Molina Healthcare of Michigan

August 2021

Molina Healthcare of Michigan Preferred Drug List (Formulary) •• 1 Non-Discrimination Notification ill~!?r~~~ Molina Healthcare of Michigan Your Extended FamilJI Medicaid

Molina Healthcare of Michigan (Molina) complies with all Federal civil rights laws that relate to healthcare services. Molina offers healthcare services to all members without regard to race, color, national origin, age, disability, or sex. Molina does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Thi s includes gender identity, pregnancy and sex stereotyping.

To help you talk with us, Molina provides services free of cha rge:

• Aids and services to people with disabilities o Skilled sign language interpreters o Written material in other formats (large print, audio, accessible electronic formats, Braille) • Language services to people who speak another la nguage or have limited English skills o Skilled interpreters o Written material translated in your language o Material that is simply written in plain language If you need these services, contact Molina Member Services at (888) 898-7969. Hearing Impaired: Ml Relay (800) 649-3777 or 711.

If you think that Molina failed to provide these services or treated you differently based on your race, color, national origin, age, disability, or sex, you can file a complaint. You can file a complaint in person, by mail, fax, or email. If you need help writing your complaint, we w ill help you. Ca ll our Civil Ri ght s Coordinator at (866) 606-3889, or TTY, 711. Mail your complaint to:

Civil Rights Coordinator 200 Oceangate Long Beach, CA 90802

You can also email your complaint to [email protected]. Or, fax your complaint to (248) 925-1765.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. You can mail it to:

U.S. Department of Hea lth and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

You can also send it to a website through the Office for Civi l Rights Complaint Portal, ava ilable at https ://ocrporta l. hhs.gov/ocr /portal/lobby. jsf.

If you need help, call 1-800-368-1019; TTY 800-537-7697.

M olina Healthcare Notice 1557 - M l M edicaid Updated 10.14.16 •• 1 Non-Discrimination Tag Line- Section 1557 i))Mflr~~~ Molina Healthcare of Michigan, Inc. Your Extended F~ Medicaid English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-898- 7969 (TTY: 711). Spanish ATENCION: si habla espaiiol, tiene a su disposici6n servicios gratuitos de asistencia lingiiistica. Llame al 1-888-898-7969 (TTY: 711). Arabic f-2Y. J..,.,:il .u~l, ~ _)lfo :i..,;y.lll o.lc-W\ wl...~ l)~ ,Wll _foj\ ~ ~ 1:i,1 ::U._,,.J... .(711 :/4IJ ~I <....:ii.A f-2..;) 1-888-898-7969 Chinese 5±~ : :ittl*fif~ffl~R g:ix , tioJ ~~-311~~13~J:tJJ§a~ 0 §~ i~~

1-888-898-7969 ( TTY : 711 ) 0 Syriac «~ '9~:-. '9~_? ,,<;;;a&\r< ~ '9~~~ ~ '9~~ ,~ :«;m9, ~ -4- '9'\C -~~ ~ r

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Japanese 3.1~:f;:i:Ji : E3:.$:~B~~li~.no@~~, 1ftt;j!,j.O) ~ ~B~fi~ ~f!Jffl L'f=f::lt*-t o 1-888-898-7969 (TTY: 711) *--c', i61lr~lil:."'C~i.IM!-(t::~L'o Russian BHHMAHHE: EcJIH Bbl roBopHTe Ha pyccKoM ~3b!Ke, TO BaM ;:iocryrrnu 6ecrmaTHhre ycJiyrH rrepeBo;:ia. 3BOHHTe 1-888-898-7969 (TeJieraiirr: 711 ). Serbo OBAVJESTENJE: Ako govorite srpsko-hrvatski, usluge jezicke pomoci dostupne su vam Croatian besplatno. Nazovite 1-888-898-7969 (TTY- Telefon za osobe sa ostecenim govorom iii sluhom: 711). Tagalog P AUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-898-7969 (TTY: 711 ).

MHMI - 1557 tag lines_v4 Created 10/14/16, rev 12/14/16 Table of Contents INTRODUCTION ...... 12 PREFACE ...... 12 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE ...... 12 DRUG LIST PRODUCT DESCRIPTIONS ...... 13 GENERIC SUBSTITUTION ...... 13 PLAN DESIGN ...... 13 CATEGORIES OF CONSIDERATION ...... 13 PRIOR AUTHORIZATION REQUEST PROCEDURE ...... 13 PRIOR AUTHORIZATION HELPFUL HINTS ...... 14 LEGEND ...... 14 ...... 14 REQUESTING FORMULARY CHANGES ...... 14 ...... 14 STATE OF MICHIGAN, MEDICAID CARVE-OUT ...... 14 NON-COVERED MEDICATIONS ...... 18 URGENT AND AFTER-HOURS MEDICATION POLICY ...... 18 NOTICE ...... 18 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ...... 19 ANALEPTICS ...... 19 ALLERGENIC EXTRACTS/BIOLOGICALS MISC - DRUGS FOR ALLERGIES ...... 19 ALLERGENIC EXTRACTS ...... 19 ALTERNATIVE MEDICINES - COMPLEMENTARY AND ALTERNATIVE MEDICINES ...... 19 ALTERNATIVE MEDICINE - M'S ...... 19 AMINOGLYCOSIDES - DRUGS TO TREAT INFECTIONS ...... 19 AMINOGLYCOSIDES - DRUGS TO TREAT INFECTIONS ...... 19 ANALGESICS - ANTI-INFLAMMATORY - DRUGS TO TREAT PAIN AND INFLAMMATION CONDITIONS ...... 20 ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES ...... 20 ANTIRHEUMATIC - ENZYME INHIBITORS ...... 20 INTERLEUKIN-6 RECEPTOR INHIBITORS ...... 20 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) ...... 20 PHOSPHODIESTERASE 4 (PDE4) INHIBITORS ...... 23 PYRIMIDINE SYNTHESIS INHIBITORS ...... 23 SELECTIVE COSTIMULATION MODULATORS ...... 24 SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ...... 24 ANALGESICS - NONNARCOTIC ...... 24 ANALGESIC COMBINATIONS ...... 24 ANALGESICS OTHER ...... 24 SALICYLATES ...... 24 ANALGESICS - OPIOID - DRUGS TO TREAT PAIN ...... 25 OPIOID AGONISTS ...... 25 OPIOID COMBINATIONS ...... 30 OPIOID PARTIAL AGONISTS ...... 32 1 ANDROGENS-ANABOLIC - DRUGS TO REGULATE MALE HORMONES ...32 ANDROGENS ...... 32 ANORECTAL AND RELATED PRODUCTS ...... 33 RECTAL STEROIDS ...... 33 ANTACIDS - DRUGS FOR ULCERS AND STOMACH ACID ...... 33 ANTACID COMBINATIONS ...... 33 ANTACIDS - ALUMINUM SALTS ...... 34 ANTACIDS - BICARBONATE ...... 34 ANTACIDS - CALCIUM SALTS ...... 34 ANTACIDS - MAGNESIUM SALTS ...... 34 ANTHELMINTICS - DRUGS TO TREAT INFECTIONS OF PARASITES .....34 ANTHELMINTICS - DRUGS TO TREAT INFECTIONS OF PARASITES ...... 34 ANTI-INFECTIVE AGENTS - MISC. - DRUGS TO TREAT INFECTIONS ...34 ANTI-INFECTIVE AGENTS - MISC. - DRUGS TO TREAT INFECTIONS ...... 34 ANTI-INFECTIVE MISC. - COMBINATIONS ...... 35 ANTIPROTOZOAL AGENTS ...... 35 GLYCOPEPTIDES ...... 35 LEPROSTATICS ...... 35 LINCOSAMIDES ...... 36 MONOBACTAMS ...... 36 OXAZOLIDINONES ...... 36 URINARY ANTI-INFECTIVES - DRUGS TO TREAT URINARY TRACT INFECTIONS ...... 36 ANTIANGINAL AGENTS - DRUGS TO TREAT HEART CONDITIONS ...... 36 ANTIANGINALS-OTHER ...... 36 NITRATES ...... 36 ANTIANXIETY AGENTS - DRUGS TO TREAT ANXIETY ...... 37 ANTIANXIETY AGENTS - MISC...... 37 ANTIARRHYTHMICS - DRUGS TO TREAT HEART CONDITIONS ...... 38 ANTIARRHYTHMICS TYPE I-A ...... 38 ANTIARRHYTHMICS TYPE I-B ...... 38 ANTIARRHYTHMICS TYPE I-C ...... 38 ANTIARRHYTHMICS TYPE III ...... 38 ANTIASTHMATIC AND BRONCHODILATOR AGENTS - DRUGS TO TREAT ASTHMA AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE ...... 38 ANTI-INFLAMMATORY AGENTS ...... 38 ANTIASTHMATIC - MONOCLONAL ANTIBODIES ...... 38 BRONCHODILATORS - ANTICHOLINERGICS ...... 38 LEUKOTRIENE MODULATORS ...... 39 SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS ...... 39 STEROID INHALANTS ...... 39 SYMPATHOMIMETICS ...... 40 XANTHINES ...... 42 ANTICOAGULANTS - DRUGS TO PREVENT BLOOD CLOTS ...... 42 COUMARIN ANTICOAGULANTS ...... 42 DIRECT FACTOR XA INHIBITORS ...... 43 HEPARINS AND HEPARINOID-LIKE AGENTS ...... 43 2 THROMBIN INHIBITORS ...... 44 ANTIDIABETICS - DRUGS TO TREAT DIABETES ...... 44 ALPHA-GLUCOSIDASE INHIBITORS ...... 44 ANTIDIABETIC - AMYLIN ANALOGS ...... 44 ANTIDIABETIC COMBINATIONS ...... 44 BIGUANIDES ...... 46 DIABETIC OTHER ...... 47 DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS ...... 47 INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) ...... 47 INSULIN ...... 48 INSULIN SENSITIZING AGENTS ...... 49 MEGLITINIDE ANALOGUES ...... 49 SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS ...... 49 SULFONYLUREAS ...... 50 ANTIDIARRHEAL/PROBIOTIC AGENTS - DRUGS TO TREAT DIARRHEA ...... 51 ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC...... 51 ANTIPERISTALTIC AGENTS ...... 51 ANTIDOTES AND SPECIFIC ANTAGONISTS - DRUGS FOR OVERDOSE OR POISONING ...... 51 ANTIDOTES - CHELATING AGENTS ...... 51 OPIOID ANTAGONISTS ...... 51 ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING ...... 51 5-HT3 RECEPTOR ANTAGONISTS ...... 51 ANTIEMETICS - ANTICHOLINERGIC ...... 52 ANTIEMETICS - MISCELLANEOUS ...... 52 SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS ...... 52 ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ...... 52 ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ...... 52 IMIDAZOLE-RELATED ANTIFUNGALS ...... 53 ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES ...... 53 ANTIHISTAMINES - ALKYLAMINES ...... 53 ANTIHISTAMINES - ETHANOLAMINES ...... 54 ANTIHISTAMINES - NON-SEDATING ...... 54 ANTIHISTAMINES - PHENOTHIAZINES ...... 54 ANTIHISTAMINES - PIPERIDINES ...... 55 ANTIHYPERLIPIDEMICS - DRUGS TO TREAT HIGH CHOLESTEROL .....55 ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS ...... 55 ANTIHYPERLIPIDEMICS - COMBINATIONS ...... 55 ANTIHYPERLIPIDEMICS - MISC...... 55 BILE ACID SEQUESTRANTS ...... 55 FIBRIC ACID DERIVATIVES ...... 56 HMG COA REDUCTASE INHIBITORS ...... 57 INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ...... 58 NICOTINIC ACID DERIVATIVES ...... 58 PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS ...... 58 ANTIHYPERTENSIVES - DRUGS TO TREAT HIGH BLOOD PRESSURE ...59 3 ACE INHIBITORS ...... 59 ANGIOTENSIN II RECEPTOR ANTAGONISTS ...... 60 ANTIADRENERGIC ANTIHYPERTENSIVES ...... 62 ANTIHYPERTENSIVE COMBINATIONS ...... 62 DIRECT RENIN INHIBITORS ...... 67 VASODILATORS ...... 68 ANTIMALARIALS - DRUGS TO TREAT MALARIA ...... 68 ANTIMALARIALS - DRUGS TO TREAT MALARIA ...... 68 ANTIMYASTHENIC/CHOLINERGIC AGENTS - DRUGS TO TREAT MUSCLE DISORDERS ...... 68 ANTIMYASTHENIC/CHOLINERGIC AGENTS - DRUGS TO TREAT MUSCLE DISORDERS ...... 68 ANTIMYCOBACTERIAL AGENTS - DRUGS TO TREAT INFECTIONS ...... 68 ANTIMYCOBACTERIAL AGENTS - DRUGS TO TREAT INFECTIONS ...... 68 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - DRUGS TO TREAT CANCER ...... 69 ALKYLATING AGENTS ...... 69 ANTIMETABOLITES ...... 69 ANTINEOPLASTIC - BCL-2 INHIBITORS ...... 70 ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS ...... 70 ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS ...... 70 ANTINEOPLASTIC - IMMUNOMODULATORS ...... 71 ANTINEOPLASTIC - XPO1 INHIBITORS ...... 71 ANTINEOPLASTIC COMBINATIONS ...... 71 ANTINEOPLASTIC ENZYME INHIBITORS ...... 71 ANTINEOPLASTICS MISC...... 71 CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS ...... 72 MITOTIC INHIBITORS ...... 72 TOPOISOMERASE I INHIBITORS ...... 72 ANTIPARKINSON AND RELATED THERAPY AGENTS - DRUGS TO TREAT PARKINSONS DISEASE ...... 72 ANTIPARKINSON ADJUNCTIVE THERAPY ...... 72 ANTIPARKINSON COMT INHIBITORS ...... 72 ANTIPARKINSON DOPAMINERGICS ...... 72 ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS ...... 75 ANTIPSYCHOTICS/ANTIMANIC AGENTS - DRUGS TO TREAT PSYCHOSES ...... 75 PHENOTHIAZINES ...... 75 ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS ...... 75 CMV AGENTS ...... 75 HEPATITIS AGENTS ...... 75 HERPES AGENTS ...... 76 INFLUENZA AGENTS ...... 76 BETA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS ...... 77 ALPHA-BETA BLOCKERS ...... 77 BETA BLOCKERS CARDIO-SELECTIVE ...... 77 4 BETA BLOCKERS NON-SELECTIVE ...... 78 CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS ...... 80 CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS ...... 80 CARDIOTONICS - DRUGS TO TREAT HEART CONDITIONS ...... 84 CARDIAC GLYCOSIDES ...... 84 CARDIOVASCULAR AGENTS - MISC. - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ...... 84 CARDIOVASCULAR AGENTS MISC. - COMBINATIONS ...... 84 PROSTAGLANDIN VASODILATORS ...... 84 PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS ....85 PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ...... 85 PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST ...... 85 PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR ...86 TRANSTHYRETIN STABILIZERS ...... 86 VASOACTIVE SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC) ...... 86 CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS ...... 86 CEPHALOSPORINS - 1ST GENERATION ...... 86 CEPHALOSPORINS - 2ND GENERATION ...... 86 CEPHALOSPORINS - 3RD GENERATION ...... 87 CHEMICALS - PRODUCTS FOR DRUG COMPOUNDING ...... 87 LIQUIDS ...... 87 CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL ...... 87 COMBINATION CONTRACEPTIVES - ORAL ...... 87 COMBINATION CONTRACEPTIVES - TRANSDERMAL ...... 92 COMBINATION CONTRACEPTIVES - VAGINAL ...... 92 EMERGENCY CONTRACEPTIVES ...... 92 PROGESTIN CONTRACEPTIVES - INJECTABLE ...... 92 PROGESTIN CONTRACEPTIVES - ORAL ...... 92 CORTICOSTEROIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE .93 GLUCOCORTICOSTEROIDS ...... 93 MINERALOCORTICOIDS ...... 94 COUGH/COLD/ALLERGY - DRUGS TO TREAT COUGH, COLD, AND ALLERGY SYMPTOMS ...... 94 ANTITUSSIVES ...... 94 COUGH/COLD/ALLERGY COMBINATIONS ...... 94 EXPECTORANTS ...... 95 MISC. RESPIRATORY INHALANTS ...... 95 MUCOLYTICS ...... 95 DERMATOLOGICALS - DRUGS TO TREAT SKIN CONDITIONS ...... 95 ACNE PRODUCTS ...... 95 ANTI-INFLAMMATORY AGENTS - TOPICAL ...... 96 ANTIBIOTICS - TOPICAL ...... 96 ANTIFUNGALS - TOPICAL ...... 97 ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL ...... 98 ANTIPSORIATICS ...... 98 5 ANTISEBORRHEIC PRODUCTS ...... 99 ANTIVIRALS - TOPICAL ...... 99 BURN PRODUCTS ...... 99 CORTICOSTEROIDS - TOPICAL ...... 99 ECZEMA AGENTS ...... 103 EMOLLIENTS ...... 103 ENZYMES - TOPICAL ...... 104 IMMUNOMODULATING AGENTS - TOPICAL ...... 104 IMMUNOSUPPRESSIVE AGENTS - TOPICAL ...... 104 KERATOLYTIC/ANTIMITOTIC AGENTS ...... 104 LOCAL ANESTHETICS - TOPICAL ...... 104 PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL ...... 104 ROSACEA AGENTS ...... 104 SCABICIDES & PEDICULICIDES ...... 104 DIAGNOSTIC PRODUCTS - PRODUCTS FOR DIAGNOSIS ...... 105 DIAGNOSTIC TESTS ...... 105 DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS - DRUGS FOR NUTRITION ...... 105 DIETARY MANAGEMENT PRODUCTS ...... 105 NUTRITIONAL SUPPLEMENTS ...... 105 DIGESTIVE AIDS - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ...... 105 DIGESTIVE ENZYMES ...... 105 DIURETICS - DRUGS TO TREAT HEART CONDITIONS ...... 106 CARBONIC ANHYDRASE INHIBITORS ...... 106 DIURETIC COMBINATIONS ...... 106 LOOP DIURETICS ...... 106 POTASSIUM SPARING DIURETICS ...... 107 THIAZIDES AND THIAZIDE-LIKE DIURETICS ...... 107 ENDOCRINE AND METABOLIC AGENTS - MISC. - DRUGS TO REGULATE HORMONES ...... 107 BONE DENSITY REGULATORS...... 107 GNRH/LHRH ANTAGONISTS ...... 108 GROWTH HORMONES ...... 108 HORMONE RECEPTOR MODULATORS ...... 109 INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) ...... 109 METABOLIC MODIFIERS ...... 109 POSTERIOR PITUITARY HORMONES ...... 109 PROLACTIN INHIBITORS ...... 110 SOMATOSTATIC AGENTS ...... 110 ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES ...... 110 ESTROGEN COMBINATIONS ...... 110 ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES ...... 110 FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ...... 112 FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ...... 112 GASTROINTESTINAL AGENTS - MISC. - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ...... 112 6 5-HT4 RECEPTOR AGONISTS ...... 112 AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC) ...... 112 ANTIFLATULENTS ...... 112 GALLSTONE SOLUBILIZING AGENTS ...... 112 GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS ...... 113 GASTROINTESTINAL STIMULANTS ...... 113 INFLAMMATORY BOWEL AGENTS ...... 113 IRRITABLE BOWEL SYNDROME (IBS) AGENTS ...... 114 PERIPHERAL OPIOID RECEPTOR ANTAGONISTS ...... 114 PHOSPHATE BINDER AGENTS ...... 114 GENITOURINARY AGENTS - MISCELLANEOUS - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS ...... 115 ACIDIFIERS ...... 115 ALKALINIZERS ...... 115 INTERSTITIAL CYSTITIS AGENTS ...... 115 PROSTATIC HYPERTROPHY AGENTS ...... 115 URINARY ANALGESICS ...... 116 GOUT AGENTS - DRUGS TO TREAT GOUT ...... 116 GOUT AGENT COMBINATIONS ...... 116 GOUT AGENTS - DRUGS TO TREAT GOUT ...... 116 URICOSURICS ...... 116 HEMATOLOGICAL AGENTS - MISC. - DRUGS TO TREAT BLOOD DISORDERS ...... 116 HEMATORHEOLOGIC AGENTS ...... 116 PLATELET AGGREGATION INHIBITORS ...... 116 HEMATOPOIETIC AGENTS - DRUGS TO TREAT BLOOD DISORDERS ..117 AGENTS FOR SICKLE CELL DISEASE ...... 117 COBALAMINS ...... 117 FOLIC ACID/FOLATES ...... 117 HEMATOPOIETIC GROWTH FACTORS ...... 117 HEMATOPOIETIC MIXTURES ...... 118 IRON ...... 120 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS - DRUGS TO TREAT SLEEP DISORDERS ...... 121 NON-BARBITURATE HYPNOTICS ...... 121 LAXATIVES - DRUGS TO TREAT CONSTIPATION ...... 121 BULK LAXATIVES ...... 121 LAXATIVE COMBINATIONS ...... 122 LAXATIVES - MISCELLANEOUS ...... 122 LUBRICANT LAXATIVES ...... 123 SALINE LAXATIVES ...... 123 STIMULANT LAXATIVES ...... 123 SURFACTANT LAXATIVES ...... 124 MACROLIDES - DRUGS TO TREAT INFECTIONS ...... 124 AZITHROMYCIN ...... 124 CLARITHROMYCIN ...... 125 ERYTHROMYCINS ...... 125 7 FIDAXOMICIN ...... 125 MEDICAL DEVICES AND SUPPLIES - MEDICAL DEVICES AND SUPPLIES FOR DIAGNOSIS, TREATMENT, OR MONITORING ...... 125 CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL ...... 125 DIABETIC SUPPLIES ...... 126 MISC. DEVICES ...... 126 PARENTERAL THERAPY SUPPLIES ...... 126 RESPIRATORY AIDS ...... 127 RESPIRATORY THERAPY SUPPLIES ...... 127 MIGRAINE PRODUCTS - DRUGS TO TREAT SEVERE HEADACHES ...... 128 CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG ...... 128 MIGRAINE COMBINATIONS ...... 128 SEROTONIN AGONISTS ...... 128 MINERALS & ELECTROLYTES - DRUGS FOR NUTRITION ...... 130 CALCIUM ...... 130 ELECTROLYTE MIXTURES ...... 131 FLUORIDE ...... 132 MAGNESIUM ...... 132 MINERAL COMBINATIONS ...... 133 PHOSPHATE ...... 133 POTASSIUM ...... 133 MISCELLANEOUS THERAPEUTIC CLASSES ...... 134 IMMUNOMODULATORS ...... 134 IMMUNOSUPPRESSIVE AGENTS ...... 134 POTASSIUM REMOVING AGENTS ...... 135 MOUTH/THROAT/DENTAL AGENTS - DRUGS FOR THE MOUTH AND THROAT ...... 135 ANESTHETICS TOPICAL ORAL ...... 135 ANTI-INFECTIVES - THROAT ...... 135 ANTISEPTICS - MOUTH/THROAT ...... 135 DENTAL PRODUCTS ...... 135 STEROIDS - MOUTH/THROAT/DENTAL ...... 135 THROAT PRODUCTS - MISC...... 136 MULTIVITAMINS - DRUGS FOR NUTRITION ...... 136 B-COMPLEX VITAMINS ...... 136 B-COMPLEX W/ C ...... 136 B-COMPLEX W/ FOLIC ACID ...... 136 B-COMPLEX W/ IRON ...... 137 B-COMPLEX W/ MINERALS ...... 137 IRON W/ VITAMINS ...... 137 MULTIPLE VITAMINS W/ CALCIUM ...... 137 MULTIPLE VITAMINS W/ IRON ...... 137 MULTIPLE VITAMINS W/ MINERALS ...... 137 MULTIPLE VITAMINS W/ MINERALS & CALCIUM-FOLIC ACID ...... 141 MULTIVITAMINS - DRUGS FOR NUTRITION ...... 141 PED MULTI VITAMINS W/FL & FE ...... 142 PED MULTIPLE VITAMINS W/ MINERALS ...... 142 8 PED MV W/ FLUORIDE ...... 142 PED MV W/ IRON ...... 142 PEDIATRIC MULTIPLE VITAMINS ...... 143 PEDIATRIC VITAMINS ...... 143 PRENATAL VITAMINS ...... 143 SPECIALTY VITAMINS PRODUCTS ...... 144 VITAMIN MIXTURES ...... 144 VITAMINS W/ LIPOTROPICS ...... 144 MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS ...... 144 CENTRAL MUSCLE RELAXANTS ...... 144 DIRECT MUSCLE RELAXANTS ...... 145 MUSCLE RELAXANT COMBINATIONS ...... 145 VISCOSUPPLEMENTS ...... 145 NASAL AGENTS - SYSTEMIC AND TOPICAL - DRUGS FOR THE NOSE 145 NASAL AGENT COMBINATIONS ...... 145 NASAL AGENTS - MISC...... 145 NASAL ANTIALLERGY ...... 145 NASAL ANTICHOLINERGICS ...... 146 NASAL STEROIDS ...... 146 NUTRIENTS - DRUGS FOR NUTRITION ...... 146 MISC. NUTRITIONAL SUBSTANCES ...... 146 OPHTHALMIC AGENTS - DRUGS TO TREAT EYE CONDITIONS ...... 147 ARTIFICIAL TEARS AND LUBRICANTS ...... 147 BETA-BLOCKERS - OPHTHALMIC ...... 147 CYCLOPLEGIC MYDRIATICS ...... 148 MIOTICS ...... 148 OPHTHALMIC ADRENERGIC AGENTS ...... 148 OPHTHALMIC ANTI-INFECTIVES ...... 149 OPHTHALMIC DECONGESTANTS ...... 149 OPHTHALMIC IMMUNOMODULATORS ...... 150 OPHTHALMIC KINASE INHIBITORS ...... 150 OPHTHALMIC LOCAL ANESTHETICS ...... 150 OPHTHALMIC NERVE GROWTH FACTORS ...... 150 OPHTHALMIC STEROIDS ...... 150 OPHTHALMICS - MISC...... 150 PROSTAGLANDINS - OPHTHALMIC ...... 151 OTIC AGENTS - DRUGS TO TREAT CONDITIONS OF THE EAR ...... 152 OTIC AGENTS - MISCELLANEOUS ...... 152 OTIC ANTI-INFECTIVES ...... 152 OTIC COMBINATIONS ...... 152 OTIC STEROIDS ...... 152 OXYTOCICS - DRUGS FOR PREGNANCY ...... 152 OXYTOCICS - DRUGS FOR PREGNANCY ...... 152 PASSIVE IMMUNIZING AND TREATMENT AGENTS - DRUGS FOR IMMUNE SYSTEM CONDITIONS ...... 152 MONOCLONAL ANTIBODIES ...... 152 9 PENICILLINS - DRUGS TO TREAT INFECTIONS ...... 152 AMINOPENICILLINS ...... 152 NATURAL PENICILLINS...... 153 PENICILLIN COMBINATIONS ...... 153 PENICILLINASE-RESISTANT PENICILLINS ...... 153 PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES ...... 153 PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES...... 153 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ...... 154 AGENTS FOR CHEMICAL DEPENDENCY ...... 154 ANTI-CATAPLECTIC AGENTS ...... 154 ANTIDEMENTIA AGENTS...... 154 FIBROMYALGIA AGENTS...... 156 MOVEMENT DISORDER DRUG THERAPY...... 156 MULTIPLE SCLEROSIS AGENTS ...... 156 POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS ...... 157 RESTLESS LEG SYNDROME (RLS) AGENTS ...... 157 SMOKING DETERRENTS ...... 157 RESPIRATORY AGENTS - MISC. - DRUGS FOR THE LUNGS ...... 158 CYSTIC FIBROSIS AGENTS ...... 158 TETRACYCLINES - DRUGS TO TREAT INFECTIONS ...... 158 TETRACYCLINES - DRUGS TO TREAT INFECTIONS ...... 158 THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS ...... 158 ANTITHYROID AGENTS...... 158 THYROID HORMONES ...... 158 TOXOIDS - DRUGS TO PREVENT INFECTIONS...... 160 TOXOID COMBINATIONS ...... 160 ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS - DRUGS FOR ULCERS AND STOMACH ACID ...... 160 ANTISPASMODICS...... 160 H-2 ANTAGONISTS ...... 160 MISC. ANTI-ULCER ...... 160 PROTON PUMP INHIBITORS ...... 160 ULCER DRUGS - PROSTAGLANDINS ...... 162 ULCER THERAPY COMBINATIONS ...... 162 URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE ...... 163 URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) ...163 URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS...... 164 URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS...... 164 URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS...... 164 VACCINES - DRUGS TO PREVENT INFECTIONS ...... 164 BACTERIAL VACCINES ...... 164 VIRAL VACCINES...... 164 VAGINAL AND RELATED PRODUCTS - DRUGS TO TREAT VAGINAL CONDITIONS...... 164 SPERMICIDES ...... 164 10 VAGINAL ANTI-INFECTIVES ...... 165 VAGINAL ESTROGENS ...... 165 VAGINAL PROGESTINS ...... 165 VASOPRESSORS - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ...... 165 ANAPHYLAXIS THERAPY AGENTS ...... 165 VASOPRESSORS - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ...... 166 VITAMINS - DRUGS FOR NUTRITION ...... 166 OIL SOLUBLE VITAMINS ...... 166 WATER SOLUBLE VITAMINS ...... 166 Index ...... 168

11 Molina Healthcare of Michigan Preferred Drug List (Formulary)

(08/01/2021)

INTRODUCTION The Michigan Department of Health and Human Services has worked with its health plan partners to create a list of drugs that all Medicaid health plans must cover. This list is called the Michigan Medicaid Managed Care Common Formulary.

The 2021 Molina Healthcare of Michigan Preferred Drug List (Formulary) is the Michigan Medicaid Managed Care Common Formulary. We are pleased to provide this Formulary as a useful reference and informational tool. This document can assist medical providers in selecting clinically appropriate and cost-effective products for their patients.

The drugs represented have been reviewed by a Pharmacy and Therapeutics (P&T) Committee and are approved for inclusion. The document is reflective of current medical practice as of the date of review.

This Formulary is up to date through its date of publication. Please notify Molina Healthcare of Michigan at [email protected] or 1-855-322-4077 with any mistakes in the formulary.

Molina Healthcare of Michigan only covers drugs made by a manufacturer that participates in the Federal Medicaid drug rebate program. Drugs obtained through the Molina Healthcare of Michigan prescription drug benefit are covered at no cost to the member.

The information contained in this document and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. All the information in the document is provided as a reference for drug therapy selection.

The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information. PREFACE The document is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Products are listed by generic name with brand name for reference only. Unless the cited drug is available as an injectable or an exception is specifically noted, generally, all applicable dosage forms and strengths of the drug cited are included in the document. PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of the Common Formulary Committee, the State of Michigan Pharmacy and Therapeutics Committee (“P&T Committee”), and Molina Healthcare’s Pharmacy and Therapeutics Committee are utilized to approve safe and clinically effective drug therapies. Committee voting members include physicians and pharmacists, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

12 DRUG LIST PRODUCT DESCRIPTIONS To assist in understanding which specific strengths and dosage forms on the document are covered, general principles are noted below.

 The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR). Generic drugs are listed in lowercase italics (e.g., atorvastatin).  Listed products on the document generally include all strengths and dosage forms of the cited product.  This document may not contain all available dosage forms (including injectable dosage forms).  If the OTC and Prescription versions of the product are covered, then both are listed.  Extended-release and delayed-release products are listed separately.  Dosage forms on the document will be consistent with the category and use where listed. GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. In this document, lowercase italicized type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. This document is subject to state specific regulations and rules regarding generic substitution and mandatory generic rules apply where appropriate.

Generic drugs are usually priced lower than their brand-name equivalents. Prescription generic drugs are:

 Approved by the U.S. Food and Drug Administration for safety and efficacy and are manufactured under the same strict standards that apply to brand-name drugs.  Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different from the brand in size, color and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.  Manufactured in the same strength and dosage form as the brand-name drugs.

When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence). PLAN DESIGN The document represents a closed formulary plan design. The medications listed on the document are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits, etc.); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non- formulary prescription request criteria. Log in to www.molinahealthcare.com to check coverage. CATEGORIES OF CONSIDERATION OPIOID ANALGESICS

All Opioid Analgesics are subject to a Morphine Equivalent Dose of 90MME per day and Acute Pain Duration Limits.

PRIOR AUTHORIZATION REQUEST PROCEDURE Prescriptions for medications requiring prior approval or for medications not included on the Molina Drug Formulary may be approved when medically necessary and when formulary options have demonstrated ineffectiveness. When these exceptional situations arise, the physician may fax a completed drug prior authorization form to Molina at (888) 373-3059. The forms may be obtained by logging into the website www.molinahealthcare.com. Trials of pharmaceutical samples will not be considered as rationale for approving a prior authorization request.

13 PRIOR AUTHORIZATION HELPFUL HINTS To ensure the quickest response possible from Molina Healthcare of Michigan Pharmacy Department, please provide relevant information with the Prior Authorization request such as medication log, progress notes documenting previous use of Formulary medications, and/or lab reports.

LEGEND AGE Age Limit MED Max 90 mg Morphine EQ Dose Per Day OTC Over-the-counter, covered benefit with a prescription PA Prior Authorization QL Quantity Limit SP Specialty Drug; these drugs must be obtained through a specialty pharmacy ST Step Therapy Biologic MI Biologic Class Preferred Preferred product, requires Prior Authorization if PA indicator is present Non-preferred Non-Preferred product, requires Prior Authorization and documentation of medical necessity

REQUESTING FORMULARY CHANGES If you are a prescriber and would like to request a formulary change, please submit your request and rationale to the Michigan Medicaid Health Plan Common Formulary with your contact information.

Email: [email protected]

STATE OF MICHIGAN, MEDICAID CARVE-OUT The State of Michigan enacted a carve-out for Medicaid beneficiaries. This impacts all Medicaid members including Healthy Michigan Medicaid members. Claims for these medications must be submitted directly to the State Fee-for-Service Pharmacy Program, Magellan. These medications are subject to a $1.10 or $3.30 copay. The Medicaid Carve-Out includes:

 ADHD Stimulants  Anticonvulsants  Antidepressants  Antipsychotics  Antiretroviral Agents  Benzodiazepines  Drugs to treat substance abuse disorders  Hemophilia Factor products  Hepatitis C Agents  Kinase Inhibitors  Mood Stabilizers

STATE OF MICHIGAN, MEDICAID CARVE-OUT LIST Medications on the Medicaid Carve-Out List include all dosage forms, i.e. oral, injectable, etc.

ABILIFY (aripiprazole) ADAGEN (pegademase bovine) dextroamphetamine ER) ABILIFY MYCITE (aripiprazole tab with ADASUVE (loxapine) ADHANSIA XR (methylphenidate ER) sensor) ADDERALL (amphetamine- ADVATE (antihemophilic factor) ACTHAR (corticotropin) dextroamphetamine) ADYNOVATE (antihemophilic factor) ACTHREL (corticorelin ovine) ADDERALL XR (amphetamine- ADZENYS XR-ODT (amphetamine ER)

14 AFSTYLA (antihemophilic factor) CELEXA (citalopram) EMSAM (selegiline) ALBURX (albumin, human) CELONTIN (methsuximide) EMTRIVA (emtricitabine) ALDURAZYME (laronidase) CEPHULAC ** (lactulose) EPCLUSA (sofosbuvir-velpatasvir) ALECENSA (alectinib) CEPROTIN (protein C concentrate) EPIDIOLEX (cannabidiol) ALPHANATE (antihemophilic factor/VWF) CERDELGA (eliglustat) EPIVIR (lamivudine) ALPHANINE SD (coagulation factor IX) CEREBYX (fosphenytoin) EPZICOM (abacavir-lamivudine) ALPROLIX (coagulation factor IX) CEREDASE (alglucerase) EQUETRO (carbamazepine ER) ALUNBRIG (brigatinib) CEREZYME (imiglucerase) ESKALITH (lithium carbonate) AMBIEN (zolpidem) CINRYZE (C1 esterase inhibitor) ESKALITH CR (lithium carbonate ER) AMBIEN CR (zolpidem ER) CLOZARIL (clozapine) ESPEROCT (antihemophilic factor) AMICAR (aminocaproic acid) COGENTIN (benztropine) ETRAFON (perphenazine-amitriptyline) AMMONUL (sodium benzoate-sodium COMBIVIR (lamivudine-zidovudine) EVEKEO (amphetamine) phenylacetate) COMETRIQ (cabozantinib) EVOTAZ (atazanavir-cobicistat) ANAFRANIL (clomipramine) CONCERTA (methylphenidate ER) EVRYSDI (risdiplam) ANTABUSE (disulfiram) COPIKTRA (duvelisib) EXONDYS 51 (eteplirsen) APLENZIN (bupropion ER) CORIFACT (factor XIII concentrate) FABRAZYME (agalsidase beta) APTENSIO XR (methylphenidate ER) CORTROSYN (cosyntropin) FANATREX (gabapentin) APTIOM (eslicarbazepine) COSELA (trilaciclib dihydrochloride) FANAPT (iloperidone) APTIVUS (tipranavir) COTELLIC (cobimetinib) FAZACLO (clozapine) ARCALYST (rilonacept) CRIXIVAN (indinavir) FEIBA VH (anti inhibitor coagulant ARISTADA (aripiprazole lauroxil ER) CYKLOKAPRON (tranexamic acid) complex) ARTANE (trihexyphenidyl) CYMBALTA (duloxetine DR) FELBATOL (felbamate) ASENDIN (amoxapine) CYSTADANE (betaine) FETZIMA (levomilnacipran) ATIVAN (lorazepam) DAKLINZA (daclatasvir) FINTEPLA (fenfluramine HCl) ATRIPLA (efavirenz-emtricitabine- DALMANE (flurazepam) FIRDAPSE (amifampridine) tenofovir disoproxil) DAYTRANA (methylphenidate) FOCALIN (dexmethylphenidate) ATRYN (antithrombin) DAYVIGO (lemborexant) FOCALIN XR (dexmethylphenidate ER) AYVAKIT (avapritinib) DELSTRIGO (doravirine-lamivudine- FORFIVO XL (bupropion ER) BANZEL (rufinamide) tenofovir disoproxil) FOVEX (dietary management caps) BELSOMRA (suvorexant) DEPACON (valproate) FUZEON (enfuvirtide) BENEFIX (coagulation factor IX) DEPAKENE (valproic acid) FYCOMPA (perampanel) BERINERT (C1 esterase inhibitor) DEPAKOTE (divalproex sodium DR) GABACAINE (gabapentin/lidocaine) BIKTARVY (bictegravir-emtricitabine- DEPAKOTE ER (divalproex sodium ER) GABITRIL (tiagabine) tenofovir alafenamide) DESCOVY (emtricitabine-tenofovir GALAFOLD (migalastat) BOSULIF (bosutinib) alafenamide) GENVOYA (elvitegravir-cobicistat- BRISDELLE (paroxetine mesylate) DESOXYN (methamphetamine) emtricitabine-tenofovir alafenamide) BRIVIACT (brivaracetam) DESYREL (trazodone) GEODON (ziprasidone) BRUKINSA (zanubrutinib) DEXEDRINE (dextroamphetamine) GILOTRIF (afatinib) BUNAVAIL (buprenorphine-naloxone) DIASTAT (diazepam) GLEEVEC (imatinib) BUPHENYL (sodium phenylbutyrate) DILANTIN (phenytoin) HAEGARDA (C1 esterase inhibitor) BUSPAR (buspirone) DRIZALMA (duloxetine DR) HALCION (triazolam) BUTISOL (butabarbital) DYANAVEL XR (amphetamine ER) HALDOL (haloperidol) CABOMETYX (cabozantinib) EDURANT (rilpivirine) HARVONI (ledipasvir-sofosbuvir) CAMPRAL (acamprosate) EFFEXOR (venlafaxine) HELIXATE (antihemophilic factor) CAPLYTA (lumateperone) EFFEXOR XR (venlafaxine ER) HEMOFIL M (antihemophilic factor) CAPRELSA (vandetanib) ELAPRASE (idursulfase) HETLIOZ (tasimelteon) CARBAGLU (carglumic acid) ELAVIL (amitriptyline) HETLIOZ LQ (tasimelteon) CARBATROL (carbamazepine ER) ELELYSO (taliglucerase alfa) HUMATE-P (antihemophilic factor/VFW) CARNITOR (levocarnitine) ELOCTATE (antihemophilic factor) IBRANCE (palbociclib)

15 ICLUSIG (ponatinib) LUDIOMIL (maprotiline) OCTAPLAS (plasma, human) IDELVION (coagulation factor IX) LUMINAL (phenobarbital) ODEFSEY (emtricitabine-rilpivirine- ILARIS (canakinumab) LUMIZYME (alglucosidase alfa) tenofovir alafenamide) IMBRUVICA (ibrutinib) LUNESTA (eszopiclone) OLEPTRO (trazodone ER) INAPSINE (droperidol) LUVOX (fluvoxamine) ONFI (clobazam) INLYTA (axitinib) LUVOX CR (fluvoxamine ER) ORAP (pimozide) INREBIC (fedratinib) LYNPARZA (olaparib) ORFADIN (nitisinone) INTELENCE (etravirine) LYRICA (pregabalin) ORKAMBI (lumacaftor-ivacaftor) INTERMEZZO (zolpidem) LYRICA CR (pregabalin ER) OXTELLAR XR (oxcarbazepine ER) INTUNIV (guanfacine ER) LYSTEDA (tranexamic acid) PAMELOR (nortriptyline) INVEGA (paliperidone ER) MARPLAN (isocarboxazid) PANHEMATIN (hemin) INVIRASE (saquinavir) MAVYRET (glecaprevir-pibrentasvir) PARNATE (tranylcypromine) IRENKA (duloxetine DR) MEKINIST (trametinib) PAXIL (paroxetine HCl) IRESSA (gefitinib) MEKTOVI (binimetinib) PAXIL CR (paroxetine HCl ER) ISENTRESS (raltegravir) MELLARIL (thioridazine) PEGANONE (ethotoin) IXINITY (coagulation factor IX) METADATE CD (methylphenidate ER) PEGASYS (peginterferon alfa-2a) JIVI (antihemophilic factor, recombinant) METADATE ER (methylphenidate ER) PEGINTRON (peginterferon alfa-2b) JORNAY PM (methylphenidate ER) METHYLIN (methylphenidate) PEMAZYRE (pemigatinib) KALBITOR (ecallantide) MILTOWN (meprobamate) PERMITAL (dimenhydrinate) KALETRA (lopinavir-ritonavir) MOBAN (molindone) PERSERIS (risperidone ER injection) KALYDECO (ivacaftor) MONOCLATE-P (antihemophilic factor) PEXEVA (paroxetine mesylate) KAPVAY (clonidine ER) MONONINE (coagulation factor IX) PHENYTEK (phenytoin ER) KEPPRA (levetiracetam) MYALEPT (metreleptin) PIFELTRO (doravirine) KEPPRA XR (levetiracetam ER) MYDAYIS ER (amphetamine- PLASMANATE (plasma protein fraction) KETAMINE (ketamine HCl troche) dextroamphetamine) POTIGA (ezogabine) KHEDEZLA (desvenlafaxine ER) MYSOLINE (primidone) PREZCOBIX (darunavir-cobicistat) KINERET (anakinra) NAGLAZYME (galsulfase) PREZISTA (darunavir) KISQALI (ribociclib) NARDIL (phenelzine) PRISTIQ (desvenlafaxine succinate ER) KLONOPIN (clonazepam) NAVANE (thiothixene) PROLIXIN (fluphenazine) KOATE-DVI (antihemophilic factor) NAYZILAM (midazolam) PROSOM (estazolam) KOGENATE FS (antihemophilic factor) NEOKE BCAA4 (dietary management PROVIGIL (modafinil) KOSELUGO (selumetinib sulfate) powder) PROZAC (fluoxetine) KUVAN (sapropterin) NERLYNX (neratinib) PROZAC WEEKLY (fluoxetine DR) KYPROLIS (carfilzomib) NEURONTIN (gabapentin) QINLOCK (ripretinib) LAMICTAL (lamotrigine) NEXAVAR (sorafenib) QUDEXY XR (topiramate ER) LAMICTAL XR (lamotrigine ER) NINLARO (ixazomib) QUILLICHEW ER (methylphenidate chew LATUDA (lurasidone) NIRAVAM (alprazolam) tab ER) LENVIMA (lenvatinib) NITYR (nitisinone) QUILLIVANT XR (methylphenidate ER) LEXAPRO (escitalopram) NORPRAMIN (desipramine) RAVICTI (glycerol LEXIVA (fosamprenavir) NORTRIPTYLINE (nortriptyline solution) phenylbutyrate) LIBRIUM (chlordiazepoxide) NORVIR (ritonavir) RECOMBINATE (antihemophilic factor) LIMBITROL (amitriptyline- NOVOEIGHT (antihemophilic factor) REMERON (mirtazapine) chlordiazepoxide) NOVOSEVEN (coagulation factor VIIa) RESCRIPTOR (delavirdine) LIMBITROL DS (amitriptyline- NOVOSEVEN RT (coagulation factor RESTORIL (temazepam) chlordiazepoxide) VIIa) RETEVMO (selpercatinib) LITHOBID (lithium carbonate ER) NUPLAZID (pimavanserin) RETROVIR (zidovudine) LITHOSTAT (acetohydroxamic acid) NUVIGIL (armodafinil) REVCOVI (elapegademase) LORBRENA (lorlatinib) NUWIQ (antihemophilic factor) REVIA (naltrexone) LOXITANE (loxapine) OBIZUR (antihemophilic factor) REXULTI (brexpiprazole)

16 REYATAZ (atazanavir) emtricitabine-tenofovir alafenamide) + dasabuvir) RIASTAP (fibrinogen) TABRECTA (capmatinib hydrochloride) VIEKIRA XR (dasabuvir-ombitasvir- RIBAVIRIN (ribavirin) TAFINLAR (dabrafenib) paritaprevir-ritonavir ER) RISPERDAL (risperidone) TAGRISSO (osimertinib) VIIBRYD (vilazodone) RITALIN (methylphenidate) TAKHZYRO (lanadelumab-flyo) VIMIZIM (elosulfase alfa) RITALIN LA, SR (methylphenidate ER) TALZENNA (talazoparib) VIMPAT (lacosamide) RIXUBIS (coagulation factor IX) TARCEVA (erlotinib) VIRACEPT (nelfinavir) ROZEREM (ramelteon) TASIGNA (nilotinib) VIRAMUNE (nevirapine) ROZLYTREK (entrectinib) TECHNIVIE (ombitasvir-paritaprevir- VIRAMUNE XR (nevirapine ER) RUBRACA (rucaparib) ritonavir) VIREAD (tenofovir disoproxil) RUCONEST (C1 esterase inhibitor) TEGRETOL (carbamazepine) VIVACTIL (protriptyline) RYDAPT (midostaurin) TEGRETOL XR (carbamazepine ER) VIVITROL (naltrexone ER) SABRIL (vigabatrin) TEPMETKO (tepotinib HCl) VIZIMPRO (dacomitinib) SAPHRIS (asenapine) THORAZINE (chlorpromazine) VONVENDI (Von Willebrand factor) SARAFEM (fluoxetine HCl) THROMBATE III (antithrombin III) VOSEVI (sofosbuvir-velpatasvir- SECUADO (asenapine) TIVICAY (dolutegravir) voxilaprevir) SECONAL (secobarbital) TOFRANIL (imipramine HCl) VOTRIENT (pazopanib) SELZENTRY (maraviroc) TOFRANIL-PM (imipramine pamoate) VPRIV (velaglucerase alfa) SERAX (oxazepam) TOPAMAX (topiramate) VRAYLAR (cariprazine) SEROQUEL (quetiapine) TRANXENE (clorazepate) VYONDYS 53 (golodirsen) SEROQUEL XR (quetiapine ER) TRETTEN (coagulation factor XIII A- VYVANSE (lisdexamfetamine) SERZONE (nefazodone) subunit) WAKIX (pitolisant) SEVENFACT (coagulation VIIa, recomb- TRIAVIL (perphenazine-amitriptyline) WELLBUTRIN (bupropion) jncw) TRILAFON (perphenazine) WELLBUTRIN SR, XL (bupropion ER) SILENOR (doxepin) TRILEPTAL (oxcarbazepine) WILATE (antihemophilic factor/VFW) SINEQUAN (doxepin) TRINTELLIX (vortioxetine) XALKORI (crizotinib) SOLIRIS (eculizumab) TRIUMEQ (abacavir-dolutegravir- XANAX (alprazolam) SONATA (zaleplon) lamivudine) XANAX XR (alprazolam ER) SOVALDI (sofosbuvir) TRIZIVIR (abacavir-lamivudine- XCOPRI (cenobamate) SPINRAZA (nusinersen sodium/pf) zidovudine) XOSPATA (gilteritinib) SPRAVATO (esketamine HCl) TROKENDI XR (topiramate ER) XYNTHA (antihemophilic factor) SPRITAM (levetiracetam) TRUVADA (emtricitabine-tenofovir ZARONTIN (ethosuximide) SPRYCEL (dasatinib) disoproxil) ZAVESCA (miglustat) STELAZINE (trifluoperazine) TURALIO (pexidartinib) ZEJULA (niraparib) STIVARGA (regorafenib) TYBOST (cobicistat) ZELBORAF (vemurafenib) STRATTERA (atomoxetine) TYKERB (lapatinib) ZENZEDI (dextroamphetamine) STRIBILD (elvitegravir-cobicistat- UKONIQ (umbralisib tosylate) ZEPATIER (elbasvir-grazoprevir) emtricitabine-tenofovir disoproxil) ULTOMIRIS (ravulizumab-cwvz) ZERIT (stavudine) SUBOXONE (buprenorphine-naloxone) VALIUM (diazepam) ZIAGEN (abacavir) SUBUTEX (buprenorphine) VALTOCO (diazepam) ZOLOFT (sertraline) SUNOSI (solriamfetol) VANSPAR (buspirone) ZOLPIMIST (zolpidem tartrate) SURMONTIL (trimipramine) VELCADE (bortezomib) ZONEGRAN (zonisamide) SUSTIVA (efavirenz) VERSACLOZ (clozapine) ZUBSOLV (buprenorphine-naloxone) SUTENT (sunitinib) VERZENIO (abemaciclib) ZYDELIG (idelalisib) SYMBYAX (olanzapine-fluoxetine) VIDEX (didanosine) ZYKADIA (ceritinib) SYMDEKO (tezacaftor-ivacaftor) VIDEX EC(didanosine DR) ZYPREXA (olanzapine SYMTUZA (darunavir-cobicistat- VIEKIRA (ombitasvir-paritaprevir-ritonavir

** CEPHULAC (lactulose) is carved out for the treatment of Hepatic Encephalopathy only

17 NON-COVERED MEDICATIONS Please note that certain medications are not covered. These may include, but are not limited to:

 Anorexiants for weight loss  Drugs for Cosmetic Purposes  Experimental or Investigational Medications  Convenience Dosage Forms not listed in the Formulary  Fertility Drugs  Sexual Dysfunction Drugs  OTC Medications not listed on the Formulary  Medications used for non-FDA approved indications, unless approved by Medical Director  Pharmaceuticals determined by the Federal Drug Administration (FDA) to be less than effective and identical, related or similar drugs (frequently referred to as “DESI 5 and 6” drugs)

URGENT AND AFTER-HOURS MEDICATION POLICY To prevent a member’s condition from worsening in an urgent situation, it may be necessary to dispense a 72-hour supply of an acute medication before prior authorization may be obtained from Molina Healthcare. (e.g., a member is discharged from a hospital after regular business hours with a special antibiotic prescription). Pharmacies are instructed to use their professional judgment. Molina Healthcare will reimburse pharmacies for a 72-hour supply of an acute medication at contracted rates for these prescriptions. Pharmacies may contact CVS Caremark Help Desk at (800) 364-6331 to obtain an override for a 72-hour supply.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers.

18 Effective: 08/01/2021 Drug Name Drug Tier Requirements/Limits ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANALEPTICS caffeine citrate oral soln 60 mg/3ml (10 Pref AGE mg/ml base equiv) ALLERGENIC EXTRACTS/BIOLOGICALS MISC - DRUGS FOR ALLERGIES ALLERGENIC EXTRACTS PALFORZIA CAP ESCALAT Pref SP, PA, AGE PALFORZIA CAP LEVEL 1 Pref SP, PA, AGE PALFORZIA CAP LEVEL 2 Pref SP, PA, AGE PALFORZIA CAP LEVEL 3 Pref SP, PA, AGE PALFORZIA CAP LEVEL 4 Pref SP, PA, AGE PALFORZIA CAP LEVEL 5 Pref SP, PA, AGE PALFORZIA CAP LEVEL 6 Pref SP, PA, AGE PALFORZIA CAP LEVEL 7 Pref SP, PA, AGE PALFORZIA CAP LEVEL 8 Pref SP, PA, AGE PALFORZIA CAP LEVEL 9 Pref SP, PA, AGE PALFORZIA CAP LEVEL 10 Pref SP, PA, AGE PALFORZIA POW LEVEL 11 Pref SP, PA, AGE ALTERNATIVE MEDICINES - COMPLEMENTARY AND ALTERNATIVE MEDICINES ALTERNATIVE MEDICINE - M'S melatonin liquid 1 mg/ml Pref OTC melatonin tab 3 mg Pref QL, AGE, OTC melatonin tab 5 mg Pref QL, AGE, OTC sleep child/ liq melatoni Pref OTC AMINOGLYCOSIDES - DRUGS TO TREAT INFECTIONS AMINOGLYCOSIDES - DRUGS TO TREAT INFECTIONS BETHKIS NEB 300/4ML Pref SP, QL KITABIS PAK NEB 300/5ML Pref SP, QL neomycin sulfate tab 500 mg Pref QL paromomycin sulfate cap 250 mg (generic Pref QL of HUMATIN) TOBI NEB 300/5ML Non-Pref SP, PA, QL TOBI PODHALR CAP 28MG Pref SP, QL tobramycin nebu soln 300 mg/4ml (generic Non-Pref SP, PA, QL of BETHKIS) tobramycin nebu soln 300 mg/5ml (generic Non-Pref SP, PA, QL of KITABIS PAK)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 19 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ANALGESICS - ANTI-INFLAMMATORY - DRUGS TO TREAT PAIN AND INFLAMMATION CONDITIONS ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA INJ 10/0.1ML Pref SP; BIOLOGIC HUMIRA INJ 20/0.2ML Pref SP; BIOLOGIC HUMIRA INJ 40/0.4ML Pref SP; BIOLOGIC HUMIRA KIT 40MG/0.8 Pref SP; BIOLOGIC HUMIRA PEDIA INJ CROHNS Pref SP; BIOLOGIC HUMIRA PEN INJ 40/0.4ML Pref SP; BIOLOGIC HUMIRA PEN INJ 40MG/0.8 Pref SP; BIOLOGIC HUMIRA PEN INJ 80/0.8ML Pref SP; BIOLOGIC HUMIRA PEN INJ CD/UC/HS Pref SP; BIOLOGIC HUMIRA PEN INJ PS/UV Pref SP; BIOLOGIC HUMIRA PEN KIT CD/UC/HS Pref SP; BIOLOGIC HUMIRA PEN KIT PED UC Pref SP; BIOLOGIC HUMIRA PEN KIT PS/UV Pref SP; BIOLOGIC SIMPONI ARIA SOL 50MG/4ML Non-Pref SP, PA; BIOLOGIC SIMPONI INJ 50/0.5ML Non-Pref SP, PA; BIOLOGIC SIMPONI INJ 100MG/ML Non-Pref SP, PA; BIOLOGIC ANTIRHEUMATIC - ENZYME INHIBITORS OLUMIANT TAB 1MG Non-Pref SP, PA; BIOLOGIC OLUMIANT TAB 2MG Non-Pref SP, PA; BIOLOGIC RINVOQ TAB 15MG ER Non-Pref SP, PA; BIOLOGIC XELJANZ SOL 1MG/ML Non-Pref SP, PA; BIOLOGIC XELJANZ TAB 5MG Non-Pref SP, PA; BIOLOGIC XELJANZ TAB 10MG Non-Pref SP, PA; BIOLOGIC XELJANZ XR TAB 11MG Non-Pref SP, PA; BIOLOGIC XELJANZ XR TAB 22MG Non-Pref SP, PA; BIOLOGIC INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA INJ 162/0.9 Non-Pref SP, PA; BIOLOGIC ACTEMRA INJ ACTPEN Non-Pref SP, PA; BIOLOGIC KEVZARA INJ 150/1.14 Non-Pref SP, PA; BIOLOGIC KEVZARA INJ 200/1.14 Non-Pref SP, PA; BIOLOGIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) ARTHROTEC 50 TAB Non-Pref PA ARTHROTEC 75 TAB Non-Pref PA CELEBREX CAP 50MG Non-Pref ST, PA, QL CELEBREX CAP 100MG Non-Pref ST, PA, QL CELEBREX CAP 200MG Non-Pref ST, PA, QL CELEBREX CAP 400MG Non-Pref ST, PA, QL celecoxib cap 50 mg (generic of Pref ST, QL CELEBREX)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 20 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits celecoxib cap 100 mg (generic of Pref ST, QL CELEBREX) celecoxib cap 200 mg (generic of Pref ST, QL CELEBREX) celecoxib cap 400 mg (generic of Pref ST, QL CELEBREX) DAYPRO TAB 600MG Non-Pref PA diclofenac potassium tab 50 mg Non-Pref PA diclofenac sodium tab delayed release 25 Pref mg diclofenac sodium tab delayed release 50 Pref mg diclofenac sodium tab delayed release 75 Pref mg diclofenac sodium tab er 24hr 100 mg Non-Pref PA diclofenac w/ misoprostol tab delayed Non-Pref PA release 50-0.2 mg (generic of ARTHROTEC 50) diclofenac w/ misoprostol tab delayed Non-Pref PA release 75-0.2 mg (generic of ARTHROTEC 75) DUEXIS TAB 800-26.6 Non-Pref PA EC-NAPROSYN TAB 375MG Non-Pref PA EC-NAPROSYN TAB 500MG Non-Pref PA ec-naproxen tab 375mg (generic of EC- Non-Pref PA NAPROSYN) ec-naproxen tab 500mg (generic of EC- Non-Pref PA NAPROSYN) etodolac cap 200 mg Non-Pref PA etodolac cap 300 mg Non-Pref PA etodolac tab 400 mg (generic of LODINE) Non-Pref PA etodolac tab 500 mg Non-Pref PA etodolac tab er 24hr 400 mg Non-Pref PA etodolac tab er 24hr 500 mg Non-Pref PA etodolac tab er 24hr 600 mg Non-Pref PA FELDENE CAP 10MG Non-Pref PA FELDENE CAP 20MG Non-Pref PA fenoprofen calcium cap 400 mg Non-Pref PA fenoprofen calcium tab 600 mg Non-Pref PA flurbiprofen tab 50 mg Non-Pref PA flurbiprofen tab 100 mg Non-Pref PA gnp naproxen cap 220mg Pref OTC ibuprofen cap 200 mg Pref OTC ibuprofen chew tab 100 mg Pref OTC ibuprofen susp 40 mg/ml Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 21 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ibuprofen susp 100 mg/5ml Pref ibuprofen susp 100 mg/5ml Pref OTC ibuprofen tab 100 mg Pref OTC ibuprofen tab 200 mg Pref OTC ibuprofen tab 400 mg Pref ibuprofen tab 600 mg Pref ibuprofen tab 800 mg Pref INDOCIN SUP 50MG Non-Pref PA INDOCIN SUS 25MG/5ML Non-Pref PA indomethacin cap 20 mg Non-Pref PA indomethacin cap 25 mg Pref indomethacin cap 50 mg Pref indomethacin cap er 75 mg Non-Pref PA ketoprofen cap 50 mg Pref ketoprofen cap 75 mg Pref ketoprofen cap er 24hr 200 mg Non-Pref PA KETOR TROMET SPR 15.75MG Non-Pref PA ketorolac tromethamine tab 10 mg Pref QL LODINE TAB 400MG Non-Pref PA meclofenamate sodium cap 50 mg Non-Pref PA meclofenamate sodium cap 100 mg Non-Pref PA mefenamic acid cap 250 mg Non-Pref PA meloxicam cap 5 mg (generic of Non-Pref PA VIVLODEX) meloxicam cap 10 mg (generic of Non-Pref PA VIVLODEX) meloxicam tab 7.5 mg (generic of MOBIC) Pref meloxicam tab 15 mg (generic of MOBIC) Pref MOBIC TAB 7.5MG Non-Pref PA MOBIC TAB 15MG Non-Pref PA nabumetone tab 500 mg Pref nabumetone tab 750 mg Pref NALFON CAP 400MG Non-Pref PA NALFON TAB 600MG Non-Pref PA NAPRELAN TAB 375MG CR Non-Pref PA NAPRELAN TAB 500MG CR Non-Pref PA NAPRELAN TAB 750MG CR Non-Pref PA NAPROSYN SUS 125/5ML Non-Pref PA naproxen sodium cap 220 mg Pref OTC naproxen sodium tab 220 mg Pref OTC naproxen sodium tab 275 mg Non-Pref PA naproxen sodium tab 550 mg (generic of Non-Pref PA ANAPROX DS)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 22 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits naproxen sodium tab er 24hr 375 mg Non-Pref PA (base equiv) (generic of NAPRELAN) naproxen sodium tab er 24hr 500 mg Non-Pref PA (base equiv) (generic of NAPRELAN) naproxen sodium tab er 24hr 750 mg Non-Pref PA (base equiv) (generic of NAPRELAN) naproxen susp 125 mg/5ml (generic of Non-Pref PA NAPROSYN) naproxen tab 250 mg Pref naproxen tab 375 mg Pref naproxen tab 500 mg (generic of Pref NAPROSYN) naproxen tab ec 375 mg (generic of EC- Non-Pref PA NAPROSYN) naproxen tab ec 500 mg (generic of EC- Non-Pref PA NAPROSYN) naproxen-esomeprazole magnesium tab dr Non-Pref PA 375-20 mg (generic of VIMOVO) naproxen-esomeprazole magnesium tab dr Non-Pref PA 500-20 mg (generic of VIMOVO) oxaprozin tab 600 mg (generic of DAYPRO) Non-Pref PA piroxicam cap 10 mg (generic of FELDENE) Non-Pref PA piroxicam cap 20 mg (generic of FELDENE) Non-Pref PA QMIIZ ODT TAB 7.5MG Non-Pref PA QMIIZ ODT TAB 15 MG Non-Pref PA RELAFEN DS TAB 1000MG Non-Pref PA SPRIX SPR 15.75MG Non-Pref PA sulindac tab 150 mg Pref sulindac tab 200 mg Pref TIVORBEX CAP 20MG Non-Pref PA tolmetin sodium cap 400 mg Non-Pref PA tolmetin sodium tab 600 mg Non-Pref PA VIMOVO TAB 375-20MG Non-Pref PA VIMOVO TAB 500-20MG Non-Pref PA VIVLODEX CAP 5MG Non-Pref PA VIVLODEX CAP 10MG Non-Pref PA ZIPSOR CAP 25MG Non-Pref PA ZORVOLEX CAP 18MG Non-Pref PA ZORVOLEX CAP 35MG Non-Pref PA PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA TAB 10/20/30 Non-Pref SP, PA; BIOLOGIC OTEZLA TAB 30MG Non-Pref SP, PA; BIOLOGIC PYRIMIDINE SYNTHESIS INHIBITORS leflunomide tab 10 mg (generic of ARAVA) Pref QL leflunomide tab 20 mg (generic of ARAVA) Pref QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 23 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits SELECTIVE COSTIMULATION MODULATORS ORENCIA CLCK INJ 125MG/ML Non-Pref SP, PA; BIOLOGIC ORENCIA INJ 50/0.4ML Non-Pref SP, PA; BIOLOGIC ORENCIA INJ 87.5/0.7 Non-Pref SP, PA; BIOLOGIC ORENCIA INJ 125MG/ML Non-Pref SP, PA; BIOLOGIC SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL INJ 25/0.5ML Pref SP; BIOLOGIC ENBREL INJ 25MG Pref SP; BIOLOGIC ENBREL INJ 50MG/ML Pref SP; BIOLOGIC ENBREL MINI INJ 50MG/ML Pref SP; BIOLOGIC ENBREL SRCLK INJ 50MG/ML Pref SP; BIOLOGIC ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS bac tab (generic of ESGIC) Pref AGE butalbital-acetaminophen tab 50-325 mg Pref AGE butalbital-acetaminophen-caffeine tab 50- Pref AGE 325-40 mg (generic of ESGIC) butalbital-aspirin-caffeine cap 50-325-40 Pref AGE mg ANALGESICS OTHER acetaminophen cap 500 mg Pref OTC acetaminophen chew tab 80 mg Pref OTC acetaminophen disintegrating tab 80 mg Pref OTC acetaminophen disintegrating tab 160 mg Pref OTC acetaminophen elixir 160 mg/5ml Pref OTC acetaminophen liquid 160 mg/5ml Pref OTC acetaminophen soln 160 mg/5ml Pref OTC acetaminophen suppos 120 mg Pref OTC acetaminophen suppos 650 mg Pref OTC acetaminophen susp 160 mg/5ml Pref OTC acetaminophen tab 325 mg Pref OTC acetaminophen tab 500 mg Pref OTC acetaminophen tab er 650 mg Pref OTC FEVERALL SUP 325MG Pref OTC TYLENOL CHLD SUS 160/5ML Pref OTC TYLENOL TAB 325MG Pref OTC TYLENOL TAB 500MG Pref OTC SALICYLATES aspirin buffered (ca carb-mg carb-mg ox) Pref AGE, OTC tab 325 mg aspirin chew tab 81 mg Pref QL, OTC ASPIRIN SUP 300MG Pref OTC ASPIRIN SUP 600MG Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 24 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits aspirin tab 325 mg Pref QL, AGE, OTC aspirin tab delayed release 81 mg Pref QL, OTC aspirin tab delayed release 325 mg Pref QL, AGE, OTC BUFFERIN TAB 325MG Pref AGE, OTC diflunisal tab 500 mg Non-Pref PA ANALGESICS - OPIOID - DRUGS TO TREAT PAIN OPIOID AGONISTS ACTIQ LOZ 200MCG Non-Pref PA, QL; MED ACTIQ LOZ 400MCG Non-Pref PA, QL; MED ACTIQ LOZ 600MCG Non-Pref PA, QL; MED ACTIQ LOZ 800MCG Non-Pref PA, QL; MED ACTIQ LOZ 1200MCG Non-Pref PA, QL; MED ACTIQ LOZ 1600MCG Non-Pref PA, QL; MED CODEINE SULF TAB 15MG Pref QL; MED CODEINE SULF TAB 60MG Pref QL; MED codeine sulfate tab 30 mg Pref QL; MED CONZIP CAP 100MG Non-Pref PA; MED CONZIP CAP 200MG Non-Pref PA; MED CONZIP CAP 300MG Non-Pref PA; MED DILAUDID LIQ 1MG/ML Non-Pref PA, QL; MED DILAUDID TAB 2MG Non-Pref PA, QL; MED DILAUDID TAB 4MG Non-Pref PA, QL; MED DILAUDID TAB 8MG Non-Pref PA, QL; MED DURAGESIC DIS 12MCG/HR Non-Pref PA; 10 per fill; MED DURAGESIC DIS 25MCG/HR Non-Pref PA; 10 per fill; MED DURAGESIC DIS 50MCG/HR Non-Pref PA; 10 per fill; MED DURAGESIC DIS 75MCG/HR Non-Pref PA; 10 per fill; MED DURAGESIC DIS 100MCG/H Non-Pref PA; 10 per fill; MED fentanyl citrate buccal tab 100 mcg (base Non-Pref PA, QL; MED equiv) fentanyl citrate buccal tab 200 mcg (base Non-Pref PA, QL; MED equiv) fentanyl citrate buccal tab 400 mcg (base Non-Pref PA, QL; MED equiv) fentanyl citrate buccal tab 600 mcg (base Non-Pref PA, QL; MED equiv) fentanyl citrate buccal tab 800 mcg (base Non-Pref PA, QL; MED equiv) fentanyl citrate lozenge on a handle 200 Non-Pref PA, QL; MED mcg (generic of ACTIQ) fentanyl citrate lozenge on a handle 400 Non-Pref PA, QL; MED mcg (generic of ACTIQ) fentanyl citrate lozenge on a handle 600 Non-Pref PA, QL; MED mcg (generic of ACTIQ)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 25 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits fentanyl citrate lozenge on a handle 800 Non-Pref PA, QL; MED mcg (generic of ACTIQ) fentanyl citrate lozenge on a handle 1200 Non-Pref PA, QL; MED mcg (generic of ACTIQ) fentanyl citrate lozenge on a handle 1600 Non-Pref PA, QL; MED mcg (generic of ACTIQ) fentanyl td patch 72hr 12 mcg/hr (generic Pref 10 per fill; MED of DURAGESIC) fentanyl td patch 72hr 25 mcg/hr (generic Pref 10 per fill; MED of DURAGESIC) fentanyl td patch 72hr 37.5 mcg/hr Non-Pref PA; MED fentanyl td patch 72hr 50 mcg/hr (generic Pref 10 per fill; MED of DURAGESIC) fentanyl td patch 72hr 62.5 mcg/hr Non-Pref PA; MED fentanyl td patch 72hr 75 mcg/hr (generic Pref 10 per fill; MED of DURAGESIC) fentanyl td patch 72hr 87.5 mcg/hr Non-Pref PA; MED fentanyl td patch 72hr 100 mcg/hr (generic Pref 10 per fill; MED of DURAGESIC) FENTORA TAB 100MCG Non-Pref PA, QL; MED FENTORA TAB 200MCG Non-Pref PA, QL; MED FENTORA TAB 400MCG Non-Pref PA, QL; MED FENTORA TAB 600MCG Non-Pref PA, QL; MED FENTORA TAB 800MCG Non-Pref PA, QL; MED hydrocodone bitartrate cap er 12hr 10 mg Non-Pref PA; MED (generic of ZOHYDRO ER) hydrocodone bitartrate cap er 12hr 15 mg Non-Pref PA; MED (generic of ZOHYDRO ER) hydrocodone bitartrate cap er 12hr 20 mg Non-Pref PA; MED (generic of ZOHYDRO ER) hydrocodone bitartrate cap er 12hr 30 mg Non-Pref PA; MED (generic of ZOHYDRO ER) hydrocodone bitartrate cap er 12hr 40 mg Non-Pref PA; MED (generic of ZOHYDRO ER) hydrocodone bitartrate cap er 12hr 50 mg Non-Pref PA; MED (generic of ZOHYDRO ER) hydrocodone bitartrate tab er 24hr deter Non-Pref PA; MED 20 mg (generic of HYSINGLA ER) hydrocodone bitartrate tab er 24hr deter Non-Pref PA; MED 30 mg (generic of HYSINGLA ER) hydrocodone bitartrate tab er 24hr deter Non-Pref PA; MED 40 mg (generic of HYSINGLA ER) hydrocodone bitartrate tab er 24hr deter Non-Pref PA; MED 60 mg (generic of HYSINGLA ER) hydrocodone bitartrate tab er 24hr deter Non-Pref PA; MED 80 mg (generic of HYSINGLA ER)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 26 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits hydrocodone bitartrate tab er 24hr deter Non-Pref PA; MED 100 mg (generic of HYSINGLA ER) hydrocodone bitartrate tab er 24hr deter Non-Pref PA; MED 120 mg (generic of HYSINGLA ER) HYDROMORPHON SUP 3MG Non-Pref PA; MED hydromorphone hcl liqd 1 mg/ml (generic Pref QL; MED of DILAUDID) hydromorphone hcl tab 2 mg (generic of Pref QL; MED DILAUDID) hydromorphone hcl tab 4 mg (generic of Pref QL; MED DILAUDID) hydromorphone hcl tab 8 mg (generic of Pref QL; MED DILAUDID) hydromorphone hcl tab er 24hr 8 mg Non-Pref PA; MED hydromorphone hcl tab er 24hr 12 mg Non-Pref PA; MED hydromorphone hcl tab er 24hr 16 mg Non-Pref PA; MED hydromorphone hcl tab er 24hr 32 mg Non-Pref PA; MED HYSINGLA ER TAB 20 MG Non-Pref PA; MED HYSINGLA ER TAB 30 MG Non-Pref PA; MED HYSINGLA ER TAB 40 MG Non-Pref PA; MED HYSINGLA ER TAB 60 MG Non-Pref PA; MED HYSINGLA ER TAB 80 MG Non-Pref PA; MED HYSINGLA ER TAB 100 MG Non-Pref PA; MED HYSINGLA ER TAB 120 MG Non-Pref PA; MED levorphanol tartrate tab 2 mg Non-Pref PA; MED levorphanol tartrate tab 3 mg Non-Pref PA; MED meperidine hcl oral soln 50 mg/5ml Non-Pref PA, QL; MED meperidine hcl tab 50 mg Non-Pref PA, QL; MED methadone hcl conc 10 mg/ml (generic of Non-Pref PA; MED METHADOSE) methadone hcl soln 5 mg/5ml Non-Pref PA; MED methadone hcl soln 10 mg/5ml Non-Pref PA; MED methadone hcl tab 5 mg Non-Pref PA; MED methadone hcl tab 10 mg Non-Pref PA; MED methadone hcl tab for oral susp 40 mg Non-Pref PA; MED METHADOSE CON 10MG/ML Non-Pref PA; MED METHADOSE SF CON 10MG/ML Non-Pref PA; MED methadose tab 40mg Non-Pref PA; MED morphine sulfate beads cap er 24hr 30 mg Non-Pref PA; MED morphine sulfate beads cap er 24hr 45 mg Non-Pref PA; MED morphine sulfate beads cap er 24hr 60 mg Non-Pref PA; MED morphine sulfate beads cap er 24hr 75 mg Non-Pref PA; MED morphine sulfate beads cap er 24hr 90 mg Non-Pref PA; MED morphine sulfate beads cap er 24hr 120 Non-Pref PA; MED mg

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 27 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits morphine sulfate cap er 24hr 10 mg Non-Pref PA; MED morphine sulfate cap er 24hr 20 mg Non-Pref PA; MED morphine sulfate cap er 24hr 30 mg Non-Pref PA; MED morphine sulfate cap er 24hr 40 mg Non-Pref PA; MED morphine sulfate cap er 24hr 50 mg Non-Pref PA; MED morphine sulfate cap er 24hr 60 mg Non-Pref PA; MED morphine sulfate cap er 24hr 80 mg Non-Pref PA; MED morphine sulfate cap er 24hr 100 mg Non-Pref PA; MED morphine sulfate oral soln 10 mg/5ml Pref QL; MED morphine sulfate oral soln 20 mg/5ml Pref QL; MED morphine sulfate oral soln 100 mg/5ml (20 Pref QL; MED mg/ml) morphine sulfate suppos 5 mg Pref MED morphine sulfate suppos 10 mg Pref MED morphine sulfate suppos 20 mg Pref MED morphine sulfate suppos 30 mg Pref MED morphine sulfate tab 15 mg Pref QL; MED morphine sulfate tab 30 mg Pref QL; MED morphine sulfate tab er 15 mg (generic of Pref MED MS CONTIN) morphine sulfate tab er 30 mg (generic of Pref MED MS CONTIN) morphine sulfate tab er 60 mg (generic of Pref MED MS CONTIN) morphine sulfate tab er 100 mg (generic of Pref MED MS CONTIN) morphine sulfate tab er 200 mg (generic of Pref MED MS CONTIN) MS CONTIN TAB 15MG ER Non-Pref PA; MED MS CONTIN TAB 30MG ER Non-Pref PA; MED MS CONTIN TAB 60MG ER Non-Pref PA; MED MS CONTIN TAB 100MG ER Non-Pref PA; MED MS CONTIN TAB 200MG ER Non-Pref PA; MED NUCYNTA ER TAB 50MG Non-Pref PA; MED NUCYNTA ER TAB 100MG Non-Pref PA; MED NUCYNTA ER TAB 150MG Non-Pref PA; MED NUCYNTA ER TAB 200MG Non-Pref PA; MED NUCYNTA ER TAB 250MG Non-Pref PA; MED NUCYNTA TAB 50MG Non-Pref PA; MED NUCYNTA TAB 75MG Non-Pref PA; MED NUCYNTA TAB 100MG Non-Pref PA; MED OXAYDO TAB 5MG Pref QL; MED OXAYDO TAB 7.5MG Non-Pref PA, QL; MED oxycodone hcl cap 5 mg Non-Pref PA, QL; MED

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 28 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits oxycodone hcl conc 100 mg/5ml (20 Non-Pref PA, QL; MED mg/ml) oxycodone hcl soln 5 mg/5ml Pref QL; MED oxycodone hcl tab 5 mg (generic of Pref QL; MED ROXICODONE) oxycodone hcl tab 10 mg Pref QL; MED oxycodone hcl tab 15 mg (generic of Pref QL; MED ROXICODONE) oxycodone hcl tab 20 mg Non-Pref PA, QL; MED oxycodone hcl tab 30 mg (generic of Non-Pref PA, QL; MED ROXICODONE) OXYCODONE HCL TAB ER 12HR DETER 10 Non-Pref PA, QL; MED MG oxycodone hcl tab er 12hr deter 15 mg Non-Pref PA, QL; MED OXYCODONE HCL TAB ER 12HR DETER 20 Non-Pref PA, QL; MED MG oxycodone hcl tab er 12hr deter 30 mg Non-Pref PA, QL; MED OXYCODONE HCL TAB ER 12HR DETER 40 Non-Pref PA, QL; MED MG oxycodone hcl tab er 12hr deter 60 mg Non-Pref PA, QL; MED oxycodone hcl tab er 12hr deter 80 mg Non-Pref PA, QL; MED OXYCONTIN TAB 10MG CR Non-Pref PA, QL; MED OXYCONTIN TAB 15MG CR Non-Pref PA, QL; MED OXYCONTIN TAB 20MG CR Non-Pref PA, QL; MED OXYCONTIN TAB 30MG CR Non-Pref PA, QL; MED OXYCONTIN TAB 40MG CR Non-Pref PA, QL; MED OXYCONTIN TAB 60MG CR Non-Pref PA, QL; MED OXYCONTIN TAB 80MG CR Non-Pref PA, QL; MED oxymorphone hcl tab 5 mg Non-Pref PA, QL; MED oxymorphone hcl tab 10 mg Non-Pref PA, QL; MED oxymorphone hcl tab er 12hr 5 mg Non-Pref PA; MED oxymorphone hcl tab er 12hr 7.5 mg Non-Pref PA; MED oxymorphone hcl tab er 12hr 10 mg Non-Pref PA; MED oxymorphone hcl tab er 12hr 15 mg Non-Pref PA; MED oxymorphone hcl tab er 12hr 20 mg Non-Pref PA; MED oxymorphone hcl tab er 12hr 30 mg Non-Pref PA; MED oxymorphone hcl tab er 12hr 40 mg Non-Pref PA; MED ROXICODONE TAB 5MG Non-Pref PA, QL; MED ROXICODONE TAB 15MG Non-Pref PA, QL; MED ROXICODONE TAB 30MG Non-Pref PA, QL; MED tramadol hcl cap er 24hr biphasic release Non-Pref PA; MED 100 mg tramadol hcl cap er 24hr biphasic release Non-Pref PA; MED 200 mg

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 29 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits tramadol hcl cap er 24hr biphasic release Non-Pref PA; MED 300 mg tramadol hcl tab 50 mg (generic of Pref MED ULTRAM) tramadol hcl tab 100 mg Pref MED tramadol hcl tab er 24hr 100 mg Pref MED tramadol hcl tab er 24hr 200 mg Pref MED tramadol hcl tab er 24hr 300 mg Pref MED tramadol hcl tab er 24hr biphasic release Non-Pref PA; MED 100 mg tramadol hcl tab er 24hr biphasic release Non-Pref PA; MED 200 mg tramadol hcl tab er 24hr biphasic release Non-Pref PA; MED 300 mg ULTRAM TAB 50MG Non-Pref PA; MED XTAMPZA ER CAP 9MG Non-Pref PA, QL; MED XTAMPZA ER CAP 13.5MG Non-Pref PA, QL; MED XTAMPZA ER CAP 18MG Non-Pref PA, QL; MED XTAMPZA ER CAP 27MG Non-Pref PA, QL; MED XTAMPZA ER CAP 36MG Non-Pref PA, QL; MED ZOHYDRO ER CAP 10MG Non-Pref PA; MED ZOHYDRO ER CAP 15MG Non-Pref PA; MED ZOHYDRO ER CAP 20MG Non-Pref PA; MED ZOHYDRO ER CAP 30MG Non-Pref PA; MED ZOHYDRO ER CAP 40MG Non-Pref PA; MED ZOHYDRO ER CAP 50MG Non-Pref PA; MED OPIOID COMBINATIONS acetaminophen w/ codeine soln 120-12 Pref MED mg/5ml acetaminophen w/ codeine tab 300-15 mg Pref MED acetaminophen w/ codeine tab 300-30 mg Pref MED acetaminophen w/ codeine tab 300-60 mg Pref MED acetaminophen-caffeine-dihydrocodeine Non-Pref PA; MED cap 320.5-30-16 mg APADAZ TAB 4.08-325 Non-Pref PA; MED APADAZ TAB 6.12-325 Non-Pref PA; MED APADAZ TAB 8.16-325 Non-Pref PA; MED ascomp/cod cap 30mg Non-Pref PA; MED BENZHY/ACETA TAB 4.08-325 Non-Pref PA; MED BENZHY/ACETA TAB 6.12-325 Non-Pref PA; MED BENZHY/ACETA TAB 8.16-325 Non-Pref PA; MED butalbital-acetaminophen-caff w/ cod cap Non-Pref PA; MED 50-300-40-30 mg butalbital-acetaminophen-caff w/ cod cap Non-Pref PA; MED 50-325-40-30 mg

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 30 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits butalbital-aspirin-caff w/ codeine cap 50- Non-Pref PA; MED 325-40-30 mg endocet tab 2.5-325 (generic of Pref MED PERCOCET) endocet tab 5-325mg (generic of Pref MED PERCOCET) endocet tab 7.5-325 (generic of Pref MED PERCOCET) endocet tab 10-325mg (generic of Pref MED PERCOCET) FIORICET CAP CODEINE Non-Pref PA; MED hydrocodone-acetaminophen soln 7.5-325 Pref MED mg/15ml hydrocodone-acetaminophen tab 5-300 mg Pref MED (generic of XODOL) hydrocodone-acetaminophen tab 5-325 mg Pref MED hydrocodone-acetaminophen tab 7.5-300 Pref MED mg hydrocodone-acetaminophen tab 7.5-325 Pref MED mg hydrocodone-acetaminophen tab 10-300 Pref MED mg hydrocodone-acetaminophen tab 10-325 Pref MED mg hydrocodone-ibuprofen tab 5-200 mg Non-Pref PA; MED hydrocodone-ibuprofen tab 7.5-200 mg Non-Pref PA; MED hydrocodone-ibuprofen tab 10-200 mg Non-Pref PA; MED LORTAB ELX 10-300MG Non-Pref PA; MED NALOCET TAB 2.5-300 Non-Pref PA; MED oxycodone w/ acetaminophen tab 2.5-325 Pref MED mg (generic of PERCOCET) oxycodone w/ acetaminophen tab 5-325 Pref MED mg (generic of PERCOCET) oxycodone w/ acetaminophen tab 7.5-325 Pref MED mg (generic of PERCOCET) oxycodone w/ acetaminophen tab 10-325 Pref MED mg (generic of PERCOCET) oxycodone-aspirin tab 4.8355-325 mg Non-Pref PA; MED PERCOCET TAB 2.5-325 Non-Pref PA; MED PERCOCET TAB 5-325MG Non-Pref PA; MED PERCOCET TAB 7.5-325 Non-Pref PA; MED PERCOCET TAB 10-325MG Non-Pref PA; MED PROLATE SOL 10/300MG Non-Pref PA; MED PROLATE TAB 5-300MG Non-Pref PA; MED PROLATE TAB 7.5-300 Non-Pref PA; MED PROLATE TAB 10-300MG Non-Pref PA; MED

