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Medicaid List of Covered Drugs (Formulary) ______HealthPartners HealthPartners® Families and Children* HealthPartners® MinnesotaCare HealthPartners® Inspire (SNBC) HealthPartners® Minnesota Senior Care Plus (MSC+)

HealthPartners® Families and Children/MinnesotaCare/SNBC counties: Aitkin, Anoka, Becker, Benton, Carlton, Carver, Cass, Chisago, Clay, Cook, Crow Wing, , Hennepin, Kittson, Koochiching, Lake, Mahnomen, Marshall, Mille Lacs, Norman, Otter Tail, Pennington, Pine, Polk, Ramsey, Red Lake, Roseau, Scott, St. Louis, Sherburne, Stearns, Washington, Wilkin, Wright

HealthPartners® MSC+ counties: Anoka, Benton, Carver, Chisago, Dakota, Hennepin, Ramsey, Scott, Sherburne, Stearns, Washington, Wright

HealthPartners 8170 33rd Ave. S. P.O. Box 1309 Bloomington, MN 55425 healthpartners.com/spp

Member Services: 952-967-7998 or 1-866-885-8880 (TTY 711) Monday – Friday, 8 a.m. to 6 p.m. CT

The information included in this list of covered drugs was correct as of 07/2021. To see the most current information, visit healthpartners.com/mhcpdruglist. If you have questions, contact Member Services at the number listed on this page. You can ask for a printed copy of this Medicaid List of Covered Drugs at any time.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Members must use HealthPartners network pharmacies to receive benefits.

This list is subject to change and is not all-inclusive. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. Note to existing members: This list of covered drugs has changed since last year and may change throughout the year. Please review this document to make sure the drugs you take are still on the list. Please contact Member Services at the number listed on this page with questions. You can also find updates to this list at healthpartners.com/mhcpdruglist.

If you have Medicare, you need to get most of your prescription drugs through the Medicare Prescription Drug Program (Medicare Part D). You must be enrolled in a Medicare prescription drug plan to get prescription drug benefits.

*This is also known as the Prepaid Medical Assistance Program (PMAP). Updated 07/2021 20-814858 HPCare_001020 DHS Approved 05/27/2021 1-866-885-8880 (TTY:711)

Attention. If you need free help interpreting this document, call the above number.

CB5 (MCOs) (5-2020)

Civil Rights Notice

Discrimination is against the law. HealthPartners does not discriminate on the basis of any of the following:

• Race • Public Assistance Status • Medical Condition • Color • Age • Health Status • National Origin • Disability (including physical or mental impairment) • Receipt of Health Care Services • Creed • Sex (including sex stereotypes and gender identity) • Claims Experience • Religion • Marital Status • Medical History • Sexual Orientation • Political Beliefs • Genetic Information

Auxiliary Aids and Services HealthPartners provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner to ensure an equal opportunity to participate in our health care programs. Contact 1-866-885-8880.

Language Assistance Services HealthPartners provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact 1-866-885- 8880.

Civil Rights Complaints You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by HealthPartners. You may contact any of the following three agencies directly to file a discrimination complaint.

U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following: • Race • National Origin • Disability • Religion (in some cases) • Color • Age • Sex

Contact the OCR directly to file a complaint: U.S. Department of Health and Human Services Office of Civil Rights 200 Independence Avenue SW Room 515F HHH Building Washington, DC 20201 Customer Response Center: Toll-free: 800-368-1019 TDD: 800-537-7697 Email: [email protected] Minnesota Department of Human Rights (MDHR) In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following:

• Race • Religion • Sexual Orientation • Public Assistance Status • Color • Creed • Marital Status • Disability • National Origin • Sex

Contact the MDHR directly to file a complaint: Minnesota Department of Human Rights 540 Fairview Avenue North Suite 201 St. Paul, MN 55104 651-539-1100 (voice) 800-657-3704 (toll free) 711 or 800-627-3529 (MN Relay) 651-296-9042 (fax) [email protected] (email)

Minnesota Department of Human Services (DHS) You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following: • Race • Age • Medical Condition • Color • Disability (including physical or • Health Status • National Origin mental impairment) • Receipt of Health Care Services • Creed • Sex (including sex stereotypes and • Claims Experience • Religion gender identity) • Medical History • Sexual Orientation • Marital Status • Genetic Information • Public Assistance Status • Political Beliefs

Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint.

DHS will notify you in writing of the investigation’s outcome. You have a right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome period. Be brief and state why you disagree with the decision. Include additional information you think is important.

If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administrative actions.

Contact DHS directly to file a discrimination complaint: Civil Rights Coordinator Minnesota Department of Human Services Equal Opportunity and Access Division P.O. Box 64997 St. Paul, MN 55164-0997 651-431-3040 (voice) or use your preferred relay service

HealthPartners Complaint Notice You have the right to file a complaint with HealthPartners if you believe you have been discriminated against because of any of the following: • Medical Condition • Sex (including sex stereotypes and gender identity) • Health Status • Sexual Orientation • Receipt of Health Care Services • National Origin • Claims Experience • Race • Medical History • Color • Genetic Information • Religion • Disability (including physical or mental impairment) • Creed • Marital Status • Public Assistance Status • Age • Political Beliefs

You can file a complaint and ask for help in filing a complaint in person or by mail, phone, fax, or email at: Civil Rights Coordinator Office of Integrity and Compliance, MS 21103K HealthPartners P.O. Box 1309 Minneapolis, MN 55440-1309 1-844-363-8732 (toll free), 711 (TTY), 952-883-5522 (fax) [email protected] (email)

American Indian Health Statement American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.

Table of Contents

Important Information…………………...... ………………………………………………………………………………………………….2

List of Covered Drugs……………………………………………………………………………….……………………………………………….………...7

Index of Covered Drugs………………………………………………………………………….…………………………………………………….....279

______1

IMPORTANT INFORMATION

What is a list of covered drugs? A list of covered drugs includes the prescription drugs covered by HealthPartners. The drugs on the list are selected by HealthPartners with the help of a team of doctors and pharmacists. HealthPartners will generally cover the drugs listed in the list of covered drugs as long as the drug is medically necessary, the prescription is filled at a HealthPartners network pharmacy, and other requirements related to the drug are followed.

Does the list of covered drugs ever change? The HealthPartners list of covered drugs can change during the course of a calendar year. If changes affect the coverage of a drug you are taking, HealthPartners will make reasonable efforts to contact you and your prescriber to tell you about the change. HealthPartners will also tell you about alternative drugs that are covered.

Examples of some changes that may occur are:

• A drug you are taking is no longer preferred. (See “What is a Preferred Drug List?” below.) • A drug is removed from the list of covered drugs for safety reasons. • Prior authorization requirements have changed. (See “Are there any restrictions on my coverage?”)

How are drugs listed in the list of covered drugs? There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or

• You can search by drug type.

To search alphabetically, go to the Index of Covered Drugs section. You can find it in the back of this book. The Index of Covered Drugs is an alphabetical list of all of the drugs included in the Drug List. Brand name drugs, generic drugs, and over-the-counter (OTC) drugs are listed in the index.

To search by drug type, find the list of covered drugs starting on page 7. The drugs in this section are grouped into categories by type. A category starts with a title in a gray row. Drugs are listed below the category. For example, if you are taking a for , you should look in the “Antimigraine Agents” category title in gray. That is where you will find drugs that treat migraines.

What is a Preferred Drug List? In Minnesota, all health plans are required to use the Department of Human Services’ (DHS) Preferred Drug List (PDL). The PDL is created by DHS, in consultation with the Drug Formulary Committee, to let prescribers and members know about drugs or drug classes that are cost effective. Generally, drugs that are “preferred” are more cost effective and drugs that are “non-preferred” are less cost effective. Preferred drugs are available to members with fewer restrictions. Non-preferred drugs require a prior authorization. To get a non-preferred drug, your doctor or health care provider must get prior authorization. The PDL is included as part of HealthPartners’ list of covered drugs. HealthPartners’ complete list of covered drugs includes other drugs in addition to those on the PDL. The PDL is available on DHS’s website at http://minnesota.magellanmedicaid.com/pdl.asp.

______2 What are generic or biosimilar drugs? A is approved by the and Drug Administration (FDA) and has the same active ingredients as the brand name drug. It produces the same clinical effect as the brand name drug.

A biosimilar drug is an FDA-approved biologic drug (most often an injectable prescription drug) that is highly similar to an already-approved biological product. It has no clinically meaningful differences in terms of safety and effectiveness. Biosimilar drugs are not the same as generic drugs, but like generics, biosimilar drugs may offer more affordable treatment options.

Generic or biosimilar substitution means a generic version or biosimilar version of a drug is given instead of the brand name or non-biosimilar version of the drug.

HealthPartners will cover the brand name or non-biosimilar version of the drug only when: 1. Your prescriber informs HealthPartners in writing that the brand name or non-biosimilar version of the drug is medically necessary; OR 2. HealthPartners may prefer the dispensing of certain brand name version over the generic or non- biosimilar version over the biosimilar version of the drug; OR 3. Minnesota law requires the dispensing of the brand name or non-biosimilar version of the drug.

Within the list of covered drugs, brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lowercase italics (e.g., atorvastatin).

What are over-the-counter drugs? Drugs and products that are available for purchase without a prescription are referred to as over-the-counter (OTC). Although an OTC product is available without a prescription, if a doctor writes a prescription for an OTC product, HealthPartners may cover it. Within the list of covered drugs, OTC drugs and products are marked with an OTC symbol.

What are specialty drugs? Specialty drugs are used by people with complex or chronic diseases. These drugs often require special handling, dispensing, or monitoring by a specially trained pharmacist.

If you are prescribed a drug that is on the HealthPartners Specialty Drug List, your prescriber will need to send the prescription to one of HealthPartners’ specialty pharmacies listed here.

Name of Specialty Pharmacy: & Hemophilia Fairview Specialty Pharmacy Phone: 612-672-5260 Toll-free: 1-800-595-7140 TTY: 711 Fax: 1-866-347-4939 Hours of Operation: Mon-Fri: 8 a.m. – 7 p.m. (CST) *call center only Sat: 8 a.m. – 4 p.m. (CST) *call center only Sun: Closed On-site prescription pick-up Mon-Fri: 8 a.m. - 4 p.m. (CST) Sat: Closed Sun: Closed https://www.fairview.org/services/specialty-pharmacy

______3 Name of Specialty Pharmacy: Hemophilia Medications Fairview Pharmacy – Center for and Clotting Disorders Phone: 612-273-5006 Toll-free: 1-833-310-1499 TTY: 711 Fax: 612-273-5010 Hours of Operation: Mon-Fri: 8:30 a.m. – 4:30 p.m. (CST) Sat: Closed Sun: Closed

Name of Specialty Pharmacy: Cystic Fibrosis & Hemophilia Medications Children’s Home Care Pharmacy Phone: 612-813-7206 Toll-free: 1-866-656-1020 TTY: 711 Fax: 612-813-7207 Hours of Operation: Mon-Fri: 8 a.m. – 4:30 p.m. (CST) Sat: Closed Sun: Closed

Name of Specialty Pharmacy: Pulmonary Arterial (PAH) Accredo Specialty Pharmacy Phone: 1-866-344-4874 TTY: 711 Fax: 1-888-302-1028 Hours of Operation: Mon-Fri: 7 a.m. – 10 p.m. (CST) Sat: 7 a.m. – 4:30 p.m. (CST) Sun: Closed https://www.accredo.com

All other specialty medications Name of Specialty Pharmacy: CVS Caremark Specialty Pharmacy Phone: 1-800-368-1624 TTY: 711 Fax: 1-800-441-5809 Hours of Operation: Mon-Fri: 9 a.m. – 9 p.m. CST Sat: 10 a.m. – 2 p.m. CST Sun: Closed https://www.cvsspecialty.com/wps/portal/specialty

You will also need to call the specialty pharmacy where your prescription is sent to set up an account. You will need to have your HealthPartners member identification card when you call the specialty pharmacy.

______4 What if a drug is not on the list of covered drugs? Not all drugs are covered. If a drug you want to take is not listed in the list of covered drugs, you can call Member Services at 952-967-7998 or 1-866-885-8880, TTY 711, and ask if the drug is covered. If not, it is considered a “non-formulary” drug. If you need a drug that is not included in the list of covered drugs, you can ask HealthPartners to make an exception to cover it. You can also ask us to change the rules on your drug. For example, HealthPartners may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. You can also ask us to drop step therapy restrictions or prior authorization requirements.

To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. Once a complete request is submitted by your provider, we will give you a decision on your exception request within 24 hours.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include the following:

● Prior authorization: HealthPartners requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from HealthPartners before you fill your prescription. If you don’t get approval, HealthPartners may not cover the drug.

● Quantity limits: For certain drugs, HealthPartners limits the amount of the drug that we will cover.

● Age requirements: Some drugs have age requirements. A prior authorization may be needed depending on your age and the specific drug prescribed.

You can find out if your drug requires prior authorization, has quantity limits, or has an age requirement by looking in this list of covered drugs. An exception to a drug restriction or limit can be made if your doctor submits a statement or documentation supporting the request. See Section 7: Covered Services (Prescription Drugs) in your Member Handbook for more information. You can also get more information about the restrictions applied to specific covered drugs by calling Member Services at 952-967-7998 or 1-866-885-8880, TTY 711, or by visiting our website at healthpartners.com/mhcpdruglist. Also see “Can I ask for an exception to the coverage restrictions?”

● Excluded drugs: Some drugs are excluded from the list of covered drugs. This means they are not covered. Excluded drugs include the following: • Drugs used to treat sexual or • Drugs used to enhance fertility • Drugs used for cosmetic purposes, including drugs to treat hair loss • Drugs or products to promote weight loss • Drugs not clinically proven to be effective • Investigational or experimental drugs • Medical

______5 Can I ask for an exception to the coverage restrictions? Yes. You or your health care provider can get the Pharmacy Administration – Prior Authorization/Exception Form from https://www.healthpartners.com/hp/pharmacy/forms/index.html or by calling Member Services at 952-967-7998 or 1-866-885-8880, TTY 711. Your provider must return this form to the fax number or address listed on the document. To allow for a thorough review and to ensure that you or your health care provider gets a response within 24 hours, all information requested in the form should be provided, including documentation of which medications have been tried and failed, including the dosages used, and the reason for failure (e.g. side effects).

What will a prescription cost? All copay information for prescriptions is listed in the Member Handbook in Section 6: Cost-Sharing. If you have additional questions, call Member Services at 952-967-7998 or 1-866-885-8880, TTY 711, or visit our website at healthpartners.com/mhcpdruglist.

______6 LEGEND TYPE DESCRIPTION

P Preferred Drug

NP Non-Preferred Drug

C Covered

TYPE DESCRIPTION

There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame.

You (or your physician) are required to get prior authorization before PA Prior Authorization you fill your prescription for this drug. Without prior approval, we may not cover this drug.

In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before we will cover another drug for that condition.

This prescription drug may only be covered if you meet the minimum AL1 Age Limit or maximum age limit.

Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions, such as , , C, and hemophilia.

There is a limit on the amount of drug covered per prescription, or AQ1 Age Quantity Limit within a specific time frame. Must also fall into the specified age range.

Medicines marked with this symbol are in a trial drug program. The first 6 fills may be limited to less than a month supply. If tolerated and TD Trial Drug effective you will receive the remainder of the supply and pay no more than one copay for each full month supply.

Medicines marked with this symbol may be covered under your medical benefit. Go to MED Medical Drug https://www.healthpartners.com/public/coverage-criteria/ for medical benefit criteria or log on to your secure account.

New users will be limited to a 7 days supply for their first fill, and a total of 14 days supply for each episode. Longer therapy requires OP Program prior authorization: Provider attestation, that therapy for this patient is being managed per standard opioid prescribing guidelines, including assessment and documentation of risk factors for chronic opioid use.

PAGE 7 LAST UPDATED 07/2021 Oncology () medicines must be filled at a specialty pharmacy, ONC Oncology but are not subject to the specialty benefit. Your regular generic or brand pharmacy copay or coinsurance will apply.

OTC OTC Drugs Medicines marked with this symbol are considered over the counter

PAGE 8 LAST UPDATED 07/2021 LIST OF COVERED PRESCRIPTION MEDICATIONS

DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ALPHA- BLOCKING AGENT(SYMPATH)

NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

hcl C PA

SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT

hcl er P FLOMAX PA hcl NP RAPAFLO PA NP

silodosin NP PA

tamsulosin hcl P UROXATRAL PA alfuzosin hcl NP AND ANTIPYRETICS

ANALGESICS AND ANTIPYRETICS, MISC.

8 HOUR RELIEF OTC acetaminophen C 8HR ARTHRITIS PAIN OTC acetaminophen C

acetaminophen 120 mg suppos C OTC

acetaminophen 160 mg rapid tab C OTC

acetaminophen 160 mg/5 ml elix C OTC

acetaminophen 160 mg/5 ml liq C OTC

acetaminophen 160 mg/5 ml sol C OTC

acetaminophen 160 mg/5 ml susp C OTC

acetaminophen 325 mg gelcap C OTC

acetaminophen 325 mg C OTC

acetaminophen 500 mg caplet C OTC

acetaminophen 500 mg gelcap C OTC

PAGE 9 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

acetaminophen 500 mg tablet C OTC

acetaminophen 650 mg suppos C OTC

acetaminophen 80 mg rapid tab C OTC

acetaminophen er C OTC

ARTHRITIS PAIN ER 650 MG CAPLT OTC acetaminophen C ARTHRITIS PAIN RELF ER 650 MG OTC acetaminophen C

butalb-acetamin-caff 50-325-40 C QL 6 TABS / 1 DAY

-acetaminophn 50-325 C QL 6 TABS / 1 DAY

CHILD REDUCER OTC acetaminophen C

CHILD FEVER REDUCER-PAIN RELVR C OTC

CHILD PAIN RLF 160 MG/5 ML ELX C OTC

CHILD 160 MG POWD PKT acetaminophen C

children's acetaminophen C OTC

CHILDREN'S AUROPHEN PAIN-FEVER C OTC

CHILDREN'S FEVER REDUCER OTC acetaminophen C

CHILDREN'S PAIN-FEVER C OTC

cvs acetaminophen 325 mg gelcp C OTC

cvs acetaminophen 500 mg cplt C OTC

cvs acetaminophen 500 mg tab C OTC

cvs acetaminophen 500 mg/15 ml C OTC

CVS ARTHRIT PAIN RLF ER 650 MG OTC acetaminophen C

CVS PAIN RELIEVER 500 MG CPLT C OTC

EQ ARTHRITIS PAIN ER 650 MG OTC acetaminophen C EQL ARTHRIT PAIN RLF ER 650 MG OTC acetaminophen C

PAGE 10 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS FEVERALL OTC acetaminophen C

gnp acetaminophen 325 mg gelcp C OTC

gnp acetaminophen 500 mg tab C OTC

GNP ARTHRIT PAIN RLF ER 650 MG C OTC

GNP PAIN RELIEVER 500 MG CAPLT C OTC

GNP PAIN RELIEVER 500 MG TAB C OTC

GRALISE 30-DAY STARTER PACK QL 1 RX / YEAR NP PA

GRALISE ER 300 MG TABLET QL 1 TAB / 1 DAY NP gabapentin PA

GRALISE ER 600 MG TABLET QL 3 TABS / 1 DAY NP gabapentin PA

GS ARTHRITIS PAIN ER 650 MG OTC acetaminophen C HM ARTHRIT PAIN RLF ER 650 MG OTC acetaminophen C HM ARTHRITIS PAIN ER 650 MG OTC acetaminophen C

HM PAIN RELIEF 325 MG TABLET C OTC

HM PAIN RELIEF 500 MG GELCAP C OTC

HM PAIN RELIEF 500 MG TABLET C OTC

HM PAIN RELIEF ER 650 MG CPLT OTC acetaminophen C

HM PAIN RELIEVER 500 MG TABLET C OTC

INFANTS' PAIN-FEVER C OTC

JR PAIN & FEVER C OTC

kro acetaminophen 325 mg tab C OTC

KRO ARTHRIT PAIN RLF ER 650 MG OTC acetaminophen C

LYRICA CR 165 MG TABLET QL 1 TAB / 1 DAY NP PA

PAGE 11 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

LYRICA CR 330 MG TABLET QL 2 TABS / 1 DAY NP pregabalin PA

LYRICA CR 82.5 MG TABLET QL 1 TAB / 1 DAY NP pregabalin PA

M-PAP C OTC

MAPAP 500 MG C OTC

MAPAP 500 MG/15 ML C OTC

NON- CHILD'S DROPS C OTC

PAIN RELIEF 160 MG/5 ML LIQUID C OTC

PAIN RELIEF 325 MG TABLET C OTC

PAIN RELIEF ADULT C OTC

PAIN RELIEF EXTRA STRENGTH C OTC

PAIN RELIEVER 500 MG CAPLET C OTC

PAIN RELIEVER 500 MG GELCAP C OTC

PAIN RELIEVER 500 MG TABLET C OTC

PAIN RELIEVER ADULT C OTC

PUB ARTHRITIS PAIN ER 650 MG OTC acetaminophen C QC ARTHRITIS PAIN ER 650 MG OTC acetaminophen C

ra acetaminophen 325 mg tablet C OTC

RA ARTHRITIS PAIN ER 650 MG C OTC

SILAPAP C OTC

SM ARTHRIT PAIN RLF ER 650 MG OTC acetaminophen C SM ARTHRITIS PAIN ER 650 MG OTC acetaminophen C

SM ARTHRITIS PAIN RELF ER 650 C OTC

SM PAIN RELIEVER 500 MG CAPLET C OTC

PAGE 12 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

SM PAIN RELIEVER 500 MG GELCAP C OTC

SM PAIN RELIEVER 500 MG TABLET C OTC

TENCON QL 6 TABS / 1 DAY butalbital/acetaminophen C ZEBUTAL QL 6 CAPS / 1 DAY butalbital/acetaminophen/ C

AQ1 At least 12 yrs old; 60 / acetamin-codein 300-30 mg/12.5 C 1 DAY OP

QL 40 ML / 1 DAY

acetaminop- 120-12 mg/5 C AQ1 At least 12 yrs old; 60 / 1 DAY OP

AQ1 At least 12 yrs old; 8 / acetaminophen-cod #2 tablet C 1 DAY OP

AQ1 At least 12 yrs old; 8 / acetaminophen-cod #3 tablet C 1 DAY OP

AQ1 At least 12 yrs old; 8 / acetaminophen-cod #4 tablet C 1 DAY OP

AQ1 At least 12 yrs old; 8 / codeine sulfate C 1 DAY OP

QL 10 PATCHES / 30 DURAGESIC DAYS NP PA

EMBEDA ER 100-4 MG CAPSULE QL 1 CAP / 1 DAY NP sulfate/ hcl PA

EMBEDA ER 20-0.8 MG CAPSULE QL 4 CAPS / 1 DAY NP morphine sulfate/naltrexone hcl PA

EMBEDA ER 30-1.2 MG CAPSULE QL 2 CAPS / 1 DAY NP morphine sulfate/naltrexone hcl PA

PAGE 13 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

EMBEDA ER 50-2 MG CAPSULE QL 1 CAP / 1 DAY NP morphine sulfate/naltrexone hcl PA

EMBEDA ER 60-2.4 MG CAPSULE QL 1 CAP / 1 DAY NP morphine sulfate/naltrexone hcl PA

EMBEDA ER 80-3.2 MG CAPSULE QL 1 CAP / 1 DAY NP morphine sulfate/naltrexone hcl PA

ENDOCET 10-325 MG TABLET QL 5 TABS / 1 DAY C hcl/acetaminophen OP

ENDOCET 5-325 TABLET QL 8 TABS / 1 DAY C oxycodone hcl/acetaminophen OP

ENDOCET 7.5-325 MG TABLET QL 7 TABS / 1 DAY C oxycodone hcl/acetaminophen OP

QL 10 PATCHES / 30 fentanyl 100 mcg/hr patch NP DAYS PA

QL 10 PATCHES / 30 fentanyl 12 mcg/hr patch NP DAYS PA

QL 10 PATCHES / 30 fentanyl 25 mcg/hr patch P DAYS PA

QL 10 PATCHES / 30 fentanyl 37.5 mcg/hr patch NP DAYS PA

QL 10 PATCHES / 30 fentanyl 50 mcg/hr patch P DAYS PA

QL 10 PATCHES / 30 fentanyl 62.5 mcg/hr patch NP DAYS PA

QL 10 PATCHES / 30 fentanyl 75 mcg/hr patch NP DAYS PA

QL 10 PATCHES / 30 fentanyl 87.5 mcg/hr patch NP DAYS PA

PAGE 14 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 8 TABS / 1 DAY -acetamin 10-325 mg C OP

QL 120 ML / 1 DAY hydrocodone-acetamin 2.5-108/5 C OP

QL 120 ML / 1 DAY hydrocodone-acetamin 5-217/10 C OP

QL 8 TABS / 1 DAY hydrocodone-acetamin 5-325 mg C OP

QL 8 TABS / 1 DAY hydrocodone-acetamin 7.5-325 C OP

QL 120 ML / 1 DAY hydrocodone-acetamn 7.5-325/15 C OP

QL 8 TABS / 1 DAY hydrocodone- 7.5-200 C OP

QL 20 ML / 1 DAY 1 mg/ml C OP

QL 8 TABS / 1 DAY hydromorphone 2 mg tablet C OP

QL 4 SUPP / 1 DAY hydromorphone 3 mg suppos C OP

QL 5 TABS / 1 DAY hydromorphone 4 mg tablet C OP

QL 20 ML / 1 DAY hydromorphone 5 mg/5 ml soln C OP

QL 2 TABS / 1 DAY hydromorphone 8 mg tablet C OP

QL 1 TAB / 1 DAY hydromorphone hcl er 12 mg tab NP PA

QL 2 TABS / 1 DAY hydromorphone hcl er 16 mg tab NP PA

PAGE 15 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 TAB / 1 DAY hydromorphone hcl er 32 mg tab NP PA

QL 4 TABS / 1 DAY hydromorphone hcl er 8 mg tab NP PA

HYSINGLA ER 100 MG TABLET PA hydrocodone bitartrate NP HYSINGLA ER 120 MG TABLET PA hydrocodone bitartrate NP

HYSINGLA ER 20 MG TABLET QL 4 TABS / 1 DAY NP hydrocodone bitartrate PA

HYSINGLA ER 30 MG TABLET QL 2 TABS / 1 DAY NP hydrocodone bitartrate PA

HYSINGLA ER 40 MG TABLET QL 2 TABS / 1 DAY NP hydrocodone bitartrate PA

HYSINGLA ER 60 MG TABLET QL 1 TAB / 1 DAY NP hydrocodone bitartrate PA

HYSINGLA ER 80 MG TABLET QL 1 TAB / 1 DAY NP hydrocodone bitartrate PA

KADIAN ER 10 MG CAPSULE QL 4 CAPS / 1 DAY NP morphine sulfate PA

KADIAN ER 100 MG CAPSULE QL 1 CAP / 1 DAY NP morphine sulfate PA

KADIAN ER 20 MG CAPSULE QL 4 CAPS / 1 DAY NP morphine sulfate PA

KADIAN ER 200 MG CAPSULE QL 1 CAP / 1 DAY NP morphine sulfate PA

KADIAN ER 30 MG CAPSULE QL 2 CAPS / 1 DAY NP morphine sulfate PA

KADIAN ER 40 MG CAPSULE QL 2 CAPS / 1 DAY NP morphine sulfate PA

KADIAN ER 50 MG CAPSULE QL 1 CAP / 1 DAY NP morphine sulfate PA

PAGE 16 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

KADIAN ER 60 MG CAPSULE QL 1 CAP / 1 DAY NP morphine sulfate PA

KADIAN ER 80 MG CAPSULE QL 1 CAP / 1 DAY NP morphine sulfate PA

LORCET QL 8 TABS / 1 DAY C hydrocodone bitartrate/acetaminophen OP

LORCET HD QL 8 TABS / 1 DAY C hydrocodone bitartrate/acetaminophen OP

LORCET PLUS QL 8 TABS / 1 DAY C hydrocodone bitartrate/acetaminophen OP

QL 10 ML / 1 DAY 10 mg/5 ml solution C PA

QL 2 ML / 1 DAY methadone 10 mg/ml oral conc C PA

QL 1 TAB / 1 DAY methadone 40 mg tablet dispr NP PA

QL 20 ML / 1 DAY methadone 5 mg/5 ml solution C PA

QL 2 TABS / 1 DAY methadone hcl 10 mg tablet NP PA

QL 4 TABS / 1 DAY methadone hcl 5 mg tablet NP PA

METHADONE INTENSOL QL 2 ML / 1 DAY C methadone hcl PA

METHADOSE 40 MG TABLET DISPR QL 1 TAB / 1 DAY C methadone hcl PA

MORPHABOND ER 100 MG TABLET PA morphine sulfate NP

MORPHABOND ER 15 MG TABLET QL 5 TABS / 1 DAY NP morphine sulfate PA

PAGE 17 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

MORPHABOND ER 30 MG TABLET QL 2 TABS / 1 DAY NP morphine sulfate PA

MORPHABOND ER 60 MG TABLET PA morphine sulfate NP

QL 6 SUPP / 1 DAY morphine sulf 10 mg suppos C OP

QL 30 ML / 1 DAY morphine sulf 10 mg/5 ml soln C OP

QL 4 ML / 1 DAY morphine sulf 100 mg/5 ml conc C OP

QL 6 SUPP / 1 DAY morphine sulf 20 mg suppos C OP

QL 20 ML / 1 DAY morphine sulf 20 mg/5 ml soln C OP

QL 6 SUPP / 1 DAY morphine sulf 30 mg suppos C OP

QL 6 SUPP / 1 DAY morphine sulf 5 mg suppos C OP

QL 1 TAB / 1 DAY morphine sulf er 100 mg tablet P PA

QL 4 TABS / 1 DAY morphine sulf er 15 mg tablet P PA

QL 1 TAB / 1 DAY morphine sulf er 200 mg tablet P PA

QL 2 TABS / 1 DAY morphine sulf er 30 mg tablet P PA

QL 1 TAB / 1 DAY morphine sulf er 60 mg tablet P PA

QL 4 CAPS / 1 DAY morphine sulfate er 10 mg cap NP PA

PAGE 18 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 CAP / 1 DAY morphine sulfate er 100 mg cap NP PA

QL 1 CAP / 1 DAY morphine sulfate er 120 mg cap NP PA

QL 4 CAPS / 1 DAY morphine sulfate er 20 mg cap NP PA

QL 2 CAPS / 1 DAY morphine sulfate er 30 mg cap NP PA

QL 2 CAPS / 1 DAY morphine sulfate er 40 mg cap NP PA

QL 1 CAP / 1 DAY morphine sulfate er 45 mg cap NP PA

QL 1 CAP / 1 DAY morphine sulfate er 50 mg cap NP PA

QL 1 CAP / 1 DAY morphine sulfate er 60 mg cap NP PA

QL 1 CAP / 1 DAY morphine sulfate er 75 mg cap NP PA

QL 1 CAP / 1 DAY morphine sulfate er 80 mg cap NP PA

QL 1 CAP / 1 DAY morphine sulfate er 90 mg cap NP PA

QL 5 TABS / 1 DAY morphine sulfate ir 15 mg tab C OP

MORPHINE SULFATE IR 15 MG TAB (BRAND) QL 5 TABS / 1 DAY C morphine sulfate OP

QL 2 TABS / 1 DAY morphine sulfate ir 30 mg tab C OP

MORPHINE SULFATE IR 30 MG TAB (BRAND) QL 2 TABS / 1 DAY C morphine sulfate OP

PAGE 19 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

MS CONTIN ER 100 MG TABLET QL 1 TAB / 1 DAY NP morphine sulfate PA

MS CONTIN ER 15 MG TABLET QL 4 TABS / 1 DAY NP morphine sulfate PA

MS CONTIN ER 200 MG TABLET QL 1 TAB / 1 DAY NP morphine sulfate PA

MS CONTIN ER 30 MG TABLET QL 2 TABS / 1 DAY NP morphine sulfate PA

MS CONTIN ER 60 MG TABLET QL 1 TAB / 1 DAY NP morphine sulfate PA

NUCYNTA ER 100 MG TABLET QL 2 TABS / 1 DAY NP hcl PA

NUCYNTA ER 150 MG TABLET QL 2 TABS / 1 DAY NP tapentadol hcl PA

NUCYNTA ER 200 MG TABLET QL 2 TABS / 1 DAY NP tapentadol hcl PA

NUCYNTA ER 250 MG TABLET QL 2 TABS / 1 DAY NP tapentadol hcl PA

NUCYNTA ER 50 MG TABLET QL 4 TABS / 1 DAY NP tapentadol hcl PA

QL 5 TABS / 1 DAY oxycodone hcl 10 mg tablet C OP

QL 2 ML / 1 DAY oxycodone hcl 100 mg/5 ml conc C OP

QL 3 TABS / 1 DAY oxycodone hcl 15 mg tablet C OP

QL 2 TABS / 1 DAY oxycodone hcl 20 mg tablet C OP

QL 2 TABS / 1 DAY

oxycodone hcl 30 mg tablet C PA

OP

PAGE 20 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 8 CAPS / 1 DAY oxycodone hcl 5 mg capsule C OP

QL 8 TABS / 1 DAY oxycodone hcl 5 mg tablet C OP

QL 40 ML / 1 DAY oxycodone hcl 5 mg/5 ml soln C OP

QL 4 TABS / 1 DAY oxycodone hcl er 10 mg tablet NP PA

QL 3 TABS / 1 DAY oxycodone hcl er 15 mg tablet NP PA

QL 2 TABS / 1 DAY oxycodone hcl er 20 mg tablet NP PA

QL 2 TABS / 1 DAY oxycodone hcl er 30 mg tablet NP PA

QL 2 TABS / 1 DAY oxycodone hcl er 40 mg tablet NP PA

QL 2 TABS / 1 DAY oxycodone hcl er 60 mg tablet NP PA

QL 2 TABS / 1 DAY oxycodone hcl er 80 mg tablet NP PA

QL 8 TABS / 1 DAY oxycodone hcl-aspirin C OP

QL 5 TABS / 1 DAY oxycodone-acetaminophen 10-325 C OP

QL 8 TABS / 1 DAY oxycodone-acetaminophen 5-325 C OP

QL 7 TABS / 1 DAY oxycodone-acetaminophn 7.5-325 C OP

OXYCONTIN ER 10 MG TABLET QL 4 TABS / 1 DAY NP oxycodone hcl PA

PAGE 21 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

OXYCONTIN ER 15 MG TABLET QL 3 TABS / 1 DAY NP oxycodone hcl PA

OXYCONTIN ER 20 MG TABLET QL 2 TABS / 1 DAY NP oxycodone hcl PA

OXYCONTIN ER 30 MG TABLET QL 2 TABS / 1 DAY NP oxycodone hcl PA

OXYCONTIN ER 40 MG TABLET QL 2 TABS / 1 DAY NP oxycodone hcl PA

OXYCONTIN ER 60 MG TABLET QL 2 TABS / 1 DAY NP oxycodone hcl PA

OXYCONTIN ER 80 MG TABLET QL 2 TABS / 1 DAY NP oxycodone hcl PA

QL 2 TABS / 1 DAY hcl er 10 mg tab NP PA

QL 2 TABS / 1 DAY oxymorphone hcl er 15 mg tab NP PA

QL 2 TABS / 1 DAY oxymorphone hcl er 20 mg tab NP PA

QL 2 TABS / 1 DAY oxymorphone hcl er 30 mg tab NP PA

QL 2 TABS / 1 DAY oxymorphone hcl er 40 mg tab NP PA

QL 4 TABS / 1 DAY oxymorphone hcl er 5 mg tablet NP PA

QL 3 TABS / 1 DAY oxymorphone hcl er 7.5 mg tab NP PA

QL 8 TABS / 1 DAY

hcl 50 mg tablet C AL1 At least 12 yrs old

OP

PAGE 22 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

XTAMPZA ER QL 2 CAPS / 1 DAY NP oxycodone myristate PA

QL 4 CAPS / 1 DAY ZOHYDRO ER 10 MG CAPSULE PA hydrocodone bitartrate NP OP

QL 4 CAPS / 1 DAY ZOHYDRO ER 15 MG CAPSULE PA hydrocodone bitartrate NP OP

QL 4 CAPS / 1 DAY ZOHYDRO ER 20 MG CAPSULE PA hydrocodone bitartrate NP OP

QL 2 CAPS / 1 DAY ZOHYDRO ER 30 MG CAPSULE PA hydrocodone bitartrate NP OP

QL 2 CAPS / 1 DAY ZOHYDRO ER 40 MG CAPSULE PA hydrocodone bitartrate NP OP

QL 1 CAP / 1 DAY ZOHYDRO ER 50 MG CAPSULE PA hydrocodone bitartrate NP OP

OPIATE PARTIAL AGONISTS

BELBUCA 150 MCG FILM QL 4 FILMS / 1 DAY P hcl PA

BELBUCA 300 MCG FILM QL 4 FILMS / 1 DAY P buprenorphine hcl PA

BELBUCA 450 MCG FILM QL 4 FILMS / 1 DAY P buprenorphine hcl PA

BELBUCA 600 MCG FILM QL 3 FILMS / 1 DAY P buprenorphine hcl PA

BELBUCA 75 MCG FILM QL 4 FILMS / 1 DAY P buprenorphine hcl PA

PAGE 23 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

BELBUCA 750 MCG FILM QL 2 FILMS / 1 DAY P buprenorphine hcl PA

BELBUCA 900 MCG FILM QL 2 FILMS / 1 DAY P buprenorphine hcl PA

BUNAVAIL 2.1-0.3 MG FILM QL 6 FILMS / 1 DAY NP buprenorphine hcl/ hcl PA

BUNAVAIL 4.2-0.7 MG FILM QL 3 FILMS / 1 DAY NP buprenorphine hcl/naloxone hcl PA

BUNAVAIL 6.3-1 MG FILM QL 2 FILMS / 1 DAY NP buprenorphine hcl/naloxone hcl PA

QL 4 PATCHES / 28 buprenorphine NP DAYS PA

QL 12 TABS / 1 DAY buprenorphine 2 mg tablet sl NP PA

QL 3 TABS / 1 DAY buprenorphine 8 mg tablet sl NP PA

QL 2 FILMS / 1 DAY buprenorphine-nalox 12-3mg flm NP PA

QL 3 FILMS / 1 DAY buprenorphine-nalox 2-0.5mg fm NP PA

buprenorphine-nalox 2-0.5mg tb P QL 3 TABS / 1 DAY

QL 3 FILMS / 1 DAY buprenorphine-nalox 4-1mg film NP PA

buprenorphine-nalox 8-2 mg tab P QL 3 TABS / 1 DAY

QL 3 FILMS / 1 DAY buprenorphine-nalox 8-2mg film NP PA

PROBUPHINE PA buprenorphine hcl NP SUBLOCADE PA buprenorphine NP

PAGE 24 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SUBOXONE 12 MG-3 MG SL FILM QL 2 FILMS / 1 DAY buprenorphine hcl/naloxone hcl P SUBOXONE 2 MG-0.5 MG SL FILM QL 3 FILMS / 1 DAY buprenorphine hcl/naloxone hcl P SUBOXONE 4 MG-1 MG SL FILM QL 3 FILMS / 1 DAY buprenorphine hcl/naloxone hcl P SUBOXONE 8 MG-2 MG SL FILM QL 3 FILMS / 1 DAY buprenorphine hcl/naloxone hcl P

ZUBSOLV 0.7-0.18 MG TABLET SL QL 12 TABS / 1 DAY NP buprenorphine hcl/naloxone hcl PA

ZUBSOLV 1.4-0.36 MG TABLET SL QL 12 TABS / 1 DAY NP buprenorphine hcl/naloxone hcl PA

ZUBSOLV 11.4-2.9 MG TABLET SL QL 1 TAB / 1 DAY NP buprenorphine hcl/naloxone hcl PA

ZUBSOLV 2.9-0.71 MG TABLET SL QL 4 TABS / 1 DAY NP buprenorphine hcl/naloxone hcl PA

ZUBSOLV 5.7-1.4 MG TABLET SL QL 3 TABS / 1 DAY NP buprenorphine hcl/naloxone hcl PA

ZUBSOLV 8.6-2.1 MG TABLET SL QL 2 TABS / 1 DAY NP buprenorphine hcl/naloxone hcl PA

ANOREXIGENICS;RESPIRATORY,CNS

AMPHETAMINES

ADDERALL XR sulf-saccharate/ sulf- P QL 2 CAPS / 1 DAY aspartate

ADZENYS ER QL 15 ML / 1 DAY NP amphetamine PA

ADZENYS XR-ODT 12.5 MG TABLET QL 1 TAB / 1 DAY NP amphetamine PA

ADZENYS XR-ODT 15.7 MG TABLET QL 1 TAB / 1 DAY NP amphetamine PA

ADZENYS XR-ODT 18.8 MG TABLET QL 1 TAB / 1 DAY NP amphetamine PA

PAGE 25 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

ADZENYS XR-ODT 3.1 MG TABLET QL 2 TABS / 1 DAY NP amphetamine PA

ADZENYS XR-ODT 6.3 MG TABLET QL 2 TABS / 1 DAY NP amphetamine PA

ADZENYS XR-ODT 9.4 MG TABLET QL 2 TABS / 1 DAY NP amphetamine PA

QL 15 ML / 1 DAY amphetamine NP PA

QL 6 TABS / 1 DAY amphetamine sulfate 10 mg tab NP PA

QL 4 TABS / 1 DAY amphetamine sulfate 5 mg tab NP PA

DEXEDRINE QL 4 CAPS / 1 DAY NP dextroamphetamine sulfate PA

dextroamp-amphetam 12.5 mg tab P QL 3 TABS / 1 DAY

dextroamp-amphetam 7.5 mg tab P QL 3 TABS / 1 DAY

dextroamp-amphetamin 10 mg tab P QL 3 TABS / 1 DAY

DEXTROAMP-AMPHETAMIN 15 MG TAB (Generic ) P QL 3 TABS / 1 DAY

DEXTROAMP-AMPHETAMIN 20 MG TAB (Generic Adderall) P QL 3 TABS / 1 DAY

dextroamp-amphetamin 30 mg tab P QL 2 TABS / 1 DAY

dextroamp-amphetamine 5 mg tab P QL 3 TABS / 1 DAY

dextroamphetamine 10 mg tab P QL 3 TABS / 1 DAY

dextroamphetamine 5 mg tab P QL 3 TABS / 1 DAY

QL 60 ML / 1 DAY dextroamphetamine 5 mg/5 ml NP PA

dextroamphetamine sulfate er P QL 4 CAPS / 1 DAY

QL 2 CAPS / 1 DAY dextroamphetamine-amphet er NP PA

PAGE 26 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

DYANAVEL XR QL 8 ML / 1 DAY NP amphetamine PA

EVEKEO 10 MG TABLET QL 6 TABS / 1 DAY NP amphetamine sulfate PA

EVEKEO 5 MG TABLET QL 4 TABS / 1 DAY NP amphetamine sulfate PA

MYDAYIS QL 1 CAP / 1 DAY dextroamphetamine sulf-saccharate/amphetamine sulf- NP aspartate PA

PROCENTRA QL 60 ML / 1 DAY NP dextroamphetamine sulfate PA

VYVANSE 10 MG CAPSULE QL 2 CAPS / 1 DAY dimesylate P

QL 2 CHEW TABS / 1 VYVANSE 10 MG CHEWABLE TABLET DAY lisdexamfetamine dimesylate NP PA

VYVANSE 20 MG CAPSULE QL 2 CAPS / 1 DAY lisdexamfetamine dimesylate P

QL 2 CHEW TABS / 1 VYVANSE 20 MG CHEWABLE TABLET DAY lisdexamfetamine dimesylate NP PA

VYVANSE 30 MG CAPSULE QL 2 CAPS / 1 DAY lisdexamfetamine dimesylate P

QL 2 CHEW TABS / 1 VYVANSE 30 MG CHEWABLE TABLET DAY lisdexamfetamine dimesylate NP PA

VYVANSE 40 MG CAPSULE QL 1 CAP / 1 DAY lisdexamfetamine dimesylate P

VYVANSE 40 MG CHEWABLE TABLET QL 1 CHEW TAB / 1 DAY NP lisdexamfetamine dimesylate PA

VYVANSE 50 MG CAPSULE QL 1 CAP / 1 DAY lisdexamfetamine dimesylate P

VYVANSE 50 MG CHEWABLE TABLET QL 1 CHEW TAB / 1 DAY NP lisdexamfetamine dimesylate PA

VYVANSE 60 MG CAPSULE QL 1 CAP / 1 DAY lisdexamfetamine dimesylate P

PAGE 27 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

VYVANSE 60 MG CHEWABLE TABLET QL 1 CHEW TAB / 1 DAY NP lisdexamfetamine dimesylate PA

VYVANSE 70 MG CAPSULE QL 1 CAP / 1 DAY lisdexamfetamine dimesylate P

ZENZEDI 10 MG TABLET QL 3 TABS / 1 DAY NP dextroamphetamine sulfate PA

ZENZEDI 15 MG TABLET QL 3 TABS / 1 DAY NP dextroamphetamine sulfate PA

ZENZEDI 2.5 MG TABLET QL 3 TABS / 1 DAY NP dextroamphetamine sulfate PA

ZENZEDI 20 MG TABLET QL 3 TABS / 1 DAY NP dextroamphetamine sulfate PA

ZENZEDI 30 MG TABLET QL 2 TABS / 1 DAY NP dextroamphetamine sulfate PA

ZENZEDI 5 MG TABLET QL 3 TABS / 1 DAY NP dextroamphetamine sulfate PA

ZENZEDI 7.5 MG TABLET QL 3 TABS / 1 DAY NP dextroamphetamine sulfate PA

RESPIRATORY AND CNS STIMULANTS

ADHANSIA XR 25 MG CAPSULE QL 2 CAPS / 1 DAY NP hcl PA

ADHANSIA XR 35 MG CAPSULE QL 2 CAPS / 1 DAY NP methylphenidate hcl PA

ADHANSIA XR 45 MG CAPSULE QL 1 CAP / 1 DAY NP methylphenidate hcl PA

ADHANSIA XR 55 MG CAPSULE QL 1 CAP / 1 DAY NP methylphenidate hcl PA

ADHANSIA XR 70 MG CAPSULE QL 1 CAP / 1 DAY NP methylphenidate hcl PA

ADHANSIA XR 85 MG CAPSULE QL 1 CAP / 1 DAY NP methylphenidate hcl PA

PAGE 28 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

APTENSIO XR 10 MG CAPSULE QL 2 CAPS / 1 DAY NP methylphenidate hcl PA

APTENSIO XR 15 MG CAPSULE QL 2 CAPS / 1 DAY NP methylphenidate hcl PA

APTENSIO XR 20 MG CAPSULE QL 2 CAPS / 1 DAY NP methylphenidate hcl PA

APTENSIO XR 30 MG CAPSULE QL 2 CAPS / 1 DAY NP methylphenidate hcl PA

APTENSIO XR 40 MG CAPSULE QL 1 CAP / 1 DAY NP methylphenidate hcl PA

APTENSIO XR 50 MG CAPSULE QL 1 CAP / 1 DAY NP methylphenidate hcl PA

APTENSIO XR 60 MG CAPSULE QL 1 CAP / 1 DAY NP methylphenidate hcl PA

CONCERTA ER 18 MG TABLET QL 2 TABS / 1 DAY methylphenidate hcl P CONCERTA ER 27 MG TABLET QL 2 TABS / 1 DAY methylphenidate hcl P CONCERTA ER 36 MG TABLET QL 2 TABS / 1 DAY methylphenidate hcl P CONCERTA ER 54 MG TABLET QL 1 TAB / 1 DAY methylphenidate hcl P

COTEMPLA XR-ODT QL 2 TABS / 1 DAY NP methylphenidate PA

DAYTRANA QL 1 PATCH / 1 DAY NP methylphenidate PA

QL 2 CAPS / 1 DAY er 10 mg cp NP PA

QL 2 CAPS / 1 DAY dexmethylphenidate er 15 mg cp NP PA

QL 2 CAPS / 1 DAY dexmethylphenidate er 20 mg cp NP PA

PAGE 29 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 CAP / 1 DAY dexmethylphenidate er 25 mg cp NP PA

QL 1 CAP / 1 DAY dexmethylphenidate er 30 mg cp NP PA

QL 1 CAP / 1 DAY dexmethylphenidate er 35 mg cp NP PA

QL 1 CAP / 1 DAY dexmethylphenidate er 40 mg cp NP PA

QL 2 CAPS / 1 DAY dexmethylphenidate er 5 mg cap NP PA

dexmethylphenidate hcl P QL 2 TABS / 1 DAY

FOCALIN QL 2 TABS / 1 DAY NP dexmethylphenidate hcl PA

FOCALIN XR 10 MG CAPSULE QL 2 CAPS / 1 DAY dexmethylphenidate hcl P FOCALIN XR 15 MG CAPSULE QL 2 CAPS / 1 DAY dexmethylphenidate hcl P FOCALIN XR 20 MG CAPSULE QL 2 CAPS / 1 DAY dexmethylphenidate hcl P FOCALIN XR 25 MG CAPSULE QL 1 CAP / 1 DAY dexmethylphenidate hcl P FOCALIN XR 30 MG CAPSULE QL 1 CAP / 1 DAY dexmethylphenidate hcl P FOCALIN XR 35 MG CAPSULE QL 1 CAP / 1 DAY dexmethylphenidate hcl P FOCALIN XR 40 MG CAPSULE QL 1 CAP / 1 DAY dexmethylphenidate hcl P FOCALIN XR 5 MG CAPSULE QL 2 CAPS / 1 DAY dexmethylphenidate hcl P

JORNAY PM QL 1 CAP / 1 DAY NP methylphenidate hcl PA

METADATE ER QL 3 TABS / 1 DAY methylphenidate hcl C METHYLIN 10 MG/5 ML SOLUTION QL 30 ML / 1 DAY methylphenidate hcl P

PAGE 30 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS METHYLIN 5 MG/5 ML SOLUTION QL 60 ML / 1 DAY methylphenidate hcl P

QL 6 CHEW TABS / 1 methylphenidate 10 mg chew tab NP DAY PA

methylphenidate 10 mg tablet P QL 3 TABS / 1 DAY

methylphenidate 10 mg/5 ml sol P QL 30 ML / 1 DAY

QL 4 CHEW TABS / 1 methylphenidate 2.5 mg chew tb NP DAY PA

methylphenidate 20 mg tablet P QL 3 TABS / 1 DAY

QL 4 CHEW TABS / 1 methylphenidate 5 mg chew tab NP DAY PA

methylphenidate 5 mg tablet P QL 3 TABS / 1 DAY

methylphenidate 5 mg/5 ml soln P QL 60 ML / 1 DAY

QL 2 CAPS / 1 DAY methylphenidate cd 10 mg cap NP PA

QL 2 CAPS / 1 DAY methylphenidate cd 20 mg cap NP PA

QL 2 CAPS / 1 DAY methylphenidate cd 30 mg cap NP PA

QL 1 CAP / 1 DAY methylphenidate cd 40 mg cap NP PA

QL 1 CAP / 1 DAY methylphenidate cd 50 mg cap NP PA

QL 1 CAP / 1 DAY methylphenidate cd 60 mg cap NP PA

QL 2 CAPS / 1 DAY methylphenidate er 10 mg cap (authorized generic) NP PA

methylphenidate er 10 mg tab C QL 4 TABS / 1 DAY

PAGE 31 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 2 CAPS / 1 DAY methylphenidate er 15 mg cap (authorized generic) NP PA

QL 2 TABS / 1 DAY methylphenidate er 18 mg tab NP PA

QL 2 CAPS / 1 DAY methylphenidate er 20 mg cap (authorized generic) NP PA

methylphenidate er 20 mg tab P QL 3 TABS / 1 DAY

QL 2 TABS / 1 DAY methylphenidate er 27 mg tab NP PA

QL 2 CAPS / 1 DAY methylphenidate er 30 mg cap (authorized generic) NP PA

QL 2 TABS / 1 DAY methylphenidate er 36 mg tab NP PA

QL 1 CAP / 1 DAY methylphenidate er 40 mg cap (authorized generic) NP PA

QL 1 CAP / 1 DAY methylphenidate er 50 mg cap (authorized generic) NP PA

QL 1 TAB / 1 DAY methylphenidate er 54 mg tab NP PA

QL 1 CAP / 1 DAY methylphenidate er 60 mg cap (authorized generic) NP PA

QL 1 TAB / 1 DAY methylphenidate er 72 mg tab NP PA

QL 2 CAPS / 1 DAY methylphenidate er(cd) 10mg cp NP PA

QL 2 CAPS / 1 DAY methylphenidate er(cd) 20mg cp NP PA

QL 2 CAPS / 1 DAY methylphenidate er(cd) 30mg cp NP PA

PAGE 32 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 CAP / 1 DAY methylphenidate er(cd) 40mg cp NP PA

QL 1 CAP / 1 DAY methylphenidate er(cd) 50mg cp NP PA

QL 1 CAP / 1 DAY methylphenidate er(cd) 60mg cp NP PA

QL 2 CAPS / 1 DAY methylphenidate er(la) 10mg cp NP PA

QL 2 CAPS / 1 DAY methylphenidate er(la) 20mg cp NP PA

QL 2 CAPS / 1 DAY methylphenidate er(la) 30mg cp NP PA

QL 1 CAP / 1 DAY methylphenidate er(la) 40mg cp NP PA

QL 2 CAPS / 1 DAY methylphenidate la 10 mg cap NP PA

QL 2 CAPS / 1 DAY methylphenidate la 20 mg cap NP PA

QL 2 CAPS / 1 DAY methylphenidate la 30 mg cap NP PA

QL 1 CAP / 1 DAY methylphenidate la 40 mg cap NP PA

QL 1 CAP / 1 DAY methylphenidate la 60 mg cap NP PA

QL 3 CHEW TABS / 1 QUILLICHEW ER 20 MG CHEW TAB DAY methylphenidate hcl NP PA

QL 2 CHEW TABS / 1 QUILLICHEW ER 30 MG CHEW TAB DAY methylphenidate hcl NP PA

QUILLICHEW ER 40 MG CHEW TAB QL 1 CHEW TAB / 1 DAY NP methylphenidate hcl PA

PAGE 33 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QUILLIVANT XR QL 12 ML / 1 DAY NP methylphenidate hcl PA

RITALIN QL 3 TABS / 1 DAY NP methylphenidate hcl PA

RITALIN LA 10 MG CAPSULE QL 2 CAPS / 1 DAY methylphenidate hcl P RITALIN LA 20 MG CAPSULE QL 2 CAPS / 1 DAY methylphenidate hcl P RITALIN LA 30 MG CAPSULE QL 2 CAPS / 1 DAY methylphenidate hcl P RITALIN LA 40 MG CAPSULE QL 1 CAP / 1 DAY methylphenidate hcl P WAKEFULNESS-PROMOTING AGENTS

150 mg tablet C QL 1 TAB / 1 DAY

armodafinil 200 mg tablet C QL 1 TAB / 1 DAY

armodafinil 250 mg tablet C QL 1 TAB / 1 DAY

armodafinil 50 mg tablet C QL 2 TABS / 1 DAY

C QL 2 TABS / 1 DAY

SUNOSI QL 1 TAB / 1 DAY C hcl PA

WAKIX PA C hcl S Specialty Drug

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

albendazole C PA

3 mg tablet C

PIN-X C

PINAWAY C

PINWORM MEDICINE C

PINWORM TREATMENT C

praziquantel C

PAGE 34 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

REESE'S PINWORM C URINARY ANTI-INFECTIVES

fosfomycin tromethamine C QL 1 PACKET / Rx

25 mg/5 ml susp C AL1 Up to 12 yrs old

nitrofurantoin mcr 100 mg cap C

nitrofurantoin mcr 25 mg cap C AL1 Up to 12 yrs old

nitrofurantoin mcr 50 mg cap C

nitrofurantoin mono-macro C

PHOSPHASAL C

C ANTI-INFECTIVES (EENT)

ANTIBACTERIALS (EENT)

AK-POLY-BAC / sulfate C AZASITE PA NP

bacitracin 500 unit/gm ophth C

bacitracin-polymyxin C BESIVANCE PA hcl NP BLEPH-10 C BLEPHAMIDE S.O.P. sulfacetamide sodium/ C CILOXAN PA hcl NP CIPRO HC ciprofloxacin hcl/ P CIPRODEX ciprofloxacin hcl/ P

ciprofloxacin 0.2% otic soln NP PA

ciprofloxacin 0.3% drop P

ciprofloxacin hcl- NP PA

PAGE 35 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

ciprofloxacin-dexamethasone C

hyclate 20 mg tab C

0.5% eye ointment C

NP PA

GENTAK sulfate C

0.5% eye drops NP PA

MOXEZA PA hcl NP

moxifloxacin 0.5% eye drops P NEO-POLYCIN sulfate/bacitracin/polymyxin b C

neomycin-bacitracin-polymyxin C

neomycin-polymyxin-dexameth C

neomycin-polymyxin-gramicidin C

neomycin-polymyxin-hc ear susp P

neomycin-polymyxin-hydrocort P OCUFLOX PA NP

ofloxacin 0.3% ear drops P

ofloxacin 0.3% eye drops P OTIPRIO PA ciprofloxacin NP OTOVEL PA ciprofloxacin hcl/ NP POLYCIN bacitracin/polymyxin b sulfate C

polymyxin b sul-trimethoprim C

sulfacetamide 10% eye drops C

sulfacetamide 10% eye ointment C

sulfacetamide-prednisolone C TOBRADEX EYE OINTMENT tobramycin/dexamethasone C

tobramycin 0.3% C

PAGE 36 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

tobramycin-dexamethasone C TOBREX 0.3% EYE OINTMENT tobramycin C VIGAMOX PA moxifloxacin hcl NP ZYMAXID PA gatifloxacin NP ANTIVIRALS (EENT)

C ZIRGAN C EENT ANTI-INFECTIVES, MISCELLANEOUS

2% ear solution C

gluconate C

EAR WAX REMOVAL C OTC

PAROEX chlorhexidine gluconate C PERIOGARD chlorhexidine gluconate C ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

ACANYA PA / NP

bacitracin 500 unit/gm ointmnt C OTC

bacitracin C OTC

BENZACLIN PA clindamycin phosphate/benzoyl peroxide NP CENTANY PA NP CENTANY AT PA mupirocin NP CLEOCIN 100 MG VAGINAL OVULE clindamycin phosphate C CLEOCIN T 1% PA clindamycin phosphate NP

PAGE 37 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS CLEOCIN T 1% PA clindamycin phosphate NP CLINDACIN P PA clindamycin phosphate NP CLINDACIN PAC PA clindamycin phosphate/skin cleanser comb no.19 NP CLINDAGEL PA clindamycin phosphate NP

clindamycin 2% vaginal C

clindamycin ph 1% gel (generic for Cleocin T) P

clindamycin ph 1% solution P

clindamycin phos 1% pledget P

clindamycin phos-benzoyl perox P

clindamycin phos- NP PA

clindamycin phosp 1% lotion P

clindamycin phosphate 1% foam NP PA

clindamycin phosphate 1% gel (generic for Clindagel) P

clindamycin-benzoyl perox 1-5% P

clindamycin-bnz perox 1-5% pmp NP PA

DUAC PA clindamycin phosphate/benzoyl peroxide NP ERY erythromycin base in C

erythromycin 2% gel P

erythromycin 2% pledgets P

erythromycin 2% solution P QL 60 ML / 30 DAYS

erythromycin-benzoyl peroxide P

FIRST AID C OTC

gentamicin 0.1% cream C QL 30 GM / 30 DAYS

gentamicin 0.1% ointment C

HM TRIPLE ANTIBIOTIC OINTMENT C OTC

0.75% cream C

PAGE 38 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

metronidazole 0.75% lotion C

metronidazole topical 0.75% gl C

metronidazole vaginal 0.75% gl C

QL 30 GM / 30 DAYS mupirocin 2% cream NP PA

mupirocin 2% ointment P NEOSPORIN OTC neomycin sulfate/bacitracin zinc/polymyxin b C NEUAC 1.2-5% KIT PA clindamycin phosphate/benzoyl peroxide/emollient comb no.94 NP NEUAC GEL PA clindamycin phosphate/benzoyl peroxide NP ONEXTON 1.2%-3.75% GEL PA clindamycin phosphate/benzoyl peroxide NP ONEXTON GEL PUMP PA clindamycin phosphate/benzoyl peroxide NP

qc bacitracin 500 unit/gm oint C OTC

ROSADAN 0.75% CREAM metronidazole C TRIPLE ANTIBIOTIC OINTMENT OTC neomycin sulfate/bacitracin zinc/polymyxin b C TRIPLE ANTIBIOTIC OINTMENT PKT OTC neomycin sulfate/bacitracin zinc/polymyxin b C

TRIPLE ANTIBIOTIC-PAIN RELIEF C OTC

ZIANA PA clindamycin phosphate/tretinoin NP ANTIVIRALS (SKIN AND MUCOUS MEMBRANE)

QL 5 GM / RX acyclovir 5% cream NP PA

acyclovir 5% ointment P DENAVIR P XERESE PA acyclovir/hydrocortisone NP ZOVIRAX 5% CREAM PA acyclovir NP

PAGE 39 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ZOVIRAX 5% OINTMENT PA acyclovir NP LOCAL ANTI-INFECTIVES, MISCELLANEOUS

ALCOHOL PREP PADS OTC pads C BETADINE 10% SOLUTION OTC povidone-iodine C

DERMAZENE CREAM C

hydrocortisone-iodoquinol C

povidone-iodine 10% ointment C OTC

povidone-iodine 10% solution C OTC

sulfide 2.5% lotion C

silver C

sod sulface- 9-4.5% wash P

sodium sulf-sulfur cleanser C

sodium sulfacetamide 10% lotn P

sodium sulfacetamide 10% wash P SSD C

sulfacetamide sod 10% top susp P SCABICIDES AND PEDICULICIDES

COMPLETE LICE TREATMENT P OTC

LICE KILLING P OTC

LICE SOLUTION C OTC

LICE TREATMENT P OTC

NP PA

NP PA

NATROBA P OVIDE PA malathion NP

P

PAGE 40 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SKLICE PA ivermectin NP

spinosad NP PA

ANTI-INFLAMMATORY AGENTS (EENT)

CORTICOSTEROIDS (EENT)

24 HOUR OTC propionate C 24 HOUR NASAL ALLERGY OTC acetonide C ALLER-CORT OTC C ALREX PA etabonate NP BECONASE AQ PA beclomethasone dipropionate NP

dexamethasone 0.1% eye drop C

NP PA

fluocinolone acetonide oil C

P

fluticasone prop 50 mcg spray P OTC

fluticasone prop 50 mcg spray (Rx only) P OTC

FML S.O.P. fluorometholone C

gnp fluticasone prop 50 mcg sp C OTC

loteprednol etabonate 0.5% drp C

furoate 50 mcg spry P NASONEX PA mometasone furoate NP OMNARIS PA NP

prednisolone ac 1% eye drop (Generic Pred Forte) P

prednisolone sod 1% eye drop C QNASL PA beclomethasone dipropionate NP

PAGE 41 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS QNASL CHILDREN PA beclomethasone dipropionate NP

PA ra 32 mcg spray NP OTC

SINUVA PA NP mometasone furoate MED

TICANASE PA /sodium /sodium bicarbonate NP

triamcinolone 55 mcg nasal spr C OTC

XHANCE PA fluticasone propionate NP ZETONNA PA ciclesonide NP EENT ANTI-INFLAMMATORY AGENTS, MISC.

