This Document Contains Information About the Drugs Covered Under Your Pharmacy Benefit Plan

Please read: This document contains information about the drugs covered under your pharmacy benefit plan.

For a complete list of covered drugs or if you have questions:

Call the toll-free member phone number on the back of your ID card.

• Locate a participating retail pharmacy by zip code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

Version 2 OptumRx Last updated April 14, 2017

Your Formulary This Formulary includes medications from your plan’s complete pharmacy benefit coverage list. A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the Formulary is giving you choices so you and your doctor can choose the best course of treatment for you. Your formulary utilizes a Pharmacy and Therapeutics Committee made up of practicing physicians, pharmacists, and nurses to help ensure that your formulary is medically sound and that it supports patient health. This committee reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.

Go to your plan’s member website for complete and up-to-date drug information Since the Formulary may change, we encourage you to visit your plan’s member website. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

What is a Formulary? This document is a list of medications preferred by your plan sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). Please note: Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule. Please look at your benefit plan documents provided by your employer or plan sponsor to see what medications are covered under your plan. You may also log on to your plan’s member website or call the toll-free member phone number on the back of your ID card for more information.

How do I use my Formulary? When choosing a medication, you and your doctor should consult the Formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed in this document, please visit your plan’s member website or call the toll-free member phone number on the back of your ID card.

Table of Contents Antiemetics : Emetogenic Therapy Adjuncts ...... 20 Antifungals ...... 20 Antigout Agents ...... 21 What are tiers? ...... 6 Antimigraine Agents : Ergot Alkaloids ...... 21 Programs and Limits ...... 7 Antimigraine Agents : Serotonin (5-HT) 1b/1d Receptor Agonists ...... 21 Drugs by category Antimyasthenic Agents : Parasympathomimetics ...... 21 Analgesics ...... 10 Antimycobacterials : Antimycobacterials, Other ...... 21 Analgesics : Nonsteroidal Anti-inflammatory Drugs ...... 10 Antimycobacterials : Antituberculars ...... 21 Analgesics : Opioid Analgesics, Long-acting ...... 11 Antineoplastic Agents ...... 21 Analgesics : Opioid Analgesics, Short-acting ...... 12 Antineoplastics : Alkylating Agents ...... 21 Anesthetics : Local Anesthetics ...... 12 Antineoplastics : Antiandrogens ...... 22 Anti-Addiction/Substance Abuse Treatment Agents : Alcohol Antineoplastics : Antiangiogenic Agents...... 22 Deterrents/Anti-craving ...... 13 Antineoplastics : Antiestrogens/Modifiers ...... 22 Anti-Addiction/Substance Abuse Treatment Agents : Opioid Antineoplastics : Antimetabolites ...... 22 Reversal Agents ...... 13 Antineoplastics : Antineoplastics, Other ...... 22 Anti-Addiction/Substance Abuse Treatment Agents : Antineoplastics : Aromatase Inhibitors, 3rd Generation ...... 22 Smoking Cessation Agents ...... 13 Antineoplastics : Enzyme Inhibitors ...... 22 Anti-infective Agents : Antibacterials ...... 14 Antineoplastics : Molecular Target Inhibitors ...... 23 Anti-infective Agents : Antivirals ...... 14 Antineoplastics : Monoclonal Antibodies ...... 23 Anti-inflammatory Agents : Nonsteroidal Anti-inflammatory Antineoplastics : Retinoids ...... 23 Drugs ...... 14 Antiparasitics : Anthelmintics ...... 23 Antibacterials : Aminoglycosides ...... 14 Antiparasitics : Antiprotozoals ...... 23 Antibacterials : Antibacterials, Other ...... 14 Antiparasitics : Pediculicides/Scabicides ...... 23 Antibacterials : Beta-lactam, Cephalosporins ...... 15 Antiparkinson Agents : Anticholinergics ...... 23 Antibacterials : Beta-lactam, Other ...... 16 Antiparkinson Agents : Antiparkinson Agents, Other ...... 23 Antibacterials : Beta-lactam, Penicillins ...... 16 Antiparkinson Agents : Dopamine Agonists ...... 23 Antibacterials : Macrolides ...... 16 Antiparkinson Agents : Dopamine Precursors/L- Amino Acid Antibacterials : Quinolones ...... 17 Decarboxylase Inhibitors ...... 24 Antibacterials : Sulfonamides ...... 17 Antiparkinson Agents : Monoamine Oxidase B (MAO-B) Antibacterials : Tetracyclines ...... 17 Inhibitors ...... 24 Anticonvulsants : Anticonvulsants, Other...... 17 Antipsychotics : 1st Generation/Typical ...... 24 Anticonvulsants : Calcium Channel Modifying Agents ...... 17 Antipsychotics : 2nd Generation/Atypical ...... 24 Anticonvulsants : Gamma-aminobutyric Acid (GABA) Antipsychotics : Treatment-Resistant ...... 24 Augmenting Agents ...... 18 Antispasticity Agents ...... 24 Anticonvulsants : Glutamate Reducing Agents ...... 18 Antitoxins, Immune Globulins, Toxoids, and Vaccines : Anticonvulsants : Sodium Channel Agents ...... 18 Vaccines ...... 24 Antidementia Agents : Antidementia Agents, Other ...... 18 Antivirals : Anti-cytomegalovirus (CMV) Agents ...... 24 Antidementia Agents : Cholinesterase Inhibitors ...... 18 Antivirals : Anti-hepatitis B (HBV) Agents ...... 24 Antidementia Agents : N-methyl-D-aspartate (NMDA) Antivirals : Anti-hepatitis C (HCV) Agents ...... 24 Receptor Antagonist ...... 18 Antivirals : Anti-HIV Agents, Integrase Inhibitors (INSTI) .... 25 Antidepressants : Antidepressants, Other ...... 19 Antivirals : Anti-HIV Agents, Non-nucleoside Reverse Antidepressants : Monoamine Oxidase Inhibitors ...... 19 Transcriptase Inhibitors (NNRTI) ...... 25 Antidepressants : SSRIs/SNRIs (Selective Serotonin Antivirals : Anti-HIV Agents, Nucleoside and Nucleotide Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Reverse Transcriptase Inhibitors (NRTI) ...... 25 Inhibitors) ...... 19 Antivirals : Anti-HIV Agents, Other ...... 25 Antidepressants : Tricyclics ...... 19 Antivirals : Anti-HIV Agents, Protease Inhibitors ...... 25 Antiemetics : Antiemetics, Other ...... 19 Antivirals : Anti-influenza Agents ...... 25

Antivirals : Antiherpetic Agents ...... 25 Central Nervous System Agents : Attention Deficit Anxiolytics : Anxiolytics, Other ...... 26 Hyperactivity Disorder Agents, Non-amphetamines ...... 32 Anxiolytics : Benzodiazepines ...... 26 Central Nervous System Agents : Central Nervous System, Autonomic Drugs : Sympathomimetic (Adrenergic) Agents . 26 Other ...... 32 Bipolar Agents : Bipolar Agents, Other ...... 26 Central Nervous System Agents : Fibromyalgia Agents ...... 32 Bipolar Agents : Mood Stabilizers ...... 26 Central Nervous System Agents : Multiple Sclerosis Agents Blood Formation,Coagulation & Thrombosis : Antithrombotic ...... 32 Agents ...... 26 Dental and Oral Agents ...... 32 Blood Formation,Coagulation & Thrombosis : Hematopoietic Dermatological Agents ...... 33 Agents ...... 26 Devices ...... 34 Blood Glucose Regulators : Antidiabetic Agents ...... 26 Electrolytic, Caloric, and Water Balance : Replacement Blood Glucose Regulators : Glycemic Agents ...... 27 Preparations ...... 34 Blood Glucose Regulators : Insulins ...... 27 Enzyme Replacement/Modifiers ...... 34 Blood Products/Modifiers/Volume Expanders : Gastrointestinal Agents : Antispasmodics, Gastrointestinal 35 Anticoagulants ...... 27 Gastrointestinal Agents : Gastrointestinal Agents, Other .... 35 Blood Products/Modifiers/Volume Expanders : Blood Gastrointestinal Agents : Histamine2 (H2) Receptor Formation Modifiers ...... 27 Antagonists ...... 35 Blood Products/Modifiers/Volume Expanders ...... 28 Gastrointestinal Agents : Irritable Bowel Syndrome Agents 35 Blood Products/Modifiers/Volume Expanders : Coagulants 28 Gastrointestinal Agents : Laxatives ...... 35 Blood Products/Modifiers/Volume Expanders : Platelet Gastrointestinal Agents : Protectants ...... 36 Modifying Agents ...... 28 Gastrointestinal Agents : Proton Pump Inhibitors ...... 36 Cardiovascular Agents : Alpha-adrenergic Agonists ...... 28 Gastrointestinal Drugs : GI Drugs, Miscellaneous ...... 36 Cardiovascular Agents : Alpha-adrenergic Blocking Agents 28 Genitourinary Agents : Antispasmodics, Urinary ...... 36 Cardiovascular Agents : Angiotensin II Receptor Antagonists Genitourinary Agents : Benign Prostatic Hypertrophy Agents ...... 28 ...... 37 Cardiovascular Agents : Angiotensin-converting Enzyme Genitourinary Agents : Genitourinary Agents, Other ...... 37 (ACE) Inhibitors ...... 29 Genitourinary Agents : Phosphate Binders ...... 37 Cardiovascular Agents : Antiarrhythmics ...... 29 Hormonal Agents, Stimulant/Replacement/Modifying Cardiovascular Agents : Beta-adrenergic Blocking Agents . 29 (Adrenal) ...... 37 Cardiovascular Agents : Calcium Channel Blocking Agents 30 Hormonal Agents, Stimulant/Replacement/Modifying Cardiovascular Agents ...... 30 (Pituitary) ...... 38 Cardiovascular Agents : Cardiovascular Agents, Other ...... 30 Hormonal Agents, Stimulant/Replacement/Modifying Cardiovascular Agents : Diuretics, Carbonic Anhydrase (Prostaglandins) ...... 38 Inhibitors ...... 30 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Cardiovascular Agents : Diuretics, Loop ...... 31 Hormones/Modifiers) : Anabolic Steroids ...... 38 Cardiovascular Agents : Diuretics, Potassium-sparing ...... 31 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Cardiovascular Agents : Diuretics, Thiazide ...... 31 Hormones/Modifiers) : Androgens ...... 38 Cardiovascular Agents : Dyslipidemics, Fibric Acid Hormonal Agents, Stimulant/Replacement/Modifying (Sex Derivatives ...... 31 Hormones/Modifiers) : Estrogens ...... 38 Cardiovascular Agents : Dyslipidemics, HMG CoA Reductase Hormonal Agents, Stimulant/Replacement/Modifying (Sex Inhibitors ...... 31 Hormones/Modifiers) ...... 40 Cardiovascular Agents : Dyslipidemics, Other ...... 31 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Progesterone Agonists/Antagonists 40 Cardiovascular Agents : Vasodilators, Direct-acting Arterial 31 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Cardiovascular Agents : Vasodilators, Direct-acting Hormones/Modifiers) : Progestins ...... 40 Arterial/Venous ...... 31 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Central Nervous System Agents : Analgesics and Hormones/Modifiers) : Selective Estrogen Receptor Antipyretics ...... 32 Modifying Agents ...... 40 Central Nervous System Agents : Attention Deficit Hormonal Agents, Stimulant/Replacement/Modifying Hyperactivity Disorder Agents, Amphetamines ...... 32

(Thyroid) ...... 40 Sleep Disorder Agents : GABA Receptor Modulators ...... 52 Hormonal Agents, Suppressant (Adrenal) ...... 40 Sleep Disorder Agents : Sleep Disorders, Other ...... 52 Hormonal Agents, Suppressant (Parathyroid) ...... 40 Therapeutic Nutrients/Minerals/Electrolytes : Hormonal Agents, Suppressant (Pituitary) ...... 40 Electrolyte/Mineral Modifiers ...... 52 Hormonal Agents, Suppressant (Thyroid) : Antithyroid Agents Therapeutic Nutrients/Minerals/Electrolytes : ...... 41 Electrolyte/Mineral Replacement ...... 52 Hormones and Synthetic Substitutes : Adrenals ...... 41 Therapeutic Nutrients/Minerals/Electrolytes ...... 53 Hormones and Synthetic Substitutes : Antidiabetic Agents . 41 Therapeutic Nutrients/Minerals/Electrolytes : Vitamins ...... 53 Immunological Agents : Immune Suppressants ...... 41 Vitamins : Vitamin D ...... 56 Immunological Agents : Immunizing Agents, Passive ...... 41 Index of Covered Drugs ...... 57 Immunological Agents : Immunomodulators ...... 42 Nondiscrimination Notice and Access to Communication Immunological Agents : Vaccines ...... 42 Services ...... 81 Inflammatory Bowel Disease Agents : Aminosalicylates ..... 42 Multi-language Interpreter Services ...... 82 Inflammatory Bowel Disease Agents : Glucocorticoids ...... 42 Inflammatory Bowel Disease Agents : Sulfonamides ...... 42 Local Anesthetics ...... 42 Metabolic Bone Disease Agents ...... 42 Miscellaneous Therapeutic Agents : Antidotes ...... 43 Miscellaneous Therapeutic Agents : Disease-modifying Antirheumatic Drugs ...... 43 Miscellaneous Therapeutic Agents ...... 43 Multiple Classifications ...... 47 Ophthalmic Agents : Ophthalmic Prostaglandin and Prostamide Analogs ...... 49 Ophthalmic Agents : Ophthalmic Agents, Other ...... 49 Ophthalmic Agents : Ophthalmic Anti-allergy Agents ...... 49 Ophthalmic Agents : Ophthalmic Anti-inflammatories ...... 49 Ophthalmic Agents : Ophthalmic Antiglaucoma Agents ...... 49 Otic Agents ...... 50 Oxytocics ...... 50 Respiratory Tract/Pulmonary Agents : Anti-inflammatories, Inhaled Corticosteroids ...... 50 Respiratory Tract/Pulmonary Agents : Antihistamines ...... 50 Respiratory Tract/Pulmonary Agents : Antileukotrienes ...... 50 Respiratory Tract/Pulmonary Agents : Bronchodilators, Anticholinergic ...... 50 Respiratory Tract/Pulmonary Agents : Bronchodilators, Sympathomimetic ...... 50 Respiratory Tract/Pulmonary Agents : Cystic Fibrosis Agents ...... 51 Respiratory Tract/Pulmonary Agents : Mast Cell Stabilizers 51 Respiratory Tract/Pulmonary Agents : Phosphodiesterase Inhibitors, Airways Disease ...... 51 Respiratory Tract/Pulmonary Agents : Pulmonary Antihypertensives ...... 51 Respiratory Tract/Pulmonary Agents : Respiratory Tract Agents, Other...... 51 Skeletal Muscle Relaxants ...... 52

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. Generally, medications in a lower tier cost less than medications in higher tiers. If your medication is placed in a higher tier, look to see if there is a lower cost option available. Discuss these options with your doctor. Check your benefit plan documents to find out your specific pharmacy plan costs.

Drug Tier

Tier 1 $$

Tier 2 $$$

Tier 3 $$$$

Tier 4 $$$$$

Refer to your enrollment and plan materials on your plan’s member website, or call the toll-free member phone number on the back of your ID card for more information about your benefit plan.

When does the Formulary change? • Medications may move to a lower tier at any time. • Medications may move to nonformulary tier when its generic becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication.

For the most up-to-date list, please visit your plan’s member website or call the toll- free member phone number on the back of your ID card. Programs and Limits Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.

Prior Authorization – Your doctor is required to provide additional PA information to determine coverage.

Step Therapy – Trial of lower cost medication(s) is required before ST a higher-cost medication is covered.

Quantity Limits – Amount of medication covered per copayment QL or in a specific time period is limited.

AR Age Restrictions – Some restrictions may apply based on patient age.

Preventive drugs – May have coverage and no co-payment when health

PV care reform requirements are met. PV* – Available at $0 if prior authorization is approved. ST* – Available at $0 if step criteria is met or coverage exception is approved. If criteria are not met, copays will apply per plan benefit.

Optum’s formulary uses medical and utilization management functions to determine whether a prescription is medically necessary. These industry recognized and accepted management functions include but are not limited to quantity limits, step therapy, and prior authorization and help Optum and its clients determine whether the medication was prescribed in accordance with generally accepted medical practice standards, is clinically appropriate, and confirm that the prescribed medication is not more costly than an alternative product that is as likely to produce therapeutically equivalent results. As recommended by the United States Department of Labor, Optum’s reasonable medical and utilization management functions apply to ACA preventive drugs.

To learn more about a pharmacy program or to find out if it applies to you, please visit your plan’s member website or call the toll-free member phone number on the back of your ID card.

Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card.

Should I talk to my doctor about OTC medications? An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications.

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes the same company that makes a brand-name medication also makes the generic version.

Is it a generic or brand-name drug? The drug list shows brand-name drugs in bold type (for example, Lamictal) and generic drugs in plain type (for example, lamotrigine).

What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit your plan’s member website to make sure.

Are you taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications. BriovaRx®, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx® at 1-888-702- 8423 and have your prescriptions delivered right to your home or office.

Is home delivery available? Convenient home delivery service is available through OptumRx Home Delivery. Call the toll-free member phone number on the back of your ID card. Customer Service is available 24 hours a day, 7 days a week.

How do I get updated information about my pharmacy benefit? Since the Formulary may change during your plan year, we encourage you to visit your plan’s member website or call the toll-free member phone number on the back of your ID card for more current information. When you register at your plan’s member website and open an account, you can use the website’s helpful tools and features to: • Look up the price of drugs covered by your plan • Find lower-cost options • Refill and renew mail service prescriptions • View your order status and claims history • Sign up for text reminders to take and refill your medicine • View your benefits in real time • Order medical supplies

• Shop for health and wellness products

More information If you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit your plan’s member website.

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits CVS Aspirin (325mg Tablet, 325mg 1 PV Tablet Delayed-Release) Butalbital/Acetaminophen (300mg- 1 50mg Tablet, 50mg-325mg Tablet) CVS Aspirin Low Dose (Tablet 1 PV Delayed-Release) Capacet (Capsule) 1 CVS Childrens Aspirin (Tablet 1 PV Esgic (Capsule) 1 Chewable) Gralise (Tablet) 3 QL,ST Diclofenac Potassium (Tablet) 1 Gralise ST 3 QL,ST Diclofenac Sodium DR (Tablet 1 Marten-Tab (Tablet) 1 Delayed-Release) Prialt (Injection) 4 Diclofenac Sodium ER (Tablet 1 Tencon (Tablet) 1 Extended-Release 24 Hour) Zebutal (Capsule) 1 Diclofenac Sodium/Misoprostol 1 (Tablet Delayed-Release) Diflunisal (Tablet) 1 Duraxin (Capsule) Aspir-81 (Tablet Delayed-Release) 1 PV 1 Ecotrin (Tablet Delayed-Release) 1 PV Aspir-Low (Tablet Delayed- 1 PV Release) Ecotrin Low Strength (Tablet 1 PV Delayed-Release) Aspirin (325mg Tablet, 81mg Tablet 1 PV Chewable, 81mg Tablet Delayed- Ecpirin (Tablet Delayed-Release) 1 PV Release) ED-Flex (Capsule) 1 Aspirin 81 (Tablet Delayed-Release) 1 PV EQ Aspirin (325mg Tablet, 325mg 1 PV Aspirin 81 Low Dose (Tablet 1 PV Tablet Delayed-Release) Chewable) EQ Childrens Aspirin (Tablet 1 PV Aspirin Adult Low Dose (Tablet 1 PV Chewable) Delayed-Release) EQL Aspirin (Tablet) 1 PV Aspirin Childrens (Tablet 1 PV EQL Aspirin EC (Tablet Delayed- 1 PV Chewable) Release) Aspirin EC (Tablet Delayed- 1 PV Etodolac (200mg Capsule, 300mg 1 Release) Capsule, 400mg Tablet, 500mg Aspirin EC Low Dose (Tablet 1 PV Tablet) Delayed-Release) Etodolac ER (Tablet Extended- 1 Aspirin Low Dose (Tablet 1 PV Release 24 Hour) Chewable) Fenoprofen Calcium (200mg 1 Aspirtab (Tablet Delayed-Release) 1 PV Capsule, 400mg Capsule, 600mg Tablet) Bayer Advanced Aspirin Regular 1 PV Strength (Tablet) Fenortho (Capsule) 3 Bayer Aspirin EC Low Dose (Tablet 1 PV Flurbiprofen (100mg Tablet, 50mg 1 Delayed-Release) Tablet) Bayer Aspirin Regimen (Tablet 1 PV GNP Adult Aspirin Low Strength 1 PV Delayed-Release) (Tablet Chewable) Bayer Chewable Low Dose (Tablet 1 PV GNP Aspirin (325mg Tablet, 325mg 1 PV Chewable) Tablet Delayed-Release, 81mg Tablet Delayed-Release) Bayer Low Dose (Tablet Delayed- 1 PV Release) GNP Aspirin Low Dose (Tablet 1 PV Delayed-Release) Butalbital/Acetaminophen/Caffeine 1 (325mg-50mg-40mg Tablet, 50mg- HM Aspirin (325mg Tablet, 81mg 1 PV 300mg-40mg Capsule) Tablet Chewable) Butalbital/Aspirin/Caffeine 1 Hydrocodone/Ibuprofen (Tablet) 1 (Capsule) Ibudone (5mg-200mg Tablet) 1 Celecoxib (Capsule) 1 QL Ibuprofen (100mg/5ml Suspension - 1 Childrens Aspirin (Tablet 1 PV RX, 400mg Tablet, 600mg Tablet, Chewable) 800mg Tablet) Childrens Aspirin Low Strength 1 PV Indomethacin (25mg Capsule, 50mg 1 (Tablet Chewable) Capsule) Choline Magnesium Trisalicylate 1 Indomethacin ER (Capsule 1 (500mg/5ml Liquid) (MANUF Extended-Release) CYPRESS PH) Ketoprofen (Capsule Immediate- 1 Release)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Ketoprofen ER (Capsule Extended- 1 Salsalate (500mg Tablet, 750mg 1 Release 24 Hour) Tablet) (MANUF MARLEX) Ketorolac Tromethamine (10mg 1 QL SB Aspirin (Tablet) 1 PV Tablet) SB Aspirin EC (Tablet Delayed- 1 PV KLS Aspirin EC (Tablet Delayed- 1 PV Release) Release) SB Childrens Aspirin (Tablet 1 PV KLS Aspirin Low Dose (Tablet 1 PV Chewable) Delayed-Release) SM Aspirin (Tablet) 1 PV KP Aspirin (Tablet Delayed- 1 PV SM Aspirin Adult Low Strength 1 PV Release) (Tablet Chewable) Meclofenamate Sodium (100mg 1 SM Aspirin EC Low Strength 1 PV Capsule, 50mg Capsule) (Tablet Delayed-Release) Mefenamic Acid (250mg Capsule) 1 SM Aspirin Enteric Coated (Tablet 1 PV Meijer Aspirin EC (Tablet Delayed- 1 PV Delayed-Release) Release) SM Childrens Aspirin (Tablet 1 PV Meloxicam (Tablet) 1 Chewable) Miniprin Low Dose (Tablet 1 PV Sprix (Nasal Solution) 3 PA,QL Delayed-Release) St Joseph Low Dose Aspirin (Tablet 1 PV Mm Aspirin (Tablet) 1 PV Chewable) Nabumetone (Tablet) 1 Sulindac (150mg Tablet, 200mg 1 Nalfon (Capsule) 3 Tablet) Naprelan (750mg Tablet 3 TGT Aspirin (325mg Tablet, 81mg 1 PV Extended-Release 24 Hour) Tablet Chewable, 81mg Tablet Naproxen (125mg/5ml Suspension, 1 Delayed-Release) 250mg Tablet, 375mg Tablet, TGT Aspirin Low Dose (Tablet 1 PV 500mg Tablet) Delayed-Release) Naproxen DR (Tablet Delayed- 1 TGT Childrens Aspirin (Tablet 1 PV Release) Chewable) Naproxen Sodium (275mg Tablet, 1 Tolmetin Sodium (200mg Tablet, 1 550mg Tablet) 600mg Tablet, 400mg Capsule) Naproxen Sodium CR (Tablet 1 Xylon (Tablet) 1 Extended-Release 24 Hour) Naproxen Sodium ER (Tablet 1 Buprenorphine HCl (0.3mg/ml 1 Extended-Release 24 Hour) Solution) Norwich Aspirin (Tablet) 1 PV Buprenorphine HCl (2mg Tablet 1 QL Oxaprozin (Tablet) 1 Sublingual, 8mg Tablet Sublingual) Oxycodone/Ibuprofen (Tablet) 1 Buprenorphine HCl/Naloxone HCl 1 QL Piroxicam (10mg Capsule, 20mg 1 (Tablet Sublingual) Capsule) Butrans (Patch Weekly) 3 QL PX Aspirin (325mg Tablet, 81mg 1 PV Embeda (Capsule Extended- 2 QL Tablet Chewable) Release) PX Enteric Aspirin (Tablet Delayed- 1 PV Fentanyl (Patch 72 Hour) 1 QL Release) Hydromorphone HCl ER (Tablet 1 QL QC Aspirin (325mg Tablet, 325mg 1 PV Extended-Release 24 Hour Abuse- Tablet Delayed-Release) Deterrent) QC Childrens Aspirin (Tablet 1 PV Hysingla ER (Tablet Extended- 3 QL,ST Chewable) Release 24 Hour Abuse-Deterrent) QC Enteric Aspirin (Tablet 1 PV Methadone HCl (Tablet, Oral 1 Delayed-Release) Solution, Concentrate, 40mg Tablet RA Aspirin (Tablet) 1 PV Soluble) RA Aspirin Adult Low Strength 1 PV Methadose (40mg Tablet Soluble) 1 (Tablet Chewable) Morphine Sulfate ER (Capsule 1 QL RA Aspirin EC (Tablet Delayed- 1 PV Extended-Release 24 Hour, Tablet Release) Extended-Release) RA Childrens Aspirin (Tablet 1 PV Nucynta ER (Tablet Extended- 3 QL,ST Chewable) Release 12 Hour) Reprexain (10mg-200mg Tablet) 1 Opana ER (Tablet Extended- 3 QL Release 12 Hour Abuse-Deterrent)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Oxycodone HCl ER (10mg, 15mg, 1 QL 10mg/ml Injection, 25mg/ml 20mg, 30mg, 40mg, 60mg Tablet Injection, 50mg/ml Injection, Extended-Release 12 Hour Abuse- 50mg/5ml Oral Solution) Deterrent) Meperidine HCl/Sodium Chloride 1 Oxycodone HCl ER (80mg Tablet 2 QL (Injection) Extended-Release 12 Hour Abuse- Morphine Sulfate (0.5mg/ml 1 Deterrent) Injection, 100mg/5ml Oral Solution, OxyContin (Tablet Extended- 2 QL 10mg/5ml Oral Solution, 20mg/5ml Release 12 Hour Abuse-Deterrent) Oral Solution, 10mg/ml Injection, Oxymorphone HCl ER (Tablet 1 QL 1mg/ml Injection, 4mg/ml Injection, Extended-Release 12 Hour) 8mg/ml Injection, 15mg Tablet, Suboxone (Film) 2 QL 30mg Tablet) Tramadol HCl ER (150mg Capsule 1 QL Morphine Sulfate/Sodium Chloride 1 Extended-Release 24 Hour) (0.5mg/ml-0.9% Injection, 50mg/50ml-0.9% Injection) Tramadol HCl ER (Tablet 1 QL,ST Extended-Release 24 Hour) Nalbuphine HCl (Injection) 1 Nucynta (Tablet) 3 Oxaydo (5mg Tablet Abuse- 3 Acetaminophen/Caffeine/Dihydroco 1 Deterrent) deine (Capsule) Oxycodone HCl (100mg/5ml 1 Acetaminophen/Codeine (Oral 1 Concentrate, 10mg Tablet, 15mg Solution, Tablet) Tablet, 20mg Tablet, 30mg Tablet, Alfentanil (Injection) 1 5mg Tablet, 5mg Capsule, 5mg/5ml Ascomp/Codeine (Capsule) 1 Oral Solution) Aspirin-Caffeine-Dihydrocodeine 1 Oxycodone/Acetaminophen (2.5mg- 1 (Capsule) 325mg Tablet, 325mg-10mg Tablet, Butalbital/Acetaminophen/Caffeine/ 1 325mg-5mg Tablet, 325mg-7.5mg Codeine (Capsule) Tablet) Butalbital/Aspirin/Caffeine/Codeine 1 Oxycodone/Aspirin (Tablet) 1 (Capsule) Oxymorphone HCl (Tablet 1 Butorphanol Tartrate (Nasal 1 Immediate-Release) Solution, Injection) Pentazocine/Naloxone HCl (Tablet) 1 Codeine Sulfate (Tablet) 1 Tramadol HCl (Tablet Immediate- 1 Duramorph (Injection) 1 Release) Endocet (Tablet) 1 Tramadol HCl/Acetaminophen 1 Fentanyl Citrate Oral Transmucosal 1 PA,QL (Tablet) (Lollipop) Verdrocet (Tablet) 1 Hydrocodone 1 Vicodin (Tablet) 1 Bitartrate/Acetaminophen (Tablet, Vicodin ES (Tablet) 1 Oral Solution) Vicodin HP (Tablet) 1 Hydrocodone/Acetaminophen 1 (Tablet) Bupivacaine HCl (Injection) 1 Hydromorphone HCl (1mg/ml 1 Injection, 2mg/ml Injection, 4mg/ml Bupivacaine Spinal (Injection) 1 Injection, 500mg/50ml Injection, Bupivacaine/Dextrose Spinal 1 1mg/ml Liquid, 2mg Tablet, 4mg (Injection) Tablet, 8mg Tablet) Bupivacaine/Epinephrine (0.25%- 1 Hydromorphone HCl/Sodium 1 1:200000 Injection) Chloride (10mg/50ml-0.9% DermacinRx Empricaine (Kit) 1 Injection, 15mg/30ml-0.9% DermacinRx Prizopak (Kit) 1 Injection, 5mg/25ml-0.9% Injection) Glydo (Gel) 1 Lorcet (Tablet) 1 Leva Set/Occlusive Dressing (Kit) 1 Lorcet HD (Tablet) 1 Lidocaine (3% Cream, 5% 1 Lorcet Plus (Tablet) 1 Ointment, 5% Patch) Lortab (10mg-325mg Tablet, 5mg- 1 Lidocaine HCl (0.5% Injection, 1% 1 325mg Tablet, 7.5mg-325mg Injection, 1.5% Injection, 2% Tablet) Injection, 4% Injection, 2% Gel, 4% Meperidine HCl (100mg Tablet, 1 External Solution) 50mg Tablet, 100mg/ml Injection, Lidocaine HCl (Gel) 1

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Lidocaine Pak (Ointment) 1 7mg/24hr Patch 24 Hour, 4mg Lidocaine Viscous (Solution) 1 Lozenge) Lidocaine/Epinephrine (Injection) 1 EQ Nicotine Gum Refill (Gum) 1 PV,QL Lidocaine/Prilocaine (2.5%-2.5% 1 EQ Nicotine Gum Starter (Gum) 1 PV,QL Cream, 2.5%-2.5% Kit) EQ Nicotine Polacrilex (2mg Gum, 1 PV,QL Lidopril (Kit) 1 4mg Gum, 2mg Lozenge, 4mg Lidopril XR (Kit) 1 Lozenge) Livixil Pak (Kit) 1 EQL Nicotine (Lozenge) 1 PV,QL Polocaine (Injection) 1 EQL Nicotine Polacrilex (2mg 1 PV,QL Gum, 4mg Gum, 2mg Lozenge, 4mg Polocaine-Mpf (Injection) 1 Lozenge) Relador Pak (Kit) 1 GNP Nicotine Mini Lozenge 1 PV,QL Relador Pak Plus (Kit) 1 (Lozenge) Ropivacaine (Injection) 1 GNP Nicotine Polacrilex (2mg 1 PV,QL Ropivacaine HCl (Injection) 1 Gum, 4mg Gum, 2mg Lozenge, 4mg Ropivacaine HCl/Sodium Chloride 1 Lozenge) (0.1%-0.9% Solution, 0.2%-0.9% GNP Nicotine Transdermal System 1 PV,QL Injection) (Patch 24 Hour) Sensorcaine (Injection) 1 Goodsense Nicotine Gum (Gum) 1 PV,QL Sensorcaine-MPF (Injection) 1 HM Nicotine Polacrilex (2mg Gum, 1 PV,QL Sensorcaine-MPF Spinal (Injection) 1 4mg Gum, 2mg Lozenge, 4mg Sensorcaine/Epinephrine (Injection) 1 Lozenge) Synera (Patch) 3 HM Nicotine Transdermal System 1 PV,QL Xylocaine Dental (Injection) 1 (Patch 24 Hour) HM Nicotine Transdermal System 1 PV,QL (Patch 24 Hour) KLS Quit2 (2mg Gum, 2mg 1 PV,QL Acamprosate Calcium DR (Tablet 1 Lozenge) Delayed-Release) KLS Quit4 (4mg Gum, 4mg 1 PV,QL Disulfiram (Tablet) 1 Lozenge) Naltrexone HCl (Tablet) 1 NICOrelief (Gum) 1 PV,QL Vivitrol (Injection) 4 PA Nicotine (14mg/24hr Patch 24 Hour, 1 PV,QL 21mg/24hr Patch 24 Hour, 7mg/24hr Patch 24 Hour, 2mg Gum, 2mg Lozenge, 4mg Lozenge) Naloxone HCl (Injection) 1 Nicotine Mini Lozenge (Lozenge) 1 PV,QL Narcan (Liquid) 3 Nicotine Polacrilex (2mg Gum, 4mg 1 PV,QL Gum, 2mg Lozenge, 4mg Lozenge, 4mg Lozenge) Bupropion HCl (Tablet) 1 Nicotine Polacrilex Refill (Gum) 1 PV,QL Bupropion HCl SR (150mg Tablet 1 PV,QL Nicotine Polacrilex Starter Kit 1 PV,QL Extended-Release 12 Hour) (Gum) Bupropion HCl XL (Tablet 1 QL Nicotine Step 1 (Patch 24 Hour) 1 PV,QL Extended-Release 24 Hour) Nicotine Step 2 (Patch 24 Hour) 1 PV,QL Chantix (Tablet) 2 PV,QL,ST* Nicotine Step 3 (Patch 24 Hour) 1 PV,QL Chantix Continuing Month Pak 2 PV,QL,ST* Nicotine Transdermal System 1 PV,QL (Tablet) (14mg/24hr Patch 24 Hour, Chantix ST 2 PV,QL,ST* 21mg/24hr Patch 24 Hour, 7mg/24hr Patch 24 Hour) CVS Nicotine (Patch 24 Hour) 1 PV,QL Nicotine Transdermal System 2 PV,QL CVS Nicotine Polacrilex (2mg 1 PV,QL (Kit) Gum, 4mg Gum, 2mg Lozenge, 4mg Lozenge) Nicotrol Inhaler (Inhaler) 3 PV,QL,ST* CVS Nicotine Transdermal System 1 PV,QL Nicotrol NS (Nasal Solution) 3 PV,QL,ST* (Patch 24 Hour) PX Stop Smoking Aid (2mg Gum, 1 PV,QL CVS NTS Step 1 (Patch 24 Hour) 1 PV,QL 4mg Gum, 2mg Lozenge, 2mg Lozenge, 4mg Lozenge) EQ Nicotine (14mg/24hr Patch 24 1 PV,QL Hour, 21mg/24hr Patch 24 Hour, QC Nicotine Polacrilex (Gum) 1 PV,QL

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits RA Nicotine (14mg/24hr Patch 24 1 PV,QL Neomycin/Polymyxin B Sulfates 1 Hour, 21mg/24hr Patch 24 Hour, (Irrigation Solution) 2mg Gum, 4mg Gum) Neomycin/Polymyxin/Gramicidin 1 RA Nicotine Gum (Gum) 1 PV,QL (Ophthalmic Solution) RA Nicotine Polacrilex (2mg Gum, 1 PV,QL Paromomycin Sulfate (Capsule) 1 2mg Lozenge, 4mg Lozenge) Streptomycin Sulfate (1gm 1 SM Nicotine (14mg/24hr Patch 24 1 PV,QL Injection) Hour, 21mg/24hr Patch 24 Hour, Tobradex (0.3%-0.1% 3 7mg/24hr Patch 24 Hour, 2mg Ophthalmic Ointment) Lozenge, 4mg Gum) Tobradex ST (Ophthalmic 3 SM Nicotine Polacrilex (2mg Gum, 1 PV,QL Suspension) 4mg Gum, 4mg Lozenge) Tobramycin (300mg/5ml Nebulized 4 SM Nicotine Transdermal System 1 PV,QL Solution) (Patch 24 Hour) Tobramycin Sulfate (0.3% 1 SR Nicotine Gum (Gum) 1 PV,QL Ophthalmic Solution, 1.2gm SW Nicotine Polacrilex (2mg Gum, 1 PV,QL Injection, 1.2gm/30ml Injection, 4mg Gum, 2mg Lozenge, 4mg 10mg/ml Injection, 80mg/2ml Lozenge) Injection) TGT Nicotine Gum (Gum) 1 PV,QL Tobramycin/Dexamethasone 1 TGT Nicotine Polacrilex (2mg 1 PV,QL (Ophthalmic Suspension) Gum, 4mg Gum, 2mg Lozenge, 4mg Tobrex (0.3% Ophthalmic 3 Lozenge) Ointment) TGT Nicotine Step One (Patch 24 1 PV,QL Hour) Alcoh-Glove Contoured Wipe 2 TGT Nicotine Step Three (Patch 24 1 PV,QL Alcoh-Wipe 12" X 12" 2 Hour) Alcohol Prep Pads 2 TGT Nicotine Step Two (Patch 24 1 PV,QL Hour) Alcohol Prep Pads 2 Thrive (Gum) 1 PV,QL Alcohol Prep Pads 2 Alcohol Prep Pads 2 Alcohol Swabs 2 Ofloxacin (300mg Tablet) 1 Alcohol Swabstick 2 Vancomycin HCl/Dextrose (5%- 1 Altabax (Ointment) 3 1.5gm/250ml Injection) BACiiM (Injection) 1 Vancomycin HCl/Sodium Chloride 1 (0.9%-1.5gm/500ml Injection) Bacitracin (50000unit Injection, 1 500unit/gm Ophthalmic Ointment) Bacitracin/Polymyxin B 1 Selzentry (25mg Tablet, 75mg 2 PA (Ophthalmic Ointment) Tablet) Bactroban Nasal (Ointment) 3 BD Swabs Single Use 2 BD Swabs Single Use Butterfly 2 Diclofenac Sodium (3% Gel) 1 QL Caretouch Alcohol Prep Pads 2 Clindamycin HCl (Capsule 1 Immediate-Release) Amikacin Sulfate (1gm/4ml 1 Clindamycin Palmitate HCl (Oral 1 Injection, 500mg/2ml Injection) Solution) Gentak (Ophthalmic Ointment) 1 Clindamycin Phosphate (2% Cream, 1 Gentamicin Sulfate (0.1% Cream, 1 300mg/2ml Injection, 600mg/4ml 0.1% Ointment, 0.3% Ophthalmic Injection, 9000mg/60ml Injection, Ointment, 0.3% Ophthalmic 900mg/6ml Injection) Solution, 10mg/ml Injection, Clindamycin Phosphate in D5W 1 40mg/ml Injection) (Injection) Gentamicin Sulfate/0.9% Sodium 1 Colistimethate Sodium (Injection) 1 Chloride (0.8mg/ml-0.9% Injection, Curity Alcohol Prep 2 1.2mg/ml-0.9% Injection, 1mg/ml- Pads/Medium 2 Ply 0.9% Injection) Curity Alcohol Swabs 2 Isotonic Gentamicin (Injection) 1 CVS Prep Pads 2 Neomycin Sulfate (Tablet) 1 Daptomycin (Solution) 1

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Easy Touch Alcohol Prep 2 SB Alcohol Prep Pads 2 Pads/Medium Silver Sulfadiazine (Cream) 1 EQL Alcohol Swabs 2 Sivextro (200mg Tablet) 3 QL Fifty50 Alcohol Prep Pads 2 SM Alcohol Prep Pads 2 Global Alcohol Prep Ease Pads 2 SSD (Cream) 1 GNP Alcohol Swabs 2 Sulfamylon (85mg/gm Cream) 3 H-E-B Incontrol Alcohol Prep 2 Sure Comfort Alcohol Prep Pads 2 Pads Trimethoprim (100mg Tablet) 1 Impavido (Capsule) 3 Trimethoprim Sulfate/Polymyxin B 1 IV Prep Wipes 3 Sulfate (Ophthalmic Solution) Lincomycin HCl (Injection) 1 Tygacil (Injection) 3 Linezolid (100mg/5ml Suspension, 1 QL Ulticare Alcohol Swabs 2 600mg Tablet) Uni-Solve Wipes 3 Linezolid (600mg/300ml Injection) 1 Vancomycin (Injection) 1 Meijer Alcohol Swabs Extra- 2 Vancomycin HCl (0.9%-1gm/200ml 1 Thick Injection, 1000mg Injection, 10gm Methenamine Hippurate (Tablet) 1 Injection, 5000mg Injection, 125mg Metronidazole (0.75% Cream, 1 Capsule, 250mg Capsule) 0.75% Gel, 1% Gel, 0.75% Lotion, Vancomycin HCl/Dextrose (5%- 1 250mg Tablet, 500mg Tablet, 1gm/250ml Injection, 5%- 375mg Capsule) 2gm/500ml Injection) Metronidazole in NaCl 0.79% 1 Vancomycin HCl/Sodium Chloride 1 (Injection) (0.9%-1.5gm/150ml Injection, Metronidazole Vaginal (Gel) 1 0.9%-1.5gm/250ml Injection, 0.9%- Microclens Wipes 3 1gm/150ml Injection, 0.9%- Monurol (Packet) 3 1gm/250ml Injection, 0.9%- 750mg/150ml Injection) Mupirocin (2% Cream, 2% 1 Ointment) Vandazole (Gel) 1 Neo-Polycin (Ointment) 1 Vibativ (Injection) 3 Neo-Polycin HC (Ointment) 1 Webcol Alcohol Prep Large 1 Ply 2 Neomycin/Bacitracin/Polymyxin 1 Webcol Alcohol Prep Medium 2 2 (Ointment) Ply Neomycin/Polymyxin/Bacitracin/Hy 1 Xifaxan (Tablet) 3 PA drocortisone (Ointment) Zyvox (200mg/100ml Injection) 3 Neomycin/Polymyxin/Dexamethaso 1 ne (0.1% Ophthalmic Suspension, Cedax (180mg/5ml Suspension, 3 0.1%-3.5mg/gm-10000unit/gm 400mg Capsule) Ointment) Cefaclor (250mg Capsule 1 Neomycin/Polymyxin/Hydrocortiso 1 Immediate-Release, 500mg Capsule ne (1% Ophthalmic Suspension) Immediate-Release, 250mg/5ml Nitrofurantoin (Suspension) 1 Suspension, 375mg/5ml Nitrofurantoin Macrocrystals 1 Suspension) (Capsule) Cefaclor ER (Tablet Extended- 1 Nitrofurantoin Monohydrate (100mg 1 Release 12 Hour) Capsule) Cefadroxil (1gm Tablet, 250mg/5ml 1 Polycin (Ointment) 1 Suspension, 500mg/5ml Suspension, Polymyxin B Sulfate (500000unit 1 500mg Capsule) Injection) Cefazolin Sodium (10gm Injection, 1 Polymyxin B Sulfate/Trimethoprim 1 1gm Injection, 20gm Injection, Sulfate (Ophthalmic Solution) 500mg Injection) Primsol (Oral Solution) 3 Cefazolin Sodium/Sodium Chloride 1 Pro Comfort Alcohol Prep Pads 2 (Injection) QC Alcohol Swabs 2 Cefazolin/D5W (Injection) 1 RA Alcohol Swabs 2 Cefazolin/Dextrose (Injection) 1 Reality Swabs 2 Cefazolin/Sodium Chloride 1 Rosadan (0.75% Cream, 0.75% Gel) 1 (Injection) Saps Care Alcohol Prep Pads 2

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Cefdinir (125mg/5ml Suspension, 1 125mg/5ml Suspension, 200mg/5ml 250mg/5ml Suspension, 300mg Suspension, 250mg/5ml Suspension, Capsule) 400mg/5ml Suspension, 250mg Cefditoren Pivoxil (Tablet) 1 Capsule, 500mg Capsule, 500mg Cefepime (1gm Injection, 2gm 1 Tablet, 875mg Tablet) Injection) Amoxicillin/Clavulanate Potassium 1 Cefixime (Suspension) 1 (Tablet Chewable, Oral Suspension, Tablet Immediate-Release) Cefotaxime Sodium (Injection) 1 Amoxicillin/Clavulanate Potassium 1 Cefotetan/Dextrose (Injection) 1 ER (Tablet Extended-Release 12 Cefoxitin Sodium (10gm Injection, 1 Hour) 1gm Injection, 2gm Injection) Ampicillin (125mg/5ml Suspension, 1 Cefpodoxime Proxetil (100mg 1 250mg/5ml Suspension, 250mg Tablet, 200mg Tablet, 100mg/5ml Capsule, 500mg Capsule) Suspension, 50mg/5ml Suspension) Ampicillin Sodium (10gm Injection, 1 Cefprozil (125mg/5ml Suspension, 1 1gm Injection, 250mg Injection, 250mg/5ml Suspension, 250mg 2gm Injection, 500mg Injection) Tablet, 500mg Tablet) Ampicillin-Sulbactam (10gm-5gm 1 Ceftazidime (Injection) 1 Injection, 1gm-0.5gm Injection, Ceftin (Suspension) 3 2gm-1gm Injection) Ceftriaxone in Iso-Osmotic 1 Augmentin (125mg/5ml- 2 Dextrose (Injection) 31.25mg/5ml Suspension) Ceftriaxone Sodium (100gm 1 Bactocill in Dextrose (0-1gm/50ml 3 Injection, 1gm Injection, 250mg Injection) Injection, 500mg Injection, 10gm Bicillin C-R (300000unit/ml- 3 Injection, 2gm Solution) 300000unit/ml Injection) Cefuroxime Axetil (Tablet) 1 Bicillin L-A (Injection) 3 Cefuroxime Sodium (Injection) 1 Dicloxacillin Sodium (Capsule) 1 Cephalexin (125mg/5ml 1 Moxatag (Tablet Extended- 3 Suspension, 250mg/5ml Suspension, Release 24 Hour) 250mg Capsule, 500mg Capsule, Nafcillin (Injection) 1 750mg Capsule, 250mg Tablet, 500mg Tablet) Nafcillin Sodium (10gm Injection, 1 1gm Injection, 2gm Injection) Claforan (1gm Injection) 3 Oxacillin Sodium (Injection) 1 Maxipime (2gm Injection) 3 Penicillin G Potassium (Injection) 1 Suprax (100mg Tablet Chewable, 3 200mg Tablet Chewable, Penicillin V Potassium (125mg/5ml 1 500mg/5ml Suspension) Oral Solution, 250mg/5ml Oral Solution, 250mg Tablet, 500mg Tazicef (1gm Injection, 2gm 1 Tablet) Injection, 6gm Injection) Piperacillin/Tazobactam (2gm- 1 Teflaro (Injection) 3 0.25gm Injection, 3gm-0.375gm Zinacef (1.5gm-0 Injection) 3 Injection, 4gm-0.5gm Injection, 36gm-4.5gm Solution) Azactam in Iso-Osmotic Dextrose 3 (1gm-0 Injection) Azasite (Ophthalmic Solution) 3 Aztreonam (Injection) 1 Azithromycin (100mg/5ml 1 Cayston (Inhalation Solution) 4 PA Suspension, 200mg/5ml Suspension, Cefotetan (Injection) 1 1gm Packet, 250mg Tablet, 500mg Doribax (500mg Injection) 3 Tablet, 600mg Tablet, 500mg Doripenem (500mg Injection) 3 Injection) Imipenem/Cilastatin (Injection) 1 Clarithromycin (125mg/5ml 1 Invanz (Injection) 3 Suspension, 250mg/5ml Suspension, 250mg Tablet, 500mg Tablet) Meropenem (Injection) 1 Clarithromycin ER (Tablet 1 Meropenem/Sodium Chloride 1 Extended-Release 24 Hour) (Injection) Dificid (Tablet) 3 E.E.S. 400 (Tablet) 1 Amoxicillin (125mg Tablet 1 Ery-Tab (333mg Tablet Delayed- 3 Chewable, 250mg Tablet Chewable, Release)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Erythrocin Lactobionate 3 (Injection) Avidoxy (Tablet) 1 Erythromycin (250mg Capsule 1 Demeclocycline HCl (150mg 1 Delayed-Release, 5mg/gm Tablet, 300mg Tablet) Ointment) Doxy 100 (Injection) 1 Erythromycin Base (Tablet) 1 Doxycycline (25mg/5ml 1 Erythromycin Ethylsuccinate 1 Suspension) (200mg/5ml Suspension, 400mg Tablet) Doxycycline Hyclate (100mg 1 Capsule, 50mg Capsule, 100mg PCE (500mg Tablet Delayed- 3 Injection, 100mg Tablet, 20mg Release) Tablet) Zithromax (1gm Packet) 2 Doxycycline Hyclate DR (Tablet 1 Delayed-Release) Avelox (400mg/250ml-0.8% 3 Doxycycline Monohydrate (100mg 1 Injection) Capsule, 150mg Capsule, 50mg Besivance (Suspension) 3 Capsule, 75mg Capsule, 100mg Ciloxan (0.3% Ointment) 3 Tablet, 150mg Tablet, 50mg Tablet, 75mg Tablet) Ciprofloxacin (250mg/5ml 1 Suspension, 500mg/5ml Minocycline HCl (100mg Capsule, 1 Suspension) 50mg Capsule, 75mg Capsule, 100mg Tablet, 50mg Tablet, 75mg Ciprofloxacin ER (Tablet Extended- 1 Tablet) Release 24 Hour) Minocycline HCl ER (Tablet Ciprofloxacin HCl (0.3% 1 1 Extended-Release 24 Hour) Ophthalmic Solution, Tablet Immediate-Release) Mondoxyne NL (Capsule) 1 Ciprofloxacin I.V. in D5W 1 Morgidox 1x100mg (100mg 1 (Injection) Capsule) Factive (Tablet) 3 Morgidox 1x50mg (Capsule) 1 Gatifloxacin (Ophthalmic Solution) 1 Morgidox 2x100mg (100mg 1 Capsule) Levofloxacin (0.5% Ophthalmic 1 Solution, 250mg Tablet, 500mg Tetracycline HCl (Capsule) 1 Tablet, 750mg Tablet, 25mg/ml Injection, 25mg/ml Oral Solution) Aptiom (Tablet) 3 Levofloxacin in D5W (Injection) 1 Fycompa (0.5mg/ml Suspension, 3 Moxeza (Ophthalmic Solution) 2 10mg Tablet, 12mg Tablet, 2mg Moxifloxacin HCl (400mg Tablet, 1 Tablet, 4mg Tablet, 6mg Tablet, 400mg/250ml Injection) 8mg Tablet) Ofloxacin (0.3% Ophthalmic 1 Levetiracetam (Tablet Immediate- 1 Solution, 0.3% Otic Solution, Release, Oral Solution, 500mg/5ml 400mg Tablet) Injection) Vigamox (Ophthalmic Solution) 2 Levetiracetam ER (Tablet Extended- 1 Release 24 Hour) Magnesium Sulfate in D5W (5%- 1 AVC (Cream) 3 10mg/ml Injection) Sodium Sulfacetamide (Ophthalmic 1 Solution) Potiga (Tablet) 3 Roweepra (Tablet) Sulfacetamide Sodium (10% 1 1 Ophthalmic Solution) Sulfacetamide Sodium/Prednisolone 1 Sodium Phosphate (Ophthalmic Celontin (Capsule) 3 Solution) Ethosuximide (250mg Capsule, 1 Sulfadiazine (500mg Tablet) 1 250mg/5ml Oral Solution) Sulfamethoxazole/Trimethoprim 1 Lyrica (100mg Capsule, 150mg 2 QL (200mg/5ml-40mg/5ml Suspension, Capsule, 200mg Capsule, 225mg 400mg-80mg Tablet) Capsule, 25mg Capsule, 300mg Sulfamethoxazole/Trimethoprim DS 1 Capsule, 50mg Capsule, 75mg (Tablet) Capsule) Sulfatrim Pediatric (Suspension) 1 Lyrica (20mg/ml Oral Solution) 3 QL

