2020 Welldyne Formulary.Pdf

Home , Demecarium bromide

LEGEND TIER DESCRIPTION

1 Preferred Generics

2 Non-Preferred Generics

3 Preferred Brands

4 Non-Preferred Brands

5 Preferred Specialty

6 Non-Preferred Specialty

TYPE DESCRIPTION

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

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

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

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

LA Limited Access This prescription drug is limited to certain pharmacies.

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

PAGE 1 LAST UPDATED 01/2020 LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADHD/ANTI-NARCOLEPSY /ANTI-OBESITY/ANOREXIANT AGENTS

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

ADDERALL 4 AL1 Up to 25 yrs old

ADDERALL XR 4 AL1 Up to 25 yrs old

QL 30 / 30 day(s) ADHANSIA XR 4 AL1 Up to 25 yrs old

QL 30 / 30 Days ADIPEX-P 4 PA

QL 300 / 30 day(s) ADZENYS ER 4 AL1 Up to 25 yrs old

QL 30 / 30 Days ADZENYS XR-ODT 4 AL1 Up to 25 yrs old

QL 300 / 30 day(s) AMPHETAMINE ER 4 AL1 Up to 25 yrs old

QL 180 / 30 day(s) amphetamine sulfate 10 mg tab 1 AL1 Up to 25 yrs old

QL 90 / 30 day(s) amphetamine sulfate 5 mg tab 1 AL1 Up to 25 yrs old

amphetamine-dextroamphet er 1 AL1 Up to 25 yrs old

amphetamine-dextroamphetamine 1 AL1 Up to 25 yrs old

QL 30 / 30 Days APTENSIO XR 4 AL1 Up to 25 yrs old

QL 30 / 30 Days armodafinil (150 mg tab, 200 mg tab, 250 mg tab) 1 PA

QL 60 / 30 Days armodafinil 50 mg tab 1 PA

QL 60 / 30 Days atomoxetine hcl (18 mg cap, 25 mg cap) 1 AL1 Up to 25 yrs old

PAGE 2 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

atomoxetine hcl (40 mg cap, 60 mg cap, 80 mg cap, 100 mg QL 30 / 30 Days 1 cap) AL1 Up to 25 yrs old

QL 90 / 30 Days atomoxetine hcl 10 mg cap 1 AL1 Up to 25 yrs old

QL 60 / 30 Days BELVIQ 4 PA

QL 30 / 30 Days BELVIQ XR 4 PA

QL 90 / 30 Days BENZPHETAMINE HCL 25 MG TAB 3 PA

QL 90 / 30 Days benzphetamine hcl 50 mg tab 1 PA

BONTRIL PDM 4

CAFCIT 4

CAFFEINE 4

CAFFEINE ANHYDROUS 4

caffeine citrate 1

CAFFEINE CITRATED 4

CAFFEINE-SODIUM BENZOATE 3

clonidine hcl er 1 QL 120 / 30 Days

CONCERTA (18 MG TAB ER, 27 MG TAB ER, 54 MG TAB QL 30 / 30 Days 4 ER) AL1 Up to 25 yrs old

QL 60 / 30 Days CONCERTA 36 MG TAB ER 4 AL1 Up to 25 yrs old

QL 120 / 30 Days CONTRAVE 4 PA

COTEMPLA XR-ODT (17.3 MG TAB ER DISP, 25.9 MG TAB QL 60 / 30 Days 4 ER DISP) AL1 Up to 25 yrs old

QL 30 / 30 Days COTEMPLA XR-ODT 8.6 MG TAB ER DISP 4 AL1 Up to 25 yrs old

PAGE 3 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Box / 30 Days DAYTRANA 3 AL1 Up to 25 yrs old

PA DESOXYN 4 AL1 Up to 25 yrs old

DEXEDRINE (5 MG CAP ER 24H, 10 MG CAP ER 24H, 15 MG AL1 Up to 25 yrs old CAP ER 24H) 4

QL 60 / 30 Days dexedrine (5 mg tab, 10 mg tab) 1 AL1 Up to 25 yrs old

QL 90 / 30 Days dexmethylphenidate hcl (2.5 mg tab, 5 mg tab) 1 AL1 Up to 25 yrs old

QL 60 / 30 Days dexmethylphenidate hcl 10 mg tab 1 AL1 Up to 25 yrs old

QL 30 / 30 Days dexmethylphenidate hcl er 1 AL1 Up to 25 yrs old

QL 60 / 30 Days dextroamphetamine sulfate (5 mg tab, 10 mg tab) 1 AL1 Up to 25 yrs old

QL 1800 Milliliters / 30 dextroamphetamine sulfate 5 mg/5ml solution 1 Days AL1 Up to 25 yrs old

dextroamphetamine sulfate er 1 AL1 Up to 25 yrs old

QL 90 / 30 Days diethylpropion hcl 25 mg tab 1 PA

DIETHYLPROPION HCL 25 MG TAB 4

QL 30 / 30 Days DIETHYLPROPION HCL ER 2 PA

diethylpropion hcl er 1 PA

QL 240 Milliliters / 30 Days DYANAVEL XR 4 AL1 Up to 25 yrs old

QL 180 / 30 day(s) EVEKEO 10 MG TAB 3 AL1 Up to 25 yrs old

PAGE 4 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 90 / 30 day(s) EVEKEO 5 MG TAB 3 AL1 Up to 25 yrs old

EVEKEO ODT (ODT 5 MG TAB DISP, ODT 10 MG TAB DISP, QL 30 / 30 day(s) 4 ODT 15 MG TAB DISP) AL1 Up to 25 yrs old

QL 90 / 30 day(s) EVEKEO ODT 20 MG TAB DISP 4 AL1 Up to 25 yrs old

QL 90 / 30 Days FOCALIN (2.5 MG TAB, 5 MG TAB) 4 AL1 Up to 25 yrs old

QL 60 / 30 Days FOCALIN 10 MG TAB 4 AL1 Up to 25 yrs old

QL 30 / 30 Days FOCALIN XR 4 AL1 Up to 25 yrs old

guanfacine hcl er 1 QL 30 / 30 Days

INTUNIV 4 QL 30 / 30 Days

KAPVAY 4 QL 120 / 30 Days

QL 90 / 30 Days LOMAIRA 4 PA

METADATE CD 4

QL 90 / 30 Days metadate er 1 AL1 Up to 25 yrs old

PA methamphetamine hcl 1 AL1 Up to 25 yrs old

METHYLIN (2.5 MG CHEW TAB, 5 MG CHEW TAB, 10 MG CHEW TAB) 4

QL 900 Milliliters / 30 Days METHYLIN 10 MG/5ML SOLUTION 4 AL1 Up to 25 yrs old

QL 450 Milliliters / 30 Days METHYLIN 5 MG/5ML SOLUTION 4 AL1 Up to 25 yrs old

methylphenidate hcl (2.5 mg chew tab, 5 mg chew tab, 5 mg QL 90 / 30 Days 1 tab, 10 mg tab, 20 mg tab) AL1 Up to 25 yrs old

PAGE 5 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 180 / 30 Days methylphenidate hcl 10 mg chew tab 1 AL1 Up to 25 yrs old

QL 900 Milliliters / 30 Days methylphenidate hcl 10 mg/5ml solution 1 AL1 Up to 25 yrs old

QL 450 Milliliters / 30 Days methylphenidate hcl 5 mg/5ml solution 1 AL1 Up to 25 yrs old

QL 30 / 30 Days methylphenidate hcl er (cd) 1 AL1 Up to 25 yrs old

QL 90 / 30 Days methylphenidate hcl er (er 10 mg tab er, er 20 mg tab er) 1 AL1 Up to 25 yrs old

METHYLPHENIDATE HCL ER (ER 18 MG TAB ER 24H, ER QL 30 / 30 Days 3 27 MG TAB ER 24H, ER 54 MG TAB ER 24H) AL1 Up to 25 yrs old

methylphenidate hcl er (er 18 mg tab er, er 27 mg tab er, er 27 QL 30 / 30 Days 1 mg tab er 24h, er 54 mg tab er, er 54 mg tab er 24h) AL1 Up to 25 yrs old

QL 60 / 30 Days methylphenidate hcl er (er 36 mg tab er, er 36 mg tab er 24h) 1 AL1 Up to 25 yrs old

QL 30 / 30 Days methylphenidate hcl er (la) 1 AL1 Up to 25 yrs old

METHYLPHENIDATE HCL ER 18 MG TAB ER 4

QL 60 / 30 Days METHYLPHENIDATE HCL ER 36 MG TAB ER 24H 3 AL1 Up to 25 yrs old

QL 30 / 30 day(s) METHYLPHENIDATE HCL ER 72 MG TAB ER 3 AL1 Up to 25 yrs old

QL 60 / 30 Days modafinil 1 PA

QL 30 / 30 Days MYDAYIS 4 AL1 Up to 25 yrs old

NUVIGIL (150 MG TAB, 200 MG TAB, 250 MG TAB) 4 QL 30 / 30 Days

NUVIGIL 50 MG TAB 4 QL 60 / 30 Days

PAGE 6 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 90 / 30 Days phendimetrazine tartrate 1 PA

QL 30 / 30 Days PHENDIMETRAZINE TARTRATE ER 4 PA

QL 30 / 30 Days phentermine hcl (15 mg cap, 30 mg cap, 37.5 mg cap) 1 PA

phentermine hcl 37.5 mg tab 1 QL 30 / 30 Days

QL 1800 Milliliters / 30 PROCENTRA 4 Days AL1 Up to 25 yrs old

PROVIGIL 4 QL 60 / 30 Days

QSYMIA (3.75-23 MG CAP ER 24H, 11.25-69 MG CAP ER QL 14 / 365 Days 4 24H) PA

QL 30 / 30 Days QSYMIA (7.5-46 MG CAP ER 24H, 15-92 MG CAP ER 24H) 4 PA

QL 30 / 30 Days QUILLICHEW ER (ER 20 MG, ER 40 MG) 3 AL1 Up to 25 yrs old

QL 60 / 30 Days QUILLICHEW ER 30 MG CHER 3 AL1 Up to 25 yrs old

QL 360 Milliliters / 30 Days QUILLIVANT XR 3 AL1 Up to 25 yrs old

QL 90 / 30 Days REGIMEX 4 PA

QL 30 / 30 day(s) RELEXXII 3 AL1 Up to 25 yrs old

QL 90 / 30 Days RITALIN 4 AL1 Up to 25 yrs old

RITALIN LA (10 MG CAP ER 24H, 20 MG CAP ER 24H, 30 MG QL 30 / 30 Days 4 CAP ER 24H, 40 MG CAP ER 24H) AL1 Up to 25 yrs old

PAGE 7 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 Days RITALIN LA 60 MG CAP ER 24H 3 AL1 Up to 25 yrs old

QL 1 Box / 30 Days SAXENDA 4 PA

QL 60 / 30 Days STRATTERA (18 MG CAP, 25 MG CAP) 4 AL1 Up to 25 yrs old

STRATTERA (40 MG CAP, 60 MG CAP, 80 MG CAP, 100 MG QL 30 / 30 Days 4 CAP) AL1 Up to 25 yrs old

QL 90 / 30 Days STRATTERA 10 MG CAP 4 AL1 Up to 25 yrs old

QL 30 / 30 day(s) SUNOSI (75 MG TAB, 150 MG TAB) 4 PA

SUPRENZA 4 PA

QL 30 / 30 Days VYVANSE 3 AL1 Up to 25 yrs old

QL 60 / 30 day(s)

WAKIX 17.8 MG TAB 6 AL1 At least 18 yrs old

LA Limited Access

QL 60 / 30 day(s)

WAKIX 4.45 MG TAB 4 AL1 At least 18 yrs old

LA Limited Access

QL 90 / 30 Days XENICAL 4 PA

ZENZEDI (2.5 MG TAB, 7.5 MG TAB, 15 MG TAB, 20 MG TAB, QL 60 / 30 Days 4 30 MG TAB) AL1 Up to 25 yrs old

QL 60 / 30 Days zenzedi (5 mg tab, 10 mg tab) 1 AL1 Up to 25 yrs old

PAGE 8 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANALGESIC/ANTI-INFLAMMATORY/MIGRAINE/GOUT AGENTS/ANESTHETICS

ANALGESICS - ANTI-INFLAMMATORY

PA ACTEMRA (80 MG/4ML SOLUTION, 200 MG/10ML LA Limited Access SOLUTION, 400 MG/20ML SOLUTION) 5 S

QL 4 Syringes / 28 Days

PA ACTEMRA 162 MG/0.9ML SOLN PRSYR 5 LA Limited Access

QL 4 / 28 day(s)

PA ACTEMRA ACTPEN 5 LA Limited Access

ANAPROX DS 4

ANODYNE ILE 4

ARAVA 4

ARCALYST 5 LA Limited Access

ARTHROTEC 4 QL 120 / 30 Days

CELEBREX (50 MG CAP, 100 MG CAP, 200 MG CAP) 4 QL 60 / 30 Days

CELEBREX 400 MG CAP 4 QL 30 / 30 Days

celecoxib (50 mg cap, 100 mg cap, 200 mg cap) 1 QL 60 / 30 Days

QL 30 / 30 Days celecoxib 400 mg cap 1 ST

DAYPRO 4

diclofenac potassium 1

diclofenac sodium (25 mg tab dr, 50 mg tab dr, 75 mg tab dr) 1

diclofenac sodium er 1

diclofenac-misoprostol 1 QL 120 / 30 Days

PAGE 9 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DYLOJECT 4

EC-NAPROSYN 4

EC-NAPROXEN 4

QL 4 Syringes / 28 Days ENBREL (25 MG/0.5ML SOLN PRSYR, 50 MG/ML SOLN PA PRSYR) 5 S

PA ENBREL 25 MG RECON SOLN 5 S

QL 4 Syringes / 28 Days

ENBREL MINI 5 PA

QL 4 Auto-Injectors / 28 Days ENBREL SURECLICK 5 PA

etodolac 1

etodolac er 1

FELDENE 4

FENOPROFEN CALCIUM POWDER 4

FENOPROFEN CALCIUM (200 MG CAP, 400 MG CAP) 4 ST

fenoprofen calcium 600 mg tab 1

FENORTHO 4 ST

FLURBIPROFEN POWDER 4

flurbiprofen (50 mg tab, 100 mg tab) 1

PA HUMIRA 5 S

PA HUMIRA PEDIATRIC CROHNS START 5 S

PA HUMIRA PEN 5 S

PAGE 10 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA HUMIRA PEN-CD/UC/HS STARTER 40 MG/0.8ML PEN KIT 5 S

QL 1 Kit / 28 Days

HUMIRA PEN-CD/UC/HS STARTER 80 MG/0.8ML PEN KIT 5 PA

HUMIRA PEN-PS/UV/ADOL HS START 40 MG/0.8ML PEN PA 5 KIT S

QL 1 Kit / 28 Days HUMIRA PEN-PS/UV/ADOL HS START 80 MG/0.8ML & PA 40MG/0.4ML PEN KIT 5 S

ibu 1

IBUPROFEN POWDER 4 ibuprofen (100 mg/5ml suspension, 400 mg tab, 600 mg tab, 800 mg tab) 1

ibuprofen lysine 1

LA Limited Access ILARIS 150 MG RECON SOLN 5 S

ILARIS 150 MG/ML SOLUTION 5 LA Limited Access

INDOCIN (25 MG/5ML SUSPENSION, 50 MG SUPPOS) 4

INDOMETHACIN POWDER 4

indomethacin (25 mg cap, 50 mg cap) 1

indomethacin er 1 ST

indomethacin sodium 1

KETOPROFEN (50 MG CAP, 75 MG CAP) 1

KETOPROFEN 25 MG CAP 4

KETOPROFEN ER 3 ST

ketorolac tromethamine (15 mg/ml solution, 30 mg/ml solution, 60 mg/2ml solution) 1 KETOROLAC TROMETHAMINE (60 MG/20ML SOLN PRSYR, 60 MG/2ML SOLUTION) 3

PAGE 11 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ketorolac tromethamine 10 mg tab 1 QL 20 / 14 Days

KETOROLAC-ROPIV-KETAMINE 4

QL 2 Auto-Injectors / 28 Days KEVZARA (150 MG/1.14ML SOLN A-INJ, 200 MG/1.14ML PA SOLN A-INJ) 6 LA Limited Access

QL 2 Syringes / 28 Days

KEVZARA (150 MG/1.14ML SOLN PRSYR, 200 MG/1.14ML PA 6 SOLN PRSYR) LA Limited Access

KINERET 6 LA Limited Access

leflunomide (10 mg tab, 20 mg tab) 1

LODINE 4

MECLOFENAMATE SODIUM POWDER 4

MECLOFENAMATE SODIUM (50 MG CAP, 100 MG CAP) 3 ST

MEFENAMIC ACID POWDER 4

mefenamic acid 250 mg cap 1

meloxicam (7.5 mg tab, 15 mg tab) 1

MELOXICAM 7.5 MG/5ML SUSPENSION 3

METHOTREXATE (ANTI-RHEUMATIC) 4

MOBIC (7.5 MG TAB, 15 MG TAB) 4

MOBIC 7.5 MG/5ML SUSPENSION 3

nabumetone (500 mg tab, 750 mg tab) 1

NALFON 400 MG CAP 4 ST

NALFON 600 MG TAB 4 NAPROSYN (125 MG/5ML SUSPENSION, 250 MG TAB, 375 MG TAB, 500 MG TAB) 4

NAPROXEN POWDER 4

PAGE 12 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS naproxen (125 mg/5ml suspension, 250 mg tab, 375 mg tab, 500 mg tab) 1

naproxen dr 1

naproxen kit 1

NAPROXEN SODIUM POWDER 4

naproxen sodium (275 mg tab, 550 mg tab) 1

QL 30 / 30 day(s)

OLUMIANT 1 MG TAB 6 PA

QL 30 / 30 Days

OLUMIANT 2 MG TAB 6 PA

QL 4 Syringes / 28 Days ORENCIA (50 MG/0.4ML SOLN PRSYR, 87.5 MG/0.7ML PA SOLN PRSYR, 125 MG/ML SOLN PRSYR) 6 S

QL 4 Vials / 28 Days

ORENCIA 250 MG RECON SOLN 6 PA

QL 4 Auto-Injectors / 28 Days ORENCIA CLICKJECT 6 PA

QL 1 / Lifetime

OTEZLA 10 & 20 & 30 MG TAB THPK 5 PA

QL 60 / 30 Days

OTEZLA 30 MG TAB 5 PA

OTREXUP (10 MG/0.4ML SOLN A-INJ, 12.5 MG/0.4ML SOLN QL 4 Auto-Injectors / 28 A-INJ, 15 MG/0.4ML SOLN A-INJ, 17.5 MG/0.4ML SOLN A- Days INJ, 20 MG/0.4ML SOLN A-INJ, 22.5 MG/0.4ML SOLN A-INJ, 5 PA 25 MG/0.4ML SOLN A-INJ) S

PAGE 13 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA OTREXUP 7.5 MG/0.4ML SOLN A-INJ 5 S

oxaprozin 1 ST

PHENYLBUTAZONE 4

PIROXICAM POWDER 4

piroxicam (10 mg cap, 20 mg cap) 1

PONSTEL 4

profeno 1 RASUVO (7.5 MG/0.15ML SOLN A-INJ, 10 MG/0.2ML SOLN QL 4 Auto-Injectors / 28 A-INJ, 12.5 MG/0.25ML SOLN A-INJ, 15 MG/0.3ML SOLN A- Days INJ, 17.5 MG/0.35ML SOLN A-INJ, 20 MG/0.4ML SOLN A-INJ, 5 PA 22.5 MG/0.45ML SOLN A-INJ, 25 MG/0.5ML SOLN A-INJ, 30 MG/0.6ML SOLN A-INJ) S

RASUVO 27.5 MG/0.55ML SOLN A-INJ 5 S

QL 60 / 30 day(s) RELAFEN DS 4 ST

RHEUMATREX 4

RIDAURA 3

QL 30 / 30 day(s)

PA RINVOQ 6 AL1 At least 18 yrs old

PA SIMPONI 6 S

PA SIMPONI ARIA 6 S

SPRIX 4

SULINDAC POWDER 4

sulindac (150 mg tab, 200 mg tab) 1

TOLMETIN SODIUM 3 ST

VOLTAREN-XR 4

PAGE 14 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 Days

XELJANZ 5 PA

QL 30 / 30 Days

XELJANZ XR 5 PA

ANALGESICS - NONNARCOTIC

ACETYL SALICYLIC ACID 4

ASPIRIN 4

butalbital-acetaminophen 50-325 mg tab 1 QL 180 / 30 Days

butalbital-apap 1 QL 180 / 30 Days

butalbital-apap-caffeine 1 QL 180 / 30 Days

butalbital-asa-caffeine 1 QL 180 / 30 Days

butalbital-aspirin-caffeine 50-325-40 mg cap 1 QL 180 / 30 Days

BUTALBITAL-ASPIRIN-CAFFEINE 50-325-40 MG TAB 2 QL 180 / 30 Days

capacet 1 QL 180 / 30 Days

CHOLINE & MAG TRISALICYLATE 4

choline-mag trisalicylate 1

clonidine hcl (analgesia) 5 S

DIFLUNISAL POWDER 4

diflunisal 500 mg tab 1

DISALCID 4

DURACLON 100 MCG/ML SOLUTION 6 S

DURACLON 500 MCG/ML SOLUTION 5 S

DURAXIN 3

esgic 50-325-40 mg cap 1 QL 180 / 30 Days

ESGIC 50-325-40 MG TAB 4 QL 180 / 30 Days

FIORICET 4 QL 180 / 30 Days

PAGE 15 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FIORINAL 4 QL 180 / 30 Days

LEVACET 4

margesic 1 QL 180 / 30 Days

marten-tab 1 QL 180 / 30 Days

OFIRMEV 3

phrenilin forte 1 QL 180 / 30 Days

PRIALT 5 S

salsalate (500 mg tab, 750 mg tab) 1

SODIUM SALICYLATE 4

TENCON 4 QL 180 / 30 Days

VANATOL LQ 4 QL 2700 Milliliters / 30 Days

VANATOL S 4 QL 2700 Milliliters / 30 Days

zebutal 1 QL 180 / 30 Days

ANALGESICS - OPIOID

acetaminophen-codeine #2 1

acetaminophen-codeine #3 1

acetaminophen-codeine #4 1 acetaminophen-codeine (120-12 mg/5ml solution, 300-15 mg tab, 300-30 mg tab, 300-60 mg tab) 1 ACTIQ (200 MCG LOZ HANDLE, 400 MCG LOZ HANDLE, 600 MCG LOZ HANDLE, 1200 MCG LOZ HANDLE, 1600 MCG 4 QL 120 / 30 Days LOZ HANDLE)

QL 120 / 30 Days ACTIQ 800 MCG LOZ HANDLE 4 PA

alfentanil hcl 1

ALFENTANIL HCL 4

APADAZ 4 QL 168 / 14 day(s)

APAP-CAFF-DIHYDROCODEINE 320.5-30-16 MG CAP 4

APAP-CAFF-DIHYDROCODEINE 325-30-16 MG TAB 4 QL 300 / 30 day(s)

PAGE 16 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ARYMO ER 4 QL 90 / 30 Days

ascomp-codeine 1 QL 180 / 30 Days

ASPIRIN-CAFF-DIHYDROCODEINE 3

AVINZA 30 MG CAP ER 24H 4

QL 60 / 30 Days BELBUCA 4 PA

BENZHYDROCODONE-ACETAMINOPHEN 4 QL 168 / 14 day(s)

BUNAVAIL (2.1-0.3 MG FILM, 4.2-0.7 MG FILM) 4 QL 90 / 30 Days

BUNAVAIL 6.3-1 MG FILM 4 QL 60 / 30 Days

BUPRENEX 4 buprenorphine (5 mcg/hr patch wk, 10 mcg/hr patch wk, 15 QL 1 Box / 30 Days mcg/hr patch wk, 20 mcg/hr patch wk) 1 BUPRENORPHINE (5 MCG/HR PATCH WK, 7.5 MCG/HR PATCH WK, 10 MCG/HR PATCH WK, 15 MCG/HR PATCH 4 QL 1 Box / 28 Days WK, 20 MCG/HR PATCH WK)

buprenorphine hcl (2 mg sl tab, 8 mg sl tab) 1 QL 90 / 30 Days

buprenorphine hcl 0.3 mg/ml solution 1 buprenorphine hcl-naloxone hcl (-naloxone 2-0.5 mg film, - naloxone 4-1 mg film, -naloxone 8-2 mg film, -naloxone 12-3 1 QL 90 / 30 day(s) mg film) buprenorphine hcl-naloxone hcl (-naloxone 2-0.5 mg sl tab, - QL 90 / 30 Days naloxone 8-2 mg sl tab) 1

butalbital-apap-caff-cod 1 QL 180 / 30 Days

butalbital-asa-caff-codeine 1 QL 180 / 30 Days

QL 5 Vials / 30 Days BUTORPHANOL TARTRATE 1 MG/ML SOLUTION 3 PA

QL 2 / 30 Days butorphanol tartrate 10 mg/ml solution 1 PA

QL 5 Vials / 30 Days butorphanol tartrate 2 mg/ml solution 1 PA

BUTRANS (5 MCG/HR PATCH WK, 15 MCG/HR PATCH WK, QL 1 Box / 30 Days 20 MCG/HR PATCH WK) 4

PAGE 17 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BUTRANS 10 MCG/HR PATCH WK 3 QL 1 Box / 30 Days

BUTRANS 7.5 MCG/HR PATCH WK 4 QL 1 Box / 28 Days

CAPITAL/CODEINE 4

CODEINE PHOSPHATE 4 CODEINE SULFATE (15 MG TAB, 30 MG TAB, 30 MG/5ML SOLUTION, 60 MG TAB) 4

codeine sulfate (15 mg tab, 30 mg tab, 60 mg tab) 1

CONZIP 4 QL 30 / 30 Days

DEMEROL (50 MG TAB, 100 MG TAB) 4 DILAUDID (1 MG/ML LIQUID, 1 MG/ML SOLUTION, 2 MG TAB, 2 MG/ML SOLUTION, 4 MG TAB, 4 MG/ML SOLUTION, 4 8 MG TAB)

DILAUDID-HP 250 MG RECON SOLN 4

DOLOPHINE 4

DSUVIA 4

DURAGESIC-100 4 QL 1 Box / 30 Days

DURAGESIC-12 4 QL 1 Box / 30 Days

DURAGESIC-25 4 QL 1 Box / 30 Days

DURAGESIC-50 4 QL 1 Box / 30 Days

DURAGESIC-75 4 QL 1 Box / 30 Days

duramorph 1

DVORAH 4 QL 300 / 30 day(s)

EMBEDA 4

endocet 1 QL 300 / 30 Days

endodan 1

EXALGO (16 MG TB24 DETER, 32 MG TB24 DETER) 4 QL 60 / 30 Days

EXALGO (8 MG TB24 DETER, 12 MG TB24 DETER) 4 QL 30 / 30 Days

fentanyl 1 QL 1 Box / 30 Days

FENTANYL CIT-ROPIVACAINE-NACL 0.3-0.2-0.9 MG/150ML- % SOLUTION 4

PAGE 18 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FENTANYL CITRATE (1500 MCG/30ML SOLN PRSYR, 2750 MCG/55ML SOLN PRSYR, POWDER) 4

fentanyl citrate (200 mcg loz handle, 400 mcg loz handle, 600 QL 120 / 30 Days mcg loz handle, 800 mcg loz handle, 1200 mcg loz handle, 1 1600 mcg loz handle) PA fentanyl citrate (pf) (100 mcg/2ml solution, 250 mcg/5ml solution, 1000 mcg/20ml solution, 2500 mcg/50ml solution) 1

FENTANYL CITRATE (PF) 50 MCG/ML SOLUTION 3 FENTANYL CITRATE-NACL (5-0.9 MCG/ML-% SOLN PRSYR, 10-0.9 MCG/2ML-% SOLN PRSYR, 550-0.9 MCG/55ML-% 4 SOLN PRSYR)

FIORICET/CODEINE 4 QL 180 / 30 Days

FIORINAL/CODEINE #3 4 QL 180 / 30 Days

HYCET 4

HYDROCODONE BITARTRATE ER 4 QL 60 / 30 day(s)

hydrocodone-acetaminophen (2.5-108 mg/5ml solution, 2.5-325 mg tab, 5-217 mg/10ml solution, 5-300 mg tab, 5-325 mg tab, 7.5-300 mg tab, 7.5-325 mg tab, 7.5-325 mg/15ml solution, 10- 1 300 mg tab, 10-325 mg tab, 10-325 mg/15ml solution) HYDROCODONE-ACETAMINOPHEN 10-325 MG/15ML SOLUTION 4

hydrocodone-ibuprofen 1

HYDROMORPHONE HCL (0.2 MG/ML SOLUTION, POWDER) 4 hydromorphone hcl (1 mg/ml liquid, 1 mg/ml solution, 2 mg tab, 2 mg/ml solution, 4 mg tab, 8 mg tab) 1

HYDROMORPHONE HCL 3 MG SUPPOS 3 hydromorphone hcl er (er 16 mg tb24 deter, er 32 mg tb24 QL 60 / 30 Days deter) 1

hydromorphone hcl er (er 8 mg tb24 deter, er 12 mg tb24 deter) 1 QL 30 / 30 Days

hydromorphone hcl pf (2 mg/ml solution, 10 mg/ml solution, 50 mg/5ml solution, 500 mg/50ml solution) 1

HYDROMORPHONE HCL PF 2 MG/ML SOLUTION 4

PAGE 19 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HYDROMORPHONE HCL-NACL (0.2-0.9 MG/0.2ML-% SOLN PRSYR, 0.5-0.9 MG/0.5ML-% SOLN PRSYR, 2-0.9 MG/ML-% SOLN PRSYR, 4-0.9 MG/ML-% SOLN PRSYR, 9-0.9 MG/45ML-% SOLN PRSYR, 12.5-0.9 MG/50ML-% SOLUTION, 4 15-0.9 MG/15ML-% SOLN PRSYR, 62.5-0.9 MG/250ML-% SOLUTION, 75-0.9 MG/250ML-% SOLUTION)

HYSINGLA ER 3 QL 30 / 30 Days

IBUDONE 10-200 MG TAB 4

ibudone 5-200 mg tab 1

IONSYS 4 KADIAN (10 MG CAP ER 24H, 20 MG CAP ER 24H, 30 MG CAP ER 24H, 40 MG CAP ER 24H, 50 MG CAP ER 24H, 60 4 QL 60 / 30 Days MG CAP ER 24H, 80 MG CAP ER 24H, 100 MG CAP ER 24H)

KADIAN 200 MG CAP ER 24H 4

LAZANDA (100 MCG/ACT SOLUTION, 300 MCG/ACT QL 5 / 30 Days 3 SOLUTION, 400 MCG/ACT SOLUTION) PA

lorcet 1

lorcet hd 1

lorcet plus 1

lortab (5-325 mg tab, 7.5-325 mg tab, 10-325 mg tab) 1

LORTAB 10-300 MG/15ML ELIXIR 4 MEPERIDINE HCL (10 MG/ML SOLUTION, 50 MG TAB, 100 MG TAB) 3 meperidine hcl (25 mg/ml solution, 50 mg tab, 50 mg/ml solution, 100 mg tab, 100 mg/ml solution) 1

MEPERIDINE HCL (50 MG/5ML SOLUTION, POWDER) 4

MEPERIDINE-PROMETHAZINE 4 methadone hcl (5 mg tab, 5 mg/5ml solution, 10 mg tab, 10 mg/5ml solution, 10 mg/ml conc, 10 mg/ml solution, 40 mg tab 1 sol) METHADONE HCL (5 MG/5ML SOLUTION, 10 MG/5ML SOLUTION, 10 MG/ML SOLUTION, POWDER) 4

methadone hcl intensol 1

METHADOSE 10 MG/ML CONC 4

methadose 40 mg tab sol 1

PAGE 20 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

METHADOSE SUGAR-FREE 4

mitigo 1

MORPHABOND ER 4 QL 90 / 30 Days

morphine sulfate (1 mg/ml solution, 8 mg/ml solution, 10 mg/5ml solution, 15 mg tab, 20 mg/5ml solution, 30 mg tab) 1 MORPHINE SULFATE (15 MG TAB, 15 MG/ML SOLUTION, 30 MG TAB, POWDER) 4 MORPHINE SULFATE (5 MG SUPPOS, 10 MG SUPPOS, 20 MG SUPPOS, 30 MG SUPPOS) 3

morphine sulfate (concentrate) 1 morphine sulfate (pf) (0.5 mg/ml solution, 1 mg/ml solution, 4 mg/ml solution, 8 mg/ml solution, 10 mg/ml solution) 1

MORPHINE SULFATE (PF) 15 MG/ML SOLUTION 3 morphine sulfate er (er 10 mg cap er 24h, er 20 mg cap er 24h, er 30 mg cap er 24h, er 50 mg cap er 24h, er 60 mg cap er 24h, 1 QL 60 / 30 Days er 80 mg cap er 24h, er 100 mg cap er 24h) morphine sulfate er (er 15 mg tab er, er 30 mg tab er, er 60 mg QL 90 / 30 Days tab er, er 100 mg tab er, er 200 mg tab er) 1

morphine sulfate er 40 mg cap er 24h 1 MORPHINE SULFATE ER BEADS (ER BEADS 30 MG CAP ER 24H, ER BEADS 45 MG CAP ER 24H, ER BEADS 60 MG QL 30 / 30 Days CAP ER 24H, ER BEADS 75 MG CAP ER 24H, ER BEADS 90 4 MG CAP ER 24H)

MORPHINE SULFATE ER BEADS 120 MG CAP ER 24H 3 QL 30 / 30 Days

MORPHINE SULFATE-NACL (5-0.9 MG/5ML-% SOLN PRSYR, 30-0.9 MG/30ML-% SOLN PRSYR, 500-0.9 4 MG/250ML-% SOLUTION, 2500-0.9 MG/250ML-% SOLUTION)

MS CONTIN 4 QL 90 / 30 Days

nalbuphine hcl (10 mg/ml solution, 20 mg/ml solution) 1

NALOCET 4

NORCO 4

NUCYNTA 100 MG TAB 3 QL 180 / 30 Days

NUCYNTA 50 MG TAB 3 QL 300 / 30 Days

NUCYNTA 75 MG TAB 3 QL 240 / 30 Days

PAGE 21 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NUCYNTA ER (ER 100 MG TAB ER 12H, ER 150 MG TAB ER QL 60 / 30 Days 12H, ER 200 MG TAB ER 12H, ER 250 MG TAB ER 12H) 3

NUCYNTA ER 50 MG TAB ER 12H 3 QL 300 / 30 Days

OPANA (5 MG TAB, 10 MG TAB) 4 QL 360 / 30 Days

OPANA 1 MG/ML SOLUTION 4

OPANA ER 3

OXAYDO 4

OXYCODONE HCL POWDER 4 oxycodone hcl (5 mg cap, 5 mg tab, 5 mg/5ml solution, 10 mg tab, 15 mg tab, 20 mg tab, 30 mg tab, 100 mg/5ml conc) 1

OXYCODONE HCL ER 3 QL 90 / 30 Days

oxycodone-acetaminophen (2.5-325 mg tab, 5-325 mg tab, 7.5- QL 300 / 30 Days 325 mg tab, 10-325 mg tab) 1

OXYCODONE-ACETAMINOPHEN 5-325 MG/5ML SOLUTION 4

OXYCODONE-ASPIRIN 3

oxycodone-aspirin 1

OXYCODONE-IBUPROFEN 4 QL 120 / 30 Days

OXYCONTIN 3 QL 90 / 30 Days

oxymorphone hcl 1 QL 360 / 30 Days

OXYMORPHONE HCL ER 4 QL 60 / 30 Days

oxymorphone hcl er 1

panlor 1 QL 300 / 30 day(s)

pentazocine-naloxone hcl 1

PERCOCET 4 QL 300 / 30 Days

PERCODAN 4

PRIMLEV 4 QL 300 / 30 Days

QL 1 Box / 180 Days

PA PROBUPHINE IMPLANT KIT 6 LA Limited Access

PAGE 22 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

remifentanil hcl 1

reprexain 10-200 mg tab 1

REPREXAIN 5-200 MG TAB 4

ROXICET 4

ROXICODONE 4

ROXYBOND 4

SUBLIMAZE 4

QL 1 / 30 Days

PA SUBLOCADE 6 LA Limited Access

QL 8 / 30 Days SUBSYS (1200 (600 MCG LIQUID, 1600 (800 MCG LIQUID) 4 PA

SUBSYS (200 MCG LIQUID, 400 MCG LIQUID, 600 MCG QL 4 / 30 Days 4 LIQUID, 800 MCG LIQUID) PA

QL 12 / 30 Days SUBSYS 100 MCG LIQUID 4 PA

sufentanil citrate (50 mcg/ml solution, 100 mcg/2ml solution, 250 mcg/5ml solution) 1

SYNALGOS-DC 4

TALWIN 4

tramadol hcl 50 mg tab 1

tramadol hcl er (biphasic) 1 QL 30 / 30 Days

TRAMADOL HCL ER (ER 100 MG CAP ER 24H, ER 200 MG QL 30 / 30 Days CAP ER 24H, ER 300 MG CAP ER 24H) 4 tramadol hcl er (er 100 mg tab er 24h, er 200 mg tab er 24h, er 300 mg tab er 24h) 1

TRAMADOL HCL ER 150 MG CAP ER 24H 4 QL 30 / 30 day(s)

tramadol-acetaminophen 1

TREZIX 4

TYLENOL WITH CODEINE #3 4

PAGE 23 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TYLENOL WITH CODEINE #4 4