RESTASIS PA cyclosporine C RESTASIS MULTIDOSE PA cyclosporine C EENT ANTI-INFLAM. AGENTS

ACULAR PA tromethamine NP ACULAR LS PA ketorolac tromethamine NP ACUVAIL PA ketorolac tromethamine/pf NP

sodium NP PA

BROMSITE PA bromfenac sodium NP

0.1% eye drops P

sodium NP PA

ketorolac 0.4% ophth solution P

ketorolac 0.5% ophth solution P NEVANAC PA nepafenac NP

PAGE 42 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS PROLENSA PA bromfenac sodium NP ANTI-INFLAMMATORY AGENTS (RESPIRATORY)

INTERLEUKIN ANTAGONISTS

QL 2.28 ML / 28 DAYS DUPIXENT 200 MG/1.14 ML PEN PA dupilumab NP S Specialty Drug

QL 2.28 ML / 28 DAYS DUPIXENT 200 MG/1.14 ML SYRING PA dupilumab NP S Specialty Drug

FASENRA PEN PA C benralizumab S Specialty Drug

NUCALA 100 MG/ML AUTO-INJECTOR PA C mepolizumab S Specialty Drug

NUCALA 100 MG/ML PA C mepolizumab S Specialty Drug

LEUKOTRIENE MODIFIERS

ACCOLATE PA zafirlukast NP

montelukast sod 10 mg tablet P

montelukast sod 4 mg granules NP PA

montelukast sod 4 mg tab chew P

montelukast sod 5 mg tab chew P SINGULAIR PA montelukast sodium NP

zafirlukast P

zileuton er NP PA

ZYFLO PA zileuton NP MAST-CELL STABILIZERS

ALOCRIL PA sodium NP

PAGE 43 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

cromolyn 20 mg/2 ml neb soln C

cromolyn 4% eye drops P NASALCROM OTC cromolyn sodium C ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

ANTI-INFLAMMATORY AGENTS, MISC (SKIN)

EUCRISA QL 60 GM / 30 DAYS NP crisaborole PA

CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)

ALA-CORT 1% CREAM hydrocortisone C

dipropionate C

ANTI- 1% CREAM C OTC

ANUCORT-HC C

AQUANIL HC C OTC

AQUAPHOR ITCH RELIEF C OTC

dipropionate C

betamethasone dp aug 0.05% crm C

betamethasone dp aug 0.05% gel C

betamethasone dp aug 0.05% lot C

betamethasone dp aug 0.05% oin C

betamethasone va 0.1% cream C

betamethasone va 0.1% lotion C

betamethasone valer 0.1% ointm C

0.05% cream C

clobetasol 0.05% gel C

clobetasol 0.05% ointment C

clobetasol 0.05% solution C

clobetasol emollient 0.05% crm C COLOCORT hydrocortisone C

PAGE 44 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS CORMAX C

CVS ANTI-ITCH 1% CREAM C OTC

0.05% cream C

desonide 0.05% lotion C

desonide 0.05% ointment C

0.05% cream C

desoximetasone 0.05% gel C

desoximetasone 0.25% cream C

desoximetasone 0.25% ointment C

eq hydrocortisone 1% cream C OTC

EQL ANTI-ITCH 1% CREAM C OTC

fluocinolone 0.01% body oil C

fluocinolone 0.01% cream C

fluocinolone 0.01% scalp oil C

fluocinolone 0.01% solution C QL 60 ML / 30 DAYS

fluocinolone 0.025% cream C

fluocinolone 0.025% ointment C

C

fluocinonide-e C

fluticasone prop 0.005% oint C

fluticasone prop 0.05% cream C

gnp hydrocort acetate 1% cr C OTC

gnp hydrocortisone 1% ointment C OTC

GS ANTI-ITCH 1% CREAM C OTC

hydrocort-pramoxine 1%-1% crm C

hydrocort-pramoxine 2.5-1% crm C

hydrocortisone 0.5% cream C OTC

hydrocortisone 0.5% ointment C OTC

hydrocortisone 1% cream C OTC

PAGE 45 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

hydrocortisone 1% lotion C OTC

hydrocortisone 1% ointment C OTC

hydrocortisone 100 mg/60 ml C

hydrocortisone 2.5% cream C

hydrocortisone 2.5% lotion C

hydrocortisone 2.5% ointment C

hydrocortisone ac 25 mg supp C

hydrocortisone buty 0.1% cream C

hydrocortisone butyr 0.1% oint C

C

HYDROCORTISONE-1% OINTMENT C OTC

hydrocortisone-aloe C OTC

-hc 3-0.5% cream C

mometasone furoate 0.1% cream C

mometasone furoate 0.1% oint C

mometasone furoate 0.1% soln C ORALONE triamcinolone acetonide C

PREPARATION H HC 1% CREAM C OTC

PROCTO-MED HC hydrocortisone C PROCTOSOL-HC hydrocortisone C PROCTOZONE-HC hydrocortisone C

QC ANTI-ITCH 1% CREAM C OTC

RA ANTI-ITCH 1% CREAM C OTC

sm hydrocortisone 0.5% ointmnt C OTC

sm hydrocortisone 1% ointment C OTC

triamcinolone 0.025% cream C

triamcinolone 0.025% lotion C

PAGE 46 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

triamcinolone 0.025% oint C

triamcinolone 0.1% cream C

triamcinolone 0.1% lotion C

triamcinolone 0.1% ointment C

triamcinolone 0.1% C

triamcinolone 0.5% cream C

triamcinolone 0.5% ointment C TRIDERM triamcinolone acetonide C ANTIANEMIA DRUGS

IRON PREPARATIONS

children's ferrous sulfate C OTC

FERGON C OTC

FEROSUL C OTC

FERREX 150 PLUS C OTC

FERROCITE PLUS C OTC

ferrous fumarate C OTC

ferrous gluconate C OTC

ferrous sulf 15 mg iron/ml drp C OTC

ferrous sulf 220 mg/5 ml elix C OTC

ferrous sulf 220 mg/5 ml liq C OTC

ferrous sulf 300 mg/5 ml liq C OTC

ferrous sulf 300 mg/6.8ml soln C OTC

ferrous sulf 44 mg iron/5ml lq C OTC

ferrous sulf ec 325 mg tablet C OTC

ferrous sulfate 325 mg tablet C OTC

HEMATOGEN FORTE C OTC

iron C OTC

PAGE 47 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS NU-IRON 150 OTC iron polysaccharide complex C

PEDIATRIC FE-VITE C OTC

pediatric iron C OTC

polysaccharide iron C OTC

ANTIARRHYTHMIC AGENTS

CLASS IA ANTIARRHYTHMICS

phosphate C NORPACE CR disopyramide phosphate C

sulfate C CLASS IB ANTIARRHYTHMICS

hcl C CLASS IC ANTIARRHYTHMICS

acetate C

hcl C CLASS III ANTIARRHYTHMICS

hcl 100 mg tablet C

amiodarone hcl 200 mg tablet C

amiodarone hcl 400 mg tablet C

C MULTAQ PA hcl C PACERONE 100 MG TABLET amiodarone hcl C PACERONE 200 MG TABLET amiodarone hcl C ANTIBACTERIALS

AMINOGLYCOSIDE

BETHKIS PA P tobramycin S Specialty Drug

gentamicin 40 mg/ml vial C

PAGE 48 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

gentamicin 80 mg/2 ml vial C

gentamicin 800 mg/20 ml vial C

KITABIS PAK PA P tobramycin/ S Specialty Drug

neomycin sulfate C

TOBI PA NP tobramycin in 0.225 % S Specialty Drug

TOBI PODHALER PA NP tobramycin S Specialty Drug

PA tobramycin 300 mg/4 ml ampule NP S Specialty Drug

PA tobramycin 300 mg/5 ml ampule NP S Specialty Drug

PA tobramycin pak 300 mg/5 ml NP S Specialty Drug

tobramycin sulfate NP PA

QUINOLONE ANTIBIOTICS

BAXDELA 450 MG TABLET PA meglumine NP CIPRO 10% PA ciprofloxacin NP CIPRO 250 MG TABLET PA ciprofloxacin hcl NP CIPRO 5% SUSPENSION PA ciprofloxacin NP CIPRO 500 MG TABLET PA ciprofloxacin hcl NP

ciprofloxacin NP PA

ciprofloxacin hcl 100 mg tab P

ciprofloxacin hcl 250 mg tab P

ciprofloxacin hcl 500 mg tab P

ciprofloxacin hcl 750 mg tab P

PAGE 49 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS LEVAQUIN PA levofloxacin NP

levofloxacin 25 mg/ml solution P

levofloxacin 250 mg tablet P

levofloxacin 500 mg tablet P

levofloxacin 750 mg tablet P

moxifloxacin hcl NP PA

ofloxacin 300 mg tablet NP PA

ofloxacin 400 mg tablet NP PA

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)

AZULFIDINE PA NP

-tmp ds tablet C

sulfamethoxazole-tmp ss tablet C

sulfamethoxazole-tmp susp C

sulfasalazine P

sulfasalazine dr P SULFATRIM sulfamethoxazole/trimethoprim C ANTIBIOTICS

hcl C

doxycycline 25 mg/5 ml susp C

doxycycline hyclate 100 mg cap C

doxycycline hyclate 100 mg tab C

doxycycline hyclate 50 mg cap C

doxycycline mono 100 mg cap C

doxycycline mono 100 mg tablet C

doxycycline mono 50 mg cap C

doxycycline mono 50 mg tablet C

100 mg capsule C

minocycline 50 mg capsule C

PAGE 50 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

minocycline 75 mg capsule C OKEBO doxycycline monohydrate C ANTIBACTERIALS, MISCELLANEOUS

GLYCOPEPTIDE ANTIBIOTICS

hcl 125 mg capsule C

vancomycin hcl 250 mg capsule C LINCOMYCIN ANTIBIOTICS

clindamycin (pediatric) C AL1 Up to 12 yrs old

clindamycin hcl C OXAZOLIDINONE ANTIBIOTICS

100 mg/5 ml susp C PA

linezolid 600 mg tablet C QL 28 TABLETS / Rx

SIVEXTRO 200 MG TABLET PA phosphate C PLEUROMUTILINS

XENLETA 600 MG TABLET QL 10 TABS / RX C lefamulin acetate PA

RIFAMYCIN ANTIBIOTICS

XIFAXAN PA C AGENTS

ANTIMUSCARINICS/

ANORO ELLIPTA PA umeclidinium / trifenatate NP ATROVENT HFA P BEVESPI AEROSPHERE PA glycopyrrolate/ fumarate NP COMBIVENT ipratropium bromide/albuterol sulfate P CUVPOSA PA glycopyrrolate C

PAGE 51 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

dicyclomine 10 mg capsule C

dicyclomine 10 mg/5 ml soln C

dicyclomine 20 mg tablet C

ED-SPAZ C

glycopyrrolate 1 mg tablet C

glycopyrrolate 2 mg tablet C

0.125 mg odt C

hyoscyamine 0.125 mg tab sl C

hyoscyamine 0.125 mg/5 ml elix C

hyoscyamine 0.125 mg/ml drop C

hyoscyamine sulf 0.125 mg tab C

hyoscyamine sulfate er C

hyoscyamine sulfate sr C

HYOSYNE C INCRUSE ELLIPTA PA NP

ipratropium br 0.02% soln P

ipratropium-albuterol P LONHALA MAGNAIR REFILL PA glycopyrrolate/nebulizer accessories NP LONHALA MAGNAIR STARTER PA glycopyrrolate/nebulizer and accessories NP

OSCIMIN C

OSCIMIN SL C

OSCIMIN SR C

C SEEBRI NEOHALER PA glycopyrrolate NP SPIRIVA P SPIRIVA RESPIMAT tiotropium bromide P STIOLTO RESPIMAT tiotropium bromide/olodaterol hcl P

PAGE 52 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

SYMAX-SR C TUDORZA PRESSAIR P YUPELRI PA NP ANTICOAGULANTS

ANTICOAGULANTS, MISCELLANEOUS

ARIXTRA PA fondaparinux sodium NP

fondaparinux sodium NP PA

THROMBATE III S Specialty Drug C antithrombin iii (human plasma derived) MED

COUMARIN DERIVATIVES

QL 10 TABS / 1 DAY coumadin 1 mg tablet NP PA

QL 2 TABS / 1 DAY coumadin 10 mg tablet NP PA

QL 10 TABS / 1 DAY coumadin 2 mg tablet NP PA

QL 8 TABS / 1 DAY coumadin 2.5 mg tablet NP PA

QL 8 TABS / 1 DAY coumadin 3 mg tablet NP PA

QL 5 TABS / 1 DAY coumadin 4 mg tablet NP PA

QL 4 TABS / 1 DAY coumadin 5 mg tablet NP PA

QL 3 TABS / 1 DAY coumadin 6 mg tablet NP PA

QL 3 TABS / 1 DAY coumadin 7.5 mg tablet NP PA

PAGE 53 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

jantoven 1 mg tablet P QL 10 TABS / 1 DAY

jantoven 10 mg tablet P QL 2 TABS / 1 DAY

jantoven 2 mg tablet P QL 10 TABS / 1 DAY

jantoven 2.5 mg tablet P QL 8 TABS / 1 DAY

jantoven 3 mg tablet P QL 8 TABS / 1 DAY

jantoven 4 mg tablet P QL 5 TABS / 1 DAY

jantoven 5 mg tablet P QL 4 TABS / 1 DAY

jantoven 6 mg tablet P QL 3 TABS / 1 DAY

jantoven 7.5 mg tablet P QL 3 TABS / 1 DAY

sodium 1 mg tablet P QL 10 TABS / 1 DAY

warfarin sodium 10 mg tablet P QL 2 TABS / 1 DAY

warfarin sodium 2 mg tablet P QL 10 TABS / 1 DAY

warfarin sodium 2.5 mg tablet P QL 8 TABS / 1 DAY

warfarin sodium 3 mg tablet P QL 8 TABS / 1 DAY

warfarin sodium 4 mg tablet P QL 5 TABS / 1 DAY

warfarin sodium 5 mg tablet P QL 4 TABS / 1 DAY

warfarin sodium 6 mg tablet P QL 3 TABS / 1 DAY

warfarin sodium 7.5 mg tablet P QL 3 TABS / 1 DAY

DIRECT FACTOR XA INHIBITORS

BEVYXXA PA betrixaban maleate NP

ELIQUIS 2.5 MG TABLET QL 2 TABS / 1 DAY NP apixaban PA

ELIQUIS 5 MG TABLET QL 2 TABS / 1 DAY NP apixaban PA

ELIQUIS DVT-PE TREAT START 5MG QL 74 TABS / 30 DAYS NP apixaban PA

PAGE 54 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SAVAYSA PA edoxaban tosylate NP XARELTO 10 MG TABLET QL 1 TAB / 1 DAY rivaroxaban P XARELTO 15 MG TABLET QL 2 TABS / 1 DAY rivaroxaban P

XARELTO 2.5 MG TABLET QL 2 TABS / 1 DAY NP rivaroxaban PA

XARELTO 20 MG TABLET QL 1 TAB / 1 DAY rivaroxaban P

XARELTO DVT-PE TREAT START 30D QL 51 TABS / 30 DAYS NP rivaroxaban PA

DIRECT THROMBIN INHIBITORS

PRADAXA QL 2 CAPS / 1 DAY dabigatran etexilate mesylate P HEPARINS

enoxaparin 100 mg/ml syringe P QL 28 ML / 14 DAYS

enoxaparin 120 mg/0.8 ml syr P QL 28 ML / 14 DAYS

enoxaparin 150 mg/ml syringe P QL 28 ML / 14 DAYS

enoxaparin 30 mg/0.3 ml syr P QL 8.4 ML / 14 DAYS

enoxaparin 300 mg/3 ml vial P QL 84 ML / 14 DAYS

enoxaparin 40 mg/0.4 ml syr P QL 11.2 ML / 14 DAYS

enoxaparin 60 mg/0.6 ml syr P QL 16.8 ML / 14 DAYS

enoxaparin 80 mg/0.8 ml syr P QL 28 ML / 14 DAYS

FRAGMIN 10,000 UNIT/ML SYRINGE QL 10 ML / 14 DAYS NP dalteparin sodium,porcine PA

FRAGMIN 12,500 UNIT/0.5 ML SYR QL 14 ML / 14 DAYS NP dalteparin sodium,porcine PA

FRAGMIN 15,000 UNIT/0.6 ML SYR QL 16.8 ML / 14 DAYS NP dalteparin sodium,porcine PA

FRAGMIN 18,000 UNIT/0.72 ML QL 20.16 ML / 14 DAYS NP dalteparin sodium,porcine PA

PAGE 55 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

FRAGMIN 2,500 UNIT/0.2 ML SYR QL 5.6 ML / 14 DAYS NP dalteparin sodium,porcine PA

FRAGMIN 5,000 UNIT/0.2 ML SYR QL 5.6 ML / 14 DAYS NP dalteparin sodium,porcine PA

FRAGMIN 7,500 UNIT/0.3 ML SYR QL 8.4 ML / 14 DAYS NP dalteparin sodium,porcine PA

FRAGMIN 95,000 UNIT/3.8 ML VL QL 22.8 ML / 14 DAYS dalteparin sodium,porcine P

heparin 10,000 unit/10 ml vial C

heparin 30,000 unit/30 ml vial C

heparin 40,000 unit/4 ml vial C

heparin 5,000 unit/ml carpujct C

heparin 50,000 unit/10 ml vial C

heparin 50,000 unit/5 ml vial C

heparin sod 1,000 unit/ml vial C

heparin sod 10,000 unit/ml vl C

heparin sod 20,000 unit/ml vl C

heparin sod 5,000 unit/0.5 ml C

heparin sod 5,000 unit/ml syrg C

heparin sod 5,000 unit/ml vial C

LOVENOX 100 MG/ML SYRINGE QL 28 ML / 14 DAYS NP enoxaparin sodium PA

LOVENOX 120 MG/0.8 ML SYRINGE QL 28 ML / 14 DAYS NP enoxaparin sodium PA

LOVENOX 150 MG/ML SYRINGE QL 28 ML / 14 DAYS NP enoxaparin sodium PA

LOVENOX 30 MG/0.3 ML SYRINGE QL 8.4 ML / 14 DAYS NP enoxaparin sodium PA

LOVENOX 300 MG/3 ML VIAL QL 84 ML / 14 DAYS NP enoxaparin sodium PA

LOVENOX 40 MG/0.4 ML SYRINGE QL 11.2 ML / 14 DAYS NP enoxaparin sodium PA

PAGE 56 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

LOVENOX 60 MG/0.6 ML SYRINGE QL 16.8 ML / 14 DAYS NP enoxaparin sodium PA

LOVENOX 80 MG/0.8 ML SYRINGE QL 28 ML / 14 DAYS NP enoxaparin sodium PA

ANTICONVULSANTS

ANTICONVULSANTS, MISCELLANEOUS

APTIOM PA NP

BANZEL 200 MG TABLET QL 16 TABS / 1 DAY NP PA

BANZEL 40 MG/ML SUSPENSION QL 80 ML / 1 DAY NP rufinamide PA

BANZEL 400 MG TABLET QL 8 TABS / 1 DAY NP rufinamide PA

BRIVIACT 10 MG TABLET PA NP BRIVIACT 10 MG/ML ORAL SOLN PA brivaracetam NP BRIVIACT 100 MG TABLET PA brivaracetam NP BRIVIACT 25 MG TABLET PA brivaracetam NP BRIVIACT 50 MG TABLET PA brivaracetam NP BRIVIACT 75 MG TABLET PA brivaracetam NP

100 mg tab chew P

carbamazepine 100 mg/5 ml susp P

carbamazepine 200 mg tablet P

carbamazepine 200 mg/10ml susp C

carbamazepine er 100 mg cap NP PA

carbamazepine er 100 mg tablet P

carbamazepine er 200 mg cap NP PA

PAGE 57 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

carbamazepine er 200 mg tablet P

carbamazepine er 300 mg cap NP PA

carbamazepine er 400 mg tablet P CARBATROL PA carbamazepine NP DEPAKOTE PA divalproex sodium NP DEPAKOTE ER PA divalproex sodium NP DEPAKOTE SPRINKLE PA divalproex sodium NP

QL 12 CAPS / 1 DAY DIACOMIT 250 MG CAPSULE PA NP S Specialty Drug

QL 12 PACKETS / 1 DAY DIACOMIT 250 MG PACKET PA stiripentol NP S Specialty Drug

QL 6 CAPS / 1 DAY DIACOMIT 500 MG CAPSULE PA stiripentol NP S Specialty Drug

QL 6 PACKETS / 1 DAY DIACOMIT 500 MG POWDER PACKET PA stiripentol NP S Specialty Drug

divalproex sodium P

divalproex sodium er P

QL 20 ML / 1 DAY EPIDIOLEX PA (cbd) NP S Specialty Drug

EPITOL carbamazepine C

P FELBATOL 400 MG TABLET PA felbamate NP

PAGE 58 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS FELBATOL 600 MG TABLET PA felbamate NP FELBATOL 600 MG/5 ML SUSP felbamate P

FINTEPLA PA NP hcl S Specialty Drug

FYCOMPA PA NP

gabapentin 100 mg capsule P QL 12 CAPS / 1 DAY

gabapentin 250 mg/5 ml soln P QL 72 ML / 1 DAY

gabapentin 300 mg capsule P QL 12 CAPS / 1 DAY

gabapentin 300 mg/6 ml soln P QL 72 ML / 1 DAY

gabapentin 400 mg capsule P QL 9 CAPS / 1 DAY

gabapentin 600 mg tablet P QL 6 TABS / 1 DAY

gabapentin 800 mg tablet P QL 4 TABS / 1 DAY

GABITRIL hcl P

HORIZANT ER 300 MG TABLET QL 1 TAB / 1 DAY NP PA

HORIZANT ER 600 MG TABLET QL 2 TABS / 1 DAY NP gabapentin enacarbil PA

KEPPRA 1,000 MG TABLET PA NP KEPPRA 100 MG/ML ORAL SOLN PA levetiracetam NP KEPPRA 250 MG TABLET PA levetiracetam NP KEPPRA 500 MG TABLET PA levetiracetam NP

KEPPRA 500 MG/5 ML VIAL QL 3 ML / 1 DAY NP levetiracetam PA

KEPPRA 750 MG TABLET PA levetiracetam NP

PAGE 59 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS KEPPRA XR PA levetiracetam NP LAMICTAL PA NP LAMICTAL (BLUE) PA lamotrigine NP LAMICTAL (GREEN) PA lamotrigine NP LAMICTAL (ORANGE) PA lamotrigine NP LAMICTAL ODT PA lamotrigine NP LAMICTAL ODT (BLUE) PA lamotrigine NP LAMICTAL ODT (GREEN) PA lamotrigine NP LAMICTAL ODT (ORANGE) PA lamotrigine NP LAMICTAL XR PA lamotrigine NP LAMICTAL XR (BLUE) PA lamotrigine NP LAMICTAL XR (GREEN) PA lamotrigine NP LAMICTAL XR (ORANGE) PA lamotrigine NP

lamotrigine P

lamotrigine (blue) NP PA

lamotrigine (green) NP PA

lamotrigine (orange) NP PA

lamotrigine er P

lamotrigine odt NP PA

lamotrigine odt (blue) NP PA

lamotrigine odt (green) NP PA

lamotrigine odt (orange) NP PA

PAGE 60 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

levetiracetam 1,000 mg tablet P

levetiracetam 100 mg/ml soln P

levetiracetam 1000 mg/10 ml P

levetiracetam 250 mg tablet P

levetiracetam 500 mg tablet P

levetiracetam 500 mg/5 ml soln P

levetiracetam 750 mg tablet P

levetiracetam er P

LYRICA 100 MG CAPSULE QL 3 CAPS / 1 DAY NP pregabalin PA

LYRICA 150 MG CAPSULE QL 3 CAPS / 1 DAY NP pregabalin PA

LYRICA 20 MG/ML ORAL SOLUTION QL 30 ML / 1 DAY NP pregabalin PA

LYRICA 200 MG CAPSULE QL 3 CAPS / 1 DAY NP pregabalin PA

LYRICA 225 MG CAPSULE QL 2 CAPS / 1 DAY NP pregabalin PA

LYRICA 25 MG CAPSULE QL 3 CAPS / 1 DAY NP pregabalin PA

LYRICA 300 MG CAPSULE QL 2 CAPS / 1 DAY NP pregabalin PA

LYRICA 50 MG CAPSULE QL 3 CAPS / 1 DAY NP pregabalin PA

LYRICA 75 MG CAPSULE QL 3 CAPS / 1 DAY NP pregabalin PA

NEURONTIN 100 MG CAPSULE QL 12 CAPS / 1 DAY NP gabapentin PA

NEURONTIN 250 MG/5 ML SOLN QL 72 ML / 1 DAY NP gabapentin PA

PAGE 61 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

NEURONTIN 250 MG/5 ML SOLUTION QL 72 ML / 1 DAY NP gabapentin PA

NEURONTIN 300 MG CAPSULE QL 12 CAPS / 1 DAY NP gabapentin PA

NEURONTIN 400 MG CAPSULE QL 9 CAPS / 1 DAY NP gabapentin PA

NEURONTIN 600 MG TABLET QL 6 TABS / 1 DAY NP gabapentin PA

NEURONTIN 800 MG TABLET QL 4 TABS / 1 DAY NP gabapentin PA

P OXTELLAR XR PA oxcarbazepine NP

pregabalin 100 mg capsule P QL 3 CAPS / 1 DAY

pregabalin 150 mg capsule P QL 3 CAPS / 1 DAY

QL 30 ML / 1 DAY pregabalin 20 mg/ml solution NP PA

pregabalin 200 mg capsule P QL 3 CAPS / 1 DAY

pregabalin 225 mg capsule P QL 2 CAPS / 1 DAY

pregabalin 25 mg capsule P QL 3 CAPS / 1 DAY

pregabalin 300 mg capsule P QL 2 CAPS / 1 DAY

pregabalin 50 mg capsule P QL 3 CAPS / 1 DAY

pregabalin 75 mg capsule P QL 3 CAPS / 1 DAY

QUDEXY XR PA NP ROWEEPRA levetiracetam P ROWEEPRA XR levetiracetam P

QL 16 TABS / 1 DAY rufinamide 200 mg tablet C PA

PAGE 62 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 80 ML / 1 DAY rufinamide 40 mg/ml suspension NP PA

QL 8 TABS / 1 DAY rufinamide 400 mg tablet C PA

SABRIL PA NP S Specialty Drug

SPRITAM PA levetiracetam NP SUBVENITE lamotrigine C SUBVENITE (BLUE) lamotrigine C SUBVENITE (GREEN) lamotrigine C SUBVENITE (ORANGE) lamotrigine C TEGRETOL PA carbamazepine NP TEGRETOL XR PA carbamazepine NP

tiagabine hcl NP PA

TOPAMAX PA topiramate NP

topiramate P

topiramate er C PA

TRILEPTAL PA oxcarbazepine NP TROKENDI XR PA topiramate NP

valproic acid 250 mg capsule P

valproic acid 250 mg/5 ml soln P

valproic acid 500 mg/10 ml sol P

PA vigabatrin NP S Specialty Drug

PAGE 63 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

VIGADRONE PA C vigabatrin S Specialty Drug

VIMPAT 10 MG/ML SOLUTION QL 40 ML / 1 DAY NP PA

VIMPAT 100 MG TABLET QL 4 TABS / 1 DAY NP lacosamide PA

VIMPAT 150 MG TABLET QL 2 TABS / 1 DAY NP lacosamide PA

VIMPAT 200 MG TABLET QL 2 TABS / 1 DAY NP lacosamide PA

VIMPAT 50 MG TABLET QL 8 TABS / 1 DAY NP lacosamide PA

XCOPRI 100 MG TABLET QL 1 TAB / 1 DAY NP PA

XCOPRI 12.5-25 MG TITRATION PK QL 1 TAB / 1 DAY NP cenobamate PA

XCOPRI 150 MG TABLET QL 1 TAB / 1 DAY NP cenobamate PA

XCOPRI 150-200 MG TITRATION PK QL 1 TAB / 1 DAY NP cenobamate PA

XCOPRI 200 MG TABLET QL 2 TABS / 1 DAY NP cenobamate PA

XCOPRI 250 MG DAILY DOSE PACK QL 2 TABS / 1 DAY NP cenobamate PA

XCOPRI 350 MG DAILY DOSE PACK QL 2 TABS / 1 DAY NP cenobamate PA

XCOPRI 50 MG TABLET QL 1 TAB / 1 DAY NP cenobamate PA

XCOPRI 50-100 MG TITRATION PAK QL 1 TAB / 1 DAY NP cenobamate PA

PAGE 64 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ZONEGRAN PA NP

zonisamide P (ANTICONVULSANTS)

MYSOLINE PA NP

primidone P (ANTICONVULSANTS)

10 mg tablet P

QL 16 ML / 1 DAY clobazam 2.5 mg/ml suspension NP PA

clobazam 20 mg tablet P

0.125 mg dis tab C QL 6 TABS / 1 DAY

clonazepam 0.125 mg odt C QL 6 TABS / 1 DAY

clonazepam 0.25 mg odt C QL 6 TABS / 1 DAY

clonazepam 0.5 mg dis tablet C QL 6 TABS / 1 DAY

clonazepam 0.5 mg odt C QL 6 TABS / 1 DAY

clonazepam 0.5 mg tablet C QL 6 TABS / 1 DAY

clonazepam 1 mg dis tablet C QL 4 TABS / 1 DAY

clonazepam 1 mg odt C QL 4 TABS / 1 DAY

clonazepam 1 mg tablet C QL 4 TABS / 1 DAY

clonazepam 2 mg odt C QL 2 TABS / 1 DAY

clonazepam 2 mg tablet C QL 2 TABS / 1 DAY

NAYZILAM PA NP

ONFI 10 MG TABLET QL 4 TABS / 1 DAY NP clobazam PA

ONFI 2.5 MG/ML SUSPENSION QL 16 ML / 1 DAY NP clobazam PA

ONFI 20 MG TABLET QL 2 TABS / 1 DAY NP clobazam PA

PAGE 65 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SYMPAZAN PA clobazam NP

DILANTIN 100 MG CAPSULE sodium extended P DILANTIN 30 MG CAPSULE phenytoin sodium extended P DILANTIN 50 MG INFATAB PA phenytoin NP DILANTIN-125 PA phenytoin NP PEGANONE P PHENYTEK phenytoin sodium extended P

phenytoin P

phenytoin sod ext 100 mg cap C

phenytoin sod ext 200 mg cap P

phenytoin sod ext 300 mg cap P

CELONTIN methsuximide P

P ZARONTIN PA ethosuximide NP

ANTIDEPRESSANTS, MISCELLANEOUS

APLENZIN PA hbr NP

bupropion hcl P

bupropion hcl sr P

bupropion xl P FORFIVO XL PA bupropion hcl NP

P

PAGE 66 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS REMERON PA mirtazapine NP WELLBUTRIN SR PA bupropion hcl NP WELLBUTRIN XL PA bupropion hcl NP INHIBITORS

sulfate C

sulfate C SEL.,NOREPI

CYMBALTA 20 MG CAPSULE QL 2 CAPS / 1 DAY NP hcl PA

CYMBALTA 30 MG CAPSULE QL 3 CAPS / 1 DAY NP duloxetine hcl PA

CYMBALTA 60 MG CAPSULE QL 2 CAPS / 1 DAY NP duloxetine hcl PA

er NP PA

desvenlafaxine suc er 100 mg tablet (generic for Pristiq) NP PA

desvenlafaxine suc er 25 mg tablet (generic for Pristiq) NP PA

desvenlafaxine suc er 50 mg tablet (generic for Pristiq) NP PA

duloxetine hcl dr 20 mg cap P QL 2 CAPS / 1 DAY

duloxetine hcl dr 30 mg cap P QL 3 CAPS / 1 DAY

duloxetine hcl dr 60 mg cap P QL 2 CAPS / 1 DAY

EFFEXOR XR PA hcl NP FETZIMA PA hcl NP PRISTIQ PA desvenlafaxine succinate NP

venlafaxine hcl P

venlafaxine hcl er 150 mg cap P

venlafaxine hcl er 150 mg tab NP PA

PAGE 67 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

venlafaxine hcl er 225 mg tab NP PA

venlafaxine hcl er 37.5 mg cap P

venlafaxine hcl er 37.5 mg tab NP PA

venlafaxine hcl er 75 mg cap P

venlafaxine hcl er 75 mg tab NP PA

SELECTIVE-SEROTONIN REUPTAKE INHIBITORS

BRISDELLE PA mesylate NP CELEXA PA hydrobromide NP

citalopram hbr P

P

20 mg/5 ml solution P

fluoxetine dr NP PA

fluoxetine hcl 10 mg capsule P

fluoxetine hcl 10 mg tablet NP PA

fluoxetine hcl 20 mg capsule P

fluoxetine hcl 20 mg tablet NP PA

fluoxetine hcl 40 mg capsule P

fluoxetine hcl 60 mg tablet NP PA

maleate P

fluvoxamine maleate er NP PA

LEXAPRO PA escitalopram oxalate NP

-fluoxetine hcl NP PA

paroxetine cr NP PA

paroxetine er NP PA

paroxetine hcl P

paroxetine mesylate NP PA

PAXIL PA paroxetine hcl NP

PAGE 68 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS PAXIL CR PA paroxetine hcl NP PEXEVA PA paroxetine mesylate NP PROZAC PA fluoxetine hcl NP SARAFEM PA fluoxetine hcl NP

hcl P SYMBYAX PA olanzapine/fluoxetine hcl NP ZOLOFT PA sertraline hcl NP SEROTONIN MODULATORS

hcl P

hcl P TRINTELLIX PA hydrobromide NP VIIBRYD PA hcl NP , OTHER NOREPI-RU INHIBITORS

hcl C

hcl C

hcl C

10 mg capsule C

doxepin 10 mg/ml oral conc C

doxepin 100 mg capsule C

doxepin 150 mg capsule C

doxepin 25 mg capsule C

doxepin 50 mg capsule C

doxepin 75 mg capsule C

hcl C

hcl 10 mg cap C

nortriptyline hcl 25 mg cap C

PAGE 69 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

nortriptyline hcl 50 mg cap C

nortriptyline hcl 75 mg cap C ANTIDIABETIC AGENTS

ALPHA-GLUCOSIDASE INHIBITORS

acarbose P GLYSET PA miglitol NP

miglitol NP PA

PRECOSE PA acarbose NP AMYLINOMIMETICS

SYMLINPEN 120 acetate P SYMLINPEN 60 pramlintide acetate P BIGUANIDES

METFORMIN HCL 1,000 MG TABLET (generic for GLUCOPHAGE) C METFORMIN HCL 500 MG TABLET (generic for GLUCOPHAGE) C

metformin hcl 850 mg tablet C

metformin hcl er C DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

QL 1 TAB / 1 DAY alogliptin NP PA

QL 2 TABS / 1 DAY alogliptin-metformin NP PA

QL 1 TAB / 1 DAY alogliptin-pioglitazone NP PA

JANUMET sitagliptin phosphate/metformin hcl P

JANUMET XR QL 2 TABS / 1 DAY NP sitagliptin phosphate/metformin hcl PA

PAGE 70 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS JANUVIA sitagliptin phosphate P JENTADUETO linagliptin/metformin hcl P

JENTADUETO XR QL 2 TABS / 1 DAY NP linagliptin/metformin hcl PA

KAZANO QL 2 TABS / 1 DAY NP alogliptin benzoate/metformin hcl PA

KOMBIGLYZE XR saxagliptin hcl/metformin hcl P

NESINA QL 1 TAB / 1 DAY NP alogliptin benzoate PA

ONGLYZA saxagliptin hcl P

OSENI QL 1 TAB / 1 DAY NP alogliptin benzoate/pioglitazone hcl PA

TRADJENTA linagliptin P INCRETIN MIMETICS

ADLYXIN QL 6 ML / 28 DAYS NP PA

BYDUREON BCISE microspheres P BYDUREON PEN exenatide microspheres C BYETTA exenatide P

OZEMPIC 0.25-0.5 MG/DOSE PEN QL 1.5 ML / 28 DAYS NP PA

OZEMPIC 1 MG/DOSE (2 MG/1.5ML) QL 3 ML / 28 DAYS NP semaglutide PA

OZEMPIC 1 MG/DOSE (4 MG/3 ML) QL 3 ML / 28 DAYS NP semaglutide PA

PAGE 71 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

RYBELSUS QL 1 TAB / 1 DAY NP semaglutide PA

TRULICITY QL 2 ML / 28 DAYS NP PA

VICTOZA 2-PAK P VICTOZA 3-PAK liraglutide P MEGLITINIDES

C

C SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

FARXIGA QL 1 TAB / 1 DAY dapagliflozin propanediol P

GLYXAMBI QL 1 TAB / 1 DAY NP empagliflozin/linagliptin PA

INVOKAMET QL 2 TABS / 1 DAY NP canagliflozin/metformin hcl PA

INVOKAMET XR QL 2 TABS / 1 DAY NP canagliflozin/metformin hcl PA

INVOKANA QL 1 TAB / 1 DAY canagliflozin P JARDIANCE QL 1 TAB / 1 DAY empagliflozin P

QTERN QL 1 TAB / 1 DAY NP dapagliflozin propanediol/saxagliptin hcl PA

SEGLUROMET QL 2 TABS / 1 DAY NP ertugliflozin pidolate/metformin hcl PA

STEGLATRO QL 1 TAB / 1 DAY NP ertugliflozin pidolate PA

STEGLUJAN QL 1 TAB / 1 DAY NP ertugliflozin pidolate/sitagliptin phosphate PA

PAGE 72 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

SYNJARDY QL 2 TABS / 1 DAY NP empagliflozin/metformin hcl PA

SYNJARDY XR QL 2 TABS / 1 DAY NP empagliflozin/metformin hcl PA

TRIJARDY XR 10-5-1,000 MG TAB QL 1 TAB / 1 DAY NP empagliflozin/linagliptin/metformin hcl PA

TRIJARDY XR 12.5-2.5-1,000 MG QL 2 TABS / 1 DAY NP empagliflozin/linagliptin/metformin hcl PA

TRIJARDY XR 25-5-1,000 MG TAB QL 1 TAB / 1 DAY NP empagliflozin/linagliptin/metformin hcl PA

TRIJARDY XR 5-2.5-1,000 MG TAB QL 2 TABS / 1 DAY NP empagliflozin/linagliptin/metformin hcl PA

XIGDUO XR QL 1 TAB / 1 DAY NP dapagliflozin propanediol/metformin hcl PA

SULFONYLUREAS

AMARYL PA NP

glimepiride P

P

glipizide er P

glipizide xl P

glipizide-metformin C GLUCOTROL PA glipizide NP GLUCOTROL XL PA glipizide NP

glyburide P

glyburide micronized P

glyburide-metformin hcl C PA

GLYNASE PA glyburide,micronized NP

PAGE 73 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS THIAZOLIDINEDIONES

ACTOPLUS MET PA pioglitazone hcl/metformin hcl NP ACTOPLUS MET XR PA pioglitazone hcl/metformin hcl NP AVANDIA PA rosiglitazone maleate NP DUETACT PA pioglitazone hcl/glimepiride NP

pioglitazone hcl P

pioglitazone-glimepiride NP PA

pioglitazone-metformin NP PA

ANTIEMETICS

5-HT3 ANTAGONISTS

hcl 1 mg tablet NP PA

4 mg/5 ml solution P

ondansetron hcl 24 mg tablet P

ondansetron hcl 4 mg tablet P

ondansetron hcl 8 mg tablet P

ondansetron odt P SANCUSO PA granisetron NP ZOFRAN PA ondansetron hcl NP ZUPLENZ PA ondansetron NP ANTIEMETICS, MISCELLANEOUS

CESAMET PA NP

10 mg capsule C QL 4 CAPS / 1 DAY

dronabinol 2.5 mg capsule C QL 6 CAPS / 1 DAY

dronabinol 5 mg capsule C QL 6 CAPS / 1 DAY

C

PAGE 74 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS (GI DRUGS)

COMPRO C

CVS MOTION SICKNESS RELIEF TAB C OTC

12.5 mg caplet C OTC

meclizine 12.5 mg tablet C OTC

meclizine 25 mg tablet C

meclizine 25 mg tablet chew C OTC

MOTION SICKNESS RELIEF TB CHEW C OTC

prochlorperazine C

prochlorperazine maleate C

RA MOTION SICKNESS RLF TB CHEW C OTC

trimethobenzamide hcl C NEUROKININ-1 RECEPTOR ANTAGONISTS

AKYNZEO 300-0.5 MG CAPSULE PA netupitant/ hcl NP

C EMEND 125 MG CAPSULE aprepitant C EMEND 125 MG POWDER PACKET aprepitant C EMEND 40 MG CAPSULE aprepitant C (SYSTEMIC)

ALLYLAMINE

terbinafine hcl P ANTIFUNGALS, MISCELLANEOUS

NP PA

griseofulvin ultramicrosize NP PA

PAGE 75 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS AZOLE ANTIFUNGALS

CRESEMBA 186 MG CAPSULE PA isavuconazonium sulfate NP DIFLUCAN PA NP

fluconazole P

10 mg/ml solution NP PA

itraconazole 100 mg capsule NP PA

200 mg tablet NP PA

NOXAFIL 40 MG/ML SUSPENSION PA posaconazole NP NOXAFIL DR 100 MG TABLET PA posaconazole NP ONMEL PA itraconazole NP

posaconazole NP PA

SPORANOX 10 MG/ML SOLUTION PA itraconazole NP SPORANOX 100 MG CAPSULE PA itraconazole NP TOLSURA PA itraconazole NP

voriconazole 200 mg tablet C PA

voriconazole 40 mg/ml susp C PA

voriconazole 50 mg tablet C PA

POLYENE ANTIFUNGALS

100,000 unit/ml susp P

nystatin 500,000 unit oral tab NP PA

nystatin 500,000 unit/5 ml sus P PYRIMIDINE ANTIFUNGALS

ANCOBON PA flucytosine NP

flucytosine NP PA

PAGE 76 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)

ALLYLAMINES (SKIN AND MUCOUS MEMBRANE)

ATHLETE'S FOOT 1% CREAM OTC terbinafine hcl C EQ ATHLETE'S FOOT 1% CREAM OTC terbinafine hcl C LAMISIL OTC terbinafine hcl C

naftifine hcl 1% cream NP PA

QL 60 GM / 30 DAYS naftifine hcl 2% cream NP PA

NAFTIN 1% GEL PA naftifine hcl NP

NAFTIN 2% CREAM QL 60 GM / 30 DAYS NP naftifine hcl PA

NAFTIN 2% GEL PA naftifine hcl NP

terbinafine P OTC

AZOLES (SKIN AND MUCOUS MEMBRANE)

1-DAY C OTC

ANTI-FUNGAL POWDER P OTC

ANTIFUNGAL 1% TOPICAL CREAM C OTC

ANTIFUNGAL CREAM P

ANTIFUNGAL POWDER P OTC

ATHLETE'S FOOT 2% POWDER P OTC

clotrimazole 1% solution C OTC

clotrimazole 1% top cream grx P OTC

clotrimazole 1% topical cream P OTC

clotrimazole 1% vaginal cream C OTC

clotrimazole 10 mg troche C

PAGE 77 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

CLOTRIMAZOLE-1% SOLUTION P OTC

clotrimazole-3 C OTC

clotrimazole-7 C OTC

clotrimazole-betamethasone crm P

clotrimazole-betamethasone lot NP PA

cvs clotrimazole 1% solution C OTC

cvs clotrimazole 1% top cream P OTC

DESENEX P OTC

econazole nitrate P EXELDERM PA sulconazole nitrate NP FUNGOID OTC nitrate C GYNE-LOTRIMIN-7 OTC clotrimazole C JUBLIA PA efinaconazole NP

ketoconazole 2% cream C QL 60 GM / 30 DAYS

ketoconazole 2% foam NP PA

ketoconazole 2% P KETODAN 2% FOAM ketoconazole C

LOTRIMIN AF 2% POWDER P OTC

LUZU PA luliconazole NP

MICATIN P OTC

miconazole 100 mg vag supp C OTC

miconazole 2% topical cream P OTC

miconazole 3 combo pack C OTC

miconazole 7 C OTC

PAGE 78 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS MICONAZOLE 7 100 MG VAG SUPP OTC miconazole nitrate C

miconazole-7 C OTC

MICONAZORB AF P OTC

MICRO-GUARD P OTC

MONISTAT 3 C OTC

MONISTAT 7 OTC miconazole nitrate C

MYCOZYL AP P OTC

ORAVIG PA miconazole NP

QL 60 GM / 30 DAYS oxiconazole nitrate NP PA

OXISTAT 1% CREAM QL 60 GM / 30 DAYS NP oxiconazole nitrate PA

QC ATHLETE'S FOOT 1% CREAM P OTC

qc clotrimazole 1% top cream P OTC

ra clotrimazole 1% vag cream C OTC

REMEDY ANTIFUNGAL P OTC

REMEDY PHYTOPLEX ANTIFUNGAL P OTC

sm clotrimazole 1% top cream P OTC

sm clotrimazole 1% vag cream C OTC

C

THERA ANTIFUNGAL P OTC

-1 C OTC

TRIPLE PASTE AF C OTC

VUSION PA miconazole nitrate/zinc oxide/petrolatum,white NP

ZEASORB P OTC

PAGE 79 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

ZEASORB AF P OTC

HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)

CICLODAN 0.77% CREAM PA ciclopirox olamine NP CICLODAN 8% SOLUTION PA ciclopirox NP

ciclopirox 0.77% cream P

ciclopirox 0.77% gel NP PA

ciclopirox 0.77% topical susp P

ciclopirox 1% shampoo NP PA

ciclopirox 8% solution P LOPROX 0.77% CREAM PA ciclopirox olamine NP LOPROX 0.77% TOPICAL SUSP PA ciclopirox olamine NP LOPROX 1% SHAMPOO PA ciclopirox NP PENLAC PA ciclopirox NP OXABOROLES

C PA

POLYENES (SKIN AND MUCOUS MEMBRANE)

NYAMYC QL 240 GM / Rx nystatin C

nystatin 100,000 unit/gm cream P

nystatin 100,000 unit/gm oint P

nystatin 100,000 unit/gm powd P QL 240 GM / Rx

nystatin-triamcinolone cream P

nystatin-triamcinolone ointm NP PA

NYSTOP QL 240 GM / Rx nystatin C

PAGE 80 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS THIOCARBAMATES(SKIN AND MUCOUS MEMBRANE)

ANTIFUNGAL 1% LIQUID SPRAY C OTC

CVS ATHLETE'S FOOT 1% LQ SPRAY C OTC

gnp tolnaftate 1% cream P OTC

qc tolnaftate 1% cream P OTC

RA ANTIFUNGAL 1% LIQUID SPRAY C OTC

TOLCYLEN C OTC

tolnaftate 1% cream P OTC

tolnaftate 1% spray powder C OTC

ANTIGLAUCOMA AGENTS

ALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P tartrate P

brimonidine 0.2% eye drop P

brimonidine tartrate 0.15% drp NP PA

COMBIGAN brimonidine tartrate/ maleate P BETA-ADRENERGIC BLOCKING AGENTS (EENT)

hcl 0.5% eye drop NP PA

BETOPTIC S PA betaxolol hcl NP

hcl NP PA

ISTALOL PA timolol maleate NP

hcl NP PA

timolol 0.25% gel-solution P

timolol 0.25% gfs gel-solution P

timolol 0.5% eye drop (Generic for Istalol) NP PA

timolol 0.5% gel-solution P

timolol 0.5% gfs gel-solution P

PAGE 81 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

timolol maleate 0.25% eye drop (generic for Timoptic) P

timolol maleate 0.5% eye drops (generic for Timoptic) P TIMOPTIC PA timolol maleate NP TIMOPTIC OCUDOSE PA timolol maleate/pf NP TIMOPTIC-XE PA timolol maleate NP CARBONIC ANHYDRASE INHIBITORS (EENT)

C

acetazolamide er C AZOPT PA NP

brinzolamide C COSOPT PA hcl/timolol maleate NP COSOPT PF PA dorzolamide hcl/timolol maleate/pf NP

dorzolamide P

dorzolamide hcl P

dorzolamide-timolol 2%-0.5% NP PA

dorzolamide-timolol eye drops P

C SIMBRINZA PA brinzolamide/brimonidine tartrate NP

timolol-dorzolamide NP PA

TRUSOPT PA dorzolamide hcl NP MIOTICS

1% eye drops C

pilocarpine 2% eye drops C

pilocarpine 4% eye drops C

PAGE 82 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ANALOGS

0.03% eye drops NP PA

P LUMIGAN PA bimatoprost NP TRAVATAN Z P

travoprost NP PA

VYZULTA PA latanoprostene bunod NP XALATAN PA latanoprost NP XELPROS PA latanoprost NP ZIOPTAN PA /pf NP RHO KINASE INHIBITORS

RHOPRESSA PA netarsudil mesylate NP ROCKLATAN PA netarsudil mesylate/latanoprost NP ANTIHEMORRHAGIC AGENTS

HEMOSTATICS

ADVATE PA P antihemophilic factor (fviii) recombinant,full length S Specialty Drug

ADYNOVATE PA NP antihemophilic factor (fviii) recombinant, full length, peg S Specialty Drug

AFSTYLA PA NP antihemophilic factor viii recomb,single-chn,b-dom truncated S Specialty Drug

ALPHANATE PA P antihemophilic factor, human/von willebrand factor,human S Specialty Drug

ALPHANINE SD PA NP factor ix S Specialty Drug

PAGE 83 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

ALPROLIX PA NP factor ix recombinant, fc fusion protein S Specialty Drug

aminocaproic acid 0.25 gram/ml C

aminocaproic acid 1,000 mg tab C

aminocaproic acid 500 mg tab C

BENEFIX PA P factor ix human recombinant S Specialty Drug

COAGADEX PA P coagulation factor x S Specialty Drug

CORIFACT PA P factor xiii S Specialty Drug

ELOCTATE PA NP antihemophilic factor (fviii) recombinant, fc fusion protein S Specialty Drug

ESPEROCT PA NP antihemophilic factor (fviii) rec, b-dom truncated peg-exei S Specialty Drug

FEIBA NF PA P anti-inhibitor coagulant complex S Specialty Drug

HELIXATE FS PA C antihemophilic factor (fviii) recombinant,full length S Specialty Drug

HEMLIBRA PA C emicizumab-kxwh S Specialty Drug

HEMOFIL M PA P antihemophilic factor, human S Specialty Drug

HUMATE-P PA P antihemophilic factor, human/von willebrand factor,human S Specialty Drug

IDELVION PA NP factor ix recombinant,albumin fusion protein S Specialty Drug

IXINITY PA NP factor ix human recombinant, threonine 148 S Specialty Drug

JIVI PA NP antihemophilic factor (fviii) rec, b-domain deleted peg-aucl S Specialty Drug

PAGE 84 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

KOATE PA P antihemophilic factor, human S Specialty Drug

KOGENATE FS PA NP antihemophilic factor (fviii) recombinant,full length S Specialty Drug

KOVALTRY PA NP antihemophilic factor (fviii) recombinant,full length S Specialty Drug

MONONINE PA P factor ix S Specialty Drug

NOVOEIGHT PA P antihemophilic factor viii recombinant, b-domain truncated S Specialty Drug

NOVOSEVEN RT PA NP coagulation factor viia (recombinant) S Specialty Drug

NUWIQ PA P antihemophilic factor viii rec hek cell, b-domain deleted S Specialty Drug

OBIZUR PA NP antihemophilic factor viii, recombinant porcine sequence S Specialty Drug

PROFILNINE PA P factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor S Specialty Drug

REBINYN PA NP factor ix (human) recombinant, pegylated S Specialty Drug

RECOMBINATE PA NP antihemophilic factor viii, human recombinant S Specialty Drug

RIXUBIS PA NP factor ix human recombinant S Specialty Drug

SEVENFACT PA C coagulation factor viia recombinant-jncw S Specialty Drug

tranexamic acid 650 mg tablet C QL 30 TABS / RX

TRETTEN PA P factor xiii a-subunit, recombinant S Specialty Drug

PAGE 85 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

VONVENDI PA NP von willebrand factor (recombinant) S Specialty Drug

WILATE PA P antihemophilic factor, human/von willebrand factor,human S Specialty Drug

XYNTHA PA P antihemophilic factor (factor viii) recomb,b-domain deleted S Specialty Drug

XYNTHA SOLOFUSE PA P antihemophilic factor (factor viii) recomb,b-domain deleted S Specialty Drug

ANTIHISTAMINE DRUGS

SECOND GENERATION ANTIHISTAMINES

ALL DAY ALLERGY OTC hcl P ALL DAY ALLERGY-D OTC cetirizine hcl/ hcl C ALLER-TEC D OTC cetirizine hcl/pseudoephedrine hcl C ALLERGY () 10 MG TAB OTC loratadine C ALLERGY COMPLETE-D OTC cetirizine hcl/pseudoephedrine hcl C ALLERGY RELIEF 10 MG TABLET OTC loratadine C ALLERGY RELIEF D-12 OTC loratadine/pseudoephedrine sulfate P ALLERGY RELIEF NASAL DECONGEST OTC cetirizine hcl/pseudoephedrine hcl C ALLERGY RELIEF-D OTC cetirizine hcl/pseudoephedrine hcl C ALLERGY RLF (CETRZN) 10 MG TAB OTC cetirizine hcl P ALLERGY-CONGESTION RLF 12H TAB OTC loratadine/pseudoephedrine sulfate P

cetirizine hcl P OTC

cetirizine-pseudoephedrine er P OTC

PAGE 86 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS CHILD ALLERGY RELIEF 1 MG/ML OTC cetirizine hcl C CHILD ALLERGY RELIEF 5 MG/5 ML OTC loratadine C

child loratadine 5 mg tab chew C OTC

child loratadine 5 mg/5 ml sol P OTC

child loratadine 5 mg/5 ml syr P OTC

CHILD'S CLARITIN 5 MG TAB CHEW OTC loratadine C CLARINEX PA NP CLARINEX-D 12 HOUR PA desloratadine/pseudoephedrine sulfate NP CLARITIN 10 MG LIQUI-GEL CAP OTC loratadine C CLARITIN 10 MG TABLET OTC loratadine C CVS ALLERGY (CETRZN) 10 MG TAB OTC cetirizine hcl P CVS CHILD ALLERGY RLF 5 MG CHW OTC loratadine C

desloratadine NP PA

EQ ALLERGY (LORAT) 10 MG TAB OTC loratadine C EQ CHILD ALLERGY 5 MG/5 ML SOL OTC loratadine C EQL ALLERGY-CONGESTION 12H TAB OTC loratadine/pseudoephedrine sulfate P GNP ALLERGY RELIEF 5 MG TABLET OTC dihydrochloride C

gnp chld loratadine 5 mg/5 ml P OTC

GS ALLERGY RELIEF 10 MG TABLET OTC loratadine C HM ALLERGY RELIEF 10 MG TABLET OTC cetirizine hcl P HM ALLERGY-CONGESTION 12HR TAB OTC loratadine/pseudoephedrine sulfate P

PAGE 87 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS HM CHILD ALLERGY RLF 5 MG CHEW OTC loratadine C

hm child loratadine 5 mg/5 ml P OTC

levocetirizine 2.5 mg/5 ml sol P

levocetirizine 5 mg tablet P OTC

loratadine P OTC

loratadine allergy P OTC

LORATADINE-D OTC loratadine/pseudoephedrine sulfate P

RA ALLERGY-CONGESTION 12HR TAB P OTC

SEMPREX-D PA pseudoephedrine hcl/ NP WAL-ITIN OTC loratadine C ANTIHYPOGLYCEMIC AGENTS

GLYCOGENOLYTIC AGENTS

BAQSIMI C GLUCAGEN 1 MG HYPOKIT glucagon C GLUCAGON EMERGENCY KIT glucagon C

glucagon hcl C GVOKE HYPOPEN 1-PACK glucagon C GVOKE HYPOPEN 2-PACK glucagon C GVOKE PFS 1-PACK SYRINGE glucagon C GVOKE PFS 2-PACK SYRINGE glucagon C

PAGE 88 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ANTILIPEMIC AGENTS

ANTILIPEMIC AGENTS, MISCELLANEOUS

fish oil 1,000 mg capsule C OTC

fish oil omega-3 C OTC

icosapent ethyl C PA

JUXTAPID PA C lomitapide mesylate S Specialty Drug

LOVAZA PA omega-3 acid ethyl esters NP NEXLETOL PA bempedoic acid NP NEXLIZET PA bempedoic acid/ezetimibe NP

100 mg tablet P OTC

niacin 250 mg tablet P OTC

niacin 50 mg tablet P OTC

niacin 500 mg capsule sa P OTC

niacin 500 mg tablet P OTC

niacin 500 mg tablet (Rx only) C OTC

niacin er P

niacin er 1,000 mg caplet P OTC

niacin er 1,000 mg tablet P OTC

niacin er 250 mg capsule P OTC

niacin er 500 mg caplet P OTC

niacin er 500 mg capsule P OTC

niacin er 500 mg tablet P OTC

niacin sa 250 mg capsule P OTC

niacin tr 250 mg capsule P OTC

niacin tr 500 mg caplet P OTC

PAGE 89 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

niacin tr 500 mg capsule P OTC

niacin tr 500 mg tablet P OTC

NIACOR PA niacin NP NIASPAN niacin P

NIAVASC C OTC

omega-3 acid ethyl esters NP PA

plain niacin P OTC

ra niacin 100 mg tablet P OTC

ra niacin 500 mg tablet P OTC

SLO-NIACIN OTC niacin P TRIKLO omega-3 acid ethyl esters C VASCEPA PA icosapent ethyl NP BILE ACID SEQUESTRANTS

cholestyramine P

cholestyramine light P

colesevelam hcl NP PA

COLESTID PA hcl NP

colestipol hcl P PREVALITE cholestyramine/ C QUESTRAN PA cholestyramine (with ) NP QUESTRAN LIGHT PA cholestyramine/aspartame NP WELCHOL PA colesevelam hcl NP

PAGE 90 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS INHIBITORS

ezetimibe P

ezetimibe-simvastatin NP PA

VYTORIN PA ezetimibe/simvastatin NP ZETIA PA ezetimibe NP FIBRIC ACID DERIVATIVES

ANTARA PA fenofibrate,micronized NP

fenofibrate 120 mg tablet NP PA

fenofibrate 130 mg capsule NP PA

fenofibrate 134 mg capsule P

fenofibrate 145 mg tablet P

fenofibrate 150 mg capsule NP PA

fenofibrate 160 mg tablet P

fenofibrate 200 mg capsule P

fenofibrate 40 mg tablet NP PA

fenofibrate 43 mg capsule NP PA

fenofibrate 48 mg tablet P

fenofibrate 50 mg capsule NP PA

fenofibrate 54 mg tablet P

fenofibrate 67 mg capsule P

fenofibric acid 105 mg tablet NP PA

fenofibric acid 35 mg tablet NP PA

fenofibric acid dr 135 mg cap NP PA

fenofibric acid dr 45 mg cap NP PA

FENOGLIDE PA fenofibrate NP FIBRICOR PA fenofibric acid NP

PAGE 91 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

P LIPOFEN PA fenofibrate NP LOPID PA gemfibrozil NP TRICOR PA fenofibrate nanocrystallized NP TRIGLIDE PA fenofibrate nanocrystallized NP TRILIPIX PA fenofibric acid () NP HMG-COA REDUCTASE INHIBITORS

ALTOPREV PA lovastatin NP

-atorvastatin NP PA

atorvastatin P CADUET PA amlodipine besylate/atorvastatin calcium NP CRESTOR PA calcium NP EZALLOR SPRINKLE PA rosuvastatin calcium NP

fluvastatin er NP PA

fluvastatin sodium NP PA

LESCOL XL PA fluvastatin sodium NP LIPITOR PA atorvastatin calcium NP LIVALO PA calcium NP

lovastatin P PRAVACHOL PA sodium NP

pravastatin sodium P

rosuvastatin calcium P

simvastatin 10 mg tablet P

PAGE 92 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

simvastatin 20 mg tablet P

simvastatin 40 mg tablet P

simvastatin 5 mg tablet P

simvastatin 80 mg tablet P ZOCOR PA simvastatin NP ZYPITAMAG PA pitavastatin NP PCSK9 INHIBITORS

PRALUENT PEN QL 2 ML / 28 DAYS NP alirocumab PA

REPATHA PUSHTRONEX QL 3.5 ML / 28 DAYS NP evolocumab PA

REPATHA SURECLICK QL 2 ML / 28 DAYS NP evolocumab PA

REPATHA SYRINGE QL 2 ML / 28 DAYS NP evolocumab PA

ANTIMIGRAINE AGENTS

CALCITONIN -RELATED ANTAG.

