Small Group and Individual Community Drug Formulary 2019

Key * Generic Available AG Age Limits F Females Only M Males Only OTC Over the Counter P Preventive PA Prior Authorization QL Quantity Limit SP Specialty Pharmacy ST Step Therapy

MHPCC20190105 G-3245 Beecher Road • Flint, Michigan • 48532 tel 888-327-0671 • fax 833-540-8648 McLarenHealthPlan.org Rev. 11/2020 Table of Contents

Allergy...... 3 Antiemesis/Antivertigo...... 6 Asthma And Copd...... 7 Autonomic Nervous System Disorders...... 11 Behavioral Health - Antidepressants...... 12 Behavioral Health - Other...... 15 Cardiovascular Disease - Arrhythmia...... 20 Cardiovascular Disease - Cardiac Stimulant...... 21 Cardiovascular Disease - Hypertension...... 21 Cardiovascular Disease - Lipid Irregularity...... 28 Cardiovascular Disease - Miscellaneous Agents...... 31 Cardiovascular Disease - Vasodilation...... 31 Contraception/Oxytocics...... 32 Cough And Cold...... 41 Dermatology - Acne...... 42 Dermatology - Antiinfective...... 44 Dermatology - Antiinflammatory...... 47 Dermatology - Antipruritic Drugs...... 51 Dermatology - Miscellaneous...... 51 Dermatology - Psoriasis/Eczema...... 55 Diabetes...... 56 Ear - General Disorders...... 65 Electrolyte Regulation...... 65 Endocrine Disorder - Fertility...... 67 Endocrine Disorder - Other...... 67 Endocrine Disorder - Thyroid...... 70 Eye - General Disorders...... 71 Eye - Glaucoma...... 75 Eye - Miscellaneous...... 76 Fluid Replacement...... 77 Gout And Related Diseases...... 77 Hematological Disorders...... 77 Hormonal Deficiency...... 80 Immunization...... 83 Immunosuppression/Modulation...... 84 Infectious Disease - Bacterial...... 85 Infectious Disease - Fungal...... 89 Infectious Disease - Miscellaneous...... 90 Infectious Disease - Parasitic...... 91 Infectious Disease - Viral...... 92 Inflammatory Disease...... 96 Local Anesthesia...... 101 Lower Gastrointestinal Disorders - Bowel Inflammat...... 101

1 Lower Gastrointestinal Disorders - Other...... 103 Medical Supplies...... 105 Miscellaneous Agents...... 125 Neoplastic Disease...... 126 Neurological Disease - Miscellaneous...... 129 Oral/Pharyngeal Disorders...... 130 Other Drugs...... 131 Other Respiratory Disorders...... 141 Pain Management - Analgesics...... 142 Parkinsons Disease...... 148 Seizure Disorder...... 149 Skeletal Muscle Disorder...... 152 Smoking Cessation...... 153 Upper Gastrointestinal Disorders - Digestive...... 154 Upper Gastrointestinal Disorders - Spastic Disease...... 154 Upper Gastrointestinal Disorders - Ulcer Disease...... 155 Urinary Tract - Functional Disorders...... 157 Vaginal Disorders...... 158 Vitamin And/Or Mineral Deficiency...... 159 Weight Reduction...... 164

2 Drug Status Notes Allergy 2Nd Gen Antihistamine & Decongestant Combinations ALAVERT D-12 ALLERGY-SINUS Tier 1 QL (2 EA per 1 day) ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG ALL DAY ALLERGY-D ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 12 HR 5-120 MG ALLERCLEAR D-12HR ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 12 HR 5-120 MG ALLERCLEAR D-24HR ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 24 HR 10-240 MG ALLERGY AND CONGESTION RELIEF Tier 1 QL (2 EA per 1 day) ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG ALLERGY AND CONGESTION RELIEF Tier 1 QL (2 EA per 1 day) ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG ALLERGY COMPLETE-D ORAL Tier 1 QL (2 EA per 1 day) TABLET EXTENDED RELEASE 12 HR 5-120 MG ALLERGY RELIEF D12 ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 12 HR 5-120 MG ALLERGY RELIEF D-24HR ORAL Tier 1 QL (2 EA per 1 day) TABLET EXTENDED RELEASE 24 HR 10-240 MG ALLERGY RELIEF,NASAL Tier 1 QL (2 EA per 1 day) DECONGEST ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG ALLERGY RELIEF-D (CETIRIZINE) Tier 1 QL (2 EA per 1 day) ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG ALLERGY RELIEF-D (LORATADINE) Tier 1 QL (2 EA per 1 day) ORAL TABLET EXTENDED RELEASE 12 HR 5-120 MG ALLERGY-CONGESTION RELIEF-D Tier 1 QL (2 EA per 1 day) ORAL TABLET EXTENDED RELEASE 24 HR 10-240 MG ALLER-TEC D ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 12 HR 5-120 MG CETIRI-D ORAL TABLET EXTENDED Tier 1 QL (2 EA per 1 day) RELEASE 12 HR 5-120 MG cetirizine-pseudoephedrine oral tablet (All Day Allergy-D) Tier 1 QL (2 EA per 1 day) extended release 12 hr 5-120 mg CLARINEX-D 12 HOUR ORAL TABLET, Tier 3 ER MULTIPHASE 12 HR 2.5-120 MG LORATA-D ORAL TABLET EXTENDED Tier 1 QL (2 EA per 1 day) RELEASE 24 HR 10-240 MG

3 Drug Status Notes LORATA-DINE D ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 24 HR 10-240 MG LORATADINE-D ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 12 HR 5-120 MG LORATADINE-D ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 24 HR 10-240 MG SEMPREX-D ORAL CAPSULE 8-60 MG Tier 3 WAL-ITIN D 12 HOUR ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 12 HR 5-120 MG WAL-ITIN D ORAL TABLET EXTENDED Tier 1 QL (2 EA per 1 day) RELEASE 24 HR 10-240 MG WAL-ZYR D ORAL TABLET Tier 1 QL (2 EA per 1 day) EXTENDED RELEASE 12 HR 5-120 MG Allergenic Extracts, Therapeutics GRASTEK SUBLINGUAL TABLET Tier 4 PA 2,800 BAU ORALAIR SUBLINGUAL TABLET 100 Tier 3 INDX REACTIVITY, 100 IR (3) /300 IR (6), 300 INDX REACTIVITY Antihistamines - 1St Generation carbinoxamine maleate oral liquid 4 Tier 1 mg/5 ml carbinoxamine maleate oral tablet 4 mg Tier 1 cyproheptadine oral syrup 2 mg/5 ml Tier 1 cyproheptadine oral tablet 4 mg Tier 1 hydroxyzine hcl oral solution 10 mg/5 ml Tier 1 hydroxyzine hcl oral tablet 10 mg, 25 Tier 1 mg, 50 mg hydroxyzine pamoate oral capsule 100 Tier 1 mg hydroxyzine pamoate oral capsule 25 (Vistaril) Tier 1 mg, 50 mg promethazine oral syrup 6.25 mg/5 ml Tier 1 promethazine oral tablet 12.5 mg, 25 Tier 1 mg, 50 mg Antihistamines - 2Nd Generation 24HOUR ALLERGY ORAL TABLET 10 Tier 1 QL (1 EA per 1 day) MG 24HR ALLERGY RELIEF ORAL Tier 1 QL (1 EA per 1 day) TABLET 5 MG ALAVERT ORAL Tier 1 QL (1 EA per 1 day) TABLET,DISINTEGRATING 10 MG ALL DAY ALLERGY (CETIRIZINE) Tier 1 QL (1 EA per 1 day) ORAL TABLET 10 MG ALLERCLEAR ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day) ALLER-EASE ORAL TABLET 60 MG Tier 1 QL (2 EA per 1 day) ALLERGY RELIEF (CETIRIZINE) ORAL Tier 1 QL (1 EA per 1 day) TABLET 10 MG

4 Drug Status Notes ALLERGY RELIEF (FEXOFENADINE) Tier 1 QL (2 EA per 1 day) ORAL TABLET 60 MG ALLERGY RELIEF (LEVOCETIRIZIN) Tier 1 QL (1 EA per 1 day) ORAL TABLET 5 MG ALLERGY RELIEF (LORATADINE) Tier 1 QL (150 ML per 30 days) ORAL SOLUTION 5 MG/5 ML ALLERGY RELIEF (LORATADINE) Tier 1 QL (1 EA per 1 day) ORAL TABLET 10 MG ALLERGY RELIEF (LORATADINE) Tier 1 QL (1 EA per 1 day) ORAL TABLET,DISINTEGRATING 10 MG ALLER-TEC ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day) cetirizine oral tablet 10 mg (24Hour Allergy) Tier 1 QL (1 EA per 1 day) cetirizine oral tablet 5 mg Tier 1 CHILDREN'S ALLERGY RELIEF(LOR) Tier 1 QL (150 ML per 30 days) ORAL SOLUTION 5 MG/5 ML CLARITIN ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day) desloratadine oral tablet 5 mg (Clarinex) Tier 1 QL (1 EA per 1 day) desloratadine oral tablet,disintegrating Tier 1 QL (1 EA per 1 day) 2.5 mg, 5 mg fexofenadine oral tablet 60 mg (Aller-ease) Tier 1 QL (2 EA per 1 day) levocetirizine oral solution 2.5 mg/5 ml (Xyzal) Tier 1 levocetirizine oral tablet 5 mg (24HR Allergy Relief) Tier 1 QL (1 EA per 1 day) LORADAMED ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day) loratadine oral solution 5 mg/5 ml (Allergy Relief (loratadine)) Tier 1 QL (150 ML per 30 days) loratadine oral tablet 10 mg (Allerclear) Tier 1 QL (1 EA per 1 day) loratadine oral tablet,disintegrating 10 (Alavert) Tier 1 QL (1 EA per 1 day) mg WAL-FEX ALLERGY ORAL TABLET 60 Tier 1 QL (2 EA per 1 day) MG WAL-ITIN ORAL SOLUTION 5 MG/5 ML Tier 1 QL (150 ML per 30 days) WAL-ITIN ORAL TABLET 10 MG Tier 1 QL (1 EA per 1 day) WAL-ZYR (CETIRIZINE) ORAL TABLET Tier 1 QL (1 EA per 1 day) 10 MG Nasal Antihistamine azelastine nasal aerosol,spray 137 mcg Tier 1 QL (30 ML per 30 days) (0.1 %) azelastine nasal spray,non-aerosol 0.15 Tier 1 QL (30 ML per 30 days) % (205.5 mcg) olopatadine nasal spray,non-aerosol 0.6 (Patanase) Tier 3 % Nasal Antihistamine & Anti-Inflam. Steroid Comb. DYMISTA NASAL SPRAY,NON- Tier 3 QL (23 GM per 30 days) AEROSOL 137-50 MCG/SPRAY Nasal Anti-Inflammatory Steroids 24 HOUR NASAL ALLERGY NASAL Tier 1 QL (16.9 ML per 30 days) AEROSOL,SPRAY 55 MCG

5 Drug Status Notes ALLER-CORT NASAL Tier 1 QL (16.9 ML per 30 days) AEROSOL,SPRAY 55 MCG BECONASE AQ NASAL SPRAY,NON- Tier 3 QL (25 GM per 30 days) AEROSOL 42 MCG (0.042 %) budesonide nasal spray,non-aerosol 32 (Rhinocort Allergy) Tier 1 QL (16.86 ML per 30 days) mcg/actuation CHILDREN'S NASACORT NASAL Tier 1 QL (16.9 ML per 30 days) AEROSOL,SPRAY 55 MCG flunisolide nasal spray,non-aerosol 25 Tier 1 mcg (0.025 %) fluticasone propionate nasal (24 Hour Allergy Relief) Tier 1 QL (16 GM per 30 days) spray,suspension 50 mcg/actuation mometasone nasal spray,non-aerosol 50 (Nasonex) Tier 3 QL (17 GM per 30 days) mcg/actuation NASAL ALLERGY NASAL Tier 1 QL (16.9 ML per 30 days) AEROSOL,SPRAY 55 MCG OMNARIS NASAL SPRAY,NON- Tier 3 QL (12.5 GM per 30 days) AEROSOL 50 MCG QNASL NASAL HFA AEROSOL Tier 3 QL (8.7 GM per 30 days) INHALER 80 MCG/ACTUATION RHINOCORT ALLERGY NASAL Tier 2 QL (16.86 ML per 30 days) SPRAY,NON-AEROSOL 32 MCG/ACTUATION triamcinolone acetonide nasal (24 Hour Nasal Allergy) Tier 1 QL (16.9 ML per 30 days) aerosol,spray 55 mcg ZETONNA NASAL HFA AEROSOL Tier 3 INHALER 37 MCG/ACTUATION Antiemesis/Antivertigo Antiemetic, Cannibinoid-Type CESAMET ORAL CAPSULE 1 MG Tier 3 dronabinol oral capsule 10 mg, 2.5 mg, 5 (Marinol) Tier 1 mg Antiemetic/Antivertigo Agents AKYNZEO (NETUPITANT) ORAL Tier 3 CAPSULE 300-0.5 MG aprepitant oral capsule 125 mg Tier 3 aprepitant oral capsule 40 mg, 80 mg (Emend) Tier 3 aprepitant oral capsule,dose pack 125 (Emend) Tier 3 mg (1)- 80 mg (2) COMPRO RECTAL SUPPOSITORY 25 Tier 1 QL (12 EA per 5 days) MG DRAMAMINE LESS DROWSY ORAL Tier 1 TABLET 25 MG granisetron hcl oral tablet 1 mg Tier 1 meclizine oral tablet 12.5 mg Tier 1 meclizine oral tablet 25 mg (Dramamine Less Drowsy) Tier 1 MEDI-MECLIZINE ORAL TABLET 25 Tier 1 MG MOTION RELIEF (MECLIZINE) ORAL Tier 1 TABLET 25 MG

6 Drug Status Notes MOTION SICKNESS (MECLIZINE) Tier 1 ORAL TABLET 25 MG MOTION SICKNESS II ORAL TABLET Tier 1 25 MG MOTION SICKNESS RELIEF(MECLIZ) Tier 1 ORAL TABLET 25 MG ondansetron hcl oral solution 4 mg/5 ml Tier 1 Age (Max 12 Years) ondansetron hcl oral tablet 24 mg Tier 1 QL (1 EA per 1 day) ondansetron hcl oral tablet 4 mg (Zofran) Tier 1 QL (4 EA per 1 day) ondansetron hcl oral tablet 8 mg Tier 1 QL (3 EA per 1 day) ondansetron oral tablet,disintegrating 4 Tier 1 QL (4 EA per 1 day) mg ondansetron oral tablet,disintegrating 8 Tier 1 QL (3 EA per 1 day) mg prochlorperazine maleate oral tablet 10 (Compazine) Tier 1 mg, 5 mg prochlorperazine rectal suppository 25 (Compro) Tier 1 QL (12 EA per 5 days) mg promethazine rectal suppository 12.5 (Promethegan) Tier 1 QL (12 EA per 5 days) mg, 25 mg, 50 mg PROMETHEGAN RECTAL Tier 1 QL (12 EA per 5 days) SUPPOSITORY 12.5 MG, 25 MG, 50 MG SANCUSO TRANSDERMAL PATCH Tier 3 WEEKLY 3.1 MG/24 HOUR scopolamine base transdermal patch 3 (Transderm-Scop) Tier 1 QL (1 EA per 3 days) day 1 mg over 3 days TRAVEL-EASE (MECLIZINE) ORAL Tier 1 TABLET 25 MG trimethobenzamide oral capsule 300 mg (Tigan) Tier 1 VERTICALM ORAL TABLET 25 MG Tier 1 WAL-DRAM 2 ORAL TABLET 25 MG Tier 1 ZUPLENZ ORAL FILM 4 MG, 8 MG Tier 3 Asthma And Copd 5-Lipoxygenase Inhibitors zileuton oral tablet, er multiphase 12 hr Tier 3 QL (4 EA per 1 day) 600 mg Anticholinergic, Orally Inhaled Short Acting ATROVENT HFA INHALATION HFA Tier 2 QL (25.8 GM per 30 days) AEROSOL INHALER 17 MCG/ACTUATION ipratropium bromide inhalation solution Tier 1 0.02 % Anticholinergics, Orally Inhaled Long Acting INCRUSE ELLIPTA INHALATION Tier 3 QL (30 EA per 30 days) BLISTER WITH DEVICE 62.5 MCG/ACTUATION

7 Drug Status Notes SPIRIVA RESPIMAT INHALATION Tier 2 QL (4 GM per 30 days) MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER Tier 2 QL (30 EA per 30 days) INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG TUDORZA PRESSAIR INHALATION Tier 3 QL (1 EA per 30 days) AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION Beta-Adrenergic Agents albuterol sulfate oral syrup 2 mg/5 ml Tier 1 albuterol sulfate oral tablet 2 mg, 4 mg Tier 1 albuterol sulfate oral tablet extended Tier 1 release 12 hr 4 mg, 8 mg metaproterenol oral syrup 10 mg/5 ml Tier 1 terbutaline oral tablet 2.5 mg, 5 mg Tier 1 Beta-Adrenergic Agents, Inhaled, Short Acting albuterol sulfate inhalation hfa aerosol (ProAir HFA) Tier 1 QL (13.4 GM per 30 days) inhaler 90 mcg/actuation albuterol sulfate inhalation solution for Tier 1 nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml levalbuterol hcl inhalation solution for (Xopenex) Tier 1 nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for (Xopenex Concentrate) Tier 1 nebulization 1.25 mg/0.5 ml levalbuterol tartrate inhalation hfa (Xopenex HFA) Tier 1 QL (30 GM per 30 days) aerosol inhaler 45 mcg/actuation PROAIR HFA INHALATION HFA Tier 3 AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION Tier 2 QL (2 EA per 30 days) AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION PROVENTIL HFA INHALATION HFA Tier 3 AEROSOL INHALER 90 MCG/ACTUATION VENTOLIN HFA INHALATION HFA Tier 3 QL (36 GM per 30 days) AEROSOL INHALER 90 MCG/ACTUATION Beta-Adrenergic Agents, Inhaled, Ultra- Long Acting ARCAPTA NEOHALER INHALATION Tier 2 QL (30 EA per 30 days) CAPSULE, W/INHALATION DEVICE 75 MCG STRIVERDI RESPIMAT INHALATION Tier 3 QL (4 GM per 25 days) MIST 2.5 MCG/ACTUATION

8 Drug Status Notes Beta-Adrenergic Agents, Orally Inhaled,Long Acting BROVANA INHALATION SOLUTION Tier 2 FOR NEBULIZATION 15 MCG/2 ML PERFOROMIST INHALATION Tier 3 SOLUTION FOR NEBULIZATION 20 MCG/2 ML SEREVENT DISKUS INHALATION Tier 2 QL (60 EA per 30 days) BLISTER WITH DEVICE 50 MCG/DOSE Beta-Adrenergic And Anticholinergic Combinations ANORO ELLIPTA INHALATION Tier 3 QL (60 EA per 30 days) BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION Tier 2 QL (4 GM per 20 days) MIST 20-100 MCG/ACTUATION ipratropium-albuterol inhalation solution Tier 1 for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml STIOLTO RESPIMAT INHALATION Tier 3 QL (4 GM per 30 days) MIST 2.5-2.5 MCG/ACTUATION Beta-Adrenergic And Glucocorticoid Combinations ADVAIR DISKUS INHALATION Tier 1 QL (60 EA per 30 days) BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500- 50 MCG/DOSE ADVAIR HFA INHALATION HFA Tier 3 QL (12 GM per 30 days) AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER Tier 3 QL (60 EA per 30 days) WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE DULERA INHALATION HFA AEROSOL Tier 2 QL (13 GM per 30 days) INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION SYMBICORT INHALATION HFA Tier 2 QL (10.2 GM per 30 days) AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION Glucocorticoids, Orally Inhaled ALVESCO INHALATION HFA Tier 3 QL (12.2 GM per 30 days) AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION

9 Drug Status Notes ARNUITY ELLIPTA INHALATION Tier 2 QL (30 EA per 30 days) BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION ASMANEX TWISTHALER INHALATION Tier 3 QL (1 EA per 30 days) AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60) budesonide inhalation suspension for (Pulmicort) Tier 1 Age (Max 12 Years) nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml FLOVENT DISKUS INHALATION Tier 2 QL (60 EA per 30 days) BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA Tier 2 QL (12 GM per 30 days) AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION PULMICORT FLEXHALER Tier 2 QL (1 EA per 30 days) INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QVAR REDIHALER INHALATION HFA Tier 2 QL (10.6 GM per 30 days) AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION Leukotriene Receptor Antagonists montelukast oral granules in packet 4 (Singulair) Tier 1 mg montelukast oral tablet 10 mg (Singulair) Tier 1 QL (1 EA per 1 day) montelukast oral tablet,chewable 4 mg, 5 (Singulair) Tier 1 QL (1 EA per 1 day) mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) Tier 1 QL (2 EA per 1 day) Mast Cell Stabilizers cromolyn oral concentrate 100 mg/5 ml (Gastrocrom) Tier 1 Mast Cell Stabilizers, Orally Inhaled cromolyn inhalation solution for Tier 1 nebulization 20 mg/2 ml Phosphodiesterase-4 (Pde4) Inhibitors DALIRESP ORAL TABLET 250 MCG, Tier 2 500 MCG Respiratory Aids,Devices,Equipment AEROCHAMBER MINI SPACER Tier 2 AEROCHAMBER MV SPACER Tier 2

10 Drug Status Notes AEROCHAMBER PLUS FLOW-VU Tier 2 SPACER AEROCHAMBER PLUS FLOW-VU,L Tier 2 MSK SPACER AEROCHAMBER PLUS FLOW-VU,M Tier 2 MSK SPACER AEROCHAMBER PLUS FLOW-VU,S Tier 2 MSK SPACER AEROCHAMBER PLUS Z STAT LG Tier 2 MSK SPACER AEROCHAMBER PLUS Z STAT MD Tier 2 MSK SPACER AEROCHAMBER PLUS Z STAT SM Tier 2 MSK SPACER AEROCHAMBER PLUS Z STAT Tier 2 SPACER AEROCHAMBER WITH FLOWSIGNAL Tier 2 SPACER AEROCHAMBER Z-STAT PLUS-FLW Tier 2 SG SPACER Xanthines ELIXOPHYLLIN ORAL ELIXIR 80 Tier 2 MG/15 ML THEOCHRON ORAL TABLET Tier 1 EXTENDED RELEASE 12 HR 100 MG, 200 MG, 300 MG theophylline oral elixir 80 mg/15 ml (Elixophyllin) Tier 1 theophylline oral solution 80 mg/15 ml Tier 1 theophylline oral tablet extended release Tier 1 12 hr 300 mg, 450 mg theophylline oral tablet extended release Tier 1 24 hr 400 mg, 600 mg Autonomic Nervous System Disorders Alzheimer's Therapy, Nmda Receptor Antagonists memantine oral capsule,sprinkle,er 24hr (Namenda XR) Tier 1 14 mg, 21 mg, 28 mg, 7 mg memantine oral tablet 10 mg, 5 mg (Namenda) Tier 1 QL (2 EA per 1 day) memantine oral tablets,dose pack 5-10 (Namenda Titration Pak) Tier 1 QL (49 EA per 28 days) mg NAMENDA XR ORAL Tier 3 CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG NAMENDA XR ORAL Tier 3 CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG Cholinesterase Inhibitors donepezil oral tablet 10 mg, 5 mg (Aricept) Tier 1 QL (2 EA per 1 day) donepezil oral tablet 23 mg (Aricept) Tier 1 QL (1 EA per 1 day)

11 Drug Status Notes donepezil oral tablet,disintegrating 10 Tier 1 mg, 5 mg galantamine oral capsule,ext rel. pellets (Razadyne ER) Tier 1 QL (1 EA per 1 day) 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml Tier 1 galantamine oral tablet 12 mg, 4 mg, 8 Tier 1 QL (2 EA per 1 day) mg MESTINON ORAL SYRUP 60 MG/5 ML Tier 2 pyridostigmine bromide oral tablet 60 mg (Mestinon) Tier 1 pyridostigmine bromide oral tablet (Mestinon Timespan) Tier 1 extended release 180 mg rivastigmine tartrate oral capsule 1.5 mg, Tier 1 QL (2 EA per 1 day) 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour (Exelon) Tier 3 13.3 mg/24 hour rivastigmine transdermal patch 24 hour (Exelon) Tier 3 QL (1 EA per 1 day) 4.6 mg/24 hr, 9.5 mg/24 hr Behavioral Health - Antidepressants Alpha-2 Receptor Antagonist Antidepressants mirtazapine oral tablet 15 mg, 30 mg (Remeron) Tier 1 mirtazapine oral tablet 45 mg, 7.5 mg Tier 1 mirtazapine oral tablet,disintegrating 15 (Remeron SolTab) Tier 1 mg, 30 mg, 45 mg Maois - Non-Selective & Irreversible MARPLAN ORAL TABLET 10 MG Tier 3 phenelzine oral tablet 15 mg (Nardil) Tier 1 tranylcypromine oral tablet 10 mg (Parnate) Tier 1 Norepinephrine And Dopamine Reuptake Inhib (Ndris) APLENZIN ORAL TABLET EXTENDED Tier 3 PA RELEASE 24 HR 174 MG, 348 MG, 522 MG bupropion hcl oral tablet 100 mg, 75 mg Tier 1 bupropion hcl oral tablet extended (Wellbutrin XL) Tier 1 QL (1 EA per 1 day) release 24 hr 150 mg, 300 mg bupropion hcl oral tablet sustained- (Wellbutrin SR) Tier 1 QL (2 EA per 1 day) release 12 hr 100 mg, 150 mg, 200 mg WELLBUTRIN SR ORAL TABLET Tier 1 QL (2 EA per 1 day) SUSTAINED-RELEASE 12 HR 150 MG Selective Serotonin Reuptake Inhibitor (Ssris) citalopram oral solution 10 mg/5 ml Tier 1 QL (20 ML per 1 day) citalopram oral tablet 10 mg, 20 mg, 40 (Celexa) Tier 1 mg escitalopram oxalate oral solution 5 mg/5 Tier 1 ml escitalopram oxalate oral tablet 10 mg, (Lexapro) Tier 1 20 mg, 5 mg

12 Drug Status Notes fluoxetine oral capsule 10 mg, 20 mg, 40 (Prozac) Tier 1 mg fluoxetine oral capsule,delayed Tier 1 QL (4 EA per 28 days) release(dr/ec) 90 mg fluoxetine oral solution 20 mg/5 ml (4 Tier 1 mg/ml) fluoxetine oral tablet 10 mg, 20 mg (Sarafem) Tier 1 fluoxetine oral tablet 60 mg Tier 1 fluvoxamine oral capsule,extended Tier 1 release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, Tier 1 50 mg paroxetine hcl oral tablet 10 mg, 20 mg, (Paxil) Tier 1 30 mg, 40 mg paroxetine hcl oral tablet extended (Paxil CR) Tier 1 QL (1 EA per 1 day) release 24 hr 12.5 mg, 25 mg, 37.5 mg PAXIL ORAL SUSPENSION 10 MG/5 Tier 3 PA ML PEXEVA ORAL TABLET 10 MG, 20 MG, Tier 3 PA 30 MG, 40 MG sertraline oral concentrate 20 mg/ml (Zoloft) Tier 1 sertraline oral tablet 100 mg, 25 mg, 50 (Zoloft) Tier 1 mg Serotonin-2 Antagonist/Reuptake Inhibitors (Saris) nefazodone oral tablet 100 mg, 150 mg, Tier 1 200 mg, 250 mg, 50 mg trazodone oral tablet 100 mg, 150 mg, Tier 1 300 mg, 50 mg Serotonin-Norepinephrine Reuptake- Inhib (Snris) desvenlafaxine oral tablet extended Tier 3 PA release 24 hr 100 mg desvenlafaxine oral tablet extended Tier 3 release 24 hr 50 mg desvenlafaxine succinate oral tablet (Pristiq) Tier 3 extended release 24 hr 100 mg, 25 mg, 50 mg duloxetine oral capsule,delayed (Cymbalta) Tier 1 QL (2 EA per 1 day) release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed (Cymbalta) Tier 1 QL (1 EA per 1 day) release(dr/ec) 30 mg FETZIMA ORAL CAPSULE,EXT REL Tier 3 PA 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED Tier 3 PA RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG venlafaxine oral capsule,extended (Effexor XR) Tier 1 release 24hr 150 mg, 37.5 mg, 75 mg

13 Drug Status Notes venlafaxine oral tablet 100 mg, 25 mg, Tier 1 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release Tier 3 QL (1 EA per 1 day) 24hr 150 mg, 225 mg, 37.5 mg, 75 mg Ssri & 5Ht1a Partial Agonist Antidepressant VIIBRYD ORAL TABLET 10 MG, 20 MG, Tier 3 QL (1 EA per 1 day) 40 MG VIIBRYD ORAL TABLETS,DOSE PACK Tier 3 10 MG (7)- 20 MG (23) Ssri & Serotonin Receptor Modulator Antidepressant TRINTELLIX ORAL TABLET 10 MG, 5 Tier 3 PA; QL (1 EA per 1 day) MG TRINTELLIX ORAL TABLET 20 MG Tier 3 PA Tricyclic Antidepressant/Benzodiazepine Combinatns amitriptyline-chlordiazepoxide oral tablet Tier 1 12.5-5 mg, 25-10 mg Tricyclic Antidepressant/Phenothiazine Combinatns perphenazine-amitriptyline oral tablet 2- Tier 1 10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg Tricyclic Antidepressants & Rel. Non- Sel. Ru-Inhib amitriptyline oral tablet 10 mg, 100 mg, Tier 1 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, Tier 1 25 mg, 50 mg clomipramine oral capsule 25 mg, 50 (Anafranil) Tier 1 mg, 75 mg desipramine oral tablet 10 mg, 25 mg (Norpramin) Tier 1 desipramine oral tablet 100 mg, 150 mg, Tier 1 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, Tier 1 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml Tier 1 imipramine hcl oral tablet 10 mg, 25 mg, Tier 1 50 mg imipramine pamoate oral capsule 100 Tier 1 QL (1 EA per 1 day) mg, 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 Tier 1 mg nortriptyline oral capsule 10 mg, 25 mg, (Pamelor) Tier 1 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml Tier 1 protriptyline oral tablet 10 mg, 5 mg Tier 1

14 Drug Status Notes trimipramine oral capsule 100 mg, 25 Tier 1 mg, 50 mg Behavioral Health - Other Adrenergics, Aromatic, Non- Catecholamine amphetamine sulfate oral tablet 10 mg, 5 (Evekeo) Tier 1 mg dextroamphetamine oral capsule, (Dexedrine Spansule) Tier 1 QL (1 EA per 1 day) extended release 10 mg, 5 mg dextroamphetamine oral capsule, (Dexedrine Spansule) Tier 1 PA; QL (1 EA per 1 day) extended release 15 mg dextroamphetamine oral solution 5 mg/5 (ProCentra) Tier 3 Age (Max 12 Years) ml dextroamphetamine oral tablet 10 mg (Zenzedi) Tier 1 PA dextroamphetamine oral tablet 5 mg (Zenzedi) Tier 1 dextroamphetamine-amphetamine oral (Adderall XR) Tier 1 QL (1 EA per 1 day) capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral (Adderall XR) Tier 1 QL (2 EA per 1 day) capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral (Adderall) Tier 1 QL (2 EA per 1 day) tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg EVEKEO ORAL TABLET 10 MG, 5 MG Tier 3 PA methamphetamine oral tablet 5 mg (Desoxyn) Tier 1 PA VYVANSE ORAL CAPSULE 10 MG, 20 Tier 3 QL (1 EA per 1 day) MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG ZENZEDI ORAL TABLET 10 MG Tier 1 PA ZENZEDI ORAL TABLET 5 MG Tier 1 Anti-Alcoholic Preparations acamprosate oral tablet,delayed release Tier 1 (dr/ec) 333 mg disulfiram oral tablet 250 mg, 500 mg (Antabuse) Tier 1 Anti-Anxiety - Benzodiazepines ALPRAZOLAM INTENSOL ORAL Tier 3 CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25 mg, 0.5 mg, 1 (Xanax) Tier 1 mg, 2 mg alprazolam oral tablet extended release (Xanax XR) Tier 1 QL (45 EA per 30 days) 24 hr 0.5 mg, 1 mg alprazolam oral tablet extended release (Xanax XR) Tier 1 QL (93 EA per 30 days) 24 hr 2 mg, 3 mg alprazolam oral tablet,disintegrating 0.25 Tier 1 mg, 0.5 mg, 1 mg, 2 mg chlordiazepoxide hcl oral capsule 10 mg, Tier 1 25 mg, 5 mg clorazepate dipotassium oral tablet 15 Tier 1 mg, 3.75 mg

15 Drug Status Notes clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) Tier 1 mg DIAZEPAM INTENSOL ORAL Tier 1 CONCENTRATE 5 MG/ML diazepam oral concentrate 5 mg/ml (Diazepam Intensol) Tier 1 diazepam oral solution 5 mg/5 ml (1 Tier 1 mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) Tier 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 (Ativan) Tier 1 mg oxazepam oral capsule 10 mg, 15 mg, Tier 1 30 mg Anti-Anxiety Drugs buspirone oral tablet 10 mg, 15 mg, 30 Tier 1 mg, 5 mg, 7.5 mg meprobamate oral tablet 200 mg, 400 Tier 1 mg Anti-Mania Drugs lithium carbonate oral capsule 150 mg, Tier 1 300 mg, 600 mg lithium carbonate oral tablet 300 mg Tier 1 lithium carbonate oral tablet extended (Lithobid) Tier 1 release 300 mg lithium carbonate oral tablet extended Tier 1 release 450 mg lithium citrate oral solution 8 meq/5 ml Tier 3 Anti-Narcolepsy & Anti- Cataplexy,Sedative-Type Agt XYREM ORAL SOLUTION 500 MG/ML Tier 4 PA; SP Antipsych,Dopamine Antag.,Diphenylbutylpiperidines pimozide oral tablet 1 mg, 2 mg Tier 3 Antipsychotic-Atypical,D3/D2 Partial Ag-5Ht Mixed VRAYLAR ORAL CAPSULE 1.5 MG, 3 Tier 3 PA MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE Tier 3 PA PACK 1.5 MG (1)- 3 MG (6) Antipsychotics, Atyp, D2 Partial Agonist/5Ht Mixed aripiprazole oral solution 1 mg/ml Tier 1 Age (Max 12 Years) aripiprazole oral tablet 10 mg, 15 mg, 2 (Abilify) Tier 1 QL (1 EA per 1 day) mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet,disintegrating 10 Tier 1 mg, 15 mg REXULTI ORAL TABLET 0.25 MG, 0.5 Tier 3 PA; QL (1 EA per 1 day) MG, 1 MG, 2 MG, 3 MG, 4 MG

16 Drug Status Notes Antipsychotics, Dopamine & Serotonin Antagonists loxapine succinate oral capsule 10 mg, Tier 1 25 mg, 5 mg, 50 mg Antipsychotics,Atypical,Dopamine,& Serotonin Antag clozapine oral tablet 100 mg, 200 mg, 25 (Clozaril) Tier 1 mg, 50 mg clozapine oral tablet,disintegrating 100 Tier 1 mg, 12.5 mg, 25 mg clozapine oral tablet,disintegrating 150 Tier 3 mg, 200 mg FANAPT ORAL TABLET 1 MG, 10 MG, Tier 3 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK Tier 3 1MG(2)-2MG(2)- 4MG(2)-6MG(2) LATUDA ORAL TABLET 120 MG, 20 Tier 3 PA; QL (1 EA per 1 day) MG, 40 MG, 60 MG, 80 MG olanzapine oral tablet 10 mg, 15 mg, 2.5 (Zyprexa) Tier 1 QL (1 EA per 1 day) mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) Tier 1 mg, 15 mg, 20 mg, 5 mg paliperidone oral tablet extended release (Invega) Tier 3 QL (1 EA per 1 day) 24hr 1.5 mg, 3 mg, 6 mg, 9 mg quetiapine oral tablet 100 mg, 200 mg, (Seroquel) Tier 1 25 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release (Seroquel XR) Tier 3 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg RISPERDAL CONSTA Tier 4 PA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml (Risperdal) Tier 1 risperidone oral tablet 0.25 mg Tier 1 QL (45 EA per 30 days) risperidone oral tablet 0.5 mg, 1 mg (Risperdal) Tier 1 QL (45 EA per 30 days) risperidone oral tablet 2 mg (Risperdal) Tier 1 QL (1 EA per 1 day) risperidone oral tablet 3 mg, 4 mg (Risperdal) Tier 1 QL (2 EA per 1 day) risperidone oral tablet,disintegrating 0.25 Tier 1 QL (45 EA per 30 days) mg, 0.5 mg, 1 mg risperidone oral tablet,disintegrating 2 Tier 1 QL (1 EA per 1 day) mg risperidone oral tablet,disintegrating 3 Tier 1 QL (2 EA per 1 day) mg, 4 mg SAPHRIS SUBLINGUAL TABLET 10 Tier 3 MG, 2.5 MG, 5 MG VERSACLOZ ORAL SUSPENSION 50 Tier 3 MG/ML

17 Drug Status Notes ziprasidone hcl oral capsule 20 mg, 40 (Geodon) Tier 1 QL (2 EA per 1 day) mg, 60 mg, 80 mg Antipsychotics,Dopamine Antagonists, Thioxanthenes thiothixene oral capsule 1 mg, 10 mg, 2 Tier 1 mg, 5 mg Antipsychotics,Dopamine Antagonists,Butyrophenones haloperidol lactate oral concentrate 2 Tier 1 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 Tier 1 mg, 2 mg, 20 mg, 5 mg Anti-Psychotics,Phenothiazines chlorpromazine oral tablet 10 mg, 100 Tier 1 mg, 200 mg, 25 mg, 50 mg fluphenazine hcl oral concentrate 5 Tier 1 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml Tier 1 fluphenazine hcl oral tablet 1 mg, 10 mg, Tier 1 2.5 mg, 5 mg perphenazine oral tablet 16 mg, 2 mg, 4 Tier 1 mg, 8 mg thioridazine oral tablet 10 mg, 100 mg, Tier 1 25 mg, 50 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 Tier 1 mg, 5 mg Barbiturates phenobarbital oral elixir 20 mg/5 ml (4 Tier 1 mg/ml) phenobarbital oral tablet 100 mg, 15 mg, Tier 1 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg SECONAL SODIUM ORAL CAPSULE Tier 3 100 MG Hsdd Agents-Mixed Serotonin Agonist/Antagonists ADDYI ORAL TABLET 100 MG Tier 3 PA Hypnotics, Melatonin Mt1/Mt2 Receptor Agonists HETLIOZ ORAL CAPSULE 20 MG Tier 4 PA; SP; QL (1 EA per 1 day) ROZEREM ORAL TABLET 8 MG Tier 3 QL (1 EA per 1 day) Monoamine Oxidase(Mao) Inhibitors EMSAM TRANSDERMAL PATCH 24 Tier 3 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR Narcolepsy And Sleep Disorder Therapy Agents armodafinil oral tablet 150 mg, 250 mg, (Nuvigil) Tier 3 QL (1 EA per 1 day) 50 mg

18 Drug Status Notes modafinil oral tablet 100 mg, 200 mg (Provigil) Tier 1 Narcotic Antagonists naloxone injection syringe 0.4 mg/ml Tier 1 QL (4 ML per 1 FILL) naloxone injection syringe 1 mg/ml Tier 1 naltrexone oral tablet 50 mg Tier 1 NARCAN NASAL SPRAY,NON- Tier 3 AEROSOL 4 MG/ACTUATION Sedative-Hypnotics - Benzodiazepines estazolam oral tablet 1 mg, 2 mg Tier 1 QL (1 EA per 1 day) flurazepam oral capsule 15 mg, 30 mg Tier 1 quazepam oral tablet 15 mg (Doral) Tier 1 temazepam oral capsule 15 mg, 22.5 (Restoril) Tier 1 mg, 30 mg, 7.5 mg triazolam oral tablet 0.125 mg Tier 1 triazolam oral tablet 0.25 mg (Halcion) Tier 1 Sedative-Hypnotics,Non-Barbiturate BELSOMRA ORAL TABLET 10 MG, 15 Tier 3 QL (1 EA per 1 day) MG, 20 MG, 5 MG EDLUAR SUBLINGUAL TABLET 10 Tier 3 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) Tier 1 QL (1 EA per 1 day) SILENOR ORAL TABLET 3 MG, 6 MG Tier 3 zaleplon oral capsule 10 mg Tier 1 QL (2 EA per 1 day) zaleplon oral capsule 5 mg Tier 1 zolpidem oral tablet 10 mg, 5 mg (Ambien) Tier 1 zolpidem oral tablet,ext release (Ambien CR) Tier 1 QL (1 EA per 1 day) multiphase 12.5 mg, 6.25 mg zolpidem sublingual tablet 1.75 mg (Intermezzo) Tier 1 zolpidem sublingual tablet 3.5 mg (Intermezzo) Tier 3 ZOLPIMIST ORAL SPRAY,NON- Tier 3 QL (7.7 ML per 30 days) AEROSOL 5 MG/SPRAY (0.1 ML) Ssri &Antipsych,Atyp,Dopamine&Serotonin Antag Comb olanzapine-fluoxetine oral capsule 12-25 Tier 1 mg olanzapine-fluoxetine oral capsule 12-50 (Symbyax) Tier 1 mg, 3-25 mg, 6-25 mg, 6-50 mg Tx For Adhd - Selective Alpha-2A Receptor Agonist clonidine hcl oral tablet extended release (Kapvay) Tier 1 12 hr 0.1 mg guanfacine oral tablet extended release (Intuniv ER) Tier 1 QL (1 EA per 1 day) 24 hr 1 mg, 2 mg, 3 mg, 4 mg Tx For Attention Deficit- Hyperact(Adhd)/Narcolepsy DAYTRANA TRANSDERMAL PATCH Tier 3 24 HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR

19 Drug Status Notes dexmethylphenidate oral capsule,er (Focalin XR) Tier 1 QL (1 EA per 1 day) biphasic 50-50 10 mg, 20 mg, 25 mg, 30 mg, 35 mg, 5 mg dexmethylphenidate oral capsule,er (Focalin XR) Tier 1 QL (1 EA per 1 day); Age biphasic 50-50 15 mg, 40 mg (Max 18 Years) dexmethylphenidate oral tablet 10 mg, (Focalin) Tier 1 QL (2 EA per 1 day) 2.5 mg, 5 mg METADATE ER ORAL TABLET Tier 1 QL (1 EA per 1 day) EXTENDED RELEASE 20 MG methylphenidate hcl oral capsule, er Tier 1 QL (1 EA per 1 day) biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er (Ritalin LA) Tier 1 QL (1 EA per 1 day) biphasic 50-50 10 mg, 20 mg, 30 mg, 40 mg methylphenidate hcl oral solution 10 (Methylin) Tier 1 Age (Max 12 Years) mg/5 ml, 5 mg/5 ml methylphenidate hcl oral tablet 10 mg, (Ritalin) Tier 1 20 mg, 5 mg methylphenidate hcl oral tablet extended Tier 1 QL (1 EA per 1 day) release 10 mg methylphenidate hcl oral tablet extended (Metadate ER) Tier 1 QL (1 EA per 1 day) release 20 mg methylphenidate hcl oral tablet extended (Concerta) Tier 1 QL (1 EA per 1 day) release 24hr 18 mg, 27 mg, 54 mg methylphenidate hcl oral tablet extended (Concerta) Tier 1 QL (2 EA per 1 day) release 24hr 36 mg methylphenidate hcl oral tablet,chewable Tier 3 Age (Max 12 Years) 10 mg, 2.5 mg, 5 mg QUILLIVANT XR ORAL Tier 3 Age (Max 12 Years) SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) RITALIN LA ORAL CAPSULE,ER Tier 3 QL (1 EA per 1 day) BIPHASIC 50-50 10 MG Tx For Attention Deficit- Hyperact.(Adhd), Nri-Type atomoxetine oral capsule 10 mg, 100 (Strattera) Tier 3 QL (1 EA per 1 day) mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg Cardiovascular Disease - Arrhythmia Antiarrhythmics amiodarone oral tablet 100 mg, 200 mg, (Pacerone) Tier 1 400 mg disopyramide phosphate oral capsule (Norpace) Tier 1 100 mg, 150 mg dofetilide oral capsule 125 mcg, 250 (Tikosyn) Tier 3 QL (2 EA per 1 day) mcg, 500 mcg flecainide oral tablet 100 mg, 150 mg, 50 Tier 1 mg mexiletine oral capsule 150 mg, 200 mg, Tier 1 250 mg

20 Drug Status Notes MULTAQ ORAL TABLET 400 MG Tier 3 PACERONE ORAL TABLET 100 MG, Tier 1 200 MG, 400 MG propafenone oral capsule,extended (Rythmol SR) Tier 1 release 12 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, Tier 1 300 mg quinidine gluconate oral tablet extended Tier 1 release 324 mg quinidine sulfate oral tablet 200 mg, 300 Tier 1 mg Cardiovascular Disease - Cardiac Stimulant Adrenergic Agents,Catecholamines epinephrine injection syringe 0.1 mg/ml Tier 1 Digitalis Glycosides DIGITEK ORAL TABLET 125 MCG Tier 1 (0.125 MG), 250 MCG (0.25 MG) DIGOX ORAL TABLET 125 MCG (0.125 Tier 1 MG), 250 MCG (0.25 MG) digoxin oral solution 50 mcg/ml (0.05 Tier 1 mg/ml) digoxin oral tablet 125 mcg (0.125 mg), (Digitek) Tier 1 250 mcg (0.25 mg) Cardiovascular Disease - Hypertension Ace Inhibitor/Calcium Channel Blocker Combination amlodipine-benazepril oral capsule 10- (Lotrel) Tier 1 QL (1 EA per 1 day) 20 mg, 10-40 mg, 5-10 mg, 5-20 mg, 5- 40 mg amlodipine-benazepril oral capsule 2.5- Tier 1 QL (1 EA per 1 day) 10 mg Ace Inhibitor/Thiazide & Thiazide-Like Diuretic benazepril-hydrochlorothiazide oral (Lotensin HCT) Tier 1 tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg benazepril-hydrochlorothiazide oral Tier 1 tablet 5-6.25 mg captopril-hydrochlorothiazide oral tablet Tier 1 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet (Vaseretic) Tier 1 10-25 mg enalapril-hydrochlorothiazide oral tablet Tier 1 5-12.5 mg fosinopril-hydrochlorothiazide oral tablet Tier 1 10-12.5 mg, 20-12.5 mg lisinopril-hydrochlorothiazide oral tablet (Zestoretic) Tier 1 10-12.5 mg, 20-12.5 mg, 20-25 mg

21 Drug Status Notes quinapril-hydrochlorothiazide oral tablet (Accuretic) Tier 1 10-12.5 mg, 20-12.5 mg, 20-25 mg Alpha/Beta-Adrenergic Blocking Agents carvedilol oral tablet 12.5 mg, 25 mg, (Coreg) Tier 1 3.125 mg, 6.25 mg carvedilol phosphate oral capsule, er (Coreg CR) Tier 3 multiphase 24 hr 10 mg, 20 mg, 40 mg, 80 mg labetalol oral tablet 100 mg, 200 mg, 300 Tier 1 mg Alpha-Adrenergic Blocking Agents doxazosin oral tablet 1 mg, 2 mg, 4 mg, (Cardura) Tier 1 8 mg phenoxybenzamine oral capsule 10 mg (Dibenzyline) Tier 1 prazosin oral capsule 1 mg, 2 mg, 5 mg (Minipress) Tier 1 terazosin oral capsule 1 mg, 10 mg, 2 Tier 1 mg, 5 mg Angioten.Receptr Antag./Cal.Chanl Blkr/Thiazide Cb amlodipine-valsartan-hcthiazid oral tablet (Exforge HCT) Tier 3 QL (1 EA per 1 day) 10-160-12.5 mg, 10-160-25 mg, 10-320- 25 mg, 5-160-12.5 mg, 5-160-25 mg olmesartan-amlodipin-hcthiazid oral (Tribenzor) Tier 3 tablet 20-5-12.5 mg, 40-10-12.5 mg, 40- 10-25 mg, 40-5-12.5 mg, 40-5-25 mg Angiotensin Receptor Antag./Thiazide Diuretic Comb candesartan-hydrochlorothiazid oral (Atacand HCT) Tier 1 QL (1 EA per 1 day) tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg irbesartan-hydrochlorothiazide oral tablet (Avalide) Tier 1 150-12.5 mg, 300-12.5 mg losartan-hydrochlorothiazide oral tablet (Hyzaar) Tier 1 100-12.5 mg, 100-25 mg, 50-12.5 mg olmesartan-hydrochlorothiazide oral (Benicar HCT) Tier 1 QL (1 EA per 1 day) tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg valsartan-hydrochlorothiazide oral tablet (Diovan HCT) Tier 1 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg Angiotensin Receptor Antgnst & Calc.Channel Blockr amlodipine-valsartan oral tablet 10-160 (Exforge) Tier 1 QL (1 EA per 1 day) mg, 10-320 mg, 5-160 mg, 5-320 mg telmisartan-amlodipine oral tablet 40-10 (Twynsta) Tier 1 QL (1 EA per 1 day) mg, 40-5 mg, 80-10 mg, 80-5 mg Antihypertensives, Ace Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 (Lotensin) Tier 1 mg benazepril oral tablet 5 mg Tier 1

22 Drug Status Notes captopril oral tablet 100 mg, 12.5 mg, 25 Tier 1 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 (Vasotec) Tier 1 mg, 20 mg, 5 mg fosinopril oral tablet 10 mg, 20 mg, 40 Tier 1 mg lisinopril oral tablet 10 mg, 20 mg (Prinivil) Tier 1 lisinopril oral tablet 2.5 mg, 30 mg, 40 (Zestril) Tier 1 mg, 5 mg moexipril oral tablet 15 mg, 7.5 mg Tier 1 QL (1 EA per 1 day) perindopril erbumine oral tablet 2 mg, 4 Tier 1 mg, 8 mg quinapril oral tablet 10 mg, 20 mg, 40 (Accupril) Tier 1 mg, 5 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 (Altace) Tier 1 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1 Antihypertensives, Angiotensin Receptor Antagonist candesartan oral tablet 16 mg, 32 mg, 4 (Atacand) Tier 1 QL (1 EA per 1 day) mg, 8 mg EDARBI ORAL TABLET 40 MG, 80 MG Tier 3 QL (1 EA per 1 day) eprosartan oral tablet 600 mg Tier 1 QL (1 EA per 1 day) irbesartan oral tablet 150 mg, 300 mg, (Avapro) Tier 1 75 mg losartan oral tablet 100 mg, 25 mg, 50 (Cozaar) Tier 1 mg olmesartan oral tablet 20 mg, 40 mg, 5 (Benicar) Tier 1 QL (1 EA per 1 day) mg telmisartan oral tablet 20 mg, 40 mg, 80 (Micardis) Tier 1 QL (1 EA per 1 day) mg valsartan oral tablet 160 mg, 320 mg, 40 (Diovan) Tier 1 mg, 80 mg Antihypertensives, Ganglionic Blockers VECAMYL ORAL TABLET 2.5 MG Tier 3 Antihypertensives, Miscellaneous DEMSER ORAL CAPSULE 250 MG Tier 2 Antihypertensives, Sympatholytic clonidine hcl oral tablet 0.1 mg, 0.2 mg, (Catapres) Tier 1 0.3 mg clonidine transdermal patch weekly 0.1 (Catapres-TTS-1) Tier 1 QL (1 EA per 7 days) mg/24 hr clonidine transdermal patch weekly 0.2 (Catapres-TTS-2) Tier 1 QL (1 EA per 7 days) mg/24 hr clonidine transdermal patch weekly 0.3 (Catapres-TTS-3) Tier 1 QL (1 EA per 7 days) mg/24 hr guanfacine oral tablet 1 mg, 2 mg Tier 1 methyldopa oral tablet 250 mg, 500 mg Tier 1 methyldopa-hydrochlorothiazide oral Tier 1 tablet 250-15 mg, 250-25 mg

23 Drug Status Notes Antihypertensives, Vasodilators hydralazine oral tablet 10 mg, 100 mg, Tier 1 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg Tier 1 Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg Tier 1 atenolol oral tablet 100 mg, 25 mg, 50 (Tenormin) Tier 1 mg betaxolol oral tablet 10 mg, 20 mg Tier 1 bisoprolol fumarate oral tablet 10 mg, 5 Tier 1 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 Tier 3 QL (1 EA per 1 day) MG, 20 MG, 5 MG INDERAL XL ORAL Tier 3 PA CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG INNOPRAN XL ORAL Tier 3 PA CAPSULE,EXTENDED RELEASE 24HR 120 MG, 80 MG LEVATOL ORAL TABLET 20 MG Tier 3 metoprolol succinate oral tablet (Toprol XL) Tier 1 extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 50 (Lopressor) Tier 1 mg metoprolol tartrate oral tablet 25 mg Tier 1 nadolol oral tablet 20 mg, 40 mg (Corgard) Tier 1 QL (1 EA per 1 day) nadolol oral tablet 80 mg (Corgard) Tier 1 pindolol oral tablet 10 mg, 5 mg Tier 1 propranolol oral capsule,extended (Inderal LA) Tier 1 release 24 hr 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 Tier 1 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 Tier 1 mg, 60 mg, 80 mg SORINE ORAL TABLET 120 MG, 160 Tier 1 MG, 240 MG, 80 MG SOTALOL AF ORAL TABLET 120 MG, Tier 1 160 MG, 80 MG sotalol oral tablet 120 mg, 160 mg, 240 (Sorine) Tier 1 mg, 80 mg timolol maleate oral tablet 10 mg, 20 mg, Tier 1 5 mg Beta-Adrenergic Blocking Agents/Thiazide & Related atenolol-chlorthalidone oral tablet 100-25 (Tenoretic 100) Tier 1 mg atenolol-chlorthalidone oral tablet 50-25 (Tenoretic 50) Tier 1 mg

24 Drug Status Notes bisoprolol-hydrochlorothiazide oral tablet (Ziac) Tier 1 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg metoprolol ta-hydrochlorothiaz oral tablet Tier 1 100-25 mg, 100-50 mg metoprolol ta-hydrochlorothiaz oral tablet (Lopressor HCT) Tier 1 50-25 mg nadolol-bendroflumethiazide oral tablet Tier 1 QL (1 EA per 1 day) 80-5 mg propranolol-hydrochlorothiazid oral tablet Tier 1 40-25 mg, 80-25 mg Calcium Channel Blocking Agents amlodipine oral tablet 10 mg, 2.5 mg, 5 (Norvasc) Tier 1 mg CARTIA XT ORAL Tier 1 CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG diltiazem hcl oral capsule,ext.rel 24h (DILT-XR) Tier 1 degradable 120 mg, 180 mg, 240 mg diltiazem hcl oral capsule,extended Tier 1 release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended (Taztia XT) Tier 1 release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral capsule,extended (Tiadylt ER) Tier 1 release 24 hr 420 mg diltiazem hcl oral capsule,extended (Cartia XT) Tier 1 release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral capsule,extended (Cardizem CD) Tier 1 release 24hr 360 mg diltiazem hcl oral tablet 120 mg, 30 mg, (Cardizem) Tier 1 60 mg diltiazem hcl oral tablet 90 mg Tier 1 diltiazem hcl oral tablet extended release (Matzim LA) Tier 1 QL (1 EA per 1 day) 24 hr 360 mg DILT-XR ORAL CAPSULE,EXT.REL Tier 1 24H DEGRADABLE 120 MG, 180 MG, 240 MG felodipine oral tablet extended release Tier 1 24 hr 10 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg Tier 1 MATZIM LA ORAL TABLET EXTENDED Tier 1 QL (1 EA per 1 day) RELEASE 24 HR 360 MG nicardipine oral capsule 20 mg, 30 mg Tier 1 nifedipine oral capsule 10 mg (Procardia) Tier 1 nifedipine oral capsule 20 mg Tier 1 nifedipine oral tablet extended release (Procardia XL) Tier 1 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release (Adalat CC) Tier 1 30 mg, 60 mg, 90 mg

25 Drug Status Notes nimodipine oral capsule 30 mg Tier 1 nisoldipine oral tablet extended release (Sular) Tier 1 24 hr 17 mg, 34 mg, 8.5 mg nisoldipine oral tablet extended release Tier 1 24 hr 20 mg, 25.5 mg, 30 mg, 40 mg TAZTIA XT ORAL Tier 1 CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG TIADYLT ER ORAL Tier 1 CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG verapamil oral capsule, 24 hr er pellet ct (Verelan PM) Tier 1 100 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 (Verelan) Tier 1 hr 120 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 mg, 80 Tier 1 mg verapamil oral tablet extended release (Calan SR) Tier 1 120 mg, 180 mg, 240 mg Loop Diuretics bumetanide oral tablet 0.5 mg, 1 mg, 2 Tier 1 mg ethacrynic acid oral tablet 25 mg (Edecrin) Tier 3 furosemide oral solution 10 mg/ml, 40 Tier 1 mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 (Lasix) Tier 1 mg torsemide oral tablet 10 mg, 100 mg, 20 Tier 1 mg, 5 mg Potassium Sparing Diuretics amiloride oral tablet 5 mg Tier 1 DYRENIUM ORAL CAPSULE 100 MG, Tier 3 50 MG eplerenone oral tablet 25 mg, 50 mg (Inspra) Tier 1 spironolactone oral tablet 100 mg, 25 (Aldactone) Tier 1 mg, 50 mg Potassium Sparing Diuretics In Combination ALDACTAZIDE ORAL TABLET 50-50 Tier 3 MG amiloride-hydrochlorothiazide oral tablet Tier 1 5-50 mg spironolacton-hydrochlorothiaz oral (Aldactazide) Tier 1 tablet 25-25 mg triamterene-hydrochlorothiazid oral (Dyazide) Tier 1 capsule 37.5-25 mg triamterene-hydrochlorothiazid oral tablet (Maxzide-25mg) Tier 1 37.5-25 mg