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Zonisamide (Capsule) 1 Topiramate ER (Capsule Extended- 1 Release 24 Hour Sprinkle)

Clonazepam (Tablet Immediate- 1 QL Banzel (200mg Tablet, 400mg 3 Release) Tablet, 40mg/ml Suspension) Clonazepam ODT (Tablet 1 QL Carbamazepine (100mg Tablet 1 Dispersible) Chewable, 100mg/5ml Suspension, Clorazepate Dipotassium (Tablet) 1 QL 200mg Tablet Immediate-Release) Diazepam (10mg Gel, 2.5mg Gel, 1 Carbamazepine ER (100mg, 200mg, 1 20mg Gel, 10mg Tablet, 2mg 300mg Capsule Extended-Release Tablet, 5mg Tablet, 1mg/ml Oral 12 Hour; 100mg, 200mg, 400mg Solution, 5mg/ml Injection) Tablet Extended-Release 12 Hour) Diazepam Intensol (5mg/ml 1 Dilantin (30mg Capsule) 3 Concentrate) Epitol (Tablet) 1 Divalproex Sodium (Capsule 1 Fosphenytoin Sodium (Injection) 1 Sprinkle Delayed-Release) Oxcarbazepine (150mg Tablet, 1 Divalproex Sodium DR (Tablet 1 300mg Tablet, 600mg Tablet, Delayed-Release) 60mg/ml Suspension) Divalproex Sodium ER (Tablet 1 Peganone (Tablet) 3 Extended-Release 24 Hour) Phenytoin (125mg/5ml Suspension, 1 Gabitril (12mg Tablet, 16mg 3 50mg Tablet Chewable) Tablet) Phenytoin Sodium (50mg/ml 1 Gene-Xene Tab 15mg (Tablet) 1 QL Injection) Gene-Xene Tab 3.75mg (Tablet) 1 QL Phenytoin Sodium Extended 1 Gene-Xene Tab 7.5mg (Tablet) 1 QL (Capsule) Lorazepam (0.5mg Tablet, 1mg 1 QL Vimpat (100mg Tablet, 150mg 3 Tablet, 2mg Tablet) Tablet, 200mg Tablet, 50mg Tablet, 10mg/ml Oral Solution) Onfi (10mg Tablet, 20mg Tablet, 3 PA 2.5mg/ml Suspension) Phenobarbital (100mg Tablet, 15mg 1 Tablet, 16.2mg Tablet, 30mg Tablet, Ergoloid Mesylates (Tablet) 1 32.4mg Tablet, 60mg Tablet, 64.8mg Tablet, 97.2mg Tablet, 20mg/5ml Elixir, 20mg/5ml Oral Solution) Donepezil HCl (10mg Tablet 1 Primidone (Tablet) 1 Dispersible, 5mg Tablet Dispersible, Sabril (500mg Packet) 4 PA 10mg Tablet, 23mg Tablet, 5mg Tiagabine HCl (Tablet) 1 Tablet) Valproate Sodium (100mg/ml 1 Galantamine HBr (12mg Tablet, 1 Injection) 4mg Tablet, 8mg Tablet, 4mg/ml Oral Solution) Valproic Acid (250mg Capsule, 1 250mg/5ml Oral Solution, Galantamine HBr ER (Capsule 1 250mg/5ml Syrup) Extended-Release 24 Hour) Rivastigmine Tartrate (Capsule 1 Immediate-Release) Rivastigmine Transdermal System 1 Felbamate (400mg Tablet, 600mg 1 (Patch 24 Hour) Tablet, 600mg/5ml Suspension) Lamotrigine (Tablet Immediate- 1 Release, Tablet Chewable) Lamotrigine ER (Tablet Extended- 1 Memantine HCl (10mg Tablet, 5mg 1 Release 24 Hour) Tablet, 2mg/ml Oral Solution) Lamotrigine ODT (Tablet 1 Memantine HCl Titration Pak 1 Dispersible) (Tablet) Lamotrigine Titration (Kit) 1 Namenda XR (Capsule Extended- 2 QL Release 24 Hour) Topiramate (Tablet Immediate- 1 Release, Capsule Sprinkle Namenda XR Titration Pack 2 QL Immediate-Release) (Capsule Extended-Release 24 Hour)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Fetzima (Capsule Extended- 3 QL,ST Release 24 Hour) Aplenzin (Tablet Extended- 3 QL,ST Release 24 Hour) Fluoxetine (Capsule) 1 Aripiprazole (10mg Tablet, 15mg 1 QL Fluoxetine DR (Capsule Delayed- 1 QL Tablet, 20mg Tablet, 2mg Tablet, Release) 30mg Tablet, 5mg Tablet, 1mg/ml Fluoxetine HCl (10mg Tablet, 20mg 1 Oral Solution) Tablet, 60mg Tablet, 20mg/5ml Oral Bupropion HCl ER (Tablet 1 QL Solution, 40mg Capsule) Extended-Release 12 Hour) Fluvoxamine Maleate (Tablet) 1 Bupropion HCl SR (100mg Tablet 1 QL Fluvoxamine Maleate ER (Capsule 1 QL Extended-Release 12 Hour, 150mg Extended-Release 24 Hour) Tablet Extended-Release 12 Hour, Paroxetine HCl (Tablet) 1 200mg Tablet Extended-Release 12 Paroxetine HCl ER (Tablet 1 Hour) Extended-Release 24 Hour) Maprotiline HCl (Tablet) 1 Paxil (10mg/5ml Suspension) 2 Mirtazapine (Tablet) 1 Sertraline HCl (100mg Tablet, 25mg 1 Mirtazapine ODT (Tablet 1 Tablet, 50mg Tablet, 20mg/ml Dispersible) Concentrate) Nefazodone HCl (Tablet) 1 Venlafaxine HCl (Tablet Immediate- 1 Quetiapine Fumarate (Tablet) 1 QL Release) Quetiapine Fumarate ER (Tablet 1 QL Venlafaxine HCl ER (150mg, 1 Extended-Release 24 Hour) 37.5mg, 75mg Capsule Extended- Seroquel XR (150mg Tablet 2 QL Release 24 Hour; 150mg, 225mg, Extended-Release 24 Hour, 200mg 37.5mg, 75mg Tablet Extended- Tablet Extended-Release 24 Hour, Release 24 Hour) 300mg Tablet Extended-Release Viibryd (Tablet) 3 QL,ST 24 Hour, 50mg Tablet Extended- Viibryd ST 3 QL,ST Release 24 Hour) Trazodone HCl (100mg Tablet, 1 Amitriptyline HCl (100mg Tablet, 1 150mg Tablet, 300mg Tablet, 50mg 10mg Tablet, 150mg Tablet, 25mg Tablet) Tablet, 50mg Tablet, 75mg Tablet) Trintellix (Tablet) 3 QL,ST Amoxapine (Tablet) 1 Chlordiazepoxide/Amitriptyline 1 (Tablet) Emsam (Patch 24 Hour) 3 QL Clomipramine HCl (Capsule) 1 Marplan (Tablet) 3 Desipramine HCl (100mg Tablet, 1 Phenelzine Sulfate (Tablet) 1 10mg Tablet, 150mg Tablet, 25mg Tablet, 50mg Tablet, 75mg Tablet) Doxepin HCl (100mg Capsule, 1 10mg Capsule, 150mg Capsule, 25mg Capsule, 50mg Capsule, 75mg Citalopram HBr (10mg Tablet, 1 Capsule, 10mg/ml Concentrate) 20mg Tablet, 40mg Tablet, Imipramine HCl (10mg Tablet, 1 10mg/5ml Oral Solution) 25mg Tablet, 50mg Tablet) Desvenlafaxine ER (100mg Tablet 1 QL Imipramine Pamoate (Capsule) 1 Extended-Release 24 Hour, 25mg Nortriptyline HCl (10mg Capsule, 1 Tablet Extended-Release 24 Hour, 25mg Capsule, 50mg Capsule, 75mg 50mg Tablet Extended-Release 24 Capsule, 10mg/5ml Oral Solution) Hour) Perphenazine/Amitriptyline (10mg- 1 Duloxetine HCl (20mg Capsule 1 QL 2mg Tablet, 25mg-2mg Tablet, Delayed-Release, 30mg Capsule 25mg-4mg Tablet) Delayed-Release, 60mg Capsule Protriptyline HCl (Tablet) 1 Delayed-Release) Trimipramine Maleate (100mg 1 Duloxetine HCl (40mg Capsule 3 QL Capsule, 25mg Capsule, 50mg Delayed-Release) Capsule) Escitalopram Oxalate (10mg Tablet, 1 20mg Tablet, 5mg Tablet, 5mg/5ml Oral Solution) Akynzeo (Capsule) 3 QL

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Chlorpromazine HCl (100mg 1 Ondansetron ODT (Tablet 1 QL Tablet, 10mg Tablet, 200mg Tablet, Dispersible) 25mg Tablet, 50mg Tablet) Sancuso (Patch) 3 QL Compro (Suppository) 1 Trimethobenzamide HCl (Capsule) 1 Diphenhydramine HCl (12.5mg/5ml 1 Elixir, 50mg/ml Injection) Abelcet (Injection) 3 Droperidol (2.5mg/ml Injection) 1 AmBisome (Injection) 3 Hydroxyzine HCl (10mg Tablet, 1 25mg Tablet, 50mg Tablet, Amphotericin B (50mg Injection) 1 10mg/5ml Syrup, 50mg/ml Bio-Statin (Powder) 1 Injection) Ciclodan (0.77% Cream, 8% 1 Hydroxyzine Pamoate (100mg 1 External Solution) Capsule, 25mg Capsule, 50mg Ciclopirox (0.77% Gel, 0.77% 1 Capsule) Suspension, 1% Shampoo) Metoclopramide HCl (10mg Tablet, 1 Ciclopirox Nail Lacquer (External 1 5mg Tablet, 5mg/5ml Oral Solution) Solution) Metoclopramide ODT (5mg Tablet 1 Ciclopirox Olamine (0.77% Cream) 1 Dispersible) Clotrimazole (1% Cream, 1% 1 Perphenazine (Tablet) 1 External Solution - RX, 10mg Pharbedryl (Capsule) (RX) 1 Lozenge, 10mg Troche) Phenadoz (Suppository) 1 Clotrimazole/Betamethasone 1 Phenergan (12.5mg Suppository, 1 Dipropionate (0.05%-1% Cream, 25mg Suppository, 50mg 1%-0.05% Lotion) Suppository) Cresemba (186mg Capsule, 372mg 3 Prochlorperazine (Suppository) 1 Injection) Prochlorperazine Edisylate 1 Econazole Nitrate (1% Cream) 1 (Injection) Eraxis (50mg Injection) 3 Prochlorperazine Maleate (10mg 1 Ertaczo (Cream) 3 Tablet, 5mg Tablet) Exelderm (1% Cream, 1% 3 Promethazine HCl (12.5mg 1 External Solution) Suppository, 25mg Suppository, Fluconazole (100mg Tablet, 150mg 1 50mg Suppository, 12.5mg Tablet, Tablet, 200mg Tablet, 50mg Tablet, 25mg Tablet, 50mg Tablet, 50mg/ml 10mg/ml Suspension, 40mg/ml Injection, 6.25mg/5ml Oral Suspension) Solution) Fluconazole in Dextrose (Injection) 1 Promethazine HCl Plain (Syrup) 1 Fluconazole in NaCl 1 Promethegan (Suppository) 1 (200mg/100ml-0.9% Injection, Transderm-Scop (Patch 72 Hour) 3 400mg/200ml-0.9% Injection) Flucytosine (Capsule) 1 Griseofulvin Microsize (125mg/5ml 1 Aloxi (Injection) 2 Suspension, 500mg Tablet) Anzemet (Tablet) 3 QL Griseofulvin Ultramicrosize (Tablet) 1 Aprepitant (Capsule) 1 QL Gynazole-1 (Cream) 3 Cesamet (Capsule) 3 PA,QL Itraconazole (Capsule) 1 PA Dronabinol (Capsule) 1 PA,QL Jublia (External Solution) 3 PA Granisetron HCl (0.1mg/ml 1 Kerydin (External Solution) 3 PA Injection, 1mg/ml Injection, 4mg/4ml Injection) Ketoconazole (2% Cream, 2% 1 Foam, 2% Shampoo, 200mg Tablet) Granisetron HCl (1mg Tablet) 1 QL Ketodan (Foam) 1 Meclizine HCl (12.5mg Tablet, 1 25mg Tablet) (RX) Luzu (Cream) 3 Ondansetron HCl (24mg Tablet, 1 QL Mentax (Cream) 3 4mg Tablet, 8mg Tablet, 4mg/5ml Miconazole 3 (Suppository) 1 Oral Solution) Mycamine (Injection) 3 Ondansetron HCl (40mg/20ml 1 Naftifine HCl (Cream) 1 Injection, 4mg/2ml Injection) Naftifine HCl (Cream) 1 Ondansetron HCl/Sodium Chloride 1 Natacyn (Suspension) 2 (Injection) Noxafil (100mg Tablet Delayed- 3 Release)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Nyamyc (Powder) 1 Zomig (2.5mg Nasal Solution, 5mg 2 QL Nystatin (100000unit/gm Cream, 1 Nasal Solution) 100000unit/gm Ointment, 100000unit/gm Powder, 100000unit/ml Suspension, 500000unit Tablet) Guanidine HCl (Tablet) 1 Nystatin/Triamcinolone 1 Mestinon (60mg/5ml Syrup) 2 (100000unit/gm-0.1% Ointment, Neostigmine Methylsulfate 1 100000unit/gm-1mg/gm Cream) (10mg/10ml Injection, 5mg/10ml Nystop (Powder) 1 Injection, 5mg/5ml Solution Oxiconazole Nitrate (Cream) 1 Prefilled Syringe) Oxistat (1% Lotion) 3 Pyridostigmine Bromide (Tablet) 1 Terbinafine HCl (Tablet) 1 QL Pyridostigmine Bromide ER (Tablet 1 Extended-Release) Terconazole (0.4% Cream, 0.8% 1 Cream, 80mg Suppository) Voriconazole (200mg Injection, 1 200mg Tablet, 50mg Tablet, Dapsone (Tablet) 1 40mg/ml Suspension) Rifabutin (Capsule) 1 Xolegel (Gel) 3 Zazole (0.8% Cream, 80mg 1 Suppository) Capastat Sulfate (Injection) 3 Cycloserine (Capsule) 1 Ethambutol HCl (100mg Tablet, 1 Allopurinol (Tablet) 1 400mg Tablet) Allopurinol Sodium (Injection) 1 Isoniazid (100mg Tablet, 300mg 1 Colchicine (0.6mg Tablet) 1 Tablet, 50mg/5ml Syrup) Colcrys (Tablet) 2 Paser (Packet) 3 Krystexxa (Injection) 4 PA Priftin (Tablet) 3 Probenecid (Tablet) 1 Pyrazinamide (Tablet) 1 Probenecid/Colchicine (Tablet) 1 Rifamate (Capsule) 3 Uloric (Tablet) 2 ST Rifampin (150mg Capsule, 300mg 1 Capsule, 600mg Injection) Dihydroergotamine Mesylate 1 Rifater (Tablet) 3 (1mg/ml Injection) Sirturo (Tablet) 3 Dihydroergotamine Mesylate 1 QL Trecator (Tablet) 3 (4mg/ml Nasal Solution) Ergomar (Tablet Sublingual) 3 Campath (Injection) 2 Ergotamine Tartrate/Caffeine 1 Imlygic (Suspension) 4 (Tablet) Lartruvo (500mg/50ml Injection) 4 PA

Adriamycin (Injection) 4 Almotriptan Malate (Tablet) 1 QL Alkeran (2mg Tablet) CM Frovatriptan Succinate (Tablet) 1 QL Bendeka (Injection) 4 Naratriptan HCl (Tablet) 1 QL BiCNU (Injection) 4 Relpax (Tablet) 3 QL Busulfex (Injection) 4 Rizatriptan Benzoate (Tablet) 1 QL Carboplatin (Injection) 4 Rizatriptan Benzoate ODT (Tablet 1 QL Cisplatin (100mg/100ml Injection, 4 Dispersible) 50mg/50ml Injection) Sumatriptan (Nasal Solution) 1 QL Cisplatin (200mg/200ml Injection) 4 Sumatriptan Succinate (100mg 1 QL Cyclophosphamide (1gm Injection, 4 Tablet, 25mg Tablet, 50mg Tablet, 2gm Injection, 500mg Injection) 4mg/0.5ml Injection, 6mg/0.5ml Injection) Cyclophosphamide (25mg CM Capsule, 50mg Capsule) Zolmitriptan (Tablet) 1 QL Dacarbazine (100mg Injection) 4 Zolmitriptan ODT (Tablet 1 QL Dispersible) Dacarbazine (200mg Injection) 4 Doxorubicin HCl (Injection) 4

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Gleostine (Capsule) CM Hydroxyurea (Capsule) CM Gliadel Wafer (Wafer) 4 Lonsurf (Tablet) CM PA,QL Hexalen (Capsule) CM Mercaptopurine (Tablet) CM Ifex (3gm Injection) 4 Nipent (Injection) 4 Ifosfamide (1gm Injection, 4 Tabloid (Tablet) CM 1gm/20ml Injection, 3gm/60ml Injection) Alferon N (Injection) 4 Ifosfamide (3gm Injection) 4 Cotellic (Tablet) CM PA,QL Leukeran (Tablet) CM Decitabine (Injection) 4 PA Matulane (Capsule) CM Docetaxel (160mg/16ml Injection, 4 Melphalan HCl (Injection) 4 160mg/8ml Injection, 20mg/2ml Mitoxantrone HCl (Injection) 4 PA Injection, 20mg/ml Injection, Mustargen (Injection) 4 80mg/4ml Injection, 80mg/8ml Myleran (Tablet) CM Injection) Temodar (100mg Injection) 4 Docetaxel (Non-Alcohol Formula) 4 Temozolomide (Capsule) CM PA (Injection) Thiotepa (Injection) 1 Farydak (Capsule) CM PA,QL Treanda (Injection) 4 Ibrance (Capsule) CM PA Yondelis (Injection) 4 Intron A (Injection) 4 PA Zanosar (Injection) 4 Jakafi (10mg Tablet) CM PA,QL Jakafi (15mg Tablet, 20mg Tablet, CM PA 25mg Tablet, 5mg Tablet) Bicalutamide (Tablet) CM Leucovorin Calcium (10mg CM Flutamide (Capsule) CM Tablet, 15mg Tablet) Nilutamide (Tablet) CM Leucovorin Calcium (25mg Tablet, CM Xtandi (Capsule) CM PA 5mg Tablet) Levoleucovorin (175mg/17.5ml 4 Caprelsa (100mg Tablet) CM PA,QL Injection) Caprelsa (300mg Tablet) CM PA Levoleucovorin (250mg/25ml 4 Pomalyst (Capsule) CM PA Injection) Revlimid (Capsule) CM PA Lynparza (Capsule) CM PA Thalomid (Capsule) CM PA Marqibo (Injection) 4 Mesna (Injection) 4 Ninlaro (Capsule) CM PA,QL Emcyt (Capsule) CM Paclitaxel (100mg/16.7ml Injection, 4 Fareston (Tablet) CM 300mg/50ml Injection, 30mg/5ml Faslodex (Injection) 4 Injection) Soltamox (Oral Solution) CM Paclitaxel (150mg/25ml Injection) 4 Tamoxifen Citrate (Tablet) CM PV* Portrazza (Injection) 4 PA Sylatron (Injection) 4 PA Adrucil (Injection) 4 Teniposide (Injection) 4 Arranon (Injection) 4 Venclexta (Tablet) CM PA Capecitabine (Tablet) CM PA Venclexta Starting Pack (Tablet CM PA Therapy Pack) Cladribine (Injection) 4 Vinblastine Sulfate (Injection) 4 Clolar (Injection) 4 Vinorelbine Tartrate (Injection) 4 Cytarabine Aqueous (Injection) 4 Zolinza (Capsule) CM PA Depocyt (Injection) 4 Zytiga (Tablet) CM PA Droxia (Capsule) 3 Elitek (Injection) 3 Floxuridine (Injection) 4 Fluorouracil (1gm/20ml Injection, 4 Anastrozole (Tablet) CM 2.5gm/50ml Injection, 500mg/10ml Exemestane (Tablet) CM Injection, 5gm/100ml Injection) Letrozole (Tablet) CM Fluorouracil (5% Cream) 1 Folotyn (Injection) 4 PA Etopophos (Injection) 4 Gemcitabine (Injection) 4

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Etoposide (100mg/5ml Injection, 4 Vectibix (Injection) 4 1gm/50ml Injection, 500mg/25ml Yervoy (Injection) 4 PA Injection) Etoposide (50mg Capsule) CM Bexarotene (Capsule) CM PA Hycamtin (0.25mg Capsule, 1mg CM Capsule) Panretin (Gel) 3 Kyprolis (30mg Injection) 4 PA Targretin (1% Gel) 3 Toposar (Injection) 4 Tretinoin (10mg Capsule) CM Topotecan HCl (4mg Injection) 4 Topotecan HCl (4mg/4ml 4 Albenza (Tablet) 3 Injection) Biltricide (Tablet) 2 Zydelig (Tablet) CM PA Ivermectin (Tablet) 1

Afinitor (Tablet) CM PA,QL Alinia (100mg/5ml Suspension, 2 Afinitor Disperz (Tablet Soluble) CM PA 500mg Tablet) Bosulif (Tablet) CM PA Atovaquone (Suspension) 1 Cabometyx (Tablet) CM PA Atovaquone/Proguanil HCl (Tablet) 1 Cometriq (Kit) CM PA Chloroquine Phosphate (250mg 1 Erivedge (Capsule) CM PA Tablet, 500mg Tablet) Gilotrif (Tablet) CM PA,QL Coartem (Tablet) 3 Iclusig (15mg Tablet) CM PA,QL DARAPRIM (Tablet) 3 PA Iclusig (45mg Tablet) CM PA Hydroxychloroquine Sulfate 1 Imatinib Mesylate (Tablet) CM PA (Tablet) Imbruvica (Capsule) CM PA Mefloquine HCl (Tablet) 1 Inlyta (Tablet) CM PA Nebupent (Inhalation Solution) 2 Lenvima (Capsule Therapy Pack) CM PA Primaquine Phosphate (Tablet) 1 Mekinist (Tablet) CM PA Quinine Sulfate (324mg Capsule) 1 PA Nexavar (Tablet) CM PA Tinidazole (Tablet) 1 Sprycel (Tablet) CM PA Stivarga (Tablet) CM PA Eurax (10% Cream, 10% Lotion) 2 Sutent (Capsule) CM PA Lindane (Shampoo) 1 Tafinlar (Capsule) CM PA Malathion (Lotion) 1 Tarceva (Tablet) CM PA,QL Permethrin (Cream) 1 Tasigna (Capsule) CM PA Sklice (Lotion) 3 Tykerb (Tablet) CM PA Spinosad (Suspension) 1 Votrient (Tablet) CM PA Ulesfia (Lotion) 3 Xalkori (Capsule) CM PA Zelboraf (Tablet) CM PA,QL Benztropine Mesylate (0.5mg 1 Zykadia (Capsule) CM PA Tablet, 1mg Tablet, 2mg Tablet, 1mg/ml Injection) Adcetris (Injection) 4 PA Trihexyphenidyl HCl (0.4mg/ml 1 Arzerra (Injection) 4 PA Elixir, 2mg Tablet, 5mg Tablet) Avastin (Injection) 4 Blincyto (Injection) 4 PA Darzalex (Injection) 4 PA Amantadine HCl (100mg Capsule, 1 Empliciti (Injection) 4 PA 100mg Tablet, 50mg/5ml Syrup) Erbitux (Injection) 4 PA Entacapone (Tablet) 1 Gazyva (Injection) 4 PA Tolcapone (Tablet) 1 Herceptin (Injection) 4 PA Opdivo (Injection) 4 PA Apokyn (Injection) 4 PA,QL Perjeta (Injection) 4 PA Neupro (Patch 24 Hour) 3 Rituxan (Injection) 4 PA Pramipexole Dihydrochloride 1 Tagrisso (Tablet) CM PA,QL (Tablet Immediate-Release) Tecentriq (Injection) 4 Pramipexole Dihydrochloride ER 1 Unituxin (Injection) 4 (Tablet Extended-Release 24 Hour)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Ropinirole ER (Tablet Extended- 1 Ziprasidone HCl (Capsule) 1 QL Release 24 Hour) Ropinirole HCl (Tablet) 1 Clozapine (Tablet Immediate- 1 QL Release) Clozapine ODT (Tablet Dispersible) 1 QL Fazaclo (12.5mg Tablet 3 QL Carbidopa (Tablet) 1 Dispersible, 150mg Tablet Dispersible, 200mg Tablet Carbidopa/Levodopa (Tablet 1 Dispersible) Immediate-Release) Carbidopa/Levodopa ER (Tablet 1 Extended-Release) Baclofen (10mg Tablet, 20mg 1 Carbidopa/Levodopa/Entacapone 1 Tablet) (Tablet) Cyproheptadine HCl (2mg/5ml 1 Syrup, 4mg Tablet) Dantrolene Sodium (Capsule) 1 Gabapentin (100mg Capsule, 300mg 1 Rasagiline Mesylate (Tablet) 1 Capsule, 400mg Capsule, Selegiline HCl (5mg Capsule, 5mg 1 250mg/5ml Oral Solution, 600mg Tablet) Tablet, 800mg Tablet) Tizanidine HCl (2mg Capsule, 4mg 1 Fluphenazine Decanoate (Injection) 1 Capsule, 6mg Capsule, 2mg Tablet, Fluphenazine HCl (10mg Tablet, 1 4mg Tablet) 1mg Tablet, 2.5mg Tablet, 5mg Tablet) Haloperidol (0.5mg Tablet, 10mg 1 Fluzone Quadrivalent 2016-2017 2 PV Tablet, 1mg Tablet, 20mg Tablet, (Injection) 2mg Tablet, 5mg Tablet, 2mg/ml Concentrate) Haloperidol Decanoate (Injection) 1 Haloperidol Lactate (Injection) 1 Cidofovir (Injection) 1 Loxapine Succinate (Capsule) 1 Ganciclovir (Injection) 1 Molindone HCl (Tablet) 1 Valganciclovir (Tablet) 4 Pimozide (Tablet) 1 Valganciclovir Hydrochlorde (Oral 4 Thioridazine HCl (Tablet) 1 Solution) Thiothixene (Capsule) 1 Zirgan (Gel) 3 Trifluoperazine HCl (Tablet) 1 Adefovir Dipivoxil (Tablet) 4 Fanapt (Tablet) 3 QL,ST Baraclude (0.05mg/ml Oral 4 QL Fanapt Titration Pack (Tablet) 3 QL,ST Solution) Invega Sustenna (Injection) 3 Entecavir (Tablet) 4 QL Invega Trinza (Injection) 3 Epivir HBV (5mg/ml Oral 2 Latuda (Tablet) 3 QL,ST Solution) Lamivudine (100mg Tablet) Olanzapine (Tablet Immediate- 1 QL 1 Release) Olanzapine ODT (Tablet 1 QL Daklinza (Tablet) 4 PA,QL Dispersible) Epclusa (Tablet) 4 PA,QL Paliperidone ER (Tablet Extended- 1 Harvoni (Tablet) 4 PA Release 24 Hour) Moderiba 4 Rexulti (Tablet) 3 QL Moderiba (200mg Tablet) 4 Risperidone (0.25mg Tablet, 0.5mg 1 QL Moderiba 1200 Dose Pack 4 Tablet, 1mg Tablet, 2mg Tablet, (Tablet) 3mg Tablet, 4mg Tablet, 1mg/ml Moderiba 800 Dose Pack (Tablet) 4 Oral Solution) Olysio (Capsule) 4 PA,QL Risperidone ODT (Tablet 1 QL Dispersible) Peg intron Redipen (Injection) 4 PA Saphris (10mg Tablet Sublingual) 2 PegIntron (Injection) 4 PA Rebetol (40mg/ml Oral Solution) 4

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Ribasphere (200mg Capsule, 200mg 4 Viread (150mg Tablet, 200mg 2 Tablet) Tablet, 250mg Tablet, 300mg Ribasphere (400mg Tablet, 600mg 4 Tablet, 40mg/gm Powder) Tablet) Zerit (1mg/ml Oral Solution) 2 Ribasphere Ribapak (Tablet) 4 Ziagen (20mg/ml Oral Solution) 2 Ribavirin (200mg Capsule, 200mg 4 Zidovudine (100mg Capsule, 300mg 1 Tablet) Tablet, 50mg/5ml Syrup) Sovaldi (Tablet) 4 PA,QL Viekira Pak (Tablet Therapy 4 PA,QL Fuzeon (Injection) 2 QL Pack) Selzentry (150mg Tablet, 300mg 2 PA Zepatier (Tablet) 4 PA,QL Tablet) Tybost (Tablet) 2

Atripla (Tablet) 2 Isentress (100mg Packet, 100mg 2 Aptivus (100mg/ml Oral Solution, 2 Tablet Chewable, 25mg Tablet 250mg Capsule) Chewable, 400mg Tablet) Crixivan (Capsule) 2 Tivicay (Tablet) 2 Evotaz (Tablet) 2 Invirase (200mg Capsule, 500mg 2 Tablet) Complera (Tablet) 2 Kaletra (100mg-25mg Tablet, 2 Edurant (Tablet) 2 200mg-50mg Tablet) Intelence (Tablet) 2 Lexiva (50mg/ml Suspension, 2 Nevirapine (200mg Tablet, 1 700mg Tablet) 50mg/5ml Suspension) Lopinavir/Ritonavir (Solution) 1 Nevirapine ER (Tablet Extended- 1 Norvir (100mg Capsule, 100mg 2 Release 24 Hour) Tablet, 80mg/ml Oral Solution) Odefsey (Tablet) 2 Prezcobix (Tablet) 2 Rescriptor (Tablet) 2 Prezista (100mg/ml Suspension, 2 Stribild (Tablet) 2 150mg Tablet, 600mg Tablet, 75mg Tablet, 800mg Tablet) Sustiva (200mg Capsule, 50mg 2 Capsule, 600mg Tablet) Reyataz (150mg Capsule, 200mg 2 Capsule, 300mg Capsule, 50mg Viramune (50mg/5ml Suspension) 2 Packet) Viracept (Tablet) 2

Flulaval Quadrivalent 2016-2017 2 PV Abacavir (Tablet) 1 (Injection) Abacavir 1 Flumist Quadrivalent 2 PV Sulfate/Lamivudine/Zidovudine (Suspension) (Tablet) Medical Provider Single Use EZ 2 PV Abacavir/Lamivudine (Tablet) 1 Flu Shot (Injection) Didanosine (Capsule Delayed- 1 Oseltamivir Phosphate (Capsule) 1 QL Release) Relenza Diskhaler (Aerosol 3 QL Emtriva (10mg/ml Oral Solution, 2 Powder) 200mg Capsule) Rimantadine HCl (Tablet) 1 Lamivudine (10mg/ml Oral 1 Tamiflu (6mg/ml Suspension) 3 QL Solution, 150mg Tablet, 300mg Tablet) Lamivudine/Zidovudine (Tablet) 1 Acyclovir (200mg Capsule, 1 Retrovir IV Infusion (Solution) 2 200mg/5ml Suspension, 400mg Tablet, 800mg Tablet, 5% Stavudine (Capsule) 1 Ointment) Triumeq (Tablet) 2 Acyclovir Sodium (Injection) 1 Truvada (Tablet) 2 Denavir (Cream) 3 Videx Pediatric (Oral Solution) 2 Famciclovir (Tablet) 1 Trifluridine (Ophthalmic Solution) 1

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Valacyclovir HCl (Tablet) 1 QL Bydureon Pen (Injection) 2 QL,ST Zovirax (5% Cream) 2 Bydureon Vial (Injection) 2 QL,ST Byetta (Injection) 2 QL,ST Buspirone HCl (Tablet) 1 Chlorpropamide (Tablet) 1 Dexmedetomidine HCl (Injection) 1 Cycloset (Tablet) 3 ST Meprobamate (Tablet) 1 Farxiga (Tablet) 3 ST Glimepiride (Tablet) 1 Glipizide (Tablet Immediate- 1 Alprazolam (Tablet Immediate- 1 QL Release) Release) Glipizide ER (Tablet Extended- 1 Alprazolam ER (Tablet Extended- 1 QL Release 24 Hour) Release 24 Hour) Glipizide XL (Tablet Extended- 1 Alprazolam ODT (Tablet 1 Release 24 Hour) Dispersible) Glipizide/Metformin HCl (Tablet) 1 Alprazolam XR (Tablet Extended- 1 QL Glyburide (1.25mg Tablet, 2.5mg 1 Release 24 Hour) Tablet, 5mg Tablet) Chlordiazepoxide HCl (Capsule) 1 QL Glyburide Micronized (Tablet) 1 Estazolam (Tablet) 1 QL Glyburide/Metformin HCl (Tablet) 1 Flurazepam HCl (Capsule) 1 PA,QL Invokamet (Tablet) 2 ST Lorazepam (20mg/10ml Injection, 1 Invokamet XR (Tablet Extended- 2 ST 4mg/ml Injection) Release 24 Hour) Lorazepam Intensol (2mg/ml 1 Invokana (Tablet) 2 ST Concentrate) Janumet (Tablet) 2 ST Oxazepam (Capsule) 1 QL Janumet XR (Tablet Extended- 2 ST Quazepam (Tablet) 1 QL Release 24 Hour) Temazepam (Capsule) 1 QL Januvia (Tablet) 2 ST Triazolam (Tablet) 1 QL Jardiance (Tablet) 3 ST Kombiglyze XR (Tablet 2 ST Extended-Release 24 Hour) Ephedrine Sulfate (Solution) 1 Metformin HCl (Tablet) 1 Phenylephrine HCl/Sodium 1 Metformin HCl ER (Tablet 1 Chloride (50mg/250ml-0.9% Extended-Release 24 Hour) Solution) (Generic for Fortamet, Generic for Glucophage XR) Metformin HCl ER (Tablet 1 PA Olanzapine/Fluoxetine (Capsule) 1 QL Extended-Release 24 Hour) (Generic for Glumetza) Lithium (Oral Solution) 1 Miglitol (Tablet) 1 Lithium Carbonate (150mg Capsule, 1 Nateglinide (Tablet) 1 300mg Capsule, 600mg Capsule, Nesina (Tablet) 3 ST 300mg Tablet) Onglyza (Tablet) 2 ST Lithium Carbonate ER (Tablet 1 Pioglitazone HCl (Tablet) 1 Extended-Release) Pioglitazone HCl/Glimepiride 1 (Tablet) Pioglitazone HCl/Metformin HCl 1 (Tablet) Heparin Sodium/Sodium Chloride 1 Repaglinide (Tablet) 1 (2000unit/500ml-0.9% Solution) Repaglinide/Metformin HCl 1 (Tablet) Riomet (Oral Solution) 3 Mircera (150mcg/0.3ml Injection, 4 PA SymlinPen 120 (Injection) 3 PA 30mcg/0.3ml Injection) SymlinPen 60 (Injection) 3 PA Synjardy (Tablet), Synjardy XR 2 ST (Tablet) Tolazamide (Tablet) Acarbose (Tablet) 1 1 Tolbutamide (Tablet) Alogliptin (Tablet) 3 ST 1 Avandia (Tablet) 3 ST Tradjenta (Tablet) 3 ST

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Tranylcypromine Sulfate (Tablet) 1 Bivalirudin (Injection) 1 Trulicity (Injection) 2 QL,ST Ceprotin (Injection) 4 Victoza (Injection) 2 QL,ST Eliquis (Tablet) 3 QL Welchol (3.75gm Packet, 625mg 2 Enoxaparin Sodium (100mg/ml 1 QL Tablet) Injection, 120mg/0.8ml Injection, Xigduo XR (Tablet Extended- 3 ST 150mg/ml Injection, 30mg/0.3ml Release 24 Hour) Injection, 40mg/0.4ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection, 300mg/3ml Injection) Dextrose 70% (Injection) 1 Fondaparinux Sodium (Injection) 1 QL GlucaGen HypoKit (Injection) 2 Fragmin (Injection) 3 QL Glucagon Emergency Kit 2 Heparin Lock Flush (Injection) 1 (Injection) Heparin Sodium (10000unit/10ml 1 Proglycem (Suspension) 2 Injection, 3000unit/3ml Injection, 5000unit/5ml Injection, Apidra (Injection) 3 ST 10000unit/ml Injection, 1000unit/ml Injection, 20000unit/ml Injection, Apidra SoloST 3 ST 5000unit/0.5ml Injection, Humalog (Injection) 2 5000unit/ml Injection) Humalog KwikPen (Injection) 2 Heparin Sodium Lock Flush (Kit) 1 Humalog Mix 50/50 (Injection) 2 Heparin Sodium/D5W (5%- 1 Humalog Mix 50/50 KwikPen 2 40unit/ml Injection, 5%-50unit/ml (Injection) Injection) Humalog Mix 75/25 (Injection) 2 Heparin Sodium/NaCl 0.9% 1 Humalog Mix 75/25 KwikPen 2 (Injection) (Injection) Heparin Sodium/Sodium Ch Loride 1 Humulin 70/30 (Injection) 2 (Injection) Humulin 70/30 KwikPen 2 Heparin Sodium/Sodium Chloride 1 (Injection) (20unit/20ml-0.9% Injection, Humulin N (Injection) 2 25000unit/250ml-0.45% Injection, Humulin N KwikPen (Injection) 2 30000unit/L-0.9% Injection, Humulin R (Injection) 2 4000unit/L-0.9% Injection, 50unit/50ml-0.45% Injection) Humulin R U-500 (Concentrated) 2 (Injection) Heparin Sodium/Sodium Chloride 1 0.9% Premix (Injection) Lantus (Injection) 2 Jantoven (Tablet) 1 Lantus SoloStar (Injection) 2 Pradaxa (Capsule) 2 QL Levemir (Injection) 3 Sash Kit for Flushing Vascular 1 Levemir FlexTouch (Injection) 3 Access Devices (Kit) Novolin 70/30 (Injection) 2 Thrombate III (Injection) 4 Novolin 70/30 Relion (Injection) 2 Thrombate III w/20 Ml Sterile 4 Novolin N (Injection) 2 Water (Injection) Novolin N Relion (Injection) 2 Warfarin Sodium (Tablet) 1 Novolin R (Injection) 2 Xarelto (Tablet) 2 QL Novolin R Relion (Injection) 2 Xarelto Starter Pack (Tablet 2 QL NovoLog (Injection) 2 Therapy Pack) NovoLog FlexPen (Injection) 2 NovoLog Mix 70/30 (Injection) 2 NovoLog Mix 70/30 Prefilled 2 FlexPen (Injection) Anagrelide HCl (Capsule) 1 NovoLog PenFill (Injection) 2 Leukine (Injection) 4 PA Toujeo SoloStar (Injection) 2 Mircera (100mcg/0.3ml Injection, 4 PA 200mcg/0.3ml Injection, 50mcg/0.3ml Injection, 75mcg/0.3ml Injection) Argatroban (125mg/125ml-0.9% 3 Mozobil (Injection) 4 PA,QL Injection, 250mg/250ml-0.9% Neulasta (Injection) 4 PA Injection) Neulasta Onpro Kit (Injection) 4 PA Argatroban (250mg/2.5ml Injection) 1 Neupogen (Injection) 4 PA

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Nplate (Injection) 4 PA Xyntha (Injection) 4 Procrit (Injection) 4 PA Xyntha Solofuse (Injection) 4 Promacta (Tablet) 4 PA

Aggrastat (Injection) 3 Albuked 25 (Injection) 1 Aspirin/Dipyridamole (Capsule 1 Albuked 5 (Injection) 1 Extended-Release 12 Hour) Albumin Human (Injection) 1 Brilinta (60mg Tablet) 2 Albumin-Zlb (Injection) 1 Cilostazol (Tablet) 1 Albuminar-25 (Injection) 1 Clopidogrel (Tablet) 1 Albuminar-5 (Injection) 1 Dipyridamole (25mg Tablet, 50mg 1 Alburx (Injection) 1 Tablet, 75mg Tablet) Albutein (Injection) 1 Effient (Tablet) 2 Buminate (Injection) 1 Eptifibatide (Injection) 1 Flexbumin (Injection) 1 Zontivity (Tablet) 3 Hetastarch 6%/NaCl (Injection) 1 Kedbumin (Injection) 1 Plasbumin-25 (Injection) 1 Clonidine HCl (0.1mg Tablet, 1 Plasbumin-5 (Injection) 1 0.2mg Tablet, 0.3mg Tablet, 0.1mg/24hr Patch Weekly, 0.2mg/24hr Patch Weekly, 0.3mg/24hr Patch Weekly, Advate (Injection) 4 100mcg/ml Injection, 500mcg/ml Alphanate/Von Willebrand Factor 4 Injection) Complex/Human (Injection) Guanfacine HCl (Tablet Immediate- 1 Alphanine SD (Injection) 4 Release) Bebulin (Injection) 4 Methyldopa (Tablet) 1 Benefix (Injection) 4 Methyldopa/Hydrochlorothiazide 1 Brilinta (90mg Tablet) 2 (Tablet) Coagadex (Injection) 4 Methyldopate HCl (Injection) 1 Corifact (Injection) 4 Midodrine HCl (Tablet) 1 Eloctate (Injection) 4 Phenylephrine HCl (10mg/ml 1 Feiba (Injection) 4 Injection) Helixate FS (Injection) 4 Hemofil M (Injection) 4 Humate-P (Injection) 4 Doxazosin (Tablet) 1 Idelvion (Injection) 4 Doxazosin Mesylate (Tablet) 1 Koate (Solution) 4 Phenoxybenzamine HCl (Capsule) 1 Koate-Dvi (Injection) 4 Prazosin HCl (1mg Capsule, 2mg 1 Kogenate FS (Injection) 4 Capsule, 5mg Capsule) Kogenate FS Bio-Set (Injection) 4 Terazosin HCl (Capsule) 1 Monoclate-P (Injection) 4 Mononine (Injection) 4 Novoseven (Solution) 4 Amlodipine Besylate/Valsartan 1 Novoseven RT (Injection) 4 (Tablet) Obizur (Injection) 4 Amlodipine/Olmesartan Medoxomil 1 Profilnine (Injection) 4 (Tablet) Recombinate (Injection) 4 Amlodipine/Valsartan/Hydrochlorot 1 Riastap (Injection) 4 hiazide (Tablet) Rixubis (Injection) 4 Candesartan Cilexetil (Tablet) 1 Tranexamic Acid (1000mg/10ml 1 Candesartan 1 Injection, 1000mg/10ml Solution, Cilexetil/Hydrochlorothiazide 650mg Tablet) (Tablet) Tretten (Injection) 4 Edarbi (Tablet) 3 Vonvendi (Injection) 4 Eprosartan Mesylate (Tablet) 1

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Irbesartan (Tablet) 1 Adenosine (12mg/4ml Injection, 1 Irbesartan/Hydrochlorothiazide 1 6mg/2ml Injection) (Tablet) Amiodarone HCl (100mg Tablet, 1 Losartan Potassium (Tablet) 1 200mg Tablet, 400mg Tablet, Losartan 1 50mg/ml Injection) Potassium/Hydrochlorothiazide Amiodarone HCl/Dextrose 1 (Tablet) (Injection) Olmesartan Medoxomil (Tablet) 1 Dilt-XR (Capsule Extended-Release 1 Olmesartan 1 24 Hour) Medoxomil/Amlodipine/Hydrochlor Diltiazem HCl (Tablet Immediate- 1 othiazide (Tablet) Release) Olmesartan 1 Diltiazem HCl ER (Capsule 1 Medoxomil/Hydrochlorothiazide Extended-Release 24 Hour; Capsule (Tablet) Extended-Release 12 Hour) Telmisartan (Tablet) 1 Disopyramide Phosphate (Capsule) 1 Telmisartan/Amlodipine (Tablet) 1 Dofetilide (Capsule) 1 Telmisartan/Hydrochlorothiazide 1 Flecainide Acetate (Tablet) 1 (Tablet) Ibutilide Fumarate (Injection) 1 Valsartan (Tablet) 1 Lidocaine HCl (10mg/ml Injection, 1 Valsartan/Hydrochlorothiazide 1 20mg/ml Injection) (Tablet) Lidocaine HCl in D5W (Injection) 1 Mexiletine HCl (Capsule) 1 Multaq (Tablet) 3 Nexterone (150mg/100ml- 3 Amlodipine Besylate/Benazepril 1 42.1mg/ml Injection) HCl (Capsule) Norpace CR (100mg Capsule 2 Benazepril HCl (Tablet) 1 Extended-Release 12 Hour) Benazepril 1 Pacerone (Tablet) 1 HCl/Hydrochlorothiazide (Tablet) Procainamide HCl (500mg/ml 1 Captopril (Tablet) 1 Solution) Captopril/Hydrochlorothiazide 1 Propafenone HCl (Tablet) 1 (Tablet) Propafenone HCl ER (Capsule 1 Enalapril Maleate (Tablet) 1 Extended-Release 12 Hour) Enalapril 1 Quinidine Gluconate CR (Tablet 1 Maleate/Hydrochlorothiazide Extended-Release) (Tablet) Quinidine Gluconate ER (Tablet 1 Enalaprilat (Injection) 1 Extended-Release) Fosinopril Sodium (Tablet) 1 Quinidine Sulfate (Tablet) 1 Fosinopril 1 Sorine (Tablet) 1 Sodium/Hydrochlorothiazide (Tablet) Sotalol HCl (AF) (Tablet) 1 Lisinopril (Tablet) 1 Sotalol HCl (Tablet) 1 Lisinopril/Hydrochlorothiazide 1 Taztia XT (Capsule Extended- 1 (Tablet) Release 24 Hour) Moexipril HCl (Tablet) 1 Moexipril/Hydrochlorothiazide 1 (Tablet) Acebutolol HCl (200mg Capsule, 1 Perindopril Erbumine (Tablet) 1 400mg Capsule) Quinapril HCl (Tablet) 1 Atenolol (100mg Tablet, 25mg 1 Quinapril/Hydrochlorothiazide 1 Tablet, 50mg Tablet) (Tablet) Atenolol/Chlorthalidone (Tablet) 1 Ramipril (Capsule) 1 Betaxolol HCl (10mg Tablet, 20mg 1 Trandolapril (Tablet) 1 Tablet) Trandolapril/Verapamil HCl (Tablet 1 Bisoprolol Fumarate (Tablet) 1 Extended-Release) Bisoprolol 1 Trandolapril/Verapamil HCl ER 1 Fumarate/Hydrochlorothiazide (Tablet Extended-Release) (Tablet) Bystolic (Tablet) 2

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Carvedilol (Tablet) 1 Matzim LA (Tablet Extended- 1 Coreg CR (Capsule Extended- 3 ST Release 24 Hour) Release 24 Hour) Nicardipine HCl (2.5mg/ml 1 Esmolol HCl (Injection) 1 Injection, 20mg Capsule, 30mg Hemangeol (Oral Solution) 3 Capsule) Inderal XL (Capsule Extended- 3 Nifedipine (10mg Capsule, 20mg 1 Release 24 Hour) Capsule) Innopran XL (Capsule Extended- 3 Nifedipine ER (Tablet Extended- 1 Release 24 Hour) Release 24 Hour) Labetalol HCl (100mg Tablet, 1 Nimodipine (Capsule) 1 200mg Tablet, 300mg Tablet, Nisoldipine (Tablet Extended- 1 5mg/ml Injection) Release 24 Hour) Metoprolol Succinate ER (Tablet 1 Nisoldipine ER (Tablet Extended- 1 Extended-Release 24 Hour) Release 24 Hour) Metoprolol Tartrate (100mg Tablet, 1 Verapamil HCl (Tablet Immediate- 1 25mg Tablet, 37.5mg Tablet, 50mg Release, 2.5mg/ml Injection) Tablet, 75mg Tablet, 5mg/5ml Verapamil HCl ER (100mg, 120mg, 1 Injection) 180mg, 200mg, 240mg, 300mg Metoprolol/Hydrochlorothiazide 1 Capsule Extended-Release 24 Hour; (Tablet) 120mg, 180mg, 240mg Tablet Nadolol (20mg Tablet, 40mg Tablet, 1 Extended-Release) 80mg Tablet) Verapamil HCl SR (Capsule 1 Nadolol/Bendroflumethiazide 1 Extended-Release 24 Hour) (Tablet) Pindolol (Tablet) 1 Norepinephrine Bitartrate (Injection) 1 Propranolol HCl (Tablet Immediate- 1 Release, 1mg/ml Injection, Oral Solution) Propranolol HCl (Tablet) 1 Demser (Capsule) 3 Propranolol HCl ER (Capsule 1 Digitek (Tablet) 1 Extended-Release 24 Hour) Digox (Tablet) 1 Propranolol/Hydrochlorothiazide 1 Digoxin (0.05mg/ml Oral Solution, 1 (Tablet) 0.25mg/ml Injection, 125mcg Timolol Maleate (10mg Tablet, 1 Tablet, 250mcg Tablet) 20mg Tablet, 5mg Tablet) Dobutamine HCl (Injection) 1 Dobutamine HCl/D5W (Injection) 1 Dopamine HCl (40mg/ml Injection, 1 80mg/ml Injection) Afeditab CR (Tablet Extended- 1 Dopamine/D5W (Injection) 1 Release 24 Hour) Mannitol (Injection) 1 Amlodipine Besylate (Tablet) 1 Milrinone in Dextrose (5%- 1 Amlodipine Besylate/Atorvastatin 1 20mg/100ml Injection, 5%- Calcium (Tablet) 40mg/200ml Solution) Cardene IV (20mg/200ml-0.86% 3 Milrinone Lactate (Injection) 1 Injection) Osmitrol Viaflex (15% Injection, 1 Cardizem LA (120mg Tablet 3 20% Injection) Extended-Release 24 Hour) Pentoxifylline ER (Tablet Extended- 1 Cartia XT (Capsule Extended- 1 Release) Release 24 Hour) Praluent (Injection) 4 PA,QL Diltiazem CD (Capsule Extended- 1 Release 24 Hour) Ranexa (Tablet Extended-Release 2 ST 12 Hour) Diltiazem HCl CD (Capsule 1 Extended-Release 24 Hour) Repatha (Injection) 4 PA,QL Diltiazem HCl ER (Capsule 1 Repatha Pushtronex System 4 PA,QL Extended-Release 24 Hour, Tablet (Injection) Extended-Release 24 Hour) Repatha SureClick (Injection) 4 PA,QL Felodipine ER (Tablet Extended- 1 Tekturna (Tablet) 2 ST Release 24 Hour) Vecamyl (Tablet) 3 Isradipine (Capsule) 1

