Comprehensive PREFERRED DRUG LIST

WSI

PAGE 1 LAST UPDATED 02/2018 LEGEND TYPE DESCRIPTION

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

PA Prior Authorization Prior Authorization required before prescription can be filled.

MDD Max Daily Dose A limit on the number of times the drug can be taken per day.

C Custom This drug has unique restrictions.

PAGE 2 LAST UPDATED 02/2018 LIST OF COVERED OVER-THE-COUNTER MEDICATIONS

BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

ibuprofen tab 200 mg generic adult aspirin ec low strength 81 mg tab dr generic adult aspirin regimen 81 mg tab dr generic advil junior strength 100 mg chew tab generic ALKA-SELTZER EXTRA STRENGTH 500 MG EFFER TAB BRAND C Non-Formulary Drug aspirin effervescent anacin 81 mg tab dr generic ASCRIPTIN MS 500-33-33-237 MG TAB BRAND aspirin buffered (al hydrox-mg hydrox-ca carb) aspir-81 81 mg tab dr generic aspir-low 81 mg tab dr generic aspirin 300 mg suppos generic aspirin 81 mg tab generic aspirin 81 mg tab dr generic aspirin adult low dose 81 mg tab dr generic aspirin adult low strength 81 mg tab dr generic aspirin ec 81 mg tab dr generic aspirin ec adult low strength 81 mg tab dr generic aspirin ec lo-dose 81 mg tab dr generic aspirin ec low dose 81 mg tab dr generic aspirin ec low strength 81 mg tab dr generic aspirin low dose 81 mg tab dr generic aspirin regimen low dose adult 81 mg tab dr generic

backache relief extra strength 580 mg tab generic C Non-Formulary Drug

bayer aspirin ec low dose 81 mg tab dr generic bayer low dose 81 mg tab dr generic

PAGE 3 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS bayer low strength 81 mg tab dr generic BC FAST PAIN RELIEF ARTHRITIS 742-222-38 MG PACKET BRAND C Non-Formulary Drug aspirin-salicylamide-caffeine child ibuprofen 100 mg/5ml suspension generic childrens ibuprofen 100 100 mg/5ml suspension generic childrens ibuprofen 100 mg/5ml suspension generic childrens medi-profen 100 mg/5ml suspension generic childs ibuprofen 100 mg/5ml suspension generic

cope 400-32 mg tab generic C Non-Formulary Drug

cvs aspirin 81 mg tab dr generic cvs aspirin adult low strength 81 mg tab dr generic cvs aspirin ec 81 mg tab dr generic cvs aspirin low dose 81 mg tab dr generic cvs aspirin low strength 81 mg tab dr generic cvs childrens ibuprofen 100 mg/5ml suspension generic

cvs effervescent antacid 325-1000-1916 mg effer tab generic C Non-Formulary Drug

ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic cvs ibuprofen childrens 100 mg/5ml suspension generic ibuprofen tab 200 mg generic cvs ibuprofen junior strength 100 mg chew tab generic

doans extra strength 580 mg tab generic C Non-Formulary Drug

ibuprofen tab 200 mg generic ec-81 aspirin 81 mg tab dr generic ecotrin low strength 81 mg tab dr generic

effervescent antacid/pain rel 325-1000-1916 mg effer tab generic C Non-Formulary Drug

effervescent pain relief 325 mg effer tab generic C Non-Formulary Drug

effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug

eq adult aspirin low strength 81 mg tab dr generic

PAGE 4 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

eq antacid & pain relief 325 mg effer tab generic C Non-Formulary Drug

eq aspirin adult low dose 81 mg tab dr generic eq aspirin low dose 81 mg tab dr generic eq childrens ibuprofen 100 mg/5ml suspension generic

eq effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug

ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic eq ibuprofen junior 100 mg chew tab generic eql adult aspirin low strength 81 mg tab dr generic

eql antacid/pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug

eql aspirin ec 81 mg tab dr generic eql aspirin low dose 81 mg tab dr generic eql childrens ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic eql ibuprofen junior strength 100 mg chew tab generic ibuprofen tab 200 mg generic gnp adult aspirin low strength 81 mg tab dr generic gnp aspirin 81 mg tab dr generic gnp aspirin low dose 81 mg tab dr generic gnp childrens ibuprofen 100 mg/5ml suspension generic

gnp effervescent antacid/pain 325-1000-1916 mg effer tab generic C Non-Formulary Drug

ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic gnp ibuprofen junior strength 100 mg chew tab generic

goodsense antacid/pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug

goodsense aspirin low dose 81 mg tab dr generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic

PAGE 5 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS goodsense ibuprofen childrens 100 mg/5ml suspension generic goodsense ibuprofen junior st 100 mg chew tab generic GOODYS EXTRA STRENGTH 520-260-32.5 MG PACKET BRAND C Non-Formulary Drug aspirin-acetaminophen-caffeine h-e-b aspirin 81 mg tab dr generic halfprin 81 mg tab dr generic hm aspirin ec low dose 81 mg tab dr generic hm ibuprofen 100 mg chew tab generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic hm ibuprofen childrens 100 mg/5ml suspension generic ibuprofen tab 200 mg generic hyvee ibuprofen childrens 100 mg/5ml suspension generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic ibuprofen 100 junior strength 100 mg chew tab generic ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ibuprofen childrens 100 mg/5ml suspension generic ibuprofen junior strength 100 mg chew tab generic kls aspirin low dose 81 mg tab dr generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic kp aspirin 81 mg tab dr generic ibuprofen cap 200 mg generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic

medi-seltzer 325 mg effer tab generic C Non-Formulary Drug

ibuprofen tab 200 mg generic

PAGE 6 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ibuprofen cap 200 mg generic miniprin low dose 81 mg tab dr generic ibuprofen tab 200 mg generic

neutralin 325-1000-1916 mg effer tab generic C Non-Formulary Drug

p-a-c 400-32 mg tab generic C Non-Formulary Drug

ibuprofen tab 200 mg generic px childrens profen ib 100 mg/5ml suspension generic

px effervescent 325-1000-1916 mg effer tab generic C Non-Formulary Drug

px enteric aspirin 81 mg tab dr generic ibuprofen tab 200 mg generic px ibuprofen junior strength 100 mg chew tab generic qc aspirin low dose 81 mg tab dr generic qc childrens ibuprofen 100 mg/5ml suspension generic

qc effervescent antacid/pain 325-1000-1916 mg effer tab generic C Non-Formulary Drug

ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ibuprofen tab 200 mg generic

ra antacid pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug

ra aspirin adult low strength 81 mg tab dr generic ra aspirin ec 81 mg tab dr generic ra aspirin ec adult low st 81 mg tab dr generic

ra backache relief 580 mg tab generic C Non-Formulary Drug

ra ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic ra ibuprofen childrens 100 mg/5ml suspension generic ra ibuprofen junior strength 100 mg chew tab generic sb aspirin 81 mg tab dr generic sb aspirin adult low strength 81 mg tab dr generic

PAGE 7 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS sb childrens ibuprofen 100 mg/5ml suspension generic

sb effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug

ibuprofen tab 200 mg generic sb low dose asa ec 81 mg tab dr generic sm aspirin adult low strength 81 mg tab dr generic sm aspirin ec low strength 81 mg tab dr generic sm aspirin low dose 81 mg tab dr generic sm childrens ibuprofen 100 mg/5ml suspension generic

sm effervescent pain relief 325-1000-1916 mg effer tab generic C Non-Formulary Drug

ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic sm ibuprofen ib 100 mg chew tab generic ibuprofen tab 200 mg generic st joseph aspirin 81 mg tab dr generic tgt aspirin 81 mg tab dr generic tgt aspirin low dose 81 mg tab dr generic tgt childrens ibuprofen 100 mg/5ml suspension generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic tgt ibuprofen childrens 100 mg/5ml suspension generic tgt ibuprofen junior strength 100 mg chew tab generic th aspirin low dose 81 mg tab dr generic ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic VANQUISH 227-194-33 MG TAB BRAND C Non-Formulary Drug aspirin-acetaminophen-caffeine (buffered) ibuprofen cap 200 mg generic ibuprofen tab 200 mg generic

zee-zeltzer 325-1000-1916 mg tbef generic C Non-Formulary Drug

PAGE 8 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANESTHETICS

LOCAL ANESTHETICS

anesthetic maximum strength 20 % gel generic PA

benz-o-sthetic 20 % gel generic PA

cvs oral anesthetic max str 20 % gel generic PA

cvs oral pain reliever 20 % cream generic

hurricaine 20 % gel generic PA

intense toothache pain relief 20 % gel generic PA

orabase maximum strength 20 % gel generic PA

oral analgesic max st 20 % gel generic PA

oral pain relief max st 20 % gel generic PA

orastat maximum strength 20 % gel generic PA

ra anesthetic oral 20 % gel generic PA

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

SMOKING CESSATION AGENTS

cvs nicotine polacrilex 2 mg gum generic PA

cvs nicotine polacrilex 4 mg gum generic

cvs nicotine polacrilex 4 mg lozenge generic PA

eq nicotine 2 mg gum generic PA

eq nicotine 4 mg gum generic

eq nicotine 4 mg lozenge generic PA

eq nicotine polacrilex 2 mg gum generic PA

eq nicotine polacrilex 4 mg gum generic

eq nicotine polacrilex 4 mg lozenge generic PA

eql nicotine 4 mg lozenge generic PA

eql nicotine polacrilex 2 mg gum generic PA

PAGE 9 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS eql nicotine polacrilex 4 mg gum generic

eql nicotine polacrilex 4 mg lozenge generic PA

gnp nicotine polacrilex 2 mg gum generic PA

gnp nicotine polacrilex 4 mg gum generic

gnp nicotine polacrilex 4 mg lozenge generic PA

goodsense nicotine 4 mg gum generic

goodsense nicotine 4 mg lozenge generic PA

hm nicotine polacrilex 2 mg gum generic PA

hm nicotine polacrilex 4 mg gum generic

hm nicotine polacrilex 4 mg lozenge generic PA

kls quit2 2 mg gum generic PA

kls quit4 4 mg gum generic

kls quit4 4 mg lozenge generic PA

nicorelief 2 mg gum generic PA

nicorelief 4 mg gum generic

nicorelief 4 mg lozenge generic PA

nicotine mini 4 mg lozenge generic PA

nicotine polacrilex 2 mg gum generic PA

nicotine polacrilex 4 mg gum generic

nicotine polacrilex 4 mg lozenge generic PA

px stop smoking aid 2 mg gum generic PA

px stop smoking aid 4 mg gum generic

px stop smoking aid 4 mg lozenge generic PA

qc nicotine polacrilex 4 mg gum generic

ra mini nicotine 4 mg lozenge generic PA

ra nicotine 2 mg gum generic PA

ra nicotine 4 mg gum generic

PAGE 10 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

ra nicotine gum 2 mg gum generic PA

ra nicotine gum 4 mg gum generic

ra nicotine polacrilex 2 mg gum generic PA

ra nicotine polacrilex 4 mg gum generic

ra nicotine polacrilex 4 mg lozenge generic PA

sm nicotine 4 mg gum generic

sm nicotine polacrilex 2 mg gum generic PA

sm nicotine polacrilex 4 mg gum generic

sm nicotine polacrilex 4 mg lozenge generic PA

sr nicotine 2 mg gum generic PA

sw nicotine polacrilex 2 mg gum generic PA

sw nicotine polacrilex 4 mg gum generic

sw nicotine polacrilex 4 mg lozenge generic PA

tgt nicotine 2 mg gum generic PA

tgt nicotine 4 mg gum generic

tgt nicotine polacrilex 2 mg gum generic PA

tgt nicotine polacrilex 4 mg gum generic

tgt nicotine polacrilex 4 mg lozenge generic PA

thrive 2 mg gum generic PA

thrive 4 mg gum generic ANTIEMETICS

ANTIEMETICS, OTHER

ambizine 25 mg tab generic COCA COLA SYRUP BRAND phosphorated carbohydrate w/caffeine cvs motion sickness ii 25 mg tab generic dramamine less drowsy 25 mg tab generic eq motion sickness relief 25 mg tab generic

PAGE 11 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS eql motion sickness relief 25 mg tab generic gnp motion sickness relief 25 mg tab generic hm motion relief 25 mg tab generic hm motion sickness relief 25 mg tab generic meclizine hcl 12.5 mg tab generic meclizine hcl 25 mg tab generic medi-meclizine 25 mg tab generic motion sickness relief ii 25 mg tab generic ra motion sickness relief 25 mg tab generic sm motion sickness 25 mg tab generic th motion relief 25 mg tab generic wal-dram ii 25 mg tab generic ANTIFUNGALS

anti-fungal 1 % cream generic

anti-fungal 2 % crea generic PA

antifungal 2 % cream generic PA

athletes foot 2 % powder generic PA

AZOLEN TINCTURE 2 % SOLUTION BRAND miconazole nitrate (topical)

baza antifungal 2 % cream generic PA

butenafine hcl 1 % cream generic PA

carrington antifungal 2 % cream generic PA

clotrimazole 1 % crea generic PA

clotrimazole 1 % cream generic

clotrimazole 1 % cream generic PA

clotrimazole af 1 % cream generic clotrimazole anti-fungal 1 % cream generic clotrimazole grx 1 % cream generic

clotrimazole-7 1 % cream generic PA

PAGE 12 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS critic-aid clear af 2 % ointment generic

cvs anti-fungal 2 % powder generic PA

cvs clotrimazole 1 % cream generic cvs itch relief 1 % cream generic cvs miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic cvs miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic

cvs miconazole 7 2 % cream generic PA

cvs ringworm 1 % cream generic dermafungal 2 % ointment generic dermagran af 2 % ointment generic desenex 1 % cream generic

desenex 2 % powder generic PA

eq antifungal 1 % cream generic eq athletes foot 1 % cream generic eq jock itch 1 % cream generic eq miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic

eq miconazole 7 2 % cream generic PA

eq miconazole 7 day treatment 2 % cream generic PA

eql antifungal 1 % cream generic eql athletes foot 1 % cream generic eql miconazole 3 200 & 2 mg-% (9gm) kit generic

eql miconazole 7 2 % cream generic PA

FUNGOID TINCTURE 2 % SOLUTION BRAND miconazole nitrate (topical) gnp athletes foot 1 % cream generic gnp miconazole 3 200 & 2 mg-% (9gm) kit generic

gnp miconazole 7 2 % cream generic PA

gnp miconazorb af 2 % powder generic PA

jock itch 1 % cream generic

PAGE 13 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS jock itch relief 1 % cream generic kp clotrimazole 1 % cream generic

kp miconazole nitrate 2 % cream generic PA

lotrimin af 2 % powder generic PA

micaderm 2 % cream generic PA

miconazole 3 4 % cream generic PA

miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic

miconazole 7 2 % cream generic PA

miconazole nitrate 2 % cream generic PA

miconazorb af 2 % powder generic PA

micro guard 2 % cream generic PA

micro guard 2 % powder generic PA

MONISTAT 7 COMBO PACK APP 100 & 2 MG-% (9GM) KIT BRAND PA miconazole nitrate vaginal

neosporin af 2 % cream generic PA

podactin 2 % cream generic PA

pro-ex antifungal 1 % cream generic px athletic foot 1 % cream generic px miconazole 3-day combo 200 & 2 mg-% (9gm) kit generic

qc 3 day 4 % cream generic PA

qc clotrimazole 1 % cream generic

qc miconazole 7 2 % cream generic PA

ra antifungal 2 % cream generic PA

ra athletes foot 1 % cream generic ra clotrimazole 1 % cream generic

ra clotrimazole 7 1 % cream generic PA

PAGE 14 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ra jock itch 1 % cream generic ra miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic ra miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic

ra miconazole 7 2 % cream generic PA

remedy antifungal 2 % cream generic PA

remedy antifungal 2 % powder generic PA

remedy antifungal clear 2 % ointment generic

remedy phytoplex antifungal 2 % powder generic PA

sb clotrimazole foot 1 % cream generic

secura antifungal 2 % cream generic PA

secura antifungal extra thick 2 % cream generic PA

shopko athletes foot 1 % cream generic sm antifungal clotrimazole 1 % cream generic

sm antifungal miconazole 2 % cream generic PA

sm clotrimazole vaginal 1 % cream generic PA

sm miconazole 3 200 & 2 mg-% (9gm) kit generic

sm miconazole 7 2 % cream generic PA

soothe & cool inzo antifungal 2 % cream generic PA

tetterine 2 % ointment generic tgt clotrimazole 1 % cream generic tgt miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic tgt miconazole 3 combo pack 200 & 2 mg-% (9gm) kit generic

tgt miconazole 7 2 % cream generic PA

th clotrimazole 1 % cream generic

tineacide 2 % cream generic PA

triple paste af 2 % ointment generic vagistat-3 200 & 2 mg-% (9gm) kit generic

zeasorb-af 2 % powder generic PA

PAGE 15 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANTIPARASITICS

ANTIHELMINTHICS

pin-x 50 mg/ml suspension generic C Non-Formulary Drug

PIN-X 720.5 MG CHEW TAB BRAND C Non-Formulary Drug pyrantel pamoate

pinworm medicine 144 mg/ml suspension generic C Non-Formulary Drug

reeses pinworm medicine 144 mg/ml suspension generic C Non-Formulary Drug

BLOOD GLUCOSE REGULATORS

GLYCEMIC AGENTS

glucose 4 gm chew tab generic CARDIOVASCULAR AGENTS

DYSLIPIDEMICS, OTHER

cvs fish oil 1200 mg cap generic PA

cvs natural fish oil 1200 mg cap generic PA

eql fish oil 1200 mg cap generic PA

eql omega 3 fish oil 1200 mg cap generic PA

fish oil 1200 mg cap generic PA

fish oil burp-less 1200 mg cap generic PA

fish oil double strength 1200 mg cap generic PA

fish oil extra strength 1200 mg cap generic PA

fish oil maximum strength 1200 mg cap generic PA

hm fish oil 1200 mg cap generic PA

kp fish oil 1200 mg cap generic PA

kp omega-3 fish oil 1200 mg cap generic PA

omega 3 1200 mg cap generic PA

omega-3 fish oil 1200 mg cap generic PA

PAGE 16 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

sea-omega 30 1200 mg cap generic PA

sm fish oil 1200 mg cap generic PA

sm omega-3 fish oil 1200 mg cap generic PA

th fish oil extra strength 1200 mg cap generic PA

theragran-m fish oil conc 1200 mg cap generic PA

CENTRAL NERVOUS SYSTEM AGENTS

CENTRAL NERVOUS SYSTEM, OTHER

acetaminophen 80 mg/0.8ml solution generic C Non-Formulary Drug

little remedies for fever 160 mg/5ml liquid generic C Non-Formulary Drug

mapap 160 mg/5ml liquid generic C Non-Formulary Drug

q-pap infants 80 mg/0.8ml solution generic C Non-Formulary Drug

DENTAL AND ORAL AGENTS

antiseptic mouth rinse liquid generic PA

antiseptic oral rinse 0.05 % liquid generic PA

BIOTENE DRY MOUTH MOISTURIZING SOLUTION BRAND artificial saliva BIOTENE MOISTURIZING MOUTH SOLUTION BRAND artificial saliva CURASORE 1 % LIQUID BRAND PA pramoxine hcl (dental)

cvs antiseptic mouth rinse liquid generic PA

CVS DRY MOUTH SOLUTION BRAND artificial saliva

cvs mouthwash liquid generic PA

cvs sore throat max strength 15-2.6 mg lozenge generic PA

dobells solution generic PA

dry mouth mouthwash liquid generic PA

DRY MOUTH SPRAY SOLUTION BRAND artificial saliva

PAGE 17 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

eql antiseptic mouthrinse liquid generic PA

EQL DRY MOUTH ORAL RINSE SOLUTION BRAND artificial saliva

eql mouthwash/gargle liquid generic PA

fresh n'free liquid generic PA

gnp dry mouth mouthwash liquid generic PA

goodsense mouthwash liquid generic PA

MOI-STIR SOLUTION BRAND artificial saliva MOUTH KOTE SOLUTION BRAND artificial saliva

mouthwash/gargle liquid generic PA

ORAL RELIEF SPRAY SOLUTION BRAND artificial saliva

ra antiseptic mouth rinse liquid generic PA

RA DRY MOUTH SOLUTION BRAND artificial saliva

ra mouthwash alcohol free liquid generic PA

ra mouthwash/gargle liquid generic PA

sm antiseptic mouth rinse liquid generic PA

sm mouth rinse antiseptic liquid generic PA

sore throat relief 10 mg lozenge generic PA

trocaine throat 10 mg lozenge generic PA

ZILACTIN 10 % GEL BRAND PA benzyl alcohol (anesthetic) DERMATOLOGICAL AGENTS

acne foaming wash 10 % liquid generic PA

acne medication 10 10 % gel generic PA

acne medication 5 5 % gel generic

PAGE 18 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ACNE MEDICATION 5 5 % LOTION BRAND benzoyl peroxide

acne pimple medication 10 % gel generic PA

acne treatment 10 % bar generic

acne treatment 10 % gel generic PA

acne wash 2 % liquid generic PA

acne-clear 10 % gel generic PA

al12 12 % lotion generic PA

allergy 2-0.1 % cream generic ALOE GRANDE 10000-1500 UNIT/30ML LOTION BRAND PA vitamins a & e

alph-e-cream cream generic PA

aluminum acetate solution generic PA

amlactin 12 % lotion generic PA

ammonium lactate 12 % lotion generic PA

anecream 4 % cream generic anti-dandruff 1 % shampoo generic anti-itch 1-0.1 % cream generic anti-itch 2-0.1 % cream generic anti-itch extra strength 2-0.1 % cream generic anti-itch intensive healing 1 % lotion generic anti-itch maximum strength 1 % cream generic anti-itch maximum strength 2 % cream generic antifungal foot/sneaker spray 1 % aero powd generic antifungal spray powder 1 % aero powd generic aquanil hc 1 % lotion generic

arctic relief pain relieving 4 % gel generic PA

PA arnica 20 % tincture generic C Non-Formulary Drug

PAGE 19 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS aspercreme w/lidocaine 4 % cream generic aveeno anti-itch max st 1 % cream generic

baby vitamin a & d ointment generic PA

bacitracin zinc 500 unit/gm ointment generic bacitracin zinc 500 unit/gm ointment generic BALNETAR 2.5 % EMULSION BRAND PA coal tar extract BAMA FREEZE 3.7 % GEL BRAND PA menthol (topical analgesic) banophen 2-0.1 % cream generic

baza clear ointment generic PA

beauty lotion lotion generic PA

BENADRYL ITCH RELIEF 2-0.1 % STICK BRAND diphenhydramine-zinc acetate bengay vanishing scent 2.5 % gel generic

benzoyl peroxide 10 % gel generic PA

benzoyl peroxide 5 % gel generic

benzoyl peroxide wash 10 % liquid generic PA

benzoyl peroxide wash 5 % liquid generic PA

beta hc 1 % lotion generic

biofreeze 4 % gel generic PA

biofreeze colorless 4 % gel generic PA

biofreeze roll-on 4 % gel generic PA

biofreeze roll-on colorless 4 % gel generic PA

BP CLEANSING 4 % LOTION BRAND benzoyl peroxide

bp gel 10 % gel generic PA

bp gel 5 % gel generic

bp wash 10 % liquid generic PA

PAGE 20 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

bp wash 5 % liquid generic PA

bpo-10 wash 10 % liquid generic PA

bpo-5 wash 5 % liquid generic PA

BRASIVOL PASTE BRAND PA aluminum oxide caldecort 1 % cream generic CAPSAGEL EXTRA STRENGTH 0.05 % GEL BRAND C Non-Formulary Drug capsaicin castellani paint 1.5 % liquid generic castellani paint modified 1.5 % liquid generic CHIGGEREX 2 % OINTMENT BRAND benzocaine (topical)

clean & clear acne cleanser 2 % liquid generic PA

clean & clear acne scrub 2 % liquid generic PA

clean & clear advantage 3-in-1 2 % liquid generic PA

CLEAN & CLEAR ADVANTAGE 3-IN-1 5 % LOTION BRAND benzoyl peroxide

clean & clear advantage scrub 2 % liquid generic PA

clean & clear advantage wash 2 % liquid generic PA

clean & clear deep cleaning 2 % liquid generic PA

clean & clear persa-gel ex st 5 % gel generic

clean & clear persa-gel max st 10 % gel generic PA

clearasil daily clear 2 % liquid generic PA

clearplex v 5 % gel generic

cocoa butter lotion generic PA

COCOA BUTTER PETROLEUM JELLY GEL BRAND PA emollient

cocoa butter skin cream generic PA

collagen cream generic PA

PAGE 21 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

complete moisture lotion generic PA

cool therapy 4 % gel generic PA

cortaid advanced 12 hour 1 % cream generic cortaid intensive therapy 1 % cream generic cortaid maximum strength 1 % cream generic corticool 1 % gel generic cortizone-10 1 % gel generic cortizone-10 1 % ointment generic cortizone-10 diabetics skin 1 % lotion generic cortizone-10 eczema 1 % lotion generic cortizone-10 hydratensive 1 % lotion generic cvs acne cleansing 10 % bar generic

cvs acne foaming face wash 10 % liquid generic PA

cvs acne treatment 10 % gel generic PA

cvs adv acne spot treatment 2 % liquid generic PA

cvs advanced 3-in-1 cleanser 5 % liquid generic PA

cvs af spray powder 1 % aero powd generic cvs anti-dandruff 1 % lotion generic cvs anti-itch max str 2 % cream generic cvs anti-itch maximum strength 1 % cream generic cvs bacitracin 500 unit/gm ointment generic cvs bacitracin zinc 500 unit/gm ointment generic cvs cortisone + max st 1 % cream generic cvs cortisone cooling relief 1 % gel generic cvs cortisone intense healing 1 % cream generic cvs cortisone intensive heal 1 % cream generic cvs cortisone long-lasting 1 % lotion generic cvs cortisone maximum strength 1 % cream generic cvs cortisone maximum strength 1 % gel generic

PAGE 22 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS cvs cortisone maximum strength 1 % lotion generic cvs cortisone maximum strength 1 % ointment generic

cvs creamy acne face wash 4 % liquid generic PA

cvs dry skin care lotion generic PA

cvs dry skin therapy lotion generic PA

cvs dual action cleanser/mask 3.5 % liquid generic cvs eczema anti-itch 1 % cream generic

cvs extra moisturizing lotion generic PA

cvs foaming acne face wash 10 % liquid generic PA

cvs foot & sneaker 1 % aero powd generic

cvs gentle skin cleanser lotion generic PA

PA cvs hair regrowth for men 5 % solution generic C Non-Formulary Drug

cvs hair regrowth for women 2 % solution generic C Non-Formulary Drug

cvs hair regrowth womens 2 % solution generic C Non-Formulary Drug

cvs hemorrhoidal 0.25-3-85.5 % suppos generic PA

cvs hydrating skin treatment 12 % lotion generic PA

cvs hydrocortisone anti-itch 1 % cream generic cvs hydrocortisone max st 1 % cream generic cvs hydrocortisone plus max st 1 % cream generic cvs itch relief 1-0.1 % cream generic cvs itch relief extra strength 2-0.1 % cream generic

cvs lanolin cream generic PA

cvs medicated wipes 50 % pad generic PA

cvs moisturizing cream generic PA

cvs moisturizing lotion generic PA

cvs moisturizing extra dry cream generic PA

PAGE 23 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS cvs pure glycerin 99.5 % liquid generic

cvs skin treatment 12 % lotion generic PA

cvs sore muscle rub 2.5 % gel generic

cvs special care lotion generic PA

cvs vitamin a & d ointment generic PA

cvs vitamin e moisturizing cream generic

daily face wash 2 % liquid generic PA

dandrex 1 % shampoo generic dandruff shampoo 1 % lotion generic DEMAREST PLUS 2-1 % LIQUID BRAND diphenhydramine-menthol

dermadaily lotion generic PA

dermarest eczema 1 % lotion generic

dermavantage lotion generic PA

DERMAZINC BABY LIQUID BRAND PA antiseborrheic products, misc. DERMAZINC SCALP LIQUID BRAND PA antiseborrheic products, misc.

dhea 1 % cream generic PA

DI-DELAMINE 1-0.5 % LIQUID BRAND diphenhydramine-tripelenamine diphenhydramine-zinc acetate 2-0.1 % cream generic

dmae cream generic PA

dml lotion generic PA

dr jh mcleans volcanic oil liquid generic DURAFLEX COMFORT GEL BRAND menthol-methyl salicylate (liniments) e-cream 6000 unit cream generic

e-cream complex cream generic PA

elta lotion generic PA

PAGE 24 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ELTA TAR 2 % CREAM BRAND PA coal tar extract eq anti-itch extra strength 2-0.1 % cream generic eq anti-itch max strength 1 % cream generic eq athletes foot 1 % aero powd generic

eq hemorrhoidal 50 % pad generic PA

eq hydrocortisone 1 % cream generic eq hydrocortisone max st 1 % cream generic eq hydrocortisone plus 1 % cream generic

eq hygienic cleansing wipes pad generic PA

eq vitamins a & d ointment generic PA

eql absolute moisture dry skin lotion generic PA

eql acne scrub pink grapefruit 2 % liquid generic PA

eql advanced recovery lotion generic PA

eql advanced skin therapy lotion generic PA

eql aloe after sun lotion generic PA

eql anti-itch extra strength 2-0.1 % cream generic eql anti-itch intensive heal 1 % cream generic eql anti-itch maximum strength 1 % cream generic eql anti-itch maximum strength 1 % ointment generic

eql apricot scrub 2 % liquid generic PA

eql athletes foot 1 % aero powd generic eql bacitracin zinc 500 unit/gm ointment generic

PA eql hair regrowth 5 % solution generic C Non-Formulary Drug

PA eql hair regrowth for men 5 % solution generic C Non-Formulary Drug

eql hair regrowth for women 2 % solution generic C Non-Formulary Drug

PAGE 25 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS eql hemorrhoidal 0.25-3-12-18 % cream generic

eql hemorrhoidal 0.25-3-85.5 % suppos generic PA

eql medicated dandruff 1 % lotion generic

eql medicated wipes 50 % pad generic PA

first aid antibiotic 4 % ointment generic FLEXALL ULTRA PLUS 3.1-16-10 % GEL BRAND PA camphor-menthol-methyl salicylate FUNGI-NAIL 25 % SOLUTION BRAND PA undecylenic acid

gentian violet 1 % solution generic PA

geri-hydrolac 12 12 % lotion generic PA

glycerin liquid generic gnp anti-itch 2-0.1 % cream generic gnp bacitracin zinc 500 unit/gm ointment generic gnp glycerin 99.5 % liquid generic

gnp hemorrhoidal 0.25-3-85.5 % suppos generic PA

gnp hydro-lotion 1 % lotion generic gnp hydrocortisone max st 1 % ointment generic gnp hydrocortisone plus 1 % cream generic

gnp hygienic cleansing 50 % pad generic PA

gnp medicated wipes 50 % pad generic PA

gnp vitamin a & d 15.5-53.4 % ointment generic PA

GORDOCHOM 25 % SOLUTION BRAND PA undecylenic acid

gordomatic lotion generic PA

GORDONS-VITE A 100000 UNIT LOTION BRAND PA vitamin a (topical) gordons-vite e 1500 unit/30gm cream generic grx vitamin e cream generic

PAGE 26 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA hair regrowth treatment men 5 % solution generic C Non-Formulary Drug

hem-prep 0.25-3-85.5 % suppos generic PA

hemorrhoid 0.25-3-85.5 % suppos generic PA

hemorrhoidal 0.25-3-12-18 % cream generic

hemorrhoidal 0.25-3-85.5 % suppos generic PA

hemorrhoidal 50 % pad generic PA

hemorrhoidal 51 % suppos generic PA

hemorrhoidal hygiene 50 % pad generic PA

hemorrhoidal relief 0.25-3-85.5 % suppos generic PA

hm glycerin liquid generic

hm medicated cooling 50 % pad generic PA

hydro skin maximum strength 1 % lotion generic hydrocortisone 1 % cream generic hydrocortisone 1 % cream generic hydrocortisone 1 % lotion generic hydrocortisone 1 % lotion generic hydrocortisone 1 % ointment generic hydrocortisone intensive heal 1 % cream generic hydrocortisone max st 1 % cream generic hydrocortisone max st/12 moist 1 % cream generic hydrocortisone plus 1 % cream generic hydrocortisone plus 12 1 % cream generic hydroskin 1 % cream generic hydroskin 1 % lotion generic ionil-t 1 % shampoo generic itch relief 2 % cream generic itch relief extra strength 2-0.1 % cream generic

PAGE 27 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS IVY BLOCK 5 % LOTION BRAND bentoquatam IVY DRY 2 % LOTION BRAND PA zinc acetate (topical) jock itch spray 1 % aero powd generic jock itch spray powder 1 % aero powd generic KERA TEK GEL BRAND menthol-methyl salicylate (liniments) kericort 10 1 % cream generic

PA kls minoxidil 5 % solution generic C Non-Formulary Drug

kp bacitracin zinc 500 unit/gm ointment generic

kp benzoyl peroxide 10 % gel generic PA

kp benzoyl peroxide 5 % gel generic

kp benzoyl peroxide wash 10 % liquid generic PA

kp benzoyl peroxide wash 5 % liquid generic PA

kp hydrocortisone 1 % cream generic kp hydrocortisone max st 1 % ointment generic

lactic acid e 10-3500 %-unt/30gm cream generic PA

lamisil af defense 1 % aero powd generic lc-4 lidocaine 4 % cream generic lidocaine 4 % cream generic lidocream 4 % cream generic LIQUIMAT 5 % LOTION BRAND PA sulfur

lubricating lotion lotion generic PA

lubrisilk lotion generic PA

lubriskin lotion generic PA

med-derm hydrocortisone 1 % cream generic

medicated cleansing 50 % pad generic PA

PAGE 28 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

medicated wipes pad generic PA

medicated wipes 50 % pad generic PA

meijer hydrocortisone 1 % cream generic mg217 psoriasis anit-itch 1 % gel generic MINERAL OIL-HYDROPHIL PETROLAT OINTMENT BRAND C Non-Formulary Drug mineral oil-hydrophilic petrolatum

minerin lotion generic PA

minoxidil 2 % solution generic C Non-Formulary Drug

PA minoxidil 5 % soln generic C Non-Formulary Drug

PA minoxidil 5 % solution generic C Non-Formulary Drug

minoxidil for men 2 % solution generic C Non-Formulary Drug

PA minoxidil for men 5 % solution generic C Non-Formulary Drug

minoxidil for women 2 % solution generic C Non-Formulary Drug

moisture lotion generic PA

moisture recovery lotion generic PA

moisturizing cream cream generic PA

moisturizing lotion lotion generic PA

moisturizing sensitive skin lotion generic PA

moisturizing vitamin e/aloe lotion generic PA

monistat soothing care 1 % cream generic MYCO NAIL A 25 % SOLUTION BRAND PA undecylenic acid neosporin eczema essent max st 1 % cream generic

neutrogena body clear wash 2 % liquid generic PA

neutrogena oil-free acne wash 2 % liquid generic PA

PAGE 29 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS NEUTROGENA T/GEL CONDITIONER 0.5 % LIQUID BRAND PA coal tar extract neutrogena t/gel ex st 1 % shampoo generic NEW TEROCIN 0.025-10-25 % LOTION BRAND capsaicin-menthol-methyl salicylate noble formula hc 1 % cream generic

noble formula s 2 % liquid generic PA

OC8 7 % GEL BRAND PA benzoyl peroxide odor control foot & sneaker 1 % aero powd generic odor eaters foot/sneaker spray 1 % aero powd generic OUTGRO PAIN RELIEF 20 % LIQUID BRAND PA benzocaine (topical) P & S LIQUID BRAND PA antiseborrheic products, misc. P & S LIQUID BRAND PA antiseborrheic products, misc. panoxyl 10 % bar generic PANOXYL 3 % GEL BRAND benzoyl peroxide

panoxyl aqua 10 % gel generic PA

panoxyl wash 10 % liquid generic PA

PANTHODERM 2 % CREAM BRAND dexpanthenol (topical) pc-tar 1 % shampoo generic PERNOX 1.5-2 % LOTION BRAND PA salicylic acid & sulfur (keratolytic)

polar frost 4 % gel generic PA

pre-moistened witch hazel 50 % pad generic PA

preparation h 50 % pad generic PA

preparation h for women 20 % pad generic PA

preparation h hydrocortisone 1 % cream generic

PAGE 30 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

preparation h totables wipes 50 % pad generic PA

PREVACARE ANTIMICROBIAL 60 % GEL BRAND PA ethyl alcohol (skin cleanser) procomycin 4 % ointment generic PROPA PH ACNE MED CLEANSING 0.6 % LOTION BRAND PA salicylic acid

propa ph foaming face wash 2 % liquid generic PA

px hemorrhoidal 0.25-3-85.5 % suppos generic PA

px hydrocream 1 % cream generic

PA px minoxidil for men 5 % solution generic C Non-Formulary Drug

px minoxidil for women 2 % solution generic C Non-Formulary Drug

qc anti-itch extra strength 2-0.1 % cream generic qc glycerin 99.5 % liquid generic qc hydrocortisone 1 % cream generic qc hydrocortisone max st 1 % cream generic

qc medicated pre-moistened 50 % pad generic PA

ra acne cleanser oil-free 2 % liquid generic PA

ra advanced recovery lotion generic PA

ra allergy 2-0.1 % cream generic RA ANTI-FUNGAL FOOT CARE 25 % SOLUTION BRAND PA undecylenic acid ra anti-itch maximum strength 1 % cream generic ra anti-itch maximum strength 1 % ointment generic

ra apricot scrub 2 % liquid generic PA

ra baby care vit a&d to go ointment generic PA

ra bacitracin 500 unit/gm ointment generic ra bacitracin zinc first aid 500 unit/gm ointment generic

ra calming daily moisturizing cream generic PA

PAGE 31 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ra dandruff shampoo 1 % lotion generic

ra derma lotion generic PA

ra gentle skin lotion generic PA

ra glycerin liquid generic

PA ra hair regrowth ex st for men 5 % solution generic C Non-Formulary Drug

ra hair regrowth for women 2 % solution generic C Non-Formulary Drug

ra hemorrhoid relief medicated 50 % pad generic PA

ra hemorrhoidal 0.25-3-12-18 % cream generic

ra hemorrhoidal 0.25-3-85.5 % suppos generic PA

ra hydrocortisone max st 1 % cream generic ra hydrocortisone plus 12 1 % cream generic ra jock itch max st 1 % aero powd generic

ra medicated wipes 50 % pad generic PA

ra moisturizing oatmeal lotion generic PA

ra moisturizing therapy cream generic PA

ra pain care muscle & joint 2.5 % gel generic

ra renewal acne treatment 10 % gel generic PA

ra renewal cocoa butter lotion generic PA

ra renewal dandruff 1 % shampoo generic

ra renewal moisturizing cream generic PA

ra total moisture lotion generic PA

ra vitamin a & d ointment generic PA

ra vitamin e-vit a & d 20000 unit cream generic PA

ra vitamin e-vit a & d 4000 unit cream generic PA

ra vitamins a & d ointment generic PA

recort plus 1 % cream generic

PAGE 32 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS rederm 1 % lotion generic

refreshing aloe lotion generic PA

SARDOETTES PAD BRAND PA emollient sarnol-hc 1 % lotion generic sb anti-itch maximum strength 2-0.1 % cream generic sb hydrocortisone 1 % cream generic sb hydrocortisone max st 1 % ointment generic sb hydrocortisone plus 1 % cream generic sb triple antibiotic 4 % ointment generic sm allergy maximum strength 2 % cream generic sm anti-itch extra strength 2-0.1 % cream generic sm antibiotic 500 unit/gm ointment generic sm athletes foot 1 % aero powd generic

sm dry skin therapy lotion generic PA

sm glycerin 99.5 % liquid generic sm hemorrhoidal 0.25-3-12-18 % cream generic

sm hemorrhoidal 51 % suppos generic PA

sm hydrocortisone 1 % cream generic sm hydrocortisone max st 1 % ointment generic

sm medicated wipes 50 % pad generic PA

softden lotion generic PA

STYPTOCAINE 46 % LIQUID BRAND aluminum sulfate (topical astringent) tgt anti-itch maximum strength 1 % cream generic tgt anti-itch maximum strength 1 % ointment generic tgt anti-itch plus oatmeal 1 % cream generic tgt anti-itch/aloe/vit e 1 % cream generic tgt antifungal spray powder 1 % aero powd generic

tgt hair regrowth for women 2 % solution generic C Non-Formulary Drug

PAGE 33 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

tgt hemorrhoidal 0.25-3-85.5 % suppos generic PA

tgt itch relief extra strength 2-0.1 % cream generic

tgt medicated hemorrhoidal pad generic PA

tgt medicated wipe/witch hazel 50 % pad generic PA

PA tgt minoxidil hair regrowth 5 % solution generic C Non-Formulary Drug

th hydrocortisone 1 % cream generic

thera-derm lotion generic PA

theracort 1 % lotion generic

therapeutic bath lotn generic PA

tn dickinsons witch hazel pad generic PA

tn dickinsons witch hazel 50 % pad generic PA

tolnaftate 1 % aero powd generic tru-micin 10 % lotion generic

tucks 50 % pad generic PA

tucks medicated cooling 50 % pad generic PA

ultracin t 10 % lotion generic vitamin e cream generic vitamin e 1000 unit cream generic vitamin e 30000 unit/60gm cream generic

vitamin e skin 4000 unit cream generic PA

vitamin e with panthenol cream generic PA

vitamin e-vit a & d cream generic PA

vitamins a & d ointment generic PA

vitec lotion generic wal-dryl 2-0.1 % cream generic xtra-care lotion generic

PAGE 34 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS yagers liniment 3.1-8.2 % liquid generic ZIMS MAX-FREEZE 3.7 % GEL BRAND PA menthol (topical analgesic) GASTROINTESTINAL AGENTS

GASTROINTESTINAL AGENTS, OTHER

acid gone 95-358 mg/15ml suspension generic alamag plus 200-200-25 mg chew tab generic almacone 200-200-25 mg chew tab generic antacid 550-110 mg chew tab generic antacid extra strength 675-135 mg chew tab generic

loperamide hcl tab 2 mg generic PA

anti-gas ultra strength 180 mg cap generic calcium rich supreme antacid 400-135 mg/5ml suspension generic cvs antacid supreme 400-135 mg/5ml suspension generic

loperamide hcl tab 2 mg generic PA

cvs dairy relief 9000 unit chew tab generic cvs dairy relief fast acting 9000 unit chew tab generic cvs gas relief 80 mg chew tab generic cvs gas relief infants 20 mg/0.3ml suspension generic cvs gas relief ultra strength 180 mg cap generic cvs infants gas relief 20 mg/0.3ml suspension generic dairy-digestive 9000 unit chew tab generic

loperamide hcl tab 2 mg generic PA

drxchoice gas relief 80 mg chew tab generic eq antacid extra strength 675-135 mg chew tab generic

loperamide hcl tab 2 mg generic PA

eq dairy digestive fast acting 9000 unit chew tab generic eq infants gas relief 40 mg/0.6ml suspension generic

loperamide hcl tab 2 mg generic PA

PAGE 35 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS eql gas relief ultra strength 180 mg cap generic eql infants gas relief 20 mg/0.3ml suspension generic gas relief 180 mg cap generic gas relief 20 mg/0.3ml suspension generic gas relief 80 mg chew tab generic gas relief ultra strength 180 mg cap generic gas-x ultra strength 180 mg cap generic geri-lanta supreme 400-135 mg/5ml suspension generic gnp antacid 550-110 mg chew tab generic

loperamide hcl tab 2 mg generic PA

gnp anti-gas 180 mg cap generic gnp fast acting dairy relief 9000 unit chew tab generic gnp foaming antacid 95-358 mg/15ml suspension generic gnp gas relief 80 mg chew tab generic gnp infants gas relief 20 mg/0.3ml suspension generic

loperamide hcl tab 2 mg generic PA

hm gas relief 80 mg chew tab generic hm gas relief infants drops 20 mg/0.3ml suspension generic hm magnesium 400 mg tab generic infants gas relief 20 mg/0.3ml suspension generic infants gas relief 40 mg/0.6ml suspension generic infants simethicone 20 mg/0.3ml suspension generic

loperamide hcl tab 2 mg generic PA

lactose fast acting relief 9000 unit chew tab generic little remedies for tummys 20 mg/0.3ml suspension generic little tummys gas relief 20 mg/0.3ml suspension generic

loperamide hcl tab 2 mg generic PA

magnesium oxide 400 mg tab generic

PAGE 36 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

loperamide hcl tab 2 mg generic PA

mi-acid gas relief 80 mg chew tab generic mintox plus 200-200-25 mg chew tab generic mytab gas 80 mg chew tab generic pediacare infants gas relief 20 mg/0.3ml suspension generic

loperamide hcl tab 2 mg generic PA

px gas relief infants 20 mg/0.3ml suspension generic px gas relief ultra strength 180 mg cap generic

loperamide hcl tab 2 mg generic PA

qc anti-gas 180 mg cap generic qc gas relief 80 mg chew tab generic quick action dairy relief 9000 unit chew tab generic

loperamide hcl tab 2 mg generic PA

ra dairy relief fast acting 9000 unit chew tab generic ra gas relief 40 mg/0.6ml suspension generic ra gas relief 80 mg chew tab generic ra gas relief ultra strength 180 mg cap generic ra gas relief/infants 20 mg/0.3ml suspension generic rolaids 550-110 mg chew tab generic

loperamide hcl tab 2 mg generic PA

sb anti-gas 180 mg cap generic sb gas relief 40 mg/0.6ml suspension generic simeped 40 mg/0.6ml suspension generic simethicone 180 mg cap generic simethicone 20 mg/0.3ml suspension generic simethicone 40 mg/0.6ml suspension generic simethicone 80 mg chew generic simethicone 80 mg chew tab generic

loperamide hcl tab 2 mg generic PA

PAGE 37 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS sm gas relief 80 mg chew tab generic sm gas relief antiflatuent 180 mg cap generic sm gas relief infants 20 mg/0.3ml suspension generic sm gas relief infants drops 40 mg/0.6ml suspension generic

loperamide hcl tab 2 mg generic PA

tgt antacid extra strength 675-135 mg chew tab generic

loperamide hcl tab 2 mg generic PA

th antacid supreme 400-135 mg/5ml suspension generic

loperamide hcl tab 2 mg generic PA

URO-MAG 140 MG CAP BRAND PA magnesium oxide HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

acid control 150 mg tab generic MDD 2 per day

acid control maximum strength 150 mg tab generic MDD 2 per day

acid controller 10 mg tab generic MDD 2 per day

acid controller complete 10-800-165 mg chew tab generic acid reducer + antacid 10-800-165 mg chew tab generic

acid reducer 10 mg tab generic MDD 2 per day

acid reducer 150 mg tab generic MDD 2 per day

acid reducer 200 mg tab generic MDD 1 per day

acid reducer 75 mg tab generic MDD 2 per day

acid reducer complete 10-800-165 mg chew tab generic

acid reducer maximum strength 150 mg tab generic MDD 2 per day

acid relief 200 mg tab generic MDD 1 per day

cimetidine 200 200 mg tab generic MDD 1 per day

cimetidine 200 mg tab generic MDD 1 per day

cimetidine 200 mg tabs generic MDD 1 per day

PAGE 38 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

cimetidine acid reducer 200 mg tab generic MDD 1 per day

cvs acid reducer 10 mg tab generic MDD 2 per day

cvs acid reducer max st 150 mg tab generic MDD 2 per day

cvs dual action complete 10-800-165 mg chew tab generic

cvs heartburn relief 200 mg tab generic MDD 1 per day

cvs ranitidine 75 mg tab generic MDD 2 per day

dual action complete 10-800-165 mg chew tab generic duo fusion 10-800-165 mg chew tab generic

eq acid reducer 10 mg tab generic MDD 2 per day

eq acid reducer 150 mg tab generic MDD 2 per day

eq acid reducer 200 mg tab generic MDD 1 per day

eq acid reducer 75 mg tab generic MDD 2 per day

eq acid reducer complete 10-800-165 mg chew tab generic

eq heartburn relief 200 mg tab generic MDD 1 per day

eq ranitidine 75 mg tab generic MDD 2 per day

eql acid reducer 150 mg tab generic MDD 2 per day

eql acid reducer 200 mg tab generic MDD 1 per day

eql acid reducer 75 mg tab generic MDD 2 per day

eql dual action complete 10-800-165 mg chew tab generic

eql heartburn prevention 10 mg tab generic MDD 2 per day

eql heartburn relief 75 mg tab generic MDD 2 per day

eql heartburn relief max st 150 mg tab generic MDD 2 per day

famotidine 10 mg tab generic MDD 2 per day

gnp acid control 150 max st 150 mg tab generic MDD 2 per day

gnp acid control 75 75 mg tab generic MDD 2 per day

gnp acid reducer 10 mg tab generic MDD 2 per day

PAGE 39 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

gnp acid reducer 75 mg tab generic MDD 2 per day

gnp dual action complete 10-800-165 mg chew tab generic

gnp heartburn relief 200 200 mg tab generic MDD 1 per day

gnp heartburn relief 200 mg tab generic MDD 1 per day

goodsense acid reducer 150 mg tab generic MDD 2 per day

goodsense acid reducer 75 mg tab generic MDD 2 per day

heartburn relief 10 mg tab generic MDD 2 per day

heartburn relief 150 max st 150 mg tab generic MDD 2 per day

heartburn relief 200 mg tab generic MDD 1 per day

heartburn relief 75 mg tab generic MDD 2 per day

heartburn relief max st 150 mg tab generic MDD 2 per day

hm acid reducer 150 mg tab generic MDD 2 per day

hm acid reducer 75 mg tab generic MDD 2 per day

hm acid reducer max strength 150 mg tab generic MDD 2 per day

hm complete dual action 10-800-165 mg chew tab generic

hm famotidine 10 mg tab generic MDD 2 per day

kls acid controller complete 10-800-165 mg chew tab generic

kls acid reducer 75 mg tab generic MDD 2 per day

kls acid reducer max st 150 mg tab generic MDD 2 per day

px acid reducer 10 mg tab generic MDD 2 per day

px acid reducer 200 mg tab generic MDD 1 per day

px acid reducer 75 mg tab generic MDD 2 per day

px acid reducer max st 150 mg tab generic MDD 2 per day

px dual action 10-800-165 mg chew tab generic

px ranitidine 75 mg tab generic MDD 2 per day

qc acid controller 10 mg tab generic MDD 2 per day

PAGE 40 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

ra acid reducer 10 mg tab generic MDD 2 per day

ra acid reducer 200 mg tab generic MDD 1 per day

ra acid reducer 75 mg tab generic MDD 2 per day

ra acid reducer max st 150 mg tab generic MDD 2 per day

ra acid reducer plus antacid 10-800-165 mg chew tab generic ra dual action complete 10-800-165 mg chew tab generic

ranitidine acid reducer 75 mg tab generic MDD 2 per day

ranitidine hcl 150 mg tab generic MDD 2 per day

ranitidine hcl 75 mg tab generic MDD 2 per day

sb acid controller 10 mg tab generic MDD 2 per day

sb acid reducer 10 mg tab generic MDD 2 per day

sb acid reducer 150 mg tab generic MDD 2 per day

sb acid reducer ranitidine 75 mg tab generic MDD 2 per day

sb cimetidine 200 mg tab generic MDD 1 per day

sm acid reducer 10 mg tab generic MDD 2 per day

sm acid reducer 200 mg tab generic MDD 1 per day

sm acid reducer 75 mg tab generic MDD 2 per day

sm acid reducer max st 150 mg tab generic MDD 2 per day

sm complete dual action 10-800-165 mg chew tab generic

sw acid reducer 150 max st 150 mg tab generic MDD 2 per day

tgt acid controller complete 10-800-165 mg chew tab generic

tgt acid reducer 10 mg tab generic MDD 2 per day

tgt acid reducer 200 mg tab generic MDD 1 per day

tgt acid reducer 75 mg tab generic MDD 2 per day

tgt acid reducer complete 10-800-165 mg chew tab generic

th famotidine 10 10 mg tab generic MDD 2 per day

PAGE 41 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

wal-zan 150 maximum strength 150 mg tab generic MDD 2 per day

wal-zan 75 75 mg tab generic MDD 2 per day

LAXATIVES

bisacodyl laxative suppos 10 mg generic bisacodyl laxative suppos 10 mg generic bisacodyl laxative suppos 10 mg generic bisacodyl laxative suppos 10 mg generic calcium polycarbophil 625 mg tab generic bisacodyl laxative suppos 10 mg generic cvs fiber laxative 625 mg tab generic bisacodyl laxative suppos 10 mg generic cvs glycerin adult 2 gm suppos generic cvs laxative dietary supplemnt 500 mg tab generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic cvs natural daily fiber 58.6 % powder generic cvs natural fiber supplement 58.6 % powder generic cvs phosphate saline laxative 2.7-7.2 gm/15ml solution generic cvs stool softener 50 mg cap generic diocto 60 mg/15ml syrup generic docusate sodium 60 mg/15ml syrup generic milk of magnesia suspension 400 mg/5ml generic eq fiber laxative 625 mg tab generic eq fiber therapy 625 mg tab generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic eq natural fiber laxative 58.6 % powder generic eql fiber laxative 625 mg tab generic

