2020 Drug Formulary

CHPW_RX_311_08_2020_Medicaid_Formulary_SEP COMMUNITY HEALTH PLAN of WASHINGTON

2020 DRUG FORMULARY

The Community Health Plan of Washington (CHPW) drug formulary is developed by a Pharmacy and Therapeutics Committee. For medications included in the Apple Health Preferred Drug List, formulary status and coverage criteria are developed and approved by the Washington State Authority (HCA) Pharmacy and Therapeutics Committee before adoption by CHPW. All other medications’ formulary status and coverage criteria are developed and approved by the CHPW Pharmacy and Therapeutics Committee. The formulary is searchable on the website at http:// chpw.org/for-members/pharmacy. For more information on the Apple Health Preferred Drug List, please visit: https://www.hca.wa.gov/billers-providers-partners/programs-and-services/apple- health-preferred-drug-list-pdl. The Formulary may change at any time.

For updates regarding periodic changes to the Formulary and other pharmaceutical management programs please check our website at www.chpw.org/for-members/pharmacy.

This Drug Formulary is intended for use by our providers and pharmacies and applies only to medications prescribed to our members and dispensed by participating network pharmacies. The Formulary does not apply to inpatient medications.

Generic Drug Policy

Community Health Plan of Washington utilizes a mandatory generic policy. This means that unless specified, the brand product won’t be covered without adequate trial and documented failure of the formulary generic product. Only when generic substitution conflicts with state regulations or restrictions, the pharmacist must gain approval from the prescriber to use the generic equivalent.

OTC Medication Policy Some Over-The-Counter (OTC) products are covered with a written prescription. If a prescription product is available in the identical strength, dosage form, and active ingredient(s) as an OTC product, the prescription product will not be covered. In these instances, providers and pharmacists should refer members to the OTC equivalent product. If the member or provider insists on the prescription equivalent product, the member must pay the entire cost of the prescription.

Age Restrictions

Age restrictions apply to selected drugs. These drugs are covered without prior authorization for specific age ranges but otherwise require prior authorization.

 Mental health medications outside of HCA mandated age/dose limits  Tretinoin—covered for members under 30 years old  Opioid prescriptions outside of HCA mandated age/dose limits

1 Second Opinion Network (SON) Community Health Plan of Washington has adopted Washington State Health Care Authority medication review thresholds for certain psychotropic medications for children under 18 years old. Clients currently receiving medications outside of these medication review thresholds will be allowed to continue, regardless of previous payer (whether HCA FFS, the plan themselves, or a previous payer prior to the client becoming a Medicaid enrollee). Clients being prescribed medications for the first time, or receiving prescriptions for dose escalations which exceed thresholds, will have those prescriptions denied by the managed care plans, and referred to HCA for initiation of the second opinion review process. After completion of the second opinion review, the managed care plan will receive a copy of the SON written recommendation, and approve or deny future prescriptions accordingly.

Exception Request

The health care professionals consulted in the development of this Formulary attempted to include medications for all therapeutic needs. Providers are expected to comply with the Drug Formulary when prescribing medications for plan members. If a patient requires a medication that is not covered, the provider may request an exception to allow payment for the non-covered medication. It is anticipated that such exceptions will be rare, and that most of the time, providers should be able to find a Formulary medication for the vast majority of therapeutic needs. However, if providers desire a non-covered product for members, they must call or submit a request explaining the necessity, past therapeutic failures and patient identification (name, address and Community Health Plan of Washington member number).

Prior Authorization To promote the most appropriate utilization, selected high-risk or high-cost medications require prior authorization to be eligible for coverage. Prior authorization criteria have been developed using current, published, peer-reviewed, medical literature, as well as input from local providers. The prior authorization criteria are approved by the P&T Committee. The Formulary medications that require prior authorization are identified by a “PA” following their name. Most authorizations are good for one year; after that, the drugs listed here will need to be reauthorized. Drugs may be added or deleted from this list as deemed necessary.

Prior Authorization Requests:

Non Formulary and Prior Authorization requests must be directed to:

Express Scripts Attn: Prior Authorization Mail Stop B401-03 8640 Evans Road St. Louis, MO 63134 Phone: 844-605-8168 Fax: 877-251-5896

Electronic Prior Authorization requests can be submitted through: www.express-scripts.com/PA

2 Step Therapy Step-­­therapy promotes appropriate utilization of first line drugs and/or therapeutic categories. Step-­­ therapy requires that participants receive one or more first-­­line drug(s), as defined by program criteria, before prescriptions are covered for second-­­line drugs. All step-­­therapy programs are supported by prior authorization criteria to determine coverage in the event that a participant does not meet the automated, on-­­line step-­­therapy criteria and coverage of a second line product is medically necessary.

Benefit Exclusions Drugs in the following categories are not available as benefits of the plan:  Non-­­FDA approved drug products Medications will be eligible for coverage only if they are FDA-­­ approved prescription medications used for non-­­experimental indications.  Experimental and Investigational (E & I) drugs These are drugs that do not have FDA-­­ approved indication(s) for use, or other indications that are considered effective based on published scientific evidence.  Compounded drugs with non-­­FDA approved ingredients (e.g. Estriol used in Bi-­­Est and Tri-­­Est)  Samples Members started on samples of a non-­­formulary drug are not guaranteed coverage for that drug.  Drugs for weight loss or appetite suppression (e.g. Xenical)  Drugs for impotence or sexual dysfunction (e.g.Viagra)  Drugs to treat cosmetic issues (e.g.Rogaine)  Infertility drugs  Prescription drugs that are equivalent to OTC medications or with an OTC add on (Some OTC medications are covered for Apple Health.)

Benefit Information:

Retail Pharmacy A 30 day supply is allowed at all network retail pharmacies and a 90-day supply of select generic maintenance medications at select pharmacies. Mail Order Pharmacy Contact Walmart pharmacy at 1-800-273-3455 to get your medications sent to you. Copay Determinations There is no copay or deductible for formulary products for Apple Health. OTC products: Only certain OTC products are covered for Community Health Plan of Washington members as determined by the Apple Health Preferred Drug List.

3 Formulary Legend: Generic drugs are listed in lower case BRAND drugs are listed in UPPER case

Tier 1: Preferred. No limits. Tier 2: Preferred. With limits. Tier 3: Non Preferred. Tier 4: Medical Benefit.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, there are limits on the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

4 COMMUNITY HEALTH PLAN OF WASHINGTON

FORMULARIO DE MEDICAMENTOS 2020

El Formulario de medicamentos de Community Health Plan of Washington (CHPW) es desarrollado por el Comité de Farmacia y Terapéutica (P&T). Para los medicamentos incluidos en la Lista de medicamentos preferidos de Apple Health, el Comité de Farmacia y Terapéutica de la Autoridad de Atención Médica de Washington (HCA) desarrolla y aprueba el estado del formulario y el criterio de cobertura antes de que CHPW los adopte. El resto de los criterios de cobertura y de los estados de los formularios de medicamentos son desarrollados y aprobados por el Comité de Farmacia y Terapéutica de CHPW. El formulario se puede consultar en el sitio web http://chpw.org/for-members/pharmacy. Para obtener más información sobre la Lista de medicamentos preferidos de Apple Health, visite https://www.hca.wa.gov/billers-providers-partners/programs-and-services/apple-health- preferred-drug-list-pdl. El Formulario puede cambiar en cualquier momento.

Para acceder a los cambios periódicos en el Formulario y otros programas de administración de productos farmacéuticos, visite nuestro sitio web en www.chpw.org/for-members/pharmacy.

Este Formulario de medicamentos está destinado a nuestros proveedores y farmacias, y se aplica solo a los medicamentos recetados a nuestros miembros y proporcionados por las farmacias de la red participantes. El Formulario no se aplica a medicamentos para pacientes internados.

Política de medicamentos genéricos

Community Health Plan of Washington utiliza una política genérica obligatoria. Esto significa que, a menos que se especifique lo contrario, el producto de marca no estará cubierto sin un estudio adecuado y un registro del fracaso del producto genérico del formulario. Solo cuando la sustitución por un genérico entre en conflicto con las restricciones o regulaciones estatales, el farmacéutico debe obtener la aprobación de la persona autorizada a dar recetas para usar el equivalente genérico.

Política de medicamentos de venta libre (OTC) Algunos productos de venta libre (OTC, por sus siglas en inglés) están cubiertos con una receta escrita. Si un producto con receta está disponible con los mismos ingredientes activos, potencia y dosificación que un producto de venta libre, el producto con receta no estará cubierto. En estos casos, los proveedores y farmacéuticos deberían ofrecer a los miembros el producto equivalente de venta libre. Si el miembro o proveedor insisten en el producto equivalente con receta, el miembro debe pagar el costo total de la receta.

Restricciones de edad A ciertos medicamentos seleccionados se les aplican restricciones de edad. Estos medicamentos están cubiertos sin autorización previa en grupos de edad específicos, pero, en otros casos, se requiere autorización previa.

• Medicamentos para la salud mental no contemplados en los límites de dosis y edad indicados por la HCA • Tretinoína: cubierta para miembros menores de 30 años • Medicamentos con receta opiáceos no contemplados en los límites de dosis y edad indicados por la HCA 5 Red de segunda opinión (SON) Community Health Plan of Washington ha adoptado la revisión de los límites de medicamentos de la Autoridad de Atención Médica de Washington (Washington Health Care Authority, HCA) para ciertos medicamentos psicotrópicos para niños menores de 18 años. Los clientes que actualmente reciben los medicamentos fuera de esta revisión de medicamentos podrán continuar, independientemente del pagador anterior (ya sea HCA FFS, el plan mismo o un pagador anterior previo a que el cliente se inscribiera en Medicaid). Los planes de atención administrada rechazarán las recetas de los clientes a quienes se les recetan medicamentos por primera vez o quienes reciben medicamentos con receta con aumentos de dosis que superen los umbrales, y los derivarán a la HCA para que inicien el proceso de revisión de segunda opinión. Luego de finalizar la revisión de segunda opinión, el plan de atención administrada recibirá una copia de la recomendación escrita correspondiente a la red de segunda opinión (SON, por sus siglas en inglés) y aprobará o denegará las futuras recetas en consecuencia.

Solicitud de excepción Los profesionales de la atención médica consultados durante el desarrollo de este Formulario intentaron incluir medicamentos para todas las necesidades terapéuticas. Se espera que los proveedores cumplan con el Formulario de medicamentos cuando receten medicamentos a los miembros del plan. Si un paciente requiere un medicamento que no está cubierto, el proveedor puede solicitar una excepción para permitir el pago del medicamento no cubierto. Está previsto que dichas excepciones sean poco frecuentes y, la mayoría de las veces, los proveedores deberían poder encontrar un medicamento dentro del Formulario para la amplia mayoría de las necesidades terapéuticas. No obstante, si un proveedor desea un producto no cubierto para los miembros, debe llamar o presentar una solicitud en la que detalle la necesidad, los fracasos terapéuticos anteriores y la identificación del paciente (nombre, dirección y número de miembro de Community Health Plan of Washington).

Autorización previa A fin de promover la utilización más adecuada, los medicamentos de alto riesgo o alto costo seleccionados requieren autorización previa para calificar para la cobertura. Los criterios de autorización previa se han desarrollado con documentación médica actual, publicada y revisada por pares, así como también mediante aportes de proveedores locales. Los criterios de autorización previa son aprobados por el Comité de Farmacia y Terapéutica. Los medicamentos del Formulario que requieren autorización previa están identificados con las letras "PA" luego del nombre. La mayoría de las autorizaciones tienen validez durante un año; después se deberán volver a autorizar los medicamentos incluidos aquí. Community Health Plan of Washington puede agregar o eliminar medicamentos de la lista, según lo considere necesario.

Solicitudes de autorización previa: Las solicitudes de autorización previa y de medicamentos externos al Formulario deben dirigirse a: Express Scripts Attn: Prior Authorization Mail Stop B401-03 8640 Evans Road St. Louis, MO 63134 Teléfono: 844-605-8168 Fax: 877-251-5896

6 Las solicitudes de autorización previa electrónicas deben enviarse a: www.express-scripts.com/PA

Tratamiento escalonado El tratamiento escalonado promociona una utilización adecuada de medicamentos de primera línea o categorías terapéuticas. El tratamiento escalonado requiere que los participantes reciban uno o más medicamentos de primera línea, según lo definan los criterios del programa, antes de que se cubran las recetas de medicamentos de segunda línea. Todos los programas de tratamiento escalonado están respaldados por los criterios de autorización previa para determinar la cobertura en caso de que un participante no cumpla con los criterios de tratamiento escalonado automatizados y en línea, y la cobertura de un medicamento de segunda línea sea médicamente necesario.

Exclusiones de los beneficios Los medicamentos en las siguientes categorías no están disponibles como beneficios del plan: • Productos farmacológicos no aprobados por la FDA: los medicamentos calificarán para la cobertura solo si son medicamentos con receta aprobados por la FDA utilizados con indicaciones no experimentales. • Medicamentos experimentales y de investigación: estos son medicamentos que no tienen indicaciones aprobadas por la FDA para el uso u otras indicaciones que se consideran efectivas sobre la base de evidencia científica publicada. • Medicamentos compuestos con ingredientes no aprobados por la FDA: (p. ej., Estriol utilizado en Biest y Triest) • Muestras: los miembros que comenzaron con una muestra de un medicamento externo al formulario no tienen garantía de cobertura para ese medicamento. • Medicamentos para la pérdida de peso o suspensión del apetito: (p. ej., Xenical) • Medicamentos para la impotencia o disfunción sexual: (p. ej., Viagra) • Medicamentos para tratar problemas estéticos: (p. ej., Rogaine) • Medicamentos contra la infertilidad • Medicamentos con receta que son equivalentes a medicamentos de venta libre o con un complemento de venta libre: (algunos medicamentos de venta libre están cubiertos para Apple Health).

7 Información sobre los beneficios:

Farmacia minorista Se permite un suministro de 30 días en todas las farmacias minoristas de la red y un suministro de 90 días de medicamentos genéricos de mantenimiento seleccionados en farmacias seleccionadas. Farmacias de venta por correo Póngase en contacto con la farmacia de Walmart al 1-800-273-3455 para que le envíen los medicamentos. Determinaciones de copago No hay copago ni deducible para los productos del formulario de Apple Health. Productos de venta libre Solo ciertos productos de venta libre incluidos en la Lista de medicamentos preferidos de Apple Health están cubiertos para los miembros de Community Health Plan of Washington.

Texto del formulario Los medicamentos genéricos están en minúscula. Los medicamentos de MARCA están en MAYÚSCULA.

Nivel 1: Preferido. Sin límites. Nivel 2: Preferido. Con límites. Nivel 3: No preferido. Nivel 4: Beneficio médico.

PA (Prior Authorization): autorización previa. El Plan requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted deberá obtener aprobación antes de surtir sus recetas. Si usted no obtiene la aprobación, puede que no cubramos el medicamento. QL (Quantity Limit): límite de cantidades. Para ciertos medicamentos, existen límites a la cantidad del medicamento que cubriremos. ST (Step Therapy): tratamiento escalonado. En algunos casos, el Plan requiere que usted pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para su afección. Por ejemplo, si el medicamento A y el medicamento B tratan la misma afección médica, es posible que no cubramos el medicamento B a menos que pruebe el medicamento A primero. Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B.

8 Community Health Plan of Washington 2020 Apple Health Drug Formulary

Table of Contents ALTERNATIVE THERAPY ...... 11 ANALGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC ...... 13 ANESTHETICS ...... 24 ANORECTAL PREPARATIONS ...... 27 ANTIDOTES AND OTHER REVERSAL AGENTS ...... 28 ANTI-INFECTIVE AGENTS ...... 30 ANTINEOPLASTICS ...... 46 ANTISEPTICS AND DISINFECTANTS ...... 58 BIOLOGICALS ...... 58 CARDIOVASCULAR THERAPY AGENTS ...... 62 CENTRAL NERVOUS SYSTEM AGENTS ...... 77 CHEMICAL DEPENDENCY, AGENTS TO TREAT ...... 95 CHEMICALS-PHARMACEUTICAL ADJUVANTS...... 96 COGNITIVE DISORDER THERAPY ...... 110 CONTRACEPTIVES ...... 110 DERMATOLOGICAL ...... 114 DIAGNOSTIC AGENTS ...... 132 DRUGS TO TREAT ERECTILE DYSFUNCTION ...... 135 EATING DISORDER THERAPY ...... 136 ELECTROLYTE BALANCE-NUTRITIONAL PRODUCTS ...... 136 ENDOCRINE ...... 170 ENZYMES ...... 184 FDB CLASS OBSOLETE-NOT USED ...... 184 GASTROINTESTINAL THERAPY AGENTS ...... 184 GENITOURINARY THERAPY ...... 193 GOUT AND HYPERURICEMIA THERAPY ...... 197 HEMATOLOGICAL AGENTS ...... 197 HEPATOBILIARY SYSTEM TREATMENT AGENTS ...... 203 HISTAMINE PREPARATIONS FOR DESENSITIZATION ...... 203 IMMUNOSUPPRESSIVE AGENTS ...... 203 LOCOMOTOR SYSTEM ...... 204 MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (DME) ...... 207 MEDICAL SUPPLY, FDB SUPERSET ...... 215 METABOLIC DISEASE ENZYME REPLACEMENT AGENTS ...... 222 METABOLIC MODIFIERS ...... 222 MOUTH-THROAT-DENTAL - PREPARATIONS ...... 224 MULTIPLE SCLEROSIS AGENTS ...... 226 OPHTHALMIC AGENTS ...... 227 OTIC (EAR)...... 234 RESPIRATORY THERAPY AGENTS ...... 234 VAGINAL PRODUCTS ...... 241

9 Community Health Plan of Washington 2020 AppleHealth Drug Formulary

Table of Contents ALTERNATIVE THERAPY...... 11 ANALGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC...... 13 ANESTHETICS...... 26 ANORECTAL PREPARATIONS...... 29 ANTIDOTES AND OTHER REVERSAL AGENTS...... 30 ANTI-INFECTIVE AGENTS...... 32 ANTINEOPLASTICS...... 48 ANTISEPTICS AND DISINFECTANTS...... 61 BIOLOGICALS...... 61 CARDIOVASCULAR THERAPY AGENTS...... 65 CENTRAL NERVOUS SYSTEM AGENTS...... 81 CHEMICAL DEPENDENCY, AGENTS TO TREAT...... 103 CHEMICALS-PHARMACEUTICAL ADJUVANTS...... 105 COGNITIVE DISORDER THERAPY...... 118 CONTRACEPTIVES...... 119 DERMATOLOGICAL...... 123 DIAGNOSTIC AGENTS...... 141 DRUGS TO TREAT ERECTILE DYSFUNCTION...... 144 EATING DISORDER THERAPY...... 144 ELECTROLYTE BALANCE-NUTRITIONAL PRODUCTS...... 145 ENDOCRINE...... 178 ENZYMES...... 194 FDB CLASS OBSOLETE-NOT USED...... 194 GASTROINTESTINAL THERAPY AGENTS...... 194 GENITOURINARY THERAPY...... 205 GOUT AND HYPERURICEMIA THERAPY...... 209 HEMATOLOGICAL AGENTS...... 209 HEPATOBILIARY SYSTEM TREATMENT AGENTS...... 215 HISTAMINE PREPARATIONS FOR DESENSITIZATION...... 216 IMMUNOSUPPRESSIVE AGENTS...... 216 LOCOMOTOR SYSTEM...... 217 MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (DME)...... 220 MEDICAL SUPPLY, FDB SUPERSET...... 228 METABOLIC DISEASE ENZYME REPLACEMENT AGENTS...... 235 METABOLIC MODIFIERS...... 235 MOUTH-THROAT-DENTAL - PREPARATIONS...... 237 MULTIPLE SCLEROSIS AGENTS...... 239 OPHTHALMIC AGENTS...... 240 OTIC (EAR)...... 248 RESPIRATORY THERAPY AGENTS...... 248 VAGINAL PRODUCTS...... 256

9 10 2020 AppleHealth Drug Formulary Drug Name Drug Tier Limits GLUCOSAMINE- CHONDROITIN CURRENT AS OF 9/1/2020 1 COMPLX ORAL Drug Name Drug Tier Limits CAPSULE ALTERNATIVE GLUCOSAMINE- CHONDROITIN DS 1 THERAPY ORAL CAPSULE ALTERNATIVE glucosamine- THERAPY - chondroitin oral tablet 1 ANDROGENIC 250-200 mg, 500-400 AGENTS mg, 750-600 mg DEHYDROEPIANDR glucosamine-chondroit- 3 1 OSTERONE (MICRO) vit c-mn oral tablet DHEA ORAL methylsulfonylmethane 3 3 CAPSULE 50 MG oral capsule 900 mg DHEA ORAL TABLET methylsulfonylmethane 3 3 50 MG oral tablet 1,000 mg prasterone (dhea), N-ACETYL-ALPHA- 3 3 micro(bulk) D-GLUCOSAMINE ALTERNATIVE OSTEO BI-FLEX 1 THERAPY - ALTERNATIVE ANTIARTHRITIC THERAPY - S ANTIOXIDANT CIDAFLEX 1 HEALTHY EYES LUTEIN- 3 glucosam-chon-msm1- ZEAXANTHIN c-mang-bosw oral tablet 1 750-625-30 mg LIPOIC ACID 3 GLUCOSAMINE lutein oral tablet 10 mg 1 1 COMPLEX-MSM PROSIGHT 3 GLUCOSAMINE tetrahydrocurcumin 3 RELIEF ORAL 1 (bulk) TABLET ALTERNATIVE glucosamine su 2kcl- THERAPY - chondroit oral capsule 3 250-200 mg DIETARY SUPPLEMENT, glucosamine su 2kcl- chondroit oral tablet 3 STEROID 750-600 mg STRUCTURE glucosamine sulfate oral 7-KETO DHEA, 1 3 tablet MICRONIZED GLUCOSAMINE 1 SULF-CHONDROITIN

You can find information on what the symbols and abbreviations on this table mean on page 4. 11 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CRANBERRY ALTERNATIVE 1 THERAPY - URINARY COMFORT echinacea oral capsule PINEAL 1 HORMONE 400 mg AGENTS evening primrose oil 1 flaxseed oil oral capsule TOPROPHAN 1 3 1,000 mg ALTERNATIVE garlic oral capsule 1,500 THERAPY - 1 mg, 500 mg SEDATIVE/HYPN gelatin oral capsule 650 OTICS 1 mg LYDIA PINKHAM ginseng oral capsule 100 HERBAL ORAL 3 1 mg ELIXIR GLUCOLESS 1 tryptophan 3 LECITHIN-KELP-B6 3 ALTERNATIVE mag oxide-d3-turmeric THERAPY - 3 rt xt UNCLASSIFIED MANNXTRA 3 AIRSHIELD IMMUNE 3 MENS POTENT 3 aloe vera (bulk) powder 3 FORMULA AZO CRANBERRY + 1 MG-PLUS-PROTEIN 1 PROBIOTIC milk thistle oral tablet 1 CHEW Q 1 milk thistle seed extract CHILDREN'S 1 3 oral capsule 175 mg MIGRELIEF milk thistle seed extract CO Q-10 (WITH VIT 3 1 oral tablet E) ODORLESS GARLIC CO Q-10 ORAL 1 1 ORAL CAPSULE CAPSULE 150 MG ORTHODIET 1 coenzyme q10 (bulk) 3 PROSTATE powder 100 % 3 CONTROL coenzyme q10 oral capsule 200 mg, 30 mg, 3 Q-GEL MEGA 1 400 mg, 50 mg, 60 mg REFEX 1 coenzyme q10 oral SAW PALMETTO 3 1 tablet 100 mg EXTRACT (W-ZINC) coenzyme q10-vitamin e saw palmetto fruit 1 oral capsule 100-5 mg- 3 saw palmetto oral 1 unit capsule 160 mg cranberry extract- saw palmetto-pumpkin 3 1 vitamin c seed oil cranberry fruit oral 1 tablet 400 mg You can find information on what the symbols and abbreviations on this table mean on page 4. 12 Drug Name Drug Tier Limits Drug Name Drug Tier Limits saw palmto frt xtr-zinc DEMEROL (PF) 1 picoli INJECTION 4 TEARS AGAIN SOLUTION 100 MG/2 HYDRATE ORAL ML 3 CAPSULE 250-125-10 DEMEROL (PF) MG INJECTION SYRINGE 4 thymus gland,calf (bulk) 3 25 MG/ML, 50 MG/ML, 75 MG/ML turmeric 3 DEMEROL turmeric-turmeric ext- INJECTION 4 pepper oral capsule 900- 3 SOLUTION 50 MG/ML 100-5 mg DEMEROL ORAL 3 VALINEX 1 TABLET 100 MG ANALGESIC, DILAUDID 3 ANTI- DISKETS 3 INFLAMMATOR DOLOPHINE ORAL 3 Y OR DSUVIA 3 PA ANTIPYRETIC DURAGESIC 3 ANALGESIC - DURAMORPH (PF) 4 CENTRAL EXALGO ER ORAL ALPHA-2 TABLET EXTENDED 3 RECEPTOR RELEASE 24 HR 16 AGONISTS MG clonidine (pf) 2 fentanyl citrate 3 ANALGESIC fentanyl citrate (bulk) 3 OPIOID fentanyl citrate (pf) AGONISTS intravenous pt controlled analgesia 4 ACTIQ 3 syring 1,500 mcg/30 ml alfentanil 4 (50 mcg/ml), 2,750 ARYMO ER 3 mcg/55 ml (50 mcg/ml) ASTRAMORPH-PF fentanyl citrate (pf) INJECTION intravenous syringe 100 4 4 SOLUTION 0.5 mcg/2 ml (50 mcg/ml) MG/ML fentanyl citrate (pf)- codeine phosphate 0.9%nacl injection pt 3 4 (bulk) controlled analgesia syring 550 mcg/55 ml codeine sulfate oral 1 tablet fentanyl citrate (pf)- 0.9%nacl intravenous 4 CONZIP 3 solution 10 mcg/ml, 20 mcg/ml, 5 mcg/ml

You can find information on what the symbols and abbreviations on this table mean on page 4. 13 Drug Name Drug Tier Limits Drug Name Drug Tier Limits fentanyl citrate (pf)- hydromorphone 0.9%nacl intravenous injection syringe 0.5 4 4 syringe 50 mcg/5 ml (10 mg/0.5 ml, 2 mg/ml mcg/ml) hydromorphone fentanyl transdermal injection syringe 1 1 patch 72 hour 100 mg/ml, 4 mg/ml mcg/hr, 12 mcg/hr, 25 2 PA hydromorphone oral 3 mcg/hr, 50 mcg/hr, 75 liquid mcg/hr hydromorphone oral 1 fentanyl transdermal tablet patch 72 hour 37.5 mcg/hour, 62.5 3 PA hydromorphone oral mcg/hour, 87.5 tablet extended release 3 mcg/hour 24 hr FENTORA 3 hydromorphone rectal 1 hydromorphone (bulk) 3 HYSINGLA ER 3 hydromorphone (pf) in INFUMORPH P/F 4 4 water injection KADIAN ORAL hydromorphone (pf) CAPSULE,EXTEND.R injection solution 10 ELEASE PELLETS 10 4 mg/ml, 2 mg/ml, 4 MG, 100 MG, 20 MG, 3 mg/ml 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 hydromorphone (pf)-0.9 MG % nacl intravenous 4 patient control.analgesia LAZANDA 3 soln levorphanol tartrate 3 PA hydromorphone (pf)-0.9 levorphanol tartrate 3 % nacl intravenous pt (bulk) controlled analgesia meperidine (pf) syring 10 mg/50 ml (0.2 4 injection solution 100 4 mg/ml), 50 mg/50 ml (1 mg/ml, 25 mg/ml, 50 mg/ml), 55 mg/55 ml (1 mg/ml mg/ml) meperidine injection 4 hydromorphone (pf)-0.9 cartridge % nacl intravenous 4 solution 0.5 mg/ml, 1 meperidine oral 3 mg/ml methadone (bulk) 3 hydromorphone (pf)-0.9 methadone injection 4 % nacl intravenous solution syringe 1 mg/5 ml (0.2 4 METHADONE QL (60 ML per 3 mg/ml), 1 mg/ml, 2 INTENSOL 23 days) mg/ml methadone oral 3 hydromorphone concentrate injection solution 1 4 mg/ml, 2 mg/ml methadone oral solution 3 methadone oral tablet 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 14 Drug Name Drug Tier Limits Drug Name Drug Tier Limits methadone oral morphine in 0.9 % 3 tablet,soluble sodium chlor METHADOSE ORAL intravenous pt 3 CONCENTRATE controlled analgesia syring 150 mg/30 ml (5 4 METHADOSE ORAL 3 mg/ml), 275 mg/55 ml TABLET,SOLUBLE (5 mg/ml), 50 mg/50 ml morphine (bulk) 3 (1 mg/ml), 60 mg/30 ml morphine (pf) in 0.9 % (2 mg/ml) sod chl intravenous pt morphine in 0.9 % controlled analgesia sodium chlor 4 syring 30 mg/30 ml (1 4 intravenous solution 1 mg/ml), 50 mg/50 ml (1 mg/ml, 5 mg/ml mg/ml), 55 mg/55 ml (1 morphine injection mg/ml) solution 2 mg/ml, 4 4 morphine (pf) in 0.9 % mg/ml, 8 mg/ml sod chl intravenous morphine injection syringe 0.5 mg/ml, 2 syringe 10 mg/ml, 2 4 4 mg/2 ml (1 mg/ml), 2 mg/ml, 4 mg/ml, 5 mg/ml, 5 mg/5 ml (1 mg/ml, 8 mg/ml mg/ml) morphine intramuscular 4 morphine (pf) in 4 dextrose 5 % morphine intravenous pt controlled analgesia 4 morphine (pf) injection syring solution 0.5 mg/ml, 1 4 mg/ml morphine intravenous solution 10 mg/ml, 100 morphine (pf) 4 4 mg/4 ml, 25 mg/ml, 250 intravenous syringe mg/10 ml, 50 mg/ml morphine concentrate 1 morphine intravenous oral solution syringe 10 mg/ml, 2 4 morphine concentrate mg/ml, 4 mg/ml, 8 oral syringe 10 mg/0.5 3 mg/ml ml morphine oral capsule, 3 morphine in 0.9 % er multiphase 24 hr sodium chlor injection morphine oral pt controlled analgesia 4 capsule,extend.release 3 syring 55 mg/55 ml (1 pellets mg/ml) morphine oral solution 3 morphine in 0.9 % PA; QL (42 EA sodium chlor morphine oral tablet 15 intravenous prefilled 1 Max Qty Per 4 mg pump reservoir 1,000 Fill Retail) mg/ 100 ml, 50 mg/50 morphine oral tablet 30 1 LA ml (1 mg/ml) mg morphine oral tablet 2 PA extended release

You can find information on what the symbols and abbreviations on this table mean on page 4. 15 Drug Name Drug Tier Limits Drug Name Drug Tier Limits morphine rectal 1 ULTRAM ER ORAL TABLET EXTENDED MS CONTIN 3 3 RELEASE 24 HR 300 NUCYNTA 3 PA MG NUCYNTA ER 3 XTAMPZA ER 3 OXAYDO 3 ZOHYDRO ER ORAL oxycodone (bulk) 3 CAPSULE, ORAL 3 oxycodone oral capsule 3 ONLY, ER 12HR oxycodone oral ANALGESIC 3 concentrate OPIOID oxycodone oral solution 1 CODEINE oxycodone oral syringe 3 COMBINATIONS oxycodone oral tablet 1 acetaminophen-codeine oral solution 120-12 oxycodone oral mg/5 ml, 240 mg-24 mg 1 tablet,oral 3 /10 ml (10 ml), 300 mg- only,ext.rel.12 hr 30 mg /12.5 ml OXYCONTIN ORAL acetaminophen-codeine TABLET,ORAL 1 3 oral tablet ONLY,EXT.REL.12 ASCOMP WITH HR 1 CODEINE oxymorphone oral tablet 3 BUTALBITAL oxymorphone oral tablet COMPOUND 1 extended release 12 hr 2 PA W/CODEINE 10 mg, 20 mg, 30 mg, butalbital-acetaminop- 40 mg, 5 mg, 7.5 mg 1 caf-cod oxymorphone oral tablet codeine-butalbital-asa- extended release 12 hr 3 PA 2 15 mg caff FIORINAL-CODEINE ROXICODONE 3 3 #3 SUBSYS 3 ANALGESIC tramadol oral capsule,er biphase 24 hr 25-75 150 3 OPIOID mg DIHYDROCODEI tramadol oral tablet 50 NE 1 mg COMBINATIONS tramadol oral tablet acetaminophen-caff- 2 PA 3 extended release 24 hr dihydrocod oral capsule tramadol oral tablet, er DVORAH 1 3 multiphase 24 hr TREZIX ORAL ULTRAM 3 CAPSULE 320.5-30-16 3 MG

You can find information on what the symbols and abbreviations on this table mean on page 4. 16 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANALGESIC hydrocodone- acetaminophen oral OPIOID 3 DIHYDROCODEI solution 7.5-325 mg/15 ml NE, NON- SALICYLATE hydrocodone- acetaminophen oral ANALGESIC,XAN tablet 10-300 mg, 10- 1 THINE 325 mg, 5-300 mg, 5- acetaminophen-caff- 325 mg, 7.5-300 mg, 3 dihydrocod oral capsule 7.5-325 mg DVORAH 1 hydrocodone- acetaminophen oral 2 TREZIX ORAL tablet 2.5-325 mg CAPSULE 320.5-30-16 3 LORCET MG 3 (HYDROCODONE) ANALGESIC OPIOID LORCET HD 3 FENTANYL LORTAB ELIXIR COMBINATIONS ORAL SOLUTION 10- 3 300 MG/15 ML fentanyl (pf)- NORCO 3 bupivacaine-nacl 4 epidural solution 2 VERDROCET 2 mcg/ml- 0.08 % VICODIN HP 3 fentanyl-ropivacaine- ANALGESIC nacl (pf) epidural 4 OPIOID prefilled pump reservoir 2-0.2 mcg/ml-% HYDROCODONE AND NSAID fentanyl-ropivacaine- nacl (pf) injection COMBINATIONS 4 solution 2-0.2 mcg/ml- hydrocodone-ibuprofen % oral tablet 10-200 mg, 2 ANALGESIC 5-200 mg, 7.5-200 mg IBUDONE ORAL OPIOID 3 HYDROCODONE TABLET 10-200 MG REPREXAIN ORAL AND NON- 3 SALICYLATE TABLET 2.5-200 MG COMBINATIONS XYLON 10 2 APADAZ ORAL ANALGESIC 3 PA TABLET 4.08-325 MG OPIOID APADAZ ORAL HYDROCODONE TABLET 6.12-325 MG, 3 COMBINATIONS 8.16-325 MG HYCET 1 benzhydrocodone- 3 acetaminophen HYCET 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 17 Drug Name Drug Tier Limits Drug Name Drug Tier Limits hydrocodone- oxycodone- acetaminophen oral acetaminophen oral 3 solution 7.5-325 mg/15 tablet 10-325 mg, 2.5- 1 ml 325 mg, 5-325 mg, 7.5- hydrocodone- 325 mg acetaminophen oral PERCOCET ORAL tablet 10-300 mg, 10- TABLET 10-325 MG, 1 3 325 mg, 5-300 mg, 5- 2.5-325 MG, 5-325 MG, 325 mg, 7.5-300 mg, 7.5-325 MG 7.5-325 mg PRIMLEV 3 hydrocodone- ANALGESIC acetaminophen oral 2 tablet 2.5-325 mg OPIOID OXYCODONE hydrocodone-ibuprofen oral tablet 10-200 mg, 2 AND NSAID 5-200 mg, 7.5-200 mg COMBINATIONS IBUDONE ORAL ibuprofen-oxycodone 3 3 TABLET 10-200 MG ANALGESIC LORCET 3 OPIOID (HYDROCODONE) OXYCODONE LORCET HD 3 AND LORTAB ELIXIR SALICYLATE ORAL SOLUTION 10- 3 COMBINATIONS 300 MG/15 ML oxycodone-aspirin 1 NORCO 3 ANALGESIC REPREXAIN ORAL 3 OPIOID TABLET 2.5-200 MG OXYCODONE VERDROCET 2 COMBINATIONS VICODIN HP 3 ENDOCET ORAL XYLON 10 2 TABLET 10-325 MG, 1 ANALGESIC 2.5-325 MG, 5-325 MG, OPIOID 7.5-325 MG OXYCODONE ibuprofen-oxycodone 3 AND NON- NALOCET 3 SALICYLATE oxycodone- COMBINATIONS acetaminophen oral tablet 10-325 mg, 2.5- 1 ENDOCET ORAL 325 mg, 5-325 mg, 7.5- TABLET 10-325 MG, 1 325 mg 2.5-325 MG, 5-325 MG, 7.5-325 MG oxycodone-aspirin 1 NALOCET 3 PERCOCET ORAL TABLET 10-325 MG, 3 2.5-325 MG, 5-325 MG, 7.5-325 MG You can find information on what the symbols and abbreviations on this table mean on page 4. 18 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PRIMLEV 3 ANALGESIC ANALGESIC OPIOID OPIOID TRAMADOL PARTIAL-MIXED COMBINATIONS AGONISTS tramadol- 1 BELBUCA 3 PA acetaminophen BUPRENEX 4 ULTRACET 3 buprenorphine hcl ANALGESIC OR 3 (bulk) ANTIPYRETIC buprenorphine hcl NON- 4 injection OPIOID/SEDATIV buprenorphine E transdermal patch COMBINATIONS QL (4 EA per weekly 10 mcg/hour, 15 1 28 days) ALLZITAL 3 mcg/hour, 20 mcg/hour, BUPAP ORAL 5 mcg/hour 3 TABLET 50-300 MG buprenorphine QL (0.29 EA transdermal patch 1 butalbital- per 1 day) weekly 7.5 mcg/hour acetaminophen oral 3 capsule butorphanol injection 4 butalbital- QL (5 ML per acetaminophen oral butorphanol nasal 3 1 23 days) tablet 50-300 mg, 50- BUTRANS 3 PA 325 mg nalbuphine injection butalbital- 4 solution 10 mg/ml acetaminophen-caff oral 3 nalbuphine injection capsule 50-300-40 mg 1 solution 20 mg/ml butalbital- pentazocine-naloxone 3 acetaminophen-caff oral 1 capsule 50-325-40 mg ANALGESIC butalbital- OPIOID acetaminophen-caff oral 1 TRAMADOL AND tablet 50-325-40 mg NON- ESGIC 3 SALICYLATE TENCON ORAL 3 COMBINATIONS TABLET 50-325 MG tramadol- 1 VANATOL LQ 3 acetaminophen ZEBUTAL ORAL ULTRACET 3 CAPSULE 50-325-40 3 MG

You can find information on what the symbols and abbreviations on this table mean on page 4. 19 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANALGESIC OR ANTI- ANTIPYRETIC INFLAMMATOR NON-OPIOID Y TUMOR acetaminophen (bulk) 3 NECROSIS OFIRMEV 4 FACTOR INHIBITING ANTI- AGNTS,TNF- INFLAMMATOR ALPHA SEL Y - INTERLEUKIN-1 CIMZIA 3 CIMZIA POWDER BETA 3 BLOCKERS FOR RECONST CIMZIA STARTER ILARIS (PF) 3 KIT SUBCUTANEOUS 3 PA PA; QL (2 EA SOLUTION HUMIRA PEN 2 per 28 days) ANTI- INFLAMMATOR HUMIRA PEN CROHNS-UC-HS 2 PA Y - START INTERLEUKIN-1 HUMIRA PEN PSOR- 2 PA RECEPTOR UVEITS-ADOL HS ANTAGONIST HUMIRA ARCALYST 3 SUBCUTANEOUS ANTI- SYRINGE KIT 10 2 PA INFLAMMATOR MG/0.2 ML, 20 MG/0.4 ML Y TUMOR NECROSIS HUMIRA SUBCUTANEOUS PA; QL (2 EA 2 FACTOR SYRINGE KIT 40 per 28 days) INHIBITING MG/0.8 ML AGNTS,NON- HUMIRA(CF) 2 PA SEIECTIVE HUMIRA(CF) PEDI 2 PA ENBREL MINI 3 CROHNS STARTER ENBREL PA; QL (8 EA HUMIRA(CF) PEN 2 PA SUBCUTANEOUS 2 per 21 days) INFLECTRA 4 PA RECON SOLN REMICADE 4 PA ENBREL SUBCUTANEOUS 2 PA RENFLEXIS 4 PA SYRINGE SIMPONI 3 PA PA; QL (8 ML ENBREL SURECLICK 2 SIMPONI ARIA 4 PA per 21 days)

You can find information on what the symbols and abbreviations on this table mean on page 4. 20 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DMARD - ANTI- HUMIRA(CF) PEN 2 PA INFLAMMATOR INFLECTRA 4 PA Y TUMOR REMICADE 4 PA NECROSIS RENFLEXIS 4 PA FACTOR SIMPONI 3 PA INHIBITING AGENTS SIMPONI ARIA 4 PA CIMZIA 3 DMARD - ANTIMALARIAL CIMZIA POWDER 3 FOR RECONST S CIMZIA STARTER hydroxychloroquine 1 3 KIT hydroxychloroquine sulf 3 ENBREL MINI 3 (bulk) ENBREL PLAQUENIL 3 PA; QL (8 EA SUBCUTANEOUS 2 per 21 days) DMARD - RECON SOLN ANTIMETABOLI ENBREL TES SUBCUTANEOUS 2 PA methotrexate sodium SYRINGE 1 oral PA; QL (8 ML ENBREL SURECLICK 2 OTREXUP (PF) per 21 days) SUBCUTANEOUS PA; QL (2 EA HUMIRA PEN 2 AUTO-INJECTOR 10 per 28 days) MG/0.4 ML, 12.5 HUMIRA PEN MG/0.4 ML, 15 MG/0.4 3 PA CROHNS-UC-HS 2 PA ML, 17.5 MG/0.4 ML, START 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 HUMIRA PEN PSOR- 2 PA ML UVEITS-ADOL HS RASUVO (PF) HUMIRA SUBCUTANEOUS SUBCUTANEOUS AUTO-INJECTOR 10 SYRINGE KIT 10 2 PA MG/0.2 ML, 12.5 MG/0.2 ML, 20 MG/0.4 MG/0.25 ML, 15 ML MG/0.3 ML, 17.5 2 PA HUMIRA MG/0.35 ML, 20 SUBCUTANEOUS PA; QL (2 EA 2 MG/0.4 ML, 22.5 SYRINGE KIT 40 per 28 days) MG/0.45 ML, 25 MG/0.8 ML MG/0.5 ML, 30 MG/0.6 HUMIRA(CF) 2 PA ML, 7.5 MG/0.15 ML HUMIRA(CF) PEDI TREXALL 1 CROHNS STARTER XATMEP 1 SUBCUTANEOUS 2 PA SYRINGE KIT 80 MG/0.8 ML

You can find information on what the symbols and abbreviations on this table mean on page 4. 21 Drug Name Drug Tier Limits Drug Name Drug Tier Limits cyclosporine modified DMARD - 1 ANTINFLAMMAT oral solution cyclosporine oral ORY, SELECT. 1 COSTIMULATIO capsule N GENGRAF ORAL MODULATOR,T- CAPSULE 100 MG, 25 1 CELL INHIB. MG GENGRAF ORAL ORENCIA 3 PA 1 SOLUTION ORENCIA (WITH 4 PA IMURAN 3 MALTOSE) mycophenolate mofetil 1 ORENCIA 3 PA mycophenolate mofetil CLICKJECT 4 (hcl) DMARD - B CELL TARGETED NEORAL 3 SANDIMMUNE ORAL AGENTS 3 CAPSULE RITUXAN 4 PA SANDIMMUNE ORAL 3 PA DMARD - GOLD SOLUTION COMPOUNDS DMARD - RIDAURA 1 INTERLEUKIN-1 DMARD - RECEPTOR IMMUNOSUPPRE ANTAGONIST SSIVES (IL-1RA) AZASAN 3 KINERET 3 PA azathioprine 1 DMARD - azathioprine sodium 4 INTERLEUKIN-6 CELLCEPT (IL-6) RECEPTOR 4 INTRAVENOUS INHIBITORS, CELLCEPT ORAL MONOCLONAL 3 CAPSULE ANTIBODY CELLCEPT ORAL ACTEMRA ACTPEN 3 PA SUSPENSION FOR 4 ACTEMRA 4 PA RECONSTITUTION INTRAVENOUS cyclophosphamide ACTEMRA 4 3 PA intravenous recon soln SUBCUTANEOUS cyclophosphamide oral 1 KEVZARA capsule SUBCUTANEOUS 3 PA cyclosporine modified PEN INJECTOR oral capsule 100 mg, 25 1 KEVZARA mg SUBCUTANEOUS 3 cyclosporine modified SYRINGE 3 PA oral capsule 50 mg

You can find information on what the symbols and abbreviations on this table mean on page 4. 22 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DMARD - JANUS IMMUNOMODUL KINASE (JAK) ATOR B- INHIBITORS LYMPHOCYTE OLUMIANT 3 PA STIMULATOR XELJANZ ORAL (BLYS)-SPECIFIC 3 TABLET 5 MG INHIBITOR XELJANZ XR ORAL MCAB TABLET EXTENDED BENLYSTA 3 RELEASE 24 HR 11 INTRAVENOUS 2 PA MG RECON SOLN 120 MG DMARD - OTHER BENLYSTA INTRAVENOUS 4 PA AZULFIDINE 3 RECON SOLN 400 MG AZULFIDINE EN- 3 TABS NSAID ANALGESIC AND CUPRIMINE 3 PA HISTAMINE H2 DEPEN TITRATABS 1 RECEPTOR D-PENAMINE 3 PA ANTAGONIST minocycline oral 1 COMBINATIONS capsule DUEXIS 3 minocycline oral tablet 3 NSAID penicillamine (bulk) 3 ANALGESIC AND penicillamine oral 2 PA PROSTAGLANDI capsule N ANALOG PENICILLAMINE(D-) 3 COMBINATIONS sulfasalazine 1 ARTHROTEC 50 3 DMARD - ARTHROTEC 75 3 PHOSPHODIEST diclofenac-misoprostol 3 ERASE-4 (PDE4) INHIBITORS NSAID ANALGESIC AND OTEZLA 3 PROTON PUMP OTEZLA STARTER 3 INHIBITOR DMARD - COMBINATIONS PYRIMIDINE VIMOVO 3 SYNTHESIS INHIBITORS QL (30 EA per ARAVA 3 23 days) QL (30 EA per leflunomide 1 23 days)

You can find information on what the symbols and abbreviations on this table mean on page 4. 23 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NSAID NSAID ANALGESIC AND ANALGESICS TOPICAL (COX NON- IRRITANT SPECIFIC) - COUNTER- OTHER IRRITANT ketorolac injection 4 COMBINATIONS cartridge FLEXIPAK 3 ketorolac injection 4 NUDROXIPAK DSDR- solution 3 50 ketorolac injection 4 NUDROXIPAK DSDR- syringe 30 mg/ml 3 75 ketorolac intramuscular 4 NUDROXIPAK E-400 3 solution ketorolac intramuscular NUDROXIPAK I-800 3 4 syringe NUDROXIPAK N-500 3 ketorolac oral 2 PA NSAID nabumetone 1 ANALGESIC, CYCLOOXYGEN SPRIX 3 ASE-2 (COX-2) sulindac 1 SELECTIVE tolmetin 2 PA INHIBITORS NSAID CELEBREX 3 ANALGESICS celecoxib 2 PA (COX NON- celecoxib (bulk) 3 SPECIFIC) - OXICAM NUDROXIPAK 3 DERIVATIVES NSAID FELDENE 3 ANALGESICS (COX NON- meloxicam 1 SPECIFIC) - meloxicam (bulk) 3 MOBIC ORAL ANTHRANILIC 3 ACID TABLET DERIVATIVES piroxicam 2 PA meclofenamate 2 PA VIVLODEX 3 mefenamic acid 2 PA mefenamic acid (bulk) 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 24 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NSAID NAPRELAN CR 3 ANALGESICS NAPROSYN ORAL 3 (COX NON- SUSPENSION SPECIFIC) - NAPROSYN ORAL 3 PHENYLACETIC TABLET 500 MG ACID naproxen (bulk) 3 DERIVATIVES naproxen oral 1 CAMBIA 2 PA suspension diclofenac potassium 1 naproxen oral tablet 1 diclofenac sodium oral 1 naproxen oral tablet,delayed release 3 VOLTAREN-XR 3 (dr/ec) ZIPSOR 3 naproxen sodium (bulk) 3 ZORVOLEX 3 naproxen sodium oral 1 NSAID tablet 275 mg, 550 mg ANALGESICS naproxen sodium oral (COX NON- tablet, er multiphase 24 3 SPECIFIC) - hr PROPIONIC oxaprozin 1 ACID NSAID DERIVATIVES ANALGESICS ANAPROX DS 3 (COX NON- CALDOLOR SPECIFIC) - INTRAVENOUS 4 PYRAZOLONE RECON SOLN DERIVATIVES DAYPRO 3 phenylbutazone (bulk) 3 EC-NAPROSYN 3 NSAID EC-NAPROXEN 3 ANALGESICS fenoprofen 3 (CYCLOOXYGEN flurbiprofen oral tablet ASE 1 100 mg INHIBITORS- ibuprofen (bulk) 3 NON- ibuprofen oral tablet 400 SELECTIVE) 1 mg, 600 mg, 800 mg CAMBIA 2 PA ketoprofen oral capsule 1 ketoprofen oral capsule,ext rel. pellets 3 24 hr 200 mg NALFON ORAL 3 CAPSULE 400 MG NALFON ORAL 3 TABLET You can find information on what the symbols and abbreviations on this table mean on page 4. 25 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NSAID ANESTHETICS ANALGESICS, ANESTHETIC, (COX NON- NON- SPECIFIC) - PARENTERAL- INDOLE ACETIC BENZODIAZEPIN ACID E-ANTI-EMETIC DERIVATIVES COMBINATIONS etodolac 1 MKO (MIDAZOLAM- 3 LA INDOCIN ORAL 1 KETAMINE-ONDAN) INDOCIN RECTAL 3 ANESTHETICS indomethacin (bulk) 3 dibucaine hcl (bulk) 3 indomethacin oral 1 GENERAL TIVORBEX ORAL 3 ANESTHETIC - CAPSULE 20 MG INHALANT SALICYLATE VOLATILE ANALGESIC AND desflurane 4 SEDATIVE GENERAL COMBINATIONS ANESTHETIC - butalbital-aspirin- 1 PARENTERAL, caffeine oral capsule ARYLCYCLOHE FIORINAL 3 XYLAMINES SALICYLATE ketamine (bulk) 3 ANALGESIC ketamine in 0.9 % sod COMBINATIONS chloride intravenous 4 choline,magnesium syringe 100 mg/10 ml 1 salicylate (10 mg/ml) ketamine in nacl, iso- SALICYLATE 4 ANALGESICS osmotic ketamine in sterile water diflunisal 2 PA 4 injection DISALCID 3 ketamine injection DURLAZA 3 solution 100 mg/ml, 50 4 salsalate 1 mg/ml GENERAL ANESTHETIC - PARENTERAL, BENZODIAZEPIN ES midazolam (pf) in 0.9 % nacl intravenous 1 LA solution

You can find information on what the symbols and abbreviations on this table mean on page 4. 26 Drug Name Drug Tier Limits Drug Name Drug Tier Limits midazolam (pf) in 0.9 % DIPRIVAN 4 nacl intravenous syringe 3 propofol intravenous 4 2 mg/2 ml (1 mg/ml) emulsion midazolam (pf) in 0.9 % GENERAL nacl intravenous syringe 4 5 mg/5 ml (1 mg/ml) ANESTHETIC ADJUNCTS - midazolam (pf) 1 LA injection NEUROLEPTIC, BUTYROPHENO midazolam in 0.9 % sod chlorid intravenous 4 LA NE DERIVATIVE solution 1 mg/ml droperidol injection 1 LA midazolam in 0.9 % sod solution chlorid intravenous GENERAL syringe 2 mg/2 ml (1 3 LA ANESTHETIC mg/ml), 5 mg/5 ml (1 ADJUNCTS - mg/ml) OPIOID midazolam injection 1 LA fentanyl citrate (pf) 4 midazolam intravenous injection solution syringe 150 mg/30 ml (5 1 LA mg/ml) fentanyl citrate (pf) intravenous pt GENERAL controlled analgesia 4 ANESTHETIC - syring 1,500 mcg/30 ml PARENTERAL, (50 mcg/ml) OTHERS fentanyl citrate (pf) 4 AMIDATE intravenous solution INTRAVENOUS 4 fentanyl citrate (pf) SOLUTION intravenous syringe 100 4 etomidate 4 mcg/2 ml (50 mcg/ml) GENERAL sufentanil citrate 4 ANESTHETIC - ULTIVA 4 PARENTERAL, LOCAL PHENOL ANESTHETIC - DERIVATIVES AMIDES ANESTHESIA S/I-40 BUFFERED 4 (PROPOFOL) LIDOCAINE 4 ANESTHESIA S/I-40A INJECTION SYRINGE 4 (PROPOFOL) 0.9 % (5 ML) ANESTHESIA S/I-40H bupivacaine 4 4 (PROPOFOL) bupivacaine (bulk) 3 ANESTHESIA S/I-40S bupivacaine (pf) 4 4 (PROPOFOL) injection solution ANESTHESIA S/I-60 4 (PROPOFOL)

You can find information on what the symbols and abbreviations on this table mean on page 4. 27 Drug Name Drug Tier Limits Drug Name Drug Tier Limits bupivacaine in nacl(pf) ropivacaine (pf)- 4 epidural solution 0.0625 nacl,iso-osm 4 % (625 mcg/ml), 0.125 ropivacaine(pf)-0.9 % % (1,250 mcg/ml) sodchlor epidural 4 bupivacaine in nacl(pf) prefilled pump reservoir epidural syringe 25 0.2 % (2 mg/ml) 4 mg/10 ml ropivacaine(pf)-0.9 % (2.5mg/ml)0.25% sodchlor epidural 4 bupivacaine in nacl(pf) solution 0.2 % injection prefilled pump 4 ropivacaine(pf)-0.9 % reservoir sodchlor local bupivacaine in nacl(pf) infiltration elastomeric 4 4 injection syringe pump,hi var rate 0.2 % CARBOCAINE 545 ml, 0.2 % 745 ml INJECTION 4 SCANDONEST PLAIN 4 CARTRIDGE XYLOCAINE 4 lidocaine (pf) injection INJECTION 4 solution XYLOCAINE-MPF lidocaine (pf) injection INJECTION syringe 100 mg/5 ml (2 SOLUTION 10 MG/ML 4 %), 200 mg/10 ml (2 4 (1 %), 15 MG/ML (1.5 %), 400 mg/20 ml (2 %), 20 MG/ML (2 %), 5 %), 50 mg/5 ml (1 %) MG/ML (0.5 %) lidocaine hcl injection ZINGO 4 solution 10 mg/ml (1 4 LOCAL %), 20 mg/ml (2 %) ANESTHETIC - lidocaine hcl injection ESTERS syringe 100 mg/5 ml (2 4 %), 30 mg/3 ml (1%), CLOROTEKAL 4 50 mg/5 ml (1 %) LOCAL lidocaine hcl 4 ANESTHETIC - intradermal SYMPATHOMIM lidocaine hcl(pf) in ETIC 0.9% nacl injection 4 COMBINATIONS syringe 10 mg/ml (1 %) (1 ml) bupivacaine-epinephrine 4 lidocaine topical QL (2 GM per bupivacaine-epinephrine 2 4 ointment 23 days) (pf) LTA PRE-ATTACHED 4 lidocaine-epinephrine injection solution 0.5 %- NAROPIN (PF) 4 1:200,000, 1 %- 4 prilocaine (bulk) 3 1:100,000, 2 %- ropivacaine (pf) 1:100,000 4 injection solution lidocaine-epineph- 4 sodium chlor

You can find information on what the symbols and abbreviations on this table mean on page 4. 28 Drug Name Drug Tier Limits Drug Name Drug Tier Limits XYLOCAINE WITH ANALPRAM-HC 4 EPINEPHRINE SINGLES RECTAL 3 LOCAL CREAM 2.5-1 % (4G) ANESTHETIC- hydrocortisone- NSAID-NMDA pramoxine rectal cream 1 2.5-1 % RECEPTOR lidocaine hcl- ANTAGONIST QL (2 GM per hydrocortison ac rectal 1 23 days) COMBINATIONS cream 3-0.5 % bupivacaine-ketorolac- lidocaine hcl- 4 QL (2 GM per ketamine hydrocortison ac rectal 3 23 days) ANORECTAL gel PREPARATIONS lidocaine hcl- hydrocortison ac rectal 3 PA ANAL FISSURE kit 2 %-2 % (7 gram) PAIN/TREATMEN lidocaine hcl- T AGENTS - hydrocortison ac rectal QL (2 EA per 3 NITRATES kit 3-0.5 %, 3-1 % (7 23 days) RECTIV 2 PA gram) lidocaine- ANORECTAL - QL (2 GM per hydrocortisone-aloe 3 GLUCOCORTICO 23 days) rectal gel IDS lidocaine- hydrocortisone topical hydrocortisone-aloe QL (2 EA per 3 cream with perineal 1 rectal kit 3-2.5 % (7 23 days) applicator gram) PROCTOCORT 3 PROCORT 3 TOPICAL PROCTOFOAM HC 3 PROCTO-MED HC 1 ANORECTAL - PROCTO-PAK 1 HEMORRHOIDA PROCTOSOL HC 1 L SINGLE TOPICAL AGENTS OTHER PROCTOZONE-HC 1 phenylephrine hcl (bulk) 3 ANORECTAL - HEMORRHOIDA L RECTAL GLUCOCORTICO ID-LOCAL ANESTHETIC COMB ANA-LEX KIT 3 ANALPRAM-HC 3 RECTAL CREAM

You can find information on what the symbols and abbreviations on this table mean on page 4. 29 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIDOTES ANTIDOTE - AND OTHER CYANIDE REVERSAL POISONING AGENTS CYANOKIT 4 ANTICOAGULAN NITHIODOTE 4 T REVERSAL sodium nitrite 4 AGENT FOR sodium thiosulfate 3 DIRECT (bulk) powder THROMBIN sodium thiosulfate intravenous solution INHIBITORS 4 12.5 gram/50 ml (250 PRAXBIND 4 mg/ml) ANTICOAGULAN ANTIDOTE - T REVERSAL DIGITALIS AGENT FOR GLYCOSIDE FACTOR XA TOXICITY INHIBITORS AGENTS ANDEXXA 4 DIGIFAB 4 ANTIDOTE - ANTIDOTE - ACETAMINOPHE METHEMOGLOB N POISONING INEMIA ACETADOTE 4 methylene blue 4 acetylcysteine 1 (antidote) acetylcysteine 4 ANTIDOTE - intravenous RADIOACTIVE ANTIDOTE - AGENTS ALCOHOL RADIOGARDASE 3 DEHYDROGENA ANTIDOTE SE ENZYME OTHERS INHIBITOR GALZIN 3 fomepizole 4 RADIOGARDASE 3 ANTIDOTE - CHOLINESTERA BENZODIAZEPIN SE E REVERSAL REACTIVATING AGENTS - AGENT AND BENZODIAZEPIN MUSCARINIC E ANTAGONISTS ANTAGONIST flumazenil 4 DUODOTE 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 30 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CHELATING CHELATING AGENTS - AGENTS - COPPER OTHERS CLOVIQUE 2 PA BAL IN OIL 4 CUPRIMINE 3 PA CA-DTPA 4 DEPEN TITRATABS 1 pentetate calcium 4 D-PENAMINE 3 PA trisodium penicillamine (bulk) 3 ZN-DTPA 4 penicillamine oral MU-OPIOID 2 PA capsule RECEPTOR PENICILLAMINE(D-) 3 ANTAGONISTS, SYPRINE 3 PERIPHERALLY- ACTING trientine 2 PA ENTEREG 3 CHELATING AGENTS - IRON MOVANTIK 2 PA RELISTOR ORAL 3 PA deferasirox oral tablet 1 360 mg, 90 mg RELISTOR SUBCUTANEOUS 3 PA deferasirox oral tablet, 1 SOLUTION dispersible RELISTOR deferoxamine injection 4 SUBCUTANEOUS 3 PA recon soln 500 mg SYRINGE EXJADE 3 PA SYMPROIC 3 PA FERRIPROX ORAL 3 PA SOLUTION OPIOID REVERSAL FERRIPROX ORAL 3 PA TABLET 500 MG AGENTS - OPIOID JADENU 2 ANTAGONISTS JADENU SPRINKLE 1 EVZIO INJECTION CHELATING AUTO-INJECTOR 2 3 AGENTS - LEAD MG/0.4 ML POISONING naloxone (bulk) 3 BAL IN OIL 4 naloxone injection 1 CALCIUM DISODIUM solution 4 VERSENATE naloxone injection 1 CHEMET 1 syringe DMSA (BULK) 3 naltrexone 1 naltrexone hcl (bulk) 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 31 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NARCAN NASAL tobramycin sulfate 3 SPRAY,NON- (bulk) 1 AEROSOL 4 ZEMDRI 4 MG/ACTUATION AMINOMETHYL REVIA 3 CYCLINE REVERSAL ANTIBIOTICS AGENTS - NUZYRA 4 PA HEPARIN INTRAVENOUS ANTAGONISTS NUZYRA ORAL 3 protamine 4 AMINOPENICILL ANTI- IN ANTIBIOTIC - INFECTIVE BETA- AGENTS LACTAMASE AMEBICIDES INHIBITOR iodoquinol (bulk) 3 COMBINATIONS amoxicillin-pot paromomycin 1 1 clavulanate AMINOGLYCOSI ampicillin-sulbactam DE ANTIBIOTIC injection recon soln 1.5 4 PA ARIKAYCE 3 PA gram, 3 gram gentamicin (bulk) 3 ampicillin-sulbactam gentamicin in nacl (iso- injection recon soln 15 4 osm) intravenous gram ampicillin-sulbactam piggyback 100 mg/100 4 ml, 100 mg/50 ml, 120 intravenous 4 mg/100 ml, 60 mg/50 AUGMENTIN ES-600 3 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 AUGMENTIN ORAL ml, 90 mg/100 ml SUSPENSION FOR RECONSTITUTION 3 gentamicin injection 4 125-31.25 MG/5 ML, solution 20 mg/2 ml 250-62.5 MG/5 ML gentamicin sulfate (pf) AUGMENTIN ORAL intravenous solution 100 4 TABLET 500-125 MG, 3 mg/10 ml, 60 mg/6 ml 875-125 MG neomycin 1 AUGMENTIN XR 3 streptomycin 4 UNASYN INJECTION 4 tobramycin (bulk) 3 AMINOPENICILL tobramycin in 0.9 % IN ANTIBIOTIC nacl intravenous 4 piggyback 60 mg/50 ml amoxicillin oral capsule 1 tobramycin sulfate 4 amoxicillin oral suspension for 1 reconstitution

You can find information on what the symbols and abbreviations on this table mean on page 4. 32 Drug Name Drug Tier Limits Drug Name Drug Tier Limits amoxicillin oral tablet 1 sulfamethoxazole- 1 amoxicillin oral trimethoprim oral tablet,chewable 125 mg, 1 SULFATRIM 1 250 mg ANTIBACTERIAL ampicillin oral capsule 1 FOLATE ampicillin sodium 4 ANTAGONIST MOXATAG 3 OTHERS ANTHELMINTIC PRIMSOL 3 AGENTS - trimethoprim 1 BENZIMIDAZOL trimethoprim (bulk) 3 E DERIVATIVES trimethoprim, micro 3 albendazole 3 (bulk) ALBENZA 3 ANTIBACTERIAL EMVERM 3 PA NITROFURAN thiabendazole (bulk) 3 DERIVATIVES ANTHELMINTIC FURADANTIN 1 AGENTS - MACROBID 3 MACROCYCLIC MACRODANTIN 3 LACTONES nitrofurantoin 1 ivermectin (bulk) 3 nitrofurantoin (bulk) 3 ivermectin oral 2 PA nitrofurantoin 1 STROMECTOL 3 macrocrystal nitrofurantoin ANTHELMINTIC 1 AGENTS OTHER monohyd/m-cryst BILTRICIDE 3 ANTIBACTERIAL OTHER ivermectin oral 2 PA MONUROL 1 praziquantel 3 STROMECTOL 3 ANTIFUNGAL - ALLYLAMINES ANTIBACTERIAL FOLATE terbinafine (bulk) 3 ANTAGONIST - terbinafine hcl oral 1 OTHER ANTIFUNGAL - COMBINATIONS AMPHOTERIC BACTRIM 3 POLYENE BACTRIM DS 3 MACROLIDES sulfamethoxazole- ABELCET 4 trimethoprim 4 AMBISOME 4 intravenous amphotericin b 2 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 33 Drug Name Drug Tier Limits Drug Name Drug Tier Limits nystatin (bulk) powder 1 DIFLUCAN ORAL billion unit, 10 billion TABLET 100 MG, 200 3 unit, 2 billion unit, 5 1 MG, 50 MG billion unit, 500 million DIFLUCAN ORAL QL (2 EA per 3 unit TABLET 150 MG 23 days) nystatin oral tablet 1 fluconazole in nacl (iso- 4 ANTIFUNGAL - osm) FLUORINATED fluconazole oral PYRIMIDINE- suspension for 1 TYPE AGENTS reconstitution fluconazole oral tablet ANCOBON 3 1 100 mg, 200 mg, 50 mg flucytosine 3 fluconazole oral tablet QL (2 EA per 2 ANTIFUNGAL - 150 mg 23 days) GLUCAN itraconazole oral 3 PA SYNTHESIS capsule INHIBITORS itraconazole oral 2 PA (ECHINOCANDIN solution S) NOXAFIL 4 CANCIDAS 4 INTRAVENOUS caspofungin 4 NOXAFIL ORAL 3 PA ERAXIS(WATER SUSPENSION 4 DILUENT) NOXAFIL ORAL MYCAMINE 4 TABLET,DELAYED 3 RELEASE (DR/EC) ANTIFUNGAL - SPORANOX ORAL 2 PA IMIDAZOLES SOLUTION clotrimazole (bulk) 3 SPORANOX 3 econazole nitrate (bulk) 3 PULSEPAK ketoconazole (bulk) TOLSURA 3 PA 3 powder VFEND 3 ketoconazole oral 3 PA VFEND IV 4 ORAVIG 2 PA voriconazole 4 PA ANTIFUNGAL - intravenous TRIAZOLES voriconazole oral CRESEMBA suspension for 3 4 INTRAVENOUS reconstitution CRESEMBA ORAL 3 voriconazole oral tablet 3 PA DIFLUCAN ORAL ANTIFUNGAL SUSPENSION FOR 3 OTHER RECONSTITUTION ANCOBON 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 34 Drug Name Drug Tier Limits Drug Name Drug Tier Limits benzoic acid (bulk) hydroxychloroquine sulf 1 3 crystals (bulk) benzoic acid (bulk) KRINTAFEL 3 PA 3 powder mefloquine 1 clioquinol (bulk) 3 PLAQUENIL 3 flucytosine 3 primaquine 3 PA griseofulvin (bulk) 3 pyrimethamine (bulk) 3 griseofulvin microsize 1 QUALAQUIN 3 griseofulvin 1 quinacrine (bulk) 3 ultramicrosize quinine sulfate 2 PA ANTI-INFECTIVE ANTIPROTOZOA IMMUNOLOGIC L AGENTS - ADJUVANTS - OTHER INTERFERONS ALINIA ORAL ACTIMMUNE 2 SUSPENSION FOR 2 PA ANTILEPROTIC - RECONSTITUTION IMMUNOMODUL ALINIA ORAL 3 ATORS TABLET THALOMID 3 atovaquone 1 ANTILEPROTIC - IMPAVIDO 3 SULFONE MEPRON 3 AGENTS ANTIPROTOZOA dapsone oral 1 L AGENTS ANTIMALARIAL (ANTIPARASITIC COMBINATIONS ) - 5- atovaquone-proguanil 2 PA NITROTHIAZOL YL COARTEM 1 DERIVATIVES MALARONE 3 ALINIA ORAL MALARONE 3 SUSPENSION FOR 2 PA PEDIATRIC RECONSTITUTION ANTIMALARIAL ALINIA ORAL 3 S TABLET ARAKODA 3 chloroquine phosphate 1 chloroquine phosphate 3 (bulk) DARAPRIM 3 PA hydroxychloroquine 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 35 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIPROTOZOA ANTIRETROVIR L- AL - HIV-1 ANTIBACTERIAL FUSION 1ST INHIBITORS GENERATION 2- FUZEON METHYL-5- SUBCUTANEOUS 1 NITROIMIDAZO RECON SOLN LE ANTIRETROVIR FLAGYL 3 AL - HIV-1 METRO I.V. 4 INTEGRASE metronidazole in nacl STRAND 4 (iso-os) TRANSFER metronidazole oral INHIBITORS 3 capsule ISENTRESS 1 metronidazole oral ISENTRESS HD 1 1 tablet TIVICAY 1 ANTIPROTOZOA ANTIRETROVIR L- AL - INTEGRASE ANTIBACTERIAL INHIBITOR AND 2ND NNRTI GENERATION 2- COMBINATIONS METHYL-5- JULUCA 3 NITROIMIDAZO LE ANTIRETROVIR AL - INTEGRASE SOLOSEC 2 PA INHIBITOR AND tinidazole 1 NRTI tinidazole (bulk) 3 COMBINATIONS ANTIRETROVIR DOVATO 3 PA AL - ANTI-CD4 ANTIRETROVIR DOMAIN 2 AL - NON- MONOCLONAL NUCLEOSIDE ANTIBODY REVERSE TROGARZO 4 TRANSCRIPTASE ANTIRETROVIR INHIB (NNRTI) AL - CCR5 CO- EDURANT 1 RECEPTOR efavirenz 1 ANTAGONIST INTELENCE 1 SELZENTRY 1 nevirapine 1 PIFELTRO 3 SUSTIVA 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 36 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VIRAMUNE ORAL stavudine oral capsule 1 1 SUSPENSION ZERIT ORAL 3 VIRAMUNE ORAL CAPSULE 30 MG 3 TABLET ZIAGEN 3 VIRAMUNE XR zidovudine 1 ORAL TABLET EXTENDED 3 ANTIRETROVIR RELEASE 24 HR 400 AL - MG NUCLEOTIDE ANTIRETROVIR ANALOG AL - REVERSE NUCLEOSIDE TRANSCRIPTASE AND INHIBITORS NUCLEOTIDE tenofovir disoproxil 1 ANALOG RTIS fumarate COMBINATIONS VIREAD ORAL 1 CIMDUO 3 POWDER DESCOVY 3 PA VIREAD ORAL TABLET 150 MG, 200 1 TRUVADA 1 MG, 250 MG ANTIRETROVIR VIREAD ORAL 3 AL - TABLET 300 MG NUCLEOSIDE ANTIRETROVIR REVERSE AL TRANSCRIPTASE COMBINATIONS INHIBITORS - PROTEASE (NRTI) INHIBITORS abacavir 1 EVOTAZ 1 didanosine oral KALETRA ORAL capsule,delayed 3 1 SOLUTION release(dr/ec) 250 mg, KALETRA ORAL 400 mg 1 TABLET EMTRIVA 1 lopinavir-ritonavir 1 EPIVIR 3 PREZCOBIX 1 lamivudine oral solution 1 lamivudine oral tablet 1 150 mg, 300 mg RETROVIR 4 INTRAVENOUS RETROVIR ORAL 3 CAPSULE RETROVIR ORAL 3 SYRUP You can find information on what the symbols and abbreviations on this table mean on page 4. 37 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIRETROVIR ANTIRETROVIR AL- AL- NUCLEOSIDE NUCLEOSIDE, AND NUCLEOTIDE NUCLEOTIDE ANALOGS AND ANALOGS,PROT NON- EASE NUCLEOSIDE INHIBITORS RTI SYMTUZA 3 ATRIPLA 1 ANTIRETROVIR COMPLERA 1 AL-INTEGRASE DELSTRIGO 3 INHIBITOR,NUC ODEFSEY 1 LEOSIDE AND SYMFI 3 NUCLEOTIDE SYMFI LO 3 RTIS COMB ANTITUBERCUL BIKTARVY 3 AR - GENVOYA 1 AMINOBENZOIC STRIBILD 1 ACID ANALOGS ANTIRETROVIR aminosalicylic acid 3 AL-NUCLEOSIDE (bulk) ANALOGS AND PASER 3 INTEGRASE ANTITUBERCUL INHIBITOR AR - CYCLIC COMBINATIONS PEPTIDE TRIUMEQ 1 ANTIBIOTICS ANTIRETROVIR CAPASTAT 4 AL-NUCLEOSIDE ANTITUBERCUL REVERSE AR - D-ALANINE TRANSCRIPTASE ANALOGS INHIBITORS (NRTI) COMB cycloserine 2 PA abacavir-lamivudine 1 ANTITUBERCUL AR - abacavir-lamivudine- 1 zidovudine DIARYLQUINOLI NE ANTIBIOTICS COMBIVIR 3 SIRTURO ORAL EPZICOM 3 1 TABLET 100 MG lamivudine-zidovudine 1 TRIZIVIR 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 38 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTITUBERCUL ANTITUBERCUL AR - AR ISONICOTINIC COMBINATIONS ACID RIFAMATE 3 PA DERIVATIVES RIFATER 3 PA isoniazid injection 4 CARBAPENEM isoniazid oral 1 ANTIBIOTIC ANTITUBERCUL COMBINATIONS AR - imipenem-cilastatin 4 NIACINAMIDE PRIMAXIN IV DERIVATIVES INTRAVENOUS 4 pyrazinamide 1 RECON SOLN 500 MG ANTITUBERCUL VABOMERE 4 AR - CARBAPENEM NITROIMIDAZO ANTIBIOTICS LE (THIENAMYCINS DERIVATIVES ) pretomanid 3 ertapenem 4 ANTITUBERCUL INVANZ INJECTION 4 AR - RIFAMYCIN meropenem 4 AND meropenem-0.9% 4 DERIVATIVES sodium chloride MYCOBUTIN 3 MERREM 4 PRIFTIN 1 CATHETER rifabutin 2 PA LOCK - RIFADIN AMINOGLYCOSI 4 INTRAVENOUS DE RIFADIN ORAL 3 ANTIBIOTICS- rifampin intravenous 4 ANTICOAGULAN T COMB rifampin oral 1 gentamicin-sodium ANTITUBERCUL citrate intra-catheter 4 AR AGENTS solution OTHER CEPHALOSPORI ethambutol 1 N ANTIBIOTIC MYAMBUTOL ORAL 3 AND BETA- TABLET 400 MG LACTAMASE TRECATOR 2 PA INHIBITOR COMBINATIONS AVYCAZ 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 39 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ZERBAXA 4 CEFOTAN 2 PA CEPHALOSPORI cefotetan 2 PA N ANTIBIOTICS - cefotetan in dextrose, 2 PA 1ST iso-osm GENERATION cefoxitin 2 PA cefadroxil oral capsule 1 cefoxitin in dextrose, 2 PA cefadroxil oral iso-osm suspension for cefprozil 1 1 reconstitution 250 mg/5 cefuroxime axetil oral 1 ml, 500 mg/5 ml tablet cefadroxil oral tablet 1 cefuroxime sodium cefazolin in 0.9% sod injection recon soln 750 2 PA chloride intravenous mg 4 piggyback 3 gram/100 cefuroxime sodium 2 PA ml intravenous cefazolin in 0.9% sod MEFOXIN IN chloride intravenous 4 DEXTROSE (ISO- 4 solution OSM) cefazolin in dextrose CEPHALOSPORI (iso-os) intravenous piggyback 1 gram/50 2 PA N ANTIBIOTICS - ml, 2 gram/100 ml, 2 3RD gram/50 ml GENERATION cefazolin injection recon cefdinir 1 soln 1 gram, 10 gram, 2 PA cefditoren pivoxil 3 20 gram, 500 mg cefixime 1 cefazolin injection recon 4 cefotaxime injection soln 100 gram, 300 g 2 PA recon soln 1 gram cefazolin intravenous 2 PA cefpodoxime 1 cephalexin 1 ceftazidime 2 PA KEFLEX ORAL 3 CAPSULE ceftazidime in d5w 2 PA ceftriaxone in CEPHALOSPORI 2 PA dextrose,iso-os N ANTIBIOTICS - 2ND ceftriaxone injection recon soln 1 gram, 10 2 PA GENERATION gram, 2 gram, 250 mg, cefaclor oral capsule 1 500 mg cefaclor oral suspension ceftriaxone injection 1 for reconstitution 125 recon soln 100 gram 1 mg/5 ml, 250 mg/5 ml, ceftriaxone intravenous 2 PA 375 mg/5 ml cefaclor oral tablet 3 PA extended release 12 hr You can find information on what the symbols and abbreviations on this table mean on page 4. 40 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CLAFORAN CHLORAMPHENI INJECTION RECON 4 COL SOLN 1 GRAM, 2 ANTIBIOTICS GRAM AND CLAFORAN DERIVATIVES - INTRAVENOUS 4 RECON SOLN SINGLE AGENTS SPECTRACEF ORAL chloramphenicol (bulk) 3 1 TABLET 400 MG chloramphenicol sod 4 SUPRAX ORAL succinate 3 PA CAPSULE CMV ANTIVIRAL SUPRAX ORAL AGENT - SUSPENSION FOR 3 INORGANIC RECONSTITUTION PYROPHOSPHAT SUPRAX ORAL 1 E ANALOGS TABLET,CHEWABLE FOSCAVIR 4 TAZICEF INJECTION 2 PA CMV ANTIVIRAL TAZICEF 4 PA AGENT - INTRAVENOUS NUCLEOSIDE CEPHALOSPORI ANALOGS N ANTIBIOTICS - CYTOVENE 4 4TH ganciclovir sodium GENERATION 4 PA intravenous recon soln cefepime 2 PA ganciclovir sodium cefepime in dextrose 5 4 2 PA intravenous solution % VALCYTE 3 cefepime in 2 PA valganciclovir 1 dextrose,iso-osm CEPHALOSPORI CMV ANTIVIRAL N ANTIBIOTICS - AGENT - 5TH NUCLEOTIDE GENERATION ANALOGS cidofovir 4 TEFLARO 4 CEPHALOSPORI CMV ANTIVIRAL N ANTIBIOTICS - AGENT - SIDEROPHORE TERMINASE COMPLEX FETROJA 2 PA INHIBITORS PREVYMIS 4 INTRAVENOUS

You can find information on what the symbols and abbreviations on this table mean on page 4. 41 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ofloxacin oral tablet 300 CYCLIC 3 LIPOPEPTIDE mg, 400 mg ANTIBIOTICS GLYCOPEPTIDE CUBICIN 4 ANTIBIOTICS daptomycin 4 FIRVANQ 1 FLUOROCYCLIN VANCOCIN 3 PA E ANTIBIOTICS vancomycin hcl in water 4 XERAVA 4 vancomycin in 0.9 % sodium chl intravenous 4 FLUOROQUINOL piggyback ONE vancomycin in dextrose ANTIBIOTICS 5 % intravenous 4 AVELOX IN NACL piggyback 4 (ISO-OSMOTIC) vancomycin in dextrose BAXDELA 5 % intravenous 4 INTRAVENOUS solution 1 gram/100 ml, 1 gram/250 ml, 1.25 CIPRO ORAL 4 SUSPENSION,MICRO 3 PA gram/250 ml, 1.5 CAPSULE RECON gram/250 ml, 1.5 gram/500 ml, 1.75 CIPRO ORAL gram/500 ml TABLET 250 MG, 500 3 MG vancomycin intravenous recon soln 1,000 mg, CIPRO XR 3 1.25 gram, 1.5 gram, 10 4 ciprofloxacin hcl oral 1 gram, 5 gram, 500 mg, ciprofloxacin in 5 % 750 mg 4 dextrose vancomycin oral 1 ciprofloxacin oral capsule suspension,microcapsul 4 vancomycin oral recon 1 e recon 250 mg/5 ml soln ciprofloxacin oral vancomycin-water inject suspension,microcapsul 1 (peg) intravenous 4 e recon 500 mg/5 ml piggyback 1 gram/200 levofloxacin in d5w 4 ml, 1.5 gram/300 ml levofloxacin intravenous 4 GLYCYLCYCLIN levofloxacin oral E ANTIBIOTICS 3 solution tigecycline 4 levofloxacin oral tablet 1 TYGACIL 4 moxifloxacin oral 3 PA moxifloxacin- 4 sod.ace,sul-water moxifloxacin- 4 sod.chloride(iso)

You can find information on what the symbols and abbreviations on this table mean on page 4. 42 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ZOVIRAX ORAL HEPATITIS B 3 TREATMENT- SUSPENSION NUCLEOSIDE HERPES ANALOGS ANTIVIRAL (ANTIVIRAL) AGENT - BARACLUDE 3 THYMIDINE entecavir 1 ANALOGS EPIVIR HBV ORAL famciclovir 2 PA 1 SOLUTION INFLUENZA EPIVIR HBV ORAL ANTIVIRAL 3 TABLET AGENTS - lamivudine oral tablet NEURAMINIDAS 1 100 mg E INHIBITORS HEPATITIS B oseltamivir oral capsule 1 TREATMENT- oseltamivir oral QL (180 ML NUCLEOTIDE suspension for 2 Max Qty Per ANALOGS reconstitution Fill Retail) (ANTIVIRAL) oseltamivir phosphate 3 adefovir 2 PA (bulk) HEPSERA 3 RAPIVAB (PF) 4 RELENZA QL (20 EA per VEMLIDY 3 3 DISKHALER 23 days) HERPES TAMIFLU ORAL 3 ANTIVIRAL CAPSULE AGENT - PURINE TAMIFLU ORAL QL (180 ML ANALOGS SUSPENSION FOR 3 Max Qty Per acyclovir (bulk) 3 RECONSTITUTION Fill Retail) acyclovir oral capsule 1 INFLUENZA acyclovir oral ANTIVIRAL 1 suspension 200 mg/5 ml AGENTS - PA acyclovir oral tablet 1 ENDONUCLEASE acyclovir sodium 4 INHIBITOR SITAVIG 3 XOFLUZA 3 PA valacyclovir oral tablet QL (30 EA per INFLUENZA-A 2 1 gram 23 days) ANTIVIRAL valacyclovir oral tablet AGENTS 1 500 mg FLUMADINE ORAL 3 VALTREX ORAL QL (30 EA per TABLET 3 TABLET 1 GRAM 23 days) rimantadine 1 VALTREX ORAL 3 TABLET 500 MG

You can find information on what the symbols and abbreviations on this table mean on page 4. 43 Drug Name Drug Tier Limits Drug Name Drug Tier Limits clarithromycin oral LINCOSAMIDE 1 ANTIBIOTICS tablet CLEOCIN HCL 3 clarithromycin oral tablet extended release 3 CLEOCIN INJECTION 4 24 hr CLEOCIN PEDIATRIC 3 PA DIFICID 3 clindamycin hcl 1 E.E.S. 400 ORAL 3 clindamycin hcl (bulk) 3 TABLET clindamycin in 5 % E.E.S. GRANULES 3 4 dextrose ERYPED 200 3 clindamycin palmitate 1 ERYPED 400 3 hcl ERY-TAB 1 CLINDAMYCIN 1 PEDIATRIC ERYTHROCIN 4 clindamycin phosphate ERYTHROCIN (AS 1 (bulk) crystals STEARATE) ORAL 3 TABLET 250 MG clindamycin phosphate 3 (bulk) powder erythromycin ethylsuccinate oral clindamycin phosphate 1 4 suspension for injection reconstitution LINCOCIN 4 erythromycin lincomycin 4 ethylsuccinate oral 1 LIPOGLYCOPEP tablet TIDE erythromycin oral ANTIBIOTICS capsule,delayed 1 release(dr/ec) DALVANCE 4 erythromycin oral tablet 3 VIBATIV erythromycin oral INTRAVENOUS 4 tablet,delayed release 1 RECON SOLN 750 MG (dr/ec) 250 mg, 333 mg MACROLIDE ZITHROMAX 4 ANTIBIOTICS INTRAVENOUS azithromycin ZITHROMAX ORAL 4 3 PA intravenous PACKET azithromycin oral 2 PA ZITHROMAX ORAL packet SUSPENSION FOR 3 azithromycin oral RECONSTITUTION suspension for 1 ZITHROMAX ORAL reconstitution TABLET 250 MG, 500 3 azithromycin oral tablet 1 MG ZITHROMAX TRI- clarithromycin oral 3 suspension for 1 PAK reconstitution ZITHROMAX Z-PAK 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 44 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MISC ANTI- linezolid oral INFECTIVE suspension for 2 PA COMBINATIONS reconstitution linezolid oral tablet 1 HYOPHEN 3 linezolid-0.9% sodium methen-sod phos-meth 4 3 chloride blue-hyos SIVEXTRO PHOSPHASAL 1 4 INTRAVENOUS URELLE 3 SIVEXTRO ORAL 3 URETRON D-S ORAL ZYVOX TABLET 81.6-10.8- 1 4 INTRAVENOUS 40.8 MG ZYVOX ORAL 3 URIBEL 3 URIMAR-T 3 PENICILLIN ANTIBIOTIC - URIN DS 1 NATURAL UROGESIC-BLUE 3 BICILLIN L-A 4 URO-MP 3 penicillin g pot in 4 URYL 3 dextrose USTELL 3 penicillin g potassium UTIRA-C 3 injection recon soln 20 4 MISC ANTI- million unit INFECTIVE penicillin g procaine 4 HIPREX 3 penicillin g sodium 2 PA methenamine hippurate 1 penicillin v potassium 1 methenamine mandelate 3 PENICILLIN QL (1 EA per ANTIBIOTIC - NEBUPENT 2 23 days) PENICILLINASE- PENTAM 4 RESISTANT pentamidine inhalation 2 dicloxacillin 1 pentamidine injection 4 nafcillin 4 nafcillin in dextrose iso- UROQID-ACID NO.2 3 4 osm MONOBACTAM oxacillin 4 ANTIBIOTICS oxacillin in 4 AZACTAM 4 dextrose(iso-osm) aztreonam injection 4 recon soln 2 gram OXAZOLIDINON E ANTIBIOTICS linezolid in dextrose 5% 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 45 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PENICILLIN polymyxin b sulf,micron.(bulk) ANTIBIOTIC, 3 EXTENDED- powder 50 million unit, 6,000 unit/mg SPECTRUM AND BETA- PROTEASE LACTAMASE INHIBITORS INHIB COMB (NON-PEPTIDIC) ANTIRETROVIR piperacillin-tazobactam intravenous recon soln 4 AL 13.5 gram, 40.5 gram APTIVUS 1 piperacillin-tazobactam APTIVUS (WITH 1 intravenous recon soln VITAMIN E) 4 PA 2.25 gram, 3.375 gram, PREZCOBIX 1 4.5 gram PREZISTA ORAL 1 ZOSYN IN SUSPENSION DEXTROSE (ISO- 4 OSM) PREZISTA ORAL TABLET 150 MG, 600 1 PENICILLIN MG, 75 MG, 800 MG NATURAL PROTEASE ANTIBIOTIC INHIBITORS COMBINATIONS (PEPTIDIC) - EXTENDED ANTIRETROVIR RELEASE AL BICILLIN C-R 4 atazanavir 1 POLYMYXINS CRIXIVAN ORAL AND CAPSULE 200 MG, 1 DERIVATIVES - 400 MG SINGLE AGENTS EVOTAZ 1 bacitracin (bulk) powder 3 fosamprenavir 1 5 million unit INVIRASE ORAL 1 bacitracin intramuscular 4 TABLET bacitracin, micronized LEXIVA ORAL 1 (bulk) powder 75.7 3 SUSPENSION unit/mg LEXIVA ORAL colistin (colistimethate 3 PA 4 TABLET na) NORVIR 3 PA colistin sulfate (bulk) 3 REYATAZ ORAL COLY-MYCIN M 4 CAPSULE 150 MG, 3 PARENTERAL 300 MG REYATAZ ORAL 3 PA CAPSULE 200 MG