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Gemfibrozil (600mg Tablet) 1 Acetazolamide (Tablet Immediate- 1 Triglide (Tablet) 3 Release) Dorzolamide HCl (Ophthalmic 1 Solution) Atorvastatin Calcium (Tablet) 1 Methazolamide (Tablet) 1 Fluvastatin (Capsule) 1 Fluvastatin Sodium ER (Tablet 1 Bumetanide (0.25mg/ml Injection, 1 Extended-Release 24 Hour) 0.5mg Tablet, 1mg Tablet, 2mg Livalo (Tablet) 3 Tablet) Lovastatin (Tablet) 1 Ethacrynate Sodium (Injection) 1 Pravastatin Sodium (Tablet) 1 Ethacrynic Acid (Tablet) 1 Rosuvastatin Calcium (Tablet) 1 Furosemide (10mg/ml Injection, 1 Simvastatin (10mg Tablet, 20mg 1 10mg/ml Oral Solution, 8mg/ml Tablet, 40mg Tablet, 5mg Tablet) Oral Solution, 20mg Tablet, 40mg Tablet, 80mg Tablet) Simvastatin (80mg Tablet) 1 PA Torsemide (Tablet) 1

Cholestyramine (Powder) 1 Cholestyramine Light (Powder) Amiloride HCl (5mg Tablet) 1 1 Colestipol HCl (1gm Tablet, 5gm Amiloride/Hydrochlorothiazide 1 1 (Tablet) Packet) Ezetimibe (Tablet) Dyrenium (0-100mg Capsule) 3 1 Eplerenone (Tablet) 1 Juxtapid (Capsule) 4 PA,QL Niacin ER (Tablet Extended- Spironolactone (100mg Tablet, 1 1 25mg Tablet, 50mg Tablet) Release) Omega-3-Acid Ethyl Esters Spironolactone/Hydrochlorothiazide 1 1 (Tablet) (Capsule) Prevalite (4gm Packet, 4gm/dose Triamterene/Hydrochlorothiazide 1 1 (25mg-37.5mg Tablet, 50mg-75mg Powder) Tablet, 37.5mg-25mg Capsule, Vascepa (Capsule) 2 50mg-25mg Capsule)

Chlorothiazide (Tablet) 1 Hydralazine HCl (100mg Tablet, 1 Chlorothiazide Sodium (Injection) 1 10mg Tablet, 25mg Tablet, 50mg Chlorthalidone (25mg Tablet, 50mg 1 Tablet, 20mg/ml Injection) Tablet) Minoxidil (Tablet) 1 Hydrochlorothiazide (12.5mg 1 Capsule, 12.5mg Tablet, 25mg Tablet, 50mg Tablet) BiDil (Tablet) 3 Indapamide (Tablet) 1 Dilatrate SR (Capsule Extended- 2 Methyclothiazide (5mg Tablet) 1 Release) Metolazone (Tablet) 1 Isosorbide Dinitrate (Tablet 1 Tekturna HCT (Tablet) 2 ST Immediate-Release) Isosorbide Dinitrate ER (Tablet 1 Extended-Release) Fenofibrate (120mg Tablet, 145mg 1 Isosorbide Mononitrate (Tablet 1 Tablet, 160mg Tablet, 40mg Tablet, Immediate-Release) 48mg Tablet, 54mg Tablet, 130mg Isosorbide Mononitrate ER (Tablet 1 Capsule, 150mg Capsule, 43mg Extended-Release 24 Hour) Capsule, 50mg Capsule) Minitran (Patch 24 Hour) 1 Fenofibrate Micronized (Capsule) 1 Nitro-Bid (Ointment) 2 Fenofibric Acid (Tablet) 1 Nitroglycerin (0.3mg Tablet 1 Fenofibric Acid DR (Capsule 1 Sublingual, 0.4mg Tablet Delayed-Release) Sublingual, 0.6mg Tablet Fibricor (35mg Tablet) 2 Sublingual)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Nitroglycerin ER (Capsule 1 Dexmethylphenidate HCl ER 1 QL Extended-Release) (MANUF (10mg, 15mg, 20mg, 30mg, 40mg, TRIMARC) 5mg, 25mg, 35mg Capsule Nitroglycerin in 5% Dextrose 1 Extended-Release 24 Hour) (Injection) Guanfacine ER (Tablet Extended- 1 Nitroglycerin in Dextrose 5% (5%- 1 Release 24 Hour) 100mcg/ml Injection) Metadate ER (Tablet Extended- 1 QL Nitroglycerin Lingual 1 Release) (0.4mg/sprayTranslingual Solution, Methylphenidate HCl (Tablet 1 QL 400mcg/spray Aerosol Solution) Immediate-Release, Tablet Nitroglycerin Transdermal (Patch 24 1 Chewable, Oral Solution) Hour) Methylphenidate HCl CD (Capsule 1 QL NitroMist (Aerosol Solution) 3 Extended-Release) Rectiv (Ointment) 3 Methylphenidate HCl ER (Tablet 1 QL Sodium Nitroprusside (Injection) 1 Extended-Release, Capsule Extended-Release 24 Hour) Methylphenidate HCl SR (Tablet 1 QL Extended-Release) Fentanyl Citrate/Bupivacaine 1 Quillivant XR (Suspension) 3 QL HCl/Sodium Chloride (Solution) Strattera (Capsule) 2 QL Hydromorphone HCl/Sodium 1 Chloride (10mg/25ml-0.9% Solution Prefilled Syringe, 1mg/5ml-0.9% Solution Prefilled Syringe, Caffeine Citrate (20mg/ml Oral 1 3mg/30ml-0.9% Solution Prefilled Solution, 60mg/3ml Injection) Syringe, 15mg/50ml-0.9% Injection) Flumazenil (Injection) 1 Hetlioz (Capsule) 4 PA,QL Horizant (Tablet Extended- 3 PA,QL Release) Namzaric (Capsule Extended- 2 QL Amphetamine/Dextroamphetamine 1 QL Release 24 Hour) (10mg, 12.5mg, 15mg, 20mg, 30mg, 5mg, 7.5mg Tablet; 10mg, 15mg, Nuedexta (Capsule) 3 20mg, 25mg, 30mg, 5mg Capsule Riluzole (Tablet) 1 PA,QL Extended-Release 24 Hour) Tetrabenazine (Tablet) 4 PA Dexedrine (10mg Tablet, 5mg 1 QL Tablet) Dextroamphetamine Sulfate (10mg 1 QL Savella (Tablet) 3 QL,ST Tablet, 5mg Tablet, 5mg/5ml Oral Solution) Dextroamphetamine Sulfate ER 1 (10mg Capsule Extended-Release Ampyra (Tablet Extended-Release 4 PA,QL 24 Hour, 5mg Capsule Extended- 12 Hour) Release 24 Hour) Aubagio (Tablet) 4 PA,QL Dextroamphetamine Sulfate ER 1 QL Avonex (Injection) 4 PA,QL (15mg Capsule Extended-Release Avonex Pen (Injection) 4 PA,QL 24 Hour) Betaseron (Injection) 4 PA,QL Methamphetamine HCl (Tablet) 1 QL Copaxone (Injection) 4 PA,QL Vyvanse (Capsule) 2 QL Gilenya (Capsule) 4 PA,QL Zenzedi (10mg Tablet, 5mg Tablet) 1 QL Glatopa (Injection) 4 PA,QL Tecfidera (Capsule Delayed- 4 PA,QL Release) Tecfidera Starter Pack 4 PA,QL Clonidine HCl ER (Tablet 1 Extended-Release 12 Hour) Cavarest (Gel) 1 Daytrana (Patch) 3 QL Cevimeline HCl (Capsule) 1 Dexmethylphenidate HCl (Tablet 1 QL Chlorhexidine Gluconate (0.12% 1 Immediate-Release) Solution)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Easygel (Gel) 1 Clindamycin Phosphate (1% 1 Karigel (Gel) 1 External Solution, 1% Foam, 1% Karigel-N (Gel) 1 Gel, 1% Lotion, 1% Swab) Kepivance (Injection) 4 Clindamycin Phosphate/Tretinoin 1 (Gel) Neutragard Advanced (Gel) 1 Clindamycin/Benzoyl Peroxide 1 Neutral Sodium Fluoride (Solution) 1 (Gel) Oralone (Paste) 1 Clobetasol Propionate (0.05% 1 Paroex (Solution) 1 Cream, 0.05% External Solution, Periogard (Solution) 1 0.05% Foam, 0.05% Gel, 0.05% Phos-Flur (Gel) 1 Liquid, 0.05% Lotion, 0.05% Pilocarpine HCl (5mg Tablet, 7.5mg 1 Ointment, 0.05% Shampoo) Tablet) Clobetasol Propionate Emollient 1 Topex Topical Anesthetic (Solution) 1 (Cream) Triamcinolone Acetonide (0.1% 1 Clocortolone Pivalate (Cream) 1 Paste) Clodan (Shampoo) 1 Triamcinolone in Orabase (Paste) 1 Condylox (0.5% Gel) 3 Cordran (4mcg/sqcm Tape) 3 Acitretin (Capsule) 1 Cormax Scalp Application (External 1 Adapalene (0.1% Cream, 0.1% Gel, 1 PA Solution) 0.3% Gel) Cortisporin (0.5%-0.5% Cream, 3 Adapalene Pump (Gel) 1 PA 1%-0.5% Ointment) Ala-Cort (Cream) 1 Cosentyx (Injection) 4 PA Alclometasone Dipropionate (0.05% 1 Cosentyx Sensoready Pen 4 PA Cream, 0.05% Ointment) (Injection) Alphatrex (Gel) 1 Desonide (0.05% Cream, 0.05% 1 Lotion, 0.05% Ointment) Amcinonide (0.1% Cream, 0.1% 1 Lotion, 0.1% Ointment) Desoximetasone (0.05% Cream, 1 0.25% Cream, 0.05% Gel, 0.05% Ammonium Lactate (12% Cream, 1 Ointment, 0.25% Ointment) 12% Lotion) (RX) Diclofenac Sodium (1% Gel) 1 QL Ana-Lex (Kit) 1 Diclofenac Sodium (1.5% 1 PA ApexiCon E (Cream) 1 Transdermal Solution) Augmented Betamethasone 1 Diflorasone Diacetate (0.05% 1 Dipropionate (0.05% Cream, 0.05% Cream, 0.05% Ointment) Gel, 0.05% Lotion, 0.05% Ointment) Doxepin HCl (Cream) 1 Avita (0.025% Cream, 0.025% Gel) 1 PA Doxycycline (40mg Capsule 1 Delayed-Release) Azelex (Cream) 3 Elidel (Cream) 2 ST Betamethasone Dipropionate 1 (0.05% Cream, 0.05% Lotion, Epiduo (Gel) 3 0.05% Ointment) Epiduo Forte (Gel) 3 Betamethasone Valerate (0.1% 1 Ery 1 Cream, 0.1% Lotion, 0.1% Erythromycin (2% External 1 Ointment, 0.12% Foam) Solution, 2% Gel, 2% Pad) BP Cleansing Wash (Emulsion) 3 Erythromycin/Benzoyl Peroxide 1 Calcipotriene (0.005% Cream, 1 (Gel) 0.005% External Solution, 0.005% Finacea (15% Foam, 15% Gel) 2 Ointment) Fluocinolone Acetonide (0.01% 1 Calcipotriene/Betamethasone 1 QL Cream, 0.025% Cream, 0.01% Dipropionate (Ointment) External Solution, 0.01% Oil, Calcitrene (Ointment) 1 0.025% Ointment) Calcitriol (3mcg/gm Ointment) 1 Fluocinolone Acetonide Body (Oil) 1 Capex (Shampoo) 3 Fluocinolone Acetonide Ear Drops 1 Cerovel (40% Gel, 40% Lotion) 1 (Oil) Claravis (Capsule) 1 PA Fluocinolone Acetonide Scalp (Oil) 1 Clindacin ETZ Pledgets (Swab) 1 Fluocinonide (0.05% Cream, 0.1% 1 Cream, 0.05% External Solution, Clindacin-P (Swab) 1 0.05% Gel, 0.05% Ointment) Clindamax (Gel) 1

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Fluocinonide-E (Cream) 1 Salicylic Acid (6% Cream, 6% Gel, 1 Fluoroplex (Cream) 3 6% Lotion) Fluorouracil (0.5% Cream) 1 Salicylic Acid Cream (Kit) 1 Fluorouracil (2% External Solution, 4 Salicylic Acid Lotion (Kit) 1 5% External Solution) Salitech Forte (Lotion) 1 Flurandrenolide (0.05% Cream, 1 Santyl (Ointment) 3 0.05% Lotion, 0.05% Ointment) Scalacort (Lotion) 1 Fluticasone Propionate (0.005% 1 Selenium Sulfide (Lotion) 1 Ointment, 0.05% Cream, 0.05% Stelara (45mg/0.5ml Injection, 4 PA Lotion) 90mg/ml Injection) Halobetasol Propionate (0.05% 1 Sulfacetamide Sodium (10% Lotion, 1 Cream, 0.05% Ointment) 10% Suspension) Halog (0.1% Cream, 0.1% 3 Taclonex (0.064%-0.005% 3 QL Ointment) Suspension) Hydrocortisone (1% Cream RX, 1 Tacrolimus (0.03% Ointment, 0.1% 1 2.5% Cream, 1% Ointment RX, Ointment) 2.5% Ointment, 2.5% Cream, 2.5% Tazorac (0.05% Cream, 0.1% 3 QL Lotion) Cream, 0.05% Gel, 0.1% Gel) Hydrocortisone 1% in Absorbase 1 Texacort (External Solution) 3 (Ointment) Tretinoin (0.01% Gel, 0.025% Gel, 1 PA Hydrocortisone Butyrate (0.1% 1 0.05% Gel, 0.025% Cream, 0.05% Cream, 0.1% External Solution, Cream, 0.1% Cream) 0.1% Ointment) Tretinoin Microsphere (Gel) 1 PA Hydrocortisone in Absorbase 1 (Ointment) Tretinoin Microsphere Pump (Gel) 1 PA Triamcinolone Acetonide (0.025% Hydrocortisone Valerate (0.2% 1 1 Cream, 0.2% Ointment) Cream, 0.1% Cream, 0.5% Cream, 0.025% Lotion, 0.1% Lotion, Imiquimod (Cream) 1 0.025% Ointment, 0.1% Ointment, Klofensaid II (Transdermal 1 PA 0.5% Ointment, 0.147mg/gm Solution) Aerosol Solution) Lactic Acid (Lotion) 1 Triderm (Cream) 1 Lactic Acid E (Cream) 1 Urea (40% Cream, 45% Lotion) 1 Lactic Acid with Vitamin E (Cream) 1 Urea Nail Gel (Gel) 1 Lidazone HC (Cream) 1 Urea Topical (Suspension) 1 Lidocaine HCl/Hydrocortisone 1 Urea-C40 (Lotion) 1 Acetate (0.5%-3% Cream, 0.5%-3% Uvadex (Injection) 3 Kit, 1%-3% Kit, 2%-2% Kit, 2.5%- 3% Kit) Valchlor (Gel) 4 PA Locoid (0.1% Lotion) 3 Vectical (Ointment) 2 LoKara (Lotion) 1 Veltin (Gel) 3 Methoxsalen (10mg Capsule) 1 Veregen (Ointment) 3 Zenatane (Capsule) Mirvaso (Gel) 2 1 PA Mometasone Furoate (0.1% External 1 Solution) Insulin Syringes, Needles (BD 2 Myorisan (Capsule) 1 PA MEDICAL) Neo-Synalar (Cream) 3 Vanishpoint Insulin 3 Neuac (Gel) 1 Syringe/1ml/29g X 5/16" Oracea (Capsule Delayed-Release) 3 Picato (Gel) 3 ST Podofilox (External Solution) 1 Magnesium Sulfate/Lactated 1 Prednicarbate (0.1% Cream, 0.1% 1 Ringers (100mg/500ml- Ointment) 20gm/500ml-150mg/500ml- Procto-Med HC (Cream) 1 3gm/500ml-1.55gm/500ml Solution) Procto-Pak (Cream) 1 Magnesium Sulfate/Sodium 1 Proctosol HC (Cream) 1 Chloride (4gm/100ml-0.9% Proctozone-HC (Cream) 1 Solution) Regranex (Gel) 3 PA

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Adagen (Injection) 4 Diphenoxylate/Atropine (2.5mg- 1 Aldurazyme (Injection) 4 PA 0.025mg Tablet, 2.5mg- Buphenyl (500mg Tablet) 4 0.025mg/5ml Liquid) Cerdelga (Capsule) 4 PA GaviLyte-H (Kit) 1 Cerezyme (Injection) 4 PA Lansoprazole/Amoxicillin/Clarithro 1 mycin (Therapy Pack) Creon (Capsule Delayed-Release) 2 Lofene (Tablet) 1 Cystadane (Powder) 4 Loperamide HCl (2mg Capsule) Cystagon (Capsule) 4 1 (RX) Elaprase (Injection) 4 PA Mytesi (Tablet Delayed-Release) 3 QL Elelyso (Injection) 4 PA Omeclamox-Pak (Therapy Pack) 2 Fabrazyme (Injection) 4 PA OsmoPrep (Tablet) 3 Kanuma (Injection) 4 PA Peg-Prep (Kit) 1 Kuvan (100mg Packet, 500mg 4 PA Packet, 100mg Tablet Soluble) Pylera (Capsule) 2 Lumizyme (Injection) 4 PA Relistor (12mg/0.6ml Injection, 2 PA,QL 8mg/0.4ml Injection) Naglazyme (Injection) 4 PA Ursodiol (250mg Tablet, 500mg 1 Orfadin (10mg Capsule, 20mg 4 Tablet, 300mg Capsule) Capsule, 2mg Capsule, 5mg Capsule) RAVICTI (Liquid) 4 PA Sodium Phenylbutyrate (Powder) 4 Cimetidine (200mg Tablet RX, 1 Strensiq (Injection) 4 PA 300mg Tablet, 400mg Tablet, Sucraid (Oral Solution) 4 800mg Tablet) Vimizim (Injection) 4 PA Cimetidine HCl (Oral Solution) 1 VPRIV (Injection) 4 PA Famotidine (200mg/20ml Injection, 1 Xiaflex (Injection) 4 PA 20mg/2ml Injection, 40mg/4ml Injection, 20mg Tablet, 40mg Zavesca (Capsule) 4 PA Tablet, 40mg/5ml Suspension) Zenpep (Capsule Delayed- 2 Nizatidine (150mg Capsule, 300mg 1 Release) Capsule, 15mg/ml Oral Solution) Ranitidine HCl (150mg Capsule, 1 300mg Capsule, 150mg Tablet RX, Atropen (0.5mg/0.7ml Injection) 3 300mg Tablet, 150mg/6ml Injection, 50mg/2ml Injection, 15mg/ml Atropine Sulfate (0.1mg/ml 1 Syrup, 75mg/5ml Syrup) Injection, 0.4mg/ml Injection, 1mg/ml Injection, 1mg/2.5ml Solution Prefilled Syringe) Chlordiazepoxide HCl/Clidinium 1 Alosetron HCl (Tablet) 1 PA Bromide (Capsule) Amitiza (Capsule) 2 QL,ST Cuvposa (Oral Solution) 3 Gattex (Injection) 4 PA Dicyclomine HCl (10mg Capsule, 1 Linzess (145mcg Capsule, 290mcg 2 QL,ST 10mg/5ml Oral Solution, 10mg/ml Capsule) Injection, 20mg Tablet) Glycopyrrolate (0.4mg/2ml 1 Injection, 1mg/5ml Injection, Alophen (Tablet Delayed-Release) 1 PV 4mg/20ml Injection, 1mg Tablet, Bisacodyl EC (Tablet Delayed- 1 PV 2mg Tablet) Release) Hyoscyamine Sulfate (0.125mg 1 Carters Little Pills (Tablet Delayed- 1 PV Tablet Dispersible) (MANUF Release) MARLEX, TRIGEN) Citroma (Oral Solution) 1 PV Methscopolamine Bromide (Tablet) 1 ClearLax (Powder) 1 PV Propantheline Bromide (15mg 1 Constulose (Oral Solution) 1 Tablet) Correct (Tablet Delayed-Release) 1 PV Correctol (Tablet Delayed-Release) 1 PV CVS Purelax (Powder) 1 PV Cromolyn Sodium (100mg/5ml 1 Ducodyl (Tablet Delayed-Release) 1 PV Concentrate) Dulcolax Balance (Powder) 1 PV

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Enulose (Oral Solution) 1 RA Laxative (Powder, 5mg Tablet 1 PV EQ ClearLax (Powder) 1 PV Delayed-Release) EQL ClearLax (Powder) 1 PV SB Bisacodyl Laxative EC (Tablet 1 PV EQL Gentle Laxative (Tablet 1 PV Delayed-Release) Delayed-Release) SM ClearLax (Powder) 1 PV EQL Laxative (Tablet Delayed- 1 PV SM Gentle Laxative (Tablet 1 PV Release) Delayed-Release) Ex-Lax Ultra (Tablet Delayed- 1 PV Smooth Lax (Powder) 1 PV Release) Stimulant Laxative (Tablet Delayed- 1 PV Feenamint (Tablet Delayed-Release) 1 PV Release) Fleet Laxative (Tablet Delayed- 1 PV Suprep Bowel Prep (Oral 3 Release) Solution) GaviLAX (Powder) 1 PV SW ClearLax (Powder) 1 PV GaviLyte-C (Oral Solution) 1 PV,QL TGT Powderlax (Powder) 1 PV GaviLyte-G (Oral Solution) 1 PV,QL TriLyte (Oral Solution) 1 PV,QL GaviLyte-N/Flavor Pack (Oral 1 PV,QL Veracolate (Tablet Delayed- 1 PV Solution) Release) Generlac (Oral Solution) 1 Womans Laxative (Tablet Delayed- 1 PV Gentle Laxative (Tablet Delayed- 1 PV Release) Release) Womens Laxative (Tablet Delayed- 1 PV Gentlelax (Powder) 1 PV Release) Glycolax (Powder) 1 PV GNP Bisa-Lax (Tablet Delayed- 1 PV Carafate (1gm/10ml Suspension) 2 Release) Misoprostol (Tablet) 1 GNP ClearLax (Powder) 1 PV Sucralfate (1gm Tablet) 1 GNP Womens Laxative (Tablet 1 PV Delayed-Release) Goodsense Magnesium Citrate 1 PV (Solution) Aciphex Sprinkle (Capsule 3 QL HM ClearLax (Powder) 1 PV Sprinkle) HM Laxative (Tablet Delayed- 1 PV Dexilant (Capsule Delayed- 2 QL Release) Release) KLS LaxaClear (Powder) 1 PV Esomeprazole Magnesium (Capsule 1 QL Delayed-Release) KP Bisacodyl (Tablet Delayed- 1 PV Release) Esomeprazole Sodium (40mg 1 Injection) Lactulose (Oral Solution) 1 Laxative (Tablet Delayed-Release) 1 PV Esomeprazole Strontium (Capsule 3 QL Delayed-Release) Laxative Feminine (Tablet Delayed- 1 PV Release) Lansoprazole (Capsule Delayed- 1 QL Release) RX Magnesium Citrate (Oral Solution) 1 PV Omeprazole (Capsule Delayed- 1 QL Mineral Oil Heavy (RX) 1 Release) MoviPrep (Oral Solution) 3 Omeprazole/Sodium Bicarbonate 1 QL PEG 3350 (Powder) 1 PV (20mg-1100mg Capsule RX, 40mg- PEG 3350 (Powder) 1 PV 1100mg Capsule, 20mg-1680mg PEG 3350/Electrolytes (Oral 1 PV,QL Packet, 40mg-1680mg Packet) Solution) Pantoprazole Sodium (20mg Tablet 1 QL PEG-3350/Electrolytes (Oral 1 PV,QL Delayed-Release, 40mg Tablet Solution) Delayed-Release, 40mg Injection) PEG-3350/NaCl/Na 1 PV,QL Rabeprazole Sodium (Tablet 1 QL Bicarbonate/KCl (Oral Solution) Delayed-Release) Pegylax (Powder) 1 PV Polyethylene Glycol 3350 (Packet, 1 Powder) RX Linzess (72mcg Capsule) 2 QL,ST Prepopik (Packet) 3 Relistor (150mg Tablet) 2 PA QC Gentle Laxative (Tablet 1 PV Delayed-Release) QC Natura-Lax (Powder) 1 PV

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Darifenacin HBr ER (Tablet 1 Calcium Acetate (667mg Capsule, 1 Extended-Release 24 Hour) 667mg Tablet) Flavoxate HCl (Tablet) 1 Fosrenol (1000mg Packet, 750mg 3 Gelnique (Gel) 2 Packet, 1000mg Tablet Chewable, Myrbetriq (Tablet Extended- 2 ST 500mg Tablet Chewable, 750mg Release 24 Hour) Tablet Chewable) Oxybutynin Chloride (5mg Tablet, 1 Phoslyra (Oral Solution) 3 5mg/5ml Syrup) Renagel (Tablet) 3 Oxybutynin Chloride ER (Tablet 1 Renvela (0.8gm Packet, 2.4gm 3 Extended-Release 24 Hour) Packet) Tolterodine Tartrate (Tablet) 1 Renvela (800mg Tablet) 2 Tolterodine Tartrate ER (Capsule 1 Velphoro (Tablet Chewable) 3 Extended-Release 24 Hour) Toviaz (Tablet Extended-Release 3 24 Hour) Betamethasone Sodium 1 Trospium Chloride (Tablet) 1 Phosphate/Betamethasone Acetate Trospium Chloride ER (Capsule 1 (Injection) Extended-Release 24 Hour) Colocort (Enema) 1 Vesicare (Tablet) 2 Cortisone Acetate (25mg Tablet) 1 Deltasone (Tablet) 1 Depo-Medrol (20mg/ml Injection) 3 Alfuzosin HCl ER (Tablet 1 Dexamethasone (0.5mg Tablet, 1 Extended-Release 24 Hour) 0.75mg Tablet, 1.5mg Tablet, 1mg Cardura XL (4mg Tablet 3 Tablet, 2mg Tablet, 4mg Tablet, Extended-Release 24 Hour) 6mg Tablet, 0.5mg/5ml Elixir, Cialis (2.5mg Tablet, 5mg Tablet) 2 PA,QL 0.5mg/5ml Oral Solution) Dutasteride (Capsule) 1 Dexamethasone Intensol (1mg/ml 3 Concentrate) Dutasteride/Tamsulosin HCl 1 (Capsule) Dexamethasone Sodium Phosphate 1 (120mg/30ml Injection, 20mg/5ml Finasteride (5mg Tablet) 1 Solution) Rapaflo (Capsule) 2 DexPak 10 Day (Tablet Therapy 3 Tamsulosin HCl (Capsule) 1 Pack) DexPak 13 Day (Tablet Therapy 3 Pack) Acetic Acid 0.25% (Irrigation 1 DexPak 6 Day (Tablet Therapy 3 Solution) Pack) Aminoacetic Acid (Irrigation 1 Fludrocortisone Acetate (0.1mg 1 Solution) Tablet) Bethanechol Chloride (Tablet) 1 Hydrocort Enema 100mg (Enema) 1 Cuprimine (Capsule) 3 PA Hydrocortisone (10mg Tablet, 20mg 1 Depen Titratabs (Tablet) 3 Tablet, 5mg Tablet) Elmiron (Capsule) 2 Methylprednisolone (16mg Tablet, 1 32mg Tablet, 4mg Tablet, 8mg Encare (Suppository) 3 PV Tablet) Glycine (1.5% Irrigation Solution) 1 Methylprednisolone Acetate 1 Options Gynol II Vaginal 3 PV (40mg/ml Injection, 80mg/ml Contraceptive (Gel) Injection) Phenazo (Tablet) 1 Mometasone Furoate (0.1% Cream, 1 Shur-Seal (Gel) 3 PV 0.1% Ointment) Today Sponge 3 PV Prednisolone (15mg/5ml Oral 1 VCF Vaginal Contraceptive Film 3 PV Solution, 15mg/5ml Syrup) (Film) Prednisolone Sodium Phosphate 1 VCF Vaginal Contraceptive Foam 3 PV (10mg/5ml Solution, 20mg/5ml (Foam) Solution, 25mg/5ml Oral Solution, VCF Vaginal Contraceptive Gel 1 PV 5mg/5ml Oral Solution) (Gel) Prednisolone Sodium Phosphate 1 ODT (Tablet Dispersible)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Prednisone (10mg Tablet, 1mg 1 Amethia (Tablet) 1 PV,QL Tablet, 2.5mg Tablet, 20mg Tablet, Amethia Lo (Tablet) 1 PV,QL 50mg Tablet, 5mg Tablet) Amethyst (Tablet) 1 PV Prednisone Intensol (5mg/ml 2 Apri (Tablet) 1 PV Concentrate) Aranelle (Tablet) 1 PV Triamcinolone (Injection) 1 Ashlyna (Tablet) 1 PV,QL Aubra (Tablet) 1 PV Aviane (Tablet) 1 PV Chorionic Gonadotropin (Injection) 4 PA Azurette (Tablet) 1 PV Desmopressin Acetate (0.01% Nasal 1 Balziva (Tablet) 1 PV Solution, 0.1mg/ml Nasal Solution, Bekyree (Tablet) 1 PV 0.1mg Tablet, 0.2mg Tablet, Blisovi 24 Fe (Tablet) 1 PV 4mcg/ml Injection) Blisovi Fe 1.5/30 (Tablet) 1 PV Egrifta (Injection) 4 PA,QL Blisovi Fe 1/20 (Tablet) 1 PV H.P. Acthar (Injection) 4 PA Briellyn (Tablet) 1 PV Increlex (Injection) 4 PA Camrese (Tablet) 1 PV,QL Norditropin FlexPro (Injection) 4 PA Camrese Lo (Tablet) 1 PV,QL Novarel (Injection) 4 PA Caziant (Tablet) 1 PV Nutropin AQ (Injection) 4 PA Chateal (Tablet) 1 PV Oxytocin (Injection) 1 Combipatch (Patch Twice 3 Pregnyl w/Diluent Benzyl 4 PA Weekly) Alcohol/NaCl (Injection) Cryselle-28 (Tablet) 1 PV Serostim (Injection) 4 PA Cyclafem (Tablet) 1 PV Stimate (Nasal Solution) 4 Cyred (Tablet) 1 PV Zorbtive (Injection) 4 PA Dasetta 1/35 (Tablet) 1 PV Dasetta 7/7/7 (Tablet) 1 PV Daysee (Tablet) 1 PV,QL Delyla (Tablet) 1 PV Alprostadil (Injection) 1 Desogestrel/Ethinyl Estradiol 1 PV (Tablet) Drospirenone/Ethinyl Estradiol 1 PV (Tablet) Drospirenone/Ethinyl 1 PV Anadrol-50 (Tablet) 3 PA Estradiol/Levomefolate Calcium Oxandrolone (Tablet) 1 PA,QL (Tablet) Elinest (Tablet) 1 PV Emoquette (Tablet) 1 PV Enpresse-28 (Tablet) 1 PV Enskyce (Tablet) 1 PV AndroGel (40.5mg/2.5gm Gel) 2 PA Estarylla (Tablet) 1 PV Androxy (Tablet) 2 PA Estrace (0.1mg/gm Cream) 3 Danazol (100mg Capsule, 200mg 1 Estradiol (0.025mg/24hr Patch 1 Capsule, 50mg Capsule) Weekly, 0.05mg/24hr Patch Methitest (Tablet) 3 PA Weekly, 0.06mg/24hr Patch Methyltestosterone (10mg Capsule) 1 PA,QL Weekly, 0.075mg/24hr Patch Striant 3 PA Weekly, 37.5mcg/24hr Patch Testosterone Cypionate (Injection) 1 PA Weekly, 0.1mg/24hr Patch Weekly, Testosterone Enanthate (Injection) 1 PA 0.5mg Tablet, 1mg Tablet, 2mg Tablet) Estradiol Valerate (Injection) 1 Estradiol/Norethindrone Acetate 1 (Tablet) Altavera (Tablet) 1 PV Estropipate (Tablet) 1 Alyacen 1/35 (Tablet) 1 PV Ethynodiol Diacetate/Ethinyl 1 PV Alyacen 7/7/7 (Tablet) 1 PV Estradiol (Tablet) Amabelz (Tablet) 1 Evamist (Transdermal Solution) 3 Falmina (Tablet) 1 PV

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Femynor (Tablet) 1 PV Natazia (Tablet) 2 PV Fyavolv (Tablet) 1 Necon 0.5/35-28 (Tablet) 1 PV Gianvi (Tablet) 1 PV Necon 1/50-28 (Tablet) 1 PV Gildagia (Tablet) 1 PV Necon 7/7/7 (Tablet) 1 PV Introvale (Tablet) 1 PV,QL Nikki (Tablet) 1 PV Jevantique Lo (Tablet) 1 Norethindrone Acetate/Ethinyl 1 Jinteli (Tablet) 1 Estradiol (Tablet) Jolessa (Tablet) 1 PV,QL Norethindrone Acetate/Ethinyl 1 PV Juleber (Tablet) 1 PV Estradiol/Ferrous Fumarate (Tablet) Junel 1.5/30 (Tablet) 1 PV Norethindrone/Ethinyl 1 PV Estradiol/Ferrous Fumarate (Tablet Junel 1/20 (Tablet) 1 PV Chewable) Junel Fe 1.5/30 (Tablet) 1 PV Norgestimate/Ethinyl Estradiol (0- 1 PV Junel Fe 1/20 (Tablet) 1 PV Tablet, 35mcg-0.25mg Tablet) Junel Fe 24 (Tablet) 1 PV Nortrel 0.5/35 (28) (Tablet) 1 PV Kaitlib Fe (Tablet Chewable) 1 PV Nortrel 1/35 (Tablet) 1 PV Kariva (Tablet) 1 PV Nortrel 7/7/7 (Tablet) 1 PV Kelnor 1/35 (Tablet) 1 PV NuvaRing (Ring) 2 PV Kimidess (Tablet) 1 PV Ocella (Tablet) 1 PV Kurvelo (Tablet) 1 PV Ogestrel (Tablet) 1 PV LARIN 1.5/30 (Tablet) 1 PV Orsythia (Tablet) 1 PV LARIN 1/20 (Tablet) 1 PV Philith (Tablet) 1 PV LARIN 24 Fe (Tablet) 1 PV Pimtrea (Tablet) 1 PV LARIN Fe 1.5/30 (Tablet) 1 PV Pirmella 1/35 (Tablet) 1 PV LARIN Fe 1/20 (Tablet) 1 PV Pirmella 7/7/7 (Tablet) 1 PV Larissia (Tablet) 1 PV Portia-28 (Tablet) 1 PV Layolis Fe (Tablet Chewable) 1 PV Premarin (0.3mg Tablet, 0.45mg 2 Leena (Tablet) 1 PV Tablet, 0.625mg Tablet, 0.9mg Lessina (Tablet) 1 PV Tablet, 1.25mg Tablet) Levonest (Tablet) 1 PV Premphase (Tablet) 2 Levonorgestrel and Ethinyl 1 PV Prempro (Tablet) 2 Estradiol (Tablet) Previfem (Tablet) 1 PV Levonorgestrel/Ethinyl Estradiol (0- 1 PV Quasense (Tablet) 1 PV,QL Tablet, 20mcg-0.1mg Tablet) Rajani (Tablet) 1 PV Levonorgestrel/Ethinyl Estradiol 1 PV,QL Reclipsen (Tablet) 1 PV (0.03mg-0.15mg Tablet) Setlakin (Tablet) 1 PV,QL Levora 0.15/30-28 (Tablet) 1 PV Sprintec 28 (Tablet) 1 PV Lo Loestrin Fe (Tablet) 3 Sronyx (Tablet) 1 PV Lomedia 24 Fe (Tablet) 1 PV Syeda (Tablet) 1 PV Loryna (Tablet) 1 PV Tarina Fe 1/20 (Tablet) 1 PV Low-Ogestrel (Tablet) 1 PV Tilia Fe (Tablet) 1 PV Lutera (Tablet) 1 PV Tri-Estarylla (Tablet) 1 PV Marlissa (Tablet) 1 PV Tri-Legest Fe (Tablet) 1 PV Menest (Tablet) 2 Tri-Linyah (Tablet) 1 PV Microgestin 1.5/30 (Tablet) 1 PV Tri-Lo-Estarylla (Tablet) 1 PV Microgestin 1/20 (Tablet) 1 PV Tri-Lo-Marzia (Tablet) 1 PV Microgestin 24 Fe (Tablet) 1 PV Tri-Lo-Sprintec (Tablet) 1 PV Microgestin Fe (Tablet) 1 PV Tri-Previfem (Tablet) 1 PV Microgestin Fe 1.5/30 (Tablet) 1 PV Tri-Sprintec (Tablet) 1 PV Mimvey (Tablet) 1 Trinessa (Tablet) 1 PV Mimvey Lo (Tablet) 1 Trinessa Lo (Tablet) 1 PV Minastrin 24 Fe (Tablet 3 Trivora-28 (Tablet) Chewable) 1 PV Velivet (Tablet) 1 PV Mono-Linyah (Tablet) 1 PV Vestura (Tablet) 1 PV MonoNessa (Tablet) 1 PV Vienva (Tablet) Myzilra (Tablet) 1 PV 1 PV Viorele (Tablet) 1 PV

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Vyfemla (Tablet) 1 PV Norethindrone Acetate (5mg Tablet) 1 Wera (Tablet) 1 PV Norlyroc (Tablet) 1 PV WYMZYA Fe (Tablet Chewable) 1 PV Opcicon One-Step (Tablet) 1 PV Xulane (Patch Weekly) 1 PV Option 2 (Tablet) 1 PV Yuvafem (Tablet) 1 Progesterone (100mg Capsule, 1 Zarah (Tablet) 1 PV 200mg Capsule) Zenchent (Tablet) 1 PV Progesterone (50mg/ml Injection) 4 Zenchent Fe (Tablet Chewable) 1 PV React (Tablet) 1 PV Zovia 1/35E (Tablet) 1 PV Sharobel (Tablet) 1 PV Zovia 1/50E (Tablet) 1 PV Skyla (IUD) 3 PV Take Action (Tablet) 1 PV

Kyleena (IUD) 4 PV Liletta (IUD) 4 PV Osphena (Tablet) 3 Raloxifene HCl (Tablet) 1 PV*

Ella (Tablet) 3 PV Armour Thyroid (120mg Tablet, 3 180mg Tablet, 240mg Tablet, 300mg Tablet) Levo-T (Tablet) 1 Levothyroxine Sodium (100mcg 1 Aftera (Tablet) 1 PV Tablet, 112mcg Tablet, 125mcg Camila (Tablet) 1 PV Tablet, 137mcg Tablet, 150mcg Crinone (Gel) 4 QL Tablet, 175mcg Tablet, 200mcg Tablet, 25mcg Tablet, 300mcg Deblitane (Tablet) 1 PV Tablet, 50mcg Tablet, 75mcg Depo-Provera (Injection) 3 Tablet, 88mcg Tablet) Depo-SubQ Provera104 3 QL Levoxyl (Tablet) 1 (Injection) Liothyronine Sodium (10mcg/ml 1 Econtra EZ (Tablet) 1 PV Injection, 25mcg Tablet, 50mcg Errin (Tablet) 1 PV Tablet, 5mcg Tablet) Fallback Solo (Tablet) 1 PV NP Thyroid 15 (Tablet) 1 Heather (Tablet) 1 PV NP Thyroid 60 (Tablet) 1 Jencycla (Tablet) 1 PV NP Thyroid 90 (Tablet) 1 Jolivette (Tablet) 1 PV Thyrolar (Tablet) 3 Levonorgestrel (Tablet) 1 PV Unithroid (Tablet) 1 Lyza (Tablet) 1 PV Unithroid Direct (Tablet) 1 Makena (Injection) 4 PA WP Thyroid (Tablet) 3 Medroxyprogesterone Acetate 1 (10mg Tablet, 2.5mg Tablet, 5mg Tablet) Lysodren (Tablet) CM Medroxyprogesterone Acetate 1 PV,QL (150mg/ml Injection) Sensipar (Tablet) 3 PA Megestrol Acetate (20mg Tablet, CM 40mg Tablet, 40mg/ml Suspension) Megestrol Acetate (625mg/5ml 1 Bromocriptine Mesylate (2.5mg 1 Suspension) Tablet, 5mg Capsule) Mirena (IUD) 3 PV Cabergoline (Tablet) 1 My Way (Tablet) 1 PV Eligard (Injection) 4 PA,QL Nexplanon (Injection) 4 PV Firmagon (Injection) 4 PA,QL Next Choice One Dose (Tablet) 1 PV Leuprolide Acetate (Injection) 4 PA Nora-BE (Tablet) 1 PV Lupaneta Pack (Kit) 4 PA,QL Norethindrone (Tablet) 1 PV Lupron Depot (Injection) 4 PA

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Lupron Depot-PED (Injection) 4 PA Methotrexate Sodium (Injection) 1 Octreotide Acetate (Injection) 4 PA Mycophenolate Mofetil (200mg/ml 1 Sandostatin LAR Depot 4 PA Suspension, 250mg Capsule, 500mg (Injection) Injection, 500mg Tablet) Signifor (Injection) 4 PA,QL Mycophenolic Acid DR (Tablet 1 Somatuline Depot (Injection) 4 PA Delayed-Release) Somavert (Injection) 4 PA Nulojix (Injection) 3 PA Supprelin LA (Injection) 4 PA,QL Orencia (125mg/ml Injection, 4 PA 250mg Injection) Synarel (Nasal Solution) 2 Trelstar (Injection) 4 PA,QL Orencia Clickject (Injection) 4 PA Trelstar Mixject (Injection) 4 PA,QL Prograf (5mg/ml Injection) 3 Rapamune (1mg/ml Oral 3 Vantas (Injection) 4 PA,QL Solution) Zoladex (Injection) 4 QL Remicade (Injection) 4 PA Sandimmune (100mg/ml Oral 2 Solution) Methimazole (10mg Tablet, 5mg 1 Simponi (Injection) 4 PA Tablet) Simponi Aria (Injection) 4 PA Propylthiouracil (Tablet) 1 Sirolimus (Tablet) 1 Tacrolimus (0.5mg Capsule, 1mg 1 Capsule, 5mg Capsule) Torisel (Injection) 4 Dexamethasone Sodium Phosphate 1 (10mg/ml Injection) Trexall (Tablet) CM Prednisone (10mg Tablet Therapy 1 Zortress (Tablet) 3 PA Pack, 5mg Tablet Therapy Pack)

Atgam (Injection) 4 Actoplus Met XR (Tablet 3 ST BIVIGAM (Injection) 4 PA Extended-Release 24 Hour) Carimune Nanofiltered (Injection) 4 PA Cuvitru (Injection) 4 PA Cytogam (Injection) 4 PA Flebogamma DIF (Injection) 4 PA Azasan (Tablet) 3 Gamastan S/D (Injection) 4 PA Azathioprine (100mg Injection, 1 50mg Tablet) Gammagard Liquid (Injection) 4 PA Benlysta (Injection) 4 PA Gammagard S/D IGA Less Than 4 PA 1 mcg/ml (Injection) Cimzia (Injection) 4 PA Gammaked (Injection) 4 PA Cimzia Starter Kit (Injection) 4 PA Gammaplex (Injection) 4 PA Cyclosporine (100mg Capsule, 1 25mg Capsule, 50mg/ml Injection) Gamunex-C (Injection) 4 PA Cyclosporine Modified (100mg 1 Hepagam B (Injection) 4 Capsule, 25mg Capsule, 50mg Hizentra (Injection) 4 PA Capsule, 100mg/ml Oral Solution) Hyperhep B S/D (Injection) 4 Enbrel (25mg Injection) 4 PA Hyperrab S/D (Injection) 2 Gengraf (100mg Capsule, 25mg 1 Hyperrho S/D (Injection) 4 Capsule, 50mg Capsule, 100mg/ml Hyperrho S/D Mini-Dose 4 Oral Solution) (Injection) Humira (20mg/0.4ml Injection, 4 PA Micrhogam Ultra-Filtered Plus 4 40mg/0.8ml Injection) (Injection) Humira Pediatric Crohns Disease 4 PA Nabi-Hb (Injection) 4 Starter Pack (Injection) Octagam (Injection) 4 PA Humira Pen (Injection) 4 PA Privigen (Injection) 4 PA Humira Pen Crohns Disease 4 PA Rhogam Ultra-Filtered Plus 4 Starter Pack (Injection) (Injection) Humira Pen-Psoriasis Starter 4 PA Rhophylac (Injection) 4 (Injection) Thymoglobulin (Injection) 3 Methotrexate (2.5mg Tablet) CM WinRho SDF (Injection) 4

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Tetanus/Diphtheria Toxoids- 2 PV Adsorbed (Injection) Actimmune (Injection) 4 Theracys (Injection) 4 Arcalyst (Injection) 4 PA Trumenba (Injection) 2 PV Ilaris (Injection) 4 PA,QL Twinrix (Injection) 2 PV Leflunomide (Tablet) 1 Typhim VI (Injection) 3 Lemtrada (Injection) 4 PA VAQTA (Injection) 2 PV Otezla (30mg Tablet) 4 PA Varivax (Injection) 2 PV Ridaura (Capsule) 3 Vivotif (Capsule Delayed-Release) 3 Simulect (20mg Injection) 3 YF-Vax (Injection) 3 Sodium Hyaluronate (Gel) 1 Zostavax (Injection) 2 PV Stelara (130mg/26ml Injection) 4 PA Synagis (Injection) 4 PA Xeljanz (Tablet) 4 PA Apriso (Capsule Extended-Release 2 24 Hour) ActHIB (Injection) 2 PV Balsalazide Disodium (Capsule) 1 Adacel (Injection) 2 PV Canasa (Suppository) 2 Afluria 2016-2017 (Injection) 2 PV Dipentum (Capsule) 3 BCG Vaccine (Injection) 3 Lialda (Tablet Delayed-Release) 2 Bexsero (Injection) 2 PV Mesalamine (4gm Enema, 4gm Kit) 1 Biothrax (Injection) 3 Mesalamine DR (Tablet Delayed- 1 Boostrix (Injection) 2 PV Release) Daptacel (Injection) 2 PV Pentasa (Capsule Extended- 3 Diphtheria/Tetanus Toxoids 2 PV Release) Adsorbed Pediatric (Injection) Engerix-B (Injection) 2 PV Fluvirin 2016-2017 (Injection) 2 PV Gardasil (Injection) 2 PV Budesonide (3mg Capsule Delayed- 1 Gardasil 9 (Injection) 2 PV Release) Havrix (Injection) 2 PV Cortifoam (Foam) 3 Hiberix (Injection) 2 PV Hyqvia (Injection) 4 PA Imovax Rabies (H.D.C.V.) 3 Sulfasalazine (500mg Tablet, 500mg 1 (Injection) Tablet Delayed-Release) Infanrix (Injection) 2 PV IPOL Inactivated IPV (Injection) 2 PV Bupivacaine HCl/Sodium Chloride 1 Ixiaro (Injection) 3 (Solution Prefilled Syringe) Kinrix (Injection) 2 PV Bupivacaine/Epinephrine (0.5%- 1 M-M-R II (Injection) 2 PV 1:200000 Injection) Menactra (Injection) 2 PV Lidocaine HCl (Prefilled Syringe) 1 MENHIBRIX (Injection) 2 PV Sensorcaine-Mpf/Epinephrine 1 Menomune-A/C/Y/W-135 2 PV (Injection) (Injection) Menveo (Injection) 2 PV Alendronate Sodium (10mg Tablet, 1 Pediarix (Injection) 2 PV 40mg Tablet, 5mg Tablet) Pedvax HIB (Injection) 2 PV Alendronate Sodium (35mg Tablet, 1 QL Pentacel (Injection) 2 PV 70mg Tablet) Pneumovax 23 (Injection) 2 PV Alendronate Sodium (70mg/75ml 2 Prevnar 13 (Injection) 2 PV Oral Solution) ProQuad (Injection) 2 PV Calcitonin-Salmon (Nasal Solution) 1 QL Quadracel (Injection) 2 PV Calcitriol (0.25mcg Capsule, 0.5mcg 1 Rabavert (Injection) 3 Capsule, 1mcg/ml Injection, Recombivax HB (Injection) 2 PV 1mcg/ml Oral Solution) Rotarix (Suspension) 2 PV Doxercalciferol (0.5mcg Capsule, 1 RotaTeq (Oral Solution) 2 PV 1mcg Capsule, 2.5mcg Capsule, 4mcg/2ml Injection) Tenivac (Injection) 2 PV

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Etidronate Disodium (Tablet) 1 AeroChamber Plus Flow- 2 Forteo (Injection) 4 PA Vu/Small Mask Fosamax Plus D (Tablet) 3 QL AeroChamber Z-Stat 2 Hectorol (2mcg/ml Injection) 3 Plus/Medium Mask Ibandronate Sodium (150mg Tablet, 1 QL AeroChamber/FlowSignal 2 3mg/3ml Injection) Aerovent Plus Holding 2 Miacalcin (200unit/ml Injection) 3 Chamber/Collapsible Pamidronate Disodium (30mg 4 Argyle Sterile Saline 100ml 1 Injection, 30mg/10ml Injection, (Solution) 90mg Injection, 90mg/10ml Argyle Sterile Water 100ml 1 Injection) (Solution) Pamidronate Disodium (6mg/ml 4 Arial Chamber 2 Injection) Asilnasal Rms (Capsule) 1 Paricalcitol (1mcg Capsule, 2mcg 1 Aurora Pen Needles 29gx12mm 3 Capsule, 4mcg Capsule, 2mcg/ml Aurora Pen Needles 31g X 8mm 3 Injection, 5mcg/ml Injection) Aurora Unifine Pentips/32gx5/32" 3 Prolia (Injection) 4 PA,QL Aurora Unifine 3 Risedronate Sodium (150mg Tablet, 1 QL Pentips/Mini/31gx3/16" 35mg Tablet) Autopen 3 Risedronate Sodium (30mg Tablet, 1 BD Autoshield 29g X 3/16" 2 5mg Tablet) BD Autoshield 29g X 5/16" 2 Risedronate Sodium DR (Tablet 1 QL BD Autoshield Duo 30g X 3/16" 2 Delayed-Release) Bd insul Syr Mis Lo Dose 2 Xgeva (Injection) 4 PA BD Pen 3 Zoledronic Acid (4mg Injection, 4 4mg/100ml Injection) BD Pen Mini 3 Zoledronic Acid (4mg/5ml 4 Botox (Injection) 4 PA Injection, 5mg/100ml Injection) BreatheRite 2 Zometa (4mg/100ml Injection) 4 BreatheRite Collapsible Spacer 2 w/ Neonate Mask BreatheRite Rigid Spacer w/Mask 2 BreatheRite w/Large Mask 2 Levoleucovorin (175mg Solution) 4 BreatheRite w/Medium Mask 2 BreatheRite w/Small Mask 2 Carefine Pen Needle 32gx4mm 3 Inflectra (Injection) 4 PA Carefine Pen Needles 31gx8mm 3 Carefine Pen Needles 32gx5mm 3 Carefine Pen Needles 32gx6mm 3 1st Tier Unifine Pentips 3 Careone Unifine Pentips 3 /Mini/31gx5mm 29gx12mm 1st Tier Unifine Pentips 3 Careone Unifine Pentips 3 29gx12mm 31gx8mm 1st Tier Unifine Pentips 31gx6mm 3 Careone Unifine Pentips Pen 3 1st Tier Unifine Pentips 31gx8mm 3 Needles 32gx4mm 1st Tier Unifine Pentips 32gx4mm 3 Caretouch Pen Needles 31 G X 6 3 1st Tier Unifine Pentips Plus 3 Mm 31gx8mm Caretouch Pen Needles 31gx 5mm 3 AeroChamber Mini Aerosol 2 Caretouch Pen Needles 31gx 8mm 3 Chamber Caretouch Pen Needles 32gx 4mm 3 AeroChamber MV 2 Caretouch Pen Needles 32gx 5mm 3 AeroChamber Plus Flow Vu 2 Caya 3 PV AeroChamber Plus Flow-Vu 2 Chek-Stix Control 3 AeroChamber Plus Flow- 2 Chemstrip 10 MD 3 Vu/Large Mask Chemstrip 2 GP Strips 3 AeroChamber Plus Flow- 2 Vu/Mask Chemstrip 5 OB 3 AeroChamber Plus Flow- 2 Chemstrip 7 3 Vu/Medium Mask Chemstrip 9 Strips 3