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 31 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits tramadol-acetaminophen tab 37.5-325 mg Pref MED (generic of ULTRACET) ULTRACET TAB 37.5-325 Non-Pref PA; MED OPIOID PARTIAL AGONISTS BELBUCA MIS 75MCG Non-Pref PA, QL; MED BELBUCA MIS 150MCG Non-Pref PA, QL; MED BELBUCA MIS 300MCG Non-Pref PA, QL; MED BELBUCA MIS 450MCG Non-Pref PA, QL; MED BELBUCA MIS 600MCG Non-Pref PA, QL; MED BELBUCA MIS 750MCG Non-Pref PA, QL; MED BELBUCA MIS 900MCG Non-Pref PA, QL; MED buprenorphine td patch weekly 5 mcg/hr Non-Pref PA, QL; MED (generic of BUTRANS) buprenorphine td patch weekly 7.5 mcg/hr Non-Pref PA, QL; MED (generic of BUTRANS) buprenorphine td patch weekly 10 mcg/hr Non-Pref PA, QL; MED (generic of BUTRANS) buprenorphine td patch weekly 15 mcg/hr Non-Pref PA, QL; MED (generic of BUTRANS) buprenorphine td patch weekly 20 mcg/hr Non-Pref PA, QL; MED (generic of BUTRANS) butorphanol tartrate nasal soln 10 mg/ml Non-Pref PA, QL; MED BUTRANS DIS 5MCG/HR Pref QL; MED BUTRANS DIS 7.5/HR Pref QL; MED BUTRANS DIS 10MCG/HR Pref QL; MED BUTRANS DIS 15MCG/HR Pref QL; MED BUTRANS DIS 20MCG/HR Pref QL; MED pentazocine w/ naloxone tab 50-0.5 mg Non-Pref PA; MED ANDROGENS-ANABOLIC - DRUGS TO REGULATE MALE HORMONES ANDROGENS ANDRODERM DIS 2MG/24HR Non-Pref PA ANDRODERM DIS 4MG/24HR Non-Pref PA ANDROGEL GEL 1%(25MG) Non-Pref PA ANDROGEL GEL 1.62% Non-Pref PA danazol cap 50 mg Pref danazol cap 100 mg Pref danazol cap 200 mg Pref FORTESTA GEL 10MG/ACT Non-Pref PA TESTIM GEL 1%(50MG) Non-Pref PA testosterone cypionate im inj in oil 100 Pref mg/ml (generic of DEPO-TESTOSTERONE) testosterone cypionate im inj in oil 200 Pref mg/ml (generic of DEPO-TESTOSTERONE) testosterone td gel 10mg/act (2%) Non-Pref PA (generic of FORTESTA) AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 32 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits testosterone td gel 12.5 mg/act (1%) Non-Pref PA testosterone td gel 20.25 mg/1.25gm Non-Pref PA (1.62%) (generic of ANDROGEL) testosterone td gel 20.25 mg/act (1.62%) Pref PA (generic of ANDROGEL PUMP) testosterone td gel 25 mg/2.5gm (1%) Non-Pref PA (generic of ANDROGEL) testosterone td gel 40.5 mg/2.5gm Non-Pref PA (1.62%) (generic of ANDROGEL) testosterone td gel 50 mg/5gm (1%) Non-Pref PA (generic of TESTIM) testosterone td soln 30 mg/act Non-Pref PA VOGELXO GEL 1%(50MG) Non-Pref PA VOGELXO GEL PUMP 1% Non-Pref PA ANORECTAL AND RELATED PRODUCTS RECTAL STEROIDS hydrocortisone rectal cream 2.5% (generic Pref QL of HYDROCORTISONE RECTAL CREAM 2.5%) ANTACIDS - DRUGS FOR ULCERS AND STOMACH ACID ANTACID COMBINATIONS ALKA SELTZER TAB HEARTBRN Pref OTC alum & mag hydroxide-simethicone chew Pref OTC tab 200-200-25 mg alum & mag hydroxide-simethicone susp Pref OTC 200-200-20 mg/5ml alum & mag hydroxide-simethicone susp Pref OTC 400-400-40 mg/5ml aluminum hydroxide-magnesium carbonate Pref OTC chew tab 160-105 mg aluminum hydroxide-magnesium carbonate Pref OTC susp 95-358 mg/15ml ant/anti-gas chw 1000-60 Pref OTC antacid chw 550-110 Pref OTC antacid extr chw 675-135 Pref OTC antacid mult chw symptom Pref OTC ANTACID ULTR CHW 1000-200 Pref OTC calcium carbonate-mag hydroxide susp Pref OTC 400-135 mg/5ml DEWEES CARMI LIQ Pref OTC E-Z-GAS II GRA Pref OTC foam antacid chw 80-20mg Pref OTC GAVISCON CHW Pref OTC GAVISCON SUS Pref OTC heartbrn rel sus cherry Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 33 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits MAG-AL LIQ Pref OTC ANTACIDS - ALUMINUM SALTS ALUM HYDROX SUS 320/5ML Pref OTC ANTACIDS - BICARBONATE sodium bicarbonate tab 325 mg Pref OTC sodium bicarbonate tab 650 mg Pref OTC ANTACIDS - CALCIUM SALTS calcium carbonate (antacid) chew tab 400 Pref OTC mg calcium carbonate (antacid) chew tab 500 Pref OTC mg calcium carbonate (antacid) chew tab 750 Pref OTC mg calcium carbonate (antacid) chew tab 1000 Pref OTC mg calcium carbonate (antacid) susp 1250 Pref OTC mg/5ml titralac chw 420mg Pref OTC TUMS CHEWY CHW BITES Pref OTC TUMS CHW 500MG Pref OTC TUMS CHW DEL CHW 1177MG Pref OTC TUMS E-X CHW 750MG Pref OTC TUMS EXTRA CHW 750MG Pref OTC TUMS SMOOTHI CHW 750MG Pref OTC TUMS ULTRA CHW 1000MG Pref OTC ANTACIDS - MAGNESIUM SALTS magnesium oxide tab 420 mg Pref OTC maox tab 420mg Pref OTC URO MAG CAP 140MG Pref OTC ANTHELMINTICS - DRUGS TO TREAT INFECTIONS OF PARASITES ANTHELMINTICS - DRUGS TO TREAT INFECTIONS OF PARASITES BENZNIDAZOLE TAB 12.5MG Pref PA BENZNIDAZOLE TAB 100MG Pref PA ivermectin tab 3 mg (generic of Pref STROMECTOL) pinworm med sus 144mg/ml Pref OTC ANTI-INFECTIVE AGENTS - MISC. - DRUGS TO TREAT INFECTIONS ANTI-INFECTIVE AGENTS - MISC. - DRUGS TO TREAT INFECTIONS FLAGYL CAP 375MG Non-Pref PA FLAGYL TAB 500MG Non-Pref PA metronidazole cap 375 mg (generic of Non-Pref PA FLAGYL) metronidazole tab 250 mg Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 34 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits metronidazole tab 500 mg (generic of Pref FLAGYL) tinidazole tab 250 mg Pref tinidazole tab 500 mg Pref trimethoprim tab 100 mg Pref XIFAXAN TAB 200MG Non-Pref PA, AGE XIFAXAN TAB 550MG Non-Pref PA, AGE ANTI-INFECTIVE MISC. - COMBINATIONS sulfamethoxazole-trimethoprim susp 200- Pref 40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 Pref mg (generic of BACTRIM) sulfamethoxazole-trimethoprim tab 800- Pref 160 mg (generic of BACTRIM DS) sulfatrim pd sus 200-40/5 Pref ANTIPROTOZOAL AGENTS atovaquone susp 750 mg/5ml (generic of Pref PA MEPRON) nitazoxanide tab 500 mg (generic of Non-Pref PA ALINIA) GLYCOPEPTIDES FIRVANQ SOL 25MG/ML Pref FIRVANQ SOL 50MG/ML Pref VANCOCIN CAP 250MG Non-Pref PA VANCOCIN HCL CAP 125MG Non-Pref PA vancomycin hcl cap 125 mg (base Pref equivalent) (generic of VANCOCIN HCL) vancomycin hcl cap 250 mg (base Pref equivalent) (generic of VANCOCIN) vancomycin hcl for iv soln 1 gm (base Pref equivalent) vancomycin hcl for iv soln 5 gm (base Pref equivalent) vancomycin hcl for iv soln 10 gm (base Pref equivalent) vancomycin hcl for iv soln 500 mg (base Pref equivalent) vancomycin hcl for iv soln 750 mg (base Pref equivalent) vancomycin inj 750mg Pref VANCOMYCIN SOL 250/5ML Non-Pref PA LEPROSTATICS dapsone tab 25 mg Pref dapsone tab 100 mg Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 35 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits LINCOSAMIDES clindamycin hcl cap 75 mg (generic of Pref CLEOCIN) clindamycin hcl cap 150 mg (generic of Pref CLEOCIN) clindamycin hcl cap 300 mg (generic of Pref CLEOCIN) clindamycin palmitate hcl for soln 75 Pref AGE mg/5ml (base equiv) (generic of CLEOCIN PEDIATRIC GRANULE) MONOBACTAMS CAYSTON INH 75MG Pref SP OXAZOLIDINONES linezolid for susp 100 mg/5ml (generic of Non-Pref PA ZYVOX) linezolid tab 600 mg (generic of ZYVOX) Pref SIVEXTRO TAB 200MG Non-Pref PA ZYVOX SUS 100MG/5M Non-Pref PA ZYVOX TAB 600MG Non-Pref PA URINARY ANTI-INFECTIVES - DRUGS TO TREAT URINARY TRACT INFECTIONS methenamine hippurate tab 1 gm (generic Pref of HIPREX) methenamine mandelate tab 0.5 gm Pref methenamine mandelate tab 1 gm Pref nitrofurantoin macrocrystalline cap 50 mg Pref QL, AGE (generic of MACRODANTIN) nitrofurantoin macrocrystalline cap 100 mg Pref QL, AGE (generic of MACRODANTIN) nitrofurantoin monohydrate Pref QL, AGE macrocrystalline cap 100 mg (generic of MACROBID) ANTIANGINAL AGENTS - DRUGS TO TREAT HEART CONDITIONS ANTIANGINALS-OTHER ranolazine tab er 12hr 500 mg (generic of Pref PA, QL RANEXA) ranolazine tab er 12hr 1000 mg (generic of Pref PA, QL RANEXA) NITRATES isosorbide dinitrate tab 5 mg (generic of Pref ISORDIL TITRADOSE) isosorbide dinitrate tab 10 mg Pref isosorbide dinitrate tab 20 mg Pref isosorbide dinitrate tab 30 mg Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 36 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits isosorbide mononitrate tab 10 mg Pref isosorbide mononitrate tab 20 mg Pref isosorbide mononitrate tab er 24hr 30 mg Pref QL isosorbide mononitrate tab er 24hr 60 mg Pref QL isosorbide mononitrate tab er 24hr 120 mg Pref QL minitran dis 0.1mg/hr (generic of NITRO- Pref QL DUR) minitran dis 0.2mg/hr (generic of NITRO- Pref QL DUR) minitran dis 0.4mg/hr (generic of NITRO- Pref QL DUR) minitran dis 0.6mg/hr (generic of NITRO- Pref QL DUR) NITRO-BID OIN 2% Pref nitro-time cap 2.5mg cr Pref nitro-time cap 6.5mg cr Pref nitro-time cap 9mg cr Pref nitroglycerin sl tab 0.3 mg (generic of Pref NITROSTAT) nitroglycerin sl tab 0.4 mg (generic of Pref NITROSTAT) nitroglycerin sl tab 0.6 mg (generic of Pref NITROSTAT) nitroglycerin td patch 24hr 0.1 mg/hr Pref QL nitroglycerin td patch 24hr 0.2 mg/hr Pref QL nitroglycerin td patch 24hr 0.4 mg/hr Pref QL nitroglycerin td patch 24hr 0.6 mg/hr Pref QL nitroglycerin tl soln 0.4 mg/spray (400 Pref ST mcg/spray) (generic of NITROLINGUAL PUMPSPRAY) ANTIANXIETY AGENTS - DRUGS TO TREAT ANXIETY ANTIANXIETY AGENTS - MISC. hydroxyzine hcl im soln 25 mg/ml Pref hydroxyzine hcl im soln 50 mg/ml Pref hydroxyzine hcl syrup 10 mg/5ml Pref AGE hydroxyzine hcl tab 10 mg Pref hydroxyzine hcl tab 25 mg Pref hydroxyzine hcl tab 50 mg Pref hydroxyzine pamoate cap 25 mg (generic Pref of VISTARIL) hydroxyzine pamoate cap 50 mg (generic Pref of VISTARIL) hydroxyzine pamoate cap 100 mg Pref VISTARIL CAP 25MG Non-Pref PA VISTARIL CAP 50MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 37 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ANTIARRHYTHMICS - DRUGS TO TREAT HEART CONDITIONS ANTIARRHYTHMICS TYPE I-A disopyramide phosphate cap 100 mg Pref AGE (generic of NORPACE) disopyramide phosphate cap 150 mg Pref AGE (generic of NORPACE) quinidine sulfate tab 200 mg Pref quinidine sulfate tab 300 mg Pref ANTIARRHYTHMICS TYPE I-B mexiletine hcl cap 150 mg Pref mexiletine hcl cap 200 mg Pref mexiletine hcl cap 250 mg Pref ANTIARRHYTHMICS TYPE I-C flecainide acetate tab 50 mg Pref flecainide acetate tab 100 mg Pref flecainide acetate tab 150 mg Pref propafenone hcl tab 150 mg Pref propafenone hcl tab 225 mg Pref propafenone hcl tab 300 mg Pref ANTIARRHYTHMICS TYPE III amiodarone hcl tab 100 mg Pref QL amiodarone hcl tab 200 mg Pref amiodarone hcl tab 400 mg Pref pacerone tab 100mg Pref QL pacerone tab 200mg Pref pacerone tab 400mg Pref ANTIASTHMATIC AND BRONCHODILATOR AGENTS - DRUGS TO TREAT ASTHMA AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE ANTI-INFLAMMATORY AGENTS cromolyn sodium soln nebu 20 mg/2ml Pref ANTIASTHMATIC - MONOCLONAL ANTIBODIES XOLAIR SOL 150MG Pref SP, PA BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA AER 17MCG Pref QL INCRUSE ELPT INH 62.5MCG Pref ipratropium bromide inhal soln 0.02% Pref (inh soln) LONHALA MAGN SOL 25MCG Non-Pref PA SPIRIVA AER 1.25MCG Pref QL SPIRIVA CAP HANDIHLR Pref QL SPIRIVA SPR 2.5MCG Pref QL TUDORZA PRES AER 400/ACT Non-Pref PA YUPELRI SOL Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 38 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits LEUKOTRIENE MODULATORS ACCOLATE TAB 10MG Non-Pref PA ACCOLATE TAB 20MG Non-Pref PA montelukast sodium chew tab 4 mg (base Pref AGE equiv) (generic of SINGULAIR) montelukast sodium chew tab 5 mg (base Pref AGE equiv) (generic of SINGULAIR) montelukast sodium oral granules packet 4 Non-Pref PA, AGE mg (base equiv) (generic of SINGULAIR) montelukast sodium tab 10 mg (base Pref equiv) (generic of SINGULAIR) SINGULAIR CHW 4MG Non-Pref PA, AGE SINGULAIR CHW 5MG Non-Pref PA, AGE SINGULAIR GRA 4MG Non-Pref PA, AGE SINGULAIR TAB 10MG Non-Pref PA zafirlukast tab 10 mg (generic of Non-Pref PA ACCOLATE) zafirlukast tab 20 mg (generic of Non-Pref PA ACCOLATE) zileuton tab er 12hr 600 mg Non-Pref PA ZYFLO TAB 600MG Non-Pref PA SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP TAB 250MCG Non-Pref PA DALIRESP TAB 500MCG Non-Pref PA STEROID INHALANTS ALVESCO AER 80MCG Non-Pref PA ALVESCO AER 160MCG Non-Pref PA ARMONAIR DIG AER 55MCG Non-Pref PA ARMONAIR DIG AER 113MCG Non-Pref PA ARMONAIR DIG AER 232MCG Non-Pref PA ARNUITY ELPT INH 50MCG Non-Pref PA ARNUITY ELPT INH 100MCG Non-Pref PA ARNUITY ELPT INH 200MCG Non-Pref PA ASMANEX 7 AER 110MCG Pref QL, AGE ASMANEX 14 AER 220MCG Pref QL ASMANEX 30 AER 110MCG Pref QL, AGE ASMANEX 30 AER 220MCG Pref QL ASMANEX 60 AER 220MCG Pref QL ASMANEX 120 AER 220MCG Pref QL ASMANEX HFA AER 50MCG Non-Pref PA, QL ASMANEX HFA AER 100 MCG Non-Pref PA, QL ASMANEX HFA AER 200 MCG Non-Pref PA, QL budesonide inhalation susp 0.5 mg/2ml Pref (generic of PULMICORT)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 39 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits budesonide inhalation susp 0.25 mg/2ml Pref (generic of PULMICORT) budesonide inhalation susp 1 mg/2ml Pref (generic of PULMICORT) FLOVENT DISK AER 50MCG Non-Pref PA FLOVENT DISK AER 100MCG Non-Pref PA FLOVENT DISK AER 250MCG Non-Pref PA FLOVENT HFA AER 44MCG Pref QL FLOVENT HFA AER 110MCG Pref QL FLOVENT HFA AER 220MCG Pref QL PULMICORT INH 90MCG Non-Pref PA, QL PULMICORT INH 180MCG Non-Pref PA, QL PULMICORT SUS 0.5MG/2 Non-Pref PA PULMICORT SUS 0.25MG/2 Non-Pref PA PULMICORT SUS 1MG/2ML Non-Pref PA QVAR REDIHA AER 80MCG Non-Pref PA QVAR REDIHAL AER 40MCG Non-Pref PA SYMPATHOMIMETICS ADVAIR DISKU AER 100/50 Pref QL ADVAIR DISKU AER 250/50 Pref QL ADVAIR DISKU AER 500/50 Pref QL ADVAIR HFA AER 45/21 Pref QL ADVAIR HFA AER 115/21 Pref QL ADVAIR HFA AER 230/21 Pref QL AIRDUO DGHLR INH 55-14 Non-Pref PA, QL AIRDUO DGHLR INH 113-14 Non-Pref PA, QL AIRDUO DGHLR INH 232-14 Non-Pref PA, QL AIRDUO RESPI INH 55-14 Non-Pref PA, QL AIRDUO RESPI INH 113-14 Non-Pref PA, QL AIRDUO RESPI INH 232-14 Non-Pref PA, QL albuterol sulfate inhal aero 108 mcg/act Non-Pref PA, QL; (Albuterol HFA) (90mcg base equiv) albuterol sulfate inhal aero 108 mcg/act Non-Pref PA, QL; (Albuterol HFA) (90mcg base equiv) (generic of PROAIR HFA) albuterol sulfate inhal aero 108 mcg/act Non-Pref PA, QL; (Albuterol HFA) (90mcg base equiv) (generic of PROVENTIL HFA) albuterol sulfate soln nebu 0.5% (5 mg/ml) Pref albuterol sulfate soln nebu 0.63 mg/3ml Pref (base equiv) albuterol sulfate soln nebu 0.083% (2.5 Pref mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml Pref (base equiv)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 40 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ANORO ELLIPT AER 62.5-25 Pref arformoterol tartrate soln nebu 15 Non-Pref PA mcg/2ml (base equiv) (generic of BROVANA) ARFORMOTEROL TARTRATE SOLN NEBU 15 Non-Pref PA MCG/2ML (BASE EQUIV) BEVESPI AER 9-4.8MCG Pref BREO ELLIPTA INH 100-25 Non-Pref PA, QL BREO ELLIPTA INH 200-25 Non-Pref PA, QL BREZTRI AERO AER SPHERE Non-Pref PA BROVANA NEB 15MCG Non-Pref PA budesonide-formoterol fumarate dihyd Non-Pref PA, QL aerosol 80-4.5 mcg/act budesonide-formoterol fumarate dihyd Non-Pref PA, QL aerosol 160-4.5 mcg/act COMBIVENT AER 20-100 Pref DUAKLIR AER 400/12 Non-Pref PA DULERA AER 50-5MCG Pref QL DULERA AER 100-5MCG Pref QL DULERA AER 200-5MCG Pref QL fluticasone-salmeterol aer powder ba 55- Non-Pref PA, QL 14 mcg/act fluticasone-salmeterol aer powder ba 100- Non-Pref PA, QL 50 mcg/dose (generic of ADVAIR DISKUS) fluticasone-salmeterol aer powder ba 113- Non-Pref PA, QL 14 mcg/act fluticasone-salmeterol aer powder ba 232- Non-Pref PA, QL 14 mcg/act fluticasone-salmeterol aer powder ba 250- Non-Pref PA, QL 50 mcg/dose (generic of ADVAIR DISKUS) fluticasone-salmeterol aer powder ba 500- Non-Pref PA, QL 50 mcg/dose (generic of ADVAIR DISKUS) formoterol fumarate soln nebu 20 mcg/2ml Non-Pref PA (generic of PERFOROMIST) ipratropium-albuterol nebu soln 0.5-2.5(3) Pref (neb soln) mg/3ml levalbuterol hcl soln nebu 0.31 mg/3ml Non-Pref PA (base equiv) (generic of XOPENEX) levalbuterol hcl soln nebu 0.63 mg/3ml Non-Pref PA (base equiv) (generic of XOPENEX) levalbuterol hcl soln nebu 1.25 mg/3ml Non-Pref PA (base equiv) (generic of XOPENEX) levalbuterol hcl soln nebu conc 1.25 Non-Pref PA mg/0.5ml (base equiv) (generic of XOPENEX CONCENTRATE)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 41 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits levalbuterol tartrate inhal aerosol 45 Non-Pref PA, QL mcg/act (base equiv) PERFOROMIST NEB 20MCG Non-Pref PA PROAIR DIGIH AER Non-Pref PA, QL PROAIR HFA AER Pref QL PROAIR RESPI AER Non-Pref PA, QL PROVENTIL AER HFA Non-Pref PA, QL SEREVENT DIS AER 50MCG Pref QL STIOLTO AER 2.5-2.5 Pref STRIVERDI AER 2.5MCG Non-Pref PA SYMBICORT AER 80-4.5 Pref QL SYMBICORT AER 160-4.5 Pref QL terbutaline sulfate tab 2.5 mg Pref terbutaline sulfate tab 5 mg Pref TRELEGY AER ELLIPTA Pref VENTOLIN HFA AER Pref QL wixela inhub aer 100/50 (generic of Non-Pref PA, QL ADVAIR DISKUS) wixela inhub aer 250/50 (generic of Non-Pref PA, QL ADVAIR DISKUS) wixela inhub aer 500/50 (generic of Non-Pref PA, QL ADVAIR DISKUS) XOPENEX CONC NEB 1.25/0.5 Non-Pref PA XOPENEX HFA AER Non-Pref PA, QL XOPENEX NEB 0.31MG Non-Pref PA XOPENEX NEB 0.63MG Non-Pref PA XOPENEX NEB 1.25/3ML Non-Pref PA XANTHINES ELIXOPHYLLIN ELX 80/15ML Pref theophylline soln 80 mg/15ml Pref theophylline tab er 12hr 300 mg Pref theophylline tab er 12hr 450 mg Pref theophylline tab er 24hr 400 mg Pref theophylline tab er 24hr 600 mg Pref ANTICOAGULANTS - DRUGS TO PREVENT BLOOD CLOTS COUMARIN ANTICOAGULANTS warfarin sodium tab 1 mg Pref warfarin sodium tab 2 mg Pref warfarin sodium tab 2.5 mg Pref warfarin sodium tab 3 mg Pref warfarin sodium tab 4 mg Pref warfarin sodium tab 5 mg Pref warfarin sodium tab 6 mg Pref warfarin sodium tab 7.5 mg Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 42 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits warfarin sodium tab 10 mg Pref DIRECT FACTOR XA INHIBITORS ELIQUIS ST P TAB 5MG Pref ELIQUIS TAB 2.5MG Pref ELIQUIS TAB 5MG Pref SAVAYSA TAB 15MG Non-Pref PA SAVAYSA TAB 30MG Non-Pref PA SAVAYSA TAB 60MG Non-Pref PA XARELTO STAR TAB 15/20MG Pref XARELTO TAB 2.5MG Pref XARELTO TAB 10MG Pref XARELTO TAB 15MG Pref XARELTO TAB 20MG Pref HEPARINS AND HEPARINOID-LIKE AGENTS ARIXTRA INJ 2.5/0.5 Non-Pref PA ARIXTRA INJ 5/0.4ML Non-Pref PA ARIXTRA INJ 7.5/0.6 Non-Pref PA ARIXTRA INJ 10/0.8ML Non-Pref PA enoxaparin sodium inj 30 mg/0.3ml Pref (generic of LOVENOX) enoxaparin sodium inj 40 mg/0.4ml Pref (generic of LOVENOX) enoxaparin sodium inj 60 mg/0.6ml Pref (generic of LOVENOX) enoxaparin sodium inj 80 mg/0.8ml Pref (generic of LOVENOX) enoxaparin sodium inj 100 mg/ml (generic Pref of LOVENOX) enoxaparin sodium inj 120 mg/0.8ml Pref (generic of LOVENOX) enoxaparin sodium inj 150 mg/ml (generic Pref of LOVENOX) enoxaparin sodium inj 300 mg/3ml Pref (generic of LOVENOX) fondaparinux sodium subcutaneous inj 2.5 Non-Pref PA mg/0.5ml (generic of ARIXTRA) fondaparinux sodium subcutaneous inj 5 Non-Pref PA mg/0.4ml (generic of ARIXTRA) fondaparinux sodium subcutaneous inj 7.5 Non-Pref PA mg/0.6ml (generic of ARIXTRA) fondaparinux sodium subcutaneous inj 10 Non-Pref PA mg/0.8ml (generic of ARIXTRA) FRAGMIN INJ 2500/0.2 Non-Pref PA FRAGMIN INJ 5000/0.2 Non-Pref PA FRAGMIN INJ 7500/0.3 Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 43 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits FRAGMIN INJ 10000/ML Non-Pref PA FRAGMIN INJ 12500UNT Non-Pref PA FRAGMIN INJ 15000UNT Non-Pref PA FRAGMIN INJ 18000UNT Non-Pref PA FRAGMIN INJ 95000UNT Non-Pref PA heparin sodium (porcine) inj 5000 unit/ml Pref heparin sodium (porcine) inj 10000 unit/ml Pref LOVENOX INJ 30/0.3ML Non-Pref PA LOVENOX INJ 40/0.4ML Non-Pref PA LOVENOX INJ 60/0.6ML Non-Pref PA LOVENOX INJ 80/0.8ML Non-Pref PA LOVENOX INJ 100MG/ML Non-Pref PA LOVENOX INJ 120/0.8 Non-Pref PA LOVENOX INJ 150MG/ML Non-Pref PA LOVENOX INJ 300/3ML Non-Pref PA THROMBIN INHIBITORS PRADAXA CAP 75MG Pref PRADAXA CAP 110MG Pref PRADAXA CAP 150MG Pref ANTIDIABETICS - DRUGS TO TREAT DIABETES ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 mg (generic of PRECOSE) Pref acarbose tab 50 mg (generic of PRECOSE) Pref acarbose tab 100 mg (generic of Pref PRECOSE) miglitol tab 25 mg Pref miglitol tab 50 mg Pref miglitol tab 100 mg Pref PRECOSE TAB 25MG Non-Pref PA PRECOSE TAB 50MG Non-Pref PA PRECOSE TAB 100MG Non-Pref PA ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG Pref SYMLNPEN 120 INJ 1000MCG Pref ANTIDIABETIC COMBINATIONS ACTOPLUS MET TAB 15-500MG Non-Pref PA ACTOPLUS MET TAB 15-850MG Non-Pref PA alogliptin-metformin hcl tab 12.5-500 mg Non-Pref PA alogliptin-metformin hcl tab 12.5-1000 mg Non-Pref PA alogliptin-pioglitazone tab 12.5-15 mg Non-Pref PA alogliptin-pioglitazone tab 12.5-30 mg Non-Pref PA alogliptin-pioglitazone tab 12.5-45 mg Non-Pref PA alogliptin-pioglitazone tab 25-15 mg Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 44 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits alogliptin-pioglitazone tab 25-30 mg Non-Pref PA alogliptin-pioglitazone tab 25-45 mg Non-Pref PA DUETACT TAB 30-2MG Non-Pref PA DUETACT TAB 30-4MG Non-Pref PA glipizide-metformin hcl tab 2.5-250 mg Non-Pref PA glipizide-metformin hcl tab 2.5-500 mg Non-Pref PA glipizide-metformin hcl tab 5-500 mg Non-Pref PA glyburide-metformin tab 1.25-250 mg Pref glyburide-metformin tab 2.5-500 mg Pref glyburide-metformin tab 5-500 mg Pref GLYXAMBI TAB 10-5 MG Pref GLYXAMBI TAB 25-5 MG Pref INVOKAMET TAB 50-500MG Pref INVOKAMET TAB 50-1000 Pref INVOKAMET TAB 150-500 Pref INVOKAMET TAB 150-1000 Pref INVOKAMET XR TAB 50-500MG Non-Pref PA INVOKAMET XR TAB 50-1000 Non-Pref PA INVOKAMET XR TAB 150-500 Non-Pref PA INVOKAMET XR TAB 150-1000 Non-Pref PA JANUMET TAB 50-500MG Pref QL JANUMET TAB 50-1000 Pref QL JANUMET XR TAB 50-500MG Pref JANUMET XR TAB 50-1000 Pref JANUMET XR TAB 100-1000 Pref JENTADUETO TAB 2.5-500 Pref JENTADUETO TAB 2.5-850 Pref JENTADUETO TAB 2.5-1000 Pref JENTADUETO TAB XR Non-Pref PA KAZANO 12.5- TAB 500MG Non-Pref PA KAZANO 12.5- TAB 1000MG Non-Pref PA KOMBIGLYZ XR TAB 2.5-1000 Non-Pref PA KOMBIGLYZ XR TAB 5-500MG Non-Pref PA KOMBIGLYZ XR TAB 5-1000MG Non-Pref PA OSENI TAB 12.5-15 Non-Pref PA OSENI TAB 12.5-30 Non-Pref PA OSENI TAB 12.5-45 Non-Pref PA OSENI TAB 25-15MG Non-Pref PA OSENI TAB 25-30MG Non-Pref PA OSENI TAB 25-45MG Non-Pref PA pioglitazone hcl-glimepiride tab 30-2 mg Non-Pref PA (generic of DUETACT) pioglitazone hcl-glimepiride tab 30-4 mg Non-Pref PA (generic of DUETACT)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 45 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits pioglitazone hcl-metformin hcl tab 15-500 Non-Pref PA mg (generic of ACTOPLUS MET) pioglitazone hcl-metformin hcl tab 15-850 Non-Pref PA mg (generic of ACTOPLUS MET) QTERN TAB 5-5MG Non-Pref PA QTERN TAB 10-5MG Non-Pref PA SEGLUROMET TAB 2.5-500 Non-Pref PA SEGLUROMET TAB 2.5-1000 Non-Pref PA SEGLUROMET TAB 7.5-500 Non-Pref PA SEGLUROMET TAB 7.5-1000 Non-Pref PA SOLIQUA INJ 100/33 Non-Pref PA STEGLUJAN TAB 5-100MG Non-Pref PA STEGLUJAN TAB 15-100MG Non-Pref PA SYNJARDY TAB Non-Pref PA SYNJARDY TAB 5-500MG Non-Pref PA SYNJARDY TAB 5-1000MG Non-Pref PA SYNJARDY TAB 12.5-500 Non-Pref PA SYNJARDY XR TAB Non-Pref PA SYNJARDY XR TAB 5-1000MG Non-Pref PA SYNJARDY XR TAB 10-1000 Non-Pref PA SYNJARDY XR TAB 25-1000 Non-Pref PA TRIJARDY XR TAB Non-Pref PA XIGDUO XR TAB 2.5-1000 Pref XIGDUO XR TAB 5-500MG Pref XIGDUO XR TAB 5-1000MG Pref XIGDUO XR TAB 10-500MG Pref XIGDUO XR TAB 10-1000 Pref XULTOPHY INJ 100/3.6 Non-Pref PA BIGUANIDES FORTAMET TAB 500MG Non-Pref PA FORTAMET TAB 1000MG Non-Pref PA GLUMETZA TAB 500MG Non-Pref PA GLUMETZA TAB 1000MG Non-Pref PA metformin hcl oral soln 500 mg/5ml Non-Pref PA (generic of RIOMET) metformin hcl tab 500 mg Pref metformin hcl tab 850 mg Pref metformin hcl tab 1000 mg Pref metformin hcl tab er 24hr 500 mg Pref metformin hcl tab er 24hr 750 mg Pref metformin hcl tab er 24hr modified release Non-Pref PA 500 mg (generic of GLUMETZA) metformin hcl tab er 24hr modified release Non-Pref PA 1000 mg (generic of GLUMETZA)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 46 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits metformin hcl tab er 24hr osmotic 500 mg Non-Pref PA metformin hcl tab er 24hr osmotic 1000 Non-Pref PA mg RIOMET SOL Pref RIOMET SOL 500/5ML Pref DIABETIC OTHER BAQSIMI ONE POW 3MG/DOSE Pref QL, AGE BAQSIMI TWO POW 3MG/DOSE Pref QL, AGE GLUCAGEN INJ HYPOKIT Pref QL glucagon (rdna) for inj kit 1 mg (generic of Pref QL GLUCAGON EMERGENCY KIT) GVOKE HYPO 1 INJ 1MG/.2ML Pref QL, AGE GVOKE HYPO 1 INJ .5/.1ML Pref QL, AGE GVOKE HYPO 2 INJ 1MG/.2ML Pref QL, AGE GVOKE HYPO 2 INJ .5/.1ML Pref QL, AGE GVOKE PFS INJ Pref QL, AGE DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate tab 6.25 mg (base Non-Pref PA equiv) alogliptin benzoate tab 12.5 mg (base Non-Pref PA equiv) alogliptin benzoate tab 25 mg (base equiv) Non-Pref PA JANUVIA TAB 25MG Pref QL JANUVIA TAB 50MG Pref QL JANUVIA TAB 100MG Pref QL NESINA TAB 6.25MG Non-Pref PA NESINA TAB 12.5MG Non-Pref PA NESINA TAB 25MG Non-Pref PA ONGLYZA TAB 2.5MG Non-Pref PA ONGLYZA TAB 5MG Non-Pref PA TRADJENTA TAB 5MG Pref INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) ADLYXIN INJ 10/20MCG Non-Pref PA ADLYXIN INJ 20MCG Non-Pref PA BYDUREON BC INJ 2/0.85ML Non-Pref PA BYETTA INJ 5MCG Pref BYETTA INJ 10MCG Pref OZEMPIC INJ 2/1.5ML Non-Pref PA OZEMPIC INJ 4MG/3ML Non-Pref PA RYBELSUS TAB 3MG Non-Pref PA RYBELSUS TAB 7MG Non-Pref PA RYBELSUS TAB 14MG Non-Pref PA TRULICITY INJ 0.75/0.5 Pref TRULICITY INJ 1.5/0.5 Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 47 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits TRULICITY INJ 3/0.5 Pref TRULICITY INJ 4.5/0.5 Pref VICTOZA INJ 18MG/3ML Pref INSULIN ADMELOG INJ 100U/ML Non-Pref PA, QL ADMELOG SOLO INJ 100U/ML Non-Pref PA, QL AFREZZA POW 4-8 UNIT Non-Pref PA AFREZZA POW 4-8-12 Non-Pref PA AFREZZA POW 4UNIT Non-Pref PA AFREZZA POW 8 UNIT Non-Pref PA AFREZZA POW 8-12UNIT Non-Pref PA AFREZZA POW 12 UNIT Non-Pref PA APIDRA INJ SOLOSTAR Pref QL APIDRA INJ U-100 Pref QL BASAGLAR INJ 100UNIT Non-Pref PA, QL FIASP FLEX INJ TOUCH Non-Pref PA FIASP INJ 100/ML Non-Pref PA FIASP PENFIL INJ U-100 Non-Pref PA HUMALOG INJ 100/ML Pref QL HUMALOG JR INJ 100/ML Pref QL HUMALOG KWIK INJ 100/ML Pref QL HUMALOG KWIK INJ 200/ML Non-Pref PA HUMALOG MIX INJ 50/50 Pref QL HUMALOG MIX INJ 50/50KWP Pref QL HUMALOG MIX INJ 75/25KWP Pref QL HUMALOG MIX SUS 75/25 Pref QL HUMULIN INJ 70/30 Pref QL, OTC HUMULIN INJ 70/30KWP Pref QL, OTC HUMULIN N INJ U-100 Pref QL, OTC HUMULIN N INJ U-100KWP Non-Pref PA, QL, OTC HUMULIN R INJ U-100 Pref QL, OTC HUMULIN R INJ U-500 Pref (Kwikpen) HUMULIN R INJ U-500 Pref QL INS ASP PROT INJ FLEXPEN Non-Pref PA, QL INSULIN ASPA INJ 70/30 Non-Pref PA, QL INSULIN ASPA INJ 100/ML Non-Pref PA, QL INSULIN ASPA INJ FLEXPEN Non-Pref PA, QL INSULIN ASPA INJ PENFILL Non-Pref PA, QL INSULIN LISP INJ 100/ML Non-Pref PA, QL INSULIN LISP INJ JUNIOR Non-Pref PA, QL INSULIN LISP INJ PROTAMIN Non-Pref PA, QL LANTUS INJ 100/ML Pref LANTUS SOLOS INJ 100/ML Pref QL LEVEMIR INJ Pref QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 48 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits LEVEMIR INJ FLEXTOUC Pref QL LYUMJEV INJ 100UT/ML Non-Pref PA, AGE; Max 90 per fill LYUMJEV KWPN INJ 100UT/ML Non-Pref PA, AGE; Max 90 per fill LYUMJEV KWPN INJ 200UT/ML Non-Pref PA, AGE; Max 90 per fill NOVOLIN70/30 INJ RELION Non-Pref PA, QL, OTC NOVOLIN INJ 70/30 Non-Pref PA, QL, OTC NOVOLIN INJ 70/30 FP Non-Pref PA, QL, OTC NOVOLIN N INJ 100 UNIT Pref QL, OTC NOVOLIN N INJ RELION Pref QL, OTC NOVOLIN N INJ U-100 Pref QL, OTC NOVOLIN R INJ 100 UNIT Pref QL, OTC NOVOLIN R INJ RELION Pref QL, OTC NOVOLIN R INJ U-100 Pref QL, OTC NOVOLOG INJ 100/ML Pref QL NOVOLOG INJ FLEXPEN Pref QL NOVOLOG INJ PENFILL Pref QL NOVOLOG MIX INJ 70/30 Pref QL NOVOLOG MIX INJ FLEXPEN Pref QL SEMGLEE INJ 100U/ML Non-Pref PA, QL SEMGLEE SOL 100U/ML Non-Pref PA, QL TOUJEO MAX INJ 300IU/ML Non-Pref PA TOUJEO SOLO INJ 300IU/ML Non-Pref PA TRESIBA FLEX INJ 100UNIT Non-Pref PA TRESIBA FLEX INJ 200UNIT Non-Pref PA TRESIBA INJ 100UNIT Non-Pref PA INSULIN SENSITIZING AGENTS ACTOS TAB 15MG Non-Pref PA ACTOS TAB 30MG Non-Pref PA ACTOS TAB 45MG Non-Pref PA pioglitazone hcl tab 15 mg (base equiv) Pref (generic of ACTOS) pioglitazone hcl tab 30 mg (base equiv) Pref (generic of ACTOS) pioglitazone hcl tab 45 mg (base equiv) Pref (generic of ACTOS) MEGLITINIDE ANALOGUES nateglinide tab 60 mg Pref nateglinide tab 120 mg Pref repaglinide tab 0.5 mg Pref repaglinide tab 1 mg Pref repaglinide tab 2 mg Pref SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA TAB 5MG Pref FARXIGA TAB 10MG Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 49 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits INVOKANA TAB 100MG Pref INVOKANA TAB 300MG Pref JARDIANCE TAB 10MG Pref JARDIANCE TAB 25MG Pref STEGLATRO TAB 5MG Non-Pref PA STEGLATRO TAB 15MG Non-Pref PA SULFONYLUREAS AMARYL TAB 1MG Non-Pref PA AMARYL TAB 2MG Non-Pref PA AMARYL TAB 4MG Non-Pref PA glimepiride tab 1 mg (generic of AMARYL) Pref glimepiride tab 2 mg (generic of AMARYL) Pref glimepiride tab 4 mg (generic of AMARYL) Pref glipizide tab 5 mg Pref glipizide tab 10 mg Pref glipizide tab er 24hr 2.5 mg (generic of Pref GLUCOTROL XL) glipizide tab er 24hr 5 mg (generic of Pref GLUCOTROL XL) glipizide tab er 24hr 10 mg (generic of Pref GLUCOTROL XL) glipizide xl tab 2.5mg (generic of Pref GLUCOTROL XL) glipizide xl tab 5mg (generic of Pref GLUCOTROL XL) glipizide xl tab 10mg (generic of Pref GLUCOTROL XL) GLUCOTROL XL TAB 2.5MG Non-Pref PA GLUCOTROL XL TAB 5MG Non-Pref PA GLUCOTROL XL TAB 10MG Non-Pref PA glyburide micronized tab 1.5 mg (generic Pref of GLYNASE) glyburide micronized tab 3 mg (generic of Pref GLYNASE) glyburide micronized tab 6 mg (generic of Pref GLYNASE) glyburide tab 1.25 mg Pref glyburide tab 2.5 mg Pref glyburide tab 5 mg Pref GLYNASE TAB 1.5MG Non-Pref PA GLYNASE TAB 3MG Non-Pref PA GLYNASE TAB 6MG Non-Pref PA tolbutamide tab 500 mg Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 50 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ANTIDIARRHEAL/PROBIOTIC AGENTS - DRUGS TO TREAT DIARRHEA ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC. bismuth subsalicylate chew tab 262 mg Pref OTC bismuth subsalicylate susp 262 mg/15ml Pref OTC bismuth subsalicylate susp 525 mg/15ml Pref OTC bismuth subsalicylate tab 262 mg Pref OTC PEPTO BISMOL TAB 262MG Pref OTC PEPTO-BISMOL CHW 262MG Pref OTC PEPTO-BISMOL SUS 262/15ML Pref OTC PEPTO-BISMOL SUS 525/15ML Pref OTC ANTIPERISTALTIC AGENTS diphenoxylate w/ atropine liq 2.5-0.025 Pref mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 Pref mg (generic of LOMOTIL) IMODIUM A-D CAP 2MG Pref OTC loperamide hcl cap 2 mg Pref loperamide hcl cap 2 mg Pref OTC loperamide hcl tab 2 mg Pref OTC loperamide sus 1mg/7.5 Pref OTC ANTIDOTES AND SPECIFIC ANTAGONISTS - DRUGS FOR OVERDOSE OR POISONING ANTIDOTES - CHELATING AGENTS CHEMET CAP 100MG Pref OPIOID ANTAGONISTS naloxone hcl inj 0.4 mg/ml Pref QL naloxone hcl inj 4 mg/10ml Pref naloxone hcl soln cartridge 0.4 mg/ml Pref naloxone hcl soln prefilled syringe 2 Pref QL mg/2ml NARCAN SPR Pref QL ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING 5-HT3 RECEPTOR ANTAGONISTS granisetron hcl tab 1 mg Pref Max 15 per fill ondansetron hcl oral soln 4 mg/5ml Pref ondansetron hcl tab 4 mg (generic of Pref Max 15 per fill ZOFRAN) ondansetron hcl tab 8 mg Pref Max 15 per fill ondansetron hcl tab 24 mg Pref Max 15 per fill ondansetron orally disintegrating tab 4 mg Pref Max 15 per fill ondansetron orally disintegrating tab 8 mg Pref Max 15 per fill SANCUSO DIS 3.1MG Non-Pref PA, QL ZOFRAN TAB 4MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 51 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ZOFRAN TAB 8MG Non-Pref PA ZUPLENZ MIS 4MG Non-Pref PA ZUPLENZ MIS 8MG Non-Pref PA ANTIEMETICS - ANTICHOLINERGIC dimenhydrinate tab 50 mg Pref OTC meclizine hcl chew tab 25 mg Pref OTC meclizine hcl tab 12.5 mg Pref meclizine hcl tab 12.5 mg Pref OTC meclizine hcl tab 25 mg Pref meclizine hcl tab 25 mg Pref OTC ANTIEMETICS - MISCELLANEOUS AKYNZEO CAP 300-0.5 Non-Pref PA dronabinol cap 2.5 mg (generic of Pref PA MARINOL) dronabinol cap 5 mg (generic of MARINOL) Pref PA dronabinol cap 10 mg (generic of Pref PA MARINOL) SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS aprepitant capsule 40 mg Non-Pref PA, QL, AGE aprepitant capsule 80 mg (generic of Non-Pref PA, AGE EMEND) aprepitant capsule 125 mg Non-Pref PA, AGE aprepitant capsule therapy pack 80 & 125 Non-Pref PA, AGE mg EMEND CAP 80MG Pref QL, AGE EMEND SUS 125MG Non-Pref PA, AGE EMEND TRIPAC PAK 80 & 125 Non-Pref PA, AGE VARUBI TAB 90MG Non-Pref PA, QL ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ANCOBON CAP 250MG Non-Pref PA, QL ANCOBON CAP 500MG Non-Pref PA, QL flucytosine cap 250 mg (generic of Non-Pref PA, QL ANCOBON) flucytosine cap 500 mg (generic of Non-Pref PA, QL ANCOBON) griseofulvin microsize susp 125 mg/5ml Pref QL griseofulvin microsize tab 500 mg Non-Pref PA, QL griseofulvin ultramicrosize tab 125 mg Non-Pref PA, QL griseofulvin ultramicrosize tab 250 mg Non-Pref PA, QL nystatin tab 500000 unit Pref QL terbinafine hcl tab 250 mg (generic of Pref QL LAMISIL)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 52 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits IMIDAZOLE-RELATED ANTIFUNGALS CRESEMBA CAP 186 MG Non-Pref PA DIFLUCAN SUS 10MG/ML Non-Pref PA DIFLUCAN SUS 40MG/ML Non-Pref PA DIFLUCAN TAB 50MG Non-Pref PA DIFLUCAN TAB 100MG Non-Pref PA DIFLUCAN TAB 150MG Non-Pref PA DIFLUCAN TAB 200MG Non-Pref PA fluconazole for susp 10 mg/ml (generic of Pref DIFLUCAN) fluconazole for susp 40 mg/ml (generic of Pref DIFLUCAN) fluconazole tab 50 mg (generic of Pref DIFLUCAN) fluconazole tab 100 mg (generic of Pref DIFLUCAN) fluconazole tab 150 mg (generic of Pref DIFLUCAN) fluconazole tab 200 mg (generic of Pref DIFLUCAN) itraconazole cap 100 mg (generic of Non-Pref PA SPORANOX) itraconazole oral soln 10 mg/ml (generic of Non-Pref PA SPORANOX) ketoconazole tab 200 mg Pref NOXAFIL SUS 40MG/ML Non-Pref PA NOXAFIL TAB 100MG Non-Pref PA posaconazole tab delayed release 100 mg Non-Pref PA (generic of NOXAFIL) SPORANOX CAP 100MG Non-Pref PA SPORANOX CAP PULSEPAK Non-Pref PA SPORANOX SOL 10MG/ML Non-Pref PA TOLSURA CAP 65MG Non-Pref PA VFEND SUS 40MG/ML Non-Pref PA VFEND TAB 50MG Non-Pref PA VFEND TAB 200MG Non-Pref PA voriconazole for susp 40 mg/ml (generic of Non-Pref PA VFEND) voriconazole tab 50 mg (generic of VFEND) Non-Pref PA voriconazole tab 200 mg (generic of Non-Pref PA VFEND) ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES ANTIHISTAMINES - ALKYLAMINES CHLOR-TRIMET TAB 4MG Pref OTC chlorpheniramine tab 4 mg Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 53 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits chlorpheniramine tab er 12 mg Pref OTC ANTIHISTAMINES - ETHANOLAMINES carbinoxamine maleate soln 4 mg/5ml Pref carbinoxamine maleate tab 4 mg Pref clemastine fumarate tab 1.34 mg Pref OTC clemastine fumarate tab 2.68 mg Pref diphenhydramine hcl cap 25 mg Pref AGE, OTC diphenhydramine hcl cap 50 mg Pref AGE, OTC diphenhydramine hcl elixir 12.5 mg/5ml Pref QL diphenhydramine hcl inj 50 mg/ml Pref AGE diphenhydramine hcl liquid 12.5 mg/5ml Pref QL, OTC diphenydramine hcl tab 25 mg Pref AGE, OTC ANTIHISTAMINES - NON-SEDATING all day allg cap 10mg Non-Pref PA, OTC allergy rel cap 10mg Non-Pref PA, OTC allergy relf tab 5mg Pref OTC cetirizine chw 5mg Non-Pref PA, OTC cetirizine chw 10mg Non-Pref PA, OTC cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) Pref cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) Pref OTC cetirizine hcl tab 5 mg Pref OTC cetirizine hcl tab 10 mg Pref OTC CLARINEX TAB 5MG Non-Pref PA desloratadine tab 5 mg (generic of Non-Pref PA CLARINEX) desloratadine tab orally disintegrating 2.5 Non-Pref PA, AGE mg desloratadine tab orally disintegrating 5 Non-Pref PA mg fexofenadine hcl tab 60 mg Non-Pref PA, OTC fexofenadine hcl tab 180 mg Non-Pref PA, OTC levocetirizine dihydrochloride soln 2.5 Non-Pref PA mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg Pref levocetirizine dihydrochloride tab 5 mg Pref OTC loratadine cap 10 mg Pref OTC loratadine chw 5mg Pref OTC loratadine rapidly-disintegrating tab 10 mg Pref OTC loratadine syrup 5 mg/5ml Pref OTC loratadine tab 10 mg Pref OTC ANTIHISTAMINES - PHENOTHIAZINES promethazine hcl suppos 12.5 mg Pref AGE promethazine hcl suppos 25 mg Pref AGE promethazine hcl suppos 50 mg Pref AGE

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 54 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits promethazine hcl syrup 6.25 mg/5ml Pref AGE promethazine hcl tab 12.5 mg Pref AGE promethazine hcl tab 25 mg Pref AGE promethazine hcl tab 50 mg Pref AGE ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl syrup 2 mg/5ml Pref AGE cyproheptadine hcl tab 4 mg Pref AGE ANTIHYPERLIPIDEMICS - DRUGS TO TREAT HIGH CHOLESTEROL ADENOSINE TRIPHOSPHATE-CITRATE LYASE (ACL) INHIBITORS NEXLETOL TAB 180MG Non-Pref PA, AGE ANTIHYPERLIPIDEMICS - COMBINATIONS ezetimibe-simvastatin tab 10-10 mg Non-Pref PA, QL (generic of VYTORIN) ezetimibe-simvastatin tab 10-20 mg Non-Pref PA, QL (generic of VYTORIN) ezetimibe-simvastatin tab 10-40 mg Non-Pref PA, QL (generic of VYTORIN) ezetimibe-simvastatin tab 10-80 mg Non-Pref PA, QL (generic of VYTORIN) NEXLIZET TAB 180/10MG Non-Pref PA, AGE VYTORIN TAB 10-10MG Non-Pref PA, QL VYTORIN TAB 10-20MG Non-Pref PA, QL VYTORIN TAB 10-40MG Non-Pref PA, QL VYTORIN TAB 10-80MG Non-Pref PA, QL ANTIHYPERLIPIDEMICS - MISC. icosapent ethyl cap 1 gm Non-Pref PA LOVAZA CAP 1GM Non-Pref PA omega-3-acid ethyl esters cap 1 gm Non-Pref PA (generic of LOVAZA) VASCEPA CAP 0.5GM Non-Pref PA VASCEPA CAP 1GM Non-Pref PA BILE ACID SEQUESTRANTS cholestyramine light powder 4 gm/dose Pref (generic of QUESTRAN LIGHT) cholestyramine light powder packets 4 gm Pref cholestyramine powder 4 gm/dose (generic Pref of QUESTRAN) cholestyramine powder packets 4 gm Pref (generic of QUESTRAN) colesevelam hcl packet for susp 3.75 gm Non-Pref PA (generic of WELCHOL) colesevelam hcl tab 625 mg (generic of Non-Pref PA WELCHOL) COLESTID FLA GRA 5/7.5GM Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 55 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits COLESTID FLA GRA 5GM Non-Pref PA COLESTID GRA 5GM Non-Pref PA COLESTID POW 5GM Non-Pref PA COLESTID TAB 1GM Non-Pref PA colestipol hcl granule packets 5 gm Non-Pref PA (generic of COLESTID) colestipol hcl granules 5 gm (generic of Non-Pref PA COLESTID) colestipol hcl tab 1 gm (generic of Pref COLESTID) prevalite pow 4gm (generic of QUESTRAN Pref LIGHT) prevalite pow 4gm pk Pref QUESTRAN POW 4GM Non-Pref PA QUESTRAN POW 4GM LITE Non-Pref PA WELCHOL PAK 3.75GM Non-Pref PA WELCHOL TAB 625MG Non-Pref PA FIBRIC ACID DERIVATIVES ANTARA CAP 30MG Non-Pref PA ANTARA CAP 90MG Non-Pref PA choline fenofibrate cap dr 45 mg (fenofibric Non-Pref PA acid equiv) (generic of TRILIPIX) choline fenofibrate cap dr 135 mg Non-Pref PA (fenofibric acid equiv) (generic of TRILIPIX) fenofibrate cap 50 mg Non-Pref PA fenofibrate cap 150 mg Non-Pref PA fenofibrate micronized cap 43 mg Non-Pref PA fenofibrate micronized cap 67 mg Pref fenofibrate micronized cap 130 mg Non-Pref PA fenofibrate micronized cap 134 mg Pref fenofibrate micronized cap 200 mg Pref fenofibrate tab 40 mg (generic of Non-Pref PA FENOGLIDE) fenofibrate tab 48 mg (generic of TRICOR) Pref fenofibrate tab 54 mg Pref fenofibrate tab 120 mg (generic of Non-Pref PA FENOGLIDE) fenofibrate tab 145 mg (generic of Pref TRICOR) fenofibrate tab 160 mg Pref fenofibric acid tab 35 mg Non-Pref PA fenofibric acid tab 105 mg Non-Pref PA FENOGLIDE TAB 40MG Non-Pref PA FENOGLIDE TAB 120MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 56 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits FIBRICOR TAB 35MG Non-Pref PA FIBRICOR TAB 105MG Non-Pref PA gemfibrozil tab 600 mg (generic of LOPID) Pref LIPOFEN CAP 50MG Non-Pref PA LIPOFEN CAP 150MG Non-Pref PA LOPID TAB 600MG Non-Pref PA TRICOR TAB 48MG Non-Pref PA TRICOR TAB 145MG Non-Pref PA TRIGLIDE TAB 160MG Non-Pref PA TRILIPIX CAP 45MG Non-Pref PA TRILIPIX CAP 135MG Non-Pref PA HMG COA REDUCTASE INHIBITORS ALTOPREV TAB 20MG ER Non-Pref PA, QL ALTOPREV TAB 40MG ER Non-Pref PA, QL ALTOPREV TAB 60MG ER Non-Pref PA, QL atorvastatin calcium tab 10 mg (base Pref QL equivalent) (generic of LIPITOR) atorvastatin calcium tab 20 mg (base Pref QL equivalent) (generic of LIPITOR) atorvastatin calcium tab 40 mg (base Pref QL equivalent) (generic of LIPITOR) atorvastatin calcium tab 80 mg (base Pref QL equivalent) (generic of LIPITOR) CRESTOR TAB 5MG Non-Pref PA, QL CRESTOR TAB 10MG Non-Pref PA, QL CRESTOR TAB 20MG Non-Pref PA, QL CRESTOR TAB 40MG Non-Pref PA, QL EZALLOR SPR CAP 5MG Non-Pref PA, QL EZALLOR SPR CAP 10MG Non-Pref PA, QL EZALLOR SPR CAP 20MG Non-Pref PA, QL EZALLOR SPR CAP 40MG Non-Pref PA, QL fluvastatin sodium cap 20 mg (base Non-Pref PA, QL equivalent) fluvastatin sodium cap 40 mg (base Non-Pref PA, QL equivalent) fluvastatin sodium tab er 24 hr 80 mg Non-Pref PA, QL (base equivalent) (generic of LESCOL XL) LESCOL XL TAB 80MG Non-Pref PA, QL LIPITOR TAB 10MG Non-Pref PA, QL LIPITOR TAB 20MG Non-Pref PA, QL LIPITOR TAB 40MG Non-Pref PA, QL LIPITOR TAB 80MG Non-Pref PA, QL LIVALO TAB 1MG Non-Pref PA, QL LIVALO TAB 2MG Non-Pref PA, QL LIVALO TAB 4MG Non-Pref PA, QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 57 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits lovastatin tab 10 mg Pref QL lovastatin tab 20 mg Pref QL lovastatin tab 40 mg Pref QL pravastatin sodium tab 10 mg Pref QL pravastatin sodium tab 20 mg Pref QL pravastatin sodium tab 40 mg (generic of Pref QL PRAVACHOL) pravastatin sodium tab 80 mg Pref QL rosuvastatin calcium tab 5 mg (generic of Pref QL CRESTOR) rosuvastatin calcium tab 10 mg (generic of Pref QL CRESTOR) rosuvastatin calcium tab 20 mg (generic of Pref QL CRESTOR) rosuvastatin calcium tab 40 mg (generic of Pref QL CRESTOR) simvastatin tab 5 mg Pref QL simvastatin tab 10 mg (generic of ZOCOR) Pref QL simvastatin tab 20 mg (generic of ZOCOR) Pref QL simvastatin tab 40 mg (generic of ZOCOR) Pref QL simvastatin tab 80 mg (generic of ZOCOR) Pref QL ZOCOR TAB 10MG Non-Pref PA, QL ZOCOR TAB 20MG Non-Pref PA, QL ZOCOR TAB 40MG Non-Pref PA, QL ZOCOR TAB 80MG Non-Pref PA, QL ZYPITAMAG TAB 1MG Non-Pref PA, QL ZYPITAMAG TAB 2MG Non-Pref PA, QL ZYPITAMAG TAB 4MG Non-Pref PA, QL INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg (generic of ZETIA) Pref ZETIA TAB 10MG Non-Pref PA NICOTINIC ACID DERIVATIVES niacin tab er 500 mg (antihyperlipidemic) Non-Pref PA (generic of NIASPAN) niacin tab er 750 mg (antihyperlipidemic) Non-Pref PA (generic of NIASPAN) niacin tab er 1000 mg (antihyperlipidemic) Non-Pref PA (generic of NIASPAN) NIASPAN TAB 500MG ER Pref NIASPAN TAB 750MG ER Pref NIASPAN TAB 1000 ER Pref PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS PRALUENT INJ 75MG/ML Non-Pref PA, QL PRALUENT INJ 150MG/ML Non-Pref PA, QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 58 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits REPATHA INJ 140MG/ML Pref PA, QL REPATHA PUSH INJ 420/3.5 Pref PA, QL REPATHA SURE INJ 140MG/ML Pref PA, QL ANTIHYPERTENSIVES - DRUGS TO TREAT HIGH BLOOD PRESSURE ACE INHIBITORS ACCUPRIL TAB 5MG Non-Pref PA ACCUPRIL TAB 10MG Non-Pref PA ACCUPRIL TAB 20MG Non-Pref PA ACCUPRIL TAB 40MG Non-Pref PA ALTACE CAP 1.25MG Non-Pref PA ALTACE CAP 2.5MG Non-Pref PA ALTACE CAP 5MG Non-Pref PA ALTACE CAP 10MG Non-Pref PA benazepril hcl tab 5 mg Pref benazepril hcl tab 10 mg (generic of Pref LOTENSIN) benazepril hcl tab 20 mg (generic of Pref LOTENSIN) benazepril hcl tab 40 mg (generic of Pref LOTENSIN) captopril tab 12.5 mg Non-Pref PA captopril tab 25 mg Non-Pref PA captopril tab 50 mg Non-Pref PA captopril tab 100 mg Non-Pref PA enalapril maleate tab 2.5 mg (generic of Pref VASOTEC) enalapril maleate tab 5 mg (generic of Pref VASOTEC) enalapril maleate tab 10 mg (generic of Pref VASOTEC) enalapril maleate tab 20 mg (generic of Pref VASOTEC) EPANED SOL 1MG/ML Non-Pref PA fosinopril sodium tab 10 mg Non-Pref PA fosinopril sodium tab 20 mg Non-Pref PA fosinopril sodium tab 40 mg Non-Pref PA lisinopril tab 2.5 mg (generic of ZESTRIL) Pref lisinopril tab 5 mg (generic of ZESTRIL) Pref lisinopril tab 10 mg (generic of ZESTRIL) Pref lisinopril tab 20 mg (generic of PRINIVIL) Pref lisinopril tab 30 mg (generic of ZESTRIL) Pref lisinopril tab 40 mg (generic of ZESTRIL) Pref LOTENSIN TAB 10MG Non-Pref PA LOTENSIN TAB 20MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 59 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits LOTENSIN TAB 40MG Non-Pref PA moexipril hcl tab 7.5 mg Non-Pref PA moexipril hcl tab 15 mg Non-Pref PA perindopril erbumine tab 2 mg Non-Pref PA perindopril erbumine tab 4 mg Non-Pref PA perindopril erbumine tab 8 mg Non-Pref PA PRINIVIL TAB 20MG Non-Pref PA QBRELIS SOL 1MG/ML Non-Pref PA quinapril hcl tab 5 mg (generic of Non-Pref PA ACCUPRIL) quinapril hcl tab 10 mg (generic of Non-Pref PA ACCUPRIL) quinapril hcl tab 20 mg (generic of Non-Pref PA ACCUPRIL) quinapril hcl tab 40 mg (generic of Non-Pref PA ACCUPRIL) ramipril cap 1.25 mg (generic of ALTACE) Non-Pref PA ramipril cap 2.5 mg (generic of ALTACE) Non-Pref PA ramipril cap 5 mg (generic of ALTACE) Non-Pref PA ramipril cap 10 mg (generic of ALTACE) Non-Pref PA trandolapril tab 1 mg Non-Pref PA trandolapril tab 2 mg Non-Pref PA trandolapril tab 4 mg (generic of MAVIK) Non-Pref PA VASOTEC TAB 2.5MG Non-Pref PA VASOTEC TAB 5MG Non-Pref PA VASOTEC TAB 10MG Non-Pref PA VASOTEC TAB 20MG Non-Pref PA ZESTRIL TAB 2.5MG Non-Pref PA ZESTRIL TAB 5MG Non-Pref PA ZESTRIL TAB 10MG Non-Pref PA ZESTRIL TAB 20MG Non-Pref PA ZESTRIL TAB 30MG Non-Pref PA ZESTRIL TAB 40MG Non-Pref PA ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND TAB 4MG Non-Pref PA ATACAND TAB 8MG Non-Pref PA ATACAND TAB 16MG Non-Pref PA ATACAND TAB 32MG Non-Pref PA AVAPRO TAB 75MG Non-Pref PA AVAPRO TAB 150MG Non-Pref PA AVAPRO TAB 300MG Non-Pref PA BENICAR TAB 5MG Non-Pref PA BENICAR TAB 20MG Non-Pref PA BENICAR TAB 40MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 60 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits candesartan cilexetil tab 4 mg (generic of Non-Pref PA ATACAND) candesartan cilexetil tab 8 mg (generic of Non-Pref PA ATACAND) candesartan cilexetil tab 16 mg (generic of Non-Pref PA ATACAND) candesartan cilexetil tab 32 mg (generic of Non-Pref PA ATACAND) COZAAR TAB 25MG Non-Pref PA COZAAR TAB 50MG Non-Pref PA COZAAR TAB 100MG Non-Pref PA DIOVAN TAB 40MG Non-Pref PA DIOVAN TAB 80MG Non-Pref PA DIOVAN TAB 160MG Non-Pref PA DIOVAN TAB 320MG Non-Pref PA EDARBI TAB 40MG Non-Pref PA EDARBI TAB 80MG Non-Pref PA irbesartan tab 75 mg (generic of AVAPRO) Non-Pref PA irbesartan tab 150 mg (generic of Non-Pref PA AVAPRO) irbesartan tab 300 mg (generic of Non-Pref PA AVAPRO) losartan potassium tab 25 mg (generic of Pref COZAAR) losartan potassium tab 50 mg (generic of Pref COZAAR) losartan potassium tab 100 mg (generic of Pref COZAAR) MICARDIS TAB 20MG Non-Pref PA MICARDIS TAB 40MG Non-Pref PA MICARDIS TAB 80MG Non-Pref PA olmesartan medoxomil tab 5 mg (generic Pref of BENICAR) olmesartan medoxomil tab 20 mg (generic Pref of BENICAR) olmesartan medoxomil tab 40 mg (generic Pref of BENICAR) telmisartan tab 20 mg (generic of Non-Pref PA MICARDIS) telmisartan tab 40 mg (generic of Non-Pref PA MICARDIS) telmisartan tab 80 mg (generic of Non-Pref PA MICARDIS) valsartan tab 40 mg (generic of DIOVAN) Pref valsartan tab 80 mg (generic of DIOVAN) Pref valsartan tab 160 mg (generic of DIOVAN) Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 61 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits valsartan tab 320 mg (generic of DIOVAN) Pref ANTIADRENERGIC ANTIHYPERTENSIVES CARDURA TAB 1MG Non-Pref PA CARDURA TAB 2MG Non-Pref PA CARDURA TAB 4MG Non-Pref PA CARDURA TAB 8MG Non-Pref PA CATAPRES-TTS DIS 0.1/24HR Pref QL CATAPRES-TTS DIS 0.2/24HR Pref QL CATAPRES-TTS DIS 0.3/24HR Pref QL clonidine hcl tab 0.1 mg Pref clonidine hcl tab 0.2 mg Pref clonidine hcl tab 0.3 mg Pref clonidine td patch weekly 0.1 mg/24hr Non-Pref PA, QL (generic of CATAPRES-TTS-1) clonidine td patch weekly 0.2 mg/24hr Non-Pref PA, QL (generic of CATAPRES-TTS-2) clonidine td patch weekly 0.3 mg/24hr Non-Pref PA, QL (generic of CATAPRES-TTS-3) doxazosin mesylate tab 1 mg (generic of Pref CARDURA) doxazosin mesylate tab 2 mg (generic of Pref CARDURA) doxazosin mesylate tab 4 mg (generic of Pref CARDURA) doxazosin mesylate tab 8 mg (generic of Pref CARDURA) guanfacine hcl tab 1 mg Pref guanfacine hcl tab 2 mg Pref methyldopa tab 250 mg Pref methyldopa tab 500 mg Pref MINIPRESS CAP 1MG Non-Pref PA MINIPRESS CAP 2MG Non-Pref PA MINIPRESS CAP 5MG Non-Pref PA prazosin hcl cap 1 mg (generic of Pref MINIPRESS) prazosin hcl cap 2 mg (generic of Pref MINIPRESS) prazosin hcl cap 5 mg (generic of Pref MINIPRESS) terazosin hcl cap 1 mg (base equivalent) Pref terazosin hcl cap 2 mg (base equivalent) Pref terazosin hcl cap 5 mg (base equivalent) Pref terazosin hcl cap 10 mg (base equivalent) Pref ANTIHYPERTENSIVE COMBINATIONS ACCURETIC TAB 10-12.5 Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 62 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ACCURETIC TAB 20-12.5 Non-Pref PA ACCURETIC TAB 20-25MG Non-Pref PA amlodipine besylate-benazepril hcl cap 2.5- Pref 10 mg amlodipine besylate-benazepril hcl cap 5- Pref 10 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 5- Pref 20 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 5- Pref 40 mg amlodipine besylate-benazepril hcl cap 10- Pref 20 mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap 10- Pref 40 mg (generic of LOTREL) amlodipine besylate-olmesartan medoxomil Pref tab 5-20 mg (generic of AZOR) amlodipine besylate-olmesartan medoxomil Pref tab 5-40 mg (generic of AZOR) amlodipine besylate-olmesartan medoxomil Pref tab 10-20 mg (generic of AZOR) amlodipine besylate-olmesartan medoxomil Pref tab 10-40 mg (generic of AZOR) amlodipine besylate-valsartan tab 5-160 Pref mg (generic of EXFORGE) amlodipine besylate-valsartan tab 5-320 Pref mg (generic of EXFORGE) amlodipine besylate-valsartan tab 10-160 Pref mg (generic of EXFORGE) amlodipine besylate-valsartan tab 10-320 Pref mg (generic of EXFORGE) amlodipine-valsartan-hydrochlorothiazide Pref tab 5-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide Pref tab 5-160-25 mg amlodipine-valsartan-hydrochlorothiazide Pref tab 10-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide Pref tab 10-160-25 mg amlodipine-valsartan-hydrochlorothiazide Pref tab 10-320-25 mg ATACAND HCT TAB 16-12.5 Non-Pref PA ATACAND HCT TAB 32-12.5 Non-Pref PA ATACAND HCT TAB 32-25MG Non-Pref PA atenolol & chlorthalidone tab 50-25 mg Pref (generic of TENORETIC 50)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 63 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits atenolol & chlorthalidone tab 100-25 mg Pref (generic of TENORETIC 100) AVALIDE TAB 150-12.5 Non-Pref PA AVALIDE TAB 300-12.5 Non-Pref PA AZOR TAB 5-20MG Non-Pref PA AZOR TAB 5-40MG Non-Pref PA AZOR TAB 10-20MG Non-Pref PA AZOR TAB 10-40MG Non-Pref PA benazepril & hydrochlorothiazide tab 5- Pref 6.25 mg benazepril & hydrochlorothiazide tab 10- Pref 12.5 mg (generic of LOTENSIN HCT) benazepril & hydrochlorothiazide tab 20- Pref 12.5 mg (generic of LOTENSIN HCT) benazepril & hydrochlorothiazide tab 20-25 Pref mg (generic of LOTENSIN HCT) BENICAR HCT TAB 20-12.5 Non-Pref PA BENICAR HCT TAB 40-12.5 Non-Pref PA BENICAR HCT TAB 40-25MG Non-Pref PA bisoprolol & hydrochlorothiazide tab 2.5- Pref 6.25 mg (generic of ZIAC) bisoprolol & hydrochlorothiazide tab 5-6.25 Pref mg (generic of ZIAC) bisoprolol & hydrochlorothiazide tab 10- Pref 6.25 mg (generic of ZIAC) candesartan cilexetil-hydrochlorothiazide Non-Pref PA tab 16-12.5 mg (generic of ATACAND HCT) candesartan cilexetil-hydrochlorothiazide Non-Pref PA tab 32-12.5 mg (generic of ATACAND HCT) candesartan cilexetil-hydrochlorothiazide Non-Pref PA tab 32-25 mg (generic of ATACAND HCT) DIOVAN HCT TAB 80/12.5 Non-Pref PA DIOVAN HCT TAB 160-12.5 Non-Pref PA DIOVAN HCT TAB 160-25MG Non-Pref PA DIOVAN HCT TAB 320-12.5 Non-Pref PA DIOVAN HCT TAB 320-25MG Non-Pref PA EDARBYCLOR TAB 40-12.5 Non-Pref PA EDARBYCLOR TAB 40-25MG Non-Pref PA enalapril maleate & hydrochlorothiazide tab Pref 5-12.5 mg enalapril maleate & hydrochlorothiazide tab Pref 10-25 mg (generic of VASERETIC) EXFORGE TAB 5-160MG Non-Pref PA EXFORGE TAB 5-320MG Non-Pref PA EXFORGE TAB 10-160MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 64 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits EXFORGE TAB 10-320MG Non-Pref PA EXFORGEH/5- TAB 160-12.5 Non-Pref PA EXFORGEH/5- TAB 160-25 Non-Pref PA EXFORGEH/10- TAB 160-12.5 Non-Pref PA EXFORGEH/10- TAB 160-25 Non-Pref PA EXFORGEH/10- TAB 320-25 Non-Pref PA fosinopril sodium & hydrochlorothiazide tab Non-Pref PA 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab Non-Pref PA 20-12.5 mg HYZAAR TAB 50-12.5 Non-Pref PA HYZAAR TAB 100-12.5 Non-Pref PA HYZAAR TAB 100-25 Non-Pref PA irbesartan-hydrochlorothiazide tab 150- Non-Pref PA 12.5 mg (generic of AVALIDE) irbesartan-hydrochlorothiazide tab 300- Non-Pref PA 12.5 mg (generic of AVALIDE) lisinopril & hydrochlorothiazide tab 10-12.5 Pref mg (generic of ZESTORETIC) lisinopril & hydrochlorothiazide tab 20-12.5 Pref mg (generic of ZESTORETIC) lisinopril & hydrochlorothiazide tab 20-25 Pref mg (generic of ZESTORETIC) losartan potassium & hydrochlorothiazide Pref tab 50-12.5 mg (generic of HYZAAR) losartan potassium & hydrochlorothiazide Pref tab 100-12.5 mg (generic of HYZAAR) losartan potassium & hydrochlorothiazide Pref tab 100-25 mg (generic of HYZAAR) LOTENSIN HCT TAB 10-12.5 Non-Pref PA LOTENSIN HCT TAB 20-12.5 Non-Pref PA LOTENSIN HCT TAB 20-25MG Non-Pref PA LOTREL CAP 5-10MG Non-Pref PA LOTREL CAP 5-20MG Non-Pref PA LOTREL CAP 10-20MG Non-Pref PA LOTREL CAP 10-40MG Non-Pref PA methyldopa & hydrochlorothiazide tab 250- Non-Pref PA 15 mg methyldopa & hydrochlorothiazide tab 250- Non-Pref PA 25 mg metoprolol & hydrochlorothiazide tab 50- Non-Pref PA 25 mg metoprolol & hydrochlorothiazide tab 100- Non-Pref PA 25 mg metoprolol & hydrochlorothiazide tab 100- Non-Pref PA 50 mg

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 65 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits MICARDIS HCT TAB 40/12.5 Non-Pref PA MICARDIS HCT TAB 80-25MG Non-Pref PA MICARDIS HCT TAB 80/12.5 Non-Pref PA olmesartan medoxomil-hydrochlorothiazide Pref tab 20-12.5 mg (generic of BENICAR HCT) olmesartan medoxomil-hydrochlorothiazide Pref tab 40-12.5 mg (generic of BENICAR HCT) olmesartan medoxomil-hydrochlorothiazide Pref tab 40-25 mg (generic of BENICAR HCT) olmesartan-amlodipine-hydrochlorothiazide Non-Pref PA tab 20-5-12.5 mg (generic of TRIBENZOR) olmesartan-amlodipine-hydrochlorothiazide Non-Pref PA tab 40-5-12.5 mg (generic of TRIBENZOR) olmesartan-amlodipine-hydrochlorothiazide Non-Pref PA tab 40-5-25 mg (generic of TRIBENZOR) olmesartan-amlodipine-hydrochlorothiazide Non-Pref PA tab 40-10-12.5 mg (generic of TRIBENZOR) olmesartan-amlodipine-hydrochlorothiazide Non-Pref PA tab 40-10-25 mg (generic of TRIBENZOR) propranolol & hydrochlorothiazide tab 40- Non-Pref PA 25 mg propranolol & hydrochlorothiazide tab 80- Non-Pref PA 25 mg quinapril-hydrochlorothiazide tab 10-12.5 Non-Pref PA mg (generic of ACCURETIC) quinapril-hydrochlorothiazide tab 20-12.5 Non-Pref PA mg (generic of ACCURETIC) quinapril-hydrochlorothiazide tab 20-25 mg Non-Pref PA (generic of ACCURETIC) TARKA TAB 2-180 CR Non-Pref PA TARKA TAB 2-240 CR Non-Pref PA TARKA TAB 4-240 CR Non-Pref PA TEKTURNA HCT TAB 150-12.5 Non-Pref PA TEKTURNA HCT TAB 150-25MG Non-Pref PA TEKTURNA HCT TAB 300-12.5 Non-Pref PA TEKTURNA HCT TAB 300-25MG Non-Pref PA telmisartan-amlodipine tab 40-5 mg Non-Pref PA (generic of TWYNSTA) telmisartan-amlodipine tab 40-10 mg Non-Pref PA (generic of TWYNSTA) telmisartan-amlodipine tab 80-5 mg Non-Pref PA (generic of TWYNSTA) telmisartan-amlodipine tab 80-10 mg Non-Pref PA (generic of TWYNSTA)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 66 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits telmisartan-hydrochlorothiazide tab 40- Non-Pref PA 12.5 mg (generic of MICARDIS HCT) telmisartan-hydrochlorothiazide tab 80- Non-Pref PA 12.5 mg (generic of MICARDIS HCT) telmisartan-hydrochlorothiazide tab 80-25 Non-Pref PA mg (generic of MICARDIS HCT) TENORETIC TAB 50 Non-Pref PA TENORETIC TAB 100 Non-Pref PA trandolapril-verapamil hcl tab er 1-240 mg Non-Pref PA trandolapril-verapamil hcl tab er 2-180 mg Non-Pref PA (generic of TARKA) trandolapril-verapamil hcl tab er 2-240 mg Non-Pref PA (generic of TARKA) trandolapril-verapamil hcl tab er 4-240 mg Non-Pref PA (generic of TARKA) TRIBENZOR20- TAB 5-12.5MG Non-Pref PA TRIBENZOR40- TAB 5-12.5MG Non-Pref PA TRIBENZOR40- TAB 5-25MG Non-Pref PA TRIBENZOR40- TAB 10-12.5 Non-Pref PA TRIBENZOR40- TAB 10-25MG Non-Pref PA TWYNSTA TAB 40-5MG Non-Pref PA TWYNSTA TAB 40-10MG Non-Pref PA TWYNSTA TAB 80-5MG Non-Pref PA TWYNSTA TAB 80-10MG Non-Pref PA valsartan-hydrochlorothiazide tab 80-12.5 Pref mg (generic of DIOVAN HCT) valsartan-hydrochlorothiazide tab 160-12.5 Pref mg (generic of DIOVAN HCT) valsartan-hydrochlorothiazide tab 160-25 Pref mg (generic of DIOVAN HCT) valsartan-hydrochlorothiazide tab 320-12.5 Pref mg (generic of DIOVAN HCT) valsartan-hydrochlorothiazide tab 320-25 Pref mg (generic of DIOVAN HCT) VASERETIC TAB 10-25MG Non-Pref PA ZESTORETIC TAB 10-12.5 Non-Pref PA ZESTORETIC TAB 20-12.5 Non-Pref PA ZESTORETIC TAB 20-25MG Non-Pref PA ZIAC TAB 2.5/6.25 Non-Pref PA ZIAC TAB 5-6.25MG Non-Pref PA ZIAC TAB 10/6.25 Non-Pref PA DIRECT RENIN INHIBITORS aliskiren fumarate tab 150 mg (base Non-Pref PA equivalent) (generic of TEKTURNA)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 67 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits aliskiren fumarate tab 300 mg (base Non-Pref PA equivalent) (generic of TEKTURNA) TEKTURNA TAB 150MG Non-Pref PA TEKTURNA TAB 300MG Non-Pref PA VASODILATORS hydralazine hcl inj 20 mg/ml Pref hydralazine hcl tab 10 mg Pref QL hydralazine hcl tab 25 mg Pref QL hydralazine hcl tab 50 mg Pref QL hydralazine hcl tab 100 mg Pref QL minoxidil tab 2.5 mg Pref minoxidil tab 10 mg Pref ANTIMALARIALS - DRUGS TO TREAT MALARIA ANTIMALARIALS - DRUGS TO TREAT MALARIA chloroquine phosphate tab 250 mg Pref QL chloroquine phosphate tab 500 mg Pref QL hydroxychloroquine sulfate tab 200 mg Pref (generic of PLAQUENIL) KRINTAFEL TAB 150MG Pref PA, QL, AGE mefloquine hcl tab 250 mg Pref PA, QL primaquine phosphate tab 26.3 mg (15 mg Pref base) (generic of PRIMAQUINE PHOSPHATE) pyrimethamine tab 25 mg (generic of Pref PA, QL DARAPRIM) ANTIMYASTHENIC/CHOLINERGIC AGENTS - DRUGS TO TREAT MUSCLE DISORDERS ANTIMYASTHENIC/CHOLINERGIC AGENTS - DRUGS TO TREAT MUSCLE DISORDERS pyridostigmine bromide tab 60 mg (generic Pref of MESTINON) ANTIMYCOBACTERIAL AGENTS - DRUGS TO TREAT INFECTIONS ANTIMYCOBACTERIAL AGENTS - DRUGS TO TREAT INFECTIONS cycloserine cap 250 mg Pref QL ethambutol hcl tab 100 mg Pref QL ethambutol hcl tab 400 mg (generic of Pref QL MYAMBUTOL) isoniazid syrup 50 mg/5ml Pref QL, AGE isoniazid tab 100 mg Pref QL isoniazid tab 300 mg Pref QL PRETOMANID TAB 200MG Pref PA, QL, AGE PRIFTIN TAB 150MG Pref QL pyrazinamide tab 500 mg Pref QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 68 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits rifabutin cap 150 mg (generic of Pref QL MYCOBUTIN) rifampin cap 150 mg Pref QL rifampin cap 300 mg Pref QL TRECATOR TAB 250MG Pref QL ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - DRUGS TO TREAT CANCER ALKYLATING AGENTS cyclophosphamide cap 25 mg Pref SP, QL cyclophosphamide cap 50 mg Pref SP, QL GLEOSTINE CAP 10MG Pref PA GLEOSTINE CAP 40MG Pref PA GLEOSTINE CAP 100MG Pref PA LEUKERAN TAB 2MG Pref PA melphalan tab 2 mg (generic of ALKERAN) Pref PA MYLERAN TAB 2MG Pref PA temozolomide cap 5 mg Pref SP, PA temozolomide cap 20 mg Pref SP, PA temozolomide cap 100 mg (generic of Pref SP, PA TEMODAR) temozolomide cap 140 mg (generic of Pref SP, PA TEMODAR) temozolomide cap 180 mg (generic of Pref SP, PA TEMODAR) temozolomide cap 250 mg (generic of Pref SP, PA TEMODAR) ANTIMETABOLITES capecitabine tab 150 mg (generic of Pref SP, PA XELODA) capecitabine tab 500 mg (generic of Pref SP, PA XELODA) mercaptopurine tab 50 mg Pref methotrexate sodium inj 50 mg/2ml (25 Pref mg/ml) methotrexate sodium inj 250 mg/10ml (25 Pref mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 Pref mg/ml) methotrexate sodium inj pf 250 mg/10ml Pref (25 mg/ml) methotrexate sodium inj pf 1000 mg/40ml Pref (25 mg/ml) METHOTREXATE TAB 2.5MG Pref ONUREG TAB 200MG Pref SP, PA ONUREG TAB 300MG Pref SP, PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 69 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits TABLOID TAB 40MG Pref PA XATMEP SOL 2.5MG/ML Pref PA ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA TAB 10MG Pref SP, PA VENCLEXTA TAB 50MG Pref SP, PA VENCLEXTA TAB 100MG Pref SP, PA VENCLEXTA TAB START PK Pref SP, PA ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS DAURISMO TAB 25MG Pref SP, PA DAURISMO TAB 100MG Pref SP, PA ERIVEDGE CAP 150MG Pref SP, PA, QL ODOMZO CAP 200MG Pref SP, PA ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS abiraterone acetate tab 250 mg (generic of Pref SP, PA, QL ZYTIGA) anastrozole tab 1 mg (generic of Pref ARIMIDEX) bicalutamide tab 50 mg (generic of Pref QL CASODEX) DEPO-PROVERA INJ 400/ML Non-Pref PA EMCYT CAP 140MG Pref PA ERLEADA TAB 60MG Pref SP, PA, QL exemestane tab 25 mg (generic of Pref AROMASIN) flutamide cap 125 mg Pref PA hydroxyprogesterone caproate im in oil Pref PA 1.25 gm/5ml letrozole tab 2.5 mg (generic of FEMARA) Pref QL, AGE leuprolide acetate inj kit 5 mg/ml Pref PA LYSODREN TAB 500MG Pref PA megestrol acetate susp 40 mg/ml Pref megestrol acetate tab 20 mg Pref megestrol acetate tab 40 mg Pref nilutamide tab 150 mg (generic of Pref PA NILANDRON) NUBEQA TAB 300MG Pref SP, PA tamoxifen citrate tab 10 mg (base Pref QL equivalent) tamoxifen citrate tab 20 mg (base Pref QL equivalent) toremifene citrate tab 60 mg (base Pref PA equivalent) (generic of FARESTON) XTANDI CAP 40MG Pref SP, PA, QL ZOLADEX IMP 3.6MG Pref SP, PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 70 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ZOLADEX IMP 10.8MG Pref SP, PA ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST CAP 1MG Pref SP, PA, QL POMALYST CAP 2MG Pref SP, PA, QL POMALYST CAP 3MG Pref SP, PA, QL POMALYST CAP 4MG Pref SP, PA, QL ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO PAK 60MG Pref SP, PA XPOVIO PAK 80MG Pref SP, PA XPOVIO PAK 100MG Pref SP, PA ANTINEOPLASTIC COMBINATIONS INQOVI TAB 35-100MG Pref SP, PA LONSURF TAB 15-6.14 Pref SP, PA LONSURF TAB 20-8.19 Pref SP, PA ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR DIS TAB 2MG Pref SP, PA, QL AFINITOR DIS TAB 3MG Pref SP, PA, QL AFINITOR DIS TAB 5MG Pref SP, PA, QL AFINITOR TAB 10MG Pref SP, PA, QL BRAFTOVI CAP 75MG Pref PA everolimus tab 2.5 mg (generic of Pref SP, PA, QL AFINITOR) everolimus tab 5 mg (generic of AFINITOR) Pref SP, PA, QL everolimus tab 7.5 mg (generic of Pref SP, PA, QL AFINITOR) FARYDAK CAP 10MG Pref SP, PA FARYDAK CAP 15MG Pref SP, PA FARYDAK CAP 20MG Pref SP, PA IDHIFA TAB 50MG Pref SP, PA IDHIFA TAB 100MG Pref SP, PA JAKAFI TAB 5MG Pref SP, PA, QL JAKAFI TAB 10MG Pref SP, PA, QL JAKAFI TAB 15MG Pref SP, PA, QL JAKAFI TAB 20MG Pref SP, PA, QL JAKAFI TAB 25MG Pref SP, PA, QL LUMAKRAS TAB 120MG Pref PA TAZVERIK TAB 200MG Pref SP, PA TIBSOVO TAB 250MG Pref SP, PA, QL ZOLINZA CAP 100MG Pref SP, PA ANTINEOPLASTICS MISC. bexarotene cap 75 mg (generic of Pref SP, PA TARGRETIN) hydroxyurea cap 500 mg (generic of Pref HYDREA)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 71 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits INTRON A INJ 10MU Non-Pref SP, PA INTRON A INJ 18MU Non-Pref SP, PA INTRON A INJ 25MU Non-Pref SP, PA INTRON A INJ 50MU Non-Pref SP, PA MATULANE CAP 50MG Pref SP, PA tretinoin cap 10 mg Pref PA CHEMOTHERAPY RESCUE/ANTIDOTE/PROTECTIVE AGENTS leucovorin calcium tab 5 mg Pref leucovorin calcium tab 10 mg Pref leucovorin calcium tab 15 mg Pref leucovorin calcium tab 25 mg Pref MESNEX TAB 400MG Pref PA MITOTIC INHIBITORS etoposide cap 50 mg Pref PA TOPOISOMERASE I INHIBITORS HYCAMTIN CAP 0.25MG Pref SP, PA HYCAMTIN CAP 1MG Pref SP, PA ANTIPARKINSON AND RELATED THERAPY AGENTS - DRUGS TO TREAT PARKINSONS DISEASE ANTIPARKINSON ADJUNCTIVE THERAPY carbidopa tab 25 mg (generic of LODOSYN) Non-Pref PA LODOSYN TAB 25MG Non-Pref PA NOURIANZ TAB 20MG Non-Pref PA NOURIANZ TAB 40MG Non-Pref PA ANTIPARKINSON COMT INHIBITORS COMTAN TAB 200MG Non-Pref PA entacapone tab 200 mg (generic of Non-Pref PA COMTAN) ONGENTYS CAP 25MG Non-Pref PA ONGENTYS CAP 50MG Non-Pref PA TASMAR TAB 100MG Non-Pref PA tolcapone tab 100 mg (generic of TASMAR) Non-Pref PA ANTIPARKINSON DOPAMINERGICS amantadine hcl cap 100 mg Pref amantadine hcl syrup 50 mg/5ml Pref amantadine hcl tab 100 mg Non-Pref PA bromocriptine mesylate cap 5 mg (base Non-Pref PA equivalent) (generic of PARLODEL) bromocriptine mesylate tab 2.5 mg (base Non-Pref PA equivalent) (generic of PARLODEL) carbidopa & levodopa orally disintegrating Non-Pref PA tab 10-100 mg

