN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily); SYRINGEU-100/1ML/30G F COMFORT INSULIN F RX/OTC X 1/2" MISC SYRINGE/0.3ML/30G X TECHLITE INSULIN QL(5 ea daily); 5/16" MISC SYRINGEU-100/1ML/30G F RX/OTC TOPCARE ULTRA QL(5 ea daily) X 5/16" MISC COMFORT INSULIN F TECHLITE INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X SYRINGEU-100/1ML/31G F 5/16" MISC X 5/16" MISC

Louisiana Healthcare Connections Updated April 1, 2019

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPCARE ULTRA QL(5 ea daily); TRUE COMFORT INSULIN QL(5 ea daily) COMFORT INSULIN F RX/OTC SYRINGE/0.5ML/31G X F SYRINGE/0.5ML/30G X 5/16" MISC 5/16" MISC TRUE COMFORT INSULIN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily) SYRINGE/1ML/31G X F COMFORT INSULIN F 5/16" MISC SYRINGE/0.5ML/31G X TRUE COMFORT PEN QL(5 ea daily); 5/16" MISC NEEDLES31G X 5MM F RX/OTC TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN F RX/OTC TRUE COMFORT PEN QL(5 ea daily); SYRINGE/1ML/30G X NEEDLES31G X 6MM F RX/OTC 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily) TRUE COMFORT PEN QL(5 ea daily); COMFORT INSULIN F NEEDLES32G X 4MM F RX/OTC SYRINGE/1ML/31G X MISC 5/16" MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); NEEDLES 29GX12.7MM F RX/OTC COMFORT INSULIN RX/OTC MISC SYRINGE/U- F 100/0.3ML/29G X 1/2" TRUEPLUS 5-BEVEL PEN QL(5 ea daily); MISC NEEDLES 31GX5MM F RX/OTC MISC TOPCARE ULTRA QL(5 ea daily); COMFORT INSULIN RX/OTC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); SYRINGE/U- F NEEDLES 31GX6MM F RX/OTC 100/0.5ML/29G X 1/2" MISC MISC TRUEPLUS 5-BEVEL PEN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); NEEDLES 31GX8MM F RX/OTC MISC COMFORT INSULIN F RX/OTC SYRINGE/U-100/1ML/29G TRUEPLUS 5-BEVEL PEN QL(5 ea daily); X 1/2" MISC NEEDLES 32GX4MM F RX/OTC TOPCO INSULIN QL(5 ea daily); MISC TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" SYRINGE/U- F RX/OTC MISC 100/0.3ML/29G X 1/2" TOPCO INSULIN QL(5 ea daily); MISC TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" SYRINGE/U- F RX/OTC MISC 100/0.3ML/30G X 5/16" TOPCO INSULIN QL(5 ea daily); MISC TRUEPLUS INSULIN QL(5 ea daily) SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" SYRINGE/U- F MISC 100/0.3ML/31G X 5/16" TOPCO INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/28G F RX/OTC TRUEPLUS INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/U- F RX/OTC TOPCO INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2" SYRINGE/U-100/1ML/29G F RX/OTC MISC X 1/2" MISC

Louisiana Healthcare Connections Updated April 1, 2019

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC SYRINGE/0.3ML/29G X F RX/OTC 100/0.5ML/29G X 1/2" 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X F SYRINGE/U- F RX/OTC 1/2" MISC 100/0.5ML/30G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X F RX/OTC TRUEPLUS INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- F ULTICARE INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/0.5ML/28G X F RX/OTC MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G F RX/OTC SYRINGE/0.5ML/29G X F RX/OTC X 1/2" MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/29G F RX/OTC SYRINGE/0.5ML/30G X F X 1/2" MISC 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G F RX/OTC SYRINGE/0.5ML/30G X F RX/OTC X 5/16" MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G F SYRINGE/1ML/28G X 1/2" F RX/OTC X 5/16" MISC MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 29GX12MM F RX/OTC SYRINGE/1ML/29G X 1/2" F RX/OTC MISC MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES 31GX5MM F RX/OTC SYRINGE/1ML/30G X 1/2" F MISC MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 31GX6MM F RX/OTC SYRINGE/1ML/30G X F RX/OTC MISC 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); NEEDLES 31GX8MM F RX/OTC SYRINGE/SHORT/0.3ML/3 F RX/OTC MISC 0G X 5/16" MISC TRUEPLUS PEN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) NEEDLES 32GX4MM F RX/OTC SYRINGE/SHORT/0.3ML/3 F MISC 1G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SAFETY F RX/OTC SYRINGE/SHORT/0.5ML/3 F RX/OTC SYRINGE/0.5ML/29G X 0G X 5/16" MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 F SAFETY F RX/OTC 1G X 5/16" MISC SYRINGE/1ML/29G X 1/2" MISC ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/1ML/30 F RX/OTC G X 5/16" MISC Louisiana Healthcare Connections Updated April 1, 2019

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

Louisiana Healthcare Connections Updated April 1, 2019

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE PEN NEEDLES F QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) 31GX 5MM/MINI MISC RX/OTC SYRINGE/SHORT/1ML/31 F ULTICARE PEN QL(5 ea daily); G X 5/16" MISC NEEDLES/29GX 12.7MM F RX/OTC ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/U- F ULTICARE SHORT PEN QL(5 ea daily); 100/0.5ML/30G X 1/2" NEEDLES 31GX8MM F RX/OTC MISC MISC ULTILET INSULIN QL(5 ea daily) ULTICARE SHORT PEN QL(5 ea daily); SYRINGE/U-100/1ML/30G F NEEDLES ULTI-FINE IV F RX/OTC X 1/2" MISC MISC ULTILET PEN NEEDLE F QL(5 ea daily); ULTICARE SHORT PEN QL(5 ea daily); 29GX12.7MM MISC RX/OTC NEEDLES/31G X 8MM F RX/OTC ULTILET PEN NEEDLE F QL(5 ea daily); MISC 31GX5MM MISC RX/OTC ULTILET INSULIN QL(5 ea daily); ULTILET PEN NEEDLE F QL(5 ea daily); SYRINGE/0.3ML/30G X F RX/OTC 31GX8MM MISC RX/OTC 8MM MISC ULTILET PEN NEEDLE F QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) 32GX4MM MISC RX/OTC SYRINGE/0.3ML/31G X F ULTILET PEN NEEDLE F QL(5 ea daily); 8MM MISC 32GX4MM/SHORT MISC RX/OTC ULTILET INSULIN QL(5 ea daily); ULTILET SHORT PEN QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC NEEDLES 31GX5/16" F RX/OTC 8MM MISC MISC ULTILET INSULIN QL(5 ea daily); ULTILET SHORT PEN F QL(5 ea daily); SYRINGE/1ML/30G X F RX/OTC NEEDLES31GX3/16" MISC RX/OTC 8MM MISC ULTRA COMFORT QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) INSULIN SYRINGE/U- F RX/OTC SYRINGE/1ML/31G X F 100/0.3ML/30G X 5/16" 8MM MISC MISC ULTILET INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 F INSULIN SYRINGE/U- F RX/OTC 0G X 12.7MM MISC 100/0.3ML/29G X 1/2" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.3ML/3 F RX/OTC ULTRA-COMFORT QL(5 ea daily); 0G X 5/16" MISC INSULIN SYRINGE/U- F RX/OTC ULTILET INSULIN QL(5 ea daily) 100/0.3ML/30G X 5/16" SYRINGE/SHORT/0.3ML/3 F MISC 1G X 5/16" MISC ULTRA-COMFORT QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F SYRINGE/SHORT/0.5ML/3 F RX/OTC 100/0.3ML/31G X 5/16" 0G X 5/16" MISC MISC ULTILET INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); F SYRINGE/SHORT/0.5ML/3 INSULIN SYRINGE/U- F RX/OTC 1G X 5/16" MISC 100/0.5ML/28G X 1/2" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/1ML/30 F RX/OTC G X 5/16" MISC

Louisiana Healthcare Connections Updated April 1, 2019

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" 100/0.3ML/29GX1/2" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); SYRINGE/U- F RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/29GX1/2" MISC 100/0.5ML/30G X 5/16" ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC ULTRA-COMFORT QL(5 ea daily) 100/1ML/29GX1/2" MISC INSULIN SYRINGE/U- F ULTRA-THIN II MINI PEN QL(5 ea daily); 100/0.5ML/31G X 5/16" NEEEDLES/31GX3/16" F RX/OTC MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II PEN F QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC NEEDLES 29GX1/2" MISC RX/OTC 100/1ML/28G X 1/2" MISC ULTRA-THIN II PEN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); NEEDLES/SHORT/31GX5/ F RX/OTC INSULIN SYRINGE/U- F RX/OTC 16" MISC 100/1ML/29G X 1/2" MISC ULTRACARE INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); SYRINGE/U- F RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" 100/1ML/30G X 5/16" MISC MISC ULTRACARE INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily) SYRINGE/U- F INSULIN SYRINGE/U- F 100/0.3ML/31G X 5/16" 100/1ML/31G X 5/16" MISC MISC ULTRACARE INSULIN QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE/U- F SYRINGE SHORT/U- F RX/OTC 100/0.5ML/30G X 1/2" 100/0.3ML/30GX5/16" MISC MISC ULTRACARE INSULIN QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE/U- F RX/OTC SYRINGE SHORT/U- F 100/0.5ML/30G X 5/16" 100/0.3ML/31GX5/16" MISC MISC ULTRACARE INSULIN QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE/U- F SYRINGE SHORT/U- F RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/30GX5/16" MISC MISC ULTRACARE INSULIN QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G F SYRINGE SHORT/U- F X 1/2" MISC 100/0.5ML/31GX5/16" MISC ULTRACARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G F RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE SHORT/U- F RX/OTC 100/1ML/30GX5/16" MISC ULTRACARE INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G F ULTRA-THIN II INSULIN QL(5 ea daily) X 5/16" MISC SYRINGE SHORT/U- F 100/1ML/31GX5/16" MISC

Louisiana Healthcare Connections Updated April 1, 2019

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRACARE PEN QL(5 ea daily); UNIFINE PENTIPS PLUS F QL(5 ea daily) NEEDLES/31G X 1/4" F RX/OTC 33GX4MM MISC MISC V-R MONOJECT INSULIN QL(5 ea daily); ULTRACARE PEN QL(5 ea daily); SYRINGE/U- F RX/OTC NEEDLES/31G X 3/16" F RX/OTC 100/0.3ML/29G X 1/2" MISC MISC ULTRACARE PEN QL(5 ea daily); V-R MONOJECT INSULIN QL(5 ea daily); F NEEDLES/31G X 5/16" RX/OTC SYRINGE/U- F RX/OTC MISC 100/0.5ML/28G X 1/2" ULTRACARE PEN QL(5 ea daily) MISC NEEDLES/32G X 1/14" F V-R MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC ULTRACARE PEN QL(5 ea daily); 100/0.5ML/29G X 1/2" NEEDLES/32G X 3/16" F RX/OTC MISC MISC V-R MONOJECT INSULIN QL(5 ea daily); ULTRACARE PEN QL(5 ea daily); SYRINGE/U-100/1ML/28G F RX/OTC NEEDLES/32G X 5/32" F RX/OTC X 1/2" MISC MISC V-R MONOJECT INSULIN QL(5 ea daily); ULTRACARE PEN QL(5 ea daily) SYRINGE/U-100/1ML/29G F RX/OTC NEEDLES/33G X 5/32" F X 1/2" MISC MISC VALUE HEALTH INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC UNIFINE PENTIPS F QL(5 ea daily); F 29GX12MM MISC RX/OTC 100/0.5ML/29G X 1/2" MISC UNIFINE PENTIPS 31G X F QL(5 ea daily); 3/16" MISC RX/OTC VALUE HEALTH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G F RX/OTC UNIFINE PENTIPS F QL(5 ea daily); X 1/2" MISC 31GX5MM MISC RX/OTC VALUMARK PEN QL(5 ea daily); UNIFINE PENTIPS F QL(5 ea daily); NEEDLES 29GX12MM F RX/OTC 31GX6MM MISC RX/OTC MISC UNIFINE PENTIPS F QL(5 ea daily); VALUMARK PEN QL(5 ea daily); 31GX8MM MISC RX/OTC NEEDLES 31GX 6MM F RX/OTC UNIFINE PENTIPS F QL(5 ea daily); MISC 32GX4MM MISC RX/OTC VALUMARK PEN QL(5 ea daily); UNIFINE PENTIPS F QL(5 ea daily) NEEDLES 31GX 8MM F RX/OTC 32GX6MM MISC MISC UNIFINE PENTIPS F QL(5 ea daily) VANISHPOINT INSULIN QL(5 ea daily) 33GX4MM MISC SYRINGE/0.5ML/30G X F 1/2" MISC UNIFINE PENTIPS PLUS F QL(5 ea daily); 29GX12MM MISC RX/OTC VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC UNIFINE PENTIPS PLUS F QL(5 ea daily); 31GX5MM MISC RX/OTC 5/16" MISC VANISHPOINT INSULIN QL(5 ea daily); UNIFINE PENTIPS PLUS F QL(5 ea daily); 31GX6MM MISC RX/OTC SYRINGE/1ML/29G X 1/2" F RX/OTC MISC UNIFINE PENTIPS PLUS F QL(5 ea daily); 31GX8MM MISC RX/OTC VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/1ML/30G X F RX/OTC UNIFINE PENTIPS PLUS F QL(5 ea daily); 32GX4MM MISC RX/OTC 5/16" MISC Louisiana Healthcare Connections Updated April 1, 2019

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDA MIA UNIFINE QL(5 ea daily); F AEROCHAMBER MV QL(2 ea per PENTIPS32GX4MM MISC RX/OTC F 360 days MISC VIDA MIA UNIFINE QL(5 ea daily); retail); RX/OTC PENTIPSMINI 31GX6MM F RX/OTC AEROCHAMBER PLUS QL(2 ea per MISC F 360 days FLOW VU MISC VIDA MIA UNIFINE QL(5 ea daily); retail); RX/OTC PENTIPSORIGINAL F RX/OTC AEROCHAMBER PLUS QL(2 ea per 29GX12MM MISC F 360 days FLOW-VU MISC VIDA MIA UNIPFINE QL(5 ea daily); retail); RX/OTC PENTIPSSHORT F RX/OTC AEROCHAMBER PLUS QL(2 ea per 31GX8MM MISC FLOW-VU/LARGE MASK F 360 days VP INSULIN SYRINGE/U- QL(5 ea daily); MISC retail); RX/OTC 100/0.3ML/29G X 1/2" F RX/OTC AEROCHAMBER PLUS QL(2 ea per MISC F 360 days FLOW-VU/MASK MISC WEGMANS UNIFINE QL(5 ea daily); retail); RX/OTC PENTIPS PLUS 32GX4MM F RX/OTC AEROCHAMBER PLUS QL(2 ea per MISC FLOW-VU/MEDIUM MASK F 360 days WEGMANS UNIFINE QL(5 ea daily); MISC retail); RX/OTC PENTIPS F RX/OTC AEROCHAMBER PLUS QL(2 ea per PLUS/MINI/31GX5MM FLOW-VU/SMALL MASK F 360 days MISC MISC retail); RX/OTC WEGMANS UNIFINE QL(5 ea daily); AEROCHAMBER Z-STAT QL(2 ea per PENTIPS F RX/OTC PLUS VALVED HOLDING F 360 days PLUS/SHORT/31GX8MM CHAMBER W/FLOW VU retail); RX/OTC MISC MISC WEGMANS UNIFINE QL(5 ea daily); QL(2 ea per PENTIPS PLUS/ULTRA F RX/OTC AEROCHAMBER Z-STAT F PLUS/FLOWSIGNAL MISC 360 days SHORT/31GX6MM MISC retail); RX/OTC Respiratory Therapy Supplies QL(2 ea per AEROCHAMBER Z-STAT F 360 days QL(1 ea per PLUS/LARGE MASK MISC ACE AEROSOL CLOUD F retail); RX/OTC ENHANCER MISC 360 days retail); RX/OTC AEROCHAMBER Z-STAT QL(2 ea per F QL(1 ea per PLUS/MEDIUM MASK 360 days MISC retail); RX/OTC ACTIVITY POUCH MISC F 360 days retail); RX/OTC QL(2 ea per AEROCHAMBER Z-STAT F 360 days QL(1 ea per PLUS/SMALL MASK MISC ADULT AEROSOL MASK F retail); RX/OTC MISC 360 days retail); RX/OTC QL(2 ea per AEROCHAMBER/FLOWSI F 360 days QL(1 ea per GNAL MISC ADULT MASK LARGE F retail); RX/OTC MISC 360 days retail); RX/OTC QL(1 ea per F QL(1 ea per AEROTRACH PLUS MISC 360 days retail); RX/OTC ADULT MASK MISC F 360 days retail); RX/OTC AEROVENT PLUS QL(2 ea per HOLDING 360 days AEROCHAMBER MINI QL(2 ea per F AEROSOLCHAMBER F 360 days CHAMBER/COLLAPSIBLE retail); RX/OTC DEVI DEVI retail); RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AIRS PEDIATRIC QL(1 ea per QL(2 ea per F 360 days BREATHERITE W/SMALL F 360 days AEROSOL MASK MISC MASK MISC retail); RX/OTC retail); RX/OTC ALL FLOW 1000 QL(1 ea per BUBBLES THE FISH II QL(1 ea per PULMONARY FUNCTION F 360 days PEDIATRIC MASK/PVC F 360 days FILTER MISC retail); RX/OTC MISC retail); RX/OTC QL(2 ea per CLEVER CHOICE ANTI- QL(2 ea per ARIAL CHAMBER DEVI F 360 days STATICVALVED 360 days retail); RX/OTC HOLDING F retail); RX/OTC QL(2 ea per CHAMBER/ADULT LARGE BREATHE EASE/LARGE F DEVI MASK DEVI 360 days retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per QL(2 ea per STATICVALVED F 360 days BREATHE EASE/MEDIUM F HOLDING retail); RX/OTC MASK DEVI 360 days retail); RX/OTC CHAMBER/MEDIUM DEVI QL(2 ea per CLEVER CHOICE ANTI- QL(2 ea per BREATHE EASE/SMALL F STATICVALVED 360 days MASK DEVI 360 days F retail); RX/OTC HOLDING retail); RX/OTC CHAMBER/SMALL DEVI BREATHERITE QL(2 ea per COLLAPSIBLEADULT F 360 days CO MONITOR QL(1 ea per SPACER W/MASK MISC retail); RX/OTC REPLACEMENT TPIECES F 360 days MISC retail); RX/OTC BREATHERITE QL(2 ea per COLLAPSIBLECHILD F 360 days COMPACT SPACE QL(2 ea per SPACER W/MASK MISC retail); RX/OTC CHAMBER/ANTI-STATIC F 360 days DEVI retail); RX/OTC BREATHERITE QL(2 ea per COLLAPSIBLEINFANT F 360 days COMPACT SPACE QL(2 ea per SPACER W/MASK MISC retail); RX/OTC CHAMBER/ANTI- F 360 days STATIC/LARGE MASK retail); RX/OTC BREATHERITE QL(2 ea per DEVI COLLAPSIBLESMALL F 360 days CHILD SPACER W/MASK retail); RX/OTC COMPACT SPACE QL(2 ea per MISC CHAMBER/ANTI- F 360 days STATIC/MEDIUM MASK retail); RX/OTC BREATHERITE QL(2 ea per DEVI COLLAPSIBLESPACER F 360 days W/ NEONATE MASK MISC retail); RX/OTC COMPACT SPACE QL(2 ea per CHAMBER/ANTI- F 360 days QL(2 ea per STATIC/SMALL MASK retail); RX/OTC BREATHERITE MISC F 360 days DEVI retail); RX/OTC QL(2 ea per QL(2 ea per E-Z SPACER DEVI F 360 days BREATHERITE RIGID F SPACERW/MASK MISC 360 days retail); RX/OTC retail); RX/OTC QL(2 ea per QL(2 ea per E-Z SPACER THE BODY F 360 days BREATHERITE W/LARGE F GUARDS PACK DEVI MASK MISC 360 days retail); RX/OTC retail); RX/OTC QL(2 ea per QL(2 ea per EASIVENT MISC F 360 days BREATHERITE F W/MEDIUM MASK MISC 360 days retail); RX/OTC retail); RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASIVENT/MASK-LARGE QL(2 ea per QL(2 ea per F 360 days INSPIRACHAMBER/LARG F 360 days MISC E DEVI retail); RX/OTC retail); RX/OTC EASIVENT/MASK- QL(2 ea per INSPIRACHAMBER/SOOT QL(2 ea per F 360 days HERMASK/INSPIRAMASK F 360 days MEDIUM MISC retail); RX/OTC /MEDIUM DEVI retail); RX/OTC EASIVENT/MASK-SMALL QL(2 ea per INSPIRACHAMBER/SOOT QL(2 ea per F 360 days HERMASK/INSPIRAMASK F 360 days MISC retail); RX/OTC /SMALL DEVI retail); RX/OTC EBASE CONTROLLER KIT QL(1 ea per QL(2 ea per F 360 days INSPIREASE DRUG F 360 days MISC DELIVERYSYSTEM MISC retail); RX/OTC retail); RX/OTC EFLOW SCF AEROSOL QL(1 ea per INSPIREASE RESERVOIR F QL(3 ea per F 360 days BAGS MISC 180 days retail) HEAD MISC retail); RX/OTC QL(2 ea per F ELITE DC AUTO QL(1 ea per LITEAIRE DEVI 360 days F 360 days retail); RX/OTC ADAPTER MISC retail); RX/OTC QL(1 ea per QL(1 ea per LITETOUCH MASK F LARGE MISC 360 days FILTER AIR PP MISC F 360 days retail); RX/OTC retail); RX/OTC QL(1 ea per QL(2 ea per LITETOUCH MASK F MEDIUM MISC 360 days FLEXICHAMBER DEVI F 360 days retail); RX/OTC retail); RX/OTC QL(1 ea per LITETOUCH MASK F FULL KIT NEBULIZER QL(1 ea per 360 days F 360 days SMALL MISC retail); RX/OTC SET MISC retail); RX/OTC QL(2 ea per HEALTHY LIVING QL(1 ea per MICROCHAMBER MISC F 360 days REPLACEMENT FILTERS F 360 days retail); RX/OTC MISC retail); RX/OTC QL(1 ea per HEALTHY LIVING QL(1 ea per MICROELITE FILTER F REPLACEMENTS MISC 360 days REPLACEMENT KIT FOR F 360 days retail); RX/OTC NEBULIZER MISC retail); RX/OTC MICROELITE QL(1 ea per HEALTHY LIVING QL(1 ea per RECHARGEABLE F 360 days REPLACEMENT MASKS F 360 days BATTERY MISC retail); RX/OTC MISC retail); RX/OTC QL(2 ea per HUDSON RCI SEE-THRU QL(1 ea per MICROSPACER MISC F 360 days AEROSOL MASK F 360 days retail); RX/OTC ELONGATED/ADULT retail); RX/OTC QL(1 ea per MISC MINIELITE FILTER F REPLACEMENTS MISC 360 days INNOSPIRE QL(1 ea per retail); RX/OTC REPLACEMENT FILTER F 360 days MINIELITE QL(1 ea per MISC retail); RX/OTC RECHARGEABLE F 360 days INSPIRACHAMBER/ANTI- QL(2 ea per BATTERY MISC retail); RX/OTC STATIC F 360 days QL(1 ea per VALVED/MOUTHPIECE retail); RX/OTC NEBULIZER AIR F TUBE/PLUGS MISC 360 days DEVI retail); RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEBULIZER PEDIATRIC QL(1 ea per QL(1 ea per F 360 days PARI BABY CONVERSION F 360 days MASK MISC KITSIZE 2 MISC retail); RX/OTC retail); RX/OTC QL(1 ea per QL(1 ea per NOSE CLIP MISC F 360 days PARI BABY CONVERSION F KITSIZE 3 MISC 360 days retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(1 ea per ADVANTAGE/LARGE F 360 days PARI ERAPID NEBULIZER F HANDSET MISC 360 days MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(1 ea per ADVANTAGE/MEDIUM F 360 days PARI EXPIRATORY F FILTER VALVE SET DEVI 360 days FACE MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(1 ea per ADVANTAGE/SMALL F 360 days PARI MASK SET MISC F 360 days FACE MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(1 ea per F 360 days PARI SOFT PLASTIC F 360 days DIAMOND MISC ADULT MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(1 ea per DIAMOND/LARGEFACE F 360 days PARI SOFT PLASTIC F PEDIATRIC MASK MISC 360 days MASK DEVI retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per QL(1 ea per DIAMOND/MEDIUM FACE F 360 days PEDIATRIC AEROSOL F MASK MISC 360 days MASK MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER QL(2 ea per PEDIATRIC QL(1 ea per DIAMOND/SMALLFACE F 360 days MOUTHPIECE/DISPOSAB F 360 days MASK MISC retail); RX/OTC LE MISC retail); RX/OTC OPTICHAMBER FACE QL(2 ea per QL(1 ea per F 360 days PFLEX MISC F 360 days MASK/LARGE MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER FACE QL(2 ea per QL(1 ea per F 360 days PILLOW MASK/ADULT F 360 days MASK/MEDIUM MISC MISC retail); RX/OTC retail); RX/OTC OPTICHAMBER FACE QL(2 ea per QL(1 ea per F 360 days PILLOW MASK/CHILD F 360 days MASK/SMALL MISC MISC retail); RX/OTC retail); RX/OTC OPTIHALER MDI DRUG QL(2 ea per QL(1 ea per F 360 days PILLOW F 360 days DELIVERY SYSTEM DEVI MASK/PEDIATRIC MISC retail); RX/OTC retail); RX/OTC QL(2 ea per QL(2 ea per OPTIHALER MISC F 360 days POCKET CHAMBER DEVI F 360 days retail); RX/OTC retail); RX/OTC PARI ALTERA QL(1 ea per QL(2 ea per NEBULIZER HANDSET F 360 days POCKET SPACER DEVI F 360 days MISC retail); RX/OTC retail); RX/OTC PARI BABY CONVERSION QL(1 ea per PRO COMFORT INHALER QL(2 ea per F 360 days SPACER CHAMBER F 360 days KITSIZE 1 MISC retail); RX/OTC ADULT MISC retail); RX/OTC Louisiana Healthcare Connections Updated April 1, 2019

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT INHALER QL(2 ea per QL(1 ea per SPACER CHAMBER F 360 days SOOTHENEB NBL 100 F CHILD MASK MISC 360 days CHILD MISC retail); RX/OTC retail); RX/OTC PRONEB ULTRA FILTER QL(1 ea per QL(1 ea per F 360 days SOOTHENEB NBL 100 F 360 days SET MISC MEDICATION CUP MISC retail); RX/OTC retail); RX/OTC REPLACEMENT AIR QL(1 ea per QL(1 ea per F 360 days SOOTHENEB NBL 100 F 360 days FILTER MISC MESH CAP MISC retail); RX/OTC retail); RX/OTC REPLACEMENT FILTERS QL(1 ea per QL(1 ea per F 360 days SOOTHENEB NBL100 F 360 days MISC ADULT MASK MISC retail); RX/OTC retail); RX/OTC QL(2 ea per QL(1 ea per RITEFLO DEVI F 360 days THRESHOLD IMT MISC F 360 days retail); RX/OTC retail); RX/OTC SAMI THE SEAL QL(1 ea per QL(1 ea per REPLACEMENTFILTERS F 360 days TUBING/WING TIP MISC F 360 days MISC retail); RX/OTC retail); RX/OTC SIDESTREAM ADULT QL(1 ea per QL(2 ea per F 360 days VALVED HOLDING F 360 days FACE MASK MISC CHAMBER DEVI retail); RX/OTC retail); RX/OTC SIDESTREAM PEDIATRIC QL(1 ea per VORTEX VALVED QL(2 ea per F 360 days HOLDING CHAMBER F 360 days FACEMASK MISC retail); RX/OTC DEVI retail); RX/OTC SIDESTREAM PEDIATRIC QL(1 ea per QL(2 ea per FACEMASK/SAMI THE F 360 days WATCHHALER DEVI F 360 days SEAL MISC retail); RX/OTC retail); RX/OTC SIDESTREAM PEDIATRIC QL(1 ea per QL(1 ea per FACEMASK/TUCKER THE F 360 days WINDMILL TRAINER F MISC 360 days TURTLE MISC retail); RX/OTC retail); RX/OTC QL(1 ea per MIGRAINE PRODUCTS - Drugs to Treat Migraine SIDESTREAM PLUS F ADULT FACE MASK MISC 360 days Headaches retail); RX/OTC Migraine Combinations SILICONE MASK FOR QL(1 ea per BREATHERITE F 360 days CAFERGOT TABS (Use NF CHAMBER/ADULT MISC retail); RX/OTC w/ Caffeine) SILICONE MASK FOR QL(1 ea per ergotamine w/ caffeine tabs F BREATHERITE F 360 days 1mg-100mg CHAMBER/INFANT MISC retail); RX/OTC Migraine Products SILICONE MASK FOR QL(1 ea per D.H.E. 45 SOLN (Use BREATHERITE F 360 days NF CHAMBER/PEDIATRIC retail); RX/OTC Mesylate) MISC dihydroergotamine F SILICONE MASK FOR QL(1 ea per mesylate soln ij 1 mg/ml BREATHRITE F 360 days CHAMBER/ADULT MISC retail); RX/OTC dihydroergotamine F mesylate soln na 4 mg/ml

Louisiana Healthcare Connections Updated April 1, 2019

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MIGRANAL SOLN F QL(6 ea per 30 soln na 5 F days retail); Serotonin Agonists mg/act, 20 mg/act AL(At least 12 yrs old) QL(9 ea per 30 QL(2 ml per 30 AMERGE TABS (Use NF days retail); HCl) AL(At least 18 sumatriptan succinate soaj F days retail); yrs old) sc 6 mg/0.5ml AL(At least 12 yrs old) hydrobromide F QL(6 ea per 30 tabs days retail) QL(2 ml per 30 sumatriptan succinate soct F days retail); QL(6 ea per 30 sc 6 mg/0.5ml AL(At least 12 IMITREX SOLN NA 5 days retail); MG/ACT, 20 MG/ACT (Use NF yrs old) Sumatriptan) AL(At least 12 yrs old) QL(2.5 ml per sumatriptan succinate soln 30 days retail); QL(2.5 ml per F IMITREX SOLN SC 6 sc 6 mg/0.5ml AL(At least 12 NF 30 days retail); yrs old) MG/0.5ML (Use AL(At least 12 Sumatriptan Succinate) QL(2 ml per 30 yrs old) SUMATRIPTAN F days retail); IMITREX STATDOSE QL(2 ml per 30 SUCCINATE SOSY SC 6 AL(At least 12 MG/0.5ML REFILL SOCT 6 MG/0.5ML NF days retail); yrs old) (Use Sumatriptan AL(At least 12 Succinate) yrs old) QL(6 ea per 30 sumatriptan succinate tabs F days retail); IMITREX STATDOSE QL(2 ml per 30 or 25 mg, 50 mg, 100 mg AL(At least 12 SYSTEM SOAJ 6 NF days retail); yrs old) MG/0.5ML (Use AL(At least 12 Sumatriptan Succinate) yrs old) tabs or 5 mg, F QL(6 ea per 30 2.5 mg days retail) QL(6 ea per 30 IMITREX TABS OR 25 MG, days retail); zolmitriptan tbdp or 5 mg, F QL(6 ea per 30 50 MG, 100 MG (Use NF 2.5 mg days retail) Sumatriptan Succinate) AL(At least 12 yrs old) QL(6 ea per 30 QL(12 ea per F days retail); ZOMIG SOLN NA 5 MG AL(At least 12 MAXALT TABS (Use NF 30 days retail); Benzoate) AL(At least 6 yrs old) yrs old) ZOMIG TABS OR 5 MG, NF QL(6 ea per 30 2.5 MG (Use Zolmitriptan) days retail) MAXALT-MLT TBDP (Use NF QL(0.4 ea Rizatriptan Benzoate) daily) ZOMIG ZMT TBDP (Use NF QL(6 ea per 30 QL(9 ea per 30 Zolmitriptan) days retail) F days retail); MINERALS & ELECTROLYTES naratriptan hcl tabs AL(At least 18 yrs old) Calcium RELPAX TABS (Use NF QL(6 ea per 30 calcium carbonate- Eletriptan Hydrobromide) days retail) cholecalciferol tabs 500mg- F QL(12 ea per 200unit rizatriptan benzoate tabs 5 F 30 days retail); mg, 10 mg AL(At least 6 yrs old) rizatriptan benzoate tbdp 5 F QL(0.4 ea mg, 10 mg daily)

Louisiana Healthcare Connections Updated April 1, 2019

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcium carbonate-vitamin PEDIALYTE SOLN d tabs 125unit-250mg, 20MEQ/L-45MEQ/L- 125unit-500mg, 200unit- 35MEQ/L-5GM/L-20GM/L, 500mg, 250mg-125unit, F 20MEQ/L-45MEQ/L- 500mg-125unit, 500mg- 35MEQ/L-30MEQ/L- 200unit, 500mg-500mg- 25GM/L, 35MEQ/L- 200unit-200unit 45MEQ/L-7.8MG/L- calcium carbonate-vitamin QL(2 ea daily) 20MEQ/L-25GM/L, 4.7MEQ/237ML- NF d tabs 200unit-600mg, F 400unit-600mg, 600mg- 10.6MEQ/237ML- 200unit, 600mg-400unit 8.3MEQ/237ML, 2.1MEQ/59ML- oyster shell tabs F 2.7MEQ/59ML- 0.5MG/59ML- RA OYSTER SHELL 1.2MEQ/59ML- CALCIUM/VITAMIN D F 1.5GM/59ML (Use Oral TABS 500MG-200UNIT Electrolytes) Electrolyte Mixtures Fluoride CERASPORT EX1 SOLN F FLURA-DROPS SOLN F CERASPORT SOLN LURIDE SOLN (Use NF 4MEQ/L-18MEQ/L- F Sodium Fluoride) 20MEQ/L-6MEQ/L sodium fluoride chew or ENFAMIL ENFALYTE F 0.25 mg, 0.5 mg, 1 mg, 2.2 VC SOLN mg EQUALYTE SOLN (Use NF sodium fluoride soln or VC Oral Electrolytes) 0.125 mg/drop HYDRALYTE FREEZER F sodium fluoride soln or 0.5 F POPS SOLN mg/ml HYDRALYTE SOLN 270MG/250ML- Magnesium 210MG/250ML, 45MEQ/L- F MAGNESIUM CAPS 400 F 45MEQ/L-20MEQ/L- MG 90MEQ/L-16GM/L magnesium oxide (mg supplement) tabs 400 mg, F oral electrolytes soln F 241.3 mg PEDIALYTE ADVANCED MAGNESIUM OXIDE F CARE SOLN (Use Oral NF CAPS 400 MG Electrolytes) MAGOX 400 TABS (Use PEDIALYTE FREEZER Magnesium Oxide (Mg NF POPS SOLN (Use Oral NF Supplement)) Electrolytes) Phosphate PEDIALYTE SINGLES SOLN (Use Oral NF K-PHOS NEUTRAL TABS QL(8 ea daily) Electrolytes) (Use Pot Phosphate Monobasic w/ Sod NF Phosphate Dibasic & Monobasic)

Louisiana Healthcare Connections Updated April 1, 2019

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pot phosphate monobasic QL(8 ea daily) CELLCEPT SUSR 200 QL(15 ml daily) w/ sod phosphate dibasic & F MG/ML (Use NF monobasic tabs 130mg- Mycophenolate Mofetil) 155mg-852mg CELLCEPT TABS 500 MG QL(4 ea daily) Potassium (Use Mycophenolate NF Mofetil) K-TAB TBCR 10 MEQ (Use NF Potassium Chloride) cyclosporine caps or 25 F QL(4 ea daily) mg, 100 mg K-TAB TBCR 8 MEQ F cyclosporine modified (for QL(4 ea daily) microemulsion) caps 25 F KLOR-CON M15 TBCR F mg, 50 mg, 100 mg cyclosporine modified (for QL(8 ml daily) KLOR-CON/25 PACK F microemulsion) soln 100 F mg/ml potassium bicarbonate tbef F or 25 meq, 2.5gm-2gm CYCLOSPORINE F QL(4 ea daily) MODIFIED CAPS potassium chloride cpcr or F 10 meq CYCLOSPORINE QL(4 ea daily) MODIFIED CAPS (Use potassium chloride cpcr or F QL(1 ea daily) NF 8 meq Cyclosporine Modified (For Microemulsion)) POTASSIUM CHLORIDE F ER TBCR 8 MEQ cyclosporine soln iv 50 F potassium chloride mg/ml microencapsulated crystals F IMURAN TABS (Use NF er tbcr Azathioprine) mycophenolate mofetil QL(2 ea daily); potassium chloride pack or F F 20 meq caps 250 mg SP mycophenolate mofetil susr QL(15 ml daily) potassium chloride soln or F F 10 %, 20 % 200 mg/ml mycophenolate mofetil tabs QL(4 ea daily) potassium chloride tbcr or F F 8 meq, 10 meq 500 mg Zinc mycophenolate sodium F QL(2 ea daily); tbec 180 mg SP zinc sulfate caps or 220 mg F mycophenolate sodium F QL(4 ea daily) tbec 360 mg MISCELLANEOUS THERAPEUTIC CLASSES MYFORTIC TBEC 180 MG QL(2 ea daily); (Use Mycophenolate NF SP Chelating Agents Sodium) DEPEN TITRATABS TABS F MYFORTIC TBEC 360 MG QL(4 ea daily) 250 MG (Use Mycophenolate NF Immunosuppressive Agents Sodium) AZASAN TABS F QL(3 ea daily) NEORAL CAPS 25 MG, QL(4 ea daily) 100 MG (Use Cyclosporine NF Modified (For azathioprine tabs or 50 mg F Microemulsion)) CELLCEPT CAPS 250 MG QL(2 ea daily); (Use Mycophenolate NF SP Mofetil)

Louisiana Healthcare Connections Updated April 1, 2019

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEORAL SOLN 100 QL(8 ml daily) PERIDEX SOLN (Use MG/ML (Use Cyclosporine NF Chlorhexidine Gluconate NF Modified (For (Mouth-Throat)) Microemulsion)) Dental Products PROGRAF CAPS OR 0.5 QL(3 ea daily) PREVIDENT 5000 QL(106 ml per MG, 1 MG, 5 MG (Use NF Tacrolimus) BOOSTER PLUS PSTE NF fill retail) (Use Sodium Fluoride RAPAMUNE SOLN (Use NF (Dental)) Sirolimus) PREVIDENT 5000 DRY QL(125 ml per RAPAMUNE TABS (Use NF MOUTH GEL (Use Sodium NF fill retail) Sirolimus) Fluoride (Dental)) SANDIMMUNE CAPS OR QL(4 ea daily) PREVIDENT 5000 PLUS QL(60 gm per 25 MG, 100 MG (Use NF CREA (Use Sodium NF fill retail) Cyclosporine) Fluoride (Dental)) SANDIMMUNE SOLN IV PREVIDENT FLUORIDE QL(125 ml per 50 MG/ML (Use F GEL (Use Sodium Fluoride NF fill retail) Cyclosporine) (Dental)) SANDIMMUNE SOLN OR F QL(8 ml daily) PREVIDENT RINSE SOLN 100 MG/ML (Use Sodium Fluoride NF sirolimus soln or 1 mg/ml F (Dental)) sodium fluoride (dental) F QL(60 gm per sirolimus tabs or 0.5 mg, 1 F crea dt 1.1 % fill retail) mg, 2 mg sodium fluoride (dental) gel F QL(125 ml per tacrolimus caps or 0.5 mg, F QL(3 ea daily) dt 1.1 % fill retail) 1 mg, 5 mg sodium fluoride (dental) F QL(106 ml per Potassium Removing Agents pste dt 1.1 % fill retail) KAYEXALATE POWD (Use QL(454 gm per sodium fluoride (dental) F Sodium Polystyrene NF fill retail) soln mt 0.2 % Sulfonate) stannous fluoride conc mt F RX/OTC 0.63 % sodium polystyrene F QL(454 gm per sulfonate powd or fill retail) Steroids - Mouth/Throat sodium polystyrene triamcinolone acetonide F QL(5 gm per fill sulfonate susp or 15 F (mouth) pste retail) gm/60ml Throat Products - Misc. MOUTH/THROAT/DENTAL AGENTS QL(900 ml per Anesthetics Topical Oral AQUORAL SOLN F fill retail); RX/OTC lidocaine hcl (mouth-throat) F QL(100 ml per soln 2 % fill retail) BIOTENE DRY MOUTH QL(900 ml per MOISTURIZING SPRAY F fill retail); Anti-infectives - Throat SOLN RX/OTC nystatin (mouth-throat) F QL(120 ml per QL(900 ml per susp fill retail) CAPHOSOL SOLN F fill retail); Antiseptics - Mouth/Throat RX/OTC chlorhexidine gluconate QL(900 ml per F CVS DRY MOUTH SPRAY F (mouth-throat) soln 0.12 % SOLN fill retail); RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(900 ml per b-complex vitamins tabs or QL(1 ea daily) EQL DRY MOUTH ORAL F 0.1mg-20mg-2mg-5mcg- RINSE SOLN fill retail); RX/OTC 3mg-1mg, 10mg-10mg- QL(900 ml per 2mg-1.5mg-0.2mg, 10mg- MOI-STIR SOLN F fill retail); 14mg-25mcg-7mg-4.5mg, RX/OTC 15mg-2mg-5mg-2mcg- 2mg-2mg, 3mg-10mg- QL(900 ml per 20mg-3mg-6mcg-2mg, MOUTHKOTE SOLN F fill retail); 3mg-20mg-3mg-10mg- RX/OTC 6mcg-2mg, 83mg-3mg- F QL(900 ml per 20mg-2mg-5mcg-1mg, NUMOISYN LIQD F fill retail); 100mg-50mg-40mg-10mg- RX/OTC 20mg-5mg-4.6mg-1mcg- ORAL RELIEF SPRAY QL(900 ml per 5mg-1mg, 3mg-3mg-20mg- FOR DRYMOUTH & F fill retail); 20mg-3mg-3mg-10mg- DISCOMFORT SOLN RX/OTC 10mg-6mcg-6mcg-2mg- 2mg, 30mg-50mg-50mg- pilocarpine hcl (oral) tabs 5 F QL(6 ea daily) mg 50mg-50mg-50mg-50mcg- 50mg-100mcg-50mcg- QL(900 ml per 50mg RA DRY MOUTH SOLN F fill retail); RX/OTC B-Complex w/ C SALAGEN TABS 5 MG QL(6 ea daily) b complex w/ c caps 10mg- QL(1 ea daily) (Use Pilocarpine HCl NF 50mg-10mg-15mg-5mg- (Oral)) 300mg, 10.2mg-10mg- F QL(900 ml per 15mg-50mg-5mg-300mg, RELIEF F 10mg-50mg-10.2mg-15mg- SPRAY SOLN fill retail); RX/OTC 5mg-300mg B-Complex w/ Folic Acid MULTIVITAMINS b-complex w/ c & folic acid QL(1 ea daily); B-Complex Vitamins caps 1.5mg-5mg-20mg- RX/OTC b-complex vitamins caps or QL(1 ea daily) 1.7mg-6mcg-1mg-150mcg- F 70mg-100mg-1mg-10mg- 10mg-100mg, 5mg-1.7mg- 2mg-1.5mg-100mcg, 6mcg-20mg-1.5mg-1mg- 60mg-60mg-3mg-5mg- F 150mcg-10mg-100mg 20mg-3mg-1mcg-0.5mg, 60mg-60mg-5mg-20mg- 3mg-1mcg-3mg-0.5mg

Louisiana Healthcare Connections Updated April 1, 2019

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits b-complex w/ c & folic acid QL(1 ea daily); ALIVE WOMENS ENERGY F QL(1 ea daily); tabs 1.5mg-10mg-20mg- RX/OTC TABS RX/OTC 1.7mg-6mcg-1mg-300mcg- ANTIOXIDANT FORTE F QL(1 ea daily); 10mg-60mg, 30mcg- TABS RX/OTC 1.5mg-20mg-1.7mg-1mg- QL(1 ea daily); 1mg-300mcg-8mg-200mg, AP-ZEL TABS F 10mg-20mg-1.7mg-6mcg- RX/OTC QL(1 ea daily); 1.5mg-1mg-300mcg-10mg- BACMIN TABS F 100mg, 6mcg-1.5mg- RX/OTC 10mg-20mg-1.7mg-1mg- QL(1 ea daily); F BASIC AM TABS F 300mcg-10mg-100mg, RX/OTC 1.5mg-1.7mg-10mg- BASIC PM TABS F QL(1 ea daily); 0.01mcg-20mg-1mg- RX/OTC 300mcg-10mg-60mg, QL(1 ea daily); 20mg-1.7mg-10mg- CAL-DAY 1000 TABS F 0.006mg-1.5mg-1mg- RX/OTC 0.3mg-10mg-100mg, CENTRAVITES 50 PLUS F QL(1 ea daily); 6mcg-1.5mg-10mg-20mg- TABS RX/OTC 1.7mg-1000mcg-300mcg- CENTRAVITES ADULTS F QL(1 ea daily); 10mg-100mg TABS RX/OTC NEPHRO-VITE RX TABS QL(1 ea daily); CENTRUM ADULTS TABS QL(1 ea daily); (Use B-Complex w/ C & NF RX/OTC (Use Multiple Vitamins w/ NF RX/OTC Folic Acid) Minerals) NEPHROCAPS CAPS QL(1 ea daily); CENTRUM CARDIO TABS F QL(1 ea daily); (Use B-Complex w/ C & NF RX/OTC RX/OTC Folic Acid) QL(1 ea daily); CENTRUM MEN TABS F Multiple Vitamins w/ Iron RX/OTC CENTRUM SILVER QL(1 ea daily); multiple vitamins w/ iron F QL(1 ea daily) tabs 50+MEN TABS (Use NF RX/OTC Multiple Vitamins w/ Multiple Vitamins w/ Minerals Minerals) ABC COMPLETE SENIOR F QL(1 ea daily); CENTRUM SILVER QL(1 ea daily); WOMENS 50+ TABS RX/OTC 50+WOMEN TABS (Use NF RX/OTC ADVANCED DIABETIC QL(1 ea daily); Multiple Vitamins w/ MULTIVITAMIN FORMULA F RX/OTC Minerals) TABS CENTRUM SILVER QL(1 ea daily); QL(1 ea daily); ALIVE ENERGY 50+ TABS F ADULT 50+ TABS (Use NF RX/OTC RX/OTC Multiple Vitamins w/ Minerals) ALIVE MENS ENERGY F QL(1 ea daily); TABS RX/OTC ALIVE ONCE DAILY QL(1 ea daily); WOMENS 50+ ULTRA F RX/OTC TABS ALIVE ONCE DAILY QL(1 ea daily); WOMENS ULTRA F RX/OTC POTENCY TABS ALIVE WOMENS 50+ F QL(1 ea daily); TABS RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTRUM SILVER TABS QL(1 ea daily); CENTRUM ULTRA F QL(1 ea daily); 45MCG-2MG-72MG- RX/OTC WOMENS TABS RX/OTC 10MCG-55MCG-2.3MG- CENTRUM WOMEN TABS QL(1 ea daily); 5MCG-0.5MG-20MG- (Use Multiple Vitamins w/ NF RX/OTC 50UNIT-150MCG-45MCG- Minerals) 220MG-80MG-50MG- 150MCG-11MG-1.5MG- CERTAVITE QL(1 ea daily); 10MG-2500UNIT-20MG- SENIOR/ANTIOXIDANT F RX/OTC 30MCG-1.7MG-25MCG- NUTRIENTS TABS 500UNIT-400MCG- CLINICAL NUTRIENTS 45- F QL(1 ea daily); 30MCG-3MG-60MG, 2MG- PLUS WOMEN TABS RX/OTC 72MG-10MCG-20MCG- NF CLINICAL NUTRIENTS 50- F QL(1 ea daily); 150MCG-2MG-5MCG- PLUS MEN TABS RX/OTC 48MG-150MCG-75MCG- CLINICAL NUTRIENTS QL(1 ea daily); 200MG-150MCG-80MG- FOR FEMALE TEENS F RX/OTC 100MG-45UNIT-2MG- TABS 15MG-1.5MG-300MCG- 10MG-3500UNIT- CLINICAL NUTRIENTS F QL(1 ea daily); 250MCG-20MG-10MCG- FOR MALE TEENS TABS RX/OTC 1.7MG-25MCG-400MCG- CLINICAL NUTRIENTS F QL(1 ea daily); 30MCG-3MG-60MG- FOR MEN TABS RX/OTC 400UNIT (Use Multiple CLINICAL NUTRIENTS F QL(1 ea daily); Vitamins w/ Minerals) FOR WOMEN TABS RX/OTC CENTRUM SILVER QL(1 ea daily); F CVS ONE DAILY MENS F QL(1 ea daily); ULTRA MENS TABS RX/OTC 50+ ADVANCED TABS RX/OTC CENTRUM SILVER F QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); ULTRA WOMENS TABS RX/OTC ADULT 50+ TABS 50MCG- RX/OTC 2MG-72MG-10MCG- CENTRUM SPECIALIST F QL(1 ea daily); HEART TABS RX/OTC 19MCG-2.3MG-5MCG- 0.5MG-20MG-50UNIT- CENTRUM SPECIALIST F QL(1 ea daily); IMMUNE SUPPORT TABS RX/OTC 150MCG-45MCG-220MG- 80MG-11MG-50MG- CENTRUM SPECIALIST F QL(1 ea daily); 1.5MG-300MCG-10MG- VISION TABS RX/OTC 2500UNIT-250MCG-20MG- CENTRUM TABS 35MCG- QL(1 ea daily); 30MCG-1.7MG-25MCG- 2MG-72MG-10MCG- RX/OTC 1000UNIT-400MCG- 55MCG-75MCG-2.3MG- 30MCG-3MG-60MG, F 10MCG-5MCG-0.5MG- 45MCG-2MG-72MG- 20MG-150MCG-45MCG- 10MCG-55MCG-2.3MG- 80MG-200MG-30UNIT- 5MCG-0.5MG-20MG- 11MG-50MG-1.5MG- NF 50UNIT-150MCG-45MCG- 18MG-10MG-3500UNIT- 220MG-150MCG-80MG- 20MG-25MCG-1.7MG- 11MG-50MG-1.5MG- 6MCG-400UNIT-400MCG- 300MCG-10MG-2500UNIT- 30MCG-2MG-60MG (Use 250MCG-20MG-30MCG- Multiple Vitamins w/ 1.7MG-25MCG-500UNIT- Minerals) 400MCG-30MCG-3MG- CENTRUM ULTRA MENS QL(1 ea daily); 60MG TABS (Use Multiple NF RX/OTC CVS SPECTRAVITE F QL(1 ea daily); Vitamins w/ Minerals) ULTRA MEN50+ TABS RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS SPECTRAVITE QL(1 ea daily); HAIR SKIN & NAILS QL(1 ea daily); ULTRA MENS HEALTH F RX/OTC ADVANCED FORMULA F RX/OTC SENIOR TABS TABS CVS SPECTRAVITE QL(1 ea daily); HAIR-VITES TABS F QL(1 ea daily); ULTRA MENS HEALTH F RX/OTC RX/OTC TABS HM COMPLETE 50+ F QL(1 ea daily); CVS SPECTRAVITE F QL(1 ea daily); MENS ULTIMATE TABS RX/OTC ULTRA WOMEN TABS RX/OTC HM COMPLETE 50+ QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); WOMENS ULTIMATE F RX/OTC ULTRA WOMENS F RX/OTC TABS HEALTH SENIOR TABS HM COMPLETE MEN F QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); TABS RX/OTC ULTRA WOMENS F RX/OTC HM COMPLETE TABS F QL(1 ea daily); HEALTH TABS RX/OTC QL(1 ea daily); DERMAVITE TABS F HM HAIR/SKIN/NAILS F QL(1 ea daily); RX/OTC TABS RX/OTC EQ COMPLETE QL(1 ea daily); HM ONE DAILY MENS F QL(1 ea daily); MULTIVITAMINADULTS F RX/OTC TABS RX/OTC UNDER 50 TABS HM ONE DAILY WOMENS F QL(1 ea daily); EQ ONE DAILY MENS 50+ F QL(1 ea daily); TABS RX/OTC TABS RX/OTC QL(1 ea daily); HYALEX TABS F EQ ONE DAILY MENS F QL(1 ea daily); RX/OTC HEALTH TABS RX/OTC ICAPS AREDS FORMULA F QL(1 ea daily); EQ ONE DAILY WOMENS F QL(1 ea daily); TABS RX/OTC 50+ TABS RX/OTC QL(1 ea daily); ICAPS PLUS TABS F EQ ONE DAILY WOMENS F QL(1 ea daily); RX/OTC HEALTH TABS RX/OTC K-PAX IMMUNE QL(1 ea daily); EQL CENTURY MATURE QL(1 ea daily); F SUPPORT FORMULA F RX/OTC ADULTS50+ TABS RX/OTC PROFESSIONAL EQL CENTURY MENS F QL(1 ea daily); STRENGTH TABS TABS RX/OTC MACULAR VITAMIN F QL(1 ea daily); EQL CENTURY WOMENS F QL(1 ea daily); BENEFIT TABS RX/OTC TABS RX/OTC MEGA MULTI FOR MEN F QL(1 ea daily); EQL ONE DAILY MENS F QL(1 ea daily); TABS RX/OTC TABS RX/OTC MEGA MULTI FOR F QL(1 ea daily); FITNESS TABS FOR MEN F QL(1 ea daily); WOMEN TABS RX/OTC AM/PM/LYCOPENE TABS RX/OTC MEGA MULTIVITAMIN F QL(1 ea daily); FITNESS TABS FOR QL(1 ea daily); FOR MEN TABS RX/OTC WOMEN F RX/OTC MEGA MULTIVITAMIN F QL(1 ea daily); AM/PM/LYCOPENE TABS FOR WOMEN TABS RX/OTC FOSFREE TABS (Use QL(1 ea daily); MEGAVITE FRUITS & F QL(1 ea daily); Multiple Vitamins w/ NF RX/OTC VEGGIES TABS RX/OTC Minerals) MEGAVITE GOLDEN F QL(1 ea daily); FREEDAVITE TABS F QL(1 ea daily); YEARS 55+ TABS RX/OTC RX/OTC GERI-FREEDA SENIOR F QL(1 ea daily); FORMULA TABS RX/OTC Louisiana Healthcare Connections Updated April 1, 2019