26 Drug Status Notes triamterene-hydrochlorothiazid oral tablet (Maxzide) Tier 1 75-50 mg Pulm Anti-Htn,Soluble Guanylate Cyclase Stimulator ADEMPAS ORAL TABLET 0.5 MG, 1 Tier 3 MG, 1.5 MG, 2 MG, 2.5 MG Pulm.Anti-Htn,Sel.C-Gmp Phosphodiesterase T5 Inhib ADCIRCA ORAL TABLET 20 MG Tier 3 ALYQ ORAL TABLET 20 MG Tier 1 sildenafil (pulm.hypertension) oral tablet (Revatio) Tier 1 PA; QL (6 EA per 30 days) 20 mg tadalafil (pulm. hypertension) oral tablet (Alyq) Tier 1 20 mg Pulmonary Anti-Htn, Endothelin Receptor Antagonist LETAIRIS ORAL TABLET 10 MG, 5 MG Tier 4 PA; SP OPSUMIT ORAL TABLET 10 MG Tier 4 PA; SP TRACLEER ORAL TABLET 125 MG, Tier 4 PA; SP; QL (2 EA per 1 62.5 MG day) TRACLEER ORAL TABLET FOR Tier 4 PA; SP SUSPENSION 32 MG Pulmonary Antihypertensives, Prostacyclin-Type ORENITRAM ORAL TABLET Tier 4 PA; SP EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG TYVASO INHALATION SOLUTION FOR Tier 4 PA; SP NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO INSTITUTIONAL START KIT Tier 4 PA; SP INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML TYVASO REFILL KIT INHALATION Tier 4 PA; SP SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION Tier 4 PA; SP SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML VENTAVIS INHALATION SOLUTION Tier 4 PA; SP FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML Renin Inhibitor, Direct TEKTURNA ORAL TABLET 150 MG, Tier 2 PA; QL (1 EA per 1 day) 300 MG Renin Inhibitor, Direct/Thiazide Diuretic Comb TEKTURNA HCT ORAL TABLET 150- Tier 2 PA; QL (1 EA per 1 day) 12.5 MG, 150-25 MG, 300-12.5 MG, 300-25 MG

27 Drug Status Notes Thiazide And Related Diuretics chlorothiazide oral tablet 500 mg Tier 1 chlorthalidone oral tablet 25 mg, 50 mg Tier 1 DIURIL ORAL SUSPENSION 250 MG/5 Tier 2 Age (Max 12 Years) ML hydrochlorothiazide oral capsule 12.5 Tier 1 mg hydrochlorothiazide oral tablet 12.5 mg, Tier 1 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg Tier 1 metolazone oral tablet 10 mg, 2.5 mg, 5 Tier 1 mg Vasodilators, Combination BIDIL ORAL TABLET 20-37.5 MG Tier 3 Cardiovascular Disease - Lipid Irregularity Antihyperlip.Hmg Coa Reduct Inhib&Cholest.Ab.Inhib ezetimibe-simvastatin oral tablet 10-10 (Vytorin 10-10) Tier 3 QL (1 EA per 1 day) mg ezetimibe-simvastatin oral tablet 10-20 (Vytorin 10-20) Tier 3 QL (1 EA per 1 day) mg ezetimibe-simvastatin oral tablet 10-40 (Vytorin 10-40) Tier 3 QL (1 EA per 1 day) mg ezetimibe-simvastatin oral tablet 10-80 (Vytorin 10-80) Tier 3 QL (1 EA per 1 day) mg Antihyperlipidemic - Hmg Coa Reductase Inhibitors ALTOPREV ORAL TABLET EXTENDED Tier 3 QL (1 EA per 1 day) RELEASE 24 HR 20 MG, 40 MG, 60 MG atorvastatin oral tablet 10 mg, 20 mg (Lipitor) Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS atorvastatin oral tablet 40 mg, 80 mg (Lipitor) Tier 1 fluvastatin oral capsule 20 mg, 40 mg (Lescol) Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS LIVALO ORAL TABLET 1 MG, 2 MG, 4 Tier 3 QL (1 EA per 1 day) MG lovastatin oral tablet 10 mg, 20 mg, 40 Tier 1 $0 COPAY IF AGE 40-75 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS

28 Drug Status Notes pravastatin oral tablet 10 mg, 80 mg Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS pravastatin oral tablet 20 mg, 40 mg (Pravachol) Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS rosuvastatin oral tablet 10 mg, 5 mg (Crestor) Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) rosuvastatin oral tablet 20 mg, 40 mg (Crestor) Tier 1 QL (1 EA per 1 day) simvastatin oral tablet 10 mg, 20 mg, 40 (Zocor) Tier 1 $0 COPAY IF AGE 40-75 mg YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS simvastatin oral tablet 5 mg Tier 1 $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS simvastatin oral tablet 80 mg (Zocor) Tier 1 Antihyperlipidemic - Mtp Inhibitor JUXTAPID ORAL CAPSULE 10 MG, 20 Tier 4 PA; SP MG, 5 MG Antihyperlipidemic - Pcsk9 Inhibitors PRALUENT PEN SUBCUTANEOUS Tier 4 PA PEN INJECTOR 150 MG/ML, 75 MG/ML REPATHA PUSHTRONEX Tier 4 PA SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK Tier 4 PA SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS Tier 4 PA SYRINGE 140 MG/ML Bile Salt Sequestrants cholestyramine (with sugar) oral powder (Questran) Tier 1 4 gram cholestyramine (with sugar) oral powder (Questran) Tier 1 in packet 4 gram

29 Drug Status Notes CHOLESTYRAMINE LIGHT ORAL Tier 1 POWDER 4 GRAM CHOLESTYRAMINE LIGHT ORAL Tier 1 POWDER IN PACKET 4 GRAM colesevelam oral powder in packet 3.75 (WelChol) Tier 1 gram colesevelam oral tablet 625 mg (WelChol) Tier 1 colestipol oral granules 5 gram (Colestid) Tier 1 colestipol oral packet 5 gram (Colestid) Tier 1 colestipol oral tablet 1 gram (Colestid) Tier 1 PREVALITE ORAL POWDER 4 GRAM Tier 1 PREVALITE ORAL POWDER IN Tier 1 PACKET 4 GRAM WELCHOL ORAL POWDER IN Tier 2 PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG Tier 2 Lipotropics ANTARA ORAL CAPSULE 30 MG, 90 Tier 3 MG ezetimibe oral tablet 10 mg (Zetia) Tier 1 QL (1 EA per 1 day) fenofibrate micronized oral capsule 130 Tier 1 mg, 134 mg, 200 mg, 43 mg, 67 mg fenofibrate nanocrystallized oral tablet (Tricor) Tier 1 145 mg, 48 mg fenofibrate oral capsule 150 mg, 50 mg (Lipofen) Tier 3 fenofibrate oral tablet 120 mg, 40 mg (Fenoglide) Tier 3 fenofibrate oral tablet 160 mg, 54 mg Tier 1 fenofibric acid (choline) oral (Trilipix) Tier 3 QL (1 EA per 1 day) capsule,delayed release(dr/ec) 135 mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) Tier 1 FISH OIL ORAL CAPSULE 1,000 MG Tier 3 (120 MG-180 MG), 300-1,000 MG FISH OIL ORAL CAPSULE,DELAYED Tier 3 RELEASE(DR/EC) 300-1,000 MG gemfibrozil oral tablet 600 mg (Lopid) Tier 1 niacin oral tablet extended release 24 hr (Niaspan Extended- Tier 3 1,000 mg Release) niacin oral tablet extended release 24 hr (Niaspan Extended- Tier 3 QL (3 EA per 1 day) 500 mg Release) niacin oral tablet extended release 24 hr (Niaspan Extended- Tier 3 QL (2 EA per 1 day) 750 mg Release) NIACOR ORAL TABLET 500 MG Tier 1 omega-3 acid ethyl esters oral capsule 1 (Lovaza) Tier 1 QL (4 EA per 1 day) gram VASCEPA ORAL CAPSULE 1 GRAM Tier 3 Niacin Preparations niacin oral tablet extended release 500 (Endur-Acin) Tier 1 mg

30 Drug Status Notes Cardiovascular Disease - Miscellaneous Agents Adrenergic Vasopressor Agents midodrine oral tablet 10 mg, 2.5 mg, 5 Tier 1 mg NORTHERA ORAL CAPSULE 100 MG, Tier 3 PA 200 MG, 300 MG Antianginal & Anti-Ischemic Agents,Non-Hemodynamic RANEXA ORAL TABLET EXTENDED Tier 2 QL (2 EA per 1 day) RELEASE 12 HR 1,000 MG, 500 MG Antianginal, Heart Rate Reducing, I(F) Inhibitor CORLANOR ORAL TABLET 5 MG, 7.5 Tier 3 PA MG Antihyperlip - Hmg-Coa&Calcium Channel Blocker Cb amlodipine-atorvastatin oral tablet 10-10 (Caduet) Tier 1 QL (1 EA per 1 day) mg, 10-20 mg, 10-40 mg, 10-80 mg, 5- 10 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-atorvastatin oral tablet 2.5-10 Tier 1 QL (1 EA per 1 day) mg, 2.5-20 mg, 2.5-40 mg Cardiovascular Disease - Vasodilation Vasodilators,Coronary DILATRATE-SR ORAL CAPSULE, Tier 2 EXTENDED RELEASE 40 MG ISOCHRON ORAL TABLET EXTENDED Tier 1 RELEASE 40 MG ISORDIL ORAL TABLET 40 MG Tier 3 isosorbide dinitrate oral tablet 10 mg, 20 Tier 1 mg, 30 mg isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) Tier 1 isosorbide dinitrate oral tablet extended (ISOCHRON) Tier 1 release 40 mg isosorbide mononitrate oral tablet 10 mg, Tier 1 20 mg isosorbide mononitrate oral tablet Tier 1 extended release 24 hr 120 mg, 30 mg, 60 mg MINITRAN TRANSDERMAL PATCH 24 Tier 1 QL (1 EA per 1 day) HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL Tier 2 OINTMENT 2 % NITRO-DUR TRANSDERMAL PATCH Tier 2 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet 0.3 mg, 0.4 (Nitrostat) Tier 1 mg, 0.6 mg

31 Drug Status Notes nitroglycerin transdermal patch 24 hour (Minitran) Tier 1 QL (1 EA per 1 day) 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual spray,non- (Nitrolingual) Tier 1 aerosol 400 mcg/spray NITRO-TIME ORAL CAPSULE, Tier 1 EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG Vasodilators,Peripheral ergoloid oral tablet 1 mg Tier 1 isoxsuprine oral tablet 10 mg, 20 mg Tier 1 Contraception/Oxytocics Contraceptives, Intravaginal, Systemic NUVARING VAGINAL RING 0.12-0.015 $0 QL (1 EA per 28 days) MG/24 HR Contraceptives,Injectable medroxyprogesterone intramuscular (Depo-Provera) $0 QL (1 ML per 84 days) suspension 150 mg/ml medroxyprogesterone intramuscular (Depo-Provera) $0 QL (1 ML per 84 days) syringe 150 mg/ml Contraceptives,Intravaginal VCF CONTRACEPTIVE GEL VAGINAL $0 GEL 4 % Contraceptives,Oral AFIRMELLE ORAL TABLET 0.1-20 MG- $0 QL (1 EA per 1 day) MCG AFTERA ORAL TABLET 1.5 MG Tier 3 QL (1 EA per 15 days) ALTAVERA (28) ORAL TABLET 0.15- $0 QL (1 EA per 1 day) 0.03 MG ALYACEN 1/35 (28) ORAL TABLET 1- $0 QL (1 EA per 1 day) 35 MG-MCG ALYACEN 7/7/7 (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.5/0.75/1 MG- 35 MCG AMETHIA LO ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) AMETHIA ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) AMETHYST (28) ORAL TABLET 90-20 $0 QL (1 EA per 1 day) MCG (28) APRI ORAL TABLET 0.15-0.03 MG $0 QL (1 EA per 1 day) ARANELLE (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.5/1/0.5-35 MG-MCG ASHLYNA ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) AUBRA EQ ORAL TABLET 0.1-20 MG- $0 QL (1 EA per 1 day) MCG AUBRA ORAL TABLET 0.1-20 MG-MCG $0 QL (1 EA per 1 day)

32 Drug Status Notes AUROVELA 1.5/30 (21) ORAL TABLET $0 QL (1 EA per 1 day) 1.5-30 MG-MCG AUROVELA 1/20 (21) ORAL TABLET 1- $0 QL (1 EA per 1 day) 20 MG-MCG AUROVELA 24 FE ORAL TABLET 1 $0 QL (1 EA per 1 day) MG-20 MCG (24)/75 MG (4) AUROVELA FE 1.5/30 (28) ORAL $0 QL (1 EA per 1 day) TABLET 1.5 MG-30 MCG (21)/75 MG (7) AUROVELA FE 1-20 (28) ORAL $0 QL (1 EA per 1 day) TABLET 1 MG-20 MCG (21)/75 MG (7) AVIANE ORAL TABLET 0.1-20 MG- $0 QL (1 EA per 1 day) MCG AYUNA ORAL TABLET 0.15-0.03 MG $0 QL (1 EA per 1 day) AZURETTE (28) ORAL TABLET 0.15- $0 QL (1 EA per 1 day) 0.02 MGX21 /0.01 MG X 5 BALCOLTRA ORAL TABLET 0.1 MG- Tier 3 QL (1 EA per 1 day) 0.02 MG (21)/36.5 MG(7) BALZIVA (28) ORAL TABLET 0.4-35 $0 QL (1 EA per 1 day) MG-MCG BEKYREE (28) ORAL TABLET 0.15- $0 QL (1 EA per 1 day) 0.02 MGX21 /0.01 MG X 5 BLISOVI 24 FE ORAL TABLET 1 MG-20 $0 QL (1 EA per 1 day) MCG (24)/75 MG (4) BLISOVI FE 1.5/30 (28) ORAL TABLET $0 QL (1 EA per 1 day) 1.5 MG-30 MCG (21)/75 MG (7) BLISOVI FE 1/20 (28) ORAL TABLET 1 $0 QL (1 EA per 1 day) MG-20 MCG (21)/75 MG (7) BRIELLYN ORAL TABLET 0.4-35 MG- $0 QL (1 EA per 1 day) MCG CAMILA ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) CAMRESE LO ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) CAMRESE ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) CAZIANT (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.1/.125/.15-25 MG-MCG CHARLOTTE 24 FE ORAL $0 QL (1 EA per 1 day) TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4) CHATEAL (28) ORAL TABLET 0.15- $0 QL (1 EA per 1 day) 0.03 MG CHATEAL EQ (28) ORAL TABLET 0.15- $0 QL (1 EA per 1 day) 0.03 MG CRYSELLE (28) ORAL TABLET 0.3-30 $0 QL (1 EA per 1 day) MG-MCG CYCLAFEM 1/35 (28) ORAL TABLET 1- $0 QL (1 EA per 1 day) 35 MG-MCG

33 Drug Status Notes CYCLAFEM 7/7/7 (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.5/0.75/1 MG- 35 MCG CYRED EQ ORAL TABLET 0.15-0.03 $0 QL (1 EA per 1 day) MG CYRED ORAL TABLET 0.15-0.03 MG $0 QL (1 EA per 1 day) DASETTA 1/35 (28) ORAL TABLET 1- $0 QL (1 EA per 1 day) 35 MG-MCG DASETTA 7/7/7 (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.5/0.75/1 MG- 35 MCG DAYSEE ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) DEBLITANE ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) desog-e.estradiol/e.estradiol oral tablet (Azurette (28)) $0 QL (1 EA per 1 day) 0.15-0.02 mgx21 /0.01 mg x 5 drospirenone-e.estradiol-lm.fa oral tablet (Beyaz) $0 QL (1 EA per 1 day) 3-0.02-0.451 mg (24) (4) drospirenone-e.estradiol-lm.fa oral tablet (Safyral) $0 QL (1 EA per 1 day) 3-0.03-0.451 mg (21) (7) drospirenone-ethinyl estradiol oral tablet (Gianvi (28)) $0 QL (1 EA per 1 day) 3-0.02 mg drospirenone-ethinyl estradiol oral tablet (Ocella) $0 QL (1 EA per 1 day) 3-0.03 mg ECONTRA EZ ORAL TABLET 1.5 MG Tier 3 QL (1 EA per 15 days) ECONTRA ONE-STEP ORAL TABLET Tier 3 QL (1 EA per 15 days) 1.5 MG ELINEST ORAL TABLET 0.3-30 MG- $0 QL (1 EA per 1 day) MCG ELLA ORAL TABLET 30 MG Tier 3 QL (1 EA per 15 days) EMOQUETTE ORAL TABLET 0.15-0.03 $0 QL (1 EA per 1 day) MG ENPRESSE ORAL TABLET 50-30 $0 QL (1 EA per 1 day) (6)/75-40 (5)/125-30(10) ENSKYCE ORAL TABLET 0.15-0.03 $0 QL (1 EA per 1 day) MG ERRIN ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) ESTARYLLA ORAL TABLET 0.25-35 $0 QL (1 EA per 1 day) MG-MCG ethynodiol diac-eth estradiol oral tablet (Kelnor 1/35 (28)) $0 QL (1 EA per 1 day) 1-35 mg-mcg ethynodiol diac-eth estradiol oral tablet (Kelnor 1-50) $0 QL (1 EA per 1 day) 1-50 mg-mcg FALMINA (28) ORAL TABLET 0.1-20 $0 QL (1 EA per 1 day) MG-MCG FAYOSIM ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG FEMYNOR ORAL TABLET 0.25-35 MG- $0 QL (1 EA per 1 day) MCG GIANVI (28) ORAL TABLET 3-0.02 MG $0 QL (1 EA per 1 day)

34 Drug Status Notes HAILEY 24 FE ORAL TABLET 1 MG-20 $0 QL (1 EA per 1 day) MCG (24)/75 MG (4) HAILEY FE 1.5/30 (28) ORAL TABLET $0 QL (1 EA per 1 day) 1.5 MG-30 MCG (21)/75 MG (7) HAILEY FE 1/20 (28) ORAL TABLET 1 $0 QL (1 EA per 1 day) MG-20 MCG (21)/75 MG (7) HAILEY ORAL TABLET 1.5-30 MG- $0 QL (1 EA per 1 day) MCG HEATHER ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) INCASSIA ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) INTROVALE ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-30 MCG (91) ISIBLOOM ORAL TABLET 0.15-0.03 $0 QL (1 EA per 1 day) MG JAIMIESS ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) JASMIEL (28) ORAL TABLET 3-0.02 $0 QL (1 EA per 1 day) MG JENCYCLA ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) JOLESSA ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-30 MCG (91) JULEBER ORAL TABLET 0.15-0.03 MG $0 QL (1 EA per 1 day) JUNEL 1.5/30 (21) ORAL TABLET 1.5- $0 QL (1 EA per 1 day) 30 MG-MCG JUNEL 1/20 (21) ORAL TABLET 1-20 $0 QL (1 EA per 1 day) MG-MCG JUNEL FE 1.5/30 (28) ORAL TABLET $0 QL (1 EA per 1 day) 1.5 MG-30 MCG (21)/75 MG (7) JUNEL FE 1/20 (28) ORAL TABLET 1 $0 QL (1 EA per 1 day) MG-20 MCG (21)/75 MG (7) JUNEL FE 24 ORAL TABLET 1 MG-20 $0 QL (1 EA per 1 day) MCG (24)/75 MG (4) KAITLIB FE ORAL $0 QL (1 EA per 1 day) TABLET,CHEWABLE 0.8MG- 25MCG(24) AND 75 MG (4) KALLIGA ORAL TABLET 0.15-0.03 MG $0 QL (1 EA per 1 day) KARIVA (28) ORAL TABLET 0.15-0.02 $0 QL (1 EA per 1 day) MGX21 /0.01 MG X 5 KELNOR 1/35 (28) ORAL TABLET 1-35 $0 QL (1 EA per 1 day) MG-MCG KELNOR 1-50 ORAL TABLET 1-50 MG- $0 QL (1 EA per 1 day) MCG KURVELO (28) ORAL TABLET 0.15- $0 QL (1 EA per 1 day) 0.03 MG l norgest/e.estradiol-e.estrad oral (Amethia Lo) $0 QL (1 EA per 1 day) tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)

35 Drug Status Notes l norgest/e.estradiol-e.estrad oral (Fayosim) $0 QL (1 EA per 1 day) tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg l norgest/e.estradiol-e.estrad oral (Amethia) $0 QL (1 EA per 1 day) tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) LARIN 1.5/30 (21) ORAL TABLET 1.5- $0 QL (1 EA per 1 day) 30 MG-MCG LARIN 1/20 (21) ORAL TABLET 1-20 $0 QL (1 EA per 1 day) MG-MCG LARIN 24 FE ORAL TABLET 1 MG-20 $0 QL (1 EA per 1 day) MCG (24)/75 MG (4) LARIN FE 1.5/30 (28) ORAL TABLET $0 QL (1 EA per 1 day) 1.5 MG-30 MCG (21)/75 MG (7) LARIN FE 1/20 (28) ORAL TABLET 1 $0 QL (1 EA per 1 day) MG-20 MCG (21)/75 MG (7) LARISSIA ORAL TABLET 0.1-20 MG- $0 QL (1 EA per 1 day) MCG LAYOLIS FE ORAL $0 QL (1 EA per 1 day) TABLET,CHEWABLE 0.8MG- 25MCG(24) AND 75 MG (4) LEENA 28 ORAL TABLET 0.5/1/0.5-35 $0 QL (1 EA per 1 day) MG-MCG LESSINA ORAL TABLET 0.1-20 MG- $0 QL (1 EA per 1 day) MCG LEVONEST (28) ORAL TABLET 50-30 $0 QL (1 EA per 1 day) (6)/75-40 (5)/125-30(10) levonorgestrel oral tablet 1.5 mg (Aftera) Tier 3 QL (1 EA per 15 days) levonorgestrel-ethinyl estrad oral tablet (Afirmelle) $0 QL (1 EA per 1 day) 0.1-20 mg-mcg levonorgestrel-ethinyl estrad oral tablet (Altavera (28)) $0 QL (1 EA per 1 day) 0.15-0.03 mg levonorgestrel-ethinyl estrad oral tablet (Amethyst (28)) $0 QL (1 EA per 1 day) 90-20 mcg (28) levonorgestrel-ethinyl estrad oral (Introvale) $0 QL (1 EA per 1 day) tablets,dose pack,3 month 0.15 mg-30 mcg (91) levonorg-eth estrad triphasic oral tablet (Enpresse) $0 QL (1 EA per 1 day) 50-30 (6)/75-40 (5)/125-30(10) LEVORA-28 ORAL TABLET 0.15-0.03 $0 QL (1 EA per 1 day) MG LILLOW (28) ORAL TABLET 0.15-0.03 $0 QL (1 EA per 1 day) MG LO LOESTRIN FE ORAL TABLET 1 Tier 3 QL (1 EA per 1 day) MG-10 MCG (24)/10 MCG (2) LOJAIMIESS ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) LORYNA (28) ORAL TABLET 3-0.02 $0 QL (1 EA per 1 day) MG

36 Drug Status Notes LOW-OGESTREL (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.3-30 MG-MCG LO-ZUMANDIMINE (28) ORAL TABLET $0 QL (1 EA per 1 day) 3-0.02 MG LUTERA (28) ORAL TABLET 0.1-20 $0 QL (1 EA per 1 day) MG-MCG LYZA ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) MARLISSA (28) ORAL TABLET 0.15- $0 QL (1 EA per 1 day) 0.03 MG MELODETTA 24 FE ORAL $0 QL (1 EA per 1 day) TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4) MIBELAS 24 FE ORAL $0 QL (1 EA per 1 day) TABLET,CHEWABLE 1 MG-20 MCG(24) /75 MG (4) MICROGESTIN 1.5/30 (21) ORAL $0 QL (1 EA per 1 day) TABLET 1.5-30 MG-MCG MICROGESTIN 1/20 (21) ORAL $0 QL (1 EA per 1 day) TABLET 1-20 MG-MCG MICROGESTIN FE 1.5/30 (28) ORAL $0 QL (1 EA per 1 day) TABLET 1.5 MG-30 MCG (21)/75 MG (7) MICROGESTIN FE 1/20 (28) ORAL $0 QL (1 EA per 1 day) TABLET 1 MG-20 MCG (21)/75 MG (7) MILI ORAL TABLET 0.25-35 MG-MCG $0 QL (1 EA per 1 day) MONO-LINYAH ORAL TABLET 0.25-35 $0 QL (1 EA per 1 day) MG-MCG MY CHOICE ORAL TABLET 1.5 MG Tier 3 QL (1 EA per 15 days) MY WAY ORAL TABLET 1.5 MG Tier 3 QL (1 EA per 15 days) NATAZIA ORAL TABLET 3 MG/2 MG-2 Tier 3 QL (1 EA per 1 day) MG/ 2 MG-3 MG/1 MG NECON 0.5/35 (28) ORAL TABLET 0.5- $0 QL (1 EA per 1 day) 35 MG-MCG NEW DAY ORAL TABLET 1.5 MG Tier 3 QL (1 EA per 15 days) NIKKI (28) ORAL TABLET 3-0.02 MG $0 QL (1 EA per 1 day) NORA-BE ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) noreth-ethinyl estradiol-iron oral (Wymzya Fe) $0 QL (1 EA per 1 day) tablet,chewable 0.4mg-35mcg(21) and 75 mg (7) noreth-ethinyl estradiol-iron oral (Kaitlib Fe) $0 QL (1 EA per 1 day) tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) norethindrone (contraceptive) oral tablet (Camila) $0 QL (1 EA per 1 day) 0.35 mg norethindrone ac-eth estradiol oral tablet (Aurovela 1.5/30 (21)) $0 QL (1 EA per 1 day) 1.5-30 mg-mcg norethindrone ac-eth estradiol oral tablet (Aurovela 1/20 (21)) $0 QL (1 EA per 1 day) 1-20 mg-mcg norethindrone-e.estradiol-iron oral tablet (Aurovela Fe 1-20 (28)) $0 QL (1 EA per 1 day) 1 mg-20 mcg (21)/75 mg (7)

37 Drug Status Notes norethindrone-e.estradiol-iron oral tablet (Aurovela Fe 1.5/30 (28)) $0 QL (1 EA per 1 day) 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-e.estradiol-iron oral (Charlotte 24 Fe) $0 QL (1 EA per 1 day) tablet,chewable 1 mg-20 mcg(24) /75 mg (4) norgestimate-ethinyl estradiol oral tablet (Tri-Lo-Estarylla) $0 QL (1 EA per 1 day) 0.18/0.215/0.25 mg-25 mcg norgestimate-ethinyl estradiol oral tablet (Tri Femynor) $0 QL (1 EA per 1 day) 0.18/0.215/0.25 mg-35 mcg (28) norgestimate-ethinyl estradiol oral tablet (Estarylla) $0 QL (1 EA per 1 day) 0.25-35 mg-mcg NORLYDA ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) NORTREL 0.5/35 (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.5-35 MG-MCG NORTREL 1/35 (21) ORAL TABLET 1- $0 QL (1 EA per 1 day) 35 MG-MCG (21) NORTREL 1/35 (28) ORAL TABLET 1- $0 QL (1 EA per 1 day) 35 MG-MCG NORTREL 7/7/7 (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.5/0.75/1 MG- 35 MCG OCELLA ORAL TABLET 3-0.03 MG $0 QL (1 EA per 1 day) OPCICON ONE-STEP ORAL TABLET Tier 3 QL (1 EA per 15 days) 1.5 MG OPTION-2 ORAL TABLET 1.5 MG Tier 3 QL (1 EA per 15 days) ORSYTHIA ORAL TABLET 0.1-20 MG- $0 QL (1 EA per 1 day) MCG PHILITH ORAL TABLET 0.4-35 MG- $0 QL (1 EA per 1 day) MCG PIMTREA (28) ORAL TABLET 0.15-0.02 $0 QL (1 EA per 1 day) MGX21 /0.01 MG X 5 PIRMELLA ORAL TABLET 0.5/0.75/1 $0 QL (1 EA per 1 day) MG- 35 MCG, 1-35 MG-MCG PORTIA 28 ORAL TABLET 0.15-0.03 $0 QL (1 EA per 1 day) MG PREVIFEM ORAL TABLET 0.25-35 MG- $0 QL (1 EA per 1 day) MCG RECLIPSEN (28) ORAL TABLET 0.15- $0 QL (1 EA per 1 day) 0.03 MG RIVELSA ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG SAFYRAL ORAL TABLET 3-0.03-0.451 Tier 3 QL (1 EA per 1 day) MG (21) (7) SETLAKIN ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-30 MCG (91) SHAROBEL ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) SIMLIYA (28) ORAL TABLET 0.15-0.02 $0 QL (1 EA per 1 day) MGX21 /0.01 MG X 5

38 Drug Status Notes SIMPESSE ORAL TABLETS,DOSE $0 QL (1 EA per 1 day) PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) SPRINTEC (28) ORAL TABLET 0.25-35 $0 QL (1 EA per 1 day) MG-MCG SRONYX ORAL TABLET 0.1-20 MG- $0 QL (1 EA per 1 day) MCG SYEDA ORAL TABLET 3-0.03 MG $0 QL (1 EA per 1 day) TAKE ACTION ORAL TABLET 1.5 MG Tier 3 QL (1 EA per 15 days) TARINA 24 FE ORAL TABLET 1 MG-20 $0 QL (1 EA per 1 day) MCG (24)/75 MG (4) TARINA FE 1/20 (28) ORAL TABLET 1 $0 QL (1 EA per 1 day) MG-20 MCG (21)/75 MG (7) TARINA FE 1-20 EQ (28) ORAL $0 QL (1 EA per 1 day) TABLET 1 MG-20 MCG (21)/75 MG (7) TAYTULLA ORAL CAPSULE 1 MG-20 Tier 3 QL (1 EA per 1 day) MCG (24)/75 MG (4) TILIA FE ORAL TABLET 1-20(5)/1-30(7) $0 QL (1 EA per 1 day) /1MG-35MCG (9) TRI FEMYNOR ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-35 MCG (28) TRI-ESTARYLLA ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-35 MCG (28) TRI-LEGEST FE ORAL TABLET 1- $0 QL (1 EA per 1 day) 20(5)/1-30(7) /1MG-35MCG (9) TRI-LINYAH ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-35 MCG (28) TRI-LO-ESTARYLLA ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-25 MCG TRI-LO-MARZIA ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-25 MCG TRI-LO-MILI ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-25 MCG TRI-LO-SPRINTEC ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-25 MCG TRI-MILI ORAL TABLET 0.18/0.215/0.25 $0 QL (1 EA per 1 day) MG-35 MCG (28) TRI-PREVIFEM (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-35 MCG (28) TRI-SPRINTEC (28) ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-35 MCG (28) TRIVORA (28) ORAL TABLET 50-30 $0 QL (1 EA per 1 day) (6)/75-40 (5)/125-30(10) TRI-VYLIBRA LO ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-25 MCG TRI-VYLIBRA ORAL TABLET $0 QL (1 EA per 1 day) 0.18/0.215/0.25 MG-35 MCG (28) TULANA ORAL TABLET 0.35 MG $0 QL (1 EA per 1 day) TYDEMY ORAL TABLET 3-0.03-0.451 $0 QL (1 EA per 1 day) MG (21) (7)

39 Drug Status Notes VELIVET TRIPHASIC REGIMEN (28) $0 QL (1 EA per 1 day) ORAL TABLET 0.1/.125/.15-25 MG- MCG VIENVA ORAL TABLET 0.1-20 MG- $0 QL (1 EA per 1 day) MCG VIORELE (28) ORAL TABLET 0.15-0.02 $0 QL (1 EA per 1 day) MGX21 /0.01 MG X 5 VOLNEA (28) ORAL TABLET 0.15-0.02 $0 QL (1 EA per 1 day) MGX21 /0.01 MG X 5 VYFEMLA (28) ORAL TABLET 0.4-35 $0 QL (1 EA per 1 day) MG-MCG VYLIBRA ORAL TABLET 0.25-35 MG- $0 QL (1 EA per 1 day) MCG WERA (28) ORAL TABLET 0.5-35 MG- $0 QL (1 EA per 1 day) MCG WYMZYA FE ORAL $0 QL (1 EA per 1 day) TABLET,CHEWABLE 0.4MG- 35MCG(21) AND 75 MG (7) ZARAH ORAL TABLET 3-0.03 MG $0 QL (1 EA per 1 day) ZOVIA 1/35E (28) ORAL TABLET 1-35 $0 QL (1 EA per 1 day) MG-MCG ZUMANDIMINE (28) ORAL TABLET 3- $0 QL (1 EA per 1 day) 0.03 MG Contraceptives,Transdermal XULANE TRANSDERMAL PATCH $0 QL (3 EA per 28 days) WEEKLY 150-35 MCG/24 HR Diaphragms/Cervical Cap CAYA CONTOURED VAGINAL $0 DIAPHRAGM 65-80 MM WIDE-SEAL DIAPHRAGM 60 VAGINAL $0 DIAPHRAGM 60 MM WIDE-SEAL DIAPHRAGM 65 VAGINAL $0 DIAPHRAGM 65 MM WIDE-SEAL DIAPHRAGM 70 VAGINAL $0 DIAPHRAGM 70 MM WIDE-SEAL DIAPHRAGM 75 VAGINAL $0 DIAPHRAGM 75 MM WIDE-SEAL DIAPHRAGM 80 VAGINAL $0 DIAPHRAGM 80 MM WIDE-SEAL DIAPHRAGM 85 VAGINAL $0 DIAPHRAGM 85 MM WIDE-SEAL DIAPHRAGM 90 VAGINAL $0 DIAPHRAGM 90 MM WIDE-SEAL DIAPHRAGM 95 VAGINAL $0 DIAPHRAGM 95 MM Oxytocics methylergonovine oral tablet 0.2 mg (Methergine) Tier 1

40 Drug Status Notes Cough And Cold 1St Gen Antihistamine & Decongestant Combinations promethazine-phenylephrine oral syrup (Promethazine VC) Tier 1 6.25-5 mg/5 ml Antitussives,Non-Narcotic benzonatate oral capsule 100 mg (Tessalon Perles) Tier 1 QL (6 EA per 1 day) benzonatate oral capsule 200 mg Tier 1 QL (3 EA per 1 day) Expectorants SSKI ORAL SOLUTION 1 GRAM/ML Tier 3 Narcotic Antituss-1St Gen. Antihistamine-Decongest promethazine-phenyleph-codeine oral Tier 1 Age (Min 18 Years) syrup 6.25-5-10 mg/5 ml Narcotic Antituss-Decongestant- Expectorant Comb GUAIFENESIN DAC ORAL SYRUP 30- Tier 1 Age (Min 12 Years) 10-100 MG/5 ML VIRTUSSIN DAC ORAL SYRUP 30-10- Tier 1 Age (Min 12 Years) 100 MG/5 ML Narcotic Antitussive-1St Generation Antihistamine hydrocodone-chlorpheniramine oral Tier 1 QL (10 ML per 1 day); Age suspension,extended rel 12 hr 10-8 mg/5 (Min 18 Years) ml promethazine-codeine oral syrup 6.25- Tier 1 Age (Min 18 Years) 10 mg/5 ml TUSSICAPS ORAL Tier 3 QL (4 EA per 1 day); Age CAPSULE,EXTENDED RELEASE 12 (Min 18 Years) HR 10-8 MG TUZISTRA XR ORAL Tier 3 QL (20 ML per 1 day); Age SUSPENSION,EXTENDED REL 12 HR (Min 18 Years) 14.7-2.8 MG/5 ML Narcotic Antitussive-Anticholinergic Comb. hydrocodone-homatropine oral syrup 5- (Hydromet) Tier 1 QL (240 ML per 30 days); 1.5 mg/5 ml Age (Min 18 Years) hydrocodone-homatropine oral tablet 5- Tier 1 Age (Min 18 Years) 1.5 mg HYDROMET ORAL SYRUP 5-1.5 MG/5 Tier 1 QL (240 ML per 30 days); ML Age (Min 18 Years) Narcotic Antitussive-Expectorant Combination codeine-guaifenesin oral liquid 10-100 (G Tussin AC) Tier 1 Age (Min 12 Years) mg/5 ml G TUSSIN AC ORAL LIQUID 10-100 Tier 1 Age (Min 12 Years) MG/5 ML GUAIATUSSIN AC ORAL LIQUID 10- Tier 1 Age (Min 12 Years) 100 MG/5 ML GUAIFENESIN AC ORAL LIQUID 10- Tier 1 Age (Min 12 Years) 100 MG/5 ML

41 Drug Status Notes MAXI-TUSS AC ORAL LIQUID 10-100 Tier 1 Age (Min 12 Years) MG/5 ML VIRTUSSIN AC ORAL LIQUID 10-100 Tier 1 Age (Min 12 Years) MG/5 ML Non-Narc Antitussive-1St Gen Antihistamine Comb. promethazine-dm oral syrup 6.25-15 Tier 1 mg/5 ml Nose Preparations, Vasoconstrictors (Rx) TYZINE NASAL DROPS 0.1 % Tier 3 TYZINE NASAL SPRAY,NON- Tier 3 AEROSOL 0.1 % Dermatology - Acne Acne Agents,Systemic AMNESTEEM ORAL CAPSULE 10 MG, Tier 1 20 MG, 40 MG CLARAVIS ORAL CAPSULE 10 MG, 20 Tier 1 MG, 30 MG, 40 MG isotretinoin oral capsule 10 mg, 20 mg, (Amnesteem) Tier 1 40 mg isotretinoin oral capsule 30 mg (Claravis) Tier 1 MYORISAN ORAL CAPSULE 10 MG, Tier 1 20 MG, 30 MG, 40 MG ZENATANE ORAL CAPSULE 10 MG, Tier 1 20 MG, 30 MG, 40 MG Acne Agents,Topical ACANYA TOPICAL GEL WITH PUMP Tier 3 1.2-2.5 % AZELEX TOPICAL CREAM 20 % Tier 3 QL (30 GM per 30 days) clindamycin-benzoyl peroxide topical gel (Neuac) Tier 1 1.2 %(1 % base) -5 % clindamycin-benzoyl peroxide topical gel (Benzaclin) Tier 1 1-5 % clindamycin-benzoyl peroxide topical gel (Acanya) Tier 1 with pump 1.2-2.5 % clindamycin-tretinoin topical gel 1.2- (Veltin) Tier 3 0.025 % dapsone topical gel 5 % (Aczone) Tier 3 EPIDUO TOPICAL GEL WITH PUMP Tier 3 QL (45 GM per 30 days) 0.1-2.5 % NEUAC TOPICAL GEL 1.2 %(1 % Tier 1 BASE) -5 % sulfacetamide sodium (acne) topical (Klaron) Tier 1 suspension 10 % Keratolytic-Glucocorticoid Combinations VANOXIDE-HC TOPICAL Tier 3 SUSPENSION 5-0.5 %

42 Drug Status Notes Rosacea Agents, Topical azelaic acid topical gel 15 % (Finacea) Tier 1 QL (50 GM per 30 days) FINACEA TOPICAL GEL 15 % Tier 3 QL (50 GM per 30 days) metronidazole topical cream 0.75 % (Rosadan) Tier 1 metronidazole topical gel 1 % (Metrogel) Tier 1 metronidazole topical gel with pump 1 % Tier 1 metronidazole topical lotion 0.75 % (MetroLotion) Tier 1 MIRVASO TOPICAL GEL WITH PUMP Tier 3 0.33 % NORITATE TOPICAL CREAM 1 % Tier 3 QL (30 GM per 30 days) ROSADAN TOPICAL CREAM 0.75 % Tier 1 Topical Preparations,Antibacterials ALA-QUIN TOPICAL CREAM 3-0.5 % Tier 3 ALCORTIN A TOPICAL GEL 2-1-1 % Tier 3 ALCORTIN A TOPICAL GEL IN Tier 3 PACKET 2-1-1 % hydrocortisone-iodoquinl-aloe2 topical (Alcortin A) Tier 3 gel 2-1-1 % hydrocortisone-iodoquinol topical cream Tier 1 1-1 % NORMLGEL AG TOPICAL GEL 0.11 % Tier 3 silver nitrate topical solution 0.5 %, 25 Tier 1 %, 50 % SILVRSTAT TOPICAL GEL 32 PPM Tier 3 Vitamin A Derivatives adapalene topical cream 0.1 % (Differin) Tier 1 QL (45 GM per 30 days) adapalene topical gel 0.1 % (Effaclar Adapalene) Tier 1 QL (45 GM per 30 days) AVITA TOPICAL CREAM 0.025 % Tier 1 QL (45 GM per 30 days); Age (Max 30 Years) AVITA TOPICAL GEL 0.025 % Tier 1 QL (45 GM per 30 days); Age (Max 30 Years) EFFACLAR ADAPALENE TOPICAL Tier 1 QL (45 GM per 30 days) GEL 0.1 % tretinoin topical cream 0.025 % (Avita) Tier 1 QL (45 GM per 30 days); Age (Max 30 Years) tretinoin topical cream 0.05 %, 0.1 % (Retin-A) Tier 1 QL (45 GM per 30 days); Age (Max 30 Years) tretinoin topical gel 0.01 % (Retin-A) Tier 1 QL (45 GM per 30 days); Age (Max 30 Years) tretinoin topical gel 0.025 % (Avita) Tier 1 QL (45 GM per 30 days); Age (Max 30 Years) tretinoin topical gel 0.05 % (Atralin) Tier 3 PA; QL (45 GM per 30 days); Age (Max 30 Years) TRETIN-X CREAM KIT TOPICAL Tier 3 PA COMBO PACK 0.025 %, 0.05 %, 0.1 % TRETIN-X TOPICAL CREAM 0.075 % Tier 3

43 Drug Status Notes Vitamin A Derivatives, Topical Cosmetic Agents REFISSA TOPICAL CREAM 0.05 % Tier 4 QL (40 GM per 30 days); Age (Max 30 Years) tretinoin (emollient) topical cream 0.05 % (Refissa) Tier 4 QL (40 GM per 30 days); Age (Max 30 Years) Dermatology - Antiinfective Topical Antibiotics CLINDAGEL TOPICAL GEL, ONCE Tier 3 DAILY 1 % clindamycin phosphate topical foam 1 % (Evoclin) Tier 1 clindamycin phosphate topical gel 1 % Tier 1 clindamycin phosphate topical lotion 1 % (Cleocin T) Tier 1 clindamycin phosphate topical solution 1 (Cleocin T) Tier 1 % clindamycin phosphate topical swab 1 % (Clindacin ETZ) Tier 1 QL (2 EA per 1 day) ERY PADS TOPICAL SWAB 2 % Tier 1 QL (2 EA per 1 day) erythromycin with ethanol topical gel 2 % (Erygel) Tier 1 erythromycin with ethanol topical Tier 1 solution 2 % erythromycin-benzoyl peroxide topical (Benzamycin) Tier 3 QL (46.6 GM per 30 days) gel 3-5 % gentamicin topical cream 0.1 % Tier 1 gentamicin topical ointment 0.1 % Tier 1 mupirocin calcium topical cream 2 % Tier 1 mupirocin topical ointment 2 % (Centany) Tier 1 Topical Antifungal/Antiinflammatory,Steriod Agent clotrimazole-betamethasone topical Tier 1 cream 1-0.05 % clotrimazole-betamethasone topical Tier 1 lotion 1-0.05 % Topical Antifungals ANTIFUNGAL (CLOTRIMAZOLE) Tier 1 TOPICAL CREAM 1 % ANTIFUNGAL CREAM (MICONAZOLE) Tier 1 TOPICAL CREAM 2 % ANTIFUNGAL RINGWORM TOPICAL Tier 1 CREAM 1 % ATHLETE'S FOOT (CLOTRIMAZOLE) Tier 1 TOPICAL CREAM 1 % ATHLETIC FOOT CREAM TOPICAL Tier 1 CREAM 1 % BAZA ANTIFUNGAL TOPICAL CREAM Tier 1 2 % CICLODAN KIT TOPICAL COMBO Tier 3 PACK 0.77 % CICLODAN TOPICAL CREAM 0.77 % Tier 1 CICLODAN TOPICAL SOLUTION 8 % Tier 1

44 Drug Status Notes ciclopirox topical cream 0.77 % (Ciclodan) Tier 1 ciclopirox topical gel 0.77 % Tier 1 ciclopirox topical shampoo 1 % (Loprox) Tier 1 ciclopirox topical solution 8 % (Ciclodan) Tier 1 ciclopirox topical suspension 0.77 % (Loprox (as olamine)) Tier 1 ciclopirox-ure-camph-menth-euc topical (Ciclodan Kit) Tier 1 solution 8 % CLOTRIMAZOLE AF TOPICAL CREAM Tier 1 1 % clotrimazole topical cream 1 % (Antifungal (clotrimazole)) Tier 1 econazole topical cream 1 % Tier 1 QL (30 GM per 15 days) ERTACZO TOPICAL CREAM 2 % Tier 3 EXELDERM TOPICAL CREAM 1 % Tier 3 EXELDERM TOPICAL SOLUTION 1 % Tier 3 INZO ANTIFUNGAL TOPICAL CREAM Tier 1 2 % ITCH RELIEF (CLOTRIMAZOLE) Tier 1 TOPICAL CREAM 1 % JOCK ITCH (CLOTRIMAZOLE) Tier 1 TOPICAL CREAM 1 % JUBLIA TOPICAL SOLUTION WITH Tier 3 PA APPLICATOR 10 % KERYDIN TOPICAL SOLUTION WITH Tier 3 PA; QL (4 ML per 30 days) APPLICATOR 5 % ketoconazole topical cream 2 % Tier 1 ketoconazole topical foam 2 % (Ketodan) Tier 1 ketoconazole topical shampoo 2 % Tier 1 KETODAN TOPICAL FOAM 2 % Tier 1 LOPROX (AS OLAMINE) TOPICAL Tier 1 CREAM 0.77 % LOTRIMIN ULTRA TOPICAL CREAM 1 Tier 3 % luliconazole topical cream 1 % (Luzu) Tier 1 QL (60 GM per 30 days) LUZU TOPICAL CREAM 1 % Tier 3 QL (60 GM per 30 days) MICATIN TOPICAL CREAM 2 % Tier 1 miconazole nitrate topical cream 2 % (Antifungal Cream Tier 1 (miconazole)) naftifine topical cream 1 % Tier 3 NAFTIN TOPICAL GEL 1 % Tier 3 QL (45 GM per 15 days) nystatin topical cream 100,000 unit/gram Tier 1 nystatin topical ointment 100,000 Tier 1 unit/gram nystatin-triamcinolone topical cream Tier 1 100,000-0.1 unit/g-% nystatin-triamcinolone topical ointment Tier 1 100,000-0.1 unit/gram-% oxiconazole topical cream 1 % (Oxistat) Tier 3 OXISTAT TOPICAL LOTION 1 % Tier 3

45 Drug Status Notes REMEDY ANTIFUNGAL TOPICAL Tier 1 CREAM 2 % RINGWORM TOPICAL CREAM 1 % Tier 1 SECURA ANTIFUNGAL EXTRA THICK Tier 1 TOPICAL CREAM 2 % SECURA ANTIFUNGAL TOPICAL Tier 1 CREAM 2 % XOLEGEL TOPICAL GEL 2 % Tier 3 Topical Antiparasitics CROTAN TOPICAL LOTION 10 % Tier 3 EURAX TOPICAL CREAM 10 % Tier 3 EURAX TOPICAL LOTION 10 % Tier 3 lindane topical shampoo 1 % Tier 1 malathion topical lotion 0.5 % (Ovide) Tier 1 permethrin topical cream 5 % (Elimite) Tier 1 SKLICE TOPICAL LOTION 0.5 % Tier 3 ULESFIA TOPICAL LOTION 5 % Tier 3 QL (227 GM per 15 days) Topical Antivirals ABREVA TOPICAL CREAM 10 % Tier 2 QL (2 GM per 30 days) acyclovir topical ointment 5 % (Zovirax) Tier 1 QL (30 GM per 15 days) DENAVIR TOPICAL CREAM 1 % Tier 3 QL (1.5 GM per 30 days) ZOVIRAX TOPICAL CREAM 5 % Tier 3 Topical Antivirals/Antiinflammatory, Steroid Agent XERESE TOPICAL CREAM 5-1 % Tier 3 Topical Genital Wart-Hpv Treatment Agents VEREGEN TOPICAL OINTMENT 15 % Tier 3 Topical Pleuromutilin Derivatives ALTABAX TOPICAL OINTMENT 1 % Tier 3 QL (30 GM per 15 days) Topical Sulfonamides AVAR LS TOPICAL PADS, Tier 3 MEDICATED 10-2 % AVAR TOPICAL PADS, MEDICATED Tier 3 9.5-5 % AVAR-E GREEN TOPICAL CREAM 10- Tier 3 5 % (W/W) AVAR-E TOPICAL CREAM 10-5 % Tier 3 (W/W) CLEANSING WASH TOPICAL Tier 1 CLEANSER 10-4-10 % silver sulfadiazine topical cream 1 % (SSD) Tier 1 SSD TOPICAL CREAM 1 % Tier 1 SSS 10-5 TOPICAL CREAM 10-5 % Tier 1 (W/W) SSS 10-5 TOPICAL FOAM 10-5 % Tier 1 sulfacetamide sodium-sulfur topical (Avar LS) Tier 1 cleanser 10-2 %

46 Drug Status Notes sulfacetamide sodium-sulfur topical (Avar) Tier 1 cleanser 10-5 % (w/w) sulfacetamide sodium-sulfur topical (Sumadan) Tier 1 cleanser 9-4.5 % sulfacetamide sodium-sulfur topical (SSS 10-5) Tier 1 cream 10-5 % (w/w) sulfacetamide sodium-sulfur topical Tier 1 lotion 10-5 % (w/v), 10-5 % (w/w) sulfacetamide sodium-sulfur topical (Sumaxin) Tier 1 pads, medicated 10-4 % sulfacetamide sodium-sulfur topical Tier 1 suspension 10-5 % sulfacetamide sodium-sulfur topical (SulfaCleanse 8-4) Tier 1 suspension 8-4 % sulfacetamide sod-sulfur-urea topical Tier 1 cleanser 10-5-10 % sulfacetamide-sulfur-cleansr23 topical kit (Sumadan) Tier 1 9-4.5 % SULFACLEANSE 8-4 TOPICAL Tier 1 SUSPENSION 8-4 % SULFAMYLON TOPICAL CREAM 85 Tier 3 MG/G Dermatology - Antiinflammatory Topical Antibiotics/Antiinflammatory,Steroidal CORTISPORIN TOPICAL CREAM 3.5- Tier 3 QL (15 GM per 30 days) 10,000-0.5 MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 Tier 3 % NEO-SYNALAR TOPICAL CREAM 0.5 Tier 3 QL (60 GM per 30 days) % (0.35 % BASE)-0.025 % Topical Anti-Inflammatory Steroidal ALA-CORT TOPICAL CREAM 1 % Tier 1 alclometasone topical cream 0.05 % Tier 1 alclometasone topical ointment 0.05 % Tier 1 amcinonide topical cream 0.1 % Tier 1 amcinonide topical lotion 0.1 % Tier 1 ANTI-ITCH (HC) TOPICAL CREAM 1 % Tier 1 ANTI-ITCH (HC) TOPICAL LOTION 1 % Tier 3 ANTI-ITCH (HC) TOPICAL OINTMENT Tier 1 1 % ANTI-ITCH(HYDROCORTISONE)-ALOE Tier 1 TOPICAL CREAM 1 % ANUSOL-HC TOPICAL CREAM WITH Tier 1 PERINEAL APPLICATOR 2.5 % AQUANIL HC TOPICAL LOTION 1 % Tier 3 BETA-HC TOPICAL LOTION 1 % Tier 3 betamethasone dipropionate topical Tier 1 cream 0.05 %

47 Drug Status Notes betamethasone dipropionate topical Tier 1 lotion 0.05 % betamethasone dipropionate topical Tier 1 ointment 0.05 % betamethasone valerate topical cream Tier 1 0.1 % betamethasone valerate topical foam (Luxiq) Tier 1 0.12 % betamethasone valerate topical lotion Tier 1 0.1 % betamethasone valerate topical ointment Tier 1 0.1 % betamethasone, augmented topical Tier 1 cream 0.05 % betamethasone, augmented topical gel Tier 1 0.05 % betamethasone, augmented topical Tier 1 lotion 0.05 % betamethasone, augmented topical (Diprolene (augmented)) Tier 1 ointment 0.05 % clobetasol scalp solution 0.05 % Tier 1 QL (50 ML per 15 days) clobetasol topical cream 0.05 % (Temovate) Tier 1 QL (45 GM per 15 days) clobetasol topical foam 0.05 % (Olux) Tier 1 QL (50 GM per 15 days) clobetasol topical gel 0.05 % Tier 1 QL (45 GM per 15 days) clobetasol topical lotion 0.05 % (Clobex) Tier 1 QL (60 ML per 15 days) clobetasol topical ointment 0.05 % (Temovate) Tier 1 QL (45 GM per 15 days) clobetasol topical shampoo 0.05 % (Clobex) Tier 1 QL (118 ML per 30 days) clobetasol topical spray,non-aerosol 0.05 (Clobex) Tier 3 % clobetasol-emollient topical cream 0.05 Tier 1 QL (30 GM per 15 days) % clobetasol-emollient topical foam 0.05 % (Olux-E) Tier 1 QL (50 GM per 15 days) clocortolone pivalate topical cream 0.1 % (Cloderm) Tier 1 CORTAID TOPICAL CREAM 1 % Tier 1 CORTISONE (HYDROCORTISONE) Tier 1 TOPICAL CREAM 1 % CORTISONE (HYDROCORTISONE) Tier 3 TOPICAL LOTION 1 % CORTISONE WITH ALOE TOPICAL Tier 1 CREAM 1 % CORTIZONE-10 PLUS TOPICAL Tier 1 CREAM 1 % CORTIZONE-10 TOPICAL CREAM 1 % Tier 1 CORTIZONE-10 TOPICAL LOTION 1 % Tier 3 CORTIZONE-10 TOPICAL OINTMENT Tier 1 1 % CORTIZONE-10 WITH ALOE TOPICAL Tier 1 CREAM 1 %

48 Drug Status Notes DERMACINRX SILAPAK TOPICAL KIT Tier 3 PA 0.1-5 % DERMAREST ECZEMA (HYDROCORT) Tier 3 TOPICAL LOTION 1 % DERMAWERX SDS TOPICAL KIT 0.1-5 Tier 3 PA % desonide topical cream 0.05 % (DesOwen) Tier 1 desonide topical lotion 0.05 % (DesOwen) Tier 1 desonide topical ointment 0.05 % Tier 1 desoximetasone topical cream 0.05 %, (Topicort) Tier 1 QL (30 GM per 15 days) 0.25 % desoximetasone topical gel 0.05 % (Topicort) Tier 1 QL (30 GM per 15 days) desoximetasone topical ointment 0.05 (Topicort) Tier 1 QL (30 GM per 15 days) %, 0.25 % diflorasone topical cream 0.05 % (Psorcon) Tier 1 diflorasone topical ointment 0.05 % Tier 1 fluocinolone and shower cap scalp oil (Derma-Smoothe/FS Scalp Tier 1 0.01 % Oil) fluocinolone topical cream 0.01 % Tier 1 fluocinolone topical cream 0.025 % (Synalar) Tier 1 fluocinolone topical oil 0.01 % (Derma-Smoothe/FS Body Tier 1 Oil) fluocinolone topical ointment 0.025 % (Synalar) Tier 1 fluocinolone topical solution 0.01 % (Synalar) Tier 1 fluocinonide topical cream 0.05 % Tier 1 fluocinonide topical cream 0.1 % (Vanos) Tier 3 fluocinonide topical gel 0.05 % Tier 1 fluocinonide topical ointment 0.05 % Tier 1 fluocinonide topical solution 0.05 % Tier 1 FLUOCINONIDE-E TOPICAL CREAM Tier 1 0.05 % fluocinonide-emollient topical cream 0.05 (Fluocinonide-E) Tier 1 % flurandrenolide topical cream 0.05 % (Cordran) Tier 3 QL (30 GM per 30 days) flurandrenolide topical lotion 0.05 % (Cordran) Tier 3 flurandrenolide topical ointment 0.05 % (Cordran) Tier 3 fluticasone propionate topical cream (Cutivate) Tier 1 0.05 % fluticasone propionate topical lotion 0.05 (Beser) Tier 1 % fluticasone propionate topical ointment Tier 1 0.005 % halobetasol propionate topical cream Tier 1 0.05 % halobetasol propionate topical ointment Tier 1 0.05 % HALOG TOPICAL CREAM 0.1 % Tier 1 QL (60 GM per 15 days) HALOG TOPICAL OINTMENT 0.1 % Tier 1 QL (60 GM per 15 days)

49 Drug Status Notes hydrocortisone acetate topical cream 1 (Vanicream HC) Tier 1 % hydrocortisone acetate topical ointment Tier 1 1 % hydrocortisone butyrate topical cream Tier 3 0.1 % hydrocortisone butyrate topical ointment Tier 1 0.1 % hydrocortisone butyrate topical solution Tier 1 0.1 % hydrocortisone butyr-emollient topical (Locoid Lipocream) Tier 3 cream 0.1 % HYDROCORTISONE PLUS TOPICAL Tier 1 CREAM 1 % hydrocortisone topical cream 1 % (Ala-Cort) Tier 1 hydrocortisone topical cream 2.5 % Tier 1 hydrocortisone topical cream with (Procto-Pak) Tier 1 perineal applicator 1 % hydrocortisone topical cream with (Anusol-HC) Tier 1 perineal applicator 2.5 % hydrocortisone topical lotion 1 % (Anti-Itch (HC)) Tier 3 hydrocortisone topical lotion 2.5 % Tier 1 hydrocortisone topical ointment 1 % (Anti-Itch (HC)) Tier 1 hydrocortisone topical ointment 2.5 % Tier 1 hydrocortisone valerate topical cream Tier 1 0.2 % hydrocortisone valerate topical ointment Tier 1 0.2 % hydrocortisone-aloe vera topical cream 1 (Anti-Itch(hydrocortisone)- Tier 1 % Aloe) HYDROCREAM TOPICAL CREAM 1 % Tier 1 mometasone topical cream 0.1 % Tier 1 mometasone topical ointment 0.1 % Tier 1 mometasone topical solution 0.1 % Tier 1 NOBLE FORMULA HC TOPICAL Tier 1 CREAM 1 % NUTRIARX TOPICAL KIT 0.1-5 % Tier 3 PA prednicarbate topical cream 0.1 % Tier 1 prednicarbate topical ointment 0.1 % Tier 1 PREPARATION H HYDROCORTISONE Tier 1 TOPICAL CREAM 1 % PROCTO-MED HC TOPICAL CREAM Tier 1 WITH PERINEAL APPLICATOR 2.5 % PROCTO-PAK TOPICAL CREAM WITH Tier 1 PERINEAL APPLICATOR 1 % PROCTOSOL HC TOPICAL CREAM Tier 1 WITH PERINEAL APPLICATOR 2.5 % PROCTOZONE-HC TOPICAL CREAM Tier 1 WITH PERINEAL APPLICATOR 2.5 %