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 72 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits carbidopa & levodopa orally disintegrating Non-Pref PA tab 25-100 mg carbidopa & levodopa orally disintegrating Non-Pref PA tab 25-250 mg carbidopa & levodopa tab 10-100 mg Pref (generic of SINEMET) carbidopa & levodopa tab 25-100 mg Pref (generic of SINEMET) carbidopa & levodopa tab 25-250 mg Pref carbidopa & levodopa tab er 25-100 mg Pref carbidopa & levodopa tab er 50-200 mg Pref carbidopa-levodopa-entacapone tabs 12.5- Non-Pref PA 50-200 mg (generic of STALEVO 50) carbidopa-levodopa-entacapone tabs Non-Pref PA 18.75-75-200 mg (generic of STALEVO 75) carbidopa-levodopa-entacapone tabs 25- Non-Pref PA 100-200 mg (generic of STALEVO 100) carbidopa-levodopa-entacapone tabs Non-Pref PA 31.25-125-200 mg (generic of STALEVO 125) carbidopa-levodopa-entacapone tabs 37.5- Non-Pref PA 150-200 mg (generic of STALEVO 150) carbidopa-levodopa-entacapone tabs 50- Non-Pref PA 200-200 mg DUOPA SUS 4.63-20 Non-Pref SP, PA GOCOVRI CAP 68.5MG Non-Pref SP, PA GOCOVRI CAP 137MG Non-Pref SP, PA INBRIJA CAP 42MG Non-Pref SP, PA KYNMOBI MIS 10MG Non-Pref SP, PA KYNMOBI MIS 15MG Non-Pref SP, PA KYNMOBI MIS 20MG Non-Pref SP, PA KYNMOBI MIS 25MG Non-Pref SP, PA KYNMOBI MIS 30MG Non-Pref SP, PA MIRAPEX ER TAB 0.75MG Non-Pref PA MIRAPEX ER TAB 0.375MG Non-Pref PA MIRAPEX ER TAB 1.5MG Non-Pref PA MIRAPEX ER TAB 2.25MG Non-Pref PA MIRAPEX ER TAB 3.75MG Non-Pref PA MIRAPEX ER TAB 3MG Non-Pref PA MIRAPEX ER TAB 4.5MG Non-Pref PA NEUPRO DIS 1MG/24HR Non-Pref PA, QL NEUPRO DIS 2MG/24HR Non-Pref PA, QL NEUPRO DIS 3MG/24HR Non-Pref PA, QL NEUPRO DIS 4MG/24HR Non-Pref PA, QL NEUPRO DIS 6MG/24HR Non-Pref PA, QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 73 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits NEUPRO DIS 8MG/24HR Non-Pref PA, QL OSMOLEX ER TAB 129MG Non-Pref PA OSMOLEX ER TAB 193MG Non-Pref PA OSMOLEX ER TAB 258MG Non-Pref PA PARLODEL CAP 5MG Non-Pref PA PARLODEL TAB 2.5MG Non-Pref PA pramipexole dihydrochloride tab 0.5 mg Pref (generic of MIRAPEX) pramipexole dihydrochloride tab 0.25 mg Pref pramipexole dihydrochloride tab 0.75 mg Pref (generic of MIRAPEX) pramipexole dihydrochloride tab 0.125 mg Pref (generic of MIRAPEX) pramipexole dihydrochloride tab 1 mg Pref (generic of MIRAPEX) pramipexole dihydrochloride tab 1.5 mg Pref pramipexole dihydrochloride tab er 24hr Non-Pref PA 0.75 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr Non-Pref PA 0.375 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr Non-Pref PA 1.5 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr Non-Pref PA 2.25 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr 3 Non-Pref PA mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr Non-Pref PA 3.75 mg (generic of MIRAPEX ER) pramipexole dihydrochloride tab er 24hr Non-Pref PA 4.5 mg (generic of MIRAPEX ER) REQUIP XL TAB 6MG Non-Pref PA REQUIP XL TAB 12MG Non-Pref PA ropinirole hydrochloride tab 0.5 mg Pref ropinirole hydrochloride tab 0.25 mg Pref ropinirole hydrochloride tab 1 mg Pref ropinirole hydrochloride tab 2 mg Pref ropinirole hydrochloride tab 3 mg Pref ropinirole hydrochloride tab 4 mg Pref ropinirole hydrochloride tab 5 mg Pref ropinirole hydrochloride tab er 24hr 2 mg Non-Pref PA (base equivalent) ropinirole hydrochloride tab er 24hr 4 mg Non-Pref PA (base equivalent) ropinirole hydrochloride tab er 24hr 6 mg Non-Pref PA (base equivalent)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 74 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ropinirole hydrochloride tab er 24hr 8 mg Non-Pref PA (base equivalent) ropinirole hydrochloride tab er 24hr 12 mg Non-Pref PA (base equivalent) RYTARY CAP 95MG Non-Pref PA RYTARY CAP 145MG Non-Pref PA RYTARY CAP 195MG Non-Pref PA RYTARY CAP 245MG Non-Pref PA SINEMET TAB 10-100MG Non-Pref PA SINEMET TAB 25-100MG Non-Pref PA STALEVO 50 TAB Non-Pref PA STALEVO 75 TAB Non-Pref PA STALEVO 100 TAB Non-Pref PA STALEVO 125 TAB Non-Pref PA STALEVO 150 TAB Non-Pref PA STALEVO 200 TAB Non-Pref PA ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS AZILECT TAB 0.5MG Non-Pref PA, AGE AZILECT TAB 1MG Non-Pref PA, AGE rasagiline mesylate tab 0.5 mg (base Non-Pref PA, AGE equiv) (generic of AZILECT) rasagiline mesylate tab 1 mg (base equiv) Non-Pref PA, AGE (generic of AZILECT) selegiline hcl cap 5 mg Non-Pref PA selegiline hcl tab 5 mg Non-Pref PA XADAGO TAB 50MG Non-Pref PA XADAGO TAB 100MG Non-Pref PA ZELAPAR TAB 1.25MG Non-Pref PA ANTIPSYCHOTICS/ANTIMANIC AGENTS - DRUGS TO TREAT PSYCHOSES PHENOTHIAZINES compro sup 25mg Pref QL prochlorperazine maleate tab 5 mg (base Pref QL equivalent) prochlorperazine maleate tab 10 mg (base Pref QL equivalent) prochlorperazine suppos 25 mg Pref QL ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS CMV AGENTS valganciclovir hcl tab 450 mg (base Pref PA, QL equivalent) (generic of VALCYTE) HEPATITIS AGENTS adefovir dipivoxil tab 10 mg (generic of Pref QL HEPSERA)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 75 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits entecavir tab 0.5 mg (generic of Pref QL BARACLUDE) entecavir tab 1 mg (generic of Pref QL BARACLUDE) lamivudine tab 100 mg (hbv) (generic of Pref QL EPIVIR HBV) VEMLIDY TAB 25MG Pref PA, QL HERPES AGENTS acyclovir cap 200 mg Pref acyclovir susp 200 mg/5ml (generic of Pref ZOVIRAX) acyclovir tab 400 mg Pref acyclovir tab 800 mg Pref famciclovir tab 125 mg Pref famciclovir tab 250 mg Pref famciclovir tab 500 mg Pref SITAVIG TAB 50MG Non-Pref PA valacyclovir hcl tab 1 gm (generic of Pref VALTREX) valacyclovir hcl tab 500 mg (generic of Pref VALTREX) VALTREX TAB 1GM Non-Pref PA VALTREX TAB 500MG Non-Pref PA ZOVIRAX SUS 200/5ML Non-Pref PA INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base Pref equiv) (generic of TAMIFLU) oseltamivir phosphate cap 45 mg (base Pref equiv) (generic of TAMIFLU) oseltamivir phosphate cap 75 mg (base Pref equiv) (generic of TAMIFLU) oseltamivir phosphate for susp 6 mg/ml Pref (base equiv) (generic of TAMIFLU) RELENZA MIS DISKHALE Pref QL rimantadine hydrochloride tab 100 mg Pref TAMIFLU CAP 30MG Pref QL TAMIFLU CAP 45MG Pref QL TAMIFLU CAP 75MG Pref QL TAMIFLU SUS 6MG/ML Pref QL XOFLUZA TAB 20MG Pref XOFLUZA TAB 40MG Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 76 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits BETA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS ALPHA-BETA BLOCKERS carvedilol phosphate cap er 24hr 10 mg Non-Pref PA (generic of COREG CR) carvedilol phosphate cap er 24hr 20 mg Non-Pref PA (generic of COREG CR) carvedilol phosphate cap er 24hr 40 mg Non-Pref PA (generic of COREG CR) carvedilol phosphate cap er 24hr 80 mg Non-Pref PA (generic of COREG CR) carvedilol tab 3.125 mg (generic of Pref COREG) carvedilol tab 6.25 mg (generic of COREG) Pref carvedilol tab 12.5 mg (generic of COREG) Pref carvedilol tab 25 mg (generic of COREG) Pref COREG CR CAP 10MG Non-Pref PA COREG CR CAP 20MG Non-Pref PA COREG CR CAP 40MG Non-Pref PA COREG CR CAP 80MG Non-Pref PA COREG TAB 3.125MG Non-Pref PA COREG TAB 6.25MG Non-Pref PA COREG TAB 12.5MG Non-Pref PA COREG TAB 25MG Non-Pref PA labetalol hcl tab 100 mg Pref labetalol hcl tab 200 mg Pref labetalol hcl tab 300 mg Pref BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl cap 200 mg Non-Pref PA acebutolol hcl cap 400 mg Non-Pref PA atenolol tab 25 mg (generic of TENORMIN) Pref atenolol tab 50 mg (generic of TENORMIN) Pref atenolol tab 100 mg (generic of Pref TENORMIN) betaxolol hcl tab 10 mg Non-Pref PA betaxolol hcl tab 20 mg Non-Pref PA bisoprolol fumarate tab 5 mg Non-Pref PA bisoprolol fumarate tab 10 mg Non-Pref PA BYSTOLIC TAB 2.5MG Pref BYSTOLIC TAB 5MG Pref BYSTOLIC TAB 10MG Pref BYSTOLIC TAB 20MG Pref KAPSPARGO CAP 25MG Non-Pref PA KAPSPARGO CAP 50MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 77 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits KAPSPARGO CAP 100MG Non-Pref PA KAPSPARGO CAP 200MG Non-Pref PA LOPRESSOR TAB 50MG Non-Pref PA LOPRESSOR TAB 100MG Non-Pref PA metoprolol succinate tab er 24hr 25 mg Pref (tartrate equiv) (generic of TOPROL XL) metoprolol succinate tab er 24hr 50 mg Pref (tartrate equiv) (generic of TOPROL XL) metoprolol succinate tab er 24hr 100 mg Pref (tartrate equiv) (generic of TOPROL XL) metoprolol succinate tab er 24hr 200 mg Pref (tartrate equiv) (generic of TOPROL XL) metoprolol tartrate tab 25 mg Pref metoprolol tartrate tab 37.5 mg Pref metoprolol tartrate tab 50 mg (generic of Pref LOPRESSOR) metoprolol tartrate tab 75 mg Pref metoprolol tartrate tab 100 mg (generic of Pref LOPRESSOR) TENORMIN TAB 25MG Non-Pref PA TENORMIN TAB 50MG Non-Pref PA TENORMIN TAB 100MG Non-Pref PA TOPROL XL TAB 25MG Non-Pref PA TOPROL XL TAB 50MG Non-Pref PA TOPROL XL TAB 100MG Non-Pref PA TOPROL XL TAB 200MG Non-Pref PA BETA BLOCKERS NON-SELECTIVE BETAPACE AF TAB 80MG Non-Pref PA BETAPACE AF TAB 120MG Non-Pref PA BETAPACE AF TAB 160MG Non-Pref PA BETAPACE TAB 80MG Non-Pref PA BETAPACE TAB 120MG Non-Pref PA BETAPACE TAB 160MG Non-Pref PA CORGARD TAB 20MG Non-Pref PA CORGARD TAB 40MG Non-Pref PA CORGARD TAB 80MG Non-Pref PA HEMANGEOL SOL 4.28/ML Non-Pref PA INDERAL LA CAP 60MG Non-Pref PA INDERAL LA CAP 80MG Non-Pref PA INDERAL LA CAP 120MG Non-Pref PA INDERAL LA CAP 160MG Non-Pref PA INDERAL XL CAP 80MG Non-Pref PA INDERAL XL CAP 120MG Non-Pref PA INNOPRAN XL CAP 80MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 78 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits INNOPRAN XL CAP 120MG Non-Pref PA nadolol tab 20 mg (generic of CORGARD) Non-Pref PA nadolol tab 40 mg (generic of CORGARD) Non-Pref PA nadolol tab 80 mg (generic of CORGARD) Non-Pref PA pindolol tab 5 mg Non-Pref PA pindolol tab 10 mg Non-Pref PA propranolol hcl cap er 24hr 60 mg (generic Pref of INDERAL LA) propranolol hcl cap er 24hr 80 mg (generic Pref of INDERAL LA) propranolol hcl cap er 24hr 120 mg Pref (generic of INDERAL LA) propranolol hcl cap er 24hr 160 mg Pref (generic of INDERAL LA) propranolol hcl oral soln 20 mg/5ml Pref propranolol hcl oral soln 40 mg/5ml Pref propranolol hcl tab 10 mg Pref propranolol hcl tab 20 mg Pref propranolol hcl tab 40 mg Pref propranolol hcl tab 60 mg Pref propranolol hcl tab 80 mg Pref sorine tab 80mg (generic of BETAPACE) Pref sorine tab 120mg (generic of BETAPACE) Pref sorine tab 160mg (generic of BETAPACE) Pref sorine tab 240mg Pref sotalol hcl (afib/afl) tab 80 mg (generic of Pref BETAPACE AF) sotalol hcl (afib/afl) tab 120 mg (generic of Pref BETAPACE AF) sotalol hcl (afib/afl) tab 160 mg (generic of Pref BETAPACE AF) sotalol hcl tab 80 mg (generic of Pref BETAPACE) sotalol hcl tab 120 mg (generic of Pref BETAPACE) sotalol hcl tab 160 mg (generic of Pref BETAPACE) sotalol hcl tab 240 mg Pref SOTYLIZE SOL 5MG/ML Non-Pref PA timolol maleate tab 5 mg Non-Pref PA timolol maleate tab 10 mg Non-Pref PA timolol maleate tab 20 mg Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 79 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate tab 2.5 mg (base Pref equivalent) (generic of NORVASC) amlodipine besylate tab 5 mg (base Pref equivalent) (generic of NORVASC) amlodipine besylate tab 10 mg (base Pref equivalent) (generic of NORVASC) CALAN SR TAB 120MG Non-Pref PA CALAN SR TAB 180MG Non-Pref PA CALAN SR TAB 240MG Non-Pref PA CARDIZEM CD CAP 120MG/24 Non-Pref PA CARDIZEM CD CAP 180MG/24 Non-Pref PA CARDIZEM CD CAP 240MG/24 Non-Pref PA CARDIZEM CD CAP 300MG/24 Non-Pref PA CARDIZEM CD CAP 360MG/24 Non-Pref PA CARDIZEM LA TAB 120MG Non-Pref PA CARDIZEM LA TAB 180MG Non-Pref PA CARDIZEM LA TAB 240MG Non-Pref PA CARDIZEM LA TAB 300MG/24 Non-Pref PA CARDIZEM LA TAB 360MG Non-Pref PA CARDIZEM LA TAB 420MG/24 Non-Pref PA CARDIZEM TAB 30MG Non-Pref PA CARDIZEM TAB 60MG Non-Pref PA CARDIZEM TAB 120MG Non-Pref PA cartia xt cap 120/24hr (generic of Pref CARDIZEM CD) cartia xt cap 180/24hr (generic of Pref CARDIZEM CD) cartia xt cap 240/24hr (generic of Pref CARDIZEM CD) cartia xt cap 300/24hr (generic of Pref CARDIZEM CD) dilt-xr cap 120mg Pref dilt-xr cap 180mg Pref dilt-xr cap 240mg Pref diltiazem hcl cap er 12hr 60 mg Pref diltiazem hcl cap er 12hr 90 mg Pref diltiazem hcl cap er 12hr 120 mg Pref diltiazem hcl cap er 24hr 120 mg Pref diltiazem hcl cap er 24hr 180 mg Pref diltiazem hcl cap er 24hr 240 mg Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 80 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits diltiazem hcl coated beads cap er 24hr 120 Pref mg (generic of CARDIZEM CD) diltiazem hcl coated beads cap er 24hr 180 Pref mg (generic of CARDIZEM CD) diltiazem hcl coated beads cap er 24hr 240 Pref mg (generic of CARDIZEM CD) diltiazem hcl coated beads cap er 24hr 300 Pref mg (generic of CARDIZEM CD) diltiazem hcl coated beads cap er 24hr 360 Pref mg (generic of CARDIZEM CD) diltiazem hcl coated beads tab er 24hr 180 Non-Pref PA mg (generic of CARDIZEM LA) diltiazem hcl coated beads tab er 24hr 240 Non-Pref PA mg (generic of CARDIZEM LA) diltiazem hcl coated beads tab er 24hr 300 Non-Pref PA mg (generic of CARDIZEM LA) diltiazem hcl coated beads tab er 24hr 360 Non-Pref PA mg (generic of CARDIZEM LA) diltiazem hcl coated beads tab er 24hr 420 Non-Pref PA mg (generic of CARDIZEM LA) diltiazem hcl extended release beads cap Pref er 24hr 120 mg (generic of TIAZAC) diltiazem hcl extended release beads cap Pref er 24hr 180 mg (generic of TIAZAC) diltiazem hcl extended release beads cap Pref er 24hr 240 mg (generic of TIAZAC) diltiazem hcl extended release beads cap Pref er 24hr 300 mg (generic of TIAZAC) diltiazem hcl extended release beads cap Pref er 24hr 360 mg (generic of TIAZAC) diltiazem hcl extended release beads cap Pref er 24hr 420 mg (generic of TIAZAC) diltiazem hcl tab 30 mg (generic of Pref CARDIZEM) diltiazem hcl tab 60 mg (generic of Pref CARDIZEM) diltiazem hcl tab 90 mg Pref diltiazem hcl tab 120 mg (generic of Pref CARDIZEM) felodipine tab er 24hr 2.5 mg Non-Pref PA felodipine tab er 24hr 5 mg Non-Pref PA felodipine tab er 24hr 10 mg Non-Pref PA isradipine cap 2.5 mg Non-Pref PA isradipine cap 5 mg Non-Pref PA KATERZIA SUS 1MG/ML Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 81 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits matzim la tab 180mg/24 (generic of Non-Pref PA CARDIZEM LA) matzim la tab 240mg/24 (generic of Non-Pref PA CARDIZEM LA) matzim la tab 300mg/24 (generic of Non-Pref PA CARDIZEM LA) matzim la tab 360mg/24 (generic of Non-Pref PA CARDIZEM LA) matzim la tab 420mg/24 (generic of Non-Pref PA CARDIZEM LA) nicardipine hcl cap 20 mg Non-Pref PA nicardipine hcl cap 30 mg Non-Pref PA nifedipine cap 10 mg Pref nifedipine cap 20 mg Pref nifedipine tab er 24hr 30 mg Pref nifedipine tab er 24hr 60 mg Pref nifedipine tab er 24hr 90 mg Pref nifedipine tab er 24hr osmotic release 30 Pref mg (generic of PROCARDIA XL) nifedipine tab er 24hr osmotic release 60 Pref mg (generic of PROCARDIA XL) nifedipine tab er 24hr osmotic release 90 Pref mg (generic of PROCARDIA XL) nimodipine cap 30 mg Pref QL nisoldipine tab er 24hr 8.5 mg (generic of Non-Pref PA SULAR) nisoldipine tab er 24hr 17 mg (generic of Non-Pref PA SULAR) nisoldipine tab er 24hr 20 mg Non-Pref PA nisoldipine tab er 24hr 25.5 mg Non-Pref PA nisoldipine tab er 24hr 30 mg Non-Pref PA nisoldipine tab er 24hr 34 mg (generic of Non-Pref PA SULAR) nisoldipine tab er 24hr 40 mg Non-Pref PA NORVASC TAB 2.5MG Non-Pref PA NORVASC TAB 5MG Non-Pref PA NORVASC TAB 10MG Non-Pref PA PROCARDIA XL TAB 30MG CR Non-Pref PA PROCARDIA XL TAB 60MG CR Non-Pref PA PROCARDIA XL TAB 90MG CR Non-Pref PA SULAR TAB 8.5MG Non-Pref PA SULAR TAB 17MG Non-Pref PA SULAR TAB 34MG Non-Pref PA taztia xt cap 120mg/24 (generic of Pref TIAZAC)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 82 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits taztia xt cap 180mg/24 (generic of Pref TIAZAC) taztia xt cap 240mg/24 (generic of Pref TIAZAC) taztia xt cap 300mg er (generic of TIAZAC) Pref taztia xt cap 360mg/24 (generic of Pref TIAZAC) tiadylt cap 120mg/24 (generic of TIAZAC) Pref tiadylt cap 180mg/24 (generic of TIAZAC) Pref tiadylt cap 240mg/24 (generic of TIAZAC) Pref tiadylt cap 300mg/24 (generic of TIAZAC) Pref tiadylt cap 360mg/24 (generic of TIAZAC) Pref tiadylt cap 420mg/24 (generic of TIAZAC) Pref TIAZAC CAP 120MG/24 Non-Pref PA TIAZAC CAP 180MG/24 Non-Pref PA TIAZAC CAP 240MG/24 Non-Pref PA TIAZAC CAP 300MG/24 Non-Pref PA TIAZAC CAP 360MG/24 Non-Pref PA TIAZAC CAP 420MG/24 Non-Pref PA verapamil hcl cap er 24hr 100 mg (generic Non-Pref PA of VERELAN PM) verapamil hcl cap er 24hr 120 mg (generic Non-Pref PA of VERELAN) verapamil hcl cap er 24hr 180 mg (generic Non-Pref PA of VERELAN) verapamil hcl cap er 24hr 200 mg (generic Non-Pref PA of VERELAN PM) verapamil hcl cap er 24hr 240 mg (generic Non-Pref PA of VERELAN) verapamil hcl cap er 24hr 300 mg Non-Pref PA verapamil hcl cap er 24hr 360 mg Non-Pref PA verapamil hcl tab 40 mg Pref verapamil hcl tab 80 mg Pref verapamil hcl tab 120 mg Pref verapamil hcl tab er 120 mg (generic of Pref CALAN SR) verapamil hcl tab er 180 mg Pref verapamil hcl tab er 240 mg (generic of Pref CALAN SR) VERELAN CAP 120MG SR Non-Pref PA VERELAN CAP 180MG SR Non-Pref PA VERELAN CAP 240MG SR Non-Pref PA VERELAN CAP 360MG SR Non-Pref PA VERELAN PM CAP 100MG ER Non-Pref PA VERELAN PM CAP 200MG ER Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 83 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits VERELAN PM CAP 300MG ER Non-Pref PA CARDIOTONICS - DRUGS TO TREAT HEART CONDITIONS CARDIAC GLYCOSIDES digoxin tab 125 mcg (0.125 mg) (generic Pref of DIGOXIN TAB 125 MCG (0.125 MG)) digoxin tab 250 mcg (0.25 mg) (generic of Pref DIGOXIN TAB 250 MCG (0.25 MG)) CARDIOVASCULAR AGENTS - MISC. - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS CARDIOVASCULAR AGENTS MISC. - COMBINATIONS amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 2.5-10 mg amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 2.5-20 mg amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 2.5-40 mg amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 5-10 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 5-20 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 5-40 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 5-80 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 10-10 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 10-20 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 10-40 mg (generic of CADUET) amlodipine besylate-atorvastatin calcium Non-Pref PA, QL tab 10-80 mg (generic of CADUET) CADUET TAB 5-10MG Non-Pref PA, QL CADUET TAB 5-20MG Non-Pref PA, QL CADUET TAB 5-40MG Non-Pref PA, QL CADUET TAB 5-80MG Non-Pref PA, QL CADUET TAB 10-10MG Non-Pref PA, QL CADUET TAB 10-20MG Non-Pref PA, QL CADUET TAB 10-40MG Non-Pref PA, QL CADUET TAB 10-80MG Non-Pref PA, QL ENTRESTO TAB 24-26MG Pref QL ENTRESTO TAB 49-51MG Pref QL ENTRESTO TAB 97-103MG Pref QL PROSTAGLANDIN VASODILATORS ORENITRAM TAB 0.25MG Non-Pref SP, PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 84 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ORENITRAM TAB 0.125MG Non-Pref SP, PA ORENITRAM TAB 1MG Non-Pref SP, PA ORENITRAM TAB 2.5MG Non-Pref SP, PA ORENITRAM TAB 5MG Non-Pref SP, PA TYVASO REFIL SOL 0.6MG/ML Pref SP, PA TYVASO SOL 0.6MG/ML Pref SP, PA TYVASO START SOL 0.6MG/ML Pref SP, PA VENTAVIS SOL 10MCG/ML Pref SP, PA VENTAVIS SOL 20MCG/ML Pref SP, PA PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS ambrisentan tab 5 mg (generic of Pref SP, PA LETAIRIS) ambrisentan tab 10 mg (generic of Pref SP, PA LETAIRIS) bosentan tab 62.5 mg (generic of Non-Pref SP, PA TRACLEER) bosentan tab 125 mg (generic of Non-Pref SP, PA TRACLEER) LETAIRIS TAB 5MG Non-Pref SP, PA LETAIRIS TAB 10MG Non-Pref SP, PA OPSUMIT TAB 10MG Pref SP, PA TRACLEER TAB 32MG Non-Pref SP, PA TRACLEER TAB 62.5MG Pref SP, PA TRACLEER TAB 125MG Pref SP, PA PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS ADCIRCA TAB 20MG Non-Pref SP, PA alyq tab 20mg (generic of ADCIRCA) Non-Pref SP, PA REVATIO SUS 10MG/ML Pref SP, PA REVATIO TAB 20MG Non-Pref SP, PA sildenafil citrate for suspension 10 mg/ml Non-Pref SP, PA (generic of REVATIO) sildenafil citrate tab 20 mg (generic of Pref SP, PA REVATIO) tadalafil tab 20 mg (pah) (generic of Pref SP, PA ADCIRCA) PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST UPTRAVI TAB 200/800 Pref SP, PA UPTRAVI TAB 200MCG Pref SP, PA UPTRAVI TAB 400MCG Pref SP, PA UPTRAVI TAB 600MCG Pref SP, PA UPTRAVI TAB 800MCG Pref SP, PA UPTRAVI TAB 1000MCG Pref SP, PA UPTRAVI TAB 1200MCG Pref SP, PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 85 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits UPTRAVI TAB 1400MCG Pref SP, PA UPTRAVI TAB 1600MCG Pref SP, PA PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR ADEMPAS TAB 0.5MG Non-Pref SP, PA ADEMPAS TAB 1.5MG Non-Pref SP, PA ADEMPAS TAB 1MG Non-Pref SP, PA ADEMPAS TAB 2.5MG Non-Pref SP, PA ADEMPAS TAB 2MG Non-Pref SP, PA TRANSTHYRETIN STABILIZERS VYNDAMAX CAP 61MG Pref SP, PA, QL, AGE VYNDAQEL CAP 20MG Pref SP, PA, QL, AGE VASOACTIVE SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC) VERQUVO TAB 2.5MG Pref PA, QL, AGE VERQUVO TAB 5MG Pref PA, QL, AGE VERQUVO TAB 10MG Pref PA, QL, AGE CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS CEPHALOSPORINS - 1ST GENERATION cefadroxil cap 500 mg Pref cefadroxil for susp 250 mg/5ml Pref cefadroxil for susp 500 mg/5ml Pref cefadroxil tab 1 gm Non-Pref PA cephalexin cap 250 mg Pref cephalexin cap 500 mg Pref cephalexin cap 750 mg (generic of Pref KEFLEX) cephalexin for susp 125 mg/5ml Pref cephalexin for susp 250 mg/5ml Pref cephalexin tab 250 mg Pref cephalexin tab 500 mg Pref KEFLEX CAP 750MG Non-Pref PA CEPHALOSPORINS - 2ND GENERATION cefaclor cap 250 mg Non-Pref PA cefaclor cap 500 mg Non-Pref PA CEFACLOR ER TAB 500MG Non-Pref PA cefaclor for susp 125 mg/5ml Non-Pref PA cefaclor for susp 250 mg/5ml Non-Pref PA cefaclor for susp 375 mg/5ml Non-Pref PA cefprozil for susp 125 mg/5ml Pref cefprozil for susp 250 mg/5ml Pref cefprozil tab 250 mg Pref cefprozil tab 500 mg Pref cefuroxime axetil tab 250 mg Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 86 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits cefuroxime axetil tab 500 mg Pref CEPHALOSPORINS - 3RD GENERATION cefdinir cap 300 mg Pref cefdinir for susp 125 mg/5ml Pref cefdinir for susp 250 mg/5ml Pref cefixime cap 400 mg (generic of SUPRAX) Non-Pref PA cefixime for susp 100 mg/5ml (generic of Non-Pref PA SUPRAX) cefixime for susp 200 mg/5ml (generic of Non-Pref PA SUPRAX) cefpodoxime proxetil for susp 50 mg/5ml Non-Pref PA cefpodoxime proxetil for susp 100 mg/5ml Non-Pref PA cefpodoxime proxetil tab 100 mg Non-Pref PA cefpodoxime proxetil tab 200 mg Non-Pref PA SUPRAX CAP 400MG Non-Pref PA SUPRAX CHW 100MG Non-Pref PA SUPRAX CHW 200MG Non-Pref PA SUPRAX SUS 100/5ML Non-Pref PA SUPRAX SUS 200/5ML Non-Pref PA SUPRAX SUS 500/5ML Non-Pref PA CHEMICALS - PRODUCTS FOR DRUG COMPOUNDING LIQUIDS CASTOR OIL Pref OTC HM CASTOR OIL Pref OTC QC CASTOR OIL Pref OTC CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL COMBINATION CONTRACEPTIVES - ORAL afirmelle tab 0.1-0.02 Pref altavera tab Pref alyacen tab 1/35 Pref alyacen tab 7/7/7 Pref amethyst tab 90-20mcg Pref apri tab Pref aranelle tab Pref aubra eq tab 0.1-0.02 Pref aubra tab 0.1-0.02 Pref aurovela 24 tab fe 1/20 Pref aurovela fe tab 1.5/30 Pref aurovela fe tab 1/20 Pref aurovela tab 1.5/30 Pref aurovela tab 1/20 Pref aviane tab Pref ayuna tab Pref azurette tab (generic of MIRCETTE) Pref AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 87 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits azurette tab 28 day (generic of MIRCETTE) Pref balziva tab Pref bekyree tab (generic of MIRCETTE) Pref blisovi 24 tab fe 1/20 Pref blisovi fe tab 1.5/30 Pref blisovi fe tab 1/20 Pref briellyn tab Pref caziant pak Pref charlotte 24 chw fe 1/20 (generic of Pref MINASTRIN 24 FE) chateal eq tab 0.15/30 Pref chateal tab 0.15/30 Pref cryselle-28 tab 28 tabs Pref cyclafem tab 1/35 Pref cyclafem tab 7/7/7 Pref cyred eq tab Pref cyred tab Pref dasetta tab 1/35 Pref dasetta tab 7/7/7 Pref delyla tab 0.1-0.02 Pref desogest-eth estrad & eth estrad tab 0.15- Pref 0.02/0.01 mg(21/5) (generic of MIRCETTE) desogestrel & ethinyl estradiol tab 0.15 Pref mg-30 mcg dolishale tab 90-20mcg Pref drospirenone-ethinyl estrad-levomefolate Pref tab 3-0.03-0.451 mg (generic of SAFYRAL) drospirenone-ethinyl estradiol tab 3-0.02 Pref mg (generic of YAZ) drospirenone-ethinyl estradiol tab 3-0.03 Pref mg (generic of YASMIN 28) elinest tab Pref emoquette tab Pref enpresse-28 tab Pref enskyce tab Pref estarylla tab 0.25-35 Pref ethynodiol diacetate & ethinyl estradiol tab Pref 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol tab Pref 1 mg-50 mcg falmina tab Pref femynor tab 0.25-35 Pref hailey 24 tab fe Pref hailey fe tab 1.5/30 Pref hailey fe tab 1/20 Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 88 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits hailey tab 1.5/30 Pref iclevia tab Pref introvale tab Pref isibloom tab Pref jasmiel tab 3-0.02mg (generic of YAZ) Pref jolessa tab Pref juleber tab Pref junel 1.5/30 tab Pref junel 1/20 tab Pref junel fe 24 tab 1/20 Pref junel fe tab 1.5/30 Pref junel fe tab 1/20 Pref kaitlib fe chw (generic of GENERESS FE) Pref kalliga tab Pref kariva tab 28 day (generic of MIRCETTE) Pref kelnor 1/50 tab Pref kelnor tab 1/35 Pref kurvelo tab 0.15/30 Pref larin 24 tab fe 1/20 Pref larin fe tab 1.5/30 Pref larin fe tab 1/20 Pref larin tab 1.5/30 Pref larin tab 1/20 Pref larissia tab Pref layolis fe chw (generic of GENERESS FE) Pref leena tab Pref lessina tab Pref levonest tab Pref levonorgestrel & ethinyl estradiol (91-day) Pref tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.1 Pref mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 Pref mg-30 mcg levonorgestrel-eth estra tab 0.05- Pref 30/0.075-40/0.125-30mg-mcg levonorgestrel-ethinyl estradiol Pref (continuous) tab 90-20 mcg levora-28 tab 0.15/30 Pref lillow tab 0.15/30 Pref LO LOESTRIN TAB 1-10-10 Pref lo-zumandimi tab 3-0.02mg (generic of Pref YAZ) loestrin 21 tab 1.5/30 Pref loestrin fe tab 1.5/30 Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 89 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits loestrin fe tab 1/20 Pref loestrin tab 1/20-21 Pref loryna tab 3-0.02mg (generic of YAZ) Pref low-ogestrel tab Pref lutera tab Pref marlissa tab 0.15/30 Pref mibelas 24 chw fe (generic of MINASTRIN Pref 24 FE) micrgstin 24 tab fe 1/20 Pref microgestin tab 1.5/30 Pref microgestin tab 1/20 Pref microgestin tab fe1.5/30 Pref microgestin tab fe 1/20 Pref mili tab 0.25/35 Pref mono-linyah tab 0.25-35 Pref necon tab 0.5/35 Pref nikki tab 3-0.02mg (generic of YAZ) Pref norethindrone & ethinyl estradiol-fe chew Pref tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol-fe chew Pref tab 0.8 mg-25 mcg (generic of GENERESS FE) norethindrone ace & ethinyl estradiol tab 1 Pref mg-20 mcg norethindrone ace & ethinyl estradiol tab Pref 1.5 mg-30 mcg norethindrone ace & ethinyl estradiol-fe Pref tab 1 mg-20 mcg norethindrone ace & ethinyl estradiol-fe Pref tab 1.5 mg-30 mcg norethindrone ace-eth estradiol-fe chew Pref tab 1 mg-20 mcg (24) (generic of MINASTRIN 24 FE) norgestimate & ethinyl estradiol tab 0.25 Pref mg-35 mcg norgestimate-eth estrad tab 0.18- Pref 25/0.215-25/0.25-25 mg-mcg (generic of ORTHO TRI-CYCLEN LO) norgestimate-eth estrad tab 0.18- Pref 35/0.215-35/0.25-35 mg-mcg nortrel tab 0.5/35 Pref nortrel tab 1/35 Pref nortrel tab 7/7/7 Pref nylia tab 7/7/7 Pref nymyo tab 0.25-35 Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 90 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ocella tab 3-0.03mg (generic of YASMIN Pref 28) orsythia tab Pref philith tab 0.4-35 Pref pimtrea tab (generic of MIRCETTE) Pref pirmella tab 1/35 Pref pirmella tab 7/7/7 Pref portia-28 tab Pref previfem tab Pref reclipsen tab Pref setlakin tab Pref simliya tab 28 day (generic of MIRCETTE) Pref sprintec 28 tab 28 day Pref sronyx tab Pref syeda tab 3-0.03mg (generic of YASMIN Pref 28) tarina 24 fe tab Pref tarina fe tab 1/20 Pref tarina fe tab 1/20 eq Pref tilia fe tab (generic of ESTROSTEP FE) Pref tri femynor tab Pref tri-estaryll tab Pref tri-legest tab fe (generic of ESTROSTEP FE) Pref tri-linyah tab Pref tri-lo tab estaryll (generic of ORTHO TRI- Pref CYCLEN LO) tri-lo- tab marzia (generic of ORTHO TRI- Pref CYCLEN LO) tri-lo- tab sprintec (generic of ORTHO TRI- Pref CYCLEN LO) tri-lo-mili tab (generic of ORTHO TRI- Pref CYCLEN LO) tri-mili tab Pref tri-nymyo tab Pref tri-previfem tab Pref tri-sprintec tab Pref tri-vylibra tab Pref tri-vylibra tab lo (generic of ORTHO TRI- Pref CYCLEN LO) trivora-28 tab Pref tyblume chw 0.1-0.02 Pref tydemy tab (generic of SAFYRAL) Pref velivet pak Pref vestura tab 3-0.02mg (generic of YAZ) Pref vienva tab 0.1-20 Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 91 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits viorele tab (generic of MIRCETTE) Pref volnea tab (generic of MIRCETTE) Pref vyfemla tab 0.4-35 Pref vylibra tab 0.25-35 Pref wera tab 0.5/35 Pref wymzya fe chw 0.4mg-35 Pref zarah tab 3-0.03mg (generic of YASMIN Pref 28) zovia 1/35 tab Pref zovia 1/35e tab Pref zumandimine tab 3-0.03mg (generic of Pref YASMIN 28) COMBINATION CONTRACEPTIVES - TRANSDERMAL xulane dis 150-35 Pref QL zafemy dis 150/35 Pref QL COMBINATION CONTRACEPTIVES - VAGINAL eluryng mis (generic of NUVARING) Pref QL etonogestrel-ethinyl estradiol va ring Pref QL 0.120-0.015 mg/24hr (generic of NUVARING) EMERGENCY CONTRACEPTIVES ELLA TAB 30MG Pref levonorgestrel tab 1.5 mg Pref OTC PLAN B TAB 1.5MG Pref OTC PROGESTIN CONTRACEPTIVES - INJECTABLE medroxyprogesterone acetate im susp 150 Pref QL mg/ml (generic of DEPO-PROVERA CONTRACEPTIV) medroxyprogesterone acetate im susp Pref prefilled syr 150 mg/ml (generic of DEPO- PROVERA CONTRACEPTIV) PROGESTIN CONTRACEPTIVES - ORAL camila tab 0.35mg Pref deblitane tab 0.35mg Pref errin tab 0.35mg Pref heather tab 0.35mg Pref incassia tab 0.35mg Pref jencycla tab 0.35mg Pref lyleq tab 0.35mg Pref lyza tab 0.35mg Pref nora-be tab 0.35mg Pref norethindrone tab 0.35 mg Pref norlyda tab 0.35mg Pref norlyroc tab 0.35mg Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 92 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits sharobel tab 0.35mg Pref tulana tab 0.35mg Pref CORTICOSTEROIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE GLUCOCORTICOSTEROIDS ALKINDI SPRI CAP 0.5MG Pref SP, PA, AGE ALKINDI SPRI CAP 1MG Pref SP, PA, AGE ALKINDI SPRI CAP 2MG Pref SP, PA, AGE ALKINDI SPRI CAP 5MG Pref SP, PA, AGE budesonide tab er 24hr 9 mg (generic of Non-Pref PA UCERIS) decadron tab 0.5mg Pref decadron tab 0.75mg Pref decadron tab 4mg Pref decadron tab 6mg Pref dexamethasone elixir 0.5 mg/5ml Pref dexamethasone soln 0.5 mg/5ml Pref dexamethasone tab 0.5 mg Pref dexamethasone tab 0.75 mg Pref dexamethasone tab 1 mg Pref dexamethasone tab 1.5 mg Pref dexamethasone tab 2 mg Pref dexamethasone tab 4 mg Pref dexamethasone tab 6 mg Pref EMFLAZA SUS 22.75/ML Pref SP, PA, AGE EMFLAZA TAB 6MG Pref SP, PA, AGE EMFLAZA TAB 18MG Pref SP, PA, AGE EMFLAZA TAB 30MG Pref SP, PA, AGE EMFLAZA TAB 36MG Pref SP, PA, AGE hydrocortisone tab 5 mg (generic of Pref CORTEF) hydrocortisone tab 10 mg (generic of Pref CORTEF) hydrocortisone tab 20 mg (generic of Pref CORTEF) methylprednisolone tab 4 mg (generic of Pref MEDROL) methylprednisolone tab 8 mg (generic of Pref MEDROL) methylprednisolone tab 16 mg (generic of Pref MEDROL) methylprednisolone tab 32 mg (generic of Pref MEDROL) methylprednisolone tab therapy pack 4 mg Pref (21) (generic of MEDROL DOSEPAK)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 93 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits prednisolone sod phosph oral soln 6.7 Pref mg/5ml (5 mg/5ml base) (generic of PEDIAPRED) prednisolone sod phosphate oral soln 15 Pref mg/5ml (base equiv) prednisolone syrup 15 mg/5ml (usp Pref solution equivalent) prednisone oral soln 5 mg/5ml Pref prednisone tab 1 mg Pref prednisone tab 2.5 mg Pref prednisone tab 5 mg Pref prednisone tab 10 mg Pref prednisone tab 20 mg Pref prednisone tab 50 mg Pref prednisone tab therapy pack 5 mg (21) Pref prednisone tab therapy pack 5 mg (48) Pref prednisone tab therapy pack 10 mg (21) Pref prednisone tab therapy pack 10 mg (48) Pref UCERIS TAB 9MG Non-Pref PA MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 mg Pref COUGH/COLD/ALLERGY - DRUGS TO TREAT COUGH, COLD, AND ALLERGY SYMPTOMS ANTITUSSIVES benzonatate cap 100 mg (generic of Pref QL TESSALON PERLES) benzonatate cap 200 mg Pref QL COUGH/COLD/ALLERGY COMBINATIONS brompheniramine & pseudoephedrine elixir Pref QL, OTC 1-15 mg/5ml cetirizine-pseudoephedrine tab er 12hr 5- Pref QL, AGE, OTC 120 mg cold/flu liq daytime Pref OTC day cold/flu liq 10-5-325 Pref OTC day-time liq cold/flu Pref OTC dextromethorphan-guaifenesin liquid 10- Pref QL, OTC 100 mg/5ml dextromethorphan-guaifenesin liquid 10- Pref QL, OTC 200 mg/5ml dextromethorphan-guaifenesin syrup 10- Pref QL, OTC 100 mg/5ml dextromethorphan-guaifenesin tab er 12hr Pref QL, OTC 30-600 mg diphenhydramine-phenylephrine liq 6.25- Pref QL, OTC 2.5 mg/5ml

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 94 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits diphenhydramine-phenylephrine tab 25-10 Pref OTC mg gnp day time liq cold/flu Pref OTC guaifenesin-codeine soln 100-10 mg/5ml Pref QL, AGE, OTC hm daytime liq cold/flu Pref OTC loratadine & pseudoephedrine tab er 12hr Pref QL, OTC 5-120 mg loratadine & pseudoephedrine tab er 24hr Pref OTC 10-240 mg prometh vc syp 6.25-5/5 Pref QL, AGE prometh vc/ syp codeine Pref QL, AGE promethazine & phenylephrine syrup 6.25- Pref QL, AGE 5 mg/5ml promethazine w/ codeine syrup 6.25-10 Pref QL, AGE mg/5ml promethazine-dm syrup 6.25-15 mg/5ml Pref QL, AGE promethazine-phenylephrine-codeine syrup Pref QL, AGE 6.25-5-10 mg/5ml pseudoephed-bromphen-dm syrup 30-2-10 Pref QL mg/5ml pseudoephedrine-guaifenesin tab er 12hr Pref AGE, OTC 60-600 mg qc daytime liq cold/flu Pref OTC sb daytime liq Pref OTC sb flu relf liq daytime Pref OTC sm day time liq cold/flu Pref OTC theraflu liq exprsmx Pref OTC EXPECTORANTS guaifenesin liquid 100 mg/5ml Pref QL, AGE, OTC guaifenesin syrup 100 mg/5ml Pref QL, AGE, OTC guaifenesin tab 200 mg Pref AGE, OTC guaifenesin tab 400 mg Pref AGE, OTC guaifenesin tab er 12hr 600 mg Pref QL, AGE, OTC MISC. RESPIRATORY INHALANTS sodium chloride soln nebu 0.9% Pref sodium chloride soln nebu 7% Pref MUCOLYTICS acetylcysteine inhal soln 10% Pref acetylcysteine inhal soln 20% Pref DERMATOLOGICALS - DRUGS TO TREAT SKIN CONDITIONS ACNE PRODUCTS ACANYA GEL 1.2-2.5% Non-Pref PA adapalene gel 0.1% Pref QL, OTC avar cleanse emu 10-5% Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 95 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits avita cre 0.025% (generic of RETIN-A) Pref ST, QL, AGE BENZACLIN GEL 1-5% Non-Pref PA BENZACLIN GEL 1-5%PUMP Non-Pref PA benzoyl peroxide gel 5% Pref OTC benzoyl peroxide gel 10% Pref QL, OTC benzoyl peroxide liq 5% Pref OTC benzoyl peroxide liq 10% Pref OTC benzoyl peroxide-erythromycin gel 5-3% Pref (generic of BENZAMYCIN) clindacin mis etz 1% Pref clindacin-p pad 1% Pref clindamycin phosph-benzoyl peroxide Pref (refrig) gel 1.2 (1)-5% clindamycin phosphate soln 1% Pref QL clindamycin phosphate swab 1% Pref clindamycin phosphate-benzoyl peroxide Pref gel 1-5% (generic of BENZACLIN) clindamycin phosphate-benzoyl peroxide Pref gel 1.2-2.5% (generic of ACANYA) erythromycin soln 2% Pref isotretinoin cap 10 mg Pref PA, QL isotretinoin cap 20 mg Pref PA, QL isotretinoin cap 30 mg Pref PA, QL isotretinoin cap 40 mg Pref PA, QL neuac gel 1.2-5% Pref NEUAC KIT 1.2-5% Non-Pref PA ONEXTON GEL 1.2-3.75 Non-Pref PA panoxyl wash liq 4% Pref OTC sulfacetamide sodium w/ sulfur emulsion Pref 10-5% tretinoin cream 0.025% (generic of RETIN- Pref ST, QL, AGE A) ANTI-INFLAMMATORY AGENTS - TOPICAL diclofenac epolamine patch 1.3% Non-Pref PA, QL diclofenac sodium gel 1% (generic of Pref VOLTAREN) diclofenac sodium soln 1.5% Pref FLECTOR DIS 1.3% Non-Pref PA, QL LICART DIS 1.3% Non-Pref PA, QL PENNSAID SOL 2% Non-Pref PA ANTIBIOTICS - TOPICAL bacitracin oint 500 unit/gm Pref OTC bacitracin zinc oint 500 unit/gm Pref OTC CENTANY AT KIT 2% Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 96 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits CENTANY OIN 2% Non-Pref PA gentamicin sulfate cream 0.1% Pref gentamicin sulfate oint 0.1% Pref mupirocin calcium cream 2% Non-Pref PA mupirocin oint 2% Pref neomycin-bacitracin-polymyxin oint Pref OTC XEPI CRE 1% Non-Pref PA, QL ANTIFUNGALS - TOPICAL butenafine hcl cream 1% Non-Pref PA, OTC ciclodan sol 8% Pref PA ciclopirox gel 0.77% Non-Pref PA ciclopirox kit 8% Non-Pref PA ciclopirox olamine cream 0.77% (base Pref equiv) (generic of LOPROX) ciclopirox olamine susp 0.77% (base Non-Pref PA equiv) (generic of LOPROX) ciclopirox shampoo 1% (generic of LOPROX Non-Pref PA SHAMPOO) ciclopirox solution 8% Pref PA clotrimazole cream 1% Pref clotrimazole cream 1% Pref OTC clotrimazole soln 1% Pref clotrimazole soln 1% Pref OTC clotrimazole w/ betamethasone cream 1- Pref 0.05% clotrimazole w/ betamethasone lotion 1- Non-Pref PA 0.05% econazole nitrate cream 1% Non-Pref PA ERTACZO CRE 2% Non-Pref PA EXELDERM CRE 1% Non-Pref PA EXELDERM SOL 1% Non-Pref PA EXTINA AER 2% Non-Pref PA JUBLIA SOL 10% Non-Pref PA KERYDIN SOL 5% Non-Pref PA ketoconazole cream 2% Pref ketoconazole foam 2% (generic of EXTINA) Non-Pref PA ketoconazole shampoo 2% Pref ketodan aer 2% (generic of EXTINA) Non-Pref PA KETODAN KIT 2% Non-Pref PA LOPROX CRE 0.77% Non-Pref PA LOPROX KIT 0.77% Non-Pref PA LOPROX SHA 1% Non-Pref PA LOPROX SUS 0.77% Non-Pref PA LOTRIMIN ULT CRE 1% Non-Pref PA, OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 97 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits luliconazole cream 1% Non-Pref PA LUZU CRE 1% Non-Pref PA MENTAX CRE 1% Non-Pref PA miconazole nitrate cream 2% Pref OTC miconazole-zinc oxide-white petrolatum Non-Pref PA oint 0.25-15-81.35% naftifine hcl cream 1% Non-Pref PA naftifine hcl cream 2% Non-Pref PA naftifine hcl gel 1% (generic of NAFTIN) Non-Pref PA NAFTIN GEL 1% Non-Pref PA NAFTIN GEL 2% Non-Pref PA nystatin cream 100000 unit/gm Pref nystatin oint 100000 unit/gm Pref nystatin topical powder 100000 unit/gm Pref nystatin-triamcinolone cream 100000-0.1 Pref unit/gm-% nystatin-triamcinolone oint 100000-0.1 Pref unit/gm-% oxiconazole nitrate cream 1% (generic of Non-Pref PA OXISTAT) OXISTAT CRE 1% Non-Pref PA OXISTAT LOT 1% Non-Pref PA sulconazole nitrate cream 1% Non-Pref PA sulconazole nitrate solution 1% Non-Pref PA tavaborole soln 5% (generic of KERYDIN) Non-Pref PA terbinafine hcl cream 1% Pref OTC TINACTIN CRE 1% Non-Pref PA, OTC tolnaftate aerosol pow 1% Pref OTC tolnaftate cream 1% Pref OTC tolnaftate powder 1% Pref OTC VUSION OIN Non-Pref PA ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL diclofenac sodium (actinic keratoses) gel Pref PA, QL 3% fluorouracil cream 0.5% (generic of Pref PA, QL CARAC) fluorouracil cream 5% (generic of EFUDEX) Pref PA, QL ANTIPSORIATICS acitretin cap 10 mg (generic of Pref PA, QL SORIATANE) acitretin cap 17.5 mg Pref PA, QL acitretin cap 25 mg (generic of Pref PA, QL SORIATANE) calcipotriene oint 0.005% Pref PA, QL calcipotriene soln 0.005% (50 mcg/ml) Pref PA, QL AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 98 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits calcitrene oin 0.005% Pref PA, QL COSENTYX INJ 150MG/ML Pref SP; BIOLOGIC COSENTYX INJ 300DOSE Pref SP; BIOLOGIC COSENTYX PEN INJ 150MG/ML Pref SP; BIOLOGIC COSENTYX PEN INJ 300DOSE Pref SP; BIOLOGIC ILUMYA SOL 100MG/ML Non-Pref SP, PA; BIOLOGIC SILIQ INJ 210/1.5 Non-Pref SP, PA; BIOLOGIC SKYRIZI INJ 150DOSE Non-Pref SP, PA; BIOLOGIC SKYRIZI INJ 150MG/ML Non-Pref SP, PA; BIOLOGIC SKYRIZI PEN INJ 150MG/ML Non-Pref SP, PA; BIOLOGIC STELARA INJ 45MG/0.5 Non-Pref SP, PA; BIOLOGIC STELARA INJ 90MG/ML Non-Pref SP, PA; BIOLOGIC TALTZ INJ 80MG/ML Non-Pref SP, PA; BIOLOGIC TREMFYA INJ 100MG/ML Non-Pref SP, PA; BIOLOGIC ANTISEBORRHEIC PRODUCTS selenium sulfide lotion 2.5% Pref ANTIVIRALS - TOPICAL acyclovir cream 5% (generic of ZOVIRAX) Non-Pref PA acyclovir oint 5% (generic of ZOVIRAX) Non-Pref PA DENAVIR CRE 1% Pref docosanol cream 10% Pref OTC hm docosan cre 10% Pref OTC XERESE CRE 5-1% Non-Pref PA ZOVIRAX CRE 5% Pref ZOVIRAX OIN 5% Pref BURN PRODUCTS silver sulfadiazine cream 1% (generic of Pref SILVADENE) ssd cre 1% (generic of SILVADENE) Pref CORTICOSTEROIDS - TOPICAL ala-cort cre 2.5% Pref alclometasone dipropionate cream 0.05% Non-Pref PA alclometasone dipropionate oint 0.05% Non-Pref PA amcinonide cream 0.1% Non-Pref PA amcinonide lotion 0.1% Non-Pref PA APEXICON E CRE 0.05% Non-Pref PA BESER KIT 0.05% Non-Pref PA beser lot 0.05% (generic of CUTIVATE) Non-Pref PA betamethasone dipropionate augmented Non-Pref PA cream 0.05% (generic of DIPROLENE AF) betamethasone dipropionate augmented Non-Pref PA gel 0.05% betamethasone dipropionate augmented Non-Pref PA lotion 0.05%

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 99 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits betamethasone dipropionate augmented Non-Pref PA oint 0.05% (generic of DIPROLENE) betamethasone dipropionate cream 0.05% Pref betamethasone dipropionate lotion 0.05% Pref betamethasone dipropionate oint 0.05% Pref betamethasone valerate aerosol foam Non-Pref PA 0.12% (generic of LUXIQ) betamethasone valerate cream 0.1% (base Pref equivalent) betamethasone valerate lotion 0.1% (base Pref equivalent) betamethasone valerate oint 0.1% (base Pref equivalent) BRYHALI LOT 0.01% Non-Pref PA CAPEX SHA 0.01% Non-Pref PA clobetasol propionate cream 0.05% Pref clobetasol propionate cream 0.05% Pref (generic of TEMOVATE) clobetasol propionate emollient base cream Non-Pref PA 0.05% clobetasol propionate emulsion foam Non-Pref PA 0.05% (generic of OLUX-E) clobetasol propionate foam 0.05% (generic Non-Pref PA of OLUX) clobetasol propionate gel 0.05% Pref clobetasol propionate lotion 0.05% Non-Pref PA (generic of CLOBEX) clobetasol propionate oint 0.05% (generic Pref of TEMOVATE) clobetasol propionate shampoo 0.05% Non-Pref PA (generic of CLOBEX) clobetasol propionate soln 0.05% Pref clobetasol propionate spray 0.05% Non-Pref PA (generic of CLOBEX) CLOBEX LOT 0.05% Non-Pref PA CLOBEX SHA 0.05% Non-Pref PA CLOBEX SPR 0.05% Non-Pref PA clocortolone pivalate cream 0.1% (generic Non-Pref PA of CLODERM) CLODAN KIT 0.05% Non-Pref PA clodan sha 0.05% (generic of CLOBEX) Non-Pref PA CLODERM CRE 0.1% Non-Pref PA CORDRAN 80X3 TAP 4MCG/CM Non-Pref PA CUTIVATE LOT 0.05% Non-Pref PA DERMA-SMOOTH OIL /FS BODY Non-Pref PA DERMA-SMOOTH OIL /FS SCLP Non-Pref PA AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 100 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits DESONATE GEL 0.05% Non-Pref PA desonide cream 0.05% (generic of Non-Pref PA DESOWEN) desonide gel 0.05% (generic of Non-Pref PA DESONATE) desonide lotion 0.05% Non-Pref PA desonide oint 0.05% Non-Pref PA DESOWEN CRE 0.05% Non-Pref PA desoximetasone cream 0.05% (generic of Non-Pref PA TOPICORT) desoximetasone cream 0.25% (generic of Non-Pref PA TOPICORT) desoximetasone gel 0.05% (generic of Non-Pref PA TOPICORT) desoximetasone oint 0.05% (generic of Non-Pref PA TOPICORT) desoximetasone oint 0.25% (generic of Non-Pref PA TOPICORT) desoximetasone spray 0.25% (generic of Non-Pref PA TOPICORT) diflorasone diacetate cream 0.05% Non-Pref PA diflorasone diacetate oint 0.05% Non-Pref PA DIPROLENE AF CRE 0.05% Non-Pref PA DIPROLENE OIN 0.05% Non-Pref PA fluocinolone acetonide cream 0.01% Non-Pref PA fluocinolone acetonide cream 0.025% Non-Pref PA (generic of SYNALAR) fluocinolone acetonide oil 0.01% (body oil) Non-Pref PA (generic of DERMA-SMOOTHE/FS BODY) fluocinolone acetonide oil 0.01% (scalp oil) Non-Pref PA (generic of DERMA-SMOOTHE/FS SCALP) fluocinolone acetonide oint 0.025% Non-Pref PA (generic of SYNALAR) fluocinolone acetonide soln 0.01% (generic Non-Pref PA of SYNALAR) fluocinonide cream 0.1% (generic of Non-Pref PA VANOS) fluocinonide cream 0.05% Non-Pref PA fluocinonide emulsified base cream 0.05% Non-Pref PA fluocinonide gel 0.05% Non-Pref PA fluocinonide oint 0.05% Non-Pref PA fluocinonide soln 0.05% Non-Pref PA flurandrenolide cream 0.05% (generic of Non-Pref PA CORDRAN) flurandrenolide lotion 0.05% (generic of Non-Pref PA CORDRAN)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 101 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits flurandrenolide oint 0.05% (generic of Non-Pref PA CORDRAN) fluticasone propionate cream 0.05% Pref fluticasone propionate lotion 0.05% Non-Pref PA (generic of CUTIVATE) fluticasone propionate oint 0.005% Pref halcinonide cream 0.1% (generic of Non-Pref PA HALOG) HALOBETASOL AER 0.05% Non-Pref PA halobetasol propionate cream 0.05% Pref halobetasol propionate oint 0.05% Pref HALOG CRE 0.1% Non-Pref PA HALOG OIN 0.1% Non-Pref PA HYDROCORT OIN 1% Pref OTC hydrocortisone butyrate cream 0.1% Non-Pref PA hydrocortisone butyrate hydrophilic lipo Non-Pref PA base cream 0.1% (generic of LOCOID LIPOCREAM) hydrocortisone butyrate lotion 0.1% Non-Pref PA (generic of LOCOID) hydrocortisone butyrate oint 0.1% Non-Pref PA hydrocortisone butyrate soln 0.1% Non-Pref PA hydrocortisone cream 0.5% Pref OTC hydrocortisone cream 1% Pref OTC hydrocortisone cream 1%- rx Pref hydrocortisone cream 2.5% Pref hydrocortisone lotion 2.5% Pref hydrocortisone oint 0.5% Pref OTC hydrocortisone oint 1% Pref OTC hydrocortisone oint 1%- rx Pref hydrocortisone oint 2.5% Pref hydrocortisone valerate cream 0.2% Non-Pref PA hydrocortisone valerate oint 0.2% Non-Pref PA hydrocortisone-aloe vera cream 0.5% Pref OTC hydrocortisone-aloe vera cream 1% Pref OTC IMPEKLO LOT 0.05% Non-Pref PA KENALOG AER SPRAY Non-Pref PA LEXETTE AER 0.05% Non-Pref PA LOCOID LIPO CRE 0.1% Non-Pref PA LOCOID LOT 0.1% Non-Pref PA LUXIQ AER 0.12% Non-Pref PA mometasone furoate cream 0.1% Pref mometasone furoate oint 0.1% Pref mometasone furoate solution 0.1% (lotion) Pref OLUX AER 0.05% Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 102 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits OLUX-E AER 0.05% Non-Pref PA PANDEL CRE 0.1% Non-Pref PA prednicarbate oint 0.1% Non-Pref PA PSORCON CRE 0.05% Non-Pref PA scalpicin sol 1% Non-Pref PA, OTC SERNIVO SPR Non-Pref PA SYNALAR CRE 0.025% Non-Pref PA SYNALAR KIT 0.025% Non-Pref PA SYNALAR OIN 0.025% Non-Pref PA SYNALAR SOL 0.01% Non-Pref PA SYNALAR TS KIT 0.01% Non-Pref PA TEMOVATE CRE 0.05% Non-Pref PA TEMOVATE OIN 0.05% Non-Pref PA TEXACORT SOL 2.5% Non-Pref PA TOPICORT CRE 0.05% Non-Pref PA TOPICORT CRE 0.25% Non-Pref PA TOPICORT GEL 0.05% Non-Pref PA TOPICORT OIN 0.05% Non-Pref PA TOPICORT OIN 0.25% Non-Pref PA TOPICORT SPR 0.25% Non-Pref PA tovet aer 0.05% (generic of OLUX-E) Non-Pref PA TOVET KIT KIT 0.05% Non-Pref PA triamcinolone acetonide aerosol soln 0.147 Non-Pref PA mg/gm (generic of KENALOG) triamcinolone acetonide cream 0.1% Pref triamcinolone acetonide cream 0.5% Pref triamcinolone acetonide cream 0.025% Pref triamcinolone acetonide lotion 0.1% Pref triamcinolone acetonide lotion 0.025% Pref triamcinolone acetonide oint 0.1% Pref triamcinolone acetonide oint 0.5% Pref triamcinolone acetonide oint 0.05% Pref triamcinolone acetonide oint 0.025% Pref trianex oin 0.05% Pref triderm cre 0.1% Pref triderm cre 0.5% Pref ULTRAVATE LOT 0.05% Non-Pref PA VANOS CRE 0.1% Non-Pref PA ECZEMA AGENTS DUPIXENT INJ 200/1.14 Non-Pref SP, PA DUPIXENT INJ 300/2ML Non-Pref SP, PA EMOLLIENTS lactic acid (ammonium lactate) cream 12% Pref QL lactic acid (ammonium lactate) cream 12% Pref QL, OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 103 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits lactic acid (ammonium lactate) lotion 12% Pref QL lactic acid (ammonium lactate) lotion 12% Pref QL, OTC vitamin e liq Pref OTC ENZYMES - TOPICAL SANTYL OIN 250/GM Pref QL IMMUNOMODULATING AGENTS - TOPICAL imiquimod cream 5% (generic of ALDARA) Pref QL IMMUNOSUPPRESSIVE AGENTS - TOPICAL ELIDEL CRE 1% Pref PA, QL, AGE pimecrolimus cream 1% (generic of Non-Pref PA, QL, AGE ELIDEL) PROTOPIC OIN 0.1% Non-Pref PA, QL, AGE PROTOPIC OIN 0.03% Non-Pref PA, QL, AGE tacrolimus oint 0.1% (generic of Non-Pref PA, QL, AGE PROTOPIC) tacrolimus oint 0.03% (generic of Non-Pref PA, QL, AGE PROTOPIC) KERATOLYTIC/ANTIMITOTIC AGENTS podofilox soln 0.5% Pref LOCAL ANESTHETICS - TOPICAL glydo gel 2% Pref lidocaine cre pain 4% Pref QL, OTC lidocaine hcl cream 3% Pref QL lidocaine hcl urethral/mucosal gel 2% Pref lidocaine hcl urethral/mucosal gel prefilled Pref syringe 2% lidocaine oint 5% Pref QL lidocaine patch 4% Pref QL, OTC lidocaine patch 5% (generic of LIDODERM) Pref PA lidocaine-prilocaine cream 2.5-2.5% Pref QL PHOSPHODIESTERASE 4 (PDE4) INHIBITORS - TOPICAL EUCRISA OIN 2% Pref PA, QL, AGE; Min age of 3 months ROSACEA AGENTS metronidazole cream 0.75% (generic of Pref METROCREAM) metronidazole gel 0.75% Pref rosadan cre 0.75% (generic of Pref METROCREAM) rosadan gel 0.75% Pref SCABICIDES & PEDICULICIDES lice treatmt liq 1% Pref QL, OTC lice trtmnt liq 1% Pref QL, OTC lindane shampoo 1% Pref QL AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 104 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits malathion lotion 0.5% Pref ST, QL NIX CREM RIN LIQ 1% Pref QL, OTC permethrin cream 5% Pref QL permethrin lotion 1% Pref QL, OTC pyrethrins-piperonyl butoxide liq 0.33-4% Pref QL, OTC pyrethrins-piperonyl butoxide shampoo Pref QL, OTC 0.33-4% RID LIQ Pref QL, OTC spinosad susp 0.9% Pref ST, QL DIAGNOSTIC PRODUCTS - PRODUCTS FOR DIAGNOSIS DIAGNOSTIC TESTS CHEMSTRIP TES UGK Pref OTC CVS KETONE TES CARE Pref OTC KETO-DIASTIX TES Pref OTC TRUE METRIX TES GLUCOSE Pref OTC DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS - DRUGS FOR NUTRITION DIETARY MANAGEMENT PRODUCTS FOLBIC RF TAB Pref FOLTANX TAB Pref L-METHYL- TAB B6-B12 Pref L-METHYL-MC TAB Pref L-METHYL-MC TAB NAC Pref METAFOLBIC TAB Pref METAFOLBIC TAB PLUS Pref METAFOLBIC TAB PLUS RF Pref METHYLFOL/CA TAB ME-CBL Pref westab max tab 2.5-25-2 Pref NUTRITIONAL SUPPLEMENTS BLADDER 2.2 TAB Pref OTC fiber weight chw manageme Pref OTC FIBER-STAT LIQ Pref OTC nutritional supplement caps Pref OTC sm estroplus tab ex st Pref OTC SYTRINOL CAP Pref OTC TYR COOLER LIQ Pref OTC DIGESTIVE AIDS - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS DIGESTIVE ENZYMES CREON CAP 3000UNIT Pref PA CREON CAP 6000UNIT Pref PA CREON CAP 12000UNT Pref PA CREON CAP 24000UNT Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 105 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits CREON CAP 36000UNT Pref PA PANCREAZE CAP 2600UNIT Non-Pref PA PANCREAZE CAP 4200UNIT Non-Pref PA PANCREAZE CAP 10500UNT Non-Pref PA PANCREAZE CAP 16800UNT Non-Pref PA PANCREAZE CAP 21000UNT Non-Pref PA PANCREAZE CAP 37000 Non-Pref PA PERTZYE CAP 4000UNIT Non-Pref PA PERTZYE CAP 8000UNIT Non-Pref PA PERTZYE CAP 16000U Non-Pref PA PERTZYE CAP 24000U Non-Pref PA VIOKACE TAB 10440 Non-Pref PA VIOKACE TAB 20880 Non-Pref PA ZENPEP CAP 3000UNIT Pref PA ZENPEP CAP 5000UNIT Pref PA ZENPEP CAP 10000UNT Pref PA ZENPEP CAP 15000UNT Pref PA, QL ZENPEP CAP 20000UNT Pref PA, QL ZENPEP CAP 25000 Pref PA ZENPEP CAP 40000 Pref PA DIURETICS - DRUGS TO TREAT HEART CONDITIONS CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg Pref QL acetazolamide tab 125 mg Pref QL acetazolamide tab 250 mg Pref QL DIURETIC COMBINATIONS amiloride & hydrochlorothiazide tab 5-50 Pref QL mg spironolactone & hydrochlorothiazide tab Pref QL 25-25 mg (generic of ALDACTAZIDE) triamterene & hydrochlorothiazide cap Pref 37.5-25 mg triamterene & hydrochlorothiazide tab Pref 37.5-25 mg (generic of MAXZIDE-25) triamterene & hydrochlorothiazide tab 75- Pref 50 mg (generic of MAXZIDE) LOOP DIURETICS bumetanide tab 0.5 mg (generic of Pref BUMEX) bumetanide tab 1 mg Pref bumetanide tab 2 mg Pref furosemide oral soln 8 mg/ml Pref AGE furosemide oral soln 10 mg/ml Pref AGE furosemide tab 20 mg (generic of LASIX) Pref QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 106 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits furosemide tab 40 mg (generic of LASIX) Pref QL furosemide tab 80 mg (generic of LASIX) Pref QL torsemide tab 5 mg Pref QL torsemide tab 10 mg Pref QL torsemide tab 20 mg Pref QL torsemide tab 100 mg Pref QL POTASSIUM SPARING DIURETICS amiloride hcl tab 5 mg Pref QL spironolactone tab 25 mg (generic of Pref QL ALDACTONE) spironolactone tab 50 mg (generic of Pref QL ALDACTONE) spironolactone tab 100 mg (generic of Pref QL ALDACTONE) THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorthalidone tab 25 mg Pref QL chlorthalidone tab 50 mg Pref QL DIURIL SUS 250/5ML Pref AGE hydrochlorothiazide cap 12.5 mg Pref hydrochlorothiazide tab 12.5 mg Pref hydrochlorothiazide tab 25 mg Pref hydrochlorothiazide tab 50 mg Pref indapamide tab 1.25 mg Pref QL indapamide tab 2.5 mg Pref QL metolazone tab 2.5 mg Pref QL metolazone tab 5 mg Pref QL metolazone tab 10 mg Pref QL ENDOCRINE AND METABOLIC AGENTS - MISC. - DRUGS TO REGULATE HORMONES BONE DENSITY REGULATORS ACTONEL TAB 35MG Non-Pref PA, QL ACTONEL TAB 150MG Non-Pref PA alendronate sodium oral soln 70 mg/75ml Non-Pref PA alendronate sodium tab 5 mg Pref alendronate sodium tab 10 mg Pref alendronate sodium tab 35 mg Pref QL alendronate sodium tab 70 mg (generic of Pref QL FOSAMAX) ATELVIA TAB Non-Pref PA, QL BINOSTO TAB 70MG Non-Pref PA BONIVA INJ 3MG/3ML Non-Pref PA BONIVA TAB 150MG Non-Pref PA, QL calcitonin (salmon) inj 200 unit/ml (generic Non-Pref PA of MIACALCIN)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 107 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits calcitonin (salmon) nasal soln 200 unit/act Pref (generic of MIACALCIN) FORTEO INJ 620/2.48 Non-Pref SP, PA FOSAMAX + D TAB 70-2800 Non-Pref PA, QL FOSAMAX + D TAB 70-5600 Non-Pref PA, QL FOSAMAX TAB 70MG Non-Pref PA, QL ibandronate sodium iv soln 3 mg/3ml Non-Pref PA (base equivalent) ibandronate sodium tab 150 mg (base Non-Pref PA, QL equivalent) (generic of BONIVA) MIACALCIN INJ 200/ML Non-Pref PA risedronate sodium tab 5 mg Non-Pref PA risedronate sodium tab 30 mg Non-Pref PA risedronate sodium tab 35 mg (generic of Non-Pref PA, QL ACTONEL) risedronate sodium tab 150 mg (generic of Non-Pref PA ACTONEL) risedronate sodium tab delayed release 35 Non-Pref PA, QL mg (generic of ATELVIA) TERIPARATIDE INJ Non-Pref SP, PA TYMLOS INJ Non-Pref SP, PA GNRH/LHRH ANTAGONISTS ORILISSA TAB 150MG Pref PA, AGE ORILISSA TAB 200MG Pref PA, AGE GROWTH HORMONES GENOTROPIN INJ 0.2MG Pref SP, PA GENOTROPIN INJ 0.4MG Pref SP, PA GENOTROPIN INJ 0.6MG Pref SP, PA GENOTROPIN INJ 0.8MG Pref SP, PA GENOTROPIN INJ 1.2MG Pref SP, PA GENOTROPIN INJ 1.4MG Pref SP, PA GENOTROPIN INJ 1.6MG Pref SP, PA GENOTROPIN INJ 1.8MG Pref SP, PA GENOTROPIN INJ 1MG Pref SP, PA GENOTROPIN INJ 2MG Pref SP, PA GENOTROPIN INJ 5MG Pref SP, PA GENOTROPIN INJ 12MG Pref SP, PA HUMATROPE INJ 5MG Non-Pref SP, PA HUMATROPE INJ 6MG Non-Pref SP, PA HUMATROPE INJ 12MG Non-Pref SP, PA HUMATROPE INJ 24MG Non-Pref SP, PA NORDITROPIN INJ 5/1.5ML Pref SP, PA NORDITROPIN INJ 10/1.5ML Pref SP, PA NORDITROPIN INJ 15/1.5ML Pref SP, PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 108 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits NORDITROPIN INJ 30/3ML Pref SP, PA NUTROPIN AQ INJ 10MG/2ML Non-Pref SP, PA NUTROPIN AQ INJ 20MG/2ML Non-Pref SP, PA NUTROPIN AQ INJ NUSPIN 5 Non-Pref SP, PA OMNITROPE INJ 5.8MG Non-Pref SP, PA OMNITROPE INJ 5/1.5ML Non-Pref SP, PA OMNITROPE INJ 10/1.5ML Non-Pref SP, PA SAIZEN INJ 5MG Non-Pref SP, PA SAIZEN INJ 8.8MG Non-Pref SP, PA SAIZENPREP INJ 8.8MG Non-Pref SP, PA SEROSTIM INJ 4MG Non-Pref SP, PA SEROSTIM INJ 5MG Non-Pref SP, PA SEROSTIM INJ 6MG Non-Pref SP, PA ZOMACTON INJ 5MG Non-Pref SP, PA ZOMACTON INJ 10MG Non-Pref SP, PA ZORBTIVE INJ 8.8MG Non-Pref SP, PA HORMONE RECEPTOR MODULATORS EVISTA TAB 60MG Non-Pref PA raloxifene hcl tab 60 mg (generic of Pref EVISTA) INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX INJ 40MG/4ML Pref SP, PA METABOLIC MODIFIERS calcitriol cap 0.5 mcg (generic of Pref QL ROCALTROL) calcitriol cap 0.25 mcg (generic of Pref QL ROCALTROL) calcitriol oral soln 1 mcg/ml (generic of Pref AGE ROCALTROL) cinacalcet hcl tab 30 mg (base equiv) Pref PA, QL (generic of SENSIPAR) cinacalcet hcl tab 60 mg (base equiv) Pref PA, QL (generic of SENSIPAR) cinacalcet hcl tab 90 mg (base equiv) Pref PA, QL (generic of SENSIPAR) POSTERIOR PITUITARY HORMONES desmopressin acetate nasal spray soln Pref PA 0.01% desmopressin acetate nasal spray soln Pref PA 0.01% (refrigerated) desmopressin acetate tab 0.1 mg (generic Pref QL of DDAVP) desmopressin acetate tab 0.2 mg (generic Pref QL of DDAVP) STIMATE SOL 1.5MG/ML Pref SP, PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 109 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits PROLACTIN INHIBITORS cabergoline tab 0.5 mg Pref SOMATOSTATIC AGENTS octreotide acetate inj 50 mcg/ml (0.05 Pref SP, PA mg/ml) (generic of SANDOSTATIN) octreotide acetate inj 100 mcg/ml (0.1 Pref SP, PA mg/ml) (generic of SANDOSTATIN) octreotide acetate inj 200 mcg/ml (0.2 Pref SP, PA mg/ml) octreotide acetate inj 1000 mcg/ml (1 Pref SP, PA mg/ml) ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES ESTROGEN COMBINATIONS amabelz tab 0.5-0.1 Pref AGE amabelz tab 1-0.5mg (generic of Pref AGE ACTIVELLA) estradiol & norethindrone acetate tab 0.5- Pref AGE 0.1 mg estradiol & norethindrone acetate tab 1-0.5 Pref AGE mg (generic of ACTIVELLA) fyavolv tab 0.5-2.5 (generic of FEMHRT) Pref QL, AGE fyavolv tab 1-5 Pref AGE jinteli tab 1mg-5mcg Pref AGE mimvey tab 1-0.5mg (generic of Pref AGE ACTIVELLA) norethindrone acetate-ethinyl estradiol tab Pref QL, AGE 0.5 mg-2.5 mcg (generic of FEMHRT) norethindrone acetate-ethinyl estradiol tab Pref AGE 1 mg-5 mcg ORIAHNN CAP Pref PA, AGE PREMPHASE TAB Pref QL, AGE PREMPRO TAB Pref QL, AGE PREMPRO TAB 0.3-1.5 Pref QL, AGE PREMPRO TAB 0.45-1.5 Pref QL, AGE PREMPRO TAB 0.625-5 Pref QL, AGE ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES ALORA DIS 0.1MG Pref QL, AGE ALORA DIS 0.05MG Pref QL, AGE ALORA DIS 0.025MG Pref QL, AGE ALORA DIS 0.075MG Pref QL, AGE dotti dis 0.1mg (generic of VIVELLE-DOT) Pref QL, AGE dotti dis 0.05mg (generic of VIVELLE-DOT) Pref QL, AGE dotti dis 0.025mg (generic of VIVELLE- Pref QL, AGE DOT)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 110 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits dotti dis 0.075mg (generic of VIVELLE- Pref QL, AGE DOT) dotti dis 0.0375mg (generic of VIVELLE- Pref QL, AGE DOT) estradiol tab 0.5 mg (generic of ESTRACE) Pref AGE estradiol tab 1 mg (generic of ESTRACE) Pref AGE estradiol tab 2 mg (generic of ESTRACE) Pref AGE estradiol td patch twice weekly 0.1 Pref QL, AGE mg/24hr (generic of MINIVELLE) estradiol td patch twice weekly 0.05 Pref QL, AGE mg/24hr (generic of MINIVELLE) estradiol td patch twice weekly 0.025 Pref QL, AGE mg/24hr (generic of MINIVELLE) estradiol td patch twice weekly 0.075 Pref QL, AGE mg/24hr (generic of MINIVELLE) estradiol td patch twice weekly 0.0375 Pref QL, AGE mg/24hr (generic of MINIVELLE) estradiol td patch weekly 0.1 mg/24hr Pref QL, AGE (generic of CLIMARA) estradiol td patch weekly 0.05 mg/24hr Pref QL, AGE (generic of CLIMARA) estradiol td patch weekly 0.06 mg/24hr Pref QL, AGE (generic of CLIMARA) estradiol td patch weekly 0.025 mg/24hr Pref QL, AGE (generic of CLIMARA) estradiol td patch weekly 0.075 mg/24hr Pref QL, AGE (generic of CLIMARA) estradiol td patch weekly 0.0375 mg/24hr Pref QL, AGE (37.5 mcg/24hr) (generic of CLIMARA) lyllana dis 0.1mg (generic of MINIVELLE) Pref QL, AGE lyllana dis 0.05mg (generic of MINIVELLE) Pref QL, AGE lyllana dis 0.025mg (generic of MINIVELLE) Pref QL, AGE lyllana dis 0.075mg (generic of MINIVELLE) Pref QL, AGE lyllana dis 0.0375mg (generic of Pref QL, AGE MINIVELLE) MENEST TAB 0.3MG Pref AGE MENEST TAB 0.625MG Pref AGE MENEST TAB 1.25MG Pref AGE PREMARIN TAB 0.3MG Pref QL, AGE PREMARIN TAB 0.9MG Pref QL, AGE PREMARIN TAB 0.45MG Pref QL, AGE PREMARIN TAB 0.625MG Pref QL, AGE PREMARIN TAB 1.25MG Pref QL, AGE