You can find information on what the symbols and abbreviations on this table mean on page 4. 46 Drug Name Drug Tier Limits Drug Name Drug Tier Limits REYATAZ ORAL 3 TETRACYCLINE POWDER IN PACKET AND VIRACEPT ORAL 1 TETRACYCLINE TABLET ANTIBIOTIC RIFAMYCINS COMBINATIONS AND RELATED AVIDOXY DK 3 DERIVATIVE BENZODOX 30 3 ANTIBIOTICS BENZODOX 60 3 AEMCOLO 3 TETRACYCLINE MYCOBUTIN 3 ANTIBIOTICS PRIFTIN 1 ACTICLATE 3 rifabutin 2 PA AVIDOXY 3 RIFADIN 4 COREMINO 3 INTRAVENOUS demeclocycline 3 RIFADIN ORAL 3 DORYX MPC 3 rifampin (bulk) 3 DORYX ORAL rifampin intravenous 4 TABLET,DELAYED 3 rifampin oral 1 RELEASE (DR/EC) XIFAXAN 2 200 MG, 50 MG STREPTOGRAMI DOXY-100 4 doxycycline hyclate N ANTIBIOTICS 3 (bulk) SYNERCID 4 doxycycline hyclate oral 1 SULFONAMIDE capsule ANTIBIOTIC doxycycline hyclate oral sulfacetamide (bulk) 3 tablet 100 mg, 150 mg, 1 sulfacetamide sod, 50 mg 3 mono (bulk) doxycycline hyclate oral sulfacetamide sodium tablet,delayed release 3 3 (bulk) (dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75 mg sulfadiazine 2 PA doxycycline sulfadiazine (bulk) 3 monohydrate oral 1 sulfadiazine sodium 3 capsule 100 mg, 50 mg (bulk) doxycycline sulfamethoxazole (bulk) 3 monohydrate oral 3 sulfanilamide (bulk) 3 capsule 150 mg, 75 mg sulfisoxazole (bulk) 1 doxycycline monohydrate oral 3 capsule,ir - delay rel,biphase

You can find information on what the symbols and abbreviations on this table mean on page 4. 47 Drug Name Drug Tier Limits Drug Name Drug Tier Limits doxycycline VIBRAMYCIN ORAL 3 monohydrate oral CAPSULE 100 MG 3 suspension for VIBRAMYCIN ORAL reconstitution SUSPENSION FOR 3 doxycycline RECONSTITUTION 1 monohydrate oral tablet VIBRAMYCIN ORAL 3 MINOCIN SYRUP 4 INTRAVENOUS XERAVA 4 minocycline oral 1 ANTINEOPLAST capsule ICS minocycline oral tablet 3 minocycline oral tablet ANP - HUMAN extended release 24 hr 3 PA VASCULAR 105 mg, 65 mg, 80 mg ENDOTHELIAL minocycline oral tablet GROWTH extended release 24 hr FACTOR INHIB 3 115 mg, 135 mg, 45 mg, REC-MC 55 mg, 90 mg ANTIBODY MINOLIRA ER 3 PA AVASTIN 4 MONDOXYNE NL ZIRABEV 4 ORAL CAPSULE 100 3 MG, 75 MG ANTINEOPLASIC MONODOX 3 - EPIDERM.GROW MORGIDOX 2X100 3 TH FACTOR- MORGIDOX ORAL 1 EGFR CAPSULE 100 MG (ERBB1),HER-2 NUZYRA 4 PA (ERBB2)R.INHIB INTRAVENOUS TYKERB 2 NUZYRA ORAL 3 ORACEA 3 ANTINEOPLASTI C - CYP17 (17 oxytetracycline (bulk) 3 ALPHA- SEYSARA 3 HYDROXYLASE/ SOLODYN ORAL C17,20-LYASE) TABLET EXTENDED INHIBITOR RELEASE 24 HR 105 3 MG, 115 MG, 55 MG, abiraterone 1 65 MG, 80 MG YONSA 3 tetracycline 1 ZYTIGA 3 PA tetracycline hcl (bulk) 3 tigecycline 4 TYGACIL 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 48 Drug Name Drug Tier Limits Drug Name Drug Tier Limits thiotepa injection recon ANTINEOPLASTI 4 C - 1ST soln 15 mg GENERATION ANTINEOPLASTI EGFR TYROSINE C - ALKYLATING KINASE AGENT - INHIBITOR METHYLHYDRA erlotinib 1 PA ZINES IRESSA 2 MATULANE 3 PA TARCEVA 2 ANTINEOPLASTI ANTINEOPLASTI C - ALKYLATING C - 2ND AGENT - GENERATION NITROGEN EGFR TYROSINE MUSTARDS KINASE ALKERAN 1 INHIBITOR ALKERAN (AS HCL) 4 GILOTRIF 2 cyclophosphamide 4 NERLYNX 2 PA intravenous recon soln cyclophosphamide oral VIZIMPRO 2 PA 1 capsule ANTINEOPLASTI EVOMELA 4 C - 3RD GENERATION IFEX 4 EGFR TYROSINE ifosfamide 4 KINASE LEUKERAN 1 INHIBITOR melphalan hcl 4 TAGRISSO 2 ANTINEOPLASTI ANTINEOPLASTI C - ALKYLATING C - ALKYLATING AGENT - AGENT - ALKYL NITROSOUREAS SULFONATES BICNU 4 BUSULFEX 4 carmustine 3 MYLERAN 1 GLEOSTINE ORAL ANTINEOPLASTI CAPSULE 10 MG, 100 3 MG, 40 MG C - ALKYLATING AGENT - GLIADEL WAFER 4 ETHYLENIMINE ANTINEOPLASTI S AND C - ALKYLATING METHYLMELAM AGENT - OTHER INES BELRAPZO 4 TEPADINA 4 BENDEKA 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 49 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TREANDA XTANDI 2 INTRAVENOUS 4 YONSA 3 RECON SOLN ZYTIGA 3 PA ANTINEOPLASTI ANTINEOPLASTI C - ALKYLATING C - ANTIBODY- AGENT - DRUG TRIAZENES CONJUGATES dacarbazine 4 (ADCS) TEMODAR 4 ADCETRIS 4 PA INTRAVENOUS KADCYLA 4 PA TEMODAR ORAL 3 POLIVY 4 temozolomide 1 ANTINEOPLASTI ANTINEOPLASTI C - ANAPLASTIC C - ANTI-GD2 LYMPHOMA GANGLIOSIDE KINASE (ALK) MONOCLONAL INHIBITORS ANTIBODY UNITUXIN 4 ALECENSA 2 PA ALUNBRIG 2 PA ANTINEOPLASTI C - LORBRENA 2 PA ANTIMETABOLI XALKORI 2 TE - FOLIC ACID ZYKADIA ORAL 2 PA ANALOGS TABLET ALIMTA 4 PA ANTINEOPLASTI FOLOTYN 4 C - methotrexate sodium ANTIADRENALS 1 (pf) LYSODREN 1 methotrexate sodium 4 ANTINEOPLASTI injection C - methotrexate sodium 1 ANTIANDROGEN oral S TREXALL 1 abiraterone 1 XATMEP 1 bicalutamide 1 ANTINEOPLASTI CASODEX 3 PA C - ERLEADA 2 PA ANTIMETABOLI flutamide 1 TE - PURINE NILANDRON 3 ANALOGS nilutamide 2 PA ARRANON 4 NUBEQA 2 PA cladribine 4 clofarabine 4 You can find information on what the symbols and abbreviations on this table mean on page 4. 50 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CLOLAR 4 ANTINEOPLASTI fludarabine 4 C - mercaptopurine 1 ANTIMETABOLI NIPENT 4 TES - PYRIMIDINE PURIXAN 2 PA ANALOG TABLOID 1 COMBINATIONS ANTINEOPLASTI LONSURF 1 C - ANTIMETABOLI ANTINEOPLASTI TE - PYRIMIDINE C - ANTI-SLAMF7 ANALOGS MONOCLONAL ANTIBODY ADRUCIL AGENTS INTRAVENOUS 4 SOLUTION 2.5 EMPLICITI 4 GRAM/50 ML ANTINEOPLASTI azacitidine 4 C - AROMATASE capecitabine 1 PA INHIBITORS cytarabine 4 anastrozole 1 cytarabine (pf) injection ARIMIDEX 3 4 solution AROMASIN 3 PA DACOGEN 4 exemestane 1 decitabine 4 FEMARA 3 floxuridine 4 letrozole 1 fluorouracil (bulk) 3 ANTINEOPLASTI fluorouracil intravenous 4 C - ARSENIC gemcitabine 4 COMPOUNDS INFUGEM 4 arsenic trioxide (bulk) 4 VIDAZA 4 arsenic trioxide XELODA 3 intravenous solution 1 4 mg/ml ANTINEOPLASTI C - TRISENOX INTRAVENOUS 4 ANTIMETABOLI SOLUTION 2 MG/ML TE - UREA DERIVATIVES ANTINEOPLASTI C - HYDREA 3 ASPARAGINASE hydroxyurea 1 ENZYME THERAPY AGENTS ERWINAZE 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 51 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ONCASPAR 4 RITUXAN 4 PA ANTINEOPLASTI RITUXAN HYCELA 4 PA C - B-CELL ANTINEOPLASTI LYMPHOMA-2 C - CD22 (BCL-2) DIRECTED INHIBITORS ANTIBODY AND VENCLEXTA 2 PA CYTOTOXIN VENCLEXTA CONJUGATE 3 STARTING PACK LUMOXITI 4 ANTINEOPLASTI ANTINEOPLASTI C - BRAF KINASE C - CD38 INHIBITORS SPECIFIC BRAFTOVI 2 PA RECOMBINANT TAFINLAR 2 MONOCLONAL ZELBORAF 2 ANTIBODY AGENTS ANTINEOPLASTI C - BRUTON'S DARZALEX 4 TYROSINE ANTINEOPLASTI KINASE (BTK) C - CD52 INHIBITOR SPECIFIC BRUKINSA 2 PA RECOMBINANT MONOCLONAL CALQUENCE 2 PA ANTIBODY IMBRUVICA 2 PA AGENTS ANTINEOPLASTI CAMPATH 4 C - CC CHEMOKINE ANTINEOPLASTI RECEPTOR 4 C - CYCLIN- (CCR4) DEPENDENT ANTAGONIST, KINASE (CDK) REC-MAB 4/6 INHIBITORS IBRANCE ORAL POTELIGEO 4 2 CAPSULE ANTINEOPLASTI KISQALI ORAL C - CD20 TABLET 200 MG/DAY 2 PA SPECIFIC (200 MG X 1) RECOMBINANT VERZENIO 2 PA MONOCLONAL ANTIBODY AGENTS ARZERRA 4 GAZYVA 4 You can find information on what the symbols and abbreviations on this table mean on page 4. 52 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTINEOPLASTI ANTINEOPLASTI C - CYTOTOXIC C - FMS-LIKE T-LYMPHOCYTE TYROSINE ANTIGEN (CTLA- KINASE 3 (FLT3) 4),R-MC INHIBITORS ANTIBODY XOSPATA 2 PA YERVOY 4 PA ANTINEOPLASTI ANTINEOPLASTI C - C - HALICHONDRIN EPIPODOPHYLL B ANALOGS, OTOXINS MICROTUBULE ETOPOPHOS 4 INHIBITORS etoposide intravenous 4 HALAVEN 4 etoposide oral 2 PA ANTINEOPLASTI teniposide 4 C - HEDGEHOG TOPOSAR 4 PATHWAY INHIBITOR ANTINEOPLASTI C - DAURISMO 2 PA EPOTHILONES ERIVEDGE 2 AND ANALOGS ODOMZO 2 PA IXEMPRA 4 ANTINEOPLASTI ANTINEOPLASTI C - HISTONE C - ESTROGEN DEACETYLASE RECEPTOR (HDAC) ANTAGONIST INHIBITORS FASLODEX 3 BELEODAQ 4 fulvestrant 4 FARYDAK 2 PA ANTINEOPLASTI ISTODAX 4 C - ESTROGENS ZOLINZA 2 diethylstilbestrol (bulk) 3 ANTINEOPLASTI EMCYT 1 C - IMMUNOTHERA ANTINEOPLASTI PY, C - FIBROBLAST THERAPEUTIC GROWTH VACCINES FACTOR RECEPTOR PROVENGE 4 (FGFR) KINASE INHIB BALVERSA 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 53 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTINEOPLASTI ANTINEOPLASTI C - C - KINASE IMMUNOTHERA INHIBITOR AND PY, VIRUS- AROMATASE BASED INHIBITOR IMLYGIC 4 COMBINATION ANTINEOPLASTI KISQALI FEMARA C - CO-PACK ORAL TABLET 200 2 PA IMMUNOTOXINS MG/DAY(200 MG X LUMOXITI 4 1)-2.5 MG ANTINEOPLASTI ANTINEOPLASTI C - C - LHRH (GNRH) INTERLEUKIN-6 AGONIST (IL-6) ANALOG INHIBITORS, PITUITARY MONOCLONAL SUPPRESSANTS ANTIBODY ELIGARD 1 SYLVANT 4 ELIGARD (3 MONTH) 1 ANTINEOPLASTI ELIGARD (4 MONTH) 1 C - ELIGARD (6 MONTH) 1 INTERLEUKINS leuprolide subcutaneous 4 PROLEUKIN 4 kit ANTINEOPLASTI LUPRON DEPOT (3 C - JANUS MONTH) KINASE (JAK) INTRAMUSCULAR 4 PA SYRINGE KIT 22.5 INHIBITORS MG JAKAFI 2 LUPRON DEPOT (4 4 PA ANTINEOPLASTI MONTH) C - JANUS LUPRON DEPOT (6 4 PA KINASE(JAK),FM MONTH) S-LIKE LUPRON DEPOT TYROSINE INTRAMUSCULAR 4 PA KINASE(FLT) SYRINGE KIT 7.5 MG INHIB VANTAS 4 PA INREBIC 2 PA ZOLADEX 4 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 54 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTINEOPLASTI ANTINEOPLASTI C - LHRH (GNRH) C - ANTAGONIST MULTIKINASE PITUITARY INHIBITORS SUPPRESSANTS CABOMETYX 2 FIRMAGON KIT W 2 COMETRIQ 2 PA DILUENT SYRINGE ICLUSIG 2 PA ANTINEOPLASTI NEXAVAR 2 C - MAST CELL STIVARGA 2 STABILIZERS ANTINEOPLASTI cromolyn (bulk) 1 C - MUTANT cromolyn oral 1 ISOCITRATE GASTROCROM 1 DEHYDROGENA ANTINEOPLASTI SE 1 (MIDH1) C - MEK1 AND INHIBITORS MEK2 KINASE TIBSOVO 2 PA INHIBITORS ANTINEOPLASTI COTELLIC 2 C - MUTANT MEKINIST 2 ISOCITRATE MEKTOVI 2 PA DEHYDROGENA ANTINEOPLASTI SE 2 (MIDH2) C - INHIBITORS MONOCLONAL IDHIFA 2 PA ANTIBODIES ANTINEOPLASTI FOR C - OTHER RADIOPHARMA levamisole (bulk) 3 CEUTICAL TICE BCG 4 THERAPY ANTINEOPLASTI ZEVALIN (Y-90) 4 C - PAN-CLASS I ANTINEOPLASTI PI3K C - MTOR INHIBITORS KINASE ALIQOPA 4 INHIBITORS ANTINEOPLASTI AFINITOR 2 C - AFINITOR DISPERZ 2 PHOSPHATIDYLI everolimus 2 PA NOSITOL 3- (antineoplastic) KINASE (PI3K) TORISEL 4 INHIBITORS ALIQOPA 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 55 Drug Name Drug Tier Limits Drug Name Drug Tier Limits COPIKTRA 2 PA TALZENNA 2 PA ZYDELIG 2 PA ZEJULA 2 PA ANTINEOPLASTI ANTINEOPLASTI C - C - PROGESTINS PHOTOSENSITIZ DEPO-PROVERA ERS INTRAMUSCULAR 1 methoxsalen (bulk) SUSPENSION 400 3 crystals MG/ML PHOTOFRIN 4 megestrol oral tablet 1 UVADEX 4 ANTINEOPLASTI ANTINEOPLASTI C - C - PI3K-ALPHA PROTEASOME INHIBITORS ENZYME INHIBITORS PIQRAY 2 PA bortezomib 4 ANTINEOPLASTI KYPROLIS 4 C - PI3K-DELTA AND GAMMA NINLARO 2 INHIBITORS VELCADE 4 COPIKTRA 2 PA ANTINEOPLASTI ANTINEOPLASTI C - PROTEIN- C - PI3K-DELTA TYROSINE INHIBITORS KINASE INHIBITORS ZYDELIG 2 PA AYVAKIT 2 PA ANTINEOPLASTI BOSULIF ORAL C - PLATINUM TABLET 100 MG, 500 2 PA COMPLEXES MG carboplatin 4 BRUKINSA 2 PA cisplatin 4 CALQUENCE 2 PA oxaliplatin 4 CAPRELSA 2 PA ANTINEOPLASTI GLEEVEC 3 C - POLY (ADP- imatinib 1 RIBOSE) IMBRUVICA 2 PA POLYMERASE INLYTA 2 (PARP) INHIBITORS LENVIMA 2 PA OFEV 2 PA LYNPARZA ORAL 2 PA TABLET 100 MG QINLOCK 2 PA RUBRACA ORAL ROZLYTREK 2 PA 2 PA TABLET 200 MG RYDAPT 2 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 56 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SPRYCEL 2 docetaxel intravenous SUTENT 2 PA solution 160 mg/16 ml (10 mg/ml), 160 mg/8 TASIGNA 2 PA ml (20 mg/ml), 20 mg/2 4 TURALIO 2 PA ml (10 mg/ml), 20 VOTRIENT 2 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ANTINEOPLASTI ml (10 mg/ml) C - JEVTANA 4 RADIOPHARMA paclitaxel 4 PA CEUTICALS TAXOTERE METASTRON 4 INTRAVENOUS strontium-89 chloride 3 SOLUTION 20 MG/ML 4 XOFIGO 4 (1 ML), 80 MG/4 ML (20 MG/ML) ANTINEOPLASTI C - RETINOIDS ANTINEOPLASTI C - tretinoin (antineoplastic) 1 THALIDOMIDE ANTINEOPLASTI ANALOGS C - SELECTIVE POMALYST 2 PA ESTROGEN REVLIMID 2 RECEPTOR MODULATORS THALOMID 3 (SERMS) ANTINEOPLASTI FARESTON 1 C - TOPOISOMERAS SOLTAMOX 3 E I INHIBITORS tamoxifen 1 CAMPTOSAR 4 tamoxifen (bulk) 3 HYCAMTIN 4 toremifene 3 INTRAVENOUS ANTINEOPLASTI HYCAMTIN ORAL 2 C - SELECTIVE irinotecan intravenous RETINOID X solution 100 mg/5 ml, 4 RECEPTOR 40 mg/2 ml, 500 mg/25 AGONISTS ml bexarotene 1 ONIVYDE 4 topotecan intravenous TARGRETIN ORAL 3 4 recon soln ANTINEOPLASTI C - TAXANES topotecan intravenous solution 4 mg/4 ml (1 4 ABRAXANE 4 PA mg/ml) DOCEFREZ 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 57 Drug Name Drug Tier Limits Drug Name Drug Tier Limits doxorubicin intravenous ANTINEOPLASTI 4 C - solution doxorubicin, peg- TROPOMYOSIN 4 RECEPTOR liposomal KINASE (TRK) ELLENCE 4 INHIBITOR epirubicin 4 VITRAKVI 2 PA IDAMYCIN PFS 4 ANTINEOPLASTI idarubicin 4 C - VASC mitoxantrone 4 ENDOTHELIAL valrubicin 4 GROWTH VALSTAR 4 FACTOR ANTINEOPLASTI RECEPTOR C ANTIBIOTIC - (VEGFR) ANTAG OTHERS CYRAMZA 4 PA bleomycin injection 4 ANTINEOPLASTI recon soln 15 unit C - VINCA bleomycin injection 1 ALKALOIDS AND recon soln 30 unit ANALOGS mitomycin intravenous 4 MARQIBO 4 mitomycin intravesical 4 NAVELBINE 4 syringe vinblastine intravenous ZANOSAR 4 4 solution ANTINEOPLASTI vincristine 4 C - vinorelbine 4 CEPHALOTAXIN ANTINEOPLASTI ES C ANTIBIOTIC - SYNRIBO 3 ACTINOMYCINS ANTINEOPLASTI COSMEGEN 4 C-ALKYLATING ANTINEOPLASTI AGENT- C ANTIBIOTIC - TETRAHYDROIS ANTHRACYCLIN OQUINOLINE ES AND ADRIAMYCIN DERIVATIVES INTRAVENOUS 4 YONDELIS 4 SOLUTION daunorubicin 4 DOXIL 4 doxorubicin intravenous 4 recon soln 50 mg

You can find information on what the symbols and abbreviations on this table mean on page 4. 58 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTINEOPLASTI ANTINEOPLASTI C-ANTI- C-HER2 PROGRAMMED TARGETED CELL DEATH ANTIBODY- LIGAND-1 (PD- MICROTUBULE L1) MC ANTIB. INHIBITOR TECENTRIQ 4 CONJUGATE ANTINEOPLASTI KADCYLA 4 PA C-ANTI- ANTINEOPLASTI PROGRAMMED C-VASC CELL DEATH ENDOTHELIAL RECEPTOR-1 GROWTH (PD-1) MC ANTIB. FAC(VEGF-A,B KEYTRUDA AND INTRAVENOUS 4 PA PLGF)INHIBITO SOLUTION R LIBTAYO 4 ZALTRAP 4 PA OPDIVO 4 PA BISPECIFIC ANTINEOPLASTI CD19-DIRECTED C-CD123- CD3 T-CELL DIRECTED ENGAGER, CYTOTOXIN (IL- MONOCLONAL 3 AND DIPHTH.) ANTIBODY CONJUGATE BLINCYTO 4 ELZONRIS 4 INTRAVENOUS KIT ANTINEOPLASTI CARDIAC C-CD30 PROTECTIVE DIRECTED AGENTS USED IN ANTIBODY- CONJUNCTION MICROTUBULE WITH DISRUPTING CHEMOTHERAP CONJUGATE Y ADCETRIS 4 PA dexrazoxane hcl 4 ANTINEOPLASTI EPIDERMAL C-CD79B DIRECT GROWTH ANTIBODY- FACTOR MICROTUBULE RECEPT (HER-2) DISRUPTING SUBDOMAIN II CONJUGATE BLOCKER, REC- POLIVY 4 MC AB PERJETA 4 PA You can find information on what the symbols and abbreviations on this table mean on page 4. 59 Drug Name Drug Tier Limits Drug Name Drug Tier Limits EPIDERMAL leucovorin calcium injection recon soln 100 GROWTH 1 FACTOR mg, 200 mg, 350 mg, 500 mg RECEPT BLOCKER (HER- leucovorin calcium injection recon soln 50 4 1 TYPE), REC-MC mg ANTIBODY leucovorin calcium ERBITUX 4 PA injection solution 10 4 PORTRAZZA 4 mg/ml leucovorin calcium oral VECTIBIX 4 PA 3 PA tablet 10 mg, 15 mg EPIDERMAL leucovorin calcium oral GROWTH 1 tablet 25 mg, 5 mg FACTOR RECEPT levoleucovorin calcium intravenous recon soln 4 BLOCKER (HER- 50 mg 2 TYPE), REC-MC levoleucovorin calcium 4 ANTIBODY intravenous solution HERCEPTIN 3 PA METHOTREXAT HYLECTA E RESCUE HERCEPTIN AGENTS INTRAVENOUS 4 PA RECON SOLN 150 MG FUSILEV 4 FLUOROURACIL KHAPZORY 4 AND RELATED leucovorin calcium injection recon soln 100 RESCUE AGENTS 1 mg, 200 mg, 350 mg, VISTOGARD 3 500 mg METHOTREXAT leucovorin calcium E RESCUE injection recon soln 50 4 AGENTS - mg CARBOXYPEPTI leucovorin calcium DASE G2 TYPE injection solution 10 4 mg/ml VORAXAZE 4 leucovorin calcium oral 3 PA METHOTREXAT tablet 10 mg, 15 mg E RESCUE leucovorin calcium oral 1 AGENTS - FOLIC tablet 25 mg, 5 mg ACID levoleucovorin calcium ANTAGONIST intravenous recon soln 4 TYPE 50 mg FUSILEV 4 levoleucovorin calcium 4 KHAPZORY 4 intravenous solution

You can find information on what the symbols and abbreviations on this table mean on page 4. 60 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VORAXAZE 4 ANTISEPTIC - URINARY TRACT PHENOL PROTECTIVE DERIVATIVES AGENTS USED IN phenol 1 CONJUNCTION phenol (bulk) liquid 1 WITH ANTISEPTIC CHEMOTHERAP AND Y DISINFECTANT mesna 4 COMBINATIONS MESNEX SQUARIC ACID IN 4 1 INTRAVENOUS BUTANOL MESNEX ORAL 1 BIOLOGICALS ANTISEPTICS ALLERGENIC AND EXTRACT DISINFECTANT OTHERS S CANDIN 4 ANTISEPTIC - ALLERGENIC BIGUANIDES EXTRACTS - chlorhexidine gluconate 1 GRASS POLLEN (bulk) GRASTEK 2 PA ANTISEPTIC - ORALAIR CHLORINE SUBLINGUAL 2 PA RELEASING TABLET 300 INDX DELUO 3 REACTIVITY HYCLODEX 3 ALLERGENIC ANTISEPTIC - EXTRACTS - IODINE/IODOPH MITE EXTRACTS ORES ODACTRA 3 iodine (bulk) crystals 1 ALLERGENIC IODOFLEX 1 EXTRACTS - IODOSORB 1 WEED POLLEN STRONG IODINE RAGWITEK 2 PA 1 TOPICAL ANTIVENOMS - ANTISEPTIC - SCORPION OTHERS ANTIVENOMS silver protein mild ANASCORP 4 3 (bulk)

You can find information on what the symbols and abbreviations on this table mean on page 4. 61 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIVENOMS - HEPATITIS B SNAKE VACCINES - ANTIVENOMS SINGLE AGENTS ANAVIP 4 ENGERIX-B (PF) 1 CROFAB 4 ENGERIX-B PEDIATRIC (PF) ANTIVIRAL 1 INTRAMUSCULAR MONOCLONAL SYRINGE ANTIBODIES - HEPLISAV-B (PF) RESPIRATORY INTRAMUSCULAR 1 SYNCYTIAL SYRINGE VIRUS (RSV) RECOMBIVAX HB 1 SYNAGIS 2 PA (PF) ANTIVIRAL IMMUNE MONOCLONAL GLOBULIN - ANTIBODIES CYTOMEGALOV SYNAGIS 2 PA IRUS (CMV) HEPATITIS A CYTOGAM AND HEPATITIS INTRAVENOUS 4 SOLUTION 50 MG/ML B VACCINE COMBINATIONS IMMUNE GLOBULIN - TWINRIX (PF) INTRAMUSCULAR 1 GAMMA SYRINGE GLOBULIN HEPATITIS A (IGG), HUMAN VACCINE - BIVIGAM 4 PA SINGLE AGENTS CUTAQUIG 3 HAVRIX (PF) CUVITRU INTRAMUSCULAR SUBCUTANEOUS 1 SUSPENSION 1,440 SOLUTION 1 GRAM/5 ML (20 %), 2 ELISA UNIT/ML 3 PA GRAM/10 ML (20 %), HAVRIX (PF) 4 GRAM/20 ML (20 INTRAMUSCULAR 1 %), 8 GRAM/40 ML SYRINGE (20 %) VAQTA (PF) 1 FLEBOGAMMA DIF 4 PA HEPATITIS B GAMASTAN S/D 4 VACCINE GAMMAGARD 4 PA COMBINATIONS LIQUID PEDIARIX (PF) 4 GAMMAGARD S-D 4 PA (IGA < 1 MCG/ML)

You can find information on what the symbols and abbreviations on this table mean on page 4. 62 Drug Name Drug Tier Limits Drug Name Drug Tier Limits GAMMAKED IMMUNE INJECTION GLOBULIN - SOLUTION 1 TETANUS GRAM/10 ML (10 %), 4 PA 10 GRAM/100 ML (10 HYPERTET S/D (PF) 1 %), 20 GRAM/200 ML IMMUNE (10 %), 5 GRAM/50 SERUMS ML (10 %) ATGAM 4 GAMMAPLEX (WITH 4 PA SORBITOL) THYMOGLOBULIN 4 GAMUNEX-C 4 PA LIVE VACCINE HIZENTRA AND LIVE VIRUS SUBCUTANEOUS 4 PA FORMULATIONS SOLUTION bcg vaccine, live (pf) 4 HYQVIA 3 IMLYGIC 4 HYQVIA IG 3 M-M-R II (PF) 1 COMPONENT PROQUAD (PF) 1 OCTAGAM 4 PA ROTARIX 3 PANZYGA 4 ROTATEQ VACCINE 3 PRIVIGEN 4 PA TICE BCG 4 IMMUNE VARIVAX (PF) 4 GLOBULIN - HEPATITIS B ZOSTAVAX (PF) 1 HEPAGAM B 4 PEANUT DESENSITIZATI HYPERHEP B S/D 3 ON AGENTS HYPERHEP B S-D 3 PALFORZIA (LEVEL NEONATAL 2 PA 1) NABI-HB 3 PALFORZIA (LEVEL 2 PA IMMUNE 2) GLOBULIN - PALFORZIA (LEVEL 2 PA RABIES 3) HYPERRAB (PF) 4 PALFORZIA (LEVEL 2 PA HYPERRAB S/D (PF) 1 4) IMOGAM RABIES-HT PALFORZIA (LEVEL 3 2 PA (PF) 5) PALFORZIA (LEVEL KEDRAB (PF) 4 2 PA 6) IMMUNE PALFORZIA (LEVEL GLOBULIN - 2 PA 7) RHO(D) PALFORZIA (LEVEL 2 PA WINRHO SDF 4 8)

You can find information on what the symbols and abbreviations on this table mean on page 4. 63 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PALFORZIA (LEVEL 2 PA VACCINE 9) BACTERIAL - PALFORZIA (LEVEL 2 PA GRAM 10) NEGATIVE PALFORZIA (LEVEL 2 PA COCCI 11 UP-DOSE) MENACTRA (PF) PALFORZIA INITIAL 2 PA INTRAMUSCULAR 4 DOSE SOLUTION PALFORZIA LEVEL MENVEO A-C-Y-W- 2 PA 4 11 MAINTENANCE 135-DIP (PF) TOXOID VACCINE VACCINE BACTERIAL - COMBINATIONS GRAM POSITIVE ADACEL(TDAP COCCI ADOLESN/ADULT)(P 1 PNEUMOVAX-23 F) INJECTION 1 BOOSTRIX TDAP 1 SOLUTION DAPTACEL (DTAP PNEUMOVAX-23 4 4 PEDIATRIC) (PF) INJECTION SYRINGE INFANRIX (DTAP) PREVNAR 13 (PF) 4 4 (PF) VACCINE KINRIX (PF) 4 BACTERIAL - PEDIARIX (PF) 4 MENINGOCOCC QUADRACEL (PF) 4 AL GROUP B TDVAX 1 VACCINES TENIVAC (PF) 4 BEXSERO 4 tetanus,diphtheria tox TRUMENBA 4 4 ped(pf) VACCINE VACCINE BACTERIAL - BACTERIAL - OTHER GRAM bcg vaccine, live (pf) 4 NEGATIVE VACCINE BACILLI (NON- BACTERIAL - ENTERIC) TOXIN- ACTHIB (PF) 1 PRODUCING HIBERIX (PF) 1 BACILLI PEDVAX HIB (PF) 1 BIOTHRAX 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 64 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VACCINE MIXED ROTATEQ VACCINE 3 COMBINATIONS VACCINE VIRAL (BACTERIAL - RUBELLA AND VIRAL) M-M-R II (PF) 1 PENTACEL (PF) PROQUAD (PF) 1 INTRAMUSCULAR 4 KIT 15 LF UNIT-20 VACCINE VIRAL MCG-5 LF/0.5 ML - VARICELLA VACCINE VIRAL PROQUAD (PF) 1 - HUMAN SHINGRIX (PF) 2 PAPILLOMAVIR VARIVAX (PF) 4 US (HPV) ZOSTAVAX (PF) 1 VACCINES VACCINE VIRAL GARDASIL 9 (PF) 1 COMBINATIONS VACCINE VIRAL M-M-R II (PF) 1 - JAPANESE PROQUAD (PF) 1 ENCEPHALITIS CARDIOVASCU IXIARO (PF) 4 LAR THERAPY VACCINE VIRAL AGENTS - MEASLES ACE INHIBITOR M-M-R II (PF) 1 AND CALCIUM PROQUAD (PF) 1 CHANNEL VACCINE VIRAL BLOCKER - MUMPS AND COMBINATIONS RELATED amlodipine-benazepril 2 PA M-M-R II (PF) 1 LOTREL ORAL PROQUAD (PF) 1 CAPSULE 10-20 MG, 3 VACCINE VIRAL 10-40 MG, 5-10 MG, 5- 20 MG - POLIOMYELITIS PRESTALIA 3 TARKA ORAL IPOL 1 TABLET, IR - ER, VACCINE VIRAL BIPHASIC 24HR 2-180 3 - RABIES MG, 2-240 MG, 4-240 IMOVAX RABIES MG 3 VACCINE (PF) trandolapril-verapamil 3 RABAVERT (PF) 4 ACE INHIBITOR VACCINE VIRAL AND DIURETIC - ROTAVIRUS COMBINATIONS ROTARIX 3 ACCURETIC 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 65 Drug Name Drug Tier Limits Drug Name Drug Tier Limits benazepril- ZESTRIL 3 1 hydrochlorothiazide ALDOSTERONE captopril- 3 RECEPTOR hydrochlorothiazide ANTAGONISTS enalapril- 1 ALDACTONE 3 hydrochlorothiazide eplerenone 1 fosinopril- 1 hydrochlorothiazide INSPRA 3 lisinopril- spironolactone oral 1 4 hydrochlorothiazide tablet 100 mg spironolactone oral LOTENSIN HCT 3 1 tablet 25 mg, 50 mg quinapril- 1 hydrochlorothiazide ALPHA-BETA VASERETIC 3 BLOCKERS ZESTORETIC 3 carvedilol 1 ACE INHIBITORS carvedilol phosphate 1 ACCUPRIL 3 COREG 3 ALTACE 3 COREG CR 3 labetalol intravenous benazepril 1 4 solution captopril 1 labetalol intravenous enalapril maleate 1 syringe 20 mg/4 ml (5 4 enalaprilat intravenous mg/ml), 25 mg/5 ml (5 3 solution mg/ml) EPANED ORAL labetalol oral 1 3 SOLUTION ANGIOTENSIN II fosinopril 1 RECEPTOR lisinopril 1 BLOCKER (ARB)- LOTENSIN ORAL CALCIUM TABLET 10 MG, 20 3 CHANNEL MG, 40 MG BLOCKER moexipril 3 COMB. perindopril erbumine 3 amlodipine-olmesartan 3 PRINIVIL ORAL amlodipine-valsartan 1 TABLET 10 MG, 20 3 AZOR 3 MG EXFORGE 3 QBRELIS 3 telmisartan-amlodipine 1 quinapril 3 TWYNSTA 1 ramipril 1 trandolapril 3 VASOTEC 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 66 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANGIOTENSIN II ANGIOTENSIN II RECEPTOR RECEPTOR BLOCKER (ARB)- BLOCKER- CALCIUM NEPRILYSIN CHANNEL INHIBITOR BLOCKER- COMB. (ARNI) DIURETIC ENTRESTO 2 PA amlodipine-valsartan- 1 ANGIOTENSIN II hcthiazid RECEPTOR EXFORGE HCT 3 BLOCKERS olmesartan-amlodipin- 3 (ARBS) hcthiazid ATACAND 3 TRIBENZOR 1 AVAPRO 3 ANGIOTENSIN II BENICAR ORAL 3 ST RECEPTOR TABLET 20 MG, 5 MG BLOCKER (ARB)- BENICAR ORAL 3 DIURETIC TABLET 40 MG COMBINATIONS candesartan 3 ATACAND HCT 1 COZAAR 3 AVALIDE 3 DIOVAN 3 BENICAR HCT 3 EDARBI 3 candesartan- 3 eprosartan 3 hydrochlorothiazid irbesartan 1 DIOVAN HCT ORAL TABLET 160-12.5 MG, losartan 1 1 160-25 MG, 80-12.5 MICARDIS 3 MG olmesartan 1 DIOVAN HCT ORAL telmisartan 3 TABLET 320-12.5 MG, 3 valsartan oral tablet 160 320-25 MG 1 ST mg, 40 mg, 80 mg EDARBYCLOR 1 valsartan oral tablet 320 2 HYZAAR 1 mg irbesartan- 1 ANTIANGINAL - hydrochlorothiazide CORONARY losartan- 1 VASODILATORS hydrochlorothiazide (NITRATES) MICARDIS HCT 3 DILATRATE-SR 3 PA telmisartan- 3 hydrochlorothiazid ISOCHRON 3 valsartan- ISORDIL 3 PA 1 hydrochlorothiazide ISORDIL TITRADOSE 3 ORAL TABLET 5 MG You can find information on what the symbols and abbreviations on this table mean on page 4. 67 Drug Name Drug Tier Limits Drug Name Drug Tier Limits isosorbide dinitrate oral 1 NORPACE 3 isosorbide mononitrate 1 NORPACE CR 3 MINITRAN 1 procainamide injection 4 NITRO-BID 1 quinidine gluconate oral 1 NITRO-DUR quinidine sulfate (bulk) 1 TRANSDERMAL crystals 3 PATCH 24 HOUR 0.1 quinidine sulfate oral 3 MG/HR, 0.8 MG/HR tablet NITRO-DUR ANTIARRHYTH TRANSDERMAL PATCH 24 HOUR 0.2 MIC - CLASS IB 3 PA MG/HR, 0.3 MG/HR, lidocaine (pf) 4 0.4 MG/HR, 0.6 intravenous MG/HR lidocaine in 5 % nitroglycerin in 5 % dextrose (pf) 4 dextrose intravenous parenteral 4 nitroglycerin solution 4 mg/ml (0.4 4 intravenous %), 8 mg/ml (0.8 %) nitroglycerin oral 1 mexiletine 1 nitroglycerin sublingual 1 phenytoin sodium (bulk) 3 phenytoin sodium nitroglycerin 4 transdermal patch 24 1 intravenous solution hour phenytoin sodium 2 PA nitroglycerin intravenous syringe translingual spray,non- 3 XYLOCAINE 4 aerosol (CARDIAC) (PF) NITROLINGUAL 3 ANTIARRHYTH NITROMIST 3 MIC - CLASS IC NITROSTAT 1 flecainide 1 NITRO-TIME 3 propafenone 1 ANTIANGINAL RYTHMOL SR 3 AND ANTI- ANTIARRHYTH ISCHEMIC MIC - CLASS II AGENTS, NON- BETAPACE 3 HEMODYNAMIC BETAPACE AF 3 RANEXA 3 PA BREVIBLOC IN 4 ranolazine 2 PA NACL (ISO-OSM) ANTIARRHYTH BREVIBLOC INTRAVENOUS MIC - CLASS IA 4 SOLUTION 100 MG/10 disopyramide phosphate 1 ML (10 MG/ML) oral capsule esmolol 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 68 Drug Name Drug Tier Limits Drug Name Drug Tier Limits esmolol in nacl (iso- 4 ANTIHYPERLIPI osm) DEMIC - ATP- SORINE 3 CITRATE LYASE SOTALOL AF 1 (ACLY) sotalol intravenous 4 INHIBITOR sotalol oral 1 NEXLETOL 2 PA SOTYLIZE 1 ANTIHYPERLIPI ANTIARRHYTH DEMIC - BILE MIC - CLASS III ACID SEQUESTRANTS amiodarone in dextrose 5 % intravenous cholestyramine (bulk) 3 solution 150 mg/100 ml cholestyramine (with 1 (1.5 mg/ml), 450 4 sugar) mg/250 ml (1.8 mg/ml), CHOLESTYRAMINE 900 mg/500 ml (1.8 1 LIGHT mg/ml) colesevelam oral amiodarone intravenous 4 3 powder in packet amiodarone oral 1 colesevelam oral tablet 3 PA CORVERT 4 COLESTID dofetilide 1 FLAVORED ORAL 3 ibutilide fumarate 4 PACKET COLESTID ORAL MULTAQ 3 3 GRANULES NEXTERONE 4 COLESTID ORAL PACERONE ORAL 3 TABLET TABLET 100 MG, 200 1 MG, 400 MG colestipol oral granules 3 TIKOSYN 3 colestipol oral packet 3 ANTIARRHYTH colestipol oral tablet 1 MIC - CLASS IV PREVALITE 1 diltiazem hcl QUESTRAN 3 4 intravenous QUESTRAN LIGHT 3 verapamil intravenous 4 ORAL POWDER verapamil oral tablet 1 WELCHOL 3 ANTIARRHYTH ANTIHYPERLIPI MIC OTHERS DEMIC - FIBRIC adenosine (bulk) 3 ACID DERIVATIVES adenosine intravenous 4 PA solution ANTARA ORAL CAPSULE 30 MG, 90 3 adenosine intravenous 4 MG syringe

You can find information on what the symbols and abbreviations on this table mean on page 4. 69 Drug Name Drug Tier Limits Drug Name Drug Tier Limits fenofibrate micronized LESCOL ORAL 3 oral capsule 130 mg, 3 CAPSULE 20 MG 134 mg, 43 mg LESCOL ORAL QL (60 EA per 3 fenofibrate micronized CAPSULE 40 MG 23 days) oral capsule 200 mg, 67 1 QL (30 EA per LESCOL XL 3 mg 23 days) fenofibrate QL (30 EA per LIPITOR 3 nanocrystallized oral 1 23 days) tablet 145 mg, 48 mg LIVALO 3 fenofibrate oral capsule 3 lovastatin oral tablet 10 QL (30 EA per 2 fenofibrate oral tablet 1 mg 23 days) fenofibric acid 3 lovastatin oral tablet 20 QL (120 EA 2 fenofibric acid (choline) 3 mg per 23 days) FENOGLIDE 3 lovastatin oral tablet 40 QL (60 EA per 4 FIBRICOR 3 mg 23 days) PRAVACHOL ORAL QL (30 EA per gemfibrozil 1 3 TABLET 20 MG 23 days) LIPOFEN 3 PRAVACHOL ORAL QL (34 EA per 3 LOPID 3 TABLET 40 MG 23 days) TRICOR 3 pravastatin oral tablet 10 QL (30 EA per 2 TRIGLIDE ORAL mg, 20 mg, 80 mg 23 days) 3 TABLET 160 MG pravastatin oral tablet 40 QL (60 EA per 2 TRILIPIX 3 mg 23 days) rosuvastatin oral tablet QL (30 EA per ANTIHYPERLIPI 1 DEMIC - HMG 10 mg, 20 mg, 5 mg 23 days) rosuvastatin oral tablet COA 1 ST REDUCTASE 40 mg QL (30 EA per INHIBITORS simvastatin oral tablet 2 (STATINS) 23 days) ZOCOR ORAL ALTOPREV 3 QL (30 EA per TABLET 10 MG, 20 3 QL (30 EA per 23 days) atorvastatin 1 MG, 40 MG, 80 MG 30 days) ZYPITAMAG ORAL CRESTOR ORAL 3 QL (30 EA per TABLET 2 MG, 4 MG TABLET 10 MG, 20 3 23 days) MG, 5 MG ANTIHYPERLIPI CRESTOR ORAL DEMIC - 3 TABLET 40 MG NICOTINIC ACID EZALLOR SPRINKLE 3 DERIVATIVES niacin oral tablet fluvastatin oral capsule 3 1 extended release 24 hr fluvastatin oral tablet QL (30 EA per 3 extended release 24 hr 23 days) NIACOR 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 70 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NIASPAN LIPOCHOL PLUS 3 EXTENDED- 3 OMEGA-3 (WITH 3 RELEASE DPA) ANTIHYPERLIPI OMEGA-3 2100 3 DEMIC - OMEGA- omega-3 fatty acids-fish 3 FATTY ACID oil oral capsule 300- 3 TYPE 1,000 mg omega-3 acid ethyl OMEGA-3 FISH OIL 3 esters ORAL CAPSULE 910- 3 VASCEPA ORAL 1,400 MG 3 CAPSULE 1 GRAM omega-3s-dha-epa-fish oil oral capsule,delayed ANTIHYPERLIPI 3 release(dr/ec) 300-1,000 DEMIC - mg SELECTIVE vitamin e oral capsule 1 CHOLESTEROL 100 unit ABSORPTION ANTIHYPERLIPI INHIBITOR DEMIC AGENTS - ezetimibe 1 DIETARY ZETIA 3 SOURCE ANTIHYPERLIPI ALGAL OMEGA-3 3 DEMIC AGENTS - DHA DIETARY ALGAL-900 DHA SOURCE ORAL CAPSULE 300 1 COMBINATIONS MG FISH OIL EXTRA DHA ALGAL-900 1 1 STRENGTH FISH OIL ORAL 1 FISH OIL ORAL CAPSULE 120-180 MG CAPSULE 360-1,200 1 fish oil-dha-epa 3 MG inositol 1 FISH OIL ORAL lecithin oral capsule CAPSULE 900 MG-360 1 3 1,200 mg MG- 455 MG-1,000 lecithin, soy oral MG 1 capsule 1,200 mg FISH OIL ORAL omega-3 acid ethyl CAPSULE,DELAYED 3 RELEASE(DR/EC) 120 esters 1 MG-180 MG- 60 MG- VASCEPA ORAL 3 1,200 MG, 360-1,200 CAPSULE 1 GRAM MG fish oil-dha-epa 3 krill-om-3-dha-epa- phospho-ast oral capsule 3 1,000-170-50-80 mg You can find information on what the symbols and abbreviations on this table mean on page 4. 71 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHYPERLIPI ANTI-PCSK9 DEMIC HMG MONOCLONAL COA REDUCT ANTIBODIES INHIB AND PRALUENT PEN 3 CALCIUM REPATHA 3 PA CHANNEL PUSHTRONEX BLOCKER REPATHA 3 PA QL (30 EA per SURECLICK amlodipine-atorvastatin 3 30 days) REPATHA SYRINGE 3 PA CADUET ORAL BETA TABLET 10-10 MG, 10-20 MG, 10-40 MG, QL (30 EA per BLOCKERS 3 10-80 MG, 5-10 MG, 5- 23 days) CARDIAC 20 MG, 5-40 MG, 5-80 SELECTIVE, MG INTRINSIC ANTIHYPERLIPI SYMPATHOMIM DEMIC-HMG ETIC ACTIVITY COA REDUCT acebutolol 1 INHIB AND acebutolol (bulk) 3 CHOLESTEROL BETA ABSORP INHIBIT BLOCKERS ezetimibe-simvastatin CARDIAC oral tablet 10-40 mg, 3 PA SELECTIVE 10-80 mg atenolol 1 QL (30 EA per VYTORIN 10-10 3 23 days) betaxolol oral 1 QL (30 EA per bisoprolol fumarate 1 VYTORIN 10-20 3 23 days) BREVIBLOC IN 4 QL (30 EA per NACL (ISO-OSM) VYTORIN 10-40 3 23 days) BREVIBLOC INTRAVENOUS VYTORIN 10-80 3 4 SOLUTION 100 MG/10 ANTIHYPERLIPI ML (10 MG/ML) DEMIC- BYSTOLIC 3 MICROSOMAL TRIGLYCERIDE esmolol 4 esmolol in nacl (iso- TRANSFER 4 PROTEIN osm) KAPSPARGO (MTP)INHIB 3 SPRINKLE JUXTAPID 2 PA LOPRESSOR 4 INTRAVENOUS LOPRESSOR ORAL 3 metoprolol succinate 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 72 Drug Name Drug Tier Limits Drug Name Drug Tier Limits metoprolol tartrate SOTYLIZE 1 4 intravenous solution timolol maleate oral 3 metoprolol tartrate oral 1 BRADYKININ B2 TENORMIN 3 RECEPTOR TOPROL XL 3 ANTAGONISTS BETA FIRAZYR 3 PA BLOCKERS NON- icatibant 2 PA CARDIAC CALCIUM SELECT., CHANNEL INTRINSIC BLOCKERS - SYMPATHOMIM BENZOTHIAZEPI ETIC ACTIVITY NES pindolol 3 CARDIZEM CD 3 BETA CARDIZEM LA 3 BLOCKERS NON- CARDIZEM ORAL CARDIAC TABLET 120 MG, 30 3 SELECTIVE MG, 60 MG BETAPACE 3 CARTIA XT 3 BETAPACE AF 3 diltiazem hcl in 0.9% 4 CORGARD 3 nacl diltiazem hcl HEMANGEOL 3 4 intravenous INDERAL LA 3 diltiazem hcl oral INDERAL XL 3 capsule,ext.rel 24h 1 INNOPRAN XL 3 degradable 180 mg, 240 nadolol 1 mg propranolol intravenous 4 diltiazem hcl oral capsule,extended release 1 propranolol oral 12 hr capsule,extended release 1 24 hr 120 mg, 160 mg, diltiazem hcl oral 80 mg capsule,extended release 1 24 hr propranolol oral capsule,extended release 4 diltiazem hcl oral 24 hr 60 mg capsule,extended release 1 24hr propranolol oral 1 solution diltiazem hcl oral tablet 1 propranolol oral tablet 1 DILT-XR 1 SORINE 3 TIADYLT ER ORAL CAPSULE,EXTENDE SOTALOL AF 1 1 D RELEASE 24 HR sotalol intravenous 4 360 MG sotalol oral 1 TIAZAC 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 73 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CALCIUM SULAR ORAL TABLET EXTENDED CHANNEL 3 BLOCKERS - RELEASE 24 HR 17 MG, 34 MG, 8.5 MG DIHYDROPYRIDI NES - CALCIUM CEREBROVASCU CHANNEL LAR SPECIFIC BLOCKERS - PHENYLAKYLA nimodipine 3 MINES CALCIUM CALAN SR 3 CHANNEL BLOCKERS - verapamil (bulk) 3 DIHYDROPYRIDI verapamil intravenous 4 verapamil oral capsule, NES 3 24 hr er pellet ct ADALAT CC 3 verapamil oral amlodipine 1 capsule,ext rel. pellets 3 CARDENE IV 4 24 hr CARDENE IV IN verapamil oral tablet 1 DEXTROSE verapamil oral tablet INTRAVENOUS 1 4 extended release PIGGYBACK 20 MG/200 ML (0.1 VERELAN 3 MG/ML) VERELAN PM 3 CARDENE IV IN 4 CARDIAC SODIUM CHLORIDE INOTROPES - CLEVIPREX 4 PHOSPHODIEST felodipine 1 ERASE isradipine 3 INHIBITORS nicardipine in 0.9 % sod milrinone 4 PA chlor intravenous 4 milrinone in 5 % 4 syringe 1 mg/10 ml dextrose nicardipine intravenous 4 CARDIAC solution SELECTIVE nicardipine oral 3 BETA BLOCKER- nifedipine 1 THIAZIDE nifedipine (bulk) 3 DIURETIC AND nifedipine, micronized RELATED COMB. 3 (bulk) atenolol-chlorthalidone 1 nisoldipine 3 bisoprolol- 1 NORVASC 3 hydrochlorothiazide PROCARDIA 3 DUTOPROL 3 PROCARDIA XL 3 LOPRESSOR HCT 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 74 Drug Name Drug Tier Limits Drug Name Drug Tier Limits metoprolol ta- 1 CARDIOVASCUL hydrochlorothiaz AR TENORETIC 100 3 SYMPATHOMIM TENORETIC 50 3 ETICS ZIAC 3 ADRENALIN INJECTION QL (3 ML per CARDIOVASCUL 3 SOLUTION 1 MG/ML 21 days) AR (1 ML) SYMPATHOMIM AKOVAZ 4 ETIC - ANAPHYLAXIS BIORPHEN 4 THERAPY dobutamine in d5w SINGLE AGENTS intravenous parenteral solution 1,000 mg/250 ADRENALIN ml (4,000 mcg/ml), 250 INJECTION QL (3 ML per 4 3 mg/250 ml (1 mg/ml), SOLUTION 1 MG/ML 21 days) 500 mg/250 ml (2,000 (1 ML) mcg/ml), 500 mg/500 AUVI-Q 3 ml (1,000 mcg/ml) epinephrine (bulk) 3 dobutamine intravenous solution 250 mg/20 ml 4 epinephrine injection (12.5 mg/ml) auto-injector 0.15 PA; QL (4 EA 3 dopamine in 5 % mg/0.15 ml, 0.3 mg/0.3 per 21 days) 4 ml dextrose epinephrine injection dopamine intravenous QL (4 EA per 4 auto-injector 0.15 1 solution 21 days) mg/0.3 ml ephedrine hcl (bulk) 3 epinephrine injection QL (3 ML per 2 ephedrine sulfate (bulk) 3 solution 21 days) ephedrine sulfate EPINEPHRINESNAP- 4 3 injection solution EMS ephedrine sulfate 4 EPIPEN 2-PAK 3 intravenous EPIPEN JR 2-PAK 3 ephedrine sulfate- 0.9%nacl(pf) SYMJEPI INJECTION 4 SYRINGE 0.3 MG/0.3 1 intravenous syringe 50 ML mg/5 ml (10 mg/ml) CARDIOVASCUL epinephrine hcl in 5% AR dextrose intravenous 4 solution SYMPATHOMIM epinephrine in sod ETIC - BETA- 4 chlor,iso ADRENERGIC epinephrine injection QL (3 ML per AGONISTS 2 solution 1 mg/ml (1 ml) 21 days) isoproterenol hcl 4 LEVOPHED 4 isoproterenol hcl (bulk) 4 (BITARTRATE) You can find information on what the symbols and abbreviations on this table mean on page 4. 75 Drug Name Drug Tier Limits Drug Name Drug Tier Limits midodrine 1 CENTRAL norepinephrine bitartrate 1 ALPHA-2 norepinephrine AGONISTS- bitartrate-d5w THIAZIDE intravenous solution 16 DIURETIC AND mg/250 ml (64 mcg/ml), 4 RELATED COMB. 4 mg/250 ml (16 mcg/ml), 8 mg/250 ml CLORPRES 3 (32 mcg/ml) methyldopa- 3 norepinephrine hydrochlorothiazide bitartrate-nacl CENTRAL intravenous solution 16 ALPHA-2 mg/250 ml (64 mcg/ml), 4 RECEPTOR 16 mg/500 ml (32 mcg/ml), 4 mg/250 ml AGONISTS (16 mcg/ml), 8 mg/250 CATAPRES 3 LA ml (32 mcg/ml) CATAPRES-TTS-1 3 LA norepinephrine CATAPRES-TTS-2 3 LA bitartrate-nacl 4 intravenous syringe CATAPRES-TTS-3 3 LA NORTHERA 3 PA clonidine 1 LA phenylephrine hcl (bulk) 3 clonidine hcl oral tablet 1 LA phenylephrine hcl in guanfacine oral tablet 1 LA 0.9% nacl intravenous methyldopa 2 LA solution 20 mg/250 ml methyldopate 4 LA (80 mcg/ml), 40 mg/250 4 ml (160 mcg/ml), 50 DIGITALIS mg/250 ml (200 GLYCOSIDES mcg/ml), 80 mg/250 ml DIGITEK 1 (320 mcg/ml) DIGOX 1 phenylephrine hcl in 0.9% nacl intravenous digoxin injection 4 syringe 0.4 mg/10 ml digoxin oral solution 50 2 PA (40 mcg/ml), 0.5 mg/5 mcg/ml (0.05 mg/ml) ml (100 mcg/ml), 0.8 digoxin oral tablet 1 mg/10 ml (80 mcg/ml), 4 digoxin, micronized 1 mg/10 ml (100 3 mcg/ml), 20 mg/50 ml (bulk) (400 mcg/ml), 200 LANOXIN INJECTION SOLUTION 250 mcg/5 ml (40 mcg/ml), 4 5 mg/50 ml (100 MCG/ML (0.25 mcg/ml) MG/ML) phenylephrine hcl LANOXIN ORAL 4 PA injection TABLET 125 MCG (0.125 MG), 250 MCG 3 (0.25 MG), 62.5 MCG (0.0625 MG) You can find information on what the symbols and abbreviations on this table mean on page 4. 76 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LANOXIN 4 DIURETIC - PEDIATRIC CARBONIC DIRECT ACTING ANHYDRASE VASODILATORS INHIBITORS hydralazine injection 4 acetazolamide 1 hydralazine oral 1 acetazolamide (bulk) 3 minoxidil (bulk) 3 acetazolamide sodium 4 minoxidil oral 1 methazolamide 1 NIPRIDE RTU 4 DIURETIC - NITROPRESS 4 INORGANIC sodium nitroprusside 4 SALT DIURETIC - ammonium chloride 4 ALDOSTERONE DIURETIC - RECEPTOR LOOP ANTAGONIST, bumetanide injection 4 NON-SELECTIVE bumetanide oral 1 ALDACTONE 3 EDECRIN 3 spironolactone oral 4 ethacrynate sodium 4 tablet 100 mg ethacrynic acid 1 spironolactone oral 1 furosemide in 0.9 % tablet 25 mg, 50 mg 4 nacl DIURETIC - furosemide injection 4 ALDOSTERONE RECEPTOR furosemide oral 1 ANTAGONIST, LASIX 3 SELECTIVE SODIUM EDECRIN 4 eplerenone 1 torsemide oral 1 INSPRA 3 DIURETIC - DIURETIC - OSMOTIC ARGININE mannitol 10 % 4 VASOPRESSIN mannitol 20 % 4 V1A/V2 mannitol 25 % 4 RECEPTOR intravenous solution ANTAGONISTS mannitol 5 % 4 VAPRISOL IN 5 % 4 OSMITROL 10 % 4 DEXTROSE OSMITROL 15 % 4 OSMITROL 20 % 4 OSMITROL 5 % 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 77 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DIURETIC - DIURETIC - POTASSIUM THIAZIDES AND SPARING RELATED amiloride 1 chlorothiazide oral 1 DYRENIUM 3 tablet 500 mg triamterene (bulk) 3 chlorothiazide sodium 4 PA chlorthalidone oral DIURETIC - 1 tablet 25 mg, 50 mg POTASSIUM SPARING- DIURIL 3 THIAZIDE AND DIURIL IV 4 RELATED hydrochlorothiazide 1 COMBINATIONS hydrochlorothiazide 3 ALDACTAZIDE 3 (bulk) amiloride- indapamide 1 1 hydrochlorothiazide metolazone 1 DYAZIDE 3 DOPAMINE D1 MAXZIDE 3 RECEPTOR MAXZIDE-25MG 3 AGONISTS, spironolacton- ANTIHYPERTEN 1 hydrochlorothiaz SIVE triamterene- CORLOPAM 4 hydrochlorothiazid oral 1 GANGLIONIC capsule 37.5-25 mg BLOCKING, triamterene- NON- hydrochlorothiazid oral 1 DEPOLARIZING tablet VECAMYL 3 DIURETIC - SELECTIVE HYPERPOLARIZ ARGININE ATION- VASOPRESSIN V2 ACTIVATED RECEPTOR CYCLIC ANTAGONISTS NUCLEOTIDE- GATED JYNARQUE ORAL 2 PA TABLET CHANNEL INHIBITORS JYNARQUE ORAL TABLETS, CORLANOR 2 PA SEQUENTIAL 45 MG (AM)/ 15 MG (PM), 60 3 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM) SAMSCA 2 You can find information on what the symbols and abbreviations on this table mean on page 4. 78 Drug Name Drug Tier Limits Drug Name Drug Tier Limits HYPERTROPHIC PATENT DUCTUS CARDIOMYOPAT ARTERIOSUS HY TREATMENT (PDA) AGENTS, TREATMENT ABLATIVE AGENTS , NSAID- ABLYSINOL 4 TYPE MUSCARINIC indomethacin sodium 4 RECEPTOR NEOPROFEN ANTAGONISTS (IBUPROFEN 4 (ANTICHOLINER LYSN)(PF) GIC) PATENT DUCTUS ATROPEN ARTERIOSUS INTRAMUSCULAR (PDA) PEN INJECTOR 0.5 4 TREATMENT MG/0.7 ML, 1 MG/0.7 AGENTS, ML PROSTAGLANDI atropine (bulk) 3 N-TYPE atropine injection 4 alprostadil 4 solution 1 mg/ml PROSTIN VR 4 atropine injection PEDIATRIC syringe 0.05 mg/ml, 0.1 4 mg/ml PERIPHERAL ALPHA-1 glycopyrrolate (bulk) 3 RECEPTOR NON-CARDIAC BLOCKERS SELECTIVE CARDURA ORAL QL (30 EA per BETA BLOCKER- TABLET 1 MG, 2 MG, 3 23 days) THIAZIDE 4 MG DIURETIC AND CARDURA ORAL QL (60 EA per 3 RELATED COMB. TABLET 8 MG 23 days) nadolol- QL (30 EA per CARDURA XL 3 bendroflumethiazide 3 23 days) oral tablet 80-5 mg DIBENZYLINE 3 propranolol- 1 doxazosin oral tablet 1 QL (30 EA per hydrochlorothiazid 2 mg, 2 mg, 4 mg 23 days) PAH AGENTS - doxazosin oral tablet 8 QL (60 EA per 2 SELECTIVE mg 23 days) PROSTACYCLIN MINIPRESS 3 LA RECEPTOR (IP) phenoxybenzamine 1 AGONISTS phentolamine injection 4 UPTRAVI 2 PA recon soln prazosin 1 LA

You can find information on what the symbols and abbreviations on this table mean on page 4. 79 Drug Name Drug Tier Limits Drug Name Drug Tier Limits terazosin oral capsule 1 QL (30 EA per 2 POSTGANGLION mg, 2 mg, 5 mg 23 days) IC BLOCKERS, terazosin oral capsule 10 QL (60 EA per 2 ANTIHYPERTEN mg 23 days) SIVE PERIPHERAL guanethidine sulfate 3 VASODILATORS, (bulk) SINGLE AGENTS PULMONARY isoxsuprine oral tablet 3 ANTIHYPERTEN 20 mg SIVE AGENTS - nylidrin (bulk) 3 PROSTACYCLIN- papaverine (bulk) 3 TYPE papaverine injection epoprostenol (glycine) 4 PA 4 solution FLOLAN 4 PA PHEOCHROMOC ORENITRAM 3 YTOMA, AGENTS REMODULIN 4 PA TO TREAT treprostinil sodium 4 DEMSER 3 TYVASO 2 PA PLASMA TYVASO KALLIKREIN INSTITUTIONAL 2 PA INHIBITOR START KIT AGENTS, TYVASO REFILL KIT 2 PA RECOMBINANT TYVASO STARTER 2 PA MONOCLONAL KIT ANTIBODY VELETRI 4 PA TAKHZYRO 3 PA VENTAVIS 2 PA PLASMA PULMONARY KALLIKREIN ANTIHYPERTEN INHIBITOR SIVE AGENTS- AGENTS, SOLUBLE RECOMBINANT GUANYLATE PROTEIN CYCLASE KALBITOR 4 PA STIMULATOR PLASMA ADEMPAS 2 PA KALLIKREIN PULMONARY INHIBITOR ARTERIAL AGENTS HYPERTENSION KALBITOR 4 PA - ENDOTHELIN RECEPTOR ANTAGONISTS ambrisentan 2 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 80 Drug Name Drug Tier Limits Drug Name Drug Tier Limits bosentan 2 PA SCLEROSING LETAIRIS 2 PA AGENTS OPSUMIT 3 ASCLERA 4 TRACLEER 3 PA ETHAMOLIN 4 PULMONARY SOTRADECOL 4 ARTERIAL VARITHENA 4 HYPERTENSION VASODILATOR AGENTS- COMBINATIONS SELECTIVE BIDIL 3 CGMP-PDE5 INHIBITORS CENTRAL ADCIRCA 3 NERVOUS SYSTEM ALYQ 3 PA AGENTS REVATIO 4 INTRAVENOUS AGENTS TO REVATIO ORAL 3 TREAT sildenafil EPISODIC (pulm.hypertension) 4 CLUSTER intravenous HEADACHES sildenafil EMGALITY SYRINGE (pulm.hypertension) SUBCUTANEOUS 3 2 PA oral suspension for SYRINGE 300 MG/3 reconstitution ML (100 MG/ML X 3) sildenafil ANTIANXIETY (pulm.hypertension) 2 PA AGENT - oral tablet ANTIHISTAMINE tadalafil (pulm. 3 PA TYPE hypertension) hydroxyzine hcl tadalafil oral tablet 20 1 LA 2 PA intramuscular mg hydroxyzine hcl oral 1 LA RENIN solution 10 mg/5 ml INHIBITOR, hydroxyzine hcl oral DIRECT AND solution 10 mg/5 ml (5 2 LA DIURETIC ml) COMBINATIONS hydroxyzine hcl oral 1 LA TEKTURNA HCT 3 tablet RENIN hydroxyzine pamoate 1 LA INHIBITOR, VISTARIL 3 LA DIRECT aliskiren 3 PA TEKTURNA 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 81 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIANXIETY VALIUM 3 LA AGENT - XANAX 3 LA BENZODIAZEPIN XANAX XR 3 LA ES ANTIANXIETY ALPRAZOLAM 3 LA AGENT - INTENSOL DICARBAMATE alprazolam oral tablet 1 LA TYPE alprazolam oral tablet 3 LA meprobamate 3 LA extended release 24 hr ANTIANXIETY alprazolam oral 3 LA tablet,disintegrating AGENT - NON- BENZODIAZEPIN ATIVAN ORAL 3 LA E chlordiazepoxide hcl 1 LA buspirone 1 LA clonazepam oral tablet 1 LA ANTICONVULSA clonazepam oral 3 LA tablet,disintegrating NT - AMPA-TYPE GLUTAMATE clorazepate dipotassium 1 LA RECEPTOR diazepam injection 1 LA ANTAGONISTS DIAZEPAM 1 LA FYCOMPA ORAL INTENSOL 2 PA SUSPENSION diazepam oral 1 LA FYCOMPA ORAL concentrate 2 PA TABLET diazepam oral solution 5 2 LA mg/5 ml (1 mg/ml) ANTICONVULSA NT - diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 1 LA BARBITURATES ml) AND diazepam oral tablet 10 DERIVATIVES 2 LA mg butalbital (bulk) 3 diazepam oral tablet 2 MYSOLINE 3 LA 1 LA mg, 5 mg phenobarbital 1 KLONOPIN 3 LA phenobarbital (bulk) 3 LORAZEPAM phenobarbital sodium 1 LA 4 INTENSOL injection solution lorazepam oral 1 LA primidone 1 LA concentrate ANTICONVULSA lorazepam oral tablet 1 LA NT - oxazepam 3 LA BENZODIAZEPIN TRANXENE T-TAB ES ORAL TABLET 7.5 3 LA MG clobazam 1 LA clonazepam oral tablet 1 LA You can find information on what the symbols and abbreviations on this table mean on page 4. 82 Drug Name Drug Tier Limits Drug Name Drug Tier Limits clonazepam oral valproic acid (as sodium 3 LA tablet,disintegrating salt) oral solution 250 2 LA DIASTAT 1 LA mg/5 ml, 500 mg/10 ml (10 ml) DIASTAT ACUDIAL 1 LA ANTICONVULSA diazepam rectal 1 LA NT - KLONOPIN 3 LA FUNCTIONALIZE NAYZILAM 3 LA D AMINO ACID ONFI ORAL VIMPAT 3 LA 2 PA; LA SUSPENSION INTRAVENOUS ONFI ORAL TABLET VIMPAT ORAL 3 LA 1 LA 10 MG, 20 MG SOLUTION SYMPAZAN 3 LA VIMPAT ORAL 1 LA VALTOCO 3 LA TABLET ANTICONVULSA ANTICONVULSA NT - NT - GABA CANNABINOID ANALOGS TYPE ACTIVE-PAC 3 EPIDIOLEX 3 PA gabapentin oral capsule 1 LA ANTICONVULSA gabapentin oral solution 2 LA NT - 250 mg/5 ml CARBAMATES gabapentin oral solution felbamate oral 250 mg/5 ml (5 ml), 300 1 LA 1 PA suspension mg/6 ml (6 ml) gabapentin oral tablet felbamate oral tablet 2 PA 1 LA 600 mg FELBATOL 3 gabapentin oral tablet 2 LA ANTICONVULSA 800 mg NT - LYRICA 3 LA CARBOXYLIC NEURONTIN 3 LA ACID DERIVATIVES pregabalin oral capsule 100 mg, 150 mg, 200 1 LA DEPAKOTE 3 LA mg, 225 mg, 25 mg, 50 DEPAKOTE ER 3 LA mg, 75 mg DEPAKOTE pregabalin oral capsule 3 LA 1 SPRINKLES 300 mg divalproex 1 LA pregabalin oral solution 1 LA valproate sodium 1 LA valproic acid 1 LA valproic acid (as sodium salt) oral solution 250 1 LA mg/5 ml (5 ml)

You can find information on what the symbols and abbreviations on this table mean on page 4. 83 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTICONVULSA phenytoin sodium (bulk) 3 NT - GABA RE- phenytoin sodium 1 UPTAKE extended INHIBITOR, phenytoin sodium 4 NIPECOTIC ACID intravenous solution DERIVATIVES phenytoin sodium 2 PA GABITRIL ORAL intravenous syringe TABLET 12 MG, 16 3 ANTICONVULSA MG NT - GABITRIL ORAL 2 PA IMINOSTILBENE TABLET 2 MG, 4 MG DERIVATIVES tiagabine 2 PA APTIOM 3 LA ANTICONVULSA carbamazepine 1 LA NT - GABA CARBATROL 3 LA TRANSAMINASE EPITOL 1 LA (GABA-T) INHIBITOR EQUETRO 2 PA; LA oxcarbazepine oral SABRIL ORAL 1 LA 3 suspension POWDER IN PACKET oxcarbazepine oral SABRIL ORAL 2 LA 3 PA; LA tablet TABLET OXTELLAR XR 3 LA vigabatrin oral tablet 2 PA TEGRETOL ORAL VIGADRONE 2 PA 3 LA SUSPENSION ANTICONVULSA TEGRETOL ORAL 3 LA NT - TABLET HYDANTOINS TEGRETOL XR 3 LA CEREBYX 2 PA TRILEPTAL 3 LA DILANTIN 3 ANTICONVULSA DILANTIN 3 NT - EXTENDED MONOSACCHAR DILANTIN INFATABS 3 IDE DILANTIN-125 3 DERIVATIVES fosphenytoin 2 PA QUDEXY XR 3 LA PEGANONE 3 TOPAMAX 3 LA PHENYTEK 3 topiramate oral capsule, 1 LA phenytoin (bulk) 3 sprinkle phenytoin oral topiramate oral 1 3 LA suspension capsule,sprinkle,er 24hr phenytoin oral topiramate oral tablet 1 1 LA tablet,chewable 100 mg, 50 mg

You can find information on what the symbols and abbreviations on this table mean on page 4. 84 Drug Name Drug Tier Limits Drug Name Drug Tier Limits topiramate oral tablet lamotrigine oral tablet, 2 LA 3 LA 200 mg, 25 mg chewable dispersible TROKENDI XR 1 LA lamotrigine oral 3 LA ANTICONVULSA tablet,disintegrating NT - SUBVENITE 1 LA SUBVENITE PHENYLTRIAZIN 3 E DERIVATIVES STARTER (BLUE) KIT LAMICTAL ODT 3 LA SUBVENITE STARTER (GREEN) 3 LAMICTAL ODT 3 LA KIT STARTER (BLUE) SUBVENITE LAMICTAL ODT 3 LA STARTER (ORANGE) 3 STARTER (GREEN) KIT LAMICTAL ODT 3 LA ANTICONVULSA STARTER (ORANGE) NT - LAMICTAL ORAL 3 LA PYRROLIDINE TABLET DERIVATIVES LAMICTAL ORAL TABLET, CHEWABLE BRIVIACT 3 LA 2 PA; LA DISPERSIBLE 25 MG, INTRAVENOUS 5 MG BRIVIACT ORAL 3 LA LAMICTAL STARTER KEPPRA 3 LA 3 LA (BLUE) KIT KEPPRA XR 3 LA LAMICTAL STARTER levetiracetam in nacl 3 LA 2 PA; LA (GREEN) KIT (iso-os) LAMICTAL STARTER levetiracetam 3 LA 2 PA; LA (ORANGE) KIT intravenous LAMICTAL XR 3 LA levetiracetam oral 1 LAMICTAL XR solution 100 mg/ml 3 LA STARTER (BLUE) levetiracetam oral LAMICTAL XR solution 500 mg/5 ml (5 2 LA 3 LA STARTER (GREEN) ml) LAMICTAL XR levetiracetam oral tablet 1 LA 3 LA STARTER (ORANGE) levetiracetam oral tablet 1 LA lamotrigine oral tablet extended release 24 hr 1 LA 100 mg, 150 mg, 25 mg ROWEEPRA 1 LA lamotrigine oral tablet 2 LA ROWEEPRA XR 1 LA 200 mg SPRITAM 3 LA lamotrigine oral tablet 3 PA; LA disintegrating, dose pk lamotrigine oral tablet 3 LA extended release 24hr

You can find information on what the symbols and abbreviations on this table mean on page 4. 85 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTICONVULSA mirtazapine oral NT - tablet,disintegrating 30 2 LA SUCCINIMIDES mg REMERON ORAL CELONTIN ORAL 3 PA TABLET 15 MG, 30 3 LA CAPSULE 300 MG MG ethosuximide 1 REMERON SOLTAB 3 LA ZARONTIN 1 ANTIDEPRESSAN ANTICONVULSA T - MAO NT - INHIBITOR SULFONAMIDE NONSELECTIVE DERIVATIVES AND ZONEGRAN ORAL IRREVERSIBLE- CAPSULE 100 MG, 25 3 LA TYPES A,B MG EMSAM 1 LA zonisamide oral capsule 2 LA 100 mg MARPLAN 3 LA zonisamide oral capsule NARDIL 3 LA 1 LA 25 mg, 50 mg PARNATE 3 LA ANTICONVULSA phenelzine 1 LA NT - TRIAZOLE tranylcypromine 1 LA DERIVATIVES ANTIDEPRESSAN BANZEL 3 LA T - ANTICONVULSA NEUROACTIVE NT OTHERS STEROID GABA- DIACOMIT 3 PA A RECEPTOR MODULATOR FINTEPLA 3 LA ZULRESSO 4 XCOPRI 3 XCOPRI TITRATION ANTIDEPRESSAN 3 PACK T - N-METHYL D- ANTIDEPRESSAN ASPARTATE T - ALPHA-2 (NMDA) RECEPTOR RECEPTOR ANTAGONISTS ANTAGONIST (NASSA) SPRAVATO 4 LA mirtazapine oral tablet 1 LA 15 mg, 30 mg, 7.5 mg mirtazapine oral tablet 2 LA 45 mg mirtazapine oral tablet,disintegrating 15 1 LA mg, 45 mg You can find information on what the symbols and abbreviations on this table mean on page 4. 86 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIDEPRESSAN SARAFEM ORAL T - SELECTIVE TABLET 10 MG, 20 3 LA SEROTONIN MG sertraline oral REUPTAKE 3 LA INHIBITORS concentrate (SSRIS) sertraline oral tablet 1 LA CELEXA ORAL LA; QL (40 EA ZOLOFT 3 LA 3 TABLET per 1 day) ANTIDEPRESSAN LA; QL (40 T - SEROTONIN-2 citalopram oral solution 3 ML per 1 day) ANTAGONIST- LA; QL (40 EA REUPTAKE citalopram oral tablet 1 per 1 day) INHIBITORS escitalopram oxalate (SARIS) 3 LA oral solution nefazodone 3 LA escitalopram oxalate 1 LA trazodone 1 LA oral tablet ANTIDEPRESSAN fluoxetine oral capsule 3 LA 10 mg, 20 mg T - SEROTONIN- NOREPINEPHRIN fluoxetine oral capsule 1 LA 40 mg E REUPTAKE INHIBITORS fluoxetine oral capsule,delayed 3 LA (SNRIS) release(dr/ec) LA; QL (60 EA CYMBALTA 3 fluoxetine oral solution 1 LA per 1 day) fluoxetine oral tablet 3 LA desvenlafaxine oral tablet extended release 3 LA fluvoxamine oral 24 hr capsule,extended release 3 LA desvenlafaxine 24hr 3 LA succinate fluvoxamine oral tablet 1 LA DRIZALMA LEXAPRO ORAL 3 LA 3 LA SPRINKLE TABLET LA; QL (60 EA paroxetine hcl oral duloxetine 1 1 LA per 1 day) tablet EFFEXOR XR 3 LA paroxetine hcl oral tablet extended release 3 LA FETZIMA 3 LA 24 hr PRISTIQ 3 LA PAXIL 3 LA SAVELLA 3 PAXIL CR 3 LA venlafaxine oral PEXEVA 3 LA capsule,extended release 1 LA 24hr PROZAC ORAL 3 LA CAPSULE venlafaxine oral tablet 1 LA

You can find information on what the symbols and abbreviations on this table mean on page 4. 87 Drug Name Drug Tier Limits Drug Name Drug Tier Limits venlafaxine oral tablet SYMBYAX ORAL 3 LA extended release 24hr CAPSULE 12-50 MG, 3 LA ANTIDEPRESSAN 3-25 MG, 6-25 MG, 6- 50 MG T - SSRI AND 5HT1A PARTIAL ANTIDEPRESSAN AGONIST T- NOREPINEPHRIN VIIBRYD ORAL 3 LA TABLET E AND DOPAMINE VIIBRYD ORAL TABLETS,DOSE REUPTAKE 3 LA PACK 10 MG (7)- 20 INHIBITORS MG (23) (NDRIS) ANTIDEPRESSAN APLENZIN 3 LA T - SSRI AND bupropion hcl 1 LA SEROTONIN (5- bupropion hcl (bulk) 1 HT) RECEPTOR FORFIVO XL 3 LA MODULATOR WELLBUTRIN SR 3 LA TRINTELLIX 3 LA WELLBUTRIN XL 3 LA ANTIDEPRESSAN ANTIDEPRESSAN T - TRICYCLIC T-TRICYCLICS AND AND RELATED ANTIPSYCHOTIC (NON-SELECT , PHENOTHIAZIN REUPTAKE E COMB INHIBITORS) perphenazine- 1 LA amitriptyline 1 LA amitriptyline amitriptyline (bulk) 3 ANTIDEPRESSAN T - TRICYCLIC- amoxapine 1 LA BENZODIAZEPIN ANAFRANIL 3 LA E clomipramine 3 LA COMBINATIONS desipramine 1 LA amitriptyline- doxepin oral capsule 10 3 LA chlordiazepoxide mg, 100 mg, 25 mg, 50 1 LA ANTIDEPRESSAN mg, 75 mg doxepin oral capsule T- SSRI AND 2 LA ATYPICAL 150 mg ANTIPSYCH,DOP doxepin oral concentrate 1 LA AMINE,SEROTO imipramine hcl 1 LA NIN ANTAGON imipramine pamoate 3 LA olanzapine-fluoxetine 3 LA maprotiline 3 LA

You can find information on what the symbols and abbreviations on this table mean on page 4. 88 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NORPRAMIN ORAL ANTIPARKINSON TABLET 10 MG, 25 3 LA ADJUVANT - MG CENTRAL/PERIP nortriptyline oral 1 LA HERAL COMT capsule INHIBITORS nortriptyline oral 3 LA TASMAR ORAL solution 3 TABLET 100 MG PAMELOR 3 LA tolcapone 1 protriptyline 3 LA ANTIPARKINSON trimipramine 3 LA ADJUVANT - ANTIPARKINSON PERIPHERAL - COMT DOPAMINERGIC- INHIBITORS PERIPH COMT- COMTAN 3 DOPA- entacapone 1 DECARBOXYLAS E INHIB COMB ANTIPARKINSON ADJUVANT - carbidopa-levodopa- 3 LA entacapone PERIPHERAL DOPA- STALEVO 100 3 LA DECARBOXYLAS STALEVO 125 3 LA E INHIBITORS STALEVO 150 3 LA carbidopa 1 LA STALEVO 200 3 LA carbidopa (bulk) 3 STALEVO 50 3 LA LODOSYN 3 LA STALEVO 75 3 LA ANTIPARKINSON ANTIPARKINSON THERAPY - - DOPAMINERG- ANTICHOLINER PERIPHERAL GIC AGENTS DOPA- benztropine 1 LA DECARBOXYLAS E INHIBIT COMB COGENTIN 1 LA trihexyphenidyl 1 LA carbidopa-levodopa oral 1 LA tablet ANTIPARKINSON carbidopa-levodopa oral THERAPY - 1 LA tablet extended release DOPAMINE carbidopa-levodopa oral PRECURSORS 3 LA tablet,disintegrating INBRIJA DUOPA 3 LA INHALATION 3 CAPSULE RYTARY 3 LA SINEMET 3 LA

You can find information on what the symbols and abbreviations on this table mean on page 4. 89 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INBRIJA MIRAPEX 3 LA INHALATION MIRAPEX ER 3 LA CAPSULE, 3 PA W/INHALATION NEUPRO 3 LA DEVICE OSMOLEX ER 3 LA ANTIPARKINSON pramipexole oral tablet THERAPY - 0.125 mg, 0.25 mg, 0.75 1 LA ERGOT mg, 1 mg, 1.5 mg pramipexole oral tablet ALKALOIDS AND 1 DERIVATIVES 0.5 mg pramipexole oral tablet bromocriptine 3 LA 3 LA extended release 24 hr PARLODEL 3 LA REQUIP ORAL ANTIPARKINSON TABLET 0.25 MG, 3 3 THERAPY - MG, 5 MG MONOAMINE REQUIP XL ORAL TABLET EXTENDED OXIDASE 3 LA INHIBITOR(MAO RELEASE 24 HR 12 -B) MG, 6 MG REQUIP XL ORAL AZILECT 3 LA TABLET EXTENDED 3 ELDEPRYL 3 LA RELEASE 24 HR 2 MG rasagiline 3 LA ropinirole oral tablet 1 LA selegiline hcl 1 LA ropinirole oral tablet 3 LA XADAGO 3 LA extended release 24 hr ZELAPAR 3 LA ANTIPSYCHOTIC ANTIPARKINSON - ATYP THERAPY - NON- DOPAMINE- ERGOT SEROTONIN DOPAMINE ANTAG AGONIST DIBENZO- AGENTS OXEPINO PYRROLES amantadine hcl (bulk) 3 SAPHRIS 1 LA amantadine hcl oral 1 LA capsule SECUADO 3 LA amantadine hcl oral 1 LA solution amantadine hcl oral 3 LA tablet APOKYN 3 LA GOCOVRI 3 LA KYNMOBI 3 LA

You can find information on what the symbols and abbreviations on this table mean on page 4. 90 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIPSYCHOTIC risperidone oral solution 1 LA - ATYPICAL risperidone oral syringe 2 LA DOPAMINE- risperidone oral tablet SEROTONIN 0.25 mg, 1 mg, 2 mg, 3 1 LA ANTAG- mg BENZISOTHIAZO risperidone oral tablet 2 LA LONES 0.5 mg, 4 mg GEODON LA; QL (40 EA risperidone oral 1 1 LA INTRAMUSCULAR per 1 day) tablet,disintegrating GEODON ORAL 3 LA ANTIPSYCHOTIC LATUDA 1 LA - ATYPICAL ziprasidone hcl 1 LA DOPAMINE- SEROTONIN ziprasidone mesylate 1 LA ANTAG- ANTIPSYCHOTIC BUTYROPHENO - ATYPICAL NE DERIV DOPAMINE- CAPLYTA 2 PA; LA SEROTONIN ANTAG- ANTIPSYCHOTIC BENZISOXAZOL - ATYPICAL E DERIV DOPAMINE- SEROTONIN FANAPT ORAL 1 LA TABLET ANTAG- DIBENZODIAZEP FANAPT ORAL TABLETS,DOSE 3 LA INE DER PACK clozapine oral tablet 1 LA INVEGA 3 LA clozapine oral 3 LA LA; QL (1 ML tablet,disintegrating INVEGA SUSTENNA 1 per 30 days) CLOZARIL 3 LA LA; QL (819 VERSACLOZ 3 LA INVEGA TRINZA 1 ML per 90 ANTIPSYCHOTIC days) - BUTYROPHENO paliperidone 1 LA NE PERSERIS 3 LA DERIVATIVES LA; QL (100 HALDOL 3 LA RISPERDAL CONSTA 1 EA per 30 HALDOL days) 3 LA DECANOATE RISPERDAL ORAL 3 LA SOLUTION haloperidol 1 LA RISPERDAL ORAL haloperidol decanoate 1 LA TABLET 0.5 MG, 1 haloperidol lactate 3 LA 1 LA MG, 2 MG, 3 MG, 4 injection MG haloperidol lactate oral 1 LA You can find information on what the symbols and abbreviations on this table mean on page 4. 91 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIPSYCHOTIC ANTIPSYCHOTIC - - PHENOTHIAZIN DIBENZOXAZEPI ES, PIPERIDINE NE thioridazine 1 LA DERIVATIVES ANTIPSYCHOTIC ADASUVE 3 LA - loxapine succinate 1 LA THIOXANTHENE ANTIPSYCHOTIC S - thiothixene 1 LA DIHYDROINDOL ANTIPSYCHOTIC ONES -ATYPICAL molindone 1 LA DOPAMINE- ANTIPSYCHOTIC SEROTONIN - ANTAG- DIPHENYLBUTY DIBENZOTHIAZ LPIPERIDINE EPINE DER DERIVATIVES quetiapine 1 LA pimozide oral tablet 1 SEROQUEL 3 LA 1 LA mg SEROQUEL XR ORAL pimozide oral tablet 2 TABLET EXTENDED 3 LA 3 PA mg RELEASE 24 HR ANTIPSYCHOTIC ANTIPSYCHOTIC - PHENOTHIAZIN -ATYPICAL ES, ALIPHATIC DOPAMINE- chlorpromazine 1 LA SEROTONIN ANTIPSYCHOTIC ANTAG- - PHENOTHIAZIN THIENOBENZOD ES, PIPERAZINE IAZEPINES olanzapine LA; QL (10 EA COMPAZINE ORAL 3 LA 1 intramuscular per 1 day) fluphenazine decanoate 1 LA olanzapine oral 1 LA fluphenazine hcl 1 LA olanzapine-fluoxetine 3 LA perphenazine 1 LA SYMBYAX ORAL prochlorperazine CAPSULE 12-50 MG, 3 LA maleate oral tablet 10 1 LA 3-25 MG, 6-25 MG, 6- mg 50 MG prochlorperazine ZYPREXA LA; QL (10 EA 2 LA 3 maleate oral tablet 5 mg INTRAMUSCULAR per 1 day) trifluoperazine 1 LA ZYPREXA ORAL 3 LA ZYPREXA LA; QL (3 EA 3 RELPREVV per 10 days)

You can find information on what the symbols and abbreviations on this table mean on page 4. 92 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ZYPREXA ZYDIS 3 LA ANTIPSYCHOTIC ANTIPSYCHOTIC - -ATYP ATYPICAL,D3/D2 SELECTIVE RECEPTOR SEROTONIN 5- PARTIAL HT2A INVERSE AGONIST- AGONISTS (SSIA) SEROTONIN NUPLAZID ORAL MIXED 2 PA; LA CAPSULE VRAYLAR 2 PA; LA NUPLAZID ORAL 2 PA; LA ATTENTION TABLET 10 MG DEFICIT- ANTIPSYCHOTIC HYPERACT. -ATYPICAL,D2 DISORDER RECEPTOR (ADHD)- ALPHA- PARTIAL 2 RECEPTOR AGONIST-5HT AGONIST SEROTONIN clonidine hcl oral tablet 1 LA MIXED extended release 12 hr LA; QL (400 guanfacine oral tablet 1 LA ABILIFY MAINTENA 1 EA per 30 extended release 24 hr days) INTUNIV ER 3 LA ABILIFY MYCITE 3 LA KAPVAY 3 LA ABILIFY ORAL 3 LA ATTENTION TABLET DEFICIT- aripiprazole oral 1 LA HYPERACTIVITY solution (ADHD) aripiprazole oral tablet 1 LA THERAPY, aripiprazole oral 3 LA STIMULANT- tablet,disintegrating TYPE LA; QL (882 ADDERALL 3 LA ARISTADA 1 ML per 30 days) ADDERALL XR 3 LA ARISTADA INITIO 3 LA ADHANSIA XR 3 LA REXULTI 1 LA ADZENYS ER 3 LA ADZENYS XR-ODT 3 LA amphetamine 3 LA amphetamine sulfate 3 LA APTENSIO XR 1 LA CONCERTA 3 LA COTEMPLA XR-ODT 3 LA DAYTRANA 3 LA You can find information on what the symbols and abbreviations on this table mean on page 4. 93 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DESOXYN 3 LA methylphenidate hcl DEXEDRINE oral tablet extended 3 LA 3 LA SPANSULE release 24hr 72 mg methylphenidate hcl dexmethylphenidate 1 LA 1 LA oral tablet,chewable dextroamphetamine oral capsule, extended 1 LA MYDAYIS 3 LA release QUILLICHEW ER 3 LA dextroamphetamine oral QUILLIVANT XR 3 LA 3 LA tablet RELEXXII 3 LA dextroamphetamine- 1 LA RITALIN 3 LA amphetamine RITALIN LA ORAL DYANAVEL XR 3 LA CAPSULE,ER EVEKEO 3 LA BIPHASIC 50-50 10 3 LA EVEKEO ODT 3 LA MG, 20 MG, 30 MG, 40 MG FOCALIN 3 LA LA; QL (30 EA VYVANSE 1 FOCALIN XR 3 LA per 30 days) JORNAY PM 3 LA ZENZEDI 3 LA METADATE ER 1 LA ATTENTION methamphetamine 3 LA DEFICIT- METHYLIN ORAL 1 LA HYPERACTIVITY SOLUTION DISORDER methylphenidate hcl (ADHD) oral cap,er 1 LA THERAPY, NRI- sprinkle,biphasic 40-60 TYPE methylphenidate hcl LA; QL (120 oral capsule, er biphasic 1 LA atomoxetine 1 EA per 1 day) 30-70 LA; QL (120 methylphenidate hcl STRATTERA 3 EA per 1 day) oral capsule,er biphasic 1 LA 50-50 BENZODIAZEPIN methylphenidate hcl ES 1 LA oral solution ALPRAZOLAM 3 LA methylphenidate hcl INTENSOL 1 LA oral tablet alprazolam oral tablet 1 LA methylphenidate hcl alprazolam oral tablet 3 LA oral tablet extended 1 LA extended release 24 hr release alprazolam oral 3 LA methylphenidate hcl tablet,disintegrating oral tablet extended 1 LA amitriptyline- release 24hr 18 mg, 27 3 LA chlordiazepoxide mg, 36 mg, 54 mg ATIVAN 3 LA