PAGE 42 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic eql natural fiber 58.6 % powder generic fiber 625 mg tab generic fiber laxative 625 mg tab generic fiber laxative 625 mg tabs generic fiber plus calcium cap generic fiber therapy 2 gm/10.2gm powder generic fiber therapy 2 gm/19gm powder generic fiber therapy 58.6 % powder generic fiber-caps 625 mg tab generic fiber-lax 625 mg tab generic fibergen 625 mg tab generic genfiber 50 % powd generic bisacodyl laxative suppos 10 mg generic geri-mucil 68 % powder generic glycerin (adult) 2 gm suppos generic glycerin (child) 1.2 gm suppos generic glycerin (infants & children) 1.2 gm suppos generic glycerin (pediatric) 1.2 gm suppos generic glycerin adult 2 gm suppos generic gnp fiber-caps 625 mg tab generic gnp glycerin (infant) 1.2 gm suppos generic gnp glycerin child 1.2 gm suppos generic bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic

PAGE 43 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS gnp stool softener 60 mg/15ml syrup generic hm fiber 58.6 % powder generic bisacodyl laxative suppos 10 mg generic milk of magnesia suspension 400 mg/5ml generic kls fiber-tabs 625 mg tab generic kls natural psyllium fiber 58.6 % powder generic KONDREMUL 50 % EMULSION BRAND mineral oil KONSYL 60.3 % POWDER BRAND psyllium KONSYL 71.67 % POWDER BRAND psyllium konsyl fiber 625 mg tab generic KONSYL-D 52.3 % POWDER BRAND psyllium bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic senna maximum strength tab 25 mg generic METAMUCIL WAFER BRAND psyllium METAMUCIL MULTIHEALTH FIBER 55.46 % POWDER BRAND psyllium metamucil multihealth fiber 58.6 % powder generic metamucil smooth texture 58.6 % powder generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic NAT-RUL PSYLLIUM SEED HUSKS 500 MG CAP BRAND psyllium natrul colon care 100 % powder generic natural fiber 58.6 % powder generic natural fiber laxative 58.6 % powder generic

PAGE 44 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS natural fiber laxative 68 % powder generic natural fiber therapy 30 % powder generic natural psyllium seed 100 % powder generic milk of magnesia suspension 400 mg/5ml generic phosphate laxative 0.9-2.4 gm/5ml solution generic psyldex 30 % powder generic psyllium husk 100 % powder generic px fiber 625 mg tab generic milk of magnesia suspension 400 mg/5ml generic bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic qc natural vegetable 95 % powder generic ra col-rite 50 mg cap generic bisacodyl laxative suppos 10 mg generic ra fiber 58.6 % powder generic ra fiber therapy 625 mg tab generic ra fiber-cap 625 mg tab generic ra fiber-tab 625 mg tab generic senna maximum strength tab 25 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic ra multihealth fiber 58.6 % powder generic ra oral saline laxative 0.9-2.4 gm/5ml solution generic ra oral saline laxative 2.7-7.2 gm/15ml solution generic ra saline laxative 2.7-7.2 gm/5ml solution generic bisacodyl laxative suppos 10 mg generic reguloid 58.6 % powder generic reguloid 68 % powder generic saline laxative 0.9-2.4 gm/5ml solution generic

PAGE 45 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS sani-supp adult 2 gm suppos generic sani-supp pediatric 1.2 gm suppos generic sb fib lax orange 30 % powder generic sb fiber laxative 625 mg tab generic sb glycerin pediatric 1.2 gm suppos generic bisacodyl laxative suppos 10 mg generic milk of magnesia suspension 400 mg/5ml generic senna maximum strength tab 25 mg generic silace 60 mg/15ml syrup generic sm fiber 58.6 % powder generic sm fiber 625 mg tab generic sm fiber laxative 625 mg tab generic sm glycerin pediatric 1.2 gm suppos generic bisacodyl laxative suppos 10 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic sm oral saline laxative 0.9-2.4 gm/5ml solution generic sm oral saline laxative 2.7-7.2 gm/5ml solution generic senna maximum strength tab 25 mg generic soluble fiber therapy powder generic sorbulax 100 % powder generic tgt fiber laxative 625 mg tab generic tgt fiber therapy 58.6 % powder generic senna maximum strength tab 25 mg generic senna maximum strength tab 25 mg generic milk of magnesia suspension 400 mg/5ml generic milk of magnesia suspension 400 mg/5ml generic bisacodyl laxative suppos 10 mg generic wal-mucil 100 % powder generic

PAGE 46 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS wal-mucil 58.6 % powder generic wal-mucil plus calcium cap generic PROTON PUMP INHIBITORS

PA cvs esomeprazole magnesium 20 mg cap dr generic MDD 1 per day

cvs lansoprazole 15 mg cap dr generic MDD 2 per day

eq lansoprazole 15 mg cap dr generic MDD 2 per day

eql lansoprazole 15 mg cap dr generic MDD 2 per day

PA esomeprazole magnesium 20 mg cap dr generic MDD 1 per day

gnp lansoprazole 15 mg cap dr generic MDD 2 per day

PA goodsense esomeprazole 20 mg cap dr generic MDD 1 per day

goodsense lansoprazole 15 mg cap dr generic MDD 2 per day

heartburn relief 24 hour 15 mg cap dr generic MDD 2 per day

heartburn treatment 24 hour 15 mg cap dr generic MDD 2 per day

PA heartburn treatment 24 hour 20 mg cap dr generic MDD 1 per day

PA hm esomeprazole magnesium dr 20 mg cap dr generic MDD 1 per day

hm lansoprazole 15 mg cap dr generic MDD 2 per day

PA kls esomeprazole magnesium 20 mg cap dr generic MDD 1 per day

kls lansoprazole 15 mg cap dr generic MDD 2 per day

lansoprazole 15 mg cap dr generic MDD 2 per day

ra lansoprazole 15 mg cap dr generic MDD 2 per day

PA sm esomeprazole magnesium 20 mg cap dr generic MDD 1 per day

PAGE 47 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

sm lansoprazole 15 mg cap dr generic MDD 2 per day

GENITOURINARY AGENTS

GENITOURINARY AGENTS, OTHER

azo dine 95 mg tab generic azo tabs 95 mg tab generic azo urinary pain relief 95 mg tab generic azo-standard 95 mg tab generic cvs urinary pain relief 95 mg tab generic eq urinary pain relief 95 mg tab generic gnp urinary pain relief 95 mg tab generic phenazo 95 mg tab generic phenazopyridine hcl 95 mg tab generic qc azo 95 mg tab generic ra urinary pain relief 95 mg tab generic ra urinary tract pain relief 95 mg tab generic sb urinary pain relief 95 mg tab generic sm urinary pain relief 95 mg tab generic th urinary pain relief 95 mg tab generic TRIMO-SAN 0.025 % GEL BRAND oxyquinolone sulfate vaginal urinary pain relief 95 mg tab generic uristat 95 mg tab generic HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

PROGESTINS

aftera 1.5 mg tab generic PA

econtra ez 1.5 mg tab generic PA

fallback solo 1.5 mg tab generic PA

levonorgestrel 1.5 mg tab generic PA

my choice 1.5 mg tab generic PA

PAGE 48 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

my way 1.5 mg tab generic PA

next choice one dose 1.5 mg tab generic PA

opcicon one-step 1.5 mg tab generic PA

option 2 1.5 mg tab generic PA

react 1.5 mg tab generic PA

take action 1.5 mg tab generic PA

MISCELLANEOUS THERAPEUTIC AGENTS

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

8 hour arthritis pain reliever 650 mg tab er generic C Non-Formulary Drug

8 hour pain relief 650 mg tab er generic C Non-Formulary Drug

8 hour pain reliever 650 mg tab er generic C Non-Formulary Drug

8hr muscle aches & pain 650 mg tab er generic C Non-Formulary Drug

a1c test at-home kit generic

acetaminophen 160 mg/5ml liquid generic C Non-Formulary Drug

acetaminophen 325 mg tab generic

acetaminophen 8 hour 650 mg tab er generic C Non-Formulary Drug

acetaminophen 80 mg chew tab generic C Non-Formulary Drug

acetaminophen er 650 mg tab er generic C Non-Formulary Drug

acetaminophen rapid tabs child 80 mg tab disp generic actidose/sorbitol 25 gm/120ml liquid generic actidose/sorbitol 50 gm/240ml liquid generic

activated vegetable charcoal 260 mg cap generic PA

ADVANCED CARE CHOLESTEROL KIT BRAND PA cholesterol test

PAGE 49 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS aminofen 325 mg tab generic

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

antiseptic 10 % solution generic PA

apap 325 mg tab generic

apap 80 mg chew tab generic C Non-Formulary Drug

aphen 325 mg tab generic AQUAFRESH PASTE BRAND dentifrices AQUAFRESH ADVANCED PASTE BRAND dentifrices AQUAFRESH CAVITY PROTECTION 0.15 % PASTE BRAND dentifrices AQUAFRESH EXTREME CLEAN 0.15 % PASTE BRAND dentifrices AQUAFRESH EXTREME CLEAN 0.25 % PASTE BRAND dentifrices AQUAFRESH FOR KIDS PASTE BRAND dentifrices AQUAFRESH SENSITIVE 5 % PASTE BRAND dentifrices AQUAFRESH TARTAR CONTROL PASTE BRAND dentifrices AQUAFRESH WHITENING PASTE BRAND dentifrices

arthritis pain 650 mg tab er generic C Non-Formulary Drug

arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

arthritis pain reliever 650 mg tab er generic C Non-Formulary Drug

PAGE 50 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

athletes foot 2 % powder generic PA

AZO TEST STRIP BRAND PA leukocyte test AZOSTIX STRIP BRAND PA bun test BABY ORAJEL TOOTH/GUM CLEANSER 2-0.12 % GEL BRAND PA oral hygiene products BETADINE SPRAY 5 % AERO SOLN BRAND PA povidone-iodine BIOTENE DRY MOUTH PASTE BRAND dentifrices BIOTENE DRY MOUTH GENTLE PASTE BRAND dentifrices BIOTENE PBF DRY MOUTH PASTE BRAND dentifrices BUG ITCH RELEAF SOLUTION BRAND PA misc natural products CA-REZZ 0.25 % LIQUID BRAND triclosan

charcoal 260 mg cap generic PA

CHARCOAL PLUS DS 250 MG TAB BRAND PA charcoal activated

charcocaps 260 mg cap generic PA

childrens acetaminophen 80 mg chew tab generic C Non-Formulary Drug

childrens acetaminophen 80 mg tab disp generic

childrens apap 80 mg chew tab generic C Non-Formulary Drug

childrens mapap rapid tabs 80 mg tab disp generic

childrens medi-tabs 80 mg chew tab generic C Non-Formulary Drug

childrens non-asa pain relief 80 mg chew tab generic C Non-Formulary Drug

childrens non-aspirin 80 mg chew tab generic C Non-Formulary Drug

childrens non-aspirin 80 mg tab disp generic

childrens pain reliever 80 mg chew tab generic C Non-Formulary Drug

PAGE 51 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS childrens pain reliever 80 mg tab disp generic

childrens silapap 160 mg/5ml liquid generic C Non-Formulary Drug

childrens silfedrine 15 mg/5ml liquid generic C Non-Formulary Drug

childrens tactinal 80 mg chew tab generic C Non-Formulary Drug

COLGATE PLATINUM 0.76 % PASTE BRAND dentifrices CREST PASTE BRAND dentifrices CREST 0.243 % PASTE BRAND dentifrices CREST TARTAR CONTROL PASTE BRAND dentifrices CREST TC/BAKING SODA PASTE BRAND dentifrices CURITY POVIDONE-IODINE PAINT 1 % SOLUTION BRAND PA povidone-iodine

cvs 8 hour pain relief 650 mg tab er generic C Non-Formulary Drug

cvs acetaminophen 325 mg tab generic

cvs anti-fungal 2 % powder generic PA

cvs arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

cvs at home a1c test kit generic

cvs childs non-aspirin 80 mg chew tab generic C Non-Formulary Drug

cvs digital pregnancy test test generic PA

cvs early pregnancy test generic PA

cvs early result pregnancy test generic PA

CVS EPSOM SALT GRANULES BRAND magnesium sulfate (laxative)

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PAGE 52 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

cvs non-aspirin childrens 80 mg chew tab generic C Non-Formulary Drug

cvs non-aspirin jr 160 mg chew tab generic C Non-Formulary Drug

cvs one step pregnancy test generic PA

cvs pain relief 650 mg tab er generic C Non-Formulary Drug

cvs pain relief regular st 325 mg tab generic

cvs povidone-iodine 10 % solution generic PA

cvs pregnancy test kit test generic PA

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

cvs tension headache 500-65 mg tab generic C Non-Formulary Drug

digital pregnancy test generic PA

ed-apap 160 mg/5ml liquid generic C Non-Formulary Drug

ELIXSURE CONGESTION 15 MG/5ML GEL BRAND PA pseudoephedrine hcl EPSOM SALT GRANULES BRAND magnesium sulfate (laxative)

eq 8hr arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

eq acetaminophen 325 mg tab generic eq acetaminophen childrens 80 mg tab disp generic

eq arthritis pain 650 mg tab er generic C Non-Formulary Drug

eq childrens pain reliever 80 mg chew tab generic C Non-Formulary Drug

eq first aid antiseptic 10 % solution generic PA

eq menstrual complete 500-60-15 mg tab generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

eq pain reliever 325 mg tab generic

PAGE 53 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

eq pain reliever junior 160 mg chew tab generic C Non-Formulary Drug

eq povidone-iodine 10 % solution generic PA

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

eql acetaminophen 325 mg tab generic

eql acetaminophen 8 hour 650 mg tab er generic C Non-Formulary Drug

eql acetaminophen 80 mg tab disp generic

eql arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

eql childrens nasal decongest 15 mg/5ml liquid generic C Non-Formulary Drug

EQL EPSOM SALT GRANULES BRAND magnesium sulfate (laxative)

eql menstrual relief max st 500-60-15 mg tab generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

eql pain relief 325 mg tab generic

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

fattibase ointment generic FEVERALL 80 MG SUPPOS BRAND acetaminophen FEVERALL INFANTS 80 MG SUPPOS BRAND acetaminophen

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PAGE 54 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS genebs 325 mg tabs generic

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

gnp 8 hour pain relief 650 mg tab er generic C Non-Formulary Drug

gnp 8 hour pain reliever 650 mg tab er generic C Non-Formulary Drug

gnp arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

gnp childrens easy-melts 80 mg tab disp generic

gnp headache relief 500-65 mg tab generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

gnp pain relief 325 mg tab generic

gnp povidone-iodine 10 % solution generic PA

gnp suphedrin 15 mg/5ml liquid generic C Non-Formulary Drug

goodsense arthritis pain 650 mg tab er generic C Non-Formulary Drug

goodsense menstrual relief 500-60-15 mg tab generic C Non-Formulary Drug

goodsense pain relief 325 mg tab generic

goodsense pain relief 650 mg tab er generic C Non-Formulary Drug

grx dyne 10 % solution generic PA

HEMATEST TAB BRAND occult blood

hm acetaminophen childrens 160 mg chew tab generic C Non-Formulary Drug

hm arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

PAGE 55 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

hm pain relief 650 mg tab er generic C Non-Formulary Drug

hm pain reliever 325 mg tab generic

hm povidone-iodine 10 % solution generic PA

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

HOME ACCESS EXPRESS HIV-1 TEST KIT BRAND PA hiv-1 test HOME ACCESS HIV-1 TEST SYSTEM KIT BRAND PA hiv-1 test

inositol hexanicotinate powder generic PA

iodine whirlpool concentrate 10 % solution generic PA

isopropyl alcohol 50 % solution generic IVY ITCH RELEAF SOLUTION BRAND PA misc natural products kerr insta-char in sorbitol 25 gm/120ml liquid generic kerr insta-char in sorbitol 50 gm/240ml liquid generic

kls arthritis pain 650 mg tab er generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

liquid pain relief 160 mg/5ml liquid generic C Non-Formulary Drug

little remedies for fever 160 mg/5ml liquid generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PAGE 56 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

mapap 160 mg/5ml liquid generic C Non-Formulary Drug

mapap 325 mg tab generic

mapap 80 mg chew tab generic C Non-Formulary Drug

mapap arthritis pain 650 mg tab er generic C Non-Formulary Drug

mapap childrens 160 mg chew tab generic C Non-Formulary Drug

mapap childrens 80 mg tab disp generic MAPAP HEADACHE PLUS 500-250 MG TAB BRAND C Non-Formulary Drug acetaminophen w/ calcium carbonate maxapap regular strength 325 mg tab generic medi-tabs 325 mg tab generic

medi-tabs junior strength 160 mg chew tab generic C Non-Formulary Drug

meijer aspirin free 325 mg tab generic

meijer jr st aspirin free 160 mg chew tab generic C Non-Formulary Drug

menstrual complete 500-60-15 mg tab generic C Non-Formulary Drug

menstrual relief max strength 500-60-15 mg tab generic C Non-Formulary Drug

midol 650 mg tab er generic C Non-Formulary Drug

midol caffeine free 500-25 mg tab generic C Non-Formulary Drug

midol teen 500-25 mg tab generic C Non-Formulary Drug

ms-aid 500-25 mg tab generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PAGE 57 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PAGE 58 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS NEO-SYNEPHRINE 0.5 % SOLUTION BRAND C Non-Formulary Drug phenylephrine hcl NASAL DECONGESTANT SOLUTION 1 % BRAND C Non-Formulary Drug phenylephrine hcl NEO-SYNEPHRINE COLD & SINUS 0.5 % SOLUTION BRAND C Non-Formulary Drug phenylephrine hcl NASAL DECONGESTANT SOLUTION 1 % BRAND C Non-Formulary Drug phenylephrine hcl

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

non-aspirin 325 mg tab generic

non-aspirin 8 hour 650 mg tab er generic C Non-Formulary Drug

non-aspirin childrens 160 mg/5ml liquid generic C Non-Formulary Drug

non-aspirin jr strength 160 mg chew tab generic C Non-Formulary Drug

non-aspirin pain relief 325 mg tab generic

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

operand povidone-iodine 10 % solution generic PA

ORAJEL BABY TOOTH/GUM 2-0.12 % GEL BRAND PA oral hygiene products

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

pain & fever 325 mg tab generic

pain & fever childrens 160 mg chew tab generic C Non-Formulary Drug

pain & fever childrens 80 mg chew tab generic C Non-Formulary Drug

pain relief 325 mg tab generic

pain relief 8 hour 650 mg tab er generic C Non-Formulary Drug

pain relief regular strength 325 mg tab generic

PAGE 59 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS pain reliever 325 mg tab generic PEARL DROPS EXTRA STRENGTH PASTE BRAND dentifrices

PEDIACARE CHILDRENS DECONGEST 2.5 MG/5ML PA SOLUTION BRAND phenylephrine hcl (oral) C Non-Formulary Drug peg blend ointment generic peg ointment base ointment generic pharbetol 325 mg tab generic

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

phenylgesic 30-325 mg tabs generic C Non-Formulary Drug

phosphatidylcholine powder generic

povidone-iodine 10 % solution generic PA

pregnancy test test generic PA

pvp prep 10 % solution generic PA

px arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

q-pap 160 mg/5ml liquid generic C Non-Formulary Drug

q-pap 325 mg tab generic

qc acetaminophen 8 hours 650 mg tab er generic C Non-Formulary Drug

qc arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

PAGE 60 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

qc non-aspirin 8 hour 650 mg tab er generic C Non-Formulary Drug

qc pain relief 325 mg tab generic

qc povidone iodine 10 % solution generic PA

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

ra 8 hour pain relief 650 mg tab er generic C Non-Formulary Drug

ra acetaminophen 325 mg tab generic

ra acetaminophen 650 mg tab er generic C Non-Formulary Drug

ra acetaminophen childrens 160 mg chew tab generic C Non-Formulary Drug

ra acetaminophen rapid melts 80 mg tab disp generic

ra antiseptic 10 % solution generic PA

ra arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

RA EPSOM SALT GRANULES BRAND magnesium sulfate (laxative) RA EPSOM SALT LAVENDER GRANULES BRAND magnesium sulfate (laxative) RA FLUORIDE TOOTHPASTE 0.15 % PASTE BRAND dentifrices

ra menstrual complete 500-60-15 mg tab generic C Non-Formulary Drug

PAGE 61 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

ra menstrual relief 500-60-15 mg tab generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

RA SENSITIVE TOOTHPASTE/FL 5-0.14 % PASTE BRAND dentifrices

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

ra tension headache 500-65 mg tab generic C Non-Formulary Drug

RA WHITENING TOOTHPASTE/FL 0.76 % PASTE BRAND dentifrices

rhinall 0.25 % solution generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

sb arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

sb childrens non-aspirin 80 mg tab disp generic

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

sb non-aspirin 160 mg chew tab generic C Non-Formulary Drug

sb non-aspirin 325 mg tab generic

PAGE 62 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

sb non-aspirin 80 mg chew tab generic C Non-Formulary Drug

sb povidone-iodine 10 % solution generic PA

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

SENSITIVE EXTRA WHITENING 5-0.243 % PASTE BRAND dentifrices SENSITIVE TOOTHPASTE/FLUORIDE 5-0.243 % PASTE BRAND dentifrices SENSODYNE MAXIMUM STRENGTH 5-0.13 % PASTE BRAND dentifrices SENSODYNE MAXIMUM STRENGTH 5-0.15 % PASTE BRAND dentifrices SENSODYNE MAXIMUM STRENGTH 5-0.25 % PASTE BRAND dentifrices SENSODYNE PRONAMEL PASTE BRAND dentifrices SENSODYNE PRONAMEL 5-0.25 % PASTE BRAND dentifrices SENSODYNE TARTAR CONTROL 5-0.145 % PASTE BRAND dentifrices

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PAGE 63 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

sm 8 hour pain relief 650 mg tab er generic C Non-Formulary Drug

sm adult nasal decongestant 15 mg/5ml liquid generic C Non-Formulary Drug

sm arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

sm arthritis pain reliever 650 mg tab er generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

sm pain reliever 325 mg tab generic

sm pain reliever 8 hour ex st 650 mg tab er generic C Non-Formulary Drug

sm pain reliever ex st 650 mg tab er generic C Non-Formulary Drug

sm pain reliever jr st 160 mg chew tab generic C Non-Formulary Drug

sm povidone-iodine 10 % solution generic PA

sm tension headache 500-65 mg tab generic C Non-Formulary Drug

SUDAFED 24 HOUR 240 MG TAB ER 24H PA BRAND pseudoephedrine hcl C Non-Formulary Drug

SUDAFED PE CHILDRENS 2.5 MG/5ML SOLUTION PA BRAND phenylephrine hcl (oral) C Non-Formulary Drug

PAGE 64 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

tactinal 325 mg tab generic

tension headache 500-65 mg tab generic C Non-Formulary Drug

tension headache relief 500-65 mg tab generic C Non-Formulary Drug

tgt acetaminophen melts child 80 mg tab disp generic

tgt arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

tgt menstrual relief 500-60-15 mg tab generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

th arthritis pain relief 650 mg tab er generic C Non-Formulary Drug

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

PA 12 hour nasal relief spray solution 0.05 % generic C Non-Formulary Drug

VIADENT PASTE BRAND dentifrices VIADENT ADVANCED CARE 0.8-2 % PASTE BRAND dentifrices

PAGE 65 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS VIADENT FLUORIDE PASTE BRAND dentifrices VIADENT PLAQUE PASTE BRAND dentifrices VICKS SINEX 0.5 % SOLUTION BRAND C Non-Formulary Drug phenylephrine hcl VICKS SINEX ULTRAFINE MIST 0.5 % SOLUTION BRAND C Non-Formulary Drug phenylephrine hcl

PA phenylephrine hcl tab 10 mg generic C Non-Formulary Drug

womens menstrual relief 500-25 mg tab generic C Non-Formulary Drug

womens tylenol 500-25 mg tab generic C Non-Formulary Drug

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

advanced lubricant 0.05-1 % solution generic C Non-Formulary Drug

alaway 0.025 % solution generic alaway childrens allergy 0.025 % solution generic

allergy eye 0.025-0.3 % solution generic C Non-Formulary Drug

allergy eye drops 0.025 % solution generic artificial tears 0.1-0.3 % solution generic artificial tears 0.1-0.3 % solution generic

artificial tears 0.2-0.2-1 % solution generic C Non-Formulary Drug

artificial tears 1-0.3 % solution generic C Non-Formulary Drug

artificial tears 1.4 % solution generic

biolle gel tears 1 % gel generic C Non-Formulary Drug

bion tears 0.1-0.3 % solution generic claritin eye 0.025 % solution generic cvs allergy eye drops 0.025 % solution generic cvs antihistamine eye drops 0.025 % solution generic

cvs artificial tears 1-0.3 % solution generic C Non-Formulary Drug

PAGE 66 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

cvs dry eye relief 0.2-0.2-1 % solution generic C Non-Formulary Drug

cvs eye allergy relief 0.025-0.3 % solution generic C Non-Formulary Drug

cvs eye drops 0.05 % solution generic cvs eye itch relief 0.025 % solution generic CVS LUBRICANT DROPS 1 % GEL BRAND C Non-Formulary Drug carboxymethylcellulose sodium (ophth)

cvs lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug

cvs maximum redness relief 0.03-0.5 % solution generic C Non-Formulary Drug

cvs natural tears 0.1-0.3 % solution generic

cvs redness relief 0.012-0.2 % solution generic C Non-Formulary Drug

eq artificial tears 1-0.3 % solution generic C Non-Formulary Drug

eq eye allergy relief 0.027-0.315 % solution generic PA

eq eye drops 0.05 % solution generic eq eye itch relief 0.025 % solution generic eq itchy eye drops 0.025 % solution generic

eq lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug

eql eye drops 0.05 % solution generic

eye allergy relief 0.025-0.3 % solution generic C Non-Formulary Drug

eye allergy relief 0.027-0.315 % solution generic PA

eye drops 0.012-0.2 % solution generic C Non-Formulary Drug

eye drops 0.05 % solution generic

eye drops extra 0.05-1 % solution generic C Non-Formulary Drug

eye itch relief 0.025 % solution generic GENTEAL MILD 0.2 % SOLUTION BRAND C Non-Formulary Drug hypromellose (ophth) GENTEAL SEVERE 0.3 % GEL BRAND C Non-Formulary Drug hypromellose (ophth) genteal tears 0.1-0.2-0.3 % solution generic genteal tears 0.1-0.3 % solution generic

PAGE 67 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS gnp eye drops 0.05 % solution generic gnp eye itch relief 0.025 % solution generic gnp itchy eye 0.025 % solution generic

gnp lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug

gnp ultra lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug

goniosoft 2.5 % solution generic C Non-Formulary Drug

goniotaire 2.5 % solution generic C Non-Formulary Drug

goniovisc 2.5 % solution generic C Non-Formulary Drug

goodsense eye drops 0.05 % solution generic goodsense itchy eye 0.025 % solution generic

hm dry eye relief 0.2-0.2-1 % solution generic C Non-Formulary Drug

hm eye drops 0.05 % solution generic hm eye itch relief 0.025 % solution generic

hm lubricating tears 0.4-0.3 % solution generic C Non-Formulary Drug

HYPOTEARS 1-1 % SOLUTION BRAND C Non-Formulary Drug polyethylene glycol-polyvinyl alcohol (ophth) ISOPTO TEARS 0.5 % SOLUTION BRAND C Non-Formulary Drug hypromellose (ophth) just tears eye drops solution generic ketotifen fumarate 0.025 % solution generic kp ketotifen fumarate 0.025 % solution generic liquitears 1.4 % solution generic lubricant drops 1.4 % solution generic

lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug

lubricating eye drops 0.4-0.3 % solution generic C Non-Formulary Drug

MURO 128 2 % SOLUTION BRAND PA sodium chloride hypertonic natural balance tears solution generic

PAGE 68 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS natural balance tears 0.4 % solution generic natures tears solution generic natures tears 0.1-0.3 % solution generic natures tears 0.4 % solution generic opti-clear 0.05 % solution generic

optics mini drops 1.4-0.6 % solution generic C Non-Formulary Drug

polyvinyl alcohol 1.4 % solution generic px sterile eye drops 0.05 % solution generic ra antihistamine eye drops 0.025 % solution generic

ra artificial tears 1-0.3 % solution generic C Non-Formulary Drug

ra eye allergy relief 0.027-0.315 % solution generic PA

ra eye drops extra 0.05-1 % solution generic C Non-Formulary Drug

ra eye itch relief 0.025 % solution generic ra lubricant eye 0.1-0.3 % solution generic

ra lubricant eye 0.4-0.3 % solution generic C Non-Formulary Drug

ra lubricant eye 1-0.3 % solution generic C Non-Formulary Drug

ra sterile eye drops 0.012-0.2 % solution generic C Non-Formulary Drug

ra sterile eye drops 0.03-0.5 % solution generic C Non-Formulary Drug

redness reliever eye drops 0.05 % solution generic REFRESH CELLUVISC 1 % SOLUTION BRAND C Non-Formulary Drug carboxymethylcellulose sodium (ophth) REFRESH LIQUIGEL 1 % SOLUTION BRAND C Non-Formulary Drug carboxymethylcellulose sodium (ophth) sm artificial tears solution generic

sm dry eye relief 0.2-0.2-1 % solution generic C Non-Formulary Drug

sm eye drops 0.05 % solution generic sm eye itch relief 0.025 % solution generic

sm lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug

sm lubricating tears 0.4-0.3 % solution generic C Non-Formulary Drug

PAGE 69 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS soothe hydration 1.25 % solution generic soothe xp solution generic soothe xp xtra protection solution generic systane contacts solution generic SYSTANE OVERNIGHT THERAPY 0.3 % GEL BRAND C Non-Formulary Drug hypromellose (ophth) tears again solution generic tears again advanced eyelid solution generic tears naturale free 0.1-0.3 % solution generic tears naturale ii solution generic tears pure 0.1-0.3 % solution generic tetrahydrozoline hcl 0.05 % solution generic

tgt eye allergy relief 0.027-0.315 % solution generic PA

tgt eye itch relief 0.025 % solution generic TGT LUBRICANT EYE DROPS 0.95 % SOLUTION BRAND C Non-Formulary Drug propylene glycol (ophth)

tgt lubricant eye drops 1-0.3 % solution generic C Non-Formulary Drug

tgt lubricant redness reliever 0.03-0.5 % solution generic C Non-Formulary Drug

tgt redness reliever 0.012-0.2 % solution generic C Non-Formulary Drug

th eye drop original 0.05 % solution generic

th eye drop tears 0.2-0.2-1 % solution generic C Non-Formulary Drug

THERATEARS 0.25 % SOLUTION BRAND C Non-Formulary Drug carboxymethylcellulose sodium (ophth) theratears allergy 0.025 % solution generic THERATEARS PF 0.25 % SOLUTION BRAND C Non-Formulary Drug carboxymethylcellulose sodium (ophth)

ultra lubricant eye drops 0.4-0.3 % solution generic C Non-Formulary Drug

VISINE MAXIMUM REDNESS RELIEF 0.05-0.2-0.36-1 % SOLUTION BRAND C Non-Formulary Drug tetrahydrozoline-glycerin-hypromellose-peg 400 VISINE TEARS 0.2-0.36-1 % SOLUTION BRAND C Non-Formulary Drug glycerin-hypromellose-polyethylene glycol 400

PAGE 70 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS VISINE TIRED EYE RELIEF 0.2-0.36-1 % SOLUTION BRAND C Non-Formulary Drug glycerin-hypromellose-polyethylene glycol 400

visine-a 0.025-0.3 % solution generic C Non-Formulary Drug

VISINE-LR 0.025 % SOLUTION BRAND C Non-Formulary Drug oxymetazoline hcl (ophth) VIVA DROPS 1 % SOLUTION BRAND C Non-Formulary Drug polysorbate 80 (ophth) VIVA DROPS 1 % SOLUTION BRAND C Non-Formulary Drug polysorbate 80 (ophth) wal-zyr 0.025 % solution generic zyrtec itchy eye 0.025 % solution generic OTIC AGENTS

auraphene-b 6.5 % solution generic C Non-Formulary Drug

auro eardrops 6.5 % solution generic C Non-Formulary Drug

carbamoxide ear drops 6.5 % solution generic C Non-Formulary Drug

cvs ear drops 6.5 % solution generic C Non-Formulary Drug

cvs ear wax removal system 6.5 % solution generic C Non-Formulary Drug

e-r-o ear drops 6.5 % solution generic C Non-Formulary Drug

e-r-o ear wax removal system 6.5 % solution generic C Non-Formulary Drug

ear drops 6.5 % solution generic C Non-Formulary Drug

ear drops earwax aid 6.5 % solution generic C Non-Formulary Drug

ear wax drops 6.5 % solution generic C Non-Formulary Drug

ear wax removal aid 6.5 % solution generic C Non-Formulary Drug

ear wax removal drops 6.5 % solution generic C Non-Formulary Drug

ear wax removal kit 6.5 % solution generic C Non-Formulary Drug

ear wax removal system 6.5 % solution generic C Non-Formulary Drug

ear wax remover 6.5 % solution generic C Non-Formulary Drug

earwax removal 6.5 % solution generic C Non-Formulary Drug

PAGE 71 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

earwax removal kit 6.5 % solution generic C Non-Formulary Drug

earwax treatment drops 6.5 % solution generic C Non-Formulary Drug

eq ear wax removal aid 6.5 % solution generic C Non-Formulary Drug

eql ear drops 6.5 % solution generic C Non-Formulary Drug

gnp ear drops 6.5 % solution generic C Non-Formulary Drug

gnp ear systems 6.5 % solution generic C Non-Formulary Drug

goodsense ear wax removal 6.5 % solution generic C Non-Formulary Drug

hm earwax removal aid 6.5 % solution generic C Non-Formulary Drug

hm earwax removal kit 6.5 % solution generic C Non-Formulary Drug

murine ear 6.5 % solution generic C Non-Formulary Drug

murine ear wax removal system 6.5 % solution generic C Non-Formulary Drug

otix 6.5 % solution generic C Non-Formulary Drug

qc ear wax removal 6.5 % solution generic C Non-Formulary Drug

ra ear drops 6.5 % solution generic C Non-Formulary Drug

ra earwax removal kit 6.5 % solution generic C Non-Formulary Drug

sb ear wax remover 6.5 % solution generic C Non-Formulary Drug

sm ear drops 6.5 % solution generic C Non-Formulary Drug

thera-ear 6.5 % solution generic C Non-Formulary Drug

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

FLONASE SENSIMIST 27.5 MCG/SPRAY SUSPENSION BRAND PA fluticasone furoate ANTIHISTAMINES

loratadine tab 10 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

PA cetirizine hcl chew tab 10 mg generic MDD 1 per day

PAGE 72 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

aller-chlor 2 mg/5ml syrup generic C Non-Formulary Drug

fexofenadine hcl tab 180 mg generic MDD 1 per day

PA fexofenadine hcl tab 60 mg generic MDD 2 per day

aller-ease childrens 30 mg/5ml suspension generic PA

loratadine tab 10 mg generic MDD 1 per day

fexofenadine hcl tab 180 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

childrens loratadine syrup 5 mg/5ml generic PA

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

allergy rapid melts childrens 12.5 mg chew tab generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

fexofenadine hcl tab 180 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

childrens loratadine syrup 5 mg/5ml generic PA

PA fexofenadine hcl tab 60 mg generic MDD 2 per day

childrens loratadine syrup 5 mg/5ml generic PA

PA cetirizine hcl chew tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic PA

clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug

altaryl 12.5 mg/5ml syrup generic C Non-Formulary Drug

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

PAGE 73 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

diphenhydramine hcl cap 50 mg generic PA

PA benadryl allergy 25 mg strp generic C Non-Formulary Drug

PA cetirizine hcl chew tab 10 mg generic MDD 1 per day

cetirizine hcl 5 mg tab generic MDD 1 per day

PA cetirizine hcl chew tab 10 mg generic MDD 1 per day

childrens complete allergy 12.5 mg chew tab generic C Non-Formulary Drug

childrens loratadine syrup 5 mg/5ml generic PA

clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

cvs allergy childrens 12.5 mg chew tab generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

fexofenadine hcl tab 180 mg generic MDD 1 per day

PA fexofenadine hcl tab 60 mg generic MDD 2 per day

cvs allergy relief childrens 30 mg/5ml suspension generic PA

childrens loratadine syrup 5 mg/5ml generic PA

PA cetirizine hcl chew tab 10 mg generic MDD 1 per day

loratadine tab 10 mg generic MDD 1 per day

PAGE 74 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug

diabetic tussin allergy 2 mg/5ml syrup generic C Non-Formulary Drug

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

diphenhydramine hcl cap 50 mg generic PA

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

ED CHLORPED 2 MG/ML LIQUID BRAND C Non-Formulary Drug chlorpheniramine maleate

ed chlorped jr 2 mg/5ml syrup generic C Non-Formulary Drug

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

fexofenadine hcl tab 180 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

childrens loratadine syrup 5 mg/5ml generic PA

clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

fexofenadine hcl tab 180 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

eql allergy childrens 30 mg/5ml suspension generic PA

loratadine tab 10 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

childrens loratadine syrup 5 mg/5ml generic PA

clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug

fexofenadine hcl tab 180 mg generic MDD 1 per day

PAGE 75 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA fexofenadine hcl tab 60 mg generic MDD 2 per day

fexofenadine hcl childrens 30 mg/5ml suspension generic PA

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

fexofenadine hcl tab 180 mg generic MDD 1 per day

clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic PA

fexofenadine hcl tab 180 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

HISTEX 2.5 MG/5ML SYRUP BRAND C Non-Formulary Drug triprolidine hcl

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

fexofenadine hcl tab 180 mg generic MDD 1 per day

PA fexofenadine hcl tab 60 mg generic MDD 2 per day

loratadine tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic PA

J-TAN PD 1 MG/ML LIQUID PA BRAND brompheniramine maleate C Non-Formulary Drug

fexofenadine hcl tab 180 mg generic MDD 1 per day

PAGE 76 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

loratadine tab 10 mg generic MDD 1 per day

kp cetirizine hcl 5 mg tab generic MDD 1 per day

diphenhydramine hcl cap 50 mg generic PA

fexofenadine hcl tab 180 mg generic MDD 1 per day

PA fexofenadine hcl tab 60 mg generic MDD 2 per day

loratadine tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic PA

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

childrens loratadine syrup 5 mg/5ml generic PA

fexofenadine hcl tab 180 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

diphenhydramine hcl cap 50 mg generic PA

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

diphenhydramine hcl cap 50 mg generic PA

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

fexofenadine hcl tab 180 mg generic MDD 1 per day

PAGE 77 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

loratadine tab 10 mg generic MDD 1 per day

clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

childrens loratadine syrup 5 mg/5ml generic PA

loratadine tab 10 mg generic MDD 1 per day

quenalin 12.5 mg/5ml syrup generic C Non-Formulary Drug

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

fexofenadine hcl tab 180 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

PA cetirizine hcl chew tab 10 mg generic MDD 1 per day

loratadine tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic PA

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic PA

loratadine tab 10 mg generic MDD 1 per day

clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic PA

fexofenadine hcl tab 180 mg generic MDD 1 per day

PA fexofenadine hcl tab 60 mg generic MDD 2 per day

PAGE 78 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

loratadine tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic PA

loratadine tab 10 mg generic MDD 1 per day

fexofenadine hcl tab 180 mg generic MDD 1 per day

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

childrens loratadine syrup 5 mg/5ml generic PA

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

TRIAMINIC COUGH/RUNNY NOSE 12.5 MG STRIP BRAND C Non-Formulary Drug diphenhydramine hcl

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

fexofenadine hcl tab 180 mg generic MDD 1 per day

PA fexofenadine hcl tab 60 mg generic MDD 2 per day

wal-fex childrens 30 mg/5ml suspension generic PA

clemastine fumarate tab 1.34 mg generic C Non-Formulary Drug

loratadine tab 10 mg generic MDD 1 per day

childrens loratadine syrup 5 mg/5ml generic PA

PA cetirizine hcl chew tab 10 mg generic MDD 1 per day

BRONCHODILATORS, SYMPATHOMIMETIC

PRIMATENE MIST 0.22 MG/ACT AERO SOLN PA BRAND epinephrine (base) C Non-Formulary Drug

RESPIRATORY TRACT AGENTS, OTHER

666 cold preparation 10-5-325 mg/15ml liquid generic acetadryl 25-500 mg tab generic

PAGE 79 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ALDEX-CT 12.5-5 MG CHEW TAB BRAND PA diphenhydramine hcl-phenylephrine hcl tannate alka-seltzer pls sinus & cough 10-5-325 mg cap generic alka-seltzer plus day cold/flu 10-5-325 mg cap generic

all day pain relf sinus/cold d 120-220 mg tab er 12h generic PA

all-nite cold & flu nighttime 30-12.5-650 mg/30ml liquid generic all-nite multi-sympt cold/flu 15-6.25-325 mg/15ml liquid generic allergy multi-symptom 2-5-325 mg tab generic allergy multi-symptom daytime 2-5-325 mg tab generic

ambi 10peh/400gfn 10-400 mg tab generic PA

ambi 40pse/400gfn 40-400 mg tab generic PA

ambi 60pse/4cpm 60-4 mg tab generic ap-hist dm 7.5-4-15 mg/5ml liquid generic

bidex 400 mg tab generic PA

biogtuss 10-15-300 mg/5ml liquid generic PA

bpm-dm-phen 5-2-10 mg/5ml syrup generic PA

BROHIST D 4-10 MG TAB BRAND PA brompheniramine & phenyleph bronchial asthma relief 12.5-200 mg tab generic

brontuss sf nr 10-15-300 mg/5ml liquid generic PA

BROVEX PSE DM 40-4-20 MG TAB BRAND PA pseudoephed-bromphen-dm

buckleys chest congestion 100 mg/5ml liquid generic PA

chest congestion childrens 100 mg/5ml liquid generic PA

chest congestion relief 400 mg tab generic PA

chest congestion relief pe 10-400 mg tab generic PA

chest congestion/sinus relief 10-400 mg tab generic PA

childrens advil cold 15-100 mg/5ml suspension generic PA

childrens cold & allergy 1-2.5 mg/5ml elixir generic

PAGE 80 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

childrens cough 5-100 mg/5ml liquid generic PA

childrens mucus relief cough 5-100 mg/5ml liquid generic PA

childrens mucus relief expect 100 mg/5ml liquid generic PA

childrens plus flu 2.5-1-5-160 mg/5ml suspension generic PA

childrens plus multi-sympt cld 2.5-1-5-160 mg/5ml generic PA suspension CODITUSS DM 5-8.33-10 MG/5ML SYRUP BRAND phenylephrine-pyrilamine-dm CODITUSSIN AC 200-10 MG/5ML LIQUID BRAND PA guaifenesin-codeine cold & allergy 1-2.5 mg/5ml elixir generic cold & allergy childrens 1-2.5 mg/5ml elixir generic

cold & cough childrens 2.5-1-5 mg/5ml elixir generic PA

cold & flu nighttime 15-6.25-325 mg/15ml liquid generic cold & flu relief nighttime 15-6.25-325 mg/15ml liquid generic

cold & flu severe 5-10-200-325 mg tab generic PA

cold & flu severe daytime 5-10-200-325 mg tab generic PA

cold & flu severe daytime 5-10-200-325 mg/15ml liquid generic PA

cold head congest severe day 5-325-200 mg tab generic PA

cold head congestion severe 5-10-200-325 mg tab generic PA

cold multi-symptom severe day 5-10-200-325 mg tab generic PA

cold/allergy childrens 1-2.5 mg/5ml elixir generic

cold/cough childrens 2.5-1-5 mg/5ml elixir generic PA

cold/cough dm childrens 2.5-1-5 mg/5ml elixir generic PA

cold/flu relief 10-5-325 mg/15ml liquid generic cold/flu relief nighttime 15-6.25-325 mg/15ml liquid generic corfen-dm 10-4-15 mg/5ml liquid generic coricidin d cold/flu/sinus 2-5-325 mg tab generic coricidin hbp nighttime cold 15-6.25-325 mg/15ml liquid generic