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MENS 50+ MULTI QL(1 ea daily); multiple vitamins w/ QL(1 ea daily); VITAMIN &MINERAL F RX/OTC minerals tabs 0.6mg-10mg- RX/OTC FORMULA TABS 50mg-10mg-897mcg- MENS MULTI VITAMIN & QL(1 ea daily); 73mg-54mg-25unit- MINERAL FORMULA F RX/OTC 150mcg-0.5mg-20mg-5mg- TABS 10mg-3.3mg-15mg-10mg- 10mg-25mg-5mg-2500unit- MULTI-BETIC DIABETES F QL(1 ea daily); TABS RX/OTC 25mcg-50unit-7.2mg- 7.5mg-25mcg-25mcg- MULTI-VITAMIN F QL(1 ea daily); 6.5mg-3.5mg-50mg, MONOCAPS TABS RX/OTC 0.6mg-10mg-10mg- QL(1 ea daily); MULTILEX T&M TABS F 897mcg-58mg-25unit- RX/OTC 150mcg-125mg-0.6mg- 20mg-5mg-10mg-3.3mg- MULTILEX TABS F QL(1 ea daily); RX/OTC 15mg-10mg-10mg-25mg- 5mg-2500unit-25mcg- 50unit-7.2mg-7.5mg- 25mcg-25mcg-6.5mg- 3.5mg-50mg, 0.5mg- 25000unit-30mg-0.15mg- 6mg-25mg-7mg-100unit- 1000unit-30mg-5mg-10mg- 50mg-10mg-30mg-80mg- 30mg-80mg-80mg-80mg- 80mg-80mg-80mcg-80mg- 400mcg-80mcg-80mg- F 250mg, 0.2mg-35mcg- 150mcg-30mg-2mg-50unit- 15mg-7.5mg-10mg-30mg- 100mg-30mg-5000unit- 30mcg-30mg-400mcg- 30mcg-30mg-300mg- 400unit, 0.5mg-1mg-50mg- 50mg-100mg-7.5mg- 30unit-0.75mg-2500unit- 250mcg-10mg-0.85mg- 100unit-50mg-25mg- 100mcg-1250mcg-50mg- 60mg, 0.5mg-0.375mg- 1.5mg-80mg-15unit- 75mcg-100mg-2.5mg- 7.5mg-5mg-5000unit- 15mg-2.5mg-1mcg- 400unit-400mcg-1mg- 60mg, 0.5mg-0.37mg- 1.5mg-80mg-15unit- 75mcg-100mg-2.5mg- 2.5mg-5000unit-15mg- 2.5mg-5mg-1mcg-400unit- 400mcg-1mg-60mg, 0.05mg-50mcg-60unit- 20mcg-3mg-15mg-50mg- Louisiana Healthcare Connections Updated April 1, 2019

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 20mg-10mg-100mg-20mg- 166.667mg, 25mcg-3mg- 25mg-50mcg-1mg-0.15mg- 2mg-500mg-30unit-2mg- 25mg-500mg-400unit, 10mg-2mg-10mg-10mg, 0.5mg-15mg-155mcg- 16.667mcg-133.333unit- 9.5mg-15unit-150mg- 53.333mg-8333.333unit- 9.5mg-22mg-12.5mcg- 166.667mg, 40mcg- 99mg-12.5mg-1mg- 6000unit-50unit-5mg-2mg- 222mcg-99mg-122mg- 40mg-40mg-3mg-5mg- 22mcg, 0.12mg-3.75mg- 200mg, 12.5mg-1.5mg- 5unit-15mg-10mg-3.33mg- 10mg-20mg-1.7mg-6mcg- 0.33mcg-1.67mg, 2mg- 800mcg-300mcg-10mg- 12mg-8mg-500mcg, 60mg, 30unit-10mg-18mg- 30unit-2mg-15mg-6mg- 20mg-100mg-10mg- 60mg, 10000unit-25mcg- 12mcg-400mcg-45mcg- 200unit-200mg, 100mcg- 5mg-500mg, 69mg-30unit- 200unit-5000unit-250mg, 10mg-20mg-100mg-10mg- 200unit-1mg-40mg-1mg- 12mcg-400mcg-45mcg- 5mg-250mg, 50mcg- 5mg-500mg, 30unit- 100unit-10000unit-400unit, 5000unit-1.7mg-10mg- 17mcg-53mg-133unit- 6mcg-1.5mg-20mg-0.4mg- 8333unit-167mg, 40mcg- 2mg-60mg-400unit, 5000unit-30mg-2mg-40mg- 150mcg-5mg-15mg-2mg- 60mg, 100unit-7160unit- 30mg-100mg-125mg- 0.4mg-17.4mg-113mg, 500mg-6mcg-35mg- 40mcg-2mg-30unit- 400mcg-100mcg, 23.9mg- 1000unit-40mg-60mg, 30unit-3mg-10mg-20mg- 40mcg-2mg-30unit- 100mg-10mg-12mcg- 5000unit-40mg-60mg, 400mcg-45mcg-5mg- 40mcg-30unit-5000unit- 500mg, 46mg-60mg-3mg- 2mg-40mg-60mg, 40mcg- 24mg-20mg-20mg-5mg- 5000unit-2mg-40mg- 20mcg-100mg-400mcg- 30unit-60mg, 40mcg- 100mcg-20mg-500mg, 5000unit-30unit-2mg- 150mcg-15mg-2mg-5mg- 40mg-60mg, 5000unit- 18mg-30mg-65mg-125mg- 30unit-40mcg-2mg-40mg- 100mg-6mcg-35mg- 60mg, 5000unit-40mcg- 400mcg-300mcg, 15mg- 40mg-2mg-30unit-60mg, 30unit-20mg-10mg-4mg- 7160unit-0.4mg-17.4mg- 20mg-100mg-10mg- 100unit-113mg, 7160unit- 12mcg-400mcg-45mcg- 100unit-0.4mg-17.4mg- 5mg-300mg, 30unit-45mg- 113mg, 55mcg-60unit- 10mg-3000unit-20mg- 1000unit-2mg-40mg- 1.7mg-6mcg-400unit- 200mg, 5000unit-30unit- 1.5mg-0.4mg-2mg-60mg, 40mcg-2mg-40mg-2mg- 77mg-24mg-30unit-3mg- 60mg, 40mcg-30unit- 10mg-20mg-100mg-10mg- 44mg-5000unit-2mg-40mg- 12mcg-400mcg-45mcg- 60mg, 55mcg-2mg-60unit- 5mg-500mg, 15mcg- 1000unit-40mg-2mg- 2500unit-500mg-7.5mg- 200mg, 55mcg-60unit- 1mg-50mg-18mg-15unit- 1000unit-2mg-40mg-2mg- 200unit-6mcg-0.4mg-90mg, 200mg, 16.667mcg-53mg- 18mg-0.8mg-1.3mg-7mg- 133.333unit-8333.333unit- 50unit-25mg-100mg-10mg- Louisiana Healthcare Connections Updated April 1, 2019

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 25mg-25mcg-10mg-0.4mg- 25mcg-50mcg-200mg- 300mg, 25mcg-30mg- 10.5mg-25mcg-500mcg- 60mg-30unit-5mg-100mg- 50mcg-500mcg-2.4mg- 50mg-50mg-25mcg-50mg- 32mg-50mcg-5mg-100mg- 400mcg-50mg-600mg, 3.6mg, 60mg-5000unit- 30unit-1.5mg-45mg- 50mcg-12mg-1.5mg-75mg- 10mcg-3000unit-20mg- 13.5mg-25mg-15mg- 1.7mg-6mcg-400unit- 1.3mg-200mg-1.25mg- 0.4mg-2mg-60mg, 30unit- 30unit-500mg, 30unit- 45mg-1.5mg-10mg- 15mg-50mg-1.5mg-450mg- 3000unit-20mg-1.7mg- 18mg-5mg-2500unit- 6mcg-400unit-400mcg- 1.7mg-6mcg-400unit- 2mg-60mg, 5000unit- 10mg-400mcg-2mg-60mg, 5000unit-40mcg-40mcg- 30unit-15mg-50mg-1.5mg- 40mg-40mg-2mg-2mg- 450mg-18mg-5mg- 30unit-30unit-60mg-60mg, 2500unit-10mg-1.7mg- 15unit-20mg-30mg-1.5mg- 6mcg-400unit-400mcg- 20mg-1.5mg-2500unit- 2mg-60mg, 5000unit- 50mcg-400unit-400mcg- 125mg-18mg-150mcg- 5mg-30mg, 22.5mg-27mg- 160mg-100mg-15mg- 45unit-400unit-2mg- 400unit-1.7mg-6mcg- 5000unit-30mg-2.6mg- 1.2mg-20mg-0.4mg-2mg- 9mcg-0.4mg-20.6mg- 60mg, 16.6mcg-16.66mg- 90mg, 30unit-1.5mg-75mg- 16.6mcg-66unit-5mg- 18mg-10mg-5000unit- 8333unit-33.3unit- 20mg-1.7mg-6mcg- 16.66mcg-8.33mg- 400unit-400mcg-2mg- 133.33mcg-8.3mg-166mg, 60mg, 70mcg-30unit- 1mg-1.5mg-15mg-5.5unit- 15mg-1.5mg-20mg-1.7mg- 0.15mg-1mg-5mg-10mg- 10mg-6mcg-2000unit- 10mg-10000unit-30mg- 800mcg-300mcg-10mg- 5mg-3mcg-400unit-1.7mg- 80mg, 5000unit-450mg- 100mg, 30unit-450mg- 15mg-27mg-30unit-1.5mg- 15mg-27mg-2500unit- 1.7mg-10mg-6mcg-20mg- 2500unit-20mg-1.7mg- 0.4mg-2mg-60mg-400unit, 10mg-6mcg-1.5mg- 10unit-150mcg-125mg- 400mcg-2mg-60mg- 1mg-5mg-400unit- 400unit, 1mg-1.5mg- 5000unit-20mg-1.7mg- 5.5unit-0.15mg-1mg-5mg- 3mcg-1.5mg-100mcg-1mg- 15mg-15mg-10mg- 50mg, 30unit-15mg-1.5mg- 10000unit-100mg-10mg- 450mg-27mg-10mg- 7.5mcg-400unit-2mg- 5000unit-20mg-1.7mg- 150mg, 50mcg-10mg- 6mcg-400unit-400mcg- 60mg-100unit-125mg- 2mg-60mg, 3mg-30mg- 33mg-25mg-5000unit- 23.9mg-30unit-70mg- 50mg-25mg-25mg-200unit- 25mg-10mg-20mg-100mg- 1mg-300mcg-25mg- 10mg-12mcg-400mcg- 500mg, 50mcg-10mg- 45mcg-5mg-500mg, 80mg-125mg-200unit- 5000unit-450mg-15mg- 33mg-25mg-5000unit- 27mg-30unit-400unit- 50mg-25mg-25mg-25mg- 1.5mg-1.7mg-10mg-6mcg- 1mg-100unit-300mcg- 20mg-400mcg-2mg-60mg, 500mg, 1400unit-0.67mg- Louisiana Healthcare Connections Updated April 1, 2019

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 5unit-140unit-41.7mg- 50mcg-66mg-2.5mg- 3.3mg-66.7mg-11.7mg- 50unit-400unit-20mg- 100mg-33.3mg-3.3mg- 50mg-20mg-5000unit- 50mcg-0.33mg-3.3mg, 100mg-20mg-25mg- 10000unit-150mcg-1.5mg- 50mcg-1000mcg-200mcg- 2mg-1mg-65mg-12mg- 25mg-500mg, 10000unit- 15unit-100mg-10mg-20mg- 57mg-0.15mg-125mg-5mg- 5mcg-10mg-0.4mg-5mg- 2mg-2mg-40mg-15mg- 120mg-400unit, 30unit- 100unit-400unit-25mg- 0.1mg-5mg-3mg-22.5mg- 10mg-25mg-15mcg-10mg- 50mg-20mg-27mg- 400mcg-25mcg-10mg- 5000unit-100mg-20mg- 250mg, 20mcg-5250unit- 25mg-50mcg-0.8mg- 120mcg-2mg-2mg-15mg- 0.15mg-25mg-500mg, 1.5mg-450mg-27mg-10mg- 5000unit-5mcg-10mg- 20mg-25mcg-1.7mg-6mcg- 150mcg-19mg-3.75mg- 400unit-400mcg-30unit- 5mcg-1mg-10mg-4.5mg- 30mcg-2mg-60mg, 2.5mg-1mg-1mcg-400unit- 10000unit-0.125mg- 1mg-20mg-2mg-50mg, 150mcg-0.161mg-15mg- 7mg-5mg-30unit-200mg- 2mg-1.25mg-100mg-24mg- 60mg-15mg-50mg-1.5mg- 30unit-400unit-100mg- 5mg-2500unit-10mg-1mg- 10mg-20mg-6mcg-10mg- 1.7mg-6mcg-1000unit- 0.4mg-5mg-250mg, 1mg- 400mcg-300mcg-2mg, 150mcg-125unit-125mcg- 5mcg-5mcg-1mg-15.8mg- 35mg-35mg-10mg-25mg- 11.6mg-4.5mg-150mcg- 125mcg-35mg-400mcg- 3.75mg-10mg-1mg- 35mg-3.4mg-5mg-70mcg- 5000unit-20mg-2.5mg- 400unit-1.25mg-75mcg- 1mcg-400unit-2mg-1mg- 35mg-500mg, 20mcg- 50mg, 5mg-200mcg- 120mcg-2mg-2mg-30unit- 30unit-200mg-60mg-15mg- 15mg-50mg-5mg-450mg- 50mg-1.5mg-5mg- 15mg-5mg-10mg-25mcg- 2500unit-10mg-1mg- 1.7mg-2500unit-5mcg- 1.7mg-6mcg-1000unit- 500unit-400mcg-30mcg- 400mcg-300mcg-2mg, 2mg-60mg, 20mcg- 1mg-5mg-45mg-150mcg- 120mcg-2mg-2mg-30unit- 60mg-15mg-2mg-16mg- 450mg-50mg-15mg-18mg- 1.5mg-5000unit-1.7mg- 5mg-2500unit-10mg- 10mg-6mcg-400unit-20mg- 25mcg-1.7mg-6mcg- 400mcg-30unit-2mg-60mg, 800unit-1.5mg-0.4mg- 25mcg-5mg-2mg-5mg- 30mcg-2mg-60mg, 75mcg-150mg-30unit- 6.25mcg-72.5mg-50mg- 150mg-2mg-22.5mg- 30unit-100mg-2.5mg- 100mg-30mg-5mg-10mg- 0.5mg-7.5mg-0.75mg- 18mg-5000unit-10mg- 2500unit-250mcg-10mg- 10mg-400unit, 12.5mcg- 0.85mg-500unit-50mg- 2.5mg-1mg-2.5mg- 100mcg-1500mcg-60mg, 37.5mcg-75mg-15unit- 120mcg-2mg-2500unit- 2500unit-1mg-11.25mg- 2mg-30unit-20mcg-50mg- 50mg-15mg-2.5mg-10mg- 15mg-1.5mg-450mg-18mg- 9mg-10mg-10mg-200unit- 5mg-25mcg-1.7mg-6mcg- 300mcg, 200mcg-5mg- 400unit-10mg-400mcg- Louisiana Healthcare Connections Updated April 1, 2019

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 30mcg-2mg-60mg, 20mcg- 300mg-50mg-15mg-2.3mg- 2mg-120mcg-2mg-30unit- 18mg-10mg-2500unit- 15mg-50mg-1.5mg-450mg- 30mg-25mcg-2.6mg-9mcg- 18mg-5mg-2500unit-10mg- 800unit-400mcg-300mcg- 25mcg-1.7mg-6mcg- 3mg-120mg, 27.5mcg- 800unit-400mcg-30mcg- 25mcg-1.8mg-7.5mg- 2mg-60mg, 20mcg- 150mcg-0.9mg-8mg- 120mcg-2mg-2mg-30unit- 1.2mg-380mg-18mg-5mg- 15mg-50mg-1.5mg-450mg- 700mcg-16mg-25mcg- 18mg-5mg-2500unit-10mg- 1.3mg-6mcg-25mcg- 25mcg-1.7mg-6mcg- 400mcg-1000mcg-1.7mg- 1000unit-400mcg-30mcg- 75mg, 70mcg-200mcg- 2mg-60mg, 20mcg- 2mg-2mg-30unit-50mg- 120mcg-2mg-2mg-30unit- 15mg-1.9mg-200mg-18mg- 50mg-15mg-1.5mg-450mg- 12.5mg-2500unit-25mg- 18mg-5mg-2500unit-10mg- 80mcg-2.1mg-7.5mcg- 25mcg-1.7mg-6mcg- 400unit-400mcg-2.5mg- 1000unit-400mcg-30mcg- 10mg-60mg, 110mcg- 2mg-60mg, 70mcg-2mg- 120mcg-2mg-210mg- 150mcg-2mg-30unit- 22.5unit-2mg-15mg- 2500unit-15mg-50mg- 120mg-1.2mg-300mcg- 1.9mg-300mg-18mg- 5mg-3500unit-16mg- 12.5mg-25mg-80mcg- 20mcg-1.7mg-18mcg- 2.1mg-7.5mcg-400unit- 700unit-400mcg-30mcg- 400mcg-2.5mg-60mg, 3mg-60mg, 110mcg- 20mcg-120mcg-2mg-2mg- 120mcg-2mg-22.5unit- 22.5unit-15mg-50mg- 2mg-15mg-120mg-1.2mg- 1.5mg-500mg-18mg-5mg- 300mcg-210mg-5mg- 2500unit-10mg-25mcg- 3500unit-16mg-20mcg- 1.7mg-6mcg-1000unit- 1.7mg-18mcg-700unit- 400mcg-30mcg-2mg- 400mcg-30mcg-3mg-60mg, 60mg, 20mcg-120mcg- 120mcg-20mcg-22.5unit- 2mg-2mg-22.5unit-15mg- 2mg-2mg-150mcg-15mg- 50mg-1.5mg-500mg-18mg- 1.5mg-500mg-18mg-10mg- 5mg-2500unit-25mcg- 2500unit-20mg-25mcg- 1.7mg-6mcg-1000unit- 1.7mg-6mcg-1000unit- 10mg-400mcg-30mcg- 400mcg-300mcg-2mg- 2mg-60mg, 20mcg- 60mg, 20mcg-120mcg- 120mcg-2mg-2mg- 2mg-150mcg-500mg- 22.5unit-15mg-50mg- 22.5unit-2mg-15mg-1.5mg- 1.6mg-500mg-18mg-5mg- 18mg-10mg-2500unit- 2500unit-10mg-25mcg- 20mg-25mcg-1.7mg-6mcg- 1.7mg-6mcg-1000unit- 1000unit-400mcg-300mcg- 400mcg-30mcg-2mg- 2mg-60mg, 20mcg- 60mg, 20mcg-120mcg- 120mcg-2mg-22.5unit- 2mg-2mg-22.5unit-500mg- 150mcg-20mg-2mg-15mg- 15mg-50mg-1.5mg-18mg- 1.5mg-500mg-18mg-10mg- 5mg-2500unit-10mg- 2500unit-25mcg-1.7mg- 25mcg-1.7mg-6mcg- 6mcg-1000unit-400mcg- 1000unit-400mcg-30mcg- 300mcg-2mg-60mg, 2mg-60mg, 20mcg- 20mcg-120mcg-2mg-2mg- 120mcg-2mg-2mg-30unit- 22.5unit-150mcg-15mg- Louisiana Healthcare Connections Updated April 1, 2019

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1.5mg-500mg-18mg-10mg- 22.5unit-210mg-2mg- 2500unit-20mg-25mcg- 15mg-140mg-1.35mg- 1.7mg-6mcg-1000unit- 300mcg-16mg-3500unit- 400mcg-300mcg-2mg- 18mg-20mcg-1.7mg- 60mg, 20mcg-120mcg- 18mcg-700unit-400mcg- 2mg-2mg-22.5unit- 75mcg-3mg-60mg, 150mcg-500mg-15mg- 110mcg-120mcg-2mg- 1.5mg-18mg-10mg- 22.5unit-2mg-15mg- 2500unit-20mg-25mcg- 140mg-1.35mg-300mcg- 1.7mg-6mcg-1000unit- 210mg-16mg-3500unit- 400mcg-300mcg-2mg- 18mg-20mcg-1.7mg- 60mg, 10mg-70mcg- 18mcg-700unit-400mcg- 20mcg-120mcg-2mg- 75mcg-3mg-60mg, 33unit-100mg-2mg-15mg- 110mcg-120mcg-2mg- 120mg-1.1mg-240mg-5mg- 2mg-22.5unit-15mg- 3000unit-14mg-1.7mg- 140mg-1.35mg-300mcg- 18mcg-400unit-400mcg- 210mg-16mg-3500unit- 30mcg-3mg-75mg, 32mg- 18mg-20mcg-1.7mg- 70mcg-200mcg-2mg-2mg- 18mcg-700unit-400mcg- 30unit-300mg-50mg- 75mcg-3mg-60mg, 18mcg- 2500unit-15mg-1.9mg- 20mcg-2mg-105mcg- 18mg-12.5mg-25mg- 99mg-2mg-120mcg-45unit- 80mcg-2.125mg-7.5mcg- 400unit-15mg-120mg- 400unit-400mcg-2.5mg- 1.2mg-0.6mg-210mg- 60mg, 32mg-70mcg- 3500unit-1.7mg-5mg-3mg- 200mcg-2mg-30unit- 16mg-400mcg-30mcg- 300mg-2500unit-2mg- 90mg, 105mcg-120mcg- 15mg-50mg-1.9mg-18mg- 2mg-45unit-100mg-120mg- 12.5mg-25mg-80mcg- 2mg-15mg-1.2mg-0.6mg- 2.125mg-7.5mcg-400unit- 210mg-5mg-3500unit- 400mcg-2.5mg-60mg, 16mg-20mcg-1.7mg- 32mg-70mcg-80mcg- 18mcg-400mcg-30mcg- 200mcg-2mg-2mg-30unit- 3mg-90mg-400unit, 2500unit-15mg-50mg- 105mcg-120mcg-2mg- 1.9mg-300mg-18mg- 45unit-210mg-99mg-2mg- 12.5mg-25mg-2.125mg- 15mg-120mg-1.2mg- 7.5mcg-400unit-400mcg- 600mcg-5mg-3500unit- 2.5mg-60mg, 50mg-30mg- 16mg-20mcg-1.7mg- 150mcg-1.35mg-75mg- 18mcg-400mcg-30mcg- 30unit-100mg-1.1mg- 3mg-90mg-400unit, 100mg-15mg-10mg-6.5mg- 105mcg-120mcg-2mg- 5mg-10mg-5000unit- 45unit-99mg-210mg- 12mcg-400unit-5mg-20mg- 120mg-2mg-15mg-1.2mg- 400mcg-2mg-150mg, 600mcg-5mg-3500unit- 110mcg-120mcg-2mg- 16mg-20mcg-1.7mg- 210mg-140mg-22.5unit- 18mcg-400unit-400mcg- 2mg-15mg-1.35mg- 30mcg-3mg-90mg, 300mcg-16mg-3500unit- 105mcg-2mg-45unit-99mg- 18mg-20mcg-1.7mg- 120mcg-2mg-15mg- 18mcg-700unit-400mcg- 120mg-1.2mg-600mcg- 75mcg-3mg-60mg, 210mg-5mg-3500unit- 110mcg-120mcg-2mg- 16mg-20mcg-1.7mg- Louisiana Healthcare Connections Updated April 1, 2019

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 18mcg-400unit-400mcg- 2mg-15mg-150mg-3mg- 30mcg-3mg-90mg, 100mg-20mg-5000unit- 110mcg-120mcg-2mg- 25mg-10mcg-3.4mg- 2mg-22.5unit-15mg- 30mcg-500unit-500mcg- 140mg-1.35mg-300mcg- 666mcg-4mg-100mg, 210mg-16mcg-3500unit- 10mcg-20mcg-120mcg- 18mg-20mcg-1.7mg- 2mg-10mcg-5mcg-2mg- 18mcg-700unit-400mcg- 109mg-30unit-150mcg- 75mcg-3mg-60mg, 180mg- 75mcg-150mcg-2mg- 20mcg-120mcg-2mg- 300mcg-10mg-18mg- 30unit-300mg-2mg-15mg- 3500unit-250mcg-10mg- 50mg-2.4mg-18mg-5mg- 10mg-25mcg-400unit, 2500unit-10mg-25mcg- 833unit-41.7mg-1.7mg- 2.7mg-9.5mcg-800unit- 83mcg-250mcg-28.3mg- 400mcg-30mcg-3.2mg- 5unit-33unit-5mg-5mg- 60mg, 105mcg-120mcg- 16.7mg-16.7mg-2.5mg- 2mg-45unit-100mg-2mg- 8.3mg-1.7mcg-1.7mg- 15mg-120mg-1.2mg- 2.5mg-66.7mcg-8.3mcg- 600mcg-210mg-5mg- 83mg-83mg, 110mcg- 1500unit-18mg-20mcg- 120mcg-2mg-22.5unit- 1.7mg-18mcg-400unit- 100mg-2mg-15mg-120mg- 400mcg-30mcg-3mg- 1.2mg-300mcg-210mg- 90mg, 105mcg-120mcg- 5mg-3500unit-16mg- 2mg-45unit-100mg-2mg- 20mcg-1.7mg-18mcg- 15mg-120mg-1.2mg- 700unit-400mcg-30mcg- 600mcg-210mg-5mg- 3mg-60mg, 110mcg- 3500unit-16mg-20mcg- 120mcg-2mg-22.5unit- 1.7mg-18mcg-400unit- 210mg-100mg-2mg-15mg- 400mcg-30mcg-3mg- 120mg-1.2mg-300mcg- 90mg, 105mcg-20mcg- 5mg-3500unit-16mg- 120mcg-2mg-45unit- 20mcg-1.7mg-18mcg- 100mg-2mg-15mg-120mg- 700unit-400mcg-30mcg- 1.2mg-600mcg-210mg- 3mg-60mg, 20mcg- 5mg-3500unit-16mg- 120mcg-150mcg-75mcg- 1.7mg-18mcg-400unit- 10mcg-2mg-250mcg-2mg- 400mcg-30mcg-3mg- 15mg-100mg-5mg-100mg- 90mg, 10mcg-15mcg-5mg- 10mg-20mg-100mg-5mg- 2mg-15mg-30unit-150mcg- 3500unit-30mcg-400mcg- 15mcg-10mg-40mg- 30unit-30mcg-5mg-100mg, 100mg-3mg-27mg-10mg- 70mcg-2500unit-50unit- 30mg-3.4mg-5500unit- 4mg-75mcg-150mcg- 9mcg-400unit-400mcg- 162mg-2mg-120mcg- 15mcg-3mg-120mg, 20mg-15mg-100mg-1.5mg- 10mcg-5mg-2mg-15mg- 80mcg-1.7mg-10mg- 30unit-150mcg-15mcg- 18mcg-1000unit-400mcg- 10mg-40mg-15mcg- 30mcg-4mg-180mg, 100mg-3mg-27mg-10mg- 70mcg-2500unit-60unit- 30mg-3.4mg-5500unit- 4mg-75mcg-150mcg- 9mcg-400unit-400mcg- 200mg-2mg-120mcg- 15mcg-3mg-120mg, 100mg-20mg-15mg-1.5mg- 200mcg-70mcg-5mg- 80mcg-1.7mg-10mg- 150mcg-75mcg-50unit- 25mcg-1000unit-400mcg- Louisiana Healthcare Connections Updated April 1, 2019

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 30mcg-6mg-180mg, 8mg- 100mg-15mg-1.5mg- 30unit-10mcg-150mcg- 162mg-18mg-10mg- 40mg-15mg-2mg-15mcg- 2500unit-20mg-80mcg- 8mg-15mcg-2mg-60mg- 1.7mg-6mcg-1000unit- 9mg-10mg-5000unit-20mg- 400mcg-30mg-2mg- 1.7mg-6mcg-400unit- 180mg, 10mcg-15mcg- 1.5mg-400mcg-30mcg- 5mg-31mg-30unit-150mcg- 2mg-90mg, 105mcg- 15mcg-7.5mg-40mg-2mg- 2500unit-60unit-4mg- 15mg-100mg-3mg-18mg- 75mcg-150mcg-162mg- 10mg-5500unit-30mg- 2mg-120mcg-100mg- 3.4mg-9mcg-400unit- 20mg-15mg-1.5mg-80mcg- 400mcg-15mcg-3mg- 1.7mg-10mg-25mcg- 120mg, 50mg-20mcg- 1000unit-400mcg-30mcg- 120mcg-2mg-22.5unit- 6mg-180mg, 5000unit- 300mg-50mg-2mg-15mg- 10mcg-31mg-150mcg- 2.4mg-18mg-5mg- 40mg-15mg-2mg-15mcg- 2500unit-10mg-25mcg- 10mg-15mcg-5mg-100mg- 2.7mg-9.5mcg-800unit- 27mg-30unit-400unit-3mg- 400mcg-30mcg-3.2mg- 3.4mg-10mg-9mcg-20mg- 120mg-60mg, 50mg- 400mcg-30mcg-3mg- 20mcg-120mcg-2mg-2mg- 90mg, 10mcg-10mcg- 22.5unit-15mg-50mg- 2.5mg-2mg-15mg-100mg- 2.4mg-300mg-18mg-5mg- 30unit-150mcg-40mg- 2500unit-10mg-25mcg- 130mg-10mcg-100mg- 2.7mg-9.5mcg-600unit- 1.5mg-10mg-5000unit- 400mcg-30mcg-3.2mg- 20mg-1.7mg-6mcg- 120mg-60mg, 50mg- 400mcg-30mcg-2mg- 20mcg-120mcg-2mg-2mg- 60mg-400unit, 27mcg- 22.5unit-15mg-50mg- 180mcg-4.2mg-30unit- 2.4mg-300mg-18mg-5mg- 150mcg-90mcg-2.2mg- 2500unit-10mg-25mcg- 24mg-50mg-4.5mg-500mg- 2.7mg-9.5mcg-800unit- 10mg-3500unit-20mg- 400mcg-30mcg-3.2mg- 20mcg-3.4mg-25mcg- 120mg-60mg, 7.5mg- 1000unit-400mcg-30mcg- 10mcg-150mcg-41mg- 6mg-120mg, 27mcg- 15mg-2mg-15mcg-7.5mg- 180mcg-4.2mg-30unit- 15mcg-5mg-100mg-27mg- 150mcg-90mcg-50mg- 30unit-400unit-5500unit- 2.2mg-24mg-4.5mg- 30mg-3.4mg-10mg-9mcg- 500mg-15mg-3500unit- 3mg-0.4mg-15mcg-3mg- 20mg-20mcg-3.4mg- 120mg, 105mcg-200mcg- 25mcg-1000unit-400mcg- 2mg-154mg-45unit-75mcg- 30mcg-6mg-120mg, 99mg-200mg-2500unit- 27mcg-3500unit-180mcg- 2mg-22.5mg-100mg- 4.2mg-2.2mg-30unit- 2.2mg-15mg-25mg-25mcg- 150mcg-90mcg-24mg- 2.5mg-9mcg-400unit- 50mg-4.5mg-500mg-15mg- 400mcg-450mcg-3mg- 20mg-20mcg-3.4mg- 90mg, 120mg-20mcg- 25mcg-1000unit-400mcg- 100mcg-33unit-150mcg- 30mcg-6mg-120mg, 90mcg-4mg-2mg-22.5mg- 70mcg-120mcg-4mg-2mg- 50mg-4.5mg-405mg-15mg- 50unit-150mcg-75mcg- 2500unit-20mg-20mcg- Louisiana Healthcare Connections Updated April 1, 2019

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3.4mg-25mcg-800unit- 120mg-20mcg-180mcg- 400mcg-30mcg-6mg- 4mg-2mg-22.5unit- 60mg, 120mg-20mcg- 150mcg-90mcg-500mg- 180mcg-4mg-2mg-33unit- 22.5mg-50mg-4.5mg- 150mcg-90mcg-22.5mg- 15mg-2500unit-20mg- 50mg-4.5mg-405mg-15mg- 20mcg-3.4mg-25mcg- 2500unit-20mg-20mcg- 1000unit-400mcg-30mcg- 3.4mg-25mcg-800unit- 6mg-60mg, 120mg-27mcg- 400mcg-30mcg-6mg- 4.2mg-180mcg-30unit- 60mg, 120mg-20mcg- 150mcg-90mcg-500mg- 2500unit-4mg-180mcg- 50mg-2.2mg-24mg-4.5mg- 2mg-33unit-150mcg- 15mg-3500unit-20mg- 90mcg-22.5mg-50mg- 20mcg-3.4mg-25mcg- 4.5mg-405mg-15mg-20mg- 1000unit-400mcg-30mcg- 20mcg-3.4mg-25mcg- 6mg-120mg, 7.5mg- 800unit-400mcg-30mcg- 10mcg-15mcg-5mg-31mg- 6mg-60mg, 120mg-20mcg- 30unit-150mcg-15mcg- 4mg-180mcg-2mg-33unit- 44mg-7.5mg-2mg-15mg- 150mcg-90mcg-50mg- 100mg-18mg-10mg- 22.5mg-4.5mg-405mg- 5500unit-30mg-3.4mg- 15mg-2500unit-20mg- 9mcg-400unit-3mg- 20mcg-3.4mg-25mcg- 400mcg-15mcg-3mg- 800unit-400mcg-30mcg- 120mg, 7.5mg-5000unit- 6mg-60mg, 120mg-20mcg- 10mcg-31mcg-150mcg- 2500unit-180mcg-33unit- 40mg-15mg-2mg-15mcg- 150mcg-90mcg-4mg-2mg- 7.5mg-15mcg-5mg-100mg- 22.5mg-50mg-4.5mg- 27mg-30unit-400unit- 405mg-15mcg-20mg- 3.4mg-10mg-9mcg-3mg- 20mcg-3.4mg-25mcg- 20mg-0.04mg-30mcg-3mg- 800unit-400mcg-30mcg- 90mg, 117mcg-180mcg- 6mg-60mg, 833.33unit- 4.2mg-2.2mg-30unit- 0.03mg-8.33mg-1mg- 150mcg-90mcg-24mg- 0.33mg-0.33mg-11.33mg- 110mg-4.5mg-370mcg- 3.33mg-4.67unit-66.67unit- 120mg-15mg-3500unit- 10mg-43.55mg-0.67mg- 20mg-20mcg-3.4mg- 2.5mg-1.67mg-3.33mg- 25mcg-700unit-400mcg- 0.03mg-1.33mg-33.33mg, 30mcg-6mg-120mg, 2mg- 10mg-0.5mg-10mg- 72mg-20mcg-150mcg- 17.5mcg-75mcg-120mg- 5mcg-48mg-75mcg- 1mg-30unit-60mg-35mg- 200mg-10mcg-150mcg- 7.5mg-9mg-10mg-100mg- 150mcg-80mg-2mg- 10mg-10mg-5000unit- 100mg-300mcg-10mg- 10mcg-10mg-400mcg- 20mg-10mcg-1.7mg- 30mcg-10mg-200mg- 25mcg-400unit-1.5mg- 400unit, 100mcg-50mcg- 400mcg-30mcg-3mg, 25mcg-2.5mg-7.5mg- 34mg-105mcg-180mcg- 75mcg-50mg-30unit- 4mg-2mg-33unit-150mcg- 100mg-50mg-1.5mg- 90mcg-40mg-22.5mg- 100mg-10mg-250mcg- 100mg-4.5mg-120mg- 20mg-1.7mg-2500unit- 15mg-2500unit-20mg- 5mcg-200unit-200mcg- 20mcg-3.4mg-25mcg- 75mcg-2.5mg-60mg, 400unit-400mcg-30mcg- Louisiana Healthcare Connections Updated April 1, 2019

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 6mg-120mg, 117mcg- 5mg-5mcg-15mg-10mg- 180mcg-4.2mg-2.2mg- 0.025mg-5mcg-5mg-10mg- 150mcg-90mcg-110mg- 66.6mg, 34mg-105mcg- 24mg-4.5mg-370mcg- 180mcg-4mg-60unit- 120mg-15mg-3500unit- 150mcg-90mcg-37.5mg- 20mg-20mcg-3.4mg- 100mg-2mg-22.5mg- 25mcg-700unit-400mcg- 4.5mg-120mg-15mg- 25.5unit-30mcg-6mg- 5000unit-20mg-20mcg- 120mg, 117mcg-180mcg- 3.4mg-30mcg-400unit- 4.2mg-2.2mg-25.5unit- 400mcg-30mcg-6mg- 150mcg-90mcg-110mg- 120mg, 120mg-110mcg- 24mg-4.5mg-370mcg- 180mcg-4mg-2mg- 120mg-15mg-3500unit- 22.5unit-150mcg-90mcg- 20mg-20mcg-3.4mg- 120mg-22.5mg-100mg- 25mcg-700unit-400mcg- 4.5mg-300mg-15mg- 30mcg-6mg-120mg, 2500unit-20mg-20mcg- 117mcg-180mcg-4.2mg- 3.4mg-25mcg-700unit- 2.2mg-25.5unit-150mcg- 400mcg-30mcg-6mg-60mg, 90mcg-24mg-110mg- 34mg-10mcg-100mg- 4.5mg-370mcg-120mg- 150mcg-130mg-15mg- 15mg-3500unit-20mg- 2mg-10mcg-37.5mg- 20mcg-3.4mg-25mcg- 10mcg-2.5mg-100mg- 700unit-400mcg-30mcg- 18mg-30unit-400unit- 6mg-120mg, 117mcg- 5000unit-1.7mg-10mg- 180mcg-4.2mg-25.5unit- 6mcg-1.5mg-20mg- 150mcg-90mcg-110mg- 400mcg-30mcg-2mg-60mg, 2.2mg-24mg-4.5mg- 35mcg-1mg-1mg-60mcg- 370mcg-120mg-15mg- 7mg-25unit-75mcg- 3500unit-20mg-20mcg- 37.5mcg-100mg-50mg- 3.4mg-25mcg-700unit- 500unit-11.5mg-0.75mg- 400mcg-30mcg-6mg- 150mcg-1mg-5mg-5mg- 120mg, 117mcg-180mcg- 10mg-15mcg-0.85mg- 4.2mg-25.5unit-150mcg- 3mcg-200unit-200mcg- 90mcg-120mg-110mg- 15mcg-1mg-75mg, 7.5mg- 2.2mg-24mg-4.5mg- 10mcg-31mg-150mcg- 370mcg-15mg-3500unit- 40mg-15mg-2mg-15mcg- 20mg-20mcg-3.4mg- 7.5mg-15mcg-5mg-100mg- 25mcg-700unit-400mcg- 27mg-1250unit-30unit- 30mcg-6mg-120mg, 5mg- 400unit-5000unit-30mg- 0.5mg-250mcg-1.5mg- 3.4mg-10mg-9mcg-3mg- 50mg-750mcg-50mg- 0.4mg-35mcg-3mg-90mg, 15unit-100mg-60mg- 7.5mg-10mcg-31mg- 7.5mg-5mg-0.75mg- 150mcg-40mg-15mg-2mg- 6.75mg-2500unit-5mg- 15mcg-7.5mg-15mcg-5mg- 10mg-0.85mg-100unit- 100mg-27mg-2500unit- 50mg-25mg-100mcg- 30unit-400unit-2500unit- 1500mcg-100mg, 20mg-3.4mg-10mg-9mcg- 3333.3unit-0.66mg-25mg- 3mg-0.4mg-30mcg-3mg- 115mg-5mg-0.033mg- 90mg, 7.5mg-21mcg- 15mg-10mg-0.33mg- 26mcg-3.5mg-2mg-31mg- 25mcg-26.6mg-20unit- 30unit-150mcg-32mcg- 133.3unit-16.6mg-5mg- 7.5mg-15mg-100mg-3mg- Louisiana Healthcare Connections Updated April 1, 2019

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 40mg-18mg-10mg- 1mg-37.5mcg-100mcg- 5000unit-20mg-28mcg- 25mcg-35mcg-1mg-75mcg- 3.4mg-9mcg-400unit- 1mg-15unit-200mg-7.5mg- 400mcg-30mcg-3mg- 0.75mg-125mg-5mg-10mg- 90mg, 7.5mg-5mg-10mcg- 0.85mg-2500unit-3mcg- 2mg-31mg-30unit-150mcg- 200unit-1mg-200mcg- 15mg-40mg-15mcg-7.5mg- 150mcg-30mg, 50mcg- 15mcg-1250unit-100mg- 1.75mg-5mg-0.5mg-1.5mg- 3mg-27mg-5000unit-30mg- 25mcg-32mg-12.5mcg- 3.4mg-10mg-9mcg-0.4mg- 200mg-0.75mg-3.75mg- 35mcg-3mg-90mg-400unit, 75mg-1.25mg-11.25mcg- 32mcg-72mg-18mcg- 5mg-5mg-12.5mg-75mcg- 1.8mg-0.5mg-20mg-35unit- 5mg-12.5mcg-200unit- 150mcg-50mcg-80mg- 5mg-200mcg-6.25mg- 200mg-8mg-100mg-1.1mg- 30mg, 15mg-25mg-1.5mg- 18mg-15mg-3500unit- 50mg-5mg-64mg-7.5unit- 14mg-50mcg-1.1mg-6mcg- 25mg-1mg-3.75mg-5mg- 800unit-400mcg-40mcg- 130mg-4mg-5mg-7.5mg- 2mg-75mg, 120mg- 12.5mg-15mg-5mg-2.5mg- 105mcg-180mcg-4mg- 2500unit-4mcg-500unit- 2mg-33unit-150mcg- 2.5mg-100mcg-2500mcg- 90mcg-40mg-100mg- 2.5mg-30mg, 100mcg- 22.5mg-4.5mg-600mcg- 70mcg-150mcg-75mcg- 120mg-15mg-2500unit- 10mcg-2mg-60unit- 20mg-20mcg-3.4mg- 250mcg-2mg-15mg- 25mcg-400unit-400mcg- 100mg-10mg-100mg- 30mcg-6mg-120mg, 18mg-10mg-25mg-100mg- 120mg-105mcg-180mcg- 100mcg-10mg-3000unit- 4mg-2mg-33unit-150mcg- 25mcg-2000unit-400mcg- 90mcg-40mg-22.5mg- 30mcg-6mg-100mg, 30mg- 100mg-4.5mg-600mcg- 2mg-72mg-10mcg-20mcg- 120mg-15mg-2500unit- 120mcg-10mcg-5mcg-2mg- 20mg-20mcg-3.4mg- 109mg-30unit-150mcg- 25mcg-400unit-400mcg- 0.75mcg-150mcg-80mg- 30mcg-6mg-120mg, 2mg-300mcg-10mg-18mg- 120mg-105mcg-2500unit- 3500unit-250mcg-10mg- 180mcg-33unit-150mcg- 10mg-25mcg-400unit- 90mcg-40mg-4mg-2mg- 400mcg, 150mcg-120mcg- 22.5mg-100mg-4.5mg- 70mcg-2mg-2mg-30unit- 600mcg-120mg-15mg- 150mcg-75mcg-15mg- 20mg-20mcg-3.4mg- 50mg-4.5mg-700mcg- 25mcg-400unit-400mcg- 500mg-18mg-15mg- 30mcg-6mg-120mg, 3500unit-100mcg-20mg- 120mg-105mcg-4mg- 60mcg-5.1mg-18mcg- 180mcg-2mg-33unit- 1000unit-400mcg-300mcg- 150mcg-90mcg-40mg- 6mg-60mg, 16.7unit- 22.5mg-100mg-4.5mg- 16.7mcg-12.5mcg-4.16mg- 600mcg-120mg-15mg- 0.08mg-16.7mcg-7.9mg- 2500unit-20mg-20mcg- 1.67mg-41.7mg-2.5mg- 3.4mg-25mcg-400unit- 16.7unit-4.16mg-4.16mg- 400mcg-30mcg-6mg- 52.08mg-4.16mg- 120mg, 45mg-25mg-40mg- 2083.3unit-10.4mcg- Louisiana Healthcare Connections Updated April 1, 2019

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 4.16mg-33.3mcg-4.16mg- 0.25mg-25000unit-15mg- 250mg, 25mcg-300mcg- 24.3mg-0.1mg-53.5mg- 25mcg-25mcg-27mg-5mg- 50mg-6.15mg-2.2mg- 2mg-125mg-34unit- 7.2mg-12.5unit-400unit- 150mcg-162mg-30mg- 25mg-5mg-15mg-12.5mg- 5000unit-15mg-100mg- 50mg-250mg-150mg- 2.25mg-27mg-10mg-20mg- 25mg-50mcg-25mg-0.4mg- 25mcg-2.6mg-9mcg- 1mcg-15mg-150mg, 5mg- 400unit-400mcg-45mcg- 90mg-10mcg-45mcg- 3mg-90mg, 25mg-120mcg- 3500unit-2mg-10mcg- 25mg-70mcg-80mcg- 5mcg-30unit-150mcg- 5000unit-2mg-50unit- 25mcg-2mg-100mcg- 150mcg-75mcg-150mcg- 99mg-40mg-150mcg- 2mg-15mg-100mg-225mg- 15mg-3mg-250mg-9mg- 9mg-275mcg-20mg-1.7mg- 10mg-40mg-25mcg-3.4mg- 10mg-12mcg-400unit- 12mcg-400unit-400mcg- 1.5mg-400mcg-30mcg- 300mcg-4mg-60mg, 2mg-120mg, 60mcg-72mg- 10mcg-0.5mg-35mg- 21mcg-4mg-0.5mg-20mg- 107.5unit-37.5mcg-30mcg- 60unit-150mcg-50mcg- 18.75mcg-0.9mg-21.15mg- 80mg-210mg-15mg-75mg- 25mg-0.38mg-0.075mg- 1.5mg-600mcg-10mg- 83.25mg-0.83mg-2.5mg- 3500unit-300mcg-20mg- 1.67mg-2.5mg-6.25mcg- 60mcg-1.7mg-100mcg- 2.5mg-1.5mcg-100unit- 600unit-300mcg-30mcg- 0.5mg-100mcg-7.5mcg- 6mg-120mg, 35mg-2mg- 128mg, 32mcg-2mg-72mg- 72mg-10mcg-55mcg- 10mcg-18mcg-1.8mg- 75mcg-2.3mg-10mcg- 10mcg-5mcg-0.5mg-20mg- 5mcg-0.5mg-20mg-30unit- 35unit-150mcg-50mcg- 150mcg-45mcg-200mg- 80mg-100mg-8mg-1.1mg- 80mg-11mg-50mg-1.5mg- 200mg-18mg-15mg- 18mg-10mg-3500unit- 3500unit-14mg-50mcg- 20mg-25mcg-1.7mg- 1.1mg-6mcg-800unit- 400unit-30mcg-2mg-60mg, 400mcg-40mcg-2mg-75mg, 5000unit-5000unit-450mg- 72mg-10mcg-5000unit- 450mg-15mg-15mg-27mg- 20mcg-46mg-150mcg- 27mg-30unit-30unit- 200mg-15mg-10mcg-2mg- 400unit-400unit-1.7mg- 130mcg-150mcg-2mg- 1.7mg-10mg-10mg-6mcg- 60mg-5mcg-160mcg- 6mcg-20mg-20mg-1.5mg- 3.5mg-100mg-4mg-45unit- 1.5mg-400mcg-400mcg- 400unit-15mg-1.7mg- 2mg-2mg-60mg-60mg, 10mg-25mcg-3mg-20mg- 72mg-10mcg-6000unit- 400mcg-30mcg-60mg, 5mcg-25mcg-48mg- 72mg-10mcg-5000unit- 150mcg-200mg-15mg- 20mcg-48mg-150mcg- 10mcg-2mg-100mcg- 200mg-15mg-10mcg-2mg- 10mcg-80mg-25mcg- 130mcg-150mcg-2mg- 2.5mg-100mg-9mg-45unit- 80mg-5mcg-160mg-3.5mg- 400unit-1.5mg-20mg- 100mg-4mg-45unit- 1.7mg-10mg-25mcg- 400unit-20mg-1.7mg- 200mcg-30mcg-3mg- 10mg-25mcg-3mg-1.5mg- 60mg, 50mg-162mg- 400mcg-30mcg-60mg, Louisiana Healthcare Connections Updated April 1, 2019

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 12.667mg-1mg-30mg- 1.7mg-10mg-25mcg- 5unit-66.667mg-0.667mg- 400mcg-30mcg-3mg- 2.5mg-16.667mg- 60mg-400unit, 2mg-7.5mg- 16.667mg-3.333mg-5mg- 10mcg-70mcg-50mcg-2mg- 8.333mg-10mg-3.333mg- 10mcg-5mcg-31mg-60unit- 0.667mg-1666.667unit- 150mcg-75mcg-7.5mg- 2.667mcg-333.333unit- 40mg-150mcg-2mg-15mg- 1.667mg-66.667mcg-1mg- 100mg-9mg-10mg- 1.667mg-20mg, 2mg- 5000unit-20mg-28mcg- 72mg-10mcg-20mcg- 3.4mg-12mcg-400unit- 150mcg-2mg-5mcg-48mg- 3mg-400mcg-30mcg-6mg- 45unit-150mcg-75mcg- 90mg, 2mg-7.5mg-10mcg- 80mg-150mcg-2mg-15mg- 70mcg-50mcg-2mg-10mcg- 100mg-1.5mg-200mg- 5mcg-40mg-31mg-60unit- 10mg-3500unit-250mcg- 150mcg-75mcg-7.5mg- 20mg-10mcg-1.7mg- 150mcg-2mg-15mg- 25mcg-400unit-400mcg- 100mg-9mg-10mg- 30mcg-3mg-60mg, 52mcg- 5000unit-20mg-28mcg- 2mg-72mg-10mcg-50mcg- 3.4mg-12mcg-400unit- 22mcg-2.3mg-5mcg- 3mg-400mcg-30mcg-6mg- 0.5mg-20mg-150mcg- 90mg, 36.3mg-10mcg- 80mg-100mg-35unit-15mg- 25mcg-5000unit-25mcg- 1.1mg-300mg-8mg-5mg- 2.5mg-10mcg-5mg-125mg- 3500unit-300mcg-14mg- 30unit-150mcg-25mcg- 50mcg-1.1mg-50mcg- 162mg-10mcg-40mg- 800unit-400mcg-30mcg- 400unit-2mg-15mg-100mg- 5mg-100mg, 72mg-10mcg- 1.5mg-18mg-10mg-20mg- 20mcg-150mcg-2mg- 25mcg-1.7mg-6mcg- 5mcg-48mg-45unit- 400mcg-30mcg-2mg-60mg, 150mcg-75mcg-80mg- 50mcg-2mg-10mcg-7.5mg- 200mg-150mcg-100mg- 70mcg-2mg-10mcg-5mcg- 2mg-2mg-15mg-1.5mg- 2mg-31mg-60unit-150mcg- 10mg-5000unit-250mcg- 75mcg-40mg-150mcg- 20mg-10mcg-1.7mg- 7.5mg-15mg-100mg-3mg- 25mcg-400unit-400mcg- 9mg-10mg-5000unit-20mg- 30mcg-3mg-60mg, 72mg- 28mcg-3.4mg-12mcg- 10mcg-5000unit-45unit- 400unit-400mcg-30mcg- 20mcg-48mg-150mcg- 6mg-90mg, 7.5mg-10mcg- 200mg-15mg-10mcg-2mg- 70mcg-50mcg-2mg-10mcg- 130mcg-150mcg-2mg- 5mcg-2mg-31mg-60unit- 80mg-5mcg-160mcg- 150mcg-75mcg-40mg- 3.5mg-100mg-4mg- 2mg-7.5mg-100mg- 400unit-1.5mg-20mg- 150mcg-15mg-3mg-9mg- 1.7mg-10mg-25mcg- 10mg-5000unit-20mg- 400mcg-30mcg-3mg- 28mcg-3.4mg-12mcg- 60mg, 72mg-2.5mg-5mcg- 400unit-400mcg-30mcg- 20mcg-48mg-45unit- 6mg-90mg, 7.5mg-10mcg- 150mcg-2mg-200mg- 70mcg-50mcg-2mg-10mcg- 10mcg-130mcg-150mcg- 5mcg-2mg-31mg-60unit- 80mg-160mcg-4mg-2mg- 150mcg-75mcg-40mg- 15mg-100mg-1.5mg- 2mg-7.5mg-150mcg-15mg- 5000unit-20mg-10mcg- 100mg-3mg-9mg-10mg- Louisiana Healthcare Connections Updated April 1, 2019