You can find information on what the symbols and abbreviations on this table mean on page 4. 94 Drug Name Drug Tier Limits Drug Name Drug Tier Limits chlordiazepoxide hcl 1 LA lorazepam oral tablet 1 LA chlordiazepoxide- midazolam (pf) in 0.9 % 3 clidinium nacl intravenous 1 LA clobazam 1 LA solution clonazepam oral tablet 1 LA midazolam (pf) in 0.9 % nacl intravenous syringe 3 clonazepam oral 3 LA 2 mg/2 ml (1 mg/ml) tablet,disintegrating midazolam (pf) in 0.9 % clorazepate dipotassium 1 LA nacl intravenous syringe 4 DIASTAT 1 LA 5 mg/5 ml (1 mg/ml) DIASTAT ACUDIAL 1 LA midazolam (pf) 1 LA diazepam injection 1 LA injection DIAZEPAM midazolam in 0.9 % sod 1 LA INTENSOL chlorid intravenous 4 LA solution 1 mg/ml diazepam oral 1 LA concentrate midazolam in 0.9 % sod chlorid intravenous diazepam oral solution 5 2 LA syringe 2 mg/2 ml (1 3 LA mg/5 ml (1 mg/ml) mg/ml), 5 mg/5 ml (1 diazepam oral solution 5 mg/ml) mg/5 ml (1 mg/ml, 5 1 LA midazolam injection 1 LA ml) midazolam intravenous diazepam oral tablet 10 2 LA syringe 150 mg/30 ml (5 1 LA mg mg/ml) diazepam oral tablet 2 midazolam oral syrup 2 1 LA 3 LA mg, 5 mg mg/ml diazepam rectal 1 LA NAYZILAM 3 LA DORAL 3 LA ONFI ORAL 3 LA estazolam 3 LA SUSPENSION flurazepam 3 LA ONFI ORAL TABLET 3 LA HALCION ORAL 10 MG, 20 MG 3 LA TABLET 0.25 MG oxazepam 3 LA KLONOPIN 3 LA quazepam 2 LIBRAX (WITH RESTORIL 3 LA 3 CLIDINIUM) SYMPAZAN 3 LA lorazepam injection temazepam oral capsule 1 1 LA solution 2 mg/ml 15 mg, 30 mg, 7.5 mg lorazepam injection temazepam oral capsule 1 LA 2 LA syringe 22.5 mg LORAZEPAM 1 LA TRANXENE T-TAB INTENSOL ORAL TABLET 7.5 3 LA lorazepam oral MG 1 LA concentrate

You can find information on what the symbols and abbreviations on this table mean on page 4. 95 Drug Name Drug Tier Limits Drug Name Drug Tier Limits triazolam oral tablet LAMICTAL STARTER 1 LA 3 LA 0.125 mg (BLUE) KIT triazolam oral tablet LA; QL (30 EA LAMICTAL STARTER 1 3 LA 0.25 mg per 22 days) (GREEN) KIT VALIUM 3 LA LAMICTAL STARTER 3 LA VALTOCO 3 LA (ORANGE) KIT lamotrigine oral tablet XANAX 3 LA 3 PA; LA disintegrating, dose pk XANAX XR 3 LA lamotrigine oral 3 LA BIPOLAR tablet,disintegrating THERAPY SUBVENITE 3 AGENTS - STARTER (BLUE) KIT ANTICONVULSA SUBVENITE NT TYPE STARTER (GREEN) 3 carbamazepine oral KIT capsule, er multiphase 1 LA SUBVENITE 12 hr STARTER (ORANGE) 3 carbamazepine oral KIT 1 LA suspension TEGRETOL ORAL 3 LA carbamazepine oral SUSPENSION 1 LA tablet TEGRETOL ORAL 3 LA carbamazepine oral TABLET tablet extended release 1 LA TEGRETOL XR ORAL 12 hr 200 mg, 400 mg TABLET EXTENDED 3 LA carbamazepine oral RELEASE 12 HR 200 1 LA tablet,chewable MG, 400 MG CARBATROL 3 LA valproic acid 1 LA DEPAKOTE 3 LA valproic acid (as sodium salt) oral solution 250 1 LA DEPAKOTE ER 3 LA mg/5 ml (5 ml) DEPAKOTE 3 LA valproic acid (as sodium SPRINKLES salt) oral solution 250 2 LA divalproex 1 LA mg/5 ml, 500 mg/10 ml EPITOL 1 LA (10 ml) EQUETRO 2 PA; LA BIPOLAR LAMICTAL ODT 3 LA THERAPY LAMICTAL ODT AGENTS - 3 LA STARTER (BLUE) ATYPICAL LAMICTAL ODT ANTIPSYCHOTIC 3 LA STARTER (GREEN) S LAMICTAL ODT ABILIFY MYCITE 3 LA 3 LA STARTER (ORANGE) ABILIFY ORAL 3 LA TABLET

You can find information on what the symbols and abbreviations on this table mean on page 4. 96 Drug Name Drug Tier Limits Drug Name Drug Tier Limits aripiprazole oral ZYPREXA ORAL 3 LA 1 LA solution ZYPREXA ZYDIS 3 LA aripiprazole oral tablet 1 LA BIPOLAR aripiprazole oral 3 LA THERAPY tablet,disintegrating AGENTS - GEODON LA; QL (40 EA 1 LITHIUM INTRAMUSCULAR per 1 day) lithium carbonate 1 LA GEODON ORAL 3 LA lithium citrate oral olanzapine LA; QL (10 EA 1 LA 1 solution 8 meq/5 ml intramuscular per 1 day) LITHOBID 3 LA olanzapine oral 1 LA CANNABIS AND olanzapine-fluoxetine 3 LA CANNABINOID quetiapine 1 LA RECEPTOR RISPERDAL ORAL 3 LA AGONISTS SOLUTION CESAMET 2 PA RISPERDAL ORAL TABLET 0.5 MG, 1 dronabinol oral capsule 3 LA 3 MG, 2 MG, 3 MG, 4 10 mg MG dronabinol oral capsule 3 PA risperidone oral solution 1 LA 2.5 mg, 5 mg risperidone oral syringe 2 LA SYNDROS 3 risperidone oral tablet CNS AND 0.25 mg, 1 mg, 2 mg, 3 1 LA RESPIRATORY mg STIMULANT risperidone oral tablet 2 LA DOPRAM 4 0.5 mg, 4 mg doxapram 4 risperidone oral 1 LA tablet,disintegrating CNS STIMULANT - AMPHETAMINE SAPHRIS 1 LA COMBINATIONS SEROQUEL 3 LA ADDERALL 3 LA SEROQUEL XR ORAL TABLET EXTENDED 3 LA ADDERALL XR 3 LA RELEASE 24 HR ADZENYS ER 3 LA SYMBYAX ORAL ADZENYS XR-ODT 3 LA CAPSULE 12-50 MG, 3 LA amphetamine 3 LA 3-25 MG, 6-25 MG, 6- dextroamphetamine- 50 MG 1 LA amphetamine VRAYLAR 2 PA; LA DYANAVEL XR 3 LA ziprasidone hcl 1 LA MYDAYIS 3 LA ziprasidone mesylate 1 LA ZYPREXA LA; QL (10 EA 3 INTRAMUSCULAR per 1 day)

You can find information on what the symbols and abbreviations on this table mean on page 4. 97 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CNS STIMULANT caffeine citrate oral 3 - caffeine-sodium 4 AMPHETAMINES benzoate amphetamine sulfate 3 LA DOPRAM 4 DESOXYN 3 LA doxapram 4 DEXEDRINE DIABETIC 3 LA SPANSULE PERIPHERAL dextroamphetamine oral NEUROPATHY capsule, extended 1 LA AGENTS release LYRICA CR 3 dextroamphetamine oral 3 LA solution FIBROMYALGIA AGENTS - GABA dextroamphetamine oral 3 LA tablet ANALOGS EVEKEO 3 LA LYRICA 3 LA EVEKEO ODT 3 LA pregabalin oral capsule 100 mg, 150 mg, 200 1 LA methamphetamine 3 LA mg, 225 mg, 25 mg, 50 PROCENTRA 3 LA mg, 75 mg ZENZEDI 3 LA pregabalin oral capsule 1 CNS STIMULANT 300 mg - ANALEPTICS, pregabalin oral solution 1 LA METHYLXANTHI FIBROMYALGIA NE-TYPE AGENTS - CAFCIT SEROTONIN- 4 INTRAVENOUS NOREPINEPHRIN caffeine (bulk) 3 E REUPTAKE- caffeine citrate (bulk) 3 INHIB (SNRIS) caffeine citrate LA; QL (60 EA 4 CYMBALTA 3 intravenous per 1 day) DRIZALMA caffeine citrate oral 3 3 LA SPRINKLE caffeine-sodium 4 LA; QL (60 EA benzoate duloxetine 1 per 1 day) CNS STIMULANT SAVELLA 3 - ANALEPTICS HSDD AGENTS- CAFCIT 4 INTRAVENOUS MIXED SEROTONIN caffeine (bulk) 3 AGONIST/ANTA caffeine citrate (bulk) 3 GONISTS caffeine citrate 4 ADDYI 3 LA intravenous

You can find information on what the symbols and abbreviations on this table mean on page 4. 98 Drug Name Drug Tier Limits Drug Name Drug Tier Limits HYPNOTICS - MIGRAINE MELATONIN THERAPY - COMBINATIONS CARBOXYLIC melatonin-lemon balm ACID leaf extr oral tablet 3 3 DERIVATIVES mg- 500 mcg DEPAKOTE ER 3 LA TOPROPHAN 1 divalproex oral tablet 1 LA HYPNOTICS - extended release 24 hr MELATONIN MIGRAINE M1/M2 THERAPY - RECEPTOR CGRP LIGAND AGONISTS BLOCKER, HETLIOZ 3 LA MONOCLONAL ramelteon 2 PA; LA ANTIBODY ROZEREM 3 LA AJOVY SYRINGE 3 PA MIGRAINE EMGALITY PEN 2 PA THERAPY - EMGALITY SYRINGE ANALGESIC- SUBCUTANEOUS 2 PA VASOCONSTRIC SYRINGE 120 MG/ML TOR-SEDATIVE MIGRAINE COMBINATIONS THERAPY - isometh-dichloral- CGRP 3 acetaminophn RECEPTOR MIGRAINE BLOCKERS THERAPY - (GEPANTS) CALCITONIN UBRELVY 3 GENE-RELATED MIGRAINE PEPTIDE THERAPY - INHIBITORS CGRP AIMOVIG RECEPTOR 3 AUTOINJECTOR BLOCKERS, AJOVY SYRINGE 3 PA MONOCLONAL EMGALITY PEN 2 PA ANTIBODY AIMOVIG EMGALITY SYRINGE 3 SUBCUTANEOUS 2 PA AUTOINJECTOR SYRINGE 120 MG/ML MIGRAINE THERAPY - ERGOT ALKALOIDS AND DERIVATIVES D.H.E.45 4 You can find information on what the symbols and abbreviations on this table mean on page 4. 99 Drug Name Drug Tier Limits Drug Name Drug Tier Limits dihydroergotamine QL (12 EA per 4 IMITREX NASAL 3 injection 23 days) QL (8 ML per QL (9 EA per dihydroergotamine nasal 2 IMITREX ORAL 3 23 days) 23 days) ERGOMAR 1 PA IMITREX STATDOSE QL (4 ML per 3 ergotamine tartrate PEN 30 days) 3 (bulk) IMITREX STATDOSE QL (4 ML per 3 PA; QL (8 ML REFILL 30 days) MIGRANAL 2 per 23 days) IMITREX QL (4 ML per 3 MIGRAINE SUBCUTANEOUS 30 days) MAXALT ORAL THERAPY - 3 ERGOT TABLET 10 MG COMBINATIONS MAXALT-MLT ORAL TABLET,DISINTEGR 3 CAFERGOT 3 PA ATING 10 MG MIGERGOT 2 PA MIGRANOW 2 PA MIGRAINE QL (9 EA per naratriptan 2 THERAPY - 23 days) NSAID ONZETRA XSAIL 3 ANALGESICS(CY RELPAX 3 CLOOXYGENAS rizatriptan 1 ST E INHIB-NON- QL (12 EA per SELECTIV) sumatriptan 2 23 days) CAMBIA 2 PA sumatriptan succinate QL (9 EA per 2 MIGRAINE oral 23 days) THERAPY - sumatriptan succinate QL (4 ML per 2 SELECTIVE subcutaneous cartridge 30 days) SEROTONIN sumatriptan succinate QL (4 ML per AGONISTS 5- subcutaneous pen 2 30 days) HT(1) injector QL (6 EA per sumatriptan succinate QL (4 ML per almotriptan malate 3 1 23 days) subcutaneous solution 30 days) QL (4 ML per ZEMBRACE ALSUMA 3 3 30 days) SYMTOUCH QL (9 EA per zolmitriptan 3 AMERGE 3 23 days) ZOMIG NASAL 3 eletriptan 3 ZOMIG ORAL 3 QL (9 EA per TABLET 5 MG FROVA 3 23 days) ZOMIG ZMT 3 QL (9 EA per frovatriptan 3 23 days)

You can find information on what the symbols and abbreviations on this table mean on page 4. 100 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INGREZZA MIGRAINE 3 THERAPY - INITIATION PACK INGREZZA ORAL SEROTONIN 3 AGONIST 5-HT(1) CAPSULE 40 MG AND NSAID NARCOLEPSY COMB. AND sumatriptan-naproxen 2 PA CATAPLEXY TREXIMET ORAL THERAPY 2 PA TABLET 85-500 MG AGENTS - MOVEMENT SEDATIVE-TYPE DISORDER DRUG XYREM 3 THERAPY NARCOLEPSY AUSTEDO 3 THERAPY INGREZZA AGENTS - 3 INITIATION PACK DOPAMINE AND INGREZZA ORAL NE REUPTAKE 3 CAPSULE 40 MG INHIBITOR tetrabenazine 2 (DNRI) XENAZINE 3 SUNOSI 3 MOVEMENT NARCOLEPSY DISORDER THERAPY THERAPY - AGENTS - H3- HUNTINGTON'S RECEPTOR DISEASE ANTAGONIST/IN VERSE AGONIST AUSTEDO 3 WAKIX 2 PA; LA tetrabenazine 2 XENAZINE 3 NARCOLEPSY THERAPY MOVEMENT AGENTS - NON- DISORDER SYMPATHOMIM THERAPY - ETIC RESTLESS LEGS SYNDROME armodafinil 2 PA; LA modafinil 2 PA; LA HORIZANT 3 PA NUVIGIL 3 LA MOVEMENT DISORDER PROVIGIL 3 LA THERAPY - TARDIVE DYSKINESIA AUSTEDO 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 101 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NARCOLEPSY POSTHERPETIC THERAPY NEURALGIA AGENTS - AGENTS STIMULANT- ACTIVE-PAC 3 TYPE, GRALISE 3 PIPERADINE LYRICA CR 3 DERIVATIVE PSEUDOBULBAR METHYLIN ORAL 1 LA SOLUTION AFFECT (PBA) AGENTS, NMDA methylphenidate hcl 1 LA oral solution ANTAGONISTS TYPE methylphenidate hcl 1 LA oral tablet NUEDEXTA 3 LA methylphenidate hcl SEDATIVE- 1 LA oral tablet,chewable HYPNOTIC - RITALIN 3 LA BARBITURATES NARCOLEPSY AMYTAL 4 THERAPY butalbital (bulk) 3 AGENTS- NEMBUTAL SODIUM 3 STIMULANT- phenobarbital 1 TYPE,SYMPATH phenobarbital (bulk) 3 OMIMETIC,AMP phenobarbital sodium HETAMINES 4 injection solution ADDERALL 3 LA SECONAL SODIUM 3 amphetamine sulfate 3 LA SEDATIVE- DEXEDRINE 3 LA HYPNOTIC - SPANSULE BENZODIAZEPIN dextroamphetamine oral ES capsule, extended 1 LA release ATIVAN INJECTION 3 LA dextroamphetamine oral DORAL 3 LA 3 LA tablet estazolam 3 LA dextroamphetamine- 1 LA flurazepam 3 LA amphetamine oral tablet HALCION ORAL 3 LA EVEKEO 3 LA TABLET 0.25 MG ZENZEDI 3 LA lorazepam injection 1 NEUROPATHIC solution 2 mg/ml lorazepam injection PAIN THERAPY 1 LA syringe LYRICA CR 3 midazolam oral syrup 2 3 LA mg/ml

You can find information on what the symbols and abbreviations on this table mean on page 4. 102 Drug Name Drug Tier Limits Drug Name Drug Tier Limits quazepam 2 SEDATIVE- RESTORIL 3 LA HYPNOTIC - temazepam oral capsule SELECTIVE 1 LA 15 mg, 30 mg, 7.5 mg ALPHA2- temazepam oral capsule ADRENORECEPT 2 LA 22.5 mg OR AGONISTS triazolam oral tablet dexmedetomidine 4 LA 1 LA 0.125 mg dexmedetomidine in 0.9 triazolam oral tablet LA; QL (30 EA % nacl intravenous 4 1 0.25 mg per 22 days) solution dexmedetomidine in SEDATIVE- 4 HYPNOTIC - dextrose 5% GABA- PRECEDEX 4 LA RECEPTOR PRECEDEX IN 0.9 % 4 LA MODULATORS SODIUM CHLOR AMBIEN 3 LA SEDATIVE- AMBIEN CR 3 LA HYPNOTIC - EDLUAR 3 LA TRICYCLIC ANTIDEPRESSAN eszopiclone 3 LA T TYPE INTERMEZZO 3 LA doxepin oral tablet 3 LA LUNESTA 3 LA SILENOR 3 LA zaleplon 3 LA SEDATIVE- zolpidem oral tablet 10 LA; QL (15 EA 1 mg per 22 days) HYPNOTIC COMBINATIONS zolpidem oral tablet 5 LA; QL (30 EA 1 mg per 22 days) OTHER zolpidem oral tablet,ext MKO (MIDAZOLAM- LA; QL (10 EA 3 LA release multiphase 12.5 2 KETAMINE-ONDAN) per 30 days) mg CHEMICAL zolpidem oral tablet,ext LA; QL (10 EA DEPENDENCY, release multiphase 6.25 1 per 30 days) AGENTS TO mg TREAT LA; QL (10 EA zolpidem sublingual 1 per 30 days) AGENTS FOR ZOLPIMIST 3 LA OPIOID WITHDRAWAL, SEDATIVE- CENTRAL HYPNOTIC - ALPHA-2 OREXIN ADRENERGIC RECEPTOR AGONIST-TYPE ANTAGONIST PA; QL (12 EA LUCEMYRA 3 BELSOMRA 3 LA per 1 day) You can find information on what the symbols and abbreviations on this table mean on page 4. 103 Drug Name Drug Tier Limits Drug Name Drug Tier Limits AGENTS FOR ALCOHOL OPIOID ABSTINENCE WITHDRAWAL, THERAPY - OPIOID-TYPE OPIOID PA; QL (32 RECEPTOR BUNAVAIL 3 MG per 1 day) ANTAGONIST- buprenorphine hcl PA; QL (32 TYPE 3 sublingual MG per 1 day) VIVITROL 2 LA buprenorphine-naloxone PA; QL (32 3 ALCOHOL sublingual film MG per 1 day) DETERRENTS buprenorphine-naloxone QL (32 MG per 2 ANTABUSE 3 sublingual tablet 1 day) disulfiram 1 PROBUPHINE 4 PA SUBLOCADE SMOKING SUBCUTANEOUS DETERRENTS - SOLUTION, NE AND 1 PA; LA EXTENDED REL DOPAMINE SYRINGE 100 MG/0.5 REUPTAKE ML INHIBITOR SUBLOCADE (NDRI)-TYPE SUBCUTANEOUS SOLUTION, bupropion hcl (smoking 1 PA 1 LA EXTENDED REL deter) SYRINGE 300 MG/1.5 bupropion hcl oral tablet ML sustained-release 12 hr 1 LA QL (32 MG per 150 mg SUBOXONE 2 1 day) SMOKING PA; QL (32 DETERRENTS - ZUBSOLV 3 MG per 1 day) NICOTINE-TYPE ALCOHOL QL (112 EA NICOTROL 3 ABSTINENCE per 273 days) THERAPY - NICOTROL NS 3 GLUTAMATE SMOKING AND GABA DETERRENTS - SYSTEM TYPE NICOTINIC acamprosate 1 RECEPTOR PARTIAL AGONIST, ALPHA4BETA2 LA; QL (336 CHANTIX 1 EA per 273 days)

You can find information on what the symbols and abbreviations on this table mean on page 4. 104 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CHANTIX AMINOSALICYLIC QL (336 EA 3 CONTINUING 2 ACID-5 per 273 days) MONTH BOX amitriptyline (bulk) 3 CHANTIX STARTING QL (336 EA ammonium sulfate 2 1 MONTH BOX per 273 days) (bulk) CHEMICALS- anise flavor extract 1 PHARMACEUTI (bulk) CAL anthralin (bulk) 3 ADJUVANTS apple flavor (bulk) 1 BULK liquid CHEMICALS APPLE-ADE FLAVOR 1 (d)-limonene flavor apricot flavor (bulk) 1 1 (bulk) liquid 5-AMINOSALICYLIC arsenic trioxide (bulk) 4 3 ACID ATREVIS 3 5-hydroxy-l-tryptophan HYDROGEL 3 (bulk) atropine (bulk) 3 7-KETO DHEA, AZ 1 3 MICRONIZED bacitracin (bulk) powder 3 acacia (bulk) 3 5 million unit acebutolol (bulk) 3 bacitracin, micronized acetaminophen (bulk) 3 (bulk) powder 75.7 3 unit/mg acetazolamide (bulk) 3 baclofen (bulk) 3 acetylcholine chloride 3 BANANA (bulk) 1 CONCENTRATE acyclovir (bulk) 3 BANANA CREAM 1 adenosine (bulk) 3 FLAVOR albuterol sulfate (bulk) 3 banana creme flavor 1 alginic acid (bulk) 3 (bulk) alkyl (c12-15) benzoate banana flavor (bulk) 1 1 (bulk) barium sulfate (bulk) 3 aloe vera (bulk) powder 3 BASE aluminum, (acetato- B,POLYETHYLENE 3 3 o)dih(bulk) GLYCOL3350 amantadine hcl (bulk) 3 BASE W301 1 aminobenzoic acid BASE X 1 3 (bulk) BASE, PCCA 3 aminophylline (bulk) 3 POLYPEG aminosalicylic acid BASE, PCCA 3 1 (bulk) VANPEN

You can find information on what the symbols and abbreviations on this table mean on page 4. 105 Drug Name Drug Tier Limits Drug Name Drug Tier Limits beclomethasone diprop butalbital (bulk) 3 3 (bulk) butter flavor (bulk) 1 belladonna tincture 1 butter rum flavor (bulk) 1 (bulk) butterscotch flavor benzoic acid (bulk) 1 1 (bulk) crystals BUTTERSCOTCH benzoic acid (bulk) 1 3 FLAVORING powder caffeine (bulk) 3 benzoin compound 1 (bulk) caffeine citrate (bulk) 3 calcium glucon benzoyl peroxide (bulk) 3 3 monohyd (bulk) betamethasone sod phos 3 calcium phos, tribasic (bulk) 3 (bulk) betamethasone valerate 3 calcium phosphate (bulk) 3 (bulk) bethanechol chloride 3 (bulk) caramel flavor (bulk) 1 bioflavonoids, citrus carbidopa (bulk) 3 3 (bulk) powder 100 % carboxymethylcellul.sod 3 biotin (bulk) 3 .(bulk) granules bismuth citrate (bulk) 3 carisoprodol (bulk) 3 bismuth subnitrate celecoxib (bulk) 3 3 (bulk) cheesecake flavor (bulk) 1 bitter almond oil (bulk) 1 cherry flavor (bulk) 1 bitter mask flavoring chloramphenicol (bulk) 3 1 (bulk) chlorhexidine (bulk) 1 BITTERNESS MASK chlorhexidine gluconate 1 1 FLAVOR (bulk) blackberry flavor (bulk) 1 chloroquine phosphate 3 BLUEBERRY (bulk) 1 FLAVOR chocolate flavor (bulk) 1 brompheniramine liquid 3 maleate (bulk) chocolate hazelnut flav 1 BUBBLE GUM (bulk) 1 CONCENTRATE cholestyramine (bulk) 3 bubblegum flavor (bulk) 1 ciclopirox olamine 3 budesonide, micronized (bulk) 3 (bulk) citrulline (bulk) 3 bupivacaine (bulk) 3 clindamycin hcl (bulk) 3 buprenorphine hcl clindamycin phosphate 3 1 (bulk) (bulk) crystals bupropion hcl (bulk) 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 106 Drug Name Drug Tier Limits Drug Name Drug Tier Limits clindamycin phosphate dexamethasone ac, 3 3 (bulk) powder micro (bulk) clioquinol (bulk) 3 dexamethasone acetate 3 clomiphene citrate (bulk) 3 (bulk) dexamethasone sod 3 clotrimazole (bulk) 3 phos (bulk) coal tar (crude) (bulk) dexamethasone,microni 1 3 tar zed(bulk) cocoa butter (bulk) dextromethorphan hbr 1 3 topical ointment (bulk) coconut flavor (bulk) 1 dibucaine hcl (bulk) 3 cod liver oil (bulk) 1 diethylstilbestrol (bulk) 3 codeine phosphate digoxin, micronized 3 3 (bulk) (bulk) coenzyme q10 (bulk) 3 diltiazem hcl (bulk) 3 dimethyl sulfoxide coffee flavor (bulk) 1 1 (bulk) liquid 99 % cola flavor (bulk) 1 dinitrochlorobenzen(2,4 3 colchicine (bulk) 3 )(bulk) colistin sulfate (bulk) 3 diphencyprone (bulk) 3 collodion (bulk) 1 powder 98 % corn starch (bulk) 3 diphenhydramine (bulk) 3 corticotropin (bulk) 3 DMSA (BULK) 3 cortisone (bulk) 3 doxycycline hyclate 3 cotton candy flavor (bulk) 1 (bulk) dutasteride (bulk) 3 cran-raspberry flavor econazole nitrate (bulk) 3 1 (bulk) ENGLISH TOFFEE 1 cream base no.64 (bulk) 1 FLAVOR cream de menthe (bulk) 1 ephedrine hcl (bulk) 3 cromolyn (bulk) 1 ephedrine sulfate (bulk) 3 cyclobenzaprine (bulk) 3 epinephrine (bulk) 3 cyclosporine (bulk) 3 ergocalciferol (vit d2) 3 dalfampridine (bulk) 3 (bulk) ergotamine tartrate dantrolene (bulk) 3 3 (bulk) DEHYDROEPIANDR 3 estradiol cypionate OSTERONE (MICRO) 3 (bulk) desmopressin acetate 3 estradiol hemihydrate (bulk) 3 (bulk) desoximetasone, micro 3 (bulk) estradiol valerate (bulk) 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 107 Drug Name Drug Tier Limits Drug Name Drug Tier Limits estriol (bulk) 3 hydrochlorothiazide 3 estriol micronized (bulk) 3 (bulk) hydrocortisone (bulk) 3 estrone (bulk) crystals 1 hydrocortisone acetate 3 estrone (bulk) powder 3 (bulk) ethinyl estradiol (bulk) 3 hydromorphone (bulk) 3 FATTYBLEND 3 HYDROPHILIC OINTMENT 1 fentanyl citrate (bulk) 3 BASE(FAG) ferric chloride (bulk) HYDROUS 3 1 powder EMULSIFIED BASE ferrous fumarate (bulk) 3 hydroxychloroquine sulf 3 ferrous gluconate (bulk) 3 (bulk) FIXED OIL hydroxyprogesterone 3 3 SUSPENSION capr(bulk) FLAVORX 1 hyoscyamine sulfate 3 flunisolide (bulk) 3 (bulk) fluocinolone acetonide ibuprofen (bulk) 3 3 (bulk) indomethacin (bulk) 3 fluocinonide, INOSITOL 3 3 micronized(bulk) HEXANICOTINATE fluorouracil (bulk) 3 iodine (bulk) crystals 1 gentamicin (bulk) 3 iodoquinol (bulk) 3 glipizide (bulk) 3 iopanoic acid (bulk) 3 glycerol formal (bulk) 1 ipratropium bromide 1 glycolic acid (bulk) (bulk) 1 crystals isoproterenol hcl (bulk) 4 glycopyrrolate (bulk) 3 ivermectin (bulk) 3 grape flavor (bulk) 1 kahlua flavor (bulk) 1 GRAPEFRUIT 1 karaya gum (bulk) 3 griseofulvin (bulk) 3 ketamine (bulk) 3 guaifenesin (bulk) 3 ketoconazole (bulk) 3 guanethidine sulfate powder 3 (bulk) lactic acid (bulk) 1 guava flavor (bulk) 1 lactobacill.acidophilus histamine phosphate (bulk) powder , 10 3 1 (bulk) crystals billion unit/gram homatropine lactose (bulk) 3 3 methylbrom (bulk) L-ALANINE 3 honey flavor (bulk) 1 lansoprazole (bulk) 3 L-CARNITINE 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 108 Drug Name Drug Tier Limits Drug Name Drug Tier Limits lecithin (bulk) 3 mesalamine (bulk) 3 lemonade flavor oil methacholine chloride 1 3 (bulk) (bulk) leucovorin calcium methadone (bulk) 3 3 (bulk) methenamine mandelate 3 levamisole (bulk) 3 (bulk) levorphanol tartrate methoxsalen (bulk) 3 3 (bulk) methylcellulose 1500cps 3 levothyroxine (bulk) 3 (bulk) L-GLUTAMINE 3 methylcellulose 4000cps 3 licorice flavor (bulk) 1 (bulk) methylprednisolon LIME FLAVOR 1 3 ac,mic(bulk) liothyronine (bulk) 3 methylprednisolone, powder 1 mg/gram 3 mic (bulk) LIP BALM BASE 3 methyltestosterone (BULK) 3 (bulk) LIPOBASE REGULAR 1 methyltestosterone,micr 3 LIPOIC ACID 3 o(bulk) LIPOVAN CREAM 1 metoclopramide (bulk) 3 BASE mineral oil 1 L-ISOLEUCINE 3 minoxidil (bulk) 3 loperamide (bulk) 3 mint chocolate chip flv 1 MAGNASWEET 110 1 (bulk) magnesium carbonate 3 morphine (bulk) 3 (bulk) MULTIBASE 1 magnesium gluconate 3 (bulk) MULTIUSE BASE 1 magnesium glycinate N-ACETYL-ALPHA- 3 3 (bulk) powder 10 % D-GLUCOSAMINE magnesium hydroxide naloxone (bulk) 3 3 (bulk) naltrexone hcl (bulk) 3 maple flavor (bulk) 1 naproxen (bulk) 3 marshmallow flavor naproxen sodium (bulk) 3 1 (bulk) niacinamide (bulk) 1 mecobalamin (bulk) crystals 3 powder 100 %, 96 % nifedipine (bulk) 3 MEDIUM CREAM 1 nifedipine, micronized 3 mefenamic acid (bulk) 3 (bulk) meloxicam (bulk) 3 nitrofurantoin (bulk) 3 menthol (bulk) 1 nylidrin (bulk) 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 109 Drug Name Drug Tier Limits Drug Name Drug Tier Limits nystatin (bulk) powder 1 PHARMABASE 1 billion unit, 10 billion HEAVY unit, 2 billion unit, 5 1 PHARMABASE 1 billion unit, 50 million LIGHT unit, 500 million unit PHARMABASE 1 omeprazole (bulk) 3 NATURAL ORANGE PHARMABASE 1 1 CONCENTRATE VAGINAL orange cream flavor 1 phenobarbital (bulk) 3 (bulk) phenol (bulk) crystals 3 orange flavor (bulk) 1 liquid phenol (bulk) liquid 1 oseltamivir phosphate phenylbutazone (bulk) 3 3 (bulk) phenylephrine hcl (bulk) 3 oxalic acid (bulk) 1 phenytoin (bulk) 3 oxybutynin chloride phenytoin sodium (bulk) 3 3 (bulk) pilocarpine hcl (bulk) 3 oxycodone (bulk) 3 pineapple flavor (bulk) 1 oxytetracycline (bulk) 3 polyethylene glycol 3 oxytocin (bulk) 3 1000(bulk) papaverine (bulk) 3 polyethylene glycol 1 PCCA NATACREAM 1 1450(bulk) powder PCCA T4 SODIUM polyethylene glycol 3 3 DILUTION 1450(bulk) wax polyethylene glycol peach flavor (bulk) 1 1 3350(bulk) granules PEANUT BUTTER 1 FLAVOR polymyxin b sulf,micron.(bulk) peanut butter flavor 3 1 powder 50 million unit, (bulk) 6,000 unit/mg pectin (bulk) 3 potassium bicarbonate 1 PEG OINTMENT (bulk) granules 1 BASE (BULK) potassium chloride 1 PEGBLEND 3 (bulk) granules penicillamine (bulk) 3 potassium chloride 3 PENICILLAMINE(D-) 3 (bulk) powder potassium iodide (bulk) PENSOMAL 3 1 crystals PEPPERMINT 1 potassium iodide (bulk) FLAVORING 3 granules PHARMABASE 1 potassium phosph, PHARMABASE 1 1 mono (bulk) COSMETIC

You can find information on what the symbols and abbreviations on this table mean on page 4. 110 Drug Name Drug Tier Limits Drug Name Drug Tier Limits potassium sorbate (bulk) salicylic acid (bulk) 3 1 powder crystals pralines and cream salicylic acid (bulk) 1 3 flavr(bulk) powder pramoxine hcl (bulk) 3 SALTSTABLE LO 3 prasterone (dhea), CREAM BASE 3 micro(bulk) SALTSTABLE LS 1 prednisolone (bulk) 3 silicon,colloidal (bulk) 3 prednisolone ac, micro silver protein mild 3 3 (bulk) (bulk) prednisolone sod phos sodium benzoate (bulk) 3 3 (bulk) sodium citrate (bulk) 3 prednisolone, micro sodium citrate 3 1 (bulk) dihydrate(bulk) granules prednisone (bulk) 3 sodium fluoride (bulk) 3 prednisone micronized sodium saccharin (bulk) 3 1 (bulk) oral granules prilocaine (bulk) 3 sodium saccharin (bulk) 3 procaine (bulk) 1 oral powder promethazine (bulk) 3 sodium thiosulfate 1 pseudoephedrine hcl (bulk) crystals 3 (bulk) sodium thiosulfate 3 PUMPKIN FLAVOR 1 (bulk) powder pyridostigmine bromide squaric acid (bulk) 3 3 (bulk) squaric acid 3 pyridoxine (bulk) dibutylest.(bulk) powder 1 crystals SQUARIC ACID IN 1 pyrilamine maleate BUTANOL 3 (bulk) STEVIA 3 pyrimethamine (bulk) 3 strawberry flavor (bulk) 1 quinacrine (bulk) 3 SUBSOLV RDT 3 quinidine sulfate (bulk) sucralfate (bulk) 3 1 crystals sucrose (bulk) 3 raspberry flavor (bulk) 1 sulfacetamide (bulk) 3 liquid sulfacetamide sod, resorcinol (bulk) 3 1 mono (bulk) crystals sulfacetamide sodium 3 RETINOIC ACID 3 (bulk) rifampin (bulk) 3 sulfadiazine (bulk) 3 root beer flavor (bulk) 1 sulfadiazine sodium 3 (bulk)

You can find information on what the symbols and abbreviations on this table mean on page 4. 111 Drug Name Drug Tier Limits Drug Name Drug Tier Limits sulfamethoxazole (bulk) 3 triamcinolone diacetate 3 sulfanilamide (bulk) 3 (bulk) sulfisoxazole (bulk) 1 triamterene (bulk) 3 SWEET OIL 1 trimethoprim (bulk) 3 SWEETNESS trimethoprim, micro 1 3 ENHANCER FLAVOR (bulk) talc (bulk) 3 TROCHIBASE 3 TROCHIBASE S tamoxifen (bulk) 3 1 CLASSIC tangerine oil (bulk) 1 tropical punch flavor TANGERINE OIL, 1 1 (bulk) NATURAL tutti-frutti flavor (bulk) 1 teaberry oil flavor (bulk) 1 U-BASE 1 terbinafine (bulk) 3 urea (bulk) beads 1 terbutaline sulfate (bulk) 3 urea (bulk) powder 3 testosterone (bulk) 3 ursodiol (bulk) 3 testosterone cypionate 3 (bulk) VANIBASE 1 testosterone propionate VANIBASE 3 (bulk) TRADITIONAL 1 FORMULA tetracycline hcl (bulk) 3 VANILLA tetrahydrocurcumin 3 BUTTERNUT 1 (bulk) FLAVOR theophylline (bulk) 3 vanilla butternut 1 thiabendazole (bulk) 3 flavor(bulk) thymus gland,calf (bulk) 3 vanilla extract flavor 1 thyroid, pork (bulk) (bulk) 3 powder 100 % usp VANISHING CREAM 1 tinidazole (bulk) 3 TOPICAL VANISH-PEN CREAM tobramycin (bulk) 3 1 BASE tobramycin sulfate 3 (bulk) verapamil (bulk) 3 tranexamic acid (bulk) VERSATILE 1 3 powder watermelon flavor 1 tretinoin (bulk) 3 (bulk) triamcin diacet, micro white petrolatum (bulk) 1 3 (bulk) wild cherry flavor (bulk) 1 triamcinolone (bulk) 3 CHEMICALS - triamcinolone acetonide ACIDS 3 (bulk) glycolic acid (bulk) 1 crystals

You can find information on what the symbols and abbreviations on this table mean on page 4. 112 Drug Name Drug Tier Limits Drug Name Drug Tier Limits lactic acid (bulk) 1 CAPSULE #1 1 oxalic acid (bulk) 1 (CELLULOSE) CAPSULE #3 CHEMICALS - 1 (CELLULOSE) ESSENTIAL OILS PHARMACEUTIC tangerine oil (bulk) 1 AL ADJUVANT - TANGERINE OIL, 1 CREAM/OINTME NATURAL NT VEHICLES CHEMICALS - ATREVIS 3 FIXED OILS HYDROGEL castor oil 1 AZ 1 olive oil 1 BASE SWEET OIL 1 B,POLYETHYLENE 3 CHEMICALS - GLYCOL3350 SOLVENTS BASE W301 1 acetone 1 cocoa butter 1 ALCOHOL, cocoa butter (bulk) 1 1 DENATURED topical ointment dimethyl sulfoxide cream base no.64 (bulk) 1 1 (bulk) liquid 99 % hydrophilic 1 glycerol formal (bulk) 1 HYDROPHILIC LIP BALM BASE OINTMENT 1 3 (BULK) BASE(FAG) HYDROPHILIC mineral oil 1 1 PETROLATUM PEG OINTMENT 1 HYDROUS BASE (BULK) 1 EMULSIFIED BASE sodium succinate 3 LIPOBASE REGULAR 1 PHARMACEUTIC LIPOVAN CREAM 1 AL ADJUVANT - BASE ANTICORROSIV MEDIUM CREAM 1 E AGENTS MULTIBASE 1 sodium bisulfite (bulk) 3 MULTIUSE BASE 1 PHARMACEUTIC PCCA NATACREAM 1 AL ADJUVANT - CELLULOSE PEGBLEND 3 CAPSULES PENSOMAL 3 (EMPTY) PETROLATUM 1 CAPSULE #0 petrolatum, yellow 1 1 (CELLULOSE) (bulk) CAPSULE #00 PHARMABASE 1 1 (CELLULOSE) You can find information on what the symbols and abbreviations on this table mean on page 4. 113 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PHARMABASE apricot flavor (bulk) 1 1 HEAVY liquid PHARMABASE BANANA 1 1 LIGHT CONCENTRATE PHARMABASE BANANA CREAM 1 1 NATURAL FLAVOR PHARMABASE banana creme flavor 1 1 VAGINAL (bulk) polyethylene glycol banana flavor (bulk) 1 3 1000(bulk) bitter almond oil (bulk) 1 polyethylene glycol bitter mask flavoring 1 1 3350(bulk) granules (bulk) SALTSTABLE LO BITTERNESS MASK 3 1 CREAM BASE FLAVOR SALTSTABLE LS 1 blackberry flavor (bulk) 1 U-BASE 1 BLUEBERRY 1 VANISH-PEN CREAM FLAVOR 1 BASE BUBBLE GUM 1 VERSATILE 1 CONCENTRATE white petrolatum (bulk) 1 bubblegum flavor (bulk) 1 PHARMACEUTIC butter flavor (bulk) 1 AL ADJUVANT - butter rum flavor (bulk) 1 EXTERNAL butterscotch flavor 1 VEHICLES (bulk) BASE, PCCA BUTTERSCOTCH 3 1 POLYPEG FLAVORING BASE, PCCA caramel flavor (bulk) 1 1 VANPEN cheesecake flavor (bulk) 1 VANIBASE chlorhexidine (bulk) 1 TRADITIONAL 1 chocolate flavor (bulk) FORMULA 1 liquid PHARMACEUTIC chocolate hazelnut flav 1 AL ADJUVANT - (bulk) FLAVORING coconut flavor (bulk) 1 AGENTS coffee flavor (bulk) 1 (d)-limonene flavor 1 (bulk) cola flavor (bulk) 1 anise flavor extract cotton candy flavor 1 1 (bulk) (bulk) apple flavor (bulk) cran-raspberry flavor 1 1 liquid (bulk) APPLE-ADE FLAVOR 1 cream de menthe (bulk) 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 114 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ENGLISH TOFFEE SWEET OIL 1 1 FLAVOR SWEETNESS 1 FLAVORX 1 ENHANCER FLAVOR grape flavor (bulk) 1 tangerine oil (bulk) 1 GRAPEFRUIT 1 TANGERINE OIL, 1 guava flavor (bulk) 1 NATURAL honey flavor (bulk) 1 teaberry oil flavor (bulk) 1 tropical punch flavor kahlua flavor (bulk) 1 1 (bulk) lemon flavor extract 1 (bulk) tutti-frutti flavor (bulk) 1 lemonade flavor oil VANILLA 1 (bulk) BUTTERNUT 1 FLAVOR licorice flavor (bulk) 1 vanilla butternut 1 LIME FLAVOR 1 flavor(bulk) MAGNASWEET 110 1 vanilla extract flavor 1 maple flavor (bulk) 1 (bulk) marshmallow flavor watermelon flavor 1 1 (bulk) (bulk) mint chocolate chip flv wild cherry flavor (bulk) 1 1 (bulk) PHARMACEUTIC ORANGE 1 AL ADJUVANT - CONCENTRATE GELATIN orange cream flavor 1 CAPSULES (bulk) (EMPTY) peach flavor (bulk) 1 CAPSULE #0 1 PEANUT BUTTER 1 CAPSULE #00 1 FLAVOR CAPSULE #000 1 peanut butter flavor 1 (bulk) CAPSULE #1 1 PEPPERMINT CAPSULE #10 1 1 FLAVORING CAPSULE #13 1 pineapple flavor (bulk) 1 CAPSULE #2 1 pralines and cream 1 CAPSULE #3 1 flavr(bulk) CAPSULE #4 1 PUMPKIN FLAVOR 1 CAPSULE #5 1 raspberry flavor (bulk) 1 CAPSULE #7 1 liquid CAPSULE CONI- root beer flavor (bulk) 1 1 SNAP #0 (GELATIN) spearmint oil 1 CAPSULE CONI- 1 strawberry flavor (bulk) 1 SNAP #00 (GELATIN

You can find information on what the symbols and abbreviations on this table mean on page 4. 115 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CAPSULE CONI- PULMOSAL 3 1 SNAP #000 sodium chloride 1 CAPSULE CONI- inhalation 1 SNAP #1 (GELATIN) PHARMACEUTIC CAPSULE CONI- 1 AL ADJUVANT - SNAP #2 (GELATIN) ORAL CAPSULE CONI- 1 THICKENING SNAP #3 (GELATIN) AGENTS CAPSULE CONI- 1 corn starch (bulk) 3 SNAP #4 (GELATIN) DIAFOODS THICK-IT 3 PHARMACEUTIC DIAFOODS THICK-IT AL ADJUVANT - 3 #2 HYPROMELLOS E CAPSULES RESOURCE THICKENUP ORAL 3 (EMPTY) POWDER CAPSULE #0 1 SIMPLYTHICK ORAL 1 CAPSULE #0 GEL 1 (HYPROMELLOSE) SIMPLYTHICK ORAL CAPSULE #0 DRCAPS 1 GEL IN PACKET 12 3 CAPSULE #00 GRAM, 48 GRAM, 6 1 (HYPROMELLOSE) GRAM, 96 GRAM CAPSULE #1 SIMPLYTHICK ORAL 1 GEL IN PACKET 120 (HYPROMELLOSE) 1 GRAM, 15 GRAM, 240 CAPSULE #1 DRCAPS 1 GRAM, 30 GRAM CAPSULE #3 1 SIMPLYTHICK ORAL (HYPROMELLOSE) GEL WITH PUMP 6 3 CAPSULE #4 1 GRAM/ACTUATION CAPSULE CONI- THICK NOW 3 SNAP 1 THICKEN UP CLEAR 3 #0(HYPROMEL) ORAL POWDER CAPSULE CONI- THICK-IT #2 ORAL 3 SNAP 1 POWDER #1(HYPROMEL) THICK-IT #2 ORAL 1 CAPSULE CONI- POWDER IN PACKET SNAP 1 #3(HYPROMEL) PHARMACEUTIC PHARMACEUTIC AL ADJUVANT - AL ADJUVANT - ORAL VEHICLES INHALATION cherry flavor (bulk) 1 FLAVOR BLEND 2 IN VEHICLES 1 1 HYPER-SAL 3 FLAVOR PLUS 1 NEBUSAL 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 116 Drug Name Drug Tier Limits Drug Name Drug Tier Limits FLAVOR SWEET 1 PHARMACEUTIC FLAVOR SWEET-SF 1 AL ADJUVANT - ORA-BLEND 3 PRESERVATIVES benzoic acid (bulk) ORA-BLEND SF 3 1 crystals ORAL MIX 1 sodium benzoate (bulk) 3 ORAL MIX SF 1 ORAL SUSPEND 1 PHARMACEUTIC AL ADJUVANT - ORAL SUSPENDING 3 COMPOUND PLUS SUPPOSITORY VEHICLES ORAL SYRUP 1 BASE X 1 ORAL SYRUP SF 1 FATTYBLEND 3 orange flavor (bulk) 1 liquid PHARMACEUTIC ORA-PLUS 1 AL ADJUVANT - ORA-SWEET 1 SURFACTANTS LUMOXITI IV SOLN ORA-SWEET SF 1 4 STABILIZER simple syrup 1 polysorbate 80 1 SYRPALTA VEHICLE 1 PHARMACEUTIC SYRSPEND SF ALKA 1 AL ADJUVANT - SYRSPEND SF 1 SUSPENDING LIQUID AGENTS VERSA FREE 1 alginic acid (bulk) 3 VERSA PLUS 1 alkyl (c12-15) benzoate 1 PHARMACEUTIC (bulk) AL ADJUVANT - FIXED OIL 3 PARENTERAL SUSPENSION VEHICLES gelatin (bulk) gel 1 BACTERIOSTATIC 4 gelatin (bulk) powder 3 WATER(PARABENS) LIP BALM BASE 3 DILUENT FOR (BULK) EPOPROSTENOL/FLO 4 PA METHOCEL E 4 M LA 1 GRANULES DILUENT FOR 4 methylcellulose 1500cps IXEMPRA (15 MG) 3 (bulk) DILUENT FOR 4 methylcellulose 4000cps IXEMPRA (45 MG) 3 (bulk) diluent for treprostinil 4 PEG OINTMENT (gly) 1 BASE (BULK) SUSPENDOL-S 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 117 Drug Name Drug Tier Limits Drug Name Drug Tier Limits tragacanth 3 EXELON 3 LA PHARMACEUTIC TRANSDERMAL AL ADJUVANT - galantamine 2 LA TABLETING RAZADYNE ER 3 LA RAZADYNE ORAL lactose (bulk) 3 3 LA TABLET SUBSOLV RDT 3 rivastigmine 2 LA PHARMACEUTIC AL ADJUVANT - rivastigmine tartrate 2 TROCHE/SOFT ALZHEIMER'S LOZENGE BASE DISEASE polyethylene glycol THERAPY - 1 1450(bulk) powder NMDA polyethylene glycol RECEPTOR 3 1450(bulk) wax ANTAGONISTS memantine oral TROCHIBASE 3 3 LA capsule,sprinkle,er 24hr TROCHIBASE S 1 CLASSIC memantine oral solution 2 LA PHARMACEUTIC memantine oral tablet 2 LA memantine oral AL ADJUVANT - 3 LA VEHICLE tablets,dose pack NAMENDA ORAL EXCIPIENTS 3 LA TABLET stearyl alcohol 1 NAMENDA 3 LA COGNITIVE TITRATION PAK DISORDER NAMENDA XR 3 LA THERAPY ALZHEIMER'S ALZHEIMER'S THX - NMDA DISEASE RECEPTOR THERAPY - ANTAG. AND CHOLINESTERA CHOLINESTERA SE INHIBITORS SE INHIB. COMB ARICEPT ORAL 3 NAMZARIC ORAL TABLET 10 MG, 5 MG CAPSULE,SPRINKLE, 3 LA ARICEPT ORAL ER 24HR 14-10 MG, 3 LA TABLET 23 MG 28-10 MG donepezil oral tablet 10 COGNITIVE 1 mg, 5 mg DISORDER donepezil oral tablet 23 3 LA THERAPY - mg CEREBRAL donepezil oral 2 LA VASODILATORS tablet,disintegrating ergoloid 2 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 118 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CONTRACEPTI AZURETTE (28) 1 VES BEKYREE (28) 1 CONTRACEPTIV CAMRESE 1 E IMPLANT - CAMRESE LO 1 PROGESTIN DAYSEE 1 NEXPLANON 1 desog- 1 CONTRACEPTIV e.estradiol/e.estradiol E INJECTABLE - KARIVA (28) 1 PROGESTIN l norgest/e.estradiol- e.estrad oral tablets,dose DEPO-PROVERA pack,3 month 0.10 mg- INTRAMUSCULAR 1 1 20 mcg (84)/10 mcg (7), SUSPENSION 150 0.15 mg-30 mcg (84)/10 MG/ML mcg (7) DEPO-PROVERA LO LOESTRIN FE 1 INTRAMUSCULAR 1 SYRINGE LOSEASONIQUE 1 DEPO-SUBQ MIRCETTE (28) 1 1 PROVERA 104 PIMTREA (28) 1 medroxyprogesterone 1 SEASONIQUE 1 intramuscular SIMLIYA (28) 1 CONTRACEPTIV SIMPESSE 1 E VIORELE (28) 1 INTRAUTERINE - COPPER IUD CONTRACEPTIV E ORAL - PARAGARD T 380A 1 MONOPHASIC CONTRACEPTIV AFIRMELLE 1 E INTRAUTERINE - ALTAVERA (28) 1 PROGESTERONE ALYACEN 1/35 (28) 1 IUD AMETHYST (28) 1 KYLEENA 1 APRI 1 LILETTA 1 AUBRA 1 MIRENA 1 AUBRA EQ 1 AUROVELA 1.5/30 SKYLA 1 1 (21) CONTRACEPTIV E ORAL - AUROVELA 1/20 (21) 1 BIPHASIC AUROVELA 24 FE 1 AUROVELA FE 1.5/30 AMETHIA 1 1 (28) AMETHIA LO 1 AUROVELA FE 1-20 1 ASHLYNA 1 (28) You can find information on what the symbols and abbreviations on this table mean on page 4. 119 Drug Name Drug Tier Limits Drug Name Drug Tier Limits AVIANE 1 JUNEL 1.5/30 (21) 1 AYUNA 1 JUNEL 1/20 (21) 1 BALCOLTRA 1 JUNEL FE 1.5/30 (28) 1 BALZIVA (28) 1 JUNEL FE 1/20 (28) 1 BEYAZ 1 JUNEL FE 24 1 BLISOVI 24 FE 1 KAITLIB FE 1 BLISOVI FE 1.5/30 KALLIGA 1 1 (28) KELNOR 1/35 (28) 1 BLISOVI FE 1/20 (28) 1 KELNOR 1-50 1 BRIELLYN 1 KURVELO (28) 1 CHATEAL (28) 1 LARIN 1.5/30 (21) 1 CHATEAL EQ (28) 1 LARIN 1/20 (21) 1 CRYSELLE (28) 1 LARIN 24 FE 1 CYCLAFEM 1/35 (28) 1 LARIN FE 1.5/30 (28) 1 CYRED 1 LARIN FE 1/20 (28) 1 CYRED EQ 1 LAYOLIS FE 1 DASETTA 1/35 (28) 1 LESSINA 1 desogestrel-ethinyl levonorgestrel-ethinyl 1 1 estradiol estrad drospirenone- LEVORA-28 1 e.estradiol-lm.fa oral 1 tablet 3-0.03-0.451 mg LOESTRIN 1.5/30 (21) 1 (21) (7) LOESTRIN 1/20 (21) 1 drospirenone-ethinyl LOESTRIN FE 1.5/30 1 1 estradiol (28-DAY) ELINEST 1 LOESTRIN FE 1/20 1 ENSKYCE 1 (28-DAY) ESTARYLLA 1 LORYNA (28) 1 ethynodiol diac-eth LOW-OGESTREL (28) 1 1 estradiol LO-ZUMANDIMINE 1 FALMINA (28) 1 (28) GENERESS FE 1 LUTERA (28) 1 GIANVI (28) 1 MARLISSA (28) 1 HAILEY 1 MELODETTA 24 FE 1 HAILEY 24 FE 1 MIBELAS 24 FE 1 MICROGESTIN 1.5/30 INTROVALE 1 1 (21) JASMIEL (28) 1 MICROGESTIN 1/20 1 JOLESSA 1 (21) JULEBER 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 120 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MICROGESTIN FE TARINA FE 1-20 EQ 1 1 1.5/30 (28) (28) MICROGESTIN FE TYDEMY 1 1 1/20 (28) VIENVA 1 MILI 1 VYFEMLA (28) 1 MINASTRIN 24 FE 1 VYLIBRA 1 MONO-LINYAH 1 WERA (28) 1 NECON 0.5/35 (28) 1 WYMZYA FE 1 NIKKI (28) 1 YASMIN (28) 1 noreth-ethinyl estradiol- 1 YAZ (28) 1 iron ZARAH 1 norethindrone ac-eth estradiol oral tablet 1-20 1 ZOVIA 1/35E (28) 1 mg-mcg ZUMANDIMINE (28) 1 norethindrone- CONTRACEPTIV e.estradiol-iron oral 1 E ORAL - tablet 1 mg-20 mcg PROGESTIN (21)/75 mg (7) CAMILA 1 norgestimate-ethinyl estradiol oral tablet 1 DEBLITANE 1 0.25-35 mg-mcg ERRIN 1 NORTREL 0.5/35 (28) 1 HEATHER 1 NORTREL 1/35 (21) 1 INCASSIA 1 OCELLA 1 JENCYCLA 1 ORSYTHIA 1 LYZA 1 ORTHO-NOVUM 1/35 1 NORA-BE 1 (28) norethindrone 1 PHILITH 1 (contraceptive) PIRMELLA ORAL ORTHO MICRONOR 1 TABLET 1-35 MG- 1 SHAROBEL 1 MCG SLYND 1 PORTIA 28 1 TULANA 1 PREVIFEM 1 RECLIPSEN (28) 1 CONTRACEPTIV E ORAL - SAFYRAL 1 QUADRAPHASIC SETLAKIN 1 NATAZIA 1 SPRINTEC (28) 1 QUARTETTE 1 SRONYX 1 SYEDA 1 TARINA 24 FE 1 TARINA FE 1/20 (28) 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 121 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CONTRACEPTIV TRI-VYLIBRA LO 1 E ORAL - VELIVET TRIPHASIC 1 TRIPHASIC REGIMEN (28) ALYACEN 7/7/7 (28) 1 CONTRACEPTIV ARANELLE (28) 1 E CAZIANT (28) 1 TRANSDERMAL COMBINATIONS CYCLAFEM 7/7/7 (28) 1 - ESTROGEN DASETTA 7/7/7 (28) 1 AND PROGESTIN ENPRESSE 1 COMB. ESTROSTEP FE-28 1 XULANE 1 LEENA 28 1 CONTRACEPTIV LEVONEST (28) 1 E levonorg-eth estrad 1 TRANSDERMAL triphasic COMBINATIONS norgestimate-ethinyl XULANE 1 estradiol oral tablet 0.18/0.215/0.25 mg-25 1 CONTRACEPTIV mcg, 0.18/0.215/0.25 ES - mg-35 mcg (28) INTRAVAGINAL, NORTREL 7/7/7 (28) 1 SYSTEMIC - ORTHO TRI-CYCLEN ESTROGEN AND 1 (28) PROGESTIN ORTHO-NOVUM 7/7/7 COMB. 1 (28) ANNOVERA 1 PIRMELLA ORAL ELURYNG 1 TABLET 0.5/0.75/1 1 etonogestrel-ethinyl MG- 35 MCG 1 estradiol TILIA FE 1 NUVARING 1 TRI-ESTARYLLA 1 CONTRACEPTIV TRI-LEGEST FE 1 ES - TRI-LINYAH 1 INTRAVAGINAL, TRI-LO-ESTARYLLA 1 SYSTEMIC TRI-LO-MARZIA 1 etonogestrel-ethinyl 1 TRI-LO-MILI 1 estradiol TRI-LO-SPRINTEC 1 NUVARING 1 TRI-MILI 1 TRI-PREVIFEM (28) 1 TRI-SPRINTEC (28) 1 TRIVORA (28) 1 TRI-VYLIBRA 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 122 Drug Name Drug Tier Limits Drug Name Drug Tier Limits EMERGENCY SOLODYN ORAL CONTRACEPTIV TABLET EXTENDED ES - RELEASE 24 HR 105 3 MG, 115 MG, 55 MG, PROGESTERONE 65 MG, 80 MG AGONIST/ANTA ACNE THERAPY GONIST TYPE TOPICAL - ANTI- ELLA 1 INFECTIVE EMERGENCY COMBINATIONS CONTRACEPTIV OTHER ES CLINDACIN ETZ 3 ELLA 1 TOPICAL KIT DERMATOLOGI CLINDACIN PAC 3 CAL ACNE THERAPY ACNE THERAPY TOPICAL - ANTI- SYSTEMIC - INFECTIVE RETINOIDS AND ACZONE 3 DERIVATIVES azelaic acid 1 ABSORICA 2 PA AZELEX 3 AMNESTEEM 2 PA CLEOCIN T TOPICAL 3 CLARAVIS 2 PA GEL CLEOCIN T TOPICAL isotretinoin 2 PA 3 LOTION MYORISAN 2 PA CLEOCIN T TOPICAL 3 ZENATANE 2 PA SOLUTION ACNE THERAPY CLINDACIN P 3 SYSTEMIC - CLINDAGEL 3 TETRACYCLINE clindamycin phosphate 3 ANTIBIOTIC topical foam COREMINO 3 clindamycin phosphate 1 minocycline oral tablet topical gel extended release 24 hr 3 PA clindamycin phosphate 3 105 mg, 65 mg, 80 mg topical gel, once daily minocycline oral tablet clindamycin phosphate extended release 24 hr 1 3 topical lotion 115 mg, 135 mg, 45 mg, clindamycin phosphate 55 mg, 90 mg 1 topical solution MINOLIRA ER 3 PA clindamycin phosphate 3 SEYSARA 3 topical swab ERY PADS 1 ERYGEL 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 123 Drug Name Drug Tier Limits Drug Name Drug Tier Limits erythromycin with NEUAC 1 1 ethanol topical gel ONEXTON TOPICAL 3 erythromycin with GEL WITH PUMP 1 ethanol topical solution PLEXION 3 EVOCLIN 3 PLEXION 3 FINACEA 1 CLEANSING CLOTHS KLARON 1 ROSANIL 3 METROCREAM 3 ROSULA 3 METROLOTION 3 ROSULA CLEANSING 3 metronidazole topical CLOTHS 1 cream SSS 10-5 TOPICAL 3 metronidazole topical FOAM 1 lotion sulfacetamide sodium- 3 NORITATE 3 sulfur topical cleanser ROSADAN TOPICAL sulfacetamide sodium- 1 CREAM sulfur topical cream 10- 3 2 %, 9.8-4.8 % sulfacetamide sodium 1 (acne) sulfacetamide sodium- sulfur topical lotion 10- 1 ACNE THERAPY 5 % (w/v), 10-5 % TOPICAL - ANTI- (w/w) INFECTIVE- sulfacetamide sodium- KERATOLYTIC sulfur topical lotion 9.8- 3 COMBINATIONS 4.8 % ACANYA TOPICAL sulfacetamide sodium- 3 GEL WITH PUMP sulfur topical pads, 3 medicated 10-4 % AVAR LS 3 sulfacetamide sodium- AVAR TOPICAL 3 sulfur topical 3 CLEANSER suspension AVAR TOPICAL 3 sulfacetamide sod- PADS, MEDICATED sulfur-urea topical 3 AVAR-E LS 3 cleanser BENZACLIN 3 sulfacetamide-sulfur- 3 BENZACLIN PUMP 3 cleansr23 BENZAMYCIN 3 SULFACLEANSE 8-4 3 BP 10-1 3 SUMADAN 3 CLEANSING WASH SUMADAN XLT 3 3 TOPICAL CLEANSER SUMAXIN 3 clindamycin-benzoyl 3 SUMAXIN CP 3 peroxide SUMAXIN TS 3 erythromycin-benzoyl 1 peroxide You can find information on what the symbols and abbreviations on this table mean on page 4. 124 Drug Name Drug Tier Limits Drug Name Drug Tier Limits EPIDUO TOPICAL ACNE THERAPY 3 TOPICAL - ANTI- GEL WITH PUMP INFECTIVE- ACNE THERAPY RETINOID TOPICAL - COMBINATIONS RETINOIDS AND VELTIN 3 DERIVATIVES ZIANA 3 adapalene topical cream 1 adapalene topical gel ACNE THERAPY 3 TOPICAL - 0.3 % adapalene topical gel KERATOLYTIC 3 COMBINATIONS with pump OTHER adapalene topical swab 3 INOVA 4-1 3 ALTRENO 3 INOVA 8-2 3 ATRALIN 3 AVITA TOPICAL ACNE THERAPY 3 CREAM TOPICAL - DIFFERIN TOPICAL KERATOLYTIC 3 GEL 0.3 % BENZEPRO 3 DIFFERIN TOPICAL (MICROSPHERES) 3 GEL WITH PUMP BENZEPRO TOPICAL 3 DIFFERIN TOPICAL TOWELETTE 3 LOTION benzoyl peroxide topical 3 FABIOR 3 cleanser 7 % RETIN-A 3 INOVA 3 RETIN-A MICRO 3 PACNEX 3 RETIN-A MICRO PR BENZOYL 3 PUMP TOPICAL GEL PEROXIDE 3 WITH PUMP 0.04 %, ACNE THERAPY 0.08 %, 0.1 % TOPICAL - tretinoin microspheres 3 KERATOLYTIC- tretinoin topical cream 2 PA GLUCOCORTICO tretinoin topical gel 0.01 2 PA ID %, 0.025 % COMBINATIONS tretinoin topical gel 0.05 3 VANOXIDE-HC 1 % ACNE THERAPY TRETIN-X CREAM 3 TOPICAL - KIT RETINOID TRETIN-X TOPICAL 3 COMBINATIONS CREAM 0.075 % OTHER EPIDUO FORTE 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 125 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIPSORIATIC ANTIPSORIATIC - RETINOID AGENTS- (VITAMIN A INTERLEUKIN-17 DERIVATIVE) - (IL-17) GLUCOCORTICO ANTAGONIST, ID MC ANTIBODY DUOBRII 3 COSENTYX 3 COSENTYX (2 ANTIPSORIATIC 3 - VITAMIN D SYRINGES) ANALOG - COSENTYX PEN 3 GLUCOCORTICO COSENTYX PEN (2 3 ID PENS) COMBINATIONS SILIQ 3 calcipotriene- TALTZ 3 betamethasone topical 1 AUTOINJECTOR ointment TALTZ ENSTILAR 3 AUTOINJECTOR (2 3 TACLONEX TOPICAL PACK) 3 SUSPENSION TALTZ ANTIPSORIATIC AUTOINJECTOR (3 3 PACK) AGENTS - INTERLEUKIN 12 TALTZ SYRINGE 3 AND IL-23 DERMATITIS OR INHIBITORS,MC ECZEMA ANTIBODY AGENTS, STELARA SYSTEMIC- 3 PA SUBCUTANEOUS INTERLEUKIN-4 (IL-4RA) ANTIPSORIATIC ANTAG.MAB AGENTS - INTERLEUKIN-23 DUPIXENT SYRINGE SUBCUTANEOUS (IL-23) 3 PA SYRINGE 200 ANTAGONIST, MG/1.14 ML MC ANTIBODY DUPIXENT SYRINGE SKYRIZI 3 SUBCUTANEOUS 3 TREMFYA 3 PA SYRINGE 300 MG/2 ML

You can find information on what the symbols and abbreviations on this table mean on page 4. 126 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI DERMATOLOGI CAL - CAL - ANTIBACTERIAL ANTIBACTERIAL AMINOGLYCOSI - DES GLUCOCORTICO gentamicin topical 1 ID DERMATOLOGI COMBINATIONS CORTISPORIN CAL - 3 ANTIBACTERIAL TOPICAL OTHER NEO-SYNALAR 3 CENTANY 3 NEO-SYNALAR KIT 3 CENTANY AT 3 DERMATOLOGI mupirocin 1 CAL - ANTIFUNGAL mupirocin calcium 3 ALLYLAMINES silver nitrate topical 3 solution 10 % naftifine topical cream 3 ST SOLOX GEL 3 naftifine topical gel 3 NAFTIN TOPICAL DERMATOLOGI 3 GEL CAL - ANTIBACTERIAL DERMATOLOGI PLEUROMUTILI CAL - N DERIVATIVES ANTIFUNGAL AMPHOTERIC ALTABAX 1 POLYENE DERMATOLOGI MACROLIDES CAL - NYAMYC 1 ANTIBACTERIAL QUINOLONES nystatin topical 1 NYSTOP 1 XEPI 3 DERMATOLOGI DERMATOLOGI CAL - CAL - ANTIBACTERIAL ANTIFUNGAL SULFONAMIDES BENZYLAMINES MENTAX 3 PA AVAR-E GREEN 3 SSS 10-5 TOPICAL DERMATOLOGI 3 CREAM CAL - sulfacetamide sodium- ANTIFUNGAL sulfur topical cream 10- 3 COMBINATIONS 5 % (w/w) OTHER EXODERM 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 127 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI LUZU 3 CAL - miconazole nitrate-zinc 3 ANTIFUNGAL ox-pet HYDROXYPYRID NIZORAL TOPICAL 3 INONE SHAMPOO CICLODAN TOPICAL oxiconazole 3 1 CREAM OXISTAT TOPICAL 3 CICLODAN TOPICAL LOTION 3 SOLUTION VUSION 3 ciclopirox olamine 3 XOLEGEL 3 (bulk) DERMATOLOGI ciclopirox topical cream 1 CAL - ciclopirox topical gel 3 ANTIFUNGAL ciclopirox topical 1 OXABOROLE shampoo KERYDIN 3 PA ciclopirox topical 3 solution DERMATOLOGI CAL - ciclopirox topical 1 suspension ANTIFUNGAL TRIAZOLE ciclopirox-ure-camph- 3 menth-euc JUBLIA 3 LOPROX TOPICAL DERMATOLOGI 3 SHAMPOO CAL - DERMATOLOGI ANTIFUNGAL- CAL - GLUCOCORTICO ANTIFUNGAL ID IMIDAZOLE AND COMBINATIONS RELATED clotrimazole- 1 AGENTS betamethasone hydrocortisone- econazole 3 PA 3 PA iodoquinol ECOZA 3 nystatin-triamcinolone 1 ERTACZO 3 PA EXELDERM 3 DERMATOLOGI CAL - EXTINA 3 ANTIFUNGALS ketoconazole topical 1 OTHER cream triacetin 3 ketoconazole topical 3 foam ketoconazole topical 1 shampoo luliconazole 3 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 128 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI DERMATOLOGI CAL - CAL - ANTINEOPLASTI ANTINEOPLASTI C ALKYLATING C RETINOIDS AGENTS PANRETIN 2 PA VALCHLOR 2 PA DERMATOLOGI DERMATOLOGI CAL - CAL - ANTINEOPLASTI ANTINEOPLASTI C SELECTIVE C RETINOID X ANTIMETABOLI RECEPTOR TES AGONIST CARAC 3 PA TARGRETIN 1 EFUDEX TOPICAL TOPICAL 3 PA CREAM DERMATOLOGI FLUOROPLEX 1 CAL - fluorouracil topical ANTIPSORIATIC 3 cream 0.5 % AGENTS fluorouracil topical SYSTEMIC, 1 cream 5 % PHOTOSENSITIZ fluorouracil topical ING 1 solution methoxsalen 3 TOLAK 2 PA methoxsalen (bulk) 3 DERMATOLOGI crystals CAL - OXSORALEN ULTRA 3 ANTINEOPLASTI DERMATOLOGI C OR PREMALIG. CAL - LESIONS - ANTIPSORIATIC DITERPENE AGENTS ESTERS SYSTEMIC, PICATO 2 PA VITAMIN A DERMATOLOGI DERIVATIVES CAL - acitretin 1 ANTINEOPLASTI SORIATANE ORAL C OR CAPSULE 10 MG, 25 3 PREMALIGNANT MG LESIONS - NSAID'S diclofenac sodium 1 topical gel 3 % SOLARAZE 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 129 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI LOUTREX 3 CAL - OVACE 3 ANTIPSORIATIC OVACE PLUS 3 AGENTS SHAMPOO TOPICAL OVACE PLUS 3 anthralin (bulk) 3 TOPICAL CREAM OVACE PLUS BRYHALI 3 PA 3 TOPICAL FOAM calcipotriene scalp 1 OVACE PLUS calcipotriene topical 3 1 TOPICAL LOTION cream OVACE PLUS WASH 3 calcipotriene topical 1 ointment PROMISEB 3 selenium sulfide topical calcitriol topical 3 1 lotion DOVONEX TOPICAL 3 selenium sulfide topical DRITHOCREME HP 1 3 shampoo 2.25 %, 2.3 % halobetasol propionate 3 SELRX 3 topical foam sulfacetamide sodium IMPOYZ 3 3 topical LEXETTE 3 TERSI FOAM 3 SORILUX 3 DERMATOLOGI tazarotene 3 CAL - TAZORAC 3 ANTIVIRAL, ULTRAVATE 3 HERPES TOPICAL LOTION acyclovir topical 3 PA VECTICAL 3 DENAVIR 3 ZITHRANOL 3 ZOVIRAX TOPICAL 3 DERMATOLOGI CREAM CAL - DERMATOLOGI ANTIPSORIATIC CAL - S SYSTEMIC, ANTIVIRAL- PHOSPHODIEST GLUCOCORTICO ERASE 4 INHIB. ID OTEZLA 3 COMBINATIONS OTEZLA STARTER 3 XERESE 3 DERMATOLOGI DERMATOLOGI CAL - CAL - ANTISEBORRHEI ASTRINGENTS C ferric chloride (bulk) 3 ESKATA 3 powder

You can find information on what the symbols and abbreviations on this table mean on page 4. 130 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI DERMATOLOGI CAL - BURN CAL - PRODUCTS EMOLLIENT ANTI-INFECTIVE MIXTURES SILVADENE 3 ALOE GRANDE 1 silver sulfadiazine 1 ALPHABATH 1 SSD 1 AMERIPHOR 1 SULFAMYLON 1 AMLACTIN TOPICAL 1 DERMATOLOGI CREAM CAL - ATOPADERM 3 CALCINEURIN ATOPICLAIR 3 INHIBITORS ATRAPRO CP 3 ELIDEL 2 PA; ST ATRAPRO 3 pimecrolimus 2 PA HYDROGEL PROTOPIC 3 AVO CREAM 3 tacrolimus topical 3 PA; ST AVOSIL 1 BALNEOL TOPICAL DERMATOLOGI 1 LOTION CAL - EMOLLIENT BETAMIDE 1 COMBINATIONS BIAFINE EMULSION 3 OTHER CELACYN 3 ELON 1 CERACADE 3 HPR PLUS CERAMAX 3 3 HYDROGEL COCOA BUTTER 1 HPR PLUS-MB CREAM 3 HYDROGEL DERMACERIN 1 MB HYDROGEL 3 ELETONE 3 MB HYDROGEL EMULSION SB 3 (CYCLOMETHICONE 3 ENTTY 3 ) EPICERAM 3 DERMATOLOGI CAL - EUCERIN 1 EMOLLIENT HPR 3 COMBINATIONS HPR PLUS 3 CERAVE TOPICAL HYDROCERIN 1 1 CREAM HYLATOPIC 3 HYLATOPICPLUS 3 TOPICAL CREAM HYLATOPICPLUS 3 TOPICAL FOAM

You can find information on what the symbols and abbreviations on this table mean on page 4. 131 Drug Name Drug Tier Limits Drug Name Drug Tier Limits HYPER-HEAL 1 GORMEL 1 LOUTREX 3 LAC-HYDRIN FIVE 1 LUXAMEND 3 MAPO BATH 1 MIADERM 1 RADIAGEL 1 NEOSALUS 3 SUPERSOFT 1 NIVATOPIC PLUS 3 ULTRA MIDE 25 1 PENLEN 3 UNSCENTED COLD 1 PETROLATUM 1 CREAM PHARMABASE urea topical cream 39 % 3 1 COSMETIC UREACIN-10 1 PRESERA 3 UREACIN-20 1 PROMISEB 3 UREDEB 3 PRUCLAIR 3 VANISHING CREAM 1 PRUMYX 3 TOPICAL REMEDY DERMATOLOGI PHYTOPLEX 3 CAL - ENZYMES MOISTURIZER SANTYL 3 PA SONAFINE 3 DERMATOLOGI SOOTHE AND COOL 3 CAL - EYELID SKIN CREAM CLEANSERS SORBOLENE 3 ACUICYN 3 SWEEN CREAM 1 HYPOCYN 3 THERA BATH 1 DERMATOLOGI VANIBASE 1 CAL - vitamin e-safflower oil 1 GLUCOCORTICO VITAMN E BEAUTY 1 ID WITH SAFFLOWER ADVANCED VITA-RAY 1 ALLERGY COLLECT 3 XCLAIR 3 KIT ALA-CORT TOPICAL DERMATOLOGI 3 CAL - CREAM 1 % EMOLLIENTS alclometasone 1 amcinonide topical AMERISTORE 1 3 PA cream AQUA CARE 1 amcinonide topical AQUANIL SKIN 3 1 lotion CLEANSER beclomethasone diprop 3 DERMACLOUD 1 (bulk) emollient 1 BESER 3 PA GORDONS-VITE E 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 132 Drug Name Drug Tier Limits Drug Name Drug Tier Limits betamethasone DERMA- 3 PA dipropionate SMOOTHE/FS BODY 3 PA betamethasone valerate OIL 1 topical cream DERMA- betamethasone valerate SMOOTHE/FS SCALP 3 PA 3 topical foam OIL betamethasone valerate DESONATE 3 3 PA topical lotion desonide topical cream 1 betamethasone valerate desonide topical lotion 3 1 topical ointment desonide topical 1 betamethasone, ointment 3 PA augmented DESOWEN 3 BRYHALI 3 PA desoximetasone topical 3 PA CAPEX 3 PA cream clobetasol scalp 1 desoximetasone topical 3 PA clobetasol topical cream 1 gel desoximetasone topical clobetasol topical foam 3 3 PA ointment clobetasol topical gel 1 desoximetasone topical 3 clobetasol topical lotion 3 spray,non-aerosol clobetasol topical diflorasone topical 1 3 ointment cream clobetasol topical diflorasone topical 3 3 PA shampoo ointment clobetasol topical DIPROLENE 3 3 spray,non-aerosol TOPICAL OINTMENT clobetasol-emollient 3 PA fluocinolone 3 PA CLOBEX 3 fluocinolone and shower 3 PA clocortolone pivalate 3 PA cap CLODAN 3 fluocinonide 3 PA CLODERM 3 FLUOCINONIDE-E 3 PA CORDRAN TOPICAL flurandrenolide topical 3 3 PA CREAM 0.025 % cream CORDRAN TOPICAL fluticasone propionate 3 1 LOTION topical cream CORDRAN TOPICAL fluticasone propionate 3 3 OINTMENT topical lotion CUTIVATE TOPICAL fluticasone propionate 3 1 CREAM topical ointment CUTIVATE TOPICAL halobetasol propionate 3 1 LOTION topical cream

You can find information on what the symbols and abbreviations on this table mean on page 4. 133 Drug Name Drug Tier Limits Drug Name Drug Tier Limits halobetasol propionate prednicarbate topical 3 3 PA topical foam ointment halobetasol propionate PROCTOCORT 1 3 topical ointment TOPICAL HALOG TOPICAL PROCTO-MED HC 1 3 PA CREAM PROCTO-PAK 1 HALOG TOPICAL PROCTOSOL HC 3 PA 1 OINTMENT TOPICAL hydrocortisone butyrate 3 PROCTOZONE-HC 1 hydrocortisone butyr- 3 PSORCON 3 emollient SCALACORT 1 hydrocortisone topical 1 cream 2.5 % SCALACORT DK 3 hydrocortisone topical SERNIVO 3 cream with perineal 1 SILAZONE-II 3 applicator SYNALAR TOPICAL 3 hydrocortisone topical SOLUTION 1 lotion 2.5 % TEMOVATE 3 hydrocortisone topical TOPICAL CREAM 1 ointment 2.5 % TEXACORT 1 hydrocortisone valerate 3 PA TOPICORT TOPICAL 3 IMPOYZ 3 OINTMENT 0.05 % KENALOG TOPICAL 3 TOPICORT TOPICAL LEXETTE 3 SPRAY,NON- 3 AEROSOL LOCOID LIPOCREAM 3 triamcinolone acetonide LOCOID TOPICAL 3 3 topical aerosol LOTION triamcinolone acetonide 1 LUXIQ 3 topical cream mometasone topical triamcinolone acetonide 2 PA 1 cream topical lotion mometasone topical 2 PA triamcinolone acetonide ointment topical ointment 0.025 1 mometasone topical %, 0.1 %, 0.5 % 1 solution TRIANEX 1 PA NOLIX TOPICAL TRIDERM TOPICAL 3 1 CREAM CREAM 0.1 % OLUX 3 ULTRAVATE 3 OLUX-E 3 PA TOPICAL LOTION PANDEL 3 VANOS 3 prednicarbate topical VERDESO 3 3 cream

You can find information on what the symbols and abbreviations on this table mean on page 4. 134 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PRAMOSONE DERMATOLOGI 1 CAL - TOPICAL OINTMENT GLUCOCORTICO DERMATOLOGI ID-EMOLLIENT CAL - COMBINATIONS GLUCOCORTICO BESER KIT 3 PA ID-SKIN DERMACINRX CLEANSER 3 SILAPAK COMBINATIONS DERMAWERX SDS 3 AQUA GLYCOLIC HC 3 NOXIPAK 3 SYNALAR TS 3 SANADERMRX 3 DERMATOLOGI SURE RESULT TAC CAL - HAIR 3 PAK GROWTH SYNALAR CREAM AGENTS 3 KIT diphencyprone (bulk) 3 SYNALAR powder 98 % 3 OINTMENT KIT DERMATOLOGI WHYTEDERM 3 CAL - TDPAK IMMUNOMODUL WHYTEDERM 3 ATOR - TRILASIL PAK CATECHINS - DERMATOLOGI GENITAL CAL - WART/HPV TX GLUCOCORTICO VEREGEN 3 PA ID-LOCAL DERMATOLOGI ANESTHETIC CAL - COMBINATIONS IMMUNOMODUL ANALPRAM-HC 3 ATOR - TOPICAL IMIDAZOQUINO EPIFOAM 3 LINAMINES lidocaine hcl- QL (2 GM per 1 ALDARA 3 hydrocortison ac topical 23 days) imiquimod topical 1 NOVACORT 3 cream in packet PRAMOSONE ZYCLARA 3 TOPICAL CREAM 1-1 3 % DERMATOLOGI PRAMOSONE CAL - TOPICAL CREAM 2.5- 1 IMMUNOMODUL 1 % ATOR - PRAMOSONE INTERFERONS 3 TOPICAL LOTION ALFERON N 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 135 Drug Name Drug Tier Limits Drug Name Drug Tier Limits salicylic acid (bulk) DERMATOLOGI 3 CAL - powder KERATOLYTIC salicylic acid er- ceramides topical COMBINATIONS 3 OTHER kit,cleanser and cream er URAMAXIN GT salicylic acid topical TOPICAL 3 3 cream KIT,CREAM AND salicylic acid topical GEL 3 cream,extended release DERMATOLOGI CAL - salicylic acid topical film forming liquid 3 KERATOLYTIC- w/appl ANTIMITOTIC salicylic acid topical COMBINATIONS film-forming soln er w/ 3 SALKERA 3 appl SALVAX DUO PLUS 3 salicylic acid topical 3 silver nitrate applicators 3 foam DERMATOLOGI salicylic acid topical gel 3 salicylic acid topical CAL - 3 KERATOLYTIC- liquid 26 % salicylic acid topical ANTIMITOTIC 3 SINGLE AGENTS lotion salicylic acid topical BENSAL HP TOPICAL 3 3 lotion,extended release OINTMENT 3 % salicylic acid topical cantharidin in acetone 3 3 ointment CEM-UREA 3 salicylic acid topical CONDYLOX 3 1 shampoo TOPICAL GEL SALVAX 3 HYDRO 35 3 ULTRASAL-ER 3 HYDRO 40 3 UMECTA TOPICAL 3 KERAFOAM 3 FOAM KERALAC 3 URAMAXIN GT 3 KERALYT RX 3 TOPICAL GEL KERALYT SCALP URAMAXIN 3 3 COMPLETE TOPICAL FOAM URAMAXIN PODOCON 3 3 TOPICAL GEL podofilox 1 urea (bulk) powder 3 RYNODERM 3 UREA NAIL STICK 3 SALEX TOPICAL 3 SHAMPOO

You can find information on what the symbols and abbreviations on this table mean on page 4. 136 Drug Name Drug Tier Limits Drug Name Drug Tier Limits urea topical cream 40 RELADOR PAK 3 %, 41 %, 45 %, 47 %, 3 RELADOR PAK PLUS 3 50 % WPR PLUS 3 urea topical foam 3 DERMATOLOGI urea topical gel 45 % 3 CAL - LOCAL URE-K 3 ANESTHETIC UREVAZ 3 GAS SINGLE UTOPIC 3 AGENTS VIRASAL 3 ethyl chloride 3 DERMATOLOGI DERMATOLOGI CAL - CAL - KERATOPLASTI MISCELLANEOU C TAR S SINGLE PRODUCTS AGENTS coal tar 3 NEURAPTINE coal tar (crude) (bulk) TOPICAL CREAM IN 3 1 tar PACKET DERMATOLOGI squaric acid (bulk) 3 squaric acid CAL - LIVER 3 DERIVATIVE dibutylest.(bulk) powder COMPLEX DERMATOLOGI NEXAVIR 4 CAL - NSAID AND DERMATOLOGI LOCAL CAL - LOCAL ANESTHETIC ANESTHETIC COMBINATION COMBINATIONS DICLOVIX 3 APRIZIO PAK 3 DERMATOLOGI CETACAINE CAL - NSAID 3 ANESTHETIC COMBINATIONS KAMDOY 3 CAPSFENAC PAK 3 lidocaine-prilocaine QL (90 GM per DERMACINRX 2 3 topical cream 23 days) LEXITRAL lidocaine-prilocaine DICLOFEX DC 3 1 topical kit DICLOPAK 3 LIVIXIL PAK 3 DICLOTRAL 3 NUVAKAAN 3 INFLAMMA-K 3 PRIKAAN 3 SURE RESULT DSS 3 PRIKAAN LITE 3 PREMIUM PACK PRILOVIX LITE 3 XELITRAL 3 PRILOVIX PLUS 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 137 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI DERMATOLOGI CAL - NSAID CAL - POWDERS SINGLE AGENTS VAGISIL TOPICAL 3 diclofenac epolamine 3 POWDER diclofenac sodium DERMATOLOGI 3 topical drops CAL - DICLOFONO 3 PROTECTANT FLECTOR 3 COMBINATIONS FROTEK TOPICAL KELARX 3 3 CREAM IN PACKET SCARCIN GEL 3 PENNSAID TOPICAL SCARCIN ROLL-ON 3 SOLUTION IN 3 SCARSILK GEL 3 METERED-DOSE PUMP SILIPAC 3 VOLTAREN TOPICAL 3 DERMATOLOGI XRYLIX CAL - (DICLOFENAC- 3 PROTECTANTS KINES TAPE) ANTI MONKEY BUTT 1 DERMATOLOGI benzoin compound 1 CAL - (bulk) ORNITHINE BIONECT TOPICAL 4 DECARBOXYLAS FOAM E (ODC) SCARCARE 3 INHIBITORS talc (bulk) 3 VANIQA 3 zinc oxide topical paste 1 DERMATOLOGI DERMATOLOGI CAL - CAL - PHOTODYNAMI RETINOIDS C THERAPY (VITAMIN A AGENTS DERIVATIVES) - TOPICAL TOPICAL AMELUZ 2 PA COSMETIC LEVULAN 2 PA REFISSA 3 DERMATOLOGI tazarotene 3 CAL - tretinoin (emollient) 3 PIGMENTING, PHOTOSENSITIZ ING AGENTS methoxsalen (bulk) 3 crystals