QL 1 / AIMOVIG AUTOINJECTOR 30 DAYS -aooe NP PA S Specialty Drug

QL 1.5 ML / 30 DAYS AJOVY AUTOINJECTOR PA -vfrm P S Specialty Drug

QL 1.5 ML / 30 DAYS AJOVY SYRINGE PA fremanezumab-vfrm P S Specialty Drug

QL 3 ML / 30 DAYS EMGALITY 100 MG/ML SYR(1 OF 3) PA -gnlm C S Specialty Drug

PAGE 93 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 ML / 30 DAYS EMGALITY 120 MG/ML SYRINGE PA galcanezumab-gnlm P S Specialty Drug

QL 3 ML / 30 DAYS EMGALITY 300 MG (100 MG X3SYR) PA galcanezumab-gnlm C S Specialty Drug

QL 1 ML / 30 DAYS EMGALITY PEN PA galcanezumab-gnlm P S Specialty Drug

NURTEC ODT QL 8 TABS / 30 DAYS C sulfate PA

SELECTIVE SEROTONIN AGONISTS

malate NP PA

AMERGE QL 12 TABS / 30 DAYS NP hcl PA

QL 18 TABS / 28 DAYS hbr NP PA

FROVA QL 12 TABS / 28 DAYS NP succinate PA

QL 12 TABS / 28 DAYS frovatriptan succinate NP PA

IMITREX 100 MG TABLET QL 18 TABS / 28 DAYS NP succinate PA

IMITREX 20 MG QL 18 ML / 30 DAYS NP sumatriptan PA

IMITREX 25 MG TABLET QL 18 TABS / 28 DAYS NP sumatriptan succinate PA

IMITREX 5 MG NASAL SPRAY QL 18 ML / 30 DAYS NP sumatriptan PA

IMITREX 50 MG TABLET QL 18 TABS / 28 DAYS NP sumatriptan succinate PA

PAGE 94 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

MAXALT QL 18 TABS / 28 DAYS NP benzoate PA

MAXALT MLT QL 18 TABS / 28 DAYS NP rizatriptan benzoate PA

QL 12 TABS / 30 DAYS naratriptan hcl NP PA

ONZETRA XSAIL QL 16 CAPS / 30 DAYS NP sumatriptan succinate PA

RELPAX QL 18 TABS / 28 DAYS eletriptan hydrobromide P

REYVOW QL 8 TABS / 30 DAYS C succinate PA

rizatriptan P QL 18 TABS / 28 DAYS

sumatriptan P QL 18 ML / 30 DAYS

sumatriptan 4 mg/0.5 ml cart C QL 5 ML / 30 DAYS

sumatriptan 4 mg/0.5 ml inject C QL 5 ML / 30 DAYS

sumatriptan 6 mg/0.5 ml cart C QL 5 ML / 30 DAYS

sumatriptan 6 mg/0.5 ml inject C QL 5 ML / 30 DAYS

sumatriptan 6 mg/0.5 ml syrng C QL 5 ML / 30 DAYS

sumatriptan 6 mg/0.5 ml vial C QL 5 ML / 30 DAYS

sumatriptan succ 100 mg tablet P QL 18 TABS / 28 DAYS

sumatriptan succ 25 mg tablet P QL 18 TABS / 28 DAYS

sumatriptan succ 50 mg tablet P QL 18 TABS / 28 DAYS

QL 12 TABS / 28 DAYS sumatriptan succ- sod NP PA

TOSYMRA QL 6 DOSES / 30 DAYS NP sumatriptan PA

TREXIMET QL 12 TABS / 28 DAYS NP sumatriptan succinate/naproxen sodium PA

PAGE 95 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

ZEMBRACE SYMTOUCH QL 4 ML / 30 DAYS NP sumatriptan succinate PA

QL 12 TABS / 28 DAYS 2.5 mg tablet NP PA

QL 12 TABS / 28 DAYS zolmitriptan 5 mg tablet NP PA

QL 12 TABS / 28 DAYS zolmitriptan odt NP PA

ZOMIG 2.5 MG NASAL SPRAY QL 12 ML / 30 DAYS NP zolmitriptan PA

ZOMIG 2.5 MG TABLET QL 12 TABS / 28 DAYS NP zolmitriptan PA

ZOMIG 5 MG NASAL SPRAY QL 12 ML / 30 DAYS NP zolmitriptan PA

ZOMIG 5 MG TABLET QL 12 TABS / 28 DAYS NP zolmitriptan PA

ZOMIG ZMT QL 12 TABS / 28 DAYS NP zolmitriptan PA

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, MISCELLANEOUS

100 mg tablet C

dapsone 25 mg tablet C ANTITUBERCULOSIS AGENTS

C PA

hcl C

100 mg tablet C

isoniazid 300 mg tablet C

isoniazid 50 mg/5 ml solution C

pretomanid C PA

PAGE 96 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS PRIFTIN C

C

C

rifampin 150 mg capsule C

rifampin 300 mg capsule C SIRTURO PA fumarate C TRECATOR PA C ANTINEOPLASTIC AGENTS

QL 2 TABS / 1 DAY

PA

abiraterone 500 mg tablet C S Specialty Drug

TD

ONC

QL 4 TABS / 1 DAY

PA

250 mg tab C S Specialty Drug

TD

ONC

QL 1 TAB / 1 DAY

PA AFINITOR 10 MG TABLET S Specialty Drug C TD

ONC

QL 2 TABS / 1 DAY

PA AFINITOR DISPERZ 2 MG TABLET S Specialty Drug everolimus C TD

ONC

PAGE 97 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 2 TABS / 1 DAY

PA AFINITOR DISPERZ 5 MG TABLET S Specialty Drug everolimus C TD

ONC

QL 8 CAPS / 1 DAY

ALECENSA PA C hcl S Specialty Drug

ONC

C

QL 1 TAB / 1 DAY

AYVAKIT PA C S Specialty Drug

ONC

PA BALVERSA S Specialty Drug C ONC

C

QL 4 TABS / 1 DAY

PA BOSULIF 100 MG TABLET S Specialty Drug C TD

ONC

QL 1 TAB / 1 DAY

PA BOSULIF 400 MG TABLET S Specialty Drug bosutinib C TD

ONC

QL 1 TAB / 1 DAY

PA BOSULIF 500 MG TABLET S Specialty Drug bosutinib C TD

ONC

PAGE 98 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 2 CAPS / 1 DAY

BRAFTOVI 50 MG CAPSULE PA C S Specialty Drug

ONC

QL 6 CAPS / 1 DAY

BRAFTOVI 75 MG CAPSULE PA C encorafenib S Specialty Drug

ONC

PA BRUKINSA S Specialty Drug C ONC

QL 1 TAB / 1 DAY

PA CABOMETYX S Specialty Drug s-malate C TD

ONC

S Specialty Drug capecitabine C ONC

QL 2 TABS / 1 DAY

CAPRELSA 100 MG TABLET PA C S Specialty Drug

ONC

QL 1 TAB / 1 DAY

CAPRELSA 300 MG TABLET PA C vandetanib S Specialty Drug

ONC

QL 2 TABS / 1 DAY

PA COMETRIQ 100 MG DAILY-DOSE PK S Specialty Drug cabozantinib s-malate C TD

ONC

PAGE 99 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 3 TABS / 1 DAY

PA COMETRIQ 60 MG DAILY-DOSE PACK S Specialty Drug cabozantinib s-malate C TD

ONC

QL 2 CAPS / 1 DAY

PA COPIKTRA S Specialty Drug duvelisib C TD

ONC

QL 3 TABS / 1 DAY

COTELLIC PA C fumarate S Specialty Drug

ONC

cyclophosphamide 25 mg capsule C

cyclophosphamide 50 mg capsule C

QL 1 TAB / 1 DAY

PA DAURISMO 100 MG TABLET S Specialty Drug maleate C TD

ONC

QL 3 TABS / 1 DAY

PA DAURISMO 25 MG TABLET S Specialty Drug glasdegib maleate C TD

ONC

DROXIA 200 MG CAPSULE QL 2 CAPS / 1 DAY P hydroxyurea PA

DROXIA 300 MG CAPSULE QL 2 CAPS / 1 DAY P hydroxyurea PA

DROXIA 400 MG CAPSULE QL 8 CAPS / 1 DAY P hydroxyurea PA

PAGE 100 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS EMCYT sodium C

QL 1 CAP / 1 DAY

PA ERIVEDGE S Specialty Drug C TD

ONC

PA ERLEADA S Specialty Drug C ONC

QL 1 TAB / 1 DAY

PA

hcl 100 mg tablet C S Specialty Drug

TD

ONC

QL 1 TAB / 1 DAY

PA

erlotinib hcl 150 mg tablet C S Specialty Drug

TD

ONC

QL 3 TABS / 1 DAY

PA

erlotinib hcl 25 mg tablet C S Specialty Drug

TD

ONC

etoposide 50 mg capsule C

QL 1 TAB / 1 DAY

PA

everolimus 2.5 mg tablet C S Specialty Drug

TD

ONC

PAGE 101 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 TAB / 1 DAY

PA

everolimus 7.5 mg tablet C S Specialty Drug

TD

ONC

C

fluorouracil 2% topical soln C

fluorouracil 5% cream C

fluorouracil 5% topical soln C

C

QL 21 CAPS / 28 DAYS

FOTIVDA PA C hcl S Specialty Drug

ONC

PA GAVRETO S Specialty Drug C ONC

QL 1 TAB / 1 DAY

GILOTRIF PA C dimaleate S Specialty Drug

ONC

GLEOSTINE lomustine C

HYCAMTIN S Specialty Drug C topotecan hcl ONC

hydroxyurea C

QL 21 CAPS / 28 DAYS

IBRANCE 100 MG CAPSULE PA C S Specialty Drug

ONC

PAGE 102 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 21 CAPS / 28 DAYS

IBRANCE 125 MG CAPSULE PA C palbociclib S Specialty Drug

ONC

QL 21 TABS / 28 DAYS

IBRANCE 125 MG TABLET PA C palbociclib S Specialty Drug

ONC

QL 21 CAPS / 28 DAYS

IBRANCE 75 MG CAPSULE PA C palbociclib S Specialty Drug

ONC

QL 21 TABS / 28 DAYS

IBRANCE 75 MG TABLET PA C palbociclib S Specialty Drug

ONC

QL 2 TABS / 1 DAY

PA ICLUSIG 10 MG TABLET S Specialty Drug hcl C TD

ONC

QL 2 TABS / 1 DAY

PA ICLUSIG 15 MG TABLET S Specialty Drug ponatinib hcl C TD

ONC

QL 1 TAB / 1 DAY

PA ICLUSIG 30 MG TABLET S Specialty Drug ponatinib hcl C TD

ONC

PAGE 103 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 TAB / 1 DAY

IDHIFA PA C mesylate S Specialty Drug

ONC

S Specialty Drug

mesylate C TD

ONC

QL 4 CAPS / 1 DAY

IMBRUVICA 140 MG CAPSULE PA C S Specialty Drug

ONC

QL 1 TAB / 1 DAY

IMBRUVICA 420 MG TABLET PA C ibrutinib S Specialty Drug

ONC

QL 1 TAB / 1 DAY

IMBRUVICA 560 MG TABLET PA C ibrutinib S Specialty Drug

ONC

QL 1 CAP / 1 DAY

IMBRUVICA 70 MG CAPSULE PA C ibrutinib S Specialty Drug

ONC

QL 6 TABS / 1 DAY

PA INLYTA 1 MG TABLET S Specialty Drug C TD

ONC

QL 4 TABS / 1 DAY

PA INLYTA 5 MG TABLET S Specialty Drug axitinib C TD

ONC

PAGE 104 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 5 TABS / 28 DAYS

INQOVI PA C decitabine/cedazuridine S Specialty Drug

ONC

PA INREBIC S Specialty Drug dihydrochloride C ONC

QL 1 TAB / 1 DAY

IRESSA PA C S Specialty Drug

ONC

QL 2 TABS / 1 DAY

PA JAKAFI S Specialty Drug phosphate C TD

ONC

QL 21 TABS / 28 DAYS

KISQALI 200 MG DAILY DOSE PA C succinate S Specialty Drug

ONC

QL 42 TABS / 28 DAYS

KISQALI 400 MG DAILY DOSE PA C ribociclib succinate S Specialty Drug

ONC

QL 63 TABS / 28 DAYS

KISQALI 600 MG DAILY DOSE PA C ribociclib succinate S Specialty Drug

ONC

QL 49 TABS / 28 DAYS

KISQALI FEMARA 200 MG CO-PACK PA C ribociclib succinate/ S Specialty Drug

ONC

PAGE 105 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 70 TABS / 28 DAYS

KISQALI FEMARA 400 MG CO-PACK PA C ribociclib succinate/letrozole S Specialty Drug

ONC

QL 91 TABS / 28 DAYS

KISQALI FEMARA 600 MG CO-PACK PA C ribociclib succinate/letrozole S Specialty Drug

ONC

QL 8 CAPS / 1 DAY

KOSELUGO 10 MG CAPSULE PA C sulfate/vitamin e tpgs S Specialty Drug

ONC

QL 4 CAPS / 1 DAY

KOSELUGO 25 MG CAPSULE PA C selumetinib sulfate/vitamin e tpgs S Specialty Drug

ONC

QL 6 TABS / 1 DAY

PA C S Specialty Drug

ONC

QL 1 CAP / 1 DAY

PA LENVIMA 10 MG DAILY DOSE S Specialty Drug mesylate C TD

ONC

letrozole C LEUKERAN chlorambucil C

QL 60 TABS / 30 DAYS

LONSURF 15 MG-6.14 MG TABLET PA C trifluridine/tipiracil hcl S Specialty Drug

ONC

PAGE 106 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 80 TABS / 30 DAYS

LONSURF 20 MG-8.19 MG TABLET PA C trifluridine/tipiracil hcl S Specialty Drug

ONC

QL 1 TAB / 1 DAY

PA LORBRENA 100 MG TABLET S Specialty Drug C TD

ONC

QL 3 TABS / 1 DAY

PA LORBRENA 25 MG TABLET S Specialty Drug lorlatinib C TD

ONC

LUMAKRAS PA C ONC

QL 4 TABS / 1 DAY

PA LYNPARZA S Specialty Drug olaparib C TD

ONC

QL 2 CAPS / 1 DAY

MATULANE PA C hcl S Specialty Drug

ONC

QL 3 TABS / 1 DAY

MEKINIST 0.5 MG TABLET PA C S Specialty Drug

ONC

QL 1 TAB / 1 DAY

MEKINIST 2 MG TABLET PA C trametinib dimethyl sulfoxide S Specialty Drug

ONC

PAGE 107 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 6 TABS / 1 DAY

MEKTOVI PA C S Specialty Drug

ONC

melphalan C

mercaptopurine C

2.5 mg tablet C

methotrexate 250 mg/10 ml vial C

methotrexate 50 mg/2 ml vial C

methotrexate sodium C MYLERAN busulfan C

QL 6 TABS / 1 DAY

PA NERLYNX S Specialty Drug maleate C TD

ONC

QL 4 TABS / 1 DAY

PA NEXAVAR S Specialty Drug tosylate C TD

ONC

QL 3 CAPS / 28 DAYS

NINLARO PA C ixazomib citrate S Specialty Drug

ONC

PA NUBEQA S Specialty Drug C ONC

QL 1 CAP / 1 DAY

PA ODOMZO S Specialty Drug phosphate C TD

ONC

PAGE 108 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 14 TABS / 28 DAYS

ONUREG PA C azacitidine S Specialty Drug

ONC

QL 14 TABS / 21 DAYS

PEMAZYRE PA C S Specialty Drug

ONC

PICATO PA C

QL 1 CAP / 1 DAY

POMALYST PA C pomalidomide S Specialty Drug

ONC

QL 3 TABS / 1 DAY

QINLOCK PA C S Specialty Drug

ONC

RASUVO PA methotrexate/pf C

QL 6 CAPS / 1 DAY

RETEVMO 40 MG CAPSULE PA C S Specialty Drug

ONC

QL 4 CAPS / 1 DAY

RETEVMO 80 MG CAPSULE PA C selpercatinib S Specialty Drug

ONC

QL 1 CAP / 1 DAY REVLIMID S Specialty Drug lenalidomide C ONC

PA ROZLYTREK S Specialty Drug C ONC

PAGE 109 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PA RYDAPT S Specialty Drug C ONC

SIKLOS QL 2 TABS / 1 DAY NP hydroxyurea PA

PA

SPRYCEL S Specialty Drug C TD

ONC

PA STIVARGA S Specialty Drug C ONC

QL 1 CAP / 1 DAY

PA SUTENT S Specialty Drug malate C TD

ONC

TABLOID thioguanine C

QL 4 TABS / 1 DAY

TABRECTA PA C hydrochloride S Specialty Drug

ONC

QL 4 CAPS / 1 DAY

TAFINLAR PA C mesylate S Specialty Drug

ONC

QL 1 TAB / 1 DAY

PA TAGRISSO S Specialty Drug mesylate C TD

ONC

PAGE 110 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PA

TASIGNA S Specialty Drug C hcl TD

ONC

QL 8 TABS / 1 DAY

TAZVERIK PA C tazemetostat hydrobromide S Specialty Drug

ONC

S Specialty Drug temozolomide C ONC

QL 2 TABS / 1 DAY

TEPMETKO PA C hcl S Specialty Drug

ONC

QL 2 TABS / 1 DAY

TIBSOVO PA C S Specialty Drug

ONC

S Specialty Drug tretinoin 10 mg capsule C ONC

TRUSELTIQ PA C phosphate ONC

PA TURALIO S Specialty Drug hydrochloride C ONC

QL 4 TABS / 1 DAY

UKONIQ PA C umbralisib tosylate S Specialty Drug

ONC

QL 120 GM / 30 DAYS

VALCHLOR PA C mechlorethamine hcl S Specialty Drug

ONC

PAGE 111 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 56 TABS / 28 DAYS

VERZENIO PA C S Specialty Drug

ONC

QL 2 CAPS / 1 DAY

PA VITRAKVI 100 MG CAPSULE S Specialty Drug sulfate C TD

ONC

QL 10 ML / 1 DAY

PA VITRAKVI 20 MG/ML SOLUTION S Specialty Drug larotrectinib sulfate C TD

ONC

QL 6 CAPS / 1 DAY

PA VITRAKVI 25 MG CAPSULE S Specialty Drug larotrectinib sulfate C TD

ONC

QL 1 TAB / 1 DAY

PA VIZIMPRO S Specialty Drug C TD

ONC

QL 4 TABS / 1 DAY

PA VOTRIENT S Specialty Drug hcl C TD

ONC

QL 2 CAPS / 1 DAY

PA XALKORI S Specialty Drug C TD

ONC

PAGE 112 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 3 TABS / 1 DAY

XOSPATA PA C fumarate S Specialty Drug

ONC

PA XPOVIO S Specialty Drug selinexor C ONC

PA

XTANDI S Specialty Drug C TD

ONC

QL 3 CAPS / 1 DAY

PA ZEJULA S Specialty Drug niraparib tosylate C TD

ONC

QL 8 TABS / 1 DAY

ZELBORAF PA C S Specialty Drug

ONC

QL 4 CAPS / 1 DAY

PA ZOLINZA S Specialty Drug C TD

ONC

QL 3 CAPS / 1 DAY

PA ZYKADIA 150 MG CAPSULE S Specialty Drug C TD

ONC

PAGE 113 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ANTIPARKINSONIAN AGENTS (CNS)

ADAMANTANES (CNS)

C GOCOVRI PA amantadine hcl NP ANTICHOLINERGIC AGENTS (CNS)

benztropine mes 0.5 mg tab C

benztropine mes 1 mg tablet C

benztropine mes 2 mg tablet C

hcl C CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.

C PRECURSORS

-levodopa P

carbidopa-levodopa er P

carbidopa-levodopa-entacapone C

INBRIJA PA NP levodopa S Specialty Drug

RYTARY PA carbidopa/levodopa NP SINEMET 10-100 PA carbidopa/levodopa NP SINEMET 25-100 PA carbidopa/levodopa NP SINEMET 25-250 PA carbidopa/levodopa NP SINEMET CR PA carbidopa/levodopa NP INHIBITORS

mesylate C PA

hcl C XADAGO PA mesylate NP

PAGE 114 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ANTIPROTOZOALS

ANTIMALARIALS

atovaquone-proguanil hcl C

chloroquine phosphate C

hydroxychloroquine sulfate C

hcl C ANTIPROTOZOALS, MISCELLANEOUS

atovaquone C

C PA

LAMPIT PA nifurtimox C

metronidazole 250 mg tablet C

metronidazole 500 mg tablet C

nitazoxanide C PA

ANTIPSYCHOTIC AGENTS

ANTIPSYCHOTICS, MISCELLANEOUS

C

C ATYPICAL

ABILIFY PA NP ABILIFY MAINTENA AL1 At least 13 yrs old aripiprazole P ABILIFY MYCITE PA aripiprazole NP

aripiprazole P AL1 At least 13 yrs old

aripiprazole odt NP PA

ARISTADA PA NP ARISTADA INITIO PA aripiprazole lauroxil, submicronized NP

maleate C AL1 At least 13 yrs old

PAGE 115 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

CAPLYTA QL 1 CAP / 1 DAY NP lumateperone tosylate PA

P AL1 At least 13 yrs old

clozapine odt P AL1 At least 13 yrs old

CLOZARIL 100 MG TABLET PA clozapine NP

CLOZARIL 200 MG TABLET PA NP clozapine AL1 At least 12 yrs old

CLOZARIL 25 MG TABLET PA clozapine NP

CLOZARIL 50 MG TABLET PA NP clozapine AL1 At least 12 yrs old

FANAPT PA NP AL1 At least 13 yrs old

FAZACLO 100 MG ODT PA clozapine NP FAZACLO 12.5 MG ODT PA clozapine NP FAZACLO 150 MG ODT PA clozapine NP

FAZACLO 200 MG ODT PA NP clozapine AL1 At least 13 yrs old

FAZACLO 25 MG ODT PA clozapine NP GEODON 20 MG CAPSULE PA hcl NP GEODON 20 MG/ML VIAL PA ziprasidone mesylate NP GEODON 40 MG CAPSULE PA ziprasidone hcl NP GEODON 60 MG CAPSULE PA ziprasidone hcl NP GEODON 80 MG CAPSULE PA ziprasidone hcl NP INVEGA PA NP

PAGE 116 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS INVEGA SUSTENNA AL1 At least 13 yrs old paliperidone palmitate P INVEGA TRINZA AL1 At least 13 yrs old paliperidone palmitate P LATUDA AL1 At least 13 yrs old hcl P

PA NUPLAZID S Specialty Drug tartrate NP TD

olanzapine P AL1 At least 13 yrs old

olanzapine odt NP PA

paliperidone er NP PA

PERSERIS PA NP

fumarate P AL1 At least 13 yrs old

quetiapine fumarate er P AL1 At least 13 yrs old

REXULTI PA NP RISPERDAL PA risperidone NP RISPERDAL CONSTA AL1 At least 13 yrs old risperidone microspheres P

risperidone P AL1 At least 13 yrs old

risperidone odt P AL1 At least 13 yrs old

SAPHRIS PA NP asenapine maleate AL1 At least 13 yrs old

SECUADO PA NP asenapine AL1 At least 13 yrs old

SEROQUEL PA quetiapine fumarate NP SEROQUEL XR 150 MG TABLET PA quetiapine fumarate NP SEROQUEL XR 200 MG TABLET PA quetiapine fumarate NP

PAGE 117 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SEROQUEL XR 300 MG TABLET PA quetiapine fumarate NP SEROQUEL XR 400 MG TABLET PA quetiapine fumarate NP SEROQUEL XR 50 MG TABLET PA quetiapine fumarate NP

SEROQUEL XR SAMPLE KIT PA NP quetiapine fumarate AL1 At least 12 yrs old

VERSACLOZ PA NP clozapine AL1 At least 13 yrs old

VRAYLAR 1.5 MG CAPSULE QL 2 CAPS / 1 DAY NP hcl PA

VRAYLAR 1.5 MG-3 MG PACK QL 2 CAPS / 1 DAY NP cariprazine hcl PA

VRAYLAR 3 MG CAPSULE QL 1 CAP / 1 DAY NP cariprazine hcl PA

VRAYLAR 4.5 MG CAPSULE QL 1 CAP / 1 DAY NP cariprazine hcl PA

VRAYLAR 6 MG CAPSULE QL 1 CAP / 1 DAY NP cariprazine hcl PA

ziprasidone hcl P AL1 At least 13 yrs old

PA ziprasidone mesylate NP AL1 At least 13 yrs old

ZYPREXA PA olanzapine NP ZYPREXA RELPREVV PA olanzapine pamoate NP

ZYPREXA ZYDIS PA NP olanzapine AL1 At least 13 yrs old

BUTYROPHENONES

HALDOL lactate C

PAGE 118 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS HALDOL DECANOATE 100 C HALDOL DECANOATE 50 haloperidol decanoate C

haloperidol C

haloperidol decanoate C

haloperidol decanoate 100 C

haloperidol lactate C

10 mg tablet C

chlorpromazine 100 mg tablet C

chlorpromazine 200 mg tablet C

chlorpromazine 25 mg tablet C

chlorpromazine 50 mg tablet C

1 mg tablet C

fluphenazine 10 mg tablet C

fluphenazine 2.5 mg tablet C

fluphenazine 2.5 mg/5 ml elix C

fluphenazine 5 mg tablet C

fluphenazine 5 mg/ml conc C

fluphenazine decanoate C

C

hcl C

hcl C

thiothixene C ANTIRETROVIRALS

HIV ENTRY AND FUSION INHIBITORS

FUZEON S Specialty Drug enfuvirtide C RUKOBIA PA fostemsavir tromethamine C

PAGE 119 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SELZENTRY maraviroc C HIV ANTIRETROVIRALS

ISENTRESS raltegravir C ISENTRESS HD raltegravir potassium C JULUCA dolutegravir sodium/ hcl C TIVICAY dolutegravir sodium C TIVICAY PD dolutegravir sodium C VOCABRIA cabotegravir sodium C HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.

EDURANT rilpivirine hcl C

C

C INTELENCE etravirine C

nevirapine C

nevirapine er C HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS

abacavir C

abacavir- C

abacavir-lamivudine-zidovudine C BIKTARVY bictegravir sodium/emtricitabine/ fumar C COMPLERA emtricitabine/rilpivirine hcl/ fumarate C DESCOVY emtricitabine/tenofovir alafenamide fumarate C

efavirenz-emtric-tenofov disop C

emtricitabine C

PAGE 120 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

emtricitabine-tenofovir disop C EPIVIR HBV lamivudine P GENVOYA elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide C

lamivudine C

lamivudine hbv P

lamivudine-zidovudine C ODEFSEY emtricitabine/rilpivirine hcl/tenofovir alafenamide fumarate C STRIBILD elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil C

tenofovir disoproxil fumarate C TRIUMEQ abacavir sulfate/dolutegravir sodium/lamivudine C TRUVADA 100 MG-150 MG TABLET emtricitabine/tenofovir disoproxil fumarate C TRUVADA 133 MG-200 MG TABLET emtricitabine/tenofovir disoproxil fumarate C TRUVADA 167 MG-250 MG TABLET emtricitabine/tenofovir disoproxil fumarate C VIREAD 150 MG TABLET tenofovir disoproxil fumarate C VIREAD 200 MG TABLET tenofovir disoproxil fumarate C VIREAD 250 MG TABLET tenofovir disoproxil fumarate C VIREAD POWDER tenofovir disoproxil fumarate C

zidovudine C HIV PROTEASE INHIBITOR ANTIRETROVIRALS

APTIVUS 100 MG/ML SOLUTION /vitamin e tpgs C APTIVUS 250 MG CAPSULE tipranavir C

atazanavir sulfate C EVOTAZ atazanavir sulfate/cobicistat C

PAGE 121 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

calcium C INVIRASE saquinavir mesylate C KALETRA 100-25 MG TABLET lopinavir/ C KALETRA 200-50 MG TABLET lopinavir/ritonavir C LEXIVA 50 MG/ML SUSPENSION fosamprenavir calcium C

lopinavir-ritonavir C NORVIR 80 MG/ML SOLUTION ritonavir C PREZCOBIX ethanolate/cobicistat C PREZISTA darunavir ethanolate C REYATAZ 50 MG POWDER PACKET atazanavir sulfate C

ritonavir C SYMTUZA darunavir eth/cobicistat/emtricitabine/tenofovir alafenamide C ANTITHROMBOTIC AGENTS

ANTITHROMBOTIC AGENTS, MISCELLANEOUS

CABLIVI 11 MG KIT PA C caplacizumab-yhdp S Specialty Drug

PLATELET-AGGREGATION INHIBITORS

BRILINTA ticagrelor P

C

clopidogrel P EFFIENT PA prasugrel hcl NP PLAVIX PA clopidogrel bisulfate NP

prasugrel hcl P

PAGE 122 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ZONTIVITY PA vorapaxar sulfate NP PLATELET-REDUCING AGENTS

hcl C ANTITOXINS,IMMUNE GLOB,TOXOIDS,

ALLERGENIC EXTRACTS (THERAPEUTIC)

GRASTEK PA allergenic extract,grass pollen-timothy,standard C

PALFORZIA PA C peanut powder-dnfp S Specialty Drug

RAGWITEK PA allergenic extract-weed pollen-short ragweed C ANTITOXINS AND IMMUNE GLOBULINS

PA BIVIGAM S Specialty Drug immune globulin,gamm(igg)//iga greater than 50 mcg/ml C MED

PA CUVITRU 1 GRAM/5 ML VIAL S Specialty Drug immune globulin,gamm(igg)/glycine/iga greater than 50 mcg/ml C MED

PA CUVITRU 2 GRAM/10 ML VIAL S Specialty Drug immune globulin,gamm(igg)/glycine/iga greater than 50 mcg/ml C MED

PA CUVITRU 4 GRAM/20 ML VIAL S Specialty Drug immune globulin,gamm(igg)/glycine/iga greater than 50 mcg/ml C MED

PA CUVITRU 8 GRAM/ 40 ML VIAL S Specialty Drug immune globulin,gamm(igg)/glycine/iga greater than 50 mcg/ml C MED

PA FLEBOGAMMA DIF S Specialty Drug immune globulin,gamma (igg)//iga 0 to 50 mcg/ml C MED

PAGE 123 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PA GAMASTAN S-D S Specialty Drug immune globulin,gamma(igg)/glycine C MED

PA GAMMAGARD LIQUID S Specialty Drug immune globulin,gamm(igg)/glycine/iga greater than 50 mcg/ml C MED

PA GAMMAGARD S-D S Specialty Drug immune globulin,gamm(igg)/glycine//iga 0 to 50 mcg/ml C MED

PA GAMMAKED S Specialty Drug immune globulin,gamma(igg)/glycine/iga average 46 mcg/ml C MED

PA GAMMAPLEX 10 GRAM/100 ML VIAL S Specialty Drug immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml C MED

PA GAMMAPLEX 10 GRAM/200 ML VIAL S Specialty Drug immune globulin,gamm(igg)/sorbitol/glycin/iga 0 to 50 mcg/ml C MED

PA GAMMAPLEX 20 GRAM/200 ML VIAL S Specialty Drug immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml C MED

PA GAMMAPLEX 20 GRAM/400 ML VIAL S Specialty Drug immune globulin,gamm(igg)/sorbitol/glycin/iga 0 to 50 mcg/ml C MED

PA GAMMAPLEX 5 GRAM/100 ML VIAL S Specialty Drug immune globulin,gamm(igg)/sorbitol/glycin/iga 0 to 50 mcg/ml C MED

PA GAMMAPLEX 5 GRAM/50 ML VIAL S Specialty Drug immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml C MED

PAGE 124 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PA HYQVIA immune globulin,gamma(igg) human/, human C S Specialty Drug recomb MED

PA HYQVIA IG COMPONENT S Specialty Drug immune globulin,gamm(igg)/glycine/iga greater than 50 mcg/ml C MED

PA OCTAGAM S Specialty Drug immune globulin,gamm(igg)/maltose/iga greater than 50 mcg/ml C MED

PANZYGA PA C immune globulin,gamma(igg)-ifas human/glycine S Specialty Drug

TOXOIDS

ADACEL TDAP diphtheria,pertussis(acellular),tetanus /pf C BOOSTRIX TDAP diphtheria,pertussis(acellular),tetanus vaccine C DAPTACEL DTAP diphtheria, pertussis (acell), tetanus pediatric vaccine/pf C

diphtheria-tetanus toxoids-ped C INFANRIX DTAP diphtheria, pertussis (acell), tetanus pediatric vaccine/pf C

tdvax C TENIVAC tetanus and diphtheria toxoids, adsorbed, adult/pf C VAXELIS diphtheria,pertus(acell),tetanus/hepb/polio/hib conj-meng/pf C VACCINES

ACAM2000 (NATIONAL STOCKPILE) vaccine,live C ACTHIB haemophilus b conjugate vaccine(tetanus toxoid conjugate)/pf C

adenovirus type 4 C

adenovirus type 4 and type 7 C

adenovirus type 7 C

PAGE 125 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS AFLURIA QUAD 2019-20 (3YR UP) influenza virus vaccine quadrivalent 2019-20 (36 mos up)/pf C AFLURIA QUAD 2019-20 (6-35MO) influenza virus vaccine quadrival 2019-20 (6 mos-35 mos)/pf C AFLURIA QUAD 2019-2020 influenza virus vaccine quadrivalent 2019-20 (6 mos and up) C AFLURIA QUAD 2020-2021 influenza virus vaccine quadrivalent 2020-21 (6 mos and up) C AFLURIA QUAD 2020-21 (3YR UP) influenza virus vaccine quadrivalent 2020-21 (36 mos up)/pf C AFLURIA QUAD 2020-21 (6-35MO) influenza virus vaccine quadrival 2020-21 (6 mos-35 mos)/pf C AFLURIA QUAD 2021-2022 influenza virus vaccine quadrivalent 2021-22 (6 mos and up) C AFLURIA QUAD 2021-22 (3YR UP) influenza virus vaccine quadrivalent 2021-22 (36 mos up)/pf C AFLURIA QUAD 2021-22 (6-35MO) influenza virus vaccine quadrival 2021-22 (6 mos-35 mos)/pf C ASTRAZENECA COVID19 VAC(UNAPP) covid-19 vaccine, azd-1222 (astrazeneca)/pf C

bcg vaccine (tice strain) C BEXSERO meningococcal group b vaccine, 4-component C BIOTHRAX anthrax vaccine C ENGERIX-B ADULT virus vaccine recombinant/pf C ENGERIX-B PEDIATRIC-ADOLESCENT hepatitis b virus vaccine recombinant/pf C FLUAD 2019-2020 influenza vaccine tvs 2019-20 (65 yr up)/adjuvant mf59c.1/pf C FLUAD 2020-2021 influenza vaccine tvs 2020-21 (65 yr up)/adjuvant mf59c.1/pf C FLUAD QUAD 2020-2021 influenza vaccine quadrivalent 2020-21 (65 yr up)/mf59c.1/pf C FLUAD QUAD 2021-2022 influenza vaccine quadrivalent 2021-22 (65 yr up)/mf59c.1/pf C FLUARIX QUAD 2019-2020 influenza virus vaccine quadrival 2019-2020(6 mos and up)/pf C

PAGE 126 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS FLUARIX QUAD 2020-2021 influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf C FLUARIX QUAD 2021-2022 influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf C FLUBLOK QUAD 2019-2020 influenza virus vaccine qv 2019-20(18 yrs and older)rcmb/pf C FLUBLOK QUAD 2020-2021 influenza virus vaccine qv 2020-21(18 yrs and older)rcmb/pf C FLUBLOK QUAD 2021-2022 influenza virus vaccine qv 2021-22(18 yrs and older)rcmb/pf C FLUCELVAX QUAD 2019-2020 SYR flu vaccine quad 2019-2020(4 years and older)cell derived/pf C FLUCELVAX QUAD 2019-2020 VIAL flu vaccine quadriv 2019-2020(4 years and older)cell derived C FLUCELVAX QUAD 2020-2021 SYR flu vaccine quad 2020-2021(4 years and older)cell derived/pf C FLUCELVAX QUAD 2020-2021 VIAL flu vaccine quadriv 2020-2021(4 years and older)cell derived C FLUCELVAX QUAD 2021-2022 SYR flu vaccine quad 2021-2022(2 years and older)cell derived/pf C FLUCELVAX QUAD 2021-2022 VIAL flu vaccine quadriv 2021-2022(2 years and older)cell derived C FLULAVAL QUAD 2019-2020 SYR influenza virus vaccine quadrival 2019-2020(6 mos and up)/pf C FLULAVAL QUAD 2019-2020 VIAL influenza virus vaccine quadrivalent 2019-20 (6 mos and up) C FLULAVAL QUAD 2020-2021 influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf C FLULAVAL QUAD 2021-2022 influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf C FLUMIST QUAD 2019-2020 influenza vaccine quadrivalent live 2019-2020 (2 yrs-49 yrs) C FLUMIST QUAD 2020-2021 influenza vaccine quadrivalent live 2020-2021 (2 yrs-49 yrs) C FLUZONE HIGH-DOSE 2019-2020 influenza virus vaccine trival split 2019-2020(65 yr up)/pf C FLUZONE HIGH-DOSE QUAD 2020-21 influenza virus vaccine quadrival split 2020-21(65 yr up)/pf C FLUZONE HIGH-DOSE QUAD 2021-22 influenza virus vaccine quadrival split 2021-22(65 yr up)/pf C

PAGE 127 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS FLUZONE QUAD 2019-2020 influenza virus vaccine quadrival 2019-2020(6 mos and up)/pf C FLUZONE QUAD 2020-2021 influenza virus vaccine quadrival 2020-2021(6 mos and up)/pf C FLUZONE QUAD 2021-2022 influenza virus vaccine quadrival 2021-2022(6 mos and up)/pf C FLUZONE QUAD PEDI 2019-2020 influenza virus vaccine quadrival 2019-20 (6 mos-35 mos)/pf C FLUZONE QUAD SOUTH HEM 2020 VL influenza virus vacc quad 2020 south hem (6 mos and up) C FLUZONE QUAD SOUTH HEM 2021 VL influenza virus vacc quad 2021 south hem (6 months and up) C FLUZONE QUAD SOUTH HEM2020 SYR influenza virus vacc quad 2020 south hem (6 mos and up)/pf C FLUZONE QUAD SOUTH HEM2021 SYR influenza virus vacc quad 2021 south hem (6 mos and up)/pf NP GARDASIL 9 human papillomavirus vaccine, 9-valent/pf C HAVRIX virus vaccine/pf C HEPLISAV-B hepatitis b vaccine recombinant/vaccine adjuvant cpg 1018/pf C HIBERIX haemophilus b conjugate vaccine(tetanus toxoid conjugate)/pf C IMOVAX RABIES VACCINE rabies vaccine, human diploid cell/pf C IPOL poliomyelitis vaccine, killed C IXIARO japanese encephalitis vaccine/pf C JANSSEN COVID-19 VACCINE (EUA) covid-19 vac, ad26.cov2.s (janssen)/pf C JYNNEOS (NATIONAL STOCKPILE) smallpox and vaccine, live, nonreplicating/pf C KINRIX diphtheria, pertussis(acell),tetanus,polio vaccine/pf C M-M-R II VACCINE measles, mumps, and rubella vaccine live/pf C MENACTRA meningococcalvaccine a,c,y,w-135,diphtheria toxoid conj/pf C

PAGE 128 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS MENQUADFI meningococcal vaccine a,c,y and w-135,conj tetanus toxoid/pf C MENVEO A-C-Y-W-135-DIP meningococcalvaccine a,c,y,w-135,diphtheria toxoid conj/pf C MENVEO MENA COMPONENT meningococcal a diphtheria-conj vaccine component 1 of 2/pf C MENVEO MENCYW-135 COMPONENT meningococcal c,y,w-135,dip-conj vaccine component 2 of 2/pf C MODERNA COVID-19 VACCINE (EUA) covid-19 vaccine, mrna-1273, lnp-s (moderna)/pf C NOVAVAX COVID19 VAC,ADJ(UNAPP) covid-19 vaccine, nvx-cov2373 (novavax)/adjuvant-matrix/pf C PEDIARIX hep b virus,rcmb/dipth,pertus(acell),tet,polio vaccine/pf C PEDVAXHIB haemophilus b conjugate vaccine (meningococcal prot.conj)/pf C PENTACEL diphtheria,pertussis(acell),tetanus,polio/haemophilus b/pf C PENTACEL ACTHIB COMPONENT haemophilus b polysacc conj-tetanus tox,component 2 of 2/pf C PENTACEL DTAP-IPV COMPONENT diphther,pertus(acel),tetanus,polio vacc,component 1 of 2/pf C COVID-19 VACCINE (EUA) covid-19 vaccine, mrna, bnt162b2, lnp-s (pfizer)/pf C PNEUMOVAX 23 pneumococcal 23-valent polysaccharide vaccine C PREVNAR 13 pneumococcal 13-valent conjugate vaccine (diphtheria crm)/pf C PREVNAR 20 pneumococcal 20-valent conjugate vaccine (diphtheria crm)/pf C PROQUAD measles, mumps, rubella, and varicella vaccine live/pf C QUADRACEL DTAP-IPV diphtheria, pertussis(acell),tetanus,polio vaccine/pf C RABAVERT rabies vaccine, purified chicken embryo cell (pcec)/pf C RECOMBIVAX HB hepatitis b virus vaccine recombinant/pf C ROTARIX vaccine, live oral attenuated,89-12 strain, g1p(8) C

PAGE 129 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ROTATEQ rotavirus vaccine, live oral pentavalent C SHINGRIX QL 1 DOSE / RX varicella-zoster virus glycoprotein e,rec/as01b adjuvant/pf C SHINGRIX GE ANTIGEN COMPONENT QL 1 DOSE / RX varicella-zoster virus glycoprotein e,rec,component 2 of 2 C STAMARIL yellow fever vaccine live/pf C TRUMENBA neisseria meningitidis group b, lipidated fhbp recombinant C TWINRIX hepatitis a virus and hepatitis b virus vaccine/pf C TYPHIM VI typhoid vaccine vi capsular polysaccharide C VAQTA hepatitis a virus vaccine/pf C VARIVAX VACCINE varicella virus vaccine live/pf C VAXCHORA ACTIVE COMPONENT cholera vaccine, live C VAXCHORA VACCINE cholera vaccine, live C VIVOTIF typhoid vacc,live,attenuated C YF-VAX yellow fever vaccine live/pf C ZOSTAVAX AL1 At least 50 yrs old zoster vaccine live/pf C ANTIULCER AGENTS AND ACID SUPPRESSANTS

ANTIULCER AGENTS AND ACID SUPPRESS.,MISC

TALICIA PA omeprazole magnesium/ trihydrate/rifabutin C H2-ANTAGONISTS

ACID CONTROL 150 MG TABLET OTC hcl C ACID CONTROLLER OTC C ACID REDUCER 10 MG TABLET OTC famotidine C

PAGE 130 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ACID REDUCER 20 MG TABLET OTC famotidine C ACID-PEP OTC famotidine C

200 mg tablet C OTC

cimetidine 300 mg tablet C

cimetidine 300 mg/5 ml soln C

cimetidine 400 mg tablet C

cimetidine 400 mg/6.67 ml soln C

cimetidine 800 mg tablet C CVS ACID REDUCER 150 MG TABLET OTC ranitidine hcl C

cvs cimetidine 200 mg tablet C OTC

CVS HEARTBURN RELIEF 200 MG TB OTC cimetidine C EQ ACID REDUCER 10 MG TABLET OTC famotidine C

famotidine 10 mg tablet C OTC

famotidine 20 mg tablet C

famotidine 40 mg tablet C

famotidine 40 mg/5 ml susp C AL1 Up to 12 yrs old

GNP ACID CONTROL 150 MG TABLET C OTC

GNP ACID REDUCER 10 MG TABLET OTC famotidine C

gnp cimetidine 200 mg tablet C OTC

GS ACID REDUCER 10 MG TABLET OTC famotidine C HEARTBURN RELIEF 200 MG TABLET OTC cimetidine C PEPCID AC 10 MG TABLET OTC famotidine C

PUB ACID REDUCER 10 MG TABLET C OTC

RA ACID REDUCER 10 MG TABLET C OTC

PAGE 131 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

ranitidine 15 mg/ml C

ranitidine 150 mg tablet C OTC

ranitidine 150 mg/10 ml syrup C

ranitidine 300 mg tablet C SM ACID REDUCER 10 MG TABLET OTC famotidine C

SM HEARTBURN RELIEF 200 MG TAB C OTC

ZANTAC-360(FAMOTIDINE) 20MG TB C

C PROTECTANTS

sucralfate 1 gm tablet C PROTON-PUMP INHIBITORS

ACIPHEX PA sodium NP ACIPHEX SPRINKLE PA rabeprazole sodium NP

cvs esomeprazole mag 20 mg cap P OTC

PA cvs omeprazole-bicarb 20-1,100 NP OTC

DEXILANT PA dexlansoprazole NP

esomeprazole dr 10 mg packet NP PA

esomeprazole dr 20 mg packet NP PA

esomeprazole dr 40 mg packet NP PA

esomeprazole mag dr 20 mg cap P OTC

esomeprazole mag dr 40 mg cap P

esomeprazole strontium NP PA

gnp esomeprazole mag dr 20 mg P OTC

gs esomeprazole mag dr 20 mg P OTC

PAGE 132 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

hm esomeprazole mag dr 20 mg P OTC

lansoprazole dr 15 mg capsule P

lansoprazole dr 15 mg capsule (Rx only) P

lansoprazole dr 30 mg capsule P

PA

lansoprazole odt 15 mg tablet NP AL1 Up to 9 yrs old

OTC

PA lansoprazole odt 30 mg tablet NP AL1 Up to 9 yrs old

NEXIUM DR 10 MG PACKET esomeprazole magnesium P NEXIUM DR 2.5 MG PACKET esomeprazole magnesium P NEXIUM DR 20 MG CAPSULE PA esomeprazole magnesium NP NEXIUM DR 20 MG PACKET esomeprazole magnesium P NEXIUM DR 40 MG CAPSULE PA esomeprazole magnesium NP NEXIUM DR 40 MG PACKET esomeprazole magnesium P NEXIUM DR 5 MG PACKET esomeprazole magnesium P

omeprazole dr 10 mg capsule P

omeprazole dr 20 mg capsule P

omeprazole dr 40 mg capsule P

PA omeprazole-bicarb 20-1,100 cap NP OTC

omeprazole-bicarb 20-1,680 pkt NP PA

omeprazole-bicarb 40-1,100 cap NP PA

omeprazole-bicarb 40-1,680 pkt NP PA

pantoprazole 40 mg suspension C

pantoprazole sod dr 20 mg tab P

PAGE 133 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

pantoprazole sod dr 40 mg tab P

PREVACID 15 MG SOLUTAB PA NP lansoprazole AL1 Up to 9 yrs old

PREVACID 30 MG SOLUTAB PA NP lansoprazole AL1 Up to 9 yrs old

PREVACID DR 15 MG CAPSULE PA lansoprazole NP PREVACID DR 30 MG CAPSULE PA lansoprazole NP PRILOSEC PA omeprazole magnesium NP PROTONIX PA pantoprazole sodium NP

qc esomeprazole mag dr 20 mg P OTC

ra esomeprazole mag dr 20 mg P OTC

rabeprazole sod dr 20 mg tab NP PA

sm esomeprazole mag dr 20 mg P OTC

ZEGERID PA omeprazole/sodium bicarbonate NP ANTIVIRALS (SYSTEMIC)

ADAMANTANE ANTIVIRALS

hcl C ANTIVIRALS, MISCELLANEOUS

PREVYMIS 240 MG TABLET C PREVYMIS 480 MG TABLET letermovir C TPOXX (NATIONAL STOCKPILE) PA C XOFLUZA 20 MG TAB (40 MG DOSE) PA baloxavir marboxil NP XOFLUZA 40 MG TAB (80 MG DOSE) PA baloxavir marboxil NP XOFLUZA 40 MG TABLET PA baloxavir marboxil NP

PAGE 134 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ANTIVIRALS

ALFERON N S Specialty Drug interferon alfa-n3 C INTRON A S Specialty Drug interferon alfa-2b,recomb. C PEGASYS S Specialty Drug peginterferon alfa-2a P PEGASYS PROCLICK S Specialty Drug peginterferon alfa-2a P

PEGINTRON PA NP peginterferon alfa-2b S Specialty Drug

SYLATRON S Specialty Drug C peginterferon alfa-2b ONC

NEURAMINIDASE INHIBITOR ANTIVIRALS

oseltamivir 6 mg/ml suspension P QL 180 ML / FILL

oseltamivir phos 30 mg capsule P QL 20 CAPS / FILL

oseltamivir phos 45 mg capsule P QL 10 CAPS / FILL

oseltamivir phos 75 mg capsule P QL 10 CAPS / FILL

RELENZA QL 20 CAPS / FILL zanamivir P

TAMIFLU 30 MG CAPSULE QL 20 CAPS / FILL NP oseltamivir phosphate PA

TAMIFLU 45 MG CAPSULE QL 10 CAPS / FILL NP oseltamivir phosphate PA

TAMIFLU 6 MG/ML SUSPENSION QL 180 ML / FILL NP oseltamivir phosphate PA

TAMIFLU 75 MG CAPSULE QL 10 CAPS / FILL NP oseltamivir phosphate PA

NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS

acyclovir 200 mg capsule P

acyclovir 200 mg/5 ml susp P

PAGE 135 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

acyclovir 400 mg tablet P

acyclovir 800 mg tablet P

dipivoxil P BARACLUDE P

entecavir P

NP PA

HEPSERA adefovir dipivoxil P

RIBASPHERE 600 MG TABLET PA NP S Specialty Drug

RIBASPHERE RIBAPAK PA NP ribavirin S Specialty Drug

ribavirin 200 mg capsule P S Specialty Drug

ribavirin 200 mg tablet P S Specialty Drug

SITAVIG PA acyclovir NP

valacyclovir P

hcl C VALTREX PA valacyclovir hcl NP VEMLIDY PA tenofovir alafenamide NP ZOVIRAX 200 MG CAPSULE PA acyclovir NP ZOVIRAX 200 MG/5 ML SUSP PA acyclovir NP ZOVIRAX 400 MG TABLET PA acyclovir NP ZOVIRAX 800 MG TABLET PA acyclovir NP

PAGE 136 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ANXIOLYTICS, AND

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

AMBIEN PA tartrate NP AMBIEN CR PA zolpidem tartrate NP

BELSOMRA 10 MG TABLET QL 2 TABS / 1 DAY NP PA

BELSOMRA 15 MG TABLET QL 1 TAB / 1 DAY NP suvorexant PA

BELSOMRA 20 MG TABLET QL 1 TAB / 1 DAY NP suvorexant PA

BELSOMRA 5 MG TABLET QL 2 TABS / 1 DAY NP suvorexant PA

hcl C

DAYVIGO QL 1 TAB / 1 DAY NP PA

EDLUAR PA zolpidem tartrate NP

P

QL 1 CAP / 1 DAY HETLIOZ PA tasimelteon NP S Specialty Drug

HETLIOZ LQ PA C tasimelteon S Specialty Drug

10 mg/5 ml soln C

hydroxyzine 10 mg/5 ml syrup C

hydroxyzine 50 mg/25 ml syrup C

hydroxyzine hcl 10 mg tablet C

hydroxyzine hcl 25 mg tablet C

hydroxyzine hcl 50 mg tablet C

PAGE 137 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

hydroxyzine pamoate C INTERMEZZO PA zolpidem tartrate NP LUNESTA PA eszopiclone NP

QL 1 TAB / 1 DAY NP PA

ROZEREM ramelteon P

P

zolpidem tart 1.75 mg tab sl NP PA

zolpidem tart 3.5 mg tablet sl NP PA

zolpidem tartrate 10 mg tablet P

zolpidem tartrate 5 mg tablet P

zolpidem tartrate er NP PA

ZOLPIMIST PA zolpidem tartrate NP BARBITURATES (ANXIOLYTIC, /HYP)

C BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

0.25 mg tablet C QL 6 TABS / 1 DAY

alprazolam 0.5 mg tablet C QL 6 TABS / 1 DAY

alprazolam 1 mg tablet C QL 6 TABS / 1 DAY

alprazolam 2 mg tablet C QL 3 TABS / 1 DAY

alprazolam er 0.5 mg tablet C QL 6 TABS / 1 DAY

alprazolam er 1 mg tablet C QL 6 TABS / 1 DAY

alprazolam er 2 mg tablet C QL 3 TABS / 1 DAY

alprazolam er 3 mg tablet C QL 2 TABS / 1 DAY

alprazolam xr 0.5 mg tablet C QL 6 TABS / 1 DAY

alprazolam xr 1 mg tablet C QL 6 TABS / 1 DAY

PAGE 138 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

alprazolam xr 2 mg tablet C QL 3 TABS / 1 DAY

alprazolam xr 3 mg tablet C QL 2 TABS / 1 DAY

10 mg capsule C QL 6 CAPS / 1 DAY

chlordiazepoxide 25 mg capsule C QL 4 CAPS / 1 DAY

chlordiazepoxide 5 mg capsule C QL 6 CAPS / 1 DAY

DIASTAT QL 4 KITS / 30 DAYS P DIASTAT ACUDIAL QL 4 KITS / 30 DAYS diazepam P

QL 4 KIT / 30 DAYS diazepam 10 mg rectal gel syst NP PA

diazepam 10 mg tablet C QL 4 TABS / 1 DAY

diazepam 2 mg tablet C QL 6 TABS / 1 DAY

QL 4 KITS / 30 DAYS diazepam 2.5 mg rectal gel sys NP PA

QL 4 KIT / 30 DAYS diazepam 20 mg rectal gel syst NP PA

diazepam 5 mg tablet C QL 6 TABS / 1 DAY

diazepam 5 mg/5 ml solution C QL 40 ML / 1 DAY

diazepam 5 mg/ml oral conc C QL 8 ML / 1 DAY

0.5 mg tablet C QL 6 TABS / 1 DAY

lorazepam 1 mg tablet C QL 6 TABS / 1 DAY

lorazepam 2 mg tablet C QL 5 TABS / 1 DAY

lorazepam 2 mg/ml oral concent C QL 5 ML / 1 DAY

LORAZEPAM INTENSOL QL 5 ML / 1 DAY lorazepam C

15 mg capsule C QL 2 CAPS / 1 DAY

temazepam 30 mg capsule C QL 1 CAP / 1 DAY

VALTOCO QL 1 CARTON / RX diazepam P

PAGE 139 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX tartrate P

gum P OTC

nicotine lozenge P OTC

P OTC

NICOTROL PA nicotine NP NICOTROL NS PA nicotine NP

QUIT 2 C OTC

QUIT 4 C OTC

varenicline tartrate C PARASYMPATHOMIMETIC ( AGENTS)

ARICEPT PA hcl NP

chloride C

hcl C

donepezil hcl 10 mg tablet P

donepezil hcl 23 mg tablet NP PA

donepezil hcl 5 mg tablet P

donepezil hcl odt P EXELON PA rivastigmine NP

galantamine er NP PA

galantamine hbr NP PA

galantamine hydrobromide NP PA

pilocarpine hcl 5 mg tablet C

pilocarpine hcl 7.5 mg tablet C

pyridostigmine br 30 mg tablet C QL 1 TAB / 1 DAY

PAGE 140 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

pyridostigmine br 60 mg tablet C

pyridostigmine bromide er C PA

RAZADYNE PA galantamine hbr NP RAZADYNE ER PA galantamine hbr NP

rivastigmine 1.5 mg capsule NP PA

rivastigmine 13.3 mg/24hr ptch NP PA

rivastigmine 3 mg capsule NP PA

rivastigmine 4.5 mg capsule NP PA

rivastigmine 4.6 mg/24hr patch NP PA

rivastigmine 6 mg capsule NP PA

rivastigmine 9.5 mg/24hr patch NP PA

BETA-3-ADRENERGIC AGONISTS

SELECTIVE BETA-3-ADRENERGIC AGONISTS

MYRBETRIQ PA NP BETA-ADRENERGIC AGONISTS

SELECTIVE BETA-2-ADRENERGIC AGONISTS

albuterol 100 mg/20 ml soln P

albuterol 2.5 mg/0.5 ml sol P

albuterol 5 mg/ml solution P

albuterol sul 0.63 mg/3 ml sol P

albuterol sul 1.25 mg/3 ml sol P

albuterol sul 2.5 mg/3 ml soln P

albuterol sulf 2 mg/5 ml syrup P

albuterol sulfate 2 mg tab NP PA

albuterol sulfate 4 mg tab NP PA

ALBUTEROL SULFATE 90 MCG HFA AER AD (GENERIC PROAIR) P

PAGE 141 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

Albuterol Sulfate 90 mcg hfa aer ad (Generic ProAir) P

Albuterol Sulfate 90 mcg hfa aer ad (Generic Proventil) P

Albuterol Sulfate 90 mcg hfa aer ad (Generic Ventolin) P

albuterol sulfate er 4 mg tab NP PA

albuterol sulfate er 8 mg tab NP PA

albuterol sulfate hfa P ARCAPTA NEOHALER PA maleate NP BROVANA PA tartrate NP

levalbuterol concentrate NP PA

levalbuterol hcl NP PA

levalbuterol tartrate hfa C

metaproterenol sulfate P PERFOROMIST PA formoterol fumarate NP PROAIR DIGIHALER PA albuterol sulfate NP PROAIR HFA albuterol sulfate P PROAIR RESPICLICK albuterol sulfate P PROVENTIL HFA albuterol sulfate P SEREVENT DISKUS xinafoate P STRIVERDI RESPIMAT PA olodaterol hcl NP UTIBRON NEOHALER PA indacaterol maleate/glycopyrrolate NP VENTOLIN HFA albuterol sulfate P XOPENEX PA levalbuterol hcl NP XOPENEX CONCENTRATE PA levalbuterol hcl NP

PAGE 142 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS XOPENEX HFA levalbuterol tartrate P BLOOD FORMATION, COAGULATION, THROMBOSIS

BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.

QL 60 ML / 28 DAYS

ADAKVEO PA P crizanlizumab-tmca S Specialty Drug

MED

QL 3 TABS / 1 DAY OXBRYTA PA voxelotor P S Specialty Drug

HEMATOPOIETIC AGENTS

ARANESP S Specialty Drug darbepoetin alfa in polysorbate 80 P EPOGEN S Specialty Drug epoetin alfa P FULPHILA -jmdb C GRANIX S Specialty Drug tbo- C

LEUKINE PA C S Specialty Drug

NYVEPRIA PA pegfilgrastim-apgf C

PROCRIT PA NP epoetin alfa S Specialty Drug

QL 1 PACKET / 1 DAY PROMACTA 12.5 MG SUSPEN PACKET PA eltrombopag olamine C S Specialty Drug

PROMACTA 12.5 MG TABLET PA C eltrombopag olamine S Specialty Drug

QL 3 PACKETS / 1 DAY PROMACTA 25 MG SUSPENSION PCKT PA eltrombopag olamine C S Specialty Drug

PAGE 143 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PROMACTA 25 MG TABLET PA C eltrombopag olamine S Specialty Drug

PROMACTA 50 MG TABLET PA C eltrombopag olamine S Specialty Drug

PROMACTA 75 MG TABLET PA C eltrombopag olamine S Specialty Drug

REBLOZYL PA NP luspatercept-aamt MED

RETACRIT S Specialty Drug epoetin alfa-epbx P UDENYCA pegfilgrastim-cbqv C ZIEXTENZO pegfilgrastim-bmez C HEMORRHEOLOGIC AGENTS

C CALCIUM-CHANNEL BLOCKING AGENTS

CALCIUM-CHANNEL BLOCKING AGENTS, MISC.