PAGE 81 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

cough & chest congestion dm 5-100 mg/5ml liquid generic PA

cough & cold 4-30 mg tab generic PA

cough dm 30 mg/5ml susp generic dextromethorphan polistirex er liquid er 30 mg/5ml generic cough dm childrens 30 mg/5ml susp generic dextromethorphan polistirex er liquid er 30 mg/5ml generic cough relief 15 mg/5ml liquid generic

coughtab 200 mg tab generic PA

cvs allergy relief d 60-120 mg tab er 12h generic C Non-Formulary Drug

cvs allergy-d 25-10 mg tab generic

cvs chest congest/cough child 5-100 mg/5ml liquid generic PA

cvs chest congestion childrens 100 mg/5ml liquid generic PA

cvs chest congestion relief 400 mg tab generic PA

cvs chest congestion relief pe 10-400 mg tab generic PA

cvs childrens multi-sympt cld 2.5-1-5-160 mg/5ml generic PA suspension cvs cold & allergy childrens 1-2.5 mg/5ml elixir generic

cvs cold & cough dm childrens 2.5-1-5 mg/5ml elixir generic PA

cvs cold & cough nighttime 6.25-2.5 mg/5ml liquid generic

cvs cold/cough dm childrens 2.5-1-5 mg/5ml elixir generic PA

cvs cough dm 30 mg/5ml susp generic dextromethorphan polistirex er liquid er 30 mg/5ml generic cvs cough dm childrens 30 mg/5ml susp generic

cvs dm maximum adult 5-100 mg/5ml liquid generic PA

cvs flu relief childrens 2.5-1-5-160 mg/5ml suspension generic PA

cvs flu/severe cold daytime 10-5-325 mg/15ml liquid generic

cvs mucus extended release 1200 mg tab er 12h generic PA

cvs mucus extended release 600 mg tab er 12h generic

PAGE 82 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS cvs nighttime cold/flu relief 15-6.25-325 mg/15ml liquid generic

cvs sinus & cold-d 120-220 mg tab er 12h generic PA

cvs sinus pain/congest night 2-5-325 mg tab generic

cvs sinus relief pressure/pain 5-325-200 mg tab generic PA

cvs stuffy nose & cold child 2.5-100 mg/5ml liquid generic

cvs tussin adult chest congest 100 mg/5ml liquid generic PA

cvs tussin long-acting 15 mg/5ml liquid generic day time cold/flu relief 10-5-325 mg/15ml liquid generic day time multi-sympt cold/flu 10-5-325 mg/15ml liquid generic day time pe cold/flu relief 10-5-325 mg cap generic day-time cold/flu relief 10-5-325 mg cap generic day-time cold/flu relief 10-5-325 mg/15ml liquid generic day-time pe 10-5-325 mg cap generic day-time pe cold/flu relief 10-5-325 mg cap generic daytime cold & flu relief 10-5-325 mg cap generic daytime cold & flu relief 10-5-325 mg/15ml liquid generic daytime cold & flu relief plus 10-5-325 mg cap generic DAYTIME COLD MEDICINE 325-15 MG/15ML LIQUID BRAND acetaminophen w/ dm daytime cold/flu relief 10-5-325 mg cap generic daytime cold/flu relief 10-5-325 mg/15ml liquid generic

daytime severe cold & flu 5-10-200-325 mg tab generic PA

daytime severe cold & flu 5-10-200-325 mg/15ml liquid generic PA

decongestant plus 4-60 mg tab generic

delsym cgh/chest cong dm child 5-100 mg/5ml liquid generic PA

delsym cough/chest congest dm 5-100 mg/5ml liquid generic PA

delsym nght time cgh/cld child 12.5-5 mg/5ml liquid generic PA

delsym night cgh/cold children 6.25-2.5 mg/5ml liquid generic delsym night time cough/cold 6.25-2.5 mg/5ml liquid generic

PAGE 83 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS delsym night time multi-sympt 15-6.25-325 mg/15ml liquid generic desgen pediatric 2.5-5-50 mg/ml liquid generic despec dm 5-10-100 mg/5ml syrup generic despec dm-g 5-10-100 mg/5ml syrup generic despec eda 2.5-5-50 mg/ml liquid generic DEX-TUSS 300-10 MG/5ML LIQUID BRAND PA guaifenesin-codeine dextromethorphan polistirex er liquid er 30 mg/5ml generic

diabetic siltussin das-na 100 mg/5ml liquid generic PA

diabetic tussin 100 mg/5ml liquid generic PA

DIABETIC TUSSIN COLD/FLU 325-4-15 MG CAP BRAND dextromethorphan-acetaminophen-chlorpheniramine

diabetic tussin mucus relief 400 mg tab generic PA

dimaphen childrens 1-2.5 mg/5ml elixir generic

dimaphen dm cold/cough 2.5-1-5 mg/5ml elixir generic PA

dimaphen dm cold/cough child 2.5-1-5 mg/5ml elixir generic PA

dimetane dx 30-2-10 mg/5ml syrup generic PA

dimetapp night cold/congestion 6.25-2.5 mg/5ml liquid generic

dm max maximum strength 20-400 mg/20ml liquid generic PA

dm-guaifenesin er 60-1200 mg tab er 12h generic DONATUSSIN DM 1.5-1-3 MG/ML LIQUID BRAND PA phenylephrine-chlorphen-dm dristan cold 2-5-325 mg tab generic ed-a-hist dm 10-4-15 mg/5ml liquid generic endacof-c 2-10 mg/5ml liquid generic eq allergy relief 2-5-325 mg tab generic eq allergy/sinus headache 12.5-30-500 mg tab generic

eq cold flu & sore throat 5-10-200-325 mg tab generic PA

eq cold multi-symptom severe 5-10-200-325 mg tab generic PA

PAGE 84 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

eq cold relief 30-15-200-325 mg tab generic PA

eq cold/cough dm 15-1-5 mg/5ml elixir generic

eq cold/cough dm childrens 2.5-1-5 mg/5ml elixir generic PA

eq cough childrens 5-100 mg/5ml liquid generic PA

eq cough dm 30 mg/5ml susp generic dextromethorphan polistirex er liquid er 30 mg/5ml generic eq daytime cold/flu ms relief 10-5-325 mg cap generic eq daytime cold/flu ms relief 10-5-325 mg/15ml liquid generic eq flu relief 30-500-15 mg tab generic

eq ibuprofen cold childrens 15-100 mg/5ml suspension generic PA

eq mucus er 600 mg tab er 12h generic eq night time cold & cough 6.25-2.5 mg/5ml liquid generic eq nitetime cold/flu ms relief 15-6.25-325 mg cap generic eq nitetime cold/flu ms relief 15-6.25-325 mg/15ml liquid generic

eq sinus congestion & pain 5-325-200 mg tab generic PA

eq tussin 100 mg/5ml liquid generic PA

eql allergy multi-symptom 2-5-325 mg tab generic eql allergy/sinus headache 12.5-30-500 mg tab generic eql childrens pain relief plus 2.5-1-5-160 mg/5ml generic PA suspension eql childrens plus cold multi 2.5-1-5-160 mg/5ml generic PA suspension

eql cold head congestion day 5-10-200-325 mg tab generic PA

eql cold multi-symptom severe 5-10-200-325 mg tab generic PA

eql cough & cold relief hbp 4-30 mg tab generic PA

eql cough dm 30 mg/5ml susp generic dextromethorphan polistirex er liquid er 30 mg/5ml generic eql daytime cold & flu relief 10-5-325 mg cap generic eql daytime cold & flu relief 10-5-325 mg/15ml liquid generic

PAGE 85 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS eql daytime cold/flu relief 10-5-325 mg cap generic eql daytime cold/flu relief 10-5-325 mg/15ml liquid generic

eql daytime severe cold/flu 5-10-200-325 mg/15ml liquid generic PA

eql flu/severe cold/congestion 60-4-30-1000 mg packet generic PA

eql ibuprofen cold childrens 15-100 mg/5ml suspension generic PA

eql mucus relief max strength 5-10-200-325 mg tab generic PA

eql mucus-dm maximum strength 60-1200 mg tab er 12h generic eql mucus-er 600 mg tab er 12h generic

eql mucus-er maximum strength 1200 mg tab er 12h generic PA

eql nighttime cold & flu 15-6.25-325 mg/15ml liquid generic eql nighttime cold/flu relief 15-6.25-325 mg cap generic eql nighttime cold/flu relief 30-12.5-650 mg/30ml liquid generic

eql pain relief/cold 30-15-200-325 mg tab generic PA

eql pressure & pain pls/mucus 5-325-200 mg tab generic PA

eql severe cold 30-500-15 mg tab generic

eql sinus congestion/pain day 5-325-200 mg tab generic PA

eql triacting cold/cough 15-1-5 mg/5ml elixir generic eql triacting cold/cough 15-1-7.5 mg/5ml liquid generic eql tussin cf cgh/cold/congest 30-10-100 mg/5ml liquid generic

eql tussin mucus/chest congest 100 mg/5ml liquid generic PA

ESOCOR P 30-4-30 MG/5ML SUSPENSION BRAND PA pseudoephedrine-chlorphen-dm

exefen dmx 60-20-400 mg tab generic PA

fenesin ir 400 mg tab generic PA

fenesin pe ir 10-400 mg tab generic PA

fexofenadine-pseudoephed er 180-240 mg tab er 24h generic C Non-Formulary Drug

fexofenadine-pseudoephed er 60-120 mg tab er 12h generic C Non-Formulary Drug

flu relief therapy daytime 10-5-325 mg/15ml liquid generic

PAGE 86 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

g-fen ex 400 mg tab generic PA

g-supress dx pediatric 2.5-5-50 mg/ml liquid generic

giltuss cough & cold 10-15-300 mg/5ml liquid generic PA

giltuss cough & cold childrens 7.5-150-5 mg/2.5ml liquid generic PA

gnp allergy multi-symptom 2-5-325 mg tab generic

gnp allergy-d allergy & conges 60-120 mg tab er 12h generic C Non-Formulary Drug

gnp childrens ibuprofen cold 15-100 mg/5ml suspension generic PA

gnp childrens pain relief/cold 2.5-1-5-160 mg/5ml generic PA suspension gnp childrens plus multi-sympt 2.5-1-5-160 mg/5ml generic PA suspension

gnp cold head congestion 5-10-200-325 mg tab generic PA

gnp cold relief cold & flu 5-10-200-325 mg tab generic PA

gnp cold relief daytime 5-10-200-325 mg tab generic PA

gnp cold relief multi-symptom 5-10-200-325 mg tab generic PA

gnp cold severe congestion day 5-10-200-325 mg tab generic PA

gnp cold/allergy childrens 1-2.5 mg/5ml elixir generic

gnp cold/cough childrens 2.5-1-5 mg/5ml elixir generic PA

dextromethorphan polistirex er liquid er 30 mg/5ml generic gnp cough relief 15 mg/5ml liquid generic gnp day time cold/flu 10-5-325 mg cap generic gnp day time cold/flu relief 10-5-325 mg/15ml liquid generic gnp flu relief therapy daytime 10-5-325 mg/15ml liquid generic

gnp mucus er 1200 mg tab er 12h generic PA

gnp mucus er 600 mg tab er 12h generic

gnp mucus relief 400 mg tab generic PA

gnp mucus relief childrens 100 mg/5ml liquid generic PA

gnp mucus relief cold & sinus 5-325-200 mg tab generic PA

PAGE 87 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

gnp mucus relief cold flu 5-10-200-325 mg tab generic PA

gnp mucus relief congest/cold 5-10-200-325 mg tab generic PA

gnp mucus relief cough child 5-100 mg/5ml liquid generic PA

gnp mucus relief dm max 5-100 mg/5ml liquid generic PA

gnp mucus relief pe 10-400 mg tab generic PA

gnp multi-symptom cold daytime 5-10-200-325 mg/15ml generic PA liquid gnp night time cold & flu 15-6.25-325 mg cap generic gnp night time cold & flu 15-6.25-325 mg/15ml liquid generic gnp night time cold-flu 15-6.25-325 mg cap generic

gnp sinus & cold-d 120-220 mg tab er 12h generic PA

gnp sinus congest/pain night 2-5-325 mg tab generic gnp sinus relief congest/pain 2-5-325 mg tab generic

gnp sinus relief congest/pain 5-325-200 mg tab generic PA

gnp tab tussin 400 mg tab generic PA

gnp triacting night time child 6.25-2.5 mg/5ml liquid generic gnp tussin cf cough & cold 5-10-100 mg/5ml syrup generic

gnp tussin mucus & chest cong 100 mg/5ml liquid generic PA

goodsense cold & flu 10-5-325 mg/15ml liquid generic

goodsense cold & flu 5-10-200-325 mg tab generic PA

goodsense cold & head congest 5-325-200 mg tab generic PA

goodsense cough dm 30 mg/5ml susp generic goodsense cough dm childrens 30 mg/5ml susp generic goodsense day time cold & flu 10-5-325 mg cap generic

goodsense day time cold & flu 5-10-200-325 mg tab generic PA

goodsense day time cold & flu 5-10-200-325 mg/15ml generic PA liquid goodsense daytime 10-5-325 mg cap generic

PAGE 88 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

goodsense mucus relief 400 mg tab generic PA

goodsense nighttime cold & flu 15-6.25-325 mg cap generic

goodsense pressure/pain/mucus 5-325-200 mg tab generic PA

goodsense sinus relief max st 5-325-200 mg tab generic PA

goodsense sinus severe daytime 5-325-200 mg tab generic PA

guaifenesin 100 mg/5ml liquid generic PA

guaifenesin 100 mg/5ml solution generic PA

guaifenesin 200 mg tab generic PA

guaifenesin 200 mg/10ml solution generic PA

guaifenesin 300 mg/15ml solution generic PA

guaifenesin 400 mg tab generic PA

guaifenesin 400 mg tabs generic PA

guaifenesin er 1200 mg tab er 12h generic PA

guaifenesin er 600 mg tab er 12h generic guaifenex la 600 mg tab er 12h generic hist-pse 0.938-10 mg/ml liquid generic

hm chest congestion relief 400 mg tab generic PA

hm cold & allergy childrens 1-2.5 mg/5ml elixir generic

hm cold & cough childrens 2.5-1-5 mg/5ml elixir generic PA

hm cough dm 30 mg/5ml susp generic dextromethorphan polistirex er liquid er 30 mg/5ml generic hm cough relief 15 mg/5ml liquid generic hm day time 10-5-325 mg cap generic hm daytime cold & flu 10-5-325 mg/15ml liquid generic

hm mucus er 1200 mg tab er 12h generic PA

hm mucus er 600 mg tab er 12h generic hm mucus relief dm max st 60-1200 mg tab er 12h generic

PAGE 89 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

hm mucus relief fm cold/flu 5-10-200-325 mg tab generic PA

hm mucus relief fm cold/sinus 5-325-200 mg tab generic PA

hm mucus relief fm severe 5-10-200-325 mg tab generic PA

hm night time cold & flu 15-6.25-325 mg cap generic hm night time cold & flu 15-6.25-325 mg/15ml liquid generic hm night time ms cold & flu 15-6.25-325 mg cap generic

hm severe cold/flu 5-10-200-325 mg tab generic PA

hm sinus & cold-d 120-220 mg tab er 12h generic PA

hm tussin adult 100 mg/5ml liquid generic PA

iophen-nr 100 mg/5ml liquid generic PA

J-TAN D PD 1-7.5 MG/ML LIQUID BRAND PA brompheniramine & pseudoeph

kls mucus relief chest 400 mg tab generic PA

kls multi-symptom cold child 2.5-1-5-160 mg/5ml generic PA suspension

liquibid 400 mg tab generic PA

liquibid d-r 10-400 mg tab generic PA

lohist-peb 4-10 mg/5ml liquid generic PA

m-hist dm 7.5-4-15 mg/5ml liquid generic MAXICHLOR DM 4-20 MG TAB BRAND PA chlorpheniramine-dm MAXICHLOR PEH DM 10-4-20 MG TAB BRAND phenylephrine-chlorphen-dm MAXIFED DM 40-20-400 MG TAB BRAND PA pseudoephedrine w/ dm-gg medicidin-d 2-5-325 mg tab generic

mucaphed 10-400 mg tab generic PA

mucinex chest congestion child 100 mg/5ml liquid generic PA

mucinex cough childrens 5-100 mg/5ml liquid generic PA

PAGE 90 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS mucinex fast-max cold & sinus 10-5-325 mg cap generic

mucinex fast-max cold & sinus 5-325-200 mg tab generic PA

mucinex fast-max cold flu 5-10-200-325 mg tab generic PA

mucinex fast-max cong headache 10-5-325 mg cap generic

mucinex fast-max congest cold 5-10-200-325 mg tab generic PA

mucinex fast-max dm max 20-400 mg/20ml liquid generic PA

mucinex fast-max severe cold 5-10-200-325 mg tab generic PA

MUCINEX FOR KIDS 50 MG PACKET BRAND PA guaifenesin

mucinex sinus-max congestion 5-325-200 mg tab generic PA

mucinex sinus-max press & pain 5-325-200 mg tab generic PA

mucosa 400 mg tab generic PA

mucus relief 400 mg tab generic PA

mucus relief chest congestion 200 mg tab generic PA

mucus relief chest congestion 400 mg tab generic PA

mucus relief chest congestion 400 mg/20ml liquid generic PA

mucus relief childrens 100 mg/5ml liquid generic PA

mucus relief cold flu throat 5-10-200-325 mg tab generic PA

mucus relief cough childrens 5-100 mg/5ml liquid generic PA

mucus relief d 10-400 mg tab generic PA

mucus relief d 40-400 mg tab generic PA

mucus relief dm 60-1200 mg tab er 12h generic

mucus relief dm max 20-400 mg/20ml liquid generic PA

mucus relief dm max 5-100 mg/5ml liquid generic PA

mucus relief er 1200 mg tab er 12h generic PA

mucus relief er 600 mg tab er 12h generic

PAGE 91 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

mucus relief pe 10-400 mg tab generic PA

mucus relief pe sinus 10-400 mg tab generic PA

mucus relief plus 5-10-200-325 mg tab generic PA

mucus relief severe cold 5-10-200-325 mg tab generic PA

mucus relief severe cong/cold 5-10-200-325 mg tab generic PA

mucus relief severe sinus 5-325-200 mg tab generic PA

mucus relief sinus pressure 5-325-200 mg tab generic PA

mucus relief sinus severe cong 5-325-200 mg tab generic PA

mucus-dm max 60-1200 mg tab er 12h generic mucus-er 600 mg tab er 12h generic

mucusrelief sinus 10-400 mg tab generic PA

multi-symptom cold childrens 2.5-1-5-160 mg/5ml generic PA suspension multi-symptom cold plus child 2.5-1-5-160 mg/5ml generic PA suspension nasohist 1-2 mg/ml liquid generic night time cold/flu relief 15-6.25-325 mg cap generic night time cough/cold child 6.25-2.5 mg/5ml liquid generic night time cough/cold relief 6.25-2.5 mg/5ml liquid generic night time ms cold/flu relief 15-6.25-325 mg/15ml liquid generic night time sinus/pain 2-5-325 mg tab generic night-time cold/flu relief 15-6.25-325 mg cap generic nighttime cold & flu max str 15-6.25-325 mg/15ml liquid generic nighttime cold/flu relief 15-6.25-325 mg cap generic nighttime cold/flu relief 15-6.25-325 mg/15ml liquid generic nighttime pain plus sleep 25-500 mg/15ml liquid generic nite time multi-symptom relief 15-6.25-325 mg cap generic nite-time cold/flu 15-6.25-325 mg cap generic nite-time cold/flu relief 15-6.25-325 mg cap generic

PAGE 92 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS nite-time cold/flu relief 15-6.25-325 mg/15ml liquid generic nite-time cold/flu relief 30-12.5-650 mg/30ml liquid generic niva-hist dm 7.5-4-15 mg/5ml liquid generic nohist-dm 10-4-15 mg/5ml liquid generic

non-aspirin severe congestion 5-10-200-325 mg tab generic PA

nortuss-de 2.5-5-50 mg/ml liquid generic

nu-copd 10-400 mg tab generic PA

organ-i nr 200 mg tab generic PA

pa mucus relief 600 mg tab er 12h generic

pain relief cold congestion 5-10-200-325 mg tab generic PA

pain relief plus multi-symptom 2.5-1-5-160 mg/5ml generic PA suspension pedi-atric nightrest 15-1-7.5 mg/5ml liquid generic

pediacare child allergy/cold 12.5-5 mg/5ml liquid generic PA

pediacare childrens nightrest 12.5-5 mg/5ml solution generic PA

pediacare cough/congestion 5-100 mg/5ml liquid generic PA

phenylephrine-guaifenesin 10-400 mg tab generic PA

POLY-VENT IR 45-400 MG TAB BRAND PA pseudoephedrine-guaifenesin

pseudoeph-bromphen-dm 30-2-10 mg/5ml syrup generic PA

pseudoephedrine-dm-gg 30-10-100 mg/5ml liquid generic px allergy sinus pe 2-5-325 mg tab generic px daytime cold/flu relief 10-5-325 mg/15ml liquid generic px daytime pe 10-5-325 mg cap generic px dibromm cold/allergy child 1-2.5 mg/5ml elixir generic

px dibromm dm cold/cough child 2.5-1-5 mg/5ml elixir generic PA

px nitetime cold/flu relief 15-6.25-325 mg cap generic

px severe cold 5-10-200-325 mg tab generic PA

px tussin 100 mg/5ml solution generic PA

PAGE 93 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS q-tapp dm 15-1-5 mg/5ml elixir generic

q-tussin 100 mg/5ml solution generic PA

qc allergy relief multi-sympt 2-5-325 mg tab generic

qc cold head congestion day 5-10-200-325 mg tab generic PA

qc cold multi-symptom daytime 5-10-200-325 mg tab generic PA

qc cold relief plus multi-symp 2.5-1-5-160 mg/5ml generic PA suspension qc cough relief 15 mg/5ml liquid generic

qc cough/cold hbp 4-30 mg tab generic PA

qc daytime cold/flu 10-5-325 mg cap generic qc daytime cold/flu 10-5-325 mg/15ml liquid generic qc flu relief therapy daytime 10-5-325 mg/15ml liquid generic

qc medifin 400 400 mg tab generic PA

qc medifin mucus relief child 100 mg/5ml liquid generic PA

qc nighttime multi-symptom 15-6.25-325 mg cap generic

qc sinus congest/pain severe 5-325-200 mg tab generic PA

qc tussin mucus/congestion 100 mg/5ml liquid generic PA

ra allergy multi-symptom 2-5-325 mg tab generic ra allergy plus sinus 25-10 mg tab generic

ra allergy relief-d 60-120 mg tab er 12h generic C Non-Formulary Drug

ra childrens cold & allergy 1-2.5 mg/5ml elixir generic

ra childrens flu relief plus 2.5-1-5-160 mg/5ml suspension generic PA

ra childrens plus cold 2.5-1-5-160 mg/5ml suspension generic PA

ra cold & allergy 1-2.5 mg/5ml elixir generic

ra cold & cough childrens 2.5-1-5 mg/5ml elixir generic PA

ra cold multi-symptom daytime 5-10-200-325 mg tab generic PA

ra cold/cough dm 2.5-1-5 mg/5ml elixir generic PA

ra cold/flu multi-symptom nite 15-6.25-325 mg cap generic

PAGE 94 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ra cold/flu relief daytime 10-5-325 mg cap generic ra cold/flu relief nighttime 15-6.25-325 mg cap generic

ra cold/flu/sore throat max 5-10-200-325 mg tab generic PA

ra cold/sinus max 5-325-200 mg tab generic PA

dextromethorphan polistirex er liquid er 30 mg/5ml generic ra day time cold/flu formula 10-5-325 mg/15ml liquid generic ra daytime cold/flu relief 10-5-325 mg/15ml liquid generic ra daytime multi-symp cold/flu 10-5-325 mg cap generic ra daytime multi-symptom cold 10-5-325 mg cap generic

ra head congest cold daytime 5-10-200-325 mg tab generic PA

ra ibuprofen cold childrens 15-100 mg/5ml suspension generic PA

ra mucus relief 400 mg tab generic PA

ra mucus relief 600 mg tab er 12h generic

ra mucus relief chest 400 mg tab generic PA

ra mucus relief plus 5-10-200-325 mg tab generic PA

ra mucus relief sinus 10-400 mg tab generic PA

ra nighttime cold/flu relief 30-12.5-650 mg/30ml liquid generic

ra severe congestion/cold max 5-10-200-325 mg tab generic PA

ra sinus congest/pain relief 5-325-200 mg tab generic PA

ra suphedrine 4-60 mg tab generic

ra tussin chest congestion 100 mg/5ml liquid generic PA

ra tussin long acting cough 15 mg/5ml liquid generic

recofen d 5-100 mg/5ml liquid generic PA

reeses onetab congest/cough 10-400 mg tab generic PA

refenesen 200 mg tab generic PA

refenesen 400 400 mg tab generic PA

refenesen pe 10-400 mg tab generic PA

PAGE 95 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS relcof dm 7.5-4-15 mg/5ml liquid generic RELHIST BP 4-10 MG TAB BRAND PA brompheniramine & phenyleph RESCON DM 30-2-10 MG/5ML SYRUP BRAND pseudoephedrine-chlorphen-dm robafen cf cough/cold 5-10-100 mg/5ml syrup generic robitussin 12 hour cough 30 mg/5ml susp generic robitussin 12 hour cough child 30 mg/5ml susp generic robitussin cold+flu daytime 10-5-325 mg cap generic robitussin cold+flu nighttime 15-6.25-325 mg cap generic

robitussin cough+chest cong dm 20-400 mg/20ml liquid generic PA

robitussin cough+chest cong dm 5-100 mg/5ml liquid generic PA

robitussin lingering la cough 15 mg/5ml liquid generic

robitussin mucus+chest congest 100 mg/5ml liquid generic PA

robitussin night cgh/cold/flu 2.5-1-5-160 mg/5ml generic PA suspension robitussin night time cgh/cold 6.25-2.5 mg/5ml liquid generic robitussin peak cold nasal rlf 2-5-325 mg tab generic RU-HIST D 4-10 MG TAB BRAND PA brompheniramine & phenyleph rynex pe 1-2.5 mg/5ml elixir generic sb allergy multi-symptom 2-5-325 mg tab generic sb allergy/sinus/headache 12.5-30-500 mg tab generic sb bronchial 12.5-200 mg tab generic sb childrens multisympt cold 2.5-1-5-160 mg/5ml generic PA suspension sb cold & allergy childrens 1-2.5 mg/5ml elixir generic

sb cold & cough dm childrens 2.5-1-5 mg/5ml elixir generic PA

sb cold & cough hbp 4-30 mg tab generic PA

sb cold & flu severe 5-10-200-325 mg tab generic PA

sb cold head congestion severe 5-10-200-325 mg tab generic PA

PAGE 96 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

sb cold medicine 30-15-200-325 mg tab generic PA

sb cold multi-symptom severe 5-10-200-325 mg tab generic PA

sb cough relief 15 mg/5ml liquid generic

sb coughtab 200 mg tab generic PA

sb day time cold/flu relief 10-5-325 mg cap generic sb daytime 10-5-325 mg/15ml liquid generic sb flu relief therapy daytime 10-5-325 mg/15ml liquid generic

sb mucus relief 400 mg tab generic PA

sb mucus relief pe 10-400 mg tab generic PA

sb night time cold/flu relief 15-6.25-325 mg cap generic sb pseudoephedrine plus 4-60 mg tab generic

sb severe cold congestion 30-15-200-325 mg tab generic PA

sb sinus congestion/pain 5-325-200 mg tab generic PA

sb sinus congestion/pain night 2-5-325 mg tab generic

scot-tussin expectorant 100 mg/5ml liquid generic PA

severe sinus congestion & pain 5-325-200 mg tab generic PA

siltussin das 100 mg/5ml liquid generic PA

sinus & cold-d 120-220 mg tab er 12h generic PA

sinus congestion/pain daytime 5-325-200 mg tab generic PA

sinus congestion/pain night 2-5-325 mg tab generic sm allergy multi-symptom 2-5-325 mg tab generic sm allergy/sinus headache 12.5-30-500 mg tab generic

sm chest congestion relief 400 mg tab generic PA

sm chest congestion relief pe 10-400 mg tab generic PA

sm childrens plus ms cold 2.5-1-5-160 mg/5ml suspension generic PA

sm cold & allergy childrens 1-2.5 mg/5ml elixir generic sm cold & cough childrens 15-1-5 mg/5ml elixir generic

PAGE 97 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

sm cold & cough dm childrens 2.5-1-5 mg/5ml elixir generic PA

sm cold & flu severe 5-10-200-325 mg tab generic PA

sm cold head congestion 5-10-200-325 mg tab generic PA

sm day time 10-5-325 mg cap generic sm day time cold & flu relief 10-5-325 mg/15ml liquid generic sm day time non drowsy 10-5-325 mg cap generic sm day time pe cold/flu relief 10-5-325 mg cap generic

sm ibuprofren cold childrens 15-100 mg/5ml suspension generic PA

sm mucus er 600 mg tab er 12h generic

sm mucus relief childrens 100 mg/5ml liquid generic PA

sm mucus relief cough children 5-100 mg/5ml liquid generic PA

sm night time cold & flu 15-6.25-325 mg cap generic sm nite time cold & flu 15-6.25-325 mg/15ml liquid generic sm nite time cold & flu relief 15-6.25-325 mg cap generic

sm pain reliever cold 30-15-200-325 mg tab generic PA

sm sinus & allergy max st 4-60 mg tab generic

sm sinus & cold-d 120-220 mg tab er 12h generic PA

sm tussin cf 30-10-100 mg/5ml liquid generic

sm tussin mucus+chest congest 100 mg/5ml liquid generic PA

sudafed pe non-drying sinus 5-200 mg tab generic PA

sudafed pe pressure+pain+mucus 5-325-200 mg tab generic PA

sudafed pressure+pain 12 hr 120-220 mg tab er 12h generic PA

sudogest sinus/allergy 4-60 mg tab generic supress-dx pediatric 2.5-5-50 mg/ml liquid generic

tabtussin 400 mg tab generic PA

TG 45PSE/400GFN 45-400 MG TAB BRAND PA pseudoephedrine-guaifenesin tgq 7.5peh/4brm/15dm 7.5-4-15 mg/5ml liquid generic

PAGE 98 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

tgt allergy+ congestion relief 60-120 mg tab er 12h generic C Non-Formulary Drug

tgt cold/cough childrens 2.5-1-5 mg/5ml elixir generic PA

tgt cold/cough relief night 6.25-2.5 mg/5ml liquid generic tgt cold/flu relief day time 10-5-325 mg/15ml liquid generic tgt cold/flu relief day-time 10-5-325 mg cap generic tgt cold/flu relief nighttime 15-6.25-325 mg cap generic

tgt mucus relief childrens 100 mg/5ml liquid generic PA

tgt mucus relief cough child 5-100 mg/5ml liquid generic PA

tgt multi-symptom cold child 2.5-1-5-160 mg/5ml generic PA suspension tgt pain reliever pm ex st 25-500 mg tab generic

tgt severe cold relief 5-10-200-325 mg tab generic PA

th chest congestion relief 400 mg tab generic PA

th chest congestion relief pe 10-400 mg tab generic PA

th childrens mucus relief cgh 5-100 mg/5ml liquid generic PA

th cold & allergy 1-2.5 mg/5ml elixir generic th day time cold/flu relief 10-5-325 mg cap generic th day time cold/flu relief 10-5-325 mg/15ml liquid generic th nite time cold/flu relief 15-6.25-325 mg cap generic

th severe cold multi-symptom 5-10-200-325 mg tab generic PA

th tussin 100 mg/5ml liquid generic PA

theraflu expressmax 20-10-650 mg/30ml liquid generic

theraflu expressmax sev cld/fl 5-10-200-325 mg tab generic PA

theraflu expressmax sev cld/fl 5-10-200-325 mg/15ml liquid generic PA

theraflu warming relief day 10-5-325 mg/15ml liquid generic tl-hist dm 7.5-4-15 mg/5ml liquid generic TRIACTIN CHEST CONGESTION 50 MG/5ML SOLUTION BRAND guaifenesin

PAGE 99 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS triacting night time cold/cgh 6.25-2.5 mg/5ml liquid generic triacting nightime cold&cough 6.25-2.5 mg/5ml liquid generic

triaminic fever & cold 2.5-1-5-160 mg/5ml suspension generic PA

trip-pse 0.938-10 mg/ml liquid generic tussi-pres pe pediatric 2.5-100 mg/5ml liquid generic

tussin 100 mg/5ml liquid generic PA

tussin cf 30-10-100 mg/5ml liquid generic

tussin cold/congestion 30-10-200 mg cap generic PA

tussin cough long-acting 15 mg/5ml liquid generic

tussin mucus & chest congest 100 mg/5ml liquid generic PA

tussin mucus+chest congestion 100 mg/5ml liquid generic PA

tylenol allergy multi-symptom 2-5-325 mg tab generic TYLENOL CHILDRENS PLUS CLD/CGH 5-2.5-160 MG/5ML SUSPENSION BRAND PA dextromethorphan-phenylephrine-acetaminophen tylenol sinus congestion/pain 2-5-325 mg tab generic vicks dayquil cold & flu 10-5-325 mg cap generic vicks dayquil cold & flu 10-5-325 mg/15ml liquid generic vicks dayquil multi-symptom 10-5-325 mg cap generic

vicks dayquil severe cold/flu 5-10-200-325 mg tab generic PA

vicks dayquil severe cold/flu 5-10-200-325 mg/15ml liquid generic PA

vicks nyquil cold & flu 15-6.25-325 mg cap generic vicks nyquil cold & flu night 15-6.25-325 mg cap generic

virdec dm 3.5-1-3 mg/ml liquid generic PA

wal-dryl pe allergy & sinus 25-10 mg tab generic WAL-DRYL-D 25-60 MG TAB BRAND PA diphenhydramine & pseudoephed wal-dryl-d allergy/sinus 25-10 mg tab generic

wal-fex d allergy & congestion 180-240 mg tab er 24h generic C Non-Formulary Drug

PAGE 100 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

wal-fex d allergy & congestion 60-120 mg tab er 12h generic C Non-Formulary Drug

wal-finate-d 4-60 mg tab generic wal-flu severe cold & cough 10-5-325 mg/15ml liquid generic

wal-phed pe triple relief 5-325-200 mg tab generic PA

wal-phed sinus/allergy 4-60 mg tab generic wal-tap childrens 1-2.5 mg/5ml elixir generic wal-tap dm cold/cough 15-1-5 mg/5ml elixir generic

wal-tap dm cold/cough 2.5-1-5 mg/5ml elixir generic PA

wal-tussin cf 30-10-100 mg/5ml liquid generic

wal-tussin chest congestion 100 mg/5ml liquid generic PA

wal-tussin cough long acting 15 mg/5ml liquid generic

xpect 400 mg tab generic PA

SLEEP DISORDER AGENTS

SLEEP DISORDERS, OTHER

cvs ibuprofen pm 200-38 mg tab generic

PA cvs sleep-aid nighttime 25 mg tab generic C Non-Formulary Drug

PA cvs ultra sleep 25 mg tab generic C Non-Formulary Drug

eq ibuprofen pm 200-38 mg tab generic

PA eq sleep aid 25 mg tab generic C Non-Formulary Drug

eql ibuprofen pm 200-38 mg tab generic

PA eql sleep aid 25 mg tab generic C Non-Formulary Drug

gnp ibuprofen pm 200-38 mg tab generic

PA gnp sleep aid 25 mg tab generic C Non-Formulary Drug

PAGE 101 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS goodsense ibuprofen pm 200-38 mg tab generic hm ibuprofen pm 200-38 mg tab generic

PA hm sleep aid 25 mg tab generic C Non-Formulary Drug

ibuprofen pm 200-38 mg tab generic

PA kls sleep aid 25 mg tab generic C Non-Formulary Drug

PA medi-sleep 25 mg tab generic C Non-Formulary Drug

motrin pm 200-38 mg tab generic

PA nitetime sleep-aid 25 mg tab generic C Non-Formulary Drug

ra ibuprofen pm 200-38 mg tab generic

PA ra night sleep aid 25 mg tab generic C Non-Formulary Drug

PA ra sleep aid 25 mg tab generic C Non-Formulary Drug

PA sleep aid 25 mg tab generic C Non-Formulary Drug

sm ibuprofen pm 200-38 mg tab generic

PA sm sleep aid 25 mg tab generic C Non-Formulary Drug

tgt ibuprofen pm 200-38 mg tab generic TYLENOL PM EXTRA STRENGTH 1000-50 MG/30ML LIQUID BRAND diphenhydramine-acetaminophen (sleep)

PA wal-som 25 mg tab generic C Non-Formulary Drug

PAGE 102 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

ELECTROLYTE/MINERAL REPLACEMENT

BIFERA 28 MG TAB BRAND PA polysaccharide iron complex-iron heme polypeptide

bprotected pedia iron 75 (15 fe) mg/ml solution generic PA

CAL-GLU 500 MG CAP BRAND PA calcium gluconate

calcitrate 950 mg tab generic PA

CALCIUM CITRATE 1040 MG TAB BRAND PA calcium citrate

calcium citrate 950 mg tab generic PA

calcium lactate 100 mg tab generic cvs iron 325 (65 fe) mg tab generic DUOFER 28 MG TAB BRAND PA polysaccharide iron complex-iron heme polypeptide eql iron supplement therapy 325 mg tab generic feosol 325 (65 fe) mg tab generic FEOSOL BIFERA 28 MG TAB BRAND PA polysaccharide iron complex-iron heme polypeptide

fer-iron 75 (15 fe) mg/ml solution generic PA

ferro-bob 325 (65 fe) mg tab generic

ferrous sulfate 220 (44 fe) mg/5ml liquid generic PA

ferrous sulfate 325 (65 fe) mg tab generic ferrous sulfate 325 (65 fe) mg tabs generic

ferrous sulfate 75 (15 fe) mg/ml solution generic PA

ferrousul 325 (65 fe) mg tab generic FLORICAL 8.3-364 MG CAP BRAND PA sodium fluoride w/ calcium carbonate gnp iron 325 (65 fe) mg tab generic HOMOCYSTEINE FORMULA 800-50-100 MCG-MG-MCG TAB BRAND PA folic acid-vitamin b6-vitamin b12

PAGE 103 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS iron 325 (65 fe) mg tab generic iron high-potency 325 mg tab generic iron supplement 325 (65 fe) mg tab generic

iron supplement childrens 75 (15 fe) mg/ml solution generic PA

kp ferrous sulfate 325 (65 fe) mg tab generic

mag-g 500 (27 mg) mg tab generic PA

MAG-TAB SR 84 MG (7MEQ) TAB ER BRAND PA magnesium lactate

magnesium 27 500 (27 mg) mg tab generic PA

magonate 500 (27 mg) mg tab generic PA

meijer ferrous sulfate 325 (65 fe) mg tab generic MYKIDZ IRON 10 15 MG/1.5ML SUSPENSION BRAND PA iron nat-rul iron 325 mg tab generic POSTURE 600-280 MG TAB BRAND PA calcium & phosphorus qc ferrous sulfate 325 (65 fe) mg tab generic ra iron 325 (65 fe) mg tab generic sm iron 325 (65 fe) mg tab generic th iron 325 (65 fe) mg tab generic a thru z advanced tab generic a thru z advanced adult tab generic a thru z high potency tab generic a thru z select chew tab generic a thru z select tab generic a thru z select 50+ advanced tab generic a thru z select 50+ mens tab generic a thru z select advanced tab generic a thru z select ultimate women tab generic a thru z ultimate mens tab generic

PAGE 104 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS abc plus tab generic abc plus senior tab generic abc plus senior adults 50+ tab generic adult gummy chew tab generic advanced multi ea chew tab generic airborne chew tab generic airborne gummies chew tab generic akedamins chew tab generic antioxidant a/c/e/selenium tab generic antioxidant formula tab generic antioxidant protection formula tab generic antioxidant vitamins tab generic b complex-c-biotin-e-fa 0.4 mg tab generic

b complex-c-folic acid tab generic PA

b-12 100 mcg tab generic PA

b-12 50 mcg tab generic

b-complex balanced tab generic PA

b-complex/vitamin c tab generic PA

b-redi/red hearts/red roosters tab generic biotin plus/calcium/vit d3 tab generic

brewers yeast tab generic PA

brewers yeast 487.5 mg tab generic PA

brewers yeast 500 mg tab generic PA

calcet plus tab generic

carnitine 250 mg cap generic PA

carravite tab generic centavite a-z complete-mineral tab generic centravites tab generic

PAGE 105 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS centravites 50 plus tab generic century tab generic century mature tab generic cerovite advanced formula tab generic cerovite senior tab generic certa plus tab generic certagen tab generic certavite/antioxidants tab generic

choline 648 mg cap generic PA

companion tab generic compete tab generic complere tab generic complete tab generic complete daily/lutein tab generic complete energy tab generic complete senior tab generic complete womens tab generic cvs daily energy tab generic cvs daily gummies chew tab generic cvs daily multiple fe/ca/zn tab generic cvs daily multiple for men tab generic cvs daily multiple for men 50+ tab generic cvs daily multiple for women tab generic cvs daily multiple women 50+ tab generic

cvs folic acid 400 mcg tab generic PA

cvs mens daily gummies chew tab generic cvs spectravite advanced tab generic cvs spectravite performance tab generic cvs spectravite senior tab generic cvs spectravite ultra mens tab generic

PAGE 106 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS cvs spectravite womens senior tab generic

cvs stress formula tab generic PA

cvs vision formula tab generic

cvs vitamin b-12 100 mcg tab generic PA

cvs womens active daily tab generic cvs womens daily gummies chew tab generic daily betic tab generic daily combo multi vitamins tab generic daily mens health formula tab generic daily multi tab generic daily multi 50+ tab generic daily multiple vitamins/min tab generic daily multiple weight loss tab generic daily vitamin formula+minerals tab generic daily womens health formula tab generic daily-vitamin maximum formula tab generic diabetes health formula tab generic dialyvite 800/ultra d tab generic doctors choice men tab generic ecolovit tab generic ELDERTONIC ELIXIR BRAND multiple vitamins w/ minerals ELLIS TONIC ELIXIR BRAND multiple vitamins w/ minerals enviro-stress tab generic eq complete multivit adult 50+ tab generic eq one daily womens health tab generic eq one daily womens pro-active tab generic

eql b complex tab generic PA

eql central-vite tab generic

PAGE 107 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS eql central-vite performance tab generic eql central-vite select tab generic eql century tab generic eql century cardio health tab generic eql century mature tab generic eql century mature men 50+ tab generic eql century mature women 50+ tab generic

eql folic acid 400 mcg tab generic PA

eql gummy adult chew tab generic eql one daily 50 plus tab generic eql one daily dieters support tab generic eql one daily maximum tab generic eql one daily mens 50+ advance tab generic eql one daily mens health tab generic eql one daily womens 50+ adv tab generic

eql super b complex/vitamin c tab generic PA

eql ultimate mens century tab generic eql ultimate womens century tab generic eql vision formula tab generic essentia tab generic essential balance tab generic eye support tab generic eye vitamins & minerals tab generic eye-vite extra plus lutein tab generic eye-vites tab generic eyeprotect tab generic

fa-8 0.8 mg cap generic PA

ferrex 150 150 mg cap generic PA

ferric x-150 150 mg cap generic PA

PAGE 108 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

ferus 150 mg cap generic PA

folic acid 0.8 mg cap generic PA

folic acid 400 mcg tab generic PA

generix t tabs generic gerivite complete tab generic gnp century tab generic gnp century active performance tab generic gnp century adult formula tab generic gnp century adults 50+ senior tab generic gnp century cardio health tab generic gnp century mature tab generic gnp century ultimate mens tab generic gnp century ultimate womens tab generic gnp diabetic support formula tab generic

gnp folic acid 400 mcg tab generic PA

gnp hair/skin/nails tab generic gnp healthy eyes tab generic gnp maximum one daily tab generic gnp mega multi for men tab generic gnp mega multi for women tab generic gnp one daily maximum tab generic gnp one daily mens 50+advanced tab generic gnp one daily mens health 50+ tab generic gnp one daily mens/lycopene tab generic gnp one daily womens tab generic gnp one daily womens 50+ tab generic gnp opti-vitamins tab generic gnp therapeutic-m tab generic gnp womens one daily tab generic

PAGE 109 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS hair formula extra strength tab generic hair skin and nails formula tab generic hair vitamins tab generic hair/skin/nails tab generic hair/skin/nails/biotin tab generic healthy eyes tab generic healthy eyes/lutein tab generic hi-kovite 2-part formula tab generic hi-potency multi-vitamin tab generic hm antioxidant vitamins tab generic hm complete tab generic hm complete 50+ tab generic hm complete women tab generic

hm folic acid 400 mcg tab generic PA

hm mens 50+ advanced one daily tab generic hm multivitamin adult gummy chew tab generic

hm super vitamin b complex/c tab generic PA

hm vitamin b complex/vitamin c tab generic PA

hm womens 50+ advanced daily tab generic i-vite tab generic i-vite protect tab generic icaps mv tab generic

iferex 150 150 mg cap generic PA

inositol 500 mg tab generic PA

inositol 650 mg tab generic kp adults 50+ daily formula tab generic kp adults daily formula tab generic

kp b complex-c tab generic PA

kp mens 50+ daily formula tab generic

PAGE 110 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS kp mens daily formula tab generic kp vision formula tab generic kp vision formula/lutein tab generic kp womens 50+ daily formula tab generic kp womens daily formula tab generic

l-carnitine 250 mg cap generic PA

lecithin concentrate 400 mg cap generic

levocarnitine 1 gm/10ml solution generic PA

macuvite tab generic macuvite eye care tab generic macuvite/lutein tab generic maximum blue label tab generic maximum daily green tab generic maximum green label tab generic maximum red label tab generic mccarnitine 330 mg tab generic mediplex plus tab generic mega vm-80 tab generic meijer advanced formula tab generic memory vite tab generic mens hair formula ultra man tab generic mens life pack tab generic mens multiple vitamin/lycopene tab generic mens multivitamin plus tab generic methionine 500 mg tab generic milltrium advanced formula tab generic milltrium cardio tab generic milltrium senior tab generic multi + omega-3 adult gummies chew tab generic multi adult gummies chew tab generic

PAGE 111 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS multi complete/iron tab generic multi for her tab generic multi for her 50+ tab generic multi for him tab generic multi for him 50+ tab generic multi vitamin/minerals tab generic multi-day plus minerals tab generic multi-day weight trim tab generic multi-lean tab generic multi-vitamin gummies chew tab generic multi-vitamin menopausal tab generic multi-vitamin/minerals tab generic multilex tab generic multilex-t&m tab generic multimineral plus tab generic multiple vit/minerals/no iron tab generic multiple vitamins/womens tab generic multivital chew tab generic multivital tab generic multivital performance tab generic multivital platinum tab generic multivital platinum silver chew tab generic multivital-m tab generic multivitamin adults tab generic multivitamin adults 50+ tab generic multivitamin gummies adult chew tab generic multivitamin gummies adults chew tab generic multivitamin gummies mens chew tab generic multivitamin gummies womens chew tab generic multivitamin men tab generic

PAGE 112 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS multivitamin men 50+ tab generic multivitamin women tab generic multivitamin women 50+ tab generic multivitamin/extra vitamin d3 chew tab generic multivitamins chew tab generic myamulti tab generic

myferon 150 150 mg cap generic PA

nu-iron 150 mg cap generic PA

ocusoft vms tab generic ocutabs tab generic ocutabs-lutein tab generic ocuvite extra tab generic ocuvite eye + multi tab generic ocuvite eye heatlh gummies chew tab generic ocuvite-lutein tab generic one daily 50 plus tab generic one daily adults 50+ tab generic one daily calcium/iron tab generic one daily complete tab generic one daily complete for men tab generic one daily for men 50+ advanced tab generic one daily for men/lycopene tab generic one daily for women tab generic one daily for women 50+ adv tab generic one daily healthy weight tab generic one daily healthy weight adv tab generic one daily maximum tab generic one daily mens tab generic one daily mens 50+ multivit tab generic one daily mens 50+/lycopene tab generic