You can find information on what the symbols and abbreviations on this table mean on page 4. 138 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DERMATOLOGI DERMATOLOGI CAL - ROSACEA CAL - SKIN THERAPY, CONTACT SYSTEMIC SENSITIZING doxycycline AGENTS monohydrate oral dinitrochlorobenzen(2,4 3 3 capsule,ir - delay )(bulk) rel,biphase DERMATOLOGI ORACEA 3 CAL - SOAP AND DERMATOLOGI CLEANSER CAL - ROSACEA SINGLE AGENTS THERAPY, green soap 1 TOPICAL DERMATOLOGI azelaic acid 1 CAL - SOAP AZELEX 3 AND/OR CLEANSING WASH 3 CLEANSER TOPICAL CLEANSER COMBINATIONS FINACEA 1 BABY WASH 1 METROCREAM 3 CETA-KLENZ 1 METROGEL TOPICAL GENTLE 3 GEL 1 % CETAPHIL TOPICAL 1 METROLOTION 3 BAR metronidazole topical 1 CETAPHIL TOPICAL 1 MIRVASO TOPICAL CLEANSER 3 GEL WITH PUMP CONTI CASTILE 1 NORITATE 3 SOAP ROSADAN TOPICAL GENTLE SKIN 1 1 CREAM CLEANSER ROSADAN TOPICAL NEUTROGENA ACNE 1 1 GEL CLEANSING SOAP NEUTROGENA SOOLANTRA 3 1 FACIAL SOAP sulfacetamide sod- PERIANAL sulfur-urea topical 3 1 cleanser CLEANSING SUMADAN XLT 3 PERIFRESH 1 DERMATOLOGI PROSHIELD FOAM/SPRAY 1 CAL - CLEANSER SHAMPOOS SAF-CLENS AF NEUTROGENA 1 1 DERMAL WOUND TOPICAL SHAMPOO SKIN CLEANSER 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 139 Drug Name Drug Tier Limits Drug Name Drug Tier Limits TECNU 3 DERMATOLOGI DERMATOLOGI CAL - TOPICAL CAL - TOPICAL LOCAL LOCAL ANESTHETICS ANESTHETIC dibucaine hcl (bulk) 3 AMIDES DERMATOLOGI GLYDO 3 CAL L.E.T. (LIDO- ANTIPRURITICS 3 EPINEPH-TETRA) - lidocaine hcl mucous QL (2 ML per ANTIHISTAMINE 2 membrane jelly 23 days) S lidocaine hcl mucous doxepin topical 2 PA membrane jelly in 3 PRUDOXIN 2 PA applicator ZONALON 2 PA lidocaine hcl topical QL (2 ML per 3 lotion 23 days) DERMATOLOGI lidocaine topical CAL IRRITANTS- adhesive 2 PA COUNTER- patch,medicated 5 % IRRITANT lidocaine topical QL (2 GM per SINGLE AGENTS 2 ointment 23 days) menthol (bulk) 1 QL (2 GM per lidocaine-tetracaine 1 QUTENZA 4 23 days) WINTERGREEN OIL 1 LIDODERM 3 HAIR GROWTH LIDO-K 3 AGENTS - LIDOPIN 3 TOPICAL LIDORX 3 minoxidil (bulk) 3 LIDOTREX 3 SCABICIDE AND LIDOVEX 3 PEDICULICIDE LIDOZION 3 SINGLE AGENTS SUVICORT 3 CROTAN 3 SYNERA 3 ELIMITE 3 ZTLIDO 3 EURAX 1 DERMATOLOGI LICE BEDDING 1 CAL - TOPICAL SPRAY LOCAL lindane topical shampoo 1 ANESTHETICS malathion 2 PA AND NATROBA 3 COMBINATIONS OVIDE 3 NEURCAINE 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 140 Drug Name Drug Tier Limits Drug Name Drug Tier Limits permethrin topical 1 WOUND CARE cream COMBINATIONS SKLICE 2 PA OTHER spinosad 1 balsam peru-castor oil 3 ULESFIA 1 BPCO TOPICAL 3 WOUND CARE - OINTMENT CLEANSER DERMULCERA 3 COMBINATIONS VENELEX 3 DELUO 3 DIAGNOSTIC EPICYN 3 AGENTS HYCLODEX 3 CONTRAST WOUND CARE - MEDIA - BARIUM CLEANSERS barium sulfate (bulk) 3 VASHE WOUND 3 CONTRAST THERAPY MEDIA - WOUND CARE - IODINATED DRESSINGS IONIC ACTICOAT 7 CONRAY-30 4 DRESSING TOPICAL 1 CONRAY-43 4 BANDAGE 4 X 5 " iopanoic acid (bulk) 3 ALLEVYN TOPICAL 1 BANDAGE 8 X 8 " SINOGRAFIN 4 COLLATYL 3 CONTRAST PROTYL AG 3 MEDIA - RESTORE FOAM IODINATED DRESSING SILVER NONIONIC 1 TOPICAL BANDAGE ISOVUE-200 4 4 X 4 " INTRAVENOUS RESTORE TOPICAL 4 ISOVUE-250 4 BANDAGE 2 X 2 " ISOVUE-300 4 SPECTRAGEL 4 ISOVUE-370 4 WOUND CARE - ISOVUE-M 300 4 GROWTH OMNIPAQUE 3 FACTOR AGENTS OMNIPAQUE 140 4 OMNIPAQUE 240 4 QL (15 GM per REGRANEX 1 23 days) OMNIPAQUE 300 4 OMNIPAQUE 350 4 OPTIRAY 240 INTRAVENOUS 4 SOLUTION

You can find information on what the symbols and abbreviations on this table mean on page 4. 141 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OPTIRAY 300 4 DIAGNOSTIC OPTIRAY 320 4 DRUGS - OPTIRAY 350 4 BILIARY VISIPAQUE 4 IC GREEN 4 CONTRAST indocyanine green 4 MEDIA - DIAGNOSTIC IODINATED OIL DRUGS - BASED CARDIOVASCUL LIPIODOL 4 AR CONTRAST ADENOSCAN 4 MEDIA - adenosine (bulk) 3 MAGNETIC adenosine (diagnostic) 4 RESONANCE dipyridamole 4 GADOLINIUM intravenous COMPLEXES LEXISCAN 4 DOTAREM 4 DIAGNOSTIC EOVIST 4 DRUGS - GADAVIST 4 GASTROINTESTI MAGNEVIST 4 NAL MULTIHANCE 4 RADIOLOGICAL ADJUNCT MULTIHANCE 4 GLUCAGEN MULTIPACK 4 DIAGNOSTIC KIT OMNISCAN 4 glucagon hcl 4 PROHANCE 4 CONTRAST DIAGNOSTIC MEDIA - DRUGS - MAGNETIC GLUCOSE RESONANCE TOLERANCE IRON TEST, ORAL COMPOUNDS GLUTOL GEL 4 FERIDEX IV 4 DIAGNOSTIC CONTRAST DRUGS - IN VIVO MEDIA - OTHER ULTRASOUND KINEVAC 4 AGENTS DIAGNOSTIC DEFINITY 4 DRUGS - OPTISON 4 METABOLIC FUNCTION CHIRHOSTIM 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 142 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MACRILEN 3 DIAGNOSTIC METOPIRONE 4 RADIOPHARMA R-GENE 10 4 CEUTICALS - DIAGNOSTIC DOPAMINE DRUGS - TRANSPORTER PITUITARY (DAT) IMAGING FUNCTION DATSCAN 4 ACTHREL 4 DIAGNOSTIC CORTROSYN 4 RADIOPHARMA CEUTICALS - cosyntropin 4 ENDOCRINE DIAGNOSTIC ADREVIEW 4 DRUGS - PULMONARY fludeoxyglucose f-18 intravenous solution 20 3 methacholine chloride 3 mci to 200 mci/ml (bulk) OCTREOSCAN 4 PROVOCHOLINE 4 DIAGNOSTIC DIAGNOSTIC RADIOPHARMA DRUGS - CEUTICALS - THYROID HEPATOBILIAR FUNCTION Y IMAGING THYROGEN 4 CHOLETEC 3 DIAGNOSTIC DIAGNOSTIC RADIOPHARMA RADIOPHARMA CEUTICALS - CEUTICALS - BRAIN, MYOCARDIAL AMYLOID PERFUSION PLAQUE IMAGING IMAGING MYOVIEW KIT 4 AMYVID 4 thallous chloride tl-201 DIAGNOSTIC intravenous solution 37 4 RADIOPHARMA mbq/ml (1 mci/ml) CEUTICALS - DIAGNOSTIC CEREBRAL RADIOPHARMA PERFUSION CEUTICALS - IMAGING PROSTATIC CERETEC 4 AXUMIN 4 INTRAVENOUS KIT NEUROLITE 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 143 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CAVERJECT DIAGNOSTIC QL (12 EA per INTRACAVERNOSAL 4 RADIOPHARMA 23 days) CEUTICALS - RECON SOLN QL (12 EA per RADIOLABELIN EDEX 4 G AUTOLOGOUS 23 days) LEUKOCYTES IFE-PG20 3 indium in-111 QL (12 EA per 4 MUSE 3 oxyquinoline 23 days) DIAGNOSTIC ERECTILE RADIOPHARMA DYSFUNCTION CEUTICALS - (ED) DRUGS- RADIOLABELIN ALPHA G FOR BLOCKER, LYMPHATIC PERIPHERAL MAPPING VASODILATOR LYMPHOSEEK 4 IFE-BIMIX 30/1 3 DIAGNOSTIC ERECTILE RADIOPHARMA DYSFUNCTION CEUTICALS - (ED) DRUGS- RENAL IMAGING SEL.CGMP PHOSPHODIEST DMSA 4 ERASE TYPE5 DRAXIMAGE DTPA 4 INHIB FLUORESCENCE CIALIS 3 IMAGING LEVITRA ORAL AGENTS - TABLET 10 MG, 20 3 MALIGNANT MG BRAIN TISSUE STAXYN 3 GLEOLAN 3 STENDRA 3 DRUGS TO tadalafil 2 PA TREAT vardenafil 3 ERECTILE QL (10 EA per VIAGRA 3 DYSFUNCTION 23 days) ERECTILE EATING DYSFUNCTION DISORDER (ED) DRUGS - THERAPY PROSTAGLANDI APPETITE NS STIMULANTS - CAVERJECT QL (12 EA per 4 CANNABINOIDS IMPULSE 23 days) dronabinol oral capsule 3 10 mg You can find information on what the symbols and abbreviations on this table mean on page 4. 144 Drug Name Drug Tier Limits Drug Name Drug Tier Limits dronabinol oral capsule arginine hcl (l-arginine) 3 PA 1 2.5 mg, 5 mg oral tablet SYNDROS 3 ENDARI 3 APPETITE glycine oral powder 3 STIMULANTS - ISOLEUCINE AMINO 1 PROGESTIN ACID SUPPLMNT HORMONE TYPE l-cystine 1 megestrol oral leucine oral powder in 1 suspension 400 mg/10 packet ml (10 ml), 400 mg/10 1 L-LYSINE ORAL 1 ml (40 mg/ml), 625 TABLET mg/5 ml (125 mg/ml) lysine hcl oral tablet 500 1 ELECTROLYTE mg BALANCE- lysine oral tablet 1,000 1 NUTRITIONAL mg, 500 mg PRODUCTS PURE L-CITRULLINE 1 AMINO ACID - ORAL CAPSULE VALINE AMINO CARNITINE 1 DERIVATIVES ACID SUPPLEMENT acetylcarnitine 3 B-COMPLEX VITAMIN AMINO ACID - COMBINATIONS TYROSINE ACTIVITE 3 tyrosine oral packet 1 ALBA-LYBE 3 AMINO ACID- APETEX 3 AMINO ACID COMBINATIONS, APETIGEN 3 B COMPLEX 100 ORAL 1 ORAL COMPLETE AMINO 1 B COMPLEX PLUS ACID MIX 3 VITAMIN C DAILY AMINO 1 b complex-vitamin c- PRE PROTEIN 1 folic acid oral tablet 3 AMINO ACIDS, extended release SINGLE B-100 COMPLEX ORAL TABLET INGREDIENT, 1 ORAL (NON- EXTENDED INJECTABLE) RELEASE BALANCED B-100 arginine (l-arginine) oral COMPLEX ORAL powder in packet 500 1 3 TABLET EXTENDED mg RELEASE 100 MG arginine (l-arginine) oral 1 tablet You can find information on what the symbols and abbreviations on this table mean on page 4. 145 Drug Name Drug Tier Limits Drug Name Drug Tier Limits BALANCED B-100 FOLBEE AR 4 ORAL TABLET 0.4 1 FOLBEE PLUS 3 MG FULL SPECTRUM B- 1 BALANCED B-100 VITAMIN C ORAL TABLET 3 EXTENDED GENICIN VITA-S 1 RELEASE HYLAVITE 3 B-COMPLEX PLUS KOBEE 1 3 VIT C (CALCIUM) LORID 1 b-complex with vitamin MEDTYCHOLL-B 3 3 c oral tablet COMPLEX-LIVER B-COMPLEX WITH MYNEPHROCAPS 1 VITAMIN C ORAL 3 NATURAL B-100 TABLET 400-500 3 MCG-MG COMPLEX b-complex with vitamin NEPHRONEX 3 c oral tablet extended 1 NEPHRONEX-SL 1 release NEPHRO-VITE 1 B-STRESS 3 NUTRIVIT 3 COMPLEX B-100 PRORENAL 3 ORAL TABLET 3 EXTENDED QUIN B STRONG 3 RELEASE 400 MCG RENAL CAPS 1 COMPLEX B-50 3 RENAL VITAMIN 3 DEXIFOL 1 RENAPLEX 3 DIALYVITE 3000 3 RENAPLEX-D 3 DIALYVITE 800 RENA-VITE 1 1 ORAL TABLET RENO CAPS 1 DIALYVITE 800 STRESS B PLUS ZINC 3 ORAL 3 STRESS B WITH TABLET,CHEWABLE 3 ZINC DIALYVITE 800 3 WITH ZINC 15 STRESS FORMULA 3 DIALYVITE 800 STRESS FORMULA 3 1 WITH ZINC 50 600 C DIALYVITE 800- STRESS FORMULA 3 3 ULTRA D WITH IRON DIALYVITE ORAL STRESS FORMULA 3 3 TABLET 100-1 MG WITH IRON(SULF) DIALYVITE STRESS FORMULA 3 3 SUPREME D WITH ZINC FATIGUE RELIEF SUPER B COMPLEX- 3 1 COMPLEX VITAMIN C SUPER B/C 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 146 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SUPER QUINTS 1 SUPER QUINTS B-50 1 SUPERVITE 3 VITAMINS B SUPPORT-500 3 COMPLEX ORAL 1 CAPSULE TRIPHROCAPS 1 VITAMINS B TRONVITE 1 COMPLEX ORAL 1 VIRT-CAPS 3 TABLET VIRT-VITE PLUS 3 BIOFLAVONOID VITAMINS B COMBINATIONS COMPLEX ORAL 3 EAR CARE 1 TABLET 500 MG-400 EAR HEALTH MCG- 18 MG IRON 1 FORMULA VITAMINS FOR HAIR 1 ORAL TABLET PERIDIN-C 1 VITASURE 1 TROMBONEX 1 XVITE 1 VASOFLEX FORTE 1 B-COMPLEX DEXTROSE AND VITAMINS AND LACTATED COMBINATIONS RINGER'S SOLUTIONS APETIGEN PLUS 3 dextrose 5 %-lactated ORAL LIQUID 4 ringers DIALYVITE ORAL TABLET 1-100-300-50 3 DEXTROSE AND MG-MG-MCG-MG SODIUM NEPHPLEX RX 3 CHLORIDE NEPHRO-VITE RX 3 SOLUTIONS d10 %-0.45 % sodium RENA-VITE RX 3 4 chloride VP-VITE RX 3 d2.5 %-0.45 % sodium 4 B-COMPLEX chloride VITAMINS d5 % and 0.9 % sodium B COMPLEX 100 4 4 chloride INJECTION d5 %-0.45 % sodium B COMPLEX 4 3 chloride SUBLINGUAL dextrose 10 % and 0.2 BALANCED B-50 4 1 % nacl ORAL TABLET dextrose 5%-0.2 % sod 4 COMPLEX B-100 chloride ORAL TABLET 1 dextrose 5%-0.3 % EXTENDED 4 sod.chloride RELEASE PODIAPN 3 STRESS FORMULA 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 147 Drug Name Drug Tier Limits Drug Name Drug Tier Limits coenzyme q10 (bulk) DEXTROSE 3 SOLUTIONS, powder CRANBERRY- CONCENTRATED 1 PROBIOTIC dextrose 20 % in water 4 (d20w) CYTOTINE 1 dextrose 25 % in water ENSURE CLEAR 4 3 (d25w) ORAL LIQUID dextrose 30 % in water ENSURE ORIGINAL 4 3 (d30w) ORAL POWDER dextrose 40 % in water HYPROST 1 4 (d40w) NURETIN 3 dextrose 50 % in water NUTRA PRO HIGH 4 1 (d50w) PROTEIN dextrose 70 % in water 4 NUTRISURE PLUS 3 (d70w) PEDIASURE 3 DEXTROSE HARVEST SOLUTIONS PEDIASURE dextrose 10 % in water SIDEKICKS ORAL 4 3 (d10w) LIQUID 0.04-0.8 GRAM-KCAL/ML dextrose 20 % in water 4 (d20w) PHLEXY-VITS 1 dextrose 25 % in water SIMILAC 4 3 (d25w) LAMEHADRIN dextrose 30 % in water TALIVA 3 4 (d30w) TART CHERRY 1 dextrose 40 % in water TURKEY-SWEET 4 3 (d40w) POTATOES-PEACHES dextrose 5 % in water 4 DIETARY (d5w) PRODUCT - dextrose 50 % in water 4 INFANT (d50w) FORMULAS dextrose 70 % in water 4 ADVANTAGE WITH (d70w) 1 IRON DIETARY CALCILO XD 1 PRODUCT - ENFAGROW DIETARY TODDLR 1 SUPPLEMENTS TRANSITION SOY 5-hydroxy-l-tryptophan 3 ENFAMIL (bulk) GENTLEASE ORAL 1 BRIGHT LIQUID 1 BEGINNINGS SOY

You can find information on what the symbols and abbreviations on this table mean on page 4. 148 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ENFAMIL PREMIUM INFANT 1 GENTLEASE ORAL 1 FORMULA POWDER RCF SOY PROTEIN 1 ENFAMIL INFANT FORMULA BASE 1 ORAL POWDER SIMILAC ADVANCE 3 ENFAMIL NEURO LAMEHADRIN ENFACARE NON- 3 SIMILAC ADVANCE GMO ORAL 1 ENFAMIL NEURO CONCENTRATE GENTLEASE 3 SIMILAC ADVANCE 1 NONGMO ORAL LIQUID ENFAMIL SIMILAC ADVANCE NEUROPRO NON- 1 ORAL POWDER IN 1 GMO ORAL LIQUID PACKET ENFAMIL NEWBORN SIMILAC ADVANCE 1 1 ORAL POWDER WITH IRON ENFAMIL PROSOBEE SIMILAC EXPERT 1 1 LIPIL CARE NEOSURE ENFAMIL PROSOBEE SIMILAC EXPERT 3 1 ORAL POWDER CARE ORAL LIQUID GERBER GOOD SIMILAC FOR SPIT- 1 START GENTLE 1 UP ORAL POWDER ORAL LIQUID SIMILAC HUMAN GERBER GOOD MILK FORTIFIER 1 START SOY ORAL 1 ORAL POWDER IN LIQUID PACKET GERBER GOOD SIMILAC LOW-IRON 1 START SOY ORAL 1 POWDER SIMILAC NEOSURE 1 infant formula with iron SIMILAC PM 1 1 oral powder SIMILAC PRO-TOTAL 3 ISOMIL ADVANCE 1 CMFT NON-GMO SIMILAC SENSITIVE ISOMIL DF 1 1 ISOMIL SOY ISOMIL/IRON 1 SIMILAC SOY 1 MSUD ANALOG 1 ISOMIL NUTRAMIGEN DHA- SIMILAC SPECIAL 1 1 ARA CARE 24 NUTRAMIGEN SIMILAC TOTAL 3 TODDLER ENFLORA- 1 COMFORT NON-GMO LGG SIMILAC TOTAL PREGESTIMIL ORAL 3 COMFORT ORAL 1 POWDER POWDER XLEU ANALOG 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 149 Drug Name Drug Tier Limits Drug Name Drug Tier Limits XLYS- XTRP DILUENT FOR 1 4 ANALOG RABAVERT XMET ANALOG 3 ELECTROLYTE XMTVI ANALOG 1 DEPLETERS - XPHE, XTYR ION EXCHANGE 1 ANALOG RESIN XPTM ANALOG 1 LOKELMA 3 sodium polystyrene DIETARY 1 PRODUCT - sulfonate oral powder SPS (WITH SWEETENERS 1 SORBITOL) saccharin 3 VELTASSA 1 sodium saccharin (bulk) 1 oral granules GERIATRIC sodium saccharin (bulk) VITAMINS 3 oral powder DAILY STEVIA 3 MULTIVITAMIN- 3 MINERALS sucrose (bulk) 3 ELDERTONIC 1 DILUENTS - GERITOL TONIC SODIUM 1 WITH FERREX 18 CHLORIDE IRRIGATION sodium chlor 0.9% 4 bacteriostat SOLUTIONS sodium chloride 0.9 % AQUA CARE 4 3 (flush) SODIUM CHLORIDE sodium chloride 0.9 % AQUA CARE 1 3 injection STERILE WATER lactated ringers SWABFLUSH 4 1 irrigation DILUENTS - PHYSIOLYTE 1 STERILE WATER PHYSIOSOL FOR INJECTION 3 IRRIGATION water for inject, 1 ringer's irrigation 3 bacteriostat sodium chloride water for injection, 1 1 irrigation sterile injection solution TIS-U-SOL water for injection, 1 4 PENTALYTE sterile injection syringe water for irrigation, 1 DILUENTS - sterile VACCINE DILUENTS DILUENT FOR 1 HIBERIX You can find information on what the symbols and abbreviations on this table mean on page 4. 150 Drug Name Drug Tier Limits Drug Name Drug Tier Limits calcium carb-d3-mag MINERALS AND 3 ELECTROLYTES cmb11-zinc calcium carb-mag - BICARBONATE 3 PRODUCING OR oxide-zinc ox calcium carb-mag ox- CONTAINING 3 AGENTS zinc gluc sodium acetate 4 calcium carb-mag ox- zinc sulf oral tablet 333- 3 sodium bicarbonate in 133-5 mg d5w intravenous 4 calcium carbonate-vit solution 150 meq/1,000 1 ml d3-min oral tablet sodium bicarbonate CALCIUM FOR 4 1 intravenous WOMEN CALCIUM THAM 4 3 MAGNESIUM MINERALS AND CALCIUM ELECTROLYTES MAGNESIUM + D 3 - CALCIUM ORAL TABLET 400- REPLACEMENT 167-133 MG-MG-UNIT COMBINATIONS CALCIUM SOFT ADVANCED CHEW ORAL 3 TABLET,CHEWABLE CALCIUM 1 500-100-40 MG-UNIT- BIOCAL 3 MCG, 500-200-40 MG- BONE DENSITY 3 UNIT-MCG CALCIUM + D CALCIUM WITH 3 BONE ESSENTIALS 3 BORON ca-d3-mag ox-zinc-cop- CALCIUM-FOLIC 3 3 mang-bor oral tablet ACID-VITAMIN D ca-d3-mag ox-zinc-cop- calcium-magnesium- mang-bor oral 1 zinc oral tablet 333-133- 1 tablet,chewable 600 mg 5 mg calcium- 400 unit-40 mg calcium-vitamin d3- ca-d3-mag ox-zinc-cop- vitamin k oral mang-bor oral 3 tablet,chewable 500 mg- 3 tablet,chewable 600 mg 1,000 unit-40 mcg, 500- calcium- 800 unit-40 mg 200-40 mg-unit-mcg ca-d3-mag-zinc-cop- 3 calcium-vitamin d3- mang-bor vitamin k oral 1 CAL MAG ZINC PLUS tablet,chewable 500- 3 D3 500-40 mg-unit-mcg CALCI-MAX 3 CAL-MAG 3 CALCIUM 600 + CALMAG THINS 3 1 MINERALS

You can find information on what the symbols and abbreviations on this table mean on page 4. 151 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CALTRATE + D3 CALCIUM 600 + D(3) 3 1 PLUS MINERALS ORAL CAPSULE CALTRATE 600-D CALCIUM 600 + D(3) PLUS MINERALS ORAL TABLET 600 3 1 ORAL MG(1,500MG) -400 TABLET,CHEWABLE UNIT CITRACAL PLUS CALCIUM 600 WITH 3 BONE DENSITY VITAMIN D3 ORAL 1 CITRACAL-D3 PLUS TABLET,CHEWABLE 3 HEART HEALTH calcium carb and citrate- 3 CITRACAL-D3 PLUS vitd3 3 MAGNESIUM calcium carbonate- vitamin d3 oral capsule CORAL CALCIUM 1 ORAL CAPSULE 133 600 mg(1,500mg) -400 MG CALCIUM -133 unit UNIT-67 MG, 185-50- calcium carbonate- 3 100 MG-MG-UNIT, vitamin d3 oral capsule 250-125-100 MG-MG- 600 mg(1,500mg) -500 3 UNIT, 250-200-125 unit, 600mg (1,500mg) - MG-UNIT-MG 1,000 unit FEM-CAL CITRATE 3 calcium carbonate- LOCALNESIUM 3 vitamin d3 oral tablet 1,000 mg(2,500 mg)- LOCALNESIUM-C 3 800 unit, 500 ORTHO-TABS 3 mg(1,250mg) -200 unit, PRO-CAL ORAL 500 mg(1,250mg) -400 3 3 TABLET unit, 600 mg(1,500mg) - 200 unit, 600 SOY FORMULA 3 mg(1,500mg) -400 unit, VIACTIV ORAL 600 mg(1,500mg) -800 TABLET,CHEWABLE unit 3 650 MG-12.5 MCG-40 calcium carbonate- MCG vitamin d3 oral 3 MINERALS AND tablet,chewable ELECTROLYTES CALCIUM CITRATE + 3 - CALCIUM D REPLACEMENT/ calcium citrate malate- 3 VITAMIN D vit d3 COMBINATIONS calcium citrate-vitamin 3 CALCET PETITES 3 d2 calcium citrate-vitamin CAL-CITRATE 3 3 d3 oral liquid CALCIUM 500 + D 1 ORAL TABLET CALCIUM 500 WITH 3 D You can find information on what the symbols and abbreviations on this table mean on page 4. 152 Drug Name Drug Tier Limits Drug Name Drug Tier Limits calcium citrate-vitamin OS-CAL 500 + D3 d3 oral tablet 200 mg ORAL TABLET 3 calcium -250 unit, 250 3 500MG (1,250MG) - mg calcium- 200 unit, 600 UNIT 315 mg- 250 unit OYSCO 500/D ORAL 1 calcium citrate-vitamin TABLET d3 oral tablet 200-125 1 OYSTER SHELL mg-unit CALCIUM-VIT D3 3 calcium phosphate- ORAL POWDER IN vitamin d3 oral PACKET tablet,chewable 200 mg PARVA-CAL 250 3 calcium- 200 unit, 250 3 mg calcium -200 unit, PARVA-CAL 500 3 250 mg calcium- 500 PROSTEON 3 unit RISACAL-D 3 CALCIUM WITH 1 THERACAL D2000 3 VITAMIN D THERACAL D4000 3 CAL-QUICK 2 PA UPCAL D 3 CALTRATE 600 PLUS 3 D MINERALS AND CALTRATE GUMMY ELECTROLYTES 3 BITES - CALCIUM CALTRATE WITH REPLACEMENT 3 VITAMIN D3 CALCIUM 500 ORAL 1 CITRACAL + D TABLET 3 MAXIMUM calcium acetate oral CITRACAL tablet 668 mg (169 mg 3 3 REGULAR calcium) CITRACAL-D3 calcium GUMMIES ORAL acetate(phosphat bind) 1 TABLET,CHEWABLE 3 oral tablet 250 MG CALCIUM- calcium amino acid 3 500 UNIT chelate CITRACAL-D3 calcium carbonate oral 3 PETITES tablet 500 mg calcium CITRACAL-D3 SLOW (1,250 mg), 600 mg 3 3 RELEASE calcium (1,500 mg), 650 mg calcium (1,625 mg) HI-CAL PLUS VIT D 1 calcium carbonate oral LIQUID CALCIUM 1 tablet,chewable 500 mg 3 WITH VITAMIN D calcium (1,250 mg) OS-CAL 500 + D3 calcium chloride 4 ORAL TABLET 500 1 calcium citrate oral MG(1,250MG) -200 1 UNIT tablet 250 mg calcium

You can find information on what the symbols and abbreviations on this table mean on page 4. 153 Drug Name Drug Tier Limits Drug Name Drug Tier Limits calcium gluc in nacl, STRONG IODINE 1 iso-osm intravenous 4 ORAL solution 1 gram/50 ml MINERALS AND calcium gluconate in ELECTROLYTES 0.9% nacl intravenous 4 - IRON solution 1 gram/100 ml COMBINATIONS calcium gluconate in 3 water ABATRON 3 calcium gluconate ACTIVE FE 3 4 intravenous APETIGEN PLUS 3 calcium phos, tribasic ORAL TABLET 3 (bulk) CENTRATEX 3 CALPHRON 1 CHEWABLE IRON 3 OYSTER SHELL CHROMAGEN(SUMA 1 1 CALCIUM LATE-QUATREFOLI) OYSTER SHELL CORVITA 150 1 1 CALCIUM 500 CORVITE 150 ORAL MINERALS AND TABLET 150 MG 3 ELECTROLYTES IRON- 1 MG - CORVITE FE ORAL ELECTROLYTES TABLET 150 MG 3 AND DEXTROSE IRON- 1 MG DUOFER 3 dextrose 5 % in ringer's 4 FE C 1 electrolyte-48 in d5w 4 FEOSOL BIFERA 3 IONOSOL-B IN D5W 4 FEROCON 1 IONOSOL-MB IN 4 D5W FERRACTIV 3 ISOLYTE-P IN 5 % FERREX 150 FORTE 3 4 DEXTROSE FERREX 150 FORTE 3 NORMOSOL-M IN 5 PLUS 4 % DEXTROSE FERREX 150 PLUS 3 NORMOSOL-R IN 5 % 4 FERREX 28 3 DEXTROSE FERROCITE PLUS 3 MINERALS AND FERRO-SEQUELS 3 ELECTROLYTES (IRON-VIT C) - IODINE FOLITAB 3 IODOPEN 4 FOLIVANE-F 3 LUGOLS ORAL 1 FOLIVANE-PLUS 3 potassium iodide (bulk) 1 FUSION 3 crystals FUSION PLUS 3 SSKI 1 FUSION SPRINKLES 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 154 Drug Name Drug Tier Limits Drug Name Drug Tier Limits HEMATINIC PLUS SIDEROL ORAL 1 3 VIT/MINERALS TABLET HEMATINIC/FOLIC STRESS FORMULA 3 3 ACID TARON FORTE 3 HEMATOGEN 1 TRICON 1 HEMATOGEN FA 3 TRIGELS-F FORTE 1 HEMATOGEN FORTE 1 VITAFOL 1 HEMAX 1 VITRON-C 3 HEMETAB 3 MINERALS AND HEMOCYTE-F 3 ELECTROLYTES HEMOCYTE-PLUS 3 - IRON I.L.X. B-12 3 AURYXIA 3 ICAR-C 3 CHILDREN'S IRON 1 IFEREX 150 FORTE 1 EZFE 200 1 INTEGRA 3 FE C PLUS 1 INTEGRA F 3 FEOSOL ORAL INTEGRA PLUS 3 TABLET 325 MG (65 1 MG IRON) iron,carbonyl-vitamin c 1 FEOSOL ORAL IRO-PLEX (IRON 3 3 TABLET 45 MG CARBONYL) FERAHEME 4 IRO-PLEX (IRON 3 POLYSACCHARIDE) FERGON ORAL TABLET 240 MG (27 3 IROSPAN 24/6 3 MG IRON) LYDIA PINKHAM FER-IN-SOL 3 HERBAL ORAL 3 FEROSUL ORAL TABLET 1 TABLET MULTIGEN FOLIC 3 FERRETTS IPS 3 MULTIGEN PLUS 3 FERRIMIN 150 3 MYFERON 150 1 FORTE FERRLECIT 4 NUFERA 3 FERRO-TIME 1 OB COMPLETE ORAL ferrous fumarate 3 3 TABLET ferrous fumarate (bulk) 3 OB COMPLETE 3 ferrous gluconate (bulk) 3 PREMIER ferrous gluconate oral PARVLEX 3 tablet 236 mg (27 mg POLY-IRON 150 iron), 240 mg (27 mg 1 3 FORTE iron), 256 mg (28 mg iron), 324 mg (38 mg PROFERRIN-FORTE 3 iron)

You can find information on what the symbols and abbreviations on this table mean on page 4. 155 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ferrous gluconate oral SLOW RELEASE tablet 324 mg (37.5 mg 1 IRON ORAL TABLET iron) EXTENDED ferrous sulfate oral RELEASE 142 MG (45 3 1 drops MG IRON), 159 MG (45 MG IRON), 168 ferrous sulfate oral 1 MG (50 MG IRON) liquid sodium ferric gluconat- ferrous sulfate oral 4 1 sucrose solution TANDEM DUAL 3 ferrous sulfate oral ACTION tablet,delayed release 1 (dr/ec) 324 mg (65 mg VENOFER INTRAVENOUS iron) 2 PA SOLUTION 100 MG HEMOCYTE 3 IRON/5 ML HIGH POTENCY VENOFER IRON ORAL TABLET 3 INTRAVENOUS 27 MG IRON SOLUTION 200 MG 4 ICAR ORAL IRON/10 ML, 50 MG 3 SUSPENSION IRON/2.5 ML ICAR-C PLUS 3 WEE CARE 1 INFED 2 PA MINERALS AND INJECTAFER 2 PA ELECTROLYTES IRON (DRIED) 3 - MAGNESIUM IRON 100 PLUS 1 COMBINATIONS IRON CHEWS 3 BEELITH 1 iron oral tablet 18 mg 3 MINERALS AND IRON ORAL TABLET ELECTROLYTES 1 325 MG (65 MG IRON) - MAGNESIUM IRONUP 3 magnesium amino acid chelate oral tablet 100 1 NOVAFERRUM 125 3 mg NOVAFERRUM 50 3 magnesium chloride NOVAFERRUM 4 3 injection ORAL DROPS magnesium gluconate 3 NU-IRON 3 (bulk) PEDIA IRON 3 magnesium glycinate 3 PERFECT IRON 3 (bulk) powder 10 % POLY-IRON 3 magnesium l-lactate 3 magnesium oral tablet PRO FE 3 1 PROFERRIN ES 3 250 mg magnesium oxide oral 3 powder in packet

You can find information on what the symbols and abbreviations on this table mean on page 4. 156 Drug Name Drug Tier Limits Drug Name Drug Tier Limits magnesium oxide oral MINERALS AND tablet 250 mg 1 ELECTROLYTES magnesium - MULTIPLE magnesium oxide oral MINERAL tablet 400 mg 3 COMBINATIONS magnesium FLORICAL 1 magnesium oxide oral 3 magnesium, potassium tablet,chewable 3 aspartate magnesium sulfate in 0.9 %nacl intravenous MEDI-LYTE 3 4 piggyback 3 gram/150 MONOCAL 1 ml MINERALS AND magnesium sulfate in ELECTROLYTES d5w intravenous piggyback 1 gram/100 - MULTIPLE ml, 1 gram/50 ml, 2 MINERALS 4 gram/100 ml, 2 gram/50 calcium-magnesium- 3 ml, 3 gram/50 ml, 4 copper-zinc gram/50 ml, 6 gram/100 ml, 6 gram/50 ml MINERALS AND ELECTROLYTES magnesium sulfate in d5w intravenous 4 - ORAL solution 50 gram/500 ml ELECTROLYTES CERALYTE 50 magnesium sulfate in lr 3 intravenous solution 10 POTASSIUM FREE gram/250 ml, 20 CERALYTE 90 1 gram/500 ml, 25 4 CERALYTE-70 ORAL gram/250 ml, 40 1 PACKET gram/1,000 ml, 40 gram/500 ml, 50 CERALYTE-70 ORAL POWDER IN PACKET gram/500 ml 1 2.3-1.5-2.9-160 G-G-G- magnesium sulfate in 4 KCAL/50 G water CERASPORT ORAL magnesium sulfate 4 LIQUID 115 MG-40 3 injection MG- 40 KCAL/250 ML PHILLIPS 1 CERASPORT ORAL 3 MINERALS AND POWDER ELECTROLYTES electrolytes-dextrose 1 - MANGANESE ENFAMIL ENFALYTE 1 manganese chloride 4 ORALYTE 1 manganese sulfate 4 PEDIALYTE 1 ADVANCED CARE PEDIALYTE 1 FREEZER POPS

You can find information on what the symbols and abbreviations on this table mean on page 4. 157 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PEDIALYTE ORAL potassium phosphate m- 1 SOLUTION /d-basic intravenous 4 PEDIALYTE SINGLES 1 solution 3 mmol/ml potassium, sodium PEDIATRIC 3 ELECTROLYTE 1 phosphates ORAL SOLUTION sodium phosphate 4 PEDIATRIC FREEZER sodium phosphate in 0.9 1 POPS % nacl intravenous MINERALS AND solution 15 mmol/100 4 ml, 15 mmol/250 ml, 30 ELECTROLYTES mmol/250 ml - PARENTERAL sodium phosphate in 4 ELECTROLYTE d5w COMBINATIONS VIRT-PHOS 250 1 HYPERLYTE CR 4 NEUTRAL ISOLYTE S PH 7.4 4 MINERALS AND ISOLYTE-S 4 ELECTROLYTES NORMOSOL-R 4 - POTASSIUM NORMOSOL-R PH 7.4 4 FOR INJECTION NUTRILYTE 4 potassium acetate intravenous solution 2 2 PA PLASMA-LYTE 148 4 meq/ml PLASMA-LYTE A 4 potassium chlorid-d5- 4 TPN ELECTROLYTES 4 0.45%nacl TPN ELECTROLYTES 4 potassium chloride in II 0.9%nacl intravenous MINERALS AND parenteral solution 20 4 ELECTROLYTES meq/250 ml (80 meq/l), 20 meq/l, 40 meq/l - PHOSPHATE potassium chloride in GLYCOPHOS 4 0.9%nacl intravenous 4 K-PHOS-NEUTRAL 3 piggyback PHOS-NAK 1 potassium chloride in PHOSPHA 250 0.9%nacl intravenous 4 1 NEUTRAL syringe PHOSPHOROUS 1 potassium chloride in 5 % dex intravenous PHOSPHO-TRIN 250 1 parenteral solution 20 4 NEUTRAL meq/l, 30 meq/l, 40 potassium phos in 0.9 % meq/l nacl intravenous potassium chloride in lr- 4 4 solution 15 mmol/250 d5 ml, 30 mmol/500 ml potassium phosph, 1 mono (bulk) You can find information on what the symbols and abbreviations on this table mean on page 4. 158 Drug Name Drug Tier Limits Drug Name Drug Tier Limits potassium chloride in potassium chloride oral water intravenous capsule, extended 1 2 PA piggyback 10 meq/100 release ml, 20 meq/100 ml potassium chloride oral 1 potassium chloride in liquid water intravenous potassium chloride oral piggyback 10 meq/50 3 4 packet ml, 20 meq/50 ml, 30 meq/100 ml, 40 potassium chloride oral meq/100 ml tablet extended release 1 10 meq, 8 meq potassium chloride 2 PA intravenous potassium chloride oral tablet extended release 3 potassium chloride-0.45 4 20 meq % nacl potassium chloride oral potassium chloride-d5- 4 tablet,er 1 0.2%nacl particles/crystals potassium chloride-d5- potassium gluconate 0.3%nacl intravenous oral tablet 2.5 meq, 500 4 1 parenteral solution 20 mg (83 mg), 550 mg (90 meq/l mg) potassium chloride-d5- 4 potassium gluconate 0.9%nacl oral tablet 595 mg (99 3 MINERALS AND mg) ELECTROLYTES MINERALS AND - POTASSIUM, ELECTROLYTES ORAL - POTASSIUM EFFER-K ORAL potassium chloride TABLET, 3 1 (bulk) powder EFFERVESCENT 10 MEQ, 25 MEQ MINERALS AND ELECTROLYTES EFFER-K ORAL TABLET, - TRACE 3 EFFERVESCENT 20 MINERAL MEQ COMBINATIONS KLOR-CON 1 ADDAMEL N 4 KLOR-CON 10 1 MULTITRACE-4 4 KLOR-CON 8 1 MULTITRACE-4 4 KLOR-CON M10 1 CONCENTRATE MULTITRACE-4 KLOR-CON M15 1 4 NEONATAL KLOR-CON M20 1 MULTITRACE-4 4 KLOR-CON/EF 1 PEDIATRIC K-TAB 3 MULTITRACE-5 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 159 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MULTITRACE-5 AIRSHIELD ORAL 4 CONCENTRATE TABLET, PEDITRACE 4 EFFERVESCENT 3 5,000-1000-30 UNIT- TRACE ELEMENTS 4 MG-UNIT 4/PEDIATRIC ALIVE ONCE DAILY 3 MINERALS AND WOMEN 50 PLUS ELECTROLYTES ALIVE WOMEN'S 3 - TRACE ENERGY MINERALS AQUADEKS ORAL 1 chromium chloride 4 TABLET,CHEWABLE chromium picolinate BACMIN 3 1 oral tablet 200 mcg BEROCCA (FA- 3 COPPER CHLORIDE 4 GUARANA-CAFF) selenium intravenous 4 BIO-35, GLUTEN 3 selenium oral tablet 1 FREE MINERALS AND BIOTECT PLUS 3 ELECTROLYTES BIOTIN PLUS- - ZINC CALCIUM AND VIT 3 D3 ORAZINC ORAL 1 BIOVOL 1 TABLET BLADDER 2.2 3 zinc chloride 4 BODY, HAIR, SKIN zinc gluconate oral 3 1 AND NAILS tablet 100 mg, 30 mg CALCIUM CITRATE zinc sulfate intravenous 1 4 PLUS (VIT B6) solution 5 mg/ml CENTRAL-VITE ZINC-15 1 3 WOMEN'S MATURE MULTIVITAMIN CENTRAVITES 3 AND MINERAL CENTRUM 3 COMBINATIONS CHEWABLES A THRU Z SELECT CENTRUM MEN 3 ORAL TABLET 300- 3 600-300 MCG CENTRUM ORAL LIQUID 9 MG 3 ACTICAL 3 IRON/15 ML ADULT CENTRUM SILVER 3 MULTIVITAMIN 3 ORAL TABLET GUMMIES CENTRUM SILVER ADULT ONE DAILY 3 3 ULTRA MEN'S GUMMIES CENTRUM SILVER 3 WOMEN CENTRUM 3 SPECIALIST ENERGY You can find information on what the symbols and abbreviations on this table mean on page 4. 160 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CENTRUM ULTRA DIABETES HEALTH 3 3 MEN'S FORMULA CENTURY DIALYVITE 5000 3 ULTIMATE MEN'S ELON MATRIX 5000 3 3 ORAL TABLET 300- COMPLETE 600-300 MCG ESSENTIAL CENTURY BALANCE WITH 3 ULTIMATE MEN'S LUTEIN ORAL TABLET 8 MG 4 IRON- 200 MCG-600 ESSENTIAL MAN 3 MCG ESSENTIAL WOMAN 3 CERTA PLUS 3 50+ COMPLETE MULTI 3 FOLIVANE-OB 3 COMPLETE FOSFREE 3 MULTIVITAMIN 3 FREEDAVITE 3 ORAL TABLET GERITOL COMPLETE 1 COMPLETE HAIR FORMULA 3 MULTIVITAMIN- 3 HAIR, SKIN AND MINERAL ORAL 3 LIQUID NAILS-ARGAN OIL COMPLETE MV HAIR,SKIN AND 3 NAILS ORAL ADULT 50 PLUS 3 TABLET 1 MG IRON- COMPLETE 3 66.7 MCG-1,000 MCG PREMIUM VITAMIN HAIR,SKIN AND 3 CONCEPT DHA 3 NAILS(FA-BIOTIN) CONCEPT OB 3 HAIR-SKIN-NAILS 3 CORVITA 3 (PABA) CORVITE 3 HEARTBURN AND 3 CORVITE FREE 3 ACID REFLUX-ALOE DAILY GUMMIES 3 ICAPS 3 DAILY MULTIPLE ICAPS MV 3 ORAL TABLET 400- 3 K-PAX IMMUNE 3 120 MCG-MG SUPPORT DAILY K-PAX ORAL 3 3 MULTIVITAMIN POWDER DAILY LIPOTRIAD (WITH 1 MULTIVITAMIN- 3 LUTEIN) MINERALS MAXIMIN PACK 3 DEKAS BARIATRIC 3 MEGA DEKAS PLUS (FOLIC MULTIPLE/CHELATE 1 ACID) ORAL 3 D MINERAL CAPSULE DIABETES HEALTH 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 161 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MEGA OB COMPLETE ORAL 3 MULTIVITAMIN FOR 3 TABLET MEN O-CAL F.A. 1 MEGA OCUTABS 3 MULTIVITAMIN WITH MINERAL OCUVITE EYE PLUS 3 3 ORAL TABLET 13.5- MULTI 200-250 MG-MCG- ONE DAILY FOR 3 MCG MEN MEN'S 50 PLUS ONE DAILY FOR 3 3 MULTIVITAMIN WOMEN MEN'S DAILY 3 ONE DAILY 3 MEN'S DAILY HEALTHY WEIGHT 3 GUMMIES ONE DAILY MEN'S 50 3 MEN'S DAILY PLUS W-D3 3 MULTIVIT-MINERAL ONE DAILY MULTI- VIT W-MINERAL MEN'S 3 MULTIVITAMIN 3 ORAL POWDER IN GUMMIES PACKET MEN'S ONE DAILY ONE DAILY ORAL TABLET 400- 3 MULTIVITAMIN- 3 20-300 MCG IRON ONE DAILY MEN'S PACK 3 3 WOMENS 50 PLUS MONOCAPS 3 ONE-A-DAY MULTI FOR HER 3 3 CHOLESTEROL PLUS ORAL TABLET ONE-A-DAY MEN 3 MULTI VITAMIN 3 VITACRAVES MULTI-DAY PLUS 3 ONE-A-DAY MINERALS MENOPAUSE 3 MULTI-DELYN WITH FORMULA 3 IRON ONE-A-DAY MEN'S 3 MULTIPLE VITAMIN, 50 PLUS 3 WOMENS ONE-A-DAY MEN'S 3 MULTI-VITAMIN MULTIVITAMIN 3 HP/MINERALS ONE-A-DAY 3 MULTIVITAMIN VITACRAVES 3 WOMEN 50 PLUS ONE-A-DAY MULTI-VITE 3 VITACRAVES 3 mv-min-folic acid-lutein 3 IMMUNITY NICOMIDE ONE-A-DAY (SELENIUM- 3 VITACRAVES 3 CHROMIUM) OMEGA-3 NIVA-PLUS 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 162 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ONE-A-DAY SUNVITE 3 3 WEIGHTSMART SUPER GINSENG 3 ONE-A-DAY WOMEN MULTIVITAMIN 3 VITACRAVES SUPER MULTIPLE - 3 ONE-A-DAY LOW IRON 3 WOMEN'S ACTIVE SUPER MULTIPLE 3 ONE-A-DAY ORAL CAPSULE WOMENS FORMULA TARON-C DHA 3 ORAL TABLET 18 MG 3 THERAGRAN-M IRON-400 MCG-500 3 MG PREMIER 50 PLUS THERANATAL ORAL ONE-A-DAY 3 WOMEN'S HEALTHY 3 COMBO PACK SKIN THERAPEUTIC-M 3 OPTISOURCE 3 VITAMIN/MINERALS OPURITY TRUEPLUS 3 MULTIVITAMIN DIABETIC 3 MULTIVITAMIN PNV-OMEGA 3 UDAMIN SP 3 POLYVITAMIN WITH 1 ULTIMATE MEN'S IRON (VIT K) 3 COMPLETE 50+ PRENATAL DAILY 3 DUO ULTIMATE WOMEN'S 3 PROCERV HP 3 COMPLETE 50+ PRORENAL QD 3 ULTRA FREEDA 3 PROTECT CARDIO 3 V-C FORTE 3 AF VIC-FORTE 3 PROTECT IRON 3 VIRT-C DHA 3 PROTECT PLUS SO 3 VIRT-PN PLUS 3 PUREFE OB PLUS 3 VITABEX PLUS 3 PUREFE PLUS 3 VITAL-D RX 3 QUINTABS-M 3 VITAMIN D-3 WITH 3 SOLO 3 ALOE SPECTRAVITE VITAMINS A-D-E 3 3 ULTRA MEN 50+ SELENIUM SPECTRAVITE 3 VITRUM SENIOR ULTRA MEN'S SR ORAL TABLET 500- 3 STRESS B-COMPLEX 300-250 MCG ORAL TABLET 500- WOMEN'S 50 PLUS 3 3 400-23.9-3 MG-MCG- MULTIVITAMIN MG-MG WOMEN'S DAILY 3 STROVITE FORTE 3 CAPLET STROVITE ONE 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 163 Drug Name Drug Tier Limits Drug Name Drug Tier Limits WOMENS DAILY FORTAVIT 3 3 GUMMIES HAIR-SKIN-NAILS 3 WOMEN'S DAILY (MV-FA-BIOTIN) 3 PACK INFUVITE ADULT 4 WOMEN'S M.V.I. ADULT 4 MULTIVITAMIN 3 M.V.I.-12 (WITHOUT GUMMIES 4 VITAMIN K) WOMEN'S MULTIVITAMIN METAFOLBIC 1 ORAL TABLET 18 3 multivitamin oral 1 MG-400 MCG- 500 capsule MG-50 MCG NEEVODHA (WITH 3 ZATEAN-PN PLUS 3 ALGAL OIL) NORWEGIAN COD MULTIVITAMINS 1 LIVER OIL A THRU Z ADVANCED 3 OMNIVEX 3 FORMULA ONCOVITE 3 ANIMI-3 WITH 3 ONE DAILY VITAMIN D ESSENTIAL ORAL 3 CALCIUM PNV 3 TABLET 400 MCG CENTRUM ONE DAILY MEN'S 50 3 3 COMPLETE PLUS MEMORY CEREFOLIN 3 ONE DAILY MULTIVITAMIN cod liver oil oral capsule 1 3 ORAL POWDER IN cod liver oil oral oil 3 PACKET CRANBERRY 1 ONE DAILY URINARY COMFORT MULTIVITAMIN 3 DAILY MULTIPLE ORAL TABLET 400 3 FOR WOMEN MCG ONE DAILY DAILY 3 MULTIVITAMIN 3 WOMEN'S HEALTH WITH IRON ONE DAILY DAILY VALUE 1 WOMEN'S ORAL TABLET 18 MG 1 DECUBI VITE 3 IRON-400 MCG-450 DEKAS ESSENTIAL 3 MG CA ORAL CAPSULE ONE-A-DAY ENERGY 3 DIALYVITE 800 3 ONE-A-DAY WITH IRON WOMENS FORMULA ENBRACE HR 3 ORAL TABLET 18 MG 3 ESSENTIAL IRON-400 MCG-500 BALANCE WITH 3 MG CA LUTEIN

You can find information on what the symbols and abbreviations on this table mean on page 4. 164 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ONE-A-DAY 3 NUTRITIONAL WOMEN'S PETITES PRODUCT - PNV-DHA 1 GLUTARIC PRENATAL-U 3 ACIDURIA TYPE PRENATE AM 3 1 SPECIFIC PRENATE FORMULATION 3 CHEWABLE GLUTARADE JUNIOR 1 PRENATE XLYS- XTRP 1 ESSENTIAL(IRON- 3 ANALOG ASP-GL) NUTRITIONAL PUREVIT DUALFE 1 PRODUCT - PLUS ISOVALERIC QUINTABS 3 ACIDEMIA SE-TAN PLUS 1 SPECIFIC TANDEM PLUS 3 FORMULATION TOBAKIENT 3 XLEU ANALOG 1 VINATE CARE 3 NUTRITIONAL VINATE DHA RF 3 PRODUCT - VIRT-PN DHA 3 KETOGENIC VIT 3 3 FORMULATION vitamins a and d 3 KETOCAL 2.5:1 3 VITAMINS FOR HAIR KETOQ10 5.5:1 3 1 ORAL TABLET MICROLIPID 1 WOMEN'S DAILY NUTRITIONAL FORMULA ORAL PRODUCT - TABLET 18 MG 3 LIPID OTHERS IRON-400 MCG-500 MCT OIL ORAL OIL MG CA 1 7.7 KCAL/ML WOMEN'S ONE 1 DAILY MICROLIPID 1 XYZBAC 3 NUTRITIONAL ZATEAN-PN DHA 3 PRODUCT - NUTRITIONAL MEDICAL PRODUCT - CONDITION CARBOHYDRAT SPECIFIC ES, ORAL FORMULATION CHOLEXTRA T-F 3 ENFAMIL GLUCOSE 1 ENDARI 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 165 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NUTRITIONAL PERIFLEX LQ PKU 1 PRODUCT - PHENYLADE 40 1 METHIONINE- PHENYLADE GMP FREE SPECIFIC MIX-IN ORAL 3 FORMULATION POWDER PHENYLADE GMP XMET ANALOG 3 3 READY NUTRITIONAL PRODUCT - PHENYLADE MTE AMINO ACIDS ORAL 1 MSUD SPECIFIC POWDER FORMULATION PHENYL-FREE 1 1 COMPLEX 1 XPHE MAXAMUM ESSENTIAL ORAL POWDER IN 1 COMPLEX MSUD 1 PACKET AMINO ACID BLEND NUTRITIONAL ISOLEUCINE AMINO 1 PRODUCT - ACID SUPPLMNT PROPIONIC MSUD ANALOG 1 ACIDEMIA NUTRITIONAL SPECIFIC PRODUCT - FORMULATION NUTRITIONAL XMTVI ANALOG 1 THERAPY NUTRITIONAL PRONOURISH 3 PRODUCT - PURAMINO JR 3 PROTEIN NUTRITIONAL REPLACEMENTS PRODUCT - citrulline (bulk) 3 PARENTERAL G-PREPROTEIN 1 AND OTHER L-ALANINE 3 AMINO ACIDS L-GLUTAMINE 3 AMINOPROTECT 4 L-ISOLEUCINE 3 arginine-lysine in 0.9 % 4 PRE-PROTEIN nacl 1 (WHEY) NUTRITIONAL PRE-PROTEIN ORAL 1 PRODUCT - LIQUID PHENYLKETON PROCEL 1 URIA (PKU) SPECIFIC PROCEL 100 1 FORMULATION PROCEL SINGLES 1 GLYTACTIN PROMOD PROTEIN 1 15PECOMPLETE- 3 PROSOURCE NO 1 TAURINE CARB PERIFLEX INFANT 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 166 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PROSOURCE ORAL CLINIMIX 4.25%/D5W 1 4 POWDER SULFIT FREE PRO-STAT RENAL CLINIMIX 4.25%- 1 4 CARE D25W SULF-FREE PRO-STAT SUGAR CLINIMIX 5%- 1 FREE D20W(SULFITE- 4 PROSYNMINIC 1 FREE) protein oral powder 3 PARENTERAL PROTEINEX ORAL NUTRITION - 1 LIQUID AMINO ACID PROTEINEX-18 1 AND ELECTROLYTES NUTRITIONAL COMBINATION PRODUCT - TYROSINEMIA AMINOSYN 7 % WITH 4 SPECIFIC ELECTROLYTES FORMULATION AMINOSYN 8.5 %- TYR LOPHLEX GMP 4 3 ELECTROLYTES MIX-IN AMINOSYN II 8.5 %- XPHE, XTYR 4 1 ELECTROLYTES ANALOG AMINOSYN M 3.5 % 4 XPTM ANALOG 1 PROCALAMINE 3% 4 NUTRITIONAL PARENTERAL PRODUCT - NUTRITION - UREA CYCLE AMINO ACID DISORDER SOLUTIONS SPECIFIC FORMULATION AMINOSYN 10 % 4 AMINOSYN 3.5 % 4 ESSENTIAL AMINO 1 ACID MIX AMINOSYN 7 % 4 PARENTERAL AMINOSYN 8.5 % 4 NUTRITION - AMINOSYN II 10 % 4 AMINO ACID AMINOSYN II 15 % 4 AND DEXTROSE AMINOSYN II 7 % 4 COMBINATIONS AMINOSYN II 8.5 % 4 CLINIMIX 5%/D15W 4 AMINOSYN M 3.5 % 4 SULFITE FREE AMINOSYN-HBC 7% 4 CLINIMIX 5%/D25W 4 SULFITE-FREE AMINOSYN-PF 10 % 4 AMINOSYN-PF 7 % CLINIMIX 4 4.25%/D10W SULF 4 (SULFITE-FREE) FREE AMINOSYN-RF 5.2 % 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 167 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CLINIMIX E PARENTERAL 2.75%/D5W SULF 4 NUTRITION - FREE INTRAVENOUS CLINIMIX E FAT EMULSIONS 4.25%/D10W SUL 4 FREE INTRALIPID INTRAVENOUS 4 CLINIMIX E EMULSION 20 %, 30 4.25%/D5W SULF 4 % FREE LIPOSYN II 4 CLINIMIX E 5%/D15W SULFIT 4 LIPOSYN III 4 FREE NUTRILIPID 4 CLINIMIX E OMEGAVEN 4 5%/D20W SULFIT 4 PARENTERAL FREE NUTRITION- CLINISOL SF 15 % 4 AMINO ACID, FREAMINE III 10 % 4 DEXTROSE AND HEPATAMINE 8% 4 ELECTROLYTES NEPHRAMINE 5.4 % 4 COMBINATION PLENAMINE 4 CLINIMIX E PREMASOL 10 % 4 2.75%/D5W SULF 4 FREE PROCALAMINE 3% 4 CLINIMIX E PROSOL 20 % 4 4.25%/D10W SUL 4 SYNTHAMIN 17 FREE 4 WITHOUT ELYTE CLINIMIX E TRAVASOL 10 % 4 4.25%/D5W SULF 4 TROPHAMINE 10 % 4 FREE PARENTERAL CLINIMIX E 5%/D15W SULFIT 4 NUTRITION - FREE AMINO ACID, CLINIMIX E DEXTROSE, E- 5%/D20W SULFIT 4 LYTES AND FAT FREE EMUL COMB PEDIATRIC KABIVEN 4 VITAMINS AND PERIKABIVEN 4 MINERAL COMBINATIONS ANIMAL SHAPES 1 COMPLETE AQUADEKS 1 PEDIATRIC

You can find information on what the symbols and abbreviations on this table mean on page 4. 168 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CEROVITE JR ORAL PEDIA POLY-VITE 1 TABLET,CHEWABLE 1 PEDIA POLY-VITE 18 MG IRON- 10 MCG WITH IRON ORAL 1 CHILD CHEWABLE DROPS 1 VITAMN COMPLETE SCOOBY-DOO ONE A 1 CHILD COMPLETE DAY 1 MULTIVITAMIN VITALETS ORAL CHILDREN'S CHEW TABLET,CHEWABLE 3 1 MULTIVIT-IRON 10 MG IRON CHILDREN'S PEDIATRIC CHEWABLE VITAMINS WITH COMPLETE ORAL 3 FLUORIDE AND TABLET,CHEWABLE 9-200 MG IRON-MCG MINERALS COMBINATIONS CHILDREN'S 1 MULTI-VIT WITH MULTIVITAMIN 3 FLUORIDE-IRON CHILD'S CHEWABLE 1 VITAMINS/IRON PEDIATRIC CHILDS/IRON 1 VITAMINS WITH DINO-LIFE WITH FLUORIDE 1 IRON-ZINC COMBINATIONS EMERGEN-C KIDZ 3 FLORIVA 3 FLINTSTONES FLORIVA 1 COMPLETE (IRON) (FLUORIDE- 3 VITAMIN D3) FLINTSTONES MULTI-VIT FLORIVA PLUS 3 GUMMIES ORAL 3 MULTI-VIT WITH 3 TABLET,CHEWABLE FLUORIDE-IRON 100 MCG MULTIVITAMIN FLINTSTONES PLUS 3 3 WITH FLUORIDE CALCIUM MULTI-VITAMIN FLINTSTONES TAB 3 WITH FLUORIDE 1 CHEW ORAL DROPS FLINTSTONES WITH 1 MULTI-VITAMIN IRON WITH FLUORIDE 3 HONEY BEARS WITH ORAL 1 IRON-ZINC TABLET,CHEWABLE LYSIPLEX PLUS MULTIVITAMINS 1 3 ORAL LIQUID WITH FLUORIDE NANOVM 9-18 3 MVC-FLUORIDE 3 NANOVM T-F 3 POLY-VI-FLOR 3 NOVAFERRUM POLY-VI-FLOR WITH 1 3 PEDIATRIC IRON

You can find information on what the symbols and abbreviations on this table mean on page 4. 169 Drug Name Drug Tier Limits Drug Name Drug Tier Limits QUFLORA 3 FLINTSTONES 3 QUFLORA FE COMPLETE 1 (FERROUS SULFATE) FLINTSTONES 1 QUFLORA GUMMIES 3 PEDIATRIC FLINTSTONES 3 QUFLORA GUMMIES OMEGA-3 3 PEDIATRIC DROPS FLINTSTONES TRI-VI-FLOR 3 MULTI-VIT GUMMIES ORAL 3 TRI-VITAMIN WITH 3 TABLET,CHEWABLE FLUORIDE 200 MCG TRI-VITE WITH FLINTSTONES 3 1 FLUORIDE MULTIVITAMIN VITAMINS A,C,D FLINTSTONES SOUR 3 3 AND FLUORIDE GUMMIES PEDIATRIC FLINTSTONES/EXTR 3 VITAMINS A C ANIMAL CHEWS 1 GUMMI BEAR 1 ANIMAL SHAPE MULTIVITAMIN 1 VITAMINS GUMMIES ANIMAL SHAPES CHILDREN 1 COMPLETE ORAL 1 MULTIVITAMIN TABLET,CHEWABLE GUMMY DINOS 1 CHILD HONEY BEARS WITH 3 1 MULTIVITAMINS IRON-ZINC CHILDREN INFUVITE 1 2 PA MULTIVITAMIN PEDIATRIC CHILDREN'S KIDS COD LIVER OIL 3 CHEWABLE 1 AND VIT D VITAMIN KIDS' GUMMY 1 CHILDREN'S 3 KIDS CHEWABLES MULTIVITAMIN- 3 CHILDREN'S MINERALS CHEWABLES EXTRA 3 LITTLE ANIMALS- C IRON ORAL 1 CHILDREN'S MULTI- TABLET,CHEWABLE 1 VIT GUMMIES 15 MG IRON CHILDREN'S M.V.I. PEDIATRIC 2 PA 1 MULTIVITAMIN MVW COMPLETE DEKAS PLUS LIQUID 3 FORMUL MULTIVIT 3 DINO-LIFE WITH ORAL CAPSULE 1 IRON-ZINC

You can find information on what the symbols and abbreviations on this table mean on page 4. 170 Drug Name Drug Tier Limits Drug Name Drug Tier Limits MVW COMPLETE BAL-CARE DHA 3 FORMUL MULTIVIT ESSENTIAL 1 ORAL BRAINSTRONG 3 TABLET,CHEWABLE PRENATAL MVW COMPLETE 3 CADEAU DHA 3 FORMUL PEDIATRIC CALCIUM PNV 3 MVW COMPLETE FORMULATION CITRANATAL B- 3 3 D3000 ORAL CALM (FE GLUC) CAPSULE CLASSIC PRENATAL 1 MVW COMPLETE C-NATE DHA 3 FORMULATION COMPLETE NATAL 1 3 D3000 ORAL DHA TABLET,CHEWABLE COMPLETENATE 1 MVW COMPLETE FORMULATION CONCEPT DHA 3 3 D5000 ORAL CONCEPT OB 3 CAPSULE DAILY PRENATAL 1 MVW COMPLETE DUET DHA FORMULATION 1 BALANCED ORAL D5000 ORAL COMBO PACK 25 MG 3 TABLET,CHEWABLE IRON-1 MG -267 MG- NANO VM 1-3 ORAL 233 MG 3 POWDER DUET DHA WITH NANO VM 4-8 ORAL OMEGA-3 ORAL 3 3 POWDER COMBO PACK 25 MG NOVAMV 3 IRON-1 MG -400 MG ONE-A-DAY KID'S 3 ENBRACE HR 3 ONE-A-DAY TEEN EXPECTA 3 1 HIM VITACRAVES PRENATAL EXTRA-VIRT PLUS PEDIA POLY-VITE 1 3 DHA PEDIA TRI-VITE 1 FOLIVANE-OB 3 POLY-VITAMINS 1 KPN ORAL TABLET 1 SCOOBY-DOO ONE A 3 KPN ORAL TABLET 9 DAY KIDS 3 MG IRON- 267 MCG ZOO CHEWS 1 MARNATAL-F 3 ZOO FRIENDS ORAL 3 TABLET,CHEWABLE MINI PRENATAL 3 PRENATAL M-NATAL PLUS 3 MYNATAL ORAL VITAMINS AND 1 MINERALS CAPSULE MYNATAL PLUS 1 BAL-CARE DHA 3 MYNATAL-Z 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 171 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NATACHEW (FE BIS- PRENA1 TRUE 3 3 GLYCINATE) PRENATA 3 NEEVODHA (WITH 3 PRENATABS FA 1 ALGAL OIL) PRENATABS RX 1 NESTABS 3 PRENATAL + DHA NESTABS ABC 3 ORAL COMBO PACK 3 NESTABS DHA 3 28 MG IRON- 975 NEWGEN 3 MCG-200 MG NIVA-PLUS 1 PRENATAL + DHA ORAL COMBO PACK 1 OB COMPLETE ONE 3 28 MG IRON-800 OB COMPLETE ORAL MCG-200 MG 3 TABLET PRENATAL 19 3 OB COMPLETE PRENATAL 3 3 PETITE COMPLETE OB COMPLETE PRENATAL 3 3 PREMIER FORMULA OB COMPLETE WITH 3 PRENATAL GUMMY 3 DHA PRENATAL LOW 1 O-CAL PRENATAL 3 IRON ONE A DAY PRENATAL MULTI 1 WOMEN'S 3 PRENATAL MULTI- PRENATAL DHA 3 DHA (ALGAL OIL) ONE DAILY 3 PRENATAL PRENATAL 1 MULTIVITAMINS ONE-A-DAY PRENATAL ONE WOMEN'S 3 1 PRENATAL 1 DAILY PERRY PRENATAL 3 PRENATAL ORAL TABLET 28 MG 1 PNV 29-1 3 IRON- 800 MCG PNV-DHA 1 PRENATAL PLUS 1 PNV-FERROUS PRENATAL PLUS 1 FUMARATE-DOCU- 3 (CALCIUM CARB) FA PRENATAL TABLET 1 PNV-OMEGA 3 PRENATAL VITAMIN PNV-SELECT 3 ORAL TABLET 27 MG 1 PR NATAL 400 3 IRON- 0.8 MG, 27 MG PR NATAL 400 EC 3 IRON- 800 MCG PRENATAL VITAMIN PR NATAL 430 3 3 PLUS LOW IRON PR NATAL 430 EC 3 PRENATAL VITAMIN 1 PRENA1 CHEW 3 WITH MINERALS PRENA1 PEARL 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 172 Drug Name Drug Tier Limits Drug Name Drug Tier Limits prenatal vit-iron fum- THERANATAL ORAL 1 1 folic ac TABLET prenatal vits96-iron THERANATAL 1 3 fum-folic OVAVITE PRENATAL-U 3 THERANATAL PLUS 3 PRENATE AM 3 THRIVITE RX 3 PRENATE TRIADVANCE 1 3 CHEWABLE TRICARE 3 PRENATE DHA 3 TRINATAL RX 1 3 (FERR ASP GLYCIN) TRINATE 3 PRENATE ELITE 3 (IRON ASP GLYC) TRISTART DHA 3 PRENATE ENHANCE 3 TRIVEEN-DUO DHA 3 PRENATE VINACAL B 3 ESSENTIAL(IRON- 3 VINATE CARE 3 ASP-GL) VINATE DHA RF 3 PRENATE MINI 3 VINATE II 3 (FERR ASP GLYCIN) VINATE M 1 PRENATE PIXIE 3 VINATE ONE 1 PRENATE RESTORE 3 VINATE ULTRA 1 PRENATE STAR 3 VIRT-C DHA 3 PREPLUS 1 VIRT-NATE DHA 3 PRETAB 3 VIRT-PN DHA 3 PROVIDA OB 3 VIRT-PN PLUS 3 PUREFE OB PLUS 3 VITAFOL GUMMIES 3 PUREFE PLUS 3 VITAFOL NANO 3 R-NATAL OB 3 VITAFOL ULTRA 3 SELECT-OB 3 VITAFOL-OB 1 SELECT-OB + DHA 3 VITAFOL-OB+DHA 3 SE-NATAL 19 1 CHEWABLE VITAFOL-ONE 3 VITAMED MD ONE SE-NATAL-19 1 3 RX SIMILAC PRENATAL 3 VITAMEDMD 3 STUART ONE 3 REDICHEW RX TARON-C DHA 3 VITAPEARL 3 TENDERA-OB 3 VITATRUE 3 THERANATAL 3 VIVA DHA 3 COMPLETE VP-CH PLUS 3 THERANATAL ONE 3 VP-CH-PNV 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 173 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VP-PNV-DHA 3 SODIUM ZATEAN-PN DHA 3 CHLORIDE ZATEAN-PN PLUS 3 SOLUTIONS, PRENATAL CONCENTRATED VITAMINS WITH sodium chloride 3 % 4 LOW OR NO sodium chloride 5 % 4 IRON (LESS sodium chloride THAN 27 MG) intravenous parenteral 4 solution 2.5 meq/ml ALIVE PRENATAL 3 sodium chloride AZESCO 3 intravenous parenteral 1 PRENATAL ORAL 3 solution 4 meq/ml TABLET,CHEWABLE SODIUM ZINGIBER 3 CHLORIDE, RINGER'S AND PARENTERAL LACTATED BD PRE-FILLED 4 RINGER'S NORMAL SALINE SOLUTIONS LIQUIVIDA 4 lactated ringers HYDRATION KIT 4 intravenous MONOJECT 0.9% 4 ringer's intravenous 4 SODIUM CHLORIDE MONOJECT PREFILL SODIUM 4 CHLORIDE ADVANCED NS NORMAL SALINE FLUSHES 4 FLUSH BD PRE-FILLED 4 NORMAL SALINE sodium chloride 0.45 % intravenous parenteral 4 MONOJECT 0.9% 4 solution SODIUM CHLORIDE sodium chloride 0.9 % MONOJECT PREFILL 4 4 (flush) ADVANCED NS sodium chloride 0.9 % NORMAL SALINE 4 4 intravenous FLUSH sodium chloride 3 % 4 sodium chlor 0.9% 4 bacteriostat sodium chloride 5 % 4 sodium chloride 0.9 % sodium chloride 4 (flush) intravenous parenteral 4 solution 2.5 meq/ml sodium chloride 0.9 % 1 injection sodium chloride intravenous parenteral 1 SWABFLUSH 4 solution 4 meq/ml SWABFLUSH 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 174 Drug Name Drug Tier Limits Drug Name Drug Tier Limits STERILE WATER VITAMINS - B FOR INJECTION PREPARATION water for injection, COMBINATIONS 4 sterile intravenous APATATE 1 VITAMIN C B COMPLEX W-VIT C 3 COMBINATIONS B-COMPLEX WITH B- 3 EMERGEN-C ORAL 12 3 TABLET,CHEWABLE CEREFOLIN NAC 3 VITAMIN C FIZZY (ALGAL OIL) 3 DRINK FABB 1 VITAMIN D AND FOLBEE 3 FOLIC ACID FOLBIC 3 COMBINATIONS folic acid-vit b6-vit b12 3 CIFEREX 3 oral tablet 0.5-5-0.2 mg DERMACINRX FOLINIC-PLUS 3 3 PUREFOLIX FOLPLEX 2.2 1 DURACHOL 3 FOLTABS 800 3 FOLVITE-D 1 FOLTANX 1 GENICIN VITA-D 3 FOLTX 3 NOXIFOL-D3 3 HOMOCYSTEINE 3 REVESTA 3 FORMULA ZAVARA 3 METANX (ALGAL 3 VITAMINS - A OIL) AND D METHAVER 3 COMBINATIONS, NEURIN-SL 3 SYSTEMIC NIVA-FOL 3 cod liver oil (bulk) 1 VIRT-GARD 1 COD LIVER OIL VIRT-VITE 3 ORAL CAPSULE 1 VITA-RESPA 3 1,250-135 UNIT WESTAB ONE 1 NORWEGIAN COD 1 LIVER OIL ZINGIBER 3 vit a and d3 in cod liver VITAMINS - B-1, 1 oil THIAMINE AND VITAMINS - A DERIVATIVES AQUASOL A 4 ARKALIOX 3 thiamine hcl (vitamin beta carotene 1 2 PA b1) injection LUMITENE 1 thiamine hcl (vitamin vitamin a oral capsule 1 1 b1) oral tablet 100 mg 10,000 unit, 8,000 unit

You can find information on what the symbols and abbreviations on this table mean on page 4. 175 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VITAMIN B-1 INOSITOL 1 3 (MONONITRATE) HEXANICOTINATE VITAMIN B-1 ORAL niacin (inositol TABLET 250 MG, 50 1 niacinate) oral capsule 1 MG 400 mg niacin (500 mg), VITAMINS - B-12 500 mg niacin (inositol AND FOLIC ACID 1 COMBINATIONS niacinate) oral tablet NIACIN FLUSH FREE FOLTRATE 3 ORAL CAPSULE 400 1 VITAMINS - B-12, MG NIACIN (500 MG) CYANOCOBALA NIACIN NO FLUSH 1 MIN AND niacin oral capsule, DERIVATIVES extended release 250 1 B12 1 mg, 500 mg niacin oral tablet 250 B-12 DOTS 1 1 mg cyanocobalamin 1 (vitamin b-12) injection niacin oral tablet extended release 250 1 hydroxocobalamin 2 PA mg, 500 mg, 750 mg LIQUID B-12 1 niacinamide (bulk) mecobalamin (bulk) 1 3 crystals powder 100 %, 96 % niacinamide oral tablet 1 NEURIN-SL 3 500 mg VITAMIN B-12 ORAL niacinamide oral tablet 1 1 TABLET 100 MCG extended release VITAMINS - B-2, VITAMINS - B-5, RIBOFLAVIN PANTOTHENIC AND ACID AND DERIVATIVES DERIVATIVES VITAMIN B-2 ORAL pantothenic acid (vit b5) 1 TABLET 100 MG, 50 1 MG VITAMINS - B-6, PYRIDOXINE VITAMINS - B-3, AND NIACIN AND DERIVATIVES DERIVATIVES pyridoxine (bulk) 1 ENDUR-ACIN ORAL crystals TABLET EXTENDED 1 pyridoxine (vitamin b6) RELEASE 500 MG 4 injection ENDUR-AMIDE ORAL TABLET pyridoxine (vitamin b6) 1 1 EXTENDED oral tablet 50 mg RELEASE 500 MG VITAMIN B-6 ORAL 1 TABLET 50 MG You can find information on what the symbols and abbreviations on this table mean on page 4. 176 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VITAMINS - cholecalciferol (vitamin BIOFLAVONOID d3) oral capsule 25 mcg 1 S (1,000 unit) cholecalciferol (vitamin bioflavonoids, citrus 3 d3) oral tablet 25 mcg 1 (bulk) powder 100 % (1,000 unit) VITAMINS - cholecalciferol (vitamin 3 BIOTIN d3) sublingual biotin (bulk) 3 CIFEREX 3 biotin oral capsule 1 mg, 3 D3-2000 1 10,000 mcg, 5 mg DDROPS 3 biotin oral tablet 300 1 DECARA ORAL mcg CAPSULE 1,250 MCG 3 CYTO B7 3 (50,000 UNIT), 625 MEGA BIOTIN 3 MCG (25,000 UNIT) DERMACINRX MERIBIN 3 3 PUREFOLIX VB7 MAX 3 DIALYVITE 3 VITAMINS - C, VITAMIN D3 MAX ASCORBIC ACID DURACHOL 3 AND ergocalciferol (vit d2) DERIVATIVES 3 (bulk) ASCOR 4 ergocalciferol (vitamin ascorbic acid (vitamin c) 3 4 d2) injection KIDS FIRST VITAMIN ascorbic acid (vitamin c) 3 3 D3 oral powder in packet KIDS VITAMIN D3 3 VITAMINS - D NOXIFOL-D3 3 AND K OPTIMAL D3 3 COMBINATIONS OPTIMAL D3 M 3 D3 + K2 DOTS 3 PEDIA D-VITE ORAL 3 K2 PLUS D3 3 DROPS VITAMINS - D REPLESTA NX 3 DERIVATIVES REVESTA 3 BABY DDROPS 3 ROCALTROL 3 BABY VITAMIN D3 3 SUPER DAILY D3 BABY'S SUPER ORAL DROPS 25 3 3 DAILY D3 MCG/DROP ( 1000 calcitriol intravenous UNIT/DROP) 4 solution 1 mcg/ml THERA-D 1 calcitriol oral capsule 1 THERA-D 4000 3 calcitriol oral solution 3 VITAL-D RX 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 177 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VITAMIN D3 ORAL VITA-RESPA 3 CAPSULE 25 MCG 1 WESTAB ONE 1 (1,000 UNIT) VITAMINS - K, VITAMIN D3 ORAL TABLET 25 MCG 1 PHYTONADIONE (1,000 UNIT) AND ZAVARA 3 DERIVATIVES VITAMINS - E MEPHYTON 3 phytonadione (vitamin vitamin e oral capsule 3 1 k1) injection solution 100 unit, 600 unit phytonadione (vitamin 1 VITAMINS - k1) injection syringe FOLIC ACID AND phytonadione (vitamin 3 DERIVATIVES k1) oral tablet 100 mcg DENOVO 3 phytonadione (vitamin 1 DEPLIN (ALGAL OIL) 3 k1) oral tablet 5 mg ELFOLATE 3 VITAMIN K 4 FA-8 1 VITAMIN K1 4 folic acid injection 2 PA INJECTION folic acid oral capsule vitamin k2 3 1 0.8 mg VITAMINS - folic acid oral capsule PABA 3 20 mg POTABA ORAL 3 folic acid oral tablet 400 CAPSULE 3 mcg ENDOCRINE folic acid oral tablet 800 1 mcg ABORTIFACIENT GENICIN VITA-Q 3 S OR CERVICAL RIPENING XAQUIL XR 3 AGENTS - VITAMINS - PROSTAGLANDI FOLIC ACID N ANALOGS COMBINATIONS CERVIDIL 3 ENLYTE 3 PREPIDIL 3 FABB 1 PROSTIN E2 3 FOLBEE 3 ABORTIFACIENT FOLBIC 3 S- FOLPLEX 2.2 1 PROGESTERONE NIVA-FOL 3 RECEPTOR RESTORA RX 3 ANTAGONIST VIRT-GARD 1 MIFEPREX 3 VIRT-VITE 3 mifepristone 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 178 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ADRENOCORTIC AMYLOIDOSIS OTROPHIC AGENTS-TTR HORMONES SUPPRESSION, ACTHAR 2 PA ANTISENSE corticotropin (bulk) 3 OLIGONUCLEOT IDE-BASED AGENTS TO TREAT TEGSEDI 2 PA HYPOGLYCEMIA AMYLOIDOSIS (HYPERGLYCEM AGENTS-TTR ICS) SUPPRESSION, DEX4 GLUCOSE BITS 1 RNA INTERFERING DEX4 GLUCOSE 1 POUCH PACK (RNAI) BASED DEX4 GLUCOSE ONPATTRO 4 1 QUICK DISSOLVE ANABOLIC GLUCAGEN STEROID - 1 HYPOKIT SINGLE AGENTS GLUCAGON (HCL) 3 ANADROL-50 2 PA EMERGENCY KIT OXANDRIN 3 GLUCAGON oxandrolone 1 EMERGENCY KIT 1 (HUMAN) ANDROGEN - glucagon hcl 4 SINGLE AGENTS GLUTOSE-45 1 ANDRODERM 2 PA GVOKE PFS 1-PACK ANDROGEL SYRINGE TRANSDERMAL GEL SUBCUTANEOUS 3 IN METERED-DOSE 3 SYRINGE 0.5 MG/0.1 PUMP 20.25 MG/1.25 ML GRAM (1.62 %) PROGLYCEM 3 ANDROGEL TRANSDERMAL GEL 3 SUGARUP 3 IN PACKET AMYLOIDOSIS ANDROID 3 AGENTS- AVEED 3 TRANSTHYRETI DEPO- N (TTR) 3 PA TESTOSTERONE STABILIZER FORTESTA 3 VYNDAQEL 3 METHITEST 3 PA methyltestosterone 3 (bulk) methyltestosterone oral 3 PA capsule You can find information on what the symbols and abbreviations on this table mean on page 4. 179 Drug Name Drug Tier Limits Drug Name Drug Tier Limits methyltestosterone,micr desmopressin acetate 3 3 o(bulk) (bulk) NATESTO 3 desmopressin injection 4 TESTIM 3 desmopressin nasal 1 TESTONE CIK 4 spray with pump desmopressin nasal TESTOPEL 4 1 spray,non-aerosol testosterone (bulk) 3 desmopressin oral 1 testosterone cypionate 3 (bulk) NOCDURNA (MEN) 3 NOCDURNA testosterone cypionate 3 intramuscular oil 100 2 PA (WOMEN) mg/ml, 200 mg/ml NOCTIVA 3 testosterone enanthate 1 vasopressin in 0.9 % sod testosterone propionate chlor intravenous 3 (bulk) solution 20 unit/100 ml (0.2 unit/ml), 40 4 testosterone transdermal 2 PA unit/100 ml (0.4 gel unit/ml), 60 unit/100 ml testosterone transdermal (0.6 unit/ml) gel in metered-dose VASOSTRICT 4 pump 10 mg/0.5 gram 3 PA /actuation, 20.25 ANTIHYPERGLY mg/1.25 gram (1.62 %) CEMIC - ALPHA- testosterone transdermal GLUCOSIDASE gel in metered-dose INHIBITORS 2 PA pump 12.5 mg/ 1.25 acarbose 1 gram (1 %) GLYSET 1 testosterone transdermal gel in packet 1 % (25 miglitol 3 2 PA mg/2.5gram), 1 % (50 PRECOSE 3 mg/5 gram) ANTIHYPERGLY testosterone transdermal CEMIC - gel in packet 1.62 % DIPEPTIDYL (20.25 mg/1.25 gram), 3 PA 1.62 % (40.5 mg/2.5 PEPTIDASE-4 gram) (DPP-4) TESTRED 3 INHIBITORS VOGELXO 3 alogliptin 3 XYOSTED 3 PA JANUVIA 1 ANTIDIURETIC NESINA 3 AND ONGLYZA 3 VASOPRESSOR TRADJENTA 1 HORMONES DDAVP ORAL 3 PA You can find information on what the symbols and abbreviations on this table mean on page 4. 180 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHYPERGLY ANTIHYPERGLY CEMIC - CEMIC - SGLT-2 DOPAMINE INHIBITOR AND RECEPTOR DPP-4 AGONISTS INHIBITOR CYCLOSET 3 COMBINATIONS ANTIHYPERGLY GLYXAMBI 3 CEMIC - QTERN 3 GLUCOCORTICO STEGLUJAN 3 ID (CORTISOL) ANTIHYPERGLY RECEPTOR CEMIC - SODIUM BLOCKER (GR- GLUCOSE II) COTRANSPORTE KORLYM 1 R-2 (SGLT2) ANTIHYPERGLY INHIBITORS CEMIC - FARXIGA 1 MEGLITINIDE INVOKANA 1 ANALOG AND JARDIANCE 1 BIGUANIDE STEGLATRO 3 COMBINATIONS ANTIHYPERGLY repaglinide-metformin 1 CEMIC - ANTIHYPERGLY SULFONYLUREA CEMIC - AND BIGUANIDE MEGLITINIDE COMBINATIONS ANALOGS glipizide-metformin 1 nateglinide 1 glyburide-metformin 1 PRANDIN ORAL 3 TABLET 1 MG, 2 MG ANTIHYPERGLY CEMIC - repaglinide 1 SULFONYLUREA STARLIX 3 DERIVATIVES ANTIHYPERGLY AMARYL 3 CEMIC - SGLT-2 glimepiride 1 INHIBITOR AND BIGUANIDE glipizide 1 COMBINATIONS glipizide (bulk) 3 INVOKAMET 1 GLUCOTROL 3 SEGLUROMET 3 GLUCOTROL XL 3 SYNJARDY 3 glyburide 1 SYNJARDY XR 3 glyburide micronized 1 XIGDUO XR 1 GLYNASE 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 181 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHYPERGLY BYETTA SUBCUTANEOUS CEMIC - QL (2.4 ML PEN INJECTOR 10 1 THIAZOLIDINED per 30 days) MCG/DOSE(250 IONE AND MCG/ML) 2.4 ML BIGUANIDE BYETTA COMBINATIONS SUBCUTANEOUS QL (1.2 ML ACTOPLUS MET 3 PEN INJECTOR 5 1 per 30 days) ACTOPLUS MET XR MCG/DOSE (250 ORAL TABLET, ER MCG/ML) 1.2 ML 3 MULTIPHASE 24 HR OZEMPIC 3 15-1,000 MG TRULICITY 3 pioglitazone-metformin 1 QL (6 ML per VICTOZA 2-PAK 1 ANTIHYPERGLY 30 days) CEMIC - QL (9 ML per VICTOZA 3-PAK 1 THIAZOLIDINED 30 days) IONE AND ANTIHYPERGLY SULFONYLUREA CEMIC- COMBINATIONS DIPEPTIDYL DUETACT 3 PEPTIDASE-4 pioglitazone-glimepiride 3 INHIBIT AND ANTIHYPERGLY THIAZOLIDINED CEMIC, AMYLIN IONE ANALOG-TYPE alogliptin-pioglitazone 2 PA SYMLINPEN 120 2 PA OSENI 3 SYMLINPEN 60 2 PA ANTIHYPERGLY ANTIHYPERGLY CEMIC- CEMIC, DIPEPTIDYL INCRETIN PEPTIDASE- MIMETIC,GLP-1 4(DPP- RECEPTOR 4)INHIBITOR AGONIST AND BIGUANIDE ANALOG-TYPE alogliptin-metformin 3 ADLYXIN 3 JANUMET 1 BYDUREON BCISE 3 JANUMET XR 1 BYDUREON JENTADUETO 1 SUBCUTANEOUS 1 JENTADUETO XR 1 PEN INJECTOR KAZANO 3 KOMBIGLYZE XR 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 182 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHYPERGLY BONE CEMIC-INSULIN, FORMATION LONG ACTING STIMULATING AND GLP-1 AGENTS - RECEPTOR PARATHYROID AGONIST COMB HORMONE-TYPE SOLIQUA 100/33 3 FORTEO 2 PA XULTOPHY 100/3.6 3 teriparatide 2 ANTITHYROID BONE AGENTS, RESORPTION THIONAMIDES - INHIBITORS - IMIDAZOLE BISPHOSPHONA DERIVATIVES TE AND methimazole oral tablet VITAMIN D 1 10 mg, 5 mg COMBINATIONS TAPAZOLE 3 FOSAMAX PLUS D 3 ANTITHYROID BONE AGENTS, RESORPTION THIONAMIDES - INHIBITORS - THIOURACIL BISPHOSPHONA DERIVATIVES TES propylthiouracil 1 ACTONEL ORAL BONE TABLET 150 MG, 35 3 MG, 5 MG FORMATION alendronate oral AGENTS - 1 solution SCLEROSTIN alendronate oral tablet INHIBITOR, 1 10 mg MONOCLONAL alendronate oral tablet QL (5 EA per ANTIBODY 2 35 mg 23 days) EVENITY 3 alendronate oral tablet 5 QL (30 EA per 2 BONE mg, 70 mg 23 days) FORMATION ATELVIA 3 STIMULATING BINOSTO 3 AGENTS - BONIVA 4 PA PARATHYROID INTRAVENOUS HORMONE REL BONIVA ORAL 3 PEPTIDES etidronate disodium oral 3 PA TYMLOS 3 PA tablet 200 mg FOSAMAX ORAL QL (5 EA per 3 TABLET 70 MG 23 days)