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 111 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS BAXDELA TAB 450MG Non-Pref PA, QL CIPRO (5%) SUS 250MG/5 Pref QL CIPRO (10%) SUS 500MG/5 Pref QL CIPRO TAB 250MG Non-Pref PA, QL CIPRO TAB 500MG Non-Pref PA, QL ciprofloxacin hcl tab 100 mg (base equiv) Pref QL ciprofloxacin hcl tab 250 mg (base equiv) Pref QL (generic of CIPRO) ciprofloxacin hcl tab 500 mg (base equiv) Pref QL (generic of CIPRO) ciprofloxacin hcl tab 750 mg (base equiv) Pref QL levofloxacin oral soln 25 mg/ml Pref QL levofloxacin tab 250 mg (generic of Pref QL LEVAQUIN) levofloxacin tab 500 mg (generic of Pref QL LEVAQUIN) levofloxacin tab 750 mg (generic of Pref QL LEVAQUIN) moxifloxacin hcl tab 400 mg (base equiv) Non-Pref PA, QL ofloxacin tab 300 mg Non-Pref PA, QL ofloxacin tab 400 mg Non-Pref PA, QL GASTROINTESTINAL AGENTS - MISC. - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS 5-HT4 RECEPTOR AGONISTS MOTEGRITY TAB 1MG Non-Pref PA MOTEGRITY TAB 2MG Non-Pref PA AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC) TRULANCE TAB 3MG Non-Pref PA ANTIFLATULENTS GAS-X EX-STR CHW 125MG Pref OTC simethicone chew tab 80 mg Pref OTC simethicone chew tab 125 mg Pref OTC simethicone liquid 40 mg/0.6ml Pref OTC simethicone susp 40 mg/0.6ml Pref OTC GALLSTONE SOLUBILIZING AGENTS URSO 250 TAB 250MG Non-Pref PA URSO FORTE TAB 500MG Non-Pref PA ursodiol cap 300 mg Pref ursodiol tab 250 mg (generic of URSO 250) Pref ursodiol tab 500 mg (generic of URSO Pref FORTE)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 112 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS AMITIZA CAP 8MCG Pref AMITIZA CAP 24MCG Pref lubiprostone cap 8 mcg Non-Pref PA lubiprostone cap 24 mcg Non-Pref PA GASTROINTESTINAL STIMULANTS metoclopramide hcl soln 5 mg/5ml (10 Pref mg/10ml) (base equiv) metoclopramide hcl tab 5 mg (base Pref equivalent) (generic of REGLAN) metoclopramide hcl tab 10 mg (base Pref equivalent) (generic of REGLAN) INFLAMMATORY BOWEL AGENTS APRISO CAP 0.375GM Pref ASACOL HD TAB 800MG Non-Pref PA AZULFIDINE TAB 500MG Non-Pref PA AZULFIDINE TAB 500MG EN Non-Pref PA balsalazide disodium cap 750 mg (generic Non-Pref PA of COLAZAL) CIMZIA KIT 200MG Non-Pref SP, PA; BIOLOGIC CIMZIA PREFL KIT 200MG/ML Non-Pref SP, PA; BIOLOGIC CIMZIA START KIT 200MG/ML Non-Pref SP, PA; BIOLOGIC COLAZAL CAP 750MG Non-Pref PA DELZICOL CAP 400MG Non-Pref PA DIPENTUM CAP 250MG Non-Pref PA ENTYVIO INJ 300MG Non-Pref SP, PA; BIOLOGIC LIALDA TAB 1.2GM Pref mesalamine cap dr 400 mg (generic of Non-Pref PA DELZICOL) mesalamine cap er 24hr 0.375 gm (generic Non-Pref PA of APRISO) mesalamine enema 4 gm Pref mesalamine tab delayed release 1.2 gm Non-Pref PA (generic of LIALDA) mesalamine tab delayed release 800 mg Non-Pref PA (generic of ASACOL HD) PENTASA CAP 250MG CR Non-Pref PA PENTASA CAP 500MG CR Non-Pref PA STELARA INJ 5MG/ML Non-Pref SP, PA; BIOLOGIC sulfasalazine tab 500 mg (generic of Pref AZULFIDINE) sulfasalazine tab delayed release 500 mg Pref (generic of AZULFIDINE EN-TABS)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 113 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits IRRITABLE BOWEL SYNDROME (IBS) AGENTS alosetron hcl tab 0.5 mg (base equiv) Non-Pref PA (generic of LOTRONEX) alosetron hcl tab 1 mg (base equiv) Non-Pref PA (generic of LOTRONEX) LINZESS CAP 72MCG Pref LINZESS CAP 145MCG Pref LINZESS CAP 290MCG Pref LOTRONEX TAB 0.5MG Non-Pref PA LOTRONEX TAB 1MG Non-Pref PA VIBERZI TAB 75MG Non-Pref PA, QL VIBERZI TAB 100MG Non-Pref PA, QL ZELNORM TAB 6MG Non-Pref PA PERIPHERAL OPIOID RECEPTOR ANTAGONISTS MOVANTIK TAB 12.5MG Pref MOVANTIK TAB 25MG Pref RELISTOR INJ 8/0.4ML Non-Pref PA RELISTOR INJ 12/0.6ML Non-Pref PA RELISTOR TAB 150MG Non-Pref PA SYMPROIC TAB 0.2MG Non-Pref PA PHOSPHATE BINDER AGENTS AURYXIA TAB 210MG Non-Pref PA calcium acetate (phosphate binder) cap Pref PA 667 mg (169 mg ca) (generic of PHOSLO) calcium acetate (phosphate binder) tab Pref PA 667 mg calphron tab 667mg Pref OTC FOSRENOL CHW 500MG Non-Pref PA FOSRENOL CHW 750MG Non-Pref PA FOSRENOL CHW 1000MG Non-Pref PA FOSRENOL POW 750MG Non-Pref PA FOSRENOL POW 1000MG Non-Pref PA lanthanum carbonate chew tab 500 mg Non-Pref PA (elemental) (generic of FOSRENOL) lanthanum carbonate chew tab 750 mg Non-Pref PA (elemental) (generic of FOSRENOL) lanthanum carbonate chew tab 1000 mg Non-Pref PA (elemental) (generic of FOSRENOL) PHOSLYRA SOL Non-Pref PA RENAGEL TAB 800MG Non-Pref PA RENVELA POW 0.8GM Non-Pref PA RENVELA POW 2.4GM Non-Pref PA RENVELA TAB 800MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 114 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits sevelamer carbonate packet 0.8 gm Non-Pref PA (generic of RENVELA) sevelamer carbonate packet 2.4 gm Non-Pref PA (generic of RENVELA) sevelamer carbonate tab 800 mg (generic Pref PA of RENVELA) sevelamer hcl tab 400 mg Non-Pref PA sevelamer hcl tab 800 mg (generic of Non-Pref PA RENAGEL) VELPHORO CHW 500MG Non-Pref PA GENITOURINARY AGENTS - MISCELLANEOUS - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS ACIDIFIERS K-PHOS TAB NO 2 Pref ALKALINIZERS cytra k gra crystals Pref potassium citrate & citric acid soln 1100- Pref 334 mg/5ml potassium citrate tab er 5 meq (540 mg) Pref (generic of UROCIT-K 5) potassium citrate tab er 10 meq (1080 mg) Pref (generic of UROCIT-K 10) sodium citrate & citric acid soln 500-334 Pref mg/5ml INTERSTITIAL CYSTITIS AGENTS ELMIRON CAP 100MG Pref PA, QL PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl tab er 24hr 10 mg (generic of Pref UROXATRAL) AVODART CAP 0.5MG Non-Pref PA CARDURA XL TAB 4MG Non-Pref PA CARDURA XL TAB 8MG Non-Pref PA dutasteride cap 0.5 mg (generic of Pref AVODART) dutasteride-tamsulosin hcl cap 0.5-0.4 mg Non-Pref PA (generic of JALYN) finasteride tab 5 mg (generic of PROSCAR) Pref FLOMAX CAP 0.4MG Non-Pref PA JALYN CAP Non-Pref PA PROSCAR TAB 5MG Non-Pref PA RAPAFLO CAP 4MG Non-Pref PA RAPAFLO CAP 8MG Non-Pref PA silodosin cap 4 mg (generic of RAPAFLO) Non-Pref PA silodosin cap 8 mg (generic of RAPAFLO) Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 115 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits tamsulosin hcl cap 0.4 mg (generic of Pref FLOMAX) URINARY ANALGESICS phenazo tab 200mg Pref phenazopyridine hcl tab 100 mg Pref phenazopyridine hcl tab 200 mg Pref GOUT AGENTS - DRUGS TO TREAT GOUT GOUT AGENT COMBINATIONS colchicine w/ probenecid tab 0.5-500 mg Pref GOUT AGENTS - DRUGS TO TREAT GOUT allopurinol tab 100 mg (generic of Pref ZYLOPRIM) allopurinol tab 300 mg (generic of Pref ZYLOPRIM) colchicine cap 0.6 mg Non-Pref PA colchicine tab 0.6 mg (generic of Non-Pref PA COLCRYS) COLCRYS TAB 0.6MG Non-Pref PA febuxostat tab 40 mg (generic of ULORIC) Non-Pref PA febuxostat tab 80 mg (generic of ULORIC) Non-Pref PA GLOPERBA SOL 0.6/5ML Non-Pref PA MITIGARE CAP 0.6MG Pref ULORIC TAB 40MG Non-Pref PA ULORIC TAB 80MG Non-Pref PA ZYLOPRIM TAB 100MG Non-Pref PA ZYLOPRIM TAB 300MG Non-Pref PA URICOSURICS probenecid tab 500 mg Pref HEMATOLOGICAL AGENTS - MISC. - DRUGS TO TREAT BLOOD DISORDERS HEMATORHEOLOGIC AGENTS pentoxifylline tab er 400 mg Pref PLATELET AGGREGATION INHIBITORS AGGRENOX CAP 25-200MG Non-Pref PA anagrelide hcl cap 0.5 mg (generic of Pref AGRYLIN) anagrelide hcl cap 1 mg Pref aspirin-dipyridamole cap er 12hr 25-200 Non-Pref PA mg BRILINTA TAB 60MG Pref BRILINTA TAB 90MG Pref cilostazol tab 50 mg Pref QL cilostazol tab 100 mg Pref QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 116 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits clopidogrel bisulfate tab 75 mg (base Pref equiv) (generic of PLAVIX) clopidogrel bisulfate tab 300 mg (base Pref equiv) dipyridamole tab 25 mg Non-Pref PA dipyridamole tab 50 mg Non-Pref PA dipyridamole tab 75 mg Non-Pref PA EFFIENT TAB 5MG Non-Pref PA, AGE EFFIENT TAB 10MG Non-Pref PA, AGE PLAVIX TAB 75MG Non-Pref PA prasugrel hcl tab 5 mg (base equiv) Pref AGE (generic of EFFIENT) prasugrel hcl tab 10 mg (base equiv) Pref AGE (generic of EFFIENT) ZONTIVITY TAB 2.08MG Non-Pref PA HEMATOPOIETIC AGENTS - DRUGS TO TREAT BLOOD DISORDERS AGENTS FOR SICKLE CELL DISEASE DROXIA CAP 200MG Pref DROXIA CAP 300MG Pref DROXIA CAP 400MG Pref ENDARI POW 5GM Pref SP, PA, QL, AGE OXBRYTA TAB 500MG Pref SP, PA, QL, AGE COBALAMINS cyanocobalamin inj 1000 mcg/ml Pref cyanocobalamin tab 100 mcg Pref QL, OTC cyanocobalamin tab 500 mcg Pref QL, OTC cyanocobalamin tab 1000 mcg Pref QL, OTC FOLIC ACID/FOLATES folic acid tab 1 mg Pref folic acid tab 400 mcg Pref QL, OTC folic acid tab 800 mcg Pref OTC HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG Pref PA ARANESP INJ 25MCG Pref PA ARANESP INJ 40MCG Pref PA ARANESP INJ 60MCG Pref PA ARANESP INJ 100MCG Pref PA ARANESP INJ 150MCG Pref PA ARANESP INJ 200MCG Pref PA ARANESP INJ 300MCG Pref PA ARANESP INJ 500MCG Pref PA EPOGEN INJ 2000/ML Pref PA EPOGEN INJ 3000/ML Pref PA EPOGEN INJ 4000/ML Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 117 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits EPOGEN INJ 10000/ML Pref PA EPOGEN INJ 20000/ML Pref PA FULPHILA INJ 6/0.6ML Pref QL GRANIX INJ 300/0.5 Non-Pref PA GRANIX INJ 300/1ML Non-Pref PA GRANIX INJ 480/0.8 Non-Pref PA GRANIX INJ 480/1.6 Non-Pref PA LEUKINE INJ 250MCG Non-Pref PA NEULASTA INJ 6MG/0.6M Non-Pref PA, QL NEULASTA KIT 6MG/0.6M Non-Pref PA, QL NEUPOGEN INJ 300/0.5 Pref NEUPOGEN INJ 300MCG Pref NEUPOGEN INJ 480/0.8 Pref NEUPOGEN INJ 480MCG Pref NIVESTYM INJ 300/0.5 Non-Pref PA NIVESTYM INJ 300MCG Non-Pref PA NIVESTYM INJ 480/0.8 Non-Pref PA NIVESTYM INJ 480MCG Non-Pref PA NYVEPRIA INJ 6/0.6ML Pref QL PROCRIT INJ 2000/ML Non-Pref PA PROCRIT INJ 3000/ML Non-Pref PA PROCRIT INJ 4000/ML Non-Pref PA PROCRIT INJ 10000/ML Non-Pref PA PROCRIT INJ 20000/ML Non-Pref PA PROCRIT INJ 40000/ML Non-Pref PA RETACRIT INJ 2000UNIT Pref PA RETACRIT INJ 3000UNIT Pref PA RETACRIT INJ 4000UNIT Pref PA RETACRIT INJ 10000UNT Pref PA RETACRIT INJ 20000UNI Pref RETACRIT INJ 40000UNT Pref PA UDENYCA INJ 6MG/.6ML Pref QL ZARXIO INJ 300/0.5 Non-Pref PA, QL ZARXIO INJ 480/0.8 Non-Pref PA, QL ZIEXTENZO INJ 6/0.6ML Non-Pref PA, QL HEMATOPOIETIC MIXTURES ACTIVE FE TAB 75-1.25 Pref airavite tab Pref ANIMI-3 CAP Pref ANIMI-3 CAP VIT D Pref BIFERA TAB 28MG Pref OTC CENTRATEX CAP Pref chromagen cap Pref QL corvita 150 tab Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 118 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits CORVITE 150 TAB Pref CORVITE FE TAB Pref fabb tab 2.2-25-1 Pref FEOSOL BIFER TAB 28MG Pref OTC FERIVA TAB 21/7 Pref FERIVAFA CAP 110-1MG Pref ferocon cap Pref QL ferotrinsic cap Pref QL FERRALET 90 TAB Pref FERRAPLUS 90 TAB Pref ferrocite tab plus Pref folbee tab Pref folic acid-vitamin b6-vitamin b12 tab 2.2- Pref 25-0.5 mg FOLINIC-PLUS TAB 4-50-2MG Pref OTC FOLITAB 500 TAB Pref OTC FOLIVANE-F CAP Pref FOLIVANE-PLS CAP Pref folplex 2.2 tab Pref foltabs 800 tab Pref OTC foltrin cap Pref QL hematinic pl tab vit/min Pref hematinic/fa tab Pref hematogen cap Pref QL, OTC hematogen cap forte Pref OTC HEMATOGEN FA CAP Pref HEMETAB TAB Pref HOMOCYSTEINE TAB FORMULA Pref OTC iferex 150 cap forte Pref QL IRO-PLEX LIQ Pref OTC IRON 21/7 MIS Pref OTC iron 100 tab plus Pref AGE, OTC iron 100/c tab 100-250 Pref OTC IROSPAN 24/6 MIS Pref MULTIGEN PLS TAB Pref MULTIGEN TAB Pref MULTIGEN TAB FOLIC Pref NEPHRON FA TAB Pref NIFEREX TAB Pref NUFERA TAB Pref nufol tab Pref poly-iron cap 150 fort Pref QL polysacchari cap iron Pref QL purevit dual cap fe plus Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 119 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits RX SUPPORT TAB HEARTBUR Pref OTC se-tan plus cap Pref TARON FORTE CAP Pref tl-hem 150 tab Pref tricon cap Pref QL trigels-f cap forte Pref VIRT-FEFA CAP PLUS Pref virt-gard tab 2.2-25-1 Pref VITRON-C TAB 65-125 Pref OTC westab mini tab 2.2-25-1 Pref westab one tab 2.5-25-1 Pref IRON carbonyl tab fe 45mg Pref OTC FEOSOL TAB 200MG Pref OTC FERAHEME INJ 510/17ML Pref FERRETTS IPS SOL Pref OTC ferrex 150 cap 150mg Pref QL, OTC FERRIMIN 150 TAB Pref OTC ferrocite tab 324mg Pref OTC FERROUS FUM TAB 29MG Pref OTC ferrous fumarate tab 324 mg (106 mg Pref OTC elemental fe) FERROUS GLUC TAB 324MG Pref OTC ferrous gluconate tab 240 mg (27 mg Pref OTC elemental fe) FERROUS SULF LIQ 44MG/5ML Pref AGE, OTC FERROUS SULF TAB 324MG EC Pref OTC ferrous sulfate dried tab 200 mg (65 mg Pref OTC elemental fe) ferrous sulfate dried tab er 160 mg (50 mg Pref OTC fe equivalent) ferrous sulfate elixir 220 mg/5ml (44 Pref AGE, OTC mg/5ml elemental fe) ferrous sulfate soln 75 mg/ml (15 mg/ml Pref AGE, OTC elemental fe) ferrous sulfate syrup 300 mg/5ml (60 Pref AGE, OTC mg/5ml elemental fe) ferrous sulfate tab 325 mg (65 mg Pref OTC elemental fe) ferrous sulfate tab ec 325 mg (65 mg fe Pref OTC equivalent) ferrous sulfate tab er 142 mg (45 mg fe Pref OTC equivalent) IRON CHW PEDIATRI Pref OTC IRON UP LIQ Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 120 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits NOVAFERRUM DRO 15MG/ML Pref OTC NOVAFERRUM LIQ 125 Pref OTC nu-iron 150 cap 150mg Pref QL, OTC poly-iron cap 150mg Pref QL, OTC polysaccharide iron complex cap 150 mg Pref QL, OTC (iron equivalent) PROFE CAP 180MG Pref OTC PROFERRIN ES TAB 12 MG Pref OTC px iron tab 27mg Pref OTC SLOW REL FE TAB 143MG CR Pref OTC wee care sus 15/1.25 Pref OTC HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS - DRUGS TO TREAT SLEEP DISORDERS NON-BARBITURATE HYPNOTICS midazolam hcl inj 5 mg/ml (base Pref QL equivalent) midazolam hcl inj 10 mg/2ml (base Pref QL equivalent) midazolam hcl inj 25 mg/5ml (base Pref QL equivalent) midazolam hcl inj 50 mg/10ml (base Pref QL equivalent) midazolam hcl inj pf 5 mg/ml (base Pref QL equivalent) midazolam hcl inj pf 10 mg/2ml (base Pref equivalent) LAXATIVES - DRUGS TO TREAT CONSTIPATION BULK LAXATIVES calcium polycarbophil tab 625 mg Pref OTC corn dextrin oral powder Pref OTC EQUALACTIN CHW 625MG Pref OTC FIBER CHOICE CHW 1.5GM Pref OTC geri-mucil pow 68% Pref OTC HYDROCIL INS POW 95% Pref OTC HYDROCIL POW 95% Pref OTC KONSYL DAILY POW 28.3% Pref OTC KONSYL DAILY POW 60.3% Pref OTC KONSYL DAILY POW 100% Pref OTC KONSYL ORIG POW 100% Pref OTC KONSYL-D POW 52.3% Pref OTC METAMUCIL POW 28%ORG Pref OTC METAMUCIL POW 48.57% Pref OTC METAMUCIL POW 58.12% Pref OTC METAMUCIL POW 63% Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 121 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits METAMUCIL WAF Pref OTC methylcellulose tab 500 mg Pref OTC NAT FIBER POW 58.6% Pref OTC NUTRISOURCE PAK FIBER Pref OTC NUTRISOURCE POW FIBER Pref OTC pedialax fbr chw gummies Pref OTC psyllium cap 0.52 gm Pref OTC psyllium powder 28.3% Pref OTC psyllium powder 30.9% Pref OTC psyllium powder 48.57% Pref OTC psyllium powder 58.6% Pref OTC psyllium powder 100% Pref OTC qc natural pow vegetabl Pref OTC soluble fib pow therapy Pref OTC UNIFIBER POW Pref OTC wheat dextrin oral powder Pref OTC WHEAT DEXTRIN PACKET Pref OTC LAXATIVE COMBINATIONS CLENPIQ SOL Pref easy fiber/ chw calcium Pref OTC gavilyte-c sol Pref gavilyte-g sol (generic of GOLYTELY) Pref GOLYTELY SOL Pref MOVIPREP SOL Pref NULYTELY SOL LMN/LIME Pref peg 3350-kcl-na bicarb-nacl-na sulfate for Pref soln 236 gm (generic of GOLYTELY) peg 3350-kcl-sod bicarb-nacl for soln 420 Pref gm (generic of PEG 3350-KCL-SOD BICARB-NACL FOR SOLN 420 GM) peg/nasul,c sol nacl/pot (generic of Pref MOVIPREP) PLENVU SOL Pref SENNA PLUS CAP 8.6-50MG Pref OTC sennosides-docusate sodium tab 8.6-50 Pref OTC mg SENOKOT S TAB 8.6-50MG Pref OTC STL SOFT/LAX CAP 8.5-50MG Pref OTC SUPREP BOWEL SOL PREP KIT Pref SUTAB TAB Pref wal-mucil cap plus ca Pref OTC LAXATIVES - MISCELLANEOUS CEO-TWO SUP Pref OTC constulose sol 10gm/15 Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 122 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits FLEET LIQUID ENE GLYCERIN Pref OTC glycerin sup 1gm Pref OTC glycerin sup 2gm Pref OTC glycerin suppos 1.2 gm Pref OTC glycerin suppos 2.1 gm Pref OTC glycerin suppos 80.7% Pref OTC lactulose solution 10 gm/15ml Pref PEDIA-LAX SUP 2.8GM Pref OTC polyethylene glycol 3350 oral powder Pref OTC LUBRICANT LAXATIVES FLEET OIL ENE Pref OTC KONDREMUL EMU 50% Pref OTC mineral oil Pref OTC mineral oil enema Pref OTC SALINE LAXATIVES epsom salt gra Pref OTC EPSOM SALT GRA Pref OTC EPSOM SALT GRA LAVENDER Pref OTC FLEET ENE Pref OTC FLEET ENE ENEMA Pref OTC gnp epsom gra salt Pref OTC lax diet sup tab 500mg Pref OTC magnesium citrate soln Pref OTC magnesium hydroxide susp 400 mg/5ml Pref OTC MILK OF MAGN CHW 311MG Pref OTC milk of magn sus 2400mg Pref OTC PEDIA-LAX CHW 400MG Pref OTC PHILLIPS TAB 500MG Pref OTC qc epsom gra salt Pref OTC RA EPSOM GRA SALT Pref OTC RA EPSOM GRA SALT/LVN Pref OTC sm epsom gra salt Pref OTC sodium phosphates - enema Pref OTC STIMULANT LAXATIVES bisacodyl suppos 10 mg Pref OTC bisacodyl tab delayed release 5 mg Pref OTC castor oil 100% Pref OTC DULCOLAX TAB 5MG EC Pref OTC FLEET BISACO ENE 10/30ML Pref OTC gnp castor oil 100% Pref OTC laxative reg tab 15mg Pref OTC laxative tab 15mg Pref OTC medi-lax tab 15mg Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 123 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits perdiem tab 15mg Pref OTC senna smooth tab 15mg Pref OTC SENNA SYP Pref OTC sennosides cap 8.6 mg Pref OTC sennosides chew tab 15 mg Pref OTC sennosides syrup 8.8 mg/5ml Pref OTC sennosides tab 8.6 mg Pref OTC sennosides tab 25 mg Pref OTC senokot extr tab 17.2mg Pref OTC SENOKOT TAB 8.6MG Pref OTC sm castor oil 100% Pref OTC SURFACTANT LAXATIVES BENZOCAINE-DOCUSATE SODIUM RECTAL Pref OTC ENEMA 20-283 MG COLACE CLEAR CAP 50MG Pref OTC docusate calcium cap 240 mg Pref OTC docusate min ene 283mg Pref OTC docusate sodium cap 50 mg Pref OTC docusate sodium cap 100 mg Pref OTC docusate sodium cap 250 mg Pref OTC docusate sodium liquid 150 mg/15ml Pref OTC docusate sodium syrup 60 mg/15ml Pref QL, OTC docusate sodium tab 100 mg Pref OTC docusol mini ene Pref OTC enemeez mini ene Pref OTC mini enema ene 100/5ml Pref OTC PEDIA-LAX LIQ 50MG Pref QL, OTC MACROLIDES - DRUGS TO TREAT INFECTIONS AZITHROMYCIN azithromycin for susp 100 mg/5ml (generic Pref of ZITHROMAX) azithromycin for susp 200 mg/5ml (generic Pref of ZITHROMAX) azithromycin powd pack for susp 1 gm Pref QL azithromycin tab 250 mg (generic of Pref ZITHROMAX) azithromycin tab 500 mg (generic of Pref ZITHROMAX) azithromycin tab 600 mg Pref ZITHROMAX POW 1GM PAK Non-Pref PA, QL ZITHROMAX SUS 100/5ML Non-Pref PA ZITHROMAX SUS 200/5ML Non-Pref PA ZITHROMAX TAB 250MG Non-Pref PA ZITHROMAX TAB 500MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 124 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ZITHROMAX TAB TRI-PAK Non-Pref PA ZITHROMAX TAB Z-PAK Non-Pref PA CLARITHROMYCIN clarithromycin for susp 125 mg/5ml Pref QL clarithromycin for susp 250 mg/5ml Pref QL clarithromycin tab 250 mg Pref QL clarithromycin tab 500 mg Pref QL clarithromycin tab er 24hr 500 mg (generic Non-Pref PA, QL of BIAXIN XL) ERYTHROMYCINS E.E.S. GRAN SUS 200/5ML Pref ery-tab tab 250mg ec Non-Pref PA ery-tab tab 333mg ec Non-Pref PA ery-tab tab 500mg ec Non-Pref PA ERYPED SUS 200/5ML Non-Pref PA ERYPED SUS 400/5ML Non-Pref PA erythrocin tab 250mg Pref erythromycin ethylsuccinate for susp 200 Pref mg/5ml (generic of E.E.S. GRANULES) erythromycin ethylsuccinate for susp 400 Non-Pref PA mg/5ml (generic of ERYPED 400) erythromycin ethylsuccinate tab 400 mg Pref erythromycin tab 250 mg Non-Pref PA erythromycin tab 500 mg Non-Pref PA erythromycin tab delayed release 250 mg Non-Pref PA erythromycin tab delayed release 333 mg Non-Pref PA erythromycin tab delayed release 500 mg Non-Pref PA erythromycin w/ delayed release particles Non-Pref PA cap 250 mg FIDAXOMICIN DIFICID SUS Non-Pref PA DIFICID TAB 200MG Non-Pref PA, QL MEDICAL DEVICES AND SUPPLIES - MEDICAL DEVICES AND SUPPLIES FOR DIAGNOSIS, TREATMENT, OR MONITORING CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL CAYA DPR Pref CONDOMS - FEMALE Pref QL, OTC CONDOMS LATEX LUBRICATED Pref QL, OTC CONDOMS LATEX NON-LUBRICATED Pref QL, OTC FEMCAP MIS 22MM Pref FEMCAP MIS 26MM Pref FEMCAP MIS 30MM Pref WIDE-SEAL DPR KIT 60 Pref WIDE-SEAL DPR KIT 65 Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 125 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits WIDE-SEAL DPR KIT 70 Pref WIDE-SEAL DPR KIT 75 Pref WIDE-SEAL DPR KIT 80 Pref WIDE-SEAL DPR KIT 85 Pref WIDE-SEAL DPR KIT 90 Pref WIDE-SEAL DPR KIT 95 Pref DIABETIC SUPPLIES DEXCOM G5 MIS RECEIVER Pref PA, QL DEXCOM G5 MIS TRANSMIT Pref PA, QL DEXCOM G6 MIS RECEIVER Pref PA, QL DEXCOM G6 MIS SENSOR Pref PA, QL DEXCOM G6 MIS TRANSMIT Pref PA, QL FREESTY LIBR KIT 2 SENSOR Pref PA, QL FREESTY LIBR MIS 2 READER Pref PA, QL FREESTYLE KIT SENSOR Pref PA, QL FREESTYLE MIS READER Pref PA, QL G5/G4 MIS SENSOR Pref PA, QL LANCETS Pref OTC TRUE METRIX KIT AIR Pref QL, OTC TRUE METRIX KIT METER Pref QL, OTC MISC. DEVICES ALCOHOL SWABS Pref QL, OTC ESSENTRA MIS 9X9" Pref QL PARENTERAL THERAPY SUPPLIES BD U-500 MIS 31GX6MM Pref QL INSULIN SYRINGE/NEEDLE Pref QL, OTC; TECHLITE/TRUEPLUS PEN NEEDLES MIS 29GX10MM Pref QL, OTC; TECHLITE/TRUEPLUS PEN NEEDLES MIS 29GX12.7 Pref QL, OTC; TECHLITE/TRUEPLUS PEN NEEDLES MIS 29GX12MM Pref QL, OTC; TECHLITE/TRUEPLUS PEN NEEDLES MIS 31GX5MM Pref QL, OTC; TECHLITE/TRUEPLUS PEN NEEDLES MIS 31GX6MM Pref QL, OTC; TECHLITE/TRUEPLUS PEN NEEDLES MIS 31GX8MM Pref QL, OTC; TECHLITE/TRUEPLUS PEN NEEDLES MIS 32GX4MM Pref QL, OTC; TECHLITE/TRUEPLUS PEN NEEDLES MIS 32GX6MM Pref QL, OTC; TECHLITE/TRUEPLUS PEN NEEDLES MIS 32GX8MM Pref QL, OTC; TECHLITE/TRUEPLUS

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 126 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits RESPIRATORY AIDS PEDIATRIC MD MIS MASK Pref QL, OTC PEDIATRIC SM MIS MASK Pref QL, OTC RESPIRATORY THERAPY SUPPLIES ADULT DISPOS MIS MOUTHPIE Pref QL, OTC ADULT MASK MIS Pref QL AEROBIKA MIS Pref QL BREATHERITE MIS MDI CHMB Pref QL DISPOSABLE MIS MTHPIECE Pref QL, OTC EXPIRATORY MIS MTHPIECE Pref QL, OTC IN-CHK FLOW MIS METER Pref QL INSPIRATORY MIS MTHPIECE Pref QL, OTC KOKO PEAK PR MIS MOUTHPIE Pref QL, OTC MASK VORTEX/ MIS FROG Pref QL, OTC MASK VORTEX/ MIS LADY BUG Pref QL, OTC MOUTHPIECE MIS DISP/PPR Pref QL, OTC MOUTHPIECE MIS PED ADAP Pref QL, OTC ONE FLOW MIS MTHPIECE Pref QL, OTC PANDA MASK MIS LARGE Pref QL, OTC PANDA MASK MIS MEDIUM Pref QL, OTC PANDA MASK MIS PEDIATRI Pref QL, OTC PANDA MASK MIS SMALL Pref QL, OTC PARI MANUAL MIS INTERRUP Pref QL PARI TREK S KIT COMBO Pref QL PEAK FLOW METER Pref QL, OTC PEAK FLOW METER- RX Pref QL PFT FILTER MIS 1000 Pref QL PFT FILTER MIS 2000 Pref QL PFT FILTER MIS 3000 Pref QL PFT FILTER MIS 4000 Pref QL PFT FILTER MIS 5000 Pref QL PFT FILTER MIS 6000 Pref QL PFT FILTER MIS 7000 Pref QL RESPIRATORY THERAPY SUPPLIES - MISC Pref QL, OTC (MASK) RESPIRATORY THERAPY SUPPLIES - MISC Pref QL (MASK)- RX SPACER/AEROSOL-HOLDING CHAMBERS - Pref QL, OTC DEVICE SPACER/AEROSOL-HOLDING CHAMBERS - Pref QL DEVICE- RX THRESHOLD MIS PEP Pref QL VORTEX/MASK MIS CHILDS Pref QL VORTEX/MASK MIS TODDLER Pref QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 127 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits MIGRAINE PRODUCTS - DRUGS TO TREAT SEVERE HEADACHES CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG AIMOVIG INJ 70MG/ML Pref PA, QL AIMOVIG INJ 140MG/ML Pref PA, QL AJOVY INJ 225/1.5 Non-Pref PA, QL EMGALITY INJ 100MG/ML Pref PA, QL EMGALITY INJ 120MG/ML Pref PA, QL NURTEC TAB 75MG ODT Pref PA, QL, AGE UBRELVY TAB 50MG Non-Pref PA, QL UBRELVY TAB 100MG Non-Pref PA, QL MIGRAINE COMBINATIONS sumatriptan-naproxen sodium tab 85-500 Non-Pref PA mg (generic of TREXIMET) TREXIMET TAB 85-500MG Non-Pref PA SEROTONIN AGONISTS almotriptan malate tab 6.25 mg Non-Pref PA almotriptan malate tab 12.5 mg Non-Pref PA AMERGE TAB 1MG Non-Pref PA AMERGE TAB 2.5MG Non-Pref PA eletriptan hydrobromide tab 20 mg (base Non-Pref PA, QL equivalent) (generic of RELPAX) eletriptan hydrobromide tab 40 mg (base Non-Pref PA, QL equivalent) (generic of RELPAX) FROVA TAB 2.5MG Non-Pref PA frovatriptan succinate tab 2.5 mg (base Non-Pref PA equivalent) (generic of FROVA) IMITREX INJ 4MG/0.5 Non-Pref PA IMITREX INJ 6MG/0.5 Non-Pref PA IMITREX SPR 5MG/ACT Pref QL IMITREX SPR 20MG/ACT Pref QL IMITREX TAB 25MG Non-Pref PA IMITREX TAB 50MG Non-Pref PA IMITREX TAB 100MG Non-Pref PA MAXALT TAB 10MG Non-Pref PA, QL; 18 per claim MAXALT-MLT TAB 10MG Non-Pref PA, QL; 18 per claim naratriptan hcl tab 1 mg (base equiv) Non-Pref PA (generic of AMERGE) naratriptan hcl tab 2.5 mg (base equiv) Non-Pref PA (generic of AMERGE) ONZETRA XSAI MIS 11MG Non-Pref PA RELPAX TAB 20MG Non-Pref PA, QL RELPAX TAB 40MG Non-Pref PA, QL REYVOW TAB 50MG Non-Pref PA, QL, AGE REYVOW TAB 100MG Non-Pref PA, QL, AGE

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 128 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits rizatriptan benzoate oral disintegrating tab Pref QL; 18 per claim 5 mg (base eq) rizatriptan benzoate oral disintegrating tab Pref QL; 18 per claim 10 mg (base eq) (generic of MAXALT-MLT) rizatriptan benzoate tab 5 mg (base Pref QL; 18 per claim equivalent) rizatriptan benzoate tab 10 mg (base Pref QL; 18 per claim equivalent) (generic of MAXALT) sumatriptan nasal spray 5 mg/act (generic Non-Pref PA, QL of IMITREX) sumatriptan nasal spray 20 mg/act Non-Pref PA, QL (generic of IMITREX) sumatriptan succinate inj 6 mg/0.5ml Pref QL (generic of IMITREX) sumatriptan succinate solution auto- Pref injector 4 mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) sumatriptan succinate solution auto- Pref injector 6 mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) sumatriptan succinate solution cartridge 4 Pref mg/0.5ml (generic of IMITREX STATDOSE REFILL) sumatriptan succinate solution cartridge 6 Pref QL mg/0.5ml (generic of IMITREX STATDOSE REFILL) sumatriptan succinate tab 25 mg (generic Pref of IMITREX) sumatriptan succinate tab 50 mg (generic Pref of IMITREX) sumatriptan succinate tab 100 mg (generic Pref of IMITREX) TOSYMRA SOL 10MG Non-Pref PA ZEMBRACE SYM INJ 3/0.5ML Non-Pref PA zolmitriptan nasal spray 2.5 mg/spray unit Non-Pref PA zolmitriptan nasal spray 5 mg/spray unit Non-Pref PA zolmitriptan orally disintegrating tab 2.5 Non-Pref PA mg (generic of ZOMIG ZMT) zolmitriptan orally disintegrating tab 5 mg Non-Pref PA (generic of ZOMIG ZMT) zolmitriptan tab 2.5 mg (generic of Non-Pref PA ZOMIG) zolmitriptan tab 5 mg (generic of ZOMIG) Non-Pref PA ZOMIG SPR 2.5MG Non-Pref PA ZOMIG SPR 5MG Non-Pref PA ZOMIG TAB 2.5MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 129 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ZOMIG TAB 5MG Non-Pref PA ZOMIG ZMT TAB 2.5 MG Non-Pref PA ZOMIG ZMT TAB 5MG ODT Non-Pref PA MINERALS & ELECTROLYTES - DRUGS FOR NUTRITION CALCIUM BONE DENSITY TAB Pref OTC CA CITRATE TAB 250MG Pref OTC CA GLUCONATE TAB 50MG Pref OTC CA LACTATE TAB 100MG Pref OTC CAL-MINT CHW 260MG Pref OTC CAL-QUICK LIQ 500-400 Pref OTC CAL/MAG TAB CHEW Pref OTC CALCET PETIT TAB 200-250 Pref OTC calcium 600 chw +d/miner Pref OTC calcium + d chw Pref OTC CALCIUM CARB CHW 260MG Pref OTC CALCIUM CARB CHW 500MG Pref OTC CALCIUM CARB POW 800/2GM Pref OTC calcium carb-vit d w/ minerals chew tab Pref OTC 600 mg-400 unit calcium carb-vit d w/ minerals chew tab Pref OTC 600 mg-800 unit calcium carbonate tab 1500 mg (600 mg Pref OTC elemental ca) calcium carbonate-cholecalciferol chew tab Pref OTC 500 mg-400 unit calcium carbonate-cholecalciferol tab 250 Pref OTC mg-125 unit calcium carbonate-cholecalciferol tab 500 Pref OTC mg-200 unit calcium carbonate-cholecalciferol tab 500 Pref OTC mg-400 unit calcium carbonate-cholecalciferol tab 600 Pref OTC mg-400 unit calcium carbonate-cholecalciferol tab 600 Pref OTC mg-800 unit calcium carbonate-vitamin d cap 600 mg- Pref OTC 200 unit calcium carbonate-vitamin d tab 500 mg- Pref OTC 200 unit calcium carbonate-vitamin d tab 500 mg- Pref OTC 400 unit calcium carbonate-vitamin d tab 600 mg- Pref OTC 200 unit

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 130 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits calcium carbonate-vitamin d tab 600 mg- Pref OTC 400 unit calcium chloride inj 10% Pref calcium citrate-vitamin d tab 200 mg-250 Pref OTC unit (elemental ca) calcium citrate-vitamin d tab 250 mg-200 Pref OTC unit (elemental ca) calcium citrate-vitamin d tab 315 mg-200 Pref OTC unit (elemental ca) calcium citrate-vitamin d tab 315 mg-250 Pref OTC unit (elemental ca) CALCIUM GLUC INJ 10% Pref CALCIUM GRA CITRATE Pref OTC calcium plus tab 600 +d Pref OTC calcium soft chw mlk choc Pref OTC CALCIUM TAB FORMULA Pref OTC calcium w/ magnesium tab 500-250 mg Pref OTC calcium+d3 tab grad rel Pref OTC calcium-magnesium-zinc tab 333-133-5 Pref OTC mg calcium/d3 tab Pref OTC calcium/d3 tab 600-800 Pref OTC CALMAG THINS TAB 200-50MG Pref OTC CALTRATE 600 CHW 600-800 Pref OTC CALTRATE +D3 TAB 600-800 Pref OTC CHELATED CA TAB 200MG Pref OTC CITRACAL+D3 CHW 250-500 Pref OTC CITRACAL+D3 TAB MAXIMUM Pref OTC LOCALNESIUM TAB Pref OTC LOCALNESIUM TAB -C Pref OTC os-cal extra tab d3 Pref OTC OSTEO-PORETI TAB Pref OTC oys shell+d tab 250-125 Pref OTC oyster shell calcium tab 500 mg Pref OTC PARVA-CAL TAB 250-100 Pref OTC PARVA-CAL TAB 500MG Pref OTC qc calcium tab 600mg Pref OTC sm calcium chw Pref OTC SM CORAL CAL TAB 1000MG Pref OTC super cal/ tab mag Pref OTC UPCAL D POW Pref OTC ELECTROLYTE MIXTURES ENFAMIL SOL ENFALYTE Pref OTC oral electrolyte solution Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 131 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits PEDIALYTE SOL BUBL GUM Pref OTC PEDIALYTE SOL FREEZE Pref OTC PEDIALYTE SOL FRUIT Pref OTC PEDIALYTE SOL SINGLES Pref OTC PEDIALYTE SOL UNFLAVOR Pref OTC FLUORIDE sodium fluoride chew tab 0.5 mg f (from Pref QL, AGE 1.1 mg naf) sodium fluoride chew tab 0.25 mg f (from Pref QL, AGE 0.55 mg naf) sodium fluoride chew tab 1 mg f (from 2.2 Pref QL, AGE mg naf) sodium fluoride soln 0.5 mg/ml f (from 1.1 Pref QL, AGE mg/ml naf) MAGNESIUM BEELITH TAB Pref OTC MAG CITRATE TAB 100MG Pref OTC MAG GLYCINAT TAB 100MG Pref OTC mag-g tab 500mg Pref OTC MAGINEX TAB 615 MG Pref OTC magnesium chloride inj 200 mg/ml Pref magnesium chloride tab dr 64 mg Pref OTC (elemental mg) magnesium gluconate tab 27.5 mg Pref OTC (elemental mg) magnesium lactate tab er 84 mg Pref OTC (elemental mg) (7 meq) magnesium oxide tab 400 mg (240 mg Pref OTC elemental mg) magnesium oxide tab 400 mg (241.3 mg Pref OTC elemental mg) magnesium sulfate in dextrose 5% iv soln Pref 1 gm/100ml (generic of MAGNESIUM SULFATE IN D5W) magnesium sulfate inj 50% Pref magnesium sulfate iv soln 2 gm/50ml (40 Pref mg/ml) (generic of MAGNESIUM SULFATE) magnesium sulfate iv soln 4 gm/50ml (80 Pref mg/ml) (generic of MAGNESIUM SULFATE) magnesium sulfate iv soln 4 gm/100ml (40 Pref mg/ml) (generic of MAGNESIUM SULFATE) magnesium sulfate iv soln 20 gm/500ml Pref (40 mg/ml) (generic of MAGNESIUM SULFATE)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 132 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits magnesium sulfate iv soln 40 gm/1000ml Pref (40 mg/ml) (generic of MAGNESIUM SULFATE) magnesium tab 100 mg Pref OTC magnesium tab 250 mg Pref OTC magnesium tab 500mg Pref OTC MAGONATE LIQ 1000/5ML Pref OTC MAGOX 400 TAB 400MG Pref OTC NU-MAG TAB 71.5-119 Pref OTC SLOW-MAG TAB Pref OTC SLOW-MAG TAB 71.5-119 Pref OTC SLOWMAG MG TAB MUS/HRT Pref OTC MINERAL COMBINATIONS ca citrate + tab Pref OTC cal-mag-zinc tab +d3 Pref OTC CITRACAL PLS TAB Pref OTC FEM-CAL TAB CITRATE Pref OTC MULT MINERAL TAB Pref OTC NUTRA-SUPPRT CAP BONE Pref OTC PHOSPHATE GLYCOPHOS SOL 1MM/ML Pref K-PHOS TAB Pref PHOS-NAK POW CONCENTR Pref OTC potassium & sodium phosphates powder Pref OTC pack 280-160-250 mg POTASSIUM INJ PHOSPHAT Pref potassium phosphates inj 15 mm/5ml Pref (phos) 22 meq/5ml (k) potassium phosphates inj 45 mm/15ml Pref (phos) 66 meq/15ml (k) potassium phosphates inj 150 mm/50ml Pref (phos) 220 meq/50ml (k) sod, potass pow phosphor Pref OTC sodium phosphates inj 15 mm/5ml (phos) Pref 20 meq/5ml (na) sodium phosphates inj 45 mm/15ml (phos) Pref 60 meq/15ml (na) POTASSIUM klor-con 8 tab 8meq er Pref klor-con 10 tab 10meq er Pref potassium bicarbonate effer tab 25 meq Pref potassium chloride cap er 8 meq Pref potassium chloride cap er 10 meq Pref

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 133 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits potassium chloride microencapsulated crys Pref er tab 10 meq potassium chloride microencapsulated crys Pref er tab 20 meq potassium chloride oral soln 10% (20 Pref meq/15ml) potassium chloride oral soln 20% (40 Pref meq/15ml) potassium chloride tab er 8 meq (600 mg) Pref potassium chloride tab er 10 meq Pref potassium chloride tab er 10 meq (generic Pref of K-TAB) MISCELLANEOUS THERAPEUTIC CLASSES IMMUNOMODULATORS REVLIMID CAP 2.5MG Pref SP, PA, QL REVLIMID CAP 5MG Pref SP, PA, QL REVLIMID CAP 10MG Pref SP, PA, QL REVLIMID CAP 15MG Pref SP, PA, QL REVLIMID CAP 20MG Pref SP, PA, QL REVLIMID CAP 25MG Pref SP, PA, QL THALOMID CAP 50MG Pref SP, PA THALOMID CAP 100MG Pref SP, PA THALOMID CAP 150MG Pref SP, PA THALOMID CAP 200MG Pref SP, PA IMMUNOSUPPRESSIVE AGENTS azathioprine tab 50 mg (generic of Pref QL IMURAN) cyclosporine cap 25 mg (generic of Pref SANDIMMUNE) cyclosporine cap 100 mg (generic of Pref SANDIMMUNE) cyclosporine modified cap 25 mg (generic Pref of NEORAL) cyclosporine modified cap 50 mg Pref cyclosporine modified cap 100 mg (generic Pref of NEORAL) cyclosporine modified oral soln 100 mg/ml Pref AGE (generic of NEORAL) ENSPRYNG INJ Pref SP, PA, QL, AGE gengraf cap 25mg (generic of NEORAL) Pref gengraf cap 100mg (generic of NEORAL) Pref gengraf sol 100mg/ml (generic of NEORAL) Pref AGE mycophenolate mofetil cap 250 mg Pref (generic of CELLCEPT)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 134 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits mycophenolate mofetil for oral susp 200 Pref AGE mg/ml (generic of CELLCEPT) mycophenolate mofetil tab 500 mg Pref (generic of CELLCEPT) mycophenolate sodium tab dr 180 mg Pref ST (mycophenolic acid equiv) (generic of MYFORTIC) mycophenolate sodium tab dr 360 mg Pref ST (mycophenolic acid equiv) (generic of MYFORTIC) sirolimus tab 0.5 mg (generic of Pref RAPAMUNE) sirolimus tab 1 mg (generic of RAPAMUNE) Pref sirolimus tab 2 mg (generic of RAPAMUNE) Pref tacrolimus cap 0.5 mg (generic of Pref PROGRAF) tacrolimus cap 1 mg (generic of PROGRAF) Pref tacrolimus cap 5 mg (generic of PROGRAF) Pref POTASSIUM REMOVING AGENTS sodium polystyrene sulfonate powder Pref sps sus 15gm/60 Pref MOUTH/THROAT/DENTAL AGENTS - DRUGS FOR THE MOUTH AND THROAT ANESTHETICS TOPICAL ORAL lidocaine hcl viscous soln 2% Pref ANTI-INFECTIVES - THROAT clotrimazole troche 10 mg Pref nystatin susp 100000 unit/ml Pref ORAVIG TAB 50MG Non-Pref PA ANTISEPTICS - MOUTH/THROAT chlorhexidine gluconate soln 0.12% Pref (generic of CHLORHEXIDINE GLUCONATE SOLN 0.12%) DENTAL PRODUCTS denta 5000 cre plus Pref denta 5000 cre plus 2pk Pref dentagel gel 1.1% Pref sf 5000 plus cre 1.1% Pref sf gel 1.1% Pref sodium fluor cre 5000 pls Pref sodium fluor cre 5000 ppm Pref sodium fluoride gel 1.1% (0.5% f) Pref STEROIDS - MOUTH/THROAT/DENTAL oralone dent pst 0.1% Pref QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 135 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits triamcinolone acetonide dental paste 0.1% Pref QL THROAT PRODUCTS - MISC. pilocarpine hcl tab 5 mg (generic of Pref SALAGEN) pilocarpine hcl tab 7.5 mg (generic of Pref SALAGEN) MULTIVITAMINS - DRUGS FOR NUTRITION B-COMPLEX VITAMINS APETEX ELX Pref OTC APETIGEN ELX Pref OTC B-COMPLEX INJ Pref b-complex inj 100 Pref B-COMPLEX INJ HYDRXCB Pref b-complex vitamin cap Pref OTC b-complex vitamin tab Pref OTC biopetit elx Pref OTC brewers yeast tab Pref OTC B-COMPLEX W/ C b-complex w/ c cap Pref OTC b-complex w/ c tab Pref OTC stress b com tab vit c/zn Pref OTC stress form/ tab zinc Pref OTC super b comp tab vit c Pref OTC B-COMPLEX W/ FOLIC ACID b-100 tr tab Pref OTC b-complex w/ c & folic acid cap 1 mg Pref OTC b-complex w/ c & folic acid cap 1 mg- rx Pref b-complex w/ c & folic acid tab Pref OTC b-complex w/ c & folic acid tab 0.8 mg Pref OTC b-complex w/ c & folic acid tab 1 mg Pref OTC b-complex w/ c & folic acid tab 1 mg- rx Pref b-complex w/ c & folic acid tab 5 mg- rx Pref DIALYVIT 800 TAB ZINC 15 Pref OTC DIALYVITE TAB 800/IRON Pref OTC DIALYVITE TAB 800/ZINC Pref OTC DIALYVITE TAB 3000 Pref DIALYVITE TAB 5000 Pref DIALYVITE WAF PLUS D Pref OTC DIALYVITE/ TAB ZINC Pref folbee plus tab cz Pref kobee tab Pref OTC NEPHPLEX RX TAB Pref NEPHRO-VITE TAB Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 136 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits NEPHROCAPS CAP Pref NEPHRONEX LIQ 0.9/5ML Pref OTC NUTRIVIT LIQ 800-15-1 Pref quin b stron tab b-25 Pref OTC SM B-COMPLEX TAB /VIT C Pref OTC sm balanced tab b-50 Pref OTC sm balanced tab b-100 Pref OTC super dec tab b-100 Pref OTC super quints tab Pref OTC SUPERVITE LIQ Pref VITAL-D RX TAB Pref WEST-VITE TAB W/FA Pref OTC B-COMPLEX W/ IRON APETIGEN-PLS SOL Pref OTC B-COMPLEX W/ MINERALS eldertonic liq Pref OTC GLYCO-TECH TAB Pref OTC IRON W/ VITAMINS geritol tab complete Pref OTC s.s.s. tonic tab Pref OTC vitafol tab Pref MULTIPLE VITAMINS W/ CALCIUM HM ONE DAILY TAB ESSENTIA Pref OTC one daily tab womens Pref OTC MULTIPLE VITAMINS W/ IRON multiple vitamins w/ iron tab Pref OTC MULTIPLE VITAMINS W/ MINERALS a thru z chw select Pref OTC ACTIVE 55 LIQ PLUS Pref QL, OTC ACTIVNUTRIEN CAP Pref OTC adlt multivi chw gummies Pref OTC ADLT ONE DLY CHW GUMMIES Pref OTC ADULT 50+ CAP EYE HLTH Pref OTC ADULT 50+ CAP OCUVITE Pref OTC adult gummy chw Pref OTC advanced chw multi ea Pref OTC airborne chw Pref OTC AIRBORNE CHW Pref OTC airborne chw gummies Pref OTC airborne chw immune Pref OTC airborne chw kids Pref OTC AIRBORNE CHW KIDS Pref OTC AIRBORNE+ CHW PROBIOTI Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 137 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits AIRBORNE+ CHW REST Pref OTC airshield chw Pref OTC AIRSHIELD CHW IMMUNITY Pref OTC ALGAE BASED TAB CALCIUM Pref OTC ALIVE MULTI CHW VITAMIN Pref OTC ALIVE WOMENS CHW 50+ Pref OTC ALIVE WOMENS CHW GUMMY Pref OTC AQUADEKS CHW Pref OTC BACMIN TAB Pref BARIATRIC CAP MULTIVIT Pref OTC BARIATRIC CHW FUSION Pref OTC berocca tab Pref OTC BIO-35 GLUTE CAP FREE Pref OTC BIO-35 IRON CAP FREE Pref OTC BIOCAL CAP Pref OTC CELEBRATE CAP 18 Pref OTC CELEBRATE CAP 36 Pref OTC CELEBRATE CAP 45 Pref OTC CELEBRATE CAP 60 Pref OTC CELEBRATE CHW 18 Pref OTC CELEBRATE CHW 36 Pref OTC CELEBRATE CHW 45 Pref OTC CELEBRATE CHW 60 Pref OTC CENTRUM 50+ CHW FRSH/FRU Pref OTC CENTRUM CHW Pref OTC CENTRUM CHW FLAV BST Pref OTC CENTRUM CHW SILVER Pref OTC CENTRUM CHW VITAMINT Pref OTC CENTRUM MULT CHW OMEGA 3 Pref OTC CENTRUM POW DRINK Pref OTC CENTRUM SILV TAB 50+MEN Pref OTC CENTRUM SILV TAB 50+WOMEN Pref OTC CENTRUM SILV TAB ADULT 50 Pref OTC CENTRUM SPEC TAB HEART Pref OTC CENTRUM SPEC TAB IMMUNE Pref OTC CENTRUM SPEC TAB VISION Pref OTC CENTRUM TAB ADULTS Pref OTC CENTRUM TAB CARDIO Pref OTC CENTRUM TAB MEN Pref OTC CENTRUM TAB SILVER Pref OTC CENTRUM TAB ULTRA Pref OTC CENTRUM TAB WOMEN Pref OTC CERTAVITE TAB SENIOR Pref OTC CHOICEFUL CAP MULTIVIT Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 138 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits CHOICEFUL CHW MULTIVIT Pref OTC corvita tab Pref CULTURELLE CHW MULTIVIT Pref OTC cvs daily chw gummies Pref OTC CVS VISION CAP HEALTH Pref OTC DECUBI-VITE CAP Pref OTC DEKAS CHW BARIATRI Pref OTC DEKAS PLUS CAP Pref OTC DEKAS PLUS CHW Pref OTC DERMAVITE TAB Pref OTC DIALYVITE TAB SUPREM D Pref EMERGEN-C CHW IMMUNE/D Pref OTC EMERGEN-C CHW VITA C Pref OTC ENDUR-VM TAB Pref OTC EVOLUTION60 POW Pref OTC EYE HEALTH CAP Pref OTC EYE HEALTH CAP ADLT 50+ Pref OTC FOSFREE TAB Pref OTC FREEDAVITE TAB Pref OTC GENADEK CAP STEP 1 Pref OTC GENADEK CAP STEP 2 Pref OTC GERI-FREEDA TAB SENIOR Pref OTC HAIR/SKIN/ CAP NAILS Pref OTC hm multivit chw gummy Pref OTC ICAPS AREDS TAB FORMULA Pref OTC IMMUNE CHW SUPPORT Pref OTC K-PAX CAP DOUBLE Pref OTC K-PAX CAP SINGLE Pref OTC MEGA MULTIVI TAB MEN Pref OTC MEGA MULTIVI TAB WOMEN Pref OTC MENS 50+ CAP ADVANCED Pref OTC mens daily chw gummies Pref OTC MENS MULTI CHW Pref OTC MULTI ADULT CHW EXTRA C Pref OTC multi adult chw gummies Pref OTC multi gummie chw mens Pref OTC multi gummie chw womens Pref OTC multi+omega3 chw adult Pref OTC multi-vitami chw gummies Pref OTC MULTI-VITAMI TAB MONOCAPS Pref OTC MULTI-VITE LIQ Pref QL, OTC multiple vitamins w/ minerals cap Pref OTC multiple vitamins w/ minerals cap- rx Pref multiple vitamins w/ minerals liquid Pref QL, OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 139 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits multiple vitamins w/ minerals tab Pref OTC multiple vitamins w/ minerals tab- rx Pref multivi adlt chw gummies Pref OTC MULTIVITAMIN CHW ADLT GUM Pref OTC multivitamin chw vita d3 Pref OTC MVW COMPLETE CAP D3000 Pref OTC MVW COMPLETE CAP D5000 Pref OTC MVW COMPLETE CAP FORMULAT Pref OTC MVW COMPLETE CAP MINIS Pref OTC NUTRICAP TAB Pref NUTRIENTS CAP ANTIOXID Pref OTC OCUHEALTH CAP VISION 2 Pref OTC OCUVITE CAP ADULT Pref OTC ocuvite eye chw heatlh Pref OTC OCUVITE LUTE CAP Pref OTC ONCOVITE TAB Pref OTC ONE DAILY CHW ADLT GUM Pref OTC ONE-A-DAY CHW IMMUNITY Pref OTC ONE-A-DAY CHW VITACRAV Pref OTC ONE-DAILY CAP MULTI Pref OTC OPTIMUM CHW AIRVITES Pref OTC OPTISOURCE CHW BARIATRC Pref OTC OPURITY CHW BYPASS Pref OTC PA WOMENS PAK VITAPAK Pref OTC PARVLEX TAB Pref OTC PORENAL+D CAP OMEGA 3 Pref OTC PRESERVISION CAP AREDS Pref OTC PRESERVISION CAP AREDS 2 Pref OTC PRESERVISION CAP LUTEIN Pref OTC PRESERVISION CHW AREDS 2 Pref OTC PRESERVISION TAB AREDS Pref OTC PRORENAL +D TAB Pref OTC PRORENAL+D CAP OMEGA-3 Pref OTC PRORENAL+D TAB Pref OTC PROTECT CAP CARDIO Pref OTC PROTECT CAP PLUS SO Pref OTC PROTEGRA CAP Pref OTC QUIN B TAB STRONG Pref OTC QUINTABS-M TAB Pref OTC RENAPLEX-D TAB Pref OTC REQ 49+ TAB Pref SAVISION CAP Pref OTC SPECTRAVITE CHW ADLT 50+ Pref OTC SPECTRAVITE CHW WOMEN Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 140 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits SUPER ANTIOX CAP Pref OTC SUPPORT LIQ Pref QL SYSTANE ICAP CHW AREDS2 Pref OTC SYSTANE ICAP TAB AREDS2 Pref OTC T-VITES TAB Pref OTC THERA M PLUS TAB Pref OTC THERA-M TAB Pref OTC THERAMILL CAP FORTE Pref OTC THERANATAL CAP LACTATIO Pref OTC THEREMS-M TAB Pref OTC ultra-mega tab cr Pref OTC VENEXA FE TAB Pref VISTA ADVAN CAP AREDS2 Pref OTC VISTA ADVAN CAP DRY EYE Pref OTC VITABEX CAP Pref OTC VITABEX PLUS CAP Pref OTC VITACRAVES CHW GUMMIES Pref OTC VITACRAVES CHW IMMUNITY Pref OTC VITACRAVES CHW MENS Pref OTC VITACRAVES CHW SOUR GUM Pref OTC VITACRAVES CHW WOMENS Pref OTC VITAROCA PLU TAB Pref vitatrum chw Pref OTC VITEYES CAP CLASSIC Pref OTC VITEYES CLAS CAP ADV Pref OTC viteyes clas cap advanced Pref OTC VITEYES CLAS CAP MAC SUPP Pref OTC VITEYES CLAS CAP OMEGA-3 Pref OTC WAL-BORN CHW VIT C Pref OTC WMNS MULTIVI CHW +COLLAGE Pref OTC womens daily chw gummies Pref OTC WOMENS MULT CHW GUMMIES Pref OTC YELETS TEEN TAB FORMULA Pref OTC YOUR LIFE CHW GUMMIES Pref OTC YOUR LIFE CHW MULTIVIT Pref OTC ZINTREXYL-C TAB Pref MULTIPLE VITAMINS W/ MINERALS & CALCIUM-FOLIC ACID FOLGARD OS TAB Pref MULTIVITAMINS - DRUGS FOR NUTRITION multiple vitamin tab Pref OTC ONE-A-DAY TAB ESSENT Pref OTC QUINTABS TAB Pref OTC THERA TAB Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 141 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits PED MULTI VITAMINS W/FL & FE pediatric multiple vitamins w/ fl-fe drops Pref QL, AGE 0.25-10 mg/ml PED MULTIPLE VITAMINS W/ MINERALS aquadeks dro Pref OTC CENTRUM KIDS CHW Pref OTC CENTRUM KIDS CHW FLAV BST Pref OTC FLINTSTONES CHW TODDLER Pref OTC HEALTHY KIDS CHW GUMMIES Pref OTC KIDZ MULTVIT CHW PROBIOTI Pref OTC MVW COMPLETE CHW GRAPE Pref OTC MVW COMPLETE DRO PEDIATRI Pref OTC NF FORMULAS CHW CHILDREN Pref OTC pediatric multiple vitamin w/ minerals & c Pref OTC chew tab VITALETS CHW CHILD Pref OTC ZOO FRIENDS CHW COMPLETE Pref OTC PED MV W/ FLUORIDE FLORIVA DRO PLUS Pref QL, AGE pediatric multiple vitamins w/ fluoride Pref QL, AGE chew tab 0.5 mg pediatric multiple vitamins w/ fluoride Pref QL, AGE chew tab 0.25 mg pediatric multiple vitamins w/ fluoride Pref QL, AGE chew tab 1 mg pediatric multiple vitamins w/ fluoride soln Pref QL, AGE 0.5 mg/ml pediatric multiple vitamins w/ fluoride soln Pref QL, AGE 0.25 mg/ml pediatric vitamins acd w/ fluoride soln 0.5 Pref QL, AGE mg/ml pediatric vitamins acd w/ fluoride soln 0.25 Pref QL, AGE mg/ml QUFLORA PED CHW 0.5MG Pref QL, AGE QUFLORA PED CHW 0.25MG Pref QL, AGE QUFLORA PED CHW 1MG Pref QL, AGE QUFLORA PED DRO 0.5MG/ML Pref QL, AGE QUFLORA PED DRO 0.25MG Pref QL, AGE TRI-VI-FLOR SUS 0.5MG/ML Pref TRI-VI-FLOR SUS 0.25/ML Pref PED MV W/ IRON pediatric multiple vitamins w/ iron chew Pref QL, OTC tab 15 mg

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 142 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits PEDIATRIC MULTIPLE VITAMINS CULTURELLE CHW Pref OTC novamv ped dro 10mg/ml Pref QL, OTC pediatric multiple vitamin w/ c & fa chew Pref OTC tab pediatric multiple vitamin w/ extra c & fa Pref QL, OTC chew tab POLY-VI-SOL SOL 50MG/ML Pref OTC poly-vita dro Pref OTC poly-vite dro Pref OTC POLY-VITE SOL 50MG/ML Pref OTC VITACRAVES CHW +OMEGA-3 Pref OTC PEDIATRIC VITAMINS bprotected sol tri-vite Pref OTC tri-vite dro pediatri Pref OTC PRENATAL VITAMINS CO-NATAL FA TAB 29-1MG Pref QL, AGE COMPLETENATE CHW Pref QL, AGE MYNATAL-Z TAB Pref QL, AGE NESTABS DHA PAK Pref QL, AGE NESTABS TAB Pref QL, AGE PNV TABS TAB 29-1MG Pref QL, AGE PRENATABS FA TAB 29-1MG Pref QL, AGE, OTC prenatal vit w/ dss-iron carbonyl-fa tab 90- Pref QL, AGE 1 mg- rx prenatal vit w/ fe fumarate-fa chew tab 29- Pref QL, AGE 1 mg- rx PRENATAL VIT W/ FE FUMARATE-FA TAB Pref QL, AGE, OTC 27-0.8 MG PRENATAL VIT W/ FE FUMARATE-FA TAB Pref QL, AGE 27-1 MG- RX PRENATAL VIT W/ FE FUMARATE-FA TAB Pref QL, AGE, OTC 28-0.8 MG prenatal vit w/ iron carbonyl-fa tab 29-1 Pref QL, AGE mg PRENATAL-U CAP 106.5-1 Pref QL, AGE PRETAB TAB 29-1MG Pref QL, AGE SE-NATAL 19 CHW Pref QL, AGE SE-NATAL 19 TAB Pref QL, AGE THRIVITE RX TAB 29-1MG Pref QL, AGE TRINATAL RX TAB 1 Pref QL, AGE trinate tab Pref QL, AGE VINATE II TAB Pref QL, AGE VINATE ONE TAB Pref QL, AGE

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 143 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits SPECIALTY VITAMINS PRODUCTS CENTRUM SPEC TAB ENERGY Pref OTC CENTRUM TAB PERFORMA Pref OTC GNP CENTURY TAB ENERGY Pref OTC SUPPORT-500 CAP Pref ULTRA MAN TAB Pref OTC urosex tab Pref VITAMIN MIXTURES ECEE PLUS TAB Pref OTC niacin cap 400mg Pref OTC niacinamide w/ zn-cu-methylfol-se-cr tab Pref 750-27-2-0.5 mg NICOMIDE TAB Pref VITAMINS W/ LIPOTROPICS ACTIFLOVIT TAB EAR HEAL Pref OTC b-100 comp tab tr Pref OTC lipoflavovit tab Pref OTC methacholine cap /liver Pref OTC risanoid tab plus Pref OTC MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS CENTRAL MUSCLE RELAXANTS AMRIX CAP 15MG Non-Pref PA AMRIX CAP 30MG Non-Pref PA baclofen tab 5 mg Pref baclofen tab 10 mg Pref baclofen tab 20 mg Pref CHLORZOXAZON TAB 250MG Pref chlorzoxazone tab 375 mg Pref chlorzoxazone tab 500 mg Pref chlorzoxazone tab 750 mg Pref cyclobenzaprine hcl cap er 24hr 15 mg Non-Pref PA (generic of AMRIX) cyclobenzaprine hcl cap er 24hr 30 mg Non-Pref PA (generic of AMRIX) cyclobenzaprine hcl tab 5 mg Pref cyclobenzaprine hcl tab 7.5 mg Pref cyclobenzaprine hcl tab 10 mg Pref fexmid tab 7.5mg Non-Pref PA lorzone tab 375mg Pref lorzone tab 750mg Pref metaxalone tab 400 mg Non-Pref PA metaxalone tab 800 mg (generic of Non-Pref PA SKELAXIN)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 144 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits methocarbamol tab 500 mg Pref methocarbamol tab 750 mg Pref orphenadrine citrate tab er 12hr 100 mg Pref SKELAXIN TAB 800MG Non-Pref PA tizanidine hcl cap 2 mg (base equivalent) Non-Pref PA (generic of ZANAFLEX) tizanidine hcl cap 4 mg (base equivalent) Non-Pref PA (generic of ZANAFLEX) tizanidine hcl cap 6 mg (base equivalent) Non-Pref PA (generic of ZANAFLEX) tizanidine hcl tab 2 mg (base equivalent) Pref tizanidine hcl tab 4 mg (base equivalent) Pref (generic of ZANAFLEX) ZANAFLEX CAP 2MG Non-Pref PA ZANAFLEX CAP 4MG Non-Pref PA ZANAFLEX CAP 6MG Non-Pref PA ZANAFLEX TAB 4MG Non-Pref PA DIRECT MUSCLE RELAXANTS DANTRIUM CAP 25MG Non-Pref PA DANTRIUM CAP 50MG Non-Pref PA dantrolene sodium cap 25 mg (generic of Non-Pref PA DANTRIUM) dantrolene sodium cap 50 mg (generic of Non-Pref PA DANTRIUM) dantrolene sodium cap 100 mg Non-Pref PA MUSCLE RELAXANT COMBINATIONS NORGESIC TAB FORTE Non-Pref PA orphengesic tab forte (generic of Non-Pref PA NORGESIC FORTE) VISCOSUPPLEMENTS HYALGAN INJ 20MG/2ML Pref PA NASAL AGENTS - SYSTEMIC AND TOPICAL - DRUGS FOR THE NOSE NASAL AGENT COMBINATIONS azelastine hcl-fluticasone prop nasal spray Non-Pref PA 137-50 mcg/act (generic of DYMISTA) DYMISTA SPR 137-50 Non-Pref PA NASAL AGENTS - MISC. OCEAN NASAL SPR 0.65% Pref OTC saline nasal spray 0.65% Pref OTC NASAL ANTIALLERGY azelastine hcl nasal spray 0.1% (137 Pref mcg/spray) azelastine hcl nasal spray 0.15% (205.5 Pref mcg/spray)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 145 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits cromolyn sodium nasal aerosol soln 5.2 Pref OTC mg/act (4%) NASALCROM SPR 5.2/ACT Pref OTC olopatadine hcl nasal soln 0.6% (generic of Non-Pref PA PATANASE) PATANASE SPR 0.6% Non-Pref PA NASAL ANTICHOLINERGICS ipratropium bromide nasal soln 0.03% (21 Pref mcg/spray) ipratropium bromide nasal soln 0.06% (42 Pref mcg/spray) NASAL STEROIDS BECONASE AQ SUS 0.042% Non-Pref PA budesonide sus 32mcg Non-Pref PA, OTC FLONASE ALGY SPR 50MCG Non-Pref PA, OTC FLONASE SENS SUS 27.5MCG Non-Pref PA, OTC flunisolide nasal soln 25 mcg/act (0.025%) Non-Pref PA fluticasone propionate nasal susp 50 Pref mcg/act fluticasone propionate nasal susp 50 Non-Pref PA, OTC mcg/act mometasone furoate nasal susp 50 Non-Pref PA mcg/act (generic of NASONEX) NASONEX SPR 50MCG/AC Non-Pref PA OMNARIS SPR Non-Pref PA QNASL AER 80MCG Non-Pref PA QNASL CHILD SPR 40MCG Non-Pref PA triamcinolone acetonide nasal aerosol Non-Pref PA, OTC suspension 55 mcg/act XHANCE MIS 93MCG Non-Pref PA ZETONNA AER 37MCG Non-Pref PA NUTRIENTS - DRUGS FOR NUTRITION MISC. NUTRITIONAL SUBSTANCES ALBA-LYBE NR LIQ Pref OTC docosahexaenoic acid cap 200 mg Pref OTC FISH OIL CAP 150MG Pref OTC FISH OIL CAP 180MG Pref OTC fish oil cap 300mg Pref OTC fish oil cap 435mg Pref OTC KELP/LEC/B6 CAP Pref OTC MINICAPS OMG CAP -3 350MG Pref OTC OMEGA-3 CAP 1400MG Pref OTC omega-3 conc cap 600mg Pref OTC omega-3 fatty acids cap 500 mg Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 146 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits omega-3 fatty acids cap 1000 mg Pref OTC omega-3 fatty acids cap 1200 mg Pref OTC omega-3 fatty acids cap delayed release Pref OTC 1000 mg omega-3 fatty acids cap delayed release Pref OTC 1200 mg PRO NUTRIENT CAP OMEGA3 Pref OTC SUPER TWIN CAP EPA/DHA Pref OTC OPHTHALMIC AGENTS - DRUGS TO TREAT EYE CONDITIONS ARTIFICIAL TEARS AND LUBRICANTS artificial tear ophth solution Pref OTC carboxymethylcellulose sodium (pf) ophth Pref OTC soln 0.5% carboxymethylcellulose sodium ophth soln Pref OTC 0.5% dextran 70-hypromellose ophth soln 0.1- Pref OTC 0.3% GENTEAL TEAR GEL SEV D/N Pref OTC lubricnt gel dro 1% Pref OTC MOISTURE EYE DRO Pref OTC polyethylene glycol-propylene glycol ophth Pref OTC soln 0.4-0.3% polyvinyl alcohol ophth soln 1.4% Pref OTC propylene glycol-glycerin ophth soln 1- Pref OTC 0.3% refresh cell gel 1% op Pref OTC REFRESH TEAR DRO 0.5% OP Pref OTC SYSTANE GEL DRO 0.4-0.3% Pref OTC SYSTANE SOL Pref OTC SYSTANE ULTR SOL Pref OTC white petrolatum-mineral oil ophth Pref OTC ointment BETA-BLOCKERS - OPHTHALMIC betaxolol hcl ophth soln 0.5% Non-Pref PA BETOPTIC-S SUS 0.25% OP Pref carteolol hcl ophth soln 1% Pref COMBIGAN SOL 0.2/0.5% Pref COSOPT PF SOL 2%-0.5% Non-Pref PA COSOPT SOL 22.3-6.8 Non-Pref PA dorzolamide hcl-timolol maleate ophth soln Pref 22.3-6.8 mg/ml (generic of COSOPT) ISTALOL SOL 0.5% OP Non-Pref PA levobunolol hcl ophth soln 0.5% Non-Pref PA timolol maleate ophth gel forming soln Pref 0.5% (generic of TIMOPTIC-XE)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 147 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits timolol maleate ophth gel forming soln Pref 0.25% (generic of TIMOPTIC-XE) timolol maleate ophth soln 0.5% (generic Pref of TIMOPTIC) timolol maleate ophth soln 0.5% (once- Non-Pref PA daily) (generic of ISTALOL) timolol maleate ophth soln 0.25% (generic Pref of TIMOPTIC) timolol maleate preservative free ophth Non-Pref PA soln 0.5% (generic of TIMOPTIC OCUDOSE) TIMOPTIC OCU SOL 0.5% OP Non-Pref PA TIMOPTIC OCU SOL 0.25% OP Non-Pref PA TIMOPTIC SOL 0.5% OP Non-Pref PA TIMOPTIC SOL 0.25% OP Non-Pref PA TIMOPTIC-XE SOL 0.5% OP Non-Pref PA TIMOPTIC-XE SOL 0.25% OP Non-Pref PA CYCLOPLEGIC MYDRIATICS ATROPINE SUL SOL 1% OP Pref ATROPINE SULFATE OPHTH OINT 1% Pref cyclopentolate hcl ophth soln 1% (generic Pref of CYCLOGYL) cyclopentolate hcl ophth soln 2% Pref homatropaire sol 5% op Pref ISOPTO ATROP SOL 1% OP Pref phenylephrine hcl ophth soln 2.5% Pref tropicamide ophth soln 0.5% Pref tropicamide ophth soln 1% (generic of Pref MYDRIACYL) MIOTICS pilocarpine hcl ophth soln 1% (generic of Pref ISOPTO CARPINE) pilocarpine hcl ophth soln 2% (generic of Pref ISOPTO CARPINE) pilocarpine hcl ophth soln 4% (generic of Pref ISOPTO CARPINE) OPHTHALMIC ADRENERGIC AGENTS ALPHAGAN P SOL 0.1% Non-Pref PA ALPHAGAN P SOL 0.15% Non-Pref PA apraclonidine hcl ophth soln 0.5% (base Pref equivalent) brimonidine tartrate ophth soln 0.2% Pref brimonidine tartrate ophth soln 0.15% Non-Pref PA (generic of ALPHAGAN P) IOPIDINE SOL 1% OP Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 148 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits SIMBRINZA SUS 1-0.2% Pref OPHTHALMIC ANTI-INFECTIVES AZASITE SOL 1% Non-Pref PA bacitracin ophth oint 500 unit/gm Pref bacitracin-polymyxin b ophth oint Pref BESIVANCE SUS 0.6% Non-Pref PA CILOXAN OIN 0.3% OP Non-Pref PA CILOXAN SOL 0.3% OP Non-Pref PA ciprofloxacin hcl ophth soln 0.3% (base Pref equivalent) (generic of CILOXAN) erythromycin ophth oint 5 mg/gm Pref gatifloxacin ophth soln 0.5% (generic of Non-Pref PA ZYMAXID) gentak oin 0.3% op Pref gentamicin sulfate ophth soln 0.3% Pref levofloxacin ophth soln 0.5% Non-Pref PA MOXEZA SOL 0.5% Non-Pref PA moxifloxacin hcl ophth soln 0.5% (base eq) Non-Pref PA (2 times daily) (generic of MOXEZA) moxifloxacin hcl ophth soln 0.5% (base Pref equiv) (generic of VIGAMOX) neo-polycin oin op Pref neomycin-bacitrac zn-polymyx 5(3.5)mg- Pref 400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.75- Pref 10000-0.025mg-unt-mg/ml OCUFLOX DRO 0.3% OP Non-Pref PA ofloxacin ophth soln 0.3% (generic of Pref OCUFLOX) polymyxin b-trimethoprim ophth soln Pref 10000 unit/ml-0.1% (generic of POLYTRIM) sulfacetamide sodium ophth oint 10% Pref sulfacetamide sodium ophth soln 10% Pref (generic of BLEPH-10) tobramycin ophth soln 0.3% (generic of Pref TOBREX) trifluridine ophth soln 1% Pref QL VIGAMOX DRO 0.5% Pref ZYMAXID SOL 0.5% Non-Pref PA OPHTHALMIC DECONGESTANTS allergy eye dro Pref OTC; (Generic of Naphcon-A) eye allergy sol relief Pref OTC; (Generic of Opcon- A)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 149 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits NAPHCON-A SOL OP Pref OTC OPCON-A SOL OP Pref OTC OPHTHALMIC IMMUNOMODULATORS RESTASIS EMU 0.05% Pref PA, QL, AGE RESTASIS MUL EMU 0.05% Pref PA, QL, AGE OPHTHALMIC KINASE INHIBITORS RHOPRESSA SOL 0.02% Pref ROCKLATAN DRO Pref OPHTHALMIC LOCAL ANESTHETICS proparacaine hcl ophth soln 0.5% (generic Pref of ALCAINE) OPHTHALMIC NERVE GROWTH FACTORS OXERVATE SOL 20MCG/ML Pref SP, PA, QL, AGE OPHTHALMIC STEROIDS ALREX SUS 0.2% Non-Pref PA bacitracin-polymyxin-neomycin-hc ophth Pref oint 1% dexamethasone sodium phosphate ophth Pref soln 0.1% EYSUVIS DRO 0.25% Pref PA, QL, AGE fluorometholone ophth susp 0.1% Pref QL neo-polycin oin hc 1%op Pref neomycin-polymyxin-dexamethasone Pref ophth oint 0.1% (generic of MAXITROL) neomycin-polymyxin-dexamethasone Pref ophth susp 0.1% (generic of MAXITROL) PRED SOD PHO SOL 1% OP Pref prednisolone acetate ophth susp 1% Pref (generic of PRED FORTE) PREDNISOLONE SUS 1% Pref sulfacetamide sodium-prednisolone ophth Pref soln 10-0.23(0.25)% tobramycin-dexamethasone ophth susp Pref 0.3-0.1% (generic of TOBRADEX) OPHTHALMICS - MISC. ACULAR LS SOL 0.4% Non-Pref PA ACULAR SOL 0.5% OP Non-Pref PA ACUVAIL SOL 0.45% Non-Pref PA ALOCRIL SOL 2% Non-Pref PA ALOMIDE SOL 0.1% OP Non-Pref PA azelastine hcl ophth soln 0.05% Pref AZOPT SUS 1% OP Pref bepotastine besilate ophth soln 1.5% Non-Pref PA (generic of BEPREVE)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 150 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits BEPREVE DRO 1.5% Non-Pref PA brinzolamide ophth susp 1% (generic of Non-Pref PA AZOPT) bromfenac sodium ophth soln 0.09% (base Non-Pref PA equiv) (once-daily) BROMSITE DRO 0.075% Non-Pref PA cromolyn sodium ophth soln 4% Pref diclofenac sodium ophth soln 0.1% Pref dorzolamide hcl ophth soln 2% (generic of Pref TRUSOPT) epinastine hcl ophth soln 0.05% Non-Pref PA flurbiprofen sodium ophth soln 0.03% Pref ILEVRO DRO 0.3% OP Non-Pref PA ketorolac tromethamine ophth soln 0.5% Pref (generic of ACULAR) ketotifen fumarate ophth soln 0.025% Pref OTC (base equiv) LASTACAFT SOL 0.25% Non-Pref PA NEVANAC SUS 0.1% Non-Pref PA olopatadine hcl ophth soln 0.1% (base Pref equivalent) olopatadine hcl ophth soln 0.2% (base Pref equivalent) PATADAY SOL 0.1% Non-Pref PA, OTC PATADAY SOL 0.2% Non-Pref PA, OTC PATADAY SOL 0.7% Non-Pref PA, OTC PROLENSA SOL 0.07% Non-Pref PA sod chloride oin 5% op Pref OTC sodium chloride hypertonic ophth soln 5% Pref OTC TRUSOPT SOL 2% OP Non-Pref PA ZADITOR DRO 0.025%OP Pref OTC ZERVIATE DRO 0.24% Non-Pref PA PROSTAGLANDINS - OPHTHALMIC bimatoprost ophth soln 0.03% Non-Pref PA latanoprost ophth soln 0.005% (generic of Pref XALATAN) LUMIGAN SOL 0.01% Non-Pref PA travoprost ophth soln 0.004% Non-Pref PA (benzalkonium free) (bak free) (generic of TRAVATAN Z) VYZULTA SOL 0.024% Non-Pref PA XALATAN SOL 0.005% Non-Pref PA XELPROS EMU 0.005% Non-Pref PA ZIOPTAN DRO 0.0015% Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 151 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits OTIC AGENTS - DRUGS TO TREAT CONDITIONS OF THE EAR OTIC AGENTS - MISCELLANEOUS acetic acid otic soln 2% Pref OTIC ANTI-INFECTIVES ciprofloxacin hcl otic soln 0.2% (base Non-Pref PA equivalent) ofloxacin otic soln 0.3% Pref OTIC COMBINATIONS CIPRO HC SUS OTIC Non-Pref PA CIPRODEX SUS 0.3-0.1% Pref ciprofloxacin-dexamethasone otic susp 0.3- Non-Pref PA 0.1% (generic of CIPRODEX) ciprofloxacin-fluocinolone aceton (pf) otic Non-Pref PA soln 0.3-0.025% neomycin-polymyxin-hc otic soln 1% Pref neomycin-polymyxin-hc otic susp 3.5 Pref mg/ml-10000 unit/ml-1% OTOVEL DRO Non-Pref PA OTIC STEROIDS hydrocortisone w/ acetic acid otic soln 1- Pref 2% OXYTOCICS - DRUGS FOR PREGNANCY OXYTOCICS - DRUGS FOR PREGNANCY methergine tab 0.2mg Pref QL, AGE methylergonovine maleate tab 0.2 mg Pref QL, AGE PASSIVE IMMUNIZING AND TREATMENT AGENTS - DRUGS FOR IMMUNE SYSTEM CONDITIONS MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG Pref SP, PA SYNAGIS INJ 100MG/ML Pref SP, PA PENICILLINS - DRUGS TO TREAT INFECTIONS AMINOPENICILLINS amoxicillin (trihydrate) cap 250 mg Pref amoxicillin (trihydrate) cap 500 mg Pref amoxicillin (trihydrate) chew tab 125 mg Pref amoxicillin (trihydrate) chew tab 250 mg Pref amoxicillin (trihydrate) for susp 125 Pref mg/5ml amoxicillin (trihydrate) for susp 200 Pref mg/5ml amoxicillin (trihydrate) for susp 250 Pref mg/5ml

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 152 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits amoxicillin (trihydrate) for susp 400 Pref mg/5ml amoxicillin (trihydrate) tab 500 mg Pref amoxicillin (trihydrate) tab 875 mg Pref ampicillin cap 500 mg Pref NATURAL PENICILLINS penicillin v potassium for soln 125 mg/5ml Pref penicillin v potassium for soln 250 mg/5ml Pref penicillin v potassium tab 250 mg Pref penicillin v potassium tab 500 mg Pref PENICILLIN COMBINATIONS amoxicillin & k clavulanate chew tab 200- Pref 28.5 mg amoxicillin & k clavulanate chew tab 400- Pref 57 mg amoxicillin & k clavulanate for susp 200- Pref 28.5 mg/5ml amoxicillin & k clavulanate for susp 250- Pref 62.5 mg/5ml (generic of AUGMENTIN) amoxicillin & k clavulanate for susp 400-57 Pref mg/5ml amoxicillin & k clavulanate for susp 600- Pref 42.9 mg/5ml (generic of AUGMENTIN ES- 600) amoxicillin & k clavulanate tab 250-125 mg Pref amoxicillin & k clavulanate tab 500-125 mg Pref (generic of AUGMENTIN) amoxicillin & k clavulanate tab 875-125 mg Pref PENICILLINASE-RESISTANT PENICILLINS dicloxacillin sodium cap 250 mg Pref dicloxacillin sodium cap 500 mg Pref PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES AYGESTIN TAB 5MG Non-Pref PA hydroxyprogesterone caproate im in oil Pref SP, PA; Max Approval 21 250 mg/ml (generic of MAKENA) weeks MAKENA INJ 250MG/ML Non-Pref SP, PA; Max Approval 21 weeks MAKENA INJ 275MG Non-Pref SP, PA; Max Approval 21 weeks medroxyprogesterone acetate tab 2.5 mg Pref (generic of PROVERA) medroxyprogesterone acetate tab 5 mg Pref (generic of PROVERA)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 153 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits medroxyprogesterone acetate tab 10 mg Pref (generic of PROVERA) megestrol acetate susp 625 mg/5ml Non-Pref PA norethindrone acetate tab 5 mg (generic of Pref AYGESTIN) progesterone cap 100 mg (generic of Pref PROMETRIUM) progesterone cap 200 mg (generic of Pref PROMETRIUM) progesterone im in oil 50 mg/ml Non-Pref PA PROMETRIUM CAP 100MG Non-Pref PA PROMETRIUM CAP 200MG Non-Pref PA PROVERA TAB 2.5MG Non-Pref PA PROVERA TAB 5MG Non-Pref PA PROVERA TAB 10MG Non-Pref PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS AGENTS FOR CHEMICAL DEPENDENCY LUCEMYRA TAB 0.18MG Non-Pref PA, QL, AGE; Max 14 days ANTI-CATAPLECTIC AGENTS XYREM SOL 500MG/ML Pref SP, PA, QL, AGE XYWAV SOL 0.5GM/ML Pref SP, PA, AGE ANTIDEMENTIA AGENTS ARICEPT TAB 5MG Non-Pref PA ARICEPT TAB 10MG Non-Pref PA ARICEPT TAB 23MG Non-Pref PA donepezil hydrochloride orally Pref disintegrating tab 5 mg donepezil hydrochloride orally Pref disintegrating tab 10 mg donepezil hydrochloride tab 5 mg (generic Pref of ARICEPT) donepezil hydrochloride tab 10 mg (generic Pref of ARICEPT) donepezil hydrochloride tab 23 mg (generic Non-Pref PA of ARICEPT) EXELON DIS 4.6MG/24 Pref EXELON DIS 9.5MG/24 Pref EXELON DIS 13.3/24 Pref galantamine hydrobromide cap er 24hr 8 Non-Pref PA mg (generic of RAZADYNE ER) galantamine hydrobromide cap er 24hr 16 Non-Pref PA mg (generic of RAZADYNE ER)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 154 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits galantamine hydrobromide cap er 24hr 24 Non-Pref PA mg (generic of RAZADYNE ER) galantamine hydrobromide oral soln 4 Non-Pref PA mg/ml galantamine hydrobromide tab 4 mg Pref galantamine hydrobromide tab 8 mg Pref galantamine hydrobromide tab 12 mg Pref memantine hcl cap er 24hr 7 mg (generic Non-Pref PA of NAMENDA XR) memantine hcl cap er 24hr 14 mg (generic Non-Pref PA of NAMENDA XR) memantine hcl cap er 24hr 21 mg (generic Non-Pref PA of NAMENDA XR) memantine hcl cap er 24hr 28 mg (generic Non-Pref PA of NAMENDA XR) memantine hcl oral solution 2 mg/ml Pref memantine hcl tab 5 mg Pref memantine hcl tab 10 mg Pref memantine hcl tab 28 x 5 mg & 21 x 10 Pref mg titration pack (generic of NAMENDA TITRATION PAK) NAMENDA TAB 5-10MG Non-Pref PA NAMENDA TAB 5MG Non-Pref PA NAMENDA TAB 10MG Non-Pref PA NAMENDA XR CAP 7MG Non-Pref PA NAMENDA XR CAP 14MG Non-Pref PA NAMENDA XR CAP 21MG Non-Pref PA NAMENDA XR CAP 28MG Non-Pref PA NAMENDA XR CAP TITRATIO Non-Pref PA NAMZARIC CAP Non-Pref PA NAMZARIC CAP 7-10MG Non-Pref PA NAMZARIC CAP 14-10MG Non-Pref PA NAMZARIC CAP 21-10MG Non-Pref PA NAMZARIC CAP 28-10MG Non-Pref PA RAZADYNE ER CAP 8MG Non-Pref PA RAZADYNE ER CAP 16MG Non-Pref PA RAZADYNE ER CAP 24MG Non-Pref PA RAZADYNE TAB 4MG Non-Pref PA rivastigmine tartrate cap 1.5 mg (base Pref equivalent) rivastigmine tartrate cap 3 mg (base Pref equivalent) rivastigmine tartrate cap 4.5 mg (base Pref equivalent)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 155 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits rivastigmine tartrate cap 6 mg (base Pref equivalent) rivastigmine td patch 24hr 4.6 mg/24hr Non-Pref PA (generic of EXELON) rivastigmine td patch 24hr 9.5 mg/24hr Non-Pref PA (generic of EXELON) rivastigmine td patch 24hr 13.3 mg/24hr Non-Pref PA (generic of EXELON) FIBROMYALGIA AGENTS SAVELLA MIS TITR PAK Pref QL SAVELLA TAB 12.5MG Pref QL SAVELLA TAB 25MG Pref QL SAVELLA TAB 50MG Pref QL SAVELLA TAB 100MG Pref QL MOVEMENT DISORDER DRUG THERAPY AUSTEDO TAB 6MG Pref SP, PA, AGE AUSTEDO TAB 9MG Pref SP, PA, AGE AUSTEDO TAB 12MG Pref SP, PA, AGE INGREZZA CAP 40-80MG Pref SP, PA, AGE INGREZZA CAP 40MG Pref SP, PA, AGE INGREZZA CAP 60MG Pref SP, PA, AGE INGREZZA CAP 80MG Pref SP, PA, AGE MULTIPLE SCLEROSIS AGENTS AUBAGIO TAB 7MG Non-Pref SP, PA AUBAGIO TAB 14MG Non-Pref SP, PA AVONEX PEN KIT 30MCG Pref SP AVONEX PREFL KIT 30MCG Pref SP, QL BAFIERTAM CAP 95MG Non-Pref SP, PA, QL BETASERON INJ 0.3MG Pref SP COPAXONE INJ 20MG/ML Pref SP COPAXONE INJ 40MG/ML Non-Pref SP, PA dalfampridine tab er 12hr 10 mg (generic Pref SP, PA, QL, AGE of AMPYRA) dimethyl fumarate capsule delayed release Non-Pref SP, PA 120 mg (generic of TECFIDERA) dimethyl fumarate capsule delayed release Non-Pref SP, PA 240 mg (generic of TECFIDERA) dimethyl fumarate capsule dr starter pack Non-Pref SP, PA 120 mg & 240 mg (generic of TECFIDERA STARTER PACK) EXTAVIA INJ 0.3MG Non-Pref SP, PA GILENYA CAP 0.5MG Pref SP glatiramer acetate soln prefilled syringe 20 Non-Pref SP, PA mg/ml (generic of COPAXONE)