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Chemstrip UGK 3 Diascreen 4NL 3 Chemstrip-10 with SG 3 Diascreen 4OBL 3 Chemstrip-K 3 Diascreen 4PH 3 Clever Choice Anti-Static Valved 2 Diascreen 5 3 Holding Chamber/Adult Large Diascreen 6 3 Clever Choice Anti-Static Valved 2 Diascreen 7 3 Holding Chamber/Medium Diascreen 8 3 Clever Choice Anti-Static Valved 2 Diascreen 9 3 Holding Chamber/Small Diascreen Liquid Urine Controls 3 Clever Choice Comfort EZ Insulin 3 Diastix 3 Pen Needles 31gx8mm Droplet Pen Needles 29gx10mm 3 Clever Choice Comfort EZ Pen 3 Needles 29gx12mm Droplet Pen Needles 32gx5mm 3 Clever Choice Comfort EZ Pen 3 E-Z Spacer 2 Needles 31gx5mm E-Z Spacer the Body Guards Pack 2 Clever Choice Comfort EZ Pen 3 Easivent 2 Needles 31gx6mm Easivent/Mask-Large 2 Clever Choice Comfort EZ Pen 3 Easivent/Mask-Medium 2 Needles 32gx4mm Easivent/Mask-Small 2 Clever Choice Comfort EZ Pen 3 Easy Comfort Pen Needles 3 Needles 32gx5mm 31gx1/4" Clever Choice Comfort EZ Pen 3 Easy Comfort Pen Needles 3 Needles 32gx6mm 31gx3/16" Clever Choice Comfort EZ Pen 3 Easy Comfort Pen Needles 3 Needles 32gx8mm 31gx5/16" Clever Choice Comfort EZ Pen 3 Easy Comfort Pen Needles 3 Needles 33gx4mm 32gx5/32" Clever Choice Comfort EZ Pen 3 Easy Touch 32gx5mm 3 Needles 33gx5mm Easy Touch 32gx6mm 3 Clever Choice Comfort EZ Pen 3 Easy Touch Insulin Syringe/U- 3 Needles 33gx6mm 100/1ml/31g X 5/16" Clever Choice Comfort EZ Pen 3 Easy Touch Pen Needles 29gx1/2" 3 Needles 33gx8mm Easy Touch Pen Needles 31gx1/4" 3 Clickfine Pen Needle 32gx5/32" 3 Easy Touch Pen Needles 3 Clickfine Pen Needles/31gx1/4" 3 31gx5/16" Clickfine Pen Needles/31gx5/16" 3 Easy Touch Pen Needles 32gx1/4" 3 Combistix 3 Easy Touch Pen Needles 3 Compact Space Chamber/Anti- 2 32gx3/16" Static Easy Touch Pen Needles 3 Compact Space Chamber/Anti- 2 32gx5/32" Static/Large Mask Easy Touch Pen Needles/31g X 3 Compact Space Chamber/Anti- 2 3/16" Static/Medium Mask Excel Comfort Point Insulin Pen 3 Curity Sterile Saline (Solution) 1 Needles 31g X 4mm CVS Ketone Care 3 Exel Comfort Point Insulin Pen 3 Deferoxamine Mesylate (Injection) 4 Needles 29g X 12mm Delflex-Sm/1.5% Dextrose 1 Exel Comfort Point Insulin Pen 3 (Injection) Needles 31g X 8mm Delflex-Sm/2.5% Dextrose 1 Exel Comfort Point Insulin 3 (Injection) Syringe/0.3ml/29g X 1/2" Diascreen 10 3 Exel Comfort Point Insulin 3 Diascreen 1B 3 Syringe/0.3ml/30g X 5/16" Diascreen 1G 3 FC Female Condom 3 PV Diascreen 1K 3 FC2 Female Condom 3 PV Diascreen 2GK 3 Femcap 3 PV Diascreen 2GP 3 Ferriprox (500mg Tablet) 4 PA Diascreen 3 3 Fifty50 Pen Needles 31g X3/16" 3 (5mm)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Fifty50 Pen Needles 31g X5/16" 3 Labstix 3 (8mm) Lactated Ringers Irrigation 1 Fifty50 Pen Needles 31gx5mm 3 (Solution) Fifty50 Pen Needles/31gx8mm 3 Leader Unifine Pentips 3 Fifty50 Pen Needles/32gx4mm 3 Plus/Short/31gx5/16" Fifty50 Pen Needles/32gx6mm 3 Levocarnitine (1gm/10ml Oral 1 Flexichamber 2 Solution, 200mg/ml Injection, 330mg Tablet) Flexichamber Child Mask/Large 2 Lifescan Unistik 2 Deep 2 QL Flexichamber Child Mask/Small 2 Penetration Fomepizole (Injection) 1 Lifescan Unistik II Lancets 2 QL GlucoCom Autolink 3 Telemonitoring System LiteAire 2 H-E-B in Control Pen Needles 3 LiteTouch Pen Needles 3 31gx6mm 29gx12.7mm H-E-B in Control Pen Needles 3 LiteTouch Pen Needles 31gx8mm 3 31gx8mm Short H-E-B in Control Pen 3 Mask Vortex/Baby Whirl 2 Needles/Nano/32gx4mm Duckling H-E-B in Control Unifine Pentips 3 Mask Vortex/Child/Frog 2 Plus 31gx5mm Mask Vortex/Spinner the Duck 2 H-E-B Incontrol Pen Needles 3 Mask Vortex/Toddler/Lady Bug 2 29gx12mm Meijer Pen Needles 31g X 6mm 3 Hema-Combistix 3 Methergine (Tablet) 1 Humapen Luxura HD 3 Methylergonovine Maleate 1 In Touch Diabetes Management 2 (Injection) Software Microchamber 2 InspiraChamber/Anti-Static 2 Microspacer 2 Valved/Mouthpiece Monoject Insulin Syringe/1ml 3 InspiraChamber/Large 2 Monoject Insulin Syringe/Detach 3 InspiraChamber/Soother 2 Needle/1ml/25g X 5/8" Mask/InspiraMask/Medium Monoject Insulin 3 InspiraChamber/Soother 2 Syringe/Softpack/1ml/27g X 1/2" Mask/InspiraMask/Small Monoject Insulin 3 Inspirease Bags 2 Syringe/Softpack/U-100/0.5ml/28g Inspirease Drug Delivery System 2 X 1/2" Inspirease Mouthpiece 2 Monoject Ultra Comfort Insulin 3 Inspirease Reservoir Bags 2 Syringe/1ml/30g X 5/16" Insulin Syringe/0.5ml/27g X 1/2" 3 Monovisc (Injection) 4 PA Multistix 3 Insulin Syringe/U-100/1ml/28g X 3 1/2" Multistix 10 Sg 3 Insulin Syringes, Needles (BD 2 Multistix 5 3 MEDICAL) Multistix 7 3 Insupen 33gx4mm 3 Multistix 8 SG 3 Insupen Pen Needles 32g X4mm 3 Multistix 9 3 Insupen Sensitive 32gx6mm 3 Multistix 9 SG 3 Insupen Sensitive 32gx8mm 3 Myalept (Injection) 4 PA Insupen Ultrafin 29gx12mm 3 Myobloc (Injection) 4 PA Insupen Ultrafin 30gx8mm 3 N-Acetyl-L-Cysteine (Capsule) 1 Insupen Ultrafin 31gx6mm 3 Novofine 30gx8mm 3 Insupen Ultrafin 31gx8mm 3 Novofine 32gx6mm 3 Intralipid (20gm/100ml Injection) 1 Novofine Autocover 30gx8mm 3 J-Tip Kit w/Vial Adapters (Kit) 3 Novofine Plus 32gx4mm 3 Kalbitor (Injection) 4 PA NovoPen Echo 3 Keto-Diastix 3 Novotwist 32gx5mm 3 Ketocare 3 Nutrilipid (Injection) 1 Ketone Test Strips 3 Omniflex Diaphragm 3 PV Ketostix 3 Onetouch Club Lancets Fine Point 2 QL

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Onetouch Combo Pack 2 QL Pen Needles 30gx5mm 3 Onetouch Delica Lancets Extra 2 QL Pen Needles 30gx8mm 3 Fine 33g Penlet II Automatic Blood 2 Onetouch Delica Lancets Fine 30g 2 QL Sampler (Kit) Onetouch Delica Lancing Device 2 Penlet II Replacement Caps-Deep 2 Onetouch Ping Meter Remote 2 Pentips 29gx12mm 3 Onetouch Ultra 2 (Kit) 2 Pentips 31gx5mm 3 Onetouch Ultra Blue 2 QL Pentips 31gx6mm 3 Onetouch Ultra Control (In Vitro 2 Pentips 31gx8mm 3 Solution) Pentips 32gx4mm 3 Onetouch Ultra Mini (Kit) 2 Physiolyte (Irrigation Solution) 1 Onetouch Ultralink System (Hex) 2 Physiosol Irrigation (Solution) 1 (Kit) Pocket Chamber 2 Onetouch Ultrasoft Lancets 2 QL Pocket Spacer 2 Onetouch Verio (Kit) 2 Pro Comfort Pen Needles/ 32g X 3 Onetouch Verio Control Solution 2 5mm High (Solution) Pro Comfort Pen Needles/ 32g X 3 Onetouch Verio Flex Bloodglucose 2 6mm Monitoring System (Kit) PX Mini Pen Needles 31gx5mm 3 Onetouch Verio Iq Blood Glucose 2 RA Pen Needles 31g X 5mm 3/16" 3 Monitoring System (Kit) Relion Ketone 3 Onetouch Verio Mid Control 2 Relion Ketone Test Strips 3 Solution (Solution) Relion Pen Needles 29gx12mm 3 Onetouch Verio Sync 2 Bloodglucose Monitoring System Relion Pen Needles 31gx6mm 3 (Kit) Relion Pen Needles 31gx8mm 3 Onetouch Verio Test Strips 2 QL Relion Pen Needles 32gx4mm 3 OptiChamber Advantage 2 Ringers Irrigation (Solution) 1 OptiChamber Advantage/Large 2 RiteFlo 2 Mask Safety Insulin Syringes 3 OptiChamber Advantage/Medium 2 1ml/27gx1/2" Face Mask Safety Insulin Syringes 3 OptiChamber Advantage/Small 2 1ml/30gx1/2" Face Mask Safety-Glide Insulin 2 OptiChamber Diamond 2 Syringe/0.3ml/29g X 1/2" OptiChamber Diamond/Large 2 Sodium Chloride 0.9% (Irrigation 1 Face Mask Solution) OptiChamber Diamond/Medium 2 Sodium Phenylacetate/Sodium 1 Face Mask Benzoate (Injection) OptiChamber Diamond/Small 2 Sterile Diluent for Epoprostenol 1 Face Mask Sodium (Injection) OptiChamber Face Mask/Small 2 Sterile Water for Injection 1 Optihaler MDI Drug Delivery 2 Sterile Water Irrigation (Solution) 1 System Super Daily D3 (2000UT/0.028ml 3 PV Orthovisc (Injection) 4 PA Liquid) Panda Mask Large 2 Supreme II Confidence Paddles 3 Panda Mask Medium 2 Sure Comfort Pen Needles 3 Panda Mask Small 2 29gx1/2" 12.7mm Paragard Intrauterine Copper 4 PV Sure Comfort Pen Needles 3 Contraceptive T380a (IUD) 30gx5/16" Short PC Unifine Pentips 29g X 1/2" 3 Sure Comfort Pen Needles 3 31gx3/16" (5mm) PC Unifine Pentips 31g X 5mm 3 Mini Sure Comfort Pen Needles 3 31gx5/16" (8mm) PC Unifine Pentips 31g X 6mm 3 Ultra Short Sure Comfort Pen Needles 3 32gx5/32" Pediatric Panda Mask 2 Sure Comfort Pen Needles 3 Pen Needles 30gx5/16" 3 32gx6mm

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Sure-Fine Pen Needles 29gx1/2" 3 Ultra-Thin II Pen Needles 3 12.7mm 29gx1/2" Sure-Fine Pen Needles 31gx3/16" 3 Urin-Tek (Kit, 0 Misc) 3 5mm Uristix 3 Sure-Fine Pen Needles 31gx5/16" 3 Uristix 4 3 8mm Valved Holding Chamber 2 Surestep Glucose Control (In 2 Vanishpoint Insulin 3 Vitro Solution) Syringe/0.5ml/30g X 5/16" Surestep Glucose Control Solution 2 Vanishpoint Insulin 3 (In Vitro Solution) Syringe/1ml/30g X 5/16" Surestep Pro High Glucosecontrol 2 Voraxaze (Injection) 3 (Liquid) Vortex Valved Holding Chamber 2 Surestep Pro Linearity Kit (Kit) 2 WatchHaler 2 Surestep Pro Low Glucose 2 Wegmans Unifine Pentips Plus 3 Control (Liquid) 32gx4mm Surestep Pro Normal Glucose 2 Wide-Seal Silicone Diaphragm Kit 3 PV Control (Liquid) 60 Synvisc (Injection) 4 PA Wide-Seal Silicone Diaphragm Kit 3 PV Synvisc One (Injection) 4 PA 65 Techlite Pen Needles/32g X 6mm 3 Wide-Seal Silicone Diaphragm Kit 3 PV Techlite Pen Needles/32g X 8mm 3 70 Tis-U-Sol (Irrigation Solution) 1 Wide-Seal Silicone Diaphragm Kit 3 PV Todays Health Mini Pen Needles 3 75 31g X 1/4" Wide-Seal Silicone Diaphragm Kit 3 PV Todays Health Original Pen 3 80 Needles 29g X 1/2" Wide-Seal Silicone Diaphragm Kit 3 PV Todays Health Short Pen Needles 3 85 31g X 5/16" Wide-Seal Silicone Diaphragm Kit 3 PV Tracer II 3 Volt Battery 3 90 Ulticare Insulin Safety 3 Wide-Seal Silicone Diaphragm Kit 3 PV Syringe/0.5ml/29g X 1/2" 95 Ulticare Insulin Safety 3 Xeomin (100unit Injection, 50unit 4 PA Syringe/1ml/29g X 1/2" Injection) Ulticare Insulin Syringe/0.5ml/28g 3 X 1/2" Abilify Maintena (Injection) 3 Ulticare Insulin Syringe/U- 3 Abraxane (Injection) 4 100/0.3ml/29g X 1/2" Acetazolamide Sodium (Injection) 1 Ulticare Insulin Syringe/U- 3 100/0.3ml/30g X 1/2" Afluria PF 2016-2017 (Injection) 2 PV Ulticare Insulin Syringe/U- 3 Afluria Quadrivalent 2016-2017 2 PV 100/0.3ml/31g X 5/16" (Injection) Ulticare Insulin Syringe/U- 3 Alimta (Injection) 4 100/0.5ml/31g X 5/16" Amifostine (Injection) 4 Ulticare Pen Needles/29g X 3 Aripiprazole ODT (Tablet 1 QL 12.7mm Dispersible) Ulticare U-100 Insulin 3 Azacitidine (Injection) 4 Syringes/0.3ml/31g X1/4" Berinert (Injection) 4 PA Ulticare U-100 Insulin 3 Bethkis (Nebulized Solution) 4 Syringes/0.5ml/31g X 1/4" Bleomycin Sulfate (Injection) 4 Ulticare U-100 Insulin 3 Camptosar (300mg/15ml 4 Syringes/1ml/31g X 1/4" Injection) Ultiguard Insulin Syringe/U- 3 Cinryze (Injection) 4 PA 100/0.5ml/30g X 5/16" Daunorubicin HCl (Injection) 4 Ultilet Insulin 3 Dexamethasone Sodium Phosphate 1 Syringe/Short/1ml/31g X 5/16" (4mg/ml Solution) Ultilet Pen Needle 32gx4mm/Short 3 Dexrazoxane (Injection) 4 Ultilet Short Pen 3 Dextrose 10% (Injection) 1 Needles31gx3/16"

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Dextrose 2.5%/NaCl 0.45% 1 KCl 0.15%/D5W/NaCl 0.2% 1 (Injection) (Injection) Dextrose 5% (Injection) 1 KCl 0.15%/D5W/NaCl 0.45% 1 Dextrose 5%/NaCl 0.2% (Injection) 1 (Injection) Dextrose 5%/NaCl 0.33% 1 KCl 0.15%/D5W/NaCl 0.9% 1 (Injection) (Injection) Dextrose 5%/NaCl 0.45% 1 KCl 0.3%/D5W/NaCl 0.45% 1 (Injection) (Injection) Dextrose 5%/NaCl 0.9% (Injection) 1 Ketorolac Tromethamine (15mg/ml 1 Dextrose 50% (Injection) 1 Injection, 30mg/ml Injection, 30mg/ml Injection) Diltiazem HCl (125mg/25ml 1 Injection, 25mg/5ml Injection, Kineret (Injection) 4 PA 50mg/10ml Injection) Kyprolis (60mg Injection) 4 PA Diltiazem HCl/Dextrose (Injection) 1 Leucovorin Calcium (100mg 1 Diltiazem HCl/Sodium Chloride 1 Injection, 200mg Injection, 350mg (Injection) Injection, 50mg Injection) Docefrez (Injection) 4 Levoleucovorin (50mg Injection) 4 Docetaxel (20mg/0.5ml Injection, 4 Lipodox 50 (Injection) 4 80mg/2ml Injection) Mesnex (Tablet) CM Duavee (Tablet) 2 Methylprednisolone Sodium 1 Dysport (Injection) 4 PA Succinate (Injection) Enbrel (25mg/0.5ml Injection, 4 PA Metoclopramide HCl (5mg/ml 1 50mg/ml Injection) Injection) Enbrel SureClick (Injection) 4 PA Mitomycin (20mg Injection, 40mg 4 Injection) Epirubicin HCl (Injection) 4 Mitomycin (5mg Injection) 4 Erwinaze (Injection) 4 Firazyr (Injection) 4 PA Nucala (Injection) 4 PA,QL Olanzapine (10mg Injection) Fluad 2016-2017 (Injection) 2 PV 1 Oncaspar (Injection) 4 Fluarix Quadrivalent 2016-2017 2 PV (Injection) Onivyde (Injection) 4 Flublok 2016-2017 (Injection) 2 PV Oxaliplatin (IV Solution 4 100mg/20ml) Flucelvax Quadrivalent 2016-2017 2 PV (Injection) Pegasys (Injection) 4 PA Fludarabine Phosphate (Injection) 4 Pegasys ProClick (Injection) 4 PA Fluzone High-Dose Pf 2016-2017 2 PV Photofrin (Injection) 4 (Injection) Plegridy (Injection) 4 PA,QL Geodon (Injection) 3 Plegridy Starter Pack (Injection) 4 PA,QL Halaven (Injection) 4 PA Potassium Chloride 0.15% 1 Hematinic/Folic Acid (Tablet) 1 D5W/NaCl 0.33% (Injection) Hemocyte-F (Tablet) 1 Potassium Chloride 0.15% 1 D5W/NaCl 0.45% (Injection) Humira (10mg/0.2ml Injection) 4 PA Potassium Chloride 0.22% Ibuprofen Lysine (Injection) 1 1 D5W/NaCl 0.45% (Injection) Idarubicin HCl (Injection) 4 Potassium Chloride 1 Indomethacin (1mg Solution) 1 0.224%D5W/NaCl 0.45% Viaflex Intron A w/Diluent (Injection) 4 PA (Injection) Ipratropium Bromide/Albuterol 1 QL Potassium Chloride/Dextrose (5%- 1 Sulfate (Inhalation Solution) 20meq/L Injection) Irinotecan (40mg/2ml Injection) 4 Proleukin (Injection) 4 Irinotecan (500mg/25ml Injection) 4 Promethazine HCl (25mg/ml 1 Irinotecan HCl (Injection) 4 Injection) Istodax (Injection) 4 PA Pulmozyme (Inhalation Solution) 4 PA Istodax (Overfill) (Injection) 4 PA Risperdal Consta (Injection) 3 Ixempra Kit (Injection) 4 Saphris (2.5mg Tablet Sublingual, 2 Jevtana (Injection) 4 PA 5mg Tablet Sublingual) Kadcyla (Injection) 4 PA Soliris (Injection) 4 PA KCl 0.075%/D5W/NaCl 0.45% 1 Solu-Cortef (1000mg Injection) 3 (Injection)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Synribo (Injection) 4 PA Alomide (Ophthalmic Solution) 3 Tice BCG (Injection) 4 Azelastine HCl (0.05% Ophthalmic 1 Trigels-F Forte (Capsule) 1 Solution) Trisenox (Injection) 4 Bepreve (Ophthalmic Solution) 3 ST Valstar (Injection) 4 Cromolyn Sodium (4% Ophthalmic 1 Velcade (Injection) 4 PA Solution) Vincasar PFS (Injection) 4 Emadine (Ophthalmic Solution) 3 Vincristine Sulfate (Injection) 4 Epinastine HCl (Ophthalmic 1 Solution) Xeomin (200unit Injection) 4 PA LaST 3 ST Zaltrap (Injection) 4 PA Olopatadine HCl (0.1% Ophthalmic 1 Zyprexa Relprevv (Injection) 3 Solution) Pataday (Ophthalmic Solution) 2 Pazeo (Ophthalmic Solution) 2 Bimatoprost (0.03% Ophthalmic 1 QL Solution) Latanoprost (Ophthalmic Solution) 1 QL Lumigan (Ophthalmic Solution) 2 QL Acuvail (Ophthalmic Solution) 3 Rescula (Ophthalmic Solution) 3 QL Alrex (Suspension) 3 Bromfenac (0.09% Ophthalmic 1 Travatan Z (Ophthalmic Solution) 2 QL Solution) Zioptan (Ophthalmic Solution) 3 QL Bromfenac (0.09% Ophthalmic 1 QL Solution) Dexamethasone Sodium Phosphate 1 Altacaine (Ophthalmic Solution) 1 (0.1% Ophthalmic Solution) Altafrin (Ophthalmic Solution) 1 Diclofenac Sodium (0.1% 1 Atropine Sulfate (1% Ophthalmic 1 Ophthalmic Solution) Solution) Durezol (Emulsion) 3 Balanced Salt (Injection) 1 Flarex (Suspension) 3 Balanced Salt Solution (Injection) 1 Fluorometholone (Ophthalmic 1 BSS (Injection) 1 Suspension) Cyclopentolate HCl (Ophthalmic 1 Flurbiprofen Sodium (Ophthalmic 1 Solution) Solution) Cyclopentolate HCl (Ophthalmic 1 FML (Ointment) 2 Solution) Ilevro (Suspension) 3 QL Cystaran (Ophthalmic Solution) 4 PA,QL Ketorolac Tromethamine (0.4% 1 Eylea (Injection) 4 Ophthalmic Solution, 0.5% Ophthalmic Solution) Jetrea (Injection) 4 Lotemax (0.5% Gel, 0.5% 3 QL Lacrisert (Insert) 3 Ointment) Lucentis (Injection) 4 Lotemax (0.5% Suspension) 3 Macugen (Injection) 4 Nevanac (Suspension) 3 QL Phenylephrine HCl (10% 1 Ozurdex (Injection) 4 Ophthalmic Solution, 2.5% Ophthalmic Solution) Pred Mild (Suspension) 2 Procysbi (Capsule Delayed- 4 PA Prednisolone Acetate (Suspension) 1 Release) Prednisolone Sodium Phosphate 1 Proparacaine HCl (Ophthalmic 1 (1% Ophthalmic Solution) Solution) Restasis (Emulsion) 2 PA Restasis Multidose (Emulsion) 2 PA Acetazolamide ER (Capsule 1 Tetcaine (Ophthalmic Solution) 1 Extended-Release 12 Hour) Tetracaine HCl (Ophthalmic 1 Alphagan P (0.1% Ophthalmic 2 Solution) Solution) Visudyne (Injection) 4 Apraclonidine (Ophthalmic 1 Solution) Azopt (Suspension) 2 Alocril (Ophthalmic Solution) 3

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Betaxolol HCl (0.5% Ophthalmic 1 Flunisolide (Nasal Solution) 1 QL Solution) Fluticasone Propionate (50mcg/act 1 Betimol (Ophthalmic Solution) 3 Suspension) RX Brimonidine Tartrate (Ophthalmic 1 Mometasone Furoate (50mcg/act 1 QL Solution) Suspension) Carteolol HCl (Ophthalmic 1 Omnaris (Suspension) 3 QL Solution) Pulmicort Flexhaler (Aerosol 2 QL Combigan (Ophthalmic Solution) 2 Powder) Dorzolamide HCl/Timolol Maleate 1 Symbicort (Aerosol) 2 QL (Ophthalmic Solution) Triamcinolone Acetonide 1 Iopidine (1% Ophthalmic 3 (55mcg/act Aerosol) RX Solution) Keveyis (Tablet) 4 PA,QL Levobunolol HCl (Ophthalmic 1 Solution) Arbinoxa (Tablet) 1 Metipranolol (Ophthalmic Solution) 1 Azelastine HCl (0.1% Nasal 1 QL Solution, 0.15% Nasal Solution) Phospholine Iodide (Ophthalmic 2 Solution) Carbinoxamine Maleate (4mg 1 Tablet, 4mg/5ml Oral Solution) Pilocarpine HCl (1% Ophthalmic 1 Solution, 2% Ophthalmic Solution, Cetirizine HCl (Syrup) RX 1 4% Ophthalmic Solution) Clarinex (0.5mg/ml Syrup) 3 Simbrinza (Suspension) 3 Desloratadine (Tablet) 1 Timolol Maleate (0.25% 1 Desloratadine ODT (Tablet 1 Ophthalmic Solution, 0.5% Dispersible) Ophthalmic Solution) Dymista (Suspension) 3 QL Timolol Maleate Ophthalmic Gel 1 Levocetirizine Dihydrochloride 1 Forming (Solution) (2.5mg/5ml Oral Solution, 5mg Tablet) Olopatadine HCl (0.6% Nasal 1 QL Acetasol HC (Otic Solution) 1 Solution) Acetic Acid (Otic Solution) 1 Vituz (Oral Solution) 3 Acetic Acid/Aluminum Acetate 1 (Otic Solution) Cipro HC (Suspension) 3 Ciprodex (Otic Suspension) 2 Montelukast Sodium (10mg Tablet, 1 Coly-Mycin S (Suspension) 3 4mg Packet, 4mg Tablet Chewable, 5mg Tablet Chewable) Hydrocortisone/Acetic Acid (Otic 1 Solution) Zafirlukast (Tablet) 1 Neomycin/Polymyxin/Hydrocortiso 1 Zyflo CR (Tablet Extended- 3 ST ne (1% Otic Solution, 1% Otic Release 12 Hour) Suspension)

Oxytocin/Sodium Chloride 1 Anoro Ellipta (Aerosol Powder) 2 QL (30unit/500ml-0.9% Solution) Atrovent HFA (Aerosol Solution) 3 QL Combivent Respimat (Aerosol 2 QL Solution) Incruse Ellipta (Aerosol Powder) 3 QL Advair Diskus (Aerosol Powder) 2 QL Ipratropium Bromide (0.02% 1 QL Advair HFA (Aerosol) 2 QL Inhalation Solution) Arnuity Ellipta (Aerosol Powder) 2 QL Ipratropium Bromide (0.03% Nasal 1 Beconase AQ (Suspension) 3 QL Solution, 0.06% Nasal Solution) Breo Ellipta (Aerosol Powder) 2 QL Spiriva HandiHaler (Capsule) 2 QL Budesonide (0.25mg/2ml 1 Spiriva Respimat (Aerosol 2 QL Suspension, 0.5mg/2ml Suspension) Solution) Budesonide (1mg/2ml Suspension, 1 QL 32mcg/act Suspension) RX Flovent Diskus (Aerosol Powder) 2 QL Flovent HFA (Aerosol) 2 QL

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Adrenaclick (0.3mg/0.3ml 2 Theophylline CR (Tablet Extended- 1 Injection) Release 12 Hour) Albuterol Sulfate (0.083% 1 QL Theophylline ER (100mg Tablet ER 1 Nebulized Solution, 0.5% Nebulized 12 Hour, 200mg Tablet ER 12 Hour, Solution, 0.63mg/3ml Nebulized 300mg Tablet ER 12 Hour, 450mg Solution, 1.25mg/3ml Nebulized Tablet ER 12 Hour, 400mg Tablet Solution) ER 24 Hour, 600mg Tablet ER 24 Albuterol Sulfate (2mg Tablet, 4mg 1 Hour) Tablet, 2mg/5ml Syrup) Albuterol Sulfate ER (Tablet 1 Extended-Release 12 Hour) Adcirca (Tablet) 4 PA,QL Arcapta Neohaler (Capsule) 3 QL,ST Adempas (Tablet) 4 PA,QL Brovana (Nebulized Solution) 3 QL Epoprostenol Sodium (Injection) 4 PA Ephedrine Sulfate/Sodium Chloride 1 (50mg/5ml-0.9% Solution Prefilled Letairis (Tablet) 4 PA,QL Syringe) Opsumit (Tablet) 4 PA,QL Epinephrine (0.15mg/0.3ml 2 Orenitram (Tablet Extended- 4 PA Injection, 0.3mg/0.3ml Injection) Release) (authorized generic Epi-Pen made Remodulin (Injection) 4 PA by Mylan) Sildenafil (10mg/12.5ml Injection) 4 PA EpiPen (Injection) 2 Sildenafil (20mg Tablet) 4 PA,QL Levalbuterol (Nebulized Solution) 1 QL Tracleer (Tablet) 4 PA,QL Metaproterenol Sulfate (10mg 1 Tyvaso (Inhalation Solution) 4 PA,QL Tablet, 20mg Tablet, 10mg/5ml Tyvaso Refill (Inhalation 4 PA,QL Syrup) Solution) Perforomist (Nebulized Solution) 3 QL Tyvaso Starter (Inhalation 4 PA,QL ProAir HFA (Aerosol Solution) 2 QL Solution) ProAir RespiClick (Aerosol 2 QL Uptravi (Tablet Therapy Pack, 4 PA,QL Powder) 1000mcg Tablet, 1200mcg Tablet, Serevent Diskus (Aerosol Powder) 2 QL 1400mcg Tablet, 1600mcg Tablet, ST 3 QL,ST 200mcg Tablet, 400mcg Tablet, Terbutaline Sulfate (1mg/ml 1 600mcg Tablet, 800mcg Tablet) Injection, 2.5mg Tablet, 5mg Veletri (Injection) 4 PA Tablet) Ventavis (Inhalation Solution) 4 PA,QL Ventolin HFA (Aerosol Solution) 2 QL

Acetylcysteine (10% Inhalation 1 Kalydeco (150mg Tablet, 50mg 4 PA Solution, 20% Inhalation Solution, Packet, 75mg Packet) 200mg/ml Injection) Orkambi (125mg-100mg Tablet) 4 PA,QL Aralast NP (Injection) 4 PA Benzonatate (Capsule) 1 Esbriet (Capsule) 4 PA Flowtuss (Oral Solution) 3 Cromolyn Sodium (20mg/2ml 1 Glassia (Injection) 4 PA Nebulized Solution) Hydrocodone 1 Bitartrate/Homatropine Methylbromide (1.5mg-5mg Tablet, 1.5mg/5ml-5mg/5ml Syrup) Hydromet (Syrup) Aminophylline (Injection) 1 1 Nebusal (3% Nebulized Solution) Daliresp (Tablet) 3 PA 1 Difil-G Forte (Liquid) 1 Obredon (Oral Solution) 3 Elixophyllin (Elixir) 2 Ofev (Capsule) 4 PA Theo-24 (Capsule Extended- 3 Prolastin-C (Injection) 4 PA Release 24 Hour) Pulmosal (Nebulized Solution) 1 Theochron (Tablet Extended- 1 Ribavirin (6gm Solution) 4 Release 12 Hour) Sodium Chloride (0.9% Nebulized 1 Theophylline (Oral Solution) 1 Solution, 10% Nebulized Solution,

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits 3% Nebulized Solution, 7% Kionex (Powder, 15gm/60ml 1 Nebulized Solution) Suspension) SSKI (Oral Solution) 3 Samsca (Tablet) 4 QL Stiolto Respimat (Aerosol 2 QL Sodium Acetate (2meq/ml Injection) 1 Solution) Sodium Bicarbonate (7.5% 1 Tussigon (Tablet) 1 Injection) Xolair (Injection) 4 PA Sodium Polystyrene Sulfonate 1 Zemaira (Injection) 4 PA (Powder, 15gm/60ml Suspension, 30gm/120ml Suspension, 50gm/200ml Suspension) Atracurium Besylate (Injection) 1 SPS (Suspension) 1 Carisoprodol (250mg Tablet, 350mg 1 Syprine (Capsule) 4 PA Tablet) Veltassa (Packet) 3 Chlorzoxazone (Tablet) 1 Cisatracurium Besylate (Injection) 1 Cyclobenzaprine HCl (Tablet) 1 Lorzone (Tablet) 3 Aminosyn 8.5%/Electrolytes 1 Metaxall (Tablet) 1 (Injection) Metaxalone (Tablet) 1 Aminosyn II 8.5%/Electrolytes 1 (Injection) Methocarbamol (1000mg/10ml 1 Injection, 500mg Tablet, 750mg AV-Phos 250 Neutral (Tablet) 1 Tablet) BD Posiflush (Solution) 1 Orphenadrine Citrate (30mg/ml 1 Calcium Chloride (Injection) 1 Injection) Cardioplegic (Injection) 1 Orphenadrine Citrate ER (Tablet 1 Chromagen (Capsule) 1 Extended-Release 12 Hour) Chromium Chloride (Injection) 1 Pancuronium Bromide (Injection) 1 Clinisol SF 15% (Injection) 1 Revonto (Injection) 1 Corvita 150 (Tablet) 1 Rocuronium Bromide (100mg/10ml 1 Dextrose 5%/Lactated Ringers 1 Injection, 50mg/5ml Injection) (Injection) Vecuronium Bromide (10mg 1 Effer-K (Tablet Effervescent) 1 Injection, 20mg Injection) Effervescent Potassium/Chloride 1 (Tablet Effervescent) Ferocon (Capsule) 1 Eszopiclone (Tablet) 1 QL Ferotrinsic (Capsule) 1 Zaleplon (Capsule) 1 QL Ferrocite Plus (Tablet) 1 Zolpidem Tartrate (1.75mg Tablet 1 Fluor-A-Day (Oral Solution) 1 PV Sublingual, 3.5mg Tablet Fluoride (Tablet Chewable) 1 PV Sublingual) Fluoritab (0.125mg/drop Oral 1 PV Zolpidem Tartrate (10mg Tablet, 1 QL Solution, 0.25mg Tablet Chewable, 5mg Tablet) 0.5mg Tablet Chewable, 1mg Tablet Zolpidem Tartrate ER (Tablet 1 QL Chewable) Extended-Release) Flura-Drops (Oral Solution) 1 PV Foltrin (Capsule) 1 Hematinic Plus Vitamins/Minerals 1 (Tablet) Armodafinil (Tablet) 1 PA,QL Hemocyte-Plus (Tablet) 1 Belsomra (Tablet) 3 QL,ST Iferex 150 Forte (Capsule) 1 Modafinil (Tablet) 1 PA,QL Isolyte-S (Injection) 3 Rozerem (Tablet) 3 QL K-Effervescent (Tablet 3 Xyrem (Oral Solution) 4 PA,QL Effervescent) K-Prime (Tablet Effervescent) 1 K-Tan Plus (Capsule) 1 Carbaglu (Tablet) 4 Karidium (Oral Solution) 1 PV Chemet (Capsule) 3 Klor-Con 10 (Tablet Extended- 1 Release) Exjade (Tablet Soluble) 4 PA Jadenu (Tablet) 4 PA

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Klor-Con 8 (Tablet Extended- 1 PureVitamin Dualfe Plus (Capsule) 1 Release) Ringers Injection 1 Klor-Con M10 (Tablet Extended- 1 Saline Flush (Injection) 1 Release) Saline Flush Zr/Sterile Field 1 Klor-Con M15 (Tablet Extended- 3 (Injection) Release) Sodium Chloride (2.5meq/ml 1 Klor-Con M20 (Tablet Extended- 1 Injection, 3% Injection, 5% Release) Injection) Klor-Con Sprinkle (Capsule 1 Sodium Chloride 0.45% (Injection) 1 Extended-Release) Sodium Chloride Bacteriostatic 1 Lactated Ringers (Injection) 1 (Injection) Ludent (Tablet Chewable) 1 PV Sodium Chloride Flush (Injection) 1 Magnesium Chloride (200mg/ml 1 Sodium Ferric Gluconate 4 Injection) Complex/Sucrose (Injection) Magnesium Sulfate (20gm/500ml 1 Sodium Fluoride (0.25mg Tablet 1 PV Injection, 2gm/50ml Injection, Chewable, 1.1mg Tablet Chewable, 40gm/1000ml Injection, 4gm/100ml 1mg Tablet Chewable, 0.5mg/ml Injection, 4gm/50ml Injection, 50% Oral Solution, 1mg Tablet) Injection) Sodium Phosphate (Injection) 1 Monoject Pharma Grade Flush 1 Swabflush Saline Flush (Injection) 1 Syringe (Solution) Taron-Crystals (Packet) 1 Nafrinse (Tablet Chewable) 1 PV TL Icon (Capsule) 1 Nafrinse Drops (Oral Solution) 1 PV TPN Electrolytes (Injection) 1 Normal Saline Flush (Solution) 1 Tricon (Capsule) 1 Nutrilyte (Injection) 1 Virt-Phos 250 Neutral (Tablet) 1 Plasma-Lyte A (Injection) 3 Virtrate-2 (Oral Solution) 1 Plasma-Lyte-148 (Injection) 3 Virtrate-3 (Oral Solution) 1 Plasma-Lyte-56/D5W (Injection) 3 Virtrate-K (Oral Solution) 1 Plenamine (Injection) 1 Poly-Iron 150 Forte (Capsule) 1 Polysaccharide Iron Forte (Capsule) 1 Aminoam Rms (Capsule) 1 Potassium Acetate (2meq/ml 1 Aminorelief Rms (Capsule) 1 Injection) Potassium Chloride (10% Oral 1 Solution, 20% Oral Solution, Airavite (Tablet) 1 10meq/100ml Injection, 20meq/50ml Injection, 2meq/ml Atabex Prenatal (Tablet 3 PV Injection, 40meq/100ml Injection, Chewable) 20meq Packet) AV-Vite FB (Tablet) 1 Potassium Chloride CR (Tablet 1 B-Plex (Tablet) 1 Extended-Release) B-Plex Plus (Tablet) 1 Potassium Chloride ER (10meq 1 Baby Super Daily D3 (Liquid) 3 PV Capsule Extended-Release, 8meq Baby Vitamin D3 Drops (Liquid) 3 PV Capsule Extended-Release, 10meq Bio-D-Mulsion (Liquid) 1 PV Tablet Extended-Release, 20meq Bio-D-Mulsion Forte (Liquid) 1 PV Tablet Extended-Release, 8meq Biocel (Tablet) 1 Tablet Extended-Release) BP Folinatal Plus B (Tablet) 1 Potassium Chloride SR (Tablet 1 Extended-Release) BP Multinatal Plus (Tablet, Tablet 1 Chewable) Potassium Chloride/Lidocaine HCl 1 (Injection) BP Vit 3 (Capsule) 1 Potassium Chloride/Sodium 1 Bprotected Pedia D-Vite (Liquid) 1 PV Chloride (20meq/L-0.9% Injection, Brainstrong Prenatal 3 PV 40meq/L-0.9% Injection) Cadeau DHA (Capsule) 3 PV Potassium Citrate ER (Tablet 1 Calcidol (Oral Solution) 1 PV Extended-Release) Calciferol (Oral Solution) 1 PV Premasol (6% Injection) 1 Centrum Specialist Prenatal 3 PV Prenatal Multi +DHA (Capsule) 3 PV Classic Prenatal (Tablet) 1 PV

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Co-Natal FA (Tablet) 1 Fabb (Tablet) 1 Complete Natal DHA 1 Folbee (Tablet) 1 Completenate (Tablet Chewable) 1 Folbee Plus (Tablet) 1 Corvita (Tablet) 1 Folic Acid (1mg Tablet, 400mcg 1 Corvite Free (Tablet) 1 Tablet, 800mcg Capsule) RX CVS D3 (1000unit Capsule, 1 PV Folic Acid/Vitamin B-6/Vitamin B- 1 2000unit Capsule, 400unit Capsule, 12 (Tablet) 5000unit Capsule, 1000unit Tablet Folplex 2.2 (Tablet) 1 Chewable) GNP D 1000 (Capsule) 1 PV CVS Prenatal (Tablet) 1 PV GNP D 2000 (Tablet Chewable) 1 PV CVS Prenatal Gummy/DHA/Folic 3 PV GNP Daily Prenatal 3 PV Acid (Tablet Chewable) GNP Prenatal (Tablet) 3 PV CVS Prenatal Multi+DHA 3 PV GNP Vitamin D (Tablet) 1 PV (Capsule) GNP Vitamin D Super Strength 1 PV CVS Vitamin D Childrens Gummies 1 PV (Tablet) (Tablet Chewable) GNP Vitamin D3 Extra Strength 1 PV CVS Vitamin D3 Drops/Infants 3 PV (Tablet) (Liquid) Goodsense Prenatal Vitamins 3 PV Cyanocobalamin (1000mcg/ml 1 (Tablet) Injection) Healthy Kids Vitamin D3 (Tablet 1 PV D 1000 (1000unit Capsule, 1000unit 1 PV Chewable) Tablet Chewable) Healthy Mama Be Well Rounded 3 PV D 10000 (Capsule) 1 PV (Therapy Pack) D 2000 (Tablet) 1 PV HM One Daily Prenatal Combo 3 PV D 400 (400unit Tablet, 400unit 1 PV HM Prenatal (Tablet) 3 PV Tablet Chewable) HM Vitamin D (Tablet) 1 PV D-Vita (Liquid) 1 PV HM Vitamin D3 (Capsule) 1 PV D3 (1000unit Capsule, 2000unit 1 PV Inatal GT (Tablet) 1 Capsule, 400unit Capsule, 1000unit Tablet, 2000unit Tablet) Just D (Liquid) 1 PV KP Folic Acid (Tablet) D3 2000 (Tablet) 1 PV 1 PV D3 Adult (Tablet Chewable) 1 PV KP Prenatal Multivitamins 3 PV (Tablet) D3 Dots (Tablet Dispersible) 3 PV KP Vitamin D (1000unit Capsule, 1 PV D3 High Potency (Tablet) 1 PV 2000unit Capsule, 400unit Tablet D3 Kids (Tablet Chewable) 1 PV Chewable) D3 Maximum Strength (5000unit 1 PV Lysiplex Plus (Tablet) 1 Capsule, 5000unit/ml Liquid) M-Vit (Tablet) 1 D3 Super Strength (Capsule) 1 PV MacNatal CN DHA (Capsule) 1 D3-1000 (Capsule) 1 PV Mephyton (Tablet) 2 D3-50 (Capsule) 1 PV Mission Prenatal (Tablet) 3 PV Ddrops (Liquid) 3 PV Mission Prenatal HP (Tablet) 1 PV Ddrops Booster (Liquid) 3 PV Multi Prenatal (Tablet) 1 PV Decara (25000unit Capsule) 3 PV Multi-Vit/Fluoride (32mg/ml- 1 Decara (50000unit Capsule) 1 PV 3mcg/ml-1mg/ml-400unit/ml- Delta D3 (Tablet) 1 PV 2mcg/ml-5unit/ml-29.7mcg/ml- Dialyvite Vitamin D 5000 (Capsule) 1 PV 2mg/ml-0.4mg/ml-0.6mg/ml- Dialyvite Vitamin D3 Max (Tablet) 1 PV 0.25mg/ml-0.5mg/ml-1150unit/ml Elite-Ob (Tablet) 1 Oral Solution) Enfamil Expecta 3 PV Multi-Vit/Iron/Fluoride (Solution) 1 EQL Prenatal Formula (Tablet) 1 PV Multivitamin with Fluoride (32-3-1- 1 400-2-5-29.7-2-0.4-0.6-0.25-0.5- EQL Vitamin D3 (Capsule) 1 PV 1150 Solution; 35mg/ml- EQL Vitamin D3 Gummies (Tablet 1 PV 400unit/ml-2mcg/ml-5unit/ml- Chewable) 8mg/ml-0.4mg/ml-0.6mg/ml- Ergocalciferol (8000unit/ml Oral 1 PV 0.5mg/ml-0.5mg/ml-1500unit/ml Solution) Solution) FA-8 (0.8mg Capsule, 800mcg 1 PV Multivitamins/Fluoride (Tablet 1 Tablet) Chewable)

Drug Name Drug Requirements Drug Name Drug Requirements Tier & Limits Tier & Limits Mynatal Advance (Tablet) 1 Prenatal/Omega-3/Folic Acid/Iron 3 PV Mynatal Plus (Tablet) 1 (Capsule) Mynatal Ultracaplet (Tablet) 1 Pronutrients Vitamin D3 (Capsule) 1 PV Mynatal-Z (Tablet) 1 PX Prenatal Multivitamins (Tablet) 1 PV Mynate 90 Plus (Tablet Extended- 1 Pyridoxine HCl (100mg/ml 1 Release) Injection) NascoBAL (Nasal Solution) 3 QC Prenatal (Tablet) 3 PV Nat-Rul Prenatal Vitamins 3 PV Quflora Pediatric (32mg/ml- 1 (Tablet) 3mcg/ml-1mg/ml-400unit/ml- Nat-Rul Vitamin D (Tablet) 1 PV 2mcg/ml-5unit/ml-29.7mcg/ml- 2mg/ml-0.4mg/ml-0.6mg/ml- Natural Vitamin D-3 (Tablet) 1 PV 0.25mg/ml-0.5mg/ml-1150unit/ml Nephronex (Tablet) 1 Oral Solution) Nufol (Tablet) 1 RA One Daily 3 PV Nutrifac ZX (Tablet) 1 RA Prenatal (Tablet) 1 PV Obstetrix EC (Tablet) 1 RA Prenatal Formula/Folic Acid 3 PV One A Day Womens 3 PV (Tablet) Prenatal/DHA RA Vitamin D-3 (1000unit Tablet, 1 PV One A Day Womens Prenatal1 3 PV 2000unit Capsule) (Capsule) Rena-Vite Rx (Tablet) 1 One-A-Day Womens Prenatal 3 PV Replesta (Wafer) 3 PV Optimal D3 M (Capsule) 3 PV Replesta Childrens (Wafer) 3 PV Optimal-D Pack (Capsule) 1 PV Replesta Nx (Wafer) 3 PV Opurity Vitamin D (Tablet 1 PV Right Step Prenatal (Tablet) 3 PV Chewable) Similac Prenatal Early Shield 3 PV Ortho-CS 250 (Injection) 1 SM Folic Acid (Tablet) 1 PV PA Prenatal Formula (Tablet) 3 PV SM One Daily Prenatal 3 PV PA Vitamin D-3 (Capsule) 1 PV SM Vitamin D (Tablet) 1 PV PA Vitamin D-3 Gummy (Tablet 1 PV Chewable) SM Vitamin D3 Maximum 3 PV Strength (Capsule) Perry Prenatal (Capsule) 1 PV Stuart One (Capsule) 3 PV Phytonadione (Injection) 1 Super Daily D3 (1000unit/0.03ml 3 PV Pre-Natal Formula (Tablet) 1 PV Liquid) Prenatabs Rx (Tablet) 1 Taron-Prex (Capsule) 1 Prenatal (100mg-0-0-263mg- 1 PV Thera-D 2000 (Tablet) 1 PV 400unit-4mcg-27mg-0.8mg-18mg- 2.6mg-1.7mg-1.5mg-11unit- Thera-D 4000 (Tablet) 3 PV 4000unit-25mg Tablet) Thiamine HCl (100mg/ml Injection) 1 Prenatal (120mg-4000unit-200mg- 3 PV TL Gard Rx (Tablet) 1 400unit-8mcg-28mg-800mcg- Trinatal Rx 1 (Tablet) 1 20mg-2.6mg-1.7mg-1.8mg-30unit- Trinate (Tablet) 1 25mg Tablet) Triphrocaps (Capsule) 1 Prenatal 19 (Tablet, Tablet 1 Ultimatecare One (Capsule) 1 Chewable) Urosex (Tablet) 1 Prenatal and Iron (Tablet) 1 PV V-C Forte (Capsule) 1 Prenatal Complete (Tablet) 3 PV Vic-Forte (Capsule) 1 Prenatal Formula (Capsule) 3 PV Vinate II (Tablet) 1 Prenatal Forte (Tablet) 1 PV Vinate M (Tablet) 1 Prenatal Low Iron (Tablet) 1 PV Vinate One (Tablet) 1 Prenatal Multi + DHA (Capsule) 3 PV Virt-Caps (Capsule) 1 Prenatal Multivitamin + DHA 3 PV Virt-Gard (Tablet) 1 Prenatal Multivitamin Plus DHA 3 PV Virt-Vite (Tablet) 1 (Capsule) Virt-Vite Plus (Tablet) 1 Prenatal One Daily (Tablet) 3 PV Vita S Forte (Tablet) 1 Prenatal Vitamin/Iron (Tablet) 3 PV Vita-Min (Capsule) RX 1 Prenatal Vitamins (Tablet) 1 PV Vitacel (Tablet) 1 Prenatal-U (Capsule) 1

Drug Name Drug Requirements Tier & Limits Vitajoy Daily D Gummies (Tablet 1 PV Chewable) Vitamax Pediatric (Oral Solution) 1 Vitamelts Vitamin D (Tablet 3 PV Dispersible) Vitamin C 222mg (Injection) 1 Vitamin D (2000unit Tablet, 400unit 1 PV Capsule, 400unit Tablet, 400unit/ml Liquid, 50000unit Capsule) Vitamin D-1000 (Tablet) 1 PV Vitamin D-3 (1000unit Capsule, 1 PV 1000unit Tablet, 400unit Tablet, 2000unit Tablet) Vitamin D2 (Tablet) 3 PV Vitamin D3 (10000unit Tablet, 3 PV 1000unit/spray Liquid, 1200unit/15ml Liquid, 3000unit Tablet) Vitamin D3 (Capsule, Tablet, Tablet 1 PV Chewable, 400unit/ml Liquid, 5000unit/ml Liquid) Vitamin D3 Gummies (Tablet 1 PV Chewable) Vitamin K1 (1mg/0.5ml Injection) 1 Vitamins A/C/D/Fluoride (Solution) 1 Vol-Care Rx (Tablet) 1 VP-Vite Rx (Tablet) 1 Wellesse Vitamin D3 (Liquid) 3 PV YL Folic Acid (Tablet) 1 PV Your Life Multi Prenatal 3 PV (Capsule)