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 5000unit-20mg-28mcg- 150mcg-10mcg-2mg- 3.4mg-12mcg-400unit- 7.5mg-5mcg-32mcg- 400mcg-30mcg-6mg- 3.5mg-100mg-18mg- 90mg, 72mg-10mcg- 30unit-400unit-3.4mg- 20mcg-65mcg-3.5mg- 10mg-9mcg-3mg-20mg- 10mcg-2mg-109mg-30unit- 3mg-400mcg-30mcg-90mg, 150mcg-160mcg-2mg- 7.5mg-28mcg-5000unit- 80mg-100mg-150mcg- 21mcg-31mg-150mcg- 15mg-1.5mg-162mg-18mg- 40mg-15mg-10mcg-2mg- 10mg-2500unit-20mg- 26mcg-150mcg-10mcg- 25mcg-1.7mg-6mcg- 2mg-7.5mg-5mcg-32mcg- 400unit-400mcg-30mcg- 3.5mg-100mg-18mg- 2mg-60mg, 34mg-25mcg- 30unit-400unit-3.4mg- 6000unit-10mcg-15mcg- 10mg-9mcg-3mg-20mg- 125mg-150mcg-162mg- 400mcg-30mcg-3mg-90mg, 15mg-10mcg-2mg-15mcg- 10mg-25mcg-25mcg- 80mcg-37.5mg-5mcg- 4000unit-15mg-50mg- 15mcg-2.5mg-100mg- 5mcg-50unit-100mg-15mg- 18mg-30unit-400unit- 0.25mg-1mg-10mg-5mg- 1.7mg-10mg-6mcg-1.5mg- 15mg-1000unit-10mg- 20mg-400mcg-45mcg- 100unit-10mg-10mcg-5mg- 2mg-60mg, 50mcg-2mg- 15mg-10mg-25mg-10mg- 72mg-10mcg-19mcg- 10mg-25mg-15mg-25mg- 2.3mg-5mcg-0.5mg-20mg- 200mcg-1mcg-100mg, 50unit-150mcg-45mcg- 35mcg-2mg-72mg-10mcg- 80mg-50mg-20mg-11mg- 55mcg-2.3mg-10mcg- 1.5mg-300mcg-220mg- 5mcg-0.5mg-20mg-30unit- 10mg-2500unit-250mcg- 150mcg-45mcg-200mg- 30mcg-1.7mg-25mcg- 75mcg-80mg-11mg-50mg- 500unit-400mcg-30mcg- 1.5mg-18mg-10mg- 3mg-60mg, 50mcg-2mg- 3500unit-20mg-25mcg- 72mg-19mcg-2.3mg-5mcg- 1.7mg-6mcg-400unit- 0.5mg-20mg-50unit- 400mcg-30mcg-2mg-60mg, 150mg-45mcg-80mg- 35mcg-2mg-72mg-10mcg- 10mcg-11mg-50mg-1.5mg- 55mcg-2.3mg-10mcg- 300mcg-220mg-10mg- 5mcg-0.5mg-20mg-30unit- 2500unit-250mcg-20mg- 150mcg-45mcg-200mg- 30mcg-1.7mg-25mcg- 75mcg-80mg-50mg-11mg- 1000unit-400mcg-30mcg- 1.5mg-18mg-10mg- 3mg-60mg, 21mcg-28mcg- 3500unit-20mg-25mcg- 5000unit-26mcg-3.5mg- 1.7mg-6mcg-400unit- 2mg-31mg-30unit-150mcg- 400mcg-30mcg-2mg-60mg, 32mcg-7.5mg-40mg- 35mcg-2mg-72mg-10mcg- 10mcg-150mcg-10mcg- 55mcg-2.3mg-10mcg- 2mg-7.5mg-5mcg-15mg- 5mcg-0.5mg-20mg-30unit- 100mg-18mg-10mg-20mg- 150mcg-45mcg-200mg- 3.4mg-9mcg-400unit-3mg- 80mg-50mg-75mcg-11mg- 400mcg-30mcg-3mg- 1.5mg-18mg-10mg- 90mg, 7.5mg-28mcg- 3500unit-20mg-25mcg- 5000unit-21mcg-31mg- 1.7mg-6mcg-400unit- 150mcg-40mg-15mg- 400mcg-30mcg-2mg-60mg, 10mcg-2mg-26mcg- 35mcg-2mg-72mg-10mcg- Louisiana Healthcare Connections Updated April 1, 2019

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 55mcg-2.3mg-10mcg- 20mg-25mcg-1.7mg-6mcg- 5mcg-0.5mg-20mg-30unit- 400unit-400mcg-30mcg- 150mcg-45mcg-80mg- 2mg-60mg, 35mcg-72mg- 200mg-50mg-75mcg- 10mcg-55mcg-2.3mg- 11mg-1.5mg-18mg-10mg- 10mcg-5mcg-0.5mg-20mg- 3500unit-20mg-25mcg- 30unit-150mcg-45mcg- 1.7mg-6mcg-400unit- 200mg-2mg-80mg-75mcg- 400mcg-30mcg-2mg- 11mg-50mg-1.5mg-18mg- 60mg, 35mcg-2mg-72mg- 10mg-3500unit-20mg- 10mcg-55mcg-2.3mg- 25mcg-1.7mg-6mcg- 10mcg-5mcg-0.5mg-20mg- 400unit-400mcg-30mcg- 30unit-150mcg-45mcg- 2mg-60mg, 35mcg-72mg- 80mg-200mg-75mcg- 10mcg-55mcg-2.3mg- 11mg-50mg-1.5mg-18mg- 10mcg-5mcg-0.5mg-20mg- 10mg-3500unit-20mg- 30unit-150mcg-45mcg- 25mcg-1.7mg-6mcg- 200mg-80mg-2mg-75mcg- 400unit-400mcg-30mcg- 11mg-50mg-1.5mg-18mg- 2mg-60mg, 35mcg-2mg- 10mg-3500unit-20mg- 72mg-10mcg-55mcg- 25mcg-1.7mg-6mcg- 2.3mg-10mcg-5mcg- 400unit-400mcg-30mcg- 0.9mg-20mg-30unit- 2mg-60mg, 35mcg-72mg- 150mcg-45mcg-200mg- 10mcg-55mcg-2.3mg- 75mcg-80mg-11mg-50mg- 10mcg-5mcg-0.5mg-20mg- 1.5mg-18mg-10mg- 30unit-150mcg-45mcg- 3500unit-20mg-25mcg- 80mg-200mg-2mg-50mg- 1.7mg-6mcg-400unit- 75mcg-11mg-1.5mg-18mg- 400mcg-30mcg-2mg- 10mg-3500unit-20mg- 60mg, 35mcg-2mg-72mg- 25mcg-1.7mg-6mcg- 10mcg-55mcg-75mcg- 400unit-400mcg-30mcg- 2.3mg-10mcg-5mcg- 2mg-60mg, 45mcg-2mg- 0.5mg-20mg-30unit- 10mcg-55mcg-2.3mg- 150mcg-45mcg-200mg- 5mcg-0.5mg-20mg-50unit- 80mg-11mg-50mg-1.5mg- 150mcg-45mcg-80mg- 18mg-10mg-3500unit- 220mg-150mcg-11mg- 20mg-25mcg-1.7mg-6mcg- 50mg-1.5mg-300mcg- 400unit-400mcg-30mcg- 10mg-2500unit-250mcg- 2mg-60mg, 35mcg-2mg- 20mg-30mcg-1.7mg- 72mg-10mcg-55mcg- 25mcg-500unit-400mcg- 75mcg-2.3mg-10mcg- 30mcg-3mg-60mg, 45mcg- 5mcg-0.5mg-20mg-30unit- 72mg-10mcg-55mcg- 150mcg-45mcg-80mg- 2.3mg-5mcg-0.9mg-50unit- 200mg-11mg-50mg-1.5mg- 45mcg-150mcg-220mg- 18mg-10mg-3500unit- 80mg-2mg-150mcg-11mg- 20mg-25mcg-1.7mg-6mcg- 50mg-1.5mg-300mcg- 400unit-400mcg-30mcg- 10mg-2500unit-250mcg- 2mg-60mg, 35mcg-2mg- 20mg-30mcg-1.7mg- 72mg-10mcg-55mcg- 25mcg-500unit-500mcg- 75mcg-2.3mg-10mcg- 30mcg-3mg-90mg, 5mcg-0.5mg-20mg-30unit- 200mcg-12mg-72mg- 150mcg-45mcg-80mg- 1.5mg-2.3mg-35mcg- 200mg-50mg-11mg-1.5mg- 110mg-50unit-150mcg- 18mg-10mg-3500unit- 2mg-80mg-220mg-10mcg- Louisiana Healthcare Connections Updated April 1, 2019

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 150mcg-5mcg-45mcg- 150mcg-65mcg-72mg- 50mg-1.5mg-10mg- 10mcg-20mcg-3.5mg- 2500unit-250mcg-20mg- 10mcg-5mcg-2mg-125mg- 30mcg-1.7mg-30mcg- 30unit-150mcg-160mcg- 600unit-500mcg-300mcg- 162mg-15mg-80mg-2mg- 3mg-90mg, 25mcg-72mg- 20mg-100mg-1.5mg-18mg- 10mcg-55mcg-1.8mg- 10mg-5000unit-25mcg- 10mcg-5mcg-0.9mg-20mg- 1.7mg-6mcg-400unit- 35unit-150mcg-50mcg- 400mcg-30mcg-2mg-90mg, 80mg-500mg-2mg-100mg- 150mcg-72mg-10mcg- 150mcg-8mg-1.1mg-18mg- 20mcg-65mcg-3.5mg- 15mg-3500unit-14mg- 10mcg-5mcg-109mg- 50mcg-1.1mg-6mcg- 30unit-150mcg-160mcg- 800unit-400mcg-40mcg- 80mg-162mg-2mg-2mg- 2mg-75mg, 2mg-72mg- 15mg-100mg-1.5mg-18mg- 10mcg-55mcg-25mcg- 10mg-5000unit-20mg- 1.8mg-10mcg-5mcg-20mg- 25mcg-1.7mg-6mcg- 150mcg-50mcg-80mg- 400unit-400mcg-30mcg- 150mcg-100mg-35unit- 2mg-60mg, 2mg-72mg- 0.9mg-8mg-1.1mg-500mg- 10mcg-20mcg-3.5mg- 18mg-15mg-3500unit- 65mcg-10mcg-5mcg-2mg- 14mg-50mcg-1.1mg-6mcg- 109mg-30unit-150mcg- 800unit-400mcg-40mcg- 160mcg-80mg-162mg- 2mg-75mg, 50mcg-2mg- 150mcg-15mg-100mg- 72mg-10mcg-50mcg- 1.5mg-18mg-10mg- 55mcg-150mcg-2.3mg- 2500unit-20mg-25mcg- 5mcg-0.5mg-20mg-150mg- 1.7mg-6mcg-400unit- 80mg-500mg-50mg-35unit- 400mcg-30mcg-2mg-60mg, 15mg-1.1mg-8mg-5mg- 2mg-72mg-10mcg-20mcg- 3500unit-300mcg-14mg- 65mcg-3.5mg-5mcg-2mg- 50mcg-1.1mg-50mcg- 109mg-15mg-30unit- 800unit-400mcg-30mcg- 150mcg-160mcg-162mg- 5mg-100mg, 600mcg- 10mcg-80mg-150mcg- 12mg-72mg-10mcg- 100mg-1.5mg-18mg- 35mcg-1.5mg-2.3mg- 2500unit-20mg-25mcg- 5mcg-110mg-50unit- 1.7mg-10mg-6mcg- 150mcg-45mcg-2mg- 400unit-400mcg-30mcg- 80mg-220mg-150mcg- 2mg-60mg, 50mcg-2mg- 50mg-1.5mg-10mg- 72mg-10mcg-55mcg- 2500unit-250mcg-20mg- 2.3mg-5mcg-0.5mg-20mg- 30mcg-1.7mg-30mcg- 35unit-150mcg-50mcg- 600unit-500mcg-300mcg- 500mg-150mcg-80mg- 3mg-90mg, 72mg-25mcg- 15mg-50mg-1.1mg-8mg- 5000unit-20mcg-109mg- 5mg-3500unit-300mcg- 150mcg-162mg-15mg- 14mg-50mcg-1.1mg- 10mcg-2mg-65mcg- 50mcg-800unit-400mcg- 150mcg-10mcg-2mg- 30mcg-5mg-100mg, 80mg-5mcg-160mg-3.5mg- 50mcg-2mg-72mg-10mcg- 100mg-18mg-30unit- 55mcg-2.3mg-5mcg- 400unit-20mg-1.7mg- 0.5mg-20mg-35unit- 10mg-6mcg-2mg-1.5mg- 150mcg-50mcg-500mg- 400mcg-30mcg-60mg, 80mg-50mg-150mcg- Louisiana Healthcare Connections Updated April 1, 2019

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 15mg-1.1mg-8mg-5mg- 20mcg-65mcg-3.5mg- 3500unit-300mcg-14mg- 10mcg-5mcg-2mg-109mg- 50mcg-1.1mg-50mcg- 30unit-150mcg-160mcg- 800unit-400mcg-30mcg- 162mg-2mg-80mg- 5mg-100mg, 50mcg-2mg- 150mcg-15mg-100mg- 72mg-10mcg-55mcg- 1.5mg-18mg-10mg-20mg- 2.3mg-5mcg-0.5mg-20mg- 25mcg-1.7mg-2500unit- 35unit-150mcg-50mcg- 6mcg-400unit-400mcg- 80mg-500mg-50mg- 30mcg-2mg-50mg, 72mg- 150mcg-15mg-1.1mg-8mg- 25mcg-5000unit-10mcg- 5mg-3500unit-300mcg- 20mcg-109mg-30unit- 14mg-50mcg-1.1mg- 150mcg-162mg-15mg- 50mcg-800unit-400mcg- 10mcg-2mg-65mcg- 30mcg-5mg-100mg, 150mcg-2mg-80mg-5mcg- 50mcg-2mg-72mg-10mcg- 160mcg-3.5mg-100mg- 55mcg-3500unit-2.3mg- 18mg-400unit-1.5mg- 5mcg-0.5mg-20mg-35unit- 20mg-1.7mg-10mg-6mcg- 150mcg-50mcg-500mg- 400mcg-30mcg-2mg-60mg, 80mg-150mcg-15mg- 150mcg-50mcg-10mcg- 50mg-1.1mg-8mg-5mg- 72mg-55mcg-35unit- 300mcg-14mg-50mcg- 2.3mg-20mg-150mcg- 1.1mg-50mcg-800unit- 50mcg-15mg-80mg- 400mcg-30mcg-5mg- 500mg-5mcg-50mg-0.5mg- 100mg, 50mcg-2mg-72mg- 15mg-1.1mg-8mg- 10mcg-55mcg-3500unit- 3500unit-300mcg-14mg- 2.3mg-5mcg-0.5mg-20mg- 50mcg-1.1mg-5mg-50mcg- 8mg-150mcg-50mcg- 800unit-400mcg-30mcg- 500mg-80mg-150mcg- 5mg-100mg, 2mg-72mg- 15mg-50mg-1.1mg-5mg- 10mcg-20mcg-10mcg- 300mcg-14mg-50mcg- 150mcg-2mg-5mcg-48mg- 1.1mg-50mcg-800unit- 45unit-75mcg-150mcg- 400mcg-35unit-30mcg- 150mcg-80mg-2mg-15mg- 5mg-100mg, 50mcg-72mg- 100mg-1.5mg-300mcg- 10mcg-55mcg-2.3mg- 200mg-10mg-3500unit- 5mcg-0.5mg-20mg-35unit- 250mcg-20mg-1.7mg- 150mcg-50mcg-80mg- 25mcg-400unit-400mcg- 500mg-2mg-50mg- 30mcg-3mg-60mg, 2mg- 150mcg-15mg-1.1mg-8mg- 72mg-10mcg-20mcg- 5mg-3500unit-300mcg- 150mcg-2mg-5mcg-48mg- 14mg-50mcg-1.1mg- 45unit-150mcg-75mcg- 50mcg-800unit-400mcg- 200mg-80mg-150mcg- 30mcg-5mg-100mg, 72mg- 2mg-15mg-100mg-1.5mg- 10mcg-20mcg-2mg- 300mcg-10mg-3500unit- 10mcg-5mcg-109mg- 250mcg-20mg-10mcg- 30unit-150mcg-75mcg- 1.7mg-25mcg-400unit- 162mg-120mg-150mcg- 400mcg-30mcg-3mg-60mg, 2mg-80mg-2mg-15mg- 2mg-72mg-10mcg-20mcg- 100mg-1.5mg-300mcg- 45unit-150mcg-2mg-5mcg- 3500unit-250mcg-20mg- 2mg-48mg-150mcg- 1.7mg-10mg-6mcg- 75mcg-80mg-200mg- 400unit-400mcg-30mcg- 150mcg-15mg-100mg- 2mg-60mg, 72mg-10mcg- 1.5mg-300mcg-10mg- Louisiana Healthcare Connections Updated April 1, 2019

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3500unit-250mcg-20mg- 10mcg-3500unit-20mcg- 10mcg-1.7mg-25mcg- 48mg-150mcg-200mg- 400unit-400mcg-30mcg- 15mg-10mcg-2mg- 3mg-60mg, 2mg-72mg- 150mcg-150mcg-2mg- 10mcg-20mcg-65mcg- 80mg-5mcg-75mcg-2mg- 3.5mg-10mcg-5mcg-2mg- 100mg-45unit-400unit- 15mg-109mg-30unit- 300mcg-250mcg-1.7mg- 150mcg-160mcg-162mg- 10mg-25mcg-20mg-1.5mg- 80mg-150mcg-100mg- 400mcg-30mcg-3mg-60mg, 1.5mg-18mg-10mcg- 72mg-20mcg-3500unit- 2500unit-20mg-25mcg- 45unit-2mg-48mg-150mcg- 1.7mg-6mcg-400unit- 75mcg-80mg-200mg- 400mcg-30mcg-2mg- 10mcg-2mg-150mcg- 60mg, 36.3mg-25mcg- 150mcg-2mg-5mcg-15mg- 10mcg-25mcg-125mg- 100mg-1.5mg-300mcg- 150mcg-162mg-15mg- 10mg-250mcg-20mg- 10mcg-2mg-25mcg- 10mcg-1.7mg-25mcg- 150mcg-10mcg-40mg- 400unit-400mcg-30mcg- 5mcg-25mcg-2.5mg- 3mg-60mg, 36.3mg- 100mg-18mg-30unit- 25mcg-5000unit-10mcg- 400unit-5000unit-20mg- 5mcg-20mcg-109mg- 2mg-10mg-6mcg-1.7mg- 150mcg-162mg-15mg- 400mcg-30mcg-3mg- 10mcg-2mg-25mcg- 60mg, 50mcg-2mg-72mg- 150mcg-2mcg-40mg- 10mcg-55mcg-2.3mg- 25mcg-2.5mg-100mg- 5mcg-0.05mg-20mg- 18mg-30unit-400unit- 35unit-150mcg-50mcg- 1.5mg-20mg-1.7mg-10mg- 500mg-80mg-150mcg- 6mcg-400mcg-30mcg-2mg- 15mg-50mg-1.1mg-8mg- 60mg, 45mg-2mg-72mg- 5mg-3500unit-300mcg- 10mcg-55mcg-2.3mg- 14mg-50mcg-1.1mg- 5mcg-0.5mg-20mg-50unit- 50mcg-800unit-400mcg- 150mcg-45mcg-220mg- 30mcg-5mg-100mg, 72mg- 150mcg-80mg-11mg- 10mcg-20mcg-150mcg- 50mg-1.5mg-300mcg- 2mg-5mcg-48mg-45unit- 10mg-2500unit-250mcg- 150mcg-75mcg-200mg- 20mg-30mcg-1.7mg- 2mg-80mg-150mcg-2mg- 25mcg-500unit-400mcg- 15mg-100mg-1.5mg- 30mcg-3mg-60mg, 2mg- 300mcg-10mg-3500unit- 7.5mg-10mcg-70mcg- 250mcg-20mg-10mcg- 120mcg-2mg-10mcg-5mcg- 1.7mg-25mcg-400unit- 31mg-60unit-150mcg- 400mcg-30mcg-3mg- 75mcg-40mg-150mcg- 60mg, 72mg-10mcg- 7.5mg-2mg-15mg-100mg- 20mcg-3500unit-150mcg- 9mg-10mg-5000unit- 2mg-5mcg-48mg-45unit- 250mcg-20mg-28mcg- 150mcg-75mcg-150mcg- 3.4mg-12mcg-400unit- 2mg-80mg-2mg-15mg- 3mg-400mcg-30mcg-6mg- 100mg-1.5mg-300mcg- 90mg, 2mg-72mg-10mcg- 200mg-10mg-250mcg- 55mcg-2.3mg-5mcg- 20mg-10mcg-1.7mg- 0.5mg-20mg-50unit- 25mcg-400unit-400mcg- 150mcg-45mcg-80mg- 30mcg-3mg-60mg, 72mg- 220mg-45mcg-50mg- Louisiana Healthcare Connections Updated April 1, 2019

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 150mcg-11mg-1.5mg- 25mcg-500unit-400mcg- 300mcg-10mg-2500unit- 30mcg-3mg-60mg, 45mcg- 250mcg-20mg-30mcg- 2mg-72mg-10mcg-55mcg- 1.7mg-25mcg-500unit- 2.3mg-5mcg-0.5mg-20mg- 400mcg-30mcg-3mg- 50unit-150mcg-45mcg- 60mg, 2mg-72mg-10mcg- 220mg-80mg-150mcg- 55mcg-45mcg-2.3mg- 11mg-50mg-1.5mg- 5mcg-0.5mg-20mg- 300mcg-10mg-2500unit- 150mcg-45mcg-80mg- 250mcg-20mg-30mcg- 50mg-50unit-150mcg- 1.7mg-25mcg-500unit- 11mg-1.5mg-300mcg- 400mcg-30mcg-3mg-60mg, 220mg-10mg-2500unit- 45mcg-2mg-72mg-10mcg- 250mcg-20mg-30mcg- 55mcg-2.3mg-5mcg- 1.7mg-25mcg-500unit- 0.5mg-20mg-50unit- 400mcg-30mcg-3mg- 150mcg-45mcg-80mg- 60mg, 2mg-72mg-10mcg- 220mg-150mcg-11mg- 55mcg-45mcg-2.3mg- 50mg-1.5mg-300mcg- 5mcg-0.5mg-20mg-50unit- 10mg-2500unit-250mcg- 150mcg-45mcg-80mg- 20mg-30mcg-1.7mg- 50mg-150mcg-11mg- 25mcg-500unit-400mcg- 1.5mg-300mcg-220mg- 30mcg-3mg-60mg, 45mcg- 10mg-2500unit-250mcg- 2mg-72mg-10mcg-55mcg- 20mg-30mcg-1.7mg- 2.3mg-5mcg-0.5mg-20mg- 25mcg-500unit-400mcg- 50unit-150mcg-45mcg- 30mcg-3mg-60mg, 35mcg- 80mg-220mg-50mg- 2mg-72mg-10mcg-55mcg- 150mcg-11mg-1.5mg- 75mcg-2.3mg-10mcg- 300mcg-10mg-2500unit- 5mcg-0.5mg-20mg-30unit- 250mcg-20mg-30mcg- 150mcg-45mcg-200mg- 1.7mg-25mcg-500unit- 80mg-15mg-11mg-50mg- 400mcg-30mcg-3mg-60mg, 1.5mg-18mg-10mg- 45mcg-2mg-72mg-10mcg- 3500unit-20mg-25mcg- 55mcg-2.3mg-5mcg- 1.7mg-6mcg-400unit- 0.5mg-20mg-50unit- 400mcg-30mcg-2mg- 150mcg-45mcg-80mg- 60mg, 45mcg-2mg-72mg- 50mg-150mcg-11mg- 10mcg-55mcg-2.3mg- 1.5mg-300mcg-220mg- 5mcg-0.5mg-20mg- 10mg-2500unit-250mcg- 150mcg-45mcg-80mg- 20mg-30mcg-1.7mg- 50mg-50unit-150mcg- 25mcg-500unit-400mcg- 11mg-1.5mg-300mcg- 30mcg-3mg-60mg, 45mcg- 220mg-10mg-2500unit- 2mg-72mg-10mcg-55mcg- 250mcg-20mg-30mcg- 2.3mg-5mcg-0.5mg-20mg- 1.7mg-25mcg-500unit- 50unit-150mcg-45mcg- 400mcg-30mcg-3mg- 80mg-50mg-150mcg- 60mg, 45mcg-2mg-72mg- 11mg-1.5mg-300mcg- 10mcg-55mcg-2.3mg- 220mg-10mg-250mcg- 5mcg-0.5mg-20mg-50unit- 20mg-30mcg-1.7mg- 150mcg-45mcg-220mg- 2500unit-25mcg-500unit- 150mcg-80mg-11mg- 400mcg-30mcg-3mg-60mg, 50mg-1.5mg-300mcg- 45mcg-72mg-10mcg- 10mg-2500unit-250mcg- 55mcg-2.3mg-5mcg- 20mg-30mcg-1.7mg- 0.5mg-20mg-50unit- Louisiana Healthcare Connections Updated April 1, 2019

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 150mcg-45mcg-80mg- 10mg-2500unit-250mcg- 220mg-2mg-150mcg- 20mg-30mcg-1.7mg- 11mg-50mg-1.5mg- 25mcg-500unit-500mcg- 300mcg-10mg-2500unit- 30mcg-3mg-90mg, 45mcg- 250mcg-20mg-30mcg- 72mg-10mcg-55mcg- 1.7mg-25mcg-500unit- 2.3mg-5mcg-0.9mg- 400mcg-30mcg-3mg- 110mg-50unit-150mcg- 60mg, 45mcg-72mg- 220mg-80mg-45mcg- 10mcg-55mcg-2.3mg- 50mg-2mg-150mcg-11mg- 5mcg-0.5mg-20mg-50unit- 1.5mg-300mcg-2500unit- 150mcg-45mcg-80mg- 250mcg-20mg-30mcg- 220mg-2mg-50mg- 1.7mg-10mg-25mcg- 150mcg-11mg-1.5mg- 500unit-500mcg-30mcg- 300mcg-10mg-2500unit- 3mg-90mg, 45mcg-72mg- 250mcg-20mg-30mcg- 10mcg-55mcg-2.3mg- 1.7mg-25mcg-500unit- 5mcg-0.9mg-110mg- 400mcg-30mcg-3mg- 50unit-150mcg-45mcg- 60mg, 45mcg-72mg- 80mg-220mg-2mg-50mg- 10mcg-55mcg-2.3mg- 150mcg-11mg-1.5mg- 5mcg-0.5mg-20mg-50unit- 300mcg-10mg-2500unit- 45mcg-100mcg-80mg- 250mcg-20mg-30mcg- 2mg-150mcg-11mg-50mg- 1.7mg-25mcg-500unit- 1.5mg-300mcg-220mg- 500mcg-30mcg-3mg-90mg, 10mg-2500unit-250mcg- 60mcg-2mg-72mg-10mcg- 20mg-30mcg-1.7mg- 100mcg-4mg-5mcg-0.7mg- 25mcg-500unit-400mcg- 20mg-60unit-150mcg- 30mcg-3mg-60mg, 50mcg-250mg-80mg- 120mcg-50mg-72mg- 150mcg-15mg-50mg- 10mcg-70mcg-4mg- 1.5mg-600mcg-10mg- 10mcg-5mcg-0.9mg-48mg- 3500unit-300mcg-20mg- 60unit-150mcg-75mcg- 60mcg-1.7mg-100mcg- 100mg-80mg-4mg-60mcg- 600unit-300mcg-30mcg- 11mg-40mg-4.5mg-18mg- 6mg-120mg, 60mcg-2mg- 12mg-3500unit-40mg- 72mg-10mcg-100mcg- 25mcg-5.1mg-18mcg- 4mg-5mcg-0.7mg-20mg- 400unit-400mcg-50mcg- 60unit-150mcg-50mcg- 6mg-120mg, 36mg-10mcg- 80mg-250mg-50mg- 25mcg-25mcg-120mcg- 150mcg-15mg-1.5mg- 2mg-10mcg-5mcg-77mg- 600mcg-10mg-3500unit- 50unit-150mcg-25mcg- 300mcg-20mg-60mcg- 100mg-2mg-40mg-100mg- 1.7mg-100mcg-600unit- 20mg-150mcg-2mg-15mg- 300mcg-30mcg-6mg- 1.5mg-9mg-10mg- 120mg, 60mcg-72mg- 3000unit-250mcg-1.7mg- 10mcg-100mcg-4mg-5mcg- 6mcg-400unit-400mcg- 0.7mg-20mg-60unit- 30mcg-2mg-120mg, 150mcg-50mcg-80mg- 45mcg-2mg-72mg-10mcg- 250mg-2mg-50mg- 55mcg-2.3mg-5mcg- 150mcg-15mg-1.5mg- 0.9mg-110mg-50unit- 600mcg-10mg-3500unit- 150mcg-45mcg-220mg- 300mcg-20mg-60mcg- 150mcg-80mg-11mg- 1.7mg-100mcg-600unit- 50mg-1.5mg-300mcg- 300mcg-30mcg-6mg- Louisiana Healthcare Connections Updated April 1, 2019

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 120mg, 72mg-50unit- 20mg-150mcg-50mcg- 55mcg-110mg-150mcg- 250mg-80mg-150mcg- 220mg-11mg-10mcg- 15mg-50mg-1.5mg- 0.9mg-45mcg-150mcg- 600mcg-10mg-300mcg- 2mg-80mg-5mcg-45mcg- 20mg-60mcg-1.7mg- 2.3mg-50mg-300mcg- 3500unit-100mcg-600unit- 2500unit-250mcg-20mg- 300mcg-60unit-30mcg- 30mcg-1.7mg-10mg- 6mg-120mg, 2mg-72mg- 25mcg-500unit-1.5mg- 10mcg-20mcg-65mcg- 500mcg-30mcg-3mg- 3.5mg-10mcg-5mcg- 90mg, 10mcg-20mcg- 109mg-30unit-150mcg- 25mcg-120mcg-2mg- 160mcg-162mg-80mg- 10mcg-5mcg-72mg-2mg- 150mcg-2mg-15mg- 108mg-30unit-75mcg- 100mg-1.5mg-600mcg- 150mcg-162mg-150mcg- 18mg-10mg-2500unit- 2mg-80mg-15mg-100mg- 20mg-25mcg-1.7mg-6mcg- 1.5mg-18mg-10mg- 400mcg-30mcg-2mg- 5000unit-250mcg-20mg- 60mg-400unit, 30unit- 1.7mg-6mcg-400unit- 10mg-70mcg-5000unit- 400mcg-30mcg-2mg- 10mg-25mcg-100mcg- 60mg, 150mcg-60mcg- 100mg-30mg-25mcg-2mg- 10mcg-72mg-100mcg- 200mcg-2.4mg-25mg- 60unit-4mg-20mg-150mcg- 100mcg-6mg-100mg- 50mcg-15mg-80mg- 5000unit-10mg-8mg-10mg- 250mg-5mcg-50mg-0.7mg- 10mg-15mg-25mg-25mcg- 15mg-1.5mg-600mcg- 400unit-15mg-25mg- 3500unit-300mcg-20mg- 400mcg-300mcg-25mg- 60mcg-1.7mg-10mg- 100mg, 35mcg-2mg-72mg- 100mcg-600unit-300mcg- 10mcg-100mcg-150mcg- 30mcg-6mg-120mg, 2.3mg-10mcg-5mcg- 1666.67unit-8.33mg- 0.9mg-20mg-45unit- 4.17mcg-50mg-37.5mcg- 150mcg-50mcg-210mg- 100mg-2.5mg-1.67mg- 80mg-11mg-100mg-1.2mg- 33.33mg-1mg-5unit- 600mcg-8mg-15mg- 33.33unit-8.33mg-4.17mg- 3500unit-16mg-60mcg- 8.33mg-10mg-8.33mg- 1.3mg-6mcg-600unit- 10mg-1.67mg-5mg- 200mcg-40mcg-2mg-90mg, 2.67mcg-1.67mg-25mg- 35mcg-72mg-10mcg- 66.67mcg-66.67mcg- 100mcg-2.3mg-10mcg- 1.67mg-20mg, 2mg-36mg- 5mcg-0.9mg-20mg-45unit- 250mg-25mcg-50unit-2mg- 150mcg-50mcg-80mg- 5mcg-77mg-25mcg- 210mg-2mg-100mg- 150mcg-10mcg-2mg- 150mcg-11mg-1.2mg- 120mcg-10mcg-40mg- 600mcg-8mg-15mg- 18mg-20mg-400unit- 3500unit-16mg-60mcg- 150mcg-15mg-100mg- 1.3mg-6mcg-600unit- 1.5mg-3000unit-250mcg- 200mcg-40mcg-2mg-90mg, 100mcg-1.7mg-10mg- 60mg-50mg-72mg-10mcg- 6mcg-400mcg-30mcg- 70mcg-4mg-10mcg-5mcg- 2mg-120mg, 60mcg- 48mg-60unit-150mcg- 10mcg-72mg-10mcg- 75mcg-80mg-120mcg- 100mcg-4mg-5mcg-0.7mg- 4mg-40mg-60mcg-2mg- Louisiana Healthcare Connections Updated April 1, 2019

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 15mg-4.5mg-100mg-18mg- 30mg-5mg-10mg-12mcg- 10mg-3500unit-40mg- 400unit-400mcg-40mcg- 25mcg-5.1mg-16mcg- 5mg-90mg, 400mg-16mcg- 400mcg-40mcg-6mg- 1mg-29mg-5mcg-10mcg- 120mg-400unit, 25mg- 60mcg-1mg-5mcg-2.5mcg- 50mg-50mcg-1mg- 0.35mg-40mg-15unit- 10000unit-5mg-100mcg- 75mcg-37.5mcg-54mg- 7.5mg-18mg-75mcg-35mg- 32mg-3.75mg-20mg- 25mg-1mg-10mg-25unit- 0.75mg-3mg-5mg- 400unit-150mcg-15mg- 1750unit-10mg-12.5mcg- 5mg-6mg-25mg-25mcg- 0.85mg-100mcg-200unit- 50mg-100mg-250mcg- 200mcg-15mcg-2.5mg- 150mcg-25mg-100mcg- 30mg, 25mg-1mg-12.5mg- 25mg-400mcg-30mcg- 1mg-75mcg-50mcg-1mg- 25mg-150mg, 2mg-72mg- 50mcg-1mg-25mcg-2.5mg- 10mcg-55mcg-45mcg- 13.5mg-12.5mg-7.5mg- 2.3mg-5mcg-0.5mg-20mg- 100mg-40mg-250mg-5mg- 20mg-150mcg-45mcg- 40mg-250mcg-40mg- 80mg-50mg-50unit- 10mcg-5mg-37.5mcg- 150mcg-11mg-1.5mg- 40mg-5000unit-40mcg- 300mcg-220mg-10mg- 200unit-200mcg-50unit- 2500unit-250mcg-20mg- 40mcg-40mg-100mg, 2mg- 30mcg-1.7mg-25mcg- 10mcg-20mcg-120mcg- 500unit-400mcg-30mcg- 2mg-10mcg-5mcg-2mg- 3mg-60mg, 36.3mg- 109mg-30unit-150mcg- 10mcg-5000unit-25mcg- 75mcg-72mg-162mg- 2.5mg-10mcg-5mcg- 150mcg-80mg-15mg- 20mcg-109mg-30unit- 100mg-1.5mg-300mcg- 150mcg-25mcg-150mcg- 18mg-10mg-3500unit- 162mg-2mg-40mg-400unit- 250mcg-20mg-25mcg- 150mcg-2mg-15mg- 1.7mg-6mcg-400unit- 100mg-1.5mg-18mg-10mg- 400mcg-30mcg-2mg-60mg, 20mg-25mcg-1.7mg-6mcg- 2mg-72mg-10mcg-20mcg- 400mcg-30mcg-2mg- 120mcg-2mg-10mcg-5mcg- 60mg, 30unit-10mg- 109mg-30unit-150mcg- 70mcg-10000unit-10mg- 75mcg-162mg-80mg- 25mcg-52mg-100mcg- 150mcg-2mg-15mg- 100mg-30mg-25mcg-2mg- 100mg-1.5mg-300mcg- 500mcg-2.4mg-25mg- 18mg-10mg-3500unit- 100mcg-6mg-100mg- 250mcg-20mg-25mcg- 20mg-10mg-8mg-10mg- 1.7mg-6mcg-400mcg- 10mg-15mg-25mg-25mcg- 30mcg-2mg-60mg-400unit, 400unit-15mg-25mg- 2mg-72mg-10mcg-20mcg- 400mcg-300mcg-25mg- 25mcg-120mcg-2mg- 100mg, 7mg-10mcg- 10mcg-5mcg-109mg- 50mcg-25mcg-7.5mg- 30unit-75mcg-150mcg- 10mcg-5mcg-125mg- 150mcg-80mg-2mg-15mg- 30unit-50mcg-2mg- 100mg-1.5mg-300mcg- 150mcg-162mg-50mcg- 162mg-18mg-10mg- 150mcg-7.7mg-3mg-15mg- 3500unit-250mcg-20mg- 100mg-5mg-300mcg- 1.7mg-6mcg-400unit- 25mg-3500unit-275mcg- 400mcg-30mcg-2mg-60mg, Louisiana Healthcare Connections Updated April 1, 2019

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 30unit-10mg-70mcg- 150mcg-2.3mg-10mcg- 5000unit-10mg-25mcg- 5mcg-0.9mg-109mg- 100mcg-100mg-30mg- 30unit-150mcg-45mcg- 25mcg-2mg-200mcg- 200mg-80mg-11mg- 2.4mg-25mg-100mcg-6mg- 100mg-1.5mg-300mcg- 100mg-20mg-5000unit- 18mg-10mg-3500unit- 10mg-8mg-10mg-10mg- 250mcg-20mg-25mcg- 15mg-25mg-25mcg- 1.7mg-6mcg-400unit- 400unit-15mg-25mg- 500mcg-30mcg-2mg-90mg, 400mcg-300mcg-25mg- 35mcg-2mg-72mg-10mcg- 100mg, 72mg-10mcg- 55mcg-2.3mg-10mcg- 20mcg-25mcg-2mg- 5mcg-0.9mg-109mg- 10mcg-5mcg-109mg- 30unit-150mcg-45mcg- 75mcg-150mcg-162mg- 200mg-150mcg-80mg- 120mcg-2mg-80mg- 11mg-100mg-1.5mg- 100mg-30unit-150mcg- 300mcg-18mg-10mg- 2mg-15mg-1.5mg-300mcg- 3500unit-250mcg-20mg- 18mg-10mg-3500unit- 25mcg-1.7mg-6mcg- 250mcg-20mg-1.7mg- 400unit-500mcg-30mcg- 6mcg-400mcg-30mcg- 2mg-90mg, 35mcg-2mg- 2mg-60mg-400unit, 72mg-10mcg-55mcg- 16.666mg-1mg-3.333mg- 2.3mg-10mcg-5mcg- 42.666mg-5unit-86.666mg- 0.9mg-109mg-30unit- 0.666mg-2.5mg-16.666mg- 150mcg-45mcg-200mg- 3.333mg-3.333mg-5mg- 150mcg-80mg-11mg- 8.333mg-10mg-3.333mg- 100mg-1.5mg-300mcg- 1.666mg-1666.666unit- 18mg-3500unit-250mcg- 2.666mcg-333.333unit- 20mg-25mcg-1.7mg-10mg- 1.666mg-66.666mcg- 6mcg-400unit-500mcg- 1666.666mcg-1.666mg- 30mcg-2mg-90mg, 35mcg- 20mg, 2mg-72mg-10mcg- 2mg-72mg-10mcg-55mcg- 55mcg-200mg-35mcg- 2.3mg-10mcg-5mcg- 2.3mg-10mcg-5mcg- 0.9mg-109mg-30unit- 0.9mg-109mg-30unit- 150mcg-45mcg-200mg- 150mcg-45mcg-80mg- 80mg-100mg-150mcg- 150mcg-11mg-100mg- 11mg-1.5mg-300mcg- 1.5mg-300mcg-18mg- 18mg-10mg-3500unit- 10mg-3500unit-250mcg- 250mcg-20mg-25mcg- 20mg-25mcg-1.7mg-6mcg- 1.7mg-6mcg-400unit- 400unit-500mcg-30mcg- 500mcg-30mcg-2mg-90mg, 2mg-90mg, 2mg-72mg- 35mcg-72mg-10mcg- 10mcg-55mcg-25mcg- 55mcg-2.3mg-10mcg- 35mcg-2.3mg-10mcg- 5mcg-0.9mg-109mg- 5mcg-109mg-30unit- 30unit-150mcg-45mcg- 45mcg-150mcg-150mcg- 200mg-80mg-2mg- 80mg-0.9mg-11mg-100mg- 150mcg-11mg-100mg- 1.5mg-300mcg-200mg- 1.5mg-300mcg-18mg- 18mg-10mg-3500unit- 10mg-3500unit-250mcg- 250mcg-20mg-1.7mg- 20mg-25mcg-1.7mg-6mcg- 6mcg-400unit-500mcg- 400unit-500mcg-30mcg- 30mcg-2mg-90mg, 35mcg- 2mg-90mg, 25mcg- 2mg-72mg-10mcg-55mcg- 12.5mg-2.5mg-1mg-5mcg- Louisiana Healthcare Connections Updated April 1, 2019

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 50mcg-250mg-75mcg- 33.333mcg-0.667mg- 2mg-50mcg-1mg-25mcg- 1.667mg-3.333mg- 2.5mg-13.5mcg-12.5mg- 26.667mg-5mcg- 7.5mg-50mg-40mg-5mg- 66.667unit-5mg-66.667mg- 40mg-250mcg-40mg- 1666.667unit-5mg- 10mcg-5mg-37.5mcg- 16.667mg-66.667mg- 40mg-5000unit-40mg- 133.333mg-16.667mcg- 200unit-200mg-50unit- 133.333unit-16.667mg- 40mg-40mg-100mg, 133.333mg-16.667mg- 66.667mcg-4.167mcg- 333.333mcg-50mcg- 66.667unit-33.333mg- 16.667mg-333.333mg- 33.333mcg-50mcg- 166.667mg, 8.333mg-1mg- 83.333mg-7.5mg- 10mg-50mg-37.5mcg- 11.667mg-33.333mg- 244.333mg-3.333mg- 3.333mg-333.333mg- 1.667mg-2.5mg-4.167mcg- 33.333mg-33.333mg- 33.333mg-8.333mg-1mg- 16.667mg-1666.667unit- 4.167mg-8.333mg-5mg- 33.333mcg-16.667mg- 8.333mg-10mg-25mg- 266.667mcg-100mcg- 1.667mg-1666.667unit- 16.667mg-133.333unit, 2.667mcg-33.333unit- 35mcg-72mg-10mcg- 1.667mg-66.667mcg-5unit- 55mcg-10mcg-5mcg- 1000mcg-1.667mg-40mg, 109mg-30unit-150mcg- 10mg-25mg-10mg-10mg- 45mcg-80mg-200mg- 10mg-36mg-10mcg-27mg- 0.9mg-2.3mg-100mg- 70mcg-120mcg-2mg- 1250unit-2mg-150mcg- 10mcg-5mcg-77mg-45unit- 11mg-1.5mg-300mcg- 150mcg-75mcg-250mg- 18mg-3500unit-250mcg- 150mcg-40mg-2mg-15mg- 20mg-25mcg-1.7mg-10mg- 100mg-1.875mg-12.5mg- 6mcg-400unit-500mcg- 5000unit-300mcg-25mg- 30mcg-2mg-90mg, 80mcg-2.1mg-7.5mcg- 33.333mg-33.333mcg- 400unit-400mcg-37.5mcg- 50mcg-83.333mg-7.5mg- 2.5mg-120mg, 50mg- 66.667mcg-11.667mg- 25mg-60mg-45mg-72.5mg- 4.167mcg-33.333mg- 10mcg-18mg-70mcg-4mg- 3.333mg-333.333mg-6mg- 10mcg-5mcg-48mg-60unit- 33.333mg-33.333mg- 150mcg-75mcg-100mg- 16.667mg-33.333mcg- 120mcg-150mcg-4mg- 16.667mg-266.667mcg- 80mg-2000unit-2mg-15mg- 66.667unit-100mcg- 40mg-4.5mg-3000unit- 16.667mg-1666.667unit- 250mcg-35mg-25mcg- 133.333unit, 25mg-75mg- 5.1mg-10mg-21mcg- 10mcg-18mg-70mcg- 400unit-400mcg-40mcg- 2.5mg-10mcg-5mcg-77mg- 6mg-120mg, 25mg-25mg- 45unit-150mcg-75mcg- 35mg-50mcg-12.5mg- 162mg-120mcg-150mcg- 35mg-25mcg-15mg-15mg- 2mg-80mg-2000unit-2mg- 35mg-5mcg-25mg-100mg- 15mg-100mg-1.9mg- 75mcg-5000unit-2.5mg- 3000unit-300mcg-25mg- 1mg-12.5mg-50mg-2.5mg- 25mcg-2.1mg-12.5mg- 15mg-175mcg-5mg-15mg- 7.5mcg-400unit-400mcg- 250mcg-15mg-5mg-5mg- 37.5mcg-2.5mg-120mg, 37.5mcg-15mg-15mcg- Louisiana Healthcare Connections Updated April 1, 2019

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 100unit-5mg-200mcg- 4.167mcg-33.333mg- 50unit-125mcg-15mg- 8.333mg-1mg-4.167mg- 25mg-150mg, 16.67mg- 8.333mg-5mg-8.333mg- 66.67unit-2500unit- 10mg-8.333mg-0.667mg- 16.67mg-33.33mg-25mcg- 1666.666unit-2.667mcg- 83.33mg-5mg-4.17mcg- 33.333unit-1.667mg- 33.33mcg-0.4mg-16.5mg- 66.667mcg-5unit-1000mcg- 8.33mcg-3.33mg-83.33mg- 1.667mg-40mg, 16.67mg- 8.33mg-16.67mg-33.33mg- 66.67unit-2500unit- 8.33mg-66.67mg- 16.67mg-33.33mg-25mcg- 16.67mcg-16.67unit- 83.33mg-5mg-4.17mcg- 16.67mg-31.67mg- 0.33mg-33.33mcg-0.4mg- 133.33mcg-50mcg- 16.5mg-8.33mcg-3.33mg- 16.67mg-100mg-200mg, 83.33mg-8.33mg-16.67mg- 10mg-25mg-10mg-10mg- 33.33mg-8.33mg-66.67mg- 75mg-15mcg-105mcg- 16.67mcg-16.67unit- 4mg-15mcg-7.5mcg-48mg- 16.67mg-31.67mg- 60unit-150mcg-112.5mcg- 133.33mcg-50mcg- 200mg-180mg-225mcg- 16.67mg-100mg-200mg, 10mg-2mg-80mg-3000unit- 16.67mg-66.67unit- 2mg-22.5mg-100mg- 2500unit-16.67mg- 1.5mg-350mcg-3000unit- 33.33mg-25mcg-83.33mg- 300mcg-20mg-1.7mg- 5mg-4.17mcg-0.33mg- 15mg-30mcg-400unit- 33.33mcg-0.4mg-16.5mg- 400mcg-30mcg-3mg- 8.33mcg-3.33mg-83.33mg- 120mg, 12.667mg-1mg- 3.33mg-8.33mg-16.67mg- 30mg-5unit-5unit- 33.33mg-8.33mg-66.67mg- 66.667mg-0.667mg-2.5mg- 16.67mcg-66.67unit- 2.5mg-16.667mg- 16.67mg-31.67mg- 4.167mcg-16.667mg- 133.33mcg-50mcg- 4.167mg-3.333mg-5mg- 16.67mg-100mg-200mg, 8.333mg-10mg-3.333mg- 1mg-5mg-25mg-10mg- 0.667mg-1666.667unit- 25mg-10mg-13mcg-72mg- 1666.667unit-2.667mcg- 200mcg-5mg-80mcg- 333.333unit-1.667mg- 5000unit-7.5mg-5mg- 1.667mg-66.667mcg-1mg- 10mg-6.5mcg-80mg- 1.667mg-20mg, 1mg- 60unit-200mcg-150mcg- 25mg-5mg-25mg-10mg- 165mg-200mcg-200mcg- 72mg-80mcg-5mg-10mg- 13mcg-2mg-80mg-3.5mg- 200mcg-130mg-60unit- 15mg-100mg-300mcg- 150mcg-165mg-15mg- 18mg-275mcg-40mg- 13mcg-3.5mg-200mcg- 5.1mg-10mg-18mcg- 200mcg-13mcg-2mg- 400unit-4.5mg-400mcg- 80mg-6.5mcg-208mcg- 60mcg-6mg-120mg, 7.5mg-100mg-18mg- 12.5mg-100mcg-25mg- 7500unit-5mg-5.1mg- 5mg-15mg-0.5mg-12.5mg- 10mg-18mcg-6mg-40mg- 20mg-5mg-36mg-6.5mcg- 4.5mg-400mcg-60mcg- 100mcg-3.75mg-100mcg- 120mg-400unit, 8.333mg- 6.5mcg-2.5mg-2.5mg- 1mg-15mg-1.667mg-50mg- 12.5mg-3.25mcg-65mg- 37.5mcg-236.667mg- 30unit-75mcg-82.5mg- 3.333mg-1.667mg-2.5mg- 1mg-40mg-1.75mg- Louisiana Healthcare Connections Updated April 1, 2019

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 12.5mg-50mg-2.25mg- 0.667mg-25mcg-20mg- 3750unit-37.5mcg-20mg- 1666.667unit-0.5mg-10mg- 40mcg-2.55mg-5mg-9mcg- 71.667mg-26.667mcg- 200unit-200mcg-150mcg- 20mg-166.667mcg- 3mg-90mg, 20mg-0.5mg- 266.667unit-20mg-30mg- 12.5mg-100mcg-25mg- 266.667mcg-200mcg- 15mg-12.5mg-5mg- 8.333mg-100mg, 12.5mg- 6.5mcg-100mcg-100mcg- 2.5mg-1mg-5mg-5mg- 3.75mg-6.5mcg-2.5mg- 12.5mg-0.5mg-12.5mg- 2.5mg-5mg-12.5mg- 12.5mg-12.5mg-5mg- 3.25mcg-36mg-65mg- 36mg-6.5mcg-100mcg- 30unit-75mcg-82.5mg- 3.75mg-100mcg-6.5mcg- 1mg-40mg-1.75mg- 2.5mg-2.5mg-3.25mcg- 12.5mg-50mg-2.25mg- 65mg-30unit-75mcg- 5mg-3750unit-37.5mcg- 104mcg-250mg-1mg- 20mg-40mcg-2.55mg- 40mg-1.75mg-7.5mg- 9mcg-200unit-200mcg- 100mg-6mg-13.5mg-15mg- 150mcg-3mg-90mg, 1mg- 3750unit-37.5mcg-20mg- 25mg-5mg-25mg-1mg- 40mcg-8.5mg-9mcg- 500mcg-1mg-1mg-5mg- 200unit-200mcg-30mcg- 2mg-90mg-13mcg- 5mg-60mg, 4.58mg- 200mcg-10mg-200mcg- 16.66unit-4.58mg-1.66mg- 7.5mg-13mcg-2mg-5mg- 0.0125mg-25mg-16.66mg- 6.5mcg-130mg-60unit- 12.5mg-25mg-2.5mg- 150mcg-200mcg-165mg- 0.33mg-0.16mg-12.5mg- 2mg-100mg-500mcg- 0.016mg-0.83mg-41.66mg- 3.5mg-15mg-100mg- 1.66mg-16.66mg-1.66mg- 4.5mg-3.6mg-10mg- 66.66unit-4.16mg-4.16mg- 7500unit-500mcg-40mg- 8.33mg-4.16mg-2.5mg- 80mcg-5.1mg-24mcg- 16.66mg-833.33unit- 400mcg-60mcg-6mg- 33.33mg-16.66mg-25mg- 120mg-400unit, 1mg-1mg- 1.66mg-16.66mcg-4.16mg- 25mg-1mg-0.5mg-1mg- 8.33mg-0.16mg-4.16mg- 25mg-5mg-2mg-13mcg- 8.33mg-33.33mg, 90mg-200mcg-10mg- 33.333mg-33.333mg- 80mcg-5000unit-7.5mg- 0.667mg-3.333mcg- 2mg-10mg-6.5mcg-80mg- 73.333mcg-0.667mg- 60unit-200mcg-150mcg- 1.667mcg-16mg- 165mg-200mcg-1mg- 133.333unit-50mcg-25mcg- 13mcg-2mg-100mg-0.5mg- 24mg-166.667mg- 3.5mg-15mg-100mg- 116.667mcg-50mcg- 300mcg-18mg-275mcg- 26.667mg-0.667mg-5mg- 40mg-5.1mg-10mg-24mcg- 33.333mg-16.667mg- 400unit-4.5mg-400mcg- 0.5mg-100mcg-3.333mg- 60mcg-6mg-120mg, 1666.667unit-83.333mcg- 3.333mg-66.667mcg- 6.667mg-3.333mcg- 50mg-10mg-15mg-5mg- 0.567mg-8.333mcg- 50mcg-0.667mg-100mcg- 133.333unit-166.667mcg- 25mcg-100mg-5mg-50mg- 10mcg-1mg-166.667mg, 0.667mg-5.333mg- 2mg-72mg-72mg-10mcg- 66.667mcg-22.333unit- 10mcg-20mcg-20mcg- 0.667mg-33.333mg- 120mcg-120mcg-2mg- Louisiana Healthcare Connections Updated April 1, 2019