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 156 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits glatiramer acetate soln prefilled syringe 40 Non-Pref SP, PA mg/ml (generic of COPAXONE) glatopa inj 20mg/ml (generic of Non-Pref SP, PA COPAXONE) glatopa inj 40mg/ml (generic of Non-Pref SP, PA COPAXONE) KESIMPTA INJ 20/.4ML Non-Pref PA MAVENCLAD PAK 10MG(4) Non-Pref SP, PA MAVENCLAD PAK 10MG(5) Non-Pref SP, PA MAVENCLAD PAK 10MG(6) Non-Pref SP, PA MAVENCLAD PAK 10MG(7) Non-Pref SP, PA MAVENCLAD PAK 10MG(8) Non-Pref SP, PA MAVENCLAD PAK 10MG(9) Non-Pref SP, PA MAVENCLAD PAK 10MG(10) Non-Pref SP, PA MAYZENT TAB 0.25MG Non-Pref SP, PA MAYZENT TAB 2MG Non-Pref SP, PA PLEGRIDY INJ Non-Pref SP, PA PLEGRIDY INJ PEN Non-Pref SP, PA PLEGRIDY INJ STARTER Non-Pref SP, PA PLEGRIDY PEN INJ STARTER Non-Pref SP, PA REBIF INJ 22/0.5 Non-Pref SP, PA REBIF INJ 44/0.5 Non-Pref SP, PA, QL REBIF REBIDO INJ 22/0.5 Non-Pref SP, PA REBIF REBIDO INJ 44/0.5 Non-Pref SP, PA REBIF REBIDO INJ TITRATN Non-Pref SP, PA REBIF TITRTN INJ PACK Non-Pref SP, PA TECFIDERA CAP 120MG Pref SP TECFIDERA CAP 240MG Pref SP TECFIDERA MIS STARTER Pref SP VUMERITY CAP 231MG Non-Pref SP, PA ZEPOSIA 7DAY CAP STR PACK Non-Pref SP, PA ZEPOSIA CAP .92MG Non-Pref SP, PA ZEPOSIA CAP STR KIT Non-Pref SP, PA POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS GRALISE TAB 300MG Non-Pref PA, QL GRALISE TAB 600MG Non-Pref PA, QL RESTLESS LEG SYNDROME (RLS) AGENTS HORIZANT TAB 300MG ER Non-Pref PA, QL HORIZANT TAB 600MG ER Non-Pref PA, QL SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er Pref QL 12hr 150 mg CHANTIX PAK 0.5& 1MG Pref QL CHANTIX PAK 1MG Pref QL

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 157 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits CHANTIX TAB 0.5MG Pref QL CHANTIX TAB 1MG Pref QL nicotine polacrilex gum 2 mg Pref QL, OTC nicotine polacrilex gum 4 mg Pref QL, OTC nicotine polacrilex lozenge 2 mg Pref QL, OTC nicotine polacrilex lozenge 4 mg Pref QL, OTC NICOTINE SYS KIT TRANSDER Pref QL, OTC nicotine td patch 24hr 7 mg/24hr Pref QL, OTC nicotine td patch 24hr 14 mg/24hr Pref QL, OTC nicotine td patch 24hr 21 mg/24hr Pref QL, OTC NICOTROL INH Pref QL NICOTROL NS SPR 10MG/ML Pref QL RESPIRATORY AGENTS - MISC. - DRUGS FOR THE LUNGS CYSTIC FIBROSIS AGENTS PULMOZYME SOL 1MG/ML Pref SP, PA, QL TETRACYCLINES - DRUGS TO TREAT INFECTIONS TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxycycline hyclate cap 50 mg Pref QL doxycycline hyclate cap 100 mg (generic of Pref QL VIBRAMYCIN) doxycycline hyclate tab 100 mg Pref QL doxycycline monohydrate cap 50 mg Pref QL doxycycline monohydrate cap 100 mg Pref QL doxycycline monohydrate for susp 25 Pref QL mg/5ml (generic of VIBRAMYCIN) doxycycline monohydrate tab 50 mg Pref QL doxycycline monohydrate tab 100 mg Pref QL minocycline hcl cap 50 mg Pref QL minocycline hcl cap 75 mg Pref QL minocycline hcl cap 100 mg (generic of Pref QL MINOCIN) morgidox cap 1x100mg (generic of Pref QL VIBRAMYCIN) morgidox cap 2x100mg (generic of Pref QL VIBRAMYCIN) THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS ANTITHYROID AGENTS methimazole tab 5 mg (generic of Pref TAPAZOLE) methimazole tab 10 mg (generic of Pref TAPAZOLE) propylthiouracil tab 50 mg Pref THYROID HORMONES ARMOUR THYRO TAB 15MG Pref AGE

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 158 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ARMOUR THYRO TAB 30MG Pref AGE ARMOUR THYRO TAB 60MG Pref AGE ARMOUR THYRO TAB 90MG Pref AGE ARMOUR THYRO TAB 120MG Pref AGE ARMOUR THYRO TAB 180MG Pref AGE ARMOUR THYRO TAB 240MG Pref AGE ARMOUR THYRO TAB 300MG Pref AGE levothyroxine sodium tab 25 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 25 MCG) levothyroxine sodium tab 50 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 50 MCG) levothyroxine sodium tab 75 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 75 MCG) levothyroxine sodium tab 88 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 88 MCG) levothyroxine sodium tab 100 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 100 MCG) levothyroxine sodium tab 112 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 112 MCG) levothyroxine sodium tab 125 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 125 MCG) levothyroxine sodium tab 137 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 137 MCG) levothyroxine sodium tab 150 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 150 MCG) levothyroxine sodium tab 175 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 175 MCG) levothyroxine sodium tab 200 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 200 MCG) levothyroxine sodium tab 300 mcg (generic Pref of LEVOTHYROXINE SODIUM TAB 300 MCG) liothyronine sodium tab 5 mcg (generic of Pref CYTOMEL) liothyronine sodium tab 25 mcg (generic of Pref CYTOMEL) liothyronine sodium tab 50 mcg (generic of Pref CYTOMEL) np thyroid tab 15mg Pref AGE

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 159 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits np thyroid tab 30mg Pref AGE np thyroid tab 60mg Pref AGE np thyroid tab 90mg Pref AGE np thyroid tab 120mg Pref AGE TOXOIDS - DRUGS TO PREVENT INFECTIONS TOXOID COMBINATIONS ADACEL INJ Pref AGE BOOSTRIX INJ Pref AGE TDVAX INJ 2-2 LF Pref QL, AGE TENIVAC INJ 5-2LF Pref QL, AGE ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS - DRUGS FOR ULCERS AND STOMACH ACID ANTISPASMODICS CUVPOSA SOL 1MG/5ML Pref AGE dicyclomine hcl cap 10 mg Pref AGE dicyclomine hcl oral soln 10 mg/5ml Pref AGE dicyclomine hcl tab 20 mg Pref AGE glycopyrrolate tab 1 mg Pref glycopyrrolate tab 2 mg Pref hyoscyamine sulfate elixir 0.125 mg/5ml Pref AGE hyoscyamine sulfate sl tab 0.125 mg Pref AGE hyoscyamine sulfate soln 0.125 mg/ml Pref AGE hyoscyamine sulfate tab 0.125 mg Pref AGE hyoscyamine sulfate tab disint 0.125 mg Pref AGE hyoscyamine sulfate tab er 12hr 0.375 mg Pref AGE oscimin tab 0.125mg Pref AGE H-2 ANTAGONISTS cimetidine tab 200 mg Pref cimetidine tab 200 mg Pref OTC cimetidine tab 300 mg Pref cimetidine tab 400 mg Pref cimetidine tab 800 mg Pref famotidine for susp 40 mg/5ml Pref QL, AGE famotidine tab 10 mg Pref OTC famotidine tab 20 mg Pref OTC famotidine tab 20 mg (generic of PEPCID) Pref famotidine tab 40 mg (generic of PEPCID) Pref MISC. ANTI-ULCER sucralfate tab 1 gm (generic of CARAFATE) Pref QL PROTON PUMP INHIBITORS acid reducer cap 20.6mgdr Non-Pref PA, OTC ACIPHEX SPR CAP 5MG Non-Pref PA ACIPHEX SPR CAP 10MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 160 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits ACIPHEX TAB 20MG Non-Pref PA DEXILANT CAP 30MG DR Non-Pref PA DEXILANT CAP 60MG DR Non-Pref PA esomeprazole magnesium cap delayed Non-Pref PA, OTC release 20 mg (base eq) esomeprazole magnesium cap delayed Non-Pref PA release 20 mg (base eq) (generic of NEXIUM) esomeprazole magnesium cap delayed Non-Pref PA release 40 mg (base eq) (generic of NEXIUM) esomeprazole magnesium for delayed Non-Pref PA release susp packet 10 mg (generic of NEXIUM) esomeprazole magnesium for delayed Non-Pref PA release susp packet 20 mg (generic of NEXIUM) esomeprazole magnesium for delayed Non-Pref PA release susp packet 40 mg (generic of NEXIUM) lansoprazole cap delayed release 15 mg Non-Pref PA, OTC lansoprazole cap delayed release 15 mg Non-Pref PA (generic of PREVACID) lansoprazole cap delayed release 30 mg Non-Pref PA (generic of PREVACID) lansoprazole tab delayed release orally Non-Pref PA disintegrating 15 mg (generic of PREVACID SOLUTAB) lansoprazole tab delayed release orally Non-Pref PA disintegrating 30 mg (generic of PREVACID SOLUTAB) NEXIUM 24HR CAP 20MG Non-Pref PA, OTC NEXIUM CAP 20MG Non-Pref PA NEXIUM CAP 40MG Non-Pref PA NEXIUM GRA 2.5MG DR Pref NEXIUM GRA 5MG DR Pref NEXIUM GRA 10MG DR Pref NEXIUM GRA 20MG DR Pref NEXIUM GRA 40MG DR Pref omeprazole cap delayed release 10 mg Pref omeprazole cap delayed release 20 mg Pref omeprazole cap delayed release 40 mg Pref omeprazole delayed release tab 20 mg Non-Pref PA, OTC omeprazole magnesium cap dr 20.6 mg Non-Pref PA, OTC (20 mg base equiv) omeprazole tab 20mg Non-Pref PA, OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 161 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits pantoprazole sodium ec tab 20 mg (base Pref equiv) (generic of PROTONIX) pantoprazole sodium ec tab 40 mg (base Pref equiv) (generic of PROTONIX) pantoprazole sodium for delayed release Pref susp packet 40 mg PREVACID 24H CAP 15MG DR Non-Pref PA, OTC PREVACID CAP 30MG DR Non-Pref PA PREVACID TAB 15MG STB Non-Pref PA PREVACID TAB 30MG STB Non-Pref PA PRILOSEC POW 2.5MG Non-Pref PA PRILOSEC POW 10MG Non-Pref PA PROTONIX PAK 40MG Non-Pref PA PROTONIX TAB 20MG Non-Pref PA PROTONIX TAB 40MG Non-Pref PA rabeprazole sodium ec tab 20 mg (generic Non-Pref PA of ACIPHEX) ULCER DRUGS - PROSTAGLANDINS misoprostol tab 100 mcg (generic of Pref QL CYTOTEC) misoprostol tab 200 mcg (generic of Pref QL CYTOTEC) ULCER THERAPY COMBINATIONS amoxicillin cap-clarithro tab-lansopraz cap Non-Pref PA dr therapy pack OMECLAMOX- MIS PAK Non-Pref PA omeprazole-sodium bicarbonate cap 20- Non-Pref PA 1100 mg (generic of ZEGERID) omeprazole-sodium bicarbonate cap 40- Non-Pref PA 1100 mg (generic of ZEGERID) omeprazole-sodium bicarbonate powd pack Non-Pref PA for susp 20-1680 mg (generic of ZEGERID) omeprazole-sodium bicarbonate powd pack Non-Pref PA for susp 40-1680 mg (generic of ZEGERID) PYLERA CAP Pref TALICIA CAP Non-Pref PA ZEGERID CAP 20-1100 Non-Pref PA ZEGERID CAP 40-1100 Non-Pref PA ZEGERID POW 20-1680 Non-Pref PA ZEGERID POW 40-1680 Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 162 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC) darifenacin hydrobromide tab er 24hr 7.5 Non-Pref PA mg (base equiv) darifenacin hydrobromide tab er 24hr 15 Non-Pref PA mg (base equiv) (generic of ENABLEX) DETROL LA CAP 2MG Non-Pref PA DETROL LA CAP 4MG Non-Pref PA DETROL TAB 1MG Non-Pref PA DETROL TAB 2MG Non-Pref PA DITROPAN XL TAB 5MG Non-Pref PA DITROPAN XL TAB 10MG Non-Pref PA GELNIQUE GEL 10% Non-Pref PA oxybutynin chloride syrup 5 mg/5ml Pref oxybutynin chloride tab 5 mg Pref oxybutynin chloride tab er 24hr 5 mg Pref (generic of DITROPAN XL) oxybutynin chloride tab er 24hr 10 mg Pref (generic of DITROPAN XL) oxybutynin chloride tab er 24hr 15 mg Pref OXYTROL DIS 3.9MG/24 Non-Pref PA OXYTROL/WOMN DIS 3.9MG/24 Pref OTC solifenacin succinate tab 5 mg (generic of Pref VESICARE) solifenacin succinate tab 10 mg (generic of Pref VESICARE) tolterodine tartrate cap er 24hr 2 mg Non-Pref PA (generic of DETROL LA) tolterodine tartrate cap er 24hr 4 mg Non-Pref PA (generic of DETROL LA) tolterodine tartrate tab 1 mg (generic of Non-Pref PA DETROL) tolterodine tartrate tab 2 mg (generic of Non-Pref PA DETROL) TOVIAZ TAB 4MG Pref TOVIAZ TAB 8MG Pref trospium chloride cap er 24hr 60 mg Non-Pref PA trospium chloride tab 20 mg Non-Pref PA VESICARE LS SUS 5MG/5ML Non-Pref PA VESICARE TAB 5MG Non-Pref PA VESICARE TAB 10MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 163 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS MYRBETRIQ TAB 25MG Non-Pref PA MYRBETRIQ TAB 50MG Non-Pref PA URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS bethanechol chloride tab 5 mg Pref QL bethanechol chloride tab 10 mg Pref QL bethanechol chloride tab 25 mg Pref QL bethanechol chloride tab 50 mg Pref QL URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS flavoxate hcl tab 100 mg Non-Pref PA VACCINES - DRUGS TO PREVENT INFECTIONS BACTERIAL VACCINES PNEUMOVAX 23 INJ 25/0.5 Pref QL, AGE PREVNAR 13 INJ Pref QL VIRAL VACCINES AFLURIA QUAD INJ 2020-21 Pref QL ENGERIX-B INJ 10/0.5ML Pref QL, AGE; Max #6 per lifetime ENGERIX-B INJ 20MCG/ML Pref QL, AGE; Max #3 per lifetime FLUCLVX QUAD INJ 2020-21 Pref QL FLUMIST QUAD SUS 2020-21 Pref QL FLUZONE QUAD INJ 2020-21 Pref QL HAVRIX INJ 720UNIT Pref QL, AGE; Max #2 per lifetime HAVRIX INJ 1440UNIT Pref QL, AGE; Max #2 per lifetime RECOMBIVA HB INJ 5MCG/0.5 Pref QL, AGE; Max #6 per lifetime RECOMBIVA HB INJ 10MCG/ML Pref QL, AGE; Max #3 per lifetime SHINGRIX INJ 50/0.5ML Pref QL, AGE; Max #2 per lifetime VAQTA INJ 25/0.5ML Pref QL, AGE; Max #2 per lifetime VAQTA INJ 50UNT/ML Pref QL, AGE; Max #2 per lifetime VAGINAL AND RELATED PRODUCTS - DRUGS TO TREAT VAGINAL CONDITIONS SPERMICIDES GYNOL II GEL 3% Pref OTC TODAY SPONGE MIS Pref OTC VCF VAGINAL AER CONTRACP Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 164 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits VAGINAL ANTI-INFECTIVES CLEOCIN CRE 2% VAG Non-Pref PA CLEOCIN SUP 100MG Pref clindamycin phosphate vaginal cream 2% Pref (generic of CLEOCIN) CLINDESSE CRE 2% Non-Pref PA clotrimazole vaginal cream 1% Pref OTC clotrimazole vaginal cream 2% Pref OTC GYNE-LOTRIMI CRE 3 Pref OTC metronidazole vaginal gel 0.75% Pref miconazole nitrate vaginal app 200 mg & Pref OTC 2% cream 9 gm kit miconazole nitrate vaginal cream 2% Pref OTC miconazole nitrate vaginal supp 200 mg & Pref OTC 2% cream 9 gm kit miconazole nitrate vaginal suppos 100 mg Pref OTC MONISTAT 3 KIT 200MG/2% Pref OTC MONISTAT 7 CRE 2% Pref OTC NUVESSA GEL 1.3% Pref terconazole vaginal cream 0.4% Pref terconazole vaginal cream 0.8% Pref vandazole gel 0.75% Pref VAGINAL ESTROGENS estradiol vaginal cream 0.1 mg/gm Pref QL (generic of ESTRACE) estradiol vaginal tab 10 mcg (generic of Pref ESTRADIOL VAGINAL TAB 10 MCG) VAGINAL PROGESTINS CRINONE GEL 4% VAG Non-Pref PA CRINONE GEL 8% VAG Non-Pref PA VASOPRESSORS - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ANAPHYLAXIS THERAPY AGENTS AUVI-Q INJ 0.3MG Pref AUVI-Q INJ 0.15MG Non-Pref PA epinephrine solution auto-injector 0.3 Pref mg/0.3ml (1:1000) (generic of EPIPEN 2- PAK) epinephrine solution auto-injector 0.15 Pref mg/0.3ml (1:2000) (generic of EPIPEN-JR 2-PAK) epinephrine solution auto-injector 0.15 Non-Pref PA mg/0.15ml (1:1000) EPIPEN 2-PAK INJ 0.3MG Non-Pref PA

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 165 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits EPIPEN-JR INJ 0.15MG Non-Pref PA SYMJEPI INJ 0.3MG Non-Pref PA SYMJEPI INJ 0.15MG Non-Pref PA VASOPRESSORS - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS midodrine hcl tab 2.5 mg Pref QL midodrine hcl tab 5 mg Pref QL midodrine hcl tab 10 mg Pref QL VITAMINS - DRUGS FOR NUTRITION OIL SOLUBLE VITAMINS aqueous e dro 50unt/ml Pref AGE, OTC calcidol dro 8000/ml Pref QL, OTC cholecalciferol cap 10 mcg (400 unit) Pref OTC cholecalciferol cap 1000 unit Pref OTC cholecalciferol cap 2000 unit Pref OTC cholecalciferol cap 5000 unit Pref OTC cholecalciferol cap 50000 unit Pref OTC cholecalciferol chew tab 400 unit Pref OTC cholecalciferol oral liquid 400 unit/ml Pref OTC cholecalciferol tab 400 unit Pref OTC cholecalciferol tab 1000 unit Pref OTC cholecalciferol tab 2000 unit Pref OTC cholecalciferol tab 5000 unit Pref OTC ergocalciferol cap 1.25 mg (50000 unit) Pref (generic of DRISDOL) ergocalciferol soln 200 mcg/ml (8000 Pref QL, OTC unit/ml) phytonadione tab 5 mg (generic of Pref QL MEPHYTON) REPLESTA WAF 50000UNT Pref OTC soluvita e sol 50unt/ml Pref AGE, OTC vitamin d3 tab 50000unt Pref OTC vitamin e cap 450mg Pref OTC VITAMIN E TAB 100UNIT Pref OTC VITAMIN E TAB 200UNIT Pref OTC vitamin e tab 400unit Pref OTC WATER SOLUBLE VITAMINS ARKALIOX CAP 200MG Pref OTC biotin cap 5 mg Pref OTC biotin tab 5 mg Pref OTC biotin tab 10 mg Pref OTC CYTO B7 LIQ 5MG/ML Pref OTC HARD NAILS CAP 2.5MG Pref OTC niacin cap er 250 mg Pref OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 166 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Drug Name Drug Tier Requirements/Limits niacin cap er 500 mg Non-Pref PA, OTC niacin tab 50 mg Pref OTC niacin tab 100 mg Non-Pref PA, OTC niacin tab 500 mg Pref OTC niacin tab er 750 mg Pref OTC NIACIN TR TAB 1000MG Pref OTC niacinamide tab 100 mg Pref OTC niacinamide tab 500 mg Pref OTC pyridoxine hcl tab 25 mg Pref QL, OTC pyridoxine hcl tab 50 mg Pref QL, OTC pyridoxine hcl tab 100 mg Pref QL, OTC ra biotin cap 2500mcg Pref OTC SLO-NIACIN TAB 750MG ER Pref OTC thiamine hcl tab 50 mg Pref QL, OTC thiamine hcl tab 100 mg Pref QL, OTC thiamine mononitrate tab 100 mg Pref QL, OTC

AGE - Age Limit Biologic - MI Biologic Class MED - Max 90 mg Morphine EQ Dose 167 Per Day Non-Pref - Non-Preferred OTC - Over the counter PA - Prior Authorization Pref - Preferred QL - Quantity Limits SP - Specialty ST - Step Therapy Index A acetaminophen soln 160 mg/5ml .....24 abiraterone acetate tab 250 mg ...... 70 acetaminophen suppos 120 mg ...... 24 ACANYA acetaminophen suppos 650 mg ...... 24 see clindamycin phosphate-benzoyl acetaminophen susp 160 mg/5ml .....24 peroxide gel 1.2-2.5% ...... 96 acetaminophen tab 325 mg ...... 24 ACANYA GEL 1.2-2.5% ...... 95 acetaminophen tab 500 mg ...... 24 acarbose tab 100 mg ...... 44 acetaminophen tab er 650 mg ...... 24 acarbose tab 25 mg ...... 44 acetaminophen w/ codeine soln 120-12 acarbose tab 50 mg ...... 44 mg/5ml ...... 30 ACCOLATE acetaminophen w/ codeine tab 300-15 see zafirlukast tab 10 mg ...... 39 mg ...... 30 see zafirlukast tab 20 mg ...... 39 acetaminophen w/ codeine tab 300-30 ACCOLATE TAB 10MG ...... 39 mg ...... 30 ACCOLATE TAB 20MG ...... 39 acetaminophen w/ codeine tab 300-60 ACCUPRIL mg ...... 30 see quinapril hcl tab 10 mg ...... 60 acetazolamide cap er 12hr 500 mg .106 see quinapril hcl tab 20 mg ...... 60 acetazolamide tab 125 mg ...... 106 see quinapril hcl tab 40 mg ...... 60 acetazolamide tab 250 mg ...... 106 see quinapril hcl tab 5 mg ...... 60 acetic acid otic soln 2% ...... 152 ACCUPRIL TAB 10MG ...... 59 acetylcysteine inhal soln 10% ...... 95 ACCUPRIL TAB 20MG ...... 59 acetylcysteine inhal soln 20% ...... 95 ACCUPRIL TAB 40MG ...... 59 acid reducer cap 20.6mgdr ...... 160 ACCUPRIL TAB 5MG ...... 59 ACIPHEX ACCURETIC see rabeprazole sodium ec tab 20 mg see quinapril-hydrochlorothiazide tab ...... 162 10-12.5 mg ...... 66 ACIPHEX SPR CAP 10MG ...... 160 see quinapril-hydrochlorothiazide tab ACIPHEX SPR CAP 5MG ...... 160 20-12.5 mg ...... 66 ACIPHEX TAB 20MG ...... 161 see quinapril-hydrochlorothiazide tab acitretin cap 10 mg ...... 98 20-25 mg ...... 66 acitretin cap 17.5 mg ...... 98 ACCURETIC TAB 10-12.5 ...... 62 acitretin cap 25 mg ...... 98 ACCURETIC TAB 20-12.5 ...... 63 ACTEMRA INJ 162/0.9 ...... 20 ACCURETIC TAB 20-25MG ...... 63 ACTEMRA INJ ACTPEN ...... 20 acebutolol hcl cap 200 mg ...... 77 ACTIFLOVIT TAB EAR HEAL ...... 144 acebutolol hcl cap 400 mg ...... 77 ACTIQ acetaminophen-caffeine- see fentanyl citrate lozenge on a dihydrocodeine cap 320.5-30-16 mg handle 1200 mcg ...... 26 ...... 30 see fentanyl citrate lozenge on a acetaminophen cap 500 mg ...... 24 handle 1600 mcg ...... 26 acetaminophen chew tab 80 mg ...... 24 see fentanyl citrate lozenge on a acetaminophen disintegrating tab 160 handle 200 mcg ...... 25 mg ...... 24 see fentanyl citrate lozenge on a acetaminophen disintegrating tab 80 handle 400 mcg ...... 25 mg ...... 24 see fentanyl citrate lozenge on a acetaminophen elixir 160 mg/5ml ....24 handle 600 mcg ...... 25 acetaminophen liquid 160 mg/5ml ....24 168 see fentanyl citrate lozenge on a acyclovir cream 5% ...... 99 handle 800 mcg ...... 26 acyclovir oint 5% ...... 99 ACTIQ LOZ 1200MCG ...... 25 acyclovir susp 200 mg/5ml ...... 76 ACTIQ LOZ 1600MCG ...... 25 acyclovir tab 400 mg ...... 76 ACTIQ LOZ 200MCG ...... 25 acyclovir tab 800 mg ...... 76 ACTIQ LOZ 400MCG ...... 25 ADACEL INJ ...... 160 ACTIQ LOZ 600MCG ...... 25 adapalene gel 0.1% ...... 95 ACTIQ LOZ 800MCG ...... 25 ADCIRCA ACTIVE 55 LIQ PLUS ...... 137 see alyq tab 20mg ...... 85 ACTIVE FE TAB 75-1.25 ...... 118 see tadalafil tab 20 mg (pah) ...... 85 ACTIVELLA ADCIRCA TAB 20MG ...... 85 see amabelz tab 1-0.5mg ...... 110 adefovir dipivoxil tab 10 mg ...... 75 see estradiol & norethindrone acetate ADEMPAS TAB 0.5MG ...... 86 tab 1-0.5 mg ...... 110 ADEMPAS TAB 1.5MG ...... 86 see mimvey tab 1-0.5mg ...... 110 ADEMPAS TAB 1MG ...... 86 ACTIVNUTRIEN CAP ...... 137 ADEMPAS TAB 2.5MG ...... 86 ACTONEL ADEMPAS TAB 2MG ...... 86 see risedronate sodium tab 150 mg adlt multivi chw gummies ...... 137 ...... 108 ADLT ONE DLY CHW GUMMIES ...... 137 see risedronate sodium tab 35 mg ADLYXIN INJ 10/20MCG ...... 47 ...... 108 ADLYXIN INJ 20MCG ...... 47 ACTONEL TAB 150MG ...... 107 ADMELOG INJ 100U/ML ...... 48 ACTONEL TAB 35MG ...... 107 ADMELOG SOLO INJ 100U/ML ...... 48 ACTOPLUS MET ADULT 50+ CAP EYE HLTH ...... 137 see pioglitazone hcl-metformin hcl ADULT 50+ CAP OCUVITE ...... 137 tab 15-500 mg ...... 46 ADULT DISPOS MIS MOUTHPIE ...... 127 see pioglitazone hcl-metformin hcl adult gummy chw ...... 137 tab 15-850 mg ...... 46 ADULT MASK MIS ...... 127 ACTOPLUS MET TAB 15-500MG ...... 44 ADVAIR DISKU AER 100/50 ...... 40 ACTOPLUS MET TAB 15-850MG ...... 44 ADVAIR DISKU AER 250/50 ...... 40 ACTOS ADVAIR DISKU AER 500/50 ...... 40 see pioglitazone hcl tab 15 mg (base ADVAIR DISKUS equiv) ...... 49 see fluticasone-salmeterol aer see pioglitazone hcl tab 30 mg (base powder ba 100-50 mcg/dose ...... 41 equiv) ...... 49 see fluticasone-salmeterol aer see pioglitazone hcl tab 45 mg (base powder ba 250-50 mcg/dose ...... 41 equiv) ...... 49 see fluticasone-salmeterol aer ACTOS TAB 15MG ...... 49 powder ba 500-50 mcg/dose ...... 41 ACTOS TAB 30MG ...... 49 see wixela inhub aer 100/50 ...... 42 ACTOS TAB 45MG ...... 49 see wixela inhub aer 250/50 ...... 42 ACULAR see wixela inhub aer 500/50 ...... 42 see ketorolac tromethamine ophth ADVAIR HFA AER 115/21 ...... 40 soln 0.5% ...... 151 ADVAIR HFA AER 230/21 ...... 40 ACULAR LS SOL 0.4% ...... 150 ADVAIR HFA AER 45/21 ...... 40 ACULAR SOL 0.5% OP ...... 150 advanced chw multi ea ...... 137 ACUVAIL SOL 0.45% ...... 150 AEROBIKA MIS ...... 127 acyclovir cap 200 mg ...... 76 AFINITOR 169 see everolimus tab 2.5 mg ...... 71 albuterol sulfate soln nebu 0.63 see everolimus tab 5 mg ...... 71 mg/3ml (base equiv) ...... 40 see everolimus tab 7.5 mg ...... 71 albuterol sulfate soln nebu 1.25 AFINITOR DIS TAB 2MG ...... 71 mg/3ml (base equiv) ...... 40 AFINITOR DIS TAB 3MG ...... 71 ALCAINE AFINITOR DIS TAB 5MG ...... 71 see proparacaine hcl ophth soln 0.5% AFINITOR TAB 10MG ...... 71 ...... 150 afirmelle tab 0.1-0.02 ...... 87 alclometasone dipropionate cream AFLURIA QUAD INJ 2020-21 ...... 164 0.05% ...... 99 AFREZZA POW 12 UNIT ...... 48 alclometasone dipropionate oint 0.05% AFREZZA POW 4-8-12 ...... 48 ...... 99 AFREZZA POW 4-8 UNIT ...... 48 ALCOHOL SWABS ...... 126 AFREZZA POW 4UNIT ...... 48 ALDACTAZIDE AFREZZA POW 8-12UNIT ...... 48 see spironolactone & AFREZZA POW 8 UNIT ...... 48 hydrochlorothiazide tab 25-25 mg AGGRENOX CAP 25-200MG ...... 116 ...... 106 AGRYLIN ALDACTONE see anagrelide hcl cap 0.5 mg .....116 see spironolactone tab 100 mg ....107 AIMOVIG INJ 140MG/ML ...... 128 see spironolactone tab 25 mg ...... 107 AIMOVIG INJ 70MG/ML ...... 128 see spironolactone tab 50 mg ...... 107 airavite tab ...... 118 ALDARA AIRBORNE+ CHW PROBIOTI ...... 137 see imiquimod cream 5% ...... 104 AIRBORNE+ CHW REST ...... 138 alendronate sodium oral soln 70 airborne chw ...... 137 mg/75ml ...... 107 AIRBORNE CHW ...... 137 alendronate sodium tab 10 mg ...... 107 airborne chw gummies ...... 137 alendronate sodium tab 35 mg ...... 107 airborne chw immune ...... 137 alendronate sodium tab 5 mg ...... 107 airborne chw kids ...... 137 alendronate sodium tab 70 mg ...... 107 AIRBORNE CHW KIDS ...... 137 alfuzosin hcl tab er 24hr 10 mg ...... 115 AIRDUO DGHLR INH 113-14 ...... 40 ALGAE BASED TAB CALCIUM ...... 138 AIRDUO DGHLR INH 232-14 ...... 40 ALINIA AIRDUO DGHLR INH 55-14 ...... 40 see nitazoxanide tab 500 mg ...... 35 AIRDUO RESPI INH 113-14 ...... 40 aliskiren fumarate tab 150 mg (base AIRDUO RESPI INH 232-14 ...... 40 equivalent) ...... 67 AIRDUO RESPI INH 55-14 ...... 40 aliskiren fumarate tab 300 mg (base airshield chw ...... 138 equivalent) ...... 68 AIRSHIELD CHW IMMUNITY ...... 138 ALIVE MULTI CHW VITAMIN ...... 138 AJOVY INJ 225/1.5 ...... 128 ALIVE WOMENS CHW 50+ ...... 138 AKYNZEO CAP 300-0.5 ...... 52 ALIVE WOMENS CHW GUMMY ...... 138 ala-cort cre 2.5% ...... 99 ALKA SELTZER TAB HEARTBRN ...... 33 ALBA-LYBE NR LIQ ...... 146 ALKERAN albuterol sulfate inhal aero 108 see melphalan tab 2 mg ...... 69 mcg/act (90mcg base equiv) ...... 40 ALKINDI SPRI CAP 0.5MG ...... 93 albuterol sulfate soln nebu 0.083% ALKINDI SPRI CAP 1MG ...... 93 (2.5 mg/3ml) ...... 40 ALKINDI SPRI CAP 2MG ...... 93 albuterol sulfate soln nebu 0.5% (5 ALKINDI SPRI CAP 5MG ...... 93 mg/ml) ...... 40 all day allg cap 10mg ...... 54 170 allergy eye dro ...... 149 ALTACE CAP 10MG ...... 59 allergy rel cap 10mg ...... 54 ALTACE CAP 2.5MG ...... 59 allergy relf tab 5mg ...... 54 ALTACE CAP 5MG ...... 59 allopurinol tab 100 mg ...... 116 altavera tab ...... 87 allopurinol tab 300 mg ...... 116 ALTOPREV TAB 20MG ER ...... 57 almotriptan malate tab 12.5 mg .....128 ALTOPREV TAB 40MG ER ...... 57 almotriptan malate tab 6.25 mg .....128 ALTOPREV TAB 60MG ER ...... 57 ALOCRIL SOL 2% ...... 150 alum & mag hydroxide-simethicone alogliptin benzoate tab 12.5 mg (base chew tab 200-200-25 mg ...... 33 equiv) ...... 47 alum & mag hydroxide-simethicone alogliptin benzoate tab 25 mg (base susp 200-200-20 mg/5ml ...... 33 equiv) ...... 47 alum & mag hydroxide-simethicone alogliptin benzoate tab 6.25 mg (base susp 400-400-40 mg/5ml ...... 33 equiv) ...... 47 ALUM HYDROX SUS 320/5ML ...... 34 alogliptin-metformin hcl tab 12.5-1000 aluminum hydroxide-magnesium mg ...... 44 carbonate chew tab 160-105 mg ...33 alogliptin-metformin hcl tab 12.5-500 aluminum hydroxide-magnesium mg ...... 44 carbonate susp 95-358 mg/15ml ...33 alogliptin-pioglitazone tab 12.5-15 mg ALVESCO AER 160MCG ...... 39 ...... 44 ALVESCO AER 80MCG ...... 39 alogliptin-pioglitazone tab 12.5-30 mg alyacen tab 1/35 ...... 87 ...... 44 alyacen tab 7/7/7 ...... 87 alogliptin-pioglitazone tab 12.5-45 mg alyq tab 20mg ...... 85 ...... 44 amabelz tab 0.5-0.1 ...... 110 alogliptin-pioglitazone tab 25-15 mg .44 amabelz tab 1-0.5mg ...... 110 alogliptin-pioglitazone tab 25-30 mg .45 amantadine hcl cap 100 mg ...... 72 alogliptin-pioglitazone tab 25-45 mg .45 amantadine hcl syrup 50 mg/5ml .....72 ALOMIDE SOL 0.1% OP ...... 150 amantadine hcl tab 100 mg ...... 72 ALORA DIS 0.025MG ...... 110 AMARYL ALORA DIS 0.05MG ...... 110 see glimepiride tab 1 mg ...... 50 ALORA DIS 0.075MG ...... 110 see glimepiride tab 2 mg ...... 50 ALORA DIS 0.1MG ...... 110 see glimepiride tab 4 mg ...... 50 alosetron hcl tab 0.5 mg (base equiv) AMARYL TAB 1MG ...... 50 ...... 114 AMARYL TAB 2MG ...... 50 alosetron hcl tab 1 mg (base equiv) 114 AMARYL TAB 4MG ...... 50 ALPHAGAN P ambrisentan tab 10 mg ...... 85 see brimonidine tartrate ophth soln ambrisentan tab 5 mg ...... 85 0.15% ...... 148 amcinonide cream 0.1% ...... 99 ALPHAGAN P SOL 0.1% ...... 148 amcinonide lotion 0.1% ...... 99 ALPHAGAN P SOL 0.15% ...... 148 AMERGE ALREX SUS 0.2% ...... 150 see naratriptan hcl tab 1 mg (base ALTACE equiv) ...... 128 see ramipril cap 1.25 mg ...... 60 see naratriptan hcl tab 2.5 mg (base see ramipril cap 10 mg ...... 60 equiv) ...... 128 see ramipril cap 2.5 mg ...... 60 AMERGE TAB 1MG ...... 128 see ramipril cap 5 mg ...... 60 AMERGE TAB 2.5MG ...... 128 ALTACE CAP 1.25MG ...... 59 amethyst tab 90-20mcg ...... 87 171 amiloride & hydrochlorothiazide tab 5- amlodipine besylate-olmesartan 50 mg ...... 106 medoxomil tab 5-20 mg ...... 63 amiloride hcl tab 5 mg ...... 107 amlodipine besylate-olmesartan amiodarone hcl tab 100 mg ...... 38 medoxomil tab 5-40 mg ...... 63 amiodarone hcl tab 200 mg ...... 38 amlodipine besylate tab 10 mg (base amiodarone hcl tab 400 mg ...... 38 equivalent) ...... 80 AMITIZA CAP 24MCG ...... 113 amlodipine besylate tab 2.5 mg (base AMITIZA CAP 8MCG ...... 113 equivalent) ...... 80 amlodipine besylate-atorvastatin amlodipine besylate tab 5 mg (base calcium tab 10-10 mg ...... 84 equivalent) ...... 80 amlodipine besylate-atorvastatin amlodipine besylate-valsartan tab 10- calcium tab 10-20 mg ...... 84 160 mg ...... 63 amlodipine besylate-atorvastatin amlodipine besylate-valsartan tab 10- calcium tab 10-40 mg ...... 84 320 mg ...... 63 amlodipine besylate-atorvastatin amlodipine besylate-valsartan tab 5- calcium tab 10-80 mg ...... 84 160 mg ...... 63 amlodipine besylate-atorvastatin amlodipine besylate-valsartan tab 5- calcium tab 2.5-10 mg ...... 84 320 mg ...... 63 amlodipine besylate-atorvastatin amlodipine-valsartan- calcium tab 2.5-20 mg ...... 84 hydrochlorothiazide tab 10-160-12.5 amlodipine besylate-atorvastatin mg ...... 63 calcium tab 2.5-40 mg ...... 84 amlodipine-valsartan- amlodipine besylate-atorvastatin hydrochlorothiazide tab 10-160-25 calcium tab 5-10 mg ...... 84 mg ...... 63 amlodipine besylate-atorvastatin amlodipine-valsartan- calcium tab 5-20 mg ...... 84 hydrochlorothiazide tab 10-320-25 amlodipine besylate-atorvastatin mg ...... 63 calcium tab 5-40 mg ...... 84 amlodipine-valsartan- amlodipine besylate-atorvastatin hydrochlorothiazide tab 5-160-12.5 calcium tab 5-80 mg ...... 84 mg ...... 63 amlodipine besylate-benazepril hcl cap amlodipine-valsartan- 10-20 mg ...... 63 hydrochlorothiazide tab 5-160-25 mg amlodipine besylate-benazepril hcl cap ...... 63 10-40 mg ...... 63 amoxicillin (trihydrate) cap 250 mg 152 amlodipine besylate-benazepril hcl cap amoxicillin (trihydrate) cap 500 mg 152 2.5-10 mg ...... 63 amoxicillin (trihydrate) chew tab 125 amlodipine besylate-benazepril hcl cap mg ...... 152 5-10 mg ...... 63 amoxicillin (trihydrate) chew tab 250 amlodipine besylate-benazepril hcl cap mg ...... 152 5-20 mg ...... 63 amoxicillin (trihydrate) for susp 125 amlodipine besylate-benazepril hcl cap mg/5ml ...... 152 5-40 mg ...... 63 amoxicillin (trihydrate) for susp 200 amlodipine besylate-olmesartan mg/5ml ...... 152 medoxomil tab 10-20 mg ...... 63 amoxicillin (trihydrate) for susp 250 amlodipine besylate-olmesartan mg/5ml ...... 152 medoxomil tab 10-40 mg ...... 63 amoxicillin (trihydrate) for susp 400 mg/5ml ...... 153 172 amoxicillin (trihydrate) tab 500 mg .153 see testosterone td gel 20.25 amoxicillin (trihydrate) tab 875 mg .153 mg/1.25gm (1.62%) ...... 33 amoxicillin & k clavulanate chew tab see testosterone td gel 25 mg/2.5gm 200-28.5 mg ...... 153 (1%) ...... 33 amoxicillin & k clavulanate chew tab see testosterone td gel 40.5 400-57 mg ...... 153 mg/2.5gm (1.62%) ...... 33 amoxicillin & k clavulanate for susp ANDROGEL GEL 1.62% ...... 32 200-28.5 mg/5ml ...... 153 ANDROGEL GEL 1%(25MG) ...... 32 amoxicillin & k clavulanate for susp ANDROGEL PUMP 250-62.5 mg/5ml ...... 153 see testosterone td gel 20.25 mg/act amoxicillin & k clavulanate for susp (1.62%) ...... 33 400-57 mg/5ml ...... 153 ANIMI-3 CAP ...... 118 amoxicillin & k clavulanate for susp ANIMI-3 CAP VIT D ...... 118 600-42.9 mg/5ml ...... 153 ANORO ELLIPT AER 62.5-25 ...... 41 amoxicillin & k clavulanate tab 250-125 ant/anti-gas chw 1000-60 ...... 33 mg ...... 153 antacid chw 550-110 ...... 33 amoxicillin & k clavulanate tab 500-125 antacid extr chw 675-135 ...... 33 mg ...... 153 antacid mult chw symptom ...... 33 amoxicillin & k clavulanate tab 875-125 ANTACID ULTR CHW 1000-200 ...... 33 mg ...... 153 ANTARA CAP 30MG ...... 56 amoxicillin cap-clarithro tab-lansopraz ANTARA CAP 90MG ...... 56 cap dr therapy pack ...... 162 APADAZ TAB 4.08-325 ...... 30 ampicillin cap 500 mg ...... 153 APADAZ TAB 6.12-325 ...... 30 AMPYRA APADAZ TAB 8.16-325 ...... 30 see dalfampridine tab er 12hr 10 mg APETEX ELX ...... 136 ...... 156 APETIGEN ELX ...... 136 AMRIX APETIGEN-PLS SOL ...... 137 see cyclobenzaprine hcl cap er 24hr APEXICON E CRE 0.05% ...... 99 15 mg ...... 144 APIDRA INJ SOLOSTAR ...... 48 see cyclobenzaprine hcl cap er 24hr APIDRA INJ U-100 ...... 48 30 mg ...... 144 apraclonidine hcl ophth soln 0.5% AMRIX CAP 15MG ...... 144 (base equivalent) ...... 148 AMRIX CAP 30MG ...... 144 aprepitant capsule 125 mg ...... 52 anagrelide hcl cap 0.5 mg ...... 116 aprepitant capsule 40 mg ...... 52 anagrelide hcl cap 1 mg ...... 116 aprepitant capsule 80 mg ...... 52 ANAPROX DS aprepitant capsule therapy pack 80 & see naproxen sodium tab 550 mg ..22 125 mg ...... 52 anastrozole tab 1 mg ...... 70 APRISO ANCOBON see mesalamine cap er 24hr 0.375 see flucytosine cap 250 mg ...... 52 gm ...... 113 see flucytosine cap 500 mg ...... 52 APRISO CAP 0.375GM ...... 113 ANCOBON CAP 250MG ...... 52 apri tab ...... 87 ANCOBON CAP 500MG ...... 52 AQUADEKS CHW ...... 138 ANDRODERM DIS 2MG/24HR ...... 32 aquadeks dro ...... 142 ANDRODERM DIS 4MG/24HR ...... 32 aqueous e dro 50unt/ml ...... 166 ANDROGEL aranelle tab ...... 87 ARANESP INJ 100MCG ...... 117 173 ARANESP INJ 10MCG ...... 117 ARMOUR THYRO TAB 240MG ...... 159 ARANESP INJ 150MCG ...... 117 ARMOUR THYRO TAB 300MG ...... 159 ARANESP INJ 200MCG ...... 117 ARMOUR THYRO TAB 30MG ...... 159 ARANESP INJ 25MCG ...... 117 ARMOUR THYRO TAB 60MG ...... 159 ARANESP INJ 300MCG ...... 117 ARMOUR THYRO TAB 90MG ...... 159 ARANESP INJ 40MCG ...... 117 ARNUITY ELPT INH 100MCG ...... 39 ARANESP INJ 500MCG ...... 117 ARNUITY ELPT INH 200MCG ...... 39 ARANESP INJ 60MCG ...... 117 ARNUITY ELPT INH 50MCG ...... 39 ARAVA AROMASIN see leflunomide tab 10 mg ...... 23 see exemestane tab 25 mg ...... 70 see leflunomide tab 20 mg ...... 23 ARTHROTEC 50 arformoterol tartrate soln nebu 15 see diclofenac w/ misoprostol tab mcg/2ml (base equiv) ...... 41 delayed release 50-0.2 mg ...... 21 ARFORMOTEROL TARTRATE SOLN ARTHROTEC 50 TAB ...... 20 NEBU 15 MCG/2ML (BASE EQUIV) .41 ARTHROTEC 75 ARICEPT see diclofenac w/ misoprostol tab see donepezil hydrochloride tab 10 delayed release 75-0.2 mg ...... 21 mg ...... 154 ARTHROTEC 75 TAB ...... 20 see donepezil hydrochloride tab 23 artificial tear ophth solution ...... 147 mg ...... 154 ASACOL HD see donepezil hydrochloride tab 5 mg see mesalamine tab delayed release ...... 154 800 mg ...... 113 ARICEPT TAB 10MG ...... 154 ASACOL HD TAB 800MG ...... 113 ARICEPT TAB 23MG ...... 154 ascomp/cod cap 30mg ...... 30 ARICEPT TAB 5MG ...... 154 ASMANEX 120 AER 220MCG ...... 39 ARIMIDEX ASMANEX 14 AER 220MCG ...... 39 see anastrozole tab 1 mg ...... 70 ASMANEX 30 AER 110MCG ...... 39 ARIXTRA ASMANEX 30 AER 220MCG ...... 39 see fondaparinux sodium ASMANEX 60 AER 220MCG ...... 39 subcutaneous inj 10 mg/0.8ml ...43 ASMANEX 7 AER 110MCG ...... 39 see fondaparinux sodium ASMANEX HFA AER 100 MCG ...... 39 subcutaneous inj 2.5 mg/0.5ml ..43 ASMANEX HFA AER 200 MCG ...... 39 see fondaparinux sodium ASMANEX HFA AER 50MCG ...... 39 subcutaneous inj 5 mg/0.4ml .....43 aspirin buffered (ca carb-mg carb-mg see fondaparinux sodium ox) tab 325 mg ...... 24 subcutaneous inj 7.5 mg/0.6ml ..43 aspirin chew tab 81 mg ...... 24 ARIXTRA INJ 10/0.8ML ...... 43 aspirin-dipyridamole cap er 12hr 25- ARIXTRA INJ 2.5/0.5 ...... 43 200 mg ...... 116 ARIXTRA INJ 5/0.4ML ...... 43 ASPIRIN SUP 300MG ...... 24 ARIXTRA INJ 7.5/0.6 ...... 43 ASPIRIN SUP 600MG ...... 24 ARKALIOX CAP 200MG ...... 166 aspirin tab 325 mg ...... 25 ARMONAIR DIG AER 113MCG ...... 39 aspirin tab delayed release 325 mg ..25 ARMONAIR DIG AER 232MCG ...... 39 aspirin tab delayed release 81 mg ....25 ARMONAIR DIG AER 55MCG ...... 39 ATACAND ARMOUR THYRO TAB 120MG ...... 159 see candesartan cilexetil tab 16 mg ARMOUR THYRO TAB 15MG ...... 158 ...... 61 ARMOUR THYRO TAB 180MG ...... 159 174 see candesartan cilexetil tab 32 mg AUBAGIO TAB 7MG ...... 156 ...... 61 aubra eq tab 0.1-0.02 ...... 87 see candesartan cilexetil tab 4 mg .61 aubra tab 0.1-0.02 ...... 87 see candesartan cilexetil tab 8 mg .61 AUGMENTIN ATACAND HCT see amoxicillin & k clavulanate for see candesartan cilexetil- susp 250-62.5 mg/5ml ...... 153 hydrochlorothiazide tab 16-12.5 see amoxicillin & k clavulanate tab mg ...... 64 500-125 mg ...... 153 see candesartan cilexetil- AUGMENTIN ES-600 hydrochlorothiazide tab 32-12.5 see amoxicillin & k clavulanate for mg ...... 64 susp 600-42.9 mg/5ml ...... 153 see candesartan cilexetil- aurovela 24 tab fe 1/20 ...... 87 hydrochlorothiazide tab 32-25 mg aurovela fe tab 1/20 ...... 87 ...... 64 aurovela fe tab 1.5/30 ...... 87 ATACAND HCT TAB 16-12.5 ...... 63 aurovela tab 1/20 ...... 87 ATACAND HCT TAB 32-12.5 ...... 63 aurovela tab 1.5/30 ...... 87 ATACAND HCT TAB 32-25MG ...... 63 AURYXIA TAB 210MG ...... 114 ATACAND TAB 16MG ...... 60 AUSTEDO TAB 12MG ...... 156 ATACAND TAB 32MG ...... 60 AUSTEDO TAB 6MG ...... 156 ATACAND TAB 4MG ...... 60 AUSTEDO TAB 9MG ...... 156 ATACAND TAB 8MG ...... 60 AUVI-Q INJ 0.15MG ...... 165 ATELVIA AUVI-Q INJ 0.3MG ...... 165 see risedronate sodium tab delayed AVALIDE release 35 mg ...... 108 see irbesartan-hydrochlorothiazide ATELVIA TAB ...... 107 tab 150-12.5 mg ...... 65 atenolol & chlorthalidone tab 100-25 see irbesartan-hydrochlorothiazide mg ...... 64 tab 300-12.5 mg ...... 65 atenolol & chlorthalidone tab 50-25 mg AVALIDE TAB 150-12.5 ...... 64 ...... 63 AVALIDE TAB 300-12.5 ...... 64 atenolol tab 100 mg ...... 77 AVAPRO atenolol tab 25 mg ...... 77 see irbesartan tab 150 mg ...... 61 atenolol tab 50 mg ...... 77 see irbesartan tab 300 mg ...... 61 a thru z chw select ...... 137 see irbesartan tab 75 mg ...... 61 atorvastatin calcium tab 10 mg (base AVAPRO TAB 150MG ...... 60 equivalent) ...... 57 AVAPRO TAB 300MG ...... 60 atorvastatin calcium tab 20 mg (base AVAPRO TAB 75MG ...... 60 equivalent) ...... 57 avar cleanse emu 10-5% ...... 95 atorvastatin calcium tab 40 mg (base aviane tab ...... 87 equivalent) ...... 57 avita cre 0.025% ...... 96 atorvastatin calcium tab 80 mg (base AVODART equivalent) ...... 57 see dutasteride cap 0.5 mg ...... 115 atovaquone susp 750 mg/5ml ...... 35 AVODART CAP 0.5MG ...... 115 ATROPINE SULFATE OPHTH OINT 1% AVONEX PEN KIT 30MCG ...... 156 ...... 148 AVONEX PREFL KIT 30MCG ...... 156 ATROPINE SUL SOL 1% OP ...... 148 AYGESTIN ATROVENT HFA AER 17MCG ...... 38 see norethindrone acetate tab 5 mg AUBAGIO TAB 14MG ...... 156 ...... 154 175 AYGESTIN TAB 5MG ...... 153 AZULFIDINE TAB 500MG EN ...... 113 ayuna tab ...... 87 azurette tab ...... 87 AZASITE SOL 1% ...... 149 azurette tab 28 day ...... 88 azathioprine tab 50 mg ...... 134 B azelastine hcl-fluticasone prop nasal b-100 comp tab tr ...... 144 spray 137-50 mcg/act ...... 145 b-100 tr tab ...... 136 azelastine hcl nasal spray 0.1% (137 bacitracin oint 500 unit/gm ...... 96 mcg/spray) ...... 145 bacitracin ophth oint 500 unit/gm ...149 azelastine hcl nasal spray 0.15% bacitracin-polymyxin b ophth oint ...149 (205.5 mcg/spray) ...... 145 bacitracin-polymyxin-neomycin-hc azelastine hcl ophth soln 0.05% .....150 ophth oint 1% ...... 150 AZILECT bacitracin zinc oint 500 unit/gm ...... 96 see rasagiline mesylate tab 0.5 mg baclofen tab 10 mg ...... 144 (base equiv) ...... 75 baclofen tab 20 mg ...... 144 see rasagiline mesylate tab 1 mg baclofen tab 5 mg ...... 144 (base equiv) ...... 75 BACMIN TAB ...... 138 AZILECT TAB 0.5MG ...... 75 bac tab ...... 24 AZILECT TAB 1MG ...... 75 BACTRIM azithromycin for susp 100 mg/5ml ..124 see sulfamethoxazole-trimethoprim azithromycin for susp 200 mg/5ml ..124 tab 400-80 mg ...... 35 azithromycin powd pack for susp 1 gm BACTRIM DS ...... 124 see sulfamethoxazole-trimethoprim azithromycin tab 250 mg ...... 124 tab 800-160 mg ...... 35 azithromycin tab 500 mg ...... 124 BAFIERTAM CAP 95MG ...... 156 azithromycin tab 600 mg ...... 124 balsalazide disodium cap 750 mg ...113 AZOPT balziva tab ...... 88 see brinzolamide ophth susp 1% .151 BAQSIMI ONE POW 3MG/DOSE ...... 47 AZOPT SUS 1% OP ...... 150 BAQSIMI TWO POW 3MG/DOSE ...... 47 AZOR BARACLUDE see amlodipine besylate-olmesartan see entecavir tab 0.5 mg ...... 76 medoxomil tab 10-20 mg ...... 63 see entecavir tab 1 mg ...... 76 see amlodipine besylate-olmesartan BARIATRIC CAP MULTIVIT ...... 138 medoxomil tab 10-40 mg ...... 63 BARIATRIC CHW FUSION ...... 138 see amlodipine besylate-olmesartan BASAGLAR INJ 100UNIT ...... 48 medoxomil tab 5-20 mg ...... 63 BAXDELA TAB 450MG ...... 112 see amlodipine besylate-olmesartan B-COMPLEX INJ ...... 136 medoxomil tab 5-40 mg ...... 63 b-complex inj 100 ...... 136 AZOR TAB 10-20MG ...... 64 B-COMPLEX INJ HYDRXCB ...... 136 AZOR TAB 10-40MG ...... 64 b-complex vitamin cap ...... 136 AZOR TAB 5-20MG ...... 64 b-complex vitamin tab ...... 136 AZOR TAB 5-40MG ...... 64 b-complex w/ c & folic acid cap 1 mg AZULFIDINE ...... 136 see sulfasalazine tab 500 mg ...... 113 b-complex w/ c & folic acid cap 1 mg- AZULFIDINE EN-TABS rx ...... 136 see sulfasalazine tab delayed release b-complex w/ c & folic acid tab ...... 136 500 mg ...... 113 b-complex w/ c & folic acid tab 0.8 mg AZULFIDINE TAB 500MG ...... 113 ...... 136 176 b-complex w/ c & folic acid tab 1 mg see olmesartan medoxomil- ...... 136 hydrochlorothiazide tab 40-25 mg b-complex w/ c & folic acid tab 1 mg- ...... 66 rx ...... 136 BENICAR HCT TAB 20-12.5 ...... 64 b-complex w/ c & folic acid tab 5 mg- BENICAR HCT TAB 40-12.5 ...... 64 rx ...... 136 BENICAR HCT TAB 40-25MG ...... 64 b-complex w/ c cap ...... 136 BENICAR TAB 20MG ...... 60 b-complex w/ c tab ...... 136 BENICAR TAB 40MG ...... 60 BD U-500 MIS 31GX6MM ...... 126 BENICAR TAB 5MG ...... 60 BECONASE AQ SUS 0.042% ...... 146 BENZACLIN BEELITH TAB ...... 132 see clindamycin phosphate-benzoyl bekyree tab ...... 88 peroxide gel 1-5% ...... 96 BELBUCA MIS 150MCG ...... 32 BENZACLIN GEL 1-5% ...... 96 BELBUCA MIS 300MCG ...... 32 BENZACLIN GEL 1-5%PUMP ...... 96 BELBUCA MIS 450MCG ...... 32 BENZAMYCIN BELBUCA MIS 600MCG ...... 32 see benzoyl peroxide-erythromycin BELBUCA MIS 750MCG ...... 32 gel 5-3% ...... 96 BELBUCA MIS 75MCG ...... 32 BENZHY/ACETA TAB 4.08-325 ...... 30 BELBUCA MIS 900MCG ...... 32 BENZHY/ACETA TAB 6.12-325 ...... 30 benazepril & hydrochlorothiazide tab BENZHY/ACETA TAB 8.16-325 ...... 30 10-12.5 mg ...... 64 BENZNIDAZOLE TAB 100MG ...... 34 benazepril & hydrochlorothiazide tab BENZNIDAZOLE TAB 12.5MG ...... 34 20-12.5 mg ...... 64 BENZOCAINE-DOCUSATE SODIUM benazepril & hydrochlorothiazide tab RECTAL ENEMA 20-283 MG ...... 124 20-25 mg ...... 64 benzonatate cap 100 mg ...... 94 benazepril & hydrochlorothiazide tab 5- benzonatate cap 200 mg ...... 94 6.25 mg ...... 64 benzoyl peroxide-erythromycin gel 5- benazepril hcl tab 10 mg ...... 59 3% ...... 96 benazepril hcl tab 20 mg ...... 59 benzoyl peroxide gel 10% ...... 96 benazepril hcl tab 40 mg ...... 59 benzoyl peroxide gel 5% ...... 96 benazepril hcl tab 5 mg ...... 59 benzoyl peroxide liq 10% ...... 96 BENICAR benzoyl peroxide liq 5% ...... 96 see olmesartan medoxomil tab 20 bepotastine besilate ophth soln 1.5% mg ...... 61 ...... 150 see olmesartan medoxomil tab 40 BEPREVE mg ...... 61 see bepotastine besilate ophth soln see olmesartan medoxomil tab 5 mg 1.5% ...... 150 ...... 61 BEPREVE DRO 1.5% ...... 151 BENICAR HCT berocca tab ...... 138 see olmesartan medoxomil- BESER KIT 0.05% ...... 99 hydrochlorothiazide tab 20-12.5 beser lot 0.05% ...... 99 mg ...... 66 BESIVANCE SUS 0.6% ...... 149 see olmesartan medoxomil- betamethasone dipropionate hydrochlorothiazide tab 40-12.5 augmented cream 0.05% ...... 99 mg ...... 66 betamethasone dipropionate augmented gel 0.05% ...... 99

177 betamethasone dipropionate see tobramycin nebu soln 300 augmented lotion 0.05% ...... 99 mg/4ml ...... 19 betamethasone dipropionate BETHKIS NEB 300/4ML ...... 19 augmented oint 0.05% ...... 100 BETOPTIC-S SUS 0.25% OP ...... 147 betamethasone dipropionate cream BEVESPI AER 9-4.8MCG ...... 41 0.05% ...... 100 bexarotene cap 75 mg ...... 71 betamethasone dipropionate lotion BIAXIN XL 0.05% ...... 100 see clarithromycin tab er 24hr 500 betamethasone dipropionate oint mg ...... 125 0.05% ...... 100 bicalutamide tab 50 mg ...... 70 betamethasone valerate aerosol foam BIFERA TAB 28MG ...... 118 0.12% ...... 100 bimatoprost ophth soln 0.03% ...... 151 betamethasone valerate cream 0.1% BINOSTO TAB 70MG ...... 107 (base equivalent) ...... 100 BIO-35 GLUTE CAP FREE ...... 138 betamethasone valerate lotion 0.1% BIO-35 IRON CAP FREE ...... 138 (base equivalent) ...... 100 BIOCAL CAP ...... 138 betamethasone valerate oint 0.1% biopetit elx ...... 136 (base equivalent) ...... 100 biotin cap 5 mg ...... 166 BETAPACE biotin tab 10 mg ...... 166 see sorine tab 120mg ...... 79 biotin tab 5 mg ...... 166 see sorine tab 160mg ...... 79 bisacodyl suppos 10 mg ...... 123 see sorine tab 80mg ...... 79 bisacodyl tab delayed release 5 mg .123 see sotalol hcl tab 120 mg ...... 79 bismuth subsalicylate chew tab 262 mg see sotalol hcl tab 160 mg ...... 79 ...... 51 see sotalol hcl tab 80 mg ...... 79 bismuth subsalicylate susp 262 BETAPACE AF mg/15ml ...... 51 see sotalol hcl (afib/afl) tab 120 mg bismuth subsalicylate susp 525 ...... 79 mg/15ml ...... 51 see sotalol hcl (afib/afl) tab 160 mg bismuth subsalicylate tab 262 mg ....51 ...... 79 bisoprolol & hydrochlorothiazide tab see sotalol hcl (afib/afl) tab 80 mg 79 10-6.25 mg ...... 64 BETAPACE AF TAB 120MG ...... 78 bisoprolol & hydrochlorothiazide tab BETAPACE AF TAB 160MG ...... 78 2.5-6.25 mg ...... 64 BETAPACE AF TAB 80MG ...... 78 bisoprolol & hydrochlorothiazide tab 5- BETAPACE TAB 120MG ...... 78 6.25 mg ...... 64 BETAPACE TAB 160MG ...... 78 bisoprolol fumarate tab 10 mg ...... 77 BETAPACE TAB 80MG ...... 78 bisoprolol fumarate tab 5 mg ...... 77 BETASERON INJ 0.3MG ...... 156 BLADDER 2.2 TAB ...... 105 betaxolol hcl ophth soln 0.5% ...... 147 BLEPH-10 betaxolol hcl tab 10 mg ...... 77 see sulfacetamide sodium ophth soln betaxolol hcl tab 20 mg ...... 77 10% ...... 149 bethanechol chloride tab 10 mg ...... 164 blisovi 24 tab fe 1/20 ...... 88 bethanechol chloride tab 25 mg ...... 164 blisovi fe tab 1/20 ...... 88 bethanechol chloride tab 50 mg ...... 164 blisovi fe tab 1.5/30 ...... 88 bethanechol chloride tab 5 mg ...... 164 BONE DENSITY TAB ...... 130 BETHKIS BONIVA