Rayaldee (Capsule Extended- 3 Release) Upspringbaby Vitamin D3 3 PV (Liquid) Vitamin D3 (5000unit Tablet 3 PV Dispersible)

Adempas (Tablet) ...... 51 Aldurazyme (Injection) ...... 34 1 Adenosine (12mg/4ml Injection, 6mg/2ml Alendronate Sodium (10mg Tablet, 40mg Injection) ...... 29 Tablet, 5mg Tablet) ...... 42 1st Tier Unifine Pentips /Mini/31gx5mm ... 43 Adrenaclick (0.3mg/0.3ml Injection) ...... 50 Alendronate Sodium (35mg Tablet, 70mg 1st Tier Unifine Pentips 29gx12mm ...... 43 Adriamycin (Injection) ...... 21 Tablet) ...... 42 1st Tier Unifine Pentips 31gx6mm ...... 43 Adrucil (Injection)...... 22 Alendronate Sodium (70mg/75ml Oral 1st Tier Unifine Pentips 31gx8mm ...... 43 Advair Diskus (Aerosol Powder) ...... 50 Solution) ...... 42 1st Tier Unifine Pentips 32gx4mm ...... 43 Advair HFA (Aerosol) ...... 50 Alfentanil (Injection) ...... 12 1st Tier Unifine Pentips Plus 31gx8mm ...... 43 Advate (Injection) ...... 28 Alferon N (Injection) ...... 22 AeroChamber Mini Aerosol Chamber ...... 43 Alfuzosin HCl ER (Tablet Extended-Release 24 A AeroChamber MV ...... 43 Hour) ...... 37 Abacavir (Tablet) ...... 25 AeroChamber Plus Flow Vu ...... 43 Alimta (Injection) ...... 47 Abacavir Sulfate/Lamivudine/Zidovudine AeroChamber Plus Flow-Vu ...... 43 Alinia (100mg/5ml Suspension, 500mg (Tablet) ...... 25 AeroChamber Plus Flow-Vu/Large Mask ... 43 Tablet) ...... 23 Abacavir/Lamivudine (Tablet) ...... 25 AeroChamber Plus Flow-Vu/Mask ...... 43 Alkeran (2mg Tablet) ...... 21 Abelcet (Injection) ...... 20 AeroChamber Plus Flow-Vu/Medium Mask Allopurinol (Tablet) ...... 21 Abilify Maintena (Injection)...... 47 ...... 43 Allopurinol Sodium (Injection) ...... 21 Abraxane (Injection) ...... 47 AeroChamber Plus Flow-Vu/Small Mask ... 43 Almotriptan Malate (Tablet) ...... 21 Acamprosate Calcium DR (Tablet Delayed- AeroChamber Z-Stat Plus/Medium Mask .. 43 Alocril (Ophthalmic Solution) ...... 49 Release) ...... 13 AeroChamber/FlowSignal ...... 43 Alogliptin (Tablet) ...... 26 Acarbose (Tablet) ...... 26 Aerovent Plus Holding Chamber/Collapsible Alomide (Ophthalmic Solution) ...... 49 Acebutolol HCl (200mg Capsule, 400mg ...... 43 Alophen (Tablet Delayed-Release) ...... 35 Capsule) ...... 29 Afeditab CR (Tablet Extended-Release 24 Alosetron HCl (Tablet) ...... 35 Acetaminophen/Caffeine/Dihydrocodeine Hour) ...... 30 Aloxi (Injection) ...... 20 (Capsule) ...... 12 Afinitor (Tablet) ...... 23 Alphagan P (0.1% Ophthalmic Solution) .... 49 Acetaminophen/Codeine (Oral Solution, Afinitor Disperz (Tablet Soluble) ...... 23 Alphanate/Von Willebrand Factor Tablet)...... 12 Afluria 2016-2017 (Injection) ...... 42 Complex/Human (Injection) ...... 28 Acetasol HC (Otic Solution) ...... 50 Afluria PF 2016-2017 (Injection) ...... 47 Alphanine SD (Injection) ...... 28 Acetazolamide (Tablet Immediate-Release) 30 Afluria Quadrivalent 2016-2017 (Injection) 47 Alphatrex (Gel) ...... 33 Acetazolamide ER (Capsule Extended-Release Aftera (Tablet) ...... 40 Alprazolam (Tablet Immediate-Release) ..... 25 12 Hour) ...... 49 Aggrastat (Injection) ...... 28 Alprazolam ER (Tablet Extended-Release 24 Acetazolamide Sodium (Injection) ...... 47 Airavite (Tablet) ...... 53 Hour) ...... 25 Acetic Acid (Otic Solution) ...... 50 Akynzeo (Capsule) ...... 19 Alprazolam ODT (Tablet Dispersible) ...... 26 Acetic Acid 0.25% (Irrigation Solution) ...... 37 Ala-Cort (Cream) ...... 33 Alprazolam XR (Tablet Extended-Release 24 Acetic Acid/Aluminum Acetate (Otic Solution) Albenza (Tablet) ...... 23 Hour) ...... 26 ...... 50 Albuked 25 (Injection) ...... 27 Alprostadil (Injection) ...... 38 Acetylcysteine (10% Inhalation Solution, 20% Albuked 5 (Injection) ...... 27 Alrex (Suspension) ...... 49 Inhalation Solution, 200mg/ml Injection) Albumin Human (Injection) ...... 27 Altabax (Ointment) ...... 14 ...... 51 Albuminar-25 (Injection) ...... 27 Altacaine (Ophthalmic Solution) ...... 49 Aciphex Sprinkle (Capsule Sprinkle) ...... 36 Albuminar-5 (Injection) ...... 28 Altafrin (Ophthalmic Solution) ...... 49 Acitretin (Capsule) ...... 33 Albumin-Zlb (Injection) ...... 27 Altavera (Tablet) ...... 38 ActHIB (Injection) ...... 42 Alburx (Injection) ...... 28 Alyacen 1/35 (Tablet) ...... 38 Actimmune (Injection) ...... 41 Albutein (Injection) ...... 28 Alyacen 7/7/7 (Tablet) ...... 38 Actoplus Met XR (Tablet Extended-Release Albuterol Sulfate (0.083% Nebulized Solution, Amabelz (Tablet) ...... 38 24 Hour)...... 41 0.5% Nebulized Solution, 0.63mg/3ml Amantadine HCl (100mg Capsule, 100mg Acuvail (Ophthalmic Solution) ...... 49 Nebulized Solution, 1.25mg/3ml Nebulized Tablet, 50mg/5ml Syrup) ...... 23 Acyclovir (200mg Capsule, 200mg/5ml Solution) ...... 50 AmBisome (Injection) ...... 20 Suspension, 400mg Tablet, 800mg Tablet, Albuterol Sulfate (2mg Tablet, 4mg Tablet, Amcinonide (0.1% Cream, 0.1% Lotion, 0.1% 5% Ointment) ...... 25 2mg/5ml Syrup)...... 50 Ointment) ...... 33 Acyclovir Sodium (Injection) ...... 25 Albuterol Sulfate ER (Tablet Extended- Amethia (Tablet) ...... 38 Adacel (Injection) ...... 42 Release 12 Hour) ...... 50 Amethia Lo (Tablet) ...... 38 Adagen (Injection) ...... 34 Alclometasone Dipropionate (0.05% Cream, Amethyst (Tablet) ...... 38 Adapalene (0.1% Cream, 0.1% Gel, 0.3% Gel) 0.05% Ointment) ...... 33 Amifostine (Injection) ...... 47 ...... 33 Alcoh-Glove Contoured Wipe ...... 14 Amikacin Sulfate (1gm/4ml Injection, Adapalene Pump (Gel) ...... 33 Alcohol Prep Pads ...... 14 500mg/2ml Injection) ...... 14 Adcetris (Injection) ...... 23 Alcohol Swabs ...... 14 Amiloride HCl (5mg Tablet) ...... 31 Adcirca (Tablet) ...... 51 Alcohol Swabstick ...... 14 Amiloride/Hydrochlorothiazide (Tablet) ..... 31 Adefovir Dipivoxil (Tablet) ...... 24 Alcoh-Wipe 12" X 12" ...... 14 Aminoacetic Acid (Irrigation Solution) ...... 37

Aminoam Rms (Capsule)...... 53 Apidra (Injection) ...... 27 Atovaquone (Suspension) ...... 23 Aminophylline (Injection) ...... 51 Apidra SoloST ...... 27 Atovaquone/Proguanil HCl (Tablet) ...... 23 Aminorelief Rms (Capsule) ...... 53 Aplenzin (Tablet Extended-Release 24 Hour) Atracurium Besylate (Injection) ...... 51 Aminosyn 8.5%/Electrolytes (Injection) ...... 52 ...... 18 Atripla (Tablet) ...... 25 Aminosyn II 8.5%/Electrolytes (Injection).... 52 Apokyn (Injection) ...... 23 Atropen (0.5mg/0.7ml Injection) ...... 35 Amiodarone HCl (100mg Tablet, 200mg Apraclonidine (Ophthalmic Solution) ...... 49 Atropine Sulfate (0.1mg/ml Injection, Tablet, 400mg Tablet, 50mg/ml Injection) Aprepitant (Capsule) ...... 20 0.4mg/ml Injection, 1mg/ml Injection, ...... 29 Apri (Tablet) ...... 38 1mg/2.5ml Solution Prefilled Syringe) .... 35 Amiodarone HCl/Dextrose (Injection) ...... 29 Apriso (Capsule Extended-Release 24 Hour) Atropine Sulfate (1% Ophthalmic Solution) . 49 Amitiza (Capsule) ...... 35 ...... 42 Atrovent HFA (Aerosol Solution) ...... 50 Amitriptyline HCl (100mg Tablet, 10mg Aptiom (Tablet) ...... 17 Aubagio (Tablet) ...... 32 Tablet, 150mg Tablet, 25mg Tablet, 50mg Aptivus (100mg/ml Oral Solution, 250mg Aubra (Tablet) ...... 38 Tablet, 75mg Tablet) ...... 19 Capsule) ...... 25 Augmented Betamethasone Dipropionate Amlodipine Besylate (Tablet) ...... 30 Aralast NP (Injection) ...... 51 (0.05% Cream, 0.05% Gel, 0.05% Lotion, Amlodipine Besylate/Atorvastatin Calcium Aranelle (Tablet) ...... 38 0.05% Ointment)...... 33 (Tablet) ...... 30 Arbinoxa (Tablet) ...... 50 Augmentin (125mg/5ml-31.25mg/5ml Amlodipine Besylate/Benazepril HCl (Capsule) Arcalyst (Injection) ...... 41 Suspension) ...... 16 ...... 29 Arcapta Neohaler (Capsule) ...... 50 Aurora Pen Needles 29gx12mm ...... 43 Amlodipine Besylate/Valsartan (Tablet) ...... 28 Argatroban (125mg/125ml-0.9% Injection, Aurora Pen Needles 31g X 8mm ...... 43 Amlodipine/Olmesartan Medoxomil (Tablet) 250mg/250ml-0.9% Injection) ...... 27 Aurora Unifine Pentips/32gx5/32" ...... 43 ...... 28 Argatroban (250mg/2.5ml Injection) ...... 27 Aurora Unifine Pentips/Mini/31gx3/16" ... 43 Amlodipine/Valsartan/Hydrochlorothiazide Argyle Sterile Saline 100ml (Solution) ...... 43 Autopen ...... 43 (Tablet) ...... 28 Argyle Sterile Water 100ml (Solution) ...... 43 Avandia (Tablet) ...... 26 Ammonium Lactate (12% Cream, 12% Lotion) Arial Chamber ...... 43 Avastin (Injection) ...... 23 (RX) ...... 33 Aripiprazole (10mg Tablet, 15mg Tablet, AVC (Cream) ...... 17 Amoxapine (Tablet) ...... 19 20mg Tablet, 2mg Tablet, 30mg Tablet, Avelox (400mg/250ml-0.8% Injection) ...... 17 Amoxicillin (125mg Tablet Chewable, 250mg 5mg Tablet, 1mg/ml Oral Solution) ...... 18 Aviane (Tablet) ...... 38 Tablet Chewable, 125mg/5ml Suspension, Aripiprazole ODT (Tablet Dispersible) ...... 47 Avidoxy (Tablet) ...... 17 200mg/5ml Suspension, 250mg/5ml Armodafinil (Tablet) ...... 52 Avita (0.025% Cream, 0.025% Gel) ...... 33 Suspension, 400mg/5ml Suspension, Armour Thyroid (120mg Tablet, 180mg Avonex (Injection) ...... 32 250mg Capsule, 500mg Capsule, 500mg Tablet, 240mg Tablet, 300mg Tablet) ... 40 Avonex Pen (Injection)...... 32 Tablet, 875mg Tablet) ...... 16 Arnuity Ellipta (Aerosol Powder) ...... 50 AV-Phos 250 Neutral (Tablet) ...... 52 Amoxicillin/Clavulanate Potassium (Tablet Arranon (Injection) ...... 22 AV-Vite FB (Tablet) ...... 53 Chewable, Oral Suspension, Tablet Arzerra (Injection) ...... 23 Azacitidine (Injection) ...... 47 Immediate-Release) ...... 16 Ascomp/Codeine (Capsule) ...... 12 Azactam in Iso-Osmotic Dextrose (1gm-0 Amoxicillin/Clavulanate Potassium ER (Tablet Ashlyna (Tablet) ...... 38 Injection) ...... 16 Extended-Release 12 Hour) ...... 16 Asilnasal Rms (Capsule) ...... 43 Azasan (Tablet) ...... 41 Amphetamine/Dextroamphetamine (10mg, Aspir-81 (Tablet Delayed-Release) ...... 10 Azasite (Ophthalmic Solution) ...... 16 12.5mg, 15mg, 20mg, 30mg, 5mg, 7.5mg Aspirin (325mg Tablet, 81mg Tablet Azathioprine (100mg Injection, 50mg Tablet) Tablet ...... 32 Chewable, 81mg Tablet Delayed-Release) ...... 41 Amphotericin B (50mg Injection) ...... 20 ...... 10 Azelastine HCl (0.05% Ophthalmic Solution)49 Ampicillin (125mg/5ml Suspension, Aspirin 81 (Tablet Delayed-Release) ...... 10 Azelastine HCl (0.1% Nasal Solution, 0.15% 250mg/5ml Suspension, 250mg Capsule, Aspirin 81 Low Dose (Tablet Chewable) ...... 10 Nasal Solution) ...... 50 500mg Capsule) ...... 16 Aspirin Adult Low Dose (Tablet Delayed- Azelex (Cream) ...... 33 Ampicillin Sodium (10gm Injection, 1gm Release) ...... 10 Azithromycin (100mg/5ml Suspension, Injection, 250mg Injection, 2gm Injection, Aspirin Childrens (Tablet Chewable) ...... 10 200mg/5ml Suspension, 1gm Packet, 500mg Injection) ...... 16 Aspirin EC (Tablet Delayed-Release) ...... 10 250mg Tablet, 500mg Tablet, 600mg Ampicillin-Sulbactam (10gm-5gm Injection, Aspirin EC Low Dose (Tablet Delayed-Release) Tablet, 500mg Injection) ...... 16 1gm-0.5gm Injection, 2gm-1gm Injection) ...... 10 Azopt (Suspension) ...... 49 ...... 16 Aspirin Low Dose (Tablet Chewable) ...... 10 Aztreonam (Injection) ...... 16 Ampyra (Tablet Extended-Release 12 Hour) Aspirin/Dipyridamole (Capsule Extended- Azurette (Tablet) ...... 38 ...... 32 Release 12 Hour) ...... 28 Anadrol-50 (Tablet) ...... 38 Aspirin-Caffeine-Dihydrocodeine (Capsule) 12 B Anagrelide HCl (Capsule) ...... 27 Aspir-Low (Tablet Delayed-Release) ...... 10 Ana-Lex (Kit) ...... 33 Aspirtab (Tablet Delayed-Release) ...... 10 Baby Super Daily D3 (Liquid) ...... 53 Anastrozole (Tablet) ...... 22 Atabex Prenatal (Tablet Chewable) ...... 53 Baby Vitamin D3 Drops (Liquid) ...... 53 AndroGel (40.5mg/2.5gm Gel) ...... 38 Atenolol (100mg Tablet, 25mg Tablet, 50mg BACiiM (Injection) ...... 14 Androxy (Tablet) ...... 38 Tablet) ...... 29 Bacitracin (50000unit Injection, 500unit/gm Anoro Ellipta (Aerosol Powder) ...... 50 Atenolol/Chlorthalidone (Tablet) ...... 29 Ophthalmic Ointment) ...... 14 Anzemet (Tablet) ...... 20 Atgam (Injection) ...... 41 Bacitracin/Polymyxin B (Ophthalmic ApexiCon E (Cream) ...... 33 Atorvastatin Calcium (Tablet) ...... 31 Ointment) ...... 14

Baclofen (10mg Tablet, 20mg Tablet) ...... 24 Bicalutamide (Tablet) ...... 22 Tablet, 1mg Tablet, 2mg Tablet) ...... 30 Bactocill in Dextrose (0-1gm/50ml Injection) Bicillin C-R (300000unit/ml-300000unit/ml Buminate (Injection) ...... 28 ...... 16 Injection) ...... 16 Buphenyl (500mg Tablet) ...... 34 Bactroban Nasal (Ointment) ...... 14 Bicillin L-A (Injection) ...... 16 Bupivacaine HCl (Injection) ...... 12 Balanced Salt (Injection) ...... 49 BiCNU (Injection) ...... 21 Bupivacaine HCl/Sodium Chloride (Solution Balanced Salt Solution (Injection) ...... 49 BiDil (Tablet) ...... 31 Prefilled Syringe) ...... 42 Balsalazide Disodium (Capsule) ...... 42 Biltricide (Tablet) ...... 23 Bupivacaine Spinal (Injection) ...... 12 Balziva (Tablet) ...... 38 Bimatoprost (0.03% Ophthalmic Solution) . 48 Bupivacaine/Dextrose Spinal (Injection)...... 12 Banzel (200mg Tablet, 400mg Tablet, Biocel (Tablet) ...... 53 Bupivacaine/Epinephrine (0.25%-1 40mg/ml Suspension) ...... 18 Bio-D-Mulsion (Liquid) ...... 53 200000 Injection) ...... 12 Baraclude (0.05mg/ml Oral Solution) ...... 24 Bio-D-Mulsion Forte (Liquid) ...... 53 Bupivacaine/Epinephrine (0.5%-1 Bayer Advanced Aspirin Regular Strength Bio-Statin (Powder) ...... 20 200000 Injection) ...... 42 (Tablet) ...... 10 Biothrax (Injection) ...... 42 Buprenorphine HCl (0.3mg/ml Solution) ..... 11 Bayer Aspirin EC Low Dose (Tablet Delayed- Bisacodyl EC (Tablet Delayed-Release) ...... 35 Buprenorphine HCl (2mg Tablet Sublingual, Release) ...... 10 Bisoprolol Fumarate (Tablet) ...... 29 8mg Tablet Sublingual) ...... 11 Bayer Aspirin Regimen (Tablet Delayed- Bisoprolol Fumarate/Hydrochlorothiazide Buprenorphine HCl/Naloxone HCl (Tablet Release) ...... 10 (Tablet) ...... 29 Sublingual) ...... 11 Bayer Chewable Low Dose (Tablet Chewable) Bivalirudin (Injection) ...... 27 Bupropion HCl (Tablet) ...... 13 ...... 10 BIVIGAM (Injection) ...... 41 Bupropion HCl ER (Tablet Extended-Release Bayer Low Dose (Tablet Delayed-Release) .. 10 Bleomycin Sulfate (Injection) ...... 47 12 Hour) ...... 19 BCG Vaccine (Injection)...... 42 Blincyto (Injection) ...... 23 Bupropion HCl SR (100mg Tablet Extended- BD Autoshield 29g X 3/16" ...... 43 Blisovi 24 Fe (Tablet) ...... 38 Release 12 Hour, 150mg Tablet Extended- BD Autoshield 29g X 5/16" ...... 43 Blisovi Fe 1.5/30 (Tablet) ...... 38 Release 12 Hour, 200mg Tablet Extended- BD Autoshield Duo 30g X 3/16"...... 43 Blisovi Fe 1/20 (Tablet) ...... 38 Release 12 Hour) ...... 19 Bd insul Syr Mis Lo Dose ...... 43 Boostrix (Injection) ...... 42 Bupropion HCl SR (150mg Tablet Extended- BD Pen ...... 43 Bosulif (Tablet) ...... 23 Release 12 Hour) ...... 13 BD Pen Mini ...... 43 Botox (Injection) ...... 43 Bupropion HCl XL (Tablet Extended-Release BD Posiflush (Solution) ...... 52 BP Cleansing Wash (Emulsion) ...... 33 24 Hour) ...... 13 BD Swabs Single Use ...... 14 BP Folinatal Plus B (Tablet) ...... 53 Buspirone HCl (Tablet) ...... 25 BD Swabs Single Use Butterfly ...... 14 BP Multinatal Plus (Tablet, Tablet Chewable) Busulfex (Injection) ...... 21 Bebulin (Injection) ...... 28 ...... 53 Butalbital/Acetaminophen (300mg-50mg Beconase AQ (Suspension) ...... 50 BP Vit 3 (Capsule) ...... 53 Tablet, 50mg-325mg Tablet) ...... 10 Bekyree (Tablet) ...... 38 B-Plex (Tablet) ...... 53 Butalbital/Acetaminophen/Caffeine (325mg- Belsomra (Tablet)...... 52 B-Plex Plus (Tablet) ...... 53 50mg-40mg Tablet, 50mg-300mg-40mg Benazepril HCl (Tablet) ...... 29 Bprotected Pedia D-Vite (Liquid) ...... 53 Capsule) ...... 10 Benazepril HCl/Hydrochlorothiazide (Tablet) Brainstrong Prenatal ...... 53 Butalbital/Acetaminophen/Caffeine/Codeine ...... 29 BreatheRite ...... 43 (Capsule) ...... 12 Bendeka (Injection) ...... 21 BreatheRite Collapsible Spacer w/ Neonate Butalbital/Aspirin/Caffeine (Capsule) ...... 10 Benefix (Injection)...... 28 Mask ...... 43 Butalbital/Aspirin/Caffeine/Codeine (Capsule) Benlysta (Injection) ...... 41 BreatheRite Rigid Spacer w/Mask ...... 43 ...... 12 Benzonatate (Capsule) ...... 51 BreatheRite w/Large Mask ...... 43 Butorphanol Tartrate (Nasal Solution, Benztropine Mesylate (0.5mg Tablet, 1mg BreatheRite w/Medium Mask ...... 43 Injection) ...... 12 Tablet, 2mg Tablet, 1mg/ml Injection) ... 23 BreatheRite w/Small Mask ...... 43 Butrans (Patch Weekly) ...... 11 Bepreve (Ophthalmic Solution) ...... 49 Breo Ellipta (Aerosol Powder) ...... 50 Bydureon Pen (Injection) ...... 26 Berinert (Injection) ...... 47 Briellyn (Tablet) ...... 38 Bydureon Vial (Injection) ...... 26 Besivance (Suspension) ...... 17 Brilinta (60mg Tablet)...... 28 Byetta (Injection) ...... 26 Betamethasone Dipropionate (0.05% Cream, Brilinta (90mg Tablet)...... 28 Bystolic (Tablet) ...... 29 0.05% Lotion, 0.05% Ointment) ...... 33 Brimonidine Tartrate (Ophthalmic Solution) Betamethasone Sodium ...... 49 C Phosphate/Betamethasone Acetate Bromfenac (0.09% Ophthalmic Solution) .... 49 (Injection) ...... 37 Bromocriptine Mesylate (2.5mg Tablet, 5mg Cabergoline (Tablet) ...... 40 Betamethasone Valerate (0.1% Cream, 0.1% Capsule) ...... 40 Cabometyx (Tablet) ...... 23 Lotion, 0.1% Ointment, 0.12% Foam) ..... 33 Brovana (Nebulized Solution) ...... 50 Cadeau DHA (Capsule) ...... 53 Betaseron (Injection) ...... 32 BSS (Injection) ...... 49 Caffeine Citrate (20mg/ml Oral Solution, Betaxolol HCl (0.5% Ophthalmic Solution) .. 49 Budesonide (0.25mg/2ml Suspension, 60mg/3ml Injection) ...... 32 Betaxolol HCl (10mg Tablet, 20mg Tablet) .. 29 0.5mg/2ml Suspension) ...... 50 Calcidol (Oral Solution) ...... 53 Bethanechol Chloride (Tablet) ...... 37 Budesonide (1mg/2ml Suspension, 32mcg/act Calciferol (Oral Solution) ...... 53 Bethkis (Nebulized Solution) ...... 47 Suspension) RX ...... 50 Calcipotriene (0.005% Cream, 0.005% Betimol (Ophthalmic Solution) ...... 49 Budesonide (3mg Capsule Delayed-Release) External Solution, 0.005% Ointment) ..... 33 Bexarotene (Capsule) ...... 23 ...... 42 Calcipotriene/Betamethasone Dipropionate Bexsero (Injection) ...... 42 Bumetanide (0.25mg/ml Injection, 0.5mg (Ointment) ...... 33

Calcitonin-Salmon (Nasal Solution) ...... 42 Caretouch Pen Needles 31gx 8mm ...... 43 Cephalexin (125mg/5ml Suspension, Calcitrene (Ointment) ...... 33 Caretouch Pen Needles 32gx 4mm ...... 43 250mg/5ml Suspension, 250mg Capsule, Calcitriol (0.25mcg Capsule, 0.5mcg Capsule, Caretouch Pen Needles 32gx 5mm ...... 43 500mg Capsule, 750mg Capsule, 250mg 1mcg/ml Injection, 1mcg/ml Oral Solution) Carimune Nanofiltered (Injection) ...... 41 Tablet, 500mg Tablet) ...... 16 ...... 42 Carisoprodol (250mg Tablet, 350mg Tablet)51 Ceprotin (Injection) ...... 27 Calcitriol (3mcg/gm Ointment) ...... 33 Carteolol HCl (Ophthalmic Solution) ...... 49 Cerdelga (Capsule) ...... 34 Calcium Acetate (667mg Capsule, 667mg Carters Little Pills (Tablet Delayed-Release) 35 Cerezyme (Injection) ...... 34 Tablet)...... 37 Cartia XT (Capsule Extended-Release 24 Hour) Cerovel (40% Gel, 40% Lotion) ...... 33 Calcium Chloride (Injection) ...... 52 ...... 30 Cesamet (Capsule) ...... 20 Camila (Tablet) ...... 40 Carvedilol (Tablet) ...... 29 Cetirizine HCl (Syrup) RX ...... 50 Campath (Injection) ...... 21 Cavarest (Gel) ...... 32 Cevimeline HCl (Capsule) ...... 32 Camptosar (300mg/15ml Injection) ...... 47 Caya ...... 43 Chantix (Tablet) ...... 13 Camrese (Tablet) ...... 38 Cayston (Inhalation Solution) ...... 16 Chantix Continuing Month Pak (Tablet) ..... 13 Camrese Lo (Tablet) ...... 38 Caziant (Tablet) ...... 38 Chantix ST...... 13 Canasa (Suppository) ...... 42 Cedax (180mg/5ml Suspension, 400mg Chateal (Tablet) ...... 38 Candesartan Cilexetil (Tablet) ...... 28 Capsule) ...... 15 Chek-Stix Control ...... 43 Candesartan Cilexetil/Hydrochlorothiazide Cefaclor (250mg Capsule Immediate-Release, Chemet (Capsule) ...... 52 (Tablet) ...... 28 500mg Capsule Immediate-Release, Chemstrip 10 MD ...... 43 Capacet (Capsule) ...... 10 250mg/5ml Suspension, 375mg/5ml Chemstrip 2 GP Strips ...... 43 Capastat Sulfate (Injection) ...... 21 Suspension) ...... 15 Chemstrip 5 OB ...... 43 Capecitabine (Tablet) ...... 22 Cefaclor ER (Tablet Extended-Release 12 Chemstrip 7 ...... 43 Capex (Shampoo) ...... 33 Hour) ...... 15 Chemstrip 9 Strips ...... 43 Caprelsa (100mg Tablet) ...... 22 Cefadroxil (1gm Tablet, 250mg/5ml Chemstrip UGK ...... 43 Caprelsa (300mg Tablet) ...... 22 Suspension, 500mg/5ml Suspension, Chemstrip-10 with SG ...... 43 Diltiazem HCl ER (Capsule Extended-Release 500mg Capsule) ...... 15 Chemstrip-K ...... 43 24 Hour ...... 29 Cefazolin Sodium (10gm Injection, 1gm Childrens Aspirin (Tablet Chewable) ...... 10 Captopril (Tablet)...... 29 Injection, 20gm Injection, 500mg Injection) Childrens Aspirin Low Strength (Tablet Captopril/Hydrochlorothiazide (Tablet) ...... 29 ...... 15 Chewable) ...... 10 Carafate (1gm/10ml Suspension) ...... 36 Cefazolin Sodium/Sodium Chloride (Injection) Chlordiazepoxide HCl (Capsule) ...... 26 Carbaglu (Tablet) ...... 52 ...... 15 Chlordiazepoxide HCl/Clidinium Bromide Carbamazepine (100mg Tablet Chewable, Cefazolin/D5W (Injection) ...... 15 (Capsule) ...... 35 100mg/5ml Suspension, 200mg Tablet Cefazolin/Dextrose (Injection) ...... 15 Chlordiazepoxide/Amitriptyline (Tablet) ..... 19 Immediate-Release) ...... 18 Cefazolin/Sodium Chloride (Injection) ...... 15 Chlorhexidine Gluconate (0.12% Solution) .. 32 Carbamazepine ER (100mg, 200mg, 300mg Cefdinir (125mg/5ml Suspension, 250mg/5ml Chloroquine Phosphate (250mg Tablet, Capsule Extended-Release 12 Hour ...... 18 Suspension, 300mg Capsule) ...... 15 500mg Tablet) ...... 23 Carbidopa (Tablet) ...... 23 Cefditoren Pivoxil (Tablet) ...... 15 Chlorothiazide (Tablet) ...... 31 Carbidopa/Levodopa (Tablet Immediate- Cefepime (1gm Injection, 2gm Injection) .... 15 Chlorothiazide Sodium (Injection) ...... 31 Release) ...... 23 Cefixime (Suspension) ...... 15 Chlorpromazine HCl (100mg Tablet, 10mg Carbidopa/Levodopa ER (Tablet Extended- Cefotaxime Sodium (Injection)...... 16 Tablet, 200mg Tablet, 25mg Tablet, 50mg Release) ...... 23 Cefotetan (Injection) ...... 16 Tablet) ...... 19 Carbidopa/Levodopa/Entacapone (Tablet) . 24 Cefotetan/Dextrose (Injection) ...... 16 Chlorpropamide (Tablet) ...... 26 Carbinoxamine Maleate (4mg Tablet, Cefoxitin Sodium (10gm Injection, 1gm Chlorthalidone (25mg Tablet, 50mg Tablet) 31 4mg/5ml Oral Solution) ...... 50 Injection, 2gm Injection) ...... 16 Chlorzoxazone (Tablet) ...... 51 Carboplatin (Injection) ...... 21 Cefpodoxime Proxetil (100mg Tablet, 200mg Cholestyramine (Powder) ...... 31 Cardene IV (20mg/200ml-0.86% Injection) 30 Tablet, 100mg/5ml Suspension, 50mg/5ml Cholestyramine Light (Powder) ...... 31 Cardioplegic (Injection)...... 52 Suspension) ...... 16 Choline Magnesium Trisalicylate (500mg/5ml Cardizem LA (120mg Tablet Extended- Cefprozil (125mg/5ml Suspension, Liquid) (MANUF CYPRESS PH) ...... 10 Release 24 Hour) ...... 30 250mg/5ml Suspension, 250mg Tablet, Chorionic Gonadotropin (Injection) ...... 37 Cardura XL (4mg Tablet Extended-Release 24 500mg Tablet) ...... 16 Chromagen (Capsule) ...... 52 Hour) ...... 37 Ceftazidime (Injection) ...... 16 Chromium Chloride (Injection) ...... 52 Carefine Pen Needle 32gx4mm ...... 43 Ceftin (Suspension) ...... 16 Cialis (2.5mg Tablet, 5mg Tablet) ...... 37 Carefine Pen Needles 31gx8mm ...... 43 Ceftriaxone in Iso-Osmotic Dextrose Ciclodan (0.77% Cream, 8% External Solution) Carefine Pen Needles 32gx5mm ...... 43 (Injection) ...... 16 ...... 20 Carefine Pen Needles 32gx6mm ...... 43 Ceftriaxone Sodium (100gm Injection, 1gm Ciclopirox (0.77% Gel, 0.77% Suspension, 1% Careone Unifine Pentips 29gx12mm ...... 43 Injection, 250mg Injection, 500mg Shampoo) ...... 20 Careone Unifine Pentips 31gx8mm ...... 43 Injection, 10gm Injection, 2gm Solution) 16 Ciclopirox Nail Lacquer (External Solution) . 20 Careone Unifine Pentips Pen Needles Cefuroxime Axetil (Tablet) ...... 16 Ciclopirox Olamine (0.77% Cream) ...... 20 32gx4mm ...... 43 Cefuroxime Sodium (Injection) ...... 16 Cidofovir (Injection) ...... 24 Caretouch Alcohol Prep Pads ...... 14 Celecoxib (Capsule) ...... 10 Cilostazol (Tablet) ...... 28 Caretouch Pen Needles 31 G X 6 Mm ...... 43 Celontin (Capsule) ...... 17 Ciloxan (0.3% Ointment) ...... 17 Caretouch Pen Needles 31gx 5mm ...... 43 Centrum Specialist Prenatal ...... 53 Cimetidine (200mg Tablet RX, 300mg Tablet,

400mg Tablet, 800mg Tablet) ...... 35 33gx8mm ...... 44 Compact Space Chamber/Anti-Static/Large Cimetidine HCl (Oral Solution) ...... 35 Clickfine Pen Needle 32gx5/32" ...... 44 Mask ...... 44 Cimzia (Injection) ...... 41 Clickfine Pen Needles/31gx1/4" ...... 44 Compact Space Chamber/Anti- Cimzia Starter Kit (Injection) ...... 41 Clickfine Pen Needles/31gx5/16" ...... 44 Static/Medium Mask ...... 44 Cinryze (Injection) ...... 47 Clindacin ETZ Pledgets (Swab)...... 33 Complera (Tablet) ...... 25 Cipro HC (Suspension)...... 50 Clindacin-P (Swab) ...... 33 Complete Natal DHA ...... 53 Ciprodex (Otic Suspension)...... 50 Clindamax (Gel) ...... 33 Completenate (Tablet Chewable) ...... 53 Ciprofloxacin (250mg/5ml Suspension, Clindamycin HCl (Capsule Immediate-Release) Compro (Suppository) ...... 19 500mg/5ml Suspension) ...... 17 ...... 14 Co-Natal FA (Tablet) ...... 53 Ciprofloxacin ER (Tablet Extended-Release 24 Clindamycin Palmitate HCl (Oral Solution) .. 14 Condylox (0.5% Gel) ...... 33 Hour) ...... 17 Clindamycin Phosphate (1% External Solution, Constulose (Oral Solution) ...... 35 Ciprofloxacin HCl (0.3% Ophthalmic Solution, 1% Foam, 1% Gel, 1% Lotion, 1% Swab) . 33 Copaxone (Injection) ...... 32 Tablet Immediate-Release) ...... 17 Clindamycin Phosphate (2% Cream, Cordran (4mcg/sqcm Tape) ...... 33 Ciprofloxacin I.V. in D5W (Injection)...... 17 300mg/2ml Injection, 600mg/4ml Coreg CR (Capsule Extended-Release 24 Cisatracurium Besylate (Injection) ...... 51 Injection, 9000mg/60ml Injection, Hour) ...... 29 Cisplatin (100mg/100ml Injection, 900mg/6ml Injection) ...... 14 Corifact (Injection) ...... 28 50mg/50ml Injection) ...... 21 Clindamycin Phosphate in D5W (Injection) . 14 Cormax Scalp Application (External Solution) Cisplatin (200mg/200ml Injection) ...... 21 Clindamycin Phosphate/Tretinoin (Gel) ...... 33 ...... 33 Citalopram HBr (10mg Tablet, 20mg Tablet, Clindamycin/Benzoyl Peroxide (Gel) ...... 33 Correct (Tablet Delayed-Release) ...... 35 40mg Tablet, 10mg/5ml Oral Solution) .. 19 Clinisol SF 15% (Injection) ...... 52 Correctol (Tablet Delayed-Release) ...... 35 Citroma (Oral Solution) ...... 35 Clobetasol Propionate (0.05% Cream, 0.05% Cortifoam (Foam) ...... 42 Cladribine (Injection) ...... 22 External Solution, 0.05% Foam, 0.05% Gel, Cortisone Acetate (25mg Tablet) ...... 37 Claforan (1gm Injection) ...... 16 0.05% Liquid, 0.05% Lotion, 0.05% Cortisporin (0.5%-0.5% Cream, 1%-0.5% Claravis (Capsule) ...... 33 Ointment, 0.05% Shampoo) ...... 33 Ointment) ...... 33 Clarinex (0.5mg/ml Syrup) ...... 50 Clobetasol Propionate Emollient (Cream) ... 33 Corvita (Tablet) ...... 53 Clarithromycin (125mg/5ml Suspension, Clocortolone Pivalate (Cream) ...... 33 Corvita 150 (Tablet) ...... 52 250mg/5ml Suspension, 250mg Tablet, Clodan (Shampoo) ...... 33 Corvite Free (Tablet) ...... 53 500mg Tablet) ...... 16 Clolar (Injection) ...... 22 Cosentyx (Injection) ...... 33 Clarithromycin ER (Tablet Extended-Release Clomipramine HCl (Capsule) ...... 19 Cosentyx Sensoready Pen (Injection) ...... 33 24 Hour) ...... 16 Clonazepam (Tablet Immediate-Release) ... 17 Cotellic (Tablet) ...... 22 Classic Prenatal (Tablet) ...... 53 Clonazepam ODT (Tablet Dispersible) ...... 17 Creon (Capsule Delayed-Release) ...... 34 ClearLax (Powder) ...... 35 Clonidine HCl (0.1mg Tablet, 0.2mg Tablet, Cresemba (186mg Capsule, 372mg Injection) Clever Choice Anti-Static Valved Holding 0.3mg Tablet, 0.1mg/24hr Patch Weekly, ...... 20 Chamber/Adult Large ...... 43 0.2mg/24hr Patch Weekly, 0.3mg/24hr Crinone (Gel) ...... 40 Clever Choice Anti-Static Valved Holding Patch Weekly, 100mcg/ml Injection, Crixivan (Capsule) ...... 25 Chamber/Medium ...... 43 500mcg/ml Injection) ...... 28 Cromolyn Sodium (100mg/5ml Concentrate) Clever Choice Anti-Static Valved Holding Clonidine HCl ER (Tablet Extended-Release 12 ...... 35 Chamber/Small ...... 43 Hour) ...... 32 Cromolyn Sodium (20mg/2ml Nebulized Clever Choice Comfort EZ Insulin Pen Clopidogrel (Tablet) ...... 28 Solution) ...... 51 Needles 31gx8mm ...... 43 Clorazepate Dipotassium (Tablet) ...... 18 Cromolyn Sodium (4% Ophthalmic Solution) Clever Choice Comfort EZ Pen Needles Clotrimazole (1% Cream, 1% External Solution ...... 49 29gx12mm ...... 43 - RX, 10mg Lozenge, 10mg Troche) ...... 20 Cryselle-28 (Tablet) ...... 38 Clever Choice Comfort EZ Pen Needles Clotrimazole/Betamethasone Dipropionate Cuprimine (Capsule)...... 37 31gx5mm ...... 43 (0.05%-1% Cream, 1%-0.05% Lotion) ..... 20 Curity Alcohol Prep Pads/Medium 2 Ply .... 14 Clever Choice Comfort EZ Pen Needles Clozapine (Tablet Immediate-Release) ...... 24 Curity Alcohol Swabs ...... 14 31gx6mm ...... 44 Clozapine ODT (Tablet Dispersible) ...... 24 Curity Sterile Saline (Solution) ...... 44 Clever Choice Comfort EZ Pen Needles Coagadex (Injection)...... 28 Cuvitru (Injection) ...... 41 32gx4mm ...... 44 Coartem (Tablet) ...... 23 Cuvposa (Oral Solution) ...... 35 Clever Choice Comfort EZ Pen Needles Codeine Sulfate (Tablet)...... 12 CVS Aspirin (325mg Tablet, 325mg Tablet 32gx5mm ...... 44 Colchicine (0.6mg Tablet)...... 21 Delayed-Release) ...... 10 Clever Choice Comfort EZ Pen Needles Colcrys (Tablet) ...... 21 CVS Aspirin Low Dose (Tablet Delayed- 32gx6mm ...... 44 Colestipol HCl (1gm Tablet, 5gm Packet) .... 31 Release) ...... 10 Clever Choice Comfort EZ Pen Needles Colistimethate Sodium (Injection) ...... 14 CVS Childrens Aspirin (Tablet Chewable)..... 10 32gx8mm ...... 44 Colocort (Enema) ...... 37 CVS D3 (1000unit Capsule, 2000unit Capsule, Clever Choice Comfort EZ Pen Needles Coly-Mycin S (Suspension) ...... 50 400unit Capsule, 5000unit Capsule, 33gx4mm ...... 44 Combigan (Ophthalmic Solution) ...... 49 1000unit Tablet Chewable) ...... 53 Clever Choice Comfort EZ Pen Needles Combipatch (Patch Twice Weekly) ...... 38 CVS Ketone Care ...... 44 33gx5mm ...... 44 Combistix ...... 44 CVS Nicotine (Patch 24 Hour) ...... 13 Clever Choice Comfort EZ Pen Needles Combivent Respimat (Aerosol Solution).... 50 CVS Nicotine Polacrilex (2mg Gum, 4mg Gum, 33gx6mm ...... 44 Cometriq (Kit) ...... 23 2mg Lozenge, 4mg Lozenge) ...... 13 Clever Choice Comfort EZ Pen Needles Compact Space Chamber/Anti-Static ...... 44 CVS Nicotine Transdermal System (Patch 24

Hour) ...... 13 50mg Capsule) ...... 38 Concentrate) ...... 37 CVS NTS Step 1 (Patch 24 Hour) ...... 13 Dantrolene Sodium (Capsule) ...... 24 Dexamethasone Sodium Phosphate (0.1% CVS Prenatal (Tablet) ...... 53 Dapsone (Tablet) ...... 21 Ophthalmic Solution) ...... 49 CVS Prenatal Gummy/DHA/Folic Acid (Tablet Daptacel (Injection) ...... 42 Dexamethasone Sodium Phosphate Chewable) ...... 53 Daptomycin (Solution) ...... 14 (10mg/ml Injection) ...... 41 CVS Prenatal Multi+DHA (Capsule) ...... 53 DARAPRIM (Tablet) ...... 23 Dexamethasone Sodium Phosphate CVS Prep Pads ...... 14 Darifenacin HBr ER (Tablet Extended-Release (120mg/30ml Injection, 20mg/5ml CVS Purelax (Powder) ...... 35 24 Hour) ...... 36 Solution) ...... 37 CVS Vitamin D Childrens Gummies (Tablet Darzalex (Injection) ...... 23 Dexamethasone Sodium Phosphate (4mg/ml Chewable) ...... 53 Dasetta 1/35 (Tablet) ...... 38 Solution) ...... 47 CVS Vitamin D3 Drops/Infants (Liquid) ...... 53 Dasetta 7/7/7 (Tablet) ...... 38 Dexedrine (10mg Tablet, 5mg Tablet) ...... 32 Cyanocobalamin (1000mcg/ml Injection) .... 54 Daunorubicin HCl (Injection) ...... 47 Dexilant (Capsule Delayed-Release) ...... 36 Cyclafem (Tablet) ...... 38 Daysee (Tablet) ...... 38 Dexmedetomidine HCl (Injection) ...... 25 Cyclobenzaprine HCl (Tablet) ...... 51 Daytrana (Patch)...... 32 Dexmethylphenidate HCl (Tablet Immediate- Cyclopentolate HCl (Ophthalmic Solution) .. 49 Ddrops (Liquid) ...... 54 Release) ...... 32 Cyclophosphamide (1gm Injection, 2gm Ddrops Booster (Liquid) ...... 54 Dexmethylphenidate HCl ER (10mg, 15mg, Injection, 500mg Injection) ...... 21 Deblitane (Tablet) ...... 40 20mg, 30mg, 40mg, 5mg, 25mg, 35mg Cyclophosphamide (25mg Capsule, 50mg Decara (25000unit Capsule) ...... 54 Capsule Extended-Release 24 Hour) ...... 32 Capsule) ...... 21 Decara (50000unit Capsule) ...... 54 DexPak 10 Day (Tablet Therapy Pack) ...... 37 Cycloserine (Capsule) ...... 21 Decitabine (Injection) ...... 22 DexPak 13 Day (Tablet Therapy Pack) ...... 37 Cycloset (Tablet) ...... 26 Deferoxamine Mesylate (Injection) ...... 44 DexPak 6 Day (Tablet Therapy Pack) ...... 37 Cyclosporine (100mg Capsule, 25mg Capsule, Delflex-Sm/1.5% Dextrose (Injection) ...... 44 Dexrazoxane (Injection) ...... 47 50mg/ml Injection) ...... 41 Delflex-Sm/2.5% Dextrose (Injection) ...... 44 Dextroamphetamine Sulfate (10mg Tablet, Cyclosporine Modified (100mg Capsule, 25mg Delta D3 (Tablet) ...... 54 5mg Tablet, 5mg/5ml Oral Solution) ...... 32 Capsule, 50mg Capsule, 100mg/ml Oral Deltasone (Tablet) ...... 37 Dextroamphetamine Sulfate ER (10mg Solution) ...... 41 Delyla (Tablet) ...... 38 Capsule Extended-Release 24 Hour, 5mg Cyproheptadine HCl (2mg/5ml Syrup, 4mg Demeclocycline HCl (150mg Tablet, 300mg Capsule Extended-Release 24 Hour) ...... 32 Tablet)...... 24 Tablet) ...... 17 Dextroamphetamine Sulfate ER (15mg Cyred (Tablet) ...... 38 Demser (Capsule) ...... 30 Capsule Extended-Release 24 Hour) ...... 32 Cystadane (Powder) ...... 34 Denavir (Cream) ...... 25 Dextrose 10% (Injection) ...... 47 Cystagon (Capsule)...... 34 Depen Titratabs (Tablet) ...... 37 Dextrose 2.5%/NaCl 0.45% (Injection) ...... 47 Cystaran (Ophthalmic Solution) ...... 49 Depocyt (Injection) ...... 22 Dextrose 5% (Injection) ...... 47 Cytarabine Aqueous (Injection) ...... 22 Depo-Medrol (20mg/ml Injection) ...... 37 Dextrose 5%/Lactated Ringers (Injection) ... 52 Cytogam (Injection) ...... 41 Depo-Provera (Injection) ...... 40 Dextrose 5%/NaCl 0.2% (Injection) ...... 47 Depo-SubQ Provera104 (Injection) ...... 40 Dextrose 5%/NaCl 0.33% (Injection) ...... 47 D DermacinRx Empricaine (Kit) ...... 12 Dextrose 5%/NaCl 0.45% (Injection) ...... 47 DermacinRx Prizopak (Kit) ...... 12 Dextrose 5%/NaCl 0.9% (Injection) ...... 47 D 1000 (1000unit Capsule, 1000unit Tablet Desipramine HCl (100mg Tablet, 10mg Tablet, Dextrose 50% (Injection) ...... 47 Chewable) ...... 54 150mg Tablet, 25mg Tablet, 50mg Tablet, Dextrose 70% (Injection) ...... 26 D 10000 (Capsule) ...... 54 75mg Tablet) ...... 19 Dialyvite Vitamin D 5000 (Capsule) ...... 54 D 2000 (Tablet) ...... 54 Desloratadine (Tablet) ...... 50 Dialyvite Vitamin D3 Max (Tablet) ...... 54 D 400 (400unit Tablet, 400unit Tablet Desloratadine ODT (Tablet Dispersible) ...... 50 Diascreen 10 ...... 44 Chewable) ...... 54 Desmopressin Acetate (0.01% Nasal Solution, Diascreen 1B ...... 44 D3 (1000unit Capsule, 2000unit Capsule, 0.1mg/ml Nasal Solution, 0.1mg Tablet, Diascreen 1G ...... 44 400unit Capsule, 1000unit Tablet, 0.2mg Tablet, 4mcg/ml Injection) ...... 37 Diascreen 1K...... 44 2000unit Tablet) ...... 54 Desogestrel/Ethinyl Estradiol (Tablet) ...... 38 Diascreen 2GK ...... 44 D3 2000 (Tablet) ...... 54 Desonide (0.05% Cream, 0.05% Lotion, 0.05% Diascreen 2GP ...... 44 D3 Adult (Tablet Chewable) ...... 54 Ointment) ...... 33 Diascreen 3 ...... 44 D3 Dots (Tablet Dispersible) ...... 54 Desoximetasone (0.05% Cream, 0.25% Diascreen 4NL ...... 44 D3 High Potency (Tablet) ...... 54 Cream, 0.05% Gel, 0.05% Ointment, 0.25% Diascreen 4OBL ...... 44 D3 Kids (Tablet Chewable) ...... 54 Ointment) ...... 33 Diascreen 4PH ...... 44 D3 Maximum Strength (5000unit Capsule, Desvenlafaxine ER (100mg Tablet Extended- Diascreen 5 ...... 44 5000unit/ml Liquid) ...... 54 Release 24 Hour, 25mg Tablet Extended- Diascreen 6 ...... 44 D3 Super Strength (Capsule) ...... 54 Release 24 Hour, 50mg Tablet Extended- Diascreen 7 ...... 44 D3-1000 (Capsule) ...... 54 Release 24 Hour) ...... 19 Diascreen 8 ...... 44 D3-50 (Capsule) ...... 54 Dexamethasone (0.5mg Tablet, 0.75mg Diascreen 9 ...... 44 Dacarbazine (100mg Injection) ...... 21 Tablet, 1.5mg Tablet, 1mg Tablet, 2mg Diascreen Liquid Urine Controls ...... 44 Dacarbazine (200mg Injection) ...... 21 Tablet, 4mg Tablet, 6mg Tablet, Diastix...... 44 Daklinza (Tablet) ...... 24 0.5mg/5ml Elixir, 0.5mg/5ml Oral Solution) Diazepam (10mg Gel, 2.5mg Gel, 20mg Gel, Daliresp (Tablet) ...... 51 ...... 37 10mg Tablet, 2mg Tablet, 5mg Tablet, Danazol (100mg Capsule, 200mg Capsule, Dexamethasone Intensol (1mg/ml 1mg/ml Oral Solution, 5mg/ml Injection)