CALAN PA hcl NP CALAN SR PA verapamil hcl NP CARDIZEM PA hcl NP CARDIZEM CD PA diltiazem hcl NP CARDIZEM LA PA diltiazem hcl NP CARTIA XT diltiazem hcl C DILT-XR diltiazem hcl C

diltiazem 120 mg tablet P

diltiazem 12hr er P

PAGE 144 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

diltiazem 24h er(cd) 120 mg cp P

diltiazem 24h er(cd) 180 mg cp P

diltiazem 24h er(cd) 240 mg cp P

diltiazem 24h er(cd) 300 mg cp P

diltiazem 24h er(la) 180 mg tb P

diltiazem 24h er(la) 240 mg tb P

diltiazem 24h er(la) 300 mg tb P DILTIAZEM 24H ER(LA) 360 MG TB (generic for CARDIZEM LA) P

diltiazem 24h er(la) 420 mg tb P

diltiazem 24hr er P

diltiazem 24hr er (xr) P DILTIAZEM 24HR ER 360 MG CAP (generic for CARDIZEM CD) P

diltiazem 30 mg tablet P

diltiazem 60 mg tablet P

diltiazem 90 mg tablet P MATZIM LA 180 MG TABLET diltiazem hcl P MATZIM LA 240 MG TABLET diltiazem hcl P MATZIM LA 300 MG TABLET diltiazem hcl P MATZIM LA 360 MG TABLET (generic for CARDIZEM LA) diltiazem hcl P MATZIM LA 420 MG TABLET diltiazem hcl P TAZTIA XT diltiazem hcl C TIADYLT ER diltiazem hcl C TIAZAC PA diltiazem hcl NP

verapamil 120 mg tablet P

verapamil 360 mg cap pellet P

PAGE 145 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

verapamil 40 mg tablet P

verapamil 80 mg tablet P

verapamil er P

verapamil er pm P

verapamil sr P VERELAN PA verapamil hcl NP VERELAN PM PA verapamil hcl NP DIHYDROPYRIDINES

ADALAT CC PA NP

amlodipine besylate P

amlodipine besylate- P

amlodipine-olmesartan NP PA

amlodipine- P

amlodipine-valsartan-hctz P AZOR PA amlodipine besylate/olmesartan medoxomil NP EXFORGE PA amlodipine besylate/valsartan NP EXFORGE HCT PA amlodipine besylate/valsartan/ NP

er P

P LOTREL PA amlodipine besylate/benazepril hcl NP

20 mg capsule P

nicardipine 30 mg capsule P

nifedipine P

nifedipine er P

NP PA

NP PA

PAGE 146 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS NORVASC PA amlodipine besylate NP NYMALIZE PA nimodipine NP PROCARDIA PA nifedipine NP PROCARDIA XL PA nifedipine NP SULAR PA nisoldipine NP CARDIAC DRUGS

CARDIAC DRUGS, MISCELLANEOUS

CORLANOR PA ivabradine hcl C

VYNDAMAX PA C S Specialty Drug

VYNDAQEL PA C tafamidis meglumine S Specialty Drug

CARDIOTONIC AGENTS

DIGITEK 125 MCG TABLET C DIGITEK 250 MCG TABLET AL1 Up to 64 yrs old digoxin C DIGOX digoxin C

digoxin 0.05 mg/ml solution C

digoxin 0.125 mg tablet C

digoxin 0.25 mg tablet C

digoxin 125 mcg tablet C

digoxin 250 mcg tablet C CARDIOVASCULAR DRUGS

ALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA PA mesylate NP

PAGE 147 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS CARDURA XL PA doxazosin mesylate NP

doxazosin mesylate P

hcl C

hcl P BETA-ADRENERGIC BLOCKING AGENTS

hcl NP PA

P

atenolol-chlorthalidone C BETAPACE PA hcl NP BETAPACE AF PA sotalol hcl NP

betaxolol 10 mg tablet NP PA

betaxolol 20 mg tablet NP PA

fumarate P

bisoprolol-hydrochlorothiazide C BYSTOLIC PA hcl NP

P

carvedilol er NP PA

COREG PA carvedilol NP COREG CR PA carvedilol phosphate NP CORGARD PA NP DUTOPROL PA succinate/hydrochlorothiazide NP HEMANGEOL PA hcl NP INDERAL LA PA propranolol hcl NP INDERAL XL PA propranolol hcl NP

PAGE 148 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS INNOPRAN XL PA propranolol hcl NP KAPSPARGO SPRINKLE PA metoprolol succinate NP

hcl 100 mg tablet P

labetalol hcl 200 mg tablet P

labetalol hcl 300 mg tablet P LOPRESSOR 100 MG TABLET PA metoprolol tartrate NP LOPRESSOR 50 MG TABLET PA metoprolol tartrate NP LOPRESSOR HCT PA metoprolol tartrate/hydrochlorothiazide NP

metoprolol succinate P

metoprolol tartrate 100 mg tab P

metoprolol tartrate 25 mg tab P

metoprolol tartrate 37.5 mg tb P

metoprolol tartrate 50 mg tab P

metoprolol tartrate 75 mg tab P

metoprolol-hydrochlorothiazide C

nadolol P

P

propranolol 10 mg tablet P

propranolol 20 mg tablet P

propranolol 20 mg/5 ml soln P

propranolol 40 mg tablet P

propranolol 40 mg/5 ml soln P

propranolol 60 mg tablet P

propranolol 80 mg tablet P

propranolol hcl er P

propranolol-hydrochlorothiazid C SORINE sotalol hcl C

PAGE 149 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

sotalol P SOTALOL AF sotalol hcl P SOTYLIZE PA sotalol hcl NP TENORETIC 100 PA atenolol/chlorthalidone NP TENORETIC 50 PA atenolol/chlorthalidone NP TENORMIN PA atenolol NP

timolol maleate 10 mg tablet NP PA

timolol maleate 20 mg tablet NP PA

timolol maleate 5 mg tablet NP PA

TOPROL XL PA metoprolol succinate NP ZIAC PA bisoprolol fumarate/hydrochlorothiazide NP CENTRAL AGENTS

ANTIMANIC AGENTS

C

C

lithium carbonate er C CENTRAL NERVOUS SYSTEM AGENTS, MISC.

calcium C

hcl 10 mg capsule P QL 2 CAPS / 1 DAY

atomoxetine hcl 100 mg capsule P QL 1 CAP / 1 DAY

atomoxetine hcl 18 mg capsule P QL 2 CAPS / 1 DAY

atomoxetine hcl 25 mg capsule P QL 2 CAPS / 1 DAY

atomoxetine hcl 40 mg capsule P QL 2 CAPS / 1 DAY

atomoxetine hcl 60 mg capsule P QL 1 CAP / 1 DAY

atomoxetine hcl 80 mg capsule P QL 1 CAP / 1 DAY

PAGE 150 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

hcl er 1 mg tablet P QL 3 TABS / 1 DAY

guanfacine hcl er 2 mg tablet P QL 2 TABS / 1 DAY

guanfacine hcl er 3 mg tablet P QL 1 TAB / 1 DAY

guanfacine hcl er 4 mg tablet P QL 1 TAB / 1 DAY

INTUNIV ER 1 MG TABLET QL 3 TABS / 1 DAY NP guanfacine hcl PA

INTUNIV ER 2 MG TABLET QL 2 TABS / 1 DAY NP guanfacine hcl PA

INTUNIV ER 3 MG TABLET QL 1 TAB / 1 DAY NP guanfacine hcl PA

INTUNIV ER 4 MG TABLET QL 1 TAB / 1 DAY NP guanfacine hcl PA

5-10 mg titration pk P

memantine hcl 10 mg tablet P

memantine hcl 2 mg/ml solution NP PA

memantine hcl 5 mg tablet P

memantine hcl er NP PA

NAMENDA 10 MG TABLET PA memantine hcl NP NAMENDA 5 MG TABLET PA memantine hcl NP NAMENDA 5-10 MG TITRATION PK PA memantine hcl NP NAMENDA XR 14 MG CAPSULE PA memantine hcl NP NAMENDA XR 21 MG CAPSULE PA memantine hcl NP NAMENDA XR 28 MG CAPSULE PA memantine hcl NP NAMENDA XR 7 MG CAPSULE PA memantine hcl NP NAMENDA XR TITRATION PACK PA memantine hcl NP

PAGE 151 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS NAMZARIC PA memantine hcl/donepezil hcl NP

NOURIANZ PA NP S Specialty Drug

C

STRATTERA 10 MG CAPSULE QL 2 CAPS / 1 DAY NP atomoxetine hcl PA

STRATTERA 100 MG CAPSULE QL 1 CAP / 1 DAY NP atomoxetine hcl PA

STRATTERA 18 MG CAPSULE QL 2 CAPS / 1 DAY NP atomoxetine hcl PA

STRATTERA 25 MG CAPSULE QL 2 CAPS / 1 DAY NP atomoxetine hcl PA

STRATTERA 40 MG CAPSULE QL 2 CAPS / 1 DAY NP atomoxetine hcl PA

STRATTERA 60 MG CAPSULE QL 1 CAP / 1 DAY NP atomoxetine hcl PA

STRATTERA 80 MG CAPSULE QL 1 CAP / 1 DAY NP atomoxetine hcl PA

QL 18 ML / 1 DAY XYREM PA C S Specialty Drug

QL 18 ML / 1 DAY XYWAV sodium oxybate/calcium oxybate/magnesium oxybate/pot C PA oxybate S Specialty Drug

FIBROMYALGIA AGENTS

SAVELLA 100 MG TABLET QL 2 TABS / 1 DAY hcl P SAVELLA 12.5 MG TABLET QL 2 TABS / 1 DAY milnacipran hcl P SAVELLA 25 MG TABLET QL 2 TABS / 1 DAY milnacipran hcl P

PAGE 152 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SAVELLA 50 MG TABLET QL 2 TABS / 1 DAY milnacipran hcl P SAVELLA TITRATION PACK QL 55 TABS / 30 DAYS milnacipran hcl P OPIATE ANTAGONISTS

KLOXXADO naloxone hcl C

naloxone 0.4 mg/ml carpuject C

naloxone 0.4 mg/ml vial P

naloxone 2 mg/2 ml syringe P

naloxone 4 mg/10 ml vial P

naltrexone hcl C NARCAN naloxone hcl P VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

AUSTEDO PA C S Specialty Drug

INGREZZA PA C tosylate S Specialty Drug

INGREZZA INITIATION PACK PA C valbenazine tosylate S Specialty Drug

PA C S Specialty Drug

CEPHALOSPORIN ANTIBIOTICS

1ST GENERATION ANTIBIOTICS

cefadroxil 1 gm tablet NP PA

cefadroxil 250 mg/5 ml susp P

cefadroxil 500 mg capsule P

cefadroxil 500 mg/5 ml susp P

cephalexin 125 mg/5 ml susp P

cephalexin 250 mg capsule P

cephalexin 250 mg/5 ml susp P

PAGE 153 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

cephalexin 500 mg capsule P

cephalexin 750 mg capsule P KEFLEX PA cephalexin NP 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS

cefaclor P

cefaclor er NP PA

cefprozil P

cefuroxime P 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS

cefdinir P

cefixime NP PA

QL 14 TABS / RX cefpodoxime 100 mg tablet NP PA

QL 100 ML / RX cefpodoxime 100 mg/5 ml susp NP PA

QL 14 TABS / RX cefpodoxime 200 mg tablet NP PA

QL 100 ML / RX cefpodoxime 50 mg/5 ml susp NP PA

ceftriaxone 1 gm add-vant vial C MED

SUPRAX 100 MG TABLET CHEWABLE PA cefixime NP SUPRAX 100 MG/5 ML SUSPENSION cefixime P SUPRAX 200 MG TABLET CHEWABLE PA cefixime NP SUPRAX 200 MG/5 ML SUSPENSION cefixime P SUPRAX 400 MG CAPSULE cefixime P SUPRAX 500 MG/5 ML SUSPENSION cefixime P

PAGE 154 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS CORTICOSTEROIDS (RESPIRATORY TRACT)

ORALLY INHALED PREPARATIONS ()

ADVAIR DISKUS fluticasone propionate/salmeterol xinafoate P ADVAIR HFA fluticasone propionate/salmeterol xinafoate P AIRDUO RESPICLICK PA fluticasone propionate/salmeterol xinafoate NP ALVESCO PA ciclesonide NP ARNUITY ELLIPTA PA NP ASMANEX mometasone furoate P ASMANEX HFA PA mometasone furoate NP BREO ELLIPTA PA fluticasone furoate/vilanterol trifenatate NP

budesonide 0.25 mg/2 ml susp P

budesonide 0.5 mg/2 ml susp P

budesonide 1 mg/2 ml inh susp P

budesonide-formoterol fumarate NP PA

DULERA mometasone furoate/formoterol fumarate P FLOVENT DISKUS fluticasone propionate P FLOVENT HFA fluticasone propionate P

fluticasone-salmeterol 100-50 P FLUTICASONE-SALMETEROL 113-14 (generic for AIRDUO PA RESPICLICK) NP FLUTICASONE-SALMETEROL 232-14 (generic for AIRDUO PA RESPICLICK) NP

fluticasone-salmeterol 250-50 P

fluticasone-salmeterol 500-50 P FLUTICASONE-SALMETEROL 55-14 (generic for AIRDUO PA RESPICLICK) NP

PAGE 155 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS PULMICORT PA budesonide NP PULMICORT FLEXHALER budesonide P QVAR REDIHALER PA beclomethasone dipropionate NP SYMBICORT budesonide/formoterol fumarate P TRELEGY ELLIPTA PA fluticasone furoate/umeclidinium bromide/vilanterol trifenat NP WIXELA INHUB fluticasone propionate/salmeterol xinafoate P CYSTIC FIBROSIS (CFTR) MODULATORS

CYSTIC FIBROSIS (CFTR) CORRECTORS

SYMDEKO 100/150 MG-150 MG TABS PA C / S Specialty Drug

SYMDEKO 50/75 MG-75 MG TABLETS PA tezacaftor/ivacaftor C

TRIKAFTA PA C /tezacaftor/ivacaftor S Specialty Drug

CYSTIC FIBROSIS (CFTR) POTENTIATORS

KALYDECO 150 MG TABLET PA C ivacaftor S Specialty Drug

KALYDECO 50 MG GRANULES PACKET PA C ivacaftor S Specialty Drug

KALYDECO 75 MG GRANULES PACKET PA C ivacaftor S Specialty Drug

ORKAMBI PA C /ivacaftor S Specialty Drug

DEVICES

0.3 ML SYRINGE OTC syringe with needle,insulin,0.3 ml C 0.5 ML INSULIN SYRINGE OTC syringe with needle,insulin,0.5 ml C

PAGE 156 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS 1 ML INSULIN SYRINGE OTC syringe with needle,disposable,insulin 1 ml C 2-in-1 lancet device OTC lancets C

accu-chek aviva plus meter QL 1 METER / 365 DAYS P blood-glucose meter OTC

accu-chek aviva solution OTC blood glucose calibration control high and low C accu-chek compact plus control OTC blood glucose calibration control high and low C accu-chek fastclix lancing dev OTC lancing device/lancets C accu-chek guide control soln OTC blood glucose calibration control high and low C

accu-chek guide me glucose mtr QL 1 METER / 365 DAYS P blood-glucose meter OTC

accu-chek guide monitor system QL 1 METER / 365 DAYS P blood-glucose meter OTC

accu-chek multiclix lancet OTC lancing device/lancets C accu-chek multiclix lancets OTC lancets C accu-chek smartview contrl sol OTC blood glucose calibration control solution, normal C accu-chek softclix lancet kit OTC lancing device/lancets C accu-chek softclix lancets OTC lancets C assure lance OTC lancets C autolet lancing device OTC lancing device C

QL 1 METER / 365 DAYS biotel care bgm-4 PA blood-glucose meter C OTC

BIOTENE MOISTURIZING MOUTH OTC saliva combination no.3 C

PAGE 157 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS butterfly touch lancet OTC lancets C caretouch safety lancets OTC lancets C comfort touch plus safety lanc OTC lancets C comfort touch ult thin lancet OTC lancets C

contour QL 1 METER / 365 DAYS P blood-glucose meter OTC

contour next QL 1 METER / 365 DAYS P blood-glucose meter OTC

contour next ez QL 1 METER / 365 DAYS P blood-glucose meter OTC

contour next glucose meter QL 1 METER / 365 DAYS P blood-glucose meter OTC

contour next link QL 1 METER / 365 DAYS P blood-glucose meter, wireless OTC

contour next link 2.4 QL 1 METER / 365 DAYS P blood-glucose meter, wireless OTC

contour next one QL 1 METER / 365 DAYS P blood-glucose meter OTC

dexcom PA blood-glucose meter,continuous NP dexcom g4 (ped) receiver kit OTC blood-glucose meter,continuous C dexcom g4 receiver kit PA blood-glucose meter,continuous C dexcom g4 receiver-share (ped) OTC blood-glucose meter,continuous C dexcom g4 receiver-share kit OTC blood-glucose meter,continuous C dexcom g4 transmitter kit PA blood-glucose transmitter C

PAGE 158 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS dexcom g5 receiver kit PA blood-glucose meter,continuous NP dexcom g5 transmitter kit PA blood-glucose transmitter NP dexcom g5-g4 sensor PA blood-glucose sensor NP dexcom g6 receiver blood-glucose meter,continuous P dexcom g6 sensor blood-glucose sensor P dexcom g6 transmitter blood-glucose transmitter P droplet genteel lancing device OTC lancing device C droplet lancets OTC lancets C easy touch blu link ctrl soln blood glucose calibration control high and low C

easy touch blu link gluc syst QL 1 METER / 365 DAYS C blood-glucose meter PA

easy trak ii control solution OTC blood glucose calibration control solution, normal C embrace lancing device OTC lancing device C

QL 1 METER / 365 DAYS embrace pro blood glucose mtr PA blood-glucose meter C OTC

ez-lets OTC lancets C

QL 1 METER / 365 DAYS fora g20 blood glucose system PA blood-glucose meter NP OTC

fora ketone control solution blood-ketone control, normal C

fora tn'g advance pro monitor QL 1 METER / 365 DAYS C blood ketone and glucose monitor PA

PAGE 159 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

fortiscare t1 blood gluc sys QL 1 METER / 365 DAYS C blood-glucose meter PA

QL 1 METER / 365 DAYS freestyle freedom lite PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS freestyle insulinx glucose sys PA blood-glucose meter NP OTC

freestyle libre 10 day reader PA flash glucose scanning reader C freestyle libre 10 day sensor PA flash glucose sensor C freestyle libre 14 day reader flash glucose scanning reader P freestyle libre 14 day sensor flash glucose sensor P freestyle libre 2 reader PA flash glucose scanning reader C freestyle libre 2 sensor PA flash glucose sensor C

QL 1 METER / 365 DAYS freestyle lite meter PA blood-glucose meter NP OTC

ge100 blood glucose system OTC blood-glucose meter C

QL 1 METER / 365 DAYS ge333 blood glucose system PA blood-glucose meter C OTC

ge333 control solution normal OTC blood glucose calibration control solution, normal C

QL 1 METER / 365 DAYS glucocard expression meter PA blood-glucose meter NP OTC

PAGE 160 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 METER / 365 DAYS glucocard shine meter PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS glucocard shine meter kit PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS glucocard shine xl PA blood-glucose meter NP OTC

gojji glucose control solution OTC blood glucose calibration control solution, normal C gojji ketone control solution OTC blood-ketone control, normal C gojji lancet-glucose test strp OTC lancets with blood glucose test strips C gojji lancets OTC lancets C

gojji multifunctional meter kt QL 1 METER / 365 DAYS C blood ketone and glucose monitor PA

onetouch delica OTC lancing device/lancets C

QL 1 METER / 365 DAYS onetouch ultra2 PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS onetouch ultramini PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS onetouch verio flex meter PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS onetouch verio flex startr kit PA blood-glucose meter NP OTC

PAGE 161 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 METER / 365 DAYS onetouch verio iq meter PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS onetouch verio iq system kit PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS onetouch verio meter PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS onetouch verio reflect kit PA blood-glucose meter C OTC

QL 1 METER / 365 DAYS onetouch verio reflect meter PA blood-glucose meter C OTC

pip lancet OTC lancets C

QL 1 METER / 365 DAYS pogo automatic blood gluc sys PA blood-glucose meter C OTC

pogo automatic test cartridge OTC lancets with blood glucose test strips C

QL 1 METER / 365 DAYS precision xtra ketone-glucose PA blood ketone and glucose monitor NP OTC

QL 1 METER / 365 DAYS precision xtra monitor PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS prodigy PA blood-glucose meter NP OTC

PAGE 162 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 METER / 365 DAYS prodigy pocket PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS prodigy voice PA blood-glucose meter NP OTC

pure comfort lancets OTC lancets C pure comfort safety lancets OTC lancets C rightest gc700 lev 2 ctrl soln OTC blood glucose calibration control solution, normal C

QL 1 METER / 365 DAYS rightest gm700sb glucose meter PA blood-glucose meter C OTC

QL 1 METER / 365 DAYS rightest gt333 glucose meter PA blood-glucose meter C OTC

rightest gt333 lev 2 ctrl soln OTC blood glucose calibration control solution, normal C

QL 1 METER / 365 DAYS rightest max plus glucose mtr PA blood-glucose meter C OTC

soft touch OTC lancets C t:slim x2 with basal-iq subcutaneous insulin pump C

QL 1 METER / 365 DAYS TRUE METRIX AIR GLUCOSE METER PA blood-glucose meter NP OTC

QL 1 METER / 365 DAYS TRUE METRIX BLOOD GLUCOSE MTR PA blood-glucose meter NP OTC

PAGE 163 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 1 METER / 365 DAYS true metrix go PA blood-glucose meter NP OTC

true metrix level 1 ctrl soln OTC blood glucose calibration control solution, low C true metrix level 2 ctrl soln OTC blood glucose calibration control solution, normal C true metrix level 3 ctrl soln OTC blood glucose calibration control solution, high C unilet lancets OTC lancets C vivaguard ino ctrl soln-l1, l3 OTC blood glucose calibration control high and low C vivaguard ino ctrl soln-l2 OTC blood glucose calibration control solution, normal C

QL 1 METER / 365 DAYS vivaguard ino smart gluc meter PA blood-glucose meter C OTC

QL 1 METER / 365 DAYS wavesense presto system kit PA blood-glucose meter NP OTC

DIAGNOSTIC AGENTS

ADRENOCORTICAL INSUFFICIENCY

ACTHAR PA C corticotropin S Specialty Drug

DIABETES MELLITUS

accu-chek aviva plus test strp QL 10 STRIPS / 1 DAY P blood sugar diagnostic OTC

accu-chek compact plus strips QL 10 STRIPS / 1 DAY P blood sugar diagnostic, drum-type OTC

accu-chek guide test strip QL 10 STRIPS / 1 DAY P blood sugar diagnostic OTC

accu-chek smartview test strip QL 10 STRIPS / 1 DAY P blood sugar diagnostic OTC

PAGE 164 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 10 STRIPS / 1 DAY agamatrix presto PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY assure platinum test strip PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY breeze 2 PA blood sugar diagnostic, disc-type C OTC

QL 10 STRIPS / 1 DAY caretouch test strip PA blood sugar diagnostic C OTC

contour next test strip QL 10 STRIPS / 1 DAY P blood sugar diagnostic OTC

contour test strip QL 10 STRIPS / 1 DAY P blood sugar diagnostic OTC

QL 10 STRIPS / 1 DAY dario blood glucose test strip PA blood sugar diagnostic C OTC

easy touch blu link test strip QL 10 STRIPS / 1 DAY C blood sugar diagnostic PA

QL 10 STRIPS / 1 DAY easy trak ii test strip PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY embrace pro test strip PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY fora g20 glucose test strips PA blood sugar diagnostic NP OTC

PAGE 165 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 10 STRIPS / 1 DAY fora v10-v12-d10-d20 PA blood sugar diagnostic C OTC

fortiscare g1 test strip QL 10 STRIPS / 1 DAY C blood sugar diagnostic PA

QL 10 STRIPS / 1 DAY freestyle insulinx test strip PA blood sugar diagnostic NP OTC

QL 10 STRIPS / 1 DAY freestyle insulinx test strips PA blood sugar diagnostic NP OTC

QL 10 STRIPS / 1 DAY freestyle lite test strip PA blood sugar diagnostic NP OTC

QL 10 STRIPS / 1 DAY freestyle precision neo PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY freestyle test strips PA blood sugar diagnostic NP OTC

QL 10 STRIPS / 1 DAY ge100 blood glucose test strip PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY ge333 blood glucose test strip PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY gluco navii PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY glucocard expression test strp PA blood sugar diagnostic NP OTC

PAGE 166 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 10 STRIPS / 1 DAY glucocard shine test strips PA blood sugar diagnostic NP OTC

QL 10 STRIPS / 1 DAY gojji blood glucose test strip PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY healthpro glucose test strips PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY nova max glucose test strips PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY test strip PA blood sugar diagnostic NP OTC

QL 10 STRIPS / 1 DAY onetouch verio test strip PA blood sugar diagnostic NP OTC

QL 10 STRIPS / 1 DAY precision xtra test strips PA blood sugar diagnostic NP OTC

QL 10 STRIPS / 1 DAY prodigy no coding PA blood sugar diagnostic NP OTC

QL 10 STRIPS / 1 DAY rightest gs700 test strip PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY rightest gt333 test strip PA blood sugar diagnostic C OTC

PAGE 167 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 10 STRIPS / 1 DAY true metrix glucose test strip PA blood sugar diagnostic NP OTC

ultima QL 10 STRIPS / 1 DAY C blood sugar diagnostic OTC

QL 10 STRIPS / 1 DAY vivaguard ino test strip PA blood sugar diagnostic C OTC

QL 10 STRIPS / 1 DAY wavesense presto test strips PA blood sugar diagnostic NP OTC

DIURETICS

LOOP

0.5 mg tablet C

bumetanide 1 mg tablet C

bumetanide 2 mg tablet C

10 mg/ml solution C

furosemide 20 mg tablet C

furosemide 40 mg tablet C

furosemide 40 mg/5 ml soln C

furosemide 80 mg tablet C

torsemide C POTASSIUM-SPARING DIURETICS

hcl C

amiloride-hydrochlorothiazide C

-hydrochlorothiazid C DIURETICS

C

hydrochlorothiazide C

PAGE 168 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS THIAZIDE-LIKE DIURETICS

chlorthalidone C

C

C AGONISTS

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

mesylate C

C CYCLOSET PA bromocriptine mesylate C NONERGOT-DERIV.DOPAMINE RECEPTOR

MIRAPEX PA di-hcl NP MIRAPEX ER PA pramipexole di-hcl NP NEUPRO PA C

pramipexole dihydrochloride P

pramipexole er NP PA

REQUIP XL PA hcl NP

ropinirole er NP PA

ropinirole hcl P ELECTROLYTIC, CALORIC, AND BALANCE

ALKALINIZING AGENTS

er C AMMONIA DETOXICANTS

CARBAGLU PA C S Specialty Drug

CONSTULOSE C ENULOSE lactulose C

PAGE 169 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS GENERLAC lactulose C

lactulose 10 gm/15 ml solution C

PA powder C S Specialty Drug

CALORIC AGENTS

CYCLINEX-1 PA C infant formula, special metabolic, cycle disorder OTC

CYCLINEX-2 PA C nutritional therapy, urea cycle disorder OTC

DOJOLVI PA C S Specialty Drug

ELECARE PA C infant form. iron, lactose free/dha/ (ara) OTC

ESSENTIAL MIX PA C nutritional therapy, urea cycle disorder without iron OTC

glucose C OTC

glucose gel C OTC

GLUTAREX-1 PA C inf form, glutaric aciduria i OTC

GLUTAREX-2 PA C nutritional therapy, glutaric aciduria type 1 OTC

GLYTACTIN 15 PE BETTERMILK nutritional therapy for pku no.64 C GLYTACTIN 20PE BETTERMILK LITE nutritional therapy for phenylketonuria(pku) with iron no.41 C GLYTACTIN BUILD 20-20 nutritional therapy for pku no.64 C GLYTACTIN BURST 10-10 nutritional therapy for pku no.64 C GLYTACTIN BURST 20-20 nutritional therapy for pku no.64 C

PAGE 170 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS GLYTACTIN RTD 10 PE nutritional therapy for phenylketonuria(pku) with iron no.41 C GLYTACTIN RTD 15 PE nutritional therapy for phenylketonuria(pku) with iron no.41 C

HCU EXPRESS POWDER PA C nutritional therapy, metabolic disorder, -free OTC

HOMINEX-1 PA C infant formula, special metabolic, iron, methionine-free OTC

HOMINEX-2 PA C nutritional therapy, metabolic disorder, methionine-free OTC

I-VALEX-1 PA C infant formula,spec. metabolic,isovaleric acidemia with iron OTC

I-VALEX-2 PA C nutritional therapy for isovaleric acidemia with iron OTC

JUVEN PA C arginine//calcium beta-hydroxy-beta-methylbutyrate OTC

KETONEX-1 PA C infant formula with iron,spec.metabolic,maple syrup dx OTC

KETONEX-2 PA C nutritional therapy for msud with iron OTC

l-arginine C OTC

LANAFLEX OTC nutritional therapy for phenylketonuria(pku) with iron no.25 C

levocarnitine 330 mg tablet C OTC

LOPHLEX OTC nutritional therapy for phenylketonuria (pku) with iron no.7 C

MSUD AID PA C nutritional therapy for msud with iron OTC

MSUD EXPRESS COOLER PA C nutritional therapy for msud with iron OTC

MSUD EXPRESS15 OTC nutritional therapy for msud with iron C

PAGE 171 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

NEOCATE INFANT DHA-ARA PA C infant formula with iron/docosahexanoic acid/arachidonic ac OTC

NEOCATE JUNIOR PA C nutritional therapy for impaired digestive function OTC

PA NUTRAMINE C OTC

PERIFLEX ADVANCE OTC nutritional tx for phenylketonuria (pku) with iron, comb #20 C PERIFLEX LQ PKU OTC nutritional therapy for phenylketonuria (pku) with iron no.2 C PHENEX-1 OTC infant formula for pku, iron, no.2 C PHENEX-2 OTC nutritional therapy for phenylketonuria (pku) with iron no.1 C PHENYL-FREE 2 OTC nutritional therapy for phenylketonuria(pku) with iron no.45 C PHENYL-FREE 2HP OTC nutritional therapy for phenylketonuria(pku) with iron no.45 C PHENYLADE AMINO ACID POWDER OTC nutritional therapy for phenylketonuria (pku) no.31 C PHENYLADE GMP OTC nutritional therapy for phenylketonuria(pku) with iron no.57 C PHLEXY-10 DRINK MIX POWDER OTC nutritional therapy for phenylketonuria (pku) no.8 C PHLEXY-10 TABLET OTC nutritional therapy for phenylketonuria (pku) no.54 C PKU COOLER 10 OTC nutritional therapy for phenylketonuria(pku) with iron no.4 C PKU COOLER 15 OTC nutritional therapy for phenylketonuria(pku) with iron no.4 C PKU COOLER 20 OTC nutritional therapy for phenylketonuria(pku) with iron no.4 C PKU EASY OTC nutritional therapy for phenylketonuria(pku) no.56 C PKU EXPLORE10 OTC nutritional therapy for phenylketonuria(pku) with iron no.52 C PKU EXPRESS15 OTC nutritional therapy for phenylketonuria(pku) with iron no.52 C

PAGE 172 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS PKU EXPRESS20 OTC nutritional therapy for phenylketonuria(pku) with iron no.52 C PKU GEL OTC nutritional therapy for phenylketonuria with iron, no.47 C PKU GO OTC nutritional therapy for phenylketonuria(pku) with iron no.60 C PKU LOPHLEX OTC nutritional therapy for phenylketonuria(pku) with iron no.42 C PKU PERIFLEX JUNIOR PLUS OTC nutritional therapy for phenylketonuria(pku) with iron no.55 C PKU SPHERE15 OTC nutritional therapy for phenylketonuria (pku) no.67 C PKU SPHERE20 OTC nutritional therapy for phenylketonuria (pku) no.67 C

PRO-PHREE PA C infant formula, special metabolic with iron OTC

PROPIMEX-1 PA C infant formula,spec. metabolic, propionic acidemia,with iron OTC

TYR EASY OTC nutritional therapy for tyrosinemia without iron C

TYR EXPRESS PA C nutritional therapy for tyrosinemia with iron OTC

TYREX-1 PA C infant formula, special metabolic, tyrosinemia, with iron OTC

TYREX-2 PA C nutritional therapy for tyrosinemia with iron OTC

VILACTIN AA PLUS 20 PE nutritional therapy for msud with iron C

VITAL HIGH PA C lactose-reduced food OTC

XPHE MAXAMUM OTC nutritional therapy for phenylketonuria (pku) with iron no.6 C REPLACEMENT PREPARATIONS

calcium 500 mg chewable tablet C OTC

PAGE 173 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

calcium 500 mg tablet C OTC

calcium 500 mg-vit d3 5 mcg tb C OTC

calcium 500-vit d3 10 mcg chew C OTC

calcium 500-vit d3 125 caplet C OTC

calcium 500-vit d3 200 caplet C OTC

calcium 500-vit d3 200 tablet C OTC

calcium 500-vit d3 400 chew tb C OTC

calcium 500-vit d3 400 tablet C OTC

calcium 500mg-vit d3 10mcg tab C OTC

calcium 600 mg tablet C OTC

calcium 600 mg-d3 20 mcg cplt C

calcium 600 mg-d3 20 mcg tab C

calcium 600 mg-vit d3 10mcg tb C OTC

calcium 600 mg-vit d3 5 mcg tb C OTC

calcium 600-d3 20mcg(800 unit) C

calcium 600-vit d3 200 tablet C OTC

calcium 600-vit d3 400 caplet C OTC

calcium 600-vit d3 400 tablet C OTC

calcium acetate 668 mg tablet P OTC

calcium carb 1,250 mg/5 ml sus C OTC

calcium cit 200 mg-d3 125 unit C OTC

calcium cit 250 mg-d3 200 unit C OTC

calcium citrate C OTC

calcium citrate - C OTC

calcium citrate-vitamin d3 C OTC

CALCIUM MAGNESIUM OTC calcium carbonate, gluconate/, gluconate C

PAGE 174 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS CALTRATE 600 PLUS D3 OTC calcium carbonate/ (vitamin d3) C

cvs cal cit 315 mg-d3 6.25 mcg C OTC

cvs calcium 500-vit d3 125 tab C OTC

cvs calcium 600mg-d3 20mcg tab C

HI-CAL C OTC

hm calcium 500-vit d3 200 cplt C OTC

hm calcium 600-vit d3 400 tab C OTC

HYDRALYTE C OTC

KINDERLYTE C OTC

KLOR-CON M10 C KLOR-CON M15 potassium chloride C KLOR-CON M20 potassium chloride C

magnesium gluconate C OTC

MOUTHKOTE OTC miscellaneous electrolyte replacement/yerba santa C

OS-CAL 500-VIT D3 C OTC

OYSCO 500-VIT D3 C OTC

oyster shell calcium C OTC

oyster shell calcium-vit d3 C OTC

oyster shell-d C OTC

PEDIALYTE OTC electrolytes/dextrose C

phosphorus-sodium-potassium C OTC

potassium cl 10% (20 meq/15ml) C

potassium cl 10% (40 meq/30ml) C

potassium cl 20 meq packet C

potassium cl 20% (40 meq/15ml) C

PAGE 175 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

potassium cl er 10 meq capsule C

potassium cl er 10 meq tablet C

potassium cl er 20 meq tablet C

potassium cl er 8 meq capsule C

potassium cl er 8 meq tablet C

qc calcium 600-vit d3 400 tab C OTC

ra calcium 600 mg tablet C OTC

ra calcium 600-vit d3 400 tab C OTC

sm calcium 500-vit d3 200 cplt C OTC

sm calcium 500-vit d3 400 tab C OTC

sm calcium 600 mg tablet C OTC

sm calcium 600-vit d3 400 tab C OTC

sodium chloride 1 gm tablet C OTC

sodium phosphate-potassium pho C OTC

sodium-potassium-phosphorus C OTC

super calcium 600-vit d3 C OTC

THERMOTABS OTC sodium chloride/potassium chloride C

zinc C OTC

zinc 50 mg capsule C OTC

zinc sulfate 220 mg (50mg) cap C OTC

zinc sulfate 220 mg capsule C OTC

zinc sulfate 50 mg (220 mg) tb C OTC

URICOSURIC AGENTS

C

probenecid-colchicine C

PAGE 176 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

BASIC AND

ammonium lactate 12% lotion C

calamine C OTC

HYDROCERIN C OTC

LAC-HYDRIN FIVE OTC ammonium lactate C BASIC OINTMENTS AND PROTECTANTS

ADVANCED HEALING C OTC

AMERIPHOR C OTC

ammonium lactate 12% cream C BAZA PROTECT CREAM OTC dimethicone/zinc oxide C

DERMAPHOR C OTC

EUCERIN OTC lanolin //petrolatum,white/ceresin C

GERI-HYDROLAC C OTC

LANTISEPTIC OTC lanolin C

MINERIN C OTC

PETROLATUM BASE OINTMENT C OTC

zinc oxide paste C

PA HYQVIA HY COMPONENT S Specialty Drug hyaluronidase, human recomb. C MED

STRENSIQ PA C S Specialty Drug

SUCRAID PA C S Specialty Drug

PAGE 177 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS AND

ESTROGEN AGONIST-ANTAGONISTS

EVISTA PA hcl NP

raloxifene hcl P SOLTAMOX citrate C

tamoxifen citrate C ESTROGENS

DOTTI C

estradiol (once weekly) C

estradiol (twice weekly) C

estradiol 0.01% cream C

estradiol 0.5 mg tablet C

estradiol 1 mg tablet C

estradiol 10 mcg vaginal insrt C

estradiol 2 mg tablet C FYAVOLV 1 MG-5 MCG TABLET norethindrone acetate-ethinyl estradiol C JINTELI norethindrone acetate-ethinyl estradiol C

norethin-eth estrad 1 mg-5 mcg C YUVAFEM estradiol C EYE, EAR, NOSE AND THROAT (EENT) PREPS.

ANTIALLERGIC AGENTS

ALOMIDE PA lodoxamide tromethamine NP

0.1% (137 mcg) spry P

azelastine 0.15% nasal spray P

azelastine hcl 0.05% drops NP PA

BEPREVE PA besilate NP

PAGE 178 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS CVS EYE ITCH RELIEF 0.025% DRP OTC ketotifen fumarate P

cvs 0.2% eye drops C OTC

DYMISTA PA azelastine hcl/fluticasone propionate NP

hcl NP PA

EQ EYE ITCH RELIEF 0.025% DROP OTC ketotifen fumarate P EYE ALLERGY ITCH RELIEF olopatadine hcl C EYE ALLERGY ITCH-REDNESS RLF olopatadine hcl C EYE ITCH RELIEF 0.025% DROPS OTC ketotifen fumarate P

gnp olopatadine 0.1% eye drops C OTC

gnp olopatadine 0.2% eye drops C OTC

HM EYE ITCH RELIEF 0.025% DROP OTC ketotifen fumarate P

ketotifen fumarate P OTC

KRO EYE ITCH RLF 0.025% DROPS OTC ketotifen fumarate P LASTACAFT PA NP

olopatadine 665 mcg nasal spry NP PA

olopatadine hcl 0.1% eye drops C OTC

olopatadine hcl 0.2% eye drop C OTC

PATADAY PA olopatadine hcl NP PATANASE PA olopatadine hcl NP PATANOL PA olopatadine hcl NP PAZEO olopatadine hcl P

RA EYE ITCH RELIEF 0.025% DROP P OTC

PAGE 179 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SM EYE ITCH RELIEF 0.025% DROP OTC ketotifen fumarate P

ZADITOR PA NP ketotifen fumarate OTC

ZERVIATE PA cetirizine hcl NP EENT DRUGS, MISCELLANEOUS

hcl NP PA

ARTIFICIAL EYE LUBRICANT C

ARTIFICIAL C OTC

ARTIFICIAL TEARS EYE DROPS C OTC

ARTIFICIALS TEARS DROPS C OTC

AYR OTC sodium chloride C AYR OTC sodium chloride C

carboxymethylcellulose sodium C OTC

CVS LUBRICANT EYE DROPS C OTC

cvs sodium chloride 5% eye drp C OTC

cvs sodium chloride 5% oint C OTC

QL 5 ML / RX CYSTADROPS PA hcl C S Specialty Drug

QL 15 ML / RX CYSTARAN PA cysteamine hcl C S Specialty Drug

EQ GENTLE C OTC

FOR STY RELIEF C OTC

GENTEAL TEARS 0.1%-0.2%-0.3% OTC dextran/hypromellose/glycerin C GENTEAL TEARS 0.1%-0.3% DROP OTC dextran 70/hypromellose/pf C

PAGE 180 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS GENTEAL TEARS SEVERE 0.3% GEL OTC hypromellose C IOPIDINE PA apraclonidine hcl NP

ipratropium 0.03% spray P

ipratropium 0.06% spray P

LUBRICANT EYE DROPS C OTC

LUBRICANT EYE OINTMENT C OTC

LUBRICANT GEL DROPS C OTC

LUBRICANT PM C OTC

LUBRICATING TEARS C

MURO-128 C OTC

NASAL MOISTURIZING C OTC

NIGHTTIME DRY-EYE RELIEF C OTC

QL 1 ML / 1 DAY OXERVATE PA -bkbj C S Specialty Drug

C OTC

PURE & GENTLE EYE DROPS C OTC

ra sodium chloride 5% eye drop C OTC

REFRESH CELLUVISC OTC carboxymethylcellulose sodium C REFRESH CLASSIC OTC polyvinyl alcohol/povidone/pf C REFRESH LIQUIGEL OTC carboxymethylcellulose sodium C REFRESH OPTIVE OTC carboxymethylcellulose sodium/glycerin C REFRESH OPTIVE SENSITIVE OTC carboxymethylcellulose sodium/glycerin/pf C REFRESH P.M. OTC mineral oil/petrolatum,white C

PAGE 181 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS REFRESH PLUS OTC carboxymethylcellulose sodium C REFRESH RELIEVA OTC carboxymethylcellulose sodium/glycerin C

saline nasal spray C OTC

sodium chloride 5% eye drop C OTC

sodium chloride 5% eye oint C OTC

sodium chloride 5% opht soln C OTC

sodium chloride 5% ophth soln C OTC

SYSTANE GEL OTC hypromellose C THERA TEARS 0.25% EYE DROPS OTC carboxymethylcellulose sodium C

THERA TEARS 1% LIQUID GEL C OTC

LOCAL ANESTHETICS (EENT)

GLYDO lidocaine hcl C

lidocaine hcl 2% jel urojet ac C

lidocaine hcl 2% jelly C

lidocaine hcl 2% jelly uro-jet C

lidocaine hcl 4% solution C

lidocaine hcl viscous C AND GARGLES

hydrogen peroxide C OTC

MYDRIATICS

1% eye drops C

atropine 1% eye ointment C

1% eye drop C

cyclopentolate 1% eye drops C

HOMATROPAIRE C

hydrobromide C

PAGE 182 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS VASOCONSTRICTORS

12 HOUR NASAL RELIEF C OTC

ALLERGY EYE DROPS OTC hcl/ maleate C

CHILD MUCINEX STUFFY NOSE SPRY C OTC

CVS EYE ALLERGY RELIEF EYE DRP C OTC

EYE ALLERGY RELIEF DROPS C OTC

EYE DROPS C OTC

EYE DROPS ADVANCED RELIEF C OTC

GNP EYE DROPS C OTC

MUCINEX SINUS-MAX C OTC

NAPHCON-A OTC naphazoline hcl/pheniramine maleate C

NASAL DECONGESTANT 0.05% SPRAY C OTC

10% eye drops C

phenylephrine 2.5% eye drop C

PV ALLERGY EYE DROPS C OTC

VISINE-A OTC naphazoline hcl/pheniramine maleate C FIRST GENERATION ANTIHISTAMINES

ETHANOLAMINE DERIVATIVES

ALLERGY C OTC

ALLERGY RELIEF 12.5 MG/5 ML C OTC

ALLERGY RELIEF 25 MG CAPSULE C OTC

ALLERGY RELIEF 25 MG C OTC

BENADRYL ALLERGY C OTC

CHILD ALLERGY RLF 12.5 MG/5 ML C OTC

CHILDREN'S AURODRYL ALLERGY C OTC

CHILDREN'S WAL-DRYL ALLERGY C OTC

PAGE 183 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

CVS ALLERGY RELIEF 25 MG CAP C OTC

CVS NIGHTTIME SLEEP 25 MG CAP C OTC

CVS SLEEP AID 50 MG SOFTGEL C OTC

12.5 mg/5 ml C OTC

diphenhydramine 25 mg caplet C OTC

diphenhydramine 25 mg capsule C OTC

diphenhydramine 25 mg tablet C OTC

diphenhydramine 25 mg/10 ml C OTC

diphenhydramine 50 mg capsule C OTC

EQ ALLERGY RELIEF 25 MG TABLET C OTC

EQ SLEEP AID 25 MG TABLET OTC succinate C EQL SLEEP AID 25 MG TABLET OTC doxylamine succinate C

EQL SLEEP AID 50 MG SOFTGEL C OTC

GERI-DRYL 12.5 MG/5 ML LIQUID C OTC

GNP ALLERGY RELIEF 25 MG LQ CP C OTC

GNP ALLERGY RELIEF 25 MG TAB C OTC

GNP ALLERGY RELIEF 50 MG/20 ML C OTC

GNP CHILD ALLERGY 12.5 MG/5 ML C OTC

GNP NIGHTTIME SLEEP AID 50 MG C OTC

GNP SLEEP AID 25 MG CAPLET C OTC

GS ALLERGY RELIEF 25 MG TABLET C OTC

GS NIGHTTIME SLEEP AID 25 MG C OTC

GS SLEEP AID 25 MG TABLET OTC doxylamine succinate C

HM ALLERGY RELIEF 25 MG CAP C OTC

HM ALLERGY RELIEF 25 MG TABLET C OTC

PAGE 184 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

HM NIGHTTIME SLEEP 25 MG CPLT C OTC

HM NIGHTTIME SLEEP AID 50 MG C OTC

HM SLEEP AID 25 MG TABLET OTC doxylamine succinate C

M-DRYL C OTC

NIGHTTIME SEVERE COUGH-COLD C OTC

NIGHTTIME SLEEP AID 25 MG CPLT C OTC

QC CHILD ALLERGY 12.5 MG/5 ML C OTC

RA SLEEP AID 25 MG CAPLET C OTC

RA SLEEP AID 25 MG TABLET C OTC

SEVERE COLD COUGH-FLU C OTC

SLEEP AID 25 MG CAPLET C OTC

SLEEP AID 25 MG TABLET OTC doxylamine succinate C

SLEEP AID 50 MG LIQUIDGEL C OTC

SLEEP AID 50 MG SOFTGEL C OTC

SM ALLERGY RELIEF 1.34 MG TAB C OTC

SM ALLERGY RELIEF 25 MG CAP C OTC

SM SLEEP AID 25 MG TABLET OTC doxylamine succinate C

SM SLEEP AID SOFTGEL C OTC

SOMINEX C OTC

WAL-DRYL ALLERGY C OTC

WAL-SOM OTC doxylamine succinate C FIRST GEN. ANTIHIST. DERIVATIVES, MISC.

hcl C DERIVATIVES

PHENADOZ hcl C

PAGE 185 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

promethazine 12.5 mg suppos C

promethazine 12.5 mg tablet C

promethazine 25 mg C

promethazine 25 mg tablet C

promethazine 50 mg suppository C

promethazine 50 mg tablet C

promethazine 6.25 mg/5 ml soln C

promethazine 6.25 mg/5 ml syrp C

promethazine vc C

promethazine-phenylephrine C PROMETHEGAN promethazine hcl C PROPYLAMINE DERIVATIVES

ALLERGY RELIEF 4 MG TABLET C OTC

CHILD'S DIBROMM COLD-ALLERGY C OTC

CHILDREN'S COLD-ALLERGY C OTC

COLD-ALLERGY C OTC

CVS ALLERGY RELIEF 4 MG TABLET C OTC

DIMETAPP OTC maleate/phenylephrine hcl C

GNP ALLERGY RELIEF 4 MG TABLET C OTC

GS ALLERGY RELIEF 4 MG TABLET C OTC

HM ALLERGY RELIEF 4 MG TABLET C OTC

RA ALLERGY RELIEF 4 MG TABLET C OTC

RYNEX PSE C OTC

SINUS PE PLUS ALLERGY C OTC

SINUS-ALLERGY PE C OTC

SM ALLERGY RELIEF 4 MG TABLET C OTC

SUPHEDRINE PE SINUS-ALLERGY C OTC

PAGE 186 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

VALU-TAPP C OTC

GASTROINTESTINAL DRUGS

ANTACIDS AND ADSORBENTS

alum-mag hydroxide-simethicone C OTC

aluminum hydroxide C OTC

ANTACID 500 MG CHEW TABLET C OTC

ANTACID 675-135 MG TAB CHEW C OTC

ANTACID 750 MG CHEWABLE TABLET C OTC

ANTACID ANTI-GAS LIQUID C OTC

ANTACID ANTI-GAS MAX STR LIQ C OTC

ANTACID EX-STR 750 MG TAB CHEW C OTC

ANTACID EX-STR TABLET CHEW C OTC

ANTACID EXTRA STRNGTH TAB CHEW C OTC

ANTACID LIQUID C OTC

ANTACID PLUS ANTI-GAS C OTC

ANTACID PLUS GAS RELIEF C OTC

ANTACID SUPREME C OTC

ANTACID SUSPENSION C OTC

ANTACID ULTRA STR 1,000 MG CHW C OTC

ANTACID-ANTIGAS LIQUID OTC /aluminum hydroxide/simethicone C

CALCIUM ANTACID C OTC

calcium carbonate 648 mg tab C OTC

CVS ANTACID 750 MG CHEW TABLET C OTC

CVS ANTACID EX-STR 750 MG CHEW C OTC

CVS ANTACID ULTRA STR TAB CHEW C OTC

CVS ANTACID-ANTIGAS LIQUID C OTC

PAGE 187 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

EQ ANTACID EX-STR 750 MG CHEW C OTC

EQ ANTACID EXTRA STR TAB CHEW C OTC

EZ CHAR OTC activated charcoal C GAVISCON OTC /aluminum hydroxide C GELUSIL OTC magnesium hydroxide/aluminum hydroxide/simethicone C

GERI-LANTA C OTC

GNP ANTACID EX-STR 750 MG CHEW C OTC

GNP ANTACID SUSPENSION C OTC

GS ANTACID 500 MG CHEWABLE TAB C OTC

HM ANTACID 500 MG CHEW TABLET C OTC

HM ANTACID EX-STR 750 MG CHEW C OTC

HM ANTACID-ANTIGAS SUSPENSION C OTC

INSTA-CHAR C OTC

MAALOX MAXIMUM STRENGTH C OTC

magnesium oxide 400 mg tablet C OTC

MAGOX 400 OTC magnesium oxide C

MI-ACID 400-400-40 MG/10 ML LQ C OTC

MI-ACID MAX STRENGTH LIQUID C OTC

MINTOX PLUS C OTC

MYLANTA MAXIMUM STRENGTH C OTC

pub calcium carb 1,000 mg tab C OTC

RA ANTACID 500 MG CHEWABLE TAB C OTC

RA ANTACID-ANTIGAS LIQUID C OTC

SM ANTACID 500 MG CHEW TABLET C OTC

SM ANTACID 750 MG CHEW TABLET C OTC

PAGE 188 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

SM ANTACID-ANTIGAS LIQUID C OTC

sodium bicarb 10 grain tablet C OTC

sodium bicarb 325 mg tablet C OTC

sodium bicarb 650 mg tablet C OTC

ANTI-INFLAMMATORY AGENTS (GI DRUGS)

hcl C PA

APRISO PA mesalamine NP ASACOL HD PA mesalamine NP

balsalazide disodium P CANASA mesalamine P COLAZAL PA balsalazide disodium NP DELZICOL mesalamine P DIPENTUM PA sodium NP LIALDA PA mesalamine NP

mesalamine 1,000 mg supp NP PA

mesalamine 4 gm/60 ml P

mesalamine 4 gm/60 ml kit P

mesalamine 800 mg dr tablet NP PA

mesalamine dr NP PA

mesalamine dr 1.2 gm tablet NP PA

mesalamine er NP PA

PENTASA mesalamine P ROWASA 4 GM/60 ML ENEMA PA mesalamine NP ROWASA 4 GM/60 ML ENEMA KIT PA mesalamine with cleansing wipes NP

PAGE 189 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SFROWASA PA mesalamine NP ANTIDIARRHEA AGENTS

ANTI-DIARRHEAL 2 MG CAPLET OTC hcl C

ANTI-DIARRHEAL 2 MG SOFTGEL C OTC

bismuth subsalicylate C OTC

CVS ANTI-DIARRHEAL 2 MG CAPLET OTC loperamide hcl C

CVS ANTI-DIARRHEAL 2 MG SFTGEL C OTC

cvs loperamide 1 mg/7.5 ml sus C OTC

CVS RELIEF MAX STR LIQ C OTC

CVS STOMACH RLF 262 MG CHEW TB C OTC

diphenoxylat-atrop 2.5-0.025/5 C QL 40 ML / 1 DAY

-atrop 2.5-0.025 C QL 8 TABS / 1 DAY

EQ ANTI-DIARRHEAL 2 MG SFTGEL C OTC

eq loperamide 1 mg/7.5 ml susp C OTC

EQ STOMACH RLF 262 MG CHEW TAB C OTC

eql loperamide 1 mg/7.5 ml sus C OTC

EQL STOMACH RLF 262 MG CHEW TB C OTC

GERI-PECTATE C OTC

GNP ANTI-DIARRHEAL 2 MG SFTGEL C OTC

gnp loperamide 1 mg/7.5 ml liq C OTC

GNP STOMACH RELIEF 525MG/15 ML C OTC

GS ANTI-DIARRHEAL 1 MG/7.5 ML OTC loperamide hcl C

GS STOMACH RLF 262 MG CHEW TAB C OTC

HM ANTI-DIARRHEAL 2 MG SOFTGEL C OTC

hm loperamide 1 mg/7.5 ml liq C OTC

PAGE 190 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

hm loperamide 2 mg softgel C OTC

HM STOMACH RELIEF 525 MG/15 ML C OTC

HM STOMACH RELIEF 525 MG/30 ML C OTC

HM STOMACH RLF 262 MG CHEW TAB C OTC

IMODIUM A-D OTC loperamide hcl C

KAOPECTATE C OTC

kro loperamide 1 mg/7.5 ml sus C OTC

KRO STOMACH RLF 262 MG CHEW TB C OTC

loperamide 1 mg/7.5 ml liquid C OTC

loperamide 1 mg/7.5 ml soln C OTC

loperamide 1 mg/7.5 ml susp C OTC

loperamide 2 mg capsule C OTC

loperamide hcl C OTC

C QL 40 ML / 1 DAY

PUB STOMACH RLF 262 MG CHEW TB C OTC

RA ANTI-DIARRHEAL 2 MG SOFTGEL C OTC

ra loperamide 1 mg/7.5 ml susp C OTC

SM ANTI-DIARRHEAL 2 MG SOFTGEL C OTC

sm loperamide 1 mg/7.5 ml liq C OTC

SM STOMACH RELIEF 525 MG/30 ML C OTC

SM STOMACH RLF 262 MG CHEW TAB C OTC

SOOTHE C OTC

STOMACH RELIEF 262 MG CHEW TAB C OTC

STOMACH RELIEF 525 MG/15 ML C OTC

STOMACH RLF 525 MG/30 ML SUSP C OTC

XERMELO PA C telotristat etiprate S Specialty Drug

PAGE 191 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ANTIFLATULENTS

ANTI-GAS C OTC

CVS GAS RELF(SIMETH) 80 MG CHW C OTC

GAS RELIEF (SIMETH) 80 MG CHEW OTC simethicone C

GAS RELIEF 125 MG CHEW TABLET C OTC

GAS RELIEF 180 MG SOFTGEL C OTC

GAS-X EX-STR 125 MG TAB CHEW OTC simethicone C

GAS-X EXTRA STRENGTH SOFTGEL C OTC

GNP GAS RLF(SIMETH) 80 MG CHEW C OTC

HM GAS RELIEF 125 MG CHEW TAB C OTC

HM GAS RELIEF(SIMETH) 80MG CHW C OTC

INFANT GAS RELIEF C OTC

INFANTS' GAS RELIEF C OTC

INFANTS' SIMETHICONE C OTC

LITTLE REMEDIES GAS RELIEF C OTC

MI-ACID GAS 80 MG TAB CHEW C OTC

simethicone C OTC

SM GAS RELIEF(SIMETH) 80MG CHW C OTC

CATHARTICS AND

10 mg suppository C OTC

bisacodyl ec 5 mg tablet C OTC

child glycerin suppository C OTC

CITROMA OTC C CITRUCEL OTC methylcellulose C CLEARLAX POWDER OTC 3350 C

PAGE 192 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS CLEARLAX POWDER PACKET polyethylene glycol 3350 C COLACE CLEAR OTC sodium C

cvs citrate of magnesia soln C OTC

CVS FIBER THERAPY 500 MG CAPLT C OTC

cvs glycerin suppository C OTC

CVS 25 MG TABLET C OTC

CVS LAXATIVE PILLS C OTC

cvs magnesium citrate soln C OTC

cvs milk of magnesia susp C OTC

CVS STOOL SOFTENER 100 MG SFTG C OTC

CVS STOOL SOFTENER 50 MG SFTGL C OTC

CVS STOOL SOFTENER-STIM LAX TB C OTC

docusate sod 60 mg/15 ml syrp C OTC

docusate sodium 100 mg capsule C OTC

docusate sodium 100 mg softgel C OTC

docusate sodium 250 mg capsule C OTC

docusate sodium 250 mg softgel C OTC

docusate sodium 50 mg/5 ml liq C OTC

DOCUSOL C OTC

DULCOLAX 1,200 MG/15 ML LIQUID C OTC

EQ FIBER THERAPY 625 MG CAPLET C OTC

EQ FIBER THERAPY CAPLET C OTC

EQ LAXATIVE 25 MG TABLET C OTC

eq magnesium citrate solution C OTC

EQ MAX STR LAXATIVE PILL C OTC

PAGE 193 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

eq milk of magnesia suspension C OTC

EQ NATURAL FIBER LAXATIVE POWD C OTC

EQ STOOL SOFTENER 100 MG SFTGL C OTC

EQ STOOL SOFTENER-STIM LAX TAB C OTC

EQL FIBER THERAPY 500 MG CPLT C OTC

EQL LAXATIVE 25 MG TABLET C OTC

eql magnesium citrate solution C OTC

eql milk of magnesia susp C OTC

EQL NATURAL FIBER LAXATIVE CAP C OTC

EVAC-U-GEN C OTC

EX-LAX MAXIMUM STRENGTH OTC sennosides C

FIBER LAXATIVE C OTC

FIBER SMOOTH C OTC

FIBER THERAPY 500 MG CAPLET C OTC

FIBER THERAPY CAPLET C OTC

FIBERCON OTC calcium polycarbophil C FLEET BISACODYL 10 MG ENEMA OTC bisacodyl C

FLEET GLYCERIN 2 GM ADULT SUPP C OTC

FLEET GLYCERIN ADULT SUPPOS C OTC

GAVILAX polyethylene glycol 3350 C GAVILYTE-C peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride C GAVILYTE-G peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride C GAVILYTE-N sodium chloride/sodium bicarbonate/potassium chloride/peg C

GENTLE LAXATIVE C OTC

PAGE 194 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS GENTLELAX polyethylene glycol 3350 C

GERI-KOT C OTC

glycerin adult suppository C OTC

GLYCOLAX polyethylene glycol 3350 C

GNP FIBER THERAPY 500 MG CAPLT C OTC

GNP LAXATIVE 25 MG PILL C OTC

GNP LAXATIVE EC 5 MG TABLET C OTC

gnp milk of magnesia susp C OTC

GNP NATURAL FIBER LAXATIVE CAP C OTC

GNP NATURAL FIBER POWDER C OTC

GNP SENNA PLUS 8.6-50 MG TAB C OTC

GNP STOOL SOFTENER 100 MG SFGL C OTC

GNP STOOL SOFTENER 250 MG SFGL C OTC

GNP STOOL SOFTENER-STIM LAX TB C OTC

gs milk of magnesia suspension C OTC

HEALTHYLAX OTC polyethylene glycol 3350 C

HM FIBER POWDER C OTC

HM LAXATIVE EC 5 MG TABLET C OTC

hm magnesium citrate solution C OTC

hm milk of magnesia suspension C OTC

HM SENNA 8.6 MG TABLET C OTC

HM STOOL SOFTENER 100 MG SFTGL C OTC

HM STOOL SOFTENER 250 MG SFTGL C OTC

HM STOOL SOFTENER-STIM LAX TAB C OTC

hv milk of magnesia suspension C OTC

PAGE 195 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS HYDROCIL INSTANT OTC seed C KONSYL DAILY FIBER POWDER PKT OTC psyllium husk C KONSYL ORIGINAL 6 GM POWD PKT OTC psyllium husk C KONSYL ORIGINAL FIBER POWDER OTC psyllium husk C