178 see ibandronate sodium tab 150 mg budesonide tab er 24hr 9 mg ...... 93 (base equivalent) ...... 108 BUFFERIN TAB 325MG ...... 25 BONIVA INJ 3MG/3ML ...... 107 bumetanide tab 0.5 mg ...... 106 BONIVA TAB 150MG ...... 107 bumetanide tab 1 mg ...... 106 BOOSTRIX INJ ...... 160 bumetanide tab 2 mg ...... 106 bosentan tab 125 mg ...... 85 BUMEX bosentan tab 62.5 mg ...... 85 see bumetanide tab 0.5 mg ...... 106 bprotected sol tri-vite ...... 143 buprenorphine td patch weekly 10 BRAFTOVI CAP 75MG ...... 71 mcg/hr ...... 32 BREATHERITE MIS MDI CHMB ...... 127 buprenorphine td patch weekly 15 BREO ELLIPTA INH 100-25 ...... 41 mcg/hr ...... 32 BREO ELLIPTA INH 200-25 ...... 41 buprenorphine td patch weekly 20 brewers yeast tab ...... 136 mcg/hr ...... 32 BREZTRI AERO AER SPHERE ...... 41 buprenorphine td patch weekly 5 briellyn tab ...... 88 mcg/hr ...... 32 BRILINTA TAB 60MG ...... 116 buprenorphine td patch weekly 7.5 BRILINTA TAB 90MG ...... 116 mcg/hr ...... 32 brimonidine tartrate ophth soln 0.15% bupropion hcl (smoking deterrent) tab ...... 148 er 12hr 150 mg ...... 157 brimonidine tartrate ophth soln 0.2% butalbital-acetaminophen-caffeine tab ...... 148 50-325-40 mg ...... 24 brinzolamide ophth susp 1% ...... 151 butalbital-acetaminophen-caff w/ cod bromfenac sodium ophth soln 0.09% cap 50-300-40-30 mg ...... 30 (base equiv) (once-daily) ...... 151 butalbital-acetaminophen-caff w/ cod bromocriptine mesylate cap 5 mg (base cap 50-325-40-30 mg ...... 30 equivalent) ...... 72 butalbital-acetaminophen tab 50-325 bromocriptine mesylate tab 2.5 mg mg ...... 24 (base equivalent) ...... 72 butalbital-aspirin-caffeine cap 50-325- brompheniramine & pseudoephedrine 40 mg ...... 24 elixir 1-15 mg/5ml ...... 94 butalbital-aspirin-caff w/ codeine cap BROMSITE DRO 0.075% ...... 151 50-325-40-30 mg ...... 31 BROVANA butenafine hcl cream 1% ...... 97 see arformoterol tartrate soln nebu butorphanol tartrate nasal soln 10 15 mcg/2ml (base equiv) ...... 41 mg/ml ...... 32 BROVANA NEB 15MCG ...... 41 BUTRANS BRYHALI LOT 0.01% ...... 100 see buprenorphine td patch weekly budesonide-formoterol fumarate dihyd 10 mcg/hr ...... 32 aerosol 160-4.5 mcg/act ...... 41 see buprenorphine td patch weekly budesonide-formoterol fumarate dihyd 15 mcg/hr ...... 32 aerosol 80-4.5 mcg/act ...... 41 see buprenorphine td patch weekly budesonide inhalation susp 0.25 20 mcg/hr ...... 32 mg/2ml ...... 40 see buprenorphine td patch weekly 5 budesonide inhalation susp 0.5 mg/2ml mcg/hr ...... 32 ...... 39 see buprenorphine td patch weekly budesonide inhalation susp 1 mg/2ml 7.5 mcg/hr ...... 32 ...... 40 BUTRANS DIS 10MCG/HR ...... 32 budesonide sus 32mcg ...... 146 BUTRANS DIS 15MCG/HR ...... 32 179 BUTRANS DIS 20MCG/HR ...... 32 CALAN SR TAB 120MG ...... 80 BUTRANS DIS 5MCG/HR ...... 32 CALAN SR TAB 180MG ...... 80 BUTRANS DIS 7.5/HR ...... 32 CALAN SR TAB 240MG ...... 80 BYDUREON BC INJ 2/0.85ML ...... 47 CALCET PETIT TAB 200-250 ...... 130 BYETTA INJ 10MCG ...... 47 calcidol dro 8000/ml ...... 166 BYETTA INJ 5MCG ...... 47 calcipotriene oint 0.005% ...... 98 BYSTOLIC TAB 10MG ...... 77 calcipotriene soln 0.005% (50 mcg/ml) BYSTOLIC TAB 2.5MG ...... 77 ...... 98 BYSTOLIC TAB 20MG ...... 77 calcitonin (salmon) inj 200 unit/ml .107 BYSTOLIC TAB 5MG ...... 77 calcitonin (salmon) nasal soln 200 C unit/act ...... 108 cabergoline tab 0.5 mg ...... 110 calcitrene oin 0.005% ...... 99 ca citrate + tab ...... 133 calcitriol cap 0.25 mcg ...... 109 CA CITRATE TAB 250MG ...... 130 calcitriol cap 0.5 mcg ...... 109 CADUET calcitriol oral soln 1 mcg/ml ...... 109 see amlodipine besylate-atorvastatin calcium/d3 tab ...... 131 calcium tab 10-10 mg ...... 84 calcium/d3 tab 600-800 ...... 131 see amlodipine besylate-atorvastatin calcium+d3 tab grad rel ...... 131 calcium tab 10-20 mg ...... 84 calcium + d chw ...... 130 see amlodipine besylate-atorvastatin calcium 600 chw +d/miner ...... 130 calcium tab 10-40 mg ...... 84 calcium acetate (phosphate binder) cap see amlodipine besylate-atorvastatin 667 mg (169 mg ca) ...... 114 calcium tab 10-80 mg ...... 84 calcium acetate (phosphate binder) tab see amlodipine besylate-atorvastatin 667 mg ...... 114 calcium tab 5-10 mg ...... 84 CALCIUM CARB CHW 260MG ...... 130 see amlodipine besylate-atorvastatin CALCIUM CARB CHW 500MG ...... 130 calcium tab 5-20 mg ...... 84 calcium carbonate (antacid) chew tab see amlodipine besylate-atorvastatin 1000 mg ...... 34 calcium tab 5-40 mg ...... 84 calcium carbonate (antacid) chew tab see amlodipine besylate-atorvastatin 400 mg ...... 34 calcium tab 5-80 mg ...... 84 calcium carbonate (antacid) chew tab CADUET TAB 10-10MG ...... 84 500 mg ...... 34 CADUET TAB 10-20MG ...... 84 calcium carbonate (antacid) chew tab CADUET TAB 10-40MG ...... 84 750 mg ...... 34 CADUET TAB 10-80MG ...... 84 calcium carbonate (antacid) susp 1250 CADUET TAB 5-10MG ...... 84 mg/5ml ...... 34 CADUET TAB 5-20MG ...... 84 calcium carbonate-cholecalciferol chew CADUET TAB 5-40MG ...... 84 tab 500 mg-400 unit ...... 130 CADUET TAB 5-80MG ...... 84 calcium carbonate-cholecalciferol tab caffeine citrate oral soln 60 mg/3ml 250 mg-125 unit ...... 130 (10 mg/ml base equiv) ...... 19 calcium carbonate-cholecalciferol tab CA GLUCONATE TAB 50MG ...... 130 500 mg-200 unit ...... 130 CAL/MAG TAB CHEW ...... 130 calcium carbonate-cholecalciferol tab CA LACTATE TAB 100MG ...... 130 500 mg-400 unit ...... 130 CALAN SR calcium carbonate-cholecalciferol tab see verapamil hcl tab er 120 mg ...83 600 mg-400 unit ...... 130 see verapamil hcl tab er 240 mg ...83 180 calcium carbonate-cholecalciferol tab camila tab 0.35mg ...... 92 600 mg-800 unit ...... 130 candesartan cilexetil- calcium carbonate-mag hydroxide susp hydrochlorothiazide tab 16-12.5 mg 400-135 mg/5ml ...... 33 ...... 64 calcium carbonate tab 1500 mg (600 candesartan cilexetil- mg elemental ca) ...... 130 hydrochlorothiazide tab 32-12.5 mg calcium carbonate-vitamin d cap 600 ...... 64 mg-200 unit ...... 130 candesartan cilexetil- calcium carbonate-vitamin d tab 500 hydrochlorothiazide tab 32-25 mg .64 mg-200 unit ...... 130 candesartan cilexetil tab 16 mg ...... 61 calcium carbonate-vitamin d tab 500 candesartan cilexetil tab 32 mg ...... 61 mg-400 unit ...... 130 candesartan cilexetil tab 4 mg ...... 61 calcium carbonate-vitamin d tab 600 candesartan cilexetil tab 8 mg ...... 61 mg-200 unit ...... 130 capecitabine tab 150 mg ...... 69 calcium carbonate-vitamin d tab 600 capecitabine tab 500 mg ...... 69 mg-400 unit ...... 131 CAPEX SHA 0.01% ...... 100 CALCIUM CARB POW 800/2GM ...... 130 captopril tab 100 mg ...... 59 calcium carb-vit d w/ minerals chew captopril tab 12.5 mg ...... 59 tab 600 mg-400 unit ...... 130 captopril tab 25 mg ...... 59 calcium carb-vit d w/ minerals chew captopril tab 50 mg ...... 59 tab 600 mg-800 unit ...... 130 CARAC calcium chloride inj 10% ...... 131 see fluorouracil cream 0.5% ...... 98 calcium citrate-vitamin d tab 200 mg- CARAFATE 250 unit (elemental ca) ...... 131 see sucralfate tab 1 gm ...... 160 calcium citrate-vitamin d tab 250 mg- carbidopa & levodopa orally 200 unit (elemental ca) ...... 131 disintegrating tab 10-100 mg ...... 72 calcium citrate-vitamin d tab 315 mg- carbidopa & levodopa orally 200 unit (elemental ca) ...... 131 disintegrating tab 25-100 mg ...... 73 calcium citrate-vitamin d tab 315 mg- carbidopa & levodopa orally 250 unit (elemental ca) ...... 131 disintegrating tab 25-250 mg ...... 73 CALCIUM GLUC INJ 10% ...... 131 carbidopa & levodopa tab 10-100 mg 73 CALCIUM GRA CITRATE ...... 131 carbidopa & levodopa tab 25-100 mg 73 calcium-magnesium-zinc tab 333-133- carbidopa & levodopa tab 25-250 mg 73 5 mg ...... 131 carbidopa & levodopa tab er 25-100 calcium plus tab 600 +d ...... 131 mg ...... 73 calcium polycarbophil tab 625 mg ...121 carbidopa & levodopa tab er 50-200 calcium soft chw mlk choc ...... 131 mg ...... 73 CALCIUM TAB FORMULA ...... 131 carbidopa-levodopa-entacapone tabs calcium w/ magnesium tab 500-250 12.5-50-200 mg ...... 73 mg ...... 131 carbidopa-levodopa-entacapone tabs CALMAG THINS TAB 200-50MG ...... 131 18.75-75-200 mg ...... 73 cal-mag-zinc tab +d3 ...... 133 carbidopa-levodopa-entacapone tabs CAL-MINT CHW 260MG ...... 130 25-100-200 mg ...... 73 calphron tab 667mg ...... 114 carbidopa-levodopa-entacapone tabs CAL-QUICK LIQ 500-400 ...... 130 31.25-125-200 mg ...... 73 CALTRATE +D3 TAB 600-800 ...... 131 carbidopa-levodopa-entacapone tabs CALTRATE 600 CHW 600-800 ...... 131 37.5-150-200 mg ...... 73 181 carbidopa-levodopa-entacapone tabs see matzim la tab 240mg/24 ...... 82 50-200-200 mg ...... 73 see matzim la tab 300mg/24 ...... 82 carbidopa tab 25 mg ...... 72 see matzim la tab 360mg/24 ...... 82 carbinoxamine maleate soln 4 mg/5ml see matzim la tab 420mg/24 ...... 82 ...... 54 CARDIZEM LA TAB 120MG ...... 80 carbinoxamine maleate tab 4 mg .....54 CARDIZEM LA TAB 180MG ...... 80 carbonyl tab fe 45mg ...... 120 CARDIZEM LA TAB 240MG ...... 80 carboxymethylcellulose sodium (pf) CARDIZEM LA TAB 300MG/24 ...... 80 ophth soln 0.5% ...... 147 CARDIZEM LA TAB 360MG ...... 80 carboxymethylcellulose sodium ophth CARDIZEM LA TAB 420MG/24 ...... 80 soln 0.5% ...... 147 CARDIZEM TAB 120MG ...... 80 CARDIZEM CARDIZEM TAB 30MG ...... 80 see diltiazem hcl tab 120 mg ...... 81 CARDIZEM TAB 60MG ...... 80 see diltiazem hcl tab 30 mg ...... 81 CARDURA see diltiazem hcl tab 60 mg ...... 81 see doxazosin mesylate tab 1 mg ..62 CARDIZEM CD see doxazosin mesylate tab 2 mg ..62 see cartia xt cap 120/24hr ...... 80 see doxazosin mesylate tab 4 mg ..62 see cartia xt cap 180/24hr ...... 80 see doxazosin mesylate tab 8 mg ..62 see cartia xt cap 240/24hr ...... 80 CARDURA TAB 1MG ...... 62 see cartia xt cap 300/24hr ...... 80 CARDURA TAB 2MG ...... 62 see diltiazem hcl coated beads cap er CARDURA TAB 4MG ...... 62 24hr 120 mg ...... 81 CARDURA TAB 8MG ...... 62 see diltiazem hcl coated beads cap er CARDURA XL TAB 4MG ...... 115 24hr 180 mg ...... 81 CARDURA XL TAB 8MG ...... 115 see diltiazem hcl coated beads cap er carteolol hcl ophth soln 1% ...... 147 24hr 240 mg ...... 81 cartia xt cap 120/24hr ...... 80 see diltiazem hcl coated beads cap er cartia xt cap 180/24hr ...... 80 24hr 300 mg ...... 81 cartia xt cap 240/24hr ...... 80 see diltiazem hcl coated beads cap er cartia xt cap 300/24hr ...... 80 24hr 360 mg ...... 81 carvedilol phosphate cap er 24hr 10 CARDIZEM CD CAP 120MG/24 ...... 80 mg ...... 77 CARDIZEM CD CAP 180MG/24 ...... 80 carvedilol phosphate cap er 24hr 20 CARDIZEM CD CAP 240MG/24 ...... 80 mg ...... 77 CARDIZEM CD CAP 300MG/24 ...... 80 carvedilol phosphate cap er 24hr 40 CARDIZEM CD CAP 360MG/24 ...... 80 mg ...... 77 CARDIZEM LA carvedilol phosphate cap er 24hr 80 see diltiazem hcl coated beads tab er mg ...... 77 24hr 180 mg ...... 81 carvedilol tab 12.5 mg ...... 77 see diltiazem hcl coated beads tab er carvedilol tab 25 mg ...... 77 24hr 240 mg ...... 81 carvedilol tab 3.125 mg ...... 77 see diltiazem hcl coated beads tab er carvedilol tab 6.25 mg ...... 77 24hr 300 mg ...... 81 CASODEX see diltiazem hcl coated beads tab er see bicalutamide tab 50 mg ...... 70 24hr 360 mg ...... 81 CASTOR OIL ...... 87 see diltiazem hcl coated beads tab er castor oil 100% ...... 123 24hr 420 mg ...... 81 CATAPRES-TTS-1 see matzim la tab 180mg/24 ...... 82 182 see clonidine td patch weekly 0.1 CELEBRATE CHW 36 ...... 138 mg/24hr ...... 62 CELEBRATE CHW 45 ...... 138 CATAPRES-TTS-2 CELEBRATE CHW 60 ...... 138 see clonidine td patch weekly 0.2 CELEBREX mg/24hr ...... 62 see celecoxib cap 100 mg ...... 21 CATAPRES-TTS-3 see celecoxib cap 200 mg ...... 21 see clonidine td patch weekly 0.3 see celecoxib cap 400 mg ...... 21 mg/24hr ...... 62 see celecoxib cap 50 mg ...... 20 CATAPRES-TTS DIS 0.1/24HR ...... 62 CELEBREX CAP 100MG ...... 20 CATAPRES-TTS DIS 0.2/24HR ...... 62 CELEBREX CAP 200MG ...... 20 CATAPRES-TTS DIS 0.3/24HR ...... 62 CELEBREX CAP 400MG ...... 20 CAYA DPR ...... 125 CELEBREX CAP 50MG ...... 20 CAYSTON INH 75MG ...... 36 celecoxib cap 100 mg ...... 21 caziant pak ...... 88 celecoxib cap 200 mg ...... 21 cefaclor cap 250 mg ...... 86 celecoxib cap 400 mg ...... 21 cefaclor cap 500 mg ...... 86 celecoxib cap 50 mg ...... 20 CEFACLOR ER TAB 500MG ...... 86 CELLCEPT cefaclor for susp 125 mg/5ml ...... 86 see mycophenolate mofetil cap 250 cefaclor for susp 250 mg/5ml ...... 86 mg ...... 134 cefaclor for susp 375 mg/5ml ...... 86 see mycophenolate mofetil for oral cefadroxil cap 500 mg ...... 86 susp 200 mg/ml ...... 135 cefadroxil for susp 250 mg/5ml ...... 86 see mycophenolate mofetil tab 500 cefadroxil for susp 500 mg/5ml ...... 86 mg ...... 135 cefadroxil tab 1 gm ...... 86 CENTANY AT KIT 2% ...... 96 cefdinir cap 300 mg ...... 87 CENTANY OIN 2% ...... 97 cefdinir for susp 125 mg/5ml ...... 87 CENTRATEX CAP ...... 118 cefdinir for susp 250 mg/5ml ...... 87 CENTRUM 50+ CHW FRSH/FRU ...... 138 cefixime cap 400 mg ...... 87 CENTRUM CHW ...... 138 cefixime for susp 100 mg/5ml ...... 87 CENTRUM CHW FLAV BST ...... 138 cefixime for susp 200 mg/5ml ...... 87 CENTRUM CHW SILVER ...... 138 cefpodoxime proxetil for susp 100 CENTRUM CHW VITAMINT ...... 138 mg/5ml ...... 87 CENTRUM KIDS CHW ...... 142 cefpodoxime proxetil for susp 50 CENTRUM KIDS CHW FLAV BST ...... 142 mg/5ml ...... 87 CENTRUM MULT CHW OMEGA 3 ...... 138 cefpodoxime proxetil tab 100 mg .....87 CENTRUM POW DRINK ...... 138 cefpodoxime proxetil tab 200 mg .....87 CENTRUM SILV TAB 50+MEN ...... 138 cefprozil for susp 125 mg/5ml ...... 86 CENTRUM SILV TAB 50+WOMEN ....138 cefprozil for susp 250 mg/5ml ...... 86 CENTRUM SILV TAB ADULT 50 ...... 138 cefprozil tab 250 mg ...... 86 CENTRUM SPEC TAB ENERGY ...... 144 cefprozil tab 500 mg ...... 86 CENTRUM SPEC TAB HEART ...... 138 cefuroxime axetil tab 250 mg ...... 86 CENTRUM SPEC TAB IMMUNE ...... 138 cefuroxime axetil tab 500 mg ...... 87 CENTRUM SPEC TAB VISION ...... 138 CELEBRATE CAP 18 ...... 138 CENTRUM TAB ADULTS ...... 138 CELEBRATE CAP 36 ...... 138 CENTRUM TAB CARDIO ...... 138 CELEBRATE CAP 45 ...... 138 CENTRUM TAB MEN ...... 138 CELEBRATE CAP 60 ...... 138 CENTRUM TAB PERFORMA ...... 144 CELEBRATE CHW 18 ...... 138 CENTRUM TAB SILVER ...... 138 183 CENTRUM TAB ULTRA ...... 138 cholecalciferol cap 1000 unit ...... 166 CENTRUM TAB WOMEN ...... 138 cholecalciferol cap 10 mcg (400 unit) CEO-TWO SUP ...... 122 ...... 166 cephalexin cap 250 mg ...... 86 cholecalciferol cap 2000 unit ...... 166 cephalexin cap 500 mg ...... 86 cholecalciferol cap 50000 unit ...... 166 cephalexin cap 750 mg ...... 86 cholecalciferol cap 5000 unit ...... 166 cephalexin for susp 125 mg/5ml ...... 86 cholecalciferol chew tab 400 unit ....166 cephalexin for susp 250 mg/5ml ...... 86 cholecalciferol oral liquid 400 unit/ml cephalexin tab 250 mg ...... 86 ...... 166 cephalexin tab 500 mg ...... 86 cholecalciferol tab 1000 unit ...... 166 CERTAVITE TAB SENIOR ...... 138 cholecalciferol tab 2000 unit ...... 166 cetirizine chw 10mg ...... 54 cholecalciferol tab 400 unit ...... 166 cetirizine chw 5mg ...... 54 cholecalciferol tab 5000 unit ...... 166 cetirizine hcl oral soln 1 mg/ml (5 cholestyramine light powder 4 gm/dose mg/5ml) ...... 54 ...... 55 cetirizine hcl tab 10 mg ...... 54 cholestyramine light powder packets 4 cetirizine hcl tab 5 mg ...... 54 gm ...... 55 cetirizine-pseudoephedrine tab er 12hr cholestyramine powder 4 gm/dose ...55 5-120 mg ...... 94 cholestyramine powder packets 4 gm55 CHANTIX PAK 0.5& 1MG ...... 157 choline fenofibrate cap dr 135 mg CHANTIX PAK 1MG ...... 157 (fenofibric acid equiv) ...... 56 CHANTIX TAB 0.5MG ...... 158 choline fenofibrate cap dr 45 mg CHANTIX TAB 1MG ...... 158 (fenofibric acid equiv) ...... 56 charlotte 24 chw fe 1/20 ...... 88 chromagen cap ...... 118 chateal eq tab 0.15/30 ...... 88 ciclodan sol 8% ...... 97 chateal tab 0.15/30 ...... 88 ciclopirox gel 0.77% ...... 97 CHELATED CA TAB 200MG ...... 131 ciclopirox kit 8% ...... 97 CHEMET CAP 100MG ...... 51 ciclopirox olamine cream 0.77% (base CHEMSTRIP TES UGK ...... 105 equiv) ...... 97 chlorhexidine gluconate soln 0.12% 135 ciclopirox olamine susp 0.77% (base CHLORHEXIDINE GLUCONATE SOLN equiv) ...... 97 0.12% ciclopirox shampoo 1% ...... 97 see chlorhexidine gluconate soln ciclopirox solution 8% ...... 97 0.12% ...... 135 cilostazol tab 100 mg ...... 116 chloroquine phosphate tab 250 mg ...68 cilostazol tab 50 mg ...... 116 chloroquine phosphate tab 500 mg ...68 CILOXAN chlorpheniramine tab 4 mg ...... 53 see ciprofloxacin hcl ophth soln 0.3% chlorpheniramine tab er 12 mg ...... 54 (base equivalent) ...... 149 chlorthalidone tab 25 mg ...... 107 CILOXAN OIN 0.3% OP ...... 149 chlorthalidone tab 50 mg ...... 107 CILOXAN SOL 0.3% OP ...... 149 CHLOR-TRIMET TAB 4MG ...... 53 cimetidine tab 200 mg ...... 160 chlorzoxazone tab 375 mg ...... 144 cimetidine tab 300 mg ...... 160 chlorzoxazone tab 500 mg ...... 144 cimetidine tab 400 mg ...... 160 chlorzoxazone tab 750 mg ...... 144 cimetidine tab 800 mg ...... 160 CHLORZOXAZON TAB 250MG ...... 144 CIMZIA KIT 200MG ...... 113 CHOICEFUL CAP MULTIVIT ...... 138 CIMZIA PREFL KIT 200MG/ML ...... 113 CHOICEFUL CHW MULTIVIT ...... 139 CIMZIA START KIT 200MG/ML ...... 113 184 cinacalcet hcl tab 30 mg (base equiv) clemastine fumarate tab 1.34 mg .....54 ...... 109 clemastine fumarate tab 2.68 mg .....54 cinacalcet hcl tab 60 mg (base equiv) CLENPIQ SOL ...... 122 ...... 109 CLEOCIN cinacalcet hcl tab 90 mg (base equiv) see clindamycin hcl cap 150 mg ....36 ...... 109 see clindamycin hcl cap 300 mg ....36 CIPRO see clindamycin hcl cap 75 mg ...... 36 see ciprofloxacin hcl tab 250 mg see clindamycin phosphate vaginal (base equiv)...... 112 cream 2% ...... 165 see ciprofloxacin hcl tab 500 mg CLEOCIN CRE 2% VAG ...... 165 (base equiv)...... 112 CLEOCIN PEDIATRIC GRANULE CIPRO (10%) SUS 500MG/5 ...... 112 see clindamycin palmitate hcl for soln CIPRO (5%) SUS 250MG/5 ...... 112 75 mg/5ml (base equiv) ...... 36 CIPRODEX CLEOCIN SUP 100MG ...... 165 see ciprofloxacin-dexamethasone otic CLIMARA susp 0.3-0.1% ...... 152 see estradiol td patch weekly 0.025 CIPRODEX SUS 0.3-0.1% ...... 152 mg/24hr ...... 111 ciprofloxacin-dexamethasone otic susp see estradiol td patch weekly 0.0375 0.3-0.1% ...... 152 mg/24hr (37.5 mcg/24hr) ...... 111 ciprofloxacin-fluocinolone aceton (pf) see estradiol td patch weekly 0.05 otic soln 0.3-0.025% ...... 152 mg/24hr ...... 111 ciprofloxacin hcl ophth soln 0.3% (base see estradiol td patch weekly 0.06 equivalent) ...... 149 mg/24hr ...... 111 ciprofloxacin hcl otic soln 0.2% (base see estradiol td patch weekly 0.075 equivalent) ...... 152 mg/24hr ...... 111 ciprofloxacin hcl tab 100 mg (base see estradiol td patch weekly 0.1 equiv) ...... 112 mg/24hr ...... 111 ciprofloxacin hcl tab 250 mg (base clindacin mis etz 1% ...... 96 equiv) ...... 112 clindacin-p pad 1% ...... 96 ciprofloxacin hcl tab 500 mg (base clindamycin hcl cap 150 mg ...... 36 equiv) ...... 112 clindamycin hcl cap 300 mg ...... 36 ciprofloxacin hcl tab 750 mg (base clindamycin hcl cap 75 mg ...... 36 equiv) ...... 112 clindamycin palmitate hcl for soln 75 CIPRO HC SUS OTIC ...... 152 mg/5ml (base equiv) ...... 36 CIPRO TAB 250MG ...... 112 clindamycin phosphate-benzoyl CIPRO TAB 500MG ...... 112 peroxide gel 1.2-2.5% ...... 96 CITRACAL+D3 CHW 250-500 ...... 131 clindamycin phosphate-benzoyl CITRACAL+D3 TAB MAXIMUM ...... 131 peroxide gel 1-5% ...... 96 CITRACAL PLS TAB ...... 133 clindamycin phosphate soln 1% ...... 96 CLARINEX clindamycin phosphate swab 1% ...... 96 see desloratadine tab 5 mg ...... 54 clindamycin phosphate vaginal cream CLARINEX TAB 5MG ...... 54 2% ...... 165 clarithromycin for susp 125 mg/5ml 125 clindamycin phosph-benzoyl peroxide clarithromycin for susp 250 mg/5ml 125 (refrig) gel 1.2 (1)-5% ...... 96 clarithromycin tab 250 mg ...... 125 CLINDESSE CRE 2% ...... 165 clarithromycin tab 500 mg ...... 125 clobetasol propionate cream 0.05% 100 clarithromycin tab er 24hr 500 mg ..125 185 clobetasol propionate emollient base clotrimazole vaginal cream 2% ...... 165 cream 0.05% ...... 100 clotrimazole w/ betamethasone cream clobetasol propionate emulsion foam 1-0.05% ...... 97 0.05% ...... 100 clotrimazole w/ betamethasone lotion clobetasol propionate foam 0.05% ..100 1-0.05% ...... 97 clobetasol propionate gel 0.05% .....100 codeine sulfate tab 30 mg ...... 25 clobetasol propionate lotion 0.05% .100 CODEINE SULF TAB 15MG ...... 25 clobetasol propionate oint 0.05% ...100 CODEINE SULF TAB 60MG ...... 25 clobetasol propionate shampoo 0.05% COLACE CLEAR CAP 50MG ...... 124 ...... 100 COLAZAL clobetasol propionate soln 0.05% ...100 see balsalazide disodium cap 750 mg clobetasol propionate spray 0.05% .100 ...... 113 CLOBEX COLAZAL CAP 750MG ...... 113 see clobetasol propionate lotion colchicine cap 0.6 mg ...... 116 0.05% ...... 100 colchicine tab 0.6 mg ...... 116 see clobetasol propionate shampoo colchicine w/ probenecid tab 0.5-500 0.05% ...... 100 mg ...... 116 see clobetasol propionate spray COLCRYS 0.05% ...... 100 see colchicine tab 0.6 mg ...... 116 see clodan sha 0.05% ...... 100 COLCRYS TAB 0.6MG ...... 116 CLOBEX LOT 0.05% ...... 100 cold/flu liq daytime ...... 94 CLOBEX SHA 0.05% ...... 100 colesevelam hcl packet for susp 3.75 CLOBEX SPR 0.05% ...... 100 gm ...... 55 clocortolone pivalate cream 0.1% ...100 colesevelam hcl tab 625 mg ...... 55 CLODAN KIT 0.05% ...... 100 COLESTID clodan sha 0.05% ...... 100 see colestipol hcl granule packets 5 CLODERM gm ...... 56 see clocortolone pivalate cream 0.1% see colestipol hcl granules 5 gm ....56 ...... 100 see colestipol hcl tab 1 gm ...... 56 CLODERM CRE 0.1% ...... 100 COLESTID FLA GRA 5/7.5GM ...... 55 clonidine hcl tab 0.1 mg ...... 62 COLESTID FLA GRA 5GM ...... 56 clonidine hcl tab 0.2 mg ...... 62 COLESTID GRA 5GM ...... 56 clonidine hcl tab 0.3 mg ...... 62 COLESTID POW 5GM ...... 56 clonidine td patch weekly 0.1 mg/24hr COLESTID TAB 1GM ...... 56 ...... 62 colestipol hcl granule packets 5 gm ..56 clonidine td patch weekly 0.2 mg/24hr colestipol hcl granules 5 gm ...... 56 ...... 62 colestipol hcl tab 1 gm ...... 56 clonidine td patch weekly 0.3 mg/24hr COMBIGAN SOL 0.2/0.5% ...... 147 ...... 62 COMBIVENT AER 20-100 ...... 41 clopidogrel bisulfate tab 300 mg (base COMPLETENATE CHW ...... 143 equiv) ...... 117 compro sup 25mg ...... 75 clopidogrel bisulfate tab 75 mg (base COMTAN equiv) ...... 117 see entacapone tab 200 mg ...... 72 clotrimazole cream 1% ...... 97 COMTAN TAB 200MG ...... 72 clotrimazole soln 1% ...... 97 CO-NATAL FA TAB 29-1MG ...... 143 clotrimazole troche 10 mg ...... 135 CONDOMS - FEMALE ...... 125 clotrimazole vaginal cream 1% ...... 165 CONDOMS LATEX LUBRICATED ...... 125 186 CONDOMS LATEX NON-LUBRICATED CORGARD TAB 40MG ...... 78 ...... 125 CORGARD TAB 80MG ...... 78 constulose sol 10gm/15 ...... 122 corn dextrin oral powder ...... 121 CONZIP CAP 100MG ...... 25 CORTEF CONZIP CAP 200MG ...... 25 see hydrocortisone tab 10 mg ...... 93 CONZIP CAP 300MG ...... 25 see hydrocortisone tab 20 mg ...... 93 COPAXONE see hydrocortisone tab 5 mg ...... 93 see glatiramer acetate soln prefilled corvita 150 tab ...... 118 syringe 20 mg/ml ...... 156 corvita tab ...... 139 see glatiramer acetate soln prefilled CORVITE 150 TAB ...... 119 syringe 40 mg/ml ...... 157 CORVITE FE TAB ...... 119 see glatopa inj 20mg/ml ...... 157 COSENTYX INJ 150MG/ML ...... 99 see glatopa inj 40mg/ml ...... 157 COSENTYX INJ 300DOSE ...... 99 COPAXONE INJ 20MG/ML ...... 156 COSENTYX PEN INJ 150MG/ML ...... 99 COPAXONE INJ 40MG/ML ...... 156 COSENTYX PEN INJ 300DOSE ...... 99 CORDRAN COSOPT see flurandrenolide cream 0.05% 101 see dorzolamide hcl-timolol maleate see flurandrenolide lotion 0.05% .101 ophth soln 22.3-6.8 mg/ml ...... 147 see flurandrenolide oint 0.05% ....102 COSOPT PF SOL 2%-0.5% ...... 147 CORDRAN 80X3 TAP 4MCG/CM ...... 100 COSOPT SOL 22.3-6.8 ...... 147 COREG COZAAR see carvedilol tab 12.5 mg ...... 77 see losartan potassium tab 100 mg61 see carvedilol tab 25 mg ...... 77 see losartan potassium tab 25 mg .61 see carvedilol tab 3.125 mg ...... 77 see losartan potassium tab 50 mg .61 see carvedilol tab 6.25 mg ...... 77 COZAAR TAB 100MG ...... 61 COREG CR COZAAR TAB 25MG ...... 61 see carvedilol phosphate cap er 24hr COZAAR TAB 50MG ...... 61 10 mg ...... 77 CREON CAP 12000UNT ...... 105 see carvedilol phosphate cap er 24hr CREON CAP 24000UNT ...... 105 20 mg ...... 77 CREON CAP 3000UNIT ...... 105 see carvedilol phosphate cap er 24hr CREON CAP 36000UNT ...... 106 40 mg ...... 77 CREON CAP 6000UNIT ...... 105 see carvedilol phosphate cap er 24hr CRESEMBA CAP 186 MG ...... 53 80 mg ...... 77 CRESTOR COREG CR CAP 10MG ...... 77 see rosuvastatin calcium tab 10 mg COREG CR CAP 20MG ...... 77 ...... 58 COREG CR CAP 40MG ...... 77 see rosuvastatin calcium tab 20 mg COREG CR CAP 80MG ...... 77 ...... 58 COREG TAB 12.5MG ...... 77 see rosuvastatin calcium tab 40 mg COREG TAB 25MG ...... 77 ...... 58 COREG TAB 3.125MG ...... 77 see rosuvastatin calcium tab 5 mg .58 COREG TAB 6.25MG ...... 77 CRESTOR TAB 10MG ...... 57 CORGARD CRESTOR TAB 20MG ...... 57 see nadolol tab 20 mg ...... 79 CRESTOR TAB 40MG ...... 57 see nadolol tab 40 mg ...... 79 CRESTOR TAB 5MG ...... 57 see nadolol tab 80 mg ...... 79 CRINONE GEL 4% VAG ...... 165 CORGARD TAB 20MG ...... 78 CRINONE GEL 8% VAG ...... 165 187 cromolyn sodium nasal aerosol soln 5.2 cyred eq tab ...... 88 mg/act (4%) ...... 146 cyred tab ...... 88 cromolyn sodium ophth soln 4% .....151 CYTO B7 LIQ 5MG/ML ...... 166 cromolyn sodium soln nebu 20 mg/2ml CYTOMEL ...... 38 see liothyronine sodium tab 25 mcg cryselle-28 tab 28 tabs ...... 88 ...... 159 CULTURELLE CHW ...... 143 see liothyronine sodium tab 50 mcg CULTURELLE CHW MULTIVIT ...... 139 ...... 159 CUTIVATE see liothyronine sodium tab 5 mcg see beser lot 0.05% ...... 99 ...... 159 see fluticasone propionate lotion CYTOTEC 0.05% ...... 102 see misoprostol tab 100 mcg ...... 162 CUTIVATE LOT 0.05% ...... 100 see misoprostol tab 200 mcg ...... 162 CUVPOSA SOL 1MG/5ML ...... 160 cytra k gra crystals ...... 115 cvs daily chw gummies ...... 139 D CVS KETONE TES CARE ...... 105 dalfampridine tab er 12hr 10 mg ....156 CVS VISION CAP HEALTH ...... 139 DALIRESP TAB 250MCG ...... 39 cyanocobalamin inj 1000 mcg/ml ...117 DALIRESP TAB 500MCG ...... 39 cyanocobalamin tab 1000 mcg ...... 117 danazol cap 100 mg ...... 32 cyanocobalamin tab 100 mcg ...... 117 danazol cap 200 mg ...... 32 cyanocobalamin tab 500 mcg ...... 117 danazol cap 50 mg ...... 32 cyclafem tab 1/35 ...... 88 DANTRIUM cyclafem tab 7/7/7 ...... 88 see dantrolene sodium cap 25 mg 145 cyclobenzaprine hcl cap er 24hr 15 mg see dantrolene sodium cap 50 mg 145 ...... 144 DANTRIUM CAP 25MG ...... 145 cyclobenzaprine hcl cap er 24hr 30 mg DANTRIUM CAP 50MG ...... 145 ...... 144 dantrolene sodium cap 100 mg ...... 145 cyclobenzaprine hcl tab 10 mg ...... 144 dantrolene sodium cap 25 mg ...... 145 cyclobenzaprine hcl tab 5 mg ...... 144 dantrolene sodium cap 50 mg ...... 145 cyclobenzaprine hcl tab 7.5 mg ...... 144 dapsone tab 100 mg ...... 35 CYCLOGYL dapsone tab 25 mg ...... 35 see cyclopentolate hcl ophth soln 1% DARAPRIM ...... 148 see pyrimethamine tab 25 mg ...... 68 cyclopentolate hcl ophth soln 1% ...148 darifenacin hydrobromide tab er 24hr cyclopentolate hcl ophth soln 2% ...148 15 mg (base equiv) ...... 163 cyclophosphamide cap 25 mg ...... 69 darifenacin hydrobromide tab er 24hr cyclophosphamide cap 50 mg ...... 69 7.5 mg (base equiv) ...... 163 cycloserine cap 250 mg...... 68 dasetta tab 1/35 ...... 88 cyclosporine cap 100 mg ...... 134 dasetta tab 7/7/7 ...... 88 cyclosporine cap 25 mg ...... 134 DAURISMO TAB 100MG ...... 70 cyclosporine modified cap 100 mg ..134 DAURISMO TAB 25MG ...... 70 cyclosporine modified cap 25 mg ....134 day cold/flu liq 10-5-325 ...... 94 cyclosporine modified cap 50 mg ....134 DAYPRO cyclosporine modified oral soln 100 see oxaprozin tab 600 mg ...... 23 mg/ml ...... 134 DAYPRO TAB 600MG ...... 21 cyproheptadine hcl syrup 2 mg/5ml ..55 day-time liq cold/flu ...... 94 cyproheptadine hcl tab 4 mg ...... 55 DDAVP 188 see desmopressin acetate tab 0.1 mg desmopressin acetate nasal spray soln ...... 109 0.01% ...... 109 see desmopressin acetate tab 0.2 mg desmopressin acetate nasal spray soln ...... 109 0.01% (refrigerated) ...... 109 deblitane tab 0.35mg ...... 92 desmopressin acetate tab 0.1 mg ...109 decadron tab 0.5mg ...... 93 desmopressin acetate tab 0.2 mg ...109 decadron tab 0.75mg ...... 93 desogest-eth estrad & eth estrad tab decadron tab 4mg ...... 93 0.15-0.02/0.01 mg(21/5) ...... 88 decadron tab 6mg ...... 93 desogestrel & ethinyl estradiol tab 0.15 DECUBI-VITE CAP ...... 139 mg-30 mcg ...... 88 DEKAS CHW BARIATRI ...... 139 DESONATE DEKAS PLUS CAP ...... 139 see desonide gel 0.05% ...... 101 DEKAS PLUS CHW ...... 139 DESONATE GEL 0.05% ...... 101 delyla tab 0.1-0.02 ...... 88 desonide cream 0.05% ...... 101 DELZICOL desonide gel 0.05% ...... 101 see mesalamine cap dr 400 mg ...113 desonide lotion 0.05% ...... 101 DELZICOL CAP 400MG ...... 113 desonide oint 0.05% ...... 101 DENAVIR CRE 1% ...... 99 DESOWEN denta 5000 cre plus ...... 135 see desonide cream 0.05% ...... 101 denta 5000 cre plus 2pk ...... 135 DESOWEN CRE 0.05% ...... 101 dentagel gel 1.1% ...... 135 desoximetasone cream 0.05% ...... 101 DEPO-PROVERA CONTRACEPTIV desoximetasone cream 0.25% ...... 101 see medroxyprogesterone acetate im desoximetasone gel 0.05% ...... 101 susp 150 mg/ml ...... 92 desoximetasone oint 0.05% ...... 101 see medroxyprogesterone acetate im desoximetasone oint 0.25% ...... 101 susp prefilled syr 150 mg/ml ...... 92 desoximetasone spray 0.25% ...... 101 DEPO-PROVERA INJ 400/ML ...... 70 DETROL DEPO-TESTOSTERONE see tolterodine tartrate tab 1 mg 3.16 see testosterone cypionate im inj in see tolterodine tartrate tab 2 mg 3.16 oil 100 mg/ml ...... 32 DETROL LA see testosterone cypionate im inj in see tolterodine tartrate cap er 24hr 2 oil 200 mg/ml ...... 32 mg ...... 163 DERMA-SMOOTHE/FS BODY see tolterodine tartrate cap er 24hr 4 see fluocinolone acetonide oil 0.01% mg ...... 163 (body oil) ...... 101 DETROL LA CAP 2MG ...... 163 DERMA-SMOOTHE/FS SCALP DETROL LA CAP 4MG ...... 163 see fluocinolone acetonide oil 0.01% DETROL TAB 1MG ...... 163 (scalp oil) ...... 101 DETROL TAB 2MG ...... 163 DERMA-SMOOTH OIL /FS BODY ...... 100 DEWEES CARMI LIQ ...... 33 DERMA-SMOOTH OIL /FS SCLP ...... 100 dexamethasone elixir 0.5 mg/5ml ....93 DERMAVITE TAB ...... 139 dexamethasone sodium phosphate desloratadine tab 5 mg ...... 54 ophth soln 0.1% ...... 150 desloratadine tab orally disintegrating dexamethasone soln 0.5 mg/5ml .....93 2.5 mg ...... 54 dexamethasone tab 0.5 mg ...... 93 desloratadine tab orally disintegrating dexamethasone tab 0.75 mg ...... 93 5 mg ...... 54 dexamethasone tab 1.5 mg ...... 93 dexamethasone tab 1 mg ...... 93 189 dexamethasone tab 2 mg ...... 93 dicloxacillin sodium cap 250 mg .....153 dexamethasone tab 4 mg ...... 93 dicloxacillin sodium cap 500 mg .....153 dexamethasone tab 6 mg ...... 93 dicyclomine hcl cap 10 mg ...... 160 DEXCOM G5 MIS RECEIVER ...... 126 dicyclomine hcl oral soln 10 mg/5ml DEXCOM G5 MIS TRANSMIT ...... 126 ...... 160 DEXCOM G6 MIS RECEIVER ...... 126 dicyclomine hcl tab 20 mg ...... 160 DEXCOM G6 MIS SENSOR ...... 126 DIFICID SUS ...... 125 DEXCOM G6 MIS TRANSMIT ...... 126 DIFICID TAB 200MG ...... 125 DEXILANT CAP 30MG DR ...... 161 diflorasone diacetate cream 0.05% .101 DEXILANT CAP 60MG DR ...... 161 diflorasone diacetate oint 0.05% ....101 dextran 70-hypromellose ophth soln DIFLUCAN 0.1-0.3% ...... 147 see fluconazole for susp 10 mg/ml .53 dextromethorphan-guaifenesin liquid see fluconazole for susp 40 mg/ml .53 10-100 mg/5ml ...... 94 see fluconazole tab 100 mg ...... 53 dextromethorphan-guaifenesin liquid see fluconazole tab 150 mg ...... 53 10-200 mg/5ml ...... 94 see fluconazole tab 200 mg ...... 53 dextromethorphan-guaifenesin syrup see fluconazole tab 50 mg ...... 53 10-100 mg/5ml ...... 94 DIFLUCAN SUS 10MG/ML ...... 53 dextromethorphan-guaifenesin tab er DIFLUCAN SUS 40MG/ML ...... 53 12hr 30-600 mg ...... 94 DIFLUCAN TAB 100MG ...... 53 DIALYVIT 800 TAB ZINC 15 ...... 136 DIFLUCAN TAB 150MG ...... 53 DIALYVITE/ TAB ZINC ...... 136 DIFLUCAN TAB 200MG ...... 53 DIALYVITE TAB 3000 ...... 136 DIFLUCAN TAB 50MG ...... 53 DIALYVITE TAB 5000 ...... 136 diflunisal tab 500 mg ...... 25 DIALYVITE TAB 800/IRON ...... 136 digoxin tab 125 mcg (0.125 mg) ...... 84 DIALYVITE TAB 800/ZINC ...... 136 DIGOXIN TAB 125 MCG (0.125 MG) DIALYVITE TAB SUPREM D ...... 139 see digoxin tab 125 mcg (0.125 mg) DIALYVITE WAF PLUS D ...... 136 ...... 84 diclofenac epolamine patch 1.3% .....96 digoxin tab 250 mcg (0.25 mg) ...... 84 diclofenac potassium tab 50 mg ...... 21 DIGOXIN TAB 250 MCG (0.25 MG) diclofenac sodium (actinic keratoses) see digoxin tab 250 mcg (0.25 mg) gel 3% ...... 98 ...... 84 diclofenac sodium gel 1% ...... 96 DILAUDID diclofenac sodium ophth soln 0.1% .151 see hydromorphone hcl liqd 1 mg/ml diclofenac sodium soln 1.5% ...... 96 ...... 27 diclofenac sodium tab delayed release see hydromorphone hcl tab 2 mg ..27 25 mg ...... 21 see hydromorphone hcl tab 4 mg ..27 diclofenac sodium tab delayed release see hydromorphone hcl tab 8 mg ..27 50 mg ...... 21 DILAUDID LIQ 1MG/ML ...... 25 diclofenac sodium tab delayed release DILAUDID TAB 2MG ...... 25 75 mg ...... 21 DILAUDID TAB 4MG ...... 25 diclofenac sodium tab er 24hr 100 mg DILAUDID TAB 8MG ...... 25 ...... 21 diltiazem hcl cap er 12hr 120 mg .....80 diclofenac w/ misoprostol tab delayed diltiazem hcl cap er 12hr 60 mg ...... 80 release 50-0.2 mg ...... 21 diltiazem hcl cap er 12hr 90 mg ...... 80 diclofenac w/ misoprostol tab delayed diltiazem hcl cap er 24hr 120 mg .....80 release 75-0.2 mg ...... 21 diltiazem hcl cap er 24hr 180 mg .....80 190 diltiazem hcl cap er 24hr 240 mg .....80 DIOVAN diltiazem hcl coated beads cap er 24hr see valsartan tab 160 mg ...... 61 120 mg ...... 81 see valsartan tab 320 mg ...... 62 diltiazem hcl coated beads cap er 24hr see valsartan tab 40 mg ...... 61 180 mg ...... 81 see valsartan tab 80 mg ...... 61 diltiazem hcl coated beads cap er 24hr DIOVAN HCT 240 mg ...... 81 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads cap er 24hr 160-12.5 mg ...... 67 300 mg ...... 81 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads cap er 24hr 160-25 mg ...... 67 360 mg ...... 81 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads tab er 24hr 320-12.5 mg ...... 67 180 mg ...... 81 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads tab er 24hr 320-25 mg ...... 67 240 mg ...... 81 see valsartan-hydrochlorothiazide tab diltiazem hcl coated beads tab er 24hr 80-12.5 mg ...... 67 300 mg ...... 81 DIOVAN HCT TAB 160-12.5 ...... 64 diltiazem hcl coated beads tab er 24hr DIOVAN HCT TAB 160-25MG ...... 64 360 mg ...... 81 DIOVAN HCT TAB 320-12.5 ...... 64 diltiazem hcl coated beads tab er 24hr DIOVAN HCT TAB 320-25MG ...... 64 420 mg ...... 81 DIOVAN HCT TAB 80/12.5 ...... 64 diltiazem hcl extended release beads DIOVAN TAB 160MG ...... 61 cap er 24hr 120 mg ...... 81 DIOVAN TAB 320MG ...... 61 diltiazem hcl extended release beads DIOVAN TAB 40MG ...... 61 cap er 24hr 180 mg ...... 81 DIOVAN TAB 80MG ...... 61 diltiazem hcl extended release beads DIPENTUM CAP 250MG ...... 113 cap er 24hr 240 mg ...... 81 diphenhydramine hcl cap 25 mg ...... 54 diltiazem hcl extended release beads diphenhydramine hcl cap 50 mg ...... 54 cap er 24hr 300 mg ...... 81 diphenhydramine hcl elixir 12.5 diltiazem hcl extended release beads mg/5ml ...... 54 cap er 24hr 360 mg ...... 81 diphenhydramine hcl inj 50 mg/ml ...54 diltiazem hcl extended release beads diphenhydramine hcl liquid 12.5 cap er 24hr 420 mg ...... 81 mg/5ml ...... 54 diltiazem hcl tab 120 mg ...... 81 diphenhydramine-phenylephrine liq diltiazem hcl tab 30 mg ...... 81 6.25-2.5 mg/5ml ...... 94 diltiazem hcl tab 60 mg ...... 81 diphenhydramine-phenylephrine tab diltiazem hcl tab 90 mg ...... 81 25-10 mg ...... 95 dilt-xr cap 120mg ...... 80 diphenoxylate w/ atropine liq 2.5-0.025 dilt-xr cap 180mg ...... 80 mg/5ml ...... 51 dilt-xr cap 240mg ...... 80 diphenoxylate w/ atropine tab 2.5- dimenhydrinate tab 50 mg ...... 52 0.025 mg ...... 51 dimethyl fumarate capsule delayed diphenydramine hcl tab 25 mg ...... 54 release 120 mg ...... 156 DIPROLENE dimethyl fumarate capsule delayed see betamethasone dipropionate release 240 mg ...... 156 augmented oint 0.05% ...... 100 dimethyl fumarate capsule dr starter DIPROLENE AF pack 120 mg & 240 mg ...... 156 191 see betamethasone dipropionate doxazosin mesylate tab 2 mg ...... 62 augmented cream 0.05% ...... 99 doxazosin mesylate tab 4 mg ...... 62 DIPROLENE AF CRE 0.05% ...... 101 doxazosin mesylate tab 8 mg ...... 62 DIPROLENE OIN 0.05% ...... 101 doxycycline hyclate cap 100 mg .....158 dipyridamole tab 25 mg ...... 117 doxycycline hyclate cap 50 mg ...... 158 dipyridamole tab 50 mg ...... 117 doxycycline hyclate tab 100 mg .....158 dipyridamole tab 75 mg ...... 117 doxycycline monohydrate cap 100 mg disopyramide phosphate cap 100 mg 38 ...... 158 disopyramide phosphate cap 150 mg 38 doxycycline monohydrate cap 50 mg DISPOSABLE MIS MTHPIECE ...... 127 ...... 158 DITROPAN XL doxycycline monohydrate for susp 25 see oxybutynin chloride tab er 24hr mg/5ml ...... 158 10 mg ...... 163 doxycycline monohydrate tab 100 mg see oxybutynin chloride tab er 24hr 5 ...... 158 mg ...... 163 doxycycline monohydrate tab 50 mg DITROPAN XL TAB 10MG ...... 163 ...... 158 DITROPAN XL TAB 5MG ...... 163 DRISDOL DIURIL SUS 250/5ML ...... 107 see ergocalciferol cap 1.25 mg docosahexaenoic acid cap 200 mg ..146 (50000 unit) ...... 166 docosanol cream 10% ...... 99 dronabinol cap 10 mg ...... 52 docusate calcium cap 240 mg ...... 124 dronabinol cap 2.5 mg ...... 52 docusate min ene 283mg ...... 124 dronabinol cap 5 mg ...... 52 docusate sodium cap 100 mg ...... 124 drospirenone-ethinyl estradiol tab 3- docusate sodium cap 250 mg ...... 124 0.02 mg ...... 88 docusate sodium cap 50 mg ...... 124 drospirenone-ethinyl estradiol tab 3- docusate sodium liquid 150 mg/15ml 0.03 mg ...... 88 ...... 124 drospirenone-ethinyl estrad- docusate sodium syrup 60 mg/15ml 124 levomefolate tab 3-0.03-0.451 mg 88 docusate sodium tab 100 mg ...... 124 DROXIA CAP 200MG ...... 117 docusol mini ene ...... 124 DROXIA CAP 300MG ...... 117 dolishale tab 90-20mcg ...... 88 DROXIA CAP 400MG ...... 117 donepezil hydrochloride orally DUAKLIR AER 400/12 ...... 41 disintegrating tab 10 mg ...... 154 DUETACT donepezil hydrochloride orally see pioglitazone hcl-glimepiride tab disintegrating tab 5 mg ...... 154 30-2 mg ...... 45 donepezil hydrochloride tab 10 mg .154 see pioglitazone hcl-glimepiride tab donepezil hydrochloride tab 23 mg .154 30-4 mg ...... 45 donepezil hydrochloride tab 5 mg ...154 DUETACT TAB 30-2MG ...... 45 dorzolamide hcl ophth soln 2% ...... 151 DUETACT TAB 30-4MG ...... 45 dorzolamide hcl-timolol maleate ophth DUEXIS TAB 800-26.6 ...... 21 soln 22.3-6.8 mg/ml ...... 147 DULCOLAX TAB 5MG EC ...... 123 dotti dis 0.025mg ...... 110 DULERA AER 100-5MCG ...... 41 dotti dis 0.0375mg ...... 111 DULERA AER 200-5MCG ...... 41 dotti dis 0.05mg ...... 110 DULERA AER 50-5MCG ...... 41 dotti dis 0.075mg ...... 111 DUOPA SUS 4.63-20 ...... 73 dotti dis 0.1mg ...... 110 DUPIXENT INJ 200/1.14 ...... 103 doxazosin mesylate tab 1 mg ...... 62 DUPIXENT INJ 300/2ML ...... 103 192 DURAGESIC see prasugrel hcl tab 5 mg (base see fentanyl td patch 72hr 100 equiv) ...... 117 mcg/hr ...... 26 EFFIENT TAB 10MG ...... 117 see fentanyl td patch 72hr 12 mcg/hr EFFIENT TAB 5MG ...... 117 ...... 26 EFUDEX see fentanyl td patch 72hr 25 mcg/hr see fluorouracil cream 5% ...... 98 ...... 26 eldertonic liq ...... 137 see fentanyl td patch 72hr 50 mcg/hr eletriptan hydrobromide tab 20 mg ...... 26 (base equivalent) ...... 128 see fentanyl td patch 72hr 75 mcg/hr eletriptan hydrobromide tab 40 mg ...... 26 (base equivalent) ...... 128 DURAGESIC DIS 100MCG/H ...... 25 ELIDEL DURAGESIC DIS 12MCG/HR ...... 25 see pimecrolimus cream 1% ...... 104 DURAGESIC DIS 25MCG/HR ...... 25 ELIDEL CRE 1% ...... 104 DURAGESIC DIS 50MCG/HR ...... 25 elinest tab ...... 88 DURAGESIC DIS 75MCG/HR ...... 25 ELIQUIS ST P TAB 5MG ...... 43 dutasteride cap 0.5 mg ...... 115 ELIQUIS TAB 2.5MG ...... 43 dutasteride-tamsulosin hcl cap 0.5-0.4 ELIQUIS TAB 5MG ...... 43 mg ...... 115 ELIXOPHYLLIN ELX 80/15ML ...... 42 DYMISTA ELLA TAB 30MG ...... 92 see azelastine hcl-fluticasone prop ELMIRON CAP 100MG ...... 115 nasal spray 137-50 mcg/act .....145 eluryng mis ...... 92 DYMISTA SPR 137-50 ...... 145 EMCYT CAP 140MG ...... 70 E EMEND E.E.S. GRAN SUS 200/5ML ...... 125 see aprepitant capsule 80 mg ...... 52 E.E.S. GRANULES EMEND CAP 80MG ...... 52 see erythromycin ethylsuccinate for EMEND SUS 125MG ...... 52 susp 200 mg/5ml ...... 125 EMEND TRIPAC PAK 80 & 125 ...... 52 easy fiber/ chw calcium ...... 122 EMERGEN-C CHW IMMUNE/D ...... 139 ECEE PLUS TAB ...... 144 EMERGEN-C CHW VITA C ...... 139 EC-NAPROSYN EMFLAZA SUS 22.75/ML ...... 93 see ec-naproxen tab 375mg ...... 21 EMFLAZA TAB 18MG ...... 93 see ec-naproxen tab 500mg ...... 21 EMFLAZA TAB 30MG ...... 93 see naproxen tab ec 375 mg ...... 23 EMFLAZA TAB 36MG ...... 93 see naproxen tab ec 500 mg ...... 23 EMFLAZA TAB 6MG ...... 93 EC-NAPROSYN TAB 375MG ...... 21 EMGALITY INJ 100MG/ML ...... 128 EC-NAPROSYN TAB 500MG ...... 21 EMGALITY INJ 120MG/ML ...... 128 ec-naproxen tab 375mg ...... 21 emoquette tab ...... 88 ec-naproxen tab 500mg ...... 21 ENABLEX econazole nitrate cream 1% ...... 97 see darifenacin hydrobromide tab er EDARBI TAB 40MG ...... 61 24hr 15 mg (base equiv) ...... 163 EDARBI TAB 80MG ...... 61 enalapril maleate & hydrochlorothiazide EDARBYCLOR TAB 40-12.5 ...... 64 tab 10-25 mg ...... 64 EDARBYCLOR TAB 40-25MG ...... 64 enalapril maleate & hydrochlorothiazide EFFIENT tab 5-12.5 mg ...... 64 see prasugrel hcl tab 10 mg (base enalapril maleate tab 10 mg ...... 59 equiv) ...... 117 enalapril maleate tab 2.5 mg ...... 59 193 enalapril maleate tab 20 mg ...... 59 EPIPEN-JR 2-PAK enalapril maleate tab 5 mg ...... 59 see epinephrine solution auto- ENBREL INJ 25/0.5ML ...... 24 injector 0.15 mg/0.3ml (1:2000) ENBREL INJ 25MG ...... 24 ...... 165 ENBREL INJ 50MG/ML ...... 24 EPIPEN-JR INJ 0.15MG ...... 166 ENBREL MINI INJ 50MG/ML ...... 24 EPIVIR HBV ENBREL SRCLK INJ 50MG/ML ...... 24 see lamivudine tab 100 mg (hbv) ..76 ENDARI POW 5GM ...... 117 EPOGEN INJ 10000/ML ...... 118 endocet tab 10-325mg ...... 31 EPOGEN INJ 2000/ML ...... 117 endocet tab 2.5-325 ...... 31 EPOGEN INJ 20000/ML ...... 118 endocet tab 5-325mg ...... 31 EPOGEN INJ 3000/ML ...... 117 endocet tab 7.5-325 ...... 31 EPOGEN INJ 4000/ML ...... 117 ENDUR-VM TAB ...... 139 epsom salt gra ...... 123 enemeez mini ene ...... 124 EPSOM SALT GRA ...... 123 ENFAMIL SOL ENFALYTE ...... 131 EPSOM SALT GRA LAVENDER ...... 123 ENGERIX-B INJ 10/0.5ML ...... 164 EQUALACTIN CHW 625MG ...... 121 ENGERIX-B INJ 20MCG/ML ...... 164 ergocalciferol cap 1.25 mg (50000 unit) enoxaparin sodium inj 100 mg/ml ....43 ...... 166 enoxaparin sodium inj 120 mg/0.8ml 43 ergocalciferol soln 200 mcg/ml (8000 enoxaparin sodium inj 150 mg/ml ....43 unit/ml) ...... 166 enoxaparin sodium inj 300 mg/3ml ..43 ERIVEDGE CAP 150MG ...... 70 enoxaparin sodium inj 30 mg/0.3ml .43 ERLEADA TAB 60MG ...... 70 enoxaparin sodium inj 40 mg/0.4ml .43 errin tab 0.35mg ...... 92 enoxaparin sodium inj 60 mg/0.6ml .43 ERTACZO CRE 2% ...... 97 enoxaparin sodium inj 80 mg/0.8ml .43 ERYPED 400 enpresse-28 tab ...... 88 see erythromycin ethylsuccinate for enskyce tab ...... 88 susp 400 mg/5ml ...... 125 ENSPRYNG INJ ...... 134 ERYPED SUS 200/5ML ...... 125 entacapone tab 200 mg ...... 72 ERYPED SUS 400/5ML ...... 125 entecavir tab 0.5 mg ...... 76 ery-tab tab 250mg ec ...... 125 entecavir tab 1 mg ...... 76 ery-tab tab 333mg ec ...... 125 ENTRESTO TAB 24-26MG ...... 84 ery-tab tab 500mg ec ...... 125 ENTRESTO TAB 49-51MG ...... 84 erythrocin tab 250mg ...... 125 ENTRESTO TAB 97-103MG ...... 84 erythromycin ethylsuccinate for susp ENTYVIO INJ 300MG ...... 113 200 mg/5ml ...... 125 EPANED SOL 1MG/ML ...... 59 erythromycin ethylsuccinate for susp epinastine hcl ophth soln 0.05% .....151 400 mg/5ml ...... 125 epinephrine solution auto-injector 0.15 erythromycin ethylsuccinate tab 400 mg/0.15ml (1:1000) ...... 165 mg ...... 125 epinephrine solution auto-injector 0.15 erythromycin ophth oint 5 mg/gm ..149 mg/0.3ml (1:2000) ...... 165 erythromycin soln 2% ...... 96 epinephrine solution auto-injector 0.3 erythromycin tab 250 mg ...... 125 mg/0.3ml (1:1000) ...... 165 erythromycin tab 500 mg ...... 125 EPIPEN 2-PAK erythromycin tab delayed release 250 see epinephrine solution auto- mg ...... 125 injector 0.3 mg/0.3ml (1:1000) 165 erythromycin tab delayed release 333 EPIPEN 2-PAK INJ 0.3MG ...... 165 mg ...... 125 194 erythromycin tab delayed release 500 estradiol td patch weekly 0.05 mg/24hr mg ...... 125 ...... 111 erythromycin w/ delayed release estradiol td patch weekly 0.06 mg/24hr particles cap 250 mg ...... 125 ...... 111 ESGIC estradiol td patch weekly 0.075 see bac tab ...... 24 mg/24hr ...... 111 see butalbital-acetaminophen- estradiol td patch weekly 0.1 mg/24hr caffeine tab 50-325-40 mg ...... 24 ...... 111 esomeprazole magnesium cap delayed estradiol vaginal cream 0.1 mg/gm .165 release 20 mg (base eq) ...... 161 estradiol vaginal tab 10 mcg ...... 165 esomeprazole magnesium cap delayed ESTRADIOL VAGINAL TAB 10 MCG release 40 mg (base eq) ...... 161 see estradiol vaginal tab 10 mcg ..165 esomeprazole magnesium for delayed ESTROSTEP FE release susp packet 10 mg ...... 161 see tilia fe tab ...... 91 esomeprazole magnesium for delayed see tri-legest tab fe ...... 91 release susp packet 20 mg ...... 161 ethambutol hcl tab 100 mg...... 68 esomeprazole magnesium for delayed ethambutol hcl tab 400 mg...... 68 release susp packet 40 mg ...... 161 ethynodiol diacetate & ethinyl estradiol ESSENTRA MIS 9X9 ...... 126 tab 1 mg-35 mcg ...... 88 estarylla tab 0.25-35 ...... 88 ethynodiol diacetate & ethinyl estradiol ESTRACE tab 1 mg-50 mcg ...... 88 see estradiol tab 0.5 mg ...... 111 etodolac cap 200 mg ...... 21 see estradiol tab 1 mg ...... 111 etodolac cap 300 mg ...... 21 see estradiol tab 2 mg ...... 111 etodolac tab 400 mg ...... 21 see estradiol vaginal cream 0.1 etodolac tab 500 mg ...... 21 mg/gm ...... 165 etodolac tab er 24hr 400 mg ...... 21 estradiol & norethindrone acetate tab etodolac tab er 24hr 500 mg ...... 21 0.5-0.1 mg ...... 110 etodolac tab er 24hr 600 mg ...... 21 estradiol & norethindrone acetate tab etonogestrel-ethinyl estradiol va ring 1-0.5 mg ...... 110 0.120-0.015 mg/24hr ...... 92 estradiol tab 0.5 mg ...... 111 etoposide cap 50 mg ...... 72 estradiol tab 1 mg ...... 111 EUCRISA OIN 2% ...... 104 estradiol tab 2 mg ...... 111 everolimus tab 2.5 mg ...... 71 estradiol td patch twice weekly 0.025 everolimus tab 5 mg ...... 71 mg/24hr ...... 111 everolimus tab 7.5 mg ...... 71 estradiol td patch twice weekly 0.0375 EVISTA mg/24hr ...... 111 see raloxifene hcl tab 60 mg ...... 109 estradiol td patch twice weekly 0.05 EVISTA TAB 60MG ...... 109 mg/24hr ...... 111 EVOLUTION60 POW ...... 139 estradiol td patch twice weekly 0.075 EXELDERM CRE 1% ...... 97 mg/24hr ...... 111 EXELDERM SOL 1% ...... 97 estradiol td patch twice weekly 0.1 EXELON mg/24hr ...... 111 see rivastigmine td patch 24hr 13.3 estradiol td patch weekly 0.025 mg/24hr ...... 156 mg/24hr ...... 111 see rivastigmine td patch 24hr 4.6 estradiol td patch weekly 0.0375 mg/24hr ...... 156 mg/24hr (37.5 mcg/24hr) ...... 111 195 see rivastigmine td patch 24hr 9.5 famciclovir tab 125 mg ...... 76 mg/24hr ...... 156 famciclovir tab 250 mg ...... 76 EXELON DIS 13.3/24 ...... 154 famciclovir tab 500 mg ...... 76 EXELON DIS 4.6MG/24 ...... 154 famotidine for susp 40 mg/5ml ...... 160 EXELON DIS 9.5MG/24 ...... 154 famotidine tab 10 mg ...... 160 exemestane tab 25 mg ...... 70 famotidine tab 20 mg ...... 160 EXFORGE famotidine tab 40 mg ...... 160 see amlodipine besylate-valsartan FARESTON tab 10-160 mg ...... 63 see toremifene citrate tab 60 mg see amlodipine besylate-valsartan (base equivalent) ...... 70 tab 10-320 mg ...... 63 FARXIGA TAB 10MG ...... 49 see amlodipine besylate-valsartan FARXIGA TAB 5MG ...... 49 tab 5-160 mg ...... 63 FARYDAK CAP 10MG ...... 71 see amlodipine besylate-valsartan FARYDAK CAP 15MG ...... 71 tab 5-320 mg ...... 63 FARYDAK CAP 20MG ...... 71 EXFORGEH/10- TAB 160-12.5 ...... 65 febuxostat tab 40 mg ...... 116 EXFORGEH/10- TAB 160-25 ...... 65 febuxostat tab 80 mg ...... 116 EXFORGEH/10- TAB 320-25 ...... 65 FELDENE EXFORGEH/5- TAB 160-12.5 ...... 65 see piroxicam cap 10 mg ...... 23 EXFORGEH/5- TAB 160-25 ...... 65 see piroxicam cap 20 mg ...... 23 EXFORGE TAB 10-160MG ...... 64 FELDENE CAP 10MG ...... 21 EXFORGE TAB 10-320MG ...... 65 FELDENE CAP 20MG ...... 21 EXFORGE TAB 5-160MG ...... 64 felodipine tab er 24hr 10 mg ...... 81 EXFORGE TAB 5-320MG ...... 64 felodipine tab er 24hr 2.5 mg ...... 81 EXPIRATORY MIS MTHPIECE ...... 127 felodipine tab er 24hr 5 mg ...... 81 EXTAVIA INJ 0.3MG ...... 156 FEMARA EXTINA see letrozole tab 2.5 mg ...... 70 see ketoconazole foam 2% ...... 97 FEM-CAL TAB CITRATE ...... 133 see ketodan aer 2% ...... 97 FEMCAP MIS 22MM ...... 125 EXTINA AER 2% ...... 97 FEMCAP MIS 26MM ...... 125 eye allergy sol relief ...... 149 FEMCAP MIS 30MM ...... 125 EYE HEALTH CAP ...... 139 FEMHRT EYE HEALTH CAP ADLT 50+ ...... 139 see fyavolv tab 0.5-2.5 ...... 110 EYSUVIS DRO 0.25% ...... 150 see norethindrone acetate-ethinyl EZALLOR SPR CAP 10MG ...... 57 estradiol tab 0.5 mg-2.5 mcg ...110 EZALLOR SPR CAP 20MG ...... 57 femynor tab 0.25-35 ...... 88 EZALLOR SPR CAP 40MG ...... 57 fenofibrate cap 150 mg ...... 56 EZALLOR SPR CAP 5MG ...... 57 fenofibrate cap 50 mg ...... 56 ezetimibe-simvastatin tab 10-10 mg .55 fenofibrate micronized cap 130 mg ...56 ezetimibe-simvastatin tab 10-20 mg .55 fenofibrate micronized cap 134 mg ...56 ezetimibe-simvastatin tab 10-40 mg .55 fenofibrate micronized cap 200 mg ...56 ezetimibe-simvastatin tab 10-80 mg .55 fenofibrate micronized cap 43 mg .....56 ezetimibe tab 10 mg ...... 58 fenofibrate micronized cap 67 mg .....56 E-Z-GAS II GRA ...... 33 fenofibrate tab 120 mg ...... 56 F fenofibrate tab 145 mg ...... 56 fabb tab 2.2-25-1 ...... 119 fenofibrate tab 160 mg ...... 56 falmina tab ...... 88 fenofibrate tab 40 mg ...... 56 196 fenofibrate tab 48 mg ...... 56 FEOSOL TAB 200MG ...... 120 fenofibrate tab 54 mg ...... 56 FERAHEME INJ 510/17ML ...... 120 fenofibric acid tab 105 mg ...... 56 FERIVAFA CAP 110-1MG ...... 119 fenofibric acid tab 35 mg ...... 56 FERIVA TAB 21/7 ...... 119 FENOGLIDE ferocon cap ...... 119 see fenofibrate tab 120 mg ...... 56 ferotrinsic cap ...... 119 see fenofibrate tab 40 mg ...... 56 FERRALET 90 TAB ...... 119 FENOGLIDE TAB 120MG ...... 56 FERRAPLUS 90 TAB ...... 119 FENOGLIDE TAB 40MG ...... 56 FERRETTS IPS SOL ...... 120 fenoprofen calcium cap 400 mg ...... 21 ferrex 150 cap 150mg ...... 120 fenoprofen calcium tab 600 mg ...... 21 FERRIMIN 150 TAB ...... 120 fentanyl citrate buccal tab 100 mcg ferrocite tab 324mg ...... 120 (base equiv) ...... 25 ferrocite tab plus ...... 119 fentanyl citrate buccal tab 200 mcg ferrous fumarate tab 324 mg (106 mg (base equiv) ...... 25 elemental fe) ...... 120 fentanyl citrate buccal tab 400 mcg FERROUS FUM TAB 29MG ...... 120 (base equiv) ...... 25 ferrous gluconate tab 240 mg (27 mg fentanyl citrate buccal tab 600 mcg elemental fe) ...... 120 (base equiv) ...... 25 FERROUS GLUC TAB 324MG ...... 120 fentanyl citrate buccal tab 800 mcg ferrous sulfate dried tab 200 mg (65 (base equiv) ...... 25 mg elemental fe) ...... 120 fentanyl citrate lozenge on a handle ferrous sulfate dried tab er 160 mg (50 1200 mcg ...... 26 mg fe equivalent) ...... 120 fentanyl citrate lozenge on a handle ferrous sulfate elixir 220 mg/5ml (44 1600 mcg ...... 26 mg/5ml elemental fe) ...... 120 fentanyl citrate lozenge on a handle ferrous sulfate soln 75 mg/ml (15 200 mcg ...... 25 mg/ml elemental fe) ...... 120 fentanyl citrate lozenge on a handle ferrous sulfate syrup 300 mg/5ml (60 400 mcg ...... 25 mg/5ml elemental fe) ...... 120 fentanyl citrate lozenge on a handle ferrous sulfate tab 325 mg (65 mg 600 mcg ...... 25 elemental fe) ...... 120 fentanyl citrate lozenge on a handle ferrous sulfate tab ec 325 mg (65 mg 800 mcg ...... 26 fe equivalent) ...... 120 fentanyl td patch 72hr 100 mcg/hr ...26 ferrous sulfate tab er 142 mg (45 mg fentanyl td patch 72hr 12 mcg/hr .....26 fe equivalent) ...... 120 fentanyl td patch 72hr 25 mcg/hr .....26 FERROUS SULF LIQ 44MG/5ML ...... 120 fentanyl td patch 72hr 37.5 mcg/hr ..26 FERROUS SULF TAB 324MG EC ...... 120 fentanyl td patch 72hr 50 mcg/hr .....26 FEVERALL SUP 325MG ...... 24 fentanyl td patch 72hr 62.5 mcg/hr ..26 fexmid tab 7.5mg ...... 144 fentanyl td patch 72hr 75 mcg/hr .....26 fexofenadine hcl tab 180 mg...... 54 fentanyl td patch 72hr 87.5 mcg/hr ..26 fexofenadine hcl tab 60 mg ...... 54 FENTORA TAB 100MCG ...... 26 FIASP FLEX INJ TOUCH ...... 48 FENTORA TAB 200MCG ...... 26 FIASP INJ 100/ML ...... 48 FENTORA TAB 400MCG ...... 26 FIASP PENFIL INJ U-100 ...... 48 FENTORA TAB 600MCG ...... 26 FIBER CHOICE CHW 1.5GM ...... 121 FENTORA TAB 800MCG ...... 26 FIBER-STAT LIQ ...... 105 FEOSOL BIFER TAB 28MG ...... 119 fiber weight chw manageme ...... 105 197 FIBRICOR TAB 105MG ...... 57 fludrocortisone acetate tab 0.1 mg ...94 FIBRICOR TAB 35MG ...... 57 FLUMIST QUAD SUS 2020-21 ...... 164 finasteride tab 5 mg ...... 115 flunisolide nasal soln 25 mcg/act FIORICET CAP CODEINE ...... 31 (0.025%) ...... 146 FIRVANQ SOL 25MG/ML ...... 35 fluocinolone acetonide cream 0.01% FIRVANQ SOL 50MG/ML ...... 35 ...... 101 FISH OIL CAP 150MG ...... 146 fluocinolone acetonide cream 0.025% FISH OIL CAP 180MG ...... 146 ...... 101 fish oil cap 300mg ...... 146 fluocinolone acetonide oil 0.01% (body fish oil cap 435mg ...... 146 oil) ...... 101 FLAGYL fluocinolone acetonide oil 0.01% (scalp see metronidazole cap 375 mg ...... 34 oil) ...... 101 see metronidazole tab 500 mg ...... 35 fluocinolone acetonide oint 0.025% 101 FLAGYL CAP 375MG ...... 34 fluocinolone acetonide soln 0.01% ..101 FLAGYL TAB 500MG ...... 34 fluocinonide cream 0.05% ...... 101 flavoxate hcl tab 100 mg ...... 164 fluocinonide cream 0.1% ...... 101 flecainide acetate tab 100 mg ...... 38 fluocinonide emulsified base cream flecainide acetate tab 150 mg ...... 38 0.05% ...... 101 flecainide acetate tab 50 mg ...... 38 fluocinonide gel 0.05% ...... 101 FLECTOR DIS 1.3% ...... 96 fluocinonide oint 0.05% ...... 101 FLEET BISACO ENE 10/30ML ...... 123 fluocinonide soln 0.05% ...... 101 FLEET ENE ...... 123 fluorometholone ophth susp 0.1% ..150 FLEET ENE ENEMA ...... 123 fluorouracil cream 0.5% ...... 98 FLEET LIQUID ENE GLYCERIN ...... 123 fluorouracil cream 5% ...... 98 FLEET OIL ENE ...... 123 flurandrenolide cream 0.05% ...... 101 FLINTSTONES CHW TODDLER ...... 142 flurandrenolide lotion 0.05% ...... 101 FLOMAX flurandrenolide oint 0.05% ...... 102 see tamsulosin hcl cap 0.4 mg .....116 flurbiprofen sodium ophth soln 0.03% FLOMAX CAP 0.4MG ...... 115 ...... 151 FLONASE ALGY SPR 50MCG ...... 146 flurbiprofen tab 100 mg ...... 21 FLONASE SENS SUS 27.5MCG ...... 146 flurbiprofen tab 50 mg ...... 21 FLORIVA DRO PLUS ...... 142 flutamide cap 125 mg ...... 70 FLOVENT DISK AER 100MCG ...... 40 fluticasone propionate cream 0.05% FLOVENT DISK AER 250MCG ...... 40 ...... 102 FLOVENT DISK AER 50MCG ...... 40 fluticasone propionate lotion 0.05% 102 FLOVENT HFA AER 110MCG ...... 40 fluticasone propionate nasal susp 50 FLOVENT HFA AER 220MCG ...... 40 mcg/act ...... 146 FLOVENT HFA AER 44MCG ...... 40 fluticasone propionate oint 0.005% .102 FLUCLVX QUAD INJ 2020-21 ...... 164 fluticasone-salmeterol aer powder ba fluconazole for susp 10 mg/ml ...... 53 100-50 mcg/dose ...... 41 fluconazole for susp 40 mg/ml ...... 53 fluticasone-salmeterol aer powder ba fluconazole tab 100 mg ...... 53 113-14 mcg/act ...... 41 fluconazole tab 150 mg ...... 53 fluticasone-salmeterol aer powder ba fluconazole tab 200 mg ...... 53 232-14 mcg/act ...... 41 fluconazole tab 50 mg ...... 53 fluticasone-salmeterol aer powder ba flucytosine cap 250 mg ...... 52 250-50 mcg/dose ...... 41 flucytosine cap 500 mg ...... 52 198 fluticasone-salmeterol aer powder ba see alendronate sodium tab 70 mg 500-50 mcg/dose ...... 41 ...... 107 fluticasone-salmeterol aer powder ba FOSAMAX + D TAB 70-2800 ...... 108 55-14 mcg/act ...... 41 FOSAMAX + D TAB 70-5600 ...... 108 fluvastatin sodium cap 20 mg (base FOSAMAX TAB 70MG ...... 108 equivalent) ...... 57 FOSFREE TAB ...... 139 fluvastatin sodium cap 40 mg (base fosinopril sodium & hydrochlorothiazide equivalent) ...... 57 tab 10-12.5 mg ...... 65 fluvastatin sodium tab er 24 hr 80 mg fosinopril sodium & hydrochlorothiazide (base equivalent) ...... 57 tab 20-12.5 mg ...... 65 FLUZONE QUAD INJ 2020-21 ...... 164 fosinopril sodium tab 10 mg ...... 59 foam antacid chw 80-20mg ...... 33 fosinopril sodium tab 20 mg ...... 59 folbee plus tab cz ...... 136 fosinopril sodium tab 40 mg ...... 59 folbee tab ...... 119 FOSRENOL FOLBIC RF TAB ...... 105 see lanthanum carbonate chew tab FOLGARD OS TAB ...... 141 1000 mg (elemental) ...... 114 folic acid tab 1 mg ...... 117 see lanthanum carbonate chew tab folic acid tab 400 mcg ...... 117 500 mg (elemental) ...... 114 folic acid tab 800 mcg ...... 117 see lanthanum carbonate chew tab folic acid-vitamin b6-vitamin b12 tab 750 mg (elemental) ...... 114 2.2-25-0.5 mg ...... 119 FOSRENOL CHW 1000MG ...... 114 FOLINIC-PLUS TAB 4-50-2MG ...... 119 FOSRENOL CHW 500MG ...... 114 FOLITAB 500 TAB ...... 119 FOSRENOL CHW 750MG ...... 114 FOLIVANE-F CAP ...... 119 FOSRENOL POW 1000MG ...... 114 FOLIVANE-PLS CAP ...... 119 FOSRENOL POW 750MG ...... 114 folplex 2.2 tab ...... 119 FRAGMIN INJ 10000/ML ...... 44 foltabs 800 tab ...... 119 FRAGMIN INJ 12500UNT ...... 44 FOLTANX TAB ...... 105 FRAGMIN INJ 15000UNT ...... 44 foltrin cap ...... 119 FRAGMIN INJ 18000UNT ...... 44 fondaparinux sodium subcutaneous inj FRAGMIN INJ 2500/0.2 ...... 43 10 mg/0.8ml ...... 43 FRAGMIN INJ 5000/0.2 ...... 43 fondaparinux sodium subcutaneous inj FRAGMIN INJ 7500/0.3 ...... 43 2.5 mg/0.5ml ...... 43 FRAGMIN INJ 95000UNT ...... 44 fondaparinux sodium subcutaneous inj FREEDAVITE TAB ...... 139 5 mg/0.4ml ...... 43 FREESTYLE KIT SENSOR ...... 126 fondaparinux sodium subcutaneous inj FREESTYLE MIS READER ...... 126 7.5 mg/0.6ml ...... 43 FREESTY LIBR KIT 2 SENSOR ...... 126 formoterol fumarate soln nebu 20 FREESTY LIBR MIS 2 READER ...... 126 mcg/2ml ...... 41 FROVA FORTAMET TAB 1000MG ...... 46 see frovatriptan succinate tab 2.5 mg FORTAMET TAB 500MG ...... 46 (base equivalent) ...... 128 FORTEO INJ 620/2.48 ...... 108 FROVA TAB 2.5MG ...... 128 FORTESTA frovatriptan succinate tab 2.5 mg (base see testosterone td gel 10mg/act equivalent) ...... 128 (2%) ...... 32 FULPHILA INJ 6/0.6ML ...... 118 FORTESTA GEL 10MG/ACT ...... 32 furosemide oral soln 10 mg/ml ...... 106 FOSAMAX furosemide oral soln 8 mg/ml ...... 106 199 furosemide tab 20 mg ...... 106 GENOTROPIN INJ 1.8MG ...... 108 furosemide tab 40 mg ...... 107 GENOTROPIN INJ 12MG ...... 108 furosemide tab 80 mg ...... 107 GENOTROPIN INJ 1MG ...... 108 fyavolv tab 0.5-2.5 ...... 110 GENOTROPIN INJ 2MG ...... 108 fyavolv tab 1-5 ...... 110 GENOTROPIN INJ 5MG ...... 108 G gentak oin 0.3% op ...... 149 G5/G4 MIS SENSOR ...... 126 gentamicin sulfate cream 0.1% ...... 97 galantamine hydrobromide cap er 24hr gentamicin sulfate oint 0.1% ...... 97 16 mg ...... 154 gentamicin sulfate ophth soln 0.3% 149 galantamine hydrobromide cap er 24hr GENTEAL TEAR GEL SEV D/N ...... 147 24 mg ...... 155 GERI-FREEDA TAB SENIOR ...... 139 galantamine hydrobromide cap er 24hr geri-mucil pow 68% ...... 121 8 mg ...... 154 geritol tab complete ...... 137 galantamine hydrobromide oral soln 4 GILENYA CAP 0.5MG ...... 156 mg/ml ...... 155 glatiramer acetate soln prefilled syringe galantamine hydrobromide tab 12 mg 20 mg/ml ...... 156 ...... 155 glatiramer acetate soln prefilled syringe galantamine hydrobromide tab 4 mg 40 mg/ml ...... 157 ...... 155 glatopa inj 20mg/ml ...... 157 galantamine hydrobromide tab 8 mg glatopa inj 40mg/ml ...... 157 ...... 155 GLEOSTINE CAP 100MG ...... 69 GAS-X EX-STR CHW 125MG ...... 112 GLEOSTINE CAP 10MG ...... 69 gatifloxacin ophth soln 0.5% ...... 149 GLEOSTINE CAP 40MG ...... 69 gavilyte-c sol ...... 122 glimepiride tab 1 mg ...... 50 gavilyte-g sol ...... 122 glimepiride tab 2 mg ...... 50 GAVISCON CHW ...... 33 glimepiride tab 4 mg ...... 50 GAVISCON SUS ...... 33 glipizide-metformin hcl tab 2.5-250 mg GELNIQUE GEL 10% ...... 163 ...... 45 gemfibrozil tab 600 mg ...... 57 glipizide-metformin hcl tab 2.5-500 mg GENADEK CAP STEP 1 ...... 139 ...... 45 GENADEK CAP STEP 2 ...... 139 glipizide-metformin hcl tab 5-500 mg 45 GENERESS FE glipizide tab 10 mg ...... 50 see kaitlib fe chw ...... 89 glipizide tab 5 mg ...... 50 see layolis fe chw ...... 89 glipizide tab er 24hr 10 mg...... 50 see norethindrone & ethinyl glipizide tab er 24hr 2.5 mg...... 50 estradiol-fe chew tab 0.8 mg-25 glipizide tab er 24hr 5 mg ...... 50 mcg ...... 90 glipizide xl tab 10mg ...... 50 gengraf cap 100mg ...... 134 glipizide xl tab 2.5mg ...... 50 gengraf cap 25mg ...... 134 glipizide xl tab 5mg ...... 50 gengraf sol 100mg/ml ...... 134 GLOPERBA SOL 0.6/5ML ...... 116 GENOTROPIN INJ 0.2MG ...... 108 GLUCAGEN INJ HYPOKIT ...... 47 GENOTROPIN INJ 0.4MG ...... 108 glucagon (rdna) for inj kit 1 mg ...... 47 GENOTROPIN INJ 0.6MG ...... 108 GLUCAGON EMERGENCY KIT GENOTROPIN INJ 0.8MG ...... 108 see glucagon (rdna) for inj kit 1 mg GENOTROPIN INJ 1.2MG ...... 108 ...... 47 GENOTROPIN INJ 1.4MG ...... 108 GLUCOTROL XL GENOTROPIN INJ 1.6MG ...... 108 see glipizide tab er 24hr 10 mg .....50 200 see glipizide tab er 24hr 2.5 mg ....50 gnp day time liq cold/flu ...... 95 see glipizide tab er 24hr 5 mg ...... 50 gnp epsom gra salt ...... 123 see glipizide xl tab 10mg ...... 50 gnp naproxen cap 220mg ...... 21 see glipizide xl tab 2.5mg ...... 50 GOCOVRI CAP 137MG ...... 73 see glipizide xl tab 5mg ...... 50 GOCOVRI CAP 68.5MG ...... 73 GLUCOTROL XL TAB 10MG ...... 50 GOLYTELY GLUCOTROL XL TAB 2.5MG ...... 50 see gavilyte-g sol ...... 122 GLUCOTROL XL TAB 5MG ...... 50 see peg 3350-kcl-na bicarb-nacl-na GLUMETZA sulfate for soln 236 gm ...... 122 see metformin hcl tab er 24hr GOLYTELY SOL ...... 122 modified release 1000 mg ...... 46 GRALISE TAB 300MG ...... 157 see metformin hcl tab er 24hr GRALISE TAB 600MG ...... 157 modified release 500 mg ...... 46 granisetron hcl tab 1 mg ...... 51 GLUMETZA TAB 1000MG ...... 46 GRANIX INJ 300/0.5 ...... 118 GLUMETZA TAB 500MG ...... 46 GRANIX INJ 300/1ML ...... 118 glyburide-metformin tab 1.25-250 mg GRANIX INJ 480/0.8 ...... 118 ...... 45 GRANIX INJ 480/1.6 ...... 118 glyburide-metformin tab 2.5-500 mg 45 griseofulvin microsize susp 125 mg/5ml glyburide-metformin tab 5-500 mg ...45 ...... 52 glyburide micronized tab 1.5 mg ...... 50 griseofulvin microsize tab 500 mg ....52 glyburide micronized tab 3 mg ...... 50 griseofulvin ultramicrosize tab 125 mg glyburide micronized tab 6 mg ...... 50 ...... 52 glyburide tab 1.25 mg ...... 50 griseofulvin ultramicrosize tab 250 mg glyburide tab 2.5 mg ...... 50 ...... 52 glyburide tab 5 mg ...... 50 guaifenesin-codeine soln 100-10 glycerin sup 1gm ...... 123 mg/5ml ...... 95 glycerin sup 2gm ...... 123 guaifenesin liquid 100 mg/5ml ...... 95 glycerin suppos 1.2 gm ...... 123 guaifenesin syrup 100 mg/5ml ...... 95 glycerin suppos 2.1 gm ...... 123 guaifenesin tab 200 mg ...... 95 glycerin suppos 80.7% ...... 123 guaifenesin tab 400 mg ...... 95 GLYCOPHOS SOL 1MM/ML ...... 133 guaifenesin tab er 12hr 600 mg ...... 95 glycopyrrolate tab 1 mg ...... 160 guanfacine hcl tab 1 mg ...... 62 glycopyrrolate tab 2 mg ...... 160 guanfacine hcl tab 2 mg ...... 62 GLYCO-TECH TAB ...... 137 GVOKE HYPO 1 INJ .5/.1ML ...... 47 glydo gel 2% ...... 104 GVOKE HYPO 1 INJ 1MG/.2ML ...... 47 GLYNASE GVOKE HYPO 2 INJ .5/.1ML ...... 47 see glyburide micronized tab 1.5 mg GVOKE HYPO 2 INJ 1MG/.2ML ...... 47 ...... 50 GVOKE PFS INJ ...... 47 see glyburide micronized tab 3 mg 50 GYNE-LOTRIMI CRE 3 ...... 165 see glyburide micronized tab 6 mg 50 GYNOL II GEL 3% ...... 164 GLYNASE TAB 1.5MG ...... 50 H GLYNASE TAB 3MG ...... 50 hailey 24 tab fe ...... 88 GLYNASE TAB 6MG ...... 50 hailey fe tab 1/20 ...... 88 GLYXAMBI TAB 10-5 MG ...... 45 hailey fe tab 1.5/30 ...... 88 GLYXAMBI TAB 25-5 MG ...... 45 hailey tab 1.5/30 ...... 89 gnp castor oil 100% ...... 123 HAIR/SKIN/ CAP NAILS ...... 139 GNP CENTURY TAB ENERGY ...... 144 halcinonide cream 0.1% ...... 102 201 HALOBETASOL AER 0.05% ...... 102 HUMATIN halobetasol propionate cream 0.05% see paromomycin sulfate cap 250 mg ...... 102 ...... 19 halobetasol propionate oint 0.05% .102 HUMATROPE INJ 12MG ...... 108 HALOG HUMATROPE INJ 24MG ...... 108 see halcinonide cream 0.1% ...... 102 HUMATROPE INJ 5MG ...... 108 HALOG CRE 0.1% ...... 102 HUMATROPE INJ 6MG ...... 108 HALOG OIN 0.1% ...... 102 HUMIRA INJ 10/0.1ML ...... 20 HARD NAILS CAP 2.5MG ...... 166 HUMIRA INJ 20/0.2ML ...... 20 HAVRIX INJ 1440UNIT ...... 164 HUMIRA INJ 40/0.4ML ...... 20 HAVRIX INJ 720UNIT ...... 164 HUMIRA KIT 40MG/0.8 ...... 20 HEALTHY KIDS CHW GUMMIES ...... 142 HUMIRA PEDIA INJ CROHNS ...... 20 heartbrn rel sus cherry ...... 33 HUMIRA PEN INJ 40/0.4ML ...... 20 heather tab 0.35mg ...... 92 HUMIRA PEN INJ 40MG/0.8 ...... 20 HEMANGEOL SOL 4.28/ML ...... 78 HUMIRA PEN INJ 80/0.8ML ...... 20 hematinic/fa tab ...... 119 HUMIRA PEN INJ CD/UC/HS ...... 20 hematinic pl tab vit/min ...... 119 HUMIRA PEN INJ PS/UV ...... 20 hematogen cap ...... 119 HUMIRA PEN KIT CD/UC/HS ...... 20 hematogen cap forte ...... 119 HUMIRA PEN KIT PED UC ...... 20 HEMATOGEN FA CAP ...... 119 HUMIRA PEN KIT PS/UV ...... 20 HEMETAB TAB ...... 119 HUMULIN INJ 70/30 ...... 48 heparin sodium (porcine) inj 10000 HUMULIN INJ 70/30KWP ...... 48 unit/ml ...... 44 HUMULIN N INJ U-100 ...... 48 heparin sodium (porcine) inj 5000 HUMULIN N INJ U-100KWP ...... 48 unit/ml ...... 44 HUMULIN R INJ U-100 ...... 48 HEPSERA HUMULIN R INJ U-500 ...... 48 see adefovir dipivoxil tab 10 mg ....75 HYALGAN INJ 20MG/2ML ...... 145 HIPREX HYCAMTIN CAP 0.25MG ...... 72 see methenamine hippurate tab 1 gm HYCAMTIN CAP 1MG ...... 72 ...... 36 hydralazine hcl inj 20 mg/ml ...... 68 HM CASTOR OIL ...... 87 hydralazine hcl tab 100 mg ...... 68 hm daytime liq cold/flu ...... 95 hydralazine hcl tab 10 mg ...... 68 hm docosan cre 10% ...... 99 hydralazine hcl tab 25 mg ...... 68 hm multivit chw gummy ...... 139 hydralazine hcl tab 50 mg ...... 68 HM ONE DAILY TAB ESSENTIA ...... 137 HYDREA homatropaire sol 5% op ...... 148 see hydroxyurea cap 500 mg ...... 71 HOMOCYSTEINE TAB FORMULA ...... 119 hydrochlorothiazide cap 12.5 mg ....107 HORIZANT TAB 300MG ER ...... 157 hydrochlorothiazide tab 12.5 mg ....107 HORIZANT TAB 600MG ER ...... 157 hydrochlorothiazide tab 25 mg ...... 107 HUMALOG INJ 100/ML ...... 48 hydrochlorothiazide tab 50 mg ...... 107 HUMALOG JR INJ 100/ML ...... 48 HYDROCIL INS POW 95% ...... 121 HUMALOG KWIK INJ 100/ML ...... 48 HYDROCIL POW 95% ...... 121 HUMALOG KWIK INJ 200/ML ...... 48 hydrocodone-acetaminophen soln 7.5- HUMALOG MIX INJ 50/50 ...... 48 325 mg/15ml ...... 31 HUMALOG MIX INJ 50/50KWP ...... 48 hydrocodone-acetaminophen tab 10- HUMALOG MIX INJ 75/25KWP ...... 48 300 mg ...... 31 HUMALOG MIX SUS 75/25 ...... 48 202 hydrocodone-acetaminophen tab 10- hydrocortisone butyrate hydrophilic lipo 325 mg ...... 31 base cream 0.1% ...... 102 hydrocodone-acetaminophen tab 5-300 hydrocortisone butyrate lotion 0.1% mg ...... 31 ...... 102 hydrocodone-acetaminophen tab 5-325 hydrocortisone butyrate oint 0.1% ..102 mg ...... 31 hydrocortisone butyrate soln 0.1% .102 hydrocodone-acetaminophen tab 7.5- hydrocortisone cream 0.5% ...... 102 300 mg ...... 31 hydrocortisone cream 1% ...... 102 hydrocodone-acetaminophen tab 7.5- hydrocortisone cream 1%- rx ...... 102 325 mg ...... 31 hydrocortisone cream 2.5% ...... 102 hydrocodone bitartrate cap er 12hr 10 hydrocortisone lotion 2.5% ...... 102 mg ...... 26 hydrocortisone oint 0.5% ...... 102 hydrocodone bitartrate cap er 12hr 15 hydrocortisone oint 1% ...... 102 mg ...... 26 hydrocortisone oint 1%- rx ...... 102 hydrocodone bitartrate cap er 12hr 20 hydrocortisone oint 2.5% ...... 102 mg ...... 26 hydrocortisone rectal cream 2.5% ....33 hydrocodone bitartrate cap er 12hr 30 HYDROCORTISONE RECTAL CREAM mg ...... 26 2.5% hydrocodone bitartrate cap er 12hr 40 see hydrocortisone rectal cream mg ...... 26 2.5% ...... 33 hydrocodone bitartrate cap er 12hr 50 hydrocortisone tab 10 mg ...... 93 mg ...... 26 hydrocortisone tab 20 mg ...... 93 hydrocodone bitartrate tab er 24hr hydrocortisone tab 5 mg ...... 93 deter 100 mg ...... 27 hydrocortisone valerate cream 0.2% hydrocodone bitartrate tab er 24hr ...... 102 deter 120 mg ...... 27 hydrocortisone valerate oint 0.2% ..102 hydrocodone bitartrate tab er 24hr hydrocortisone w/ acetic acid otic soln deter 20 mg ...... 26 1-2% ...... 152 hydrocodone bitartrate tab er 24hr HYDROCORT OIN 1% ...... 102 deter 30 mg ...... 26 hydromorphone hcl liqd 1 mg/ml ...... 27 hydrocodone bitartrate tab er 24hr hydromorphone hcl tab 2 mg ...... 27 deter 40 mg ...... 26 hydromorphone hcl tab 4 mg ...... 27 hydrocodone bitartrate tab er 24hr hydromorphone hcl tab 8 mg ...... 27 deter 60 mg ...... 26 hydromorphone hcl tab er 24hr 12 mg hydrocodone bitartrate tab er 24hr ...... 27 deter 80 mg ...... 26 hydromorphone hcl tab er 24hr 16 mg hydrocodone-ibuprofen tab 10-200 mg ...... 27 ...... 31 hydromorphone hcl tab er 24hr 32 mg hydrocodone-ibuprofen tab 5-200 mg ...... 27 ...... 31 hydromorphone hcl tab er 24hr 8 mg 27 hydrocodone-ibuprofen tab 7.5-200 mg HYDROMORPHON SUP 3MG ...... 27 ...... 31 hydroxychloroquine sulfate tab 200 mg hydrocortisone-aloe vera cream 0.5% ...... 68 ...... 102 hydroxyprogesterone caproate im in oil hydrocortisone-aloe vera cream 1% 210 1.25 gm/5ml ...... 70 hydrocortisone butyrate cream 0.1% hydroxyprogesterone caproate im in oil ...... 102 250 mg/ml ...... 153 203 hydroxyurea cap 500 mg ...... 71 see losartan potassium & hydroxyzine hcl im soln 25 mg/ml ....37 hydrochlorothiazide tab 100-25 mg hydroxyzine hcl im soln 50 mg/ml ....37 ...... 65 hydroxyzine hcl syrup 10 mg/5ml .....37 see losartan potassium & hydroxyzine hcl tab 10 mg ...... 37 hydrochlorothiazide tab 50-12.5 hydroxyzine hcl tab 25 mg ...... 37 mg ...... 65 hydroxyzine hcl tab 50 mg ...... 37 HYZAAR TAB 100-12.5 ...... 65 hydroxyzine pamoate cap 100 mg ....37 HYZAAR TAB 100-25 ...... 65 hydroxyzine pamoate cap 25 mg ...... 37 HYZAAR TAB 50-12.5 ...... 65 hydroxyzine pamoate cap 50 mg ...... 37 I hyoscyamine sulfate elixir 0.125 ibandronate sodium iv soln 3 mg/3ml mg/5ml ...... 160 (base equivalent) ...... 108 hyoscyamine sulfate sl tab 0.125 mg ibandronate sodium tab 150 mg (base ...... 160 equivalent) ...... 108 hyoscyamine sulfate soln 0.125 mg/ml ibuprofen cap 200 mg ...... 21 ...... 160 ibuprofen chew tab 100 mg ...... 21 hyoscyamine sulfate tab 0.125 mg .160 ibuprofen susp 100 mg/5ml ...... 22 hyoscyamine sulfate tab disint 0.125 ibuprofen susp 40 mg/ml ...... 21 mg ...... 160 ibuprofen tab 100 mg ...... 22 hyoscyamine sulfate tab er 12hr 0.375 ibuprofen tab 200 mg ...... 22 mg ...... 160 ibuprofen tab 400 mg ...... 22 HYSINGLA ER ibuprofen tab 600 mg ...... 22 see hydrocodone bitartrate tab er ibuprofen tab 800 mg ...... 22 24hr deter 100 mg ...... 27 ICAPS AREDS TAB FORMULA ...... 139 see hydrocodone bitartrate tab er iclevia tab ...... 89 24hr deter 120 mg ...... 27 icosapent ethyl cap 1 gm ...... 55 see hydrocodone bitartrate tab er IDHIFA TAB 100MG ...... 71 24hr deter 20 mg ...... 26 IDHIFA TAB 50MG ...... 71 see hydrocodone bitartrate tab er iferex 150 cap forte ...... 119 24hr deter 30 mg ...... 26 ILEVRO DRO 0.3% OP ...... 151 see hydrocodone bitartrate tab er ILUMYA SOL 100MG/ML ...... 99 24hr deter 40 mg ...... 26 imiquimod cream 5% ...... 104 see hydrocodone bitartrate tab er IMITREX 24hr deter 60 mg ...... 26 see sumatriptan nasal spray 20 see hydrocodone bitartrate tab er mg/act ...... 129 24hr deter 80 mg ...... 26 see sumatriptan nasal spray 5 HYSINGLA ER TAB 100 MG ...... 27 mg/act ...... 129 HYSINGLA ER TAB 120 MG ...... 27 see sumatriptan succinate inj 6 HYSINGLA ER TAB 20 MG ...... 27 mg/0.5ml ...... 129 HYSINGLA ER TAB 30 MG ...... 27 see sumatriptan succinate tab 100 HYSINGLA ER TAB 40 MG ...... 27 mg ...... 129 HYSINGLA ER TAB 60 MG ...... 27 see sumatriptan succinate tab 25 mg HYSINGLA ER TAB 80 MG ...... 27 ...... 129 HYZAAR see sumatriptan succinate tab 50 mg see losartan potassium & ...... 129 hydrochlorothiazide tab 100-12.5 IMITREX INJ 4MG/0.5 ...... 128 mg ...... 65 IMITREX INJ 6MG/0.5 ...... 128 204 IMITREX SPR 20MG/ACT ...... 128 indomethacin cap er 75 mg ...... 22 IMITREX SPR 5MG/ACT ...... 128 INGREZZA CAP 40-80MG ...... 156 IMITREX STATDOSE REFILL INGREZZA CAP 40MG ...... 156 see sumatriptan succinate solution INGREZZA CAP 60MG ...... 156 cartridge 4 mg/0.5ml ...... 129 INGREZZA CAP 80MG ...... 156 see sumatriptan succinate solution INNOPRAN XL CAP 120MG ...... 79 cartridge 6 mg/0.5ml ...... 129 INNOPRAN XL CAP 80MG ...... 78 IMITREX STATDOSE SYSTEM INQOVI TAB 35-100MG ...... 71 see sumatriptan succinate solution INS ASP PROT INJ FLEXPEN ...... 48 auto-injector 4 mg/0.5ml ...... 129 INSPIRATORY MIS MTHPIECE ...... 127 see sumatriptan succinate solution INSULIN ASPA INJ 100/ML ...... 48 auto-injector 6 mg/0.5ml ...... 129 INSULIN ASPA INJ 70/30 ...... 48 IMITREX TAB 100MG ...... 128 INSULIN ASPA INJ FLEXPEN ...... 48 IMITREX TAB 25MG ...... 128 INSULIN ASPA INJ PENFILL ...... 48 IMITREX TAB 50MG ...... 128 INSULIN LISP INJ 100/ML ...... 48 IMMUNE CHW SUPPORT ...... 139 INSULIN LISP INJ JUNIOR ...... 48 IMODIUM A-D CAP 2MG ...... 51 INSULIN LISP INJ PROTAMIN ...... 48 IMPEKLO LOT 0.05% ...... 102 INSULIN SYRINGE/NEEDLE ...... 126 IMURAN INTRON A INJ 10MU ...... 72 see azathioprine tab 50 mg ...... 134 INTRON A INJ 18MU ...... 72 INBRIJA CAP 42MG ...... 73 INTRON A INJ 25MU ...... 72 incassia tab 0.35mg ...... 92 INTRON A INJ 50MU ...... 72 IN-CHK FLOW MIS METER ...... 127 introvale tab ...... 89 INCRELEX INJ 40MG/4ML ...... 109 INVOKAMET TAB 150-1000 ...... 45 INCRUSE ELPT INH 62.5MCG ...... 38 INVOKAMET TAB 150-500 ...... 45 indapamide tab 1.25 mg ...... 107 INVOKAMET TAB 50-1000 ...... 45 indapamide tab 2.5 mg ...... 107 INVOKAMET TAB 50-500MG ...... 45 INDERAL LA INVOKAMET XR TAB 150-1000 ...... 45 see propranolol hcl cap er 24hr 120 INVOKAMET XR TAB 150-500 ...... 45 mg ...... 79 INVOKAMET XR TAB 50-1000 ...... 45 see propranolol hcl cap er 24hr 160 INVOKAMET XR TAB 50-500MG ...... 45 mg ...... 79 INVOKANA TAB 100MG ...... 50 see propranolol hcl cap er 24hr 60 INVOKANA TAB 300MG ...... 50 mg ...... 79 IOPIDINE SOL 1% OP ...... 148 see propranolol hcl cap er 24hr 80 ipratropium-albuterol nebu soln 0.5- mg ...... 79 2.5(3) mg/3ml ...... 41 INDERAL LA CAP 120MG ...... 78 ipratropium bromide inhal soln 0.02% INDERAL LA CAP 160MG ...... 78 ...... 38 INDERAL LA CAP 60MG ...... 78 ipratropium bromide nasal soln 0.03% INDERAL LA CAP 80MG ...... 78 (21 mcg/spray) ...... 146 INDERAL XL CAP 120MG ...... 78 ipratropium bromide nasal soln 0.06% INDERAL XL CAP 80MG ...... 78 (42 mcg/spray) ...... 146 INDOCIN SUP 50MG ...... 22 irbesartan-hydrochlorothiazide tab INDOCIN SUS 25MG/5ML ...... 22 150-12.5 mg ...... 65 indomethacin cap 20 mg ...... 22 irbesartan-hydrochlorothiazide tab indomethacin cap 25 mg ...... 22 300-12.5 mg ...... 65 indomethacin cap 50 mg ...... 22 irbesartan tab 150 mg ...... 61 205 irbesartan tab 300 mg ...... 61 JAKAFI TAB 15MG ...... 71 irbesartan tab 75 mg ...... 61 JAKAFI TAB 20MG ...... 71 iron 100/c tab 100-250 ...... 119 JAKAFI TAB 25MG ...... 71 iron 100 tab plus ...... 119 JAKAFI TAB 5MG ...... 71 IRON 21/7 MIS ...... 119 JALYN IRON CHW PEDIATRI ...... 120 see dutasteride-tamsulosin hcl cap IRON UP LIQ ...... 120 0.5-0.4 mg ...... 115 IRO-PLEX LIQ ...... 119 JALYN CAP ...... 115 IROSPAN 24/6 MIS ...... 119 JANUMET TAB 50-1000 ...... 45 isibloom tab ...... 89 JANUMET TAB 50-500MG ...... 45 isoniazid syrup 50 mg/5ml ...... 68 JANUMET XR TAB 100-1000 ...... 45 isoniazid tab 100 mg ...... 68 JANUMET XR TAB 50-1000 ...... 45 isoniazid tab 300 mg ...... 68 JANUMET XR TAB 50-500MG ...... 45 ISOPTO ATROP SOL 1% OP ...... 148 JANUVIA TAB 100MG ...... 47 ISOPTO CARPINE JANUVIA TAB 25MG ...... 47 see pilocarpine hcl ophth soln 1% 148 JANUVIA TAB 50MG ...... 47 see pilocarpine hcl ophth soln 2% 148 JARDIANCE TAB 10MG ...... 50 see pilocarpine hcl ophth soln 4% 148 JARDIANCE TAB 25MG ...... 50 ISORDIL TITRADOSE jasmiel tab 3-0.02mg ...... 89 see isosorbide dinitrate tab 5 mg ...36 jencycla tab 0.35mg ...... 92 isosorbide dinitrate tab 10 mg ...... 36 JENTADUETO TAB 2.5-1000 ...... 45 isosorbide dinitrate tab 20 mg ...... 36 JENTADUETO TAB 2.5-500 ...... 45 isosorbide dinitrate tab 30 mg ...... 36 JENTADUETO TAB 2.5-850 ...... 45 isosorbide dinitrate tab 5 mg ...... 36 JENTADUETO TAB XR ...... 45 isosorbide mononitrate tab 10 mg ....37 jinteli tab 1mg-5mcg ...... 110 isosorbide mononitrate tab 20 mg ....37 jolessa tab ...... 89 isosorbide mononitrate tab er 24hr 120 JUBLIA SOL 10% ...... 97 mg ...... 37 juleber tab ...... 89 isosorbide mononitrate tab er 24hr 30 junel 1/20 tab ...... 89 mg ...... 37 junel 1.5/30 tab ...... 89 isosorbide mononitrate tab er 24hr 60 junel fe 24 tab 1/20 ...... 89 mg ...... 37 junel fe tab 1/20 ...... 89 isotretinoin cap 10 mg ...... 96 junel fe tab 1.5/30 ...... 89 isotretinoin cap 20 mg ...... 96 K isotretinoin cap 30 mg ...... 96 kaitlib fe chw ...... 89 isotretinoin cap 40 mg ...... 96 kalliga tab ...... 89 isradipine cap 2.5 mg ...... 81 KAPSPARGO CAP 100MG ...... 78 isradipine cap 5 mg ...... 81 KAPSPARGO CAP 200MG ...... 78 ISTALOL KAPSPARGO CAP 25MG ...... 77 see timolol maleate ophth soln 0.5% KAPSPARGO CAP 50MG ...... 77 (once-daily) ...... 148 kariva tab 28 day ...... 89 ISTALOL SOL 0.5% OP ...... 147 KATERZIA SUS 1MG/ML ...... 81 itraconazole cap 100 mg ...... 53 KAZANO 12.5- TAB 1000MG ...... 45 itraconazole oral soln 10 mg/ml ...... 53 KAZANO 12.5- TAB 500MG ...... 45 ivermectin tab 3 mg ...... 34 KEFLEX J see cephalexin cap 750 mg ...... 86 JAKAFI TAB 10MG ...... 71 KEFLEX CAP 750MG ...... 86 206 kelnor 1/50 tab ...... 89 K-PAX CAP DOUBLE ...... 139 kelnor tab 1/35 ...... 89 K-PAX CAP SINGLE ...... 139 KELP/LEC/B6 CAP ...... 146 K-PHOS TAB ...... 133 KENALOG K-PHOS TAB NO 2 ...... 115 see triamcinolone acetonide aerosol KRINTAFEL TAB 150MG ...... 68 soln 0.147 mg/gm ...... 103 K-TAB KENALOG AER SPRAY ...... 102 see potassium chloride tab er 10 meq KERYDIN ...... 134 see tavaborole soln 5% ...... 98 kurvelo tab 0.15/30 ...... 89 KERYDIN SOL 5% ...... 97 KYNMOBI MIS 10MG ...... 73 KESIMPTA INJ 20/.4ML ...... 157 KYNMOBI MIS 15MG ...... 73 ketoconazole cream 2% ...... 97 KYNMOBI MIS 20MG ...... 73 ketoconazole foam 2% ...... 97 KYNMOBI MIS 25MG ...... 73 ketoconazole shampoo 2% ...... 97 KYNMOBI MIS 30MG ...... 73 ketoconazole tab 200 mg ...... 53 L ketodan aer 2% ...... 97 labetalol hcl tab 100 mg ...... 77 KETODAN KIT 2% ...... 97 labetalol hcl tab 200 mg ...... 77 KETO-DIASTIX TES ...... 105 labetalol hcl tab 300 mg ...... 77 ketoprofen cap 50 mg ...... 22 lactic acid (ammonium lactate) cream ketoprofen cap 75 mg ...... 22 12% ...... 103 ketoprofen cap er 24hr 200 mg ...... 22 lactic acid (ammonium lactate) lotion ketorolac tromethamine ophth soln 12% ...... 104 0.5% ...... 151 lactulose solution 10 gm/15ml ...... 123 ketorolac tromethamine tab 10 mg ...22 LAMISIL KETOR TROMET SPR 15.75MG ...... 22 see terbinafine hcl tab 250 mg ...... 52 ketotifen fumarate ophth soln 0.025% lamivudine tab 100 mg (hbv) ...... 76 (base equiv) ...... 151 LANCETS ...... 126 KEVZARA INJ 150/1.14 ...... 20 lansoprazole cap delayed release 15 KEVZARA INJ 200/1.14 ...... 20 mg ...... 161 KIDZ MULTVIT CHW PROBIOTI ...... 142 lansoprazole cap delayed release 30 KITABIS PAK mg ...... 161 see tobramycin nebu soln 300 lansoprazole tab delayed release orally mg/5ml ...... 19 disintegrating 15 mg ...... 161 KITABIS PAK NEB 300/5ML ...... 19 lansoprazole tab delayed release orally klor-con 10 tab 10meq er ...... 133 disintegrating 30 mg ...... 161 klor-con 8 tab 8meq er ...... 133 lanthanum carbonate chew tab 1000 kobee tab ...... 136 mg (elemental) ...... 114 KOKO PEAK PR MIS MOUTHPIE ...... 127 lanthanum carbonate chew tab 500 mg KOMBIGLYZ XR TAB 2.5-1000 ...... 45 (elemental) ...... 114 KOMBIGLYZ XR TAB 5-1000MG ...... 45 lanthanum carbonate chew tab 750 mg KOMBIGLYZ XR TAB 5-500MG ...... 45 (elemental) ...... 114 KONDREMUL EMU 50% ...... 123 LANTUS INJ 100/ML ...... 48 KONSYL DAILY POW 100% ...... 121 LANTUS SOLOS INJ 100/ML ...... 48 KONSYL DAILY POW 28.3% ...... 121 larin 24 tab fe 1/20 ...... 89 KONSYL DAILY POW 60.3% ...... 121 larin fe tab 1/20 ...... 89 KONSYL-D POW 52.3% ...... 121 larin fe tab 1.5/30 ...... 89 KONSYL ORIG POW 100% ...... 121 larin tab 1/20 ...... 89 207 larin tab 1.5/30 ...... 89 LEVEMIR INJ ...... 48 larissia tab ...... 89 LEVEMIR INJ FLEXTOUC ...... 49 LASIX levobunolol hcl ophth soln 0.5% .....147 see furosemide tab 20 mg ...... 106 levocetirizine dihydrochloride soln 2.5 see furosemide tab 40 mg ...... 107 mg/5ml (0.5 mg/ml) ...... 54 see furosemide tab 80 mg ...... 107 levocetirizine dihydrochloride tab 5 mg LASTACAFT SOL 0.25% ...... 151 ...... 54 latanoprost ophth soln 0.005% ...... 151 levofloxacin ophth soln 0.5% ...... 149 laxative reg tab 15mg ...... 123 levofloxacin oral soln 25 mg/ml ...... 112 laxative tab 15mg ...... 123 levofloxacin tab 250 mg ...... 112 lax diet sup tab 500mg ...... 123 levofloxacin tab 500 mg ...... 112 layolis fe chw ...... 89 levofloxacin tab 750 mg ...... 112 leena tab ...... 89 levonest tab ...... 89 leflunomide tab 10 mg ...... 23 levonorgestrel & ethinyl estradiol (91- leflunomide tab 20 mg ...... 23 day) tab 0.15-0.03 mg ...... 89 LESCOL XL levonorgestrel & ethinyl estradiol tab see fluvastatin sodium tab er 24 hr 0.15 mg-30 mcg ...... 89 80 mg (base equivalent) ...... 57 levonorgestrel & ethinyl estradiol tab LESCOL XL TAB 80MG ...... 57 0.1 mg-20 mcg ...... 89 lessina tab ...... 89 levonorgestrel-eth estra tab 0.05- LETAIRIS 30/0.075-40/0.125-30mg-mcg .....89 see ambrisentan tab 10 mg ...... 85 levonorgestrel-ethinyl estradiol see ambrisentan tab 5 mg ...... 85 (continuous) tab 90-20 mcg ...... 89 LETAIRIS TAB 10MG ...... 85 levonorgestrel tab 1.5 mg ...... 92 LETAIRIS TAB 5MG ...... 85 levora-28 tab 0.15/30 ...... 89 letrozole tab 2.5 mg ...... 70 levorphanol tartrate tab 2 mg ...... 27 leucovorin calcium tab 10 mg ...... 72 levorphanol tartrate tab 3 mg ...... 27 leucovorin calcium tab 15 mg ...... 72 levothyroxine sodium tab 100 mcg .159 leucovorin calcium tab 25 mg ...... 72 LEVOTHYROXINE SODIUM TAB 100 leucovorin calcium tab 5 mg ...... 72 MCG LEUKERAN TAB 2MG ...... 69 see levothyroxine sodium tab 100 LEUKINE INJ 250MCG ...... 118 mcg ...... 159 leuprolide acetate inj kit 5 mg/ml .....70 levothyroxine sodium tab 112 mcg .159 levalbuterol hcl soln nebu 0.31 mg/3ml LEVOTHYROXINE SODIUM TAB 112 (base equiv) ...... 41 MCG levalbuterol hcl soln nebu 0.63 mg/3ml see levothyroxine sodium tab 112 (base equiv) ...... 41 mcg ...... 