...... 18 Disulfiram (Tablet) ...... 13 Droxia (Capsule) ...... 22 Diazepam Intensol (5mg/ml Concentrate) .. 18 Divalproex Sodium (Capsule Sprinkle Delayed- Duavee (Tablet) ...... 48 Diclofenac Potassium (Tablet) ...... 10 Release) ...... 18 Ducodyl (Tablet Delayed-Release) ...... 35 Diclofenac Sodium (0.1% Ophthalmic Divalproex Sodium DR (Tablet Delayed- Dulcolax Balance (Powder) ...... 35 Solution) ...... 49 Release) ...... 18 Duloxetine HCl (20mg Capsule Delayed- Diclofenac Sodium (1% Gel) ...... 33 Divalproex Sodium ER (Tablet Extended- Release, 30mg Capsule Delayed-Release, Diclofenac Sodium (1.5% Transdermal Release 24 Hour) ...... 18 60mg Capsule Delayed-Release) ...... 19 Solution) ...... 33 Dobutamine HCl (Injection)...... 30 Duloxetine HCl (40mg Capsule Delayed- Diclofenac Sodium (3% Gel) ...... 14 Dobutamine HCl/D5W (Injection) ...... 30 Release) ...... 19 Diclofenac Sodium DR (Tablet Delayed- Docefrez (Injection) ...... 48 Duramorph (Injection) ...... 12 Release) ...... 10 Docetaxel (160mg/16ml Injection, Duraxin (Capsule) ...... 10 Diclofenac Sodium ER (Tablet Extended- 160mg/8ml Injection, 20mg/2ml Durezol (Emulsion) ...... 49 Release 24 Hour) ...... 10 Injection, 20mg/ml Injection, 80mg/4ml Dutasteride (Capsule) ...... 37 Diclofenac Sodium/Misoprostol (Tablet Injection, 80mg/8ml Injection)...... 22 Dutasteride/Tamsulosin HCl (Capsule) ...... 37 Delayed-Release) ...... 10 Docetaxel (20mg/0.5ml Injection, 80mg/2ml D-Vita (Liquid) ...... 54 Dicloxacillin Sodium (Capsule) ...... 16 Injection) ...... 48 Dymista (Suspension) ...... 50 Dicyclomine HCl (10mg Capsule, 10mg/5ml Docetaxel (Non-Alcohol Formula) (Injection) Dyrenium (0-100mg Capsule) ...... 31 Oral Solution, 10mg/ml Injection, 20mg ...... 22 Dysport (Injection) ...... 48 Tablet)...... 35 Dofetilide (Capsule) ...... 29 Didanosine (Capsule Delayed-Release) ...... 25 Donepezil HCl (10mg Tablet Dispersible, 5mg E Dificid (Tablet)...... 16 Tablet Dispersible, 10mg Tablet, 23mg Difil-G Forte (Liquid) ...... 51 Tablet, 5mg Tablet) ...... 18 E.E.S. 400 (Tablet) ...... 16 Diflorasone Diacetate (0.05% Cream, 0.05% Dopamine HCl (40mg/ml Injection, 80mg/ml Easivent ...... 44 Ointment) ...... 33 Injection) ...... 30 Easivent/Mask-Large ...... 44 Diflunisal (Tablet) ...... 10 Dopamine/D5W (Injection) ...... 30 Easivent/Mask-Medium ...... 44 Digitek (Tablet) ...... 30 Doribax (500mg Injection) ...... 16 Easivent/Mask-Small ...... 44 Digox (Tablet) ...... 30 Doripenem (500mg Injection) ...... 16 Easy Comfort Pen Needles 31gx1/4" ...... 44 Digoxin (0.05mg/ml Oral Solution, 0.25mg/ml Dorzolamide HCl (Ophthalmic Solution) ..... 30 Easy Comfort Pen Needles 31gx3/16" ...... 44 Injection, 125mcg Tablet, 250mcg Tablet) Dorzolamide HCl/Timolol Maleate Easy Comfort Pen Needles 31gx5/16" ...... 44 ...... 30 (Ophthalmic Solution) ...... 49 Easy Comfort Pen Needles 32gx5/32" ...... 44 Dihydroergotamine Mesylate (1mg/ml Doxazosin (Tablet)...... 28 Easy Touch 32gx5mm...... 44 Injection) ...... 21 Doxazosin Mesylate (Tablet) ...... 28 Easy Touch 32gx6mm...... 44 Dihydroergotamine Mesylate (4mg/ml Nasal Doxepin HCl (100mg Capsule, 10mg Capsule, Easy Touch Alcohol Prep Pads/Medium ..... 14 Solution) ...... 21 150mg Capsule, 25mg Capsule, 50mg Easy Touch Insulin Syringe/U-100/1ml/31g X Dilantin (30mg Capsule)...... 18 Capsule, 75mg Capsule, 10mg/ml 5/16" ...... 44 Dilatrate SR (Capsule Extended-Release) ... 31 Concentrate) ...... 19 Easy Touch Pen Needles 29gx1/2" ...... 44 Diltiazem CD (Capsule Extended-Release 24 Doxepin HCl (Cream) ...... 33 Easy Touch Pen Needles 31gx1/4" ...... 44 Hour) ...... 30 Doxercalciferol (0.5mcg Capsule, 1mcg Easy Touch Pen Needles 31gx5/16" ...... 44 Diltiazem HCl (125mg/25ml Injection, Capsule, 2.5mcg Capsule, 4mcg/2ml Easy Touch Pen Needles 32gx1/4" ...... 44 25mg/5ml Injection, 50mg/10ml Injection) Injection) ...... 42 Easy Touch Pen Needles 32gx3/16" ...... 44 ...... 47 Doxorubicin HCl (Injection) ...... 21 Easy Touch Pen Needles 32gx5/32" ...... 44 Diltiazem HCl (Tablet Immediate-Release) .. 29 Doxy 100 (Injection) ...... 17 Easy Touch Pen Needles/31g X 3/16" ...... 44 Diltiazem HCl CD (Capsule Extended-Release Doxycycline (25mg/5ml Suspension) ...... 17 Easygel (Gel) ...... 32 24 Hour) ...... 30 Doxycycline (40mg Capsule Delayed-Release) Econazole Nitrate (1% Cream) ...... 20 Diltiazem HCl ER (Capsule Extended-Release ...... 33 Econtra EZ (Tablet) ...... 40 24 Hour, Tablet Extended-Release 24 Doxycycline Hyclate (100mg Capsule, 50mg Ecotrin (Tablet Delayed-Release) ...... 10 Hour) ...... 30 Capsule, 100mg Injection, 100mg Tablet, Ecotrin Low Strength (Tablet Delayed- Diltiazem HCl/Dextrose (Injection) ...... 47 20mg Tablet) ...... 17 Release) ...... 10 Diltiazem HCl/Sodium Chloride (Injection) .. 47 Doxycycline Hyclate DR (Tablet Delayed- Ecpirin (Tablet Delayed-Release) ...... 10 Dilt-XR (Capsule Extended-Release 24 Hour) Release) ...... 17 Edarbi (Tablet)...... 28 ...... 29 Doxycycline Monohydrate (100mg Capsule, ED-Flex (Capsule) ...... 10 Dipentum (Capsule) ...... 42 150mg Capsule, 50mg Capsule, 75mg Edurant (Tablet) ...... 25 Diphenhydramine HCl (12.5mg/5ml Elixir, Capsule, 100mg Tablet, 150mg Tablet, Effer-K (Tablet Effervescent) ...... 52 50mg/ml Injection) ...... 19 50mg Tablet, 75mg Tablet) ...... 17 Effervescent Potassium/Chloride (Tablet Diphenoxylate/Atropine (2.5mg-0.025mg Dronabinol (Capsule) ...... 20 Effervescent) ...... 52 Tablet, 2.5mg-0.025mg/5ml Liquid) ...... 35 Droperidol (2.5mg/ml Injection) ...... 19 Effient (Tablet) ...... 28 Diphtheria/Tetanus Toxoids Adsorbed Droplet Pen Needles 29gx10mm ...... 44 Egrifta (Injection) ...... 38 Pediatric (Injection)...... 42 Droplet Pen Needles 32gx5mm ...... 44 Elaprase (Injection) ...... 34 Dipyridamole (25mg Tablet, 50mg Tablet, Drospirenone/Ethinyl Estradiol (Tablet) ..... 38 Elelyso (Injection)...... 34 75mg Tablet) ...... 28 Drospirenone/Ethinyl Estradiol/Levomefolate Elidel (Cream) ...... 33 Disopyramide Phosphate (Capsule) ...... 29 Calcium (Tablet) ...... 38 Eligard (Injection) ...... 40

Elinest (Tablet) ...... 38 EQ ClearLax (Powder)...... 35 0.1mg/24hr Patch Weekly, 0.5mg Tablet, Eliquis (Tablet) ...... 27 EQ Nicotine (14mg/24hr Patch 24 Hour, 1mg Tablet, 2mg Tablet) ...... 38 Elitek (Injection) ...... 22 21mg/24hr Patch 24 Hour, 7mg/24hr Estradiol Valerate (Injection) ...... 38 Elite-Ob (Tablet) ...... 54 Patch 24 Hour, 4mg Lozenge) ...... 13 Estradiol/Norethindrone Acetate (Tablet)... 38 Elixophyllin (Elixir) ...... 51 EQ Nicotine Gum Refill (Gum) ...... 13 Estropipate (Tablet) ...... 38 Ella (Tablet) ...... 40 EQ Nicotine Gum Starter (Gum) ...... 13 Eszopiclone (Tablet)...... 52 Elmiron (Capsule) ...... 37 EQ Nicotine Polacrilex (2mg Gum, 4mg Gum, Ethacrynate Sodium (Injection) ...... 31 Eloctate (Injection)...... 28 2mg Lozenge, 4mg Lozenge) ...... 13 Ethacrynic Acid (Tablet) ...... 31 Emadine (Ophthalmic Solution) ...... 49 EQL Alcohol Swabs ...... 14 Ethambutol HCl (100mg Tablet, 400mg Embeda (Capsule Extended-Release) ...... 11 EQL Aspirin (Tablet) ...... 10 Tablet) ...... 21 Emcyt (Capsule) ...... 22 EQL Aspirin EC (Tablet Delayed-Release) .... 10 Ethosuximide (250mg Capsule, 250mg/5ml Emoquette (Tablet) ...... 38 EQL ClearLax (Powder) ...... 35 Oral Solution) ...... 17 Empliciti (Injection) ...... 23 EQL Gentle Laxative (Tablet Delayed-Release) Ethynodiol Diacetate/Ethinyl Estradiol Emsam (Patch 24 Hour) ...... 19 ...... 35 (Tablet) ...... 38 Emtriva (10mg/ml Oral Solution, 200mg EQL Laxative (Tablet Delayed-Release) ...... 35 Etidronate Disodium (Tablet) ...... 42 Capsule) ...... 25 EQL Nicotine (Lozenge) ...... 13 Etodolac (200mg Capsule, 300mg Capsule, Enalapril Maleate (Tablet) ...... 29 EQL Nicotine Polacrilex (2mg Gum, 4mg Gum, 400mg Tablet, 500mg Tablet) ...... 10 Enalapril Maleate/Hydrochlorothiazide 2mg Lozenge, 4mg Lozenge) ...... 13 Etodolac ER (Tablet Extended-Release 24 (Tablet) ...... 29 EQL Prenatal Formula (Tablet) ...... 54 Hour) ...... 10 Enalaprilat (Injection) ...... 29 EQL Vitamin D3 (Capsule) ...... 54 Etopophos (Injection) ...... 22 Enbrel (25mg Injection) ...... 41 EQL Vitamin D3 Gummies (Tablet Chewable) Etoposide (100mg/5ml Injection, 1gm/50ml Enbrel (25mg/0.5ml Injection, 50mg/ml ...... 54 Injection, 500mg/25ml Injection) ...... 22 Injection) ...... 48 Eraxis (50mg Injection) ...... 20 Etoposide (50mg Capsule) ...... 22 Enbrel SureClick (Injection)...... 48 Erbitux (Injection) ...... 23 Eurax (10% Cream, 10% Lotion) ...... 23 Encare (Suppository) ...... 37 Ergocalciferol (8000unit/ml Oral Solution) . 54 Evamist (Transdermal Solution) ...... 38 Endocet (Tablet) ...... 12 Ergoloid Mesylates (Tablet) ...... 18 Evotaz (Tablet) ...... 25 Enfamil Expecta...... 54 Ergomar (Tablet Sublingual) ...... 21 Excel Comfort Point Insulin Pen Needles 31g Engerix-B (Injection) ...... 42 Ergotamine Tartrate/Caffeine (Tablet) ...... 21 X 4mm ...... 44 Enoxaparin Sodium (100mg/ml Injection, Erivedge (Capsule) ...... 23 Exel Comfort Point Insulin Pen Needles 29g X 120mg/0.8ml Injection, 150mg/ml Errin (Tablet) ...... 40 12mm ...... 44 Injection, 30mg/0.3ml Injection, Ertaczo (Cream) ...... 20 Exel Comfort Point Insulin Pen Needles 31g X 40mg/0.4ml Injection, 60mg/0.6ml Erwinaze (Injection)...... 48 8mm ...... 44 Injection, 80mg/0.8ml Injection, Ery ...... 33 Exel Comfort Point Insulin 300mg/3ml Injection) ...... 27 Ery-Tab (333mg Tablet Delayed-Release) .. 16 Syringe/0.3ml/29g X 1/2" ...... 44 Enpresse-28 (Tablet) ...... 38 Erythrocin Lactobionate (Injection) ...... 16 Exel Comfort Point Insulin Enskyce (Tablet)...... 38 Erythromycin (2% External Solution, 2% Gel, Syringe/0.3ml/30g X 5/16" ...... 44 Entacapone (Tablet) ...... 23 2% Pad) ...... 33 Exelderm (1% Cream, 1% External Solution) Entecavir (Tablet) ...... 24 Erythromycin (250mg Capsule Delayed- ...... 20 Enulose (Oral Solution) ...... 35 Release, 5mg/gm Ointment) ...... 16 Exemestane (Tablet) ...... 22 Epclusa (Tablet) ...... 24 Erythromycin Base (Tablet) ...... 16 Exjade (Tablet Soluble) ...... 52 Ephedrine Sulfate (Solution) ...... 26 Erythromycin Ethylsuccinate (200mg/5ml Ex-Lax Ultra (Tablet Delayed-Release) ...... 35 Ephedrine Sulfate/Sodium Chloride Suspension, 400mg Tablet) ...... 17 Eylea (Injection) ...... 49 (50mg/5ml-0.9% Solution Prefilled Erythromycin/Benzoyl Peroxide (Gel) ...... 33 E-Z Spacer ...... 44 Syringe) ...... 50 Esbriet (Capsule) ...... 51 E-Z Spacer the Body Guards Pack ...... 44 Epiduo (Gel) ...... 33 Escitalopram Oxalate (10mg Tablet, 20mg Ezetimibe (Tablet)...... 31 Epiduo Forte (Gel) ...... 33 Tablet, 5mg Tablet, 5mg/5ml Oral Epinastine HCl (Ophthalmic Solution) ...... 49 Solution) ...... 19 F Epinephrine (0.15mg/0.3ml Injection, Esgic (Capsule) ...... 10 0.3mg/0.3ml Injection) (authorized Esmolol HCl (Injection) ...... 29 FA-8 (0.8mg Capsule, 800mcg Tablet) ...... 54 generic Epi-Pen made by Mylan) ...... 51 Esomeprazole Magnesium (Capsule Delayed- Fabb (Tablet) ...... 54 EpiPen (Injection) ...... 51 Release) ...... 36 Fabrazyme (Injection) ...... 34 Epirubicin HCl (Injection) ...... 48 Esomeprazole Sodium (40mg Injection) ..... 36 Factive (Tablet) ...... 17 Epitol (Tablet) ...... 18 Esomeprazole Strontium (Capsule Delayed- Fallback Solo (Tablet) ...... 40 Epivir HBV (5mg/ml Oral Solution) ...... 24 Release) ...... 36 Falmina (Tablet) ...... 38 Eplerenone (Tablet) ...... 31 Estarylla (Tablet) ...... 38 Famciclovir (Tablet) ...... 25 Epoprostenol Sodium (Injection) ...... 51 Estazolam (Tablet)...... 26 Famotidine (200mg/20ml Injection, Eprosartan Mesylate (Tablet) ...... 28 Estrace (0.1mg/gm Cream) ...... 38 20mg/2ml Injection, 40mg/4ml Injection, Eptifibatide (Injection) ...... 28 Estradiol (0.025mg/24hr Patch Weekly, 20mg Tablet, 40mg Tablet, 40mg/5ml EQ Aspirin (325mg Tablet, 325mg Tablet 0.05mg/24hr Patch Weekly, 0.06mg/24hr Suspension) ...... 35 Delayed-Release) ...... 10 Patch Weekly, 0.075mg/24hr Patch Fanapt (Tablet) ...... 24 EQ Childrens Aspirin (Tablet Chewable) ...... 10 Weekly, 37.5mcg/24hr Patch Weekly, Fanapt Titration Pack (Tablet) ...... 24

Fareston (Tablet) ...... 22 Flovent HFA (Aerosol) ...... 50 Fluticasone Propionate (0.005% Ointment, Farxiga (Tablet) ...... 26 Flowtuss (Oral Solution) ...... 51 0.05% Cream, 0.05% Lotion) ...... 33 Farydak (Capsule) ...... 22 Floxuridine (Injection) ...... 22 Fluticasone Propionate (50mcg/act Faslodex (Injection)...... 22 Fluad 2016-2017 (Injection) ...... 48 Suspension) RX ...... 50 Fazaclo (12.5mg Tablet Dispersible, 150mg Fluarix Quadrivalent 2016-2017 (Injection) 48 Fluvastatin (Capsule) ...... 31 Tablet Dispersible, 200mg Tablet Flublok 2016-2017 (Injection) ...... 48 Fluvastatin Sodium ER (Tablet Extended- Dispersible) ...... 24 Flucelvax Quadrivalent 2016-2017 (Injection) Release 24 Hour) ...... 31 FC Female Condom ...... 44 ...... 48 Fluvirin 2016-2017 (Injection) ...... 42 FC2 Female Condom ...... 44 Fluconazole (100mg Tablet, 150mg Tablet, Fluvoxamine Maleate (Tablet) ...... 19 Feenamint (Tablet Delayed-Release) ...... 35 200mg Tablet, 50mg Tablet, 10mg/ml Fluvoxamine Maleate ER (Capsule Extended- Feiba (Injection) ...... 28 Suspension, 40mg/ml Suspension) ...... 20 Release 24 Hour) ...... 19 Felbamate (400mg Tablet, 600mg Tablet, Fluconazole in Dextrose (Injection) ...... 20 Fluzone High-Dose Pf 2016-2017 (Injection) 600mg/5ml Suspension) ...... 18 Fluconazole in NaCl (200mg/100ml-0.9% ...... 48 Felodipine ER (Tablet Extended-Release 24 Injection, 400mg/200ml-0.9% Injection) 20 Fluzone Quadrivalent 2016-2017 (Injection) Hour) ...... 30 Flucytosine (Capsule) ...... 20 ...... 24 Femcap ...... 44 Fludarabine Phosphate (Injection) ...... 48 FML (Ointment) ...... 49 Femynor (Tablet) ...... 38 Fludrocortisone Acetate (0.1mg Tablet) ..... 37 Folbee (Tablet)...... 54 Fenofibrate (120mg Tablet, 145mg Tablet, Flulaval Quadrivalent 2016-2017 (Injection) Folbee Plus (Tablet) ...... 54 160mg Tablet, 40mg Tablet, 48mg Tablet, ...... 25 Folic Acid (1mg Tablet, 400mcg Tablet, 54mg Tablet, 130mg Capsule, 150mg Flumazenil (Injection) ...... 32 800mcg Capsule) RX ...... 54 Capsule, 43mg Capsule, 50mg Capsule) . 31 Flumist Quadrivalent (Suspension) ...... 25 Folic Acid/Vitamin B-6/Vitamin B-12 (Tablet) Fenofibrate Micronized (Capsule) ...... 31 Flunisolide (Nasal Solution) ...... 50 ...... 54 Fenofibric Acid (Tablet) ...... 31 Fluocinolone Acetonide (0.01% Cream, Folotyn (Injection)...... 22 Fenofibric Acid DR (Capsule Delayed-Release) 0.025% Cream, 0.01% External Solution, Folplex 2.2 (Tablet) ...... 54 ...... 31 0.01% Oil, 0.025% Ointment) ...... 33 Foltrin (Capsule) ...... 52 Fenoprofen Calcium (200mg Capsule, 400mg Fluocinolone Acetonide Body (Oil) ...... 33 Fomepizole (Injection) ...... 44 Capsule, 600mg Tablet) ...... 10 Fluocinolone Acetonide Ear Drops (Oil) ...... 33 Fondaparinux Sodium (Injection) ...... 27 Fenortho (Capsule) ...... 10 Fluocinolone Acetonide Scalp (Oil) ...... 33 Forteo (Injection) ...... 42 Fentanyl (Patch 72 Hour) ...... 11 Fluocinonide (0.05% Cream, 0.1% Cream, Fosamax Plus D (Tablet)...... 42 Fentanyl Citrate Oral Transmucosal (Lollipop) 0.05% External Solution, 0.05% Gel, 0.05% Fosinopril Sodium (Tablet) ...... 29 ...... 12 Ointment) ...... 33 Fosinopril Sodium/Hydrochlorothiazide Fentanyl Citrate/Bupivacaine HCl/Sodium Fluocinonide-E (Cream) ...... 33 (Tablet) ...... 29 Chloride (Solution) ...... 32 Fluor-A-Day (Oral Solution) ...... 52 Fosphenytoin Sodium (Injection) ...... 18 Ferocon (Capsule) ...... 52 Fluoride (Tablet Chewable) ...... 52 Fosrenol (1000mg Packet, 750mg Packet, Ferotrinsic (Capsule) ...... 52 Fluoritab (0.125mg/drop Oral Solution, 1000mg Tablet Chewable, 500mg Tablet Ferriprox (500mg Tablet) ...... 44 0.25mg Tablet Chewable, 0.5mg Tablet Chewable, 750mg Tablet Chewable) ..... 37 Ferrocite Plus (Tablet) ...... 52 Chewable, 1mg Tablet Chewable) ...... 52 Fragmin (Injection) ...... 27 Fetzima (Capsule Extended-Release 24 Hour) Fluorometholone (Ophthalmic Suspension) 49 Frovatriptan Succinate (Tablet) ...... 21 ...... 19 Fluoroplex (Cream) ...... 33 Furosemide (10mg/ml Injection, 10mg/ml Fibricor (35mg Tablet)...... 31 Fluorouracil (0.5% Cream)...... 33 Oral Solution, 8mg/ml Oral Solution, 20mg Fifty50 Alcohol Prep Pads ...... 14 Fluorouracil (1gm/20ml Injection, Tablet, 40mg Tablet, 80mg Tablet) ...... 31 Fifty50 Pen Needles 31g X3/16" (5mm) ..... 44 2.5gm/50ml Injection, 500mg/10ml Fuzeon (Injection) ...... 25 Fifty50 Pen Needles 31g X5/16" (8mm) ..... 44 Injection, 5gm/100ml Injection) ...... 22 Fyavolv (Tablet) ...... 38 Fifty50 Pen Needles 31gx5mm ...... 44 Fluorouracil (2% External Solution, 5% Fycompa (0.5mg/ml Suspension, 10mg Fifty50 Pen Needles/31gx8mm ...... 44 External Solution) ...... 33 Tablet, 12mg Tablet, 2mg Tablet, 4mg Fifty50 Pen Needles/32gx4mm ...... 44 Fluorouracil (5% Cream)...... 22 Tablet, 6mg Tablet, 8mg Tablet) ...... 17 Fifty50 Pen Needles/32gx6mm ...... 44 Fluoxetine (Capsule) ...... 19 Finacea (15% Foam, 15% Gel) ...... 33 Fluoxetine DR (Capsule Delayed-Release)... 19 G Finasteride (5mg Tablet)...... 37 Fluoxetine HCl (10mg Tablet, 20mg Tablet, Firazyr (Injection) ...... 48 60mg Tablet, 20mg/5ml Oral Solution, Gabapentin (100mg Capsule, 300mg Capsule, Firmagon (Injection) ...... 40 40mg Capsule) ...... 19 400mg Capsule, 250mg/5ml Oral Solution, Flarex (Suspension) ...... 49 Fluphenazine Decanoate (Injection) ...... 24 600mg Tablet, 800mg Tablet) ...... 24 Flavoxate HCl (Tablet)...... 36 Fluphenazine HCl (10mg Tablet, 1mg Tablet, Gabitril (12mg Tablet, 16mg Tablet)...... 18 Flebogamma DIF (Injection) ...... 41 2.5mg Tablet, 5mg Tablet) ...... 24 Galantamine HBr (12mg Tablet, 4mg Tablet, Flecainide Acetate (Tablet) ...... 29 Flura-Drops (Oral Solution) ...... 52 8mg Tablet, 4mg/ml Oral Solution) ...... 18 Fleet Laxative (Tablet Delayed-Release) ...... 35 Flurandrenolide (0.05% Cream, 0.05% Lotion, Galantamine HBr ER (Capsule Extended- Flexbumin (Injection) ...... 28 0.05% Ointment) ...... 33 Release 24 Hour) ...... 18 Flexichamber ...... 44 Flurazepam HCl (Capsule) ...... 26 Gamastan S/D (Injection) ...... 41 Flexichamber Child Mask/Large ...... 44 Flurbiprofen (100mg Tablet, 50mg Tablet) . 10 Gammagard Liquid (Injection) ...... 41 Flexichamber Child Mask/Small ...... 44 Flurbiprofen Sodium (Ophthalmic Solution) 49 Gammagard S/D IGA Less Than 1 mcg/ml Flovent Diskus (Aerosol Powder) ...... 50 Flutamide (Capsule) ...... 22 (Injection) ...... 41

Gammaked (Injection) ...... 41 1mg/5ml Injection, 4mg/20ml Injection, Pack) ...... 54 Gammaplex (Injection) ...... 41 1mg Tablet, 2mg Tablet) ...... 35 Heather (Tablet) ...... 40 Gamunex-C (Injection) ...... 41 Glydo (Gel) ...... 12 H-E-B in Control Pen Needles 31gx6mm .... 44 Ganciclovir (Injection) ...... 24 GNP Adult Aspirin Low Strength (Tablet H-E-B in Control Pen Needles 31gx8mm .... 45 Gardasil (Injection) ...... 42 Chewable) ...... 10 H-E-B in Control Pen Gardasil 9 (Injection)...... 42 GNP Alcohol Swabs ...... 15 Needles/Nano/32gx4mm ...... 45 Gatifloxacin (Ophthalmic Solution) ...... 17 GNP Aspirin (325mg Tablet, 325mg Tablet H-E-B in Control Unifine Pentips Plus Gattex (Injection) ...... 35 Delayed-Release, 81mg Tablet Delayed- 31gx5mm ...... 45 GaviLAX (Powder) ...... 36 Release) ...... 10 H-E-B Incontrol Alcohol Prep Pads ...... 15 GaviLyte-C (Oral Solution) ...... 36 GNP Aspirin Low Dose (Tablet Delayed- H-E-B Incontrol Pen Needles 29gx12mm .... 45 GaviLyte-G (Oral Solution) ...... 36 Release) ...... 10 Hectorol (2mcg/ml Injection) ...... 42 GaviLyte-H (Kit) ...... 35 GNP Bisa-Lax (Tablet Delayed-Release) ...... 36 Helixate FS (Injection) ...... 28 GaviLyte-N/Flavor Pack (Oral Solution) ...... 36 GNP ClearLax (Powder) ...... 36 Hema-Combistix ...... 45 Gazyva (Injection) ...... 23 GNP D 1000 (Capsule) ...... 54 Hemangeol (Oral Solution) ...... 29 Gelnique (Gel) ...... 36 GNP D 2000 (Tablet Chewable) ...... 54 Hematinic Plus Vitamins/Minerals (Tablet) . 52 Gemcitabine (Injection) ...... 22 GNP Daily Prenatal ...... 54 Hematinic/Folic Acid (Tablet) ...... 48 Gemfibrozil (600mg Tablet) ...... 31 GNP Nicotine Mini Lozenge (Lozenge) ...... 13 Hemocyte-F (Tablet) ...... 48 Generlac (Oral Solution) ...... 36 GNP Nicotine Polacrilex (2mg Gum, 4mg Hemocyte-Plus (Tablet) ...... 52 Gene-Xene Tab 15mg (Tablet) ...... 18 Gum, 2mg Lozenge, 4mg Lozenge) ...... 13 Hemofil M (Injection) ...... 28 Gene-Xene Tab 3.75mg (Tablet) ...... 18 GNP Nicotine Transdermal System (Patch 24 Hepagam B (Injection) ...... 41 Gene-Xene Tab 7.5mg (Tablet) ...... 18 Hour) ...... 13 Heparin Lock Flush (Injection) ...... 27 Gengraf (100mg Capsule, 25mg Capsule, GNP Prenatal (Tablet)...... 54 Heparin Sodium (10000unit/10ml Injection, 50mg Capsule, 100mg/ml Oral Solution) 41 GNP Vitamin D (Tablet) ...... 54 3000unit/3ml Injection, 5000unit/5ml Gentak (Ophthalmic Ointment) ...... 14 GNP Vitamin D Super Strength (Tablet) ...... 54 Injection, 10000unit/ml Injection, Gentamicin Sulfate (0.1% Cream, 0.1% GNP Vitamin D3 Extra Strength (Tablet) ..... 54 1000unit/ml Injection, 20000unit/ml Ointment, 0.3% Ophthalmic Ointment, GNP Womens Laxative (Tablet Delayed- Injection, 5000unit/0.5ml Injection, 0.3% Ophthalmic Solution, 10mg/ml Release) ...... 36 5000unit/ml Injection) ...... 27 Injection, 40mg/ml Injection) ...... 14 Goodsense Magnesium Citrate (Solution) .. 36 Heparin Sodium Lock Flush (Kit) ...... 27 Gentamicin Sulfate/0.9% Sodium Chloride Goodsense Nicotine Gum (Gum) ...... 13 Heparin Sodium/D5W (5%-40unit/ml (0.8mg/ml-0.9% Injection, 1.2mg/ml-0.9% Goodsense Prenatal Vitamins (Tablet) ...... 54 Injection, 5%-50unit/ml Injection) ...... 27 Injection, 1mg/ml-0.9% Injection) ...... 14 Gralise (Tablet) ...... 10 Heparin Sodium/NaCl 0.9% (Injection) ...... 27 Gentle Laxative (Tablet Delayed-Release) ... 36 Gralise ST ...... 10 Heparin Sodium/Sodium Ch Loride (Injection) Gentlelax (Powder) ...... 36 Granisetron HCl (0.1mg/ml Injection, 1mg/ml ...... 27 Geodon (Injection) ...... 48 Injection, 4mg/4ml Injection) ...... 20 Heparin Sodium/Sodium Chloride Gianvi (Tablet) ...... 38 Granisetron HCl (1mg Tablet) ...... 20 (2000unit/500ml-0.9% Solution) ...... 26 Gildagia (Tablet) ...... 38 Griseofulvin Microsize (125mg/5ml Heparin Sodium/Sodium Chloride Gilenya (Capsule) ...... 32 Suspension, 500mg Tablet) ...... 20 (20unit/20ml-0.9% Injection, Gilotrif (Tablet) ...... 23 Griseofulvin Ultramicrosize (Tablet) ...... 20 25000unit/250ml-0.45% Injection, Glassia (Injection) ...... 51 Guanfacine ER (Tablet Extended-Release 24 30000unit/L-0.9% Injection, 4000unit/L- Glatopa (Injection) ...... 32 Hour) ...... 32 0.9% Injection, 50unit/50ml-0.45% Gleostine (Capsule) ...... 21 Guanfacine HCl (Tablet Immediate-Release) Injection) ...... 27 Gliadel Wafer (Wafer) ...... 21 ...... 28 Heparin Sodium/Sodium Chloride 0.9% Glimepiride (Tablet)...... 26 Guanidine HCl (Tablet) ...... 21 Premix (Injection) ...... 27 Glipizide (Tablet Immediate-Release) ...... 26 Gynazole-1 (Cream) ...... 20 Herceptin (Injection) ...... 23 Glipizide ER (Tablet Extended-Release 24 Hetastarch 6%/NaCl (Injection) ...... 28 Hour) ...... 26 H Hetlioz (Capsule) ...... 32 Glipizide XL (Tablet Extended-Release 24 Hexalen (Capsule) ...... 21 Hour) ...... 26 H.P. Acthar (Injection) ...... 38 Hiberix (Injection) ...... 42 Glipizide/Metformin HCl (Tablet) ...... 26 Halaven (Injection) ...... 48 Hizentra (Injection) ...... 41 Global Alcohol Prep Ease Pads ...... 14 Halobetasol Propionate (0.05% Cream, 0.05% HM Aspirin (325mg Tablet, 81mg Tablet GlucaGen HypoKit (Injection) ...... 26 Ointment) ...... 33 Chewable) ...... 10 Glucagon Emergency Kit (Injection) ...... 27 Halog (0.1% Cream, 0.1% Ointment) ...... 34 HM ClearLax (Powder) ...... 36 GlucoCom Autolink Telemonitoring System Haloperidol (0.5mg Tablet, 10mg Tablet, 1mg HM Laxative (Tablet Delayed-Release) ...... 36 ...... 44 Tablet, 20mg Tablet, 2mg Tablet, 5mg HM Nicotine Polacrilex (2mg Gum, 4mg Gum, Glyburide (1.25mg Tablet, 2.5mg Tablet, 5mg Tablet, 2mg/ml Concentrate) ...... 24 2mg Lozenge, 4mg Lozenge) ...... 13 Tablet)...... 26 Haloperidol Decanoate (Injection) ...... 24 HM Nicotine Transdermal System (Patch 24 Glyburide Micronized (Tablet) ...... 26 Haloperidol Lactate (Injection)...... 24 Hour) ...... 13 Glyburide/Metformin HCl (Tablet) ...... 26 Harvoni (Tablet)...... 24 HM Nicotine Transdermal System (Patch 24 Glycine (1.5% Irrigation Solution) ...... 37 Havrix (Injection) ...... 42 Hour) ...... 13 Glycolax (Powder)...... 36 Healthy Kids Vitamin D3 (Tablet Chewable) 54 HM One Daily Prenatal Combo ...... 54 Glycopyrrolate (0.4mg/2ml Injection, Healthy Mama Be Well Rounded (Therapy HM Prenatal (Tablet) ...... 54

HM Vitamin D (Tablet) ...... 54 Release 24 Hour Abuse-Deterrent) ...... 11 Increlex (Injection) ...... 38 HM Vitamin D3 (Capsule) ...... 54 Hydromorphone HCl/Sodium Chloride Incruse Ellipta (Aerosol Powder) ...... 50 Horizant (Tablet Extended-Release) ...... 32 (10mg/25ml-0.9% Solution Prefilled Indapamide (Tablet) ...... 31 Humalog (Injection) ...... 27 Syringe, 1mg/5ml-0.9% Solution Prefilled Inderal XL (Capsule Extended-Release 24 Humalog KwikPen (Injection) ...... 27 Syringe, 3mg/30ml-0.9% Solution Prefilled Hour) ...... 29 Humalog Mix 50/50 (Injection) ...... 27 Syringe, 15mg/50ml-0.9% Injection) ...... 32 Indomethacin (1mg Solution) ...... 48 Humalog Mix 50/50 KwikPen (Injection) ... 27 Hydromorphone HCl/Sodium Chloride Indomethacin (25mg Capsule, 50mg Capsule) Humalog Mix 75/25 (Injection) ...... 27 (10mg/50ml-0.9% Injection, 15mg/30ml- ...... 10 Humalog Mix 75/25 KwikPen (Injection) ... 27 0.9% Injection, 5mg/25ml-0.9% Injection) Indomethacin ER (Capsule Extended-Release) Humapen Luxura HD ...... 45 ...... 12 ...... 10 Humate-P (Injection) ...... 28 Hydroxychloroquine Sulfate (Tablet) ...... 23 Infanrix (Injection) ...... 42 Humira (10mg/0.2ml Injection) ...... 48 Hydroxyurea (Capsule) ...... 22 Inflectra (Injection) ...... 43 Humira (20mg/0.4ml Injection, 40mg/0.8ml Hydroxyzine HCl (10mg Tablet, 25mg Tablet, Inlyta (Tablet) ...... 23 Injection) ...... 41 50mg Tablet, 10mg/5ml Syrup, 50mg/ml Innopran XL (Capsule Extended-Release 24 Humira Pediatric Crohns Disease Starter Injection) ...... 19 Hour) ...... 29 Pack (Injection) ...... 41 Hydroxyzine Pamoate (100mg Capsule, 25mg InspiraChamber/Anti-Static Humira Pen (Injection) ...... 41 Capsule, 50mg Capsule) ...... 20 Valved/Mouthpiece ...... 45 Humira Pen Crohns Disease Starter Pack Hyoscyamine Sulfate (0.125mg Tablet InspiraChamber/Large ...... 45 (Injection) ...... 41 Dispersible) (MANUF MARLEX, TRIGEN) 35 InspiraChamber/Soother Humira Pen-Psoriasis Starter (Injection) .... 41 Hyperhep B S/D (Injection) ...... 41 Mask/InspiraMask/Medium ...... 45 Humulin 70/30 (Injection) ...... 27 Hyperrab S/D (Injection) ...... 41 InspiraChamber/Soother Humulin 70/30 KwikPen (Injection) ...... 27 Hyperrho S/D (Injection) ...... 41 Mask/InspiraMask/Small ...... 45 Humulin N (Injection) ...... 27 Hyperrho S/D Mini-Dose (Injection) ...... 41 Inspirease Bags ...... 45 Humulin N KwikPen (Injection) ...... 27 Hyqvia (Injection) ...... 42 Inspirease Drug Delivery System ...... 45 Humulin R (Injection) ...... 27 Hysingla ER (Tablet Extended-Release 24 Inspirease Mouthpiece ...... 45 Humulin R U-500 (Concentrated) (Injection) Hour Abuse-Deterrent)...... 11 Inspirease Reservoir Bags ...... 45 ...... 27 Insulin Syringe/0.5ml/27g X 1/2" ...... 45 Hycamtin (0.25mg Capsule, 1mg Capsule) . 22 I Insulin Syringe/U-100/1ml/28g X 1/2" ...... 45 Hydralazine HCl (100mg Tablet, 10mg Tablet, Insulin Syringes, Needles (BD MEDICAL) ... 34, 25mg Tablet, 50mg Tablet, 20mg/ml Ibandronate Sodium (150mg Tablet, 3mg/3ml 45 Injection) ...... 31 Injection) ...... 42 Insupen 33gx4mm ...... 45 Hydrochlorothiazide (12.5mg Capsule, Ibrance (Capsule) ...... 22 Insupen Pen Needles 32g X4mm ...... 45 12.5mg Tablet, 25mg Tablet, 50mg Tablet) Ibudone (5mg-200mg Tablet) ...... 10 Insupen Sensitive 32gx6mm ...... 45 ...... 31 Ibuprofen (100mg/5ml Suspension - RX, Insupen Sensitive 32gx8mm ...... 45 Hydrocodone Bitartrate/Acetaminophen 400mg Tablet, 600mg Tablet, 800mg Insupen Ultrafin 29gx12mm ...... 45 (Tablet, Oral Solution) ...... 12 Tablet) ...... 10 Insupen Ultrafin 30gx8mm ...... 45 Hydrocodone Bitartrate/Homatropine Ibuprofen Lysine (Injection) ...... 48 Insupen Ultrafin 31gx6mm ...... 45 Methylbromide (1.5mg-5mg Tablet, Ibutilide Fumarate (Injection) ...... 29 Insupen Ultrafin 31gx8mm ...... 45 1.5mg/5ml-5mg/5ml Syrup) ...... 51 Iclusig (15mg Tablet) ...... 23 Intelence (Tablet) ...... 25 Hydrocodone/Acetaminophen (Tablet) ...... 12 Iclusig (45mg Tablet) ...... 23 Intralipid (20gm/100ml Injection) ...... 45 Hydrocodone/Ibuprofen (Tablet) ...... 10 Idarubicin HCl (Injection) ...... 48 Intron A (Injection) ...... 22 Hydrocort Enema 100mg (Enema) ...... 37 Idelvion (Injection) ...... 28 Intron A w/Diluent (Injection) ...... 48 Hydrocortisone (1% Cream RX, 2.5% Cream, Iferex 150 Forte (Capsule) ...... 52 Introvale (Tablet) ...... 38 1% Ointment RX, 2.5% Ointment, 2.5% Ifex (3gm Injection) ...... 21 Invanz (Injection) ...... 16 Cream, 2.5% Lotion) ...... 34 Ifosfamide (1gm Injection, 1gm/20ml Invega Sustenna (Injection) ...... 24 Hydrocortisone (10mg Tablet, 20mg Tablet, Injection, 3gm/60ml Injection) ...... 21 Invega Trinza (Injection) ...... 24 5mg Tablet) ...... 37 Ifosfamide (3gm Injection) ...... 21 Invirase (200mg Capsule, 500mg Tablet) ... 25 Hydrocortisone 1% in Absorbase (Ointment) Ilaris (Injection) ...... 41 Invokamet (Tablet) ...... 26 ...... 34 Ilevro (Suspension) ...... 49 Invokamet XR (Tablet Extended-Release 24 Hydrocortisone Butyrate (0.1% Cream, 0.1% Imatinib Mesylate (Tablet) ...... 23 Hour) ...... 26 External Solution, 0.1% Ointment) ...... 34 Imbruvica (Capsule) ...... 23 Invokana (Tablet) ...... 26 Hydrocortisone in Absorbase (Ointment).... 34 Imipenem/Cilastatin (Injection) ...... 16 Iopidine (1% Ophthalmic Solution) ...... 49 Hydrocortisone Valerate (0.2% Cream, 0.2% Imipramine HCl (10mg Tablet, 25mg Tablet, IPOL Inactivated IPV (Injection) ...... 42 Ointment) ...... 34 50mg Tablet) ...... 19 Ipratropium Bromide (0.02% Inhalation Hydrocortisone/Acetic Acid (Otic Solution) . 50 Imipramine Pamoate (Capsule) ...... 19 Solution) ...... 50 Hydromet (Syrup) ...... 51 Imiquimod (Cream) ...... 34 Ipratropium Bromide (0.03% Nasal Solution, Hydromorphone HCl (1mg/ml Injection, Imlygic (Suspension) ...... 21 0.06% Nasal Solution) ...... 50 2mg/ml Injection, 4mg/ml Injection, Imovax Rabies (H.D.C.V.) (Injection) ...... 42 Ipratropium Bromide/Albuterol Sulfate 500mg/50ml Injection, 1mg/ml Liquid, Impavido (Capsule) ...... 15 (Inhalation Solution) ...... 48 2mg Tablet, 4mg Tablet, 8mg Tablet) ..... 12 In Touch Diabetes Management Software 45 Irbesartan (Tablet) ...... 28 Hydromorphone HCl ER (Tablet Extended- Inatal GT (Tablet) ...... 54 Irbesartan/Hydrochlorothiazide (Tablet) ..... 28

Irinotecan (40mg/2ml Injection) ...... 48 Kaletra (100mg-25mg Tablet, 200mg-50mg KP Folic Acid (Tablet) ...... 54 Irinotecan (500mg/25ml Injection) ...... 48 Tablet) ...... 25 KP Prenatal Multivitamins (Tablet) ...... 54 Irinotecan HCl (Injection) ...... 48 Kalydeco (150mg Tablet, 50mg Packet, 75mg KP Vitamin D (1000unit Capsule, 2000unit Isentress (100mg Packet, 100mg Tablet Packet) ...... 51 Capsule, 400unit Tablet Chewable) ...... 54 Chewable, 25mg Tablet Chewable, 400mg Kanuma (Injection) ...... 35 K-Prime (Tablet Effervescent) ...... 52 Tablet) ...... 25 Karidium (Oral Solution)...... 52 Krystexxa (Injection) ...... 21 Isolyte-S (Injection) ...... 52 Karigel (Gel) ...... 32 K-Tan Plus (Capsule) ...... 52 Isoniazid (100mg Tablet, 300mg Tablet, Karigel-N (Gel) ...... 32 Kurvelo (Tablet) ...... 39 50mg/5ml Syrup) ...... 21 Kariva (Tablet) ...... 39 Kuvan (100mg Packet, 500mg Packet, 100mg Isosorbide Dinitrate (Tablet Immediate- KCl 0.075%/D5W/NaCl 0.45% (Injection) .... 48 Tablet Soluble) ...... 35 Release) ...... 31 KCl 0.15%/D5W/NaCl 0.2% (Injection) ...... 48 Kyleena (IUD) ...... 40 Isosorbide Dinitrate ER (Tablet Extended- KCl 0.15%/D5W/NaCl 0.45% (Injection) ...... 48 Kyprolis (30mg Injection) ...... 22 Release) ...... 31 KCl 0.15%/D5W/NaCl 0.9% (Injection) ...... 48 Kyprolis (60mg Injection) ...... 48 Isosorbide Mononitrate (Tablet Immediate- KCl 0.3%/D5W/NaCl 0.45% (Injection) ...... 48 Release) ...... 31 Kedbumin (Injection) ...... 28 L Isosorbide Mononitrate ER (Tablet Extended- K-Effervescent (Tablet Effervescent) ...... 52 Release 24 Hour) ...... 31 Kelnor 1/35 (Tablet) ...... 39 Labetalol HCl (100mg Tablet, 200mg Tablet, Isotonic Gentamicin (Injection) ...... 14 Kepivance (Injection) ...... 32 300mg Tablet, 5mg/ml Injection) ...... 29 Isradipine (Capsule) ...... 30 Kerydin (External Solution) ...... 20 Labstix ...... 45 Istodax (Injection) ...... 48 Ketocare...... 45 Lacrisert (Insert) ...... 49 Istodax (Overfill) (Injection) ...... 48 Ketoconazole (2% Cream, 2% Foam, 2% Lactated Ringers (Injection) ...... 52 Itraconazole (Capsule) ...... 20 Shampoo, 200mg Tablet) ...... 20 Lactated Ringers Irrigation (Solution) ...... 45 IV Prep Wipes ...... 15 Ketodan (Foam) ...... 20 Lactic Acid (Lotion) ...... 34 Ivermectin (Tablet) ...... 23 Keto-Diastix ...... 45 Lactic Acid E (Cream) ...... 34 Ixempra Kit (Injection) ...... 48 Ketone Test Strips ...... 45 Lactic Acid with Vitamin E (Cream) ...... 34 Ixiaro (Injection) ...... 42 Ketoprofen (Capsule Immediate-Release) .. 10 Lactulose (Oral Solution) ...... 36 Ketoprofen ER (Capsule Extended-Release 24 Lamivudine (100mg Tablet) ...... 24 Lamivudine (10mg/ml Oral Solution, 150mg J Hour) ...... 10 Ketorolac Tromethamine (0.4% Ophthalmic Tablet, 300mg Tablet) ...... 25 Jadenu (Tablet) ...... 52 Solution, 0.5% Ophthalmic Solution) ..... 49 Lamivudine/Zidovudine (Tablet)...... 25 Jakafi (10mg Tablet) ...... 22 Ketorolac Tromethamine (10mg Tablet) ..... 11 Lamotrigine (Tablet Immediate-Release, Jakafi (15mg Tablet, 20mg Tablet, 25mg Ketorolac Tromethamine (15mg/ml Injection, Tablet Chewable) ...... 18 Tablet, 5mg Tablet) ...... 22 30mg/ml Injection, 30mg/ml Injection) . 48 Lamotrigine ER (Tablet Extended-Release 24 Jantoven (Tablet) ...... 27 Ketostix ...... 45 Hour) ...... 18 Janumet (Tablet) ...... 26 Keveyis (Tablet) ...... 49 Lamotrigine ODT (Tablet Dispersible) ...... 18 Janumet XR (Tablet Extended-Release 24 Kimidess (Tablet) ...... 39 Lamotrigine Titration (Kit) ...... 18 Hour) ...... 26 Kineret (Injection) ...... 48 Lansoprazole (Capsule Delayed-Release) RX36 Januvia (Tablet) ...... 26 Kinrix (Injection) ...... 42 Lansoprazole/Amoxicillin/Clarithromycin Jardiance (Tablet) ...... 26 Kionex (Powder, 15gm/60ml Suspension) .. 52 (Therapy Pack) ...... 35 Jencycla (Tablet) ...... 40 Klofensaid II (Transdermal Solution) ...... 34 Lantus (Injection) ...... 27 Jetrea (Injection) ...... 49 Klor-Con 10 (Tablet Extended-Release) ...... 52 Lantus SoloStar (Injection) ...... 27 Jevantique Lo (Tablet) ...... 38 Klor-Con 8 (Tablet Extended-Release) ...... 52 LARIN 1.5/30 (Tablet) ...... 39 Jevtana (Injection) ...... 48 Klor-Con M10 (Tablet Extended-Release) ... 52 LARIN 1/20 (Tablet) ...... 39 Jinteli (Tablet) ...... 38 Klor-Con M15 (Tablet Extended-Release) .. 52 LARIN 24 Fe (Tablet) ...... 39 Jolessa (Tablet) ...... 38 Klor-Con M20 (Tablet Extended-Release) ... 52 LARIN Fe 1.5/30 (Tablet) ...... 39 Jolivette (Tablet) ...... 40 Klor-Con Sprinkle (Capsule Extended-Release) LARIN Fe 1/20 (Tablet) ...... 39 J-Tip Kit w/Vial Adapters (Kit) ...... 45 ...... 52 Larissia (Tablet) ...... 39 Jublia (External Solution) ...... 20 KLS Aspirin EC (Tablet Delayed-Release) ..... 11 Lartruvo (500mg/50ml Injection) ...... 21 Juleber (Tablet) ...... 38 KLS Aspirin Low Dose (Tablet Delayed- LaST ...... 49 Junel 1.5/30 (Tablet) ...... 38 Release) ...... 11 Latanoprost (Ophthalmic Solution) ...... 49 Junel 1/20 (Tablet) ...... 38 KLS LaxaClear (Powder) ...... 36 Latuda (Tablet) ...... 24 Junel Fe 1.5/30 (Tablet) ...... 38 KLS Quit2 (2mg Gum, 2mg Lozenge) ...... 13 Laxative (Tablet Delayed-Release) ...... 36 Junel Fe 1/20 (Tablet) ...... 39 KLS Quit4 (4mg Gum, 4mg Lozenge) ...... 13 Laxative Feminine (Tablet Delayed-Release) Junel Fe 24 (Tablet) ...... 39 Koate (Solution) ...... 28 ...... 36 Just D (Liquid) ...... 54 Koate-Dvi (Injection) ...... 28 Layolis Fe (Tablet Chewable) ...... 39 Juxtapid (Capsule) ...... 31 Kogenate FS (Injection) ...... 28 Leader Unifine Pentips Kogenate FS Bio-Set (Injection) ...... 28 Plus/Short/31gx5/16" ...... 45 K Kombiglyze XR (Tablet Extended-Release 24 Leena (Tablet) ...... 39 Leflunomide (Tablet) ...... 41 Kadcyla (Injection) ...... 48 Hour) ...... 26 KP Aspirin (Tablet Delayed-Release) ...... 11 Lemtrada (Injection) ...... 41 Kaitlib Fe (Tablet Chewable) ...... 39 Lenvima (Capsule Therapy Pack) ...... 23 Kalbitor (Injection) ...... 45 KP Bisacodyl (Tablet Delayed-Release) ...... 36 68