You can find information on what the symbols and abbreviations on this table mean on page 4. 183 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ibandronate intravenous 4 ESTROGEN AND solution SELECTIVE ibandronate intravenous 4 PA ESTROGEN syringe RECEPTOR ibandronate oral 1 ST MODULATOR pamidronate 4 (SERM) RECLAST 4 PA COMBINATIONS risedronate oral tablet DUAVEE 2 PA 3 PA 150 mg, 30 mg, 5 mg ESTROGEN- risedronate oral tablet 3 ANDROGEN 35 mg COVARYX 3 risedronate oral COVARYX H.S. 3 tablet,delayed release 3 (dr/ec) EEMT 3 zoledronic acid 4 PA EEMT HS 3 zoledronic acid- estrogens- 4 PA 1 mannitol-water methyltestosterone zoledronic ac-mannitol- ESTROGEN- 4 PA 0.9nacl PROGESTIN CALCIMIMETIC, ACTIVELLA 3 PARATHYROID AMABELZ 1 CALCIUM BIJUVA 3 RECEPTOR CLIMARA PRO 1 SENSITIVITY ENHANCER COMBIPATCH 1 estradiol-norethindrone cinacalcet 2 PA 1 acet SENSIPAR 3 PA FEMHRT LOW DOSE 3 PA CALCITONINS FYAVOLV 1 calcitonin (salmon) 1 JINTELI 1 MIACALCIN LOPREEZA ORAL 4 PA 1 INJECTION TABLET 1-0.5 MG ESTROGEN AND MIMVEY 1 PROGESTIN norethindrone ac-eth WITH estradiol oral tablet 0.5- 1 ANTIMINERALO 2.5 mg-mcg, 1-5 mg- CORTICOID mcg ACTIVITY,COMB PREFEST 3 INATION PREMPHASE 1 ANGELIQ 1 PREMPRO 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 184 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ESTROGENS estrone (bulk) crystals 1 QL (10 EA per estrone (bulk) powder 3 ALORA 3 23 days) ethinyl estradiol (bulk) 3 CLIMARA 3 EVAMIST 3 DELESTROGEN 4 PA MENEST ORAL DEPO-ESTRADIOL 1 TABLET 0.3 MG, 1 0.625 MG, 1.25 MG DIVIGEL TRANSDERMAL GEL MENOSTAR 3 IN PACKET 0.25 MINIVELLE MG/0.25 GRAM (0.1 TRANSDERMAL 3 QL (10 EA per %), 0.5 MG/0.5 GRAM PATCH 3 23 days) (0.1 %), 0.75 MG/0.75 SEMIWEEKLY 0.025 GRAM (0.1%), 1 MG/24 HR MG/GRAM (0.1 %) MINIVELLE DOTTI 1 TRANSDERMAL ELESTRIN 3 PATCH SEMIWEEKLY 0.0375 ESTRACE ORAL 3 3 MG/24 HR, 0.05 estradiol cypionate 3 MG/24 HR, 0.075 (bulk) MG/24 HR, 0.1 MG/24 estradiol hemihydrate HR 3 (bulk) PREMARIN 4 PA estradiol oral 1 INJECTION estradiol transdermal PREMARIN ORAL 1 patch semiweekly 0.025 QL (10 EA per VIVELLE-DOT 3 mg/24 hr, 0.05 mg/24 1 23 days) hr, 0.075 mg/24 hr, 0.1 FERTILITY mg/24 hr ENHANCER - estradiol transdermal LUTEAL PHASE patch semiweekly 1 SUPPORTING, 0.0375 mg/24 hr PROGESTERONE estradiol transdermal -TYPE patch weekly 0.025 CRINONE VAGINAL 3 mg/24 hr, 0.0375 mg/24 1 GEL 8 % hr, 0.06 mg/24 hr, 0.075 mg/24 hr FERTILITY ENHANCER - estradiol transdermal QL (5 EA per patch weekly 0.05 1 OVULATION 23 days) mg/24 hr, 0.1 mg/24 hr STIMULANT - estradiol valerate (bulk) 3 SYNTHETIC (NON-FSH) estriol (bulk) 3 clomiphene citrate estriol micronized 3 3 (bulk) (bulk) ESTROGEL 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 185 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DECADRON ORAL GLUCOCORTICO 1 ID SALT TABLET COMBINATIONS DEPO-MEDROL INJECTION betameth ac,sod 2 PA 4 SUSPENSION 20 phos(pf)-water MG/ML betamethasone ace,sod 4 DEPO-MEDROL phos-wtr INJECTION betamethasone acet,sod 3 PA 4 SUSPENSION 40 phos MG/ML, 80 MG/ML CELESTONE desoximetasone, micro 3 PA 3 SOLUSPAN (bulk) POD-CARE 100C 4 dexamethasone ac, 3 POD-CARE 100CG 4 micro (bulk) dexamethasone ac, sod GLUCOCORTICO 4 ID-ANESTHETIC ph-water dexamethasone ace- COMBINATIONS 4 nacl,iso-osm methylprednisol ac- 4 dexamethasone acetate bupivac-wat 3 (bulk) triamcinol ace-bupiv- 4 DEXAMETHASONE 0.9% nacl 1 INTENSOL GLUCOCORTICO dexamethasone oral 1 IDS elixir A-HYDROCORT 4 dexamethasone oral 2 PA ARISTOSPAN INTRA- solution 4 ARTICULAR dexamethasone oral ARISTOSPAN tablet 0.5 mg, 0.75 mg, 4 1 INTRALESIONAL 1 mg, 1.5 mg, 2 mg, 4 beclomethasone diprop mg 3 (bulk) dexamethasone oral 4 betamethasone sod phos tablet 6 mg 3 (bulk) dexamethasone oral 1 betamethasone sod tablets,dose pack 4 phosph-water dexamethasone sod 3 betamethasone valerate phos (bulk) 3 (bulk) dexamethasone sodium budesonide, micronized phos (pf) injection 2 PA 3 (bulk) solution CORTEF 3 dexamethasone sodium phos (pf) injection 4 cortisone 1 syringe cortisone (bulk) 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 186 Drug Name Drug Tier Limits Drug Name Drug Tier Limits dexamethasone sodium methylprednisolone 4 phosphate injection 1 PA acet-water solution 10 mg/ml methylprednisolone dexamethasone sodium sodium succ injection 1 phosphate injection 2 PA recon soln 125 mg, 40 solution 4 mg/ml mg dexamethasone sodium methylprednisolone phosphate injection 2 PA sodium succ intravenous 1 syringe recon soln 1,000 mg dexamethasone,microni methylprednisolone, 3 3 zed(bulk) mic (bulk) DXEVO 3 MILLIPRED DP 3 EMFLAZA 3 MILLIPRED ORAL 3 fluocinolone acetonide TABLET 3 (bulk) ORAPRED ODT 3 fluocinonide, POD-CARE 100K 4 3 micronized(bulk) POD-CARE 100KG 4 HIDEX 3 prednisolone (bulk) 3 hydrocortisone (bulk) 3 prednisolone ac, micro 3 hydrocortisone acetate (bulk) 3 (bulk) prednisolone oral 1 hydrocortisone oral 1 solution 15 mg/5 ml KENALOG prednisolone sod phos 3 INJECTION (bulk) 2 PA SUSPENSION 10 prednisolone sodium MG/ML phosphate oral solution KENALOG 10 mg/5 ml, 15 mg/5 ml INJECTION (3 mg/ml), 20 mg/5 ml 1 3 PA SUSPENSION 40 (4 mg/ml), 25 mg/5 ml MG/ML (5 mg/ml), 5 mg base/5 KENALOG-80 3 ml (6.7 mg/5 ml) MAS CARE-PAK (PF) 4 prednisolone sodium phosphate oral 1 MEDROL 3 tablet,disintegrating MEDROL (PAK) 3 prednisolone, micro 3 methylpred ac(pf)- (bulk) 4 nacl,iso-osm prednisone 1 methylprednisolon 3 prednisone (bulk) 3 ac,mic(bulk) PREDNISONE 1 methylprednisolone 1 INTENSOL methylprednisolone prednisone micronized 1 3 acetate (bulk) RAYOS 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 187 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SOLU-CORTEF 1 triamcinolone diacet- 4 SOLU-CORTEF ACT- 0.9% nacl O-VIAL (PF) triamcinolone diacetate 3 INJECTION RECON (bulk) 2 PA SOLN 1,000 MG/8 ML, VERIPRED 20 3 250 MG/2 ML, 500 MG/4 ML ZILRETTA 4 PA SOLU-CORTEF ACT- GONADOTROPIN O-VIAL (PF) INHIBITOR 1 INJECTION RECON PITUITARY SOLN 100 MG/2 ML SUPPRESSANTS SOLU-MEDROL (PF) 3 PA danazol 1 SOLU-MEDROL GROWTH INTRAVENOUS 3 PA RECON SOLN 1,000 HORMONE MG, 500 MG RECEPTOR SOLU-MEDROL ANTAGONISTS INTRAVENOUS SOMAVERT 4 PA RECON SOLN 2 SUBCUTANEOUS 1 GRAM RECON SOLN 15 MG, TAPERDEX ORAL 20 MG, 25 MG, 30 MG TABLETS,DOSE GROWTH PACK 1.5 MG (21 1 HORMONE TABS), 1.5 MG (49 RELEASING TABS) HORMONES TAPERDEX ORAL (GHRH) TABLETS,DOSE 3 PACK 1.5 MG (27 EGRIFTA SV 2 PA TABS) GROWTH triamcinol ac (pf) in 4 HORMONES 0.9%nacl GENOTROPIN 4 PA triamcinolone (bulk) 3 GENOTROPIN triamcinolone aceton- 4 PA 4 MINIQUICK 0.9% nacl HUMATROPE 4 PA triamcinolone acetonide 3 NORDITROPIN (bulk) 2 PA FLEXPRO triamcinolone acetonide NUTROPIN AQ injection suspension 10 2 PA 3 NUSPIN mg/ml OMNITROPE 3 triamcinolone acetonide injection suspension 40 1 SAIZEN 3 mg/ml SAIZEN SAIZENPREP 3 triamcinolone dia(pf)- 4 0.9%nacl

You can find information on what the symbols and abbreviations on this table mean on page 4. 188 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SEROSTIM HUMAN SUBCUTANEOUS 4 PA INSULINS - RECON SOLN 4 MG, 5 SHORT ACTING MG, 6 MG AFREZZA ZOMACTON 3 INHALATION ZORBTIVE 4 PA CARTRIDGE WITH INHALER 12 UNIT, 4 HUMAN 3 CHORIONIC UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 GONADOTROPIN UNIT/ 12 UNIT (60), 8 (HCG) UNIT chorionic gonadotropin, HUMULIN R U-500 QL (60 ML per human injection recon 2 4 (CONC) INSULIN 23 days) soln 12,000 unit, 6,000 HUMULIN R U-500 QL (60 ML per unit 2 (CONC) KWIKPEN 23 days) NOVAREL INTRAMUSCULAR INSULIN 3 RECON SOLN 10,000 ANALOGS - UNIT FIXED OVIDREL 3 COMBINATIONS HUMALOG MIX 50-50 QL (60 ML per PREGNYL 3 2 INSULN U-100 23 days) HUMAN HUMALOG MIX 50-50 QL (60 ML per INSULINS - 2 KWIKPEN 23 days) RAPID ACTING HUMALOG MIX 75-25 QL (60 ML per 2 AFREZZA KWIKPEN 23 days) INHALATION HUMALOG MIX 75- QL (60 ML per CARTRIDGE WITH 2 INHALER 12 UNIT, 4 25(U-100)INSULN 23 days) 3 UNIT, 4 UNIT (90)/ 8 insulin lispro protamin- 3 UNIT (90), 4 UNIT/8 lispro UNIT/ 12 UNIT (60), 8 NOVOLOG MIX 70-30 QL (60 ML per 2 UNIT U-100 INSULN 23 days) AFREZZA NOVOLOG MIX 70- QL (60 ML per 2 INHALATION 30FLEXPEN U-100 23 days) CARTRIDGE WITH 3 PA INHALER 8 UNIT INSULIN (90)/ 12 UNIT (90) ANALOGS - LONG ACTING BASAGLAR QL (60 ML per KWIKPEN U-100 3 23 days) INSULIN LANTUS SOLOSTAR QL (60 ML per 1 U-100 INSULIN 23 days) LANTUS U-100 QL (60 ML per 2 INSULIN 23 days) You can find information on what the symbols and abbreviations on this table mean on page 4. 189 Drug Name Drug Tier Limits Drug Name Drug Tier Limits LEVEMIR NOVOLOG U-100 QL (60 ML per QL (60 ML per 2 FLEXTOUCH U-100 2 INSULIN ASPART 23 days) 30 days) INSULN INSULIN LEVEMIR U-100 QL (60 ML per 2 RESPONSE INSULIN 23 days) ENHANCERS - TOUJEO MAX U-300 3 BIGUANIDES SOLOSTAR FORTAMET 3 TOUJEO SOLOSTAR QL (60 ML per 3 U-300 INSULIN 22 days) GLUCOPHAGE 3 TRESIBA GLUCOPHAGE XR 3 3 FLEXTOUCH U-100 GLUMETZA 3 TRESIBA metformin oral solution 3 3 FLEXTOUCH U-200 metformin oral tablet 1 TRESIBA U-100 metformin oral tablet 3 1 INSULIN extended release 24 hr INSULIN metformin oral tablet 3 PA ANALOGS - extended release 24hr RAPID ACTING metformin oral tablet,er 3 ADMELOG gast.retention 24 hr SOLOSTAR U-100 3 PA RIOMET 3 INSULIN INSULIN ADMELOG U-100 3 PA RESPONSE INSULIN LISPRO ENHANCERS - APIDRA SOLOSTAR QL (60 ML per 3 THIAZOLIDINED U-100 INSULIN 22 days) IONES (PPAR- APIDRA U-100 QL (60 ML per 3 GAMMA INSULIN 22 days) AGONISTS) FIASP FLEXTOUCH 3 ACTOS ORAL U-100 INSULIN 3 TABLET 15 MG FIASP U-100 INSULIN 3 ACTOS ORAL QL (30 EA per HUMALOG JUNIOR QL (60 ML per TABLET 30 MG, 45 3 2 23 days) KWIKPEN U-100 23 days) MG HUMALOG QL (60 ML per AVANDIA ORAL 2 3 KWIKPEN INSULIN 23 days) TABLET 2 MG, 4 MG HUMALOG U-100 QL (60 ML per pioglitazone oral tablet 2 1 ST INSULIN 23 days) 15 mg insulin lispro 3 pioglitazone oral tablet ST; QL (30 EA 1 NOVOLOG FLEXPEN QL (60 ML per 30 mg, 45 mg per 23 days) 2 U-100 INSULIN 23 days) NOVOLOG PENFILL QL (60 ML per 2 U-100 INSULIN 23 days)

You can find information on what the symbols and abbreviations on this table mean on page 4. 190 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INSULIN-LIKE LHRH (GNRH) GROWTH AGONIST FACTOR-1 (IGF- ANALOG 1) PITUITARY INCRELEX 2 SUPPRESSANTS LEPTIN LUPRON DEPOT (3 HORMONE MONTH) INTRAMUSCULAR 4 PA ANALOGS SYRINGE KIT 11.25 MYALEPT 3 MG LHRH (GNRH) LUPRON DEPOT INTRAMUSCULAR AGONIST 4 PA ANALOG PIT SYRINGE KIT 3.75 MG SUPPRES - CENTRAL SYNAREL 1 PRECOCIOUS LHRH (GNRH) PUBERTY ANTAGONISTS LUPRON DEPOT-PED 4 PA CETROTIDE SUBCUTANEOUS KIT 3 LUPRON DEPOT-PED 4 PA 0.25 MG (3 MONTH) ganirelix 3 SUPPRELIN LA 4 PA ORILISSA 2 PA TRIPTODUR 4 PA LHRH (GNRH) MENOPAUSAL AGONIST SYMPTOMS ANALOG SUPPRESSANT- PITUITARY SSRI SUPP. AND ANTIDEPRESSAN PROGESTIN T TYPE COMB. BRISDELLE 3 LA LUPANETA PACK (1 MENOPAUSAL 2 PA MONTH) SYMPTOMS LUPANETA PACK (3 SUPRESSANT - 2 PA MONTH) HORMONAL AGENTS IMVEXXY MAINTENANCE 3 PACK IMVEXXY STARTER 3 PACK MINERALOCORT ICOIDS fludrocortisone 1 You can find information on what the symbols and abbreviations on this table mean on page 4. 191 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OXYTOCIC - PROLACTIN ERGOT INHIBITOR - ALKALOIDS ERGOT METHERGINE 1 DERIVATIVE methylergonovine DOPAMINE 4 injection RECEPTOR OXYTOCIC - AGONISTS OXYTOCIN AND cabergoline 1 ANALOGS RANK LIGAND oxytocin (bulk) 3 (RANKL) oxytocin in 0.9 % sod INHIBITOR, MC chloride intravenous ANTIBODY solution 10 unit/500 ml, PROLIA 4 PA 15 unit/250 ml, 20 4 XGEVA 4 PA unit/1000 ml, 30 unit/1000 ml, 30 RENIN- unit/500 ml, 40 ANGIOTENSIN- unit/1000 ml ALDOSTERONE oxytocin injection 4 SYSTEM (RAAS) solution HORMONES PARATHYROID GIAPREZA 4 HORMONES SELECTIVE NATPARA 4 ESTROGEN PROGESTINS RECEPTOR AYGESTIN 3 MODULATORS hydroxyprogesterone (SERMS) 3 capr(bulk) EVISTA 3 PA medroxyprogesterone raloxifene 1 1 oral SOMATOSTATIC norethindrone acetate 1 AGENTS progesterone 1 octreotide acetate 4 progesterone micronized 1 SANDOSTATIN PROMETRIUM 3 INJECTION SOLUTION 100 PROVERA 3 4 MCG/ML, 50 MCG/ML, 500 MCG/ML SANDOSTATIN LAR DEPOT INTRAMUSCULAR 3 SUSPENSION,EXTEN DED REL RECON

You can find information on what the symbols and abbreviations on this table mean on page 4. 192 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SIGNIFOR 3 THYROID SOMATULINE HORMONES - 3 DEPOT SYNTHETIC T3 THYROID (TRIIODOTHYRO HORMONE NINE) COMBINATIONS CYTOMEL 3 - SYNTHETIC T3 liothyronine (bulk) 3 AND T4 powder 1 mg/gram THYROLAR-1 3 liothyronine intravenous 4 THYROLAR-1/2 3 liothyronine oral 1 THYROLAR-1/4 3 TRIOSTAT 4 THYROLAR-2 3 THYROID THYROLAR-3 3 HORMONES - THYROID SYNTHETIC T4 HORMONES - (THYROXINE) ANIMAL EUTHYROX 1 SOURCE LEVO-T 1 (PORCINE) levothyroxine (bulk) 3 ARMOUR THYROID 3 levothyroxine 4 NATURE-THROID intravenous ORAL TABLET 113.75 levothyroxine oral 1 MG, 130 MG, 146.25 LEVOXYL ORAL MG, 16.25 MG, 162.5 3 TABLET 100 MCG, MG, 195 MG, 260 MG, 112 MCG, 125 MCG, 32.5 MG, 325 MG, 137 MCG, 150 MCG, 1 48.75 MG, 81.25 MG, 175 MCG, 200 MCG, 97.5 MG 25 MCG, 50 MCG, 75 NATURE-THROID 1 MCG, 88 MCG ORAL TABLET 65 MG PCCA T4 SODIUM 3 NP THYROID ORAL DILUTION TABLET 15 MG, 30 3 SYNTHROID 3 MG, 60 MG, 90 MG TIROSINT ORAL thyroid (pork) 3 CAPSULE 100 MCG, thyroid, pork (bulk) 3 112 MCG, 125 MCG, powder 100 % usp 13 MCG, 137 MCG, 3 WESTHROID ORAL 150 MCG, 25 MCG, 50 TABLET 130 MG, 195 MCG, 75 MCG, 88 3 MG, 32.5 MG, 65 MG, MCG 97.5 MG TIROSINT ORAL WP THYROID 3 CAPSULE 175 MCG, 3 PA 200 MCG TIROSINT-SOL 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 193 Drug Name Drug Tier Limits Drug Name Drug Tier Limits UNITHROID 1 ANTIDIARRHEA ENZYMES L ANTIPERISTALT ENZYMES IC- AMPHADASE 4 ANTICHOLINER carica papaya oral 1 GIC tablet,chewable COMBINATIONS HYLENEX 4 diphenoxylate-atropine 1 HYQVIA HY 3 LOMOTIL 3 COMPONENT MOTOFEN 3 VITRASE 4 ANTIDIARRHEA FDB CLASS L OBSOLETE- MISCELLANEOU NOT USED S ARGININE COMBINATIONS VASOPRESSIN BANATROL PLUS 3 (AVP) V2 ANTIDIARRHEA RECEPTOR L OPIOID ANTAGONIST, AGENTS SELECTIVE opium tincture 3 JYNARQUE ORAL 2 PA TABLET ANTIEMETIC - SAMSCA 2 ANTICHOLINER GICS GASTROINTEST QL (12 EA per TRANSDERM-SCOP 3 INAL THERAPY 30 days) AGENTS ANTIEMETIC - ANTIDIARRHEA ANTIHISTAMINE L - S ANTIPERISTALT ANTIVERT ORAL IC AGENTS TABLET 12.5 MG, 25 3 loperamide (bulk) 3 MG opium tincture 3 dimenhydrinate 3 ANTIDIARRHEA injection solution L - BISMUTH ANTIEMETIC - AGENTS ANTIHISTAMINE bismuth citrate (bulk) 3 -VITAMIN COMBINATIONS BONJESTA 3 DICLEGIS 3 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 194 Drug Name Drug Tier Limits Drug Name Drug Tier Limits doxylamine-pyridoxine prochlorperazine 3 (vit b6) maleate oral tablet 10 1 LA ANTIEMETIC - mg prochlorperazine CANNABINOID 2 LA TYPE maleate oral tablet 5 mg promethazine (bulk) 3 CESAMET 2 PA promethazine injection dronabinol oral capsule 3 3 solution 25 mg/ml 10 mg promethazine injection dronabinol oral capsule 1 3 PA solution 50 mg/ml 2.5 mg, 5 mg promethazine oral tablet 1 SYNDROS 3 promethazine rectal ANTIEMETIC - suppository 12.5 mg, 25 1 DOPAMINE mg (D2)/5-HT3 promethazine rectal 3 ANTAGONISTS suppository 50 mg TIGAN 3 PROMETHEGAN 1 INTRAMUSCULAR ANTIEMETIC - TIGAN ORAL 3 SELECTIVE CAPSULE 300 MG SEROTONIN 5- trimethobenzamide oral 1 HT3 ANTIEMETIC - ANTAGONISTS OTHER ALOXI 4 cola (syrup) 1 granisetron (pf) 1 ANTIEMETIC - granisetron hcl 1 PHENOTHIAZIN intravenous ES QL (6 EA per granisetron hcl oral 1 COMPAZINE ORAL 3 LA 23 days) COMPAZINE ondansetron 1 3 RECTAL ondansetron hcl 1 COMPRO 1 LA ondansetron hcl (pf) 1 PHENERGAN palonosetron 4 INJECTION 3 SANCUSO 3 PA SOLUTION 25 MG/ML SUSTOL 3 PHENERGAN ZOFRAN ORAL INJECTION 1 3 SOLUTION 50 MG/ML TABLET prochlorperazine 1 LA ZUPLENZ 3 prochlorperazine 2 PA; LA edisylate

You can find information on what the symbols and abbreviations on this table mean on page 4. 195 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIEMETIC - CHRONIC SUBSTANCE P- IDIOPATHIC NEUROKININ 1 CONST. AGENTS (NK1) RECEPTOR - GUANYLATE ANTAGONISTS CYCLASE-C (GC- aprepitant 1 C) AGONISTS CINVANTI 4 PA LINZESS 2 PA EMEND TRULANCE 3 PA 4 (FOSAPREPITANT) COLONIC EMEND ORAL ACIDIFIER CAPSULE 40 MG, 80 3 PA (AMMONIA MG INHIBITOR) EMEND ORAL ENULOSE 1 CAPSULE,DOSE 3 PA PACK GENERLAC 1 lactulose oral solution EMEND ORAL 1 SUSPENSION FOR 3 PA 10 gram/15 ml RECONSTITUTION DIGESTIVE fosaprepitant 4 ENZYME VARUBI MIXTURES 4 INTRAVENOUS CREON 1 VARUBI ORAL 3 PA PANCREAZE ORAL ANTIEMETIC - CAPSULE,DELAYED SUBSTANCE P- RELEASE(DR/EC) NEUROKININ 1 10,500-35,500- 61,500 UNIT, 16,800-56,800- 3 AND 5-HT3 98,400 UNIT, 2,600- RECEPT 6,200- 10,850 UNIT, ANTAGONIST 21,000-54,700- 83,900 COMB UNIT, 4,200-14,200- 24,600 UNIT AKYNZEO 2 PA (FOSNETUPITANT) PERTZYE 3 AKYNZEO VIOKACE 3 3 PA (NETUPITANT) BILE ACIDS CHOLBAM 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 196 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ZENPEP ORAL GASTRIC ACID CAPSULE,DELAYED SECRETION RELEASE(DR/EC) REDUCERS - 10,000-32,000 -42,000 UNIT, 15,000-47,000 - HISTAMINE H2- 63,000 UNIT, 20,000- RECEPTOR 63,000- 84,000 UNIT, 1 ANTAGONISTS 25,000-79,000- 105,000 cimetidine hcl oral 1 UNIT, 3,000-10,000 - cimetidine oral tablet 14,000-UNIT, 40,000- 1 126,000- 168,000 300 mg, 800 mg UNIT, 5,000-17,000- cimetidine oral tablet 3 24,000 UNIT 400 mg DIGESTIVE famotidine (pf) 3 ENZYMES famotidine (pf)-nacl 3 DAIRY AID 1 (iso-os) DAIRY DIGESTIVE 1 famotidine in 0.9 % nacl intravenous syringe 20 3 DAIRY DIGESTIVE 1 mg/10 ml SUPPLEMENT famotidine intravenous 3 DAIRY RELIEF 1 solution lactase 1 famotidine oral 1 LACTASE FAST suspension 1 ACTING famotidine oral tablet 40 1 LACTOSE FAST mg 1 ACTING RELIEF nizatidine oral capsule 2 PA SUCRAID 1 nizatidine oral solution 3 ULTRA DAIRY PEPCID ORAL 1 3 DIGESTIVE TABLET GALLSTONE ranitidine hcl oral syrup 1 SOLUBILIZING ranitidine hcl oral tablet 1 (LITHOLYSIS) 300 mg AGENTS GASTRIC ACID ACTIGALL 3 SECRETION CHENODAL 3 REDUCING URSO 250 3 AGENTS - URSO FORTE 3 PROTON PUMP ursodiol 1 INHIBITORS (PPIS) ursodiol (bulk) 3 ACIPHEX 3 QL (60 EA per ACIPHEX SPRINKLE 3 365 days)

You can find information on what the symbols and abbreviations on this table mean on page 4. 197 Drug Name Drug Tier Limits Drug Name Drug Tier Limits QL (60 EA per PROTONIX ORAL DEXILANT 2 QL (60 EA per 365 days) TABLET,DELAYED 3 365 days) ESOMEP-EZS 3 RELEASE (DR/EC) rabeprazole oral esomeprazole QL (60 EA per magnesium oral QL (60 EA per tablet,delayed release 1 3 365 days) capsule,delayed 365 days) (dr/ec) release(dr/ec) 40 mg GASTRIC ACID esomeprazole sodium SECRETION intravenous recon soln 2 PA REDUCING- 20 mg PROTON PUMP esomeprazole sodium INHIBITOR AND intravenous recon soln 4 ANTACID COMB 40 mg omeprazole-sodium QL (60 EA per lansoprazole (bulk) 3 bicarbonate oral capsule 3 365 days) lansoprazole oral 40-1.1 mg-gram QL (60 EA per capsule,delayed 2 365 days) omeprazole-sodium release(dr/ec) 30 mg bicarbonate oral packet 3 QL (60 EA per 20-1,680 mg NEXIUM 3 365 days) ZEGERID ORAL QL (60 EA per 3 NEXIUM IV CAPSULE 365 days) INTRAVENOUS 2 PA ZEGERID ORAL 3 RECON SOLN 40 MG PACKET NEXIUM PACKET 3 GASTRIC omeprazole (bulk) 3 MUCOSA - omeprazole oral QL (60 EA per CYTOPROTECTI capsule,delayed 1 365 days) VE release(dr/ec) PROSTAGLANDI pantoprazole 2 PA N ANALOGS intravenous CYTOTEC 3 pantoprazole oral QL (60 EA per tablet,delayed release 1 misoprostol 1 365 days) (dr/ec) GASTROINTESTI PREVACID 3 NAL - QL (60 EA per PROKINETIC PREVACID SOLUTAB 3 365 days) AGENTS - 5-HT4 PRILOSEC ORAL RECEPTOR SUSP,DELAYED AGONISTS 3 RELEASE FOR MOTEGRITY 3 RECON PROTONIX 2 PA INTRAVENOUS PROTONIX ORAL GRANULES DR FOR 3 SUSP IN PACKET You can find information on what the symbols and abbreviations on this table mean on page 4. 198 Drug Name Drug Tier Limits Drug Name Drug Tier Limits hyoscyamine sulfate GASTROINTESTI 1 NAL oral hyoscyamine sulfate ANTIFLATULEN 1 TS sublingual activated charcoal oral HYOSYNE 1 1 capsule 260 mg LEVBID 3 BEANO ORAL LEVSIN 3 1 TABLET LEVSIN/SL 3 GASTROINTESTI methscopolamine 1 NAL NULEV 1 PROKINETIC OSCIMIN ORAL 1 AGENTS - D2 TABLET ANTAGONIST/5- OSCIMIN SL 1 HT4 AGONISTS OSCIMIN SR 1 metoclopramide hcl 3 injection SYMAX DUOTAB 3 metoclopramide hcl oral SYMAX FASTABS 1 1 solution SYMAX-SL 1 metoclopramide hcl oral SYMAX-SR 1 1 tablet GI metoclopramide hcl oral 3 ANTISPASMODIC tablet,disintegrating - QUATERNARY REGLAN ORAL 3 AMMONIUM GI COMPOUNDS ANTISPASMODIC glycopyrrolate (pf) in 4 - BELLADONNA water injection ALKALOIDS glycopyrrolate (pf) in water intravenous ANASPAZ 3 4 syringe 0.4 mg/2 ml (0.2 atropine (bulk) 3 mg/ml) atropine injection 4 glycopyrrolate injection 1 solution glycopyrrolate oral atropine injection 1 4 tablet 1 mg, 2 mg syringe 0.05 mg/ml GLYRX-PF 4 belladonna tincture 1 (bulk) propantheline 1 ED-SPAZ 1 homatropine 3 methylbrom (bulk) hyoscyamine sulfate 3 (bulk)

You can find information on what the symbols and abbreviations on this table mean on page 4. 199 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DONNATAL ORAL GI 3 ANTISPASMODIC TABLET LIBRAX (WITH - SYNTHETIC 3 TERTIARY CLIDINIUM) AMINES PHENOHYTRO ORAL ELIXIR 16.2-0.1037 - 3 BENTYL 3 0.0194 MG/5 ML INTRAMUSCULAR PHENOHYTRO ORAL dicyclomine 3 1 TABLET intramuscular dicyclomine oral IBS AGENT - 1 capsule GASTROINTESTI dicyclomine oral NAL CHLORIDE 1 solution CHANNEL dicyclomine oral tablet 1 ACTIVATOR AGENTS GI ANTISPASMODIC AMITIZA 3 AND IBS AGENT - BENZODIAZEPIN GUANYLATE E CYCLASE-C (GC- COMBINATIONS C) AGONISTS chlordiazepoxide- LINZESS 2 PA 3 clidinium TRULANCE 3 PA LIBRAX (WITH 3 IBS AGENT - CLIDINIUM) MIXED OPIOID GI RECEPTOR ANTISPASMODIC AGONIST AND AND OPIOID ANTAGONIST COMBINATIONS VIBERZI 3 belladonna alkaloids- 3 IBS AGENT - opium SELECTIVE 5- GI HT3 RECEPTOR ANTISPASMODIC ANTAGONISTS COMBINATIONS alosetron 3 PA OTHER LOTRONEX 3 belladonna alkaloids- 3 opium chlordiazepoxide- 3 clidinium DONNATAL ORAL ELIXIR 16.2-0.1037 - 3 0.0194 MG/5 ML

You can find information on what the symbols and abbreviations on this table mean on page 4. 200 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INFLAMMATOR SFROWASA 1 Y BOWEL sulfasalazine 1 AGENT - INFLAMMATOR INTERLEUKIN-12 Y BOWEL AND IL-23 AGENT - INHIBITORS, MC GLUCOCORTICO AB IDS STELARA 4 PA budesonide oral 1 INTRAVENOUS CORTENEMA 3 STELARA SUBCUTANEOUS 3 PA CORTIFOAM 3 SOLUTION ENTOCORT EC 3 STELARA hydrocortisone rectal 1 SUBCUTANEOUS 3 PA UCERIS ORAL 3 SYRINGE 90 MG/ML UCERIS RECTAL 3 PA INFLAMMATOR INFLAMMATOR Y BOWEL Y BOWEL AGENT - AGENT - AMINOSALICYL INTEGRIN ATES AND RECEPTOR RELATED ANTAGONIST, AGENTS MC ANTIBODY APRISO 3 ENTYVIO 4 PA ASACOL HD 1 INFLAMMATOR AZULFIDINE 3 Y BOWEL AZULFIDINE EN- 3 AGENT - JANUS TABS KINASE (JAK) balsalazide 1 INHIBITORS CANASA 1 XELJANZ ORAL 3 PA COLAZAL 3 TABLET 10 MG DELZICOL ORAL XELJANZ ORAL 3 CAPSULE (WITH DEL 3 PA TABLET 5 MG REL TABLETS) XELJANZ XR ORAL DIPENTUM 3 ST TABLET EXTENDED 3 LIALDA 1 RELEASE 24 HR 22 MG mesalamine 1 mesalamine with 3 cleansing wipe PENTASA 1 ROWASA RECTAL 3 ENEMA KIT

You can find information on what the symbols and abbreviations on this table mean on page 4. 201 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INFLAMMATOR INTESTINAL Y BOWEL FLORA AGENT - TUMOR MODIFIERS NECROSIS ACIDOPHILUS EX 1 FACTOR ALPHA STR (L. SPOROG) BLOCKERS ACIDOPHILUS 1 CIMZIA 3 PROBIOTIC BLEND CIMZIA POWDER acidophilus-pectin, 3 FOR RECONST citrus oral capsule 100 3 million cell-10 mg CIMZIA STARTER 3 acidophilus-pectin, KIT 1 citrus oral tablet PA; QL (2 EA HUMIRA PEN 2 per 28 days) BACID 1 BIOGAIA PROTECTIS HUMIRA PEN 3 CROHNS-UC-HS 2 PA WITH VIT D3 START CULTURELLE HUMIRA PEN PSOR- WOMEN HEALTH 3 2 PA UVEITS-ADOL HS BALANC DAILY PROBIOTIC HUMIRA 3 SUBCUTANEOUS (10 STRAINS) SYRINGE KIT 10 2 PA EVIVO 3 MG/0.2 ML, 20 MG/0.4 EVIVO STARTER KIT 3 ML EVIVO WITH MCT HUMIRA 3 OIL SUBCUTANEOUS PA; QL (2 EA 2 SYRINGE KIT 40 per 28 days) FLORAJEN3 1 MG/0.8 ML FLORAJEN4KIDS 1 HUMIRA(CF) 2 PA FLORANEX ORAL 1 HUMIRA(CF) PEDI TABLET 2 PA CROHNS STARTER GERBER GENTLE 3 HUMIRA(CF) PEN 2 PA PROBIOTIC GERBER SOOTHE INFLECTRA 4 PA 3 VIT D-PROBIOTIC REMICADE 4 PA HIGH POTENCY RENFLEXIS 4 PA 3 PROBIOTIC SIMPONI l.acidoph,saliva-b.bif- SUBCUTANEOUS 1 3 PA s.therm PEN INJECTOR 100 MG/ML LACTINEX 1 SIMPONI lactobacill.acidophilus SUBCUTANEOUS 3 PA (bulk) powder , 10 3 SYRINGE 100 MG/ML billion unit/gram

You can find information on what the symbols and abbreviations on this table mean on page 4. 202 Drug Name Drug Tier Limits Drug Name Drug Tier Limits lactobacillus acidophilus LAXATIVE - oral tablet 1 billion cell, 1 BULK FORMING 500 million cell BENEFIBER lactobacillus acidoph- 3 3 HEALTHY SHAPE l.bulgar COLOX 1 MOOD SUPPORT 3 EASY FIBER ORAL PROBIOTIC 1 POWDER ONE-A-DAY TRUBIOTICS ORAL 3 FIBER (DEXTRIN) 1 CAPSULE karaya gum (bulk) 3 PHILLIPS' COLON METAMUCIL FREE 3 1 HEALTH METAMUCIL PLUS 1 PROBIOTIC CALCIUM COMPLEX (WITH 3 LAXATIVE - FOS) SALINE AND PROBIOTIC-10 (WITH 3 OSMOTIC INULIN) CONSTULOSE 1 PRODIGEN 3 KRISTALOSE 1 PROVAD 3 lactulose oral packet 3 PROVELLA 1 lactulose oral solution RESTORA RX 3 10 gram/15 ml, 20 1 RISA-BID 1 gram/30 ml SENIOR PROBIOTIC 1 LAXATIVE - ULTIMATE FLORA 3 SALINE/OSMOTI PROBIOTIC C MIXTURES VSL#3 DS 3 GAVILYTE-C 1 ZELAC 3 GAVILYTE-G 1 IRRITABLE GAVILYTE-N 1 BOWEL GOLYTELY 3 SYNDROME (IBS) MOVIPREP 1 AGENTS NULYTELY WITH 1 alosetron 3 PA FLAVOR PACKS AMITIZA 3 OSMOPREP 1 LINZESS 2 PA peg 3350-electrolytes LOTRONEX 3 oral recon soln 236- 1 VIBERZI 3 22.74-6.74 -5.86 gram PEG-3350 WITH KERATINOCYTE 1 FLAVOR PACKS GROWTH FACTOR (KGF) peg-electrolyte soln 1 PLENVU 3 KEPIVANCE 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 203 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SUPREP BOWEL 1 PEPTIC ULCER- PREP KIT TREATMENT H. TRILYTE WITH 3 PYLORI-PROTON FLAVOR PACKETS PUMP LAXATIVE - INHIBITOR AND STIMULANT AND ANTIBIOTICS SALINE/OSMOTI amoxicil-clarithromy- QL (112 EA 3 C lansopraz per 23 days) COMBINATIONS OMECLAMOX-PAK 3 CLENPIQ 3 SHORT BOWEL PEG-PREP 3 SYNDROME PREPOPIK 2 PA (SBS) - LAXATIVE - GLUCAGON- STIMULANT LIKE PEPTIDE-2 (GLP-2) ANALOG castor oil oral oil 1 GATTEX 30-VIAL 2 PA SENNA ORAL SYRUP 1 176 MG/5 ML GATTEX ONE-VIAL 2 PA PEPTIC ULCER - SHORT BOWEL GASTRIC SYNDROME LUMEN (SBS) AGENTS ADHERENT ENDARI 3 CYTOPROTECTI octreotide acetate 4 VES SAIZEN CARAFATE ORAL SUBCUTANEOUS 3 1 SUSPENSION RECON SOLN 8.8 MG CARAFATE ORAL SANDOSTATIN 3 TABLET INJECTION SOLUTION 100 sucralfate 1 4 MCG/ML, 50 sucralfate (bulk) 3 MCG/ML, 500 PEPTIC ULCER - MCG/ML TREATMENT OF SANDOSTATIN LAR H. PYLORI: DEPOT INTRAMUSCULAR ANTIBIOTIC- 3 BISMUTH SUSPENSION,EXTEN DED REL RECON 10 COMBINATIONS MG, 20 MG PYLERA 1 ZORBTIVE 4 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 204 Drug Name Drug Tier Limits Drug Name Drug Tier Limits GENITOURINA THIOLA EC 2 PA RY THERAPY OVERACTIVE BPH AGENT- 5- BLADDER ALPHA AGENTS - BETA - REDUCTASE 3 ADRENERGIC INHIB AND RECEPTOR ALPHA-1 AGONIST ADRENOCEPTOR MYRBETRIQ 2 PA ANTAG COMB PHOSPHATE dutasteride-tamsulosin 3 BINDERS - JALYN 3 CALCIUM- CYSTINOSIS BASED THERAPY calcium acetate oral (CYSTINE tablet 668 mg (169 mg 3 calcium) DEPLETING calcium AGENTS) 1 acetate(phosphat bind) CYSTAGON 1 CALPHRON 1 PROCYSBI ORAL PHOSLYRA 1 CAPSULE, DELAYED 3 REL SPRINKLE PHOSPHATE G.U. IRRIGANTS - BINDERS - IRON- ANTI-INFECTIVE BASED neomycin-polymyxin b AURYXIA 3 4 gu VELPHORO 3 G.U. IRRIGANTS PHOSPHATE acetic acid irrigation 3 BINDERS RENACIDIN AURYXIA 3 IRRIGATION calcium acetate oral SOLUTION 1980.6 1 tablet 668 mg (169 mg 3 MG-59.4 MG- calcium) 980.4MG/30ML calcium 1 sorbitol irrigation 3 acetate(phosphat bind) sorbitol-mannitol 3 CALPHRON 1 INTERSTITIAL FOSRENOL ORAL 3 PA CYSTITIS POWDER IN PACKET AGENTS FOSRENOL ORAL 2 PA ELMIRON 2 TABLET,CHEWABLE KIDNEY STONE lanthanum 3 PA AGENTS MAGNEBIND 300 3 THIOLA 2 PA MAGNEBIND 400 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 205 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PHOSLYRA 1 PROSTATIC RENAGEL ORAL HYPERTROPHY 3 TABLET 800 MG AGENT - TYPE II RENVELA 2 PA 5-ALPHA sevelamer carbonate 3 PA REDUCTASE sevelamer hcl 2 PA INHIBITORS finasteride oral tablet 5 VELPHORO 3 1 mg POLYCYSTIC PROSCAR 3 KIDNEY DISEASE - PROSTATIC VASOPRESSIN V2 HYPERTROPHY RECEPTOR AGENT- ANTAGONISTS SEL.CGMP PHOSPHODIEST JYNARQUE ORAL 2 PA TABLET ERASE TYPE5 INHIBITOR JYNARQUE ORAL TABLETS, CIALIS ORAL SEQUENTIAL 45 MG TABLET 2.5 MG, 5 3 (AM)/ 15 MG (PM), 60 3 MG MG (AM)/ 30 MG tadalafil oral tablet 2.5 2 PA (PM), 90 MG (AM)/ 30 mg, 5 mg MG (PM) PROSTATIC SAMSCA 2 HYPERTROPHY PROSTATIC AGENT-TYPE I HYPERTROPHY AND II 5-ALPHA AGENT - ALPHA- REDUCTASE 1- INHIBITORS ADRENOCEPTOR AVODART 3 ANTAGONISTS dutasteride 1 alfuzosin 2 PA dutasteride (bulk) 3 FLOMAX 3 URINARY RAPAFLO 3 ACIDIFIER - silodosin 3 PA BACTERIAL tamsulosin 1 UREASE UROXATRAL 3 INHIBITOR LITHOSTAT 2 PA URINARY ACIDIFIER - OTHERS ammonium chloride 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 206 Drug Name Drug Tier Limits Drug Name Drug Tier Limits URINARY URINARY ACIDIFIER - ANALGESICS PHOSPHATES phenazopyridine oral 1 K-PHOS NO 2 1 tablet 100 mg, 200 mg K-PHOS ORIGINAL 1 PYRIDIUM 3 K-PHOS-NEUTRAL 3 URINARY PHOSPHA 250 ANTIBACTERIAL 1 NEUTRAL - METHENAMINE PHOSPHOROUS 1 AND SALTS PHOSPHO-TRIN 250 HIPREX 3 1 NEUTRAL methenamine hippurate 1 VIRT-PHOS 250 1 methenamine mandelate 3 NEUTRAL methenamine mandelate 3 URINARY (bulk) ALKALINIZER - UROQID-ACID NO.2 3 CITRATES URINARY CYTRA-2 3 ANTIBACTERIAL CYTRA-3 3 - NITROFURAN cytra-k 3 DERIVATIVES ORACIT 1 FURADANTIN 1 pot,sodium citrate-citric MACROBID 3 1 acid MACRODANTIN 3 potassium citrate 3 nitrofurantoin 1 potassium citrate-citric nitrofurantoin 1 1 acid oral solution macrocrystal SHOHL'S MODIFIED 1 nitrofurantoin 1 sodium citrate monohyd/m-cryst 1 dihydrate(bulk) granules URINARY sodium citrate-citric 1 ANTIBACTERIAL acid - QUINOLONES TRICITRATES 1 CIPRO XR 3 UROCIT-K 10 3 URINARY UROCIT-K 15 3 ANTIBACTERIAL UROCIT-K 5 3 S OTHER VIRTRATE-2 3 MONUROL 1 VIRTRATE-3 3 ZEMDRI 4 VIRTRATE-K 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 207 Drug Name Drug Tier Limits Drug Name Drug Tier Limits URINARY ANTI- URINARY INFECTIVE ANTISPASMODIC METHENAMINE- - ANTISPAS- ANTICHOLINER ANALG GICS, NON- COMBINATIONS SELECTIVE HYOPHEN 3 ANASPAZ 3 PHOSPHASAL 1 ED-SPAZ 1 URELLE 3 hyoscyamine sulfate 3 URETRON D-S ORAL (bulk) TABLET 81.6-10.8- 1 hyoscyamine sulfate 1 40.8 MG oral URIBEL 3 hyoscyamine sulfate 1 URIMAR-T 3 sublingual URIN DS 1 HYOSYNE 1 URO-MP 3 LEVBID 3 USTELL 3 LEVSIN ORAL 3 UTIRA-C 3 LEVSIN/SL 3 URINARY ANTI- NULEV 1 OSCIMIN ORAL INFECTIVE 1 METHENAMINE- TABLET ANTISPASMODIC OSCIMIN SL 1 COMBINATIONS OSCIMIN SR 1 methen-sod phos-meth SYMAX DUOTAB 3 3 blue-hyos SYMAX FASTABS 1 UROGESIC-BLUE 3 SYMAX-SL 1 URYL 3 SYMAX-SR 1 URINARY URINARY ANTISPASMODIC ANTISPASMODIC - ANTICHOL., - SMOOTH M(3) MUSCLE MUSCARINIC RELAXANTS SELECTIVE DETROL 3 PA (BLADDER) DETROL LA 3 PA darifenacin 2 PA DITROPAN XL ORAL solifenacin 3 TABLET EXTENDED 3 VESICARE 3 RELEASE 24HR 10 MG, 5 MG flavoxate 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 208 Drug Name Drug Tier Limits Drug Name Drug Tier Limits GELNIQUE GOUT AND TRANSDERMAL GEL 3 HYPERURICEMI IN PACKET A - oxybutynin chloride 1 ANTIMITOTIC- OXYTROL 3 URICOSURIC tolterodine 3 COMBINATIONS TOVIAZ 3 probenecid-colchicine 1 trospium 3 HYPERURICEMI URINARY PH A THERAPY - MODIFIERS URATE-OXIDASE aminobenzoic acid ENZYME-TYPE 3 (bulk) ELITEK 4 URINARY KRYSTEXXA 4 PA RETENTION HYPERURICEMI THERAPY - A THERAPY - PARASYMPATH URICOSURICS OMIMETIC probenecid 1 AGENTS HYPERURICEMI bethanechol chloride 1 A THERAPY - bethanechol chloride 3 XANTHINE (bulk) OXIDASE URECHOLINE ORAL INHIBITORS TABLET 25 MG, 50 3 MG allopurinol 1 GOUT AND ALOPRIM 4 HYPERURICEM febuxostat 3 IA THERAPY ULORIC 3 ST GOUT ACUTE ZYLOPRIM 3 THERAPY - HEMATOLOGIC ANTIMITOTICS AL AGENTS colchicine (bulk) 3 AGENTS TO colchicine oral capsule 1 TREAT ATTP- colchicine oral tablet 3 ANTI VON COLCRYS 3 WILLEBRAND FACTOR (VWF) GLOPERBA 3 PA A1 DOMAIN MITIGARE 3 CABLIVI INJECTION 4 PA KIT CABLIVI INJECTION 3 PA RECON SOLN

You can find information on what the symbols and abbreviations on this table mean on page 4. 209 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ELIQUIS DVT-PE ANTICOAGULAN 1 TS - CITRATE- TREAT 30D START BASED SAVAYSA 3 XARELTO DVT-PE QL (51 EA per ACD SOLUTION A 3 1 TREAT 30D START 23 days) anticoag citrate phos 1 XARELTO ORAL dextrose QL (30 EA per TABLET 10 MG, 15 1 sodium citrate (bulk) 3 23 days) MG, 20 MG sodium citrate in 0.9 % 4 XARELTO ORAL nacl 1 TABLET 2.5 MG sodium citrate intra- 4 catheter ERYTHROPOIET INS ANTICOAGULAN TS - COUMARIN ARANESP (IN POLYSORBATE) 4 PA JANTOVEN 1 INJECTION warfarin 1 SOLUTION BLOOD CELL ARANESP (IN AND PLATELET POLYSORBATE) 2 PA INJECTION SYRINGE DISORDER TX- SPLEEN EPOGEN INJECTION SOLUTION 10,000 TYROSINE UNIT/ML, 2,000 KINASE UNIT/ML, 20,000 4 PA INHIBITORS UNIT/2 ML, 20,000 TAVALISSE 2 PA UNIT/ML, 3,000 UNIT/ML, 4,000 C1 ESTERASE UNIT/ML INHIBITOR MIRCERA 3 PA AGENTS PROCRIT 3 PA BERINERT 4 PA RETACRIT 3 PA INTRAVENOUS KIT CINRYZE 4 PA GRANULOCYTE COLONY- HAEGARDA 2 PA STIMULATING RUCONEST 4 PA FACTOR (G-CSF) CXCR4 FULPHILA 3 PA CHEMOKINE GRANIX 2 PA RECEPTOR ANTAGONISTS NEULASTA 3 PA NEUPOGEN 4 PA MOZOBIL 3 NIVESTYM 3 DIRECT FACTOR INJECTION XA INHIBITORS UDENYCA 3 PA ELIQUIS 1 ZARXIO 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 210 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ZIEXTENZO 4 SURGIFOAM GRANULOCYTE- TOPICAL SPONGE 3 100 MACROPHAGE COLONY- HEPARIN FLUSH STIMULATING FORMULATIONS FACTOR (GM- HEP FLUSH-10 (PF) 4 CSF) heparin (porcine) in nacl 2 PA LEUKINE INJECTION (pf) 3 RECON SOLN heparin flush(porcine)- 4 HEMATORHEOL 0.9nacl OGIC AGENTS HEPARIN LOCK 4 pentoxifylline 1 heparin lock flush (porcine) intravenous 2 PA HEMOSTATIC solution SYSTEMIC - heparin lock flush ANTIFIBRINOLY (porcine) intravenous 4 TIC AGENTS syringe 10 unit/ml AMICAR 1 heparin lock flush aminocaproic acid (porcine) intravenous 2 PA 4 intravenous syringe 100 unit/ml aminocaproic acid oral HEPARIN LOCK 1 FLUSH tablet 4 INTRAVENOUS CYKLOKAPRON 4 SOLUTION LYSTEDA 3 HEPARIN LOCK tranexamic acid (bulk) FLUSH 3 2 PA powder INTRAVENOUS tranexamic acid in SYRINGE 4 nacl,iso-os HEPARIN tranexamic acid LOCKFLUSH(PORCIN 4 4 intravenous E)(PF) tranexamic acid oral 1 heparin, porcine (pf) intravenous solution 100 4 HEMOSTATIC unit/ml (1 ml) TOPICAL heparin, porcine (pf) 2 PA AGENTS intravenous syringe ferric chloride (bulk) 3 HEPARINS powder HEP FLUSH-10 (PF) 4 GEL-FLOW 3 heparin (porcine) in GEL-FLOW NT 4 0.9% nacl intravenous 1 MONSEL'S 1 parenteral solution 30,000 unit/1,000 ml

You can find information on what the symbols and abbreviations on this table mean on page 4. 211 Drug Name Drug Tier Limits Drug Name Drug Tier Limits heparin (porcine) in 5 % heparin(porcine) in dex intravenous 0.45% nacl intravenous parenteral solution parenteral solution 2 PA 20,000 unit/500 ml (40 12,500 unit/250 ml, 2 PA unit/ml), 25,000 25,000 unit/250 ml, unit/250 ml(100 25,000 unit/500 ml unit/ml), 25,000 heparin, porcine (pf) 2 PA unit/500 ml (50 unit/ml) injection solution heparin (porcine) in nacl 2 PA heparin, porcine (pf) (pf) injection syringe 5,000 2 PA heparin (porcine) unit/0.5 ml 2 PA injection cartridge heparin, porcine (pf) heparin (porcine) injection syringe 5,000 1 injection solution 1,000 1 unit/ml unit/ml, 5,000 unit/ml heparin, porcine (pf) heparin (porcine) intravenous solution 100 4 injection solution unit/ml (1 ml) 2 PA 10,000 unit/ml, 20,000 heparin, porcine (pf) 2 PA unit/ml intravenous syringe heparin flush(porcine)- heparin, porcine (pf) 4 2 PA 0.9nacl subcutaneous HEPARIN LOCK 4 HUMAN heparin lock flush ALBUMIN (porcine) intravenous 2 PA solution ALBUKED-25 4 heparin lock flush ALBUKED-5 4 (porcine) intravenous 4 albumin, human 25 % 4 syringe 10 unit/ml albumin, human 5 % 4 heparin lock flush ALBUMINAR 25 % 4 (porcine) intravenous 2 PA syringe 100 unit/ml ALBUMINAR 5 % 4 HEPARIN LOCK ALBUMINEX 4 FLUSH ALBURX (HUMAN) 4 4 INTRAVENOUS 25 % SOLUTION ALBURX (HUMAN) 5 4 HEPARIN LOCK % FLUSH 2 PA ALBUTEIN 25 % 4 INTRAVENOUS SYRINGE ALBUTEIN 5 % 4 HEPARIN BUMINATE 25 % 4 LOCKFLUSH(PORCIN 4 BUMINATE 5 % 4 E)(PF) FLEXBUMIN 25 % 4 FLEXBUMIN 5 % 4 PLASBUMIN 25 % 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 212 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PLASBUMIN 5 % 4 LMD 10 % IN 5 % 4 HUMAN DEXTROSE MONOCLONAL PLASMA ANTIBODY FRACTIONS COMPLEMENT OCTAPLAS (BLOOD 4 (C5) INHIBITORS GROUP A) OCTAPLAS (BLOOD SOLIRIS 4 4 GROUP AB) ULTOMIRIS 4 PA OCTAPLAS (BLOOD 4 INDIRECT GROUP B) FACTOR XA OCTAPLAS (BLOOD 4 INHIBITORS GROUP O) ARIXTRA 3 PLASMANATE 4 fondaparinux 3 PLASMA LOW PROTEINS MOLECULAR WHICH WEIGHT FACILITATE HEPARINS ANTICOAGULAT QL (20 ML per ION enoxaparin 1 10 days) THROMBATE III 4 FRAGMIN PLATELET SUBCUTANEOUS 3 SOLUTION AGGREGATION INHIB - FRAGMIN SUBCUTANEOUS 3 CYCLOPENTYL- SYRINGE TRIAZOLO- QL (20 ML per PYRIMIDINES LOVENOX 3 10 days) (CPTPS) MONOCLONAL BRILINTA 1 ST ANTIBODY - P- KENGREAL 3 SELECTIN PLATELET INHIBITORS AGGREGATION ADAKVEO 4 INHIBITOR PLASMA COMBINATIONS EXPANDERS AGGRENOX 3 HESPAN 6 % IN NS 4 aspirin-dipyridamole 1 hetastarch 6 % in 0.9 % 4 nacl HEXTEND 4 LMD 10 % IN 0.9 % 4 SODIUM CHLOR

You can find information on what the symbols and abbreviations on this table mean on page 4. 213 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PLATELET PLATELET AGGREGATION AGGREGATION INHIBITORS - INHIB- GLYCOPROTEIN PDESTERASE IIB/IIIA AND ADENOSINE RECEPTOR DEAMINASE INHIB INHIBITR AGGRASTAT IN dipyridamole 4 4 SODIUM CHLORIDE intravenous INTEGRILIN 4 dipyridamole oral 1 PLATELET PLATELET AGGREGATION AGGREGATION INHIBITORS - INHIB- PHOSPHODIEST PROTEASE- ERASE III ACTIV.RECEPTO INHIBITORS R-1(PAR-1) cilostazol 1 ANTAGONIST PLATELET ZONTIVITY 3 AGGREGATION PROTEIN C INHIBITORS - PREPARATIONS QUINAZOLINE CEPROTIN (BLUE 4 AGENTS BAR) AGRYLIN 3 CEPROTIN (GREEN 4 anagrelide 1 BAR) PLATELET SICKLE CELL AGGREGATION ANEMIA INHIBITORS - AGENTS, SALICYLATES OTHERS DURLAZA 3 DROXIA 1 PLATELET ENDARI 3 AGGREGATION L-GLUTAMINE 3 SIKLOS ORAL INHIBITORS - 1 THIENOPYRIDIN TABLET 1,000 MG SIKLOS ORAL E AGENTS 2 TABLET 100 MG clopidogrel 1 EFFIENT 3 ST SICKLE CELL ANEMIA PLAVIX ORAL 3 TABLET 75 MG AGENTS prasugrel 3 PA DROXIA 1 ENDARI 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 214 Drug Name Drug Tier Limits Drug Name Drug Tier Limits L-GLUTAMINE 3 THROMBOPOIET SIKLOS ORAL IN RECEPTOR 1 TABLET 1,000 MG AGONISTS SIKLOS ORAL DOPTELET (10 TAB 2 2 TABLET 100 MG PACK) THROMBIN DOPTELET (15 TAB 2 INHIBITOR - PACK) SELECTIVE MULPLETA 3 PA DIRECT AND NPLATE 4 REVERSIBLE - PROMACTA ORAL HIRUDIN TYPE POWDER IN PACKET 2 PA bivalirudin intravenous 12.5 MG 4 recon soln PROMACTA ORAL 2 bivalirudin-0.9 % TABLET 4 sodium chlor HEPATOBILIAR THROMBIN Y SYSTEM INHIBITOR - TREATMENT SELECTIVE AGENTS DIRECT AND AHP AGENTS - REVERSIBLE ALAS1 argatroban 4 DEGRADATION, argatroban in 0.9 % sod 4 SMALL chlor INTERFERING argatroban in nacl (iso- 4 RNA (SIRNA) os) BASED PRADAXA 1 GIVLAARI 4 THROMBOLYTI FARNESOID X C - NUCLEOTIDE RECEPTOR TYPE (FXR) AGONIST, DEFITELIO 4 BILE ACID THROMBOLYTI ANALOG C - TISSUE OCALIVA 3 PLASMINOGEN ACTIVATORS ACTIVASE 4 CATHFLO ACTIVASE 1 RETAVASE INTRAVENOUS 4 PA RECON SOLN TNKASE 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 215 Drug Name Drug Tier Limits Drug Name Drug Tier Limits cyclosporine oral HISTAMINE 1 PREPARATIONS capsule FOR ENVARSUS XR 3 DESENSITIZATI GENGRAF ORAL CAPSULE 100 MG, 25 1 ON MG HISTAMINE GENGRAF ORAL 1 PREPARATIONS SOLUTION FOR NEORAL 3 DESENSITIZATI PROGRAF 4 ON INTRAVENOUS histamine phosphate PROGRAF ORAL 1 3 PA (bulk) crystals CAPSULE HISTATROL 4 PROGRAF ORAL PERCUTANEOUS GRANULES IN 3 IMMUNOSUPPR PACKET SANDIMMUNE ESSIVE AGENTS 4 INTRAVENOUS IMMUNOSUPPRE SANDIMMUNE ORAL 3 SSIVE - CAPSULE INTERFERON SANDIMMUNE ORAL 3 PA GAMMA SOLUTION INHIBITOR, tacrolimus oral capsule 1 MONOCLONAL 0.5 mg, 1 mg ANTIBODY tacrolimus oral capsule 4 GAMIFANT 4 5 mg IMMUNOSUPPRE IMMUNOSUPPRE SSIVE - SSIVE - INOSINE CALCINEURIN MONOPHOSPHA INHIBITORS TE ASTAGRAF XL 3 DEHYDROGENA cyclosporine (bulk) 3 SE INHIBITORS cyclosporine CELLCEPT 4 4 intravenous INTRAVENOUS CELLCEPT ORAL cyclosporine modified 3 oral capsule 100 mg, 25 1 CAPSULE mg CELLCEPT ORAL cyclosporine modified SUSPENSION FOR 4 3 PA oral capsule 50 mg RECONSTITUTION cyclosporine modified mycophenolate mofetil 1 1 oral solution mycophenolate mofetil 4 (hcl)

You can find information on what the symbols and abbreviations on this table mean on page 4. 216 Drug Name Drug Tier Limits Drug Name Drug Tier Limits mycophenolate sodium IMMUNOSUPPRE oral tablet,delayed 3 PA SSIVE - release (dr/ec) 180 mg SELECTIVE T- mycophenolate sodium CELL oral tablet,delayed 3 COSTIMULATIO release (dr/ec) 360 mg N BLOCKER MYFORTIC 3 NULOJIX 4 IMMUNOSUPPRE SSIVE - LOCOMOTOR MAMMALIAN SYSTEM TARGET OF AGENTS TO RAPAMYCIN TREAT (MTOR) PERIODIC INHIBITORS PARALYSIS - RAPAMUNE 3 CARBONIC sirolimus oral solution 3 ANHYDRASE INHIBITORS sirolimus oral tablet 2 PA KEVEYIS 3 ZORTRESS 3 IMMUNOSUPPRE ALS AGENTS - SSIVE - BENZATHIAZOL MONOCLONAL ES ANTIBODIES RILUTEK 3 SIMULECT 4 riluzole 1 IMMUNOSUPPRE TIGLUTIK 3 PA SSIVE - ANTIMYASTHEN MONOCLONAL IC AGENT - ANTIBODY REVERSIBLE INHIB. T CHOLINESTERA LYMPHOCYTE SE INHIBITORS FUNCTION BLOXIVERZ 2 PA SIMULECT 4 MESTINON ORAL 2 PA IMMUNOSUPPRE SYRUP MESTINON ORAL SSIVE - PURINE 3 PA ANALOGS TABLET MESTINON AZASAN 3 3 PA TIMESPAN azathioprine 1 neostigmine azathioprine sodium 4 methylsulfate 2 PA IMURAN 3 intravenous solution

You can find information on what the symbols and abbreviations on this table mean on page 4. 217 Drug Name Drug Tier Limits Drug Name Drug Tier Limits neostigmine MUSCULOSKELE methylsulfate 2 PA TAL TX AGENT- intravenous syringe 3 JOINT mg/3 ml (1 mg/ml) CONTRACTURE neostigmine THERAPY, methylsulfate 4 intravenous syringe 5 COLLAGENASE mg/5 ml (1 mg/ml) ENZYME pyridostigmine bromide XIAFLEX 4 3 (bulk) NEUROMUSCUL pyridostigmine bromide 2 PA AR BLOCKER - oral syrup DEPOLARIZING pyridostigmine bromide 1 AGENTS oral tablet succinylcholine-sod 4 pyridostigmine bromide cl,iso(pf) oral tablet extended 1 release NEUROMUSCUL AR BLOCKER - REGONOL 2 PA NEUROTOXINS ANTIMYASTHEN BOTOX 4 PA IC AGENTS OTHER DYSPORT 4 PA MYOBLOC 4 PA guanidine 3 PA MUSCULOSKELE NEUROMUSCUL TAL THERAPY AR BLOCKER - AGENT - NONDEPOLARIZ VISCOSUPPLEM ING AGENTS ENTS atracurium 4 cisatracurium DUROLANE 4 PA 4 intravenous solution EUFLEXXA 4 PA NIMBEX 4 GEL-ONE 4 PA pancuronium GELSYN-3 4 PA intravenous solution 1 4 GENVISC 850 4 PA mg/ml HYALGAN 4 PA rocuronium intravenous 4 HYMOVIS 4 PA solution MONOVISC 4 PA rocuronium intravenous syringe 100 mg/10 ml 4 ORTHOVISC 4 PA (10 mg/ml), 75 mg/7.5 SUPARTZ FX 4 PA ml (10 mg/ml) SYNVISC 4 PA vecuronium bromide 4 SYNVISC-ONE 4 PA TRIVISC 4 VISCO-3 4 PA You can find information on what the symbols and abbreviations on this table mean on page 4. 218 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SELECTIVE LIORESAL RELAXANT INTRATHECAL BINDING AGENT SOLUTION 2,000 4 PA MCG/ML, 500 - MODIFIED MCG/ML GAMMA- LIORESAL CYCLODEXTRIN INTRATHECAL 4 BRIDION 4 SOLUTION 50 SKELETAL MCG/ML MUSCLE LORZONE 3 RELAXANT - METAXALL 3 ANALGESIC metaxalone oral tablet 3 SALICYLATE 400 mg COMBINATIONS metaxalone oral tablet 3 PA carisoprodol-aspirin 3 800 mg methocarbamol NORGESIC FORTE 3 4 PA injection SKELETAL methocarbamol oral 1 MUSCLE orphenadrine citrate RELAXANT - 4 PA injection CENTRAL MUSCLE orphenadrine citrate oral 3 RELAXANTS ROBAXIN INJECTION 4 AMRIX 3 ROBAXIN-750 3 baclofen (bulk) 3 SKELAXIN 3 baclofen intrathecal 4 PA SOMA 3 baclofen oral tablet 10 tizanidine oral capsule 3 PA 1 mg, 20 mg tizanidine oral tablet 1 baclofen oral tablet 5 ZANAFLEX ORAL 3 PA mg CAPSULE 2 MG, 4 3 PA carisoprodol (bulk) 3 MG carisoprodol oral tablet ZANAFLEX ORAL 3 3 250 mg CAPSULE 6 MG carisoprodol oral tablet ZANAFLEX ORAL 3 PA 3 350 mg TABLET chlorzoxazone 3 SKELETAL cyclobenzaprine (bulk) 3 MUSCLE RELAXANT - cyclobenzaprine oral capsule,extended release 3 PA DIRECT MUSCLE 24hr RELAXANTS cyclobenzaprine oral DANTRIUM 1 4 tablet INTRAVENOUS FEXMID 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 219 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DANTRIUM ORAL MEDICAL CAPSULE 25 MG, 50 1 SUPPLIES AND MG DME - BLOOD dantrolene (bulk) 3 COLLECTION dantrolene oral 3 PA NEEDLES REVONTO 4 MONOJECT BLOOD COLLECTION RYANODEX 4 4 NEEDLE 20 GAUGE X SKELETAL 1" MUSCLE RELAXANT - MEDICAL OPIOID SUPPLIES AND ANALGESIC DME - CERVICAL COMBINATIONS CAPS FEMCAP 1 carisoprodol-aspirin- 3 PA codeine MEDICAL SKELETAL SUPPLIES AND MUSCLE DME - RELAXANT, COMPRESSION SALICYLATE, STOCKINGS AND OPIOID T.E.D. ANTI- ANALGESIC EMBOLISM 4 COMB. STOCKING T.E.D. KNEE carisoprodol-aspirin- 3 PA LENGTH-S- 4 codeine REGULAR MEDICAL MEDICAL SUPPLIES AND SUPPLIES AND DURABLE DME - DENTAL MEDICAL SUPPLIES EQUIPMENT OTHER (DME) Q-CARE RX Q4 3 MEDICAL MEDICAL SUPPLIES AND SUPPLIES AND DME - DME - APPLICATORS DIAPHRAGMS AND COTTON CAYA CONTOURED 4 SUPPLIES WIDE-SEAL 4 COSMETIC BALLS 4 DIAPHRAGM 60 COSMETIC PUFFS 4 WIDE-SEAL 4 DIAPHRAGM 65

You can find information on what the symbols and abbreviations on this table mean on page 4. 220 Drug Name Drug Tier Limits Drug Name Drug Tier Limits WIDE-SEAL DEXCOM G5 4 2 PA DIAPHRAGM 70 RECEIVER WIDE-SEAL DEXCOM G5 4 2 PA DIAPHRAGM 75 TRANSMITTER WIDE-SEAL DEXCOM G5-G4 4 2 PA DIAPHRAGM 80 SENSOR WIDE-SEAL DEXCOM G6 4 2 PA DIAPHRAGM 85 RECEIVER MEDICAL DEXCOM G6 SENSOR 2 PA SUPPLIES AND DEXCOM G6 2 PA DME - GAUZE TRANSMITTER PADS AND DEXCOM RECEIVER 2 PA DRESSINGS ENLITE SYSTEM 3 RESTORE TOPICAL EVERSENSE 4 3 BANDAGE 2 X 2 " SENSOR-HOLDER XEROFORM 4 EVERSENSE SMART 3 XEROFORM TRANSMITTER PETROLATUM FREESTYLE LIBRE 2 PA DRESSING TOPICAL 4 14 DAY READER BANDAGE 2 X 2 ", 4 FREESTYLE LIBRE X 3 "-YARD, 4 X 4 " 2 PA 14 DAY SENSOR XEROFORM GUARDIAN PETROLATUM 4 CONNECT 4 OVERWRAP TRANSMITTER MEDICAL GUARDIAN REAL- QL (1 EA per 3 SUPPLIES AND TIME GLU MONITOR 390 days) DME - GLUCOSE MEDICAL MONITORING SUPPLIES AND TEST SUPPLIES DME - DEXCOM G4 PA; QL (1 EA 2 INCONTINENCE RECEIVER per 365 days) SUPPLIES DEXCOM G4 PREVAIL BRIEF RECEIVER 2 PA 4 YOUTH PEDIATRIC SLEEP COMFORTS 4 DEXCOM G4 RECEIVER-SHARE 2 PA SLEEP OVERS PANTS 4 (PED) SLEEP PANTS 4 DEXCOM G4 TUGABOOS 4 RECEIVER-SHARE 2 PA OVERNIGHTS KIT UNDERJAMS L-XL 4 DEXCOM G4 2 PA UNDERJAMS TRANSMITTER 4 SMALL-MEDIUM

You can find information on what the symbols and abbreviations on this table mean on page 4. 221 Drug Name Drug Tier Limits Drug Name Drug Tier Limits WELL BEGINNINGS HUGGIES SNUG AND 4 4 SLEEP PANTS DRY STEP 6 MEDICAL LUVS NEWBORN 4 SUPPLIES AND LUVS SIZE 1 4 DME - INFANT LUVS SIZE 2 4 DIAPERS LUVS SIZE 3 4 COMFORT-STRETCH 4 LUVS SIZE 4 4 DIAPERS LUVS SIZE 5 4 COMFORT-STRETCH 4 TRAINING PANTS LUVS SIZE 6 4 CUTIEPANTS PAMPERS BABY- 4 4 TRAINING PANTS DRY SIZE 1 CUTIES BABY PAMPERS BABY- 4 4 DIAPERS DRY SIZE 2 diaper,brief,infant- PAMPERS BABY- 4 4 todd,disp DRY SIZE 3 PAMPERS BABY- DIAPERS 4 4 DRY SIZE 4 DIAPERS, UNISEX 4 PAMPERS BABY- SIZE 3 4 DRY SIZE 5 DIAPERS, UNISEX 4 PAMPERS BABY- SIZE 4 4 DRY SIZE 6 DIAPERS, UNISEX 4 PAMPERS BABY- SIZE 5 4 DRY SIZE N DIAPERS, UNISEX 4 SIZE 6 PAMPERS CRUISERS 4 PAMPERS CRUISERS DIAPERS-DISP- 4 POLYETHYLENE 4 SIZE 3 BACK PAMPERS CRUISERS 4 GOODNITES SIZE 5 1 UNDERPANTS L-XL PAMPERS CRUISERS 4 HUGGIES LITTLE SIZE 6 4 MOVERS PAMPERS CRUISERS 4 HUGGIES PULL-UPS 4 SIZE 7 HUGGIES PULL-UPS PAMPERS EASY UPS 4 4 2T-3T PAMPERS EXTRA 4 HUGGIES PULL-UPS PROTECTION SZ 3 4 3T-4T PAMPERS EXTRA 4 HUGGIES PULL-UPS PROTECTION SZ 4 4 4T-5T PAMPERS EXTRA 4 HUGGIES SLIP-ON 4 PROTECTION SZ 5 HUGGIES SNUG AND PAMPERS EXTRA 4 4 DRY STEP 5 PROTECTION SZ 6

You can find information on what the symbols and abbreviations on this table mean on page 4. 222 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PAMPERS PREEMIE TUGABOOS 4 4 SWAD SIZE P-S TRAINING PANTS PAMPERS PREMIE 4 WELL BEGINNINGS 4 PAMPERS SLEEP PANTS SWADDLERS SENS. 4 WONDERPANTS 4 SIZE 1 MEDICAL PAMPERS 4 SUPPLIES AND SWADDLERS SIZE 1 DME - INSULIN PAMPERS 4 NEEDLES- SWADDLERS SIZE 2 SYRINGES AND PAMPERS 4 ADMIN SWADDLERS SIZE 3 SUPPLIES PAMPERS 4 BD INSULIN SWADDLERS SIZE N 1 SYRINGE U-500 PAMPERS UNISEX 4 MAGELLAN INSULIN BABY-DRY SAFETY SYRNG PREMIUM BABY 1 4 SYRINGE 1 ML 29 DIAPERS GAUGE X 1/2" PREMIUM 4 MAGELLAN COMFORT-STRETCH SYRINGE SYRINGE 1 PREMIUM TRAINING 0.5 ML 30 GAUGE X 4 PANTS 5/16" SELECT KIDS BRIEFS 4 MONOJECT INSULIN SAFETY SYRING SLEEP PANTS 4 SYRINGE 0.3 ML 30 SUPREME DIAPERS 4 GAUGE X 5/16", 0.5 1 SIZE 1 ML 29 GAUGE X 1/2", SUPREME DIAPERS 0.5 ML 30 GAUGE X 4 SIZE 2 5/16" SUPREME DIAPERS NOVOPEN ECHO 1 4 SIZE 3 OMNIPOD DASH 2 PA SUPREME DIAPERS PDM KIT 4 SIZE 4 SNAP INSULIN PUMP 4 SUPREME DIAPERS CONTROLLER 4 SIZE 5 MEDICAL SUPREME DIAPERS 4 SUPPLIES AND SIZE 6 DME - IV SETS- TRAINING PANTS 4 TUBING 2T-3T COMFORT INFUSION TRAINING PANTS 4 4 SET 31" 3T-4T TRAINING PANTS 4 4T-5T

You can find information on what the symbols and abbreviations on this table mean on page 4. 223 Drug Name Drug Tier Limits Drug Name Drug Tier Limits INNOSPIRE GO MEDICAL 4 SUPPLIES AND NEBULIZER LC D NEBULIZER DME - 4 MISCELLANEOU SET S OTHER LC PLUS 4 adapter cap for bottle 4 LC PLUS NEBULIZER-PED 4 BOSTON ROUND 4 MASK NATURAL MICROAIR MESH BOTTLE 4 4 NEBULIZER BOTTLETOP PARI BABY DISPENSER 4 4 NEBULIZER ADAPTER PARI LC SPRINT DISPOSERX 3 4 NEBULIZER SET OMNIPOD INSULIN 2 PRODIGY MINI-MIST REFILL 4 NEBULIZER PRO COMFORT TENS 4 SIDESTREAM 4 ELECTRODE SIDESTREAM PRO COMFORT TENS 4 4 NEBULIZER UNIT SUPPOSISTRIP 4 MEDICAL SUPPLIES AND suppository molds 4 DME - NEEDLES SUPPOSITORY 4 AND SYRINGES SHELL, MEDIUM ALLERGIST TRAY SUPPOSITORY 4 1/2 ML 27GX3/8" 4 SHELL, SMALL SYRINGE T.E.D. ANTI- ALLERGIST TRAY EMBOLISM 4 INTRADERMAL BEV STOCKING SYRINGE 1 ML 26 4 T:SLIM 3 GAUGE X 3/8", 1 ML T:SLIM G4 3 27 GAUGE X 3/8" UNGUATOR LID 4 BD ALLERGIST TRAY REG BEVEL 1 MEDICAL SYRINGE SUPPLIES AND BD ALLERGIST DME - TRAY REG BEVEL 1 NEBULIZERS TRAY 1/2 ML 27 X AIRS DISPOSABLE 1/2" 4 NEBULIZER BD FILTER NEEDLE- 1 DEVILBISS 5 MICRON DISPOSABLE 4 BD SAFETYGLIDE NEBULIZER ALLERGIST TRAY 1 FLYP NEBULIZER 4 SYRINGE 1 ML 27 X 1/2" You can find information on what the symbols and abbreviations on this table mean on page 4. 224 Drug Name Drug Tier Limits Drug Name Drug Tier Limits blunt needle, disposable 3 MEDICAL needle 18 x 1 1/2 " SUPPLIES AND MONOJECT DME - CONTROL SYRINGE 1 PARENTERAL LUER THERAPY MONOJECT SUPPLIES HYPODERMIC NEEDLES NEEDLE 25 ACCU-CHEK SPIRIT 1 3 GAUGE X 1 1/2", 25 ADAPTER GAUGE X 1", 30 EMPTY STERILIZED 4 GAUGE X 3/4" VIAL MONOJECT SAFETY empty vial 4 SYRINGES SYRINGE INTERLINK LEVER 1 4 3 ML 22 GAUGE X 1 LOCK CANNULA 1/2" PARADIGM MONOJECT SYRINGE 1 SILHOUETTE INFUS 4 SYRINGE 3 ML SET MONOJECT TB LUER 1 PHASEAL LOK PROTECTOR DEVICE 4 NORM-JECT 20 MM SYRINGE 10 ML, 20 3 SURE-T INFUSION 4 ML SET SURGUARD2 TOPI-CLICK FILLING 4 SAFETY NEEDLE 18 4 NOZZLE GAUGE X 1" UNIVERSAL SLEEVE 4 syringe (reusable) 1 MEDICAL TUBERCULIN SYRINGE SYRINGE 1 4 SUPPLIES AND ML 25 GAUGE X 1" DME - PEAK ULTICARE SYRINGE FLOW METERS 1 ML 25 GAUGE X 3 ASTHMAPACK 1 5/8" CHILDREN'S MEDICAL MEDICAL SUPPLIES AND SUPPLIES AND DME - OSTOMY DME - SUPPLIES RESPIRATORY FRESHNET 4 THERAPY HEX-ON LIGHT SUPPLIES 4 ODOR ACE AEROSOL 4 karaya gum (bulk) 3 CLOUD ENHANCER ODOR ELIMINATOR AEROCHAMBER MV 1 4 DROPS AEROCHAMBER 1 PLUS FLOW-VU

You can find information on what the symbols and abbreviations on this table mean on page 4. 225 Drug Name Drug Tier Limits Drug Name Drug Tier Limits AEROCHAMBER LITETOUCH-SMALL 1 PLUS FLOW-VU,L 1 MASK MSK MICROCHAMBER 1 AEROCHAMBER MICROSPACER 1 PLUS FLOW-VU,M 1 MOUTHPIECE MSK 4 REUSABLE MW AEROCHAMBER PLUS FLOW-VU,S 1 OPTICHAMBER MSK ADULT MASK- 1 LARGE AEROCHAMBER 1 OPTICHAMBER WITH FLOWSIGNAL 1 DIAMOND LG MASK AEROTRACH PLUS 1 OPTICHAMBER 1 COMP-AIR DIAMOND VHC NEBULIZER 4 OPTICHAMBER COMPRESSOR 1 DIAMOND-MED MSK DEVILBISS COMPACT 4 OPTICHAMBER COMPRESSOR DIAMOND-SML 1 MASK DEVILBISS PULMO- 4 PARI BABY CONV AIDE COMPRESSR 4 KIT - SIZE 1 DEVILBISS PULMOMATE 4 PFLEX COMPRESSOR INSPIRATORY 4 TRAINER DEVILBISS PILLOW MASK TRAVELER 4 4 COMPRESSOR CHILD EASIVENT HOLDING POCKET CHAMBER 1 1 CHAMBER PRIMEAIRE 3 EASIVENT MASK PRO COMFORT 1 LARGE SPACER-ADULT 3 EASIVENT MASK MASK 1 MEDIUM PRO COMFORT EASIVENT MASK SPACER-CHILD 3 1 SMALL MASK INNOSPIRE PROCARE 4 ELEGANCE COMPRESSOR 4 NEBULIZER INNOSPIRE ESSENCE 4 PROCHAMBER 1 LITE TOUCH- 1 MEDIUM MASK PRONEB ULTRA II 4 LITEAIRE MDI PRONEB ULTRA II 1 4 CHAMBER FILTER ASSEM LITETOUCH-LARGE PULMO-AIDE 1 4 MASK COMPRESSOR

You can find information on what the symbols and abbreviations on this table mean on page 4. 226 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PULMONEB LT NERIA COMPRESSOR 4 SUBCUTANEOUS 4 NEBUL INFUSION SET 8 X REUSABLE 110 MM-CM 4 NEBULIZER KIT SOFT-GLIDE SAF-Q 3 SAMI THE SEAL 4 MEDICAL SAMI THE SEAL SUPPLIES AND 4 MASK DME - SILICONE MASK - SUBCUTANEOUS 4 INFANT INSULIN VIOS AEROSOL DELIVERY 4 DELIVERY SYSTEM DEVICES VORTEX HOLDING 4 V-GO 20 4 CHAMBER V-GO 30 4 VORTEX VHC FROG 4 V-GO 40 4 MASK-CHILD VORTEX VHC MEDICAL LADYBUG MASK- 4 SUPPLIES AND TODDLR DME - MEDICAL SUBCUTANEOUS SUPPLIES AND INSULIN PUMP OMNIPOD INSULIN DME - SCAR 1 TREATMENTS MANAGEMENT ONETOUCH PING CELACYN 3 4 INSULIN PUMP CICATRACE PAD 3 REVEL DERM-SILK 3 PROGRAMMABLE 4 KELOTOP 3 PUMP NUVAKAAN 3 T:FLEX INSULIN 4 SCARCARE 3 DELIVERY PUMP T:SLIM X2 BASAL-IQ SCARCINPAD 3 3 INSULIN PMP SILIVEX 3 MEDICAL SILTREX 3 SUPPLIES AND MEDICAL DME - TISSUE SUPPLIES AND BULKING DME - IMPLANTS NON- SUBCUTANEOUS COSMETIC ADMINISTRATIO SOLESTA 4 N SUPPLY INSUFLON 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 227 Drug Name Drug Tier Limits Drug Name Drug Tier Limits CONTACT DETACH MEDICAL 4 SUPPLIES AND INFUS SET 43" MINIMED INFUSION DME - TISSUE 4 BULKING SET-MMT 390 IMPLANTS MIO INFUSION SET 3 QUICK-SET SOLESTA 4 4 PARADIGM MEDICAL SNAP INSULIN SUPPLIES AND 4 PUMP-INFUSION SET DME - URINARY CATHETERS SURE-T PARADIGM 4 AND RELATED T:30 INFUSION SET 4 T:90 INFUSION SET DEVICES 3 23" LOFRIC 14-16 FR-" 4 SILASTIC FOLEY TISSUE 4 CATHETER BULKING TOUCH-TROL 4 IMPLANTS - ANORECTAL MEDICAL SUPPLIES AND SOLESTA 4 DME-GLUCOSE MEDICAL MONITORING SUPPLY, FDB AND INSULIN SUPERSET ADMIN MEDICAL SUPPLIES SUPPLY, FDB ACCU-CHEK COMBO 3 SUPERSET SYSTEM ACCU-CHEK COMBO AUTOSOFT XC 3 4 SYSTEM INFUSION SET 23" ACCU-CHEK SPIRIT CLEO 90 INFUSION 3 4 ADAPTER SET 24" ACE AEROSOL CLEO 90 INFUSION 4 4 CLOUD ENHANCER SET 31" adapter cap for bottle 4 COMFORT INFUSION 4 AEROCHAMBER MV 1 SET 31" AEROCHAMBER COMFORT INFUSION 1 4 PLUS FLOW-VU SET 43" AEROCHAMBER COMFORT SHORT 4 PLUS FLOW-VU,L 1 INSULIN PUMP 23" MSK CONTACT DETACH 4 AEROCHAMBER INFUS SET 23" PLUS FLOW-VU,M 1 CONTACT DETACH 4 MSK INFUS SET 32"

You can find information on what the symbols and abbreviations on this table mean on page 4. 228 Drug Name Drug Tier Limits Drug Name Drug Tier Limits AEROCHAMBER BOTTLETOP PLUS FLOW-VU,S 1 DISPENSER 4 MSK ADAPTER AEROCHAMBER CAYA CONTOURED 4 1 WITH FLOWSIGNAL CICATRACE PAD 3 AEROTRACH PLUS 1 CLEO 90 INFUSION 4 AIRS DISPOSABLE SET 24" 4 NEBULIZER CLEO 90 INFUSION 4 ALLERGIST TRAY SET 31" 1/2 ML 27GX3/8" 4 COMFORT INFUSION 4 SYRINGE SET 31" ALLERGIST TRAY COMFORT INFUSION 4 INTRADERMAL BEV SET 43" SYRINGE 1 ML 26 4 COMFORT SHORT GAUGE X 3/8", 1 ML 4 27 GAUGE X 3/8" INSULIN PUMP 23" ALLEVYN TOPICAL COMFORT-STRETCH 1 4 BANDAGE 8 X 8 " DIAPERS ASTHMAPACK COMFORT-STRETCH 1 4 CHILDREN'S TRAINING PANTS AUTOSOFT XC COMP-AIR 4 INFUSION SET 23" NEBULIZER 4 COMPRESSOR BD ALLERGIST CONTACT DETACH TRAY REG BEVEL 1 4 SYRINGE INFUS SET 23" CONTACT DETACH BD ALLERGIST 4 TRAY REG BEVEL INFUS SET 32" 1 TRAY 1/2 ML 27 X CONTACT DETACH 4 1/2" INFUS SET 43" BD FILTER NEEDLE- COSMETIC BALLS 4 1 5 MICRON COSMETIC PUFFS 4 BD INSULIN CUTIEPANTS 1 4 SYRINGE U-500 TRAINING PANTS BD SAFETYGLIDE CUTIES BABY ALLERGIST TRAY 4 1 DIAPERS SYRINGE 1 ML 27 X 1/2" DERM-SILK 3 blunt needle, disposable DEVILBISS 3 needle 18 x 1 1/2 " COMPACT 4 COMPRESSOR BOSTON ROUND 4 NATURAL DEVILBISS DISPOSABLE 4 BOTTLE 4 NEBULIZER DEVILBISS PULMO- 4 AIDE COMPRESSR You can find information on what the symbols and abbreviations on this table mean on page 4. 229 Drug Name Drug Tier Limits Drug Name Drug Tier Limits DEVILBISS DIAPERS-DISP- PULMOMATE 4 POLYETHYLENE 4 COMPRESSOR BACK DEVILBISS DISPOSERX 3 TRAVELER 4 EASIVENT HOLDING 1 COMPRESSOR CHAMBER DEXCOM G4 PA; QL (1 EA EASIVENT MASK 2 1 RECEIVER per 365 days) LARGE DEXCOM G4 EASIVENT MASK 1 RECEIVER 2 PA MEDIUM PEDIATRIC EASIVENT MASK 1 DEXCOM G4 SMALL RECEIVER-SHARE 2 PA EMPTY STERILIZED (PED) 4 VIAL DEXCOM G4 RECEIVER-SHARE 2 PA empty vial 4 KIT ENLITE SYSTEM 3 DEXCOM G4 EVERSENSE 2 PA 3 TRANSMITTER SENSOR-HOLDER DEXCOM G5 EVERSENSE SMART 2 PA 3 RECEIVER TRANSMITTER DEXCOM G5 FEMCAP 1 2 PA TRANSMITTER FLYP NEBULIZER 4 DEXCOM G5-G4 FREESTYLE LIBRE 2 PA 2 PA SENSOR 14 DAY READER DEXCOM G6 FREESTYLE LIBRE 2 PA 2 PA RECEIVER 14 DAY SENSOR DEXCOM G6 SENSOR 2 PA GOODNITES 1 DEXCOM G6 UNDERPANTS L-XL 2 PA TRANSMITTER GUARDIAN DEXCOM RECEIVER 2 PA CONNECT 4 diaper,brief,infant- TRANSMITTER 4 todd,disp GUARDIAN REAL- QL (1 EA per 3 DIAPERS 4 TIME GLU MONITOR 390 days) DIAPERS, UNISEX HUGGIES LITTLE 4 4 SIZE 3 MOVERS DIAPERS, UNISEX HUGGIES PULL-UPS 4 4 SIZE 4 HUGGIES PULL-UPS 4 DIAPERS, UNISEX 2T-3T 4 SIZE 5 HUGGIES PULL-UPS 4 DIAPERS, UNISEX 3T-4T 4 SIZE 6 HUGGIES PULL-UPS 4 4T-5T