159 levalbuterol hcl soln nebu 1.25 mg/3ml levothyroxine sodium tab 125 mcg .159 (base equiv) ...... 41 LEVOTHYROXINE SODIUM TAB 125 levalbuterol hcl soln nebu conc 1.25 MCG mg/0.5ml (base equiv) ...... 41 see levothyroxine sodium tab 125 levalbuterol tartrate inhal aerosol 45 mcg ...... 159 mcg/act (base equiv) ...... 42 levothyroxine sodium tab 137 mcg .159 LEVAQUIN LEVOTHYROXINE SODIUM TAB 137 see levofloxacin tab 250 mg ...... 112 MCG see levofloxacin tab 500 mg ...... 112 see levothyroxine sodium tab 137 see levofloxacin tab 750 mg ...... 112 mcg ...... 159 208 levothyroxine sodium tab 150 mcg .159 lidocaine hcl urethral/mucosal gel 2% LEVOTHYROXINE SODIUM TAB 150 ...... 104 MCG lidocaine hcl urethral/mucosal gel see levothyroxine sodium tab 150 prefilled syringe 2% ...... 104 mcg ...... 159 lidocaine hcl viscous soln 2% ...... 135 levothyroxine sodium tab 175 mcg .159 lidocaine oint 5% ...... 104 LEVOTHYROXINE SODIUM TAB 175 lidocaine patch 4% ...... 104 MCG lidocaine patch 5% ...... 104 see levothyroxine sodium tab 175 lidocaine-prilocaine cream 2.5-2.5% mcg ...... 159 ...... 104 levothyroxine sodium tab 200 mcg .159 LIDODERM LEVOTHYROXINE SODIUM TAB 200 see lidocaine patch 5% ...... 104 MCG lillow tab 0.15/30 ...... 89 see levothyroxine sodium tab 200 lindane shampoo 1% ...... 104 mcg ...... 159 linezolid for susp 100 mg/5ml ...... 36 levothyroxine sodium tab 25 mcg ...159 linezolid tab 600 mg ...... 36 LEVOTHYROXINE SODIUM TAB 25 MCG LINZESS CAP 145MCG ...... 114 see levothyroxine sodium tab 25 mcg LINZESS CAP 290MCG ...... 114 ...... 159 LINZESS CAP 72MCG ...... 114 levothyroxine sodium tab 300 mcg .159 liothyronine sodium tab 25 mcg .....159 LEVOTHYROXINE SODIUM TAB 300 liothyronine sodium tab 50 mcg .....159 MCG liothyronine sodium tab 5 mcg ...... 159 see levothyroxine sodium tab 300 LIPITOR mcg ...... 159 see atorvastatin calcium tab 10 mg levothyroxine sodium tab 50 mcg ...159 (base equivalent) ...... 57 LEVOTHYROXINE SODIUM TAB 50 MCG see atorvastatin calcium tab 20 mg see levothyroxine sodium tab 50 mcg (base equivalent) ...... 57 ...... 159 see atorvastatin calcium tab 40 mg levothyroxine sodium tab 75 mcg ...159 (base equivalent) ...... 57 LEVOTHYROXINE SODIUM TAB 75 MCG see atorvastatin calcium tab 80 mg see levothyroxine sodium tab 75 mcg (base equivalent) ...... 57 ...... 159 LIPITOR TAB 10MG ...... 57 levothyroxine sodium tab 88 mcg ...159 LIPITOR TAB 20MG ...... 57 LEVOTHYROXINE SODIUM TAB 88 MCG LIPITOR TAB 40MG ...... 57 see levothyroxine sodium tab 88 mcg LIPITOR TAB 80MG ...... 57 ...... 159 LIPOFEN CAP 150MG ...... 57 LEXETTE AER 0.05% ...... 102 LIPOFEN CAP 50MG ...... 57 LIALDA lipoflavovit tab ...... 144 see mesalamine tab delayed release lisinopril & hydrochlorothiazide tab 10- 1.2 gm ...... 113 12.5 mg ...... 65 LIALDA TAB 1.2GM ...... 113 lisinopril & hydrochlorothiazide tab 20- LICART DIS 1.3% ...... 96 12.5 mg ...... 65 lice treatmt liq 1% ...... 104 lisinopril & hydrochlorothiazide tab 20- lice trtmnt liq 1% ...... 104 25 mg ...... 65 lidocaine cre pain 4% ...... 104 lisinopril tab 10 mg ...... 59 lidocaine hcl cream 3% ...... 104 lisinopril tab 2.5 mg ...... 59 lisinopril tab 20 mg ...... 59 209 lisinopril tab 30 mg ...... 59 LOPRESSOR TAB 50MG ...... 78 lisinopril tab 40 mg ...... 59 LOPROX lisinopril tab 5 mg ...... 59 see ciclopirox olamine cream 0.77% LIVALO TAB 1MG ...... 57 (base equiv) ...... 97 LIVALO TAB 2MG ...... 57 see ciclopirox olamine susp 0.77% LIVALO TAB 4MG ...... 57 (base equiv) ...... 97 L-METHYL-MC TAB ...... 105 LOPROX CRE 0.77% ...... 97 L-METHYL-MC TAB NAC ...... 105 LOPROX KIT 0.77% ...... 97 L-METHYL- TAB B6-B12 ...... 105 LOPROX SHA 1% ...... 97 LOCALNESIUM TAB ...... 131 LOPROX SHAMPOO LOCALNESIUM TAB -C ...... 131 see ciclopirox shampoo 1% ...... 97 LOCOID LOPROX SUS 0.77% ...... 97 see hydrocortisone butyrate lotion loratadine & pseudoephedrine tab er 0.1% ...... 102 12hr 5-120 mg ...... 95 LOCOID LIPO CRE 0.1% ...... 102 loratadine & pseudoephedrine tab er LOCOID LIPOCREAM 24hr 10-240 mg ...... 95 see hydrocortisone butyrate loratadine cap 10 mg ...... 54 hydrophilic lipo base cream 0.1% loratadine chw 5mg ...... 54 ...... 102 loratadine rapidly-disintegrating tab 10 LOCOID LOT 0.1% ...... 102 mg ...... 54 LODINE loratadine syrup 5 mg/5ml ...... 54 see etodolac tab 400 mg ...... 21 loratadine tab 10 mg ...... 54 LODINE TAB 400MG ...... 22 LORTAB ELX 10-300MG ...... 31 LODOSYN loryna tab 3-0.02mg ...... 90 see carbidopa tab 25 mg ...... 72 lorzone tab 375mg ...... 144 LODOSYN TAB 25MG ...... 72 lorzone tab 750mg ...... 144 loestrin 21 tab 1.5/30 ...... 89 losartan potassium & loestrin fe tab 1/20 ...... 90 hydrochlorothiazide tab 100-12.5 mg loestrin fe tab 1.5/30 ...... 89 ...... 65 loestrin tab 1/20-21 ...... 90 losartan potassium & LO LOESTRIN TAB 1-10-10 ...... 89 hydrochlorothiazide tab 100-25 mg 65 LOMOTIL losartan potassium & see diphenoxylate w/ atropine tab hydrochlorothiazide tab 50-12.5 mg 2.5-0.025 mg ...... 51 ...... 65 LONHALA MAGN SOL 25MCG ...... 38 losartan potassium tab 100 mg ...... 61 LONSURF TAB 15-6.14 ...... 71 losartan potassium tab 25 mg ...... 61 LONSURF TAB 20-8.19 ...... 71 losartan potassium tab 50 mg ...... 61 loperamide hcl cap 2 mg ...... 51 LOTENSIN loperamide hcl tab 2 mg ...... 51 see benazepril hcl tab 10 mg ...... 59 loperamide sus 1mg/7.5 ...... 51 see benazepril hcl tab 20 mg ...... 59 LOPID see benazepril hcl tab 40 mg ...... 59 see gemfibrozil tab 600 mg ...... 57 LOTENSIN HCT LOPID TAB 600MG ...... 57 see benazepril & hydrochlorothiazide LOPRESSOR tab 10-12.5 mg ...... 64 see metoprolol tartrate tab 100 mg78 see benazepril & hydrochlorothiazide see metoprolol tartrate tab 50 mg .78 tab 20-12.5 mg ...... 64 LOPRESSOR TAB 100MG ...... 78 210 see benazepril & hydrochlorothiazide see enoxaparin sodium inj 40 tab 20-25 mg ...... 64 mg/0.4ml ...... 43 LOTENSIN HCT TAB 10-12.5 ...... 65 see enoxaparin sodium inj 60 LOTENSIN HCT TAB 20-12.5 ...... 65 mg/0.6ml ...... 43 LOTENSIN HCT TAB 20-25MG ...... 65 see enoxaparin sodium inj 80 LOTENSIN TAB 10MG ...... 59 mg/0.8ml ...... 43 LOTENSIN TAB 20MG ...... 59 LOVENOX INJ 100MG/ML ...... 44 LOTENSIN TAB 40MG ...... 60 LOVENOX INJ 120/0.8 ...... 44 LOTREL LOVENOX INJ 150MG/ML ...... 44 see amlodipine besylate-benazepril LOVENOX INJ 30/0.3ML ...... 44 hcl cap 10-20 mg ...... 63 LOVENOX INJ 300/3ML ...... 44 see amlodipine besylate-benazepril LOVENOX INJ 40/0.4ML ...... 44 hcl cap 10-40 mg ...... 63 LOVENOX INJ 60/0.6ML ...... 44 see amlodipine besylate-benazepril LOVENOX INJ 80/0.8ML ...... 44 hcl cap 5-10 mg ...... 63 low-ogestrel tab ...... 90 see amlodipine besylate-benazepril lo-zumandimi tab 3-0.02mg ...... 89 hcl cap 5-20 mg ...... 63 lubiprostone cap 24 mcg ...... 113 LOTREL CAP 10-20MG ...... 65 lubiprostone cap 8 mcg ...... 113 LOTREL CAP 10-40MG ...... 65 lubricnt gel dro 1% ...... 147 LOTREL CAP 5-10MG ...... 65 LUCEMYRA TAB 0.18MG ...... 154 LOTREL CAP 5-20MG ...... 65 luliconazole cream 1% ...... 98 LOTRIMIN ULT CRE 1% ...... 97 LUMAKRAS TAB 120MG ...... 71 LOTRONEX LUMIGAN SOL 0.01% ...... 151 see alosetron hcl tab 0.5 mg (base lutera tab ...... 90 equiv) ...... 114 LUXIQ see alosetron hcl tab 1 mg (base see betamethasone valerate aerosol equiv) ...... 114 foam 0.12% ...... 100 LOTRONEX TAB 0.5MG ...... 114 LUXIQ AER 0.12% ...... 102 LOTRONEX TAB 1MG ...... 114 LUZU CRE 1% ...... 98 lovastatin tab 10 mg ...... 58 lyleq tab 0.35mg ...... 92 lovastatin tab 20 mg ...... 58 lyllana dis 0.025mg ...... 111 lovastatin tab 40 mg ...... 58 lyllana dis 0.0375mg ...... 111 LOVAZA lyllana dis 0.05mg ...... 111 see omega-3-acid ethyl esters cap 1 lyllana dis 0.075mg ...... 111 gm ...... 55 lyllana dis 0.1mg ...... 111 LOVAZA CAP 1GM ...... 55 LYSODREN TAB 500MG ...... 70 LOVENOX LYUMJEV INJ 100UT/ML ...... 49 see enoxaparin sodium inj 100 LYUMJEV KWPN INJ 100UT/ML ...... 49 mg/ml ...... 43 LYUMJEV KWPN INJ 200UT/ML ...... 49 see enoxaparin sodium inj 120 lyza tab 0.35mg ...... 92 mg/0.8ml ...... 43 M see enoxaparin sodium inj 150 MACROBID mg/ml ...... 43 see nitrofurantoin monohydrate see enoxaparin sodium inj 300 macrocrystalline cap 100 mg ...... 36 mg/3ml ...... 43 MACRODANTIN see enoxaparin sodium inj 30 see nitrofurantoin macrocrystalline mg/0.3ml ...... 43 cap 100 mg ...... 36 211 see nitrofurantoin macrocrystalline magnesium sulfate iv soln 4 gm/50ml cap 50 mg ...... 36 (80 mg/ml) ...... 132 MAG-AL LIQ ...... 34 magnesium tab 100 mg ...... 133 MAG CITRATE TAB 100MG ...... 132 magnesium tab 250 mg ...... 133 MAG GLYCINAT TAB 100MG ...... 132 magnesium tab 500mg ...... 133 mag-g tab 500mg ...... 132 MAGONATE LIQ 1000/5ML ...... 133 MAGINEX TAB 615 MG ...... 132 MAGOX 400 TAB 400MG ...... 133 magnesium chloride inj 200 mg/ml .132 MAKENA magnesium chloride tab dr 64 mg see hydroxyprogesterone caproate (elemental mg) ...... 132 im in oil 250 mg/ml ...... 153 magnesium citrate soln ...... 123 MAKENA INJ 250MG/ML ...... 153 magnesium gluconate tab 27.5 mg MAKENA INJ 275MG ...... 153 (elemental mg) ...... 132 malathion lotion 0.5% ...... 105 magnesium hydroxide susp 400 maox tab 420mg ...... 34 mg/5ml ...... 123 MARINOL magnesium lactate tab er 84 mg see dronabinol cap 10 mg ...... 52 (elemental mg) (7 meq) ...... 132 see dronabinol cap 2.5 mg ...... 52 magnesium oxide tab 400 mg (240 mg see dronabinol cap 5 mg ...... 52 elemental mg) ...... 132 marlissa tab 0.15/30 ...... 90 magnesium oxide tab 400 mg (241.3 MASK VORTEX/ MIS FROG ...... 127 mg elemental mg) ...... 132 MASK VORTEX/ MIS LADY BUG ...... 127 magnesium oxide tab 420 mg ...... 34 MATULANE CAP 50MG ...... 72 MAGNESIUM SULFATE matzim la tab 180mg/24 ...... 82 see magnesium sulfate iv soln 20 matzim la tab 240mg/24 ...... 82 gm/500ml (40 mg/ml) ...... 132 matzim la tab 300mg/24 ...... 82 see magnesium sulfate iv soln 2 matzim la tab 360mg/24 ...... 82 gm/50ml (40 mg/ml) ...... 132 matzim la tab 420mg/24 ...... 82 see magnesium sulfate iv soln 40 MAVENCLAD PAK 10MG(10) ...... 157 gm/1000ml (40 mg/ml) ...... 133 MAVENCLAD PAK 10MG(4) ...... 157 see magnesium sulfate iv soln 4 MAVENCLAD PAK 10MG(5) ...... 157 gm/100ml (40 mg/ml) ...... 132 MAVENCLAD PAK 10MG(6) ...... 157 see magnesium sulfate iv soln 4 MAVENCLAD PAK 10MG(7) ...... 157 gm/50ml (80 mg/ml) ...... 132 MAVENCLAD PAK 10MG(8) ...... 157 MAGNESIUM SULFATE IN D5W MAVENCLAD PAK 10MG(9) ...... 157 see magnesium sulfate in dextrose MAVIK 5% iv soln 1 gm/100ml ...... 132 see trandolapril tab 4 mg ...... 60 magnesium sulfate in dextrose 5% iv MAXALT soln 1 gm/100ml ...... 132 see rizatriptan benzoate tab 10 mg magnesium sulfate inj 50% ...... 132 (base equivalent) ...... 129 magnesium sulfate iv soln 20 MAXALT-MLT gm/500ml (40 mg/ml) ...... 132 see rizatriptan benzoate oral magnesium sulfate iv soln 2 gm/50ml disintegrating tab 10 mg (base eq) (40 mg/ml) ...... 132 ...... 129 magnesium sulfate iv soln 40 MAXALT-MLT TAB 10MG ...... 128 gm/1000ml (40 mg/ml) ...... 133 MAXALT TAB 10MG ...... 128 magnesium sulfate iv soln 4 gm/100ml MAXITROL (40 mg/ml) ...... 132 212 see neomycin-polymyxin- megestrol acetate tab 20 mg ...... 70 dexamethasone ophth oint 0.1% megestrol acetate tab 40 mg ...... 70 ...... 150 melatonin liquid 1 mg/ml ...... 19 see neomycin-polymyxin- melatonin tab 3 mg ...... 19 dexamethasone ophth susp 0.1% melatonin tab 5 mg ...... 19 ...... 150 meloxicam cap 10 mg ...... 22 MAXZIDE meloxicam cap 5 mg ...... 22 see triamterene & meloxicam tab 15 mg ...... 22 hydrochlorothiazide tab 75-50 mg meloxicam tab 7.5 mg ...... 22 ...... 106 melphalan tab 2 mg ...... 69 MAXZIDE-25 memantine hcl cap er 24hr 14 mg ..155 see triamterene & memantine hcl cap er 24hr 21 mg ..155 hydrochlorothiazide tab 37.5-25 memantine hcl cap er 24hr 28 mg ..155 mg ...... 106 memantine hcl cap er 24hr 7 mg ....155 MAYZENT TAB 0.25MG ...... 157 memantine hcl oral solution 2 mg/ml MAYZENT TAB 2MG ...... 157 ...... 155 meclizine hcl chew tab 25 mg ...... 52 memantine hcl tab 10 mg ...... 155 meclizine hcl tab 12.5 mg ...... 52 memantine hcl tab 28 x 5 mg & 21 x meclizine hcl tab 25 mg ...... 52 10 mg titration pack ...... 155 meclofenamate sodium cap 100 mg ..22 memantine hcl tab 5 mg ...... 155 meclofenamate sodium cap 50 mg ...22 MENEST TAB 0.3MG ...... 111 medi-lax tab 15mg ...... 123 MENEST TAB 0.625MG ...... 111 MEDROL MENEST TAB 1.25MG ...... 111 see methylprednisolone tab 16 mg 93 MENS 50+ CAP ADVANCED ...... 139 see methylprednisolone tab 32 mg 93 mens daily chw gummies ...... 139 see methylprednisolone tab 4 mg ..93 MENS MULTI CHW ...... 139 see methylprednisolone tab 8 mg ..93 MENTAX CRE 1% ...... 98 MEDROL DOSEPAK meperidine hcl oral soln 50 mg/5ml ..27 see methylprednisolone tab therapy meperidine hcl tab 50 mg ...... 27 pack 4 mg (21) ...... 93 MEPHYTON medroxyprogesterone acetate im susp see phytonadione tab 5 mg ...... 166 150 mg/ml ...... 92 MEPRON medroxyprogesterone acetate im susp see atovaquone susp 750 mg/5ml .35 prefilled syr 150 mg/ml ...... 92 mercaptopurine tab 50 mg ...... 69 medroxyprogesterone acetate tab 10 mesalamine cap dr 400 mg ...... 113 mg ...... 154 mesalamine cap er 24hr 0.375 gm ..113 medroxyprogesterone acetate tab 2.5 mesalamine enema 4 gm ...... 113 mg ...... 153 mesalamine tab delayed release 1.2 medroxyprogesterone acetate tab 5 mg gm ...... 113 ...... 153 mesalamine tab delayed release 800 mefenamic acid cap 250 mg ...... 22 mg ...... 113 mefloquine hcl tab 250 mg ...... 68 MESNEX TAB 400MG ...... 72 MEGA MULTIVI TAB MEN ...... 139 MESTINON MEGA MULTIVI TAB WOMEN ...... 139 see pyridostigmine bromide tab 60 megestrol acetate susp 40 mg/ml ....70 mg ...... 68 megestrol acetate susp 625 mg/5ml METAFOLBIC TAB ...... 105 ...... 154 METAFOLBIC TAB PLUS ...... 105 213 METAFOLBIC TAB PLUS RF ...... 105 methotrexate sodium inj pf 1000 METAMUCIL POW 28%ORG ...... 121 mg/40ml (25 mg/ml) ...... 69 METAMUCIL POW 48.57% ...... 121 methotrexate sodium inj pf 250 METAMUCIL POW 58.12% ...... 121 mg/10ml (25 mg/ml) ...... 69 METAMUCIL POW 63% ...... 121 methotrexate sodium inj pf 50 mg/2ml METAMUCIL WAF ...... 122 (25 mg/ml) ...... 69 metaxalone tab 400 mg ...... 144 METHOTREXATE TAB 2.5MG ...... 69 metaxalone tab 800 mg ...... 144 methylcellulose tab 500 mg ...... 122 metformin hcl oral soln 500 mg/5ml .46 methyldopa & hydrochlorothiazide tab metformin hcl tab 1000 mg ...... 46 250-15 mg ...... 65 metformin hcl tab 500 mg ...... 46 methyldopa & hydrochlorothiazide tab metformin hcl tab 850 mg ...... 46 250-25 mg ...... 65 metformin hcl tab er 24hr 500 mg ....46 methyldopa tab 250 mg ...... 62 metformin hcl tab er 24hr 750 mg ....46 methyldopa tab 500 mg ...... 62 metformin hcl tab er 24hr modified methylergonovine maleate tab 0.2 mg release 1000 mg ...... 46 ...... 152 metformin hcl tab er 24hr modified METHYLFOL/CA TAB ME-CBL ...... 105 release 500 mg ...... 46 methylprednisolone tab 16 mg ...... 93 metformin hcl tab er 24hr osmotic methylprednisolone tab 32 mg ...... 93 1000 mg ...... 47 methylprednisolone tab 4 mg ...... 93 metformin hcl tab er 24hr osmotic 500 methylprednisolone tab 8 mg ...... 93 mg ...... 47 methylprednisolone tab therapy pack 4 methacholine cap /liver ...... 144 mg (21) ...... 93 methadone hcl conc 10 mg/ml ...... 27 metoclopramide hcl soln 5 mg/5ml (10 methadone hcl soln 10 mg/5ml ...... 27 mg/10ml) (base equiv) ...... 113 methadone hcl soln 5 mg/5ml ...... 27 metoclopramide hcl tab 10 mg (base methadone hcl tab 10 mg ...... 27 equivalent) ...... 113 methadone hcl tab 5 mg ...... 27 metoclopramide hcl tab 5 mg (base methadone hcl tab for oral susp 40 mg equivalent) ...... 113 ...... 27 metolazone tab 10 mg ...... 107 METHADOSE metolazone tab 2.5 mg ...... 107 see methadone hcl conc 10 mg/ml .27 metolazone tab 5 mg ...... 107 METHADOSE CON 10MG/ML ...... 27 metoprolol & hydrochlorothiazide tab METHADOSE SF CON 10MG/ML ...... 27 100-25 mg ...... 65 methadose tab 40mg ...... 27 metoprolol & hydrochlorothiazide tab methenamine hippurate tab 1 gm ....36 100-50 mg ...... 65 methenamine mandelate tab 0.5 gm 36 metoprolol & hydrochlorothiazide tab methenamine mandelate tab 1 gm ...36 50-25 mg ...... 65 methergine tab 0.2mg ...... 152 metoprolol succinate tab er 24hr 100 methimazole tab 10 mg ...... 158 mg (tartrate equiv) ...... 78 methimazole tab 5 mg ...... 158 metoprolol succinate tab er 24hr 200 methocarbamol tab 500 mg ...... 145 mg (tartrate equiv) ...... 78 methocarbamol tab 750 mg ...... 145 metoprolol succinate tab er 24hr 25 mg methotrexate sodium inj 250 mg/10ml (tartrate equiv) ...... 78 (25 mg/ml) ...... 69 metoprolol succinate tab er 24hr 50 mg methotrexate sodium inj 50 mg/2ml (tartrate equiv) ...... 78 (25 mg/ml) ...... 69 metoprolol tartrate tab 100 mg ...... 78 214 metoprolol tartrate tab 25 mg ...... 78 miconazole nitrate vaginal suppos 100 metoprolol tartrate tab 37.5 mg ...... 78 mg ...... 165 metoprolol tartrate tab 50 mg ...... 78 miconazole-zinc oxide-white metoprolol tartrate tab 75 mg ...... 78 petrolatum oint 0.25-15-81.35% ...98 METROCREAM micrgstin 24 tab fe 1/20 ...... 90 see metronidazole cream 0.75% ..104 microgestin tab 1/20 ...... 90 see rosadan cre 0.75% ...... 104 microgestin tab 1.5/30 ...... 90 metronidazole cap 375 mg ...... 34 microgestin tab fe 1/20 ...... 90 metronidazole cream 0.75% ...... 104 microgestin tab fe1.5/30 ...... 90 metronidazole gel 0.75% ...... 104 midazolam hcl inj 10 mg/2ml (base metronidazole tab 250 mg ...... 34 equivalent) ...... 121 metronidazole tab 500 mg ...... 35 midazolam hcl inj 25 mg/5ml (base metronidazole vaginal gel 0.75% ....165 equivalent) ...... 121 mexiletine hcl cap 150 mg ...... 38 midazolam hcl inj 50 mg/10ml (base mexiletine hcl cap 200 mg ...... 38 equivalent) ...... 121 mexiletine hcl cap 250 mg ...... 38 midazolam hcl inj 5 mg/ml (base MIACALCIN equivalent) ...... 121 see calcitonin (salmon) inj 200 midazolam hcl inj pf 10 mg/2ml (base unit/ml ...... 107 equivalent) ...... 121 see calcitonin (salmon) nasal soln midazolam hcl inj pf 5 mg/ml (base 200 unit/act ...... 108 equivalent) ...... 121 MIACALCIN INJ 200/ML ...... 108 midodrine hcl tab 10 mg ...... 166 mibelas 24 chw fe ...... 90 midodrine hcl tab 2.5 mg ...... 166 MICARDIS midodrine hcl tab 5 mg ...... 166 see telmisartan tab 20 mg ...... 61 miglitol tab 100 mg ...... 44 see telmisartan tab 40 mg ...... 61 miglitol tab 25 mg ...... 44 see telmisartan tab 80 mg ...... 61 miglitol tab 50 mg ...... 44 MICARDIS HCT mili tab 0.25/35 ...... 90 see telmisartan-hydrochlorothiazide MILK OF MAGN CHW 311MG ...... 123 tab 40-12.5 mg ...... 67 milk of magn sus 2400mg ...... 123 see telmisartan-hydrochlorothiazide mimvey tab 1-0.5mg ...... 110 tab 80-12.5 mg ...... 67 MINASTRIN 24 FE see telmisartan-hydrochlorothiazide see charlotte 24 chw fe 1/20 ...... 88 tab 80-25 mg ...... 67 see mibelas 24 chw fe ...... 90 MICARDIS HCT TAB 40/12.5 ...... 66 see norethindrone ace-eth estradiol- MICARDIS HCT TAB 80/12.5 ...... 66 fe chew tab 1 mg-20 mcg (24) ...90 MICARDIS HCT TAB 80-25MG ...... 66 mineral oil ...... 123 MICARDIS TAB 20MG ...... 61 mineral oil enema ...... 123 MICARDIS TAB 40MG ...... 61 MINICAPS OMG CAP -3 350MG ...... 146 MICARDIS TAB 80MG ...... 61 mini enema ene 100/5ml ...... 124 miconazole nitrate cream 2% ...... 98 MINIPRESS miconazole nitrate vaginal app 200 mg see prazosin hcl cap 1 mg ...... 62 & 2% cream 9 gm kit ...... 165 see prazosin hcl cap 2 mg ...... 62 miconazole nitrate vaginal cream 2% see prazosin hcl cap 5 mg ...... 62 ...... 165 MINIPRESS CAP 1MG ...... 62 miconazole nitrate vaginal supp 200 MINIPRESS CAP 2MG ...... 62 mg & 2% cream 9 gm kit ...... 165 MINIPRESS CAP 5MG ...... 62 215 minitran dis 0.1mg/hr ...... 37 see pramipexole dihydrochloride tab minitran dis 0.2mg/hr ...... 37 er 24hr 3 mg ...... 74 minitran dis 0.4mg/hr ...... 37 see pramipexole dihydrochloride tab minitran dis 0.6mg/hr ...... 37 er 24hr 4.5 mg ...... 74 MINIVELLE MIRAPEX ER TAB 0.375MG ...... 73 see estradiol td patch twice weekly MIRAPEX ER TAB 0.75MG ...... 73 0.025 mg/24hr ...... 111 MIRAPEX ER TAB 1.5MG ...... 73 see estradiol td patch twice weekly MIRAPEX ER TAB 2.25MG ...... 73 0.0375 mg/24hr ...... 111 MIRAPEX ER TAB 3.75MG ...... 73 see estradiol td patch twice weekly MIRAPEX ER TAB 3MG ...... 73 0.05 mg/24hr ...... 111 MIRAPEX ER TAB 4.5MG ...... 73 see estradiol td patch twice weekly MIRCETTE 0.075 mg/24hr ...... 111 see azurette tab ...... 87 see estradiol td patch twice weekly see azurette tab 28 day ...... 88 0.1 mg/24hr ...... 111 see bekyree tab ...... 88 see lyllana dis 0.025mg ...... 111 see desogest-eth estrad & eth estrad see lyllana dis 0.0375mg ...... 111 tab 0.15-0.02/0.01 mg(21/5) .....88 see lyllana dis 0.05mg ...... 111 see kariva tab 28 day ...... 89 see lyllana dis 0.075mg ...... 111 see pimtrea tab ...... 91 see lyllana dis 0.1mg ...... 111 see simliya tab 28 day ...... 91 MINOCIN see viorele tab ...... 92 see minocycline hcl cap 100 mg ...158 see volnea tab ...... 92 minocycline hcl cap 100 mg ...... 158 misoprostol tab 100 mcg ...... 162 minocycline hcl cap 50 mg ...... 158 misoprostol tab 200 mcg ...... 162 minocycline hcl cap 75 mg ...... 158 MITIGARE CAP 0.6MG ...... 116 minoxidil tab 10 mg ...... 68 MOBIC minoxidil tab 2.5 mg ...... 68 see meloxicam tab 15 mg ...... 22 MIRAPEX see meloxicam tab 7.5 mg ...... 22 see pramipexole dihydrochloride tab MOBIC TAB 15MG ...... 22 0.125 mg ...... 74 MOBIC TAB 7.5MG ...... 22 see pramipexole dihydrochloride tab moexipril hcl tab 15 mg ...... 60 0.5 mg ...... 74 moexipril hcl tab 7.5 mg ...... 60 see pramipexole dihydrochloride tab MOISTURE EYE DRO ...... 147 0.75 mg ...... 74 mometasone furoate cream 0.1% ...102 see pramipexole dihydrochloride tab mometasone furoate nasal susp 50 1 mg ...... 74 mcg/act ...... 146 MIRAPEX ER mometasone furoate oint 0.1% ...... 102 see pramipexole dihydrochloride tab mometasone furoate solution 0.1% er 24hr 0.375 mg ...... 74 (lotion) ...... 102 see pramipexole dihydrochloride tab MONISTAT 3 KIT 200MG/2% ...... 165 er 24hr 0.75 mg ...... 74 MONISTAT 7 CRE 2% ...... 165 see pramipexole dihydrochloride tab mono-linyah tab 0.25-35 ...... 90 er 24hr 1.5 mg ...... 74 montelukast sodium chew tab 4 mg see pramipexole dihydrochloride tab (base equiv) ...... 39 er 24hr 2.25 mg ...... 74 montelukast sodium chew tab 5 mg see pramipexole dihydrochloride tab (base equiv) ...... 39 er 24hr 3.75 mg ...... 74 216 montelukast sodium oral granules MOUTHPIECE MIS PED ADAP ...... 127 packet 4 mg (base equiv) ...... 39 MOVANTIK TAB 12.5MG ...... 114 montelukast sodium tab 10 mg (base MOVANTIK TAB 25MG ...... 114 equiv) ...... 39 MOVIPREP morgidox cap 1x100mg ...... 158 see peg/nasul,c sol nacl/pot ...... 122 morgidox cap 2x100mg ...... 158 MOVIPREP SOL ...... 122 morphine sulfate beads cap er 24hr MOXEZA 120 mg ...... 27 see moxifloxacin hcl ophth soln 0.5% morphine sulfate beads cap er 24hr 30 (base eq) (2 times daily) ...... 149 mg ...... 27 MOXEZA SOL 0.5% ...... 149 morphine sulfate beads cap er 24hr 45 moxifloxacin hcl ophth soln 0.5% (base mg ...... 27 eq) (2 times daily) ...... 149 morphine sulfate beads cap er 24hr 60 moxifloxacin hcl ophth soln 0.5% (base mg ...... 27 equiv) ...... 149 morphine sulfate beads cap er 24hr 75 moxifloxacin hcl tab 400 mg (base mg ...... 27 equiv) ...... 112 morphine sulfate beads cap er 24hr 90 MS CONTIN mg ...... 27 see morphine sulfate tab er 100 mg morphine sulfate cap er 24hr 100 mg ...... 28 ...... 28 see morphine sulfate tab er 15 mg 28 morphine sulfate cap er 24hr 10 mg .28 see morphine sulfate tab er 200 mg morphine sulfate cap er 24hr 20 mg .28 ...... 28 morphine sulfate cap er 24hr 30 mg .28 see morphine sulfate tab er 30 mg 28 morphine sulfate cap er 24hr 40 mg .28 see morphine sulfate tab er 60 mg 28 morphine sulfate cap er 24hr 50 mg .28 MS CONTIN TAB 100MG ER ...... 28 morphine sulfate cap er 24hr 60 mg .28 MS CONTIN TAB 15MG ER ...... 28 morphine sulfate cap er 24hr 80 mg .28 MS CONTIN TAB 200MG ER ...... 28 morphine sulfate oral soln 100 mg/5ml MS CONTIN TAB 30MG ER ...... 28 (20 mg/ml) ...... 28 MS CONTIN TAB 60MG ER ...... 28 morphine sulfate oral soln 10 mg/5ml multi+omega3 chw adult ...... 139 ...... 28 MULTI ADULT CHW EXTRA C ...... 139 morphine sulfate oral soln 20 mg/5ml multi adult chw gummies ...... 139 ...... 28 MULTIGEN PLS TAB ...... 119 morphine sulfate suppos 10 mg ...... 28 MULTIGEN TAB ...... 119 morphine sulfate suppos 20 mg ...... 28 MULTIGEN TAB FOLIC ...... 119 morphine sulfate suppos 30 mg ...... 28 multi gummie chw mens ...... 139 morphine sulfate suppos 5 mg ...... 28 multi gummie chw womens ...... 139 morphine sulfate tab 15 mg ...... 28 multiple vitamins w/ iron tab 7...... 13 morphine sulfate tab 30 mg ...... 28 multiple vitamins w/ minerals cap9 ...13 morphine sulfate tab er 100 mg ...... 28 multiple vitamins w/ minerals cap- rx morphine sulfate tab er 15 mg ...... 28 ...... 139 morphine sulfate tab er 200 mg ...... 28 multiple vitamins w/ minerals liquid 139 morphine sulfate tab er 30 mg ...... 28 multiple vitamins w/ minerals tab 0.. .14 morphine sulfate tab er 60 mg ...... 28 multiple vitamins w/ minerals tab- rx MOTEGRITY TAB 1MG ...... 112 ...... 140 MOTEGRITY TAB 2MG ...... 112 multiple vitamin tab ...... 141 MOUTHPIECE MIS DISP/PPR ...... 127 multivi adlt chw gummies ...... 140 217 multi-vitami chw gummies ...... 139 naftifine hcl gel 1% ...... 98 MULTIVITAMIN CHW ADLT GUM .....140 NAFTIN multivitamin chw vita d3 ...... 140 see naftifine hcl gel 1% ...... 98 MULTI-VITAMI TAB MONOCAPS ...... 139 NAFTIN GEL 1% ...... 98 MULTI-VITE LIQ ...... 139 NAFTIN GEL 2% ...... 98 MULT MINERAL TAB ...... 133 NALFON CAP 400MG ...... 22 mupirocin calcium cream 2% ...... 97 NALFON TAB 600MG ...... 22 mupirocin oint 2% ...... 97 NALOCET TAB 2.5-300 ...... 31 MVW COMPLETE CAP D3000 ...... 140 naloxone hcl inj 0.4 mg/ml ...... 51 MVW COMPLETE CAP D5000 ...... 140 naloxone hcl inj 4 mg/10ml ...... 51 MVW COMPLETE CAP FORMULAT ....140 naloxone hcl soln cartridge 0.4 mg/ml MVW COMPLETE CAP MINIS ...... 140 ...... 51 MVW COMPLETE CHW GRAPE ...... 142 naloxone hcl soln prefilled syringe 2 MVW COMPLETE DRO PEDIATRI .....142 mg/2ml ...... 51 MYAMBUTOL NAMENDA TAB 10MG ...... 155 see ethambutol hcl tab 400 mg .....68 NAMENDA TAB 5-10MG ...... 155 MYCOBUTIN NAMENDA TAB 5MG ...... 155 see rifabutin cap 150 mg ...... 69 NAMENDA TITRATION PAK mycophenolate mofetil cap 250 mg .134 see memantine hcl tab 28 x 5 mg & mycophenolate mofetil for oral susp 21 x 10 mg titration pack ...... 155 200 mg/ml ...... 135 NAMENDA XR mycophenolate mofetil tab 500 mg .135 see memantine hcl cap er 24hr 14 mycophenolate sodium tab dr 180 mg mg ...... 155 (mycophenolic acid equiv) ...... 135 see memantine hcl cap er 24hr 21 mycophenolate sodium tab dr 360 mg mg ...... 155 (mycophenolic acid equiv) ...... 135 see memantine hcl cap er 24hr 28 MYDRIACYL mg ...... 155 see tropicamide ophth soln 1% ....148 see memantine hcl cap er 24hr 7 mg MYFORTIC ...... 155 see mycophenolate sodium tab dr NAMENDA XR CAP 14MG ...... 155 180 mg (mycophenolic acid equiv) NAMENDA XR CAP 21MG ...... 155 ...... 135 NAMENDA XR CAP 28MG ...... 155 see mycophenolate sodium tab dr NAMENDA XR CAP 7MG ...... 155 360 mg (mycophenolic acid equiv) NAMENDA XR CAP TITRATIO ...... 155 ...... 135 NAMZARIC CAP ...... 155 MYLERAN TAB 2MG ...... 69 NAMZARIC CAP 14-10MG ...... 155 MYNATAL-Z TAB ...... 143 NAMZARIC CAP 21-10MG ...... 155 MYRBETRIQ TAB 25MG ...... 164 NAMZARIC CAP 28-10MG ...... 155 MYRBETRIQ TAB 50MG ...... 164 NAMZARIC CAP 7-10MG ...... 155 N NAPHCON-A SOL OP ...... 150 nabumetone tab 500 mg ...... 22 NAPRELAN nabumetone tab 750 mg ...... 22 see naproxen sodium tab er 24hr 375 nadolol tab 20 mg ...... 79 mg (base equiv) ...... 23 nadolol tab 40 mg ...... 79 see naproxen sodium tab er 24hr 500 nadolol tab 80 mg ...... 79 mg (base equiv) ...... 23 naftifine hcl cream 1% ...... 98 see naproxen sodium tab er 24hr 750 naftifine hcl cream 2% ...... 98 mg (base equiv) ...... 23 218 NAPRELAN TAB 375MG CR ...... 22 neomycin-polymyxin-dexamethasone NAPRELAN TAB 500MG CR ...... 22 ophth oint 0.1% ...... 150 NAPRELAN TAB 750MG CR ...... 22 neomycin-polymyxin-dexamethasone NAPROSYN ophth susp 0.1% ...... 150 see naproxen susp 125 mg/5ml ....23 neomycin-polymyxin-hc otic soln 1% see naproxen tab 500 mg ...... 23 ...... 152 NAPROSYN SUS 125/5ML ...... 22 neomycin-polymyxin-hc otic susp 3.5 naproxen-esomeprazole magnesium mg/ml-10000 unit/ml-1% ...... 152 tab dr 375-20 mg ...... 23 neomycin sulfate tab 500 mg ...... 19 naproxen-esomeprazole magnesium neo-polycin oin hc 1%op ...... 150 tab dr 500-20 mg ...... 23 neo-polycin oin op ...... 149 naproxen sodium cap 220 mg ...... 22 NEORAL naproxen sodium tab 220 mg ...... 22 see cyclosporine modified cap 100 naproxen sodium tab 275 mg ...... 22 mg ...... 134 naproxen sodium tab 550 mg ...... 22 see cyclosporine modified cap 25 mg naproxen sodium tab er 24hr 375 mg ...... 134 (base equiv) ...... 23 see cyclosporine modified oral soln naproxen sodium tab er 24hr 500 mg 100 mg/ml ...... 134 (base equiv) ...... 23 see gengraf cap 100mg ...... 134 naproxen sodium tab er 24hr 750 mg see gengraf cap 25mg ...... 134 (base equiv) ...... 23 see gengraf sol 100mg/ml ...... 134 naproxen susp 125 mg/5ml ...... 23 NEPHPLEX RX TAB ...... 136 naproxen tab 250 mg ...... 23 NEPHROCAPS CAP ...... 137 naproxen tab 375 mg ...... 23 NEPHRONEX LIQ 0.9/5ML ...... 137 naproxen tab 500 mg ...... 23 NEPHRON FA TAB ...... 119 naproxen tab ec 375 mg ...... 23 NEPHRO-VITE TAB ...... 136 naproxen tab ec 500 mg ...... 23 NESINA TAB 12.5MG ...... 47 naratriptan hcl tab 1 mg (base equiv) NESINA TAB 25MG ...... 47 ...... 128 NESINA TAB 6.25MG ...... 47 naratriptan hcl tab 2.5 mg (base equiv) NESTABS DHA PAK ...... 143 ...... 128 NESTABS TAB ...... 143 NARCAN SPR ...... 51 neuac gel 1.2-5% ...... 96 NASALCROM SPR 5.2/ACT ...... 146 NEUAC KIT 1.2-5% ...... 96 NASONEX NEULASTA INJ 6MG/0.6M ...... 118 see mometasone furoate nasal susp NEULASTA KIT 6MG/0.6M ...... 118 50 mcg/act ...... 146 NEUPOGEN INJ 300/0.5 ...... 118 NASONEX SPR 50MCG/AC ...... 146 NEUPOGEN INJ 300MCG ...... 118 nateglinide tab 120 mg ...... 49 NEUPOGEN INJ 480/0.8 ...... 118 nateglinide tab 60 mg ...... 49 NEUPOGEN INJ 480MCG ...... 118 NAT FIBER POW 58.6% ...... 122 NEUPRO DIS 1MG/24HR ...... 73 necon tab 0.5/35 ...... 90 NEUPRO DIS 2MG/24HR ...... 73 neomycin-bacitracin-polymyxin oint ..97 NEUPRO DIS 3MG/24HR ...... 73 neomycin-bacitrac zn-polymyx NEUPRO DIS 4MG/24HR ...... 73 5(3.5)mg-400unt-10000unt op oin NEUPRO DIS 6MG/24HR ...... 73 ...... 149 NEUPRO DIS 8MG/24HR ...... 74 neomycin-polymy-gramicid op sol NEVANAC SUS 0.1% ...... 151 1.75-10000-0.025mg-unt-mg/ml .149 NEXIUM 219 see esomeprazole magnesium cap see niacin tab er 500 mg delayed release 20 mg (base eq) (antihyperlipidemic) ...... 58 ...... 161 see niacin tab er 750 mg see esomeprazole magnesium cap (antihyperlipidemic) ...... 58 delayed release 40 mg (base eq) NIASPAN TAB 1000 ER ...... 58 ...... 161 NIASPAN TAB 500MG ER ...... 58 see esomeprazole magnesium for NIASPAN TAB 750MG ER ...... 58 delayed release susp packet 10 mg nicardipine hcl cap 20 mg ...... 82 ...... 161 nicardipine hcl cap 30 mg ...... 82 see esomeprazole magnesium for NICOMIDE TAB ...... 144 delayed release susp packet 20 mg nicotine polacrilex gum 2 mg ...... 158 ...... 161 nicotine polacrilex gum 4 mg ...... 158 see esomeprazole magnesium for nicotine polacrilex lozenge 2 mg .....158 delayed release susp packet 40 mg nicotine polacrilex lozenge 4 mg .....158 ...... 161 NICOTINE SYS KIT TRANSDER ...... 158 NEXIUM 24HR CAP 20MG ...... 161 nicotine td patch 24hr 14 mg/24hr .158 NEXIUM CAP 20MG ...... 161 nicotine td patch 24hr 21 mg/24hr .158 NEXIUM CAP 40MG ...... 161 nicotine td patch 24hr 7 mg/24hr ...158 NEXIUM GRA 10MG DR ...... 161 NICOTROL INH ...... 158 NEXIUM GRA 2.5MG DR ...... 161 NICOTROL NS SPR 10MG/ML ...... 158 NEXIUM GRA 20MG DR ...... 161 nifedipine cap 10 mg ...... 82 NEXIUM GRA 40MG DR ...... 161 nifedipine cap 20 mg ...... 82 NEXIUM GRA 5MG DR ...... 161 nifedipine tab er 24hr 30 mg ...... 82 NEXLETOL TAB 180MG ...... 55 nifedipine tab er 24hr 60 mg ...... 82 NEXLIZET TAB 180/10MG ...... 55 nifedipine tab er 24hr 90 mg ...... 82 NF FORMULAS CHW CHILDREN ...... 142 nifedipine tab er 24hr osmotic release niacinamide tab 100 mg ...... 167 30 mg ...... 82 niacinamide tab 500 mg ...... 167 nifedipine tab er 24hr osmotic release niacinamide w/ zn-cu-methylfol-se-cr 60 mg ...... 82 tab 750-27-2-0.5 mg ...... 144 nifedipine tab er 24hr osmotic release niacin cap 400mg ...... 144 90 mg ...... 82 niacin cap er 250 mg ...... 166 NIFEREX TAB ...... 119 niacin cap er 500 mg ...... 167 nikki tab 3-0.02mg ...... 90 niacin tab 100 mg ...... 167 NILANDRON niacin tab 500 mg ...... 167 see nilutamide tab 150 mg ...... 70 niacin tab 50 mg ...... 167 nilutamide tab 150 mg ...... 70 niacin tab er 1000 mg nimodipine cap 30 mg ...... 82 (antihyperlipidemic) ...... 58 nisoldipine tab er 24hr 17 mg ...... 82 niacin tab er 500 mg nisoldipine tab er 24hr 20 mg ...... 82 (antihyperlipidemic) ...... 58 nisoldipine tab er 24hr 25.5 mg ...... 82 niacin tab er 750 mg ...... 167 nisoldipine tab er 24hr 30 mg ...... 82 niacin tab er 750 mg nisoldipine tab er 24hr 34 mg ...... 82 (antihyperlipidemic) ...... 58 nisoldipine tab er 24hr 40 mg ...... 82 NIACIN TR TAB 1000MG ...... 167 nisoldipine tab er 24hr 8.5 mg ...... 82 NIASPAN nitazoxanide tab 500 mg ...... 35 see niacin tab er 1000 mg NITRO-BID OIN 2% ...... 37 (antihyperlipidemic) ...... 58 NITRO-DUR 220 see minitran dis 0.1mg/hr ...... 37 norethindrone ace & ethinyl estradiol-fe see minitran dis 0.2mg/hr ...... 37 tab 1.5 mg-30 mcg ...... 90 see minitran dis 0.4mg/hr ...... 37 norethindrone ace & ethinyl estradiol-fe see minitran dis 0.6mg/hr ...... 37 tab 1 mg-20 mcg ...... 90 nitrofurantoin macrocrystalline cap 100 norethindrone ace & ethinyl estradiol mg ...... 36 tab 1.5 mg-30 mcg ...... 90 nitrofurantoin macrocrystalline cap 50 norethindrone ace & ethinyl estradiol mg ...... 36 tab 1 mg-20 mcg ...... 90 nitrofurantoin monohydrate norethindrone ace-eth estradiol-fe macrocrystalline cap 100 mg ...... 36 chew tab 1 mg-20 mcg (24) ...... 90 nitroglycerin sl tab 0.3 mg ...... 37 norethindrone acetate-ethinyl estradiol nitroglycerin sl tab 0.4 mg ...... 37 tab 0.5 mg-2.5 mcg ...... 110 nitroglycerin sl tab 0.6 mg ...... 37 norethindrone acetate-ethinyl estradiol nitroglycerin td patch 24hr 0.1 mg/hr tab 1 mg-5 mcg ...... 110 ...... 37 norethindrone acetate tab 5 mg .....154 nitroglycerin td patch 24hr 0.2 mg/hr norethindrone tab 0.35 mg ...... 92 ...... 37 NORGESIC FORTE nitroglycerin td patch 24hr 0.4 mg/hr see orphengesic tab forte ...... 145 ...... 37 NORGESIC TAB FORTE ...... 145 nitroglycerin td patch 24hr 0.6 mg/hr norgestimate & ethinyl estradiol tab ...... 37 0.25 mg-35 mcg ...... 90 nitroglycerin tl soln 0.4 mg/spray (400 norgestimate-eth estrad tab 0.18- mcg/spray) ...... 37 25/0.215-25/0.25-25 mg-mcg ...... 90 NITROLINGUAL PUMPSPRAY norgestimate-eth estrad tab 0.18- see nitroglycerin tl soln 0.4 mg/spray 35/0.215-35/0.25-35 mg-mcg ...... 90 (400 mcg/spray) ...... 37 norlyda tab 0.35mg ...... 92 NITROSTAT norlyroc tab 0.35mg ...... 92 see nitroglycerin sl tab 0.3 mg ...... 37 NORPACE see nitroglycerin sl tab 0.4 mg ...... 37 see disopyramide phosphate cap 100 see nitroglycerin sl tab 0.6 mg ...... 37 mg ...... 38 nitro-time cap 2.5mg cr ...... 37 see disopyramide phosphate cap 150 nitro-time cap 6.5mg cr ...... 37 mg ...... 38 nitro-time cap 9mg cr ...... 37 nortrel tab 0.5/35 ...... 90 NIVESTYM INJ 300/0.5 ...... 118 nortrel tab 1/35 ...... 90 NIVESTYM INJ 300MCG ...... 118 nortrel tab 7/7/7 ...... 90 NIVESTYM INJ 480/0.8 ...... 118 NORVASC NIVESTYM INJ 480MCG ...... 118 see amlodipine besylate tab 10 mg NIX CREM RIN LIQ 1% ...... 105 (base equivalent) ...... 80 nora-be tab 0.35mg ...... 92 see amlodipine besylate tab 2.5 mg NORDITROPIN INJ 10/1.5ML ...... 108 (base equivalent) ...... 80 NORDITROPIN INJ 15/1.5ML ...... 108 see amlodipine besylate tab 5 mg NORDITROPIN INJ 30/3ML ...... 109 (base equivalent) ...... 80 NORDITROPIN INJ 5/1.5ML ...... 108 NORVASC TAB 10MG ...... 82 norethindrone & ethinyl estradiol-fe NORVASC TAB 2.5MG ...... 82 chew tab 0.4 mg-35 mcg ...... 90 NORVASC TAB 5MG ...... 82 norethindrone & ethinyl estradiol-fe NOURIANZ TAB 20MG ...... 72 chew tab 0.8 mg-25 mcg ...... 90 NOURIANZ TAB 40MG ...... 72 221 NOVAFERRUM DRO 15MG/ML ...... 121 nutritional supplement caps ...... 105 NOVAFERRUM LIQ 125 ...... 121 NUTRIVIT LIQ 800-15-1 ...... 137 novamv ped dro 10mg/ml ...... 143 NUTROPIN AQ INJ 10MG/2ML ...... 109 NOVOLIN70/30 INJ RELION ...... 49 NUTROPIN AQ INJ 20MG/2ML ...... 109 NOVOLIN INJ 70/30 ...... 49 NUTROPIN AQ INJ NUSPIN 5 ...... 109 NOVOLIN INJ 70/30 FP ...... 49 NUVARING NOVOLIN N INJ 100 UNIT ...... 49 see eluryng mis ...... 92 NOVOLIN N INJ RELION ...... 49 see etonogestrel-ethinyl estradiol va NOVOLIN N INJ U-100 ...... 49 ring 0.120-0.015 mg/24hr ...... 92 NOVOLIN R INJ 100 UNIT ...... 49 NUVESSA GEL 1.3% ...... 165 NOVOLIN R INJ RELION ...... 49 nylia tab 7/7/7 ...... 90 NOVOLIN R INJ U-100 ...... 49 nymyo tab 0.25-35 ...... 90 NOVOLOG INJ 100/ML ...... 49 nystatin cream 100000 unit/gm ...... 98 NOVOLOG INJ FLEXPEN ...... 49 nystatin oint 100000 unit/gm ...... 98 NOVOLOG INJ PENFILL ...... 49 nystatin susp 100000 unit/ml ...... 135 NOVOLOG MIX INJ 70/30 ...... 49 nystatin tab 500000 unit ...... 52 NOVOLOG MIX INJ FLEXPEN ...... 49 nystatin topical powder 100000 NOXAFIL unit/gm ...... 98 see posaconazole tab delayed release nystatin-triamcinolone cream 100000- 100 mg ...... 53 0.1 unit/gm-% ...... 98 NOXAFIL SUS 40MG/ML ...... 53 nystatin-triamcinolone oint 100000-0.1 NOXAFIL TAB 100MG ...... 53 unit/gm-% ...... 98 np thyroid tab 120mg ...... 160 NYVEPRIA INJ 6/0.6ML ...... 118 np thyroid tab 15mg ...... 159 O np thyroid tab 30mg ...... 160 OCEAN NASAL SPR 0.65% ...... 145 np thyroid tab 60mg ...... 160 ocella tab 3-0.03mg ...... 91 np thyroid tab 90mg ...... 160 octreotide acetate inj 1000 mcg/ml (1 NUBEQA TAB 300MG ...... 70 mg/ml) ...... 110 NUCYNTA ER TAB 100MG ...... 28 octreotide acetate inj 100 mcg/ml (0.1 NUCYNTA ER TAB 150MG ...... 28 mg/ml) ...... 110 NUCYNTA ER TAB 200MG ...... 28 octreotide acetate inj 200 mcg/ml (0.2 NUCYNTA ER TAB 250MG ...... 28 mg/ml) ...... 110 NUCYNTA ER TAB 50MG ...... 28 octreotide acetate inj 50 mcg/ml (0.05 NUCYNTA TAB 100MG ...... 28 mg/ml) ...... 110 NUCYNTA TAB 50MG ...... 28 OCUFLOX NUCYNTA TAB 75MG ...... 28 see ofloxacin ophth soln 0.3% .....149 NUFERA TAB ...... 119 OCUFLOX DRO 0.3% OP ...... 149 nufol tab ...... 119 OCUHEALTH CAP VISION 2 ...... 140 nu-iron 150 cap 150mg ...... 121 OCUVITE CAP ADULT ...... 140 NULYTELY SOL LMN/LIME ...... 122 ocuvite eye chw heatlh ...... 140 NU-MAG TAB 71.5-119 ...... 133 OCUVITE LUTE CAP ...... 140 NURTEC TAB 75MG ODT ...... 128 ODOMZO CAP 200MG ...... 70 NUTRA-SUPPRT CAP BONE ...... 133 ofloxacin ophth soln 0.3% ...... 149 NUTRICAP TAB ...... 140 ofloxacin otic soln 0.3% ...... 152 NUTRIENTS CAP ANTIOXID ...... 140 ofloxacin tab 300 mg ...... 112 NUTRISOURCE PAK FIBER ...... 122 ofloxacin tab 400 mg ...... 112 NUTRISOURCE POW FIBER ...... 122 222 olmesartan-amlodipine- omega-3 fatty acids cap 1200 mg ...147 hydrochlorothiazide tab 20-5-12.5 omega-3 fatty acids cap 500 mg ....146 mg ...... 66 omega-3 fatty acids cap delayed olmesartan-amlodipine- release 1000 mg ...... 147 hydrochlorothiazide tab 40-10-12.5 omega-3 fatty acids cap delayed mg ...... 66 release 1200 mg ...... 147 olmesartan-amlodipine- omeprazole cap delayed release 10 mg hydrochlorothiazide tab 40-10-25 mg ...... 161 ...... 66 omeprazole cap delayed release 20 mg olmesartan-amlodipine- ...... 161 hydrochlorothiazide tab 40-5-12.5 omeprazole cap delayed release 40 mg mg ...... 66 ...... 161 olmesartan-amlodipine- omeprazole delayed release tab 20 mg hydrochlorothiazide tab 40-5-25 mg ...... 161 ...... 66 omeprazole magnesium cap dr 20.6 mg olmesartan medoxomil- (20 mg base equiv) ...... 161 hydrochlorothiazide tab 20-12.5 mg omeprazole-sodium bicarbonate cap ...... 66 20-1100 mg ...... 162 olmesartan medoxomil- omeprazole-sodium bicarbonate cap hydrochlorothiazide tab 40-12.5 mg 40-1100 mg ...... 162 ...... 66 omeprazole-sodium bicarbonate powd olmesartan medoxomil- pack for susp 20-1680 mg ...... 162 hydrochlorothiazide tab 40-25 mg .66 omeprazole-sodium bicarbonate powd olmesartan medoxomil tab 20 mg ....61 pack for susp 40-1680 mg ...... 162 olmesartan medoxomil tab 40 mg ....61 omeprazole tab 20mg ...... 161 olmesartan medoxomil tab 5 mg ...... 61 OMNARIS SPR ...... 146 olopatadine hcl nasal soln 0.6% .....146 OMNITROPE INJ 10/1.5ML ...... 109 olopatadine hcl ophth soln 0.1% (base OMNITROPE INJ 5/1.5ML ...... 109 equivalent) ...... 151 OMNITROPE INJ 5.8MG ...... 109 olopatadine hcl ophth soln 0.2% (base ONCOVITE TAB ...... 140 equivalent) ...... 151 ondansetron hcl oral soln 4 mg/5ml ..51 OLUMIANT TAB 1MG ...... 20 ondansetron hcl tab 24 mg ...... 51 OLUMIANT TAB 2MG ...... 20 ondansetron hcl tab 4 mg ...... 51 OLUX ondansetron hcl tab 8 mg ...... 51 see clobetasol propionate foam ondansetron orally disintegrating tab 4 0.05% ...... 100 mg ...... 51 OLUX AER 0.05% ...... 102 ondansetron orally disintegrating tab 8 OLUX-E mg ...... 51 see clobetasol propionate emulsion ONE-A-DAY CHW IMMUNITY ...... 140 foam 0.05% ...... 100 ONE-A-DAY CHW VITACRAV ...... 140 see tovet aer 0.05% ...... 103 ONE-A-DAY TAB ESSENT ...... 141 OLUX-E AER 0.05% ...... 103 ONE-DAILY CAP MULTI ...... 140 OMECLAMOX- MIS PAK ...... 162 ONE DAILY CHW ADLT GUM ...... 140 omega-3-acid ethyl esters cap 1 gm .55 one daily tab womens ...... 137 OMEGA-3 CAP 1400MG ...... 146 ONE FLOW MIS MTHPIECE ...... 127 omega-3 conc cap 600mg ...... 146 ONEXTON GEL 1.2-3.75 ...... 96 omega-3 fatty acids cap 1000 mg ...147 ONGENTYS CAP 25MG ...... 72 223 ONGENTYS CAP 50MG ...... 72 oseltamivir phosphate for susp 6 ONGLYZA TAB 2.5MG ...... 47 mg/ml (base equiv) ...... 76 ONGLYZA TAB 5MG ...... 47 OSENI TAB 12.5-15 ...... 45 ONUREG TAB 200MG ...... 69 OSENI TAB 12.5-30 ...... 45 ONUREG TAB 300MG ...... 69 OSENI TAB 12.5-45 ...... 45 ONZETRA XSAI MIS 11MG ...... 128 OSENI TAB 25-15MG ...... 45 OPCON-A SOL OP ...... 150 OSENI TAB 25-30MG ...... 45 OPSUMIT TAB 10MG ...... 85 OSENI TAB 25-45MG ...... 45 OPTIMUM CHW AIRVITES ...... 140 OSMOLEX ER TAB 129MG ...... 74 OPTISOURCE CHW BARIATRC ...... 140 OSMOLEX ER TAB 193MG ...... 74 OPURITY CHW BYPASS ...... 140 OSMOLEX ER TAB 258MG ...... 74 oral electrolyte solution ...... 131 OSTEO-PORETI TAB ...... 131 oralone dent pst 0.1% ...... 135 OTEZLA TAB 10/20/30 ...... 23 ORAVIG TAB 50MG ...... 135 OTEZLA TAB 30MG ...... 23 ORENCIA CLCK INJ 125MG/ML ...... 24 OTOVEL DRO ...... 152 ORENCIA INJ 125MG/ML ...... 24 oxaprozin tab 600 mg ...... 23 ORENCIA INJ 50/0.4ML ...... 24 OXAYDO TAB 5MG ...... 28 ORENCIA INJ 87.5/0.7 ...... 24 OXAYDO TAB 7.5MG ...... 28 ORENITRAM TAB 0.125MG ...... 85 OXBRYTA TAB 500MG ...... 117 ORENITRAM TAB 0.25MG ...... 84 OXERVATE SOL 20MCG/ML ...... 150 ORENITRAM TAB 1MG ...... 85 oxiconazole nitrate cream 1% ...... 98 ORENITRAM TAB 2.5MG ...... 85 OXISTAT ORENITRAM TAB 5MG ...... 85 see oxiconazole nitrate cream 1% .98 ORIAHNN CAP ...... 110 OXISTAT CRE 1% ...... 98 ORILISSA TAB 150MG ...... 108 OXISTAT LOT 1% ...... 98 ORILISSA TAB 200MG ...... 108 oxybutynin chloride syrup 5 mg/5ml orphenadrine citrate tab er 12hr 100 ...... 163 mg ...... 145 oxybutynin chloride tab 5 mg ...... 163 orphengesic tab forte ...... 145 oxybutynin chloride tab er 24hr 10 mg orsythia tab ...... 91 ...... 163 ORTHO TRI-CYCLEN LO oxybutynin chloride tab er 24hr 15 mg see norgestimate-eth estrad tab ...... 163 0.18-25/0.215-25/0.25-25 mg-mcg oxybutynin chloride tab er 24hr 5 mg ...... 90 ...... 163 see tri-lo-mili tab ...... 91 oxycodone-aspirin tab 4.8355-325 mg see tri-lo tab estaryll ...... 91 ...... 31 see tri-lo- tab marzia ...... 91 oxycodone hcl cap 5 mg ...... 28 see tri-lo- tab sprintec ...... 91 oxycodone hcl conc 100 mg/5ml (20 see tri-vylibra tab lo ...... 91 mg/ml) ...... 29 os-cal extra tab d3 ...... 131 oxycodone hcl soln 5 mg/5ml ...... 29 oscimin tab 0.125mg ...... 160 oxycodone hcl tab 10 mg ...... 29 oseltamivir phosphate cap 30 mg (base oxycodone hcl tab 15 mg ...... 29 equiv) ...... 76 oxycodone hcl tab 20 mg ...... 29 oseltamivir phosphate cap 45 mg (base oxycodone hcl tab 30 mg ...... 29 equiv) ...... 76 oxycodone hcl tab 5 mg ...... 29 oseltamivir phosphate cap 75 mg (base OXYCODONE HCL TAB ER 12HR DETER equiv) ...... 76 10 MG ...... 29 224 oxycodone hcl tab er 12hr deter 15 mg PALFORZIA CAP LEVEL 1 ...... 19 ...... 29 PALFORZIA CAP LEVEL 10 ...... 19 OXYCODONE HCL TAB ER 12HR DETER PALFORZIA CAP LEVEL 2 ...... 19 20 MG ...... 29 PALFORZIA CAP LEVEL 3 ...... 19 oxycodone hcl tab er 12hr deter 30 mg PALFORZIA CAP LEVEL 4 ...... 19 ...... 29 PALFORZIA CAP LEVEL 5 ...... 19 OXYCODONE HCL TAB ER 12HR DETER PALFORZIA CAP LEVEL 6 ...... 19 40 MG ...... 29 PALFORZIA CAP LEVEL 7 ...... 19 oxycodone hcl tab er 12hr deter 60 mg PALFORZIA CAP LEVEL 8 ...... 19 ...... 29 PALFORZIA CAP LEVEL 9 ...... 19 oxycodone hcl tab er 12hr deter 80 mg PALFORZIA POW LEVEL 11 ...... 19 ...... 29 PANCREAZE CAP 10500UNT ...... 106 oxycodone w/ acetaminophen tab 10- PANCREAZE CAP 16800UNT ...... 106 325 mg ...... 31 PANCREAZE CAP 21000UNT ...... 106 oxycodone w/ acetaminophen tab 2.5- PANCREAZE CAP 2600UNIT ...... 106 325 mg ...... 31 PANCREAZE CAP 37000 ...... 106 oxycodone w/ acetaminophen tab 5- PANCREAZE CAP 4200UNIT ...... 106 325 mg ...... 31 PANDA MASK MIS LARGE ...... 127 oxycodone w/ acetaminophen tab 7.5- PANDA MASK MIS MEDIUM ...... 127 325 mg ...... 31 PANDA MASK MIS PEDIATRI ...... 127 OXYCONTIN TAB 10MG CR ...... 29 PANDA MASK MIS SMALL ...... 127 OXYCONTIN TAB 15MG CR ...... 29 PANDEL CRE 0.1% ...... 103 OXYCONTIN TAB 20MG CR ...... 29 panoxyl wash liq 4% ...... 96 OXYCONTIN TAB 30MG CR ...... 29 pantoprazole sodium ec tab 20 mg OXYCONTIN TAB 40MG CR ...... 29 (base equiv) ...... 162 OXYCONTIN TAB 60MG CR ...... 29 pantoprazole sodium ec tab 40 mg OXYCONTIN TAB 80MG CR ...... 29 (base equiv) ...... 162 oxymorphone hcl tab 10 mg ...... 29 pantoprazole sodium for delayed oxymorphone hcl tab 5 mg ...... 29 release susp packet 40 mg ...... 162 oxymorphone hcl tab er 12hr 10 mg .29 PARI MANUAL MIS INTERRUP ...... 127 oxymorphone hcl tab er 12hr 15 mg .29 PARI TREK S KIT COMBO ...... 127 oxymorphone hcl tab er 12hr 20 mg .29 PARLODEL oxymorphone hcl tab er 12hr 30 mg .29 see bromocriptine mesylate cap 5 mg oxymorphone hcl tab er 12hr 40 mg .29 (base equivalent) ...... 72 oxymorphone hcl tab er 12hr 5 mg ...29 see bromocriptine mesylate tab 2.5 oxymorphone hcl tab er 12hr 7.5 mg 29 mg (base equivalent) ...... 72 OXYTROL/WOMN DIS 3.9MG/24 .....163 PARLODEL CAP 5MG ...... 74 OXYTROL DIS 3.9MG/24 ...... 163 PARLODEL TAB 2.5MG ...... 74 oys shell+d tab 250-125 ...... 131 paromomycin sulfate cap 250 mg .....19 oyster shell calcium tab 500 mg .....131 PARVA-CAL TAB 250-100 ...... 131 OZEMPIC INJ 2/1.5ML ...... 47 PARVA-CAL TAB 500MG ...... 131 OZEMPIC INJ 4MG/3ML ...... 47 PARVLEX TAB ...... 140 P PATADAY SOL 0.1% ...... 151 pacerone tab 100mg ...... 38 PATADAY SOL 0.2% ...... 151 pacerone tab 200mg ...... 38 PATADAY SOL 0.7% ...... 151 pacerone tab 400mg ...... 38 PATANASE PALFORZIA CAP ESCALAT ...... 19 225 see olopatadine hcl nasal soln 0.6% peg 3350-kcl-na bicarb-nacl-na sulfate ...... 146 for soln 236 gm ...... 122 PATANASE SPR 0.6% ...... 146 peg 3350-kcl-sod bicarb-nacl for soln PA WOMENS PAK VITAPAK ...... 140 420 gm ...... 122 PEAK FLOW METER ...... 127 PEG 3350-KCL-SOD BICARB-NACL FOR PEAK FLOW METER- RX ...... 127 SOLN 420 GM PEDIA-LAX CHW 400MG ...... 123 see peg 3350-kcl-sod bicarb-nacl for pedialax fbr chw gummies ...... 122 soln 420 gm ...... 122 PEDIA-LAX LIQ 50MG ...... 124 penicillin v potassium for soln 125 PEDIA-LAX SUP 2.8GM ...... 123 mg/5ml ...... 153 PEDIALYTE SOL BUBL GUM ...... 132 penicillin v potassium for soln 250 PEDIALYTE SOL FREEZE ...... 132 mg/5ml ...... 153 PEDIALYTE SOL FRUIT ...... 132 penicillin v potassium tab 250 mg ...153 PEDIALYTE SOL SINGLES ...... 132 penicillin v potassium tab 500 mg ...153 PEDIALYTE SOL UNFLAVOR ...... 132 PEN NEEDLES MIS 29GX10MM ...... 126 PEDIAPRED PEN NEEDLES MIS 29GX12.7 ...... 126 see prednisolone sod phosph oral PEN NEEDLES MIS 29GX12MM ...... 126 soln 6.7 mg/5ml (5 mg/5ml base) PEN NEEDLES MIS 31GX5MM ...... 126 ...... 94 PEN NEEDLES MIS 31GX6MM ...... 126 PEDIATRIC MD MIS MASK ...... 127 PEN NEEDLES MIS 31GX8MM ...... 126 pediatric multiple vitamins w/ fl-fe PEN NEEDLES MIS 32GX4MM ...... 126 drops 0.25-10 mg/ml ...... 142 PEN NEEDLES MIS 32GX6MM ...... 126 pediatric multiple vitamins w/ fluoride PEN NEEDLES MIS 32GX8MM ...... 126 chew tab 0.25 mg ...... 142 PENNSAID SOL 2% ...... 96 pediatric multiple vitamins w/ fluoride PENTASA CAP 250MG CR ...... 113 chew tab 0.5 mg ...... 142 PENTASA CAP 500MG CR ...... 113 pediatric multiple vitamins w/ fluoride pentazocine w/ naloxone tab 50-0.5 chew tab 1 mg ...... 142 mg ...... 32 pediatric multiple vitamins w/ fluoride pentoxifylline tab er 400 mg ...... 116 soln 0.25 mg/ml ...... 142 PEPCID pediatric multiple vitamins w/ fluoride see famotidine tab 20 mg ...... 160 soln 0.5 mg/ml ...... 142 see famotidine tab 40 mg ...... 160 pediatric multiple vitamins w/ iron PEPTO-BISMOL CHW 262MG ...... 51 chew tab 15 mg ...... 142 PEPTO-BISMOL SUS 262/15ML ...... 51 pediatric multiple vitamin w/ c & fa PEPTO-BISMOL SUS 525/15ML ...... 51 chew tab ...... 143 PEPTO BISMOL TAB 262MG ...... 51 pediatric multiple vitamin w/ extra c & PERCOCET fa chew tab ...... 143 see endocet tab 10-325mg ...... 31 pediatric multiple vitamin w/ minerals see endocet tab 2.5-325 ...... 31 & c chew tab ...... 142 see endocet tab 5-325mg ...... 31 PEDIATRIC SM MIS MASK ...... 127 see endocet tab 7.5-325 ...... 31 pediatric vitamins acd w/ fluoride soln see oxycodone w/ acetaminophen tab 0.25 mg/ml ...... 142 10-325 mg ...... 31 pediatric vitamins acd w/ fluoride soln see oxycodone w/ acetaminophen tab 0.5 mg/ml ...... 142 2.5-325 mg ...... 31 peg/nasul,c sol nacl/pot ...... 122 see oxycodone w/ acetaminophen tab 5-325 mg ...... 31 226 see oxycodone w/ acetaminophen tab pindolol tab 10 mg ...... 79 7.5-325 mg ...... 31 pindolol tab 5 mg ...... 79 PERCOCET TAB 10-325MG ...... 31 pinworm med sus 144mg/ml ...... 34 PERCOCET TAB 2.5-325 ...... 31 pioglitazone hcl-glimepiride tab 30-2 PERCOCET TAB 5-325MG ...... 31 mg ...... 45 PERCOCET TAB 7.5-325 ...... 31 pioglitazone hcl-glimepiride tab 30-4 perdiem tab 15mg ...... 124 mg ...... 45 PERFOROMIST pioglitazone hcl-metformin hcl tab 15- see formoterol fumarate soln nebu 500 mg ...... 46 20 mcg/2ml ...... 41 pioglitazone hcl-metformin hcl tab 15- PERFOROMIST NEB 20MCG ...... 42 850 mg ...... 46 perindopril erbumine tab 2 mg ...... 60 pioglitazone hcl tab 15 mg (base equiv) perindopril erbumine tab 4 mg ...... 60 ...... 49 perindopril erbumine tab 8 mg ...... 60 pioglitazone hcl tab 30 mg (base equiv) permethrin cream 5% ...... 105 ...... 49 permethrin lotion 1% ...... 105 pioglitazone hcl tab 45 mg (base equiv) PERTZYE CAP 16000U ...... 106 ...... 49 PERTZYE CAP 24000U ...... 106 pirmella tab 1/35 ...... 91 PERTZYE CAP 4000UNIT ...... 106 pirmella tab 7/7/7 ...... 91 PERTZYE CAP 8000UNIT ...... 106 piroxicam cap 10 mg ...... 23 PFT FILTER MIS 1000 ...... 127 piroxicam cap 20 mg ...... 23 PFT FILTER MIS 2000 ...... 127 PLAN B TAB 1.5MG ...... 92 PFT FILTER MIS 3000 ...... 127 PLAQUENIL PFT FILTER MIS 4000 ...... 127 see hydroxychloroquine sulfate tab PFT FILTER MIS 5000 ...... 127 200 mg ...... 68 PFT FILTER MIS 6000 ...... 127 PLAVIX PFT FILTER MIS 7000 ...... 127 see clopidogrel bisulfate tab 75 mg phenazopyridine hcl tab 100 mg .....116 (base equiv)...... 117 phenazopyridine hcl tab 200 mg .....116 PLAVIX TAB 75MG ...... 117 phenazo tab 200mg ...... 116 PLEGRIDY INJ ...... 157 phenylephrine hcl ophth soln 2.5% .148 PLEGRIDY INJ PEN ...... 157 philith tab 0.4-35 ...... 91 PLEGRIDY INJ STARTER ...... 157 PHILLIPS TAB 500MG ...... 123 PLEGRIDY PEN INJ STARTER ...... 157 PHOSLO PLENVU SOL ...... 122 see calcium acetate (phosphate PNEUMOVAX 23 INJ 25/0.5 ...... 164 binder) cap 667 mg (169 mg ca) PNV TABS TAB 29-1MG ...... 143 ...... 114 podofilox soln 0.5% ...... 104 PHOSLYRA SOL ...... 114 polyethylene glycol 3350 oral powder PHOS-NAK POW CONCENTR ...... 133 ...... 123 phytonadione tab 5 mg ...... 166 polyethylene glycol-propylene glycol pilocarpine hcl ophth soln 1% ...... 148 ophth soln 0.4-0.3% ...... 147 pilocarpine hcl ophth soln 2% ...... 148 poly-iron cap 150 fort ...... 119 pilocarpine hcl ophth soln 4% ...... 148 poly-iron cap 150mg ...... 121 pilocarpine hcl tab 5 mg ...... 136 polymyxin b-trimethoprim ophth soln pilocarpine hcl tab 7.5 mg ...... 136 10000 unit/ml-0.1% ...... 149 pimecrolimus cream 1% ...... 104 polysacchari cap iron ...... 119 pimtrea tab ...... 91 227 polysaccharide iron complex cap 150 potassium phosphates inj 45 mm/15ml mg (iron equivalent) ...... 121 (phos) 66 meq/15ml (k) ...... 133 POLYTRIM PRADAXA CAP 110MG ...... 44 see polymyxin b-trimethoprim ophth PRADAXA CAP 150MG ...... 44 soln 10000 unit/ml-0.1% ...... 149 PRADAXA CAP 75MG ...... 44 polyvinyl alcohol ophth soln 1.4% ...147 PRALUENT INJ 150MG/ML ...... 58 POLY-VI-SOL SOL 50MG/ML ...... 143 PRALUENT INJ 75MG/ML ...... 58 poly-vita dro ...... 143 pramipexole dihydrochloride tab 0.125 poly-vite dro ...... 143 mg ...... 74 POLY-VITE SOL 50MG/ML ...... 143 pramipexole dihydrochloride tab 0.25 POMALYST CAP 1MG ...... 71 mg ...... 74 POMALYST CAP 2MG ...... 71 pramipexole dihydrochloride tab 0.5 POMALYST CAP 3MG ...... 71 mg ...... 74 POMALYST CAP 4MG ...... 71 pramipexole dihydrochloride tab 0.75 PORENAL+D CAP OMEGA 3 ...... 140 mg ...... 74 portia-28 tab ...... 91 pramipexole dihydrochloride tab 1.5 posaconazole tab delayed release 100 mg ...... 74 mg ...... 53 pramipexole dihydrochloride tab 1 mg potassium & sodium phosphates ...... 74 powder pack 280-160-250 mg .....133 pramipexole dihydrochloride tab er potassium bicarbonate effer tab 25 24hr 0.375 mg ...... 74 meq ...... 133 pramipexole dihydrochloride tab er potassium chloride cap er 10 meq ..133 24hr 0.75 mg ...... 74 potassium chloride cap er 8 meq ....133 pramipexole dihydrochloride tab er potassium chloride microencapsulated 24hr 1.5 mg ...... 74 crys er tab 10 meq ...... 134 pramipexole dihydrochloride tab er potassium chloride microencapsulated 24hr 2.25 mg ...... 74 crys er tab 20 meq ...... 134 pramipexole dihydrochloride tab er potassium chloride oral soln 10% (20 24hr 3.75 mg ...... 74 meq/15ml) ...... 134 pramipexole dihydrochloride tab er potassium chloride oral soln 20% (40 24hr 3 mg ...... 74 meq/15ml) ...... 134 pramipexole dihydrochloride tab er potassium chloride tab er 10 meq ...134 24hr 4.5 mg ...... 74 potassium chloride tab er 8 meq (600 prasugrel hcl tab 10 mg (base equiv) mg) ...... 134 ...... 117 potassium citrate & citric acid soln prasugrel hcl tab 5 mg (base equiv) 117 1100-334 mg/5ml ...... 115 PRAVACHOL potassium citrate tab er 10 meq (1080 see pravastatin sodium tab 40 mg .58 mg) ...... 115 pravastatin sodium tab 10 mg ...... 58 potassium citrate tab er 5 meq (540 pravastatin sodium tab 20 mg ...... 58 mg) ...... 115 pravastatin sodium tab 40 mg ...... 58 POTASSIUM INJ PHOSPHAT ...... 133 pravastatin sodium tab 80 mg ...... 58 potassium phosphates inj 150 prazosin hcl cap 1 mg ...... 62 mm/50ml (phos) 220 meq/50ml (k) prazosin hcl cap 2 mg ...... 62 ...... 133 prazosin hcl cap 5 mg ...... 62 potassium phosphates inj 15 mm/5ml PRECOSE (phos) 22 meq/5ml (k) ...... 133 see acarbose tab 100 mg ...... 44 228 see acarbose tab 25 mg ...... 44 prenatal vit w/ dss-iron carbonyl-fa tab see acarbose tab 50 mg ...... 44 90-1 mg- rx ...... 143 PRECOSE TAB 100MG ...... 44 prenatal vit w/ fe fumarate-fa chew tab PRECOSE TAB 25MG ...... 44 29-1 mg- rx ...... 143 PRECOSE TAB 50MG ...... 44 PRENATAL VIT W/ FE FUMARATE-FA PRED FORTE TAB 27-0.8 MG ...... 143 see prednisolone acetate ophth susp PRENATAL VIT W/ FE FUMARATE-FA 1% ...... 150 TAB 27-1 MG- RX ...... 143 prednicarbate oint 0.1% ...... 103 PRENATAL VIT W/ FE FUMARATE-FA prednisolone acetate ophth susp 1% TAB 28-0.8 MG ...... 143 ...... 150 prenatal vit w/ iron carbonyl-fa tab 29- prednisolone sod phosphate oral soln 1 mg ...... 143 15 mg/5ml (base equiv) ...... 94 PRESERVISION CAP AREDS ...... 140 prednisolone sod phosph oral soln 6.7 PRESERVISION CAP AREDS 2 ...... 140 mg/5ml (5 mg/5ml base) ...... 94 PRESERVISION CAP LUTEIN ...... 140 PREDNISOLONE SUS 1% ...... 150 PRESERVISION CHW AREDS 2 ...... 140 prednisolone syrup 15 mg/5ml (usp PRESERVISION TAB AREDS ...... 140 solution equivalent) ...... 94 PRETAB TAB 29-1MG ...... 143 prednisone oral soln 5 mg/5ml ...... 94 PRETOMANID TAB 200MG ...... 68 prednisone tab 10 mg ...... 94 PREVACID prednisone tab 1 mg ...... 94 see lansoprazole cap delayed release prednisone tab 2.5 mg ...... 94 15 mg ...... 161 prednisone tab 20 mg ...... 94 see lansoprazole cap delayed release prednisone tab 50 mg ...... 94 30 mg ...... 161 prednisone tab 5 mg ...... 94 PREVACID 24H CAP 15MG DR ...... 162 prednisone tab therapy pack 10 mg PREVACID CAP 30MG DR ...... 162 (21) ...... 94 PREVACID SOLUTAB prednisone tab therapy pack 10 mg see lansoprazole tab delayed release (48) ...... 94 orally disintegrating 15 mg ...... 161 prednisone tab therapy pack 5 mg (21) see lansoprazole tab delayed release ...... 94 orally disintegrating 30 mg ...... 161 prednisone tab therapy pack 5 mg (48) PREVACID TAB 15MG STB ...... 162 ...... 94 PREVACID TAB 30MG STB ...... 162 PRED SOD PHO SOL 1% OP ...... 150 prevalite pow 4gm ...... 56 PREMARIN TAB 0.3MG ...... 111 prevalite pow 4gm pk ...... 56 PREMARIN TAB 0.45MG ...... 111 previfem tab ...... 91 PREMARIN TAB 0.625MG ...... 111 PREVNAR 13 INJ ...... 164 PREMARIN TAB 0.9MG ...... 111 PRIFTIN TAB 150MG ...... 68 PREMARIN TAB 1.25MG ...... 111 PRILOSEC POW 10MG ...... 162 PREMPHASE TAB ...... 110 PRILOSEC POW 2.5MG ...... 162 PREMPRO TAB ...... 110 PRIMAQUINE PHOSPHATE PREMPRO TAB 0.3-1.5 ...... 110 see primaquine phosphate tab 26.3 PREMPRO TAB 0.45-1.5 ...... 110 mg (15 mg base) ...... 68 PREMPRO TAB 0.625-5 ...... 110 primaquine phosphate tab 26.3 mg (15 PRENATABS FA TAB 29-1MG ...... 143 mg base) ...... 68 PRENATAL-U CAP 106.5-1 ...... 143 PRINIVIL see lisinopril tab 20 mg ...... 59 229 PRINIVIL TAB 20MG ...... 60 promethazine hcl suppos 12.5 mg ....54 PROAIR DIGIH AER ...... 42 promethazine hcl suppos 25 mg ...... 54 PROAIR HFA promethazine hcl suppos 50 mg ...... 54 see albuterol sulfate inhal aero 108 promethazine hcl syrup 6.25 mg/5ml 55 mcg/act (90mcg base equiv) ...... 40 promethazine hcl tab 12.5 mg ...... 55 PROAIR HFA AER ...... 42 promethazine hcl tab 25 mg ...... 55 PROAIR RESPI AER ...... 42 promethazine hcl tab 50 mg ...... 55 probenecid tab 500 mg ...... 116 promethazine-phenylephrine-codeine PROCARDIA XL syrup 6.25-5-10 mg/5ml ...... 95 see nifedipine tab er 24hr osmotic promethazine w/ codeine syrup 6.25- release 30 mg ...... 82 10 mg/5ml ...... 95 see nifedipine tab er 24hr osmotic prometh vc/ syp codeine ...... 95 release 60 mg ...... 82 prometh vc syp 6.25-5/5 ...... 95 see nifedipine tab er 24hr osmotic PROMETRIUM release 90 mg ...... 82 see progesterone cap 100 mg .....154 PROCARDIA XL TAB 30MG CR ...... 82 see progesterone cap 200 mg .....154 PROCARDIA XL TAB 60MG CR ...... 82 PROMETRIUM CAP 100MG ...... 154 PROCARDIA XL TAB 90MG CR ...... 82 PROMETRIUM CAP 200MG ...... 154 prochlorperazine maleate tab 10 mg PRO NUTRIENT CAP OMEGA3 ...... 147 (base equivalent) ...... 75 propafenone hcl tab 150 mg ...... 38 prochlorperazine maleate tab 5 mg propafenone hcl tab 225 mg ...... 38 (base equivalent) ...... 75 propafenone hcl tab 300 mg ...... 38 prochlorperazine suppos 25 mg ...... 75 proparacaine hcl ophth soln 0.5% ...150 PROCRIT INJ 10000/ML ...... 118 propranolol & hydrochlorothiazide tab PROCRIT INJ 2000/ML ...... 118 40-25 mg ...... 66 PROCRIT INJ 20000/ML ...... 118 propranolol & hydrochlorothiazide tab PROCRIT INJ 3000/ML ...... 118 80-25 mg ...... 66 PROCRIT INJ 4000/ML ...... 118 propranolol hcl cap er 24hr 120 mg ..79 PROCRIT INJ 40000/ML ...... 118 propranolol hcl cap er 24hr 160 mg ..79 PROFE CAP 180MG ...... 121 propranolol hcl cap er 24hr 60 mg ....79 PROFERRIN ES TAB 12 MG ...... 121 propranolol hcl cap er 24hr 80 mg ....79 progesterone cap 100 mg ...... 154 propranolol hcl oral soln 20 mg/5ml ..79 progesterone cap 200 mg ...... 154 propranolol hcl oral soln 40 mg/5ml ..79 progesterone im in oil 50 mg/ml .....154 propranolol hcl tab 10 mg ...... 79 PROGRAF propranolol hcl tab 20 mg ...... 79 see tacrolimus cap 0.5 mg ...... 135 propranolol hcl tab 40 mg ...... 79 see tacrolimus cap 1 mg ...... 135 propranolol hcl tab 60 mg ...... 79 see tacrolimus cap 5 mg ...... 135 propranolol hcl tab 80 mg ...... 79 PROLATE SOL 10/300MG ...... 31 propylene glycol-glycerin ophth soln 1- PROLATE TAB 10-300MG ...... 31 0.3% ...... 147 PROLATE TAB 5-300MG ...... 31 propylthiouracil tab 50 mg ...... 158 PROLATE TAB 7.5-300 ...... 31 PRORENAL+D CAP OMEGA-3 ...... 140 PROLENSA SOL 0.07% ...... 151 PRORENAL+D TAB ...... 140 promethazine & phenylephrine syrup PRORENAL +D TAB ...... 140 6.25-5 mg/5ml ...... 95 PROSCAR promethazine-dm syrup 6.25-15 see finasteride tab 5 mg ...... 115 mg/5ml ...... 95 PROSCAR TAB 5MG ...... 115 230 PROTECT CAP CARDIO ...... 140 see budesonide inhalation susp 1 PROTECT CAP PLUS SO ...... 140 mg/2ml ...... 40 PROTEGRA CAP ...... 140 PULMICORT INH 180MCG ...... 40 PROTONIX PULMICORT INH 90MCG ...... 40 see pantoprazole sodium ec tab 20 PULMICORT SUS 0.25MG/2 ...... 40 mg (base equiv) ...... 162 PULMICORT SUS 0.5MG/2 ...... 40 see pantoprazole sodium ec tab 40 PULMICORT SUS 1MG/2ML ...... 40 mg (base equiv) ...... 162 PULMOZYME SOL 1MG/ML ...... 158 PROTONIX PAK 40MG ...... 162 purevit dual cap fe plus ...... 119 PROTONIX TAB 20MG ...... 162 px iron tab 27mg ...... 121 PROTONIX TAB 40MG ...... 162 PYLERA CAP ...... 162 PROTOPIC pyrazinamide tab 500 mg ...... 68 see tacrolimus oint 0.03% ...... 104 pyrethrins-piperonyl butoxide liq 0.33- see tacrolimus oint 0.1% ...... 104 4% ...... 105 PROTOPIC OIN 0.03% ...... 104 pyrethrins-piperonyl butoxide shampoo PROTOPIC OIN 0.1% ...... 104 0.33-4% ...... 105 PROVENTIL AER HFA ...... 42 pyridostigmine bromide tab 60 mg ...68 PROVENTIL HFA pyridoxine hcl tab 100 mg ...... 167 see albuterol sulfate inhal aero 108 pyridoxine hcl tab 25 mg ...... 167 mcg/act (90mcg base equiv) ...... 40 pyridoxine hcl tab 50 mg ...... 167 PROVERA pyrimethamine tab 25 mg ...... 68 see medroxyprogesterone acetate Q tab 10 mg ...... 154 QBRELIS SOL 1MG/ML ...... 60 see medroxyprogesterone acetate qc calcium tab 600mg ...... 131 tab 2.5 mg ...... 153 QC CASTOR OIL ...... 87 see medroxyprogesterone acetate qc daytime liq cold/flu ...... 95 tab 5 mg ...... 153 qc epsom gra salt ...... 123 PROVERA TAB 10MG ...... 154 qc natural pow vegetabl ...... 122 PROVERA TAB 2.5MG ...... 154 QMIIZ ODT TAB 15 MG ...... 23 PROVERA TAB 5MG ...... 154 QMIIZ ODT TAB 7.5MG ...... 23 pseudoephed-bromphen-dm syrup 30- QNASL AER 80MCG ...... 146 2-10 mg/5ml ...... 95 QNASL CHILD SPR 40MCG ...... 146 pseudoephedrine-guaifenesin tab er QTERN TAB 10-5MG ...... 46 12hr 60-600 mg ...... 95 QTERN TAB 5-5MG ...... 46 PSORCON CRE 0.05% ...... 103 QUESTRAN psyllium cap 0.52 gm ...... 122 see cholestyramine powder 4 psyllium powder 100% ...... 122 gm/dose ...... 55 psyllium powder 28.3% ...... 122 see cholestyramine powder packets 4 psyllium powder 30.9% ...... 122 gm ...... 55 psyllium powder 48.57% ...... 122 QUESTRAN LIGHT psyllium powder 58.6% ...... 122 see cholestyramine light powder 4 PULMICORT gm/dose ...... 55 see budesonide inhalation susp 0.25 see prevalite pow 4gm ...... 56 mg/2ml ...... 40 QUESTRAN POW 4GM ...... 56 see budesonide inhalation susp 0.5 QUESTRAN POW 4GM LITE ...... 56 mg/2ml ...... 39 QUFLORA PED CHW 0.25MG ...... 142 QUFLORA PED CHW 0.5MG ...... 142 231 QUFLORA PED CHW 1MG ...... 142 rasagiline mesylate tab 0.5 mg (base QUFLORA PED DRO 0.25MG ...... 142 equiv) ...... 75 QUFLORA PED DRO 0.5MG/ML ...... 142 rasagiline mesylate tab 1 mg (base quinapril hcl tab 10 mg ...... 60 equiv) ...... 75 quinapril hcl tab 20 mg ...... 60 RAZADYNE ER quinapril hcl tab 40 mg ...... 60 see galantamine hydrobromide cap quinapril hcl tab 5 mg ...... 60 er 24hr 16 mg ...... 154 quinapril-hydrochlorothiazide tab 10- see galantamine hydrobromide cap 12.5 mg ...... 66 er 24hr 24 mg ...... 155 quinapril-hydrochlorothiazide tab 20- see galantamine hydrobromide cap 12.5 mg ...... 66 er 24hr 8 mg ...... 154 quinapril-hydrochlorothiazide tab 20-25 RAZADYNE ER CAP 16MG ...... 155 mg ...... 66 RAZADYNE ER CAP 24MG ...... 155 quin b stron tab b-25 ...... 137 RAZADYNE ER CAP 8MG ...... 155 QUIN B TAB STRONG ...... 140 RAZADYNE TAB 4MG ...... 155 quinidine sulfate tab 200 mg ...... 38 REBIF INJ 22/0.5 ...... 157 quinidine sulfate tab 300 mg ...... 38 REBIF INJ 44/0.5 ...... 157 QUINTABS-M TAB ...... 140 REBIF REBIDO INJ 22/0.5 ...... 157 QUINTABS TAB ...... 141 REBIF REBIDO INJ 44/0.5 ...... 157 QVAR REDIHA AER 80MCG ...... 40 REBIF REBIDO INJ TITRATN ...... 157 QVAR REDIHAL AER 40MCG ...... 40 REBIF TITRTN INJ PACK ...... 157 R reclipsen tab ...... 91 rabeprazole sodium ec tab 20 mg ...162 RECOMBIVA HB INJ 10MCG/ML ...... 164 ra biotin cap 2500mcg ...... 167 RECOMBIVA HB INJ 5MCG/0.5 ...... 164 RA EPSOM GRA SALT ...... 123 refresh cell gel 1% op ...... 147 RA EPSOM GRA SALT/LVN ...... 123 REFRESH TEAR DRO 0.5% OP ...... 147 raloxifene hcl tab 60 mg ...... 109 REGLAN ramipril cap 1.25 mg ...... 60 see metoclopramide hcl tab 10 mg ramipril cap 10 mg ...... 60 (base equivalent) ...... 113 ramipril cap 2.5 mg ...... 60 see metoclopramide hcl tab 5 mg ramipril cap 5 mg ...... 60 (base equivalent) ...... 113 RANEXA RELAFEN DS TAB 1000MG ...... 23 see ranolazine tab er 12hr 1000 mg RELENZA MIS DISKHALE ...... 76 ...... 36 RELISTOR INJ 12/0.6ML ...... 114 see ranolazine tab er 12hr 500 mg 36 RELISTOR INJ 8/0.4ML ...... 114 ranolazine tab er 12hr 1000 mg ...... 36 RELISTOR TAB 150MG ...... 114 ranolazine tab er 12hr 500 mg ...... 36 RELPAX RAPAFLO see eletriptan hydrobromide tab 20 see silodosin cap 4 mg ...... 115 mg (base equivalent) ...... 128 see silodosin cap 8 mg ...... 115 see eletriptan hydrobromide tab 40 RAPAFLO CAP 4MG ...... 115 mg (base equivalent) ...... 128 RAPAFLO CAP 8MG ...... 115 RELPAX TAB 20MG ...... 128 RAPAMUNE RELPAX TAB 40MG ...... 128 see sirolimus tab 0.5 mg ...... 135 RENAGEL see sirolimus tab 1 mg ...... 135 see sevelamer hcl tab 800 mg .....115 see sirolimus tab 2 mg ...... 135 RENAGEL TAB 800MG ...... 114 RENAPLEX-D TAB ...... 140 232 RENVELA REYVOW TAB 100MG ...... 128 see sevelamer carbonate packet 0.8 REYVOW TAB 50MG ...... 128 gm ...... 115 RHOPRESSA SOL 0.02% ...... 150 see sevelamer carbonate packet 2.4 RID LIQ ...... 105 gm ...... 115 rifabutin cap 150 mg ...... 69 see sevelamer carbonate tab 800 mg rifampin cap 150 mg ...... 69 ...... 115 rifampin cap 300 mg ...... 69 RENVELA POW 0.8GM ...... 114 rimantadine hydrochloride tab 100 mg RENVELA POW 2.4GM ...... 114 ...... 76 RENVELA TAB 800MG ...... 114 RINVOQ TAB 15MG ER ...... 20 repaglinide tab 0.5 mg ...... 49 RIOMET repaglinide tab 1 mg ...... 49 see metformin hcl oral soln 500 repaglinide tab 2 mg ...... 49 mg/5ml ...... 46 REPATHA INJ 140MG/ML ...... 59 RIOMET SOL ...... 47 REPATHA PUSH INJ 420/3.5 ...... 59 RIOMET SOL 500/5ML ...... 47 REPATHA SURE INJ 140MG/ML ...... 59 risanoid tab plus ...... 144 REPLESTA WAF 50000UNT ...... 166 risedronate sodium tab 150 mg ...... 108 REQ 49+ TAB ...... 140 risedronate sodium tab 30 mg ...... 108 REQUIP XL TAB 12MG ...... 74 risedronate sodium tab 35 mg ...... 108 REQUIP XL TAB 6MG ...... 74 risedronate sodium tab 5 mg ...... 108 RESPIRATORY THERAPY SUPPLIES - risedronate sodium tab delayed release MISC (MASK) ...... 127 35 mg ...... 108 RESPIRATORY THERAPY SUPPLIES - rivastigmine tartrate cap 1.5 mg (base MISC (MASK)- RX ...... 127 equivalent) ...... 155 RESTASIS EMU 0.05% ...... 150 rivastigmine tartrate cap 3 mg (base RESTASIS MUL EMU 0.05% ...... 150 equivalent) ...... 155 RETACRIT INJ 10000UNT ...... 118 rivastigmine tartrate cap 4.5 mg (base RETACRIT INJ 20000UNI ...... 118 equivalent) ...... 155 RETACRIT INJ 2000UNIT ...... 118 rivastigmine tartrate cap 6 mg (base RETACRIT INJ 3000UNIT ...... 118 equivalent) ...... 156 RETACRIT INJ 40000UNT ...... 118 rivastigmine td patch 24hr 13.3 RETACRIT INJ 4000UNIT ...... 118 mg/24hr ...... 156 RETIN-A rivastigmine td patch 24hr 4.6 mg/24hr see avita cre 0.025% ...... 96 ...... 156 see tretinoin cream 0.025% ...... 96 rivastigmine td patch 24hr 9.5 mg/24hr REVATIO ...... 156 see sildenafil citrate for suspension rizatriptan benzoate oral disintegrating 10 mg/ml ...... 85 tab 10 mg (base eq) ...... 129 see sildenafil citrate tab 20 mg ...... 85 rizatriptan benzoate oral disintegrating REVATIO SUS 10MG/ML ...... 85 tab 5 mg (base eq) ...... 129 REVATIO TAB 20MG ...... 85 rizatriptan benzoate tab 10 mg (base REVLIMID CAP 10MG ...... 134 equivalent) ...... 129 REVLIMID CAP 15MG ...... 134 rizatriptan benzoate tab 5 mg (base REVLIMID CAP 2.5MG ...... 134 equivalent) ...... 129 REVLIMID CAP 20MG ...... 134 ROCALTROL REVLIMID CAP 25MG ...... 134 see calcitriol cap 0.25 mcg ...... 109 REVLIMID CAP 5MG ...... 134 see calcitriol cap 0.5 mcg ...... 109 233 see calcitriol oral soln 1 mcg/ml ...109 SAIZEN INJ 5MG ...... 109 ROCKLATAN DRO ...... 150 SAIZEN INJ 8.8MG ...... 109 ropinirole hydrochloride tab 0.25 mg 74 SAIZENPREP INJ 8.8MG ...... 109 ropinirole hydrochloride tab 0.5 mg ..74 SALAGEN ropinirole hydrochloride tab 1 mg .....74 see pilocarpine hcl tab 5 mg ...... 136 ropinirole hydrochloride tab 2 mg .....74 see pilocarpine hcl tab 7.5 mg .....136 ropinirole hydrochloride tab 3 mg .....74 saline nasal spray 0.65% ...... 145 ropinirole hydrochloride tab 4 mg .....74 SANCUSO DIS 3.1MG ...... 51 ropinirole hydrochloride tab 5 mg .....74 SANDIMMUNE ropinirole hydrochloride tab er 24hr 12 see cyclosporine cap 100 mg ...... 134 mg (base equivalent) ...... 75 see cyclosporine cap 25 mg ...... 134 ropinirole hydrochloride tab er 24hr 2 SANDOSTATIN mg (base equivalent) ...... 74 see octreotide acetate inj 100 ropinirole hydrochloride tab er 24hr 4 mcg/ml (0.1 mg/ml) ...... 110 mg (base equivalent) ...... 74 see octreotide acetate inj 50 mcg/ml ropinirole hydrochloride tab er 24hr 6 (0.05 mg/ml) ...... 110 mg (base equivalent) ...... 74 SANTYL OIN 250/GM ...... 104 ropinirole hydrochloride tab er 24hr 8 SAVAYSA TAB 15MG ...... 43 mg (base equivalent) ...... 75 SAVAYSA TAB 30MG ...... 43 rosadan cre 0.75% ...... 104 SAVAYSA TAB 60MG ...... 43 rosadan gel 0.75% ...... 104 SAVELLA MIS TITR PAK ...... 156 rosuvastatin calcium tab 10 mg ...... 58 SAVELLA TAB 100MG ...... 156 rosuvastatin calcium tab 20 mg ...... 58 SAVELLA TAB 12.5MG ...... 156 rosuvastatin calcium tab 40 mg ...... 58 SAVELLA TAB 25MG ...... 156 rosuvastatin calcium tab 5 mg ...... 58 SAVELLA TAB 50MG ...... 156 ROXICODONE SAVISION CAP ...... 140 see oxycodone hcl tab 15 mg ...... 29 sb daytime liq ...... 95 see oxycodone hcl tab 30 mg ...... 29 sb flu relf liq daytime ...... 95 see oxycodone hcl tab 5 mg ...... 29 scalpicin sol 1% ...... 103 ROXICODONE TAB 15MG ...... 29 SEGLUROMET TAB 2.5-1000 ...... 46 ROXICODONE TAB 30MG ...... 29 SEGLUROMET TAB 2.5-500 ...... 46 ROXICODONE TAB 5MG ...... 29 SEGLUROMET TAB 7.5-1000 ...... 46 RX SUPPORT TAB HEARTBUR ...... 120 SEGLUROMET TAB 7.5-500 ...... 46 RYBELSUS TAB 14MG ...... 47 selegiline hcl cap 5 mg ...... 75 RYBELSUS TAB 3MG ...... 47 selegiline hcl tab 5 mg ...... 75 RYBELSUS TAB 7MG ...... 47 selenium sulfide lotion 2.5% ...... 99 RYTARY CAP 145MG ...... 75 SEMGLEE INJ 100U/ML ...... 49 RYTARY CAP 195MG ...... 75 SEMGLEE SOL 100U/ML ...... 49 RYTARY CAP 245MG ...... 75 SE-NATAL 19 CHW ...... 143 RYTARY CAP 95MG ...... 75 SE-NATAL 19 TAB ...... 143 S SENNA PLUS CAP 8.6-50MG ...... 122 s.s.s. tonic tab ...... 137 senna smooth tab 15mg ...... 124 SAFYRAL SENNA SYP ...... 124 see drospirenone-ethinyl estrad- sennosides cap 8.6 mg ...... 124 levomefolate tab 3-0.03-0.451 mg sennosides chew tab 15 mg ...... 124 ...... 88 sennosides-docusate sodium tab 8.6- see tydemy tab ...... 91 50 mg ...... 122 234 sennosides syrup 8.8 mg/5ml ...... 124 SIMPONI INJ 50/0.5ML ...... 20 sennosides tab 25 mg ...... 124 simvastatin tab 10 mg ...... 58 sennosides tab 8.6 mg ...... 124 simvastatin tab 20 mg ...... 58 senokot extr tab 17.2mg ...... 124 simvastatin tab 40 mg ...... 58 SENOKOT S TAB 8.6-50MG ...... 122 simvastatin tab 5 mg ...... 58 SENOKOT TAB 8.6MG ...... 124 simvastatin tab 80 mg ...... 58 SENSIPAR SINEMET see cinacalcet hcl tab 30 mg (base see carbidopa & levodopa tab 10-100 equiv) ...... 109 mg ...... 73 see cinacalcet hcl tab 60 mg (base see carbidopa & levodopa tab 25-100 equiv) ...... 109 mg ...... 73 see cinacalcet hcl tab 90 mg (base SINEMET TAB 10-100MG ...... 75 equiv) ...... 109 SINEMET TAB 25-100MG ...... 75 SEREVENT DIS AER 50MCG ...... 42 SINGULAIR SERNIVO SPR ...... 103 see montelukast sodium chew tab 4 SEROSTIM INJ 4MG ...... 109 mg (base equiv) ...... 39 SEROSTIM INJ 5MG ...... 109 see montelukast sodium chew tab 5 SEROSTIM INJ 6MG ...... 109 mg (base equiv) ...... 39 se-tan plus cap ...... 120 see montelukast sodium oral setlakin tab ...... 91 granules packet 4 mg (base equiv) sevelamer carbonate packet 0.8 gm 115 ...... 39 sevelamer carbonate packet 2.4 gm 115 see montelukast sodium tab 10 mg sevelamer carbonate tab 800 mg ...115 (base equiv) ...... 39 sevelamer hcl tab 400 mg ...... 115 SINGULAIR CHW 4MG ...... 39 sevelamer hcl tab 800 mg ...... 115 SINGULAIR CHW 5MG ...... 39 sf 5000 plus cre 1.1% ...... 135 SINGULAIR GRA 4MG ...... 39 sf gel 1.1% ...... 135 SINGULAIR TAB 10MG ...... 39 sharobel tab 0.35mg ...... 93 sirolimus tab 0.5 mg ...... 135 SHINGRIX INJ 50/0.5ML ...... 164 sirolimus tab 1 mg...... 135 sildenafil citrate for suspension 10 sirolimus tab 2 mg...... 135 mg/ml ...... 85 SITAVIG TAB 50MG ...... 76 sildenafil citrate tab 20 mg ...... 85 SIVEXTRO TAB 200MG ...... 36 SILIQ INJ 210/1.5 ...... 99 SKELAXIN silodosin cap 4 mg ...... 115 see metaxalone tab 800 mg ...... 144 silodosin cap 8 mg ...... 115 SKELAXIN TAB 800MG ...... 145 SILVADENE SKYRIZI INJ 150DOSE ...... 99 see silver sulfadiazine cream 1% ...99 SKYRIZI INJ 150MG/ML ...... 99 see ssd cre 1% ...... 99 SKYRIZI PEN INJ 150MG/ML ...... 99 silver sulfadiazine cream 1% ...... 99 sleep child/ liq melatoni ...... 19 SIMBRINZA SUS 1-0.2% ...... 149 SLO-NIACIN TAB 750MG ER ...... 167 simethicone chew tab 125 mg ...... 112 SLOWMAG MG TAB MUS/HRT ...... 133 simethicone chew tab 80 mg ...... 112 SLOW-MAG TAB ...... 133 simethicone liquid 40 mg/0.6ml .....112 SLOW-MAG TAB 71.5-119 ...... 133 simethicone susp 40 mg/0.6ml ...... 112 SLOW REL FE TAB 143MG CR ...... 121 simliya tab 28 day ...... 91 sm balanced tab b-100 ...... 137 SIMPONI ARIA SOL 50MG/4ML ...... 20 sm balanced tab b-50 ...... 137 SIMPONI INJ 100MG/ML ...... 20 SM B-COMPLEX TAB /VIT C ...... 137 235 sm calcium chw ...... 131 sotalol hcl (afib/afl) tab 160 mg ...... 79 sm castor oil 100% ...... 124 sotalol hcl (afib/afl) tab 80 mg ...... 79 SM CORAL CAL TAB 1000MG ...... 131 sotalol hcl tab 120 mg ...... 79 sm day time liq cold/flu ...... 95 sotalol hcl tab 160 mg ...... 79 sm epsom gra salt ...... 123 sotalol hcl tab 240 mg ...... 79 sm estroplus tab ex st ...... 105 sotalol hcl tab 80 mg ...... 79 sod, potass pow phosphor ...... 133 SOTYLIZE SOL 5MG/ML ...... 79 sod chloride oin 5% op ...... 151 SPACER/AEROSOL-HOLDING sodium bicarbonate tab 325 mg ...... 34 CHAMBERS - DEVICE ...... 127 sodium bicarbonate tab 650 mg ...... 34 SPACER/AEROSOL-HOLDING sodium chloride hypertonic ophth soln CHAMBERS - DEVICE- RX ...... 127 5% ...... 151 SPECTRAVITE CHW ADLT 50+ ...... 140 sodium chloride soln nebu 0.9% ...... 95 SPECTRAVITE CHW WOMEN ...... 140 sodium chloride soln nebu 7% ...... 95 spinosad susp 0.9% ...... 105 sodium citrate & citric acid soln 500- SPIRIVA AER 1.25MCG ...... 38 334 mg/5ml ...... 115 SPIRIVA CAP HANDIHLR ...... 38 sodium fluor cre 5000 pls ...... 135 SPIRIVA SPR 2.5MCG ...... 38 sodium fluor cre 5000 ppm ...... 135 spironolactone & hydrochlorothiazide sodium fluoride chew tab 0.25 mg f tab 25-25 mg ...... 106 (from 0.55 mg naf) ...... 132 spironolactone tab 100 mg ...... 107 sodium fluoride chew tab 0.5 mg f spironolactone tab 25 mg ...... 107 (from 1.1 mg naf) ...... 132 spironolactone tab 50 mg ...... 107 sodium fluoride chew tab 1 mg f (from SPORANOX 2.2 mg naf) ...... 132 see itraconazole cap 100 mg ...... 53 sodium fluoride gel 1.1% (0.5% f) ..135 see itraconazole oral soln 10 mg/ml sodium fluoride soln 0.5 mg/ml f (from ...... 53 1.1 mg/ml naf) ...... 132 SPORANOX CAP 100MG ...... 53 sodium phosphates - enema ...... 123 SPORANOX CAP PULSEPAK ...... 53 sodium phosphates inj 15 mm/5ml SPORANOX SOL 10MG/ML ...... 53 (phos) 20 meq/5ml (na) ...... 133 sprintec 28 tab 28 day ...... 91 sodium phosphates inj 45 mm/15ml SPRIX SPR 15.75MG ...... 23 (phos) 60 meq/15ml (na) ...... 133 sps sus 15gm/60 ...... 135 sodium polystyrene sulfonate powder sronyx tab ...... 91 ...... 135 ssd cre 1% ...... 99 solifenacin succinate tab 10 mg ...... 163 STALEVO 100 solifenacin succinate tab 5 mg 3...... 16 see carbidopa-levodopa-entacapone SOLIQUA INJ 100/33 ...... 46 tabs 25-100-200 mg ...... 73 soluble fib pow therapy ...... 122 STALEVO 100 TAB ...... 75 soluvita e sol 50unt/ml ...... 166 STALEVO 125 SORIATANE see carbidopa-levodopa-entacapone see acitretin cap 10 mg ...... 98 tabs 31.25-125-200 mg ...... 73 see acitretin cap 25 mg ...... 98 STALEVO 125 TAB ...... 75 sorine tab 120mg ...... 79 STALEVO 150 sorine tab 160mg ...... 79 see carbidopa-levodopa-entacapone sorine tab 240mg ...... 79 tabs 37.5-150-200 mg ...... 73 sorine tab 80mg ...... 79 STALEVO 150 TAB ...... 75 sotalol hcl (afib/afl) tab 120 mg ...... 79 STALEVO 200 TAB ...... 75 236 STALEVO 50 sulfasalazine tab 500 mg ...... 113 see carbidopa-levodopa-entacapone sulfasalazine tab delayed release 500 tabs 12.5-50-200 mg ...... 73 mg ...... 113 STALEVO 50 TAB ...... 75 sulfatrim pd sus 200-40/5 ...... 35 STALEVO 75 sulindac tab 150 mg ...... 23 see carbidopa-levodopa-entacapone sulindac tab 200 mg ...... 23 tabs 18.75-75-200 mg ...... 73 sumatriptan-naproxen sodium tab 85- STALEVO 75 TAB ...... 75 500 mg ...... 128 STEGLATRO TAB 15MG ...... 50 sumatriptan nasal spray 20 mg/act .129 STEGLATRO TAB 5MG ...... 50 sumatriptan nasal spray 5 mg/act ..129 STEGLUJAN TAB 15-100MG ...... 46 sumatriptan succinate inj 6 mg/0.5ml STEGLUJAN TAB 5-100MG ...... 46 ...... 129 STELARA INJ 45MG/0.5 ...... 99 sumatriptan succinate solution auto- STELARA INJ 5MG/ML ...... 113 injector 4 mg/0.5ml ...... 129 STELARA INJ 90MG/ML ...... 99 sumatriptan succinate solution auto- STIMATE SOL 1.5MG/ML ...... 109 injector 6 mg/0.5ml ...... 129 STIOLTO AER 2.5-2.5 ...... 42 sumatriptan succinate solution STL SOFT/LAX CAP 8.5-50MG ...... 122 cartridge 4 mg/0.5ml ...... 129 stress b com tab vit c/zn ...... 136 sumatriptan succinate solution stress form/ tab zinc ...... 136 cartridge 6 mg/0.5ml ...... 129 STRIVERDI AER 2.5MCG ...... 42 sumatriptan succinate tab 100 mg ..129 STROMECTOL sumatriptan succinate tab 25 mg ....129 see ivermectin tab 3 mg ...... 34 sumatriptan succinate tab 50 mg ....129 sucralfate tab 1 gm ...... 160 SUPER ANTIOX CAP ...... 141 SULAR super b comp tab vit c ...... 136 see nisoldipine tab er 24hr 17 mg ..82 super cal/ tab mag ...... 131 see nisoldipine tab er 24hr 34 mg ..82 super dec tab b-100 ...... 137 see nisoldipine tab er 24hr 8.5 mg .82 super quints tab ...... 137 SULAR TAB 17MG ...... 82 SUPER TWIN CAP EPA/DHA ...... 147 SULAR TAB 34MG ...... 82 SUPERVITE LIQ ...... 137 SULAR TAB 8.5MG ...... 82 SUPPORT-500 CAP ...... 144 sulconazole nitrate cream 1% ...... 98 SUPPORT LIQ ...... 141 sulconazole nitrate solution 1% ...... 98 SUPRAX sulfacetamide sodium ophth oint 10% see cefixime cap 400 mg ...... 87 ...... 149 see cefixime for susp 100 mg/5ml .87 sulfacetamide sodium ophth soln 10% see cefixime for susp 200 mg/5ml .87 ...... 149 SUPRAX CAP 400MG ...... 87 sulfacetamide sodium-prednisolone SUPRAX CHW 100MG ...... 87 ophth soln 10-0.23(0.25)% ...... 150 SUPRAX CHW 200MG ...... 87 sulfacetamide sodium w/ sulfur SUPRAX SUS 100/5ML ...... 87 emulsion 10-5% ...... 96 SUPRAX SUS 200/5ML ...... 87 sulfamethoxazole-trimethoprim susp SUPRAX SUS 500/5ML ...... 87 200-40 mg/5ml ...... 35 SUPREP BOWEL SOL PREP KIT ...... 122 sulfamethoxazole-trimethoprim tab SUTAB TAB ...... 122 400-80 mg ...... 35 syeda tab 3-0.03mg ...... 91 sulfamethoxazole-trimethoprim tab SYMBICORT AER 160-4.5 ...... 42 800-160 mg ...... 35 SYMBICORT AER 80-4.5 ...... 42 237 SYMJEPI INJ 0.15MG ...... 166 see oseltamivir phosphate cap 45 mg SYMJEPI INJ 0.3MG ...... 166 (base equiv) ...... 76 SYMLINPEN 60 INJ 1000MCG ...... 44 see oseltamivir phosphate cap 75 mg SYMLNPEN 120 INJ 1000MCG ...... 44 (base equiv) ...... 76 SYMPROIC TAB 0.2MG ...... 114 see oseltamivir phosphate for susp 6 SYNAGIS INJ 100MG/ML ...... 152 mg/ml (base equiv) ...... 76 SYNAGIS INJ 50MG ...... 152 TAMIFLU CAP 30MG ...... 76 SYNALAR TAMIFLU CAP 45MG ...... 76 see fluocinolone acetonide cream TAMIFLU CAP 75MG ...... 76 0.025% ...... 101 TAMIFLU SUS 6MG/ML ...... 76 see fluocinolone acetonide oint tamoxifen citrate tab 10 mg (base 0.025% ...... 101 equivalent) ...... 70 see fluocinolone acetonide soln tamoxifen citrate tab 20 mg (base 0.01% ...... 101 equivalent) ...... 70 SYNALAR CRE 0.025% ...... 103 tamsulosin hcl cap 0.4 mg ...... 116 SYNALAR KIT 0.025% ...... 103 TAPAZOLE SYNALAR OIN 0.025% ...... 103 see methimazole tab 10 mg ...... 158 SYNALAR SOL 0.01% ...... 103 see methimazole tab 5 mg ...... 158 SYNALAR TS KIT 0.01% ...... 103 TARGRETIN SYNJARDY TAB ...... 46 see bexarotene cap 75 mg ...... 71 SYNJARDY TAB 12.5-500 ...... 46 tarina 24 fe tab ...... 91 SYNJARDY TAB 5-1000MG ...... 46 tarina fe tab 1/20 ...... 91 SYNJARDY TAB 5-500MG ...... 46 tarina fe tab 1/20 eq ...... 91 SYNJARDY XR TAB ...... 46 TARKA SYNJARDY XR TAB 10-1000 ...... 46 see trandolapril-verapamil hcl tab er SYNJARDY XR TAB 25-1000 ...... 46 2-180 mg ...... 67 SYNJARDY XR TAB 5-1000MG ...... 46 see trandolapril-verapamil hcl tab er SYSTANE GEL DRO 0.4-0.3% ...... 147 2-240 mg ...... 67 SYSTANE ICAP CHW AREDS2 ...... 141 see trandolapril-verapamil hcl tab er SYSTANE ICAP TAB AREDS2 ...... 141 4-240 mg ...... 67 SYSTANE SOL ...... 147 TARKA TAB 2-180 CR ...... 66 SYSTANE ULTR SOL ...... 147 TARKA TAB 2-240 CR ...... 66 SYTRINOL CAP ...... 105 TARKA TAB 4-240 CR ...... 66 T TARON FORTE CAP ...... 120 TABLOID TAB 40MG ...... 70 TASMAR tacrolimus cap 0.5 mg ...... 135 see tolcapone tab 100 mg ...... 72 tacrolimus cap 1 mg ...... 135 TASMAR TAB 100MG ...... 72 tacrolimus cap 5 mg ...... 135 tavaborole soln 5% ...... 98 tacrolimus oint 0.03% ...... 104 taztia xt cap 120mg/24 ...... 82 tacrolimus oint 0.1% ...... 104 taztia xt cap 180mg/24 ...... 83 tadalafil tab 20 mg (pah) ...... 85 taztia xt cap 240mg/24 ...... 83 TALICIA CAP ...... 162 taztia xt cap 300mg er ...... 83 TALTZ INJ 80MG/ML ...... 99 taztia xt cap 360mg/24 ...... 83 TAMIFLU TAZVERIK TAB 200MG ...... 71 see oseltamivir phosphate cap 30 mg TDVAX INJ 2-2 LF ...... 160 (base equiv) ...... 76 TECFIDERA