50 Drug Status Notes SANADERMRX TOPICAL KIT 0.1-5 % Tier 3 PA SOOTHING CARE Tier 1 (HYDROCORTISONE) TOPICAL CREAM 1 % SURE RESULT TAC PAK TOPICAL KIT Tier 3 PA 0.1-5 % TEXACORT TOPICAL SOLUTION 2.5 Tier 3 % triamcinolone acetonide topical aerosol (Kenalog) Tier 1 0.147 mg/gram triamcinolone acetonide topical cream Tier 1 0.025 % triamcinolone acetonide topical cream (Triderm) Tier 1 0.1 %, 0.5 % triamcinolone acetonide topical lotion Tier 1 0.025 %, 0.1 % triamcinolone acetonide topical ointment Tier 1 0.025 %, 0.1 %, 0.5 % triamcinolone acetonide topical ointment (Trianex) Tier 3 0.05 % TRIANEX TOPICAL OINTMENT 0.05 % Tier 3 TRIDERM TOPICAL CREAM 0.1 %, 0.5 Tier 1 % TRIVIX TOPICAL KIT 0.1-5 % Tier 3 PA VANICREAM HC TOPICAL CREAM 1 % Tier 1 VERDESO TOPICAL FOAM 0.05 % Tier 3 Topical Anti-Inflammatory, Nsaids ARTHRITIS PAIN (DICLOFENAC) Tier 1 QL (300 GM per 15 days) TOPICAL GEL 1 % diclofenac sodium topical drops 1.5 % Tier 3 diclofenac sodium topical gel 1 % (Arthritis Pain (diclofenac)) Tier 1 QL (300 GM per 15 days) FLECTOR TRANSDERMAL PATCH 12 Tier 3 HOUR 1.3 % Dermatology - Antipruritic Drugs Antipruritics,Topical doxepin topical cream 5 % (Prudoxin) Tier 3 Dermatology - Miscellaneous Antiseborrheic Agents OVACE PLUS TOPICAL CREAM 10 % Tier 2 selenium sulfide topical lotion 2.5 % Tier 1 selenium sulfide topical shampoo 2.25 % Tier 1 selenium sulfide topical shampoo 2.3 % (SelRx) Tier 1 SELRX TOPICAL SHAMPOO 2.3 % Tier 3 sulfacetamide sodium topical cleanser (Ovace) Tier 1 10 % sulfacetamide sodium topical shampoo (Ovace Plus Shampoo) Tier 1 10 % TERSI FOAM TOPICAL FOAM 2.25 % Tier 3

51 Drug Status Notes Antiseptics,General ALCOHOL PADS TOPICAL PADS, Tier 2 MEDICATED ALCOHOL PREP PADS TOPICAL Tier 2 PADS, MEDICATED alcohol swabs topical pads, medicated (Alcohol Pads) Tier 2 ALCOHOL WIPES TOPICAL PADS, Tier 2 MEDICATED BD ALCOHOL SWABS TOPICAL PADS, Tier 2 MEDICATED CARETOUCH ALCOHOL PREP PAD Tier 2 TOPICAL PADS, MEDICATED CURITY ALCOHOL SWABS TOPICAL Tier 2 PADS, MEDICATED EASY COMFORT ALCOHOL PAD Tier 2 TOPICAL PADS, MEDICATED EASY TOUCH ALCOHOL PREP PADS Tier 2 TOPICAL PADS, MEDICATED INCONTROL ALCOHOL PADS Tier 2 TOPICAL PADS, MEDICATED IV PREP WIPES TOPICAL PADS, Tier 2 MEDICATED PRO COMFORT ALCOHOL PADS Tier 2 TOPICAL PADS, MEDICATED PURE COMFORT ALCOHOL PADS Tier 2 TOPICAL PADS, MEDICATED SURE COMFORT ALCOHOL PREP Tier 2 PADS TOPICAL PADS, MEDICATED SURE-PREP ALCOHOL PREP PADS Tier 2 TOPICAL PADS, MEDICATED TRUE COMFORT ALCOHOL PADS Tier 2 TOPICAL PADS, MEDICATED ULTILET ALCOHOL SWAB TOPICAL Tier 2 PADS, MEDICATED WEBCOL TOPICAL PADS, Tier 2 MEDICATED Emollients ammonium lactate topical cream 12 % (Geri-Hydrolac) Tier 1 GERI-HYDROLAC TOPICAL CREAM 12 Tier 1 % Irrigants PHYSIOLYTE IRRIGATION SOLUTION Tier 3 140-5-3-98 MEQ/L PHYSIOSOL IRRIGATION IRRIGATION Tier 3 SOLUTION 140-5-3-98 MEQ/L Irritants/Counter-Irritants capsaicin topical cream 0.025 % Tier 1 ZOSTRIX TOPICAL CREAM 0.033 % Tier 1

52 Drug Status Notes Keratolytics ACNE MEDICATION TOPICAL GEL 2.5 Tier 1 %, 5 % ACNE MEDICATION TOPICAL LOTION Tier 1 10 % ADVANCED EXFOLIATING CLEANSER Tier 1 TOPICAL CLEANSER 5 % BENSAL HP TOPICAL OINTMENT 3 % Tier 3 BENZEPRO (MICROSPHERES) Tier 1 TOPICAL CLEANSER 7 % BENZEPRO TOPICAL FOAM 5.3 %, 9.8 Tier 1 % benzoyl peroxide topical cleanser 5 % (Advanced Exfoliating Tier 1 Cleanser) benzoyl peroxide topical cleanser 6 % Tier 1 benzoyl peroxide topical cleanser 7 % (BP Wash) Tier 1 benzoyl peroxide topical foam 5.3 %, 9.8 (BenzePrO) Tier 1 % benzoyl peroxide topical gel 2.5 %, 5 % (Acne Medication) Tier 1 BP FOAM TOPICAL FOAM 5.3 %, 9.8 % Tier 1 BP TOPICAL GEL 5 % Tier 1 BP WASH ACNE TREATMENT Tier 3 TOPICAL KIT 4-5 % BP WASH ACNE TREATMENT Tier 1 TOPICAL KIT 8-5 % BP WASH TOPICAL CLEANSER 2.5 % Tier 3 BP WASH TOPICAL CLEANSER 5 %, 7 Tier 1 % BPO TOPICAL GEL 4 %, 8 % Tier 3 CONDYLOX TOPICAL GEL 0.5 % Tier 2 INOVA 4-1 TOPICAL COMBO PACK 1- Tier 3 4-5 % INOVA 8-2 TOPICAL COMBO PACK 2- Tier 3 8-5 % INOVA TOPICAL COMBO PACK 4-5 %, Tier 3 8-5 % KERAFOAM TOPICAL FOAM 30 %, 42 Tier 3 % PACNEX HP TOPICAL PADS, Tier 3 MEDICATED 7 % PACNEX LP TOPICAL PADS, Tier 3 MEDICATED 4.25 % PODOCON TOPICAL LIQUID 25 % Tier 3 podofilox topical solution 0.5 % Tier 1 PR BENZOYL PEROXIDE TOPICAL Tier 1 CLEANSER 7 % salicylic acid topical cream 6 % (Salimez) Tier 1 salicylic acid topical cream,extended Tier 1 release 6 %

53 Drug Status Notes salicylic acid topical film forming liquid (Virasal) Tier 1 w/appl 27.5 % salicylic acid topical foam 6 % (Salvax) Tier 3 salicylic acid topical gel 6 % (Keralyt Rx) Tier 1 salicylic acid topical liquid 26 % Tier 1 salicylic acid topical lotion 6 % Tier 1 salicylic acid topical lotion,extended Tier 1 release 6 % salicylic acid topical shampoo 6 % (Salex) Tier 1 SALIMEZ TOPICAL CREAM 6 % Tier 1 SALKERA TOPICAL FOAM 6 % Tier 3 SALVAX TOPICAL FOAM 6 % Tier 3 silver nitrate topical solution 10 % Tier 1 URAMAXIN TOPICAL FOAM 20 % Tier 3 Protectives NUVAIL TOPICAL NAIL FILM Tier 3 SOLUTION 16 % Topical Anti-Inflammatory Steroid- Local Anesthetic EPIFOAM TOPICAL FOAM 1-1 % Tier 3 hydrocortisone-pramoxine topical cream (Pramosone) Tier 1 2.5-1 % Topical Antineoplastic & Premalignant Lesion Agnts diclofenac sodium topical gel 3 % (Solaraze) Tier 3 PA; QL (50 GM per 15 days) FLUOROPLEX TOPICAL CREAM 1 % Tier 3 fluorouracil topical cream 0.5 % (Carac) Tier 1 fluorouracil topical cream 5 % (Efudex) Tier 1 fluorouracil topical solution 2 %, 5 % Tier 1 PANRETIN TOPICAL GEL 0.1 % Tier 4 SP PICATO TOPICAL GEL 0.015 % Tier 4 QL (3 EA per 56 days) PICATO TOPICAL GEL 0.05 % Tier 4 QL (2 EA per 56 days) TARGRETIN TOPICAL GEL 1 % Tier 4 PA; SP VALCHLOR TOPICAL GEL 0.016 % Tier 4 PA; SP Topical Local Anesthetics ANECREAM TOPICAL CREAM 4 % Tier 1 ANODYNE LPT TOPICAL KIT 2.5-2.5 % Tier 1 BLUE TUBE TOPICAL CREAM 4 % Tier 1 CETACAINE ANESTHETIC TOPICAL Tier 3 LIQUID 2-2-14 % CETACAINE TOPICAL Tier 3 AEROSOL,SPRAY 2 %-2 %-14 % (200 MG/SEC) ethyl chloride topical aerosol,spray 100 Tier 1 % lidocaine hcl laryngotracheal solution 4 (LTA Pre-Attached) Tier 1 % lidocaine hcl topical cream 3 % (Lidopin) Tier 1

54 Drug Status Notes lidocaine hcl topical lotion 3 % (Lido-K) Tier 1 lidocaine topical adhesive (Lidoderm) Tier 1 QL (1 EA per 1 day) patch,medicated 5 % lidocaine topical cream 4 % (Anecream) Tier 1 lidocaine topical ointment 5 % Tier 3 QL (50 GM per 15 days) lidocaine-prilocaine topical cream 2.5-2.5 Tier 1 % lidocaine-prilocaine topical kit 2.5-2.5 % (Anodyne LPT) Tier 1 LIDORX TOPICAL GEL WITH PUMP 3 Tier 3 % PONTOCAINE TOPICAL SOLUTION 2 Tier 3 % Topical/Mucous Membr./Subcut. Enzymes SANTYL TOPICAL OINTMENT 250 Tier 2 QL (30 GM per 15 days) UNIT/GRAM Dermatology - Psoriasis/Eczema Antipsoriatic Agents,Systemic acitretin oral capsule 10 mg, 25 mg (Soriatane) Tier 1 acitretin oral capsule 17.5 mg Tier 1 methoxsalen oral capsule,liqd-filled,rapid (Oxsoralen Ultra) Tier 1 rel 10 mg TALTZ AUTOINJECTOR (2 PACK) Tier 4 PA; SP SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ AUTOINJECTOR (3 PACK) Tier 4 PA; SP SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ AUTOINJECTOR Tier 4 PA; SP SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS Tier 4 PA; SP SYRINGE 80 MG/ML Antipsoriatics Agents calcipotriene scalp solution 0.005 % Tier 1 calcipotriene topical cream 0.005 % (Dovonex) Tier 1 QL (60 GM per 30 days) calcitriol topical ointment 3 mcg/gram (Vectical) Tier 1 DRITHOCREME HP TOPICAL CREAM Tier 3 1 % tazarotene topical cream 0.1 % (Tazorac) Tier 3 QL (30 GM per 15 days) TAZORAC TOPICAL CREAM 0.05 % Tier 3 TAZORAC TOPICAL GEL 0.05 %, 0.1 % Tier 3 ZITHRANOL TOPICAL SHAMPOO 1 % Tier 3 Topical Immunosuppressive Agents ELIDEL TOPICAL CREAM 1 % Tier 3 QL (30 GM per 15 days) PROTOPIC TOPICAL OINTMENT 0.03 Tier 3 QL (60 GM per 30 days) %, 0.1 % tacrolimus topical ointment 0.03 %, 0.1 (Protopic) Tier 3 QL (60 GM per 30 days) %

55 Drug Status Notes Topical Vit D Analog/Antiinflammatory, Steroidal calcipotriene-betamethasone topical (Taclonex) Tier 1 ointment 0.005-0.064 % TACLONEX TOPICAL SUSPENSION Tier 3 0.005-0.064 % Diabetes Antihypergly, (Dpp-4) Inhibitor & Biguanide Comb. alogliptin-metformin oral tablet 12.5- (Kazano) Tier 1 1,000 mg, 12.5-500 mg JANUMET ORAL TABLET 50-1,000 MG, Tier 2 QL (2 EA per 1 day) 50-500 MG JANUMET XR ORAL TABLET, ER Tier 2 QL (1 EA per 1 day) MULTIPHASE 24 HR 100-1,000 MG, 50- 1,000 MG, 50-500 MG JENTADUETO ORAL TABLET 2.5- Tier 3 QL (2 EA per 1 day) 1,000 MG, 2.5-500 MG, 2.5-850 MG KOMBIGLYZE XR ORAL TABLET, ER Tier 3 MULTIPHASE 24 HR 2.5-1,000 MG, 5- 1,000 MG, 5-500 MG Antihypergly,Dpp-4 Enzyme Inhib &Thiazolidinedione alogliptin-pioglitazone oral tablet 12.5-15 (Oseni) Tier 1 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg Antihypergly,Incretin Mimetic(Glp-1 Recep.Agonist) BYDUREON BCISE SUBCUTANEOUS Tier 3 QL (0.85 ML per 7 days) AUTO-INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN Tier 3 QL (1 EA per 7 days) INJECTOR 2 MG/0.65 ML BYETTA SUBCUTANEOUS PEN Tier 3 QL (2.4 ML per 30 days) INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN Tier 3 QL (1.2 ML per 30 days) INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML TRULICITY SUBCUTANEOUS PEN Tier 3 INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA 2-PAK SUBCUTANEOUS Tier 3 QL (6 ML per 30 days) PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) VICTOZA 3-PAK SUBCUTANEOUS Tier 3 QL (9 ML per 30 days) PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) Antihyperglycemc-Sod/Gluc Cotransport2(Sglt2)Inhib FARXIGA ORAL TABLET 10 MG, 5 MG Tier 3

56 Drug Status Notes INVOKANA ORAL TABLET 100 MG, Tier 3 QL (1 EA per 1 day) 300 MG JARDIANCE ORAL TABLET 10 MG, 25 Tier 2 MG Antihyperglycemic - Dopamine Receptor Agonists CYCLOSET ORAL TABLET 0.8 MG Tier 3 Antihyperglycemic, Alpha-Glucosidase Inhib (N-S) acarbose oral tablet 100 mg, 25 mg, 50 (Precose) Tier 1 mg miglitol oral tablet 100 mg, 25 mg, 50 mg (Glyset) Tier 3 Antihyperglycemic, Amylin Analog- Type SYMLINPEN 120 SUBCUTANEOUS Tier 3 PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN Tier 3 INJECTOR 1,500 MCG/1.5 ML Antihyperglycemic, Dpp-4 Inhibitors alogliptin oral tablet 12.5 mg, 25 mg, (Nesina) Tier 1 QL (1 EA per 1 day) 6.25 mg JANUVIA ORAL TABLET 100 MG, 25 Tier 2 QL (1 EA per 1 day) MG, 50 MG NESINA ORAL TABLET 12.5 MG, 25 Tier 3 QL (1 EA per 1 day) MG, 6.25 MG ONGLYZA ORAL TABLET 2.5 MG, 5 Tier 3 QL (1 EA per 1 day) MG TRADJENTA ORAL TABLET 5 MG Tier 3 QL (1 EA per 1 day) Antihyperglycemic, Insulin-Release Stimulant Type glimepiride oral tablet 1 mg, 2 mg, 4 mg (Amaryl) Tier 1 glipizide oral tablet 10 mg, 5 mg (Glucotrol) Tier 1 glipizide oral tablet extended release (Glucotrol XL) Tier 1 24hr 10 mg, 2.5 mg, 5 mg glyburide micronized oral tablet 1.5 mg, (Glynase) Tier 1 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 Tier 1 mg nateglinide oral tablet 120 mg, 60 mg (Starlix) Tier 1 QL (3 EA per 1 day) PRANDIN ORAL TABLET 1 MG, 2 MG Tier 3 QL (3 EA per 1 day) repaglinide oral tablet 0.5 mg Tier 1 QL (3 EA per 1 day) repaglinide oral tablet 1 mg, 2 mg (Prandin) Tier 1 QL (3 EA per 1 day) Antihyperglycemic, Insulin-Response Enhancer (N-S) AVANDIA ORAL TABLET 2 MG, 4 MG Tier 3 QL (1 EA per 1 day) pioglitazone oral tablet 15 mg, 30 mg, 45 (Actos) Tier 1 QL (1 EA per 1 day) mg

57 Drug Status Notes Antihyperglycemic, Sglt-2 & Dpp-4 Inhibitor Comb. GLYXAMBI ORAL TABLET 10-5 MG, Tier 3 25-5 MG Antihyperglycemic,Biguanide Type(Non-Sulfonylurea) metformin oral solution 500 mg/5 ml (Riomet) Tier 1 metformin oral tablet 1,000 mg, 500 mg, (Glucophage) Tier 1 850 mg metformin oral tablet extended release (Glucophage XR) Tier 1 24 hr 500 mg, 750 mg metformin oral tablet extended release (Fortamet) Tier 1 24hr 1,000 mg metformin oral tablet extended release (Fortamet) Tier 1 PA 24hr 500 mg metformin oral tablet,er gast.retention 24 (Glumetza) Tier 1 hr 1,000 mg, 500 mg RIOMET ORAL SOLUTION 500 MG/5 Tier 2 Age (Max 12 Years) ML Antihyperglycemic,Insulin-Rel Stim.& Biguanide Cmb glipizide-metformin oral tablet 2.5-250 Tier 1 mg, 2.5-500 mg, 5-500 mg glyburide-metformin oral tablet 1.25-250 Tier 1 mg, 2.5-500 mg, 5-500 mg repaglinide-metformin oral tablet 1-500 Tier 1 mg, 2-500 mg Antihyperglycemic,Insulin-Response & Release Comb. pioglitazone-glimepiride oral tablet 30-2 (DUETACT) Tier 1 mg, 30-4 mg Antihyperglycemic-Glucocorticoid Receptor Blocker KORLYM ORAL TABLET 300 MG Tier 3 Antihyperglycemic-Sglt2 Inhibitor & Biguanide Comb INVOKAMET ORAL TABLET 150-1,000 Tier 3 QL (2 EA per 1 day) MG, 150-500 MG, 50-1,000 MG, 50-500 MG XIGDUO XR ORAL TABLET, IR - ER, Tier 3 BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 2.5-1,000 MG, 5-1,000 MG, 5-500 MG Antihyperglycm,Insul-Resp.Enhancer & Biguanide Cmb pioglitazone-metformin oral tablet 15-500 (Actoplus MET) Tier 3 mg, 15-850 mg Blood Sugar Diagnostics ACCU-CHEK AVIVA PLUS TEST STRP Tier 2 STRIP

58 Drug Status Notes ACCU-CHEK GUIDE TEST STRIPS Tier 2 STRIP ACCU-CHEK SMARTVIEW TEST Tier 2 STRIP STRIP ACCUTREND GLUCOSE TEST STRIPS Tier 2 STRIP ADVANCED GLUC METER TEST Tier 2 STRIP STRIP ADVOCATE REDI-CODE PLUS STRIP Tier 2 ADVOCATE REDI-CODE STRIP Tier 2 ADVOCATE TEST STRIPS STRIP Tier 2 AGAMATRIX AMP TEST STRIPS Tier 2 STRIP AGAMATRIX PRESTO TEST STRIPS Tier 2 STRIP ASSURE 4 STRIPS STRIP Tier 2 ASSURE PLATINUM TEST STRIP Tier 2 STRIP ASSURE PRISM MULTI STRIP STRIP Tier 2 BIONIME RIGHTEST TEST STRIPS Tier 2 STRIP BLOOD GLUCOSE TEST STRIP Tier 2 BREEZE 2 TEST STRIPS STRIP Tier 2 CARESENS N TEST STRIPS STRIP Tier 2 CARETOUCH TEST STRIP STRIP Tier 2 CHOICEDM CLARUS STRIP Tier 2 CLEVER CHOICE MICRO TEST STRIP Tier 2 STRIP CLEVER CHOICE PRO STRIP Tier 2 CLEVER CHOICE TALK TEST STRIP Tier 2 CLEVER CHOICE TEST STRIPS STRIP Tier 2 CLEVER CHOICE VOICE+ TEST STRIP Tier 2 CONTOUR NEXT TEST STRIPS STRIP Tier 2 CONTOUR TEST STRIPS STRIP Tier 2 COOL GLUCOSE TEST STRIP STRIP Tier 2 DARIO BLOOD GLUCOSE TEST STRIP Tier 2 STRIP DIATRUE PLUS TEST STRIP STRIP Tier 2 EASY GLUCO G2 STRIP Tier 2 EASY PLUS II TEST STRIP Tier 2 EASY STEP STRIP Tier 2 EASY TALK GLUCOSE TEST STRIP Tier 2 EASY TOUCH TEST STRIP STRIP Tier 2 EASY TRAK GLUCOSE TEST STRIP Tier 2 EASY TRAK II TEST STRIP STRIP Tier 2 EASYGLUCO PLUS STRIP Tier 2 EASYGLUCO TEST STRIP Tier 2 EASYMAX 15 TEST STRIPS STRIP Tier 2

59 Drug Status Notes EASYMAX STRIP Tier 2 ELEMENT COMPACT TEST STRIPS Tier 2 STRIP ELEMENT TEST STRIPS STRIP Tier 2 EMBRACE BLOOD GLUCOSE Tier 2 SYSTEM STRIP EMBRACE EVO TEST STRIPS STRIP Tier 2 EMBRACE PRO TEST STRIPS STRIP Tier 2 EMBRACE TALK TEST STRIPS STRIP Tier 2 EVENCARE G2 STRIP Tier 2 EVENCARE G3 TEST STRIP Tier 2 EVENCARE MINI GLUCOSE TEST STR Tier 2 STRIP EVENCARE PROVIEW TEST STRIP Tier 2 STRIP EVENCARE TEST STRIP Tier 2 EVOLUTION TEST STRIPS STRIP Tier 2 EZ SMART PLUS TEST STRIP Tier 2 EZ SMART TEST STRIP Tier 2 FIFTY50 TEST STRIP STRIP Tier 2 FORA 6 CONNECT GLUCOSE STRIP Tier 2 STRIP FORA D15G STRIPS STRIP Tier 2 FORA D20 STRIP Tier 2 FORA D40-G31 TEST STRIPS STRIP Tier 2 FORA G20 STRIP Tier 2 FORA G30-PREMIUM V10 TEST STRP Tier 2 STRIP FORA GD50 TEST STRIPS STRIP Tier 2 FORA GTEL GLUCOSE TEST STRIP Tier 2 STRIP FORA TEST STRIP STRIP Tier 2 FORA TN'G VOICE TEST STRIPS Tier 2 STRIP FORA V10 STRIP Tier 2 FORA V10-V12-D10-D20 STRIPS Tier 2 STRIP FORA V12 GLUCOSE STRIP Tier 2 FORA V20 STRIP Tier 2 FORA V30A STRIP Tier 2 FORACARE GD20 STRIP Tier 2 FORACARE GD40 TEST STRIPS Tier 2 STRIP FORTISCARE GLUCOSE TEST Tier 2 STRIPS STRIP FREESTYLE INSULINX STRIP Tier 2 FREESTYLE INSULINX TEST STRIPS Tier 2 STRIP FREESTYLE LITE STRIPS STRIP Tier 2

60 Drug Status Notes FREESTYLE PRECISION NEO STRIPS Tier 2 STRIP FREESTYLE TEST STRIP Tier 2 GE100 BLOOD GLUCOSE TEST STRIP Tier 2 STRIP GENSTRIP TEST STRIP STRIP Tier 2 GENULTIMATE TEST STRIP STRIP Tier 2 GLUCO NAVII TEST STRIP STRIP Tier 2 GLUCOCARD 01 SENSOR PLUS Tier 2 STRIP GLUCOCARD EXPRESSION STRIP Tier 2 GLUCOCARD SHINE TEST STRIPS Tier 2 STRIP GLUCOCARD VITAL SENSOR STRIP Tier 2 GLUCOCARD VITAL TEST STRIPS Tier 2 STRIP GLUCOCOM GLUCOSE STRIP Tier 2 GM100 STRIP Tier 2 GOJJI BLOOD GLUCOSE TEST STRIP Tier 2 STRIP GOODLIFE AC-302 TEST STRIP STRIP Tier 2 HARMONY GLUCOSE TEST STRIP Tier 2 STRIP HEALTHPRO TEST STRIPS STRIP Tier 2 IGLUCOSE TEST STRIP STRIP Tier 2 INFINITY TEST STRIPS STRIP Tier 2 INFINITY VOICE TEST STRIP STRIP Tier 2 MICRO BLOOD GLUCOSE STRIP Tier 2 MICRODOT BLOOD GLUCOSE Tier 2 SYSTEM STRIP MICRODOT XTRA BLOOD GLUCOSE Tier 2 STRIP MYGLUCOHEALTH STRIP Tier 2 NEUTEK 2TEK TEST STRIPS STRIP Tier 2 NOVA MAX GLUCOSE TEST STRIP Tier 2 ON CALL EXPRESS TEST STRIP Tier 2 STRIP ON CALL PLUS TEST STRIP STRIP Tier 2 ON CALL VIVID TEST STRIP STRIP Tier 2 ONETOUCH ULTRA BLUE TEST Tier 2 STRIP STRIP ONETOUCH VERIO TEST STRIPS Tier 2 STRIP OPTIUM EZ STRIP Tier 2 OPTIUM TEST STRIP Tier 2 OPTUMRX STRIP Tier 2 PHARMACIST CHOICE STRIP Tier 2 PRECISION PCX PLUS TEST STRIP Tier 2 PRECISION PCX TEST STRIP Tier 2

61 Drug Status Notes PRECISION POINT OF CARE TEST Tier 2 STRIP PRECISION Q-I-D TEST STRIP Tier 2 PRECISION XTRA TEST STRIP Tier 2 PREMIER TEST STRIP STRIP Tier 2 PREMIUM V10 STRIP Tier 2 PRO VOICE V8-V9 TEST STRIP STRIP Tier 2 PRODIGY NO CODING STRIP Tier 2 QUINTET AC STRIP Tier 2 QUINTET GLUCOSE TEST STRIPS Tier 2 STRIP REFUAH PLUS STRIP Tier 2 RELION CONFIRM-MICRO STRIP Tier 2 RELION PRIME TEST STRIPS STRIP Tier 2 RELION ULTIMA STRIP Tier 2 REVEAL TEST STRIP STRIP Tier 2 RIGHTEST GS250S TEST STRIPS Tier 2 STRIP RIGHTEST GS260 TEST STRIPS Tier 2 STRIP RIGHTEST GS550 TEST STRIPS Tier 2 STRIP SMART SENSE TEST STRIPS STRIP Tier 2 SMARTEST TEST STRIP Tier 2 SOLUS V2 TEST STRIPS STRIP Tier 2 SURE-TEST EASYPLUS MINI STRIP Tier 2 TD GOLD TEST STRIP STRIP Tier 2 TELCARE TEST STRIPS STRIP Tier 2 TEST N'GO TEST STRIP Tier 2 TRUE METRIX GLUCOSE TEST STRIP Tier 2 STRIP TRUE METRIX PRO TEST STRIP Tier 2 STRIP TRUETEST TEST STRIPS STRIP Tier 2 TRUETRACK TEST STRIP Tier 2 ULTIMA TEST STRIPS STRIP Tier 2 ULTRATRAK STRIP Tier 2 ULTRATRAK ULTIMATE STRIP Tier 2 UNISTRIP1 TEST STRIP STRIP Tier 2 VERASENS TEST STRIP STRIP Tier 2 VIVAGUARD INO TEST STRIP STRIP Tier 2 WAVESENSE JAZZ STRIP Tier 2 WAVESENSE PRESTO STRIP Tier 2 Diabetic Supplies lancing device with lancets kit (Accu-Chek FastClix Tier 1 Lancing Dev) Diabetic Ulcer Preparations,Topical REGRANEX TOPICAL GEL 0.01 % Tier 4

62 Drug Status Notes Hyperglycemics GLUCAGEN HYPOKIT INJECTION Tier 3 QL (2 EA per 30 days) RECON SOLN 1 MG GLUCAGON EMERGENCY KIT Tier 2 QL (2 EA per 30 days) (HUMAN) INJECTION RECON SOLN 1 MG PROGLYCEM ORAL SUSPENSION 50 Tier 3 Age (Max 12 Years) MG/ML Insulins APIDRA SOLOSTAR U-100 INSULIN Tier 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML APIDRA U-100 INSULIN Tier 2 SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG JUNIOR KWIKPEN U-100 Tier 2 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML HUMALOG KWIKPEN INSULIN Tier 2 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML) HUMALOG MIX 50-50 INSULN U-100 Tier 2 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX 50-50 KWIKPEN Tier 2 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX 75-25 KWIKPEN Tier 2 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX 75-25(U-100)INSULN Tier 2 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMALOG U-100 INSULIN Tier 2 SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN Tier 2 SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 U-100 INSULIN Tier 2 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) HUMULIN N NPH U-100 INSULIN Tier 2 SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R REGULAR U-100 INSULN Tier 2 INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) INSULIN Tier 3 SUBCUTANEOUS SOLUTION 500 UNIT/ML

63 Drug Status Notes HUMULIN R U-500 (CONC) KWIKPEN Tier 3 SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) LANTUS U-100 INSULIN Tier 2 SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH U-100 INSULN Tier 2 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR U-100 INSULIN Tier 2 SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 U-100 INSULIN Tier 2 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N NPH U-100 INSULIN Tier 2 SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN Tier 2 INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN Tier 2 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) NOVOLOG MIX 70-30 U-100 INSULN Tier 2 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-100 Tier 2 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG PENFILL U-100 INSULIN Tier 2 SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART Tier 2 SUBCUTANEOUS SOLUTION 100 UNIT/ML SEMGLEE U-100 INSULIN Tier 2 SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO MAX U-300 SOLOSTAR Tier 2 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 INSULIN Tier 2 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) TRESIBA FLEXTOUCH U-100 Tier 3 QL (30 ML per 30 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) TRESIBA FLEXTOUCH U-200 Tier 3 QL (18 ML per 28 days) SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML)

64 Drug Status Notes Urine Glucose Test Aids DIASTIX STRIP Tier 2 NO-STICK GLUCOSE STRIP Tier 2 Ear - General Disorders Ear Preparations Anti-Inflammatory fluocinolone acetonide oil otic (ear) (DermOtic Oil) Tier 1 drops 0.01 % Ear Preparations, Misc. Anti-Infectives acetic acid otic (ear) solution 2 % Tier 1 hydrocortisone-acetic acid otic (ear) Tier 1 drops 1-2 % Ear Preparations,Antibiotics ciprofloxacin hcl otic (ear) dropperette (Cetraxal) Tier 1 0.2 % CORTISPORIN-TC OTIC (EAR) Tier 3 DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML neomycin-polymyxin-hc otic (ear) Tier 1 drops,suspension 3.5-10,000-1 mg/ml- unit/ml-% neomycin-polymyxin-hc otic (ear) Tier 1 solution 3.5-10,000-1 mg/ml-unit/ml-% ofloxacin otic (ear) drops 0.3 % Tier 1 Otic Preparations,Anti-Inflammatory- Antibiotics CIPRO HC OTIC (EAR) Tier 2 DROPS,SUSPENSION 0.2-1 % CIPRODEX OTIC (EAR) Tier 2 DROPS,SUSPENSION 0.3-0.1 % OTOVEL OTIC (EAR) SOLUTION 0.3- Tier 3 0.025 % (0.25 ML) Electrolyte Regulation Arginine Vasopressin (Avp) Receptor Antagonists JYNARQUE ORAL TABLET 15 MG, 30 Tier 3 MG JYNARQUE ORAL TABLETS, Tier 4 PA; SP SEQUENTIAL 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM) SAMSCA ORAL TABLET 15 MG, 30 MG Tier 3 Electrolyte Depleters calcium acetate(phosphat bind) oral Tier 1 capsule 667 mg calcium acetate(phosphat bind) oral Tier 1 tablet 667 mg KIONEX (WITH SORBITOL) ORAL Tier 1 SUSPENSION 15-19.3 GRAM/60 ML lanthanum oral tablet,chewable 1,000 (Fosrenol) Tier 3 mg, 500 mg, 750 mg

65 Drug Status Notes PHOSLYRA ORAL SOLUTION 667 MG Tier 3 (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 800 MG Tier 3 sevelamer carbonate oral powder in (Renvela) Tier 3 packet 0.8 gram, 2.4 gram sevelamer carbonate oral tablet 800 mg (Renvela) Tier 1 SODIUM POLYSTYRENE (SORB Tier 1 FREE) ORAL SUSPENSION 15 GRAM/60 ML sodium polystyrene sulfonate oral Tier 1 powder SPS (WITH SORBITOL) ORAL Tier 1 SUSPENSION 15-20 GRAM/60 ML SPS (WITH SORBITOL) RECTAL Tier 3 ENEMA 30-40 GRAM/120 ML VELPHORO ORAL Tier 3 TABLET,CHEWABLE 500 MG VELTASSA ORAL POWDER IN Tier 3 PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM Potassium Replacement EFFER-K ORAL TABLET, Tier 2 EFFERVESCENT 10 MEQ, 20 MEQ EFFER-K ORAL TABLET, Tier 1 EFFERVESCENT 25 MEQ KLOR-CON 10 ORAL TABLET Tier 1 EXTENDED RELEASE 10 MEQ KLOR-CON 8 ORAL TABLET Tier 1 EXTENDED RELEASE 8 MEQ KLOR-CON M10 ORAL TABLET,ER Tier 1 PARTICLES/CRYSTALS 10 MEQ KLOR-CON M15 ORAL TABLET,ER Tier 3 PARTICLES/CRYSTALS 15 MEQ KLOR-CON M20 ORAL TABLET,ER Tier 1 PARTICLES/CRYSTALS 20 MEQ KLOR-CON/EF ORAL TABLET, Tier 1 EFFERVESCENT 25 MEQ K-TAB ORAL TABLET EXTENDED Tier 1 RELEASE 10 MEQ, 8 MEQ potassium chloride oral capsule, Tier 1 extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 Tier 1 ml, 40 meq/15 ml potassium chloride oral packet 20 meq (Klor-Con) Tier 3 potassium chloride oral tablet extended (K-Tab) Tier 1 release 10 meq, 20 meq, 8 meq potassium chloride oral tablet,er (Klor-Con M10) Tier 1 particles/crystals 10 meq potassium chloride oral tablet,er (Klor-Con M20) Tier 1 particles/crystals 20 meq

66 Drug Status Notes Sodium/Saline Preparations BD POSIFLUSH NORMAL SALINE 0.9 Tier 1 INJECTION SYRINGE BD PRE-FILLED NORMAL SALINE Tier 1 INJECTION SYRINGE BD PRE-FILLED SALINE BLUNT CAN Tier 1 INJECTION SYRINGE MONOJECT 0.9% SODIUM CHLORIDE Tier 1 INJECTION SYRINGE MONOJECT PREFILL ADVANCED NS Tier 1 INJECTION SYRINGE NORMAL SALINE FLUSH INJECTION Tier 1 SYRINGE sodium chlor 0.9% bacteriostat injection Tier 1 solution 0.9 % sodium chloride 0.9 % (flush) injection (BD PosiFlush Normal Tier 1 syringe Saline 0.9) sodium chloride injection syringe 0.9 % Tier 1 sodium chloride oral tablet 1 gram Tier 1 Endocrine Disorder - Fertility Drugs To Treat Impotency CIALIS ORAL TABLET 2.5 MG, 5 MG Tier 2 PA; QL (1 EA per 1 day) sildenafil oral tablet 100 mg, 25 mg, 50 (Viagra) Tier 3 QL (6 EA per 30 days) mg tadalafil oral tablet 2.5 mg, 5 mg (Cialis) Tier 3 PA; QL (1 EA per 1 day) Fertility Stimulating Preparations,Non- Fsh clomiphene citrate oral tablet 50 mg (Serophene) Tier 1 Human Chorionic Gonadotropin (Hcg) chorionic gonadotropin, human (Novarel) Tier 4 intramuscular recon soln 10,000 unit NOVAREL INTRAMUSCULAR RECON Tier 4 SOLN 10,000 UNIT PREGNYL INTRAMUSCULAR RECON Tier 4 SOLN 10,000 UNIT Endocrine Disorder - Other Adrenocorticotrophic Hormones ACTHAR INJECTION GEL 80 UNIT/ML Tier 4 PA; SP Antidiuretic And Vasopressor Hormones desmopressin nasal spray with pump 10 Tier 1 mcg/spray (0.1 ml) desmopressin nasal spray,non-aerosol Tier 1 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg (DDAVP) Tier 1 Antineoplastic Lhrh(Gnrh) Agonist,Pituitary Suppr. ELIGARD (3 MONTH) Tier 4 PA; SP SUBCUTANEOUS SYRINGE 22.5 MG

67 Drug Status Notes ELIGARD (4 MONTH) Tier 4 PA; SP SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) Tier 4 PA; SP SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE Tier 4 PA; SP 7.5 MG (1 MONTH) leuprolide subcutaneous kit 1 mg/0.2 ml Tier 4 PA; SP Bone Formation Stim. Agents - Parathyroid Hormone FORTEO SUBCUTANEOUS PEN Tier 4 PA; SP INJECTOR 20 MCG/DOSE (600MCG/2.4ML) Bone Resorption Inhibitor & Vitamin D Combinations FOSAMAX PLUS D ORAL TABLET 70 Tier 3 QL (1 EA per 7 days) MG- 2,800 UNIT, 70 MG- 5,600 UNIT Bone Resorption Inhibitors alendronate oral solution 70 mg/75 ml Tier 1 alendronate oral tablet 10 mg, 5 mg Tier 1 QL (1 EA per 1 day) alendronate oral tablet 35 mg Tier 1 QL (1 EA per 7 days) alendronate oral tablet 70 mg (Fosamax) Tier 1 QL (1 EA per 7 days) BINOSTO ORAL TABLET, Tier 3 QL (4 EA per 28 days) EFFERVESCENT 70 MG calcitonin (salmon) nasal spray,non- Tier 1 aerosol 200 unit/actuation etidronate disodium oral tablet 200 mg Tier 1 ibandronate oral tablet 150 mg (Boniva) Tier 1 QL (1 EA per 30 days) raloxifene oral tablet 60 mg (Evista) $0 QL (1 EA per 1 day) risedronate oral tablet 150 mg (Actonel) Tier 3 QL (1 EA per 28 days) risedronate oral tablet 30 mg Tier 3 QL (1 EA per 1 day) risedronate oral tablet 35 mg (Actonel) Tier 3 QL (1 EA per 7 days) risedronate oral tablet 5 mg (Actonel) Tier 3 QL (1 EA per 1 day) risedronate oral tablet,delayed release (Atelvia) Tier 1 QL (1 EA per 7 days) (dr/ec) 35 mg Calcimimetic,Parathyroid Calcium Enhancer SENSIPAR ORAL TABLET 30 MG, 60 Tier 2 MG, 90 MG Growth Hormone Receptor Antagonists SOMAVERT SUBCUTANEOUS RECON Tier 4 PA; SP SOLN 10 MG, 15 MG, 20 MG Growth Hormones GENOTROPIN MINIQUICK Tier 4 PA; SP SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

68 Drug Status Notes GENOTROPIN SUBCUTANEOUS Tier 4 PA; SP CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) HUMATROPE INJECTION CARTRIDGE Tier 4 PA; SP 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT) HUMATROPE INJECTION RECON Tier 4 PA; SP SOLN 5 (15 UNIT) MG NORDITROPIN FLEXPRO Tier 4 PA; SP SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) NUTROPIN AQ NUSPIN Tier 4 PA; SP SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML) OMNITROPE SUBCUTANEOUS Tier 4 PA; SP CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS Tier 4 PA; SP RECON SOLN 5.8 MG SAIZEN SAIZENPREP Tier 4 PA; SP SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.) SAIZEN SUBCUTANEOUS RECON Tier 4 PA; SP SOLN 5 MG, 8.8 MG SEROSTIM SUBCUTANEOUS RECON Tier 4 PA; SP SOLN 4 MG, 5 MG, 6 MG ZOMACTON SUBCUTANEOUS Tier 4 PA; SP RECON SOLN 5 MG ZORBTIVE SUBCUTANEOUS RECON Tier 4 PA; SP SOLN 8.8 MG Hyperparathyroid Tx Agents - Vitamin D Analog-Type doxercalciferol oral capsule 0.5 mcg, 1 Tier 1 mcg, 2.5 mcg paricalcitol oral capsule 1 mcg, 2 mcg (Zemplar) Tier 3 QL (1 EA per 1 day) paricalcitol oral capsule 4 mcg Tier 3 QL (1 EA per 1 day) Insulin-Like Growth Factor-1 (Igf-1) Hormones INCRELEX SUBCUTANEOUS Tier 4 PA; SP SOLUTION 10 MG/ML Lhrh(Gnrh) Agonist Analog Pituitary Suppressants SYNAREL NASAL SPRAY,NON- Tier 3 PA AEROSOL 2 MG/ML Lhrh(Gnrh) Antagonist,Pituitary Suppressant Agents ganirelix subcutaneous syringe 250 Tier 4 mcg/0.5 ml

69 Drug Status Notes Menopausal Sympt Supp-Sel Estrogen Recep Modulator OSPHENA ORAL TABLET 60 MG Tier 3 QL (1 EA per 1 day) Parathyroid Hormones NATPARA SUBCUTANEOUS Tier 4 PA; SP CARTRIDGE 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE Pituitary Suppressive Agents cabergoline oral tablet 0.5 mg Tier 1 danazol oral capsule 100 mg, 200 mg, Tier 1 50 mg Endocrine Disorder - Thyroid Antithyroid Preparations methimazole oral tablet 10 mg, 5 mg (Tapazole) Tier 1 propylthiouracil oral tablet 50 mg Tier 1 Iodine Containing Agents STRONG IODINE ORAL SOLUTION 5 Tier 1 % Thyroid Hormones ARMOUR THYROID ORAL TABLET Tier 2 QL (1 EA per 1 day) 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG EUTHYROX ORAL TABLET 100 MCG, Tier 1 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine oral tablet 100 mcg, 112 (Euthyrox) Tier 1 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 300 mcg (Unithroid) Tier 1 LEVOXYL ORAL TABLET 100 MCG, Tier 1 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine oral tablet 25 mcg, 5 mcg, (Cytomel) Tier 1 50 mcg NP THYROID ORAL TABLET 120 MG, Tier 1 QL (1 EA per 1 day) 15 MG, 30 MG, 60 MG, 90 MG SYNTHROID ORAL TABLET 100 MCG, Tier 3 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG SYNTHROID ORAL TABLET 137 MCG Tier 1 THYROLAR-1 ORAL TABLET 12.5-50 Tier 3 MCG THYROLAR-1/2 ORAL TABLET 6.25-25 Tier 3 MCG THYROLAR-1/4 ORAL TABLET 3.1-12.5 Tier 3 MCG

70 Drug Status Notes THYROLAR-2 ORAL TABLET 25-100 Tier 3 MCG THYROLAR-3 ORAL TABLET 37.5-150 Tier 3 MCG UNITHROID ORAL TABLET 100 MCG, Tier 1 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG WESTHROID ORAL TABLET 130 MG, Tier 1 195 MG, 32.5 MG, 65 MG, 97.5 MG Eye - General Disorders Eye Antibiotic-Corticoid Combinations neomycin-bacitracin-poly-hc ophthalmic (Neo-Polycin HC) Tier 1 (eye) ointment 3.5-400-10,000 mg- unit/g-1% neomycin-polymyxin b-dexameth (Maxitrol) Tier 1 ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth (Maxitrol) Tier 1 ophthalmic (eye) ointment 3.5 mg/g- 10,000 unit/g-0.1 % neomycin-polymyxin-hc ophthalmic (eye) Tier 1 drops,suspension 3.5-10,000-10 mg- unit-mg/ml NEO-POLYCIN HC OPHTHALMIC Tier 1 (EYE) OINTMENT 3.5-400-10,000 MG- UNIT/G-1% PRED-G OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION 0.3-1 % PRED-G S.O.P. OPHTHALMIC (EYE) Tier 3 OINTMENT 0.3-0.6 % TOBRADEX OPHTHALMIC (EYE) Tier 2 OINTMENT 0.3-0.1 % TOBRADEX ST OPHTHALMIC (EYE) Tier 2 DROPS,SUSPENSION 0.3-0.05 % tobramycin-dexamethasone ophthalmic (TobraDex) Tier 1 (eye) drops,suspension 0.3-0.1 % ZYLET OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION 0.3-0.5 % Eye Antihistamines ALAWAY OPHTHALMIC (EYE) DROPS Tier 1 QL (15 ML per 30 days) 0.025 % (0.035 %) ALLERGY EYE (KETOTIFEN) Tier 1 QL (15 ML per 30 days) OPHTHALMIC (EYE) DROPS 0.025 % (0.035 %) azelastine ophthalmic (eye) drops 0.05 Tier 1 % BEPREVE OPHTHALMIC (EYE) Tier 3 QL (5 ML per 30 days) DROPS 1.5 % CHILDREN'S ALAWAY OPHTHALMIC Tier 1 QL (15 ML per 30 days) (EYE) DROPS 0.025 % (0.035 %)

71 Drug Status Notes epinastine ophthalmic (eye) drops 0.05 Tier 1 QL (5 ML per 30 days) % EYE ITCH RELIEF OPHTHALMIC (EYE) Tier 1 QL (15 ML per 30 days) DROPS 0.025 % (0.035 %) ITCHY EYE DROPS OPHTHALMIC Tier 1 QL (15 ML per 30 days) (EYE) DROPS 0.025 % (0.035 %) ketotifen fumarate ophthalmic (eye) (Alaway) Tier 1 QL (15 ML per 30 days) drops 0.025 % (0.035 %) LASTACAFT OPHTHALMIC (EYE) Tier 3 QL (3 ML per 30 days) DROPS 0.25 % olopatadine ophthalmic (eye) drops 0.1 (Pataday) Tier 1 QL (5 ML per 30 days) % olopatadine ophthalmic (eye) drops 0.2 (Pataday) Tier 3 % WAL-ZYR (KETOTIFEN) OPHTHALMIC Tier 1 QL (15 ML per 30 days) (EYE) DROPS 0.025 % (0.035 %) Eye Antiinflammatory Agents ACUVAIL (PF) OPHTHALMIC (EYE) Tier 3 QL (30 EA per 30 days) DROPPERETTE 0.45 % ALREX OPHTHALMIC (EYE) Tier 3 QL (5 ML per 30 days) DROPS,SUSPENSION 0.2 % dexamethasone sodium phosphate Tier 1 ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) Tier 1 drops 0.1 % DUREZOL OPHTHALMIC (EYE) Tier 3 QL (5 ML per 7 days) DROPS 0.05 % FLAREX OPHTHALMIC (EYE) Tier 3 QL (5 ML per 7 days) DROPS,SUSPENSION 0.1 % fluorometholone ophthalmic (eye) (FML Liquifilm) Tier 1 drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) Tier 1 drops 0.03 % FML FORTE OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION 0.25 % FML S.O.P. OPHTHALMIC (EYE) Tier 2 OINTMENT 0.1 % ILEVRO OPHTHALMIC (EYE) Tier 3 QL (2 ML per 15 days) DROPS,SUSPENSION 0.3 % ketorolac ophthalmic (eye) drops 0.4 % (Acular LS) Tier 1 ketorolac ophthalmic (eye) drops 0.5 % (Acular) Tier 1 LOTEMAX OPHTHALMIC (EYE) Tier 3 QL (5 GM per 30 days) DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) Tier 2 QL (5 ML per 30 days) DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) Tier 3 QL (3.5 GM per 20 days) OINTMENT 0.5 % MAXIDEX OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION 0.1 %

72 Drug Status Notes NEVANAC OPHTHALMIC (EYE) Tier 3 QL (3 ML per 30 days) DROPS,SUSPENSION 0.1 % PRED MILD OPHTHALMIC (EYE) Tier 2 DROPS,SUSPENSION 0.12 % prednisolone acetate ophthalmic (eye) (Pred Forte) Tier 1 drops,suspension 1 % prednisolone sodium phosphate Tier 1 ophthalmic (eye) drops 1 % PROLENSA OPHTHALMIC (EYE) Tier 3 DROPS 0.07 % Eye Antivirals trifluridine ophthalmic (eye) drops 1 % Tier 1 ZIRGAN OPHTHALMIC (EYE) GEL 0.15 Tier 3 QL (5 GM per 7 days) % Eye Local Anesthetics AKTEN (PF) OPHTHALMIC (EYE) GEL Tier 3 3.5 % ALCAINE OPHTHALMIC (EYE) DROPS Tier 1 0.5 % ALTACAINE OPHTHALMIC (EYE) Tier 1 DROPS 0.5 % ALTAFLUOR BENOX OPHTHALMIC Tier 3 (EYE) DROPS 0.25-0.4 % fluorescein-proparacaine ophthalmic Tier 3 (eye) drops 0.25-0.5 % proparacaine ophthalmic (eye) drops 0.5 (Alcaine) Tier 1 % tetracaine hcl (pf) ophthalmic (eye) drops Tier 1 0.5 % tetracaine hcl ophthalmic (eye) drops 0.5 (Altacaine) Tier 1 % Eye Sulfonamides BLEPH-10 OPHTHALMIC (EYE) Tier 1 DROPS 10 % BLEPHAMIDE OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION 10-0.2 % BLEPHAMIDE S.O.P. OPHTHALMIC Tier 2 (EYE) OINTMENT 10-0.2 % sulfacetamide sodium ophthalmic (eye) (Bleph-10) Tier 1 drops 10 % sulfacetamide sodium ophthalmic (eye) Tier 1 ointment 10 % sulfacetamide-prednisolone ophthalmic Tier 1 (eye) drops 10 %-0.23 % (0.25 %) Eye Vasoconstrictors (Rx Only) phenylephrine hcl ophthalmic (eye) Tier 1 drops 10 %, 2.5 % Ophthalmic Antibiotics AK-POLY-BAC OPHTHALMIC (EYE) Tier 1 OINTMENT 500-10,000 UNIT/GRAM

73 Drug Status Notes AZASITE OPHTHALMIC (EYE) DROPS Tier 2 QL (2.5 ML per 7 days) 1 % bacitracin ophthalmic (eye) ointment 500 (Baciguent) Tier 1 unit/gram bacitracin-polymyxin b ophthalmic (eye) (AK-Poly-Bac) Tier 1 ointment 500-10,000 unit/gram BESIVANCE OPHTHALMIC (EYE) Tier 3 QL (5 ML per 30 days) DROPS,SUSPENSION 0.6 % CILOXAN OPHTHALMIC (EYE) Tier 2 OINTMENT 0.3 % ciprofloxacin hcl ophthalmic (eye) drops (Ciloxan) Tier 1 0.3 % erythromycin ophthalmic (eye) ointment Tier 1 5 mg/gram (0.5 %) gatifloxacin ophthalmic (eye) drops 0.5 (Zymaxid) Tier 1 QL (2.5 ML per 7 days) % GENTAK OPHTHALMIC (EYE) Tier 1 OINTMENT 0.3 % (3 MG/GRAM) gentamicin ophthalmic (eye) drops 0.3 % Tier 1 levofloxacin ophthalmic (eye) drops 0.5 Tier 1 % MOXEZA OPHTHALMIC (EYE) DROPS, Tier 3 QL (3 ML per 7 days) VISCOUS 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 (Vigamox) Tier 3 QL (3 ML per 7 days) % moxifloxacin ophthalmic (eye) drops, (Moxeza) Tier 3 QL (3 ML per 7 days) viscous 0.5 % neomycin-bacitracin-polymyxin (Neo-Polycin) Tier 1 ophthalmic (eye) ointment 3.5-400- 10,000 mg-unit-unit/g neomycin-polymyxin-gramicidin Tier 1 ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml NEO-POLYCIN OPHTHALMIC (EYE) Tier 1 OINTMENT 3.5-400-10,000 MG-UNIT- UNIT/G ofloxacin ophthalmic (eye) drops 0.3 % (Ocuflox) Tier 1 POLYCIN OPHTHALMIC (EYE) Tier 1 OINTMENT 500-10,000 UNIT/GRAM polymyxin b sulf-trimethoprim ophthalmic (Polytrim) Tier 1 (eye) drops 10,000 unit- 1 mg/ml tobramycin ophthalmic (eye) drops 0.3 % (Tobrex) Tier 1 TOBREX OPHTHALMIC (EYE) Tier 2 OINTMENT 0.3 % ZYMAXID OPHTHALMIC (EYE) DROPS Tier 3 QL (2.5 ML per 7 days) 0.5 % Ophthalmic Antifungal Agents NATACYN OPHTHALMIC (EYE) Tier 2 QL (15 ML per 15 days) DROPS,SUSPENSION 5 %

74 Drug Status Notes Ophthalmic Anti-Inflammatory Immunomodulator-Type RESTASIS MULTIDOSE OPHTHALMIC Tier 3 QL (5.5 ML per 30 days) (EYE) DROPS 0.05 % RESTASIS OPHTHALMIC (EYE) Tier 3 QL (2 EA per 1 day) DROPPERETTE 0.05 % Ophthalmic Mast Cell Stabilizers ALOCRIL OPHTHALMIC (EYE) DROPS Tier 3 QL (5 ML per 30 days) 2 % ALOMIDE OPHTHALMIC (EYE) DROPS Tier 3 QL (10 ML per 30 days) 0.1 % cromolyn ophthalmic (eye) drops 4 % Tier 1 Eye - Glaucoma Carbonic Anhydrase Inhibitors acetazolamide oral capsule, extended Tier 1 release 500 mg acetazolamide oral tablet 125 mg, 250 Tier 1 mg methazolamide oral tablet 25 mg, 50 mg Tier 1 Miotics/Other Intraoc. Pressure Reducers ALPHAGAN P OPHTHALMIC (EYE) Tier 3 DROPS 0.1 % apraclonidine ophthalmic (eye) drops 0.5 Tier 1 % AZOPT OPHTHALMIC (EYE) Tier 3 QL (10 ML per 30 days) DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 0.5 % Tier 1 BETIMOL OPHTHALMIC (EYE) DROPS Tier 3 0.25 %, 0.5 % BETOPTIC S OPHTHALMIC (EYE) Tier 2 DROPS,SUSPENSION 0.25 % bimatoprost ophthalmic (eye) drops 0.03 Tier 1 QL (2.5 ML per 25 days) % brimonidine ophthalmic (eye) drops 0.15 (Alphagan P) Tier 1 % brimonidine ophthalmic (eye) drops 0.2 Tier 1 % carteolol ophthalmic (eye) drops 1 % Tier 1 COMBIGAN OPHTHALMIC (EYE) Tier 3 QL (5 ML per 30 days) DROPS 0.2-0.5 % COSOPT (PF) OPHTHALMIC (EYE) Tier 3 DROPPERETTE 2-0.5 % dorzolamide ophthalmic (eye) drops 2 % (Trusopt) Tier 1 dorzolamide-timolol (pf) ophthalmic (eye) (Cosopt (PF)) Tier 1 dropperette 2-0.5 % dorzolamide-timolol ophthalmic (eye) (Cosopt) Tier 1 drops 22.3-6.8 mg/ml ISTALOL OPHTHALMIC (EYE) DROPS, Tier 3 ONCE DAILY 0.5 %

75 Drug Status Notes latanoprost ophthalmic (eye) drops 0.005 (Xalatan) Tier 1 % levobunolol ophthalmic (eye) drops 0.5 Tier 1 % LUMIGAN OPHTHALMIC (EYE) DROPS Tier 3 QL (2.5 ML per 25 days) 0.01 % metipranolol ophthalmic (eye) drops 0.3 Tier 1 % PHOSPHOLINE IODIDE OPHTHALMIC Tier 2 (EYE) DROPS 0.125 % pilocarpine hcl ophthalmic (eye) drops 1 (Isopto Carpine) Tier 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC (EYE) Tier 3 QL (8 ML per 30 days) DROPS,SUSPENSION 1-0.2 % timolol maleate ophthalmic (eye) drops (Timoptic) Tier 1 0.25 %, 0.5 % timolol maleate ophthalmic (eye) drops, (Istalol) Tier 1 once daily 0.5 % timolol maleate ophthalmic (eye) gel (Timoptic-XE) Tier 1 forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) Tier 3 QL (2.5 ML per 25 days) DROPS 0.004 % ZIOPTAN (PF) OPHTHALMIC (EYE) Tier 3 DROPPERETTE 0.0015 % Mydriatics atropine ophthalmic (eye) drops 1 % (Isopto Atropine) Tier 1 atropine ophthalmic (eye) ointment 1 % Tier 1 CYCLOMYDRIL OPHTHALMIC (EYE) Tier 3 DROPS 0.2-1 % cyclopentolate ophthalmic (eye) drops (Cyclogyl) Tier 3 0.5 % cyclopentolate ophthalmic (eye) drops 1 (Cyclogyl) Tier 1 %, 2 % tropicamide ophthalmic (eye) drops 0.5 Tier 1 % tropicamide ophthalmic (eye) drops 1 % (Mydriacyl) Tier 1 Ophthalmic Antifibrotic Agents MITOSOL OPHTHALMIC (EYE) KIT 0.2 Tier 3 MG Eye - Miscellaneous Artificial Tears ARTIFICIAL TEARS (PF) OPHTHALMIC Tier 3 (EYE) DROPPERETTE , 0.1-0.3 % ARTIFICIAL TEARS (POLYVIN ALC) Tier 1 OPHTHALMIC (EYE) DROPS 1.4 % ARTIFICIAL TEARS(GLYCERIN-PEG) Tier 1 OPHTHALMIC (EYE) DROPS 1-0.3 % ARTIFICIAL TEARS(PG-HYPM-GLYC) Tier 1 OPHTHALMIC (EYE) DROPS 1-0.2-0.2 %