ULTRACET 4

ULTRAM 4

ULTRAM ER 4

VERDROCET 1

vicodin 1

vicodin es 1

vicodin hp 1

VICOPROFEN 4

XARTEMIS XR 4

XODOL 4

XTAMPZA ER 4 QL 60 / 30 Days

xylon 1

ZAMICET 4 ZOHYDRO ER (ER 10 MG CAP ER 12H, ER 15 MG CAP ER 12H, ER 20 MG CAP ER 12H, ER 30 MG CAP ER 12H, ER 40 4 MG CAP ER 12H, ER 50 MG CAP ER 12H) ZOHYDRO ER (ER 10 MG CP12 DETER, ER 15 MG CP12 DETER, ER 30 MG CP12 DETER, ER 40 MG CP12 DETER, 4 QL 60 / 30 day(s) ER 50 MG CP12 DETER)

ZOHYDRO ER 20 MG CP12 DETER 4 QL 60 / 30 Days

ZUBSOLV (0.7-0.18 MG SL TAB, 1.4-0.36 MG SL TAB, 2.9- QL 90 / 30 Days 0.71 MG SL TAB, 5.7-1.4 MG SL TAB) 4

ZUBSOLV (8.6-2.1 MG SL TAB, 11.4-2.9 MG SL TAB) 4 QL 60 / 30 Days

GENERAL ANESTHETICS

BREVITAL SODIUM 3

desflurane 2

DIPRIVAN 100 MG/10ML EMULSION 4

etomidate 2 mg/ml solution 1

FORANE 4

fresenius propoven 1

isoflurane 1

PAGE 24 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

KETALAR 4 KETAMINE HCL (0.6 MG/ML SOLUTION, 30 MG/3ML SOLN PRSYR, 50 MG/5ML SOLN PRSYR, 50 MG/ML SOLN PRSYR, 4 60 MG/20ML SOLN PRSYR, 100 MG/10ML SOLN PRSYR) ketamine hcl (10 mg/ml solution, 50 mg/ml solution, 100 mg/ml solution) 1 KETAMINE HCL-SODIUM CHLORIDE 10-0.9 MG/ML-% SOLN PRSYR 4 KETAMINE HCL-SODIUM CHLORIDE 50-0.9 MG/5ML-% SOLN PRSYR 3 propofol (200 mg/20ml emulsion, 500 mg/50ml emulsion, 1000 mg/100ml emulsion) 1

PROPOFOL (50 MG/5ML PRSYR, 150 MG/15ML PRSYR) 4

sevoflurane 1

sojourn 1

SUPRANE 4

terrell 1 GOUT AGENTS

allopurinol (100 mg tab, 300 mg tab) 1

allopurinol sodium 1

COLCHICINE POWDER 4

COLCHICINE 0.6 MG CAP 3 QL 60 / 30 Days

colchicine 0.6 mg tab 1 QL 60 / 30 Days

colchicine-probenecid 1

COLCRYS 3 QL 60 / 30 Days

febuxostat 1

KRYSTEXXA 5 LA Limited Access

probenecid 1

ULORIC 4 QL 30 / 30 Days

ZYLOPRIM 4

PAGE 25 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LOCAL ANESTHETICS-PARENTERAL

articadent dental 1

BL INJECTION 4

BUPIVACAINE FISIOPHARMA 4

bupivacaine hcl (0.25 % solution, 0.5 % solution) 1 BUPIVACAINE HCL (0.5 % (20 ML) SOLN PRSYR, 0.5 % (60 ML) SOLN PRSYR, POWDER) 4

bupivacaine hcl (pf) 1 BUPIVACAINE HCL-NACL (0.03-0.9 % SOLUTION, 0.0625-0.9 % (50 ML) SOLN PRSYR, 0.1-0.9 % SOLN PRSYR, 0.2-0.9 % SOLUTION, 0.25-0.9 % SOLN PRSYR, 0.375-0.9 % SOLN 4 PRSYR)

bupivacaine in dextrose 0.75-8.25 % solution 1

bupivacaine spinal 1

bupivacaine-epinephrine (0.25% solution, 0.5% solution) 1

bupivacaine-epinephrine (pf) 1 BUPIVACAINE-EPINEPHRINE 0.75% -1:400000 SOLN PRSYR 3

chloroprocaine hcl (pf) 1

lidocaine hcl (0.5 % solution, 1 % solution, 2 % solution) 1

LIDOCAINE HCL (0.5 MG J-INJ, 100 MG/5ML SOLN PRSYR) 4 lidocaine hcl (pf) (0.5 % solution, 1 % solution, 1.5 % solution, 2 % solution) 1

LIDOCAINE HCL (PF) 4 % SOLUTION 4

LIDOCAINE HCL 10 MG/ML SOLN PRSYR 3 lidocaine-epinephrine (0.5 %-1:200000 solution, 1 %-1:100000 solution, 1.5 %-1:200000 solution, 2 %-1:100000 solution, 2 %- 1 1:200000 solution, 2 %-1:50000 solution)

MEPIVACAINE HCL 4

MLD 4

NESACAINE 1 % SOLUTION 4

NESACAINE 2 % SOLUTION 3

NESACAINE-MPF 4

polocaine 1

PAGE 26 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

polocaine-mpf 1

PROCAINE HCL 4

ROPIV-CLONIDINE-KETOROLAC 4 ropivacaine hcl (2 mg/ml solution, 5 mg/ml solution, 7.5 mg/ml solution, 10 mg/ml solution) 1 ROPIVACAINE HCL-NACL (0.1-0.9 % SOLN PRSYR, 0.125- 0.9 % SOLUTION, 0.15-0.9 % SOLUTION, 0.25-0.9 % 4 SOLUTION)

sensorcaine 1

sensorcaine-mpf 1

sensorcaine-mpf spinal 1 sensorcaine-mpf/epinephrine (sensorcaine-mpf/epinephrine 0.25% solution, sensorcaine-mpf/epinephrine 0.5% solution) 1

sensorcaine/epinephrine 1

xylocaine dental 1

XYLOCAINE-MPF 1.5 % SOLUTION 4

ZINGO 4 MIGRAINE PRODUCTS

QL 2 Auto-Injectors / 30 Days AIMOVIG (140 MG DOSE) 5 PA

QL 1 Auto-Injector / 30 Days AIMOVIG 140 MG/ML SOLN A-INJ 5 PA

QL 2 Auto-Injectors / 30 Days AIMOVIG 70 MG/ML SOLN A-INJ 5 PA

QL 2 Syringes / 30 Days

AJOVY 5 PA

almotriptan malate 1 QL 12 / 30 Days

PAGE 27 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AMERGE 4 QL 12 / 30 Days

AXERT 4

CAFERGOT 4

D.H.E. 45 4 QL 20 Vials / 30 Days

DIHYDROERGOTAMINE MESYLATE (CRYSTALS, POWDER) 4

dihydroergotamine mesylate 1 mg/ml solution 1 QL 20 Vials / 30 Days

DIHYDROERGOTAMINE MESYLATE 4 MG/ML SOLUTION 3 QL 16 Vials / 30 Days

eletriptan hydrobromide 1 QL 12 / 30 Days

QL 3 Syringes / 30 Days

PA EMGALITY 100 MG/ML SOLN PRSYR 5 AL1 At least 18 yrs old

QL 2 Auto-Injectors / 30 Days PA EMGALITY 120 MG/ML SOLN A-INJ 5 AL1 At least 18 yrs old

QL 2 Syringes / 30 Days

PA EMGALITY 120 MG/ML SOLN PRSYR 5 AL1 At least 18 yrs old

ERGOMAR 4

ERGOTAMINE TARTRATE 4

ergotamine-caffeine 1

FROVA 4 QL 12 / 30 Days

frovatriptan succinate 1 QL 12 / 30 Days

IMITREX (25 MG TAB, 50 MG TAB, 100 MG TAB) 4 QL 12 / 30 Days

IMITREX (5 MG/ACT SOLUTION, 20 MG/ACT SOLUTION) 4 QL 2 Boxes / 30 Days

IMITREX 6 MG/0.5ML SOLUTION 4 QL 12 Vials / 30 Days

PAGE 28 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

IMITREX STATDOSE REFILL 4 QL 6 Boxes / 30 Days

IMITREX STATDOSE SYSTEM 4 QL 6 Boxes / 30 Days

ISOMETHEPTENE-CAFFEINE-APAP 3

isometheptene-caffeine-apap 1

ISOMETHEPTENE-DICHLORAL-APAP 3

isometheptene-dichloral-apap 1

MAXALT 10 MG TAB 4 QL 12 / 30 Days

MAXALT 5 MG TAB 4

MAXALT-MLT 4 QL 12 / 30 Days

MIGERGOT 3

MIGRAL 4

MIGRALAM 4

MIGRANAL 3 QL 16 Vials / 30 Days

naratriptan hcl 1 QL 12 / 30 Days

nodolor 1

ONZETRA XSAIL 4 QL 1 Box / 30 Days

PRODRIN 4

RELPAX 4 QL 12 / 30 Days

rizatriptan benzoate 1 QL 12 / 30 Days

sumatriptan (5 mg/act solution, 20 mg/act solution) 1 QL 2 Boxes / 30 Days

sumatriptan succinate (25 mg tab, 50 mg tab, 100 mg tab) 1 QL 12 / 30 Days

sumatriptan succinate (4 mg/0.5ml soln a-inj, 6 mg/0.5ml soln 1 QL 12 Auto-Injectors / 30 a-inj) Days

SUMATRIPTAN SUCCINATE 6 MG/0.5ML SOLN PRSYR 4

sumatriptan succinate 6 mg/0.5ml solution 1 QL 12 Vials / 30 Days

sumatriptan succinate refill 1 QL 6 Boxes / 30 Days

ZECUITY 4

ZEMBRACE SYMTOUCH 4 QL 12 Auto-Injectors / 30 Days

PAGE 29 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS zolmitriptan (2.5 mg tab, 2.5 mg tab disp, 5 mg tab, 5 mg tab QL 12 / 30 Days disp) 1

ZOMIG (2.5 MG SOLUTION, 5 MG SOLUTION) 3 QL 2 Boxes / 30 Days

ZOMIG (2.5 MG TAB, 5 MG TAB) 4 QL 12 / 30 Days

ZOMIG ZMT 4 QL 12 / 30 Days

ANTI-INFECTIVE AGENTS

AMEBICIDES

IODOQUINOL 4

SOLOSEC 4 QL 10 / 30 Days

AMINOGLYCOSIDES

AMIKACIN SULFATE POWDER 4

amikacin sulfate (1 gm/4ml solution, 500 mg/2ml solution) 1

QL 1 Box / 28 Days

PA ARIKAYCE 6 LA Limited Access

QL 1 Box / 56 Days

PA BETHKIS 5 LA Limited Access

GENTAMICIN IN SALINE (GENTAMICSALE 0.8-0.9 MG/ML-% SOLUTION, GENTAMICSALE 0.9-0.9 MG/ML-% SOLUTION, GENTAMICSALE 1-0.9 MG/ML-% SOLUTION, 3 GENTAMICSALE 1.4-0.9 MG/ML-% SOLUTION, GENTAMICSALE 1.6-0.9 MG/ML-% SOLUTION) gentamicin in saline (gentamicsale 0.8-0.9 mg/ml-% solution, gentamicsale 1-0.9 mg/ml-% solution, gentamicsale 1.2-0.9 1 mg/ml-% solution)

GENTAMICIN IN SALINE 2-0.9 MG/ML-% SOLUTION 4

gentamicin sulfate (10 mg/ml solution, 40 mg/ml solution) 1

QL 1 Box / 56 Days

KITABIS PAK 5 PA

PAGE 30 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

neomycin sulfate 500 mg tab 1

PAROMOMYCIN SULFATE 250 MG CAP 3

paromomycin sulfate 250 mg cap 1

STREPTOMYCIN SULFATE POWDER 4

STREPTOMYCIN SULFATE 1 GM RECON SOLN 3

QL 1 Box / 56 Days TOBI 6 S

QL 1 Inhaler / 56 Days

TOBI PODHALER 5 PA

QL 1 Box / 56 Days

tobramycin 300 mg/5ml nebu soln 5 PA

tobramycin sulfate (1.2 gm recon soln, 1.2 gm/30ml solution, 80 mg/2ml solution) 1

TOBRAMYCIN SULFATE (10 MG/ML SOLUTION, POWDER) 4

TOBRAMYCIN SULFATE 2 GM/50ML SOLUTION 3

QL 7 Day Supply / 180 Days ZEMDRI 6 PA

ANTHELMINTICS

albendazole 200 mg tab 1

ALBENZA 4

BENZNIDAZOLE 4 AL1 Up to 12 yrs old

BILTRICIDE 4

EGATEN 4

EMVERM 3

ivermectin 3 mg tab 1

MEBENDAZOLE 4

PIPERAZINE CITRATE 4

PAGE 31 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

praziquantel 600 mg tab 2

STROMECTOL 4

THIABENDAZOLE 4 ANTI-INFECTIVE AGENTS - MISC.

QL 12 / 365 day(s) AEMCOLO 4 PA

ALINIA 100 MG/5ML RECON SUSP 3 PA

QL 6 / 30 Days ALINIA 500 MG TAB 3 PA

atovaquone 750 mg/5ml suspension 1

AZACTAM 4

AZACTAM IN DEXTROSE 3

aztreonam 1

baciim 1

bacitracin 50000 unit recon soln 1

BACTRIM 4

BACTRIM DS 4

QL 1 Box / 56 Days

PA CAYSTON 5 LA Limited Access

CLEOCIN (75 MG CAP, 75 MG/5ML RECON SOLN, 150 MG CAP, 300 MG CAP) 4

CLEOCIN PHOSPHATE 4

clindamycin hcl (75 mg cap, 150 mg cap, 300 mg cap) 1

clindamycin palmitate hcl 1 clindamycin phosphate (9 gm/60ml solution, 300 mg/2ml solution, 600 mg/4ml solution, 900 mg/6ml solution, 9000 1 mg/60ml solution)

clindamycin phosphate in d5w 1

colistimethate sodium (cba) 1

PAGE 32 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

COLY-MYCIN M 4

CUBICIN 4

CUBICIN RF 4

dapsone (25 mg tab, 100 mg tab) 1

DAPTOMYCIN 350 MG RECON SOLN 3

daptomycin 500 mg recon soln 2

DORIBAX 3

DORIPENEM 250 MG RECON SOLN 3

DORIPENEM 500 MG RECON SOLN 4

ertapenem sodium 1

FIRST-METRONIDAZOLE 100 MG/ML RECON SUSP 3

FIRST-METRONIDAZOLE 50 MG/ML RECON SUSP 4

FIRST-VANCOMYCIN 25 MG/ML SOLUTION 3

FIRST-VANCOMYCIN 50 MG/ML SOLUTION 4

FIRVANQ 4

FLAGYL 4

imipenem-cilastatin (, 250 mg recon soln) 1

QL 84 / 365 Days

IMPAVIDO 5 PA

INVANZ 4

KETEK 4

LINCOCIN 4

lincomycin hcl 300 mg/ml solution 1

linezolid 100 mg/5ml recon susp 1 QL 1800 Milliliters / 30 Days

linezolid 600 mg tab 1 QL 60 / 30 Days

linezolid 600 mg/300ml solution 1

MEPRON 4

meropenem 1

MEROPENEM-SODIUM CHLORIDE 3

PAGE 33 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MERREM 4

metronidazole (250 mg tab, 375 mg cap, 500 mg tab) 1

METRONIDAZOLE BENZO+SYRSPEND 4 metronidazole in nacl (5-0.79 mg/ml-% solution, 500-0.79 mg/100ml-% solution) 1 METRONIDAZOLE IN NACL 500-0.74 MG/100ML-% SOLUTION 3

NEBUPENT 3

QL 3 Vials / 14 Days

ORBACTIV 6 PA

PENTAM 4

pentamidine isethionate 1

POLYMYXIN B SULFATE POWDER 4

polymyxin b sulfate 500000 unit recon soln 1

PRIMAXIN IV 4

PRIMSOL 4

SIVEXTRO 3 PA

sulfamethoxazole-trimethoprim (200-40 mg/5ml suspension, 400-80 mg tab, 400-80 mg/5ml solution, 800-160 mg tab) 1

sulfatrim pediatric 1

SYNERCID 4

TINDAMAX 4

tinidazole (250 mg tab, 500 mg tab) 1

TRIMETHOPRIM POWDER 4

trimethoprim 100 mg tab 1

TRIMPEX 4

QL 84 Vials / 28 Days VABOMERE 4 PA

VANCOCIN 4

VANCOCIN HCL 4

PAGE 34 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS vancomycin hcl (1 gm recon soln, 5 gm recon soln, 10 gm recon soln, 125 mg cap, 250 mg cap, 500 mg recon soln, 750 1 mg recon soln) VANCOMYCIN HCL (100 GM RECON SOLN, 250 MG RECON SOLN, 250 MG/5ML RECON SOLN, 500 MG/100ML SOLUTION, 750 MG RECON SOLN, 750 MG/7.5ML SOLUTION, 1000 MG/10ML SOLUTION, 1000 MG/200ML SOLUTION, 1250 MG/12.5ML SOLUTION, 1500 MG/15ML 4 SOLUTION, 1500 MG/300ML SOLUTION, 1750 MG/17.5ML SOLUTION, 2000 MG/20ML SOLUTION, 2000 MG/400ML SOLUTION)

VANCOMYCIN HCL 1.5 GM RECON SOLN 3 VANCOMYCIN HCL IN DEXTROSE (1-5 GM/100ML-% SOLUTION, 1-5 GM/200ML-% SOLUTION, 1-5 GM/250ML-% SOLUTION, 1.5-5 GM/300ML-% SOLUTION, 500-5 3 MG/100ML-% SOLUTION) VANCOMYCIN HCL IN DEXTROSE (1.25-5 GM/250ML-% SOLUTION, 1.5-5 GM/250ML-% SOLUTION, 1.5-5 GM/500ML- % SOLUTION, 1.75-5 GM/500ML-% SOLUTION, 2-5 4 GM/500ML-% SOLUTION, 750-5 MG/150ML-% SOLUTION) VANCOMYCIN HCL IN NACL (1-0.9 GM/150ML-% SOLUTION, 1-0.9 GM/200ML-% SOLUTION, 1-0.9 GM/250ML-% SOLUTION, 1.25-0.9 GM/150ML-% SOLUTION, 1.25-0.9 GM/250ML-% SOLUTION, 1.5-0.9 GM/150ML-% SOLUTION, 1.5-0.9 GM/250ML-% SOLUTION, 1.5-0.9 GM/300ML-% SOLUTION, 1.5-0.9 GM/500ML-% SOLUTION, 1.75-0.9 4 GM/250ML-% SOLUTION, 1.75-0.9 GM/300ML-% SOLUTION, 1.75-0.9 GM/500ML-% SOLUTION, 2-0.9 GM/250ML-% SOLUTION, 2-0.9 GM/500ML-% SOLUTION, 2.5-0.9 GM/500ML-% SOLUTION, 750-0.9 MG/150ML-% SOLUTION, 750-0.9 MG/250ML-% SOLUTION) VANCOMYCIN HCL IN NACL (MG/50ML-% SOLUTION, MG/100ML-% SOLUTION) 3

VANCOSOL PACK 4

VIBATIV 6 S

QL 14 / 7 day(s)

XENLETA 150 MG/15ML SOLUTION 4 AL1 At least 18 yrs old

LA Limited Access

PAGE 35 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 9 / 365 Days XIFAXAN 200 MG TAB 3 PA

XIFAXAN 550 MG TAB 3 PA

ZYVOX 100 MG/5ML RECON SUSP 4 QL 1800 Milliliters / 30 Days

ZYVOX 600 MG TAB 4 QL 60 / 30 Days

ZYVOX 600 MG/300ML SOLUTION 4 ANTIFUNGALS

ABELCET 3

AMBISOME 4

AMPHOTEC 100 MG RECON SUSP 3

AMPHOTEC 50 MG RECON SUSP 4

AMPHOTERICIN B 50 MG RECON SOLN 4

ANCOBON 4

bio-statin powder 1

BIO-STATIN 1000000 UNIT CAP 3

BIO-STATIN 500000 UNIT CAP 4

CANCIDAS 4

caspofungin acetate 1

CASPOFUNGIN ACETATE 70 MG RECON SOLN 3

QL 60 / 30 Days CRESEMBA 186 MG CAP 3 PA

QL 30 Vials / 30 Days CRESEMBA 372 MG RECON SOLN 3 PA

DIFLUCAN (10 MG/ML RECON SUSP, 40 MG/ML RECON SUSP, 50 MG TAB, 100 MG TAB, 150 MG TAB, 200 MG TAB) 4

ERAXIS 3 fluconazole (10 mg/ml recon susp, 40 mg/ml recon susp, 50 mg tab, 100 mg tab, 150 mg tab, 200 mg tab) 1

FLUCONAZOLE IN DEXTROSE (, 200 MG/100ML SOLUTION) 1 fluconazole in sodium chloride (200-0.9 mg/100ml-% solution, 400-0.9 mg/200ml-% solution) 1

PAGE 36 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

flucytosine (250 mg cap, 500 mg cap) 1

GRIFULVIN V 4

GRIS-PEG 4

griseofulvin microsize (125 mg/5ml suspension, 500 mg tab) 1

griseofulvin ultramicrosize 1

itraconazole (10 mg/ml solution, 100 mg cap) 1

ketoconazole 200 mg tab 1

LAMISIL (187.5 MG PACKET, 250 MG TAB) 4

LAMISIL 125 MG PACKET 3

MICONAZOLE 4

MYCAMINE 3 NOXAFIL (40 MG/ML SUSPENSION, 300 MG/16.7ML PA SOLUTION) 3

NOXAFIL 100 MG TAB DR 4 PA

nystatin (500000 unit tab, powder) 1

ONMEL 4 PA

posaconazole 1 PA

SPORANOX (10 MG/ML SOLUTION, 100 MG CAP) 4

SPORANOX PULSEPAK 4

terbinafine hcl 250 mg tab 1

TOLSURA 4 PA

VFEND (40 MG/ML RECON SUSP, 50 MG TAB, 200 MG TAB) 4

VFEND IV 4 voriconazole (40 mg/ml recon susp, 50 mg tab, 200 mg recon soln, 200 mg tab) 1 ANTIMALARIALS

ARAKODA 4

atovaquone-proguanil hcl 1

chloroquine phosphate (250 mg tab, 500 mg tab) 1

CHLOROQUINE PHOSPHATE (250 MG TAB, POWDER) 4

PAGE 37 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

COARTEM 3

PA DARAPRIM 3 LA Limited Access

hydroxychloroquine sulfate 200 mg tab 1

KRINTAFEL 3 QL 2 / 365 day(s)

MALARONE 4

MEFLOQUINE HCL 3

mefloquine hcl 1

PLAQUENIL 4

primaquine phosphate 1 QL 2 / 365 day(s)

PRIMAQUINE PHOSPHATE 4 QL 2 / 365 day(s)

QUALAQUIN 4 QL 42 / 30 Days

QUINACRINE HCL 4

QUININE SULFATE POWDER 4

quinine sulfate 324 mg cap 1 QL 42 / 30 Days

QUININE SULFATE DIHYDRATE 4 ANTIMYCOBACTERIAL AGENTS

AMINOSALICYLIC ACID-4 4

cycloserine 250 mg cap 1

ETHAMBUTOL HCL POWDER 4

ethambutol hcl (100 mg tab, 400 mg tab) 1

ISONIAZID POWDER 4

isoniazid (100 mg tab, 300 mg tab) 1

ISONIAZID (50 MG/5ML SYRUP, 100 MG/ML SOLUTION) 3

MYAMBUTOL 4

MYCOBUTIN 4

PASER 3

QL 30 / 30 day(s) PRETOMANID 4 PA

PAGE 38 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PRIFTIN 3

pyrazinamide 500 mg tab 1

rifabutin 1

RIFADIN 4

RIFAMATE 3

rifampin (150 mg cap, 300 mg cap, 600 mg recon soln) 1

RIFAMPIN+SYRSPEND SF 4

RIFATER 3

SIRTURO 3 LA Limited Access

TRECATOR 3 ANTIVIRALS

QL 960 Milliliters / 30 Days

abacavir sulfate 20 mg/ml solution 5 PA

QL 60 / 30 Days

abacavir sulfate 300 mg tab 5 PA

QL 30 / 30 Days abacavir sulfate-lamivudine 5 S

QL 60 / 30 Days abacavir-lamivudine-zidovudine 5 S

acyclovir (200 mg cap, 200 mg/5ml suspension, 400 mg tab, 800 mg tab) 1 ACYCLOVIR SODIUM (500 MG RECON SOLN, 1000 MG RECON SOLN) 3

acyclovir sodium 50 mg/ml solution 1

QL 30 / 30 Days

adefovir dipivoxil 5 PA

QL 380 Milliliters / 30 Days APTIVUS 100 MG/ML SOLUTION 5 S

PAGE 39 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 120 / 30 Days APTIVUS 250 MG CAP 5 S

QL 30 / 30 Days atazanavir sulfate (150 mg cap, 300 mg cap) 5 S

QL 60 / 30 Days atazanavir sulfate 200 mg cap 5 S

QL 30 / 30 Days ATRIPLA 5 S

QL 30 / 30 Days

BARACLUDE (0.5 MG TAB, 1 MG TAB) 6 PA

QL 600 Milliliters / 30 Days

BARACLUDE 0.05 MG/ML SOLUTION 6 PA

QL 30 / 30 Days BIKTARVY 5 S

cidofovir 75 mg/ml solution 1

QL 30 / 30 Days CIMDUO 6 S

QL 60 / 30 Days COMBIVIR 6 S

QL 30 / 30 Days COMPLERA 5 S

QL 210 / 30 Days

COPEGUS 5 PA

QL 360 / 30 Days CRIXIVAN 200 MG CAP 5 S

QL 180 / 30 Days CRIXIVAN 400 MG CAP 5 S

PAGE 40 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CYTOVENE 4

QL 30 / 30 Days DELSTRIGO 5 S

QL 30 / 30 Days DESCOVY 5 S

QL 30 / 30 Days didanosine (200 mg cap dr, 250 mg cap dr, 400 mg cap dr) 5 S

didanosine 125 mg cap dr 5 S

QL 30 / 30 day(s) DOVATO 6 S

QL 30 / 30 Days EDURANT 5 S

QL 90 / 30 Days efavirenz (50 mg cap, 200 mg cap) 5 S

QL 30 / 30 Days efavirenz 600 mg tab 5 S

QL 850 Milliliters / 30 Days EMTRIVA 10 MG/ML SOLUTION 5 S

QL 30 / 30 Days EMTRIVA 200 MG CAP 5 S

QL 30 / 30 Days

entecavir 5 PA

QL 960 Milliliters / 30 Days EPIVIR 10 MG/ML SOLUTION 6 S

QL 60 / 30 Days EPIVIR 150 MG TAB 6 S

QL 30 / 30 Days EPIVIR 300 MG TAB 6 S

PAGE 41 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 Days EPIVIR HBV 100 MG TAB 6 S

EPIVIR HBV 5 MG/ML SOLUTION 5 S

QL 30 / 30 Days EPZICOM 6 S

QL 30 / 30 Days EVOTAZ 6 S

famciclovir (125 mg tab, 250 mg tab, 500 mg tab) 1

FAMVIR 4

FLUMADINE 4

QL 120 / 30 Days fosamprenavir calcium 5 S

FOSCAVIR 4

QL 60 Vials / 30 Days

FUZEON 5 PA

ganciclovir sodium 500 mg recon soln 1

QL 30 / 30 Days GENVOYA 5 S

QL 30 / 30 Days HEPSERA 6 S

QL 60 / 30 Days INTELENCE (100 MG TAB, 200 MG TAB) 5 S

QL 120 / 30 Days INTELENCE 25 MG TAB 5 S

QL 300 / 30 Days INVIRASE 200 MG CAP 5 S

QL 120 / 30 Days INVIRASE 500 MG TAB 5 S

PAGE 42 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ISENTRESS (25 MG CHEW TAB, 100 MG CHEW TAB, 100 QL 180 / 30 Days 5 MG PACKET) S

QL 120 / 30 Days ISENTRESS 400 MG TAB 5 S

QL 30 / 30 Days ISENTRESS HD 5 S

QL 30 / 30 Days JULUCA 6 S

QL 90 / 30 Days KALETRA 100-25 MG TAB 5 S

QL 120 / 30 Days KALETRA 200-50 MG TAB 5 S

QL 320 Milliliters / 30 Days KALETRA 400-100 MG/5ML SOLUTION 6 S

QL 60 / 30 Days lamivudine (100 mg tab, 150 mg tab) 5 S

QL 960 Milliliters / 30 Days lamivudine 10 mg/ml solution 5 S

QL 30 / 30 Days lamivudine 300 mg tab 5 S

QL 60 / 30 Days lamivudine-zidovudine 5 S

QL 1800 Milliliters / 30 LEXIVA 50 MG/ML SUSPENSION 5 Days S

QL 120 / 30 Days LEXIVA 700 MG TAB 6 S

QL 320 Millliliters / 30 lopinavir-ritonavir 5 Days S

PAGE 43 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 84 / 28 day(s)

MAVYRET 5 PA

QL 210 / 30 Days

moderiba 5 PA

QL 60 / 30 Days

MODERIBA (1000 MG PACK) 6 PA

QL 60 / 30 day(s)

MODERIBA (1200 MG PACK) 5 PA

QL 60 / 30 Days MODERIBA (600 MG PACK) 5 S

QL 60 / 30 Days

MODERIBA (800 MG PACK) 5 PA

QL 60 / 30 Days nevirapine 200 mg tab 5 S

QL 1200 Milliliters / 30 nevirapine 50 mg/5ml suspension 5 Days S

QL 90 / 30 Days nevirapine er 100 mg tab er 24h 5 S

QL 30 / 30 Days nevirapine er 400 mg tab er 24h 5 S

QL 30 / 30 Days NORVIR 100 MG CAP 5 S

QL 360 / 30 Days NORVIR 100 MG PACKET 5 S

PAGE 44 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 360 / 30 Days NORVIR 100 MG TAB 6 S

QL 450 Milliliters / 30 Days NORVIR 80 MG/ML SOLUTION 5 S

QL 30 / 30 Days ODEFSEY 5 S

oseltamivir phosphate (45 mg cap, 75 mg cap) 1 QL 10 / 30 Days

oseltamivir phosphate 30 mg cap 1 QL 20 / 30 Days

oseltamivir phosphate 6 mg/ml recon susp 1

PEG-INTRON (80 MCG/0.5ML KIT, 120 MCG/0.5ML KIT, 150 PA 6 MCG/0.5ML KIT) S

QL 4 Kits / 28 Days

PEG-INTRON 50 MCG/0.5ML KIT 6 PA

PEG-INTRON REDIPEN (80 MCG/0.5ML KIT, 120 MCG/0.5ML PA 6 KIT, 150 MCG/0.5ML KIT) S

QL 4 Kits / 28 Days

PEG-INTRON REDIPEN 50 MCG/0.5ML KIT 6 PA

PEG-INTRON REDIPEN PAK 4 (4 120 MCG/0.5ML KIT, 4 150 PA 6 MCG/0.5ML KIT, 4 80 MCG/0.5ML KIT) S

QL 4 Kits / 28 Days

PEG-INTRON REDIPEN PAK 4 50 MCG/0.5ML KIT 6 PA

QL 1 Box / 28 Days

PEGASYS 180 MCG/0.5ML SOLUTION 5 PA

QL 4 Vials / 28 Days

PEGASYS 180 MCG/ML SOLUTION 5 PA

PAGE 45 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Box / 28 Days PEGASYS PROCLICK (135 MCG/0.5ML SOLUTION, 180 PA MCG/0.5ML SOLUTION) 5 S

PEGINTRON (80 MCG/0.5ML KIT, 120 MCG/0.5ML KIT, 150 PA 6 MCG/0.5ML KIT) S

QL 4 Kits / 28 Days

PEGINTRON 50 MCG/0.5ML KIT 6 PA

QL 30 / 30 Days PIFELTRO 5 S

QL 100 / 100 Days

PREVYMIS (240 MG TAB, 480 MG TAB) 6 PA

QL 100 Vials / 100 Days PREVYMIS (240 MG/12ML SOLUTION, 480 MG/24ML PA SOLUTION) 6 S

QL 30 / 30 Days PREZCOBIX 5 S

QL 60 / 30 Days PREZISTA (150 MG TAB, 600 MG TAB) 5 S

QL 30 / 30 Days PREZISTA (75 MG TAB, 800 MG TAB) 5 S

QL 400 Milliliters / 30 Days PREZISTA 100 MG/ML SUSPENSION 5 S

RAPIVAB 3 QL 3 Vials / 365 Days

QL 210 / 30 Days REBETOL 200 MG CAP 6 S

QL 900 Milliliters / 30 Days

REBETOL 40 MG/ML SOLUTION 6 PA

PAGE 46 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

RELENZA DISKHALER 3 QL 1 Inhaler / 180 Days

QL 360 / 30 Days RESCRIPTOR 100 MG TAB 5 S

QL 180 / 30 Days RESCRIPTOR 200 MG TAB 5 S

RETROVIR 10 MG/ML SOLUTION 5 S

QL 180 / 30 Days RETROVIR 100 MG CAP 6 S

QL 1920 Milliliters / 30 RETROVIR 50 MG/5ML SYRUP 6 Days S

QL 30 / 30 Days REYATAZ (150 MG CAP, 300 MG CAP) 6 S

QL 60 / 30 Days REYATAZ 200 MG CAP 6 S

QL 240 / 30 Days REYATAZ 50 MG PACKET 5 S

QL 210 / 30 Days

ribasphere (200 mg cap, 200 mg tab) 5 PA

QL 60 / 30 Days

RIBASPHERE 400 MG TAB 5 PA

QL 60 / 30 day(s)

RIBASPHERE 600 MG TAB 5 PA

QL 60 / 30 Days

RIBASPHERE RIBAPAK (1000 PACK) 6 PA

QL 60 / 30 day(s)

RIBASPHERE RIBAPAK (1200 PACK) 5 PA

PAGE 47 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 Days RIBASPHERE RIBAPAK (600 PACK) 5 S

QL 60 / 30 Days

RIBASPHERE RIBAPAK (800 PACK) 5 PA

QL 60 / 30 Days

RIBATAB (1000 MG PACK) 6 PA

QL 60 / 30 day(s)

RIBATAB (1200 MG PACK) 5 PA

QL 60 / 30 Days

RIBATAB (800 MG PACK) 5 PA

QL 210 / 30 Days

ribavirin (200 mg cap, 200 mg tab) 5 PA

PA ribavirin 6 gm recon soln 5 S

RIMANTADINE HCL 3

QL 360 / 30 Days ritonavir 5 S

QL 120 / 30 Days SELZENTRY (75 MG TAB, 300 MG TAB) 5 S

QL 60 / 30 Days SELZENTRY 150 MG TAB 5 S

QL 1840 Milliliters / 30 SELZENTRY 20 MG/ML SOLUTION 5 Days S

QL 240 / 30 Days SELZENTRY 25 MG TAB 5 S

PAGE 48 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 Days stavudine (15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) 5 S

stavudine 1 mg/ml recon soln 5 S

QL 30 / 30 Days STRIBILD 5 S

QL 90 / 30 Days SUSTIVA (50 MG CAP, 200 MG CAP) 6 S

QL 30 / 30 Days SUSTIVA 600 MG TAB 6 S

QL 30 / 30 Days SYMFI 6 S

QL 30 / 30 Days SYMFI LO 6 S

QL 30 / 30 Days SYMTUZA 6 S

TAMIFLU (45 MG CAP, 75 MG CAP) 4 QL 10 / 30 Days

TAMIFLU 30 MG CAP 4 QL 20 / 30 Days

TAMIFLU 6 MG/ML RECON SUSP 4

QL 30 / 30 Days TEMIXYS 6 S

QL 30 / 30 Days tenofovir disoproxil fumarate 5 S

QL 60 / 30 Days TIVICAY 5 S

QL 30 / 30 Days TRIUMEQ 5 S

QL 60 / 30 Days TRIZIVIR 6 S

PAGE 49 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 Days TRUVADA 5 S

QL 30 / 30 Days TYBOST 6 S

PA TYZEKA 5 S

valacyclovir hcl (1 gm tab, 500 mg tab) 1

VALCYTE (50 MG/ML RECON SOLN, 450 MG TAB) 4

valganciclovir hcl (50 mg/ml recon soln, 450 mg tab) 1

VALTREX 4

QL 30 / 30 Days

VEMLIDY 5 PA

QL 300 Milliliters / 30 Days VIDEX 2 GM RECON SOLN 5 S

QL 600 Milliliters / 30 Days VIDEX 4 GM RECON SOLN 5 S

VIDEX EC (EC 200 MG CAP DR, EC 250 MG CAP DR, EC 400 QL 30 / 30 Days 6 MG CAP DR) S

QL 30 / 30 Days VIDEX EC 125 MG CAP DR 5 S

QL 300 / 30 Days VIRACEPT 250 MG TAB 5 S

QL 120 / 30 Days VIRACEPT 625 MG TAB 5 S

QL 60 / 30 Days VIRAMUNE 200 MG TAB 6 S

QL 1200 Milliliters / 30 VIRAMUNE 50 MG/5ML SUSPENSION 6 Days S

PAGE 50 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 90 / 30 Days VIRAMUNE XR 100 MG TAB ER 24H 6 S

QL 30 / 30 Days VIRAMUNE XR 400 MG TAB ER 24H 6 S

VIRAZOLE 6 S

QL 30 / 30 Days VIREAD (150 MG TAB, 200 MG TAB, 250 MG TAB) 5 S

QL 30 / 30 Days VIREAD 300 MG TAB 6 S

QL 4 Bottles / 30 Days VIREAD 40 MG/GM POWDER 5 S

VITEKTA 5 S

QL 28 / 28 day(s)