You can find information on what the symbols and abbreviations on this table mean on page 4. 230 Drug Name Drug Tier Limits Drug Name Drug Tier Limits HUGGIES SLIP-ON 4 MAGELLAN HUGGIES SNUG AND SYRINGE SYRINGE 4 1 DRY STEP 5 0.5 ML 30 GAUGE X 5/16" HUGGIES SNUG AND 4 MICROAIR MESH DRY STEP 6 4 NEBULIZER INNOSPIRE 4 ELEGANCE MICROCHAMBER 1 INNOSPIRE ESSENCE 4 MICROSPACER 1 INNOSPIRE GO MINIMED INFUSION 4 4 NEBULIZER SET-MMT 390 INSUFLON 1 MIO INFUSION SET 3 INTERLINK LEVER MONOJECT BLOOD 4 COLLECTION LOCK CANNULA 4 NEEDLE 20 GAUGE X KELOTOP 3 1" LC D NEBULIZER 4 MONOJECT SET CONTROL SYRINGE 1 LC PLUS 4 LUER LC PLUS MONOJECT NEBULIZER-PED 4 HYPODERMIC MASK NEEDLES NEEDLE 25 1 LITE TOUCH- GAUGE X 1 1/2", 25 1 MEDIUM MASK GAUGE X 1", 30 GAUGE X 3/4" LITEAIRE MDI 1 CHAMBER MONOJECT INSULIN SAFETY SYRING LITETOUCH-LARGE 1 SYRINGE 0.3 ML 30 MASK GAUGE X 5/16", 0.5 1 LITETOUCH-SMALL ML 29 GAUGE X 1/2", 1 MASK 0.5 ML 30 GAUGE X LOFRIC 14-16 FR-" 4 5/16" LUVS NEWBORN 4 MONOJECT SAFETY SYRINGES SYRINGE 1 LUVS SIZE 1 4 3 ML 22 GAUGE X 1 LUVS SIZE 2 4 1/2" LUVS SIZE 3 4 MONOJECT SYRINGE 1 LUVS SIZE 4 4 SYRINGE 3 ML MONOJECT TB LUER LUVS SIZE 5 4 1 LOK LUVS SIZE 6 4 MOUTHPIECE 4 MAGELLAN INSULIN REUSABLE MW SAFETY SYRNG 1 SYRINGE 1 ML 29 NERIA SUBCUTANEOUS GAUGE X 1/2" 4 INFUSION SET 8 X 110 MM-CM You can find information on what the symbols and abbreviations on this table mean on page 4. 231 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NORM-JECT PAMPERS CRUISERS 4 SYRINGE 10 ML, 20 3 SIZE 6 ML PAMPERS CRUISERS 4 NOVOPEN ECHO 1 SIZE 7 OMNIPOD DASH PAMPERS EASY UPS 4 2 PA PDM KIT PAMPERS EXTRA 4 OMNIPOD INSULIN PROTECTION SZ 3 1 MANAGEMENT PAMPERS EXTRA 4 OMNIPOD INSULIN PROTECTION SZ 4 2 REFILL PAMPERS EXTRA 4 ONETOUCH PING PROTECTION SZ 5 4 INSULIN PUMP PAMPERS EXTRA 4 OPTICHAMBER PROTECTION SZ 6 ADULT MASK- 1 PAMPERS PREEMIE 4 LARGE SWAD SIZE P-S OPTICHAMBER 1 PAMPERS PREMIE 4 DIAMOND LG MASK PAMPERS OPTICHAMBER 1 SWADDLERS SENS. 4 DIAMOND VHC SIZE 1 OPTICHAMBER PAMPERS 1 4 DIAMOND-MED MSK SWADDLERS SIZE 1 OPTICHAMBER PAMPERS 4 DIAMOND-SML 1 SWADDLERS SIZE 2 MASK PAMPERS PAMPERS BABY- 4 4 SWADDLERS SIZE 3 DRY SIZE 1 PAMPERS PAMPERS BABY- 4 4 SWADDLERS SIZE N DRY SIZE 2 PAMPERS UNISEX PAMPERS BABY- 4 4 BABY-DRY DRY SIZE 3 PARADIGM PAMPERS BABY- 4 SILHOUETTE INFUS 4 DRY SIZE 4 SET PAMPERS BABY- PARI BABY CONV 4 4 DRY SIZE 5 KIT - SIZE 1 PAMPERS BABY- PARI BABY 4 4 DRY SIZE 6 NEBULIZER PAMPERS BABY- PARI LC SPRINT 4 4 DRY SIZE N NEBULIZER SET PAMPERS CRUISERS 4 PFLEX PAMPERS CRUISERS INSPIRATORY 4 4 SIZE 3 TRAINER PAMPERS CRUISERS 4 SIZE 5 You can find information on what the symbols and abbreviations on this table mean on page 4. 232 Drug Name Drug Tier Limits Drug Name Drug Tier Limits PHASEAL REUSABLE 4 PROTECTOR DEVICE 4 NEBULIZER KIT 20 MM REVEL PILLOW MASK PROGRAMMABLE 4 4 CHILD PUMP POCKET CHAMBER 1 SAMI THE SEAL 4 PREMIUM BABY SAMI THE SEAL 4 4 DIAPERS MASK PREMIUM SCARCINPAD 3 4 COMFORT-STRETCH SELECT KIDS BRIEFS 4 PREMIUM TRAINING 4 SIDESTREAM 4 PANTS SIDESTREAM PREVAIL BRIEF 4 4 NEBULIZER YOUTH SILASTIC FOLEY 4 PRIMEAIRE 3 CATHETER PRO COMFORT SILICONE MASK - 4 SPACER-ADULT 3 INFANT MASK SILIVEX 3 PRO COMFORT SPACER-CHILD 3 SILTREX 3 MASK SLEEP COMFORTS 4 PRO COMFORT TENS SLEEP OVERS PANTS 4 4 ELECTRODE SLEEP PANTS 4 PRO COMFORT TENS SNAP INSULIN PUMP 4 4 UNIT CONTROLLER PROCARE SNAP INSULIN 4 COMPRESSOR 4 PUMP-INFUSION SET NEBULIZER SOFT-GLIDE SAF-Q 3 PROCHAMBER 1 SPECTRAGEL 4 PRODIGY MINI-MIST 4 NEBULIZER SUPPOSISTRIP 4 PRONEB ULTRA II 4 suppository molds 4 PRONEB ULTRA II SUPPOSITORY 4 4 FILTER ASSEM SHELL, MEDIUM PULMO-AIDE SUPPOSITORY 4 4 COMPRESSOR SHELL, SMALL SUPREME DIAPERS PULMONEB LT 4 COMPRESSOR 4 SIZE 1 NEBUL SUPREME DIAPERS 4 QUICK-SET SIZE 2 4 PARADIGM SUPREME DIAPERS 4 RESTORE TOPICAL SIZE 3 4 BANDAGE 2 X 2 " You can find information on what the symbols and abbreviations on this table mean on page 4. 233 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SUPREME DIAPERS TUGABOOS 4 4 SIZE 4 TRAINING PANTS SUPREME DIAPERS ULTICARE SYRINGE 4 SIZE 5 1 ML 25 GAUGE X 3 SUPREME DIAPERS 5/8" 4 SIZE 6 UNDERJAMS L-XL 4 SURE-T INFUSION UNDERJAMS 4 4 SET SMALL-MEDIUM SURE-T PARADIGM 4 UNGUATOR LID 4 SURGUARD2 UNIVERSAL SLEEVE 4 SAFETY NEEDLE 18 4 VAPRO PLUS GAUGE X 1" INTERMITT 4 syringe (reusable) 1 CATHETER COMBO T.E.D. ANTI- PACK 14 FR- 16" EMBOLISM 4 V-GO 20 4 STOCKING V-GO 30 4 T.E.D. KNEE V-GO 40 4 LENGTH-S- 4 VIOS AEROSOL REGULAR 4 DELIVERY SYSTEM T:30 INFUSION SET 4 VORTEX HOLDING T:90 INFUSION SET 4 3 CHAMBER 23" VORTEX VHC FROG T:FLEX INSULIN 4 4 MASK-CHILD DELIVERY PUMP VORTEX VHC T:SLIM 3 LADYBUG MASK- 4 T:SLIM G4 3 TODDLR T:SLIM X2 BASAL-IQ WELL BEGINNINGS 3 4 INSULIN PMP SLEEP PANTS TOPI-CLICK FILLING WIDE-SEAL 4 4 NOZZLE DIAPHRAGM 60 TOUCH-TROL 4 WIDE-SEAL 4 TRAINING PANTS DIAPHRAGM 65 4 2T-3T WIDE-SEAL 4 TRAINING PANTS DIAPHRAGM 70 4 3T-4T WIDE-SEAL 4 TRAINING PANTS DIAPHRAGM 75 4 4T-5T WIDE-SEAL 4 TUBERCULIN DIAPHRAGM 80 SYRINGE SYRINGE 1 4 WIDE-SEAL 4 ML 25 GAUGE X 1" DIAPHRAGM 85 TUGABOOS WONDERPANTS 4 4 OVERNIGHTS XEROFORM 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 234 Drug Name Drug Tier Limits Drug Name Drug Tier Limits XEROFORM STRENSIQ PETROLATUM SUBCUTANEOUS DRESSING TOPICAL 4 SOLUTION 40 4 BANDAGE 2 X 2 ", 4 MG/ML, 80 MG/0.8 X 3 "-YARD, 4 X 4 " ML XEROFORM METABOLIC PETROLATUM 4 DISEASE OVERWRAP ENZYME METABOLIC REPLACEMENT, DISEASE LYSOSOMAL ENZYME ACID LIPASE REPLACEMENT DEFICIENCY AGENTS KANUMA 4 METABOLIC METABOLIC DISEASE DISEASE ENZYME ENZYME REPLACEMENT, REPLACEMENT, FABRY'S MUCOPOLYSAC DISEASE CHARIDOSIS FABRAZYME 4 ALDURAZYME 4 METABOLIC ELAPRASE 4 DISEASE MEPSEVII 4 ENZYME NAGLAZYME 4 REPLACEMENT, VIMIZIM 4 GAUCHER'S METABOLIC DISEASE DISEASE CEREZYME ENZYME INTRAVENOUS 4 REPLACEMENT, RECON SOLN 400 UNIT POMPE DISEASE ELELYSO 4 LUMIZYME 4 VPRIV 4 METABOLIC METABOLIC MODIFIERS DISEASE HYPERPARATHY ENZYME ROID REPLACEMENT, TREATMENT HYPOPHOSPHAT AGENTS - ASIA VITAMIN D STRENSIQ ANALOG-TYPE SUBCUTANEOUS calcitriol intravenous 2 PA 4 SOLUTION 18 solution 1 mcg/ml MG/0.45 ML

You can find information on what the symbols and abbreviations on this table mean on page 4. 235 Drug Name Drug Tier Limits Drug Name Drug Tier Limits calcitriol oral capsule 1 METABOLIC calcitriol oral solution 3 MODIFIER - doxercalciferol HEREDITARY 4 intravenous OROTIC doxercalciferol oral 3 PA ACIDURIA HECTOROL TREATMENT 4 INTRAVENOUS AGENTS paricalcitol XURIDEN 3 hemodialysis port 4 METABOLIC injection MODIFIER - paricalcitol oral 3 PA HEREDITARY ROCALTROL 3 TYROSINEMIA ZEMPLAR TREATMENT 4 INTRAVENOUS AGENTS ZEMPLAR ORAL NITYR ORAL 2 PA CAPSULE 1 MCG, 2 3 TABLET 10 MG MCG ORFADIN 2 PA METABOLIC METABOLIC MODIFIER - MODIFIER - CARNITINE HOMOCYSTINUR REPLENISHER IA TREATMENT AGENTS AGENTS CARNITOR (SUGAR- 3 CYSTADANE 3 FREE) CARNITOR METABOLIC 4 INTRAVENOUS MODIFIER - CARNITOR ORAL 3 UREA CYCLE DISORDER L-CARNITINE 3 AGENTS- levocarnitine (with 1 CONJUGATING sugar) AGENTS METABOLIC AMMONUL 4 MODIFIER - GAUCHER'S BUPHENYL 3 DISEASE, TYPE- RAVICTI 3 1, SUBSTRATE sodium phenylbutyrate 2 PA REDUCTION TX CERDELGA 3 miglustat 2 PA ZAVESCA 2 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 236 Drug Name Drug Tier Limits Drug Name Drug Tier Limits METABOLIC MOUTH- MODIFIER- THROAT- CARBAMOYL DENTAL - PHOSPHATE PREPARATIONS SYNTHETASE 1 DENTAL (CPS 1) PRODUCT - ACTIVATOR FLUORIDE CARBAGLU 2 PREPARATIONS PHARMACOENH FLORIVA ANCER - (FLUORIDE- 3 CYTOCHROME VITAMIN D3) P450 INHIBITORS FLUORABON 3 TYBOST 1 fluoride (sodium) dental 3 PHARMACOLOG gel fluoride (sodium) oral ICAL 3 CHAPERONE TX drops fluoride (sodium) oral - ALPHA- 3 GALACTOSIDAS tablet,chewable E A ENZYME FLUORIDEX STABILIZER SENSITIVITY RELIEF 3 DENTAL PASTE GALAFOLD 2 PA FLUORITAB ORAL 3 PHENYLKETON TABLET,CHEWABLE URIA(PKU) TX FLURA-DROPS 3 AGENTS - LUDENT FLUORIDE 3 COFACTOR OF PHENYLALANIN sodium fluoride (bulk) 3 E DENTAL HYDROXYLASE PRODUCT - KUVAN ORAL LOCAL POWDER IN PACKET 3 ANESTHETICS 500 MG CARBOCAINE KUVAN ORAL INJECTION 4 2 TABLET,SOLUBLE CARTRIDGE MARCAINE- EPINEPHRINE 4 INJECTION CARTRIDGE SCANDONEST PLAIN 4 VIVACAINE 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 237 Drug Name Drug Tier Limits Drug Name Drug Tier Limits triamcinolone acetonide MOUTH AND 1 THROAT - dental ANTIFUNGALS MOUTH AND clotrimazole mucous THROAT - 1 membrane LOCAL nystatin oral suspension 1 ANESTHETIC MOUTH AND AMIDES lidocaine hcl mucous QL (2 ML per THROAT - ANTI- 2 INFECTIVE membrane jelly 23 days) lidocaine hcl mucous MIXTURES QL (2 ML per membrane solution 4 % 3 23 days) DEBACTEROL (40 mg/ml) MUCOUS 3 LIDOCAINE QL (2 ML per MEMBRANE 2 SOLUTION VISCOUS 23 days) DEBACTEROL MOUTH AND MUCOUS 1 THROAT - MEMBRANE SWAB MUCOSITIS- MOUTH AND STOMATITIS THROAT - AGENTS ANTISEPTICS EPISIL 3 chlorhexidine gluconate GELCLAIR 3 1 (bulk) GELX 3 chlorhexidine gluconate 1 MUGARD 3 mucous membrane ORAMAGICRX 3 PAROEX ORAL 1 RINSE MOUTH AND PERIDEX 3 THROAT - PROTECTANTS MOUTH AND THROAT - GELX 3 ARTIFICIAL MUGARD 3 SALIVA ORAFATE 3 BOCASAL 3 PROTHELIAL 3 MUCOSITISRX 3 MOUTH AND SALIVAMAX 3 THROAT - XEROSTOMIA SALIVA 3 RELIEF STIMULANTS MOUTH AND cevimeline 2 PA THROAT - EVOXAC 3 GLUCOCORTICO pilocarpine hcl (bulk) 3 IDS pilocarpine hcl oral 1 ORALONE 3 You can find information on what the symbols and abbreviations on this table mean on page 4. 238 Drug Name Drug Tier Limits Drug Name Drug Tier Limits SALAGEN 3 MULTIPLE (PILOCARPINE) SCLEROSIS XYLIMELTS 3 AGENT - CD52 PERIODONTAL SPECIFIC PRODUCT - MONOCLONAL TETRACYCLINE- ANTIBODY TYPE, LEMTRADA 4 PA COLLAGENASE MULTIPLE INHIBITORS SCLEROSIS doxycycline hyclate oral 1 AGENT - tablet 20 mg INTERFERONS THERAPY FOR AVONEX DROOLING- INTRAMUSCULAR 2 PA PRIMARY OR PEN INJECTOR KIT SECONDARY AVONEX PA; QL (1 EA INTRAMUSCULAR 2 SIALORRHEA- per 23 days) ANTICHOLINER SYRINGE KIT BETASERON PA; QL (14 EA GIC 2 SUBCUTANEOUS KIT per 23 days) CUVPOSA 3 BETASERON MULTIPLE SUBCUTANEOUS 2 PA SCLEROSIS RECON SOLN AGENTS EXTAVIA 3 LEUKOCYTE PLEGRIDY 3 ADHESION REBIF (WITH 2 PA INHIBITORS, ALBUMIN) ALPHA4- REBIF REBIDOSE 2 PA MEDIATED, REBIF TITRATION 1 IGG4K MC PACK ANTIBODY MULTIPLE TYSABRI 4 PA SCLEROSIS MULTIPLE AGENT - SCLEROSIS OTHERS AGENT - CD20 COPAXONE SPECIFIC SUBCUTANEOUS 2 PA MONOCLONAL SYRINGE 20 MG/ML ANTIBODY COPAXONE SUBCUTANEOUS 1 OCREVUS 4 PA SYRINGE 40 MG/ML glatiramer 3 GLATOPA 3 TECFIDERA 2 PA You can find information on what the symbols and abbreviations on this table mean on page 4. 239 Drug Name Drug Tier Limits Drug Name Drug Tier Limits VUMERITY 3 PA MULTIPLE MULTIPLE SCLEROSIS SCLEROSIS AGENT - AGENT - SPHINGOSINE 1- POTASSIUM PHOSPHATE CHANNEL RECEPTOR BLOCKER MODULATOR GILENYA ORAL AMPYRA 3 3 CAPSULE 0.25 MG dalfampridine 3 PA GILENYA ORAL dalfampridine (bulk) 3 1 CAPSULE 0.5 MG FIRDAPSE 3 PA MAYZENT 3 RUZURGI 3 PA MAYZENT STARTER 3 MULTIPLE PACK SCLEROSIS OPHTHALMIC AGENT - PURINE AGENTS NUCLEOSIDE ANALOGS ARTIFICIAL TEARS AND MAVENCLAD (10 3 PA TABLET PACK) LUBRICANT SINGLE AGENTS MAVENCLAD (4 3 PA KLARITY TABLET PACK) 3 (CHONDROITIN) (PF) MAVENCLAD (5 3 PA TABLET PACK) LACRISERT 1 MAVENCLAD (6 MIOTICS - 3 PA TABLET PACK) CHOLINESTERA MAVENCLAD (7 SE INHIBITORS 3 PA TABLET PACK) PHOSPHOLINE 3 MAVENCLAD (8 IODIDE 3 PA TABLET PACK) MIOTICS - MAVENCLAD (9 3 PA DIRECT ACTING TABLET PACK) acetylcholine chloride 3 MULTIPLE (bulk) SCLEROSIS ISOPTO CARPINE 3 AGENT - MIOCHOL-E 3 PYRIMIDINE SYNTHESIS MIOSTAT 3 INHIBITORS pilocarpine hcl (bulk) 3 AUBAGIO 3 pilocarpine hcl ophthalmic (eye) drops 3 1 %, 2 %, 4 %

You can find information on what the symbols and abbreviations on this table mean on page 4. 240 Drug Name Drug Tier Limits Drug Name Drug Tier Limits dexameth-moxiflox(pf)- MYDRIATIC AND 3 CYCLOPLEGIC nacl,iso COMBINATIONS MAXITROL 3 neomycin-bacitracin- CYCLOMYDRIL 1 3 poly-hc lidocaine-phenylephrn 4 neomycin-polymyxin b- in water 1 dexameth PAREMYD 3 neomycin-polymyxin-hc racepineph-lidocaine- 3 4 ophthalmic (eye) bss 7(pf) NEO-POLYCIN HC 3 OPHTH - BETA BLOCKER- PRED-G 3 ADRENERG- PRED-G S.O.P. 3 prednisolone acet- CARBONIC 3 ANHYD INHIB- gatifloxacin prednisolone- PROSTAGLADIN 3 ANALOG moxifloxacin hcl timol-brimon-dorzo- sulfacetamide- 3 1 latanop(pf) prednisolone OPHTHALMIC - TOBRADEX OPHTHALMIC (EYE) 1 ADRENERGIC- OINTMENT CARBONIC TOBRADEX ST 3 ANHYDRASE tobramycin- INHIBITOR 1 dexamethasone COMBINATIONS triamcinolon-moxiflox- 4 SIMBRINZA 1 watr(pf) OPHTHALMIC - ZYLET 3 AGENTS FOR OPHTHALMIC - CORNEAL ANTIBACTERIAL COLLAGEN - CROSS-LINKING GLUCOCORTICO PHOTREXA CROSS- 4 ID-NSAID LINKING KIT COMBINATIONS OPHTHALMIC - dexamet-moxifl-ketoro- 3 ANTIBACTERIAL nacl(pf) - prednisol ace-gatiflox- 3 GLUCOCORTICO bromfen ID prednisoln sp-gatiflox- 3 COMBINATIONS bromfen BLEPHAMIDE 3 prednisolone-moxiflo- 3 BLEPHAMIDE S.O.P. 3 nepafenac

You can find information on what the symbols and abbreviations on this table mean on page 4. 241 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OPHTHALMIC - DUREZOL 1 ANTICHOLINER FLAREX 3 GICS fluorometholone 1 atropine ophthalmic 1 FML FORTE 3 (eye) drops FML LIQUIFILM 3 atropine ophthalmic 1 FML S.O.P. 3 (eye) ointment ILUVIEN 4 CYCLOGYL 3 INVELTYS 3 PA cyclopentolate 1 LOTEMAX 3 HOMATROPAIRE 1 LOTEMAX SM 3 ISOPTO ATROPINE 1 loteprednol etabonate 3 PA MYDRIACYL 3 MAXIDEX 3 tropicamide 1 OZURDEX 4 OPHTHALMIC - ANTIFIBROTIC PRED FORTE 3 AGENTS PRED MILD 3 MITOSOL 3 prednisolone acetate 3 prednisolone acetate OPHTHALMIC - 3 (pf) ANTIHISTAMINE S prednisolone sodium phosphate ophthalmic 3 azelastine ophthalmic 3 (eye) (eye) RETISERT 4 BEPREVE 3 TRIESENCE (PF) 4 epinastine 3 PA YUTIQ 4 LASTACAFT 3 OPHTHALMIC - olopatadine ophthalmic 3 ANTI- (eye) drops 0.1 % INFLAMMATOR PAZEO 3 Y, OPHTHALMIC - IMMUNOMODUL ANTI- ATORS INFLAMMATOR CEQUA 3 PA Y, RESTASIS 1 GLUCOCORTICO RESTASIS IDS 3 MULTIDOSE ALREX 3 XIIDRA 3 dexamethasone sodium phosphate ophthalmic 1 (eye) DEXTENZA 4 DEXYCU (PF) 4 You can find information on what the symbols and abbreviations on this table mean on page 4. 242 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OPHTHALMIC - OPHTHALMIC - ANTI- BETA BLOCKER- INFLAMMATOR CARBONIC Y, LFA-1 ANHYDRASE ANTAGONISTS INHIB- XIIDRA 3 PROSTAGLADIN OPHTHALMIC - ANALOG timolol-dorzolamid- ANTI- 3 INFLAMMATOR latanop(pf) Y, NSAIDS OPHTHALMIC - ACULAR 3 BETA BLOCKERS- ACULAR LS 3 ADRENERGIC ACUVAIL (PF) 3 COMBINATIONS bromfenac 3 COMBIGAN 1 BROMSITE 3 OPHTHALMIC - diclofenac sodium 1 BETA ophthalmic (eye) BLOCKERS- flurbiprofen sodium 1 CARBONIC ILEVRO 1 ANHYDRASE ketorolac ophthalmic 1 INHIBITOR (eye) COMBINATIONS NEVANAC 3 COSOPT 3 PROLENSA 3 COSOPT (PF) 3 PA OPHTHALMIC - dorzolamide-timolol 1 BETA BLOCKER- dorzolamide-timolol ADRENERGIC- (pf) ophthalmic (eye) 1 CARBONIC dropperette ANHYDRASE dorzolamide-timolol INHIBITOR (pf) ophthalmic (eye) 3 COMB drops timolol-brimonidi- OPHTHALMIC - 3 dorzolam(pf) BETA BLOCKERS- PROSTAGLANDI N ANALOG COMBINATIONS timolol-latanoprost(pf) 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 243 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OPHTHALMIC - OPHTHALMIC - CARBONIC INTRAOCULAR ANHYDRASE PRESSURE INHIBITORS REDUCING AZOPT 1 AGENTS, BETA- dorzolamide 1 BLOCKERS betaxolol ophthalmic dorzolamide (pf) 3 3 (eye) TRUSOPT 3 BETIMOL 3 OPHTHALMIC - BETOPTIC S 3 CYSTINE DEPLETING carteolol 3 AGENTS ISTALOL 3 levobunolol ophthalmic CYSTARAN 2 PA 1 (eye) drops 0.5 % OPHTHALMIC - metipranolol 3 DECONGESTANT timolol maleate S 1 ophthalmic (eye) phenylephrine hcl 1 TIMOPTIC OCUDOSE ophthalmic (eye) 3 (PF) OPHTHALMIC - TIMOPTIC DIAGNOSTIC OPHTHALMIC (EYE) 3 AGENTS DROPS 0.25 % AK-FLUOR 4 TIMOPTIC-XE 1 fluorescein- 1 OPHTHALMIC - proparacaine LOCAL FLUORESCITE 4 ANESTHETIC GLOSTRIPS 3 COMBINATIONS OPHTHALMIC - ALTAFLUOR BENOX 3 GLUCOCORTICO OPHTHALMIC - ID-NSAID LOCAL COMBINATIONS ANESTHETIC prednisolone acetate- ESTERS 3 nepafenac ALTACAINE 3 prednisolone sod ph- 3 proparacaine 1 bromfenac tetracaine hcl 1 OPHTHALMIC - tetracaine hcl (pf) 1 HUMAN NERVE ophthalmic (eye) GROWTH FACTOR (HNGF) OXERVATE 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 244 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OPHTHALMIC - OPHTHALMIC - LOCAL PHOTODYNAMI ANESTHETIC, C THERAPY AMIDES AGENTS AKTEN (PF) 3 VISUDYNE 4 OPHTHALMIC - OPHTHALMIC - MACULAR RHO KINASE DEGENERATION, INHIBITOR AND AGE-RELATED, PROSTAGLANDI THERAPY N ANALOG AGENTS COMBINATION bevacizumab intravitreal ROCKLATAN 3 4 syringe 2.5 mg/0.1 ml OPHTHALMIC - EYLEA SURGICAL AID INTRAVITREAL 4 COMBINATIONS SOLUTION VISCOAT 1 LUCENTIS INTRAVITREAL 4 PA OPHTHALMIC - SOLUTION SURGICAL AIDS LUCENTIS OTHER INTRAVITREAL 4 PA SILIKON 3 SYRINGE 0.3 MG/0.05 ML OPHTHALMIC - MACUGEN 3 VISCOELASTIC AGENTS OPHTHALMIC - MAST CELL AMVISC 1 STABILIZERS AMVISC PLUS 1 ALOCRIL 3 PA BIOLON 4 ALOMIDE 3 PA HEALON ENDOCOAT 4 cromolyn ophthalmic HEALON GV 4 1 (eye) HEALON PRO 4 OPHTHALMIC - HEALON5 4 MYDRIATIC- HEALON5 PRO 4 NSAID VISCOAT 1 COMBINATIONS OPHTHALMIC MYDRIATIC4(TROP- 3 ANTIBACTERIAL PROP-PE-KTRLC) MIXTURES OMIDRIA 3 bacitracin-polymyxin b 3 ophthalmic (eye) neomycin-bacitracin- 3 polymyxin

You can find information on what the symbols and abbreviations on this table mean on page 4. 245 Drug Name Drug Tier Limits Drug Name Drug Tier Limits neomycin-polymyxin- moxifloxacin 3 gramicidin ophthalmic (eye) drops, 1 NEO-POLYCIN 3 viscous POLYCIN 3 moxifloxacin-sod chlor,iso(pf) intraocular 3 polymyxin b sulf- 1 solution 5 mg/ml trimethoprim moxifloxacin-sod POLYTRIM 3 chlor,iso(pf) intraocular 4 OPHTHALMIC syringe ANTIBIOTIC - OCUFLOX 3 AMINOGLYCOSI ofloxacin ophthalmic 1 DES (eye) GENTAK VIGAMOX 1 OPHTHALMIC (EYE) 3 ZYMAXID 3 OINTMENT OPHTHALMIC gentamicin ophthalmic 1 (eye) ANTIBIOTIC - MACROLIDES tobramycin 1 AZASITE 3 TOBREX 3 erythromycin 1 OPHTHALMIC ophthalmic (eye) ANTIBIOTIC - DEHYDROPEPTI OPHTHALMIC DASE ANTIBIOTIC - INHIBITORS SULFONAMIDES BLEPH-10 3 bacitracin ophthalmic 3 sulfacetamide sodium (eye) 1 ophthalmic (eye) OPHTHALMIC ANTIBIOTIC - OPHTHALMIC FLUOROQUINOL ANTIFUNGALS - ONES TETRAENE POLYENE-TYPE BESIVANCE 3 NATACYN 1 CILOXAN 3 ciprofloxacin hcl OPHTHALMIC 1 ophthalmic (eye) ANTIFUNGALS gatifloxacin 3 NATACYN 1 levofloxacin ophthalmic OPHTHALMIC 3 (eye) ANTISEPTICS MOXEZA 1 BETADINE 3 moxifloxacin OPHTHALMIC PREP 3 ophthalmic (eye) drops

You can find information on what the symbols and abbreviations on this table mean on page 4. 246 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OPHTHALMIC OPHTHALMIC- ANTIVIRALS INTRAOCULAR trifluridine 1 PRESSURE ZIRGAN 3 REDUCING AGENTS, RHO OPHTHALMIC- KINASE INTRAOCULAR INHIBITORS PRESS. REDUCING, SEL. RHOPRESSA 3 ALPHA SELECTIVE ADRENERGIC VASCULAR AGONISTS ENDOTHELIAL ALPHAGAN P 1 GROWTH FACTOR (VEGF) apraclonidine 3 ANTAGONISTS brimonidine 1 MACUGEN 3 IOPIDINE OPHTHALMIC (EYE) 3 VASCULAR DROPPERETTE ENDOTHELIAL OPHTHALMIC- GROWTH INTRAOCULAR FACTOR (VEGF- PRESSURE A) RECEPTOR REDUCING ANTAGONISTS bevacizumab intravitreal AGENTS, 4 PROSTAGLANDI syringe 2.5 mg/0.1 ml N ANALOGS LUCENTIS INTRAVITREAL 4 PA bimatoprost ophthalmic 3 SOLUTION (eye) LUCENTIS latanoprost 1 INTRAVITREAL 4 PA latanoprost (pf) 3 SYRINGE 0.3 MG/0.05 LUMIGAN ML OPHTHALMIC (EYE) 3 VASCULAR DROPS 0.01 % ENDOTHELIAL TRAVATAN Z 1 GROWTH VYZULTA 3 FACTOR(VEGF-A XALATAN 3 PA AND XELPROS 3 PA PLGF)RECEPTO ZIOPTAN (PF) 3 R INHIBITORS EYLEA INTRAVITREAL 4 SOLUTION

You can find information on what the symbols and abbreviations on this table mean on page 4. 247 Drug Name Drug Tier Limits Drug Name Drug Tier Limits OTIC (EAR) RESPIRATORY OTIC (EAR) - THERAPY ANTI- AGENTS INFECTIVE- 1ST GLUCOCORTICO GENERATION ID ANTIHISTAMINE COMBINATIONS - CIPRO HC 1 DECONGESTANT CIPRODEX 1 COMBINATIONS neomycin-polymyxin-hc CENTERGY 3 1 otic (ear) PROMETHAZINE VC 1 OTOVEL 3 2ND OTIC (EAR) - GENERATION ANTI- ANTIHISTAMINE INFECTIVES - OTHER DECONGESTANT acetic acid otic (ear) 1 COMBINATIONS CLARINEX-D 12 OTIC (EAR) - 3 FLUOROQUINOL HOUR ONES SEMPREX-D 3 CETRAXAL 3 ANTIHISTAMINE ciprofloxacin hcl otic - 1ST 3 (ear) GENERATION - ofloxacin otic (ear) 1 ALKYLAMINES brompheniramine OTIPRIO 3 3 maleate (bulk) OTIC (EAR) - RYCLORA 3 GLUCOCORTICO IDS ANTIHISTAMINE - 1ST DERMOTIC OIL 3 GENERATION - FLAC OTIC OIL 3 ETHANOLAMINE fluocinolone acetonide 1 S oil carbinoxamine maleate hydrocortisone-acetic 2 PA 1 oral liquid acid carbinoxamine maleate 2 PA OTIC (EAR) - oral tablet 4 mg PINNA carbinoxamine maleate 3 COMBINATIONS oral tablet 6 mg CORTANE-B clemastine oral tablet 3 2 PA TOPICAL 2.68 mg

You can find information on what the symbols and abbreviations on this table mean on page 4. 248 Drug Name Drug Tier Limits Drug Name Drug Tier Limits diphenhydramine (bulk) 3 carbinoxamine maleate 3 diphenhydramine hcl oral tablet 6 mg injection solution 50 4 clemastine oral tablet 2 PA mg/ml 2.68 mg diphenhydramine hcl cyproheptadine 1 4 injection syringe diphenhydramine hcl KARBINAL ER 3 injection solution 50 4 ANTIHISTAMINE mg/ml diphenhydramine hcl - 1ST 4 GENERATION - injection syringe PHENOTHIAZIN KARBINAL ER 3 ES PHENERGAN INJECTION 3 PHENERGAN SOLUTION 25 MG/ML INJECTION 3 SOLUTION 25 MG/ML PHENERGAN INJECTION 1 PHENERGAN SOLUTION 50 MG/ML INJECTION 1 SOLUTION 50 MG/ML promethazine (bulk) 3 promethazine injection promethazine injection 3 3 solution 25 mg/ml solution 25 mg/ml promethazine injection promethazine injection 1 1 solution 50 mg/ml solution 50 mg/ml promethazine oral tablet 1 promethazine oral tablet 1 promethazine rectal promethazine rectal suppository 12.5 mg, 25 1 suppository 12.5 mg, 25 1 mg mg promethazine rectal promethazine rectal 3 3 suppository 50 mg suppository 50 mg PROMETHEGAN 1 PROMETHEGAN 1 pyrilamine maleate ANTIHISTAMINE 3 - 1ST (bulk) GENERATION - RYCLORA 3 PIPERIDINES ANTIHISTAMINE cyproheptadine 1 S - 2ND GENERATION - ANTIHISTAMINE PIPERAZINES S - 1ST levocetirizine oral GENERATION 3 solution carbinoxamine maleate 2 PA oral liquid QUZYTTIR 4 carbinoxamine maleate 2 PA oral tablet 4 mg

You can find information on what the symbols and abbreviations on this table mean on page 4. 249 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ANTIHISTAMINE ASTHMA S - 2ND THERAPY - GENERATION - ALPHA/BETA PIPERIDINES ADRENERGIC CLARINEX ORAL AGENTS 3 TABLET ADRENALIN QL (3 ML per INJECTION 3 desloratadine oral tablet 1 21 days) SOLUTION 1 MG/ML desloratadine oral 3 tablet,disintegrating epinephrine (bulk) 3 epinephrine injection QL (3 ML per ANTIHISTAMINE 2 S - 2ND solution 1 mg/ml 21 days) epinephrine injection QL (3 ML per GENERATION 2 syringe 0.1 mg/ml 21 days) CLARINEX ORAL 3 TABLET ASTHMA desloratadine oral tablet 1 THERAPY - INHALED desloratadine oral 3 tablet,disintegrating CORTICOSTERO IDS levocetirizine oral 3 solution (GLUCOCORTIC OIDS) QUZYTTIR 4 ALVESCO 3 ANTITUSSIVES - NON-OPIOID ARMONAIR RESPICLICK dextromethorphan hbr 3 INHALATION (bulk) AEROSOL POWDR 3 PA AROMATIC BREATH ANTITUSSIVE ACTIVATED 232 MCG/ACTUATION DEMULCENTS ARMONAIR menthol (bulk) 1 RESPICLICK ASTHMA INHALATION THERAPY - 5- AEROSOL POWDR 3 LIPOXYGENASE BREATH ACTIVATED 55 INHIBITORS MCG/ACTUATION zileuton 3 ARNUITY ELLIPTA 3 ZYFLO 3 ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 3 MCG/ACTUATION, 200 MCG/ACTUATION

You can find information on what the symbols and abbreviations on this table mean on page 4. 250 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ASMANEX ASTHMA TWISTHALER THERAPY - INHALATION INTERLEUKIN-5 AEROSOL POWDR BREATH (IL-5) RECEPTOR ACTIVATED 110 ALPHA MCG/ ACTUATION ANTAGONISTS, 3 (30), 220 MCG/ MAB ACTUATION (120), FASENRA 3 PA 220 MCG/ ACTUATION (14), 220 ASTHMA MCG/ ACTUATION THERAPY - (30), 220 MCG/ LEUKOTRIENE ACTUATION (60) RECEPTOR beclomethasone diprop 3 ANTAGONISTS (bulk) ACCOLATE 3 budesonide inhalation 1 montelukast oral 1 PA FLOVENT DISKUS 1 granules in packet FLOVENT HFA 1 montelukast oral tablet 1 flunisolide (bulk) 3 montelukast oral 1 PULMICORT 3 tablet,chewable PULMICORT SINGULAIR ORAL 1 FLEXHALER GRANULES IN 1 QVAR REDIHALER 3 PACKET SINGULAIR ORAL ASTHMA 3 TABLET THERAPY - SINGULAIR ORAL INTERLEUKIN-4 3 TABLET,CHEWABLE (IL-4) RECEPTOR ALPHA zafirlukast 2 PA ANTAGONISTS, ASTHMA MAB THERAPY - DUPIXENT SYRINGE MAST CELL SUBCUTANEOUS STABILIZERS 3 PA SYRINGE 200 cromolyn (bulk) 1 MG/1.14 ML cromolyn inhalation 1 DUPIXENT SYRINGE SUBCUTANEOUS ASTHMA 3 SYRINGE 300 MG/2 THERAPY - ML MONOCLONAL ANTIBODIES TO IMMUNOGLOBU LIN E (IGE) XOLAIR 2 PA

You can find information on what the symbols and abbreviations on this table mean on page 4. 251 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ASTHMA ASTHMA/COPD - THERAPY - PHOSPHODIEST XANTHINES ERASE-4 (PDE4) aminophylline (bulk) 3 INHIBITORS aminophylline DALIRESP 2 4 intravenous ASTHMA/COPD - ELIXOPHYLLIN ANTICHOLINER ORAL ELIXIR 80 3 GIC AGENTS, MG/15 ML INHALED LONG THEO-24 3 ACTING THEOCHRON 1 INCRUSE ELLIPTA 3 theophylline (bulk) 3 LONHALA MAGNAIR 3 theophylline in dextrose REFILL 5 % intravenous LONHALA MAGNAIR parenteral solution 200 3 4 STARTER mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 800 SEEBRI NEOHALER 3 mg/250 ml SPIRIVA RESPIMAT 3 theophylline oral SPIRIVA WITH 1 1 solution HANDIHALER theophylline oral tablet TUDORZA PRESSAIR 3 1 extended release 12 hr YUPELRI 3 PA theophylline oral tablet 1 ASTHMA/COPD - extended release 24 hr ANTICHOLINER ASTHMA GIC AGENTS, THERAPY- INHALED SHORT MONOCLONAL ACTING ANTIBODY - ATROVENT HFA 1 INTERLEUKIN-5 ipratropium bromide (IL-5) 1 (bulk) ANTAGONISTS ipratropium bromide 1 NUCALA inhalation SUBCUTANEOUS 2 PA AUTO-INJECTOR ASTHMA/COPD - NUCALA BETA 2- SUBCUTANEOUS 4 PA ADRENERGIC RECON SOLN AGENTS, NUCALA INHALED, SUBCUTANEOUS 2 PA ULTRA-LONG SYRINGE ACTING ARCAPTA 3 NEOHALER

You can find information on what the symbols and abbreviations on this table mean on page 4. 252 Drug Name Drug Tier Limits Drug Name Drug Tier Limits STRIVERDI 3 ASTHMA/COPD RESPIMAT THERAPY - BETA ASTHMA/COPD ADRENERGIC THERAPY - BETA AGENTS 2-ADRENERGIC albuterol sulfate oral 1 AGENTS, metaproterenol oral 3 PA INHALED, LONG syrup ACTING terbutaline 3 BROVANA 3 ASTHMA/COPD PERFOROMIST 3 THERAPY - BETA QL (56 EA per SEREVENT DISKUS 1 ADRENERGIC- 23 days) ANTICHOLINER ASTHMA/COPD GIC THERAPY - BETA COMBINATIONS 2-ADRENERGIC ANORO ELLIPTA 3 AGENTS, BEVESPI 3 INHALED, AEROSPHERE SHORT ACTING COMBIVENT 1 albuterol sulfate (bulk) 3 RESPIMAT albuterol sulfate ipratropium-albuterol 1 inhalation hfa aerosol 3 STIOLTO RESPIMAT 1 inhaler UTIBRON 3 albuterol sulfate NEOHALER inhalation solution for 1 nebulization ASTHMA/COPD levalbuterol hcl 3 THERAPY - BETA ADRENERGIC- levalbuterol tartrate 3 GLUCOCORTICO QL (2 inhalers ID PROAIR HFA 2 Max Qty Per Fill Retail) COMBINATIONS PROAIR RESPICLICK 3 ADVAIR DISKUS 1 PROVENTIL HFA 1 ADVAIR HFA 1 VENTOLIN HFA 3 AIRDUO RESPICLICK 3 PA XOPENEX 3 BREO ELLIPTA 3 PA XOPENEX budesonide-formoterol 1 3 CONCENTRATE DULERA XOPENEX HFA 3 INHALATION HFA AEROSOL INHALER 100-5 1 MCG/ACTUATION, 200-5 MCG/ACTUATION

You can find information on what the symbols and abbreviations on this table mean on page 4. 253 Drug Name Drug Tier Limits Drug Name Drug Tier Limits fluticasone propion- CYSTIC salmeterol inhalation 3 PA FIBROSIS - aerosol powdr breath INHALED activated MONOBACTAMS fluticasone propion- salmeterol inhalation 1 CAYSTON 2 PA; ST blister with device CYSTIC SYMBICORT 1 FIBROSIS- WIXELA INHUB 3 PA TRANSMEMBRA ASTHMA/COPD NE TX - BETA- CONDUCTANCE ADRENERGIC- REGULATOR ANTICHOLINER (CFTR) GIC- POTENTIATOR GLUCOCORTICO KALYDECO ORAL ID COMB, GRANULES IN 2 PA PACKET 25 MG TRELEGY ELLIPTA 3 PA KALYDECO ORAL CORTICOSTERO GRANULES IN 2 ID IMPLANT FOR PACKET 50 MG, 75 MAINTAINING MG KALYDECO ORAL SINUS PATENCY 2 TABLET SINUVA 4 CYSTIC CYSTIC FIB- FIBROSIS - TRANSMEMB INHALED CONDUCT. AMINOGLYCOSI REG.(CFTR) DES POTENTIATOR AND BETHKIS 2 PA CORRECTOR KITABIS PAK 2 PA CMB TOBI 3 ORKAMBI ORAL 2 TOBI PODHALER TABLET 200-125 MG INHALATION SYMDEKO ORAL CAPSULE, 2 PA TABLETS, 2 PA W/INHALATION SEQUENTIAL 100-150 DEVICE MG (D)/ 150 MG (N) PA; QL (280 tobramycin in 0.225 % SYMDEKO ORAL 2 ML per 23 TABLETS, nacl 3 days) SEQUENTIAL 50-75 MG (D)/ 75 MG (N) TRIKAFTA 3

You can find information on what the symbols and abbreviations on this table mean on page 4. 254 Drug Name Drug Tier Limits Drug Name Drug Tier Limits ELASTASE NASAL INHIBITORS ANTIHISTAMINE ARALAST NP 4 AND ANTI- GLASSIA 4 PA INFLAMMATOR Y STEROID PROLASTIN-C 4 COMBINATIONS ZEMAIRA 4 DYMISTA 3 EXPECTORANTS - SINGLE NASAL AGENTS, ANTIHISTAMINE GENERAL S azelastine nasal QL (60 ML per guaifenesin (bulk) 3 2 aerosol,spray 23 days) LUNG azelastine nasal 2 PA SURFACTANTS spray,non-aerosol CUROSURF 3 olopatadine nasal 3 INFASURF 3 PATANASE 3 SURFAXIN 3 NASAL SURVANTA 3 CORTICOSTERO MUCOLYTICS IDS beclomethasone diprop acetylcysteine 1 3 (bulk) PULMOZYME 2 PA BECONASE AQ 2 PA NASAL ANESTHETICS flunisolide (bulk) 3 flunisolide nasal cocaine nasal 4 QL (50 ML per spray,non-aerosol 25 2 23 days) GOPRELTO 4 mcg (0.025 %) NASAL QL (17 GM per mometasone nasal 1 ANTICHOLINER 23 days) GICS QL (17 GM per NASONEX 3 ipratropium bromide 23 days) 1 (bulk) OMNARIS 1 ipratropium bromide QNASL 3 QL (30 ML per nasal spray,non-aerosol 1 23 days) TICANASE 3 0.03 % ZETONNA 3 ipratropium bromide QL (15 ML per nasal spray,non-aerosol 1 NASAL POST- 23 days) 42 mcg (0.06 %) SURGICAL AGENTS SINUVA 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 255 Drug Name Drug Tier Limits Drug Name Drug Tier Limits NASAL VAGINAL SYMPATHOMIM PRODUCTS ETIC VAGINAL DECONGESTANT ANTIBACTERIAL S (INTRANASAL) - LINCOSAMIDES ADRENALIN NASAL 3 CLEOCIN VAGINAL TYZINE NASAL 3 3 CREAM DROPS 0.1 % CLEOCIN VAGINAL 1 TYZINE NASAL SUPPOSITORY SPRAY,NON- 3 clindamycin phosphate AEROSOL 1 vaginal PLEURAL CLINDESSE 3 SCLEROSING VAGINAL AGENTS ANTIFUNGAL - STERITALC 4 IMIDAZOLES PULMONARY GYNAZOLE-1 3 FIBROSIS MICONAZOLE-3 QL (3 EA per TREATMENT VAGINAL 2 23 days) AGENTS - SUPPOSITORY ANTIFIBROTIC VAGINAL THERAPY ANTIFUNGAL - ESBRIET 2 PA TRIAZOLES PULMONARY terconazole vaginal QL (180 GM 2 FIBROSIS cream 0.4 % per 23 days) TREATMENT terconazole vaginal QL (80 GM per 2 AGENTS - cream 0.8 % 23 days) MULTIKINASE terconazole vaginal QL (12 EA per 3 INHIBITORS suppository 23 days) OFEV 2 PA VAGINAL SYSTEMIC ANTIPROTOZOA SYMPATHOMIM L- ETIC ANTIBACTERIAL DECONGESTANT - NITROIMIDAZO S LE ephedrine hcl (bulk) 3 DERIVATIVES METROGEL ephedrine sulfate (bulk) 3 3 VAGINAL phenylephrine hcl (bulk) 3 metronidazole vaginal 1 pseudoephedrine hcl 3 (bulk) NUVESSA 3 VANDAZOLE 1

You can find information on what the symbols and abbreviations on this table mean on page 4. 256 Drug Name Drug Tier Limits VAGINAL ANTISEPTIC MIXTURES FEM PH 3 RELAGARD 3 TRIMO-SAN JELLY 3 VAGINAL ESTROGENS ESTRACE VAGINAL 1 estradiol vaginal tablet 1 ESTRING 1 FEMRING 3 PREMARIN 1 VAGINAL VAGIFEM 1 YUVAFEM 1 VAGINAL PRODUCTS MISCELLANEOU S CLEANSING WASH 3 TOPICAL SOLUTION SUMMER'S EVE 3 FEMININE WASH VAGINAL PROGESTINS CRINONE VAGINAL 3 GEL 4 %

You can find information on what the symbols and abbreviations on this table mean on page 4. 257 You can find information on what the symbols and abbreviations on this table mean on page 4. 258 Medical Benefit Drug Name Drug Tier Limits amikacin injection solution 1,000 mg/4 ml, 4 PA 500 mg/2 ml aztreonam injection 4 PA recon soln 1 gram CINQAIR 4 ganciclovir intravenous 4 gentamicin injection 4 PA solution 40 mg/ml gentamicin sulfate (ped) 4 (pf) hydroxyprogest(pf)(preg 4 PA presv) hydroxyprogesterone 4 PA cap(ppres) hydroxyprogesterone 4 caproate MAKENA 4 PA MAKENA (PF) 4 penicillin g potassium injection recon soln 5 2 PA million unit PFIZERPEN-G 4 polymyxin b sulfate 4

You can find information on what the symbols and abbreviations on this table mean on page 4. 259 You can find information on what the symbols and abbreviations on this table mean on page 4. 260 Index (d)-limonene flavor (bulk) 105, 114 ACIDOPHILUS EX STR (L. ADEMPAS...... 80 5-AMINOSALICYLIC ACID..105 SPOROG)...... 202 ADENOSCAN...... 142 5-hydroxy-l-tryptophan (bulk) ACIDOPHILUS PROBIOTIC adenosine...... 69 ...... 105, 148 BLEND...... 202 adenosine (bulk)...... 69, 105, 142 7-KETO DHEA, acidophilus-pectin, citrus...... 202 adenosine (diagnostic)...... 142 MICRONIZED...... 11, 105 ACIPHEX...... 197 ADHANSIA XR...... 93 A THRU Z ADVANCED ACIPHEX SPRINKLE...... 197 ADLYXIN...... 182 FORMULA...... 164 acitretin...... 129 ADMELOG SOLOSTAR U- A THRU Z SELECT...... 160 ACTEMRA...... 22 100 INSULIN...... 190 abacavir...... 37 ACTEMRA ACTPEN...... 22 ADMELOG U-100 INSULIN abacavir-lamivudine...... 38 ACTHAR...... 179 LISPRO...... 190 abacavir-lamivudine-zidovudine 38 ACTHIB (PF)...... 64 ADRENALIN...... 75, 250, 256 ABATRON...... 154 ACTHREL...... 143 ADREVIEW...... 143 ABELCET...... 33 ACTICAL...... 160 ADRIAMYCIN...... 58 ABILIFY...... 93, 96 ACTICLATE...... 47 ADRUCIL...... 51 ABILIFY MAINTENA...... 93 ACTICOAT 7 DRESSING...... 141 ADULT MULTIVITAMIN ABILIFY MYCITE...... 93, 96 ACTIGALL...... 197 GUMMIES...... 160 abiraterone...... 48, 50 ACTIMMUNE...... 35 ADULT ONE DAILY ABLYSINOL...... 79 ACTIQ...... 13 GUMMIES...... 160 ABRAXANE...... 57 ACTIVASE...... 215 ADVAIR DISKUS...... 253 ABSORICA...... 123 activated charcoal...... 199 ADVAIR HFA...... 253 acacia (bulk)...... 105 ACTIVE FE...... 154 ADVANCED ALLERGY acamprosate...... 104 ACTIVELLA...... 184 COLLECT KIT...... 132 ACANYA...... 124 ACTIVE-PAC...... 83, 102 ADVANCED CALCIUM...... 151 acarbose...... 180 ACTIVITE...... 145 ADVANTAGE WITH IRON... 148 ACCOLATE...... 251 ACTONEL...... 183 ADZENYS ER...... 93, 97 ACCU-CHEK COMBO ACTOPLUS MET...... 182 ADZENYS XR-ODT...... 93, 97 SYSTEM...... 228 ACTOPLUS MET XR...... 182 AEMCOLO...... 47 ACCU-CHEK SPIRIT ACTOS...... 190 AEROCHAMBER MV.... 225, 228 ADAPTER...... 225, 228 ACUICYN...... 132 AEROCHAMBER PLUS ACCUPRIL...... 66 ACULAR...... 243 FLOW-VU...... 225, 228 ACCURETIC...... 65 ACULAR LS...... 243 AEROCHAMBER PLUS ACD SOLUTION A...... 210 ACUVAIL (PF)...... 243 FLOW-VU,L MSK...... 226, 228 ACE AEROSOL CLOUD acyclovir...... 43, 130 AEROCHAMBER PLUS ENHANCER...... 225, 228 acyclovir (bulk)...... 43, 105 FLOW-VU,M MSK...... 226, 228 acebutolol...... 72 acyclovir sodium...... 43 AEROCHAMBER PLUS acebutolol (bulk)...... 72, 105 ACZONE...... 123 FLOW-VU,S MSK...... 226, 229 ACETADOTE...... 30 ADACEL(TDAP AEROCHAMBER WITH acetaminophen (bulk)...... 20, 105 ADOLESN/ADULT)(PF)...... 64 FLOWSIGNAL...... 226, 229 acetaminophen-caff-dihydrocod ADAKVEO...... 213 AEROTRACH PLUS...... 226, 229 ...... 16, 17 ADALAT CC...... 74 AFINITOR...... 55 acetaminophen-codeine...... 16 adapalene...... 125 AFINITOR DISPERZ...... 55 acetazolamide...... 77 adapter cap for bottle...... 224, 228 AFIRMELLE...... 119 acetazolamide (bulk)...... 77, 105 ADASUVE...... 92 AFREZZA...... 189 acetazolamide sodium...... 77 ADCETRIS...... 50, 59 AGGRASTAT IN SODIUM acetic acid...... 205, 248 ADCIRCA...... 81 CHLORIDE...... 214 acetone...... 113 ADDAMEL N...... 159 AGGRENOX...... 213 acetylcarnitine...... 145 ADDERALL...... 93, 97, 102 AGRYLIN...... 214 acetylcholine chloride (bulk) ADDERALL XR...... 93, 97 A-HYDROCORT...... 186 ...... 105, 240 ADDYI...... 98 AIMOVIG AUTOINJECTOR....99 acetylcysteine...... 30, 255 adefovir...... 43 AIRDUO RESPICLICK...... 253

261 AIRS DISPOSABLE alkyl (c12-15) benzoate (bulk) AMERGE...... 100 NEBULIZER...... 224, 229 ...... 105, 117 AMERIPHOR...... 131 AIRSHIELD...... 160 ALLERGIST TRAY 1/2 ML AMERISTORE...... 132 AIRSHIELD IMMUNE...... 12 27GX3/8"...... 224, 229 AMETHIA...... 119 AJOVY SYRINGE...... 99 ALLERGIST TRAY AMETHIA LO...... 119 AK-FLUOR...... 244 INTRADERMAL BEV.... 224, 229 AMETHYST (28)...... 119 AKOVAZ...... 75 ALLEVYN...... 141, 229 AMICAR...... 211 AKTEN (PF)...... 245 allopurinol...... 209 AMIDATE...... 27 AKYNZEO ALLZITAL...... 19 amikacin...... 259 (FOSNETUPITANT)...... 196 almotriptan malate...... 100 amiloride...... 78 AKYNZEO (NETUPITANT)...196 ALOCRIL...... 245 amiloride-hydrochlorothiazide....78 ALA-CORT...... 132 ALOE GRANDE...... 131 aminobenzoic acid (bulk)..105, 209 ALBA-LYBE...... 145 aloe vera (bulk)...... 12, 105 aminocaproic acid...... 211 albendazole...... 33 alogliptin...... 180 aminophylline...... 252 ALBENZA...... 33 alogliptin-metformin...... 182 aminophylline (bulk)...... 105, 252 ALBUKED-25...... 212 alogliptin-pioglitazone...... 182 AMINOPROTECT...... 166 ALBUKED-5...... 212 ALOMIDE...... 245 aminosalicylic acid (bulk)...38, 105 albumin, human 25 %...... 212 ALOPRIM...... 209 AMINOSALICYLIC ACID-5..105 albumin, human 5 %...... 212 ALORA...... 185 AMINOSYN 10 %...... 167 ALBUMINAR 25 %...... 212 alosetron...... 200, 203 AMINOSYN 3.5 %...... 167 ALBUMINAR 5 %...... 212 ALOXI...... 195 AMINOSYN 7 %...... 167 ALBUMINEX...... 212 ALPHABATH...... 131 AMINOSYN 7 % WITH ALBURX (HUMAN) 25 %...... 212 ALPHAGAN P...... 247 ELECTROLYTES...... 167 ALBURX (HUMAN) 5 %...... 212 alprazolam...... 82, 94 AMINOSYN 8.5 %...... 167 ALBUTEIN 25 %...... 212 ALPRAZOLAM INTENSOL AMINOSYN 8.5 %- ALBUTEIN 5 %...... 212 ...... 82, 94 ELECTROLYTES...... 167 albuterol sulfate...... 253 alprostadil...... 79 AMINOSYN II 10 %...... 167 albuterol sulfate (bulk)...... 105, 253 ALREX...... 242 AMINOSYN II 15 %...... 167 alclometasone...... 132 ALSUMA...... 100 AMINOSYN II 7 %...... 167 ALCOHOL, DENATURED.....113 ALTABAX...... 127 AMINOSYN II 8.5 %...... 167 ALDACTAZIDE...... 78 ALTACAINE...... 244 AMINOSYN II 8.5 %- ALDACTONE...... 66, 77 ALTACE...... 66 ELECTROLYTES...... 167 ALDARA...... 135 ALTAFLUOR BENOX...... 244 AMINOSYN M 3.5 %...... 167 ALDURAZYME...... 235 ALTAVERA (28)...... 119 AMINOSYN-HBC 7%...... 167 ALECENSA...... 50 ALTOPREV...... 70 AMINOSYN-PF 10 %...... 167 alendronate...... 183 ALTRENO...... 125 AMINOSYN-PF 7 % alfentanil...... 13 aluminum, (acetato-o)dih(bulk) 105 (SULFITE-FREE)...... 167 ALFERON N...... 135 ALUNBRIG...... 50 AMINOSYN-RF 5.2 %...... 167 alfuzosin...... 206 ALVESCO...... 250 amiodarone...... 69 ALGAL OMEGA-3 DHA...... 71 ALYACEN 1/35 (28)...... 119 amiodarone in dextrose 5 %...... 69 ALGAL-900 DHA...... 71 ALYACEN 7/7/7 (28)...... 122 AMITIZA...... 200, 203 alginic acid (bulk)...... 105, 117 ALYQ...... 81 amitriptyline...... 88 ALIMTA...... 50 AMABELZ...... 184 amitriptyline (bulk)...... 88, 105 ALINIA...... 35 amantadine hcl...... 90 amitriptyline-chlordiazepoxide ALIQOPA...... 55 amantadine hcl (bulk)...... 90, 105 ...... 88, 94 aliskiren...... 81 AMARYL...... 181 AMLACTIN...... 131 ALIVE ONCE DAILY AMBIEN...... 103 amlodipine...... 74 WOMEN 50 PLUS...... 160 AMBIEN CR...... 103 amlodipine-atorvastatin...... 72 ALIVE PRENATAL...... 174 AMBISOME...... 33 amlodipine-benazepril...... 65 ALIVE WOMEN'S ENERGY..160 ambrisentan...... 80 amlodipine-olmesartan...... 66 ALKERAN...... 49 amcinonide...... 132 amlodipine-valsartan...... 66 ALKERAN (AS HCL)...... 49 AMELUZ...... 138 amlodipine-valsartan-hcthiazid...67

262 ammonium chloride...... 77, 206 ANIMI-3 WITH VITAMIN D. 164 argatroban in 0.9 % sod chlor... 215 ammonium sulfate (bulk)...... 105 anise flavor extract (bulk).105, 114 argatroban in nacl (iso-os)...... 215 AMMONUL...... 236 ANNOVERA...... 122 arginine (l-arginine)...... 145 AMNESTEEM...... 123 ANORO ELLIPTA...... 253 arginine hcl (l-arginine)...... 145 amoxapine...... 88 ANTABUSE...... 104 arginine-lysine in 0.9 % nacl.... 166 amoxicil-clarithromy-lansopraz 204 ANTARA...... 69 ARICEPT...... 118 amoxicillin...... 32, 33 anthralin (bulk)...... 105, 130 ARIKAYCE...... 32 amoxicillin-pot clavulanate...... 32 ANTI MONKEY BUTT...... 138 ARIMIDEX...... 51 AMPHADASE...... 194 anticoag citrate phos dextrose...210 aripiprazole...... 93, 97 amphetamine...... 93, 97 ANTIVERT...... 194 ARISTADA...... 93 amphetamine sulfate..... 93, 98, 102 APADAZ...... 17 ARISTADA INITIO...... 93 amphotericin b...... 33 APATATE...... 175 ARISTOSPAN INTRA- ampicillin...... 33 APETEX...... 145 ARTICULAR...... 186 ampicillin sodium...... 33 APETIGEN...... 145 ARISTOSPAN ampicillin-sulbactam...... 32 APETIGEN PLUS...... 147, 154 INTRALESIONAL...... 186 AMPYRA...... 240 APIDRA SOLOSTAR U-100 ARIXTRA...... 213 AMRIX...... 219 INSULIN...... 190 ARKALIOX...... 175 AMVISC...... 245 APIDRA U-100 INSULIN...... 190 armodafinil...... 101 AMVISC PLUS...... 245 APLENZIN...... 88 ARMONAIR RESPICLICK.....250 AMYTAL...... 102 APOKYN...... 90 ARMOUR THYROID...... 193 AMYVID...... 143 apple flavor (bulk)...... 105, 114 ARNUITY ELLIPTA...... 250 ANADROL-50...... 179 APPLE-ADE FLAVOR....105, 114 AROMASIN...... 51 ANAFRANIL...... 88 apraclonidine...... 247 ARRANON...... 50 anagrelide...... 214 aprepitant...... 196 arsenic trioxide...... 51 ANA-LEX KIT...... 29 APRI...... 119 arsenic trioxide (bulk)...... 51, 105 ANALPRAM-HC...... 29, 135 apricot flavor (bulk)...... 105, 114 ARTHROTEC 50...... 23 ANALPRAM-HC SINGLES...... 29 APRISO...... 201 ARTHROTEC 75...... 23 ANAPROX DS...... 25 APRIZIO PAK...... 137 ARYMO ER...... 13 ANASCORP...... 61 APTENSIO XR...... 93 ARZERRA...... 52 ANASPAZ...... 199, 208 APTIOM...... 84 ASACOL HD...... 201 anastrozole...... 51 APTIVUS...... 46 ASCLERA...... 81 ANAVIP...... 62 APTIVUS (WITH VITAMIN ASCOMP WITH CODEINE...... 16 ANCOBON...... 34 E)...... 46 ASCOR...... 177 ANDEXXA...... 30 AQUA CARE...... 132 ascorbic acid (vitamin c)...... 177 ANDRODERM...... 179 AQUA CARE SODIUM ASHLYNA...... 119 ANDROGEL...... 179 CHLORIDE...... 150 ASMANEX HFA...... 250 ANDROID...... 179 AQUA CARE STERILE ASMANEX TWISTHALER.... 251 ANESTHESIA S/I-40 WATER...... 150 aspirin-dipyridamole...... 213 (PROPOFOL)...... 27 AQUA GLYCOLIC HC...... 135 ASTAGRAF XL...... 216 ANESTHESIA S/I-40A AQUADEKS...... 160 ASTHMAPACK CHILDREN'S (PROPOFOL)...... 27 AQUADEKS PEDIATRIC...... 168 ...... 225, 229 ANESTHESIA S/I-40H AQUANIL SKIN CLEANSER 132 ASTRAMORPH-PF...... 13 (PROPOFOL)...... 27 AQUASOL A...... 175 ATACAND...... 67 ANESTHESIA S/I-40S ARAKODA...... 35 ATACAND HCT...... 67 (PROPOFOL)...... 27 ARALAST NP...... 255 atazanavir...... 46 ANESTHESIA S/I-60 ARANELLE (28)...... 122 ATELVIA...... 183 (PROPOFOL)...... 27 ARANESP (IN atenolol...... 72 ANGELIQ...... 184 POLYSORBATE)...... 210 atenolol-chlorthalidone...... 74 ANIMAL CHEWS...... 170 ARAVA...... 23 ATGAM...... 63 ANIMAL SHAPE VITAMINS 170 ARCALYST...... 20 ATIVAN...... 82, 94, 102 ANIMAL SHAPES ARCAPTA NEOHALER...... 252 atomoxetine...... 94 COMPLETE...... 168, 170 argatroban...... 215 ATOPADERM...... 131

263 ATOPICLAIR...... 131 AYUNA...... 120 BALANCED B-100 atorvastatin...... 70 AYVAKIT...... 56 COMPLEX...... 145 atovaquone...... 35 AZ...... 105, 113 BALANCED B-50...... 147 atovaquone-proguanil...... 35 azacitidine...... 51 BAL-CARE DHA...... 171 atracurium...... 218 AZACTAM...... 45 BAL-CARE DHA ESSENTIAL ATRALIN...... 125 AZASAN...... 22, 217 ...... 171 ATRAPRO CP...... 131 AZASITE...... 246 BALCOLTRA...... 120 ATRAPRO HYDROGEL...... 131 azathioprine...... 22, 217 BALNEOL...... 131 ATREVIS HYDROGEL...105, 113 azathioprine sodium...... 22, 217 balsalazide...... 201 ATRIPLA...... 38 azelaic acid...... 123, 139 balsam peru-castor oil...... 141 ATROPEN...... 79 azelastine...... 242, 255 BALVERSA...... 53 atropine...... 79, 199, 242 AZELEX...... 123, 139 BALZIVA (28)...... 120 atropine (bulk)...... 79, 105, 199 AZESCO...... 174 BANANA CONCENTRATE ATROVENT HFA...... 252 AZILECT...... 90 ...... 105, 114 AUBAGIO...... 240 azithromycin...... 44 BANANA CREAM FLAVOR AUBRA...... 119 AZO CRANBERRY + ...... 105, 114 AUBRA EQ...... 119 PROBIOTIC...... 12 banana creme flavor (bulk) AUGMENTIN...... 32 AZOPT...... 244 ...... 105, 114 AUGMENTIN ES-600...... 32 AZOR...... 66 banana flavor (bulk)...... 105, 114 AUGMENTIN XR...... 32 aztreonam...... 45, 259 BANATROL PLUS...... 194 AUROVELA 1.5/30 (21)...... 119 AZULFIDINE...... 23, 201 BANZEL...... 86 AUROVELA 1/20 (21)...... 119 AZULFIDINE EN-TABS...23, 201 BARACLUDE...... 43 AUROVELA 24 FE...... 119 AZURETTE (28)...... 119 barium sulfate (bulk)...... 105, 141 AUROVELA FE 1.5/30 (28)....119 B COMPLEX...... 147 BASAGLAR KWIKPEN U-100 AUROVELA FE 1-20 (28)...... 119 B COMPLEX 100...... 145, 147 INSULIN...... 189 AURYXIA...... 155, 205 B COMPLEX PLUS VITAMIN BASE B,POLYETHYLENE AUSTEDO...... 101 C...... 145 GLYCOL3350...... 105, 113 AUTOSOFT XC INFUSION B COMPLEX W-VIT C...... 175 BASE W301...... 105, 113 SET 23"...... 228, 229 b complex-vitamin c-folic acid.145 BASE X...... 105, 117 AUVI-Q...... 75 B-100 COMPLEX...... 145 BASE, PCCA POLYPEG.105, 114 AVALIDE...... 67 B12...... 176 BASE, PCCA VANPEN.. 105, 114 AVANDIA...... 190 B-12 DOTS...... 176 BAXDELA...... 42 AVAPRO...... 67 BABY DDROPS...... 177 bcg vaccine, live (pf)...... 63, 64 AVAR...... 124 BABY VITAMIN D3...... 177 B-COMPLEX PLUS VIT C AVAR LS...... 124 BABY WASH...... 139 (CALCIUM)...... 146 AVAR-E GREEN...... 127 BABY'S SUPER DAILY D3....177 B-COMPLEX WITH B-12...... 175 AVAR-E LS...... 124 BACID...... 202 b-complex with vitamin c...... 146 AVASTIN...... 48 bacitracin...... 46, 246 B-COMPLEX WITH AVEED...... 179 bacitracin (bulk)...... 46, 105 VITAMIN C...... 146 AVELOX IN NACL (ISO- bacitracin, micronized (bulk) BD ALLERGIST TRAY REG OSMOTIC)...... 42 ...... 46, 105 BEVEL...... 224, 229 AVIANE...... 120 bacitracin-polymyxin b...... 245 BD FILTER NEEDLE-5 AVIDOXY...... 47 baclofen...... 219 MICRON...... 224, 229 AVIDOXY DK...... 47 baclofen (bulk)...... 105, 219 BD INSULIN SYRINGE U-500 AVITA...... 125 BACMIN...... 160 ...... 223, 229 AVO CREAM...... 131 BACTERIOSTATIC BD PRE-FILLED NORMAL AVODART...... 206 WATER(PARABENS)...... 117 SALINE...... 174 AVONEX...... 239 BACTRIM...... 33 BD SAFETYGLIDE AVOSIL...... 131 BACTRIM DS...... 33 ALLERGIST TRAY...... 224, 229 AVYCAZ...... 39 BAL IN OIL...... 31 BEANO...... 199 AXUMIN...... 143 BALANCED B-100...... 146 AYGESTIN...... 192

264 beclomethasone diprop (bulk) betamethasone sod phos (bulk) bismuth subnitrate (bulk)...... 106 ...... 106, 132, 186, 251, 255 ...... 106, 186 bisoprolol fumarate...... 72 BECONASE AQ...... 255 betamethasone sod phosph- bisoprolol-hydrochlorothiazide...74 BEELITH...... 156 water...... 186 bitter almond oil (bulk).....106, 114 BEKYREE (28)...... 119 betamethasone valerate...... 133 bitter mask flavoring (bulk) BELBUCA...... 19 betamethasone valerate (bulk) ...... 106, 114 BELEODAQ...... 53 ...... 106, 186 BITTERNESS MASK belladonna alkaloids-opium...... 200 betamethasone, augmented...... 133 FLAVOR...... 106, 114 belladonna tincture (bulk).106, 199 BETAMIDE...... 131 bivalirudin...... 215 BELRAPZO...... 49 BETAPACE...... 68, 73 bivalirudin-0.9 % sodium chlor 215 BELSOMRA...... 103 BETAPACE AF...... 68, 73 BIVIGAM...... 62 benazepril...... 66 BETASERON...... 239 blackberry flavor (bulk)....106, 114 benazepril-hydrochlorothiazide.. 66 betaxolol...... 72, 244 BLADDER 2.2...... 160 BENDEKA...... 49 bethanechol chloride...... 209 bleomycin...... 58 BENEFIBER HEALTHY bethanechol chloride (bulk) BLEPH-10...... 246 SHAPE...... 203 ...... 106, 209 BLEPHAMIDE...... 241 BENICAR...... 67 BETHKIS...... 254 BLEPHAMIDE S.O.P...... 241 BENICAR HCT...... 67 BETIMOL...... 244 BLINCYTO...... 59 BENLYSTA...... 23 BETOPTIC S...... 244 BLISOVI 24 FE...... 120 BENSAL HP...... 136 bevacizumab...... 245, 247 BLISOVI FE 1.5/30 (28)...... 120 BENTYL...... 200 BEVESPI AEROSPHERE...... 253 BLISOVI FE 1/20 (28)...... 120 BENZACLIN...... 124 bexarotene...... 57 BLOXIVERZ...... 217 BENZACLIN PUMP...... 124 BEXSERO...... 64 BLUEBERRY FLAVOR..106, 114 BENZAMYCIN...... 124 BEYAZ...... 120 blunt needle, disposable....225, 229 BENZEPRO...... 125 BIAFINE EMULSION...... 131 BOCASAL...... 238 BENZEPRO bicalutamide...... 50 BODY, HAIR, SKIN AND (MICROSPHERES)...... 125 BICILLIN C-R...... 46 NAILS...... 160 benzhydrocodone- BICILLIN L-A...... 45 BONE DENSITY CALCIUM + acetaminophen...... 17 BICNU...... 49 D...... 151 BENZODOX 30...... 47 BIDIL...... 81 BONE ESSENTIALS...... 151 BENZODOX 60...... 47 BIJUVA...... 184 BONIVA...... 183 benzoic acid (bulk)...... 35, 106, 117 BIKTARVY...... 38 BONJESTA...... 194 benzoin compound (bulk). 106, 138 BILTRICIDE...... 33 BOOSTRIX TDAP...... 64 benzoyl peroxide...... 125 bimatoprost...... 247 bortezomib...... 56 benzoyl peroxide (bulk)...... 106 BINOSTO...... 183 bosentan...... 81 benztropine...... 89 BIO-35, GLUTEN FREE...... 160 BOSTON ROUND NATURAL BEPREVE...... 242 BIOCAL...... 151 ...... 224, 229 BERINERT...... 210 bioflavonoids, citrus (bulk) BOSULIF...... 56 BEROCCA (FA-GUARANA- ...... 106, 177 BOTOX...... 218 CAFF)...... 160 BIOGAIA PROTECTIS WITH BOTTLE...... 224, 229 BESER...... 132 VIT D3...... 202 BOTTLETOP DISPENSER BESER KIT...... 135 BIOLON...... 245 ADAPTER...... 224, 229 BESIVANCE...... 246 BIONECT...... 138 BP 10-1...... 124 beta carotene...... 175 BIORPHEN...... 75 BPCO...... 141 BETADINE OPHTHALMIC BIOTECT PLUS...... 160 BRAFTOVI...... 52 PREP...... 246 BIOTHRAX...... 64 BRAINSTRONG PRENATAL 171 betameth ac,sod phos(pf)-water 186 biotin...... 177 BREO ELLIPTA...... 253 betamethasone ace,sod phos-wtr biotin (bulk)...... 106, 177 BREVIBLOC...... 68, 72 ...... 186 BIOTIN PLUS-CALCIUM BREVIBLOC IN NACL (ISO- betamethasone acet,sod phos.... 186 AND VIT D3...... 160 OSM)...... 68, 72 betamethasone dipropionate..... 133 BIOVOL...... 160 BRIDION...... 219 bismuth citrate (bulk)...... 106, 194 BRIELLYN...... 120

265 BRIGHT BEGINNINGS SOY. 148 butorphanol...... 19 calcium carb-mag oxide-zinc ox BRILINTA...... 213 BUTRANS...... 19 ...... 151 brimonidine...... 247 butter flavor (bulk)...... 106, 114 calcium carb-mag ox-zinc gluc.151 BRISDELLE...... 191 butter rum flavor (bulk).... 106, 114 calcium carb-mag ox-zinc sulf..151 BRIVIACT...... 85 butterscotch flavor (bulk)..106, 114 calcium carbonate...... 153 bromfenac...... 243 BUTTERSCOTCH calcium carbonate-vit d3-min... 151 bromocriptine...... 90 FLAVORING...... 106, 114 calcium carbonate-vitamin d3...152 brompheniramine maleate BYDUREON...... 182 calcium chloride...... 153 (bulk)...... 106, 248 BYDUREON BCISE...... 182 calcium citrate...... 153 BROMSITE...... 243 BYETTA...... 182 CALCIUM CITRATE + D...... 152 BROVANA...... 253 BYSTOLIC...... 72 calcium citrate malate-vit d3.....152 BRUKINSA...... 52, 56 cabergoline...... 192 CALCIUM CITRATE PLUS BRYHALI...... 130, 133 CABLIVI...... 209 (VIT B6)...... 160 B-STRESS...... 146 CABOMETYX...... 55 calcium citrate-vitamin d2...... 152 BUBBLE GUM ca-d3-mag ox-zinc-cop-mang- calcium citrate-vitamin d3 152, 153 CONCENTRATE...... 106, 114 bor...... 151 CALCIUM DISODIUM bubblegum flavor (bulk)... 106, 114 ca-d3-mag-zinc-cop-mang-bor. 151 VERSENATE...... 31 budesonide...... 201, 251 CADEAU DHA...... 171 CALCIUM FOR WOMEN...... 151 budesonide, micronized (bulk) CA-DTPA...... 31 calcium gluc in nacl, iso-osm... 154 ...... 106, 186 CADUET...... 72 calcium glucon monohyd (bulk) budesonide-formoterol...... 253 CAFCIT...... 98 ...... 106 BUFFERED LIDOCAINE...... 27 CAFERGOT...... 100 calcium gluconate...... 154 bumetanide...... 77 caffeine (bulk)...... 98, 106 calcium gluconate in 0.9% nacl 154 BUMINATE 25 %...... 212 caffeine citrate...... 98 calcium gluconate in water...... 154 BUMINATE 5 %...... 212 caffeine citrate (bulk)...... 98, 106 CALCIUM MAGNESIUM...... 151 BUNAVAIL...... 104 caffeine-sodium benzoate...... 98 CALCIUM MAGNESIUM + D BUPAP...... 19 CAL MAG ZINC PLUS D3..... 151 ...... 151 BUPHENYL...... 236 CALAN SR...... 74 calcium phos, tribasic (bulk) bupivacaine...... 27 CALCET PETITES...... 152 ...... 106, 154 bupivacaine (bulk)...... 27, 106 CALCILO XD...... 148 calcium phosphate (bulk)...... 106 bupivacaine (pf)...... 27 CALCI-MAX...... 151 calcium phosphate-vitamin d3..153 bupivacaine in nacl(pf)...... 28 calcipotriene...... 130 CALCIUM PNV...... 164, 171 bupivacaine-epinephrine...... 28 calcipotriene-betamethasone.....126 CALCIUM SOFT CHEW...... 151 bupivacaine-epinephrine (pf)...... 28 calcitonin (salmon)...... 184 CALCIUM WITH BORON...... 151 bupivacaine-ketorolac-ketamine.29 CAL-CITRATE...... 152 CALCIUM WITH VITAMIN D BUPRENEX...... 19 calcitriol...... 130, 177, 235, 236 ...... 153 buprenorphine...... 19 CALCIUM 500...... 153 CALCIUM-FOLIC ACID- buprenorphine hcl...... 19, 104 CALCIUM 500 + D...... 152 VITAMIN D...... 151 buprenorphine hcl (bulk).... 19, 106 CALCIUM 500 WITH D...... 152 calcium-magnesium-copper- buprenorphine-naloxone...... 104 CALCIUM 600 + D(3)...... 152 zinc...... 157 bupropion hcl...... 88, 104 CALCIUM 600 + MINERALS 151 calcium-magnesium-zinc...... 151 bupropion hcl (bulk)...... 88, 106 CALCIUM 600 WITH calcium-vitamin d3-vitamin k...151 bupropion hcl (smoking deter)..104 VITAMIN D3...... 152 CALDOLOR...... 25 buspirone...... 82 calcium acetate...... 153, 205 CAL-MAG...... 151 BUSULFEX...... 49 calcium acetate(phosphat bind) CALMAG THINS...... 151 butalbital (bulk)...... 82, 102, 106 ...... 153, 205 CALPHRON...... 154, 205 BUTALBITAL COMPOUND calcium amino acid chelate...... 153 CALQUENCE...... 52, 56 W/CODEINE...... 16 calcium carb and citrate-vitd3...152 CAL-QUICK...... 153 butalbital-acetaminop-caf-cod.... 16 calcium carb-d3-mag cmb11- CALTRATE + D3 PLUS butalbital-acetaminophen...... 19 zinc...... 151 MINERALS...... 152 butalbital-acetaminophen-caff.... 19 CALTRATE 600 PLUS D...... 153 butalbital-aspirin-caffeine...... 26

266 CALTRATE 600-D PLUS CAPSULE CONI-SNAP carvedilol...... 66 MINERALS...... 152 #0(HYPROMEL)...... 116 carvedilol phosphate...... 66 CALTRATE GUMMY BITES.153 CAPSULE CONI-SNAP #00 CASODEX...... 50 CALTRATE WITH VITAMIN (GELATIN...... 115 caspofungin...... 34 D3...... 153 CAPSULE CONI-SNAP #000. 116 castor oil...... 113, 204 CAMBIA...... 25, 100 CAPSULE CONI-SNAP #1 CATAPRES...... 76 CAMILA...... 121 (GELATIN)...... 116 CATAPRES-TTS-1...... 76 CAMPATH...... 52 CAPSULE CONI-SNAP CATAPRES-TTS-2...... 76 CAMPTOSAR...... 57 #1(HYPROMEL)...... 116 CATAPRES-TTS-3...... 76 CAMRESE...... 119 CAPSULE CONI-SNAP #2 CATHFLO ACTIVASE...... 215 CAMRESE LO...... 119 (GELATIN)...... 116 CAVERJECT...... 144 CANASA...... 201 CAPSULE CONI-SNAP #3 CAVERJECT IMPULSE...... 144 CANCIDAS...... 34 (GELATIN)...... 116 CAYA CONTOURED..... 220, 229 candesartan...... 67 CAPSULE CONI-SNAP CAYSTON...... 254 candesartan-hydrochlorothiazid..67 #3(HYPROMEL)...... 116 CAZIANT (28)...... 122 CANDIN...... 61 CAPSULE CONI-SNAP #4 cefaclor...... 40 cantharidin in acetone...... 136 (GELATIN)...... 116 cefadroxil...... 40 CAPASTAT...... 38 captopril...... 66 cefazolin...... 40 capecitabine...... 51 captopril-hydrochlorothiazide.....66 cefazolin in 0.9% sod chloride....40 CAPEX...... 133 CARAC...... 129 cefazolin in dextrose (iso-os)...... 40 CAPLYTA...... 91 CARAFATE...... 204 cefdinir...... 40 CAPRELSA...... 56 caramel flavor (bulk)...... 106, 114 cefditoren pivoxil...... 40 CAPSFENAC PAK...... 137 CARBAGLU...... 237 cefepime...... 41 CAPSULE #0...... 115, 116 carbamazepine...... 84, 96 cefepime in dextrose 5 %...... 41 CAPSULE #0 (CELLULOSE). 113 CARBATROL...... 84, 96 cefepime in dextrose,iso-osm..... 41 CAPSULE #0 carbidopa...... 89 cefixime...... 40 (HYPROMELLOSE)...... 116 carbidopa (bulk)...... 89, 106 CEFOTAN...... 40 CAPSULE #0 DRCAPS...... 116 carbidopa-levodopa...... 89 cefotaxime...... 40 CAPSULE #00...... 115 carbidopa-levodopa-entacapone. 89 cefotetan...... 40 CAPSULE #00 (CELLULOSE) carbinoxamine maleate..... 248, 249 cefotetan in dextrose, iso-osm.... 40 ...... 113 CARBOCAINE...... 28, 237 cefoxitin...... 40 CAPSULE #00 carboplatin...... 56 cefoxitin in dextrose, iso-osm.....40 (HYPROMELLOSE)...... 116 carboxymethylcellul.sod.(bulk) 106 cefpodoxime...... 40 CAPSULE #000...... 115 CARDENE IV...... 74 cefprozil...... 40 CAPSULE #1...... 115 CARDENE IV IN DEXTROSE. 74 ceftazidime...... 40 CAPSULE #1 (CELLULOSE). 113 CARDENE IV IN SODIUM ceftazidime in d5w...... 40 CAPSULE #1 CHLORIDE...... 74 ceftriaxone...... 40 (HYPROMELLOSE)...... 116 CARDIZEM...... 73 ceftriaxone in dextrose,iso-os..... 40 CAPSULE #1 DRCAPS...... 116 CARDIZEM CD...... 73 cefuroxime axetil...... 40 CAPSULE #10...... 115 CARDIZEM LA...... 73 cefuroxime sodium...... 40 CAPSULE #13...... 115 CARDURA...... 79 CELACYN...... 131, 227 CAPSULE #2...... 115 CARDURA XL...... 79 CELEBREX...... 24 CAPSULE #3...... 115 carica papaya...... 194 celecoxib...... 24 CAPSULE #3 (CELLULOSE). 113 carisoprodol...... 219 celecoxib (bulk)...... 24, 106 CAPSULE #3 carisoprodol (bulk)...... 106, 219 CELESTONE SOLUSPAN...... 186 (HYPROMELLOSE)...... 116 carisoprodol-aspirin...... 219 CELEXA...... 87 CAPSULE #4...... 115, 116 carisoprodol-aspirin-codeine.... 220 CELLCEPT...... 22, 216 CAPSULE #5...... 115 carmustine...... 49 CELLCEPT INTRAVENOUS CAPSULE #7...... 115 CARNITOR...... 236 ...... 22, 216 CAPSULE CONI-SNAP #0 CARNITOR (SUGAR-FREE)..236 CELONTIN...... 86 (GELATIN)...... 115 carteolol...... 244 CEM-UREA...... 136 CARTIA XT...... 73 CENTANY...... 127

267 CENTANY AT...... 127 CHANTIX STARTING chocolate hazelnut flav (bulk) CENTERGY...... 248 MONTH BOX...... 105 ...... 106, 114 CENTRAL-VITE WOMEN'S CHATEAL (28)...... 120 CHOLBAM...... 196 MATURE...... 160 CHATEAL EQ (28)...... 120 cholecalciferol (vitamin d3)...... 177 CENTRATEX...... 154 cheesecake flavor (bulk)... 106, 114 cholestyramine (bulk)...... 69, 106 CENTRAVITES...... 160 CHEMET...... 31 cholestyramine (with sugar)...... 69 CENTRUM...... 160 CHENODAL...... 197 CHOLESTYRAMINE LIGHT...69 CENTRUM CHEWABLES..... 160 cherry flavor (bulk)...... 106, 116 CHOLETEC...... 143 CENTRUM COMPLETE...... 164 CHEW Q...... 12 CHOLEXTRA T-F...... 165 CENTRUM MEN...... 160 CHEWABLE IRON...... 154 choline,magnesium salicylate..... 26 CENTRUM SILVER...... 160 CHILD CHEWABLE chorionic gonadotropin, human 189 CENTRUM SILVER ULTRA VITAMN COMPLETE...... 169 CHROMAGEN(SUMALATE- MEN'S...... 160 CHILD COMPLETE QUATREFOLI)...... 154 CENTRUM SILVER WOMEN160 MULTIVITAMIN...... 169 chromium chloride...... 160 CENTRUM SPECIALIST CHILD MULTIVITAMINS.....170 chromium picolinate...... 160 ENERGY...... 160 CHILDREN MULTIVITAMIN170 CIALIS...... 144, 206 CENTRUM ULTRA MEN'S....161 CHILDREN'S CHEW CICATRACE PAD...... 227, 229 CENTURY ULTIMATE MULTIVIT-IRON...... 169 CICLODAN...... 128 MEN'S...... 161 CHILDREN'S CHEWABLE ciclopirox...... 128 cephalexin...... 40 COMPLETE...... 169 ciclopirox olamine (bulk)..106, 128 CEPROTIN (BLUE BAR)...... 214 CHILDREN'S CHEWABLE ciclopirox-ure-camph-menth- CEPROTIN (GREEN BAR).....214 VITAMIN...... 170 euc...... 128 CEQUA...... 242 CHILDREN'S CHEWABLES..170 CIDAFLEX...... 11 CERACADE...... 131 CHILDREN'S CHEWABLES cidofovir...... 41 CERALYTE 50 POTASSIUM EXTRA C...... 170 CIFEREX...... 175, 177 FREE...... 157 CHILDREN'S IRON...... 155 cilostazol...... 214 CERALYTE 90...... 157 CHILDREN'S MIGRELIEF...... 12 CILOXAN...... 246 CERALYTE-70...... 157 CHILDREN'S MULTI-VIT CIMDUO...... 37 CERAMAX...... 131 GUMMIES...... 170 cimetidine...... 197 CERASPORT...... 157 CHILDREN'S cimetidine hcl...... 197 CERAVE...... 131 MULTIVITAMIN...... 169, 170 CIMZIA...... 20, 21, 202 CERDELGA...... 236 CHILD'S CHEWABLE CIMZIA POWDER FOR CEREBYX...... 84 VITAMINS/IRON...... 169 RECONST...... 20, 21, 202 CEREFOLIN...... 164 CHILDS/IRON...... 169 CIMZIA STARTER KIT CEREFOLIN NAC (ALGAL CHIRHOSTIM...... 142 ...... 20, 21, 202 OIL)...... 175 chloramphenicol (bulk)...... 41, 106 cinacalcet...... 184 CERETEC...... 143 chloramphenicol sod succinate... 41 CINQAIR...... 259 CEREZYME...... 235 chlordiazepoxide hcl...... 82, 95 CINRYZE...... 210 CEROVITE JR...... 169 chlordiazepoxide-clidinium 95, 200 CINVANTI...... 196 CERTA PLUS...... 161 chlorhexidine (bulk)...... 106, 114 CIPRO...... 42 CERVIDIL...... 178 chlorhexidine gluconate...... 238 CIPRO HC...... 248 CESAMET...... 97, 195 chlorhexidine gluconate (bulk) CIPRO XR...... 42, 207 CETACAINE ANESTHETIC.. 137 ...... 61, 106, 238 CIPRODEX...... 248 CETA-KLENZ GENTLE...... 139 chloroquine phosphate...... 35 ciprofloxacin...... 42 CETAPHIL...... 139 chloroquine phosphate (bulk) ciprofloxacin hcl...... 42, 246, 248 CETRAXAL...... 248 ...... 35, 106 ciprofloxacin in 5 % dextrose..... 42 CETROTIDE...... 191 chlorothiazide...... 78 cisatracurium...... 218 cevimeline...... 238 chlorothiazide sodium...... 78 cisplatin...... 56 CHANTIX...... 104 chlorpromazine...... 92 citalopram...... 87 CHANTIX CONTINUING chlorthalidone...... 78 CITRACAL + D MAXIMUM..153 MONTH BOX...... 105 chlorzoxazone...... 219 CITRACAL PLUS BONE chocolate flavor (bulk)...... 106, 114 DENSITY...... 152