76 Drug Status Notes ARTIFICIAL TEARS(PVALCH-POVID) Tier 1 OPHTHALMIC (EYE) DROPS 0.5-0.6 % CLEAR EYES NATURAL TEARS Tier 3 OPHTHALMIC (EYE) DROPS 0.5-0.6 % DRY EYE RELIEF OPHTHALMIC (EYE) Tier 1 DROPS 1-0.2-0.2 % EYE DROP TEARS OPHTHALMIC Tier 1 (EYE) DROPS 1-0.2-0.2 % LACRISERT OPHTHALMIC (EYE) Tier 3 INSERT 5 MG LUBRICANT (P-GLYCOL-GLYCERIN) Tier 1 OPHTHALMIC (EYE) DROPS 1-0.3 % NATURAL TEARS (PF) OPHTHALMIC Tier 3 (EYE) DROPPERETTE 0.1-0.3 % polyvinyl alcohol ophthalmic (eye) drops (Artificial Tears (polyvin Tier 1 1.4 % alc)) VISINE DRY EYE RELIEF Tier 1 OPHTHALMIC (EYE) DROPS 1-0.2-0.2 % Ophthalmic Cystine Depleting Agents CYSTARAN OPHTHALMIC (EYE) Tier 3 DROPS 0.44 % Fluid Replacement Nucleic Acid/Nucleotide Supplements XURIDEN ORAL GRANULES IN Tier 3 PACKET 2 GRAM Gout And Related Diseases Colchicine colchicine oral tablet 0.6 mg (Colcrys) Tier 1 QL (2 EA per 1 day) Hyperuricemia Tx - Purine Inhibitors allopurinol oral tablet 100 mg, 300 mg (Zyloprim) Tier 1 ULORIC ORAL TABLET 40 MG, 80 MG Tier 3 QL (1 EA per 1 day) Uricosuric Agents probenecid oral tablet 500 mg Tier 1 probenecid-colchicine oral tablet 500-0.5 Tier 1 mg Hematological Disorders Anticoagulants,Coumarin Type JANTOVEN ORAL TABLET 1 MG, 10 Tier 1 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, (Jantoven) Tier 1 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg Antifibrinolytic Agents aminocaproic acid oral solution 250 (Amicar) Tier 1 mg/ml (25 %) aminocaproic acid oral tablet 1,000 mg, (Amicar) Tier 1 500 mg tranexamic acid oral tablet 650 mg (Lysteda) Tier 1

77 Drug Status Notes Direct Factor Xa Inhibitors ELIQUIS DVT-PE TREAT 30D START Tier 3 ORAL TABLETS,DOSE PACK 5 MG (74 TABS) ELIQUIS ORAL TABLET 2.5 MG, 5 MG Tier 3 XARELTO DVT-PE TREAT 30D START Tier 3 QL (51 EA per 30 days) ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) XARELTO ORAL TABLET 10 MG, 15 Tier 3 QL (1 EA per 1 day) MG, 2.5 MG, 20 MG Hematinics,Other ARANESP (IN POLYSORBATE) Tier 4 PA; SP INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) Tier 4 PA; SP INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML EPOGEN INJECTION SOLUTION Tier 4 PA; SP 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION Tier 4 PA; SP 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML Hemorrheologic Agents pentoxifylline oral tablet extended Tier 1 release 400 mg Heparin And Related Preparations enoxaparin subcutaneous solution 300 (Lovenox) Tier 1 mg/3 ml enoxaparin subcutaneous syringe 100 (Lovenox) Tier 1 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 (Arixtra) Tier 1 QL (8 ML per 30 days) mg/0.8 ml fondaparinux subcutaneous syringe 2.5 (Arixtra) Tier 1 QL (5 ML per 30 days) mg/0.5 ml fondaparinux subcutaneous syringe 5 (Arixtra) Tier 1 QL (4 ML per 30 days) mg/0.4 ml fondaparinux subcutaneous syringe 7.5 (Arixtra) Tier 1 QL (6 ML per 30 days) mg/0.6 ml FRAGMIN SUBCUTANEOUS Tier 4 SOLUTION 25,000 ANTI-XA UNIT/ML

78 Drug Status Notes FRAGMIN SUBCUTANEOUS SYRINGE Tier 4 10,000 ANTI-XA UNIT/ML, 12,500 ANTI- XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML heparin (porcine) injection cartridge Tier 1 5,000 unit/ml (1 ml) heparin (porcine) injection solution 1,000 Tier 1 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 Tier 1 unit/ml heparin, porcine (pf) injection solution Tier 1 1,000 unit/ml heparin, porcine (pf) injection syringe Tier 1 5,000 unit/0.5 ml Leukocyte (Wbc) Stimulants LEUKINE INJECTION RECON SOLN Tier 4 PA; SP 250 MCG NEULASTA SUBCUTANEOUS Tier 4 PA; SP; QL (2.4 ML per 30 SYRINGE 6 MG/0.6 ML days) NEUPOGEN INJECTION SOLUTION Tier 4 PA; SP 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 Tier 4 PA; SP MCG/0.5 ML, 480 MCG/0.8 ML Platelet Aggregation Inhibitors ADULT ASPIRIN REGIMEN ORAL $0 QL (1 EA per 1 day) TABLET,DELAYED RELEASE (DR/EC) 81 MG ADULT LOW DOSE ASPIRIN ORAL $0 QL (1 EA per 1 day) TABLET,DELAYED RELEASE (DR/EC) 81 MG AGGRENOX ORAL CAPSULE, ER Tier 3 QL (2 EA per 1 day) MULTIPHASE 12 HR 25-200 MG ASPIRIN CHILDRENS ORAL $0 QL (1 EA per 1 day) TABLET,CHEWABLE 81 MG ASPIRIN LOW DOSE ORAL $0 QL (1 EA per 1 day) TABLET,DELAYED RELEASE (DR/EC) 81 MG aspirin oral tablet,chewable 81 mg (Aspirin Childrens) $0 QL (1 EA per 1 day) aspirin oral tablet,delayed release (dr/ec) (Adult Aspirin Regimen) $0 QL (1 EA per 1 day) 81 mg aspirin-dipyridamole oral capsule, er Tier 1 QL (2 EA per 1 day) multiphase 12 hr 25-200 mg BRILINTA ORAL TABLET 60 MG, 90 Tier 3 QL (2 EA per 1 day) MG CHILDREN'S ASPIRIN ORAL $0 QL (1 EA per 1 day) TABLET,CHEWABLE 81 MG

79 Drug Status Notes cilostazol oral tablet 100 mg, 50 mg Tier 1 clopidogrel oral tablet 300 mg Tier 1 QL (1 EA per 1 day) clopidogrel oral tablet 75 mg (Plavix) Tier 1 QL (1 EA per 1 day) dipyridamole oral tablet 25 mg, 50 mg, Tier 1 75 mg ECOTRIN LOW STRENGTH ORAL $0 QL (1 EA per 1 day) TABLET,DELAYED RELEASE (DR/EC) 81 MG LO-DOSE ASPIRIN ORAL $0 QL (1 EA per 1 day) TABLET,DELAYED RELEASE (DR/EC) 81 MG prasugrel oral tablet 10 mg, 5 mg (Effient) Tier 3 QL (1 EA per 1 day) ST JOSEPH ASPIRIN ORAL $0 QL (1 EA per 1 day) TABLET,CHEWABLE 81 MG ST. JOSEPH ASPIRIN ORAL $0 QL (1 EA per 1 day) TABLET,DELAYED RELEASE (DR/EC) 81 MG ZONTIVITY ORAL TABLET 2.08 MG Tier 3 QL (1 EA per 1 day) Platelet Reducing Agents anagrelide oral capsule 0.5 mg (Agrylin) Tier 1 anagrelide oral capsule 1 mg Tier 1 Sickle Cell Anemia Agents DROXIA ORAL CAPSULE 200 MG, 300 Tier 4 MG, 400 MG ENDARI ORAL POWDER IN PACKET 5 Tier 3 GRAM Thrombin Inhibitors,Selective,Direct, & Reversible PRADAXA ORAL CAPSULE 110 MG, Tier 3 QL (2 EA per 1 day) 150 MG, 75 MG Thrombopoietin Receptor Agonists PROMACTA ORAL TABLET 12.5 MG, Tier 4 PA; SP 25 MG, 50 MG, 75 MG Topical Hemostatics ASTRINGYN TOPICAL SOLUTION 259 Tier 3 MG/G RECOTHROM SPRAY KIT TOPICAL Tier 4 RECON SOLN 20,000 UNIT RECOTHROM TOPICAL RECON SOLN Tier 4 20,000 UNIT, 5,000 UNIT Vitamin K Preparations MEPHYTON ORAL TABLET 5 MG Tier 2 phytonadione (vitamin k1) oral tablet 5 (Mephyton) Tier 1 mg Hormonal Deficiency Androgenic Agents ANADROL-50 ORAL TABLET 50 MG Tier 3 ANDRODERM TRANSDERMAL PATCH Tier 3 PA 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR

80 Drug Status Notes ANDROGEL TRANSDERMAL GEL IN Tier 3 PA METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN Tier 3 PA PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) METHITEST ORAL TABLET 10 MG Tier 3 methyltestosterone oral capsule 10 mg (Android) Tier 3 oxandrolone oral tablet 10 mg, 2.5 mg (Oxandrin) Tier 1 PA testosterone cypionate intramuscular oil (Depo-Testosterone) Tier 1 100 mg/ml, 200 mg/ml testosterone transdermal gel 50 mg/5 (Testim) Tier 1 PA gram (1 %) testosterone transdermal gel in metered- (Fortesta) Tier 1 PA dose pump 10 mg/0.5 gram /actuation testosterone transdermal gel in metered- (Vogelxo) Tier 1 PA dose pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 1 (AndroGel) Tier 1 PA % (25 mg/2.5gram), 1 % (50 mg/5 gram) testosterone transdermal solution in Tier 1 PA metered pump w/app 30 mg/actuation (1.5 ml) VOGELXO TRANSDERMAL GEL IN Tier 1 PA METERED-DOSE PUMP 12.5 MG/ 1.25 GRAM (1 %) Estrogen & Progestin With Antimineralocorticoid Cb ANGELIQ ORAL TABLET 0.25-0.5 MG, Tier 3 0.5-1 MG Estrogen & Selective Estrogen Recept Mod(Serm)Comb DUAVEE ORAL TABLET 0.45-20 MG Tier 3 Estrogen/Androgen Combinations COVARYX H.S. ORAL TABLET 0.625- Tier 1 1.25 MG COVARYX ORAL TABLET 1.25-2.5 MG Tier 1 EEMT HS ORAL TABLET 0.625-1.25 Tier 1 MG EEMT ORAL TABLET 1.25-2.5 MG Tier 1 estrogens-methyltestosterone oral tablet (Covaryx H.S.) Tier 1 0.625-1.25 mg estrogens-methyltestosterone oral tablet (Covaryx) Tier 1 1.25-2.5 mg Estrogenic Agents ALORA TRANSDERMAL PATCH Tier 3 QL (2 EA per 7 days) SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.1 MG/24 HR AMABELZ ORAL TABLET 0.5-0.1 MG, Tier 1 1-0.5 MG

81 Drug Status Notes CLIMARA PRO TRANSDERMAL Tier 3 QL (4 EA per 28 days) PATCH WEEKLY 0.045-0.015 MG/24 HR COMBIPATCH TRANSDERMAL PATCH Tier 3 QL (2 EA per 7 days) SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR DIVIGEL TRANSDERMAL GEL IN Tier 3 QL (1 EA per 1 day) PACKET 0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5 GRAM (0.1 %) DIVIGEL TRANSDERMAL GEL IN Tier 3 QL (1 GM per 1 day) PACKET 1 MG/GRAM (0.1 %) DOTTI TRANSDERMAL PATCH Tier 3 QL (2 EA per 7 days) SEMIWEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR, 0.05 MG/24 HR, 0.1 MG/24 HR DOTTI TRANSDERMAL PATCH Tier 1 QL (2 EA per 7 days) SEMIWEEKLY 0.075 MG/24 HR ELESTRIN TRANSDERMAL GEL IN Tier 3 QL (52 GM per 30 days) METERED-DOSE PUMP 0.87 GRAM/ACTUATION estradiol oral tablet 0.5 mg, 1 mg, 2 mg (Estrace) Tier 1 estradiol transdermal patch semiweekly (Alora) Tier 3 QL (2 EA per 7 days) 0.025 mg/24 hr, 0.05 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch semiweekly (Dotti) Tier 3 QL (2 EA per 7 days) 0.0375 mg/24 hr estradiol transdermal patch semiweekly (Dotti) Tier 1 QL (2 EA per 7 days) 0.075 mg/24 hr estradiol transdermal patch weekly 0.025 (Climara) Tier 1 QL (4 EA per 28 days) mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol-norethindrone acet oral tablet (Amabelz) Tier 1 0.5-0.1 mg, 1-0.5 mg ESTROGEL TRANSDERMAL GEL IN Tier 3 QL (50 GM per 30 days) METERED-DOSE PUMP 1.25 GRAM/ACTUATION EVAMIST TRANSDERMAL Tier 3 QL (8.1 ML per 30 days) SPRAY,NON-AEROSOL 1.53 MG/SPRAY (1.7%) FYAVOLV ORAL TABLET 0.5-2.5 MG- $0 MCG FYAVOLV ORAL TABLET 1-5 MG-MCG Tier 1 JINTELI ORAL TABLET 1-5 MG-MCG Tier 1 MENEST ORAL TABLET 0.3 MG, 0.625 Tier 3 QL (1 EA per 1 day) MG, 1.25 MG, 2.5 MG MENOSTAR TRANSDERMAL PATCH Tier 3 QL (4 EA per 28 days) WEEKLY 14 MCG/24 HR MIMVEY ORAL TABLET 1-0.5 MG Tier 1

82 Drug Status Notes MINIVELLE TRANSDERMAL PATCH Tier 3 QL (2 EA per 7 days) SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.1 MG/24 HR norethindrone ac-eth estradiol oral tablet (Fyavolv) $0 0.5-2.5 mg-mcg norethindrone ac-eth estradiol oral tablet (Fyavolv) Tier 1 1-5 mg-mcg PREFEST ORAL TABLET 1 MG (15)/1 Tier 3 MG- 0.09 MG (15) PREMARIN ORAL TABLET 0.3 MG, Tier 2 QL (1 EA per 1 day) 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG PREMPHASE ORAL TABLET 0.625 MG Tier 2 QL (1 EA per 1 day) (14)/ 0.625MG-5MG(14) PREMPRO ORAL TABLET 0.3-1.5 MG, Tier 2 QL (1 EA per 1 day) 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG VIVELLE-DOT TRANSDERMAL PATCH Tier 3 QL (2 EA per 7 days) SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.1 MG/24 HR Progestational Agents medroxyprogesterone oral tablet 10 mg, (Provera) Tier 1 2.5 mg, 5 mg norethindrone acetate oral tablet 5 mg (Aygestin) Tier 1 progesterone micronized oral capsule (Prometrium) Tier 1 QL (2 EA per 1 day) 100 mg, 200 mg Immunization Antisera GAMMAKED INJECTION SOLUTION 1 Tier 4 PA; SP GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %) GAMUNEX-C INJECTION SOLUTION 1 Tier 4 PA; SP GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %) HIZENTRA SUBCUTANEOUS Tier 4 PA; SP SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %) Influenza Virus Vaccines AFLURIA QD 2020-21(3YR UP)(PF) $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML AFLURIA QD 2020-21(6-35MO)(PF) $0 QL (0.25 ML per 180 days) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML AFLURIA QUAD 2020-2021(6MO UP) $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

83 Drug Status Notes FLUAD 2020-2021 (65 YR UP)(PF) $0 QL (0.5 ML per 180 days); INTRAMUSCULAR SYRINGE 45 MCG Age (Min 65 Years) (15 MCG X 3)/0.5 ML FLUAD QUAD 2020-21(65Y UP)(PF) $0 QL (0.5 ML per 180 days); INTRAMUSCULAR SYRINGE 60 MCG Age (Min 65 Years) (15 MCG X 4)/0.5 ML FLUARIX QUAD 2020-2021 (PF) $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML FLUBLOK QUAD 2020-2021 (PF) $0 QL (0.5 ML per 180 days); INTRAMUSCULAR SYRINGE 180 MCG Age (Min 18 Years) (45 MCG X 4)/0.5 ML FLUCELVAX QUAD 2020-2021 (PF) $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML FLUCELVAX QUAD 2020-2021 $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML FLULAVAL QUAD 2020-2021 (PF) $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML FLUMIST QUAD 2020-2021 NASAL $0 QL (1 EA per 180 days) NASAL SPRAY SYRINGE 10EXP6.5- 7.5 FF UNIT/0.2 ML FLUZONE HIGHDOSE QUAD 20-21 PF $0 QL (0.7 ML per 180 days); INTRAMUSCULAR SYRINGE 240 Age (Min 65 Years) MCG/0.7 ML FLUZONE QUAD 2020-2021 (PF) $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML FLUZONE QUAD 2020-2021 (PF) $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML FLUZONE QUAD 2020-2021 $0 QL (0.5 ML per 180 days) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML Viral/Tumorigenic Vaccines SHINGRIX (PF) INTRAMUSCULAR $0 QL (2 EA per 1 LIFETIME); SUSPENSION FOR RECONSTITUTION Age (Min 50 Years) 50 MCG/0.5 ML SHINGRIX GE ANTIGEN COMPONENT $0 QL (2 EA per 1 LIFETIME); INTRAMUSCULAR SUSPENSION FOR Age (Min 50 Years) RECONSTITUTION 50 MCG Immunosuppression/Modulation Immunomodulators ACTIMMUNE SUBCUTANEOUS Tier 4 PA; SP SOLUTION 100 MCG/0.5 ML imiquimod topical cream in packet 5 % (Aldara) Tier 1 QL (12 EA per 25 days) INTRON A INJECTION RECON SOLN Tier 4 PA; SP 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

84 Drug Status Notes INTRON A INJECTION SOLUTION 10 Tier 4 PA; SP MILLION UNIT/ML, 6 MILLION UNIT/ML ZYCLARA TOPICAL CREAM IN Tier 3 METERED-DOSE PUMP 2.5 %, 3.75 % ZYCLARA TOPICAL CREAM IN Tier 3 PACKET 3.75 % Immunosuppressives ASTAGRAF XL ORAL Tier 4 CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG, 5 MG AZASAN ORAL TABLET 100 MG, 75 Tier 3 MG azathioprine oral tablet 50 mg (Imuran) Tier 1 CELLCEPT ORAL CAPSULE 250 MG Tier 4 PA CELLCEPT ORAL TABLET 500 MG Tier 4 PA cyclosporine modified oral capsule 100 (Gengraf) Tier 1 QL (4 EA per 1 day) mg, 25 mg cyclosporine modified oral capsule 50 Tier 1 mg cyclosporine modified oral solution 100 (Gengraf) Tier 1 mg/ml cyclosporine oral capsule 100 mg, 25 mg (Sandimmune) Tier 1 GENGRAF ORAL CAPSULE 100 MG, Tier 1 QL (4 EA per 1 day) 25 MG GENGRAF ORAL SOLUTION 100 Tier 1 MG/ML mycophenolate mofetil oral capsule 250 (CellCept) Tier 1 mg mycophenolate mofetil oral suspension (CellCept) Tier 1 Age (Max 12 Years) for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 (CellCept) Tier 1 mg mycophenolate sodium oral (Myfortic) Tier 1 tablet,delayed release (dr/ec) 180 mg, 360 mg PROGRAF ORAL CAPSULE 0.5 MG, 1 Tier 3 MG, 5 MG RAPAMUNE ORAL SOLUTION 1 Tier 4 MG/ML SANDIMMUNE ORAL SOLUTION 100 Tier 4 MG/ML sirolimus oral tablet 0.5 mg, 1 mg, 2 mg (Rapamune) Tier 3 QL (2 EA per 1 day) tacrolimus oral capsule 0.5 mg, 1 mg, 5 (Prograf) Tier 1 mg ZORTRESS ORAL TABLET 0.25 MG, Tier 4 0.5 MG, 0.75 MG, 1 MG Infectious Disease - Bacterial Absorbable Sulfonamides sulfamethoxazole-trimethoprim oral (Sulfatrim) Tier 1 suspension 200-40 mg/5 ml

85 Drug Status Notes sulfamethoxazole-trimethoprim oral (Bactrim) Tier 1 tablet 400-80 mg sulfamethoxazole-trimethoprim oral (Bactrim DS) Tier 1 tablet 800-160 mg SULFATRIM ORAL SUSPENSION 200- Tier 1 40 MG/5 ML Betalactams CAYSTON INHALATION SOLUTION Tier 4 PA; SP FOR NEBULIZATION 75 MG/ML Cephalosporins - 1St Generation cefadroxil oral capsule 500 mg Tier 1 cefadroxil oral suspension for Tier 1 reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram Tier 1 cephalexin oral capsule 250 mg, 500 (Keflex) Tier 1 mg, 750 mg cephalexin oral suspension for Tier 1 reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg Tier 1 Cephalosporins - 2Nd Generation cefaclor oral capsule 250 mg, 500 mg Tier 1 cefaclor oral suspension for Tier 1 reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 Tier 1 hr 500 mg cefprozil oral suspension for Tier 1 reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg Tier 1 cefuroxime axetil oral tablet 250 mg, 500 Tier 1 mg Cephalosporins - 3Rd Generation cefdinir oral capsule 300 mg Tier 1 cefdinir oral suspension for reconstitution Tier 1 125 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg Tier 1 cefditoren pivoxil oral tablet 400 mg (Spectracef) Tier 1 cefixime oral suspension for (Suprax) Tier 1 Age (Max 10 Years) reconstitution 100 mg/5 ml, 200 mg/5 ml cefpodoxime oral suspension for Tier 1 reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg Tier 1 SUPRAX ORAL CAPSULE 400 MG Tier 1 SUPRAX ORAL SUSPENSION FOR Tier 1 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE Tier 1 100 MG SUPRAX ORAL TABLET,CHEWABLE Tier 3 200 MG

86 Drug Status Notes Chemotherapeutics, Antibacterial, Misc. HYOPHEN ORAL TABLET 81.6-0.12- Tier 1 10.8 MG methenamine hippurate oral tablet 1 (Hiprex) Tier 1 gram methenamine mandelate oral tablet 0.5 Tier 1 g, 1 gram MONUROL ORAL PACKET 3 GRAM Tier 3 QL (1 EA per 5 days) PRIMSOL ORAL SOLUTION 50 MG/5 Tier 3 ML trimethoprim oral tablet 100 mg Tier 1 URO-458 ORAL TABLET 81-10.8-40.8 Tier 1 MG URYL ORAL TABLET 81.6-40.8-0.12 Tier 3 MG Macrolides azithromycin oral packet 1 gram (Zithromax) Tier 1 azithromycin oral suspension for (Zithromax) Tier 1 reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg (Zithromax) Tier 1 azithromycin oral tablet 600 mg Tier 1 clarithromycin oral suspension for Tier 1 reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 Tier 1 mg clarithromycin oral tablet extended Tier 1 release 24 hr 500 mg DIFICID ORAL TABLET 200 MG Tier 2 E.E.S. 400 ORAL TABLET 400 MG Tier 1 ERYPED 400 ORAL SUSPENSION Tier 3 FOR RECONSTITUTION 400 MG/5 ML ERY-TAB ORAL TABLET,DELAYED Tier 1 RELEASE (DR/EC) 250 MG, 333 MG, 500 MG ERYTHROCIN (AS STEARATE) ORAL Tier 1 TABLET 250 MG erythromycin ethylsuccinate oral (E.E.S. Granules) Tier 3 suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) Tier 1 400 mg erythromycin oral capsule,delayed Tier 1 release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Tier 1 erythromycin oral tablet,delayed release (Ery-Tab) Tier 1 (dr/ec) 250 mg, 500 mg Nitrofuran Derivatives nitrofurantoin macrocrystal oral capsule (Macrodantin) Tier 1 100 mg, 25 mg, 50 mg

87 Drug Status Notes nitrofurantoin monohyd/m-cryst oral (Macrobid) Tier 1 QL (2 EA per 1 day) capsule 100 mg nitrofurantoin oral suspension 25 mg/5 (Furadantin) Tier 1 ml Oxazolidinones linezolid oral suspension for (Zyvox) Tier 1 PA reconstitution 100 mg/5 ml linezolid oral tablet 600 mg (Zyvox) Tier 1 PA Penicillins amoxicillin oral capsule 250 mg, 500 mg Tier 1 amoxicillin oral suspension for Tier 1 reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg Tier 1 amoxicillin oral tablet,chewable 125 mg, Tier 1 250 mg amoxicillin-pot clavulanate oral Tier 1 suspension for reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml amoxicillin-pot clavulanate oral (Augmentin) Tier 1 suspension for reconstitution 250-62.5 mg/5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) Tier 1 suspension for reconstitution 600-42.9 mg/5 ml amoxicillin-pot clavulanate oral tablet Tier 1 250-125 mg amoxicillin-pot clavulanate oral tablet (Augmentin) Tier 1 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet (Augmentin XR) Tier 1 extended release 12 hr 1,000-62.5 mg amoxicillin-pot clavulanate oral Tier 1 tablet,chewable 200-28.5 mg, 400-57 mg ampicillin oral capsule 250 mg, 500 mg Tier 1 dicloxacillin oral capsule 250 mg, 500 Tier 1 mg penicillin v potassium oral recon soln Tier 1 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, Tier 1 500 mg Quinolones ciprofloxacin hcl oral tablet 100 mg, 750 Tier 1 mg ciprofloxacin hcl oral tablet 250 mg, 500 (Cipro) Tier 1 mg ciprofloxacin oral (Cipro) Tier 1 Age (Max 12 Years) suspension,microcapsule recon 500 mg/5 ml FACTIVE ORAL TABLET 320 MG Tier 3 levofloxacin oral solution 250 mg/10 ml Tier 1

88 Drug Status Notes levofloxacin oral tablet 250 mg, 500 mg, Tier 1 750 mg moxifloxacin oral tablet 400 mg Tier 1 QL (1 EA per 1 day) ofloxacin oral tablet 300 mg, 400 mg Tier 1 Tetracyclines COREMINO ORAL TABLET Tier 1 QL (1 EA per 1 day) EXTENDED RELEASE 24 HR 135 MG, 45 MG, 90 MG demeclocycline oral tablet 150 mg, 300 Tier 1 QL (2 EA per 1 day) mg doxycycline hyclate oral capsule 100 mg, (Morgidox) Tier 1 50 mg doxycycline hyclate oral tablet 100 mg Tier 1 doxycycline hyclate oral tablet,delayed Tier 1 release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule (Mondoxyne NL) Tier 1 100 mg, 75 mg doxycycline monohydrate oral capsule Tier 1 150 mg doxycycline monohydrate oral capsule (Monodox) Tier 1 50 mg doxycycline monohydrate oral capsule,ir (Oracea) Tier 1 - delay rel,biphase 40 mg doxycycline monohydrate oral (Vibramycin) Tier 3 suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) Tier 1 mg doxycycline monohydrate oral tablet 150 Tier 1 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, Tier 1 75 mg minocycline oral tablet 100 mg, 50 mg, Tier 1 75 mg minocycline oral tablet extended release (Solodyn) Tier 3 24 hr 115 mg, 65 mg minocycline oral tablet extended release (CoreMino) Tier 1 QL (1 EA per 1 day) 24 hr 135 mg, 45 mg, 90 mg MONDOXYNE NL ORAL CAPSULE 100 Tier 1 MG, 75 MG SOLODYN ORAL TABLET EXTENDED Tier 3 RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG tetracycline oral capsule 250 mg, 500 Tier 1 QL (4 EA per 1 day) mg VIBRAMYCIN ORAL SYRUP 50 MG/5 Tier 3 ML Infectious Disease - Fungal Antifungal Agents clotrimazole mucous membrane troche Tier 1 10 mg

89 Drug Status Notes fluconazole oral suspension for (Diflucan) Tier 1 reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, (Diflucan) Tier 1 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg (Ancobon) Tier 1 itraconazole oral capsule 100 mg (Sporanox) Tier 1 ketoconazole oral tablet 200 mg Tier 1 NOXAFIL ORAL SUSPENSION 200 Tier 3 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED Tier 3 RELEASE (DR/EC) 100 MG SPORANOX ORAL SOLUTION 10 Tier 2 Age (Max 12 Years) MG/ML terbinafine hcl oral tablet 250 mg Tier 1 QL (1 EA per 1 day) voriconazole oral tablet 200 mg, 50 mg (Vfend) Tier 1 Antifungal Antibiotics griseofulvin microsize oral suspension Tier 1 125 mg/5 ml griseofulvin microsize oral tablet 500 mg Tier 1 griseofulvin ultramicrosize oral tablet 125 Tier 1 mg, 250 mg nystatin oral suspension 100,000 unit/ml Tier 1 nystatin oral tablet 500,000 unit Tier 1 Infectious Disease - Miscellaneous Aminoglycosides neomycin oral tablet 500 mg Tier 1 TOBI PODHALER INHALATION Tier 4 PA; SP CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in 0.225 % nacl inhalation (Tobi) Tier 4 PA; SP solution for nebulization 300 mg/5 ml Antileprotics dapsone oral tablet 100 mg, 25 mg Tier 1 THALOMID ORAL CAPSULE 100 MG Tier 4 PA; SP; QL (1 EA per 1 day) THALOMID ORAL CAPSULE 150 MG, Tier 4 PA; SP; QL (2 EA per 1 200 MG, 50 MG day) Anti-Mycobacterium Agents ethambutol oral tablet 100 mg Tier 1 ethambutol oral tablet 400 mg (Myambutol) Tier 1 isoniazid oral solution 50 mg/5 ml Tier 1 isoniazid oral tablet 100 mg, 300 mg Tier 1 pyrazinamide oral tablet 500 mg Tier 1 rifabutin oral capsule 150 mg (Mycobutin) Tier 1 TRECATOR ORAL TABLET 250 MG Tier 3 Antitubercular Antibiotics cycloserine oral capsule 250 mg Tier 4 PRIFTIN ORAL TABLET 150 MG Tier 3

90 Drug Status Notes RIFAMATE ORAL CAPSULE 300-150 Tier 3 MG rifampin oral capsule 150 mg, 300 mg (Rifadin) Tier 1 RIFATER ORAL TABLET 50-120-300 Tier 3 MG SIRTURO ORAL TABLET 100 MG Tier 3 Lincosamides clindamycin hcl oral capsule 150 mg, (Cleocin HCl) Tier 1 300 mg, 75 mg CLINDAMYCIN PEDIATRIC ORAL Tier 1 RECON SOLN 75 MG/5 ML Rifamycins And Related Derivative Antibiotics XIFAXAN ORAL TABLET 200 MG Tier 2 QL (10 EA per 5 days) XIFAXAN ORAL TABLET 550 MG Tier 2 PA Vancomycin And Derivatives vancomycin oral capsule 125 mg, 250 (Vancocin) Tier 1 mg Infectious Disease - Parasitic 2Nd Gen. Anaerobic Antiprotozoal- Antibacterial tinidazole oral tablet 250 mg, 500 mg Tier 1 Amebacides paromomycin oral capsule 250 mg Tier 1 Anaerobic Antiprotozoal-Antibacterial Agents metronidazole oral capsule 375 mg (Flagyl) Tier 1 metronidazole oral tablet 250 mg Tier 1 metronidazole oral tablet 500 mg (Flagyl) Tier 1 Anthelmintics BILTRICIDE ORAL TABLET 600 MG Tier 2 ivermectin oral tablet 3 mg (Stromectol) Tier 1 praziquantel oral tablet 600 mg (Biltricide) Tier 1 Antimalarial Drugs atovaquone-proguanil oral tablet 250- (Malarone) Tier 1 100 mg atovaquone-proguanil oral tablet 62.5-25 (Malarone Pediatric) Tier 1 mg chloroquine phosphate oral tablet 250 Tier 1 mg, 500 mg DARAPRIM ORAL TABLET 25 MG Tier 2 hydroxychloroquine oral tablet 200 mg (Plaquenil) Tier 1 mefloquine oral tablet 250 mg Tier 1 primaquine oral tablet 26.3 mg $0 quinine sulfate oral capsule 324 mg (Qualaquin) Tier 1 Antiparasitics ALINIA ORAL SUSPENSION FOR Tier 2 Age (Max 12 Years) RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG Tier 2

91 Drug Status Notes Antiprotozoal Drugs,Miscellaneous atovaquone oral suspension 750 mg/5 (Mepron) Tier 1 Age (Max 12 Years) ml NEBUPENT INHALATION RECON Tier 2 SOLN 300 MG Infectious Disease - Viral Antiretroviral-Integrase Inhibitor And Nnrti Comb. JULUCA ORAL TABLET 50-25 MG Tier 2 QL (1 EA per 1 day) Antiretroviral- Nucleoside,Nucleotide,Protease Inh. SYMTUZA ORAL TABLET 800-150-200- Tier 2 QL (1 EA per 1 day) 10 MG Antiviral Monoclonal Antibodies SYNAGIS INTRAMUSCULAR Tier 4 PA; SP SOLUTION 100 MG/ML, 50 MG/0.5 ML Antivirals, General acyclovir oral capsule 200 mg Tier 1 acyclovir oral suspension 200 mg/5 ml (Zovirax) Tier 1 acyclovir oral tablet 400 mg, 800 mg Tier 1 famciclovir oral tablet 125 mg, 250 mg, Tier 1 QL (3 EA per 1 day) 500 mg oseltamivir oral capsule 30 mg, 45 mg, (Tamiflu) Tier 1 QL (2 EA per 1 day) 75 mg oseltamivir oral suspension for (Tamiflu) Tier 1 Age (Max 12 Years) reconstitution 6 mg/ml RELENZA DISKHALER INHALATION Tier 2 BLISTER WITH DEVICE 5 MG/ACTUATION ribavirin inhalation recon soln 6 gram (Virazole) Tier 4 rimantadine oral tablet 100 mg (Flumadine) Tier 1 valacyclovir oral tablet 1 gram, 500 mg (Valtrex) Tier 1 QL (2 EA per 1 day) valganciclovir oral recon soln 50 mg/ml (Valcyte) Tier 3 valganciclovir oral tablet 450 mg (Valcyte) Tier 3 Antivirals, Hiv-Spec, Non-Peptidic Protease Inhib APTIVUS (WITH VITAMIN E) ORAL Tier 2 SOLUTION 100 MG/ML APTIVUS ORAL CAPSULE 250 MG Tier 2 PREZCOBIX ORAL TABLET 800-150 Tier 3 QL (1 EA per 1 day) MG-MG PREZISTA ORAL SUSPENSION 100 Tier 3 MG/ML PREZISTA ORAL TABLET 150 MG, 600 Tier 2 QL (2 EA per 1 day) MG, 75 MG, 800 MG Antivirals, Hiv-Spec, Nucleoside- Nucleotide Analog CIMDUO ORAL TABLET 300-300 MG Tier 2 QL (1 EA per 1 day) DESCOVY ORAL TABLET 200-25 MG Tier 2 QL (1 EA per 1 day) TEMIXYS ORAL TABLET 300-300 MG Tier 2 QL (1 EA per 1 day)

92 Drug Status Notes TRUVADA ORAL TABLET 100-150 MG, Tier 2 QL (1 EA per 1 day) 133-200 MG, 167-250 MG TRUVADA ORAL TABLET 200-300 MG Tier 2 Antivirals, Hiv-Spec., Nucleoside Analog, Rti Comb abacavir-lamivudine oral tablet 600-300 (Epzicom) Tier 1 QL (1 EA per 1 day) mg abacavir-lamivudine-zidovudine oral (Trizivir) Tier 1 QL (2 EA per 1 day) tablet 300-150-300 mg EPZICOM ORAL TABLET 600-300 MG Tier 1 QL (1 EA per 1 day) lamivudine-zidovudine oral tablet 150- (Combivir) Tier 1 300 mg Antivirals, Hiv-Specific, Ccr5 Co- Receptor Antag. SELZENTRY ORAL SOLUTION 20 Tier 2 QL (31 ML per 1 day) MG/ML SELZENTRY ORAL TABLET 150 MG, Tier 2 300 MG SELZENTRY ORAL TABLET 25 MG Tier 2 QL (4 EA per 1 day) SELZENTRY ORAL TABLET 75 MG Tier 2 QL (2 EA per 1 day) Antivirals, Hiv-Specific, Fusion Inhibitors FUZEON SUBCUTANEOUS RECON Tier 2 SOLN 90 MG Antivirals, Hiv-Specific, Non- Nucleoside, Rti EDURANT ORAL TABLET 25 MG Tier 2 efavirenz oral capsule 200 mg, 50 mg (Sustiva) Tier 1 efavirenz oral tablet 600 mg (Sustiva) Tier 1 INTELENCE ORAL TABLET 100 MG, Tier 2 200 MG, 25 MG nevirapine oral suspension 50 mg/5 ml (Viramune) Tier 1 nevirapine oral tablet 200 mg (Viramune) Tier 1 nevirapine oral tablet extended release Tier 3 QL (4 EA per 1 day) 24 hr 100 mg nevirapine oral tablet extended release (Viramune XR) Tier 1 24 hr 400 mg PIFELTRO ORAL TABLET 100 MG Tier 2 QL (2 EA per 1 day) SUSTIVA ORAL CAPSULE 200 MG, 50 Tier 2 MG SUSTIVA ORAL TABLET 600 MG Tier 2 Antivirals, Hiv-Specific, Nucleoside Analog, Rti abacavir oral solution 20 mg/ml (Ziagen) Tier 1 Age (Max 12 Years) abacavir oral tablet 300 mg (Ziagen) Tier 1 QL (2 EA per 1 day) didanosine oral capsule,delayed Tier 1 release(dr/ec) 250 mg, 400 mg EMTRIVA ORAL CAPSULE 200 MG Tier 2 EMTRIVA ORAL SOLUTION 10 MG/ML Tier 2

93 Drug Status Notes lamivudine oral solution 10 mg/ml (Epivir) Tier 1 lamivudine oral tablet 150 mg, 300 mg (Epivir) Tier 1 stavudine oral capsule 15 mg, 20 mg, 30 Tier 1 mg, 40 mg zidovudine oral capsule 100 mg (Retrovir) Tier 1 zidovudine oral syrup 10 mg/ml (Retrovir) Tier 1 zidovudine oral tablet 300 mg Tier 1 Antivirals, Hiv-Specific, Nucleotide Analog, Rti tenofovir disoproxil fumarate oral tablet (Viread) Tier 2 $0 COPAY IF NO 300 mg HISTORY OF ANTIRETROVIRAL MEDICATION IN 120 DAYS; QL (1 EA per 1 day) VIREAD ORAL POWDER 40 Tier 2 QL (240 GM per 30 days) MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 Tier 2 MG, 250 MG, 300 MG Antivirals, Hiv-Specific, Protease Inhibitor Comb KALETRA ORAL TABLET 100-25 MG, Tier 2 200-50 MG lopinavir-ritonavir oral solution 400-100 (Kaletra) Tier 1 Age (Max 12 Years) mg/5 ml Antivirals, Hiv-Specific, Protease Inhibitors atazanavir oral capsule 150 mg, 200 mg, (Reyataz) Tier 1 QL (2 EA per 1 day) 300 mg CRIXIVAN ORAL CAPSULE 200 MG Tier 2 EVOTAZ ORAL TABLET 300-150 MG Tier 3 QL (1 EA per 1 day) fosamprenavir oral tablet 700 mg (Lexiva) Tier 1 INVIRASE ORAL TABLET 500 MG Tier 2 LEXIVA ORAL SUSPENSION 50 Tier 2 MG/ML NORVIR ORAL POWDER IN PACKET Tier 2 QL (12 EA per 1 day) 100 MG NORVIR ORAL SOLUTION 80 MG/ML Tier 2 NORVIR ORAL TABLET 100 MG Tier 2 REYATAZ ORAL CAPSULE 150 MG, Tier 2 QL (2 EA per 1 day) 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET Tier 2 QL (5 EA per 1 day) 50 MG ritonavir oral tablet 100 mg (Norvir) Tier 1 VIRACEPT ORAL TABLET 250 MG, 625 Tier 2 MG Antivirals,Hiv-1 Integrase Strand Transfer Inhibtr ISENTRESS HD ORAL TABLET 600 Tier 2 QL (2 EA per 1 day) MG

94 Drug Status Notes ISENTRESS ORAL POWDER IN Tier 2 QL (2 EA per 1 day) PACKET 100 MG ISENTRESS ORAL TABLET 400 MG Tier 2 ISENTRESS ORAL Tier 2 TABLET,CHEWABLE 100 MG, 25 MG TIVICAY ORAL TABLET 10 MG, 25 MG Tier 2 QL (2 EA per 1 day) TIVICAY ORAL TABLET 50 MG Tier 2 Artv Cmb Nucleoside,Nucleotide,&Non- Nucleoside Rti ATRIPLA ORAL TABLET 600-200-300 Tier 2 MG COMPLERA ORAL TABLET 200-25-300 Tier 2 MG DELSTRIGO ORAL TABLET 100-300- Tier 2 QL (1 EA per 1 day) 300 MG ODEFSEY ORAL TABLET 200-25-25 Tier 2 QL (1 EA per 1 day) MG SYMFI LO ORAL TABLET 400-300-300 Tier 2 QL (1 EA per 1 day) MG SYMFI ORAL TABLET 600-300-300 MG Tier 2 QL (1 EA per 1 day) Arv Cmb-Nrti,N(T)Rti, Integrase Inhibitor BIKTARVY ORAL TABLET 50-200-25 Tier 2 QL (1 EA per 1 day) MG GENVOYA ORAL TABLET 150-150- Tier 2 QL (1 EA per 1 day) 200-10 MG STRIBILD ORAL TABLET 150-150-200- Tier 2 QL (1 EA per 1 day) 300 MG Arv Comb-Nrtis & Integrase Inhibitor TRIUMEQ ORAL TABLET 600-50-300 Tier 3 QL (1 EA per 1 day) MG Cytochrome P450 Inhibitors TYBOST ORAL TABLET 150 MG Tier 3 Hep C Virus - Ns5a & Ns5b Polymerase Inhib. Combo. HARVONI ORAL TABLET 90-400 MG Tier 4 PA; SP ledipasvir-sofosbuvir oral tablet 90-400 (Harvoni) Tier 4 PA; SP mg Hep C Virus,Nucleotide Analog Ns5b Polymerase Inh SOVALDI ORAL TABLET 400 MG Tier 4 PA; SP Hepatitis B Treatment Agents adefovir oral tablet 10 mg (Hepsera) Tier 1 BARACLUDE ORAL SOLUTION 0.05 Tier 3 MG/ML entecavir oral tablet 0.5 mg, 1 mg (Baraclude) Tier 1 EPIVIR HBV ORAL SOLUTION 25 MG/5 Tier 2 ML (5 MG/ML) lamivudine oral tablet 100 mg (Epivir HBV) Tier 1 VEMLIDY ORAL TABLET 25 MG Tier 2 QL (1 EA per 1 day)

95 Drug Status Notes Hepatitis C Treatment Agents PEGASYS SUBCUTANEOUS Tier 4 PA; SP SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE Tier 4 PA; SP 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 50 Tier 4 PA; SP MCG/0.5 ML ribavirin oral capsule 200 mg Tier 1 QL (7 EA per 1 day) ribavirin oral tablet 200 mg Tier 1 QL (7 EA per 1 day) Hepatitis C Virus - Ns5a, Ns3/4A, Ns5b Inhib Cmb. VIEKIRA PAK ORAL TABLETS,DOSE Tier 4 PA; SP PACK 12.5 MG-75 MG -50 MG/250 MG Inflammatory Disease Anti-Arthritic And Chelating Agents CUPRIMINE ORAL CAPSULE 250 MG Tier 2 DEPEN TITRATABS ORAL TABLET Tier 3 250 MG Anti-Arthritic, Folate Antagonist Agents OTREXUP (PF) SUBCUTANEOUS Tier 3 QL (1.6 ML per 28 days) AUTO-INJECTOR 20 MG/0.4 ML RASUVO (PF) SUBCUTANEOUS Tier 3 QL (0.8 ML per 28 days) AUTO-INJECTOR 10 MG/0.2 ML RASUVO (PF) SUBCUTANEOUS Tier 3 QL (1 ML per 28 days) AUTO-INJECTOR 12.5 MG/0.25 ML RASUVO (PF) SUBCUTANEOUS Tier 3 QL (1.2 ML per 28 days) AUTO-INJECTOR 15 MG/0.3 ML RASUVO (PF) SUBCUTANEOUS Tier 3 QL (1.4 ML per 28 days) AUTO-INJECTOR 17.5 MG/0.35 ML RASUVO (PF) SUBCUTANEOUS Tier 3 QL (1.6 ML per 28 days) AUTO-INJECTOR 20 MG/0.4 ML RASUVO (PF) SUBCUTANEOUS Tier 3 QL (1.8 ML per 28 days) AUTO-INJECTOR 22.5 MG/0.45 ML RASUVO (PF) SUBCUTANEOUS Tier 3 QL (2 ML per 28 days) AUTO-INJECTOR 25 MG/0.5 ML RASUVO (PF) SUBCUTANEOUS Tier 3 QL (2.4 ML per 28 days) AUTO-INJECTOR 30 MG/0.6 ML RASUVO (PF) SUBCUTANEOUS Tier 3 QL (0.6 ML per 28 days) AUTO-INJECTOR 7.5 MG/0.15 ML Anti-Flam. Interleukin-1 Receptor Antagonist ARCALYST SUBCUTANEOUS RECON Tier 4 PA; SP SOLN 220 MG KINERET SUBCUTANEOUS SYRINGE Tier 4 PA; SP 100 MG/0.67 ML Anti-Inflammatory Tumor Necrosis Factor Inhibitor CIMZIA POWDER FOR RECONST Tier 4 PA; SP SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

96 Drug Status Notes CIMZIA STARTER KIT Tier 4 PA; SP SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) CIMZIA SUBCUTANEOUS SYRINGE Tier 4 PA; SP KIT 400 MG/2 ML (200 MG/ML X 2) ENBREL MINI SUBCUTANEOUS Tier 4 PA; SP CARTRIDGE 50 MG/ML (1 ML) ENBREL SUBCUTANEOUS RECON Tier 4 PA; SP SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE Tier 4 PA; SP 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML) ENBREL SURECLICK Tier 4 PA; SP SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) HUMIRA PEN CROHNS-UC-HS START Tier 4 PA; SP SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSOR-UVEITS-ADOL HS Tier 4 PA; SP SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN Tier 4 PA; SP INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE Tier 4 PA; SP KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER Tier 4 PA; SP SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN CROHNS-UC-HS Tier 4 PA; SP SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) PEN PSOR-UV-ADOL HS Tier 4 PA; SP SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN SUBCUTANEOUS Tier 4 PA; SP PEN INJECTOR KIT 40 MG/0.4 ML HUMIRA(CF) PEN SUBCUTANEOUS Tier 4 PA PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) SUBCUTANEOUS Tier 4 PA; SP SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML SIMPONI SUBCUTANEOUS PEN Tier 4 PA; SP INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE Tier 4 PA; SP 100 MG/ML, 50 MG/0.5 ML Anti-Inflammatory, Pyrimidine Synthesis Inhibitor leflunomide oral tablet 10 mg, 20 mg (Arava) Tier 1

97 Drug Status Notes Anti-Inflammatory,Phosphodiesterase- 4(Pde4) Inhib. OTEZLA ORAL TABLET 30 MG Tier 4 PA; SP OTEZLA STARTER ORAL Tier 4 PA; SP TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) Antinflammatory, Sel.Costim.Mod.,T- Cell Inhibitor ORENCIA CLICKJECT Tier 4 PA; SP SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE Tier 4 PA; SP 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML Bradykinin B2 Receptor Antagonists FIRAZYR SUBCUTANEOUS SYRINGE Tier 4 PA; SP 30 MG/3 ML icatibant subcutaneous syringe 30 mg/3 (Firazyr) Tier 4 PA; SP ml Glucocorticoids budesonide oral (Entocort EC) Tier 1 QL (3 EA per 1 day) capsule,delayed,extend.release 3 mg cortisone oral tablet 25 mg Tier 1 DECADRON ORAL TABLET 0.5 MG, Tier 1 0.75 MG, 4 MG, 6 MG DEXAMETHASONE INTENSOL ORAL Tier 3 DROPS 1 MG/ML dexamethasone oral elixir 0.5 mg/5 ml Tier 1 dexamethasone oral solution 0.5 mg/5 Tier 1 ml dexamethasone oral tablet 0.5 mg, 0.75 (Decadron) Tier 1 mg, 4 mg, 6 mg dexamethasone oral tablet 1 mg, 1.5 mg, Tier 1 2 mg dexamethasone oral tablets,dose pack (HiDex) Tier 3 1.5 mg (21 tabs) dexamethasone oral tablets,dose pack Tier 3 1.5 mg (35 tabs), 1.5 mg (51 tabs) HIDEX ORAL TABLETS,DOSE PACK Tier 3 1.5 MG (21 TABS) hydrocortisone oral tablet 10 mg, 20 mg, (Cortef) Tier 1 5 mg MEDROL ORAL TABLET 2 MG Tier 3 methylprednisolone oral tablet 16 mg, 32 (Medrol) Tier 1 mg, 4 mg, 8 mg methylprednisolone oral tablets,dose (Medrol (Pak)) Tier 1 pack 4 mg

98 Drug Status Notes MILLIPRED DP ORAL TABLETS,DOSE Tier 3 PACK 5 MG (21 TABS), 5 MG (48 TABS) MILLIPRED ORAL TABLET 5 MG Tier 3 prednisolone oral solution 15 mg/5 ml Tier 1 prednisolone sodium phosphate oral Tier 3 Age (Max 12 Years) solution 10 mg/5 ml prednisolone sodium phosphate oral Tier 1 solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml) prednisolone sodium phosphate oral (Veripred 20) Tier 3 Age (Max 12 Years) solution 20 mg/5 ml (4 mg/ml) prednisolone sodium phosphate oral (Pediapred) Tier 1 solution 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral (Orapred ODT) Tier 3 Age (Max 12 Years) tablet,disintegrating 10 mg, 15 mg, 30 mg PREDNISONE INTENSOL ORAL Tier 3 CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5 ml Tier 1 prednisone oral tablet 1 mg, 10 mg, 2.5 Tier 1 mg, 20 mg, 5 mg, 50 mg prednisone oral tablets,dose pack 10 Tier 1 mg, 5 mg TAPERDEX ORAL TABLETS,DOSE Tier 3 PACK 1.5 MG (21 TABS) Interleukin-6 (Il-6) Receptor Inhibitors ACTEMRA SUBCUTANEOUS Tier 4 PA; SP SYRINGE 162 MG/0.9 ML Janus Kinase (Jak) Inhibitors XELJANZ ORAL TABLET 10 MG, 5 MG Tier 4 PA; SP XELJANZ XR ORAL TABLET Tier 4 PA; SP EXTENDED RELEASE 24 HR 11 MG Mineralocorticoids fludrocortisone oral tablet 0.1 mg Tier 1 Monoclonal Antibody-Human Interleukin 12/23 Inhib STELARA SUBCUTANEOUS SYRINGE Tier 4 PA; SP 45 MG/0.5 ML Nasal Nsaids, Cox Non- Selective,Systemic Analgesic SPRIX NASAL SPRAY,NON-AEROSOL Tier 3 15.75 MG/SPRAY Nsaid, Cox Inhibitor-Type & Proton Pump Inhib Comb VIMOVO ORAL TABLET,IR,DELAYED Tier 2 PA; QL (4 EA per 1 day) REL,BIPHASIC 375-20 MG, 500-20 MG

99 Drug Status Notes Nsaids (Cox Non-Specific Inhib)& Prostaglandin Cmb diclofenac-misoprostol oral (Arthrotec 50) Tier 1 tablet,ir,delayed rel,biphasic 50-200 mg- mcg diclofenac-misoprostol oral (Arthrotec 75) Tier 1 tablet,ir,delayed rel,biphasic 75-200 mg- mcg Nsaids, Cyclooxygenase 2 Inhibitor - Type celecoxib oral capsule 100 mg, 200 mg, (Celebrex) Tier 1 400 mg, 50 mg Nsaids, Cyclooxygenase Inhibitor-Type CHILDREN'S IBUPROFEN ORAL Tier 1 SUSPENSION 100 MG/5 ML CHILDREN'S PROFEN IB ORAL Tier 1 SUSPENSION 100 MG/5 ML diclofenac potassium oral tablet 50 mg Tier 1 diclofenac sodium oral tablet extended (Voltaren-XR) Tier 1 QL (2 EA per 1 day) release 24 hr 100 mg diclofenac sodium oral tablet,delayed Tier 1 release (dr/ec) 25 mg, 50 mg, 75 mg EC-NAPROXEN ORAL Tier 1 TABLET,DELAYED RELEASE (DR/EC) 375 MG EC-NAPROXEN ORAL Tier 1 QL (2 EA per 1 day) TABLET,DELAYED RELEASE (DR/EC) 500 MG etodolac oral capsule 200 mg, 300 mg Tier 1 QL (2 EA per 1 day) etodolac oral tablet 400 mg (Lodine) Tier 1 QL (2 EA per 1 day) etodolac oral tablet 500 mg Tier 1 QL (2 EA per 1 day) etodolac oral tablet extended release 24 Tier 1 QL (1 EA per 1 day) hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg (Nalfon) Tier 1 flurbiprofen oral tablet 100 mg Tier 1 IBU ORAL TABLET 400 MG, 600 MG, Tier 1 QL (4 EA per 1 day) 800 MG ibuprofen oral suspension 100 mg/5 ml (Children's Ibuprofen) Tier 1 ibuprofen oral tablet 400 mg, 600 mg, (IBU) Tier 1 QL (4 EA per 1 day) 800 mg INDOCIN ORAL SUSPENSION 25 MG/5 Tier 3 ML INDOCIN RECTAL SUPPOSITORY 50 Tier 3 MG indomethacin oral capsule 25 mg, 50 mg Tier 1 indomethacin oral capsule, extended Tier 1 QL (2 EA per 1 day) release 75 mg ketoprofen oral capsule 50 mg, 75 mg Tier 1 ketoprofen oral capsule,ext rel. pellets Tier 1 24 hr 200 mg

100 Drug Status Notes ketorolac oral tablet 10 mg Tier 1 meclofenamate oral capsule 100 mg, 50 Tier 1 mg mefenamic acid oral capsule 250 mg Tier 1 meloxicam oral tablet 15 mg (Mobic) Tier 1 QL (1 EA per 1 day) meloxicam oral tablet 7.5 mg (Mobic) Tier 1 QL (2 EA per 1 day) nabumetone oral tablet 500 mg, 750 mg (Relafen) Tier 1 QL (2 EA per 1 day) naproxen oral suspension 125 mg/5 ml (Naprosyn) Tier 1 naproxen oral tablet 250 mg, 375 mg Tier 1 naproxen oral tablet 500 mg (Naprosyn) Tier 1 QL (2 EA per 1 day) naproxen oral tablet,delayed release (EC-Naproxen) Tier 1 (dr/ec) 375 mg naproxen oral tablet,delayed release (EC-Naproxen) Tier 1 QL (2 EA per 1 day) (dr/ec) 500 mg oxaprozin oral tablet 600 mg (Daypro) Tier 1 QL (2 EA per 1 day) piroxicam oral capsule 10 mg (Feldene) Tier 1 QL (2 EA per 1 day) piroxicam oral capsule 20 mg (Feldene) Tier 1 QL (1 EA per 1 day) sulindac oral tablet 150 mg, 200 mg Tier 1 tolmetin oral capsule 400 mg Tier 1 tolmetin oral tablet 200 mg, 600 mg Tier 1 ZIPSOR ORAL CAPSULE 25 MG Tier 3 ZORVOLEX ORAL CAPSULE 18 MG Tier 3 Local Anesthesia Local Anesthetics lidocaine hcl mucous membrane solution Tier 1 4 % (40 mg/ml) LIDOCAINE VISCOUS MUCOUS Tier 1 MEMBRANE SOLUTION 2 % Lower Gastrointestinal Disorders - Bowel Inflammat Bowel Antiinflamatory Agents sulfadiazine oral tablet 500 mg Tier 1 Chronic Inflam. Colon Dx, 5-A- Salicylat,Rectal Tx CANASA RECTAL SUPPOSITORY Tier 3 QL (1 EA per 1 day) 1,000 MG mesalamine rectal enema 4 gram/60 ml (Rowasa) Tier 3 QL (60 ML per 1 day) mesalamine with cleansing wipe rectal (Rowasa) Tier 1 enema kit 4 gram/60 ml Drug Tx-Chronic Inflam. Colon Dx,5- Aminosalicylat APRISO ORAL CAPSULE,EXTENDED Tier 2 QL (4 EA per 1 day) RELEASE 24HR 0.375 GRAM balsalazide oral capsule 750 mg (Colazal) Tier 1 QL (9 EA per 1 day) DIPENTUM ORAL CAPSULE 250 MG Tier 3 mesalamine oral tablet,delayed release (Lialda) Tier 3 QL (4 EA per 1 day) (dr/ec) 1.2 gram mesalamine oral tablet,delayed release (Asacol HD) Tier 1 QL (6 EA per 1 day) (dr/ec) 800 mg

101 Drug Status Notes PENTASA ORAL CAPSULE, Tier 3 QL (240 EA per 30 days) EXTENDED RELEASE 250 MG, 500 MG sulfasalazine oral tablet 500 mg (Azulfidine) Tier 1 sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) Tier 1 (dr/ec) 500 mg Hemorrhoidal Prep, Anti-Infam Steroid/Local Anesth ANALPRAM-HC RECTAL CREAM 1-1 Tier 3 % hydrocortisone-pramoxine rectal cream (Analpram-HC) Tier 1 1-1 %, 2.5-1 % hydrocortisone-pramoxine rectal cream (Analpram-HC Singles) Tier 1 2.5-1 % (4g) lidocaine-hydrocortisone-aloe rectal gel Tier 1 2.8-0.55 % PROCORT RECTAL CREAM 1.85-1.15 Tier 3 % PROCTOFOAM HC RECTAL FOAM 1-1 Tier 2 % Hemorrhoidals, Local Rectal Anesthetics ANECREAM5 TOPICAL CREAM 5 % Tier 1 HEMORRHOIDAL RELIEF TOPICAL Tier 1 CREAM 5 % LC-5 TOPICAL CREAM 5 % Tier 1 lidocaine topical cream 5 % (AneCream5) Tier 1 RECTASMOOTHE TOPICAL CREAM 5 Tier 1 % Irritable Bowel Agents,Guanylate Cylase-C Agonist LINZESS ORAL CAPSULE 145 MCG, Tier 3 QL (1 EA per 1 day) 290 MCG, 72 MCG Local Anorectal Nitrate Preparations RECTIV RECTAL OINTMENT 0.4 % Tier 3 (W/W) Rectal Preparations ANUCORT-HC RECTAL Tier 1 SUPPOSITORY 25 MG hydrocortisone acetate rectal (Anucort-HC) Tier 1 suppository 25 mg Rectal/Lower Bowel Prep.,Glucocort. (Non-Hemorr) CORTIFOAM RECTAL FOAM 10 % (80 Tier 2 MG) hydrocortisone rectal enema 100 mg/60 (Cortenema) Tier 1 QL (1800 ML per 30 days) ml