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 2mg-10mcg-10mcg-30unit- 30mcg-3mg-3mg-90mg- 30unit-75mcg-75mcg- 90mg, 35mcg-35mcg- 80mg-80mg-162mg- 72mg-72mg-10mcg- 162mg-100mg-100mg- 10mcg-55mcg-55mcg- 150mcg-150mcg-15mg- 2.3mg-2.3mg-10mcg- 15mg-1.5mg-1.5mg- 10mcg-5mcg-5mcg-0.9mg- 300mcg-300mcg-150mcg- 0.9mg-109mg-109mg- 150mcg-10mg-10mg- 30unit-30unit-150mcg- 3500unit-3500unit-250mcg- 150mcg-45mcg-45mcg- 250mcg-20mg-20mg- 80mg-80mg-200mg- 25mcg-25mcg-1.7mg- 200mg-2mg-2mg-100mg- 1.7mg-6mcg-6mcg- 100mg-150mcg-150mcg- 400unit-400unit-400mcg- 11mg-11mg-1.5mg-1.5mg- 400mcg-30mcg-30mcg- 300mcg-300mcg-18mg- 2mg-2mg-60mg-60mg, 18mg-10mg-10mg- 2mg-72mg-72mg-10mcg- 3500unit-3500unit-250mcg- 10mcg-20mcg-20mcg- 250mcg-20mg-20mg- 150mcg-150mcg-2mg- 25mcg-25mcg-1.7mg- 2mg-5mcg-5mcg-48mg- 1.7mg-6mcg-6mcg-400unit- 48mg-45unit-45unit- 400unit-500mcg-500mcg- 150mcg-150mcg-75mcg- 30mcg-30mcg-2mg-2mg- 75mcg-80mg-80mg- 90mg-90mg, 8.333mg- 200mg-200mg-100mg- 3.333mg-3.333mg- 100mg-150mcg-150mcg- 3.333mg-33.333mg- 2mg-2mg-15mg-15mg- 33.333mg-16.666mg- 1.5mg-1.5mg-300mcg- 3.333mg-3.333mg- 300mcg-10mg-10mg- 3.333mg-33.333mg- 3500unit-3500unit-250mcg- 3.333mg-11.666mg- 250mcg-20mg-20mg- 0.833mg-1.666mg- 10mcg-10mcg-1.7mg- 6.666mg-1.666mg- 1.7mg-25mcg-25mcg- 6.666mg-1.666mg- 400unit-400unit-400mcg- 8.333mg-33.333mg- 400mcg-30mcg-30mcg- 3.333mg-25mcg-10mg- 3mg-3mg-60mg-60mg, 50mcg-83.333mg-5mg- 45mcg-45mcg-72mg- 0.333mg-33.333mcg- 72mg-10mcg-10mcg- 0.333mg-20mg- 55mcg-55mcg-2.3mg- 16.666mcg-1.333mg- 2.3mg-5mcg-5mcg-0.9mg- 33.333mg-5mg-5000unit- 0.9mg-110mg-110mg- 33.333mg-83.333unit- 50unit-50unit-150mcg- 333.333mg-1.333mg- 150mcg-45mcg-45mcg- 8.333mg-6.666mg- 220mg-220mg-2mg-2mg- 8.333mg-8.333mg- 80mg-80mg-50mg-50mg- 8.333mg-8.333mg- 150mcg-150mcg-11mg- 8.333mg-8.333mg- 11mg-1.5mg-1.5mg- 8.333mg-8.333mcg- 300mcg-300mcg-10mg- 133.333unit-8.333mg- 10mg-2500unit-2500unit- 8.333mg-133.333mcg- 250mcg-250mcg-20mg- 16.666mcg-8.333mg- 20mg-30mcg-30mcg- 333.333mg 1.7mg-1.7mg-25mcg- MULTIVITAMIN ADULTS F QL(1 ea daily); 25mcg-500unit-500unit- TABS RX/OTC 500mcg-500mcg-30mcg- Louisiana Healthcare Connections Updated April 1, 2019

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MULTIVITAMIN MEN F QL(1 ea daily); ONE-A-DAY TEEN QL(1 ea daily); TABS RX/OTC ADVANTAGEFOR HIM F RX/OTC TABS NAT-RUL THERAVITE- F QL(1 ea daily); M/HIGHPOTENCY TABS RX/OTC ONE-A-DAY WEIGHT QL(1 ea daily); SMART ADVANCED TABS RX/OTC NATRUL-MEGA-75 TABS F QL(1 ea daily); NF RX/OTC (Use Multiple Vitamins w/ Minerals) NATRUL-VITES TABS F QL(1 ea daily); RX/OTC ONE-A-DAY WOMENS QL(1 ea daily); 50+ ADVANTAGE TABS RX/OTC QL(1 ea daily); NF NICADAN TABS F (Use Multiple Vitamins w/ RX/OTC Minerals) QL(1 ea daily); NICADAN ZX TABS F ONE-A-DAY WOMENS QL(1 ea daily); RX/OTC ACTIVE MIND & BODY RX/OTC QL(1 ea daily); NF NICAZEL FORTE TABS F TABS (Use Multiple RX/OTC Vitamins w/ Minerals) NICAZEL TABS F QL(1 ea daily); ONE-A-DAY WOMENS QL(1 ea daily); RX/OTC PETITES TABS (Use NF RX/OTC NO IRON MULTIPLE QL(1 ea daily); Multiple Vitamins w/ VITAMIN/MINERALS F RX/OTC Minerals) TABS ONE-A-DAY WOMENS QL(1 ea daily); PLUS HEALTHY SKIN RX/OTC NUTRICAP TABS F QL(1 ea daily); RX/OTC SUPPORT TABS (Use NF Multiple Vitamins w/ OCULAR VITAMINS TABS F QL(1 ea daily); RX/OTC Minerals) QL(1 ea daily); ONCOVITE TABS F QL(1 ea daily); OPTI-WOMAN TABS F RX/OTC RX/OTC ONE DAILY MENS QL(1 ea daily); OPTIVITE P.M.T. TABS QL(1 ea daily); FORMULA W/O IRON F RX/OTC (Use Multiple Vitamins w/ NF RX/OTC TABS Minerals) QL(1 ea daily); ONE DAILY PLUS IRON F QL(1 ea daily); OPURITY TABS F TABS RX/OTC RX/OTC OSTEOPRIME QL(1 ea daily); ONE DAILY WOMENS F QL(1 ea daily); TABS RX/OTC PLUS/CALCIUM & F RX/OTC MAGNESIUM TABS ONE-A-DAY ENERGY F QL(1 ea daily); TABS RX/OTC PARVLEX TABS F QL(1 ea daily); RX/OTC ONE-A-DAY MENOPAUSE F QL(1 ea daily); FORMULA TABS RX/OTC PHYTOMULTI TABS F QL(1 ea daily); RX/OTC ONE-A-DAY MENS 50+ F QL(1 ea daily); ADVANTAGE TABS RX/OTC PRESERVISION AREDS QL(1 ea daily); TABS 100UNIT-7160UNIT- F RX/OTC ONE-A-DAY MENS F QL(1 ea daily); 0.4MG-17.4MG-113MG HEALTH FORMULA TABS RX/OTC PRO-CAL TABS 145MG- QL(1 ea daily); ONE-A-DAY MENS PRO F QL(1 ea daily); 187.5MG-40MG-100UNIT- F RX/OTC EDGE TABS RX/OTC 7.5MG ONE-A-DAY PROACTIVE QL(1 ea daily); F PROCERV HP TABS F QL(1 ea daily); 65+ TABS RX/OTC RX/OTC PRORENAL+D TABS F QL(1 ea daily); RX/OTC Louisiana Healthcare Connections Updated April 1, 2019

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); QL(1 ea daily); PROVIT TABS F SUPERB NAILS TABS F RX/OTC RX/OTC QL(1 ea daily); QL(1 ea daily); QUENCH TABS F T-VITES TABS F RX/OTC RX/OTC QL(1 ea daily); QL(1 ea daily); QUIN B STRONG TABS F THERA M PLUS TABS F RX/OTC RX/OTC QL(1 ea daily); QL(1 ea daily); QUINTABS-M TABS F THERA-M TABS F RX/OTC RX/OTC QL(1 ea daily); QL(1 ea daily); RA CENTRAL-VITE TABS F THERA-TABS M TABS F RX/OTC RX/OTC RA CENTRAL-VITE F QL(1 ea daily); THERABETIC MULTI- F QL(1 ea daily); UNDER 50MENS TABS RX/OTC VITAMIN TABS RX/OTC RA CENTRAL-VITE QL(1 ea daily); THERAGRAN-M QL(1 ea daily); UNDER 50WOMENS F RX/OTC ADVANCED 50 PLUS F RX/OTC TABS TABS RAGUS TABS (Use QL(1 ea daily); THERAGRAN-M F QL(1 ea daily); Multiple Vitamins w/ NF RX/OTC ADVANCED TABS RX/OTC Minerals) THERAGRAN-M PREMIER F QL(1 ea daily); RENAPLEX-D TABS F QL(1 ea daily); 50 PLUS TABS RX/OTC RX/OTC THERAGRAN-M PREMIER F QL(1 ea daily); REQ 49+ TABS F QL(1 ea daily); TABS RX/OTC RX/OTC F QL(1 ea daily); QL(1 ea daily); THERAGRAN-M TABS RX/OTC SENTRY SENIOR TABS F RX/OTC QL(1 ea daily); THEREMS-H TABS F SENTRY SENIOR/LUTEIN F QL(1 ea daily); RX/OTC TABS RX/OTC F QL(1 ea daily); QL(1 ea daily); THEREMS-M TABS RX/OTC SENTRY TABS F RX/OTC QL(1 ea daily); UNICOMPLEX-M TABS F SIDEROL TABS F QL(1 ea daily); RX/OTC RX/OTC VITALINE TOTAL F QL(1 ea daily); SM ONE DAILY MENS F QL(1 ea daily); FORMULA 2 TABS RX/OTC TABS RX/OTC VITALINE TOTAL F QL(1 ea daily); SM ONE DAILY WOMENS F QL(1 ea daily); FORMULA 3 TABS RX/OTC TABS RX/OTC VITAMIN D3 COMPLETE F QL(1 ea daily); QL(1 ea daily); TABS RX/OTC SOLO TABS F RX/OTC VITAROCA PLUS TABS QL(1 ea daily); STROVITE FORTE TABS QL(1 ea daily); (Use Multiple Vitamins w/ NF RX/OTC 0.1MG-50MCG-60UNIT- RX/OTC Minerals) 25MCG-1000UNIT-15MG- VITASANA TABS F QL(1 ea daily); 3MG-50MG-20MG-10MG- RX/OTC 25MG-3000UNIT-100MG- NF QL(1 ea daily); 20MG-50MCG-0.8MG- VITATRUM TABS F 0.15MG-25MG-500MG RX/OTC (Use Multiple Vitamins w/ VITRUM 50+ SENIOR F QL(1 ea daily); Minerals) MULTI TABS RX/OTC QL(1 ea daily); STROVITE ONE TABS F QL(1 ea daily); VP-ZEL TABS F RX/OTC RX/OTC Louisiana Healthcare Connections Updated April 1, 2019

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WHOLE FOOD F QL(1 ea daily); multiple vitamin tabs QL(1 ea daily) MULTIVITAMIN TABS RX/OTC 200unit-5000unit-250mg, WOMENS 50+ MULTI QL(1 ea daily); 10000unit-200unit-250mg, VITAMIN& MINERAL F RX/OTC 30unit-100mg-15mg-20mg- FORMULA TABS 12mcg-0.4mg-45mcg- 600mg, 5000unit-20mg- WOMENS BIOMULTIPLE F QL(1 ea daily); TABS RX/OTC 1.7mg-6mcg-125unit- 1.5mg-2mg-60mg, WOMENS MULTI VITAMIN QL(1 ea daily); 5000unit-20mg-1.7mg- & MINERAL FORMULA F RX/OTC 6mcg-400unit-1.5mg-2mg- TABS 60mg, 20mg-2.5mg-1mg- YELETS TEENAGE F QL(1 ea daily); 5000unit-1mcg-2mg-1mg- FORMULA TABS RX/OTC 50mg-400unit, 5000unit- 400unit-20mg-2.5mg-1mg- Multivitamins 1mcg-1mg-2mg-50mg, CARDENZ TABS (Use NF QL(1 ea daily) 7mg-5000unit-20mg- Multiple Vitamin) 2.5mg-1mcg-2mg-1mg- ESTROFACTORS TABS F QL(1 ea daily) 50mg-400unit, 62.5mg- 40mg-50mg-10mg- QL(1 ea daily) 100mcg-10mg-400mcg- MULTI VITAMIN TABS F 5mg-120mg, 5000unit- QL(1 ea daily) 20mg-1.7mg-6mcg- MULTI VITAMIN/D-3 TABS F 400unit-1.5mg-0.4mg-2mg- 60mg, 5000unit-20mg- 1.7mg-6mcg-400unit- 1.5mg-400mcg-2mg-60mg, F 75mg-5000unit-20mg- 2.5mg-1mg-1mcg-400unit- 2mg-1mg-50mg, 28.5mg- 1.5mg-1mg-5000unit- 20mg-2mg-400unit-0.1mg- 37.5mg, 50mg-20mg- 1.7mg-10mg-6mcg-1.5mg- 800mcg-300mcg-10mg- 60mg, 30unit-100mg- 10mg-20mg-12mcg-15mg- 400mcg-45mcg-5mg- 500mg, 30unit-10mg- 100mg-10mg-20mg- 12mcg-400mcg-45mcg- 3mg-500mg, 30unit-10mg- 20mg-100mg-10mg- 12mcg-400mcg-45mcg- 5mg-500mg, 60mg- 4000unit-1.7mg-1mg- 3mcg-400unit-1.5mg-1mg- 20mg-50mg, 30unit-1.5mg- 10mg-5000unit-20mg- 1.7mg-6mcg-400unit-2mg- 60mg, 10unit-5000unit- 20mg-1.7mg-6mcg- 400unit-1.5mg-400mcg- Louisiana Healthcare Connections Updated April 1, 2019

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 2mg-60mg, 5000unit- 20mg-18mcg-0.4mg-6mg- 30unit-1.5mg-10mg-20mg- 333mg, 30unit-1.5mg- 1.7mg-400unit-400mcg- 5000unit-3000unit-20mg- 2mg-60mg, 30unit-400unit- 1.7mg-6mcg-400unit- 20mg-1.7mg-10mg- 400mcg-2mg-60mg, 30unit- 5000unit-6mcg-1.5mg- 20mg-3mg-10mg-3.4mg- 0.4mg-2mg-60mg, 30unit- 5000unit-9mcg-400unit- 5000unit-1.7mg-10mg- 400mcg-30mcg-3mg-90mg, 6mcg-1.5mg-20mg-0.4mg- 30unit-3.4mg-10mg- 2mg-60mg-400unit, 1.5mg- 5000unit-9mcg-400unit- 10mg-5000unit-20mg- 20mg-3mg-400mcg- 1.7mg-6mcg-400mcg- 30mcg-3mg-90mg, 30unit- 30unit-2mg-60mg-400unit, 3mg-5000unit-20mg- 15unit-20mg-5000unit- 3.4mg-10mg-9mcg- 20mg-1.7mg-6mcg- 400mcg-30mcg-3mg- 400unit-1.5mg-400mcg- 90mg-400unit, 5000unit- 2mg-60mg, 30unit-1.5mg- 30unit-400unit-3.4mg- 10mg-3000unit-20mg- 10mg-9mcg-20mg-3mg- 1.7mg-6mcg-400mcg-2mg- 400mcg-30mcg-3mg-90mg, 60mg-400unit, 30unit- 30unit-1.5mg-45mg-10mg- 1.5mg-10mg-3000unit- 3000unit-20mg-1.7mg- 20mg-1.7mg-6mcg- 6mcg-400unit-400mcg- 400unit-400mcg-2mg- 2mg-60mg, 30unit-1.5mg- 60mg, 30unit-1.5mg-10mg- 75mg-10mg-5000unit- 5000unit-20mg-1.7mg- 20mg-1.7mg-6mcg- 6mcg-400mcg-2mg-60mg- 400unit-400mcg-2mg- 400unit, 30unit-1.5mg- 60mg, 30unit-45mg-1.5mg- 10mg-5000unit-20mg- 10mg-3000unit-20mg- 1.7mg-6mcg-400unit- 1.7mg-6mcg-400unit- 400mcg-2mg-60mg, 400mcg-2mg-60mg, 30unit- 30unit-1.5mg-5000unit- 1.5mg-10mg-5000unit- 20mg-1.7mg-10mg-6mcg- 20mg-1.7mg-6mcg- 400unit-400mcg-2mg- 400unit-400mcg-30mcg- 60mg, 30unit-10mg- 2mg-60mg, 7.5unit-45mg- 5000unit-20mg-1.7mg- 10mg-3000unit-20mg- 6mcg-400unit-1.5mg- 1.7mg-6mcg-800unit- 400mcg-2mg-60mg, 1.5mg-500mcg-2mg-60mg, 30unit-400unit-1.5mg- 10mg-20mg-1.7mg- 5000unit-20mg-1.7mg- 5000unit-6mcg-1.5mg- 10mg-6mcg-2mg-400mcg- 400mcg-30unit-300mcg- 60mg, 30unit-5000unit- 2mg-60mg-400unit, 30unit- 20mg-1.7mg-10mg-6mcg- 10mg-20mg-1.7mg- 400unit-1.5mg-400mcg- 5000unit-6mcg-1.5mg- 2mg-60mg, 5000unit- 400mcg-300mcg-2mg- 30unit-10mg-20mg-1.7mg- 60mg-400unit, 45mg- 6mcg-1.5mg-400mcg-2mg- 30unit-10mg-5000unit- 60mg-400unit, 5000unit- 20mg-3.4mg-10mg-9mcg- 30unit-400unit-1.5mg- 400unit-3mg-400mcg- 1.7mg-10mg-6mcg-20mg- 30mcg-3mg-90mg, 50mg- 400mcg-2mg-60mg, 50mg-2500unit-50mg- 5000unit-15unit-400unit- 25mg-1.5mg-40mg-10mg- 10.3mg-100mg-10mg- 1.7mg-25mcg-100mg- Louisiana Healthcare Connections Updated April 1, 2019

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 400mcg-2000mcg-2mg, pediatric multivitamins w/fl QL(1 ea daily); 5000unit-5000unit-30unit- chew 0.25mg-15unit- AL(Up to 13 yrs 30unit-400unit-400unit- 1.2mg-2500unit-4.5mcg- old ) 1.7mg-1.7mg-10mg-10mg- 400unit-1.05mg-13.5mg- 6mcg-6mcg-1.5mg-1.5mg- 1.05mg-0.3mg-60mg, 20mg-20mg-0.4mg-0.4mg- 0.25mg-15unit-400unit- 2mg-2mg-60mg-60mg, 2500unit-1.2mg-4.5mcg- 5000unit-5000unit-45unit- 13.5mg-1.05mg-0.3mg- 45unit-400unit-400unit- 1.05mg-60mg, 0.5mg- 2.55mg-2.55mg-10mg- 15unit-1.2mg-2500unit- 10mg-9mcg-9mcg-2.25mg- 4.5mcg-400unit-1.05mg- 2.25mg-20mg-20mg- 13.5mg-1.05mg-0.3mg- 0.4mg-0.4mg-3mg-3mg- 60mg, 0.5mg-15unit- 200mg-200mg 400unit-2500unit-1.2mg- QL(1 ea daily) 4.5mcg-13.5mg-1.05mg- NEOMULTIVITE TABS F 0.3mg-1.05mg-60mg, QL(1 ea daily) 15unit-1mg-2500unit- OMNICAP TABS F 13.5mg-1.2mg-4.5mcg- ONE-A-DAY ESSENTIAL QL(1 ea daily) 400unit-1.05mg-0.3mg- F TABS (Use Multiple NF 1.05mg-60mg, 1mg-15unit- Vitamin) 1.2mg-2500unit-4.5mcg- 400unit-1.05mg-13.5mg- ONE-A-DAY MENS TABS NF QL(1 ea daily) 1.05mg-0.3mg-60mg, 1mg- (Use Multiple Vitamin) 15unit-400unit-2500unit- QUINTABS TABS F QL(1 ea daily) 1.2mg-4.5mcg-13.5mg- 1.05mg-0.3mg-1.05mg- THERA TABS F QL(1 ea daily) 60mg, 15unit-0.5mg- 1.05mg-13.5mg-1.2mg- Ped MV w/ Fluoride 2500unit-4.5mcg-400unit- 0.3mg-1.05mg-60mg, QL(50 ml per 15unit-0.5mg-2500unit- fill retail); FLORIVA PLUS SOLN F 13.5mg-1.2mg-4.5mcg- AL(Up to 13 yrs 400unit-1.05mg-0.3mg- old ) 1.05mg-60mg, 15unit- QL(1 ea daily); 0.25mg-2500unit-13.5mg- MULTIVITAMIN/FLUORID F AL(Up to 13 yrs E CHEW 1.2mg-4.5mcg-400unit- old ) 1.05mg-0.3mg-1.05mg- 60mg

Louisiana Healthcare Connections Updated April 1, 2019

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pediatric multivitamins w/fl QL(50 ml per QUFLORA PEDIATRIC QL(1 ea daily); soln 0.25mg/ml-0.6mg/ml- fill retail); CHEW 108MCG-1MG- AL(Up to 13 yrs 8mg/ml-1500unit/ml- AL(Up to 13 yrs 15UNIT-1MG-15MG- old ) 2mcg/ml-400unit/ml- old ) 1200UNIT-5MG-1.3MG- 0.5mg/ml-5unit/ml- 4MCG-400UNIT-1.2MG- 0.4mg/ml-35mg/ml, 100MCG-1.5MG-60MG, 0.25mg/ml-5unit/ml- 108MCG-1MG-15UNIT- 0.6mg/ml-8mg/ml- 0.5MG-15MG-1200UNIT- F 1500unit/ml-2mcg/ml- 5MG-1.3MG-4MCG- 400unit/ml-0.5mg/ml- 400UNIT-1.2MG-100MCG- 0.4mg/ml-35mg/ml, 1.5MG-60MG, 108MCG- 0.25mg/ml-5unit/ml- 1MG-15UNIT-0.25MG- 8mg/ml-0.6mg/ml- 15MG-1200UNIT-5MG- 1500unit/ml-2mcg/ml- 1.3MG-4MCG-400UNIT- 400unit/ml-0.5mg/ml- 1.2MG-100MCG-1.5MG- 0.4mg/ml-35mg/ml, 60MG 0.5mg/ml-0.6mg/ml- QUFLORA PEDIATRIC QL(50 ml per 8mg/ml-1500unit/ml- SOLN 150MCG/ML- fill retail); 2mcg/ml-400unit/ml- 1MG/ML-0.5MG/ML- AL(Up to 13 yrs 0.5mg/ml-5unit/ml- 12MG/ML-1100UNIT/ML- old ) 0.4mg/ml-35mg/ml, 2MG/ML-1MG/ML- 0.5mg/ml-5unit/ml- 3MCG/ML-400UNIT/ML- 0.6mg/ml-8mg/ml- F 1MG/ML-81MCG/ML- 1500unit/ml-2mcg/ml- 12UNIT/ML-1MG/ML- F 400unit/ml-0.5mg/ml- 45MG/ML, 65MCG/ML- 0.4mg/ml-35mg/ml, 1MG/ML-0.25MG/ML- 0.5mg/ml-5unit/ml-8mg/ml- 10MG/ML-1000UNIT/ML- 0.6mg/ml-1500unit/ml- 0.8MG/ML-0.6MG/ML- 2mcg/ml-400unit/ml- 2MCG/ML-400UNIT/ML- 0.5mg/ml-0.4mg/ml- 0.5MG/ML-35MCG/ML- 35mg/ml, 5unit/ml- 5UNIT/ML-0.4MG/ML- 0.5mg/ml-0.6mg/ml- 35MG/ML 8mg/ml-1500unit/ml- 2mcg/ml-400unit/ml- Ped MV w/ Iron 0.5mg/ml-0.4mg/ml- pediatric multiple vitamins QL(50 ml per 35mg/ml, 5unit/ml- w/ iron soln 0.6mg/ml- fill retail); 0.5mg/ml-8mg/ml- 10mg/ml-5unit/ml-8mg/ml- F AL(Up to 13 yrs 0.6mg/ml-1500unit/ml- 1500unit/ml-400unit/ml- old ) 2mcg/ml-400unit/ml- 0.5mg/ml-0.4mg/ml- 0.5mg/ml-0.4mg/ml- 35mg/ml 35mg/ml, 5unit/ml- QL(50 ml per 0.25mg/ml-0.6mg/ml- POLY-VI-SOL/IRON SOLN fill retail); 8mg/ml-1500unit/ml- (Use Pediatric Multiple NF Vitamins w/ Iron) AL(Up to 13 yrs 2mcg/ml-400unit/ml- old ) 0.5mg/ml-0.4mg/ml- 35mg/ml Ped Multi Vitamins w/Fl & FE QL(50 ml per QL(50 ml per ped multivitamins w/fl & fill retail); pediatric vitamins acd w/ F fill retail); F fluoride soln AL(Up to 13 yrs iron soln AL(Up to 13 yrs old ) old )

Louisiana Healthcare Connections Updated April 1, 2019

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRI-VIT/FLUORIDE/IRON QL(50 ml per INATAL GT TABS F QL(1 ea daily) SOLN 0.25MG/ML- F fill retail); 1500UNIT/ML-10MG/ML- AL(Up to 13 yrs KP PRENATAL F 400UNIT/ML-35MG/ML old ) MULTIVITAMINS TABS Pediatric Multiple Vitamins KPN PRENATAL TABS F ONE-A-DAY VITACRAVES QL(1 ea daily); RX/OTC GUMMIES+OMEGA-3 NF AL(Up to 13 yrs M-NATAL PLUS TABS F DHA CHEW (Use Pediatric old ) Multiple Vitamin w/ C & FA) M-VIT TABS F RX/OTC QL(1 ea daily); pediatric multiple vitamin w/ F AL(Up to 13 yrs MULTI PRENATAL TABS F c & fa chew old ) MYNATAL ADVANCE F QL(1 ea daily) pediatric multiple vitamin w/ QL(50 ml per TABS c soln 0.6mg/ml-5unit/ml- fill retail); QL(1 ea daily) 8mg/ml-1500unit/ml- F AL(Up to 13 yrs MYNATAL CAPS F 2mcg/ml-400unit/ml- old ) 0.5mg/ml-0.4mg/ml- MYNATAL PLUS TABS F 35mg/ml QL(50 ml per MYNATAL ULTRACAPLET F QL(1 ea daily) POLY-VI-SOL SOLN (Use TABS Pediatric Multiple Vitamin NF fill retail); w/ C) AL(Up to 13 yrs MYNATAL-Z TABS F old ) QL(1 ea daily) Pediatric Vitamins MYNATE 90 PLUS TBCR F QL(50 ml per pediatric vitamins adc soln NAT-RUL PRENATAL F F fill retail); VITAMINS TABS 1500unit/ml-400unit/ml- AL(Up to 13 yrs 35mg/ml old ) NATALVIT TABS F Prenatal Vitamins NEONATAL PLUS TABS F RX/OTC CALNA TABS F NEONATAL VITAMIN F TABS CLASSIC PRENATAL F TABS NIVA-PLUS TABS F RX/OTC CO-NATAL FA TABS F NUTRICION PORVIDA F TABS COMPLETENATE CHEW F O-CAL FA TABS F RX/OTC CVS PRENATAL TABS F O-CAL PRENATAL TABS F EQL PRENATAL F FORMULA TABS OB COMPLETE ADVANCED CAPS GNP PRENATAL TABS F 385MG-5MG-0.162MG- 42.5MG-150MG-0.15MG- F GOODSENSE PRENATAL F VITAMINS TABS 300MG-2MG-27MG- 8MCG-1200UNIT-60MG- HM PRENATAL TABS F 0.838MG-30MG-60MG PERRY PRENATAL CAPS F

Louisiana Healthcare Connections Updated April 1, 2019

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PNV FERROUS QL(1 ea daily) PRENATAL TABS 11UNIT- FUMARATE/DOCUSATE/F F 263MG-25MG-1.5MG- OLIC ACID TABS 27MG-4000UNIT-18MG- 1.7MG-4MCG-400UNIT- PNV FOLIC ACID + IRON F RX/OTC MULTIVITAMIN TABS 0.8MG-2.6MG-100MG, 30UNIT-4000UNIT-25MG- PNV PRENATAL PLUS F RX/OTC 1.8MG-200MG-28MG- MULTIVITAMIN TABS 20MG-1.7MG-8MCG- PNV TABS 29-1 TABS F QL(1 ea daily) 400UNIT-0.8MG-2.6MG- 120MG, 30UNIT-25MG- PRE-NATAL FORMULA F 1.8MG-200MG-28MG- TABS 20MG-1.7MG-4000UNIT- QL(1 ea daily) 8MCG-400UNIT-800MCG- PRENATABS RX TABS F 2.6MG-120MG, 30UNIT- PRENATAL 19 CHEW 4000UNIT-25MG-1.8MG- 30UNIT-1000UNIT-20MG- 200MG-28MG-20MG- F 3MG-200MG-29MG-7MG- 1.7MG-8MCG-400UNIT- 15MG-3MG-12MCG- 800MCG-2.6MG-120MG, 4000UNIT-30UNIT-200MG- 400UNIT-1MG-20MG- F 100MG, 1000UNIT- 25MG-1.8MG-28MG- 400UNIT-20MG-25MG- 20MG-1.7MG-8MCG- 3MG-200MG-29MG-7MG- 400UNIT-800MCG-2.6MG- 6MG-3MG-12MCG-1MG- 120MG, 4000UNIT- 30UNIT-20MG-100MG 30UNIT-25MG-1.8MG- 200MG-28MG-20MG- PRENATAL 19 TABS QL(1 ea daily) 1.7MG-8MCG-400UNIT- 1000UNIT-30UNIT-20MG- 800MCG-2.6MG-120MG, 25MG-3MG-200MG-29MG- 160MG-11UNIT-200MG- 15MG-3MG-7MG-12MCG- 25MG-1.84MG-27MG- 400UNIT-20MG-1MG- 4000UNIT-18MG-1.7MG- 100MG, 30UNIT- F 4MCG-400UNIT-800MCG- 1000UNIT-20MG-25MG- 2.6MG-100MG 3MG-200MG-29MG-7MG- 15MG-3MG-12MCG- PRENATAL TABS 22MG- RX/OTC 400UNIT-1MG-20MG- 2MG-25MG-1.84MG- 100MG 200MG-27MG-4000UNIT- F 20MG-3MG-12MCG- PRENATAL AND IRON F 400UNIT-1MG-10MG- TABS 120MG PRENATAL FORTE TABS F PRENATAL TABS 4000UNIT-200MG-11UNIT- PRENATAL LOW IRON F 27MG-25MG-1.84MG- F TABS 18MG-1.7MG-4MCG- PRENATAL F 400UNIT-0.8MG-2.6MG- MULTIVITAMIN TABS 100MG PRENATAL ONE DAILY F PRENATAL VITAMIN & F TABS MINERAL TABS PRENATAL PLUS IRON QL(1 ea daily) F PRENATAL VITAMIN F TABS TABS RX/OTC PRENATAL PLUS TABS F PRENATAL F VITAMIN/IRON TABS

Louisiana Healthcare Connections Updated April 1, 2019

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL VITAMINS F RX/OTC TRINATAL RX 1 TABS F PLUS LOW IRON TABS TRISTART ONE CAPS PRENATAL VITAMINS F TABS 432MCG-215MG-35MG- RX/OTC 200MCG-5MCG-2MG- F PREPLUS TABS F 1000UNIT-18MG-568MCG- 15UNIT-50MG-55MG PRETAB TABS F VIL-RX TABS F QL(1 ea daily) PX PRENATAL F MULTIVITAMINS TABS VINATE M TABS 20MCG- QL(1 ea daily) 25MCG-30UNIT-150MCG- QC PRENATAL TABS F 25MCG-5MG-2MG-25MG- 25MG-200MG-27MG- F RA PRENATAL 10MG-5000UNIT-20MG- FORMULA/FOLICACID F 3.4MG-12MCG-400UNIT- TABS 3MG-1MG-30MCG-10MG- RA PRENATAL TABS F 120MG VINATE ONE TABS F RIGHT STEP PRENATAL F TABS VIRT-ADVANCE TABS F QL(1 ea daily) SE-NATAL 19 CHEW 30UNIT-1000UNIT- VIRT-VITE GT TABS F QL(1 ea daily) 100MG-20MG-3MG- F 200MG-29MG-7MG-15MG- 3MG-12MCG-400UNIT- VITAFOL-OB TABS F 1MG-20MG VOL-PLUS TABS F RX/OTC SE-NATAL 19 TABS QL(1 ea daily) 30UNIT-1000UNIT-20MG- VOL-TAB RX TABS F QL(1 ea daily) 25MG-200MG-29MG-7MG- F 15MG-3MG-12MCG- Vitamins w/ Lipotropics 400UNIT-3MG-20MG- 1MG-100MG vitamins w/ lipotropics caps QL(1 ea daily) 50mg-50mg-50mg-50mg- SM PRENATAL VITAMINS F 50mcg-50mcg-50mcg- TABS 50mg, 86mg-2mg-10mg- THERANATAL CORE F RX/OTC 83mg-240mg-3mg-2mcg- NUTRITION TABS 3mg-110mg-1.65mg, THRIVITE 19 TABS F QL(1 ea daily) 50mg-50mg-50mg-50mg- 50mg-50mg-50mg-50mcg- QL(1 ea daily) 100mcg-50mcg-50mg, F THRIVITE RX TABS F 75mg-30mg-2unit- QL(1 ea daily) 10000unit-40mg-15mg- TRIADVANCE TABS F 31mg-2.5mg-4mg-2mcg- 75mg-400unit, 10000unit- TRICARE PRENATAL F DHA ONE/FOLATE CAPS 3mg-0.5mg-2mg-75mg- 58mg-30mg-2unit-0.5mg- TRICARE TABS F RX/OTC 4mg-40mg-15mg-31.4mg- 2.5mg-2mcg-5mg-1mg- TRINATAL GT TABS F QL(1 ea daily) 75mg-400unit

Louisiana Healthcare Connections Updated April 1, 2019

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MUSCULOSKELETAL THERAPY AGENTS - NASALCROM AERS (Use NF QL(26 ml per Drugs to Treat Spasms Cromolyn Sodium (Nasal)) fill retail) Central Muscle Relaxants Nasal Anticholinergics ipratropium bromide (nasal) QL(30 ml per tabs or 10 mg, 20 F F mg soln 0.03 % fill retail) ipratropium bromide (nasal) QL(25 ml per CHLORZOXAZONE TABS F F 500 MG soln 0.06 % fill retail) hcl tabs or F QL(3 ea daily) Nasal Steroids 5 mg, 10 mg FLONASE ALLERGY RX/OTC RELIEF CHILDRENS tabs or 500 F NF mg, 750 mg SUSP (Use Fluticasone Propionate (Nasal)) citrate tb12 F or 100 mg FLONASE ALLERGY RX/OTC PARAFON FORTE DSC RELIEF SUSP (Use NF TABS (Use NF Fluticasone Propionate Chlorzoxazone) (Nasal)) QL(25 ml per ROBAXIN TABS OR 500 NF FLUNISOLIDE SOLN F MG (Use Methocarbamol) fill retail) ROBAXIN-750 TABS (Use QL(16 ml per NF fluticasone propionate F fill retail); Methocarbamol) (nasal) susp 50 mcg/act RX/OTC hcl tabs or 2 mg, F 4 mg QL(16 gm per fluticasone propionate F fill retail); (nasal) susp 50 mcg/act ZANAFLEX TABS 4 MG NF RX/OTC (Use Tizanidine HCl) NASACORT ALLERGY RX/OTC NASAL AGENTS - SYSTEMIC AND TOPICAL - 24HR AERO (Use NF Drugs to treat the Nose or Sinus Triamcinolone Acetonide Nasal Agents - Misc. (Nasal)) NASACORT ALLERGY QL(17 ml per OCEAN NASAL SPRAY NF QL(480 ml per SOLN (Use Saline) fill retail) 24HR AERO (Use 2 fill retail); AL(At Triamcinolone Acetonide least 2 yrs old); saline soln na 0.65%- F QL(480 ml per (Nasal)) RX/OTC 0.002%, 0.65 % fill retail) QL(17 ml per Nasal Anti-infectives NASACORT ALLERGY F fill retail); AL(At 24HR AERO 55 MCG/ACT least 2 yrs old); BACTROBAN NASAL F OINT RX/OTC Nasal Antiallergy NASACORT ALLERGY QL(17 ml per 24HR CHILDRENS AERO 2 fill retail); AL(At ASTEPRO SOLN (Use NF (Use Triamcinolone least 2 yrs old); HCl) Acetonide (Nasal)) RX/OTC azelastine hcl soln na 0.1 F QL(1 ml daily) QL(17 ml per %, 137 mcg/spray triamcinolone acetonide F fill retail); AL(At azelastine hcl soln na 0.15 F (nasal) aero 55 mcg/act least 2 yrs old); % RX/OTC cromolyn sodium (nasal) F QL(26 ml per Sympathomimetic Decongestants aers 5.2 mg/act fill retail) ADRENALIN SOLN NA 0.1 F % Louisiana Healthcare Connections Updated April 1, 2019

153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NASAL DECONGESTANT F omega-3 fatty acids caps QL(6 ea daily) LIQD 1000mg, 1200mg, 1000 mg, 1200 mg, 180mg- NASAL DECONGESTANT F SYRP 120mg, 1200mg-2unit, 300mg-1000mg, 350mg- phenylephrine hcl (oral) F QL(24 ea per 1000mg, 360mg-1200mg, tabs fill retail) 600mg-1000mg, 600mg- pseudoephedrine hcl liqd F 1200mg, 180mg-120mg- or 15 mg/5ml 5unit, 300mg-180mg- 120mg, 300mg-200mg- pseudoephedrine hcl tabs F or 30 mg, 60 mg 1unit, 1000mg-180mg- 120mg, 160mg-1000mg- pseudoephedrine hcl tb12 F QL(2 ea daily) or 120 mg 100mg, 180mg-1000mg- 120mg, 180mg-1200mg- SUDAFED CHILDRENS 144mg, 216mg-1200mg- LIQD (Use NF 144mg, 270mg-1000mg- Pseudoephedrine HCl) 180mg, 300mg-1000mg- SUDAFED CONGESTION 1unit, 300mg-1000mg- TABS (Use NF 200mg, 300mg-1unit- Pseudoephedrine HCl) 1000mg, 336mg-1200mg- SUDAFED NASAL 276mg, 350mg-1000mg- DECONGESTANT 250mg, 400mg-1000mg- MAXIMUM STRENGTH NF 300mg, 500mg-1000mg- TABS (Use 250mg, 180mg-120mg- Pseudoephedrine HCl) 1.8unit, 300mg-180mg- F SUDAFED PE QL(120 ml per 1gm-120mg, 1000mg- CHILDRENS NASAL F fill retail) 180mg-120mg-1mg, DECONGESTANT SOLN 210mg-1000mg-75mg- 90mg, 360mg-360mg- SUDAFED PE QL(24 ea per 12mg-1200mg, 60mg- CONGESTION TABS (Use NF fill retail) 180mg-1200mg-120mg, Phenylephrine HCl (Oral)) 60mg-360mg-1200mg- 300mg, 1000mg-180mg- NUTRIENTS 120mg-1unit, 100mg- Carbohydrates 300mg-1000mg-200mg, 180mg-1000mg-120mg- QL(124 ml per POLYCOSE LIQD F 1unit, 180mg-1unit- fill retail) 1000mg-120mg, 300mg- QL(350 gm per POLYCOSE POWD F 1000mg-200mg-1unit, fill retail) 300mg-180mg-1000mg- Misc. Nutritional Substances 120mg, 360mg-216mg- 1200mg-144mg, 600mg- 324mg-1200mg-216mg, 900mg-455mg-1000mg- 360mg, 100mg-1000mg- 500mg-10unit, 216mg- 1200mg-144mg-15unit, 300mg-1000mg-1000mg- 1unit, 340mg-180mg-1unit- 1000mg-120mg OPHTHALMIC AGENTS - Drugs to Treat the Eye

Louisiana Healthcare Connections Updated April 1, 2019

154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Artificial Tears and Lubricants TIMOLOL MALEATE QL(5 ml per fill F QL(4 gm per fill OPHTHALMIC GEL retail) artificial tear ointment oint F FORMING SOLG 0.5 % retail) TIMOPTIC SOLN (Use NF QL(15 ml per HYPOTEARS SOLN F QL(30 ml per Timolol Maleate (Ophth)) fill retail) fill retail) polyvinyl alcohol soln op QL(15 ml per TIMOPTIC-XE SOLG 0.25 F F % 1.4 % fill retail) TIMOPTIC-XE SOLG 0.25 TEARS NATURALE PM QL(5 gm per fill NF % (Use Timolol Maleate NF OINT (Use White retail) )) Petrolatum-Mineral Oil) (Ophth QL(5 gm per fill TIMOPTIC-XE SOLG 0.5 F QL(5 ml per fill white petrolatum-mineral oil F % retail) oint retail) Cycloplegic Mydriatics Beta-blockers - Ophthalmic ATROPINE SULFATE QL(4 gm per fill BETAGAN SOLN (Use QL(15 ml per F NF OINT OP 1 % retail) HCl) fill retail) QL(15 ml per ATROPINE SULFATE F QL(15 ml per hcl (ophth) soln F SOLN OP 1 % fill retail) fill retail) CYCLOGYL SOLN (Use NF QL(15 ml per BETOPTIC-S SUSP F QL(15 ml per Cyclopentolate HCl) fill retail) fill retail) QL(15 ml per cyclopentolate hcl soln op F QL(15 ml per hcl (ophth) soln F 0.5 %, 1 %, 2 % fill retail) 30 days retail) QL(5 ml per fill QL(15 ml per homatropine hbr soln F CARTEOLOL HCL SOLN F retail) 30 days retail) QL(15 ml per COSOPT SOLN (Use QL(10 ml per ISOPTO ATROPINE SOLN F fill retail) Dorzolamide HCl-Timolol NF fill retail) Maleate) MYDRIACYL SOLN (Use NF QL(15 ml per Tropicamide) fill retail) dorzolamide hcl-timolol QL(10 ml per maleate soln 2%-0.5%, F fill retail) tropicamide soln op 0.5 %, F QL(15 ml per 22.3mg/ml-6.8mg/ml 1 % fill retail) DORZOLAMIDE QL(10 ml per Miotics HCL/TIMOLOL MALEATE F fill retail) ISOPTO CARPINE SOLN NF SOLN (Use Pilocarpine HCl) QL(15 ml per levobunolol hcl soln 0.5 % F pilocarpine hcl soln op 1 %, F fill retail) 2 %, 4 % SOLN F Ophthalmic Agents timolol maleate (ophth) F hcl soln F solg 0.25 % QL(15 ml per timolol maleate (ophth) QL(5 ml per fill tartrate soln op F F 0.2 % fill retail) solg 0.5 % retail) IOPIDINE SOLN 0.5 % QL(15 ml per NF timolol maleate (ophth) F (Use Apraclonidine HCl) soln 0.25 %, 0.5 % fill retail) TIMOLOL MALEATE IOPIDINE SOLN 1 % F OPHTHALMIC GEL F FORMING SOLG 0.25 % Ophthalmic Anti-infectives

Louisiana Healthcare Connections Updated April 1, 2019

155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BACITRACIN OINT OP F QL(4 gm per fill tobramycin (ophth) soln 0.3 F QL(5 ml per fill 500 UNIT/GM retail) % retail) QL(4 gm per fill bacitracin-polymyxin b F TOBREX OINT 0.3 % F QL(4 gm per fill (ophth) oint retail) retail) BLEPH-10 SOLN (Use QL(15 ml per TOBREX SOLN (Use NF QL(5 ml per fill Sulfacetamide Sodium NF fill retail) Tobramycin (Ophth)) retail) (Ophth)) F QL(8 ml per fill trifluridine soln op 1 % retail) CILOXAN OINT 0.3 % F QL(4 gm per fill retail) VIGAMOX SOLN (Use NF QL(3 ml per fill CILOXAN SOLN (Use NF QL(10 ml per Moxifloxacin HCl (Ophth)) retail) Ciprofloxacin HCl (Ophth)) fill retail) VIROPTIC SOLN (Use NF QL(8 ml per fill ciprofloxacin hcl (ophth) F QL(10 ml per Trifluridine) retail) soln 0.3 % fill retail) Ophthalmic Decongestants F QL(4 gm per fill erythromycin (ophth) oint retail) w/ QL(15 ml per soln 0.025%- F 30 days retail) F QL(4 gm per fill 0.3% GENTAK OINT retail) naphazoline w/ QL(15 ml per gentamicin sulfate (ophth) F QL(4 gm per fill pheniramine soln 0.027%- F fill retail) oint retail) 0.315% gentamicin sulfate (ophth) F QL(15 ml per NAPHCON-A SOLN (Use QL(15 ml per soln fill retail) Naphazoline w/ NF 30 days retail) Pheniramine) moxifloxacin hcl (ophth) F QL(3 ml per fill soln 0.5 % retail) OPCON-A SOLN (Use QL(15 ml per Naphazoline w/ NF fill retail) neomycin-bacitracin zn- F QL(4 gm per fill polymyxin oint retail) Pheniramine) NEOMYCIN/POLYMYXIN/ QL(10 ml per phenylephrine hcl (ophth) F QL(15 ml per GRAMICIDIN SOLN fill retail) soln 2.5 % fill retail) 0.025MG/ML- F tetrahydrozoline hcl (ophth) F QL(1 ml daily) 10000UNIT/ML- soln 0.05 % 1.75MG/ML VISINE SOLN (Use QL(1 ml daily) NEOSPORIN SOLN (Use QL(10 ml per Tetrahydrozoline HCl NF Neomycin-Polymyxin- NF fill retail) (Ophth)) Gramicidin) Ophthalmic Local Anesthetics OCUFLOX SOLN (Use NF QL(10 ml per Ofloxacin (Ophth)) fill retail) tetracaine hcl (ophth) soln F ofloxacin (ophth) soln 0.3 F QL(10 ml per % fill retail) Ophthalmic Steroids BLEPHAMIDE S.O.P. QL(4 gm per fill polymyxin b-trimethoprim F QL(10 ml per F soln 0.1%-10000unit/ml fill retail) OINT retail) QL(10 ml per POLYTRIM SOLN (Use NF QL(10 ml per BLEPHAMIDE SUSP F Polymyxin B-Trimethoprim) fill retail) fill retail) DEXAMETHASONE QL(5 ml per fill sulfacetamide sodium F QL(15 ml per (ophth) soln 10 % fill retail) SODIUM PHOSPHATE F retail) SOLN OP 0.1 % SULFACETAMIDE F QL(4 gm per fill SODIUM OINT OP 10 % retail) fluorometholone (ophth) F QL(15 ml per susp 0.1 % fill retail)

Louisiana Healthcare Connections Updated April 1, 2019

156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FML LIQUIFILM SUSP QL(15 ml per SULFACETAMIDE QL(10 ml per NF (Use Fluorometholone fill retail) SODIUM/PREDNISOLONE F fill retail) (Ophth)) SODIUM PHOSPHATE QL(4 gm per fill SOLN FML OINT 0.1 % F retail) TOBRADEX OINT 0.3%- F QL(4 gm per fill MAXITROL OINT QL(4 gm per fill 0.1% retail) 10000UNIT/GM- retail) TOBRADEX SUSP (Use QL(10 ml per 3.5MG/GM-0.1% (Use NF Tobramycin- NF fill retail) Neomycin-Polymy- Dexamethasone) Dexameth) tobramycin- QL(10 ml per MAXITROL SUSP QL(5 ml per fill dexamethasone susp F fill retail) 10000UNIT/ML-3.5MG/ML- NF retail) 0.3%-0.1% 0.1% (Use Neomycin- Polymy-Dexameth) Ophthalmics - Misc. neomycin-polymy- QL(4 gm per fill ACULAR LS SOLN (Use QL(5 ml per 30 Ketorolac Tromethamine NF days retail) dexameth oint F retail) )) 10000unit/gm-3.5mg/gm- (Ophth 0.1% ACULAR SOLN (Use QL(10 ml per NF QL(5 ml per fill Ketorolac Tromethamine fill retail) neomycin-polymy- (Ophth)) dexameth susp F retail) 10000unit/ml-3.5mg/ml- ST; Try ophth. 0.1% ALOCRIL SOLN F NEOMYCIN/POLYMYXIN/ QL(8 ml per fill first;QL(5 ml per fill retail) HYDROCORTISONE F retail) SUSP ST; Try OMNIPRED SUSP (Use QL(15 ml per F ketotifen ophth. ALOMIDE SOLN first;QL(10 ml Prednisolone Acetate NF fill retail) (Ophth)) per fill retail) QL(6 ml per fill PRED FORTE SUSP (Use QL(15 ml per azelastine hcl (ophth) soln F retail) Prednisolone Acetate NF fill retail) (Ophth)) F QL(15 ml per AZOPT SUSP fill retail) QL(10 ml per PRED MILD SUSP F fill retail) cromolyn sodium (ophth) F QL(10 ml per soln fill retail) QL(0.167 ml PRED-G SUSP 0.3%-1% F daily,5 ml per diclofenac sodium (ophth) F QL(5 ml per fill fill retail) soln retail) DORZOLAMIDE HCL QL(10 ml per prednisolone acetate F QL(15 ml per F (ophth) susp fill retail) SOLN 2 % fill retail) QL(10 ml per PREDNISOLONE F QL(15 ml per dorzolamide hcl soln 2 % F ACETATE P-F SUSP fill retail) fill retail) QL(3 ml per fill PREDNISOLONE SODIUM QL(15 ml per flurbiprofen sodium soln F PHOSPHATE SOLN OP 1 F fill retail) retail) % ketorolac tromethamine F QL(5 ml per 30 (ophth) soln 0.4 % days retail) sulfacetamide sod- F QL(10 ml per prednisolone soln fill retail) ketorolac tromethamine F QL(10 ml per (ophth) soln 0.5 % fill retail) ketotifen fumarate (ophth) F QL(10 ml per soln 0.025 % fill retail) Louisiana Healthcare Connections Updated April 1, 2019

157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSOPT SOLN (Use NF QL(10 ml per pramoxine-hc-chloroxylenol QL(0.5 ml Dorzolamide HCl) fill retail) soln 10mg/ml-1mg/ml- F daily,15 ml per ZADITOR SOLN (Use QL(10 ml per 10mg/ml fill retail) Ketotifen Fumarate NF fill retail) Otic Steroids (Ophth)) DERMOTIC OIL (Use QL(0.67 ml Prostaglandins - Ophthalmic Fluocinolone Acetonide NF daily,20 ml per (Otic)) fill retail) LATANOPROST SOLN OP F QL(3 ml per fill 0.005 % retail) QL(0.67 ml fluocinolone acetonide F daily,20 ml per latanoprost soln op 0.005 F QL(3 ml per fill (otic) oil 0.01 % % retail) fill retail) hydrocortisone w/acetic QL(10 ml per XALATAN SOLN (Use NF QL(3 ml per fill F Latanoprost) retail) acid soln fill retail) OXYTOCICS - Drugs to Prevent/Control Uterine OTIC AGENTS - Drugs to Treat the Ear Bleeding Otic Agents - Miscellaneous Oxytocics QL(15 ml per acetic acid (otic) soln F methylergonovine maleate F fill retail) tabs or 0.2 mg carbamide peroxide (otic) F QL(15 ml per PASSIVE IMMUNIZING AND TREATMENT soln 6.5 % fill retail) AGENTS - Antibody Drugs to Treat Low Immune DEBROX SOLN (Use NF QL(15 ml per System Carbamide Peroxide (Otic)) fill retail) Immune Serums Otic Anti-infectives HYPERRHO S/D SOSY F FLOXIN OTIC SOLN (Use NF QL(10 ml per 1500 UNIT Ofloxacin (Otic)) fill retail) RHOGAM ULTRA- QL(10 ml per ofloxacin (otic) soln 0.3 % F FILTERED PLUS SOSY F fill retail) 1500 UNIT Otic Combinations PENICILLINS - Drugs to Treat Bacterial Infections QL(7.5 ml per Aminopenicillins CIPRODEX SUSP F fill retail)1 rtl MAX fill,30 rtl amoxicillin caps 250 mg, F day(s) supply, 500 mg CORTANE-B-OTIC SOLN QL(0.5 ml AMOXICILLIN CHEW 125 F (Use Pramoxine-HC- NF daily,15 ml per MG, 250 MG Chloroxylenol) fill retail) amoxicillin susr 125 neomycin-polymyxin-hc F QL(10 ml per mg/5ml, 200 mg/5ml, 250 F (otic) soln fill retail) mg/5ml, 400 mg/5ml neomycin-polymyxin-hc F QL(10 ml per (otic) susp fill retail) amoxicillin tabs 875 mg F OTICIN HC NR SOLN (Use QL(0.5 ml ampicillin caps 250 mg, F Pramoxine-HC- NF daily,15 ml per 500 mg Chloroxylenol) fill retail) AMPICILLIN CAPS 500 F PRAMOTIC LIQD F QL(10 ml per MG 30 days retail) Natural Penicillins BICILLIN L-A SUSP F