PAGE 113 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS one daily mens health tab generic one daily multivit/iron-free tab generic one daily multivitamin adult tab generic one daily multivitamin men tab generic one daily multivitamin women tab generic one daily plus iron tab generic one daily plus minerals tab generic one daily womens tab generic one daily womens 50 plus tab generic one daily womens 50+ tab generic one daily/minerals tab generic one-a-day teen advantage/her tab generic optic-vites tab generic optic-vites with lutein tab generic optimum pms tab generic orthovite tab generic osteoprime ultra tab generic

poly-iron 150 150 mg cap generic PA

polysaccharide iron complex 150 mg cap generic PA

PROFERRIN ES 12 MG TAB BRAND PA iron heme polypeptide prosight tab generic px advanced formula multivits tab generic

px b complex/vitamin c tab generic PA

px complete senior multivits tab generic

px folic acid 400 mcg tab generic PA

px mens multivitamins tab generic qc daily multivit/multimineral tab generic qc mens daily multivitamin tab generic qc multi-vite tab generic

PAGE 114 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS qc multi-vite 50 & over tab generic qc multi-vite plus tab generic qc therin-m tab generic qc womens daily multivitamin tab generic quintabs-m tab generic ra central-vite tab generic ra central-vite energy tab generic ra central-vite mens mature tab generic ra central-vite select tab generic ra central-vite senior tab generic ra central-vite womens mature tab generic ra central-vite/antioxidants tab generic

ra folic acid 400 mcg tab generic PA

ra hair/skin/nails tab generic ra mature womens dietary supp tab generic ra one daily energy formula tab generic ra one daily gummy vites chew tab generic ra one daily maximum tab generic ra one daily mens 50+ w/vit d3 tab generic ra one daily mens multi tab generic ra one daily mens/vit d-3 tab generic ra one daily womens tab generic ra stress formula advanced tab generic ra stress formula energy tab generic ra therapeutic m plus beta car tab generic ra vision vite plus zinc tab generic

ra vitamin b-12 100 mcg tab generic PA

ra whole source dietary tab generic ra whole source dietary mature tab generic ra whole source dietary men tab generic

PAGE 115 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ra whole source for men tab generic ra whole source womens tab generic renal tab generic renaplex tab generic savision tab generic sclerex tab generic senior multivitamin plus tab generic senior tabs tab generic sentry tab generic sentry adult tab generic sentry senior tab generic sm antioxidant vitamins tab generic

sm b super vitamin complex tab generic PA

sm complete tab generic sm complete 50+ tab generic sm complete 50+ ultimate mens tab generic sm complete 50+ ultimate women tab generic sm complete advanced formula tab generic sm complete senior formula tab generic sm daily diet support tab generic

sm folic acid 400 mcg tab generic PA

sm hair/skin/nails tab generic sm opti-vitamins tab generic

sm vitamin b-12 100 mcg tab generic PA

stress 500 b-complex tab generic PA

stress 500 b-complex/zinc tab generic stress b-complex/c/zinc tab generic

stress formula tab generic PA

stresstabs advanced tab generic

PAGE 116 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS sunvite active adult 50+ tab generic sunvite advanced tab generic super 28 formula tab generic super antioxidant tab generic super aytinal tab generic super aytinal 50 plus tab generic

super b-complex/vit c/fa tab generic PA

super multiple tab generic super nu-thera tab generic super thera vite m tab generic super vikaps tab generic super vita-mins tab generic sure guard anti-oxidant plus tab generic sure guard multi vit/mineral tab generic tab-a-vite maximum tab generic tgt multivitamin/multimineral tab generic th complete multi tab generic th complete multi 50+ tab generic

th folic acid 400 mcg tab generic PA

th premium daily multiple tab generic th theradex-m tab generic th vision vitamins tab generic

th vitamin b12 100 mcg tab generic PA

th womens daily tab generic thera vital m tab generic thera vital-m tab generic thera-m tab generic thera-m tabs generic thera-mill m tab generic

PAGE 117 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS therabasic-m tab generic theradex m tab generic theradex m/beta carotene tab generic therapeutic formula/hematinics tab generic therapeutic m tab generic therapeutic multivit/mineral tab generic therapeutic-m tab generic therapeutic-m/lutein tab generic theratrum complete tab generic theratrum complete 50 plus tab generic theravim-m tab generic thrive for life womens tab generic total formula tab generic total formula 2 tab generic total formula 3 tab generic trueplus diabetic multivitamin tab generic ultra antioxidant formula tab generic ultra freeda tab generic ultra freeda/iron tab generic ultra vita-time tab generic ultrachoice adv formula mature tab generic ultrachoice advanced formula tab generic vision formula 2 tab generic vision formula/lutein tab generic vision vitamins tab generic visivites tab generic visivites/lutein tab generic vita hair tab generic

vita-bee/c tab generic PA

vitabasic complete tab generic

PAGE 118 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS vitabasic senior tab generic

vitamin b-12 100 mcg tab generic PA

vitamin b-12 50 mcg tab generic

vitamin b12 100 mcg tab generic PA

vitamins a-d-e/selenium tab generic vitamins/minerals tab generic vitatrum chew tab generic vitatrum complete tab generic viteyes companion/lycopene tab generic vitrum senior tab generic womens daily form/fa/ca/fe tab generic womens daily formula tab generic womens life pack tab generic womens multivitamin tab generic womens multivitamin plus tab generic womens one daily tab generic

yl folic acid 400 mcg tab generic PA

your life multi mens 50+ tab generic your life multi womens 50+ tab generic

PAGE 119 LAST UPDATED 02/2018 LIST OF COVERED PRESCRIPTION MEDICATIONS

BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

celecoxib 100 mg cap generic MDD 2 per day

celecoxib 200 mg cap generic MDD 2 per day

celecoxib 400 mg cap generic MDD 2 per day

celecoxib 50 mg cap generic MDD 2 per day

diclofenac potassium 50 mg tab generic diclofenac sodium 1.5 % solution generic diclofenac sodium 25 mg tab dr generic diclofenac sodium er 100 mg tab er 24h generic diclofenac sodium er 100 mg tab er 24h generic diclofenac-misoprostol 50-0.2 mg tab dr generic DUEXIS 800-26.6 MG TAB BRAND C Non-Formulary Drug ibuprofen-famotidine EQUAGESIC 200-325 MG TAB BRAND C Non-Formulary Drug meprobamate-aspirin etodolac 200 mg cap generic etodolac er 400 mg tab er 24h generic etodolac er 500 mg tab er 24h generic fenoprofen calcium 400 mg cap generic FLECTOR 1.3 % PATCH BRAND diclofenac epolamine ibu 400 mg tab generic ibu 600 mg tab generic ibu 800 mg tab generic ibu 800 mg tabs generic ibuprofen 100 mg/5ml suspension generic ibuprofen 400 mg tab generic

PAGE 120 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ibuprofen 600 mg tab generic ibuprofen 800 mg tab generic INDOCIN 25 MG/5ML SUSPENSION BRAND indomethacin indomethacin 50 mg cap generic ketoprofen 50 mg cap generic klofensaid ii 1.5 % solution generic

mefenamic acid 250 mg cap generic C Non-Formulary Drug

meloxicam 7.5 mg tab generic MDD 2 per day

NAPRELAN 750 MG TAB ER 24H BRAND naproxen sodium naproxen 125 mg/5ml suspension generic naproxen 500 mg tab generic naproxen dr 375 mg tab dr generic naproxen kit 500 mg tab generic naproxen sodium 550 mg tab generic naproxen sodium er 500 mg tab er 24h generic piroxicam 10 mg cap generic SPRIX 15.75 MG/SPRAY SOLUTION BRAND C Non-Formulary Drug ketorolac tromethamine tolmetin sodium 400 mg cap generic

VIMOVO 375-20 MG TAB DR PA BRAND naproxen-esomeprazole magnesium C Non-Formulary Drug

VIMOVO 500-20 MG TAB DR PA BRAND naproxen-esomeprazole magnesium C Non-Formulary Drug

ZIPSOR 25 MG CAP BRAND C Non-Formulary Drug diclofenac potassium ZORVOLEX 18 MG CAP BRAND C Non-Formulary Drug diclofenac ZORVOLEX 35 MG CAP BRAND C Non-Formulary Drug diclofenac

PAGE 121 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS OPIOID ANALGESICS, LONG-ACTING

EMBEDA 20-0.8 MG CAP ER BRAND morphine-naltrexone EMBEDA 50-2 MG CAP ER BRAND PA morphine-naltrexone

PA fentanyl 75 mcg/hr patch 72hr generic MDD 0.5 per day

PA hydromorphone hcl er 16 mg tb24 deter generic MDD 1 per day

QL 30 / 30 days HYSINGLA ER 100 MG TB24 DETER BRAND PA hydrocodone bitartrate MDD 1 per day

HYSINGLA ER 60 MG TB24 DETER QL 30 / 30 days BRAND hydrocodone bitartrate MDD 1 per day

HYSINGLA ER 80 MG TB24 DETER QL 30 / 30 days BRAND hydrocodone bitartrate MDD 1 per day

methadone hcl 10 mg/5ml solution generic PA

methadone hcl 10 mg/ml conc generic PA

methadone hcl 40 mg tab sol generic PA

methadone hcl 5 mg tab generic

methadone hcl 5 mg/5ml solution generic PA

methadone hcl intensol 10 mg/ml conc generic PA

methadose 40 mg tab sol generic PA

morphine sulfate er 100 mg cap er 24h generic morphine sulfate er 100 mg cap er 24h generic morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab generic 100 mg, tab 200 mg) morphine sulfate er 100 mg tab er generic morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab generic 100 mg, tab 200 mg)

PAGE 122 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab generic PA 100 mg, tab 200 mg)

morphine sulfate er 15 mg tab er generic PA

morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab generic PA 100 mg, tab 200 mg) morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab generic PA 100 mg, tab 200 mg)

morphine sulfate er 200 mg tab er generic PA

morphine sulfate er (tab 15 mg, tab 30 mg, tab 60 mg, tab generic PA 100 mg, tab 200 mg)

morphine sulfate er 60 mg cap er 24h generic PA

morphine sulfate er beads 45 mg cap er 24h generic MDD 1 per day

morphine sulfate er beads 60 mg cap er 24h generic MDD 1 per day

PA morphine sulfate er beads 90 mg cap er 24h generic MDD 1 per day

QL 60 / 30 days NUCYNTA ER 100 MG TAB ER 12H BRAND PA tapentadol hcl MDD 2 per day

QL 60 / 30 days NUCYNTA ER 150 MG TAB ER 12H BRAND PA tapentadol hcl MDD 2 per day

QL 60 / 30 days NUCYNTA ER 200 MG TAB ER 12H BRAND PA tapentadol hcl MDD 2 per day

QL 60 / 30 days NUCYNTA ER 250 MG TAB ER 12H BRAND PA tapentadol hcl MDD 2 per day

QL 60 / 30 days NUCYNTA ER 50 MG TAB ER 12H BRAND PA tapentadol hcl MDD 2 per day

PAGE 123 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS OPANA ER 20 MG TB12 DETER BRAND oxymorphone hcl OPANA ER 40 MG TB12 DETER BRAND PA oxymorphone hcl

PA oxycodone hcl er 15 mg tb12 deter generic MDD 3 per day

oxycodone hcl er 80 mg tb12 deter generic MDD 6 per day

QL 30 / 30 days

PA tramadol hcl er (biphasic) 100 mg tab er 24h generic MDD 2 per day

C Non-Formulary Drug

QL 30 / 30 days

tramadol hcl er (biphasic) 200 mg tab er 24h generic MDD 2 per day

C Non-Formulary Drug

QL 30 / 30 days

PA tramadol hcl er (biphasic) 300 mg tab er 24h generic MDD 2 per day

C Non-Formulary Drug

QL 30 / 30 days

tramadol hcl er 100 mg tab er 24h generic PA

MDD 2 per day

tramadol hcl er 200 mg tab er 24h generic MDD 1 Per Day

QL 30 / 30 days

tramadol hcl er 300 mg tab er 24h generic PA

MDD 2 per day

XTAMPZA ER 13.5 MG CP12 DETER PA BRAND oxycodone MDD 2 Per Day

XTAMPZA ER 18 MG CP12 DETER PA BRAND oxycodone MDD 2 Per Day

XTAMPZA ER 27 MG CP12 DETER PA BRAND oxycodone MDD 2 Per Day

PAGE 124 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

XTAMPZA ER 36 MG CP12 DETER PA BRAND oxycodone MDD 2 Per Day

XTAMPZA ER 9 MG CP12 DETER PA BRAND oxycodone MDD 2 Per Day

ZOHYDRO ER 10 MG CP12 DETER BRAND PA hydrocodone bitartrate ZOHYDRO ER 15 MG CP12 DETER BRAND PA hydrocodone bitartrate ZOHYDRO ER 20 MG CAP ER 12H BRAND C Non-Formulary Drug hydrocodone bitartrate ZOHYDRO ER 20 MG CP12 DETER BRAND PA hydrocodone bitartrate ZOHYDRO ER 30 MG CAP ER 12H BRAND C Non-Formulary Drug hydrocodone bitartrate ZOHYDRO ER 30 MG CP12 DETER BRAND PA hydrocodone bitartrate ZOHYDRO ER 40 MG CAP ER 12H BRAND C Non-Formulary Drug hydrocodone bitartrate ZOHYDRO ER 40 MG CP12 DETER BRAND PA hydrocodone bitartrate ZOHYDRO ER 50 MG CAP ER 12H BRAND C Non-Formulary Drug hydrocodone bitartrate ZOHYDRO ER 50 MG CP12 DETER BRAND PA hydrocodone bitartrate OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL 400 MCG SL TAB BRAND MDD 1 per day fentanyl citrate

ABSTRAL 800 MCG SL TAB PA BRAND fentanyl citrate MDD 1 per day

acetaminophen-codeine 120-12 mg/5ml solution generic ascomp-codeine 50-325-40-30 mg cap generic

aspirin-caff-dihydrocodeine 356.4-30-16 mg cap generic C Non-Formulary Drug

belladonna alkaloids-opium 16.2-60 mg suppos generic PA

belladonna-opium 16.2-30 mg suppos generic C Non-Formulary Drug

PAGE 125 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS butalbital compound/codeine 50-325-40-30 mg cap generic butalbital-apap-caff-cod 50-325-40-30 mg cap generic butalbital-asa-caff-codeine 50-325-40-30 mg cap generic

carisoprodol-aspirin-codeine 200-325-16 mg tab generic C Non-Formulary Drug

co-gesic 5-500 mg tab generic codeine sulfate 30 mg tab generic codeine sulfate 60 mg tab generic codeine sulfate 60 mg tabs generic endocet 10-325 mg tab generic endocet 2.5-325 mg tab generic endocet 7.5-325 mg tab generic

fentanyl citrate 1600 mcg loz handle generic MDD 1 per day

fentanyl citrate 400 mcg loz handle generic MDD 1 per day

PA fentanyl citrate 600 mcg loz handle generic MDD 1 per day

FENTORA 200 MCG TAB BRAND MDD 1 per day fentanyl citrate

FENTORA 400 MCG TAB PA BRAND fentanyl citrate MDD 1 per day

FENTORA 600 MCG TAB PA BRAND fentanyl citrate MDD 1 per day

FENTORA 800 MCG TAB PA BRAND fentanyl citrate MDD 1 per day

hydrocodone-acetaminophen 10-300 mg tab generic C Non-Formulary Drug

hydrocodone-acetaminophen 10-325 mg/15ml solution generic hydrocodone-acetaminophen 10-660 mg tab generic hydrocodone-acetaminophen 10-750 mg tab generic

hydrocodone-acetaminophen 2.5-108 mg/5ml solution generic C Non-Formulary Drug

hydrocodone-acetaminophen 5-217 mg/10ml solution generic C Non-Formulary Drug

PAGE 126 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

hydrocodone-acetaminophen 5-300 mg tab generic C Non-Formulary Drug

hydrocodone-acetaminophen 5-500 mg tab generic

hydrocodone-acetaminophen 7.5-300 mg tab generic C Non-Formulary Drug

hydrocodone-acetaminophen 7.5-325 mg tab generic

hydrocodone-acetaminophen 7.5-325 mg/15ml solution generic C Non-Formulary Drug

hydrocodone-acetaminophen 7.5-500 mg/15ml soln generic hydrocodone-acetaminophen 7.5-500 mg/15ml solution generic

hydrocodone-ibuprofen 10-200 mg tab generic C Non-Formulary Drug

hydrocodone-ibuprofen 2.5-200 mg tab generic C Non-Formulary Drug

hydrocodone-ibuprofen 5-200 mg tab generic C Non-Formulary Drug

hydrocodone-ibuprofen 7.5-200 mg tab generic hydromorphone hcl 4 mg tab generic

ibudone 5-200 mg tab generic C Non-Formulary Drug

LAZANDA 100 MCG/ACT SOLUTION BRAND C Non-Formulary Drug fentanyl citrate LAZANDA 400 MCG/ACT SOLUTION BRAND C Non-Formulary Drug fentanyl citrate lorcet plus 7.5-325 mg tab generic lortab 7.5-325 mg tab generic

meperidine hcl 100 mg tab generic C Non-Formulary Drug

meperidine hcl 50 mg tab generic C Non-Formulary Drug

meperidine hcl 50 mg/5ml solution generic C Non-Formulary Drug

meperitab 50 mg tab generic C Non-Formulary Drug

morphine sulfate (concentrate) 10 mg/0.5ml solution generic morphine sulfate (concentrate) 100 mg/5ml solution generic morphine sulfate (concentrate) 20 mg/ml solution generic morphine sulfate 10 mg suppos generic morphine sulfate 10 mg/5ml solution generic morphine sulfate 20 mg suppos generic

PAGE 127 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS morphine sulfate 30 mg suppos generic morphine sulfate 30 mg tab generic OXAYDO 5 MG TAB DETER BRAND C Non-Formulary Drug oxycodone hcl OXAYDO 7.5 MG TAB DETER BRAND C Non-Formulary Drug oxycodone hcl OXECTA 5 MG TAB DETER BRAND C Non-Formulary Drug oxycodone hcl OXECTA 7.5 MG TAB DETER BRAND C Non-Formulary Drug oxycodone hcl oxycodone hcl 15 mg tab generic oxycodone hcl 20 mg tab generic

oxycodone hcl 30 mg tab generic C Non-Formulary Drug

oxycodone-acetaminophen 10-325 mg tab generic oxycodone-acetaminophen 2.5-325 mg tab generic OXYCODONE-ACETAMINOPHEN 5-325 MG/5ML SOLUTION BRAND oxycodone w/ acetaminophen oxycodone-acetaminophen 7.5-325 mg tab generic oxymorphone hcl 5 mg tab generic pentazocine-naloxone hcl 50-0.5 mg tab generic PRIMLEV 10-300 MG TAB BRAND PA oxycodone w/ acetaminophen PRIMLEV 5-300 MG TAB BRAND PA oxycodone w/ acetaminophen PRIMLEV 7.5-300 MG TAB BRAND PA oxycodone w/ acetaminophen

reprexain 10-200 mg tab generic C Non-Formulary Drug

ROXICET 5-325 MG/5ML SOLUTION BRAND oxycodone w/ acetaminophen

tramadol-acetaminophen 37.5-325 mg tab generic MDD 10 per day

TREZIX 356.4-30-16 MG CAP BRAND acetaminophen-caff-dihydrocod

vicodin 5-300 mg tab generic C Non-Formulary Drug

PAGE 128 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

vicodin es 7.5-300 mg tab generic C Non-Formulary Drug

vicodin hp 10-300 mg tab generic C Non-Formulary Drug

vicodin hp 10-660 mg tab generic XARTEMIS XR 7.5-325 MG TAB ER BRAND C Non-Formulary Drug oxycodone w/ acetaminophen XOLOX 10-500 MG TAB BRAND oxycodone w/ acetaminophen

xylon 10-200 mg tab generic C Non-Formulary Drug

zamicet 10-325 mg/15ml solution generic ZYDONE 10-400 MG TAB BRAND C Non-Formulary Drug hydrocodone-acetaminophen ZYDONE 5-400 MG TAB BRAND C Non-Formulary Drug hydrocodone-acetaminophen ZYDONE 7.5-400 MG TAB BRAND C Non-Formulary Drug hydrocodone-acetaminophen ANESTHETICS

LOCAL ANESTHETICS

lidocaine-prilocaine 2.5-2.5 % cream generic PA

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

disulfiram 250 mg tab generic OPIOID DEPENDENCE TREATMENTS

buprenorphine hcl 2 mg sl tab generic C Non-Formulary Drug

buprenorphine hcl 8 mg sl tab generic C Non-Formulary Drug

buprenorphine hcl-naloxone hcl 2-0.5 mg sl tab generic C Non-Formulary Drug

buprenorphine hcl-naloxone hcl 8-2 mg sl tab generic C Non-Formulary Drug

ZUBSOLV 1.4-0.36 MG SL TAB BRAND C Non-Formulary Drug buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV 5.7-1.4 MG SL TAB BRAND C Non-Formulary Drug buprenorphine hcl-naloxone hcl dihydrate

PAGE 129 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS SMOKING CESSATION AGENTS

NICOTROL 10 MG INHALER BRAND C Non-Formulary Drug nicotine NICOTROL NS 10 MG/ML SOLUTION BRAND C Non-Formulary Drug nicotine ANTIBACTERIALS

AMINOGLYCOSIDES

gentamicin sulfate 0.1 % ointment generic

paromomycin sulfate 250 mg cap generic C Non-Formulary Drug

tobramycin 0.3 % solution generic tobrasol 0.3 % solution generic YODOXIN 210 MG TAB BRAND C Non-Formulary Drug iodoquinol YODOXIN 650 MG TAB BRAND C Non-Formulary Drug iodoquinol ANTIBACTERIALS, OTHER

acetic acid 0.25 % solution generic PA

BACTROBAN NASAL 2 % OINTMENT BRAND C Non-Formulary Drug mupirocin calcium CLEOCIN 100 MG SUPPOS BRAND PA clindamycin phosphate vaginal clindamycin hcl 75 mg cap generic clindamycin palmitate hcl 75 mg/5ml recon soln generic clindamycin phosphate 1 % lotion generic

e.s.p. 200-600 mg/5ml recon susp generic C Non-Formulary Drug

erythromycin-sulfisoxazole 200-600 mg/5ml recon susp generic C Non-Formulary Drug

FIRST-VANCOMYCIN 25 25 MG/ML SOLUTION BRAND PA vancomycin hcl FLAGYL ER 750 MG TAB ER 24H BRAND metronidazole hyolev mb 81 mg tab generic methenamine hippurate 1 gm tab generic

PAGE 130 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS methenamine mandelate 0.5 gm tab generic methenamine mandelate 1 gm tab generic metronidazole gel 0.75 % generic metronidazole 250 mg tab generic metronidazole 250 mg tabs generic mupirocin 2 % ointment generic

neomycin-polymyxin b gu 40-200000 solution generic PA

nitrofurantoin macrocrystal 25 mg cap generic nitrofurantoin macrocrystal 50 mg cap generic nitrofurantoin monohyd macro 100 mg cap generic PRIMSOL 50 MG/5ML SOLUTION BRAND C Non-Formulary Drug trimethoprim hcl metronidazole gel 0.75 % generic tinidazole 500 mg tab generic TRIMPEX 50 MG/5ML SOLUTION BRAND C Non-Formulary Drug trimethoprim hcl urelle 81 mg tab generic uro-458 81 mg tab generic uro-l 81 mg tab generic uroav-81 81 mg tab generic

vancomycin hcl 125 mg cap generic C Non-Formulary Drug

vancomycin hcl 250 mg cap generic C Non-Formulary Drug

vilevev mb 81 mg tab generic XIFAXAN 200 MG TAB BRAND PA rifaximin XIFAXAN 550 MG TAB BRAND PA rifaximin BETA-LACTAM, CEPHALOSPORINS

CEDAX 180 MG/5ML RECON SUSP BRAND C Non-Formulary Drug ceftibuten CEDAX 400 MG CAP BRAND C Non-Formulary Drug ceftibuten

PAGE 131 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS CEDAX 90 MG/5ML RECON SUSP BRAND C Non-Formulary Drug ceftibuten

cefaclor 125 mg/5ml recon susp generic C Non-Formulary Drug

cefaclor 250 mg cap generic C Non-Formulary Drug

cefaclor 250 mg/5ml recon susp generic C Non-Formulary Drug

cefaclor 375 mg/5ml recon susp generic C Non-Formulary Drug

cefaclor 500 mg cap generic C Non-Formulary Drug

cefaclor 500 mg caps generic C Non-Formulary Drug

cefaclor er 500 mg tab er 12h generic C Non-Formulary Drug

cefadroxil 1 gm tab generic cefadroxil 250 mg/5ml recon susp generic cefadroxil 500 mg/5ml recon susp generic cefdinir 250 mg/5ml recon susp generic

cefditoren pivoxil 200 mg tab generic C Non-Formulary Drug

cefditoren pivoxil 400 mg tab generic C Non-Formulary Drug

cefixime 100 mg/5ml recon susp generic C Non-Formulary Drug

cefixime 200 mg/5ml recon susp generic C Non-Formulary Drug

cefpodoxime proxetil 100 mg tab generic C Non-Formulary Drug

cefpodoxime proxetil 100 mg/5ml recon susp generic C Non-Formulary Drug

cefpodoxime proxetil 200 mg tab generic C Non-Formulary Drug

cefpodoxime proxetil 50 mg/5ml recon susp generic C Non-Formulary Drug

cefprozil 500 mg tab generic CEFTIBUTEN 180 MG/5ML RECON SUSP BRAND C Non-Formulary Drug ceftibuten CEFTIBUTEN 400 MG CAP BRAND C Non-Formulary Drug ceftibuten cefuroxime axetil 250 mg tab generic cephalexin 125 mg/5ml recon susp generic

PAGE 132 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS cephalexin 250 mg cap generic cephalexin 500 mg cap generic cephalexin 750 mg cap generic SUPRAX 100 MG CHEW TAB BRAND C Non-Formulary Drug cefixime SUPRAX 200 MG CHEW TAB BRAND C Non-Formulary Drug cefixime SUPRAX 400 MG CAP BRAND C Non-Formulary Drug cefixime SUPRAX 400 MG TAB BRAND C Non-Formulary Drug cefixime BETA-LACTAM, PENICILLINS

amoxicillin 875 mg tab generic AMOXICILLIN ER 775 MG TAB ER 24H BRAND C Non-Formulary Drug amoxicillin amoxicillin-pot clavulanate 200-28.5 mg chew tab generic

amoxicillin-pot clavulanate 250-125 mg tab generic C Non-Formulary Drug

amoxicillin-pot clavulanate 600-42.9 mg/5ml recon susp generic AMPICILLIN 250 MG/5ML RECON SUSP BRAND ampicillin ampicillin 500 mg cap generic AUGMENTIN 125-31.25 MG/5ML RECON SUSP BRAND amoxicillin & pot clavulanate dicloxacillin sodium 500 mg cap generic MOXATAG 775 MG TAB ER 24H BRAND C Non-Formulary Drug amoxicillin penicillin v potassium 125 mg/5ml recon soln generic penicillin v potassium 250 mg tab generic penicillin v potassium 250 mg/5ml recon soln generic MACROLIDES

AKNE-MYCIN 2 % OINTMENT BRAND PA erythromycin (acne aid) AZASITE 1 % SOLUTION BRAND azithromycin (ophth)

PAGE 133 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

azithromycin 1 gm packet generic C Non-Formulary Drug

azithromycin 200 mg/5ml recon susp generic azithromycin 250 mg tab generic azithromycin 600 mg tab generic clarithromycin 250 mg tab generic clarithromycin 250 mg/5ml recon susp generic DIFICID 200 MG TAB BRAND C Non-Formulary Drug fidaxomicin

ery 2 % pad generic PA

ERY-TAB 250 MG TAB DR BRAND erythromycin base ERY-TAB 333 MG TAB DR BRAND erythromycin base ERYPED 400 400 MG/5ML RECON SUSP BRAND C Non-Formulary Drug erythromycin ethylsuccinate

erythromycin 2 % pad generic PA

erythromycin 5 mg/gm ointment generic erythromycin base 500 mg tab generic erythromycin ethylsuccinate 200 mg/5ml recon susp generic ilotycin 5 mg/gm ointment generic PCE 333 MG TAB DR BRAND erythromycin base (coated) romycin 5 mg/gm ointment generic ZMAX 2 GM RECON SUSP BRAND C Non-Formulary Drug azithromycin ZMAX 2 GM SUSR BRAND C Non-Formulary Drug azithromycin ZMAX PEDIATRIC 2 GM SUSR BRAND C Non-Formulary Drug azithromycin QUINOLONES

CILOXAN 0.3 % OINTMENT BRAND ciprofloxacin hcl (ophth) ciprofloxacin 250 mg/5ml (5%) recon susp generic

PAGE 134 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

ciprofloxacin hcl 0.2 % solution generic C Non-Formulary Drug

ciprofloxacin-ciproflox hcl er 1000 mg tab er 24h generic C Non-Formulary Drug

FACTIVE 320 MG TAB BRAND C Non-Formulary Drug gemifloxacin mesylate

gatifloxacin 0.5 % solution generic C Non-Formulary Drug

levofloxacin 0.5 % solution generic PA

levofloxacin 250 mg tab generic MDD 1 per day

levofloxacin 750 mg tab generic MDD 1 per day

moxifloxacin hcl 0.5 % solution generic PA

NOROXIN 400 MG TAB BRAND C Non-Formulary Drug norfloxacin ofloxacin 0.3 % solution generic

ofloxacin 0.3 % solution generic PA

ofloxacin 200 mg tab generic C Non-Formulary Drug

ofloxacin 200 mg tabs generic C Non-Formulary Drug

ofloxacin 300 mg tab generic C Non-Formulary Drug

ofloxacin 400 mg tab generic C Non-Formulary Drug

SULFONAMIDES

AVC VAGINAL 15 % CREAM BRAND PA sulfanilamide vaginal silver sulfadiazine 1 % cream generic ssd 1 % cream generic ssd af 1 % cream generic

sulfadiazine 500 mg tab generic C Non-Formulary Drug

thermazene 1 % cream generic TETRACYCLINES

avidoxy 100 mg tab generic

PAGE 135 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

coremino 135 mg tab er 24h generic PA

coremino 45 mg tab er 24h generic coremino 90 mg tab er 24h generic

demeclocycline hcl 150 mg tab generic C Non-Formulary Drug

demeclocycline hcl 300 mg tab generic C Non-Formulary Drug

DOXYCYCLINE 40 MG CAP DR BRAND C Non-Formulary Drug doxycycline (rosacea) doxycycline hyclate 100 mg tab generic

doxycycline hyclate 100 mg tab dr generic C Non-Formulary Drug

doxycycline hyclate 150 mg tab generic C Non-Formulary Drug

doxycycline hyclate 150 mg tab dr generic C Non-Formulary Drug

doxycycline hyclate 20 mg tab generic C Non-Formulary Drug

doxycycline hyclate 200 mg tab dr generic C Non-Formulary Drug

doxycycline hyclate 50 mg tab dr generic C Non-Formulary Drug

doxycycline hyclate 75 mg tab generic C Non-Formulary Drug

doxycycline hyclate 75 mg tab dr generic C Non-Formulary Drug

doxycycline monohydrate 100 mg tab generic

doxycycline monohydrate 150 mg cap generic C Non-Formulary Drug

doxycycline monohydrate 150 mg tab generic

doxycycline monohydrate 25 mg/5ml recon susp generic C Non-Formulary Drug

doxycycline monohydrate 75 mg cap generic

minocycline hcl 100 mg tab generic C Non-Formulary Drug

minocycline hcl 50 mg tab generic C Non-Formulary Drug

minocycline hcl 75 mg tab generic C Non-Formulary Drug

minocycline hcl er 135 mg tab er 24h generic PA

minocycline hcl er 45 mg tab er 24h generic minocycline hcl er 90 mg tab er 24h generic

PAGE 136 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS mondoxyne nl 75 mg cap generic okebo 75 mg cap generic ORACEA 40 MG CAP DR BRAND C Non-Formulary Drug doxycycline (rosacea) SOLODYN 105 MG TAB ER 24H BRAND C Non-Formulary Drug minocycline hcl SOLODYN 115 MG TAB ER 24H BRAND C Non-Formulary Drug minocycline hcl SOLODYN 55 MG TAB ER 24H BRAND C Non-Formulary Drug minocycline hcl SOLODYN 65 MG TAB ER 24H BRAND C Non-Formulary Drug minocycline hcl SOLODYN 80 MG TAB ER 24H BRAND C Non-Formulary Drug minocycline hcl TARGADOX 50 MG TAB BRAND C Non-Formulary Drug doxycycline hyclate tetracycline hcl 500 mg cap generic tetracycline hcl 500 mg caps generic VIBRAMYCIN 50 MG/5ML SYRUP BRAND C Non-Formulary Drug doxycycline calcium ANTICONVULSANTS

ANTICONVULSANTS, OTHER

FYCOMPA 0.5 MG/ML SUSPENSION BRAND PA perampanel FYCOMPA 2 MG TAB BRAND perampanel FYCOMPA 4 MG TAB BRAND PA perampanel levetiracetam 500 mg tab generic

levetiracetam 750 mg tab generic PA

POTIGA 400 MG TAB BRAND PA ezogabine roweepra 500 mg tab generic

roweepra 750 mg tab generic PA

PAGE 137 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS CALCIUM CHANNEL MODIFYING AGENTS

ethosuximide 250 mg cap generic PA

ethosuximide 250 mg/5ml solution generic PA

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

diazepam 2.5 mg gel generic diazepam 20 mg gel generic divalproex sodium 125 mg cap dr generic gabapentin 100 mg cap generic gabapentin 400 mg cap generic gabapentin 600 mg tab generic gabapentin 800 mg tab generic GABITRIL 12 MG TAB BRAND PA tiagabine hcl GRALISE 300 MG TAB BRAND C Non-Formulary Drug gabapentin (once-daily) GRALISE 600 MG TAB BRAND C Non-Formulary Drug gabapentin (once-daily) GRALISE STARTER 300 & 600 MG MISC BRAND C Non-Formulary Drug gabapentin (once-daily) ONFI 2.5 MG/ML SUSPENSION BRAND PA clobazam ONFI 20 MG TAB BRAND clobazam

phenobarbital 15 mg tab generic PA

phenobarbital 30 mg tab generic PA

primidone 50 mg tab generic SABRIL 500 MG TAB BRAND C Non-Formulary Drug vigabatrin STAVZOR 250 MG CAP DR BRAND valproic acid

tiagabine hcl 2 mg tab generic PA

tiagabine hcl 4 mg tab generic

PAGE 138 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

vigabatrin 500 mg packet generic C Non-Formulary Drug

GLUTAMATE REDUCING AGENTS

felbamate 400 mg tab generic PA

lamotrigine 100 mg tab disp generic PA

lamotrigine 5 mg chew tab generic PA

topiragen 200 mg tab generic

topiragen 50 mg tab generic PA

topiramate 15 mg cap sprink generic PA

topiramate 200 mg tab generic

topiramate 50 mg tab generic PA

TROKENDI XR 100 MG CAP ER 24H BRAND C Non-Formulary Drug topiramate TROKENDI XR 200 MG CAP ER 24H BRAND C Non-Formulary Drug topiramate TROKENDI XR 25 MG CAP ER 24H BRAND C Non-Formulary Drug topiramate TROKENDI XR 50 MG CAP ER 24H BRAND C Non-Formulary Drug topiramate SODIUM CHANNEL AGENTS

APTIOM 400 MG TAB BRAND eslicarbazepine acetate APTIOM 600 MG TAB BRAND eslicarbazepine acetate BANZEL 200 MG TAB BRAND C Non-Formulary Drug rufinamide BANZEL 40 MG/ML SUSPENSION BRAND C Non-Formulary Drug rufinamide BANZEL 400 MG TAB BRAND C Non-Formulary Drug rufinamide

carbamazepine 100 mg/5ml suspension generic PA

carbamazepine er 300 mg cap er 12h generic carbamazepine er 400 mg tab er 12h generic

PAGE 139 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS carbamazepine er 400 mg tab er 12h generic oxcarbazepine 150 mg tab generic OXTELLAR XR 150 MG TAB ER 24H BRAND C Non-Formulary Drug oxcarbazepine OXTELLAR XR 300 MG TAB ER 24H BRAND C Non-Formulary Drug oxcarbazepine OXTELLAR XR 600 MG TAB ER 24H BRAND C Non-Formulary Drug oxcarbazepine PEGANONE 250 MG TAB BRAND C Non-Formulary Drug ethotoin phenytoin sodium extended 200 mg cap generic VIMPAT 100 MG TAB BRAND lacosamide VIMPAT 150 MG TAB BRAND PA lacosamide VIMPAT 200 MG TAB BRAND PA lacosamide ANTIDEMENTIA AGENTS

CHOLINESTERASE INHIBITORS

donepezil hcl 10 mg tab generic C Non-Formulary Drug

donepezil hcl 10 mg tab disp generic C Non-Formulary Drug

donepezil hcl 23 mg tab generic C Non-Formulary Drug

donepezil hcl 5 mg tab generic C Non-Formulary Drug

donepezil hcl 5 mg tab disp generic C Non-Formulary Drug

EXELON 2 MG/ML SOLUTION BRAND C Non-Formulary Drug rivastigmine tartrate

galantamine hydrobromide 12 mg tab generic C Non-Formulary Drug

galantamine hydrobromide 4 mg tab generic C Non-Formulary Drug

galantamine hydrobromide 4 mg/ml solution generic C Non-Formulary Drug

galantamine hydrobromide 8 mg tab generic C Non-Formulary Drug

galantamine hydrobromide er 16 mg cap er 24h generic C Non-Formulary Drug

PAGE 140 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

galantamine hydrobromide er 24 mg cap er 24h generic C Non-Formulary Drug

galantamine hydrobromide er 8 mg cap er 24h generic C Non-Formulary Drug

rivastigmine tartrate 1.5 mg cap generic C Non-Formulary Drug

rivastigmine tartrate 3 mg cap generic C Non-Formulary Drug

rivastigmine tartrate 4.5 mg cap generic C Non-Formulary Drug

rivastigmine tartrate 6 mg cap generic C Non-Formulary Drug

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

PA memantine hcl 10 mg tab generic MDD 2 per day

NAMENDA XR 14 MG CAP ER 24H BRAND C Non-Formulary Drug memantine hcl NAMENDA XR 21 MG CAP ER 24H BRAND C Non-Formulary Drug memantine hcl NAMENDA XR 28 MG CAP ER 24H BRAND C Non-Formulary Drug memantine hcl NAMENDA XR 7 MG CAP ER 24H BRAND C Non-Formulary Drug memantine hcl ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

APLENZIN 174 MG TAB ER 24H BRAND C Non-Formulary Drug bupropion hydrobromide APLENZIN 348 MG TAB ER 24H BRAND C Non-Formulary Drug bupropion hydrobromide APLENZIN 522 MG TAB ER 24H BRAND C Non-Formulary Drug bupropion hydrobromide

budeprion xl 300 mg tab er 24h generic MDD 1 per day

PA bupropion hcl er (sr) 200 mg tab er 12h generic MDD 2 per day

bupropion hcl er (xl) 300 mg tab er 24h generic MDD 1 per day

PAGE 141 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

bupropion hcl er (xl) 300 mg tab er 24h generic MDD 1 per day

chlordiazepoxide-amitriptyline 10-25 mg tab generic C Non-Formulary Drug

chlordiazepoxide-amitriptyline 5-12.5 mg tab generic C Non-Formulary Drug

mirtazapine 15 mg tab generic MDD 1 per day

mirtazapine 45 mg tab disp generic MDD 1 per day

olanzapine-fluoxetine hcl 12-25 mg cap generic C Non-Formulary Drug

olanzapine-fluoxetine hcl 12-50 mg cap generic C Non-Formulary Drug

olanzapine-fluoxetine hcl 3-25 mg cap generic C Non-Formulary Drug

olanzapine-fluoxetine hcl 6-25 mg cap generic C Non-Formulary Drug

olanzapine-fluoxetine hcl 6-50 mg cap generic C Non-Formulary Drug

perphenazine-amitriptyline 2-10 mg tab generic C Non-Formulary Drug

perphenazine-amitriptyline 2-25 mg tab generic C Non-Formulary Drug

perphenazine-amitriptyline 4-10 mg tab generic C Non-Formulary Drug

perphenazine-amitriptyline 4-25 mg tab generic C Non-Formulary Drug

perphenazine-amitriptyline 4-50 mg tab generic C Non-Formulary Drug

MONOAMINE OXIDASE INHIBITORS

EMSAM 12 MG/24HR PATCH 24HR BRAND C Non-Formulary Drug selegiline EMSAM 6 MG/24HR PATCH 24HR BRAND C Non-Formulary Drug selegiline EMSAM 9 MG/24HR PATCH 24HR BRAND C Non-Formulary Drug selegiline EMSAM 9 MG/24HR PT24 BRAND C Non-Formulary Drug selegiline

tranylcypromine sulfate 10 mg tab generic PA

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR

BRINTELLIX 10 MG TAB BRAND C Non-Formulary Drug vortioxetine hbr

PAGE 142 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS BRINTELLIX 20 MG TAB BRAND C Non-Formulary Drug vortioxetine hbr BRINTELLIX 5 MG TAB BRAND C Non-Formulary Drug vortioxetine hbr

citalopram hydrobromide 10 mg/5ml solution generic PA

PA citalopram hydrobromide 20 mg tab generic MDD 1 per day

DESVENLAFAXINE FUMARATE ER 100 MG TAB ER 24H BRAND C Non-Formulary Drug desvenlafaxine fumarate DESVENLAFAXINE FUMARATE ER 50 MG TAB ER 24H BRAND C Non-Formulary Drug desvenlafaxine fumarate

desvenlafaxine succinate er 100 mg tab er 24h generic PA

desvenlafaxine succinate er 50 mg tab er 24h generic

fluoxetine hcl (pmdd) 10 mg cap generic C Non-Formulary Drug

fluoxetine hcl (pmdd) 10 mg tab generic C Non-Formulary Drug

fluoxetine hcl (pmdd) 20 mg cap generic C Non-Formulary Drug

fluoxetine hcl (pmdd) 20 mg tab generic C Non-Formulary Drug

PA fluoxetine hcl 20 mg tab generic MDD 2 per day

fluoxetine hcl 20 mg/5ml solution generic

PA fluoxetine hcl 40 mg cap generic MDD 2 per day

fluvoxamine maleate 100 mg tab generic

fluvoxamine maleate er 100 mg cap er 24h generic C Non-Formulary Drug

fluvoxamine maleate er 150 mg cap er 24h generic C Non-Formulary Drug

maprotiline hcl 25 mg tab generic C Non-Formulary Drug

maprotiline hcl 50 mg tab generic C Non-Formulary Drug

maprotiline hcl 75 mg tab generic C Non-Formulary Drug

nefazodone hcl 100 mg tab generic C Non-Formulary Drug

PAGE 143 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

nefazodone hcl 150 mg tab generic C Non-Formulary Drug

nefazodone hcl 200 mg tab generic C Non-Formulary Drug

nefazodone hcl 250 mg tab generic C Non-Formulary Drug

nefazodone hcl 50 mg tab generic C Non-Formulary Drug

OLEPTRO 150 MG TAB ER 24H BRAND C Non-Formulary Drug trazodone hcl OLEPTRO 300 MG TAB ER 24H BRAND C Non-Formulary Drug trazodone hcl

PA paroxetine hcl 10 mg tab generic MDD 1 per day

paroxetine hcl 10 mg/5ml suspension generic PA

PA paroxetine hcl 20 mg tab generic MDD 1 per day

PA paroxetine hcl 30 mg tab generic MDD 1 per day

PA paroxetine hcl er 37.5 mg tab er 24h generic MDD 1 per day

paroxetine mesylate 7.5 mg cap generic C Non-Formulary Drug

PEXEVA 10 MG TAB BRAND C Non-Formulary Drug paroxetine mesylate PEXEVA 20 MG TAB BRAND C Non-Formulary Drug paroxetine mesylate PEXEVA 30 MG TAB BRAND C Non-Formulary Drug paroxetine mesylate PEXEVA 40 MG TAB BRAND C Non-Formulary Drug paroxetine mesylate

selfemra 10 mg cap generic C Non-Formulary Drug

selfemra 20 mg cap generic C Non-Formulary Drug

PAGE 144 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS trazodone hcl 100 mg tab generic TRINTELLIX 10 MG TAB BRAND C Non-Formulary Drug vortioxetine hbr TRINTELLIX 20 MG TAB BRAND C Non-Formulary Drug vortioxetine hbr TRINTELLIX 5 MG TAB BRAND C Non-Formulary Drug vortioxetine hbr venlafaxine hcl er 150 mg cap er 24h generic venlafaxine hcl er 150 mg cap er 24h generic venlafaxine hcl er 150 mg tab er 24h generic venlafaxine hcl er 37.5 mg cap er 24h generic venlafaxine hcl er 37.5 mg cap er 24h generic venlafaxine hcl er 37.5 mg tab er 24h generic

VIIBRYD 10 MG TAB MDD 1 per day BRAND vilazodone hcl C Non-Formulary Drug

VIIBRYD 20 MG TAB MDD 1 per day BRAND vilazodone hcl C Non-Formulary Drug

VIIBRYD 40 MG TAB MDD 1 per day BRAND vilazodone hcl C Non-Formulary Drug

TRICYCLICS

amitriptyline hcl 150 mg tab generic amitriptyline hcl 25 mg tab generic

amoxapine 100 mg tab generic C Non-Formulary Drug

amoxapine 150 mg tab generic C Non-Formulary Drug

amoxapine 25 mg tab generic C Non-Formulary Drug

amoxapine 50 mg tab generic C Non-Formulary Drug

clomipramine hcl 75 mg cap generic desipramine hcl 10 mg tab generic desipramine hcl 25 mg tab generic desipramine hcl 50 mg tab generic

PAGE 145 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS doxepin hcl 10 mg cap generic doxepin hcl 10 mg caps generic doxepin hcl 100 mg cap generic doxepin hcl 150 mg cap generic imipramine hcl 25 mg tab generic imipramine hcl 50 mg tab generic

imipramine pamoate 100 mg cap generic C Non-Formulary Drug

imipramine pamoate 125 mg cap generic C Non-Formulary Drug

imipramine pamoate 150 mg cap generic C Non-Formulary Drug

imipramine pamoate 75 mg cap generic C Non-Formulary Drug

nortriptyline hcl 10 mg/5ml solution generic nortriptyline hcl 75 mg cap generic

protriptyline hcl 10 mg tab generic C Non-Formulary Drug

protriptyline hcl 5 mg tab generic C Non-Formulary Drug

trimipramine maleate 100 mg cap generic C Non-Formulary Drug

trimipramine maleate 25 mg cap generic C Non-Formulary Drug

trimipramine maleate 50 mg cap generic C Non-Formulary Drug

ANTIEMETICS

ANTIEMETICS, OTHER

DICLEGIS 10-10 MG TAB DR BRAND C Non-Formulary Drug doxylamine-pyridoxine meclizine hcl 12.5 mg tab generic meclizine hcl 25 mg tab generic metoclopramide hcl 5 mg tab generic perphenazine 16 mg tab generic

perphenazine 2 mg tab generic PA

perphenazine 8 mg tab generic PA

prochlorperazine maleate 5 mg tab generic

PAGE 146 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS scopolamine 1 mg/3days patch 72hr generic trimethobenzamide hcl 300 mg cap generic EMETOGENIC THERAPY ADJUNCTS

ANZEMET 100 MG TAB BRAND dolasetron mesylate

PA aprepitant 125 mg cap generic MDD 1 per day

PA aprepitant 40 mg cap generic MDD 1 per day

dronabinol 10 mg cap generic PA

ondansetron hcl 24 mg tab generic

ondansetron hcl 4 mg/5ml solution generic PA

SANCUSO 3.1 MG/24HR PATCH BRAND granisetron VARUBI 90 MG TAB BRAND C Non-Formulary Drug rolapitant hcl ZUPLENZ 4 MG FILM BRAND C Non-Formulary Drug ondansetron ZUPLENZ 8 MG FILM BRAND C Non-Formulary Drug ondansetron ANTIFUNGALS

BIO-STATIN 1000000 UNIT CAP BRAND C Non-Formulary Drug nystatin BIO-STATIN 500000 UNIT CAP BRAND C Non-Formulary Drug nystatin