VOSEVI 6 PA

XOFLUZA 4 QL 2 Fills / 365 Days

QL 60 / 30 Days ZERIT (15 MG CAP, 20 MG CAP, 30 MG CAP, 40 MG CAP) 6 S

QL 2400 Milliliters / 30 ZERIT 1 MG/ML RECON SOLN 6 Days S

QL 960 Milliliters / 30 Days ZIAGEN 20 MG/ML SOLUTION 6 S

QL 60 / 30 Days ZIAGEN 300 MG TAB 6 S

QL 180 / 30 Days zidovudine 100 mg cap 5 S

QL 60 / 30 Days zidovudine 300 mg tab 5 S

PAGE 51 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1920 Milliliters / 30 zidovudine 50 mg/5ml syrup 5 Days S

ZOVIRAX (200 MG CAP, 200 MG/5ML SUSPENSION, 400 MG TAB, 800 MG TAB) 4 CEPHALOSPORINS

AVYCAZ 3

CEDAX (180 MG/5ML RECON SUSP, 400 MG CAP) 3 CEFACLOR (125 MG/5ML RECON SUSP, 250 MG/5ML RECON SUSP, 375 MG/5ML RECON SUSP) 3

cefaclor (250 mg cap, 500 mg cap) 1

CEFACLOR ER 3 cefadroxil (1 gm tab, 250 mg/5ml recon susp, 500 mg cap, 500 mg/5ml recon susp) 1

CEFAZOLIN IN SODIUM CHLORIDE 4 cefazolin sodium (1 gm recon soln, 10 gm recon soln, 500 mg recon soln) 1 CEFAZOLIN SODIUM (1 GM RECON SOLN, 20 GM RECON SOLN) 3 CEFAZOLIN SODIUM (1 GM/10ML SOLN PRSYR, 2 GM/20ML SOLN PRSYR, 3 GM/20ML SOLN PRSYR) 4 CEFAZOLIN SODIUM-DEXTROSE (1-4 GM/50ML-% SOLUTION, 2-4 GM/100ML-% SOLUTION, 2-5 GM/100ML-% 4 SOLUTION, 2-5 GM/50ML-% SOLUTION) CEFAZOLIN SODIUM-DEXTROSE (1-4 RECON SOLN, 2-3 RECON SOLN) 3

CEFAZOLIN SODIUM-NACL 4 cefdinir (125 mg/5ml recon susp, 250 mg/5ml recon susp, 300 mg cap) 1

CEFDITOREN PIVOXIL 3

cefepime hcl (1 gm recon soln, 2 gm recon soln) 1 CEFEPIME HCL (1 GM/50ML SOLUTION, 2 GM/100ML SOLUTION) 3 cefixime (100 mg/5ml recon susp, 200 mg/5ml recon susp, 400 mg cap) 1

CEFOTAN 4

PAGE 52 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CEFOTAXIME SODIUM (2 GM RECON SOLN, 10 GM RECON SOLN, 500 MG RECON SOLN) 4

cefotaxime sodium 1 gm recon soln 1

cefotetan disodium (1 gm recon soln, 2 gm recon soln) 1

CEFOTETAN DISODIUM 10 GM RECON SOLN 3

cefoxitin sodium 1

CEFOXITIN SODIUM-DEXTROSE 3 cefpodoxime proxetil (50 mg/5ml recon susp, 100 mg tab, 100 mg/5ml recon susp, 200 mg tab) 1 cefprozil (125 mg/5ml recon susp, 250 mg tab, 250 mg/5ml recon susp, 500 mg tab) 1 ceftazidime (1 gm recon soln, 2 gm recon soln, 6 gm recon soln) 1

CEFTAZIDIME AND DEXTROSE 3

CEFTIBUTEN (180 MG/5ML RECON SUSP, 400 MG CAP) 3 CEFTIN (125 MG/5ML RECON SUSP, 250 MG TAB, 250 MG/5ML RECON SUSP, 500 MG TAB) 4

CEFTRI-IM 4 ceftriaxone sodium (1 gm recon soln, 2 gm recon soln, 10 gm recon soln, 250 mg recon soln, 500 mg recon soln) 1

CEFTRIAXONE SODIUM IN DEXTROSE 3

CEFTRIAXONE SODIUM-DEXTROSE 3

CEFTRISOL PLUS 4

cefuroxime axetil 1 cefuroxime sodium (1.5 gm recon soln, 7.5 gm recon soln, 750 mg recon soln) 1 cephalexin (125 mg/5ml recon susp, 250 mg cap, 250 mg/5ml recon susp, 500 mg cap, 750 mg cap) 1

CEPHALEXIN (250 MG TAB, 500 MG TAB) 3

CLAFORAN 4

CLAFORAN IN D5W 4

DAXBIA 4

FORTAZ 4

FORTAZ IN D5W 3

PAGE 53 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

KEFLEX 4

MAXIPIME 4

ROCEPHIN 4

SPECTRACEF 3 SUPRAX (100 MG CHEW TAB, 100 MG/5ML RECON SUSP, 200 MG CHEW TAB, 200 MG/5ML RECON SUSP, 400 MG 4 CAP, 500 MG/5ML RECON SUSP)

TAZICEF (1 GM RECON SOLN, 1 GM/50ML SOLUTION) 4

tazicef (1 gm recon soln, 2 gm recon soln, 6 gm recon soln) 1

TAZICEF 2 GM RECON SOLN 3

TEFLARO 3

ZERBAXA 3

ZINACEF 4

ZINACEF IN STERILE WATER 4 FLUOROQUINOLONES

AVELOX 400 MG TAB 4

AVELOX 400 MG/250ML SOLUTION 3

AVELOX ABC PACK 4

QL 1 Box / 28 Days BAXDELA 300 MG RECON SOLN 4 PA

QL 28 / 28 Days BAXDELA 450 MG TAB 4 PA

CIPRO (250 MG TAB, 250 MG/5ML (5%) RECON SUSP, 500 MG TAB) 4

CIPRO XR 4 CIPROFLOXACIN (200 MG/20ML SOLUTION, 400 MG/40ML SOLUTION) 4 ciprofloxacin (250 mg/5ml (5%) recon susp, 500 mg/5ml (10%) recon susp) 1

ciprofloxacin hcl (250 mg tab, 500 mg tab, 750 mg tab) 1

CIPROFLOXACIN HCL 100 MG TAB 4

ciprofloxacin in d5w 1

PAGE 54 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CIPROFLOXACIN-CIPROFLOX HCL ER 1

FACTIVE 3

LEVAQUIN (250 MG TAB, 500 MG TAB, 750 MG TAB) 4 levofloxacin (25 mg/ml solution, 250 mg tab, 500 mg tab, 750 mg tab) 1

levofloxacin in d5w 1

moxifloxacin hcl 400 mg tab 1

MOXIFLOXACIN HCL 400 MG/250ML SOLUTION 3

moxifloxacin hcl in nacl 1

OFLOXACIN 300 MG TAB 4

ofloxacin 400 mg tab 1 MACROLIDES

azithromycin (100 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg tab, 500 mg recon soln, 500 mg tab, 600 mg tab) 1

AZITHROMYCIN 1 GM PACKET 3 BIAXIN (250 MG TAB, 250 MG/5ML RECON SUSP, 500 MG TAB) 4 clarithromycin (125 mg/5ml recon susp, 250 mg tab, 250 mg/5ml recon susp, 500 mg tab) 1

CLARITHROMYCIN 125 MG/5ML RECON SUSP 2

CLARITHROMYCIN 250 MG/5ML RECON SUSP 4

clarithromycin er 1

DIFICID 4 PA

E.E.S. 400 3

E.E.S. GRANULES 4

ery-tab (250 mg tab dr, 333 mg tab dr) 1

ery-tab 500 mg tab dr 2

ERYPED 200 4

ERYPED 400 4

ERYTHROCIN LACTOBIONATE 3

ERYTHROCIN STEARATE 3

ERYTHROMYCIN POWDER 4

PAGE 55 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

erythromycin (250 mg tab dr, 333 mg tab dr) 1

erythromycin 500 mg tab dr 2 erythromycin base (250 mg cp dr part, 250 mg tab, 250 mg tab dr, 333 mg tab dr, 500 mg tab) 1

erythromycin base 500 mg tab dr 2

ERYTHROMYCIN ETHYLSUCCINATE POWDER 4 erythromycin ethylsuccinate (200 mg/5ml recon susp, 400 mg/5ml recon susp) 1

ERYTHROMYCIN ETHYLSUCCINATE 400 MG TAB 3

PCE 4 ZITHROMAX (100 MG/5ML RECON SUSP, 200 MG/5ML RECON SUSP, 250 MG TAB, 500 MG RECON SOLN, 500 MG 4 TAB, 600 MG TAB)

ZITHROMAX 1 GM PACKET 3

ZITHROMAX TRI-PAK 4

ZITHROMAX Z-PAK 4

ZMAX 4 PENICILLINS

AMOXICILLIN (125 MG CHEW TAB, 250 MG CHEW TAB) 3 amoxicillin (125 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg cap, 250 mg/5ml recon susp, 400 mg/5ml recon susp, 1 500 mg cap, 500 mg tab, 875 mg tab)

AMOXICILLIN ER 4

AMOXICILLIN TRIHYDRATE 4 amoxicillin-pot clavulanate (200-28.5 mg chew tab, 200-28.5 mg/5ml recon susp, 250-125 mg tab, 250-62.5 mg/5ml recon susp, 400-57 mg chew tab, 400-57 mg/5ml recon susp, 500- 1 125 mg tab, 600-42.9 mg/5ml recon susp, 875-125 mg tab) AMOXICILLIN-POT CLAVULANATE (200-28.5 MG CHEW TAB, 400-57 MG CHEW TAB) 4

amoxicillin-pot clavulanate er 1 AMPICILLIN (125 MG/5ML RECON SUSP, 250 MG/5ML RECON SUSP) 3

ampicillin (250 mg cap, 500 mg cap) 1

AMPICILLIN 500 MG CAP 2

PAGE 56 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AMPICILLIN SODIUM (1 GM RECON SOLN, 125 MG RECON SOLN) 3 ampicillin sodium (1 gm recon soln, 2 gm recon soln, 10 gm recon soln, 250 mg recon soln, 500 mg recon soln) 1

ampicillin-sulbactam sodium 1 AMPICILLIN-SULBACTAM SODIUM (1.5 (1-0.5) GM RECON SOLN, 3 (2-1) GM RECON SOLN) 4 AUGMENTIN (250-62.5 MG/5ML RECON SUSP, 500-125 MG TAB, 875-125 MG TAB) 4

AUGMENTIN 125-31.25 MG/5ML RECON SUSP 3

AUGMENTIN ES-600 4

AUGMENTIN XR 4

BICILLIN C-R 3

BICILLIN C-R 900/300 3

BICILLIN L-A 4

dicloxacillin sodium 1

MOXATAG 4

nafcillin sodium 1 NAFCILLIN SODIUM (1 GM RECON SOLN, 2 GM RECON SOLN) 3

NAFCILLIN SODIUM 10 GM RECON SOLN 4

NAFCILLIN SODIUM IN DEXTROSE 3

oxacillin sodium 1

OXACILLIN SODIUM IN DEXTROSE 3

PENICILLIN G POT IN DEXTROSE 3

penicillin g potassium 1

PENICILLIN G PROCAINE 4

PENICILLIN G SODIUM 3 penicillin v potassium (125 mg/5ml recon soln, 250 mg tab, 250 mg/5ml recon soln, 500 mg tab) 1 PENICILLIN V POTASSIUM (125 MG/5ML RECON SOLN, 250 MG/5ML RECON SOLN) 3

PFIZERPEN 4

PAGE 57 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS piperacillin sod-tazobactam so (d-tazobactam 2.25 (2-0.25) gm recon ln, d-tazobactam 3.375 (3-0.375) gm recon ln, d- tazobactam 4.5 (4-0.5) gm recon ln, d-tazobactam 40.5 (36-4.5) 1 gm recon ln)

piperacillin sod-tazobactam so 13.5 (12-1.5) gm recon soln 2

UNASYN 4 ZOSYN (2-0.25 GM/50ML SOLUTION, 3-0.375 GM/50ML SOLUTION, 4-0.5 GM/100ML SOLUTION) 3 ZOSYN (2.25 (2-0.25) GM RECON SOLN, 3.375 (3-0.375) GM RECON SOLN, 4.5 (4-0.5) GM RECON SOLN, 40.5 (36-4.5) 4 GM RECON SOLN) SULFONAMIDES

SULFADIAZINE POWDER 4

SULFADIAZINE 500 MG TAB 3

SULFADIAZINE SODIUM 4

SULFAMETHOXAZOLE 4

SULFAMETHOXAZOLE MICRO 4

SULFAPYRIDINE 4

SULFATHIAZOLE 4

SULFISOXIZOLE 4 TETRACYCLINES

ADOXA 4

ADOXA PAK 1/100 4

ADOXA PAK 1/150 4

ADOXA PAK 2/100 4

ALODOX CONVENIENCE 4

avidoxy 1

coremino 1 PA

demeclocycline hcl 1

doxy 100 1

DOXYCYCLINE HYCLATE POWDER 4 doxycycline hyclate (20 mg tab, 50 mg cap, 100 mg cap, 100 mg recon soln, 100 mg tab) 1

PAGE 58 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS doxycycline hyclate (75 mg tab dr, 100 mg tab dr, 150 mg tab PA dr) 1 doxycycline monohydrate (25 mg/5ml recon susp, 50 mg cap, 50 mg tab, 75 mg cap, 75 mg tab, 100 mg cap, 100 mg tab, 150 1 mg cap, 150 mg tab) MINOCIN (50 MG CAP, 50 MG KIT, 75 MG CAP, 100 MG CAP, 100 MG KIT) 4

MINOCIN 100 MG RECON SOLN 3

MINOCYCLINE HCL POWDER 4 minocycline hcl (50 mg cap, 50 mg tab, 75 mg cap, 75 mg tab, 100 mg cap, 100 mg tab) 1 minocycline hcl er (er 45 mg tab er 24h, er 90 mg tab er 24h, er PA 135 mg tab er 24h) 1

mondoxyne nl 1

MONODOX 4

morgidox (50 mg cap, 100 mg cap) 1

NUZYRA 100 MG RECON SOLN 4 PA

QL 30 / 14 day(s) NUZYRA 150 MG TAB 4 PA

OCUDOX 3

okebo 1

OXYTETRACYCLINE HCL 4

QL 30 / 30 day(s)

SEYSARA 4 PA

AL1 Up to 25 yrs old

soloxide 1 PA

tetracycline hcl (250 mg cap, 500 mg cap) 1

tigecycline 1

TIGECYCLINE 4

TYGACIL 4 VIBRAMYCIN (25 MG/5ML RECON SUSP, 50 MG/5ML SYRUP, 100 MG CAP) 4

PA XERAVA 6 S

PAGE 59 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIHISTAMINES/NASAL AGENTS/COUGH & COLD/RESPIRATORY/MISC

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

ACCOLATE 4

ADVAIR DISKUS 3 QL 1 Inhaler / 30 Days

ADVAIR HFA 3 QL 1 Inhaler / 30 Days

ALBUTEROL SULFATE POWDER 4 albuterol sulfate (0.63 mg/3ml nebu soln, 1.25 mg/3ml nebu soln, 2 mg tab, 2 mg/5ml syrup, (2.5 mg/3ml) 0.083% nebu soln, 2.5 mg/0.5ml nebu soln, 4 mg tab, (5 mg/ml) 0.5% nebu 1 soln)

albuterol sulfate er 1

ALBUTEROL SULFATE ER 4

AMINOPHYLLINE POWDER 4

aminophylline 25 mg/ml solution 1

AMINOPHYLLINE ANHYDROUS 4

ANORO ELLIPTA 3 QL 1 Inhaler / 30 Days

ARCAPTA NEOHALER 3 QL 1 Inhaler / 30 Days

ARMONAIR RESPICLICK 113 4 QL 1 Inhaler / 30 Days

ARMONAIR RESPICLICK 232 4 QL 1 Inhaler / 30 Days

ARMONAIR RESPICLICK 55 4 QL 1 Inhaler / 30 Days

ARNUITY ELLIPTA 3 QL 1 Inhaler / 30 Days

ASMANEX 120 METERED DOSES 3 QL 1 Inhaler / 30 Days

ASMANEX 14 METERED DOSES 3 QL 1 Inhaler / 30 Days

ASMANEX 30 METERED DOSES 3 QL 1 Inhaler / 30 Days

ASMANEX 60 METERED DOSES 3 QL 1 Inhaler / 30 Days

ASMANEX 7 METERED DOSES 3 QL 1 Inhaler / 30 Days

ASMANEX HFA 3 QL 1 Inhaler / 30 Days

ATROVENT HFA 3 QL 1 Inhaler / 30 Days

PAGE 60 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BEVESPI AEROSPHERE 4 QL 1 Inhaler / 30 Days

BREO ELLIPTA 3 QL 1 Inhaler / 30 Days

BROVANA 4 QL 1 Box / 30 Days

budesonide (0.25 mg/2ml suspension, 0.5 mg/2ml suspension, QL 2 Boxes / 30 Days 1 mg/2ml suspension) 1

CINQAIR 6 LA Limited Access

COMBIVENT RESPIMAT 3 QL 1 Inhaler / 30 Days

CROMOLYN SODIUM POWDER 4

cromolyn sodium 20 mg/2ml nebu soln 1

QL 28 / 180 Days DALIRESP 250 MCG TAB 3 PA

QL 30 / 30 Days DALIRESP 500 MCG TAB 3 PA

difil-g forte 1

ELIXOPHYLLIN 4

EPHEDRINE HCL 4

EPHEDRINE SULFATE POWDER 4

QL 1 Syringe / 56 Days

PA FASENRA 6 LA Limited Access

QL 1 / 56 day(s)

PA FASENRA PEN 6 LA Limited Access

FLOVENT DISKUS 3 QL 1 Inhaler / 30 Days

FLOVENT HFA 3 QL 2 Inhalers / 30 Days

FLUNISOLIDE POWDER 4

PAGE 61 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluticasone-salmeterol (100-50 mcg/dose aer pow ba, 250-50 QL 1 Inhaler / 30 Days mcg/dose aer pow ba, 500-50 mcg/dose aer pow ba) 1

FORADIL AEROLIZER 3

IPRATROPIUM BROMIDE POWDER 4

ipratropium bromide 0.02 % solution 1

ipratropium-albuterol 1

isoproterenol hcl 0.2 mg/ml solution 1

ISUPREL 4 levalbuterol hcl (0.31 mg/3ml nebu soln, 0.63 mg/3ml nebu QL 4 Boxes / 30 Days soln, 1.25 mg/3ml nebu soln) 1

levalbuterol hcl 1.25 mg/0.5ml nebu soln 1 QL 3 Boxes / 30 Days

LEVALBUTEROL TARTRATE 4 QL 1 Inhaler / 30 Days

LONHALA MAGNAIR REFILL KIT 4 QL 1 Inhaler / 30 Days

LONHALA MAGNAIR STARTER KIT 4 QL 1 Inhaler / 30 Days

LUFYLLIN 4

METAPROTERENOL SULFATE POWDER 4 METAPROTERENOL SULFATE (10 MG TAB, 10 MG/5ML SYRUP, 20 MG TAB) 3 montelukast sodium (4 mg chew tab, 4 mg packet, 5 mg chew tab, 10 mg tab) 1

PA NUCALA (100 MG RECON SOLN, 100 MG/ML SOLN A-INJ, LA Limited Access 100 MG/ML SOLN PRSYR) 5 S

PERFOROMIST 3

PROAIR HFA 3 QL 1 Inhaler / 30 Days

PROAIR RESPICLICK 3 QL 1 Inhaler / 30 Days

PULMICORT 4 QL 2 Boxes / 30 Days

PULMICORT FLEXHALER 180 MCG/ACT AER POW BA 3 QL 2 Inhalers / 30 Days

PULMICORT FLEXHALER 90 MCG/ACT AER POW BA 3 QL 1 Inhaler / 30 Days

QVAR 3

PAGE 62 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QVAR REDIHALER 40 MCG/ACT AERO BA 3 QL 3 Inhalers / 30 Days

QVAR REDIHALER 80 MCG/ACT AERO BA 3 QL 2 Inhalers / 30 Days

SEEBRI NEOHALER 3 QL 1 Inhaler / 30 Days

SEREVENT DISKUS 3 QL 1 Inhaler / 30 Days

SINGULAIR 4

SPIRIVA HANDIHALER 3 QL 1 Inhaler / 30 Days

SPIRIVA RESPIMAT 3 QL 1 Inhaler / 30 Days

STIOLTO RESPIMAT 3 QL 1 Inhaler / 30 Days

STRIVERDI RESPIMAT 4 QL 1 Inhaler / 30 Days

SYMBICORT 3 QL 1 Inhaler / 30 Days

TERBUTALINE SULFATE POWDER 4

terbutaline sulfate (1 mg/ml solution, 2.5 mg tab, 5 mg tab) 1 THEO-24 (100 MG CAP ER 24H, 200 MG CAP ER 24H, 300 MG CAP ER 24H) 4

THEO-24 400 MG CAP ER 24H 3

THEOCHRON (100 MG TAB ER 12H, 200 MG TAB ER 12H) 3

theochron 300 mg tab er 12h 1

theophylline 1

theophylline er 1 THEOPHYLLINE ER (ER 300 MG TAB ER 12H, ER 450 MG TAB ER 12H) 3

THEOPHYLLINE-ETHYLENEDIAMINE 4

TRELEGY ELLIPTA 4 QL 1 Inhaler / 30 Days

UTIBRON NEOHALER 4 QL 1 Inhaler / 30 Days

VOSPIRE ER 4

wixela inhub 1 QL 1 Inhaler / 30 Days

PA XOLAIR (75 MG/0.5ML SOLN PRSYR, 150 MG RECON LA Limited Access SOLN, 150 MG/ML SOLN PRSYR) 5 S

PAGE 63 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XOPENEX (0.31 MG/3ML NEBU SOLN, 0.63 MG/3ML NEBU QL 4 Boxes / 30 Days SOLN) 4

XOPENEX CONCENTRATE 4 QL 3 Boxes / 30 Days

YUPELRI 4 QL 1 Box / 30 Days

zafirlukast 1 ANTIHISTAMINES

arbinoxa (4 mg tab, 4 mg/5ml solution) 1

BROMPHENIRAMINE MALEATE POWDER 4

BROMPHENIRAMINE MALEATE 10 MG/ML SOLUTION 3

BROMPHENIRAMINE TANNATE 4

carbinoxamine maleate (4 mg tab, 4 mg/5ml solution) 1

cetirizine hcl 1

CHLORPHENIRAMINE MALEATE 4

CLARINEX 0.5 MG/ML SYRUP 4 QL 300 Milliliters / 30 Days

CLARINEX 5 MG TAB 4 QL 30 / 30 Days

CLEMASTINE FUMARATE (2.68 MG TAB, POWDER) 4

clemastine fumarate 2.68 mg tab 1

cyproheptadine hcl (2 mg/5ml syrup, 4 mg tab) 1

DESLORATADINE (2.5 MG TAB DISP, 5 MG TAB DISP) 4 QL 30 / 30 Days

desloratadine 5 mg tab 1 QL 30 / 30 Days

DEXCHLORPHENIRAMINE MALEATE (2 MG/5ML SOLUTION, 2 MG/5ML SYRUP) 4

DICOPANOL RAPIDPAQ 4

diphen 1

DIPHENHYDRAMINE HCL POWDER 4

diphenhydramine hcl (12.5 mg/5ml elixir, 50 mg/ml solution) 1

DOXYLAMINE SUCCINATE 4

KARBINAL ER 3

levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tab) 1

phenadoz 1

PAGE 64 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

phenergan (12.5 mg suppos, 25 mg suppos, 50 mg suppos) 1

PHENERGAN (25 MG/ML SOLUTION, 50 MG/ML SOLUTION) 4 promethazine hcl (6.25 mg/5ml solution, 6.25 mg/5ml syrup, 12.5 mg suppos, 12.5 mg tab, 25 mg suppos, 25 mg tab, 25 1 mg/ml solution, 50 mg suppos, 50 mg tab, 50 mg/ml solution)

promethegan (12.5 mg suppos, 25 mg suppos) 1

PROMETHEGAN 50 MG SUPPOS 3

PYRILAMINE MALEATE 4

RESPA-BR 4

RYCLORA 4

TRIPELENNAMINE HCL 4

XYZAL (2.5 MG/5ML SOLUTION, 5 MG TAB) 4 COUGH/COLD/ALLERGY

ACETYLCYSTEINE POWDER 4

acetylcysteine (10 % solution, 20 % solution) 1

ALBATUSSIN 3

ALBATUSSIN NN 4

benzonatate 1

biotuss pediatric 1

bromfed dm 1

BROMHEXINE HCL 4

CARBAPHEN 12 4

CARBAPHEN 12 PED 4

CLARINEX-D 12 HOUR 4 QL 60 / 30 Days

CODAR AR 4

CPB WC 3

DECON-A 3

DECON-G 3

DEXTROMETHORPHAN HBR 4

DEXTROMETHORPHAN HBR MONOHYD 4

FLOWTUSS 3

PAGE 65 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GILPHEX TR 4

giltuss pediatric 1

GILTUSS TR 4

GUAIFENESIN 4

HYCOFENIX 4

hydrocod polst-cpm polst er 1

HYDROCODONE-GUAIFENESIN 3

hydrocodone-homatropine (mg tab, mg/5ml syrup) 1

hydromet 1

HYPERSAL 4

N-ACETYL-L-CYSTEINE POWDER 4

nebusal 3 % nebu soln 1

NEBUSAL 6 % NEBU SOLN 4

NEOTUSS PLUS 3

nortuss-de 1

NORTUSS-EX 4

OBREDON 3

PHENYLEPHRINE-GUAIFENESIN 4

promethazine vc plain 1

promethazine vc/codeine 1

promethazine-codeine 1

PROMETHAZINE-DM 3

promethazine-dm 6.25-15 mg/5ml syrup 1

promethazine-phenyleph-codeine 1

PROMETHAZINE-PHENYLEPHRINE 1

pseudoeph-bromphen-dm 1

pseudoeph-chlorphen-hydrocod 1

PSEUDOEPH-CHLORPHEN-HYDROCOD 4

pulmosal 1

RELHIST 4

PAGE 66 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

RESCON-JR 3-20 MG TAB ER 12H 4

REZIRA 4

SEMPREX-D 4 sodium chloride (0.9 % nebu soln, 3 % nebu soln, 7 % nebu soln, 10 % nebu soln) 1

SSKI 4

TERPIN HYDRATE 4

TERPIN HYDRATE MONOHYDRATE 4

TESSALON PERLES 4

TUSSICAPS 3

tussigon 1

TUSSIONEX PENNKINETIC ER 4

TUXARIN ER 4 QL 60 / 30 day(s)

TUZISTRA XR 4

VITUZ 3

ZONATUSS 4

ZUTRIPRO 4 NASAL AGENTS - SYSTEMIC AND TOPICAL

ADRENALIN 0.1 % SOLUTION 4

ASTEPRO 4 QL 1 Inhaler / 30 Days

ATROVENT 4

azelastine hcl (0.1 % solution, 137 mcg/spray solution) 1

azelastine hcl 0.15 % solution 1 QL 1 Inhaler / 30 Days

BACTROBAN NASAL 4

BECONASE AQ 4 QL 1 Inhaler / 30 Days

budesonide 32 mcg/act suspension 1

DYMISTA 3 QL 1 Inhaler / 30 Days

FLUNISOLIDE 25 MCG/ACT (0.025%) SOLUTION 4

fluticasone propionate 50 mcg/act suspension 1

ipratropium bromide (0.03 % solution, 0.06 % solution) 1

PAGE 67 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

mometasone furoate 50 mcg/act suspension 1 QL 1 Inhaler / 30 Days

NASONEX 4 QL 1 Inhaler / 30 Days

olopatadine hcl 0.6 % solution 1 QL 1 Inhaler / 30 Days

OMNARIS 4 QL 1 Inhaler / 30 Days

PATANASE 4 QL 1 Inhaler / 30 Days

PHENYLEPHRINE HCL (CRYSTALS, POWDER) 4

PHENYLPROPANOLAMINE HCL 4

PROPEL 4

PROPEL MINI 4

PSEUDOEPHEDRINE HCL 4

QNASL 3 QL 1 Inhaler / 30 Days

QNASL CHILDRENS 3 QL 1 Inhaler / 30 Days

QL 2 / 365 day(s)

SINUVA 4 PA

LA Limited Access

triamcinolone acetonide 55 mcg/act aerosol 1

TYZINE 4

VERAMYST 4 QL 1 Inhaler / 30 Days

ZETONNA 4 QL 1 Inhaler / 30 Days

RESPIRATORY AGENTS - MISC.

PA ARALAST NP (400 MG RECON SOLN, 500 MG RECON LA Limited Access SOLN, 1000 MG RECON SOLN) 5 S

LA Limited Access ARALAST NP 800 MG RECON SOLN 5 S

QL 270 / 30 Days

PA ESBRIET (267 MG CAP, 267 MG TAB) 5 LA Limited Access

PAGE 68 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 90 / 30 Days

PA ESBRIET 801 MG TAB 5 LA Limited Access

GLASSIA 5 LA Limited Access

QL 60 / 30 Days

PA KALYDECO (50 MG PACKET, 75 MG PACKET, 150 MG TAB) 5 LA Limited Access

QL 60 / 30 day(s)

PA KALYDECO 25 MG PACKET 5 LA Limited Access

QL 60 / 30 Days

PA OFEV 5 LA Limited Access

QL 60 / 30 Days

ORKAMBI (100-125 MG PACKET, 150-188 MG PACKET) 5 AL1 Up to 5 yrs old

LA Limited Access

QL 120 / 30 Days

PA ORKAMBI (100-125 MG TAB, 200-125 MG TAB) 5 LA Limited Access

PA PROLASTIN-C (1000 MG RECON SOLN, 1000 MG/20ML LA Limited Access SOLUTION) 5 S

PAGE 69 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 Boxes / 30 Days

PA PULMOZYME 5 LA Limited Access

SCLEROSOL INTRAPLEURAL 3

SURFAXIN 4

SURVANTA 4

QL 56 / 28 day(s)

PA SYMDEKO 6 LA Limited Access

QL 84 / 28 day(s)

TRIKAFTA 6 AL1 At least 12 yrs old

LA Limited Access

ZEMAIRA 5 LA Limited Access

ANTINEOPLASTIC AGENTS AND ADJUNCTIVE THERAPIES

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

QL 120 / 30 day(s)

abiraterone acetate 5 PA

ABRAXANE 5 S

LA Limited Access ACTIMMUNE 5 S

ADCETRIS 6 LA Limited Access

PAGE 70 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADRIAMYCIN (2 MG/ML SOLUTION, 10 MG RECON SOLN, S 50 MG RECON SOLN) 5

adrucil 5 S

QL 28 / 28 day(s)

PA AFINITOR (2.5 MG TAB, 5 MG TAB, 7.5 MG TAB) 6 LA Limited Access

QL 28 / 28 Days

PA AFINITOR 10 MG TAB 5 LA Limited Access

QL 60 / 30 Days

PA AFINITOR DISPERZ (2 MG TAB SOL, 5 MG TAB SOL) 5 LA Limited Access

QL 90 / 30 Days

PA AFINITOR DISPERZ 3 MG TAB SOL 5 LA Limited Access

QL 240 / 30 Days

PA ALECENSA 5 LA Limited Access

ALFERON N 5 S

ALIMTA 5 S

QL 3 Vials / 28 Days

PA ALIQOPA 6 LA Limited Access

ALKERAN 2 MG TAB 6 S

PA ALKERAN 50 MG RECON SOLN 6 S

PAGE 71 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 Days

PA ALUNBRIG (90 MG TAB, 180 MG TAB) 5 LA Limited Access

QL 180 / 30 Days

PA ALUNBRIG 30 MG TAB 5 LA Limited Access

QL 1 / 365 Days

PA ALUNBRIG 90 & 180 MG TAB THPK 5 LA Limited Access

amifostine 5 S

anastrozole 1 mg tab 1

ARIMIDEX 4

AROMASIN 4

ARRANON 5 S

arsenic trioxide (10 mg/10ml solution, 12 mg/6ml solution) 5 S

ARZERRA 5 LA Limited Access

PA ASPARLAS 5 S

PA AVASTIN 5 S

PA azacitidine 5 S

AZEDRA DOSIMETRIC 6 S

AZEDRA THERAPEUTIC 6 S

PAGE 72 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 84 / 28 day(s)

PA BALVERSA 3 MG TAB 6 LA Limited Access

QL 56 / 28 day(s)

PA BALVERSA 4 MG TAB 6 LA Limited Access

QL 28 / 28 day(s)

PA BALVERSA 5 MG TAB 6 LA Limited Access

BAVENCIO 5 LA Limited Access

LA Limited Access BELEODAQ 6 S

BELRAPZO 5 LA Limited Access

BENDAMUSTINE HCL 5 LA Limited Access

BENDEKA 5 LA Limited Access

QL 6 / Lifetime

BESPONSA 5 PA

PA bexarotene 5 S

PAGE 73 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

bicalutamide 1

BICNU 5 S

BLEO 15K 6 S

bleomycin sulfate 5 S

BLINCYTO 6 LA Limited Access

PA BORTEZOMIB 5 S

QL 30 / 30 Days

PA BOSULIF (400 MG TAB, 500 MG TAB) 5 LA Limited Access

QL 120 / 30 Days

PA BOSULIF 100 MG TAB 5 LA Limited Access

QL 270 / 30 Days

PA BRAFTOVI 50 MG CAP 6 LA Limited Access

QL 180 / 30 Days

PA BRAFTOVI 75 MG CAP 6 LA Limited Access

QL 120 / 30 day(s)

PA BRUKINSA 6 LA Limited Access

busulfan 5 S

PAGE 74 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BUSULFEX 6 S

QL 30 / 30 Days

PA CABOMETYX 6 LA Limited Access

QL 60 / 30 Days

PA CALQUENCE 5 LA Limited Access

CAMPATH 5 LA Limited Access

CAMPTOSAR (40 MG/2ML SOLUTION, 100 MG/5ML S SOLUTION) 6

CAMPTOSAR 300 MG/15ML SOLUTION 5 S

PA capecitabine 5 S

QL 60 / 30 Days

PA CAPRELSA 100 MG TAB 5 LA Limited Access

QL 30 / 30 Days

PA CAPRELSA 300 MG TAB 5 LA Limited Access

carboplatin 5 S

carmustine 5 S

CASODEX 4 cisplatin (50 mg recon soln, 50 mg/50ml solution, 100 mg/100ml S solution, 200 mg/200ml solution) 5

cladribine 5 S

PAGE 75 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

clofarabine 5 S

CLOLAR 6 S

QL 56 / 28 Days

PA COMETRIQ (100 MG DAILY DOSE) 6 LA Limited Access

QL 120 / 30 Days

PA COMETRIQ (140 MG DAILY DOSE) 6 LA Limited Access

QL 84 / 28 Days

PA COMETRIQ (60 MG DAILY DOSE) 6 LA Limited Access

QL 60 / 30 Days

PA COPIKTRA 5 LA Limited Access

COSMEGEN 6 S

QL 90 / 30 Days

PA COTELLIC 5 LA Limited Access

cyclophosphamide (1 gm recon soln, 2 gm recon soln, 25 mg S cap, 50 mg cap, 500 mg recon soln) 5

CYCLOPHOSPHAMIDE (25 MG CAP, 50 MG CAP) 6 S

CYRAMZA 5 LA Limited Access

CYTARABINE 5 S

PAGE 76 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cytarabine (pf) 5 S

DACARBAZINE (100 MG RECON SOLN, 200 MG RECON S SOLN) 5

DACOGEN 6 LA Limited Access

dactinomycin 5 S

DARZALEX 5 LA Limited Access

DAUNORUBICIN HCL 5 S

DAUNOXOME 6 S

QL 30 / 30 Days

PA DAURISMO 100 MG TAB 5 LA Limited Access

QL 60 / 30 Days

PA DAURISMO 25 MG TAB 5 LA Limited Access

LA Limited Access decitabine 5 S

DEPO-PROVERA 400 MG/ML SUSPENSION 3

DEPOCYT 6 S

dexrazoxane hcl 1

DOCEFREZ 5 S

PAGE 77 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DOCETAXEL (20 MG/0.5ML CONC, 20 MG/2ML SOLUTION, 20 MG/ML CONC, 80 MG/2ML CONC, 80 MG/4ML CONC, 80 MG/8ML SOLUTION, 140 MG/7ML CONC, 160 MG/16ML 5 S SOLUTION, 160 MG/8ML CONC, 200 MG/10ML CONC, 200 MG/20ML SOLUTION) DOCETAXEL (20 MG/2ML SOLUTION, 20 MG/ML CONC, 80 MG/4ML CONC, 80 MG/8ML SOLUTION, 160 MG/16ML 6 S SOLUTION)

DOCETAXEL (NON-ALCOHOL) 5 S

DOXIL 6 S

doxorubicin hcl (2 mg/ml solution, 10 mg recon soln, 50 mg S recon soln) 5

doxorubicin hcl liposomal 5 S

QL 1 Injection / 84 Days

ELIGARD 22.5 MG KIT 5 PA

QL 1 Injection / 112 Days

ELIGARD 30 MG KIT 5 PA

QL 1 / 180 Days

ELIGARD 45 MG KIT 5 PA

QL 1 Injection / 28 Days

ELIGARD 7.5 MG KIT 5 PA

ELITEK 3

ELLENCE 6 S

PA ELZONRIS 5 S

EMCYT 5 S

EMPLICITI 6 LA Limited Access

PAGE 78 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ENHERTU 6 LA Limited Access

epirubicin hcl 5 S

PA ERBITUX 5 S

QL 30 / 30 Days

PA ERIVEDGE 5 LA Limited Access

QL 120 / 30 Days

PA ERLEADA 6 LA Limited Access

QL 30 / 30 day(s)