268 CITRACAL REGULAR...... 153 CLINIMIX 4.25%/D10W cocoa butter...... 113 CITRACAL-D3 GUMMIES.... 153 SULF FREE...... 167 cocoa butter (bulk)...... 107, 113 CITRACAL-D3 PETITES...... 153 CLINIMIX 4.25%/D5W COCOA BUTTER CREAM.....131 CITRACAL-D3 PLUS HEART SULFIT FREE...... 167 coconut flavor (bulk)...... 107, 114 HEALTH...... 152 CLINIMIX 4.25%-D25W cod liver oil...... 164 CITRACAL-D3 PLUS SULF-FREE...... 167 COD LIVER OIL...... 175 MAGNESIUM...... 152 CLINIMIX 5%- cod liver oil (bulk)...... 107, 175 CITRACAL-D3 SLOW D20W(SULFITE-FREE)...... 167 codeine phosphate (bulk)....13, 107 RELEASE...... 153 CLINIMIX E 2.75%/D5W codeine sulfate...... 13 CITRANATAL B-CALM (FE SULF FREE...... 168 codeine-butalbital-asa-caff...... 16 GLUC)...... 171 CLINIMIX E 4.25%/D10W coenzyme q10...... 12 citrulline (bulk)...... 106, 166 SUL FREE...... 168 coenzyme q10 (bulk).. 12, 107, 148 cladribine...... 50 CLINIMIX E 4.25%/D5W coenzyme q10-vitamin e...... 12 CLAFORAN...... 41 SULF FREE...... 168 coffee flavor (bulk)...... 107, 114 CLARAVIS...... 123 CLINIMIX E 5%/D15W COGENTIN...... 89 CLARINEX...... 250 SULFIT FREE...... 168 cola (syrup)...... 195 CLARINEX-D 12 HOUR...... 248 CLINIMIX E 5%/D20W cola flavor (bulk)...... 107, 114 clarithromycin...... 44 SULFIT FREE...... 168 COLAZAL...... 201 CLASSIC PRENATAL...... 171 CLINISOL SF 15 %...... 168 colchicine...... 209 CLEANSING WASH clioquinol (bulk)...... 35, 107 colchicine (bulk)...... 107, 209 ...... 124, 139, 257 clobazam...... 82, 95 COLCRYS...... 209 clemastine...... 248, 249 clobetasol...... 133 colesevelam...... 69 CLENPIQ...... 204 clobetasol-emollient...... 133 COLESTID...... 69 CLEO 90 INFUSION SET 24" CLOBEX...... 133 COLESTID FLAVORED...... 69 ...... 228, 229 clocortolone pivalate...... 133 colestipol...... 69 CLEO 90 INFUSION SET 31" CLODAN...... 133 colistin (colistimethate na)...... 46 ...... 228, 229 CLODERM...... 133 colistin sulfate (bulk)...... 46, 107 CLEOCIN...... 44, 256 clofarabine...... 50 COLLATYL...... 141 CLEOCIN HCL...... 44 CLOLAR...... 51 collodion (bulk)...... 107 CLEOCIN PEDIATRIC...... 44 clomiphene citrate (bulk)..107, 185 COLOX...... 203 CLEOCIN T...... 123 clomipramine...... 88 COLY-MYCIN M CLEVIPREX...... 74 clonazepam...... 82, 83, 95 PARENTERAL...... 46 CLIMARA...... 185 clonidine...... 76 COMBIGAN...... 243 CLIMARA PRO...... 184 clonidine (pf)...... 13 COMBIPATCH...... 184 CLINDACIN ETZ...... 123 clonidine hcl...... 76, 93 COMBIVENT RESPIMAT...... 253 CLINDACIN P...... 123 clopidogrel...... 214 COMBIVIR...... 38 CLINDACIN PAC...... 123 clorazepate dipotassium...... 82, 95 COMETRIQ...... 55 CLINDAGEL...... 123 CLOROTEKAL...... 28 COMFORT INFUSION SET clindamycin hcl...... 44 CLORPRES...... 76 31"...... 223, 228, 229 clindamycin hcl (bulk)...... 44, 106 clotrimazole...... 238 COMFORT INFUSION SET clindamycin in 5 % dextrose...... 44 clotrimazole (bulk)...... 34, 107 43"...... 228, 229 clindamycin palmitate hcl...... 44 clotrimazole-betamethasone..... 128 COMFORT SHORT INSULIN CLINDAMYCIN PEDIATRIC.. 44 CLOVIQUE...... 31 PUMP 23"...... 228, 229 clindamycin phosphate44, 123, 256 clozapine...... 91 COMFORT-STRETCH clindamycin phosphate (bulk) CLOZARIL...... 91 DIAPERS...... 222, 229 ...... 44, 106, 107 C-NATE DHA...... 171 COMFORT-STRETCH clindamycin-benzoyl peroxide..124 CO Q-10...... 12 TRAINING PANTS...... 222, 229 CLINDESSE...... 256 CO Q-10 (WITH VIT E)...... 12 COMP-AIR NEBULIZER CLINIMIX 5%/D15W coal tar...... 137 COMPRESSOR...... 226, 229 SULFITE FREE...... 167 coal tar (crude) (bulk)...... 107, 137 COMPAZINE...... 92, 195 CLINIMIX 5%/D25W COARTEM...... 35 COMPLERA...... 38 SULFITE-FREE...... 167 cocaine...... 255

269 COMPLETE AMINO ACID cortisone...... 186 CUTIEPANTS TRAINING MIX...... 145 cortisone (bulk)...... 107, 186 PANTS...... 222, 229 COMPLETE MULTI...... 161 CORTISPORIN...... 127 CUTIES BABY DIAPERS COMPLETE MULTIVITAMIN CORTROSYN...... 143 ...... 222, 229 ...... 161 CORVERT...... 69 CUTIVATE...... 133 COMPLETE CORVITA...... 161 CUVITRU...... 62 MULTIVITAMIN-MINERAL.161 CORVITA 150...... 154 CUVPOSA...... 239 COMPLETE MV ADULT 50 CORVITE...... 161 cyanocobalamin (vitamin b-12) 176 PLUS...... 161 CORVITE 150...... 154 CYANOKIT...... 30 COMPLETE NATAL DHA..... 171 CORVITE FE...... 154 CYCLAFEM 1/35 (28)...... 120 COMPLETE PREMIUM CORVITE FREE...... 161 CYCLAFEM 7/7/7 (28)...... 122 VITAMIN...... 161 COSENTYX...... 126 cyclobenzaprine...... 219 COMPLETENATE...... 171 COSENTYX (2 SYRINGES)...126 cyclobenzaprine (bulk)..... 107, 219 COMPLEX B-100...... 146, 147 COSENTYX PEN...... 126 CYCLOGYL...... 242 COMPLEX B-50...... 146 COSENTYX PEN (2 PENS).... 126 CYCLOMYDRIL...... 241 COMPLEX ESSENTIAL...... 166 COSMEGEN...... 58 cyclopentolate...... 242 COMPLEX MSUD AMINO COSMETIC BALLS...... 220, 229 cyclophosphamide...... 22, 49 ACID BLEND...... 166 COSMETIC PUFFS...... 220, 229 cycloserine...... 38 COMPRO...... 195 COSOPT...... 243 CYCLOSET...... 181 COMTAN...... 89 COSOPT (PF)...... 243 cyclosporine...... 22, 216 CONCEPT DHA...... 161, 171 cosyntropin...... 143 cyclosporine (bulk)...... 107, 216 CONCEPT OB...... 161, 171 COTELLIC...... 55 cyclosporine modified...... 22, 216 CONCERTA...... 93 COTEMPLA XR-ODT...... 93 CYKLOKAPRON...... 211 CONDYLOX...... 136 cotton candy flavor (bulk).107, 114 CYMBALTA...... 87, 98 CONRAY-30...... 141 COVARYX...... 184 cyproheptadine...... 249 CONRAY-43...... 141 COVARYX H.S...... 184 CYRAMZA...... 58 CONSTULOSE...... 203 COZAAR...... 67 CYRED...... 120 CONTACT DETACH INFUS cranberry extract-vitamin c...... 12 CYRED EQ...... 120 SET 23"...... 228, 229 cranberry fruit...... 12 CYSTADANE...... 236 CONTACT DETACH INFUS CRANBERRY URINARY CYSTAGON...... 205 SET 32"...... 228, 229 COMFORT...... 12, 164 CYSTARAN...... 244 CONTACT DETACH INFUS CRANBERRY-PROBIOTIC... 148 cytarabine...... 51 SET 43"...... 228, 229 cran-raspberry flavor (bulk) cytarabine (pf)...... 51 CONTI CASTILE SOAP...... 139 ...... 107, 114 CYTO B7...... 177 CONZIP...... 13 cream base no.64 (bulk)....107, 113 CYTOGAM...... 62 COPAXONE...... 239 cream de menthe (bulk).... 107, 114 CYTOMEL...... 193 COPIKTRA...... 56 CREON...... 196 CYTOTEC...... 198 COPPER CHLORIDE...... 160 CRESEMBA...... 34 CYTOTINE...... 148 CORAL CALCIUM...... 152 CRESTOR...... 70 CYTOVENE...... 41 CORDRAN...... 133 CRINONE...... 185, 257 CYTRA-2...... 207 COREG...... 66 CRIXIVAN...... 46 CYTRA-3...... 207 COREG CR...... 66 CROFAB...... 62 cytra-k...... 207 COREMINO...... 47, 123 cromolyn...... 55, 245, 251 D.H.E.45...... 99 CORGARD...... 73 cromolyn (bulk)...... 55, 107, 251 d10 %-0.45 % sodium chloride.147 CORLANOR...... 78 CROTAN...... 140 d2.5 %-0.45 % sodium chloride147 CORLOPAM...... 78 CRYSELLE (28)...... 120 D3 + K2 DOTS...... 177 corn starch (bulk)...... 107, 116 CUBICIN...... 42 D3-2000...... 177 CORTANE-B...... 248 CULTURELLE WOMEN d5 % and 0.9 % sodium CORTEF...... 186 HEALTH BALANC...... 202 chloride...... 147 CORTENEMA...... 201 CUPRIMINE...... 23, 31 d5 %-0.45 % sodium chloride...147 corticotropin (bulk)...... 107, 179 CUROSURF...... 255 dacarbazine...... 50 CORTIFOAM...... 201 CUTAQUIG...... 62 DACOGEN...... 51

270 DAILY AMINO...... 145 DEFINITY...... 142 desonide...... 133 DAILY GUMMIES...... 161 DEFITELIO...... 215 DESOWEN...... 133 DAILY MULTIPLE...... 161 DEHYDROEPIANDROSTER desoximetasone...... 133 DAILY MULTIPLE FOR ONE (MICRO)...... 11, 107 desoximetasone, micro (bulk) WOMEN...... 164 DEKAS BARIATRIC...... 161 ...... 107, 186 DAILY MULTIVITAMIN...... 161 DEKAS ESSENTIAL...... 164 DESOXYN...... 94, 98 DAILY MULTIVITAMIN DEKAS PLUS (FOLIC ACID) 161 desvenlafaxine...... 87 WITH IRON...... 164 DEKAS PLUS LIQUID...... 170 desvenlafaxine succinate...... 87 DAILY MULTIVITAMIN- DELESTROGEN...... 185 DETROL...... 208 MINERALS...... 150, 161 DELSTRIGO...... 38 DETROL LA...... 208 DAILY PRENATAL...... 171 DELUO...... 61, 141 DEVILBISS COMPACT DAILY PROBIOTIC (10 DELZICOL...... 201 COMPRESSOR...... 226, 229 STRAINS)...... 202 demeclocycline...... 47 DEVILBISS DISPOSABLE DAILY VALUE...... 164 DEMEROL...... 13 NEBULIZER...... 224, 229 DAIRY AID...... 197 DEMEROL (PF)...... 13 DEVILBISS PULMO-AIDE DAIRY DIGESTIVE...... 197 DEMSER...... 80 COMPRESSR...... 226, 229 DAIRY DIGESTIVE DENAVIR...... 130 DEVILBISS PULMOMATE SUPPLEMENT...... 197 DENOVO...... 178 COMPRESSOR...... 226, 230 DAIRY RELIEF...... 197 DEPAKOTE...... 83, 96 DEVILBISS TRAVELER dalfampridine...... 240 DEPAKOTE ER...... 83, 96, 99 COMPRESSOR...... 226, 230 dalfampridine (bulk)...... 107, 240 DEPAKOTE SPRINKLES...83, 96 DEX4 GLUCOSE BITS...... 179 DALIRESP...... 252 DEPEN TITRATABS...... 23, 31 DEX4 GLUCOSE POUCH DALVANCE...... 44 DEPLIN (ALGAL OIL)...... 178 PACK...... 179 danazol...... 188 DEPO-ESTRADIOL...... 185 DEX4 GLUCOSE QUICK DANTRIUM...... 219, 220 DEPO-MEDROL...... 186 DISSOLVE...... 179 dantrolene...... 220 DEPO-PROVERA...... 56, 119 dexamethasone...... 186 dantrolene (bulk)...... 107, 220 DEPO-SUBQ PROVERA 104. 119 dexamethasone ac, micro (bulk) dapsone...... 35 DEPO-TESTOSTERONE...... 179 ...... 107, 186 DAPTACEL (DTAP DERMACERIN...... 131 dexamethasone ac, sod ph-water PEDIATRIC) (PF)...... 64 DERMACINRX LEXITRAL...137 ...... 186 daptomycin...... 42 DERMACINRX PUREFOLIX dexamethasone ace-nacl,iso- DARAPRIM...... 35 ...... 175, 177 osm...... 186 darifenacin...... 208 DERMACINRX SILAPAK...... 135 dexamethasone acetate (bulk) DARZALEX...... 52 DERMACLOUD...... 132 ...... 107, 186 DASETTA 1/35 (28)...... 120 DERMA-SMOOTHE/FS DEXAMETHASONE DASETTA 7/7/7 (28)...... 122 BODY OIL...... 133 INTENSOL...... 186 DATSCAN...... 143 DERMA-SMOOTHE/FS dexamethasone sod phos (bulk) daunorubicin...... 58 SCALP OIL...... 133 ...... 107, 186 DAURISMO...... 53 DERMAWERX SDS...... 135 dexamethasone sodium phos DAYPRO...... 25 DERMOTIC OIL...... 248 (pf)...... 186 DAYSEE...... 119 DERM-SILK...... 227, 229 dexamethasone sodium DAYTRANA...... 93 DERMULCERA...... 141 phosphate...... 187, 242 DDAVP...... 180 DESCOVY...... 37 dexamethasone,micronized(bulk DDROPS...... 177 desflurane...... 26 )...... 107, 187 DEBACTEROL...... 238 desipramine...... 88 dexameth-moxiflox(pf)-nacl,iso241 DEBLITANE...... 121 desloratadine...... 250 dexamet-moxifl-ketoro-nacl(pf)241 DECADRON...... 186 desmopressin...... 180 DEXCOM G4 RECEIVER DECARA...... 177 desmopressin acetate (bulk) ...... 221, 230 decitabine...... 51 ...... 107, 180 DEXCOM G4 RECEIVER DECUBI VITE...... 164 desog-e.estradiol/e.estradiol...... 119 PEDIATRIC...... 221, 230 deferasirox...... 31 desogestrel-ethinyl estradiol..... 120 DEXCOM G4 RECEIVER- deferoxamine...... 31 DESONATE...... 133 SHARE (PED)...... 221, 230

271 DEXCOM G4 RECEIVER- DIAFOODS THICK-IT...... 116 diflorasone...... 133 SHARE KIT...... 221, 230 DIAFOODS THICK-IT #2...... 116 DIFLUCAN...... 34 DEXCOM G4 TRANSMITTER DIALYVITE...... 146, 147 diflunisal...... 26 ...... 221, 230 DIALYVITE 3000...... 146 DIGIFAB...... 30 DEXCOM G5 RECEIVER DIALYVITE 5000...... 161 DIGITEK...... 76 ...... 221, 230 DIALYVITE 800...... 146 DIGOX...... 76 DEXCOM G5 TRANSMITTER DIALYVITE 800 WITH IRON164 digoxin...... 76 ...... 221, 230 DIALYVITE 800 WITH ZINC digoxin, micronized (bulk). 76, 107 DEXCOM G5-G4 SENSOR 15...... 146 dihydroergotamine...... 100 ...... 221, 230 DIALYVITE 800 WITH ZINC DILANTIN...... 84 DEXCOM G6 RECEIVER 50...... 146 DILANTIN EXTENDED...... 84 ...... 221, 230 DIALYVITE 800-ULTRA D... 146 DILANTIN INFATABS...... 84 DEXCOM G6 SENSOR...221, 230 DIALYVITE SUPREME D...... 146 DILANTIN-125...... 84 DEXCOM G6 TRANSMITTER DIALYVITE VITAMIN D3 DILATRATE-SR...... 67 ...... 221, 230 MAX...... 177 DILAUDID...... 13 DEXCOM RECEIVER.... 221, 230 diaper,brief,infant-todd,disp diltiazem hcl...... 69, 73 DEXEDRINE SPANSULE ...... 222, 230 diltiazem hcl (bulk)...... 107 ...... 94, 98, 102 DIAPERS...... 222, 230 diltiazem hcl in 0.9% nacl...... 73 DEXIFOL...... 146 DIAPERS, UNISEX SIZE 3 DILT-XR...... 73 DEXILANT...... 198 ...... 222, 230 DILUENT FOR dexmedetomidine...... 103 DIAPERS, UNISEX SIZE 4 EPOPROSTENOL/FLOLA...... 117 dexmedetomidine in 0.9 % nacl103 ...... 222, 230 DILUENT FOR HIBERIX...... 150 dexmedetomidine in dextrose DIAPERS, UNISEX SIZE 5 DILUENT FOR IXEMPRA (15 5%...... 103 ...... 222, 230 MG)...... 117 dexmethylphenidate...... 94 DIAPERS, UNISEX SIZE 6 DILUENT FOR IXEMPRA (45 dexrazoxane hcl...... 59 ...... 222, 230 MG)...... 117 DEXTENZA...... 242 DIAPERS-DISP- DILUENT FOR RABAVERT..150 dextroamphetamine...... 94, 98, 102 POLYETHYLENE BACK diluent for treprostinil (gly)...... 117 dextroamphetamine- ...... 222, 230 dimenhydrinate...... 194 amphetamine...... 94, 97, 102 DIASTAT...... 83, 95 dimethyl sulfoxide (bulk). 107, 113 dextromethorphan hbr (bulk) DIASTAT ACUDIAL...... 83, 95 dinitrochlorobenzen(2,4)(bulk) ...... 107, 250 diazepam...... 82, 83, 95 ...... 107, 139 dextrose 10 % and 0.2 % nacl...147 DIAZEPAM INTENSOL..... 82, 95 DINO-LIFE WITH IRON- dextrose 10 % in water (d10w).148 DIBENZYLINE...... 79 ZINC...... 169, 170 dextrose 20 % in water (d20w).148 dibucaine hcl (bulk).... 26, 107, 140 DIOVAN...... 67 dextrose 25 % in water (d25w).148 DICLEGIS...... 194 DIOVAN HCT...... 67 dextrose 30 % in water (d30w).148 diclofenac epolamine...... 138 DIPENTUM...... 201 dextrose 40 % in water (d40w).148 diclofenac potassium...... 25 diphencyprone (bulk)...... 107, 135 dextrose 5 % in ringer's...... 154 diclofenac sodium diphenhydramine (bulk)....107, 249 dextrose 5 % in water (d5w).....148 ...... 25, 129, 138, 243 diphenhydramine hcl...... 249 dextrose 5 %-lactated ringers....147 diclofenac-misoprostol...... 23 diphenoxylate-atropine...... 194 dextrose 5%-0.2 % sod chloride147 DICLOFEX DC...... 137 DIPRIVAN...... 27 dextrose 5%-0.3 % sod.chloride147 DICLOFONO...... 138 DIPROLENE...... 133 dextrose 50 % in water (d50w).148 DICLOPAK...... 137 dipyridamole...... 142, 214 dextrose 70 % in water (d70w).148 DICLOTRAL...... 137 DISALCID...... 26 DEXYCU (PF)...... 242 DICLOVIX...... 137 DISKETS...... 13 DHA ALGAL-900...... 71 dicloxacillin...... 45 disopyramide phosphate...... 68 DHEA...... 11 dicyclomine...... 200 DISPOSERX...... 224, 230 DIABETES HEALTH...... 161 didanosine...... 37 disulfiram...... 104 DIABETES HEALTH diethylstilbestrol (bulk)...... 53, 107 DITROPAN XL...... 208 FORMULA...... 161 DIFFERIN...... 125 DIURIL...... 78 DIACOMIT...... 86 DIFICID...... 44 DIURIL IV...... 78

272 divalproex...... 83, 96, 99 DUET DHA BALANCED...... 171 ED-SPAZ...... 199, 208 DIVIGEL...... 185 DUET DHA WITH OMEGA-3171 EDURANT...... 36 DMSA...... 144 DUETACT...... 182 EEMT...... 184 DMSA (BULK)...... 31, 107 DUEXIS...... 23 EEMT HS...... 184 dobutamine...... 75 DULERA...... 253 efavirenz...... 36 dobutamine in d5w...... 75 duloxetine...... 87, 98 EFFER-K...... 159 DOCEFREZ...... 57 DUOBRII...... 126 EFFEXOR XR...... 87 docetaxel...... 57 DUODOTE...... 30 EFFIENT...... 214 dofetilide...... 69 DUOFER...... 154 EFUDEX...... 129 DOLOPHINE...... 13 DUOPA...... 89 EGRIFTA SV...... 188 donepezil...... 118 DUPIXENT SYRINGE.... 126, 251 ELAPRASE...... 235 DONNATAL...... 200 DURACHOL...... 175, 177 ELDEPRYL...... 90 dopamine...... 75 DURAGESIC...... 13 ELDERTONIC...... 150 dopamine in 5 % dextrose...... 75 DURAMORPH (PF)...... 13 electrolyte-48 in d5w...... 154 DOPRAM...... 97, 98 DUREZOL...... 242 electrolytes-dextrose...... 157 DOPTELET (10 TAB PACK)..215 DURLAZA...... 26, 214 ELELYSO...... 235 DOPTELET (15 TAB PACK)..215 DUROLANE...... 218 ELESTRIN...... 185 DORAL...... 95, 102 dutasteride...... 206 ELETONE...... 131 DORYX...... 47 dutasteride (bulk)...... 107, 206 eletriptan...... 100 DORYX MPC...... 47 dutasteride-tamsulosin...... 205 ELFOLATE...... 178 dorzolamide...... 244 DUTOPROL...... 74 ELIDEL...... 131 dorzolamide (pf)...... 244 DVORAH...... 16, 17 ELIGARD...... 54 dorzolamide-timolol...... 243 DXEVO...... 187 ELIGARD (3 MONTH)...... 54 dorzolamide-timolol (pf)...... 243 DYANAVEL XR...... 94, 97 ELIGARD (4 MONTH)...... 54 DOTAREM...... 142 DYAZIDE...... 78 ELIGARD (6 MONTH)...... 54 DOTTI...... 185 DYMISTA...... 255 ELIMITE...... 140 DOVATO...... 36 DYRENIUM...... 78 ELINEST...... 120 DOVONEX...... 130 DYSPORT...... 218 ELIQUIS...... 210 doxapram...... 97, 98 E.E.S. 400...... 44 ELIQUIS DVT-PE TREAT doxazosin...... 79 E.E.S. GRANULES...... 44 30D START...... 210 doxepin...... 88, 103, 140 EAR CARE...... 147 ELITEK...... 209 doxercalciferol...... 236 EAR HEALTH FORMULA.....147 ELIXOPHYLLIN...... 252 DOXIL...... 58 EASIVENT HOLDING ELLA...... 123 doxorubicin...... 58 CHAMBER...... 226, 230 ELLENCE...... 58 doxorubicin, peg-liposomal...... 58 EASIVENT MASK LARGE ELMIRON...... 205 DOXY-100...... 47 ...... 226, 230 ELON...... 131 doxycycline hyclate...... 47, 239 EASIVENT MASK MEDIUM ELON MATRIX 5000 doxycycline hyclate (bulk)..47, 107 ...... 226, 230 COMPLETE...... 161 doxycycline monohydrate EASIVENT MASK SMALL ELURYNG...... 122 ...... 47, 48, 139 ...... 226, 230 ELZONRIS...... 59 doxylamine-pyridoxine (vit b6) 195 EASY FIBER...... 203 EMCYT...... 53 D-PENAMINE...... 23, 31 echinacea...... 12 EMEND...... 196 DRAXIMAGE DTPA...... 144 EC-NAPROSYN...... 25 EMEND (FOSAPREPITANT).196 DRITHOCREME HP...... 130 EC-NAPROXEN...... 25 EMERGEN-C...... 175 DRIZALMA SPRINKLE..... 87, 98 econazole...... 128 EMERGEN-C KIDZ...... 169 dronabinol...... 97, 144, 145, 195 econazole nitrate (bulk)...... 34, 107 EMFLAZA...... 187 droperidol...... 27 ECOZA...... 128 EMGALITY PEN...... 99 drospirenone-e.estradiol-lm.fa..120 EDARBI...... 67 EMGALITY SYRINGE...... 81, 99 drospirenone-ethinyl estradiol.. 120 EDARBYCLOR...... 67 emollient...... 132 DROXIA...... 214 EDECRIN...... 77 EMPLICITI...... 51 DSUVIA...... 13 EDEX...... 144 DUAVEE...... 184 EDLUAR...... 103

273 EMPTY STERILIZED VIAL ENULOSE...... 196 ERYPED 400...... 44 ...... 225, 230 ENVARSUS XR...... 216 ERY-TAB...... 44 empty vial...... 225, 230 EOVIST...... 142 ERYTHROCIN...... 44 EMSAM...... 86 EPANED...... 66 ERYTHROCIN (AS EMTRIVA...... 37 ephedrine hcl (bulk)....75, 107, 256 STEARATE)...... 44 EMULSION SB...... 131 ephedrine sulfate...... 75 erythromycin...... 44, 246 EMVERM...... 33 ephedrine sulfate (bulk) erythromycin ethylsuccinate...... 44 enalapril maleate...... 66 ...... 75, 107, 256 erythromycin with ethanol...... 124 enalaprilat...... 66 ephedrine sulfate-0.9%nacl(pf)...75 erythromycin-benzoyl peroxide 124 enalapril-hydrochlorothiazide.....66 EPICERAM...... 131 ESBRIET...... 256 ENBRACE HR...... 164, 171 EPICYN...... 141 escitalopram oxalate...... 87 ENBREL...... 20, 21 EPIDIOLEX...... 83 ESGIC...... 19 ENBREL MINI...... 20, 21 EPIDUO...... 125 ESKATA...... 130 ENBREL SURECLICK...... 20, 21 EPIDUO FORTE...... 125 esmolol...... 68, 72 ENDARI...... 145, 165, 204, 214 EPIFOAM...... 135 esmolol in nacl (iso-osm)...... 69, 72 ENDOCET...... 18 epinastine...... 242 ESOMEP-EZS...... 198 ENDUR-ACIN...... 176 epinephrine...... 75, 250 esomeprazole magnesium...... 198 ENDUR-AMIDE...... 176 epinephrine (bulk)...... 75, 107, 250 esomeprazole sodium...... 198 ENFAGROW TODDLR epinephrine hcl in 5% dextrose...75 ESSENTIAL AMINO ACID TRANSITION SOY...... 148 epinephrine in sod chlor,iso...... 75 MIX...... 167 ENFAMIL ENFALYTE...... 157 EPINEPHRINESNAP-EMS...... 75 ESSENTIAL BALANCE ENFAMIL GENTLEASE.148, 149 EPIPEN 2-PAK...... 75 WITH LUTEIN...... 161, 164 ENFAMIL GLUCOSE...... 165 EPIPEN JR 2-PAK...... 75 ESSENTIAL MAN...... 161 ENFAMIL INFANT...... 149 epirubicin...... 58 ESSENTIAL WOMAN 50+.....161 ENFAMIL NEURO EPISIL...... 238 ESTARYLLA...... 120 ENFACARE NON-GMO...... 149 EPITOL...... 84, 96 estazolam...... 95, 102 ENFAMIL NEURO EPIVIR...... 37 ESTRACE...... 185, 257 GENTLEASE NONGMO...... 149 EPIVIR HBV...... 43 estradiol...... 185, 257 ENFAMIL NEUROPRO NON- eplerenone...... 66, 77 estradiol cypionate (bulk). 107, 185 GMO...... 149 EPOGEN...... 210 estradiol hemihydrate (bulk) ENFAMIL NEWBORN...... 149 epoprostenol (glycine)...... 80 ...... 107, 185 ENFAMIL PROSOBEE...... 149 eprosartan...... 67 estradiol valerate (bulk).... 107, 185 ENFAMIL PROSOBEE LIPIL 149 EPZICOM...... 38 estradiol-norethindrone acet..... 184 ENGERIX-B (PF)...... 62 EQUETRO...... 84, 96 ESTRING...... 257 ENGERIX-B PEDIATRIC (PF).62 ERAXIS(WATER DILUENT)...34 estriol (bulk)...... 108, 185 ENGLISH TOFFEE FLAVOR ERBITUX...... 60 estriol micronized (bulk)...108, 185 ...... 107, 115 ergocalciferol (vit d2) (bulk) ESTROGEL...... 185 ENLITE SYSTEM...... 221, 230 ...... 107, 177 estrogens-methyltestosterone....184 ENLYTE...... 178 ergocalciferol (vitamin d2)...... 177 estrone (bulk)...... 108, 185 enoxaparin...... 213 ergoloid...... 118 ESTROSTEP FE-28...... 122 ENPRESSE...... 122 ERGOMAR...... 100 eszopiclone...... 103 ENSKYCE...... 120 ergotamine tartrate (bulk). 100, 107 ethacrynate sodium...... 77 ENSTILAR...... 126 ERIVEDGE...... 53 ethacrynic acid...... 77 ENSURE CLEAR...... 148 ERLEADA...... 50 ethambutol...... 39 ENSURE ORIGINAL...... 148 erlotinib...... 49 ETHAMOLIN...... 81 entacapone...... 89 ERRIN...... 121 ethinyl estradiol (bulk)...... 108, 185 entecavir...... 43 ERTACZO...... 128 ethosuximide...... 86 ENTEREG...... 31 ertapenem...... 39 ethyl chloride...... 137 ENTOCORT EC...... 201 ERWINAZE...... 51 ethynodiol diac-eth estradiol.....120 ENTRESTO...... 67 ERY PADS...... 123 etidronate disodium...... 183 ENTTY...... 131 ERYGEL...... 123 etodolac...... 26 ENTYVIO...... 201 ERYPED 200...... 44 etomidate...... 27

274 etonogestrel-ethinyl estradiol....122 famotidine in 0.9 % nacl...... 197 FERREX 28...... 154 ETOPOPHOS...... 53 FANAPT...... 91 ferric chloride (bulk).108, 130, 211 etoposide...... 53 FARESTON...... 57 FERRIMIN 150...... 155 EUCERIN...... 131 FARXIGA...... 181 FERRIPROX...... 31 EUFLEXXA...... 218 FARYDAK...... 53 FERRLECIT...... 155 EURAX...... 140 FASENRA...... 251 FERROCITE PLUS...... 154 EUTHYROX...... 193 FASLODEX...... 53 FERRO-SEQUELS (IRON-VIT EVAMIST...... 185 FATIGUE RELIEF COMPLEX C)...... 154 EVEKEO...... 94, 98, 102 ...... 146 FERRO-TIME...... 155 EVEKEO ODT...... 94, 98 FATTYBLEND...... 108, 117 ferrous fumarate...... 155 evening primrose oil...... 12 FE C...... 154 ferrous fumarate (bulk)..... 108, 155 EVENITY...... 183 FE C PLUS...... 155 ferrous gluconate...... 155, 156 everolimus (antineoplastic)...... 55 febuxostat...... 209 ferrous gluconate (bulk)....108, 155 EVERSENSE SENSOR- felbamate...... 83 ferrous sulfate...... 156 HOLDER...... 221, 230 FELBATOL...... 83 FETROJA...... 41 EVERSENSE SMART FELDENE...... 24 FETZIMA...... 87 TRANSMITTER...... 221, 230 felodipine...... 74 FEXMID...... 219 EVISTA...... 192 FEM PH...... 257 FIASP FLEXTOUCH U-100 EVIVO...... 202 FEMARA...... 51 INSULIN...... 190 EVIVO STARTER KIT...... 202 FEM-CAL CITRATE...... 152 FIASP U-100 INSULIN...... 190 EVIVO WITH MCT OIL...... 202 FEMCAP...... 220, 230 FIBER (DEXTRIN)...... 203 EVOCLIN...... 124 FEMHRT LOW DOSE...... 184 FIBRICOR...... 70 EVOMELA...... 49 FEMRING...... 257 FINACEA...... 124, 139 EVOTAZ...... 37, 46 fenofibrate...... 70 finasteride...... 206 EVOXAC...... 238 fenofibrate micronized...... 70 FINTEPLA...... 86 EVZIO...... 31 fenofibrate nanocrystallized...... 70 FIORINAL...... 26 EXALGO ER...... 13 fenofibric acid...... 70 FIORINAL-CODEINE #3...... 16 EXELDERM...... 128 fenofibric acid (choline)...... 70 FIRAZYR...... 73 EXELON...... 118 FENOGLIDE...... 70 FIRDAPSE...... 240 exemestane...... 51 fenoprofen...... 25 FIRMAGON KIT W DILUENT EXFORGE...... 66 fentanyl...... 14 SYRINGE...... 55 EXFORGE HCT...... 67 fentanyl (pf)-bupivacaine-nacl....17 FIRVANQ...... 42 EXJADE...... 31 fentanyl citrate...... 13 FISH OIL...... 71 EXODERM...... 127 fentanyl citrate (bulk)...... 13, 108 FISH OIL EXTRA EXPECTA PRENATAL...... 171 fentanyl citrate (pf)...... 13, 27 STRENGTH...... 71 EXTAVIA...... 239 fentanyl citrate (pf)-0.9%nacl fish oil-dha-epa...... 71 EXTINA...... 128 ...... 13, 14 FIXED OIL SUSPENSION EXTRA-VIRT PLUS DHA...... 171 fentanyl-ropivacaine-nacl (pf).... 17 ...... 108, 117 EYLEA...... 245, 247 FENTORA...... 14 FLAC OTIC OIL...... 248 EZALLOR SPRINKLE...... 70 FEOSOL...... 155 FLAGYL...... 36 ezetimibe...... 71 FEOSOL BIFERA...... 154 FLAREX...... 242 ezetimibe-simvastatin...... 72 FERAHEME...... 155 FLAVOR BLEND 2 IN 1...... 116 EZFE 200...... 155 FERGON...... 155 FLAVOR PLUS...... 116 FA-8...... 178 FERIDEX IV...... 142 FLAVOR SWEET...... 117 FABB...... 175, 178 FER-IN-SOL...... 155 FLAVOR SWEET-SF...... 117 FABIOR...... 125 FEROCON...... 154 FLAVORX...... 108, 115 FABRAZYME...... 235 FEROSUL...... 155 flavoxate...... 208 FALMINA (28)...... 120 FERRACTIV...... 154 flaxseed oil...... 12 famciclovir...... 43 FERRETTS IPS...... 155 FLEBOGAMMA DIF...... 62 famotidine...... 197 FERREX 150 FORTE...... 154 flecainide...... 68 famotidine (pf)...... 197 FERREX 150 FORTE PLUS....154 FLECTOR...... 138 famotidine (pf)-nacl (iso-os)....197 FERREX 150 PLUS...... 154 FLEXBUMIN 25 %...... 212

275 FLEXBUMIN 5 %...... 212 fluorescein-proparacaine...... 244 FORTEO...... 183 FLEXIPAK...... 24 FLUORESCITE...... 244 FORTESTA...... 179 FLINTSTONES COMPLETE..170 fluoride (sodium)...... 237 FOSAMAX...... 183 FLINTSTONES COMPLETE FLUORIDEX SENSITIVITY FOSAMAX PLUS D...... 183 (IRON)...... 169 RELIEF...... 237 fosamprenavir...... 46 FLINTSTONES GUMMIES.... 170 FLUORITAB...... 237 fosaprepitant...... 196 FLINTSTONES GUMMIES fluorometholone...... 242 FOSCAVIR...... 41 OMEGA-3...... 170 FLUOROPLEX...... 129 FOSFREE...... 161 FLINTSTONES MULTI-VIT fluorouracil...... 51, 129 fosinopril...... 66 GUMMIES...... 169, 170 fluorouracil (bulk)...... 51, 108 fosinopril-hydrochlorothiazide... 66 FLINTSTONES fluoxetine...... 87 fosphenytoin...... 84 MULTIVITAMIN...... 170 fluphenazine decanoate...... 92 FOSRENOL...... 205 FLINTSTONES PLUS fluphenazine hcl...... 92 FRAGMIN...... 213 CALCIUM...... 169 FLURA-DROPS...... 237 FREAMINE III 10 %...... 168 FLINTSTONES SOUR flurandrenolide...... 133 FREEDAVITE...... 161 GUMMIES...... 170 flurazepam...... 95, 102 FREESTYLE LIBRE 14 DAY FLINTSTONES TAB CHEW.. 169 flurbiprofen...... 25 READER...... 221, 230 FLINTSTONES WITH IRON..169 flurbiprofen sodium...... 243 FREESTYLE LIBRE 14 DAY FLINTSTONES/EXTRA C...... 170 flutamide...... 50 SENSOR...... 221, 230 FLOLAN...... 80 fluticasone propionate...... 133 FRESHNET...... 225 FLOMAX...... 206 fluticasone propion-salmeterol. 254 FROTEK...... 138 FLORAJEN3...... 202 fluvastatin...... 70 FROVA...... 100 FLORAJEN4KIDS...... 202 fluvoxamine...... 87 frovatriptan...... 100 FLORANEX...... 202 FLYP NEBULIZER...... 224, 230 FULL SPECTRUM B- FLORICAL...... 157 FML FORTE...... 242 VITAMIN C...... 146 FLORIVA...... 169 FML LIQUIFILM...... 242 FULPHILA...... 210 FLORIVA (FLUORIDE- FML S.O.P...... 242 fulvestrant...... 53 VITAMIN D3)...... 169, 237 FOCALIN...... 94 FURADANTIN...... 33, 207 FLORIVA PLUS...... 169 FOCALIN XR...... 94 furosemide...... 77 FLOVENT DISKUS...... 251 FOLBEE...... 175, 178 furosemide in 0.9 % nacl...... 77 FLOVENT HFA...... 251 FOLBEE AR...... 146 FUSILEV...... 60 floxuridine...... 51 FOLBEE PLUS...... 146 FUSION...... 154 fluconazole...... 34 FOLBIC...... 175, 178 FUSION PLUS...... 154 fluconazole in nacl (iso-osm)...... 34 folic acid...... 178 FUSION SPRINKLES...... 154 flucytosine...... 34, 35 folic acid-vit b6-vit b12...... 175 FUZEON...... 36 fludarabine...... 51 FOLINIC-PLUS...... 175 FYAVOLV...... 184 fludeoxyglucose f-18...... 143 FOLITAB...... 154 FYCOMPA...... 82 fludrocortisone...... 191 FOLIVANE-F...... 154 gabapentin...... 83 FLUMADINE...... 43 FOLIVANE-OB...... 161, 171 GABITRIL...... 84 flumazenil...... 30 FOLIVANE-PLUS...... 154 GADAVIST...... 142 flunisolide...... 255 FOLOTYN...... 50 GALAFOLD...... 237 flunisolide (bulk)...... 108, 251, 255 FOLPLEX 2.2...... 175, 178 galantamine...... 118 fluocinolone...... 133 FOLTABS 800...... 175 GALZIN...... 30 fluocinolone acetonide (bulk) FOLTANX...... 175 GAMASTAN S/D...... 62 ...... 108, 187 FOLTRATE...... 176 GAMIFANT...... 216 fluocinolone acetonide oil...... 248 FOLTX...... 175 GAMMAGARD LIQUID...... 62 fluocinolone and shower cap.... 133 FOLVITE-D...... 175 GAMMAGARD S-D (IGA < 1 fluocinonide...... 133 fomepizole...... 30 MCG/ML)...... 62 fluocinonide, micronized(bulk) fondaparinux...... 213 GAMMAKED...... 63 ...... 108, 187 FORFIVO XL...... 88 GAMMAPLEX (WITH FLUOCINONIDE-E...... 133 FORTAMET...... 190 SORBITOL)...... 63 FLUORABON...... 237 FORTAVIT...... 164 GAMUNEX-C...... 63

276 ganciclovir...... 259 GERITOL TONIC WITH GLUTOSE-45...... 179 ganciclovir sodium...... 41 FERREX 18...... 150 glyburide...... 181 ganirelix...... 191 GIANVI (28)...... 120 glyburide micronized...... 181 GARDASIL 9 (PF)...... 65 GIAPREZA...... 192 glyburide-metformin...... 181 garlic...... 12 GILENYA...... 240 glycerol formal (bulk)...... 108, 113 GASTROCROM...... 55 GILOTRIF...... 49 glycine...... 145 gatifloxacin...... 246 ginseng...... 12 glycolic acid (bulk)...... 108, 112 GATTEX 30-VIAL...... 204 GIVLAARI...... 215 GLYCOPHOS...... 158 GATTEX ONE-VIAL...... 204 GLASSIA...... 255 glycopyrrolate...... 199 GAVILYTE-C...... 203 glatiramer...... 239 glycopyrrolate (bulk)...... 79, 108 GAVILYTE-G...... 203 GLATOPA...... 239 glycopyrrolate (pf) in water...... 199 GAVILYTE-N...... 203 GLEEVEC...... 56 GLYDO...... 140 GAZYVA...... 52 GLEOLAN...... 144 GLYNASE...... 181 gelatin...... 12 GLEOSTINE...... 49 GLYRX-PF...... 199 gelatin (bulk)...... 117 GLIADEL WAFER...... 49 GLYSET...... 180 GELCLAIR...... 238 glimepiride...... 181 GLYTACTIN GEL-FLOW...... 211 glipizide...... 181 15PECOMPLETE-TAURINE..166 GEL-FLOW NT...... 211 glipizide (bulk)...... 108, 181 GLYXAMBI...... 181 GELNIQUE...... 209 glipizide-metformin...... 181 GOCOVRI...... 90 GEL-ONE...... 218 GLOPERBA...... 209 GOLYTELY...... 203 GELSYN-3...... 218 GLOSTRIPS...... 244 GOODNITES UNDERPANTS GELX...... 238 GLUCAGEN DIAGNOSTIC L-XL...... 222, 230 gemcitabine...... 51 KIT...... 142 GOPRELTO...... 255 gemfibrozil...... 70 GLUCAGEN HYPOKIT...... 179 GORDONS-VITE E...... 132 GENERESS FE...... 120 GLUCAGON (HCL) GORMEL...... 132 GENERLAC...... 196 EMERGENCY KIT...... 179 G-PREPROTEIN...... 166 GENGRAF...... 22, 216 GLUCAGON EMERGENCY GRALISE...... 102 GENICIN VITA-D...... 175 KIT (HUMAN)...... 179 granisetron (pf)...... 195 GENICIN VITA-Q...... 178 glucagon hcl...... 142, 179 granisetron hcl...... 195 GENICIN VITA-S...... 146 GLUCOLESS...... 12 GRANIX...... 210 GENOTROPIN...... 188 GLUCOPHAGE...... 190 grape flavor (bulk)...... 108, 115 GENOTROPIN MINIQUICK.. 188 GLUCOPHAGE XR...... 190 GRAPEFRUIT...... 108, 115 GENTAK...... 246 glucosam-chon-msm1-c-mang- GRASTEK...... 61 gentamicin...... 32, 127, 246, 259 bosw...... 11 green soap...... 139 gentamicin (bulk)...... 32, 108 GLUCOSAMINE COMPLEX- griseofulvin (bulk)...... 35, 108 gentamicin in nacl (iso-osm)...... 32 MSM...... 11 griseofulvin microsize...... 35 gentamicin sulfate (ped) (pf).....259 GLUCOSAMINE RELIEF...... 11 griseofulvin ultramicrosize...... 35 gentamicin sulfate (pf)...... 32 glucosamine su 2kcl-chondroit... 11 guaifenesin (bulk)...... 108, 255 gentamicin-sodium citrate...... 39 glucosamine sulfate...... 11 guanethidine sulfate (bulk). 80, 108 GENTLE SKIN CLEANSER...139 GLUCOSAMINE SULF- guanfacine...... 76, 93 GENVISC 850...... 218 CHONDROITIN...... 11 guanidine...... 218 GENVOYA...... 38 glucosamine-chondroitin...... 11 GUARDIAN CONNECT GEODON...... 91, 97 GLUCOSAMINE- TRANSMITTER...... 221, 230 GERBER GENTLE CHONDROITIN COMPLX...... 11 GUARDIAN REAL-TIME PROBIOTIC...... 202 GLUCOSAMINE- GLU MONITOR...... 221, 230 GERBER GOOD START CHONDROITIN DS...... 11 guava flavor (bulk)...... 108, 115 GENTLE...... 149 glucosamine-chondroit-vit c-mn.11 GUMMI BEAR GERBER GOOD START SOY149 GLUCOTROL...... 181 MULTIVITAMIN...... 170 GERBER SOOTHE VIT D- GLUCOTROL XL...... 181 GUMMIES CHILDREN PROBIOTIC...... 202 GLUMETZA...... 190 MULTIVITAMIN...... 170 GERITOL COMPLETE...... 161 GLUTARADE JUNIOR...... 165 GUMMY DINOS...... 170 GLUTOL GEL...... 142

277 GVOKE PFS 1-PACK heparin (porcine) in 0.9% nacl..211 HUGGIES PULL-UPS 2T-3T SYRINGE...... 179 heparin (porcine) in 5 % dex.....212 ...... 222, 230 GYNAZOLE-1...... 256 heparin (porcine) in nacl (pf) HUGGIES PULL-UPS 3T-4T HAEGARDA...... 210 ...... 211, 212 ...... 222, 230 HAILEY...... 120 heparin flush(porcine)-0.9nacl HUGGIES PULL-UPS 4T-5T HAILEY 24 FE...... 120 ...... 211, 212 ...... 222, 230 HAIR FORMULA...... 161 HEPARIN LOCK...... 211, 212 HUGGIES SLIP-ON...... 222, 231 HAIR, SKIN AND NAILS- HEPARIN LOCK FLUSH211, 212 HUGGIES SNUG AND DRY ARGAN OIL...... 161 heparin lock flush (porcine) STEP 5...... 222, 231 HAIR,SKIN AND NAILS...... 161 ...... 211, 212 HUGGIES SNUG AND DRY HAIR,SKIN AND NAILS(FA- HEPARIN STEP 6...... 222, 231 BIOTIN)...... 161 LOCKFLUSH(PORCINE)(PF) HUMALOG JUNIOR HAIR-SKIN-NAILS (MV-FA- ...... 211, 212 KWIKPEN U-100...... 190 BIOTIN)...... 164 heparin(porcine) in 0.45% nacl.212 HUMALOG KWIKPEN HAIR-SKIN-NAILS (PABA)...161 heparin, porcine (pf)...... 211, 212 INSULIN...... 190 HALAVEN...... 53 HEPATAMINE 8%...... 168 HUMALOG MIX 50-50 HALCION...... 95, 102 HEPLISAV-B (PF)...... 62 INSULN U-100...... 189 HALDOL...... 91 HEPSERA...... 43 HUMALOG MIX 50-50 HALDOL DECANOATE...... 91 HERCEPTIN...... 60 KWIKPEN...... 189 halobetasol propionate HERCEPTIN HYLECTA...... 60 HUMALOG MIX 75-25 ...... 130, 133, 134 HESPAN 6 % IN NS...... 213 KWIKPEN...... 189 HALOG...... 134 hetastarch 6 % in 0.9 % nacl.....213 HUMALOG MIX 75-25(U- haloperidol...... 91 HETLIOZ...... 99 100)INSULN...... 189 haloperidol decanoate...... 91 HEX-ON LIGHT ODOR...... 225 HUMALOG U-100 INSULIN..190 haloperidol lactate...... 91 HEXTEND...... 213 HUMATROPE...... 188 HAVRIX (PF)...... 62 HIBERIX (PF)...... 64 HUMIRA...... 20, 21, 202 HEALON ENDOCOAT...... 245 HI-CAL PLUS VIT D...... 153 HUMIRA PEN...... 20, 21, 202 HEALON GV...... 245 HIDEX...... 187 HUMIRA PEN CROHNS-UC- HEALON PRO...... 245 HIGH POTENCY IRON...... 156 HS START...... 20, 21, 202 HEALON5...... 245 HIGH POTENCY PROBIOTIC HUMIRA PEN PSOR- HEALON5 PRO...... 245 ...... 202 UVEITS-ADOL HS...... 20, 21, 202 HEALTHY EYES LUTEIN- HIPREX...... 45, 207 HUMIRA(CF)...... 20, 21, 202 ZEAXANTHIN...... 11 histamine phosphate (bulk) HUMIRA(CF) PEDI CROHNS HEARTBURN AND ACID ...... 108, 216 STARTER...... 20, 21, 202 REFLUX-ALOE...... 161 HISTATROL...... 216 HUMIRA(CF) PEN...... 20, 21, 202 HEATHER...... 121 HIZENTRA...... 63 HUMULIN R U-500 (CONC) HECTOROL...... 236 HOMATROPAIRE...... 242 INSULIN...... 189 HEMANGEOL...... 73 homatropine methylbrom (bulk) HUMULIN R U-500 (CONC) HEMATINIC PLUS ...... 108, 199 KWIKPEN...... 189 VIT/MINERALS...... 155 HOMOCYSTEINE FORMULA HYALGAN...... 218 HEMATINIC/FOLIC ACID.....155 ...... 175 HYCAMTIN...... 57 HEMATOGEN...... 155 HONEY BEARS WITH IRON- HYCET...... 17 HEMATOGEN FA...... 155 ZINC...... 169, 170 HYCLODEX...... 61, 141 HEMATOGEN FORTE...... 155 honey flavor (bulk)...... 108, 115 hydralazine...... 77 HEMAX...... 155 HORIZANT...... 101 HYDREA...... 51 HEMETAB...... 155 HPR...... 131 HYDRO 35...... 136 HEMOCYTE...... 156 HPR PLUS...... 131 HYDRO 40...... 136 HEMOCYTE-F...... 155 HPR PLUS HYDROGEL...... 131 HYDROCERIN...... 131 HEMOCYTE-PLUS...... 155 HPR PLUS-MB HYDROGEL. 131 hydrochlorothiazide...... 78 HEP FLUSH-10 (PF)...... 211 HUGGIES LITTLE MOVERS hydrochlorothiazide (bulk). 78, 108 HEPAGAM B...... 63 ...... 222, 230 hydrocodone-acetaminophen 17, 18 heparin (porcine)...... 212 HUGGIES PULL-UPS..... 222, 230 hydrocodone-ibuprofen...... 17, 18

278 hydrocortisone.... 29, 134, 187, 201 HYPER-SAL...... 116 IMURAN...... 22, 217 hydrocortisone (bulk)...... 108, 187 HYPERTET S/D (PF)...... 63 IMVEXXY MAINTENANCE hydrocortisone acetate (bulk) HYPOCYN...... 132 PACK...... 191 ...... 108, 187 HYPROST...... 148 IMVEXXY STARTER PACK. 191 hydrocortisone butyrate...... 134 HYQVIA...... 63 INBRIJA...... 89, 90 hydrocortisone butyr-emollient.134 HYQVIA HY COMPONENT..194 INCASSIA...... 121 hydrocortisone valerate...... 134 HYQVIA IG COMPONENT...... 63 INCRELEX...... 191 hydrocortisone-acetic acid...... 248 HYSINGLA ER...... 14 INCRUSE ELLIPTA...... 252 hydrocortisone-iodoquinol...... 128 HYZAAR...... 67 indapamide...... 78 hydrocortisone-pramoxine...... 29 I.L.X. B-12...... 155 INDERAL LA...... 73 hydromorphone...... 14 ibandronate...... 184 INDERAL XL...... 73 hydromorphone (bulk)...... 14, 108 IBRANCE...... 52 indium in-111 oxyquinoline..... 144 hydromorphone (pf)...... 14 IBUDONE...... 17, 18 INDOCIN...... 26 hydromorphone (pf) in water...... 14 ibuprofen...... 25 indocyanine green...... 142 hydromorphone (pf)-0.9 % nacl..14 ibuprofen (bulk)...... 25, 108 indomethacin...... 26 hydrophilic...... 113 ibuprofen-oxycodone...... 18 indomethacin (bulk)...... 26, 108 HYDROPHILIC OINTMENT ibutilide fumarate...... 69 indomethacin sodium...... 79 BASE(FAG)...... 108, 113 IC GREEN...... 142 INFANRIX (DTAP) (PF)...... 64 HYDROPHILIC ICAPS...... 161 infant formula with iron...... 149 PETROLATUM...... 113 ICAPS MV...... 161 INFASURF...... 255 HYDROUS EMULSIFIED ICAR...... 156 INFED...... 156 BASE...... 108, 113 ICAR-C...... 155 INFLAMMA-K...... 137 hydroxocobalamin...... 176 ICAR-C PLUS...... 156 INFLECTRA...... 20, 21, 202 hydroxychloroquine...... 21, 35 icatibant...... 73 INFUGEM...... 51 hydroxychloroquine sulf (bulk) ICLUSIG...... 55 INFUMORPH P/F...... 14 ...... 21, 35, 108 IDAMYCIN PFS...... 58 INFUVITE ADULT...... 164 hydroxyprogest(pf)(preg presv) 259 idarubicin...... 58 INFUVITE PEDIATRIC...... 170 hydroxyprogesterone cap(ppres) IDHIFA...... 55 INGREZZA...... 101 ...... 259 IFE-BIMIX 30/1...... 144 INGREZZA INITIATION hydroxyprogesterone capr(bulk) IFE-PG20...... 144 PACK...... 101 ...... 108, 192 IFEREX 150 FORTE...... 155 INJECTAFER...... 156 hydroxyprogesterone caproate..259 IFEX...... 49 INLYTA...... 56 hydroxyurea...... 51 ifosfamide...... 49 INNOPRAN XL...... 73 hydroxyzine hcl...... 81 ILARIS (PF)...... 20 INNOSPIRE ELEGANCE226, 231 hydroxyzine pamoate...... 81 ILEVRO...... 243 INNOSPIRE ESSENCE... 226, 231 HYLATOPIC...... 131 ILUVIEN...... 242 INNOSPIRE GO NEBULIZER HYLATOPICPLUS...... 131 imatinib...... 56 ...... 224, 231 HYLAVITE...... 146 IMBRUVICA...... 52, 56 inositol...... 71 HYLENEX...... 194 imipenem-cilastatin...... 39 INOSITOL HYMOVIS...... 218 imipramine hcl...... 88 HEXANICOTINATE...... 108, 176 HYOPHEN...... 45, 208 imipramine pamoate...... 88 INOVA...... 125 hyoscyamine sulfate...... 199, 208 imiquimod...... 135 INOVA 4-1...... 125 hyoscyamine sulfate (bulk) IMITREX...... 100 INOVA 8-2...... 125 ...... 108, 199, 208 IMITREX STATDOSE PEN....100 INREBIC...... 54 HYOSYNE...... 199, 208 IMITREX STATDOSE INSPRA...... 66, 77 HYPER-HEAL...... 132 REFILL...... 100 INSUFLON...... 227, 231 HYPERHEP B S/D...... 63 IMLYGIC...... 54, 63 insulin lispro...... 190 HYPERHEP B S-D IMOGAM RABIES-HT (PF)..... 63 insulin lispro protamin-lispro... 189 NEONATAL...... 63 IMOVAX RABIES VACCINE INTEGRA...... 155 HYPERLYTE CR...... 158 (PF)...... 65 INTEGRA F...... 155 HYPERRAB (PF)...... 63 IMPAVIDO...... 35 INTEGRA PLUS...... 155 HYPERRAB S/D (PF)...... 63 IMPOYZ...... 130, 134 INTEGRILIN...... 214

279 INTELENCE...... 36 ISOLYTE-P IN 5 % JUNEL 1/20 (21)...... 120 INTERLINK LEVER LOCK DEXTROSE...... 154 JUNEL FE 1.5/30 (28)...... 120 CANNULA...... 225, 231 ISOLYTE-S...... 158 JUNEL FE 1/20 (28)...... 120 INTERMEZZO...... 103 isometh-dichloral-acetaminophn 99 JUNEL FE 24...... 120 INTRALIPID...... 168 ISOMIL ADVANCE...... 149 JUXTAPID...... 72 INTROVALE...... 120 ISOMIL DF...... 149 JYNARQUE...... 78, 194, 206 INTUNIV ER...... 93 ISOMIL/IRON...... 149 K2 PLUS D3...... 177 INVANZ...... 39 isoniazid...... 39 KABIVEN...... 168 INVEGA...... 91 isoproterenol hcl...... 75 KADCYLA...... 50, 59 INVEGA SUSTENNA...... 91 isoproterenol hcl (bulk)...... 75, 108 KADIAN...... 14 INVEGA TRINZA...... 91 ISOPTO ATROPINE...... 242 kahlua flavor (bulk)...... 108, 115 INVELTYS...... 242 ISOPTO CARPINE...... 240 KAITLIB FE...... 120 INVIRASE...... 46 ISORDIL...... 67 KALBITOR...... 80 INVOKAMET...... 181 ISORDIL TITRADOSE...... 67 KALETRA...... 37 INVOKANA...... 181 isosorbide dinitrate...... 68 KALLIGA...... 120 iodine (bulk)...... 61, 108 isosorbide mononitrate...... 68 KALYDECO...... 254 IODOFLEX...... 61 isotretinoin...... 123 KAMDOY...... 137 IODOPEN...... 154 ISOVUE-200...... 141 KANUMA...... 235 iodoquinol (bulk)...... 32, 108 ISOVUE-250...... 141 KAPSPARGO SPRINKLE...... 72 IODOSORB...... 61 ISOVUE-300...... 141 KAPVAY...... 93 IONOSOL-B IN D5W...... 154 ISOVUE-370...... 141 karaya gum (bulk).....108, 203, 225 IONOSOL-MB IN D5W...... 154 ISOVUE-M 300...... 141 KARBINAL ER...... 249 iopanoic acid (bulk)...... 108, 141 isoxsuprine...... 80 KARIVA (28)...... 119 IOPIDINE...... 247 isradipine...... 74 KAZANO...... 182 IPOL...... 65 ISTALOL...... 244 KEDRAB (PF)...... 63 ipratropium bromide...... 252, 255 ISTODAX...... 53 KEFLEX...... 40 ipratropium bromide (bulk) itraconazole...... 34 KELARX...... 138 ...... 108, 252, 255 ivermectin...... 33 KELNOR 1/35 (28)...... 120 ipratropium-albuterol...... 253 ivermectin (bulk)...... 33, 108 KELNOR 1-50...... 120 irbesartan...... 67 IXEMPRA...... 53 KELOTOP...... 227, 231 irbesartan-hydrochlorothiazide... 67 IXIARO (PF)...... 65 KENALOG...... 134, 187 IRESSA...... 49 JADENU...... 31 KENALOG-80...... 187 irinotecan...... 57 JADENU SPRINKLE...... 31 KENGREAL...... 213 iron...... 156 JAKAFI...... 54 KEPIVANCE...... 203 IRON...... 156 JALYN...... 205 KEPPRA...... 85 IRON (DRIED)...... 156 JANTOVEN...... 210 KEPPRA XR...... 85 IRON 100 PLUS...... 156 JANUMET...... 182 KERAFOAM...... 136 IRON CHEWS...... 156 JANUMET XR...... 182 KERALAC...... 136 iron,carbonyl-vitamin c...... 155 JANUVIA...... 180 KERALYT RX...... 136 IRONUP...... 156 JARDIANCE...... 181 KERALYT SCALP IRO-PLEX (IRON JASMIEL (28)...... 120 COMPLETE...... 136 CARBONYL)...... 155 JENCYCLA...... 121 KERYDIN...... 128 IRO-PLEX (IRON JENTADUETO...... 182 ketamine...... 26 POLYSACCHARIDE)...... 155 JENTADUETO XR...... 182 ketamine (bulk)...... 26, 108 IROSPAN 24/6...... 155 JEVTANA...... 57 ketamine in 0.9 % sod chloride...26 ISENTRESS...... 36 JINTELI...... 184 ketamine in nacl, iso-osmotic..... 26 ISENTRESS HD...... 36 JOLESSA...... 120 ketamine in sterile water...... 26 ISOCHRON...... 67 JORNAY PM...... 94 KETOCAL 2.5:1...... 165 ISOLEUCINE AMINO ACID JUBLIA...... 128 ketoconazole...... 34, 128 SUPPLMNT...... 145, 166 JULEBER...... 120 ketoconazole (bulk)...... 34, 108 ISOLYTE S PH 7.4...... 158 JULUCA...... 36 ketoprofen...... 25 JUNEL 1.5/30 (21)...... 120 KETOQ10 5.5:1...... 165

280 ketorolac...... 24, 243 labetalol...... 66 LARIN FE 1.5/30 (28)...... 120 KEVEYIS...... 217 LAC-HYDRIN FIVE...... 132 LARIN FE 1/20 (28)...... 120 KEVZARA...... 22 LACRISERT...... 240 LASIX...... 77 KEYTRUDA...... 59 lactase...... 197 LASTACAFT...... 242 KHAPZORY...... 60 LACTASE FAST ACTING..... 197 latanoprost...... 247 KIDS COD LIVER OIL AND lactated ringers...... 150, 174 latanoprost (pf)...... 247 VIT D...... 170 lactic acid (bulk)...... 108, 113 LATUDA...... 91 KIDS FIRST VITAMIN D3.....177 LACTINEX...... 202 LAYOLIS FE...... 120 KIDS' GUMMY...... 170 lactobacill.acidophilus (bulk) LAZANDA...... 14 KIDS MULTIVITAMIN- ...... 108, 202 LC D NEBULIZER SET.. 224, 231 MINERALS...... 170 lactobacillus acidophilus...... 203 LC PLUS...... 224, 231 KIDS VITAMIN D3...... 177 lactobacillus acidoph-l.bulgar...203 LC PLUS NEBULIZER-PED KINERET...... 22 lactose (bulk)...... 108, 118 MASK...... 224, 231 KINEVAC...... 142 LACTOSE FAST ACTING L-CARNITINE...... 108, 236 KINRIX (PF)...... 64 RELIEF...... 197 l-cystine...... 145 KISQALI...... 52 lactulose...... 196, 203 lecithin...... 71 KISQALI FEMARA CO-PACK 54 L-ALANINE...... 108, 166 lecithin (bulk)...... 109 KITABIS PAK...... 254 LAMICTAL...... 85 lecithin, soy...... 71 KLARITY (CHONDROITIN) LAMICTAL ODT...... 85, 96 LECITHIN-KELP-B6...... 12 (PF)...... 240 LAMICTAL ODT STARTER LEENA 28...... 122 KLARON...... 124 (BLUE)...... 85, 96 leflunomide...... 23 KLONOPIN...... 82, 83, 95 LAMICTAL ODT STARTER lemon flavor extract (bulk)...... 115 KLOR-CON...... 159 (GREEN)...... 85, 96 lemonade flavor oil (bulk) 109, 115 KLOR-CON 10...... 159 LAMICTAL ODT STARTER LEMTRADA...... 239 KLOR-CON 8...... 159 (ORANGE)...... 85, 96 LENVIMA...... 56 KLOR-CON M10...... 159 LAMICTAL STARTER LESCOL...... 70 KLOR-CON M15...... 159 (BLUE) KIT...... 85, 96 LESCOL XL...... 70 KLOR-CON M20...... 159 LAMICTAL STARTER LESSINA...... 120 KLOR-CON/EF...... 159 (GREEN) KIT...... 85, 96 LETAIRIS...... 81 KOBEE...... 146 LAMICTAL STARTER letrozole...... 51 KOMBIGLYZE XR...... 182 (ORANGE) KIT...... 85, 96 leucine...... 145 KORLYM...... 181 LAMICTAL XR...... 85 leucovorin calcium...... 60 K-PAX...... 161 LAMICTAL XR STARTER leucovorin calcium (bulk)...... 109 K-PAX IMMUNE SUPPORT..161 (BLUE)...... 85 LEUKERAN...... 49 K-PHOS NO 2...... 207 LAMICTAL XR STARTER LEUKINE...... 211 K-PHOS ORIGINAL...... 207 (GREEN)...... 85 leuprolide...... 54 K-PHOS-NEUTRAL...... 158, 207 LAMICTAL XR STARTER levalbuterol hcl...... 253 KPN...... 171 (ORANGE)...... 85 levalbuterol tartrate...... 253 krill-om-3-dha-epa-phospho-ast. 71 lamivudine...... 37, 43 levamisole (bulk)...... 55, 109 KRINTAFEL...... 35 lamivudine-zidovudine...... 38 LEVBID...... 199, 208 KRISTALOSE...... 203 lamotrigine...... 85, 96 LEVEMIR FLEXTOUCH U- KRYSTEXXA...... 209 LANOXIN...... 76 100 INSULN...... 190 K-TAB...... 159 LANOXIN PEDIATRIC...... 77 LEVEMIR U-100 INSULIN.... 190 KURVELO (28)...... 120 lansoprazole...... 198 levetiracetam...... 85 KUVAN...... 237 lansoprazole (bulk)...... 108, 198 levetiracetam in nacl (iso-os)...... 85 KYLEENA...... 119 lanthanum...... 205 LEVITRA...... 144 KYNMOBI...... 90 LANTUS SOLOSTAR U-100 levobunolol...... 244 KYPROLIS...... 56 INSULIN...... 189 levocarnitine (with sugar)...... 236 l norgest/e.estradiol-e.estrad..... 119 LANTUS U-100 INSULIN...... 189 levocetirizine...... 249, 250 l.acidoph,saliva-b.bif-s.therm... 202 LARIN 1.5/30 (21)...... 120 levofloxacin...... 42, 246 L.E.T. (LIDO-EPINEPH- LARIN 1/20 (21)...... 120 levofloxacin in d5w...... 42 TETRA)...... 140 LARIN 24 FE...... 120 levoleucovorin calcium...... 60

281 LEVONEST (28)...... 122 linezolid...... 45 LOCOID LIPOCREAM...... 134 levonorgestrel-ethinyl estrad.....120 linezolid in dextrose 5%...... 45 LODOSYN...... 89 levonorg-eth estrad triphasic.....122 linezolid-0.9% sodium chloride..45 LOESTRIN 1.5/30 (21)...... 120 LEVOPHED (BITARTRATE)...75 LINZESS...... 196, 200, 203 LOESTRIN 1/20 (21)...... 120 LEVORA-28...... 120 LIORESAL...... 219 LOESTRIN FE 1.5/30 (28- levorphanol tartrate...... 14 liothyronine...... 193 DAY)...... 120 levorphanol tartrate (bulk).. 14, 109 liothyronine (bulk)...... 109, 193 LOESTRIN FE 1/20 (28-DAY)120 LEVO-T...... 193 LIP BALM BASE (BULK) LOFRIC...... 228, 231 levothyroxine...... 193 ...... 109, 113, 117 LOKELMA...... 150 levothyroxine (bulk)...... 109, 193 LIPIODOL...... 142 LOMOTIL...... 194 LEVOXYL...... 193 LIPITOR...... 70 LONHALA MAGNAIR LEVSIN...... 199, 208 LIPOBASE REGULAR... 109, 113 REFILL...... 252 LEVSIN/SL...... 199, 208 LIPOCHOL PLUS...... 71 LONHALA MAGNAIR LEVULAN...... 138 LIPOFEN...... 70 STARTER...... 252 LEXAPRO...... 87 LIPOIC ACID...... 11, 109 LONSURF...... 51 LEXETTE...... 130, 134 LIPOSYN II...... 168 loperamide (bulk)...... 109, 194 LEXISCAN...... 142 LIPOSYN III...... 168 LOPID...... 70 LEXIVA...... 46 LIPOTRIAD (WITH LUTEIN) 161 lopinavir-ritonavir...... 37 L-GLUTAMINE LIPOVAN CREAM BASE LOPREEZA...... 184 ...... 109, 166, 214, 215 ...... 109, 113 LOPRESSOR...... 72 LIALDA...... 201 LIQUID B-12...... 176 LOPRESSOR HCT...... 74 LIBRAX (WITH CLIDINIUM) LIQUID CALCIUM WITH LOPROX...... 128 ...... 95, 200 VITAMIN D...... 153 lorazepam...... 82, 95, 102 LIBTAYO...... 59 LIQUIVIDA HYDRATION LORAZEPAM INTENSOL. 82, 95 LICE BEDDING SPRAY...... 140 KIT...... 174 LORBRENA...... 50 licorice flavor (bulk)...... 109, 115 lisinopril...... 66 LORCET (HYDROCODONE) lidocaine...... 28, 140 lisinopril-hydrochlorothiazide.... 66 ...... 17, 18 lidocaine (pf)...... 28, 68 L-ISOLEUCINE...... 109, 166 LORCET HD...... 17, 18 lidocaine hcl...... 28, 140, 238 LITE TOUCH-MEDIUM LORID...... 146 lidocaine hcl(pf) in 0.9% nacl.....28 MASK...... 226, 231 LORTAB ELIXIR...... 17, 18 lidocaine hcl-hydrocortison ac LITEAIRE MDI CHAMBER LORYNA (28)...... 120 ...... 29, 135 ...... 226, 231 LORZONE...... 219 lidocaine in 5 % dextrose (pf).....68 LITETOUCH-LARGE MASK losartan...... 67 LIDOCAINE VISCOUS...... 238 ...... 226, 231 losartan-hydrochlorothiazide...... 67 lidocaine-epinephrine...... 28 LITETOUCH-SMALL MASK LOSEASONIQUE...... 119 lidocaine-epineph-sodium chlor. 28 ...... 226, 231 LOTEMAX...... 242 lidocaine-hydrocortisone-aloe.... 29 lithium carbonate...... 97 LOTEMAX SM...... 242 lidocaine-phenylephrn in water 241 lithium citrate...... 97 LOTENSIN...... 66 lidocaine-prilocaine...... 137 LITHOBID...... 97 LOTENSIN HCT...... 66 lidocaine-tetracaine...... 140 LITHOSTAT...... 206 loteprednol etabonate...... 242 LIDODERM...... 140 LITTLE ANIMALS-IRON...... 170 LOTREL...... 65 LIDO-K...... 140 LIVALO...... 70 LOTRONEX...... 200, 203 LIDOPIN...... 140 LIVIXIL PAK...... 137 LOUTREX...... 130, 132 LIDORX...... 140 L-LYSINE...... 145 lovastatin...... 70 LIDOTREX...... 140 LMD 10 % IN 0.9 % SODIUM LOVENOX...... 213 LIDOVEX...... 140 CHLOR...... 213 LOW-OGESTREL (28)...... 120 LIDOZION...... 140 LMD 10 % IN 5 % loxapine succinate...... 92 LILETTA...... 119 DEXTROSE...... 213 LO-ZUMANDIMINE (28)...... 120 LIME FLAVOR...... 109, 115 LO LOESTRIN FE...... 119 LTA PRE-ATTACHED...... 28 LINCOCIN...... 44 LOCALNESIUM...... 152 LUCEMYRA...... 103 lincomycin...... 44 LOCALNESIUM-C...... 152 LUCENTIS...... 245, 247 lindane...... 140 LOCOID...... 134 LUDENT FLUORIDE...... 237

282 LUGOLS...... 154 MACUGEN...... 245, 247 MAVENCLAD (4 TABLET luliconazole...... 128 mag oxide-d3-turmeric rt xt...... 12 PACK)...... 240 LUMIGAN...... 247 MAGELLAN INSULIN MAVENCLAD (5 TABLET LUMITENE...... 175 SAFETY SYRNG...... 223, 231 PACK)...... 240 LUMIZYME...... 235 MAGELLAN SYRINGE..223, 231 MAVENCLAD (6 TABLET LUMOXITI...... 52, 54 MAGNASWEET 110...... 109, 115 PACK)...... 240 LUMOXITI IV SOLN MAGNEBIND 300...... 205 MAVENCLAD (7 TABLET STABILIZER...... 117 MAGNEBIND 400...... 205 PACK)...... 240 LUNESTA...... 103 magnesium...... 156 MAVENCLAD (8 TABLET LUPANETA PACK (1 magnesium amino acid chelate.156 PACK)...... 240 MONTH)...... 191 magnesium carbonate (bulk).....109 MAVENCLAD (9 TABLET LUPANETA PACK (3 magnesium chloride...... 156 PACK)...... 240 MONTH)...... 191 magnesium gluconate (bulk) MAXALT...... 100 LUPRON DEPOT...... 54, 191 ...... 109, 156 MAXALT-MLT...... 100 LUPRON DEPOT (3 MONTH) magnesium glycinate (bulk) MAXIDEX...... 242 ...... 54, 191 ...... 109, 156 MAXIMIN PACK...... 161 LUPRON DEPOT (4 MONTH). 54 magnesium hydroxide (bulk)....109 MAXITROL...... 241 LUPRON DEPOT (6 MONTH). 54 magnesium l-lactate...... 156 MAXZIDE...... 78 LUPRON DEPOT-PED...... 191 magnesium oxide...... 156, 157 MAXZIDE-25MG...... 78 LUPRON DEPOT-PED (3 magnesium sulfate...... 157 MAYZENT...... 240 MONTH)...... 191 magnesium sulfate in 0.9 %nacl157 MAYZENT STARTER PACK 240 lutein...... 11 magnesium sulfate in d5w...... 157 MB HYDROGEL...... 131 LUTERA (28)...... 120 magnesium sulfate in lr...... 157 MB HYDROGEL LUVS NEWBORN...... 222, 231 magnesium sulfate in water...... 157 (CYCLOMETHICONE)...... 131 LUVS SIZE 1...... 222, 231 magnesium, potassium aspartate MCT OIL...... 165 LUVS SIZE 2...... 222, 231 ...... 157 meclofenamate...... 24 LUVS SIZE 3...... 222, 231 MAGNEVIST...... 142 mecobalamin (bulk)...... 109, 176 LUVS SIZE 4...... 222, 231 MAKENA...... 259 MEDI-LYTE...... 157 LUVS SIZE 5...... 222, 231 MAKENA (PF)...... 259 MEDIUM CREAM...... 109, 113 LUVS SIZE 6...... 222, 231 MALARONE...... 35 MEDROL...... 187 LUXAMEND...... 132 MALARONE PEDIATRIC...... 35 MEDROL (PAK)...... 187 LUXIQ...... 134 malathion...... 140 medroxyprogesterone...... 119, 192 LUZU...... 128 manganese chloride...... 157 MEDTYCHOLL-B LYDIA PINKHAM HERBAL manganese sulfate...... 157 COMPLEX-LIVER...... 146 ...... 12, 155 mannitol 10 %...... 77 mefenamic acid...... 24 LYMPHOSEEK...... 144 mannitol 20 %...... 77 mefenamic acid (bulk)...... 24, 109 LYNPARZA...... 56 mannitol 25 %...... 77 mefloquine...... 35 LYRICA...... 83, 98 mannitol 5 %...... 77 MEFOXIN IN DEXTROSE LYRICA CR...... 98, 102 MANNXTRA...... 12 (ISO-OSM)...... 40 lysine...... 145 maple flavor (bulk)...... 109, 115 MEGA BIOTIN...... 177 lysine hcl...... 145 MAPO BATH...... 132 MEGA LYSIPLEX PLUS...... 169 maprotiline...... 88 MULTIPLE/CHELATED LYSODREN...... 50 MARCAINE-EPINEPHRINE..237 MINERAL...... 161 LYSTEDA...... 211 MARLISSA (28)...... 120 MEGA MULTIVITAMIN FOR LYZA...... 121 MARNATAL-F...... 171 MEN...... 162 M.V.I. ADULT...... 164 MARPLAN...... 86 MEGA MULTIVITAMIN M.V.I. PEDIATRIC...... 170 MARQIBO...... 58 WITH MINERAL...... 162 M.V.I.-12 (WITHOUT marshmallow flavor (bulk)109, 115 megestrol...... 56, 145 VITAMIN K)...... 164 MAS CARE-PAK (PF)...... 187 MEKINIST...... 55 MACRILEN...... 143 MATULANE...... 49 MEKTOVI...... 55 MACROBID...... 33, 207 MAVENCLAD (10 TABLET melatonin-lemon balm leaf extr..99 MACRODANTIN...... 33, 207 PACK)...... 240 MELODETTA 24 FE...... 120

283 meloxicam...... 24 metformin...... 190 methyltestosterone...... 179 meloxicam (bulk)...... 24, 109 methacholine chloride (bulk) methyltestosterone (bulk). 109, 179 melphalan hcl...... 49 ...... 109, 143 methyltestosterone,micro(bulk) memantine...... 118 methadone...... 14, 15 ...... 109, 180 MENACTRA (PF)...... 64 methadone (bulk)...... 14, 109 metipranolol...... 244 MENEST...... 185 METHADONE INTENSOL...... 14 metoclopramide (bulk)...... 109 MENOSTAR...... 185 METHADOSE...... 15 metoclopramide hcl...... 199 MEN'S 50 PLUS methamphetamine...... 94, 98 metolazone...... 78 MULTIVITAMIN...... 162 METHAVER...... 175 METOPIRONE...... 143 MEN'S DAILY...... 162 methazolamide...... 77 metoprolol succinate...... 72 MEN'S DAILY GUMMIES..... 162 methenamine hippurate...... 45, 207 metoprolol ta-hydrochlorothiaz.. 75 MEN'S DAILY MULTIVIT- methenamine mandelate..... 45, 207 metoprolol tartrate...... 73 MINERAL...... 162 methenamine mandelate (bulk) METRO I.V...... 36 MEN'S MULTIVITAMIN ...... 109, 207 METROCREAM...... 124, 139 GUMMIES...... 162 methen-sod phos-meth blue- METROGEL...... 139 MEN'S ONE DAILY...... 162 hyos...... 45, 208 METROGEL VAGINAL...... 256 MEN'S PACK...... 162 METHERGINE...... 192 METROLOTION...... 124, 139 MENS POTENT FORMULA.... 12 methimazole...... 183 metronidazole...... 36, 124, 139, 256 MENTAX...... 127 METHITEST...... 179 metronidazole in nacl (iso-os).....36 menthol (bulk)...... 109, 140, 250 methocarbamol...... 219 mexiletine...... 68 MENVEO A-C-Y-W-135-DIP METHOCEL E 4 M...... 117 MG-PLUS-PROTEIN...... 12 (PF)...... 64 methotrexate sodium...... 21, 50 MIACALCIN...... 184 meperidine...... 14 methotrexate sodium (pf)...... 50 MIADERM...... 132 meperidine (pf)...... 14 methoxsalen...... 129 MIBELAS 24 FE...... 120 MEPHYTON...... 178 methoxsalen (bulk) MICARDIS...... 67 meprobamate...... 82 ...... 56, 109, 129, 138 MICARDIS HCT...... 67 MEPRON...... 35 methscopolamine...... 199 miconazole nitrate-zinc ox-pet..128 MEPSEVII...... 235 methylcellulose 1500cps (bulk) MICONAZOLE-3...... 256 mercaptopurine...... 51 ...... 109, 117 MICROAIR MESH MERIBIN...... 177 methylcellulose 4000cps (bulk) NEBULIZER...... 224, 231 meropenem...... 39 ...... 109, 117 MICROCHAMBER...... 226, 231 meropenem-0.9% sodium methyldopa...... 76 MICROGESTIN 1.5/30 (21).... 120 chloride...... 39 methyldopa- MICROGESTIN 1/20 (21)...... 120 MERREM...... 39 hydrochlorothiazide...... 76 MICROGESTIN FE 1.5/30 (28) mesalamine...... 201 methyldopate...... 76 ...... 121 mesalamine (bulk)...... 109 methylene blue (antidote)...... 30 MICROGESTIN FE 1/20 (28)..121 mesalamine with cleansing wipe methylergonovine...... 192 MICROLIPID...... 165 ...... 201 METHYLIN...... 94, 102 MICROSPACER...... 226, 231 mesna...... 61 methylphenidate hcl...... 94, 102 midazolam...... 27, 95, 102 MESNEX...... 61 methylpred ac(pf)-nacl,iso-osm 187 midazolam (pf)...... 27, 95 MESTINON...... 217 methylprednisol ac-bupivac-wat midazolam (pf) in 0.9 % nacl MESTINON TIMESPAN...... 217 ...... 186 ...... 26, 27, 95 METADATE ER...... 94 methylprednisolon ac,mic(bulk) midazolam in 0.9 % sod chlorid METAFOLBIC...... 164 ...... 109, 187 ...... 27, 95 METAMUCIL FREE...... 203 methylprednisolone...... 187 midodrine...... 76 METAMUCIL PLUS methylprednisolone acetate...... 187 MIFEPREX...... 178 CALCIUM...... 203 methylprednisolone acet-water.187 mifepristone...... 178 METANX (ALGAL OIL)...... 175 methylprednisolone sodium MIGERGOT...... 100 metaproterenol...... 253 succ...... 187 miglitol...... 180 METASTRON...... 57 methylprednisolone, mic (bulk) miglustat...... 236 METAXALL...... 219 ...... 109, 187 MIGRANAL...... 100 metaxalone...... 219 methylsulfonylmethane...... 11 MIGRANOW...... 100

284 MILI...... 121 MONOJECT 0.9% SODIUM MULTI FOR HER...... 162 milk thistle...... 12 CHLORIDE...... 174 MULTI VITAMIN...... 162 milk thistle seed extract...... 12 MONOJECT BLOOD MULTIBASE...... 109, 113 MILLIPRED...... 187 COLLECTION...... 220, 231 MULTI-DAY PLUS MILLIPRED DP...... 187 MONOJECT CONTROL MINERALS...... 162 milrinone...... 74 SYRINGE LUER...... 225, 231 MULTI-DELYN WITH IRON.162 milrinone in 5 % dextrose...... 74 MONOJECT HYPODERMIC MULTIGEN FOLIC...... 155 MIMVEY...... 184 NEEDLES...... 225, 231 MULTIGEN PLUS...... 155 MINASTRIN 24 FE...... 121 MONOJECT INSULIN MULTIHANCE...... 142 mineral oil...... 109, 113 SAFETY SYRING...... 223, 231 MULTIHANCE MULTIPACK142 MINI PRENATAL...... 171 MONOJECT PREFILL MULTIPLE VITAMIN, MINIMED INFUSION SET- ADVANCED NS...... 174 WOMENS...... 162 MMT 390...... 228, 231 MONOJECT SAFETY MULTITRACE-4...... 159 MINIPRESS...... 79 SYRINGES...... 225, 231 MULTITRACE-4 MINITRAN...... 68 MONOJECT SYRINGE...225, 231 CONCENTRATE...... 159 MINIVELLE...... 185 MONOJECT TB LUER LOK MULTITRACE-4 NEONATAL MINOCIN...... 48 ...... 225, 231 ...... 159 minocycline...... 23, 48, 123 MONO-LINYAH...... 121 MULTITRACE-4 PEDIATRIC159 MINOLIRA ER...... 48, 123 MONOVISC...... 218 MULTITRACE-5...... 159 minoxidil...... 77 MONSEL'S...... 211 MULTITRACE-5 minoxidil (bulk)...... 77, 109, 140 montelukast...... 251 CONCENTRATE...... 160 mint chocolate chip flv (bulk) MONUROL...... 33, 207 MULTIUSE BASE...... 109, 113 ...... 109, 115 MOOD SUPPORT MULTI-VIT WITH MIO INFUSION SET...... 228, 231 PROBIOTIC...... 203 FLUORIDE-IRON...... 169 MIOCHOL-E...... 240 MORGIDOX...... 48 multivitamin...... 164 MIOSTAT...... 240 MORGIDOX 2X100...... 48 MULTI-VITAMIN MIRAPEX...... 90 morphine...... 15, 16 HP/MINERALS...... 162 MIRAPEX ER...... 90 morphine (bulk)...... 15, 109 MULTIVITAMIN WITH MIRCERA...... 210 morphine (pf)...... 15 FLUORIDE...... 169 MIRCETTE (28)...... 119 morphine (pf) in 0.9 % sod chl... 15 MULTI-VITAMIN WITH MIRENA...... 119 morphine (pf) in dextrose 5 %.... 15 FLUORIDE...... 169 mirtazapine...... 86 morphine concentrate...... 15 MULTIVITAMIN WOMEN 50 MIRVASO...... 139 morphine in 0.9 % sodium chlor.15 PLUS...... 162 misoprostol...... 198 MOTEGRITY...... 198 MULTIVITAMINS WITH MITIGARE...... 209 MOTOFEN...... 194 FLUORIDE...... 169 mitomycin...... 58 MOUTHPIECE REUSABLE MULTI-VITE...... 162 MITOSOL...... 242 MW...... 226, 231 mupirocin...... 127 mitoxantrone...... 58 MOVANTIK...... 31 mupirocin calcium...... 127 MKO (MIDAZOLAM- MOVIPREP...... 203 MUSE...... 144 KETAMINE-ONDAN)...... 26, 103 MOXATAG...... 33 MVC-FLUORIDE...... 169 M-M-R II (PF)...... 63, 65 MOXEZA...... 246 mv-min-folic acid-lutein...... 162 M-NATAL PLUS...... 171 moxifloxacin...... 42, 246 MVW COMPLETE FORMUL MOBIC...... 24 moxifloxacin-sod chlor,iso(pf). 246 MULTIVIT...... 170, 171 modafinil...... 101 moxifloxacin-sod.ace,sul-water..42 MVW COMPLETE FORMUL moexipril...... 66 moxifloxacin-sod.chloride(iso)...42 PEDIATRIC...... 171 molindone...... 92 MOZOBIL...... 210 MVW COMPLETE mometasone...... 134, 255 MS CONTIN...... 16 FORMULATION D3000...... 171 MONDOXYNE NL...... 48 MSUD ANALOG...... 149, 166 MVW COMPLETE MONOCAL...... 157 MUCOSITISRX...... 238 FORMULATION D5000...... 171 MONOCAPS...... 162 MUGARD...... 238 MYALEPT...... 191 MONODOX...... 48 MULPLETA...... 215 MYAMBUTOL...... 39 MULTAQ...... 69 MYCAMINE...... 34