KONSYL PSYLLIUM FIBER POWDER C OTC

kro milk of magnesia susp C OTC

KRO STOOL SOFTENER 100 MG SFGL C OTC

LAXACLEAR polyethylene glycol 3350 C

LAXATIVE 25 MG PILL C OTC

LAXATIVE 25 MG TABLET C OTC

LAXATIVE 5 MG TABLET C OTC

LAXATIVE EC 5 MG TABLET C OTC

LAXATIVE MAXIMUM STRENGTH C OTC

LAXATIVE PILLS C OTC

QL 2 CAPS / 1 DAY lubiprostone C ST

magnesium citrate solution C OTC

milk of magnesia suspension C OTC

mineral oil C OTC

MINERAL OIL ENEMA OTC mineral oil C MIRALAX polyethylene glycol 3350 C

NATURAL FIBER LAXATIVE CAPSULE C OTC

NATURAL FIBER POWDER C OTC

NATURAL LAXATIVE C OTC

PAGE 196 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

NATURAL VEGETABLE LAXATIVE C OTC

NATURAL VEGETABLE POWDER C OTC

ORAL SALINE LAXATIVE C OTC

PEDIA-LAX OTC glycerin C

peg 3350 electrolyte soln C

peg 3350-electrolyte solution C

peg-3350 and electrolytes C

polyethylene glycol 3350 C OTC

POWDERLAX polyethylene glycol 3350 C

pub docusate sodium 100 mg cap C OTC

PUB LAXATIVE EC 5 MG TABLET C OTC

pub milk of magnesia susp C OTC

PURE AND GENTLE SALINE ENEMA C OTC

QC LAXATIVE 25 MG TABLET C OTC

qc magnesium citrate solution C OTC

qc milk of magnesia suspension C OTC

RA LAXATIVE 25 MG PILL C OTC

RA LAXATIVE EC 5 MG TABLET C OTC

ra milk of magnesia suspension C OTC

RA SENNA 8.6 MG TABLET C OTC

REGULOID LAXATIVE POWDER C OTC

SEN-O-TAB C OTC

SENEXON C OTC

SENEXON-S C OTC

SENNA 8.6 MG TABLET C OTC

senna 8.8 mg/5 ml liquid C OTC

PAGE 197 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

senna 8.8 mg/5 ml syrup C OTC

senna 8.8 mg/5 ml syrup grx C OTC

SENNA LAX C OTC

SENNA LAXATIVE C OTC

SENNA PLUS 8.6-50 MG TABLET C OTC

SENNA PLUS TABLET C OTC

SENNA-S C OTC

SENNA-S LAXATIVE C OTC

SENNA-TIME 8.6 MG TABLET C OTC

SENNO C OTC

SENOKOT OTC sennosides C

SM FIBER POWDER C OTC

SM LAXATIVE TABLET C OTC

sm magnesium citrate solution C OTC

sm milk of magnesia suspension C OTC

SM STOOL SOFTENER 100 MG SFTGL C OTC

SMOOTHLAX C sorbitol 70% solution OTC sorbitol solution C

STIMULANT LAXATIVE PLUS C OTC

STOOL SOFTENER 100 MG SOFTGEL OTC docusate sodium C STOOL SOFTENER 250 MG SOFTGEL OTC docusate sodium C

STOOL SOFTENER-LAXATIVE C OTC

STOOL SOFTENER-STIM LAX TABLET C OTC

SUPREP /potassium sulfate/ C

PAGE 198 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS TRILYTE WITH PACKETS sodium chloride/sodium bicarbonate/potassium chloride/peg C

VEGETABLE LAX-STOOL SOFTENER C OTC

VEGETABLE LAXATIVE C OTC

WOMEN'S LAXATIVE C OTC

CHOLELITHOLYTIC AGENTS

ursodiol C DIGESTANTS

CREON lipase/protease/ P LACTAID FAST ACT OTC C

lactase C OTC

PANCREAZE PA lipase/protease/amylase NP PERTZYE PA lipase/protease/amylase NP VIOKACE PA lipase/protease/amylase NP ZENPEP lipase/protease/amylase P GI DRUGS, MISCELLANEOUS

CHOLBAM PA C cholic acid S Specialty Drug

QL 6 PACKETS / 1 DAY ENDARI PA glutamine P S Specialty Drug

ENTYVIO PA NP vedolizumab MED

QL 2 / 28 HUMIRA(CF) PEDI CROHN 80-40 MG DAYS P PA S Specialty Drug

PAGE 199 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

LINZESS QL 1 CAP / 1 DAY C ST

MOVANTIK QL 1 TAB / 1 DAY C oxalate PA

SYMPROIC PA tosylate C PROKINETIC AGENTS

GIMOTI PA hcl C

metoclopramide 10 mg tablet C

metoclopramide 10 mg/10 ml sol C

metoclopramide 5 mg tablet C

metoclopramide 5 mg/5 ml soln C

metoclopramide hcl odt C PA

GENITOURINARY RELAXANTS

ANTIMUSCARINICS

er NP PA

DETROL PA tartrate NP DETROL LA PA tolterodine tartrate NP DITROPAN XL PA chloride NP ENABLEX PA darifenacin hydrobromide NP

hcl NP PA

GELNIQUE PA oxybutynin chloride NP

oxybutynin chloride P

oxybutynin chloride er P OXYTROL oxybutynin P

succinate P

PAGE 200 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

tolterodine tartrate P

tolterodine tartrate er P TOVIAZ fumarate P

NP PA

trospium chloride er NP PA

VESICARE PA solifenacin succinate NP GOLD COMPOUNDS

RIDAURA auranofin C AND

ANTIGONADTROPINS

ORGOVYX PA C ONC

QL 2 CAPS / 1 DAY ORIAHNN PA elagolix sodium/estradiol/norethindrone acetate C S Specialty Drug

QL 28 TABS / 28 DAYS ORILISSA 150 MG TABLET PA elagolix sodium C S Specialty Drug

QL 56 TABS / 28 DAYS ORILISSA 200 MG TABLET PA elagolix sodium C S Specialty Drug

HCV ANTIVIRALS

HCV POLYMERASE INHIBITOR ANTIVIRALS

EPCLUSA PA NP sofosbuvir/velpatasvir S Specialty Drug

HARVONI PA NP ledipasvir/sofosbuvir S Specialty Drug

PA ledipasvir-sofosbuvir NP S Specialty Drug

PAGE 201 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PA sofosbuvir-velpatasvir NP S Specialty Drug

SOVALDI PA NP sofosbuvir S Specialty Drug

VOSEVI PA P sofosbuvir/velpatasvir/voxilaprevir S Specialty Drug

HCV PROTEASE INHIBITOR ANTIVIRALS

MAVYRET PA P glecaprevir/pibrentasvir S Specialty Drug

HCV REPLICATION COMPLEX INHIBITORS

VIEKIRA PAK PA NP ombitasvir//ritonavir/ sodium S Specialty Drug

ZEPATIER PA NP elbasvir/ S Specialty Drug

HEAVY METAL ANTAGONISTS

CHEMET succimer C D-PENAMINE PA penicillamine C

PA

deferasirox 125 mg tb for susp C S Specialty Drug

TD

PA

deferasirox 180 mg tablet C S Specialty Drug

TD

PA

deferasirox 250 mg tb for susp C S Specialty Drug

TD

PA

deferasirox 360 mg tablet C S Specialty Drug

TD

PAGE 202 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PA

deferasirox 500 mg tb for susp C S Specialty Drug

TD

PA

deferasirox 90 mg tablet C S Specialty Drug

TD

PA deferiprone C S Specialty Drug

FERRIPROX PA C deferiprone S Specialty Drug

FERRIPROX (2 TIMES A DAY) PA C deferiprone S Specialty Drug

PA penicillamine 250 mg tablet C S Specialty Drug

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

budesonide ec NP PA

budesonide er NP PA

DECADRON dexamethasone C

dexamethasone 0.5 mg tablet C

dexamethasone 0.5 mg/5 ml elx C

dexamethasone 0.5 mg/5 ml liq C

dexamethasone 0.75 mg tablet C

dexamethasone 1 mg tablet C

dexamethasone 1.5 mg tablet C

dexamethasone 10 mg/ml syring C

dexamethasone 120 mg/30 ml vl C

dexamethasone 2 mg tablet C

dexamethasone 20 mg/5 ml vial C

PAGE 203 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

dexamethasone 4 mg tablet C

dexamethasone 4 mg/ml vial C

dexamethasone 6 mg tablet C DEXAMETHASONE INTENSOL dexamethasone C

acetate C

hydrocortisone 10 mg tablet C

hydrocortisone 20 mg tablet C

hydrocortisone 5 mg tablet C MEDROL 2 MG TABLET C

methylprednisolone C

prednisolone C

prednisolone 15 mg/5 ml soln C

prednisolone 5 mg/5 ml soln C

prednisolone sod ph 25 mg/5 ml C

C PREDNISONE INTENSOL prednisone C SOLU-CORTEF 100 MG ACT-O-VIAL hydrocortisone sodium succinate/pf C SOLU-CORTEF 100 MG VIAL hydrocortisone sod succinate C UCERIS PA budesonide NP

ANDRODERM PA P ANDROGEL PA testosterone P

C FORTESTA PA testosterone NP NATESTO PA testosterone NP

PAGE 204 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS STRIANT PA testosterone NP TESTIM PA testosterone NP

testosteron cyp 1,000 mg/10 ml C PA

testosteron cyp 2,000 mg/10 ml C PA

testosterone 1% (25mg/2.5g) pk NP PA

testosterone 1% (50 mg/5 g) pk NP PA

testosterone 1.62% (2.5 g) pkt NP PA

testosterone 1.62% gel pump NP PA

testosterone 1.62%(1.25 g) pkt NP PA

testosterone 10 mg gel pump C PA

testosterone 12.5 mg/1.25 gram NP PA

testosterone 30 mg/1.5 ml pump NP PA

testosterone 50 mg/5 gram gel NP PA

testosterone 50 mg/5 gram pkt NP PA

testosterone cyp 1,000 mg/5 ml C PA

testosterone cyp 100 mg/ml C PA

testosterone cyp 200 mg/ml C PA

testosterone cyp 500 mg/2.5 ml C PA

testosterone cyp 500 mg/5 ml C PA

testosterone cyp 6,000 mg/30ml C PA

testosterone enanthate C PA

testosterone propionate C PA

VOGELXO PA testosterone NP CONTRACEPTIVES

AFIRMELLE /ethinyl estradiol C

PAGE 205 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ALTAVERA levonorgestrel/ethinyl estradiol C ALYACEN norethindrone-ethinyl estradiol C AMETHIA levonorgestrel/ethinyl estradiol and ethinyl estradiol C AMETHIA LO levonorgestrel/ethinyl estradiol and ethinyl estradiol C ANNOVERA QL 1 RING / YEAR acetate/ethinyl estradiol C APRI -ethinyl estradiol C ARANELLE norethindrone-ethinyl estradiol C ASHLYNA levonorgestrel/ethinyl estradiol and ethinyl estradiol C AUBRA levonorgestrel/ethinyl estradiol C AUBRA EQ levonorgestrel/ethinyl estradiol C AUROVELA norethindrone acetate-ethinyl estradiol C AUROVELA 24 FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C AUROVELA FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C AVIANE levonorgestrel/ethinyl estradiol C AYUNA levonorgestrel/ethinyl estradiol C AZURETTE desogestrel-ethinyl estradiol/ethinyl estradiol C BALZIVA norethindrone-ethinyl estradiol C BEKYREE desogestrel-ethinyl estradiol/ethinyl estradiol C BLISOVI 24 FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C BLISOVI FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C

PAGE 206 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS BRIELLYN norethindrone-ethinyl estradiol C CAMILA norethindrone C CAMRESE levonorgestrel/ethinyl estradiol and ethinyl estradiol C CAMRESE LO levonorgestrel/ethinyl estradiol and ethinyl estradiol C CAZIANT desogestrel-ethinyl estradiol C CHATEAL levonorgestrel/ethinyl estradiol C CHATEAL EQ levonorgestrel/ethinyl estradiol C CRYSELLE -ethinyl estradiol C CYCLAFEM norethindrone-ethinyl estradiol C CYRED desogestrel-ethinyl estradiol C CYRED EQ desogestrel-ethinyl estradiol C DASETTA norethindrone-ethinyl estradiol C DAYSEE levonorgestrel/ethinyl estradiol and ethinyl estradiol C DEBLITANE norethindrone C

desogestr-eth estrad eth estra C

desogestrel-ethinyl estradiol C

-ethinyl estradiol C ELINEST norgestrel-ethinyl estradiol C ELLA C ELURYNG /ethinyl estradiol C EMOQUETTE desogestrel-ethinyl estradiol C

PAGE 207 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ENPRESSE levonorgestrel/ethinyl estradiol C ENSKYCE desogestrel-ethinyl estradiol C ERRIN norethindrone C ESTARYLLA -ethinyl estradiol C

ethynodiol-ethinyl estradiol C

etonogestrel-ethinyl estradiol C FALMINA levonorgestrel/ethinyl estradiol C FEMYNOR norgestimate-ethinyl estradiol C GIANVI ethinyl estradiol/drospirenone C HAILEY norethindrone acetate-ethinyl estradiol C HAILEY 24 FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C HAILEY FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C HEATHER norethindrone C ICLEVIA levonorgestrel/ethinyl estradiol C INCASSIA norethindrone C INTROVALE levonorgestrel/ethinyl estradiol C ISIBLOOM desogestrel-ethinyl estradiol C JAIMIESS levonorgestrel/ethinyl estradiol and ethinyl estradiol C JASMIEL ethinyl estradiol/drospirenone C JENCYCLA norethindrone C

PAGE 208 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS JOLESSA levonorgestrel/ethinyl estradiol C JULEBER desogestrel-ethinyl estradiol C JUNEL norethindrone acetate-ethinyl estradiol C JUNEL FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C JUNEL FE 24 norethindrone acetate-ethinyl estradiol/ferrous fumarate C KALLIGA desogestrel-ethinyl estradiol C KARIVA desogestrel-ethinyl estradiol/ethinyl estradiol C KELNOR 1-35 ethynodiol diacetate-ethinyl estradiol C KELNOR 1-50 ethynodiol diacetate-ethinyl estradiol C KURVELO levonorgestrel/ethinyl estradiol C LARIN norethindrone acetate-ethinyl estradiol C LARIN 24 FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C LARIN FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C LARISSIA levonorgestrel/ethinyl estradiol C LEENA norethindrone-ethinyl estradiol C LESSINA levonorgestrel/ethinyl estradiol C LEVONEST levonorgestrel/ethinyl estradiol C

levono-e estrad 0.15-0.03-0.01 C

levonor-e estrad 0.1-0.02-0.01 C

levonor-eth estrad 0.1-0.02 mg C

levonor-eth estrad 0.15-0.03 C

PAGE 209 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

levonor-eth estrad triphasic C

levonorgestrel C OTC

LEVORA-28 levonorgestrel/ethinyl estradiol C LILLOW levonorgestrel/ethinyl estradiol C LO-ZUMANDIMINE ethinyl estradiol/drospirenone C LOJAIMIESS levonorgestrel/ethinyl estradiol and ethinyl estradiol C LORYNA ethinyl estradiol/drospirenone C LOW-OGESTREL norgestrel-ethinyl estradiol C LUTERA levonorgestrel/ethinyl estradiol C LYLEQ norethindrone C LYZA norethindrone C MARLISSA levonorgestrel/ethinyl estradiol C MICROGESTIN norethindrone acetate-ethinyl estradiol C MICROGESTIN FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C MILI norgestimate-ethinyl estradiol C MONO-LINYAH norgestimate-ethinyl estradiol C MY WAY OTC levonorgestrel C NECON norethindrone-ethinyl estradiol C NIKKI ethinyl estradiol/drospirenone C NORA-BE norethindrone C

PAGE 210 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

noreth-ee-fe 1-0.02(21)-75 tab C

noreth-ee-fe 1-0.02(24)-75 tab C

noreth-ee-fe 1.5-0.03mg(21)-75 C

norethin-ee 1.5-0.03 mg(21) tb C

norethind-eth estrad 1-0.02 mg C

norethindrone C

norgestimate-ethinyl estradiol C NORLYDA norethindrone C NORTREL norethindrone-ethinyl estradiol C NYLIA norethindrone-ethinyl estradiol C NYMYO norgestimate-ethinyl estradiol C OCELLA ethinyl estradiol/drospirenone C OGESTREL norgestrel-ethinyl estradiol C ORSYTHIA levonorgestrel/ethinyl estradiol C PHILITH norethindrone-ethinyl estradiol C PIMTREA desogestrel-ethinyl estradiol/ethinyl estradiol C PIRMELLA norethindrone-ethinyl estradiol C

PLAN B ONE-STEP PA C levonorgestrel OTC

PORTIA levonorgestrel/ethinyl estradiol C PREVIFEM norgestimate-ethinyl estradiol C RECLIPSEN desogestrel-ethinyl estradiol C SETLAKIN levonorgestrel/ethinyl estradiol C

PAGE 211 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SHAROBEL norethindrone C SIMLIYA desogestrel-ethinyl estradiol/ethinyl estradiol C SIMPESSE levonorgestrel/ethinyl estradiol and ethinyl estradiol C SPRINTEC norgestimate-ethinyl estradiol C SRONYX levonorgestrel/ethinyl estradiol C SYEDA ethinyl estradiol/drospirenone C TARINA 24 FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C TARINA FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C TARINA FE 1-20 EQ norethindrone acetate-ethinyl estradiol/ferrous fumarate C TILIA FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C TRI FEMYNOR norgestimate-ethinyl estradiol C TRI-ESTARYLLA norgestimate-ethinyl estradiol C TRI-LEGEST FE norethindrone acetate-ethinyl estradiol/ferrous fumarate C TRI-LINYAH norgestimate-ethinyl estradiol C TRI-LO-ESTARYLLA norgestimate-ethinyl estradiol C TRI-LO-MARZIA norgestimate-ethinyl estradiol C TRI-LO-MILI norgestimate-ethinyl estradiol C TRI-LO-SPRINTEC norgestimate-ethinyl estradiol C TRI-MILI norgestimate-ethinyl estradiol C TRI-NYMYO norgestimate-ethinyl estradiol C

PAGE 212 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS TRI-PREVIFEM norgestimate-ethinyl estradiol C TRI-SPRINTEC norgestimate-ethinyl estradiol C TRI-VYLIBRA norgestimate-ethinyl estradiol C TRI-VYLIBRA LO norgestimate-ethinyl estradiol C TRIVORA-28 levonorgestrel/ethinyl estradiol C TULANA norethindrone C TWIRLA levonorgestrel/ethinyl estradiol C TYBLUME levonorgestrel/ethinyl estradiol C VELIVET desogestrel-ethinyl estradiol C VESTURA ethinyl estradiol/drospirenone C VIENVA levonorgestrel/ethinyl estradiol C VIORELE desogestrel-ethinyl estradiol/ethinyl estradiol C VOLNEA desogestrel-ethinyl estradiol/ethinyl estradiol C VYFEMLA norethindrone-ethinyl estradiol C VYLIBRA norgestimate-ethinyl estradiol C WERA norethindrone-ethinyl estradiol C XULANE /ethinyl estradiol C ZARAH ethinyl estradiol/drospirenone C ZOVIA 1-35 ethynodiol diacetate-ethinyl estradiol C ZOVIA 1-35E ethynodiol diacetate-ethinyl estradiol C

PAGE 213 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ZUMANDIMINE ethinyl estradiol/drospirenone C PITUITARY

0.01% solution C PA

desmopressin 10 mcg/0.1 ml spr C PA

desmopressin acetate 0.1 mg tb C AL1 At least 8 yrs old

desmopressin acetate 0.2 mg tb C AL1 At least 8 yrs old

GENOTROPIN PA somatropin NP HUMATROPE PA somatropin NP NORDITROPIN FLEXPRO PA somatropin P NUTROPIN AQ NUSPIN PA somatropin P OMNITROPE PA somatropin NP SAIZEN PA somatropin NP SAIZEN-SAIZENPREP PA somatropin NP

SEROSTIM PA NP somatropin S Specialty Drug

STIMATE PA desmopressin acetate C ZOMACTON PA somatropin NP

ZORBTIVE PA NP somatropin S Specialty Drug

PROGESTINS

10 mg tab C

medroxyprogesterone 2.5 mg tab C

medroxyprogesterone 5 mg tab C MEGACE ES PA acetate NP

PAGE 214 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

megestrol 20 mg tablet P

megestrol 40 mg tablet P

megestrol 625 mg/5 ml susp NP PA

megestrol acet 40 mg/ml susp P

megestrol acet 400 mg/10 ml P

norethindrone ac (lupaneta) C

norethindrone acetate C

100 mg capsule C

progesterone 200 mg capsule C HYPOTENSIVE AGENTS

CENTRAL ALPHA-AGONISTS

C

clonidine hcl 0.1 mg tablet C

clonidine hcl 0.2 mg tablet C

clonidine hcl 0.3 mg tablet C

QL 4 TABS / 1 DAY clonidine hcl er C PA

guanfacine hcl C

C DIRECT VASODILATORS

10 mg tablet C

hydralazine 100 mg tablet C

hydralazine 25 mg tablet C

hydralazine 50 mg tablet C

C

INTERMEDIATE-ACTING INSULINS

HUMULIN 70-30 OTC insulin nph human isophane/insulin regular, human P

HUMULIN 70/30 KWIKPEN PA NP insulin nph human isophane/insulin regular, human OTC

PAGE 215 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS HUMULIN N OTC insulin nph human isophane P

HUMULIN N KWIKPEN PA NP insulin nph human isophane OTC

NOVOLIN 70-30 100 UNIT/ML VIAL OTC insulin nph human isophane/insulin regular, human P

NOVOLIN 70-30 FLEXPEN PA NP insulin nph human isophane/insulin regular, human OTC

NOVOLIN N 100 UNIT/ML FLEXPEN PA NP insulin nph human isophane OTC

NOVOLIN N 100 UNIT/ML VIAL OTC insulin nph human isophane P

PA RELION NOVOLIN 70-30 FLEXPEN NP OTC

RELION NOVOLIN 70-30 VIAL P OTC

RELION NOVOLIN N 100 UNIT/ML P OTC

PA RELION NOVOLIN N U-100 FLEXPEN NP OTC

LONG-ACTING INSULINS

BASAGLAR KWIKPEN U-100 PA ,human recombinant analog NP LANTUS insulin glargine,human recombinant analog P LANTUS SOLOSTAR insulin glargine,human recombinant analog P LEVEMIR P LEVEMIR FLEXTOUCH insulin detemir P SEMGLEE PA insulin glargine,human recombinant analog NP SEMGLEE PEN PA insulin glargine,human recombinant analog NP

SOLIQUA 100-33 QL 15 ML / 30 DAYS NP insulin glargine,human recombinant analog/lixisenatide PA

PAGE 216 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS TOUJEO MAX SOLOSTAR PA insulin glargine,human recombinant analog NP TOUJEO SOLOSTAR PA insulin glargine,human recombinant analog NP TRESIBA PA NP TRESIBA FLEXTOUCH U-100 PA insulin degludec NP TRESIBA FLEXTOUCH U-200 PA insulin degludec NP

XULTOPHY 100-3.6 QL 15 ML / 30 DAYS NP insulin degludec/liraglutide PA

RAPID-ACTING INSULINS

ADMELOG PA NP ADMELOG SOLOSTAR PA insulin lispro NP AFREZZA PA insulin regular, human NP APIDRA PA NP APIDRA SOLOSTAR PA insulin glulisine NP FIASP PA (niacinamide) NP FIASP FLEXTOUCH PA insulin aspart (niacinamide) NP FIASP PENFILL PA insulin aspart (niacinamide) NP HUMALOG insulin lispro P HUMALOG JUNIOR KWIKPEN insulin lispro P HUMALOG KWIKPEN U-100 insulin lispro P HUMALOG KWIKPEN U-200 PA insulin lispro NP HUMALOG MIX 50-50 insulin lispro protamine and insulin lispro P

PAGE 217 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS HUMALOG MIX 50-50 KWIKPEN insulin lispro protamine and insulin lispro P HUMALOG MIX 75-25 insulin lispro protamine and insulin lispro P HUMALOG MIX 75-25 KWIKPEN insulin lispro protamine and insulin lispro P INSULIN ASPART 100 UNIT/ML CRT PA insulin aspart NP INSULIN ASPART 100 UNIT/ML PEN PA insulin aspart NP INSULIN ASPART 100 UNIT/ML VL PA insulin aspart NP INSULIN ASPART PROT-INSULN ASP PA insulin aspart protamine human/insulin aspart NP INSULIN ASPART PROT-INSULN ASP PA insulin aspart protamine human/insulin aspart NP INSULIN LISPRO 100 UNIT/ML PEN insulin lispro P INSULIN LISPRO 100 UNIT/ML VL insulin lispro P INSULIN LISPRO JR 100 UNIT/ML PA insulin lispro NP INSULIN LISPRO MIX 75-25 KWKPN PA insulin lispro protamine and insulin lispro NP LYUMJEV PA insulin lispro-aabc NP LYUMJEV KWIKPEN U-100 PA insulin lispro-aabc NP LYUMJEV KWIKPEN U-200 PA insulin lispro-aabc NP NOVOLOG 100 UNIT/ML CARTRIDGE insulin aspart P NOVOLOG 100 UNIT/ML FLEXPEN insulin aspart P NOVOLOG 100 UNIT/ML VIAL insulin aspart P NOVOLOG MIX 70-30 FLEXPEN insulin aspart protamine human/insulin aspart P NOVOLOG MIX 70-30 VIAL insulin aspart protamine human/insulin aspart P

PAGE 218 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

RELION NOVOLOG 100 UNIT/ML VL P

RELION NOVOLOG MIX 70-30 FLXPN P

RELION NOVOLOG MIX 70-30 VIAL P

RELION NOVOLOG U-100 FLEXPEN P SHORT-ACTING INSULINS

HUMULIN R OTC insulin regular, human P HUMULIN R U-500 insulin regular, human P HUMULIN R U-500 KWIKPEN insulin regular, human P

NOVOLIN R 100 UNIT/ML FLEXPEN PA NP insulin regular, human OTC

NOVOLIN R 100 UNIT/ML VIAL OTC insulin regular, human P

RELION NOVOLIN R 100 UNIT/ML P OTC

PA RELION NOVOLIN R U-100 FLEXPEN NP OTC

ION-REMOVING AGENTS

PHOSPHATE-REMOVING AGENTS

AURYXIA PA ferric citrate NP

calcium acetate 667 mg capsule P

calcium acetate 667 mg gelcap P

calcium acetate 667 mg tablet P FOSRENOL PA carbonate NP

lanthanum carbonate NP PA

PHOSLYRA calcium acetate P RENAGEL PA sevelamer hcl NP RENVELA PA sevelamer carbonate NP

PAGE 219 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

sevelamer 0.8 gm powder packet NP PA

sevelamer 2.4 gm powder packet NP PA

sevelamer carbonate 800 mg tab P

sevelamer hcl NP PA

VELPHORO PA sucroferric oxyhydroxide NP POTASSIUM-REMOVING AGENTS

KIONEX sodium polystyrene sulfonate/sorbitol solution C

sodium polystyrene sulfonate C SPS 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution C LOCAL ANESTHETICS (PARENTERAL)

hcl-nacl C MACROLIDE ANTIBIOTICS

ERYTHROMYCIN ANTIBIOTICS

E.E.S. 200 PA erythromycin ethylsuccinate NP E.E.S. 400 erythromycin ethylsuccinate P ERY-TAB PA erythromycin base NP ERYPED 200 PA erythromycin ethylsuccinate NP ERYPED 400 PA erythromycin ethylsuccinate NP ERYTHROCIN STEARATE PA erythromycin stearate NP

erythromycin 250 mg filmtab NP PA

erythromycin 500 mg filmtab NP PA

erythromycin dr 250 mg cap P

erythromycin ethylsuccinate NP PA

PAGE 220 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS OTHER MACROLIDE ANTIBIOTICS

azithromycin 1 gm pwd packet P

azithromycin 100 mg/5 ml susp P

azithromycin 200 mg/5 ml susp P

azithromycin 250 mg tablet P

azithromycin 500 mg tablet P

azithromycin 600 mg tablet P

125 mg/5 ml sus NP PA

clarithromycin 250 mg tablet P

clarithromycin 250 mg/5 ml sus NP PA

clarithromycin 500 mg tablet P

clarithromycin er NP PA

DIFICID PA C ZITHROMAX 1 GM POWDER PACKET PA azithromycin NP ZITHROMAX 100 MG/5 ML SUSP PA azithromycin NP ZITHROMAX 200 MG/5 ML SUSP PA azithromycin NP ZITHROMAX 250 MG TABLET PA azithromycin NP ZITHROMAX 250 MG Z-PAK TABLET PA azithromycin NP ZITHROMAX 500 MG TABLET PA azithromycin NP ZITHROMAX TRI-PAK PA azithromycin NP MISC. BETA-LACTAM ANTIBIOTICS

MONOBACTAM ANTIBIOTICS

CAYSTON PA NP aztreonam S Specialty Drug

PAGE 221 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

AVODART PA NP

dutasteride P

dutasteride-tamsulosin NP PA

5 mg tablet P JALYN PA dutasteride/tamsulosin hcl NP PROSCAR PA finasteride NP ALCOHOL DETERRENTS

C ANTIDOTES

leucovorin calcium 10 mg tab C

leucovorin calcium 15 mg tab C

leucovorin calcium 25 mg tab C

leucovorin calcium 5 mg tab C ANTIGOUT AGENTS

allopurinol C

colchicine C

febuxostat C BONE RESORPTION INHIBITORS

ACTONEL PA risedronate sodium NP

alendronate sodium P ATELVIA PA risedronate sodium NP BINOSTO PA alendronate sodium NP BONIVA PA ibandronate sodium NP

etidronate disodium NP PA

PAGE 222 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS FOSAMAX PA alendronate sodium NP FOSAMAX PLUS D PA alendronate sodium/cholecalciferol (vitamin d3) NP

ibandronate 3 mg/3 ml vial C

ibandronate sodium 150 mg tab P

PROLIA PA NP MED

risedronate sodium NP PA

risedronate sodium dr NP PA

CARIOSTATIC AGENTS

DENTA 5000 PLUS C

DENTAGEL C FLORIVA 0.25 MG/ML DROPS sodium fluoride/cholecalciferol (vitamin d3) C

fluoride C AL1 Up to 6 yrs old

FLUORITAB 0.5 MG TABLET CHEW C FLUORITAB 1 MG TABLET CHEW fluoride (sodium) C

LUDENT FLUORIDE 0.5 MG TB CHEW C

LUDENT FLUORIDE 1 MG TAB CHEW C

SF C

SF 5000 PLUS C

sodium fluoride 0.25 (0.55) mg C AL1 Up to 6 yrs old

sodium fluoride 0.5 mg(1.1 mg) C AL1 Up to 6 yrs old

AL1 Up to 6 yrs old sodium fluoride 0.5 mg/ml drop C OTC

sodium fluoride 1 mg (2.2 mg) C AL1 Up to 6 yrs old

sodium fluoride 1.1% cream C

sodium fluoride 1.1% gel C

SODIUM FLUORIDE 5000 PLUS C

PAGE 223 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

sodium fluoride 5000 ppm cream C COMPLEMENT INHIBITORS

BERINERT PA P c1 esterase inhibitor S Specialty Drug

CINRYZE PA NP c1 esterase inhibitor S Specialty Drug

FIRAZYR PA NP acetate S Specialty Drug

HAEGARDA PA NP c1 esterase inhibitor S Specialty Drug

PA icatibant NP S Specialty Drug

KALBITOR PA NP ecallantide S Specialty Drug

QL 1 CAP / 1 DAY ORLADEYO PA berotralstat hydrochloride C S Specialty Drug

RUCONEST PA NP c1 esterase inhibitor, recombinant S Specialty Drug

QL 4 ML / 30 DAYS TAKHZYRO PA lanadelumab-flyo NP S Specialty Drug

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

QL 3.6 ML / 28 DAYS ACTEMRA 162 MG/0.9 ML SYRINGE PA tocilizumab C S Specialty Drug

PA ACTEMRA 200 MG/10 ML VIAL S Specialty Drug tocilizumab NP MED

PAGE 224 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PA ACTEMRA 80 MG/4 ML VIAL S Specialty Drug tocilizumab NP MED

ACTEMRA ACTPEN PA NP tocilizumab S Specialty Drug

AVSOLA PA NP -axxq MED

PA CIMZIA 200 MG VIAL KIT S Specialty Drug certolizumab pegol NP MED

QL 2 SYRINGES / 28 CIMZIA 2X200 MG/ML SYRINGE KIT DAYS certolizumab pegol NP PA S Specialty Drug

QL 2 SYRINGES / 28 CIMZIA 2X200 MG/ML(X3)START KT DAYS certolizumab pegol NP PA S Specialty Drug

QL 8 VIALS (8 ML) / 28 ENBREL 25 MG KIT DAYS etanercept P PA S Specialty Drug

QL 4 ML (8 DOSES) / 28 ENBREL 25 MG/0.5 ML SYRINGE DAYS etanercept P PA S Specialty Drug

QL 4 ML (8 DOSES) / 28 ENBREL 25 MG/0.5 ML VIAL DAYS etanercept C PA S Specialty Drug

QL 4 ML (4 DOSES) / 28 ENBREL 50 MG/ML SYRINGE DAYS etanercept P PA S Specialty Drug

PAGE 225 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 4 ML (4 DOSES) / 28 ENBREL SURECLICK DAYS etanercept P PA S Specialty Drug

QL 2 SYRINGES / 28 HUMIRA DAYS adalimumab P PA S Specialty Drug

QL 2 PENS / 28 DAYS HUMIRA PEN PA adalimumab P S Specialty Drug

QL 2 PENS / 28 DAYS HUMIRA PEN CROHN'S-UC-HS PA adalimumab P S Specialty Drug

QL 2 PENS / 28 DAYS HUMIRA PEN PSOR-UVEITS-ADOL HS PA adalimumab P S Specialty Drug

QL 2 SYRINGES / 28 HUMIRA(CF) 10 MG/0.1 ML SYRING DAYS adalimumab P PA S Specialty Drug

QL 2 SYRINGES / 28 HUMIRA(CF) 20 MG/0.2 ML SYRING DAYS adalimumab P PA S Specialty Drug

QL 2 syringes / 28 day(s) HUMIRA(CF) 40 MG/0.4 ML SYRING PA adalimumab P S Specialty Drug

QL 3 SYRINGES / 28 HUMIRA(CF) PEDI CROHN 80MG/0.8 DAYS adalimumab P PA S Specialty Drug

QL 2 PENS / 28 DAYS HUMIRA(CF) PEN 40 MG/0.4 ML PA adalimumab P S Specialty Drug

PAGE 226 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 3 SYRINGES / 28 HUMIRA(CF) PEN 80 MG/0.8 ML DAYS adalimumab P PA S Specialty Drug

QL 3 SYRINGES / 28 HUMIRA(CF) PEN CROHN'S-UC-HS DAYS adalimumab P PA S Specialty Drug

QL 3 PENS / 28 DAYS HUMIRA(CF) PEN PEDIATRIC UC PA adalimumab P S Specialty Drug

QL 3 PENS / 28 DAYS HUMIRA(CF) PEN PSOR-UV-ADOL HS PA adalimumab P S Specialty Drug

INFLECTRA PA NP infliximab-dyyb MED

QL 2.8 ML / 28 DAYS KEVZARA PA sarilumab NP S Specialty Drug

QL 18.76 ML / 28 DAYS KINERET PA anakinra NP S Specialty Drug

leflunomide C

QL 1 TAB / 1 DAY OLUMIANT PA C S Specialty Drug

QL 4 SYRINGES / 28 ORENCIA 125 MG/ML SYRINGE DAYS abatacept NP PA S Specialty Drug

ORENCIA 250 MG VIAL PA NP abatacept/maltose MED

PAGE 227 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 2.8 ML / 28 DAYS ORENCIA 87.5 MG/0.7 ML SYRINGE PA abatacept NP S Specialty Drug

QL 4 ML / 28 DAYS ORENCIA CLICKJECT PA abatacept NP S Specialty Drug

QL 55 TABS / 28 DAYS OTEZLA 28 DAY STARTER PACK PA NP S Specialty Drug

QL 2 TABS / 1 DAY OTEZLA 30 MG TABLET PA apremilast NP S Specialty Drug

QL 55 TABS / 28 DAYS OTEZLA STARTER PACK PA apremilast NP S Specialty Drug

REMICADE PA NP infliximab MED

RENFLEXIS PA NP infliximab-abda MED

QL 1 TAB / 1 DAY RINVOQ PA NP S Specialty Drug

QL 1 SYRINGE / 28 DAYS SIMPONI 100 MG/ML PEN INJECTOR PA golimumab NP S Specialty Drug

QL 1 ML / 28 DAYS SIMPONI 100 MG/ML SYRINGE PA golimumab NP S Specialty Drug

QL 0.5 ML / 28 DAYS SIMPONI 50 MG/0.5 ML PEN INJEC PA golimumab NP S Specialty Drug

PAGE 228 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 0.5 ML / 28 DAYS SIMPONI 50 MG/0.5 ML SYRINGE PA golimumab NP S Specialty Drug

QL 104 ML / 54 DAYS SIMPONI ARIA PA golimumab NP S Specialty Drug

QL 10 ML / 1 DAY XELJANZ 1 MG/ML SOLUTION PA tofacitinib citrate NP S Specialty Drug

QL 2 TABS / 1 DAY XELJANZ 10 MG TABLET PA tofacitinib citrate NP S Specialty Drug

QL 2 TABS / 1 DAY XELJANZ 5 MG TABLET PA tofacitinib citrate NP S Specialty Drug

QL 1 TAB / 1 DAY XELJANZ XR PA tofacitinib citrate NP S Specialty Drug

IMMUNOMODULATORY AGENTS

AUBAGIO QL 1 TAB / 1 DAY P teriflunomide S Specialty Drug

AVONEX 30 MCG VIAL KIT QL 1 KIT / 28 DAYS P interferon beta-1a/albumin human S Specialty Drug

AVONEX PEN QL 1 KIT / 28 DAYS P interferon beta-1a S Specialty Drug

AVONEX PREFILLED SYR 30 MCG KT QL 1 KIT / 28 DAYS P interferon beta-1a S Specialty Drug

QL 4 CAPS / 1 DAY BAFIERTAM PA monomethyl fumarate NP S Specialty Drug

BETASERON QL 15 ML / 30 DAYS P interferon beta-1b S Specialty Drug

PAGE 229 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

COPAXONE 20 MG/ML SYRINGE QL 30 ML / 30 DAYS P glatiramer acetate S Specialty Drug

QL 12 ML / 28 DAYS COPAXONE 40 MG/ML SYRINGE PA glatiramer acetate NP S Specialty Drug

QL 2 CAPS / 1 DAY

dimethyl fumarate NP PA

S Specialty Drug

ENSPRYNG PA C satralizumab-mwge S Specialty Drug

QL 15 ML / 30 DAYS EXTAVIA PA interferon beta-1b NP S Specialty Drug

GILENYA QL 1 CAP / 1 DAY P fingolimod hcl S Specialty Drug

QL 30 ML / 30 DAYS

glatiramer 20 mg/ml syringe NP PA

S Specialty Drug

QL 12 ML / 28 DAYS

glatiramer 40 mg/ml syringe NP PA

S Specialty Drug

QL 30 ML / 30 DAYS GLATOPA 20 MG/ML SYRINGE PA glatiramer acetate NP S Specialty Drug

QL 12 ML / 28 DAYS GLATOPA 40 MG/ML SYRINGE PA glatiramer acetate NP S Specialty Drug

QL 0.4 ML / 28 DAYS KESIMPTA PEN PA NP S Specialty Drug

PAGE 230 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 12 TABS / 4 DAYS MAYZENT 0.25 MG STARTER PACK PA siponimod NP S Specialty Drug

QL 4 TABS / 1 DAY MAYZENT 0.25 MG TABLET PA siponimod NP S Specialty Drug

QL 1 TAB / 1 DAY MAYZENT 2 MG TABLET PA siponimod NP S Specialty Drug

PA OCREVUS S Specialty Drug ocrelizumab NP MED

QL 1 ML / 28 DAYS PLEGRIDY PA peginterferon beta-1a NP S Specialty Drug

PLEGRIDY 125 MCG/0.5 ML SYRINGE (IM) QL 1 ML / 28 DAYS C peginterferon beta-1a S Specialty Drug

QL 1 ML / 28 DAYS PLEGRIDY PEN PA peginterferon beta-1a NP S Specialty Drug

REBIF 22 MCG/0.5 ML SYRINGE QL 6 ML / 28 DAYS P interferon beta-1a/albumin human S Specialty Drug

REBIF 44 MCG/0.5 ML SYRINGE QL 6 ML / 28 DAYS P interferon beta-1a/albumin human S Specialty Drug

REBIF REBIDOSE 22 MCG/0.5 ML QL 6 ML / 28 DAYS P interferon beta-1a/albumin human S Specialty Drug

REBIF REBIDOSE 44 MCG/0.5 ML QL 6 ML / 28 DAYS P interferon beta-1a/albumin human S Specialty Drug

REBIF REBIDOSE TITRATION PACK QL 4.2 ML / 28 DAYS P interferon beta-1a/albumin human S Specialty Drug

PAGE 231 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

REBIF TITRATION PACK QL 4.2 ML / 28 DAYS P interferon beta-1a/albumin human S Specialty Drug

REDITREX PA methotrexate/pf C

QL 2 CAPS / 1 DAY TECFIDERA PA dimethyl fumarate NP S Specialty Drug

THALOMID S Specialty Drug C thalidomide ONC

PA TYSABRI S Specialty Drug natalizumab NP MED

VUMERITY PA NP diroximel fumarate S Specialty Drug

ZEPOSIA PA NP hydrochloride S Specialty Drug

IMMUNOSUPPRESSIVE AGENTS

ASTAGRAF XL PA tacrolimus NP AZASAN PA azathioprine NP

azathioprine P CELLCEPT 200 MG/ML ORAL SUSP mycophenolate mofetil P CELLCEPT 250 MG CAPSULE PA mycophenolate mofetil NP CELLCEPT 500 MG TABLET PA mycophenolate mofetil NP

cyclosporine 100 mg capsule P

cyclosporine 25 mg capsule P

cyclosporine modified P ENVARSUS XR PA tacrolimus NP

PAGE 232 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

everolimus 0.25 mg tablet NP PA

everolimus 0.5 mg tablet NP PA

everolimus 0.75 mg tablet NP PA

GENGRAF cyclosporine, modified C IMURAN PA azathioprine NP

MAVENCLAD PA NP cladribine S Specialty Drug

mycophenolate 200 mg/ml susp NP PA

mycophenolate 250 mg capsule P

mycophenolate 500 mg tablet P

mycophenolic acid NP PA

MYFORTIC PA mycophenolate sodium NP NEORAL PA cyclosporine, modified NP PROGRAF 0.5 MG CAPSULE PA tacrolimus NP PROGRAF 1 MG CAPSULE PA tacrolimus NP PROGRAF 5 MG CAPSULE PA tacrolimus NP RAPAMUNE PA NP SANDIMMUNE 100 MG CAPSULE PA cyclosporine NP SANDIMMUNE 100 MG/ML SOLN PA cyclosporine NP SANDIMMUNE 25 MG CAPSULE PA cyclosporine NP

sirolimus NP PA

tacrolimus 0.5 mg capsule (ir) P

tacrolimus 1 mg capsule (ir) P

PAGE 233 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

tacrolimus 5 mg capsule (ir) P ZORTRESS PA everolimus NP OTHER MISCELLANEOUS THERAPEUTIC AGENTS

QL 2 TABS / 1 DAY AMPYRA PA dalfampridine NP S Specialty Drug

ARCALYST PA C rilonacept S Specialty Drug

CERDELGA PA C tartrate S Specialty Drug

co q-10 C OTC

co q10 C OTC

coenzyme q-10 C OTC

coenzyme q10 C OTC

CYSTAGON cysteamine bitartrate C

CYTOTINE POWDER C

QL 2 TABS / 1 DAY

dalfampridine er NP PA

S Specialty Drug

EVRYSDI PA C risdiplam S Specialty Drug

EYE MULTIVITAMIN C OTC

QL 14 CAPS / 28 DAYS GALAFOLD PA migalastat hcl C S Specialty Drug

ICAPS OTC beta-carotene/ascorbic acid/vite ac/zinc oxide/cupric oxide C

QL 2 ML / 28 DAYS ILARIS PA canakinumab/pf NP S Specialty Drug

PAGE 234 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

ISTURISA PA C osilodrostat phosphate S Specialty Drug

levocarnitine 1 g/10 ml soln C

levocarnitine sf C

PA C S Specialty Drug

NATROL 5-HTP OTC 5-hydroxytryptophan (5-htp) C PRESERVISION AREDS 2 vit c/vit e acetate/zinc oxid/cupric oxide/lutein/zeaxanthin C PRESERVISION LUTEIN OTC ascorbic acid/vit e acetate/lutein/ oxide/zinc oxide C

QL 8 TABS / 1 DAY RUZURGI PA C S Specialty Drug

PA sapropterin dihydrochloride C S Specialty Drug

sodium chloride 1,000 mg tab C OTC

THIOLA PA C S Specialty Drug

THIOLA EC PA C tiopronin S Specialty Drug

PA tiopronin C S Specialty Drug

TYBOST cobicistat C

VISION FORMULA 2 C

ZOKINVY PA C lonafarnib S Specialty Drug

PROTECTIVE AGENTS

ELMIRON sodium C

PAGE 235 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS NONHORMONAL CONTRACEPTIVES

condoms OTC condoms, latex, lubricated C

GYNOL II C OTC

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

CELEBREX PA NP

celecoxib P OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS

ALL DAY PAIN RELIEF OTC naproxen sodium C ARTHRITIS PAIN RELIEVER 1% GEL OTC diclofenac sodium C ARTHROTEC 50 PA diclofenac sodium/misoprostol NP ARTHROTEC 75 PA diclofenac sodium/misoprostol NP

children's ibuprofen C OTC

CHILDREN'S MOTRIN OTC ibuprofen C

cvs diclofenac sodium 1% gel C OTC

cvs ibuprofen 200 mg caplet C OTC

cvs ibuprofen 200 mg capsule C OTC

cvs ibuprofen 200 mg softgel C OTC

cvs ibuprofen 200 mg tablet C OTC

cvs naproxen sod 220 mg caplet P OTC

cvs naproxen sod 220 mg tablet P OTC

diclofenac epolamine NP PA

diclofenac potassium C

diclofenac sod dr 25 mg tab P

PAGE 236 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

diclofenac sod dr 50 mg tab P

diclofenac sod dr 75 mg tab P

diclofenac sod ec 25 mg tab P

diclofenac sod ec 50 mg tab P

diclofenac sod ec 75 mg tab P

diclofenac sodium 1% gel C OTC

diclofenac sodium er P

diclofenac sodium-misoprostol NP PA

DUEXIS PA ibuprofen/famotidine NP

ec-naproxen P

eq ibuprofen 200 mg caplet C OTC

eq ibuprofen 200 mg softgel C OTC

eq ibuprofen 200 mg tablet C OTC

eq naproxen sod 220 mg caplet P OTC

eq naproxen sod 220 mg tablet P OTC

eql ibuprofen 200 mg caplet C OTC

eql ibuprofen 200 mg softgel C OTC

eql ibuprofen 200 mg tablet C OTC

eql naproxen sod 220 mg caplet P OTC

eql naproxen sod 220 mg tablet P OTC

C

etodolac er C

calcium NP PA

FLECTOR diclofenac epolamine P

flurbiprofen P GNP ARTHRITIS PAIN 1% GEL OTC diclofenac sodium C

gnp ibuprofen 100 mg chew tab C OTC

PAGE 237 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

gnp ibuprofen 200 mg caplet C OTC

gnp ibuprofen 200 mg mini sfgl C OTC

gnp ibuprofen 200 mg softgel C OTC

gnp ibuprofen 200 mg tablet C OTC

gnp naproxen sod 220 mg caplet P OTC

gnp naproxen sod 220 mg tablet P OTC

GS ARTHRITIS PAIN 1% GEL OTC diclofenac sodium C

gs ibuprofen 100 mg chew tab C OTC

gs ibuprofen 200 mg caplet C OTC

gs ibuprofen 200 mg liquid gel C OTC

gs ibuprofen 200 mg softgel C OTC

gs ibuprofen 200 mg tablet C OTC

gs naproxen sod 220 mg caplet P OTC

gs naproxen sod 220 mg tablet P OTC

gs naproxen sodium 220 mg tab P OTC

HM ARTHRITIS PAIN 1% GEL OTC diclofenac sodium C

hm ibuprofen 200 mg caplet C OTC

hm ibuprofen 200 mg capsule C OTC

hm ibuprofen 200 mg softgel C OTC

hm ibuprofen 200 mg tablet C OTC

hm naproxen sod 220 mg caplet P OTC

IBU ibuprofen C

ibuprofen 100 mg/5 ml susp C

ibuprofen 200 mg caplet C OTC

ibuprofen 200 mg capsule C OTC

PAGE 238 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

ibuprofen 200 mg softgel C OTC

ibuprofen 200 mg tablet C OTC

ibuprofen 400 mg tablet P

ibuprofen 600 mg tablet P

ibuprofen 800 mg tablet P

ibuprofen ib C OTC

ibuprofen jr str 100 mg tb chw C OTC

indomethacin 20 mg capsule C

indomethacin 25 mg capsule P

indomethacin 50 mg capsule P

infant's ibuprofen C OTC

infants ibuprofen C OTC

infants' ibuprofen C OTC

P

ketorolac 10 mg tablet P QL 20 TABS / RX

kro ibuprofen 200 mg caplet C OTC

kro ibuprofen 200 mg tablet C OTC

kro naproxen sod 220 mg caplet P OTC

kro naproxen sod 220 mg tablet P OTC

mb ibuprofen 200 mg tablet C OTC

NP PA

15 mg tablet P

meloxicam 7.5 mg tablet P MOBIC PA meloxicam NP

P

naproxen 125 mg/5 ml suspen C

naproxen 250 mg tablet P

naproxen 375 mg tablet P

PAGE 239 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

naproxen 500 mg kit P

naproxen 500 mg tablet P

naproxen dr 375 mg tablet P

naproxen dr 500 mg tablet P

naproxen sod cr 375 mg tablet P

naproxen sod cr 500 mg tablet P

naproxen sod cr 750 mg tablet C

naproxen sodium 220 mg caplet P OTC

naproxen sodium 220 mg tablet P OTC

naproxen sodium 275 mg tab P

naproxen sodium 550 mg tab P

naproxen sodium er P

NP PA

C

pub ibuprofen 200 mg tablet C OTC

pub naproxen sod 220 mg tablet P OTC

qc diclofenac sodium 1% gel C OTC

qc ibuprofen 200 mg caplet C OTC

qc ibuprofen 200 mg softgel C OTC

qc ibuprofen 200 mg tablet C OTC

qc naproxen sod 220 mg tablet P OTC

ra ibuprofen 200 mg caplet C OTC

ra ibuprofen 200 mg liquid gel C OTC

ra ibuprofen 200 mg softgel C OTC

ra ibuprofen 200 mg tablet C OTC

ra naproxen sod 220 mg tablet P OTC

SM ARTHRITIS PAIN 1% GEL OTC diclofenac sodium C

PAGE 240 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

sm ibuprofen 200 mg caplet C OTC

sm ibuprofen 200 mg softgel C OTC

sm ibuprofen 200 mg tablet C OTC

sm ibuprofen ib 200 mg caplet C OTC

sm naproxen sod 220 mg caplet P OTC

sm naproxen sod 220 mg tablet P OTC

P VIMOVO PA naproxen/esomeprazole magnesium NP ZIPSOR PA diclofenac potassium NP ZORVOLEX PA diclofenac submicronized NP SALICYLATES

aspirin C OTC

aspirin ec C OTC

BAYER CHEWABLE ASPIRIN OTC aspirin C

BUFFERIN C OTC

butalbital-asa-caffeine cap C QL 6 CAPS / 1 DAY

EXCEDRIN EXTRA STRENGTH OTC aspirin/acetaminophen/caffeine C

EXTRAPRIN C OTC

HEADACHE RELIEF C OTC

C OXYTOCICS

methylergonovine 0.2 mg tablet C

PAGE 241 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS PARATHYROID AND ANTIPARATHYROID AGENTS

ANTIPARATHYROID AGENTS

-salmon 200 units sp P

hcl C PARATHYROID AGENTS

FORTEO S Specialty Drug P

TYMLOS PA NP S Specialty Drug

PENICILLIN ANTIBIOTICS

AMINOPENICILLIN ANTIBIOTICS

amox-clav 200-28.5 mg tab chew NP PA

amox-clav 200-28.5 mg/5 ml sus P

amox-clav 250-125 mg tablet P

amox-clav 250-62.5 mg/5 ml sus P

amox-clav 400-57 mg tab chew NP PA

amox-clav 400-57 mg/5 ml susp P

amox-clav 500-125 mg tablet P

amox-clav 600-42.9 mg/5 ml sus P

amox-clav 875-125 mg tablet P

amoxicillin C

amoxicillin-clavulanate pot er NP PA

ampicillin trihydrate C AUGMENTIN 125-31.25 MG/5 ML PA amoxicillin/potassium clavulanate NP AUGMENTIN 250-62.5 MG/5 ML PA amoxicillin/potassium clavulanate NP AUGMENTIN XR PA amoxicillin/potassium clavulanate NP NATURAL ANTIBIOTICS

penicillin v potassium C

PAGE 242 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS PENICILLINASE-RESISTANT

dicloxacillin sodium C PHARMACEUTICAL AIDS

aqua glycolic OTC emollient base C SHINGRIX ADJUVANT COMPONENT QL 1 DOSE / RX vaccine adjuvant system, as01b/pf, component vial 1 of 2 C VAXCHORA BUFFER COMPONENT cholera vaccine buffer component C -ANGIOTENSIN- SYS. INHIB

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND PA cilexetil NP ATACAND HCT PA candesartan cilexetil/hydrochlorothiazide NP AVALIDE PA /hydrochlorothiazide NP AVAPRO PA irbesartan NP BENICAR PA olmesartan medoxomil NP BENICAR HCT PA olmesartan medoxomil/hydrochlorothiazide NP

candesartan cilexetil NP PA

candesartan-hydrochlorothiazid NP PA

COZAAR PA potassium NP DIOVAN PA valsartan NP DIOVAN HCT PA valsartan/hydrochlorothiazide NP EDARBI PA azilsartan medoxomil NP EDARBYCLOR PA azilsartan medoxomil/chlorthalidone NP ENTRESTO PA /valsartan NP

PAGE 243 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

eprosartan mesylate NP PA

HYZAAR PA losartan potassium/hydrochlorothiazide NP

irbesartan P

irbesartan-hydrochlorothiazide P

losartan potassium P

losartan-hydrochlorothiazide P MICARDIS PA telmisartan NP MICARDIS HCT PA telmisartan/hydrochlorothiazide NP

olmesartan medoxomil NP PA

olmesartan-amlodipine-hctz NP PA

olmesartan-hydrochlorothiazide NP PA

telmisartan NP PA

telmisartan-amlodipine NP PA

telmisartan-hydrochlorothiazid NP PA

TRIBENZOR PA olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide NP TWYNSTA PA telmisartan/amlodipine besylate NP

valsartan P

valsartan-hydrochlorothiazide P ANGIOTENSIN-CONVERTING INHIBITORS

ACCUPRIL PA hcl NP ACCURETIC PA quinapril hcl/hydrochlorothiazide NP ALTACE PA ramipril NP

benazepril hcl P

benazepril-hydrochlorothiazide P

captopril P

PAGE 244 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

captopril-hydrochlorothiazide P

enalapril maleate P

enalapril-hydrochlorothiazide P EPANED PA enalapril maleate NP

fosinopril sodium P

fosinopril-hydrochlorothiazide P

P

lisinopril-hydrochlorothiazide P LOTENSIN PA benazepril hcl NP LOTENSIN HCT PA benazepril hcl/hydrochlorothiazide NP

moexipril hcl P

perindopril erbumine P PRESTALIA PA perindopril arginine/amlodipine besylate NP PRINIVIL PA lisinopril NP QBRELIS PA lisinopril NP

quinapril hcl P

quinapril-hydrochlorothiazide P

ramipril P TARKA PA trandolapril/verapamil hcl NP

trandolapril P VASERETIC PA enalapril maleate/hydrochlorothiazide NP VASOTEC PA enalapril maleate NP ZESTORETIC PA lisinopril/hydrochlorothiazide NP ZESTRIL PA lisinopril NP

PAGE 245 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS

C

C

spironolactone-hctz C RENIN INHIBITORS

aliskiren NP PA

TEKTURNA PA aliskiren hemifumarate NP TEKTURNA HCT aliskiren hemifumarate/hydrochlorothiazide P RESPIRATORY TRACT AGENTS

ANTIFIBROTIC AGENTS

ESBRIET PA C pirfenidone S Specialty Drug

OFEV PA C esylate S Specialty Drug

ANTITUSSIVES

ADULT TUSSIN COUGH CONGEST DM C OTC

benzonatate C

CHEST CONGESTION RELIEF DM C OTC

CHILD DELSYM COUGH-CHEST DM C OTC

CHILD MUCINEX COUGH MINI-MELTS OTC / hbr C

CHILD MUCINEX FREEFROM DAY CGH C OTC

CHILD MUCUS RELIEF COUGH C OTC

CHILD MUCUS-COUGH RELIEF C OTC

QL 60 ML / 1 DAY codeine-guaifenesin C OTC

COLD HEAD CONGESTION NIGHTTIME C

COLD MAX DAYTIME C

PAGE 246 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

DAYTIME COUGH C OTC

DELSYM OTC dextromethorphan polistirex C

GERI-TUSSIN DM C OTC

GILTUSS COUGH-CONGESTION C OTC

GILTUSS DIABETIC C OTC

GILTUSS HBP C OTC

GNP TUSSIN COUGH LIQUID C OTC

GUAIASORB DM C OTC

QL 60 ML / 1 DAY guaifenesin-codeine C OTC

guaifenesin-dextromethorphan C OTC

QL 60 ML / 1 DAY MAXI-TUSS AC C OTC

MAXI-TUSS G C OTC

MUCINEX FAST-MAX DM MAX C OTC

MUCUS RELIEF DM C OTC

MUCUS RELIEF DM MAX C OTC

NIGHTTIME COUGH C OTC

AQ1 At least 6 yrs old; 60 / PRO-RED AC 1 DAY maleate/phenylephrine hcl/codeine C OTC

promethazine-dm C

ROBAFEN DM PEAK COLD C OTC

ROBITUSSIN COUGH-CHEST-CONG DM C OTC

ROBITUSSIN ER OTC dextromethorphan polistirex C TUSNEL PEDIATRIC LIQUID OTC guaifenesin/dextromethorphan hbr/pseudoephedrine hcl C

TUSSIN COUGH LIQUID C OTC

PAGE 247 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

TUSSIN DM C OTC

TUSSIN DM MAX C OTC

VIRTUSSIN AC C QL 60 ML / 1 DAY

EXPECTORANTS

CHEST CONGEST RLF 400 MG TAB C OTC

CHEST CONGESTION RELIEF SOLN OTC guaifenesin C CHILD MUCINEX CHEST MINI-MELTS OTC guaifenesin C CHILD MUCINEX STUFFY NOSE-CHST OTC guaifenesin/phenylephrine hcl C

DIABETIC TUSSIN C OTC

GERI-TUSSIN C OTC

guaifenesin C OTC

guaifenesin-pse er 600-60 mg C OTC

HM MUCUS RELIEF ER 1,200 MG TB OTC guaifenesin C HM MUCUS RELIEF ER 600 MG TAB OTC guaifenesin C

MAXI-TUSS PE MAX C OTC

MUCINEX ER 1,200 MG TABLET OTC guaifenesin C

MUCINEX FAST-MAX CHEST-CONGEST C OTC

MUCOSA C OTC

MUCUS ER OTC guaifenesin C

MUCUS RELIEF C OTC

MUCUS RELIEF D OTC guaifenesin/pseudoephedrine hcl C MUCUS RELIEF ER 1,200 MG TAB OTC guaifenesin C MUCUS RELIEF ER 600 MG TABLET OTC guaifenesin C

PAGE 248 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QC MUCUS RELIEF ER 1,200 MG TB C OTC

sm guaifenesin-pse er 600-60 C OTC

TUSNEL-EX C OTC

TUSSIN MUCUS-CHEST CONGESTION C OTC

MUCOLYTIC AGENTS

acetylcysteine 10% vial C

acetylcysteine 20% vial C

QL 150 ML / 30 DAYS PULMOZYME PA dornase alfa C S Specialty Drug

PHOSPHODIESTERASE TYPE 4 INHIBITORS

DALIRESP PA NP VASODILATING AGENTS (RESPIRATORY TRACT)