PA erlotinib hcl 5 LA Limited Access

LA Limited Access ERWINAZE 6 S

ETHYOL 6 S

ETOPOPHOS 5 S

ETOPOSIDE (1 GM/50ML SOLUTION, 50 MG CAP, 100 S MG/5ML SOLUTION, 500 MG/25ML SOLUTION) 5

QL 28 / 28 day(s)

PA everolimus 5 LA Limited Access

EVOMELA 6 LA Limited Access

PAGE 79 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

exemestane 1

FARESTON 4

QL 6 / 21 Days

PA FARYDAK 6 LA Limited Access

FASLODEX 6 S

FEMARA 4

QL 2 Vials / 365 Days

FIRMAGON 120 MG RECON SOLN 5 PA

QL 1 Vial / 28 Days

FIRMAGON 80 MG RECON SOLN 5 PA

floxuridine 0.5 gm recon soln 5 S

fludarabine phosphate (50 mg recon soln, 50 mg/2ml solution) 5 S

fluorouracil (1 gm/20ml solution, 2.5 gm/50ml solution, 5 S gm/100ml solution, 500 mg/10ml solution) 5

flutamide 1

FOLOTYN 5 S

FULVESTRANT 5 S

FUSILEV 6 S

GAZYVA 5 LA Limited Access

GEMCITABINE HCL (1 GM RECON SOLN, 1 GM/10ML SOLUTION, 1 GM/26.3ML SOLUTION, 1.5 GM/15ML SOLUTION, 2 GM RECON SOLN, 2 GM/20ML SOLUTION, 2 5 S GM/52.6ML SOLUTION, 200 MG RECON SOLN, 200 MG/2ML SOLUTION, 200 MG/5.26ML SOLUTION)

GEMCITABINE HCL 200 MG/5.26ML SOLUTION 6 S

PAGE 80 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GEMZAR 6 S

QL 30 / 30 Days

PA GILOTRIF 5 LA Limited Access

QL 90 / 30 Days GLEEVEC 100 MG TAB 6 S

QL 60 / 30 Days GLEEVEC 400 MG TAB 6 S

PA GLEOSTINE 5 S

GLIADEL WAFER 5 S

PA HALAVEN 5 S

HERCEPTIN 5 LA Limited Access

HERCEPTIN HYLECTA 6 LA Limited Access

HEXALEN 3

PA HYCAMTIN (0.25 MG CAP, 1 MG CAP) 5 S

HYCAMTIN 4 MG RECON SOLN 6 S

HYDREA 4 HYDROXYPROGESTERONE CAPROATE 1.25 GM/5ML S SOLUTION 5

hydroxyurea 500 mg cap 1

QL 21 / 28 Days

PA IBRANCE 6 LA Limited Access

PAGE 81 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 Days

PA ICLUSIG 15 MG TAB 5 LA Limited Access

QL 30 / 30 day(s)

PA ICLUSIG 45 MG TAB 5 LA Limited Access

IDAMYCIN PFS 6 S

idarubicin hcl 5 S

QL 30 / 30 Days

PA IDHIFA 6 LA Limited Access

IFEX 1 GM RECON SOLN 6 S

IFEX 3 GM RECON SOLN 5 S

ifosfamide (1 gm recon soln, 1 gm/20ml solution, 3 gm recon S soln, 3 gm/60ml solution) 5

QL 90 / 30 Days

imatinib mesylate 100 mg tab 5 PA

QL 60 / 30 Days

imatinib mesylate 400 mg tab 5 PA

QL 30 / 30 Days

IMBRUVICA (140 MG TAB, 280 MG TAB, 420 MG TAB, 560 PA 5 MG TAB) LA Limited Access

QL 120 / 30 Days

PA IMBRUVICA 140 MG CAP 5 LA Limited Access

PAGE 82 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 Days

PA IMBRUVICA 70 MG CAP 5 LA Limited Access

IMFINZI 6 LA Limited Access

PA IMLYGIC 6 S

INFUGEM (1200-0.9 MG/120ML-% SOLUTION, 1300-0.9 MG/130ML-% SOLUTION, 1400-0.9 MG/140ML-% SOLUTION, 1500-0.9 MG/150ML-% SOLUTION, 1600-0.9 MG/160ML-% S SOLUTION, 1700-0.9 MG/170ML-% SOLUTION, 1800-0.9 5 MG/180ML-% SOLUTION, 2000-0.9 MG/200ML-% SOLUTION, 2200-0.9 MG/220ML-% SOLUTION)

INFUGEM 1900-0.9 MG/190ML-% SOLUTION 6 S

QL 180 / 30 Days

PA INLYTA 1 MG TAB 5 LA Limited Access

QL 120 / 30 Days

PA INLYTA 5 MG TAB 5 LA Limited Access

QL 120 / 30 day(s)

INREBIC 6 AL1 At least 18 yrs old

LA Limited Access

INTRON A (6000000 UNIT/ML SOLUTION, 10000000 UNIT PA RECON SOLN, 10000000 UNIT/ML SOLUTION, 18000000 5 UNIT RECON SOLN, 50000000 UNIT RECON SOLN) S

QL 30 / 30 Days

PA IRESSA 5 LA Limited Access

PAGE 83 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS irinotecan hcl (40 mg/2ml solution, 100 mg/5ml solution, 500 S mg/25ml solution) 5

ISTODAX 5 S

ISTODAX (OVERFILL) 5 LA Limited Access

IXEMPRA KIT 5 S

QL 60 / 30 Days

PA JAKAFI 5 LA Limited Access

JEVTANA 5 LA Limited Access

KADCYLA 5 LA Limited Access

PA KANJINTI 6 S

KEPIVANCE 6 S

KEYTRUDA (50 MG RECON SOLN, 100 MG/4ML SOLUTION) 5 LA Limited Access

KHAPZORY 6 S

QL 1 Box / 28 Days

KISQALI 200 DOSE 5 PA

QL 1 Box / 28 Days

KISQALI 400 DOSE 5 PA

PAGE 84 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Box / 28 Days

KISQALI 600 DOSE 5 PA

QL 49 / 28 Days

KISQALI FEMARA 200 DOSE 5 PA

QL 70 / 28 Days

KISQALI FEMARA 400 DOSE 5 PA

QL 91 / 28 Days

KISQALI FEMARA 600 DOSE 5 PA

QL 1 / Lifetime

PA KYMRIAH 6 LA Limited Access

KYPROLIS 5 LA Limited Access

LARTRUVO 5 LA Limited Access

QL 30 / 30 Days

PA LENVIMA 10 MG DAILY DOSE 5 LA Limited Access

QL 90 / 30 Days

PA LENVIMA 12 MG DAILY DOSE 5 LA Limited Access

PAGE 85 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 90 / 30 Days

PA LENVIMA 18 MG DAILY DOSE 5 LA Limited Access

QL 60 / 30 Days

PA LENVIMA 20 MG DAILY DOSE 5 LA Limited Access

QL 90 / 30 Days

PA LENVIMA 24 MG DAILY DOSE 5 LA Limited Access

QL 30 / 30 Days

PA LENVIMA 4 MG DAILY DOSE 5 LA Limited Access

QL 60 / 30 Days

PA LENVIMA 8 MG DAILY DOSE 5 LA Limited Access

letrozole 2.5 mg tab 1 LEUCOVORIN CALCIUM (10 MG TAB, 15 MG TAB, 100 MG/10ML SOLUTION) 3 leucovorin calcium (5 mg tab, 25 mg tab, 50 mg recon soln, 100 mg recon soln, 200 mg recon soln, 350 mg recon soln) 1

leucovorin calcium 500 mg recon soln 5 S

leucovorin calcium 500 mg/50ml solution 2

LEUKERAN 3

PA leuprolide acetate 1 mg/0.2ml kit 5 S

LEVAMISOLE HCL 4

PAGE 86 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEVOLEUCOVORIN CALCIUM (50 MG RECON SOLN, 175 S MG RECON SOLN) 5

levoleucovorin calcium 175 mg/17.5ml solution 5

levoleucovorin calcium pf 5 S

QL 1 / 21 day(s)

PA LIBTAYO 5 LA Limited Access

lipodox 5 S

lipodox 50 5 S

PA LOMUSTINE 5 S

LONSURF 5 LA Limited Access

QL 30 / 30 day(s)

PA LORBRENA 100 MG TAB 5 LA Limited Access

QL 90 / 30 day(s)

PA LORBRENA 25 MG TAB 5 LA Limited Access

LUMOXITI 5 LA Limited Access

QL 1 Injection / 28 Days

LUPRON DEPOT (1-MONTH) 5 PA

QL 1 Injection / 84 Days

LUPRON DEPOT (3-MONTH) 5 PA

PAGE 87 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / 120 Days

LUPRON DEPOT (4-MONTH) 5 PA

QL 1 / 180 Days

LUPRON DEPOT (6-MONTH) 5 PA

QL 120 / 30 Days

PA LYNPARZA (100 MG TAB, 150 MG TAB) 5 LA Limited Access

LYNPARZA 50 MG CAP 5 LA Limited Access

QL 600 / 30 Days

PA LYSODREN 5 LA Limited Access

MARQIBO 5 S

MATULANE 5 LA Limited Access

MEGACE ORAL 4

MEGESTROL ACETATE POWDER 4 megestrol acetate (20 mg tab, 40 mg tab, 40 mg/ml suspension, 400 mg/10ml suspension) 1

QL 90 / 30 Days

PA MEKINIST 0.5 MG TAB 5 LA Limited Access

QL 30 / 30 Days

PA MEKINIST 2 MG TAB 5 LA Limited Access

PAGE 88 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 180 / 30 Days

PA MEKTOVI 6 LA Limited Access

PA melphalan 5 S

melphalan hcl 5 S

mercaptopurine 50 mg tab 1

mesna 5 S

MESNEX 100 MG/ML SOLUTION 6 S

MESNEX 400 MG TAB 5 S

METASTRON 3

METHOTREXATE POWDER 4

methotrexate 2.5 mg tab 1 methotrexate sodium (1 gm recon soln, 2.5 mg tab, 50 mg/2ml solution) 1 methotrexate sodium (pf) (, 100 mg/4ml solution, 200 mg/8ml solution) 1

METHOTREXATE SODIUM 250 MG/10ML SOLUTION 4 mitomycin (5 mg recon soln, 20 mg recon soln, 20 mg/40ml S soln prsyr, 40 mg recon soln) 5

PA mitoxantrone hcl 5 S

MUSTARGEN 5 S

mutamycin 5 S

PA MVASI (100 MG/4ML SOLUTION, 400 MG/16ML SOLUTION) 6 S

PA MYLERAN 5 S

MYLOTARG 6 LA Limited Access

PAGE 89 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NAVELBINE 6 S

QL 180 / 30 Days

PA NERLYNX 5 LA Limited Access

QL 120 / 30 Days

PA NEXAVAR 5 LA Limited Access

NILANDRON 4

nilutamide 1

QL 3 / 28 Days

PA NINLARO 5 LA Limited Access

NIPENT 6 S

QL 120 / 30 day(s)

NUBEQA 6 AL1 At least 18 yrs old

LA Limited Access

QL 30 / 30 Days

ODOMZO 6 PA

PA OGIVRI 6 S

LA Limited Access ONCASPAR 5 S

ONIVYDE 5 LA Limited Access

PAGE 90 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

OPDIVO 5 LA Limited Access

oxaliplatin (50 mg recon soln, 50 mg/10ml solution, 100 mg S recon soln, 100 mg/20ml solution) 5 paclitaxel (30 mg/5ml conc, 100 mg/16.7ml conc, 150 mg/25ml S conc, 300 mg/50ml conc) 5

PADCEV (20 MG RECON SOLN, 30 MG RECON SOLN) 6 LA Limited Access

PERJETA 5 LA Limited Access

PA PHOTOFRIN 5 S

QL 1 Box / 28 Days

PIQRAY 200MG DAILY DOSE 5 PA

QL 1 Box / 28 Days

PIQRAY 250MG DAILY DOSE 5 PA

QL 1 Box / 28 Days

PIQRAY 300MG DAILY DOSE 5 PA

PA POLIVY 5 S

QL 21 / 28 Days

PA POMALYST 5 LA Limited Access

PORTRAZZA 6 LA Limited Access

PAGE 91 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

POTELIGEO 5 LA Limited Access

PROLEUKIN 5 S

PROVENGE 5 LA Limited Access

LA Limited Access PURIXAN 5 S

RITUXAN 5 LA Limited Access

RITUXAN HYCELA 5 LA Limited Access

ROMIDEPSIN 5 LA Limited Access

QL 150 / 30 day(s)

ROZLYTREK 100 MG CAP 6 AL1 At least 12 yrs old

LA Limited Access

QL 90 / 30 day(s)

ROZLYTREK 200 MG CAP 6 AL1 At least 12 yrs old

LA Limited Access

QL 120 / 30 Days

PA RUBRACA 5 LA Limited Access

PAGE 92 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 240 / 30 Days

RYDAPT 5 PA

SOLTAMOX 3

QL 60 / 30 Days SPRYCEL (20 MG TAB, 50 MG TAB, 70 MG TAB, 80 MG TAB, PA 100 MG TAB) 5 S

QL 30 / 30 Days

SPRYCEL 140 MG TAB 5 PA

QL 84 / 28 Days

PA STIVARGA 5 LA Limited Access

QL 30 / 30 Days

PA SUTENT 5 LA Limited Access

SYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG KIT) 5 LA Limited Access

LA Limited Access SYLATRON (4 200 MCG KIT, 4 300 MCG KIT) 5 S

PA SYNRIBO 5 S

TABLOID 5 S

QL 120 / 30 Days

PA TAFINLAR 5 LA Limited Access

PAGE 93 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 Days

PA TAGRISSO 5 LA Limited Access

QL 90 / 30 day(s)

PA TALZENNA 0.25 MG CAP 5 LA Limited Access

QL 30 / 30 day(s)

PA TALZENNA 1 MG CAP 5 LA Limited Access

tamoxifen citrate (10 mg tab, 20 mg tab) 1

QL 30 / 30 day(s)

PA TARCEVA 6 LA Limited Access

TARGRETIN 75 MG CAP 6 S

QL 120 / 30 Days

TASIGNA (50 MG CAP, 150 MG CAP) 5 PA

QL 60 / 30 Days

TASIGNA 200 MG CAP 5 PA

TAXOTERE 6 S

QL 1 Vial / 21 Days

PA TECENTRIQ 1200 MG/20ML SOLUTION 5 LA Limited Access

QL 2 Vials / 28 Days

PA TECENTRIQ 840 MG/14ML SOLUTION 5 LA Limited Access

PAGE 94 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TEMODAR (5 MG CAP, 20 MG CAP, 100 MG CAP, 140 MG S CAP, 180 MG CAP, 250 MG CAP) 6

PA TEMODAR 100 MG RECON SOLN 5 S

PA temozolomide 5 S

PA temsirolimus 5 S

TENIPOSIDE 5 S

TEPADINA 100 MG RECON SOLN 5 S

TEPADINA 15 MG RECON SOLN 6 S

THERACYS 5 S

thiotepa 15 mg recon soln 5 S

QL 60 / 30 Days

PA TIBSOVO 5 LA Limited Access

TICE BCG 5 S

toposar 5 S

topotecan hcl (4 mg recon soln, 4 mg/4ml solution) 5 S

TOPOTECAN HCL 4 MG/4ML SOLUTION 6 S

toremifene citrate 1

PA TORISEL 6 S

TREANDA (25 MG RECON SOLN, 45 MG/0.5ML SOLUTION, S 100 MG RECON SOLN, 180 MG/2ML SOLUTION) 5

QL 1 Injection / 84 Days

TRELSTAR 11.25 MG RECON SUSP 6 PA

PAGE 95 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Injection / 28 Days

TRELSTAR 3.75 MG RECON SUSP 6 PA

QL 1 Injection / 84 Days

TRELSTAR MIXJECT 11.25 MG RECON SUSP 6 PA

QL 1 Box / 180 Days

TRELSTAR MIXJECT 22.5 MG RECON SUSP 6 PA

QL 1 Injection / 28 Days

TRELSTAR MIXJECT 3.75 MG RECON SUSP 6 PA

tretinoin 10 mg cap 1

TREXALL 3

TRISENOX 10 MG/10ML SOLUTION 5 S

TRISENOX 12 MG/6ML SOLUTION 6 S

PA TRUXIMA 6 S

QL 120 / 30 day(s)

TURALIO 6 AL1 At least 18 yrs old

LA Limited Access

TYKERB 5 LA Limited Access

UNITUXIN 5 S

UVADEX 5 S

valrubicin 5 S

VALSTAR 6 S

PAGE 96 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / 365 Days

VANTAS 5 PA

PA VECTIBIX 5 S

PA VELCADE 5 S

QL 60 / 30 Days

PA VENCLEXTA 10 MG TAB 5 LA Limited Access

QL 120 / 30 Days

PA VENCLEXTA 100 MG TAB 5 LA Limited Access

QL 30 / 30 Days

PA VENCLEXTA 50 MG TAB 5 LA Limited Access

QL 42 / 365 Days

PA VENCLEXTA STARTING PACK 5 LA Limited Access

QL 60 / 30 Days

PA VERZENIO 6 LA Limited Access

PA VIDAZA 6 S

VINBLASTINE SULFATE 5 S

PAGE 97 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

vincasar pfs 5 S

VINCRISTINE SULFATE 5 S

vinorelbine tartrate 5 S

QL 60 / 30 day(s)

PA VITRAKVI 100 MG CAP 5 LA Limited Access

QL 150 Milliliters / 30 Days

PA VITRAKVI 20 MG/ML SOLUTION 5 LA Limited Access

QL 180 / 30 day(s)

PA VITRAKVI 25 MG CAP 5 LA Limited Access

QL 30 / 30 Days

PA VIZIMPRO 6 LA Limited Access

QL 120 / 30 Days

PA VOTRIENT 5 LA Limited Access

PA VYXEOS 6 S

QL 60 / 30 Days

PA XALKORI 5 LA Limited Access

XATMEP 4 PA

PAGE 98 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

XELODA 6 S

QL 6 / Lifetime

PA XOFIGO 5 LA Limited Access

QL 90 / 30 day(s)

PA XOSPATA 6 LA Limited Access

QL 20 / 28 day(s)

PA XPOVIO (100 MG ONCE WEEKLY) 6 LA Limited Access

QL 12 / 28 day(s)

PA XPOVIO (60 MG ONCE WEEKLY) 6 LA Limited Access

QL 16 / 28 day(s)

PA XPOVIO (80 MG ONCE WEEKLY) 6 LA Limited Access

QL 32 / 28 day(s)

PA XPOVIO (80 MG TWICE WEEKLY) 6 LA Limited Access

QL 120 / 30 Days

PA XTANDI 5 LA Limited Access

YERVOY 5 LA Limited Access

PAGE 99 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / Lifetime

PA YESCARTA 6 LA Limited Access

YONDELIS 5 LA Limited Access

QL 120 / 30 Days

PA YONSA 6 LA Limited Access

ZALTRAP 5 LA Limited Access

ZANOSAR 5 S

QL 90 / 30 Days

PA ZEJULA 5 LA Limited Access

QL 240 / 30 Days

PA ZELBORAF 5 LA Limited Access

ZINECARD 4

ZIRABEV (100 MG/4ML SOLUTION, 400 MG/16ML PA 6 SOLUTION) S

QL 1 / 84 Days

ZOLADEX 10.8 MG IMPLANT 5 PA

QL 1 / 28 Days

ZOLADEX 3.6 MG IMPLANT 5 PA

PAGE 100 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 120 / 30 Days

ZOLINZA 5 PA

QL 60 / 30 Days

PA ZYDELIG 5 LA Limited Access

QL 150 / 30 Days

PA ZYKADIA 150 MG CAP 5 LA Limited Access

QL 90 / 30 day(s)

ZYKADIA 150 MG TAB 6 LA Limited Access

QL 120 / 30 day(s)

ZYTIGA 250 MG TAB 6 PA

QL 60 / 30 Days

PA ZYTIGA 500 MG TAB 5 LA Limited Access

CARDIOVASCULAR AGENTS

ANTIANGINAL AGENTS

DILATRATE-SR 4

GONITRO 3 QL 36 / 30 Days

ISORDIL TITRADOSE 40 MG TAB 3

ISORDIL TITRADOSE 5 MG TAB 4

isosorbide dinitrate 1

ISOSORBIDE DINITRATE ER 3

isosorbide mononitrate 1

PAGE 101 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

isosorbide mononitrate er 1

minitran 1

NITRO-BID 3 NITRO-DUR (0.1 MG/HR PATCH 24HR, 0.2 MG/HR PATCH 24HR, 0.4 MG/HR PATCH 24HR, 0.6 MG/HR PATCH 24HR, 4 0.8 MG/HR PATCH 24HR)

NITRO-DUR 0.3 MG/HR PATCH 24HR 3

NITRO-TIME (6.5 MG CAP ER, 9 MG CAP ER) 3

NITRO-TIME 2.5 MG CAP ER 1 nitroglycerin (0.1 mg/hr patch 24hr, 0.2 mg/hr patch 24hr, 0.3 mg sl tab, 0.4 mg sl tab, 0.4 mg/hr patch 24hr, 0.4 mg/spray 1 solution, 0.6 mg sl tab, 0.6 mg/hr patch 24hr) NITROGLYCERIN (5 MG/ML SOLUTION, 400 MCG/SPRAY AERO SOLN) 3

nitroglycerin er 1

nitroglycerin in d5w 1

NITROLINGUAL 4

NITROMIST 3

NITRONAL 3

NITROSTAT 4

RANEXA 4 QL 60 / 30 day(s)

ranolazine er 1 QL 60 / 30 day(s)

ANTIARRHYTHMICS

adenosine (6 mg/2ml solution, 12 mg/4ml solution) 1 amiodarone hcl (100 mg tab, 150 mg/3ml solution, 200 mg tab, 400 mg tab, 450 mg/9ml solution, 900 mg/18ml solution) 1 AMIODARONE HCL IN DEXTROSE 1000-5 MG/500ML-% SOLUTION 3

CORDARONE 4

CORVERT 4

disopyramide phosphate 1

dofetilide 5 S

flecainide acetate 1

PAGE 102 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ibutilide fumarate 1

lidocaine hcl (cardiac) 100 mg/5ml soln prsyr 1

LIDOCAINE HCL (CARDIAC) 50 MG/5ML SOLN PRSYR 3 LIDOCAINE HCL (CARDIAC) PF (100 MG/5ML SOLN PRSYR, 100 MG/5ML SOLUTION) 1 lidocaine in d5w (lidocae 4-5 mg/ml-% solution, lidocae 8-5 mg/ml-% solution) 1

LIDOCAINE IN D5W 3-5 MG/ML-% SOLUTION 3

MEXILETINE HCL (150 MG CAP, 200 MG CAP, 250 MG CAP) 3

MULTAQ 4 QL 60 / 30 Days

NEXTERONE 150-4.21 MG/100ML-% SOLUTION 3

NORPACE 4

NORPACE CR 100 MG CAP ER 12H 4

NORPACE CR 150 MG CAP ER 12H 3

pacerone 1

PROCAINAMIDE HCL POWDER 4

procainamide hcl (100 mg/ml solution, 500 mg/ml solution) 1

propafenone hcl 1

propafenone hcl er 1

QUINIDINE GLUCONATE 3

quinidine gluconate er 1

QUINIDINE SULFATE (200 MG TAB, 300 MG TAB) 3

QUINIDINE SULFATE ER 3

RYTHMOL 4

RYTHMOL SR 4

TIKOSYN 6 S

XYLOCAINE (CARDIAC) 4 ANTIHYPERLIPIDEMICS

ADVICOR (500-20 MG TAB ER 24H, 750-20 MG TAB ER 24H, 1000-20 MG TAB ER 24H) 4

ADVICOR 1000-40 MG TAB ER 24H 3

PAGE 103 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 Days ALTOPREV 4 ST

QL 30 / 30 Days ANTARA 30 MG CAP 4 ST

QL 30 / 30 Days ANTARA 90 MG CAP 3 ST

atorvastatin calcium (10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab) 1

cholestyramine (4 gm packet, 4 gm/dose powder) 1

cholestyramine light (4 gm packet, 4 gm/dose powder) 1

colesevelam hcl 3.75 gm packet 1 QL 30 / 30 Days

colesevelam hcl 625 mg tab 1 QL 180 / 30 Days

COLESTID (1 GM TAB, 5 GM GRANULES, 5 GM PACKET) 4

COLESTID FLAVORED (5 GM GRANULES, 5 GM PACKET) 4

colestipol hcl (1 gm tab, 5 gm granules, 5 gm packet) 1

CRESTOR 4 QL 30 / 30 Days

QL 30 / 30 day(s) EZALLOR SPRINKLE 3 ST

QL 30 / 30 Days ezetimibe 1 ST

QL 30 / 30 Days ezetimibe-simvastatin 1 ST

fenofibrate (48 mg tab, 134 mg cap, 145 mg tab, 200 mg cap) 1 QL 30 / 30 Days

QL 30 / 30 Days fenofibrate 120 mg tab 1 ST

FENOFIBRATE 150 MG CAP 3 QL 30 / 30 Days

fenofibrate 160 mg tab 1 QL 30 / 30 day(s)

FENOFIBRATE 160 MG TAB 4 QL 30 / 30

QL 60 / 30 Days fenofibrate 40 mg tab 1 ST

PAGE 104 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FENOFIBRATE 50 MG CAP 3 QL 60 / 30 Days

fenofibrate 54 mg tab 1 QL 90 / 30 Days

fenofibrate 67 mg cap 1 QL 60 / 30 Days

fenofibrate micronized (43 mg cap, 134 mg cap, 200 mg cap) 1 QL 30 / 30 Days

QL 30 / 30 Days fenofibrate micronized 130 mg cap 1 ST

fenofibrate micronized 67 mg cap 1 QL 60 / 30 Days

fenofibric acid (45 mg cap dr, 135 mg cap dr) 1 QL 30 / 30 Days

FENOFIBRIC ACID 105 MG TAB 3 QL 30 / 30 Days

FENOFIBRIC ACID 35 MG TAB 3 QL 60 / 30 day(s)

FENOGLIDE 120 MG TAB 4 QL 30 / 30 Days

FENOGLIDE 40 MG TAB 4 QL 60 / 30 Days

FIBRICOR 105 MG TAB 3 QL 30 / 30 Days

FIBRICOR 35 MG TAB 3 QL 60 / 30 day(s)

FLOLIPID 4 ST

QL 30 / 30 Days fluvastatin sodium 1 ST

QL 30 / 30 Days fluvastatin sodium er 1 ST

GEMFIBROZIL POWDER 4

gemfibrozil 600 mg tab 1

QL 30 / 30 Days

PA JUXTAPID 5 LA Limited Access

QL 4 Syringes / 28 Days

PA KYNAMRO 6 LA Limited Access

PAGE 105 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LESCOL 4

LESCOL XL 4 QL 30 / 30 Days

LIPITOR 4

LIPOFEN 150 MG CAP 4 QL 30 / 30 Days

LIPOFEN 50 MG CAP 4 QL 60 / 30 Days

QL 30 / 30 Days LIVALO 3 ST

LOFIBRA (54 MG TAB, 67 MG CAP, 134 MG CAP, 200 MG CAP) 4

LOFIBRA 160 MG TAB 4 QL 30 / 30 day(s)

LOPID 4

lovastatin 1

LOVAZA 4 QL 120 / 30 Days

MEVACOR 4

NIACIN (ANTIHYPERLIPIDEMIC) 3 QL 180 / 30 Days

niacin er (antihyperlipidemic) (er 500 mg tab er, er 1000 mg tab QL 60 / 30 Days er) 1

niacin er (antihyperlipidemic) 750 mg tab er 1 QL 90 / 30 Days

NIACOR 3 QL 180 / 30 Days

NIASPAN (500 MG TAB ER, 1000 MG TAB ER) 4 QL 60 / 30 Days

NIASPAN 750 MG TAB ER 4 QL 90 / 30 Days

omega-3-acid ethyl esters 1 QL 120 / 30 Days

OMEGA-3/D-3 WELLNESS PACK 3

QL 2 Auto-Injectors / 28 Days PRALUENT (75 MG/ML SOLN A-INJ, 75 MG/ML SOLN PA PRSYR, 150 MG/ML SOLN A-INJ, 150 MG/ML SOLN PRSYR) 5 LA Limited Access

PRAVACHOL 4

pravastatin sodium 1

PAGE 106 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

prevalite (4 gm packet, 4 gm/dose powder) 1

QUESTRAN (4 GM PACKET, 4 GM/DOSE POWDER) 4

QUESTRAN LIGHT 4

QL 1 Kit / 28 Days

REPATHA 5 PA

QL 1 Kit / 28 Days

REPATHA PUSHTRONEX SYSTEM 5 PA

QL 2 Auto-Injectors / 28 Days REPATHA SURECLICK 5 PA

rosuvastatin calcium 1 QL 30 / 30 Days

SIMCOR (500-20 MG TAB ER 24H, 500-40 MG TAB ER 24H, 750-20 MG TAB ER 24H, 1000-20 MG TAB ER 24H) 3

SIMCOR 1000-40 MG TAB ER 24H 4 simvastatin (5 mg tab, 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab) 1

SURE RESULT O3D3 SYSTEM 3

TRICOR 4 QL 30 / 30 Days

TRIGLIDE 4 QL 30 / 30 day(s)

triklo 1 QL 120 / 30 Days

TRILIPIX 4 QL 30 / 30 Days

VASCEPA 0.5 GM CAP 3 QL 240 / 30 Days

VASCEPA 1 GM CAP 3 QL 120 / 30 Days

VYTORIN 4 QL 30 / 30 Days

WELCHOL 3.75 GM PACKET 4 QL 30 / 30 Days

WELCHOL 625 MG TAB 4 QL 180 / 30 Days

ZETIA 4 QL 30 / 30 Days

PAGE 107 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ZOCOR 4

QL 30 / 30 Days ZYPITAMAG 4 ST

ANTIHYPERTENSIVES

ACCUPRIL 4

ACCURETIC 4

ACEON 4

QL 30 / 30 day(s) aliskiren fumarate 150 mg tab 1 ST

aliskiren fumarate 300 mg tab 1 QL 30 / 30 day(s)

ALTACE 4

amlodipine besy-benazepril hcl 1

amlodipine besylate-valsartan 1 QL 30 / 30 Days

amlodipine-olmesartan 1 QL 30 / 30 Days

QL 30 / 30 Days amlodipine-valsartan-hctz 1 ST

AMTURNIDE 4

ATACAND 4 QL 30 / 30 Days

ATACAND HCT 4

atenolol-chlorthalidone 1

AVALIDE 4

AVAPRO 4

AZOR 4 QL 30 / 30 Days

benazepril hcl (5 mg tab, 10 mg tab, 20 mg tab, 40 mg tab) 1

benazepril-hydrochlorothiazide 1

BENICAR (20 MG TAB, 40 MG TAB) 4 QL 30 / 30 Days

BENICAR 5 MG TAB 4 QL 60 / 30 Days

BENICAR HCT 4 QL 30 / 30 Days

PAGE 108 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

bisoprolol-hydrochlorothiazide 1

QL 30 / 30 Days BYVALSON 4 ST

candesartan cilexetil 1 QL 30 / 30 Days

candesartan cilexetil-hctz 1 QL 30 / 30 Days

captopril (12.5 mg tab, 25 mg tab, 50 mg tab, 100 mg tab) 1

CAPTOPRIL-HYDROCHLOROTHIAZIDE 4

CARDURA 4

CATAPRES 4

CATAPRES-TTS-1 4

CATAPRES-TTS-2 4

CATAPRES-TTS-3 4

clonidine 1

CLONIDINE HCL POWDER 4

clonidine hcl (0.1 mg tab, 0.2 mg tab, 0.3 mg tab) 1

CLORPRES (0.1-15 MG TAB, 0.3-15 MG TAB) 3

CLORPRES 0.2-15 MG TAB 4

CORZIDE 40-5 MG TAB 4

CORZIDE 80-5 MG TAB 4 ST

COZAAR 4

DEMSER 3

DIBENZYLINE 4

DIOVAN 4

DIOVAN HCT 4

doxazosin mesylate (1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab) 1

QL 30 / 30 Days EDARBI 3 ST

QL 30 / 30 Days EDARBYCLOR 3 ST

enalapril maleate (2.5 mg tab, 5 mg tab, 10 mg tab, 20 mg tab) 1

PAGE 109 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

enalapril-hydrochlorothiazide 1

enalaprilat 1

EPANED 1 MG/ML RECON SOLN 4 PA

QL 1200 Milliliters / 30 EPANED 1 MG/ML SOLUTION 4 Days PA

eplerenone 1

EPROSARTAN MESYLATE 4 QL 30 / 30 Days

EXFORGE 4 QL 30 / 30 Days

EXFORGE HCT 4 QL 30 / 30 Days

fosinopril sodium 1

fosinopril sodium-hctz 1

guanfacine hcl 1 hydralazine hcl (10 mg tab, 20 mg/ml solution, 25 mg tab, 50 mg tab, 100 mg tab) 1

HYZAAR 4

INSPRA 4

irbesartan 1

irbesartan-hydrochlorothiazide 1 lisinopril (2.5 mg tab, 5 mg tab, 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab) 1

lisinopril-hydrochlorothiazide 1

LOPRESSOR HCT 4

losartan potassium 1

losartan potassium-hctz 1

LOTENSIN 4

LOTENSIN HCT 4

LOTREL 4

MAVIK 4

methyldopa 1

METHYLDOPA-HYDROCHLOROTHIAZIDE 3

PAGE 110 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

METHYLDOPATE HCL 4

metoprolol-hydrochlorothiazide 1

METOPROLOL-HYDROCHLOROTHIAZIDE 100-50 MG TAB 4

MICARDIS 4 QL 30 / 30 Days

MICARDIS HCT 4 QL 30 / 30 Days

MINIPRESS 4

minoxidil (2.5 mg tab, 10 mg tab) 1

moexipril hcl 1

moexipril-hydrochlorothiazide 1

NADOLOL-BENDROFLUMETHIAZIDE 40-5 MG TAB 1 ST

nadolol-bendroflumethiazide 80-5 mg tab 1

NITROPRESS 4

nitroprusside sodium 1

olmesartan medoxomil (20 mg tab, 40 mg tab) 1 QL 30 / 30 Days

olmesartan medoxomil 5 mg tab 1 QL 60 / 30 Days

olmesartan medoxomil-hctz 1 QL 30 / 30 Days

olmesartan-amlodipine-hctz 1 QL 30 / 30 Days

perindopril erbumine 1

phenoxybenzamine hcl 10 mg cap 1

phentolamine mesylate 5 mg recon soln 1

PHENTOLAMINE MESYLATE 5 MG/ML SOLUTION 3

PRAZOSIN HCL POWDER 4

prazosin hcl (1 mg cap, 2 mg cap, 5 mg cap) 1

PRINIVIL 4

PROPRANOLOL-HCTZ 3

QL 2400 Milliliters / 30 QBRELIS 4 Days PA

quinapril hcl 1

quinapril-hydrochlorothiazide 1

PAGE 111 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ramipril 1

RESERPINE POWDER 4

RESERPINE (0.1 MG TAB, 0.25 MG TAB) 3

TARKA 4

TEKAMLO 3

QL 30 / 30 day(s) TEKTURNA 3 ST

QL 30 / 30 Days TEKTURNA HCT 3 ST

telmisartan 1 QL 30 / 30 Days

QL 30 / 30 Days telmisartan-amlodipine 1 ST

QL 30 / 30 Days telmisartan-hctz 1 ST

TENEX 4

TENORETIC 100 4

TENORETIC 50 4

terazosin hcl 1

TEVETEN 4

TEVETEN HCT 4

trandolapril 1 trandolapril-verapamil hcl er (er 2-180 mg tab er, er 2-240 mg ST tab er, er 4-240 mg tab er) 1

TRANDOLAPRIL-VERAPAMIL HCL ER 1-240 MG TAB ER 4 ST

trandolapril-verapamil hcl er 1-240 mg tab er 1

TRIBENZOR 4 QL 30 / 30 Days

TWYNSTA 4 QL 30 / 30 Days

valsartan 1

valsartan-hydrochlorothiazide 1

VASERETIC 4

PAGE 112 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VASOTEC 4

VECAMYL 3

ZESTORETIC 4

ZESTRIL 4

ZIAC 4 BETA BLOCKERS

ACEBUTOLOL HCL POWDER 4

acebutolol hcl (200 mg cap, 400 mg cap) 1

ATENOLOL POWDER 4

atenolol (25 mg tab, 50 mg tab, 100 mg tab) 1

ATENOLOL+SYRSPEND SF 3

BETAPACE 4

BETAPACE AF 4

betaxolol hcl (10 mg tab, 20 mg tab) 1

bisoprolol fumarate 1

BREVIBLOC 4

BREVIBLOC IN NACL 4

BREVIBLOC PREMIXED 4

BREVIBLOC PREMIXED DS 4

QL 30 / 30 Days BYSTOLIC (2.5 MG TAB, 5 MG TAB, 10 MG TAB) 3 ST

QL 60 / 30 Days BYSTOLIC 20 MG TAB 3 ST

carvedilol 1

QL 30 / 30 Days carvedilol phosphate er 1 ST

COREG 4 COREG CR (10 MG CAP ER 24H, 20 MG CAP ER 24H, 40 QL 30 / 30 Days MG CAP ER 24H) 4

COREG CR 80 MG CAP ER 24H 4 QL 60 / 30 Days

PAGE 113 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CORGARD 4

esmolol hcl 100 mg/10ml solution 1

esmolol hcl-sodium chloride 1

FIRST - METOPROLOL 3

FIRST-ATENOLOL 3

HEMANGEOL 3

INDERAL LA 4

INDERAL XL 4 ST

INNOPRAN XL 4 ST

KAPSPARGO SPRINKLE 4 labetalol hcl (5 mg/ml solution, 100 mg tab, 200 mg tab, 300 mg tab) 1