Lessina (Tablet) ...... 39 Lidocaine HCl (10mg/ml Injection, 20mg/ml Losartan Potassium (Tablet) ...... 28 Letairis (Tablet) ...... 51 Injection) ...... 29 Losartan Potassium/Hydrochlorothiazide Letrozole (Tablet) ...... 22 Lidocaine HCl (Gel) ...... 12 (Tablet) ...... 28 Leucovorin Calcium (100mg Injection, 200mg Lidocaine HCl (Prefilled Syringe) ...... 42 Lotemax (0.5% Gel, 0.5% Ointment) ...... 49 Injection, 350mg Injection, 50mg Injection) Lidocaine HCl in D5W (Injection)...... 29 Lotemax (0.5% Suspension) ...... 49 ...... 48 Lidocaine HCl/Hydrocortisone Acetate (0.5%- Lovastatin (Tablet) ...... 31 Leucovorin Calcium (10mg Tablet, 15mg 3% Cream, 0.5%-3% Kit, 1%-3% Kit, 2%-2% Low-Ogestrel (Tablet) ...... 39 Tablet) ...... 22 Kit, 2.5%-3% Kit) ...... 34 Loxapine Succinate (Capsule) ...... 24 Leucovorin Calcium (25mg Tablet, 5mg Lidocaine Pak (Ointment) ...... 12 Lucentis (Injection) ...... 49 Tablet)...... 22 Lidocaine Viscous (Solution) ...... 12 Ludent (Tablet Chewable) ...... 52 Leukeran (Tablet) ...... 21 Lidocaine/Epinephrine (Injection) ...... 13 Lumigan (Ophthalmic Solution) ...... 49 Leukine (Injection) ...... 27 Lidocaine/Prilocaine (2.5%-2.5% Cream, Lumizyme (Injection) ...... 35 Leuprolide Acetate (Injection) ...... 40 2.5%-2.5% Kit) ...... 13 Lupaneta Pack (Kit) ...... 40 Leva Set/Occlusive Dressing (Kit)...... 12 Lidopril (Kit) ...... 13 Lupron Depot (Injection) ...... 40 Levalbuterol (Nebulized Solution) ...... 51 Lidopril XR (Kit)...... 13 Lupron Depot-PED (Injection) ...... 40 Levemir (Injection) ...... 27 Lifescan Unistik 2 Deep Penetration ...... 45 Lutera (Tablet) ...... 39 Levemir FlexTouch (Injection) ...... 27 Lifescan Unistik II Lancets ...... 45 Luzu (Cream) ...... 20 Levetiracetam (Tablet Immediate-Release, Liletta (IUD) ...... 40 Lynparza (Capsule) ...... 22 Oral Solution, 500mg/5ml Injection) ...... 17 Lincomycin HCl (Injection) ...... 15 Lyrica (100mg Capsule, 150mg Capsule, Levetiracetam ER (Tablet Extended-Release Lindane (Shampoo) ...... 23 200mg Capsule, 225mg Capsule, 25mg 24 Hour) ...... 17 Linezolid (100mg/5ml Suspension, 600mg Capsule, 300mg Capsule, 50mg Capsule, Levobunolol HCl (Ophthalmic Solution) ...... 49 Tablet) ...... 15 75mg Capsule) ...... 17 Levocarnitine (1gm/10ml Oral Solution, Linezolid (600mg/300ml Injection) ...... 15 Lyrica (20mg/ml Oral Solution) ...... 17 200mg/ml Injection, 330mg Tablet) ...... 45 Linzess (145mcg Capsule, 290mcg Capsule)35 Lysiplex Plus (Tablet) ...... 54 Levocetirizine Dihydrochloride (2.5mg/5ml Linzess (72mcg Capsule) ...... 36 Lysodren (Tablet) ...... 40 Oral Solution, 5mg Tablet) ...... 50 Liothyronine Sodium (10mcg/ml Injection, Lyza (Tablet) ...... 40 Levofloxacin (0.5% Ophthalmic Solution, 25mcg Tablet, 50mcg Tablet, 5mcg Tablet) 250mg Tablet, 500mg Tablet, 750mg ...... 40 M Tablet, 25mg/ml Injection, 25mg/ml Oral Lipodox 50 (Injection) ...... 48 Solution) ...... 17 Lisinopril (Tablet) ...... 29 MacNatal CN DHA (Capsule) ...... 54 Levofloxacin in D5W (Injection) ...... 17 Lisinopril/Hydrochlorothiazide (Tablet) ...... 29 Macugen (Injection) ...... 49 Levoleucovorin (175mg Solution) ...... 43 LiteAire ...... 45 Magnesium Chloride (200mg/ml Injection) . 52 Levoleucovorin (175mg/17.5ml Injection) .. 22 LiteTouch Pen Needles 29gx12.7mm ...... 45 Magnesium Citrate (Oral Solution) ...... 36 Levoleucovorin (250mg/25ml Injection) .... 22 LiteTouch Pen Needles 31gx8mm Short .... 45 Magnesium Sulfate (20gm/500ml Injection, Levoleucovorin (50mg Injection) ...... 48 Lithium (Oral Solution) ...... 26 2gm/50ml Injection, 40gm/1000ml Levonest (Tablet) ...... 39 Lithium Carbonate (150mg Capsule, 300mg Injection, 4gm/100ml Injection, 4gm/50ml Levonorgestrel (Tablet) ...... 40 Capsule, 600mg Capsule, 300mg Tablet) 26 Injection, 50% Injection) ...... 52 Levonorgestrel and Ethinyl Estradiol (Tablet) Lithium Carbonate ER (Tablet Extended- Magnesium Sulfate in D5W (5%-10mg/ml ...... 39 Release) ...... 26 Injection) ...... 17 Levonorgestrel/Ethinyl Estradiol (0.03mg- Livalo (Tablet) ...... 31 Magnesium Sulfate/Lactated Ringers 0.15mg Tablet) ...... 39 Livixil Pak (Kit) ...... 13 (100mg/500ml-20gm/500ml- Levonorgestrel/Ethinyl Estradiol (0-Tablet, Lo Loestrin Fe (Tablet) ...... 39 150mg/500ml-3gm/500ml-1.55gm/500ml 20mcg-0.1mg Tablet) ...... 39 Locoid (0.1% Lotion) ...... 34 Solution) ...... 34 Levora 0.15/30-28 (Tablet) ...... 39 Lofene (Tablet) ...... 35 Magnesium Sulfate/Sodium Chloride Levo-T (Tablet) ...... 40 LoKara (Lotion) ...... 34 (4gm/100ml-0.9% Solution) ...... 34 Levothyroxine Sodium (100mcg Tablet, Lomedia 24 Fe (Tablet) ...... 39 Makena (Injection) ...... 40 112mcg Tablet, 125mcg Tablet, 137mcg Lonsurf (Tablet) ...... 22 Malathion (Lotion) ...... 23 Tablet, 150mcg Tablet, 175mcg Tablet, Loperamide HCl (2mg Capsule) (RX) ...... 35 Mannitol (Injection) ...... 30 200mcg Tablet, 25mcg Tablet, 300mcg Lopinavir/Ritonavir (Solution) ...... 25 Maprotiline HCl (Tablet) ...... 19 Tablet, 50mcg Tablet, 75mcg Tablet, Lorazepam (0.5mg Tablet, 1mg Tablet, 2mg Marlissa (Tablet) ...... 39 88mcg Tablet) ...... 40 Tablet) ...... 18 Marplan (Tablet) ...... 19 Levoxyl (Tablet) ...... 40 Lorazepam (20mg/10ml Injection, 4mg/ml Marqibo (Injection) ...... 22 Lexiva (50mg/ml Suspension, 700mg Tablet) Injection) ...... 26 Marten-Tab (Tablet) ...... 10 ...... 25 Lorazepam Intensol (2mg/ml Concentrate) 26 Mask Vortex/Baby Whirl Duckling ...... 45 Lialda (Tablet Delayed-Release) ...... 42 Lorcet (Tablet) ...... 12 Mask Vortex/Child/Frog ...... 45 Lidazone HC (Cream) ...... 34 Lorcet HD (Tablet) ...... 12 Mask Vortex/Spinner the Duck ...... 45 Lidocaine (3% Cream, 5% Ointment, 5% Lorcet Plus (Tablet) ...... 12 Mask Vortex/Toddler/Lady Bug ...... 45 Patch) ...... 12 Lortab (10mg-325mg Tablet, 5mg-325mg Matulane (Capsule) ...... 21 Lidocaine HCl (0.5% Injection, 1% Injection, Tablet, 7.5mg-325mg Tablet) ...... 12 Matzim LA (Tablet Extended-Release 24 1.5% Injection, 2% Injection, 4% Injection, Loryna (Tablet) ...... 39 Hour) ...... 30 2% Gel, 4% External Solution) ...... 12 Lorzone (Tablet) ...... 52 Maxipime (2gm Injection) ...... 16

Meclizine HCl (12.5mg Tablet, 25mg Tablet) Methamphetamine HCl (Tablet) ...... 32 Microgestin Fe (Tablet) ...... 39 (RX) ...... 20 Methazolamide (Tablet) ...... 30 Microgestin Fe 1.5/30 (Tablet) ...... 39 Meclofenamate Sodium (100mg Capsule, Methenamine Hippurate (Tablet) ...... 15 Microspacer ...... 45 50mg Capsule) ...... 11 Methergine (Tablet) ...... 45 Midodrine HCl (Tablet) ...... 28 Medical Provider Single Use EZ Flu Shot Methimazole (10mg Tablet, 5mg Tablet) .... 41 Miglitol (Tablet) ...... 26 (Injection) ...... 25 Methitest (Tablet) ...... 38 Milrinone in Dextrose (5%-20mg/100ml Medroxyprogesterone Acetate (10mg Tablet, Methocarbamol (1000mg/10ml Injection, Injection, 5%-40mg/200ml Solution) ...... 30 2.5mg Tablet, 5mg Tablet) ...... 40 500mg Tablet, 750mg Tablet) ...... 52 Milrinone Lactate (Injection) ...... 30 Medroxyprogesterone Acetate (150mg/ml Methotrexate (2.5mg Tablet)...... 41 Mimvey (Tablet) ...... 39 Injection) ...... 40 Methotrexate Sodium (Injection) ...... 41 Mimvey Lo (Tablet) ...... 39 Mefenamic Acid (250mg Capsule) ...... 11 Methoxsalen (10mg Capsule)...... 34 Minastrin 24 Fe (Tablet Chewable) ...... 39 Mefloquine HCl (Tablet) ...... 23 Methscopolamine Bromide (Tablet) ...... 35 Mineral Oil Heavy (RX) ...... 36 Megestrol Acetate (20mg Tablet, 40mg Methyclothiazide (5mg Tablet) ...... 31 Miniprin Low Dose (Tablet Delayed-Release) Tablet, 40mg/ml Suspension) ...... 40 Methyldopa (Tablet) ...... 28 ...... 11 Megestrol Acetate (625mg/5ml Suspension) Methyldopa/Hydrochlorothiazide (Tablet) . 28 Minitran (Patch 24 Hour) ...... 31 ...... 40 Methyldopate HCl (Injection) ...... 28 Minocycline HCl (100mg Capsule, 50mg Meijer Alcohol Swabs Extra-Thick ...... 15 Methylergonovine Maleate (Injection) ...... 45 Capsule, 75mg Capsule, 100mg Tablet, Meijer Aspirin EC (Tablet Delayed-Release) 11 Methylphenidate HCl (Tablet Immediate- 50mg Tablet, 75mg Tablet) ...... 17 Meijer Pen Needles 31g X 6mm ...... 45 Release, Tablet Chewable, Oral Solution) Minocycline HCl ER (Tablet Extended-Release Mekinist (Tablet) ...... 23 ...... 32 24 Hour) ...... 17 Meloxicam (Tablet) ...... 11 Methylphenidate HCl CD (Capsule Extended- Minoxidil (Tablet) ...... 31 Melphalan HCl (Injection) ...... 21 Release) ...... 32 Mircera (100mcg/0.3ml Injection, Memantine HCl (10mg Tablet, 5mg Tablet, Methylphenidate HCl ER (Tablet Extended- 200mcg/0.3ml Injection, 50mcg/0.3ml 2mg/ml Oral Solution) ...... 18 Release, Capsule Extended-Release 24 Injection, 75mcg/0.3ml Injection) ...... 27 Memantine HCl Titration Pak (Tablet) ...... 18 Hour) ...... 32 Mircera (150mcg/0.3ml Injection, Menactra (Injection) ...... 42 Methylphenidate HCl SR (Tablet Extended- 30mcg/0.3ml Injection) ...... 26 Menest (Tablet) ...... 39 Release) ...... 32 Mirena (IUD) ...... 40 MENHIBRIX (Injection) ...... 42 Methylprednisolone (16mg Tablet, 32mg Mirtazapine (Tablet) ...... 19 Menomune-A/C/Y/W-135 (Injection) ...... 42 Tablet, 4mg Tablet, 8mg Tablet) ...... 37 Mirtazapine ODT (Tablet Dispersible)...... 19 Mentax (Cream) ...... 20 Methylprednisolone Acetate (40mg/ml Mirvaso (Gel)...... 34 Menveo (Injection) ...... 42 Injection, 80mg/ml Injection) ...... 37 Misoprostol (Tablet) ...... 36 Meperidine HCl (100mg Tablet, 50mg Tablet, Methylprednisolone Sodium Succinate Mission Prenatal (Tablet) ...... 54 100mg/ml Injection, 10mg/ml Injection, (Injection) ...... 48 Mission Prenatal HP (Tablet) ...... 54 25mg/ml Injection, 50mg/ml Injection, Methyltestosterone (10mg Capsule) ...... 38 Mitomycin (20mg Injection, 40mg Injection) 50mg/5ml Oral Solution) ...... 12 Metipranolol (Ophthalmic Solution) ...... 50 ...... 48 Meperidine HCl/Sodium Chloride (Injection) Metoclopramide HCl (10mg Tablet, 5mg Mitomycin (5mg Injection) ...... 48 ...... 12 Tablet, 5mg/5ml Oral Solution) ...... 20 Mitoxantrone HCl (Injection) ...... 22 Mephyton (Tablet) ...... 54 Metoclopramide HCl (5mg/ml Injection) .... 48 Mm Aspirin (Tablet) ...... 11 Meprobamate (Tablet) ...... 25 Metoclopramide ODT (5mg Tablet M-M-R II (Injection) ...... 42 Mercaptopurine (Tablet) ...... 22 Dispersible) ...... 20 Modafinil (Tablet) ...... 52 Meropenem (Injection) ...... 16 Metolazone (Tablet) ...... 31 Moderiba ...... 24 Meropenem/Sodium Chloride (Injection) ... 16 Metoprolol Succinate ER (Tablet Extended- Moderiba (200mg Tablet) ...... 24 Mesalamine (4gm Enema, 4gm Kit) ...... 42 Release 24 Hour) ...... 30 Moderiba 1200 Dose Pack (Tablet) ...... 24 Mesalamine DR (Tablet Delayed-Release) ... 42 Metoprolol Tartrate (100mg Tablet, 25mg Moderiba 800 Dose Pack (Tablet) ...... 24 Mesna (Injection) ...... 22 Tablet, 37.5mg Tablet, 50mg Tablet, 75mg Moexipril HCl (Tablet) ...... 29 Mesnex (Tablet) ...... 48 Tablet, 5mg/5ml Injection) ...... 30 Moexipril/Hydrochlorothiazide (Tablet) ...... 29 Mestinon (60mg/5ml Syrup) ...... 21 Metoprolol/Hydrochlorothiazide (Tablet) .. 30 Molindone HCl (Tablet) ...... 24 Metadate ER (Tablet Extended-Release) ..... 32 Metronidazole (0.75% Cream, 0.75% Gel, 1% Mometasone Furoate (0.1% Cream, 0.1% Metaproterenol Sulfate (10mg Tablet, 20mg Gel, 0.75% Lotion, 250mg Tablet, 500mg Ointment) ...... 37 Tablet, 10mg/5ml Syrup) ...... 51 Tablet, 375mg Capsule) ...... 15 Mometasone Furoate (0.1% External Metaxall (Tablet) ...... 52 Metronidazole in NaCl 0.79% (Injection) .... 15 Solution) ...... 34 Metaxalone (Tablet) ...... 52 Metronidazole Vaginal (Gel) ...... 15 Mometasone Furoate (50mcg/act Metformin HCl (Tablet) ...... 26 Mexiletine HCl (Capsule) ...... 29 Suspension) ...... 50 Metformin HCl ER (Tablet Extended-Release Miacalcin (200unit/ml Injection) ...... 42 Mondoxyne NL (Capsule)...... 17 24 Hour) (Generic for Fortamet, Generic Miconazole 3 (Suppository) ...... 20 Monoclate-P (Injection) ...... 28 for Glucophage XR) ...... 26 Micrhogam Ultra-Filtered Plus (Injection) . 41 Monoject Insulin Syringe/1ml ...... 45 Metformin HCl ER (Tablet Extended-Release Microchamber ...... 45 Monoject Insulin Syringe/Detach 24 Hour) (Generic for Glumetza) ...... 26 Microclens Wipes ...... 15 Needle/1ml/25g X 5/8" ...... 45 Methadone HCl (Tablet, Oral Solution, Microgestin 1.5/30 (Tablet) ...... 39 Monoject Insulin Syringe/Softpack/1ml/27g Concentrate, 40mg Tablet Soluble) ...... 11 Microgestin 1/20 (Tablet) ...... 39 X 1/2" ...... 45 Methadose (40mg Tablet Soluble) ...... 11 Microgestin 24 Fe (Tablet) ...... 39 Monoject Insulin Syringe/Softpack/U-

100/0.5ml/28g X 1/2" ...... 45 Injection, 500mg Tablet) ...... 41 Nebupent (Inhalation Solution) ...... 23 Monoject Pharma Grade Flush Syringe Mycophenolic Acid DR (Tablet Delayed- Nebusal (3% Nebulized Solution) ...... 51 (Solution) ...... 53 Release) ...... 41 Necon 0.5/35-28 (Tablet) ...... 39 Monoject Ultra Comfort Insulin Myleran (Tablet) ...... 22 Necon 1/50-28 (Tablet) ...... 39 Syringe/1ml/30g X 5/16" ...... 45 Mynatal Advance (Tablet) ...... 54 Necon 7/7/7 (Tablet) ...... 39 Mono-Linyah (Tablet) ...... 39 Mynatal Plus (Tablet) ...... 54 Nefazodone HCl (Tablet)...... 19 MonoNessa (Tablet) ...... 39 Mynatal Ultracaplet (Tablet) ...... 54 Neomycin Sulfate (Tablet) ...... 14 Mononine (Injection) ...... 28 Mynatal-Z (Tablet) ...... 54 Neomycin/Bacitracin/Polymyxin (Ointment) Monovisc (Injection) ...... 45 Mynate 90 Plus (Tablet Extended-Release) 54 ...... 15 Montelukast Sodium (10mg Tablet, 4mg Myobloc (Injection) ...... 45 Neomycin/Polymyxin B Sulfates (Irrigation Packet, 4mg Tablet Chewable, 5mg Tablet Myorisan (Capsule) ...... 34 Solution) ...... 14 Chewable) ...... 50 Myrbetriq (Tablet Extended-Release 24 Neomycin/Polymyxin/Bacitracin/Hydrocortis Monurol (Packet) ...... 15 Hour) ...... 36 one (Ointment) ...... 15 Morgidox 1x100mg (100mg Capsule) ...... 17 Mytesi (Tablet Delayed-Release) ...... 35 Neomycin/Polymyxin/Dexamethasone (0.1% Morgidox 1x50mg (Capsule) ...... 17 Myzilra (Tablet) ...... 39 Ophthalmic Suspension, 0.1%-3.5mg/gm- Morgidox 2x100mg (100mg Capsule) ...... 17 10000unit/gm Ointment) ...... 15 Morphine Sulfate (0.5mg/ml Injection, N Neomycin/Polymyxin/Gramicidin 100mg/5ml Oral Solution, 10mg/5ml Oral (Ophthalmic Solution) ...... 14 Solution, 20mg/5ml Oral Solution, Nabi-Hb (Injection) ...... 41 Neomycin/Polymyxin/Hydrocortisone (1% 10mg/ml Injection, 1mg/ml Injection, Nabumetone (Tablet) ...... 11 Ophthalmic Suspension) ...... 15 4mg/ml Injection, 8mg/ml Injection, 15mg N-Acetyl-L-Cysteine (Capsule) ...... 45 Neomycin/Polymyxin/Hydrocortisone (1% Tablet, 30mg Tablet) ...... 12 Nadolol (20mg Tablet, 40mg Tablet, 80mg Otic Solution, 1% Otic Suspension) ...... 50 Morphine Sulfate ER (Capsule Extended- Tablet) ...... 30 Neo-Polycin (Ointment) ...... 15 Release 24 Hour, Tablet Extended- Nadolol/Bendroflumethiazide (Tablet) ...... 30 Neo-Polycin HC (Ointment) ...... 15 Release) ...... 11 Nafcillin (Injection) ...... 16 Neostigmine Methylsulfate (10mg/10ml Morphine Sulfate/Sodium Chloride Nafcillin Sodium (10gm Injection, 1gm Injection, 5mg/10ml Injection, 5mg/5ml (0.5mg/ml-0.9% Injection, 50mg/50ml- Injection, 2gm Injection) ...... 16 Solution Prefilled Syringe) ...... 21 0.9% Injection) ...... 12 Nafrinse (Tablet Chewable) ...... 53 Neo-Synalar (Cream) ...... 34 MoviPrep (Oral Solution) ...... 36 Nafrinse Drops (Oral Solution) ...... 53 Nephronex (Tablet) ...... 54 Moxatag (Tablet Extended-Release 24 Hour) Naftifine HCl (Cream) ...... 20 Nesina (Tablet) ...... 26 ...... 16 Naglazyme (Injection) ...... 35 Neuac (Gel) ...... 34 Moxeza (Ophthalmic Solution) ...... 17 Nalbuphine HCl (Injection) ...... 12 Neulasta (Injection) ...... 27 Moxifloxacin HCl (400mg Tablet, Nalfon (Capsule) ...... 11 Neulasta Onpro Kit (Injection) ...... 27 400mg/250ml Injection) ...... 17 Naloxone HCl (Injection) ...... 13 Neupogen (Injection) ...... 27 Mozobil (Injection) ...... 27 Naltrexone HCl (Tablet) ...... 13 Neupro (Patch 24 Hour) ...... 23 Multaq (Tablet) ...... 29 Namenda XR (Capsule Extended-Release 24 Neutragard Advanced (Gel) ...... 32 Multi Prenatal (Tablet) ...... 54 Hour) ...... 18 Neutral Sodium Fluoride (Solution) ...... 32 Multistix ...... 45 Namenda XR Titration Pack (Capsule Nevanac (Suspension) ...... 49 Multistix 10 Sg...... 45 Extended-Release 24 Hour) ...... 18 Nevirapine (200mg Tablet, 50mg/5ml Multistix 5 ...... 45 Namzaric (Capsule Extended-Release 24 Suspension) ...... 25 Multistix 7 ...... 45 Hour) ...... 32 Nevirapine ER (Tablet Extended-Release 24 Multistix 8 SG ...... 45 Naprelan (750mg Tablet Extended-Release Hour) ...... 25 Multistix 9 ...... 45 24 Hour) ...... 11 Nexavar (Tablet) ...... 23 Multistix 9 SG ...... 45 Naproxen (125mg/5ml Suspension, 250mg Nexplanon (Injection) ...... 40 Multi-Vit/Fluoride (32mg/ml-3mcg/ml- Tablet, 375mg Tablet, 500mg Tablet) .... 11 Next Choice One Dose (Tablet) ...... 40 1mg/ml-400unit/ml-2mcg/ml-5unit/ml- Naproxen DR (Tablet Delayed-Release) ...... 11 Nexterone (150mg/100ml-42.1mg/ml 29.7mcg/ml-2mg/ml-0.4mg/ml-0.6mg/ml- Naproxen Sodium (275mg Tablet, 550mg Injection) ...... 29 0.25mg/ml-0.5mg/ml-1150unit/ml Oral Tablet) ...... 11 Niacin ER (Tablet Extended-Release) ...... 31 Solution) ...... 54 Naproxen Sodium CR (Tablet Extended- Nicardipine HCl (2.5mg/ml Injection, 20mg Multi-Vit/Iron/Fluoride (Solution) ...... 54 Release 24 Hour) ...... 11 Capsule, 30mg Capsule) ...... 30 Multivitamins/Fluoride (Tablet Chewable) .. 54 Naproxen Sodium ER (Tablet Extended- NICOrelief (Gum) ...... 13 Multivitamin with Fluoride (32-3-1-400-2-5- Release 24 Hour) ...... 11 Nicotine (14mg/24hr Patch 24 Hour, 29.7-2-0.4-0.6-0.25-0.5-1150 Solution ... 54 Naratriptan HCl (Tablet) ...... 21 21mg/24hr Patch 24 Hour, 7mg/24hr Mupirocin (2% Cream, 2% Ointment) ...... 15 Narcan (Liquid) ...... 13 Patch 24 Hour, 2mg Gum, 2mg Lozenge, Mustargen (Injection) ...... 22 NascoBAL (Nasal Solution) ...... 54 4mg Lozenge) ...... 13 M-Vit (Tablet) ...... 54 Natacyn (Suspension) ...... 20 Nicotine Mini Lozenge (Lozenge) ...... 13 My Way (Tablet) ...... 40 Natazia (Tablet) ...... 39 Nicotine Polacrilex (2mg Gum, 4mg Gum, Myalept (Injection) ...... 45 Nateglinide (Tablet) ...... 26 2mg Lozenge, 4mg Lozenge, 4mg Lozenge) Mycamine (Injection) ...... 20 Nat-Rul Prenatal Vitamins (Tablet) ...... 54 ...... 13 Mycophenolate Mofetil (200mg/ml Nat-Rul Vitamin D (Tablet) ...... 54 Nicotine Polacrilex Refill (Gum) ...... 13 Suspension, 250mg Capsule, 500mg Natural Vitamin D-3 (Tablet) ...... 54 Nicotine Polacrilex Starter Kit (Gum) ...... 13

Nicotine Step 1 (Patch 24 Hour) ...... 13 Nortriptyline HCl (10mg Capsule, 25mg Octreotide Acetate (Injection) ...... 40 Nicotine Step 2 (Patch 24 Hour) ...... 13 Capsule, 50mg Capsule, 75mg Capsule, Odefsey (Tablet)...... 25 Nicotine Step 3 (Patch 24 Hour) ...... 13 10mg/5ml Oral Solution) ...... 19 Ofev (Capsule) ...... 51 Nicotine Transdermal System (14mg/24hr Norvir (100mg Capsule, 100mg Tablet, Ofloxacin (0.3% Ophthalmic Solution, 0.3% Patch 24 Hour, 21mg/24hr Patch 24 Hour, 80mg/ml Oral Solution) ...... 25 Otic Solution, 400mg Tablet) ...... 17 7mg/24hr Patch 24 Hour) ...... 13 Norwich Aspirin (Tablet) ...... 11 Ofloxacin (300mg Tablet) ...... 14 Nicotine Transdermal System (Kit) ...... 13 Novarel (Injection) ...... 38 Ogestrel (Tablet) ...... 39 Nicotrol Inhaler (Inhaler) ...... 13 Novofine 30gx8mm ...... 45 Olanzapine (10mg Injection)...... 48 Nicotrol NS (Nasal Solution) ...... 13 Novofine 32gx6mm ...... 45 Olanzapine (Tablet Immediate-Release) ..... 24 Nifedipine (10mg Capsule, 20mg Capsule) .. 30 Novofine Autocover 30gx8mm ...... 45 Olanzapine ODT (Tablet Dispersible) ...... 24 Nifedipine ER (Tablet Extended-Release 24 Novofine Plus 32gx4mm ...... 45 Olanzapine/Fluoxetine (Capsule)...... 26 Hour) ...... 30 Novolin 70/30 (Injection) ...... 27 Olmesartan Medoxomil (Tablet) ...... 28 Nikki (Tablet) ...... 39 Novolin 70/30 Relion (Injection) ...... 27 Olmesartan Nilutamide (Tablet)...... 22 Novolin N (Injection) ...... 27 Medoxomil/Amlodipine/Hydrochlorothiazi Nimodipine (Capsule) ...... 30 Novolin N Relion (Injection) ...... 27 de (Tablet) ...... 28 Ninlaro (Capsule) ...... 22 Novolin R (Injection)...... 27 Olmesartan Medoxomil/Hydrochlorothiazide Nipent (Injection) ...... 22 Novolin R Relion (Injection) ...... 27 (Tablet) ...... 29 Nisoldipine (Tablet Extended-Release 24 NovoLog (Injection) ...... 27 Olopatadine HCl (0.1% Ophthalmic Solution) Hour) ...... 30 NovoLog FlexPen (Injection) ...... 27 ...... 49 Nisoldipine ER (Tablet Extended-Release 24 NovoLog Mix 70/30 (Injection) ...... 27 Olopatadine HCl (0.6% Nasal Solution) ...... 50 Hour) ...... 30 NovoLog Mix 70/30 Prefilled FlexPen Olysio (Capsule) ...... 24 Nitro-Bid (Ointment) ...... 31 (Injection) ...... 27 Omeclamox-Pak (Therapy Pack) ...... 35 Nitrofurantoin (Suspension) ...... 15 NovoLog PenFill (Injection) ...... 27 Omega-3-Acid Ethyl Esters (Capsule)...... 31 Nitrofurantoin Macrocrystals (Capsule) ...... 15 NovoPen Echo...... 45 Omeprazole (Capsule Delayed-Release) ...... 36 Nitrofurantoin Monohydrate (100mg Novoseven (Solution) ...... 28 Omeprazole/Sodium Bicarbonate (20mg- Capsule) ...... 15 Novoseven RT (Injection) ...... 28 1100mg Capsule RX, 40mg-1100mg Nitroglycerin (0.3mg Tablet Sublingual, 0.4mg Novotwist 32gx5mm ...... 45 Capsule, 20mg-1680mg Packet, 40mg- Tablet Sublingual, 0.6mg Tablet Noxafil (100mg Tablet Delayed-Release) ... 20 1680mg Packet) ...... 36 Sublingual) ...... 31 NP Thyroid 15 (Tablet) ...... 40 Omnaris (Suspension) ...... 50 Nitroglycerin ER (Capsule Extended-Release) NP Thyroid 60 (Tablet) ...... 40 Omniflex Diaphragm ...... 45 (MANUF TRIMARC) ...... 31 NP Thyroid 90 (Tablet) ...... 40 Oncaspar (Injection)...... 48 Nitroglycerin in 5% Dextrose (Injection) ...... 31 Nplate (Injection) ...... 27 Ondansetron HCl (24mg Tablet, 4mg Tablet, Nitroglycerin in Dextrose 5% (5%-100mcg/ml Nucala (Injection) ...... 48 8mg Tablet, 4mg/5ml Oral Solution) ...... 20 Injection) ...... 31 Nucynta (Tablet) ...... 12 Ondansetron HCl (40mg/20ml Injection, Nitroglycerin Lingual Nucynta ER (Tablet Extended-Release 12 4mg/2ml Injection) ...... 20 (0.4mg/sprayTranslingual Solution, Hour) ...... 11 Ondansetron HCl/Sodium Chloride (Injection) 400mcg/spray Aerosol Solution) ...... 31 Nuedexta (Capsule) ...... 32 ...... 20 Nitroglycerin Transdermal (Patch 24 Hour) . 32 Nufol (Tablet) ...... 54 Ondansetron ODT (Tablet Dispersible) ...... 20 NitroMist (Aerosol Solution) ...... 32 Nulojix (Injection) ...... 41 One A Day Womens Prenatal/DHA ...... 54 Nizatidine (150mg Capsule, 300mg Capsule, Nutrifac ZX (Tablet) ...... 54 One A Day Womens Prenatal1 (Capsule) ... 55 15mg/ml Oral Solution) ...... 35 Nutrilipid (Injection) ...... 45 One-A-Day Womens Prenatal ...... 55 Nora-BE (Tablet) ...... 40 Nutrilyte (Injection) ...... 53 Onetouch Club Lancets Fine Point ...... 45 Norditropin FlexPro (Injection) ...... 38 Nutropin AQ (Injection) ...... 38 Onetouch Combo Pack ...... 45 Norepinephrine Bitartrate (Injection) ...... 30 NuvaRing (Ring) ...... 39 Onetouch Delica Lancets Extra Fine 33g .... 45 Norethindrone (Tablet) ...... 40 Nyamyc (Powder) ...... 20 Onetouch Delica Lancets Fine 30g ...... 45 Norethindrone Acetate (5mg Tablet) ...... 40 Nystatin (100000unit/gm Cream, Onetouch Delica Lancing Device...... 45 Norethindrone Acetate/Ethinyl Estradiol 100000unit/gm Ointment, 100000unit/gm Onetouch Ping Meter Remote ...... 45 (Tablet) ...... 39 Powder, 100000unit/ml Suspension, Onetouch Ultra 2 (Kit) ...... 45 Norethindrone Acetate/Ethinyl 500000unit Tablet) ...... 20 Onetouch Ultra Blue ...... 45 Estradiol/Ferrous Fumarate (Tablet) ...... 39 Nystatin/Triamcinolone (100000unit/gm- Onetouch Ultra Control (In Vitro Solution) 45 Norethindrone/Ethinyl Estradiol/Ferrous 0.1% Ointment, 100000unit/gm-1mg/gm Onetouch Ultra Mini (Kit) ...... 45 Fumarate (Tablet Chewable) ...... 39 Cream) ...... 20 Onetouch Ultralink System (Hex) (Kit) ...... 45 Norgestimate/Ethinyl Estradiol (0-Tablet, Nystop (Powder) ...... 20 Onetouch Ultrasoft Lancets ...... 46 35mcg-0.25mg Tablet) ...... 39 Onetouch Verio (Kit) ...... 46 Norlyroc (Tablet) ...... 40 O Onetouch Verio Control Solution High Normal Saline Flush (Solution) ...... 53 (Solution) ...... 46 Norpace CR (100mg Capsule Extended- Obizur (Injection) ...... 28 Onetouch Verio Flex Bloodglucose Release 12 Hour) ...... 29 Obredon (Oral Solution) ...... 51 Monitoring System (Kit) ...... 46 Nortrel 0.5/35 (28) (Tablet) ...... 39 Obstetrix EC (Tablet) ...... 54 Onetouch Verio Iq Blood Glucose Monitoring Nortrel 1/35 (Tablet) ...... 39 Ocella (Tablet) ...... 39 System (Kit) ...... 46 Nortrel 7/7/7 (Tablet) ...... 39 Octagam (Injection) ...... 41 Onetouch Verio Mid Control Solution

(Solution) ...... 46 Oxistat (1% Lotion) ...... 21 Paroxetine HCl (Tablet) ...... 19 Onetouch Verio Sync Bloodglucose Oxybutynin Chloride (5mg Tablet, 5mg/5ml Paroxetine HCl ER (Tablet Extended-Release Monitoring System (Kit) ...... 46 Syrup) ...... 36 24 Hour) ...... 19 Onetouch Verio Test Strips ...... 46 Oxybutynin Chloride ER (Tablet Extended- Paser (Packet) ...... 21 Onfi (10mg Tablet, 20mg Tablet, 2.5mg/ml Release 24 Hour) ...... 36 Pataday (Ophthalmic Solution) ...... 49 Suspension) ...... 18 Oxycodone HCl (100mg/5ml Concentrate, Paxil (10mg/5ml Suspension) ...... 19 Onglyza (Tablet) ...... 26 10mg Tablet, 15mg Tablet, 20mg Tablet, Pazeo (Ophthalmic Solution) ...... 49 Onivyde (Injection) ...... 48 30mg Tablet, 5mg Tablet, 5mg Capsule, PC Unifine Pentips 29g X 1/2" ...... 46 Opana ER (Tablet Extended-Release 12 Hour 5mg/5ml Oral Solution) ...... 12 PC Unifine Pentips 31g X 5mm Mini ...... 46 Abuse-Deterrent) ...... 11 Oxycodone HCl ER (10mg, 15mg, 20mg, PC Unifine Pentips 31g X 6mm Ultra Short 46 Opcicon One-Step (Tablet) ...... 40 30mg, 40mg, 60mg Tablet Extended- PCE (500mg Tablet Delayed-Release) ...... 17 Opdivo (Injection) ...... 23 Release 12 Hour Abuse-Deterrent) ...... 11 Pediarix (Injection) ...... 42 Opsumit (Tablet) ...... 51 Oxycodone HCl ER (80mg Tablet Extended- Pediatric Panda Mask ...... 46 OptiChamber Advantage ...... 46 Release 12 Hour Abuse-Deterrent) ...... 12 Pedvax HIB (Injection) ...... 42 OptiChamber Advantage/Large Mask ...... 46 Oxycodone/Acetaminophen (2.5mg-325mg PEG 3350 (Powder) ...... 36 OptiChamber Advantage/Medium Face Tablet, 325mg-10mg Tablet, 325mg-5mg PEG 3350/Electrolytes (Oral Solution) ...... 36 Mask ...... 46 Tablet, 325mg-7.5mg Tablet) ...... 12 Peg intron Redipen (Injection) ...... 24 OptiChamber Advantage/Small Face Mask 46 Oxycodone/Aspirin (Tablet) ...... 12 PEG-3350/Electrolytes (Oral Solution) ...... 36 OptiChamber Diamond ...... 46 Oxycodone/Ibuprofen (Tablet) ...... 11 PEG-3350/NaCl/Na Bicarbonate/KCl (Oral OptiChamber Diamond/Large Face Mask .. 46 OxyContin (Tablet Extended-Release 12 Solution) ...... 36 OptiChamber Diamond/Medium Face Mask Hour Abuse-Deterrent)...... 12 Peganone (Tablet) ...... 18 ...... 46 Oxymorphone HCl (Tablet Immediate- Pegasys (Injection) ...... 48 OptiChamber Diamond/Small Face Mask .. 46 Release) ...... 12 Pegasys ProClick (Injection) ...... 48 OptiChamber Face Mask/Small ...... 46 Oxymorphone HCl ER (Tablet Extended- PegIntron (Injection) ...... 24 Optihaler MDI Drug Delivery System ...... 46 Release 12 Hour) ...... 12 Peg-Prep (Kit) ...... 35 Optimal D3 M (Capsule) ...... 55 Oxytocin (Injection) ...... 38 Pegylax (Powder) ...... 36 Optimal-D Pack (Capsule) ...... 55 Oxytocin/Sodium Chloride (30unit/500ml- Pen Needles 30gx5/16" ...... 46 Option 2 (Tablet) ...... 40 0.9% Solution) ...... 50 Pen Needles 30gx5mm ...... 46 Options Gynol II Vaginal Contraceptive (Gel) Ozurdex (Injection) ...... 49 Pen Needles 30gx8mm ...... 46 ...... 37 Penicillin G Potassium (Injection) ...... 16 Opurity Vitamin D (Tablet Chewable) ...... 55 P Penicillin V Potassium (125mg/5ml Oral Oracea (Capsule Delayed-Release) ...... 34 Solution, 250mg/5ml Oral Solution, 250mg Oralone (Paste) ...... 32 PA Prenatal Formula (Tablet) ...... 55 Tablet, 500mg Tablet) ...... 16 Orencia (125mg/ml Injection, 250mg PA Vitamin D-3 (Capsule) ...... 55 Penlet II Automatic Blood Sampler (Kit) .... 46 Injection) ...... 41 PA Vitamin D-3 Gummy (Tablet Chewable) 55 Penlet II Replacement Caps-Deep ...... 46 Orencia Clickject (Injection) ...... 41 Pacerone (Tablet) ...... 29 Pentacel (Injection) ...... 42 Orenitram (Tablet Extended-Release) ...... 51 Paclitaxel (100mg/16.7ml Injection, Pentasa (Capsule Extended-Release) ...... 42 Orfadin (10mg Capsule, 20mg Capsule, 2mg 300mg/50ml Injection, 30mg/5ml Pentazocine/Naloxone HCl (Tablet) ...... 12 Capsule, 5mg Capsule) ...... 35 Injection) ...... 22 Pentips 29gx12mm ...... 46 Orkambi (125mg-100mg Tablet) ...... 51 Paclitaxel (150mg/25ml Injection) ...... 22 Pentips 31gx5mm ...... 46 Orphenadrine Citrate (30mg/ml Injection) .. 52 Paliperidone ER (Tablet Extended-Release 24 Pentips 31gx6mm ...... 46 Orphenadrine Citrate ER (Tablet Extended- Hour) ...... 24 Pentips 31gx8mm ...... 46 Release 12 Hour) ...... 52 Pamidronate Disodium (30mg Injection, Pentips 32gx4mm ...... 46 Orsythia (Tablet) ...... 39 30mg/10ml Injection, 90mg Injection, Pentoxifylline ER (Tablet Extended-Release) Ortho-CS 250 (Injection) ...... 55 90mg/10ml Injection) ...... 42 ...... 30 Orthovisc (Injection) ...... 46 Pamidronate Disodium (6mg/ml Injection) 42 Perforomist (Nebulized Solution) ...... 51 Oseltamivir Phosphate (Capsule) ...... 25 Pancuronium Bromide (Injection) ...... 52 Perindopril Erbumine (Tablet) ...... 29 Osmitrol Viaflex (15% Injection, 20% Panda Mask Large ...... 46 Periogard (Solution) ...... 32 Injection) ...... 30 Panda Mask Medium ...... 46 Perjeta (Injection) ...... 23 OsmoPrep (Tablet) ...... 35 Panda Mask Small ...... 46 Permethrin (Cream) ...... 23 Osphena (Tablet) ...... 40 Panretin (Gel) ...... 23 Perphenazine (Tablet) ...... 20 Otezla (30mg Tablet) ...... 41 Pantoprazole Sodium (20mg Tablet Delayed- Perphenazine/Amitriptyline (10mg-2mg Oxacillin Sodium (Injection) ...... 16 Release, 40mg Tablet Delayed-Release, Tablet, 25mg-2mg Tablet, 25mg-4mg Oxaliplatin (IV Solution 100mg/20ml) ...... 48 40mg Injection) ...... 36 Tablet) ...... 19 Oxandrolone (Tablet) ...... 38 Paragard Intrauterine Copper Contraceptive Perry Prenatal (Capsule) ...... 55 Oxaprozin (Tablet) ...... 11 T380a (IUD) ...... 46 Pharbedryl (Capsule) (RX) ...... 20 Oxaydo (5mg Tablet Abuse-Deterrent) ...... 12 Paricalcitol (1mcg Capsule, 2mcg Capsule, Phenadoz (Suppository)...... 20 Oxazepam (Capsule) ...... 26 4mcg Capsule, 2mcg/ml Injection, Phenazo (Tablet) ...... 37 Oxcarbazepine (150mg Tablet, 300mg Tablet, 5mcg/ml Injection) ...... 42 Phenelzine Sulfate (Tablet) ...... 19 600mg Tablet, 60mg/ml Suspension) ..... 18 Paroex (Solution)...... 32 Phenergan (12.5mg Suppository, 25mg Oxiconazole Nitrate (Cream) ...... 21 Paromomycin Sulfate (Capsule) ...... 14 Suppository, 50mg Suppository) ...... 20

Phenobarbital (100mg Tablet, 15mg Tablet, Polysaccharide Iron Forte (Capsule) ...... 53 Prednisone (10mg Tablet, 1mg Tablet, 2.5mg 16.2mg Tablet, 30mg Tablet, 32.4mg Pomalyst (Capsule) ...... 22 Tablet, 20mg Tablet, 50mg Tablet, 5mg Tablet, 60mg Tablet, 64.8mg Tablet, Portia-28 (Tablet) ...... 39 Tablet) ...... 37 97.2mg Tablet, 20mg/5ml Elixir, 20mg/5ml Portrazza (Injection) ...... 22 Prednisone Intensol (5mg/ml Concentrate) Oral Solution) ...... 18 Potassium Acetate (2meq/ml Injection) ..... 53 ...... 37 Phenoxybenzamine HCl (Capsule) ...... 28 Potassium Chloride (10% Oral Solution, 20% Pregnyl w/Diluent Benzyl Alcohol/NaCl Phenylephrine HCl (10% Ophthalmic Solution, Oral Solution, 10meq/100ml Injection, (Injection) ...... 38 2.5% Ophthalmic Solution) ...... 49 20meq/50ml Injection, 2meq/ml Injection, Premarin (0.3mg Tablet, 0.45mg Tablet, Phenylephrine HCl (10mg/ml Injection) ...... 28 40meq/100ml Injection, 20meq Packet) 53 0.625mg Tablet, 0.9mg Tablet, 1.25mg Phenylephrine HCl/Sodium Chloride Potassium Chloride 0.15% D5W/NaCl 0.33% Tablet) ...... 39 (50mg/250ml-0.9% Solution) ...... 26 (Injection) ...... 48 Premasol (6% Injection) ...... 53 Phenytoin (125mg/5ml Suspension, 50mg Potassium Chloride 0.15% D5W/NaCl 0.45% Premphase (Tablet)...... 39 Tablet Chewable) ...... 18 (Injection) ...... 48 Prempro (Tablet) ...... 39 Phenytoin Sodium (50mg/ml Injection) ...... 18 Potassium Chloride 0.22% D5W/NaCl 0.45% Prenatabs Rx (Tablet) ...... 55 Phenytoin Sodium Extended (Capsule) ...... 18 (Injection) ...... 48 Prenatal (100mg-0-0-263mg-400unit-4mcg- Philith (Tablet) ...... 39 Potassium Chloride 0.224%D5W/NaCl 0.45% 27mg-0.8mg-18mg-2.6mg-1.7mg-1.5mg- Phos-Flur (Gel) ...... 32 Viaflex (Injection) ...... 48 11unit-4000unit-25mg Tablet) ...... 55 Phoslyra (Oral Solution) ...... 37 Potassium Chloride CR (Tablet Extended- Prenatal (120mg-4000unit-200mg-400unit- Phospholine Iodide (Ophthalmic Solution) 50 Release) ...... 53 8mcg-28mg-800mcg-20mg-2.6mg-1.7mg- Photofrin (Injection) ...... 48 Potassium Chloride ER (10meq Capsule 1.8mg-30unit-25mg Tablet) ...... 55 Physiolyte (Irrigation Solution) ...... 46 Extended-Release, 8meq Capsule Prenatal 19 (Tablet, Tablet Chewable) ...... 55 Physiosol Irrigation (Solution) ...... 46 Extended-Release, 10meq Tablet Prenatal and Iron (Tablet)...... 55 Phytonadione (Injection) ...... 55 Extended-Release, 20meq Tablet Prenatal Complete (Tablet) ...... 55 Picato (Gel) ...... 34 Extended-Release, 8meq Tablet Extended- Prenatal Formula (Capsule) ...... 55 Pilocarpine HCl (1% Ophthalmic Solution, 2% Release) ...... 53 Pre-Natal Formula (Tablet) ...... 55 Ophthalmic Solution, 4% Ophthalmic Potassium Chloride SR (Tablet Extended- Prenatal Forte (Tablet) ...... 55 Solution) ...... 50 Release) ...... 53 Prenatal Low Iron (Tablet) ...... 55 Pilocarpine HCl (5mg Tablet, 7.5mg Tablet) 33 Potassium Chloride/Dextrose (5%-20meq/L Prenatal Multi + DHA (Capsule) ...... 55 Pimozide (Tablet) ...... 24 Injection) ...... 48 Prenatal Multi +DHA (Capsule) ...... 53 Pimtrea (Tablet) ...... 39 Potassium Chloride/Lidocaine HCl (Injection) Prenatal Multivitamin + DHA ...... 55 Pindolol (Tablet) ...... 30 ...... 53 Prenatal Multivitamin Plus DHA (Capsule). 55 Pioglitazone HCl (Tablet) ...... 26 Potassium Chloride/Sodium Chloride Prenatal One Daily (Tablet) ...... 55 Pioglitazone HCl/Glimepiride (Tablet) ...... 26 (20meq/L-0.9% Injection, 40meq/L-0.9% Prenatal Vitamin/Iron (Tablet) ...... 55 Pioglitazone HCl/Metformin HCl (Tablet) .... 26 Injection) ...... 53 Prenatal Vitamins (Tablet) ...... 55 Piperacillin/Tazobactam (2gm-0.25gm Potassium Citrate ER (Tablet Extended- Prenatal/Omega-3/Folic Acid/Iron (Capsule) Injection, 3gm-0.375gm Injection, 4gm- Release) ...... 53 ...... 55 0.5gm Injection, 36gm-4.5gm Solution) . 16 Potiga (Tablet) ...... 17 Prenatal-U (Capsule) ...... 55 Pirmella 1/35 (Tablet) ...... 39 Pradaxa (Capsule) ...... 27 Prepopik (Packet) ...... 36 Pirmella 7/7/7 (Tablet) ...... 39 Praluent (Injection) ...... 30 Prevalite (4gm Packet, 4gm/dose Powder) . 31 Piroxicam (10mg Capsule, 20mg Capsule) ... 11 Pramipexole Dihydrochloride (Tablet Previfem (Tablet) ...... 39 Plasbumin-25 (Injection) ...... 28 Immediate-Release) ...... 23 Prevnar 13 (Injection) ...... 42 Plasbumin-5 (Injection) ...... 28 Pramipexole Dihydrochloride ER (Tablet Prezcobix (Tablet) ...... 25 Plasma-Lyte A (Injection) ...... 53 Extended-Release 24 Hour) ...... 23 Prezista (100mg/ml Suspension, 150mg Plasma-Lyte-148 (Injection) ...... 53 Pravastatin Sodium (Tablet) ...... 31 Tablet, 600mg Tablet, 75mg Tablet, Plasma-Lyte-56/D5W (Injection) ...... 53 Prazosin HCl (1mg Capsule, 2mg Capsule, 5mg 800mg Tablet) ...... 25 Plegridy (Injection) ...... 48 Capsule) ...... 28 Prialt (Injection) ...... 10 Plegridy Starter Pack (Injection) ...... 48 Pred Mild (Suspension) ...... 49 Priftin (Tablet) ...... 21 Plenamine (Injection) ...... 53 Prednicarbate (0.1% Cream, 0.1% Ointment) Primaquine Phosphate (Tablet) ...... 23 Pneumovax 23 (Injection) ...... 42 ...... 34 Primidone (Tablet) ...... 18 Pocket Chamber ...... 46 Prednisolone (15mg/5ml Oral Solution, Primsol (Oral Solution) ...... 15 Pocket Spacer ...... 46 15mg/5ml Syrup)...... 37 Privigen (Injection) ...... 41 Podofilox (External Solution) ...... 34 Prednisolone Acetate (Suspension) ...... 49 Pro Comfort Alcohol Prep Pads ...... 15 Polocaine (Injection) ...... 13 Prednisolone Sodium Phosphate (1% Pro Comfort Pen Needles/ 32g X 5mm...... 46 Polocaine-Mpf (Injection) ...... 13 Ophthalmic Solution) ...... 49 Pro Comfort Pen Needles/ 32g X 6mm...... 46 Polycin (Ointment) ...... 15 Prednisolone Sodium Phosphate (10mg/5ml ProAir HFA (Aerosol Solution) ...... 51 Polyethylene Glycol 3350 (Packet, Powder) Solution, 20mg/5ml Solution, 25mg/5ml ProAir RespiClick (Aerosol Powder) ...... 51 RX ...... 36 Oral Solution, 5mg/5ml Oral Solution) ... 37 Probenecid (Tablet) ...... 21 Poly-Iron 150 Forte (Capsule) ...... 53 Prednisolone Sodium Phosphate ODT (Tablet Probenecid/Colchicine (Tablet) ...... 21 Polymyxin B Sulfate (500000unit Injection). 15 Dispersible) ...... 37 Procainamide HCl (500mg/ml Solution) ...... 29 Polymyxin B Sulfate/Trimethoprim Sulfate Prednisone (10mg Tablet Therapy Pack, 5mg Prochlorperazine (Suppository) ...... 20 (Ophthalmic Solution) ...... 15 Tablet Therapy Pack) ...... 41 Prochlorperazine Edisylate (Injection) ...... 20