238 see dimethyl fumarate capsule TEMOVATE OIN 0.05% ...... 103 delayed release 120 mg ...... 156 temozolomide cap 100 mg ...... 69 see dimethyl fumarate capsule temozolomide cap 140 mg ...... 69 delayed release 240 mg ...... 156 temozolomide cap 180 mg ...... 69 TECFIDERA CAP 120MG ...... 157 temozolomide cap 20 mg ...... 69 TECFIDERA CAP 240MG ...... 157 temozolomide cap 250 mg ...... 69 TECFIDERA MIS STARTER ...... 157 temozolomide cap 5 mg ...... 69 TECFIDERA STARTER PACK TENIVAC INJ 5-2LF ...... 160 see dimethyl fumarate capsule dr TENORETIC 100 starter pack 120 mg & 240 mg .156 see atenolol & chlorthalidone tab TEKTURNA 100-25 mg ...... 64 see aliskiren fumarate tab 150 mg TENORETIC 50 (base equivalent) ...... 67 see atenolol & chlorthalidone tab 50- see aliskiren fumarate tab 300 mg 25 mg ...... 63 (base equivalent) ...... 68 TENORETIC TAB 100 ...... 67 TEKTURNA HCT TAB 150-12.5 ...... 66 TENORETIC TAB 50 ...... 67 TEKTURNA HCT TAB 150-25MG ...... 66 TENORMIN TEKTURNA HCT TAB 300-12.5 ...... 66 see atenolol tab 100 mg ...... 77 TEKTURNA HCT TAB 300-25MG ...... 66 see atenolol tab 25 mg ...... 77 TEKTURNA TAB 150MG ...... 68 see atenolol tab 50 mg ...... 77 TEKTURNA TAB 300MG ...... 68 TENORMIN TAB 100MG ...... 78 telmisartan-amlodipine tab 40-10 mg TENORMIN TAB 25MG ...... 78 ...... 66 TENORMIN TAB 50MG ...... 78 telmisartan-amlodipine tab 40-5 mg .66 terazosin hcl cap 10 mg (base telmisartan-amlodipine tab 80-10 mg equivalent) ...... 62 ...... 66 terazosin hcl cap 1 mg (base telmisartan-amlodipine tab 80-5 mg .66 equivalent) ...... 62 telmisartan-hydrochlorothiazide tab 40- terazosin hcl cap 2 mg (base 12.5 mg ...... 67 equivalent) ...... 62 telmisartan-hydrochlorothiazide tab 80- terazosin hcl cap 5 mg (base 12.5 mg ...... 67 equivalent) ...... 62 telmisartan-hydrochlorothiazide tab 80- terbinafine hcl cream 1% ...... 98 25 mg ...... 67 terbinafine hcl tab 250 mg ...... 52 telmisartan tab 20 mg ...... 61 terbutaline sulfate tab 2.5 mg ...... 42 telmisartan tab 40 mg ...... 61 terbutaline sulfate tab 5 mg ...... 42 telmisartan tab 80 mg ...... 61 terconazole vaginal cream 0.4% .....165 TEMODAR terconazole vaginal cream 0.8% .....165 see temozolomide cap 100 mg ...... 69 TERIPARATIDE INJ ...... 108 see temozolomide cap 140 mg ...... 69 TESSALON PERLES see temozolomide cap 180 mg ...... 69 see benzonatate cap 100 mg ...... 94 see temozolomide cap 250 mg ...... 69 TESTIM TEMOVATE see testosterone td gel 50 mg/5gm see clobetasol propionate cream (1%) ...... 33 0.05% ...... 100 TESTIM GEL 1%(50MG) ...... 32 see clobetasol propionate oint 0.05% testosterone cypionate im inj in oil 100 ...... 100 mg/ml ...... 32 TEMOVATE CRE 0.05% ...... 103 239 testosterone cypionate im inj in oil 200 see diltiazem hcl extended release mg/ml ...... 32 beads cap er 24hr 180 mg ...... 81 testosterone td gel 10mg/act (2%) ...32 see diltiazem hcl extended release testosterone td gel 12.5 mg/act (1%) beads cap er 24hr 240 mg ...... 81 ...... 33 see diltiazem hcl extended release testosterone td gel 20.25 mg/1.25gm beads cap er 24hr 300 mg ...... 81 (1.62%) ...... 33 see diltiazem hcl extended release testosterone td gel 20.25 mg/act beads cap er 24hr 360 mg ...... 81 (1.62%) ...... 33 see diltiazem hcl extended release testosterone td gel 25 mg/2.5gm (1%) beads cap er 24hr 420 mg ...... 81 ...... 33 see taztia xt cap 120mg/24 ...... 82 testosterone td gel 40.5 mg/2.5gm see taztia xt cap 180mg/24 ...... 83 (1.62%) ...... 33 see taztia xt cap 240mg/24 ...... 83 testosterone td gel 50 mg/5gm (1%) 33 see taztia xt cap 300mg er ...... 83 testosterone td soln 30 mg/act ...... 33 see taztia xt cap 360mg/24 ...... 83 TEXACORT SOL 2.5% ...... 103 see tiadylt cap 120mg/24 ...... 83 THALOMID CAP 100MG ...... 134 see tiadylt cap 180mg/24 ...... 83 THALOMID CAP 150MG ...... 134 see tiadylt cap 240mg/24 ...... 83 THALOMID CAP 200MG ...... 134 see tiadylt cap 300mg/24 ...... 83 THALOMID CAP 50MG ...... 134 see tiadylt cap 360mg/24 ...... 83 theophylline soln 80 mg/15ml ...... 42 see tiadylt cap 420mg/24 ...... 83 theophylline tab er 12hr 300 mg ...... 42 TIAZAC CAP 120MG/24 ...... 83 theophylline tab er 12hr 450 mg ...... 42 TIAZAC CAP 180MG/24 ...... 83 theophylline tab er 24hr 400 mg ...... 42 TIAZAC CAP 240MG/24 ...... 83 theophylline tab er 24hr 600 mg ...... 42 TIAZAC CAP 300MG/24 ...... 83 theraflu liq exprsmx ...... 95 TIAZAC CAP 360MG/24 ...... 83 THERAMILL CAP FORTE ...... 141 TIAZAC CAP 420MG/24 ...... 83 THERA M PLUS TAB ...... 141 TIBSOVO TAB 250MG ...... 71 THERA-M TAB ...... 141 tilia fe tab ...... 91 THERANATAL CAP LACTATIO ...... 141 timolol maleate ophth gel forming soln THERA TAB ...... 141 0.25% ...... 148 THEREMS-M TAB ...... 141 timolol maleate ophth gel forming soln thiamine hcl tab 100 mg ...... 167 0.5% ...... 147 thiamine hcl tab 50 mg ...... 167 timolol maleate ophth soln 0.25% ..148 thiamine mononitrate tab 100 mg ...167 timolol maleate ophth soln 0.5% ....148 THRESHOLD MIS PEP ...... 127 timolol maleate ophth soln 0.5% THRIVITE RX TAB 29-1MG ...... 143 (once-daily) ...... 148 tiadylt cap 120mg/24 ...... 83 timolol maleate preservative free ophth tiadylt cap 180mg/24 ...... 83 soln 0.5% ...... 148 tiadylt cap 240mg/24 ...... 83 timolol maleate tab 10 mg ...... 79 tiadylt cap 300mg/24 ...... 83 timolol maleate tab 20 mg ...... 79 tiadylt cap 360mg/24 ...... 83 timolol maleate tab 5 mg ...... 79 tiadylt cap 420mg/24 ...... 83 TIMOPTIC TIAZAC see timolol maleate ophth soln see diltiazem hcl extended release 0.25% ...... 148 beads cap er 24hr 120 mg ...... 81 see timolol maleate ophth soln 0.5% ...... 148 240 TIMOPTIC OCUDOSE tolnaftate aerosol pow 1% ...... 98 see timolol maleate preservative free tolnaftate cream 1% ...... 98 ophth soln 0.5% ...... 148 tolnaftate powder 1% ...... 98 TIMOPTIC OCU SOL 0.25% OP ...... 148 TOLSURA CAP 65MG ...... 53 TIMOPTIC OCU SOL 0.5% OP ...... 148 tolterodine tartrate cap er 24hr 2 mg TIMOPTIC SOL 0.25% OP ...... 148 ...... 163 TIMOPTIC SOL 0.5% OP ...... 148 tolterodine tartrate cap er 24hr 4 mg TIMOPTIC-XE ...... 163 see timolol maleate ophth gel tolterodine tartrate tab 1 mg ...... 163 forming soln 0.25% ...... 148 tolterodine tartrate tab 2 mg ...... 163 see timolol maleate ophth gel TOPICORT forming soln 0.5% ...... 147 see desoximetasone cream 0.05% TIMOPTIC-XE SOL 0.25% OP ...... 148 ...... 101 TIMOPTIC-XE SOL 0.5% OP ...... 148 see desoximetasone cream 0.25% TINACTIN CRE 1% ...... 98 ...... 101 tinidazole tab 250 mg ...... 35 see desoximetasone gel 0.05% ...101 tinidazole tab 500 mg ...... 35 see desoximetasone oint 0.05% ..101 titralac chw 420mg ...... 34 see desoximetasone oint 0.25% ..101 TIVORBEX CAP 20MG ...... 23 see desoximetasone spray 0.25% 101 tizanidine hcl cap 2 mg (base TOPICORT CRE 0.05% ...... 103 equivalent) ...... 145 TOPICORT CRE 0.25% ...... 103 tizanidine hcl cap 4 mg (base TOPICORT GEL 0.05% ...... 103 equivalent) ...... 145 TOPICORT OIN 0.05% ...... 103 tizanidine hcl cap 6 mg (base TOPICORT OIN 0.25% ...... 103 equivalent) ...... 145 TOPICORT SPR 0.25% ...... 103 tizanidine hcl tab 2 mg (base TOPROL XL equivalent) ...... 145 see metoprolol succinate tab er 24hr tizanidine hcl tab 4 mg (base 100 mg (tartrate equiv) ...... 78 equivalent) ...... 145 see metoprolol succinate tab er 24hr tl-hem 150 tab ...... 120 200 mg (tartrate equiv) ...... 78 TOBI NEB 300/5ML ...... 19 see metoprolol succinate tab er 24hr TOBI PODHALR CAP 28MG ...... 19 25 mg (tartrate equiv) ...... 78 TOBRADEX see metoprolol succinate tab er 24hr see tobramycin-dexamethasone 50 mg (tartrate equiv) ...... 78 ophth susp 0.3-0.1% ...... 150 TOPROL XL TAB 100MG ...... 78 tobramycin-dexamethasone ophth susp TOPROL XL TAB 200MG ...... 78 0.3-0.1% ...... 150 TOPROL XL TAB 25MG ...... 78 tobramycin nebu soln 300 mg/4ml ...19 TOPROL XL TAB 50MG ...... 78 tobramycin nebu soln 300 mg/5ml ...19 toremifene citrate tab 60 mg (base tobramycin ophth soln 0.3% ...... 149 equivalent) ...... 70 TOBREX torsemide tab 100 mg ...... 107 see tobramycin ophth soln 0.3% ..149 torsemide tab 10 mg ...... 107 TODAY SPONGE MIS ...... 164 torsemide tab 20 mg ...... 107 tolbutamide tab 500 mg ...... 50 torsemide tab 5 mg ...... 107 tolcapone tab 100 mg ...... 72 TOSYMRA SOL 10MG ...... 129 tolmetin sodium cap 400 mg ...... 23 TOUJEO MAX INJ 300IU/ML ...... 49 tolmetin sodium tab 600 mg ...... 23 TOUJEO SOLO INJ 300IU/ML ...... 49 241 tovet aer 0.05% ...... 103 TRELEGY AER ELLIPTA ...... 42 TOVET KIT KIT 0.05% ...... 103 TREMFYA INJ 100MG/ML ...... 99 TOVIAZ TAB 4MG ...... 163 TRESIBA FLEX INJ 100UNIT ...... 49 TOVIAZ TAB 8MG ...... 163 TRESIBA FLEX INJ 200UNIT ...... 49 TRACLEER TRESIBA INJ 100UNIT ...... 49 see bosentan tab 125 mg ...... 85 tretinoin cap 10 mg ...... 72 see bosentan tab 62.5 mg ...... 85 tretinoin cream 0.025% ...... 96 TRACLEER TAB 125MG ...... 85 TREXIMET TRACLEER TAB 32MG ...... 85 see sumatriptan-naproxen sodium TRACLEER TAB 62.5MG ...... 85 tab 85-500 mg ...... 128 TRADJENTA TAB 5MG ...... 47 TREXIMET TAB 85-500MG ...... 128 tramadol-acetaminophen tab 37.5-325 triamcinolone acetonide aerosol soln mg ...... 32 0.147 mg/gm ...... 103 tramadol hcl cap er 24hr biphasic triamcinolone acetonide cream 0.025% release 100 mg ...... 29 ...... 103 tramadol hcl cap er 24hr biphasic triamcinolone acetonide cream 0.1% release 200 mg ...... 29 ...... 103 tramadol hcl cap er 24hr biphasic triamcinolone acetonide cream 0.5% release 300 mg ...... 30 ...... 103 tramadol hcl tab 100 mg ...... 30 triamcinolone acetonide dental paste tramadol hcl tab 50 mg ...... 30 0.1% ...... 136 tramadol hcl tab er 24hr 100 mg ...... 30 triamcinolone acetonide lotion 0.025% tramadol hcl tab er 24hr 200 mg ...... 30 ...... 103 tramadol hcl tab er 24hr 300 mg ...... 30 triamcinolone acetonide lotion 0.1% tramadol hcl tab er 24hr biphasic ...... 103 release 100 mg ...... 30 triamcinolone acetonide nasal aerosol tramadol hcl tab er 24hr biphasic suspension 55 mcg/act ...... 146 release 200 mg ...... 30 triamcinolone acetonide oint 0.025% tramadol hcl tab er 24hr biphasic ...... 103 release 300 mg ...... 30 triamcinolone acetonide oint 0.05% 103 trandolapril tab 1 mg ...... 60 triamcinolone acetonide oint 0.1% ..103 trandolapril tab 2 mg ...... 60 triamcinolone acetonide oint 0.5% ..103 trandolapril tab 4 mg ...... 60 triamterene & hydrochlorothiazide cap trandolapril-verapamil hcl tab er 1-240 37.5-25 mg ...... 106 mg ...... 67 triamterene & hydrochlorothiazide tab trandolapril-verapamil hcl tab er 2-180 37.5-25 mg ...... 106 mg ...... 67 triamterene & hydrochlorothiazide tab trandolapril-verapamil hcl tab er 2-240 75-50 mg ...... 106 mg ...... 67 trianex oin 0.05% ...... 103 trandolapril-verapamil hcl tab er 4-240 TRIBENZOR mg ...... 67 see olmesartan-amlodipine- TRAVATAN Z hydrochlorothiazide tab 20-5-12.5 see travoprost ophth soln 0.004% mg ...... 66 (benzalkonium free) (bak free) .151 see olmesartan-amlodipine- travoprost ophth soln 0.004% hydrochlorothiazide tab 40-10-12.5 (benzalkonium free) (bak free) ....151 mg ...... 66 TRECATOR TAB 250MG ...... 69 242 see olmesartan-amlodipine- tri-sprintec tab ...... 91 hydrochlorothiazide tab 40-10-25 TRI-VI-FLOR SUS 0.25/ML ...... 142 mg ...... 66 TRI-VI-FLOR SUS 0.5MG/ML ...... 142 see olmesartan-amlodipine- tri-vite dro pediatri ...... 143 hydrochlorothiazide tab 40-5-12.5 trivora-28 tab ...... 91 mg ...... 66 tri-vylibra tab ...... 91 see olmesartan-amlodipine- tri-vylibra tab lo ...... 91 hydrochlorothiazide tab 40-5-25 tropicamide ophth soln 0.5% ...... 148 mg ...... 66 tropicamide ophth soln 1% ...... 148 TRIBENZOR20- TAB 5-12.5MG ...... 67 trospium chloride cap er 24hr 60 mg TRIBENZOR40- TAB 10-12.5 ...... 67 ...... 163 TRIBENZOR40- TAB 10-25MG ...... 67 trospium chloride tab 20 mg ...... 163 TRIBENZOR40- TAB 5-12.5MG ...... 67 TRUE METRIX KIT AIR ...... 126 TRIBENZOR40- TAB 5-25MG ...... 67 TRUE METRIX KIT METER ...... 126 tricon cap ...... 120 TRUE METRIX TES GLUCOSE ...... 105 TRICOR TRULANCE TAB 3MG ...... 112 see fenofibrate tab 145 mg ...... 56 TRULICITY INJ 0.75/0.5 ...... 47 see fenofibrate tab 48 mg ...... 56 TRULICITY INJ 1.5/0.5 ...... 47 TRICOR TAB 145MG ...... 57 TRULICITY INJ 3/0.5 ...... 48 TRICOR TAB 48MG ...... 57 TRULICITY INJ 4.5/0.5 ...... 48 triderm cre 0.1% ...... 103 TRUSOPT triderm cre 0.5% ...... 103 see dorzolamide hcl ophth soln 2% tri-estaryll tab ...... 91 ...... 151 tri femynor tab ...... 91 TRUSOPT SOL 2% OP ...... 151 trifluridine ophth soln 1% ...... 149 TUDORZA PRES AER 400/ACT ...... 38 trigels-f cap forte ...... 120 tulana tab 0.35mg ...... 93 TRIGLIDE TAB 160MG ...... 57 TUMS CHEWY CHW BITES ...... 34 TRIJARDY XR TAB ...... 46 TUMS CHW 500MG ...... 34 tri-legest tab fe ...... 91 TUMS CHW DEL CHW 1177MG ...... 34 tri-linyah tab ...... 91 TUMS E-X CHW 750MG ...... 34 TRILIPIX TUMS EXTRA CHW 750MG ...... 34 see choline fenofibrate cap dr 135 TUMS SMOOTHI CHW 750MG ...... 34 mg (fenofibric acid equiv) ...... 56 TUMS ULTRA CHW 1000MG ...... 34 see choline fenofibrate cap dr 45 mg T-VITES TAB ...... 141 (fenofibric acid equiv) ...... 56 TWYNSTA TRILIPIX CAP 135MG ...... 57 see telmisartan-amlodipine tab 40-10 TRILIPIX CAP 45MG ...... 57 mg ...... 66 tri-lo-mili tab ...... 91 see telmisartan-amlodipine tab 40-5 tri-lo tab estaryll ...... 91 mg ...... 66 tri-lo- tab marzia ...... 91 see telmisartan-amlodipine tab 80-10 tri-lo- tab sprintec ...... 91 mg ...... 66 trimethoprim tab 100 mg ...... 35 see telmisartan-amlodipine tab 80-5 tri-mili tab ...... 91 mg ...... 66 TRINATAL RX TAB 1 ...... 143 TWYNSTA TAB 40-10MG ...... 67 trinate tab ...... 143 TWYNSTA TAB 40-5MG ...... 67 tri-nymyo tab ...... 91 TWYNSTA TAB 80-10MG ...... 67 tri-previfem tab ...... 91 TWYNSTA TAB 80-5MG ...... 67 243 tyblume chw 0.1-0.02 ...... 91 see potassium citrate tab er 5 meq tydemy tab ...... 91 (540 mg) ...... 115 TYLENOL CHLD SUS 160/5ML ...... 24 URO MAG CAP 140MG ...... 34 TYLENOL TAB 325MG ...... 24 urosex tab ...... 144 TYLENOL TAB 500MG ...... 24 UROXATRAL TYMLOS INJ ...... 108 see alfuzosin hcl tab er 24hr 10 mg TYR COOLER LIQ ...... 105 ...... 115 TYVASO REFIL SOL 0.6MG/ML ...... 85 URSO 250 TYVASO SOL 0.6MG/ML ...... 85 see ursodiol tab 250 mg ...... 112 TYVASO START SOL 0.6MG/ML ...... 85 URSO 250 TAB 250MG ...... 112 U ursodiol cap 300 mg ...... 112 UBRELVY TAB 100MG ...... 128 ursodiol tab 250 mg ...... 112 UBRELVY TAB 50MG ...... 128 ursodiol tab 500 mg ...... 112 UCERIS URSO FORTE see budesonide tab er 24hr 9 mg ..93 see ursodiol tab 500 mg ...... 112 UCERIS TAB 9MG ...... 94 URSO FORTE TAB 500MG ...... 112 UDENYCA INJ 6MG/.6ML ...... 118 V ULORIC valacyclovir hcl tab 1 gm ...... 76 see febuxostat tab 40 mg ...... 116 valacyclovir hcl tab 500 mg ...... 76 see febuxostat tab 80 mg ...... 116 VALCYTE ULORIC TAB 40MG ...... 116 see valganciclovir hcl tab 450 mg ULORIC TAB 80MG ...... 116 (base equivalent) ...... 75 ULTRACET valganciclovir hcl tab 450 mg (base see tramadol-acetaminophen tab equivalent) ...... 75 37.5-325 mg ...... 32 valsartan-hydrochlorothiazide tab 160- ULTRACET TAB 37.5-325 ...... 32 12.5 mg ...... 67 ULTRAM valsartan-hydrochlorothiazide tab 160- see tramadol hcl tab 50 mg ...... 30 25 mg ...... 67 ULTRA MAN TAB ...... 144 valsartan-hydrochlorothiazide tab 320- ultra-mega tab cr ...... 141 12.5 mg ...... 67 ULTRAM TAB 50MG ...... 30 valsartan-hydrochlorothiazide tab 320- ULTRAVATE LOT 0.05% ...... 103 25 mg ...... 67 UNIFIBER POW ...... 122 valsartan-hydrochlorothiazide tab 80- UPCAL D POW ...... 131 12.5 mg ...... 67 UPTRAVI TAB 1000MCG ...... 85 valsartan tab 160 mg ...... 61 UPTRAVI TAB 1200MCG ...... 85 valsartan tab 320 mg ...... 62 UPTRAVI TAB 1400MCG ...... 86 valsartan tab 40 mg ...... 61 UPTRAVI TAB 1600MCG ...... 86 valsartan tab 80 mg ...... 61 UPTRAVI TAB 200/800 ...... 85 VALTREX UPTRAVI TAB 200MCG ...... 85 see valacyclovir hcl tab 1 gm ...... 76 UPTRAVI TAB 400MCG ...... 85 see valacyclovir hcl tab 500 mg .....76 UPTRAVI TAB 600MCG ...... 85 VALTREX TAB 1GM ...... 76 UPTRAVI TAB 800MCG ...... 85 VALTREX TAB 500MG ...... 76 UROCIT-K 10 VANCOCIN see potassium citrate tab er 10 meq see vancomycin hcl cap 250 mg (1080 mg) ...... 115 (base equivalent) ...... 35 UROCIT-K 5 VANCOCIN CAP 250MG ...... 35 244 VANCOCIN HCL VENCLEXTA TAB 100MG ...... 70 see vancomycin hcl cap 125 mg VENCLEXTA TAB 10MG ...... 70 (base equivalent) ...... 35 VENCLEXTA TAB 50MG ...... 70 VANCOCIN HCL CAP 125MG ...... 35 VENCLEXTA TAB START PK ...... 70 vancomycin hcl cap 125 mg (base VENEXA FE TAB ...... 141 equivalent) ...... 35 VENTAVIS SOL 10MCG/ML ...... 85 vancomycin hcl cap 250 mg (base VENTAVIS SOL 20MCG/ML ...... 85 equivalent) ...... 35 VENTOLIN HFA AER ...... 42 vancomycin hcl for iv soln 10 gm (base verapamil hcl cap er 24hr 100 mg ....83 equivalent) ...... 35 verapamil hcl cap er 24hr 120 mg ....83 vancomycin hcl for iv soln 1 gm (base verapamil hcl cap er 24hr 180 mg ....83 equivalent) ...... 35 verapamil hcl cap er 24hr 200 mg ....83 vancomycin hcl for iv soln 500 mg verapamil hcl cap er 24hr 240 mg ....83 (base equivalent) ...... 35 verapamil hcl cap er 24hr 300 mg ....83 vancomycin hcl for iv soln 5 gm (base verapamil hcl cap er 24hr 360 mg ....83 equivalent) ...... 35 verapamil hcl tab 120 mg ...... 83 vancomycin hcl for iv soln 750 mg verapamil hcl tab 40 mg ...... 83 (base equivalent) ...... 35 verapamil hcl tab 80 mg ...... 83 vancomycin inj 750mg ...... 35 verapamil hcl tab er 120 mg ...... 83 VANCOMYCIN SOL 250/5ML ...... 35 verapamil hcl tab er 180 mg ...... 83 vandazole gel 0.75% ...... 165 verapamil hcl tab er 240 mg ...... 83 VANOS VERELAN see fluocinonide cream 0.1% ...... 101 see verapamil hcl cap er 24hr 120 VANOS CRE 0.1% ...... 103 mg ...... 83 VAQTA INJ 25/0.5ML ...... 164 see verapamil hcl cap er 24hr 180 VAQTA INJ 50UNT/ML ...... 164 mg ...... 83 VARUBI TAB 90MG ...... 52 see verapamil hcl cap er 24hr 240 VASCEPA CAP 0.5GM ...... 55 mg ...... 83 VASCEPA CAP 1GM ...... 55 VERELAN CAP 120MG SR ...... 83 VASERETIC VERELAN CAP 180MG SR ...... 83 see enalapril maleate & VERELAN CAP 240MG SR ...... 83 hydrochlorothiazide tab 10-25 mg VERELAN CAP 360MG SR ...... 83 ...... 64 VERELAN PM VASERETIC TAB 10-25MG ...... 67 see verapamil hcl cap er 24hr 100 VASOTEC mg ...... 83 see enalapril maleate tab 10 mg ....59 see verapamil hcl cap er 24hr 200 see enalapril maleate tab 2.5 mg ...59 mg ...... 83 see enalapril maleate tab 20 mg ....59 VERELAN PM CAP 100MG ER ...... 83 see enalapril maleate tab 5 mg .....59 VERELAN PM CAP 200MG ER ...... 83 VASOTEC TAB 10MG ...... 60 VERELAN PM CAP 300MG ER ...... 84 VASOTEC TAB 2.5MG ...... 60 VERQUVO TAB 10MG ...... 86 VASOTEC TAB 20MG ...... 60 VERQUVO TAB 2.5MG ...... 86 VASOTEC TAB 5MG ...... 60 VERQUVO TAB 5MG ...... 86 VCF VAGINAL AER CONTRACP ...... 164 VESICARE velivet pak ...... 91 see solifenacin succinate tab 10 mg VELPHORO CHW 500MG ...... 115 ...... 163 VEMLIDY TAB 25MG ...... 76 245 see solifenacin succinate tab 5 mg see hydroxyzine pamoate cap 25 mg ...... 163 ...... 37 VESICARE LS SUS 5MG/5ML ...... 163 see hydroxyzine pamoate cap 50 mg VESICARE TAB 10MG ...... 163 ...... 37 VESICARE TAB 5MG ...... 163 VISTARIL CAP 25MG ...... 37 vestura tab 3-0.02mg ...... 91 VISTARIL CAP 50MG ...... 37 VFEND VITABEX CAP ...... 141 see voriconazole for susp 40 mg/ml VITABEX PLUS CAP ...... 141 ...... 53 VITACRAVES CHW +OMEGA-3 ...... 143 see voriconazole tab 200 mg ...... 53 VITACRAVES CHW GUMMIES ...... 141 see voriconazole tab 50 mg ...... 53 VITACRAVES CHW IMMUNITY ...... 141 VFEND SUS 40MG/ML ...... 53 VITACRAVES CHW MENS ...... 141 VFEND TAB 200MG ...... 53 VITACRAVES CHW SOUR GUM ...... 141 VFEND TAB 50MG ...... 53 VITACRAVES CHW WOMENS ...... 141 VIBERZI TAB 100MG ...... 114 vitafol tab ...... 137 VIBERZI TAB 75MG ...... 114 VITAL-D RX TAB ...... 137 VIBRAMYCIN VITALETS CHW CHILD ...... 142 see doxycycline hyclate cap 100 mg vitamin d3 tab 50000unt ...... 166 ...... 158 vitamin e cap 450mg ...... 166 see doxycycline monohydrate for vitamin e liq ...... 104 susp 25 mg/5ml ...... 158 VITAMIN E TAB 100UNIT ...... 166 see morgidox cap 1x100mg ...... 158 VITAMIN E TAB 200UNIT ...... 166 see morgidox cap 2x100mg ...... 158 vitamin e tab 400unit ...... 166 VICTOZA INJ 18MG/3ML ...... 48 VITAROCA PLU TAB ...... 141 vienva tab 0.1-20 ...... 91 vitatrum chw ...... 141 VIGAMOX VITEYES CAP CLASSIC ...... 141 see moxifloxacin hcl ophth soln 0.5% VITEYES CLAS CAP ADV ...... 141 (base equiv)...... 149 viteyes clas cap advanced ...... 141 VIGAMOX DRO 0.5% ...... 149 VITEYES CLAS CAP MAC SUPP ...... 141 VIMOVO VITEYES CLAS CAP OMEGA-3 ...... 141 see naproxen-esomeprazole VITRON-C TAB 65-125 ...... 120 magnesium tab dr 375-20 mg ....23 VIVELLE-DOT see naproxen-esomeprazole see dotti dis 0.025mg ...... 110 magnesium tab dr 500-20 mg ....23 see dotti dis 0.0375mg ...... 111 VIMOVO TAB 375-20MG ...... 23 see dotti dis 0.05mg ...... 110 VIMOVO TAB 500-20MG ...... 23 see dotti dis 0.075mg ...... 111 VINATE II TAB ...... 143 see dotti dis 0.1mg ...... 110 VINATE ONE TAB ...... 143 VIVLODEX VIOKACE TAB 10440 ...... 106 see meloxicam cap 10 mg ...... 22 VIOKACE TAB 20880 ...... 106 see meloxicam cap 5 mg ...... 22 viorele tab ...... 92 VIVLODEX CAP 10MG ...... 23 VIRT-FEFA CAP PLUS ...... 120 VIVLODEX CAP 5MG ...... 23 virt-gard tab 2.2-25-1 ...... 120 VOGELXO GEL 1%(50MG) ...... 33 VISTA ADVAN CAP AREDS2 ...... 141 VOGELXO GEL PUMP 1% ...... 33 VISTA ADVAN CAP DRY EYE ...... 141 volnea tab ...... 92 VISTARIL VOLTAREN see diclofenac sodium gel 1% ...... 96 246 voriconazole for susp 40 mg/ml ...... 53 westab one tab 2.5-25-1 ...... 120 voriconazole tab 200 mg ...... 53 WEST-VITE TAB W/FA ...... 137 voriconazole tab 50 mg ...... 53 wheat dextrin oral powder ...... 122 VORTEX/MASK MIS CHILDS ...... 127 WHEAT DEXTRIN PACKET ...... 122 VORTEX/MASK MIS TODDLER ...... 127 white petrolatum-mineral oil ophth VUMERITY CAP 231MG ...... 157 ointment ...... 147 VUSION OIN ...... 98 WIDE-SEAL DPR KIT 60 ...... 125 vyfemla tab 0.4-35 ...... 92 WIDE-SEAL DPR KIT 65 ...... 125 vylibra tab 0.25-35 ...... 92 WIDE-SEAL DPR KIT 70 ...... 126 VYNDAMAX CAP 61MG ...... 86 WIDE-SEAL DPR KIT 75 ...... 126 VYNDAQEL CAP 20MG ...... 86 WIDE-SEAL DPR KIT 80 ...... 126 VYTORIN WIDE-SEAL DPR KIT 85 ...... 126 see ezetimibe-simvastatin tab 10-10 WIDE-SEAL DPR KIT 90 ...... 126 mg ...... 55 WIDE-SEAL DPR KIT 95 ...... 126 see ezetimibe-simvastatin tab 10-20 wixela inhub aer 100/50 ...... 42 mg ...... 55 wixela inhub aer 250/50 ...... 42 see ezetimibe-simvastatin tab 10-40 wixela inhub aer 500/50 ...... 42 mg ...... 55 WMNS MULTIVI CHW +COLLAGE ....141 see ezetimibe-simvastatin tab 10-80 womens daily chw gummies ...... 141 mg ...... 55 WOMENS MULT CHW GUMMIES ...... 141 VYTORIN TAB 10-10MG ...... 55 wymzya fe chw 0.4mg-35 ...... 92 VYTORIN TAB 10-20MG ...... 55 X VYTORIN TAB 10-40MG ...... 55 XADAGO TAB 100MG ...... 75 VYTORIN TAB 10-80MG ...... 55 XADAGO TAB 50MG ...... 75 VYZULTA SOL 0.024% ...... 151 XALATAN W see latanoprost ophth soln 0.005% WAL-BORN CHW VIT C ...... 141 ...... 151 wal-mucil cap plus ca ...... 122 XALATAN SOL 0.005% ...... 151 warfarin sodium tab 10 mg ...... 43 XARELTO STAR TAB 15/20MG ...... 43 warfarin sodium tab 1 mg ...... 42 XARELTO TAB 10MG ...... 43 warfarin sodium tab 2.5 mg ...... 42 XARELTO TAB 15MG ...... 43 warfarin sodium tab 2 mg ...... 42 XARELTO TAB 2.5MG ...... 43 warfarin sodium tab 3 mg ...... 42 XARELTO TAB 20MG ...... 43 warfarin sodium tab 4 mg ...... 42 XATMEP SOL 2.5MG/ML ...... 70 warfarin sodium tab 5 mg ...... 42 XELJANZ SOL 1MG/ML ...... 20 warfarin sodium tab 6 mg ...... 42 XELJANZ TAB 10MG ...... 20 warfarin sodium tab 7.5 mg ...... 42 XELJANZ TAB 5MG ...... 20 wee care sus 15/1.25 ...... 121 XELJANZ XR TAB 11MG ...... 20 WELCHOL XELJANZ XR TAB 22MG ...... 20 see colesevelam hcl packet for susp XELODA 3.75 gm ...... 55 see capecitabine tab 150 mg ...... 69 see colesevelam hcl tab 625 mg ....55 see capecitabine tab 500 mg ...... 69 WELCHOL PAK 3.75GM ...... 56 XELPROS EMU 0.005% ...... 151 WELCHOL TAB 625MG ...... 56 XEPI CRE 1% ...... 97 wera tab 0.5/35 ...... 92 XERESE CRE 5-1% ...... 99 westab max tab 2.5-25-2 ...... 105 XHANCE MIS 93MCG ...... 146 westab mini tab 2.2-25-1 ...... 120 XIFAXAN TAB 200MG ...... 35 247 XIFAXAN TAB 550MG ...... 35 see zumandimine tab 3-0.03mg ....92 XIGDUO XR TAB 10-1000 ...... 46 YAZ XIGDUO XR TAB 10-500MG ...... 46 see drospirenone-ethinyl estradiol XIGDUO XR TAB 2.5-1000 ...... 46 tab 3-0.02 mg ...... 88 XIGDUO XR TAB 5-1000MG ...... 46 see jasmiel tab 3-0.02mg ...... 89 XIGDUO XR TAB 5-500MG ...... 46 see loryna tab 3-0.02mg ...... 90 XODOL see lo-zumandimi tab 3-0.02mg ....89 see hydrocodone-acetaminophen tab see nikki tab 3-0.02mg ...... 90 5-300 mg ...... 31 see vestura tab 3-0.02mg ...... 91 XOFLUZA TAB 20MG ...... 76 YELETS TEEN TAB FORMULA ...... 141 XOFLUZA TAB 40MG ...... 76 YOUR LIFE CHW GUMMIES ...... 141 XOLAIR SOL 150MG ...... 38 YOUR LIFE CHW MULTIVIT ...... 141 XOPENEX YUPELRI SOL ...... 38 see levalbuterol hcl soln nebu 0.31 Z mg/3ml (base equiv) ...... 41 ZADITOR DRO 0.025%OP ...... 151 see levalbuterol hcl soln nebu 0.63 zafemy dis 150/35 ...... 92 mg/3ml (base equiv) ...... 41 zafirlukast tab 10 mg ...... 39 see levalbuterol hcl soln nebu 1.25 zafirlukast tab 20 mg ...... 39 mg/3ml (base equiv) ...... 41 ZANAFLEX XOPENEX CONCENTRATE see tizanidine hcl cap 2 mg (base see levalbuterol hcl soln nebu conc equivalent) ...... 145 1.25 mg/0.5ml (base equiv) ...... 41 see tizanidine hcl cap 4 mg (base XOPENEX CONC NEB 1.25/0.5 ...... 42 equivalent) ...... 145 XOPENEX HFA AER ...... 42 see tizanidine hcl cap 6 mg (base XOPENEX NEB 0.31MG ...... 42 equivalent) ...... 145 XOPENEX NEB 0.63MG ...... 42 see tizanidine hcl tab 4 mg (base XOPENEX NEB 1.25/3ML ...... 42 equivalent) ...... 145 XPOVIO PAK 100MG ...... 71 ZANAFLEX CAP 2MG ...... 145 XPOVIO PAK 60MG ...... 71 ZANAFLEX CAP 4MG ...... 145 XPOVIO PAK 80MG ...... 71 ZANAFLEX CAP 6MG ...... 145 XTAMPZA ER CAP 13.5MG ...... 30 ZANAFLEX TAB 4MG ...... 145 XTAMPZA ER CAP 18MG ...... 30 zarah tab 3-0.03mg ...... 92 XTAMPZA ER CAP 27MG ...... 30 ZARXIO INJ 300/0.5 ...... 118 XTAMPZA ER CAP 36MG ...... 30 ZARXIO INJ 480/0.8 ...... 118 XTAMPZA ER CAP 9MG ...... 30 ZEGERID XTANDI CAP 40MG ...... 70 see omeprazole-sodium bicarbonate xulane dis 150-35 ...... 92 cap 20-1100 mg ...... 162 XULTOPHY INJ 100/3.6 ...... 46 see omeprazole-sodium bicarbonate XYREM SOL 500MG/ML ...... 154 cap 40-1100 mg ...... 162 XYWAV SOL 0.5GM/ML ...... 154 see omeprazole-sodium bicarbonate Y powd pack for susp 20-1680 mg YASMIN 28 ...... 162 see drospirenone-ethinyl estradiol see omeprazole-sodium bicarbonate tab 3-0.03 mg ...... 88 powd pack for susp 40-1680 mg see ocella tab 3-0.03mg ...... 91 ...... 162 see syeda tab 3-0.03mg ...... 91 ZEGERID CAP 20-1100 ...... 162 see zarah tab 3-0.03mg ...... 92 ZEGERID CAP 40-1100 ...... 162 248 ZEGERID POW 20-1680 ...... 162 see bisoprolol & hydrochlorothiazide ZEGERID POW 40-1680 ...... 162 tab 5-6.25 mg ...... 64 ZELAPAR TAB 1.25MG ...... 75 ZIAC TAB 10/6.25 ...... 67 ZELNORM TAB 6MG ...... 114 ZIAC TAB 2.5/6.25 ...... 67 ZEMBRACE SYM INJ 3/0.5ML ...... 129 ZIAC TAB 5-6.25MG ...... 67 ZENPEP CAP 10000UNT ...... 106 ZIEXTENZO INJ 6/0.6ML ...... 118 ZENPEP CAP 15000UNT ...... 106 zileuton tab er 12hr 600 mg ...... 39 ZENPEP CAP 20000UNT ...... 106 ZINTREXYL-C TAB ...... 141 ZENPEP CAP 25000 ...... 106 ZIOPTAN DRO 0.0015% ...... 151 ZENPEP CAP 3000UNIT ...... 106 ZIPSOR CAP 25MG ...... 23 ZENPEP CAP 40000 ...... 106 ZITHROMAX ZENPEP CAP 5000UNIT ...... 106 see azithromycin for susp 100 ZEPOSIA 7DAY CAP STR PACK ...... 157 mg/5ml ...... 124 ZEPOSIA CAP .92MG ...... 157 see azithromycin for susp 200 ZEPOSIA CAP STR KIT ...... 157 mg/5ml ...... 124 ZERVIATE DRO 0.24% ...... 151 see azithromycin tab 250 mg ...... 124 ZESTORETIC see azithromycin tab 500 mg ...... 124 see lisinopril & hydrochlorothiazide ZITHROMAX POW 1GM PAK ...... 124 tab 10-12.5 mg ...... 65 ZITHROMAX SUS 100/5ML ...... 124 see lisinopril & hydrochlorothiazide ZITHROMAX SUS 200/5ML ...... 124 tab 20-12.5 mg ...... 65 ZITHROMAX TAB 250MG ...... 124 see lisinopril & hydrochlorothiazide ZITHROMAX TAB 500MG ...... 124 tab 20-25 mg ...... 65 ZITHROMAX TAB TRI-PAK ...... 125 ZESTORETIC TAB 10-12.5 ...... 67 ZITHROMAX TAB Z-PAK ...... 125 ZESTORETIC TAB 20-12.5 ...... 67 ZOCOR ZESTORETIC TAB 20-25MG ...... 67 see simvastatin tab 10 mg ...... 58 ZESTRIL see simvastatin tab 20 mg ...... 58 see lisinopril tab 10 mg ...... 59 see simvastatin tab 40 mg ...... 58 see lisinopril tab 2.5 mg ...... 59 see simvastatin tab 80 mg ...... 58 see lisinopril tab 30 mg ...... 59 ZOCOR TAB 10MG ...... 58 see lisinopril tab 40 mg ...... 59 ZOCOR TAB 20MG ...... 58 see lisinopril tab 5 mg ...... 59 ZOCOR TAB 40MG ...... 58 ZESTRIL TAB 10MG ...... 60 ZOCOR TAB 80MG ...... 58 ZESTRIL TAB 2.5MG ...... 60 ZOFRAN ZESTRIL TAB 20MG ...... 60 see ondansetron hcl tab 4 mg ...... 51 ZESTRIL TAB 30MG ...... 60 ZOFRAN TAB 4MG ...... 51 ZESTRIL TAB 40MG ...... 60 ZOFRAN TAB 8MG ...... 52 ZESTRIL TAB 5MG ...... 60 ZOHYDRO ER ZETIA see hydrocodone bitartrate cap er see ezetimibe tab 10 mg ...... 58 12hr 10 mg ...... 26 ZETIA TAB 10MG ...... 58 see hydrocodone bitartrate cap er ZETONNA AER 37MCG ...... 146 12hr 15 mg ...... 26 ZIAC see hydrocodone bitartrate cap er see bisoprolol & hydrochlorothiazide 12hr 20 mg ...... 26 tab 10-6.25 mg ...... 64 see hydrocodone bitartrate cap er see bisoprolol & hydrochlorothiazide 12hr 30 mg ...... 26 tab 2.5-6.25 mg ...... 64 249 see hydrocodone bitartrate cap er ZOMIG ZMT TAB 5MG ODT ...... 130 12hr 40 mg ...... 26 ZONTIVITY TAB 2.08MG ...... 117 see hydrocodone bitartrate cap er ZOO FRIENDS CHW COMPLETE ...... 142 12hr 50 mg ...... 26 ZORBTIVE INJ 8.8MG ...... 109 ZOHYDRO ER CAP 10MG ...... 30 ZORVOLEX CAP 18MG ...... 23 ZOHYDRO ER CAP 15MG ...... 30 ZORVOLEX CAP 35MG ...... 23 ZOHYDRO ER CAP 20MG ...... 30 zovia 1/35e tab ...... 92 ZOHYDRO ER CAP 30MG ...... 30 zovia 1/35 tab ...... 92 ZOHYDRO ER CAP 40MG ...... 30 ZOVIRAX ZOHYDRO ER CAP 50MG ...... 30 see acyclovir cream 5% ...... 99 ZOLADEX IMP 10.8MG ...... 71 see acyclovir oint 5% ...... 99 ZOLADEX IMP 3.6MG ...... 70 see acyclovir susp 200 mg/5ml .....76 ZOLINZA CAP 100MG ...... 71 ZOVIRAX CRE 5% ...... 99 zolmitriptan nasal spray 2.5 mg/spray ZOVIRAX OIN 5% ...... 99 unit ...... 129 ZOVIRAX SUS 200/5ML ...... 76 zolmitriptan nasal spray 5 mg/spray zumandimine tab 3-0.03mg ...... 92 unit ...... 129 ZUPLENZ MIS 4MG ...... 52 zolmitriptan orally disintegrating tab ZUPLENZ MIS 8MG ...... 52 2.5 mg ...... 129 ZYFLO TAB 600MG ...... 39 zolmitriptan orally disintegrating tab 5 ZYLOPRIM mg ...... 129 see allopurinol tab 100 mg ...... 116 zolmitriptan tab 2.5 mg ...... 129 see allopurinol tab 300 mg ...... 116 zolmitriptan tab 5 mg ...... 129 ZYLOPRIM TAB 100MG ...... 116 ZOMACTON INJ 10MG ...... 109 ZYLOPRIM TAB 300MG ...... 116 ZOMACTON INJ 5MG ...... 109 ZYMAXID ZOMIG see gatifloxacin ophth soln 0.5% 9.14 see zolmitriptan tab 2.5 mg ...... 129 ZYMAXID SOL 0.5% ...... 149 see zolmitriptan tab 5 mg ...... 129 ZYPITAMAG TAB 1MG ...... 58 ZOMIG SPR 2.5MG ...... 129 ZYPITAMAG TAB 2MG ...... 58 ZOMIG SPR 5MG ...... 129 ZYPITAMAG TAB 4MG ...... 58 ZOMIG TAB 2.5MG ...... 129 ZYTIGA ZOMIG TAB 5MG ...... 130 see abiraterone acetate tab 250 mg ZOMIG ZMT ...... 70 see zolmitriptan orally disintegrating ZYVOX tab 2.5 mg ...... 129 see linezolid for susp 100 mg/5ml .36 see zolmitriptan orally disintegrating see linezolid tab 600 mg ...... 36 tab 5 mg ...... 129 ZYVOX SUS 100MG/5M ...... 36 ZOMIG ZMT TAB 2.5 MG ...... 130 ZYVOX TAB 600MG ...... 36

250