PA ciclodan 8 % solution generic MDD 0.24 per day

ciclopirox 1 % shampoo generic PA

PA ciclopirox 8 % solution generic MDD 0.24 per day

clotrimazole 1 % cream generic

clotrimazole 10 mg lozenge generic PA

PAGE 147 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

clotrimazole 10 mg troche generic PA

clotrimazole anti-fungal 1 % cream generic ECOZA 1 % FOAM BRAND C Non-Formulary Drug econazole nitrate ERTACZO 2 % CREAM BRAND PA sertaconazole nitrate fluconazole 10 mg/ml recon susp generic fluconazole 150 mg tab generic fluconazole 50 mg tab generic

flucytosine 250 mg cap generic C Non-Formulary Drug

flucytosine 500 mg cap generic C Non-Formulary Drug

griseofulvin microsize 125 mg/5ml suspension generic griseofulvin microsize 500 mg tab generic

griseofulvin ultramicrosize 125 mg tab generic C Non-Formulary Drug

griseofulvin ultramicrosize 250 mg tab generic C Non-Formulary Drug

itraconazole 100 mg cap generic JUBLIA 10 % SOLUTION BRAND C Non-Formulary Drug efinaconazole LAMISIL 125 MG PACKET BRAND C Non-Formulary Drug terbinafine hcl LAMISIL 187.5 MG PACKET BRAND C Non-Formulary Drug terbinafine hcl LUZU 1 % CREAM BRAND C Non-Formulary Drug luliconazole miconazole 3 200 & 2 mg-% (9gm) kit generic

naftifine hcl 2 % cream generic PA

NAFTIN 2 % GEL BRAND PA naftifine hcl NOXAFIL 100 MG TAB DR BRAND PA posaconazole

nystatin 500000 unit tab generic PA

nystatin-triamcinolone 100000-0.1 unit/gm-% ointment generic

PAGE 148 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ONMEL 200 MG TAB BRAND C Non-Formulary Drug itraconazole OXISTAT 1 % LOTION BRAND PA oxiconazole nitrate SPORANOX 10 MG/ML SOLUTION BRAND C Non-Formulary Drug itraconazole terbinafine hcl 250 mg tab generic terbinafine hcl 250 mg tabs generic terconazole 0.4 % cream generic

voriconazole 200 mg tab generic PA

zazole 0.4 % cream generic ANTIGOUT AGENTS

colchicine 0.6 mg tab generic PA

ULORIC 80 MG TAB BRAND PA febuxostat ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS

dihydroergotamine mesylate 4 mg/ml solution generic C Non-Formulary Drug

ergotamine-caffeine 1-100 mg tab generic PA

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate 12.5 mg tab generic MDD 0.4 per day

eletriptan hydrobromide 20 mg tab generic MDD 0.4 per day

frovatriptan succinate 2.5 mg tab generic C Non-Formulary Drug

naratriptan hcl 1 mg tab generic PA

naratriptan hcl 2.5 mg tab generic PA

PA rizatriptan benzoate odt 5 mg generic MDD 0.4 per day

PA sumatriptan nasal spray (5 mg/act, 20 mg/act) generic MDD 0.4 per day

PAGE 149 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA sumatriptan succinate 25 mg tab generic MDD 0.6 per day

SUMATRIPTAN-NAPROXEN SODIUM 85-500 MG TAB PA BRAND sumatriptan-naproxen sodium MDD 0.14 per day

TREXIMET 85-500 MG TAB PA BRAND sumatriptan-naproxen sodium MDD 0.14 per day

zolmitriptan 2.5 mg tab generic MDD 0.4 per day

PA zolmitriptan 2.5 mg tab disp generic MDD 0.4 per day

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

MYTELASE 10 MG TAB BRAND PA ambenonium chloride

pyridostigmine bromide 60 mg tab generic PA

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

rifabutin 150 mg cap generic ANTITUBERCULARS

isoniazid 100 mg tab generic

isoniazid 300 mg tab generic PA

ISONIAZID 50 MG/5ML SYRUP BRAND PA isoniazid PRIFTIN 150 MG TAB BRAND C Non-Formulary Drug rifapentine

rifampin 300 mg cap generic PA

RIFATER 50-120-300 MG TAB BRAND PA isoniazid-rifampin w/ pyrazinamide TRECATOR 250 MG TAB BRAND PA ethionamide

PAGE 150 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANTINEOPLASTICS

ALKYLATING AGENTS

cyclophosphamide 25 mg tab generic PA

cyclophosphamide 50 mg tab generic PA

MYLERAN 2 MG TAB BRAND PA busulfan temozolomide 5 mg cap generic ANTIANDROGENS

flutamide 125 mg cap generic PA

nilutamide 150 mg tab generic ZYTIGA 250 MG TAB BRAND PA abiraterone acetate ANTIANGIOGENIC AGENTS

POMALYST 2 MG CAP BRAND pomalidomide POMALYST 3 MG CAP BRAND PA pomalidomide REVLIMID 5 MG CAP BRAND lenalidomide THALOMID 150 MG CAP BRAND PA thalidomide ANTIESTROGENS/MODIFIERS

FARESTON 60 MG TAB BRAND toremifene citrate tamoxifen citrate 20 mg tab generic ANTIMETABOLITES

capecitabine 150 mg tab generic PA

DROXIA 300 MG CAP BRAND PA hydroxyurea (sickle cell anemia) DROXIA 400 MG CAP BRAND hydroxyurea (sickle cell anemia) mercaptopurine 50 mg tab generic

PAGE 151 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS TABLOID 40 MG TAB BRAND PA thioguanine ANTINEOPLASTICS, OTHER

FARYDAK 15 MG CAP BRAND panobinostat lactate FARYDAK 20 MG CAP BRAND PA panobinostat lactate HEMANGEOL 4.28 MG/ML SOLUTION BRAND C Non-Formulary Drug propranolol hcl

leucovorin calcium 15 mg tab generic PA

leucovorin calcium 5 mg tab generic AROMATASE INHIBITORS, 3RD GENERATION

exemestane 25 mg tab generic MOLECULAR TARGET INHIBITORS

AFINITOR 10 MG TAB BRAND everolimus AFINITOR 5 MG TAB BRAND everolimus AFINITOR 7.5 MG TAB BRAND everolimus BOSULIF 500 MG TAB BRAND PA bosutinib COMETRIQ (100 MG DAILY DOSE) 1 X 80 & 1 X 20 MG KIT BRAND PA cabozantinib s-malate GILOTRIF 20 MG TAB BRAND PA afatinib dimaleate GILOTRIF 30 MG TAB BRAND afatinib dimaleate GILOTRIF 40 MG TAB BRAND PA afatinib dimaleate IBRANCE 75 MG CAP BRAND palbociclib ICLUSIG 15 MG TAB BRAND PA ponatinib hcl

PAGE 152 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

imatinib mesylate 400 mg tab generic PA

IRESSA 250 MG TAB BRAND PA gefitinib JAKAFI 10 MG TAB BRAND ruxolitinib phosphate JAKAFI 15 MG TAB BRAND PA ruxolitinib phosphate JAKAFI 20 MG TAB BRAND ruxolitinib phosphate JAKAFI 25 MG TAB BRAND PA ruxolitinib phosphate LENVIMA 10 MG DAILY DOSE 10 MG CAP THPK BRAND PA lenvatinib mesylate LENVIMA 20 MG DAILY DOSE 10 (2) MG CAP THPK BRAND PA lenvatinib mesylate MEKINIST 0.5 MG TAB BRAND PA trametinib dimethyl sulfoxide SPRYCEL 140 MG TAB BRAND dasatinib SUTENT 37.5 MG CAP BRAND PA sunitinib malate TARCEVA 100 MG TAB BRAND PA erlotinib hcl TASIGNA 200 MG CAP BRAND PA nilotinib hcl TYKERB 250 MG TAB BRAND PA lapatinib ditosylate VOTRIENT 200 MG TAB BRAND pazopanib hcl XALKORI 200 MG CAP BRAND PA crizotinib ZYDELIG 150 MG TAB BRAND idelalisib RETINOIDS

bexarotene 75 mg cap generic PA

TARGRETIN 1 % GEL BRAND PA bexarotene (topical)

PAGE 153 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS tretinoin 10 mg cap generic ANTIPARASITICS

ANTIHELMINTHICS

mebendazole 100 mg chew tab generic PA

SOOLANTRA 1 % CREAM BRAND PA ivermectin (rosacea) ANTIPROTOZOALS

ALINIA 100 MG/5ML RECON SUSP BRAND PA nitazoxanide

atovaquone-proguanil hcl 62.5-25 mg tab generic PA

chloroquine phosphate 250 mg tab generic PA

COARTEM 20-120 MG TAB BRAND PA artemether-lumefantrine DARAPRIM 25 MG TAB BRAND C Non-Formulary Drug pyrimethamine hydroxychloroquine sulfate 200 mg tab generic

mefloquine hcl 250 mg tab generic PA

primaquine phosphate 26.3 mg tab generic

quinine sulfate 324 mg cap generic PA

PEDICULICIDES/SCABICIDES

EURAX 10 % CREAM BRAND C Non-Formulary Drug crotamiton

EURAX 10 % LOTION PA BRAND crotamiton C Non-Formulary Drug

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

benztropine mesylate 0.5 mg tab generic PA

benztropine mesylate 2 mg tab generic ANTIPARKINSON AGENTS, OTHER

amantadine hcl 100 mg tab generic PA

PAGE 154 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

carbidopa-levodopa-entacapone 12.5-50-200 mg tab generic C Non-Formulary Drug

carbidopa-levodopa-entacapone 18.75-75-200 mg tab generic C Non-Formulary Drug

carbidopa-levodopa-entacapone 25-100-200 mg tab generic C Non-Formulary Drug

carbidopa-levodopa-entacapone 31.25-125-200 mg tab generic C Non-Formulary Drug

carbidopa-levodopa-entacapone 37.5-150-200 mg tab generic C Non-Formulary Drug

carbidopa-levodopa-entacapone 50-200-200 mg tab generic C Non-Formulary Drug

tolcapone 100 mg tab generic C Non-Formulary Drug

DOPAMINE AGONISTS

bromocriptine mesylate 5 mg cap generic pramipexole dihydrochloride 0.5 mg tab generic pramipexole dihydrochloride 0.75 mg tab generic

ropinirole hcl 0.25 mg tab generic MDD 2 per day

PA ropinirole hcl 0.5 mg tab generic MDD 2 per day

ropinirole hcl 1 mg tab generic MDD 2 per day

ropinirole hcl er 12 mg tab er 24h generic ropinirole hcl er 12 mg tab er 24h generic

ropinirole hcl er 6 mg tab er 24h generic PA

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa 25 mg tab generic

carbidopa & levodopa odt 10-100 mg generic C Non-Formulary Drug

carbidopa & levodopa odt 25-100 mg generic C Non-Formulary Drug

carbidopa-levodopa 25-250 mg tab generic PA

carbidopa & levodopa odt 25-250 mg generic C Non-Formulary Drug

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

rasagiline mesylate 0.5 mg tab generic C Non-Formulary Drug

rasagiline mesylate 1 mg tab generic C Non-Formulary Drug

PAGE 155 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

selegiline hcl 5 mg tab generic PA

ZELAPAR 1.25 MG TAB DISP BRAND PA selegiline hcl ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

ADASUVE 10 MG AER POW BA BRAND C Non-Formulary Drug loxapine

chlorpromazine hcl 25 mg tab generic PA

chlorpromazine hcl 50 mg tab generic

fluphenazine hcl 1 mg tab generic C Non-Formulary Drug

fluphenazine hcl 10 mg tab generic C Non-Formulary Drug

fluphenazine hcl 2.5 mg tab generic C Non-Formulary Drug

fluphenazine hcl 2.5 mg/5ml elixir generic C Non-Formulary Drug

fluphenazine hcl 5 mg tab generic C Non-Formulary Drug

fluphenazine hcl 5 mg/ml conc generic C Non-Formulary Drug

haloperidol 1 mg tab generic PA

haloperidol 2 mg tab generic haloperidol 5 mg tab generic

loxapine succinate 10 mg cap generic C Non-Formulary Drug

loxapine succinate 25 mg cap generic C Non-Formulary Drug

loxapine succinate 5 mg cap generic C Non-Formulary Drug

loxapine succinate 50 mg cap generic C Non-Formulary Drug

pimozide 1 mg tab generic C Non-Formulary Drug

pimozide 2 mg tab generic C Non-Formulary Drug

thioridazine hcl 10 mg tab generic C Non-Formulary Drug

thioridazine hcl 100 mg tab generic C Non-Formulary Drug

thioridazine hcl 25 mg tab generic C Non-Formulary Drug

PAGE 156 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

thioridazine hcl 50 mg tab generic C Non-Formulary Drug

thiothixene 1 mg cap generic C Non-Formulary Drug

thiothixene 10 mg cap generic C Non-Formulary Drug

thiothixene 2 mg cap generic C Non-Formulary Drug

thiothixene 5 mg cap generic C Non-Formulary Drug

trifluoperazine hcl 1 mg tab generic C Non-Formulary Drug

trifluoperazine hcl 10 mg tab generic C Non-Formulary Drug

trifluoperazine hcl 2 mg tab generic C Non-Formulary Drug

trifluoperazine hcl 5 mg tab generic C Non-Formulary Drug

2ND GENERATION/ATYPICAL

aripiprazole 1 mg/ml solution generic PA

aripiprazole 10 mg tab generic PA

FANAPT 1 MG TAB BRAND C Non-Formulary Drug iloperidone FANAPT 10 MG TAB BRAND C Non-Formulary Drug iloperidone FANAPT 12 MG TAB BRAND C Non-Formulary Drug iloperidone FANAPT 2 MG TAB BRAND C Non-Formulary Drug iloperidone FANAPT 4 MG TAB BRAND C Non-Formulary Drug iloperidone FANAPT 6 MG TAB BRAND C Non-Formulary Drug iloperidone FANAPT 8 MG TAB BRAND C Non-Formulary Drug iloperidone FANAPT TITRATION PACK 1 & 2 & 4 & 6 MG TAB BRAND C Non-Formulary Drug iloperidone LATUDA 20 MG TAB BRAND C Non-Formulary Drug lurasidone hcl LATUDA 60 MG TAB BRAND C Non-Formulary Drug lurasidone hcl

PAGE 157 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS NUPLAZID 17 MG TAB BRAND PA pimavanserin tartrate

PA olanzapine 15 mg tab generic MDD 2 per day

PA olanzapine 15 mg tab disp generic MDD 2 per day

PA olanzapine 2.5 mg tab generic MDD 2 per day

paliperidone er 1.5 mg tab er 24h generic C Non-Formulary Drug

paliperidone er 3 mg tab er 24h generic C Non-Formulary Drug

paliperidone er 6 mg tab er 24h generic C Non-Formulary Drug

paliperidone er 9 mg tab er 24h generic C Non-Formulary Drug

quetiapine fumarate 200 mg tab generic

quetiapine fumarate 300 mg tab generic PA

REXULTI 0.25 MG TAB BRAND PA brexpiprazole REXULTI 0.5 MG TAB BRAND PA brexpiprazole REXULTI 1 MG TAB BRAND PA brexpiprazole REXULTI 2 MG TAB BRAND PA brexpiprazole REXULTI 3 MG TAB BRAND PA brexpiprazole REXULTI 4 MG TAB BRAND PA brexpiprazole

risperidone orally disintegrating tab 0.25 mg generic MDD 2 per day

PA risperidone orally disintegrating tab 0.5 mg generic MDD 2 per day

risperidone 1 mg tab generic MDD 2 per day

risperidone orally disintegrating tab 1 mg generic MDD 2 per day

PAGE 158 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

risperidone orally disintegrating tab 2 mg generic MDD 2 per day

PA risperidone orally disintegrating tab 0.5 mg generic MDD 2 per day

risperidone orally disintegrating tab 1 mg generic MDD 2 per day

risperidone orally disintegrating tab 2 mg generic MDD 2 per day

SAPHRIS 10 MG SL TAB BRAND C Non-Formulary Drug asenapine maleate SAPHRIS 5 MG SL TAB BRAND C Non-Formulary Drug asenapine maleate VRAYLAR 1.5 & 3 MG CAP THPK BRAND PA cariprazine hcl VRAYLAR 1.5 MG CAP BRAND PA cariprazine hcl VRAYLAR 3 MG CAP BRAND PA cariprazine hcl VRAYLAR 4.5 MG CAP BRAND PA cariprazine hcl VRAYLAR 6 MG CAP BRAND PA cariprazine hcl

ziprasidone hcl 20 mg cap generic MDD 2 per day

PA ziprasidone hcl 80 mg cap generic MDD 2 per day

TREATMENT-RESISTANT

clozapine odt 100 mg generic C Non-Formulary Drug

clozapine odt 12.5 mg generic C Non-Formulary Drug

clozapine 150 mg tab disp generic C Non-Formulary Drug

clozapine 200 mg tab generic PA

clozapine 200 mg tab disp generic C Non-Formulary Drug

clozapine odt 25 mg generic C Non-Formulary Drug

PAGE 159 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANTISPASTICITY AGENTS

baclofen 20 mg tab generic dantrolene sodium 25 mg cap generic

dantrolene sodium 50 mg cap generic PA

tizanidine hcl 2 mg cap generic C Non-Formulary Drug

tizanidine hcl 2 mg tab generic tizanidine hcl 2 mg tab generic

tizanidine hcl 4 mg cap generic C Non-Formulary Drug

tizanidine hcl 6 mg cap generic C Non-Formulary Drug

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

valganciclovir hcl 50 mg/ml recon soln generic ANTI-HEPATITIS B (HBV) AGENTS

BARACLUDE 0.05 MG/ML SOLUTION BRAND entecavir

entecavir 0.5 mg tab generic PA

EPIVIR HBV 5 MG/ML SOLUTION BRAND PA lamivudine (hbv) ANTI-HEPATITIS C (HCV) AGENTS

DAKLINZA 30 MG TAB BRAND PA daclatasvir dihydrochloride DAKLINZA 60 MG TAB BRAND PA daclatasvir dihydrochloride DAKLINZA 90 MG TAB BRAND PA daclatasvir dihydrochloride HARVONI 90-400 MG TAB BRAND PA ledipasvir-sofosbuvir MODERIBA 1200 DOSE PACK 600 MG TAB BRAND PA ribavirin (hepatitis c) MODERIBA 800 DOSE PACK 400 MG TAB BRAND ribavirin (hepatitis c) OLYSIO 150 MG CAP BRAND PA simeprevir sodium

PAGE 160 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS REBETOL 40 MG/ML SOLUTION BRAND C Non-Formulary Drug ribavirin (hepatitis c) RIBASPHERE 400 MG TAB BRAND ribavirin (hepatitis c) RIBASPHERE 600 MG TAB BRAND PA ribavirin (hepatitis c) RIBASPHERE RIBAPAK 400 MG TAB BRAND ribavirin (hepatitis c) RIBASPHERE RIBAPAK 600 MG TAB BRAND PA ribavirin (hepatitis c) RIBATAB 400 MG TAB BRAND ribavirin (hepatitis c) RIBATAB 600 MG TAB BRAND PA ribavirin (hepatitis c) SOVALDI 400 MG TAB BRAND sofosbuvir TECHNIVIE 12.5-75-50 MG TAB BRAND PA ombitasvir-paritaprevir-ritonavir VIEKIRA PAK 12.5-75-50 &250 MG TAB THPK BRAND PA ombitasvir-paritaprevir-ritonavir-dasabuvir ZEPATIER 50-100 MG TAB BRAND PA elbasvir-grazoprevir ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

GENVOYA 150-150-200-10 MG TAB BRAND PA elvitegravir-cobicistat-emtricitabine-tenofovir alafenamide ISENTRESS 100 MG PACKET BRAND C Non-Formulary Drug raltegravir potassium ISENTRESS 400 MG TAB BRAND PA raltegravir potassium STRIBILD 150-150-200-300 MG TAB BRAND PA elvitegravir-cobicistat-emtricitabine-tenofovir df TIVICAY 50 MG TAB BRAND PA dolutegravir sodium ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

COMPLERA 200-25-300 MG TAB BRAND PA emtricitabine-rilpivirine-tenofovir disoproxil fumarate

nevirapine 200 mg tab generic PA

PAGE 161 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS nevirapine 50 mg/5ml suspension generic nevirapine er 100 mg tab er 24h generic ODEFSEY 200-25-25 MG TAB BRAND PA emtricitabine-rilpivirine-tenofovir alafenamide fumarate RESCRIPTOR 200 MG TAB BRAND delavirdine mesylate ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate 20 mg/ml solution generic PA

abacavir sulfate 300 mg tab generic

abacavir-lamivudine-zidovudine 300-150-300 mg tab generic PA

DESCOVY 200-25 MG TAB BRAND PA emtricitabine-tenofovir alafenamide fumarate didanosine 200 mg cap dr generic EMTRIVA 10 MG/ML SOLUTION BRAND emtricitabine stavudine 1 mg/ml recon soln generic

stavudine 40 mg cap generic PA

tenofovir disoproxil fumarate 300 mg tab generic PA

TRUVADA 200-300 MG TAB BRAND emtricitabine-tenofovir disoproxil fumarate VIDEX 4 GM RECON SOLN BRAND PA didanosine VIREAD 150 MG TAB BRAND PA tenofovir disoproxil fumarate VIREAD 200 MG TAB BRAND tenofovir disoproxil fumarate VIREAD 40 MG/GM POWDER BRAND PA tenofovir disoproxil fumarate

zidovudine 50 mg/5ml syrup generic PA

ANTI-HIV AGENTS, OTHER

SELZENTRY 150 MG TAB BRAND PA maraviroc TYBOST 150 MG TAB BRAND cobicistat

PAGE 162 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS 250 MG CAP BRAND PA tipranavir atazanavir sulfate 200 mg cap generic EVOTAZ 300-150 MG TAB BRAND atazanavir sulfate-cobicistat

fosamprenavir calcium 700 mg tab generic PA

INVIRASE 200 MG CAP BRAND PA saquinavir mesylate LEXIVA 50 MG/ML SUSPENSION BRAND PA fosamprenavir calcium

lopinavir-ritonavir 400-100 mg/5ml solution generic PA

NORVIR 100 MG TAB BRAND ritonavir PREZISTA 100 MG/ML SUSPENSION BRAND PA darunavir ethanolate PREZISTA 300 MG TABS BRAND PA darunavir ethanolate PREZISTA 75 MG TAB BRAND PA darunavir ethanolate VIRACEPT 250 MG TAB BRAND PA nelfinavir mesylate VIRACEPT 625 MG TAB BRAND nelfinavir mesylate ANTI-INFLUENZA AGENTS

oseltamivir phosphate 45 mg cap generic oseltamivir phosphate 6 mg/ml recon susp generic

rimantadine hcl 100 mg tab generic C Non-Formulary Drug

ANTIHERPETIC AGENTS

acyclovir 400 mg tab generic PA

acyclovir 5 % ointment generic

acyclovir 800 mg tab generic PA

famciclovir 125 mg tab generic PA

PAGE 163 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS SITAVIG 50 MG TAB BRAND C Non-Formulary Drug acyclovir

trifluridine 1 % solution generic C Non-Formulary Drug

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl 30 mg tab generic PA

buspirone hcl 5 mg tab generic PA

meprobamate 200 mg tab generic C Non-Formulary Drug

meprobamate 400 mg tab generic C Non-Formulary Drug

BENZODIAZEPINES

alprazolam 0.25 mg tab disp generic C Non-Formulary Drug

alprazolam 0.5 mg tab disp generic C Non-Formulary Drug

alprazolam 1 mg tab disp generic C Non-Formulary Drug

alprazolam 2 mg tab disp generic C Non-Formulary Drug

alprazolam er 1 mg tab er 24h generic alprazolam xr 1 mg tab er 24h generic clonazepam 0.5 mg tab disp generic clonazepam 2 mg tab disp generic clorazepate dipotassium 15 mg tab generic clorazepate dipotassium 7.5 mg tab generic diazepam 1 mg/ml solution generic diazepam 2 mg tab generic lorazepam 0.5 mg tab generic lorazepam 1 mg tab generic oxazepam 10 mg cap generic oxazepam 15 mg cap generic

PAGE 164 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS BIPOLAR AGENTS

MOOD STABILIZERS

lithium 8 meq/5ml solution generic PA

lithium carbonate 600 mg cap generic PA

lithium carbonate er 300 mg tab er generic

lithium carbonate er 450 mg tab er generic PA

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose 25 mg tab generic

acarbose 50 mg tab generic PA

AVANDAMET 2-1000 MG TAB PA BRAND rosiglitazone maleate-metformin hcl MDD 2 per day

AVANDAMET 4-500 MG TAB BRAND MDD 2 per day rosiglitazone maleate-metformin hcl AVANDARYL 4-1 MG TAB BRAND PA rosiglitazone maleate-glimepiride AVANDARYL 4-2 MG TAB BRAND PA rosiglitazone maleate-glimepiride AVANDARYL 4-4 MG TAB BRAND PA rosiglitazone maleate-glimepiride AVANDARYL 8-2 MG TAB BRAND PA rosiglitazone maleate-glimepiride AVANDARYL 8-4 MG TAB BRAND PA rosiglitazone maleate-glimepiride

AVANDIA 4 MG TAB PA BRAND rosiglitazone maleate MDD 2 per day

BYDUREON 2 MG SRER BRAND PA exenatide

chlorpropamide 100 mg tab generic C Non-Formulary Drug

chlorpropamide 250 mg tab generic C Non-Formulary Drug

PAGE 165 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS FARXIGA 10 MG TAB BRAND dapagliflozin propanediol FARXIGA 5 MG TAB BRAND dapagliflozin propanediol

glimepiride 4 mg tab generic MDD 2 per day

glipizide 10 mg tab generic PA

glipizide-metformin hcl 5-500 mg tab generic PA

glyburide 5 mg tab generic PA

glyburide micronized 6 mg tab generic

glyburide-metformin 2.5-500 mg tab generic PA

INVOKANA 100 MG TAB BRAND PA canagliflozin INVOKANA 300 MG TAB BRAND canagliflozin JANUMET 50-1000 MG TAB BRAND PA sitagliptin-metformin hcl JANUVIA 25 MG TAB BRAND PA sitagliptin phosphate KOMBIGLYZE XR 5-1000 MG TAB ER 24H BRAND PA saxagliptin-metformin hcl metformin hcl 1000 mg tab generic

metformin hcl 500 mg tab generic PA

metformin hcl 850 mg tab generic

metformin hcl er (osm) 1000 mg tab er 24h generic C Non-Formulary Drug

metformin hcl er (osm) 500 mg tab er 24h generic C Non-Formulary Drug

metformin hcl er 750 mg tab er 24h generic PA

miglitol 100 mg tab generic PA

nateglinide 120 mg tab generic PA

ONGLYZA 2.5 MG TAB BRAND PA saxagliptin hcl

PAGE 166 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

pioglitazone hcl-glimepiride 30-2 mg tab generic PA

pioglitazone hcl-metformin hcl 15-500 mg tab generic SYMLINPEN 60 1500 MCG/1.5ML SOLN PEN BRAND PA pramlintide acetate SYNJARDY 12.5-1000 MG TAB BRAND PA empagliflozin-metformin hcl SYNJARDY 12.5-500 MG TAB BRAND PA empagliflozin-metformin hcl SYNJARDY 5-1000 MG TAB BRAND PA empagliflozin-metformin hcl SYNJARDY 5-500 MG TAB BRAND PA empagliflozin-metformin hcl

tolazamide 250 mg tab generic C Non-Formulary Drug

tolazamide 250 mg tabs generic C Non-Formulary Drug

tolazamide 500 mg tab generic C Non-Formulary Drug

GLYCEMIC AGENTS

PROGLYCEM 50 MG/ML SUSPENSION BRAND diazoxide INSULINS

ADMELOG 100 UNIT/ML SOLUTION BRAND insulin lispro HUMALOG 100 UNIT/ML SOLUTION BRAND insulin lispro HUMALOG 100 UNIT/ML SOLUTION BRAND insulin lispro (human) HUMALOG MIX 50/50 (50-50) 100 UNIT/ML SUSPENSION BRAND insulin lispro protamine & lispro HUMULIN 70/30 (70-30) 100 UNIT/ML SUSPENSION BRAND insulin nph isophane & reg (human) HUMULIN R U-500 (CONCENTRATED) 500 UNIT/ML SOLUTION BRAND PA insulin regular (human) HUMULIN R U-500 KWIKPEN 500 UNIT/ML SOLN PEN BRAND PA insulin regular (human)

PAGE 167 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS LANTUS 100 UNIT/ML SOLUTION BRAND PA insulin glargine LEVEMIR 100 UNIT/ML SOLUTION BRAND insulin detemir NOVOLIN 70/30 (70-30) 100 UNIT/ML SUSPENSION BRAND insulin nph isophane & reg (human) NOVOLIN 70/30 RELION (70-30) 100 UNIT/ML SUSPENSION BRAND insulin nph isophane & reg (human) NOVOLOG MIX 70/30 (70-30) 100 UNIT/ML SUSPENSION BRAND PA insulin aspart protamine & aspart (human) RELION 70/30 (70-30) 100 UNIT/ML SUSPENSION BRAND insulin isophane & reg (human) TRESIBA FLEXTOUCH 100 UNIT/ML SOLN PEN BRAND PA insulin degludec TRESIBA FLEXTOUCH 200 UNIT/ML SOLN PEN BRAND PA insulin degludec BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

fondaparinux sodium 10 mg/0.8ml solution generic fondaparinux sodium 2.5 mg/0.5ml solution generic FRAGMIN 12500 UNIT/0.5ML SOLUTION BRAND dalteparin sodium FRAGMIN 15000 UNIT/0.6ML SOLUTION BRAND dalteparin sodium FRAGMIN 18000 UNT/0.72ML SOLUTION BRAND dalteparin sodium FRAGMIN 7500 UNIT/0.3ML SOLUTION BRAND dalteparin sodium heparin sodium (porcine) 10000 unit/ml solution generic HEPARIN SODIUM (PORCINE) 2000 UNIT/ML SOLUTION BRAND heparin sodium (porcine) heparin sodium (porcine) 20000 unit/ml solution generic jantoven 10 mg tab generic

PAGE 168 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS jantoven 3 mg tab generic jantoven 6 mg tab generic jantoven 7.5 mg tab generic PRADAXA 75 MG CAP BRAND dabigatran etexilate mesylate warfarin sodium 10 mg tab generic warfarin sodium 3 mg tab generic warfarin sodium 6 mg tab generic warfarin sodium 7.5 mg tab generic XARELTO 10 MG TAB BRAND PA rivaroxaban BLOOD FORMATION MODIFIERS

anagrelide hcl 0.5 mg cap generic PA

ARANESP (ALBUMIN FREE) 300 MCG/ML SOLUTION BRAND PA darbepoetin alfa ARANESP (ALBUMIN FREE) 60 MCG/ML SOLUTION BRAND darbepoetin alfa LEUKINE 500 MCG/ML SOLUTION BRAND PA sargramostim MOZOBIL 24 MG/1.2ML SOLUTION BRAND PA plerixafor PROMACTA 50 MG TAB BRAND PA eltrombopag olamine ZARXIO 300 MCG/0.5ML SOLN PRSYR BRAND C Non-Formulary Drug filgrastim-sndz ZARXIO 480 MCG/0.8ML SOLN PRSYR BRAND C Non-Formulary Drug filgrastim-sndz COAGULANTS

aminocaproic acid 1000 mg tab generic aminocaproic acid 500 mg tab generic tranexamic acid 650 mg tab generic PLATELET MODIFYING AGENTS

BRILINTA 90 MG TAB BRAND C Non-Formulary Drug ticagrelor

PAGE 169 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

clopidogrel bisulfate 300 mg tab generic PA

dipyridamole 25 mg tab generic PA

dipyridamole 75 mg tab generic PA

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

clonidine hcl 0.1 mg tab generic clonidine hcl 0.1 mg/24hr patch wk generic clonidine hcl 0.2 mg tab generic clonidine hcl 0.3 mg tab generic clonidine hcl 0.3 mg/24hr patch wk generic

guanfacine hcl 1 mg tab generic PA

guanfacine hcl 2 mg tab generic

methyldopa 250 mg tab generic C Non-Formulary Drug

methyldopa 500 mg tab generic C Non-Formulary Drug

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate 4 mg tab generic MDD 1.5 per day

prazosin hcl 2 mg cap generic PA

ANGIOTENSIN II RECEPTOR ANTAGONISTS

PA candesartan cilexetil 4 mg tab generic MDD 1.5 per day

EDARBI 40 MG TAB BRAND C Non-Formulary Drug azilsartan medoxomil EDARBI 80 MG TAB BRAND C Non-Formulary Drug azilsartan medoxomil eprosartan mesylate 600 mg tab generic

PA irbesartan 150 mg tab generic MDD 1 per day

irbesartan 300 mg tab generic MDD 1 per day

PAGE 170 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA losartan potassium 100 mg tab generic MDD 1 per day

olmesartan medoxomil 5 mg tab generic PA

PA telmisartan 40 mg tab generic MDD 1.5 per day

telmisartan 80 mg tab generic MDD 1 per day

PA valsartan 40 mg tab generic MDD 1 per day

PA valsartan 80 mg tab generic MDD 1 per day

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl 10 mg tab generic MDD 2 per day

captopril 12.5 mg tab generic PA

captopril 50 mg tab generic enalapril maleate 2.5 mg tab generic

PA lisinopril 2.5 mg tab generic MDD 2 per day

PA lisinopril 20 mg tab generic MDD 2 per day

PA lisinopril 30 mg tab generic MDD 2 per day

moexipril hcl 15 mg tab generic

MDD 1 per day perindopril erbumine 2 mg tab generic C Non-Formulary Drug

MDD 1 per day perindopril erbumine 4 mg tab generic C Non-Formulary Drug

MDD 2 per day perindopril erbumine 8 mg tab generic C Non-Formulary Drug

PAGE 171 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS QBRELIS 1 MG/ML SOLUTION BRAND PA lisinopril

PA quinapril hcl 10 mg tab generic MDD 2 per day

quinapril hcl 40 mg tab generic MDD 2 per day

PA ramipril 1.25 mg cap generic MDD 1 per day

PA ramipril 5 mg cap generic MDD 1 per day

PA trandolapril 1 mg tab generic MDD 1 per day

ANTIARRHYTHMICS

amiodarone hcl 100 mg tab generic C Non-Formulary Drug

amiodarone hcl 400 mg tab generic C Non-Formulary Drug

disopyramide phosphate 100 mg cap generic PA

dofetilide 250 mcg cap generic PA

dofetilide 500 mcg cap generic PA

MULTAQ 400 MG TAB BRAND C Non-Formulary Drug dronedarone hcl

pacerone 100 mg tab generic C Non-Formulary Drug

pacerone 400 mg tab generic C Non-Formulary Drug

propafenone hcl 150 mg tab generic C Non-Formulary Drug

propafenone hcl 225 mg tab generic C Non-Formulary Drug

propafenone hcl 300 mg tab generic C Non-Formulary Drug

propafenone hcl er 225 mg cap er 12h generic C Non-Formulary Drug

propafenone hcl er 325 mg cap er 12h generic C Non-Formulary Drug

PAGE 172 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

propafenone hcl er 425 mg cap er 12h generic C Non-Formulary Drug

quinidine gluconate er 324 mg tab er generic PA

sorine 120 mg tab generic sotalol hcl (af) 160 mg tab generic

sotalol hcl (af) 80 mg tab generic PA

sotalol hcl 120 mg tab generic BETA-ADRENERGIC BLOCKING AGENTS

atenolol 100 mg tab generic PA

atenolol 25 mg tab generic PA

atenolol 50 mg tab generic PA

betaxolol hcl 10 mg tab generic C Non-Formulary Drug

betaxolol hcl 20 mg tab generic C Non-Formulary Drug

carvedilol 3.125 mg tab generic PA

LEVATOL 20 MG TAB BRAND C Non-Formulary Drug penbutolol sulfate

metoprolol tartrate 100 mg tab generic PA

metoprolol tartrate 25 mg tab generic

metoprolol tartrate 50 mg tab generic PA

nadolol 80 mg tab generic PA

pindolol 10 mg tab generic propranolol hcl 10 mg tab generic propranolol hcl 20 mg tab generic propranolol hcl 20 mg/5ml solution generic propranolol hcl 40 mg/5ml solution generic propranolol hcl er 160 mg cap er 24h generic propranolol hcl er 160 mg cap er 24h generic

propranolol hcl er 60 mg cap er 24h generic PA

PAGE 173 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

timolol maleate 10 mg tab generic PA

timolol maleate 20 mg tab generic CALCIUM CHANNEL BLOCKING AGENTS

PA afeditab cr 60 mg tab er 24h generic MDD 2 per day

PA amlodipine besylate 2.5 mg tab generic MDD 1 per day

amlodipine besylate 5 mg tab generic MDD 1.5 per day

CARDENE SR 30 MG CAP ER 12H BRAND C Non-Formulary Drug nicardipine hcl CARDENE SR 60 MG CAP ER 12H BRAND C Non-Formulary Drug nicardipine hcl

cartia xt 300 mg cap er 24h generic MDD 1 per day

dilt-cd 300 mg cap er 24h generic MDD 1 per day

diltiazem cd 300 mg cap er 24h generic MDD 1 per day

diltiazem hcl 120 mg tab generic PA

diltiazem hcl 60 mg tab generic PA

diltiazem hcl er 60 mg cap er 12h generic PA

diltiazem hcl er 90 mg cap er 12h generic PA

PA diltiazem hcl er beads 420 mg cap er 24h generic MDD 1 per day

PA diltiazem hcl er coated beads 240 mg tab er 24h generic MDD 1 per day

diltiazem hcl er coated beads 300 mg cap er 24h generic MDD 1 per day

diltiazem hcl er coated beads 360 mg tab er 24h generic MDD 1 per day

PAGE 174 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

felodipine er 10 mg tab er 24h generic MDD 2 per day

isradipine 2.5 mg cap generic C Non-Formulary Drug

isradipine 5 mg cap generic C Non-Formulary Drug

PA matzim la 240 mg tab er 24h generic MDD 1 per day

matzim la 360 mg tab er 24h generic MDD 1 per day

nicardipine hcl 20 mg cap generic C Non-Formulary Drug

nicardipine hcl 30 mg cap generic C Non-Formulary Drug

PA nifediac cc 60 mg tab er 24h generic MDD 2 per day

nifedipine 10 mg cap generic PA

nifedipine 20 mg cap generic

PA nifedipine er 60 mg tab er 24h generic MDD 2 per day

nimodipine 30 mg cap generic PA

MDD 1 per day nisoldipine er 17 mg tab er 24h generic C Non-Formulary Drug

PAGE 175 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

MDD 1 per day nisoldipine er 20 mg tab er 24h generic C Non-Formulary Drug

MDD 1 per day nisoldipine er 25.5 mg tab er 24h generic C Non-Formulary Drug

MDD 1 per day nisoldipine er 30 mg tab er 24h generic C Non-Formulary Drug

MDD 1 per day nisoldipine er 34 mg tab er 24h generic C Non-Formulary Drug

MDD 1 per day nisoldipine er 40 mg tab er 24h generic C Non-Formulary Drug

MDD 1 per day nisoldipine er 8.5 mg tab er 24h generic C Non-Formulary Drug

verapamil hcl 120 mg tab generic

verapamil hcl er 100 mg cap er 24h generic MDD 2 per day

PA verapamil hcl er 120 mg tab er generic MDD 2 per day

PA verapamil hcl er 120 mg tbcr generic MDD 2 per day

PA verapamil hcl er 180 mg cap er 24h generic MDD 2 per day

PAGE 176 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

PA verapamil hcl er 180 mg tab er generic MDD 2 per day

PA verapamil hcl er 240 mg cap er 24h generic MDD 2 per day

PA verapamil hcl er 240 mg tab er generic MDD 2 per day

CARDIOVASCULAR AGENTS, OTHER

amiloride-hydrochlorothiazide 5-50 mg tab generic amlodipine besy-benazepril hcl 5-20 mg cap generic amlodipine besy-benazepril hcl 5-40 mg cap generic amlodipine besylate-valsartan 5-160 mg tab generic

amlodipine-atorvastatin 10-10 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 10-20 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 10-40 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 10-80 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 2.5-10 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 2.5-20 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 2.5-40 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 5-10 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 5-20 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 5-40 mg tab generic C Non-Formulary Drug

amlodipine-atorvastatin 5-80 mg tab generic C Non-Formulary Drug

amlodipine-olmesartan 10-20 mg tab generic

PAGE 177 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

amlodipine-olmesartan 10-40 mg tab generic PA

amlodipine-valsartan-hctz 10-160-12.5 mg tab generic

amlodipine-valsartan-hctz 10-320-25 mg tab generic PA

AMTURNIDE 150-5-12.5 MG TAB BRAND C Non-Formulary Drug aliskiren-amlodipine-hydrochlorothiazide AMTURNIDE 300-10-12.5 MG TAB BRAND C Non-Formulary Drug aliskiren-amlodipine-hydrochlorothiazide AMTURNIDE 300-10-25 MG TAB BRAND C Non-Formulary Drug aliskiren-amlodipine-hydrochlorothiazide AMTURNIDE 300-5-12.5 MG TAB BRAND C Non-Formulary Drug aliskiren-amlodipine-hydrochlorothiazide AMTURNIDE 300-5-25 MG TAB BRAND C Non-Formulary Drug aliskiren-amlodipine-hydrochlorothiazide

atenolol-chlorthalidone 50-25 mg tab generic PA

benazepril-hydrochlorothiazide 20-25 mg tab generic MDD 2 per day

benazepril-hydrochlorothiazide 20-25 mg tabs generic MDD 2 per day

BYVALSON 5-80 MG TAB BRAND PA nebivolol-valsartan

PA candesartan cilexetil-hctz 16-12.5 mg tab generic MDD 1.5 per day

candesartan cilexetil-hctz 32-25 mg tab generic

captopril-hydrochlorothiazide 50-15 mg tab generic PA

CLORPRES 0.1-15 MG TAB BRAND C Non-Formulary Drug clonidine & chlorthalidone CLORPRES 0.2-15 MG TAB BRAND C Non-Formulary Drug clonidine & chlorthalidone

clorpres 0.3-15 mg tabs generic C Non-Formulary Drug

CORLANOR 5 MG TAB BRAND C Non-Formulary Drug ivabradine hcl CORLANOR 7.5 MG TAB BRAND C Non-Formulary Drug ivabradine hcl DEMSER 250 MG CAP BRAND PA metyrosine

PAGE 178 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

digitek 250 mcg tab generic PA

digox 250 mcg tab generic PA

digoxin 250 mcg tab generic PA

EDARBYCLOR 40-12.5 MG TAB BRAND C Non-Formulary Drug azilsartan medoxomil-chlorthalidone EDARBYCLOR 40-25 MG TAB BRAND C Non-Formulary Drug azilsartan medoxomil-chlorthalidone enalapril-hydrochlorothiazide 10-25 mg tab generic ENTRESTO 24-26 MG TAB BRAND C Non-Formulary Drug sacubitril-valsartan ENTRESTO 49-51 MG TAB BRAND C Non-Formulary Drug sacubitril-valsartan ENTRESTO 97-103 MG TAB BRAND C Non-Formulary Drug sacubitril-valsartan

PA irbesartan-hydrochlorothiazide 150-12.5 mg tab generic MDD 1 per day

lisinopril-hydrochlorothiazide 10-12.5 mg tab generic MDD 1 per day

losartan potassium-hctz 100-12.5 mg tab generic MDD 1 per day

PA losartan potassium-hctz 50-12.5 mg tab generic MDD 1 per day

methyldopa-hydrochlorothiazide 250-15 mg tab generic

methyldopa-hydrochlorothiazide 250-25 mg tab generic PA

metoprolol-hydrochlorothiazide 50-25 mg tab generic PA

moexipril-hydrochlorothiazide 15-12.5 mg tab generic PA

NORTHERA 100 MG CAP BRAND C Non-Formulary Drug droxidopa NORTHERA 200 MG CAP BRAND C Non-Formulary Drug droxidopa NORTHERA 300 MG CAP BRAND C Non-Formulary Drug droxidopa

olmesartan medoxomil-hctz 40-12.5 mg tab generic PA

PAGE 179 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS PRESTALIA 14-10 MG TAB BRAND C Non-Formulary Drug perindopril arginine-amlodipine besylate PRESTALIA 3.5-2.5 MG TAB BRAND C Non-Formulary Drug perindopril arginine-amlodipine besylate PRESTALIA 7-5 MG TAB BRAND C Non-Formulary Drug perindopril arginine-amlodipine besylate propranolol-hctz 40-25 mg tab generic

PA quinapril-hydrochlorothiazide 20-25 mg tab generic MDD 2 per day

reserpine 0.1 mg tab generic C Non-Formulary Drug

reserpine 0.25 mg tab generic C Non-Formulary Drug

spironolactone-hctz 25-25 mg tab generic PA

TEKAMLO 150-10 MG TAB BRAND C Non-Formulary Drug aliskiren-amlodipine TEKAMLO 150-5 MG TAB BRAND C Non-Formulary Drug aliskiren-amlodipine TEKAMLO 300-10 MG TAB BRAND C Non-Formulary Drug aliskiren-amlodipine TEKAMLO 300-5 MG TAB BRAND C Non-Formulary Drug aliskiren-amlodipine TEKTURNA 150 MG TAB BRAND C Non-Formulary Drug aliskiren fumarate TEKTURNA 300 MG TAB BRAND C Non-Formulary Drug aliskiren fumarate

telmisartan-amlodipine 80-5 mg tab generic PA

PA telmisartan-hctz 80-12.5 mg tab generic MDD 1 per day

telmisartan-hctz 80-25 mg tab generic PA

trandolapril-verapamil hcl er 1-240 mg tab er generic C Non-Formulary Drug

trandolapril-verapamil hcl er 2-180 mg tab er generic C Non-Formulary Drug

trandolapril-verapamil hcl er 2-240 mg tab er generic C Non-Formulary Drug

trandolapril-verapamil hcl er 4-240 mg tab er generic C Non-Formulary Drug

PAGE 180 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS triamterene-hctz 37.5-25 mg tab generic

triamterene-hctz 50-25 mg cap generic PA

PA valsartan-hydrochlorothiazide 160-12.5 mg tab generic MDD 2 Per Day

PA valsartan-hydrochlorothiazide 160-25 mg tab generic MDD 2 Per Day

PA valsartan-hydrochlorothiazide 320-12.5 mg tab generic MDD 1 Per Day

PA valsartan-hydrochlorothiazide 320-25 mg tab generic MDD 1 Per Day

PA valsartan-hydrochlorothiazide 80-12.5 mg tab generic MDD 1 Per Day

DIURETICS, LOOP

bumetanide 1 mg tab generic PA

bumetanide 2 mg tab generic

ethacrynic acid 25 mg tab generic C Non-Formulary Drug

furosemide 10 mg/ml solution generic PA

furosemide 40 mg tab generic

furosemide 40 mg/4ml solution generic PA

furosemide 80 mg tab generic

torsemide 10 mg tab generic C Non-Formulary Drug

torsemide 100 mg tab generic C Non-Formulary Drug

torsemide 20 mg tab generic C Non-Formulary Drug

torsemide 5 mg tab generic C Non-Formulary Drug

DIURETICS, POTASSIUM-SPARING

DYRENIUM 100 MG CAP BRAND C Non-Formulary Drug triamterene DYRENIUM 50 MG CAP BRAND C Non-Formulary Drug triamterene

PAGE 181 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

eplerenone 25 mg tab generic PA

eplerenone 50 mg tab generic

spironolactone 25 mg tab generic PA

DIURETICS, THIAZIDE

chlorothiazide 250 mg tab generic C Non-Formulary Drug

chlorothiazide 500 mg tab generic C Non-Formulary Drug

chlorthalidone 100 mg tab generic

chlorthalidone 50 mg tab generic PA

DIURIL 250 MG/5ML SUSPENSION BRAND C Non-Formulary Drug chlorothiazide

indapamide 1.25 mg tab generic C Non-Formulary Drug

indapamide 2.5 mg tab generic C Non-Formulary Drug

methyclothiazide 5 mg tab generic C Non-Formulary Drug

metolazone 2.5 mg tab generic metolazone 2.5 mg tabs generic DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

fenofibrate 48 mg tab generic PA

fenofibrate 50 mg cap generic PA

fenofibrate 54 mg tab generic

fenofibrate micronized 134 mg cap generic PA

fenofibrate micronized 67 mg cap generic PA

gemfibrozil 600 mg tab generic C Non-Formulary Drug

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

ALTOPREV 40 MG TAB ER 24H BRAND lovastatin

PA atorvastatin calcium 40 mg tab generic MDD 1.5 per day

atorvastatin calcium 80 mg tab generic MDD 1 per day

PAGE 182 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

MDD 1 per day fluvastatin sodium 20 mg cap generic C Non-Formulary Drug

MDD 2 per day fluvastatin sodium 40 mg cap generic C Non-Formulary Drug

MDD 2 per day fluvastatin sodium er 80 mg tab er 24h generic C Non-Formulary Drug

LIVALO 1 MG TAB BRAND C Non-Formulary Drug pitavastatin calcium LIVALO 2 MG TAB BRAND C Non-Formulary Drug pitavastatin calcium LIVALO 4 MG TAB BRAND C Non-Formulary Drug pitavastatin calcium