Prochlorperazine Maleate (10mg Tablet, 5mg Q Ranexa (Tablet Extended-Release 12 Hour) Tablet)...... 20 ...... 30 QC Alcohol Swabs ...... 15 Procrit (Injection) ...... 27 Ranitidine HCl (150mg Capsule, 300mg QC Aspirin (325mg Tablet, 325mg Tablet Procto-Med HC (Cream) ...... 34 Capsule, 150mg Tablet RX, 300mg Tablet, Delayed-Release)...... 11 Procto-Pak (Cream) ...... 34 150mg/6ml Injection, 50mg/2ml Injection, QC Childrens Aspirin (Tablet Chewable) ..... 11 Proctosol HC (Cream) ...... 34 15mg/ml Syrup, 75mg/5ml Syrup)...... 35 QC Enteric Aspirin (Tablet Delayed-Release) Proctozone-HC (Cream) ...... 34 Rapaflo (Capsule) ...... 37 ...... 11 Procysbi (Capsule Delayed-Release)...... 49 Rapamune (1mg/ml Oral Solution) ...... 41 QC Gentle Laxative (Tablet Delayed-Release) Profilnine (Injection) ...... 28 Rasagiline Mesylate (Tablet) ...... 24 ...... 36 Progesterone (100mg Capsule, 200mg RAVICTI (Liquid) ...... 35 QC Natura-Lax (Powder) ...... 36 Capsule) ...... 40 Rayaldee (Capsule Extended-Release) ...... 56 QC Nicotine Polacrilex (Gum) ...... 13 Progesterone (50mg/ml Injection) ...... 40 React (Tablet) ...... 40 QC Prenatal (Tablet) ...... 55 Proglycem (Suspension)...... 27 Reality Swabs ...... 15 Quadracel (Injection) ...... 42 Prograf (5mg/ml Injection) ...... 41 Rebetol (40mg/ml Oral Solution) ...... 24 Quasense (Tablet) ...... 39 Prolastin-C (Injection) ...... 51 Reclipsen (Tablet) ...... 39 Quazepam (Tablet)...... 26 Proleukin (Injection) ...... 48 Recombinate (Injection) ...... 28 Quetiapine Fumarate (Tablet) ...... 19 Prolia (Injection) ...... 43 Recombivax HB (Injection) ...... 42 Quetiapine Fumarate ER (Tablet Extended- Promacta (Tablet) ...... 27 Rectiv (Ointment) ...... 32 Release 24 Hour) ...... 19 Promethazine HCl (12.5mg Suppository, Regranex (Gel)...... 34 Quflora Pediatric (32mg/ml-3mcg/ml- 25mg Suppository, 50mg Suppository, Relador Pak (Kit) ...... 13 1mg/ml-400unit/ml-2mcg/ml-5unit/ml- 12.5mg Tablet, 25mg Tablet, 50mg Tablet, Relador Pak Plus (Kit) ...... 13 29.7mcg/ml-2mg/ml-0.4mg/ml-0.6mg/ml- 50mg/ml Injection, 6.25mg/5ml Oral Relenza Diskhaler (Aerosol Powder) ...... 25 0.25mg/ml-0.5mg/ml-1150unit/ml Oral Solution) ...... 20 Relion Ketone ...... 46 Solution) ...... 55 Promethazine HCl (25mg/ml Injection) ...... 48 Relion Ketone Test Strips ...... 46 Quillivant XR (Suspension) ...... 32 Promethazine HCl Plain (Syrup) ...... 20 Relion Pen Needles 29gx12mm ...... 46 Quinapril HCl (Tablet) ...... 29 Promethegan (Suppository) ...... 20 Relion Pen Needles 31gx6mm ...... 46 Quinapril/Hydrochlorothiazide (Tablet) ...... 29 Pronutrients Vitamin D3 (Capsule) ...... 55 Relion Pen Needles 31gx8mm ...... 46 Quinidine Gluconate CR (Tablet Extended- Propafenone HCl (Tablet) ...... 29 Relion Pen Needles 32gx4mm ...... 46 Release) ...... 29 Propafenone HCl ER (Capsule Extended- Relistor (12mg/0.6ml Injection, 8mg/0.4ml Quinidine Gluconate ER (Tablet Extended- Release 12 Hour) ...... 29 Injection) ...... 35 Release) ...... 29 Propantheline Bromide (15mg Tablet) ...... 35 Relistor (150mg Tablet) ...... 36 Quinidine Sulfate (Tablet) ...... 29 Proparacaine HCl (Ophthalmic Solution) ..... 49 Relpax (Tablet) ...... 21 Quinine Sulfate (324mg Capsule) ...... 23 Propranolol HCl (Tablet Immediate-Release, Remicade (Injection) ...... 41 1mg/ml Injection, Oral Solution) ...... 30 Remodulin (Injection) ...... 51 Propranolol HCl (Tablet) ...... 30 R Renagel (Tablet) ...... 37 Propranolol HCl ER (Capsule Extended- RA Alcohol Swabs ...... 15 Rena-Vite Rx (Tablet) ...... 55 Release 24 Hour) ...... 30 RA Aspirin (Tablet) ...... 11 Renvela (0.8gm Packet, 2.4gm Packet) ...... 37 Propranolol/Hydrochlorothiazide (Tablet) .. 30 RA Aspirin Adult Low Strength (Tablet Renvela (800mg Tablet) ...... 37 Propylthiouracil (Tablet) ...... 41 Chewable) ...... 11 Repaglinide (Tablet) ...... 26 ProQuad (Injection) ...... 42 RA Aspirin EC (Tablet Delayed-Release) ...... 11 Repaglinide/Metformin HCl (Tablet) ...... 26 Protriptyline HCl (Tablet) ...... 19 RA Childrens Aspirin (Tablet Chewable) ...... 11 Repatha (Injection) ...... 30 Pulmicort Flexhaler (Aerosol Powder) ...... 50 RA Laxative (Powder, 5mg Tablet Delayed- Repatha Pushtronex System (Injection) ..... 30 Pulmosal (Nebulized Solution)...... 51 Release) ...... 36 Repatha SureClick (Injection) ...... 30 Pulmozyme (Inhalation Solution) ...... 48 RA Nicotine (14mg/24hr Patch 24 Hour, Replesta (Wafer) ...... 55 PureVitamin Dualfe Plus (Capsule) ...... 53 21mg/24hr Patch 24 Hour, 2mg Gum, 4mg Replesta Childrens (Wafer) ...... 55 PX Aspirin (325mg Tablet, 81mg Tablet Gum) ...... 13 Replesta Nx (Wafer) ...... 55 Chewable) ...... 11 RA Nicotine Gum (Gum) ...... 13 Reprexain (10mg-200mg Tablet) ...... 11 PX Enteric Aspirin (Tablet Delayed-Release) 11 RA Nicotine Polacrilex (2mg Gum, 2mg Rescriptor (Tablet) ...... 25 PX Mini Pen Needles 31gx5mm ...... 46 Lozenge, 4mg Lozenge) ...... 14 Rescula (Ophthalmic Solution) ...... 49 PX Prenatal Multivitamins (Tablet) ...... 55 RA One Daily ...... 55 Restasis (Emulsion) ...... 49 PX Stop Smoking Aid (2mg Gum, 4mg Gum, RA Pen Needles 31g X 5mm 3/16" ...... 46 Restasis Multidose (Emulsion)...... 49 2mg Lozenge, 2mg Lozenge, 4mg Lozenge) RA Prenatal (Tablet) ...... 55 Retrovir IV Infusion (Solution) ...... 25 ...... 13 RA Prenatal Formula/Folic Acid (Tablet) ... 55 Revlimid (Capsule) ...... 22 Pylera (Capsule) ...... 35 RA Vitamin D-3 (1000unit Tablet, 2000unit Revonto (Injection) ...... 52 Pyrazinamide (Tablet) ...... 21 Capsule) ...... 55 Rexulti (Tablet)...... 24 Pyridostigmine Bromide (Tablet) ...... 21 Rabavert (Injection)...... 42 Reyataz (150mg Capsule, 200mg Capsule, Pyridostigmine Bromide ER (Tablet Extended- Rabeprazole Sodium (Tablet Delayed- 300mg Capsule, 50mg Packet) ...... 25 Release) ...... 21 Release) ...... 36 Rhogam Ultra-Filtered Plus (Injection) ...... 41 Pyridoxine HCl (100mg/ml Injection)...... 55 Rajani (Tablet) ...... 39 Rhophylac (Injection) ...... 41 Raloxifene HCl (Tablet) ...... 40 Riastap (Injection) ...... 28 Ramipril (Capsule) ...... 29 Ribasphere (200mg Capsule, 200mg Tablet)24 75

Ribasphere (400mg Tablet, 600mg Tablet) 24 ...... 34 Sirolimus (Tablet) ...... 41 Ribasphere Ribapak (Tablet) ...... 24 Salicylic Acid Cream (Kit) ...... 34 Sirturo (Tablet) ...... 21 Ribavirin (200mg Capsule, 200mg Tablet) ... 24 Salicylic Acid Lotion (Kit) ...... 34 Sivextro (200mg Tablet) ...... 15 Ribavirin (6gm Solution) ...... 51 Saline Flush (Injection) ...... 53 Sklice (Lotion) ...... 23 Ridaura (Capsule) ...... 41 Saline Flush Zr/Sterile Field (Injection)...... 53 Skyla (IUD) ...... 40 Rifabutin (Capsule) ...... 21 Salitech Forte (Lotion) ...... 34 SM Alcohol Prep Pads ...... 15 Rifamate (Capsule) ...... 21 Salsalate (500mg Tablet, 750mg Tablet) SM Aspirin (Tablet) ...... 11 Rifampin (150mg Capsule, 300mg Capsule, (MANUF MARLEX) ...... 11 SM Aspirin Adult Low Strength (Tablet 600mg Injection) ...... 21 Samsca (Tablet) ...... 52 Chewable) ...... 11 Rifater (Tablet) ...... 21 Sancuso (Patch) ...... 20 SM Aspirin EC Low Strength (Tablet Delayed- Right Step Prenatal (Tablet) ...... 55 Sandimmune (100mg/ml Oral Solution) .... 41 Release) ...... 11 Riluzole (Tablet) ...... 32 Sandostatin LAR Depot (Injection) ...... 40 SM Aspirin Enteric Coated (Tablet Delayed- Rimantadine HCl (Tablet)...... 25 Santyl (Ointment) ...... 34 Release) ...... 11 Ringers Injection ...... 53 Saphris (10mg Tablet Sublingual)...... 24 SM Childrens Aspirin (Tablet Chewable) ..... 11 Ringers Irrigation (Solution)...... 46 Saphris (2.5mg Tablet Sublingual, 5mg SM ClearLax (Powder) ...... 36 Riomet (Oral Solution) ...... 26 Tablet Sublingual) ...... 48 SM Folic Acid (Tablet) ...... 55 Risedronate Sodium (150mg Tablet, 35mg Saps Care Alcohol Prep Pads ...... 15 SM Gentle Laxative (Tablet Delayed-Release) Tablet)...... 43 Sash Kit for Flushing Vascular Access Devices ...... 36 Risedronate Sodium (30mg Tablet, 5mg (Kit) ...... 27 SM Nicotine (14mg/24hr Patch 24 Hour, Tablet)...... 43 Savella (Tablet) ...... 32 21mg/24hr Patch 24 Hour, 7mg/24hr Risedronate Sodium DR (Tablet Delayed- SB Alcohol Prep Pads ...... 15 Patch 24 Hour, 2mg Lozenge, 4mg Gum) 14 Release) ...... 43 SB Aspirin (Tablet) ...... 11 SM Nicotine Polacrilex (2mg Gum, 4mg Gum, Risperdal Consta (Injection) ...... 48 SB Aspirin EC (Tablet Delayed-Release) ...... 11 4mg Lozenge) ...... 14 Risperidone (0.25mg Tablet, 0.5mg Tablet, SB Bisacodyl Laxative EC (Tablet Delayed- SM Nicotine Transdermal System (Patch 24 1mg Tablet, 2mg Tablet, 3mg Tablet, 4mg Release) ...... 36 Hour) ...... 14 Tablet, 1mg/ml Oral Solution) ...... 24 SB Childrens Aspirin (Tablet Chewable) ...... 11 SM One Daily Prenatal ...... 55 Risperidone ODT (Tablet Dispersible) ...... 24 Scalacort (Lotion) ...... 34 SM Vitamin D (Tablet) ...... 55 RiteFlo ...... 46 Selegiline HCl (5mg Capsule, 5mg Tablet) ... 24 SM Vitamin D3 Maximum Strength (Capsule) Rituxan (Injection) ...... 23 Selenium Sulfide (Lotion) ...... 34 ...... 55 Rivastigmine Tartrate (Capsule Immediate- Selzentry (150mg Tablet, 300mg Tablet) ... 25 Smooth Lax (Powder) ...... 36 Release) ...... 18 Selzentry (25mg Tablet, 75mg Tablet) ...... 14 Sodium Acetate (2meq/ml Injection) ...... 52 Rivastigmine Transdermal System (Patch 24 Sensipar (Tablet) ...... 40 Sodium Bicarbonate (7.5% Injection) ...... 52 Hour) ...... 18 Sensorcaine (Injection) ...... 13 Sodium Chloride 0.9% (Irrigation Solution) 46 Rixubis (Injection) ...... 28 Sensorcaine/Epinephrine (Injection)...... 13 Sodium Chloride (0.9% Nebulized Solution, Rizatriptan Benzoate (Tablet) ...... 21 Sensorcaine-MPF (Injection) ...... 13 10% Nebulized Solution, 3% Nebulized Rizatriptan Benzoate ODT (Tablet Dispersible) Sensorcaine-MPF Spinal (Injection) ...... 13 Solution, 7% Nebulized Solution) ...... 51 ...... 21 Sensorcaine-Mpf/Epinephrine (Injection) ... 42 Sodium Chloride (2.5meq/ml Injection, 3% Rocuronium Bromide (100mg/10ml Injection, Serevent Diskus (Aerosol Powder) ...... 51 Injection, 5% Injection) ...... 53 50mg/5ml Injection) ...... 52 Seroquel XR (150mg Tablet Extended- Sodium Chloride 0.45% (Injection) ...... 53 Ropinirole ER (Tablet Extended-Release 24 Release 24 Hour, 200mg Tablet Extended- Sodium Chloride Bacteriostatic (Injection) .. 53 Hour) ...... 23 Release 24 Hour, 300mg Tablet Extended- Sodium Chloride Flush (Injection) ...... 53 Ropinirole HCl (Tablet) ...... 23 Release 24 Hour, 50mg Tablet Extended- Sodium Ferric Gluconate Complex/Sucrose Ropivacaine (Injection) ...... 13 Release 24 Hour) ...... 19 (Injection) ...... 53 Ropivacaine HCl (Injection) ...... 13 Serostim (Injection) ...... 38 Sodium Fluoride (0.25mg Tablet Chewable, Ropivacaine HCl/Sodium Chloride (0.1%-0.9% Sertraline HCl (100mg Tablet, 25mg Tablet, 1.1mg Tablet Chewable, 1mg Tablet Solution, 0.2%-0.9% Injection) ...... 13 50mg Tablet, 20mg/ml Concentrate) ..... 19 Chewable, 0.5mg/ml Oral Solution, 1mg Rosadan (0.75% Cream, 0.75% Gel)...... 15 Setlakin (Tablet) ...... 39 Tablet) ...... 53 Rosuvastatin Calcium (Tablet) ...... 31 Sharobel (Tablet) ...... 40 Sodium Hyaluronate (Gel) ...... 41 Rotarix (Suspension) ...... 42 Shur-Seal (Gel) ...... 37 Sodium Nitroprusside (Injection) ...... 32 RotaTeq (Oral Solution) ...... 42 Signifor (Injection) ...... 40 Sodium Phenylacetate/Sodium Benzoate Roweepra (Tablet) ...... 17 Sildenafil (10mg/12.5ml Injection) ...... 51 (Injection) ...... 46 Rozerem (Tablet) ...... 52 Sildenafil (20mg Tablet) ...... 51 Sodium Phenylbutyrate (Powder) ...... 35 Silver Sulfadiazine (Cream) ...... 15 Sodium Phosphate (Injection) ...... 53 S Simbrinza (Suspension) ...... 50 Sodium Polystyrene Sulfonate (Powder, Similac Prenatal Early Shield ...... 55 15gm/60ml Suspension, 30gm/120ml Sabril (500mg Packet) ...... 18 Simponi (Injection) ...... 41 Suspension, 50gm/200ml Suspension) ... 52 Safety Insulin Syringes 1ml/27gx1/2" ...... 46 Simponi Aria (Injection) ...... 41 Sodium Sulfacetamide (Ophthalmic Solution) Safety Insulin Syringes 1ml/30gx1/2" ...... 46 Simulect (20mg Injection) ...... 41 ...... 17 Safety-Glide Insulin Syringe/0.3ml/29g X Simvastatin (10mg Tablet, 20mg Tablet, 40mg Soliris (Injection) ...... 48 1/2" ...... 46 Tablet, 5mg Tablet) ...... 31 Soltamox (Oral Solution) ...... 22 Salicylic Acid (6% Cream, 6% Gel, 6% Lotion) Simvastatin (80mg Tablet) ...... 31 Solu-Cortef (1000mg Injection) ...... 48

Somatuline Depot (Injection) ...... 40 Sulfatrim Pediatric (Suspension) ...... 17 Taclonex (0.064%-0.005% Suspension) ...... 34 Somavert (Injection) ...... 40 Sulindac (150mg Tablet, 200mg Tablet) ...... 11 Tacrolimus (0.03% Ointment, 0.1% Ointment) Sorine (Tablet) ...... 29 Sumatriptan (Nasal Solution) ...... 21 ...... 34 Sotalol HCl (AF) (Tablet)...... 29 Sumatriptan Succinate (100mg Tablet, 25mg Tacrolimus (0.5mg Capsule, 1mg Capsule, Sotalol HCl (Tablet) ...... 29 Tablet, 50mg Tablet, 4mg/0.5ml Injection, 5mg Capsule) ...... 41 Sovaldi (Tablet) ...... 24 6mg/0.5ml Injection) ...... 21 Tafinlar (Capsule) ...... 23 Spinosad (Suspension) ...... 23 Super Daily D3 (1000unit/0.03ml Liquid) .. 55 Tagrisso (Tablet) ...... 23 Spiriva HandiHaler (Capsule) ...... 50 Super Daily D3 (2000UT/0.028ml Liquid) .. 46 Take Action (Tablet)...... 40 Spiriva Respimat (Aerosol Solution) ...... 50 Supprelin LA (Injection) ...... 40 Tamiflu (6mg/ml Suspension) ...... 25 Spironolactone (100mg Tablet, 25mg Tablet, Suprax (100mg Tablet Chewable, 200mg Tamoxifen Citrate (Tablet) ...... 22 50mg Tablet) ...... 31 Tablet Chewable, 500mg/5ml Tamsulosin HCl (Capsule) ...... 37 Spironolactone/Hydrochlorothiazide (Tablet) Suspension)...... 16 Tarceva (Tablet) ...... 23 ...... 31 Supreme II Confidence Paddles ...... 46 Targretin (1% Gel) ...... 23 Sprintec 28 (Tablet) ...... 39 Suprep Bowel Prep (Oral Solution) ...... 36 Tarina Fe 1/20 (Tablet) ...... 39 Sprix (Nasal Solution)...... 11 Sure Comfort Alcohol Prep Pads ...... 15 Taron-Crystals (Packet) ...... 53 Sprycel (Tablet) ...... 23 Sure Comfort Pen Needles 29gx1/2" 12.7mm Taron-Prex (Capsule) ...... 55 SPS (Suspension)...... 52 ...... 46 Tasigna (Capsule) ...... 23 SR Nicotine Gum (Gum) ...... 14 Sure Comfort Pen Needles 30gx5/16" Short Tazicef (1gm Injection, 2gm Injection, 6gm Sronyx (Tablet) ...... 39 ...... 46 Injection) ...... 16 SSD (Cream) ...... 15 Sure Comfort Pen Needles 31gx3/16" (5mm) Tazorac (0.05% Cream, 0.1% Cream, 0.05% SSKI (Oral Solution) ...... 51 ...... 46 Gel, 0.1% Gel) ...... 34 ST 51 Sure Comfort Pen Needles 31gx5/16" (8mm) Taztia XT (Capsule Extended-Release 24 Hour) St Joseph Low Dose Aspirin (Tablet Chewable) ...... 46 ...... 29 ...... 11 Sure Comfort Pen Needles 32gx5/32" ...... 46 Tecentriq (Injection) ...... 23 Stavudine (Capsule) ...... 25 Sure Comfort Pen Needles 32gx6mm ...... 46 Tecfidera (Capsule Delayed-Release) ...... 32 Stelara (130mg/26ml Injection)...... 41 Sure-Fine Pen Needles 29gx1/2" 12.7mm . 46 Tecfidera Starter Pack ...... 32 Stelara (45mg/0.5ml Injection, 90mg/ml Sure-Fine Pen Needles 31gx3/16" 5mm .... 46 Techlite Pen Needles/32g X 6mm...... 47 Injection) ...... 34 Sure-Fine Pen Needles 31gx5/16" 8mm .... 46 Techlite Pen Needles/32g X 8mm...... 47 Sterile Diluent for Epoprostenol Sodium Surestep Glucose Control (In Vitro Solution) Teflaro (Injection) ...... 16 (Injection) ...... 46 ...... 46 Tekturna (Tablet) ...... 30 Sterile Water for Injection ...... 46 Surestep Glucose Control Solution (In Vitro Tekturna HCT (Tablet) ...... 31 Sterile Water Irrigation (Solution) ...... 46 Solution) ...... 46 Telmisartan (Tablet) ...... 29 Stimate (Nasal Solution) ...... 38 Surestep Pro High Glucosecontrol (Liquid) 46 Telmisartan/Amlodipine (Tablet) ...... 29 Stimulant Laxative (Tablet Delayed-Release) Surestep Pro Linearity Kit (Kit) ...... 46 Telmisartan/Hydrochlorothiazide (Tablet) .. 29 ...... 36 Surestep Pro Low Glucose Control (Liquid) 46 Temazepam (Capsule) ...... 26 Stiolto Respimat (Aerosol Solution) ...... 51 Surestep Pro Normal Glucose Control Temodar (100mg Injection) ...... 22 Stivarga (Tablet) ...... 23 (Liquid) ...... 47 Temozolomide (Capsule) ...... 22 Strattera (Capsule) ...... 32 Sustiva (200mg Capsule, 50mg Capsule, Tencon (Tablet)...... 10 Strensiq (Injection) ...... 35 600mg Tablet) ...... 25 Teniposide (Injection) ...... 22 Streptomycin Sulfate (1gm Injection) ...... 14 Sutent (Capsule) ...... 23 Tenivac (Injection) ...... 42 Striant ...... 38 SW ClearLax (Powder) ...... 36 Terazosin HCl (Capsule) ...... 28 Stribild (Tablet) ...... 25 SW Nicotine Polacrilex (2mg Gum, 4mg Gum, Terbinafine HCl (Tablet) ...... 21 Stuart One (Capsule) ...... 55 2mg Lozenge, 4mg Lozenge) ...... 14 Terbutaline Sulfate (1mg/ml Injection, 2.5mg Suboxone (Film) ...... 12 Swabflush Saline Flush (Injection) ...... 53 Tablet, 5mg Tablet) ...... 51 Sucraid (Oral Solution) ...... 35 Syeda (Tablet) ...... 39 Terconazole (0.4% Cream, 0.8% Cream, 80mg Sucralfate (1gm Tablet) ...... 36 Sylatron (Injection) ...... 22 Suppository)...... 21 Sulfacetamide Sodium (10% Lotion, 10% Symbicort (Aerosol) ...... 50 Testosterone Cypionate (Injection) ...... 38 Suspension) ...... 34 SymlinPen 120 (Injection) ...... 26 Testosterone Enanthate (Injection) ...... 38 Sulfacetamide Sodium (10% Ophthalmic SymlinPen 60 (Injection) ...... 26 Tetanus/Diphtheria Toxoids-Adsorbed Solution) ...... 17 Synagis (Injection) ...... 41 (Injection) ...... 42 Sulfacetamide Sodium/Prednisolone Sodium Synarel (Nasal Solution) ...... 40 Tetcaine (Ophthalmic Solution) ...... 49 Phosphate (Ophthalmic Solution) ...... 17 Synera (Patch) ...... 13 Tetrabenazine (Tablet) ...... 32 Sulfadiazine (500mg Tablet) ...... 17 Synjardy (Tablet), Synjardy XR (Tablet) ..... 26 Tetracaine HCl (Ophthalmic Solution) ...... 49 Sulfamethoxazole/Trimethoprim Synribo (Injection) ...... 48 Tetracycline HCl (Capsule) ...... 17 (200mg/5ml-40mg/5ml Suspension, Synvisc (Injection) ...... 47 Texacort (External Solution) ...... 34 400mg-80mg Tablet) ...... 17 Synvisc One (Injection) ...... 47 TGT Aspirin (325mg Tablet, 81mg Tablet Sulfamethoxazole/Trimethoprim DS (Tablet) Syprine (Capsule) ...... 52 Chewable, 81mg Tablet Delayed-Release) ...... 17 ...... 11 Sulfamylon (85mg/gm Cream) ...... 15 T TGT Aspirin Low Dose (Tablet Delayed- Sulfasalazine (500mg Tablet, 500mg Tablet Release) ...... 11 Delayed-Release) ...... 42 Tabloid (Tablet) ...... 22 TGT Childrens Aspirin (Tablet Chewable) .... 11

TGT Nicotine Gum (Gum) ...... 14 Today Sponge ...... 37 Triamcinolone (Injection) ...... 37 TGT Nicotine Polacrilex (2mg Gum, 4mg Gum, Todays Health Mini Pen Needles 31g X 1/4" Triamcinolone Acetonide (0.025% Cream, 2mg Lozenge, 4mg Lozenge) ...... 14 ...... 47 0.1% Cream, 0.5% Cream, 0.025% Lotion, TGT Nicotine Step One (Patch 24 Hour) ...... 14 Todays Health Original Pen Needles 29g X 0.1% Lotion, 0.025% Ointment, 0.1% TGT Nicotine Step Three (Patch 24 Hour) .... 14 1/2" ...... 47 Ointment, 0.5% Ointment, 0.147mg/gm TGT Nicotine Step Two (Patch 24 Hour) ...... 14 Todays Health Short Pen Needles 31g X Aerosol Solution) ...... 34 TGT Powderlax (Powder) ...... 36 5/16" ...... 47 Triamcinolone Acetonide (0.1% Paste) ...... 33 Thalomid (Capsule) ...... 22 Tolazamide (Tablet) ...... 26 Triamcinolone Acetonide (55mcg/act Theo-24 (Capsule Extended-Release 24 Hour) Tolbutamide (Tablet) ...... 26 Aerosol) RX ...... 50 ...... 51 Tolcapone (Tablet) ...... 23 Triamcinolone in Orabase (Paste)...... 33 Theochron (Tablet Extended-Release 12 Tolmetin Sodium (200mg Tablet, 600mg Triamterene/Hydrochlorothiazide (25mg- Hour) ...... 51 Tablet, 400mg Capsule) ...... 11 37.5mg Tablet, 50mg-75mg Tablet, Theophylline (Oral Solution) ...... 51 Tolterodine Tartrate (Tablet) ...... 36 37.5mg-25mg Capsule, 50mg-25mg Theophylline CR (Tablet Extended-Release 12 Tolterodine Tartrate ER (Capsule Extended- Capsule) ...... 31 Hour) ...... 51 Release 24 Hour) ...... 36 Triazolam (Tablet) ...... 26 Theophylline ER (100mg Tablet ER 12 Hour, Topex Topical Anesthetic (Solution)...... 33 Tricon (Capsule) ...... 53 200mg Tablet ER 12 Hour, 300mg Tablet Topiramate (Tablet Immediate-Release, Triderm (Cream) ...... 34 ER 12 Hour, 450mg Tablet ER 12 Hour, Capsule Sprinkle Immediate-Release) .... 18 Tri-Estarylla (Tablet) ...... 39 400mg Tablet ER 24 Hour, 600mg Tablet Topiramate ER (Capsule Extended-Release 24 Trifluoperazine HCl (Tablet) ...... 24 ER 24 Hour) ...... 51 Hour Sprinkle) ...... 18 Trifluridine (Ophthalmic Solution) ...... 25 Theracys (Injection) ...... 42 Toposar (Injection) ...... 22 Trigels-F Forte (Capsule) ...... 48 Thera-D 2000 (Tablet)...... 55 Topotecan HCl (4mg Injection) ...... 22 Triglide (Tablet) ...... 31 Thera-D 4000 (Tablet) ...... 55 Topotecan HCl (4mg/4ml Injection) ...... 22 Trihexyphenidyl HCl (0.4mg/ml Elixir, 2mg Thiamine HCl (100mg/ml Injection) ...... 55 Torisel (Injection) ...... 41 Tablet, 5mg Tablet) ...... 23 Thioridazine HCl (Tablet) ...... 24 Torsemide (Tablet) ...... 31 Tri-Legest Fe (Tablet) ...... 39 Thiotepa (Injection) ...... 22 Toujeo SoloStar (Injection)...... 27 Tri-Linyah (Tablet)...... 39 Thiothixene (Capsule) ...... 24 Toviaz (Tablet Extended-Release 24 Hour) 37 Tri-Lo-Estarylla (Tablet) ...... 39 Thrive (Gum) ...... 14 TPN Electrolytes (Injection) ...... 53 Tri-Lo-Marzia (Tablet) ...... 39 Thrombate III (Injection) ...... 27 Tracer II 3 Volt Battery ...... 47 Tri-Lo-Sprintec (Tablet) ...... 39 Thrombate III w/20 Ml Sterile Water Tracleer (Tablet) ...... 51 TriLyte (Oral Solution)...... 36 (Injection) ...... 27 Tradjenta (Tablet) ...... 26 Trimethobenzamide HCl (Capsule) ...... 20 Thymoglobulin (Injection) ...... 41 Tramadol HCl (Tablet Immediate-Release) . 12 Trimethoprim (100mg Tablet) ...... 15 Thyrolar (Tablet) ...... 40 Tramadol HCl ER (150mg Capsule Extended- Trimethoprim Sulfate/Polymyxin B Sulfate Tiagabine HCl (Tablet) ...... 18 Release 24 Hour) ...... 12 (Ophthalmic Solution) ...... 15 Tice BCG (Injection) ...... 48 Tramadol HCl ER (Tablet Extended-Release 24 Trimipramine Maleate (100mg Capsule, 25mg Tilia Fe (Tablet) ...... 39 Hour) ...... 12 Capsule, 50mg Capsule) ...... 19 Timolol Maleate (0.25% Ophthalmic Solution, Tramadol HCl/Acetaminophen (Tablet) ...... 12 Trinatal Rx 1 (Tablet) ...... 55 0.5% Ophthalmic Solution) ...... 50 Trandolapril (Tablet) ...... 29 Trinate (Tablet) ...... 55 Timolol Maleate (10mg Tablet, 20mg Tablet, Trandolapril/Verapamil HCl (Tablet Extended- Trinessa (Tablet) ...... 39 5mg Tablet) ...... 30 Release) ...... 29 Trinessa Lo (Tablet) ...... 39 Timolol Maleate Ophthalmic Gel Forming Trandolapril/Verapamil HCl ER (Tablet Trintellix (Tablet) ...... 19 (Solution) ...... 50 Extended-Release) ...... 29 Triphrocaps (Capsule) ...... 55 Tinidazole (Tablet) ...... 23 Tranexamic Acid (1000mg/10ml Injection, Tri-Previfem (Tablet)...... 39 Tis-U-Sol (Irrigation Solution) ...... 47 1000mg/10ml Solution, 650mg Tablet) . 28 Trisenox (Injection) ...... 48 Tivicay (Tablet) ...... 25 Transderm-Scop (Patch 72 Hour) ...... 20 Tri-Sprintec (Tablet) ...... 39 Tizanidine HCl (2mg Capsule, 4mg Capsule, Tranylcypromine Sulfate (Tablet) ...... 26 Triumeq (Tablet) ...... 25 6mg Capsule, 2mg Tablet, 4mg Tablet) .. 24 Travatan Z (Ophthalmic Solution) ...... 49 Trivora-28 (Tablet) ...... 39 TL Gard Rx (Tablet) ...... 55 Trazodone HCl (100mg Tablet, 150mg Tablet, Trospium Chloride (Tablet) ...... 37 TL Icon (Capsule) ...... 53 300mg Tablet, 50mg Tablet) ...... 19 Trospium Chloride ER (Capsule Extended- Tobradex (0.3%-0.1% Ophthalmic Ointment) Treanda (Injection) ...... 22 Release 24 Hour) ...... 37 ...... 14 Trecator (Tablet) ...... 21 Trulicity (Injection) ...... 26 Tobradex ST (Ophthalmic Suspension) ...... 14 Trelstar (Injection) ...... 40 Trumenba (Injection) ...... 42 Tobramycin (300mg/5ml Nebulized Solution) Trelstar Mixject (Injection) ...... 40 Truvada (Tablet) ...... 25 ...... 14 Tretinoin (0.01% Gel, 0.025% Gel, 0.05% Gel, Tussigon (Tablet) ...... 51 Tobramycin Sulfate (0.3% Ophthalmic 0.025% Cream, 0.05% Cream, 0.1% Cream) Twinrix (Injection) ...... 42 Solution, 1.2gm Injection, 1.2gm/30ml ...... 34 Tybost (Tablet) ...... 25 Injection, 10mg/ml Injection, 80mg/2ml Tretinoin (10mg Capsule) ...... 23 Tygacil (Injection) ...... 15 Injection) ...... 14 Tretinoin Microsphere (Gel) ...... 34 Tykerb (Tablet) ...... 23 Tobramycin/Dexamethasone (Ophthalmic Tretinoin Microsphere Pump (Gel) ...... 34 Typhim VI (Injection) ...... 42 Suspension) ...... 14 Tretten (Injection) ...... 28 Tyvaso (Inhalation Solution) ...... 51 Tobrex (0.3% Ophthalmic Ointment) ...... 14 Trexall (Tablet) ...... 41 Tyvaso Refill (Inhalation Solution) ...... 51

Tyvaso Starter (Inhalation Solution) ...... 51 Valproate Sodium (100mg/ml Injection) ..... 18 Verapamil HCl ER (100mg, 120mg, 180mg, Valproic Acid (250mg Capsule, 250mg/5ml 200mg, 240mg, 300mg Capsule Extended- U Oral Solution, 250mg/5ml Syrup) ...... 18 Release 24 Hour ...... 30 Valsartan (Tablet) ...... 29 Verapamil HCl SR (Capsule Extended-Release Ulesfia (Lotion) ...... 23 Valsartan/Hydrochlorothiazide (Tablet) ..... 29 24 Hour) ...... 30 Uloric (Tablet) ...... 21 Valstar (Injection) ...... 48 Verdrocet (Tablet) ...... 12 Ulticare Alcohol Swabs ...... 15 Valved Holding Chamber ...... 47 Veregen (Ointment) ...... 34 Ulticare Insulin Safety Syringe/0.5ml/29g X Vancomycin (Injection) ...... 15 Vesicare (Tablet) ...... 37 1/2" ...... 47 Vancomycin HCl (0.9%-1gm/200ml Injection, Vestura (Tablet) ...... 39 Ulticare Insulin Safety Syringe/1ml/29g X 1000mg Injection, 10gm Injection, 5000mg Vibativ (Injection) ...... 15 1/2" ...... 47 Injection, 125mg Capsule, 250mg Capsule) Vic-Forte (Capsule) ...... 55 Ulticare Insulin Syringe/0.5ml/28g X 1/2" . 47 ...... 15 Vicodin (Tablet) ...... 12 Ulticare Insulin Syringe/U-100/0.3ml/29g X Vancomycin HCl/Dextrose (5%-1.5gm/250ml Vicodin ES (Tablet) ...... 12 1/2" ...... 47 Injection) ...... 14 Vicodin HP (Tablet) ...... 12 Ulticare Insulin Syringe/U-100/0.3ml/30g X Vancomycin HCl/Dextrose (5%-1gm/250ml Victoza (Injection) ...... 26 1/2" ...... 47 Injection, 5%-2gm/500ml Injection) ...... 15 Videx Pediatric (Oral Solution) ...... 25 Ulticare Insulin Syringe/U-100/0.3ml/31g X Vancomycin HCl/Sodium Chloride (0.9%- Viekira Pak (Tablet Therapy Pack) ...... 24 5/16" ...... 47 1.5gm/150ml Injection, 0.9%- Vienva (Tablet) ...... 39 Ulticare Insulin Syringe/U-100/0.5ml/31g X 1.5gm/250ml Injection, 0.9%-1gm/150ml Vigamox (Ophthalmic Solution) ...... 17 5/16" ...... 47 Injection, 0.9%-1gm/250ml Injection, Viibryd (Tablet) ...... 19 Ulticare Pen Needles/29g X 12.7mm...... 47 0.9%-750mg/150ml Injection) ...... 15 Viibryd ST ...... 19 Ulticare U-100 Insulin Syringes/0.3ml/31g Vancomycin HCl/Sodium Chloride (0.9%- Vimizim (Injection) ...... 35 X1/4" ...... 47 1.5gm/500ml Injection) ...... 14 Vimpat (100mg Tablet, 150mg Tablet, 200mg Ulticare U-100 Insulin Syringes/0.5ml/31g X Vandazole (Gel) ...... 15 Tablet, 50mg Tablet, 10mg/ml Oral 1/4" ...... 47 Vanishpoint Insulin Syringe/0.5ml/30g X Solution) ...... 18 Ulticare U-100 Insulin Syringes/1ml/31g X 5/16" ...... 47 Vinate II (Tablet) ...... 55 1/4" ...... 47 Vanishpoint Insulin Syringe/1ml/29g X 5/16" Vinate M (Tablet) ...... 55 Ultiguard Insulin Syringe/U-100/0.5ml/30g X ...... 34 Vinate One (Tablet) ...... 55 5/16" ...... 47 Vanishpoint Insulin Syringe/1ml/30g X 5/16" Vinblastine Sulfate (Injection) ...... 22 Ultilet Insulin Syringe/Short/1ml/31g X ...... 47 Vincasar PFS (Injection) ...... 48 5/16" ...... 47 Vantas (Injection) ...... 40 Vincristine Sulfate (Injection) ...... 48 Ultilet Pen Needle 32gx4mm/Short ...... 47 VAQTA (Injection) ...... 42 Vinorelbine Tartrate (Injection) ...... 22 Ultilet Short Pen Needles31gx3/16" ...... 47 Varivax (Injection) ...... 42 Viorele (Tablet) ...... 39 Ultimatecare One (Capsule) ...... 55 Vascepa (Capsule) ...... 31 Viracept (Tablet) ...... 25 Ultra-Thin II Pen Needles 29gx1/2" ...... 47 V-C Forte (Capsule) ...... 55 Viramune (50mg/5ml Suspension) ...... 25 Uni-Solve Wipes ...... 15 VCF Vaginal Contraceptive Film (Film) ...... 37 Viread (150mg Tablet, 200mg Tablet, 250mg Unithroid (Tablet) ...... 40 VCF Vaginal Contraceptive Foam (Foam) ... 37 Tablet, 300mg Tablet, 40mg/gm Powder) Unithroid Direct (Tablet) ...... 40 VCF Vaginal Contraceptive Gel (Gel) ...... 37 ...... 25 Unituxin (Injection) ...... 23 Vecamyl (Tablet) ...... 30 Virt-Caps (Capsule) ...... 55 Upspringbaby Vitamin D3 (Liquid) ...... 56 Vectibix (Injection) ...... 23 Virt-Gard (Tablet) ...... 55 Uptravi (Tablet Therapy Pack, 1000mcg Vectical (Ointment) ...... 34 Virt-Phos 250 Neutral (Tablet) ...... 53 Tablet, 1200mcg Tablet, 1400mcg Tablet, Vecuronium Bromide (10mg Injection, 20mg Virtrate-2 (Oral Solution) ...... 53 1600mcg Tablet, 200mcg Tablet, 400mcg Injection) ...... 52 Virtrate-3 (Oral Solution) ...... 53 Tablet, 600mcg Tablet, 800mcg Tablet) 51 Velcade (Injection) ...... 48 Virtrate-K (Oral Solution) ...... 53 Urea (40% Cream, 45% Lotion) ...... 34 Veletri (Injection) ...... 51 Virt-Vite (Tablet) ...... 55 Urea Nail Gel (Gel) ...... 34 Velivet (Tablet) ...... 39 Virt-Vite Plus (Tablet) ...... 55 Urea Topical (Suspension) ...... 34 Velphoro (Tablet Chewable) ...... 37 Visudyne (Injection) ...... 49 Urea-C40 (Lotion) ...... 34 Veltassa (Packet) ...... 52 Vita S Forte (Tablet) ...... 55 Urin-Tek (Kit, 0 Misc) ...... 47 Veltin (Gel) ...... 34 Vitacel (Tablet) ...... 55 Uristix ...... 47 Venclexta (Tablet) ...... 22 Vitajoy Daily D Gummies (Tablet Chewable)55 Uristix 4 ...... 47 Venclexta Starting Pack (Tablet Therapy Vitamax Pediatric (Oral Solution) ...... 55 Urosex (Tablet) ...... 55 Pack) ...... 22 Vitamelts Vitamin D (Tablet Dispersible) ... 55 Ursodiol (250mg Tablet, 500mg Tablet, Venlafaxine HCl (Tablet Immediate-Release) Vita-Min (Capsule) RX ...... 55 300mg Capsule) ...... 35 ...... 19 Vitamin C 222mg (Injection) ...... 55 Uvadex (Injection) ...... 34 Venlafaxine HCl ER (150mg, 37.5mg, 75mg Vitamin D (2000unit Tablet, 400unit Capsule, Capsule Extended-Release 24 Hour ...... 19 400unit Tablet, 400unit/ml Liquid, V Ventavis (Inhalation Solution) ...... 51 50000unit Capsule) ...... 55 Valacyclovir HCl (Tablet) ...... 25 Ventolin HFA (Aerosol Solution) ...... 51 Vitamin D-1000 (Tablet) ...... 55 Valchlor (Gel) ...... 34 Veracolate (Tablet Delayed-Release) ...... 36 Vitamin D2 (Tablet) ...... 55 Valganciclovir (Tablet) ...... 24 Verapamil HCl (Tablet Immediate-Release, Vitamin D3 (10000unit Tablet, Valganciclovir Hydrochlorde (Oral Solution) 24 2.5mg/ml Injection) ...... 30 1000unit/spray Liquid, 1200unit/15ml 79

Liquid, 3000unit Tablet) ...... 55 WP Thyroid (Tablet) ...... 40 Zenatane (Capsule) ...... 34 Vitamin D-3 (1000unit Capsule, 1000unit WYMZYA Fe (Tablet Chewable) ...... 39 Zenchent (Tablet) ...... 39 Tablet, 400unit Tablet, 2000unit Tablet) 55 Zenchent Fe (Tablet Chewable) ...... 39 Vitamin D3 (5000unit Tablet Dispersible) .. 56 X Zenpep (Capsule Delayed-Release) ...... 35 Vitamin D3 (Capsule, Tablet, Tablet Zenzedi (10mg Tablet, 5mg Tablet) ...... 32 Chewable, 400unit/ml Liquid, 5000unit/ml Xalkori (Capsule)...... 23 Zepatier (Tablet) ...... 25 Liquid) ...... 55 Xarelto (Tablet) ...... 27 Zerit (1mg/ml Oral Solution) ...... 25 Vitamin D3 Gummies (Tablet Chewable) ..... 56 Xarelto Starter Pack (Tablet Therapy Pack) 27 Ziagen (20mg/ml Oral Solution) ...... 25 Vitamin K1 (1mg/0.5ml Injection) ...... 56 Xeljanz (Tablet) ...... 41 Zidovudine (100mg Capsule, 300mg Tablet, Vitamins A/C/D/Fluoride (Solution) ...... 56 Xeomin (100unit Injection, 50unit Injection) 50mg/5ml Syrup) ...... 25 Vituz (Oral Solution) ...... 50 ...... 47 Zinacef (1.5gm-0 Injection) ...... 16 Vivitrol (Injection) ...... 13 Xeomin (200unit Injection) ...... 48 Zioptan (Ophthalmic Solution) ...... 49 Vivotif (Capsule Delayed-Release) ...... 42 Xgeva (Injection) ...... 43 Ziprasidone HCl (Capsule) ...... 24 Vol-Care Rx (Tablet) ...... 56 Xiaflex (Injection) ...... 35 Zirgan (Gel) ...... 24 Vonvendi (Injection) ...... 28 Xifaxan (Tablet) ...... 15 Zithromax (1gm Packet) ...... 17 Voraxaze (Injection) ...... 47 Xigduo XR (Tablet Extended-Release 24 Zoladex (Injection) ...... 40 Voriconazole (200mg Injection, 200mg Hour) ...... 26 Zoledronic Acid (4mg Injection, 4mg/100ml Tablet, 50mg Tablet, 40mg/ml Suspension) Xolair (Injection) ...... 51 Injection) ...... 43 ...... 21 Xolegel (Gel) ...... 21 Zoledronic Acid (4mg/5ml Injection, Vortex Valved Holding Chamber ...... 47 Xtandi (Capsule) ...... 22 5mg/100ml Injection) ...... 43 Votrient (Tablet) ...... 23 Xulane (Patch Weekly) ...... 39 Zolinza (Capsule) ...... 22 VPRIV (Injection) ...... 35 Xylocaine Dental (Injection) ...... 13 Zolmitriptan (Tablet) ...... 21 VP-Vite Rx (Tablet) ...... 56 Xylon (Tablet) ...... 11 Zolmitriptan ODT (Tablet Dispersible) ...... 21 Vyfemla (Tablet) ...... 39 Xyntha (Injection) ...... 28 Zolpidem Tartrate (1.75mg Tablet Sublingual, Vyvanse (Capsule) ...... 32 Xyntha Solofuse (Injection) ...... 28 3.5mg Tablet Sublingual) ...... 52 Xyrem (Oral Solution) ...... 52 Zolpidem Tartrate (10mg Tablet, 5mg Tablet) W ...... 52 Y Zolpidem Tartrate ER (Tablet Extended- Warfarin Sodium (Tablet) ...... 27 Release) ...... 52 WatchHaler ...... 47 Yervoy (Injection) ...... 23 YF-Vax (Injection) ...... 42 Zometa (4mg/100ml Injection) ...... 43 Webcol Alcohol Prep Large 1 Ply ...... 15 Zomig (2.5mg Nasal Solution, 5mg Nasal Webcol Alcohol Prep Medium 2 Ply ...... 15 YL Folic Acid (Tablet) ...... 56 Yondelis (Injection) ...... 22 Solution) ...... 21 Wegmans Unifine Pentips Plus 32gx4mm .. 47 Zonisamide (Capsule) ...... 17 Welchol (3.75gm Packet, 625mg Tablet) .... 26 Your Life Multi Prenatal (Capsule) ...... 56 Yuvafem (Tablet) ...... 39 Zontivity (Tablet) ...... 28 Wellesse Vitamin D3 (Liquid) ...... 56 Zorbtive (Injection) ...... 38 Wera (Tablet)...... 39 Z Zortress (Tablet) ...... 41 Wide-Seal Silicone Diaphragm Kit 60 ...... 47 Zostavax (Injection) ...... 42 Wide-Seal Silicone Diaphragm Kit 65 ...... 47 Zafirlukast (Tablet) ...... 50 Zovia 1/35E (Tablet) ...... 39 Wide-Seal Silicone Diaphragm Kit 70 ...... 47 Zaleplon (Capsule) ...... 52 Zovia 1/50E (Tablet) ...... 39 Wide-Seal Silicone Diaphragm Kit 75 ...... 47 Zaltrap (Injection) ...... 48 Zovirax (5% Cream) ...... 25 Wide-Seal Silicone Diaphragm Kit 80 ...... 47 Zanosar (Injection) ...... 22 Zydelig (Tablet) ...... 22 Wide-Seal Silicone Diaphragm Kit 85 ...... 47 Zarah (Tablet) ...... 39 Zyflo CR (Tablet Extended-Release 12 Hour) Wide-Seal Silicone Diaphragm Kit 90 ...... 47 Zavesca (Capsule) ...... 35 ...... 50 Wide-Seal Silicone Diaphragm Kit 95 ...... 47 Zazole (0.8% Cream, 80mg Suppository)..... 21 Zykadia (Capsule) ...... 23 WinRho SDF (Injection) ...... 41 Zebutal (Capsule) ...... 10 Zyprexa Relprevv (Injection) ...... 48 Womans Laxative (Tablet Delayed-Release) 36 Zelboraf (Tablet) ...... 23 Zytiga (Tablet) ...... 22 Womens Laxative (Tablet Delayed-Release) 36 Zemaira (Injection) ...... 51 Zyvox (200mg/100ml Injection)...... 15

Nondiscrimination Notice and Access to Communication Services

OptumRx and its family of affiliated Optum companies does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to

OptumRx Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344 Phone: 1-800-562-6223, TTY 711 Fax: 855-351-5495 Email: [email protected]

If you need help filing a complaint, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by phone, or by mail:

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card.

Multi-language Interpreter Services

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오.

PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card.

ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте.

تنبيه: إذا كنت تتحدث العربية )Arabic(، فإن خدمات المساعدة اللغوية المجانية متاحة لك. الرجاء االتصال على رقم الهاتف المجاني الموجود على معرّف العضوية.

ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w.

ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification.

UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej.

ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação.

ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa.

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an.

注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただけます。健康保険証に記載されているフリーダイヤルにお電話ください。

توجه: اگر زبان شما فارسی )Farsi( است، خدمات امداد زبانی به طور رايگان در اختيار شما می باشد. لطفا با شماره تلفن رايگانی که روی کارت شناسايی شما قيد شده تماس بگيريد.

दी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, नन:शु쥍क उपल녍ध हℂ। कृ पयाﴂ 鵍यान दᴂ: यदद आप ह अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करᴂ।

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.

(Khmer) ចំ㮶ប់讶រម្មណ 㟈 បបើសិន诒នកនិ架យ徶羶ខ្មមរ បស玶ជំនួយ徶羶បោយឥតគិតថ្លៃ គឺ掶នសំ殶ប់诒នក។ សូម្ទូរស័寒ទបៅបេមឥតគិតថ្លៃ ខ្ែេ掶នបៅបេើ诒តដសញ្ញាណប័ណណរបស់诒នក។ PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo.

DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti'go, saad bee áka'anída'awo'ígíí, t'áá jíík'eh, bee ná'ahóót'i'. T'áá shǫǫdí ninaaltsoos nitł'izí bee nééhozinígíí bine'dę́ę́' t'áá jíík'ehgo béésh bee hane'í biká'ígíí bee hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.

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