102 Drug Status Notes Lower Gastrointestinal Disorders - Other Ammonia Inhibitors ENULOSE ORAL SOLUTION 10 Tier 1 GRAM/15 ML GENERLAC ORAL SOLUTION 10 Tier 1 GRAM/15 ML LITHOSTAT ORAL TABLET 250 MG Tier 3 RAVICTI ORAL LIQUID 1.1 GRAM/ML Tier 3 sodium phenylbutyrate oral powder 0.94 (Buphenyl) Tier 1 gram/gram sodium phenylbutyrate oral tablet 500 (Buphenyl) Tier 1 mg Antidiarrheal - G.I. Chloride Channel Inhibitors MYTESI ORAL TABLET,DELAYED Tier 3 RELEASE (DR/EC) 125 MG Antidiarrheals ANTI-DIARRHEAL (LOPERAMIDE) Tier 1 ORAL CAPSULE 2 MG diphenoxylate-atropine oral liquid 2.5- Tier 1 QL (4 ML per 1 day) 0.025 mg/5 ml diphenoxylate-atropine oral tablet 2.5- (Lomotil) Tier 1 QL (4 EA per 1 day) 0.025 mg IMODIUM A-D ORAL CAPSULE 2 MG Tier 1 loperamide oral capsule 2 mg (Anti-Diarrheal Tier 1 (loperamide)) Bile Salts CHOLBAM ORAL CAPSULE 250 MG, Tier 1 50 MG ursodiol oral capsule 300 mg (Actigall) Tier 1 ursodiol oral tablet 250 mg (URSO 250) Tier 1 ursodiol oral tablet 500 mg (URSO Forte) Tier 1 Irritable Bowel Synd. Agent,5Ht-3 Antagonist-Type alosetron oral tablet 0.5 mg, 1 mg (Lotronex) Tier 4 Laxatives And Cathartics AMITIZA ORAL CAPSULE 24 MCG, 8 Tier 3 QL (2 EA per 1 day) MCG CLEARLAX ORAL POWDER 17 Tier 1 GRAM/DOSE CLEARLAX ORAL POWDER IN Tier 1 PACKET 17 GRAM CONSTULOSE ORAL SOLUTION 10 Tier 1 GRAM/15 ML GAVILYTE-C ORAL RECON SOLN 240- Tier 1 22.72-6.72 -5.84 GRAM GAVILYTE-G ORAL RECON SOLN 236- Tier 1 22.74-6.74 -5.86 GRAM

103 Drug Status Notes GAVILYTE-N ORAL RECON SOLN 420 Tier 1 GRAM GENTLELAX ORAL POWDER 17 Tier 1 GRAM/DOSE GLYCOLAX ORAL POWDER 17 Tier 1 GRAM/DOSE GOLYTELY ORAL POWDER IN Tier 3 PACKET 227.1-21.5-6.36 GRAM HEALTHYLAX ORAL POWDER IN Tier 1 PACKET 17 GRAM KRISTALOSE ORAL PACKET 10 Tier 3 GRAM, 20 GRAM lactulose oral solution 10 gram/15 ml (Constulose) Tier 1 lactulose oral solution 10 gram/15 ml (15 Tier 1 ml), 20 gram/30 ml LAXACLEAR ORAL POWDER 17 Tier 1 GRAM/DOSE LAXATIVE PEG 3350 ORAL POWDER Tier 1 17 GRAM/DOSE MOVIPREP ORAL POWDER IN Tier 3 PACKET 100-7.5-2.691 GRAM NATURA-LAX ORAL POWDER 17 Tier 1 GRAM/DOSE OSMOPREP ORAL TABLET 1.5 GRAM Tier 3 peg 3350-electrolytes oral recon soln (GaviLyte-G) Tier 1 236-22.74-6.74 -5.86 gram peg-electrolyte soln oral recon soln 420 (GaviLyte-N) Tier 1 gram polyethylene glycol 3350 oral powder 17 (ClearLax) Tier 1 gram/dose polyethylene glycol 3350 oral powder in (ClearLax) Tier 1 packet 17 gram POWDERLAX ORAL POWDER 17 Tier 1 GRAM/DOSE POWDERLAX ORAL POWDER IN Tier 1 PACKET 17 GRAM PREPOPIK ORAL POWDER IN Tier 3 PACKET 10 MG-3.5 GRAM-12 GRAM PURELAX ORAL POWDER 17 Tier 1 GRAM/DOSE PURELAX ORAL POWDER IN PACKET Tier 1 17 GRAM SMOOTHLAX ORAL POWDER 17 Tier 1 GRAM/DOSE SMOOTHLAX ORAL POWDER IN Tier 1 PACKET 17 GRAM SUPREP BOWEL PREP KIT ORAL Tier 3 RECON SOLN 17.5-3.13-1.6 GRAM TRILYTE WITH FLAVOR PACKETS Tier 1 ORAL RECON SOLN 420 GRAM

104 Drug Status Notes Narcotic Antagonists, Peripherally- Acting ENTEREG ORAL CAPSULE 12 MG Tier 4 RELISTOR SUBCUTANEOUS Tier 4 PA SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS Tier 4 PA SYRINGE 12 MG/0.6 ML, 8 MG/0.4 ML Medical Supplies Catheters And Related Devices DOVER BULB SYRINGE SYRINGE 60 Tier 2 ML Durable Medical Equipment,Misc(Group 1) 1ST TIER UNILET COMFORTOUCH 28 Tier 2 GAUGE, 30 GAUGE ACCU-CHEK FASTCLIX LANCET Tier 2 DRUM ACCU-CHEK MULTICLIX LANCET Tier 2 ACCU-CHEK SAFE-T-PRO 23 GAUGE Tier 2 ACCU-CHEK SAFE-T-PRO PLUS 23 Tier 2 GAUGE ACCU-CHEK SOFTCLIX LANCETS Tier 2 ACTI-LANCE LANCETS 17 GAUGE, 23 Tier 2 GAUGE, 28 GAUGE ADVANCED TRAVEL LANCETS 28 Tier 2 GAUGE, 30 GAUGE ADVOCATE LANCET 26 GAUGE, 30 Tier 2 GAUGE ALTERNATE SITE LANCET 26 GAUGE Tier 2 ASSURE HAEMOLANCE PLUS 1.2 MM, Tier 2 18 GAUGE, 21 GAUGE, 25 GAUGE, 28 GAUGE ASSURE LANCE 25 GAUGE, 28 Tier 2 GAUGE ASSURE LANCE PLUS 21 GAUGE, 25 Tier 2 GAUGE, 30 GAUGE BD MICROTAINER LANCET 1.5 X 2 Tier 2 MM, 21 GAUGE, 30 GAUGE BD ULTRA FINE LANCETS 33 GAUGE Tier 2 BD ULTRA-FINE II LANCETS 30 Tier 2 GAUGE BULLSEYE MINI SAFETY LANCETS 21 Tier 2 GAUGE, 25 GAUGE, 28 GAUGE CAREONE THIN LANCET Tier 2 CAREONE ULTRA THIN LANCET Tier 2 CARESENS LANCETS 30 GAUGE Tier 2 CARETOUCH SAFETY LANCETS 26 Tier 2 GAUGE, 28 GAUGE CARETOUCH TWIST LANCET 28 Tier 2 GAUGE, 30 GAUGE, 33 GAUGE

105 Drug Status Notes CLEVER CHEK LANCETS 30 GAUGE Tier 2 COAGUCHEK LANCETS Tier 2 COLOR LANCETS 21 GAUGE Tier 2 COMFORT EZ LANCETS 21 GAUGE, Tier 2 23 GAUGE, 28 GAUGE COMFORT LANCETS Tier 2 DROPLET LANCETS 30 GAUGE Tier 2 EASY COMFORT LANCETS 30 GAUGE Tier 2 EASY TOUCH LANCETS 26 GAUGE, Tier 2 28 GAUGE, 30 GAUGE, 32 GAUGE EASY TOUCH SAFETY LANCETS 21 Tier 2 GAUGE, 23 GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE, 32 GAUGE EASY TOUCH TWIST LANCETS 26 Tier 2 GAUGE, 28 GAUGE, 30 GAUGE, 32 GAUGE, 33 GAUGE EASY TWIST AND CAP LANCETS 28 Tier 2 GAUGE EMBRACE LANCETS 30 GAUGE Tier 2 E-Z JECT LANCETS , 26 GAUGE, 30 Tier 2 GAUGE, 32 GAUGE, 33 GAUGE E-Z JECT THIN LANCETS 28 GAUGE Tier 2 EZ SMART LANCETS 28 GAUGE Tier 2 EZ-LETS 26 GAUGE Tier 2 FIFTY50 SAFETY SEAL LANCETS 30 Tier 2 GAUGE, 32 GAUGE FINE 30 UNIVERSAL LANCETS 30 Tier 2 GAUGE FINGERSTIX LANCETS Tier 2 FORACARE LANCETS 30 GAUGE Tier 2 FREESTYLE LANCETS 28 GAUGE Tier 2 FREESTYLE UNISTIK 2 Tier 2 GLUCOCOM LANCETS 28 GAUGE, 30 Tier 2 GAUGE, 33 GAUGE GOJJI LANCETS 30 GAUGE Tier 2 HEALTHY ACCENTS UNILET LANCET Tier 2 30 GAUGE INCONTROL SUPER THIN LANCETS Tier 2 30 GAUGE INCONTROL ULTRA THIN LANCETS Tier 2 28 GAUGE INJECT EASE LANCETS 28 GAUGE, Tier 2 30 GAUGE INVACARE LANCETS 30 GAUGE Tier 2 lancets (Accu-Chek Fastclix Tier 2 Lancet Drum) lancets 21 gauge (Assure Haemolance Plus) Tier 2 lancets 26 gauge (Advocate Lancet) Tier 2

106 Drug Status Notes lancets 28 gauge, 30 gauge (1st Tier Unilet Tier 2 ComforTouch) lancets 33 gauge (BD Ultra Fine Lancets) Tier 2 LANCETS, SUPER THIN Tier 2 LANCETS,THIN , 23 GAUGE, 28 Tier 2 GAUGE LANCETS,ULTRA THIN , 26 GAUGE Tier 2 LITE TOUCH LANCETS 28 GAUGE, 30 Tier 2 GAUGE, 33 GAUGE MEDISENSE THIN LANCETS 28 Tier 2 GAUGE MEDLANCE PLUS LANCETS 21 Tier 2 GAUGE, 25 GAUGE, 30 GAUGE MEDLANCE PLUS SPECIAL BLADE 0.8 Tier 2 X 2 MM MICRO THIN LANCETS 33 GAUGE Tier 2 MICROLET LANCET Tier 2 MONOLET LANCETS 21 GAUGE Tier 2 MONOLET THIN LANCETS 28 GAUGE Tier 2 MYGLUCOHEALTH LANCETS 30 Tier 2 GAUGE NOVA SAFETY LANCETS 23 GAUGE, Tier 2 28 GAUGE NOVA SUREFLEX LANCETS Tier 2 ON CALL LANCET 30 GAUGE Tier 2 ON CALL PLUS LANCET 30 GAUGE Tier 2 ONETOUCH DELICA LANCETS 30 Tier 2 GAUGE, 33 GAUGE ONETOUCH DELICA PLUS LANCET 30 Tier 2 GAUGE, 33 GAUGE ONETOUCH SURESOFT LANCING Tier 2 DEV 28 GAUGE ONETOUCH ULTRASOFT LANCETS Tier 2 ON-THE-GO LANCETS 30 GAUGE Tier 2 PIP LANCET 28 GAUGE, 30 GAUGE Tier 2 PRESSURE ACTIVATED LANCETS 21 Tier 2 GAUGE, 28 GAUGE PRO COMFORT LANCET 30 GAUGE, Tier 2 31 GAUGE PRODIGY LANCETS 26 GAUGE, 28 Tier 2 GAUGE PRODIGY TWIST TOP LANCET 28 Tier 2 GAUGE PURE COMFORT LANCETS 30 Tier 2 GAUGE PURE COMFORT SAFETY LANCETS Tier 2 30 GAUGE PUSH BUTTON SAFETY LANCETS 21 Tier 2 GAUGE, 28 GAUGE

107 Drug Status Notes READYLANCE SAFETY LANCETS 21 Tier 2 GAUGE, 23 GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE RELIAMED LANCET 23 GAUGE, 28 Tier 2 GAUGE, 30 GAUGE RELIAMED SAFETY SEAL LANCETS Tier 2 28 GAUGE, 30 GAUGE RELIAMED TWIST AND CAP LANCET Tier 2 28 GAUGE RELION THIN LANCETS 26 GAUGE Tier 2 RELION ULTRA THIN PLUS LANCETS Tier 2 RIGHTEST GL300 LANCETS 30 Tier 2 GAUGE SAFETY LANCETS 21 GAUGE, 26 Tier 2 GAUGE, 28 GAUGE SAFETY SEAL LANCETS 28 GAUGE, Tier 2 30 GAUGE SAFETY-LET LANCETS 30 GAUGE Tier 2 SINGLE-LET Tier 2 SMART SENSE LANCETS 21 GAUGE, Tier 2 26 GAUGE, 33 GAUGE SMARTEST LANCET Tier 2 SOFT TOUCH LANCETS Tier 2 SOLUS V2 LANCETS 28 GAUGE, 30 Tier 2 GAUGE STERILANCE TL 30 GAUGE, 32 Tier 2 GAUGE SUPER THIN LANCETS , 28 GAUGE, Tier 2 30 GAUGE SURE COMFORT LANCETS 18 Tier 2 GAUGE, 21 GAUGE, 23 GAUGE, 28 GAUGE, 30 GAUGE SURE-LANCE , 26 GAUGE, 28 GAUGE Tier 2 SURE-LANCE ULTRA THIN 30 GAUGE Tier 2 SURE-TOUCH LANCET Tier 2 TECHLITE LANCETS 25 GAUGE, 28 Tier 2 GAUGE, 30 GAUGE TELCARE LANCETS 30 GAUGE Tier 2 THIN LANCETS 26 GAUGE Tier 2 TOPCARE UNIVERSAL1 LANCET , 33 Tier 2 GAUGE TRUE COMFORT LANCET 30 GAUGE Tier 2 TRUEPLUS LANCETS 26 GAUGE, 28 Tier 2 GAUGE, 30 GAUGE, 33 GAUGE TWIST LANCETS 30 GAUGE, 32 Tier 2 GAUGE ULTILET BASIC LANCETS 30 GAUGE Tier 2 ULTILET CLASSIC LANCETS , 28 Tier 2 GAUGE, 30 GAUGE, 33 GAUGE

108 Drug Status Notes ULTILET LANCETS 28 GAUGE, 30 Tier 2 GAUGE, 33 GAUGE ULTILET SAFETY LANCETS 23 Tier 2 GAUGE ULTRA FINE LANCETS 30 GAUGE Tier 2 ULTRA THIN II LANCETS 30 GAUGE Tier 2 ULTRA THIN LANCETS , 28 GAUGE, Tier 2 30 GAUGE, 31 GAUGE, 33 GAUGE ULTRA THIN PLUS LANCETS 33 Tier 2 GAUGE ULTRA TLC LANCETS Tier 2 ULTRA-CARE LANCETS 30 GAUGE Tier 2 ULTRALANCE LANCETS 26 GAUGE, Tier 2 28 GAUGE ULTRA-THIN II LANCETS 28 GAUGE Tier 2 UNILET COMFORTOUCH LANCET , Tier 2 26 GAUGE UNILET EXCELITE II LANCET Tier 2 UNILET EXCELITE LANCET Tier 2 UNILET GP LANCET Tier 2 UNILET LANCET 28 GAUGE, 33 Tier 2 GAUGE UNILET LANCETS 30 GAUGE Tier 2 UNILET SUPER THIN LANCETS 30 Tier 2 GAUGE UNISTIK 3 COMFORT LANCET Tier 2 UNISTIK 3 EXTRA LANCET 21 GAUGE Tier 2 UNISTIK 3 GENTLE 30 GAUGE Tier 2 UNISTIK 3 LANCETS 21 GAUGE Tier 2 UNISTIK 3 NORMAL LANCET 23 Tier 2 GAUGE UNISTIK CZT LANCET 23 GAUGE, 28 Tier 2 GAUGE UNISTIK PRO LANCET 21 GAUGE, 25 Tier 2 GAUGE, 28 GAUGE UNISTIK SAFETY 28 GAUGE, 30 Tier 2 GAUGE UNISTIK TOUCH LANCETS 21 Tier 2 GAUGE, 23 GAUGE, 28 GAUGE, 30 GAUGE UNIVERSAL 1 LANCETS 21 GAUGE, Tier 2 26 GAUGE, 30 GAUGE, 33 GAUGE VIVAGUARD LANCET 30 GAUGE Tier 2

109 Drug Status Notes Syringes And Accessories ADVOCATE SYRINGES SYRINGE 0.3 Tier 2 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 ALLERGIST TRAY 1/2 ML 27GX3/8" Tier 2 SYRINGE 1/2 ML 27 GAUGE X 3/8" ALLERGIST TRAY INTRADERMAL BEV Tier 2 SYRINGE 1 ML 26 GAUGE X 1/2", 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 3/8" ALLERGIST TRAY REGULAR BEVEL Tier 2 SYRINGE 1 ML 27 GAUGE X 3/8" ALLERGY SYRINGE SYRINGE 1 ML 27 Tier 2 GAUGE X 3/8", 1 ML 27 X 1/2" ASSURE ID INSULIN SAFETY Tier 2 SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 GAUGE X 15/64", 1 ML 29 GAUGE X 1/2", 1 ML 31 GAUGE X 15/64" BD ALLERGIST TRAY REG BEVEL Tier 2 SYRINGE 1 ML 26 GAUGE X 1/2", 1 ML 27 X 1/2" BD ALLERGIST TRAY REG BEVEL Tier 2 TRAY 1/2 ML 27 X 1/2" BD ALLERGY SYRINGE SYRINGE 1 Tier 2 ML 28 GAUGE X 1/2" BD BLUNT PLASTIC CANNULA Tier 2 SYRINGE 17 X 3 ML BD BULK SYRINGE SLIP TIP SYRINGE Tier 2 1 ML, 5 ML BD ECCENTRIC TIP SYRINGE Tier 2 SYRINGE 10 ML BD ECLIPSE LUER-LOK SYRINGE 1 Tier 2 ML 27 X 1/2", 1 ML 30 GAUGE X 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 X 5/8" BD INSULIN SYRINGE HALF UNIT Tier 2 SYRINGE 0.3 ML 31 GAUGE X 5/16" BD INSULIN SYRINGE MICRO-FINE Tier 2 SYRINGE 1 ML 28 GAUGE X 1/2" BD INSULIN SYRINGE SAFETY-LOK Tier 2 SYRINGE 1 ML 29 GAUGE X 1/2" BD INSULIN SYRINGE SLIP TIP Tier 2 SYRINGE 1 ML

110 Drug Status Notes BD INSULIN SYRINGE SYRINGE 0.3 Tier 2 ML 29 GAUGE X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 25 GAUGE X 5/8", 1 ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" BD INSULIN SYRINGE U-500 SYRINGE Tier 2 1/2 ML 31 GAUGE X 15/64" BD INSULIN SYRINGE ULTRA-FINE Tier 2 SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16 BD INTEGRA SYRINGE SYRINGE 3 ML Tier 2 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8" BD INTERLINK BLUNT PLASTIC CAN Tier 2 SYRINGE 17 X 5 ML BD INTERLINK SYRINGE SYRINGE 17 Tier 2 X 10 ML BD LAB ECCENTRIC NON-STERILE Tier 2 SYRINGE 10 ML BD LO-DOSE MICRO-FINE IV Tier 2 SYRINGE 1/2 ML 28 GAUGE X 1/2" BD LO-DOSE ULTRA-FINE SYRINGE Tier 2 0.5 ML 29 GAUGE X 1/2" BD LUER-LOK BULK SYRINGE Tier 2 SYRINGE 20 ML BD LUER-LOK SYRINGE SYRINGE 1 Tier 2 ML, 1 ML 20 GAUGE X 1", 10 ML, 10 ML 20 X 1 1/2", 10 ML 20 X 1", 10 ML 21 GAUGE X 1", 10 ML 21 X 1 1/2", 10 ML 22 X 1", 10 ML 23X 1 1/4 ", 20 ML, 3 ML, 3 ML 18 X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 1 1/2 ", 3 ML 25 X 5/8", 3 ML 26 X 5/8", 5 ML, 5 ML 20 X 1 1/2", 5 ML 20 X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 X 1", 50 ML BD LUER-LOK TIP CONTROL SYRING Tier 2 SYRINGE 10 ML BD PRECISIONGLIDE SYRINGE 3 ML Tier 2 22 GAUGE X 3/4"

111 Drug Status Notes BD SAFETYGLIDE ALLERGIST TRAY Tier 2 SYRINGE 1 ML 26 GAUGE X 3/8", 1 ML 27 X 1/2" BD SAFETYGLIDE INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 1 ML 29 GAUGE X 1/2", 1 ML 31 GAUGE X 15/64" BD SAFETYGLIDE SHIELDING REG Tier 2 SYRINGE 1 ML 25 GAUGE X 5/8", 3 ML 21 GAUGE X 1 1/2" BD SAFETYGLIDE SYRINGE SYRINGE Tier 2 1 ML 27 GAUGE X 5/8", 10 ML 22 X 1 1/2", 3 ML 22 X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8", 5 ML 22 GAUGE X 1 1/2" BD SAFETYGLIDE TB REG BEVEL Tier 2 SYRINGE 1 ML 27 X 1/2" BD SAFETYGLIDE TUBERCULIN Tier 2 SYRINGE 1 ML 26 GAUGE X 3/8" BD SAFETY-LOK DETACHABLE Tier 2 NEEDL SYRINGE 10 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 21 GAUGE X 1 1/2" BD SAFETY-LOK TUBERCULIN Tier 2 SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2" BD SAFETY-LOK WITH LUER-LOK Tier 2 SYRINGE 10 ML, 3 ML, 5 ML BD SLIP TIP SYRINGE SYRINGE 1 ML Tier 2 26 GAUGE X 5/8", 10 ML, 3 ML, 50 ML B-D SLIP TIP SYRINGE SYRINGE 20 Tier 2 ML BD SYRINGE CATH TIP NONSTERILE Tier 2 SYRINGE 50 ML BD SYRINGE CATHETER TIP Tier 2 SYRINGE 50 ML BD SYRINGE LUER-LOK NONSTERILE Tier 2 SYRINGE 10 ML, 20 ML, 5 ML, 50 ML BD SYRINGE LUER-LOK STERILE Tier 2 SYRINGE 10 ML, 50 ML BD SYRINGE SLIP TIP NONSTERILE Tier 2 SYRINGE 10 ML, 20 ML, 50 ML BD SYRINGE SYRINGE 1 ML Tier 2

112 Drug Status Notes BD SYRINGE-DUAL CANNULA Tier 2 SYRINGE 10 ML 20 GAUGE AND 17 GAUGE BD TUBERCULIN SLIP-TIP SYRINGE 1 Tier 2 ML BD TUBERCULIN SYRINGE SYRINGE Tier 2 1 ML 21 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML 27 X 1/2", 1/2 ML 27 X 1/2 " BD VEO INSULIN SYR HALF UNIT Tier 2 SYRINGE 0.3 ML 31 GAUGE X 15/64" BD VEO INSULIN SYRINGE UF Tier 2 SYRINGE 0.3 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 15/64", 1/2 ML 31 GAUGE X 15/64" CAREPOINT LUER SLIP SYRINGE Tier 2 SYRINGE 1 ML CARETOUCH INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 X 5/16", 1 ML 29 GAUGE X 5/16, 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 COMFORT EZ INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" DAVOL IRRIGATION SYRINGE Tier 2 SYRINGE DAVOL PISTON IRRIGATION Tier 2 SYRINGE DROPLET INSULIN SYR HALF UNIT Tier 2 SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 5/16", 0.5ML 30 GAUGE X 15/64"

113 Drug Status Notes DROPLET INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 15/64", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 15/64", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16 EASY COMFORT INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1 ML 32 GAUGE X 5/16", 1/2 ML 32 GAUGE X 5/16" EASY GLIDE CATHETER TIP SYRING Tier 2 SYRINGE 60 ML EASY GLIDE DENTAL IRRIG SYRING Tier 2 SYRINGE 10 ML EASY GLIDE INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 15/64", 1/2 ML 31 GAUGE X 15/64" EASY GLIDE LUER LOCK SYRINGE Tier 2 SYRINGE 1 ML, 10 ML, 3 ML, 60 ML EASY GLIDE LUER SLIP TB SYRING Tier 2 SYRINGE 1 ML EASY TOUCH FLIPLOCK INSULIN Tier 2 SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16"

114 Drug Status Notes EASY TOUCH FLIPLOCK SYRINGE Tier 2 SYRINGE 1 ML 25 GAUGE X 1", 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 1/2", 10 ML 18 GAUGE X 1 1/2", 10 ML 18 GAUGE X 1", 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 10 ML 21 X 1", 10 ML 22 GAUGE X 1 1/2", 10 ML 25 GAUGE X 1", 3 ML 18 GAUGE X 1 1/2", 3 ML 18 GAUGE X 1", 3 ML 19 GAUGE X 1 1/2", 3 ML 19 GAUGE X 1", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 18 GAUGE X 1", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 25 GAUGE X 1", 5 ML 25 GAUGE X 5/8" EASY TOUCH FLURINGE FLIPLOCK Tier 2 SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8" EASY TOUCH FLURINGE FLU TRAY Tier 2 TRAY 1 ML 25 GAUGE X 1" EASY TOUCH FLURINGE Tier 2 SHEATHLOCK SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8" EASY TOUCH FLURINGE SYRINGE 1 Tier 2 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8" EASY TOUCH INSULIN SAFETY SYR Tier 2 SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2" EASY TOUCH INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2" EASY TOUCH LUER LOCK INSULIN Tier 2 SYRINGE 1 ML

115 Drug Status Notes EASY TOUCH LUER LOCK SYRINGE Tier 2 SYRINGE 1 ML, 10 ML, 3 ML, 5 ML EASY TOUCH SHEATHLOCK INSULIN Tier 2 SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16" EASY TOUCH SHEATHLOCK SYRG- Tier 2 NDL SYRINGE 10 ML 21 GAUGE X 1 1/2", 10 ML 22 GAUGE X 1 1/2", 10 ML 25 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 21 GAUGE X 1 1/2", 5 ML 22 GAUGE X 1 1/2", 5 ML 25 GAUGE X 1" EASY TOUCH SHEATHLOCK Tier 2 SYRINGE SYRINGE 10 ML, 3 ML, 5 ML EASY TOUCH SYR ALLERGY TRAY Tier 2 TRAY 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 1/2" EASY TOUCH SYRINGE 1 ML 25 Tier 2 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8" EASY TOUCH TUBERCULIN Tier 2 FLIPLOCK SYRINGE 1 ML 26 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2" EASY TOUCH TUBERCULIN Tier 2 SHEATHLK SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2" EASY TOUCH UNI-SLIP SYRINGE 1 Tier 2 ML, 10 ML, 3 ML, 5 ML ECLIPSE SYRINGE SYRINGE 1 ML 25 Tier 2 GAUGE X 5/8", 3 ML 21 GAUGE X 1", 3 ML 25 GAUGE X 1" EXCEL SYRINGE SYRINGE 3 ML 23 X Tier 2 1" EXEL INSULIN SYRINGE 0.3 ML 29 Tier 2 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" EXEL SYRINGE SYRINGE 10 ML, 3 ML Tier 2 23 GAUGE X 1 1/2", 3 ML 25 X 5/8", 3 ML 27 GAUGE X 1 1/4", 30 ML, 50 ML

116 Drug Status Notes FREESTYLE PRECISION SYRINGE 0.5 Tier 2 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 HEALTHWISE INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 insulin syr/ndl u100 half mark syringe 0.3 (UltiCare Insulin Syr Half Tier 2 ml 31 gauge x 1/4" Unit) INSULIN SYRINGE MICROFINE Tier 2 SYRINGE 1 ML 27 GAUGE X 5/8", 1/2 ML 28 GAUGE X 1/2" insulin syringe needleless syringe 1 ml (BD Insulin Syringe Slip Tier 2 Tip) INSULIN SYRINGE SYRINGE 0.5 ML Tier 2 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" insulin syringe-needle u-100 syringe 0.3 (Ultilet Insulin Syringe) Tier 2 ml 29 gauge insulin syringe-needle u-100 syringe 0.3 (Advocate Syringes) Tier 2 ml 29 gauge x 1/2", 0.3 ml 30 gauge x 5/16", 0.3 ml 31 gauge x 5/16", 0.5 ml 29 gauge x 1/2", 0.5 ml 30 gauge x 5/16", 0.5 ml 31 gauge x 5/16", 1 ml 29 gauge x 1/2", 1 ml 30 gauge x 5/16, 1 ml 31 gauge x 5/16 insulin syringe-needle u-100 syringe 0.3 (Ultra Comfort Insulin Tier 2 ml 30 Syringe) insulin syringe-needle u-100 syringe 0.3 (BD Insulin Syringe Ultra- Tier 2 ml 30 gauge x 1/2", 0.5 ml 30 gauge x Fine) 1/2" insulin syringe-needle u-100 syringe 0.3 (Sure Comfort Insulin Tier 2 ml 31 gauge x 1/4", 1 ml 31 gauge x Syringe) 1/4", 1/2 ml 31 gauge x 1/4" insulin syringe-needle u-100 syringe 0.3 (BD Veo Insulin Syringe Tier 2 ml 31 gauge x 15/64", 1 ml 31 gauge x UF) 15/64", 1/2 ml 31 gauge x 15/64" insulin syringe-needle u-100 syringe 1 ml (BD Insulin Syringe) Tier 2 27 gauge x 1/2", 1 ml 28 gauge x 1/2" insulin syringe-needle u-100 syringe 1 ml (Lite Touch Insulin Tier 2 28 gauge, 1 ml 30 gauge x 7/16", 1/2 ml Syringe) 28 gauge, 1/2 ml 29 , 1/2 ml 30 gauge insulin syringe-needle u-100 syringe 1 ml Tier 2 29 gauge x 7/16" insulin syringe-needle u-100 syringe 1 ml (BD Eclipse Luer-Lok) Tier 2 30 gauge x 1/2" insulin syringe-needle u-100 syringe 1 ml (Thinpro Insulin Syringe) Tier 2 30 gauge x 3/8"

117 Drug Status Notes insulin syringe-needle u-100 syringe 1/2 (Easy Touch Insulin Tier 2 ml 27 gauge x 1/2" Syringe) insulin syringe-needle u-100 syringe 1/2 (BD Lo-Dose Micro-Fine Tier 2 ml 28 gauge x 1/2" IV) INTEGRA SYRINGE SYRINGE 3 ML 21 Tier 2 GAUGE X 1" INTERLINK SYRINGE AND CANNULA Tier 2 SYRINGE 15 X 10 ML IRRIGATION SYRINGE SYRINGE Tier 2 LIFESHIELD BLUNT CANNULA Tier 2 SYRINGE 1 ML 18 GAUGE X 1", 3 ML 18 X 1" LITE TOUCH INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE LUER LOCK SYRINGE SYRINGE 30 Tier 2 ML, 60 ML LUER SLIP TIP SYRINGE TRAY Tier 2 SYRINGE 1 ML LUER-LOK TIP SYRINGE 30 ML Tier 2 MAGELLAN INSULIN SAFETY SYRNG Tier 2 SYRINGE 0.3 ML 29 X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16" MAGELLAN SAFETY SYRINGE Tier 2 SYRINGE 1 ML 23 GAUGE X 1" MAGELLAN SYRINGE SYRINGE 0.3 Tier 2 ML 30 X 5/16", 0.5 ML 30 GAUGE X 5/16", 1 ML 27 GAUGE X 1/2" MAGELLAN TUBERCULIN SAFETY Tier 2 SYR SYRINGE 1 ML 28 GAUGE X 1/2" MAXICOMFORT INSULIN SYRINGE Tier 2 SYRINGE 1 ML 27 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2" MAXI-COMFORT INSULIN SYRINGE Tier 2 SYRINGE 1 ML 28 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2" MONOJECT 140CC PISTON SYRINGE Tier 2 SYRINGE MONOJECT 35CC SYRINGE CATH TIP Tier 2 SYRINGE 35 ML

118 Drug Status Notes MONOJECT 3CC SYR 25GX1" Tier 2 SYRINGE 3 ML 25 GAUGE X 1" MONOJECT ALLERGY TRAY DETACH Tier 2 TRAY 1 ML 27 X 1/2" MONOJECT ALLERGY TRAY TRAY 0.5 Tier 2 ML 28 X 1/2", 1 ML 28 X 1/2" MONOJECT CONTROL SYRINGE Tier 2 LUER SYRINGE 12 ML MONOJECT DISPOSABLE SYRINGE Tier 2 SYRINGE 20 ML MONOJECT ECCENTRIC NON- Tier 2 STERILE SYRINGE 12 ML, 35 ML MONOJECT ENFIT STERILE SYRINGE Tier 2 SYRINGE 1 ML, 3 ML, 35 ML, 6 ML, 60 ML MONOJECT ENFIT SYRINGE CAP Tier 2 MONOJECT ENFIT SYRINGE Tier 2 SYRINGE 1 ML, 12 ML, 3 ML, 35 ML, 6 ML, 60 ML MONOJECT INSULIN SAFETY SYRING Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 29 GAUGE X 1/2" MONOJECT INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML , 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" MONOJECT LUER-LOCK TIP Tier 2 SYRINGE 12 ML, 3 ML MONOJECT MAGELLAN SYRINGE Tier 2 SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 3 ML 20 GAUGE X 1" MONOJECT PHARMACY TRAY LUER Tier 2 SYRINGE 12 ML, 20 ML, 3 ML, 35 ML, 6 ML, 60 ML MONOJECT PHARMACY TRAY REG Tier 2 TIP SYRINGE 1 ML MONOJECT REG TIP NON-STERILE Tier 2 SYRINGE 12 ML, 20 ML, 3 ML, 6 ML MONOJECT REGULAR LUER Tier 2 SYRINGE 12 ML, 35 ML, 6 ML MONOJECT SAFETY LUER LOCK TIP Tier 2 SYRINGE 3 ML

119 Drug Status Notes MONOJECT SAFETY SYRINGES Tier 2 SYRINGE , 12 ML, 12 ML 20 X 1 1/2", 12 ML 21X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 6 ML MONOJECT SMARTIP CANNULA Tier 2 SYRINGE 12 ML, 3 ML, 6 ML MONOJECT SYRINGE ECCENTRI Tier 2 LUER SYRINGE 60 ML MONOJECT SYRINGE LUER LOK Tier 2 SYRINGE 35 ML, 6 ML, 60 ML MONOJECT SYRINGE REGULAR Tier 2 LUER SYRINGE 60 ML MONOJECT SYRINGE SYRINGE 1/2 Tier 2 ML 28 GAUGE, 12 ML 18 GAUGE X 1", 12 ML 20 X 1 1/2", 12 ML 21 GAUGE X 1 1/2", 12 ML 21 GAUGE X 1", 140 ML, 3 ML, 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 20 X 3/4", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 1 1/4", 3 ML 25 X 5/8", 3 ML 27 GAUGE X 1 1/4", 6 ML, 6 ML 20 X 1 1/2", 6 ML 21 X 1 1/2", 6 ML 21 X 1", 6 ML 22 X 1 1/2" MONOJECT SYRINGE TOOMEY TYPE Tier 2 SYRINGE 60 ML MONOJECT TB LUER LOK SYRINGE 1 Tier 2 ML MONOJECT TB REGULAR LUER TIP Tier 2 SYRINGE 1 ML MONOJECT TB SAFETY SYRINGE Tier 2 SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 28 GAUGE X 1/2" MONOJECT TB SYRINGE 1 ML 28 Tier 2 GAUGE X 1/2" MONOJECT TUBERCULIN SYRINGE Tier 2 SYRINGE 1 ML, 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML 27 X 1/2", 1 ML 28 GAUGE X 1/2", 1/2 ML 28 X 1/2" MONOJECT ULTRA COMFORT Tier 2 INSULIN SYRINGE 1/2 ML 28 GAUGE NORM-JECT SYRINGE 10 ML, 20 ML Tier 2 NORM-JECT TUBERKULIN SYRINGE 1 Tier 2 ML PISTON SYRINGE WITH ENFIT Tier 2 SYRINGE 60 ML

120 Drug Status Notes PRO COMFORT INSULIN SYRINGE Tier 2 SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 PRODIGY INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2" SAFESNAP INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" SAFESNAP SYRINGE SYRINGE 1 ML Tier 2 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 10 ML, 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 10 ML 21 GAUGE X 1", 10 ML 22 GAUGE X 1 1/2", 10 ML 22 GAUGE X 1", 3 ML, 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML, 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 GAUGE X 1" SURE COMFORT INS. SYR. U-100 Tier 2 SYRINGE 0.5 ML 29 GAUGE X 1/2" SURE COMFORT INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 1/4", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 31 GAUGE X 1/4"

121 Drug Status Notes SURE-JECT INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" SURGUARD2 SAFETY SYRINGE 1 ML Tier 2 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 1/2", 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2" syringe (disposable) syringe 20 ml (B-D Slip Tip Syringe) Tier 2 syringe (disposable) syringe 3 ml (BD Luer-Lok Syringe) Tier 2 syringe (disposable) syringe 30 ml (Exel Syringe) Tier 2 syringe (disposable) syringe 5 ml (BD Bulk Syringe Slip Tip) Tier 2 syringe (disposable) syringe 60 ml (Easy Glide Catheter Tip Tier 2 Syring) SYRINGE 3CC/20GX1" SYRINGE 3 ML Tier 2 20 GAUGE X 1" SYRINGE 3CC/21GX1" SYRINGE 3 ML Tier 2 21 GAUGE X 1" SYRINGE 3CC/21GX1-1/2" SYRINGE 3 Tier 2 ML 21 GAUGE X 1 1/2" SYRINGE 3CC/22GX1" SYRINGE 3 ML Tier 2 22 GAUGE X 1" SYRINGE 3CC/22GX3/4" SYRINGE 3 Tier 2 ML 22 GAUGE X 3/4" SYRINGE 3CC/25GX1" SYRINGE 3 ML Tier 2 25 GAUGE X 1" syringe with needle syringe 1 ml 25 (Easy Touch) Tier 2 gauge x 1" syringe with needle syringe 3 ml 20 (BD Luer-Lok Syringe) Tier 2 gauge x 1 1/2", 3 ml 22 x 1 1/2", 3 ml 23 gauge x 1 1/2" syringe with needle syringe 3 ml 21 (BD Integra Syringe) Tier 2 gauge x 1 1/2" syringe with needle, safety syringe 1 ml (BD Safety-Lok Tuberculin) Tier 2 25 gauge x 5/8" syringe with needle, safety syringe 3 ml (BD Safety-Lok Tier 2 22 gauge x 1" Detachable Needl)

122 Drug Status Notes SYRINGE WITHOUT NEEDLE Tier 2 SYRINGE TECHLITE INSULIN SYR HALF UNIT Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 5/16" TECHLITE INSULIN SYRINGE Tier 2 SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16 TERUMO ALLERGY SYRINGE Tier 2 SYRINGE 1 ML 27 X 1/2" TERUMO HYPODERMIC Tier 2 NEEDLE/SYRIN SYRINGE 5 ML 20 X 1 1/2", 5 ML 20 X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 X 1" TERUMO INSULIN SYRINGE SYRINGE Tier 2 0.3 ML 30 X 3/8", 0.5 ML 29 GAUGE X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8" TERUMO SYRINGE SYRINGE 3 ML 23 Tier 2 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8", 30 ML THINPRO INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 X 3/8", 0.3 ML 31 X 3/8", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 X 3/8", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 3/8", 1 ML 31 X 3/8", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8" TOOMEY SYRINGE SYRINGE 70 ML Tier 2 TOPCARE ULTRA COMFORT Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 TRUE COMFORT INSULIN SYRINGE Tier 2 SYRINGE 0.5 ML 31 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16

123 Drug Status Notes TRUEPLUS INSULIN SYRINGE 0.3 ML Tier 2 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" TUBERCULIN SYRINGE SYRINGE 1 Tier 2 ML, 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 1 ML 27 X 1/2" tuberculin-allergy syringes syringe 1 ml (Allergist Tray Intradermal Tier 2 26 gauge x 3/8" Bev) ULTICARE INSULIN SYR HALF UNIT Tier 2 SYRINGE 0.3 ML 31 GAUGE X 1/4" ULTICARE INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 1/4", 1/2 ML 31 GAUGE X 1/4" ULTICARE SAFETY SYRINGE Tier 2 SYRINGE 3 ML, 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8" ULTICARE SYRINGE 0.3 ML 30 Tier 2 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 25 GAUGE X 5/8", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16 ULTICARE TB SAFETY SYRINGE Tier 2 SYRINGE 1 ML 27 GAUGE X 1/2", 1 ML 27 GAUGE X 5/8", 1 ML 28 GAUGE X 1/2" ULTILET INSULIN SYRINGE SYRINGE Tier 2 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 29 ULTRA CMFT INS SYR HALF UNIT Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16"

124 Drug Status Notes ULTRA COMFORT INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30, 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE ULTRA FLO INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 29 GAUGE X 1/2" ULTRACARE INSULIN SYRINGE Tier 2 SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 ULTRA-THIN II (SHORT) INS SYR Tier 2 SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 ULTRA-THIN II INSULIN SYRINGE Tier 2 SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" VANISHPOINT INSULIN SYRINGE Tier 2 SYRINGE 1 ML 30 GAUGE X 3/16" VANISHPOINT SYRINGE SYRINGE 0.5 Tier 2 ML 30 GAUGE X 1/2", 1 ML 25 GAUGE X 1", 1 ML 29 GAUGE X 1/2", 10 ML 21 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2" VANISHPOINT TUBERCULIN Tier 2 SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 27 X 1/2" Miscellaneous Agents Anaphylaxis Therapy Agents epinephrine injection auto-injector 0.15 (EpiPen Jr) Tier 1 QL (2 EA per 7 days) mg/0.3 ml

125 Drug Status Notes epinephrine injection auto-injector 0.3 (Auvi-Q) Tier 1 QL (2 EA per 7 days) mg/0.3 ml Genetic D/O Tx-Exon Inclusion Antisense Oligonucle SPINRAZA (PF) INTRATHECAL Tier 2 SOLUTION 12 MG/5 ML Parasympathetic Agents bethanechol chloride oral tablet 10 mg, Tier 1 25 mg, 5 mg, 50 mg cevimeline oral capsule 30 mg (Evoxac) Tier 1 guanidine oral tablet 125 mg Tier 1 pilocarpine hcl oral tablet 5 mg, 7.5 mg (Salagen (pilocarpine)) Tier 1 Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase KUVAN ORAL TABLET,SOLUBLE 100 Tier 4 PA; SP MG Neoplastic Disease Alkylating Agents cyclophosphamide oral capsule 25 mg, Tier 4 SP 50 mg hydroxyurea oral capsule 500 mg (Hydrea) Tier 1 LEUKERAN ORAL TABLET 2 MG Tier 4 SP melphalan oral tablet 2 mg (Alkeran) Tier 4 MYLERAN ORAL TABLET 2 MG Tier 4 SP temozolomide oral capsule 100 mg, 20 (Temodar) Tier 4 PA; SP; QL (4 EA per 1 mg day) temozolomide oral capsule 140 mg, 5 (Temodar) Tier 4 PA; SP; QL (3 EA per 1 mg day) temozolomide oral capsule 180 mg, 250 (Temodar) Tier 4 PA; SP; QL (2 EA per 1 mg day) Antiandrogenic Agents bicalutamide oral tablet 50 mg (Casodex) Tier 1 flutamide oral capsule 125 mg Tier 1 nilutamide oral tablet 150 mg (Nilandron) Tier 1 XTANDI ORAL CAPSULE 40 MG Tier 4 PA; SP ZYTIGA ORAL TABLET 250 MG, 500 Tier 4 PA; SP MG Antimetabolites capecitabine oral tablet 150 mg, 500 mg (Xeloda) Tier 4 PA; SP mercaptopurine oral tablet 50 mg Tier 1 methotrexate sodium (pf) injection recon Tier 1 soln 1 gram methotrexate sodium (pf) injection Tier 1 solution 25 mg/ml methotrexate sodium injection solution Tier 1 25 mg/ml methotrexate sodium oral tablet 2.5 mg Tier 1 TABLOID ORAL TABLET 40 MG Tier 4 SP

126 Drug Status Notes TREXALL ORAL TABLET 10 MG, 15 Tier 4 MG, 5 MG, 7.5 MG Antineoplastic Aromatase Inhibitors anastrozole oral tablet 1 mg (Arimidex) Tier 1 QL (1 EA per 1 day) exemestane oral tablet 25 mg (Aromasin) Tier 1 letrozole oral tablet 2.5 mg (Femara) Tier 1 Antineoplastic - Braf Kinase Inhibitors TAFINLAR ORAL CAPSULE 50 MG, 75 Tier 4 PA; SP MG ZELBORAF ORAL TABLET 240 MG Tier 4 PA; SP Antineoplastic - Hedgehog Pathway Inhibitor ERIVEDGE ORAL CAPSULE 150 MG Tier 4 PA; SP Antineoplastic - Janus Kinase (Jak) Inhibitors JAKAFI ORAL TABLET 10 MG, 15 MG, Tier 4 PA; SP 20 MG, 25 MG, 5 MG Antineoplastic - Mek1 And Mek2 Kinase Inhibitors MEKINIST ORAL TABLET 0.5 MG, 2 Tier 4 PA; SP MG Antineoplastic - Mtor Kinase Inhibitors AFINITOR DISPERZ ORAL TABLET Tier 4 PA; SP FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 Tier 4 PA; SP MG, 5 MG, 7.5 MG Antineoplastic - Topoisomerase I Inhibitors HYCAMTIN ORAL CAPSULE 0.25 MG, Tier 4 SP 1 MG Antineoplastic Immunomodulator Agents POMALYST ORAL CAPSULE 1 MG, 2 Tier 4 PA; SP MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 Tier 4 PA; SP; QL (1 EA per 1 MG, 2.5 MG, 20 MG, 25 MG, 5 MG day) SYLATRON SUBCUTANEOUS KIT 200 Tier 4 PA; SP MCG, 300 MCG Antineoplastic Lhrh(Gnrh) Antagonist,Pituit.Supprs FIRMAGON KIT W DILUENT SYRINGE Tier 4 SP SUBCUTANEOUS RECON SOLN 120 MG, 80 MG FIRMAGON SUBCUTANEOUS RECON Tier 4 SP SOLN 120 MG Antineoplastic Systemic Enzyme Inhibitors BOSULIF ORAL TABLET 100 MG, 400 Tier 4 PA; SP MG, 500 MG

127 Drug Status Notes COMETRIQ ORAL CAPSULE 100 Tier 4 PA; SP MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) GILOTRIF ORAL TABLET 20 MG, 30 Tier 4 PA; SP; QL (1 EA per 1 MG, 40 MG day) IBRANCE ORAL CAPSULE 100 MG, Tier 4 PA; SP 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG, 45 MG Tier 4 PA; SP imatinib oral tablet 100 mg (Gleevec) Tier 4 PA; SP; QL (4 EA per 1 day) imatinib oral tablet 400 mg (Gleevec) Tier 4 PA; SP; QL (2 EA per 1 day) IMBRUVICA ORAL CAPSULE 140 MG, Tier 4 PA; SP 70 MG IMBRUVICA ORAL TABLET 140 MG, Tier 4 PA; SP 280 MG, 420 MG, 560 MG INLYTA ORAL TABLET 1 MG, 5 MG Tier 4 PA; SP NEXAVAR ORAL TABLET 200 MG Tier 4 PA; SP SPRYCEL ORAL TABLET 100 MG, 140 Tier 4 PA; SP; QL (1 EA per 1 MG, 80 MG day) SPRYCEL ORAL TABLET 20 MG Tier 4 PA; SP; QL (4 EA per 1 day) SPRYCEL ORAL TABLET 50 MG, 70 Tier 4 PA; SP; QL (2 EA per 1 MG day) STIVARGA ORAL TABLET 40 MG Tier 4 PA; SP SUTENT ORAL CAPSULE 12.5 MG, 25 Tier 4 PA; SP MG, 50 MG TARCEVA ORAL TABLET 100 MG, 150 Tier 4 PA; SP MG, 25 MG TASIGNA ORAL CAPSULE 150 MG, Tier 4 PA; SP 200 MG, 50 MG TYKERB ORAL TABLET 250 MG Tier 4 PA; SP VOTRIENT ORAL TABLET 200 MG Tier 4 PA; SP XALKORI ORAL CAPSULE 200 MG, Tier 4 PA; SP 250 MG ZYDELIG ORAL TABLET 100 MG, 150 Tier 4 PA; SP MG Antineoplastic,Histone Deacetylase Inhibitors,Hdis FARYDAK ORAL CAPSULE 10 MG, 15 Tier 4 PA; SP MG, 20 MG ZOLINZA ORAL CAPSULE 100 MG Tier 4 SP Antineoplastics,Miscellaneous etoposide oral capsule 50 mg Tier 4 LYSODREN ORAL TABLET 500 MG Tier 2 MATULANE ORAL CAPSULE 50 MG Tier 4 SP SYNRIBO SUBCUTANEOUS RECON Tier 4 PA; SP SOLN 3.5 MG

128 Drug Status Notes tretinoin (antineoplastic) oral capsule 10 Tier 4 PA; SP mg Chemotherapy Rescue/Antidote Agents leucovorin calcium oral tablet 10 mg, 15 Tier 1 mg, 25 mg, 5 mg MESNEX ORAL TABLET 400 MG Tier 4 VISTOGARD ORAL GRANULES IN Tier 3 PACKET 10 GRAM Selective Estrogen Receptor Modulators (Serm) FARESTON ORAL TABLET 60 MG Tier 4 SP SOLTAMOX ORAL SOLUTION 20 Tier 4 MG/10 ML tamoxifen oral tablet 10 mg $0 QL (2 EA per 1 day) tamoxifen oral tablet 20 mg $0 QL (1 EA per 1 day) Selective Retinoid X Receptor Agonists (Rxr) bexarotene oral capsule 75 mg (Targretin) Tier 4 PA; SP Steroid Antineoplastics EMCYT ORAL CAPSULE 140 MG Tier 4 SP megestrol oral tablet 20 mg, 40 mg Tier 1 Neurological Disease - Miscellaneous Agents To Treat Multiple Sclerosis AUBAGIO ORAL TABLET 14 MG, 7 MG Tier 4 PA; SP AVONEX INTRAMUSCULAR PEN Tier 4 PA; SP INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE Tier 4 PA; SP KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT Tier 4 PA; SP 0.3 MG BETASERON SUBCUTANEOUS Tier 4 PA; SP RECON SOLN 0.3 MG EXTAVIA SUBCUTANEOUS KIT 0.3 Tier 4 PA; SP MG EXTAVIA SUBCUTANEOUS RECON Tier 4 PA; SP SOLN 0.3 MG GILENYA ORAL CAPSULE 0.25 MG, Tier 4 PA; SP 0.5 MG glatiramer subcutaneous syringe 20 (Glatopa) Tier 4 PA; SP mg/ml, 40 mg/ml GLATOPA SUBCUTANEOUS SYRINGE Tier 4 PA; SP 20 MG/ML, 40 MG/ML PLEGRIDY SUBCUTANEOUS PEN Tier 4 PA; SP INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS Tier 4 PA; SP SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

129 Drug Status Notes REBIF (WITH ALBUMIN) Tier 4 PA; SP SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS Tier 4 PA; SP PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK Tier 4 PA; SP SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) TECFIDERA ORAL Tier 4 PA; SP CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG Agts Tx Neuromusc Transmission Dis,Pot-Chan Blkr AMPYRA ORAL TABLET EXTENDED Tier 4 PA; SP RELEASE 12 HR 10 MG dalfampridine oral tablet extended (Ampyra) Tier 4 PA; SP release 12 hr 10 mg Amyotrophic Lateral Sclerosis Agents riluzole oral tablet 50 mg (Rilutek) Tier 1 QL (2 EA per 1 day) Fibromyalgia Agents,Serotonin- Norepineph Ru Inhib SAVELLA ORAL TABLET 100 MG, 12.5 Tier 3 QL (2 EA per 1 day) MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE Tier 3 PACK 12.5 MG (5)-25 MG(8)-50 MG(42) Movement Disorders(Drug Therapy) HORIZANT ORAL TABLET EXTENDED Tier 3 RELEASE 600 MG tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) Tier 4 PA; SP Postherpetic Neuralgia Agents GRALISE ORAL TABLET EXTENDED Tier 3 PA RELEASE 24 HR 300 MG, 600 MG Pseudobulbar Affect (Pba) Agents, Nmda Antagonists NUEDEXTA ORAL CAPSULE 20-10 MG Tier 4 PA Oral/Pharyngeal Disorders Dental Aids And Preparations chlorhexidine gluconate mucous (Paroex Oral Rinse) Tier 1 membrane mouthwash 0.12 % ORALONE DENTAL PASTE 0.1 % Tier 1 QL (5 GM per 15 days) PAROEX ORAL RINSE MUCOUS Tier 1 MEMBRANE MOUTHWASH 0.12 % PERIOGARD MUCOUS MEMBRANE Tier 1 MOUTHWASH 0.12 % triamcinolone acetonide dental paste 0.1 (Oralone) Tier 1 QL (5 GM per 15 days) %

130 Drug Status Notes Nose Preparations, Miscellaneous (Rx) ipratropium bromide nasal spray,non- Tier 1 QL (30 ML per 30 days) aerosol 0.03 % ipratropium bromide nasal spray,non- Tier 1 aerosol 42 mcg (0.06 %) Periodontal Collagenase Inhibitors doxycycline hyclate oral tablet 20 mg Tier 1 Other Drugs Abortifacient,Progesterone Receptor Antagonist-Typ MIFEPREX ORAL TABLET 200 MG Tier 3 Agents For Stomatological Use DEBACTEROL MUCOUS MEMBRANE Tier 3 SOLUTION 30-50 % DEBACTEROL MUCOUS MEMBRANE Tier 3 SWAB 30-50 % Appetite Stim. For Anorexia,Cachexia,Wasting Synd. megestrol oral suspension 400 mg/10 ml Tier 1 (10 ml), 400 mg/10 ml (40 mg/ml) megestrol oral suspension 625 mg/5 ml Tier 3 (125 mg/ml) Condoms AIMSCO LATEX CONDOM DEVICE $0 CONDOMS-PREM LUBRICATED $0 DEVICE DUREX AVANTI BARE REAL FEEL $0 FANTASY CONDOM DEVICE $0 FC2 FEMALE CONDOM $0 KIMONO CONDOMS(NON- $0 LUBRICATED) DEVICE KIMONO MAXX CONDOMS DEVICE $0 KIMONO MICROTHIN AQUA LUBE $0 CON DEVICE KIMONO MICROTHIN CONDOMS $0 DEVICE KIMONO MICROTHIN LARGE $0 CONDOMS DEVICE KIMONO TEXTURED CONDOMS $0 DEVICE TRUSTEX LATEX CONDOM DEVICE $0 TRUSTEX LUBRICATED CONDOMS $0 DEVICE TRUSTEX NON-LUB CONDOMS $0 DEVICE TRUSTEX-RIA LUB/SPERMICIDE $0 DEVICE TRUSTEX-RIA LUBRICATED $0 CONDOMS DEVICE

131 Drug Status Notes TRUSTEX-RIA NON-LUB CONDOMS $0 DEVICE Drugs To Treat Hereditary Tyrosinemia ORFADIN ORAL CAPSULE 10 MG, 2 Tier 4 PA; SP MG, 5 MG Drugs To Tx Gaucher Dx-Type 1, Substrate Reducing miglustat oral capsule 100 mg (Zavesca) Tier 4 PA; SP ZAVESCA ORAL CAPSULE 100 MG Tier 4 PA; SP General Inhalation Agents NEBUSAL INHALATION SOLUTION Tier 3 FOR NEBULIZATION 6 % sodium chloride inhalation solution for Tier 1 nebulization 0.9 %, 10 % sodium chloride inhalation solution for (Pulmosal) Tier 1 nebulization 7 % Metabolic Deficiency Agents levocarnitine (with sugar) oral solution (Carnitor) Tier 1 100 mg/ml levocarnitine oral tablet 330 mg (Carnitor) Tier 1 Metallic Poison,Agents To Treat CHEMET ORAL CAPSULE 100 MG Tier 2 CLOVIQUE ORAL CAPSULE 250 MG Tier 1 EXJADE ORAL TABLET, DISPERSIBLE Tier 4 PA; SP 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 Tier 4 PA; SP MG/ML FERRIPROX ORAL TABLET 500 MG Tier 4 PA; SP GALZIN ORAL CAPSULE 25 MG Tier 3 (ZINC), 50 MG (ZINC) SYPRINE ORAL CAPSULE 250 MG Tier 3 trientine oral capsule 250 mg (Clovique) Tier 1 Needles/Needleless Devices 1ST TIER UNIFINE PENTIPS NEEDLE Tier 2 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" 1ST TIER UNIFINE PENTIPS PLUS Tier 2 NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" ABOUTTIME PEN NEEDLE NEEDLE 30 Tier 2 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" ADVOCATE PEN NEEDLE NEEDLE 29 Tier 2 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 33 GAUGE X 5/32" ASSURE ID PEN NEEDLE NEEDLE 30 Tier 2 GAUGE X 3/16", 30 GAUGE X 5/16", 31 GAUGE X 3/16"