Louisiana Healthcare Connections Updated April 1, 2019

158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits penicillin v potassium solr F Penicillinase-Resistant Penicillins 125 mg/5ml, 250 mg/5ml PENICILLIN V dicloxacillin sodium caps F POTASSIUM SOLR 125 F MG/5ML, 250 MG/5ML PHARMACEUTICAL ADJUVANTS penicillin v potassium tabs F Internal Vehicle Ingredients/Agents 250 mg, 500 mg SIMPLYTHICK EASY MIX F QL(1816 ml per Penicillin Combinations GEL fill retail) amoxicillin & pot QL(100 ml per SIMPLYTHICK GEL F QL(1816 ml per clavulanate susr F fill retail) fill retail) 200mg/5ml-28.5mg/5ml Semi Solid Vehicles amoxicillin & pot QL(150 ml per clavulanate susr F fill retail) lanolin oint ex F RX/OTC 250mg/5ml-62.5mg/5ml amoxicillin & pot QL(200 ml per PROGESTINS - Hormone Replacement/Modifying clavulanate susr F fill retail) Drugs 400mg/5ml-57mg/5ml Progestins amoxicillin & pot QL(400 ml per AYGESTIN TABS (Use NF clavulanate susr F fill retail) Norethindrone Acetate) 600mg/5ml-42.9mg/5ml QL(0.143 ml amoxicillin & pot QL(30 ea per hydroxyprogesterone 3 daily); AL(At clavulanate tabs 250mg- F fill retail) caproate oil 250 mg/ml least 16 yrs 125mg old) amoxicillin & pot QL(20 ea per MAKENA OIL IM 250 QL(0.143 ml clavulanate tabs 500mg- F fill retail) MG/ML (Use 3 daily); AL(At 125mg, 875mg-125mg Hydroxyprogesterone least 16 yrs amoxicillin & pot QL(40 ea per Caproate) old) clavulanate tb12 1000mg- F 30 days retail) QL(4.4 ml per 62.5mg MAKENA SOAJ SC 275 VC 24 days retail); MG/1.1ML AL(At least 16 AMOXICILLIN/CLAVULAN F QL(20 ea per ATE POTASSIUM CHEW fill retail) yrs old) AUGMENTIN ES-600 QL(400 ml per medroxyprogesterone SUSR (Use Amoxicillin & NF fill retail) acetate tabs or 5 mg, 10 F Pot Clavulanate) mg, 2.5 mg AUGMENTIN SUSR QL(150 ml per norethindrone acetate tabs F or 5 mg 250MG/5ML-62.5MG/5ML NF fill retail) (Use Amoxicillin & Pot micronized F QL(1 ea daily) Clavulanate) caps 100 mg AUGMENTIN TABS QL(20 ea per progesterone micronized F QL(20 ea per 500MG-125MG, 875MG- NF fill retail) caps 200 mg 30 days retail) 125MG (Use Amoxicillin & Pot Clavulanate) progesterone oil F AUGMENTIN XR TB12 QL(40 ea per PROMETRIUM CAPS 100 QL(1 ea daily) (Use Amoxicillin & Pot NF 30 days retail) MG (Use Progesterone NF Clavulanate) Micronized) BICILLIN C-R SUSP F

Louisiana Healthcare Connections Updated April 1, 2019

159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROMETRIUM CAPS 200 QL(20 ea per RAZADYNE ER CP24 (Use QL(1 ea daily) MG (Use Progesterone NF 30 days retail) Galantamine NF Micronized) Hydrobromide) PROVERA TABS (Use RAZADYNE TABS (Use QL(2 ea daily) Medroxyprogesterone NF Galantamine NF Acetate) Hydrobromide) PSYCHOTHERAPEUTIC AND NEUROLOGICAL rivastigmine pt24 4.6 F PA; QL(1 ea AGENTS - MISC. - Drugs to Treat Mental and mg/24hr, 9.5 mg/24hr daily) Emotional Conditions PA; QL(2 ea rivastigmine tartrate caps F daily) Agents for Chemical Dependency Combination Psychotherapeutics ANTABUSE TABS 250 MG NF (Use Disulfiram) CHLORDIAZEPOXIDE/AMI F TRIPTYLINE TABS disulfiram tabs or 250 mg F PERPHENAZINE/AMITRIP F QL(4 ea daily) Antidementia Agents TYLINE TABS ARICEPT TABS 5 MG, 10 QL(1 ea daily) Fibromyalgia Agents MG (Use Donepezil NF SAVELLA TABS F PA; QL(2 ea Hydrochloride) daily) donepezil hydrochloride QL(1 ea daily) F SAVELLA TITRATION F PA tabs 5 mg, 10 mg PACK MISC EXELON PT24 4.6 PA; QL(1 ea Multiple Sclerosis Agents MG/24HR, 9.5 MG/24HR NF daily) (Use Rivastigmine) AVONEX KIT F PA galantamine hydrobromide F QL(1 ea daily) cp24 8 mg, 16 mg, 24 mg AVONEX PEN AJKT F PA GALANTAMINE QL(6 ml daily) PA HYDROBROMIDE SOLN 4 F AVONEX PSKT F MG/ML COPAXONE SOSY (Use NF PA galantamine hydrobromide F QL(2 ea daily) Glatiramer Acetate) tabs 4 mg, 8 mg, 12 mg GILENYA CAPS 0.5 MG F PA hcl soln 2 F PA; QL(10 ml mg/ml daily) glatiramer acetate sosy F PA PA; QL(49 ea memantine hcl tabs F per fill retail) PLEGRIDY SOPN F PA memantine hcl tabs 5 mg, F PA; QL(2 ea 10 mg daily) PLEGRIDY SOSY F PA NAMENDA SOLN 10 PA; QL(10 ml MG/5ML (Use Memantine NF daily) PLEGRIDY STARTER F PA HCl) PACK SOPN PLEGRIDY STARTER PA NAMENDA TABS 5 MG, 10 NF PA; QL(2 ea F MG (Use Memantine HCl) daily) PACK SOSY NAMENDA TITRATION PA; QL(49 ea TECFIDERA CPDR F PA PAK TABS (Use NF per fill retail) Memantine HCl) TECFIDERA STARTER F PA PACK MISC Psychotherapeutic and Neurological Agents -

Louisiana Healthcare Connections Updated April 1, 2019

160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MESYLATES F 2 smoking TABS OR cessation NICORETTE LOZG 2 MG, treatments Smoking Deterrents 4 MG (Use Nicotine VC ) covered per 2 smoking Polacrilex year;QL(20 ea cessation daily) treatments covered per 2 smoking bupropion hcl (smoking VC cessation deterrent) tb12 year;QL(2 ea NICORETTE MINI LOZG VC treatments daily); AL(At ) least 18 yrs (Use Nicotine Polacrilex covered per year;QL(20 ea old) daily) 2 smoking 2 smoking cessation cessation treatments NICORETTE STARTER VC treatments CHANTIX CONTINUING VC covered per KIT GUM (Use Nicotine ) covered per MONTHPAK TABS year;QL(2 ea Polacrilex year;QL(24 ea daily); AL(At daily) least 18 yrs old) 2 smoking cessation 2 smoking nicotine polacrilex gum mt treatments cessation VC 2 mg, 4 mg covered per treatments year;QL(24 ea CHANTIX STARTING covered per VC daily) MONTH PAK TABS year;QL(53 ea per fill retail); 2 smoking AL(At least 18 cessation yrs old) nicotine polacrilex lozg mt 2 VC treatments mg, 4 mg covered per 2 smoking year;QL(20 ea cessation daily) treatments 2 smoking VC covered per CHANTIX TABS year;QL(2 ea cessation treatments daily); AL(At nicotine pt24 VC least 18 yrs covered per old) year;QL(1 ea daily) 2 smoking cessation 2 smoking NICOTINE cessation NICODERM CQ PT24 (Use VC treatments Nicotine) covered per TRANSDERMAL SYSTEM VC treatments year;QL(1 ea KIT covered per daily) year 2 smoking 2 smoking cessation cessation NICORETTE GUM 2 MG, 4 treatments NICOTROL INHALER VC treatments MG (Use Nicotine VC INHA covered per ) covered per Polacrilex year;QL(24 ea year;QL(16.8 daily) ea daily)

Louisiana Healthcare Connections Updated April 1, 2019

161 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 2 smoking doxycycline (monohydrate) F cessation tabs 50 mg, 100 mg treatments NICOTROL NS SOLN VC doxycycline hyclate caps or F covered per 50 mg, 100 mg year;QL(4 ml daily) doxycycline hyclate tabs or F 100 mg 2 smoking cessation DOXYCYCLINE HYCLATE F treatments TABS OR 50 MG ZYBAN TB12 (Use covered per MINOCIN CAPS OR 50 Bupropion HCl (Smoking VC MG, 75 MG, 100 MG (Use NF )) year;QL(2 ea Deterrent daily); AL(At Minocycline HCl) least 18 yrs minocycline hcl caps or 50 F old) mg, 75 mg, 100 mg Vasomotor Symptom Agents MONODOX CAPS 100 MG BRISDELLE CAPS (Use (Use Doxycycline NF Paroxetine Mesylate NF (Monohydrate)) (Vasomotor)) TARGADOX TABS F paroxetine mesylate F (vasomotor) caps 7.5 mg VIBRAMYCIN CAPS 100 MG (Use Doxycycline NF RESPIRATORY AGENTS - MISC. - Drugs to Hyclate) Treat Lung Conditions THYROID AGENTS - Drugs to Regulate Thyroid Cystic Fibrosis Agents Hormones KALYDECO PACK F PA Antithyroid Agents PA methimazole tabs or 5 mg, F KALYDECO TABS F 10 mg ORKAMBI TABS 200MG- F PA propylthiouracil tabs or F 125MG PA TAPAZOLE TABS (Use NF SYMDEKO TBPK F Methimazole) TETRACYCLINES - Drugs to Treat Bacterial Thyroid Hormones Infections ARMOUR THYROID TABS F Tetracyclines 15 MG, 30 MG, 60 MG, 90 MG, 120 MG (Use Thyroid) ADOXA PAK 1/100 TABS (Use Doxycycline NF ARMOUR THYROID TABS F (Monohydrate)) 180 MG, 240 MG, 300 MG ADOXA PAK 2/100 TABS CYTOMEL TABS (Use NF (Use Doxycycline NF Liothyronine Sodium) (Monohydrate)) levothyroxine sodium tabs ADOXA TABS 50 MG, 100 or 25 mcg, 50 mcg, 75 MG (Use Doxycycline NF mcg, 88 mcg, 100 mcg, F (Monohydrate)) 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, doxycycline (monohydrate) F 200 mcg, 300 mcg caps 50 mg, 100 mg liothyronine sodium tabs or F 5 mcg, 25 mcg, 50 mcg

Louisiana Healthcare Connections Updated April 1, 2019

162 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NATURE-THROID TABS F LEVBID TB12 (Use NF QL(4 ea daily) 65 MG, 130 MG Sulfate) SYNTHROID TABS (Use F LEVSIN TABS OR 0.125 Levothyroxine Sodium) MG (Use Hyoscyamine NF Sulfate) thyroid tabs or 15 mg, 30 F mg, 60 mg, 90 mg, 120 mg ROBINUL FORTE TABS NF QL(4 ea daily) (Use Glycopyrrolate) THYROLAR-1 TABS F ROBINUL TABS OR 1 MG NF QL(4 ea daily) THYROLAR-1/2 TABS F (Use Glycopyrrolate) SYMAX DUOTAB TBCR F THYROLAR-1/4 TABS F H-2 Antagonists THYROLAR-2 TABS F QL(27 ml HCL SOLN F daily,240 ml THYROLAR-3 TABS F per fill retail) RX/OTC WESTHROID TABS 65 F cimetidine tabs or 200 mg F MG, 130 MG cimetidine tabs or 300 mg, WP THYROID TABS 65 F F MG, 130 MG 400 mg, 800 mg susr or 40 F ULCER DRUGS - Drugs to Treat Bowel, Intestine mg/5ml and Stomach Conditions famotidine tabs or 10 mg, F Antispasmodics 40 mg BENTYL CAPS OR 10 MG NF famotidine tabs or 20 mg F RX/OTC (Use Dicyclomine HCl) PEPCID AC MAXIMUM RX/OTC dicyclomine hcl caps or 10 F mg STRENGTH TABS (Use NF Famotidine) dicyclomine hcl soln or 10 F mg/5ml PEPCID AC TABS (Use NF Famotidine) dicyclomine hcl tabs or 20 F mg PEPCID SUSR 40 MG/5ML NF (Use Famotidine) glycopyrrolate tabs or 1 F QL(4 ea daily) mg, 2 mg PEPCID TABS 20 MG (Use NF RX/OTC Famotidine) hyoscyamine sulfate elix or F 0.125 mg/5ml PEPCID TABS 40 MG (Use NF Famotidine) hyoscyamine sulfate soln F or 0.125 mg/ml hcl caps or 150 F QL(2 ea daily) mg hyoscyamine sulfate subl sl F 0.125 mg ranitidine hcl caps or 300 F QL(1 ea daily) mg hyoscyamine sulfate tabs F or 0.125 mg ranitidine hcl syrp or 15 QL(40 ml daily) mg/ml, 75 mg/5ml, 150 F hyoscyamine sulfate tb12 F QL(4 ea daily) or 0.375 mg mg/10ml ranitidine hcl tabs or 150 QL(2 ea daily); hyoscyamine sulfate tbdp F F or 0.125 mg mg RX/OTC

Louisiana Healthcare Connections Updated April 1, 2019

163 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ranitidine hcl tabs or 75 F QL(2 ea daily) NEXIUM 24HR CPDR (Use 2 QL(2 ea daily); mg, 300 mg Esomeprazole Magnesium) RX/OTC TAGAMET HB TABS (Use NF RX/OTC NEXIUM CPDR 20 MG RX/OTC Cimetidine) (Use Esomeprazole NF ZANTAC 150 MAXIMUM QL(2 ea daily); Magnesium) STRENGTH TABS (Use NF RX/OTC omeprazole cpdr or 10 mg, F QL(2 ea daily) Ranitidine HCl) 40 mg QL(2 ea daily); ZANTAC 75 TABS (Use NF QL(2 ea daily) omeprazole cpdr or 20 mg F Ranitidine HCl) RX/OTC ZANTAC TABS OR 150 NF QL(2 ea daily); OMEPRAZOLE TBEC OR F QL(1 ea daily) MG (Use Ranitidine HCl) RX/OTC 20 MG ZANTAC TABS OR 300 NF QL(2 ea daily) pantoprazole sodium tbec F QL(1 ea daily) MG (Use Ranitidine HCl) or 20 mg Misc. Anti-Ulcer pantoprazole sodium tbec F QL(2 ea daily) or 40 mg CARAFATE SUSP 1 F GM/10ML PREVACID 24HR CPDR NF QL(4 ea daily); (Use Lansoprazole) RX/OTC CARAFATE TABS 1 GM NF QL(4 ea daily) (Use Sucralfate) PREVACID CPDR 15 MG NF QL(4 ea daily); (Use Lansoprazole) RX/OTC sucralfate tabs or F QL(4 ea daily) PREVACID CPDR 30 MG NF (Use Lansoprazole) Proton Pump Inhibitors PRILOSEC OTC TBEC 20 F QL(1 ea daily) CVS OMEPRAZOLE TBEC F QL(1 ea daily) MG ST; Try PROTONIX TBEC OR 20 QL(1 ea daily) omeprazole, MG (Use Pantoprazole NF DEXILANT CPDR F lansoprazole or Sodium) pantoprazole PROTONIX TBEC OR 40 QL(2 ea daily) first MG (Use Pantoprazole NF Sodium) EQ OMEPRAZOLE TBEC F QL(1 ea daily) PX OMEPRAZOLE TBEC F QL(1 ea daily) EQL OMEPRAZOLE TBEC F QL(1 ea daily) RA OMEPRAZOLE TBEC F QL(1 ea daily) esomeprazole magnesium F QL(2 ea daily); cpdr 20 mg RX/OTC SB OMEPRAZOLE TBEC F QL(1 ea daily) GNP OMEPRAZOLE F QL(1 ea daily) TBEC SM OMEPRAZOLE TBEC F QL(1 ea daily) HM OMEPRAZOLE TBEC F QL(1 ea daily) SW OMEPRAZOLE TBEC F QL(1 ea daily) KLS OMEPRAZOLE TBEC F QL(1 ea daily) TGT OMEPRAZOLE TBEC F QL(1 ea daily) QL(4 ea daily); lansoprazole cpdr or 15 mg F RX/OTC Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use NF lansoprazole cpdr or 30 mg F Misoprostol) NEXIUM 24HR CLEAR QL(2 ea daily); misoprostol tabs or 100 F MINIS CPDR (Use 2 RX/OTC mcg, 200 mcg Esomeprazole Magnesium) Louisiana Healthcare Connections Updated April 1, 2019

164 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits URINARY ANTI-INFECTIVES - Drugs to Treat tolterodine tartrate cp24 2 F QL(1 ea daily) Bladder/Kidney Infections mg, 4 mg tolterodine tartrate tabs 1 QL(2 ea daily) Urinary Anti-infective Combinations F mg, 2 mg methenamine-hyosc- methylene blue-sod phos- trospium chloride tabs 20 F QL(2 ea daily) mg phenyl sal tabs 40.8mg- F 0.12mg-36.2mg-81.6mg- Urinary Antispasmodics - Cholinergic Agonists 10.8mg, 40.8mg-36.2mg- bethanechol chloride tabs 0.12mg-81.6mg-10.8mg or 5 mg, 10 mg, 25 mg, 50 F Urinary Anti-infectives mg URECHOLINE TABS (Use FURADANTIN SUSP (Use NF QL(40 ml daily) NF Nitrofurantoin) Bethanechol Chloride) MACROBID CAPS (Use Urinary Antispasmodics - Direct Muscle Relaxants Nitrofurantoin Monohyd NF Macro) flavoxate hcl tabs F MACRODANTIN CAPS 50 VACCINES MG, 100 MG (Use NF Nitrofurantoin Bacterial Vaccines Macrocrystal) AL(At least 21 BEXSERO SUSY VC methenamine mandelate F yrs old) tabs or 0.5 gm, 1 gm MENACTRA INJ VC AL(At least 21 METHENAMINE yrs old) MANDELATE TABS OR F 500 MG MENVEO SOLR VC AL(At least 21 yrs old) nitrofurantoin macrocrystal F caps or 50 mg, 100 mg PNEUMOVAX 23 INJ VC AL(At least 21 yrs old) nitrofurantoin monohyd F macro caps 100 mg PNEUMOVAX 23/1 DOSE VC AL(At least 21 INJ yrs old) nitrofurantoin susp or 25 F QL(40 ml daily) mg/5ml PREVNAR 13 SUSP VC AL(At least 21 yrs old) URINARY ANTISPASMODICS - Drugs to Treat TRUMENBA SUSY VC AL(At least 21 Miscellaneous Bladder Spasms yrs old) Urinary Antispasmodic - Antimuscarinics Viral Vaccines DETROL LA CP24 (Use NF QL(1 ea daily) limit 0.5 per Tolterodine Tartrate) AFLURIA PF 2016-2017 VC 180 days;AL(At SUSY DETROL TABS (Use NF QL(2 ea daily) least 2 yrs old) Tolterodine Tartrate) limit 0.5 per DITROPAN XL TB24 (Use QL(2 ea daily) AFLURIA PF 2017-2018 VC NF SUSY 180 days;AL(At Oxybutynin Chloride) least 2 yrs old) oxybutynin chloride syrp or F limit 0.5 per 5 mg/5ml AFLURIA PF 2018-2019 VC SUSY 180 days;AL(At least 2 yrs old) oxybutynin chloride tabs or F QL(3 ea daily) 5 mg limit 0.5 per AFLURIA QUADRIVALENT VC 180 days;AL(At oxybutynin chloride tb24 or F QL(2 ea daily) 2016-2017 SUSY 5 mg, 10 mg, 15 mg least 2 yrs old)

Louisiana Healthcare Connections Updated April 1, 2019

165 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AFLURIA QUADRIVALENT VC AL(At least 2 limit 0.5 per 2017-2018 SUSP yrs old) FLUZONE HIGH-DOSE PF VC 180 days;AL(At limit 0.5 per 2018-2019 SUSY least 65 yrs AFLURIA QUADRIVALENT VC 180 days;AL(At old) 2017-2018 SUSY least 2 yrs old) FLUZONE AL(At least 2 QUADRIVALENT 2016- VC yrs old) AFLURIA QUADRIVALENT VC AL(At least 2 2018-2019 SUSP yrs old) 2017 SUSP limit 0.5 per FLUZONE limit 0.5 per AFLURIA QUADRIVALENT VC QUADRIVALENT 2016- VC 180 days;AL(At 2018-2019 SUSY 180 days;AL(At least 2 yrs old) 2017 SUSY least 2 yrs old) limit 0.5 per FLUZONE AL(At least 2 FLUARIX QUADRIVALENT VC QUADRIVALENT 2017- VC yrs old) 2016-2017 SUSY 180 days;AL(At least 2 yrs old) 2018 SUSP limit 0.5 per FLUZONE limit 0.5 per FLUARIX QUADRIVALENT VC QUADRIVALENT 2017- VC 180 days;AL(At 2017-2018 SUSY 180 days;AL(At least 2 yrs old) 2018 SUSY least 2 yrs old) limit 0.5 per FLUZONE AL(At least 2 FLUARIX QUADRIVALENT VC QUADRIVALENT 2018- VC yrs old) 2018-2019 SUSY 180 days;AL(At least 2 yrs old) 2019 SUSP FLULAVAL AL(At least 2 FLUZONE limit 0.5 per QUADRIVALENT 2016- VC yrs old) QUADRIVALENT 2018- VC 180 days;AL(At 2017 SUSP 2019 SUSY least 2 yrs old) FLULAVAL limit 0.5 per QL( 1ml per QUADRIVALENT 2016- VC 180 days;AL(At Seasonal Influenza VC 180 days 2017 SUSY least 2 yrs old) Vaccine retail); AL: At least 2 yrs old FLULAVAL AL(At least 2 QUADRIVALENT 2017- VC yrs old) QL( 1ml per 2018 SUSP Seasonal Influenza VC 180 days Vaccine-High Dose retail); AL: At FLULAVAL limit 0.5 per least 65 yrs old QUADRIVALENT 2017- VC 180 days;AL(At 2018 SUSY least 2 yrs old) QL( 1ml per 180 days FLULAVAL AL(At least 2 Seasonal Influenza VC retail); AL: At QUADRIVALENT 2018- VC yrs old) Vaccine-Quadrivalent least 18 yrs 2019 SUSP old-Up to 64 FLULAVAL limit 0.5 per yrs old QUADRIVALENT 2018- VC 180 days;AL(At QL(2 ea per 2019 SUSY least 2 yrs old) 999 days AL(At least 2 SHINGRIX SUSR F retail); AL(At FLUMIST VC yrs old - Up to QUADRIVALENT SUSP least 50 yrs 49 yrs old) old) limit 0.5 per AL(At least 21 ZOSTAVAX SUSR VC FLUZONE HIGH-DOSE PF VC 180 days;AL(At yrs old) 2016-2017 SUSY least 65 yrs old) VAGINAL PRODUCTS - Drugs to Treat Vaginal Infections and Low Hormones limit 0.5 per Spermicides FLUZONE HIGH-DOSE PF VC 180 days;AL(At 2017-2018 SUSY least 65 yrs old) Louisiana Healthcare Connections Updated April 1, 2019

166 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits miconazole nitrate vaginal QL(1 gm per fill ENCARE SUPP VC QL(12 ea per F fill retail) kit retail) nonoxynol-9 gel VC miconazole nitrate vaginal F QL(7 ea per fill supp 100 mg retail) OPTIONS CONCEPTROL MONISTAT 3 QL(1 gm per fill VAGINAL VC COMBINATION PACK KIT NF retail) CONTRACEPTIVE GEL (Use Miconazole Nitrate (Use Nonoxynol-9) Vaginal) OPTIONS GYNOL II QL(86 gm per MONISTAT 3 CREA (Use NF QL(45 gm per VAGINALCONTRACEPTIV VC fill retail) Miconazole Nitrate Vaginal) fill retail) E GEL MONISTAT 7 SIMPLY QL(45 gm per QL(24 gm per SHUR-SEAL GEL VC CURE CREA (Use NF fill retail) fill retail) Miconazole Nitrate Vaginal) PA TODAY SPONGE MISC VC TERAZOL 7 CREA (Use NF QL(45 gm per Terconazole Vaginal) fill retail) VCF VAGINAL QL(1 ea per fill TERCONAZOLE CREA F QL(20 gm per CONTRACEPTIVE FILM VC retail) fill retail) FILM terconazole vaginal crea F QL(45 gm per VCF VAGINAL QL(17 gm per 0.4 % fill retail) CONTRACEPTIVE FOAM VC fill retail) FOAM terconazole vaginal crea F QL(20 gm per 0.8 % fill retail) Vaginal Anti-infectives terconazole vaginal supp F QL(3 ea per fill CLEOCIN CREA VA 2 % QL(40 gm per 80 mg retail) (Use Clindamycin NF fill retail) QL(5 gm per fill tioconazole vaginal oint F Phosphate Vaginal) retail) clindamycin phosphate F QL(40 gm per vaginal crea 2 % fill retail) Vaginal Estrogens ESTRACE CREA VA 0.1 QL(43 gm per clotrimazole vaginal crea 1 F QL(45 gm per % fill retail) MG/GM (Use Estradiol NF fill retail) Vaginal) clotrimazole vaginal crea 2 F QL(20 gm per % fill retail) estradiol vaginal crea 0.1 F QL(43 gm per mg/gm fill retail) GYNAZOLE-1 CREA F PREMARIN CREA VA F QL(43 gm per 0.625 MG/GM fill retail) GYNE-LOTRIMIN 3 CREA NF QL(20 gm per (Use Clotrimazole Vaginal) fill retail) Vaginal Progestins GYNE-LOTRIMIN CREA NF QL(45 gm per CRINONE GEL F (Use Clotrimazole Vaginal) fill retail) METROGEL-VAGINAL QL(70 gm per FIRST-PROGESTERONE GEL (Use Metronidazole NF fill retail) VGS 100 COMPOUNDING F Vaginal) KIT SUPP FIRST-PROGESTERONE metronidazole vaginal gel F QL(70 gm per 0.75 % fill retail) VGS 200 F COMPOUNDING KIT MICONAZOLE 3 SUPP F QL(3 ea per fill retail) SUPP VASOPRESSORS - Drugs to Treat Heart and miconazole nitrate vaginal F QL(45 gm per crea 2 %, 4 % fill retail) Circulation Conditions Anaphylaxis Therapy Agents Louisiana Healthcare Connections Updated April 1, 2019

167 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea per fill QL(2 ea daily); ADRENACLICK SOAJ 0.3 F vitamin e tabs or 400 unit F AL(At least 65 MG/0.3ML retail,8 ea per 365 days retail) yrs old) epinephrine (anaphylaxis) QL(2 ea per fill Water Soluble Vitamins F retail,8 ea per soaj 0.15 mg/0.3ml, 0.3 ascorbic acid tabs or QL(100 ea per mg/0.3ml 365 days retail) 500mg, 1000mg, 250 mg, 34 days retail) EPIPEN 2-PAK SOAJ (Use NF 500 mg, 1000 mg, 10mg- Epinephrine (Anaphylaxis)) 500mg, 37mg-500mg, F Vasopressors 37mg-1000mg, 14mg- 25mg-500mg, 25mg-35mg- hcl tabs F 500mg B-1 TABS F QL(100 ea per VITAMINS 34 days retail) Oil Soluble Vitamins niacin cpcr or 250 mg, 500 F mg cholecalciferol caps or 400 F AL(At least 65 unit yrs old) niacin tabs or 500 mg F cholecalciferol caps or QL(2 ea daily) VC niacin tbcr or 250 mg, 500 F 5000 unit mg, 750 mg cholecalciferol caps or F QL(8 ea per 30 50000 unit days retail) NIACIN TR TBCR F cholecalciferol chew or 400 AL(At least 65 F pyridoxine hcl tabs or 25 F unit yrs old) mg, 50 mg, 100 mg cholecalciferol liqd or 400 F riboflavin tabs or 25 mg, 50 F unit/ml mg, 100 mg cholecalciferol tabs or 400 AL(At least 65 F SLO-NIACIN TBCR (Use NF unit yrs old) Niacin) D-VI-SOL LIQD (Use NF thiamine hcl tabs or 50 mg, F Cholecalciferol) 100 mg, 250 mg DRISDOL CAPS (Use NF thiamine mononitrate tabs F Ergocalciferol) or 100 mg ergocalciferol caps or F 50000 unit KEY-E CHEW OR F QL(2 ea daily)

MEPHYTON TABS (Use NF Phytonadione) phytonadione tabs or 5 mg F

VITAMIN D2 TABS 400 F AL(At least 65 UNIT yrs old) vitamin e caps or 100 unit, F QL(2 ea daily) 200 unit, 400 unit VITAMIN E CHEW OR 400 F QL(2 ea daily) UNIT

Louisiana Healthcare Connections Updated April 1, 2019

168 Index 1ST TIER UNIFINE ACTONEL 50 ADVOCATE INSULIN PENTIPS/MINI/31GX5MM 72 ACTOPLUS MET 16 SYRINGE/U- 1ST TIER UNIFINE 100/0.5ML/31GX5/16" 73 PENTIPS29GX12MM 72 ACTOS 17 ADVOCATE INSULIN 1ST TIER UNIFINE ACULAR 157 SYRINGE/U-100/1ML/29GX1/2" PENTIPS31GX6MM 72 ACULAR LS 157 73 1ST TIER UNIFINE ADVOCATE INSULIN PENTIPS31GX8MM 72 acyclovir 32 SYRINGE/U-100/1ML/30GX5/16" 1ST TIER UNIFINE acyclovir topical 42 73 PENTIPS32GX4MM 72 ADALAT CC 33 ADVOCATE INSULIN 1ST TIER UNIFINE ADDERALL 1 SYRINGE/U-100/1ML/31GX5/16" PENTIPSPLUS 31GX8MM 72 73 1ST TIER UNIFINE ADDERALL XR 1 ADVOCATE LANCING PENTIPSPLUS 32GX4MM 72 ADJUSTABLE LANCING DEVICE 63 1ST TIER UNIFINE DEVICE 63 ADVOCATE RAPID-SAFE PENTIPSPLUS/MINI/31GX5MM ADMELOG 17 LANCING DEVICE 63 72 ADMELOG SOLOSTAR 17 AEROCHAMBER MINI 1ST TIER UNIFINE ADOXA 162 AEROSOLCHAMBER 104 PENTIPSPLUS/ORIGINAL/29GX AEROCHAMBER MV 104 12MM 73 ADOXA PAK 1/100 162 AEROCHAMBER PLUS FLOW 1ST TIER UNIFINE ADOXA PAK 2/100 162 VU 104 PENTIPSPLUS/ULTRA ADRENACLICK 168 AEROCHAMBER PLUS FLOW- SHORT/31GX6MM 73 ADRENALIN 153 VU 104 1ST TIER UNILET AEROCHAMBER PLUS FLOW- COMFORTOUCH LANCETS ADULT AEROSOL MASK104 VU/LARGE MASK 104 28G 63 ADULT MASK 104 AEROCHAMBER PLUS FLOW- 1ST TIER UNILET VU/MASK 104 COMFORTOUCH LANCETS ADULT MASK LARGE 104 ADVANCED DIABETIC AEROCHAMBER PLUS FLOW- 30G 63 VU/MEDIUM MASK 104 A + D PERSONAL CARE MULTIVITAMIN FORMULA 114 AEROCHAMBER PLUS FLOW- LOTION 43 VU/SMALL MASK 104 abacavir sulfate 29 ADVANCED MOBILE LANCET 30G 63 AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER abacavir sulfate-lamivudine 29 ADVIL 2 abacavir sulfate-lamivudine- W/FLOW VU 104 zidovudine 29 ADVIL COLD & SINUS 38 AEROCHAMBER Z-STAT ABC COMPLETE SENIOR ADVOCATE INSULIN PEN PLUS/FLOWSIGNAL 104 WOMENS 50+ 114 NEEDLES 73 AEROCHAMBER Z-STAT ABILIFY 29 ADVOCATE INSULIN PEN PLUS/LARGE MASK 104 NEEDLES 29GX12.7MM 73 AEROCHAMBER Z-STAT ABILIFY MAINTENA 29 ADVOCATE INSULIN PEN PLUS/MEDIUM MASK 104 ACCUPRIL 22 NEEDLES 31GX5MM 73 AEROCHAMBER Z-STAT ACCURETIC 23 ADVOCATE INSULIN PEN PLUS/SMALL MASK 104 ACE AEROSOL CLOUD NEEDLES 31GX8MM 73 AEROCHAMBER/FLOWSIGNAL ADVOCATE INSULIN 104 ENHANCER 104 SYRINGE/U- acebutolol hcl 32 AEROSPAN 9 100/0.3ML/29GX1/2" 73 AEROTRACH PLUS 104 acetaminophen 4 ADVOCATE INSULIN SYRINGE/U- AEROVENT PLUS HOLDING acetaminophen w/ codeine 5 CHAMBER/COLLAPSIBLE 104 acetazolamide 49 100/0.3ML/30GX5/16" 73 ADVOCATE INSULIN AFLURIA PF 2016-2017 165 acetic acid (otic) 158 SYRINGE/U- AFLURIA PF 2017-2018 165 acetylcysteine 39 100/0.3ML/31GX5/16" 73 AFLURIA PF 2018-2019 165 ACNE MEDICATION 10 39 ADVOCATE INSULIN AFLURIA QUADRIVALENT SYRINGE/U- 2016-2017 165 ACNE MEDICATION 5 39 100/0.5ML/29GX1/2" 73 ACTIGALL 52 AFLURIA QUADRIVALENT ADVOCATE INSULIN 2017-2018 166 ACTIVELLA 51 SYRINGE/U- AFLURIA QUADRIVALENT ACTIVITY POUCH 104 100/0.5ML/30GX5/16" 73 2018-2019 166

Index 1 AGAMATRIX ULTRA-THIN alum & mag hydrox- ANTI-STICK INSULIN LANCETS 33G 63 simethicone 7 SYRINGE/U-100/0.5ML/29G X AIMSCO LUBRICATED 61 ALUMINUM HYDROXIDE 7 1/2" 73 AIRS PEDIATRIC AEROSOL amantadine hcl 26 ANTI-STICK INSULIN SYRINGE/U-100/1ML/29G X MASK 105 AMARYL 18 albuterol sulfate 10 1/2" 73 AMBIEN 54 ANTIOXIDANT FORTE 114 ALBUTEROL SULFATE ER 10 AMD FOAM DRESSING ANUSOL-HC 7 ALCOH-WIPE 12" X 12" 72 4"X4" 57 AP-ZEL 114 ALCOHOL PREP PADS 72 AMD FOAM APEXICON E 42 ALCOHOL PREPS 72 DRESSING/TOPSHEET 4"X4" 57 apraclonidine hcl 155 ALCOHOL SWABS 72 AMEDA TRIPLE ZERO APTIVUS 29 ALCOHOL WIPES 72 LANOLIN 47 AQUA GLYCOLIC HAND & ALDACTAZIDE 49 AMERGE 109 BODYLOTION 43 ALDACTONE 50 AMICAR 54 AQUA LACTEN 43 ALDARA 46 amiloride & AQUA LANCE ADJUSTABLE hydrochlorothiazide 49 ALENDRONATE SODIUM 50 LANCING DEVICE 63 amiloride hcl 50 AQUADERM alendronate sodium 50 aminocaproic acid 54 TREATMENT/MOISTURIZER ALENDRONATE SODIUM 50 aminophylline 10 43 alendronate sodium 50 AQUAMED 44 amiodarone hcl 9 ALER-DRYL 20 AQUORAL 112 amitriptyline hcl 15 ALEVE 2 ARAVA 3 amlodipine besylate 33 ALEVE ARTHRITIS 2 amlodipine besylate-benazepril ARIAL CHAMBER 105 ALIVE ENERGY 50+ 114 hcl 23 ARICEPT 160 ALIVE MENS ENERGY 114 amlodipine besylate-olmesartan ARIMIDEX 26 ALIVE ONCE DAILY WOMENS medoxomil 23 aripiprazole 29 50+ ULTRA POTENCY 114 amlodipine besylate- ALIVE ONCE DAILY WOMENS valsartan 23 ARISTADA INITIO 29 ULTRA POTENCY 114 amlodipine-valsartan- ARMOUR THYROID 162 ALIVE WOMENS 50+ 114 hydrochlorothiazide 23 AROMASIN 26 AMOXAPINE 15 ALIVE WOMENS ENERGY 114 ARTHRITIS PAIN amoxicillin 158 ALKERAN 25 RELIEVING 47 ALL FLOW 1000 PULMONARY AMOXICILLIN 158 artificial tear ointment 155 FUNCTION FILTER 105 amoxicillin 158 ascorbic acid 168 ALLEGRA ALLERGY 20 amoxicillin & pot aspirin 4 ALLEVYN PLUS CAVITY 57 clavulanate 159 ASPIRIN 4 AMOXICILLIN/CLAVULANATE ALLEVYN THIN 57 POTASSIUM 159 aspirin 4 allopurinol 53 amphetamine- aspirin buffered (cal carb-mag ALOCRIL 157 dextroamphetamine 1 carb-mag oxide) 4 ampicillin 158 ASSURE ID INSULIN ALOE AFTERSUN LOTION 43 SAFETYSYRINGE/U- alogliptin benzoate 17 AMPICILLIN 158 100/0.5ML/29G X 1/2" 73 alogliptin-metformin hcl 16 ANAFRANIL 15 ASSURE ID INSULIN SAFETYSYRINGE/U- alogliptin-pioglitazone 16 ANAPROX DS 2 anastrozole 26 100/1ML/29G X 1/2" 73 ALOMIDE 157 ASSURE ID SAFETY PEN ALORA 51 ANDRODERM 6 NEEDLES 30G X 5/16" 73 alprazolam 8 ANDROXY 6 ASSURE ID SAFETY PEN ANTABUSE 160 NEEDLES 31G X 3/16" 73 ALTACE 22 ASTEPRO 153 ALTERNATE SITE LANCING ANTI-STICK INSULIN DEVICE 63 SYRINGE/U-100/0.5ML/28G X ATACAND 22 1/2" 73 ATACAND HCT 23

Index 2 atazanavir sulfate 29 AVEENO POSITIVELY BAND-AID GAUZE PADS atenolol 32 RADIANT 44 LARGE4" X 4" 57 AVEENO STRESS RELIEF BAND-AID GAUZE PADS atenolol & chlorthalidone 23 MOISTURIZING 44 MEDIUM 3" X 3" 57 ATIVAN 8,9 AVONEX 160 BAND-AID GAUZE PADS ATLAS COLORED AVONEX PEN 160 SMALL2" X 2" 57 CONDOM/SPERMICIDE 61 BAND-AID MIRASORB GAUZE ATLAS COLORED AYGESTIN 159 SPONGES LARGE 4" X 4" 57 LUBRICATEDCONDOM 61 AZASAN 111 BASAGLAR KWIKPEN 17 ATLAS LUBRICATED azathioprine 111 BASIC AM 114 CONDOM 61 azelastine hcl 153 ATLAS LUBRICATED BASIC PM 114 CONDOM/SPERMICIDE 61 azelastine hcl (ophth) 157 BAYER MICROLET 2 LANCING atorvastatin calcium 21 AZITHROMYCIN 56 DEVICE 63 BD LO-DOSE INSULIN ATRIPLA 29 azithromycin 56 SYRINGE MICROFINE ATROPINE SULFATE 155 AZOPT 157 IV/0.5ML/28G X 1/2" 74 ATROVENT HFA 9 AZOR 23 BD GLUCOSE 16 AUGMENTIN 159 AZULFIDINE 52 BD INSULIN SYRINGE LUER- AZULFIDINE EN-TABS 52 LOK/U-100/1ML 74 AUGMENTIN ES-600 159 BD INSULIN SYRINGE AUGMENTIN XR 159 b complex w/ c 113 MICROFINE IV/U- AURORA LANCET SUPER B-1 168 100/0.5ML/28G X 1/2" 74 THIN30G 63 b-complex vitamins 113 BD INSULIN SYRINGE AURORA LANCET THIN b-complex w/ c & folic MICROFINE IV/U-100/1ML/27G 23G 63 acid 113,114 X 5/8" 74 AURORA PEN NEEDLES B-D INSULIN SYRINGE BD INSULIN SYRINGE 29GX12MM 73 ULTRAFINE II/0.3ML/31G X MICROFINE IV/U-100/1ML/28G AURORA PEN NEEDLES 31G 5/16" 73 X 1/2" 74 X6MM 73 B-D INSULIN SYRINGE BD INSULIN SYRINGE AURORA PEN NEEDLES 31G ULTRAFINE II/0.5ML/31G X MICROFINE/U-100/0.5ML/28G X 73 X8MM 5/16" 73 1/2" 74 AURORA UNIFINE B-D INSULIN SYRINGE BD INSULIN SYRINGE PENTIPS/32GX5/32" 73 ULTRAFINE II/1ML/31G X MICROFINE/U-100/1ML/27G X AURORA UNIFINE 5/8" 74 73 5/16" 73 PENTIPS/MINI/31GX3/16" B-D INSULIN SYRINGE BD INSULIN SYRINGE AUTO-LANCET 63 ULTRAFINE/0.3ML/30G X MICROFINE/U-100/1ML/28G X AUTO-LANCET MINI 63 1/2" 73 1/2" 74 AUTOLET IMPRESSION B-D INSULIN SYRINGE BD INSULIN SYRINGE LANCING DEVICE 63 ULTRAFINE/0.5ML/30G X SAFETYGLIDE/1ML/29G X AUTOLET LANCING 1/2" 74 1/2" 74 DEVICE 63 BD INSULIN SYRINGE SLIP BACIGUENT 40 TIP/U-100/1ML 74 AUTOLET MINI 63 BACITRACIN 156 BD INSULIN SYRINGE ULTRA- AUTOLET PLUS 63 bacitracin (topical) 40 FINE/0.3ML/30G X 12.7MM 74 AVALIDE 23 bacitracin zinc 40 BD INSULIN SYRINGE ULTRA- AVANDIA 17 FINE/0.3ML/31G X 8MM 74 bacitracin-polymyxin b BD INSULIN SYRINGE ULTRA- AVAPRO 22 (ophth) 156 FINE/0.5ML/30G X 12.7MM 74 AVEENO ACTIVE NATURALS baclofen 153 BD INSULIN SYRINGE ULTRA- DAILY MOISTURIZING BODY BACMIN 114 FINE/0.5ML/31G X 8MM 74 YOGURT 44 BACTRIM 7 BD INSULIN SYRINGE ULTRA- AVEENO ACTIVE NATURALS FINE/1/2 UNIT/0.3ML/31G X DAILY MOISTURIZING BODY BACTRIM DS 7 8MM 74 YOGURT/APRICO 44 BACTROBAN 40 BD INSULIN SYRINGE ULTRA- AVEENO DAILY BACTROBAN NASAL 153 FINE/1ML/30G X 12.7MM 74 MOISTURIZINGSPF 15 44 BALCOLTRA 35 BD INSULIN SYRINGE ULTRA- AVEENO POSITIVELY FINE/1ML/31G X 8MM 74 AGELESSFIRMING BODY 44 balsalazide disodium 52

Index 3 BD INSULIN SYRINGE BD SAFETY-GLIDE INSULIN BIATAIN FOAM DRESSING ULTRAFINE/0.5ML/30G X SYRINGE/0.5ML/29G X 4"X4" 57 1/2" 74 1/2" 75 BIAXIN 56 BD INSULIN SYRINGE BD SAFETY-LOK INSULIN bicalutamide 26 ULTRAFINE/0.5ML/31G X SYRINGE/PERM 5/16" 74 NEEDLE/UF/1ML/29G X BICILLIN C-R 159 BD INSULIN SYRINGE 1/2" 75 BICILLIN L-A 158 ULTRAFINE/1ML/30G X BD SAFETYGLIDE INSULIN BIKTARVY 29 1/2" 74 SYRINGE/0.3ML/29G X BIOGUARD GAUZE SPONGE BD INSULIN SYRINGE 1/2" 75 2"X2" 8 PLY 57 ULTRAFINE/U-100/0.3ML/29G X BD SAFETYGLIDE INSULIN BIOGUARD GAUZE SPONGES 1/2" 74 SYRINGE/0.3ML/31G X 4"X4" 12 PLY 57 BD INSULIN SYRINGE 5/16" 75 BIOSPEC DMX 38 ULTRAFINE/U-100/0.5ML/29G X BD SAFETYGLIDE INSULIN 1/2" 74 SYSYRINGE/0.5ML/30G X BIOTENE DRY MOUTH BD INSULIN SYRINGE 5/16" 75 MOISTURIZING SPRAY 112 ULTRAFINE/U-100/1ML/29G X BD SWABS SINGLE USE 72 bisacodyl 56 1/2" 74 BD SWABS SINGLE USE bismuth subsalicylate 18 BD INSULIN BUTTERFLY 72 bisoprolol & SYRINGE/0.3ML/29G X BD VEO INSULIN SYRINGE hydrochlorothiazide 23 12.7MM 74 ULTRA-FINE/1ML/31G X bisoprolol fumarate 32 BD INSULIN 6MM 75 BLEPH-10 156 SYRINGE/0.5ML/29G X BENADRYL ALLERGY 20 74 BLEPHAMIDE 156 12.7MM BENADRYL ALLERGY BD INSULIN SYRINGE/1ML/27G BLEPHAMIDE S.O.P. 156 74 CHILDRENS 20 X 12.7MM benazepril & BORDERED GAUZE 57 BD INSULIN SYRINGE/1ML/29G BREATHE EASE/LARGE X 12.7MM 74 hydrochlorothiazide 23 benazepril hcl 22 MASK 105 BD INSULIN BREATHE EASE/MEDIUM SYRINGE/DETACHABLE BENICAR 22 MASK 105 NEEDLE/U-100/1ML/25G X BENICAR HCT 23 BREATHE EASE/SMALL 1" 74 MASK 105 BD INSULIN BENTYL 163 SYRINGE/DETACHABLE BENZAC AC WASH 39 BREATHERITE 105 NEEDLE/U-100/1ML/25G X benzoyl peroxide 39 BREATHERITE COLLAPSIBLEADULT SPACER 5/8" 75 BENZOYL PEROXIDE 39 BD INSULIN W/MASK 105 SYRINGE/DETACHABLE benzoyl peroxide 39 BREATHERITE NEEDLE/U-100/1ML/26G X BENZOYL PEROXIDE COLLAPSIBLECHILD SPACER 1/2" 75 CLEANSER 39 W/MASK 105 BD INSULIN SYRINGE/U- benztropine mesylate 26 BREATHERITE 100/1ML/27G X 1/2" 75 BETA CARE 44 COLLAPSIBLEINFANT SPACER W/MASK 105 BD LANCET ULTRAFINE BETAGAN 155 30G 63 BREATHERITE BD PEN betamethasone dipropionate COLLAPSIBLESMALL CHILD (topical) 42 SPACER W/MASK 105 NEEDLE/MICRO/ULTRA- betamethasone dipropionate FINE/32G X 6MM 75 BREATHERITE BD PEN NEEDLE/MINI/ULTRA- augmented 42 COLLAPSIBLESPACER W/ FINE/31G X 5MM 75 betamethasone valerate 42 NEONATE MASK 105 BD PEN BETAPACE 33 BREATHERITE RIGID NEEDLE/NANO/ULTRA- BETAPACE AF 33 SPACERW/MASK 105 FINE/32G X 4MM 75 BREATHERITE W/LARGE BD PEN betaxolol hcl (ophth) 155 MASK 105 NEEDLE/ORIGINAL/ULTRA- bethanechol chloride 165 BREATHERITE W/MEDIUM FINE/29G X 12.7MM 75 BETOPTIC-S 155 MASK 105 BREATHERITE W/SMALL BD PEN BEXSERO 165 NEEDLE/SHORT/ULTRA- MASK 105 BIATAIN ADHESIVE FOAM BREVICON-28 35 FINE/31G X 8MM 75 DRESSING 4"X4" 57 BRILINTA 53

Index 4 brimonidine tartrate 155 CAM 44 CAREONE INSULIN BRISDELLE 162 camphor & menthol 41 SYRINGES/0.5ML/31G X 5/16" 75 bromocriptine mesylate 26,27 candesartan cilexetil 22 CAREONE INSULIN brompheniramine & candesartan cilexetil- SYRINGES/1ML/30G X 1/2" 75 phenyleph 38 hydrochlorothiazide 24 CAREONE INSULIN brompheniramine & CAPHOSOL 112 SYRINGES/1ML/31GX5/16" 75 pseudoeph 38 CAPSAGEL 47 CAREONE LANCET THIN 63 BROTAPP DM 38 CAPSAGEL EXTRA CAREONE LANCET ULTRA BUBBLES THE FISH II STRENGTH 47 THIN 63 PEDIATRIC MASK/PVC 105 CAPSAGEL MAXIMUM CAREONE UNIFINE PENTIPS budesonide (inhalation) 10 STRENGTH 47 29GX12MM 75 BUFFERIN 4 capsaicin 47 CAREONE UNIFINE PENTIPS 31GX5MM 75 bumetanide 50 captopril 22 CAREONE UNIFINE PENTIPS BUMEX 50 CAPTOPRIL/HYDROCHLORO 31GX6MM 76 buprenorphine hcl-naloxone hcl THIAZIDE 24 CAREONE UNIFINE PENTIPS dihydrate 6 CAPZASIN-HP 47 31GX8MM 76 bupropion hcl 13 CAPZASIN-P 47 CAREONE UNIFINE PENTIPS bupropion hcl (smoking CARAC 41 PEN NEEDLES 32GX4MM 76 CAREONE UNIFINE PENTIPS deterrent) 161 CARAFATE 164 buspirone hcl 8 PLUS PEN NEEDLES carbamazepine 11 29GX12MM 76 butalbital-acetaminophen 4 carbamide peroxide (otic) 158 CAREONE UNIFINE PENTIPS butalbital-acetaminophen- PLUS PEN NEEDLES caffeine 4 carbidopa 26 31GX5MM 76 butalbital-acetaminophen- carbidopa-levodopa 27 CAREONE UNIFINE PENTIPS caffeine w/ codeine 5 CARDENZ 146 PLUS PEN NEEDLES butalbital-aspirin-caffeine 4 CARDIOCOM LANCING 31GX6MM 76 butalbital-aspirin-caffeine DEVICE 63 CAREONE UNIFINE PENTIPS w/cod 5 CARDIZEM 33 PLUS PEN NEEDLES BUTALBITAL/ASPIRIN/CAFFEIN 31GX8MM 76 E 4 CARDIZEM CD 33 CAREONE UNIFINE PENTIPS BYDUREON 17 CARDURA 23 PLUS PEN NEEDLES BYDUREON BCISE 17 CAREFINE PEN NEEDLE 32GX4MM 76 32GX4MM 75 CARETOUCH LANCING BYDUREON PEN 17 CAREFINE PEN NEEDLES DEVICEWITH EJECTOR 63 BYETTA 17 29GX1/2" 75 CARETOUCH PEN NEEDLES CAFERGOT 108 CAREFINE PEN NEEDLES 31G X 6 MM 76 30GX5/16" 75 CARETOUCH PEN NEEDLES caffeine citrate 1 CAREFINE PEN NEEDLES 31GX 5MM 76 CAL-DAY 1000 114 31GX6MM 75 CARETOUCH PEN NEEDLES CALAN 33 CAREFINE PEN NEEDLES 31GX 8MM 76 CALAN SR 33 31GX8MM 75 CARETOUCH PEN NEEDLES CAREFINE PEN NEEDLES 32GX 4MM 76 calcipotriene 41 32GX5MM 75 CARETOUCH PEN NEEDLES calcitonin (salmon) 50 CAREFINE PEN NEEDLES 32GX 5MM 76 calcitriol 51 32GX6MM 75 CARNITOR 51 calcium acetate (phosphate CAREONE ADVANCED CARNITOR SF 51 binder) 52 LANCINGDEVICE 63 CAREONE INSULIN CARRASMART 57 calcium carbonate (antacid) 7 SYRINGES/0.3ML/30G X CARRASMART FOAM 57 calcium carbonate- 1/2" 75 CARTEOLOL HCL 155 cholecalciferol 109 CAREONE INSULIN calcium carbonate-vitamin SYRINGES/0.3ML/31G X carteolol hcl (ophth) 155 d 110 5/16" 75 carvedilol 32 calcium polycarbophil 55 CAREONE INSULIN carvedilol phosphate 32 CALNA 150 SYRINGES/0.5ML/30G X CASODEX 26 1/2" 75