LABETALOL HCL 5 MG/ML SOLUTION 3 LABETALOL HCL-DEXTROSE (100-5 MG/100ML-% SOLUTION, 250-5 MG/250ML-% SOLUTION, 500-5 4 MG/250ML-% SOLUTION)

LABETALOL HCL-SODIUM CHLORIDE 4

LOPRESSOR (50 MG TAB, 100 MG TAB) 4

metoprolol succinate er 1

METOPROLOL TARTRATE POWDER 4 metoprolol tartrate (5 mg/5ml solution, 25 mg tab, 50 mg tab, 100 mg tab) 1

QL 60 / 30 metoprolol tartrate 37.5 mg tab 1 ST

QL 60 / 30 Days metoprolol tartrate 75 mg tab 1 ST

NADOLOL POWDER 4

nadolol (20 mg tab, 40 mg tab, 80 mg tab) 1 ST

pindolol 1 propranolol hcl (1 mg/ml solution, 10 mg tab, 20 mg tab, 40 mg tab, 60 mg tab, 80 mg tab) 1

PROPRANOLOL HCL (40 MG/5ML SOLUTION, POWDER) 4

PAGE 114 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PROPRANOLOL HCL 20 MG/5ML SOLUTION 3

propranolol hcl er 1

SECTRAL 4

sorine 1

sotalol hcl (80 mg tab, 120 mg tab, 160 mg tab, 240 mg tab) 1

sotalol hcl (af) 1

SOTALOL HCL 150 MG/10ML SOLUTION 3

sotalol hydrochloride 1

SOTYLIZE 4

TENORMIN 4

TIMOLOL MALEATE POWDER 4

TIMOLOL MALEATE (10 MG TAB, 20 MG TAB) 3

timolol maleate 5 mg tab 1

TOPROL XL 4

ZEBETA 4 CALCIUM CHANNEL BLOCKERS

ADALAT CC 4

afeditab cr 1

AMLODIPINE BES+SYRSPEND SF 4

amlodipine besylate (2.5 mg tab, 5 mg tab, 10 mg tab) 1

CALAN 4

CALAN SR 4

CARDENE IV 40-5 MG/200ML-% SOLUTION 4

CARDIZEM 4

CARDIZEM CD 4 CARDIZEM LA (180 MG TAB ER 24H, 240 MG TAB ER 24H, 300 MG TAB ER 24H, 360 MG TAB ER 24H, 420 MG TAB ER 4 24H)

CARDIZEM LA 120 MG TAB ER 24H 4 ST

cartia xt 1

DILT-XR (180 MG CAP ER 24H, 240 MG CAP ER 24H) 3

PAGE 115 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DILT-XR 120 MG CAP ER 24H 4

diltiazem cd 1 DILTIAZEM HCL (25 MG/5ML SOLN PRSYR, 100 MG RECON SOLN) 3 diltiazem hcl (25 mg/5ml solution, 30 mg tab, 50 mg/10ml solution, 60 mg tab, 90 mg tab, 120 mg tab, 125 mg/25ml 1 solution)

diltiazem hcl er 1

diltiazem hcl er beads 1 diltiazem hcl er coated beads (er beads 120 mg cap er 24h, er beads 180 mg cap er 24h, er beads 180 mg tab er 24h, er beads 240 mg cap er 24h, er beads 240 mg tab er 24h, er 1 beads 300 mg cap er 24h, er beads 300 mg tab er 24h, er beads 360 mg tab er 24h, er beads 420 mg tab er 24h)

diltiazem hcl er coated beads 360 mg cap er 24h 1 ST

DILTIAZEM HCL-SODIUM CHLORIDE 250-0.9 MG/250ML-% SOLUTION 3

felodipine er 1

isradipine 1

QL 300 milliliters / 30 Days KATERZIA 4 ST

matzim la 1

nicardipine hcl (2.5 mg/ml solution, 20 mg cap, 30 mg cap) 1 NICARDIPINE HCL IN NACL 125-0.9 MG/250ML-% SOLUTION 4

nifedical xl 1

NIFEDIPINE POWDER 4

nifedipine (10 mg cap, 20 mg cap) 1

nifedipine er 1

nifedipine er osmotic release 1

nimodipine 30 mg cap 1 ST

NISOLDIPINE ER (ER 20 MG TAB ER 24H, ER 30 MG TAB ST ER 24H, ER 40 MG TAB ER 24H) 3 nisoldipine er (er 8.5 mg tab er 24h, er 17 mg tab er 24h, er 34 ST mg tab er 24h) 1

PAGE 116 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NISOLDIPINE ER 25.5 MG TAB ER 24H 4 ST

NORVASC 4

NYMALIZE 3

PROCARDIA 4

PROCARDIA XL 4

SULAR 4

taztia xt 1

tiadylt er 1

TIAZAC 4

VERAPAMIL HCL POWDER 4 verapamil hcl (2.5 mg/ml solution, 40 mg tab, 80 mg tab, 120 mg tab) 1 verapamil hcl er (er 100 mg cap er 24h, er 120 mg cap er 24h, er 120 mg tab er, er 180 mg cap er 24h, er 180 mg tab er, er 200 mg cap er 24h, er 240 mg cap er 24h, er 240 mg tab er, er 1 300 mg cap er 24h) VERAPAMIL HCL ER (ER 100 MG CAP ER 24H, ER 200 MG CAP ER 24H, ER 300 MG CAP ER 24H) 4

VERAPAMIL HCL ER 360 MG CAP ER 24H 3

VERELAN 4

VERELAN PM 4 CARDIOTONICS

digitek 1

digox 1 digoxin (0.05 mg/ml solution, 0.25 mg/ml solution, 125 mcg tab, 250 mcg tab) 1

DIGOXIN 0.05 MG/ML SOLUTION 4 LANOXIN (0.25 MG/ML SOLUTION, 125 MCG TAB, 250 MCG TAB) 4

LANOXIN (62.5 MCG TAB, 187.5 MCG TAB) 3

LANOXIN PEDIATRIC 3

milrinone lactate 1

milrinone lactate in dextrose 1

PAGE 117 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CARDIOVASCULAR AGENTS - MISC.

ABLYSINOL 4

QL 60 / 30 Days ADCIRCA 6 S

QL 90 / 30 Days

PA ADEMPAS 5 LA Limited Access

QL 60 / 30 Days

alyq 5 PA

QL 30 / 30 day(s)

PA ambrisentan 5 LA Limited Access

amlodipine-atorvastatin 1 ST

BIDIL 3

QL 60 / 30 day(s)

PA bosentan 125 mg tab 5 LA Limited Access

QL 60 / 60 day(s)

PA bosentan 62.5 mg tab 5 LA Limited Access

CADUET 4

cardioplegic 1

CAVERJECT 3 QL 6 Vials / 30 Days

CAVERJECT IMPULSE 4 QL 3 Kits / 30 Days

CIALIS (10 MG TAB, 20 MG TAB) 4 QL 6 / 30 Days

PAGE 118 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CIALIS (2.5 MG TAB, 5 MG TAB) 4 QL 30 / 30 Days

QL 60 / 30 Days CORLANOR (5 MG TAB, 7.5 MG TAB) 3 PA

QL 450 / 30 day(s) CORLANOR 5 MG/5ML SOLUTION 3 PA

EDEX (10 MCG KIT, 20 MCG KIT) 4 QL 3 Kits / 30 Days

EDEX 40 MCG KIT 4 QL 3 Boxes / 30 Days

QL 60 / 30 Days ENTRESTO 3 PA

epoprostenol sodium 5 LA Limited Access

FLOLAN 0.5 MG RECON SOLN 6 LA Limited Access

LA Limited Access FLOLAN 1.5 MG RECON SOLN 6 S

IFE-PG20 4

isoxsuprine hcl (10 mg tab, 20 mg tab) 1

QL 30 / 30 day(s)

PA LETAIRIS 6 LA Limited Access

LEVITRA 4 QL 6 / 30 day(s)

MUSE 3 QL 6 / 30 Days

NYLIDRIN HCL 4

QL 30 / 30 Days

PA OPSUMIT 5 LA Limited Access

PAGE 119 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 Days

PA ORENITRAM (1 MG TAB ER, 2.5 MG TAB ER, 5 MG TAB ER) 6 LA Limited Access

QL 90 / 30 Days

PA ORENITRAM 0.125 MG TAB ER 6 LA Limited Access

QL 120 / 30 Days

PA ORENITRAM 0.25 MG TAB ER 6 LA Limited Access

PAPAV-PHENTOLAMINE-ALPROSTADIL 12-1-0.01 MG/ML SOLUTION 4 PAPAV-PHENTOLAMINE-ALPROSTADIL 30-1-0.02 MG/ML SOLUTION 3

PAPAVERINE HCL (30 MG/ML SOLUTION, POWDER) 4

papaverine hcl 30 mg/ml solution 1

PAPAVERINE-ALPROSTADIL 4

PAPAVERINE-PHENTOLAMINE 4

PHENTOLAMINE-ALPROSTADIL 4

PHENYLEPHRINE HCL 2 MG/2ML SOLUTION 4

REMODULIN 6 LA Limited Access

REVATIO 10 MG/12.5ML SOLUTION 6 S

QL 180 / 30 day(s)

REVATIO 10 MG/ML RECON SUSP 6 PA

QL 90 / 30 Days

REVATIO 20 MG TAB 6 PA

PAGE 120 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

sildenafil citrate (25 mg tab, 50 mg tab, 100 mg tab) 1 QL 6 / 30 Days

PA sildenafil citrate 10 mg/12.5ml solution 5 S

QL 180 / 30 day(s)

sildenafil citrate 10 mg/ml recon susp 5 PA

QL 90 / 30 Days

sildenafil citrate 20 mg tab 5 PA

QL 6 / 30 Days tadalafil (10 mg tab, 20 mg tab) 1 ST

tadalafil (2.5 mg tab, 5 mg tab) 1 QL 30 / 30 Days

QL 60 / 30 Days

tadalafil (pah) 5 PA

QL 60 / 30 day(s)

PA TRACLEER 125 MG TAB 6 LA Limited Access

QL 120 / 30 Days

PA TRACLEER 32 MG TAB SOL 5 LA Limited Access

QL 60 / 30 Days

PA TRACLEER 62.5 MG TAB 6 LA Limited Access

PA treprostinil 6 S

TYVASO 5 LA Limited Access

PAGE 121 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TYVASO REFILL 5 LA Limited Access

TYVASO STARTER 5 LA Limited Access

QL 60 / 30 Days

UPTRAVI (200 MCG TAB, 400 MCG TAB, 600 MCG TAB, 800 PA MCG TAB, 1000 MCG TAB, 1200 MCG TAB, 1400 MCG TAB, 5 1600 MCG TAB) LA Limited Access S

QL 200 / 365 Days

PA UPTRAVI 200 & 800 MCG TAB THPK 5 LA Limited Access

vardenafil hcl (2.5 mg tab, 5 mg tab, 10 mg tab, 20 mg tab) 1 QL 6 / 30 day(s)

LA Limited Access VELETRI 0.5 MG RECON SOLN 6 S

VELETRI 1.5 MG RECON SOLN 6 LA Limited Access

QL 9 Boxes / 30 Days

PA VENTAVIS 5 LA Limited Access

VIAGRA 4 QL 6 / 30 Days

QL 30 / 30 day(s)

PA VYNDAMAX 6 LA Limited Access

QL 120 / 30 day(s)

PA VYNDAQEL 6 LA Limited Access

PAGE 122 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIURETICS

acetazolamide (125 mg tab, 250 mg tab) 1

acetazolamide er 1

acetazolamide sodium 1

ALDACTAZIDE 4

ALDACTONE 4

AMILORIDE HCL POWDER 4

amiloride hcl 5 mg tab 1

amiloride-hydrochlorothiazide 1 bumetanide (0.25 mg/ml solution, 0.5 mg tab, 1 mg tab, 2 mg tab) 1

BUMEX 4

QL 473 Milliliters / 30 Days CAROSPIR 4 PA

CHLOROTHIAZIDE 3

chlorothiazide 500 mg tab 1

chlorothiazide sodium 1

chlorthalidone (25 mg tab, 50 mg tab) 1

CHLORTHALIDONE 100 MG TAB 3

DEMADEX 4

DIAMOX SEQUELS 4

DIURIL 3

DYAZIDE 4

DYRENIUM 4

EDECRIN 4

ethacrynate sodium 1

ethacrynic acid 1

FUROSEMIDE POWDER 4 furosemide (10 mg/ml solution, 20 mg tab, 40 mg tab, 80 mg tab) 1

FUROSEMIDE 8 MG/ML SOLUTION 3

PAGE 123 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HYDROCHLOROTHIAZIDE POWDER 4 hydrochlorothiazide (12.5 mg cap, 12.5 mg tab, 25 mg tab, 50 mg tab) 1

indapamide 1

QL 120 / 30 day(s)

PA KEVEYIS 5 LA Limited Access

LASIX 4

mannitol (20 % solution, 25 % solution) 1

MAXZIDE 4

MAXZIDE-25 4

METHAZOLAMIDE POWDER 4

methazolamide (25 mg tab, 50 mg tab) 1

METHYCLOTHIAZIDE 4

metolazone 1

MICROZIDE 4

NEPTAZANE 4

osmitrol 20 % solution 1

SODIUM DIURIL 4

SODIUM EDECRIN 4

SPIRONOLACTONE POWDER 4

spironolactone (25 mg tab, 50 mg tab, 100 mg tab) 1

spironolactone-hctz 1 TORSEMIDE (20 MG/2ML SOLUTION, 50 MG/5ML SOLUTION) 4

torsemide (5 mg tab, 10 mg tab, 20 mg tab, 100 mg tab) 1

TRIAMTERENE POWDER 4

triamterene (50 mg cap, 100 mg cap) 1 triamterene-hctz (37.5-25 mg cap, 37.5-25 mg tab, 75-50 mg tab) 1

TRIAMTERENE-HCTZ 50-25 MG CAP 4

PAGE 124 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VASOPRESSORS

ADRENACLICK 0.15 MG/0.15ML SOLN A-INJ 4

ADRENACLICK 0.3 MG/0.3ML SOLN A-INJ 4 QL 2 2-Packs / 365 Days

ADRENALIN 1 MG/ML SOLUTION 3

dobutamine hcl 1

dobutamine in d5w 1 DOPAMINE HCL (80 MG/ML SOLUTION, 160 MG/ML SOLUTION) 3

dopamine hcl 40 mg/ml solution 1

dopamine in d5w 1

EPHEDRINE SULFATE (PRESSORS) 4

EPHEDRINE SULFATE 50 MG/ML SOLUTION 3

ephedrine sulfate 50 mg/ml solution 1

EPINEPHRINE (0.15 MG/0.15ML SOLN A-INJ, 0.3 MG/0.3ML QL 2 2-Packs / 365 Days 4 SOLN A-INJ) PA

epinephrine 0.15 mg/0.3ml soln a-inj 1 QL 2 / 365 day(s)

epinephrine 0.3 mg/0.3ml soln a-inj 1 QL 2 2-Packs / 365 Days

EPINEPHRINE 30 MG/30ML SOLUTION 4 EPINEPHRINE HCL-DEXTROSE (2-5 MG/100ML-% SOLUTION, 6.25-5 MG/250ML-% SOLUTION, 750-5 MCG/25ML-% SOLN PRSYR, 5000-5 MCG/50ML-% SOLN 4 PRSYR) EPINEPHRINE HCL-NACL (2.5-0.9 MG/250ML-% SOLUTION, 5-0.9 MG/250ML-% SOLUTION, 10-0.9 MCG/10ML-% SOLN PRSYR, 10-0.9 MG/250ML-% SOLUTION, 40-0.9 MCG/10ML- % SOLN PRSYR, 80-0.9 MCG/10ML-% SOLN PRSYR, 500-0.9 MCG/50ML-% SOLN PRSYR, 1200-0.9 MCG/50ML-% SOLN 4 PRSYR, 3000-0.9 MCG/15ML-% SOLN PRSYR, 5000-0.9 MCG/50ML-% SOLN PRSYR, 6000-0.9 MCG/50ML-% SOLN PRSYR)

epinephrine pf 1

EPINEPHRINE PF 1 MG/ML SOLUTION 4

EPINEPHRINESNAP-V 3

EPIPEN 2-PAK 3 QL 2 2-Packs / 365 Days

PAGE 125 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

EPIPEN JR 2-PAK 3 QL 2 / 365 day(s)

EPISNAP 3

LEVOPHED 4

midodrine hcl 1

norepinephrine bitartrate 1 mg/ml solution 1 NOREPINEPHRINE-DEXTROSE (12.5-5 MG/250ML-% SOLUTION, 16-5 MG/500ML-% SOLUTION) 4 NOREPINEPHRINE-SODIUM CHLORIDE (0.4-0.9 MG/50ML- % SOLN PRSYR, 2-0.9 MG/50ML-% SOLN PRSYR, 4-0.9 MG/500ML-% SOLUTION, 6-0.9 MG/50ML-% SOLUTION, 4 12.5-0.9 MG/250ML-% SOLUTION, 32-0.9 MG/250ML-% SOLUTION, 32-0.9 MG/500ML-% SOLUTION)

QL 180 / 30 Days

PA NORTHERA (200 MG CAP, 300 MG CAP) 6 LA Limited Access

QL 126 / 365 Days

PA NORTHERA 100 MG CAP 6 LA Limited Access

PHENYLEPHRINE HCL (PRESSORS) 0.5 MG/5ML SOLN PRSYR 4

phenylephrine hcl 10 mg/ml solution 1

PHENYLEPHRINE HCL 10 MG/ML SOLUTION 4 PHENYLEPHRINE HCL-DEXTROSE 40-5 MG/500ML-% SOLUTION 4 PHENYLEPHRINE HCL-NACL (1.6-0.9 MG/20ML-% SOLN PRSYR, 30-0.9 MG/100ML-% SOLUTION, 160-0.9 MG/500ML- 4 % SOLUTION, 250-0.9 MG/250ML-% SOLUTION) PHENYLEPHRINE HCL-NACL 20-0.9 MG/50ML-% SOLN PRSYR 3

SYMJEPI 3 QL 2 2-Packs / 365 Days

VAZCULEP 4

PAGE 126 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CENTRAL NERVOUS SYSTEM AGENTS

ANTIANXIETY AGENTS

alprazolam (0.25 mg tab, 0.25 mg tab disp, 0.5 mg tab, 0.5 mg tab disp, 1 mg tab, 1 mg tab disp, 2 mg tab, 2 mg tab disp) 1

alprazolam er 1

ALPRAZOLAM INTENSOL 3

alprazolam xr 1 ATIVAN (0.5 MG TAB, 1 MG TAB, 2 MG TAB, 2 MG/ML SOLUTION, 4 MG/ML SOLUTION) 4 buspirone hcl (5 mg tab, 7.5 mg tab, 10 mg tab, 15 mg tab, 30 mg tab) 1

chlordiazepoxide hcl 1

clorazepate dipotassium 1 diazepam (2 mg tab, 5 mg tab, 5 mg/ml conc, 5 mg/ml solution, 10 mg tab) 1 DIAZEPAM (5 MG/5ML SOLUTION, 5 MG/ML SOLUTION, 10 MG/2ML SOLN A-INJ) 3

diazepam intensol 1

DROPERIDOL POWDER 4

droperidol 2.5 mg/ml solution 1 hydroxyzine hcl (10 mg tab, 10 mg/5ml syrup, 25 mg tab, 50 mg tab) 1 HYDROXYZINE HCL (25 MG/ML SOLUTION, 50 MG/ML SOLUTION) 3

HYDROXYZINE PAMOATE (100 MG CAP, POWDER) 4

hydroxyzine pamoate (25 mg cap, 50 mg cap) 1 lorazepam (0.5 mg tab, 1 mg tab, 2 mg tab, 2 mg/ml conc, 2 mg/ml solution, 4 mg/ml solution) 1

lorazepam intensol 1 LORAZEPAM-SODIUM CHLORIDE 60-0.9 MG/60ML-% SOLUTION 4

meprobamate 1

oxazepam 1

OXAZEPAM 10 MG CAP 3

PAGE 127 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

OXAZEPAM 15 MG CAP 4

OXAZEPAM 30 MG CAP 2

TRANXENE-T 4

VALIUM 4

VISTARIL 4

XANAX 4

XANAX XR 4 ANTIDEPRESSANTS

amitriptyline hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 100 mg tab, 150 mg tab) 1

AMOXAPINE 3

ANAFRANIL 4

QL 30 / 30 Days BRINTELLIX 4 ST

bupropion hcl (75 mg tab, 100 mg tab) 1

bupropion hcl er (sr) 1 bupropion hcl er (xl) (er 150 mg tab er 24h, er 300 mg tab er 24h) 1

CELEXA (10 MG TAB, 40 MG TAB) 4 QL 30 / 30 Days

CELEXA 20 MG TAB 4 QL 45 / 30 Days

citalopram hydrobromide (10 mg tab, 40 mg tab) 1 QL 30 / 30 Days

citalopram hydrobromide 10 mg/5ml solution 1 QL 480 Milliliters / 30 Days

citalopram hydrobromide 20 mg tab 1 QL 45 / 30 Days

clomipramine hcl (25 mg cap, 50 mg cap, 75 mg cap) 1

CYMBALTA (20 MG CP DR PART, 60 MG CP DR PART) 4 QL 60 / 30 Days

CYMBALTA 30 MG CP DR PART 4 QL 90 / 30 Days

DESIPRAMINE HCL POWDER 4 desipramine hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 100 mg tab, 150 mg tab) 1

QL 120 / 30 Days DESVENLAFAXINE ER 100 MG TAB ER 24H 4 ST

PAGE 128 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 90 / 30 Days DESVENLAFAXINE ER 50 MG TAB ER 24H 4 ST

DESVENLAFAXINE FUMARATE ER 100 MG TAB ER 24H 4 QL 120 / 30 Days

DESVENLAFAXINE FUMARATE ER 50 MG TAB ER 24H 4 QL 90 / 30 Days

desvenlafaxine succinate er 100 mg tab er 24h 1 QL 120 / 30 Days

desvenlafaxine succinate er 25 mg tab er 24h 1 QL 60 / 30 Days

desvenlafaxine succinate er 50 mg tab er 24h 1 QL 90 / 30 Days

doxepin hcl (10 mg cap, 10 mg/ml conc, 25 mg cap, 50 mg cap, 75 mg cap, 100 mg cap) 1

DOXEPIN HCL 150 MG CAP 3

QL 60 / 30 day(s) DRIZALMA SPRINKLE (20 MG CAP DR, 60 MG CAP DR) 3 ST

QL 90 / 30 day(s) DRIZALMA SPRINKLE 30 MG CAP DR 3 ST

QL 30 / 30 day(s) DRIZALMA SPRINKLE 40 MG CAP DR 3 ST

duloxetine hcl (20 mg cp dr part, 60 mg cp dr part) 1 QL 60 / 30 Days

duloxetine hcl 30 mg cp dr part 1 QL 90 / 30 Days

duloxetine hcl 40 mg cp dr part 1 QL 30 / 30 Days

EFFEXOR XR 4

ELAVIL 4

QL 1 Box / 30 Days EMSAM 4 PA

escitalopram oxalate (5 mg tab, 5 mg/5ml solution, 10 mg tab, 20 mg tab) 1

FETZIMA 3 QL 30 / 30 Days

FETZIMA TITRATION 3 QL 1 / 365 Days

fluoxetine hcl (10 mg cap, 10 mg tab, 20 mg cap, 20 mg tab, 20 mg/5ml solution, 40 mg cap, 60 mg tab) 1

PAGE 129 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FLUOXETINE HCL 60 MG TAB 4

FLUOXETINE HCL 90 MG CAP DR 4 ST

fluvoxamine maleate 1

QL 60 / 30 Days fluvoxamine maleate er 1 ST

IMIPRAMINE HCL POWDER 4

imipramine hcl (10 mg tab, 25 mg tab, 50 mg tab) 1

imipramine pamoate 1

QL 120 / 30 Days KHEDEZLA 100 MG TAB ER 24H 4 ST

QL 90 / 30 Days KHEDEZLA 50 MG TAB ER 24H 4 ST

LEXAPRO (5 MG TAB, 5 MG/5ML SOLUTION, 10 MG TAB, 20 MG TAB) 4

MAPROTILINE HCL 3

MARPLAN 4 mirtazapine (7.5 mg tab, 15 mg tab, 15 mg tab disp, 30 mg tab, 30 mg tab disp, 45 mg tab, 45 mg tab disp) 1

NARDIL 4

NEFAZODONE HCL 4

nefazodone hcl (50 mg tab, 250 mg tab) 1

NORPRAMIN 4

NORTRIPTYLINE HCL POWDER 4

nortriptyline hcl (10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap) 1

PAMELOR 4

PARNATE 4

paroxetine hcl 1

paroxetine hcl er 1 ST

PAXIL (10 MG TAB, 10 MG/5ML SUSPENSION, 20 MG TAB, 30 MG TAB, 40 MG TAB) 4

PAXIL CR 4

PAGE 130 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 Days PEXEVA 4 ST

phenelzine sulfate 15 mg tab 1

PRAMLYTE 4

PRISTIQ 100 MG TAB ER 24H 4 QL 120 / 30 Days

PRISTIQ 25 MG TAB ER 24H 4 QL 60 / 30 Days

PRISTIQ 50 MG TAB ER 24H 4 QL 90 / 30 Days

protriptyline hcl 1

PROZAC 4

PROZAC WEEKLY 4

REMERON 4

REMERON SOLTAB 4 sertraline hcl (20 mg/ml conc, 25 mg tab, 50 mg tab, 100 mg tab) 1

QL 8 Kits / 1 Month

PA SPRAVATO (56 MG DOSE) 6 LA Limited Access

QL 12 Kits / 1 Month

PA SPRAVATO (84 MG DOSE) 6 LA Limited Access

TOFRANIL 4

tranylcypromine sulfate 1

TRAZODONE HCL POWDER 4

trazodone hcl (50 mg tab, 100 mg tab, 150 mg tab, 300 mg tab) 1

TRIMIPRAMINE MALEATE POWDER 4

QL 30 / 30 Days TRINTELLIX 4 ST

venlafaxine hcl 1

PAGE 131 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS venlafaxine hcl er (er 37.5 mg cap er 24h, er 75 mg cap er 24h, er 150 mg cap er 24h) 1 VENLAFAXINE HCL ER (ER 37.5 MG TAB ER 24H, ER 75 MG TAB ER 24H, ER 150 MG TAB ER 24H) 4 venlafaxine hcl er (er 37.5 mg tab er 24h, er 75 mg tab er 24h, ST er 150 mg tab er 24h, er 225 mg tab er 24h) 1

VENLAFAXINE HCL ER 225 MG TAB ER 24H 3

QL 30 / 30 Days VIIBRYD 3 ST

QL 30 / 365 Days VIIBRYD STARTER PACK 3 ST

WELLBUTRIN 4

WELLBUTRIN SR 4

WELLBUTRIN XL 4 ZOLOFT (20 MG/ML CONC, 25 MG TAB, 50 MG TAB, 100 MG TAB) 4

ZULRESSO 6 LA Limited Access

ANTIPSYCHOTICS/ANTIMANIC AGENTS

ABILIFY (5 MG TAB, 10 MG TAB, 15 MG TAB, 20 MG TAB, 30 QL 30 / 30 Days MG TAB) 4

ABILIFY 2 MG TAB 4 QL 60 / 30 Days

ABILIFY MAINTENA (300 MG PRSYR, 400 MG PRSYR) 3 PA

QL 1 Vial / 30 Days ABILIFY MAINTENA (300 MG, 400 MG) 3 PA

ADASUVE 4 PA

aripiprazole (5 mg tab, 10 mg tab, 10 mg tab disp, 15 mg tab, QL 30 / 30 Days 15 mg tab disp, 20 mg tab, 30 mg tab) 1

aripiprazole 1 mg/ml solution 1

aripiprazole 2 mg tab 1 QL 60 / 30 Days

ARISTADA (441 MG/1.6ML PRSYR, 662 MG/2.4ML PRSYR, QL 1 / 28 Days 3 882 MG/3.2ML PRSYR) PA

PAGE 132 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / 56 Days ARISTADA 1064 MG/3.9ML PRSYR 3 PA

QL 1 / 365 Days ARISTADA INITIO 3 PA

chlorpromazine hcl (10 mg tab, 25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) 1 CHLORPROMAZINE HCL (25 MG/ML SOLUTION, 50 MG/2ML SOLUTION) 3 CLOZAPINE (12.5 MG TAB DISP, 150 MG TAB DISP, 200 MG TAB DISP) 4 clozapine (25 mg tab, 25 mg tab disp, 50 mg tab, 100 mg tab, 100 mg tab disp, 200 mg tab) 1

CLOZARIL 4

compro 1

EQUETRO 4

FANAPT 4 QL 60 / 30 Days

FANAPT TITRATION PACK 4

FAZACLO 4

fluphenazine decanoate 25 mg/ml solution 1 FLUPHENAZINE HCL (1 MG TAB, 2.5 MG TAB, 2.5 MG/5ML ELIXIR, 2.5 MG/ML SOLUTION, 5 MG TAB, 5 MG/ML CONC, 3 10 MG TAB)

fluphenazine hcl (1 mg tab, 2.5 mg tab, 5 mg tab, 10 mg tab) 1 GEODON (20 MG CAP, 40 MG CAP, 60 MG CAP, 80 MG QL 60 / 30 Days CAP) 4

QL 60 Vials / 30 Days GEODON 20 MG RECON SOLN 4 PA

HALDOL 4

HALDOL DECANOATE 4 haloperidol (0.5 mg tab, 1 mg tab, 2 mg tab, 5 mg tab, 10 mg tab, 20 mg tab) 1

haloperidol decanoate (50 mg/ml solution, 100 mg/ml solution) 1

haloperidol lactate 1

PAGE 133 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

INVEGA 4 QL 30 / 30 Days

QL 1 / 28 Days INVEGA SUSTENNA 4 PA

QL 1 / 90 Days INVEGA TRINZA 4 PA

LATUDA (20 MG TAB, 40 MG TAB, 60 MG TAB, 120 MG TAB) 3 QL 30 / 30 Days

LATUDA 80 MG TAB 3 QL 60 / 30 Days

LITHIUM 3 lithium carbonate (150 mg cap, 300 mg cap, 300 mg tab, 600 mg cap) 1 LITHIUM CARBONATE (150 MG CAP, 600 MG CAP, POWDER) 4

lithium carbonate er 1

LITHOBID 4

loxapine succinate 1

MOLINDONE HCL 3

QL 30 / 30 Days

PA NUPLAZID (10 MG TAB, 34 MG CAP) 6 LA Limited Access

QL 60 / 30 Days

PA NUPLAZID 17 MG TAB 6 LA Limited Access

olanzapine (2.5 mg tab, 5 mg tab, 5 mg tab disp, 7.5 mg tab, 10 mg tab, 10 mg tab disp, 15 mg tab, 15 mg tab disp, 20 mg tab, 1 QL 30 / 30 Days 20 mg tab disp)

olanzapine 10 mg recon soln 1 QL 90 Vials / 30 Days

paliperidone er 1 QL 30 / 30 Days

perphenazine (2 mg tab, 4 mg tab, 8 mg tab, 16 mg tab) 1

QL 1 / 28 Days PERSERIS 4 PA

PAGE 134 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

prochlorperazine 1 prochlorperazine edisylate (10 mg/2ml solution, 50 mg/10ml solution) 1

PROCHLORPERAZINE MALEATE POWDER 4

prochlorperazine maleate (5 mg tab, 10 mg tab) 1 quetiapine fumarate (100 mg tab, 200 mg tab, 300 mg tab, 400 QL 60 / 30 Days mg tab) 1

quetiapine fumarate (25 mg tab, 50 mg tab) 1 QL 120 / 30 Days

quetiapine fumarate er 1 QL 60 / 30 Days

REXULTI 4 QL 30 / 30 Days

RISPERDAL (0.25 MG TAB, 0.5 MG TAB, 1 MG TAB, 1 MG/ML SOLUTION, 2 MG TAB, 3 MG TAB) 4

RISPERDAL 4 MG TAB 4 QL 120 / 30 Days

QL 2 Boxes / 28 Days RISPERDAL CONSTA 3 PA

RISPERDAL M-TAB 4 risperidone (0.25 mg tab, 0.25 mg tab disp, 0.5 mg tab, 0.5 mg tab disp, 1 mg tab, 1 mg tab disp, 1 mg/ml solution, 2 mg tab, 2 1 mg tab disp, 3 mg tab, 3 mg tab disp, 4 mg tab disp)

RISPERIDONE 0.25 MG TAB DISP 4

risperidone 4 mg tab 1 QL 120 / 30 Days

risperidone m-tab 1

SAPHRIS 4 QL 60 / 30 Days

QL 30 / 30 day(s) SECUADO 4 PA

SEROQUEL (100 MG TAB, 200 MG TAB, 300 MG TAB, 400 QL 60 / 30 Days MG TAB) 4

SEROQUEL (25 MG TAB, 50 MG TAB) 4 QL 120 / 30 Days

SEROQUEL XR 4 QL 60 / 30 Days

thioridazine hcl (10 mg tab, 25 mg tab, 50 mg tab, 100 mg tab) 1

thiothixene 1

PAGE 135 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

trifluoperazine hcl 1

VERSACLOZ 4

VRAYLAR (1.5 MG CAP, 3 MG CAP, 4.5 MG CAP, 6 MG CAP) 4 QL 30 / 30 Days

VRAYLAR 1.5 & 3 MG CAP THPK 4 QL 7 / 365 Days

ziprasidone hcl 1 QL 60 / 30 Days

ZYPREXA (2.5 MG TAB, 5 MG TAB, 7.5 MG TAB, 10 MG TAB, QL 30 / 30 Days 15 MG TAB, 20 MG TAB) 4

ZYPREXA 10 MG RECON SOLN 4 QL 90 Vials / 30 Days

QL 2 / 28 Days ZYPREXA RELPREVV 210 MG RECON SUSP 4 PA

QL 2 Vials / 28 Days ZYPREXA RELPREVV 300 MG RECON SUSP 4 PA

QL 1 Vial / 28 Days ZYPREXA RELPREVV 405 MG RECON SUSP 4 PA

ZYPREXA ZYDIS 4 QL 30 / 30 Days

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

AMBIEN 4 QL 30 / 30 Days

AMBIEN CR 4 QL 30 / 30 Days

AMYTAL SODIUM 3

BUTISOL SODIUM 4

CHLORAL HYDRATE 4

dexmedetomidine hcl 200 mcg/2ml solution 1

dexmedetomidine hcl in nacl 1

DORAL 4

QL 30 / 30 Days EDLUAR 4 ST

estazolam 1

eszopiclone 1 QL 30 / 30 Days

FLURAZEPAM HCL 3

PAGE 136 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HALCION 4

QL 30 / 30 Days

PA HETLIOZ 6 LA Limited Access

LUNESTA 4 QL 30 / 30 Days

midazolam hcl (2 mg/2ml solution, 2 mg/ml syrup, 5 mg/5ml solution, 5 mg/ml solution, 10 mg/10ml solution, 10 mg/2ml 1 solution, 25 mg/5ml solution, 50 mg/10ml solution) MIDAZOLAM HCL (30 MG/30ML SOLUTION, 150 MG/30ML SOLUTION) 4 midazolam hcl (pf) (2 mg/2ml solution, 5 mg/5ml solution, 5 mg/ml solution, 10 mg/2ml solution) 1 MIDAZOLAM HCL-SODIUM CHLORIDE (2-0.9 MG/2ML-% SOLN PRSYR, 4-0.9 MG/2ML-% SOLN PRSYR) 4

MIDAZOLAM+SYRSPEND SF 4

MIDAZOLAM-KETAMINE-ONDANSETRON 4

MIDAZOLAM-SODIUM CHLORIDE 3

MKO MELT DOSE PACK 4

PENTOBARBITAL SODIUM POWDER 4

pentobarbital sodium 50 mg/ml solution 1

PHENOBARBITAL POWDER 4 phenobarbital (15 mg tab, 16.2 mg tab, 20 mg/5ml elixir, 20 mg/5ml solution, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg 1 tab, 97.2 mg tab, 100 mg tab)

PHENOBARBITAL SODIUM POWDER 4 PHENOBARBITAL SODIUM (65 MG/ML SOLUTION, 130 MG/ML SOLUTION) 3 PRECEDEX (80 MCG/20ML SOLUTION, 200 MCG/50ML SOLUTION) 4

QUAZEPAM 4

ramelteon 1 QL 30 / 30 day(s)

RESTORIL 4

ROZEREM 4 QL 30 / 30 day(s)

PAGE 137 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SECONAL 3

SONATA 4

temazepam 1

triazolam 1

zaleplon 1

zolpidem tartrate (5 mg tab, 10 mg tab) 1 QL 30 / 30 Days

zolpidem tartrate er 1 QL 30 / 30 Days

DERMATOLOGICAL/ANORECTAL/MOUTH-THROAT/DENTAL/OPHTHALMIC/OTIC

ANORECTAL AGENTS

ana-lex 1

ANALPRAM ADVANCED 4

ANALPRAM E 4

ANALPRAM HC 4

ANALPRAM HC SINGLES 4 ANALPRAM-HC (1-1 % CREAM, 1-2.5 % LOTION, 2.5-1 % LOTION) 4

anucort-hc 1

ANUSOL-HC 2.5 % CREAM 4

anusol-hc 25 mg suppos 1

colocort 1

CORTENEMA 4

CORTIFOAM 3

grx hicort 25 1

hemmorex-hc 1

hydrocortisone (1 % cream, 2.5 % cream, 100 mg/60ml enema) 1 hydrocortisone ace-pramoxine (1-1 % cream, 2.5-1 % cream, 2.5-1 & 1 % kit) 1

hydrocortisone acetate (25 mg suppos, 30 mg suppos) 1

lidazone hc 1 lidocaine-hydrocortisone ace (2-2 % kit, 3-0.5 % cream, 3-0.5 % kit, 3-1 % kit, 3-2.5 % kit) 1