132 Drug Status Notes BD AUTOSHIELD DUO PEN NEEDLE Tier 2 NEEDLE 30 GAUGE X 3/16" BD ECLIPSE LUER-LOK NEEDLE 21 Tier 2 GAUGE X 1 1/2", 22 GAUGE X 1", 25 GAUGE X 1 1/2", 30 X 1/2 " BD ECLIPSE NEEDLE 21 GAUGE X 1", Tier 2 25 GAUGE X 1" BD FILTER NEEDLE 5-MICRON NOKO Tier 2 NEEDLE 18 GAUGE X 1 1/2" BD FILTER NEEDLE-5 MICRON Tier 2 NEEDLE 19 X 1 1/2 " BD INTEGRA NEEDLE NEEDLE 23 Tier 2 GAUGE X 1" BD INTRADERMAL BEVEL NEEDLES Tier 2 NEEDLE 26 GAUGE X 3/8" BD NANO 2ND GEN PEN NEEDLE Tier 2 NEEDLE 32 GAUGE X 5/32" BD NOKOR ADMIX NEEDLE NEEDLE Tier 2 18 GAUGE X 1 1/2" BD PRECISIONGLIDE NEEDLE 25 Tier 2 GAUGE X 1", 27 GAUGE X 1 1/2" BD PRECISIONGLIDE NON-STERILE Tier 2 NEEDLE 18 GAUGE X 1 1/2", 19 GAUGE X 1 1/2", 20 GAUGE X 1 1/2", 21 GAUGE X 1 1/2", 22 GAUGE X 1 1/2", 23 GAUGE X 1", 25 GAUGE X 1", 25 GAUGE X 5/8" BD REGULAR BEVEL NEEDLES Tier 2 NEEDLE 18 GAUGE X 1 1/2", 18 GAUGE X 1", 19 GAUGE X 1 1/2", 19 GAUGE X 1", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 GAUGE X 3/4", 25 GAUGE X 1 1/2", 25 GAUGE X 5/8", 26 GAUGE X 1/2", 27 GAUGE X 1/2" BD SAFETYGLIDE NEEDLE NEEDLE Tier 2 18 GAUGE X 1 1/2", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 23 GAUGE X 1", 25 GAUGE X 1", 25 X 5/8 ", 27 X 5/8 " BD SHORT BEVEL NEEDLES NEEDLE Tier 2 18 GAUGE X 1 1/2", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 22 GAUGE X 1 1/2" BD SHORT BEVEL THIN WALL Tier 2 NEEDLE 19 GAUGE X 1 1/2", 19 GAUGE X 1"

133 Drug Status Notes BD SPECIALTY USE NEEDLES Tier 2 NEEDLE 16 GAUGE X 1 1/2", 16 GAUGE X 1", 21 GAUGE X 2", 23 GAUGE X 1 1/4", 25 GAUGE X 7/8", 27 GAUGE X 1 1/4", 30 GAUGE X 1", 30 GAUGE X 1/2" BD ULTRA-FINE MICRO PEN NEEDLE Tier 2 NEEDLE 32 GAUGE X 1/4" BD ULTRA-FINE MINI PEN NEEDLE Tier 2 NEEDLE 31 GAUGE X 3/16" BD ULTRA-FINE NANO PEN NEEDLE Tier 2 NEEDLE 32 GAUGE X 5/32" BD ULTRA-FINE ORIG PEN NEEDLE Tier 2 NEEDLE 29 GAUGE X 1/2" BD ULTRA-FINE SHORT PEN NEEDLE Tier 2 NEEDLE 31 GAUGE X 5/16" blunt needle, disposable needle 18 x 1 Tier 2 1/2 ", 22 x 1 1/2 ", 23 x 1 " CAREFINE PEN NEEDLE NEEDLE 29 Tier 2 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32" CARETOUCH PEN NEEDLE NEEDLE Tier 2 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32" CLICKFINE PEN NEEDLE NEEDLE 31 Tier 2 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 5/32" COMFORT EZ PEN NEEDLES NEEDLE Tier 2 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/16", 33 GAUGE X 5/32" DISPOSABLE NEEDLES NEEDLE 22 Tier 2 GAUGE X 3/4" DROPLET MICRON PEN NEEDLE Tier 2 NEEDLE 34 GAUGE X 9/64" DROPLET PEN NEEDLE NEEDLE 29 Tier 2 GAUGE X 1/2", 29 GAUGE X 3/8", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32" DROPSAFE PEN NEEDLE NEEDLE 31 Tier 2 GAUGE X 1/4", 31 GAUGE X 5/16"

134 Drug Status Notes EASY COMFORT PEN NEEDLES Tier 2 NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/32" EASY GLIDE PEN NEEDLE NEEDLE Tier 2 33 GAUGE X 5/32" EASY TOUCH FLIPLOCK NEEDLE Tier 2 NEEDLE 18 GAUGE X 1 1/2", 18 GAUGE X 1", 19 GAUGE X 1 1/2", 19 GAUGE X 1", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 22 GAUGE X 3/4", 23 GAUGE X 1 1/2", 23 GAUGE X 1", 23 GAUGE X 5/8", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 X 5/8 ", 26 GAUGE X 1", 26 GAUGE X 1/2", 27 GAUGE X 1", 27 GAUGE X 1/2", 28 GAUGE X 1/2", 29 GAUGE X 1/2", 30 GAUGE X 5/16", 30 X 1/2 ", 31 GAUGE X 5/16" EASY TOUCH HYPODERMIC NEEDLE Tier 2 NEEDLE 16 GAUGE X 1 1/2", 16 GAUGE X 1", 18 GAUGE X 1 1/2", 18 GAUGE X 1 1/4", 18 GAUGE X 1", 19 GAUGE X 1 1/2", 19 GAUGE X 1", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 GAUGE X 1 1/2", 23 GAUGE X 1 1/4", 23 GAUGE X 1", 23 GAUGE X 3/4", 24 GAUGE X 1 1/4", 24 GAUGE X 1", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 GAUGE X 5/8", 26 GAUGE X 1/2", 26 GAUGE X 3/8", 26 GAUGE X 5/8", 27 GAUGE X 1 1/2", 27 GAUGE X 1 1/4", 27 GAUGE X 1/2", 30 GAUGE X 1", 30 GAUGE X 1/2", 31 GAUGE X 5/16", 32 GAUGE X 5/16" EASY TOUCH NEEDLE 29 GAUGE X Tier 2 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32" EASY TOUCH PEN NEEDLE NEEDLE Tier 2 30 GAUGE X 5/16" EASY TOUCH SAFETY PEN NEEDLE Tier 2 NEEDLE 29 GAUGE X 3/16", 30 GAUGE X 3/16"

135 Drug Status Notes EASYPOINT NEEDLE NEEDLE 18 Tier 2 GAUGE X 1 1/2", 18 GAUGE X 1", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 25 GAUGE X 1 1/2" ECLIPSE NEEDLE NEEDLE 23 GAUGE Tier 2 X 1", 25 X 5/8 ", 27 GAUGE X 1/2" EXEL HYPODERMIC NEEDLES Tier 2 NEEDLE 18 GAUGE X 1 1/2", 19 GAUGE X 1", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 20 X 3/4 ", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 21 GAUGE X 2", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 22 GAUGE X 3/4", 23 GAUGE X 1 1/2", 23 GAUGE X 3/4", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 GAUGE X 3/4", 25 GAUGE X 5/8", 26 GAUGE X 1 1/2", 26 GAUGE X 1/2", 26 GAUGE X 3/8", 26 GAUGE X 5/8", 27 GAUGE X 1/2", 30 GAUGE X 1/2" filter needles needle 18 gauge x 1 1/2" (BD Filter Needle 5-Micron Tier 2 Noko) filter needles needle 19 x 1 " Tier 2 filter needles needle 19 x 1 1/2 " (BD Filter Needle-5 Tier 2 Micron) FLOW-EZE VENTED NEEDLE NEEDLE Tier 2 HEALTHWISE PEN NEEDLE NEEDLE Tier 2 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" HEALTHY ACCENTS UNIFINE PENTIP Tier 2 NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" huber safety needles (disp.) needle 22 x Tier 2 3/4 " HYPODERMIC NEEDLES NEEDLE 18 Tier 2 GAUGE X 1 1/2", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 23 GAUGE X 1 1/2", 23 GAUGE X 1", 26 GAUGE X 5/8" INCONTROL PEN NEEDLE NEEDLE 29 Tier 2 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" INSUPEN NEEDLE 29 GAUGE X 1/2", Tier 2 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32" INTEGRA PRECISIONGLIDE NEEDLE Tier 2 NEEDLE 25 X 5/8 "

136 Drug Status Notes LIFESHIELD BLUNT CANNULA Tier 2 NEEDLE 18 GAUGE X 1" LITE TOUCH INSULIN PEN NEEDLES Tier 2 NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16" MAGELLAN SAFETY NEEDLE NEEDLE Tier 2 23 GAUGE X 5/8" MAXICOMFORT II PEN NEEDLE Tier 2 NEEDLE 31 GAUGE X 1/4" MAXICOMFORT SAFETY PEN Tier 2 NEEDLE NEEDLE 29 GAUGE X 3/16", 29 GAUGE X 5/16" MICRODOT INSULIN PEN NEEDLE Tier 2 NEEDLE 31 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32" MINI ULTRA-THIN II NEEDLE 31 Tier 2 GAUGE X 3/16" MONOJECT BLOOD COLLECTION Tier 2 NEEDLE 20 GAUGE X 1", 20 X 1 1/2 ", 21 GAUGE X 1", 22 GAUGE X 1" MONOJECT FILTER ASPIRATOR Tier 2 NEEDLE 18 X 3 " MONOJECT FILTER NEEDLE NEEDLE Tier 2 5 MICRON 20 X 1 1/2" MONOJECT HYPODERMIC NEEDLES Tier 2 NEEDLE 14 GAUGE X 1 1/2", 14 GAUGE X 1", 14 GAUGE X 2", 15 GAUGE X 1 1/2", 16 GAUGE X 1 1/2", 16 GAUGE X 1", 16 GAUGE X 3/4", 16 GAUGE X 5/8", 18 GAUGE X 1 1/2", 18 GAUGE X 1", 19 GAUGE X 1 1/2", 19 GAUGE X 1", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 21 GAUGE X 2", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 GAUGE X 1", 25 GAUGE X 1 1/2", 25 GAUGE X 1 1/4", 25 GAUGE X 1", 25 GAUGE X 5/8", 25 X 2 ", 26 GAUGE X 1 1/2", 27 GAUGE X 1 1/2", 27 GAUGE X 1 1/4", 27 GAUGE X 1/2", 30 GAUGE X 3/4"

137 Drug Status Notes MONOJECT HYPODERMIC Tier 2 POLYPROPYL NEEDLE 18 GAUGE X 1 1/2", 18 GAUGE X 1", 19 GAUGE X 1 1/2", 19 GAUGE X 1", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 GAUGE X 1", 23 GAUGE X 3/4", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 GAUGE X 5/8", 26 GAUGE X 1/2", 27 GAUGE X 1/2", 30 GAUGE X 3/4" MONOJECT MEDICATION TRANSF Tier 2 NDL NEEDLE 20 X 1 " MULTI-DRAW NEEDLE NEEDLE 20 Tier 2 GAUGE X 1", 21 GAUGE X 1", 22 GAUGE X 1" needle (disp) 16 g needle 16 gauge x 1" (BD Specialty Use Tier 2 Needles) needle (disp) 18 g needle 18 gauge x 1" (BD Regular Bevel Tier 2 Needles) needle (disp) 19 g needle 19 gauge x 1 (BD PrecisionGlide Non- Tier 2 1/2" Sterile) needle (disp) 23 gauge needle 23 gauge (BD Integra Needle) Tier 2 x 1" needles, huber disposable needle 22 x 1 Tier 2 " NOKOR NEEDLE NEEDLE 16 GAUGE Tier 2 X 1", 18 GAUGE X 1" NOVOFINE 32 NEEDLE 32 GAUGE X Tier 2 1/4" NOVOFINE AUTOCOVER NEEDLE 30 Tier 2 GAUGE X 1/3" NOVOFINE PLUS NEEDLE 32 GAUGE Tier 2 X 1/6" NOVOTWIST NEEDLE 32 GAUGE X Tier 2 1/5" PEN NEEDLE NEEDLE 29 GAUGE X Tier 2 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" pen needle, diabetic needle 29 gauge x (1st Tier Unifine Pentips) Tier 2 1/2", 31 gauge x 1/4", 31 gauge x 3/16", 31 gauge x 5/16", 32 gauge x 5/32" pen needle, diabetic needle 30 gauge x (AboutTime Pen Needle) Tier 2 5/16" pen needle, diabetic needle 31 gauge x Tier 2 1/3", 31 gauge x 1/6" pen needle, diabetic needle 32 gauge x (BD Ultra-Fine Micro Pen Tier 2 1/4" Needle) pen needle, diabetic needle 32 gauge x (CareFine Pen Needle) Tier 2 3/16"

138 Drug Status Notes pen needle, diabetic needle 33 gauge x (Advocate Pen Needle) Tier 2 5/32" PENTIPS NEEDLE 29 GAUGE X 1/2", Tier 2 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" PHASEAL PROTECTOR DEVICE 13 Tier 2 MM, 20 MM, 28 MM POLY HUB NEEDLE NEEDLE 18 Tier 2 GAUGE X 1 1/2", 18 GAUGE X 1", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 GAUGE X 1 1/2", 23 GAUGE X 1", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 GAUGE X 5/8", 27 GAUGE X 1 1/4", 27 GAUGE X 1/2", 30 GAUGE X 1/2" PREVENT DROPSAFE PEN NEEDLE Tier 2 NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16" PRO COMFORT PEN NEEDLE Tier 2 NEEDLE 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32" PURE COMFORT PEN NEEDLE Tier 2 NEEDLE 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32" RELION NEEDLES NEEDLE 31 Tier 2 GAUGE X 1/4" RELION PEN NEEDLES NEEDLE 32 Tier 2 GAUGE X 5/32" safety needles needle 18 gauge x 1 1/2" (BD SafetyGlide Needle) Tier 2 SAFETY PEN NEEDLE NEEDLE 31 Tier 2 GAUGE X 3/16" SURE COMFORT PEN NEEDLE Tier 2 NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32" SURE-FINE PEN NEEDLES NEEDLE Tier 2 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16" SURGUARD2 SAFETY NEEDLE 18 Tier 2 GAUGE X 1 1/2", 18 GAUGE X 1", 19 GAUGE X 1 1/2", 19 GAUGE X 1", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 GAUGE X 1 1/2", 23 GAUGE X 1", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 X 5/8 ", 26 GAUGE X 1/2", 27 GAUGE X 1/2", 30 GAUGE X 1 1/2"

139 Drug Status Notes TECHLITE PEN NEEDLE NEEDLE 29 Tier 2 GAUGE X 1/2", 29 GAUGE X 3/8", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32" TOPCARE CLICKFINE NEEDLE 31 Tier 2 GAUGE X 1/4", 31 GAUGE X 5/16" TRUE COMFORT PEN NEEDLE Tier 2 NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 5/32" TRUEPLUS PEN NEEDLE NEEDLE 29 Tier 2 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" ULTICARE PEN NEEDLE NEEDLE 29 Tier 2 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32" ULTIGUARD SAFE PACK NEEDLE 31 Tier 2 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32" ULTILET PEN NEEDLE NEEDLE 29 Tier 2 GAUGE, 32 GAUGE X 5/32" ULTRA FLO PEN NEEDLE NEEDLE 29 Tier 2 GAUGE X 1/2", 31 GAUGE X 3/16" ULTRA THIN PEN NEEDLE NEEDLE 32 Tier 2 GAUGE X 5/32" ULTRACARE PEN NEEDLE NEEDLE Tier 2 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32" ULTRA-THIN II (SHORT) PEN NDL Tier 2 NEEDLE 31 GAUGE X 5/16" ULTRA-THIN II INS PEN NEEDLES Tier 2 NEEDLE 29 GAUGE X 1/2" UNIFINE PENTIPS MAXFLOW NEEDLE Tier 2 30 GAUGE X 3/16" UNIFINE PENTIPS NEEDLE 29 Tier 2 GAUGE, 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32" UNIFINE PENTIPS PLUS MAXFLOW Tier 2 NEEDLE 30 GAUGE X 3/16" UNIFINE PENTIPS PLUS NEEDLE 29 Tier 2 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32"

140 Drug Status Notes VERIFINE PEN NEEDLE NEEDLE 31 Tier 2 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32" YALE DISPOSABLE NEEDLES Tier 2 NEEDLE 21 GAUGE X 1 1/4" Oral Mucositis/Stomatitis Agents GELCLAIR MUCOUS MEMBRANE GEL Tier 3 IN PACKET Oral Mucositis/Stomatitis Anti- Inflammatory Agent EPISIL MUCOUS MEMBRANE GEL Tier 3 FORMING SOLUTION Saliva Substitute Agents AQUORAL MUCOUS MEMBRANE Tier 3 AEROSOL,SPRAY XEROSTOMIA RELIEF MUCOUS Tier 3 MEMBRANE AEROSOL,SPRAY Somatostatic Agents SIGNIFOR SUBCUTANEOUS Tier 3 SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) Urine Acetone Test Aids KETONE CARE STRIP Tier 2 KETONE URINE TEST STRIP Tier 2 KETOSTIX STRIP Tier 2 TRUEPLUS KETONE STRIP Tier 2 Vaccine Adjuvants SHINGRIX ADJUVANT COMPONENT- $0 QL (2 ML per 1 LIFETIME); PF INTRAMUSCULAR SUSPENSION Age (Min 50 Years) Other Respiratory Disorders Antifibrotic Therapy - Pyridone Analogs ESBRIET ORAL CAPSULE 267 MG Tier 4 SP ESBRIET ORAL TABLET 267 MG, 801 Tier 4 SP MG Cystic Fib.Transmemb Conduct.Reg.(Cftr)Potentiator KALYDECO ORAL TABLET 150 MG Tier 4 PA; SP Lung Surfactants CUROSURF INTRATRACHEAL Tier 3 SUSPENSION 120 MG/1.5 ML, 240 MG/3 ML INFASURF INTRATRACHEAL Tier 4 SUSPENSION 35 MG/ML SURFAXIN INTRATRACHEAL Tier 4 SUSPENSION 34 MG/ML SURVANTA INTRATRACHEAL Tier 4 SUSPENSION 25 MG/ML Mucolytics acetylcysteine solution 100 mg/ml (10 Tier 1 %), 200 mg/ml (20 %)

141 Drug Status Notes PULMOZYME INHALATION SOLUTION Tier 4 PA; SP 1 MG/ML Pulmonary Fibrosis - Systemic Enzyme Inhibitors OFEV ORAL CAPSULE 100 MG, 150 Tier 4 SP MG Pain Management - Analgesics Analgesic, Non-Salicylate & Barbiturate Comb. butalbital-acetaminophen oral tablet 50- (Tencon) Tier 1 QL (4 EA per 1 day) 325 mg TENCON ORAL TABLET 50-325 MG Tier 1 QL (4 EA per 1 day) Analgesic, Salicylate, Barbiturate,& Xanthine Cmb butalbital-aspirin-caffeine oral capsule (Fiorinal) Tier 1 QL (4 EA per 1 day) 50-325-40 mg Analgesic,Non- Salicylate,Barbiturate,&Xanthine Cmb butalbital-acetaminophen-caff oral (Fioricet) Tier 1 QL (2 EA per 1 day) capsule 50-300-40 mg butalbital-acetaminophen-caff oral (Zebutal) Tier 1 QL (2 EA per 1 day) capsule 50-325-40 mg butalbital-acetaminophen-caff oral tablet (Esgic) Tier 1 QL (2 EA per 1 day) 50-325-40 mg FIORICET ORAL CAPSULE 50-300-40 Tier 1 QL (2 EA per 1 day) MG ZEBUTAL ORAL CAPSULE 50-325-40 Tier 1 QL (2 EA per 1 day) MG Analgesic/Antipyretics, Salicylates aspirin oral tablet 325 mg (Bayer Aspirin) $0 QL (1 EA per 1 day) aspirin oral tablet,delayed release (dr/ec) (Aspir-Trin) $0 QL (1 EA per 1 day) 325 mg aspirin oral tablet,delayed release (dr/ec) $0 500 mg, 650 mg aspirin,buffd-calcium carb-mag oral (Buffered Aspirin) $0 QL (1 EA per 1 day) tablet 325 mg ASPIR-TRIN ORAL TABLET,DELAYED $0 QL (1 EA per 1 day) RELEASE (DR/EC) 325 MG BAYER ASPIRIN ORAL TABLET 325 $0 QL (1 EA per 1 day) MG BUFFERED ASPIRIN ORAL TABLET $0 QL (1 EA per 1 day) 325 MG BUFFERIN ORAL TABLET 325 MG $0 QL (1 EA per 1 day) choline,magnesium salicylate oral liquid Tier 1 500 mg/5 ml diflunisal oral tablet 500 mg Tier 1 E.C. PRIN ORAL TABLET,DELAYED $0 QL (1 EA per 1 day) RELEASE (DR/EC) 325 MG ECOTRIN ORAL TABLET,DELAYED $0 QL (1 EA per 1 day) RELEASE (DR/EC) 325 MG

142 Drug Status Notes LITE COAT ASPIRIN ORAL TABLET $0 QL (1 EA per 1 day) 325 MG salsalate oral tablet 500 mg, 750 mg (Disalcid) Tier 1 TRI-BUFFERED ASPIRIN ORAL $0 QL (1 EA per 1 day) TABLET 325 MG Analgesics, Narcotic Agonist And Nsaid Combination hydrocodone-ibuprofen oral tablet 10- (Ibudone) Tier 1 QL (4 EA per 1 day) 200 mg hydrocodone-ibuprofen oral tablet 5-200 Tier 1 QL (4 EA per 1 day) mg, 7.5-200 mg ibuprofen-oxycodone oral tablet 400-5 Tier 1 QL (3 EA per 1 day) mg XYLON 10 ORAL TABLET 10-200 MG Tier 1 QL (4 EA per 1 day) Analgesics,Narcotics belladonna alkaloids-opium rectal Tier 1 QL (3 EA per 1 day) suppository 16.2-30 mg, 16.2-60 mg buprenorphine transdermal patch weekly (Butrans) Tier 3 QL (4 EA per 28 days) 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butorphanol nasal spray,non-aerosol 10 Tier 1 QL (5 ML per 30 days) mg/ml codeine sulfate oral tablet 15 mg, 30 mg, Tier 1 QL (4 EA per 1 day); Age 60 mg (Min 12 Years) fentanyl citrate buccal lozenge on a (Actiq) Tier 1 PA handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 (Duragesic) Tier 1 QL (10 EA per 30 days) mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, Tier 3 PA EFFERVESCENT 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG hydromorphone oral liquid 1 mg/ml (Dilaudid) Tier 1 QL (240 ML per 10 days) hydromorphone oral tablet 2 mg, 4 mg, 8 (Dilaudid) Tier 1 QL (4 EA per 1 day) mg hydromorphone oral tablet extended Tier 3 PA; QL (3 EA per 1 day) release 24 hr 12 mg, 16 mg, 32 mg, 8 mg hydromorphone rectal suppository 3 mg Tier 1 KADIAN ORAL Tier 3 PA; QL (3 EA per 1 day) CAPSULE,EXTEND.RELEASE PELLETS 200 MG LAZANDA NASAL SPRAY,NON- Tier 3 PA AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY levorphanol tartrate oral tablet 2 mg Tier 1 QL (3 EA per 1 day) meperidine oral solution 50 mg/5 ml Tier 1 QL (240 ML per 10 days) meperidine oral tablet 100 mg (Demerol) Tier 1 QL (4 EA per 1 day) meperidine oral tablet 50 mg Tier 1 QL (4 EA per 1 day)

143 Drug Status Notes METHADONE INTENSOL ORAL Tier 1 CONCENTRATE 10 MG/ML methadone oral concentrate 10 mg/ml (Methadone Intensol) Tier 1 methadone oral solution 10 mg/5 ml, 5 Tier 1 QL (3 ML per 1 day) mg/5 ml methadone oral tablet 10 mg (Dolophine) Tier 1 QL (6 EA per 1 day) methadone oral tablet 5 mg (Dolophine) Tier 1 QL (12 EA per 1 day) methadone oral tablet,soluble 40 mg (Methadose) Tier 1 QL (4 EA per 1 day) METHADOSE ORAL Tier 1 QL (4 EA per 1 day) TABLET,SOLUBLE 40 MG morphine concentrate oral solution 100 Tier 1 QL (3 ML per 1 day) mg/5 ml (20 mg/ml) morphine oral capsule, er multiphase 24 Tier 1 PA; QL (2 EA per 1 day) hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.release (Kadian) Tier 1 PA; QL (3 EA per 1 day) pellets 10 mg, 100 mg, 20 mg, 50 mg, 80 mg morphine oral capsule,extend.release (Kadian) Tier 1 PA; QL (2 EA per 1 day) pellets 30 mg, 60 mg morphine oral solution 10 mg/5 ml Tier 1 QL (3 ML per 1 day) morphine oral solution 20 mg/5 ml (4 Tier 1 mg/ml) morphine oral tablet 15 mg, 30 mg Tier 1 QL (3 EA per 1 day) morphine oral tablet extended release (MS Contin) Tier 1 QL (3 EA per 1 day) 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release (MS Contin) Tier 1 PA; QL (3 EA per 1 day) 200 mg morphine rectal suppository 10 mg, 20 Tier 1 mg, 30 mg, 5 mg NUCYNTA ER ORAL TABLET Tier 3 PA; QL (3 EA per 1 day) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 Tier 3 QL (4 EA per 1 day) MG, 75 MG oxycodone oral capsule 5 mg Tier 1 QL (4 EA per 1 day) oxycodone oral concentrate 20 mg/ml Tier 1 QL (240 ML per 10 days) oxycodone oral solution 5 mg/5 ml Tier 1 QL (240 ML per 10 days) oxycodone oral tablet 10 mg, 20 mg Tier 1 QL (4 EA per 1 day) oxycodone oral tablet 15 mg, 30 mg, 5 (Roxicodone) Tier 1 QL (4 EA per 1 day) mg oxycodone oral tablet,oral only,ext.rel.12 (OxyContin) Tier 3 QL (2 EA per 1 day) hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg oxymorphone oral tablet 10 mg, 5 mg Tier 1 QL (4 EA per 1 day) oxymorphone oral tablet extended Tier 1 PA; QL (3 EA per 1 day) release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg pentazocine-naloxone oral tablet 50-0.5 Tier 1 QL (4 EA per 1 day) mg

144 Drug Status Notes SUBSYS SUBLINGUAL SPRAY,NON- Tier 3 PA; QL (4 EA per 1 day) AEROSOL 1,200 MCG (600 MCG/SPRAY X 2), 1,600 MCG (800 MCG/SPRAY X 2), 100 MCG/SPRAY, 200 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY tramadol oral capsule,er biphase 24 hr Tier 1 QL (1 EA per 1 day); Age 25-75 150 mg (Min 12 Years) tramadol oral tablet 50 mg (Ultram) Tier 1 QL (240 EA per 30 days); Age (Min 12 Years) tramadol oral tablet extended release 24 Tier 1 QL (1 EA per 1 day); Age hr 100 mg, 200 mg, 300 mg (Min 12 Years) tramadol oral tablet, er multiphase 24 hr Tier 1 QL (1 EA per 1 day); Age 100 mg, 200 mg, 300 mg (Min 12 Years) ZOHYDRO ER ORAL CAPSULE, ORAL Tier 3 PA ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG Antimigraine Preparations almotriptan malate oral tablet 12.5 mg, Tier 3 QL: LIMITED TO 9 TABS 6.25 mg IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS dihydroergotamine nasal spray,non- (Migranal) Tier 1 QL (8 ML per 30 days) aerosol 0.5 mg/pump act. (4 mg/ml) eletriptan oral tablet 20 mg, 40 mg (Relpax) Tier 3 ERGOMAR SUBLINGUAL TABLET 2 Tier 2 MG frovatriptan oral tablet 2.5 mg (Frova) Tier 3 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS MIGERGOT RECTAL SUPPOSITORY Tier 3 2-100 MG MIGRANAL NASAL SPRAY,NON- Tier 3 QL (8 ML per 30 days) AEROSOL 0.5 MG/PUMP ACT. (4 MG/ML) naratriptan oral tablet 1 mg, 2.5 mg (Amerge) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS rizatriptan oral tablet 10 mg (Maxalt) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS

145 Drug Status Notes rizatriptan oral tablet 5 mg Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS rizatriptan oral tablet,disintegrating 10 (Maxalt-MLT) Tier 1 QL: LIMITED TO 9 TABS mg IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS rizatriptan oral tablet,disintegrating 5 mg Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS sumatriptan nasal spray,non-aerosol 20 (Imitrex) Tier 1 QL (6 EA per 30 days) mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 100 (Imitrex) Tier 1 QL: LIMITED TO 9 TABS mg, 25 mg, 50 mg IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS sumatriptan succinate subcutaneous (Imitrex STATdose Refill) Tier 1 QL (2 ML per 30 days) cartridge 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen (Imitrex STATdose Pen) Tier 1 QL (2 ML per 30 days) injector 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous (Imitrex) Tier 1 QL (2 ML per 30 days) solution 6 mg/0.5 ml sumatriptan succinate subcutaneous Tier 1 QL (2 ML per 30 days) syringe 6 mg/0.5 ml sumatriptan-naproxen oral tablet 85-500 (Treximet) Tier 3 QL: LIMITED TO 9 TABS mg IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS TREXIMET ORAL TABLET 85-500 MG Tier 3 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS zolmitriptan oral tablet 2.5 mg, 5 mg (Zomig) Tier 1 QL: LIMITED TO 9 TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS zolmitriptan oral tablet,disintegrating 2.5 (Zomig ZMT) Tier 1 QL: LIMITED TO 9 TABS mg, 5 mg IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS

146 Drug Status Notes ZOMIG NASAL SPRAY,NON-AEROSOL Tier 3 PA; QL: LIMITED TO 9 2.5 MG TABS IN 30 DAYS|MAX CUMULATIVE 9 IN 30 DAYS ACROSS ALL ORAL TRIPTANS ZOMIG NASAL SPRAY,NON-AEROSOL Tier 3 PA 5 MG Narc.& Non-Sal.Analgesic,Barbiturate &Xanthine Cmb butalbital-acetaminop-caf-cod oral (Fioricet with Codeine) Tier 1 QL (2 EA per 1 day); Age capsule 50-300-40-30 mg (Min 12 Years) butalbital-acetaminop-caf-cod oral Tier 1 QL (2 EA per 1 day); Age capsule 50-325-40-30 mg (Min 12 Years) Narcotic & Salicylate Analgesics, Barb.& Xanthine ASCOMP WITH CODEINE ORAL Tier 1 QL (4 EA per 1 day); Age CAPSULE 30-50-325-40 MG (Min 12 Years) BUTALBITAL COMPOUND Tier 1 QL (4 EA per 1 day); Age W/CODEINE ORAL CAPSULE 30-50- (Min 12 Years) 325-40 MG codeine-butalbital-asa-caff oral capsule (Ascomp with Codeine) Tier 1 QL (4 EA per 1 day); Age 30-50-325-40 mg (Min 12 Years) Narcotic Analgesic & Non-Salicylate Analgesic Comb acetaminophen-codeine oral solution Tier 1 QL (240 ML per 30 days); 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 Age (Min 12 Years) ml, 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet 300- Tier 1 QL (4 EA per 1 day); Age 15 mg, 300-30 mg, 300-60 mg (Min 12 Years) ENDOCET ORAL TABLET 10-325 MG Tier 1 QL (3 EA per 1 day) ENDOCET ORAL TABLET 2.5-325 MG, Tier 1 QL (4 EA per 1 day) 5-325 MG, 7.5-325 MG hydrocodone-acetaminophen oral Tier 1 QL (240 ML per 10 days) solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet (Vicodin HP) Tier 1 QL (4 EA per 1 day) 10-300 mg hydrocodone-acetaminophen oral tablet (Lorcet HD) Tier 1 QL (4 EA per 1 day) 10-325 mg hydrocodone-acetaminophen oral tablet Tier 1 QL (4 EA per 1 day) 2.5-325 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet (Norco) Tier 1 QL (4 EA per 1 day) 5-325 mg, 7.5-325 mg LORCET HD ORAL TABLET 10-325 MG Tier 1 QL (4 EA per 1 day) oxycodone-acetaminophen oral tablet (Endocet) Tier 1 QL (3 EA per 1 day) 10-325 mg oxycodone-acetaminophen oral tablet (Endocet) Tier 1 QL (4 EA per 1 day) 2.5-325 mg, 5-325 mg, 7.5-325 mg tramadol-acetaminophen oral tablet (Ultracet) Tier 1 QL (4 EA per 1 day); Age 37.5-325 mg (Min 12 Years) VICODIN HP ORAL TABLET 10-300 MG Tier 1 QL (4 EA per 1 day)

147 Drug Status Notes Narcotic And Salicylate Analgesic Combination oxycodone-aspirin oral tablet 4.8355-325 Tier 1 QL (4 EA per 1 day) mg Narcotic Withdrawal Therapy Agents buprenorphine hcl sublingual tablet 2 Tier 1 mg, 8 mg buprenorphine-naloxone sublingual Tier 1 QL (3 EA per 1 day) tablet 2-0.5 mg, 8-2 mg SUBOXONE SUBLINGUAL FILM 12-3 Tier 3 PA; QL (2 EA per 1 day) MG SUBOXONE SUBLINGUAL FILM 2-0.5 Tier 3 PA; QL (3 EA per 1 day) MG, 4-1 MG, 8-2 MG ZUBSOLV SUBLINGUAL TABLET 0.7- Tier 3 QL (1 EA per 1 day) 0.18 MG, 11.4-2.9 MG, 2.9-0.71 MG ZUBSOLV SUBLINGUAL TABLET 1.4- Tier 3 QL (3 EA per 1 day) 0.36 MG, 5.7-1.4 MG ZUBSOLV SUBLINGUAL TABLET 8.6- Tier 3 QL (2 EA per 1 day) 2.1 MG Skeletal Muscle Relaxant,Salicylate,Narc Analgesic carisoprodol-aspirin-codeine oral tablet Tier 1 Age (Min 12 Years) 200-325-16 mg Parkinsons Disease Antiparkinsonism Drugs,Anticholinergic benztropine oral tablet 0.5 mg, 1 mg, 2 Tier 1 mg trihexyphenidyl oral elixir 0.4 mg/ml Tier 1 trihexyphenidyl oral tablet 2 mg, 5 mg Tier 1 Antiparkinsonism Drugs,Other amantadine hcl oral capsule 100 mg Tier 1 amantadine hcl oral solution 50 mg/5 ml Tier 1 amantadine hcl oral tablet 100 mg Tier 1 APOKYN SUBCUTANEOUS Tier 3 PA CARTRIDGE 10 MG/ML bromocriptine oral capsule 5 mg (Parlodel) Tier 1 bromocriptine oral tablet 2.5 mg (Parlodel) Tier 1 carbidopa-levodopa oral tablet 10-100 (Sinemet) Tier 1 mg, 25-100 mg, 25-250 mg carbidopa-levodopa oral tablet extended Tier 1 release 25-100 mg, 50-200 mg carbidopa-levodopa oral Tier 1 tablet,disintegrating 10-100 mg, 25-100 mg, 25-250 mg carbidopa-levodopa-entacapone oral (Stalevo 50) Tier 1 tablet 12.5-50-200 mg carbidopa-levodopa-entacapone oral (Stalevo 75) Tier 1 tablet 18.75-75-200 mg

148 Drug Status Notes carbidopa-levodopa-entacapone oral (Stalevo 100) Tier 1 tablet 25-100-200 mg carbidopa-levodopa-entacapone oral (Stalevo 125) Tier 1 tablet 31.25-125-200 mg carbidopa-levodopa-entacapone oral (Stalevo 150) Tier 1 tablet 37.5-150-200 mg carbidopa-levodopa-entacapone oral (Stalevo 200) Tier 1 tablet 50-200-200 mg entacapone oral tablet 200 mg (Comtan) Tier 1 NEUPRO TRANSDERMAL PATCH 24 Tier 3 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.125 mg, 0.25 (Mirapex) Tier 1 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg pramipexole oral tablet extended release (Mirapex ER) Tier 3 QL (1 EA per 1 day) 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg rasagiline oral tablet 0.5 mg, 1 mg (Azilect) Tier 3 QL (1 EA per 1 day) ropinirole oral tablet 0.25 mg, 3 mg, 5 (Requip) Tier 1 mg ropinirole oral tablet 0.5 mg, 1 mg, 2 mg, Tier 1 4 mg ropinirole oral tablet extended release 24 (Requip XL) Tier 1 hr 12 mg, 2 mg, 6 mg ropinirole oral tablet extended release 24 Tier 1 hr 4 mg, 8 mg selegiline hcl oral capsule 5 mg Tier 1 selegiline hcl oral tablet 5 mg Tier 1 tolcapone oral tablet 100 mg (Tasmar) Tier 3 ZELAPAR ORAL Tier 3 TABLET,DISINTEGRATING 1.25 MG Decarboxylase Inhibitors carbidopa oral tablet 25 mg (Lodosyn) Tier 1 LODOSYN ORAL TABLET 25 MG Tier 3 Seizure Disorder Anticonvulsant - Benzodiazepine Type clobazam oral suspension 2.5 mg/ml (Onfi) Tier 1 clobazam oral tablet 10 mg (Onfi) Tier 1 QL (1 EA per 1 day) clobazam oral tablet 20 mg (Onfi) Tier 1 QL (2 EA per 1 day) clonazepam oral tablet 0.5 mg, 1 mg, 2 (Klonopin) Tier 1 mg clonazepam oral tablet,disintegrating Tier 1 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg diazepam rectal kit 12.5-15-17.5-20 mg, (Diastat AcuDial) Tier 1 QL (2 EA per 1 FILL) 5-7.5-10 mg diazepam rectal kit 2.5 mg (Diastat) Tier 1 QL (2 EA per 1 FILL) ONFI ORAL SUSPENSION 2.5 MG/ML Tier 3 ONFI ORAL TABLET 10 MG Tier 3 QL (1 EA per 1 day)

149 Drug Status Notes ONFI ORAL TABLET 20 MG Tier 3 QL (2 EA per 1 day) Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 Tier 3 PA MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 Tier 3 Age (Max 12 Years) MG/ML BANZEL ORAL TABLET 200 MG, 400 Tier 2 MG carbamazepine oral capsule, er (Carbatrol) Tier 1 multiphase 12 hr 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 (Tegretol) Tier 1 mg/5 ml carbamazepine oral tablet 200 mg (Epitol) Tier 1 carbamazepine oral tablet extended (Tegretol XR) Tier 1 release 12 hr 200 mg, 400 mg carbamazepine oral tablet,chewable 100 Tier 1 mg CELONTIN ORAL CAPSULE 300 MG Tier 2 DILANTIN ORAL CAPSULE 30 MG Tier 2 divalproex oral capsule, delayed rel (Depakote Sprinkles) Tier 1 sprinkle 125 mg divalproex oral tablet extended release (Depakote ER) Tier 1 24 hr 250 mg, 500 mg divalproex oral tablet,delayed release (Depakote) Tier 1 (dr/ec) 125 mg, 250 mg, 500 mg EPITOL ORAL TABLET 200 MG Tier 1 ethosuximide oral capsule 250 mg (Zarontin) Tier 1 ethosuximide oral solution 250 mg/5 ml (Zarontin) Tier 1 felbamate oral suspension 600 mg/5 ml (Felbatol) Tier 1 felbamate oral tablet 400 mg, 600 mg (Felbatol) Tier 1 FYCOMPA ORAL SUSPENSION 0.5 Tier 3 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 Tier 3 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 (Neurontin) Tier 1 mg, 400 mg gabapentin oral solution 250 mg/5 ml (Neurontin) Tier 1 gabapentin oral solution 250 mg/5 ml (5 Tier 1 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg, 800 mg (Neurontin) Tier 1 LAMICTAL XR STARTER (BLUE) ORAL Tier 3 TABLET EXTENDED REL,DOSE PACK 25 MG (21) -50 MG (7) LAMICTAL XR STARTER (GREEN) Tier 3 ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(14)-100MG (14)-200 MG (7)

150 Drug Status Notes LAMICTAL XR STARTER (ORANGE) Tier 3 ORAL TABLET EXTENDED REL,DOSE PACK 25MG (14)-50 MG (14)-100MG (7) lamotrigine oral tablet 100 mg, 200 mg (Subvenite) Tier 1 QL (4 EA per 1 day) lamotrigine oral tablet 150 mg (Subvenite) Tier 1 QL (93 EA per 30 days) lamotrigine oral tablet 25 mg (Subvenite) Tier 1 QL (7 EA per 1 day) lamotrigine oral tablet disintegrating, (Lamictal ODT Starter Tier 3 dose pk 25 mg (21) -50 mg (7) (Blue)) lamotrigine oral tablet disintegrating, (Lamictal ODT Starter Tier 3 dose pk 25 mg(14)-50 mg (14)-100 mg (Orange)) (7) lamotrigine oral tablet disintegrating, (Lamictal ODT Starter Tier 3 dose pk 50 mg (42) -100 mg (14) (Green)) lamotrigine oral tablet extended release (Lamictal XR) Tier 1 QL (1 EA per 1 day) 24hr 100 mg, 200 mg, 250 mg, 300 mg lamotrigine oral tablet extended release (Lamictal XR) Tier 1 QL (2 EA per 1 day) 24hr 25 mg, 50 mg lamotrigine oral tablet, chewable (Lamictal) Tier 1 dispersible 25 mg, 5 mg lamotrigine oral tablet,disintegrating 100 (Lamictal ODT) Tier 3 QL (2 EA per 1 day) mg lamotrigine oral tablet,disintegrating 200 (Lamictal ODT) Tier 3 QL (4 EA per 1 day) mg lamotrigine oral tablet,disintegrating 25 (Lamictal ODT) Tier 3 QL (7 EA per 1 day) mg lamotrigine oral tablet,disintegrating 50 (Lamictal ODT) Tier 3 QL (93 EA per 30 days) mg lamotrigine oral tablets,dose pack 25 mg (Subvenite Starter (Blue) Tier 1 (35) Kit) lamotrigine oral tablets,dose pack 25 mg (Subvenite Starter Tier 3 (42) -100 mg (7) (Orange) Kit) lamotrigine oral tablets,dose pack 25 mg (Subvenite Starter (Green) Tier 3 (84) -100 mg (14) Kit) levetiracetam oral solution 100 mg/ml (Keppra) Tier 1 levetiracetam oral solution 500 mg/5 ml Tier 1 (5 ml) levetiracetam oral tablet 1,000 mg, 250 (Keppra) Tier 1 mg, 500 mg, 750 mg levetiracetam oral tablet extended (Keppra XR) Tier 1 release 24 hr 500 mg, 750 mg LYRICA ORAL CAPSULE 100 MG, 150 Tier 3 PA; QL (2 EA per 1 day) MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML Tier 3 PA oxcarbazepine oral suspension 300 (Trileptal) Tier 1 mg/5 ml (60 mg/ml) oxcarbazepine oral tablet 150 mg, 300 (Trileptal) Tier 1 mg, 600 mg

151 Drug Status Notes OXTELLAR XR ORAL TABLET Tier 3 PA EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG Tier 2 phenytoin oral suspension 100 mg/4 ml Tier 1 phenytoin oral suspension 125 mg/5 ml (Dilantin-125) Tier 1 phenytoin oral tablet,chewable 50 mg (Dilantin Infatabs) Tier 1 phenytoin sodium extended oral capsule (Dilantin Extended) Tier 1 100 mg phenytoin sodium extended oral capsule (Phenytek) Tier 1 200 mg, 300 mg primidone oral tablet 250 mg, 50 mg (Mysoline) Tier 1 SABRIL ORAL TABLET 500 MG Tier 4 SP SUBVENITE ORAL TABLET 100 MG, Tier 1 QL (4 EA per 1 day) 200 MG SUBVENITE ORAL TABLET 150 MG Tier 1 QL (93 EA per 30 days) SUBVENITE ORAL TABLET 25 MG Tier 1 QL (7 EA per 1 day) SUBVENITE STARTER (BLUE) KIT Tier 1 ORAL TABLETS,DOSE PACK 25 MG (35) SUBVENITE STARTER (GREEN) KIT Tier 3 ORAL TABLETS,DOSE PACK 25 MG (84) -100 MG (14) SUBVENITE STARTER (ORANGE) KIT Tier 3 ORAL TABLETS,DOSE PACK 25 MG (42) -100 MG (7) tiagabine oral tablet 2 mg, 4 mg (Gabitril) Tier 1 topiramate oral capsule, sprinkle 15 mg, (Topamax) Tier 1 25 mg topiramate oral tablet 100 mg, 200 mg, (Topamax) Tier 1 25 mg, 50 mg valproic acid (as sodium salt) oral Tier 1 solution 250 mg/5 ml, 500 mg/10 ml (10 ml) valproic acid oral capsule 250 mg Tier 1 vigabatrin oral powder in packet 500 mg (Vigadrone) Tier 4 SP VIGADRONE ORAL POWDER IN Tier 4 SP PACKET 500 MG VIMPAT ORAL SOLUTION 10 MG/ML Tier 2 VIMPAT ORAL TABLET 100 MG, 150 Tier 2 QL (2 EA per 1 day) MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg (Zonegran) Tier 1 zonisamide oral capsule 50 mg Tier 1 Skeletal Muscle Disorder Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg Tier 1 carisoprodol oral tablet 250 mg, 350 mg (Soma) Tier 1 carisoprodol-aspirin oral tablet 200-325 Tier 1 QL (4 EA per 1 day) mg

152 Drug Status Notes chlorzoxazone oral tablet 500 mg Tier 1 cyclobenzaprine oral capsule,extended (Amrix) Tier 3 release 24hr 15 mg, 30 mg cyclobenzaprine oral tablet 10 mg, 5 mg Tier 1 cyclobenzaprine oral tablet 7.5 mg (Fexmid) Tier 1 dantrolene oral capsule 100 mg Tier 1 dantrolene oral capsule 25 mg, 50 mg (Dantrium) Tier 1 METAXALL ORAL TABLET 800 MG Tier 1 metaxalone oral tablet 800 mg (Metaxall) Tier 1 methocarbamol oral tablet 500 mg Tier 1 methocarbamol oral tablet 750 mg (Robaxin-750) Tier 1 orphenadrine citrate oral tablet extended Tier 1 release 100 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg (Zanaflex) Tier 1 tizanidine oral tablet 2 mg Tier 1 tizanidine oral tablet 4 mg (Zanaflex) Tier 1 Smoking Cessation Smoking Deterrent Agents (Ganglionic Stim,Others) nicotine (polacrilex) buccal gum 2 mg (Quit 2) $0 QL (9 EA per 1 day) nicotine (polacrilex) buccal gum 4 mg (Quit 4) $0 QL (9 EA per 1 day) nicotine (polacrilex) buccal lozenge 2 mg (Quit 2) $0 QL (9 EA per 1 day) nicotine (polacrilex) buccal lozenge 4 mg (Quit 4) $0 QL (9 EA per 1 day) nicotine (polacrilex) buccal mini lozenge (Nicorette) $0 QL (9 EA per 1 day) 2 mg, 4 mg nicotine transdermal patch 24 hour 14 (Nicoderm CQ) $0 QL (1 EA per 1 day) mg/24 hr, 21 mg/24 hr, 7 mg/24 hr nicotine transdermal patch, td daily, $0 QL (1 EA per 1 day) sequential 21-14-7 mg/24 hr NICOTROL INHALATION CARTRIDGE $0 QL (1008 EA per 90 days) 10 MG NICOTROL NS NASAL SPRAY,NON- $0 AEROSOL 10 MG/ML QUIT 2 BUCCAL GUM 2 MG $0 QL (9 EA per 1 day) QUIT 2 BUCCAL LOZENGE 2 MG $0 QL (9 EA per 1 day) QUIT 4 BUCCAL GUM 4 MG $0 QL (9 EA per 1 day) QUIT 4 BUCCAL LOZENGE 4 MG $0 QL (9 EA per 1 day) STOP SMOKING AID BUCCAL $0 QL (9 EA per 1 day) LOZENGE 2 MG, 4 MG Smoking Deterrent-Nicotinic Recept.Partial Agonist CHANTIX CONTINUING MONTH BOX $0 QL (2 EA per 1 day) ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG $0 QL (2 EA per 1 day) CHANTIX STARTING MONTH BOX $0 QL (2 EA per 1 day) ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

153 Drug Status Notes Smoking Deterrents, Other bupropion hcl (smoking deter) oral tablet $0 QL (2 EA per 1 day) extended release 12 hr 150 mg Upper Gastrointestinal Disorders - Digestive Gastric Enzymes SUCRAID ORAL SOLUTION 8,500 Tier 3 UNIT/ML Pancreatic Enzymes CREON ORAL CAPSULE,DELAYED Tier 2 RELEASE(DR/EC) 12,000-38,000 - 60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 6,000- 19,000 -30,000 UNIT CREON ORAL CAPSULE,DELAYED Tier 3 RELEASE(DR/EC) 36,000-114,000- 180,000 UNIT PANCREAZE ORAL Tier 3 CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200- 14,200- 24,600 UNIT PERTZYE ORAL CAPSULE,DELAYED Tier 3 RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 24,000-86,250- 90,750 UNIT, 4,000-14,375- 15,125 UNIT, 8,000-28,750- 30,250 UNIT VIOKACE ORAL TABLET 10,440- Tier 3 39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT ZENPEP ORAL CAPSULE,DELAYED Tier 2 RELEASE(DR/EC) 10,000-32,000 - 42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000- 10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT Upper Gastrointestinal Disorders - Spastic Disease Anticholinergics/Antispasmodics dicyclomine oral capsule 10 mg Tier 1 dicyclomine oral solution 10 mg/5 ml Tier 1 dicyclomine oral tablet 20 mg Tier 1 Belladonna Alkaloids DONNATAL ORAL ELIXIR 16.2-0.1037 - Tier 3 QL (120 ML per 30 days) 0.0194 MG/5 ML ED-SPAZ ORAL Tier 1 TABLET,DISINTEGRATING 0.125 MG

154 Drug Status Notes hyoscyamine sulfate oral drops 0.125 (Hyosyne) Tier 1 mg/ml hyoscyamine sulfate oral elixir 0.125 (Hyosyne) Tier 1 mg/5 ml hyoscyamine sulfate oral tablet 0.125 mg (Oscimin) Tier 1 hyoscyamine sulfate oral tablet extended (Oscimin SR) Tier 1 release 12 hr 0.375 mg hyoscyamine sulfate oral (Ed-Spaz) Tier 1 tablet,disintegrating 0.125 mg hyoscyamine sulfate sublingual tablet (Oscimin SL) Tier 1 0.125 mg HYOSYNE ORAL DROPS 0.125 MG/ML Tier 1 HYOSYNE ORAL ELIXIR 0.125 MG/5 Tier 1 ML methscopolamine oral tablet 2.5 mg, 5 Tier 1 mg OSCIMIN ORAL TABLET 0.125 MG Tier 1 OSCIMIN SL SUBLINGUAL TABLET Tier 1 0.125 MG OSCIMIN SR ORAL TABLET Tier 1 EXTENDED RELEASE 12 HR 0.375 MG phenobarb-hyoscy-atropine-scop oral (Donnatal) Tier 3 QL (120 ML per 30 days) elixir 16.2-0.1037 -0.0194 mg/5 ml phenobarb-hyoscy-atropine-scop oral (Donnatal) Tier 3 tablet 16.2-0.1037 -0.0194 mg PHENOHYTRO ORAL ELIXIR 16.2- Tier 3 QL (120 ML per 30 days) 0.1037 -0.0194 MG/5 ML Upper Gastrointestinal Disorders - Ulcer Disease Anticholinergics,Quaternary Ammonium chlordiazepoxide-clidinium oral capsule (Librax (with clidinium)) Tier 1 5-2.5 mg CUVPOSA ORAL SOLUTION 1 MG/5 Tier 3 ML (0.2 MG/ML) glycopyrrolate oral tablet 1 mg, 2 mg Tier 1 propantheline oral tablet 15 mg Tier 1 Anti-Ulcer Preparations misoprostol oral tablet 100 mcg, 200 (Cytotec) Tier 1 mcg sucralfate oral suspension 100 mg/ml (Carafate) Tier 1 sucralfate oral tablet 1 gram (Carafate) Tier 1 Anti-Ulcer-H.Pylori Agents HELIDAC ORAL COMBO PACK 250- Tier 3 500-262.4 MG PYLERA ORAL CAPSULE 140-125-125 Tier 3 MG Histamine H2-Receptor Inhibitors ACID CONTROLLER ORAL TABLET 20 Tier 1 MG

155 Drug Status Notes ACID REDUCER (FAMOTIDINE) ORAL Tier 1 TABLET 20 MG cimetidine hcl oral solution 300 mg/5 ml Tier 1 cimetidine oral tablet 300 mg, 400 mg, Tier 1 800 mg famotidine oral suspension 40 mg/5 ml Tier 1 (8 mg/ml) famotidine oral tablet 20 mg (Acid Controller) Tier 1 famotidine oral tablet 40 mg (Pepcid) Tier 1 HEARTBURN PREVENTION ORAL Tier 1 TABLET 20 MG HEARTBURN RELIEF (FAMOTIDINE) Tier 1 ORAL TABLET 20 MG nizatidine oral capsule 150 mg, 300 mg Tier 1 nizatidine oral solution 150 mg/10 ml Tier 1 Intestinal Motility Stimulants metoclopramide hcl oral solution 5 mg/5 Tier 1 ml metoclopramide hcl oral tablet 10 mg, 5 (Reglan) Tier 1 mg metoclopramide hcl oral Tier 3 tablet,disintegrating 10 mg, 5 mg Proton-Pump Inhibitors DEXILANT ORAL CAPSULE,BIPHASE Tier 3 QL (1 EA per 1 day) DELAYED RELEAS 30 MG, 60 MG esomeprazole magnesium oral (Nexium) Tier 1 capsule,delayed release(dr/ec) 20 mg, 40 mg lansoprazole oral capsule,delayed (Prevacid) Tier 1 QL (1 EA per 1 day) release(dr/ec) 15 mg lansoprazole oral capsule,delayed (Prevacid) Tier 1 QL (3 EA per 1 day) release(dr/ec) 30 mg NEXIUM 24HR ORAL Tier 2 CAPSULE,DELAYED RELEASE(DR/EC) 20 MG NEXIUM 24HR ORAL Tier 2 TABLET,DELAYED RELEASE (DR/EC) 20 MG NEXIUM ORAL CAPSULE,DELAYED Tier 2 RELEASE(DR/EC) 20 MG omeprazole oral capsule,delayed Tier 1 release(dr/ec) 10 mg, 20 mg, 40 mg omeprazole oral tablet,delayed release Tier 1 QL (2 EA per 1 day) (dr/ec) 20 mg omeprazole-sodium bicarbonate oral (Zegerid) Tier 1 capsule 40-1.1 mg-gram pantoprazole oral tablet,delayed release (Protonix) Tier 1 (dr/ec) 20 mg, 40 mg

156 Drug Status Notes PREVACID SOLUTAB ORAL Tier 3 Age (Max 12 Years) TABLET,DISINTEGRAT, DELAY REL 15 MG, 30 MG rabeprazole oral tablet,delayed release (AcipHex) Tier 1 QL (2 EA per 1 day) (dr/ec) 20 mg Urinary Tract - Functional Disorders Benign Prostatic Hypertrophy/Micturition Agents alfuzosin oral tablet extended release 24 (Uroxatral) Tier 1 QL (1 EA per 1 day) hr 10 mg dutasteride oral capsule 0.5 mg (Avodart) Tier 1 QL (1 EA per 1 day) finasteride oral tablet 5 mg (Proscar) Tier 1 RAPAFLO ORAL CAPSULE 4 MG, 8 Tier 3 QL (1 EA per 1 day) MG tamsulosin oral capsule 0.4 mg (Flomax) Tier 1 Bph Agents,5-Alpha-Red Inh & Alpha-1- Adr Antg Cmb dutasteride-tamsulosin oral capsule, er (Jalyn) Tier 3 QL (1 EA per 1 day) multiphase 24 hr 0.5-0.4 mg Cystine-Depleting Agents, Nephropathic Cystinosis CYSTAGON ORAL CAPSULE 150 MG, Tier 3 50 MG PROCYSBI ORAL CAPSULE, Tier 4 PA; SP DELAYED REL SPRINKLE 25 MG, 75 MG Overactive Bladder Agents, Beta-3 Adrenergic Recep MYRBETRIQ ORAL TABLET Tier 3 QL (1 EA per 1 day) EXTENDED RELEASE 24 HR 25 MG, 50 MG Urinary Ph Modifiers K-PHOS NO 2 ORAL TABLET 305-700 Tier 3 MG K-PHOS ORIGINAL ORAL Tier 3 TABLET,SOLUBLE 500 MG ORACIT ORAL SOLUTION 490-640 Tier 3 MG/5 ML potassium citrate oral tablet extended (Urocit-K 10) Tier 1 QL (3 EA per 1 day) release 10 meq (1,080 mg) potassium citrate oral tablet extended (Urocit-K 15) Tier 1 QL (3 EA per 1 day) release 15 meq potassium citrate oral tablet extended (Urocit-K 5) Tier 1 QL (3 EA per 1 day) release 5 meq (540 mg) UROQID-ACID NO.2 ORAL TABLET Tier 3 500-500 MG Urinary Tract Analgesic Agents ELMIRON ORAL CAPSULE 100 MG Tier 2