PA lovastatin 20 mg tab generic MDD 1 per day

lovastatin 40 mg tab generic MDD 2 per day

PA pravastatin sodium 40 mg tab generic MDD 1 per day

PA pravastatin sodium 40 mg tabs generic MDD 1 per day

PA pravastatin sodium 80 mg tab generic MDD 1 per day

rosuvastatin calcium 40 mg tab generic MDD 1 per day

PA rosuvastatin calcium 5 mg tab generic MDD 1 per day

simvastatin 80 mg tab generic MDD 1 per day

DYSLIPIDEMICS, OTHER

ADVICOR 1000-20 MG TAB ER 24H BRAND C Non-Formulary Drug niacin-lovastatin ADVICOR 1000-40 MG TAB ER 24H BRAND C Non-Formulary Drug niacin-lovastatin

PAGE 183 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ADVICOR 500-20 MG TAB ER 24H BRAND C Non-Formulary Drug niacin-lovastatin ADVICOR 750-20 MG TAB ER 24H BRAND C Non-Formulary Drug niacin-lovastatin

cholestyramine 4 gm/dose powder generic PA

cholestyramine light 4 gm/dose powder generic PA

colestipol hcl 1 gm tab generic ezetimibe-simvastatin 10-10 mg tab generic

ezetimibe-simvastatin 10-80 mg tab generic PA

JUXTAPID 10 MG CAP BRAND C Non-Formulary Drug lomitapide mesylate JUXTAPID 20 MG CAP BRAND C Non-Formulary Drug lomitapide mesylate JUXTAPID 5 MG CAP BRAND C Non-Formulary Drug lomitapide mesylate niacin er (antihyperlipidemic) 1000 mg tab er generic

niacin er (antihyperlipidemic) 500 mg tab er generic PA

PRALUENT 150 MG/ML SOLN PEN BRAND C Non-Formulary Drug alirocumab PRALUENT 150 MG/ML SOLN PRSYR BRAND C Non-Formulary Drug alirocumab PRALUENT 75 MG/ML SOLN PEN BRAND C Non-Formulary Drug alirocumab PRALUENT 75 MG/ML SOLN PRSYR BRAND C Non-Formulary Drug alirocumab

prevalite 4 gm/dose powder generic PA

REPATHA 140 MG/ML SOLN PRSYR BRAND C Non-Formulary Drug evolocumab REPATHA SURECLICK 140 MG/ML SOLN A-INJ BRAND C Non-Formulary Drug evolocumab SIMCOR 1000-20 MG TAB ER 24H BRAND C Non-Formulary Drug niacin-simvastatin SIMCOR 1000-40 MG TAB ER 24H BRAND C Non-Formulary Drug niacin-simvastatin

PAGE 184 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS SIMCOR 500-20 MG TAB ER 24H BRAND C Non-Formulary Drug niacin-simvastatin SIMCOR 500-40 MG TAB ER 24H BRAND C Non-Formulary Drug niacin-simvastatin SIMCOR 750-20 MG TAB ER 24H BRAND C Non-Formulary Drug niacin-simvastatin VASCEPA 1 GM CAP BRAND PA icosapent ethyl WELCHOL 3.75 GM PACKET BRAND PA colesevelam hcl WELCHOL 625 MG TAB BRAND PA colesevelam hcl VASODILATORS, DIRECT-ACTING ARTERIAL

hydralazine hcl 25 mg tab generic minoxidil 10 mg tab generic VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

DILATRATE-SR 40 MG CAP ER BRAND C Non-Formulary Drug isosorbide dinitrate

isosorbide dinitrate 5 mg tab generic PA

PA isosorbide mononitrate er 60 mg tab er 24h generic MDD 1.5 per day

minitran 0.1 mg/hr patch 24hr generic

nitro-time 2.5 mg cap er generic PA

nitro-time 6.5 mg cap er generic PA

nitro-time 9 mg cap er generic nitroglycerin 0.1 mg/hr patch 24hr generic

nitroglycerin 0.4 mg/spray solution generic PA

nitroglycerin 0.6 mg sl tab generic PA

nitroglycerin er 2.5 mg cap er generic PA

PAGE 185 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

nitroglycerin er 6.5 mg cap er generic PA

nitroglycerin er 9 mg cap er generic CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

amphetamine-dextroamphet er 5 mg cap er 24h generic MDD 2 per day

dextroamphetamine sulfate er 10 mg cap er 24h generic

methamphetamine hcl 5 mg tab generic C Non-Formulary Drug

VYVANSE 20 MG CAP BRAND PA lisdexamfetamine dimesylate ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

atomoxetine hcl 18 mg cap generic PA

DAYTRANA 10 MG/9HR PATCH BRAND C Non-Formulary Drug methylphenidate DAYTRANA 15 MG/9HR PATCH BRAND C Non-Formulary Drug methylphenidate DAYTRANA 20 MG/9HR PATCH BRAND C Non-Formulary Drug methylphenidate DAYTRANA 30 MG/9HR PATCH BRAND C Non-Formulary Drug methylphenidate

dexmethylphenidate hcl 10 mg tab generic C Non-Formulary Drug

dexmethylphenidate hcl 2.5 mg tab generic C Non-Formulary Drug

dexmethylphenidate hcl 5 mg tab generic C Non-Formulary Drug

dexmethylphenidate hcl er 10 mg cap er 24h generic C Non-Formulary Drug

dexmethylphenidate hcl er 15 mg cap er 24h generic C Non-Formulary Drug

dexmethylphenidate hcl er 20 mg cap er 24h generic C Non-Formulary Drug

dexmethylphenidate hcl er 30 mg cap er 24h generic C Non-Formulary Drug

dexmethylphenidate hcl er 40 mg cap er 24h generic C Non-Formulary Drug

dexmethylphenidate hcl er 5 mg cap er 24h generic C Non-Formulary Drug

guanfacine hcl er 2 mg tab er 24h generic PA

PAGE 186 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

metadate er 20 mg tab er generic MDD 1 per day

methylin 20 mg tab generic PA

methylin er 10 mg tab er generic

methylin er 20 mg tab er generic MDD 1 per day

methylphenidate hcl 20 mg tab generic PA

PA methylphenidate hcl er (cd) 10 mg cap er generic MDD 1 per day

PA methylphenidate hcl er (cd) 40 mg cap er generic MDD 1 per day

methylphenidate hcl er 10 mg tab er generic methylphenidate hcl er 10 mg tab er generic

methylphenidate hcl er 18 mg tab er generic MDD 1 per day

methylphenidate hcl er 20 mg tab er generic MDD 1 per day

methylphenidate hcl er 27 mg tab er generic MDD 1 per day

QUILLIVANT XR 25 MG/5ML RECON SUSP BRAND methylphenidate hcl CENTRAL NERVOUS SYSTEM, OTHER

benzphetamine hcl 50 mg tab generic PA

butalbital-apap-caffeine 50-325-40 mg cap generic C Non-Formulary Drug

butalbital-apap-caffeine 50-325-40 mg tab generic

capacet 50-325-40 mg cap generic C Non-Formulary Drug

diethylpropion hcl er 75 mg tab er 24h generic

esgic 50-325-40 mg cap generic C Non-Formulary Drug

ESGIC-PLUS 50-500-40 MG CAP BRAND C Non-Formulary Drug butalbital-acetaminophen-caffeine ESGIC-PLUS 50-500-40 MG TAB BRAND C Non-Formulary Drug butalbital-acetaminophen-caffeine

PAGE 187 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

margesic 50-325-40 mg cap generic C Non-Formulary Drug

NUEDEXTA 20-10 MG CAP BRAND C Non-Formulary Drug dextromethorphan hbr-quinidine sulfate

phentermine hcl 30 mg cap generic PA

phentermine hcl 37.5 mg cap generic PA

phentermine hcl 37.5 mg tab generic PA

PHRENILIN FORTE 50-650 MG CAP BRAND C Non-Formulary Drug butalbital-acetaminophen

riluzole 50 mg tab generic C Non-Formulary Drug

SEDAPAP 50-650 MG TAB BRAND C Non-Formulary Drug butalbital-acetaminophen TENCON 50-650 MG TAB BRAND C Non-Formulary Drug butalbital-acetaminophen

zebutal 50-325-40 mg cap generic C Non-Formulary Drug

FIBROMYALGIA AGENTS

LYRICA 150 MG CAP BRAND pregabalin LYRICA 20 MG/ML SOLUTION BRAND pregabalin LYRICA 200 MG CAP BRAND pregabalin LYRICA 225 MG CAP BRAND pregabalin LYRICA 25 MG CAP BRAND pregabalin SAVELLA 50 MG TAB BRAND milnacipran hcl MULTIPLE SCLEROSIS AGENTS

TECFIDERA 120 MG CAP DR BRAND C Non-Formulary Drug dimethyl fumarate TECFIDERA 240 MG CAP DR BRAND C Non-Formulary Drug dimethyl fumarate

PAGE 188 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS DENTAL AND ORAL AGENTS

AQUORAL SOLUTION BRAND artificial saliva ARESTIN 1 MG MISC BRAND PA minocycline hcl (subgingival) CAPHOSOL SOLUTION BRAND artificial saliva DEBACTEROL 30-50 % SOLUTION BRAND sulfuric acid-sulfonated phenolics DEBACTEROL 30-50 % SOLUTION BRAND sulfuric acid-sulfonated phenolics NUMOISYN LIQUID BRAND artificial saliva

pilocarpine hcl 7.5 mg tab generic PA

DERMATOLOGICAL AGENTS

acne medication 5 5 % gel generic ala-cort 1 % cream generic

ammonium lactate 12 % lotion generic PA

amnesteem 10 mg cap generic

amnesteem 40 mg cap generic PA

ANALPRAM-HC 1-2.5 % LOTION BRAND hydrocortisone acetate w/ pramoxine ANALPRAM-HC 2.5-1 % LOTION BRAND hydrocortisone acetate w/ pramoxine

avar-e emollient 10-5 % cream generic PA

avar-e green 10-5 % cream generic PA

avita 0.025 % gel generic PA

AZELEX 20 % CREAM BRAND PA azelaic acid (acne)

benzoyl peroxide 10 % gel generic PA

benzoyl peroxide 5 % gel generic

benzoyl peroxide creamy wash 4 % liquid generic PA

PAGE 189 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

benzoyl peroxide creamy wash 8 % liquid generic PA

benzoyl peroxide wash 10 % liquid generic PA

benzoyl peroxide-erythromycin 5-3 % gel generic PA

bp foaming wash 10 % liquid generic PA

calcipotriene 0.005 % cream generic CETACAINE 2-2-14 % AEROSOL BRAND PA butamben-tetracaine-benzocaine claravis 10 mg cap generic

claravis 40 mg cap generic PA

clearplex x 10 % gel generic PA

clenia 10-5 % cream generic PA

clotrimazole-betamethasone 1-0.05 % lotion generic COPASIL GEL BRAND PA emollient DERMASORB AF 3-0.5 % KIT BRAND clioquinol-hydrocortisone & emollient ELIDEL 1 % CREAM BRAND PA pimecrolimus FINACEA 15 % GEL BRAND PA azelaic acid

finasteride 1 mg tab generic C Non-Formulary Drug

fluorouracil 0.5 % cream generic PA

fluorouracil 5 % cream generic PA

grafco silver nit applicator 75-25 % misc generic PA

hydrocortisone 1 % cream generic hydrocortisone 1 % ointment generic hydrocortisone 2.5 % ointment generic hydrocortisone ace-pramoxine 2.5-1 % cream generic hydrocortisone in absorbase 1 % ointment generic

imiquimod 5 % cream generic PA

PAGE 190 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS keratol plus 50 % gel generic

laclotion 12 % lotion generic PA

lactic acid e 10-3500 %-unt/30gm cream generic PA

lavoclen-4 creamy wash 4 % liquid generic PA

lavoclen-8 creamy wash 8 % liquid generic PA

LIDAMANTLE HC 3-0.5 % LOTION BRAND lidocaine-hydrocortisone acetate

lido-k 3 % lotion generic PA

lidocaine hcl 3 % lotion generic PA

myorisan 10 mg cap generic

myorisan 40 mg cap generic PA

PACNEX MX 4.25 % LIQUID BRAND PA benzoyl peroxide PRAMOSONE 1-2.5 % OINTMENT BRAND pramoxine-hc

re 10 wash 10 % liquid generic PA

remeven 50 % cream generic salacyn 6 % cream generic

salacyn 6 % lotion generic PA

salicylic acid 6 % crea generic salicylic acid 6 % cream generic

salicylic acid 6 % lotion generic PA

salicylic acid 6 % lotn generic PA

salicylic acid 6 % sham generic PA

salicylic acid 6 % shampoo generic PA

salimez 6 % cream generic

salitech forte 6 % lotion generic PA

PAGE 191 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS scalacort 2 % lotion generic

se 10-5 ss 10-5 % cream generic PA

seb-prev wash 10 % liquid generic PA

silver nitrate 10 % solution generic silver nitrate 25 % solution generic

sss 10-5 10-5 % cream generic PA

sulfacetamide sodium 10 % liquid generic PA

sulfacetamide sodium-sulfur 10-5 % cream generic PA

sulfacetamide sodium-sulfur 10-5 % lotion generic SULFOAM 2 % SHAMPOO BRAND sulfur TACLONEX 0.005-0.064 % SUSPENSION BRAND calcipotriene-betamethasone dipropionate tacrolimus 0.1 % ointment generic TAZORAC 0.05 % GEL BRAND PA tazarotene

topisulf 10-5 % cream generic PA

tretinoin 0.025 % gel generic PA

tretinoin 0.05 % gel generic PA

tretinoin 0.1 % cream generic PA

tretinoin microsphere 0.1 % gel generic PA

tretinoin microsphere pump 0.1 % gel generic PA

TRI-CHLOR 80 % LIQUID BRAND trichloroacetic acid UMECTA 40 % EMULSION BRAND urea ure-k 50 % cream generic urea 50 % cream generic urealac 50 % crea generic urealac nail 50 % gel generic

PAGE 192 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS VANIQA 13.9 % CREAM BRAND C Non-Formulary Drug eflornithine hcl

virti-sulf 10-5 % cream generic PA

zenatane 10 mg cap generic

zenatane 40 mg cap generic PA

ZYCLARA 3.75 % CREAM BRAND PA imiquimod ZYCLARA PUMP 3.75 % CREAM BRAND PA imiquimod ENZYME REPLACEMENT/MODIFIERS

CREON 12000 UNIT CP DR PART BRAND pancrelipase (lipase-protease-amylase) CREON 36000 UNIT CP DR PART BRAND pancrelipase (lipase-protease-amylase) CREON 6000 UNIT CP DR PART BRAND pancrelipase (lipase-protease-amylase) KUVAN 100 MG PACKET BRAND C Non-Formulary Drug sapropterin dihydrochloride KUVAN 100 MG TAB SOL BRAND C Non-Formulary Drug sapropterin dihydrochloride PANCREAZE 21000 UNIT CP DR PART BRAND pancrelipase (lipase-protease-amylase)

pancrelipase (lip-prot-amyl) 5000 unit cp dr part generic PA

PERTZYE 16000 UNIT CP DR PART BRAND PA pancrelipase (lipase-protease-amylase) RAVICTI 1.1 GM/ML LIQUID BRAND C Non-Formulary Drug glycerol phenylbutyrate

sodium phenylbutyrate 3 gm/tsp powder generic C Non-Formulary Drug

sodium phenylbutyrate 500 mg tab generic C Non-Formulary Drug

ULTRESA 13800 UNIT CP DR PART BRAND PA pancrelipase (lipase-protease-amylase) VIOKACE 10440 UNIT TAB BRAND PA pancrelipase (lipase-protease-amylase) ZENPEP 15000 UNIT CP DR PART BRAND PA pancrelipase (lipase-protease-amylase)

PAGE 193 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ZENPEP 25000 UNIT CP DR PART BRAND PA pancrelipase (lipase-protease-amylase) GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

dicyclomine hcl 10 mg cap generic dicyclomine hcl 10 mg/5ml solution generic ed-spaz 0.125 mg tab disp generic glycopyrrolate 1 mg tab generic glycopyrrolate 2 mg tab generic hyomax-sl 0.125 mg sl tab generic hyoscyamine sulfate 0.125 mg sl tab generic hyoscyamine sulfate 0.125 mg subl generic hyoscyamine sulfate 0.125 mg tab generic hyoscyamine sulfate 0.125 mg tab disp generic hyoscyamine sulfate 0.125 mg tabs generic hyoscyamine sulfate 0.125 mg/5ml elixir generic hyoscyamine sulfate er 0.375 mg tab er 12h generic hyoscyamine sulfate sl 0.125 mg sl tab generic hyosyne 0.125 mg/5ml elixir generic methscopolamine bromide 2.5 mg tab generic nulev 0.125 mg tab disp generic oscimin 0.125 mg sl tab generic oscimin 0.125 mg tab generic oscimin 0.125 mg tab disp generic oscimin sr 0.375 mg tab er 12h generic pb-hyoscy-atropine-scopolamine 16.2 mg tab generic phenohytro 16.2 mg tab generic symax fastabs 0.125 mg tab disp generic symax-sl 0.125 mg sl tab generic symax-sr 0.375 mg tab er 12h generic

PAGE 194 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS GASTROINTESTINAL AGENTS, OTHER

diphenatol 2.5-0.025 mg tab generic diphenoxylate-atropine 2.5-0.025 mg tab generic diphenoxylate-atropine 2.5-0.025 mg/5ml liquid generic FULYZAQ 125 MG TAB DR BRAND C Non-Formulary Drug crofelemer lonox 2.5-0.025 mg tab generic MOVANTIK 12.5 MG TAB BRAND PA naloxegol oxalate MOVANTIK 25 MG TAB BRAND PA naloxegol oxalate MYTESI 125 MG TAB DR BRAND C Non-Formulary Drug crofelemer OCALIVA 10 MG TAB BRAND PA obeticholic acid OCALIVA 5 MG TAB BRAND PA obeticholic acid

opium 10 mg/ml (1%) tincture generic C Non-Formulary Drug

RELISTOR 150 MG TAB BRAND PA methylnaltrexone bromide TRULANCE 3 MG TAB BRAND PA plecanatide

ursodiol 500 mg tab generic PA

XENICAL 120 MG CAP BRAND orlistat HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine 200 mg tab generic MDD 1 per day

nizatidine 15 mg/ml solution generic

nizatidine 150 mg cap generic MDD 2 per day

ranitidine hcl 15 mg/ml syrup generic

ranitidine hcl 150 mg tab generic MDD 2 per day

ranitidine hcl 150 mg/10ml syrup generic

PAGE 195 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ranitidine hcl 300 mg cap generic

ranitidine hcl 300 mg tab generic MDD 2 per day

ranitidine hcl 75 mg/5ml syrup generic IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl 0.5 mg tab generic

PA alosetron hcl 1 mg tab generic MDD 2 per day

VIBERZI 100 MG TAB BRAND PA eluxadoline VIBERZI 75 MG TAB BRAND PA eluxadoline LAXATIVES

KRISTALOSE 10 GM PACKET BRAND lactulose KRISTALOSE 20 GM PACKET BRAND lactulose MOVIPREP 100 GM RECON SOLN BRAND peg 3350-kcl-nacl-na sulfate-na ascorbate-ascorbic acid SUCLEAR KIT na sulfate-k sulfate-mg sulfate & peg3350-nacl-na bicarb- BRAND C Non-Formulary Drug kcl PROTECTANTS

misoprostol 200 mcg tab generic sucralfate 1 gm tab generic PROTON PUMP INHIBITORS

ACIPHEX SPRINKLE 10 MG CAP SPRINK MDD 2 per day BRAND rabeprazole sodium C Non-Formulary Drug

ACIPHEX SPRINKLE 5 MG CAP SPRINK MDD 2 per day BRAND rabeprazole sodium C Non-Formulary Drug

DEXILANT 60 MG CAP DR BRAND MDD 1 per day dexlansoprazole

PA esomeprazole magnesium 20 mg cap dr generic MDD 1 per day

PAGE 196 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

esomeprazole magnesium 40 mg cap dr generic MDD 1 per day

esomeprazole strontium 49.3 mg cap dr generic C Non-Formulary Drug

lansoprazole 15 mg cap dr generic MDD 2 per day

NEXIUM 10 MG PACKET PA BRAND esomeprazole magnesium MDD 1 per day

omeprazole 40 mg cap dr generic MDD 2 per day

PREVACID SOLUTAB 15 MG TAB DISP PA BRAND lansoprazole MDD 2 per day

PREVACID SOLUTAB 30 MG TAB DISP PA BRAND lansoprazole MDD 2 per day

PRILOSEC 10 MG PACKET BRAND PA omeprazole magnesium PRILOSEC 2.5 MG PACKET BRAND PA omeprazole magnesium PROTONIX 40 MG PACKET BRAND PA pantoprazole sodium GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide er 15 mg tab er 24h generic

oxybutynin chloride er 10 mg tab er 24h generic MDD 2 per day

PA tolterodine tartrate 1 mg tab generic MDD 2 per day

tolterodine tartrate er 4 mg cap er 24h generic MDD 1 per day

TOVIAZ 4 MG TAB ER 24H BRAND PA fesoterodine fumarate VESICARE 10 MG TAB BRAND PA solifenacin succinate BENIGN PROSTATIC HYPERTROPHY AGENTS

CIALIS 2.5 MG TAB PA BRAND tadalafil MDD 1 per day

PAGE 197 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS dutasteride 0.5 mg cap generic

PA terazosin hcl 1 mg cap generic MDD 1 per day

terazosin hcl 2 mg cap generic MDD 2 per day

GENITOURINARY AGENTS, OTHER

av-phos 250 neutral 155-852-130 mg tab generic bethanechol chloride 10 mg tab generic bethanechol chloride 5 mg tab generic CERVIDIL 10 MG INSERT BRAND C Non-Formulary Drug dinoprostone

CIALIS 10 MG TAB PA BRAND tadalafil MDD 0.2 per day

CIALIS 20 MG TAB BRAND MDD 0.2 per day tadalafil LEVITRA 5 MG TAB BRAND MDD 0.2 per day vardenafil hcl LITHOSTAT 250 MG TAB BRAND PA acetohydroxamic acid

MUSE 250 MCG PELLET QL 6 / 30 day(s) BRAND alprostadil (vasodilator) PA

phenazo 200 mg tab generic PA

phenazopyridine hcl 100 mg tab generic PA

phenazopyridine hcl 200 mg tab generic PA

phospha 250 neutral 155-852-130 mg tab generic phospho-trin 250 neutral 155-852-130 mg tab generic

pot & sod cit-cit ac 550-500-334 mg/5ml solution generic PA

potassium citrate er 5 meq (540 mg) tab er generic potassium citrate er 5 meq (540 mg) tab er generic PREPIDIL 0.5 MG/3GM GEL BRAND C Non-Formulary Drug dinoprostone PROSTIN E2 20 MG SUPPOS BRAND C Non-Formulary Drug dinoprostone

PAGE 198 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS RENACIDIN SOLUTION BRAND PA citric acid-gluconolactone-magnesium carbonate RIMSO-50 50 % SOLUTION BRAND dimethyl sulfoxide SORBITOL 3 % SOLUTION BRAND sorbitol irrigation STAXYN 10 MG TAB DISP BRAND MDD 0.2 per day vardenafil hcl STENDRA 100 MG TAB BRAND PA avanafil STENDRA 200 MG TAB BRAND PA avanafil

tricitrates 550-500-334 mg/5ml solution generic PA

virt-phos 250 neutral 155-852-130 mg tab generic

virtrate-3 550-500-334 mg/5ml solution generic PA

PHOSPHATE BINDERS

lanthanum carbonate 1000 mg chew tab generic PA

sevelamer carbonate 2.4 gm packet generic sevelamer carbonate 800 mg tab generic HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

amcinonide 0.1 % cream generic

PA asmalpred 15 mg/5ml solution generic C Non-Formulary Drug

PA asmalpred plus 15 mg/5ml solution generic C Non-Formulary Drug

baycadron 0.5 mg/5ml elixir generic beta-val 0.1 % cream generic betamethasone dipropionate 0.05 % cream generic betamethasone dipropionate 0.05 % ointment generic betamethasone dipropionate aug 0.05 % cream generic betamethasone valerate 0.1 % cream generic

PAGE 199 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS betamethasone valerate 0.1 % cream generic betamethasone valerate 0.12 % foam generic CARMOL-HC 1-10 % CREAM BRAND hydrocortisone acetate-urea clobetasol propionate 0.05 % foam generic clobetasol propionate 0.05 % lotion generic clobetasol propionate 0.05 % ointment generic clobetasol propionate 0.05 % shampoo generic CLODAN 0.05 % KIT BRAND clobetasol propionate & cleanser clodan 0.05 % shampoo generic CORDRAN 4 MCG/SQCM TAPE BRAND flurandrenolide cormax 0.05 % ointment generic desonide 0.05 % cream generic desoximetasone 0.25 % cream generic desoximetasone 0.25 % ointment generic dexamethasone 0.5 mg/5ml elixir generic dexamethasone 0.5 mg/5ml solution generic dexamethasone 6 mg tab generic DEXPAK 6 DAY 1.5 MG (21) TAB THPK BRAND dexamethasone FLO-PRED 16.7 (15 BASE) MG/5ML SUSPENSION BRAND C Non-Formulary Drug prednisolone acetate fluocinolone acetonide 0.01 % solution generic fluocinolone acetonide 0.025 % ointment generic

fluocinonide 0.05 % gel generic PA

fluocinonide 0.1 % cream generic

flurandrenolide 0.05 % lotion generic PA

fluticasone propionate 0.005 % ointment generic halobetasol propionate 0.05 % cream generic halobetasol propionate 0.05 % ointment generic

PAGE 200 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS HALOG 0.1 % OINTMENT BRAND PA halcinonide hydrocortisone 10 mg tab generic hydrocortisone 20 mg tab generic hydrocortisone 5 mg tab generic hydrocortisone butyrate 0.1 % ointment generic hydrocortisone valerate 0.2 % cream generic MEDROL 2 MG TAB BRAND C Non-Formulary Drug methylprednisolone methylprednisolone 16 mg tab generic

methylprednisolone 32 mg tab generic C Non-Formulary Drug

methylprednisolone 4 mg tab generic methylprednisolone 4 mg tab thpk generic methylprednisolone 8 mg tab generic mometasone furoate 0.1 % cream generic mometasone furoate 0.1 % ointment generic

nolix 0.05 % lotion generic PA

PANDEL 0.1 % CREAM BRAND hydrocortisone probutate prednicarbate 0.1 % ointment generic

prednisolone sodium phosphate 10 mg tab disp generic C Non-Formulary Drug

prednisolone sodium phosphate 10 mg/5ml solution generic C Non-Formulary Drug

prednisolone sodium phosphate 15 mg tab disp generic C Non-Formulary Drug

PA prednisolone sodium phosphate 15 mg/5ml solution generic C Non-Formulary Drug

prednisolone sodium phosphate 20 mg/5ml solution generic C Non-Formulary Drug

prednisolone sodium phosphate 30 mg tab disp generic C Non-Formulary Drug

prednisone 1 mg tab generic prednisone 5 mg tab generic prednisone 50 mg tab generic

PAGE 201 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS RAYOS 1 MG TAB DR BRAND C Non-Formulary Drug prednisone RAYOS 2 MG TAB DR BRAND C Non-Formulary Drug prednisone RAYOS 5 MG TAB DR BRAND C Non-Formulary Drug prednisone SYNALAR (CREAM) 0.025 % KIT BRAND fluocinolone-emollient TAPERDEX 6-DAY 1.5 MG (21) TAB THPK BRAND dexamethasone TOPICORT SPRAY 0.25 % LIQUID BRAND desoximetasone triamcinolone acetonide 0.025 % cream generic triamcinolone acetonide 0.025 % lotion generic triamcinolone acetonide 0.025 % ointment generic triamcinolone acetonide 0.1 % cream generic triamcinolone acetonide 0.1 % lotion generic triamcinolone acetonide 0.1 % ointment generic ZODEX 6-DAY 1.5 MG (21) TAB THPK BRAND dexamethasone HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

desmopressin ace spray refrig 0.01 % solution generic C Non-Formulary Drug

desmopressin acetate 0.1 mg tab generic STIMATE 1.5 MG/ML SOLUTION BRAND C Non-Formulary Drug desmopressin acetate HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 50 MG TAB BRAND C Non-Formulary Drug oxymetholone oxandrolone 10 mg tab generic ANDROGENS

ANDRODERM 2 MG/24HR PATCH 24HR BRAND testosterone

PAGE 202 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS ANDROGEL 20.25 MG/1.25GM (1.62%) GEL BRAND PA testosterone ANDROGEL 40.5 MG/2.5GM (1.62%) GEL BRAND PA testosterone ANDROGEL PUMP 20.25 MG/ACT (1.62%) GEL BRAND PA testosterone ANDROXY 10 MG TAB BRAND C Non-Formulary Drug fluoxymesterone danazol 50 mg cap generic METHITEST 10 MG TAB BRAND C Non-Formulary Drug methyltestosterone

methyltestosterone 10 mg cap generic C Non-Formulary Drug

STRIANT 30 MG MISC BRAND C Non-Formulary Drug testosterone

testosterone 10 mg/act (2%) gel generic C Non-Formulary Drug

testosterone 12.5 mg/act (1%) gel generic PA

testosterone 30 mg/act solution generic C Non-Formulary Drug

ESTROGENS

levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, generic C Non-Formulary Drug chateal, kurvelo, levora, marlissa, portia) norethindrone & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) levonorg-eth est tab 0.15-0.03mg(84) & eth est tab generic C Non-Formulary Drug 0.01mg(7) (amethia, camrese, daysee) levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg generic C Non-Formulary Drug (amethia lo, camrese lo, levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg generic C Non-Formulary Drug (amethyst) ANGELIQ 0.25-0.5 MG TAB BRAND C Non-Formulary Drug drospirenone-estradiol ANGELIQ 0.5-1 MG TAB BRAND C Non-Formulary Drug drospirenone-estradiol desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, generic C Non-Formulary Drug emoquette, enskyce, reclipsen, solia)

PAGE 203 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg generic C Non-Formulary Drug (aranelle, leena) levonorg-eth est tab 0.15-0.03mg(84) & eth est tab generic C Non-Formulary Drug 0.01mg(7) (amethia, camrese, daysee) levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx) levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx) desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg generic C Non-Formulary Drug (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg generic C Non-Formulary Drug (balziva, briellyn, gildagia, philith, vyfemla, zenchent) desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg generic C Non-Formulary Drug (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg generic C Non-Formulary Drug (balziva, briellyn, gildagia, philith, vyfemla, zenchent) levonorg-eth est tab 0.15-0.03mg(84) & eth est tab generic C Non-Formulary Drug 0.01mg(7) (amethia, camrese, daysee) levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg generic C Non-Formulary Drug (amethia lo, camrese lo,

caziant 0.1/0.125/0.15 -0.025 mg tab generic C Non-Formulary Drug

CENESTIN 0.3 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic a CENESTIN 0.45 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic a CENESTIN 0.625 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic a CENESTIN 0.9 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic a CENESTIN 1.25 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic a

cesia 0.1/0.125/0.15 -0.025 mg tab generic C Non-Formulary Drug

PAGE 204 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, generic C Non-Formulary Drug chateal, kurvelo, levora, marlissa, portia) CLIMARA PRO 0.045-0.015 MG/DAY PATCH WK BRAND PA estradiol-levonorgestrel

covaryx 1.25-2.5 mg tab generic C Non-Formulary Drug

covaryx hs 0.625-1.25 mg tab generic C Non-Formulary Drug

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg (cryselle, generic C Non-Formulary Drug elinest, low-ogestrel) norethindrone & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, generic C Non-Formulary Drug emoquette, enskyce, reclipsen, solia) norethindrone & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) levonorg-eth est tab 0.15-0.03mg(84) & eth est tab generic C Non-Formulary Drug 0.01mg(7) (amethia, camrese, daysee) levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx) desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg generic C Non-Formulary Drug (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, generic C Non-Formulary Drug emoquette, enskyce, reclipsen, solia) DIVIGEL 0.25 MG/0.25GM GEL BRAND C Non-Formulary Drug estradiol DIVIGEL 0.5 MG/0.5GM GEL BRAND C Non-Formulary Drug estradiol DIVIGEL 1 MG/GM GEL BRAND C Non-Formulary Drug estradiol drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, generic C Non-Formulary Drug nikki, vestura)

drospirenone-ethinyl estradiol 3-0.03 mg tab generic C Non-Formulary Drug

DUAVEE 0.45-20 MG TAB BRAND C Non-Formulary Drug conjugated estrogens-bazedoxifene

PAGE 205 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

eemt 1.25-2.5 mg tab generic C Non-Formulary Drug

eemt hs 0.625-1.25 mg tab generic C Non-Formulary Drug

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg (cryselle, generic C Non-Formulary Drug elinest, low-ogestrel) desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, generic C Non-Formulary Drug emoquette, enskyce, reclipsen, solia) ENJUVIA 0.3 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic b ENJUVIA 0.45 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic b ENJUVIA 0.625 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic b ENJUVIA 0.9 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic b ENJUVIA 1.25 MG TAB BRAND C Non-Formulary Drug estrogens, conjugated synthetic b levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg generic C Non-Formulary Drug (enpresse, levonest, myzilra, trivora) desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, generic C Non-Formulary Drug emoquette, enskyce, reclipsen, solia)

est estrogens-methyltest 1.25-2.5 mg tab generic C Non-Formulary Drug

est estrogens-methyltest ds 1.25-2.5 mg tab generic C Non-Formulary Drug

est estrogens-methyltest hs 0.625-1.25 mg tab generic C Non-Formulary Drug

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg generic C Non-Formulary Drug (estarylla, mono-linyah, mononessa, previfem, sprintec) estradiol 0.05 mg/24hr patch wk generic estradiol 0.075 mg/24hr patch wk generic

estradiol 0.1 mg/24hr patch wk generic PA

estradiol 0.1 mg/gm cream generic PA

estradiol 0.5 mg tab generic ESTRASORB 4.35 MG/1.74GM EMULSION BRAND C Non-Formulary Drug estradiol estropipate 1.5 mg tab generic

PAGE 206 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

estropipate 3 mg tab generic PA

ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (kelnor, zovia)

ethynodiol diac-eth estradiol 1-50 mg-mcg tab generic C Non-Formulary Drug

EVAMIST 1.53 MG/SPRAY SOLUTION BRAND C Non-Formulary Drug estradiol levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx)

fayosim 42-21-21-7 days tab generic C Non-Formulary Drug

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg generic C Non-Formulary Drug (estarylla, mono-linyah, mononessa, previfem, sprintec)

fyavolv 0.5-2.5 mg-mcg tab generic PA

drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, generic C Non-Formulary Drug nikki, vestura) norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg generic C Non-Formulary Drug (balziva, briellyn, gildagia, philith, vyfemla, zenchent) norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, generic C Non-Formulary Drug emoquette, enskyce, reclipsen, solia)

jevantique lo 0.5-2.5 mg-mcg tab generic PA

desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, generic C Non-Formulary Drug emoquette, enskyce, reclipsen, solia) norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg generic C Non-Formulary Drug (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (kelnor, zovia) desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg generic C Non-Formulary Drug (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet)

PAGE 207 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, generic C Non-Formulary Drug chateal, kurvelo, levora, marlissa, portia) norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx) norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg generic C Non-Formulary Drug (aranelle, leena) levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx) levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg generic C Non-Formulary Drug (enpresse, levonest, myzilra, trivora) levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg generic C Non-Formulary Drug (enpresse, levonest, myzilra, trivora)

levonorgest-eth est & eth est 42-21-21-7 days tab generic C Non-Formulary Drug

levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg generic C Non-Formulary Drug (amethia lo, camrese lo, levonorg-eth est tab 0.15-0.03mg(84) & eth est tab generic C Non-Formulary Drug 0.01mg(7) (amethia, camrese, daysee) levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx) levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, generic C Non-Formulary Drug chateal, kurvelo, levora, marlissa, portia) levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg generic C Non-Formulary Drug (amethyst) levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, generic C Non-Formulary Drug chateal, kurvelo, levora, marlissa, portia) levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, generic C Non-Formulary Drug chateal, kurvelo, levora, marlissa, portia) drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, generic C Non-Formulary Drug nikki, vestura) norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg (cryselle, generic C Non-Formulary Drug elinest, low-ogestrel) levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx)

PAGE 208 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, generic C Non-Formulary Drug chateal, kurvelo, levora, marlissa, portia) norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg generic C Non-Formulary Drug (estarylla, mono-linyah, mononessa, previfem, sprintec) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg generic C Non-Formulary Drug (estarylla, mono-linyah, mononessa, previfem, sprintec) levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg generic C Non-Formulary Drug (enpresse, levonest, myzilra, trivora) NATAZIA 3/2-2/2-3/1 MG TAB BRAND C Non-Formulary Drug estradiol valerate-dienogest norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg generic C Non-Formulary Drug (necon, nortrel, wera) norethindrone & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) NECON 1/50 (28) 1-50 MG-MCG TAB BRAND C Non-Formulary Drug norethindrone & mestranol NECON 10/11 (28) 35 MCG TAB BRAND C Non-Formulary Drug norethindrone-eth estradiol (biphasic) norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, generic C Non-Formulary Drug nikki, vestura) norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 generic C Non-Formulary Drug mcg (wymzya, zenchent, zeosa)

norethindrone-eth estradiol 0.5-2.5 mg-mcg tab generic PA

norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-25 mcg generic C Non-Formulary Drug tab norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg generic C Non-Formulary Drug (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg generic C Non-Formulary Drug (estarylla, mono-linyah, mononessa, previfem, sprintec)

PAGE 209 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg (cryselle, generic C Non-Formulary Drug elinest, low-ogestrel) NORINYL 1+50 (28) 1-50 MG-MCG TAB BRAND C Non-Formulary Drug norethindrone & mestranol norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg generic C Non-Formulary Drug (necon, nortrel, wera) norethindrone & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) norethindrone & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) NUVARING 0.12-0.015 MG/24HR RING BRAND C Non-Formulary Drug etonogestrel-ethinyl estradiol

ocella 3-0.03 mg tab generic C Non-Formulary Drug

OGESTREL 0.5-50 MG-MCG TAB BRAND C Non-Formulary Drug norgestrel & ethinyl estradiol levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx) NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR (XULANE) BRAND C Non-Formulary Drug norelgestromin-ethinyl estradiol norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg generic C Non-Formulary Drug (balziva, briellyn, gildagia, philith, vyfemla, zenchent) desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg generic C Non-Formulary Drug (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) norethindrone & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg generic C Non-Formulary Drug (alyacen, cyclafem, dasetta, necon, nortrel, pirmella) levonorgestrel-ethinyl estrad tab 0.15-30 mg (altavera, generic C Non-Formulary Drug chateal, kurvelo, levora, marlissa, portia) PREMARIN 0.625 MG TAB BRAND estrogens, conjugated PREMARIN 0.9 MG TAB BRAND PA estrogens, conjugated PREMPRO 0.3-1.5 MG TAB BRAND conjugated estrogens-medroxyprogesterone acetate

PAGE 210 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg generic C Non-Formulary Drug (estarylla, mono-linyah, mononessa, previfem, sprintec) desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, generic C Non-Formulary Drug emoquette, enskyce, reclipsen, solia)

rivelsa 42-21-21-7 days tab generic C Non-Formulary Drug

desogestrel-ethinyl estradiol tab 0.15-30 mg-mcg (apri, generic C Non-Formulary Drug emoquette, enskyce, reclipsen, solia) norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg generic C Non-Formulary Drug (estarylla, mono-linyah, mononessa, previfem, sprintec) levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx)

syeda 3-0.03 mg tab generic C Non-Formulary Drug

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg generic C Non-Formulary Drug (gildess, junel, larin, microgestin) norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg- generic C Non-Formulary Drug mcg (tilia, tri-legest) norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg generic C Non-Formulary Drug (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg generic C Non-Formulary Drug (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg- generic C Non-Formulary Drug mcg (tilia, tri-legest) norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg generic C Non-Formulary Drug (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa)

tri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg tab generic C Non-Formulary Drug

tri-lo-marzia 0.18/0.215/0.25 mg-25 mcg tab generic C Non-Formulary Drug

tri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg tab generic C Non-Formulary Drug

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg generic C Non-Formulary Drug (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg generic C Non-Formulary Drug (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa) norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg generic C Non-Formulary Drug (tri-estarylla, tri-linyah, tri-previfem, tri-sprintec, trinessa)

trinessa lo 0.18/0.215/0.25 mg-25 mcg tab generic C Non-Formulary Drug

PAGE 211 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg generic C Non-Formulary Drug (enpresse, levonest, myzilra, trivora)

velivet 0.1/0.125/0.15 -0.025 mg tab generic C Non-Formulary Drug

drospirenone-ethinyl estradiol tab 3-0.02 mg(gianvi, loryna, generic C Non-Formulary Drug nikki, vestura) levonorgestrel-ethinyl estrad tab 0.1-20 mg (aubra, aviane, generic C Non-Formulary Drug delyla, falmina, lessina, lutera, orsythia, sronyx) desogestrel-ethinyl estradiol tab 0.15-0.02/0.01 mg generic C Non-Formulary Drug (azurette, kariva, pimtrea, viorele, caziant, cesia, velivet) norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg generic C Non-Formulary Drug (balziva, briellyn, gildagia, philith, vyfemla, zenchent) norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg generic C Non-Formulary Drug (necon, nortrel, wera) norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 generic C Non-Formulary Drug mcg (wymzya, zenchent, zeosa) NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR (XULANE) BRAND C Non-Formulary Drug norelgestromin-ethinyl estradiol

zarah 3-0.03 mg tab generic C Non-Formulary Drug

norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg generic C Non-Formulary Drug (balziva, briellyn, gildagia, philith, vyfemla, zenchent) norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 generic C Non-Formulary Drug mcg (wymzya, zenchent, zeosa) norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 generic C Non-Formulary Drug mcg (wymzya, zenchent, zeosa) ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg generic C Non-Formulary Drug (kelnor, zovia)

zovia 1/50e (28) 1-50 mg-mcg tab generic C Non-Formulary Drug

PROGESTINS

norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) CRINONE 8 % GEL BRAND progesterone (vaginal) norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel)

PAGE 212 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) FIRST-PROGESTERONE VGS 100 100 MG SUPPOS BRAND PA progesterone (vaginal) FIRST-PROGESTERONE VGS 200 200 MG SUPPOS BRAND progesterone (vaginal) FIRST-PROGESTERONE VGS 25 25 MG SUPPOS BRAND progesterone (vaginal) FIRST-PROGESTERONE VGS 400 400 MG SUPPOS BRAND progesterone (vaginal) norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel)

levonorgestrel 0.75 mg tab generic PA

levonorgestrel 1.5 mg tab generic PA

norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) megestrol acetate 20 mg tab generic

megestrol acetate 40 mg/ml suspension generic PA

megestrol acetate 400 mg/10ml suspension generic PA

megestrol acetate 800 mg/20ml suspension generic PA

MIRENA (52 MG) 20 MCG/24HR IUD BRAND C Non-Formulary Drug levonorgestrel (iud)

my way 1.5 mg tab generic PA

next choice 0.75 mg tab generic PA

next choice one dose 1.5 mg tab generic PA

PAGE 213 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) PROCHIEVE 8 % GEL BRAND progesterone (vaginal) progesterone micronized 200 mg cap generic norethindrone tab 0.35 mg (camila, deblitane, errin, heather, jencycla, jolivette, lyza, nora-be, norlyroc, generic C Non-Formulary Drug sharobel) SKYLA 13.5 MG IUD BRAND C Non-Formulary Drug levonorgestrel (iud) SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

clomiphene citrate 50 mg tab generic C Non-Formulary Drug

OSPHENA 60 MG TAB BRAND PA ospemifene

serophene 50 mg tab generic C Non-Formulary Drug

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID 180 MG TAB BRAND C Non-Formulary Drug thyroid ARMOUR THYROID 240 MG TAB BRAND C Non-Formulary Drug thyroid ARMOUR THYROID 300 MG TAB BRAND C Non-Formulary Drug thyroid levo-t 125 mcg tab generic levo-t 150 mcg tab generic levo-t 175 mcg tab generic

levo-t 88 mcg tab generic PA

PAGE 214 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS levothroid 125 mcg tab generic levothroid 150 mcg tab generic levothroid 175 mcg tab generic

levothroid 88 mcg tab generic PA

levothyroxine sodium 125 mcg tab generic levothyroxine sodium 125 mcg tabs generic levothyroxine sodium 150 mcg tab generic levothyroxine sodium 150 mcg tabs generic levothyroxine sodium 175 mcg tab generic

levothyroxine sodium 88 mcg tab generic PA

levothyroxine-liothyronine 120 mg tab generic C Non-Formulary Drug

levothyroxine-liothyronine 15 mg tab generic C Non-Formulary Drug

levothyroxine-liothyronine 30 mg tab generic C Non-Formulary Drug

levothyroxine-liothyronine 60 mg tab generic C Non-Formulary Drug

levothyroxine-liothyronine 90 mg tab generic C Non-Formulary Drug

levoxyl 125 mcg tab generic levoxyl 150 mcg tab generic levoxyl 175 mcg tab generic

levoxyl 88 mcg tab generic PA

liothyronine sodium 50 mcg tab generic NATURE-THROID 130 MG TAB BRAND C Non-Formulary Drug thyroid NATURE-THROID 195 MG TAB BRAND C Non-Formulary Drug thyroid NATURE-THROID 32.5 MG TAB BRAND C Non-Formulary Drug thyroid NATURE-THROID 65 MG TAB BRAND C Non-Formulary Drug thyroid

np thyroid 120 mg tab generic C Non-Formulary Drug

np thyroid 15 mg tab generic C Non-Formulary Drug

PAGE 215 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

np thyroid 30 mg tab generic C Non-Formulary Drug

np thyroid 60 mg tab generic C Non-Formulary Drug

np thyroid 90 mg tab generic C Non-Formulary Drug

THYROID 65 MG TAB BRAND C Non-Formulary Drug thyroid THYROLAR-1 60 (12.5-50) MG (MCG) TAB BRAND C Non-Formulary Drug liotrix (t3-t4) THYROLAR-1/2 30 (6.25-25) MG (MCG) TAB BRAND C Non-Formulary Drug liotrix (t3-t4) THYROLAR-1/4 15 (3.1-12.5) MG (MCG) TAB BRAND C Non-Formulary Drug liotrix (t3-t4) THYROLAR-2 120 (25-100) MG (MCG) TAB BRAND C Non-Formulary Drug liotrix (t3-t4) THYROLAR-3 180 (37.5-150) MG (MCG) TAB BRAND C Non-Formulary Drug liotrix (t3-t4) unithroid 125 mcg tab generic unithroid 150 mcg tab generic unithroid 175 mcg tab generic

unithroid 88 mcg tab generic PA

unithroid direct 125 mcg tab generic unithroid direct 150 mcg tab generic unithroid direct 175 mcg tab generic

unithroid direct 88 mcg tab generic PA

WESTHROID 130 MG TAB BRAND C Non-Formulary Drug thyroid WESTHROID 195 MG TAB BRAND C Non-Formulary Drug thyroid WESTHROID 32.5 MG TAB BRAND C Non-Formulary Drug thyroid WESTHROID 65 MG TAB BRAND C Non-Formulary Drug thyroid WP THYROID 130 MG TAB BRAND C Non-Formulary Drug thyroid

PAGE 216 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS WP THYROID 32.5 MG TAB BRAND C Non-Formulary Drug thyroid WP THYROID 65 MG TAB BRAND C Non-Formulary Drug thyroid HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)

SENSIPAR 90 MG TAB BRAND cinacalcet hcl HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline 0.5 mg tab generic PA

SIGNIFOR 0.3 MG/ML SOLUTION BRAND C Non-Formulary Drug pasireotide diaspartate SIGNIFOR 0.6 MG/ML SOLUTION BRAND C Non-Formulary Drug pasireotide diaspartate SIGNIFOR 0.9 MG/ML SOLUTION BRAND C Non-Formulary Drug pasireotide diaspartate SYNAREL 2 MG/ML SOLUTION BRAND C Non-Formulary Drug nafarelin acetate HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole 10 mg tab generic PA

IMMUNOLOGICAL AGENTS

ANGIOEDEMA (HAE) AGENTS

FIRAZYR 30 MG/3ML SOLUTION BRAND C Non-Formulary Drug icatibant acetate IMMUNE SUPPRESSANTS

cyclosporine 100 mg cap generic hecoria 1 mg cap generic mycophenolate mofetil 250 mg cap generic mycophenolate mofetil 500 mg tab generic RAPAMUNE 1 MG/ML SOLUTION BRAND PA sirolimus sirolimus 0.5 mg tab generic