Index 5 CASTIVA WARMING 47 CERAVE SA RENEWING 44 CIMETIDINE HCL 163 CATAPRES 23 CERTAVITE CIPRO 52 cefaclor 34 SENIOR/ANTIOXIDANT CIPRODEX 158 NUTRIENTS 115 CEFACLOR 34 CETAPHIL DAILY ADVANCE CIPROFLOXACIN HCL 52 cefadroxil 34 ULTRA HYDRATING 44 ciprofloxacin hcl 52 cefdinir 35 CETAPHIL DAILY FACIAL ciprofloxacin hcl (ophth) 156 MOISTURIZER 44 cefoxitin sodium 34 CETAPHIL DERMACONTROL citalopram hydrobromide 14 CEFOXITIN SODIUM 34 MOISTURIZER/SPF 30 44 clarithromycin 56 cefprozil 34 CETAPHIL CLARITHROMYCIN 56 CEFTIN 34,35 MOISTURIZING 44 clarithromycin 57 CETAPHIL ceftriaxone sodium 35 RESTORADERM 44 CLARITIN 20 cefuroxime axetil 35 cetirizine hcl 20 CLARITIN ALLERGY CELEBREX 2 cetirizine-pseudoephedrine CHILDRENS 20 CLARITIN REDITABS 20 celecoxib 2 38 CLARITIN-D 12 HOUR 38 CELEXA 14 CHANTIX 161 CHANTIX CONTINUING CLARITIN-D 24 HOUR 38 CELLCEPT 111 MONTHPAK 161 CLASS ACT LUBRICATED 61 CENTANY 40 CHANTIX STARTING MONTH CLASSIC PRENATAL 150 CENTRAVITES 50 PLUS 114 PAK 161 CHEK-STIX CONTROL 49 CLEAN & CLEAR ADVANTAGE CENTRAVITES ADULTS 114 3-IN-1 EXFOLIATING CENTRUM 115 CHEMET 18 CLEANSER 39 CENTRUM ADULTS 114 CHEMSTRIP-K 49 CLEANLET LANCETS 28G 63 CENTRUM CARDIO 114 CHILDRENS ADVIL 3 clemastine fumarate 20 CENTRUM MEN 114 CHILDRENS MOTRIN 3 CLEOCIN 8,167 CENTRUM SILVER 115 CHLOR-TRIMETON 19 CLEOCIN PEDIATRIC CENTRUM SILVER chlordiazepoxide hcl 9 GRANULES 8 50+MEN 114 CHLORDIAZEPOXIDE/AMITRI CLEOCIN-T 39 CENTRUM SILVER PTYLINE 160 CLEVER CHOICE ANTI- 50+WOMEN 114 chlorhexidine gluconate 29 STATICVALVED HOLDING CENTRUM SILVER ADULT chlorhexidine gluconate CHAMBER/ADULT LARGE 105 50+ 114 (mouth-throat) 112 CLEVER CHOICE ANTI- CENTRUM SILVER ULTRA CHLOROQUINE STATICVALVED HOLDING MENS 115 PHOSPHATE 25 CHAMBER/MEDIUM 105 CENTRUM SILVER ULTRA chloroquine phosphate 25 CLEVER CHOICE ANTI- WOMENS 115 STATICVALVED HOLDING CENTRUM SPECIALIST CHLOROTHIAZIDE 50 CHAMBER/SMALL 105 HEART 115 chlorothiazide 50 CLEVER CHOICE COMFORT CENTRUM SPECIALIST chlorpheniramine maleate 19 EZINSULIN PEN NEEDLES IMMUNE SUPPORT 115 31GX8MM 76 CENTRUM SPECIALIST chlorpromazine hcl 28 CLEVER CHOICE COMFORT VISION 115 chlorthalidone 50 EZINSULIN PEN NEEDLES CENTRUM ULTRA MENS 115 CHLORZOXAZONE 153 33GX4MM 76 CENTRUM ULTRA CHOLBAM 52 CLEVER CHOICE COMFORT EZINSULIN WOMENS 115 cholecalciferol 168 CENTRUM WOMEN 115 SYRINGE/0.3ML/29G X 1/2" 76 cholestyramine 21 CLEVER CHOICE COMFORT cephalexin 34 cholestyramine light 21 EZINSULIN CERASPORT 110 choline & mag salicylate 4 SYRINGE/0.3ML/30G X 1/2" 76 CERASPORT EX1 110 CLEVER CHOICE COMFORT cilostazol 53 CERAVE 44 EZINSULIN CILOXAN 156 SYRINGE/0.3ML/30G X CERAVE AM SPF 30 44 CIMDUO 29 5/16" 76 CERAVE PM 44 cimetidine 163

Index 6 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT clozapine 28 EZINSULIN EZPEN NEEDLES CLOZARIL 28 32GX8MM 77 SYRINGE/0.3ML/31G X CO MONITOR REPLACEMENT 5/16" 76 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT EZPEN NEEDLES TPIECES 105 EZINSULIN 33GX4MM 77 CO-NATAL FA 150 SYRINGE/0.5ML/28G X 1/2" 76 CLICKFINE PEN NEEDLE coal tar extract 48 CLEVER CHOICE COMFORT 32GX5/32" 77 COARTEM 25 CLICKFINE PEN NEEDLE EZINSULIN COCOA BUTTER 44 SYRINGE/0.5ML/29G X 1/2" 76 UNIVERSAL/31GX1/4" 77 CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLE COCOA BUTTER HAND & EZINSULIN UNIVERSAL/31GX5/16" 77 BODYLOTION 44 SYRINGE/0.5ML/30G X 1/2" 76 CLICKFINE PEN NEEDLES CODEINE SULFATE 5 CLEVER CHOICE COMFORT 31G X 8MM 77 codeine sulfate 5 EZINSULIN CLICKFINE PEN COLACE 56 SYRINGE/0.5ML/30G X NEEDLES/31GX1/4" 77 5/16" 76 CLICKFINE PEN COLACE CLEAR 56 CLEVER CHOICE COMFORT NEEDLES/31GX5/16" 77 COLAZAL 52 EZINSULIN CLICKFINE UNIVERSAL PEN COLCHICINE 53 NEEDLES 31GX5/16" 77 SYRINGE/0.5ML/31G X colchicine 53 5/16" 76 CLIMARA 51 colchicine w/ probenecid 53 CLEVER CHOICE COMFORT clindamycin hcl 8 EZINSULIN clindamycin palmitate COLCRYS 53 SYRINGE/1.0ML/30G X 1/2" 76 hydrochloride 8 COLESTID 21 CLEVER CHOICE COMFORT clindamycin phosphate COLESTID FLAVORED 21 EZINSULIN SYRINGE/1ML/28G (topical) 39 colestipol hcl 21 X 1/2" 76 clindamycin phosphate CLEVER CHOICE COMFORT vaginal 167 COLYTE-FLAVOR PACKS 55 EZINSULIN SYRINGE/1ML/29G CLINICAL NUTRIENTS 45- COMBIPATCH 51 X 1/2" 77 PLUS WOMEN 115 COMBIVENT RESPIMAT 10 CLEVER CHOICE COMFORT CLINICAL NUTRIENTS 50- EZINSULIN SYRINGE/1ML/30G PLUS MEN 115 COMBIVIR 29 X 5/16" 77 CLINICAL NUTRIENTS FOR COMFORT ASSIST INSULIN CLEVER CHOICE COMFORT FEMALE TEENS 115 SYRINGE 0.3ML/29G X 1/2" 77 EZINSULIN SYRINGE/U- CLINICAL NUTRIENTS FOR COMFORT ASSIST INSULIN 100/1ML/31GX5/16" 77 MALE TEENS 115 SYRINGE/0.3ML/30G X CLEVER CHOICE COMFORT CLINICAL NUTRIENTS FOR 5/16" 77 EZPEN NEEDLES MEN 115 COMFORT ASSIST INSULIN 29GX12MM 77 CLINICAL NUTRIENTS FOR SYRINGE/0.3ML/31G X CLEVER CHOICE COMFORT WOMEN 115 5/16" 77 EZPEN NEEDLES CLN FACIAL MOISTURIZER COMFORT ASSIST INSULIN 31GX5MM 77 NOURISHING 44 SYRINGE/0.5ML/29G X 1/2" 77 CLEVER CHOICE COMFORT clobetasol propionate 42 COMFORT ASSIST INSULIN EZPEN NEEDLES clobetasol propionate emollient SYRINGE/0.5ML/30G X 31GX6MM 77 base 42 5/16" 77 CLEVER CHOICE COMFORT COMFORT ASSIST INSULIN EZPEN NEEDLES clomipramine hcl 15 SYRINGE/0.5ML/31G X 31GX8MM 77 clonazepam 11 5/16" 77 CLEVER CHOICE COMFORT clonidine hcl 23 COMFORT ASSIST INSULIN EZPEN NEEDLES clonidine hcl (adhd) 1 SYRINGE/1ML/29G X 1/2" 77 32GX4MM 77 COMFORT ASSIST INSULIN CLEVER CHOICE COMFORT clopidogrel bisulfate 53 SYRINGE/1ML/30G X 5/16" 78 EZPEN NEEDLES clorazepate dipotassium 9 COMFORT ASSIST INSULIN 32GX5MM 77 CLOSERCARE 63 SYRINGE/1ML/31G X 5/16" 78 COMFORT ASSURED CLEVER CHOICE COMFORT clotrimazole (topical) 40 EZPEN NEEDLES LANCETS SUPER THIN 32GX6MM 77 clotrimazole vaginal 167 28G 63 clotrimazole w/ betamethasone 40

Index 7 COMFORT EZ INSULIN cromolyn sodium 9 CURITY GAUZE SPONGE SYRINGE/U-100/0.5ML/31G X cromolyn sodium (nasal) 153 4"X4"16 PLY 58 5/16" 78 CURITY GAUZE SPONGES COMFORT EZ INSULIN cromolyn sodium (ophth) 157 4"X4" 12 PLY 58 SYRINGE/U-100/1ML/31G X crotamiton 48 CURITY GAUZE SPONGES 5/16" 78 CURITY ALCOHOL 4"X4" 8 PLY 58 COMFORT EZ MICRO/32G X PREPS/MEDIUM 2 PLY 72 CURITY NON-ADHERENT 4MM 78 CURITY ALCOHOL STRIPS 3"X3" 58 COMFORT EZ SHORT/31G X SWABS 72 CURITY 8MM 78 CURITY ALL PURPOSE SPONGES/CELLULOSEFILLED/ COMFORT EZ/31G X 5MM 78 SPONGES 2"X2" 57 2"X2" 58 COMFORT EZ/31G X 6MM 78 CURITY ALL PURPOSE CURITY SPONGES 2"X2" 4PLY 57 SPONGES/CELLULOSEFILLED/ COMFORT LANCETS 64 CURITY ALL PURPOSE 4"X4" 58 COMPACT SPACE SPONGES 3"X3" 4PLY 57 CVS DAILY ULTRA CHAMBER/ANTI-STATIC 105 CURITY ALL PURPOSE MOISTURELOTION 44 COMPACT SPACE SPONGES 4 PLY 57 CVS DRY MOUTH SPRAY 112 CHAMBER/ANTI- CURITY ALL PURPOSE CVS GAUZE PAD 3"X3" 58 STATIC/LARGE MASK 105 SPONGES 4"X4" 58 COMPACT SPACE CVS GAUZE PADS 2"X2" 12- CURITY ALL PURPOSE PLY 58 CHAMBER/ANTI- SPONGES 4"X4" 4PLY 58 STATIC/MEDIUM MASK 105 CVS GAUZE PADS 4"X4" 12- CURITY ALL PURPOSE PLY 58 COMPACT SPACE SPONGES 4"X4" 4PLY/SOFT CHAMBER/ANTI-STATIC/SMALL CVS GAUZE PADS STERILE POUCH 58 4"X4" 12-PLY 58 MASK 105 CURITY AMD COMPLERA 29 ANTIMICROBIALGAUZE CVS GLUCOSE 16 COMPLETENATE 150 SPONGES 2"X2" 8 PLY 58 CVS LANCETS 21G 64 CURITY AMD CVS LANCETS MICRO THIN CONCERTA 1 ANTIMICROBIALGAUZE 33G 64 CONDYLOX 47 SPONGES 4"X4" 12 PLY 58 CVS LANCETS ORIGINAL 64 COPA ISLAND BORDERED CURITY COVER SPONGE CVS LANCETS THIN 26G 64 FOAM DRESSING 4"X4" 57 4"X4" 58 COPA PLUS HYDROPHILIC CURITY COVER SPONGES CVS LANCETS ULTRA THIN FOAM DRESSING 4"X4" 57 3"X3" 58 30G 64 COPAXONE 160 CURITY COVER SPONGES CVS LANCING DEVICE 64 COREG 32 4"X4" 58 CVS OMEPRAZOLE 164 CURITY DRESSING CVS ONE DAILY MENS 50+ COREG CR 32 SPONGES 4"X4" 6 PLY 58 ADVANCED 115 CORGARD 33 CURITY GAUZE PADS CVS PRENATAL 150 CORTANE-B-OTIC 158 2"X2" 58 CURITY GAUZE PADS 2"X2" CVS PREP PADS 72 CORTEF 37 12 PLY 58 CVS SPECTRAVITE ADULT CORTENEMA 6 CURITY GAUZE PADS 50+ 115 CORTISONE ACETATE 37 3"X3" 58 CVS SPECTRAVITE ULTRA MEN50+ 115 COSOPT 155 CURITY GAUZE PADS 4"X4" 12 PLY 58 CVS SPECTRAVITE ULTRA COTELLIC 26 CURITY GAUZE SPONGE MENS HEALTH 116 COUMADIN 10 2"X2" 8 PLY 58 CVS SPECTRAVITE ULTRA COVRSITE COVER CURITY GAUZE SPONGE MENS HEALTH SENIOR 116 DRESSING 57 2"X2"12 PLY 58 CVS SPECTRAVITE ULTRA COVRSITE PLUS COMPOSITE CURITY GAUZE SPONGE WOMEN 116 DRESSING 57 3"X3" 12 PLY 58 CVS SPECTRAVITE ULTRA WOMENS HEALTH 116 COZAAR 23 CURITY GAUZE SPONGE 4"X4" 12 PLY 58 CVS SPECTRAVITE ULTRA CREON 49 CURITY GAUZE SPONGE WOMENS HEALTH CRESTOR 21 4"X4" 16 PLY 58 SENIOR 116 CRINONE 167 CURITY GAUZE SPONGE CVS ULTRA THIN 4"X4" 8 PLY 58 LANCETS 64 CRIXIVAN 29 cyanocobalamin 53

Index 8 CYCLESSA 35 DERMACEA I.V. DRAIN desogestrel & ethinyl cyclobenzaprine hcl 153 SPONGES 2"X2" 59 estradiol 35 DERMACEA I.V. DRAIN desogestrel-ethinyl estradiol CYCLOGYL 155 SPONGES 4"X4" 59 (biphasic) 35 cyclopentolate hcl 155 DERMACEA I.V. SPONGES desogestrel-ethinyl estradiol cyclophosphamide 25 2"X2" 59 (triphasic) 35 DERMACEA NON-WOVEN CYCLOPHOSPHAMIDE 26 desonide 42 SPONGES 2"X2" 4 PLY 59 DESOWEN 42 cyclosporine 111 DERMACEA NON-WOVEN CYCLOSPORINE SPONGES 3"X3" 4 PLY 59 desoximetasone 42 MODIFIED 111 DERMACEA NON-WOVEN DESQUAM-X WASH 39 cyclosporine modified (for SPONGES 4"X4" 4 PLY 59 desvenlafaxine succinate 15 microemulsion) 111 DERMACEA NON-WOVEN DETROL 165 CYMBALTA 15 SPONGES 4"X4" 6 PLY 59 DETROL LA 165 cyproheptadine hcl 21 DERMACEA TYPE VII GAUZE 2"X2" 12 PLY 59 DEX4 QUICK DISSOLVE CYTOMEL 162 DERMACEA TYPE VII GAUZE GLUCOSE 16 CYTOTEC 164 2"X2" 8 PLY 59 dexamethasone 37 D-VI-SOL 168 DERMACEA TYPE VII GAUZE DEXAMETHASONE 37 3"X3" 12 PLY 59 D.H.E. 45 108 DERMACEA TYPE VII GAUZE dexamethasone 37 dapsone 8 3"X3" 12PLY 59 DEXAMETHASONE 37 DAYPRO 3 DERMACEA TYPE VII GAUZE DEXAMETHASONE DDAVP 51 4"X4" 12 PLY 59 INTENSOL 37 DERMACEA TYPE VII GAUZE dexamethasone sodium DEBROX 158 4"X4" 16 PLY 59 phosphate 37 DECON-A 38 DERMACEA TYPE VII GAUZE DEXAMETHASONE SODIUM DELSTRIGO 29 4"X4" 8 PLY 59 PHOSPHATE 156 DERMACEA X-RAY DEMADEX 50 SPONGES 4"X4" 16 PLY 59 MALEATE 20 DEMEROL 5 DERMAL THERAPY EXTRA DEXEDRINE 1 DEPAKENE 13 STRENGTH BODY LOTION 44 DEXILANT 164 DEPAKOTE 13 DERMAL THERAPY FACE dexmethylphenidate hcl 1 DEPAKOTE ER 13 CAREMOISTURIZING dextroamphetamine sulfate 1 DEPAKOTE SPRINKLES 13 LOTION 44 dextromethorphan hbr 37 DERMAL THERAPY FOOT DEPEN TITRATABS 111 dextromethorphan-guaifenesin DEPO-PROVERA MASSAGE 44 DERMAL THERAPY HAND 38 CONTRACEPTIVE 36 DHS TAR 48 DEPO-SUBQ PROVERA ELBOW & KNEE CREAM 44 104 36 DERMAL THERAPY HEEL DHS TAR GEL 48 CARE 44 DIABETIDERM 44 DEPO-TESTOSTERONE 6 DERMALEVIN ADHESIVE DERMACEA DRAIN SPONGES DIABETIDERM HAND & FOAMDRESSING 4"X4" 59 BODY 44 4"X4" 58 DERMAREST PSORIASIS 47 DERMACEA GAUZE SPONGE DIAMOX 49 2"X2" 12 PLY 58 DERMATOP 42 DIASTAT ACUDIAL 11 DERMACEA GAUZE SPONGE DERMAVITE 116 DIASTAT PEDIATRIC 11 2"X2" 8 PLY 58 DERMOTIC 158 DERMACEA GAUZE SPONGE DIATHRIVE LANCING 3"X3" 12 PLY 58 DESCOVY 29 DEVICE 64 DERMACEA GAUZE SPONGE desipramine hcl 15 DIAZEPAM 9 3"X3" 8 PLY 58 desmopressin acetate 51 diazepam 9 DERMACEA GAUZE SPONGE desmopressin acetate DIAZEPAM 11 4"X4" 12 PLY 58 spray 51 diazepam (anticonvulsant) 11 DERMACEA GAUZE SPONGE desmopressin acetate spray 4"X4" 16 PLY 58 refrigerated 51 DIAZEPAM RECTAL GEL 11 DERMACEA GAUZE SPONGE DESOGEN 35 dibucaine 47 4"X4" 8 PLY 58 diclofenac potassium 3

Index 9 diclofenac sodium 3 DORZOLAMIDE DROPLET PEN NEEDLES diclofenac sodium (ophth) 157 HCL/TIMOLOL 31GX5MM 78 MALEATE 155 DROPLET PEN NEEDLES diclofenac sodium (topical) 40 DOVONEX 41 31GX6MM 78 dicloxacillin sodium 159 doxazosin mesylate 23 DROPLET PEN NEEDLES dicyclomine hcl 163 31GX8MM 78 doxepin hcl 15 DROPLET PEN NEEDLES 32G didanosine 29 DOXEPIN HCL 15 X 1/4" 78 DIFLORASONE doxepin hcl 15 DROPLET PEN NEEDLES 32G DIACETATE 42 X 3/16" 78 diflorasone diacetate 42 doxycycline DROPLET PEN NEEDLES 32G (monohydrate) 162 X 5/16" 78 DIFLUCAN 19 doxycycline hyclate 162 diflunisal 4 DROPLET PEN NEEDLES 32G DOXYCYCLINE X 5/32" 78 DIGOXIN 34 HYCLATE 162 DROPLET PEN NEEDLES digoxin 34 doxylamine succinate 32GX4MM 78 dihydroergotamine (sleep) 54 DROPLET PEN NEEDLES mesylate 108 DRISDOL 168 32GX5MM 78 DILANTIN 12,13 DRITHO-CREME HP 41 DROPLET PEN NEEDLES 32GX6MM 79 DILANTIN INFATABS 13 DROPLET INSULIN SYRINGE U-100/0.3/31G X 5/16" 78 DROPLET PEN NEEDLES DILANTIN-125 13 DROPLET INSULIN SYRINGE 32GX8MM 79 DILAUDID 5 U-100/0.3ML/30G X 1/2" 78 DROPSAFE SAFETY PEN DROPLET INSULIN SYRINGE NEEDLES/31G X 5/16" 79 diltiazem hcl 33 DROPSAFE SAFTEY PEN diltiazem hcl coated beads 33 U-100/0.3ML/30G X 5/16" 78 DROPLET INSULIN SYRINGE NEEDLES/31G X 1/4" 79 diltiazem hcl extended release U-100/0.5ML/30G X 1/2" 78 drospirenone-ethinyl beads 33 DROPLET INSULIN SYRINGE estradiol 35 DIMETAPP COLD & U-100/0.5ML/30G X 5/16" 78 DROXIA 53 ALLERGY 38 DROPLET INSULIN SYRINGE DRUG MART ADJUSTABLE DIMETAPP LONG ACTING U-100/0.5ML/31G X 5/16" 78 LANCING DEVICE 64 COUGH PLUS COLD 38 DROPLET INSULIN SYRINGE DRUG MART LANCETS DIOVAN 23 U-100/1ML/30G X 1/2" 78 THIN 64 DIOVAN HCT 24 DROPLET INSULIN SYRINGE DRUG MART UNIFINE PENTIPS diphenhydramine hcl 20 U-100/1ML/30G X 5/16" 78 31GX5MM 79 DROPLET INSULIN SYRINGE DRUG MART UNIFINE diphenhydramine hcl (sleep) 54 U-100/1ML/31G X 5/16" 78 PENTIPS29G X 12MM 79 diphenhydramine hcl DROPLET INSULIN DRUG MART UNIFINE (topical) 41 SYRINGE/U-100/0.3ML/31G X PENTIPS31GX6MM 79 diphenoxylate w/ atropine 18 5/16" 78 DRUG MART UNIFINE DIPHENOXYLATE/ATROPINE DROPLET INSULIN PENTIPS31GX8MM 79 18 SYRINGE/U-100/0.5ML/30G X DRUG MART UNIFINE DIPROLENE AF 42 1/2" 78 PENTIPS32GX4MM 79 DRUG MART UNIFINE dipyridamole 53 DROPLET INSULIN SYRINGE/U-100/0.5ML/31G X PENTIPSPLUS 32GX4MM 79 disopyramide phosphate 9 5/16" 78 DRUG MART UNILET disulfiram 160 DROPLET INSULIN LANCETSSUPER THIN 30G64 DITROPAN XL 165 SYRINGE/U-100/1ML/30G X DRUG MART UNILET 1/2" 78 LANCETSULTRA THIN 28G 64 divalproex sodium 13 DROPLET INSULIN DRUG MART UNILET MICRO docusate sodium 56 SYRINGE/U-100/1ML/31G X THIN LANCETS 33G 64 dofetilide 9 5/16" 78 DRYMAX EXTRA 59 DOLOPHINE 5 DROPLET LANCETS ULTRA DRYSOL 47 THIN 30G 64 donepezil hydrochloride 160 DROPLET LANCING DULCOLAX 56 DORZOLAMIDE HCL 157 DEVICE 64 DULERA 10 dorzolamide hcl 157 DROPLET PEN NEEDLES duloxetine hcl 15 dorzolamide hcl-timolol 29GX12MM 78 DURAGESIC 5 maleate 155

Index 10 DUREX EXTRA SENSITIVE 61 EASY TOUCH ALCOHOL EASY TOUCH INSULIN DUTOPROL 24 PREP PADS/MEDIUM 72 SYRINGE/U-100/1ML/28G X EASY TOUCH FLIPLOCK 1/2" 80 DYAZIDE 49 SAFETY INSULIN SYRINGE EASY TOUCH INSULIN E-Z JECT LANCETS 64 1ML/29GX1/2" 79 SYRINGE/U-100/1ML/29G X E-Z JECT LANCETS 21G 64 EASY TOUCH FLIPLOCK 1/2" 80 E-Z JECT LANCETS SAFETY INSULIN SYRINGE EASY TOUCH INSULIN COLOR 64 1ML/30GX1/2" 79 SYRINGE/U-100/1ML/30G X E-Z JECT LANCETS SUPER EASY TOUCH FLIPLOCK 1/2" 80 THIN 30G 64 SAFETY INSULIN SYRINGE EASY TOUCH INSULIN E-Z JECT LANCETS THIN 1ML/30GX5/16" 79 SYRINGE/U-100/1ML/31G X 26G 64 EASY TOUCH FLIPLOCK 5/16" 80 E-Z SPACER 105 SAFETY INSULIN SYRINGE EASY TOUCH LANCETS 1ML/31GX5/16" 79 26G/PULL-TOP 64 E-Z SPACER THE BODY EASY TOUCH INSULIN EASY TOUCH LANCETS GUARDS PACK 105 SYRINGE/0.3ML/30G X 26G/TWIST 64 E-ZJECT LANCETS MICRO- 5/16" 79 EASY TOUCH LANCETS THIN 33G 64 EASY TOUCH INSULIN 28G/PULL-TOP 64 E.E.S. 400 57 SYRINGE/0.3ML/31G X EASY TOUCH LANCETS E.E.S. GRANULES 57 5/16" 79 28G/TWIST 64 EASIVENT 105 EASY TOUCH INSULIN EASY TOUCH LANCETS SYRINGE/0.5ML/29G X 30G/PULL-TOP 64 EASIVENT/MASK-LARGE 106 1/2" 79 EASY TOUCH LANCETS EASIVENT/MASK-MEDIUM EASY TOUCH INSULIN 30G/TWIST 64 106 SYRINGE/0.5ML/30G X EASY TOUCH LANCETS EASIVENT/MASK-SMALL 106 5/16" 79 32G/PULL-TOP 64 EASY COMFORT INSULIN EASY TOUCH INSULIN EASY TOUCH LANCETS SYRINGE/0.5ML/30G X SYRINGE/1ML/30G X 32G/TWIST 64 5/16" 79 5/16" 79 EASY TOUCH LANCETS EASY COMFORT INSULIN EASY TOUCH INSULIN 33G/TWIST 65 SYRINGE/0.5ML/31G X SYRINGE/SAFETY/U- EASY TOUCH LANCING 5/16" 79 100/0.5ML/29G X 1/2" 79 DEVICE/EJECTOR 65 EASY COMFORT INSULIN EASY TOUCH INSULIN EASY TOUCH PEN NEEDLE SYRINGE/1ML/30G X 5/16" 79 SYRINGE/SAFETY/U- 30G X 5/16" 80 EASY COMFORT INSULIN 100/0.5ML/30G X 5/16" 80 EASY TOUCH PEN NEEDLES SYRINGE/1ML/31G X 5/16" 79 EASY TOUCH INSULIN 29GX1/2" 80 EASY COMFORT INSULIN SYRINGE/SAFETY/U- EASY TOUCH PEN NEEDLES SYRINGE/U-100/0.5ML/30G X 100/1ML/29G X 1/2" 80 31GX1/4" 80 1/2" 79 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES EASY COMFORT INSULIN SYRINGE/SAFETY/U- 31GX5/16" 80 SYRINGE/U-100/1ML/30G X 100/1ML/30G X 1/2" 80 EASY TOUCH PEN NEEDLES 1/2" 79 EASY TOUCH INSULIN 32GX1/4" 80 EASY COMFORT PEN SYRINGE/U-100/0.3ML/30G X EASY TOUCH PEN NEEDLES NEEDLES31GX1/4" 79 1/2" 80 32GX3/16" 80 EASY COMFORT PEN EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES NEEDLES31GX3/16" 79 SYRINGE/U-100/0.5ML/27G X 32GX5/32" 80 EASY COMFORT PEN 1/2" 80 EASY TOUCH PEN NEEDLES31GX5/16" 79 EASY TOUCH INSULIN NEEDLES/31G X 3/16" 80 EASY COMFORT PEN SYRINGE/U-100/0.5ML/28G X EASY TOUCH SHEATHLOCK NEEDLES32GX5/32" 79 1/2" 80 SAFETY INSULIN SYRINGE EASY GLIDE PEN NEEDLES EASY TOUCH INSULIN 1ML/29GX1/2" 80 33G X 5/32" 79 SYRINGE/U-100/0.5ML/30G X EASY TOUCH SHEATHLOCK EASY MINI EJECT LANCING 1/2" 80 SAFETY INSULIN SYRINGE DEVICE 64 EASY TOUCH INSULIN 1ML/30GX5/16" 80 EASY MINI LANCING SYRINGE/U-100/0.5ML/31G X EASY TOUCH SHEATHLOCK DEVICE 64 5/16" 80 SAFETY INSULIN SYRINGE EASY TOUCH 32GX5MM 79 EASY TOUCH INSULIN 1ML/31GX5/16" 80 EASY TOUCH 32GX6MM 79 SYRINGE/U-100/1ML/27G X 1/2" 80

Index 11 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN EQL COLOR LANCETS 21G65 SAFETY SYRINGE SYRINGE/U-100/1ML/29G X EQL COLOR LANCETS MICRO 1ML/30GX1/2" 80 1/2" 81 THIN 33G 65 EASYTEST II LANCETS 65 ELITE-THIN INSULIN EQL DRY MOUTH ORAL EASYTEST LANCETS 65 SYRINGE/U-100/1ML/31G X RINSE 113 5/16" 81 EBASE CONTROLLER KIT106 EQL GAUZE PADS ELIXOPHYLLIN 10 2"X2"/SMALL 59 EC-NAPROSYN 3 ELLA 36 EQL GAUZE PADS EC-NAPROXEN 3 ELMIRON 53 4"X4"/LARGE 59 econazole nitrate 40 EQL GAUZE STERILE PADS ELOCON 42 3"X3" 59 ECOTRIN MAXIMUM EQL INSULIN STRENGTH 5 EMOLLIA-LOTION 44 ECOTRIN REGULAR emollient 44 SYRINGE/0.3ML/29G X 1/2" 81 STRENGTH 5 EQL INSULIN EMTRIVA 29,30 SYRINGE/0.3ML/30G X EDARBI 23 EMVERM 7 5/16" 81 EDURANT 29 enalapril maleate 22 EQL INSULIN efavirenz 29 enalapril maleate & SYRINGE/0.3ML/31G X EFFEXOR XR 15 hydrochlorothiazide 24 5/16" 81 ENBREL 4 EQL INSULIN EFFIENT 53 SYRINGE/0.5ML/29G X 1/2" 81 EFLOW SCF AEROSOL ENBREL MINI 4 EQL INSULIN HEAD 106 ENBREL SURECLICK 4 SYRINGE/0.5ML/30G X EFUDEX 41 ENCARE 167 5/16" 81 ELAVIL 15 EQL INSULIN ENFAMIL ENFALYTE 110 SYRINGE/0.5ML/31G X ELDEPRYL 27 enoxaparin sodium 11 5/16" 81 eletriptan hydrobromide 109 EPANED 22 EQL INSULIN ELEXA NATURAL FEEL 61 EPIFOAM 42 SYRINGE/1ML/29G X 1/2" 81 ELEXA STIMULATING 61 EQL INSULIN EPILYT 44 SYRINGE/1ML/30G X 5/16" 81 ELEXA ULTRA SENSITIVE 61 epinephrine (anaphylaxis)168 EQL INSULIN ELIDEL 46 EPIPEN 2-PAK 168 SYRINGE/1ML/31G X 5/16" 81 ELIMITE 48 EPIVIR 30 EQL OMEPRAZOLE 164 ELIQUIS 10 EPROSARTAN EQL ONE DAILY MENS 116 ELIQUIS STARTER PACK 10 MESYLATE 23 EQL PRENATAL ELITE DC AUTO EPZICOM 30 FORMULA 150 ADAPTER 106 EQ COMPLETE EQL SUPER THIN LANCETS ELITE-THIN INSULIN MULTIVITAMINADULTS 30G 65 SYRINGE/0.3ML/31G X UNDER 50 116 EQL THIN LANCETS 26G 65 5/16" 80 EQ OMEPRAZOLE 164 EQL ULTRA MOISTURIZING ELITE-THIN INSULIN EQ ONE DAILY MENS DAILY LOTION 44 SYRINGE/0.5ML/29G X 1/2" 80 50+ 116 EQUALYTE 110 ELITE-THIN INSULIN EQ ONE DAILY MENS ergocalciferol 168 SYRINGE/0.5ML/30G X HEALTH 116 ERGOLOID MESYLATES 161 5/16" 80 EQ ONE DAILY WOMENS ELITE-THIN INSULIN 50+ 116 ergotamine w/ caffeine 108 SYRINGE/1ML/30G X 5/16" 80 EQ ONE DAILY WOMENS ERY-TAB 57 ELITE-THIN INSULIN HEALTH 116 ERYGEL 39 SYRINGE/U-100/0.5ML/28G X EQL ADVANCED RECOVERY ERYPED 200 57 1/2" 81 SKIN CARE 44 ELITE-THIN INSULIN EQL ALCOHOL SWABS 72 ERYPED 400 57 SYRINGE/U-100/0.5ML/31G X EQL CENTURY MATURE ERYTHROCIN STEARATE 57 5/16" 81 ELITE-THIN INSULIN ADULTS50+ 116 erythromycin (acne aid) 39 SYRINGE/U-100/1ML/28G X EQL CENTURY MENS 116 erythromycin (ophth) 156 1/2" 81 EQL CENTURY erythromycin base 57 WOMENS 116

Index 12 erythromycin ethylsuccinate 57 EXEL COMFORT POINT FELDENE 3 ERYTHROMYCIN INSULIN PEN NEEDLES 29G felodipine 33 X 12MM 81 ETHYLSUCCINATE 57 FEMARA 26 escitalopram oxalate 14 EXEL COMFORT POINT INSULIN PEN NEEDLES 31G FEMCON FE 35 ESGIC 4 X 6MM 81 FEMHRT LOW DOSE 51 esomeprazole magnesium 164 EXEL COMFORT POINT fenofibrate 21 ESTRACE 51,167 INSULIN PEN NEEDLES 31G FENOFIBRATE 21 estradiol 51 X 8MM 81 EXEL COMFORT POINT fenofibrate 21 estradiol & norethindrone INSULIN SYRINGE/0.3ML/29G fenofibrate micronized 21 acetate 51 X 1/2" 81 estradiol vaginal 167 EXEL COMFORT POINT fentanyl 5 ESTROFACTORS 146 INSULIN SYRINGE/0.3ML/30G FER-IN-SOL 54 ESTROPIPATE 51 X 5/16" 81 FERRETTS 54 EXEL COMFORT POINT ferrous fumarate 54 ESTROSTEP FE 35 INSULIN SYRINGE/0.5ML/28G ethambutol hcl 25 X 1/2" 81 ferrous fumarate-fa-b complex-c- zn-mg-mn-cu 54 ethosuximide 13 EXEL COMFORT POINT ferrous gluconate 54 ethynodiol diacet & eth INSULIN SYRINGE/0.5ML/29G estrad 35 X 1/2" 81 FERROUS GLUCONATE 54 etodolac 3 EXEL COMFORT POINT ferrous sulfate 54 INSULIN SYRINGE/0.5ML/30G EUCERIN 44 X 5/16" 81 FERROUS SULFATE 54 EUCERIN BABY 44 EXEL COMFORT POINT ferrous sulfate 54 EUCERIN DAILY INSULIN SYRINGE/1ML/28G X ferrous sulfate dried 54 PROTECTION/SPF 30 44 1/2" 81 fexofenadine hcl 20 EUCERIN INTENSIVE EXEL COMFORT POINT REPAIR 44 INSULIN SYRINGE/1ML/29G X FIBERCON 55 EUCERIN ORIGINAL 1/2" 81 FIFTY50 ALCOHOL PREP HEALINGSOOTHING EXEL COMFORT POINT PADS 72 REPAIR 44 INSULIN SYRINGE/1ML/30G X FIFTY50 PEN NEEDLES 31G EUCERIN PLUS 45 5/16" 81 X3/16" (5MM) 81 EXELON 160 FIFTY50 PEN NEEDLES 31G EUCERIN PROFESSIONAL X5/16" (8MM) 81 REPAIR RICH FEEL 45 exemestane 26 FIFTY50 PEN NEEDLES EUCERIN SMOOTHING EXFORGE 24 31GX5MM 81 REPAIRADVANCED EXFORGE HCT 24 FIFTY50 PEN FORMULA 45 NEEDLES/31GX8MM 82 EURAX 48 EXTRA SENSITIVE SPERMICIDAL 61 FIFTY50 PEN EVAC 55 EZ SMART BLOOD GLUCOSE NEEDLES/32GX4MM 82 EVISTA 51 LANCETS 65 FIFTY50 PEN NEEDLES/32GX6MM 82 EVOTAZ 30 EZ-LETS LANCETS 23G 65 FIFTY50 SUPERIOR EXCEL COMFORT POINT EZ-LETS LANCETS 26G COMFORTINSULIN INSULIN PEN NEEDLES 31G X SUPER-SOFT 65 SYRINGE/0.3ML/31G X 4MM 81 EZ-LETS LANCETS 28G 5/16" 82 EXCILON AMD ULTRA-SOFT 65 FIFTY50 SUPERIOR ANTIMICROBIALDRAIN EZ-LETS LANCETS 30G 65 COMFORTINSULIN SPONGES 4"X4" 6 PLY 59 famciclovir 32 SYRINGE/0.5ML/31G X EXCILON AMD famotidine 163 5/16" 82 ANTIMICROBIALNON-WOVEN FIFTY50 SUPERIOR SPONGES 4"X4" 6 PLY 59 FANTASY LUBRICATED 61 COMFORTINSULIN EXCILON DRAIN SPONGE FANTASY SYRINGE/1ML/31G X 5/16" 82 4"X4" 59 LUBRICATED/SPERMICIDE FILTER AIR PP 106 EXCILON DRAIN SPONGES 61 4"X4" 6 PLY 59 FARESTON 26 finasteride 53 EXCILON I.V. SPONGES 2"X2" 6 felbamate 12 FIORINAL 4 PLY 59 FELBATOL 12 FIORINAL/CODEINE #3 5

Index 13 FIRST-PROGESTERONE VGS FLURAZEPAM HCL 54 FREDS PHARMACY UNILET 100 COMPOUNDING KIT 167 flurbiprofen 3 LANCETS ULTRA THIN FIRST-PROGESTERONE VGS 28G 65 200 COMPOUNDING KIT 167 flurbiprofen sodium 157 FREEDAVITE 116 FIRVANQ 7 flutamide 26 FREESTYLE PRECISION FITNESS TABS FOR MEN fluticasone propionate 43 INSULIN SYRINGE/U- AM/PM/LYCOPENE 116 fluticasone propionate 100/0.5ML/30G X 5/16" 82 FITNESS TABS FOR WOMEN (nasal) 153 FREESTYLE PRECISION AM/PM/LYCOPENE 116 fluvoxamine maleate 14 INSULIN SYRINGE/U- FLAGYL 7 FLUZONE HIGH-DOSE PF 100/0.5ML/31G X 5/16" 82 flavoxate hcl 165 2016-2017 166 FREESTYLE PRECISION INSULIN SYRINGE/U- flecainide acetate 9 FLUZONE HIGH-DOSE PF 2017-2018 166 100/1ML/31G X 5/16" 82 FLEET ENEMA 56 FLUZONE HIGH-DOSE PF FREESTYLE PRECISION FLEET ENEMA SIX PACK 56 2018-2019 166 INSULIN SYRINGES/U- FLEET PEDIATRIC 56 FLUZONE QUADRIVALENT 100/1ML/30G X 5/16" 82 FULL KIT NEBULIZER FLEXICHAMBER 106 2016-2017 166 FLUZONE QUADRIVALENT SET 106 FLOMAX 53 2017-2018 166 FURADANTIN 165 FLONASE ALLERGY FLUZONE QUADRIVALENT furosemide 50 RELIEF 153 2018-2019 166 FUROSEMIDE 50 FLONASE ALLERGY RELIEF FML 157 CHILDRENS 153 furosemide 50 FML LIQUIFILM 157 FLORIVA PLUS 148 FUZEON 30 FOCALIN 1 FLOVENT DISKUS 10 gabapentin 11 folic acid 53,54 FLOVENT HFA 10 GABITRIL 12 FORA LANCETS 65 FLOXIN OTIC 158 galantamine hydrobromide 160 FLUARIX QUADRIVALENT FORA LANCING DEVICE 65 GALANTAMINE 2016-2017 166 FORA LANCING HYDROBROMIDE 160 FLUARIX QUADRIVALENT DEVICE/CLEARCAP 65 galantamine hydrobromide 160 formaldehyde 29 2017-2018 166 GAS-X 52 FLUARIX QUADRIVALENT FORMULA 405 2018-2019 166 MOISTURIZING 45 GAUZE DRESSING 4"X4" 59 fluconazole 19 FOSAMAX 50 GAUZE PADS 2"X2" 59 fludrocortisone acetate 37 fosamprenavir calcium 30 GAUZE PADS 3"X3" 59 FLULAVAL QUADRIVALENT FOSFREE 116 GAUZE PADS 4"X4" 59 2016-2017 166 fosinopril sodium 22 GAUZE PADS 4"X4" 12 PLY 59 FLULAVAL QUADRIVALENT GAUZE SPONGE TYPE VII 2017-2018 166 fosinopril sodium & hydrochlorothiazide 24 MEDI-PAK 2"X2" 8PLY 59 FLULAVAL QUADRIVALENT GAUZE SPONGES 4"X4" 12 2018-2019 166 FREDS PHARMACY AUTOLET LANCING PLY 59 FLUMIST QUADRIVALENT166 DEVICE 65 gemfibrozil 21 FLUNISOLIDE 153 FREDS PHARMACY UNIFINE GENERESS FE 35 fluocinolone acetonide PENTIPS PEN NEEDLES (otic) 158 32GX4MM 82 GENTAK 156 fluocinonide 42 FREDS PHARMACY UNIFINE gentamicin sulfate (ophth) 156 fluocinonide emulsified base 43 PENTIPS PLUS gentamicin sulfate (topical) 40 31GX5MM 82 fluorometholone (ophth) 156 GENTEEL LANCING FREDS PHARMACY UNIFINE DEVICE/BUFF BLACK 65 FLUOROURACIL 41 PENTIPS PLUS GENTEEL LANCING fluorouracil (topical) 41 31GX8MM 82 DEVICE/BUTTERFLY BLUE 65 fluoxetine hcl 14 FREDS PHARMACY UNILET GENTEEL LANCING LANCETS SUPER THIN DEVICE/GLORIOUS GOLD 65 fluphenazine decanoate 28 30G 65 GENTEEL LANCING fluphenazine hcl 28 DEVICE/PLAYFUL PURPLE 65 FLURA-DROPS 110

Index 14 GENTEEL LANCING GLOBAL INJECT EASE GLUCOPRO INSULIN DEVICE/PRECIOUS INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/30G X PLATINUM 65 100/0.5ML/28G X 1/2" 82 5/16" 83 GENTEEL LANCING GLOBAL INJECT EASE GLUCOPRO INSULIN DEVICE/PRINCESS PINK 65 INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/31G X GENTEEL LANCING 100/0.5ML/29G X 1/2" 82 5/16" 83 DEVICE/STATELY SILVER 65 GLOBAL INJECT EASE GLUCOPRO INSULIN GENTEEL LANCING INSULIN SYRINGE/U- SYRINGE/U-100/1ML/30G X DEVICE/WILLOWY WHITE 65 100/0.5ML/30G X 1/2" 82 1/2" 83 GENTLE-LET GP LANCETS 65 GLOBAL INJECT EASE GLUCOPRO INSULIN GENTLE-LET LANCETS INSULIN SYRINGE/U- SYRINGE/U-100/1ML/30G X GENERAL PURPOSE 100/0.5ML/30G X 5/16" 83 5/16" 83 STYLE/FINE POINT 65 GLOBAL INJECT EASE GLUCOPRO INSULIN GENTLE-LET LANCETS INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G X GENERAL PURPOSE 100/0.5ML/31G X 5/16" 83 5/16" 83 STYLE/MEDIUM POINT 65 GLOBAL INJECT EASE GLUCOSE 16 GENTLE-LET LANCETS INSULIN SYRINGE/U- GLUCOSOURCE LANCET SAFETY STYLE/FINE 100/1ML/28G X 1/2" 83 DEVICE 66 POINT 65 GLOBAL INJECT EASE GLUCOSOURCE LANCETS 66 INSULIN SYRINGE/U- GENTLE-LET LANCETS GLUCOTROL 18 SAFETY STYLE/MEDIUM 100/1ML/29G X 1/2" 83 POINT 66 GLOBAL INJECT EASE GLUCOTROL XL 18 GENVOYA 30 INSULIN SYRINGE/U- GLUCOVANCE 16 100/1ML/30G X 1/2" 83 GEODON 27 GLOBAL INJECT EASE glyburide 18 GERI-FREEDA SENIOR INSULIN SYRINGE/U- glyburide micronized 18 FORMULA 116 100/1ML/30G X 5/16" 83 glyburide-metformin 16 GILENYA 160 GLOBAL INJECT EASE glycerin (laxative) 55 INSULIN SYRINGE/U- glatiramer acetate 160 GLYCERIN ADULT 55 glimepiride 18 100/1ML/31G X 5/16" 83 GLOBAL INSULIN glycopyrrolate 163 glipizide 18 SYRINGE/U-100/0.3ML/30G X GLYNASE 18 glipizide-metformin hcl 16 1/2" 83 GNP ADVANCED GLOBAL EASE INJECT PEN GLOBAL INSULIN RECOVERY 45 NEEDLES 29GX12MM 82 SYRINGES/U- GNP ALCOHOL SWABS 72 GLOBAL EASE INJECT PEN 100/0.3ML/30GX5/16" 83 GLOBAL LANCING GNP CLICKFINE PEN NEEDLES 31GX8MM 82 NEEDLEUNIVERSAL/31GX5/16" GLOBAL EASE INJECT PEN DEVICE 66 GLUCAGEN 83 NEEDLES 32GX4MM 82 GNP CLICKFINE UNIVERSAL GLOBAL EASE INJECT PEN DIAGNOSTIC 49 PEN NEEDLES 31GX1/4" 83 NEEEDLES 31GX5MM 82 GLUCAGEN HYPOKIT 16 GNP CLICKFINE UNIVERSAL GLOBAL EASY GLIDE GLUCAGON EMERGENCY PEN NEEDLES 31GX5/16" 83 INSULINSYRINGE/U- KIT 16 GNP GLUCOSE 16 100/0.3ML/31G X 5/16" 82 GLUCOPHAGE 16 GLOBAL EASY GLIDE PEN GNP INSULIN NEEDLES 32GX4MM 82 GLUCOPHAGE XR 16 SYRINGE/0.3ML/29G X 1/2" 83 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP INSULIN SYRINGE/U-100/0.3ML/29G X SYRINGE/U-100/0.3ML/30G X SYRINGE/0.3ML/30G X 1/2" 82 1/2" 83 5/16" 83 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP INSULIN SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/0.3ML/30G X SYRINGE/0.3ML/31G X 1/2" 82 5/16" 83 5/16" 83 GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP INSULIN SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/0.3ML/31G X SYRINGE/0.5ML/28G X 1/2" 83 5/16" 82 5/16" 83 GNP INSULIN GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN SYRINGE/0.5ML/29G X 1/2" 83 SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/0.5ML/30G X GNP INSULIN 5/16" 82 1/2" 83 SYRINGE/0.5ML/30G X 5/16" 84

Index 15 GNP INSULIN GNP ULTRA COMFORT GOODSENSE PEN SYRINGE/0.5ML/31G X INSULIN SYRINGE/1ML/30G X NEEDLE/PENFINE 5/16" 84 5/16" SHORT 84 CLASSIC/31G X 5/16" 84 GNP INSULIN GNP ULTRA COMFORT GOODSENSE PEN SYRINGE/1ML/28G X 1/2" 84 INSULIN SYRINGE/1ML/31G X NEEDLE/PENFINE GNP INSULIN 5/16" SHORT 84 CLASSIC/32G X 1/4" 84 SYRINGE/1ML/29G X 1/2" 84 GOLD BOND MEDICATED GOODSENSE PEN GNP INSULIN BODYLOTION 45 NEEDLE/PENFINE SYRINGE/1ML/30G X 5/16" 84 GOLD BOND MEDICATED CLASSIC/32G X 5/32" 84 GNP INSULIN BODYLOTION EXTRA GOODSENSE PRENATAL SYRINGE/1ML/31G X 5/16" 84 STRENGTH 45 VITAMINS 150 GNP LANCETS 66 GOLD BOND ULTIMATE 45 GRIS-PEG 19 GNP LANCETS 21G 66 GOLD BOND ULTIMATE griseofulvin microsize 19 GNP LANCETS MICRO THIN DIABETICS DRY SKIN griseofulvin ultramicrosize 19 33G 66 RELIEF 45 GNP LANCETS SUPER THIN GOLD BOND ULTIMATE GRX VITAMIN E 45 30G 66 DIABETICS' DRY RELIEF 45 guaifenesin 39 GNP LANCETS THIN 66 GOLD BOND ULTIMATE guanfacine hcl 23 HEALING 45 GNP LANCETS THIN 26G 66 GOLD BOND ULTIMATE guanfacine hcl (adhd) 1 GNP MICRO THIN LANCETS OVERNIGHT 45 GYNAZOLE-1 167 33G 66 GOLD BOND ULTIMATE GYNE-LOTRIMIN 167 GNP OMEPRAZOLE 164 PROTECTION 45 GYNE-LOTRIMIN 3 167 GOLD BOND ULTIMATE GNP PRENATAL 150 H-E-B IN CONTROL PEN GNP QUICK DISSOLVE RESTORING 45 GOLD BOND ULTIMATE NEEDLES 31GX5MM 84 GLUCOSE 16 H-E-B IN CONTROL PEN GNP STERILE PADS 3"X3" 59 SHEERRIBBONS PEARLRADIANCE 45 NEEDLES 31GX6MM 84 GNP SUPER THIN GOLD BOND ULTIMATE H-E-B IN CONTROL PEN LANCETS/30G 66 NEEDLES 31GX8MM 84 SHEERRIBBONS H-E-B IN CONTROL PEN GNP ULTRA COMFORT SILKSOFTNESS 45 INSULIN SYRINGE/0.3ML/29G X GOLD BOND ULTIMATE NEEDLES/NANO/32GX4MM 1/2" 84 SOFTENING 45 84 GNP ULTRA COMFORT GOLD BOND ULTIMATE H-E-B IN CONTROL INSULIN SYRINGE/0.3ML/30G X SOOTHING 45 UNIFINEPENTIPS PLUS 5/16" SHORT 84 31GX5MM 85 GNP ULTRA COMFORT GOLYTELY 55 H-E-B IN CONTROL INSULIN SYRINGE/0.3ML/31G X GOODSENSE CLICKFINE UNIFINEPENTIPS PLUS 5/16" SHORT 84 SAFETY PEN NEEDLE/31G X 32GX4MM 85 GNP ULTRA COMFORT 3/16" 84 H-E-B INCONTROL INSULIN SYRINGE/0.5ML/28G X GOODSENSE COLOR ADVANCEDLANCING 1/2" 84 LANCETS MICRO-THIN 33G DEVICE 66 GNP ULTRA COMFORT UNIVERSAL 66 H-E-B INCONTROL ALCOHOL INSULIN SYRINGE/0.5ML/29G X GOODSENSE LANCETS PADS 72 1/2" 84 MICRO-THIN 33G H-E-B INCONTROL LANCETS GNP ULTRA COMFORT UNIVERSAL 66 MICRO THIN 33G 66 INSULIN SYRINGE/0.5ML/30G X GOODSENSE LANCETS H-E-B INCONTROL LANCETS 5/16" SHORT 84 ULTRA-THIN 26G SUPER THIN 30G 66 GNP ULTRA COMFORT UNIVERSAL 66 H-E-B INCONTROL LANCETS INSULIN SYRINGE/0.5ML/31G X GOODSENSE LANCETS ULTRA THIN 28G 66 5/16" SHORT 84 ULTRA-THIN 30G H-E-B INCONTROL PEN GNP ULTRA COMFORT UNIVERSAL 66 NEEDLES 29GX12MM 85 INSULIN SYRINGE/1ML/28G X GOODSENSE LANCING HAIR SKIN & NAILS ADVANCED 1/2" 84 DEVICE 66 FORMULA 116 GNP ULTRA COMFORT GOODSENSE PEN HAIR-VITES 116 INSULIN SYRINGE/1ML/29G X NEEDLE/PENFINE CLASSIC/31G X 3/16" 84 HALCION 54 1/2" 84 HALDOL DECANOATE 100 28 HALDOL DECANOATE 50 28