PAGE 138 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LIDOCAINE-HYDROCORTISONE ACE 2.8-0.55 % GEL 3

pramcort 1

PROCORT 4

procto-med hc 1

procto-pak 1

PROCTOCORT (1 % CREAM, 30 MG SUPPOS) 4

PROCTOFOAM HC 3

proctosol hc 1

proctozone-hc 1

rectacort-hc 1

RECTIV 3

UCERIS 2 MG/ACT FOAM 4 DERMATOLOGICALS

1ST MEDX-PATCH/ LIDOCAINE 4

7t lido 1

8-MOP 4

acitretin 1

ACLARO 4

ACLOVATE 4

ACTICOAT 4

ACTICOAT 7 6"X6" SHEET 4

ACTICOAT FLEX 3 4

ACTICOAT FLEX 7 4

ACTICOAT MOISTURE CONTROL 2"X2" PAD 4

ACTICOAT SITE 4 ACTICOAT SURGICAL (4"X10" PAD, 4"X13-3/4" PAD, 4"X4- 3/4" PAD) 4

acyclovir 5 % ointment 1

ACZONE 4 AL1 Up to 25 yrs old

adapalene (0.1 % cream, 0.1 % gel, 0.3 % gel) 1 AL1 Up to 25 yrs old

PAGE 139 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ADAPALENE (0.1 % LOTION, 0.1 % SOLUTION) 4 AL1 Up to 25 yrs old

ADAPALENE 0.1 % PAD 4

adapalene-benzoyl peroxide 1 AL1 Up to 25 yrs old

ADVANCED ALLERGY COLLECTION 4

AKLIEF 4 QL 1 Tube / 30 Days

AKTIPAK 4 AL1 Up to 25 yrs old

ALA SCALP 4

ala-cort 1

alclometasone dipropionate 1

ALDARA 4

alevicyn dermal spray 1

ALLEVYN AG GENTLE 2"X2" PAD 4

ALLO-PAX 4

alphaquin hp 1

QL 1 / 30 Days ALTRENO 4 AL1 Up to 25 yrs old

ALUMINUM CHLORIDE ANHYDROUS 4

ALUMINUM CHLORIDE HEXAHYDRATE 4

ALUVEA 4

AMCINONIDE (0.1 % LOTION, 0.1 % OINTMENT) 3

AMCINONIDE 0.1 % CREAM 4

QL 2 / Lifetime AMELUZ 4 PA

ammonium lactate (12 % cream, 12 % lotion) 1

PA amnesteem 1 AL1 Up to 25 yrs old

ANACAINE 4

ANASTIA 4

anodynz 1

PAGE 140 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANTHRALIN 4

APEXICON E 3

AQUACEL AG BURN 3

arzol silver nit applicators 1

ASTERO 4

ATRALIN 4 AL1 Up to 25 yrs old

AVAR (% FOAM, % PAD) 4 AL1 Up to 25 yrs old

avar cleanser 1 AL1 Up to 25 yrs old

AVAR LS (% FOAM, % PAD) 4 AL1 Up to 25 yrs old

AVAR LS CLEANSER 4 AL1 Up to 25 yrs old

avar-e emollient 1 AL1 Up to 25 yrs old

avar-e green 1 AL1 Up to 25 yrs old

AVAR-E LS 4 AL1 Up to 25 yrs old

avita 1 AL1 Up to 25 yrs old

azelaic acid 15 % gel 1 AL1 Up to 25 yrs old

AZELEX 4 AL1 Up to 25 yrs old

BACITRACIN POWDER 4

BACITRACIN ZINC 4

BACTROBAN (2 % CREAM, 2 % OINTMENT) 4

BENSAL HP 4

BENZAC AC WASH 4 AL1 Up to 25 yrs old

BENZACLIN 4 AL1 Up to 25 yrs old

BENZACLIN WITH PUMP 4 AL1 Up to 25 yrs old

BENZAMYCIN 4 AL1 Up to 25 yrs old

BENZEFOAM 4 AL1 Up to 25 yrs old

BENZEFOAMULTRA 4 AL1 Up to 25 yrs old

benzepro 5.3 % foam 1 AL1 Up to 25 yrs old

PAGE 141 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

benzepro creamy wash 1 AL1 Up to 25 yrs old

benzepro foaming cloths 1 AL1 Up to 25 yrs old

benzepro short contact 1 AL1 Up to 25 yrs old

BENZIQ 4 AL1 Up to 25 yrs old

BENZIQ LS 4 AL1 Up to 25 yrs old

BENZIQ WASH 3 AL1 Up to 25 yrs old

BENZOIC ACID 4

benzoyl peroxide (5.3 % foam, 9.8 % foam) 1 AL1 Up to 25 yrs old

BENZOYL PEROXIDE (6.5 % GEL, 8 % GEL, 70 % POWDER) 4 AL1 Up to 25 yrs old

BENZOYL PEROXIDE FORTE- HC 4 AL1 Up to 25 yrs old

BENZOYL PEROXIDE HYDROUS 4 AL1 Up to 25 yrs old

benzoyl peroxide short contact 1 AL1 Up to 25 yrs old

benzoyl peroxide-erythromycin 1 AL1 Up to 25 yrs old

beser 0.05 % lotion 1

BETAMETHASONE DIPROPIONATE POWDER 4 betamethasone dipropionate (0.05 % cream, 0.05 % lotion, 0.05 % ointment) 1 betamethasone dipropionate aug (0.05 % cream, 0.05 % lotion, 0.05 % ointment) 1

BETAMETHASONE DIPROPIONATE AUG 0.05 % GEL 3

BETAMETHASONE VALERATE POWDER 4 betamethasone valerate (0.1 % cream, 0.1 % lotion, 0.1 % ointment, 0.12 % foam) 1

BIAFINE 3

bimatoprost 0.03 % solution 1 ST

BIONECT (0.2 % CREAM, 0.2 % FOAM) 4

blanche 1

BOTOX COSMETIC 6 S

bp 10-1 1 AL1 Up to 25 yrs old

PAGE 142 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BP CLEANSING WASH 4 AL1 Up to 25 yrs old

bp foam 1 AL1 Up to 25 yrs old

bp foaming wash 1

bp wash (2.5 % liquid, 7 % liquid) 1 AL1 Up to 25 yrs old

BPO 4 AL1 Up to 25 yrs old

bpo foaming cloths 6 % misc 1 AL1 Up to 25 yrs old

CALAMINE 4 calcipotriene (0.005 % cream, 0.005 % ointment, 0.005 % solution) 1

calcipotriene-betameth diprop 1

calcitrene 1

CALCITRIOL 3 MCG/GM OINTMENT 3

CAMPHOR 4

CANTHARIDIN (0.7 % SOLUTION, POWDER) 4

CAPEX 4

CAPSAICIN 4

carb-o-philic/40 1

celacyn 1

CEM-UREA 3

CENOVIA 4

CENTANY 4

CENTANY AT 4

cerisa wash 1 AL1 Up to 25 yrs old

cerovel 1

CHLOROACETIC ACID 4

ciclodan (0.77 % cream, 8 % solution) 1

CICLODAN SOLUTION 4

ciclopirox (0.77 % gel, 1 % shampoo, 8 % solution) 1

CICLOPIROX OLAMINE POWDER 4

ciclopirox olamine (0.77 % cream, 0.77 % suspension) 1

PAGE 143 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ciclopirox treatment 1

cidaleaze 1

PA claravis (10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) 1 AL1 Up to 25 yrs old

CLARIFOAM EF 4

CLARYS 4

clearplex x 1 CLEOCIN-T (1 % GEL, 1 % LOTION, 1 % SOLUTION, 1 % SWAB) 4

clindacin etz 1 % swab 1

clindacin-p 1

CLINDAGEL 4

clindamax 1

clindamycin phos-benzoyl perox (1-5 % gel, 1.2-5 % gel) 1 AL1 Up to 25 yrs old

clindamycin phosphate (1 % foam, 1 % gel, 1 % lotion, 1 % solution, 1 % swab) 1

CLINDAMYCIN PHOSPHATE 1 % GEL 4

CLINDAP-T 4

CLIOQUINOL 4

CLOBETASOL 17 PROPIONATE 4

clobetasol prop emollient base 1

CLOBETASOL PROPIONATE POWDER 4 clobetasol propionate (0.05 % cream, 0.05 % foam, 0.05 % gel, 0.05 % liquid, 0.05 % lotion, 0.05 % ointment, 0.05 % shampoo, 1 0.05 % solution)

clobetasol propionate e 1

clobetasol propionate emulsion 1

CLOBEX 4

CLOBEX SPRAY 4

CLOCORTOLONE PIVALATE 4

CLOCORTOLONE PIVALATE PUMP 4

clodan 0.05 % shampoo 1

PAGE 144 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CLODERM 4

CLODERM PUMP 4

clotrimazole (1 % cream, 1 % solution) 1

CLOTRIMAZOLE (CRYSTALS, POWDER) 4

clotrimazole-betamethasone (% cream, % lotion) 1

CNL8 NAIL 4

COCAINE HCL POWDER 4

COLLAGENASE 4

COLLIGINIX 4

CONDYLOX 0.5 % GEL 3

CONDYLOX 0.5 % SOLUTION 4 CORDRAN (0.025 % CREAM, 0.05 % CREAM, 0.05 % LOTION, 0.05 % OINTMENT) 4

cormax scalp application 1

CORTANE-B 10-10-1 MG/ML LOTION 4

CORTISPORIN (1 % OINTMENT, 3.5-10000-0.5 CREAM) 4

COSENTYX 5 LA Limited Access

COSENTYX (300 MG DOSE) 5 LA Limited Access

COSENTYX SENSOREADY (300 MG) 5 LA Limited Access

COSENTYX SENSOREADY PEN 5 LA Limited Access

crotan 1

CUTIVATE (0.05 % CREAM, 0.05 % LOTION) 4

dapsone 5 % gel 1 AL1 Up to 25 yrs old

PAGE 145 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DAPSONE 7.5 % GEL 4 AL1 Up to 25 yrs old

deluo 1

DERMA-SMOOTHE/FS BODY 4

DERMA-SMOOTHE/FS SCALP 4

DERMAPAK PLUS 4

DERMATOP 4

DERMAWERX SURGICAL PLUS PAK 4

dermazene 1

DERMAZONE 4

DESONATE 4

DESONIDE POWDER 4

desonide (0.05 % cream, 0.05 % lotion, 0.05 % ointment) 1

DESOWEN (0.05 % CREAM, 0.05 % LOTION) 4 desoximetasone (0.05 % cream, 0.05 % gel, 0.05 % ointment, 0.25 % cream, 0.25 % liquid, 0.25 % ointment) 1

DICLOFENAC EPOLAMINE 3 PA

diclofenac sodium (1 % gel, 1.5 % solution) 1 DIFFERIN (0.1 % CREAM, 0.1 % GEL, 0.1 % LOTION, 0.3 % AL1 Up to 25 yrs old GEL) 4

DIFLORASONE DIACETATE 0.05 % CREAM 3

diflorasone diacetate 0.05 % ointment 1

DIPROLENE (0.05 % LOTION, 0.05 % OINTMENT) 4

DIPROLENE AF 4

DOLOTRANZ 4

DOVONEX 4

DOXEPIN HCL 5 % CREAM 4

QL 30 / 30 Days DOXYCYCLINE 3 PA

DRITHO-CREME HP 3

DRYSOL 3

DUAC 4 AL1 Up to 25 yrs old

PAGE 146 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 Syringes / 28 Days

DUPIXENT 200 MG/1.14ML SOLN PRSYR 5 PA

QL 2 Syringes / 28 Days

PA DUPIXENT 300 MG/2ML SOLN PRSYR 5 LA Limited Access

DURAFIBER 4 DURAFIBER AG (2"X2" PAD, 3/4"X18" PAD, 4"X4-3/4" PAD, 8"X11-3/4" PAD) 4

econazole nitrate 1 % cream 1

ECOZA 4

EFUDEX 4

ELIDEL 4

ELIMITE 4

ELOCON (0.1 % CREAM, 0.1 % LOTION, 0.1 % OINTMENT) 4

EMLA 4

ENOVARX-BACLOFEN 4

ENOVARX-NAPROXEN 4

ENOVARX-TRAMADOL 4

ENSTILAR 3 QL 1 / 30 Days

enzoclear 1 AL1 Up to 25 yrs old

EPICYN 3

EPIDUO 4 AL1 Up to 25 yrs old

EPIDUO FORTE 3 AL1 Up to 25 yrs old

EPIFOAM 4

EPIQUIN MICRO 4

EQUIPTO-NAPROXEN 4

ERTACZO 4

ERY 1

PAGE 147 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ERYGEL 4

erythromycin (2 % gel, 2 % pad, 2 % solution) 1

QL 60 Grams / 30 Days EUCRISA 4 PA

EURAX 4

EVOCLIN 4

EXELDERM (1 % CREAM, 1 % SOLUTION) 4

EXODERM 3

EXTINA 4

FABIOR 4 AL1 Up to 25 yrs old

FINACEA 15 % FOAM 3

FINACEA 15 % GEL 4 AL1 Up to 25 yrs old

finasteride 1 mg tab 1

FIRST-HYDROCORTISONE 4

FLECTOR 3 PA

FLUOCINOLONE ACETONIDE POWDER 4 fluocinolone acetonide (0.01 % cream, 0.01 % solution, 0.025 % cream, 0.025 % ointment) 1

fluocinolone acetonide body 1

fluocinolone acetonide scalp 1

FLUOCINONIDE POWDER 4 fluocinonide (0.05 % cream, 0.05 % gel, 0.05 % ointment, 0.05 % solution, 0.1 % cream) 1

fluocinonide emulsified base 1

FLUORAC 4

FLUOROPLEX 4

fluorouracil (2 % solution, 5 % cream, 5 % solution) 1

FLUOROURACIL 2 % SOLUTION 4

FLUOROURACIL 5 % SOLUTION 3

flurandrenolide (0.05 % cream, 0.05 % lotion, 0.05 % ointment) 1 fluticasone propionate (0.005 % ointment, 0.05 % cream, 0.05 % lotion) 1

PAGE 148 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GENTAMICIN SULFATE POWDER 4

gentamicin sulfate (0.1 % cream, 0.1 % ointment) 1

GENTIAN VIOLET 4

GLYCOLIC ACID 70 % SOLUTION 4

glydo 1

GORDOFILM 4

GORDONS UREA 4

grafco silver nit applicator 1

halcinonide 1

halobetasol propionate (0.05 % cream, 0.05 % ointment) 1

HALOBETASOL PROPIONATE 0.05 % FOAM 4

HALOG 4

HALOTIN 4

HYDRO 35 4

HYDRO 40 4

HYDROCORTISONE POWDER 4

hydrocortisone (1 % ointment, 2.5 % lotion, 2.5 % ointment) 1

HYDROCORTISONE ACETATE POWDER 4

hydrocortisone butyr lipo base 1 hydrocortisone butyrate (0.1 % cream, 0.1 % lotion, 0.1 % ointment, 0.1 % solution) 1

hydrocortisone in absorbase 1

HYDROCORTISONE MICRONIZED 4

hydrocortisone valerate 1

hydrocortisone-iodoquinol 1

HYDROQUINONE POWDER 4

hydroquinone 4 % cream 1

HYGEL 4

HYLIRA 0.2 % GEL 3

hypercare 1

ICHTHAMMOL 4

PAGE 149 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Syringe / 84 Days

ILUMYA 6 PA

imiquimod 5 % cream 1

IMPOYZ 4

PA isotretinoin (10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) 1 AL1 Up to 25 yrs old

KENALOG 0.147 MG/GM AERO SOLN 4

KERALYT 4

KERALYT SCALP 4

ketoconazole (2 % cream, 2 % foam, 2 % shampoo) 1

ketodan 2 % foam 1

KETODAN 2 % KIT 3

KETOPHENE RAPIDPAQ 4

KETOROLAC TROMETHAMINE 2 % GEL 4

KLARON 4 AL1 Up to 25 yrs old

klofensaid ii 1

KYBELLA 4

L.E.T. 4

LAC-HYDRIN 12 % LOTION 4

lactic acid 10 % lotion 1

LATISSE 4

LATRIX XM 4

LDO PLUS 4

levicyn dermal spray 1

QL 2 / Lifetime LEVULAN KERASTICK 4 PA

LEXETTE 4

lido-k 1

lido-sorb 1

PAGE 150 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

lidocaine 5 % ointment 1 QL 3 / 30 Days

lidocaine 5 % patch 1 QL 3 Boxes / 30 Days

lidocaine hcl (3 % cream, 3 % lotion, 3.88 % cream, 4 % solution) 1

LIDOCAINE HCL 4.12 % CREAM 4 lidocaine hcl urethral/mucosal (urethral/mucosal, urethral/mucosal 2 % gel) 1

lidocaine pak 1 QL 3 / 30 Days

LIDOCAINE-HYDROCORTISONE ACE 1-1 % CREAM 4

lidocaine-prilocaine 2.5-2.5 % cream 1

LIDOCAINE-TETRACAINE 4

LIDOCIN 4

LIDODERM 4 QL 3 Boxes / 30 Days

lidopin 3 % cream 1

LIDOPIN 3.25 % CREAM 4

LIDORX 4

LIDOSOL-HC 4

LIDOTRAL 4

LIDOTREX 4

LIDOVEX 4

LIDOVIN 4

lidozion 1

LIDOZOL 4

lindane 1

LINDANE 4 LOCOID (0.1 % CREAM, 0.1 % LOTION, 0.1 % OINTMENT, 0.1 % SOLUTION) 4

LOCOID LIPOCREAM 4

lokara 1 LOPROX (0.77 % CREAM, 0.77 % SUSPENSION, 1 % SHAMPOO) 4

PAGE 151 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LOTRISONE 4

LURADROX 4

LUXIQ 4

mafenide acetate 5 % packet 1

malathion 1

MELQUIN 3 3

MENTHOCIN WITH LIDOCAINE 0.5-0.0375-5-20 % PATCH 4

METHOXSALEN 4

methoxsalen rapid 1

METROCREAM 4

METROGEL 4

METROLOTION 4 metronidazole (0.75 % cream, 0.75 % gel, 0.75 % lotion, 1 % gel) 1

MICONAZOLE NITRATE 4

MICORT-HC 4

migryl 1

QL 30 Grams / 30 Days MIRVASO 3 PA

mometasone furoate (0.1 % cream, 0.1 % ointment, 0.1 % solution) 1

mupirocin 2 % ointment 1

mupirocin calcium 1

MUPIROCIN CALCIUM 4

PA myorisan (10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) 1 AL1 Up to 25 yrs old

naftifine hcl 1

NAFTIN 4

NATROBA 3

NAZIREX 4

NEO-SYNALAR 0.5-0.025 % CREAM 4

PAGE 152 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NEOMYCIN SULFATE POWDER 4

neuac 1.2-5 % gel 1 AL1 Up to 25 yrs old

NITROFURAZONE 4

NIZORAL 4

nolix (0.05 % cream, 0.05 % lotion) 1

NORITATE 4 PA

NUCORT 4

NUMBONEX 4

nyamyc 1

nyata 100000 unit/gm powder 1 nystatin (100000 unit/gm cream, 100000 unit/gm ointment, 100000 unit/gm powder) 1

nystatin-triamcinolone 1

nystop 1

OLUX 4

OLUX-E 4

QL 30 / 30 Days ORACEA 3 PA

OVACE PLUS (9.8 % FOAM, 9.8 % LOTION, 10 % CREAM, 10 % SHAMPOO) 4

OVACE PLUS WASH 4

OVACE WASH 4

OVIDE 4

OXISTAT 1 % LOTION 4 PA

OXSORALEN 3

OXSORALEN ULTRA 4

PANDEL 4

PANRETIN 4

PEDIADERM AF COMPLETE 4

PEDIADERM HC 4

PENLAC 4

PAGE 153 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PENNSAID 1.5 % SOLUTION 4

PERLANE 4

PERLANE-L 4

permethrin 5 % cream 1

PICATO 3 PA

pimecrolimus 1

PLEXION 4 AL1 Up to 25 yrs old

PLEXION CLEANSER 4 AL1 Up to 25 yrs old

PLEXION CLEANSING CLOTH 4 AL1 Up to 25 yrs old

PLIAGLIS 4

PLIXDA 4

PODOCON 4

podofilox 0.5 % solution 1

PODOPHYLLUM RESIN 4

pr benzoyl peroxide wash 1 AL1 Up to 25 yrs old

PRAMOSONE (1-1 % CREAM, 1-1 % LOTION, 1-1 % OINTMENT, 1-2.5 % CREAM, 1-2.5 % LOTION, 1-2.5 % 4 OINTMENT)

PRAMOSONE E 4

pramox 1

PRAMOXINE HCL 4

prednicarbate 0.1 % cream 1

PREDNICARBATE 0.1 % CREAM 4

PREDNICARBATE 0.1 % OINTMENT 3

premium lidocaine 1 QL 3 / 30 Days

QL 1 Box / 30 Days PRIZOTRAL 4 PA

PROPECIA 4

PROTOPIC 4

PRUDOXIN 4

PAGE 154 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PSORCON 3

PYROGALLIC ACID 4

QL 30 / 30 Days

QBREXZA 4 PA

AL1 Up to 25 yrs old

rea lo 39 1

rea lo 40 (40 40 % cm, 40 40 % tion) 1

REGRANEX 4 PA

RELYYKS 4

remergent hq 1

remeven 1

RENOVO LIDO5 4

RENUU NL 4

restizan 1

RESTYLANE 4

RESTYLANE-L 4

RETIN-A 4 AL1 Up to 25 yrs old

RETIN-A MICRO 4 AL1 Up to 25 yrs old

RETIN-A MICRO PUMP 4 AL1 Up to 25 yrs old

RETINOIC ACID 4

REXAPHENAC 4

REZESOL 4 AL1 Up to 25 yrs old

RIAX 4 AL1 Up to 25 yrs old

rosadan (0.75 % cream, 0.75 % gel) 1

rosanil cleanser 1 AL1 Up to 25 yrs old

ROSULA 1

ROSULA WASH 4

RYNODERM 4

salacyn (6 % cream, 6 % lotion) 1

PAGE 155 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SALEX (6 % (CREAM) KIT, 6 % (LOTION) KIT, 6 % SHAMPOO) 4 salicylic acid (6 % cream, 6 % foam, 6 % gel, 6 % lotion, 6 % shampoo, 26 % liquid, 27.5 % liquid) 1

SALICYLIC ACID 26 % SOLUTION 4

SALICYLIC ACID 6 % LOTION 3

salicylic acid er 1

salicylic acid wart remover 1

salicylic acid-cleanser 6 % (cream) kit 1

salicylic acid-cleanser 6 % (lotion) kit 3

salimez 1

SALIMEZ FORTE 3

SALISOL 4

salisol forte 1

SALITECH 4

salitech forte 1

SALRIX 4

SALVAX 4

SALVAX DUO PLUS 4

SANTYL 3

scalacort 1

SCULPTRA 4

seb-prev wash 1 selenium sulfide (2.25 % shampoo, 2.3 % shampoo, 2.5 % lotion) 1

SELRX 4

SERNIVO 4 QL 1 / 365 Days

SILAZONE PHARMAPAK 4

SILAZONE-II 4

QL 1 Syringe / 28 Days

PA SILIQ 6 LA Limited Access

PAGE 156 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SILVADENE 4

SILVER NITRATE CRYSTALS 4 SILVER NITRATE (0.5 % SOLUTION, 10 % OINTMENT, 10 % SOLUTION, 25 % SOLUTION, 50 % SOLUTION) 3

silver sulfadiazine 1 % cream 1

SILVERSEAL HYDROGEL DRESSING 2"X3" PAD 4

skin bleaching 1

skin bleaching-sunscreen 1

SKLICE 4

QL 1 Syringe / 84 Days

SKYRIZI 150 DOSE 6 PA

SODIUM HYALURONATE 0.2 % GEL 3

sodium sulfacetamide 1

SODIUM SULFACETAMIDE WASH 3

sodium sulfacetamide wash 1

SORIATANE 4

SORILUX 4

SPINOSAD 3

ssd 1

sss 10-5 10-5 % cream 1 AL1 Up to 25 yrs old

SSS 10-5 10-5 % FOAM 4 AL1 Up to 25 yrs old

STELARA (45 MG/0.5ML SOLN PRSYR, 45 MG/0.5ML PA 5 SOLUTION, 90 MG/ML SOLN PRSYR) S

SULCONAZOLE NITRATE (1 % CREAM, 1 % SOLUTION) 4

sulfacetamide sod-sulfur wash 1 AL1 Up to 25 yrs old

SULFACETAMIDE SODIUM POWDER 4

sulfacetamide sodium (10 % (cleans) gel, 10 % liquid) 1

sulfacetamide sodium (acne) 1 AL1 Up to 25 yrs old

sulfacetamide sodium-sulfur (% lotion, % pad) 1

PAGE 157 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SULFACETAMIDE SODIUM-SULFUR (% LOTION, % AL1 Up to 25 yrs old SUSPENSION) 3 sulfacetamide sodium-sulfur (8-4 % suspension, 9-4 % liquid, 9- 4.5 % liquid, 9.8-4.8 % cream, 9.8-4.8 % liquid, 9.8-4.8 % lotion, AL1 Up to 25 yrs old 10-2 % cream, 10-2 % liquid, 10-4 % pad, 10-5 % cream, 10-5 1 % emulsion)

SULFACETAMIDE-SULFUR IN UREA 10-5 % EMULSION 3 AL1 Up to 25 yrs old

PA sulfacetamide-sulfur-sunscreen 1 AL1 Up to 25 yrs old

sulfacleanse 8/4 1 AL1 Up to 25 yrs old

sulfamez wash 1 AL1 Up to 25 yrs old

SULFAMYLON 5 % PACKET 4

SULFAMYLON 85 MG/GM CREAM 3

SUMADAN 4 AL1 Up to 25 yrs old

SUMADAN WASH 4 AL1 Up to 25 yrs old

PA SUMADAN XLT 4 AL1 Up to 25 yrs old

SUMAXIN 4 AL1 Up to 25 yrs old

SUMAXIN TS 4 AL1 Up to 25 yrs old

SUMAXIN WASH 4 AL1 Up to 25 yrs old

SUPRACIL 4 SYNALAR (0.01 % SOLUTION, 0.025 % CREAM, 0.025 % OINTMENT) 4

TACLONEX 0.005-0.064 % OINTMENT 4

TACLONEX 0.005-0.064 % SUSPENSION 3

tacrolimus (0.03 % ointment, 0.1 % ointment) 1

QL 1 Auto-Injector / 28 Days PA TALTZ 80 MG/ML SOLN A-INJ 6 LA Limited Access

PAGE 158 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Syringe / 28 Days

PA TALTZ 80 MG/ML SOLN PRSYR 6 LA Limited Access

TANNIC ACID 4

PA TARGRETIN 1 % GEL 5 S

tazarotene 0.1 % cream 1 AL1 Up to 25 yrs old

TAZORAC (0.05 % CREAM, 0.05 % GEL, 0.1 % GEL) 3 AL1 Up to 25 yrs old

TAZORAC 0.1 % CREAM 4 AL1 Up to 25 yrs old

TBC 1 TEMOVATE (0.05 % CREAM, 0.05 % GEL, 0.05 % OINTMENT, 0.05 % SOLUTION) 4

TEMOVATE E 4

TERSI 4

TETRACYCLINE HCL POWDER 4

TETRAMEX 4

TETRAVEX 4

TEXACORT 4

THERAPEVO 4

tl hydroquinone 1

TOLAK 4

TOLNAFTATE 4

TOPICORT 4

TOPICORT SPRAY 4

tovet 0.05 % foam 1

TRANSCYTE 4

TRANZAREL 4

QL 1 Auto-Injector / 56 Days TREMFYA 100 MG/ML SOLN PEN 6 PA

PAGE 159 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Syringe / 56 Days

TREMFYA 100 MG/ML SOLN PRSYR 6 PA

TRETIN-X (0.0375 % CREAM, 0.05 % CREAM KIT, 0.075 % CREAM) 4

TRETINOIN POWDER 4 tretinoin (0.01 % gel, 0.025 % cream, 0.025 % gel, 0.05 % AL1 Up to 25 yrs old cream, 0.05 % gel, 0.1 % cream) 1

tretinoin microsphere 1 AL1 Up to 25 yrs old

tretinoin microsphere pump 1 AL1 Up to 25 yrs old

TRI-CHLOR 3

TRIAMCINOLONE ACETONIDE POWDER 4 triamcinolone acetonide (0.025 % cream, 0.025 % lotion, 0.025 % ointment, 0.1 % cream, 0.1 % lotion, 0.1 % ointment, 0.147 1 mg/gm aero soln, 0.5 % cream, 0.5 % ointment)

triderm 1

TRIDERMA FORTE 4

TRIDESILON 4

TRISEON 4

ULESFIA 4

ULTRASAL-ER 4 ULTRAVATE (0.05 % CREAM, 0.05 % LOTION, 0.05 % OINTMENT) 4

ULTRAVATE X (CREAM) 4

ULTRAVATE X (OINTMENT) 4

UMECTA 4

umecta mousse 1

UMECTA NAIL FILM 4

UMECTA PD 4

URALISS 4 URAMAXIN (20 % FOAM, 45 % CREAM, 45 % GEL, 45 % LOTION) 4

PAGE 160 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

URAMAXIN GT (45 % GEL, 45 % KIT) 4

URE-K 4

UREA (35 % FOAM, 40 % SUSPENSION, 45 % CREAM) 4 urea (39 % cream, 40 % cream, 40 % gel, 40 % lotion, 45 % lotion, 50 % cream, 50 % emulsion) 1

urea hydrating 1

UREA IN ZN UNDECYL-LACTIC ACID 4

UREA NAIL (40 & 0.2 % KIT, 50 % STICK) 3

urea nail 45 % gel 1

urea nail film 1

urea-c40 1

uredeb 1

uremez-40 1

URESOL 4

UREVAZ 4

VALCHLOR 5 LA Limited Access

VALIDERM 4

VANOS 4

vashe cleansing 1

vasolex 1

VECTICAL 3

VENIPUNCTURE CPI 4

VERDESO 4

VEREGEN 4

VERRUNEX 4

VIRASAL 4

virti-sulf 1 AL1 Up to 25 yrs old

VOLTAREN 4

WESTCORT 4

PAGE 161 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

WHYTEDERM SURGIPAK 4

WHYTEDERM TDPAK 4

WHYTEDERM TRILASIL PAK 4

x-viate (40 % cream, 40 % gel, 40 % lotion) 1

XALIX 4

QL 1 / 30 Days XEPI 4 PA

XERAC AC 4

XOLEGEL 4

XOLEGEL COREPAK 4

xurea 1

XYLOCAINE 4 % SOLUTION 4

xyphex 1

ZACARE 4 AL1 Up to 25 yrs old

ZACLIR CLEANSING 3 AL1 Up to 25 yrs old

PA zenatane (10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) 1 AL1 Up to 25 yrs old

zencia 1 AL1 Up to 25 yrs old

QL 1 Box / 30 Days ZENEVIX 4 PA

zionodil 1

ZITHRANOL-RR 4

ZONALON 4

ZOVIRAX 5 % OINTMENT 4

ZTLIDO 4 MOUTH/THROAT/DENTAL AGENTS

AMPHOTERICIN B (905 UNIT/MG POWDER, POWDER) 4

AQUORAL AERO SOLN 4

ARESTIN 4

PAGE 162 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cavarest 1

cavirinse 1

cevimeline hcl 1

chlorhexidine gluconate 0.12 % solution 1

clinpro 5000 1

clotrimazole (10 mg lozenge, 10 mg troche) 1

controlrx 1

DEBACTEROL 4

denta 5000 plus 1

dentagel 1

easygel 1

EVOXAC 4

FIRST-BXN MOUTHWASH 3

FIRST-DUKES MOUTHWASH 4

FIRST-MARYS MOUTHWASH 4

FIRST-MOUTHWASH BLM 3

fluoridex 1

fluoridex daily defense 1

fluoridex daily renewal 1

fluoridex enhanced whitening 1

FLUORIDEX SENSITIVITY RELIEF 1.1-5 % GEL 4

fluoridex sensitivity relief 1.1-5 % paste 1

GELCLAIR 4

GELX 4

karigel 1

karigel-n 1

lidocaine viscous 1

lidocaine viscous hcl 1

NAFRINSE DAILY ACIDULATED 4

NAFRINSE DAILY/NEUTRAL 4

PAGE 163 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NAFRINSE WEEKLY 4

neutragard advanced 1

neutral sodium fluoride 1

nystatin 100000 unit/ml suspension 1

oralone 1

ORAPEUTIC 4

ORAVIG 4

paroex 1

PERIDEX 4

periogard 1

phos-flur 1

pilocarpine hcl (5 mg tab, 7.5 mg tab) 1

PREVIDENT (0.2 % SOLUTION, 1.1 % GEL) 4

PREVIDENT 5000 BOOSTER 4

PREVIDENT 5000 BOOSTER PLUS 4

PREVIDENT 5000 DRY MOUTH 4

PREVIDENT 5000 ENAMEL PROTECT 4

PREVIDENT 5000 ORTHO DEFENSE 4

PREVIDENT 5000 PLUS 4

PREVIDENT 5000 SENSITIVE 4

SALAGEN 4

sf 1

sf 5000 plus 1

sodium fluoride (1.1 % gel, 1.1 % paste) 1

sodium fluoride 5000 plus 1

stannous fluoride 0.63 % conc 1

THERA-FLUR-N 4

triamcinolone acetonide 0.1 % paste 1

ZINC ACETATE (100 % CRYSTALS, CRYSTALS) 4

PAGE 164 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS OPHTHALMIC AGENTS

ACULAR 4

ACULAR LS 4

ak-fluor 10 % solution 1

ak-poly-bac 1

AKTEN 4

ALCAINE 4

ALOCRIL 4

ALOMIDE 4

ALPHAGAN P 0.1 % SOLUTION 3

ALPHAGAN P 0.15 % SOLUTION 4

ALREX 3

altacaine 1

altafluor 1

altafluor benox 1

altafrin 1

PA AMVISC 6 S

PA AMVISC PLUS 6 S

apraclonidine hcl 1 ATROPINE SULFATE (0.01 % EMULSION, 1 % OINTMENT, 1 % SOLUTION) 4

atropine sulfate 1 % solution 1

ATROPINE SULFATE-NACL 4

AZASITE 3

azelastine hcl 0.05 % solution 1

AZOPT 4

bacitra-neomycin-polymyxin-hc 1

BACITRACIN 500 UNIT/GM OINTMENT 3

bacitracin-polymyxin b 1

PAGE 165 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

balanced salt 1

QL 1 / 8 Weeks

PA BEOVU 6 AL1 At least 18 yrs old

BEPREVE 3

BESIVANCE 4 ST

BETADINE OPHTHALMIC PREP 4

BETAGAN 4

betaxolol hcl 0.5 % solution 1

BETIMOL 4

BETOPTIC-S 4

QL 1 / 28 day(s)

BEVACIZUMAB (2.5 MG/0.1ML SOLN PRSYR, 3.25 PA 6 MG/0.13ML SOLN PRSYR) AL1 At least 18 yrs old