157 Drug Status Notes Urinary Tract Anesthetic/Analgesic Agnt (Azo-Dye) phenazopyridine oral tablet 100 mg, 200 (Pyridium) Tier 1 mg Urinary Tract Antispasmodic, M(3) Selective Antag. darifenacin oral tablet extended release Tier 3 QL (1 EA per 1 day) 24 hr 15 mg, 7.5 mg VESICARE ORAL TABLET 10 MG, 5 Tier 3 QL (1 EA per 1 day) MG Urinary Tract Antispasmodic/Antiincontinence Agent flavoxate oral tablet 100 mg Tier 1 GELNIQUE TRANSDERMAL GEL IN Tier 3 QL (1 GM per 1 day) PACKET 10 % (100 MG/GRAM) oxybutynin chloride oral syrup 5 mg/5 ml Tier 1 oxybutynin chloride oral tablet 5 mg Tier 1 oxybutynin chloride oral tablet extended (Ditropan XL) Tier 1 release 24hr 10 mg, 5 mg oxybutynin chloride oral tablet extended Tier 1 release 24hr 15 mg tolterodine oral capsule,extended (Detrol LA) Tier 1 QL (1 EA per 1 day) release 24hr 2 mg, 4 mg tolterodine oral tablet 1 mg, 2 mg (Detrol) Tier 1 QL (2 EA per 1 day) TOVIAZ ORAL TABLET EXTENDED Tier 3 QL (1 EA per 1 day) RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release Tier 1 QL (1 EA per 1 day) 24hr 60 mg trospium oral tablet 20 mg Tier 1 QL (2 EA per 1 day) Vaginal Disorders Vaginal Antibiotics CLEOCIN VAGINAL SUPPOSITORY Tier 3 100 MG clindamycin phosphate vaginal cream 2 (Cleocin) Tier 1 % CLINDESSE VAGINAL Tier 3 CREAM,EXTENDED RELEASE 2 % metronidazole vaginal gel 0.75 % (Metrogel Vaginal) Tier 1 Vaginal Antifungals clotrimazole vaginal cream 1 % (Clotrimazole-7) Tier 1 CLOTRIMAZOLE-7 VAGINAL CREAM 1 Tier 1 % GYNAZOLE-1 VAGINAL CREAM 2 % Tier 3 QL (6 GM per 15 days) MICONAZOLE 7 VAGINAL CREAM 2 % Tier 1 miconazole nitrate vaginal comb (Miconazole-3) Tier 1 pack,prefill appl, cream 4 % (200 mg)- 2 % (9 gram) miconazole nitrate vaginal cream 2 % (Miconazole 7) Tier 1 miconazole nitrate vaginal kit 1,200-2 (Monistat 1 Combo Pack) Tier 1 mg-%

158 Drug Status Notes MICONAZOLE-3 VAGINAL COMB Tier 1 PACK,PREFILL APPL, CREAM 4 % (200 MG)- 2 % (9 GRAM) MICONAZOLE-3 VAGINAL KIT 200 MG- Tier 1 2 % (9 GRAM) MICONAZOLE-3 VAGINAL Tier 1 SUPPOSITORY 200 MG miconazole-skin clnsr17 vaginal kit 4 % (Miconazole-3 Tier 1 (200 mg)- 2 % (9 gram) prefil,cream,wipe) MONISTAT 7 VAGINAL CREAM 2 % Tier 1 terconazole vaginal cream 0.4 %, 0.8 % Tier 1 terconazole vaginal suppository 80 mg Tier 1 Vaginal Estrogen Preparations ESTRACE VAGINAL CREAM 0.01 % Tier 2 (0.1 MG/GRAM) estradiol vaginal cream 0.01 % (0.1 (Estrace) Tier 1 mg/gram) estradiol vaginal tablet 10 mcg (Yuvafem) Tier 1 ESTRING VAGINAL RING 2 MG (7.5 Tier 3 QL (1 EA per 84 days) MCG /24 HOUR) FEMRING VAGINAL RING 0.05 MG/24 Tier 3 QL (1 EA per 84 days) HR, 0.1 MG/24 HR PREMARIN VAGINAL CREAM 0.625 Tier 2 MG/GRAM YUVAFEM VAGINAL TABLET 10 MCG Tier 1 Vitamin And/Or Mineral Deficiency Fluoride Preparations DENTA 5000 PLUS DENTAL CREAM Tier 3 1.1 % DENTAGEL DENTAL GEL 1.1 % Tier 1 fluoride (sodium) dental gel 1.1 % (DentaGel) Tier 1 fluoride (sodium) oral drops 0.5 mg (1.1 $0 QL (50 ML per 30 days); mg sod.fluorid)/ml Age (Max 6 Years) fluoride (sodium) oral tablet,chewable (Ludent Fluoride) $0 QL (1 EA per 1 day); Age 0.25 mg(0.55 mg sod. fluoride) (Max 6 Years) fluoride (sodium) oral tablet,chewable (Fluoritab) $0 QL (1 EA per 1 day); Age 0.5 mg (1.1 mg sodium fluorid), 1 mg (Max 6 Years) (2.2 mg sod. fluoride) FLUORIDEX DAILY DEFENSE DENTAL Tier 3 PASTE 1.1 % FLUORITAB ORAL $0 QL (1 EA per 1 day); Age TABLET,CHEWABLE 0.5 MG (1.1 MG (Max 6 Years) SODIUM FLUORID) LUDENT FLUORIDE ORAL $0 QL (1 EA per 1 day); Age TABLET,CHEWABLE 0.25 MG(0.55 MG (Max 6 Years) SOD. FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID) SF 5000 PLUS DENTAL CREAM 1.1 % Tier 1 SF DENTAL GEL 1.1 % Tier 1

159 Drug Status Notes Folic Acid Preparations folic acid oral tablet 1 mg Tier 1 folic acid oral tablet 400 mcg, 800 mcg $0 QL (1 EA per 1 day) Iron Replacement ferrous sulfate oral liquid 300 mg (60 mg $0 QL (150 ML per 30 days); iron)/5 ml Age (Max 12 Years) ferrous sulfate oral solution 220 mg (44 $0 QL (150 ML per 30 days); mg iron)/5 ml Age (Max 12 Years) ferrous sulfate oral tablet 325 mg (65 mg (Feosol) $0 QL (1 EA per 1 day) iron) ferrous sulfate oral tablet,delayed $0 QL (1 EA per 1 day) release (dr/ec) 324 mg (65 mg iron), 325 mg (65 mg iron) SLOW RELEASE IRON ORAL TABLET $0 QL (1 EA per 1 day) EXTENDED RELEASE 143 MG (45 MG IRON) Magnesium Salts Replacement magnesium oxide oral tablet 400 mg (MagOx) Tier 1 (241.3 mg magnesium) Multivitamin Preparations THRIVITE-19 ORAL TABLET 29 MG Tier 1 IRON-1 MG -25 MG Pediatric Vitamin Preparations MULTI-VIT WITH FLUORIDE-IRON Tier 1 ORAL DROPS 0.25MG FLUORIDE -10 MG IRON/ML Prenatal Vitamin Preparations BAL-CARE DHA ESSENTIAL ORAL Tier 3 COMBO PACK,TABLET AND CAP,DR 27 MG IRON-1 MG -374 MG CALCIUM PNV ORAL CAPSULE 28-1- Tier 3 250 MG CITRANATAL (DUAL-IRON) ORAL Tier 3 TABLET 27 MG IRON-1 MG -50 MG CITRANATAL DHA (ALGAL OIL) ORAL Tier 3 COMBO PACK 27 MG IRON-1 MG -50 MG-250 MG COMPLETENATE ORAL Tier 3 TABLET,CHEWABLE 29 MG IRON- 1 MG FOLIVANE-OB ORAL CAPSULE 85-1 Tier 3 MG MARNATAL-F ORAL CAPSULE 60 MG Tier 3 IRON-1 MG MYNATAL ORAL CAPSULE 65 MG Tier 3 IRON- 1 MG MYNATAL PLUS ORAL TABLET 65 MG Tier 3 IRON- 1 MG MYNATAL-Z ORAL TABLET 65 MG Tier 3 IRON- 1 MG

160 Drug Status Notes MYNATE 90 PLUS ORAL TABLET Tier 3 EXTENDED RELEASE 90 MG IRON-1 MG NATACHEW (FE BIS-GLYCINATE) Tier 3 ORAL TABLET,CHEWABLE 28 MG IRON -1 MG NEEVODHA (WITH ALGAL OIL) ORAL Tier 3 CAPSULE 27 MG IRON-1.13 MG- 581.92 MG NESTABS ABC ORAL COMBO PACK Tier 3 32 MG IRON-1 MG -120 MG-180 MG NEWGEN ORAL TABLET 32-1,000 MG- Tier 3 MCG OB COMPLETE ONE ORAL CAPSULE Tier 3 40-10-1-300 MG OB COMPLETE PETITE ORAL Tier 3 CAPSULE 35 MG IRON-5 MG IRON-1 MG OB COMPLETE PREMIER ORAL Tier 3 TABLET 30-20-1 MG OB COMPLETE WITH DHA ORAL Tier 3 CAPSULE 30 MG IRON-10 MG IRON-1 MG OBSTETRIX DHA ORAL COMBO Tier 1 PACK,TABLET AND CAP,DR 29 MG IRON-1 MG -50 MG OBSTETRIX EC ORAL Tier 3 TABLET,DELAYED RELEASE (DR/EC) 29 MG IRON-1 MG -50 MG O-CAL PRENATAL ORAL TABLET 15 Tier 3 MG IRON- 1,000 MCG PNV-DHA ORAL CAPSULE 27 MG Tier 3 IRON-1 MG -300 MG PNV-FERROUS FUMARATE-DOCU-FA Tier 1 ORAL TABLET 29 MG IRON- 1 MG-25 MG PNV-OMEGA ORAL CAPSULE 28-1- Tier 3 300 MG PNV-SELECT ORAL TABLET 27-1 MG Tier 3 PR NATAL 400 EC ORAL COMBO Tier 3 PACK,TABLET AND CAP,DR 29-1-400 MG PR NATAL 400 ORAL COMBO PACK Tier 3 29-1-400 MG PR NATAL 430 EC ORAL COMBO Tier 3 PACK,TABLET AND CAP,DR 29-1-430 MG PR NATAL 430 ORAL COMBO PACK Tier 3 29 MG IRON-1 MG -430 MG PRENAISSANCE PLUS ORAL Tier 3 CAPSULE 28-1-50-250 MG

161 Drug Status Notes PRENATA ORAL TABLET,CHEWABLE Tier 3 29 MG IRON- 1 MG PRENATAL 19 (WITH DOCUSATE) Tier 1 ORAL TABLET 29 MG IRON- 1 MG-25 MG PRENATAL 19 ORAL Tier 1 TABLET,CHEWABLE 29 MG IRON- 1 MG PRENATAL PLUS ORAL TABLET 29 Tier 1 MG IRON- 1 MG PRENATAL-U ORAL CAPSULE 106.5-1 Tier 1 MG PRENATE AM ORAL TABLET 1-500 Tier 3 MG PRENATE CHEWABLE ORAL Tier 3 TABLET,CHEWABLE 1 MG PRENATE DHA (FERR ASP GLYCIN) Tier 3 ORAL CAPSULE 18 MG IRON-1 MG - 300 MG PRENATE DHA ORAL CAPSULE 28 Tier 3 MG IRON-1 MG -300 MG PRENATE ELITE (IRON ASP GLYC) Tier 3 ORAL TABLET 20 MG IRON- 1 MG PRENATE ELITE ORAL TABLET 26 MG Tier 3 IRON- 1 MG PRENATE ESSENTIAL ORAL Tier 3 CAPSULE 29 MG IRON-1 MG -300 MG PRENATE ESSENTIAL(IRON-ASP-GL) Tier 3 ORAL CAPSULE 18 MG IRON- 1 MG- 300 MG PRENATE MINI (FERR ASP GLYCIN) Tier 3 ORAL CAPSULE 18-1-350 MG PRETAB ORAL TABLET 29-1 MG Tier 3 R-NATAL OB ORAL CAPSULE 20 MG Tier 1 IRON- 1 MG-320 MG SELECT-OB (FOLIC ACID) ORAL Tier 3 TABLET,CHEWABLE 29 MG IRON- 1 MG SELECT-OB + DHA ORAL COMBO Tier 3 PACK 29 MG IRON-1 MG -250 MG SELECT-OB ORAL Tier 3 TABLET,CHEWABLE 29 MG IRON- 1 MG SE-NATAL 19 CHEWABLE ORAL Tier 1 TABLET,CHEWABLE 29 MG IRON- 1 MG TARON-C DHA ORAL CAPSULE 35-1- Tier 1 200 MG THRIVITE RX ORAL TABLET 29 MG Tier 3 IRON- 1 MG

162 Drug Status Notes TRINATAL RX 1 ORAL TABLET 60 MG Tier 3 IRON-1 MG TRIVEEN-DUO DHA ORAL COMBO Tier 3 PACK 29-1-400 MG VINATE CARE ORAL Tier 3 TABLET,CHEWABLE 40 MG IRON- 1 MG VINATE ONE ORAL TABLET 60 MG Tier 3 IRON-1 MG VIRT-C DHA ORAL CAPSULE 35-1-200 Tier 1 MG VIRT-PN DHA ORAL CAPSULE 27 MG Tier 3 IRON-1 MG -300 MG VIRT-PN PLUS ORAL CAPSULE 28-1- Tier 3 300 MG VITAFOL-OB ORAL TABLET 65-1 MG Tier 3 VITAFOL-OB+DHA ORAL COMBO Tier 3 PACK 65-1-250 MG VITAFOL-ONE ORAL CAPSULE 29 MG Tier 3 IRON- 1 MG-200 MG VP-CH-PNV ORAL CAPSULE 30 MG Tier 3 IRON-1 MG -50 MG-260 MG ZATEAN-PN DHA ORAL CAPSULE 27 Tier 3 MG IRON-1 MG -300 MG ZATEAN-PN PLUS ORAL CAPSULE Tier 3 28-1-300 MG Vitamin B Preparations POTABA ORAL CAPSULE 500 MG Tier 3 Vitamin B12 Preparations cyanocobalamin (vitamin b-12) injection Tier 1 solution 1,000 mcg/ml NASCOBAL NASAL SPRAY,NON- Tier 3 AEROSOL 500 MCG/SPRAY Vitamin D Preparations calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) Tier 1 calcitriol oral solution 1 mcg/ml (Rocaltrol) Tier 1 cholecalciferol (vitamin d3) oral capsule (Vitamin D3) $0 QL (1 EA per 1 day); Age 25 mcg (1,000 unit) (Min 65 Years) cholecalciferol (vitamin d3) oral capsule (D3-2000) $0 QL (1 EA per 1 day); Age 50 mcg (2,000 unit) (Min 65 Years) cholecalciferol (vitamin d3) oral tablet 25 (Vitamin D3) $0 QL (1 EA per 1 day); Age mcg (1,000 unit) (Min 65 Years) cholecalciferol (vitamin d3) oral tablet 50 (D3 DOTS) $0 QL (1 EA per 1 day); Age mcg (2,000 unit) (Min 65 Years) ergocalciferol (vitamin d2) oral capsule (Vitamin D2) $0 1,250 mcg (50,000 unit) VITAMIN D2 ORAL CAPSULE 1,250 $0 MCG (50,000 UNIT) VITAMIN D3 ORAL TABLET 10 MCG Tier 3 (400 UNIT)

163 Drug Status Notes VITAMIN D3 ORAL TABLET 25 MCG $0 QL (1 EA per 1 day); Age (1,000 UNIT) (Min 65 Years) WEEKLY-D ORAL CAPSULE 1,250 $0 Age (Min 65 Years) MCG (50,000 UNIT) Weight Reduction Fat Absorption Decreasing Agents XENICAL ORAL CAPSULE 120 MG Tier 3

164 Index

1ST TIER UNIFINE PENTIPS...... 132 ACUVAIL (PF)...... 72 AFLURIA QD 2020-21(3YR 1ST TIER UNIFINE PENTIPS acyclovir...... 46, 92 UP)(PF)...... 83 PLUS...... 132 adapalene...... 43 AFLURIA QD 2020-21(6- 1ST TIER UNILET ADCIRCA...... 27 35MO)(PF)...... 83 COMFORTOUCH...... 105 ADDYI...... 18 AFLURIA QUAD 2020-2021(6MO 24 HOUR NASAL ALLERGY...... 5 adefovir...... 95 UP)...... 83 24HOUR ALLERGY...... 4 ADEMPAS...... 27 AFTERA...... 32 24HR ALLERGY RELIEF...... 4 ADULT ASPIRIN REGIMEN...... 79 AGAMATRIX AMP TEST STRIPS...59 abacavir...... 93 ADULT LOW DOSE ASPIRIN...... 79 AGAMATRIX PRESTO TEST abacavir-lamivudine...... 93 ADVAIR DISKUS...... 9 STRIPS...... 59 abacavir-lamivudine-zidovudine...... 93 ADVAIR HFA...... 9 AGGRENOX...... 79 ABOUTTIME PEN NEEDLE...... 132 ADVANCED EXFOLIATING AIMSCO LATEX CONDOM...... 131 ABREVA...... 46 CLEANSER...... 53 AK-POLY-BAC...... 73 acamprosate...... 15 ADVANCED GLUC METER TEST AKTEN (PF)...... 73 ACANYA...... 42 STRIP...... 59 AKYNZEO (NETUPITANT)...... 6 acarbose...... 57 ADVANCED TRAVEL LANCETS.. 105 ALA-CORT...... 47 ACCU-CHEK AVIVA PLUS TEST ADVOCATE LANCET...... 105 ALA-QUIN...... 43 STRP...... 58 ADVOCATE PEN NEEDLE...... 132 ALAVERT...... 4 ACCU-CHEK FASTCLIX LANCET ADVOCATE REDI-CODE...... 59 ALAVERT D-12 ALLERGY-SINUS....3 DRUM...... 105 ADVOCATE REDI-CODE PLUS..... 59 ALAWAY...... 71 ACCU-CHEK GUIDE TEST ADVOCATE SYRINGES...... 110 albuterol sulfate...... 8 STRIPS...... 59 ADVOCATE TEST STRIPS...... 59 ALCAINE...... 73 ACCU-CHEK MULTICLIX LANCET AEROCHAMBER MINI...... 10 alclometasone...... 47 ...... 105 AEROCHAMBER MV...... 10 ALCOHOL PADS...... 52 ACCU-CHEK SAFE-T-PRO...... 105 AEROCHAMBER PLUS FLOW-VU.11 ALCOHOL PREP PADS...... 52 ACCU-CHEK SAFE-T-PRO PLUS 105 AEROCHAMBER PLUS FLOW- alcohol swabs...... 52 ACCU-CHEK SMARTVIEW TEST VU,L MSK...... 11 ALCOHOL WIPES...... 52 STRIP...... 59 AEROCHAMBER PLUS FLOW- ALCORTIN A...... 43 ACCU-CHEK SOFTCLIX VU,M MSK...... 11 ALDACTAZIDE...... 26 LANCETS...... 105 AEROCHAMBER PLUS FLOW- alendronate...... 68 ACCUTREND GLUCOSE TEST VU,S MSK...... 11 alfuzosin...... 157 STRIPS...... 59 AEROCHAMBER PLUS Z STAT.....11 ALINIA...... 91 acebutolol...... 24 AEROCHAMBER PLUS Z STAT ALL DAY ALLERGY (CETIRIZINE)...4 acetaminophen-codeine...... 147 LG MSK...... 11 ALL DAY ALLERGY-D...... 3 acetazolamide...... 75 AEROCHAMBER PLUS Z STAT ALLERCLEAR...... 4 acetic acid...... 65 MD MSK...... 11 ALLERCLEAR D-12HR...... 3 acetylcysteine...... 141 AEROCHAMBER PLUS Z STAT ALLERCLEAR D-24HR...... 3 ACID CONTROLLER...... 155 SM MSK...... 11 ALLER-CORT...... 6 ACID REDUCER (FAMOTIDINE)..156 AEROCHAMBER WITH ALLER-EASE...... 4 acitretin...... 55 FLOWSIGNAL...... 11 ALLERGIST TRAY 1/2 ML ACNE MEDICATION...... 53 AEROCHAMBER Z-STAT PLUS- 27GX3/8"...... 110 ACTEMRA...... 99 FLW SG...... 11 ALLERGIST TRAY ACTHAR...... 67 AFINITOR...... 127 INTRADERMAL BEV...... 110 ACTI-LANCE LANCETS...... 105 AFINITOR DISPERZ...... 127 ALLERGIST TRAY REGULAR ACTIMMUNE...... 84 AFIRMELLE...... 32 BEVEL...... 110

I-1 ALLERGY AND CONGESTION AMETHIA...... 32 APLENZIN...... 12 RELIEF...... 3 AMETHIA LO...... 32 APOKYN...... 148 ALLERGY COMPLETE-D...... 3 AMETHYST (28)...... 32 apraclonidine...... 75 ALLERGY EYE (KETOTIFEN)...... 71 amiloride...... 26 aprepitant...... 6 ALLERGY RELIEF (CETIRIZINE)..... 4 amiloride-hydrochlorothiazide...... 26 APRI...... 32 ALLERGY RELIEF aminocaproic acid...... 77 APRISO...... 101 (FEXOFENADINE)...... 5 amiodarone...... 20 APTIOM...... 150 ALLERGY RELIEF AMITIZA...... 103 APTIVUS...... 92 (LEVOCETIRIZIN)...... 5 amitriptyline...... 14 APTIVUS (WITH VITAMIN E)...... 92 ALLERGY RELIEF (LORATADINE).. 5 amitriptyline-chlordiazepoxide...... 14 AQUANIL HC...... 47 ALLERGY RELIEF D12...... 3 amlodipine...... 25 AQUORAL...... 141 ALLERGY RELIEF D-24HR...... 3 amlodipine-atorvastatin...... 31 ARANELLE (28)...... 32 ALLERGY RELIEF,NASAL amlodipine-benazepril...... 21 ARANESP (IN POLYSORBATE).....78 DECONGEST...... 3 amlodipine-valsartan...... 22 ARCALYST...... 96 ALLERGY RELIEF-D amlodipine-valsartan-hcthiazid...... 22 ARCAPTA NEOHALER...... 8 (CETIRIZINE)...... 3 ammonium lactate...... 52 aripiprazole...... 16 ALLERGY RELIEF-D AMNESTEEM...... 42 armodafinil...... 18 (LORATADINE)...... 3 amoxapine...... 14 ARMOUR THYROID...... 70 ALLERGY SYRINGE...... 110 amoxicillin...... 88 ARNUITY ELLIPTA...... 10 ALLERGY-CONGESTION amoxicillin-pot clavulanate...... 88 ARTHRITIS PAIN (DICLOFENAC)..51 RELIEF-D...... 3 amphetamine sulfate...... 15 ARTIFICIAL TEARS (PF)...... 76 ALLER-TEC...... 5 ampicillin...... 88 ARTIFICIAL TEARS (POLYVIN ALLER-TEC D...... 3 AMPYRA...... 130 ALC)...... 76 allopurinol...... 77 ANADROL-50...... 80 ARTIFICIAL TEARS(GLYCERIN- almotriptan malate...... 145 anagrelide...... 80 PEG)...... 76 ALOCRIL...... 75 ANALPRAM-HC...... 102 ARTIFICIAL TEARS(PG-HYPM- alogliptin...... 57 anastrozole...... 127 GLYC)...... 76 alogliptin-metformin...... 56 ANDRODERM...... 80 ARTIFICIAL TEARS(PVALCH- alogliptin-pioglitazone...... 56 ANDROGEL...... 81 POVID)...... 77 ALOMIDE...... 75 ANECREAM...... 54 ASCOMP WITH CODEINE...... 147 ALORA...... 81 ANECREAM5...... 102 ASHLYNA...... 32 alosetron...... 103 ANGELIQ...... 81 ASMANEX TWISTHALER...... 10 ALPHAGAN P...... 75 ANODYNE LPT...... 54 aspirin...... 79, 142 alprazolam...... 15 ANORO ELLIPTA...... 9 ASPIRIN CHILDRENS...... 79 ALPRAZOLAM INTENSOL...... 15 ANTARA...... 30 ASPIRIN LOW DOSE...... 79 ALREX...... 72 ANTI-DIARRHEAL aspirin,buffd-calcium carb-mag...... 142 ALTABAX...... 46 (LOPERAMIDE)...... 103 aspirin-dipyridamole...... 79 ALTACAINE...... 73 ANTIFUNGAL (CLOTRIMAZOLE)...44 ASPIR-TRIN...... 142 ALTAFLUOR BENOX...... 73 ANTIFUNGAL CREAM ASSURE 4 STRIPS...... 59 ALTAVERA (28)...... 32 (MICONAZOLE)...... 44 ASSURE HAEMOLANCE PLUS... 105 ALTERNATE SITE LANCET...... 105 ANTIFUNGAL RINGWORM...... 44 ASSURE ID INSULIN SAFETY..... 110 ALTOPREV...... 28 ANTI-ITCH (HC)...... 47 ASSURE ID PEN NEEDLE...... 132 ALVESCO...... 9 ANTI-ITCH(HYDROCORTISONE)- ASSURE LANCE...... 105 ALYACEN 1/35 (28)...... 32 ALOE...... 47 ASSURE LANCE PLUS...... 105 ALYACEN 7/7/7 (28)...... 32 ANUCORT-HC...... 102 ASSURE PLATINUM TEST STRIP.59 ALYQ...... 27 ANUSOL-HC...... 47 ASSURE PRISM MULTI STRIP...... 59 AMABELZ...... 81 APIDRA SOLOSTAR U-100 ASTAGRAF XL...... 85 amantadine hcl...... 148 INSULIN...... 63 ASTRINGYN...... 80 amcinonide...... 47 APIDRA U-100 INSULIN...... 63 atazanavir...... 94

I-2 atenolol...... 24 BD ALCOHOL SWABS...... 52 BD PRE-FILLED NORMAL atenolol-chlorthalidone...... 24 BD ALLERGIST TRAY REG SALINE...... 67 ATHLETE'S FOOT BEVEL...... 110 BD PRE-FILLED SALINE BLUNT (CLOTRIMAZOLE)...... 44 BD ALLERGY SYRINGE...... 110 CAN...... 67 ATHLETIC FOOT CREAM...... 44 BD AUTOSHIELD DUO PEN BD REGULAR BEVEL NEEDLES.133 atomoxetine...... 20 NEEDLE...... 133 BD SAFETYGLIDE ALLERGIST atorvastatin...... 28 BD BLUNT PLASTIC CANNULA...110 TRAY...... 112 atovaquone...... 92 BD BULK SYRINGE SLIP TIP...... 110 BD SAFETYGLIDE INSULIN atovaquone-proguanil...... 91 BD ECCENTRIC TIP SYRINGE....110 SYRINGE...... 112 ATRIPLA...... 95 BD ECLIPSE...... 133 BD SAFETYGLIDE NEEDLE...... 133 atropine...... 76 BD ECLIPSE LUER-LOK...... 110, 133 BD SAFETYGLIDE SHIELDING ATROVENT HFA...... 7 BD FILTER NEEDLE 5-MICRON REG...... 112 AUBAGIO...... 129 NOKO...... 133 BD SAFETYGLIDE SYRINGE...... 112 AUBRA...... 32 BD FILTER NEEDLE-5 MICRON.. 133 BD SAFETYGLIDE TB REG AUBRA EQ...... 32 BD INSULIN SYRINGE...... 111 BEVEL...... 112 AUROVELA 1.5/30 (21)...... 33 BD INSULIN SYRINGE HALF BD SAFETYGLIDE TUBERCULIN 112 AUROVELA 1/20 (21)...... 33 UNIT...... 110 BD SAFETY-LOK DETACHABLE AUROVELA 24 FE...... 33 BD INSULIN SYRINGE MICRO- NEEDL...... 112 AUROVELA FE 1.5/30 (28)...... 33 FINE...... 110 BD SAFETY-LOK TUBERCULIN.. 112 AUROVELA FE 1-20 (28)...... 33 BD INSULIN SYRINGE SAFETY- BD SAFETY-LOK WITH LUER- AVANDIA...... 57 LOK...... 110 LOK...... 112 AVAR...... 46 BD INSULIN SYRINGE SLIP TIP..110 BD SHORT BEVEL NEEDLES...... 133 AVAR LS...... 46 BD INSULIN SYRINGE U-500...... 111 BD SHORT BEVEL THIN WALL... 133 AVAR-E...... 46 BD INSULIN SYRINGE ULTRA- BD SLIP TIP SYRINGE...... 112 AVAR-E GREEN...... 46 FINE...... 111 B-D SLIP TIP SYRINGE...... 112 AVIANE...... 33 BD INTEGRA NEEDLE...... 133 BD SPECIALTY USE NEEDLES...134 AVITA...... 43 BD INTEGRA SYRINGE...... 111 BD SYRINGE...... 112 AVONEX...... 129 BD INTERLINK BLUNT PLASTIC BD SYRINGE CATH TIP AYUNA...... 33 CAN...... 111 NONSTERILE...... 112 AZASAN...... 85 BD INTERLINK SYRINGE...... 111 BD SYRINGE CATHETER TIP...... 112 AZASITE...... 74 BD INTRADERMAL BEVEL BD SYRINGE LUER-LOK azathioprine...... 85 NEEDLES...... 133 NONSTERILE...... 112 azelaic acid...... 43 BD LAB ECCENTRIC NON- BD SYRINGE LUER-LOK azelastine...... 5, 71 STERILE...... 111 STERILE...... 112 AZELEX...... 42 BD LO-DOSE MICRO-FINE IV...... 111 BD SYRINGE SLIP TIP azithromycin...... 87 BD LO-DOSE ULTRA-FINE...... 111 NONSTERILE...... 112 AZOPT...... 75 BD LUER-LOK BULK SYRINGE... 111 BD SYRINGE-DUAL CANNULA....113 AZURETTE (28)...... 33 BD LUER-LOK SYRINGE...... 111 BD TUBERCULIN SLIP-TIP...... 113 bacitracin...... 74 BD LUER-LOK TIP CONTROL BD TUBERCULIN SYRINGE...... 113 bacitracin-polymyxin b...... 74 SYRING...... 111 BD ULTRA FINE LANCETS...... 105 baclofen...... 152 BD MICROTAINER LANCET...... 105 BD ULTRA-FINE II LANCETS...... 105 BAL-CARE DHA ESSENTIAL...... 160 BD NANO 2ND GEN PEN BD ULTRA-FINE MICRO PEN BALCOLTRA...... 33 NEEDLE...... 133 NEEDLE...... 134 balsalazide...... 101 BD NOKOR ADMIX NEEDLE...... 133 BD ULTRA-FINE MINI PEN BALZIVA (28)...... 33 BD POSIFLUSH NORMAL SALINE NEEDLE...... 134 BANZEL...... 150 0.9...... 67 BD ULTRA-FINE NANO PEN BARACLUDE...... 95 BD PRECISIONGLIDE...... 111, 133 NEEDLE...... 134 BAYER ASPIRIN...... 142 BD PRECISIONGLIDE NON- BD ULTRA-FINE ORIG PEN BAZA ANTIFUNGAL...... 44 STERILE...... 133 NEEDLE...... 134

I-3 BD ULTRA-FINE SHORT PEN BP...... 53 capsaicin...... 52 NEEDLE...... 134 BP FOAM...... 53 captopril...... 23 BD VEO INSULIN SYR HALF BP WASH...... 53 captopril-hydrochlorothiazide...... 21 UNIT...... 113 BP WASH ACNE TREATMENT...... 53 carbamazepine...... 150 BD VEO INSULIN SYRINGE UF...113 BPO...... 53 carbidopa...... 149 BECONASE AQ...... 6 BREEZE 2 TEST STRIPS...... 59 carbidopa-levodopa...... 148 BEKYREE (28)...... 33 BREO ELLIPTA...... 9 carbidopa-levodopa-entacapone belladonna alkaloids-opium...... 143 BRIELLYN...... 33 ...... 148, 149 BELSOMRA...... 19 BRILINTA...... 79 carbinoxamine maleate...... 4 benazepril...... 22 brimonidine...... 75 CAREFINE PEN NEEDLE...... 134 benazepril-hydrochlorothiazide...... 21 bromocriptine...... 148 CAREONE THIN LANCET...... 105 BENSAL HP...... 53 BROVANA...... 9 CAREONE ULTRA THIN LANCET105 BENZEPRO...... 53 budesonide...... 6, 10, 98 CAREPOINT LUER SLIP BENZEPRO (MICROSPHERES).... 53 BUFFERED ASPIRIN...... 142 SYRINGE...... 113 benzonatate...... 41 BUFFERIN...... 142 CARESENS LANCETS...... 105 benzoyl peroxide...... 53 BULLSEYE MINI SAFETY CARESENS N TEST STRIPS...... 59 benztropine...... 148 LANCETS...... 105 CARETOUCH ALCOHOL PREP BEPREVE...... 71 bumetanide...... 26 PAD...... 52 BESIVANCE...... 74 buprenorphine...... 143 CARETOUCH INSULIN SYRINGE113 BETA-HC...... 47 buprenorphine hcl...... 148 CARETOUCH PEN NEEDLE...... 134 betamethasone dipropionate..... 47, 48 buprenorphine-naloxone...... 148 CARETOUCH SAFETY LANCETS105 betamethasone valerate...... 48 bupropion hcl...... 12 CARETOUCH TEST STRIP...... 59 betamethasone, augmented...... 48 bupropion hcl (smoking deter)...... 154 CARETOUCH TWIST LANCET.....105 BETASERON...... 129 buspirone...... 16 carisoprodol...... 152 betaxolol...... 24, 75 BUTALBITAL COMPOUND carisoprodol-aspirin...... 152 bethanechol chloride...... 126 W/CODEINE...... 147 carisoprodol-aspirin-codeine...... 148 BETIMOL...... 75 butalbital-acetaminop-caf-cod...... 147 carteolol...... 75 BETOPTIC S...... 75 butalbital-acetaminophen...... 142 CARTIA XT...... 25 bexarotene...... 129 butalbital-acetaminophen-caff...... 142 carvedilol...... 22 bicalutamide...... 126 butalbital-aspirin-caffeine...... 142 carvedilol phosphate...... 22 BIDIL...... 28 butorphanol...... 143 CAYA CONTOURED...... 40 BIKTARVY...... 95 BYDUREON...... 56 CAYSTON...... 86 BILTRICIDE...... 91 BYDUREON BCISE...... 56 CAZIANT (28)...... 33 bimatoprost...... 75 BYETTA...... 56 cefaclor...... 86 BINOSTO...... 68 BYSTOLIC...... 24 cefadroxil...... 86 BIONIME RIGHTEST TEST cabergoline...... 70 cefdinir...... 86 STRIPS...... 59 calcipotriene...... 55 cefditoren pivoxil...... 86 bisoprolol fumarate...... 24 calcipotriene-betamethasone...... 56 cefixime...... 86 bisoprolol-hydrochlorothiazide...... 25 calcitonin (salmon)...... 68 cefpodoxime...... 86 BLEPH-10...... 73 calcitriol...... 55, 163 cefprozil...... 86 BLEPHAMIDE...... 73 calcium acetate(phosphat bind)...... 65 cefuroxime axetil...... 86 BLEPHAMIDE S.O.P...... 73 CALCIUM PNV...... 160 celecoxib...... 100 BLISOVI 24 FE...... 33 CAMILA...... 33 CELLCEPT...... 85 BLISOVI FE 1.5/30 (28)...... 33 CAMRESE...... 33 CELONTIN...... 150 BLISOVI FE 1/20 (28)...... 33 CAMRESE LO...... 33 cephalexin...... 86 BLOOD GLUCOSE TEST...... 59 CANASA...... 101 CESAMET...... 6 BLUE TUBE...... 54 candesartan...... 23 CETACAINE...... 54 blunt needle, disposable...... 134 candesartan-hydrochlorothiazid...... 22 CETACAINE ANESTHETIC...... 54 BOSULIF...... 127 capecitabine...... 126 CETIRI-D...... 3

I-4 cetirizine...... 5 ciprofloxacin...... 88 codeine-guaifenesin...... 41 cetirizine-pseudoephedrine...... 3 ciprofloxacin hcl...... 65, 74, 88 colchicine...... 77 cevimeline...... 126 citalopram...... 12 colesevelam...... 30 CHANTIX...... 153 CITRANATAL (DUAL-IRON)...... 160 colestipol...... 30 CHANTIX CONTINUING MONTH CITRANATAL DHA (ALGAL OIL)..160 COLOR LANCETS...... 106 BOX...... 153 CLARAVIS...... 42 COMBIGAN...... 75 CHANTIX STARTING MONTH CLARINEX-D 12 HOUR...... 3 COMBIPATCH...... 82 BOX...... 153 clarithromycin...... 87 COMBIVENT RESPIMAT...... 9 CHARLOTTE 24 FE...... 33 CLARITIN...... 5 COMETRIQ...... 128 CHATEAL (28)...... 33 CLEANSING WASH...... 46 COMFORT EZ INSULIN SYRINGE CHATEAL EQ (28)...... 33 CLEAR EYES NATURAL TEARS... 77 ...... 113 CHEMET...... 132 CLEARLAX...... 103 COMFORT EZ LANCETS...... 106 CHILDREN'S ALAWAY...... 71 CLEOCIN...... 158 COMFORT EZ PEN NEEDLES.....134 CHILDREN'S ALLERGY CLEVER CHEK LANCETS...... 106 COMFORT LANCETS...... 106 RELIEF(LOR)...... 5 CLEVER CHOICE MICRO TEST COMPLERA...... 95 CHILDREN'S ASPIRIN...... 79 STRIP...... 59 COMPLETENATE...... 160 CHILDREN'S IBUPROFEN...... 100 CLEVER CHOICE PRO...... 59 COMPRO...... 6 CHILDREN'S NASACORT...... 6 CLEVER CHOICE TALK TEST...... 59 CONDOMS-PREM LUBRICATED.131 CHILDREN'S PROFEN IB...... 100 CLEVER CHOICE TEST STRIPS... 59 CONDYLOX...... 53 chlordiazepoxide hcl...... 15 CLEVER CHOICE VOICE+ TEST...59 CONSTULOSE...... 103 chlordiazepoxide-clidinium...... 155 CLICKFINE PEN NEEDLE...... 134 CONTOUR NEXT TEST STRIPS....59 chlorhexidine gluconate...... 130 CLIMARA PRO...... 82 CONTOUR TEST STRIPS...... 59 chloroquine phosphate...... 91 CLINDAGEL...... 44 COOL GLUCOSE TEST STRIP...... 59 chlorothiazide...... 28 clindamycin hcl...... 91 COREMINO...... 89 chlorpromazine...... 18 CLINDAMYCIN PEDIATRIC...... 91 CORLANOR...... 31 chlorthalidone...... 28 clindamycin phosphate...... 44, 158 CORTAID...... 48 chlorzoxazone...... 153 clindamycin-benzoyl peroxide...... 42 CORTIFOAM...... 102 CHOICEDM CLARUS...... 59 clindamycin-tretinoin...... 42 cortisone...... 98 CHOLBAM...... 103 CLINDESSE...... 158 CORTISONE cholecalciferol (vitamin d3)...... 163 clobazam...... 149 (HYDROCORTISONE)...... 48 cholestyramine (with sugar)...... 29 clobetasol...... 48 CORTISONE WITH ALOE...... 48 CHOLESTYRAMINE LIGHT...... 30 clobetasol-emollient...... 48 CORTISPORIN...... 47 choline,magnesium salicylate...... 142 clocortolone pivalate...... 48 CORTISPORIN-TC...... 65 chorionic gonadotropin, human...... 67 clomiphene citrate...... 67 CORTIZONE-10...... 48 CIALIS...... 67 clomipramine...... 14 CORTIZONE-10 PLUS...... 48 CICLODAN...... 44 clonazepam...... 149 CORTIZONE-10 WITH ALOE...... 48 CICLODAN KIT...... 44 clonidine...... 23 COSOPT (PF)...... 75 ciclopirox...... 45 clonidine hcl...... 19, 23 COVARYX...... 81 ciclopirox-ure-camph-menth-euc..... 45 clopidogrel...... 80 COVARYX H.S...... 81 cilostazol...... 80 clorazepate dipotassium...... 15, 16 CREON...... 154 CILOXAN...... 74 clotrimazole...... 45, 89, 158 CRIXIVAN...... 94 CIMDUO...... 92 CLOTRIMAZOLE AF...... 45 cromolyn...... 10, 75 cimetidine...... 156 CLOTRIMAZOLE-7...... 158 CROTAN...... 46 cimetidine hcl...... 156 clotrimazole-betamethasone...... 44 CRYSELLE (28)...... 33 CIMZIA...... 97 CLOVIQUE...... 132 CUPRIMINE...... 96 CIMZIA POWDER FOR RECONST 96 clozapine...... 17 CURITY ALCOHOL SWABS...... 52 CIMZIA STARTER KIT...... 97 COAGUCHEK LANCETS...... 106 CUROSURF...... 141 CIPRO HC...... 65 codeine sulfate...... 143 CUVPOSA...... 155 CIPRODEX...... 65 codeine-butalbital-asa-caff...... 147 cyanocobalamin (vitamin b-12)...... 163

I-5 CYCLAFEM 1/35 (28)...... 33 desonide...... 49 doxazosin...... 22 CYCLAFEM 7/7/7 (28)...... 34 desoximetasone...... 49 doxepin...... 14, 51 cyclobenzaprine...... 153 desvenlafaxine...... 13 doxercalciferol...... 69 CYCLOMYDRIL...... 76 desvenlafaxine succinate...... 13 doxycycline hyclate...... 89, 131 cyclopentolate...... 76 dexamethasone...... 98 doxycycline monohydrate...... 89 cyclophosphamide...... 126 DEXAMETHASONE INTENSOL..... 98 DRAMAMINE LESS DROWSY...... 6 cycloserine...... 90 dexamethasone sodium phosphate.72 DRITHOCREME HP...... 55 CYCLOSET...... 57 DEXILANT...... 156 dronabinol...... 6 cyclosporine...... 85 dexmethylphenidate...... 20 DROPLET INSULIN SYR HALF cyclosporine modified...... 85 dextroamphetamine...... 15 UNIT...... 113 cyproheptadine...... 4 dextroamphetamine-amphetamine..15 DROPLET INSULIN SYRINGE..... 114 CYRED...... 34 DIASTIX...... 65 DROPLET LANCETS...... 106 CYRED EQ...... 34 DIATRUE PLUS TEST STRIP...... 59 DROPLET MICRON PEN NEEDLE CYSTAGON...... 157 diazepam...... 16, 149 ...... 134 CYSTARAN...... 77 DIAZEPAM INTENSOL...... 16 DROPLET PEN NEEDLE...... 134 dalfampridine...... 130 diclofenac potassium...... 100 DROPSAFE PEN NEEDLE...... 134 DALIRESP...... 10 diclofenac sodium...... 51, 54, 72, 100 drospirenone-e.estradiol-lm.fa...... 34 danazol...... 70 diclofenac-misoprostol...... 100 drospirenone-ethinyl estradiol...... 34 dantrolene...... 153 dicloxacillin...... 88 DROXIA...... 80 dapsone...... 42, 90 dicyclomine...... 154 DRY EYE RELIEF...... 77 DARAPRIM...... 91 didanosine...... 93 DUAVEE...... 81 darifenacin...... 158 DIFICID...... 87 DULERA...... 9 DARIO BLOOD GLUCOSE TEST diflorasone...... 49 duloxetine...... 13 STRIP...... 59 diflunisal...... 142 DUREX AVANTI BARE REAL DASETTA 1/35 (28)...... 34 DIGITEK...... 21 FEEL...... 131 DASETTA 7/7/7 (28)...... 34 DIGOX...... 21 DUREZOL...... 72 DAVOL IRRIGATION SYRINGE... 113 digoxin...... 21 dutasteride...... 157 DAVOL PISTON IRRIGATION...... 113 dihydroergotamine...... 145 dutasteride-tamsulosin...... 157 DAYSEE...... 34 DILANTIN...... 150 DYMISTA...... 5 DAYTRANA...... 19 DILATRATE-SR...... 31 DYRENIUM...... 26 DEBACTEROL...... 131 diltiazem hcl...... 25 E.C. PRIN...... 142 DEBLITANE...... 34 DILT-XR...... 25 E.E.S. 400...... 87 DECADRON...... 98 DIPENTUM...... 101 EASY COMFORT ALCOHOL PAD. 52 DELSTRIGO...... 95 diphenoxylate-atropine...... 103 EASY COMFORT INSULIN demeclocycline...... 89 dipyridamole...... 80 SYRINGE...... 114 DEMSER...... 23 disopyramide phosphate...... 20 EASY COMFORT LANCETS...... 106 DENAVIR...... 46 DISPOSABLE NEEDLES...... 134 EASY COMFORT PEN NEEDLES 135 DENTA 5000 PLUS...... 159 disulfiram...... 15 EASY GLIDE CATHETER TIP DENTAGEL...... 159 DIURIL...... 28 SYRING...... 114 DEPEN TITRATABS...... 96 divalproex...... 150 EASY GLIDE DENTAL IRRIG DERMACINRX SILAPAK...... 49 DIVIGEL...... 82 SYRING...... 114 DERMAREST ECZEMA dofetilide...... 20 EASY GLIDE INSULIN SYRINGE.114 (HYDROCORT)...... 49 donepezil...... 11, 12 EASY GLIDE LUER LOCK DERMAWERX SDS...... 49 DONNATAL...... 154 SYRINGE...... 114 DESCOVY...... 92 dorzolamide...... 75 EASY GLIDE LUER SLIP TB desipramine...... 14 dorzolamide-timolol...... 75 SYRING...... 114 desloratadine...... 5 dorzolamide-timolol (pf)...... 75 EASY GLIDE PEN NEEDLE...... 135 desmopressin...... 67 DOTTI...... 82 EASY GLUCO G2...... 59 desog-e.estradiol/e.estradiol...... 34 DOVER BULB SYRINGE...... 105 EASY PLUS II TEST...... 59

I-6 EASY STEP...... 59 EASY TRAK GLUCOSE TEST...... 59 EMCYT...... 129 EASY TALK GLUCOSE TEST...... 59 EASY TRAK II TEST STRIP...... 59 EMOQUETTE...... 34 EASY TOUCH...... 116, 135 EASY TWIST AND CAP LANCETS EMSAM...... 18 EASY TOUCH ALCOHOL PREP ...... 106 EMTRIVA...... 93 PADS...... 52 EASYGLUCO PLUS...... 59 enalapril maleate...... 23 EASY TOUCH FLIPLOCK EASYGLUCO TEST...... 59 enalapril-hydrochlorothiazide...... 21 INSULIN...... 114 EASYMAX...... 60 ENBREL...... 97 EASY TOUCH FLIPLOCK EASYMAX 15 TEST STRIPS...... 59 ENBREL MINI...... 97 NEEDLE...... 135 EASYPOINT NEEDLE...... 136 ENBREL SURECLICK...... 97 EASY TOUCH FLIPLOCK ECLIPSE NEEDLE...... 136 ENDARI...... 80 SYRINGE...... 115 ECLIPSE SYRINGE...... 116 ENDOCET...... 147 EASY TOUCH FLURINGE...... 115 EC-NAPROXEN...... 100 enoxaparin...... 78 EASY TOUCH FLURINGE econazole...... 45 ENPRESSE...... 34 FLIPLOCK...... 115 ECONTRA EZ...... 34 ENSKYCE...... 34 EASY TOUCH FLURINGE FLU ECONTRA ONE-STEP...... 34 entacapone...... 149 TRAY...... 115 ECOTRIN...... 142 entecavir...... 95 EASY TOUCH FLURINGE ECOTRIN LOW STRENGTH...... 80 ENTEREG...... 105 SHEATHLOCK...... 115 EDARBI...... 23 ENULOSE...... 103 EASY TOUCH HYPODERMIC EDLUAR...... 19 EPIDUO...... 42 NEEDLE...... 135 ED-SPAZ...... 154 EPIFOAM...... 54 EASY TOUCH INSULIN SAFETY EDURANT...... 93 epinastine...... 72 SYR...... 115 EEMT...... 81 epinephrine...... 21, 125, 126 EASY TOUCH INSULIN SYRINGE EEMT HS...... 81 EPISIL...... 141 ...... 115 efavirenz...... 93 EPITOL...... 150 EASY TOUCH LANCETS...... 106 EFFACLAR ADAPALENE...... 43 EPIVIR HBV...... 95 EASY TOUCH LUER LOCK EFFER-K...... 66 eplerenone...... 26 INSULIN...... 115 ELEMENT COMPACT TEST EPOGEN...... 78 EASY TOUCH LUER LOCK STRIPS...... 60 eprosartan...... 23 SYRINGE...... 116 ELEMENT TEST STRIPS...... 60 EPZICOM...... 93 EASY TOUCH PEN NEEDLE...... 135 ELESTRIN...... 82 ergocalciferol (vitamin d2)...... 163 EASY TOUCH SAFETY LANCETS eletriptan...... 145 ergoloid...... 32 ...... 106 ELIDEL...... 55 ERGOMAR...... 145 EASY TOUCH SAFETY PEN ELIGARD...... 68 ERIVEDGE...... 127 NEEDLE...... 135 ELIGARD (3 MONTH)...... 67 ERRIN...... 34 EASY TOUCH SHEATHLOCK ELIGARD (4 MONTH)...... 68 ERTACZO...... 45 INSULIN...... 116 ELIGARD (6 MONTH)...... 68 ERY PADS...... 44 EASY TOUCH SHEATHLOCK ELINEST...... 34 ERYPED 400...... 87 SYRG-NDL...... 116 ELIQUIS...... 78 ERY-TAB...... 87 EASY TOUCH SHEATHLOCK ELIQUIS DVT-PE TREAT 30D ERYTHROCIN (AS STEARATE).....87 SYRINGE...... 116 START...... 78 erythromycin...... 74, 87 EASY TOUCH SYR ALLERGY ELIXOPHYLLIN...... 11 erythromycin ethylsuccinate...... 87 TRAY...... 116 ELLA...... 34 erythromycin with ethanol...... 44 EASY TOUCH TEST STRIP...... 59 ELMIRON...... 157 erythromycin-benzoyl peroxide...... 44 EASY TOUCH TUBERCULIN EMBRACE BLOOD GLUCOSE ESBRIET...... 141 FLIPLOCK...... 116 SYSTEM...... 60 escitalopram oxalate...... 12 EASY TOUCH TUBERCULIN EMBRACE EVO TEST STRIPS...... 60 esomeprazole magnesium...... 156 SHEATHLK...... 116 EMBRACE LANCETS...... 106 ESTARYLLA...... 34 EASY TOUCH TWIST LANCETS..106 EMBRACE PRO TEST STRIPS...... 60 estazolam...... 19 EASY TOUCH UNI-SLIP...... 116 EMBRACE TALK TEST STRIPS.....60 ESTRACE...... 159

I-7 estradiol...... 82, 159 FANAPT...... 17 FLUBLOK QUAD 2020-2021 (PF)...84 estradiol-norethindrone acet...... 82 FANTASY CONDOM...... 131 FLUCELVAX QUAD 2020-2021...... 84 ESTRING...... 159 FARESTON...... 129 FLUCELVAX QUAD 2020-2021 ESTROGEL...... 82 FARXIGA...... 56 (PF)...... 84 estrogens-methyltestosterone...... 81 FARYDAK...... 128 fluconazole...... 90 eszopiclone...... 19 FAYOSIM...... 34 flucytosine...... 90 ethacrynic acid...... 26 FC2 FEMALE CONDOM...... 131 fludrocortisone...... 99 ethambutol...... 90 felbamate...... 150 FLULAVAL QUAD 2020-2021 (PF). 84 ethosuximide...... 150 felodipine...... 25 FLUMIST QUAD 2020-2021...... 84 ethyl chloride...... 54 FEMRING...... 159 flunisolide...... 6 ethynodiol diac-eth estradiol...... 34 FEMYNOR...... 34 fluocinolone...... 49 etidronate disodium...... 68 fenofibrate...... 30 fluocinolone acetonide oil...... 65 etodolac...... 100 fenofibrate micronized...... 30 fluocinolone and shower cap...... 49 etoposide...... 128 fenofibrate nanocrystallized...... 30 fluocinonide...... 49 EURAX...... 46 fenofibric acid...... 30 FLUOCINONIDE-E...... 49 EUTHYROX...... 70 fenofibric acid (choline)...... 30 fluocinonide-emollient...... 49 EVAMIST...... 82 fenoprofen...... 100 fluorescein-proparacaine...... 73 EVEKEO...... 15 fentanyl...... 143 fluoride (sodium)...... 159 EVENCARE G2...... 60 fentanyl citrate...... 143 FLUORIDEX DAILY DEFENSE.....159 EVENCARE G3 TEST...... 60 FENTORA...... 143 FLUORITAB...... 159 EVENCARE MINI GLUCOSE FERRIPROX...... 132 fluorometholone...... 72 TEST STR...... 60 ferrous sulfate...... 160 FLUOROPLEX...... 54 EVENCARE PROVIEW TEST FETZIMA...... 13 fluorouracil...... 54 STRIP...... 60 fexofenadine...... 5 fluoxetine...... 13 EVENCARE TEST...... 60 FIFTY50 SAFETY SEAL fluphenazine hcl...... 18 EVOLUTION TEST STRIPS...... 60 LANCETS...... 106 flurandrenolide...... 49 EVOTAZ...... 94 FIFTY50 TEST STRIP...... 60 flurazepam...... 19 EXCEL SYRINGE...... 116 filter needles...... 136 flurbiprofen...... 100 EXEL HYPODERMIC NEEDLES.. 136 FINACEA...... 43 flurbiprofen sodium...... 72 EXEL INSULIN...... 116 finasteride...... 157 flutamide...... 126 EXEL SYRINGE...... 116 FINE 30 UNIVERSAL LANCETS...106 fluticasone propionate...... 6, 49 EXELDERM...... 45 FINGERSTIX LANCETS...... 106 fluvastatin...... 28 exemestane...... 127 FIORICET...... 142 fluvoxamine...... 13 EXJADE...... 132 FIRAZYR...... 98 FLUZONE HIGHDOSE QUAD 20- EXTAVIA...... 129 FIRMAGON...... 127 21 PF...... 84 EYE DROP TEARS...... 77 FIRMAGON KIT W DILUENT FLUZONE QUAD 2020-2021...... 84 EYE ITCH RELIEF...... 72 SYRINGE...... 127 FLUZONE QUAD 2020-2021 (PF).. 84 E-Z JECT LANCETS...... 106 FISH OIL...... 30 FML FORTE...... 72 E-Z JECT THIN LANCETS...... 106 FLAREX...... 72 FML S.O.P...... 72 EZ SMART LANCETS...... 106 flavoxate...... 158 folic acid...... 160 EZ SMART PLUS TEST...... 60 flecainide...... 20 FOLIVANE-OB...... 160 EZ SMART TEST...... 60 FLECTOR...... 51 fondaparinux...... 78 ezetimibe...... 30 FLOVENT DISKUS...... 10 FORA 6 CONNECT GLUCOSE ezetimibe-simvastatin...... 28 FLOVENT HFA...... 10 STRIP...... 60 EZ-LETS...... 106 FLOW-EZE VENTED NEEDLE..... 136 FORA D15G STRIPS...... 60 FACTIVE...... 88 FLUAD 2020-2021 (65 YR UP)(PF) 84 FORA D20...... 60 FALMINA (28)...... 34 FLUAD QUAD 2020-21(65Y FORA D40-G31 TEST STRIPS...... 60 famciclovir...... 92 UP)(PF)...... 84 FORA G20...... 60 famotidine...... 156 FLUARIX QUAD 2020-2021 (PF)....84

I-8 FORA G30-PREMIUM V10 TEST GE100 BLOOD GLUCOSE TEST GRALISE...... 130 STRP...... 60 STRIP...... 61 granisetron hcl...... 6 FORA GD50 TEST STRIPS...... 60 GELCLAIR...... 141 GRASTEK...... 4 FORA GTEL GLUCOSE TEST GELNIQUE...... 158 griseofulvin microsize...... 90 STRIP...... 60 gemfibrozil...... 30 griseofulvin ultramicrosize...... 90 FORA TEST STRIP...... 60 GENERLAC...... 103 GUAIATUSSIN AC...... 41 FORA TN'G VOICE TEST STRIPS. 60 GENGRAF...... 85 GUAIFENESIN AC...... 41 FORA V10...... 60 GENOTROPIN...... 69 GUAIFENESIN DAC...... 41 FORA V10-V12-D10-D20 STRIPS.. 60 GENOTROPIN MINIQUICK...... 68 guanfacine...... 19, 23 FORA V12 GLUCOSE...... 60 GENSTRIP TEST STRIP...... 61 guanidine...... 126 FORA V20...... 60 GENTAK...... 74 GYNAZOLE-1...... 158 FORA V30A...... 60 gentamicin...... 44, 74 HAILEY...... 35 FORACARE GD20...... 60 GENTLELAX...... 104 HAILEY 24 FE...... 35 FORACARE GD40 TEST STRIPS.. 60 GENULTIMATE TEST STRIP...... 61 HAILEY FE 1.5/30 (28)...... 35 FORACARE LANCETS...... 106 GENVOYA...... 95 HAILEY FE 1/20 (28)...... 35 FORTEO...... 68 GERI-HYDROLAC...... 52 halobetasol propionate...... 49 FORTISCARE GLUCOSE TEST GIANVI (28)...... 34 HALOG...... 49 STRIPS...... 60 GILENYA...... 129 haloperidol...... 18 FOSAMAX PLUS D...... 68 GILOTRIF...... 128 haloperidol lactate...... 18 fosamprenavir...... 94 glatiramer...... 129 HARMONY GLUCOSE TEST fosinopril...... 23 GLATOPA...... 129 STRIP...... 61 fosinopril-hydrochlorothiazide...... 21 glimepiride...... 57 HARVONI...... 95 FRAGMIN...... 78, 79 glipizide...... 57 HEALTHPRO TEST STRIPS...... 61 FREESTYLE INSULINX...... 60 glipizide-metformin...... 58 HEALTHWISE INSULIN SYRINGE FREESTYLE INSULINX TEST GLUCAGEN HYPOKIT...... 63 ...... 117 STRIPS...... 60 GLUCAGON EMERGENCY KIT HEALTHWISE PEN NEEDLE...... 136 FREESTYLE LANCETS...... 106 (HUMAN)...... 63 HEALTHY ACCENTS UNIFINE FREESTYLE LITE STRIPS...... 60 GLUCO NAVII TEST STRIP...... 61 PENTIP...... 136 FREESTYLE PRECISION...... 117 GLUCOCARD 01 SENSOR PLUS.. 61 HEALTHY ACCENTS UNILET FREESTYLE PRECISION NEO GLUCOCARD EXPRESSION...... 61 LANCET...... 106 STRIPS...... 61 GLUCOCARD SHINE TEST HEALTHYLAX...... 104 FREESTYLE TEST...... 61 STRIPS...... 61 HEARTBURN PREVENTION...... 156 FREESTYLE UNISTIK 2...... 106 GLUCOCARD VITAL SENSOR...... 61 HEARTBURN RELIEF frovatriptan...... 145 GLUCOCARD VITAL TEST (FAMOTIDINE)...... 156 furosemide...... 26 STRIPS...... 61 HEATHER...... 35 FUZEON...... 93 GLUCOCOM GLUCOSE...... 61 HELIDAC...... 155 FYAVOLV...... 82 GLUCOCOM LANCETS...... 106 HEMORRHOIDAL RELIEF...... 102 FYCOMPA...... 150 glyburide...... 57 heparin (porcine)...... 79 G TUSSIN AC...... 41 glyburide micronized...... 57 heparin, porcine (pf)...... 79 gabapentin...... 150 glyburide-metformin...... 58 HETLIOZ...... 18 galantamine...... 12 GLYCOLAX...... 104 HIDEX...... 98 GALZIN...... 132 glycopyrrolate...... 155 HIZENTRA...... 83 GAMMAKED...... 83 GLYXAMBI...... 58 HORIZANT...... 130 GAMUNEX-C...... 83 GM100...... 61 huber safety needles (disp.)...... 136 ganirelix...... 69 GOJJI BLOOD GLUCOSE TEST HUMALOG JUNIOR KWIKPEN U- gatifloxacin...... 74 STRIP...... 61 100...... 63 GAVILYTE-C...... 103 GOJJI LANCETS...... 106 HUMALOG KWIKPEN INSULIN...... 63 GAVILYTE-G...... 103 GOLYTELY...... 104 HUMALOG MIX 50-50 INSULN U- GAVILYTE-N...... 104 GOODLIFE AC-302 TEST STRIP... 61 100...... 63