Index 16 haloperidol 28 HEALTHY ACCENTS UNIFINE HUMALOG MIX 75/25 haloperidol decanoate 28 PENTIPS PEN NEEDLES KWIKPEN 17 31GX8MM 85 HUMIRA 2 haloperidol lactate 28 HEALTHY ACCENTS UNIFINE HUMIRA PEDIATRIC CROHNS HEAD & SHOULDERS 2IN1 PENTIPS PEN NEEDLES DISEASE STARTER PACK 2 CLASSIC CLEAN/NORMAL 41 32GX4MM 85 HUMIRA PEN 2 HEAD & SHOULDERS HEALTHY ACCENTS UNILET CLASSICCLEAN/NORMAL 41 HUMIRA PEN-CD/UC/HS LANCETS SUPER THIN STARTER 2 HEAD & SHOULDERS DRY 30G 66 SCALP 2 IN 1 41 HUMIRA PEN-PS/UV HEALTHY LIVING 2 HEALTH CARE LANCING REPLACEMENT STARTER DEVICE 66 FILTERS 106 HUMULIN 70/30 17 HEALTHWISE INSULIN HEALTHY LIVING HUMULIN 70/30 KWIKPEN 17 SYRINGE/U-100/0.3ML/30G X REPLACEMENT KIT FOR HUMULIN N 17 5/16" 85 NEBULIZER 106 HUMULIN N KWIKPEN 17 HEALTHWISE INSULIN HEALTHY LIVING SYRINGE/U-100/0.3ML/31G X REPLACEMENT MASKS 106 HUMULIN R 17 5/16" 85 HEMANGEOL 33 HUMULIN R U-500 HEALTHWISE INSULIN (CONCENTRATED) 17 HEMOCYTE 54 SYRINGE/U-100/0.5ML/30G X HY-VEE LANCETS 66 heparin sodium (porcine) 11 5/16" 85 HY-VEE THIN LANCETS 66 HEALTHWISE INSULIN HIBICLENS 29 HYALEX 116 SYRINGE/U-100/0.5ML/31G X HIGH SENSATION 5/16" 85 SPERMICIDAL 61 hydralazine hcl 25 HEALTHWISE INSULIN HM COMPLETE 116 HYDRALYTE 110 SYRINGE/U-100/1ML/30G X HM COMPLETE 50+ MENS HYDRALYTE FREEZER 5/16" 85 POPS 110 HEALTHWISE INSULIN ULTIMATE 116 SYRINGE/U-100/1ML/31G X HM COMPLETE 50+ HYDRAZONE LOTION 45 5/16" 85 WOMENS ULTIMATE 116 HYDREA 26 HEALTHWISE LANCING HM COMPLETE MEN 116 HYDROCELL ADHESIVE PEN 66 HM HAIR/SKIN/NAILS 116 DRESSING 4"X4" 59 HEALTHWISE MICRON PEN HM OMEPRAZOLE 164 HYDROCELL DRESSING NEEDLES/32G X 5/32" 85 4"X4" 59 HM ONE DAILY MENS 116 HEALTHWISE MINI PEN hydrochlorothiazide 50 HM ONE DAILY NEEDLES 31GX6MM 85 hydrocodone-acetaminophen 6 HEALTHWISE PEN NEEDLES WOMENS 116 29GX12MM 85 HM PRENATAL 150 hydrocortisone 37 HEALTHWISE SHORT PEN HM STERILE ALCOHOL PREP hydrocortisone (intrarectal) 6 NEEDLES 31GX8MM 85 PADS 72 hydrocortisone (rectal) 7 HEALTHWISE SHORT PEN HM STERILE PADS 59 hydrocortisone (topical) 43 NEEDLES/31G X 3/16" 85 HM STERILE PADS 2"X2" 59 HEALTHWISE SHORT PEN hydrocortisone butyrate 43 NEEDLES/31G X 5/16" 85 HM ULTICARE INSULIN hydrocortisone w/acetic HEALTHWISE UNIFINE SYRINGE/1ML/30G X 1/2" 85 acid 158 PENTIPS PEN NEEDLES HM ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X hydrocortisone-aloe vera 43 32GX4MM 85 HYDROMORPHONE HCL 5 HEALTHY ACCENTS AUTOLET 5/16" 85 IMPRESSION LANCING HM ULTICARE SHORT PEN hydromorphone hcl 5 DEVICE 66 NEEDLES 31GX8MM 85 hydroquinone 48 homatropine hbr 155 HEALTHY ACCENTS UNIFINE hydroxychloroquine sulfate 25 PENTIPS PEN NEEDLES HUDSON RCI SEE-THRU AEROSOL MASK hydroxyprogesterone 29GX12MM 85 caproate 159 HEALTHY ACCENTS UNIFINE ELONGATED/ADULT 106 PENTIPS PEN NEEDLES HUMALOG MIX 50/50 17 hydroxyurea 26 31GX5MM 85 HUMALOG MIX 50/50 hydroxyzine hcl 8 HEALTHY ACCENTS UNIFINE KWIKPEN 17 HYDROXYZINE PAMOATE 8 PENTIPS PEN NEEDLES HUMALOG MIX 75/25 17 hydroxyzine pamoate 8 31GX6MM 85

Index 17 hyoscyamine sulfate 163 INSULIN SYRINGE/0.5ML/28G INSULIN HYPERRHO S/D 158 X 1/2" 86 SYRINGES/0.5ML/31GX5/16" INSULIN SYRINGE/0.5ML/30G 86 HYPOTEARS 155 X 1/2" 86 INSULIN HYZAAR 24 INSULIN SYRINGE/0.5ML/30G SYRINGES/1ML/27GX/1/2" 86 ibuprofen 3 X 5/16" 86 INSULIN INSULIN SYRINGE/0.5ML/31G SYRINGES/1ML/27GX1/2" 86 ICAPS AREDS FORMULA 116 X 5/16" 86 INSULIN ICAPS PLUS 116 INSULIN SYRINGE/1ML/28G X SYRINGES/1ML/28GX1/2" 86 IGLUCOSE BLOOD GLUCOSE 1/2" 86 INSULIN TEST STRIPS 49 INSULIN SYRINGE/1ML/29G X SYRINGES/1ML/29GX1/2" 87 imipramine hcl 15 1/2" 86 INSULIN imiquimod 46 INSULIN SYRINGE/1ML/30G X SYRINGES/1ML/30GX1/2" 87 5/16" 86 INSULIN IMITREX 109 INSULIN SYRINGE/NEEDLE SYRINGES/1ML/31GX5/16" 87 IMITREX STATDOSE 0.3ML/30G X 5/16" 86 INSUPEN 29G X 12MM 87 REFILL 109 INSULIN SYRINGE/NEEDLE INSUPEN 31G X 5MM 87 IMITREX STATDOSE 0.3ML/31G X 5/16" 86 SYSTEM 109 INSULIN SYRINGE/NEEDLE INSUPEN 31G X 8MM 87 IMODIUM A-D 18 0.5ML/29G X 1/2" 86 INSUPEN 32G X 4MM 87 IMURAN 111 INSULIN SYRINGE/NEEDLE INSUPEN 33GX4MM 87 IN TOUCH LANCING 0.5ML/30G X 5/16" 86 INSUPEN PEN NEEDLES 32G INSULIN SYRINGE/NEEDLE DEVICE 66 X4MM 87 0.5ML/31G X 5/16" 86 INSUPEN SENSITIVE INATAL GT 150 INSULIN SYRINGE/NEEDLE INCRUSE ELLIPTA 9 32GX6MM 87 1ML/29G X 1/2" 86 INSUPEN SENSITIVE INSULIN SYRINGE/NEEDLE indapamide 50 32GX8MM 87 1ML/30G X 5/16" 86 INSUPEN ULTRAFIN INDERAL LA 33 INSULIN SYRINGE/NEEDLE indomethacin 3 29GX12MM 87 1ML/31G X 5/16" 86 INSUPEN ULTRAFIN INSULIN SYRINGE/U- INFANTS ADVIL 3 30GX8MM 87 INNOSPIRE REPLACEMENT 100/0.3ML/29G X 1/2" 86 INSUPEN ULTRAFIN INSULIN SYRINGE/U- FILTER 106 31GX6MM 87 INSPIRACHAMBER/ANTI- 100/0.5ML/28G X 1/2" 86 INSUPEN ULTRAFIN INSULIN SYRINGE/U- STATIC 31GX8MM 87 100/0.5ML/29G X 1/2" 86 VALVED/MOUTHPIECE 106 INTELENCE 30 INSPIRACHAMBER/LARGE INSULIN SYRINGE/U- 106 100/1ML/28G X 1/2" 86 INTENSE SENSATION 61 INSPIRACHAMBER/SOOTHER INSULIN SYRINGE/U- INTUNIV 1 MASK/INSPIRAMASK/MEDIUM 100/1ML/29G X 1/2" 86 INVIRASE 30 106 INSULIN SYRINGE/U- INSPIRACHAMBER/SOOTHER 100/1ML/30G X 5/16" 86 IOPIDINE 155 MASK/INSPIRAMASK/SMALL INSULIN SYRINGE/U- ipratropium bromide 9 106 100/1ML/31G X 5/16" 86 ipratropium bromide (nasal)153 INSULIN INSPIREASE DRUG ipratropium-albuterol 10 DELIVERYSYSTEM 106 SYRINGES/0.5ML/27GX1/2" INSPIREASE RESERVOIR 86 irbesartan 23 BAGS 106 INSULIN irbesartan-hydrochlorothiazide INSULIN SYRINGE/0.3ML/29G X SYRINGES/0.5ML/28GX1/2" 24 1" 85 86 IRON CHEWS PEDIATRIC 54 INSULIN SYRINGE/0.3ML/29G X INSULIN ISENTRESS 30 1/2" 85 SYRINGES/0.5ML/29GX1/2" INSULIN SYRINGE/0.3ML/30G X 86 ISONIAZID 25 5/16" 85 INSULIN isoniazid 25 INSULIN SYRINGE/0.3ML/31G X SYRINGES/0.5ML/30GX5/16" ISOPTO ATROPINE 155 86 5/16" 85 ISOPTO CARPINE 155 INSULIN SYRINGE/0.5ML/27G X INSULIN 1/2" 86 SYRINGES/0.5ML/31GX ISORDIL TITRADOSE 8 5/16" 86 ISOSORBIDE DINITRATE 8

Index 18 isosorbide dinitrate 8 KERI OVERNIGHT 45 KINRAY INSULIN SYRINGE ISOSORBIDE DINITRATE ER8 KERI RENEWAL MILK PREFERRED PLUS/1ML/31G X 5/16" 87 isosorbide mononitrate 8 BODY 45 KERI RENEWAL SKIN KINRAY INSULIN isotretinoin 39 FIRMING 45 SYRINGE/0.5ML/29G X 1/2" 87 ITCH RELIEF 41 KERI RENEWAL STRETCH KITABIS PAK 2 itraconazole 19 MARK MINIMIZER 45 KLARON 39 J & J GAUZE 2"X2" 8 PLY 59 KERI SENSITIVE SKIN 45 KLONOPIN 11 KERLIX SPONGES 4" X 4" 12 KLOR-CON M15 111 J & J GAUZE 4"X4" 12 PLY 60 PLY 60 J & J GAUZE 4"X4" 8 PLY 60 KERLIX SPONGES 4" X 4" 16 KLOR-CON/25 111 J & J GAUZE SPONGES 12-PLY PLY 60 KLOUT 48 4" X 4" 60 KETOCARE 49 KLS OMEPRAZOLE 164 J & J GAUZE SPONGES 16-PLY ketoconazole (topical) 40 KMART VALU PLUS INSULIN 4" X 4" 60 KETONE TEST STRIPS 49 SYRINGE/1ML/29G 87 J & J GAUZE SPONGES 8- KMART VALU PLUS INSULIN PLY4" X 4" 60 ketoprofen 3 SYRINGE/1ML/30G 87 JADENU 18 KETOPROFEN 3 KONSYL DAILY FIBER 55 JARDIANCE 18 KETOPROFEN ER 3 KONSYL ORIGINAL JENTADUETO 16 ketorolac tromethamine 3 FORMULADAILY FIBER 55 JULUCA 30 ketorolac tromethamine KP PRENATAL MULTIVITAMINS 150 JYNARQUE 51 (ophth) 157 KPN PRENATAL 150 K-PAX IMMUNE SUPPORT KETOSTIX 49 FORMULA PROFESSIONAL ketotifen fumarate (ophth)157 KROGER INSULIN STRENGTH 116 SYRINGE/0.3ML/29G X 1/2" 87 KEY-E 168 KROGER INSULIN K-PHOS NEUTRAL 110 KIMONO COLORS 61 SYRINGE/0.3ML/30G X K-TAB 111 KIMONO LUBRICATED 61 5/16" 87 KROGER INSULIN KALETRA 30 KIMONO MICRO THIN 61 KALYDECO 162 SYRINGE/0.3ML/31G X KIMONO MICRO THIN PLUS 5/16" 87 KAMELEON LUBRICATED 61 SPERMICIDE KROGER INSULIN KAPVAY 1 LUBRICATED 61 SYRINGE/0.5ML/29G X 1/2" 87 KIMONO PLUS SPERMICIDE KAYEXALATE 112 KROGER INSULIN LUBRICATED 61 SYRINGE/0.5ML/30G X KEFLEX 34 KIMONO PLUS 5/16" 87 KENDALL HYDROPHILIC SPERMICIDE/LUBRICATED KROGER INSULIN FOAMDRESSING 2"X2" 60 61 SYRINGE/0.5ML/31G X KENDALL HYDROPHILIC KIMONO PS 5/16" 87 FOAMDRESSING 3"X3" 60 LUBRICATED 61 KROGER INSULIN KENDALL HYDROPHILIC KIMONO PS PLUS SYRINGE/1ML/29G X 1/2" 87 FOAMDRESSING 4"X4" 60 SPERMICIDE/LUBRICATED KROGER INSULIN KENDALL HYDROPHILIC 61 SYRINGE/1ML/30G X 5/16" 87 FOAMPLUS DRESSING KIMONO SENSATION KROGER INSULIN 2"X2" 60 LUBRICATED 62 SYRINGE/1ML/31G X 5/16" 87 KENDALL HYDROPHILIC KIMONO SENSATION PLUS KROGER LANCETS 66 FOAMPLUS DRESSING SPERMICIDE 3"X3" 60 LUBRICATED 62 KROGER LANCETS 21G 66 KEPPRA 11 KIMONO SPECIAL 62 KROGER LANCETS MICRO THIN33G 66 KEPPRA XR 11 KINNEY LANCETS 66 KROGER LANCETS SUPER KERALYT 47 KINNEY THIN LANCETS 66 THIN 67 KERI ADVANCED MOISTURE KINRAY INSULIN SYRINGE KROGER LANCETS THIN 67 THERAPY 45 PREFERRED KROGER LANCETS THIN KERI BASIC ESSENTIALS 45 PLUS/0.3ML/31G X 5/16" 87 26G 67 KERI NOURISHING SHEA KINRAY INSULIN SYRINGE KROGER LANCETS BUTTER 45 PREFERRED ULTRATHIN30G 67 KERI ORIGINAL 45 PLUS/0.5ML/31G X 5/16" 87

Index 19 KROGER LANCING LASIX 50 LEUKERAN 26 DEVICE 67 LATANOPROST 158 LEVAQUIN 52 KROGER PEN NEEDLES 29G X12MM 87 latanoprost 158 LEVBID 163 KROGER PEN NEEDLES 31G LATUDA 27 levetiracetam 12 X8MM 87 LEADER ADVANCED levobunolol hcl 155 KROGER PEN NEEDLES LANCING DEVICE 67 levocarnitine (metabolic 31GX1/4" 87 LEADER INSULIN modifiers) 51 KYLEENA 36 SYRINGE/0.3ML/29G X levocetirizine dihydrochloride20 labetalol hcl 32 1/2" 87 LEADER INSULIN levofloxacin 52 LAC-HYDRIN 45 SYRINGE/0.3ML/30G X levonorgestrel & eth LAC-HYDRIN TWELVE 45 5/16" 88 estradiol 35 lactic acid (ammonium LEADER INSULIN levonorgestrel (emergency lactate) 45 SYRINGE/0.3ML/31G X oc) 36 lactulose 55 5/16" 88 levonorgestrel-eth estradiol (triphasic) 35 lactulose (encephalopathy) 52 LEADER INSULIN SYRINGE/0.5ML/28G X levonorgestrel-ethinyl estradiol LAMICTAL 11 1/2" 88 (91-day) 35 LAMICTAL CHEWABLE LEADER INSULIN levothyroxine sodium 162 DISPERSIBLE 11 SYRINGE/0.5ML/29G X LEVSIN 163 LAMICTAL XR 12 1/2" 88 LEXAPRO 14 LAMISIL 19 LEADER INSULIN LEXIVA 30 LAMISIL AT 40 SYRINGE/0.5ML/30G X 5/16" 88 LIALDA 52 LAMISIL AT JOCK ITCH 40 LEADER INSULIN LIBERTY MINI LANCING lamivudine 30 SYRINGE/0.5ML/31G X DEVICE 67 lamivudine-zidovudine 30 5/16" 88 LICEMD 48 LEADER INSULIN lamotrigine 12 SYRINGE/1ML/28G X 1/2" 88 LICIDE TREATMENT KIT 48 LANCET DEVICE LEADER INSULIN lidocaine 47 ADJUSTABLE 67 SYRINGE/1ML/29G X 1/2" 88 lidocaine hcl 47 LANCET DEVICE WITH LEADER INSULIN lidocaine hcl (mouth-throat) 112 EJECTOR 67 SYRINGE/1ML/30G X LANCETS 67 5/16" 88 lidocaine-prilocaine 47 LANCETS 26G TWIST TOP 67 LEADER INSULIN LIDODERM 47 LANCETS 28G 67 SYRINGE/1ML/31G X LILETTA 36 5/16" 88 LANCETS 30G 67 LEADER QUICK DISSOLVE liothyronine sodium 162 LANCETS SAFETY SEAL GLUCOSE 16 LIPITOR 21 21G 67 LEADER UNIFINE PENTIPS lisinopril 22 LANCETS SAFETY SEAL PLUS/MINI/31GX3/16" 88 lisinopril & 26G 67 LEADER UNIFINE PENTIPS hydrochlorothiazide 24 LANCETS SAFETY SEAL PLUS/SHORT/31GX5/16" 88 LITE TOUCH LANCING 28G 67 LEADER UNIFINE PEN 67 LANCETS SUPER THIN PENTIPS/MINI/31GX3/16" LITEAIRE 106 28G 67 88 LANCETS THIN 67 LITETOUCH INSULIN PEN LEADER UNIFINE NEEDLES/32G X 4MM/MINI 88 LANCETS ULTRA THIN 67 PENTIPS/NANO/32GX5/32" LITETOUCH INSULIN LANCING DEVICE 67 88 SYRINGE/0.3ML/29G X 1/2" 88 LEADER UNIFINE LANCING DEVICE LITETOUCH INSULIN PENTIPS/PLUS/32GX5/32" SYRINGE/0.3ML/30G X ADJUSTABLE 67 88 lanolin 159 5/16" 88 leflunomide 3 LITETOUCH INSULIN lanolin (topical) 47 letrozole 26 SYRINGE/0.3ML/31G X LANOXIN 34 LEUCOVORIN CALCIUM 26 5/16" 88 lansoprazole 164 leucovorin calcium 26 LANZO 67

Index 20 LITETOUCH INSULIN LITHIUM 27 loxapine succinate 28 SYRINGE/0.5ML/30G X lithium carbonate 27 LUBRIDERM 46 5/16" 88 LITETOUCH INSULIN LITHIUM CARBONATE 27 LUBRIDERM ADVANCED lithium carbonate 27 THERAPY 45 SYRINGE/0.5ML/31G X LUBRIDERM DAILY 5/16" 88 LITHOBID 27 MOISTURE/NORMAL TO DRY LITETOUCH INSULIN LIVE BETTER ADVANCED 88 SKIN 45 SYRINGE/1ML/30G X 5/16" LANCING DEVICE 67 LUBRIDERM DAILY LITETOUCH INSULIN LIVE BETTER LANCET SYRINGE/U-100/0.3ML/30G X MOISTURESHEA + CALMING SUPERTHIN 30G 67 LAVENDER JASMINE 45 5/16" 88 LIVE BETTER LANCET LITETOUCH INSULIN LUBRIDERM INTENSE SKIN ULTRATHIN 28G 67 REPAIR 45 SYRINGE/U-100/0.3ML/31G X LMX 4 47 5/16" 88 LUBRIDERM MENS 3-IN-1 46 LITETOUCH INSULIN LOCOID 43 LUBRIDERM SERIOUSLY SYRINGE/U-100/0.5ML/28G X LODINE 3 SENSITIVE 46 LUBRIDERM SKIN 1/2" 88 LODOSYN 26 LITETOUCH INSULIN NOURISHINGWITH SHEA AND SYRINGE/U-100/0.5ML/29G X LOESTRIN 1.5/30-21 35 COCOA BUTTERS 46 1/2" 88 LOESTRIN 1/20-21 35 LUBRISOFT 46 LITETOUCH INSULIN LOESTRIN FE 1.5/30 35 LURIDE 110 SYRINGE/U-100/0.5ML/30G X LOESTRIN FE 1/20 35 LYSTEDA 54 5/16" 88 LITETOUCH INSULIN LOFIBRA 21 M-NATAL PLUS 150 SYRINGE/U-100/0.5ML/31G X LOHIST-D 38 M-VIT 150 5/16" 88 LOMOTIL 18 MACROBID 165 LITETOUCH INSULIN LONGS INSULIN SYRINGE/U-100/1ML/28G X MACRODANTIN 165 SYRINGE/0.5ML/31G X MACULAR VITAMIN 1/2" 88 5/16" 89 LITETOUCH INSULIN BENEFIT 116 LONGS LANCETS MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X STANDARD 67 1/2" 89 SYRINGE/U-100/0.3ML/29G X LITETOUCH INSULIN LONGS LANCETS THIN 67 1/2" 89 SYRINGE/U-100/1ML/30G X loperamide hcl 18 MAGELLAN INSULIN SAFETY 5/16" 89 LOPID 21 SYRINGE/U-100/0.3ML/30G X 5/16" 89 LITETOUCH INSULIN lopinavir-ritonavir 30 SYRINGE/U-100/1ML/31G X MAGELLAN INSULIN SAFETY 5/16" 89 LOPRESSOR 32 SYRINGE/U-100/0.5ML/29G X LITETOUCH MASK LOPRESSOR HCT 24 1/2" 89 LARGE 106 loratadine 20 MAGELLAN INSULIN SAFETY LITETOUCH MASK SYRINGE/U-100/0.5ML/30G X loratadine & 5/16" 89 MEDIUM 106 pseudoephedrine 38 LITETOUCH MASK SMALL106 MAGELLAN INSULIN SAFETY lorazepam 9 SYRINGE/U-100/1ML/29G X LITETOUCH PEN NEEDLES losartan potassium 23 1/2" 89 29GX12.7MM 89 losartan potassium & MAGELLAN INSULIN SAFETY LITETOUCH PEN NEEDLES SYRINGE/U-100/1ML/30G X 31G X 6MM 89 hydrochlorothiazide 24 LITETOUCH PEN NEEDLES LOTENSIN 22 5/16" 89 31G X 6MM/ULTRA SHORT 89 LOTENSIN HCT 24 MAGNESIUM 110 LITETOUCH PEN NEEDLES LOTREL 24 magnesium citrate 56 31GX8MM SHORT 89 magnesium hydroxide 56 LITETOUCH PEN LOTRIMIN AF 40 NEEDLES/31G X 3/16" 89 LOTRIMIN AF FOR HER 40 magnesium oxide 7 LITETOUCH PEN LOTRIMIN AF JOCK ITCH 41 MAGNESIUM OXIDE 110 NEEDLES/31G X 5MM/MINI 89 magnesium oxide (mg LITETOUCH PEN LOTRISONE 41 supplement) 110 NEEDLES/31G X lovastatin 21 MAGOX 400 110 8MM/SHORT 89 LOVENOX 11 MAKENA 159

Index 21 malathion 48 MEGA MULTIVITAMIN FOR methadone hcl 5 MAPROTILINE HCL 13 MEN 116 methazolamide 49 MEGA MULTIVITAMIN FOR MARATHON MEDICAL WOMEN 116 methenamine mandelate 165 PENTIPS29GX12MM 89 MEGAVITE FRUITS & METHENAMINE MARATHON MEDICAL VEGGIES 116 MANDELATE 165 PENTIPS31GX5MM 89 MEGAVITE GOLDEN YEARS methenamine-hyosc-methylene MARATHON MEDICAL 55+ 116 blue-sod phos-phenyl sal 165 PENTIPS31GX8MM 89 methimazole 162 MARATHON MEDICAL megestrol acetate 26 PENTIPS32GX4MM 89 MEIJER ALCOHOL SWABS METHITEST 6 MAVYRET 32 EXTRA-THICK 72 methocarbamol 153 MEIJER COLOR LANCETS MAXALT 109 UNIVERSAL 33G 67 METHOTREXATE 2 MAXALT-MLT 109 MEIJER LANCETS 67 methotrexate sodium 26 MAXAM 46 MEIJER LANCETS THIN 67 METHOTREXATE SODIUM 26 MAXI-COMFORT INSULIN MEIJER LANCETS methotrexate sodium 26 SYRINGE/U- UNIVERSAL21G 67 methyldopa 23 100/0.5ML/28GX1/2" 89 MEIJER LANCETS methylergonovine maleate 158 MAXI-COMFORT INSULIN UNIVERSAL30G 67 SYRINGE/U-100/1ML/28GX1/2" MEIJER LANCETS methylphenidate hcl 2 89 UNIVERSAL33G 68 METHYLPHENIDATE MAXITROL 157 MEIJER PEN NEEDLES 29G HYDROCHLORIDE ER 2 MAXX LUBRICATED 62 X12MM 89 methylprednisolone 37 MEIJER PEN NEEDLES 31G MAXX PLUS SPERMICIDE METIPRANOLOL 155 X6MM 89 LUBRICATED 62 MEIJER PEN NEEDLES 31G metoclopramide hcl 52 MAXZIDE 49 X8MM 89 metolazone 50 MAXZIDE-25 50 MEIJER SUPER THIN metoprolol & meclizine hcl 19 LANCETS 68 hydrochlorothiazide 24 MEDERMA AG HAND & BODY melatonin 2 metoprolol succinate 32,33 LOTION 46 meloxicam 3 METOPROLOL SUCCINATE MEDIC INSULIN melphalan 26 ER/HYDROCHLOROTHIAZIDE SYRINGE/0.3ML/30G X 24 160 5/16" 89 memantine hcl metoprolol tartrate 33 MEDIC INSULIN MENACTRA 165 METOPROLOL/HYDROCHLOR SYRINGE/0.5ML/30G X MENS 50+ MULTI VITAMIN OTHIAZIDE 24 5/16" 89 &MINERAL FORMULA 117 METROCREAM 48 MEDICINE SHOPPE PEN MENS MULTI VITAMIN & NEEDLES 29G X 12MM 89 MINERAL FORMULA 117 METROGEL-VAGINAL 167 MEDICINE SHOPPE PEN MENVEO 165 METROLOTION 48 NEEDLES 31G X 6MM 89 MEPERIDINE HCL 5 metronidazole 7 MEDICINE SHOPPE PEN NEEDLES 31G X 8MM 89 meperidine hcl 5 metronidazole (topical) 48 MEDISENSE THIN MEPHYTON 168 metronidazole vaginal 167 LANCETS 67 meprobamate 8 MEVACOR 21 MEDROL 37 mercaptopurine 26 mexiletine hcl 9 MEDROL DOSEPAK 37 mesalamine 52 MEXILETINE HCL 9 medroxyprogesterone MIACALCIN 50 acetate 159 MESTINON 25 medroxyprogesterone acetate MESTINON TIMESPAN 25 MICARDIS 23 (contraceptive) 36 METADATE CD 2 MICARDIS HCT 24 MEFLOQUINE HCL 25 METAMUCIL 55 MICATIN 41 mefloquine hcl 25 METAMUCIL ORIGINAL MICONAZOLE 3 167 MEGA MULTI FOR MEN 116 TEXTURE 55 miconazole nitrate (topical) 41 METAPROTERENOL MEGA MULTI FOR miconazole nitrate vaginal 167 WOMEN 116 SULFATE 10 metformin hcl 16 MICROCHAMBER 106

Index 22 MICROELITE FILTER MOI-STIR 113 MONOJECT INSULIN REPLACEMENTS 106 MOLINDONE SYRINGE/U-100/1ML/30G X MICROELITE RECHARGEABLE HYDROCHLORIDE 28 5/16" 90 BATTERY 106 mometasone furoate 43 MONOJECT INSULIN MICROLET NEXT 68 SYRINGEREGULAR LUER MONISTAT 3 167 MICROSPACER 106 TIP/SOFTPACK/1ML 90 MONISTAT 3 COMBINATION MONOJECT ULTRA COMFORT MICROZIDE 50 PACK 167 INSULIN SYRINGE/0.3ML/29G X midazolam hcl 55 MONISTAT 7 SIMPLY 1/2" 90 midodrine hcl 168 CURE 167 MONOJECT ULTRA COMFORT MONISTAT SOOTHING CARE MIGRANAL 109 INSULIN SYRINGE/0.3ML/30G X ITCH RELIEF 43 5/16" 90 MILLIPRED 37 MONODOX 162 MONOJECT ULTRA COMFORT MINI LANCING DEVICE 68 MONOJECT INSULIN INSULIN SYRINGE/0.3ML/31G X MINIELITE FILTER SYRINGE/1ML 90 5/16" 91 REPLACEMENTS 106 MONOJECT INSULIN MONOJECT ULTRA COMFORT MINIELITE RECHARGEABLE SYRINGE/1ML/31G X INSULIN SYRINGE/0.5ML/28G X BATTERY 106 5/16" 90 1/2" 91 MINIPRESS 23 MONOJECT INSULIN MONOJECT ULTRA COMFORT SYRINGE/DETACH INSULIN SYRINGE/0.5ML/29G X MINIVELLE 51 NEEDLE/1ML/25G X 5/8" 90 1/2" 91 MINOCIN 162 MONOJECT INSULIN MONOJECT ULTRA COMFORT minocycline hcl 162 SYRINGE/DETACH INSULIN SYRINGE/0.5ML/30G X minoxidil 25 NEEDLE/1ML/27G X 1/2" 90 5/16" 91 MONOJECT INSULIN MONOJECT ULTRA COMFORT MIRALAX 55 SYRINGE/PERM INSULIN SYRINGE/0.5ML/31G X MIRAPEX 27 NEEDLE/1ML/28G X 1/2" 90 5/16" 91 MIRASORB SPONGES 2" X MONOJECT INSULIN MONOJECT ULTRA COMFORT 2" 60 SYRINGE/PERM NEEDLE/U- INSULIN SYRINGE/1ML/28G X MIRASORB SPONGES 4" X 100/0.5ML/28G X 1/2" 90 1/2" 91 4" 60 MONOJECT INSULIN MONOJECT ULTRA COMFORT MIRCETTE 35 SYRINGE/SAFETY/PERM INSULIN SYRINGE/1ML/29G X MIRENA 36 NEEDLE/0.3ML/29G X 1/2" 91 1/2" 90 MONOLET LANCETS 68 mirtazapine 13 MONOJECT INSULIN MONOLET OPD LANCETS 68 misoprostol 164 SYRINGE/SAFETY/PERM MM INSULIN SYRINGE/U- NEEDLE/0.3ML/29GX1/2" 90 montelukast sodium 9 100/0.3ML/30G X 5/16" 90 MONOJECT INSULIN MOORE MED MONOJECT MM INSULIN SYRINGE/U- SYRINGE/SAFETY/PERM INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16" 90 NEEDLE/0.5ML/29G X 100/0.5ML/28G X 1/2" 91 MM INSULIN SYRINGE/U- 1/2" 90 MOORE MED MONOJECT 100/1/2ML/30G X 5/16" 90 MONOJECT INSULIN INSULIN SYRINGE/U- MM INSULIN SYRINGE/U- SYRINGE/SAFETY/PERM 100/0.5ML/29G X 1/2" 91 100/1/2ML/31G X 5/16" 90 NEEDLE/1ML/29G X 1/2" 90 MOORE MED MONOJECT MM INSULIN SYRINGE/U- MONOJECT INSULIN INSULIN SYRINGE/U- 100/1ML/30G X 5/16" 90 SYRINGE/SOFTPACK/1ML/27 100/1ML/28G X 1/2" 91 MM INSULIN SYRINGE/U- G X 1/2" 90 MOORE MED MONOJECT 100/1ML/31G X 5/16" 90 MONOJECT INSULIN INSULIN SYRINGE/U- MM LANCING DEVICE 68 SYRINGE/SOFTPACK/U- 100/1ML/29G X 1/2" 91 MM PEN NEEDLES 31G X 100/0.5ML/28G X 1/2" 90 morphine sulfate 5 1/4" 90 MONOJECT INSULIN MORPHINE SULFATE 5 MM PEN NEEDLES 31G X SYRINGE/U-100/0.3ML/30G X morphine sulfate 5 3/16" 90 5/16" 90 MM PEN NEEDLES 31G X MONOJECT INSULIN MOTHERS FRIEND 46 5/16" 90 SYRINGE/U-100/0.5ML/30G X MOTRIN INFANTS DROPS 3 MM PEN NEEDLES 32G X 5/16" 90 MOUTHKOTE 113 MONOJECT INSULIN 5/32" 90 moxifloxacin hcl (ophth) 156 MOBIC 3 SYRINGE/U-100/1ML/28G X 1/2" 90 MS CONTIN 5

Index 23 MS INSULIN NAMENDA 160 NEOMYCIN/POLYMYXIN/HYDR SYRINGE/0.3ML/31G X NAMENDA TITRATION OCORTISONE 157 5/16" 91 PAK 160 NEONATAL PLUS 150 MS INSULIN naphazoline w/ NEONATAL VITAMIN 150 SYRINGE/0.5ML/31G X pheniramine 156 NEORAL 111,112 5/16" 91 NAPHCON-A 156 MS INSULIN SYRINGE/1ML/31G NEOSPORIN 156 NAPROSYN 3 X 5/16" 91 NEOSPORIN ORIGINAL 40 MSM SKIN LOTION 46 naproxen 3 NEOSPORIN PLUS PAIN MULTI PRENATAL 150 naproxen sodium 3 RELIEF MAXIMUM MULTI VITAMIN 146 naratriptan hcl 109 STRENGTH 40 MULTI VITAMIN/D-3 146 NARCAN 19 NEPHRO-VITE RX 114 MULTI-BETIC DIABETES 117 NARDIL 14 NEPHROCAPS 114 MULTI-LANCET DEVICE 68 NASACORT ALLERGY NEPTAZANE 49 MULTI-VITAMIN 24HR 153 NEURONTIN 12 MONOCAPS 117 NASACORT ALLERGY 24HR NEUTROGENA BODY LIGHT CHILDRENS 153 MULTILEX 117 SESAME FORMULA 46 NASAL NEUTROGENA HEALTHY SKIN MULTILEX T&M 117 DECONGESTANT 154 FACE SPF 15 46 multiple vitamin 146 NASALCROM 153 NEUTROGENA MOISTURE multiple vitamins w/ iron 114 NAT-RUL PRENATAL SENSITIVE SKIN 46 multiple vitamins w/ VITAMINS 150 NEUTROGENA T/GEL 49 minerals 117 NAT-RUL THERAVITE- NEUTROGENA T/GEL MULTIVITAMIN ADULTS 143 M/HIGHPOTENCY 144 STUBBORN ITCH NATALVIT 150 MULTIVITAMIN MEN 144 CONTROL 49 MULTIVITAMIN/FLUORIDE nateglinide 17 nevirapine 30 148 NATROBA 48 NEXIUM 164 MUPIROCIN 40 NATRUL-MEGA-75 144 NEXIUM 24HR 164 mupirocin 40 NATRUL-VITES 144 NEXIUM 24HR CLEAR mupirocin calcium (topical) 40 NATURE-THROID 163 MINIS 164 NEXPLANON 36 MYAMBUTOL 25 NEBULIZER AIR niacin 168 mycophenolate mofetil 111 TUBE/PLUGS 106 NEBULIZER PEDIATRIC niacin (antihyperlipidemic) 22 mycophenolate sodium 111 MASK 107 NIACIN TR 168 MYDRIACYL 155 NECON 1/50-28 35 NIACOR 22 MYFORTIC 111 NECON 10/11-28 35 NIASPAN 22 MYLERAN 26 NEFAZODONE HCL 15 NICADAN 144 MYLICON 52 nefazodone hcl 15 MYLICON INFANTS GAS NEFAZODONE NICADAN ZX 144 RELIEF 52 HYDROCHLORIDE 15 nicardipine hcl 33 MYNATAL 150 NEOMULTIVITE 148 NICAZEL 144 MYNATAL ADVANCE 150 neomycin sulfate 2 NICAZEL FORTE 144 MYNATAL PLUS 150 neomycin-bacitracin zn- NICODERM CQ 161 MYNATAL ULTRACAPLET 150 polymyxin 156 NICORETTE 161 neomycin-bacitracin-polymyxin MYNATAL-Z 150 40 NICORETTE MINI 161 MYNATE 90 PLUS 150 neomycin-polymy- NICORETTE STARTER MYSOLINE 12 dexameth 157 KIT 161 neomycin-polymyxin w/ nicotine 161 nabumetone 3 pramoxine 40 nicotine polacrilex 161 nadolol 33 neomycin-polymyxin-hc NICOTINE TRANSDERMAL naloxone hcl 18 (otic) 158 SYSTEM 161 NALOXONE HCL 18 NEOMYCIN/POLYMYXIN/GRA MICIDIN 156 NICOTROL INHALER 161 naltrexone hcl 18

Index 24 NICOTROL NS 162 NORINYL 1+35 36 nystatin (topical) 41 nifedipine 33,34 NORPACE 9 nystatin-triamcinolone 41 NINLARO 26 NORPACE CR 9 NYTOL MAXIMUM NITRO-BID 8 NORPRAMIN 15 STRENGTH 54 O-CAL FA 150 NITRO-DUR 8 NORTEMP INFANTS 4 O-CAL PRENATAL 150 nitrofurantoin 165 nortriptyline hcl 16 OB COMPLETE nitrofurantoin macrocrystal 165 NORTRIPTYLINE HCL 16 ADVANCED 150 nitrofurantoin monohyd NORVASC 34 OCEAN NASAL SPRAY 153 macro 165 NORVIR 30 OCUFLOX 156 nitroglycerin 8 NOSE CLIP 107 OCULAR VITAMINS 144 NITROSTAT 8 NOVA MAX PLUS KETONE ODEFSEY 30 NIVA-PLUS 150 TESTSTRIPS 49 OFF DEEP WOODS 47 NIVEA 46 NOVA SUREFLEX OFF DEEP WOODS DRY 47 NIVEA EXTRA ENRICHED 46 LANCETS 68 NOVA SUREFLEX LANCING OFLOXACIN 52 NIVEA EXTRA ENRICHED DEVICE 68 LOTION 46 ofloxacin 52 NOVOFINE 30GX8MM 91 NIVEA GENTLE BODY ofloxacin (ophth) 156 NOVOFINE 32GX6MM 91 EXFOLIATOR 46 ofloxacin (otic) 158 NIVEA LIGHT 46 NOVOFINE AUTOCOVER OGESTREL 36 NIVEA ORIGINAL 46 30GX8MM 91 NOVOFINE PLUS olanzapine 28 NIVEA ORIGINAL 32GX4MM 91 MOISTURE 46 olmesartan medoxomil 23 NOVOLIN 70/30 17 NIVEA VISAGE 46 olmesartan medoxomil- NOVOLIN 70/30 amlodipine-hydrochlorothiazide NIX CREME RINSE 48 FLEXPEN 17 24 NIZORAL 41 NOVOLIN 70/30 FLEXPEN olmesartan medoxomil- NIZORAL A-D 41 RELION 17 hydrochlorothiazide 24 NO IRON MULTIPLE NOVOLIN 70/30 RELION 17 omega-3 fatty acids 154 VITAMIN/MINERALS 144 NOVOLIN N 17 omeprazole 164 nonoxynol-9 167 NOVOLIN N RELION 17 OMEPRAZOLE 164 NORCO 6 NOVOLIN R 17 OMNICAP 148 NORDITROPIN NOVOLIN R RELION 17 OMNIPRED 157 FLEXPRO 50,51 NOVOLOG MIX 70/30 17 norethin acet & estrad-fe 35 OMNITROPE 51 NOVOLOG MIX 70/30 ON CALL LANCING norethindrone & eth estradiol35 PREFILLED FLEXPEN 17 DEVICE 68 norethindrone & ethinyl estradiol- NOVOTWIST 32GX5MM 91 ON CALL PLUS LANCING fe 35 NU GAUZE 4PLY 4"X4" 60 DEVICE 68 norethindrone ONCOVITE 144 (contraceptive) 37 NU GAUZE GENERAL-USE norethindrone acet & eth SPONGES 4"X4" 4 PLY 60 ondansetron 19 estra 35 NULYTELY/FLAVOR ondansetron hcl 19 norethindrone acetate 159 PACKS 55 ONE DAILY MENS FORMULA norethindrone acetate-ethinyl NUMOISYN 113 W/O IRON 144 estradiol 51 NUPLAZID 27 ONE DAILY PLUS IRON 144 norethindrone acetate-ethinyl NUTRADERM 46 ONE DAILY WOMENS 144 estradiol-fe 35 NUTRADERM ADVANCED ONE-A-DAY ENERGY 144 norethindrone-eth estradiol FORMULA 46 ONE-A-DAY ESSENTIAL 148 (triphasic) 36 NUTRICAP 144 norgestimate-ethinyl ONE-A-DAY MENOPAUSE estradiol 36 NUTRICION PORVIDA 150 FORMULA 144 norgestimate-ethinyl estradiol NUVARING 36 ONE-A-DAY MENS 148 (triphasic) 36 nystatin 19 ONE-A-DAY MENS 50+ norgestrel & ethinyl estradiol 36 nystatin (mouth-throat) 112 ADVANTAGE 144

Index 25 ONE-A-DAY MENS HEALTH OPTIONS GYNOL II PARI ALTERA NEBULIZER FORMULA 144 VAGINALCONTRACEPTIVE HANDSET 107 ONE-A-DAY MENS PRO 167 PARI BABY CONVERSION EDGE 144 OPTIVITE P.M.T. 144 KITSIZE 1 107 ONE-A-DAY PROACTIVE OPURITY 144 PARI BABY CONVERSION 65+ 144 KITSIZE 2 107 ONE-A-DAY TEEN oral electrolytes 110 PARI BABY CONVERSION ADVANTAGEFOR HIM 144 ORAL RELIEF SPRAY FOR KITSIZE 3 107 ONE-A-DAY VITACRAVES DRYMOUTH & PARI ERAPID NEBULIZER GUMMIES+OMEGA-3 DISCOMFORT 113 HANDSET 107 DHA 150 ORKAMBI 162 PARI EXPIRATORY FILTER ONE-A-DAY WEIGHT SMART orphenadrine citrate 153 VALVE SET 107 ADVANCED 144 PARI MASK SET 107 ORTHO MICRONOR 37 ONE-A-DAY WOMENS 50+ PARI SOFT PLASTIC ADULT ADVANTAGE 144 ORTHO TRI-CYCLEN 36 MASK 107 ONE-A-DAY WOMENS ACTIVE ORTHO TRI-CYCLEN LO 36 PARI SOFT PLASTIC MIND & BODY 144 ORTHO-CYCLEN 36 PEDIATRIC MASK 107 ONE-A-DAY WOMENS PARLODEL 27 PETITES 144 ORTHO-NOVUM 1/35 36 ONE-A-DAY WOMENS PLUS ORTHO-NOVUM 7/7/7 36 PARNATE 14 HEALTHY SKIN SUPPORT144 oseltamivir phosphate 32 paroxetine hcl 14 ONETOUCH DELICA LANCING OSTEOPRIME paroxetine mesylate DEVICE 68 PLUS/CALCIUM & (vasomotor) 162 OPCON-A 156 MAGNESIUM 144 PARVLEX 144 OPTI-WOMAN 144 OTICIN HC NR 158 PAXIL 14 OPTICHAMBER OVACE PLUS WASH 42 PAXIL CR 14 ADVANTAGE/LARGE OVACE WASH 42 PC LANCETS SUPER THIN MASK 107 30G 68 OPTICHAMBER OVCON-35 36 PC UNIFINE PENTIPS 29G ADVANTAGE/MEDIUM FACE OVIDE 48 X1/2" 91 MASK 107 PC UNIFINE PENTIPS 31G OPTICHAMBER oxaprozin 3 oxazepam 9 X5MM MINI 91 ADVANTAGE/SMALL FACE PC UNIFINE PENTIPS 31G MASK 107 OXAZEPAM 9 X6MM ULTRA SHORT 91 OPTICHAMBER DIAMOND107 oxcarbazepine 12 PC UNIFINE PENTIPS 31G OPTICHAMBER oxybutynin chloride 165 X8MM SHORT 91 DIAMOND/LARGEFACE oxycodone hcl 5 PCE 57 MASK 107 ped multivitamins w/fl & OPTICHAMBER OXYCODONE HCL ER 5 iron 149 DIAMOND/MEDIUM FACE oxycodone w/ PEDIALYTE 110 MASK 107 acetaminophen 6 OPTICHAMBER PEDIALYTE ADVANCED oxycodone-aspirin 6 CARE 110 DIAMOND/SMALLFACE OXYCODONE/ACETAMINOPH MASK 107 PEDIALYTE FREEZER EN 6 POPS 110 OPTICHAMBER FACE oyster shell 110 MASK/LARGE 107 PEDIALYTE SINGLES 110 OPTICHAMBER FACE PAMELOR 16 PEDIAPRED 37 MASK/MEDIUM 107 PANCREAZE 49 PEDIATRIC AEROSOL OPTICHAMBER FACE PANOXYL-4 CREAMY MASK 107 MASK/SMALL 107 WASH 39 PEDIATRIC OPTIFOAM 60 pantoprazole sodium 164 MOUTHPIECE/DISPOSABLE OPTIHALER 107 PARAFON FORTE DSC 153 107 OPTIHALER MDI DRUG pediatric multiple vitamin w/ PARAGARD INTRAUTERINE c 150 DELIVERY SYSTEM 107 COPPER CONTRACEPTIVE OPTIONS CONCEPTROL pediatric multiple vitamin w/ c & T380A 36 fa 150 VAGINAL PAREGORIC 18 CONTRACEPTIVE 167 pediatric multiple vitamins w/ iron 149

Index 26 pediatric multivitamins PEPTO-BISMOL MAX PNEUMOVAX 23/1 DOSE 165 w/fl 148,149 STRENGTH 18 PNV FERROUS pediatric vitamins acd w/ PEPTO-BISMOL TO-GO 18 FUMARATE/DOCUSATE/FOLIC fluoride 149 PERCOCET 6 ACID 151 pediatric vitamins adc 150 PERFECT LANCETS 30G 68 PNV FOLIC ACID + IRON peg 3350-kcl-sod bicarb-sod MULTIVITAMIN 151 chloride-sod sulfate 55 PERIDEX 112 PNV PRENATAL PLUS peg 3350-potassium chloride-sod permethrin 48 MULTIVITAMIN 151 bicarbonate-sod chloride 55 perphenazine 29 PNV TABS 29-1 151 PEN NEEDLES 29G X PERPHENAZINE/AMITRIPTYL POCKET CHAMBER 107 12MM 91 INE 160 PEN NEEDLES 29GX1/2" 91 POCKET SPACER 107 PERRY PRENATAL 150 podofilox 47 PEN NEEDLES 30GX5/16" 91 PERSERIS 27 PEN NEEDLES 30GX8MM 91 POLY-VI-SOL 150 PFLEX 107 POLY-VI-SOL/IRON 149 PEN NEEDLES 31G X 1/4" PHARMACY COUNTER SHORT 91 LANCETS 68 POLYCOSE 154 PEN NEEDLES 31G X 3/16" 91 phenazopyridine hcl 53 polyethylene glycol 3350 55 PEN NEEDLES 31G X 5MM 91 phenelzine sulfate 14 POLYMEM DRESSING/3" X PEN NEEDLES 31G X 6MM 91 3" 60 phenobarbital 54 POLYMEM DRESSING/4" X PEN NEEDLES 31G X 8MM 91 phenylephrine hcl (ophth) 156 4" 60 PEN NEEDLES 31GX5/16" 91 phenylephrine hcl (oral) 154 POLYMEM FILM DOT 60 PEN NEEDLES 31GX6MM phenylephrine-dm 38 POLYMEM NON-ADHESIVE (1/4") 91 PAD 60 PEN NEEDLES 31GX8MM 92 phenylephrine-shark liver oil- cocoa butter 6 polymyxin b-trimethoprim 156 PEN NEEDLES 31GX8MM phenylephrine-shark liver oil- polysaccharide iron complex 54 (5/16") 91 mineral oil-petrolatum 7 POLYTRIM 156 PEN NEEDLES 32G X 4MM 92 phenytoin 13 PEN NEEDLES 32G X 5MM 92 polyvinyl alcohol 155 phenytoin sodium pot phosphate monobasic w/ sod PEN NEEDLES 32G X 6MM 92 extended 13 phosphate dibasic & PEN NEEDLES 32GX4MM 92 PHYTOMULTI 144 monobasic 111 penicillin v potassium 159 phytonadione 168 potassium bicarbonate 111 PENICILLIN V PIFELTRO 30 potassium chloride 111 POTASSIUM 159 PILLOW MASK/ADULT 107 POTASSIUM CHLORIDE penicillin v potassium 159 PILLOW MASK/CHILD 107 ER 111 PENTIPS 29G X 12MM 92 PILLOW potassium chloride PENTIPS 29GX12MM 92 MASK/PEDIATRIC 107 microencapsulated crystals er 111 PENTIPS 31G X 5MM 92 pilocarpine hcl 155 potassium citrate PENTIPS 31G X 8MM 92 pilocarpine hcl (oral) 113 (alkalinizer) 53 PENTIPS 31GX5MM 92 pimecrolimus 46 potassium citrate-citric acid 53 PENTIPS 31GX6MM 92 pindolol 33 pramipexole dihydrochloride 27 PENTIPS 31GX8MM 92 pioglitazone hcl 17 PRAMOTIC 158 PENTIPS 32G X 4MM 92 pioglitazone hcl-metformin pramoxine hcl (rectal) 7 hcl 16 PENTIPS 32GX4MM 92 pramoxine-hc-chloroxylenol piroxicam 3 pentoxifylline 53 158 PLAN B ONE-STEP 36 prasugrel hcl 53 PEPCID 163 PLAQUENIL 25 PRAVACHOL 22 PEPCID AC 163 PLAVIX 53 PEPCID AC MAXIMUM pravastatin sodium 22 STRENGTH 163 PLEGRIDY 160 prazosin hcl 23 PEPTO-BISMOL 18 PLEGRIDY STARTER PRE-NATAL FORMULA 151 PEPTO-BISMOL PACK 160 INSTACOOL 18 PNEUMOVAX 23 165

Index 27 PRECISION SURE-DOSE PREFERRED PLUS INSULIN PRENATAL INSULIN SYRINGE/0.3ML/30G X SYRINGE/U-100/0.5ML/28G X VITAMIN/IRON 151 5/16" 92 1/2" 92 PRENATAL VITAMINS 152 PRECISION SURE-DOSE PREFERRED PLUS INSULIN PRENATAL VITAMINS PLUS INSULIN SYRINGE/0.5ML/28G X SYRINGE/U-100/0.5ML/29G X LOW IRON 152 1/2" 92 1/2" 92 PREPLUS 152 PRECISION SURE-DOSE PREFERRED PLUS INSULIN INSULIN SYRINGE/0.5ML/29G X SYRINGE/U-100/0.5ML/30G X PRESERVISION AREDS 144 1/2" 92 5/16" 92 PRETAB 152 PRECISION SURE-DOSE PREFERRED PLUS INSULIN PREVACID 164 INSULIN SYRINGE/0.5ML/30G X SYRINGE/U-100/1ML/28G X PREVACID 24HR 164 3/8" 92 1/2" 92 PRECISION SURE-DOSE PREFERRED PLUS INSULIN PREVIDENT 5000 BOOSTER INSULIN SYRINGE/1ML/28G X SYRINGE/U-100/1ML/29G X PLUS 112 1/2" 92 1/2" 92 PREVIDENT 5000 DRY PRECISION SURE-DOSE PREFERRED PLUS INSULIN MOUTH 112 PLUSINSULIN SYRINGE/U-100/1ML/30G X PREVIDENT 5000 PLUS 112 SYRINGE/0.3ML/29G X 1/2" 92 5/16" 92 PREVIDENT FLUORIDE 112 PRECISION SURE-DOSE PREFERRED PLUS LANCETS PREVIDENT RINSE 112 PLUSINSULIN COLORED 21G 68 SYRINGE/1ML/29G X 1/2" 92 PREFERRED PLUS LANCETS PREVNAR 13 165 PRECISION THIN SUPER THIN 30G 68 PREZCOBIX 30 LANCETS 68 PREFERRED PLUS LANCETS PREZISTA 30 PRECISION THINS GP THIN 26G 68 PRILOSEC OTC 164 LANCET 68 PREFERRED PLUS UNIFINE PRECISION ULTRA PENTIPS 29G X 12MM 92 PRIMAQUINE PHOSPHATE 25 LANCET 68 PREFERRED PLUS UNIFINE primaquine phosphate 25 PRECISION XTRA 49 PENTIPS 31G X 6MM ULTRA primidone 12 PRED FORTE 157 SHORT 93 PREFERRED PLUS UNIFINE PRINIVIL 22 PRED MILD 157 PENTIPS 31G X 8MM PRISTIQ 15 PRED-G 157 SHORT 93 PRO COMFORT INHALER PREDATOR 47 PREFERRED PLUS UNIFINE SPACER CHAMBER PENTIPS 32GX4MM 93 ADULT 107 PREDNICARBATE 43 PREFERRED PLUS UNIFINE PRO COMFORT INHALER prednicarbate 43 PENTIPS/MINI/31GX5MM 93 SPACER CHAMBER PREDNISOLONE 37 PREMARIN 52,167 CHILD 108 prednisolone 37 PREMIUM CONDOMS PRO COMFORT INSULIN SYRINGES/0.5ML/30G X prednisolone acetate LUBRICATED 62 PREMPHASE 51 1/2" 93 (ophth) 157 PRO COMFORT INSULIN PREDNISOLONE ACETATE P- PREMPRO 51 SYRINGES/0.5ML/30G X F 157 PRENATABS RX 151 5/16" 93 prednisolone sodium PRO COMFORT INSULIN phosphate 37 PRENATAL 151 PREDNISOLONE SODIUM PRENATAL 19 151 SYRINGES/0.5ML/31G X 5/16" 93 PHOSPHATE 157 PRENATAL AND IRON 151 PRO COMFORT INSULIN PREDNISONE 37 PRENATAL FORTE 151 SYRINGES/1ML/30G X 1/2" 93 prednisone 37 PRENATAL LOW IRON 151 PRO COMFORT INSULIN PREDNISONE 37 PRENATAL SYRINGES/1ML/30G X PREDNISONE INTENSOL 37 5/16" 93 MULTIVITAMIN 151 PRO COMFORT INSULIN PREFERRED PLUS INSULIN PRENATAL ONE DAILY 151 SYRINGES/1ML/31G X SYRINGE/U-100/0.3ML/29G X PRENATAL PLUS 151 5/16" 93 1/2" 92 PRO COMFORT PEN PREFERRED PLUS INSULIN PRENATAL PLUS IRON 151 PRENATAL VITAMIN 151 NEEDLES/31G X 8MM 93 SYRINGE/U-100/0.3ML/30G X PRO COMFORT PEN 5/16" 92 PRENATAL VITAMIN & NEEDLES/32G X 4MM 93 MINERAL 151