285 MYCOBUTIN...... 39, 47 naproxen sodium...... 25 NERLYNX...... 49 mycophenolate mofetil...... 22, 216 naproxen sodium (bulk)...... 25, 109 NESINA...... 180 mycophenolate mofetil (hcl) naratriptan...... 100 NESTABS...... 172 ...... 22, 216 NARCAN...... 32 NESTABS ABC...... 172 mycophenolate sodium...... 217 NARDIL...... 86 NESTABS DHA...... 172 MYDAYIS...... 94, 97 NAROPIN (PF)...... 28 NEUAC...... 124 MYDRIACYL...... 242 NASONEX...... 255 NEULASTA...... 210 MYDRIATIC4(TROP-PROP- NATACHEW (FE BIS- NEUPOGEN...... 210 PE-KTRLC)...... 245 GLYCINATE)...... 172 NEUPRO...... 90 MYFERON 150 FORTE...... 155 NATACYN...... 246 NEURAPTINE...... 137 MYFORTIC...... 217 NATAZIA...... 121 NEURCAINE...... 140 MYLERAN...... 49 nateglinide...... 181 NEURIN-SL...... 175, 176 MYNATAL...... 171 NATESTO...... 180 NEUROLITE...... 143 MYNATAL PLUS...... 171 NATPARA...... 192 NEURONTIN...... 83 MYNATAL-Z...... 171 NATROBA...... 140 NEUTROGENA...... 139 MYNEPHROCAPS...... 146 NATURAL B-100 COMPLEX 146 NEUTROGENA ACNE MYOBLOC...... 218 NATURE-THROID...... 193 CLEANSING SOAP...... 139 MYORISAN...... 123 NAVELBINE...... 58 NEUTROGENA FACIAL MYOVIEW KIT...... 143 NAYZILAM...... 83, 95 SOAP...... 139 MYRBETRIQ...... 205 NEBUPENT...... 45 NEVANAC...... 243 MYSOLINE...... 82 NEBUSAL...... 116 nevirapine...... 36 NABI-HB...... 63 NECON 0.5/35 (28)...... 121 NEWGEN...... 172 nabumetone...... 24 NEEVODHA (WITH ALGAL NEXAVAR...... 55 N-ACETYL-ALPHA-D- OIL)...... 164, 172 NEXAVIR...... 137 GLUCOSAMINE...... 11, 109 nefazodone...... 87 NEXIUM...... 198 nadolol...... 73 NEMBUTAL SODIUM...... 102 NEXIUM IV...... 198 nadolol-bendroflumethiazide...... 79 neomycin...... 32 NEXIUM PACKET...... 198 nafcillin...... 45 neomycin-bacitracin-poly-hc....241 NEXLETOL...... 69 nafcillin in dextrose iso-osm...... 45 neomycin-bacitracin-polymyxin NEXPLANON...... 119 naftifine...... 127 ...... 245 NEXTERONE...... 69 NAFTIN...... 127 neomycin-polymyxin b gu...... 205 niacin...... 70, 176 NAGLAZYME...... 235 neomycin-polymyxin b- niacin (inositol niacinate)...... 176 nalbuphine...... 19 dexameth...... 241 NIACIN FLUSH FREE...... 176 NALFON...... 25 neomycin-polymyxin- NIACIN NO FLUSH...... 176 NALOCET...... 18 gramicidin...... 246 niacinamide...... 176 naloxone...... 31 neomycin-polymyxin-hc...241, 248 niacinamide (bulk)...... 109, 176 naloxone (bulk)...... 31, 109 NEO-POLYCIN...... 246 NIACOR...... 70 naltrexone...... 31 NEO-POLYCIN HC...... 241 NIASPAN EXTENDED- naltrexone hcl (bulk)...... 31, 109 NEOPROFEN (IBUPROFEN RELEASE...... 71 NAMENDA...... 118 LYSN)(PF)...... 79 nicardipine...... 74 NAMENDA TITRATION PAK NEORAL...... 22, 216 nicardipine in 0.9 % sod chlor.... 74 ...... 118 NEOSALUS...... 132 NICOMIDE (SELENIUM- NAMENDA XR...... 118 neostigmine methylsulfate 217, 218 CHROMIUM)...... 162 NAMZARIC...... 118 NEO-SYNALAR...... 127 NICOTROL...... 104 NANO VM 1-3...... 171 NEO-SYNALAR KIT...... 127 NICOTROL NS...... 104 NANO VM 4-8...... 171 NEPHPLEX RX...... 147 nifedipine...... 74 NANOVM 9-18...... 169 NEPHRAMINE 5.4 %...... 168 nifedipine (bulk)...... 74, 109 NANOVM T-F...... 169 NEPHRONEX...... 146 nifedipine, micronized (bulk) NAPRELAN CR...... 25 NEPHRONEX-SL...... 146 ...... 74, 109 NAPROSYN...... 25 NEPHRO-VITE...... 146 NIKKI (28)...... 121 naproxen...... 25 NEPHRO-VITE RX...... 147 NILANDRON...... 50 naproxen (bulk)...... 25, 109 NERIA...... 227, 231 nilutamide...... 50

286 NIMBEX...... 218 NORMOSOL-R...... 158 NULEV...... 199, 208 nimodipine...... 74 NORMOSOL-R IN 5 % NULOJIX...... 217 NINLARO...... 56 DEXTROSE...... 154 NULYTELY WITH FLAVOR NIPENT...... 51 NORMOSOL-R PH 7.4...... 158 PACKS...... 203 NIPRIDE RTU...... 77 NORPACE...... 68 NUPLAZID...... 93 nisoldipine...... 74 NORPACE CR...... 68 NURETIN...... 148 NITHIODOTE...... 30 NORPRAMIN...... 89 NUTRA PRO HIGH PROTEIN NITRO-BID...... 68 NORTHERA...... 76 ...... 148 NITRO-DUR...... 68 NORTREL 0.5/35 (28)...... 121 NUTRAMIGEN DHA-ARA.... 149 nitrofurantoin...... 33, 207 NORTREL 1/35 (21)...... 121 NUTRAMIGEN TODDLER nitrofurantoin (bulk)...... 33, 109 NORTREL 7/7/7 (28)...... 122 ENFLORA-LGG...... 149 nitrofurantoin macrocrystal.33, 207 nortriptyline...... 89 NUTRILIPID...... 168 nitrofurantoin monohyd/m-cryst NORVASC...... 74 NUTRILYTE...... 158 ...... 33, 207 NORVIR...... 46 NUTRISURE PLUS...... 148 nitroglycerin...... 68 NORWEGIAN COD LIVER NUTRIVIT...... 146 nitroglycerin in 5 % dextrose...... 68 OIL...... 164, 175 NUTROPIN AQ NUSPIN...... 188 NITROLINGUAL...... 68 NOVACORT...... 135 NUVAKAAN...... 137, 227 NITROMIST...... 68 NOVAFERRUM...... 156 NUVARING...... 122 NITROPRESS...... 77 NOVAFERRUM 125...... 156 NUVESSA...... 256 NITROSTAT...... 68 NOVAFERRUM 50...... 156 NUVIGIL...... 101 NITRO-TIME...... 68 NOVAFERRUM PEDIATRIC 169 NUZYRA...... 32, 48 NITYR...... 236 NOVAMV...... 171 NYAMYC...... 127 NIVA-FOL...... 175, 178 NOVAREL...... 189 nylidrin (bulk)...... 80, 109 NIVA-PLUS...... 162, 172 NOVOLOG FLEXPEN U-100 nystatin...... 34, 127, 238 NIVATOPIC PLUS...... 132 INSULIN...... 190 nystatin (bulk)...... 34, 110 NIVESTYM...... 210 NOVOLOG MIX 70-30 U-100 nystatin-triamcinolone...... 128 nizatidine...... 197 INSULN...... 189 NYSTOP...... 127 NIZORAL...... 128 NOVOLOG MIX 70- OB COMPLETE...... 155, 162, 172 NOCDURNA (MEN)...... 180 30FLEXPEN U-100...... 189 OB COMPLETE ONE...... 172 NOCDURNA (WOMEN)...... 180 NOVOLOG PENFILL U-100 OB COMPLETE PETITE...... 172 NOCTIVA...... 180 INSULIN...... 190 OB COMPLETE PREMIER NOLIX...... 134 NOVOLOG U-100 INSULIN ...... 155, 172 NORA-BE...... 121 ASPART...... 190 OB COMPLETE WITH DHA..172 NORCO...... 17, 18 NOVOPEN ECHO...... 223, 232 O-CAL F.A...... 162 NORDITROPIN FLEXPRO.... 188 NOXAFIL...... 34 O-CAL PRENATAL...... 172 norepinephrine bitartrate...... 76 NOXIFOL-D3...... 175, 177 OCALIVA...... 215 norepinephrine bitartrate-d5w.....76 NOXIPAK...... 135 OCELLA...... 121 norepinephrine bitartrate-nacl.....76 NP THYROID...... 193 OCREVUS...... 239 noreth-ethinyl estradiol-iron..... 121 NPLATE...... 215 OCTAGAM...... 63 norethindrone (contraceptive)...121 NUBEQA...... 50 OCTAPLAS (BLOOD GROUP norethindrone acetate...... 192 NUCALA...... 252 A)...... 213 norethindrone ac-eth estradiol NUCYNTA...... 16 OCTAPLAS (BLOOD GROUP ...... 121, 184 NUCYNTA ER...... 16 AB)...... 213 norethindrone-e.estradiol-iron.. 121 NUDROXIPAK...... 24 OCTAPLAS (BLOOD GROUP NORGESIC FORTE...... 219 NUDROXIPAK DSDR-50...... 24 B)...... 213 norgestimate-ethinyl estradiol NUDROXIPAK DSDR-75...... 24 OCTAPLAS (BLOOD GROUP ...... 121, 122 NUDROXIPAK E-400...... 24 O)...... 213 NORITATE...... 124, 139 NUDROXIPAK I-800...... 24 OCTREOSCAN...... 143 NORMAL SALINE FLUSH.... 174 NUDROXIPAK N-500...... 24 octreotide acetate...... 192, 204 NORM-JECT...... 225, 232 NUEDEXTA...... 102 OCUFLOX...... 246 NORMOSOL-M IN 5 % NUFERA...... 155 OCUTABS...... 162 DEXTROSE...... 154 NU-IRON...... 156 OCUVITE EYE PLUS MULTI162

287 ODACTRA...... 61 ONE DAILY ESSENTIAL...... 164 ONE-A-DAY WOMEN'S ODEFSEY...... 38 ONE DAILY FOR MEN...... 162 PRENATAL 1...... 172 ODOMZO...... 53 ONE DAILY FOR WOMEN... 162 ONETOUCH PING INSULIN ODOR ELIMINATOR DROPS225 ONE DAILY HEALTHY PUMP...... 227, 232 ODORLESS GARLIC...... 12 WEIGHT...... 162 ONEXTON...... 124 OFEV...... 56, 256 ONE DAILY MEN'S 50 PLUS ONFI...... 83, 95 OFIRMEV...... 20 MEMORY...... 164 ONGLYZA...... 180 ofloxacin...... 42, 246, 248 ONE DAILY MEN'S 50 PLUS ONIVYDE...... 57 olanzapine...... 92, 97 W-D3...... 162 ONPATTRO...... 179 olanzapine-fluoxetine...... 88, 92, 97 ONE DAILY MULTI-VIT W- ONZETRA XSAIL...... 100 olive oil...... 113 MINERAL...... 162 OPDIVO...... 59 olmesartan...... 67 ONE DAILY opium tincture...... 194 olmesartan-amlodipin-hcthiazid. 67 MULTIVITAMIN...... 164 OPSUMIT...... 81 olopatadine...... 242, 255 ONE DAILY OPTICHAMBER ADULT OLUMIANT...... 23 MULTIVITAMIN-IRON...... 162 MASK-LARGE...... 226, 232 OLUX...... 134 ONE DAILY PRENATAL...... 172 OPTICHAMBER DIAMOND OLUX-E...... 134 ONE DAILY WOMEN'S...... 164 LG MASK...... 226, 232 OMECLAMOX-PAK...... 204 ONE DAILY WOMENS 50 OPTICHAMBER DIAMOND OMEGA-3 (WITH DPA)...... 71 PLUS...... 162 VHC...... 226, 232 OMEGA-3 2100...... 71 ONE DAILY WOMEN'S OPTICHAMBER DIAMOND- omega-3 acid ethyl esters...... 71 HEALTH...... 164 MED MSK...... 226, 232 omega-3 fatty acids-fish oil...... 71 ONE-A-DAY CHOLESTEROL OPTICHAMBER DIAMOND- OMEGA-3 FISH OIL...... 71 PLUS...... 162 SML MASK...... 226, 232 omega-3s-dha-epa-fish oil...... 71 ONE-A-DAY ENERGY...... 164 OPTIMAL D3...... 177 OMEGAVEN...... 168 ONE-A-DAY KID'S...... 171 OPTIMAL D3 M...... 177 omeprazole...... 198 ONE-A-DAY MEN OPTIRAY 240...... 141 omeprazole (bulk)...... 110, 198 VITACRAVES...... 162 OPTIRAY 300...... 142 omeprazole-sodium bicarbonate ONE-A-DAY MENOPAUSE OPTIRAY 320...... 142 ...... 198 FORMULA...... 162 OPTIRAY 350...... 142 OMIDRIA...... 245 ONE-A-DAY MEN'S 50 PLUS162 OPTISON...... 142 OMNARIS...... 255 ONE-A-DAY MEN'S OPTISOURCE...... 163 OMNIPAQUE...... 141 MULTIVITAMIN...... 162 OPURITY MULTIVITAMIN.. 163 OMNIPAQUE 140...... 141 ONE-A-DAY TEEN HIM ORA-BLEND...... 117 OMNIPAQUE 240...... 141 VITACRAVES...... 171 ORA-BLEND SF...... 117 OMNIPAQUE 300...... 141 ONE-A-DAY TRUBIOTICS... 203 ORACEA...... 48, 139 OMNIPAQUE 350...... 141 ONE-A-DAY VITACRAVES..162 ORACIT...... 207 OMNIPOD DASH PDM KIT ONE-A-DAY VITACRAVES ORAFATE...... 238 ...... 223, 232 IMMUNITY...... 162 ORAL MIX...... 117 OMNIPOD INSULIN ONE-A-DAY VITACRAVES ORAL MIX SF...... 117 MANAGEMENT...... 227, 232 OMEGA-3...... 162 ORAL SUSPEND...... 117 OMNIPOD INSULIN REFILL ONE-A-DAY ORAL SUSPENDING ...... 224, 232 WEIGHTSMART...... 163 COMPOUND PLUS...... 117 OMNISCAN...... 142 ONE-A-DAY WOMEN ORAL SYRUP...... 117 OMNITROPE...... 188 VITACRAVES...... 163 ORAL SYRUP SF...... 117 OMNIVEX...... 164 ONE-A-DAY WOMEN'S ORALAIR...... 61 ONCASPAR...... 52 ACTIVE...... 163 ORALONE...... 238 ONCOVITE...... 164 ONE-A-DAY WOMENS ORALYTE...... 157 ondansetron...... 195 FORMULA...... 163, 164 ORAMAGICRX...... 238 ondansetron hcl...... 195 ONE-A-DAY WOMEN'S ORANGE CONCENTRATE ondansetron hcl (pf)...... 195 HEALTHY SKIN...... 163 ...... 110, 115 ONE A DAY WOMEN'S ONE-A-DAY WOMEN'S orange cream flavor (bulk)110, 115 PRENATAL DHA...... 172 PETITES...... 165 orange flavor (bulk)...... 110, 117

288 ORA-PLUS...... 117 OXANDRIN...... 179 PAMELOR...... 89 ORAPRED ODT...... 187 oxandrolone...... 179 pamidronate...... 184 ORA-SWEET...... 117 oxaprozin...... 25 PAMPERS BABY-DRY SIZE ORA-SWEET SF...... 117 OXAYDO...... 16 1...... 222, 232 ORAVIG...... 34 oxazepam...... 82, 95 PAMPERS BABY-DRY SIZE ORAZINC...... 160 oxcarbazepine...... 84 2...... 222, 232 ORENCIA...... 22 OXERVATE...... 244 PAMPERS BABY-DRY SIZE ORENCIA (WITH MALTOSE).22 oxiconazole...... 128 3...... 222, 232 ORENCIA CLICKJECT...... 22 OXISTAT...... 128 PAMPERS BABY-DRY SIZE ORENITRAM...... 80 OXSORALEN ULTRA...... 129 4...... 222, 232 ORFADIN...... 236 OXTELLAR XR...... 84 PAMPERS BABY-DRY SIZE ORILISSA...... 191 oxybutynin chloride...... 209 5...... 222, 232 ORKAMBI...... 254 oxybutynin chloride (bulk)...... 110 PAMPERS BABY-DRY SIZE orphenadrine citrate...... 219 oxycodone...... 16 6...... 222, 232 ORSYTHIA...... 121 oxycodone (bulk)...... 16, 110 PAMPERS BABY-DRY SIZE ORTHO MICRONOR...... 121 oxycodone-acetaminophen...... 18 N...... 222, 232 ORTHO TRI-CYCLEN (28).... 122 oxycodone-aspirin...... 18 PAMPERS CRUISERS.... 222, 232 ORTHODIET...... 12 OXYCONTIN...... 16 PAMPERS CRUISERS SIZE 3 ORTHO-NOVUM 1/35 (28).... 121 oxymorphone...... 16 ...... 222, 232 ORTHO-NOVUM 7/7/7 (28)... 122 oxytetracycline (bulk)...... 48, 110 PAMPERS CRUISERS SIZE 5 ORTHO-TABS...... 152 oxytocin...... 192 ...... 222, 232 ORTHOVISC...... 218 oxytocin (bulk)...... 110, 192 PAMPERS CRUISERS SIZE 6 OS-CAL 500 + D3...... 153 oxytocin in 0.9 % sod chloride. 192 ...... 222, 232 OSCIMIN...... 199, 208 OXYTROL...... 209 PAMPERS CRUISERS SIZE 7 OSCIMIN SL...... 199, 208 OYSCO 500/D...... 153 ...... 222, 232 OSCIMIN SR...... 199, 208 OYSTER SHELL CALCIUM..154 PAMPERS EASY UPS.... 222, 232 oseltamivir...... 43 OYSTER SHELL CALCIUM PAMPERS EXTRA oseltamivir phosphate (bulk) 500...... 154 PROTECTION SZ 3...... 222, 232 ...... 43, 110 OYSTER SHELL CALCIUM- PAMPERS EXTRA OSENI...... 182 VIT D3...... 153 PROTECTION SZ 4...... 222, 232 OSMITROL 10 %...... 77 OZEMPIC...... 182 PAMPERS EXTRA OSMITROL 15 %...... 77 OZURDEX...... 242 PROTECTION SZ 5...... 222, 232 OSMITROL 20 %...... 77 PACERONE...... 69 PAMPERS EXTRA OSMITROL 5 %...... 77 paclitaxel...... 57 PROTECTION SZ 6...... 222, 232 OSMOLEX ER...... 90 PACNEX...... 125 PAMPERS PREEMIE SWAD OSMOPREP...... 203 PALFORZIA (LEVEL 1)...... 63 SIZE P-S...... 223, 232 OSTEO BI-FLEX...... 11 PALFORZIA (LEVEL 2)...... 63 PAMPERS PREMIE...... 223, 232 OTEZLA...... 23, 130 PALFORZIA (LEVEL 3)...... 63 PAMPERS SWADDLERS OTEZLA STARTER...... 23, 130 PALFORZIA (LEVEL 4)...... 63 SENS. SIZE 1...... 223, 232 OTIPRIO...... 248 PALFORZIA (LEVEL 5)...... 63 PAMPERS SWADDLERS OTOVEL...... 248 PALFORZIA (LEVEL 6)...... 63 SIZE 1...... 223, 232 OTREXUP (PF)...... 21 PALFORZIA (LEVEL 7)...... 63 PAMPERS SWADDLERS OVACE...... 130 PALFORZIA (LEVEL 8)...... 63 SIZE 2...... 223, 232 OVACE PLUS...... 130 PALFORZIA (LEVEL 9)...... 64 PAMPERS SWADDLERS OVACE PLUS SHAMPOO..... 130 PALFORZIA (LEVEL 10)...... 64 SIZE 3...... 223, 232 OVACE PLUS WASH...... 130 PALFORZIA (LEVEL 11 UP- PAMPERS SWADDLERS OVIDE...... 140 DOSE)...... 64 SIZE N...... 223, 232 OVIDREL...... 189 PALFORZIA INITIAL DOSE... 64 PAMPERS UNISEX BABY- oxacillin...... 45 PALFORZIA LEVEL 11 DRY...... 223, 232 oxacillin in dextrose(iso-osm).... 45 MAINTENANCE...... 64 PANCREAZE...... 196 oxalic acid (bulk)...... 110, 113 paliperidone...... 91 pancuronium...... 218 oxaliplatin...... 56 palonosetron...... 195 PANDEL...... 134

289 PANRETIN...... 129 PEDIATRIC ELECTROLYTE 158 PETROLATUM...... 113, 132 pantoprazole...... 198 PEDIATRIC FREEZER POPS.158 petrolatum, yellow (bulk)...... 113 pantothenic acid (vit b5)...... 176 PEDITRACE...... 160 PEXEVA...... 87 PANZYGA...... 63 PEDVAX HIB (PF)...... 64 PFIZERPEN-G...... 259 papaverine...... 80 peg 3350-electrolytes...... 203 PFLEX INSPIRATORY papaverine (bulk)...... 80, 110 PEG OINTMENT BASE TRAINER...... 226, 232 PARADIGM SILHOUETTE (BULK)...... 110, 113, 117 PHARMABASE...... 110, 113 INFUS SET...... 225, 232 PEG-3350 WITH FLAVOR PHARMABASE COSMETIC PARAGARD T 380A...... 119 PACKS...... 203 ...... 110, 132 PAREMYD...... 241 PEGANONE...... 84 PHARMABASE HEAVY 110, 114 PARI BABY CONV KIT - PEGBLEND...... 110, 113 PHARMABASE LIGHT.. 110, 114 SIZE 1...... 226, 232 peg-electrolyte soln...... 203 PHARMABASE NATURAL PARI BABY NEBULIZER PEG-PREP...... 204 ...... 110, 114 ...... 224, 232 penicillamine...... 23, 31 PHARMABASE VAGINAL PARI LC SPRINT penicillamine (bulk)...... 23, 31, 110 ...... 110, 114 NEBULIZER SET...... 224, 232 PENICILLAMINE(D-).23, 31, 110 PHASEAL PROTECTOR 225, 233 paricalcitol...... 236 penicillin g pot in dextrose...... 45 phenazopyridine...... 207 PARLODEL...... 90 penicillin g potassium...... 45, 259 phenelzine...... 86 PARNATE...... 86 penicillin g procaine...... 45 PHENERGAN...... 195, 249 PAROEX ORAL RINSE...... 238 penicillin g sodium...... 45 phenobarbital...... 82, 102 paromomycin...... 32 penicillin v potassium...... 45 phenobarbital (bulk)....82, 102, 110 paroxetine hcl...... 87 PENLEN...... 132 phenobarbital sodium...... 82, 102 PARVA-CAL 250...... 153 PENNSAID...... 138 PHENOHYTRO...... 200 PARVA-CAL 500...... 153 PENSOMAL...... 110, 113 phenol...... 61 PARVLEX...... 155 PENTACEL (PF)...... 65 phenol (bulk)...... 61, 110 PASER...... 38 PENTAM...... 45 phenoxybenzamine...... 79 PATANASE...... 255 pentamidine...... 45 phentolamine...... 79 PAXIL...... 87 PENTASA...... 201 PHENYLADE 40...... 166 PAXIL CR...... 87 pentazocine-naloxone...... 19 PHENYLADE GMP MIX-IN.. 166 PAZEO...... 242 pentetate calcium trisodium...... 31 PHENYLADE GMP READY..166 PCCA NATACREAM...... 110, 113 pentoxifylline...... 211 PHENYLADE MTE AMINO PCCA T4 SODIUM PEPCID...... 197 ACIDS...... 166 DILUTION...... 110, 193 PEPPERMINT FLAVORING phenylbutazone (bulk)...... 25, 110 peach flavor (bulk)...... 110, 115 ...... 110, 115 phenylephrine hcl...... 76, 244 PEANUT BUTTER FLAVOR PERCOCET...... 18 phenylephrine hcl (bulk) ...... 110, 115 PERFECT IRON...... 156 ...... 29, 76, 110, 256 peanut butter flavor (bulk) 110, 115 PERFOROMIST...... 253 phenylephrine hcl in 0.9% nacl...76 pectin (bulk)...... 110 PERIANAL CLEANSING...... 139 PHENYL-FREE 1...... 166 PEDIA D-VITE...... 177 PERIDEX...... 238 PHENYTEK...... 84 PEDIA IRON...... 156 PERIDIN-C...... 147 phenytoin...... 84 PEDIA POLY-VITE...... 169, 171 PERIFLEX INFANT...... 166 phenytoin (bulk)...... 84, 110 PEDIA POLY-VITE WITH PERIFLEX LQ PKU...... 166 phenytoin sodium...... 68, 84 IRON...... 169 PERIFRESH...... 139 phenytoin sodium (bulk) PEDIA TRI-VITE...... 171 PERIKABIVEN...... 168 ...... 68, 84, 110 PEDIALYTE...... 158 perindopril erbumine...... 66 phenytoin sodium extended...... 84 PEDIALYTE ADVANCED PERJETA...... 59 PHILITH...... 121 CARE...... 157 permethrin...... 141 PHILLIPS...... 157 PEDIALYTE FREEZER POPS157 perphenazine...... 92 PHILLIPS' COLON HEALTH.203 PEDIALYTE SINGLES...... 158 perphenazine-amitriptyline...... 88 PHLEXY-VITS...... 148 PEDIARIX (PF)...... 62, 64 PERRY PRENATAL...... 172 PHOSLYRA...... 205, 206 PEDIASURE HARVEST...... 148 PERSERIS...... 91 PHOS-NAK...... 158 PEDIASURE SIDEKICKS...... 148 PERTZYE...... 196

290 PHOSPHA 250 NEUTRAL POD-CARE 100CG...... 186 potassium iodide (bulk).... 110, 154 ...... 158, 207 POD-CARE 100K...... 187 potassium phos in 0.9 % nacl... 158 PHOSPHASAL...... 45, 208 POD-CARE 100KG...... 187 potassium phosph, mono (bulk) PHOSPHOLINE IODIDE...... 240 PODIAPN...... 147 ...... 110, 158 PHOSPHOROUS...... 158, 207 PODOCON...... 136 potassium phosphate m-/d-basic PHOSPHO-TRIN 250 podofilox...... 136 ...... 158 NEUTRAL...... 158, 207 POLIVY...... 50, 59 potassium sorbate (bulk)...... 111 PHOTOFRIN...... 56 POLYCIN...... 246 potassium, sodium phosphates..158 PHOTREXA CROSS- polyethylene glycol 1000(bulk) POTELIGEO...... 52 LINKING KIT...... 241 ...... 110, 114 PR BENZOYL PEROXIDE..... 125 PHYSIOLYTE...... 150 polyethylene glycol 1450(bulk) PR NATAL 400...... 172 PHYSIOSOL IRRIGATION.... 150 ...... 110, 118 PR NATAL 400 EC...... 172 phytonadione (vitamin k1)...... 178 polyethylene glycol 3350(bulk) PR NATAL 430...... 172 PICATO...... 129 ...... 110, 114 PR NATAL 430 EC...... 172 PIFELTRO...... 36 POLY-IRON...... 156 PRADAXA...... 215 PILLOW MASK CHILD..226, 233 POLY-IRON 150 FORTE...... 155 pralines and cream flavr(bulk) pilocarpine hcl...... 238, 240 polymyxin b sulf,micron.(bulk) ...... 111, 115 pilocarpine hcl (bulk) 110, 238, 240 ...... 46, 110 PRALUENT PEN...... 72 pimecrolimus...... 131 polymyxin b sulfate...... 259 pramipexole...... 90 pimozide...... 92 polymyxin b sulf-trimethoprim.246 PRAMOSONE...... 135 PIMTREA (28)...... 119 polysorbate 80...... 117 pramoxine hcl (bulk)...... 111 pindolol...... 73 POLYTRIM...... 246 PRANDIN...... 181 pineapple flavor (bulk)...... 110, 115 POLY-VI-FLOR...... 169 prasterone (dhea), micro(bulk) pioglitazone...... 190 POLY-VI-FLOR WITH IRON.169 ...... 11, 111 pioglitazone-glimepiride...... 182 POLYVITAMIN WITH IRON prasugrel...... 214 pioglitazone-metformin...... 182 (VIT K)...... 163 PRAVACHOL...... 70 piperacillin-tazobactam...... 46 POLY-VITAMINS...... 171 pravastatin...... 70 PIQRAY...... 56 POMALYST...... 57 PRAXBIND...... 30 PIRMELLA...... 121, 122 PORTIA 28...... 121 praziquantel...... 33 piroxicam...... 24 PORTRAZZA...... 60 prazosin...... 79 PLAQUENIL...... 21, 35 pot,sodium citrate-citric acid.... 207 PRE PROTEIN...... 145 PLASBUMIN 25 %...... 212 POTABA...... 178 PRECEDEX...... 103 PLASBUMIN 5 %...... 213 potassium acetate...... 158 PRECEDEX IN 0.9 % PLASMA-LYTE 148...... 158 potassium bicarbonate (bulk)....110 SODIUM CHLOR...... 103 PLASMA-LYTE A...... 158 potassium chlorid-d5-0.45%nacl PRECOSE...... 180 PLASMANATE...... 213 ...... 158 PRED FORTE...... 242 PLAVIX...... 214 potassium chloride...... 159 PRED MILD...... 242 PLEGRIDY...... 239 potassium chloride (bulk). 110, 159 PRED-G...... 241 PLENAMINE...... 168 potassium chloride in 0.9%nacl 158 PRED-G S.O.P...... 241 PLENVU...... 203 potassium chloride in 5 % dex..158 prednicarbate...... 134 PLEXION...... 124 potassium chloride in lr-d5...... 158 prednisol ace-gatiflox-bromfen.241 PLEXION CLEANSING potassium chloride in water...... 159 prednisoln sp-gatiflox-bromfen 241 CLOTHS...... 124 potassium chloride-0.45 % nacl 159 prednisolone...... 187 PNEUMOVAX-23...... 64 potassium chloride-d5-0.2%nacl prednisolone (bulk)...... 111, 187 PNV 29-1...... 172 ...... 159 prednisolone ac, micro (bulk) PNV-DHA...... 165, 172 potassium chloride-d5-0.3%nacl ...... 111, 187 PNV-FERROUS FUMARATE- ...... 159 prednisolone acetate...... 242 DOCU-FA...... 172 potassium chloride-d5-0.9%nacl prednisolone acetate (pf)...... 242 PNV-OMEGA...... 163, 172 ...... 159 prednisolone acetate-nepafenac 244 PNV-SELECT...... 172 potassium citrate...... 207 prednisolone acet-gatifloxacin..241 POCKET CHAMBER...... 226, 233 potassium citrate-citric acid...... 207 prednisolone sod ph-bromfenac 244 POD-CARE 100C...... 186 potassium gluconate...... 159

291 prednisolone sod phos (bulk) PRENATAL TABLET...... 172 PRIMEAIRE...... 226, 233 ...... 111, 187 PRENATAL VITAMIN...... 172 primidone...... 82 prednisolone sodium phosphate PRENATAL VITAMIN PLUS PRIMLEV...... 18, 19 ...... 187, 242 LOW IRON...... 172 PRIMSOL...... 33 prednisolone, micro (bulk)111, 187 PRENATAL VITAMIN WITH PRINIVIL...... 66 prednisolone-moxiflo-nepafenac MINERALS...... 172 PRISTIQ...... 87 ...... 241 prenatal vit-iron fum-folic ac....173 PRIVIGEN...... 63 prednisolone-moxifloxacin hcl. 241 prenatal vits96-iron fum-folic...173 PRO COMFORT SPACER- prednisone...... 187 PRENATAL-U...... 165, 173 ADULT MASK...... 226, 233 prednisone (bulk)...... 111, 187 PRENATE AM...... 165, 173 PRO COMFORT SPACER- PREDNISONE INTENSOL.....187 PRENATE CHEWABLE. 165, 173 CHILD MASK...... 226, 233 prednisone micronized (bulk) PRENATE DHA (FERR ASP PRO COMFORT TENS ...... 111, 187 GLYCIN)...... 173 ELECTRODE...... 224, 233 PREFEST...... 184 PRENATE ELITE (IRON ASP PRO COMFORT TENS UNIT pregabalin...... 83, 98 GLYC)...... 173 ...... 224, 233 PREGESTIMIL...... 149 PRENATE ENHANCE...... 173 PRO FE...... 156 PREGNYL...... 189 PRENATE PROAIR HFA...... 253 PREMARIN...... 185, 257 ESSENTIAL(IRON-ASP-GL) PROAIR RESPICLICK...... 253 PREMASOL 10 %...... 168 ...... 165, 173 probenecid...... 209 PREMIUM BABY DIAPERS PRENATE MINI (FERR ASP probenecid-colchicine...... 209 ...... 223, 233 GLYCIN)...... 173 PROBIOTIC COMPLEX PREMIUM COMFORT- PRENATE PIXIE...... 173 (WITH FOS)...... 203 STRETCH...... 223, 233 PRENATE RESTORE...... 173 PROBIOTIC-10 (WITH PREMIUM INFANT PRENATE STAR...... 173 INULIN)...... 203 FORMULA...... 149 PREPIDIL...... 178 PROBUPHINE...... 104 PREMIUM TRAINING PREPLUS...... 173 procainamide...... 68 PANTS...... 223, 233 PREPOPIK...... 204 procaine (bulk)...... 111 PREMPHASE...... 184 PRE-PROTEIN...... 166 PRO-CAL...... 152 PREMPRO...... 184 PRE-PROTEIN (WHEY)...... 166 PROCALAMINE 3%...... 167, 168 PRENA1 CHEW...... 172 PRESERA...... 132 PROCARDIA...... 74 PRENA1 PEARL...... 172 PRESTALIA...... 65 PROCARDIA XL...... 74 PRENA1 TRUE...... 172 PRETAB...... 173 PROCARE COMPRESSOR PRENATA...... 172 pretomanid...... 39 NEBULIZER...... 226, 233 PRENATABS FA...... 172 PREVACID...... 198 PROCEL...... 166 PRENATABS RX...... 172 PREVACID SOLUTAB...... 198 PROCEL 100...... 166 PRENATAL...... 172, 174 PREVAIL BRIEF YOUTH PROCEL SINGLES...... 166 PRENATAL + DHA...... 172 ...... 221, 233 PROCENTRA...... 98 PRENATAL 19...... 172 PREVALITE...... 69 PROCERV HP...... 163 PRENATAL COMPLETE...... 172 PREVIFEM...... 121 PROCHAMBER...... 226, 233 PRENATAL DAILY DUO...... 163 PREVNAR 13 (PF)...... 64 prochlorperazine...... 195 PRENATAL FORMULA...... 172 PREVYMIS...... 41 prochlorperazine edisylate...... 195 PRENATAL GUMMY...... 172 PREZCOBIX...... 37, 46 prochlorperazine maleate....92, 195 PRENATAL LOW IRON...... 172 PREZISTA...... 46 PROCORT...... 29 PRENATAL MULTI...... 172 PRIFTIN...... 39, 47 PROCRIT...... 210 PRENATAL MULTI-DHA PRIKAAN...... 137 PROCTOCORT...... 29, 134 (ALGAL OIL)...... 172 PRIKAAN LITE...... 137 PROCTOFOAM HC...... 29 PRENATAL prilocaine (bulk)...... 28, 111 PROCTO-MED HC...... 29, 134 MULTIVITAMINS...... 172 PRILOSEC...... 198 PROCTO-PAK...... 29, 134 PRENATAL ONE DAILY...... 172 PRILOVIX LITE...... 137 PROCTOSOL HC...... 29, 134 PRENATAL PLUS...... 172 PRILOVIX PLUS...... 137 PROCTOZONE-HC...... 29, 134 PRENATAL PLUS primaquine...... 35 PROCYSBI...... 205 (CALCIUM CARB)...... 172 PRIMAXIN IV...... 39 PRODIGEN...... 203

292 PRODIGY MINI-MIST PROTECT PLUS SO...... 163 QINLOCK...... 56 NEBULIZER...... 224, 233 protein...... 167 QNASL...... 255 PROFERRIN ES...... 156 PROTEINEX...... 167 QTERN...... 181 PROFERRIN-FORTE...... 155 PROTEINEX-18...... 167 QUADRACEL (PF)...... 64 progesterone...... 192 PROTHELIAL...... 238 QUALAQUIN...... 35 progesterone micronized...... 192 PROTONIX...... 198 QUARTETTE...... 121 PROGLYCEM...... 179 PROTOPIC...... 131 quazepam...... 95, 103 PROGRAF...... 216 protriptyline...... 89 QUDEXY XR...... 84 PROHANCE...... 142 PROTYL AG...... 141 QUESTRAN...... 69 PROLASTIN-C...... 255 PROVAD...... 203 QUESTRAN LIGHT...... 69 PROLENSA...... 243 PROVELLA...... 203 quetiapine...... 92, 97 PROLEUKIN...... 54 PROVENGE...... 53 QUFLORA...... 170 PROLIA...... 192 PROVENTIL HFA...... 253 QUFLORA FE (FERROUS PROMACTA...... 215 PROVERA...... 192 SULFATE)...... 170 promethazine...... 195, 249 PROVIDA OB...... 173 QUFLORA PEDIATRIC...... 170 promethazine (bulk)..111, 195, 249 PROVIGIL...... 101 QUFLORA PEDIATRIC PROMETHAZINE VC...... 248 PROVOCHOLINE...... 143 DROPS...... 170 PROMETHEGAN...... 195, 249 PROZAC...... 87 QUICK-SET PARADIGM PROMETRIUM...... 192 PRUCLAIR...... 132 ...... 228, 233 PROMISEB...... 130, 132 PRUDOXIN...... 140 QUILLICHEW ER...... 94 PROMOD PROTEIN...... 166 PRUMYX...... 132 QUILLIVANT XR...... 94 PRONEB ULTRA II...... 226, 233 pseudoephedrine hcl (bulk) QUIN B STRONG...... 146 PRONEB ULTRA II FILTER ...... 111, 256 quinacrine (bulk)...... 35, 111 ASSEM...... 226, 233 PSORCON...... 134 quinapril...... 66 PRONOURISH...... 166 PULMICORT...... 251 quinapril-hydrochlorothiazide.... 66 propafenone...... 68 PULMICORT FLEXHALER...251 quinidine gluconate...... 68 propantheline...... 199 PULMO-AIDE quinidine sulfate...... 68 proparacaine...... 244 COMPRESSOR...... 226, 233 quinidine sulfate (bulk)...... 68, 111 propofol...... 27 PULMONEB LT quinine sulfate...... 35 propranolol...... 73 COMPRESSOR NEBUL..227, 233 QUINTABS...... 165 propranolol-hydrochlorothiazid..79 PULMOSAL...... 116 QUINTABS-M...... 163 propylthiouracil...... 183 PULMOZYME...... 255 QUTENZA...... 140 PROQUAD (PF)...... 63, 65 PUMPKIN FLAVOR...... 111, 115 QUZYTTIR...... 249, 250 PRORENAL...... 146 PURAMINO JR...... 166 QVAR REDIHALER...... 251 PRORENAL QD...... 163 PURE L-CITRULLINE...... 145 RABAVERT (PF)...... 65 PROSCAR...... 206 PUREFE OB PLUS...... 163, 173 rabeprazole...... 198 PROSHIELD FOAM/SPRAY PUREFE PLUS...... 163, 173 racepineph-lidocaine-bss 7(pf). 241 CLEANSER...... 139 PUREVIT DUALFE PLUS...... 165 RADIAGEL...... 132 PROSIGHT...... 11 PURIXAN...... 51 RADIOGARDASE...... 30 PROSOL 20 %...... 168 PYLERA...... 204 RAGWITEK...... 61 PROSOURCE...... 167 pyrazinamide...... 39 raloxifene...... 192 PROSOURCE NO CARB...... 166 PYRIDIUM...... 207 ramelteon...... 99 PRO-STAT RENAL CARE..... 167 pyridostigmine bromide...... 218 ramipril...... 66 PRO-STAT SUGAR FREE...... 167 pyridostigmine bromide (bulk) RANEXA...... 68 PROSTATE CONTROL...... 12 ...... 111, 218 ranitidine hcl...... 197 PROSTEON...... 153 pyridoxine (bulk)...... 111, 176 ranolazine...... 68 PROSTIN E2...... 178 pyridoxine (vitamin b6)...... 176 RAPAFLO...... 206 PROSTIN VR PEDIATRIC...... 79 pyrilamine maleate (bulk).111, 249 RAPAMUNE...... 217 PROSYNMINIC...... 167 pyrimethamine (bulk)...... 35, 111 RAPIVAB (PF)...... 43 protamine...... 32 QBRELIS...... 66 rasagiline...... 90 PROTECT CARDIO AF...... 163 Q-CARE RX Q4...... 220 raspberry flavor (bulk)...... 111, 115 PROTECT IRON...... 163 Q-GEL MEGA...... 12 RASUVO (PF)...... 21

293 RAVICTI...... 236 RESOURCE THICKENUP...... 116 rivastigmine tartrate...... 118 RAYOS...... 187 RESTASIS...... 242 rizatriptan...... 100 RAZADYNE...... 118 RESTASIS MULTIDOSE...... 242 R-NATAL OB...... 173 RAZADYNE ER...... 118 RESTORA RX...... 178, 203 ROBAXIN...... 219 RCF SOY PROTEIN RESTORE...... 141, 221, 233 ROBAXIN-750...... 219 FORMULA BASE...... 149 RESTORE FOAM DRESSING ROCALTROL...... 177, 236 REBIF (WITH ALBUMIN)..... 239 SILVER...... 141 ROCKLATAN...... 245 REBIF REBIDOSE...... 239 RESTORIL...... 95, 103 rocuronium...... 218 REBIF TITRATION PACK..... 239 RETACRIT...... 210 root beer flavor (bulk)...... 111, 115 RECLAST...... 184 RETAVASE...... 215 ropinirole...... 90 RECLIPSEN (28)...... 121 RETIN-A...... 125 ropivacaine (pf)...... 28 RECOMBIVAX HB (PF)...... 62 RETIN-A MICRO...... 125 ropivacaine (pf)-nacl,iso-osm..... 28 RECTIV...... 29 RETIN-A MICRO PUMP...... 125 ropivacaine(pf)-0.9 % sodchlor.. 28 REFEX...... 12 RETINOIC ACID...... 111 ROSADAN...... 124, 139 REFISSA...... 138 RETISERT...... 242 ROSANIL...... 124 REGLAN...... 199 RETROVIR...... 37 ROSULA...... 124 REGONOL...... 218 REUSABLE NEBULIZER KIT ROSULA CLEANSING REGRANEX...... 141 ...... 227, 233 CLOTHS...... 124 RELADOR PAK...... 137 REVATIO...... 81 rosuvastatin...... 70 RELADOR PAK PLUS...... 137 REVEL PROGRAMMABLE ROTARIX...... 63, 65 RELAGARD...... 257 PUMP...... 227, 233 ROTATEQ VACCINE...... 63, 65 RELENZA DISKHALER...... 43 REVESTA...... 175, 177 ROWASA...... 201 RELEXXII...... 94 REVIA...... 32 ROWEEPRA...... 85 RELISTOR...... 31 REVLIMID...... 57 ROWEEPRA XR...... 85 RELPAX...... 100 REVONTO...... 220 ROXICODONE...... 16 REMEDY PHYTOPLEX REXULTI...... 93 ROZEREM...... 99 MOISTURIZER...... 132 REYATAZ...... 46, 47 ROZLYTREK...... 56 REMERON...... 86 R-GENE 10...... 143 RUBRACA...... 56 REMERON SOLTAB...... 86 RHOPRESSA...... 247 RUCONEST...... 210 REMICADE...... 20, 21, 202 RIDAURA...... 22 RUZURGI...... 240 REMODULIN...... 80 rifabutin...... 39, 47 RYANODEX...... 220 RENACIDIN...... 205 RIFADIN...... 39, 47 RYCLORA...... 248, 249 RENAGEL...... 206 RIFAMATE...... 39 RYDAPT...... 56 RENAL CAPS...... 146 rifampin...... 39, 47 RYNODERM...... 136 RENAL VITAMIN...... 146 rifampin (bulk)...... 47, 111 RYTARY...... 89 RENAPLEX...... 146 RIFATER...... 39 RYTHMOL SR...... 68 RENAPLEX-D...... 146 RILUTEK...... 217 SABRIL...... 84 RENA-VITE...... 146 riluzole...... 217 saccharin...... 150 RENA-VITE RX...... 147 rimantadine...... 43 SAF-CLENS AF DERMAL RENFLEXIS...... 20, 21, 202 ringer's...... 150, 174 WOUND...... 139 RENO CAPS...... 146 RIOMET...... 190 SAFYRAL...... 121 RENVELA...... 206 RISA-BID...... 203 SAIZEN...... 188, 204 repaglinide...... 181 RISACAL-D...... 153 SAIZEN SAIZENPREP...... 188 repaglinide-metformin...... 181 risedronate...... 184 SALAGEN (PILOCARPINE).. 239 REPATHA PUSHTRONEX...... 72 RISPERDAL...... 91, 97 SALEX...... 136 REPATHA SURECLICK...... 72 RISPERDAL CONSTA...... 91 salicylic acid...... 136 REPATHA SYRINGE...... 72 risperidone...... 91, 97 salicylic acid (bulk)...... 111, 136 REPLESTA NX...... 177 RITALIN...... 94, 102 salicylic acid er-ceramides...... 136 REPREXAIN...... 17, 18 RITALIN LA...... 94 SALIVAMAX...... 238 REQUIP...... 90 RITUXAN...... 22, 52 SALKERA...... 136 REQUIP XL...... 90 RITUXAN HYCELA...... 52 salsalate...... 26 resorcinol (bulk)...... 111 rivastigmine...... 118

294 SALTSTABLE LO CREAM SENIOR PROBIOTIC...... 203 SIMILAC FOR SPIT-UP...... 149 BASE...... 111, 114 SENNA...... 204 SIMILAC HUMAN MILK SALTSTABLE LS...... 111, 114 SENSIPAR...... 184 FORTIFIER...... 149 SALVAX...... 136 SEREVENT DISKUS...... 253 SIMILAC LAMEHADRIN...... 148 SALVAX DUO PLUS...... 136 SERNIVO...... 134 SIMILAC LOW-IRON...... 149 SAMI THE SEAL...... 227, 233 SEROQUEL...... 92, 97 SIMILAC NEOSURE...... 149 SAMI THE SEAL MASK 227, 233 SEROQUEL XR...... 92, 97 SIMILAC PM...... 149 SAMSCA...... 78, 194, 206 SEROSTIM...... 189 SIMILAC PRENATAL...... 173 SANADERMRX...... 135 sertraline...... 87 SIMILAC PRO-TOTAL CMFT SANCUSO...... 195 SE-TAN PLUS...... 165 NON-GMO...... 149 SANDIMMUNE...... 22, 216 SETLAKIN...... 121 SIMILAC SENSITIVE SANDOSTATIN...... 192, 204 sevelamer carbonate...... 206 ISOMIL SOY...... 149 SANDOSTATIN LAR DEPOT sevelamer hcl...... 206 SIMILAC SOY ISOMIL...... 149 ...... 192, 204 SEYSARA...... 48, 123 SIMILAC SPECIAL CARE 24 149 SANTYL...... 132 SFROWASA...... 201 SIMILAC TOTAL COMFORT149 SAPHRIS...... 90, 97 SHAROBEL...... 121 SIMILAC TOTAL COMFORT SARAFEM...... 87 SHINGRIX (PF)...... 65 NON-GMO...... 149 SAVAYSA...... 210 SHOHL'S MODIFIED...... 207 SIMLIYA (28)...... 119 SAVELLA...... 87, 98 SIDEROL...... 155 SIMPESSE...... 119 saw palmetto...... 12 SIDESTREAM...... 224, 233 simple syrup...... 117 SAW PALMETTO EXTRACT SIDESTREAM NEBULIZER SIMPLYTHICK...... 116 (W-ZINC)...... 12 ...... 224, 233 SIMPONI...... 20, 21, 202 saw palmetto fruit...... 12 SIGNIFOR...... 193 SIMPONI ARIA...... 20, 21 saw palmetto-pumpkin seed oil.. 12 SIKLOS...... 214, 215 SIMULECT...... 217 saw palmto frt xtr-zinc picoli...... 13 SILASTIC FOLEY simvastatin...... 70 SCALACORT...... 134 CATHETER...... 228, 233 SINEMET...... 89 SCALACORT DK...... 134 SILAZONE-II...... 134 SINGULAIR...... 251 SCANDONEST PLAIN..... 28, 237 sildenafil (pulm.hypertension)....81 SINOGRAFIN...... 141 SCARCARE...... 138, 227 SILENOR...... 103 SINUVA...... 254, 255 SCARCIN GEL...... 138 silicon,colloidal (bulk)...... 111 sirolimus...... 217 SCARCIN ROLL-ON...... 138 SILICONE MASK - INFANT SIRTURO...... 38 SCARCINPAD...... 227, 233 ...... 227, 233 SITAVIG...... 43 SCARSILK GEL...... 138 SILIKON...... 245 SIVEXTRO...... 45 SCOOBY-DOO ONE A DAY. 169 SILIPAC...... 138 SKELAXIN...... 219 SCOOBY-DOO ONE A DAY SILIQ...... 126 SKIN CLEANSER...... 139 KIDS...... 171 SILIVEX...... 227, 233 SKLICE...... 141 SEASONIQUE...... 119 silodosin...... 206 SKYLA...... 119 SECONAL SODIUM...... 102 SILTREX...... 227, 233 SKYRIZI...... 126 SECUADO...... 90 SILVADENE...... 131 SLEEP COMFORTS...... 221, 233 SEEBRI NEOHALER...... 252 silver nitrate...... 127 SLEEP OVERS PANTS...221, 233 SEGLUROMET...... 181 silver nitrate applicators...... 136 SLEEP PANTS...... 221, 223, 233 SELECT KIDS BRIEFS...223, 233 silver protein mild (bulk).... 61, 111 SLOW RELEASE IRON...... 156 SELECT-OB...... 173 silver sulfadiazine...... 131 SLYND...... 121 SELECT-OB + DHA...... 173 SIMBRINZA...... 241 SNAP INSULIN PUMP selegiline hcl...... 90 SIMILAC ADVANCE...... 149 CONTROLLER...... 223, 233 selenium...... 160 SIMILAC ADVANCE SNAP INSULIN PUMP- selenium sulfide...... 130 LAMEHADRIN...... 149 INFUSION SET...... 228, 233 SELRX...... 130 SIMILAC ADVANCE WITH sodium acetate...... 151 SELZENTRY...... 36 IRON...... 149 sodium benzoate (bulk).....111, 117 SEMPREX-D...... 248 SIMILAC EXPERT CARE...... 149 sodium bicarbonate...... 151 SE-NATAL 19 CHEWABLE...173 SIMILAC EXPERT CARE sodium bicarbonate in d5w...... 151 SE-NATAL-19...... 173 NEOSURE...... 149 sodium bisulfite (bulk)...... 113

295 sodium chlor 0.9% bacteriostat sorbitol...... 205 STEGLUJAN...... 181 ...... 150, 174 sorbitol-mannitol...... 205 STELARA...... 126, 201 sodium chloride...... 116, 150, 174 SORBOLENE...... 132 STENDRA...... 144 sodium chloride 0.45 %...... 174 SORIATANE...... 129 STERITALC...... 256 sodium chloride 0.9 %...... 150, 174 SORILUX...... 130 STEVIA...... 111, 150 sodium chloride 0.9 % (flush) SORINE...... 69, 73 STIOLTO RESPIMAT...... 253 ...... 150, 174 sotalol...... 69, 73 STIVARGA...... 55 sodium chloride 3 %...... 174 SOTALOL AF...... 69, 73 STRATTERA...... 94 sodium chloride 5 %...... 174 SOTRADECOL...... 81 strawberry flavor (bulk)....111, 115 sodium citrate...... 210 SOTYLIZE...... 69, 73 STRENSIQ...... 235 sodium citrate (bulk)...... 111, 210 SOY FORMULA...... 152 streptomycin...... 32 sodium citrate dihydrate(bulk) spearmint oil...... 115 STRESS B PLUS ZINC...... 146 ...... 111, 207 SPECTRACEF...... 41 STRESS B WITH ZINC...... 146 sodium citrate in 0.9 % nacl...... 210 SPECTRAGEL...... 141, 233 STRESS B-COMPLEX...... 163 sodium citrate-citric acid...... 207 SPECTRAVITE ULTRA MEN STRESS FORMULA146, 147, 155 SODIUM EDECRIN...... 77 50+...... 163 STRESS FORMULA 600 C.....146 sodium ferric gluconat-sucrose.156 SPECTRAVITE ULTRA STRESS FORMULA WITH sodium fluoride (bulk)...... 111, 237 MEN'S SR...... 163 IRON...... 146 sodium nitrite...... 30 spinosad...... 141 STRESS FORMULA WITH sodium nitroprusside...... 77 SPIRIVA RESPIMAT...... 252 IRON(SULF)...... 146 sodium phenylbutyrate...... 236 SPIRIVA WITH STRESS FORMULA WITH sodium phosphate...... 158 HANDIHALER...... 252 ZINC...... 146 sodium phosphate in 0.9 % nacl158 spironolactone...... 66, 77 STRIBILD...... 38 sodium phosphate in d5w...... 158 spironolacton-hydrochlorothiaz..78 STRIVERDI RESPIMAT...... 253 sodium polystyrene sulfonate... 150 SPORANOX...... 34 STROMECTOL...... 33 sodium saccharin (bulk)....111, 150 SPORANOX PULSEPAK...... 34 STRONG IODINE...... 61, 154 sodium succinate...... 113 SPRAVATO...... 86 strontium-89 chloride...... 57 sodium thiosulfate...... 30 SPRINTEC (28)...... 121 STROVITE FORTE...... 163 sodium thiosulfate (bulk)....30, 111 SPRITAM...... 85 STROVITE ONE...... 163 SOFT-GLIDE SAF-Q...... 227, 233 SPRIX...... 24 STUART ONE...... 173 SOLARAZE...... 129 SPRYCEL...... 57 SUBLOCADE...... 104 SOLESTA...... 227, 228 SPS (WITH SORBITOL)...... 150 SUBOXONE...... 104 solifenacin...... 208 squaric acid (bulk)...... 111, 137 SUBSOLV RDT...... 111, 118 SOLIQUA 100/33...... 183 squaric acid dibutylest.(bulk) SUBSYS...... 16 SOLIRIS...... 213 ...... 111, 137 SUBVENITE...... 85 SOLO...... 163 SQUARIC ACID IN SUBVENITE STARTER SOLODYN...... 48, 123 BUTANOL...... 61, 111 (BLUE) KIT...... 85, 96 SOLOSEC...... 36 SRONYX...... 121 SUBVENITE STARTER SOLOX GEL...... 127 SSD...... 131 (GREEN) KIT...... 85, 96 SOLTAMOX...... 57 SSKI...... 154 SUBVENITE STARTER SOLU-CORTEF...... 188 SSS 10-5...... 124, 127 (ORANGE) KIT...... 85, 96 SOLU-CORTEF ACT-O-VIAL STALEVO 100...... 89 succinylcholine-sod cl,iso(pf)...218 (PF)...... 188 STALEVO 125...... 89 SUCRAID...... 197 SOLU-MEDROL...... 188 STALEVO 150...... 89 sucralfate...... 204 SOLU-MEDROL (PF)...... 188 STALEVO 200...... 89 sucralfate (bulk)...... 111, 204 SOMA...... 219 STALEVO 50...... 89 sucrose (bulk)...... 111, 150 SOMATULINE DEPOT...... 193 STALEVO 75...... 89 sufentanil citrate...... 27 SOMAVERT...... 188 STARLIX...... 181 SUGARUP...... 179 SONAFINE...... 132 stavudine...... 37 SULAR...... 74 SOOLANTRA...... 139 STAXYN...... 144 sulfacetamide (bulk)...... 47, 111 SOOTHE AND COOL SKIN stearyl alcohol...... 118 CREAM...... 132 STEGLATRO...... 181

296 sulfacetamide sod, mono (bulk) suppository molds...... 224, 233 SYMLINPEN 60...... 182 ...... 47, 111 SUPPOSITORY SHELL, SYMPAZAN...... 83, 95 sulfacetamide sodium...... 130, 246 MEDIUM...... 224, 233 SYMPROIC...... 31 sulfacetamide sodium (acne).... 124 SUPPOSITORY SHELL, SYMTUZA...... 38 sulfacetamide sodium (bulk) SMALL...... 224, 233 SYNAGIS...... 62 ...... 47, 111 SUPPRELIN LA...... 191 SYNALAR...... 134 sulfacetamide sodium-sulfur SUPRAX...... 41 SYNALAR CREAM KIT...... 135 ...... 124, 127 SUPREME DIAPERS SIZE 1 SYNALAR OINTMENT KIT..135 sulfacetamide sod-sulfur-urea ...... 223, 233 SYNALAR TS...... 135 ...... 124, 139 SUPREME DIAPERS SIZE 2 SYNAREL...... 191 sulfacetamide-prednisolone...... 241 ...... 223, 233 SYNDROS...... 97, 145, 195 sulfacetamide-sulfur-cleansr23.124 SUPREME DIAPERS SIZE 3 SYNERA...... 140 SULFACLEANSE 8-4...... 124 ...... 223, 233 SYNERCID...... 47 sulfadiazine...... 47 SUPREME DIAPERS SIZE 4 SYNJARDY...... 181 sulfadiazine (bulk)...... 47, 111 ...... 223, 234 SYNJARDY XR...... 181 sulfadiazine sodium (bulk)..47, 111 SUPREME DIAPERS SIZE 5 SYNRIBO...... 58 sulfamethoxazole (bulk)..... 47, 112 ...... 223, 234 SYNTHAMIN 17 WITHOUT sulfamethoxazole-trimethoprim..33 SUPREME DIAPERS SIZE 6 ELYTE...... 168 SULFAMYLON...... 131 ...... 223, 234 SYNTHROID...... 193 sulfanilamide (bulk)...... 47, 112 SUPREP BOWEL PREP KIT.. 204 SYNVISC...... 218 sulfasalazine...... 23, 201 SURE RESULT DSS SYNVISC-ONE...... 218 SULFATRIM...... 33 PREMIUM PACK...... 137 SYPRINE...... 31 sulfisoxazole (bulk)...... 47, 112 SURE RESULT TAC PAK...... 135 syringe (reusable)...... 225, 234 sulindac...... 24 SURE-T INFUSION SET.225, 234 SYRPALTA VEHICLE...... 117 SUMADAN...... 124 SURE-T PARADIGM...... 228, 234 SYRSPEND SF ALKA...... 117 SUMADAN XLT...... 124, 139 SURFAXIN...... 255 SYRSPEND SF LIQUID...... 117 sumatriptan...... 100 SURGIFOAM...... 211 T.E.D. ANTI-EMBOLISM sumatriptan succinate...... 100 SURGUARD2 SAFETY.. 225, 234 STOCKING...... 220, 224, 234 sumatriptan-naproxen...... 101 SURVANTA...... 255 T.E.D. KNEE LENGTH-S- SUMAXIN...... 124 SUSPENDOL-S...... 117 REGULAR...... 220, 234 SUMAXIN CP...... 124 SUSTIVA...... 36 T:30 INFUSION SET...... 228, 234 SUMAXIN TS...... 124 SUSTOL...... 195 T:90 INFUSION SET 23" 228, 234 SUMMER'S EVE FEMININE SUTENT...... 57 T:FLEX INSULIN DELIVERY WASH...... 257 SUVICORT...... 140 PUMP...... 227, 234 SUNOSI...... 101 SWABFLUSH...... 150, 174 T:SLIM...... 224, 234 SUNVITE...... 163 SWEEN CREAM...... 132 T:SLIM G4...... 224, 234 SUPARTZ FX...... 218 SWEET OIL...... 112, 113, 115 T:SLIM X2 BASAL-IQ SUPER B COMPLEX- SWEETNESS ENHANCER INSULIN PMP...... 227, 234 VITAMIN C...... 146 FLAVOR...... 112, 115 TABLOID...... 51 SUPER B/C...... 146 SYEDA...... 121 TACLONEX...... 126 SUPER DAILY D3...... 177 SYLVANT...... 54 tacrolimus...... 131, 216 SUPER GINSENG SYMAX DUOTAB...... 199, 208 tadalafil...... 81, 144, 206 MULTIVITAMIN...... 163 SYMAX FASTABS...... 199, 208 tadalafil (pulm. hypertension).....81 SUPER MULTIPLE...... 163 SYMAX-SL...... 199, 208 TAFINLAR...... 52 SUPER MULTIPLE - LOW SYMAX-SR...... 199, 208 TAGRISSO...... 49 IRON...... 163 SYMBICORT...... 254 TAKHZYRO...... 80 SUPER QUINTS...... 147 SYMBYAX...... 88, 92, 97 talc (bulk)...... 112, 138 SUPER QUINTS B-50...... 147 SYMDEKO...... 254 TALIVA...... 148 SUPERSOFT...... 132 SYMFI...... 38 TALTZ AUTOINJECTOR...... 126 SUPERVITE...... 147 SYMFI LO...... 38 TALTZ AUTOINJECTOR (2 SUPPORT-500...... 147 SYMJEPI...... 75 PACK)...... 126 SUPPOSISTRIP...... 224, 233 SYMLINPEN 120...... 182

297 TALTZ AUTOINJECTOR (3 teniposide...... 53 THERANATAL ONE...... 173 PACK)...... 126 TENIVAC (PF)...... 64 THERANATAL OVAVITE.....173 TALTZ SYRINGE...... 126 tenofovir disoproxil fumarate..... 37 THERANATAL PLUS...... 173 TALZENNA...... 56 TENORETIC 100...... 75 THERAPEUTIC-M TAMIFLU...... 43 TENORETIC 50...... 75 VITAMIN/MINERALS...... 163 tamoxifen...... 57 TENORMIN...... 73 thiabendazole (bulk)...... 33, 112 tamoxifen (bulk)...... 57, 112 TEPADINA...... 49 thiamine hcl (vitamin b1)...... 175 tamsulosin...... 206 terazosin...... 80 THICK NOW...... 116 TANDEM DUAL ACTION..... 156 terbinafine (bulk)...... 33, 112 THICKEN UP CLEAR...... 116 TANDEM PLUS...... 165 terbinafine hcl...... 33 THICK-IT #2...... 116 tangerine oil (bulk)....112, 113, 115 terbutaline...... 253 THIOLA...... 205 TANGERINE OIL, NATURAL terbutaline sulfate (bulk)...... 112 THIOLA EC...... 205 ...... 112, 113, 115 terconazole...... 256 thioridazine...... 92 TAPAZOLE...... 183 teriparatide...... 183 thiotepa...... 49 TAPERDEX...... 188 TERSI FOAM...... 130 thiothixene...... 92 TARCEVA...... 49 TESTIM...... 180 THRIVITE RX...... 173 TARGRETIN...... 57, 129 TESTONE CIK...... 180 THROMBATE III...... 213 TARINA 24 FE...... 121 TESTOPEL...... 180 THYMOGLOBULIN...... 63 TARINA FE 1/20 (28)...... 121 testosterone...... 180 thymus gland,calf (bulk).....13, 112 TARINA FE 1-20 EQ (28)...... 121 testosterone (bulk)...... 112, 180 THYROGEN...... 143 TARKA...... 65 testosterone cypionate...... 180 thyroid (pork)...... 193 TARON FORTE...... 155 testosterone cypionate (bulk) thyroid, pork (bulk)...... 112, 193 TARON-C DHA...... 163, 173 ...... 112, 180 THYROLAR-1...... 193 TART CHERRY...... 148 testosterone enanthate...... 180 THYROLAR-1/2...... 193 TASIGNA...... 57 testosterone propionate (bulk) THYROLAR-1/4...... 193 TASMAR...... 89 ...... 112, 180 THYROLAR-2...... 193 TAVALISSE...... 210 TESTRED...... 180 THYROLAR-3...... 193 TAXOTERE...... 57 tetanus,diphtheria tox ped(pf).....64 TIADYLT ER...... 73 tazarotene...... 130, 138 tetrabenazine...... 101 tiagabine...... 84 TAZICEF...... 41 tetracaine hcl...... 244 TIAZAC...... 73 TAZORAC...... 130 tetracaine hcl (pf)...... 244 TIBSOVO...... 55 TDVAX...... 64 tetracycline...... 48 TICANASE...... 255 teaberry oil flavor (bulk)...112, 115 tetracycline hcl (bulk)...... 48, 112 TICE BCG...... 55, 63 TEARS AGAIN HYDRATE...... 13 tetrahydrocurcumin (bulk).. 11, 112 TIGAN...... 195 TECENTRIQ...... 59 TEXACORT...... 134 tigecycline...... 42, 48 TECFIDERA...... 239 thallous chloride tl-201...... 143 TIGLUTIK...... 217 TECNU...... 140 THALOMID...... 35, 57 TIKOSYN...... 69 TEFLARO...... 41 THAM...... 151 TILIA FE...... 122 TEGRETOL...... 84, 96 THEO-24...... 252 timol-brimon-dorzo-latanop(pf)241 TEGRETOL XR...... 84, 96 THEOCHRON...... 252 timolol maleate...... 73, 244 TEGSEDI...... 179 theophylline...... 252 timolol-brimonidi-dorzolam(pf)243 TEKTURNA...... 81 theophylline (bulk)...... 112, 252 timolol-dorzolamid-latanop(pf) 243 TEKTURNA HCT...... 81 theophylline in dextrose 5 %.... 252 timolol-latanoprost(pf)...... 243 telmisartan...... 67 THERA BATH...... 132 TIMOPTIC...... 244 telmisartan-amlodipine...... 66 THERACAL D2000...... 153 TIMOPTIC OCUDOSE (PF)... 244 telmisartan-hydrochlorothiazid...67 THERACAL D4000...... 153 TIMOPTIC-XE...... 244 temazepam...... 95, 103 THERA-D...... 177 tinidazole...... 36 TEMODAR...... 50 THERA-D 4000...... 177 tinidazole (bulk)...... 36, 112 TEMOVATE...... 134 THERAGRAN-M PREMIER TIROSINT...... 193 temozolomide...... 50 50 PLUS...... 163 TIROSINT-SOL...... 193 TENCON...... 19 THERANATAL...... 163, 173 TIS-U-SOL PENTALYTE...... 150 TENDERA-OB...... 173 THERANATAL COMPLETE. 173 TIVICAY...... 36

298 TIVORBEX...... 26 TRAINING PANTS 4T-5T triamterene-hydrochlorothiazid.. 78 tizanidine...... 219 ...... 223, 234 TRIANEX...... 134 TNKASE...... 215 tramadol...... 16 triazolam...... 96, 103 TOBAKIENT...... 165 tramadol-acetaminophen...... 19 TRIBENZOR...... 67 TOBI...... 254 trandolapril...... 66 TRICARE...... 173 TOBI PODHALER...... 254 trandolapril-verapamil...... 65 TRICITRATES...... 207 TOBRADEX...... 241 tranexamic acid...... 211 TRICON...... 155 TOBRADEX ST...... 241 tranexamic acid (bulk)...... 112, 211 TRICOR...... 70 tobramycin...... 246 tranexamic acid in nacl,iso-os...211 TRIDERM...... 134 tobramycin (bulk)...... 32, 112 TRANSDERM-SCOP...... 194 trientine...... 31 tobramycin in 0.225 % nacl...... 254 TRANXENE T-TAB...... 82, 95 TRIESENCE (PF)...... 242 tobramycin in 0.9 % nacl...... 32 tranylcypromine...... 86 TRI-ESTARYLLA...... 122 tobramycin sulfate...... 32 TRAVASOL 10 %...... 168 trifluoperazine...... 92 tobramycin sulfate (bulk)....32, 112 TRAVATAN Z...... 247 trifluridine...... 247 tobramycin-dexamethasone...... 241 trazodone...... 87 TRIGELS-F FORTE...... 155 TOBREX...... 246 TREANDA...... 50 TRIGLIDE...... 70 TOLAK...... 129 TRECATOR...... 39 trihexyphenidyl...... 89 tolcapone...... 89 TRELEGY ELLIPTA...... 254 TRIKAFTA...... 254 tolmetin...... 24 TREMFYA...... 126 TRI-LEGEST FE...... 122 TOLSURA...... 34 treprostinil sodium...... 80 TRILEPTAL...... 84 tolterodine...... 209 TRESIBA FLEXTOUCH U- TRI-LINYAH...... 122 TOPAMAX...... 84 100...... 190 TRILIPIX...... 70 TOPI-CLICK FILLING TRESIBA FLEXTOUCH U- TRI-LO-ESTARYLLA...... 122 NOZZLE...... 225, 234 200...... 190 TRI-LO-MARZIA...... 122 TOPICORT...... 134 TRESIBA U-100 INSULIN...... 190 TRI-LO-MILI...... 122 topiramate...... 84, 85 tretinoin...... 125 TRI-LO-SPRINTEC...... 122 TOPOSAR...... 53 tretinoin (antineoplastic)...... 57 TRILYTE WITH FLAVOR topotecan...... 57 tretinoin (bulk)...... 112 PACKETS...... 204 TOPROL XL...... 73 tretinoin (emollient)...... 138 trimethobenzamide...... 195 TOPROPHAN...... 12, 99 tretinoin microspheres...... 125 trimethoprim...... 33 toremifene...... 57 TRETIN-X...... 125 trimethoprim (bulk)...... 33, 112 TORISEL...... 55 TRETIN-X CREAM KIT...... 125 trimethoprim, micro (bulk). 33, 112 torsemide...... 77 TREXALL...... 21, 50 TRI-MILI...... 122 TOUCH-TROL...... 228, 234 TREXIMET...... 101 trimipramine...... 89 TOUJEO MAX U-300 TREZIX...... 16, 17 TRIMO-SAN JELLY...... 257 SOLOSTAR...... 190 triacetin...... 128 TRINATAL RX 1...... 173 TOUJEO SOLOSTAR U-300 TRIADVANCE...... 173 TRINATE...... 173 INSULIN...... 190 triamcin diacet, micro (bulk).... 112 TRINTELLIX...... 88 TOVIAZ...... 209 triamcinol ac (pf) in 0.9%nacl.. 188 TRIOSTAT...... 193 TPN ELECTROLYTES...... 158 triamcinol ace-bupiv-0.9% nacl 186 TRIPHROCAPS...... 147 TPN ELECTROLYTES II...... 158 triamcinolone (bulk)...... 112, 188 TRI-PREVIFEM (28)...... 122 TRACE ELEMENTS triamcinolone aceton-0.9% nacl188 TRIPTODUR...... 191 4/PEDIATRIC...... 160 triamcinolone acetonide TRISENOX...... 51 TRACLEER...... 81 ...... 134, 188, 238 TRI-SPRINTEC (28)...... 122 TRADJENTA...... 180 triamcinolone acetonide (bulk) TRISTART DHA...... 173 tragacanth...... 118 ...... 112, 188 TRIUMEQ...... 38 TRAINING PANTS 2T-3T triamcinolone dia(pf)-0.9%nacl 188 TRIVEEN-DUO DHA...... 173 ...... 223, 234 triamcinolone diacet-0.9% nacl 188 TRI-VI-FLOR...... 170 TRAINING PANTS 3T-4T triamcinolone diacetate (bulk) TRIVISC...... 218 ...... 223, 234 ...... 112, 188 TRI-VITAMIN WITH triamcinolon-moxiflox-watr(pf)241 FLUORIDE...... 170 triamterene (bulk)...... 78, 112 TRI-VITE WITH FLUORIDE. 170

299 TRIVORA (28)...... 122 TYVASO STARTER KIT...... 80 URIMAR-T...... 45, 208 TRI-VYLIBRA...... 122 TYZINE...... 256 URIN DS...... 45, 208 TRI-VYLIBRA LO...... 122 U-BASE...... 112, 114 UROCIT-K 10...... 207 TRIZIVIR...... 38 UBRELVY...... 99 UROCIT-K 15...... 207 TROCHIBASE...... 112, 118 UCERIS...... 201 UROCIT-K 5...... 207 TROCHIBASE S CLASSIC UDAMIN SP...... 163 UROGESIC-BLUE...... 45, 208 ...... 112, 118 UDENYCA...... 210 URO-MP...... 45, 208 TROGARZO...... 36 ULESFIA...... 141 UROQID-ACID NO.2...... 45, 207 TROKENDI XR...... 85 ULORIC...... 209 UROXATRAL...... 206 TROMBONEX...... 147 ULTICARE...... 225, 234 URSO 250...... 197 TRONVITE...... 147 ULTIMATE FLORA URSO FORTE...... 197 TROPHAMINE 10 %...... 168 PROBIOTIC...... 203 ursodiol...... 197 tropical punch flavor (bulk) ULTIMATE MEN'S ursodiol (bulk)...... 112, 197 ...... 112, 115 COMPLETE 50+...... 163 URYL...... 45, 208 tropicamide...... 242 ULTIMATE WOMEN'S USTELL...... 45, 208 trospium...... 209 COMPLETE 50+...... 163 UTIBRON NEOHALER...... 253 TRUEPLUS DIABETIC ULTIVA...... 27 UTIRA-C...... 45, 208 MULTIVITAMIN...... 163 ULTOMIRIS...... 213 UTOPIC...... 137 TRULANCE...... 196, 200 ULTRA DAIRY DIGESTIVE..197 UVADEX...... 56 TRULICITY...... 182 ULTRA FREEDA...... 163 VABOMERE...... 39 TRUMENBA...... 64 ULTRA MIDE 25...... 132 VAGIFEM...... 257 TRUSOPT...... 244 ULTRACET...... 19 VAGISIL...... 138 TRUVADA...... 37 ULTRAM...... 16 valacyclovir...... 43 tryptophan...... 12 ULTRAM ER...... 16 VALCHLOR...... 129 TUBERCULIN SYRINGE ULTRASAL-ER...... 136 VALCYTE...... 41 ...... 225, 234 ULTRAVATE...... 130, 134 valganciclovir...... 41 TUDORZA PRESSAIR...... 252 UMECTA...... 136 VALINE AMINO ACID TUGABOOS OVERNIGHTS UNASYN...... 32 SUPPLEMENT...... 145 ...... 221, 234 UNDERJAMS L-XL...... 221, 234 VALINEX...... 13 TUGABOOS TRAINING UNDERJAMS SMALL- VALIUM...... 82, 96 PANTS...... 223, 234 MEDIUM...... 221, 234 valproate sodium...... 83 TULANA...... 121 UNGUATOR LID...... 224, 234 valproic acid...... 83, 96 TURALIO...... 57 UNITHROID...... 194 valproic acid (as sodium salt)83, 96 TURKEY-SWEET UNITUXIN...... 50 valrubicin...... 58 POTATOES-PEACHES...... 148 UNIVERSAL SLEEVE....225, 234 valsartan...... 67 turmeric...... 13 UNSCENTED COLD CREAM132 valsartan-hydrochlorothiazide.... 67 turmeric-turmeric ext-pepper...... 13 UPCAL D...... 153 VALSTAR...... 58 tutti-frutti flavor (bulk)..... 112, 115 UPTRAVI...... 79 VALTOCO...... 83, 96 TWINRIX (PF)...... 62 URAMAXIN...... 136 VALTREX...... 43 TWYNSTA...... 66 URAMAXIN GT...... 136 VANATOL LQ...... 19 TYBOST...... 237 urea...... 132, 137 VANCOCIN...... 42 TYDEMY...... 121 urea (bulk)...... 112, 136 vancomycin...... 42 TYGACIL...... 42, 48 UREA NAIL STICK...... 136 vancomycin hcl in water...... 42 TYKERB...... 48 UREACIN-10...... 132 vancomycin in 0.9 % sodium TYMLOS...... 183 UREACIN-20...... 132 chl...... 42 TYR LOPHLEX GMP MIX-IN167 URECHOLINE...... 209 vancomycin in dextrose 5 %...... 42 tyrosine...... 145 UREDEB...... 132 vancomycin-water inject (peg)... 42 TYSABRI...... 239 URE-K...... 137 VANDAZOLE...... 256 TYVASO...... 80 URELLE...... 45, 208 VANIBASE...... 112, 132 TYVASO INSTITUTIONAL URETRON D-S...... 45, 208 VANIBASE TRADITIONAL START KIT...... 80 UREVAZ...... 137 FORMULA...... 112, 114 TYVASO REFILL KIT...... 80 URIBEL...... 45, 208

300 VANILLA BUTTERNUT verapamil (bulk)...... 74, 112 VIRAMUNE XR...... 37 FLAVOR...... 112, 115 VERDESO...... 134 VIRASAL...... 137 vanilla butternut flavor(bulk) VERDROCET...... 17, 18 VIREAD...... 37 ...... 112, 115 VEREGEN...... 135 VIRT-C DHA...... 163, 173 vanilla extract flavor (bulk) VERELAN...... 74 VIRT-CAPS...... 147 ...... 112, 115 VERELAN PM...... 74 VIRT-GARD...... 175, 178 VANIQA...... 138 VERIPRED 20...... 188 VIRT-NATE DHA...... 173 VANISHING CREAM.....112, 132 VERSA FREE...... 117 VIRT-PHOS 250 NEUTRAL VANISH-PEN CREAM BASE VERSA PLUS...... 117 ...... 158, 207 ...... 112, 114 VERSACLOZ...... 91 VIRT-PN DHA...... 165, 173 VANOS...... 134 VERSATILE...... 112, 114 VIRT-PN PLUS...... 163, 173 VANOXIDE-HC...... 125 VERZENIO...... 52 VIRTRATE-2...... 207 VANTAS...... 54 VESICARE...... 208 VIRTRATE-3...... 207 VAPRISOL IN 5 % VFEND...... 34 VIRTRATE-K...... 207 DEXTROSE...... 77 VFEND IV...... 34 VIRT-VITE...... 175, 178 VAPRO PLUS INTERMITT V-GO 20...... 227, 234 VIRT-VITE PLUS...... 147 CATHETER...... 234 V-GO 30...... 227, 234 VISCO-3...... 218 VAQTA (PF)...... 62 V-GO 40...... 227, 234 VISCOAT...... 245 vardenafil...... 144 VIACTIV...... 152 VISIPAQUE...... 142 VARITHENA...... 81 VIAGRA...... 144 VISTARIL...... 81 VARIVAX (PF)...... 63, 65 VIBATIV...... 44 VISTOGARD...... 60 VARUBI...... 196 VIBERZI...... 200, 203 VISUDYNE...... 245 VASCEPA...... 71 VIBRAMYCIN...... 48 VIT 3...... 165 VASERETIC...... 66 VIC-FORTE...... 163 vit a and d3 in cod liver oil...... 175 VASHE WOUND THERAPY. 141 VICODIN HP...... 17, 18 VITABEX PLUS...... 163 VASOFLEX FORTE...... 147 VICTOZA 2-PAK...... 182 VITAFOL...... 155 vasopressin in 0.9 % sod chlor..180 VICTOZA 3-PAK...... 182 VITAFOL GUMMIES...... 173 VASOSTRICT...... 180 VIDAZA...... 51 VITAFOL NANO...... 173 VASOTEC...... 66 VIENVA...... 121 VITAFOL ULTRA...... 173 VB7 MAX...... 177 vigabatrin...... 84 VITAFOL-OB...... 173 V-C FORTE...... 163 VIGADRONE...... 84 VITAFOL-OB+DHA...... 173 VECAMYL...... 78 VIGAMOX...... 246 VITAFOL-ONE...... 173 VECTIBIX...... 60 VIIBRYD...... 88 VITAL-D RX...... 163, 177 VECTICAL...... 130 VIMIZIM...... 235 VITALETS...... 169 vecuronium bromide...... 218 VIMOVO...... 23 VITAMED MD ONE RX...... 173 VELCADE...... 56 VIMPAT...... 83 VITAMEDMD REDICHEW VELETRI...... 80 VINACAL B...... 173 RX...... 173 VELIVET TRIPHASIC VINATE CARE...... 165, 173 vitamin a...... 175 REGIMEN (28)...... 122 VINATE DHA RF...... 165, 173 VITAMIN B-1...... 176 VELPHORO...... 205, 206 VINATE II...... 173 VITAMIN B-1 VELTASSA...... 150 VINATE M...... 173 (MONONITRATE)...... 176 VELTIN...... 125 VINATE ONE...... 173 VITAMIN B-12...... 176 VEMLIDY...... 43 VINATE ULTRA...... 173 VITAMIN B-2...... 176 VENCLEXTA...... 52 vinblastine...... 58 VITAMIN B-6...... 176 VENCLEXTA STARTING vincristine...... 58 VITAMIN C FIZZY DRINK... 175 PACK...... 52 vinorelbine...... 58 VITAMIN D3...... 178 VENELEX...... 141 VIOKACE...... 196 VITAMIN D-3 WITH ALOE...163 venlafaxine...... 87, 88 VIORELE (28)...... 119 vitamin e...... 71, 178 VENOFER...... 156 VIOS AEROSOL DELIVERY vitamin e-safflower oil...... 132 VENTAVIS...... 80 SYSTEM...... 227, 234 VITAMIN K...... 178 VENTOLIN HFA...... 253 VIRACEPT...... 47 VITAMIN K1...... 178 verapamil...... 69, 74 VIRAMUNE...... 37 vitamin k2...... 178

301 vitamins a and d...... 165 VYVANSE...... 94 XADAGO...... 90 VITAMINS A,C,D AND VYZULTA...... 247 XALATAN...... 247 FLUORIDE...... 170 WAKIX...... 101 XALKORI...... 50 VITAMINS A-D-E warfarin...... 210 XANAX...... 82, 96 SELENIUM...... 163 water for inject, bacteriostat...... 150 XANAX XR...... 82, 96 VITAMINS B COMPLEX...... 147 water for injection, sterile. 150, 175 XAQUIL XR...... 178 VITAMINS FOR HAIR... 147, 165 water for irrigation, sterile...... 150 XARELTO...... 210 VITAMN E BEAUTY WITH watermelon flavor (bulk).. 112, 115 XARELTO DVT-PE TREAT SAFFLOWER...... 132 WEE CARE...... 156 30D START...... 210 VITAPEARL...... 173 WELCHOL...... 69 XATMEP...... 21, 50 VITA-RAY...... 132 WELL BEGINNINGS SLEEP XCLAIR...... 132 VITA-RESPA...... 175, 178 PANTS...... 222, 223, 234 XCOPRI...... 86 VITASURE...... 147 WELLBUTRIN SR...... 88 XCOPRI TITRATION PACK....86 VITATRUE...... 173 WELLBUTRIN XL...... 88 XELITRAL...... 137 VITRAKVI...... 58 WERA (28)...... 121 XELJANZ...... 23, 201 VITRASE...... 194 WESTAB ONE...... 175, 178 XELJANZ XR...... 23, 201 VITRON-C...... 155 WESTHROID...... 193 XELODA...... 51 VITRUM SENIOR...... 163 white petrolatum (bulk).... 112, 114 XELPROS...... 247 VIVA DHA...... 173 WHYTEDERM TDPAK...... 135 XENAZINE...... 101 VIVACAINE...... 237 WHYTEDERM TRILASIL XEPI...... 127 VIVELLE-DOT...... 185 PAK...... 135 XERAVA...... 42, 48 VIVITROL...... 104 WIDE-SEAL DIAPHRAGM 60 XERESE...... 130 VIVLODEX...... 24 ...... 220, 234 XEROFORM...... 221, 234 VIZIMPRO...... 49 WIDE-SEAL DIAPHRAGM 65 XEROFORM PETROLATUM VOGELXO...... 180 ...... 220, 234 DRESSING...... 221, 235 VOLTAREN...... 138 WIDE-SEAL DIAPHRAGM 70 XEROFORM PETROLATUM VOLTAREN-XR...... 25 ...... 221, 234 OVERWRAP...... 221, 235 VORAXAZE...... 60, 61 WIDE-SEAL DIAPHRAGM 75 XEROSTOMIA RELIEF...... 238 voriconazole...... 34 ...... 221, 234 XGEVA...... 192 VORTEX HOLDING WIDE-SEAL DIAPHRAGM 80 XIAFLEX...... 218 CHAMBER...... 227, 234 ...... 221, 234 XIFAXAN...... 47 VORTEX VHC FROG MASK- WIDE-SEAL DIAPHRAGM 85 XIGDUO XR...... 181 CHILD...... 227, 234 ...... 221, 234 XIIDRA...... 242, 243 VORTEX VHC LADYBUG wild cherry flavor (bulk)...112, 115 XLEU ANALOG...... 149, 165 MASK-TODDLR...... 227, 234 WINRHO SDF...... 63 XLYS- XTRP ANALOG..150, 165 VOTRIENT...... 57 WINTERGREEN OIL...... 140 XMET ANALOG...... 150, 166 VP-CH PLUS...... 173 WIXELA INHUB...... 254 XMTVI ANALOG...... 150, 166 VP-CH-PNV...... 173 WOMEN'S 50 PLUS XOFIGO...... 57 VP-PNV-DHA...... 174 MULTIVITAMIN...... 163 XOFLUZA...... 43 VPRIV...... 235 WOMEN'S DAILY CAPLET.. 163 XOLAIR...... 251 VP-VITE RX...... 147 WOMEN'S DAILY XOLEGEL...... 128 VRAYLAR...... 93, 97 FORMULA...... 165 XOPENEX...... 253 VSL#3 DS...... 203 WOMENS DAILY GUMMIES164 XOPENEX CONCENTRATE. 253 VUMERITY...... 240 WOMEN'S DAILY PACK...... 164 XOPENEX HFA...... 253 VUSION...... 128 WOMEN'S MULTIVITAMIN.164 XOSPATA...... 53 VYFEMLA (28)...... 121 WOMEN'S MULTIVITAMIN XPHE MAXAMUM...... 166 VYLIBRA...... 121 GUMMIES...... 164 XPHE, XTYR ANALOG. 150, 167 VYNDAQEL...... 179 WOMEN'S ONE DAILY...... 165 XPTM ANALOG...... 150, 167 VYTORIN 10-10...... 72 WONDERPANTS...... 223, 234 XRYLIX (DICLOFENAC- VYTORIN 10-20...... 72 WP THYROID...... 193 KINES TAPE)...... 138 VYTORIN 10-40...... 72 WPR PLUS...... 137 XTAMPZA ER...... 16 VYTORIN 10-80...... 72 WYMZYA FE...... 121 XTANDI...... 50

302 XULANE...... 122 ZETIA...... 71 ZOSTAVAX (PF)...... 63, 65 XULTOPHY 100/3.6...... 183 ZETONNA...... 255 ZOSYN IN DEXTROSE (ISO- XURIDEN...... 236 ZEVALIN (Y-90)...... 55 OSM)...... 46 XVITE...... 147 ZIAC...... 75 ZOVIA 1/35E (28)...... 121 XYLIMELTS...... 239 ZIAGEN...... 37 ZOVIRAX...... 43, 130 XYLOCAINE...... 28 ZIANA...... 125 ZTLIDO...... 140 XYLOCAINE (CARDIAC) zidovudine...... 37 ZUBSOLV...... 104 (PF)...... 68 ZIEXTENZO...... 211 ZULRESSO...... 86 XYLOCAINE WITH zileuton...... 250 ZUMANDIMINE (28)...... 121 EPINEPHRINE...... 29 ZILRETTA...... 188 ZUPLENZ...... 195 XYLOCAINE-MPF...... 28 zinc chloride...... 160 ZYCLARA...... 135 XYLON 10...... 17, 18 zinc gluconate...... 160 ZYDELIG...... 56 XYOSTED...... 180 zinc oxide...... 138 ZYFLO...... 250 XYREM...... 101 zinc sulfate...... 160 ZYKADIA...... 50 XYZBAC...... 165 ZINC-15...... 160 ZYLET...... 241 YASMIN (28)...... 121 ZINGIBER...... 174, 175 ZYLOPRIM...... 209 YAZ (28)...... 121 ZINGO...... 28 ZYMAXID...... 246 YERVOY...... 53 ZIOPTAN (PF)...... 247 ZYPITAMAG...... 70 YONDELIS...... 58 ziprasidone hcl...... 91, 97 ZYPREXA...... 92, 97 YONSA...... 48, 50 ziprasidone mesylate...... 91, 97 ZYPREXA RELPREVV...... 92 YUPELRI...... 252 ZIPSOR...... 25 ZYPREXA ZYDIS...... 93, 97 YUTIQ...... 242 ZIRABEV...... 48 ZYTIGA...... 48, 50 YUVAFEM...... 257 ZIRGAN...... 247 ZYVOX...... 45 zafirlukast...... 251 ZITHRANOL...... 130 zaleplon...... 103 ZITHROMAX...... 44 ZALTRAP...... 59 ZITHROMAX TRI-PAK...... 44 ZANAFLEX...... 219 ZITHROMAX Z-PAK...... 44 ZANOSAR...... 58 ZN-DTPA...... 31 ZARAH...... 121 ZOCOR...... 70 ZARONTIN...... 86 ZOFRAN...... 195 ZARXIO...... 210 ZOHYDRO ER...... 16 ZATEAN-PN DHA...... 165, 174 ZOLADEX...... 54 ZATEAN-PN PLUS...... 164, 174 zoledronic acid...... 184 ZAVARA...... 175, 178 zoledronic acid-mannitol-water 184 ZAVESCA...... 236 zoledronic ac-mannitol-0.9nacl 184 ZEBUTAL...... 19 ZOLINZA...... 53 ZEGERID...... 198 zolmitriptan...... 100 ZEJULA...... 56 ZOLOFT...... 87 ZELAC...... 203 zolpidem...... 103 ZELAPAR...... 90 ZOLPIMIST...... 103 ZELBORAF...... 52 ZOMACTON...... 189 ZEMAIRA...... 255 ZOMIG...... 100 ZEMBRACE SYMTOUCH..... 100 ZOMIG ZMT...... 100 ZEMDRI...... 32, 207 ZONALON...... 140 ZEMPLAR...... 236 ZONEGRAN...... 86 ZENATANE...... 123 zonisamide...... 86 ZENPEP...... 197 ZONTIVITY...... 214 ZENZEDI...... 94, 98, 102 ZOO CHEWS...... 171 ZERBAXA...... 40 ZOO FRIENDS...... 171 ZERIT...... 37 ZORBTIVE...... 189, 204 ZESTORETIC...... 66 ZORTRESS...... 217 ZESTRIL...... 66 ZORVOLEX...... 25

303