ADEMPAS PA NP S Specialty Drug

PA P S Specialty Drug

PA NP S Specialty Drug

PA epoprostenol sodium C S Specialty Drug

FLOLAN 1.5 MG VIAL PA C epoprostenol sodium (glycine) S Specialty Drug

LETAIRIS PA NP ambrisentan S Specialty Drug

OPSUMIT PA NP S Specialty Drug

ORENITRAM ER PA NP diolamine S Specialty Drug

PAGE 249 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

TRACLEER 125 MG TABLET PA P bosentan S Specialty Drug

TRACLEER 32 MG TABLET FOR SUSP PA NP bosentan S Specialty Drug

TRACLEER 62.5 MG TABLET PA P bosentan S Specialty Drug

PA treprostinil C S Specialty Drug

TYVASO PA NP treprostinil S Specialty Drug

TYVASO REFILL KIT PA NP treprostinil/nebulizer accessories S Specialty Drug

TYVASO STARTER KIT PA NP treprostinil/nebulizer and accessories S Specialty Drug

UPTRAVI PA NP S Specialty Drug

VELETRI PA C epoprostenol sodium S Specialty Drug

VENTAVIS PA NP tromethamine S Specialty Drug

SKELETAL MUSCLE RELAXANTS

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

500 mg tablet C

10 mg tablet C

cyclobenzaprine 5 mg tablet C

500 mg tablet C

methocarbamol 750 mg tablet C

hcl 2 mg tablet C

tizanidine hcl 4 mg tablet C

PAGE 250 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

dantrolene sodium 100 mg cap C

dantrolene sodium 25 mg cap C

dantrolene sodium 50 mg cap C GABA-DERIVATIVE SKELETAL

10 mg tablet C

baclofen 20 mg tablet C

baclofen 5 mg tablet C SKIN AND MUCOUS MEMBRANE AGENTS

ANTIPRURITICS AND LOCAL ANESTHETICS

ANODYNE LPT C

lidocaine 4% cream C OTC

QL 1 PATCH / 1 DAY lidocaine 5% patch NP PA

lidocaine-hc 2.8-0.55% gel C

lidocaine-hc 3-0.5% cream kit C

lidocaine-hc 3-1% cream kit C

lidocaine-hc 3-2.5% gel kit C

lidocaine-hydrocort 3-2.5% gel C

lidocaine- C QL 60 GM / FILL

LIDODERM QL 1 PATCH / 1 DAY NP lidocaine PA

hcl C ZTLIDO PA lidocaine NP ASTRINGENTS

DRYSOL aluminum chloride C XERAC AC aluminum chloride C

PAGE 251 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS CELL STIMULANTS AND PROLIFERANTS

ATRALIN PA tretinoin NP AVITA PA tretinoin NP RETIN-A PA tretinoin NP RETIN-A MICRO PA tretinoin microspheres NP RETIN-A MICRO PUMP PA tretinoin microspheres NP

tretinoin 0.01% gel P

tretinoin 0.025% cream P

tretinoin 0.025% gel P

tretinoin 0.05% cream P

tretinoin 0.05% gel NP PA

tretinoin 0.1% cream P

tretinoin microsphere NP PA

KERATOLYTIC AGENTS

PA CONTROL CLEANSER NP OTC

ACNE MEDICATION 10% GEL OTC benzoyl peroxide C

ACNE MEDICATION 2.5% GEL C OTC

ACNE MEDICATION 5% GEL OTC benzoyl peroxide C ACNE MEDICATION 5% LOTION OTC benzoyl peroxide P

ADVANCED EXFOLIATING CLEANSER NP PA

PA BENZEPRO 5.3% EMOLLIENT FOAM NP OTC

BENZEPRO 5.8% FOAMING CLOTHS PA NP benzoyl peroxide micronized OTC

PAGE 252 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PA BENZEPRO 9.8% FOAM NP OTC

benzoyl peroxide 10% gel P OTC

benzoyl peroxide 10% wash P OTC

benzoyl peroxide 2.5% gel P OTC

benzoyl peroxide 5% gel P OTC

benzoyl peroxide 5% wash P OTC

benzoyl peroxide 6% cleanser P OTC

BP 10-1 NP PA

BPO 4% GEL P

BPO 8% GEL P

BPO-10 NP PA

BPO-5 NP PA

CLEAN-CLEAR CONTINUOUS CONTROL NP PA

COMPOUND W C OTC

DAYLOGIC ACNE TREATMENT C OTC

DHS SAL C OTC

DURAGEL CALLUS REMOVERS C OC8 OTC benzoyl peroxide P

PANOXYL C OTC

RIAX OTC benzoyl peroxide C

6% gel C

SEBEX C OTC

sod sulfac-sulfur 9.8-4.8% crm P

sod sulfac-sulfur 9.8-4.8% lot P

sod sulface-sulf 9.8-4.8% clsr P

sod sulfacet-sulfur 10-2% clsr P

PAGE 253 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

sod sulfacet-sulfur 10-4% pad P

sod sulfacet-sulfur 10-5% clsr P

sod sulfacetamide-sulfur lotn P

sod sulfacetamide-sulfur susp P

sodium sulfacet-sulfur wash P

SSS 10-5 CREAM P

sulfacetamide-sulfur 10-2% crm P

sulfacetamide-sulfur 10-5% crm P

sulfacetamide-sulfur 8-4% susp P

SULFACLEANSE 8-4 P

THERAPEUTIC DANDRUFF SHAMPOO C OTC

urea 40% cream C

urea 40% lotion C

WART REMOVER C OTC

KERATOPLASTIC AGENTS

DHS TAR OTC coal tar C SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

acitretin C

0.1% cream NP PA

adapalene 0.1% gel NP PA

adapalene 0.1% gel (rx only) NP PA

adapalene 0.1% solution NP PA

adapalene 0.3% gel NP PA

adapalene 0.3% gel pump NP PA

adapalene-benzoyl peroxide NP PA

AKLIEF PA trifarotene NP AMNESTEEM C

PAGE 254 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

ANTI-ITCH 0.5%-0.5% LOTION C OTC

ARTHRITIS PAIN RELIEVING C OTC

C AZELEX azelaic acid P

calcipotriene 0.005% cream C QL 120 GM / 30 DAYS

calcipotriene 0.005% ointment C QL 120 GM / 30 DAYS

calcipotriene 0.005% solution C QL 120 GM / 30 DAYS

CALCITRENE QL 120 GM / 30 DAYS calcipotriene C

0.025% cream C OTC

capsaicin 0.1% cream C OTC

CLARAVIS isotretinoin C

COSENTYX (2 SYRINGES) PA NP secukinumab S Specialty Drug

COSENTYX PEN PA NP secukinumab S Specialty Drug

COSENTYX PEN (2 PENS) PA NP secukinumab S Specialty Drug

COSENTYX SYRINGE PA NP secukinumab S Specialty Drug

dapsone 5% gel NP PA

DIFFERIN 0.1% CREAM adapalene P DIFFERIN 0.1% GEL OTC adapalene P DIFFERIN 0.1% LOTION adapalene P DIFFERIN 0.3% GEL adapalene P DIFFERIN 0.3% GEL PUMP adapalene P

PAGE 255 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 4 ML / 28 DAYS DUPIXENT 300 MG/2 ML PEN PA dupilumab NP S Specialty Drug

QL 4 ML / 28 DAYS DUPIXENT 300 MG/2 ML SYRINGE PA dupilumab NP S Specialty Drug

ELIDEL PA pimecrolimus NP EPIDUO PA adapalene/benzoyl peroxide NP EPIDUO FORTE PA adapalene/benzoyl peroxide NP

FABIOR QL 50 GM / 30 DAYS NP PA

ILUMYA PA NP tildrakizumab-asmn MED

5% cream packet C

isotretinoin 10 mg capsule C

isotretinoin 20 mg capsule C

isotretinoin 30 mg capsule C

isotretinoin 40 mg capsule C MYORISAN isotretinoin C

pimecrolimus NP PA

podofilox C PROTOPIC tacrolimus P QUTENZA PA capsaicin/skin cleanser NP SARNA ORIGINAL OTC / C

QL 3 ML / 28 DAYS SILIQ PA brodalumab NP S Specialty Drug

PAGE 256 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

SKYRIZI PA C risankizumab-rzaa S Specialty Drug

SKYRIZI (2 SYRINGES) KIT PA C risankizumab-rzaa S Specialty Drug

SKYRIZI PEN PA C risankizumab-rzaa S Specialty Drug

QL 4 VIALS / 54 DAYS STELARA 130 MG/26 ML VIAL PA NP S Specialty Drug

QL 1 SYRINGE / 84 DAYS STELARA 45 MG/0.5 ML SYRINGE PA ustekinumab NP S Specialty Drug

STELARA 45 MG/0.5 ML VIAL PA NP ustekinumab S Specialty Drug

QL 1 SYRINGE / 56 DAYS STELARA 90 MG/ML SYRINGE PA ustekinumab NP S Specialty Drug

tacrolimus 0.03% ointment NP PA

tacrolimus 0.1% ointment NP PA

QL 1 SYRINGE / 28 DAYS TALTZ AUTOINJECTOR PA ixekizumab NP S Specialty Drug

QL 1 SYRINGE / 28 DAYS TALTZ AUTOINJECTOR (2 PACK) PA ixekizumab NP S Specialty Drug

QL 1 SYRINGE / 28 DAYS TALTZ AUTOINJECTOR (3 PACK) PA ixekizumab NP S Specialty Drug

QL 1 SYRINGE / 28 DAYS TALTZ SYRINGE PA ixekizumab NP S Specialty Drug

PAGE 257 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

tazarotene 0.1% cream NP PA

TAZORAC tazarotene P

QL 1 ML / 28 DAYS TREMFYA 100 MG/ML INJECTOR PA NP S Specialty Drug

QL 1 SYRINGE / 28 DAYS TREMFYA 100 MG/ML SYRINGE PA guselkumab NP S Specialty Drug

ZENATANE isotretinoin C SMOOTH MUSCLE RELAXANTS

RESPIRATORY SMOOTH MUSCLE RELAXANTS

anhydrous C

theophylline er 400 mg tablet C

theophylline er 600 mg tablet C AGONISTS AND ANTAGONISTS

SOMATOSTATIN AGONISTS

BYNFEZIA PA C acetate S Specialty Drug

QL 7.5 ML / 1 DAY octreotide 1,000 mcg/5 ml vial C S Specialty Drug

QL 45 ML / 30 DAYS octreotide 1,000 mcg/ml vial C S Specialty Drug

QL 45 ML / 30 DAYS octreotide 5,000 mcg/5 ml vial C S Specialty Drug

QL 3 ML / 1 DAY octreotide acet 0.05 mg/ml vl C S Specialty Drug

QL 5 ML / 1 DAY octreotide acet 100 mcg/ml amp C S Specialty Drug

octreotide acet 100 mcg/ml syr C S Specialty Drug

PAGE 258 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

QL 5 ML / 1 DAY octreotide acet 100 mcg/ml vl C S Specialty Drug

QL 7.5 ML / 1 DAY octreotide acet 200 mcg/ml vl C S Specialty Drug

QL 3 ML / 1 DAY octreotide acet 50 mcg/ml amp C S Specialty Drug

octreotide acet 50 mcg/ml syr C S Specialty Drug

QL 3 ML / 1 DAY octreotide acet 50 mcg/ml vial C S Specialty Drug

QL 7 ML / 1 DAY octreotide acet 500 mcg/ml amp C S Specialty Drug

octreotide acet 500 mcg/ml syr C S Specialty Drug

QL 7 ML / 1 DAY octreotide acet 500 mcg/ml vl C S Specialty Drug

SANDOSTATIN LAR DEPOT 10 MG KT QL 1 KIT / 28 DAYS C octreotide acetate, microspheres S Specialty Drug

SANDOSTATIN LAR DEPOT 10 MG VL QL 1 KIT / 28 DAYS C octreotide acetate, microspheres S Specialty Drug

SANDOSTATIN LAR DEPOT 20 MG KT QL 2 KITS / 28 DAYS C octreotide acetate, microspheres S Specialty Drug

SANDOSTATIN LAR DEPOT 20 MG VL QL 2 KITS / 28 DAYS C octreotide acetate, microspheres S Specialty Drug

SANDOSTATIN LAR DEPOT 30 MG KT QL 3 KITS / 28 DAYS C octreotide acetate, microspheres S Specialty Drug

SANDOSTATIN LAR DEPOT 30 MG VL QL 3 KITS / 28 DAYS C octreotide acetate, microspheres S Specialty Drug

SIGNIFOR PA C diaspartate S Specialty Drug

PAGE 259 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ALPHA- AND BETA-ADRENERGIC AGONISTS

ADULT NASAL DECONGESTANT C OTC

EPINEPHRINE 0.15 MG AUTO-INJCT (Generic for PA Adrenaclick) NP 0.15 MG AUTO-INJCT (Generic for Epi-Pen Jr / Mylan) P

EPINEPHRINE 0.15 MG AUTO-INJCT (TEVA) NP PA

EPINEPHRINE 0.3 MG AUTO-INJECT (Generic for PA Adrenaclick) NP EPINEPHRINE 0.3 MG AUTO-INJECT (Generic for Epi-Pen / Mylan) P

EPINEPHRINE 0.3 MG AUTO-INJECT (TEVA) NP PA

EPIPEN PA epinephrine NP EPIPEN 2-PAK PA epinephrine NP EPIPEN JR PA epinephrine NP EPIPEN JR 2-PAK PA epinephrine NP

NASAL DECONGESTANT 30 MG TAB C OTC

pseudoephedrine hcl C OTC

QC NASAL DECONGEST 30 MG TAB C OTC

SINUS 12 HOUR OTC pseudoephedrine hcl C SUDAFED 12 HOUR OTC pseudoephedrine hcl C SUDOGEST 12 HOUR 120 MG CAPLET OTC pseudoephedrine hcl C

SUDOGEST 30 MG TABLET C OTC

SUDOGEST 60 MG TABLET C OTC

SYMJEPI epinephrine P

PAGE 260 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ALPHA-ADRENERGIC AGONISTS

hcl C

AMINOMETHYLCYCLINES

NUZYRA 150 MG TABLET PA omadacycline tosylate C NUZYRA 150 MG TABLET-7 DAY PA omadacycline tosylate C NUZYRA 150 MG-7 DAY WITH LOAD PA omadacycline tosylate C THYROID AND ANTITHYROID AGENTS

ANTITHYROID AGENTS

methimazole C

propylthiouracil C THYROID AGENTS

EUTHYROX sodium C

levothyroxine 100 mcg tablet C

levothyroxine 112 mcg tablet C

levothyroxine 125 mcg tablet C

levothyroxine 137 mcg tablet C

levothyroxine 150 mcg tablet C

levothyroxine 175 mcg tablet C

levothyroxine 200 mcg tablet C

levothyroxine 25 mcg tablet C

levothyroxine 300 mcg tablet C

levothyroxine 50 mcg tablet C

levothyroxine 75 mcg tablet C

levothyroxine 88 mcg tablet C

liothyronine sod 25 mcg tab C

liothyronine sod 5 mcg tab C

liothyronine sod 50 mcg tab C

PAGE 261 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS URINE AND CONTENTS

KETONES

ketostix reagent OTC urine test,strips C trueplus ketone test strip OTC urine acetone test,strips C SUGAR

diastix reagent OTC urine glucose test strip C Uncategorized

Unclassified

benzoyl peroxide 3% cleanser P OTC

benzoyl peroxide 9% cleanser P OTC

BP GEL OTC benzoyl peroxide P VASODILATING AGENTS

NITRATES AND NITRITES

isosorbide dinitrate 10 mg tab C

isosorbide dinitrate 20 mg tab C

isosorbide dinitrate 30 mg tab C

isosorbide dinitrate 5 mg tab C

isosorbide mononitrate C

isosorbide mononitrate er C MINITRAN nitroglycerin C NITRO-BID nitroglycerin C

nitroglycerin 0.3 mg tablet sl C

nitroglycerin 0.4 mg tablet sl C

nitroglycerin 0.6 mg tablet sl C

nitroglycerin patch C

PAGE 262 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS PHOSPHODIESTERASE TYPE 5 INHIBITORS

QL 2 TABS / 1 DAY ADCIRCA PA NP S Specialty Drug

QL 2 TABS / 1 DAY ALYQ PA tadalafil C S Specialty Drug

REVATIO 10 MG/ML ORAL SUSP PA P citrate S Specialty Drug

REVATIO 20 MG TABLET PA NP sildenafil citrate S Specialty Drug

sildenafil 10 mg/ml oral susp NP PA

SILDENAFIL 20 MG TABLET (GENERIC FOR REVATIO) P PA

QL 2 TABS / 1 DAY TADALAFIL 20 MG TABLET (GENERIC FOR ADCIRCA) NP PA

VASODILATING AGENTS, MISCELLANEOUS

aspirin- er NP PA

dipyridamole P VERQUVO PA C VITAMINS

MULTIVITAMIN PREPARATIONS

ADULTS 50 PLUS MULTIVITAMIN C OTC

AQUADEKS CHEWABLE TABLET OTC multivitamin, minerals no.51/folic acid/vit k1/ubidecarenone C AQUADEKS PEDIATRIC LIQUID OTC pediatric multivitamin no.40/phytonadione (vit k1) C AZESCO prenatal vitamins no.147/ferrous gluconate/folic acid C CADEAU DHA OTC prenatal vitamins no.83/iron fumarate/folate combo no.6/dha C

CENTRUM C OTC

PAGE 263 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

CENTRUM COMPLETE C OTC

CENTRUM SILVER C OTC

CEROVITE JR OTC pediatric multivitamin no.158/ferrous fumarate/phytonadione C

CERTA PLUS C OTC

CERTAVITE SENIOR OTC multivitamin with minerals/folic acid/lycopene/lutein C CERTAVITE-ANTIOXIDANT OTC multivitamin/ferrous fumarate/folic acid C CHILD'S CHEWABLE VITAMIN TAB OTC pediatric multivitamin no.144 C

CHILDREN'S CHEW MULTIVITAMIN C OTC

CHILDRENS CHEW VITAMIN TAB C OTC

CITRANATAL B-CALM prenatal vitamin no.48/iron,carbonyl,gluconate/folic acid/b6 C

COMPLETE MV ADULT 50 PLUS C OTC

COMPLETE NATAL DHA C

COMPLETE SENIOR C OTC

COMPLETENATE C OTC

CONCEPT DHA mv-min 75/ferrous fum/iron ps cplx/folic ac/omega-3/dha/epa C CONCEPT OB mv-mins no.74/ferrous fumarate/iron ps cplx/folic acid C

CVS HAIR, SKIN AND NAILS CPLT C OTC

DAILY VITAMIN + IRON OTC multivitamin with iron C

DAILY VITAMIN FORMULA-MINERALS C OTC

DAILY VITE WITH IRON OTC multivitamin with iron C DAILY-VITE OTC multivitamin with folic acid C DUET DHA 400 prenatal vits 106/sod feredetate-iron ps/folic acid/omega-3s C

PAGE 264 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS DUET DHA BALANCED prenatal vits no.117/sod feredet.-iron ps/folic/om3/dha/epa C

ELITE-OB C ENBRACE HR multivit no.41/iron cysteine glycinat/folate no.8/phosph-dha C

EQL ONE DAILY MEN'S TABLET C OTC

EYE HEALTH PLUS LUTEIN C OTC

FLORIVA 0.25 MG CHEW TABLET pediatric multivitamin no.85 with sodium fluoride C FLORIVA 0.5 MG CHEWABLE TABLET pediatric multivitamin no.85 with sodium fluoride C FLORIVA 1 MG CHEWABLE TABLET pediatric multivitamin no.85 with sodium fluoride C

gnp prenatal vitamins tablet C OTC

HAIR VITAMIN C OTC

HIGH MULTIVITAMIN C

HM HAIR, SKIN AND NAILS CAPLET C OTC

KENWOOD THERAPEUTIC OTC multivitamin,therapeutic C

M-NATAL PLUS C

MEGA MULTI W-CHELATED MINERALS C OTC

MULTI-VITAMIN DAILY C OTC

multi-vitamin w-fluoride-iron C OTC

MULTILEX OTC multivitamin with minerals/ferrous sulfate C

multiple vitamin C OTC

multivit-fluor 0.25 mg/ml drop C OTC

multivit-fluor 0.5 mg tab chew C OTC

multivit-fluor 0.5 mg/ml drop C OTC

multivitamin C OTC

multivitamin-iron-fluoride C OTC

PAGE 265 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

multivitamins with iron C OTC

multivitamins with minerals C OTC

MVC-FLUORIDE pediatric multivitamin no.12 with sodium fluoride C

MY FAVORITE MULTIPLE C OTC

MYNATAL PLUS C

MYNATAL-Z C NATACHEW prenatal vitamin no.55/iron fumarate,bisglycinate/folic acid C NEEVODHA multivit no.37/iron/l-mefolate calc./algal oil/soy C NESTABS prenatal vitamin no.86/iron bis-glycinate/folic acid C NESTABS ABC prenatal vitamin comb no.86/iron ps cmplx/folic acid/dha/epa C NESTABS DHA prenatal vits with calcium no.87/iron bisgly/folic acid/dha C NESTABS ONE multivit 42/iron carbonyl,b-g che/methyltetrahydrofolate/dha C

NEWGEN C

NIVA-PLUS C O-CAL FA multivitamin with minerals no.61/ferrous fumarate/folic acid C O-CAL PRENATAL prenatal vit with calcium no.127/ferrous fumarate/folic acid C OB COMPLETE multivitamin with minerals no.69/iron,carbonyl/folic acid C OB COMPLETE ONE prenatal vit no.85/iron carb,asp.gly/folic acid/dha/fish oil C OB COMPLETE PETITE prenatal no56/iron carbonyl,asparto glycinate/folic acid/dha C OB COMPLETE prenatal vits no.83/iron,carbonyl,iron aspart.gly/folic acid C OB COMPLETE WITH DHA prenatal vit no.30/iron carbonyl,asp glyc/folic acid/omega-3 C

ONCOVITE C OTC

PAGE 266 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS ONE DAILY COMPLETE OTC multivitamin with minerals C

ONE DAILY ENERGY C OTC

ONE DAILY FOR WOMEN C OTC

ONE DAILY MULTIVITAMIN-MINERAL OTC multivitamin with minerals/ferrous sulfate C ONE DAILY PLUS MINERALS OTC multivitamin with minerals C

ONE DAILY WITH IRON C OTC

ONE-A-DAY MAXIMUM FORMULA C OTC

ONE-DAILY MULTI-VITAMIN C OTC

OPTI-VITAMIN C OTC

pediatric poly-vitamin C OTC

pediatric tri-vitamin C OTC

PEDIATRIC TRI-VITE C OTC

PNV 29-1 C

pnv prenatal plus multivit tab C

PNV-DHA C

PNV-VP-U C PA

POLY-VI-FLOR 0.25 MG DROPS OTC pediatric multivitamin no.37 with sodium fluoride C POLY-VI-FLOR 0.25 MG TAB CHEW OTC pediatric multivitamin no.33 with sodium fluoride C POLY-VI-FLOR 0.5 MG TAB CHEW OTC pediatric multivitamin no.33 with sodium fluoride C POLY-VI-FLOR 1 MG TAB CHEW OTC pediatric multivitamin no.33 with sodium fluoride C POLY-VI-FLOR WITH IRON 0.25 MG OTC pediatric multivit no.37/sodium fluoride/iron bisglycin.hcl C POLY-VI-FLOR WITH IRON 0.5 MG OTC pediatric multivitamin no.33/sodium fluoride/iron carbonyl C

POLY-VITA C OTC

PAGE 267 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

PRENA1 TRUE C PRENATA prenatal vitamins no.37/ferrous fumarate/folic acid C PRENATABS FA prenatal vits with calcium no.78/ferrous fumarate/folic acid C PRENATABS RX prenatal vitamin with calcium no.76/iron,carbonyl/folic acid C

prenatal C OTC

prenatal 19 C OTC

prenatal low iron C

prenatal plus iron tablet C

prenatal plus-dha C

prenatal tablet C OTC

prenatal vitamin C OTC

prenatal vitamin plus low iron C

prenatal vitamins tablet C OTC

prenatal-u C PA

PRENATE AM multivit no.38/methyltetrahydfolate glucos,folic acid/ginger C PRENATE CHEWABLE multivitamin no.36/methyltetrahydrofolate gluc,folic acid C PRENATE DHA multivitamin no.45/iron fumarate/folate comb no.6/dha C PRENATE ELITE prenatal vitamins no.36/ferrous fumarate/folate comb. no.6 C PRENATE ENHANCE prenatal vitamins no.68/iron fumarate/folate no.6/dha C PRENATE ESSENTIAL multivitamin no.40/iron asparto glycinate/folate no.1/dha C PRENATE MINI prenatal vits no.87/iron carb-asp.glycinate/folate no.1/dha C PRENATE PIXIE prenatal vitamins no.85/iron asparto glycin/folate no.1/dha C PRENATE RESTORE prenatal vitamins no.69/iron fumarate/folate comb no.6/dha C

PAGE 268 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS PRENATE STAR prenatal vitamins no.77/ferrous asparto glycinate/folic acid C

PREPLUS C

PRETAB C PRIMACARE prenatal vits no.118/iron asparto glycinate/folate no.6/dha C PROVIDA DHA prenatal vitamins no.90/iron fum,polysac comp/folic acid/dha C PROVIDA OB prenatal vits no.65/iron fumarate,polysac complex/folic acid C PUREFE OB PLUS multivit-mins no.73/iron fumarate,polysacc comp/folic acid C PUREFE PLUS multivitamin-minerals no.62/ferrous fumarate/folic acid C QUFLORA PED 0.25 MG/ML DROP pediatric multivitamin no.83 with sodium fluoride C QUFLORA PED 0.5 MG/ML DROP pediatric multivitamin no.84 with sodium fluoride C

SE-NATAL 19 C SELECT-OB + DHA prenatal vitamins no.33/iron polysach complex/folic acid/dha C

SM HAIR, SKIN AND NAILS CAPLET C OTC

sm prenatal vitamins tablet C OTC

SPECTRAVITE ADULT C

SPECTRAVITE WOMEN C OTC

STRESS FORMULA TABLET OTC multivitamin,stress formula C STRESS FORMULA WITH ZINC OTC multivitamin,stress formula/zinc C

SUPER MULTIPLE C OTC

TAB-A-VITE C OTC

TAB-A-VITE MULTIVIT WITH IRON OTC multivitamin/ferrous fumarate/folic acid C

TAB-A-VITE MULTIVIT WITH IRON (generic) C OTC

TARON-C DHA C

PAGE 269 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

THERA-TABS C OTC

THERAPEUTIC M C OTC

TRI-VI-FLOR OTC pediatric multivitamin a,c,and d3 no.38 with sodium fluoride C

tri-vitamin with fluoride C TRICARE prenatal vits with calcium 103/ferrous fumarate/folic acid C

TRINATAL RX 1 C TRINATE prenatal vits with calcium no.73/ferrous fumarate/folic acid C TRISTART DHA prenatal vitamins no.93/iron carbonyl/folate comb no.9/dha C

TRUST NATAL DHA C UNICOMPLEX-M OTC multivitamin with iron and other minerals C

V-C FORTE C OTC

VINATE CARE OTC multivitamin combination no.43/ferrous fumarate/folic acid C

VINATE ONE C OTC

VINATE-M C OTC

VIRT-C DHA C

VIRT-PN DHA C

VISION C OTC

VISION PLUS LUTEIN C OTC

VITAFOL GUMMIES prenatal vit no.112/iron phosph/folic acid/omega-3s/dha/epa C VITAFOL ULTRA prenatal vit no.67/iron polysaccharides/folate comb.no.1/dha C VITAFOL-OB prenatal vits with calcium no.10/ferrous fumarate/folic acid C VITAFOL-ONE prenatal vits no.26/iron polysaccharide cplex/folic acid/dha C VITAMEDMD ONE RX prenatal vits no.25/ferrous fumarate/folate comb. no.6/dha C

PAGE 270 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS VITAMEDMD REDICHEW RX prenatal vitamins combination no.42/folic acid C

vitamin and minerals C OTC

vitamins a,c,d and fluoride C OTC

VITAPEARL prenatal vit no.71/iron fum-sodium feredetate/folic acid/dha C VITATRUE prenatal vits no.105/iron amino acid chelate/folic acid/dha C

WOMEN'S DAILY FORMULA C OTC

ZALVIT C

ZATEAN-PN DHA C

ZINGIBER C VITAMIN A

beta carotene C OTC

vitamin a C OTC

VITAMIN B COMPLEX

b complex C OTC

b complex number 1 C OTC

b-1 C OTC

b-12 500 mcg tablet C OTC

b-complex plus vitamin c C OTC

b-complex with c C OTC

b-complex with vitamin c C OTC

BALANCE B-100 C OTC

BALANCE B-50 C OTC

BALANCED B-50 C OTC

cvs folic acid 800 mcg tablet C OTC

cvs vit b-12 tr 1,000 mcg tab C OTC

cyanocobalamin C

PAGE 271 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

eql vit b-12 er 1,000 mcg tab C OTC

eql vitamin b-12 500 mcg tab C OTC

fn vitamin b-12 1,000 mcg tab C OTC

FOLBEE C OTC

FOLBEE PLUS C OTC

folic acid 0.4 mg tablet C OTC

folic acid 0.8 mg tablet C OTC

folic acid 1 mg tablet C OTC

folic acid 1,000 mcg tablet C OTC

folic acid 400 mcg tablet C OTC

folic acid 800 mcg tablet C OTC

FOLTABS 800 C OTC

gnp folic acid 400 mcg tablet C OTC

gnp vit b-12 er 1,000 mcg tab C OTC

hm folic acid 400 mcg tablet C OTC

hm vit b-12 tr 1,000 mcg tab C OTC

hm vitamin b-12 500 mcg tablet C OTC

l-methylfolate 7.5 mg tablet C OTC

NEPHRONEX-SL PA C vitamin b complex with vitamin c no.19/folic acid/vitamin d3 OTC

ra folic acid 0.4 mg tablet C OTC

ra folic acid 800 mcg tablet C OTC

ra vit b12 1,000 mcg tab sa C OTC

ra vitamin b12 tr 1,000 mcg tb C OTC

riboflavin C OTC

sm folic acid 0.4 mg tablet C OTC

PAGE 272 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

sm folic acid 400 mcg tablet C OTC

SM STRESS FORMULA+ZINC TABLET C OTC

sm vitamin b-12 500 mcg tablet C OTC

sm vitamin b12 1,000 mcg tab C OTC

SUPER B-50 COMPLEX PLUS C OTC

SUPER QUINTS C OTC

sv folic acid 800 mcg tablet C OTC

sv vitamin b12 tr 1,000 mcg tb C OTC

thiamine hcl C

ULTRA B-100 COMPLEX C OTC

vitamin b complex C OTC

vitamin b complex-vitamin c C OTC

vitamin b-1 C OTC

vitamin b-12 1,000 mcg tablet C OTC

vitamin b-12 100 mcg tablet C OTC

vitamin b-12 250 mcg tablet C OTC

vitamin b-12 500 mcg tablet C OTC

vitamin b-12 tr 1,000 mcg tab C OTC

vitamin b-2 C OTC

vitamin b-6 C OTC

vitamin b-complex with vit c C OTC

vitamin b12 1,000 mcg tab sa C OTC

vitamin b12 500 mcg tablet C OTC

WESTAB MAX C OTC

WESTAB MINI C

WESTAB ONE C OTC

PAGE 273 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS VITAMIN C

cvs vitamin c 500 mg caplet C OTC

eql vitamin c 1,000 mg tablet C OTC

gnp vitamin c 1,000 mg tablet C OTC

gnp vitamin c 250 mg tablet C OTC

gnp vitamin c 500 mg tab chew C OTC

gnp vitamin c 500 mg tablet C OTC

gnp vitamin c er 500 mg tablet C OTC

hm vitamin c 500 mg tab chew C OTC

ra vit c-rose hips 500 mg tab C OTC

ra vitamin c 1,000 mg tablet C OTC

ra vitamin c 250 mg tablet C OTC

ra vitamin c 500 mg chew tab C OTC

ra vitamin c 500 mg tab chew C OTC

ra vitamin c 500 mg tablet C OTC

ra vitamin c tr 500 mg caplet C OTC

sm vitamin c 1,000 mg tablet C OTC

sm vitamin c 250 mg tablet C OTC

sm vitamin c 500 mg caplet C OTC

sm vitamin c 500 mg tab chew C OTC

sm vitamin c 500 mg tablet C OTC

sm vitamin c tr 500 mg tablet C OTC

sv vitamin c 500 mg tab chew C OTC

v-r vitamin c 1,000 mg tablet C OTC

v-r vitamin c 250 mg tab chew C OTC

v-r vitamin c 500 mg tab chew C OTC

PAGE 274 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

v-r vitamin c 500 mg tablet C OTC

vitamin c 1,000 mg caplet C OTC

vitamin c 1,000 mg tablet C OTC

vitamin c 250 mg tablet C OTC

vitamin c 250 mg tablet chew C OTC

vitamin c 500 mg capsule sa C OTC

vitamin c 500 mg tablet C OTC

vitamin c 500 mg tablet chew C OTC

vitamin c er 500 mg capsule C OTC

vitamin c tr 500 mg caplet C OTC

vitamin c tr 500 mg tablet C OTC

vitamin c-500 mg tablet C OTC

vitamin c-500 mg tr capsule C OTC

VITAMIN D

CALCIDOL C OTC

0.25 mcg capsule C

calcitriol 0.5 mcg capsule C

calcitriol 1 mcg/ml solution C

cvs vitamin d3 125 mcg softgel C OTC

cvs vitamin d3 25 mcg softgel C OTC

cvs vitamin d3 5,000 unit sfgl C OTC

D-VI-SOL C OTC

eql vitamin d3 5,000 unit sfgl C OTC

C OTC

gnp vitamin d3 1,000 unit tab C OTC

gnp vitamin d3 2,000 unit tab C OTC

gnp vitamin d3 25 mcg tablet C OTC

PAGE 275 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

hm vitamin d3 2,000 unit sftgl C OTC

PEDIATRIC D-VITE C OTC

pediatric vitamin d3 C OTC

ra vitamin d3 1,000 unit tab C OTC

ra vitamin d3 2,000 unit sfgl C OTC

ra vitamin d3 2,000 unit sftgl C OTC

ra vitamin d3 5,000 unit sftgl C OTC

sm vitamin d3 2,000 unit sftgl C OTC

sm vitamin d3 25 mcg tablet C OTC

sv vitamin d3 1,000 unit sftgl C OTC

sv vitamin d3 2,000 unit sftgl C OTC

sv vitamin d3 5,000 unit sftgl C OTC

vitamin d-400 C OTC

vitamin d2 1.25mg(50,000 unit) C

vitamin d2 400 unit tablet C OTC

vitamin d3 1,000 unit softgel C OTC

vitamin d3 1,000 unit tablet C OTC

vitamin d3 125 mcg (5000 unit) C OTC

vitamin d3 125 mcg capsule C OTC

vitamin d3 125 mcg softgel C OTC

vitamin d3 2,000 unit softgel C OTC

vitamin d3 2,000 unit tablet C OTC

vitamin d3 25 mcg (1,000 unit) C OTC

vitamin d3 25 mcg softgel C OTC

vitamin d3 25 mcg tablet C OTC

vitamin d3 400 unit tablet C OTC

PAGE 276 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

vitamin d3 5,000 unit capsule C OTC

vitamin d3 5,000 unit softgel C OTC

vitamin d3 50 mcg tablet C OTC

VITAMIN E

cvs vitamin e 180 mg softgel C OTC

cvs vitamin e 268 mg softgel C OTC

cvs vitamin e 90 mg softgel C OTC

eql vitamin e 1,000 unit sftgl C OTC

eql vitamin e 180 mg softgel C OTC

gnp vitamin e 180 mg softgel C OTC

gnp vitamin e 400 unit softgel C OTC

hm vitamin e 180 mg softgel C OTC

hm vitamin e 400 unit softgel C OTC

ra vitamin e 268 mg softgel C OTC

sm vitamin e 1,000 unit sftgel C OTC

sm vitamin e 200 unit softgel C OTC

sm vitamin e 400 unit capsule C OTC

sm vitamin e 400 unit softgel C OTC

sv vitamin e 180 mg softgel C OTC

sv vitamin e 400 unit softgel C OTC

sv vitamin e 450 mg softgel C OTC

sv vitamin e 670 mg softgel C OTC

vitamin e 1,000 unit capsule C OTC

vitamin e 1,000 unit softgel C OTC

vitamin e 15 unit/0.3 ml drop C OTC

vitamin e 180 mg softgel C OTC

PAGE 277 LAST UPDATED 07/2021 DRUG DESCRIPTION (RX) TYPE LIMITS & RESTRICTIONS

vitamin e 180mg(400 unit) sfgl C OTC

vitamin e 200 unit softgel C OTC

vitamin e 268 mg softgel C OTC

vitamin e 400 unit capsule C OTC

vitamin e 400 unit softgel C OTC

vitamin e 45 mg softgel C OTC

vitamin e 450 mg softgel C OTC

vitamin e 90 mg softgel C OTC

VITAMIN K ACTIVITY

MEPHYTON QL 3 TABS / FILL C phytonadione (vit k1) PA

phytonadione 5 mg tablet C QL 3 TABS / FILL

PAGE 278 LAST UPDATED 07/2021 Index of covered drugs ACCU-CHEK SMARTVIEW 157,164 2 ACCU-CHEK SOFTCLIX 157 2-IN-1 LANCET DEVICE 157 ACCUPRIL 244 24 HOUR ALLERGY 41 ACCURETIC 244 24 HOUR NASAL ALLERGY 41 ACEBUTOLOL HCL 148 ACETAMINOPHEN 9,10,11,12,13 5 ACETAMINOPHEN WITH CODEINE PHOSPHATE 13 5-HYDROXYTRYPTOPHAN (5-HTP) 235 ACETAZOLAMIDE 82 ACETIC ACID 37 8 ACETYLCYSTEINE 249 8 HOUR PAIN RELIEF 9 ACID CONTROL 130 8HR ARTHRITIS PAIN 9 ACID CONTROLLER 130 ACID REDUCER 130,131,132 A ACID-PEP 131 ABACAVIR SULFATE 120 ACIPHEX 132 ABACAVIR SULFATE/DOLUTEGRAVIR ACIPHEX SPRINKLE 132 SODIUM/LAMIVUDINE 121 ACITRETIN 254 ABACAVIR SULFATE/LAMIVUDINE 120 ACLIDINIUM BROMIDE 53 ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 120 ACNE MEDICATION 252 ABALOPARATIDE 242 ACTEMRA 224,225 ABATACEPT 227,228 ACTEMRA ACTPEN 225 ABATACEPT/MALTOSE 227 ACTHAR 164 ABEMACICLIB 112 ACTHIB 125 ABILIFY 115 ACTIVATED CHARCOAL 188 ABILIFY MAINTENA 115 ACTIVATED CHARCOAL/SORBITOL SOLUTION 188 ABILIFY MYCITE 115 ACTONEL 222 ABIRATERONE ACETATE 97 ACTOPLUS MET 74 ACAM2000 (NATIONAL STOCKPILE) 125 ACTOPLUS MET XR 74 ACAMPROSATE CALCIUM 150 ACULAR 42 ACANYA 37 ACULAR LS 42 ACARBOSE 70 ACUVAIL 42 ACCOLATE 43 ACYCLOVIR 39,40,135,136 ACCU-CHEK 157 ACYCLOVIR/HYDROCORTISONE 39 ACCU-CHEK AVIVA PLUS 157,164 ADACEL TDAP 125 ACCU-CHEK COMPACT PLUS CONTROL 157 ADAKVEO 143 ACCU-CHEK COMPACT PLUS STRIPS 164 ADALAT CC 146 ACCU-CHEK FASTCLIX LANCING DEV 157 ADALIMUMAB 199,226,227 ACCU-CHEK GUIDE CONTROL SOLN 157 ADAPALENE 254,255 ACCU-CHEK GUIDE ME GLUCOSE MTR 157 ADAPALENE/BENZOYL PEROXIDE 254,256 ACCU-CHEK GUIDE MONITOR SYSTEM 157 ADCIRCA 263 ACCU-CHEK GUIDE TEST STRIP 164 ADDERALL XR 25

PAGE 279 LAST UPDATED 07/2021 ADEFOVIR DIPIVOXIL 136 ALBENDAZOLE 34 ADEMPAS 249 ALBUTEROL SULFATE 141,142 ADENOVIRUS LIVE TYPE-4 AND ADENOVIRUS ALCAFTADINE 179 LIVE TYPE-7 VACCINE 125 ALCLOMETASONE DIPROPIONATE 44 ADENOVIRUS VACCINE LIVE TYPE-4 125 ALCOHOL ANTISEPTIC PADS 40 ADENOVIRUS VACCINE LIVE TYPE-7 125 ALCOHOL PADS 40 ADHANSIA XR 28 ALECENSA 98 ADLYXIN 71 ALECTINIB HCL 98 ADMELOG 217 230 ADMELOG SOLOSTAR 217 ALENDRONATE SODIUM 222,223 ADVAIR DISKUS 155 ALENDRONATE SODIUM/CHOLECALCIFEROL ADVAIR HFA 155 (VITAMIN D3) 223 ADVATE 83 ALFERON N 135 ADVOCATE SYRINGES 156,157 ALFUZOSIN HCL 9 ADYNOVATE 83 ALIROCUMAB 93 ADZENYS ER 25 ALISKIREN HEMIFUMARATE 246 ADZENYS XR-ODT 25,26 ALISKIREN AFATINIB DIMALEATE 102 HEMIFUMARATE/HYDROCHLOROTHIAZIDE 246 AFINITOR 97 ALL DAY ALLERGY 86 AFINITOR DISPERZ 97,98 ALL DAY ALLERGY-D 86 AFIRMELLE 205 ALL DAY PAIN RELIEF 236 AFLURIA QUAD 2019-20 (3YR UP) 126 ALLER-CORT 41 AFLURIA QUAD 2019-20 (6-35MO) 126 ALLER-TEC D 86 AFLURIA QUAD 2019-2020 126 ALLERGENIC EXTRACT,GRASS POLLEN- AFLURIA QUAD 2020-2021 126 TIMOTHY,STANDARD 123 AFLURIA QUAD 2020-21 (3YR UP) 126 ALLERGENIC EXTRACT-WEED POLLEN-SHORT AFLURIA QUAD 2020-21 (6-35MO) 126 RAGWEED 123 AFLURIA QUAD 2021-2022 126 ALLERGY COMPLETE-D 86 AFLURIA QUAD 2021-22 (3YR UP) 126 ALLERGY EYE 183 AFLURIA QUAD 2021-22 (6-35MO) 126 ALLERGY RELIEF 86,87 AFREZZA 217 ALLERGY RELIEF D-12 86 AFSTYLA 83 ALLERGY RELIEF NASAL DECONGEST 86 AGAMATRIX PRESTO 165 ALLERGY RELIEF-D 86 AIMOVIG AUTOINJECTOR 93 ALLERGY-CONGESTION 12HR 87 AIRDUO RESPICLICK 155 ALLERGY-CONGESTION RELIEF 12HR 86,87 AJOVY AUTOINJECTOR 93 ALLOPURINOL 222 AJOVY SYRINGE 93 ALMOTRIPTAN MALATE 94 AK-POLY-BAC 35 ALOCRIL 43 AKLIEF 254 ALOGLIPTIN BENZOATE 70,71 AKYNZEO 75 ALOGLIPTIN BENZOATE/METFORMIN HCL 70,71 ALA-CORT 44 ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 70,71

PAGE 280 LAST UPDATED 07/2021 ALOMIDE 178 AMMONIUM LACTATE 177 ALOSETRON HCL 189 AMNESTEEM 254 ALPHAGAN P 81 AMOXICILLIN 242 ALPHANATE 83 AMOXICILLIN/POTASSIUM CLAVULANATE 242 ALPHANINE SD 83 AMPHETAMINE 25,26,27 ALPRAZOLAM 138,139 AMPHETAMINE SULFATE 26,27 ALPROLIX 84 AMPICILLIN TRIHYDRATE 242 ALREX 41 AMPYRA 234 ALTACE 244 ANAGRELIDE HCL 123 ALTAVERA 206 ANAKINRA 227 ALTOPREV 92 ANASTROZOLE 98 ALUMINUM CHLORIDE 251 ANCOBON 76 ALUMINUM HYDROXIDE 187 ANDRODERM 204 ALVESCO 155 ANDROGEL 204 ALYACEN 206 ANNOVERA 206 ALYQ 263 ANORO ELLIPTA 51 AMANTADINE HCL 114 ANTACID-ANTIGAS 187 AMARYL 73 ANTARA 91 AMBIEN 137 ANTHRAX VACCINE 126 AMBIEN CR 137 ANTI-DIARRHEAL 190 AMBRISENTAN 249 ANTI-INHIBITOR COAGULANT COMPLEX 84 AMERGE 94 ANTIHEMOPHILIC FACTOR (FACTOR VIII) AMETHIA 206 RECOMB,B-DOMAIN DELETED 86 AMETHIA LO 206 ANTIHEMOPHILIC FACTOR (FVIII) REC, B-DOM AMIFAMPRIDINE 235 TRUNCATED PEG-EXEI 84 AMILORIDE HCL 168 ANTIHEMOPHILIC FACTOR (FVIII) REC, B-DOMAIN AMILORIDE HCL/HYDROCHLOROTHIAZIDE 168 DELETED PEG-AUCL 84 AMINO ACIDS 172 ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, AMINOCAPROIC ACID 84 FC FUSION PROTEIN 84 AMIODARONE HCL 48 ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, AMITRIPTYLINE HCL 69 FULL LENGTH, PEG 83 AMLODIPINE BESYLATE 146,147 ANTIHEMOPHILIC FACTOR (FVIII) AMLODIPINE BESYLATE/ATORVASTATIN RECOMBINANT,FULL LENGTH 83,84,85 CALCIUM 92 ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B- AMLODIPINE BESYLATE/BENAZEPRIL HCL 146 DOMAIN DELETED 85 AMLODIPINE BESYLATE/OLMESARTAN ANTIHEMOPHILIC FACTOR VIII RECOMB,SINGLE- MEDOXOMIL 146 CHN,B-DOM TRUNCATED 83 AMLODIPINE BESYLATE/VALSARTAN 146 ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B- AMLODIPINE DOMAIN TRUNCATED 85 BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ANTIHEMOPHILIC FACTOR VIII, HUMAN 146 RECOMBINANT 85

PAGE 281 LAST UPDATED 07/2021 ANTIHEMOPHILIC FACTOR VIII, RECOMBINANT ARTHROTEC 50 236 PORCINE SEQUENCE 85 ARTHROTEC 75 236 ANTIHEMOPHILIC FACTOR, HUMAN 84,85 ASACOL HD 189 ANTIHEMOPHILIC FACTOR, HUMAN/VON ASCORBATE CALCIUM 275 WILLEBRAND FACTOR,HUMAN 83,84,86 ASCORBIC ACID 274,275 ANTITHROMBIN III (HUMAN PLASMA DERIVED) 53 ASCORBIC ACID/ASCORBATE SODIUM 274 APALUTAMIDE 101 ASCORBIC ACID/VIT E ACETATE/LUTEIN/COPPER APIDRA 217 OXIDE/ZINC OXIDE 235 APIDRA SOLOSTAR 217 ASENAPINE 117 APIXABAN 54 ASENAPINE MALEATE 115,117 APLENZIN 66 ASFOTASE ALFA 177 APRACLONIDINE HCL 180,181 ASHLYNA 206 APREMILAST 228 ASMANEX 155 APREPITANT 75 ASMANEX HFA 155 APRI 206 ASPIRIN 241 APRISO 189 ASPIRIN/ACETAMINOPHEN/CAFFEINE 241 APTENSIO XR 29 ASPIRIN/CALCIUM CARBONATE/MAGNESIUM 241 APTIOM 57 ASPIRIN/DIPYRIDAMOLE 263 APTIVUS 121 ASSURE LANCE 157 AQUA GLYCOLIC 243 ASSURE PLATINUM TEST STRIP 165 AQUADEKS 263 ASTAGRAF XL 232 ARANELLE 206 ASTRAZENECA COVID19 VAC(UNAPP) 126 ARANESP 143 ATACAND 243 ARCALYST 234 ATACAND HCT 243 ARCAPTA NEOHALER 142 ATAZANAVIR SULFATE 121,122 ARFORMOTEROL TARTRATE 142 ATAZANAVIR SULFATE/COBICISTAT 121 ARGININE 171 ATELVIA 222 ARGININE/GLUTAMINE/CALCIUM BETA-HYDROXY- ATENOLOL 148,150 BETA-METHYLBUTYRATE 171 ATENOLOL/CHLORTHALIDONE 148,150 ARICEPT 140 ATHLETE'S FOOT 77 ARIPIPRAZOLE 115 ATOMOXETINE HCL 150,152 ARIPIPRAZOLE LAUROXIL 115 ATORVASTATIN CALCIUM 92 ARIPIPRAZOLE LAUROXIL, SUBMICRONIZED 115 ATOVAQUONE 115 ARISTADA 115 ATOVAQUONE/PROGUANIL HCL 115 ARISTADA INITIO 115 ATRALIN 252 ARIXTRA 53 ATROPINE SULFATE 182 ARMODAFINIL 34 ATROVENT HFA 51 ARNUITY ELLIPTA 155 AUBAGIO 229 ARTHRITIS PAIN 10,11,237,238,240 AUBRA 206 ARTHRITIS PAIN RELIEF 10,11,12 AUBRA EQ 206 ARTHRITIS PAIN RELIEVER 236 AUGMENTIN 242

PAGE 282 LAST UPDATED 07/2021 AUGMENTIN XR 242 AURANOFIN 201 B AUROVELA 206 B-COMPLEX WITH VITAMIN C 271,273 AUROVELA 24 FE 206 BACITRACIN 35,37,39 AUROVELA FE 206 BACITRACIN ZINC 37 AURYXIA 219 BACITRACIN/POLYMYXIN B SULFATE 35,36 AUSTEDO 153 BACLOFEN 251 AUTOLET LANCING DEVICE 157 BAFIERTAM 229 AVALIDE 243 BALOXAVIR MARBOXIL 134 AVANDIA 74 BALSALAZIDE DISODIUM 189 AVAPRITINIB 98 BALVERSA 98 AVAPRO 243 BALZIVA 206 AVIANE 206 BANZEL 57 AVITA 252 BAQSIMI 88 AVODART 222 BARACLUDE 136 AVONEX 229 BARICITINIB 227 AVONEX PEN 229 BASAGLAR KWIKPEN U-100 216 AVSOLA 225 BAXDELA 49 AXITINIB 104 BAYER CHEWABLE ASPIRIN 241 AYR 180 BAZA PROTECT 177 AYR SALINE 180 BCG VACCINE, LIVE/PF 126 AYUNA 206 BECLOMETHASONE DIPROPIONATE 41,42,156 AYVAKIT 98 BECONASE AQ 41 AZACITIDINE 109 BEDAQUILINE FUMARATE 97 AZASAN 232 BEKYREE 206 AZASITE 35 BELBUCA 23,24 AZATHIOPRINE 232,233 BELSOMRA 137 AZELAIC ACID 255 BEMPEDOIC ACID 89 AZELASTINE HCL 178 BEMPEDOIC ACID/EZETIMIBE 89 AZELASTINE HCL/FLUTICASONE PROPIONATE 179 BENAZEPRIL HCL 244,245 AZELEX 255 BENAZEPRIL AZESCO 263 HCL/HYDROCHLOROTHIAZIDE 244,245 AZILSARTAN MEDOXOMIL 243 BENEFIX 84 AZILSARTAN MEDOXOMIL/CHLORTHALIDONE 243 BENICAR 243 AZITHROMYCIN 35,221 BENICAR HCT 243 AZOPT 82 BENRALIZUMAB 43 AZOR 146 BENZACLIN 37 AZTREONAM LYSINE 221 BENZEPRO 252 AZULFIDINE 50 BENZNIDAZOLE 115 AZURETTE 206 BENZONATATE 246 BENZOYL PEROXIDE 252,253,262

PAGE 283 LAST UPDATED 07/2021 BENZOYL PEROXIDE MICRONIZED 252 BIOTHRAX 126 BENZTROPINE MESYLATE 114 BISACODYL 192,194,195,196,197,198,199 BEPOTASTINE BESILATE 178 BISMUTH SUBSALICYLATE 190,191 BEPREVE 178 BISOPROLOL FUMARATE 148 BERINERT 224 BISOPROLOL BEROTRALSTAT HYDROCHLORIDE 224 FUMARATE/HYDROCHLOROTHIAZIDE 148,150 BESIFLOXACIN HCL 35 BIVIGAM 123 BESIVANCE 35 BLEPH-10 35 BETA-CAROTENE 271 BLEPHAMIDE S.O.P. 35 BETA-CAROTENE (VITAMIN A) WITH VITAMINS C BLISOVI 24 FE 206 AND E/MINERALS 270 BLISOVI FE 206 BETA-CAROTENE(A) W-C AND BLOOD GLUCOSE CALIBRATION CONTROL HIGH E/LUTEIN/MINERALS 265,267 AND LOW 157,159,164 BETA-CAROTENE/ASCORBIC ACID/VITE AC/ZINC BLOOD GLUCOSE CALIBRATION CONTROL OXIDE/CUPRIC OXIDE 234 SOLUTION, HIGH 164 BETADINE 40 BLOOD GLUCOSE CALIBRATION CONTROL BETAMETHASONE DIPROPIONATE 44 SOLUTION, LOW 164 BETAMETHASONE DIPROPIONATE/PROPYLENE BLOOD GLUCOSE CALIBRATION CONTROL GLYCOL 44 SOLUTION, NORMAL 157,159,160,161,163,164 44 BLOOD KETONE AND GLUCOSE BETAPACE 148 MONITOR 159,161,162 BETAPACE AF 148 BLOOD SUGAR DIAGNOSTIC 164,165,166,167,168 BETASERON 229 BLOOD SUGAR DIAGNOSTIC, DISC-TYPE 165 BETAXOLOL HCL 81,148 BLOOD SUGAR DIAGNOSTIC, DRUM-TYPE 164 BETHANECHOL CHLORIDE 140 BLOOD-GLUCOSE BETHKIS 48 METER 157,158,159,160,161,162,163,164 BETOPTIC S 81 BLOOD-GLUCOSE METER, WIRELESS 158 BETRIXABAN MALEATE 54 BLOOD-GLUCOSE METER,CONTINUOUS 158,159 BEVESPI AEROSPHERE 51 BLOOD-GLUCOSE SENSOR 159 BEVYXXA 54 BLOOD-GLUCOSE TRANSMITTER 158,159 BEXSERO 126 BLOOD-KETONE CONTROL, NORMAL 159,161 BICALUTAMIDE 98 BONIVA 222 BICTEGRAVIR BOOSTRIX TDAP 125 SODIUM/EMTRICITABINE/TENOFOVIR BOSENTAN 249,250 ALAFENAMIDE FUMAR 120 BOSULIF 98 BIKTARVY 120 BOSUTINIB 98 BIMATOPROST 83 BP GEL 262 BINIMETINIB 108 BRAFTOVI 99 BINOSTO 222 BREEZE 2 165 BIOTEL CARE BGM-4 157 BREO ELLIPTA 155 BIOTENE MOISTURIZING MOUTH 157 BREXPIPRAZOLE 117

PAGE 284 LAST UPDATED 07/2021 BRIELLYN 207 BRILINTA 122 C BRIMONIDINE TARTRATE 81 C1 ESTERASE INHIBITOR 224 BRIMONIDINE TARTRATE/TIMOLOL MALEATE 81 C1 ESTERASE INHIBITOR, RECOMBINANT 224 BRINZOLAMIDE 82 CABERGOLINE 169 BRINZOLAMIDE/BRIMONIDINE TARTRATE 82 CABLIVI 122 BRISDELLE 68 CABOMETYX 99 BRIVARACETAM 57 CABOTEGRAVIR SODIUM 120 BRIVIACT 57 CABOZANTINIB S-MALATE 99,100 BRODALUMAB 256 CADEAU DHA 263 BROMFENAC SODIUM 42,43 CADUET 92 BROMOCRIPTINE MESYLATE 169 CALAMINE/ZINC OXIDE 177 BROMPHENIRAMINE MALEATE/PHENYLEPHRINE CALAN 144 HCL 186 CALAN SR 144 BROMPHENIRAMINE CALCIPOTRIENE 255 MALEATE/PSEUDOEPHEDRINE HCL 186,187 CALCITONIN,SALMON,SYNTHETIC 242 BROMSITE 42 CALCITRENE 255 BROVANA 142 CALCITRIOL 275 BRUKINSA 99 CALCIUM ACETATE 174,219 BUDESONIDE 42,155,156,203,204 CALCIUM CARBONATE 174,175,176,187,188 BUDESONIDE/FORMOTEROL FUMARATE 155,156 CALCIUM CARBONATE, GLUCONATE/MAGNESIUM BUMETANIDE 168 OXIDE, GLUCONATE 174 BUNAVAIL 24 CALCIUM CARBONATE/CHOLECALCIFEROL BUPRENORPHINE 24 (VITAMIN D3) 173,174,175,176 BUPRENORPHINE HCL 23,24 CALCIUM CARBONATE/MAGNESIUM BUPRENORPHINE HCL/NALOXONE HCL 24,25 HYDROXIDE 187,188 BUPROPION HBR 66 CALCIUM CITRATE 174 BUPROPION HCL 66,67 CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN BUSPIRONE HCL 137 D3) 174,175 BUSULFAN 108 CALCIUM MAGNESIUM 174 BUTALBITAL/ACETAMINOPHEN 10,13 CALCIUM POLYCARBOPHIL 193,194 BUTALBITAL/ACETAMINOPHEN/CAFFEINE 10,13 CALTRATE 600 PLUS D3 175 BUTALBITAL/ASPIRIN/CAFFEINE 241 CAMILA 207 BUTTERFLY TOUCH LANCET 158 CAMRESE 207 BYDUREON BCISE 71 CAMRESE LO 207 BYDUREON PEN 71 CANAGLIFLOZIN 72 BYETTA 71 CANAGLIFLOZIN/METFORMIN HCL 72 BYNFEZIA 258 CANAKINUMAB/PF 234 BYSTOLIC 148 CANASA 189 CANDESARTAN CILEXETIL 243

PAGE 285 LAST UPDATED 07/2021 CANDESARTAN CEFACLOR 154 CILEXETIL/HYDROCHLOROTHIAZIDE 243 CEFADROXIL 153 CANNABIDIOL (CBD) 58 CEFDINIR 154 CAPECITABINE 99 CEFIXIME 154 CAPLACIZUMAB-YHDP 122 CEFPODOXIME PROXETIL 154 CAPLYTA 116 CEFPROZIL 154 CAPMATINIB HYDROCHLORIDE 110 CEFTRIAXONE SODIUM 154 CAPRELSA 99 CEFUROXIME AXETIL 154 CAPSAICIN 255 CELEBREX 236 CAPSAICIN/SKIN CLEANSER 256 CELECOXIB 236 CAPTOPRIL 244 CELEXA 68 CAPTOPRIL/HYDROCHLOROTHIAZIDE 245 CELLCEPT 232 CARBAGLU 169 CELONTIN 66 CARBAMAZEPINE 57,58,63 CENEGERMIN-BKBJ 181 CARBAMIDE PEROXIDE 37 CENOBAMATE 64 CARBATROL 58 CENTANY 37 CARBIDOPA/LEVODOPA 114 CENTANY AT 37 CARBIDOPA/LEVODOPA/ENTACAPONE 114 CEPHALEXIN 153,154 CARBOXYMETHYLCELLULOSE CERDELGA 234 SODIUM 180,181,182 CERITINIB 113 CARBOXYMETHYLCELLULOSE CEROVITE JR 264 SODIUM/GLYCERIN 181,182 CERTAVITE SENIOR 264 CARBOXYMETHYLCELLULOSE CERTAVITE-ANTIOXIDANT 264 SODIUM/GLYCERIN/PF 181 CERTOLIZUMAB PEGOL 225 CARBOXYMETHYLCELLULOSE CESAMET 74 SODIUM/HYPROMELLOSE 181 CETIRIZINE HCL 86,87,180 CARDIZEM 144 CETIRIZINE HCL/PSEUDOEPHEDRINE HCL 86 CARDIZEM CD 144 CEVIMELINE HCL 140 CARDIZEM LA 144 CHANTIX 140 CARDURA 147 CHATEAL 207 CARDURA XL 148 CHATEAL EQ 207 CARETOUCH SAFETY LANCETS 158 CHEMET 202 CARETOUCH TEST STRIP 165 CHEST CONGESTION RELIEF 248 CARGLUMIC ACID 169 CHILD FEVER REDUCER 10 CARIPRAZINE HCL 118 CHILD MUCINEX CHEST MINI-MELTS 248 CARTEOLOL HCL 81 CHILD MUCINEX COUGH MINI-MELTS 246 CARTIA XT 144 CHILD MUCINEX STUFFY NOSE-CHST 248 CARVEDILOL 148 CHILDREN'S ALLERGY 87 CARVEDILOL PHOSPHATE 148 CHILDREN'S ALLERGY RELIEF 87,88 CAYSTON 221 CHILDREN'S CHEWABLE VITAMIN 264 CAZIANT 207 CHILDREN'S CLARITIN 87