QL 1 Syringe / 28 Days

BEVACIZUMAB 2.75 MG/0.11ML SOLN PRSYR 6 PA

QL 1 Syringe / 28 Days

PA BEVACIZUMAB 3.75 MG/0.15ML SOLN PRSYR 6 AL1 At least 18 yrs old

bio glo 1

BIOLON 6 LA Limited Access

BLEPH-10 4

BLEPHAMIDE 4

BLEPHAMIDE S.O.P. 4

brimonidine tartrate (0.15 % solution, 0.2 % solution) 1

PAGE 166 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BRIMONIDINE-DORZOLAMIDE 4

bromfenac sodium (once-daily) 1

BROMFENAC SODIUM 0.09 % SOLUTION 1

BROMSITE 4 QL 1 bottle / 30 days

CARTEOLOL HCL 3

carteolol hcl 1

CEFUROXIME SODIUM-NACL 4

CELLUGEL 4

QL 60 Vials / 30 Days CEQUA 3 PA

CHONDROITIN SULFATE 4

CILOXAN (0.3 % OINTMENT, 0.3 % SOLUTION) 4

ciprofloxacin hcl 0.3 % solution 1

COMBIGAN 3

COSOPT 4

COSOPT PF 4

cromolyn sodium 4 % solution 1

CYCLOGYL 4

CYCLOMYDRIL 4

cyclopentolate hcl (0.5 % solution, 1 % solution, 2 % solution) 1

QL 60 Vials / 30 Days CYCLOSPORINE IN KLARITY 3 PA

QL 1 / 28 Days

PA CYSTARAN 5 LA Limited Access

DEXAMETH-MOXIFLOX-KETOROLAC 4

dexamethasone sodium phosphate 0.1 % solution 1

DEXAMETHASONE SODIUM PHOSPHATE 0.1 % SOLUTION 4

DEXAMETHASONE-MOXIFLOXACIN 4

PAGE 167 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA DEXTENZA 6 S

QL 1 / 180 Days

DEXYCU 6 PA

diclofenac sodium 0.1 % solution 1

DISCOVISC 4

dorzolamide hcl 2 % solution 1

DORZOLAMIDE HCL 2 % SOLUTION 4

dorzolamide hcl-timolol mal 1

dorzolamide hcl-timolol mal pf 1

DOUBLE PM 4

DUOVISC 4

ELESTAT 4

EMADINE 4

epinastine hcl 1

erythromycin 5 mg/gm ointment 1

PA EYLEA (2 MG/0.05ML SOLN PRSYR, 2 MG/0.05ML LA Limited Access SOLUTION) 5 S

FLAREX 4

flucaine 1

fluor-i-strips a.t. 1

fluorescein-benoxinate 1

FLUORESCITE 4

fluorometholone 1

FLURA-SAFE 4

FLURBIPROFEN SODIUM 3

flurbiprofen sodium 1

flurox 1

PAGE 168 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FML 3

FML FORTE 4

FML LIQUIFILM 4

ful-glo 1 mg strip 1

GARAMYCIN 4

gatifloxacin 0.5 % solution 1

GATIFLOXACIN-DEXAMETHASONE 4

gentak 1

GENTAK 4

gentamicin sulfate (0.3 % ointment, 0.3 % solution) 1

glostrips 1

green glo lissamine green 1

HEALON 6 LA Limited Access

PA HEALON GV 6 S

PA HEALON5 6 S

homatropaire 1

homatropine hbr 1

PA HYALURONIDASE (INTRAOCULAR) 6 S

ILEVRO 3

ilotycin 1

ILUVIEN 6 LA Limited Access

INVELTYS 4

IOPIDINE (0.5 % SOLUTION, 1 % SOLUTION) 4

PAGE 169 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ISOPTO ATROPINE 4

ISOPTO CARPINE 4

ISTALOL 4

QL 2 / Lifetime

JETREA 0.375 MG/0.3ML SOLUTION 5 LA Limited Access

LA Limited Access JETREA 0.5 MG/0.2ML SOLUTION 5 S

ketorolac tromethamine (0.4 % solution, 0.5 % solution) 1

KLARITY-A 3

latanoprost 0.005 % solution 1

LATANOPROST 0.005 % SOLUTION 4

levobunolol hcl 1

levofloxacin 0.5 % solution 1

LIDOCAINE-EPINEPHRINE 7.5-0.25 MG/ML SOLUTION 3

LIDOCAINE-PHENYLEPHRINE 4

lissamine green 1

LOTEMAX (0.5 % GEL, 0.5 % OINTMENT) 3

LOTEMAX 0.5 % SUSPENSION 4

LOTEMAX SM 3

loteprednol etabonate 1

LUCENTIS 5 LA Limited Access

LUMIGAN 3 ST

QL 2 / Lifetime

PA LUXTURNA 6 LA Limited Access

QL 2 Syringes / 42 Days

PA MACUGEN 6 LA Limited Access

PAGE 170 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MAXIDEX 4

MAXITROL (OINTMENT, SUSPENSION) 4

METIPRANOLOL 4

MIOCHOL-E 4

MIOSTAT 3

MITOSOL 4

MOXEZA 3 ST

MOXIFLOXACIN HCL (0.3 MG/0.3ML SOLN PRSYR, 5 MG/ML SOLUTION) 4

moxifloxacin hcl 0.5 % solution 1 ST

MOXIFLOXACIN HCL-BSS 4

MYDRIACYL 4

NAPHAZOLINE HCL 0.1 % SOLUTION 4

NATACYN 3

neo-polycin 1

neo-polycin hc 1

neofrin 1

neomycin-bacitracin zn-polymyx 1

neomycin-polymyxin-dexameth (ointment, suspension) 1

NEOMYCIN-POLYMYXIN-GRAMICIDIN 1

NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 SUSPENSION 3

NEOSPORIN 4

NEVANAC 3

ocucoat viscoadherent 1

OCUFEN 4

OCUFLOX 4

ofloxacin 0.3 % solution 1

olopatadine hcl (0.1 % solution, 0.2 % solution) 1

OMIDRIA 4

OMNIPRED 4

PAGE 171 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

OPTIVAR 4

QL 56 Milliliters / 28 days

PA OXERVATE 5 LA Limited Access

QL 2 / 90 Days

OZURDEX 5 LA Limited Access

parcaine 1

PAREMYD 4

PATADAY 4

PATANOL 4

PAZEO 3

phenylephrine hcl (2.5 % solution, 10 % solution) 1

PHOSPHOLINE IODIDE 3

LA Limited Access PHOTREXA VISCOUS 6 S

LA Limited Access PHOTREXA-PHOTREXA VISCOUS KIT 6 S

pilocarpine hcl (1 % solution, 2 % solution, 4 % solution) 1

poly-dex 1

polycin 1

polycin b 1

polymyxin b-trimethoprim 1

POLYTRIM 4

POVIDONE-IODINE 5 % SOLUTION 4

PRED FORTE 4

PRED MILD 3

PRED-G 4

PRED-G S.O.P. 4

PAGE 172 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PREDNISOL ACE-MOXIFLOX-BROMFEN 4

PREDNISOLON-GATIFLOX-BROMFENAC 4

PREDNISOLON-MOXIFLOX-BROMFENAC 4

PREDNISOLON-MOXIFLOX-KETOROLAC 4

PREDNISOLONE ACETATE 1 % SUSPENSION 4

PREDNISOLONE ACETATE P-F 4

PREDNISOLONE SODIUM PHOSPHATE 1 % SOLUTION 3

PREDNISOLONE-BROMFENAC 1-0.075 % SOLUTION 3

PREDNISOLONE-BROMFENAC 1-0.075 % SUSPENSION 4

PREDNISOLONE-GATIFLOXACIN 1-0.5 % SOLUTION 4

PREDNISOLONE-MOXIFLOXACIN 4

PROLENSA 3

proparacaine hcl 0.5 % solution 1

proparacaine-fluorescein 1

PROVISC 6 LA Limited Access

RESCULA 4

QL 1 / 30 Days RESTASIS 3 PA

QL 1 / 30 Days RESTASIS MULTIDOSE 3 PA

RETISERT 6 LA Limited Access

RHOPRESSA 4

ROCKLATAN 4

romycin 1

PA SHELLGEL 6 S

PAGE 173 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SIMBRINZA 4

SULFACETAMIDE SODIUM 10 % OINTMENT 3

sulfacetamide sodium 10 % solution 1

SULFACETAMIDE-PREDNISOLONE 1

tetcaine 1

tetracaine hcl 0.5 % solution 1

tetravisc 1

tetravisc forte 1 timolol maleate (0.25 % gel f soln, 0.25 % solution, 0.5 % (daily) solution, 0.5 % gel f soln, 0.5 % solution) 1 TIMOLOL MALEATE (0.25 % GEL F SOLN, 0.5 % GEL F SOLN) 4

TIMOPTIC 4

TIMOPTIC OCUDOSE 4

TIMOPTIC-XE 4

TOBRADEX 0.3-0.1 % OINTMENT 3

TOBRADEX 0.3-0.1 % SUSPENSION 4

TOBRADEX ST 3

tobramycin 0.3 % solution 1

tobramycin-dexamethasone 1

TOBREX (0.3 % OINTMENT, 0.3 % SOLUTION) 4

TRAVATAN Z 4 ST

TRAVOPROST 3

travoprost (bak free) 1 ST

TRIAMCINOLONE-MOXIFLOXACIN 4

TRIESENCE 4

TRIFLURIDINE 1 % SOLUTION 3

trifluridine 1 % solution 1

TRIPLE PMB 4

TRIPLE PMK 4

TROPIC-PROPARACA-PE-KETOROLAC 3

PAGE 174 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TROPICAMIDE POWDER 4

tropicamide (0.5 % solution, 1 % solution) 1

TROPICAMIDE-CYCLOPENTOLATE-PE 4

TROPICAMIDE-PHENYLEPHRINE 4

TRUSOPT 4

VEXOL 4

VIGAMOX 4

VIROPTIC 4

VISCOAT 4

VISUDYNE 5 LA Limited Access

QL 1 / 30 Days VYZULTA 4 ST

XALATAN 4

QL 60 / 30 Days XIIDRA 3 PA

YUTIQ 6 LA Limited Access

ZIRGAN 4

ZYLET 3

ZYMAXID 4 OTIC AGENTS

acetasol hc 1

acetic acid 2 % solution 1

ACETIC ACID-ALUMINUM ACETATE 3

aero otic hc 1 antipyrine-benzocaine (5.4-1.4 % solution, 54-14 mg/ml solution) 1

ANTIPYRINE-BENZOCAINE 5.5-1.4 % SOLUTION 3

PAGE 175 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CIPRO HC 4

CIPRODEX 3

CIPROFLOXACIN-FLUOCINOLONE PF 3

CORTANE-B 10-10-1 MG/ML SOLUTION 4

CORTANE-B AQUEOUS 4

cortic-nd 1

cyotic 1

DERMOTIC 4

exotic-hc 1

flac 1

FLOXIN OTIC 4

fluocinolone acetonide 0.01 % oil 1

hydrocortisone-acetic acid 1

neomycin-polymyxin-hc 1

otic care 1

oticin 1

OTICIN HC NR 4

OTIPRIO 4 QL 1 / 30 Days

oto-end 10 1

otomax-hc 1

OTOVEL 3 QL 4 Bottles / Year

OTOZIN 4

PINNACAINE OTIC 4

PRAMOTIC 4 ENDOCRINE AND METABOLIC AGENTS

ANDROGENS-ANABOLIC

ANADROL-50 3

ANDRODERM 4 PA

ANDROGEL (20.25 MG/1.25GM (1.62%) GEL, 25 MG/2.5GM (1%) GEL, 40.5 MG/2.5GM (1.62%) GEL, 50 MG/5GM (1%) 4 PA GEL)

PAGE 176 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANDROGEL PUMP (PUMP 12.5 MG/ACT (1%) GEL, PUMP PA 20.25 MG/ACT (1.62%) GEL) 4

ANDROID 4 PA

ANDROXY 4 PA

PA AVEED 4 LA Limited Access

DANAZOL POWDER 4

danazol (50 mg cap, 100 mg cap, 200 mg cap) 1

DEPO-TESTOSTERONE 4 EC-RX TESTOSTERONE (0.2 % CREAM, 0.4 % CREAM, 10 PA % CREAM, 20 % CREAM) 4

FIRST-TESTOSTERONE 4 PA

FIRST-TESTOSTERONE MC 4 PA

QL 60 / 30 day(s) JATENZO (158 MG CAP, 237 MG CAP) 4 PA

QL 120 / 30 day(s) JATENZO 198 MG CAP 4 PA

METHITEST 3 PA

METHYLTESTOSTERONE POWDER 4

METHYLTESTOSTERONE 10 MG CAP 3 PA

NANDROLONE DECANOATE 200 MG/ML OIL 4

NANDROLONE-TESTOSTERONE CYP&EN 4

OXANDRIN 4

oxandrolone (2.5 mg tab, 10 mg tab) 1

TESTIM 4 PA

TESTONE CIK 4 PA

PA TESTOPEL 4 LA Limited Access

PAGE 177 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS testosterone (1.62 % gel, 10 mg/act (2%) gel, 12.5 mg/act (1%) gel, 20.25 mg/1.25gm (1.62%) gel, 20.25 mg/act (1.62%) gel, PA 25 mg/2.5gm (1%) gel, 30 mg/act solution, 40.5 mg/2.5gm 1 (1.62%) gel, 50 mg/5gm (1%) gel) TESTOSTERONE (12.5 MG/ACT GEL, 25 MG/2.5GM GEL, 50 PA MG/5GM GEL) 4

TESTOSTERONE COMPOUNDING KIT 4 PA

TESTOSTERONE CYPIONATE & PROP 4 PA

testosterone cypionate (100 mg/ml solution, 200 mg/ml solution) 1 TESTOSTERONE CYPIONATE (50 MG/ML SOLUTION, 100 MG/ML SOLUTION, 150 MG/ML SOLUTION, 200 MG/ML 4 SOLUTION)

TESTOSTERONE CYPIONATE 250 MG/ML SOLUTION 3

TESTOSTERONE ENANTHATE 200 MG/ML SOLUTION 3 PA

testosterone enanthate 200 mg/ml solution 1

TESTOSTERONE EO-PRO-CYP 220 4 PA

TESTOSTERONE PROPIONATE 100 MG/ML SOLUTION 4 PA

TESTRED 4 PA

VOGELXO PUMP 4 PA

XYOSTED 4 PA

ANTIDIABETICS

acarbose (25 mg tab, 50 mg tab, 100 mg tab) 1

ACTOPLUS MET 4

ACTOPLUS MET XR 15-1000 MG TAB ER 24H 3 QL 60 / 30 Days

ACTOPLUS MET XR 30-1000 MG TAB ER 24H 3 QL 30 / 30 Days

ACTOS 4

QL 1 Box / 28 Days ADLYXIN 4 PA

QL 1 Box / 365 Days ADLYXIN STARTER PACK 4 PA

PAGE 178 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AFREZZA (4 (30) & 8 (60) POWDER, 4 (60) & 8 (30) POWDER, 4 POWDER, 8 (60)& 12 (30) POWDER, 8 (90)& 12 4 (90) POWDER, 8 POWDER, 12 POWDER)

AFREZZA (4 8 12 POWDER, 4 8 POWDER) 4 QL 1 Box / 365 Days

AMARYL 4

AVANDAMET 4

AVANDARYL 4-2 MG TAB 4

AVANDIA (2 MG TAB, 4 MG TAB) 4 QL 30 / 30 Days

AVANDIA 8 MG TAB 4

BAQSIMI ONE PACK 3 QL 2 / 365 day(s)

BAQSIMI TWO PACK 3 QL 2 / 365 day(s)

CHLORPROPAMIDE 3

CYCLOSET 4 QL 180 / 30 Days

DIABETA (2.5 MG TAB, 5 MG TAB) 4

DUETACT 4

FARXIGA 3 QL 30 / 30 Days

FIASP 3

FIASP FLEXTOUCH 3

FIASP PENFILL 3

glimepiride 1

GLIPIZIDE POWDER 4

glipizide (5 mg tab, 10 mg tab) 1

glipizide er 1

glipizide xl 1

glipizide-metformin hcl 1

GLUCAGEN HYPOKIT 3 QL 2 / 365 Days

GLUCAGON EMERGENCY 1 MG KIT 3 QL 2 / 365 Days

GLUCAGON EMERGENCY 1 MG/ML RECON SOLN 3 QL 2 / 365 day(s)

GLUCOPHAGE 4

PAGE 179 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GLUCOPHAGE XR 500 MG TAB ER 24H 4 QL 150 / 30 Days

GLUCOPHAGE XR 750 MG TAB ER 24H 4 QL 90 / 30 Days

GLUCOTROL 4

GLUCOTROL XL 4

GLUCOVANCE 4

glyburide (1.25 mg tab, 2.5 mg tab, 5 mg tab) 1

GLYBURIDE (5 MG TAB, POWDER) 4

glyburide micronized 1

glyburide-metformin 1

GLYNASE 4

GLYSET 4 QL 90 / 30 Days

GLYXAMBI 3 QL 30 / 30 Days

GVOKE PFS 3 QL 2 / 365 day(s)

HUMULIN R U-500 (CONCENTRATED) 3

HUMULIN R U-500 KWIKPEN 3

INSULIN ASP PROT & ASP FLEXPEN 4

INSULIN ASPART 4

INSULIN ASPART FLEXPEN 4

INSULIN ASPART PENFILL 4

INSULIN ASPART PROT & ASPART 4

JANUMET 3 QL 60 / 30 Days

JANUMET XR (50-1000 MG TAB ER 24H, 50-500 MG TAB ER QL 60 / 30 Days 24H) 3

JANUMET XR 100-1000 MG TAB ER 24H 3 QL 30 / 30 Days

JANUVIA 3 QL 30 / 30 Days

JARDIANCE 3 QL 30 / 30 Days

QL 120 / 30 Days

PA KORLYM 6 LA Limited Access

PAGE 180 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LANTUS 3

LANTUS SOLOSTAR 3

LEVEMIR 3

LEVEMIR FLEXTOUCH 3

metformin hcl (500 mg tab, 850 mg tab, 1000 mg tab) 1

METFORMIN HCL 500 MG/5ML SOLUTION 4 QL 750 Milliliters / 30 Days

metformin hcl er 500 mg tab er 24h 1 QL 150 / 30 Days

metformin hcl er 750 mg tab er 24h 1 QL 90 / 30 Days

miglitol 1 QL 90 / 30 Days

MYXREDLIN 4

nateglinide 1

NOVOLOG 3

NOVOLOG FLEXPEN 3

NOVOLOG MIX 70/30 3

NOVOLOG MIX 70/30 FLEXPEN 3

NOVOLOG PENFILL 3

QL 1 Box / 28 Days OZEMPIC 3 PA

pioglitazone hcl 1

pioglitazone hcl-glimepiride 1

pioglitazone hcl-metformin hcl 1

PRANDIMET 4

PRANDIN 0.5 MG TAB 4

PRANDIN 1 MG TAB 4 QL 90 / 30 Days

PRANDIN 2 MG TAB 4 QL 240 / 30 Days

PRECOSE 4

PROGLYCEM 3

repaglinide (0.5 mg tab, 1 mg tab) 1 QL 90 / 30 Days

repaglinide 2 mg tab 1 QL 240 / 30 Days

PAGE 181 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

REPAGLINIDE-METFORMIN HCL 1-500 MG TAB 4 QL 90 / 30 Days

REPAGLINIDE-METFORMIN HCL 2-500 MG TAB 4 QL 150 / 30 Days

RIOMET 4 QL 750 Milliliters / 30 Days

QL 30 / 30 day(s)

RYBELSUS (7 MG TAB, 14 MG TAB) 4 PA

AL1 At least 18 yrs old

QL 1 / 365 day(s)

RYBELSUS 3 MG TAB 4 PA

AL1 At least 18 yrs old

STARLIX 4

SYMLINPEN 120 3 PA

SYMLINPEN 60 3 PA

SYNJARDY 3 QL 60 / 30 Days

SYNJARDY XR (10-1000 MG TAB ER 24H, 25-1000 MG TAB QL 30 / 30 Days ER 24H) 3 SYNJARDY XR (5-1000 MG TAB ER 24H, 12.5-1000 MG TAB QL 60 / 30 Days ER 24H) 3

TANZEUM 4 PA

TOLAZAMIDE 3

tolazamide 250 mg tab 1

TOLBUTAMIDE 3

TOUJEO MAX SOLOSTAR 3

TOUJEO SOLOSTAR 3

TRESIBA 3

TRESIBA FLEXTOUCH 3

QL 1 Box / 28 Days TRULICITY 3 PA

QL 1 Box / 28 Days VICTOZA 3 PA

XIGDUO XR (10-1000 MG TAB ER 24H, 10-500 MG TAB ER QL 30 / 30 Days 24H) 3

PAGE 182 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XIGDUO XR (2.5-1000 MG TAB ER 24H, 5-1000 MG TAB ER QL 60 / 30 Days 24H, 5-500 MG TAB ER 24H) 3

XULTOPHY 3 QL 1 Box / 30 Days

CONTRACEPTIVES

afirmelle 1

altavera 1

alyacen 1/35 1

alyacen 7/7/7 1

amethia 1 QL 91 / 91 Days

amethia lo 1 QL 91 / 91 Days

amethyst 1

ANNOVERA 4 QL 1 / year(s)

apri 1

aranelle 1

ashlyna 1 QL 91 / 91 Days

aubra 1

aubra eq 1

aurovela 1.5/30 1

aurovela 1/20 1

aurovela 24 fe 1

aurovela fe 1.5/30 1

aurovela fe 1/20 1

aviane 1

ayuna 1

azurette 1

BALCOLTRA 4

balziva 1

bekyree 1

BEYAZ 4

blisovi 24 fe 1

PAGE 183 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

blisovi fe 1.5/30 1

blisovi fe 1/20 1

BREVICON (28) 3

briellyn 1

camila 1

camrese 1 QL 91 / 91 Days

camrese lo 1 QL 91 / 91 Days

caziant 1

chateal 1

chateal eq 1

cryselle-28 1

cyclafem 1/35 1

cyclafem 7/7/7 1

CYCLESSA 4

cyred 1

cyred eq 1

dasetta 1/35 1

dasetta 7/7/7 1

daysee 1 QL 91 / 91 Days

deblitane 1

delyla 1

DEPO-PROVERA 150 MG/ML SUSP PRSYR 4 QL 1 Syringe / 84 Days

DEPO-PROVERA 150 MG/ML SUSPENSION 4 QL 1 Vial / 84 Days

DEPO-SUBQ PROVERA 104 3 QL 1 Syringe / 84 Days

DESOGEN 4 desogestrel-ethinyl estradiol (0.15-0.02/0.01 mg (21/5) tab, 0.15-30 mg-mcg tab) 1

drospiren-eth estrad-levomefol 1

drospirenone-ethinyl estradiol 1

elinest 1

PAGE 184 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ELLA 3

eluryng 1 QL 1 / 28 day(s)

emoquette 1

enpresse-28 1

enskyce 1

errin 1

estarylla 1

ESTROSTEP FE 3

ethynodiol diac-eth estradiol 1

etonogestrel-ethinyl estradiol 1 QL 1 / 28 day(s)

FALESSA 4

falmina 1

fayosim 1 QL 91 / 91 Days

FEMCON FE 4

femynor 1

GENERESS FE 3

gianvi 1

gildagia 1

gildess 1.5/30 1

gildess 1/20 1

gildess 24 fe 1

gildess fe 1.5/30 1

gildess fe 1/20 1

hailey 1.5/30 1

hailey 24 fe 1

heather 1

incassia 1

introvale 1 QL 91 / 91 Days

isibloom 1

jasmiel 1

PAGE 185 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

jencycla 1

jolessa 1 QL 91 / 91 Days

jolivette 1

juleber 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

junel fe 24 1

kaitlib fe 1

kalliga 1

kariva 1

kelnor 1/35 1

kelnor 1/50 1

kimidess 1

kurvelo 1

KYLEENA 3 LA Limited Access

larin 1.5/30 1

larin 1/20 1

larin 24 fe 1

larin fe 1.5/30 1

larin fe 1/20 1

larissia 1

layolis fe 1

leena 1

lessina 1

levonest 1

levonorg-eth estrad triphasic 1

levonorgest-eth est & eth est 1 QL 91 / 91 Days

levonorgest-eth estrad 91-day 1 QL 91 / 91 Days

PAGE 186 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levonorgestrel-ethinyl estrad (0.1-20 mg-mcg tab, 0.15-30 mg- mcg tab, 90-20 mcg tab) 1

levora 0.15/30 (28) 1

LILETTA (52 MG) 3 LA Limited Access

lillow 1

LO LOESTRIN FE 3

lo-zumandimine 1

LOESTRIN 1.5/30 (21) 4

LOESTRIN 1/20 (21) 4

LOESTRIN FE 1.5/30 4

LOESTRIN FE 1/20 4

lomedia 24 fe 1

loryna 1

LOSEASONIQUE 4 QL 91 / 91 Days

low-ogestrel 1

lutera 1

lyza 1

marlissa 1

medroxyprogesterone acetate 150 mg/ml susp prsyr 1 QL 1 Syringe / 84 Days

medroxyprogesterone acetate 150 mg/ml suspension 1 QL 1 Vial / 84 Days

melodetta 24 fe 1

mibelas 24 fe 1

microgestin 1.5/30 1

microgestin 1/20 1

microgestin 24 fe 1

microgestin fe 1.5/30 1

microgestin fe 1/20 1

mili 1

MINASTRIN 24 FE 3

MIRCETTE 4

PAGE 187 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MIRENA (52 MG) 3 LA Limited Access

MODICON (28) 3

mono-linyah 1

mononessa 1

myzilra 1

NATAZIA 3

necon 0.5/35 (28) 1

necon 1/35 (28) 1

NECON 1/50 (28) 3

NECON 10/11 (28) 3

necon 7/7/7 1

NEXPLANON 3 LA Limited Access

nikki 1

NOR-QD 4

nora-be 1

norethin ace-eth estrad-fe 1

norethin-eth estradiol-fe 1

norethindrone 0.35 mg tab 1 norethindrone acet-ethinyl est (1-20 mg-mcg tab, 1-20 mg- mcg(24) chew tab, 1.5-30 mg-mcg tab) 1

norgestim-eth estrad triphasic 1

norgestimate-eth estradiol 1

NORINYL 1+35 (28) 4

NORINYL 1+50 (28) 3

norlyda 1

norlyroc 1

nortrel 0.5/35 (28) 1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

nortrel 7/7/7 1

PAGE 188 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NUVARING 4 QL 1 / 28 day(s)

ocella 1

OGESTREL 3

orsythia 1

ORTHO MICRONOR 4

ORTHO TRI-CYCLEN (28) 4

ORTHO TRI-CYCLEN LO 4

ORTHO-CYCLEN (28) 4

ORTHO-NOVUM 1/35 (28) 4

ORTHO-NOVUM 7/7/7 (28) 4

OVCON-35 (28) 4

PARAGARD INTRAUTERINE COPPER 3

philith 1

pimtrea 1

pirmella 1/35 1

pirmella 7/7/7 1

portia-28 1

previfem 1

QUARTETTE 4 QL 91 / 91 Days

quasense 1 QL 91 / 91 Days

rajani 1

reclipsen 1

rivelsa 1 QL 91 / 91 Days

SAFYRAL 4

SEASONIQUE 4 QL 91 / 91 Days

setlakin 1 QL 91 / 91 Days

sharobel 1

simliya 1

simpesse 1 QL 91 / 91 Days

PAGE 189 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SKYLA 3 LA Limited Access

SLYND 4

sprintec 28 1

sronyx 1

syeda 1

tarina 24 fe 1

tarina fe 1/20 1

tarina fe 1/20 eq 1

TAYTULLA 3

tilia fe 1

tri femynor 1

tri-estarylla 1

tri-legest fe 1

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-mili 1

tri-lo-sprintec 1

tri-mili 1

TRI-NORINYL (28) 4

tri-previfem 1

tri-sprintec 1

tri-vylibra 1

tri-vylibra lo 1

trinessa (28) 1

trinessa lo 1

trivora (28) 1

tulana 1

tydemy 1

velivet 1

PAGE 190 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

vestura 1

vienva 1

viorele 1

vyfemla 1

vylibra 1

wera 1

wymzya fe 1

XULANE 3 QL 3 Patches / 28 Days

YASMIN 28 4

YAZ 4

zarah 1

zenchent 1

zenchent fe 1

zovia 1/35e (28) 1

zovia 1/50e (28) 1

zumandimine 1 CORTICOSTEROIDS

ARISTOSPAN INTRA-ARTICULAR 3

baycadron 1

BETAMETHASONE COMBO 4

BETAMETHASONE SOD PHOS & ACET 4

betamethasone sod phos & acet 6 (3-3) mg/ml suspension 1

BETAMETHASONE SOD PHOSPHATE 3 BETAMETHASONE SODIUM PHOSPHATE (6 MG/ML SOLUTION, 12 MG/2ML SOLUTION, POWDER) 4

budesonide 3 mg cp dr part 1

budesonide er 1

CELESTONE SOLUSPAN 4

CONTRAST ALLERGY PREMED PACK 4

CORTEF 4

CORTISONE ACETATE POWDER 4

PAGE 191 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CORTISONE ACETATE 25 MG TAB 3 decadron (0.5 mg tab, 0.5 mg/5ml elixir, 0.75 mg tab, 4 mg tab, 6 mg tab) 1

deltasone 1

DEPO-MEDROL 4

DEX COMBO 4

DEX LA 8 4 dexamethasone (0.5 mg tab, 0.5 mg/5ml elixir, 0.75 mg tab, 1.5 mg tab, 4 mg tab, 6 mg tab) 1 DEXAMETHASONE (0.5 MG/5ML SOLUTION, 1 MG TAB, 2 MG TAB) 3

DEXAMETHASONE (LA) 8 MG/ML SUSPENSION 4

DEXAMETHASONE ACE & SOD PHOS 4

DEXAMETHASONE INTENSOL 3 DEXAMETHASONE SOD PHOS IN D5W (10-5 MG/50ML-% SOLUTION, 12-5 MG/50ML-% SOLUTION, 20-5 MG/50ML-% 4 SOLUTION)

DEXAMETHASONE SOD PHOS-BUPIV 4 DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML SOLN PRSYR 3

dexamethasone sod phosphate pf 10 mg/ml solution 1 DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML SOLUTION 4 DEXAMETHASONE SODIUM PHOSPHATE (10 MG/2.5ML SOLN PRSYR, 10 MG/ML SOLUTION) 4 dexamethasone sodium phosphate (4 mg/ml solution, 20 mg/5ml solution, 100 mg/10ml solution, 120 mg/30ml solution) 1

DEXONTO 0.4% 4

DEXOPIN 4

PA EMFLAZA (6 MG TAB, 18 MG TAB, 22.75 MG/ML LA Limited Access SUSPENSION, 30 MG TAB, 36 MG TAB) 6 S

ENTOCORT EC 4

FLUDROCORTISONE ACETATE POWDER 4

PAGE 192 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

fludrocortisone acetate 0.1 mg tab 1

hydrocortisone (5 mg tab, 10 mg tab, 20 mg tab) 1 KENALOG (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION) 4

KENALOG-80 4

LIDOCIDEX I 4

LIDOCILONE I 4

MEDROL 4

METHYLPREDNISOLONE POWDER 4 methylprednisolone (4 mg tab, 4 mg tab thpk, 8 mg tab, 16 mg tab, 32 mg tab) 1

METHYLPREDNISOLONE ACE-LIDO 4 METHYLPREDNISOLONE ACETATE (40 MG/ML SUSPENSION, 50 MG/ML SUSPENSION, 80 MG/ML 4 SUSPENSION, POWDER) methylprednisolone acetate (40 mg/ml suspension, 80 mg/ml suspension) 1 METHYLPREDNISOLONE ACETATE 100 MG/ML SUSPENSION 3 methylprednisolone sodium succ (40 mg recon soln, 125 mg recon soln, 500 mg recon soln, 1000 mg recon soln) 1

MILLIPRED 10 MG/5ML SOLUTION 4

ORAPRED ODT 4

PEDIAPRED 4

prednisolone (15 mg/5ml solution, 15 mg/5ml syrup) 1

PREDNISOLONE (15 MG/5ML SOLUTION, POWDER) 4

PREDNISOLONE ACETATE POWDER 4

PREDNISOLONE ANHYDROUS 4 PREDNISOLONE SODIUM PHOSPHATE (25 MG/5ML SOLUTION, POWDER) 4 prednisolone sodium phosphate (6.7 (5 base) mg/5ml solution, 10 mg tab disp, 10 mg/5ml solution, 15 mg tab disp, 15 mg/5ml 1 solution, 20 mg/5ml solution, 30 mg tab disp)

PREDNISONE POWDER 4

PAGE 193 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS prednisone (1 mg tab, 2.5 mg tab, 5 mg tab, 10 mg tab, 20 mg tab, 50 mg tab) 1 prednisone (5 mg (21) tab thpk, 5 mg (48) tab thpk, 10 mg (21) tab thpk, 10 mg (48) tab thpk) 2

PREDNISONE 5 MG/5ML SOLUTION 3

PREDNISONE INTENSOL 3

ROPIDEX 4 SOLU-CORTEF (100 MG RECON SOLN, 250 MG RECON SOLN, 500 MG RECON SOLN) 3

SOLU-CORTEF 1000 MG RECON SOLN 4 SOLU-MEDROL (40 MG RECON SOLN, 125 MG RECON SOLN, 500 MG RECON SOLN, 1000 MG RECON SOLN) 4

SOLU-MEDROL 2 GM RECON SOLN 3 TRIAMCINOLONE ACETONIDE (40 MG/ML SUSPENSION, 50 MG/ML SUSPENSION) 4

triamcinolone acetonide 40 mg/ml suspension 1

TRIAMCINOLONE ACETONIDE-LIDO 4

TRIAMCINOLONE DIACET MICRONIZE 4 TRIAMCINOLONE DIACETATE (40 MG/ML SUSPENSION, POWDER) 4

UCERIS 9 MG TAB ER 24H 4

VERIPRED 20 4

ZILRETTA 4 QL 2 injections / Lifetime

ENDOCRINE AND METABOLIC AGENTS - MISC.

ACTONEL (5 MG TAB, 30 MG TAB) 4 QL 30 / 30 Days

ACTONEL 150 MG TAB 4 QL 1 / 28 Days

ACTONEL 35 MG TAB 4 QL 4 / 28 Days

ALDURAZYME 5 LA Limited Access

alendronate sodium (5 mg tab, 10 mg tab, 35 mg tab, 70 mg tab) 1

PAGE 194 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALENDRONATE SODIUM (5 MG TAB, 40 MG TAB, 70 MG/75ML SOLUTION) 4

ATELVIA 4 QL 4 / 28 Days

BONIVA 150 MG TAB 4 QL 1 / 28 Days

QL 1 Vial / 84 Days

BONIVA 3 MG/3ML SOLUTION 6 PA

BRINEURA 6 LA Limited Access

BUPHENYL (3 GM/TSP POWDER, 500 MG TAB) 6 LA Limited Access

cabergoline 1

calcitonin (salmon) 1

calcitriol (0.25 mcg cap, 0.5 mcg cap, 1 mcg/ml solution) 1

CALCITRIOL 1 MCG/ML SOLUTION 4

CARBAGLU 5 LA Limited Access

CARNITOR (1 GM/10ML SOLUTION, 200 MG/ML SOLUTION, 330 MG TAB) 4

CARNITOR SF 4

PA CETROTIDE 5 S

CHORIONIC GONADOTROPIN 10000 UNIT RECON SOLN 5 S

PA cinacalcet hcl 5 S

CLOMIPHENE CITRATE (50 MG TAB, POWDER) 4

clomiphene citrate 50 mg tab 1

PAGE 195 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CRYSVITA 6 LA Limited Access

CYSTADANE 4 LA Limited Access

DDAVP (0.01 % SOLUTION, 0.1 MG TAB, 0.2 MG TAB, 4 MCG/ML SOLUTION) 4

DDAVP RHINAL TUBE 4

desmopressin ace rhinal tube 1

desmopressin ace spray refrig 1 desmopressin acetate (0.1 mg tab, 0.2 mg tab, 4 mcg/ml solution) 1

desmopressin acetate spray 1 doxercalciferol (0.5 mcg cap, 1 mcg cap, 2.5 mcg cap, 4 mcg/2ml solution) 1

QL 60 Vials / 30 Days

PA EGRIFTA 5 LA Limited Access

LA Limited Access EGRIFTA SV 5 S

ELAPRASE 5 LA Limited Access

ETIDRONATE DISODIUM 4

QL 1 Box / 30 Days

EVENITY 6 PA

EVISTA 4 QL 30 / 30 Days

FABRAZYME 5 LA Limited Access

PAGE 196 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / 28 Days

FORTEO 5 PA

FORTICAL 4

FOSAMAX 4

FOSAMAX PLUS D 70-2800 MG-UNIT TAB 4 QL 4 / 28 Days

FOSAMAX PLUS D 70-5600 MG-UNIT TAB 3 QL 4 / 28 Days

QL 14 / 28 Days

PA GALAFOLD 5 LA Limited Access

PA ganirelix acetate 6 S

PA GENOTROPIN 5 S

PA GENOTROPIN MINIQUICK 5 S

GONAL-F 5 S

GONAL-F RFF 5 S

GONAL-F RFF REDIJECT 5 S

HCG 6 S

HECTOROL (0.5 MCG CAP, 1 MCG CAP, 2 MCG/ML SOLUTION, 2.5 MCG CAP, 4 MCG/2ML SOLUTION) 4

HP ACTHAR 5 LA Limited Access

ibandronate sodium 150 mg tab 1 QL 1 / 28 Days

QL 1 Vial / 84 Days

ibandronate sodium 3 mg/3ml solution 5 PA

PAGE 197 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

INCRELEX 5 LA Limited Access

QL 56 / 28 Days

JYNARQUE (45 15 MG TAB THPK, 60 30 MG TAB THPK, 90 PA 6 30 MG TAB THPK) LA Limited Access

QL 30 / 30 Days

PA JYNARQUE 15 MG TAB 5 LA Limited Access

QL 60 / 30 Days

PA JYNARQUE 30 MG TAB 5 LA Limited Access

KANUMA 5 LA Limited Access

KUVAN 5 LA Limited Access

levocarnitine (1 gm/10ml solution, 200 mg/ml solution, 330 mg tab) 1

LEVOCARNITINE 500 MG/ML SOLUTION 4

levocarnitine sf 1

LUMIZYME 5 LA Limited Access

QL 1 / 28 Days

LUPANETA PACK 6 PA

PAGE 198 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Injection / 28 Days

LUPRON DEPOT-PED (1-MONTH) 5 PA

QL 1 Injection / 84 Days

LUPRON DEPOT-PED (3-MONTH) 5 PA

MENOPUR 5 S

MEPSEVII 6 LA Limited Access

MIACALCIN 200 UNIT/ACT SOLUTION 4

MIACALCIN 200 UNIT/ML SOLUTION 3

MIFEPREX 4

mifepristone 1

MYALEPT 5 LA Limited Access

NAGLAZYME 5 LA Limited Access

QL 1 Box / 28 Days

PA NATPARA 5 LA Limited Access

nitisinone 5 LA Limited Access

NITYR 6 LA Limited Access

PAGE 199 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / 30 Days

NOCTIVA 4 PA

AL1 Up to 25 yrs old

NOVAREL 10000 UNIT RECON SOLN 5 S

NOVAREL 5000 UNIT RECON SOLN 6 S

OCTREOTIDE ACETATE (200 MCG/ML SOLUTION, 1000 PA 6 MCG/ML SOLUTION) S

octreotide acetate (50 mcg/ml solution, 100 mcg/ml solution, PA 200 mcg/ml solution, 500 mcg/ml solution, 1000 mcg/ml 5 solution) S

ORFADIN (2 MG CAP, 5 MG CAP, 10 MG CAP) 6 LA Limited Access

ORFADIN (4 MG/ML SUSPENSION, 20 MG CAP) 5 LA Limited Access

QL 30 / 30 Days

PA ORILISSA 150 MG TAB 6 LA Limited Access

QL 60 / 30 Days

PA ORILISSA 200 MG TAB 6 LA Limited Access

OSPHENA 4 QL 30 / 30 Days

PA OVIDREL 6 S

PALYNZIQ 6 LA Limited Access

PAGE 200 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PAMIDRONATE DISODIUM (6 MG/ML SOLUTION, 30 MG RECON SOLN, 30 MG/10ML SOLUTION, 90 MG RECON 5 S SOLN, 90 MG/10ML SOLUTION) paricalcitol (1 mcg cap, 2 mcg cap, 2 mcg/ml solution, 4 mcg cap, 5 mcg/ml solution) 1