PAGE 217 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS tacrolimus 1 mg cap generic TREXALL 7.5 MG TAB BRAND PA methotrexate sodium IMMUNOMODULATORS

PA leflunomide 10 mg tab generic MDD 1 per day

RIDAURA 3 MG CAP BRAND PA auranofin INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

DELZICOL 400 MG CAP DR BRAND C Non-Formulary Drug mesalamine GIAZO 1.1 GM TAB BRAND C Non-Formulary Drug balsalazide disodium mesalamine 4 gm enema generic GLUCOCORTICOIDS

UCERIS 9 MG TAB ER 24H BRAND budesonide SULFONAMIDES

sulfasalazine 500 mg tab dr generic METABOLIC BONE DISEASE AGENTS

PA alendronate sodium 40 mg tab generic MDD 1 per day

FORTEO 600 MCG/2.4ML SOLUTION BRAND teriparatide (recombinant) FOSAMAX PLUS D 70-2800 MG-UNIT TAB BRAND PA alendronate sodium-cholecalciferol FOSAMAX PLUS D 70-5600 MG-UNIT TAB BRAND alendronate sodium-cholecalciferol

paricalcitol 1 mcg cap generic PA

paricalcitol 2 mcg cap generic PA

paricalcitol 4 mcg cap generic PA

PAGE 218 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS risedronate sodium 150 mg tab generic risedronate sodium 35 mg tab generic SKELID 200 MG TAB BRAND C Non-Formulary Drug tiludronate disodium ZOLEDRONIC ACID 4 MG RECON SOLN BRAND zoledronic acid MISCELLANEOUS THERAPEUTIC AGENTS

ACCU-CHEK COMPACT PLUS CARE KIT BRAND PA blood glucose monitoring supplies ALLERX DF 4-2.5 & 8-2.5 MG MISC BRAND PA chlorpheniramine-methscopolamine ALLERX DF30 4-2.5 & 8-2.5 MG MISC BRAND PA chlorpheniramine-methscopolamine ASSURE 3 METER KIT BRAND PA blood glucose monitoring supplies AT LAST BLOOD GLUCOSE SYSTEM KIT BRAND PA blood glucose monitoring supplies CHOICE DM DIABETES RISK TEST KIT BRAND PA blood glucose monitoring supplies CONTOUR NEXT ONE KIT BRAND PA blood glucose monitoring supplies E-Z-HD 98 % RECON SUSP BRAND PA barium sulfate EASYGLUCO KIT BRAND PA blood glucose monitoring supplies EVENCARE GLUCOSE MONITORING KIT BRAND PA blood glucose monitoring supplies FORA V10/V12/D10/D20 TEST KIT BRAND PA blood glucose monitoring supplies

formadon 10 % solution generic PA

formaldehyde 10 % solution generic PA

FREESTYLE FLASH SYSTEM KIT BRAND PA blood glucose monitoring supplies FREESTYLE SYSTEM KIT BRAND PA blood glucose monitoring supplies

PAGE 219 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

inositol hexanicotinate powder generic PA

isometheptene-dichloral-apap 65-100-325 mg cap generic LIQUID E-Z-PAQUE 60 % SUSPENSION BRAND barium sulfate LIQUID POLIBAR 100 % SUSPENSION BRAND PA barium sulfate MI PASTE PASTE BRAND dentifrices MI PASTE PLUS PASTE BRAND dentifrices migragesic ida 325-65-100 mg cap generic NEXGEN METER KIT BRAND PA blood glucose monitoring supplies nodolor 325-65-100 mg cap generic phosphatidylcholine powder generic PRECISION XTRA KIT BRAND PA blood glucose monitoring supplies QUICKTEK KIT BRAND PA blood glucose monitoring supplies ULTIMA KIT BRAND PA blood glucose monitoring supplies OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

AKTEN 3.5 % GEL BRAND C Non-Formulary Drug lidocaine hcl (ophth)

altacaine 0.5 % solution generic C Non-Formulary Drug

altafrin 10 % solution generic atropine sulfate 1 % solution generic atropine-care 1 % solution generic BLEPHAMIDE 10-0.2 % SUSPENSION BRAND C Non-Formulary Drug sulfacetamide sod-prednisolone BLEPHAMIDE S.O.P. 10-0.2 % OINTMENT BRAND C Non-Formulary Drug sulfacetamide sod-prednisolone

PAGE 220 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS CYCLOMYDRIL 0.2-1 % SOLUTION BRAND C Non-Formulary Drug cyclopentolate w/ phenylephrine cyclopentolate hcl 0.5 % solution generic cyclopentolate hcl 2 % solution generic CYSTARAN 0.44 % SOLUTION BRAND C Non-Formulary Drug cysteamine hcl ISOPTO HOMATROPINE 2 % SOLUTION BRAND C Non-Formulary Drug homatropine hbr ISOPTO HYOSCINE 0.25 % SOLUTION BRAND C Non-Formulary Drug scopolamine hbr (ophth) ketotifen fumarate 0.025 % solution generic LASTACAFT 0.25 % SOLUTION BRAND C Non-Formulary Drug alcaftadine

mydral 0.5 % solution generic C Non-Formulary Drug

mydral 1 % solution generic C Non-Formulary Drug

naphazoline hcl 0.1 % solution generic C Non-Formulary Drug

neo-polycin 3.5-400-10000 ointment generic neofrin 10 % solution generic neomycin-bacitracin zn-polymyx 3.5-400-10000 ointment generic neomycin-bacitracin zn-polymyx 5-400-10000 ointment generic neomycin-bacitracin zn-polymyx 5-400-10000 ointment generic neomycin-polymyxin-dexameth 0.1 % suspension generic neomycin-polymyxin-dexameth 3.5-10000-0.1 suspension generic neomycin-polymyxin-dexameth 3.5-10000-0.1 suspension generic neomycin-polymyxin-gramicidin 1.75-10000-.025 solution generic neomycin-polymyxin-hc 3.5-10000-1 suspension generic

parcaine 0.5 % solution generic C Non-Formulary Drug

phenylephrine hcl 10 % solution generic polyvinyl alcohol 1.4 % solution generic PRED-G 0.3-1 % SUSPENSION BRAND gentamicin-prednisolone acetate PRED-G S.O.P. 0.3-0.6 % OINTMENT BRAND PA gentamicin-prednisolone acetate

PAGE 221 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

proparacaine hcl 0.5 % solution generic C Non-Formulary Drug

SULFACETAMIDE-PREDNISOLONE 10-0.2 % SUSPENSION BRAND C Non-Formulary Drug sulfacetamide sod-prednisolone

tetcaine 0.5 % solution generic C Non-Formulary Drug

tetracaine hcl 0.5 % solution generic C Non-Formulary Drug

tetravisc 0.5 % solution generic C Non-Formulary Drug

tetravisc forte 0.5 % solution generic C Non-Formulary Drug

tobramycin-dexamethasone 0.3-0.1 % suspension generic triple antibiotic 5-400-10000 ointment generic

tropicamide 0.5 % solution generic C Non-Formulary Drug

tropicamide 1 % solution generic C Non-Formulary Drug

ZYLET 0.5-0.3 % SUSPENSION BRAND C Non-Formulary Drug loteprednol etabonate-tobramycin OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL 2 % SOLUTION BRAND C Non-Formulary Drug nedocromil sodium (ophth) ALOMIDE 0.1 % SOLUTION BRAND C Non-Formulary Drug lodoxamide tromethamine

azelastine hcl 0.05 % solution generic C Non-Formulary Drug

cromolyn sodium 4 % solution generic PA

EMADINE 0.05 % SOLUTION BRAND C Non-Formulary Drug emedastine difumarate

epinastine hcl 0.05 % solution generic C Non-Formulary Drug

olopatadine hcl 0.1 % solution generic C Non-Formulary Drug

olopatadine hcl 0.2 % solution generic C Non-Formulary Drug

PAGE 222 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS OPHTHALMIC ANTI-INFLAMMATORIES

ACUVAIL 0.45 % SOLUTION BRAND C Non-Formulary Drug ketorolac tromethamine (ophth) ALREX 0.2 % SUSPENSION BRAND C Non-Formulary Drug loteprednol etabonate

bromfenac sodium 0.09 % solution generic C Non-Formulary Drug

dexamethasone sodium phosphate 0.1 % solution generic FML 0.1 % OINTMENT BRAND C Non-Formulary Drug fluorometholone (ophth) FML FORTE 0.25 % SUSPENSION BRAND C Non-Formulary Drug fluorometholone (ophth) ketorolac tromethamine 0.4 % solution generic

ketorolac tromethamine 0.5 % solution generic PA

LOTEMAX 0.5 % GEL BRAND C Non-Formulary Drug loteprednol etabonate LOTEMAX 0.5 % SUSPENSION BRAND C Non-Formulary Drug loteprednol etabonate NEVANAC 0.1 % SUSPENSION BRAND C Non-Formulary Drug nepafenac OZURDEX 0.7 MG IMPLANT BRAND C Non-Formulary Drug dexamethasone (ophth) prednisolone acetate 1 % suspension generic PROLENSA 0.07 % SOLUTION BRAND C Non-Formulary Drug bromfenac sodium (ophth) RETISERT 0.59 MG IMPLANT BRAND C Non-Formulary Drug fluocinolone acetonide (ophth) XIIDRA 5 % SOLUTION BRAND PA lifitegrast OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 0.1 % SOLUTION BRAND C Non-Formulary Drug brimonidine tartrate

apraclonidine hcl 0.5 % solution generic C Non-Formulary Drug

AZOPT 1 % SUSPENSION BRAND C Non-Formulary Drug brinzolamide

PAGE 223 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

betaxolol hcl 0.5 % solution generic C Non-Formulary Drug

BETIMOL 0.25 % SOLUTION BRAND C Non-Formulary Drug timolol BETIMOL 0.5 % SOLUTION BRAND C Non-Formulary Drug timolol BETOPTIC-S 0.25 % SUSPENSION BRAND C Non-Formulary Drug betaxolol hcl (ophth)

brimonidine tartrate 0.15 % solution generic C Non-Formulary Drug

brimonidine tartrate 0.2 % solution generic C Non-Formulary Drug

carteolol hcl 1 % solution generic C Non-Formulary Drug

IOPIDINE 1 % SOLUTION BRAND C Non-Formulary Drug apraclonidine hcl ISOPTO CARBACHOL 1.5 % SOLUTION BRAND C Non-Formulary Drug carbachol (ophth) ISOPTO CARBACHOL 3 % SOLUTION BRAND C Non-Formulary Drug carbachol (ophth)

levobunolol hcl 0.25 % solution generic C Non-Formulary Drug

levobunolol hcl 0.5 % solution generic C Non-Formulary Drug

methazolamide 25 mg tab generic PA

metipranolol 0.3 % solution generic C Non-Formulary Drug

PHOSPHOLINE IODIDE 0.125 % RECON SOLN BRAND C Non-Formulary Drug echothiophate iodide

pilocarpine hcl 1 % solution generic C Non-Formulary Drug

pilocarpine hcl 2 % solution generic C Non-Formulary Drug

pilocarpine hcl 4 % solution generic C Non-Formulary Drug

SIMBRINZA 1-0.2 % SUSPENSION BRAND C Non-Formulary Drug brinzolamide-brimonidine tartrate

timolol maleate 0.25 % gel f soln generic C Non-Formulary Drug

timolol maleate 0.25 % solution generic C Non-Formulary Drug

timolol maleate 0.5 % gel f soln generic C Non-Formulary Drug

PAGE 224 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

timolol maleate 0.5 % solution generic C Non-Formulary Drug

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

bimatoprost 0.03 % solution generic C Non-Formulary Drug

LUMIGAN 0.01 % SOLUTION BRAND C Non-Formulary Drug bimatoprost

travoprost 0.004 % solution generic C Non-Formulary Drug

ZIOPTAN 0.0015 % SOLUTION BRAND C Non-Formulary Drug tafluprost OTIC AGENTS

a/b otic 5.4-1.4 % solution generic C Non-Formulary Drug

acetasol hc 2-1 % solution generic C Non-Formulary Drug

acetic acid 2 % solution generic C Non-Formulary Drug

aero otic hc 10-10-1 mg/ml solution generic PA

antibiotic ear 3.5-10000-1 solution generic PA

antipyrine-benzocaine 5.4-1.4 % solution generic C Non-Formulary Drug

antipyrine-benzocaine 54-14 mg/ml solution generic C Non-Formulary Drug

aurodex 5.4-1.4 % solution generic C Non-Formulary Drug

auroguard 54-14 mg/ml solution generic C Non-Formulary Drug

auroto 5.4-1.4 % solution generic C Non-Formulary Drug

CIPRO HC 0.2-1 % SUSPENSION BRAND C Non-Formulary Drug ciprofloxacin-hydrocortisone CIPRODEX 0.3-0.1 % SUSPENSION BRAND C Non-Formulary Drug ciprofloxacin-dexamethasone

cortic-nd 10-10-1 mg/ml solution generic PA

cortomycin 3.5-10000-1 solution generic PA

CRESYLATE 25 % SOLUTION BRAND cresyl acetate

cyotic 10-10-1 mg/ml solution generic PA

exotic-hc 10-10-1 mg/ml solution generic PA

PAGE 225 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

fluocinolone acetonide 0.01 % oil generic C Non-Formulary Drug

hydro ear drops 10-10-1 mg/ml soln generic PA

hydrocortisone-acetic acid 1-2 % solution generic C Non-Formulary Drug

neomycin-polymyxin-hc 1 % solution generic PA

neomycin-polymyxin-hc 3.5-10000-1 solution generic PA

otic care 5.4-1.4-0.0097 % solution generic C Non-Formulary Drug

oto-end 10 10-10-1 mg/ml solution generic PA

otomax-hc 10-10-1 mg/ml solution generic PA

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ALVESCO 80 MCG/ACT AERO SOLN BRAND ciclesonide ASMANEX 120 METERED DOSES 220 MCG/INH AER POW BA BRAND PA mometasone furoate (inhalation) ASMANEX 14 METERED DOSES 220 MCG/INH AER POW BA BRAND PA mometasone furoate (inhalation) ASMANEX 30 METERED DOSES 220 MCG/INH AER POW BA BRAND PA mometasone furoate (inhalation) ASMANEX 60 METERED DOSES 220 MCG/INH AER POW BA BRAND PA mometasone furoate (inhalation) BECONASE AQ 42 MCG/SPRAY SUSPENSION BRAND MDD 0.83 per day beclomethasone diprop monohyd budesonide 0.25 mg/2ml suspension generic

budesonide 0.5 mg/2ml suspension generic PA

FLOVENT DISKUS 100 MCG/BLIST AER POW BA PA BRAND fluticasone propionate (inhalation) MDD 4 per day

FLOVENT DISKUS 50 MCG/BLIST AER POW BA BRAND MDD 4 per day fluticasone propionate (inhalation)

PAGE 226 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

FLOVENT HFA 110 MCG/ACT AEROSOL PA BRAND fluticasone propionate hfa MDD 0.87 per day

OMNARIS 50 MCG/ACT SUSPENSION BRAND PA ciclesonide (nasal) QVAR 80 MCG/ACT AERO SOLN BRAND beclomethasone dipropionate VERAMYST 27.5 MCG/SPRAY SUSPENSION BRAND PA fluticasone furoate ANTIHISTAMINES

arbinoxa 4 mg tab generic C Non-Formulary Drug

arbinoxa 4 mg/5ml solution generic C Non-Formulary Drug

BROMPHENIRAMINE TANNATE 12 MG CHEW TAB BRAND C Non-Formulary Drug brompheniramine tannate

carbinoxamine maleate 4 mg tab generic C Non-Formulary Drug

carbinoxamine maleate 4 mg/5ml solution generic C Non-Formulary Drug

CLARINEX 0.5 MG/ML SYRUP BRAND C Non-Formulary Drug desloratadine

clemastine fumarate 0.67 mg/5ml syrup generic C Non-Formulary Drug

clemastine fumarate 2.68 mg tab generic C Non-Formulary Drug

cyproheptadine hcl 4 mg tab generic PA

cyproheptadine hcl 4 mg tabs generic PA

MDD 1 per day desloratadine 2.5 mg tab disp generic C Non-Formulary Drug

MDD 1 per day desloratadine 5 mg tab generic C Non-Formulary Drug

MDD 1 per day desloratadine 5 mg tab disp generic C Non-Formulary Drug

DEXCHLORPHENIRAMINE MALEATE 2 MG/5ML SYRUP BRAND C Non-Formulary Drug dexchlorpheniramine maleate

diphenhydramine hcl cap 25 mg generic C Non-Formulary Drug

PAGE 227 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

diphenhydramine hcl cap 50 mg generic PA

hydroxyzine hcl 10 mg/5ml solution generic hydroxyzine hcl 10 mg/5ml syrup generic hydroxyzine hcl 50 mg tab generic hydroxyzine pamoate 25 mg cap generic hydroxyzine pamoate 50 mg cap generic

levocetirizine dihydrochloride 2.5 mg/5ml solution generic C Non-Formulary Drug

levocetirizine dihydrochloride 5 mg tab generic C Non-Formulary Drug

olopatadine hcl 0.6 % solution generic PA

diphenhydramine hcl cap 50 mg generic PA

promethazine hcl 12.5 mg tab generic

promethazine hcl 25 mg tab generic PA

RESPA-BR 11 MG TAB ER 12H PA BRAND brompheniramine maleate C Non-Formulary Drug

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA 17 MCG/ACT AERO SOLN BRAND ipratropium bromide hfa ipratropium bromide 0.02 % solution generic ipratropium bromide 0.03 % solution generic SEEBRI NEOHALER 15.6 MCG CAP BRAND PA glycopyrrolate (inhalation) BRONCHODILATORS, SYMPATHOMIMETIC

ADRENACLICK 0.15 MG/0.15ML SOLN A-INJ BRAND epinephrine (anaphylaxis)

ADRENALIN 0.1 % SOLUTION PA BRAND epinephrine hcl (nasal) C Non-Formulary Drug

albuterol sulfate (2.5 mg/3ml) 0.083% nebu soln generic

albuterol sulfate (5 mg/ml) 0.5% nebu soln generic PA

PAGE 228 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS albuterol sulfate 0.63 mg/3ml nebu soln generic

albuterol sulfate 1.25 mg/3ml nebu soln generic PA

albuterol sulfate 2 mg/5ml syrup generic PA

albuterol sulfate 4 mg tab generic ARCAPTA NEOHALER 75 MCG CAP BRAND C Non-Formulary Drug indacaterol maleate AUVI-Q 0.15 MG/0.15ML SOLN A-INJ BRAND epinephrine (anaphylaxis) EPINEPHRINE 0.15 MG/0.15ML SOLN A-INJ BRAND epinephrine (anaphylaxis)

FORADIL AEROLIZER 12 MCG CAP PA BRAND formoterol fumarate MDD 2 per day

levalbuterol hcl 0.31 mg/3ml nebu soln generic PA

levalbuterol hcl 1.25 mg/0.5ml nebu soln generic PA

metaproterenol sulfate 20 mg tab generic PA

PERFOROMIST 20 MCG/2ML NEBU SOLN BRAND PA formoterol fumarate

PROAIR HFA 108 (90 BASE) MCG/ACT AERO SOLN PA BRAND albuterol sulfate MDD 1.5 per day

PROAIR RESPICLICK 108 (90 BASE) MCG/ACT AER POW BA BRAND PA albuterol sulfate

PROVENTIL HFA 108 (90 BASE) MCG/ACT AERO SOLN PA BRAND albuterol sulfate MDD 1.5 per day

terbutaline sulfate 2.5 mg tab generic PA

VENTOLIN HFA 108 (90 BASE) MCG/ACT AERO SOLN PA BRAND albuterol sulfate MDD 1.5 per day

CYSTIC FIBROSIS AGENTS

BETHKIS 300 MG/4ML NEBU SOLN BRAND C Non-Formulary Drug tobramycin CAYSTON 75 MG RECON SOLN BRAND C Non-Formulary Drug aztreonam lysine

PAGE 229 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS KALYDECO 150 MG TAB BRAND C Non-Formulary Drug ivacaftor KALYDECO 50 MG PACKET BRAND C Non-Formulary Drug ivacaftor KALYDECO 75 MG PACKET BRAND C Non-Formulary Drug ivacaftor ORKAMBI 200-125 MG TAB BRAND C Non-Formulary Drug lumacaftor-ivacaftor TOBI PODHALER 28 MG CAP BRAND C Non-Formulary Drug tobramycin

tobramycin 300 mg/5ml nebu soln generic C Non-Formulary Drug

tobramycin pak 300 mg/5ml nebu soln generic C Non-Formulary Drug

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine citrate 20 mg/ml solution generic C Non-Formulary Drug

caffeine citrate 60 mg/3ml solution generic C Non-Formulary Drug

DALIRESP 500 MCG TAB BRAND C Non-Formulary Drug roflumilast DILEX-G 400 200-400 MG TAB BRAND PA dyphylline-guaifenesin LUFYLLIN 200 MG TAB BRAND PA dyphylline LUFYLLIN 400 MG TAB BRAND dyphylline PULMONARY ANTIHYPERTENSIVES

ADEMPAS 2.5 MG TAB BRAND PA riociguat LETAIRIS 5 MG TAB BRAND PA ambrisentan OPSUMIT 10 MG TAB BRAND macitentan ORENITRAM 1 MG TAB ER BRAND treprostinil diolamine TRACLEER 62.5 MG TAB BRAND bosentan UPTRAVI 1000 MCG TAB BRAND PA selexipag

PAGE 230 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS UPTRAVI 1200 MCG TAB BRAND PA selexipag UPTRAVI 1400 MCG TAB BRAND PA selexipag UPTRAVI 1600 MCG TAB BRAND PA selexipag UPTRAVI 200 & 800 MCG TAB THPK BRAND PA selexipag UPTRAVI 200 MCG TAB BRAND PA selexipag UPTRAVI 400 MCG TAB BRAND PA selexipag UPTRAVI 600 MCG TAB BRAND PA selexipag UPTRAVI 800 MCG TAB BRAND PA selexipag VENTAVIS 20 MCG/ML SOLUTION BRAND PA iloprost RESPIRATORY TRACT AGENTS, OTHER

ADVAIR HFA 115-21 MCG/ACT AEROSOL BRAND PA fluticasone-salmeterol ANORO ELLIPTA 62.5-25 MCG/INH AER POW BA BRAND PA umeclidinium-vilanterol

benzonatate 200 mg cap generic PA

biotuss 10-15-300 mg/5ml liquid generic PA

biotuss pediatric 2.5-5-50 mg/ml liquid generic BREO ELLIPTA 100-25 MCG/INH AER POW BA BRAND PA fluticasone furoate-vilanterol BREO ELLIPTA 200-25 MCG/INH AER POW BA BRAND PA fluticasone furoate-vilanterol

bromfed dm 30-2-10 mg/5ml syrup generic PA

CINQAIR 100 MG/10ML SOLUTION BRAND PA reslizumab CLARINEX-D 12 HOUR 2.5-120 MG TAB ER 12H BRAND PA desloratadine-pseudoephedrine

PAGE 231 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS CLARINEX-D 24 HOUR 5-240 MG TAB ER 24H BRAND desloratadine-pseudoephedrine

cromolyn sodium 20 mg/2ml nebu soln generic PA

DULERA 100-5 MCG/ACT AEROSOL BRAND C Non-Formulary Drug mometasone furoate-formoterol fumarate dihydrate DULERA 200-5 MCG/ACT AEROSOL BRAND C Non-Formulary Drug mometasone furoate-formoterol fumarate dihydrate DYMISTA 137-50 MCG/ACT SUSPENSION BRAND C Non-Formulary Drug azelastine hcl-fluticasone propionate ESBRIET 267 MG CAP BRAND C Non-Formulary Drug pirfenidone giltuss pediatric 2.5-5-50 mg/ml liqd generic guaifenesin er 600 mg tab er 12h generic guaifenex la 600 mg tab er 12h generic

hydrocod polst-cpm polst er 10-8 mg/5ml susp generic PA

hydrocodone-homatropine 5-1.5 mg tab generic J-TAN D SR 6-30 MG TAB ER 12H BRAND PA brompheniramine & phenyleph nebusal 3 % nebu soln generic NEBUSAL 6 % NEBU SOLN BRAND PA sodium chloride (inhalant) nohist-dm 10-4-15 mg/5ml liquid generic nortuss-de 2.5-5-50 mg/ml liquid generic NORTUSS-EX 20-200 MG/5ML LIQUID BRAND PA dextromethorphan-guaifenesin NUCALA 100 MG RECON SOLN BRAND PA mepolizumab OFEV 100 MG CAP BRAND C Non-Formulary Drug nintedanib esylate OFEV 150 MG CAP BRAND C Non-Formulary Drug nintedanib esylate

phenylephrine-chlorphen-dm 3.5-1-3 mg/ml liquid generic PA

promethazine vc 6.25-5 mg/5ml syrup generic PA

promethazine vc plain 6.25-5 mg/5ml solution generic PA

PAGE 232 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

promethazine vc/codeine 6.25-5-10 mg/5ml syrup generic PA

promethazine-phenyleph-codeine 6.25-5-10 mg/5ml syrup generic PA

promethazine-phenylephrine 6.25-5 mg/5ml syrup generic PA

pseudoeph-bromphen-dm 30-2-10 mg/5ml syrup generic PA

pulmosal 7 % nebu soln generic PULMOZYME 1 MG/ML SOLUTION BRAND C Non-Formulary Drug dornase alfa RESPAHIST-II 6-19 MG TAB ER 12H BRAND brompheniramine & phenyleph

rhinacon a 4-40-20 mg tbcr generic PA

ribavirin 6 gm recon soln generic C Non-Formulary Drug

rinate pediatric 4.5-5 mg/5ml susp generic PA

RYNATAN 9-25 MG TAB BRAND PA chlorpheniramine tannate-phenylephrine tannate

rynesa 12s 30-5 mg/5ml susp generic PA

SEMPREX-D 8-60 MG CAP BRAND PA acrivastine & pseudoephedrine

sodium chloride 0.9 % nebu soln generic PA

sodium chloride 3 % nebu soln generic sodium chloride 7 % nebu soln generic STIOLTO RESPIMAT 2.5-2.5 MCG/ACT AERO SOLN BRAND C Non-Formulary Drug tiotropium bromide-olodaterol hcl SYMBICORT 160-4.5 MCG/ACT AEROSOL BRAND budesonide-formoterol fumarate dihydrate SYMBICORT 80-4.5 MCG/ACT AEROSOL BRAND budesonide-formoterol fumarate dihydrate TUSSICAPS 10-8 MG CAP ER 12H BRAND hydrocodone polistirex-chlorpheniramine polistirex tussigon 5-1.5 mg tab generic

TYZINE 0.05 % SOLUTION PA BRAND tetrahydrozoline hcl C Non-Formulary Drug

PAGE 233 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS TYZINE 0.1 % SOLUTION BRAND C Non-Formulary Drug tetrahydrozoline hcl UTIBRON NEOHALER 27.5-15.6 MCG CAP BRAND PA indacaterol maleate-glycopyrrolate VITUZ 5-4 MG/5ML SOLUTION BRAND C Non-Formulary Drug hydrocodone-chlorpheniramine ZOTEX PEDIATRIC 2.5-3-35 MG/ML LIQUID BRAND PA phenylephrine w/ dm-gg SKELETAL MUSCLE RELAXANTS

AMRIX 15 MG CAP ER 24H BRAND C Non-Formulary Drug cyclobenzaprine hcl AMRIX 30 MG CAP ER 24H BRAND C Non-Formulary Drug cyclobenzaprine hcl

carisoprodol 250 mg tab generic C Non-Formulary Drug

carisoprodol 350 mg tab generic C Non-Formulary Drug

carisoprodol-aspirin 200-325 mg tab generic C Non-Formulary Drug

chlorzoxazone 500 mg tab generic C Non-Formulary Drug

cyclobenzaprine hcl 10 mg tab generic MDD 3 per day

LORZONE 375 MG TAB BRAND C Non-Formulary Drug chlorzoxazone LORZONE 750 MG TAB BRAND C Non-Formulary Drug chlorzoxazone metaxall 800 mg tab generic metaxalone 800 mg tab generic methocarbamol 750 mg tab generic SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

EDLUAR 10 MG SL TAB BRAND C Non-Formulary Drug zolpidem tartrate EDLUAR 5 MG SL TAB BRAND C Non-Formulary Drug zolpidem tartrate

estazolam 1 mg tab generic C Non-Formulary Drug

PAGE 234 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

estazolam 2 mg tab generic C Non-Formulary Drug

PA eszopiclone 2 mg tab generic MDD 2 per day

PA eszopiclone 3 mg tab generic MDD 2 per day

quazepam 15 mg tab generic C Non-Formulary Drug

temazepam 15 mg cap generic temazepam 22.5 mg cap generic temazepam 30 mg cap generic temazepam 7.5 mg cap generic

triazolam 0.125 mg tab generic C Non-Formulary Drug

triazolam 0.25 mg tab generic C Non-Formulary Drug

zolpidem tartrate 5 mg tab generic MDD 1 per day

SLEEP DISORDERS, OTHER

PA armodafinil 150 mg tab generic MDD 1 per day

PA armodafinil 250 mg tab generic MDD 1 per day

PA armodafinil 50 mg tab generic MDD 2 per day

BELSOMRA 10 MG TAB BRAND PA suvorexant BELSOMRA 15 MG TAB BRAND PA suvorexant BELSOMRA 20 MG TAB BRAND PA suvorexant BELSOMRA 5 MG TAB BRAND PA suvorexant BUTISOL SODIUM 30 MG TAB BRAND C Non-Formulary Drug butabarbital sodium

PAGE 235 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS BUTISOL SODIUM 30 MG/5ML ELIXIR BRAND C Non-Formulary Drug butabarbital sodium BUTISOL SODIUM 50 MG TAB BRAND C Non-Formulary Drug butabarbital sodium

flurazepam hcl 15 mg cap generic C Non-Formulary Drug

flurazepam hcl 30 mg cap generic C Non-Formulary Drug

HETLIOZ 20 MG CAP BRAND C Non-Formulary Drug tasimelteon SECONAL 100 MG CAP BRAND C Non-Formulary Drug secobarbital sodium XYREM 500 MG/ML SOLUTION BRAND C Non-Formulary Drug sodium oxybate THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

ELECTROLYTE/MINERAL MODIFIERS

kionex 15 gm/60ml suspension generic PA

sodium polystyrene sulfonate 15 gm/60ml suspension generic PA

sps 15 gm/60ml suspension generic PA

SYPRINE 250 MG CAP BRAND trientine hcl ELECTROLYTE/MINERAL REPLACEMENT

airavite 2.5-25-1 mg tab generic PA

av-vite fb 2.5-25-1 mg tab generic PA

durlaza 162.5 mg cap er 24h generic C Non-Formulary Drug

fa-cyanocobalamin-pyridoxine 2.5-1-25 mg tab generic PA

fa-vitamin b-6-vitamin b-12 2.2-25-0.5 mg tab generic PA

fabb 2.2-25-1 mg tab generic PA

folbee 2.5-25-1 mg tab generic PA

folplex 2.2 2.2-25-0.5 mg tab generic PA

PAGE 236 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS

klor-con 10 10 meq tab er generic PA

klor-con 8 meq tab er generic

klor-con m20 20 meq tab er generic PA

nufol 2.5-25-1 mg tab generic PA

potassium chloride crys er 10 meq tab er generic PA

potassium chloride crys er 20 meq tab er generic PA

potassium chloride er 10 meq tab er generic PA

potassium chloride er 20 meq tab er generic potassium chloride er 8 meq tab er generic potassium chloride er 8 meq tab er generic

tl gard rx 2.2-25-1 mg tab generic PA

virt-gard 2.2-25-1 mg tab generic PA

virt-vite 2.5-25-1 mg tab generic PA

b-plex tab generic PA

b-plex plus tab generic biocel tab generic choice-tabs tab generic corvite free tab generic

levocarnitine 1 gm/10ml solution generic PA

levocarnitine 330 mg tab generic lysiplex plus tab generic multi-b-plus tab generic nutrifac zx tab generic

PAGE 237 LAST UPDATED 02/2018 BRAND/GENE PRODUCT DESCRIPTION RIC LIMITS & RESTRICTIONS strovite plus tab generic

therobec 500-0.5mg tab generic PA

vit b3-azelac-turm-fa-b6-zn-cu tab generic vita s forte tab generic vitacel tab generic

PAGE 238 LAST UPDATED 02/2018 Index of covered drugs Aldex-CT 80 A Alendronate Sodium 218 Abacavir Sulfate 162 Alendronate Sodium-Cholecalciferol 218 Abacavir Sulfate-Lamivudine-Zidovudine 162 Alinia 154 Abiraterone Acetate 151 Alirocumab 184 Abstral 125 Aliskiren Fumarate 180 Acarbose 165 Aliskiren-Amlodipine 180 Accu-Chek Compact Plus Care 219 Aliskiren-Amlodipine-Hydrochlorothiazide 178 Acetaminophen 17,49,50,51,52,53,54,55,56,57,59,60,6 Alka-Seltzer Extra Strength 3 1,62,63,64,65 AlleRx DF 219 Acetaminophen w/ Calcium Carbonate 57 AlleRx DF30 219 Acetaminophen w/ Codeine 125 Almotriptan Malate 149 Acetaminophen w/ DM 83 Alocril 222 Acetaminophen w/ Pamabrom 57,66 Aloe Grande 19 Acetaminophen-Caff-Dihydrocod 128 Alomide 222 Acetaminophen-Caffeine 53,55,62,64,65 Alosetron HCl 196 Acetaminophen-Caffeine- Alphagan P 223 Pyrilamine 53,54,55,57,61,62,65 Alprazolam 164 Acetic Acid 130 Alprostadil (Vasodilator) 198 Acetic Acid (Otic) 225 Alrex 223 Acetohydroxamic Acid 198 Altoprev 182 AcipHex Sprinkle 196 Alum & Mag Hydrox-Simethicone 35,37 Acne Medication 5 19 Aluminum Acetate (Burow's) 19 Acrivastine & Pseudoephedrine 233 Aluminum Hydroxide-Mag Carb 35,36 Acuvail 223 Aluminum Oxide 21 Acyclovir 163,164 Aluminum Sulfate (Topical Astringent) 33 Acyclovir Topical 163 Alvesco 226 Adasuve 156 Amantadine HCl 154 Adempas 230 Ambenonium Chloride 150 Admelog 167 Ambrisentan 230 Adrenaclick 228 Amcinonide 199 Adrenalin 228 Amiloride & Hydrochlorothiazide 177 Advair HFA 231 Aminocaproic Acid 169 Advanced Care Cholesterol 49 Amiodarone HCl 172 Advicor 183,184 Amitriptyline HCl 145 Afatinib Dimaleate 152 Amlodipine Besylate 174 Afinitor 152 Amlodipine Besylate-Atorvastatin Calcium 177 Akne-Mycin 133 Amlodipine Besylate-Benazepril HCl 177 Akten 220 Amlodipine Besylate-Olmesartan Medoxomil 177,178 Albuterol Sulfate 228,229 Amlodipine Besylate-Valsartan 177 Alcaftadine 221 Amlodipine-Valsartan-Hydrochlorothiazide 178

PAGE 239 LAST UPDATED 02/2018 Amoxapine 145 Arnica 19 Amoxicillin 133 Artemether-Lumefantrine 154 Amoxicillin & Pot Clavulanate 133 Artificial Saliva 17,18,189 Amoxicillin ER 133 Artificial Tear Solution 66,67,68,69,70 Amphetamine-Dextroamphetamine 186 Ascriptin MS 3 Ampicillin 133 Asenapine Maleate 159 Amrix 234 Asmanex 120 Metered Doses 226 Amturnide 178 Asmanex 14 Metered Doses 226 Anadrol-50 202 Asmanex 30 Metered Doses 226 Anagrelide HCl 169 Asmanex 60 Metered Doses 226 Analpram-HC 189 Aspirin 3,4,5,6,7,8 Androderm 202 Aspirin (Platelet Aggregation Inhibitor) 236 AndroGel 203 Aspirin Buffered (Al Hydrox-Mg Hydrox-Ca Carb) 3 AndroGel Pump 203 Aspirin Effervescent 3,4,5,6,7,8 Androxy 203 Aspirin-Acetaminophen-Caffeine 6 Angeliq 203 Aspirin-Acetaminophen-Caffeine (Buffered) 8 Anoro Ellipta 231 Aspirin-Caffeine 4,7 Antipyrine-Benzocaine 225 Aspirin-Caffeine-Dihydrocodeine Bitartrate 125 Antipyrine-Benzocaine-Polycosanol 226 Aspirin-Salicylamide-Caffeine 4 Antiseborrheic Products, Misc. 24,30 Assure 3 Meter 219 Anzemet 147 At Last Blood Glucose System 219 Aplenzin 141 Atazanavir Sulfate 163 Apraclonidine HCl 223,224 Atazanavir Sulfate-Cobicistat 163 Aprepitant 147 Atenolol 173 Aptiom 139 Atenolol & Chlorthalidone 178 Aptivus 163 Atomoxetine HCl 186 Aquafresh 50 Atorvastatin Calcium 182 Aquafresh Advanced 50 Atovaquone-Proguanil HCl 154 Aquafresh Cavity Protection 50 Atropine Sulfate (Ophthalmic) 220 Aquafresh Extreme Clean 50 Atrovent HFA 228 Aquafresh for Kids 50 Augmentin 133 Aquafresh Sensitive 50 Auranofin 218 Aquafresh Tartar Control 50 Auvi-Q 229 Aquafresh Whitening 50 Avanafil 199 Aquoral 189 Avandamet 165 Aranesp (Albumin Free) 169 Avandaryl 165 Arcapta Neohaler 229 Avandia 165 Arestin 189 AVC Vaginal 135 Aripiprazole 157 AzaSite 133 Armodafinil 235 Azelaic Acid 190 Armour Thyroid 214 Azelaic Acid (Acne) 189

PAGE 240 LAST UPDATED 02/2018 Azelastine HCl (Ophth) 222 Benzonatate 231 Azelastine HCl-Fluticasone Propionate 232 Benzoyl Azelex 189 Peroxide 18,19,20,21,22,23,28,30,32,189,190,191 Azilsartan Medoxomil 170 Benzoyl Peroxide-Erythromycin 190 Azilsartan Medoxomil-Chlorthalidone 179 Benzphetamine HCl 187 Azithromycin 134 Benztropine Mesylate 154 Azithromycin (Ophth) 133 Benzyl Alcohol (Anesthetic) 18 Azo Test 51 Betadine Spray 51 Azolen Tincture 12 Betamethasone Dipropionate (Topical) 199 Azopt 223 Betamethasone Dipropionate Augmented 199 Azostix 51 Betamethasone Valerate 199,200 Aztreonam Lysine 229 Betaxolol HCl 173 Betaxolol HCl (Ophth) 224 B Bethanechol Chloride 198 B-Complex w/ C & Folic Bethkis 229 Acid 105,107,108,110,114,116,117,118,237,238 Betimol 224 B-Complex w/ C-Biotin-Vit E & Folic Acid 105 Betoptic-S 224 Baby Orajel Tooth/Gum Cleanser 51 Bexarotene 153 Bacitracin Zinc 20,22,25,26,28,31,33 Bexarotene (Topical) 153 Baclofen 160 Bifera 103 Bactroban Nasal 130 Bimatoprost 225 Balnetar 20 Bio-Statin 147 Balsalazide Disodium 218 Biotene Dry Mouth 51 Bama Freeze 20 Biotene Dry Mouth Gentle 51 Banzel 139 Biotene Dry Mouth Moisturizing 17 Baraclude 160 Biotene Moisturizing Mouth 17 Barium Sulfate 219,220 Biotene PBF Dry Mouth 51 BC Fast Pain Relief Arthritis 4 Bisacodyl 42,43,44,45,46 Beclomethasone Diprop Monohyd 226 Blephamide 220 Beclomethasone Dipropionate 227 Blephamide S.O.P. 220 Beconase AQ 226 Blood Glucose Monitoring Supplies 219,220 Belladonna Alkaloids & Opium 125 Bosentan 230 Belsomra 235 Bosulif 152 Benadryl Itch Relief 20 Bosutinib 152 Benazepril & Hydrochlorothiazide 178 BP Cleansing 20 Benazepril HCl 171 Brasivol 21 Bentoquatam 28 Breo Ellipta 231 Benzocaine (Dental) 9 Brewers Yeast 105 Benzocaine (Mouth-Throat) 18 Brexpiprazole 158 Benzocaine (Topical) 21,30 Brilinta 169 Benzocaine-Menthol (Mouth-Throat) 17 Brimonidine Tartrate 223,224

PAGE 241 LAST UPDATED 02/2018 Brintellix 142,143 Cal-Glu 103 Brinzolamide 223 Calcipotriene 190 Brinzolamide-Brimonidine Tartrate 224 Calcipotriene-Betamethasone Dipropionate 192 Brohist D 80 Calcium & Phosphorus 104 Bromfenac Sodium (Ophth) 223 Calcium Carbonate-Mag Hydrox 35,36,37,38 Bromocriptine Mesylate 155 Calcium Citrate 103 Brompheniramine & Calcium Gluconate 103 Phenyleph80,81,82,84,87,89,90,93,94,96,97,99,101,23 Calcium Lactate 103 2,233 Calcium Polycarbophil 42,43,44,45,46 Brompheniramine & Pseudoeph 90 Camphor-Menthol-Methyl Salicylate 26 Brompheniramine Maleate 76,228 Canagliflozin 166 Brompheniramine Tannate 227 Candesartan Cilexetil 170 Brovex PSE DM 80 Candesartan Cilexetil-Hydrochlorothiazide 178 Budesonide 218 Capecitabine 151 Budesonide (Inhalation) 226 Caphosol 189 Budesonide-Formoterol Fumarate Dihydrate 233 Capsagel Extra Strength 21 Bug Itch ReLeaf 51 Capsaicin 21 Bumetanide 181 Capsaicin-Menthol-Methyl Salicylate 30 BUN Test 51 Captopril 171 Buprenorphine HCl 129 Captopril & Hydrochlorothiazide 178 Buprenorphine HCl-Naloxone HCl Dihydrate 129 Carbachol (Ophth) 224 Bupropion HCl 141,142 Carbamazepine 139,140 Bupropion Hydrobromide 141 Carbamide Peroxide (Otic) 71,72 Buspirone HCl 164 Carbidopa 155 Busulfan 151 Carbidopa-Levodopa 155 Butabarbital Sodium 235,236 Carbidopa-Levodopa-Entacapone 155 Butalbital-Acetaminophen 188 Carbinoxamine Maleate 227 Butalbital-Acetaminophen-Caffeine 187,188 Carboxymethylcellulose Sodium (Ophth) 66,67,69,70 Butalbital-Acetaminophen-Caffeine w/ Codeine 126 Cardene SR 174 Butalbital-Aspirin-Caffeine w/Cod 125,126 Cariprazine HCl 159 Butamben-Tetracaine-Benzocaine 190 Carisoprodol 234 Butenafine HCl 12 Carisoprodol w/ Aspirin 234 Butisol Sodium 235,236 Carisoprodol w/ Aspirin & Codeine 126 Bydureon 165 Carmol-HC 200 Byvalson 178 Carteolol HCl (Ophth) 224 Carvedilol 173 C Castellani Paint 21 Ca-Rezz 51 Cayston 229 Cabergoline 217 Cedax 131,132 Cabozantinib S-Malate 152 Cefaclor 132 Caffeine Citrate 230 Cefaclor Monohydrate 132

PAGE 242 LAST UPDATED 02/2018 Cefadroxil 132 Choline Bitartrate 106 Cefdinir 132 Cialis 197,198 Cefditoren Pivoxil 132 Ciclesonide 226 Cefixime 132,133 Ciclesonide (Nasal) 227 Cefpodoxime Proxetil 132 Ciclopirox 147 Cefprozil 132 Ciloxan 134 Ceftibuten 131,132 Cimetidine 38,39,40,41,195 Cefuroxime Axetil 132 Cinacalcet HCl 217 Celecoxib 120 Cinqair 231 Cenestin 204 Cipro HC 225 Cephalexin 132,133 Ciprodex 225 Cervidil 198 Ciprofloxacin 134 Cetacaine 190 Ciprofloxacin HCl (Ophth) 134 Cetirizine HCl 72,73,74,77,78,79 Ciprofloxacin HCl (Otic) 135 Cetylpyridinium Chloride (Mouthwash) 17 Ciprofloxacin-Ciprofloxacin HCl 135 Charcoal Activated 49,51 Ciprofloxacin-Dexamethasone 225 Charcoal Activated-Sorbitol 49,56 Ciprofloxacin-Hydrocortisone 225 Charcoal Plus DS 51 Citalopram Hydrobromide 143 Chiggerex 21 Citric Acid-Gluconolactone-Magnesium Carbonate 199 Chlordiazepoxide-Amitriptyline 142 Clarinex 227 Chloroquine Phosphate 154 Clarinex-D 12 Hour 231 Chlorothiazide 182 Clarinex-D 24 Hour 232 Chlorphen-Phenyltolox-PE 233 Clarithromycin 134 Chlorpheniramine & Phenylephrine 92 Clean & Clear Advantage 3-in-1 21 Chlorpheniramine & Pseudoeph 80,83,95,97,98,101 Clemastine Fumarate 73,74,75,76,78,79,227 Chlorpheniramine Maleate 73,75 Cleocin 130 Chlorpheniramine Tannate-Phenylephrine Tannate 233 Climara Pro 205 Chlorpheniramine w/ Codeine 84 Clindamycin HCl 130 Chlorpheniramine-DM 82,85,90,94,96 Clindamycin Palmitate Hydrochloride 130 Chlorpheniramine-Methscopolamine 219 Clindamycin Phosphate (Topical) 130 Chlorpheniramine-Phenylephrine- Clindamycin Phosphate Vaginal 130 Acetaminophen 80,81,83,84,85,87,88,90,92,93,94,96,9 Clioquinol-Hydrocortisone & Emollient 190 7,100 Clobazam 138 Chlorpromazine HCl 156 Clobetasol Propionate 200 Chlorpropamide 165 Clobetasol Propionate & Cleanser 200 Chlorthalidone 182 Clodan 200 Chlorzoxazone 234 Clomiphene Citrate 214 Choice DM Diabetes Risk Test 219 Clomipramine HCl 145 Cholesterol Test 49 Clonazepam 164 Cholestyramine 184 Clonidine & Chlorthalidone 178 Cholestyramine Light 184 Clonidine HCl 170

PAGE 243 LAST UPDATED 02/2018 Clopidogrel Bisulfate 170 Curasore 17 Clorazepate Dipotassium 164 Curity Povidone-Iodine Paint 52 Clorpres 178 CVS Dry Mouth 17 Clotrimazole 147,148 CVS Epsom Salt 52 Clotrimazole (Topical) 12,13,14,15,147,148 CVS Lubricant Drops 67 Clotrimazole Vaginal 12,14,15 Cyanocobalamin 105,107,115,116,117,119 Clotrimazole w/ Betamethasone 190 Cyclobenzaprine HCl 234 Clozapine 159 Cyclomydril 221 Coal Tar Extract 20,25,27,30 Cyclopentolate HCl 221 Coartem 154 Cyclopentolate w/ Phenylephrine 221 Cobicistat 162 Cyclophosphamide 151 Coca Cola 11 Cyclosporine 217 Cocoa Butter Petroleum Jelly 21 Cyproheptadine HCl 227 Codeine Sulfate 126 Cystaran 221 Codituss DM 81 Cysteamine HCl 221 Coditussin AC 81 Colchicine 149 D Colesevelam HCl 185 Dabigatran Etexilate Mesylate 169 Colestipol HCl 184 Daclatasvir Dihydrochloride 160 Colgate Platinum 52 Daklinza 160 Cometriq (100 mg Daily Dose) 152 Daliresp 230 Complera 161 Dalteparin Sodium 168 Conjugated Estrogens-Bazedoxifene 205 Danazol 203 Conjugated Estrogens-Medroxyprogesterone Dantrolene Sodium 160 Acetate 210 Dapagliflozin Propanediol 166 Contour Next One 219 Daraprim 154 CopaSil 190 Darbepoetin Alfa 169 Cordran 200 Darifenacin Hydrobromide 197 Corlanor 178 Darunavir Ethanolate 163 Creon 193 Dasatinib 153 Crest 52 Daytime Cold Medicine 83 Crest Tartar Control 52 Daytrana 186 Crest TC/Baking Soda 52 Debacterol 189 Cresyl Acetate 225 Delavirdine Mesylate 162 Cresylate 225 Delzicol 218 Crinone 212 Demarest Plus 24 Crizotinib 153 Demeclocycline HCl 136 Crofelemer 195 Demser 178 Cromolyn Sodium 232 Dentifrices 50,51,52,60,61,62,63,65,66,220 Cromolyn Sodium (Ophth) 222 Dermasorb AF 190 Crotamiton 154 DermaZinc Baby 24