PAGE 286 LAST UPDATED 07/2021 CHILDREN'S FEVER REDUCER 10 CITALOPRAM HYDROBROMIDE 68 CHILDREN'S MOTRIN 236 CITRANATAL B-CALM 264 CHILDREN'S TYLENOL 10 CITROMA 192 CHLORAMBUCIL 106 CITRUCEL 192 CHLORDIAZEPOXIDE HCL 139 CLADRIBINE 233 CHLORHEXIDINE GLUCONATE 37 CLARAVIS 255 CHLOROQUINE PHOSPHATE 115 CLARINEX 87 CHLOROTHIAZIDE 168 CLARINEX-D 12 HOUR 87 CHLORPHENIRAMINE MALEATE 186 CLARITHROMYCIN 221 CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE CLARITIN 87 HCL 186 CLEARLAX 192,193 CHLORPROMAZINE HCL 119 FUMARATE 185 CHLORTHALIDONE 169 CLEOCIN 37 CHLORZOXAZONE 250 CLEOCIN T 37,38 CHOLBAM 199 CLINDACIN P 38 CHOLECALCIFEROL (VITAMIN D3) 275,276,277 CLINDACIN PAC 38 CHOLERA VACCINE BUFFER COMPONENT 243 CLINDAGEL 38 CHOLERA VACCINE, LIVE 130 CLINDAMYCIN HCL 51 CHOLESTYRAMINE (WITH SUGAR) 90 CLINDAMYCIN PALMITATE HCL 51 CHOLESTYRAMINE/ASPARTAME 90 CLINDAMYCIN PHOSPHATE 37,38 CHOLIC ACID 199 CLINDAMYCIN PHOSPHATE/BENZOYL CICLESONIDE 41,42,155 PEROXIDE 37,38,39 CICLODAN 80 CLINDAMYCIN PHOSPHATE/BENZOYL CICLOPIROX 80 PEROXIDE/EMOLLIENT COMB NO.94 39 CICLOPIROX OLAMINE 80 CLINDAMYCIN PHOSPHATE/SKIN CLEANSER CILOSTAZOL 122 COMB NO.19 38 CILOXAN 35 CLINDAMYCIN PHOSPHATE/TRETINOIN 38,39 CIMETIDINE 131,132 CLOBAZAM 65,66 CIMETIDINE HCL 131 CLOBETASOL PROPIONATE 44,45 CIMZIA 225 CLOBETASOL PROPIONATE/EMOLLIENT BASE 44 CINACALCET HCL 242 CLOMIPRAMINE HCL 69 CINRYZE 224 CLONAZEPAM 65 CIPRO 49 CLONIDINE 215 CIPRO HC 35 CLONIDINE HCL 215 CIPRODEX 35 CLOPIDOGREL BISULFATE 122 CIPROFLOXACIN 36,49 CLOTRIMAZOLE 77,78,79 CIPROFLOXACIN HCL 35,49 CLOTRIMAZOLE/BETAMETHASONE CIPROFLOXACIN HCL/DEXAMETHASONE 35,36 DIPROPIONATE 78 CIPROFLOXACIN HCL/FLUOCINOLONE CLOZAPINE 116,118 ACETONIDE 35,36 CLOZARIL 116 CIPROFLOXACIN HCL/HYDROCORTISONE 35 COAGADEX 84

PAGE 287 LAST UPDATED 07/2021 COAGULATION FACTOR VIIA (RECOMBINANT) 85 COREG CR 148 COAGULATION FACTOR VIIA RECOMBINANT- CORGARD 148 JNCW 85 CORIFACT 84 COAGULATION FACTOR X 84 CORLANOR 147 COAL TAR 254 CORMAX 45 COBICISTAT 235 CORTICOTROPIN 164 COBIMETINIB FUMARATE 100 COSENTYX (2 SYRINGES) 255 CODEINE PHOSPHATE/GUAIFENESIN 246,247,248 COSENTYX PEN 255 CODEINE SULFATE 13 COSENTYX PEN (2 PENS) 255 COLACE CLEAR 193 COSENTYX SYRINGE 255 COLAZAL 189 COSOPT 82 COLCHICINE 222 COSOPT PF 82 COLESEVELAM HCL 90 COTELLIC 100 COLESTID 90 COTEMPLA XR-ODT 29 COLESTIPOL HCL 90 COVID-19 VAC, AD26.COV2.S (JANSSEN)/PF 128 COLOCORT 44 COVID-19 VACCINE, AZD-1222 COMBIGAN 81 (ASTRAZENECA)/PF 126 COMBIVENT RESPIMAT 51 COVID-19 VACCINE, MRNA, BNT162B2, LNP-S COMETRIQ 99,100 (PFIZER)/PF 129 COMFORT TOUCH PLUS SAFETY LANC 158 COVID-19 VACCINE, MRNA-1273, LNP-S COMFORT TOUCH ULT THIN LANCET 158 (MODERNA)/PF 129 COMPLERA 120 COVID-19 VACCINE, NVX-COV2373 COMPRO 75 (NOVAVAX)/ADJUVANT-MATRIX/PF 129 CONCEPT DHA 264 COZAAR 243 CONCEPT OB 264 CREATINE MONOHYDRATE 234 CONCERTA 29 CREON 199 CONDOMS 236 CRESEMBA 76 CONDOMS, LATEX, LUBRICATED 236 CRESTOR 92 CONSTULOSE 169 CRISABOROLE 44 CONTOUR 158 CRIZANLIZUMAB-TMCA 143 CONTOUR NEXT 158 CRIZOTINIB 112 CONTOUR NEXT EZ 158 CROMOLYN SODIUM 44 CONTOUR NEXT GLUCOSE METER 158 CRYSELLE 207 CONTOUR NEXT LINK 158 CUVITRU 123 CONTOUR NEXT LINK 2.4 158 CUVPOSA 51 CONTOUR NEXT ONE 158 CYANOCOBALAMIN (VITAMIN B-12) 271,272,273 CONTOUR NEXT TEST STRIP 165 CYANOCOBALAMIN/FOLIC CONTOUR TEST STRIP 165 ACID/PYRIDOXINE 272,273 COPAXONE 230 CYCLAFEM 207 COPIKTRA 100 CYCLINEX-1 170 COREG 148 CYCLINEX-2 170

PAGE 288 LAST UPDATED 07/2021 CYCLOBENZAPRINE HCL 250 DARUNAVIR CYCLOPENTOLATE HCL 182 ETH/COBICISTAT/EMTRICITABINE/TENOFOVIR CYCLOPHOSPHAMIDE 100 ALAFENAMIDE 122 CYCLOSERINE 96 DARUNAVIR ETHANOLATE 122 CYCLOSET 169 DARUNAVIR ETHANOLATE/COBICISTAT 122 CYCLOSPORINE 42,232,233 DASATINIB 110 CYCLOSPORINE, MODIFIED 232,233 DASETTA 207 CYMBALTA 67 DAURISMO 100 CYPROHEPTADINE HCL 185 DAYSEE 207 CYRED 207 DAYTRANA 29 CYRED EQ 207 DAYVIGO 137 CYSTADROPS 180 DEBLITANE 207 CYSTAGON 234 DECADRON 203 CYSTARAN 180 DECITABINE/CEDAZURIDINE 105 CYSTEAMINE BITARTRATE 234 DEFERASIROX 202,203 CYSTEAMINE HCL 180 DEFERIPRONE 203 DELAFLOXACIN MEGLUMINE 49 D DELSYM 247 D-PENAMINE 202 DELZICOL 189 DABIGATRAN ETEXILATE MESYLATE 55 DEMECLOCYCLINE HCL 50 DABRAFENIB MESYLATE 110 DENAVIR 39 DACOMITINIB 112 DENOSUMAB 223 DAILY VITAMIN + IRON 264 DEPAKOTE 58 DAILY VITE WITH IRON 264 DEPAKOTE ER 58 DAILY-VITE 264 DEPAKOTE SPRINKLE 58 DALFAMPRIDINE 234 DESCOVY 120 DALIRESP 249 DESIPRAMINE HCL 69 DALTEPARIN SODIUM,PORCINE 55,56 DESLORATADINE 87 DANAZOL 204 DESLORATADINE/PSEUDOEPHEDRINE DANTROLENE SODIUM 251 SULFATE 87 DAPAGLIFLOZIN PROPANEDIOL 72 DESMOPRESSIN ACETATE 214 DAPAGLIFLOZIN PROPANEDIOL/METFORMIN DESMOPRESSIN ACETATE (NON- HCL 73 REFRIGERATED) 214 DAPAGLIFLOZIN PROPANEDIOL/SAXAGLIPTIN DESOGESTREL-ETHINYL HCL 72 ESTRADIOL 206,207,208,209,211,213 DAPSONE 96,255 DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL DAPTACEL DTAP 125 ESTRADIOL 206,207,209,211,212,213 DARBEPOETIN ALFA IN POLYSORBATE 80 143 DESONIDE 45 DARIFENACIN HYDROBROMIDE 200 DESOXIMETASONE 45 DARIO BLOOD GLUCOSE TEST STRIP 165 DESVENLAFAXINE 67 DAROLUTAMIDE 108 DESVENLAFAXINE SUCCINATE 67

PAGE 289 LAST UPDATED 07/2021 DETROL 200 DICLOFENAC EPOLAMINE 236,237 DETROL LA 200 DICLOFENAC POTASSIUM 236,241 DEUTETRABENAZINE 153 DICLOFENAC SODIUM 42,236,237,238,240 DEXAMETHASONE 203,204 DICLOFENAC SODIUM/MISOPROSTOL 236,237 DEXAMETHASONE INTENSOL 204 DICLOFENAC SUBMICRONIZED 241 DEXAMETHASONE SODIUM DICLOXACILLIN SODIUM 243 PHOSPHATE 41,203,204 DICYCLOMINE HCL 52 DEXAMETHASONE SODIUM PHOSPHATE/PF 203 DIFFERIN 255 DEXCHLORPHENIRAMINE DIFICID 221 MALEATE/PHENYLEPHRINE HCL/CODEINE 247 DIFLUCAN 76 DEXCOM 158 DIGITEK 147 DEXCOM G4 158 DIGOX 147 DEXCOM G5 159 DIGOXIN 147 DEXCOM G5-G4 SENSOR 159 DILANTIN 66 DEXCOM G6 159 DILANTIN-125 66 DEXEDRINE 26 DILT-XR 144 DEXILANT 132 DILTIAZEM HCL 144,145 DEXLANSOPRAZOLE 132 DIMETAPP 186 DEXMETHYLPHENIDATE HCL 29,30 DIMETHICONE/ZINC OXIDE 177 DEXTRAN 70/HYPROMELLOSE 180,181 DIMETHYL FUMARATE 230,232 DEXTRAN 70/HYPROMELLOSE/PF 180 DIOVAN 243 DEXTRAN/HYPROMELLOSE/GLYCERIN 180 DIOVAN HCT 243 DEXTROAMPHETAMINE SULF- DIPENTUM 189 SACCHARATE/AMPHETAMINE SULF- DIPHENHYDRAMINE HCL 183,184,185 ASPARTATE 25,26,27 DIPHENHYDRAMINE HCL/PHENYLEPHRINE DEXTROAMPHETAMINE SULFATE 26,27,28 HCL/ACETAMINOPHEN 185 DEXTROMETHORPHAN HBR 247 DIPHENOXYLATE HCL/ATROPINE SULFATE 190 DEXTROMETHORPHAN HBR/DOXYLAMINE DIPHTHER,PERTUS(ACEL),TETANUS,POLIO SUCCINATE 247 VACC,COMPONENT 1 OF 2/PF 129 DEXTROMETHORPHAN HBR/PHENYLEPHRINE DIPHTHERIA, PERTUSSIS (ACELL), TETANUS HCL/ACETAMINOPHEN 246 PEDIATRIC VACCINE/PF 125 DEXTROMETHORPHAN POLISTIREX 247 DIPHTHERIA, PERTUSSIS(ACELL),TETANUS,POLIO DEXTROMETHORPHAN/PHENYLEPHRINE/ACETAM VACCINE/PF 128,129 INOPHEN/CHLORPHENIRAMIN 246 DIPHTHERIA,PERTUS(ACELL),TETANUS/HEPB/POL DEXTROSE 170 IO/HIB CONJ-MENG/PF 125 DHS TAR 254 DIPHTHERIA,PERTUSSIS(ACELL),TETANUS,POLIO/ DIACOMIT 58 HAEMOPHILUS B/PF 129 DIASTAT 139 DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS DIASTAT ACUDIAL 139 VACCINE 125 DIASTIX REAGENT 262 DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS DIAZEPAM 139 VACCINE/PF 125

PAGE 290 LAST UPDATED 07/2021 DIPYRIDAMOLE 263 DUTASTERIDE 222 DIROXIMEL FUMARATE 232 DUTASTERIDE/TAMSULOSIN HCL 222 DISOPYRAMIDE PHOSPHATE 48 DUTOPROL 148 DISULFIRAM 222 DUVELISIB 100 DITROPAN XL 200 DYANAVEL XR 27 DIVALPROEX SODIUM 58 DYMISTA 179 DOCUSATE SODIUM 193,194,195,196,197,198 DOFETILIDE 48 E DOJOLVI 170 E.E.S. 200 220 DOLUTEGRAVIR SODIUM 120 E.E.S. 400 220 DOLUTEGRAVIR SODIUM/RILPIVIRINE HCL 120 EASY TOUCH BLU LINK CTRL SOLN 159 DONEPEZIL HCL 140 EASY TOUCH BLU LINK GLUC SYST 159 DORNASE ALFA 249 EASY TOUCH BLU LINK TEST STRIP 165 DORZOLAMIDE HCL 82 EASY TRAK II CONTROL SOLUTION 159 DORZOLAMIDE HCL/PF 82 EASY TRAK II TEST STRIP 165 DORZOLAMIDE HCL/TIMOLOL MALEATE 82 ECALLANTIDE 224 DORZOLAMIDE HCL/TIMOLOL MALEATE/PF 82 ECONAZOLE NITRATE 78 DOTTI 178 EDARBI 243 DOXAZOSIN MESYLATE 147,148 EDARBYCLOR 243 DOXEPIN HCL 69 EDLUAR 137 DOXYCYCLINE HYCLATE 36,50 EDOXABAN TOSYLATE 55 DOXYCYCLINE MONOHYDRATE 50,51 EDURANT 120 DOXYLAMINE SUCCINATE 184,185 EFAVIRENZ 120 DRONABINOL 74 EFAVIRENZ/EMTRICITABINE/TENOFOVIR DRONEDARONE HCL 48 DISOPROXIL FUMARATE 120 DROPLET GENTEEL LANCING DEVICE 159 EFFEXOR XR 67 DROPLET LANCETS 159 EFFIENT 122 DROXIA 100 EFINACONAZOLE 78 DRYSOL 251 ELAGOLIX SODIUM 201 DUAC 38 ELAGOLIX SODIUM/ESTRADIOL/NORETHINDRONE DUET DHA 400 264 ACETATE 201 DUET DHA BALANCED 265 ELBASVIR/GRAZOPREVIR 202 DUETACT 74 ELECARE 170 DUEXIS 237 ELECTROLYTES/DEXTROSE 175 DULAGLUTIDE 72 ELETRIPTAN HYDROBROMIDE 94,95 DULERA 155 ELEXACAFTOR/TEZACAFTOR/IVACAFTOR 156 DULOXETINE HCL 67 ELIDEL 256 DUPILUMAB 43,256 ELIGLUSTAT TARTRATE 234 DUPIXENT PEN 43,256 ELINEST 207 DUPIXENT SYRINGE 43,256 ELIQUIS 54 DURAGESIC 13 ELLA 207

PAGE 291 LAST UPDATED 07/2021 ELMIRON 235 ENCORAFENIB 99 ELOCTATE 84 ENDARI 199 ELTROMBOPAG OLAMINE 143,144 ENDOCET 14 ELURYNG 207 ENFUVIRTIDE 119 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN ENGERIX-B ADULT 126 OFOVIR ALAFENAMIDE 121 ENGERIX-B PEDIATRIC-ADOLESCENT 126 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN ENOXAPARIN SODIUM 55,56,57 OFOVIR DISOPROXIL 121 ENPRESSE 208 EMBEDA 13,14 ENSKYCE 208 EMBRACE LANCING DEVICE 159 ENSPRYNG 230 EMBRACE PRO BLOOD GLUCOSE MTR 159 ENTACAPONE 114 EMBRACE PRO TEST STRIP 165 ENTECAVIR 136 EMCYT 101 ENTRECTINIB 109 EMEND 75 ENTRESTO 243 EMGALITY PEN 94 ENTYVIO 199 EMGALITY SYRINGE 93,94 ENULOSE 169 EMICIZUMAB-KXWH 84 ENVARSUS XR 232 EMOLLIENT BASE 243 ENZALUTAMIDE 113 EMOQUETTE 207 EPANED 245 EMPAGLIFLOZIN 72 EPCLUSA 201 EMPAGLIFLOZIN/LINAGLIPTIN 72 EPIDIOLEX 58 EMPAGLIFLOZIN/LINAGLIPTIN/METFORMIN HCL 73 EPIDUO 256 EMPAGLIFLOZIN/METFORMIN HCL 73 EPIDUO FORTE 256 EMTRICITABINE 120 EPINASTINE HCL 179 EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR EPINEPHRINE 260 ALAFENAMIDE FUMARATE 121 EPIPEN 260 EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR EPIPEN 2-PAK 260 DISOPROXIL FUMARATE 120 EPIPEN JR 260 EMTRICITABINE/TENOFOVIR ALAFENAMIDE EPIPEN JR 2-PAK 260 FUMARATE 120 EPITOL 58 EMTRICITABINE/TENOFOVIR DISOPROXIL EPIVIR HBV 121 FUMARATE 121 EPLERENONE 246 ENABLEX 200 EPOETIN ALFA 143 ENALAPRIL MALEATE 245 EPOETIN ALFA-EPBX 144 ENALAPRIL EPOGEN 143 MALEATE/HYDROCHLOROTHIAZIDE 245 EPOPROSTENOL SODIUM 249,250 ENASIDENIB MESYLATE 104 EPOPROSTENOL SODIUM (GLYCINE) 249 ENBRACE HR 265 EPROSARTAN MESYLATE 244 ENBREL 225 ERDAFITINIB 98 ENBREL MINI 225 ERENUMAB-AOOE 93 ENBREL SURECLICK 226 ERGOCALCIFEROL (VITAMIN D2) 275,276

PAGE 292 LAST UPDATED 07/2021 ERIVEDGE 101 ETONOGESTREL/ETHINYL ESTRADIOL 207,208 ERLEADA 101 ETOPOSIDE 101 ERLOTINIB HCL 101 ETRAVIRINE 120 ERRIN 208 EUCERIN 177 ERTUGLIFLOZIN PIDOLATE 72 EUCRISA 44 ERTUGLIFLOZIN PIDOLATE/METFORMIN HCL 72 EUTHYROX 261 ERTUGLIFLOZIN PIDOLATE/SITAGLIPTIN EVEKEO 27 PHOSPHATE 72 EVEROLIMUS 97,98,101,102,233,234 ERY 38 EVISTA 178 ERY-TAB 220 EVOLOCUMAB 93 ERYPED 200 220 EVOTAZ 121 ERYPED 400 220 EVRYSDI 234 ERYTHROCIN STEARATE 220 EX-LAX MAXIMUM STRENGTH 194 ERYTHROMYCIN BASE 36,220 EXCEDRIN EXTRA STRENGTH 241 ERYTHROMYCIN BASE IN ETHANOL 38 EXELDERM 78 ERYTHROMYCIN BASE/BENZOYL PEROXIDE 38 EXELON 140 ERYTHROMYCIN ETHYLSUCCINATE 220 EXEMESTANE 102 ERYTHROMYCIN STEARATE 220 EXENATIDE 71 ESBRIET 246 EXENATIDE MICROSPHERES 71 ESCITALOPRAM OXALATE 68 EXFORGE 146 ESLICARBAZEPINE ACETATE 57 EXFORGE HCT 146 ESOMEPRAZOLE MAGNESIUM 132,133,134 EXTAVIA 230 ESOMEPRAZOLE STRONTIUM 132 EYE ALLERGY ITCH RELIEF 179 ESPEROCT 84 EYE ALLERGY ITCH-REDNESS RLF 179 ESSENTIAL AMINO ACID MIX 170 EYE ITCH RELIEF 179,180 ESTARYLLA 208 EZ CHAR 188 ESTRADIOL 178 EZ-LETS 159 ESTRAMUSTINE PHOSPHATE SODIUM 101 EZALLOR SPRINKLE 92 ESZOPICLONE 137,138 EZETIMIBE 91 ETANERCEPT 225,226 EZETIMIBE/SIMVASTATIN 91 ETHAMBUTOL HCL 96 ETHINYL F ESTRADIOL/DROSPIRENONE 207,208,210,211,212,2 FABIOR 256 13,214 FACTOR IX 83,85 ETHIONAMIDE 97 FACTOR IX (HUMAN) RECOMBINANT, ETHOSUXIMIDE 66 PEGYLATED 85 ETHOTOIN 66 FACTOR IX COMPLEX, PROTHROMBIN CPLX ETHYNODIOL DIACETATE-ETHINYL CONC(PCC) NO.4, 3-FACTOR 85 ESTRADIOL 208,209,213 FACTOR IX HUMAN RECOMBINANT 84,85 ETIDRONATE DISODIUM 222 FACTOR IX HUMAN RECOMBINANT, THREONINE ETODOLAC 237 148 84

PAGE 293 LAST UPDATED 07/2021 FACTOR IX RECOMBINANT, FC FUSION FIASP FLEXTOUCH 217 PROTEIN 84 FIASP PENFILL 217 FACTOR IX RECOMBINANT,ALBUMIN FUSION FIBERCON 194 PROTEIN 84 FIBRICOR 91 FACTOR XIII 84 FIDAXOMICIN 221 FACTOR XIII A-SUBUNIT, RECOMBINANT 85 FINASTERIDE 222 FALMINA 208 FINGOLIMOD HCL 230 FAMCICLOVIR 136 FINTEPLA 59 FAMOTIDINE 130,131,132 FIRAZYR 224 FANAPT 116 FLASH GLUCOSE SCANNING READER 160 FARXIGA 72 FLASH GLUCOSE SENSOR 160 FASENRA PEN 43 FLAVOXATE HCL 200 FAZACLO 116 FLEBOGAMMA DIF 123 FEBUXOSTAT 222 FLECAINIDE ACETATE 48 FEDRATINIB DIHYDROCHLORIDE 105 FLECTOR 237 FEIBA NF 84 FLOLAN 249 FELBAMATE 58,59 FLOMAX 9 FELBATOL 58,59 FLORIVA 223,265 FELODIPINE 146 FLOVENT DISKUS 155 FEMYNOR 208 FLOVENT HFA 155 FENFLURAMINE HCL 59 FLU VACCINE QUAD 2019-2020(4 YEARS AND FENOFIBRATE 91,92 OLDER)CELL DERIVED/PF 127 FENOFIBRATE NANOCRYSTALLIZED 91,92 FLU VACCINE QUAD 2020-2021(4 YEARS AND FENOFIBRATE,MICRONIZED 91 OLDER)CELL DERIVED/PF 127 FENOFIBRIC ACID 91 FLU VACCINE QUAD 2021-2022(2 YEARS AND FENOFIBRIC ACID (CHOLINE) 91,92 OLDER)CELL DERIVED/PF 127 FENOGLIDE 91 FLU VACCINE QUADRIV 2019-2020(4 YEARS AND FENOPROFEN CALCIUM 237 OLDER)CELL DERIVED 127 FENTANYL 13,14 FLU VACCINE QUADRIV 2020-2021(4 YEARS AND FERRIC CITRATE 219 OLDER)CELL DERIVED 127 FERRIPROX 203 FLU VACCINE QUADRIV 2021-2022(2 YEARS AND FERRIPROX (2 TIMES A DAY) 203 OLDER)CELL DERIVED 127 FERROUS FUMARATE 47 FLUAD 2019-2020 126 FERROUS FUMARATE/ASCORBIC FLUAD 2020-2021 126 ACID/CYANOCOBALAMIN/FOLIC ACID 47 FLUAD QUAD 2020-2021 126 FERROUS GLUCONATE 47 FLUAD QUAD 2021-2022 126 FERROUS SULFATE 47,48 FLUARIX QUAD 2019-2020 126 FESOTERODINE FUMARATE 201 FLUARIX QUAD 2020-2021 127 FETZIMA 67 FLUARIX QUAD 2021-2022 127 FEVERALL 11 FLUBLOK QUAD 2019-2020 127 FIASP 217 FLUBLOK QUAD 2020-2021 127

PAGE 294 LAST UPDATED 07/2021 FLUBLOK QUAD 2021-2022 127 FLUZONE HIGH-DOSE QUAD 2020-21 127 FLUCELVAX QUAD 2019-2020 127 FLUZONE HIGH-DOSE QUAD 2021-22 127 FLUCELVAX QUAD 2020-2021 127 FLUZONE QUAD 2019-2020 128 FLUCELVAX QUAD 2021-2022 127 FLUZONE QUAD 2020-2021 128 FLUCONAZOLE 76 FLUZONE QUAD 2021-2022 128 FLUCYTOSINE 76 FLUZONE QUAD PEDI 2019-2020 128 FLUDROCORTISONE ACETATE 204 FLUZONE QUAD SOUTHERN HEM 2020 128 FLULAVAL QUAD 2019-2020 127 FLUZONE QUAD SOUTHERN HEM 2021 128 FLULAVAL QUAD 2020-2021 127 FML S.O.P. 41 FLULAVAL QUAD 2021-2022 127 FOCALIN 30 FLUMIST QUAD 2019-2020 127 FOCALIN XR 30 FLUMIST QUAD 2020-2021 127 FOLIC ACID 271,272,273 FLUNISOLIDE 41 FOLIC ACID/MULTIVIT WITH IRON, FLUOCINOLONE ACETONIDE 45 MINERALS/LUTEIN 264 FLUOCINOLONE ACETONIDE OIL 41 FOLIC ACID/MULTIVITAMIN WITH IRON, FLUOCINOLONE ACETONIDE/SHOWER CAP 45 MINERALS 267 FLUOCINONIDE 45 FOLIC ACID/PYRIDOXINE HCL/CA PHOS DIBASIC & FLUOCINONIDE/EMOLLIENT BASE 45 TRIBASIC/GINGER 271 FLUORIDE (SODIUM) 223,224 FOLIC ACID/VITAMIN B COMPLEX AND VITAMIN FLUORITAB 223 C 272 FLUOROMETHOLONE 41 FONDAPARINUX SODIUM 53 FLUOROURACIL 102 FORA G20 159,165 FLUOXETINE HCL 68,69 FORA KETONE CONTROL SOLUTION 159 FLUPHENAZINE DECANOATE 119 FORA TN'G ADVAN PRO TEST STRIP 165 FLUPHENAZINE HCL 119 FORA TN'G ADVANCE PRO MONITOR 159 FLURBIPROFEN 237 FORA V10-V12-D10-D20 166 FLURBIPROFEN SODIUM 42 FORFIVO XL 66 FLUTAMIDE 102 FORMOTEROL FUMARATE 142 FLUTICASONE FUROATE 155 FORTEO 242 FLUTICASONE FUROATE/UMECLIDINIUM FORTESTA 204 BROMIDE/VILANTEROL TRIFENAT 156 FORTISCARE G1 TEST STRIP 166 FLUTICASONE FUROATE/VILANTEROL FORTISCARE T1 BLOOD GLUC SYS 160 TRIFENATATE 155 FOSAMAX 223 FLUTICASONE PROPIONATE 41,42,45,155 FOSAMAX PLUS D 223 FLUTICASONE PROPIONATE/SALMETEROL FOSAMPRENAVIR CALCIUM 122 XINAFOATE 155,156 FOSFOMYCIN TROMETHAMINE 35 FLUTICASONE PROPIONATE/SODIUM FOSINOPRIL SODIUM 245 CHLORIDE/SODIUM BICARBONATE 42 FOSINOPRIL FLUVASTATIN SODIUM 92 SODIUM/HYDROCHLOROTHIAZIDE 245 FLUVOXAMINE MALEATE 68 FOSRENOL 219 FLUZONE HIGH-DOSE 2019-2020 127 FOSTEMSAVIR TROMETHAMINE 119

PAGE 295 LAST UPDATED 07/2021 FOTIVDA 102 GAS RELIEF 192 FRAGMIN 55,56 GAS-X 192 FREESTYLE FREEDOM LITE 160 GATIFLOXACIN 36,37 FREESTYLE INSULINX 160,166 GAVILAX 194 FREESTYLE INSULINX TEST STRIPS 166 GAVILYTE-C 194 FREESTYLE LIBRE 10 DAY READER 160 GAVILYTE-G 194 FREESTYLE LIBRE 10 DAY SENSOR 160 GAVILYTE-N 194 FREESTYLE LIBRE 14 DAY READER 160 GAVISCON 188 FREESTYLE LIBRE 14 DAY SENSOR 160 GAVRETO 102 FREESTYLE LIBRE 2 READER 160 GE100 BLOOD GLUCOSE SYSTEM 160 FREESTYLE LIBRE 2 SENSOR 160 GE100 BLOOD GLUCOSE TEST STRIP 166 FREESTYLE LITE METER 160 GE333 BLOOD GLUCOSE SYSTEM 160 FREESTYLE LITE TEST STRIP 166 GE333 BLOOD GLUCOSE TEST STRIP 166 FREESTYLE PRECISION NEO 166 GE333 CONTROL SOLUTION NORMAL 160 FREESTYLE TEST STRIPS 166 GEFITINIB 105 FREMANEZUMAB-VFRM 93 GELNIQUE 200 FROVA 94 GELUSIL 188 FROVATRIPTAN SUCCINATE 94 GEMFIBROZIL 92 FULPHILA 143 GENERLAC 170 FUNGOID TINCTURE 78 GENGRAF 233 FUROSEMIDE 168 GENOTROPIN 214 FUZEON 119 GENTAK 36 FYAVOLV 178 GENTAMICIN SULFATE 36,38,48,49 FYCOMPA 59 GENTEAL TEARS 180 GENTEAL TEARS SEVERE 181 G GENTLELAX 195 GABAPENTIN 11,59,61,62 GENVOYA 121 GABAPENTIN ENACARBIL 59 GEODON 116 GABITRIL 59 GIANVI 208 GALAFOLD 234 GILENYA 230 GALANTAMINE HBR 140,141 GILOTRIF 102 GALCANEZUMAB-GNLM 93,94 GILTERITINIB FUMARATE 113 GAMASTAN 123 GIMOTI 200 GAMASTAN S-D 124 GLASDEGIB MALEATE 100 GAMMAGARD LIQUID 124 GLATIRAMER ACETATE 230 GAMMAGARD S-D 124 GLATOPA 230 GAMMAKED 124 GLECAPREVIR/PIBRENTASVIR 202 GAMMAPLEX 124 GLEOSTINE 102 GAMUNEX-C 124 GLIMEPIRIDE 73 GANCICLOVIR 37 GLIPIZIDE 73 GARDASIL 9 128 GLIPIZIDE/METFORMIN HCL 73

PAGE 296 LAST UPDATED 07/2021 GLUCAGEN 88 GOLIMUMAB 228,229 GLUCAGON 88 GRALISE 11 GLUCAGON EMERGENCY KIT 88 GRANISETRON 74 GLUCAGON HCL 88 GRANISETRON HCL 74 GLUCO NAVII 166 GRANIX 143 GLUCOCARD EXPRESSION 160,166 GRASTEK 123 GLUCOCARD SHINE 161,167 GRISEOFULVIN ULTRAMICROSIZE 75 GLUCOCARD SHINE XL 161 GRISEOFULVIN, MICROSIZE 75 GLUCOTROL 73 GUAIFENESIN 248,249 GLUCOTROL XL 73 GUAIFENESIN/DEXTROMETHORPHAN GLUTAMINE 199 HBR 246,247,248 GLUTAREX-1 170 GUAIFENESIN/DEXTROMETHORPHAN GLUTAREX-2 170 HBR/PSEUDOEPHEDRINE HCL 247 GLYBURIDE 73 GUAIFENESIN/PHENYLEPHRINE HCL 248 GLYBURIDE,MICRONIZED 73 GUAIFENESIN/PSEUDOEPHEDRINE HCL 248,249 GLYBURIDE/METFORMIN HCL 73 GUANFACINE HCL 151,215 GLYCERIN 192,193,194,195,197 GUSELKUMAB 258 GLYCOLAX 195 GVOKE HYPOPEN 1-PACK 88 GLYCOPYRROLATE 51,52 GVOKE HYPOPEN 2-PACK 88 GLYCOPYRROLATE/FORMOTEROL FUMARATE 51 GVOKE PFS 1-PACK SYRINGE 88 GLYCOPYRROLATE/NEBULIZER ACCESSORIES 52 GVOKE PFS 2-PACK SYRINGE 88 GLYCOPYRROLATE/NEBULIZER AND GYNE-LOTRIMIN-7 78 ACCESSORIES 52 GLYDO 182 H GLYNASE 73 HAEGARDA 224 GLYSET 70 HAEMOPHILUS B CONJUGATE VACCINE GLYTACTIN 15 PE BETTERMILK 170 (MENINGOCOCCAL PROT.CONJ)/PF 129 GLYTACTIN 20PE BETTERMILK LITE 170 HAEMOPHILUS B CONJUGATE VACCINE(TETANUS GLYTACTIN BUILD 20-20 170 TOXOID CONJUGATE)/PF 125,128 GLYTACTIN BURST 10-10 170 HAEMOPHILUS B POLYSACC CONJ-TETANUS GLYTACTIN BURST 20-20 170 TOX,COMPONENT 2 OF 2/PF 129 GLYTACTIN RTD 10 PE 171 HAILEY 208 GLYTACTIN RTD 15 PE 171 HAILEY 24 FE 208 GLYXAMBI 72 HAILEY FE 208 GOCOVRI 114 HALDOL 118 GOJJI BLOOD GLUCOSE TEST STRIP 167 HALDOL DECANOATE 100 119 GOJJI GLUCOSE CONTROL SOLUTION 161 HALDOL DECANOATE 50 119 GOJJI KETONE CONTROL SOLUTION 161 HALOPERIDOL 119 GOJJI LANCET-GLUCOSE TEST STRP 161 HALOPERIDOL DECANOATE 119 GOJJI LANCETS 161 HALOPERIDOL LACTATE 118,119 GOJJI MULTI-FUNCTIONAL METER 161 HARVONI 201

PAGE 297 LAST UPDATED 07/2021 HAVRIX 128 HUMATE-P 84 HCU EXPRESS POWDER 171 HUMATROPE 214 HEALTHPRO GLUCOSE TEST STRIPS 167 HUMIRA 226 HEALTHYLAX 195 HUMIRA PEN 226 HEARTBURN RELIEF 131 HUMIRA PEN CROHN'S-UC-HS 226 HEATHER 208 HUMIRA PEN PSOR-UVEITS-ADOL HS 226 HELIXATE FS 84 HUMIRA(CF) 226 HEMANGEOL 148 HUMIRA(CF) PEDIATRIC CROHN'S 199,226 HEMLIBRA 84 HUMIRA(CF) PEN 226,227 HEMOFIL M 84 HUMIRA(CF) PEN CROHN'S-UC-HS 227 HEP B HUMIRA(CF) PEN PEDIATRIC UC 227 VIRUS,RCMB/DIPTH,PERTUS(ACELL),TET,POLIO HUMIRA(CF) PEN PSOR-UV-ADOL HS 227 VACCINE/PF 129 HUMULIN 70-30 215 HEPARIN SODIUM,PORCINE 56 HUMULIN 70/30 KWIKPEN 215 HEPARIN SODIUM,PORCINE/PF 56 HUMULIN N 216 HEPATITIS A VIRUS AND HEPATITIS B VIRUS HUMULIN N KWIKPEN 216 VACCINE/PF 130 HUMULIN R 219 HEPATITIS A VIRUS VACCINE/PF 128,130 HUMULIN R U-500 219 HEPATITIS B VACCINE RECOMBINANT/VACCINE HUMULIN R U-500 KWIKPEN 219 ADJUVANT CPG 1018/PF 128 HYALURONIDASE, HUMAN RECOMB. 177 HEPATITIS B VIRUS VACCINE HYCAMTIN 102 RECOMBINANT/PF 126,129 HYDRALAZINE HCL 215 HEPLISAV-B 128 HYDROCHLOROTHIAZIDE 168 HEPSERA 136 HYDROCIL INSTANT 196 HETLIOZ 137 HYDROCODONE BITARTRATE 16,23 HETLIOZ LQ 137 HYDROCODONE HIBERIX 128 BITARTRATE/ACETAMINOPHEN 15,17 HOMATROPINE HBR 182 HYDROCODONE/IBUPROFEN 15 HOMINEX-1 171 HYDROCORTISONE 44,45,46,204 HOMINEX-2 171 44,45,46 HORIZANT 59 HYDROCORTISONE ACETATE/LIDOCAINE HUMALOG 217 HCL/ALOE VERA 251 HUMALOG JUNIOR KWIKPEN 217 HYDROCORTISONE ACETATE/PRAMOXINE HCL 45 HUMALOG KWIKPEN U-100 217 46 HUMALOG KWIKPEN U-200 217 HYDROCORTISONE SOD SUCCINATE 204 HUMALOG MIX 50-50 217 HYDROCORTISONE SODIUM SUCCINATE/PF 204 HUMALOG MIX 50-50 KWIKPEN 218 HYDROCORTISONE VALERATE 46 HUMALOG MIX 75-25 218 HYDROCORTISONE/ALOE VERA 46 HUMALOG MIX 75-25 KWIKPEN 218 HYDROCORTISONE/IODOQUINOL 40 HUMAN PAPILLOMAVIRUS VACCINE, 9- HYDROGEN PEROXIDE 182 VALENT/PF 128 HYDROMORPHONE HCL 15,16

PAGE 298 LAST UPDATED 07/2021 HYDROXYCHLOROQUINE SULFATE 115 IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA HYDROXYUREA 100,102,110 GREATER THAN 50 MCG/ML 123,124,125 HYDROXYZINE HCL 137 IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA HYDROXYZINE PAMOATE 138 GREATER THAN 50 MCG/ML 125 HYOSCYAMINE SULFATE 52,53 IMMUNE HYPROMELLOSE 180,181,182 GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0 HYQVIA 125 TO 50 MCG/ML 124 HYQVIA HY COMPONENT 177 IMMUNE GLOBULIN,GAMMA (IGG)/GLYCINE/IGA 0 HYQVIA IG COMPONENT 125 TO 50 MCG/ML 124 HYSINGLA ER 16 IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 HYZAAR 244 TO 50 MCG/ML 123 IMMUNE GLOBULIN,GAMMA(IGG) I HUMAN/HYALURONIDASE, HUMAN RECOMB 125 I-VALEX-1 171 IMMUNE GLOBULIN,GAMMA(IGG)-IFAS I-VALEX-2 171 HUMAN/GLYCINE 125 IBANDRONATE SODIUM 222,223 IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE 123,124 IBRANCE 102,103 IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA IBRUTINIB 104 AVERAGE 46 MCG/ML 124 IBU 238 IMODIUM A-D 191 IBUPROFEN 236,237,238,239,240,241 IMOVAX RABIES VACCINE 128 IBUPROFEN/FAMOTIDINE 237 IMURAN 233 ICAPS 234 INBRIJA 114 ICATIBANT ACETATE 224 INCASSIA 208 ICLEVIA 208 INCRUSE ELLIPTA 52 ICLUSIG 103 INDACATEROL MALEATE 142 ICOSAPENT ETHYL 89,90 INDACATEROL MALEATE/GLYCOPYRROLATE 142 IDELVION 84 INDAPAMIDE 169 IDHIFA 104 INDERAL LA 148 ILARIS 234 INDERAL XL 148 ILOPERIDONE 116 INDOMETHACIN 239 ILOPROST TROMETHAMINE 250 INDOMETHACIN, SUBMICRONIZED 239 ILUMYA 256 INF FORM, GLUTARIC ACIDURIA I 170 IMATINIB MESYLATE 104 INFANRIX DTAP 125 IMBRUVICA 104 INFANT FORM. IRON, LACTOSE IMIPRAMINE HCL 69 FREE/DHA/ARACHIDONIC ACID (ARA) 170 IMIQUIMOD 256 INFANT FORMULA FOR PKU, IRON, NO.2 172 IMITREX 94 INFANT FORMULA WITH IMMUNE IRON,SPEC.METABOLIC,MAPLE SYRUP URINE GLOBULIN,GAMM(IGG)/GLYCINE/GLUCOSE/IGA 0 DX 171 TO 50 MCG/ML 124 INFANT FORMULA WITH IRON/DOCOSAHEXANOIC ACID/ARACHIDONIC AC 172

PAGE 299 LAST UPDATED 07/2021 INFANT FORMULA, SPECIAL METABOLIC WITH INFLUENZA VIRUS VACCINE QUADRIVAL 2019- IRON 173 2020(6 MOS AND UP)/PF 126,127,128 INFANT FORMULA, SPECIAL METABOLIC, IRON, INFLUENZA VIRUS VACCINE QUADRIVAL 2020- METHIONINE-FREE 171 2021(6 MOS AND UP)/PF 127,128 INFANT FORMULA, SPECIAL METABOLIC, INFLUENZA VIRUS VACCINE QUADRIVAL 2020-21 TYROSINEMIA, WITH IRON 173 (6 MOS-35 MOS)/PF 126 INFANT FORMULA, SPECIAL METABOLIC, UREA INFLUENZA VIRUS VACCINE QUADRIVAL 2021- CYCLE DISORDER 170 2022(6 MOS AND UP)/PF 127,128 INFANT FORMULA,SPEC. METABOLIC, PROPIONIC INFLUENZA VIRUS VACCINE QUADRIVAL 2021-22 ACIDEMIA,WITH IRON 173 (6 MOS-35 MOS)/PF 126 INFANT FORMULA,SPEC. METABOLIC,ISOVALERIC INFLUENZA VIRUS VACCINE QUADRIVAL SPLIT ACIDEMIA WITH IRON 171 2020-21(65 YR UP)/PF 127 INFIGRATINIB PHOSPHATE 111 INFLUENZA VIRUS VACCINE QUADRIVAL SPLIT INFLECTRA 227 2021-22(65 YR UP)/PF 127 INFLIXIMAB 228 INFLUENZA VIRUS VACCINE QUADRIVALENT INFLIXIMAB-ABDA 228 2019-20 (36 MOS UP)/PF 126 INFLIXIMAB-AXXQ 225 INFLUENZA VIRUS VACCINE QUADRIVALENT INFLIXIMAB-DYYB 227 2019-20 (6 MOS AND UP) 126,127 INFLUENZA VACCINE QUADRIVALENT 2020-21 (65 INFLUENZA VIRUS VACCINE QUADRIVALENT YR UP)/MF59C.1/PF 126 2020-21 (36 MOS UP)/PF 126 INFLUENZA VACCINE QUADRIVALENT 2021-22 (65 INFLUENZA VIRUS VACCINE QUADRIVALENT YR UP)/MF59C.1/PF 126 2020-21 (6 MOS AND UP) 126 INFLUENZA VACCINE QUADRIVALENT LIVE 2019- INFLUENZA VIRUS VACCINE QUADRIVALENT 2020 (2 YRS-49 YRS) 127 2021-22 (36 MOS UP)/PF 126 INFLUENZA VACCINE QUADRIVALENT LIVE 2020- INFLUENZA VIRUS VACCINE QUADRIVALENT 2021 (2 YRS-49 YRS) 127 2021-22 (6 MOS AND UP) 126 INFLUENZA VACCINE TVS 2019-20 (65 YR INFLUENZA VIRUS VACCINE QV 2019-20(18 YRS UP)/ADJUVANT MF59C.1/PF 126 AND OLDER)RCMB/PF 127 INFLUENZA VACCINE TVS 2020-21 (65 YR INFLUENZA VIRUS VACCINE QV 2020-21(18 YRS UP)/ADJUVANT MF59C.1/PF 126 AND OLDER)RCMB/PF 127 INFLUENZA VIRUS VACC QUAD 2020 SOUTH HEM INFLUENZA VIRUS VACCINE QV 2021-22(18 YRS (6 MOS AND UP) 128 AND OLDER)RCMB/PF 127 INFLUENZA VIRUS VACC QUAD 2020 SOUTH HEM INFLUENZA VIRUS VACCINE TRIVAL SPLIT 2019- (6 MOS AND UP)/PF 128 2020(65 YR UP)/PF 127 INFLUENZA VIRUS VACC QUAD 2021 SOUTH HEM INGENOL MEBUTATE 109 (6 MONTHS AND UP) 128 INGREZZA 153 INFLUENZA VIRUS VACC QUAD 2021 SOUTH HEM INGREZZA INITIATION PACK 153 (6 MOS AND UP)/PF 128 INLYTA 104 INFLUENZA VIRUS VACCINE QUADRIVAL 2019-20 INNOPRAN XL 149 (6 MOS-35 MOS)/PF 126,128 INQOVI 105 INREBIC 105

PAGE 300 LAST UPDATED 07/2021 INSULIN ASPART 218,219 INVOKAMET 72 INSULIN ASPART (NIACINAMIDE) 217 INVOKAMET XR 72 INSULIN ASPART FLEXPEN 218 INVOKANA 72 INSULIN ASPART PENFILL 218 IOPIDINE 181 INSULIN ASPART PROT MIX 70-30 218 IPOL 128 INSULIN ASPART PROTAMINE HUMAN/INSULIN IPRATROPIUM BROMIDE 51,52,181 ASPART 218,219 IPRATROPIUM BROMIDE/ALBUTEROL INSULIN DEGLUDEC 217 SULFATE 51,52 INSULIN DEGLUDEC/LIRAGLUTIDE 217 IRBESARTAN 243,244 INSULIN DETEMIR 216 IRBESARTAN/HYDROCHLOROTHIAZIDE 243,244 INSULIN GLARGINE,HUMAN RECOMBINANT IRESSA 105 ANALOG 216,217 IRON ASP GLY,PS CMPLX/ASCORB CALCIUM/CA- INSULIN GLARGINE,HUMAN RECOMBINANT THR/SUCCINIC ACID 47 ANALOG/LIXISENATIDE 216 IRON POLYSACCHARIDE COMPLEX 48 INSULIN GLULISINE 217 IRON/FOLIC ACID/VITAMIN B COMP AND INSULIN LISPRO 217,218 C/MINERALS 47 INSULIN LISPRO JUNIOR KWIKPEN 218 ISAVUCONAZONIUM SULFATE 76 INSULIN LISPRO KWIKPEN U-100 218 ISENTRESS 120 INSULIN LISPRO PROTAMINE AND INSULIN ISENTRESS HD 120 LISPRO 217,218 ISIBLOOM 208 INSULIN LISPRO PROTAMINE MIX 218 ISONIAZID 96 INSULIN LISPRO-AABC 218 ISOSORBIDE DINITRATE 262 INSULIN NPH HUMAN ISOPHANE 216 ISOSORBIDE MONONITRATE 262 INSULIN NPH HUMAN ISOPHANE/INSULIN ISOTRETINOIN 254,255,256,258 REGULAR, HUMAN 215,216 ISRADIPINE 146 INSULIN REGULAR, HUMAN 217,219 ISTALOL 81 INTELENCE 120 ISTRADEFYLLINE 152 INTERFERON ALFA-2B,RECOMB. 135 ISTURISA 235 INTERFERON ALFA-N3 135 ITRACONAZOLE 76 INTERFERON BETA-1A 229 IVABRADINE HCL 147 INTERFERON BETA-1A/ALBUMIN IVACAFTOR 156 HUMAN 229,231,232 IVERMECTIN 34,41 INTERFERON BETA-1B 229,230 IVOSIDENIB 111 INTERMEZZO 138 IXAZOMIB CITRATE 108 INTRON A 135 IXEKIZUMAB 257 INTROVALE 208 IXIARO 128 INTUNIV 151 IXINITY 84 INVEGA 116 INVEGA SUSTENNA 117 J INVEGA TRINZA 117 JAIMIESS 208 INVIRASE 122 JAKAFI 105

PAGE 301 LAST UPDATED 07/2021 JALYN 222 KETOCONAZOLE 76,78 JANSSEN COVID-19 VACCINE (EUA) 128 KETODAN 78 JANUMET 70 KETONEX-1 171 JANUMET XR 70 KETONEX-2 171 JANUVIA 71 KETOPROFEN 239 JAPANESE ENCEPHALITIS VACCINE/PF 128 KETOROLAC TROMETHAMINE 42,239 JARDIANCE 72 KETOROLAC TROMETHAMINE/PF 42 JASMIEL 208 KETOSTIX REAGENT 262 JENCYCLA 208 KETOTIFEN FUMARATE 179,180 JENTADUETO 71 KEVZARA 227 JENTADUETO XR 71 KINERET 227 JINTELI 178 KINRIX 128 JIVI 84 KIONEX 220 JOLESSA 209 KISQALI 105 JORNAY PM 30 KISQALI FEMARA CO-PACK 105,106 JUBLIA 78 KITABIS PAK 49 JULEBER 209 KLOR-CON M10 175 JULUCA 120 KLOR-CON M15 175 JUNEL 209 KLOR-CON M20 175 JUNEL FE 209 KLOXXADO 153 JUNEL FE 24 209 KOATE 85 JUVEN 171 KOGENATE FS 85 JUXTAPID 89 KOMBIGLYZE XR 71 JYNNEOS (NATIONAL STOCKPILE) 128 KONSYL 196 KOSELUGO 106 K KOVALTRY 85 KADIAN 16,17 KURVELO 209 KALBITOR 224 KALETRA 122 L KALLIGA 209 LABETALOL HCL 149 KALYDECO 156 LAC-HYDRIN FIVE 177 KAPSPARGO SPRINKLE 149 LACOSAMIDE 64 KARIVA 209 LACTAID FAST ACT 199 KAZANO 71 LACTASE 199 KEFLEX 154 LACTOSE-REDUCED FOOD 173 KELNOR 1-35 209 LACTULOSE 169,170 KELNOR 1-50 209 LAMICTAL 60 KENWOOD THERAPEUTIC 265 LAMICTAL (BLUE) 60 KEPPRA 59 LAMICTAL (GREEN) 60 KEPPRA XR 60 LAMICTAL (ORANGE) 60 KESIMPTA PEN 230 LAMICTAL ODT 60

PAGE 302 LAST UPDATED 07/2021 LAMICTAL ODT (BLUE) 60 LEFAMULIN ACETATE 51 LAMICTAL ODT (GREEN) 60 LEFLUNOMIDE 227 LAMICTAL ODT (ORANGE) 60 LEMBOREXANT 137 LAMICTAL XR 60 LEMTRADA 230 LAMICTAL XR (BLUE) 60 LENALIDOMIDE 109 LAMICTAL XR (GREEN) 60 LENVATINIB MESYLATE 106 LAMICTAL XR (ORANGE) 60 LENVIMA 106 LAMISIL 77 LESCOL XL 92 LAMIVUDINE 121 LESSINA 209 LAMIVUDINE/ZIDOVUDINE 121 LETAIRIS 249 LAMOTRIGINE 60,63 LETERMOVIR 134 LAMPIT 115 LETROZOLE 106 LANADELUMAB-FLYO 224 LEUCOVORIN CALCIUM 222 LANAFLEX 171 LEUKERAN 106 LANCETS 157,158,159,161,162,163,164 LEUKINE 143 LANCETS WITH BLOOD GLUCOSE TEST LEVALBUTEROL HCL 142 STRIPS 161,162 LEVALBUTEROL TARTRATE 142,143 LANCING DEVICE 157,159 LEVAQUIN 50 LANCING DEVICE/LANCETS 157,161 LEVEMIR 216 LANOLIN 177 LEVEMIR FLEXTOUCH 216 LANOLIN ALCOHOLS/MINERAL LEVETIRACETAM 59,60,61,62,63 OIL/PETROLATUM,WHITE/CERESIN 177 LEVOBUNOLOL HCL 81 LANSOPRAZOLE 133,134 LEVOCARNITINE 171,235 LANTHANUM CARBONATE 219 LEVOCARNITINE (WITH SUGAR) 235 LANTISEPTIC 177 LEVOCETIRIZINE DIHYDROCHLORIDE 87,88 LANTUS 216 LEVODOPA 114 LANTUS SOLOSTAR 216 LEVOFLOXACIN 36,50 LAPATINIB DITOSYLATE 106 LEVOMEFOLATE CALCIUM 272 LARIN 209 LEVOMILNACIPRAN HCL 67 LARIN 24 FE 209 LEVONEST 209 LARIN FE 209 LEVONORGESTREL 210,211 LARISSIA 209 LEVONORGESTREL/ETHINYL LAROTRECTINIB SULFATE 112 ESTRADIOL 205,206,207,208,209,210,211,212,213 LASMIDITAN SUCCINATE 95 LEVONORGESTREL/ETHINYL ESTRADIOL AND LASTACAFT 179 ETHINYL ESTRADIOL 206,207,208,209,210,212 LATANOPROST 83 LEVORA-28 210 LATANOPROSTENE BUNOD 83 LEVOTHYROXINE SODIUM 261 LATUDA 117 LEXAPRO 68 LAXACLEAR 196 LEXIVA 122 LEDIPASVIR/SOFOSBUVIR 201 LIALDA 189 LEENA 209 LIDOCAINE 251

PAGE 303 LAST UPDATED 07/2021 LIDOCAINE HCL 182 LORATADINE-D 88 LIDOCAINE HCL/HYDROCORTISONE LORATADINE/PSEUDOEPHEDRINE ACETATE 46,251 SULFATE 86,87,88 LIDOCAINE/PRILOCAINE 251 LORAZEPAM 139 LIDODERM 251 LORAZEPAM INTENSOL 139 LILLOW 210 LORBRENA 107 LINACLOTIDE 200 LORCET 17 LINAGLIPTIN 71 LORCET HD 17 LINAGLIPTIN/METFORMIN HCL 71 LORCET PLUS 17 LINDANE 40 LORLATINIB 107 LINEZOLID 51 LORYNA 210 LINZESS 200 LOSARTAN POTASSIUM 243,244 LIOTHYRONINE SODIUM 261 LOSARTAN LIPASE/PROTEASE/AMYLASE 199 POTASSIUM/HYDROCHLOROTHIAZIDE 244 LIPITOR 92 LOTENSIN 245 LIPOFEN 92 LOTENSIN HCT 245 LIRAGLUTIDE 72 LOTEPREDNOL ETABONATE 41 LISDEXAMFETAMINE DIMESYLATE 27,28 LOTREL 146 LISINOPRIL 245 LOVASTATIN 92 LISINOPRIL/HYDROCHLOROTHIAZIDE 245 LOVAZA 89 LITHIUM CARBONATE 150 LOVENOX 56,57 150 LOW-OGESTREL 210 LIVALO 92 LOXAPINE SUCCINATE 115 LIXISENATIDE 71 LUBIPROSTONE 196 LO-ZUMANDIMINE 210 LULICONAZOLE 78 LODOXAMIDE TROMETHAMINE 178 LUMACAFTOR/IVACAFTOR 156 LOJAIMIESS 210 LUMAKRAS 107 LOMITAPIDE MESYLATE 89 LUMATEPERONE TOSYLATE 116 LOMUSTINE 102 LUMIGAN 83 LONAFARNIB 235 LUNESTA 138 LONHALA MAGNAIR REFILL 52 LURASIDONE HCL 117 LONHALA MAGNAIR STARTER 52 LUSPATERCEPT-AAMT 144 LONSURF 106,107 LUTERA 210 LOPERAMIDE HCL 190,191 LUZU 78 LOPHLEX 171 LYLEQ 210 LOPID 92 LYNPARZA 107 LOPINAVIR/RITONAVIR 122 LYRICA 61 LOPRESSOR 149 LYRICA CR 11,12 LOPRESSOR HCT 149 LYUMJEV 218 LOPROX 80 LYUMJEV KWIKPEN U-100 218 LORATADINE 86,87,88 LYUMJEV KWIKPEN U-200 218

PAGE 304 LAST UPDATED 07/2021 LYZA 210 MEMANTINE HCL/DONEPEZIL HCL 152 MENACTRA 128 M MENINGOCOCCAL A DIPHTHERIA-CONJ VACCINE M-M-R II VACCINE 128 COMPONENT 1 OF 2/PF 129 MACITENTAN 249 MENINGOCOCCAL C,Y,W-135,DIP-CONJ VACCINE MAGNESIUM CARBONATE/ALUMINUM COMPONENT 2 OF 2/PF 129 HYDROXIDE 187,188 MENINGOCOCCAL GROUP B VACCINE, 4- MAGNESIUM CITRATE 192,193,194,195,196,197,198 COMPONENT 126 MAGNESIUM GLUCONATE 175 MENINGOCOCCAL VACCINE A,C,Y AND W- MAGNESIUM HYDROXIDE 193,194,195,196,197,198 135,CONJ TETANUS TOXOID/PF 129 MAGNESIUM HYDROXIDE/ALUMINUM MENINGOCOCCALVACCINE A,C,Y,W- HYDROXIDE/SIMETHICONE 187,188,189 135,DIPHTHERIA TOXOID CONJ/PF 128,129 MAGNESIUM OXIDE 188 MENQUADFI 129 MAGOX 400 188 MENTHOL/CAMPHOR 255,256 MALATHION 40 MENVEO A-C-Y-W-135-DIP 129 MARAVIROC 120 MENVEO MENA COMPONENT 129 MARLISSA 210 MENVEO MENCYW-135 COMPONENT 129 MATULANE 107 MEPHYTON 278 MATZIM LA 145 MEPOLIZUMAB 43 MAVENCLAD 233 MERCAPTOPURINE 108 MAVYRET 202 MESALAMINE 189,190 MAXALT 95 MESALAMINE WITH CLEANSING WIPES 189 MAXALT MLT 95 METADATE ER 30 MAYZENT 231 METAPROTERENOL SULFATE 142 MEASLES, MUMPS, AND RUBELLA VACCINE METFORMIN HCL 70 LIVE/PF 128 METHADONE HCL 17 MEASLES, MUMPS, RUBELLA, AND VARICELLA METHADONE INTENSOL 17 VACCINE LIVE/PF 129 METHADOSE 17 MECHLORETHAMINE HCL 111 METHAZOLAMIDE 82 MECLIZINE HCL 75 METHENAMINE//SOD MEDROL 204 PHOS/P.SALICYLATE/HYOSCYAMINE 35 MEDROXYPROGESTERONE ACETATE 214 METHIMAZOLE 261 MEFENAMIC ACID 239 METHOCARBAMOL 250 MEFLOQUINE HCL 115 METHOTREXATE SODIUM 108 MEGACE ES 214 METHOTREXATE SODIUM/PF 108 214,215 METHOTREXATE/PF 109,232 MEKINIST 107 METHSUXIMIDE 66 MEKTOVI 108 METHYLCELLULOSE 192,193,194,195 MELOXICAM 239 METHYLDOPA 215 MELPHALAN 108 METHYLERGONOVINE MALEATE 241 MEMANTINE HCL 151 METHYLIN 30,31

PAGE 305 LAST UPDATED 07/2021 METHYLPHENIDATE 29 MIRAPEX ER 169 METHYLPHENIDATE HCL 28,29,30,31,32,33,34 MIRTAZAPINE 66,67 METHYLPREDNISOLONE 204 MISCELLANEOUS ELECTROLYTE METOCLOPRAMIDE HCL 200 REPLACEMENT/YERBA SANTA 175 METOLAZONE 169 MISOPROSTOL 132 METOPROLOL SUCCINATE 149,150 MOBIC 239 METOPROLOL MODAFINIL 34 SUCCINATE/HYDROCHLOROTHIAZIDE 148 MODERNA COVID-19 VACCINE (EUA) 129 METOPROLOL TARTRATE 149 MOEXIPRIL HCL 245 METOPROLOL MOMETASONE FUROATE 41,42,46,155 TARTRATE/HYDROCHLOROTHIAZIDE 149 MOMETASONE FUROATE/FORMOTEROL METRONIDAZOLE 38,39,115 FUMARATE 155 MEXILETINE HCL 48 MONISTAT 7 79 MICARDIS 244 MONO-LINYAH 210 MICARDIS HCT 244 MONOMETHYL FUMARATE 229 MICONAZOLE 79 MONONINE 85 MICONAZOLE 7 79 MONTELUKAST SODIUM 43 MICONAZOLE NITRATE 77,78,79,80 MORPHABOND ER 17,18 MICONAZOLE NITRATE/ZINC MORPHINE SULFATE 16,17,18,19,20 OXIDE/PETROLATUM,WHITE 79 MORPHINE SULFATE/NALTREXONE HCL 13,14 MICROGESTIN 210 MOUTHKOTE 175 MICROGESTIN FE 210 MOVANTIK 200 MIDAZOLAM 65 MOXEZA 36 MIDODRINE HCL 261 MOXIFLOXACIN HCL 36,37,50 MIDOSTAURIN 110 MS CONTIN 20 MIGALASTAT HCL 234 MSUD AID 171 MIGLITOL 70 MSUD EXPRESS COOLER 171 MIGLUSTAT 235 MSUD EXPRESS15 171 MILI 210 MUCINEX 248 MILNACIPRAN HCL 152,153 MUCUS ER 248 MINERAL OIL 196 MUCUS RELIEF D 248 MINERAL OIL ENEMA 196 MUCUS RELIEF ER 248 MINERAL OIL/ISOPROPYL MYRISTATE/WATER 177 MULTAQ 48 MINERAL OIL/PETROLATUM,HYDROPHILIC 177 MULTILEX 265 MINERAL OIL/PETROLATUM,WHITE 180,181 MULTIVIT 42/IRON CARBONYL,B-G MINITRAN 262 CHE/METHYLTETRAHYDROFOLATE/DHA 266 MINOCYCLINE HCL 50,51 MULTIVIT NO.37/IRON/L-MEFOLATE CALC./ALGAL MINOXIDIL 215 OIL/SOY LECITHIN 266 MIRABEGRON 141 MULTIVIT NO.38/METHYLTETRAHYDFOLATE MIRALAX 196 GLUCOS,FOLIC ACID/GINGER 268 MIRAPEX 169