I-9 HUMALOG MIX 50-50 KWIKPEN... 63 hydroxychloroquine...... 91 insulin syringe-needle u-100..117, 118 HUMALOG MIX 75-25 KWIKPEN... 63 hydroxyurea...... 126 INSUPEN...... 136 HUMALOG MIX 75-25(U- hydroxyzine hcl...... 4 INTEGRA PRECISIONGLIDE 100)INSULN...... 63 hydroxyzine pamoate...... 4 NEEDLE...... 136 HUMALOG U-100 INSULIN...... 63 HYOPHEN...... 87 INTEGRA SYRINGE...... 118 HUMATROPE...... 69 hyoscyamine sulfate...... 155 INTELENCE...... 93 HUMIRA...... 97 HYOSYNE...... 155 INTERLINK SYRINGE AND HUMIRA PEN...... 97 HYPODERMIC NEEDLES...... 136 CANNULA...... 118 HUMIRA PEN CROHNS-UC-HS ibandronate...... 68 INTRON A...... 84, 85 START...... 97 IBRANCE...... 128 INTROVALE...... 35 HUMIRA PEN PSOR-UVEITS- IBU...... 100 INVACARE LANCETS...... 106 ADOL HS...... 97 ibuprofen...... 100 INVIRASE...... 94 HUMIRA(CF)...... 97 ibuprofen-oxycodone...... 143 INVOKAMET...... 58 HUMIRA(CF) PEDI CROHNS icatibant...... 98 INVOKANA...... 57 STARTER...... 97 ICLUSIG...... 128 INZO ANTIFUNGAL...... 45 HUMIRA(CF) PEN...... 97 IGLUCOSE TEST STRIP...... 61 ipratropium bromide...... 7, 131 HUMIRA(CF) PEN CROHNS-UC- ILEVRO...... 72 ipratropium-albuterol...... 9 HS...... 97 imatinib...... 128 irbesartan...... 23 HUMIRA(CF) PEN PSOR-UV- IMBRUVICA...... 128 irbesartan-hydrochlorothiazide...... 22 ADOL HS...... 97 imipramine hcl...... 14 IRRIGATION SYRINGE...... 118 HUMULIN 70/30 U-100 INSULIN.... 63 imipramine pamoate...... 14 ISENTRESS...... 95 HUMULIN N NPH U-100 INSULIN.. 63 imiquimod...... 84 ISENTRESS HD...... 94 HUMULIN R REGULAR U-100 IMODIUM A-D...... 103 ISIBLOOM...... 35 INSULN...... 63 INCASSIA...... 35 ISOCHRON...... 31 HUMULIN R U-500 (CONC) INCONTROL ALCOHOL PADS...... 52 isoniazid...... 90 INSULIN...... 63 INCONTROL PEN NEEDLE...... 136 ISORDIL...... 31 HUMULIN R U-500 (CONC) INCONTROL SUPER THIN isosorbide dinitrate...... 31 KWIKPEN...... 64 LANCETS...... 106 isosorbide mononitrate...... 31 HYCAMTIN...... 127 INCONTROL ULTRA THIN isotretinoin...... 42 hydralazine...... 24 LANCETS...... 106 isoxsuprine...... 32 hydrochlorothiazide...... 28 INCRELEX...... 69 isradipine...... 25 hydrocodone-acetaminophen...... 147 INCRUSE ELLIPTA...... 7 ISTALOL...... 75 hydrocodone-chlorpheniramine...... 41 indapamide...... 28 ITCH RELIEF (CLOTRIMAZOLE)... 45 hydrocodone-homatropine...... 41 INDERAL XL...... 24 ITCHY EYE DROPS...... 72 hydrocodone-ibuprofen...... 143 INDOCIN...... 100 itraconazole...... 90 hydrocortisone...... 50, 98, 102 indomethacin...... 100 IV PREP WIPES...... 52 hydrocortisone acetate...... 50, 102 INFASURF...... 141 ivermectin...... 91 hydrocortisone butyrate...... 50 INFINITY TEST STRIPS...... 61 JAIMIESS...... 35 hydrocortisone butyr-emollient...... 50 INFINITY VOICE TEST STRIP...... 61 JAKAFI...... 127 HYDROCORTISONE PLUS...... 50 INJECT EASE LANCETS...... 106 JANTOVEN...... 77 hydrocortisone valerate...... 50 INLYTA...... 128 JANUMET...... 56 hydrocortisone-acetic acid...... 65 INNOPRAN XL...... 24 JANUMET XR...... 56 hydrocortisone-aloe vera...... 50 INOVA...... 53 JANUVIA...... 57 hydrocortisone-iodoquinl-aloe2...... 43 INOVA 4-1...... 53 JARDIANCE...... 57 hydrocortisone-iodoquinol...... 43 INOVA 8-2...... 53 JASMIEL (28)...... 35 hydrocortisone-pramoxine...... 54, 102 insulin syr/ndl u100 half mark...... 117 JENCYCLA...... 35 HYDROCREAM...... 50 INSULIN SYRINGE...... 117 JENTADUETO...... 56 HYDROMET...... 41 INSULIN SYRINGE MICROFINE.. 117 JINTELI...... 82 hydromorphone...... 143 insulin syringe needleless...... 117 JOCK ITCH (CLOTRIMAZOLE)...... 45

I-10 JOLESSA...... 35 K-PHOS NO 2...... 157 leuprolide...... 68 JUBLIA...... 45 K-PHOS ORIGINAL...... 157 levalbuterol hcl...... 8 JULEBER...... 35 KRISTALOSE...... 104 levalbuterol tartrate...... 8 JULUCA...... 92 K-TAB...... 66 LEVATOL...... 24 JUNEL 1.5/30 (21)...... 35 KURVELO (28)...... 35 LEVEMIR FLEXTOUCH U-100 JUNEL 1/20 (21)...... 35 KUVAN...... 126 INSULN...... 64 JUNEL FE 1.5/30 (28)...... 35 l norgest/e.estradiol-e.estrad..... 35, 36 LEVEMIR U-100 INSULIN...... 64 JUNEL FE 1/20 (28)...... 35 labetalol...... 22 levetiracetam...... 151 JUNEL FE 24...... 35 LACRISERT...... 77 levobunolol...... 76 JUXTAPID...... 29 lactulose...... 104 levocarnitine...... 132 JYNARQUE...... 65 LAMICTAL XR STARTER (BLUE).150 levocarnitine (with sugar)...... 132 KADIAN...... 143 LAMICTAL XR STARTER levocetirizine...... 5 KAITLIB FE...... 35 (GREEN)...... 150 levofloxacin...... 74, 88, 89 KALETRA...... 94 LAMICTAL XR STARTER LEVONEST (28)...... 36 KALLIGA...... 35 (ORANGE)...... 151 levonorgestrel...... 36 KALYDECO...... 141 lamivudine...... 94, 95 levonorgestrel-ethinyl estrad...... 36 KARIVA (28)...... 35 lamivudine-zidovudine...... 93 levonorg-eth estrad triphasic...... 36 KELNOR 1/35 (28)...... 35 lamotrigine...... 151 LEVORA-28...... 36 KELNOR 1-50...... 35 lancets...... 106, 107 levorphanol tartrate...... 143 KERAFOAM...... 53 LANCETS, SUPER THIN...... 107 levothyroxine...... 70 KERYDIN...... 45 LANCETS,THIN...... 107 LEVOXYL...... 70 ketoconazole...... 45, 90 LANCETS,ULTRA THIN...... 107 LEXIVA...... 94 KETODAN...... 45 lancing device with lancets...... 62 lidocaine...... 55, 102 KETONE CARE...... 141 lansoprazole...... 156 lidocaine hcl...... 54, 55, 101 KETONE URINE TEST...... 141 lanthanum...... 65 LIDOCAINE VISCOUS...... 101 ketoprofen...... 100 LANTUS U-100 INSULIN...... 64 lidocaine-hydrocortisone-aloe...... 102 ketorolac...... 72, 101 LARIN 1.5/30 (21)...... 36 lidocaine-prilocaine...... 55 KETOSTIX...... 141 LARIN 1/20 (21)...... 36 LIDORX...... 55 ketotifen fumarate...... 72 LARIN 24 FE...... 36 LIFESHIELD BLUNT CANNULA KIMONO CONDOMS(NON- LARIN FE 1.5/30 (28)...... 36 ...... 118, 137 LUBRICATED)...... 131 LARIN FE 1/20 (28)...... 36 LILLOW (28)...... 36 KIMONO MAXX CONDOMS...... 131 LARISSIA...... 36 lindane...... 46 KIMONO MICROTHIN AQUA LASTACAFT...... 72 linezolid...... 88 LUBE CON...... 131 latanoprost...... 76 LINZESS...... 102 KIMONO MICROTHIN CONDOMS LATUDA...... 17 liothyronine...... 70 ...... 131 LAXACLEAR...... 104 lisinopril...... 23 KIMONO MICROTHIN LARGE LAXATIVE PEG 3350...... 104 lisinopril-hydrochlorothiazide...... 21 CONDOMS...... 131 LAYOLIS FE...... 36 LITE COAT ASPIRIN...... 143 KIMONO TEXTURED CONDOMS 131 LAZANDA...... 143 LITE TOUCH INSULIN PEN KINERET...... 96 LC-5...... 102 NEEDLES...... 137 KIONEX (WITH SORBITOL)...... 65 ledipasvir-sofosbuvir...... 95 LITE TOUCH INSULIN SYRINGE.118 KLOR-CON 10...... 66 LEENA 28...... 36 LITE TOUCH LANCETS...... 107 KLOR-CON 8...... 66 leflunomide...... 97 lithium carbonate...... 16 KLOR-CON M10...... 66 LESSINA...... 36 lithium citrate...... 16 KLOR-CON M15...... 66 LETAIRIS...... 27 LITHOSTAT...... 103 KLOR-CON M20...... 66 letrozole...... 127 LIVALO...... 28 KLOR-CON/EF...... 66 leucovorin calcium...... 129 LO LOESTRIN FE...... 36 KOMBIGLYZE XR...... 56 LEUKERAN...... 126 LO-DOSE ASPIRIN...... 80 KORLYM...... 58 LEUKINE...... 79 LODOSYN...... 149

I-11 LOJAIMIESS...... 36 MAXICOMFORT INSULIN methocarbamol...... 153 loperamide...... 103 SYRINGE...... 118 methotrexate sodium...... 126 lopinavir-ritonavir...... 94 MAXI-COMFORT INSULIN methotrexate sodium (pf)...... 126 LOPROX (AS OLAMINE)...... 45 SYRINGE...... 118 methoxsalen...... 55 LORADAMED...... 5 MAXICOMFORT SAFETY PEN methscopolamine...... 155 LORATA-D...... 3 NEEDLE...... 137 methyldopa...... 23 loratadine...... 5 MAXIDEX...... 72 methyldopa-hydrochlorothiazide...... 23 LORATA-DINE D...... 4 MAXI-TUSS AC...... 42 methylergonovine...... 40 LORATADINE-D...... 4 meclizine...... 6 methylphenidate hcl...... 20 lorazepam...... 16 meclofenamate...... 101 methylprednisolone...... 98 LORCET HD...... 147 MEDI-MECLIZINE...... 6 methyltestosterone...... 81 LORYNA (28)...... 36 MEDISENSE THIN LANCETS...... 107 metipranolol...... 76 losartan...... 23 MEDLANCE PLUS LANCETS...... 107 metoclopramide hcl...... 156 losartan-hydrochlorothiazide...... 22 MEDLANCE PLUS SPECIAL metolazone...... 28 LOTEMAX...... 72 BLADE...... 107 metoprolol succinate...... 24 LOTRIMIN ULTRA...... 45 MEDROL...... 98 metoprolol ta-hydrochlorothiaz...... 25 lovastatin...... 28 medroxyprogesterone...... 32, 83 metoprolol tartrate...... 24 LOW-OGESTREL (28)...... 37 mefenamic acid...... 101 metronidazole...... 43, 91, 158 loxapine succinate...... 17 mefloquine...... 91 mexiletine...... 20 LO-ZUMANDIMINE (28)...... 37 megestrol...... 129, 131 MIBELAS 24 FE...... 37 LUBRICANT (P-GLYCOL- MEKINIST...... 127 MICATIN...... 45 GLYCERIN)...... 77 MELODETTA 24 FE...... 37 MICONAZOLE 7...... 158 LUDENT FLUORIDE...... 159 meloxicam...... 101 miconazole nitrate...... 45, 158 LUER LOCK SYRINGE...... 118 melphalan...... 126 MICONAZOLE-3...... 159 LUER SLIP TIP SYRINGE TRAY..118 memantine...... 11 miconazole-skin clnsr17...... 159 LUER-LOK TIP...... 118 MENEST...... 82 MICRO BLOOD GLUCOSE...... 61 luliconazole...... 45 MENOSTAR...... 82 MICRO THIN LANCETS...... 107 LUMIGAN...... 76 meperidine...... 143 MICRODOT BLOOD GLUCOSE LUTERA (28)...... 37 MEPHYTON...... 80 SYSTEM...... 61 LUZU...... 45 meprobamate...... 16 MICRODOT INSULIN PEN LYRICA...... 151 mercaptopurine...... 126 NEEDLE...... 137 LYSODREN...... 128 mesalamine...... 101 MICRODOT XTRA BLOOD LYZA...... 37 mesalamine with cleansing wipe... 101 GLUCOSE...... 61 MAGELLAN INSULIN SAFETY MESNEX...... 129 MICROGESTIN 1.5/30 (21)...... 37 SYRNG...... 118 MESTINON...... 12 MICROGESTIN 1/20 (21)...... 37 MAGELLAN SAFETY NEEDLE.....137 METADATE ER...... 20 MICROGESTIN FE 1.5/30 (28)...... 37 MAGELLAN SAFETY SYRINGE...118 metaproterenol...... 8 MICROGESTIN FE 1/20 (28)...... 37 MAGELLAN SYRINGE...... 118 METAXALL...... 153 MICROLET LANCET...... 107 MAGELLAN TUBERCULIN metaxalone...... 153 midodrine...... 31 SAFETY SYR...... 118 metformin...... 58 MIFEPREX...... 131 magnesium oxide...... 160 methadone...... 144 MIGERGOT...... 145 malathion...... 46 METHADONE INTENSOL...... 144 miglitol...... 57 maprotiline...... 14 METHADOSE...... 144 miglustat...... 132 MARLISSA (28)...... 37 methamphetamine...... 15 MIGRANAL...... 145 MARNATAL-F...... 160 methazolamide...... 75 MILI...... 37 MARPLAN...... 12 methenamine hippurate...... 87 MILLIPRED...... 99 MATULANE...... 128 methenamine mandelate...... 87 MILLIPRED DP...... 99 MATZIM LA...... 25 methimazole...... 70 MIMVEY...... 82 MAXICOMFORT II PEN NEEDLE.137 METHITEST...... 81 MINI ULTRA-THIN II...... 137

I-12 MINITRAN...... 31 MONOJECT MEDICATION MULTAQ...... 21 MINIVELLE...... 83 TRANSF NDL...... 138 MULTI-DRAW NEEDLE...... 138 minocycline...... 89 MONOJECT PHARMACY TRAY MULTI-VIT WITH FLUORIDE- minoxidil...... 24 LUER...... 119 IRON...... 160 mirtazapine...... 12 MONOJECT PHARMACY TRAY mupirocin...... 44 MIRVASO...... 43 REG TIP...... 119 mupirocin calcium...... 44 misoprostol...... 155 MONOJECT PREFILL MY CHOICE...... 37 MITOSOL...... 76 ADVANCED NS...... 67 MY WAY...... 37 modafinil...... 19 MONOJECT REG TIP NON- mycophenolate mofetil...... 85 moexipril...... 23 STERILE...... 119 mycophenolate sodium...... 85 mometasone...... 6, 50 MONOJECT REGULAR LUER...... 119 MYGLUCOHEALTH...... 61 MONDOXYNE NL...... 89 MONOJECT SAFETY LUER LOCK MYGLUCOHEALTH LANCETS.....107 MONISTAT 7...... 159 TIP...... 119 MYLERAN...... 126 MONOJECT 0.9% SODIUM MONOJECT SAFETY SYRINGES 120 MYNATAL...... 160 CHLORIDE...... 67 MONOJECT SMARTIP CANNULA120 MYNATAL PLUS...... 160 MONOJECT 140CC PISTON MONOJECT SYRINGE...... 120 MYNATAL-Z...... 160 SYRINGE...... 118 MONOJECT SYRINGE MYNATE 90 PLUS...... 161 MONOJECT 35CC SYRINGE ECCENTRI LUER...... 120 MYORISAN...... 42 CATH TIP...... 118 MONOJECT SYRINGE LUER LOK MYRBETRIQ...... 157 MONOJECT 3CC SYR 25GX1".... 119 ...... 120 MYTESI...... 103 MONOJECT ALLERGY TRAY...... 119 MONOJECT SYRINGE REGULAR nabumetone...... 101 MONOJECT ALLERGY TRAY LUER...... 120 nadolol...... 24 DETACH...... 119 MONOJECT SYRINGE TOOMEY nadolol-bendroflumethiazide...... 25 MONOJECT BLOOD TYPE...... 120 naftifine...... 45 COLLECTION...... 137 MONOJECT TB...... 120 NAFTIN...... 45 MONOJECT CONTROL SYRINGE MONOJECT TB LUER LOK...... 120 naloxone...... 19 LUER...... 119 MONOJECT TB REGULAR LUER naltrexone...... 19 MONOJECT DISPOSABLE TIP...... 120 NAMENDA XR...... 11 SYRINGE...... 119 MONOJECT TB SAFETY naproxen...... 101 MONOJECT ECCENTRIC NON- SYRINGE...... 120 naratriptan...... 145 STERILE...... 119 MONOJECT TUBERCULIN NARCAN...... 19 MONOJECT ENFIT STERILE SYRINGE...... 120 NASAL ALLERGY...... 6 SYRINGE...... 119 MONOJECT ULTRA COMFORT NASCOBAL...... 163 MONOJECT ENFIT SYRINGE...... 119 INSULIN...... 120 NATACHEW (FE BIS- MONOJECT ENFIT SYRINGE MONOLET LANCETS...... 107 GLYCINATE)...... 161 CAP...... 119 MONOLET THIN LANCETS...... 107 NATACYN...... 74 MONOJECT FILTER ASPIRATOR137 MONO-LINYAH...... 37 NATAZIA...... 37 MONOJECT FILTER NEEDLE...... 137 montelukast...... 10 nateglinide...... 57 MONOJECT HYPODERMIC MONUROL...... 87 NATPARA...... 70 NEEDLES...... 137 morphine...... 144 NATURAL TEARS (PF)...... 77 MONOJECT HYPODERMIC morphine concentrate...... 144 NATURA-LAX...... 104 POLYPROPYL...... 138 MOTION RELIEF (MECLIZINE)...... 6 NEBUPENT...... 92 MONOJECT INSULIN SAFETY MOTION SICKNESS (MECLIZINE)...7 NEBUSAL...... 132 SYRING...... 119 MOTION SICKNESS II...... 7 NECON 0.5/35 (28)...... 37 MONOJECT INSULIN SYRINGE.. 119 MOTION SICKNESS needle (disp) 16 g...... 138 MONOJECT LUER-LOCK TIP...... 119 RELIEF(MECLIZ)...... 7 needle (disp) 18 g...... 138 MONOJECT MAGELLAN MOVIPREP...... 104 needle (disp) 19 g...... 138 SYRINGE...... 119 MOXEZA...... 74 needle (disp) 23 gauge...... 138 moxifloxacin...... 74, 89 needles, huber disposable...... 138

I-13 NEEVODHA (WITH ALGAL OIL)...161 noreth-ethinyl estradiol-iron...... 37 NUVAIL...... 54 nefazodone...... 13 norethindrone (contraceptive)...... 37 NUVARING...... 32 neomycin...... 90 norethindrone acetate...... 83 nystatin...... 45, 90 neomycin-bacitracin-poly-hc...... 71 norethindrone ac-eth estradiol...37, 83 nystatin-triamcinolone...... 45 neomycin-bacitracin-polymyxin...... 74 norethindrone-e.estradiol-iron....37, 38 OB COMPLETE ONE...... 161 neomycin-polymyxin b-dexameth.... 71 norgestimate-ethinyl estradiol...... 38 OB COMPLETE PETITE...... 161 neomycin-polymyxin-gramicidin...... 74 NORITATE...... 43 OB COMPLETE PREMIER...... 161 neomycin-polymyxin-hc...... 65, 71 NORLYDA...... 38 OB COMPLETE WITH DHA...... 161 NEO-POLYCIN...... 74 NORMAL SALINE FLUSH...... 67 OBSTETRIX DHA...... 161 NEO-POLYCIN HC...... 71 NORM-JECT...... 120 OBSTETRIX EC...... 161 NEO-SYNALAR...... 47 NORM-JECT TUBERKULIN...... 120 O-CAL PRENATAL...... 161 NESINA...... 57 NORMLGEL AG...... 43 OCELLA...... 38 NESTABS ABC...... 161 NORTHERA...... 31 ODEFSEY...... 95 NEUAC...... 42 NORTREL 0.5/35 (28)...... 38 OFEV...... 142 NEULASTA...... 79 NORTREL 1/35 (21)...... 38 ofloxacin...... 65, 74, 89 NEUPOGEN...... 79 NORTREL 1/35 (28)...... 38 olanzapine...... 17 NEUPRO...... 149 NORTREL 7/7/7 (28)...... 38 olanzapine-fluoxetine...... 19 NEUTEK 2TEK TEST STRIPS...... 61 nortriptyline...... 14 olmesartan...... 23 NEVANAC...... 73 NORVIR...... 94 olmesartan-amlodipin-hcthiazid...... 22 nevirapine...... 93 NO-STICK GLUCOSE...... 65 olmesartan-hydrochlorothiazide...... 22 NEW DAY...... 37 NOVA MAX GLUCOSE TEST...... 61 olopatadine...... 5, 72 NEWGEN...... 161 NOVA SAFETY LANCETS...... 107 omega-3 acid ethyl esters...... 30 NEXAVAR...... 128 NOVA SUREFLEX LANCETS...... 107 omeprazole...... 156 NEXIUM...... 156 NOVAREL...... 67 omeprazole-sodium bicarbonate... 156 NEXIUM 24HR...... 156 NOVOFINE 32...... 138 OMNARIS...... 6 niacin...... 30 NOVOFINE AUTOCOVER...... 138 OMNITROPE...... 69 NIACOR...... 30 NOVOFINE PLUS...... 138 ON CALL EXPRESS TEST STRIP..61 nicardipine...... 25 NOVOLIN 70/30 U-100 INSULIN.....64 ON CALL LANCET...... 107 nicotine...... 153 NOVOLIN N NPH U-100 INSULIN.. 64 ON CALL PLUS LANCET...... 107 nicotine (polacrilex)...... 153 NOVOLIN R REGULAR U-100 ON CALL PLUS TEST STRIP...... 61 NICOTROL...... 153 INSULN...... 64 ON CALL VIVID TEST STRIP...... 61 NICOTROL NS...... 153 NOVOLOG FLEXPEN U-100 ondansetron...... 7 nifedipine...... 25 INSULIN...... 64 ondansetron hcl...... 7 NIKKI (28)...... 37 NOVOLOG MIX 70-30 U-100 ONETOUCH DELICA LANCETS...107 nilutamide...... 126 INSULN...... 64 ONETOUCH DELICA PLUS nimodipine...... 26 NOVOLOG MIX 70-30FLEXPEN LANCET...... 107 nisoldipine...... 26 U-100...... 64 ONETOUCH SURESOFT NITRO-BID...... 31 NOVOLOG PENFILL U-100 LANCING DEV...... 107 NITRO-DUR...... 31 INSULIN...... 64 ONETOUCH ULTRA BLUE TEST nitrofurantoin...... 88 NOVOLOG U-100 INSULIN STRIP...... 61 nitrofurantoin macrocrystal...... 87 ASPART...... 64 ONETOUCH ULTRASOFT nitrofurantoin monohyd/m-cryst...... 88 NOVOTWIST...... 138 LANCETS...... 107 nitroglycerin...... 31, 32 NOXAFIL...... 90 ONETOUCH VERIO TEST NITRO-TIME...... 32 NP THYROID...... 70 STRIPS...... 61 nizatidine...... 156 NUCYNTA...... 144 ONFI...... 149, 150 NOBLE FORMULA HC...... 50 NUCYNTA ER...... 144 ONGLYZA...... 57 NOKOR NEEDLE...... 138 NUEDEXTA...... 130 ON-THE-GO LANCETS...... 107 NORA-BE...... 37 NUTRIARX...... 50 OPCICON ONE-STEP...... 38 NORDITROPIN FLEXPRO...... 69 NUTROPIN AQ NUSPIN...... 69 OPSUMIT...... 27

I-14 OPTION-2...... 38 PEGANONE...... 152 PLEGRIDY...... 129 OPTIUM EZ...... 61 PEGASYS...... 96 PNV-DHA...... 161 OPTIUM TEST...... 61 peg-electrolyte soln...... 104 PNV-FERROUS FUMARATE- OPTUMRX...... 61 PEGINTRON...... 96 DOCU-FA...... 161 ORACIT...... 157 PEN NEEDLE...... 138 PNV-OMEGA...... 161 ORALAIR...... 4 pen needle, diabetic...... 138, 139 PNV-SELECT...... 161 ORALONE...... 130 penicillin v potassium...... 88 PODOCON...... 53 ORENCIA...... 98 PENTASA...... 102 podofilox...... 53 ORENCIA CLICKJECT...... 98 pentazocine-naloxone...... 144 POLY HUB NEEDLE...... 139 ORENITRAM...... 27 PENTIPS...... 139 POLYCIN...... 74 ORFADIN...... 132 pentoxifylline...... 78 polyethylene glycol 3350...... 104 orphenadrine citrate...... 153 PERFOROMIST...... 9 polymyxin b sulf-trimethoprim...... 74 ORSYTHIA...... 38 perindopril erbumine...... 23 polyvinyl alcohol...... 77 OSCIMIN...... 155 PERIOGARD...... 130 POMALYST...... 127 OSCIMIN SL...... 155 permethrin...... 46 PONTOCAINE...... 55 OSCIMIN SR...... 155 perphenazine...... 18 PORTIA 28...... 38 oseltamivir...... 92 perphenazine-amitriptyline...... 14 POTABA...... 163 OSMOPREP...... 104 PERTZYE...... 154 potassium chloride...... 66 OSPHENA...... 70 PEXEVA...... 13 potassium citrate...... 157 OTEZLA...... 98 PHARMACIST CHOICE...... 61 POWDERLAX...... 104 OTEZLA STARTER...... 98 PHASEAL PROTECTOR...... 139 PR BENZOYL PEROXIDE...... 53 OTOVEL...... 65 phenazopyridine...... 158 PR NATAL 400...... 161 OTREXUP (PF)...... 96 phenelzine...... 12 PR NATAL 400 EC...... 161 OVACE PLUS...... 51 phenobarb-hyoscy-atropine-scop.. 155 PR NATAL 430...... 161 oxandrolone...... 81 phenobarbital...... 18 PR NATAL 430 EC...... 161 oxaprozin...... 101 PHENOHYTRO...... 155 PRADAXA...... 80 oxazepam...... 16 phenoxybenzamine...... 22 PRALUENT PEN...... 29 oxcarbazepine...... 151 phenylephrine hcl...... 73 pramipexole...... 149 oxiconazole...... 45 phenytoin...... 152 PRANDIN...... 57 OXISTAT...... 45 phenytoin sodium extended...... 152 prasugrel...... 80 OXTELLAR XR...... 152 PHILITH...... 38 pravastatin...... 29 oxybutynin chloride...... 158 PHOSLYRA...... 66 praziquantel...... 91 oxycodone...... 144 PHOSPHOLINE IODIDE...... 76 prazosin...... 22 oxycodone-acetaminophen...... 147 PHYSIOLYTE...... 52 PRECISION PCX PLUS TEST...... 61 oxycodone-aspirin...... 148 PHYSIOSOL IRRIGATION...... 52 PRECISION PCX TEST...... 61 oxymorphone...... 144 phytonadione (vitamin k1)...... 80 PRECISION POINT OF CARE PACERONE...... 21 PICATO...... 54 TEST...... 62 PACNEX HP...... 53 PIFELTRO...... 93 PRECISION Q-I-D TEST...... 62 PACNEX LP...... 53 pilocarpine hcl...... 76, 126 PRECISION XTRA TEST...... 62 paliperidone...... 17 pimozide...... 16 PRED MILD...... 73 PANCREAZE...... 154 PIMTREA (28)...... 38 PRED-G...... 71 PANRETIN...... 54 pindolol...... 24 PRED-G S.O.P...... 71 pantoprazole...... 156 pioglitazone...... 57 prednicarbate...... 50 paricalcitol...... 69 pioglitazone-glimepiride...... 58 prednisolone...... 99 PAROEX ORAL RINSE...... 130 pioglitazone-metformin...... 58 prednisolone acetate...... 73 paromomycin...... 91 PIP LANCET...... 107 prednisolone sodium phosphate 73, 99 paroxetine hcl...... 13 PIRMELLA...... 38 prednisone...... 99 PAXIL...... 13 piroxicam...... 101 PREDNISONE INTENSOL...... 99 peg 3350-electrolytes...... 104 PISTON SYRINGE WITH ENFIT...120 PREFEST...... 83

I-15 PREGNYL...... 67 PROAIR HFA...... 8 PYLERA...... 155 PREMARIN...... 83, 159 PROAIR RESPICLICK...... 8 pyrazinamide...... 90 PREMIER TEST STRIP...... 62 probenecid...... 77 pyridostigmine bromide...... 12 PREMIUM V10...... 62 probenecid-colchicine...... 77 QNASL...... 6 PREMPHASE...... 83 prochlorperazine...... 7 quazepam...... 19 PREMPRO...... 83 prochlorperazine maleate...... 7 quetiapine...... 17 PRENAISSANCE PLUS...... 161 PROCORT...... 102 QUILLIVANT XR...... 20 PRENATA...... 162 PROCRIT...... 78 quinapril...... 23 PRENATAL 19...... 162 PROCTOFOAM HC...... 102 quinapril-hydrochlorothiazide...... 22 PRENATAL 19 (WITH PROCTO-MED HC...... 50 quinidine gluconate...... 21 DOCUSATE)...... 162 PROCTO-PAK...... 50 quinidine sulfate...... 21 PRENATAL PLUS...... 162 PROCTOSOL HC...... 50 quinine sulfate...... 91 PRENATAL-U...... 162 PROCTOZONE-HC...... 50 QUINTET AC...... 62 PRENATE AM...... 162 PROCYSBI...... 157 QUINTET GLUCOSE TEST PRENATE CHEWABLE...... 162 PRODIGY INSULIN SYRINGE...... 121 STRIPS...... 62 PRENATE DHA...... 162 PRODIGY LANCETS...... 107 QUIT 2...... 153 PRENATE DHA (FERR ASP PRODIGY NO CODING...... 62 QUIT 4...... 153 GLYCIN)...... 162 PRODIGY TWIST TOP LANCET.. 107 QVAR REDIHALER...... 10 PRENATE ELITE...... 162 progesterone micronized...... 83 rabeprazole...... 157 PRENATE ELITE (IRON ASP PROGLYCEM...... 63 raloxifene...... 68 GLYC)...... 162 PROGRAF...... 85 ramipril...... 23 PRENATE ESSENTIAL...... 162 PROLENSA...... 73 RANEXA...... 31 PRENATE ESSENTIAL(IRON- PROMACTA...... 80 RAPAFLO...... 157 ASP-GL)...... 162 promethazine...... 4, 7 RAPAMUNE...... 85 PRENATE MINI (FERR ASP promethazine-codeine...... 41 rasagiline...... 149 GLYCIN)...... 162 promethazine-dm...... 42 RASUVO (PF)...... 96 PREPARATION H promethazine-phenyleph-codeine... 41 RAVICTI...... 103 HYDROCORTISONE...... 50 promethazine-phenylephrine...... 41 READYLANCE SAFETY PREPOPIK...... 104 PROMETHEGAN...... 7 LANCETS...... 108 PRESSURE ACTIVATED propafenone...... 21 REBIF (WITH ALBUMIN)...... 130 LANCETS...... 107 propantheline...... 155 REBIF REBIDOSE...... 130 PRETAB...... 162 proparacaine...... 73 REBIF TITRATION PACK...... 130 PREVACID SOLUTAB...... 157 propranolol...... 24 RECLIPSEN (28)...... 38 PREVALITE...... 30 propranolol-hydrochlorothiazid...... 25 RECOTHROM...... 80 PREVENT DROPSAFE PEN propylthiouracil...... 70 RECOTHROM SPRAY KIT...... 80 NEEDLE...... 139 PROTOPIC...... 55 RECTASMOOTHE...... 102 PREVIFEM...... 38 protriptyline...... 14 RECTIV...... 102 PREZCOBIX...... 92 PROVENTIL HFA...... 8 REFISSA...... 44 PREZISTA...... 92 PULMICORT FLEXHALER...... 10 REFUAH PLUS...... 62 PRIFTIN...... 90 PULMOZYME...... 142 REGRANEX...... 62 primaquine...... 91 PURE COMFORT ALCOHOL RELENZA DISKHALER...... 92 primidone...... 152 PADS...... 52 RELIAMED LANCET...... 108 PRIMSOL...... 87 PURE COMFORT LANCETS...... 107 RELIAMED SAFETY SEAL PRO COMFORT ALCOHOL PADS.52 PURE COMFORT PEN NEEDLE..139 LANCETS...... 108 PRO COMFORT INSULIN PURE COMFORT SAFETY RELIAMED TWIST AND CAP SYRINGE...... 121 LANCETS...... 107 LANCET...... 108 PRO COMFORT LANCET...... 107 PURELAX...... 104 RELION CONFIRM-MICRO...... 62 PRO COMFORT PEN NEEDLE....139 PUSH BUTTON SAFETY RELION NEEDLES...... 139 PRO VOICE V8-V9 TEST STRIP....62 LANCETS...... 107 RELION PEN NEEDLES...... 139

I-16 RELION PRIME TEST STRIPS...... 62 SAFESNAP INSULIN SYRINGE... 121 SHINGRIX GE ANTIGEN RELION THIN LANCETS...... 108 SAFESNAP SYRINGE...... 121 COMPONENT...... 84 RELION ULTIMA...... 62 SAFETY LANCETS...... 108 SIGNIFOR...... 141 RELION ULTRA THIN PLUS safety needles...... 139 sildenafil...... 67 LANCETS...... 108 SAFETY PEN NEEDLE...... 139 sildenafil (pulm.hypertension)...... 27 RELISTOR...... 105 SAFETY SEAL LANCETS...... 108 SILENOR...... 19 REMEDY ANTIFUNGAL...... 46 SAFETY-LET LANCETS...... 108 silver nitrate...... 43, 54 RENAGEL...... 66 SAFYRAL...... 38 silver sulfadiazine...... 46 repaglinide...... 57 SAIZEN...... 69 SILVRSTAT...... 43 repaglinide-metformin...... 58 SAIZEN SAIZENPREP...... 69 SIMBRINZA...... 76 REPATHA PUSHTRONEX...... 29 salicylic acid...... 53, 54 SIMLIYA (28)...... 38 REPATHA SURECLICK...... 29 SALIMEZ...... 54 SIMPESSE...... 39 REPATHA SYRINGE...... 29 SALKERA...... 54 SIMPONI...... 97 RESTASIS...... 75 salsalate...... 143 simvastatin...... 29 RESTASIS MULTIDOSE...... 75 SALVAX...... 54 SINGLE-LET...... 108 REVEAL TEST STRIP...... 62 SAMSCA...... 65 sirolimus...... 85 REVLIMID...... 127 SANADERMRX...... 51 SIRTURO...... 91 REXULTI...... 16 SANCUSO...... 7 SKLICE...... 46 REYATAZ...... 94 SANDIMMUNE...... 85 SLOW RELEASE IRON...... 160 RHINOCORT ALLERGY...... 6 SANTYL...... 55 SMART SENSE LANCETS...... 108 ribavirin...... 92, 96 SAPHRIS...... 17 SMART SENSE TEST STRIPS...... 62 rifabutin...... 90 SAVELLA...... 130 SMARTEST LANCET...... 108 RIFAMATE...... 91 scopolamine base...... 7 SMARTEST TEST...... 62 rifampin...... 91 SECONAL SODIUM...... 18 SMOOTHLAX...... 104 RIFATER...... 91 SECURA ANTIFUNGAL...... 46 sodium chlor 0.9% bacteriostat...... 67 RIGHTEST GL300 LANCETS...... 108 SECURA ANTIFUNGAL EXTRA sodium chloride...... 67, 132 RIGHTEST GS250S TEST THICK...... 46 sodium chloride 0.9 % (flush)...... 67 STRIPS...... 62 SELECT-OB...... 162 sodium phenylbutyrate...... 103 RIGHTEST GS260 TEST STRIPS.. 62 SELECT-OB (FOLIC ACID)...... 162 SODIUM POLYSTYRENE (SORB RIGHTEST GS550 TEST STRIPS.. 62 SELECT-OB + DHA...... 162 FREE)...... 66 riluzole...... 130 selegiline hcl...... 149 sodium polystyrene sulfonate...... 66 rimantadine...... 92 selenium sulfide...... 51 SOFT TOUCH LANCETS...... 108 RINGWORM...... 46 SELRX...... 51 SOLODYN...... 89 RIOMET...... 58 SELZENTRY...... 93 SOLTAMOX...... 129 risedronate...... 68 SEMGLEE U-100 INSULIN...... 64 SOLUS V2 LANCETS...... 108 RISPERDAL CONSTA...... 17 SEMPREX-D...... 4 SOLUS V2 TEST STRIPS...... 62 risperidone...... 17 SE-NATAL 19 CHEWABLE...... 162 SOMAVERT...... 68 RITALIN LA...... 20 SENSIPAR...... 68 SOOTHING CARE ritonavir...... 94 SEREVENT DISKUS...... 9 (HYDROCORTISONE)...... 51 rivastigmine...... 12 SEROSTIM...... 69 SORINE...... 24 rivastigmine tartrate...... 12 sertraline...... 13 sotalol...... 24 RIVELSA...... 38 SETLAKIN...... 38 SOTALOL AF...... 24 rizatriptan...... 145, 146 sevelamer carbonate...... 66 SOVALDI...... 95 R-NATAL OB...... 162 SF...... 159 SPINRAZA (PF)...... 126 ropinirole...... 149 SF 5000 PLUS...... 159 SPIRIVA RESPIMAT...... 8 ROSADAN...... 43 SHAROBEL...... 38 SPIRIVA WITH HANDIHALER...... 8 rosuvastatin...... 29 SHINGRIX (PF)...... 84 spironolactone...... 26 ROZEREM...... 18 SHINGRIX ADJUVANT spironolacton-hydrochlorothiaz...... 26 SABRIL...... 152 COMPONENT-PF...... 141 SPORANOX...... 90

I-17 SPRINTEC (28)...... 39 SURE COMFORT ALCOHOL tadalafil (pulm. hypertension)...... 27 SPRIX...... 99 PREP PADS...... 52 TAFINLAR...... 127 SPRYCEL...... 128 SURE COMFORT INS. SYR. U- TAKE ACTION...... 39 SPS (WITH SORBITOL)...... 66 100...... 121 TALTZ AUTOINJECTOR...... 55 SRONYX...... 39 SURE COMFORT INSULIN TALTZ AUTOINJECTOR (2 PACK).55 SSD...... 46 SYRINGE...... 121 TALTZ AUTOINJECTOR (3 PACK).55 SSKI...... 41 SURE COMFORT LANCETS...... 108 TALTZ SYRINGE...... 55 SSS 10-5...... 46 SURE COMFORT PEN NEEDLE..139 tamoxifen...... 129 ST JOSEPH ASPIRIN...... 80 SURE RESULT TAC PAK...... 51 tamsulosin...... 157 ST. JOSEPH ASPIRIN...... 80 SURE-FINE PEN NEEDLES...... 139 TAPERDEX...... 99 stavudine...... 94 SURE-JECT INSULIN SYRINGE.. 122 TARCEVA...... 128 STELARA...... 99 SURE-LANCE...... 108 TARGRETIN...... 54 STERILANCE TL...... 108 SURE-LANCE ULTRA THIN...... 108 TARINA 24 FE...... 39 STIOLTO RESPIMAT...... 9 SURE-PREP ALCOHOL PREP TARINA FE 1/20 (28)...... 39 STIVARGA...... 128 PADS...... 52 TARINA FE 1-20 EQ (28)...... 39 STOP SMOKING AID...... 153 SURE-TEST EASYPLUS MINI...... 62 TARON-C DHA...... 162 STRIBILD...... 95 SURE-TOUCH LANCET...... 108 TASIGNA...... 128 STRIVERDI RESPIMAT...... 8 SURFAXIN...... 141 TAYTULLA...... 39 STRONG IODINE...... 70 SURGUARD2 SAFETY...... 122, 139 tazarotene...... 55 SUBOXONE...... 148 SURVANTA...... 141 TAZORAC...... 55 SUBSYS...... 145 SUSTIVA...... 93 TAZTIA XT...... 26 SUBVENITE...... 152 SUTENT...... 128 TD GOLD TEST STRIP...... 62 SUBVENITE STARTER (BLUE) SYEDA...... 39 TECFIDERA...... 130 KIT...... 152 SYLATRON...... 127 TECHLITE INSULIN SYR HALF SUBVENITE STARTER (GREEN) SYMBICORT...... 9 UNIT...... 123 KIT...... 152 SYMFI...... 95 TECHLITE INSULIN SYRINGE.....123 SUBVENITE STARTER SYMFI LO...... 95 TECHLITE LANCETS...... 108 (ORANGE) KIT...... 152 SYMLINPEN 120...... 57 TECHLITE PEN NEEDLE...... 140 SUCRAID...... 154 SYMLINPEN 60...... 57 TEKTURNA...... 27 sucralfate...... 155 SYMTUZA...... 92 TEKTURNA HCT...... 27 sulfacetamide sodium...... 51, 73 SYNAGIS...... 92 TELCARE LANCETS...... 108 sulfacetamide sodium (acne)...... 42 SYNAREL...... 69 TELCARE TEST STRIPS...... 62 sulfacetamide sodium-sulfur...... 46, 47 SYNRIBO...... 128 telmisartan...... 23 sulfacetamide sod-sulfur-urea...... 47 SYNTHROID...... 70 telmisartan-amlodipine...... 22 sulfacetamide-prednisolone...... 73 SYPRINE...... 132 temazepam...... 19 sulfacetamide-sulfur-cleansr23...... 47 syringe (disposable)...... 122 TEMIXYS...... 92 SULFACLEANSE 8-4...... 47 SYRINGE 3CC/20GX1"...... 122 temozolomide...... 126 sulfadiazine...... 101 SYRINGE 3CC/21GX1"...... 122 TENCON...... 142 sulfamethoxazole-trimethoprim..85, 86 SYRINGE 3CC/21GX1-1/2"...... 122 tenofovir disoproxil fumarate...... 94 SULFAMYLON...... 47 SYRINGE 3CC/22GX1"...... 122 terazosin...... 22 sulfasalazine...... 102 SYRINGE 3CC/22GX3/4"...... 122 terbinafine hcl...... 90 SULFATRIM...... 86 SYRINGE 3CC/25GX1"...... 122 terbutaline...... 8 sulindac...... 101 syringe with needle...... 122 terconazole...... 159 sumatriptan...... 146 syringe with needle, safety...... 122 TERSI FOAM...... 51 sumatriptan succinate...... 146 SYRINGE WITHOUT NEEDLE..... 123 TERUMO ALLERGY SYRINGE.... 123 sumatriptan-naproxen...... 146 TABLOID...... 126 TERUMO HYPODERMIC SUPER THIN LANCETS...... 108 TACLONEX...... 56 NEEDLE/SYRIN...... 123 SUPRAX...... 86 tacrolimus...... 55, 85 TERUMO INSULIN SYRINGE...... 123 SUPREP BOWEL PREP KIT...... 104 tadalafil...... 67 TERUMO SYRINGE...... 123

I-18 TEST N'GO TEST...... 62 TOVIAZ...... 158 TRIUMEQ...... 95 testosterone...... 81 TRACLEER...... 27 TRIVEEN-DUO DHA...... 163 testosterone cypionate...... 81 TRADJENTA...... 57 TRIVIX...... 51 tetrabenazine...... 130 tramadol...... 145 TRIVORA (28)...... 39 tetracaine hcl...... 73 tramadol-acetaminophen...... 147 TRI-VYLIBRA...... 39 tetracaine hcl (pf)...... 73 trandolapril...... 23 TRI-VYLIBRA LO...... 39 tetracycline...... 89 tranexamic acid...... 77 tropicamide...... 76 TEXACORT...... 51 tranylcypromine...... 12 trospium...... 158 THALOMID...... 90 TRAVATAN Z...... 76 TRUE COMFORT ALCOHOL THEOCHRON...... 11 TRAVEL-EASE (MECLIZINE)...... 7 PADS...... 52 theophylline...... 11 trazodone...... 13 TRUE COMFORT INSULIN THIN LANCETS...... 108 TRECATOR...... 90 SYRINGE...... 123 THINPRO INSULIN SYRINGE...... 123 TRESIBA FLEXTOUCH U-100...... 64 TRUE COMFORT LANCET...... 108 thioridazine...... 18 TRESIBA FLEXTOUCH U-200...... 64 TRUE COMFORT PEN NEEDLE..140 thiothixene...... 18 tretinoin...... 43 TRUE METRIX GLUCOSE TEST THRIVITE RX...... 162 tretinoin (antineoplastic)...... 129 STRIP...... 62 THRIVITE-19...... 160 tretinoin (emollient)...... 44 TRUE METRIX PRO TEST STRIP..62 THYROLAR-1...... 70 TRETIN-X...... 43 TRUEPLUS INSULIN...... 124 THYROLAR-1/2...... 70 TRETIN-X CREAM KIT...... 43 TRUEPLUS KETONE...... 141 THYROLAR-1/4...... 70 TREXALL...... 127 TRUEPLUS LANCETS...... 108 THYROLAR-2...... 71 TREXIMET...... 146 TRUEPLUS PEN NEEDLE...... 140 THYROLAR-3...... 71 TRI FEMYNOR...... 39 TRUETEST TEST STRIPS...... 62 TIADYLT ER...... 26 triamcinolone acetonide...... 6, 51, 130 TRUETRACK TEST...... 62 tiagabine...... 152 triamterene-hydrochlorothiazid.. 26, 27 TRULICITY...... 56 TILIA FE...... 39 TRIANEX...... 51 TRUSTEX LATEX CONDOM...... 131 timolol maleate...... 24, 76 triazolam...... 19 TRUSTEX LUBRICATED tinidazole...... 91 TRI-BUFFERED ASPIRIN...... 143 CONDOMS...... 131 TIVICAY...... 95 TRIDERM...... 51 TRUSTEX NON-LUB CONDOMS.131 tizanidine...... 153 trientine...... 132 TRUSTEX-RIA LUB/SPERMICIDE131 TOBI PODHALER...... 90 TRI-ESTARYLLA...... 39 TRUSTEX-RIA LUBRICATED TOBRADEX...... 71 trifluoperazine...... 18 CONDOMS...... 131 TOBRADEX ST...... 71 trifluridine...... 73 TRUSTEX-RIA NON-LUB tobramycin...... 74 trihexyphenidyl...... 148 CONDOMS...... 132 tobramycin in 0.225 % nacl...... 90 TRI-LEGEST FE...... 39 TRUVADA...... 93 tobramycin-dexamethasone...... 71 TRI-LINYAH...... 39 TUBERCULIN SYRINGE...... 124 TOBREX...... 74 TRI-LO-ESTARYLLA...... 39 tuberculin-allergy syringes...... 124 tolcapone...... 149 TRI-LO-MARZIA...... 39 TUDORZA PRESSAIR...... 8 tolmetin...... 101 TRI-LO-MILI...... 39 TULANA...... 39 tolterodine...... 158 TRI-LO-SPRINTEC...... 39 TUSSICAPS...... 41 TOOMEY SYRINGE...... 123 TRILYTE WITH FLAVOR TUZISTRA XR...... 41 TOPCARE CLICKFINE...... 140 PACKETS...... 104 TWIST LANCETS...... 108 TOPCARE ULTRA COMFORT..... 123 trimethobenzamide...... 7 TYBOST...... 95 TOPCARE UNIVERSAL1 LANCET trimethoprim...... 87 TYDEMY...... 39 ...... 108 TRI-MILI...... 39 TYKERB...... 128 topiramate...... 152 trimipramine...... 15 TYVASO...... 27 torsemide...... 26 TRINATAL RX 1...... 163 TYVASO INSTITUTIONAL START TOUJEO MAX U-300 SOLOSTAR..64 TRINTELLIX...... 14 KIT...... 27 TOUJEO SOLOSTAR U-300 TRI-PREVIFEM (28)...... 39 TYVASO REFILL KIT...... 27 INSULIN...... 64 TRI-SPRINTEC (28)...... 39 TYVASO STARTER KIT...... 27

I-19 TYZINE...... 42 UNIFINE PENTIPS PLUS VEMLIDY...... 95 ULESFIA...... 46 MAXFLOW...... 140 venlafaxine...... 13, 14 ULORIC...... 77 UNILET COMFORTOUCH VENTAVIS...... 27 ULTICARE...... 124 LANCET...... 109 VENTOLIN HFA...... 8 ULTICARE INSULIN SYR HALF UNILET EXCELITE II LANCET..... 109 verapamil...... 26 UNIT...... 124 UNILET EXCELITE LANCET...... 109 VERASENS TEST STRIP...... 62 ULTICARE INSULIN SYRINGE.....124 UNILET GP LANCET...... 109 VERDESO...... 51 ULTICARE PEN NEEDLE...... 140 UNILET LANCET...... 109 VEREGEN...... 46 ULTICARE SAFETY SYRINGE.....124 UNILET LANCETS...... 109 VERIFINE PEN NEEDLE...... 141 ULTICARE TB SAFETY SYRINGE124 UNILET SUPER THIN LANCETS..109 VERSACLOZ...... 17 ULTIGUARD SAFE PACK...... 140 UNISTIK 3 COMFORT LANCET... 109 VERTICALM...... 7 ULTILET ALCOHOL SWAB...... 52 UNISTIK 3 EXTRA LANCET...... 109 VESICARE...... 158 ULTILET BASIC LANCETS...... 108 UNISTIK 3 GENTLE...... 109 VIBRAMYCIN...... 89 ULTILET CLASSIC LANCETS...... 108 UNISTIK 3 LANCETS...... 109 VICODIN HP...... 147 ULTILET INSULIN SYRINGE...... 124 UNISTIK 3 NORMAL LANCET...... 109 VICTOZA 2-PAK...... 56 ULTILET LANCETS...... 109 UNISTIK CZT LANCET...... 109 VICTOZA 3-PAK...... 56 ULTILET PEN NEEDLE...... 140 UNISTIK PRO LANCET...... 109 VIEKIRA PAK...... 96 ULTILET SAFETY LANCETS...... 109 UNISTIK SAFETY...... 109 VIENVA...... 40 ULTIMA TEST STRIPS...... 62 UNISTIK TOUCH LANCETS...... 109 vigabatrin...... 152 ULTRA CMFT INS SYR HALF UNISTRIP1 TEST STRIP...... 62 VIGADRONE...... 152 UNIT...... 124 UNITHROID...... 71 VIIBRYD...... 14 ULTRA COMFORT INSULIN UNIVERSAL 1 LANCETS...... 109 VIMOVO...... 99 SYRINGE...... 125 URAMAXIN...... 54 VIMPAT...... 152 ULTRA FINE LANCETS...... 109 URO-458...... 87 VINATE CARE...... 163 ULTRA FLO INSULIN SYRINGE...125 UROQID-ACID NO.2...... 157 VINATE ONE...... 163 ULTRA FLO PEN NEEDLE...... 140 ursodiol...... 103 VIOKACE...... 154 ULTRA THIN II LANCETS...... 109 URYL...... 87 VIORELE (28)...... 40 ULTRA THIN LANCETS...... 109 valacyclovir...... 92 VIRACEPT...... 94 ULTRA THIN PEN NEEDLE...... 140 VALCHLOR...... 54 VIREAD...... 94 ULTRA THIN PLUS LANCETS...... 109 valganciclovir...... 92 VIRT-C DHA...... 163 ULTRA TLC LANCETS...... 109 valproic acid...... 152 VIRT-PN DHA...... 163 ULTRACARE INSULIN SYRINGE.125 valproic acid (as sodium salt)...... 152 VIRT-PN PLUS...... 163 ULTRA-CARE LANCETS...... 109 valsartan...... 23 VIRTUSSIN AC...... 42 ULTRACARE PEN NEEDLE...... 140 valsartan-hydrochlorothiazide...... 22 VIRTUSSIN DAC...... 41 ULTRALANCE LANCETS...... 109 vancomycin...... 91 VISINE DRY EYE RELIEF...... 77 ULTRA-THIN II (SHORT) INS SYR VANICREAM HC...... 51 VISTOGARD...... 129 ...... 125 VANISHPOINT INSULIN VITAFOL-OB...... 163 ULTRA-THIN II (SHORT) PEN SYRINGE...... 125 VITAFOL-OB+DHA...... 163 NDL...... 140 VANISHPOINT SYRINGE...... 125 VITAFOL-ONE...... 163 ULTRA-THIN II INS PEN VANISHPOINT TUBERCULIN VITAMIN D2...... 163 NEEDLES...... 140 SYRINGE...... 125 VITAMIN D3...... 163, 164 ULTRA-THIN II INSULIN VANOXIDE-HC...... 42 VIVAGUARD INO TEST STRIP...... 62 SYRINGE...... 125 VASCEPA...... 30 VIVAGUARD LANCET...... 109 ULTRA-THIN II LANCETS...... 109 VCF CONTRACEPTIVE GEL...... 32 VIVELLE-DOT...... 83 ULTRATRAK...... 62 VECAMYL...... 23 VOGELXO...... 81 ULTRATRAK ULTIMATE...... 62 VELIVET TRIPHASIC REGIMEN VOLNEA (28)...... 40 UNIFINE PENTIPS...... 140 (28)...... 40 voriconazole...... 90 UNIFINE PENTIPS MAXFLOW.....140 VELPHORO...... 66 VOTRIENT...... 128 UNIFINE PENTIPS PLUS...... 140 VELTASSA...... 66 VP-CH-PNV...... 163

I-20 VRAYLAR...... 16 zafirlukast...... 10 VYFEMLA (28)...... 40 zaleplon...... 19 VYLIBRA...... 40 ZARAH...... 40 VYVANSE...... 15 ZATEAN-PN DHA...... 163 WAL-DRAM 2...... 7 ZATEAN-PN PLUS...... 163 WAL-FEX ALLERGY...... 5 ZAVESCA...... 132 WAL-ITIN...... 5 ZEBUTAL...... 142 WAL-ITIN D...... 4 ZELAPAR...... 149 WAL-ITIN D 12 HOUR...... 4 ZELBORAF...... 127 WAL-ZYR (CETIRIZINE)...... 5 ZENATANE...... 42 WAL-ZYR (KETOTIFEN)...... 72 ZENPEP...... 154 WAL-ZYR D...... 4 ZENZEDI...... 15 warfarin...... 77 ZETONNA...... 6 WAVESENSE JAZZ...... 62 zidovudine...... 94 WAVESENSE PRESTO...... 62 zileuton...... 7 WEBCOL...... 52 ZIOPTAN (PF)...... 76 WEEKLY-D...... 164 ziprasidone hcl...... 18 WELCHOL...... 30 ZIPSOR...... 101 WELLBUTRIN SR...... 12 ZIRGAN...... 73 WERA (28)...... 40 ZITHRANOL...... 55 WESTHROID...... 71 ZOHYDRO ER...... 145 WIDE-SEAL DIAPHRAGM 60...... 40 ZOLINZA...... 128 WIDE-SEAL DIAPHRAGM 65...... 40 zolmitriptan...... 146 WIDE-SEAL DIAPHRAGM 70...... 40 zolpidem...... 19 WIDE-SEAL DIAPHRAGM 75...... 40 ZOLPIMIST...... 19 WIDE-SEAL DIAPHRAGM 80...... 40 ZOMACTON...... 69 WIDE-SEAL DIAPHRAGM 85...... 40 ZOMIG...... 147 WIDE-SEAL DIAPHRAGM 90...... 40 zonisamide...... 152 WIDE-SEAL DIAPHRAGM 95...... 40 ZONTIVITY...... 80 WYMZYA FE...... 40 ZORBTIVE...... 69 XALKORI...... 128 ZORTRESS...... 85 XARELTO...... 78 ZORVOLEX...... 101 XARELTO DVT-PE TREAT 30D ZOSTRIX...... 52 START...... 78 ZOVIA 1/35E (28)...... 40 XELJANZ...... 99 ZOVIRAX...... 46 XELJANZ XR...... 99 ZUBSOLV...... 148 XENICAL...... 164 ZUMANDIMINE (28)...... 40 XERESE...... 46 ZUPLENZ...... 7 XEROSTOMIA RELIEF...... 141 ZYCLARA...... 85 XIFAXAN...... 91 ZYDELIG...... 128 XIGDUO XR...... 58 ZYLET...... 71 XOLEGEL...... 46 ZYMAXID...... 74 XTANDI...... 126 ZYTIGA...... 126 XULANE...... 40 XURIDEN...... 77 XYLON 10...... 143 XYREM...... 16 YALE DISPOSABLE NEEDLES....141 YUVAFEM...... 159

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