PAGE 244 LAST UPDATED 02/2018 DermaZinc Scalp 24 Dextromethorphan-Phenylephrine- Descovy 162 Acetaminophen 79,80,81,82,83,85,86,87,88,89,91,93,9 Desipramine HCl 145 4,95,96,97,98,99,100,101 Desloratadine 227 Dextrose (Diabetic Use) 16 Desloratadine-Pseudoephedrine 231,232 Di-Delamine 24 Desmopressin Acetate 202 Diabetic Tussin Cold/Flu 84 Desmopressin Acetate Spray Refrigerated 202 Diazepam 164 Desogestrel & Ethinyl Estradiol 203,205,206,207,211 Diazepam (Anticonvulsant) 138 Desogestrel-Ethinyl Estradiol Diazoxide 167 (Biphasic) 204,205,207,210,212 Diclegis 146 Desogestrel-Ethinyl Estradiol (Triphasic) 204,212 Diclofenac 121 Desonide 200 Diclofenac Epolamine 120 Desoximetasone 200,202 Diclofenac Potassium 120,121 Desvenlafaxine Fumarate 143 Diclofenac Sodium 120 Desvenlafaxine Fumarate ER 143 Diclofenac Sodium (Topical) 120,121 Desvenlafaxine Succinate 143 Diclofenac w/ Misoprostol 120 Dex-Tuss 84 Dicloxacillin Sodium 133 Dexamethasone 199,200,202 Dicyclomine HCl 194 Dexamethasone (Ophth) 223 Didanosine 162 Dexamethasone Sodium Phosphate (Ophth) 223 Diethylpropion HCl 187 Dexchlorpheniramine Maleate 227 Dificid 134 Dexilant 196 Digoxin 179 Dexlansoprazole 196 Dihydroergotamine Mesylate 149 Dexmethylphenidate HCl 186 Dilatrate-SR 185 DexPak 6 Day 200 Dilex-G 400 230 Dexpanthenol (Topical) 30 Diltiazem HCl 174 Dextroamphetamine Sulfate 186 Diltiazem HCl Coated Beads 174,175 Dextromethorphan Diltiazem HCl Extended Release Beads 174 HBr 82,83,87,89,94,95,96,97,100,101 Dimethyl Fumarate 188 Dextromethorphan HBr-Quinidine Sulfate 188 Dimethyl Sulfoxide 199 Dextromethorphan Polistirex 82,84,85,87,88,89,95,96 Dinoprostone 198 Dextromethorphan-Acetaminophen- Diphenhydramine & Pseudoephed 100 Chlorpheniramine 84 Diphenhydramine Dextromethorphan-Doxylamine- HCl 72,73,74,75,76,77,78,79,227,228 Acetaminophen 80,81,83,84,85,86,88,89,90,92,93,94,9 Diphenhydramine HCl (Topical) 19,22,27,33 5,96,97,98,99,100 Diphenhydramine HCl-Phenylephrine HCl Tannate 80 Dextromethorphan- Diphenhydramine-Acetaminophen 79,92,99 Guaifenesin 81,82,83,84,85,86,88,89,90,91,92,93,95,9 Diphenhydramine-Acetaminophen (sleep) 102 6,98,99,232 Diphenhydramine-Menthol 24 Diphenhydramine- Phenylephrine 82,83,84,85,88,92,93,94,96,99,100

PAGE 245 LAST UPDATED 02/2018 Diphenhydramine-Pseudoephedrine- Dutasteride 198 Acetaminophen 84,85,96,97 Dymista 232 Diphenhydramine-Tripelenamine 24 Dyphylline 230 Diphenhydramine-Zinc Dyphylline-Guaifenesin 230 Acetate 19,20,23,24,25,26,27,31,33,34 Dyrenium 181 Diphenoxylate w/ Atropine 195 Dipyridamole 170 E Disopyramide Phosphate 172 E-Z-HD 219 Disulfiram 129 EasyGluco 219 Diuril 182 Echothiophate Iodide 224 Divalproex Sodium 138 Econazole Nitrate 148 Divigel 205 Ecoza 148 Docusate Sodium 42,44,45,46 Ed ChlorPed 75 Dofetilide 172 Edarbi 170 Dolasetron Mesylate 147 Edarbyclor 179 Dolutegravir Sodium 161 Edluar 234 Donatussin DM 84 Efinaconazole 148 Donepezil Hydrochloride 140 Eflornithine HCl 193 Dornase Alfa 233 Elbasvir-Grazoprevir 161 Doxazosin Mesylate 170 Eldertonic 107 Doxepin HCl 146 Eletriptan Hydrobromide 149 Doxycycline 136 Elidel 190 Doxycycline (Monohydrate) 135,136,137 ElixSure Congestion 53 Doxycycline (Rosacea) 136,137 Ellis Tonic 107 Doxycycline Calcium 137 Elta Tar 25 Doxycycline Hyclate 136,137 Eltrombopag Olamine 169 Doxylamine Succinate (Sleep) 101,102 Eluxadoline 196 Doxylamine-Pyridoxine 146 Elvitegravir-Cobicistat-Emtricitabine-Tenofovir Dronabinol 147 Alafenamide 161 Dronedarone HCl 172 Elvitegravir-Cobicistat-Emtricitabine-Tenofovir DF 161 Drospirenone-Estradiol 203 Emadine 222 Drospirenone-Ethinyl Embeda 122 Estradiol 205,207,208,209,210,211,212 Emedastine Difumarate 222 Droxia 151 Emollient 20,21,22,23,24,25,26,28,29,31,32,33,34,190 Droxidopa 179 Empagliflozin-Metformin HCl 167 Dry Mouth Spray 17 Emsam 142 Duavee 205 Emtricitabine 162 Duexis 120 Emtricitabine-Rilpivirine-Tenofovir Alafenamide Dulera 232 Fumarate 162 Duofer 103 Emtricitabine-Rilpivirine-Tenofovir Disoproxil Duraflex Comfort 24 Fumarate 161

PAGE 246 LAST UPDATED 02/2018 Emtricitabine-Tenofovir Alafenamide Fumarate 162 Estradiol Vaginal 206 Emtricitabine-Tenofovir Disoproxil Fumarate 162 Estradiol Valerate-Dienogest 209 Emtriva 162 Estradiol-Levonorgestrel 205 Enalapril Maleate 171 Estrasorb 206 Enalapril Maleate & Hydrochlorothiazide 179 Estrogens, Conjugated 210 Enjuvia 206 Estrogens, Conjugated Synthetic A 204 Entecavir 160 Estrogens, Conjugated Synthetic B 206 Entresto 179 Estropipate 206,207 Ephedrine-Guaifenesin 80,96 Eszopiclone 235 Epinastine HCl (Ophth) 222 Ethacrynic Acid 181 EPINEPHrine 229 Ethionamide 150 Epinephrine (Anaphylaxis) 228,229 Ethosuximide 138 Epinephrine (Base) 79 Ethotoin 140 Epinephrine HCl (Nasal) 228 Ethyl Alcohol (Skin Cleanser) 31 Epivir HBV 160 Ethynodiol Diacet & Eth Estrad 207,212 Eplerenone 182 Etodolac 120 Eprosartan Mesylate 170 Etonogestrel-Ethinyl Estradiol 210 Epsom Salt 53 Eurax 154 EQL Dry Mouth Oral Rinse 18 Evamist 207 EQL Epsom Salt 54 EvenCare Glucose Monitoring 219 Equagesic 120 Everolimus 152 Ergotamine w/ Caffeine 149 Evolocumab 184 Erlotinib HCl 153 Evotaz 163 Ertaczo 148 Exelon 140 Ery-Tab 134 Exemestane 152 EryPed 400 134 Exenatide 165 Erythromycin (Acne Aid) 133,134 Ezetimibe-Simvastatin 184 Erythromycin (Ophth) 134 Ezogabine 137 Erythromycin Base 134 Erythromycin Base (Coated) 134 F Erythromycin Ethylsuccinate 134 Factive 135 Erythromycin-Sulfisoxazole 130 Famciclovir 163 Esbriet 232 Famotidine 38,39,40,41 Esgic-Plus 187 Famotidine-Calcium Carbonate-Magnesium Eslicarbazepine Acetate 139 Hydroxide 38,39,40,41 Esocor P 86 Fanapt 157 Esomeprazole Magnesium 47,196,197 Fanapt Titration Pack 157 Esomeprazole Strontium 197 Fareston 151 Estazolam 234,235 Farxiga 166 Esterified Estrogens & Methyltestosterone 205,206 Farydak 152 Estradiol 205,206,207 Febuxostat 149

PAGE 247 LAST UPDATED 02/2018 Felbamate 139 Fluorometholone (Ophth) 223 Felodipine 175 Fluorouracil (Topical) 190 Fenofibrate 182 Fluoxetine HCl 143 Fenofibrate Micronized 182 Fluoxetine HCl (PMDD) 143,144 Fenoprofen Calcium 120 Fluoxymesterone 203 Fentanyl 122 Fluphenazine HCl 156 Fentanyl Citrate 125,126,127 Flurandrenolide 200,201 Fentora 126 Flurazepam HCl 236 Feosol Bifera 103 Flutamide 151 Ferrous Sulfate 103,104 Fluticasone Furoate 72,227 Fesoterodine Fumarate 197 Fluticasone Furoate-Vilanterol 231 Feverall 54 Fluticasone Propionate 200 FeverAll Infants 54 Fluticasone Propionate (Inhalation) 226 Fexofenadine HCl 73,74,75,76,77,78,79 Fluticasone Propionate HFA 227 Fexofenadine- Fluticasone-Salmeterol 231 Pseudoephedrine 82,86,87,94,99,100,101 Fluvastatin Sodium 183 Fidaxomicin 134 Fluvoxamine Maleate 143 Filgrastim-sndz 169 FML 223 Finacea 190 FML Forte 223 Finasteride (Alopecia) 190 Folic Acid 106,108,109,110,114,115,116,117,119 Firazyr 217 Folic Acid-Vitamin B6-Vitamin B12 103,236,237 First-Progesterone VGS 100 213 Fondaparinux Sodium 168 First-Progesterone VGS 200 213 FORA V10/V12/D10/D20 Test 219 First-Progesterone VGS 25 213 Foradil Aerolizer 229 First-Progesterone VGS 400 213 Formaldehyde 219 First-Vancomycin 25 130 Formoterol Fumarate 229 Flagyl ER 130 Forteo 218 Flector 120 Fosamax Plus D 218 Flexall Ultra Plus 26 Fosamprenavir Calcium 163 Flo-Pred 200 Fragmin 168 Flonase Sensimist 72 FreeStyle Flash System 219 Florical 103 FreeStyle System 219 Flovent Diskus 226 Frovatriptan Succinate 149 Flovent HFA 227 Fulyzaq 195 Fluconazole 148 Fungi-Nail 26 Flucytosine 148 Fungoid Tincture 13 Fluocinolone Acetonide 200 Furosemide 181 Fluocinolone Acetonide (Ophth) 223 Fycompa 137 Fluocinolone Acetonide (Otic) 226 Fluocinolone-Emollient 202 G Fluocinonide 200 Gabapentin 138

PAGE 248 LAST UPDATED 02/2018 Gabapentin (Once-Daily) 138 Gabitril 138 H Galantamine Hydrobromide 140,141 Halcinonide 201 Gatifloxacin (Ophth) 135 Halobetasol Propionate 200 Gefitinib 153 Halog 201 Gemfibrozil 182 Haloperidol 156 Gemifloxacin Mesylate 135 Harvoni 160 Gentamicin Sulfate (Topical) 130 Hemangeol 152 Gentamicin-Prednisolone Acetate 221 Hematest 55 GenTeal Mild 67 Hemoglobin A1c (HbA1c) Test 49,52 GenTeal Severe 67 Heparin Sodium (Porcine) 168 Gentian Violet 26 Hetlioz 236 Genvoya 161 Histex 76 Giazo 218 HIV-1 Test 56 Gilotrif 152 Homatropine HBr 221 Glimepiride 166 Home Access Express HIV-1 Test 56 Glipizide 166 Home Access HIV-1 Test System 56 Glipizide-Metformin HCl 166 Homocysteine Formula 103 Glyburide 166 HumaLOG 167 Glyburide Micronized 166 HumaLOG Mix 50/50 167 Glyburide-Metformin 166 HumuLIN 70/30 167 Glycerin (Laxative) 42,43,46 HumuLIN R U-500 (CONCENTRATED) 167 Glycerin (Topical) 24,26,27,31,32,33 HumuLIN R U-500 KwikPen 167 Glycerin-Hypromellose-Polyethylene Glycol Hydralazine HCl 185 400 66,67,68,69,70,71 Hydrocodone Bitartrate 122,125 Glycerol Phenylbutyrate 193 Hydrocodone Polistirex-Chlorpheniramine Glycopyrrolate 194 Polistirex 232,233 Glycopyrrolate (Inhalation) 228 Hydrocodone w/ Homatropine 232,233 Goodys Extra Strength 6 Hydrocodone-Acetaminophen 126,127,128,129 Gordochom 26 Hydrocodone-Chlorpheniramine 234 Gordons-Vite A 26 Hydrocodone-Ibuprofen 127,128,129 Gralise 138 Hydrocortisone 201 Gralise Starter 138 Hydrocortisone Granisetron 147 (Topical)19,20,21,22,23,24,25,26,27,28,29,30,31,32,33 Griseofulvin Microsize 148 ,34,189,190,192 Griseofulvin Ultramicrosize 148 Hydrocortisone Acetate w/ Pramoxine 189,190 Guaifenesin 80,81,82,83,84,85,86,87,88,89,90,91,92,9 Hydrocortisone Acetate-Urea 200 3,94,95,96,97,98,99,100,101,232 Hydrocortisone Butyrate 201 Guaifenesin-Codeine 81,84 Hydrocortisone Probutate 201 Guanfacine HCl 170 Hydrocortisone Valerate 201 Guanfacine HCl (ADHD) 186 Hydrocortisone w/Acetic Acid 225,226

PAGE 249 LAST UPDATED 02/2018 Hydromorphone HCl 122,127 Insulin NPH Isophane & Reg (Human) 167,168 Hydroxychloroquine Sulfate 154 Insulin Regular (Human) 167 Hydroxyurea (Sickle Cell Anemia) 151 Invirase 163 Hydroxyzine HCl 228 Invokana 166 Hydroxyzine Pamoate 228 Iodoquinol 130 Hyoscyamine Sulfate 194 Iopidine 224 HypoTears 68 Ipratropium Bromide 228 Hypromellose (Gonioscopic) 68 Ipratropium Bromide (Nasal) 228 Hypromellose (Ophth) 67,68,69,70 Ipratropium Bromide HFA 228 Hysingla ER 122 Irbesartan 170 Irbesartan-Hydrochlorothiazide 179 I Iressa 153 Ibrance 152 Iron 104 Ibuprofen 3,4,5,6,7,8,120,121 Iron Heme Polypeptide 114 Ibuprofen-Diphenhydramine Citrate 101,102 Isentress 161 Ibuprofen-Famotidine 120 Isometheptene-Dichloralphenazone- Icatibant Acetate 217 Acetaminophen 220 Iclusig 152 Isoniazid 150 Icosapent Ethyl 185 Isoniazid-Rifampin w/ Pyrazinamide 150 Idelalisib 153 Isopropyl Alcohol 56 Iloperidone 157 Isopto Carbachol 224 Iloprost 231 Isopto Homatropine 221 Imatinib Mesylate 153 Isopto Hyoscine 221 Imipramine HCl 146 Isopto Tears 68 Imipramine Pamoate 146 Isosorbide Dinitrate 185 Imiquimod 190,193 Isosorbide Mononitrate 185 Indacaterol Maleate 229 Isotretinoin 189,190,191,193 Indacaterol Maleate-Glycopyrrolate 234 Isradipine 175 Indapamide 182 Itraconazole 148,149 Indocin 121 Ivabradine HCl 178 Indomethacin 121 Ivacaftor 230 Inositol 110 Ivermectin (Rosacea) 154 Inositol Niacinate (Bulk) 56,220 Ivy Block 28 Insulin Aspart Protamine & Aspart (Human) 168 Ivy Dry 28 Insulin Degludec 168 Ivy Itch ReLeaf 56 Insulin Detemir 168 Insulin Glargine 168 J Insulin Isophane & Reg (Human) 168 J-Tan D PD 90 Insulin Lispro 167 J-Tan D SR 232 Insulin Lispro (Human) 167 J-Tan PD 76 Insulin Lispro Protamine & Lispro 167 Jakafi 153

PAGE 250 LAST UPDATED 02/2018 Janumet 166 Lenvima 20 MG Daily Dose 153 Januvia 166 Letairis 230 Jublia 148 Leucovorin Calcium 152 Juxtapid 184 Leukine 169 Leukocyte Test 51 K Levalbuterol HCl 229 Kalydeco 230 Levatol 173 Kera Tek 28 Levemir 168 Ketoprofen 121 Levetiracetam 137 Ketorolac Tromethamine 121 Levitra 198 Ketorolac Tromethamine (Ophth) 223 Levobunolol HCl 224 Ketotifen Fumarate (Ophth) 66,67,68,69,70,71,221 Levocarnitine 105,111 Kombiglyze XR 166 Levocarnitine (Metabolic Modifiers) 111,237 Kondremul 44 Levocetirizine Dihydrochloride 228 Konsyl 44 Levofloxacin 135 Konsyl-D 44 Levofloxacin (Ophth) 135 Kristalose 196 Levonorgestrel & Eth Kuvan 193 Estradiol 203,204,205,207,208,209,210,211,212 Levonorgestrel (Emergency OC) 48,49,213 L Levonorgestrel (IUD) 213,214 Lacosamide 140 Levonorgestrel-Eth Estradiol Lactase 35,36,37 (Triphasic) 206,208,209,212 Lactic Acid (Ammonium Lactate) 19,23,24,26,189,191 Levonorgestrel-Ethinyl Estradiol (91- Lactic Acid w/ Vitamin E 28,191 Day) 203,204,205,207,208,211 Lactulose 196 Levonorgestrel-Ethinyl Estradiol (Continuous) 203,208 LamISIL 148 Levothyroxine Sodium 214,215,216 Lamivudine (HBV) 160 Lexiva 163 Lamotrigine 139 LidaMantle HC 191 Lansoprazole 47,48,197 Lidocaine 19,20,28 Lanthanum Carbonate 199 Lidocaine HCl 191 Lantus 168 Lidocaine HCl (Ophth) 220 Lapatinib Ditosylate 153 Lidocaine-Hydrocortisone Acetate 191 Lastacaft 221 Lidocaine-Prilocaine 129 Latuda 157 Lifitegrast 223 Lazanda 127 Liniments & Rubs 24,35 Lecithin 111 Liothyronine Sodium 215 Ledipasvir-Sofosbuvir 160 Liotrix (T3-T4) 216 Leflunomide 218 Liquid E-Z-Paque 220 Lenalidomide 151 Liquid Polibar 220 Lenvatinib Mesylate 153 Liquimat 28 Lenvima 10 MG Daily Dose 153 Lisdexamfetamine Dimesylate 186

PAGE 251 LAST UPDATED 02/2018 Lisinopril 171,172 Maraviroc 162 Lisinopril & Hydrochlorothiazide 179 Maxichlor DM 90 Lithium 165 Maxichlor PEH DM 90 Lithium Carbonate 165 Maxifed DM 90 Lithostat 198 Mebendazole 154 Livalo 183 Meclizine HCl 11,12,146 Lodoxamide Tromethamine 222 Medrol 201 Lomitapide Mesylate 184 Mefenamic Acid 121 Loperamide HCl 35,36,37,38 Mefloquine HCl 154 Lopinavir-Ritonavir 163 Megestrol Acetate 213 Loratadine 72,73,74,75,76,77,78,79 Mekinist 153 Lorazepam 164 Meloxicam 121 Lorzone 234 Memantine HCl 141 Losartan Potassium 171 Menthol (Topical Analgesic) 19,20,22,24,30,32,35 Losartan Potassium & Hydrochlorothiazide 179 Menthol-Methyl Salicylate (Liniments) 24,28 Lotemax 223 Meperidine HCl 127 Loteprednol Etabonate 223 Mepolizumab 232 Loteprednol Etabonate-Tobramycin 222 Meprobamate 164 Lovastatin 182,183 Meprobamate-Aspirin 120 Loxapine 156 Mercaptopurine 151 Loxapine Succinate 156 Mesalamine 218 Lufyllin 230 Metamucil 44 Luliconazole 148 Metamucil MultiHealth Fiber 44 Lumacaftor-Ivacaftor 230 Metaproterenol Sulfate 229 Lumigan 225 Metaxalone 234 Lurasidone HCl 157 Metformin HCl 166 Luzu 148 Methadone HCl 122 Lyrica 188 Methamphetamine HCl 186 Methazolamide 224 M Methenamine Hippurate 130 Macitentan 230 Methenamine Mandelate 131 Mag-Tab SR 104 Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Magnesium Gluconate 104 Sal 130,131 Magnesium Hydroxide 42,43,44,45,46 Methimazole 217 Magnesium Lactate 104 Methionine 111 Magnesium Oxide 36,38 Methitest 203 Magnesium Oxide (Laxative) 42 Methocarbamol 234 Magnesium Salicylate Tetrahydrate 3,4,7 Methotrexate Sodium 218 Magnesium Sulfate (Laxative) 52,53,54,61 Methscopolamine Bromide 194 Mapap Headache Plus 57 Methyclothiazide 182 Maprotiline HCl 143 Methylcellulose (Laxative) 43,46

PAGE 252 LAST UPDATED 02/2018 Methyldopa 170 Monistat 7 Combo Pack App 14 Methyldopa & Hydrochlorothiazide 179 Morphine Sulfate 122,123,127,128 Methylnaltrexone Bromide 195 Morphine Sulfate Beads 123 Methylphenidate 186 Morphine-Naltrexone 122 Methylphenidate HCl 187 Mouth Kote 18 Methylprednisolone 201 Mouthwashes 17,18 Methyltestosterone 203 Movantik 195 Metipranolol 224 MoviPrep 196 Metoclopramide HCl 146 Moxatag 133 Metolazone 182 Moxifloxacin HCl (Ophth) 135 Metoprolol & Hydrochlorothiazide 179 Mozobil 169 Metoprolol Tartrate 173 Mucinex For Kids 91 Metronidazole 130,131 Multaq 172 Metronidazole (Topical) 131 Multiple Vitamins w/ Metyrosine 178 Minerals 104,105,106,107,108,109,110,111,112,113,11 MI Paste 220 4,115,116,117,118,119,237,238 MI Paste Plus 220 Mupirocin 131 Miconazole Nitrate (Topical) 12,13,14,15,51,52 Mupirocin Calcium 130 Miconazole Nitrate Vaginal 13,14,15,148 Muro 128 68 Miglitol 166 Muse 198 Milnacipran HCl 188 Myco Nail A 29 Mineral Oil 44 Mycophenolate Mofetil 217 Mineral Oil-Hydrophil Petrolat 29 MyKidz Iron 10 104 Mineral Oil-Hydrophilic Petrolatum 29 Myleran 151 Minocycline HCl 136,137 Mytelase 150 Minocycline HCl (Subgingival) 189 Mytesi 195 Minoxidil 185 Minoxidil (Topical) 23,25,27,28,29,31,32,33,34 N Mirena (52 MG) 213 Na Sulfate-K Sulfate-Mg Sulfate & PEG3350-NaCl-Na Mirtazapine 142 Bicarb-KCl 196 Misc Natural Products 51,56 Nadolol 173 Misoprostol 196 Nafarelin Acetate 217 Moderiba 1200 Dose Pack 160 Naftifine HCl 148 Moderiba 800 Dose Pack 160 Naftin 148 Moexipril HCl 171 Naloxegol Oxalate 195 Moexipril-Hydrochlorothiazide 179 Namenda XR 141 Moi-Stir 18 Naphazoline HCl 221 Mometasone Furoate 201 Naphazoline w/ Pheniramine 66,67,69,70,71 Mometasone Furoate (Inhalation) 226 Naphazoline-Hypromellose 67,69,70 Mometasone Furoate-Formoterol Fumarate Naphazoline-Polyethylene Glycol 300 67,69,70 Dihydrate 232 Naprelan 121

PAGE 253 LAST UPDATED 02/2018 Naproxen 121 Nilutamide 151 Naproxen Sodium 121 Nimodipine 175 Naproxen-Esomeprazole Magnesium 121 Nintedanib Esylate 232 Naratriptan HCl 149 Nisoldipine 175,176 Nat-Rul Psyllium Seed Husks 44 Nitazoxanide 154 Natazia 209 Nitrofurantoin Macrocrystal 131 Nateglinide 166 Nitrofurantoin Monohyd Macro 131 Nature-Throid 215 Nitroglycerin 185,186 Nebivolol-Valsartan 178 Nizatidine 195 Nebusal 232 Norelgestromin-Ethinyl Estradiol 210,212 Necon 1/50 (28) 209 Norethin Acet & Estrad-Fe 204,207,208,209,211 Necon 10/11 (28) 209 Norethindrone & Eth Nedocromil Sodium (Ophth) 222 Estradiol 203,204,205,207,209,210,212 Nefazodone HCl 143,144 Norethindrone & Ethinyl Estradiol-Fe 209,212 Nelfinavir Mesylate 163 Norethindrone & Mestranol 209,210 Neo-Synephrine 59 Norethindrone (Contraceptive) 212,213,214 Neo-Synephrine Cold & Sinus 59 Norethindrone Acetate-Ethinyl Estradiol 207,209 Neomycin-Bacitracin Zn-Polymyxin 221,222 Norethindrone Acetate-Ethinyl Estradiol-Fe 211 Neomycin-Bacitracin-Polymyxin w/ Lidocaine 26,31,33 Norethindrone-Eth Estradiol (Biphasic) 209 Neomycin-Polymy-Dexameth 221 Norethindrone-Eth Estradiol Neomycin-Polymyxin-Gramicidin 221 (Triphasic) 203,204,205,208,209,210 Neomycin-Polymyxin-HC (Ophth) 221 Norfloxacin 135 Neomycin-Polymyxin-HC (Otic) 225,226 Norgestimate-Ethinyl Estradiol 206,207,209,211 Neomycin/Polymyxin B GU 131 Norgestimate-Ethinyl Estradiol (Triphasic) 209,211 Nepafenac 223 Norgestrel & Ethinyl Estradiol 205,206,208,210 Neutrogena T/Gel Conditioner 30 Norinyl 1+50 (28) 210 Nevanac 223 Noroxin 135 Nevirapine 161,162 Northera 179 New Terocin 30 Nortriptyline HCl 146 NexGen Meter 220 Nortuss-Ex 232 NexIUM 197 Norvir 163 Niacin (Antihyperlipidemic) 184 NovoLIN 70/30 168 Niacin-Lovastatin 183,184 NovoLIN 70/30 ReliOn 168 Niacin-Simvastatin 184,185 NovoLOG Mix 70/30 168 Nicardipine HCl 174,175 Noxafil 148 Nicotine 130 Nucala 232 Nicotine Polacrilex 9,10,11 Nucynta ER 123 Nicotrol 130 Nuedexta 188 Nicotrol NS 130 Numoisyn 189 Nifedipine 174,175 Nuplazid 158 Nilotinib HCl 153 NuvaRing 210

PAGE 254 LAST UPDATED 02/2018 Nystatin 147,148 Orkambi 230 Nystatin-Triamcinolone 148 Orlistat 195 Ortho Evra 210 O Oseltamivir Phosphate 163 Obeticholic Acid 195 Ospemifene 214 OC8 30 Osphena 214 Ocaliva 195 Outgro Pain Relief 30 Occult Blood 55 Oxandrolone 202 Odefsey 162 Oxaydo 128 Ofev 232 Oxazepam 164 Ofloxacin 135 Oxcarbazepine 140 Ofloxacin (Ophth) 135 Oxecta 128 Ofloxacin (Otic) 135 Oxiconazole Nitrate 149 Ogestrel 210 Oxistat 149 Olanzapine 158 Oxtellar XR 140 Olanzapine-Fluoxetine HCl 142 Oxybutynin Chloride 197 Oleptro 144 Oxycodone 124,125 Olmesartan Medoxomil 171 Oxycodone HCl 124,128 Olmesartan Medoxomil-Hydrochlorothiazide 179 Oxycodone w/ Acetaminophen 126,128,129 Olopatadine HCl 222 Oxycodone-Acetaminophen 128 Olopatadine HCl (Nasal) 228 Oxymetazoline Olysio 160 HCl 49,50,52,53,54,55,56,57,58,59,60,61,62,63,64,65 Ombitasvir-Paritaprevir-Ritonavir 161 Oxymetazoline HCl (Ophth) 71 Ombitasvir-Paritaprevir-Ritonavir-Dasabuvir 161 Oxymetholone 202 Omega-3 Fatty Acids 16,17 Oxymorphone HCl 124,128 Omeprazole 197 Oxyquinolone Sulfate Vaginal 48 Omeprazole Magnesium 197 Ozurdex 223 Omnaris 227 Ondansetron 147 P Ondansetron HCl 147 P & S 30 Onfi 138 Pacnex MX 191 Onglyza 166 Palbociclib 152 Onmel 149 Paliperidone 158 Opana ER 124 Pancreaze 193 Opium Tincture 195 Pancrelipase (Lipase-Protease-Amylase) 193,194 Opsumit 230 Pandel 201 Oracea 137 Panobinostat Lactate 152 Orajel Baby Tooth/Gum 59 PanOxyl 30 Oral Hygiene Products 51,59 Panthoderm 30 Oral Relief Spray 18 Pantoprazole Sodium 197 Orenitram 230 Paricalcitol 218

PAGE 255 LAST UPDATED 02/2018 Paromomycin Sulfate 130 Phenylephrine-Chlorpheniramine-DM w/ Paroxetine HCl 144 APAP 81,82,85,87,90,92,93,94,96,97,99,100 Paroxetine Mesylate 144 Phenylephrine-DM-GG w/ Paroxetine Mesylate (Vasomotor) 144 APAP 81,83,84,85,86,87,88,90,91,92,93,94,95,96,97,9 Pasireotide Diaspartate 217 8,99,100 Pazopanib HCl 153 Phenylephrine- PCE 134 Guaifenesin 80,82,83,86,88,90,91,92,93,95,97,98,99,1 Pearl Drops Extra Strength 60 00 PediaCare Childrens Decongest 60 Phenylephrine-Pyrilamine-DM 81 PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate- Phenylephrine-Shark Liver Oil-Cocoa Ascorbic Acid 196 Butter 23,26,27,31,32,34 Peganone 140 Phenylephrine-Shark Liver Oil-Glycerin- Penbutolol Sulfate 173 Petrolatum 26,27,32,33 Penicillin V Potassium 133 Phenyltoloxamine-Acetaminophen 60 Pentazocine w/ Naloxone 128 Phenytoin Sodium Extended 140 Perampanel 137 Phosphatidylcholine (Bulk) 60,220 Perforomist 229 Phospholine Iodide 224 Perindopril Arginine-Amlodipine Besylate 180 Phosphorated Carbohydrate w/Caffeine 11 Perindopril Erbumine 171 Phrenilin Forte 188 Pernox 30 Pilocarpine HCl 224 Perphenazine 146 Pilocarpine HCl (Oral) 189 Perphenazine-Amitriptyline 142 Pimavanserin Tartrate 158 Pertzye 193 Pimecrolimus 190 Pexeva 144 Pimozide 156 Phenazopyridine HCl 48,198 Pin-X 16 Phenobarbital 138 Pindolol 173 Phenobarbital-Hyoscyamine-Atropine-Scopolamine 194 Pioglitazone HCl-Glimepiride 167 Phentermine HCl 188 Pioglitazone HCl-Metformin HCl 167 Phenylephrine HCl 59,62,66 Pirfenidone 232 Phenylephrine HCl (Ophth) 220,221 Piroxicam 121 Phenylephrine HCl Pitavastatin Calcium 183 (Oral) 52,53,54,55,56,58,59,60,61,62,64,65,66 Plecanatide 195 Phenylephrine w/ DM- Plerixafor 169 GG 80,84,87,88,93,96,98,231,232,234 Poly-Vent IR 93 Phenylephrine-Acetaminophen- Polyethylene Glycol 54,60 Guaifenesin 81,83,85,86,87,88,89,90,91,92,94,95,97,9 Polyethylene Glycol-Polyvinyl Alcohol (Ophth) 68 8,101 Polyethylene Glycol-Propylene Glycol Phenylephrine-Brompheniramine- (Ophth) 67,68,69,70 DM 80,81,82,84,85,87,89,90,93,94,96,98,99,101 Polysaccharide Iron Complex 108,109,110,113,114 Phenylephrine-Chlorphen-DM 81,84,90,93,100,232 Polysaccharide Iron Complex-Iron Heme Polypeptide 103

PAGE 256 LAST UPDATED 02/2018 Polysorbate 80 (Ophth) 71 Prepidil 198 Polyvinyl Alcohol 66,68,69,221 Prestalia 180 Polyvinyl Alcohol-Povidone (Ophth) 69 Prevacare Antimicrobial 31 Pomalidomide 151 Prevacid SoluTab 197 Pomalyst 151 Prezista 163 Ponatinib HCl 152 Priftin 150 Posaconazole 148 PriLOSEC 197 Posture 104 Primaquine Phosphate 154 Pot & Sod Citrates w/Citric Ac 198,199 Primatene Mist 79 Pot Phosphate Monobasic w/ Sod Phosphate Dibasic Primidone 138 & Monobasic 198,199 Primlev 128 Potassium Chloride 237 Primsol 131 Potassium Chloride Microencapsulated Crystals ProAir HFA 229 CR 237 ProAir RespiClick 229 Potassium Chloride Microencapsulated Crystals Prochieve 214 ER 237 Prochlorperazine Maleate 146 Potassium Citrate (Alkalinizer) 198 Proferrin ES 114 Potiga 137 Progesterone (Vaginal) 212,213,214 Povidone-Iodine 50,51,52,53,54,55,56,59,60,61,63,64 Progesterone Micronized 214 Pradaxa 169 Proglycem 167 Praluent 184 Prolensa 223 Pramipexole Dihydrochloride 155 Promacta 169 Pramlintide Acetate 167 Promethazine & Phenylephrine 232,233 Pramosone 191 Promethazine HCl 228 Pramoxine HCl (Dental) 17 Promethazine-Phenylephrine-Codeine 233 Pramoxine-HC 191 Propa pH Acne Med Cleansing 31 Pramoxine-HC-Chloroxylenol 225,226 Propafenone HCl 172,173 Pravastatin Sodium 183 Proparacaine HCl 221,222 Prazosin HCl 170 Propranolol & Hydrochlorothiazide 180 Precision Xtra 220 Propranolol HCl 152,173 Pred-G 221 Propylene Glycol (Ophth) 70 Pred-G S.O.P. 221 Propylene Glycol-Glycerin 66,67,69,70 Prednicarbate 201 Prostin E2 198 Prednisolone Acetate 200 Protonix 197 Prednisolone Acetate (Ophth) 223 Protriptyline HCl 146 Prednisolone Sodium Phosphate 199,201 Proventil HFA 229 Prednisone 201,202 Pseudoeph-CPM-DM w/APAP 86 Pregabalin 188 Pseudoephed-Bromphen- Pregnancy Test 52,53,60 DM 80,84,85,86,93,94,97,101,231,233 Premarin 210 Pseudoephedrine HCl 52,53,54,55,64 Prempro 210 Pseudoephedrine w/ DM-GG 86,90,93,98,100,101

PAGE 257 LAST UPDATED 02/2018 Pseudoephedrine-Acetaminophen- Ravicti 193 Dextromethorphan 85,86 Rayos 202 Pseudoephedrine-Chlorphen-DM 86,93,96 Rebetol 161 Pseudoephedrine-DM-GG w/ APAP 85,86,97,98 Refresh Celluvisc 69 Pseudoephedrine-Guaifenesin 80,91,93,98 Refresh Liquigel 69 Pseudoephedrine-Ibuprofen 80,85,86,87,95,98 Relhist BP 96 Pseudoephedrine-Naproxen Sodium 80,83,88,90,97,98 ReliOn 70/30 168 Psyllium 42,43,44,45,46,47 Relistor 195 Psyllium w/ Calcium 43,47 Renacidin 199 Pulmozyme 233 Repatha 184 Pyrantel Pamoate 16 Repatha SureClick 184 Pyridostigmine Bromide 150 Rescon DM 96 Pyrilamine Tannate-Phenylephrine Tannate 233 Rescriptor 162 Pyrimethamine 154 Reserpine 180 Reslizumab 231 Q Respa-BR 228 Qbrelis 172 Respahist-II 233 Quazepam 235 Retisert 223 Quetiapine Fumarate 158 Revlimid 151 QuickTek 220 Rexulti 158 Quillivant XR 187 Ribasphere 161 Quinapril HCl 172 Ribasphere RibaPak 161 Quinapril-Hydrochlorothiazide 180 RibaTab 161 Quinidine Gluconate 173 Ribavirin 233 Quinine Sulfate 154 Ribavirin (Hepatitis C) 160,161 Qvar 227 Ridaura 218 Rifabutin 150 R Rifampin 150 RA Anti-Fungal Foot Care 31 Rifapentine 150 RA Dry Mouth 18 Rifater 150 RA Epsom Salt 61 Rifaximin 131 RA Epsom Salt Lavender 61 Riluzole 188 RA Fluoride Toothpaste 61 Rimantadine Hydrochloride 163 RA Sensitive Toothpaste/Fl 62 Rimso-50 199 RA Whitening Toothpaste/Fl 62 Riociguat 230 Rabeprazole Sodium 196 Risedronate Sodium 219 Raltegravir Potassium 161 Risperidone 158,159 Ramipril 172 Ritonavir 163 Ranitidine HCl 38,39,40,41,42,195,196 Rivaroxaban 169 Rapamune 217 Rivastigmine Tartrate 140,141 Rasagiline Mesylate 155 Rizatriptan Benzoate 149

PAGE 258 LAST UPDATED 02/2018 Roflumilast 230 Sensitive Extra Whitening 63 Rolapitant HCl 147 Sensitive Toothpaste/Fluoride 63 Ropinirole Hydrochloride 155 Sensodyne Maximum Strength 63 Rosiglitazone Maleate 165 Sensodyne Pronamel 63 Rosiglitazone Maleate-Glimepiride 165 Sensodyne Tartar Control 63 Rosiglitazone Maleate-Metformin HCl 165 Sertaconazole Nitrate 148 Rosuvastatin Calcium 183 Sevelamer Carbonate 199 Roxicet 128 Signifor 217 Ru-Hist D 96 Silver Nitrate 192 Rufinamide 139 Silver Nitrate-Potassium Nitrate 190 Ruxolitinib Phosphate 153 Silver Sulfadiazine 135 Rynatan 233 Simbrinza 224 Simcor 184,185 S Simeprevir Sodium 160 Sabril 138 Simethicone 35,36,37,38 Sacubitril-Valsartan 179 Simvastatin 183 Salicylic Acid 19,21,22,24,25,29,30,31,191 Sirolimus 217 Salicylic Acid & Sulfur (Keratolytic) 30 Sitagliptin Phosphate 166 Sancuso 147 Sitagliptin-Metformin HCl 166 Saphris 159 Sitavig 164 Sapropterin Dihydrochloride 193 Skelid 219 Saquinavir Mesylate 163 Skyla 214 Sardoettes 33 Sodium Chloride (Inhalant) 232,233 Sargramostim 169 Sodium Chloride Hypertonic 68 Savella 188 Sodium Fluoride w/ Calcium Carbonate 103 Saxagliptin HCl 166 Sodium Oxybate 236 Saxagliptin-Metformin HCl 166 Sodium Phenylbutyrate 193 Scopolamine 147 Sodium Phosphates 42,45,46 Scopolamine HBr (Ophth) 221 Sodium Polystyrene Sulfonate 236 Secobarbital Sodium 236 Sofosbuvir 161 Seconal 236 Solifenacin Succinate 197 Sedapap 188 Solodyn 137 Seebri Neohaler 228 Soolantra 154 Selegiline 142 Sorbitol 199 Selegiline HCl 156 Sorbitol Irrigation 199 Selenium Sulfide 19,22,24,26,32 Sotalol HCl 173 Selexipag 230,231 Sotalol HCl (AFIB/AFL) 173 Selzentry 162 Sovaldi 161 Semprex-D 233 Spironolactone 182 Sennosides 42,43,44,45,46 Spironolactone & Hydrochlorothiazide 180 Sensipar 217 Sporanox 149

PAGE 259 LAST UPDATED 02/2018 Sprix 121 Sprycel 153 T Starch (topical) 27,33 Tabloid 152 Stavudine 162 Taclonex 192 Stavzor 138 Tacrolimus 217,218 Staxyn 199 Tacrolimus (Topical) 192 Stendra 199 Tadalafil 197,198 Stimate 202 Tafluprost 225 Stiolto Respimat 233 Tamoxifen Citrate 151 Striant 203 Tapentadol HCl 123 Stribild 161 TaperDex 6-Day 202 Styptocaine 33 Tarceva 153 Suclear 196 TargaDOX 137 Sucralfate 196 Targretin 153 Sudafed 24 Hour 64 Tasigna 153 Sudafed PE Childrens 64 Tasimelteon 236 Sulfacetamide Sod-Prednisolone 220,222 Tazarotene 192 Sulfacetamide Sodium 191,192 Tazorac 192 Sulfacetamide Sodium w/ Sulfur 189,190,192,193 Tecfidera 188 Sulfacetamide-Prednisolone 222 Technivie 161 Sulfadiazine 135 Tekamlo 180 Sulfanilamide Vaginal 135 Tekturna 180 Sulfasalazine 218 Telmisartan 171 Sulfoam 192 Telmisartan-Amlodipine 180 Sulfur 28,192 Telmisartan-Hydrochlorothiazide 180 Sulfuric Acid-Sulfonated Phenolics 189 Temazepam 235 Sumatriptan 149 Temozolomide 151 Sumatriptan Succinate 150 Tencon 188 Sumatriptan-Naproxen Sodium 150 Tenofovir Disoproxil Fumarate 162 Sunitinib Malate 153 Terazosin HCl 198 Suprax 133 Terbinafine HCl 148,149 Sutent 153 Terbutaline Sulfate 229 Suvorexant 235 Terconazole Vaginal 149 Symbicort 233 Teriparatide (Recombinant) 218 SymlinPen 60 167 Testosterone 202,203 Synalar (Cream) 202 Tetracaine HCl (Ophth) 220,222 Synarel 217 Tetracycline HCl 137 Synjardy 167 Tetrahydrozoline HCl 233,234 Syprine 236 Tetrahydrozoline HCl (Ophth) 67,68,69,70 Systane Overnight Therapy 70 Tetrahydrozoline w/ Polyethylene Glycol 66,67,69 Tetrahydrozoline-Glycerin-Hypromellose-PEG 400 70

PAGE 260 LAST UPDATED 02/2018 TG 45PSE/400GFN 98 Tramadol HCl 124 TGT Lubricant Eye Drops 70 Tramadol-Acetaminophen 128 Thalidomide 151 Trametinib Dimethyl Sulfoxide 153 Thalomid 151 Trandolapril 172 Theratears 70 Trandolapril-Verapamil HCl 180 Theratears PF 70 Tranexamic Acid 169 Thioguanine 152 Tranylcypromine Sulfate 142 Thioridazine HCl 156,157 Travoprost 225 Thiothixene 157 Trazodone HCl 144,145 Thyroid 214,215,216,217 Trecator 150 Thyrolar-1 216 Treprostinil Diolamine 230 Thyrolar-1/2 216 Tresiba FlexTouch 168 Thyrolar-1/4 216 Tretinoin 189,192 Thyrolar-2 216 Tretinoin (Chemotherapy) 154 Thyrolar-3 216 Tretinoin Microsphere 192 Tiagabine HCl 138 Trexall 218 Ticagrelor 169 Treximet 150 Tiludronate Disodium 219 Trezix 128 Timolol 224 Tri-Chlor 192 Timolol Maleate 174 Triactin Chest Congestion 99 Timolol Maleate (Ophth) 224,225 Triamcinolone Acetonide (Topical) 202 Tinidazole 131 Triaminic Cough/Runny Nose 79 Tiotropium Bromide-Olodaterol HCl 233 Triamterene 181 Tipranavir 163 Triamterene & Hydrochlorothiazide 181 Tivicay 161 Triazolam 235 Tizanidine HCl 160 Trichloroacetic Acid 192 Tobi Podhaler 230 Triclosan 51 Tobramycin 229,230 Trientine HCl 236 Tobramycin (Ophth) 130 Trifluoperazine HCl 157 Tobramycin-Dexamethasone 222 Trifluridine 164 Tolazamide 167 Trimethobenzamide HCl 147 Tolcapone 155 Trimethoprim HCl 131 Tolmetin Sodium 121 Trimipramine Maleate 146 Tolnaftate 19,22,23,25,28,30,32,33,34 Trimo-San 48 Tolterodine Tartrate 197 Trimpex 131 Topicort Spray 202 Trintellix 145 Topiramate 139 Triprolidine & Pseudoephedrine 89,100 Toremifene Citrate 151 Triprolidine HCl 76 Torsemide 181 Trokendi XR 139 Toviaz 197 Trolamine Salicylate 34 Tracleer 230 Tropicamide 221,222

PAGE 261 LAST UPDATED 02/2018 Trulance 195 Viadent Advanced Care 65 Truvada 162 Viadent Fluoride 66 TussiCaps 233 Viadent Plaque 66 Tybost 162 Viberzi 196 Tykerb 153 Vibramycin 137 Tylenol Childrens Plus Cld/Cgh 100 Vicks Sinex 66 Tylenol PM Extra Strength 102 Vicks Sinex UltraFine Mist 66 Tyzine 233,234 Videx 162 Viekira Pak 161 U Vigabatrin 138,139 Uceris 218 Viibryd 145 Uloric 149 Vilazodone HCl 145 Ultima 220 Vimovo 121 Ultresa 193 Vimpat 140 Umeclidinium-Vilanterol 231 Viokace 193 Umecta 192 Viracept 163 Undecylenic Acid 26,29,31 Viread 162 Uptravi 230,231 Visine Maximum Redness Relief 70 Urea 191,192 Visine Tears 70 Uro-Mag 38 Visine Tired Eye Relief 71 Ursodiol 195 Visine-LR 71 Utibron Neohaler 234 Vitamin A (Topical) 26 Vitamin E (Topical) 24,26,34 V Vitamin E w/ A & D 19,24,32,34 Valganciclovir HCl 160 Vitamins A & D (Topical) 20,24,25,26,31,32,34 Valproic Acid 138 Vitamins A & E 19 Valsartan 171 Vituz 234 Valsartan-Hydrochlorothiazide 181 Viva Drops 71 Vancomycin HCl 130,131 Voriconazole 149 Vaniqa 193 Vortioxetine HBr 142,143,145 Vanquish 8 Votrient 153 Vardenafil HCl 198,199 Vraylar 159 Varubi 147 Vyvanse 186 Vascepa 185 Venlafaxine HCl 145 W Ventavis 231 Wal-Dryl-D 100 Ventolin HFA 229 Warfarin Sodium 168,169 Veramyst 227 Welchol 185 Verapamil HCl 176,177 Westhroid 216 VESIcare 197 Witch Hazel (Hamamelis Viadent 65 Virginiana) 23,25,26,27,28,29,30,31,32,33,34

PAGE 262 LAST UPDATED 02/2018 WP Thyroid 216,217 Zyclara Pump 193 Zydelig 153 X Zydone 129 Xalkori 153 Zylet 222 Xarelto 169 Zytiga 151 Xartemis XR 129 Xenical 195 Xifaxan 131 Xiidra 223 Xolox 129 Xtampza ER 124,125 Xulane 212 Xyrem 236

Y Yodoxin 130

Z Zarxio 169 Zelapar 156 Zenpep 193,194 Zepatier 161 Zidovudine 162 Zilactin 18 Zims Max-Freeze 35 Zinc Acetate (Topical) 28 Zioptan 225 Ziprasidone HCl 159 Zipsor 121 Zmax 134 Zmax Pediatric 134 Zodex 6-Day 202 Zohydro ER 125 Zoledronic Acid 219 Zolmitriptan 150 Zolpidem Tartrate 234,235 Zorvolex 121 Zotex Pediatric 234 Zubsolv 129 Zuplenz 147 Zyclara 193

PAGE 263 LAST UPDATED 02/2018