Index 28 PRO COMFORT PEN pseudoephedrine w/ codeine- pyrethrins-piperonyl butoxide48 NEEDLES/32G X 5MM 93 gg 38 pyrethrins-piperonyl butoxide- PRO COMFORT PEN pseudoephedrine w/ dm- permethrin-nit remover 48 NEEDLES/32G X 6MM 93 gg 38 PYRIDIUM 53 PRO-CAL 144 pseudoephedrine-chlorphen- pyridostigmine bromide 25 PROAIR HFA 10 dm 38 pseudoephedrine-guaifenesin pyridoxine hcl 168 probenecid 53 38 pyrithione zinc 42 PROCARDIA 34 pseudoephedrine- QC ADVANCED LANCING PROCARDIA XL 34 ibuprofen 38 DEVICE 68 PROCERV HP 144 PSORCON 43 QC ALCOHOL SWABS 72 PSS SELECT GP QC ALL PURPOSE prochlorperazine 29 LANCETS 68 prochlorperazine maleate 29 DRESSINGS4"X4" 60 PSS SELECT SAFETY QC BORDER ISLAND GAUZE PROCTOFOAM 7 LANCETS 68 PAD 2"X2" 60 PRODIGY INSULIN SYRING/U- psyllium 55 QC LANCETS SUPER THIN 68 100/0.3ML/31G X 5/16" 93 PTS PANELS KETONE PRODIGY INSULIN TEST 49 QC LANCETS ULTRA THIN 68 SYRINGE/1/2ML/31G X PULMICORT 10 QC PEN NEEDLES 29G X 12MM 93 5/16" 93 PULMICORT FLEXHALER10 PRODIGY INSULIN QC PEN NEEDLES 31G X SYRINGE/1ML/28G X 1/2" 93 PURIXAN 26 6MM 93 PRODIGY LANCING PX ADVANCED LANCING QC PEN NEEDLES 31G X DEVICE 68 DEVICE 68 8MM 93 PRODIGY TWIST TOP PX EXTRA SHORT PEN QC PRENATAL 152 LANCETS 68 NEEDLES 31GX6MM 93 QC STERILE PADS 60 progesterone 159 PX INSULIN SYRINGE/U- QC UNIFINE PENTIPS 100/0.3ML/30G X 1/2" 93 32GX4MM 93 progesterone micronized 159 PX INSULIN SYRINGE/U- PROGRAF 112 QC UNILET LANCETS 100/0.3ML/31G X 5/16" 93 33G/MICRO THIN 68 promethazine & PX INSULIN SYRINGE/U- phenylephrine 38 100/0.5ML/30G X 1/2" 93 QUENCH 145 promethazine hcl 20 PX INSULIN SYRINGE/U- QUESTRAN 21 promethazine-dm 38 100/0.5ML/31G X 5/16" 93 QUESTRAN LIGHT 21 PX INSULIN SYRINGE/U- quetiapine fumarate 28 PROMETHAZINE/PHENYLEPHR 100/1ML/30G X 1/2" 93 INE 38 PX INSULIN SYRINGE/U- QUFLORA PEDIATRIC 149 PROMETRIUM 159,160 100/1ML/31G X 5/16" 93 QUIN B STRONG 145 PRONEB ULTRA FILTER PX LANCET AUTO quinapril hcl 22 SET 108 INJECTOR 68 quinapril-hydrochlorothiazide propafenone hcl 9 PX LANCETS ULTRA 24 propranolol hcl 33 THIN 68 PX LANCETS ULTRA THIN quinidine gluconate 9 PROPRANOLOL HCL 33 28G 68 QUINIDINE SULFATE 9 propranolol hcl 33 PX MINI PEN NEEDLES QUINTABS 148 PROPRANOLOL/HYDROCHLOR 31GX5MM 93 QUINTABS-M 145 OTHIAZIDE 24 PX OMEPRAZOLE 164 propylthiouracil 162 PX PEN NEEDLE RA ALCOHOL SWABS 72 RA ALL PURPOSE PRORENAL+D 144 29GX12MM 93 PX PEN NEEDLE DRESSINGS4"X4" 60 PROSCAR 53 31GX8MM 93 RA CENTRAL-VITE 145 PROTONIX 164 PX PRENATAL RA CENTRAL-VITE UNDER PROTOPIC 47 MULTIVITAMINS 152 50MENS 145 PROVERA 160 PX SHORTLENGTH PEN RA CENTRAL-VITE UNDER NEEDLES/31GX8MM 93 50WOMENS 145 PROVIT 145 pyrantel pamoate 7 RA DAYLOGIC HEALING DRY PROZAC 14 pyrazinamide 25 SKIN THERAPY 46 pseudoephedrine hcl 154 RA DRESSING SPONGES 4"X4" 60

Index 29 RA DRY MOUTH 113 REALITY INSULIN RELION PEN NEEDLES RA E-ZJECT COLOR SYRINGE/U-100/1ML/29G X 32GX4MM 94 LANCETSMICRO-THIN 33G 68 1/2" 94 RELION SHORT PEN RA E-ZJECT LANCETS 28G69 REALITY LANCETS 69 NEEDLES31GX8MM 94 REALITY LATEX RELION ULTRA THIN RA E-ZJECT LANCETS THIN LANCETS30G 69 26G 69 CONDOMS/LUBRICATED 62 REALITY LATEX/ULTRA RELION ULTRA THIN PLUS RA E-ZJECT LANCETS THIN LANCETS 32G 69 28G 69 TEXTURED 62 REALITY LATEX/ULTRA RELION ULTRA THIN PLUS RA E-ZJECT LANCETS LANCETS 33G 69 ULTRATHIN 30G 69 THIN 62 RA GAUZE SPONGES REALITY SWABS 72 RELPAX 109 4"X4" 60 REESES PINWORM REMERON 13 RA INSULIN MEDICINE 7 REMERON SOLTAB 13 SYRINGE/0.5ML/29G X 1/2" 93 REGLAN 52 RENAPLEX-D 145 RA INSULIN SYRINGE/1ML/29G RELENZA DISKHALER 32 X 1/2" 94 REPLACEMENT AIR RA INSULIN SYRINGE/U- RELION 2-IN-1 LANCING FILTER 108 100/0.5ML/30G X 5/16" 94 DEVICE 25G 69 REPLACEMENT FILTERS 108 RA INSULIN SYRINGE/U-100/1 RELION 2-IN-1 LANCING REQ 49+ 145 ML/30G X 5/16" 94 DEVICE 30G 69 RELION ALCOHOL REQUIP 27 RA LANCING DEVICE 69 SWABS 72 RESCRIPTOR 30 RA LICE SOLUTION KIT 48 RELION INSULIN SYRINGE/U- RESTA LITE 46 RA OMEPRAZOLE 164 00/1ML/29G X 1/2" 94 RESTORE CONTACT RA OYSTER SHELL RELION INSULIN SYRINGE/U- LAYER/NON-ADHERENT CALCIUM/VITAMIN D 110 100/0.3ML/29G X 1/2" 94 2"X2" 60 RA PEN NEEDLES 31G X RELION INSULIN SYRINGE/U- RESTORE FOAM DRESSING 5MM3/16" 94 100/0.3ML/30G X 5/16" 94 BORDERED 4"X4" 60 RA PEN NEEDLES 31G X RELION INSULIN SYRINGE/U- RESTORE FOAM DRESSING 8MM5/16" 94 100/0.3ML/31G X 5/16" 94 NON-BORDERED 4"X4" 60 RA PRENATAL 152 RELION INSULIN SYRINGE/U- RESTORE ODOR ABSORBING 100/0.5ML/29G X 1/2" 94 DRESSING 4"X4" 60 RA PRENATAL RELION INSULIN SYRINGE/U- FORMULA/FOLICACID 152 RESTORE TRIO ABSORBENT 100/0.5ML/30G X 5/16" 94 DRESSING 3"X3" 60 RA RENEWAL DRY SKIN RELION INSULIN SYRINGE/U- THERAPY 46 100/0.5ML/31G X 5/16" 94 RESTORIL 55 RA STERILE PADS 2"X2" 60 RELION INSULIN SYRINGE/U- RETIN-A 39 RA STERILE PADS 3"X3" 60 100/1ML/30G X 5/16" 94 RETROVIR 30 RA STERILE PADS 4"X4" 60 RELION INSULIN SYRINGE/U- RETROVIR IV INFUSION 30 100/1ML/31G X 5/16" 94 RADIAGUARD ADVANCED 46 RELION LANCETS MICRO- REXALL LANCETS ULTRA RAGUS 145 THIN33G 69 THIN 69 raloxifene hcl 51 RELION LANCETS REYATAZ 31 RHOGAM ULTRA-FILTERED ramipril 22 STANDARD 21G 69 RELION LANCETS THIN PLUS 158 ranitidine hcl 163,164 26G 69 riboflavin 168 RAPAMUNE 112 RELION LANCETS ULTRA- RID 48 RAY-TEC X-RAY THIN30G 69 RID COMPLETE LICE DETECTABLESPONGES 4" X 4" RELION LANCING ELIMINATION 48 16 PLY 60 DEVICE 69 RID ESSENTIAL LICE RAZADYNE 160 RELION MINI PEN NEEDLES ELIMINATION KIT 48 31GX6MM 94 RAZADYNE ER 160 RELION PEN NEEDLES RIFADIN 25 REALITY INSULIN SYRINGE/U- 29GX12MM 94 rifampin 25 100/0.5ML/28G X 1/2" 94 RELION PEN NEEDLES RIGHT STEP PRENATAL 152 REALITY INSULIN SYRINGE/U- 31GX6MM 94 100/0.5ML/29G X 1/2" 94 RIGHTEST GD500 LANCING RELION PEN NEEDLES DEVICE 69 REALITY INSULIN SYRINGE/U- 31GX8MM 94 100/1ML/28G X 1/2" 94 RIGHTEST GL300 LANCETS 69

Index 30 risedronate sodium 50 SAFETY SEAL LANCETS SELSUN BLUE RISPERDAL 27,28 30G 69 MEDICATED 42 SALAGEN 113 SELSUN BLUE RISPERDAL CONSTA 27 salicylic acid 47 MOISTURIZING 42 RISPERDAL M-TAB 27 SELZENTRY 31 saline 153 risperidone 28 sennosides 56 salsalate 5 RISPERIDONE ODT 28 sennosides-docusate SAMI THE SEAL sodium 55 RITALIN 2 REPLACEMENTFILTERS 10 RITEFLO 108 8 SENOKOT 56 ritonavir 31 SANDIMMUNE 112 SENOKOT S 55 rivastigmine 160 SARNA 41 SENTRY 145 rivastigmine tartrate 160 SAVELLA 160 SENTRY SENIOR 145 rizatriptan benzoate 109 SAVELLA TITRATION SENTRY SENIOR/LUTEIN 145 PACK 160 ROBAXIN 153 SEREVENT DISKUS 10 SB ALCOHOL PREP SEROQUEL 28 ROBAXIN-750 153 PADS 72 ROBINUL 163 SB INSULIN SYRINGE/U- sertraline hcl 14,15 ROBINUL FORTE 163 100/0.5ML/29G X 1/2" 95 SFROWASA 52 SB INSULIN SYRINGE/U- SHINGRIX 166 ROBITUSSIN PEAK COLD 100/0.5ML/30G X 5/16" 95 COUGH+ CHEST CONGESTION SHOPKO ALCOHOL SB INSULIN SYRINGE/U- SWABS 72 DM MAX STRENGTH 38 100/1ML/29G X 1/2" 95 ROBITUSSIN PEAK COLD SHOPKO AUTOLET LANCING SB INSULIN SYRINGE/U- DEVICE 69 DM 38 100/1ML/30G X 5/16" 95 ROC DEEP WRINKLE SHOPKO UNIFINE PENTIPS SB INSULIN SYRINGE/U- PEN SERUM 46 100/1ML/31G X 5/16" 95 ROCALTROL 51 NEEDLES/MICRO/32GX4MM SB LANCETS THIN 69 95 ropinirole hydrochloride 27 SB LANCETS ULTRA SHOPKO UNIFINE PENTIPS ROSE MILK 46 THIN 69 PEN NEEDLES/MINI/31GX5MM rosuvastatin calcium 22 SB OMEPRAZOLE 164 95 ROXICODONE 5 SCHNUCKS INSULIN SHOPKO UNIFINE PENTIPS SYRINGEULTI-FINE/U- PEN RYCLORA 20 100/0.5ML/29G X 1/2" 95 NEEDLES/ORIGINAL/29GX12M SAFESNAP INSULIN SCHNUCKS INSULIN M 95 SYRINGE/0.3ML/30G X SYRINGEULTI-FINE/U- SHOPKO UNIFINE PENTIPS 5/16" 94 100/0.5ML/30G X 5/16" 95 PEN SAFESNAP INSULIN SCHOOLTIME SHAMPOO48 NEEDLES/SHORT/31GX8MM SYRINGE/0.5ML/29G X 1/2" 94 SCOT-TUSSIN DM 38 95 SAFESNAP INSULIN SHOPKO UNIFINE PENTIPS SYRINGE/0.5ML/30G X SCOT-TUSSIN SENIOR 39 PLUS PEN 5/16" 94 SE-NATAL 19 152 NEEDLES/MICRO/REMOVR/32 SAFESNAP INSULIN Seasonal Influenza GX4MM 95 SYRINGE/1ML/28G X 1/2" 94 Vaccine 166 SHOPKO UNIFINE PENTIPS SAFESNAP INSULIN Seasonal Influenza Vaccine- PLUS PEN SYRINGE/1ML/29G X 1/2" 94 High Dose 166 NEEDLES/MINI/REMOVER/31G SAFETY INSULIN SYRINGES Seasonal Influenza Vaccine- X5MM 95 0.5ML/29GX1/2" 94 Quadrivalent 166 SHOPKO UNIFINE PENTIPS SAFETY INSULIN SYRINGES PLUS PEN 0.5ML/30GX5/16" 95 SEASONIQUE 36 SEGLUROMET 16 NEEDLES/REMOVER/29GX12M SAFETY INSULIN SYRINGES M 95 1ML/27GX1/2" 95 SELECT-LITE LANCING SHOPKO UNIFINE PENTIPS SAFETY INSULIN SYRINGES DEVICE 69 PLUS PEN 1ML/29GX1/2" 95 selegiline hcl 27 NEEDLES/SHORT/REMOVR/31 SAFETY INSULIN SYRINGES selenium sulfide 42 GX8MM 95 1ML/30GX1/2" 95 SELSUN BLUE 42 SHOPKO UNILET LANCETS SAFETY SEAL LANCETS SUPER THIN 30G 69 28G 69 SELSUN BLUE DAILY 42

Index 31 SHOPKO UNILET LANCETS SM MICRO THIN LANCETS SOOTHENEB NBL100 ADULT ULTRA THIN 28G 69 33G 69 MASK 108 SHUR-SEAL 167 SM OMEPRAZOLE 164 SORBITOL 56 SIDEROL 145 SM ONE DAILY MENS 145 sotalol hcl 33 SIDESTREAM ADULT FACE SM ONE DAILY sotalol hcl (afib/afl) 33 MASK 108 WOMENS 145 SPINOSAD 48 SIDESTREAM PEDIATRIC SM PRENATAL FACEMASK 108 VITAMINS 152 spironolactone 50 SIDESTREAM PEDIATRIC SM STERILE PADS 61 spironolactone & hydrochlorothiazide 50 FACEMASK/SAMI THE SM STERILE PADS 2"X2" 61 SEAL 108 SPORANOX 19 SM TRUEDRAW LANCING SIDESTREAM PEDIATRIC SPORANOX PULSEPAK 19 FACEMASK/TUCKER THE DEVICE 69 SMART DIABETES VANTAGE ST IVES SWISS FORMULA TURTLE 108 24HOUR MOISTURE 46 SIDESTREAM PLUS ADULT LANCING DEVICE 69 SMART SENSE COLOR FACE MASK 108 stannous fluoride 112 SILICONE MASK FOR LANCETS UNIVERSAL STARLIX 17 BREATHERITE 33G 69 SMART SENSE STANDARD stavudine 31 CHAMBER/ADULT 108 STEGLATRO 18 SILICONE MASK FOR LANCETS UNIVERSAL BREATHERITE 21G 69 STERILANCE TL 70 SMART SENSE SUPER THIN CHAMBER/INFANT 108 STERILE GAUZE PADS SILICONE MASK FOR LANCETS UNIVERSAL 2"X2" 61 BREATHERITE 30G 69 STERILE GAUZE PADS SMART SENSE THIN CHAMBER/PEDIATRIC 108 3"X3" 61 SILICONE MASK FOR LANCETSUNIVERSAL STERILE PADS 2"X2" 61 26G 70 BREATHRITE sodium bicarbonate STERILE PADS 3"X3" 61 CHAMBER/ADULT 108 (antacid) 7 STERILE PADS 4"X4" 61 SILPHEN COUGH 20 sodium chloride (gu STRIBILD 31 SILVADENE 42 irrigant) 53 STROVITE FORTE 145 silver sulfadiazine 42 sodium chloride (inhalant) 39 STROVITE ONE 145 simethicone 52 sodium citrate & citric acid 53 STUDIO 35 EXTRA SIMPLE DIAGNOSTICS sodium fluoride 110 MOISTURIZING LOTION 46 LANCING DEVICE 69 sodium fluoride (dental) 112 SUBOXONE 6 SIMPLYTHICK 159 sodium phosphates 56 sucralfate 164 SIMPLYTHICK EASY MIX 159 sodium polystyrene SUDAFED CHILDRENS 154 simvastatin 22 sulfonate 112 SODIUM SUDAFED CONGESTION 154 SINEMET 27 SUDAFED NASAL SINEMET CR 27 SULFACETAMIDE/SULFUR 40 DECONGESTANT MAXIMUM SINGULAIR 9 SOF-WICK 4"X4" 61 STRENGTH 154 sirolimus 112 SUDAFED PE CHILDRENS SOLIRIS 53 NASAL DECONGESTANT 154 SIVEXTRO 8 SOLO 145 SUDAFED PE SKIN REPAIR 46 SOLUS V2 LANCING CONGESTION 154 SKYLA 36 DEVICE 70 sulfacetamide sod- prednisolone 157 SLO-NIACIN 168 SONATA 55 sulfacetamide sodium 42 SM ALCOHOL PREP PADS 72 SOOTHE & COOL MOISTURIZING BODY SULFACETAMIDE SM GAUZE PADS 2"X2" 60 LOTION WITH ALOE 46 SODIUM 156 SM GAUZE PADS 3"X3" 60 SOOTHENEB NBL 100 CHILD sulfacetamide sodium (acne)40 SM GAUZE PADS 4"X4" 60 MASK 108 sulfacetamide sodium SM GLUCOSE 16 SOOTHENEB NBL 100 (ophth) 156 MEDICATION CUP 108 SULFACETAMIDE SM INSULIN SYRINGE/1ML/31G SOOTHENEB NBL 100 MESH SODIUM/PREDNISOLONE X 5/16" 95 CAP 108 SODIUM PHOSPHATE 157 SM IPECAC SYRUP 18

Index 32 sulfamethoxazole- SURE COMFORT LANCING SURELITE LANCETS 70 trimethoprim 7 PEN 70 SURGICAL GAUZE sulfasalazine 52 SURE COMFORT PEN SPONGE 61 sulindac 3 NEEDLES29GX1/2" SUSTIVA 31 12.7MM 96 sumatriptan 109 SURE COMFORT PEN SW OMEPRAZOLE 164 sumatriptan succinate 109 NEEDLES30GX5/16" SYMAX DUOTAB 163 SUMATRIPTAN SHORT 96 SYMBICORT 10 SURE COMFORT PEN SUCCINATE 109 SYMDEKO 162 sumatriptan succinate 109 NEEDLES31GX3/16" SYMFI 31 SUPER THIN LANCETS 70 (5MM) 96 SURE COMFORT PEN SYMFI LO 31 SUPERB NAILS 145 NEEDLES31GX5/16" SYMLINPEN 120 16 SURE COMFORT INSULIN (8MM) 96 SYRINGE/U-100/0.3ML/29G X SURE COMFORT PEN SYMLINPEN 60 16 1/2" 95 NEEDLES32GX5/32" 96 SYMTUZA 31 SURE COMFORT INSULIN SURE COMFORT PEN SYNTHROID 163 SYRINGE/U-100/0.3ML/30G X NEEDLES32GX6MM 96 1/2" 95 SURE-FINE PEN NEEDLES T-VITES 145 SURE COMFORT INSULIN 29GX1/2" 12.7MM 96 tacrolimus 112 SYRINGE/U-100/0.3ML/30G X SURE-FINE PEN NEEDLES tacrolimus (topical) 47 5/16" 95 31GX3/16" 5MM 96 TAGAMET HB 164 SURE COMFORT INSULIN SURE-FINE PEN NEEDLES SYRINGE/U-100/0.3ML/31G X 31GX5/16" 8MM 96 TAMIFLU 32 5/16 95 SURE-JECT INSULIN tamoxifen citrate 26 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X tamsulosin hcl 53 SYRINGE/U-100/0.3ML/31G X 1/2" 96 TAPAZOLE 162 5/16" 95 SURE-JECT INSULIN SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X TARGADOX 162 SYRINGE/U-100/0.5ML/28G X 5/16" 96 TARKA 24 1/2" 95 SURE-JECT INSULIN TAVIST ALLERGY 20 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/0.5ML/29G X 5/16" 96 tazarotene 41 1/2" 96 SURE-JECT INSULIN TAZORAC 41 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X TEARS NATURALE PM 155 SYRINGE/U-100/0.5ML/30G X 1/2" 96 TECFIDERA 160 1/2" 96 SURE-JECT INSULIN SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X TECFIDERA STARTER SYRINGE/U-100/0.5ML/30G X 1/2" 96 PACK 160 5/16" 96 SURE-JECT INSULIN TECHLITE AST LANCETS 70 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/31G X 5/16" 96 100/0.3ML/29G X 1/2" 97 5/16 96 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU- SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 100/0.3ML/30G X 1/2" 97 SYRINGE/U-100/1ML/28G X 5/16" 96 TECHLITE INSULIN SYRINGEU- 1/2" 96 SURE-JECT INSULIN 100/0.3ML/30G X 5/16" 97 SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/29G X 1/2" 96 100/0.3ML/31G X 5/16" 97 1/2" 96 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU- SURE COMFORT INSULIN SYRINGE/U-100/1ML/29G X 100/0.5ML/29G X 1/2" 97 SYRINGE/U-100/1ML/30G X 1/2" 96 TECHLITE INSULIN SYRINGEU- 1/2" 96 SURE-JECT INSULIN 100/0.5ML/30G X 1/2" 97 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/30G X 5/16" 96 100/0.5ML/30G X 5/16" 97 5/16" 96 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU- SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X 100/0.5ML/31G X 5/16" 97 SYRINGE/U-100/1ML/31G X 5/16" 97 TECHLITE INSULIN SYRINGEU- 5/16" 96 SURE-PEN 70 100/1ML/29G X 1/2" 97

Index 33 TECHLITE INSULIN SYRINGEU- tetrahydrozoline hcl THYROLAR-3 163 100/1ML/30G X 1/2" 97 (ophth) 156 tiagabine hcl 12 TECHLITE INSULIN SYRINGEU- TGT ALCOHOL SWABS 72 TIAZAC 34 100/1ML/30G X 5/16" 97 TGT LANCET MICRO THIN TECHLITE INSULIN SYRINGEU- 33G 70 TIKOSYN 9 100/1ML/31G X 5/16" 97 TGT LANCET THIN 26G 70 TIMOLOL MALEATE 33 TECHLITE LANCETS 70 TGT LANCET ULTRA THIN timolol maleate (ophth) 155 TECHLITE LANCETS 30G 70 30G 70 TIMOLOL MALEATE TECHLITE PEN NEEDLES 29GX TGT LANCING DEVICE 70 OPHTHALMIC GEL 12 MM 97 TGT OMEPRAZOLE 164 FORMING 155 TECHLITE PEN NEEDLES 31GX TIMOPTIC 155 5MM 97 THEO-24 10 TECHLITE PEN NEEDLES/31GX theophylline 10 TIMOPTIC-XE 155 5MM 97 THERA 148 TINACTIN 41 TECHLITE PEN NEEDLES/31GX TINACTIN JOCK ITCH 41 6 MM 97 THERA M PLUS 145 TECHLITE PEN NEEDLES/31GX THERA-M 145 tioconazole vaginal 167 8MM 97 THERA-TABS M 145 TIVICAY 31 TECHLITE PEN NEEDLES/32GX THERABETIC MULTI- tizanidine hcl 153 4MM 97 VITAMIN 145 TOBI 2 TECHLITE PEN NEEDLES/32GX THERABETIC SKIN CARE46 6MM 97 TOBRADEX 157 TECHLITE PEN NEEDLES/32GX THERAGAUZE 61 TOBRAMYCIN 2 8MM 97 THERAGRAN-M 145 tobramycin 2 TEGADERM FOAM DRESSING THERAGRAN-M tobramycin (ophth) 156 2"X2" 61 ADVANCED 145 TEGADERM FOAM DRESSING THERAGRAN-M ADVANCED TOBRAMYCIN SULFATE 2 4"X4" 61 50 PLUS 145 tobramycin sulfate 2 TEGRETOL 12 THERAGRAN-M tobramycin- TEGRETOL-XR 12 PREMIER 145 dexamethasone 157 THERAGRAN-M PREMIER 50 TOBREX 156 telmisartan 23 PLUS 145 telmisartan-amlodipine 24 THERANATAL CORE TODAY SPONGE 167 telmisartan-hydrochlorothiazide NUTRITION 152 TODAYS HEALTH ADVANCED 24 THERAPLEX LANCING DEVICE 70 temazepam 55 HYDROLOTION 46 TODAYS HEALTH MINI PEN NEEDLES 31G X 1/4" 97 TEMOVATE 43 THEREMS-H 145 TODAYS HEALTH ORIGINAL TEMOVATE E 43 THEREMS-M 145 PEN NEEDLES 29G X 1/2" 97 TENCON 4 thiamine hcl 168 TODAYS HEALTH SHORT PEN thiamine mononitrate 168 NEEDLES 31G X 5/16" 97 tenofovir disoproxil fumarate 31 TODAYS HEALTH SUPER TENORETIC 100 24 THINLETS GP LANCETS 70 THINLANCETS 30G 70 TENORETIC 50 24 THINLETS LANCET 70 TODAYS HEALTH ULTRA TENORMIN 33 thioridazine hcl 29 THINLANCETS 28G 70 TOFRANIL 16 TERAZOL 7 167 THIOTHIXENE 29 TOLMETIN SODIUM 3 terazosin hcl 23 thiothixene 29 tolnaftate 41 terbinafine hcl 19 THRESHOLD IMT 108 tolterodine tartrate 165 terbinafine hcl (topical) 41 THRIVITE 19 152 TOPAMAX 12 terbutaline sulfate 10 THRIVITE RX 152 thyroid 163 TOPAMAX SPRINKLE 12 TERCONAZOLE 167 TOPCARE CLICKFINE terconazole vaginal 167 THYROLAR-1 163 UNIVERSAL PEN EEDLES TESTOSTERONE THYROLAR-1/2 163 31GX1/4" 97 CYPIONATE 6 THYROLAR-1/4 163 TOPCARE CLICKFINE testosterone cypionate 6 THYROLAR-2 163 UNIVERSAL PEN EEDLES tetracaine hcl (ophth) 156 31GX5/16" 97

Index 34 TOPCARE ULTRA COMFORT TRECATOR 25 TROJAN PLEASURE INSULIN SYRINGE/0.3ML/30G X tretinoin 40 MESH/SPERMICIDAL 62 5/16" 97 TROJAN PLUS 62 TREXALL 26 TOPCARE ULTRA COMFORT TROJAN REGULAR 62 INSULIN SYRINGE/0.3ML/31G X TRI-NORINYL 28 36 5/16" 97 TRI-VIT/FLUORIDE/IRON TROJAN RIBBED 62 TOPCARE ULTRA COMFORT 150 TROJAN RIBBED INSULIN SYRINGE/0.5ML/30G X TRIADVANCE 152 W/SPERMICIDAL 62 TROJAN SHARED 5/16" 98 triamcinolone acetonide TOPCARE ULTRA COMFORT SENSATION/LUBRICATED 62 (mouth) 112 TROJAN SUPRAS INSULIN SYRINGE/0.5ML/31G X triamcinolone acetonide 5/16" 98 SPERMICIDAL 62 (nasal) 153 TROJAN TWISTED TOPCARE ULTRA COMFORT triamcinolone acetonide INSULIN SYRINGE/1ML/30G X PLEASURE 62 (topical) 43 TROJAN ULTRA 5/16" 98 TRIAMINIC COLD & COUGH TOPCARE ULTRA COMFORT PLEASURE/LUBRICATED 62 DAY TIME CHILDRENS 39 TROJAN VERY SENSITIVE INSULIN SYRINGE/1ML/31G X TRIAMINIC LONG ACTING 5/16" 98 LUBRICATED 62 COUGH 37 TROJAN VERY SENSITIVE TOPCARE ULTRA COMFORT triamterene & INSULIN SYRINGE/U- SPERMICIDAL LUBRICANT 62 hydrochlorothiazide 50 TROJAN VERY THIN 100/0.3ML/29G X 1/2" 98 triazolam 55 TOPCARE ULTRA COMFORT LUBRICATED 62 INSULIN SYRINGE/U- TRIBENZOR 25 TROJAN VERY THIN 100/0.5ML/29G X 1/2" 98 TRICARE 152 SPERMICIDAL LUBRICANT 62 TOPCARE ULTRA COMFORT TRICARE PRENATAL DHA TROJAN-ENZ LUBRICANT 62 INSULIN SYRINGE/U- ONE/FOLATE 152 TROJAN-ENZ 100/1ML/29G X 1/2" 98 TRIDESILON 43 LUBRICATED 62 TROJAN-ENZ TOPCO INSULIN SYRINGE/U- trifluoperazine hcl 29 100/0.3ML/29G X 1/2" 98 W/SPERMICIDAL 62 TOPCO INSULIN SYRINGE/U- trifluridine 156 tropicamide 155 100/0.5ML/28G X 1/2" 98 TRIGLIDE 21 trospium chloride 165 TOPCO INSULIN SYRINGE/U- trihexyphenidyl hcl 26 TRUE COMFORT INSULIN 100/0.5ML/29G X 1/2" 98 SYRINGE/0.5ML/31G X TOPCO INSULIN SYRINGE/U- TRILEPTAL 12 trimethoprim 7 5/16" 98 100/1ML/28G X 1/2" 98 TRUE COMFORT INSULIN TOPCO INSULIN SYRINGE/U- TRINATAL GT 152 SYRINGE/1ML/31G X 5/16" 98 100/1ML/29G X 1/2" 98 TRINATAL RX 1 152 TRUE COMFORT PEN TOPICORT 43 TRINTELLIX 15 NEEDLES31G X 5MM 98 topiramate 12 TRUE COMFORT PEN TOPPER DRESSING SPONGES TRISTART ONE 152 NEEDLES31G X 6MM 98 4"X4" 61 TRIUMEQ 31 TRUE COMFORT PEN TOPROL XL 33 TRIZIVIR 31 NEEDLES32G X 4MM 98 TROGARZO 31 TRUE METRIX BLOOD toremifene citrate 26 GLUCOSETEST STRIPS 49 torsemide 50 TROJAN 62 TRUE METRIX CONTROL TRADJENTA 17 TROJAN ASSORTMENT SOLUTION LEVEL 1 70 tramadol hcl 5 PACK 62 TRUE METRIX CONTROL TROJAN EXTENDED SOLUTION LEVEL 2 70 tramadol-acetaminophen 6 PLEASURE/LUBRICATED TRUE METRIX CONTROL trandolapril 22 62 SOLUTION LEVEL 3 70 trandolapril-verapamil hcl 24 TROJAN EXTRA TRUE METRIX SELF TRANDOLAPRIL/VERAPAMIL STRENGTH 62 MONITORING BLOOD HCL ER 24 TROJAN MAGNUM 62 GLUCOSE STRIPS 49 TRUECONTROL GLUCOSE tranexamic acid 54 TROJAN MAGNUM WARM SENSATIONS 62 CONTROL LEVEL 0 70 TRANXENE T 9 TROJAN MAGNUM XL TRUECONTROL GLUCOSE tranylcypromine sulfate 14 LUBRICATED 62 CONTROL LEVEL 1 70 trazodone hcl 15 TRUEDRAW LANCING DEVICE 70

Index 35 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES TUBING/WING TIP 108 NEEDLES 29GX12.7MM 98 31GX8MM 99 TUDORZA PRESSAIR 9 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES NEEDLES 31GX5MM 98 32GX4MM 99 TUMS 7 TRUEPLUS 5-BEVEL PEN TRUETEST BLOOD TUMS LASTING EFFECTS 7 NEEDLES 31GX6MM 98 GLUCOSE TEST 49 TWYNSTA 25 TRUEPLUS 5-BEVEL PEN TRUETEST BLOOD NEEDLES 31GX8MM 98 GLUCOSE TEST STRIPS 49 TYBOST 31 TRUEPLUS 5-BEVEL PEN TRUETEST GLUCOSE TYLENOL 4 NEEDLES 32GX4MM 98 CONTROLLEVEL 1 71 TYLENOL CHILDRENS 4 TRUEPLUS INSULIN TRUETEST GLUCOSE TYLENOL CHILDRENS SYRINGE/U-100/0.3ML/29G X CONTROLLEVEL 2 71 CHEWABLES/PAIN + FEVER4 1/2" 98 TRUETEST GLUCOSE TYLENOL EXTRA TRUEPLUS INSULIN CONTROLLEVEL 3 71 STRENGTH 4 SYRINGE/U-100/0.3ML/30G X TRUETEST STRIPS 49 TYLENOL INFANTS 4 5/16" 98 TRUETRACK BLOOD TRUEPLUS INSULIN TYLENOL INFANTS GLUCOSE TEST 49 PAIN+FEVER 4 SYRINGE/U-100/0.3ML/31G X TRUETRACK TEST 49 5/16" 98 TYLENOL/CODEINE #3 6 TRUEPLUS INSULIN TRUMENBA 165 TYLENOL/CODEINE #4 6 SYRINGE/U-100/0.5ML/28G X TRUSOPT 158 ULTI-LANCE AUTOMATIC/ 1/2" 98 TRUSTEX COLOR CONDOMS CLEAR TIP 71 TRUEPLUS INSULIN + LUBE 62 ULTICARE ALCOHOL SYRINGE/U-100/0.5ML/29G X TRUSTEX LUBRICATED 62 SWABS 72 1/2" 99 TRUSTEX LUBRICATED ULTICARE INSULIN SAFETY TRUEPLUS INSULIN EXTRALARGE 62 SYRINGE/0.5ML/29G X 1/2" 99 SYRINGE/U-100/0.5ML/30G X TRUSTEX LUBRICATED ULTICARE INSULIN SAFETY 5/16" 99 EXTRASTRENGTH 62 SYRINGE/1ML/29G X 1/2" 99 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X LUBRICATED/RIBBED/STUDD SYRINGE/0.3ML/29G X 1/2" 99 5/16" 99 ED 62 ULTICARE INSULIN TRUEPLUS INSULIN TRUSTEX SYRINGE/0.3ML/30G X 1/2" 99 SYRINGE/U-100/1ML/28G X LUBRICATED/SPERMICIDE ULTICARE INSULIN 1/2" 99 63 SYRINGE/0.3ML/30G X TRUEPLUS INSULIN TRUSTEX 5/16" 99 SYRINGE/U-100/1ML/29G X LUBRICATED/SPERMICIDE ULTICARE INSULIN 1/2" 99 EXTRA LARGE 62 SYRINGE/0.5ML/28G X 1/2" 99 TRUEPLUS INSULIN TRUSTEX ULTICARE INSULIN SYRINGE/U-100/1ML/30G X LUBRICATED/SPERMICIDE SYRINGE/0.5ML/29G X 1/2" 99 5/16" 99 EXTRA STRENGTH 62 ULTICARE INSULIN TRUEPLUS INSULIN TRUSTEX NATURAL SYRINGE/0.5ML/30G X 1/2" 99 SYRINGE/U-100/1ML/31G X CONDOMS ULTICARE INSULIN 5/16" 99 +LUBE/LUBRICATED 63 SYRINGE/0.5ML/30G X TRUEPLUS LANCETS 26G 70 TRUSTEX NON- 5/16" 99 LUBRICATED 63 ULTICARE INSULIN TRUEPLUS LANCETS 28G 70 SYRINGE/1ML/28G X 1/2" 99 TRUEPLUS LANCETS 28G TRUSTEX WITH NONOXYNOL- ULTICARE INSULIN SUPER THIN 70 SYRINGE/1ML/29G X 1/2" 99 TRUEPLUS LANCETS 30G 70 9/RIBBED/STUDDED 63 TRUSTEX/RIA ULTICARE INSULIN TRUEPLUS LANCETS 30G LUBRICATED 63 SYRINGE/1ML/30G X 1/2" 99 ULTRA THIN 70 TRUSTEX/RIA LUBRICATED ULTICARE INSULIN TRUEPLUS LANCETS 33G 70 SPERMICIDE 63 SYRINGE/1ML/30G X 5/16" 99 TRUEPLUS PEN NEEDLES TRUSTEX/RIA ULTICARE INSULIN 29GX12MM 99 LUBRICATED/SPERMICIDE SYRINGE/SHORT/0.3ML/30G X TRUEPLUS PEN NEEDLES 63 5/16" 99 31GX5MM 99 TRUSTEX/RIA NON- ULTICARE INSULIN TRUEPLUS PEN NEEDLES LUBRICATED 63 SYRINGE/SHORT/0.3ML/31G X 31GX6MM 99 TRUVADA 31 5/16" 99

Index 36 ULTICARE INSULIN ULTICARE MICRO PEN ULTILET INSULIN SYRINGE/SHORT/0.5ML/30G X NEEDLES 32G X 4MM 100 SYRINGE/SHORT/0.5ML/30G X 5/16" 99 ULTICARE MICRO PEN 5/16" 101 ULTICARE INSULIN NEEDLES/31G X 1/4" 100 ULTILET INSULIN SYRINGE/SHORT/0.5ML/31G X ULTICARE MICRO PEN SYRINGE/SHORT/0.5ML/31G X 5/16" 99 NEEDLES/31G X 5/16" 100 5/16" 101 ULTICARE INSULIN ULTICARE MICRO PEN ULTILET INSULIN SYRINGE/SHORT/1ML/30G X NEEDLES/32G X 4MM 100 SYRINGE/SHORT/1ML/30G X 5/16" 99 ULTICARE MICRO PEN 5/16" 101 ULTICARE INSULIN NEEDLES/32G X 5/32" 100 ULTILET INSULIN SYRINGE/SHORT/1ML/31G X ULTICARE MINI PEN SYRINGE/SHORT/1ML/31G X 5/16" 100 NEEDLES 31GX6MM 100 5/16" 101 ULTICARE INSULIN ULTICARE MINI PEN ULTILET INSULIN SYRINGE/U- SYRINGE/U-100/0.3ML/29G X NEEDLES ULTI-FINE IV 100 100/0.5ML/30G X 1/2" 101 1/2" 100 ULTICARE MINI PEN ULTILET INSULIN SYRINGE/U- ULTICARE INSULIN NEEDLES/31G X 6MM 100 100/1ML/30G X 1/2" 101 SYRINGE/U-100/0.3ML/30G X ULTICARE MINI PEN ULTILET PEN NEEDLE 1/2" 100 NEEDLES/32G X 1/4" 100 29GX12.7MM 101 ULTICARE INSULIN ULTICARE MINI PEN ULTILET PEN NEEDLE SYRINGE/U-100/0.3ML/30G X NEEDLES31GX6MM 100 31GX5MM 101 5/16" 100 ULTICARE ORIGINAL PEN ULTILET PEN NEEDLE ULTICARE INSULIN NEEDLES ULTI-FINE 100 31GX8MM 101 SYRINGE/U-100/0.3ML/31G X ULTICARE PEN NEEDLES ULTILET PEN NEEDLE 5/16" 100 31GX 5MM/MINI 101 32GX4MM 101 ULTICARE INSULIN ULTICARE PEN ULTILET PEN NEEDLE SYRINGE/U-100/0.5ML/29G X NEEDLES/29GX 12.7MM 101 32GX4MM/SHORT 101 1/2" 100 ULTICARE SHORT PEN ULTILET SAFETY LANCETS ULTICARE INSULIN NEEDLES 31GX8MM 101 21G X 2.2MM 71 SYRINGE/U-100/0.5ML/30G X ULTICARE SHORT PEN ULTILET SHORT PEN 1/2" 100 NEEDLES ULTI-FINE IV 101 NEEDLES 31GX5/16" 101 ULTICARE INSULIN ULTICARE SHORT PEN ULTILET SHORT PEN SYRINGE/U-100/0.5ML/30G X NEEDLES/31G X 8MM 101 NEEDLES31GX3/16" 101 5/16" 100 ULTILET CLASSIC ULTIMATE FEELING 63 ULTICARE INSULIN LANCETS 71 ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X ULTILET INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 100 SYRINGE/0.3ML/30G X 5/16" 101 ULTICARE INSULIN 8MM 101 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/29G X ULTILET INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 100 SYRINGE/0.3ML/31G X 1/2" 101 ULTICARE INSULIN 8MM 101 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X ULTILET INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 100 SYRINGE/0.5ML/30G X 5/16" 101 ULTICARE INSULIN 8MM 101 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X ULTILET INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 100 SYRINGE/1ML/30G X 5/16" 101 ULTICARE INSULIN 8MM 101 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X ULTILET INSULIN SYRINGE/U-100/0.5ML/28G X 5/16" 100 SYRINGE/1ML/31G X 1/2" 101 ULTICARE INSULIN 8MM 101 ULTRA-COMFORT INSULIN SYRINGEULTRAFINE U- ULTILET INSULIN SYRINGE/U-100/0.5ML/29G X 100/0.3ML/31G X 5/16" 100 SYRINGE/SHORT/0.3ML/30G 1/2" 102 ULTICARE INSULIN X 12.7MM 101 ULTRA-COMFORT INSULIN SYRINGEULTRAFINE U- ULTILET INSULIN SYRINGE/U-100/0.5ML/30G X 100/0.5ML/31G X 5/16" 100 SYRINGE/SHORT/0.3ML/30G 5/16" 102 ULTICARE INSULIN X 5/16" 101 ULTRA-COMFORT INSULIN SYRINGEULTRAFINE U- ULTILET INSULIN SYRINGE/U-100/0.5ML/31G X 100/1ML/31G X 5/16" 100 SYRINGE/SHORT/0.3ML/31G 5/16" 102 ULTICARE MICRO PEN X 5/16" 101 NEEDLES 31G X 8MM 100

Index 37 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNIFINE PENTIPS PLUS SYRINGE/U-100/1ML/28G X SYRINGE/U-100/0.5ML/31G X 32GX4MM 103 1/2" 102 5/16" 102 UNIFINE PENTIPS PLUS ULTRA-COMFORT INSULIN ULTRACARE INSULIN 33GX4MM 103 SYRINGE/U-100/1ML/29G X SYRINGE/U-100/1ML/30G X UNILET COMFORTOUCH 1/2" 102 1/2" 102 LANCET 71 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNILET EXCELITE 71 SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/30G X UNILET EXCELITE II 71 5/16" 102 5/16" 102 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNILET G.P. LANCET 71 SYRINGE/U-100/1ML/31G X SYRINGE/U-100/1ML/31G X UNILET G.P. SUPERLITE 5/16" 102 5/16" 102 LANCET 71 ULTRA-THIN II INSULIN ULTRACARE PEN UNILET GP 28 ULTRA THIN71 SYRINGE SHORT/U- NEEDLES/31G X 1/4" 103 UNILET LANCET 71 100/0.3ML/30GX5/16" 102 ULTRACARE PEN UNILET LANCETS MICRO- ULTRA-THIN II INSULIN NEEDLES/31G X 3/16" 103 THIN33G 71 SYRINGE SHORT/U- ULTRACARE PEN UNILET LANCETS SUPER- 100/0.3ML/31GX5/16" 102 NEEDLES/31G X 5/16" 103 THIN30G 71 ULTRA-THIN II INSULIN ULTRACARE PEN UNILET LANCETS ULTRA-THIN SYRINGE SHORT/U- NEEDLES/32G X 1/14" 103 28G 71 100/0.5ML/30GX5/16" 102 ULTRACARE PEN UNILET SUPERLITE ULTRA-THIN II INSULIN NEEDLES/32G X 3/16" 103 LANCET 71 SYRINGE SHORT/U- ULTRACARE PEN UNISOM SLEEPGELS 54 100/0.5ML/31GX5/16" 102 NEEDLES/32G X 5/32" 103 ULTRA-THIN II INSULIN ULTRACARE PEN UNISOM SLEEPTABS 54 SYRINGE SHORT/U- NEEDLES/33G X 5/32" 103 UNIVERSAL 1 LANCETS 100/1ML/30GX5/16" 102 ULTRACET 6 THIN26G 71 UNIVERSAL 1 LANCETS ULTRA ULTRA-THIN II INSULIN ULTRAM 5 SYRINGE SHORT/U- THIN 30G 71 ULTRATHON INSECT urea 43 100/1ML/31GX5/16" 102 REPELLENT 47 ULTRA-THIN II INSULIN ULTRATHON INSECT URECHOLINE 165 SYRINGE/U- REPELLENT 8 47 UROCIT-K 10 53 100/0.3ML/29GX1/2" 102 ULTRA-THIN II INSULIN UNICOMPLEX-M 145 UROCIT-K 5 53 SYRINGE/U- UNIFINE PENTIPS URSO 250 52 29GX12MM 103 100/0.5ML/29GX1/2" 102 ursodiol 52 ULTRA-THIN II INSULIN UNIFINE PENTIPS 31G X 3/16" 103 V-R MONOJECT INSULIN SYRINGE/U-100/1ML/29GX1/2" SYRINGE/U-100/0.3ML/29G X 102 UNIFINE PENTIPS 31GX5MM 103 1/2" 103 ULTRA-THIN II MINI PEN V-R MONOJECT INSULIN NEEEDLES/31GX3/16" 102 UNIFINE PENTIPS 31GX6MM 103 SYRINGE/U-100/0.5ML/28G X ULTRA-THIN II PEN NEEDLES 1/2" 103 29GX1/2" 102 UNIFINE PENTIPS 31GX8MM 103 V-R MONOJECT INSULIN ULTRA-THIN II PEN SYRINGE/U-100/0.5ML/29G X NEEDLES/SHORT/31GX5/16" UNIFINE PENTIPS 32GX4MM 103 1/2" 103 102 V-R MONOJECT INSULIN ULTRACARE INSULIN UNIFINE PENTIPS 32GX6MM 103 SYRINGE/U-100/1ML/28G X SYRINGE/U-100/0.3ML/30G X UNIFINE PENTIPS 1/2" 103 5/16" 102 33GX4MM 103 V-R MONOJECT INSULIN ULTRACARE INSULIN UNIFINE PENTIPS PLUS SYRINGE/U-100/1ML/29G X SYRINGE/U-100/0.3ML/31G X 29GX12MM 103 1/2" 103 5/16" 102 UNIFINE PENTIPS PLUS ULTRACARE INSULIN valacyclovir hcl 32 31GX5MM 103 VALCYTE 32 SYRINGE/U-100/0.5ML/30G X UNIFINE PENTIPS PLUS 1/2" 102 31GX6MM 103 valganciclovir hcl 32 ULTRACARE INSULIN UNIFINE PENTIPS PLUS VALIUM 9 SYRINGE/U-100/0.5ML/30G X 31GX8MM 103 5/16" 102 valproate sodium 13 valproic acid 13

Index 38 valsartan 23 VERIPRED 20 37 vitamins w/ lipotropics 152 valsartan-hydrochlorothiazide VERSIVA XC 3" X 3" FOAM VITAROCA PLUS 145 25 DRESSING/HYDROFIBER VITASANA 145 VALTREX 32 TECHNOLOGY 61 VITATRUM 145 VALUE HEALTH INSULIN VERSIVA XC 4" X 4" FOAM SYRINGE/U-100/0.5ML/29G X DRESSING/HYDROFIBER VITRUM 50+ SENIOR 1/2" 103 TECHNOLOGY 61 MULTI 145 VALUE HEALTH INSULIN VIBRAMYCIN 162 VIVELLE-DOT 52 SYRINGE/U-100/1ML/29G X VICTOZA 17 VIVITROL 19 1/2" 103 VIDA MIA AUTOLET VOL-PLUS 152 VALUE PLUS LANCETS LANCINGDEVICE 71 VOL-TAB RX 152 STANDARD 21G 71 VIDA MIA UNIFINE VALUE PLUS LANCETS PENTIPS32GX4MM 104 VOLTAREN 40 SUPERTHIN 30G 71 VIDA MIA UNIFINE VORTEX VALVED HOLDING VALUE PLUS LANCETS THIN PENTIPSMINI 31GX6MM104 CHAMBER 108 26G 71 VIDA MIA UNIFINE VOSPIRE ER 10 VALUE PLUS LANCING PENTIPSORIGINAL VP INSULIN SYRINGE/U- DEVICE 71 29GX12MM 104 100/0.3ML/29G X 1/2" 104 VALUMARK LANCET SUPER VIDA MIA UNILET LANCETS VP-ZEL 145 THIN 30G 71 SUPER THIN 30G 71 VYVANSE 1 VALUMARK LANCET ULTRA VIDA MIA UNILET LANCETS THIN 28G 71 ULTRA THIN 28G 71 W&F LANCETS 26G 71 VALUMARK PEN NEEDLES VIDA MIA UNIPFINE W&F LANCETS COLORED 29GX12MM 103 PENTIPSSHORT 21G 71 VALUMARK PEN NEEDLES 31GX8MM 104 WALGREENS COMFORT 31GX 6MM 103 VIDEX EC 31 ASSUREDLANCETS MICRO VALUMARK PEN NEEDLES THIN/33G 71 31GX 8MM 103 VIDEXPEDIATRIC 31 WALGREENS COMFORT VALVED HOLDING VIGAMOX 156 ASSUREDLANCETS SUPER CHAMBER 108 VIIBRYD 15 THIN/28G 72 VANCOCIN HCL 7,8 VIL-RX 152 WALGREENS GLUCOSE 16 vancomycin hcl 8 VINATE M 152 WALGREENS THIN VANICREAM LITE 46 LANCETS 72 VINATE ONE 152 VANISHPOINT INSULIN warfarin sodium 10 SYRINGE/0.5ML/30G X VIRACEPT 31 WATCHHALER 108 1/2" 103 VIRAMUNE 31 WEBCOL ALCOHOL PREP VANISHPOINT INSULIN VIRAMUNE XR 31 LARGE 1 PLY 72 SYRINGE/0.5ML/30G X VIREAD 31 WEBCOL ALCOHOL PREP 5/16" 103 LARGE 2 PLY 72 VANISHPOINT INSULIN VIROPTIC 156 WEBCOL ALCOHOL PREP SYRINGE/1ML/29G X 1/2" 103 VIRT-ADVANCE 152 MEDIUM 2 PLY 72 VANISHPOINT INSULIN VIRT-VITE GT 152 WEGMANS UNIFINE PENTIPS SYRINGE/1ML/30G X PLUS 32GX4MM 104 5/16" 103 VISINE 156 WEGMANS UNIFINE PENTIPS VASERETIC 25 VISTARIL 8 PLUS/MINI/31GX5MM 104 VASOTEC 22 VISTOGARD 18 WEGMANS UNIFINE PENTIPS VCF VAGINAL VITAFOL-OB 152 PLUS/SHORT/31GX8MM 104 VITALINE TOTAL FORMULA WEGMANS UNIFINE PENTIPS CONTRACEPTIVE FILM 167 PLUS/ULTRA VCF VAGINAL 2 145 CONTRACEPTIVE FOAM 167 VITALINE TOTAL FORMULA SHORT/31GX6MM 104 venlafaxine hcl 15 3 145 WELLBUTRIN SR 13,14 VENTOLIN HFA 10 VITAMIN D2 168 WELLBUTRIN XL 14 verapamil hcl 34 VITAMIN D3 COMPLETE 145 WESTHROID 163 VERAPAMIL HCL SR 34 vitamin e 168 white petrolatum-mineral oil 155 VITAMIN E 168 WHOLE FOOD VERELAN 34 MULTIVITAMIN 146 VERELAN PM 34 vitamin e 168

Index 39 WIBI 46 ZOMIG 109 WINDMILL TRAINER 108 ZOMIG ZMT 109 WOMENS 50+ MULTI VITAMIN& ZONEGRAN 12 MINERAL FORMULA 146 zonisamide 12 WOMENS BIOMULTIPLE 146 ZOSTAVAX 166 WOMENS MULTI VITAMIN & MINERAL FORMULA 146 ZOVIRAX 32,42 WP THYROID 163 ZYBAN 162 XALATAN 158 ZYLOPRIM 53 XANAX 9 ZYPREXA 28 XARELTO 10,11 ZYRTEC ALLERGY 20 XEROSTOMIA RELIEF ZYRTEC CHILDRENS SPRAY 113 ALLERGY 20 XULANE 36 ZYRTEC-D ALLERGY/CONGESTION 39 XYZAL 20 XYZAL ALLERGY 24HR 20 YASMIN 28 36 YAZ 36 YELETS TEENAGE FORMULA 146 ZADITOR 158 zaleplon 55 ZANAFLEX 153 ZANTAC 164 ZANTAC 150 MAXIMUM STRENGTH 164 ZANTAC 75 164 ZARONTIN 13 ZARXIO 54 ZEBETA 33 ZERIT 31 ZESTORETIC 25 ZESTRIL 22 ZIAC 25 ZIAGEN 31 zidovudine 31 zinc oxide (topical) 48 zinc sulfate 111 ziprasidone hcl 27 ZITHROMAX 56 ZITHROMAX TRI-PAK 56 ZITHROMAX Z-PAK 56 ZOCOR 22 ZOFRAN 19 ZOFRAN ODT 19 zolmitriptan 109 ZOLOFT 15 zolpidem tartrate 55

Index 40