PAGE 306 LAST UPDATED 07/2021 MULTIVIT NO.41/IRON CYSTEINE MULTIVITAMIN, MINERALS NO.51/FOLIC ACID/VIT GLYCINAT/FOLATE NO.8/PHOSPH-DHA 265 K1/UBIDECARENONE 263 MULTIVIT WITH CALCIUM, IRON, AND OTHER MULTIVITAMIN,STRESS FORMULA 269 MINERALS 271 MULTIVITAMIN,STRESS FORMULA/ZINC 269 MULTIVIT,THERAPEUTIC WITH MULTIVITAMIN,THERAPEUTIC 265,266,270 CALCIUM,IRON,MINERALS/FOLIC ACID 270 MULTIVITAMIN,THERAPEUTIC WITH MINERALS 271 MULTIVIT-MINS NO.73/IRON MULTIVITAMIN-MINERALS NO.60/FERROUS FUMARATE,POLYSACC COMP/FOLIC ACID 269 FUMARATE/FOLIC ACID 266 MULTIVITAMIN 264,265,266,267 MULTIVITAMIN-MINERALS NO.62/FERROUS MULTIVITAMIN COMBINATION NO.43/FERROUS FUMARATE/FOLIC ACID 269 FUMARATE/FOLIC ACID 270 MULTIVITAMIN/FERROUS FUMARATE/FOLIC MULTIVITAMIN COMBINATION NO.47/FERROUS ACID 264,265,269 FUM/FOLATE NO.1/DHA 267,270,271 MULTIVITAMIN/FERROUS SULFATE/FOLIC MULTIVITAMIN COMBINATION NO.51/FERROUS ACID 269 FUMARATE/FOLIC ACID 267,268 MUPIROCIN 37,39 MULTIVITAMIN MUPIROCIN CALCIUM 39 NO.36/METHYLTETRAHYDROFOLATE GLUC,FOLIC MV-MIN 75/FERROUS FUM/IRON PS CPLX/FOLIC ACID 268 AC/OMEGA-3/DHA/EPA 264,269,270 MULTIVITAMIN NO.40/IRON ASPARTO MV-MINS NO.74/FERROUS FUMARATE/IRON PS GLYCINATE/FOLATE NO.1/DHA 268 CPLX/FOLIC ACID 264 MULTIVITAMIN NO.45/IRON FUMARATE/FOLATE MVC-FLUORIDE 266 COMB NO.6/DHA 268 MY WAY 210 MULTIVITAMIN WITH FOLIC ACID 264,269 MYCOPHENOLATE MOFETIL 232,233 MULTIVITAMIN WITH IRON 264,265,266,267 MYCOPHENOLATE SODIUM 233 MULTIVITAMIN WITH IRON AND OTHER MYDAYIS 27 MINERALS 264,269,270 MYFORTIC 233 MULTIVITAMIN WITH MYLERAN 108 MINERALS 264,265,266,267,269 MYORISAN 256 MULTIVITAMIN WITH MINERALS NO.61/FERROUS MYRBETRIQ 141 FUMARATE/FOLIC ACID 266 MYSOLINE 65 MULTIVITAMIN WITH MINERALS NO.69/IRON,CARBONYL/FOLIC ACID 265,266 N MULTIVITAMIN WITH MINERALS NO.7/FOLIC NABILONE 74 ACID 270 NABUMETONE 239 MULTIVITAMIN WITH MINERALS/FERROUS NADOLOL 148,149 GLUCONATE 263 NAFTIFINE HCL 77 MULTIVITAMIN WITH MINERALS/FERROUS NAFTIN 77 SULFATE 265,267 NALDEMEDINE TOSYLATE 200 MULTIVITAMIN WITH MINERALS/FOLIC NALOXEGOL OXALATE 200 ACID/LYCOPENE/LUTEIN 263,264 NALOXONE HCL 153 MULTIVITAMIN WITH MINERALS/LUTEIN 270 NALTREXONE HCL 153

PAGE 307 LAST UPDATED 07/2021 NAMENDA 151 NEOMYCIN/POLYMYXIN B NAMENDA XR 151 SULFATE/DEXAMETHASONE 36 NAMZARIC 152 NEORAL 233 NAPHAZOLINE HCL/PHENIRAMINE MALEATE 183 NEOSPORIN 39 NAPHCON-A 183 NEPAFENAC 42 NAPROXEN 237,239,240 NEPHRONEX-SL 272 NAPROXEN SODIUM 236,237,238,239,240,241 NERATINIB MALEATE 108 NAPROXEN/ESOMEPRAZOLE MAGNESIUM 241 NERLYNX 108 NARATRIPTAN HCL 94,95 NESINA 71 NARCAN 153 NESTABS 266 NASALCROM 44 NESTABS ABC 266 NASONEX 41 NESTABS DHA 266 NATACHEW 266 NESTABS ONE 266 NATALIZUMAB 232 NETARSUDIL MESYLATE 83 NATEGLINIDE 72 NETARSUDIL MESYLATE/LATANOPROST 83 NATESTO 204 NETUPITANT/PALONOSETRON HCL 75 NATROBA 40 NEUAC 39 NATROL 5-HTP 235 NEUPRO 169 NAYZILAM 65 NEURONTIN 61,62 NEBIVOLOL HCL 148 NEVANAC 42 NECON 210 NEVIRAPINE 120 NEDOCROMIL SODIUM 43 NEXAVAR 108 NEEVODHA 266 NEXIUM 133 NEFAZODONE HCL 69 NEXLETOL 89 NEISSERIA MENINGITIDIS GROUP B, LIPIDATED NEXLIZET 89 FHBP RECOMBINANT 130 NIACIN 89,90 NEO-POLYCIN 36 NIACOR 90 NEOCATE INFANT DHA-ARA 172 NIASPAN 90 NEOCATE JUNIOR 172 NICARDIPINE HCL 146 NEOMYCIN SULF/BACITRACIN ZINC/POLYMYXIN B NICOTINE 140 SULF/PRAMOXINE HCL 39 NICOTINE POLACRILEX 140 NEOMYCIN SULFATE 49 NICOTROL 140 NEOMYCIN SULFATE/BACITRACIN NICOTROL NS 140 ZINC/POLYMYXIN B 38,39 NIFEDIPINE 146,147 NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN NIFURTIMOX 115 B 36 NIKKI 210 NEOMYCIN SULFATE/POLYMYXIN B NILOTINIB HCL 111 SULFATE/GRAMICIDIN D 36 NIMODIPINE 146,147 NEOMYCIN SULFATE/POLYMYXIN B NINLARO 108 SULFATE/HYDROCORTISONE 36 NINTEDANIB ESYLATE 246 NIRAPARIB TOSYLATE 113

PAGE 308 LAST UPDATED 07/2021 NISOLDIPINE 146,147 NOVOLOG FLEXPEN 218 NITAZOXANIDE 115 NOVOLOG MIX 70-30 218 NITRO-BID 262 NOVOLOG MIX 70-30 FLEXPEN 218 NITROFURANTOIN 35 NOVOSEVEN RT 85 NITROFURANTOIN MACROCRYSTAL 35 NOXAFIL 76 NITROFURANTOIN NU-IRON 150 48 MONOHYDRATE/MACROCRYSTALS 35 NUBEQA 108 NITROGLYCERIN 262 NUCALA 43 NONOXYNOL 9 236 NUCYNTA ER 20 NORA-BE 210 NUPLAZID 117 NORDITROPIN FLEXPRO 214 NURTEC ODT 94 NORELGESTROMIN/ETHINYL ESTRADIOL 213 NUTRITIONAL THERAPY FOR IMPAIRED NORETHINDRONE 207,208,210,211,212,213 DIGESTIVE FUNCTION 172 NORETHINDRONE ACETATE 215 NUTRITIONAL THERAPY FOR ISOVALERIC NORETHINDRONE ACETATE-ETHINYL ACIDEMIA WITH IRON 171 ESTRADIOL 178,206,208,209,210,211 NUTRITIONAL THERAPY FOR MSUD WITH NORETHINDRONE ACETATE-ETHINYL IRON 171,173 ESTRADIOL/FERROUS NUTRITIONAL THERAPY FOR PHENYLKETONURIA FUMARATE 206,208,209,210,211,212 (PKU) NO.31 172 NORETHINDRONE-ETHINYL NUTRITIONAL THERAPY FOR PHENYLKETONURIA ESTRADIOL 206,207,209,210,211,213 (PKU) NO.54 172 NORGESTIMATE-ETHINYL NUTRITIONAL THERAPY FOR PHENYLKETONURIA ESTRADIOL 208,210,211,212,213 (PKU) NO.67 173 NORGESTREL-ETHINYL ESTRADIOL 207,210,211 NUTRITIONAL THERAPY FOR PHENYLKETONURIA NORLYDA 211 (PKU) NO.8 172 NORPACE CR 48 NUTRITIONAL THERAPY FOR PHENYLKETONURIA NORTREL 211 (PKU) WITH IRON NO.1 172 NORTRIPTYLINE HCL 69,70 NUTRITIONAL THERAPY FOR PHENYLKETONURIA NORVASC 147 (PKU) WITH IRON NO.2 172 NORVIR 122 NUTRITIONAL THERAPY FOR PHENYLKETONURIA NOURIANZ 152 (PKU) WITH IRON NO.6 173 NOVA MAX GLUCOSE TEST STRIPS 167 NUTRITIONAL THERAPY FOR PHENYLKETONURIA NOVAVAX COVID19 VAC,ADJ(UNAPP) 129 (PKU) WITH IRON NO.7 171 NOVOEIGHT 85 NUTRITIONAL THERAPY FOR PHENYLKETONURIA NOVOLIN 70-30 216 WITH IRON, NO.47 173 NOVOLIN 70-30 FLEXPEN 216 NUTRITIONAL THERAPY FOR NOVOLIN N 216 PHENYLKETONURIA(PKU) NO.56 172 NOVOLIN N FLEXPEN 216 NUTRITIONAL THERAPY FOR NOVOLIN R 219 PHENYLKETONURIA(PKU) WITH IRON NO.25 171 NOVOLIN R FLEXPEN 219 NUTRITIONAL THERAPY FOR NOVOLOG 218 PHENYLKETONURIA(PKU) WITH IRON NO.4 172

PAGE 309 LAST UPDATED 07/2021 NUTRITIONAL THERAPY FOR NYVEPRIA 143 PHENYLKETONURIA(PKU) WITH IRON NO.41 170,171 O NUTRITIONAL THERAPY FOR O-CAL FA 266 PHENYLKETONURIA(PKU) WITH IRON NO.42 173 O-CAL PRENATAL 266 NUTRITIONAL THERAPY FOR OB COMPLETE 266 PHENYLKETONURIA(PKU) WITH IRON NO.45 172 OB COMPLETE ONE 266 NUTRITIONAL THERAPY FOR OB COMPLETE PETITE 266 PHENYLKETONURIA(PKU) WITH IRON OB COMPLETE PREMIER 266 NO.52 172,173 OB COMPLETE WITH DHA 266 NUTRITIONAL THERAPY FOR OBIZUR 85 PHENYLKETONURIA(PKU) WITH IRON NO.55 173 OC8 253 NUTRITIONAL THERAPY FOR OCELLA 211 PHENYLKETONURIA(PKU) WITH IRON NO.57 172 OCRELIZUMAB 231 NUTRITIONAL THERAPY FOR OCREVUS 231 PHENYLKETONURIA(PKU) WITH IRON NO.60 173 OCTAGAM 125 NUTRITIONAL THERAPY FOR PKU NO.64 170 OCTREOTIDE ACETATE 258,259 NUTRITIONAL THERAPY FOR TYROSINEMIA WITH OCTREOTIDE ACETATE, MICROSPHERES 259 IRON 173 OCUFLOX 36 NUTRITIONAL THERAPY FOR TYROSINEMIA ODEFSEY 121 WITHOUT IRON 173 ODOMZO 108 NUTRITIONAL THERAPY, GLUTARIC ACIDURIA OFATUMUMAB 230 TYPE 1 170 OFEV 246 NUTRITIONAL THERAPY, METABOLIC DISORDER, OFLOXACIN 36,50 METHIONINE-FREE 171 OGESTREL 211 NUTRITIONAL THERAPY, UREA CYCLE OKEBO 51 DISORDER 170 OLANZAPINE 117,118 NUTRITIONAL THERAPY, UREA CYCLE DISORDER OLANZAPINE PAMOATE 118 WITHOUT IRON 170 OLANZAPINE/FLUOXETINE HCL 68,69 NUTRITIONAL TX FOR PHENYLKETONURIA (PKU) OLAPARIB 107 WITH IRON, COMB #20 172 OLMESARTAN MEDOXOMIL 243,244 NUTROPIN AQ NUSPIN 214 OLMESARTAN MEDOXOMIL/AMLODIPINE NUWIQ 85 BESYLATE/HYDROCHLOROTHIAZIDE 244 NUZYRA 261 OLMESARTAN NYAMYC 80 MEDOXOMIL/HYDROCHLOROTHIAZIDE 243,244 NYLIA 211 OLODATEROL HCL 142 NYMALIZE 147 OLOPATADINE HCL 179 NYMYO 211 OLSALAZINE SODIUM 189 NYSTATIN 76,80 OLUMIANT 227 NYSTATIN/TRIAMCINOLONE ACETONIDE 80 OMADACYCLINE TOSYLATE 261 NYSTOP 80

PAGE 310 LAST UPDATED 07/2021 OMBITASVIR/PARITAPREVIR/RITONAVIR/DASABU ORIAHNN 201 VIR SODIUM 202 ORILISSA 201 OMEGA-3 ACID ETHYL ESTERS 89,90 ORKAMBI 156 OMEGA-3 FATTY ACIDS/FISH OIL 89 ORLADEYO 224 OMEPRAZOLE 133 ORSYTHIA 211 OMEPRAZOLE MAGNESIUM 134 OSELTAMIVIR PHOSPHATE 135 OMEPRAZOLE MAGNESIUM/AMOXICILLIN OSENI 71 TRIHYDRATE/RIFABUTIN 130 OSILODROSTAT PHOSPHATE 235 OMEPRAZOLE/SODIUM BICARBONATE 132,133,134 OSIMERTINIB MESYLATE 110 OMNARIS 41 OTEZLA 228 OMNITROPE 214 OTIPRIO 36 ONDANSETRON 74 OTOVEL 36 ONDANSETRON HCL 74 OVIDE 40 ONE DAILY COMPLETE 267 OXAPROZIN 240 ONE DAILY MULTIVITAMIN-MINERAL 267 OXBRYTA 143 ONE DAILY PLUS MINERALS 267 OXCARBAZEPINE 62,63 ONETOUCH DELICA 161 OXERVATE 181 ONETOUCH ULTRA TEST STRIP 167 OXICONAZOLE NITRATE 79 ONETOUCH ULTRA2 161 OXISTAT 79 ONETOUCH ULTRAMINI 161 OXTELLAR XR 62 ONETOUCH VERIO FLEX METER 161 OXYBUTYNIN 200 ONETOUCH VERIO FLEX STARTR KIT 161 OXYBUTYNIN CHLORIDE 200 ONETOUCH VERIO IQ METER 162 OXYCODONE HCL 20,21,22 ONETOUCH VERIO IQ SYSTEM KIT 162 OXYCODONE HCL/ACETAMINOPHEN 14,21 ONETOUCH VERIO METER 162 OXYCODONE HCL/ASPIRIN 21 ONETOUCH VERIO REFLECT KIT 162 OXYCODONE MYRISTATE 23 ONETOUCH VERIO REFLECT METER 162 OXYCONTIN 21,22 ONETOUCH VERIO TEST STRIP 167 HCL 183 ONEXTON 39 OXYMORPHONE HCL 22 ONFI 65 OXYTROL 200 ONGLYZA 71 OZANIMOD HYDROCHLORIDE 232 ONMEL 76 OZEMPIC 71 ONUREG 109 ONZETRA XSAIL 95 P OPSUMIT 249 PACERONE 48 ORALONE 46 PAIN RELIEF 11 ORAVIG 79 PALBOCICLIB 102,103 ORENCIA 227,228 PALFORZIA 123 ORENCIA CLICKJECT 228 PALIPERIDONE 116,117 ORENITRAM ER 249 PALIPERIDONE PALMITATE 117 ORGOVYX 201 PANCREAZE 199

PAGE 311 LAST UPDATED 07/2021 PANTOPRAZOLE SODIUM 133,134 PEDIATRIC MULTIVITAMIN NO.40/PHYTONADIONE PANZYGA 125 (VIT K1) 263 PAREGORIC 191 PEDIATRIC MULTIVITAMIN NO.45/SODIUM PAROEX 37 FLUORIDE/FERROUS SULFATE 265 PAROXETINE HCL 68,69 PEDIATRIC MULTIVITAMIN NO.83 WITH SODIUM PAROXETINE MESYLATE 68,69 FLUORIDE 269 PASIREOTIDE DIASPARTATE 259 PEDIATRIC MULTIVITAMIN NO.84 WITH SODIUM PATADAY 179 FLUORIDE 269 PATANASE 179 PEDIATRIC MULTIVITAMIN NO.85 WITH SODIUM PATANOL 179 FLUORIDE 265 PAXIL 68 PEDVAXHIB 129 PAXIL CR 69 PEG 3350/SOD SULF/SOD BICARB/SOD PAZEO 179 CHLORIDE/POTASSIUM CHLORIDE 194,197 PAZOPANIB HCL 112 PEGANONE 66 PEANUT ALLERGEN POWDER-DNFP 123 PEGASYS 135 PEDIA-LAX 197 PEGASYS PROCLICK 135 PEDIALYTE 175 PEGFILGRASTIM-APGF 143 PEDIARIX 129 PEGFILGRASTIM-BMEZ 144 PEDIATRIC MULTIVIT NO.37/SODIUM PEGFILGRASTIM-CBQV 144 FLUORIDE/IRON BISGLYCIN.HCL 267 PEGFILGRASTIM-JMDB 143 PEDIATRIC MULTIVIT WITH A,C,D3 NO.21/SODIUM PEGINTERFERON ALFA-2A 135 FLUORIDE 270,271 PEGINTERFERON ALFA-2B 135 PEDIATRIC MULTIVITAMIN A,C,AND D3 NO.38 PEGINTERFERON BETA-1A 231 WITH SODIUM FLUORIDE 270 PEGINTRON 135 PEDIATRIC MULTIVITAMIN NO.12 WITH SODIUM PEMAZYRE 109 FLUORIDE 266 PEMIGATINIB 109 PEDIATRIC MULTIVITAMIN NO.144 264 PENCICLOVIR 39 PEDIATRIC MULTIVITAMIN NO.158/FERROUS PENICILLAMINE 202,203 FUMARATE/PHYTONADIONE 264 PENICILLIN V POTASSIUM 242 PEDIATRIC MULTIVITAMIN NO.16/SODIUM PENLAC 80 FLUORIDE 265 PENTACEL 129 PEDIATRIC MULTIVITAMIN NO.17 264 PENTACEL ACTHIB COMPONENT 129 PEDIATRIC MULTIVITAMIN NO.171 267 PENTACEL DTAP-IPV COMPONENT 129 PEDIATRIC MULTIVITAMIN NO.2/SODIUM PENTASA 189 FLUORIDE 265 PENTOSAN POLYSULFATE SODIUM 235 PEDIATRIC MULTIVITAMIN NO.33 WITH SODIUM PENTOXIFYLLINE 144 FLUORIDE 267 PEPCID AC 131 PEDIATRIC MULTIVITAMIN NO.33/SODIUM PERAMPANEL 59 FLUORIDE/IRON CARBONYL 267 PERFOROMIST 142 PEDIATRIC MULTIVITAMIN NO.37 WITH SODIUM PERIFLEX ADVANCE 172 FLUORIDE 267 PERIFLEX LQ PKU 172

PAGE 312 LAST UPDATED 07/2021 PERINDOPRIL ARGININE/AMLODIPINE PIOGLITAZONE HCL/METFORMIN HCL 74 BESYLATE 245 PIP LANCET 162 PERINDOPRIL ERBUMINE 245 PIPERONYL BUTOXIDE/ 40 PERIOGARD 37 PIPERONYL PERMETHRIN 40 BUTOXIDE/PYRETHRINS/PERMETHRIN 40 PERPHENAZINE 119 PIRFENIDONE 246 PERSERIS 117 PIRMELLA 211 PERTZYE 199 PIROXICAM 240 PETROLATUM,WHITE 177 PITAVASTATIN CALCIUM 92 PEXEVA 69 PITAVASTATIN MAGNESIUM 93 PEXIDARTINIB HYDROCHLORIDE 111 PITOLISANT HCL 34 PFIZER COVID-19 VACCINE (EUA) 129 PKU COOLER 10 172 PHENADOZ 185 PKU COOLER 15 172 PHENAZOPYRIDINE HCL 251 PKU COOLER 20 172 PHENELZINE SULFATE 67 PKU EASY 172 PHENEX-1 172 PKU EXPLORE10 172 PHENEX-2 172 PKU EXPRESS15 172 PHENOBARBITAL 138 PKU EXPRESS20 173 PHENOXYBENZAMINE HCL 9 PKU GEL 173 PHENYL-FREE 2 172 PKU GO 173 PHENYL-FREE 2HP 172 PKU LOPHLEX 173 PHENYLADE 172 PKU PERIFLEX JUNIOR PLUS 173 PHENYLADE GMP 172 PKU SPHERE15 173 PHENYLEPHRINE HCL 183 PKU SPHERE20 173 PHENYLEPHRINE HCL/PROMETHAZINE HCL 186 PLAN B ONE-STEP 211 PHENYTEK 66 PLAVIX 122 PHENYTOIN 66 PLEGRIDY 231 PHENYTOIN SODIUM EXTENDED 66 PLEGRIDY PEN 231 PHILITH 211 PNEUMOCOCCAL 13-VALENT CONJUGATE PHLEXY-10 172 VACCINE (DIPHTHERIA CRM)/PF 129 PHOSLYRA 219 PNEUMOCOCCAL 20-VALENT CONJUGATE PHYTONADIONE (VIT K1) 278 VACCINE (DIPHTHERIA CRM)/PF 129 PICATO 109 PNEUMOCOCCAL 23-VALENT POLYSACCHARIDE PILOCARPINE HCL 82,140 VACCINE 129 PIMAVANSERIN TARTRATE 117 PNEUMOVAX 23 129 PIMECROLIMUS 256 PNV NO.72/FERROUS FUMARATE/FOLIC PIMOZIDE 115 ACID/OMEGA-3/DHA 268 PIMTREA 211 PODOFILOX 256 PINDOLOL 149 POGO AUTOMATIC BLOOD GLUC SYS 162 PIOGLITAZONE HCL 74 POGO AUTOMATIC TEST CARTRIDGE 162 PIOGLITAZONE HCL/GLIMEPIRIDE 74 POLIOMYELITIS VACCINE, KILLED 128

PAGE 313 LAST UPDATED 07/2021 POLY-VI-FLOR 267 PRENATAL VIT NO.112/IRON PHOSPH/FOLIC POLY-VI-FLOR WITH IRON 267 ACID/OMEGA-3S/DHA/EPA 270 POLYCIN 36 PRENATAL VIT NO.30/IRON CARBONYL,ASP POLYETHYLENE GLYCOL GLYC/FOLIC ACID/OMEGA-3 266 3350 192,193,194,195,196,197,198 PRENATAL VIT NO.67/IRON POLYMYXIN B SULFATE/TRIMETHOPRIM 36 POLYSACCHARIDES/FOLATE COMB.NO.1/DHA 270 POLYVINYL ALCOHOL 181 PRENATAL VIT NO.71/IRON FUM-SODIUM POLYVINYL ALCOHOL/POVIDONE/PF 181 FEREDETATE/FOLIC ACID/DHA 271 POMALIDOMIDE 109 PRENATAL VIT NO.85/IRON CARB,ASP.GLY/FOLIC POMALYST 109 ACID/DHA/FISH OIL 266 PONATINIB HCL 103 PRENATAL VIT WITH CALCIUM NO.127/FERROUS PORTIA 211 FUMARATE/FOLIC ACID 266 POSACONAZOLE 76 PRENATAL VIT WITH CALCIUM NO.130/FERROUS POTASSIUM CHLORIDE 175,176 FUMARATE/FOLIC ACID 268 POTASSIUM CITRATE 169 PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS POVIDONE-IODINE 40 FUMARATE/FOLIC ACID 270 POWDERLAX 197 PRENATAL VITAMIN COMB NO.86/IRON PS PRADAXA 55 CMPLX/FOLIC ACID/DHA/EPA 266 PRALSETINIB 102 PRENATAL VITAMIN PRALUENT PEN 93 NO.48/IRON,CARBONYL,GLUCONATE/FOLIC PRAMIPEXOLE DI-HCL 169 ACID/B6 264 PRAMLINTIDE ACETATE 70 PRENATAL VITAMIN NO.52/IRON/FOLIC PRASUGREL HCL 122 ACID/OMEGA-3/DHA 264,270 PRAVACHOL 92 PRENATAL VITAMIN NO.55/IRON PRAVASTATIN SODIUM 92 FUMARATE,BISGLYCINATE/FOLIC ACID 266 PRAZIQUANTEL 34 PRENATAL VITAMIN NO.86/IRON BIS- PRAZOSIN HCL 148 GLYCINATE/FOLIC ACID 266 PRECISION XTRA 162,167 PRENATAL VITAMIN WITH CALCIUM PRECISION XTRA KETONE-GLUCOSE 162 NO.76/IRON,CARBONYL/FOLIC ACID 267,268 PRECOSE 70 PRENATAL VITAMINS COMBINATION NO.42/FOLIC PREDNISOLONE 204 ACID 271 41 PRENATAL VITAMINS NO.14/FERROUS PREDNISOLONE SODIUM PHOSPHATE 41,204 FUMARATE/FOLIC ACID 264 PREDNISONE 204 PRENATAL VITAMINS NO.147/FERROUS PREDNISONE INTENSOL 204 GLUCONATE/FOLIC ACID 263,271 PREGABALIN 11,12,61,62 PRENATAL VITAMINS NO.33/IRON POLYSACH PRENATA 268 COMPLEX/FOLIC ACID/DHA 269 PRENATABS FA 268 PRENATAL VITAMINS NO.36/FERROUS PRENATABS RX 268 FUMARATE/FOLATE COMB. NO.6 268 PRENATAL NO56/IRON CARBONYL,ASPARTO PRENATAL VITAMINS NO.37/FERROUS GLYCINATE/FOLIC ACID/DHA 266 FUMARATE/FOLIC ACID 268

PAGE 314 LAST UPDATED 07/2021 PRENATAL VITAMINS NO.68/IRON PRENATAL VITS WITH CALCIUM 137/FERROUS FUMARATE/FOLATE NO.6/DHA 268 FUMARATE/FOLIC ACID 268 PRENATAL VITAMINS NO.69/IRON PRENATAL VITS WITH CALCIUM 95/FERROUS FUMARATE/FOLATE COMB NO.6/DHA 268 FUMARATE/FOLIC ACID 265,268,269 PRENATAL VITAMINS NO.77/FERROUS ASPARTO PRENATAL VITS WITH CALCIUM NO.10/FERROUS GLYCINATE/FOLIC ACID 269 FUMARATE/FOLIC ACID 270 PRENATAL VITAMINS NO.83/IRON PRENATAL VITS WITH CALCIUM NO.72/FERROUS FUMARATE/FOLATE COMBO NO.6/DHA 263 FUMARATE/FOLIC ACID 265,267,268,269 PRENATAL VITAMINS NO.85/IRON ASPARTO PRENATAL VITS WITH CALCIUM GLYCIN/FOLATE NO.1/DHA 268 NO.72/IRON,CARBONYL/FOLIC ACID 268 PRENATAL VITAMINS NO.90/IRON FUM,POLYSAC PRENATAL VITS WITH CALCIUM NO.73/FERROUS COMP/FOLIC ACID/DHA 269 FUMARATE/FOLIC ACID 270 PRENATAL VITAMINS NO.93/IRON PRENATAL VITS WITH CALCIUM NO.74/FERROUS CARBONYL/FOLATE COMB NO.9/DHA 270 FUMARATE/FOLIC ACID 268 PRENATAL VITAMINS WITH CALCIUM/FERROUS PRENATAL VITS WITH CALCIUM NO.78/FERROUS FUMARATE/FOLIC ACID 266 FUMARATE/FOLIC ACID 268,269 PRENATAL VITS 106/SOD FEREDETATE-IRON PRENATAL VITS WITH CALCIUM NO.87/IRON PS/FOLIC ACID/OMEGA-3S 264 BISGLY/FOLIC ACID/DHA 266 PRENATAL VITS NO.105/IRON AMINO ACID PRENATE AM 268 CHELATE/FOLIC ACID/DHA 268,271 PRENATE CHEWABLE 268 PRENATAL VITS NO.117/SOD FEREDET.-IRON PRENATE DHA 268 PS/FOLIC/OM3/DHA/EPA 265 PRENATE ELITE 268 PRENATAL VITS NO.118/IRON ASPARTO PRENATE ENHANCE 268 GLYCINATE/FOLATE NO.6/DHA 269 PRENATE ESSENTIAL 268 PRENATAL VITS NO.25/FERROUS PRENATE MINI 268 FUMARATE/FOLATE COMB. NO.6/DHA 270 PRENATE PIXIE 268 PRENATAL VITS NO.26/IRON POLYSACCHARIDE PRENATE RESTORE 268 CPLEX/FOLIC ACID/DHA 270 PRENATE STAR 269 PRENATAL VITS NO.65/IRON PRESERVISION AREDS 2 235 FUMARATE,POLYSAC COMPLEX/FOLIC ACID 269 PRESERVISION LUTEIN 235 PRENATAL VITS NO.83/IRON,CARBONYL,IRON PRESTALIA 245 ASPART.GLY/FOLIC ACID 266 PRETOMANID 96 PRENATAL VITS NO.87/IRON CARB- PREVACID 134 ASP.GLYCINATE/FOLATE NO.1/DHA 268 PREVALITE 90 PRENATAL VITS WITH CALCIUM 103/FERROUS PREVIFEM 211 FUMARATE/FOLIC ACID 270 PREVNAR 13 129 PRENATAL VITS WITH CALCIUM 118/FERROUS PREVNAR 20 129 FUMARATE/FOLIC ACID 268,269 PREVYMIS 134 PRENATAL VITS WITH CALCIUM 136/FERROUS PREZCOBIX 122 FUMARATE/FOLIC ACID 270 PREZISTA 122 PRIFTIN 97

PAGE 315 LAST UPDATED 07/2021 PRILOSEC 134 PROPRANOLOL HCL 148,149 PRIMACARE 269 PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE 149 PRIMIDONE 65 PROPYLENE GLYCOL/POLYETHYLENE GLYCOL PRINIVIL 245 400 180,181 PRISTIQ 67 PROPYLTHIOURACIL 261 PRO-PHREE 173 PROQUAD 129 PRO-RED AC 247 PROSCAR 222 PROAIR DIGIHALER 142 PROTONIX 134 PROAIR HFA 142 PROTOPIC 256 PROAIR RESPICLICK 142 PROVENTIL HFA 142 PROBENECID 176 PROVIDA DHA 269 PROBENECID/COLCHICINE 176 PROVIDA OB 269 PROBUPHINE 24 PROZAC 69 PROCARBAZINE HCL 107 PSEUDOEPHEDRINE HCL 260 PROCARDIA 147 PSEUDOEPHEDRINE HCL/ACRIVASTINE 88 PROCARDIA XL 147 PSYLLIUM HUSK 194,195,196 PROCENTRA 27 PSYLLIUM HUSK (WITH SUGAR) 195,196,198 PROCHLORPERAZINE 75 PSYLLIUM SEED 194,196,197 PROCHLORPERAZINE MALEATE 75 PSYLLIUM SEED (WITH SUGAR) 196 PROCRIT 143 PSYLLIUM SEED/ASPARTAME 194,195 PROCTO-MED HC 46 PULMICORT 156 PROCTOSOL-HC 46 PULMICORT FLEXHALER 156 PROCTOZONE-HC 46 PULMOZYME 249 PRODIGY 162 PURE COMFORT LANCETS 163 PRODIGY AUTOCODE 162 PURE COMFORT SAFETY LANCETS 163 PRODIGY NO CODING 167 PUREFE OB PLUS 269 PRODIGY POCKET 163 PUREFE PLUS 269 PRODIGY VOICE 163 PYRANTEL PAMOATE 34,35 PROFILNINE 85 PYRAZINAMIDE 97 PROGESTERONE, MICRONIZED 215 PYRIDOSTIGMINE BROMIDE 140,141 PROGRAF 233 PYRIDOXINE HCL (VITAMIN B6) 273 PROLENSA 43 PROLIA 223 Q PROMACTA 143,144 QBRELIS 245 PROMETHAZINE HCL 185,186 QINLOCK 109 PROMETHAZINE HCL/DEXTROMETHORPHAN QNASL 41 HBR 247 QNASL CHILDREN 42 PROMETHEGAN 186 QTERN 72 PROPAFENONE HCL 48 QUADRACEL DTAP-IPV 129 PROPANTHELINE BROMIDE 52 QUDEXY XR 62 PROPIMEX-1 173 QUESTRAN 90

PAGE 316 LAST UPDATED 07/2021 QUESTRAN LIGHT 90 REFRESH OPTIVE SENSITIVE 181 QUETIAPINE FUMARATE 117,118 REFRESH P.M. 181 QUFLORA 269 REFRESH PLUS 182 QUILLICHEW ER 33 REFRESH RELIEVA 182 QUILLIVANT XR 34 REGORAFENIB 110 QUINAPRIL HCL 244,245 RELENZA 135 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE 244,245 RELPAX 95 QUINIDINE SULFATE 48 RELUGOLIX 201 QUTENZA 256 REMERON 67 QVAR REDIHALER 156 REMICADE 228 RENAGEL 219 R RENFLEXIS 228 RABAVERT 129 RENVELA 219 RABEPRAZOLE SODIUM 132,134 REPAGLINIDE 72 RABIES VACCINE, HUMAN DIPLOID CELL/PF 128 REPATHA PUSHTRONEX 93 RABIES VACCINE, PURIFIED CHICKEN EMBRYO REPATHA SURECLICK 93 CELL (PCEC)/PF 129 REPATHA SYRINGE 93 RAGWITEK 123 REQUIP XL 169 RALOXIFENE HCL 178 RESTASIS 42 RALTEGRAVIR POTASSIUM 120 RESTASIS MULTIDOSE 42 RAMELTEON 138 RETACRIT 144 RAMIPRIL 244,245 RETEVMO 109 RANITIDINE HCL 130,131,132 RETIN-A 252 RAPAFLO 9 RETIN-A MICRO 252 RAPAMUNE 233 RETIN-A MICRO PUMP 252 RASAGILINE MESYLATE 114 REVATIO 263 RASUVO 109 REVEFENACIN 53 RAZADYNE 141 REVLIMID 109 RAZADYNE ER 141 REXULTI 117 REBIF 231,232 REYATAZ 122 REBIF REBIDOSE 231 REYVOW 95 REBINYN 85 RHOPRESSA 83 REBLOZYL 144 RIAX 253 RECLIPSEN 211 RIBASPHERE 136 RECOMBINATE 85 RIBASPHERE RIBAPAK 136 RECOMBIVAX HB 129 RIBAVIRIN 136 REDITREX 232 RIBOCICLIB SUCCINATE 105 REFRESH CELLUVISC 181 RIBOCICLIB SUCCINATE/LETROZOLE 105,106 REFRESH CLASSIC 181 RIBOFLAVIN (VITAMIN B2) 272,273 REFRESH LIQUIGEL 181 RIDAURA 201 REFRESH OPTIVE 181 RIFABUTIN 97

PAGE 317 LAST UPDATED 07/2021 RIFAMPIN 97 ROSIGLITAZONE MALEATE 74 RIFAPENTINE 97 ROSUVASTATIN CALCIUM 92 RIFAXIMIN 51 ROTARIX 129 RIGHTEST GC700 LEV 2 CTRL SOLN 163 ROTATEQ 130 RIGHTEST GM700SB GLUCOSE METER 163 ROTAVIRUS VACCINE, LIVE ORAL RIGHTEST GS700 TEST STRIP 167 ATTENUATED,89-12 STRAIN, G1P(8) 129 RIGHTEST GT333 GLUCOSE METER 163 ROTAVIRUS VACCINE, LIVE ORAL RIGHTEST GT333 LEV 2 CTRL SOLN 163 PENTAVALENT 130 RIGHTEST GT333 TEST STRIP 167 ROTIGOTINE 169 RIGHTEST MAX PLUS GLUCOSE MTR 163 ROWASA 189 RIGHTEST MAX TEST STRIP 167 ROWEEPRA 62 RILONACEPT 234 ROWEEPRA XR 62 RILPIVIRINE HCL 120 ROZEREM 138 RILUZOLE 152 ROZLYTREK 109 RIMANTADINE HCL 134 RUCONEST 224 RIMEGEPANT SULFATE 94 RUFINAMIDE 57,62,63 RINVOQ 228 RUKOBIA 119 RIOCIGUAT 249 RUXOLITINIB PHOSPHATE 105 RIPRETINIB 109 RUZURGI 235 RISANKIZUMAB-RZAA 257 RYBELSUS 72 RISDIPLAM 234 RYDAPT 110 RISEDRONATE SODIUM 222,223 RYTARY 114 RISPERDAL 117 RISPERDAL CONSTA 117 S RISPERIDONE 117 SABRIL 63 RISPERIDONE MICROSPHERES 117 SACROSIDASE 177 RITALIN 34 SACUBITRIL/VALSARTAN 243 RITALIN LA 34 SAFINAMIDE MESYLATE 114 RITONAVIR 122 SAIZEN 214 RIVAROXABAN 55 SAIZEN-SAIZENPREP 214 RIVASTIGMINE 140,141 SALICYLIC ACID 253,254 RIVASTIGMINE TARTRATE 141 SALICYLIC ACID/SULFUR 253 RIXUBIS 85 SALIVA STIMULANT COMBINATION NO.3 157 RIZATRIPTAN BENZOATE 95 SALMETEROL XINAFOATE 142 ROBITUSSIN ER 247 SALSALATE 241 ROCKLATAN 83 SANCUSO 74 ROFLUMILAST 249 SANDIMMUNE 233 ROPINIROLE HCL 169 SANDOSTATIN LAR DEPOT 259 ROPIVACAINE HCL IN SODIUM CHLORIDE, ISO- SAPHRIS 117 OSMOTIC/PF 220 SAPROPTERIN DIHYDROCHLORIDE 235 ROSADAN 39 SAQUINAVIR MESYLATE 122

PAGE 318 LAST UPDATED 07/2021 SARAFEM 69 SFROWASA 190 SARGRAMOSTIM 143 SHAROBEL 212 SARILUMAB 227 SHINGRIX 130 SARNA ORIGINAL 256 SHINGRIX ADJUVANT COMPONENT 243 SATRALIZUMAB-MWGE 230 SHINGRIX GE ANTIGEN COMPONENT 130 SAVAYSA 55 SIGNIFOR 259 SAVELLA 152,153 SIKLOS 110 SAXAGLIPTIN HCL 71 SILDENAFIL CITRATE 263 SAXAGLIPTIN HCL/METFORMIN HCL 71 SILIQ 256 SCOPOLAMINE 74 SILODOSIN 9 SECUADO 117 SILVER SULFADIAZINE 40 SECUKINUMAB 255 SIMBRINZA 82 SEEBRI NEOHALER 52 SIMETHICONE 192 /ETHINYL SIMLIYA 212 ESTRADIOL 206 SIMPESSE 212 SEGLUROMET 72 SIMPONI 228,229 SELECT-OB + DHA 269 SIMPONI ARIA 229 SELEGILINE HCL 114 SIMVASTATIN 92,93 SELENIUM SULFIDE 40 SINEMET 10-100 114 SELEXIPAG 250 SINEMET 25-100 114 SELINEXOR 113 SINEMET 25-250 114 SELPERCATINIB 109 SINEMET CR 114 SELUMETINIB SULFATE/VITAMIN E TPGS 106 SINGULAIR 43 SELZENTRY 120 SINUS 12 HOUR 260 SEMAGLUTIDE 71,72 SINUVA 42 SEMGLEE 216 SIPONIMOD 231 SEMGLEE PEN 216 SIROLIMUS 233 SEMPREX-D 88 SIRTURO 97 SENNOSIDES 193,194,195,196,197,198,199 SITAGLIPTIN PHOSPHATE 71 SENNOSIDES/DOCUSATE SITAGLIPTIN PHOSPHATE/METFORMIN HCL 70 SODIUM 193,194,195,197,198,199 SITAVIG 136 SENOKOT 198 SIVEXTRO 51 SEREVENT DISKUS 142 SKLICE 41 SEROQUEL 117 SKYRIZI 257 SEROQUEL XR 117,118 SKYRIZI (2 SYRINGES) KIT 257 SEROSTIM 214 SKYRIZI PEN 257 SERTRALINE HCL 69 SLEEP AID 184,185 SETLAKIN 211 SLO-NIACIN 90 SEVELAMER CARBONATE 219,220 SMALLPOX AND MONKEYPOX VACCINE, LIVE, SEVELAMER HCL 219,220 NONREPLICATING/PF 128 SEVENFACT 85 SMALLPOX VACCINE,LIVE 125

PAGE 319 LAST UPDATED 07/2021 SODIUM BICARBONATE 189 SOVALDI 202 SODIUM CHLORIDE 176,180,181,182,235 SPINOSAD 40,41 SODIUM CHLORIDE/POTASSIUM CHLORIDE 176 SPIRIVA 52 SODIUM CHLORIDE/SODIUM SPIRIVA RESPIMAT 52 BICARBONATE/POTASSIUM SPIRONOLACTONE 246 CHLORIDE/PEG 194,197,199 SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 246 SODIUM FLUORIDE/CHOLECALCIFEROL (VITAMIN SPORANOX 76 D3) 223 SPRINTEC 212 SODIUM OXYBATE 152 SPRITAM 63 SODIUM OXYBATE/CALCIUM SPRYCEL 110 OXYBATE/MAGNESIUM OXYBATE/POT SPS 220 OXYBATE 152 SRONYX 212 SODIUM PHENYLBUTYRATE 170 SSD 40 SODIUM PHOSPHATE,MONOBASIC/SODIUM STAMARIL 130 PHOSPHATE,DIBASIC 197 STEGLATRO 72 SODIUM PHOSPHATE/POTASSIUM , STEGLUJAN 72 MONOBASIC AND BIBASIC 175,176 STELARA 257 SODIUM POLYSTYRENE SULFONATE 220 STIMATE 214 SODIUM POLYSTYRENE SULFONATE/SORBITOL STIOLTO RESPIMAT 52 SOLUTION 220 STIRIPENTOL 58 SODIUM SULFATE/POTASSIUM STIVARGA 110 SULFATE/MAGNESIUM SULFATE 198 STOOL SOFTENER 198 SOFOSBUVIR 202 STRATTERA 152 SOFOSBUVIR/VELPATASVIR 201,202 STRENSIQ 177 SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR 202 STRESS FORMULA 269 SOFT TOUCH 163 STRESS FORMULA WITH ZINC 269 SOLIFENACIN SUCCINATE 200,201 STRIANT 205 SOLIQUA 100-33 216 STRIBILD 121 SOLRIAMFETOL HCL 34 STRIVERDI RESPIMAT 142 SOLTAMOX 178 SUBCUTANEOUS INSULIN PUMP 163 SOLU-CORTEF 204 SUBLOCADE 24 SOMATROPIN 214 SUBOXONE 25 SONIDEGIB PHOSPHATE 108 SUBVENITE 63 SORAFENIB TOSYLATE 108 SUBVENITE (BLUE) 63 SORBITOL 198 SUBVENITE (GREEN) 63 SORBITOL SOLUTION 198 SUBVENITE (ORANGE) 63 SORINE 149 SUCCIMER 202 SOTALOL AF 150 SUCRAID 177 SOTALOL HCL 148,149,150 SUCRALFATE 132 SOTORASIB 107 SUCROFERRIC OXYHYDROXIDE 220 SOTYLIZE 150 SUDAFED 12 HOUR 260

PAGE 320 LAST UPDATED 07/2021 SUDOGEST 260 SYRINGE WITH NEEDLE,INSULIN,0.3 ML 156 SULAR 147 SYRINGE WITH NEEDLE,INSULIN,0.5 ML 156 SULCONAZOLE NITRATE 78 SYSTANE GEL 182 SULFACETAMIDE SODIUM 35,36,40 SULFACETAMIDE SODIUM/PREDNISOLONE T ACETATE 35 T:SLIM X2 WITH BASAL-IQ 163 SULFACETAMIDE SODIUM/PREDNISOLONE TAB-A-VITE MULTIVIT WITH IRON 269 SODIUM PHOSPHATE 36 TABLOID 110 SULFACETAMIDE SODIUM/SULFUR 253,254 TABRECTA 110 SULFACETAMIDE SODIUM/SULFUR/SKIN TACROLIMUS 232,233,234,256,257 CLEANSER COMB NO.23 40 TADALAFIL 263 SULFACETAMIDE SODIUM/SULFUR/UREA 40 TAFAMIDIS 147 SULFAMETHOXAZOLE/TRIMETHOPRIM 50 TAFAMIDIS MEGLUMINE 147 SULFASALAZINE 50 TAFINLAR 110 SULFATRIM 50 TAFLUPROST/PF 83 SULINDAC 241 TAGRISSO 110 SUMATRIPTAN 94,95 TAKHZYRO 224 SUMATRIPTAN SUCCINATE 94,95,96 TALICIA 130 SUMATRIPTAN SUCCINATE/NAPROXEN TALTZ AUTOINJECTOR 257 SODIUM 95 TALTZ AUTOINJECTOR (2 PACK) 257 SUNITINIB MALATE 110 TALTZ AUTOINJECTOR (3 PACK) 257 SUNOSI 34 TALTZ SYRINGE 257 SUPRAX 154 TAMIFLU 135 SUPREP 198 TAMOXIFEN CITRATE 178 SUTENT 110 TAMSULOSIN HCL 9 SUVOREXANT 137 TAPENTADOL HCL 20 SYEDA 212 TARINA 24 FE 212 SYLATRON 135 TARINA FE 212 SYMBICORT 156 TARINA FE 1-20 EQ 212 SYMBYAX 69 TARKA 245 SYMDEKO 156 TASIGNA 111 SYMJEPI 260 TASIMELTEON 137 SYMLINPEN 120 70 TAVABOROLE 80 SYMLINPEN 60 70 TAZAROTENE 256,258 SYMPAZAN 66 TAZEMETOSTAT HYDROBROMIDE 111 SYMPROIC 200 TAZORAC 258 SYMTUZA 122 TAZTIA XT 145 SYNJARDY 73 TAZVERIK 111 SYNJARDY XR 73 TBO-FILGRASTIM 143 SYRINGE WITH NEEDLE,DISPOSABLE,INSULIN 1 TECFIDERA 232 ML 157 TECOVIRIMAT 134

PAGE 321 LAST UPDATED 07/2021 TEDIZOLID PHOSPHATE 51 THERA TEARS 182 TEGRETOL 63 THERMOTABS 176 TEGRETOL XR 63 THIAMINE HCL 271,273 TEKTURNA 246 THIOGUANINE 110 TEKTURNA HCT 246 THIOLA 235 TELMISARTAN 244 THIOLA EC 235 TELMISARTAN/AMLODIPINE BESYLATE 244 THIORIDAZINE HCL 119 TELMISARTAN/HYDROCHLOROTHIAZIDE 244 THIOTHIXENE 119 TELOTRISTAT ETIPRATE 191 THROMBATE III 53 TEMAZEPAM 139 TIADYLT ER 145 TEMOZOLOMIDE 111 TIAGABINE HCL 59,63 TENCON 13 TIAZAC 145 TENIVAC 125 TIBSOVO 111 TENOFOVIR ALAFENAMIDE 136 TICAGRELOR 122 TENOFOVIR DISOPROXIL FUMARATE 121 TICANASE 42 TENORETIC 100 150 TILDRAKIZUMAB-ASMN 256 TENORETIC 50 150 TILIA FE 212 TENORMIN 150 TIMOLOL MALEATE 81,82,150 TEPMETKO 111 TIMOLOL MALEATE/PF 82 TEPOTINIB HCL 111 TIMOPTIC 82 TERAZOSIN HCL 148 TIMOPTIC OCUDOSE 82 TERBINAFINE HCL 75,77 TIMOPTIC-XE 82 TERCONAZOLE 79 TIOCONAZOLE 77,79 TERIFLUNOMIDE 229 TIOPRONIN 235 TERIPARATIDE 242 TIOTROPIUM BROMIDE 52 TESTIM 205 TIOTROPIUM BROMIDE/OLODATEROL HCL 52 TESTOSTERONE 204,205 TIPRANAVIR 121 TESTOSTERONE CYPIONATE 205 TIPRANAVIR/VITAMIN E TPGS 121 TESTOSTERONE ENANTHATE 205 TIVICAY 120 TESTOSTERONE PROPIONATE 205 TIVICAY PD 120 TETANUS AND DIPHTHERIA TOXOIDS, TIVOZANIB HCL 102 ADSORBED, ADULT/PF 125 TIZANIDINE HCL 250 TETANUS AND DIPHTHERIA TOXOIDS, ADULT 125 TOBI 49 TETANUS,DIPHTHERIA TOXOID PED/PF 125 TOBI PODHALER 49 TETRABENAZINE 153 TOBRADEX 36 TETRAHYDROZOLINE HCL/DEXTRAN TOBRAMYCIN 36,37,48,49 70/POLYETHYLENE GL 400/POVIDONE 183 TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE 49 TEZACAFTOR/IVACAFTOR 156 TOBRAMYCIN SULFATE 49 THALIDOMIDE 232 TOBRAMYCIN/DEXAMETHASONE 36,37 THALOMID 232 TOBRAMYCIN/NEBULIZER 49 THEOPHYLLINE ANHYDROUS 258 TOBREX 37

PAGE 322 LAST UPDATED 07/2021 TOCILIZUMAB 224,225 TRETTEN 85 TOFACITINIB CITRATE 229 TREXIMET 95 TOLNAFTATE 81 TRI FEMYNOR 212 TOLSURA 76 TRI-ESTARYLLA 212 TOLTERODINE TARTRATE 200,201 TRI-LEGEST FE 212 TOPAMAX 63 TRI-LINYAH 212 TOPIRAMATE 62,63 TRI-LO-ESTARYLLA 212 TOPOTECAN HCL 102 TRI-LO-MARZIA 212 TOPROL XL 150 TRI-LO-MILI 212 TORSEMIDE 168 TRI-LO-SPRINTEC 212 TOSYMRA 95 TRI-MILI 212 TOUJEO MAX SOLOSTAR 217 TRI-NYMYO 212 TOUJEO SOLOSTAR 217 TRI-PREVIFEM 213 TOVIAZ 201 TRI-SPRINTEC 213 TPOXX (NATIONAL STOCKPILE) 134 TRI-VI-FLOR 270 TRACLEER 250 TRI-VYLIBRA 213 TRADJENTA 71 TRI-VYLIBRA LO 213 TRAMADOL HCL 22 TRIAMCINOLONE ACETONIDE 41,42,46,47 TRAMADOL HCL/ACETAMINOPHEN 22 TRIAMTERENE/HYDROCHLOROTHIAZIDE 168 TRAMETINIB DIMETHYL SULFOXIDE 107 TRIBENZOR 244 TRANDOLAPRIL 245 TRICARE 270 TRANDOLAPRIL/VERAPAMIL HCL 245 TRICOR 92 TRANEXAMIC ACID 85 TRIDERM 47 TRANYLCYPROMINE SULFATE 67 TRIFAROTENE 254 TRAVATAN Z 83 TRIFLUOPERAZINE HCL 119 TRAVOPROST 83 TRIFLURIDINE 37 TRAZODONE HCL 69 TRIFLURIDINE/TIPIRACIL HCL 106,107 TRECATOR 97 TRIGLIDE 92 TRELEGY ELLIPTA 156 TRIHEPTANOIN 170 TREMFYA 258 TRIHEXYPHENIDYL HCL 114 TREPROSTINIL 250 TRIJARDY XR 73 TREPROSTINIL DIOLAMINE 249 TRIKAFTA 156 TREPROSTINIL SODIUM 250 TRIKLO 90 TREPROSTINIL/NEBULIZER ACCESSORIES 250 TRILEPTAL 63 TREPROSTINIL/NEBULIZER AND TRILIPIX 92 ACCESSORIES 250 TRILYTE WITH FLAVOR PACKETS 199 TRESIBA 217 TRIMETHOBENZAMIDE HCL 75 TRESIBA FLEXTOUCH U-100 217 TRIMETHOPRIM 35 TRESIBA FLEXTOUCH U-200 217 TRINATE 270 TRETINOIN 111,252 TRINTELLIX 69 TRETINOIN MICROSPHERES 252 TRIPLE ANTIBIOTIC 39

PAGE 323 LAST UPDATED 07/2021 TRISTART DHA 270 UCERIS 204 TRIUMEQ 121 UDENYCA 144 TRIVORA-28 213 UKONIQ 111 TROKENDI XR 63 ULIPRISTAL ACETATE 207 TROSPIUM CHLORIDE 201 ULTIMA 168 TRUE METRIX 164 UMBRALISIB TOSYLATE 111 TRUE METRIX AIR GLUCOSE METER 163 UMECLIDINIUM BROMIDE 52 TRUE METRIX BLOOD GLUCOSE MTR 163 UMECLIDINIUM BROMIDE/VILANTEROL TRUE METRIX GLUCOSE TEST STRIP 168 TRIFENATATE 51 TRUE METRIX GO 164 UNICOMPLEX-M 270 TRUEPLUS KETONE TEST STRIP 262 UNILET LANCETS 164 TRULICITY 72 UPADACITINIB 228 TRUMENBA 130 UPTRAVI 250 TRUSELTIQ 111 UREA 254 TRUSOPT 82 URINE ACETONE TEST,STRIPS 262 TRUVADA 121 URINE GLUCOSE TEST STRIP 262 TUDORZA PRESSAIR 53 UROXATRAL 9 TULANA 213 URSODIOL 199 TURALIO 111 USTEKINUMAB 257 TUSNEL PEDIATRIC 247 UTIBRON NEOHALER 142 TWINRIX 130 TWIRLA 213 V TWYNSTA 244 VACCINE ADJUVANT SYSTEM, AS01B/PF, TYBLUME 213 COMPONENT VIAL 1 OF 2 243 TYBOST 235 VALACYCLOVIR HCL 136 TYMLOS 242 VALBENAZINE TOSYLATE 153 TYPHIM VI 130 VALCHLOR 111 TYPHOID VACC,LIVE,ATTENUATED 130 VALGANCICLOVIR HCL 136 TYPHOID VACCINE VI CAPSULAR VALPROIC ACID 63 POLYSACCHARIDE 130 VALPROIC ACID (AS SODIUM ) ( TYR EASY 173 SODIUM) 63 TYR EXPRESS 173 VALSARTAN 243,244 TYREX-1 173 VALSARTAN/HYDROCHLOROTHIAZIDE 243,244 TYREX-2 173 VALTOCO 139 TYSABRI 232 VALTREX 136 TYVASO 250 VANCOMYCIN HCL 51 TYVASO REFILL KIT 250 VANDETANIB 99 TYVASO STARTER KIT 250 VAQTA 130 VARENICLINE TARTRATE 140 U VARICELLA VIRUS VACCINE LIVE/PF 130 UBIDECARENONE 234

PAGE 324 LAST UPDATED 07/2021 VARICELLA-ZOSTER VIRUS GLYCOPROTEIN VIMPAT 64 E,REC,COMPONENT 2 OF 2 130 VINATE CARE 270 VARICELLA-ZOSTER VIRUS GLYCOPROTEIN VIOKACE 199 E,REC/AS01B ADJUVANT/PF 130 VIORELE 213 VARIVAX VACCINE 130 VIREAD 121 VASCEPA 90 -A 183 VASERETIC 245 VISMODEGIB 101 VASOTEC 245 VIT C/VIT E ACETATE/ZINC OXID/CUPRIC VAXCHORA ACTIVE COMPONENT 130 OXIDE/LUTEIN/ZEAXANTHIN 235 VAXCHORA BUFFER COMPONENT 243 VITAFOL GUMMIES 270 VAXCHORA VACCINE 130 VITAFOL ULTRA 270 VAXELIS 125 VITAFOL-OB 270 VEDOLIZUMAB 199 VITAFOL-ONE 270 VELETRI 250 VITAL HIGH NITROGEN 173 VELIVET 213 VITAMEDMD ONE RX 270 VELPHORO 220 VITAMEDMD REDICHEW RX 271 VEMLIDY 136 VITAMIN A 271 VEMURAFENIB 113 VITAMIN A PALMITATE/ASCORBIC VENLAFAXINE HCL 67,68 ACID/CHOLECALCIFEROL (VIT D3) 267 VENTAVIS 250 VITAMIN B COMPLEX 271,273 VENTOLIN HFA 142 VITAMIN B COMPLEX WITH VITAMIN C VERAPAMIL HCL 144,145,146 NO.19/FOLIC ACID/VITAMIN D3 272 VERELAN 146 VITAMIN B COMPLEX/FOLIC ACID 271 VERELAN PM 146 VITAMIN B COMPLEX/MINERALS 273 VERICIGUAT 263 VITAMIN E 277,278 VERQUVO 263 VITAMIN E (DL-ALPHA TOCOPHERYL VERSACLOZ 118 ACETATE) 277,278 VERZENIO 112 VITAMIN E ACETATE 277 VESICARE 201 VITAPEARL 271 VESTURA 213 VITATRUE 271 VICTOZA 2-PAK 72 VITRAKVI 112 VICTOZA 3-PAK 72 VIVAGUARD INO CONTROL SOLUTION 164 VIEKIRA PAK 202 VIVAGUARD INO SMART GLUC METER 164 VIENVA 213 VIVAGUARD INO TEST STRIP 168 VIGABATRIN 63,64 VIVOTIF 130 VIGADRONE 64 VIZIMPRO 112 VIGAMOX 37 VOCABRIA 120 VIIBRYD 69 VOGELXO 205 VILACTIN AA PLUS 20 PE 173 VOLNEA 213 VILAZODONE HCL 69 VON WILLEBRAND FACTOR (RECOMBINANT) 86 VIMOVO 241 VONVENDI 86

PAGE 325 LAST UPDATED 07/2021 VORAPAXAR SULFATE 123 XERAC AC 251 VORICONAZOLE 76 XERESE 39 VORINOSTAT 113 XERMELO 191 VORTIOXETINE HYDROBROMIDE 69 XHANCE 42 VOSEVI 202 XIFAXAN 51 VOTRIENT 112 XIGDUO XR 73 VOXELOTOR 143 XOFLUZA 134 VRAYLAR 118 XOPENEX 142 VUMERITY 232 XOPENEX CONCENTRATE 142 VUSION 79 XOPENEX HFA 143 VYFEMLA 213 XOSPATA 113 VYLIBRA 213 XPHE MAXAMUM 173 VYNDAMAX 147 XPOVIO 113 VYNDAQEL 147 XTAMPZA ER 23 VYTORIN 91 XTANDI 113 VYVANSE 27,28 XULANE 213 VYZULTA 83 XULTOPHY 100-3.6 217 XYNTHA 86 W XYNTHA SOLOFUSE 86 WAKIX 34 XYREM 152 WAL-ITIN 88 XYWAV 152 WAL-SOM 185 WARFARIN SODIUM 53,54 Y WAVESENSE PRESTO 164,168 YELLOW FEVER VACCINE LIVE/PF 130 WELCHOL 90 YF-VAX 130 WELLBUTRIN SR 67 YUPELRI 53 WELLBUTRIN XL 67 YUVAFEM 178 WERA 213 WILATE 86 Z WIXELA INHUB 156 ZADITOR 180 ZAFIRLUKAST 43 X ZALEPLON 138 XADAGO 114 ZANAMIVIR 135 XALATAN 83 ZANUBRUTINIB 99 XALKORI 112 ZARAH 213 XARELTO 55 ZARONTIN 66 XCOPRI 64 ZEBUTAL 13 XELJANZ 229 ZEGERID 134 XELJANZ XR 229 ZEJULA 113 XELPROS 83 ZELBORAF 113 XENLETA 51 ZEMBRACE SYMTOUCH 96

PAGE 326 LAST UPDATED 07/2021 ZENATANE 258 ZORTRESS 234 ZENPEP 199 ZORVOLEX 241 ZENZEDI 28 ZOSTAVAX 130 ZEPATIER 202 ZOSTER VACCINE LIVE/PF 130 ZEPOSIA 232 ZOVIA 1-35 213 ZERVIATE 180 ZOVIA 1-35E 213 ZESTORETIC 245 ZOVIRAX 39,40,136 ZESTRIL 245 ZTLIDO 251 ZETIA 91 ZUBSOLV 25 ZETONNA 42 ZUMANDIMINE 214 ZIAC 150 ZUPLENZ 74 ZIANA 39 ZYFLO 43 ZIDOVUDINE 121 ZYKADIA 113 ZIEXTENZO 144 ZYMAXID 37 ZILEUTON 43 ZYPITAMAG 93 176 ZYPREXA 118 ZINC OXIDE 177 ZYPREXA RELPREVV 118 ZINC SULFATE 176 ZYPREXA ZYDIS 118 ZIOPTAN 83 ZIPRASIDONE HCL 116,118 ZIPRASIDONE MESYLATE 116,118 ZIPSOR 241 ZIRGAN 37 ZITHROMAX 221 ZITHROMAX TRI-PAK 221 ZOCOR 93 ZOFRAN 74 ZOHYDRO ER 23 ZOKINVY 235 ZOLINZA 113 ZOLMITRIPTAN 96 ZOLOFT 69 ZOLPIDEM TARTRATE 137,138 ZOLPIMIST 138 ZOMACTON 214 ZOMIG 96 ZOMIG ZMT 96 ZONEGRAN 65 ZONISAMIDE 65 ZONTIVITY 123 ZORBTIVE 214

PAGE 327 LAST UPDATED 07/2021

20-814858 Updated 07/2021

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