PARSABIV 6 LA Limited Access

PREGNYL 6 S

PA PROLIA 6 S

raloxifene hcl 1 QL 30 / 30 Days

QL 21 / 30 Days

PA RAVICTI 5 LA Limited Access

QL 60 / 30 Days RAYALDEE 3 PA

QL 1 Box / 365 Days RECLAST 6 S

REVCOVI 5 LA Limited Access

QL 4 / 28 Days risedronate sodium (35 mg tab, 35 mg tab dr) 1 ST

QL 30 / 30 Days risedronate sodium (5 mg tab, 30 mg tab) 1 ST

QL 1 / 28 Days risedronate sodium 150 mg tab 1 ST

ROCALTROL (0.25 MCG CAP, 0.5 MCG CAP, 1 MCG/ML SOLUTION) 4

PAGE 201 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 Days

PA SAMSCA 15 MG TAB 5 LA Limited Access

QL 60 / 30 Days

PA SAMSCA 30 MG TAB 5 LA Limited Access

SANDOSTATIN (200 MCG/ML SOLUTION, 1000 MCG/ML PA 6 SOLUTION) S

SANDOSTATIN (50 MCG/ML SOLUTION, 100 MCG/ML S SOLUTION, 500 MCG/ML SOLUTION) 6

QL 1 / 28 Days

SANDOSTATIN LAR DEPOT 5 PA

PA SENSIPAR 6 S

PA SEROSTIM (4 MG RECON SOLN, 5 MG RECON SOLN, 6 MG LA Limited Access RECON SOLN) 6 S

QL 1 Box / 30 Days

SIGNIFOR 5 PA

QL 1 Kit / 28 Days

SIGNIFOR LAR (20 MG, 40 MG, 60 MG) 5 PA

SIGNIFOR LAR 10 MG SRER 5 S

PA SIGNIFOR LAR 30 MG SRER 5 S

sod benz-sod phenylacet 1

sodium phenylbutyrate (3 gm/tsp powder, 500 mg tab) 5 LA Limited Access

PAGE 202 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Syringe / 28 Days

PA SOMATULINE DEPOT 5 LA Limited Access

SOMAVERT 5 LA Limited Access

STIMATE 5 S

STRENSIQ 5 LA Limited Access

QL 1 / 365 Days

PA SUPPRELIN LA 6 LA Limited Access

PA SYNAREL 5 S

QL 1 / 180 Days

TRIPTODUR 6 AL1 Up to 25 yrs old

LA Limited Access

QL 1 Auto-Injector / 25 Days TYMLOS 5 PA

vasopressin 1 VASOPRESSIN-SODIUM CHLORIDE 80-0.9 UT/100ML-% SOLUTION 4

VIMIZIM 5 LA Limited Access

PAGE 203 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA XGEVA 5 S

QL 120 / 30 Days

PA XURIDEN 5 LA Limited Access

ZEMPLAR (1 MCG CAP, 2 MCG CAP, 2 MCG/ML SOLUTION, 5 MCG/ML SOLUTION) 4

PA ZOLEDRONIC ACID (4 MG RECON SOLN, 4 MG/5ML CONC) 5 S

PA ZOLEDRONIC ACID 4 MG/100ML SOLUTION 6 S

QL 1 Box / 365 Days

zoledronic acid 5 mg/100ml solution 5 PA

PA ZOMETA 4 MG/100ML SOLUTION 6 S

ZOMETA 4 MG/5ML CONC 6 S

PA ZORBTIVE 6 S

ESTROGENS

ACTIVELLA 4

ALORA 4 QL 8 Patches / 28 Days

amabelz 1

ANGELIQ 4 QL 28 / 28 Days

BI-EST 50:50 4

BI-EST 80:20 PROGESTERONE 3 QL 1 Kit / 30 Days

BI-EST PROGEST-TESTOSTERONE 4 QL 1 Kit / 30 Days

BIEST/PROGESTERONE 3 QL 1 Kit / 30 Days

PAGE 204 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BIJUVA 4 QL 30 / 30 day(s)

CLIMARA 4 QL 4 Patches / 28 Days

CLIMARA PRO 4 QL 4 Patches / 28 Days

COMBIPATCH 0.05-0.14 MG/DAY PATCH TW 3 QL 8 Patches / 28 Days

COMBIPATCH 0.05-0.25 MG/DAY PATCH TW 4 QL 8 Patches / 28 Days

covaryx 1

covaryx hs 1

DELESTROGEN (20 MG/ML OIL, 40 MG/ML OIL) 4

DELESTROGEN 10 MG/ML OIL 3

DEPO-ESTRADIOL 3 DIVIGEL (0.25 MG/0.25GM GEL, 0.5 MG/0.5GM GEL, 0.75 MG/0.75GM GEL, 1 MG/GM GEL, 1.25 MG/1.25GM GEL) 3

dotti 1 QL 8 Patches / 28 Days

DUAVEE 3 QL 30 / 30 Days

EC-RX ESTRADIOL 4

eemt 1

eemt hs 1

ELESTRIN 4 ENJUVIA (0.3 MG TAB, 0.45 MG TAB, 0.625 MG TAB, 0.9 MG TAB) 3

ENJUVIA 1.25 MG TAB 4

est estrogens-methyltest 1

est estrogens-methyltest ds 1

est estrogens-methyltest hs 1

ESTRACE (0.5 MG TAB, 1 MG TAB, 2 MG TAB) 4 estradiol (0.025 mg/24hr patch tw, 0.0375 mg/24hr patch tw, 0.05 mg/24hr patch tw, 0.075 mg/24hr patch tw, 0.1 mg/24hr 1 QL 8 Patches / 28 Days patch tw) estradiol (0.025 mg/24hr patch wk, 0.0375 mg/24hr patch wk, 0.05 mg/24hr patch wk, 0.06 mg/24hr patch wk, 0.075 mg/24hr 1 QL 4 Patches / 28 Days patch wk, 0.1 mg/24hr patch wk)

PAGE 205 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

estradiol (0.5 mg tab, 1 mg tab, 2 mg tab) 1 ESTRADIOL (6 MG PELLET, 10 MG PELLET, 12.5 MG PELLET, 18 MG PELLET, 20 MG PELLET, 25 MG PELLET, 31 4 MG PELLET, 37.5 MG PELLET)

ESTRADIOL 50 MG PELLET 3

estradiol valerate (20 mg/ml oil, 40 mg/ml oil) 1

estradiol-norethindrone acet 1

ESTRIOL-PROGESTERONE MICRO 4 QL 1 Kit / 30 Days

ESTROGEL 4 QL 1 / 30 Days

ESTROPIPATE 3

ETHINYL ESTRADIOL 4

EVAMIST 3 QL 2 / 30 Days

FEMHRT LOW DOSE 4 QL 28 / 28 Days

fyavolv 0.5-2.5 mg-mcg tab 1 QL 30 / 30 Days

fyavolv 1-5 mg-mcg tab 1 QL 28 / 28 Days

jevantique lo 1 QL 30 / 30 Days

jinteli 1 QL 28 / 28 Days

lopreeza 1

MENEST (0.3 MG TAB, 0.625 MG TAB, 1.25 MG TAB) 4 QL 30 / 30 Days

MENEST 2.5 MG TAB 3

MENOSTAR 4 QL 4 Patches / 28 Days

mimvey 1

mimvey lo 1

MINIVELLE 4 QL 8 Patches / 28 Days

norethindrone-eth estradiol 0.5-2.5 mg-mcg tab 1 QL 30 / 30 Days

norethindrone-eth estradiol 1-5 mg-mcg tab 1 QL 28 / 28 Days

ortho-est 0.625 1

ortho-est 1.25 1

PREFEST 4 QL 30 / 30 Days

PAGE 206 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PREMARIN (0.3 MG TAB, 0.45 MG TAB, 0.625 MG TAB, 0.9 QL 30 / 30 Days MG TAB, 1.25 MG TAB) 3

PREMARIN 25 MG RECON SOLN 3

PREMPHASE 4 QL 28 / 28 Days

PREMPRO 3 QL 28 / 28 Days

VIVELLE-DOT 4 QL 8 Patches / 28 Days

OXYTOCICS

carboprost tromethamine 2

CERVIDIL 3

HEMABATE 4

methergine 1

methylergonovine maleate (0.2 mg tab, 0.2 mg/ml solution) 1

oxytocin 10 unit/ml solution 1 OXYTOCIN-DEXTROSE (10-5 UT/250ML-% SOLUTION, 20-5 UT/250ML-% SOLUTION, 40-5 UNIT/L-% SOLUTION) 4 OXYTOCIN-DEXTROSE-LACT RINGERS 15-5 UT/500ML-% SOLUTION 4 OXYTOCIN-LACTATED RINGERS 15 UNIT/500ML SOLUTION 4

PROSTIN E2 4 PROGESTINS

AYGESTIN 4

EC-RX PROGESTERONE 4

QL 1 Vial / 35 Days

hydroxyprogesterone caproate 250 mg/ml oil 5 PA

QL 5 Vials / 35 days

MAKENA 250 MG/ML OIL 5 LA Limited Access

QL 4 Auto-Injectors / 28 Days PA MAKENA 275 MG/1.1ML SOLN A-INJ 5 LA Limited Access

PAGE 207 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MEDROXYPROGESTERONE ACE-LIDO 4 medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10 mg tab) 1

MEGACE ES 4

megestrol acetate 625 mg/5ml suspension 1

NORETHINDRONE ACETATE POWDER 4

norethindrone acetate 5 mg tab 1

progesterone 50 mg/ml oil 1

PROGESTERONE COMPOUNDING KIT 4

progesterone micronized (100 mg cap, 200 mg cap) 1

PROGESTERONE MICRONIZED 10 % CREAM 4

PROMETRIUM 4

PROVERA 4 THYROID AGENTS

ARMOUR THYROID (15 MG TAB, 30 MG TAB, 60 MG TAB, 90 MG TAB, 120 MG TAB) 4 ARMOUR THYROID (180 MG TAB, 240 MG TAB, 300 MG TAB) 3

CYTOMEL 4

euthyrox 1

levo-t 1 LEVOTHYROXINE SODIUM (100 MCG RECON SOLN, 200 MCG RECON SOLN, 500 MCG RECON SOLN) 4 LEVOTHYROXINE SODIUM (100 MCG/5ML SOLUTION, 200 MCG/5ML SOLUTION, 500 MCG/5ML SOLUTION) 3 levothyroxine sodium (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg recon soln, 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg 1 recon soln, 200 mcg tab, 300 mcg tab, 500 mcg recon soln)

levoxyl 1 liothyronine sodium (5 mcg tab, 10 mcg/ml solution, 25 mcg tab, 50 mcg tab) 1

METHIMAZOLE POWDER 4

methimazole (5 mg tab, 10 mg tab) 1

PAGE 208 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NATURE-THROID 4

np thyroid 1

propylthiouracil 50 mg tab 1

SYNTHROID 4

TAPAZOLE 4

THYROID (0.23 % POWDER, POWDER) 4 thyroid (15 mg tab, 30 mg tab, 60 mg tab, 90 mg tab, 120 mg tab) 1

THYROLAR-1 4

THYROLAR-1/2 4

THYROLAR-1/4 4

THYROLAR-2 4

THYROLAR-3 4

unithroid 1

unithroid direct 1

WESTHROID 4

WP THYROID 4 GASTROINTESTINAL AGENTS

ANTACIDS

MAGNESIUM OXIDE 4

MAGNESIUM TRISILICATE 4 ANTIDIARRHEAL/PROBIOTIC AGENTS

BISMUTH SUBGALLATE 4

diphenoxylate-atropine 2.5-0.025 mg tab 1

DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML LIQUID 3

QL 60 / 30 Days FULYZAQ 4 PA

KAOLIN 4

LOMOTIL 4

LOPERAMIDE HCL POWDER 4

PAGE 209 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

loperamide hcl 2 mg cap 1

MOTOFEN 4

QL 60 / 30 Days MYTESI 4 PA

opium 1

PAREGORIC 3

PECTIN 4 ANTIEMETICS

QL 1 Vial / 30 Days AKYNZEO 235-0.25 MG RECON SOLN 3 PA

QL 1 / 30 Days AKYNZEO 300-0.5 MG CAP 3 PA

ALOXI 4 PA

ANZEMET (20 MG/ML SOLUTION, 50 MG TAB, 100 MG TAB) 4 PA

QL 1 / 28 Days aprepitant (80 mg cap, 125 mg cap) 1 PA

aprepitant 40 mg cap 1 QL 1 / 28 Days

QL 6 / 28 Days aprepitant 80 & 125 mg cap 1 PA

QL 60 / 30 Days CESAMET 4 PA

CINVANTI 4 PA

DIMENHYDRINATE 50 MG/ML SOLUTION 3

QL 60 / 30 Days dronabinol 1 PA

QL 1 / 28 Days EMEND 125 MG CAP 4 PA

QL 5 Milliliters / 28 Days EMEND 125 MG RECON SUSP 3 PA

PAGE 210 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

EMEND 150 MG RECON SOLN 4 PA

EMEND 40 MG CAP 4 QL 2 / 28 Days

QL 2 / 28 Days EMEND 80 MG CAP 4 PA

QL 2 / 28 Days EMEND TRI-PACK 4 PA

FOSAPREPITANT DIMEGLUMINE 4 PA

fosaprepitant dimeglumine 1 PA

granisetron hcl (0.1 mg/ml solution, 1 mg tab, 1 mg/ml solution, 4 mg/4ml solution) 1

GRANISETRON HCL 0.1 MG/ML SOLUTION 4

MARINOL (2.5 MG CAP, 5 MG CAP) 4 QL 60 / 30 Days

QL 60 / 30 Days MARINOL 10 MG CAP 4 PA

MECLIZINE HCL POWDER 4

meclizine hcl (12.5 mg tab, 25 mg tab) 1

ondansetron 1

ondansetron hcl (4 mg tab, 8 mg tab) 1 QL 90 / 30 Days

ondansetron hcl (4 mg/2ml solution, 4 mg/5ml solution, 40 mg/20ml solution) 1

ondansetron hcl 24 mg tab 1 QL 30 / 30 Days

ONDANSETRON HCL 24 MG TAB 3 QL 30 / 30 Days

ONDANSETRON HCL 4 MG/2ML SOLUTION 4

ONDANSETRON HCL-NACL 4

palonosetron hcl (0.25 mg/5ml soln prsyr, 0.25 mg/5ml solution) 1 PA

PALONOSETRON HCL 0.25 MG/2ML SOLUTION 3 PA

PALONOSETRON HCL 0.25 MG/5ML SOLUTION 4 PA

QL 1 Patch / 28 Days SANCUSO 3 PA

PAGE 211 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

scopolamine 1 QL 10 / 30 day(s)

QL 4 Syringes / 28 Days SUSTOL 4 PA

SYNDROS 4 PA

TIGAN (100 MG/ML SOLUTION, 300 MG CAP) 4

TRANSDERM SCOP (1.5 MG) 4 QL 10 / 30 day(s)

TRANSDERM-SCOP (1.5 MG) 4 QL 10 / 30 day(s)

trimethobenzamide hcl 300 mg cap 1

QL 30 / 30 Days VARUBI (90 MG TAB, 166.5 MG/92.5ML EMULSION) 3 PA

ZOFRAN (4 MG TAB, 8 MG TAB) 4 QL 90 / 30 Days

ZOFRAN 4 MG/5ML SOLUTION 4

ZOFRAN ODT 4

ZUPLENZ 4 DIGESTIVE AIDS

CREON 3

L-GLUTAMIC ACID HCL 4

PANCRELIPASE (LIP-PROT-AMYL) 3

PEPSIN 4

SUCRAID 3 LA Limited Access

ULTRESA 4

VIOKACE 3

ZENPEP 3 GASTROINTESTINAL AGENTS - MISC.

ACTIGALL 4

QL 60 / 30 Days alosetron hcl 1 PA

AMINOSALICYLIC ACID-5 4

QL 60 / 30 Days AMITIZA 3 PA

PAGE 212 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

APRISO 4 QL 120 / 30 Days

ASACOL HD 4 QL 180 / 30 Days

AURYXIA 4

AZULFIDINE 4

AZULFIDINE EN-TABS 4

balsalazide disodium 1

calcium acetate (phos binder) 1

calcium acetate 667 mg tab 1

CANASA 4

LA Limited Access CHENODAL 5 S

CHOLBAM 5 LA Limited Access

QL 2 Boxes / 28 Days

CIMZIA 6 PA

QL 2 Boxes / 28 Days

CIMZIA PREFILLED 6 PA

QL 1 / 365 Days

CIMZIA STARTER KIT 6 PA

COLAZAL 4

cromolyn sodium 100 mg/5ml conc 1

DELZICOL 4 QL 180 / 30 day(s)

DEXPANTHENOL 250 MG/ML SOLUTION 3

DIPENTUM 4

ENTEREG 4

PAGE 213 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

enulose 1 FOSRENOL (500 MG CHEW TAB, 750 MG CHEW TAB, 1000 MG CHEW TAB) 4

FOSRENOL (750 MG PACKET, 1000 MG PACKET) 3

GASTROCROM 4

GATTEX 6 LA Limited Access

generlac 1

GIAZO 4

PA INFLECTRA 5 S

lactulose encephalopathy 1

lanthanum carbonate 1

LIALDA 4 QL 120 / 30 Days

QL 30 / 30 Days LINZESS 3 PA

QL 60 / 30 Days LOTRONEX 4 PA

MESALAMINE POWDER 4

mesalamine (4 gm enema, 1000 mg suppos) 1

mesalamine 1.2 gm tab dr 1 QL 120 / 30 Days

mesalamine 400 mg cap dr 1 QL 180 / 30 day(s)

mesalamine 800 mg tab dr 1 QL 180 / 30 Days

mesalamine er 1

mesalamine-cleanser 1

METOCLOPRAMIDE HCL POWDER 4 METOCLOPRAMIDE HCL (5 MG TAB DISP, 10 MG TAB DISP) 3 metoclopramide hcl (5 mg tab, 5 mg/5ml solution, 5 mg/ml solution, 10 mg tab, 10 mg/10ml solution) 1

PAGE 214 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

METOCLOPRAMIDE HCL MONOHYDRATE 4

METOZOLV ODT 4

QL 30 / 30 day(s) MOTEGRITY (1 MG TAB, 2 MG TAB) 4 PA

QL 30 / 30 Days MOVANTIK 3 PA

QL 30 / 30 Days

PA OCALIVA 5 LA Limited Access

PENTASA 3

PHOSLO 4

PHOSLYRA 4

REGLAN 4

RELISTOR (8 MG/0.4ML SOLUTION, 12 MG/0.6ML QL 28 Syringes / 28 Days 3 SOLUTION) PA

QL 90 / 30 Days RELISTOR 150 MG TAB 4 PA

PA REMICADE 5 S

RENAGEL 4

PA RENFLEXIS 6 S

RENVELA 4

ROWASA 4

sevelamer carbonate 1

SEVELAMER HCL 400 MG TAB 4

sevelamer hcl 800 mg tab 2

SFROWASA 4

SIMETHICONE 4

PAGE 215 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 Vials / 365 Days

STELARA 130 MG/26ML SOLUTION 6 PA

SULFASALAZINE POWDER 4

sulfasalazine (500 mg tab, 500 mg tab dr) 1

QL 30 / 30 day(s) SYMPROIC 4 PA

QL 30 / 30 Days TRULANCE 4 PA

URSO 250 4

URSO FORTE 4

ursodiol (250 mg tab, 300 mg cap, 500 mg tab) 1

URSODIOL+SYRSPEND SF 4

VELPHORO 4

QL 60 / 30 Days VIBERZI 3 PA

QL 90 / 30 Days

PA XERMELO 5 LA Limited Access

QL 60 / 30 day(s) ZELNORM 4 PA

LAXATIVES

BISACODYL 4

CLENPIQ 3

COLYTE WITH FLAVOR PACKS 227.1 GM RECON SOLN 3

COLYTE WITH FLAVOR PACKS 240 GM RECON SOLN 4

constulose 1

DOCUSATE SODIUM 4

gavilyte-c 1

PAGE 216 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

gavilyte-g 1

gavilyte-h 1

gavilyte-n with flavor pack 1 GOLYTELY (227.1 GM RECON SOLN, 236 GM RECON SOLN) 4

lactulose (10 gm/15ml solution, 20 gm/30ml solution) 1

MAGNESIUM SULFATE POWDER 4

MINERAL OIL 4

mineral oil heavy 1

MINERAL OIL HEAVY 4

MINERAL OIL LIGHT 4

MOVIPREP 3

MURI-LUBE 4

NULYTELY WITH FLAVOR PACKS 4

OSMOPREP 4

peg 3350-kcl-na bicarb-nacl 1

peg 3350/electrolytes 1

peg-3350/electrolytes 1

peg-prep 1

pegylax 1

PLENVU 4

POLY-PREP 4

polyethylene glycol 3350 (3350 packet, 3350 powder) 1

PREPOPIK 3

SUCLEAR 3

SUPREP BOWEL PREP KIT 3

trilyte 1 ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS

ACIPHEX 4

QL 30 / 30 day(s) ACIPHEX SPRINKLE 10 MG CAP SPRINK 4 ST

PAGE 217 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 Days ACIPHEX SPRINKLE 5 MG CAP SPRINK 4 ST

amoxicill-clarithro-lansopraz 1 QL 1 Box / 365 Days

ANASPAZ 4 ATROPEN (0.25 MG/0.3ML SOLN A-INJ, 0.5 MG/0.7ML SOLN A-INJ, 1 MG/0.7ML SOLN A-INJ) 4

ATROPEN 2 MG/0.7ML SOLN A-INJ 3 ATROPINE SULFATE (0.25 MG/5ML SOLN PRSYR, 1 MG/ML SOLUTION) 3

atropine sulfate (1 mg/10ml soln prsyr, 8 mg/20ml solution) 1

ATROPINE SULFATE (8 MG/20ML SOLUTION, POWDER) 4

ATROPINE SULFATE (PF) 3

ATROPINE SULFATE MONOHYDRATE 4

BELLADONNA ALKALOIDS-OPIUM 3

BENTYL (10 MG CAP, 10 MG/ML SOLUTION, 20 MG TAB) 4

CANTIL 3

CARAFATE 1 GM TAB 4

CARAFATE 1 GM/10ML SUSPENSION 3

chlordiazepoxide-clidinium 1

CIMETIDINE POWDER 4

cimetidine (200 mg tab, 300 mg tab, 400 mg tab, 800 mg tab) 1

CIMETIDINE HCL 3

cimetidine hcl 1

CUVPOSA 3

CYTOTEC 4

DEPRIZINE FUSEPAQ 3

DEPRIZINE RAPIDPAQ 3 dicyclomine hcl (10 mg cap, 10 mg/5ml solution, 10 mg/ml solution, 20 mg tab) 1

DONNATAL (16.2 MG TAB, 16.2 MG/5ML ELIXIR) 4

DONNATAL EXTENTABS 4

PAGE 218 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ed-spaz 1

QL 30 / 30 Days esomeprazole magnesium 1 ST

esomeprazole sodium 40 mg recon soln 1

ESOMEPRAZOLE STRONTIUM 24.65 MG CAP DR 4

QL 60 / 30 Days ESOMEPRAZOLE STRONTIUM 49.3 MG CAP DR 3 ST

famotidine (20 mg tab, 20 mg/2ml solution, 40 mg tab, 40 mg/4ml solution, 40 mg/5ml recon susp, 200 mg/20ml solution) 1

FIRST-LANSOPRAZOLE 3

FIRST-OMEPRAZOLE 3

GLYCATE 3 glycopyrrolate (0.2 mg/ml solution, 0.4 mg/2ml solution, 1 mg tab, 1 mg/5ml solution, 2 mg tab, 4 mg/20ml solution) 1

GLYCOPYRROLATE PF 4

GLYRX-PF 4

HYOSCYAMINE SULFATE POWDER 4 hyoscyamine sulfate (0.125 mg sl tab, 0.125 mg tab, 0.125 mg tab disp, 0.125 mg/5ml elixir, 0.125 mg/ml solution, 0.5 mg/ml 1 solution)

hyoscyamine sulfate er 1

hyoscyamine sulfate sl 1

hyosyne 1

ISOPROPAMIDE IODIDE 4 lansoprazole (15 mg cap dr, 15 mg tab dr disp, 30 mg cap dr, 30 mg tab dr disp) 1

LEVBID 4

LEVSIN (0.125 MG TAB, 0.5 MG/ML SOLUTION) 4

LEVSIN/SL 4

LIBRAX 4

methscopolamine bromide (2.5 mg tab, 5 mg tab) 1

misoprostol (100 mcg tab, 200 mcg tab) 1

PAGE 219 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NEXIUM (2.5 MG PACKET, 5 MG PACKET, 10 MG PACKET, QL 30 / 30 Days 3 20 MG PACKET, 40 MG PACKET) ST

NEXIUM 40 MG CAP DR 4 QL 30 / 30 Days

nizatidine (150 mg cap, 300 mg cap) 1

NIZATIDINE 15 MG/ML SOLUTION 3

nulev 1

OMECLAMOX-PAK 3 QL 80 / 365 Days

omeprazole (10 mg cap dr, 20 mg cap dr, 40 mg cap dr) 1

OMEPRAZOLE+SYRSPEND SF ALKA 3

oscimin 1

oscimin sr 1

PAMINE 4

PAMINE FORTE 4

PAMINE FQ 4 pantoprazole sodium (20 mg tab dr, 40 mg recon soln, 40 mg tab dr) 1

pb-hyoscy-atropine-scopolamine 1 PEPCID (20 MG TAB, 40 MG TAB, 40 MG/5ML RECON SUSP) 4

phenobarbital-belladonna alk 1

phenohytro (16.2 mg tab, 16.2 mg/5ml elixir) 1

PREVACID 30 MG CAP DR 4

PREVACID SOLUTAB 4

PREVPAC 4

PRILOSEC (10 MG CAP DR, 40 MG CAP DR) 4

PRILOSEC (2.5 MG PACKET, 10 MG PACKET) 3 ST

PROPANTHELINE BROMIDE POWDER 4

PROPANTHELINE BROMIDE 15 MG TAB 3

PROTONIX (20 MG TAB DR, 40 MG TAB DR) 4

PROTONIX 40 MG PACKET 4 ST

PAGE 220 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PYLERA 4 QL 1 Box / 365 Days

QL 30 / 30 day(s) RABEPRAZOLE SODIUM 10 MG CAP SPRINK 4 ST

rabeprazole sodium 20 mg tab dr 1 ranitidine hcl (15 mg/ml syrup, 50 mg/2ml solution, 75 mg/5ml syrup, 150 mg cap, 150 mg tab, 150 mg/10ml syrup, 150 1 mg/6ml solution, 300 mg cap, 300 mg tab)

RANITIDINE HCL 1000 MG/40ML SOLUTION 4 ROBINUL (0.2 MG/ML SOLUTION, 0.4 MG/2ML SOLUTION, 1 MG TAB, 1 MG/5ML SOLUTION, 4 MG/20ML SOLUTION) 4

ROBINUL-FORTE 4

SCOPOLAMINE HBR POWDER 4

SCOPOLAMINE HBR 0.4 MG/ML SOLUTION 3

SUCRALFATE POWDER 4

sucralfate (1 gm tab, 1 gm/10ml suspension) 1

SYMAX DUOTAB 4

symax-sl 1

symax-sr 1

TALICIA 3 QL 168 / 14 day(s)

ZANTAC (50 MG/2ML SOLUTION, 150 MG/6ML SOLUTION, 300 MG TAB, 1000 MG/40ML SOLUTION) 4 GU ANTI-INFECTIVES/GU ANTISPASMODICS/VAGINAL PRODUCTS/MISC

GENITOURINARY AGENTS - MISCELLANEOUS

acetic acid 0.25 % solution 1

alfuzosin hcl er 1

aminoacetic acid 1

argyle sterile saline 1

AVODART 4 QL 30 / 30 Days

CARDURA XL 4 QL 30 / 30 Days

curity sterile saline 1

CYSTAGON 5 LA Limited Access

PAGE 221 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

cytra k crystals 1

DEFLUX 4

dutasteride 0.5 mg cap 1 QL 30 / 30 Days

dutasteride-tamsulosin hcl 1 QL 30 / 30 Days

ELMIRON 3

finasteride 5 mg tab 1

FLOMAX 4

GLYCINE POWDER 4

glycine 1.5 % solution 1

glycine urologic 1

JALYN 4 QL 30 / 30 Days

K-PHOS NO 2 4

LITHOSTAT 4

NEOMYCIN-POLYMYXIN B GU 3

neomycin-polymyxin b gu 1

NEOSPORIN GU IRRIGANT 4

ORACIT 4

phenazo 1

PHENAZOPYRIDINE HCL POWDER 4

phenazopyridine hcl (100 mg tab, 200 mg tab) 1

pot & sod cit-cit ac 1

POTASSIUM CITRATE 4

potassium citrate er 1

POTASSIUM CITRATE MONOHYDRATE 4 potassium citrate-citric acid (1100-334 mg/5ml solution, 3300- 1002 mg packet) 1

PROCYSBI 6 LA Limited Access

PROSCAR 4

PAGE 222 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PYRIDIUM 4

RAPAFLO 4 QL 30 / 30 Days

RESECTISOL 3

RIMSO-50 4

silodosin 1

sod citrate-citric acid 1

sodium chloride 0.9 % solution 1

SODIUM CITRATE CRYSTALS 4

SODIUM CITRATE ANHYDROUS 4

tamsulosin hcl 1

taron-crystals 1

THIOLA 6 LA Limited Access

THIOLA EC (EC 100 MG TAB DR, EC 300 MG TAB DR) 6 LA Limited Access

tricitrates 1

UROCIT-K 10 4

UROCIT-K 15 4

UROCIT-K 5 4

UROXATRAL 4

virtrate-2 1

virtrate-3 1

virtrate-k 1 URINARY ANTI-INFECTIVES

azuphen mb 1

FURADANTIN 4

HIPREX 4

hyolev mb 1

PAGE 223 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HYOPHEN 4

indiomin mb 1

MACROBID 4

MACRODANTIN 4

me/naphos/mb/hyo1 1

methenamine hippurate 1

methenamine mandelate (0.5 gm tab, 1 gm tab) 1

MONUROL 4

NALIDIXIC ACID 4

nitrofurantoin 1

NITROFURANTOIN MACROCRYSTAL POWDER 4 nitrofurantoin macrocrystal (25 mg cap, 50 mg cap, 100 mg cap) 1

nitrofurantoin monohyd macro 1

phosphasal 1

ur n-c 1

uramit mb 1

urelle 1

uretron d/s 1

uribel 1

URIMAR-T 3

urin ds 1

uro-458 1

uro-blue 1

uro-l 1

uro-mp 1

UROGESIC-BLUE 4

urolet mb 1

urophen mb 1

uryl 1

ustell 1

PAGE 224 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

UTA 4

uticap 1

utira-c 1

utrona-c 1

vilamit mb 1

vilevev mb 1 URINARY ANTISPASMODICS

bethanechol chloride (5 mg tab, 10 mg tab, 25 mg tab, 50 mg tab) 1

QL 30 / 30 Days darifenacin hydrobromide er 1 ST

DETROL 4

DETROL LA 4 QL 30 / 30 Days

DITROPAN XL 4

ENABLEX 4 QL 30 / 30 Days

flavoxate hcl 1

GELNIQUE (3 (28) % (MG/ACT) GEL, 10 % GEL) 3

GELNIQUE PUMP 3

QL 30 / 30 Days MYRBETRIQ 3 ST

oxybutynin chloride (5 mg tab, 5 mg/5ml syrup) 1

oxybutynin chloride er 1

OXYTROL 4 QL 8 Patches / 30 Days

QL 30 / 30 day(s) solifenacin succinate 1 ST

tolterodine tartrate 1

QL 30 / 30 Days tolterodine tartrate er 1 ST

QL 30 / 30 Days TOVIAZ 3 ST

PAGE 225 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

trospium chloride 1

QL 30 / 30 Days trospium chloride er 1 ST

URECHOLINE 4

VESICARE 4 QL 30 / 30 day(s)

VAGINAL AND RELATED PRODUCTS

AVC VAGINAL 4

CLEOCIN (2 % CREAM, 100 MG SUPPOS) 4

clindamycin phosphate 2 % cream 1

CLINDESSE 4

CRINONE 3

ENDOMETRIN 4

ESTRACE 0.1 MG/GM CREAM 4

estradiol (0.1 mg/gm cream, 10 mcg tab) 1

ESTRING 4 QL 1 / 90 Days

FEM PH 3

FEMRING 4 QL 1 / 90 Days

FIRST-PROGESTERONE VGS 4

GYNAZOLE-1 4

IMVEXXY MAINTENANCE PACK 4 QL 8 / 28 Days

IMVEXXY STARTER PACK 4 QL 18 / 28 day(s)

INTRAROSA 4 QL 30 / 30 Days

METROGEL-VAGINAL 4

MICONAZOLE 3 3

NUVESSA 4

PREMARIN 0.625 MG/GM CREAM 3

RELAGARD 3

TERAZOL 3 4

TERAZOL 7 4

PAGE 226 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

terconazole (0.4 % cream, 0.8 % cream, 80 mg suppos) 1

TERCONAZOLE 0.8 % CREAM 3

TRIMO-SAN 4

VAGIFEM 4

vandazole 1

yuvafem 1

zazole (0.8 % cream, 80 mg suppos) 1 HEMATOLOGICAL AGENTS

ANTICOAGULANTS

ANGIOMAX 4

ANTICOAGULANT CIT DEXT SOLN A 3

argatroban 250 mg/2.5ml solution 1

ARGATROBAN 250 MG/2.5ML SOLUTION 4

ARGATROBAN 50 MG/50ML SOLUTION 3 ARGATROBAN IN SODIUM CHLORIDE 50-0.9 MG/50ML-% SOLUTION 3

ARIXTRA 4

QL 42 / 180 Days BEVYXXA 3 PA

bivalirudin trifluoroacetate 1

BIVALIRUDIN-SODIUM CHLORIDE 4

COUMADIN 4

PA DEFITELIO 6 S

ELIQUIS 3 QL 60 / 30 Days

ELIQUIS STARTER PACK 3 QL 60 / 30 Days

enoxaparin sodium 1

fondaparinux sodium 1 FRAGMIN (12500 UNIT/0.5ML SOLUTION, 15000 UNIT/0.6ML QL 30 Syringes / 30 Days SOLUTION, 18000 UNT/0.72ML SOLUTION) 3

PAGE 227 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FRAGMIN (2500 UNIT/0.2ML SOLUTION, 5000 UNIT/0.2ML SOLUTION, 7500 UNIT/0.3ML SOLUTION, 10000 UNIT/ML 3 QL 60 Syringes / 30 Days SOLUTION)

FRAGMIN 95000 UNIT/3.8ML SOLUTION 3 heparin (porcine) in nacl (hepar(porce) 1000-0.9 ut/500ml-% solution, hepar(porce) 2000-0.9 unit/l-% solution) 1 HEPARIN (PORCINE) IN NACL (HEPAR(PORCE) 2-0.9 UNIT/ML-% SOLUTION, HEPAR(PORCE) 4-0.9 UNIT/2ML-% SOLN PRSYR, HEPAR(PORCE) 20-0.45 UNT/20ML-% SOLN PRSYR, HEPAR(PORCE) 150-0.45 UT/150ML-% SOLUTION, HEPAR(PORCE) 250-0.45 UT/250ML-% SOLUTION, HEPAR(PORCE) 500-0.45 UT/500ML-% SOLUTION, HEPAR(PORCE) 1000-0.9 UT/500ML-% SOLUTION, HEPAR(PORCE) 1250-0.9 UT/250ML-% SOLUTION, 4 HEPAR(PORCE) 1500-0.9 UT/150ML-% SOLUTION, HEPAR(PORCE) 1500-0.9 UT/250ML-% SOLUTION, HEPAR(PORCE) 2000-0.9 UNIT/L-% SOLUTION, HEPAR(PORCE) 2500-0.9 UT/250ML-% SOLUTION, HEPAR(PORCE) 3000-0.9 UNIT/L-% SOLUTION, HEPAR(PORCE) 20000-0.9 UNIT/L-% SOLUTION, HEPAR(PORCE) 40000-0.45 UNIT/L-% SOLUTION) HEPARIN (PORCINE) IN NACL 25000-0.45 UT/500ML-% SOLUTION 3

heparin lock flush 10 unit/ml solution 1

HEPARIN LOCK FLUSH 2 UNIT/ML SOLUTION 4 HEPARIN SOD (PORCINE) IN D5W 12500-5 UT/250ML-% SOLUTION 4

heparin sod (porcine) in d5w 40-5 unit/ml-% solution 1

HEPARIN SOD (PORCINE)-D10 4 heparin sodium (porcine) (1000 unit/ml solution, 5000 unit/ml solution, 10000 unit/ml solution, 20000 unit/ml solution) 1 HEPARIN SODIUM (PORCINE) (5000 UNIT/0.5ML SOLN PRSYR, 7000 UNIT/7ML SOLN PRSYR, 15000 UNIT/3ML 4 SOLN PRSYR)

heparin sodium (porcine) pf 5000 unit/0.5ml solution 1

heparin sodium flush 100-0.9 unit/ml-% kit 1

heparin sodium lock flush 1

HEPMED 3

IPRIVASK 4

PAGE 228 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

jantoven 1

LOVENOX 4

monoject flush syr/hep lock 1

monoject prefill adv heparin 1

SASH KIT 10-0.9 UNIT/ML-% KIT 4

sash kit 100-0.9 unit/ml-% kit 1

SODIUM CITRATE 4 % SOLN PRSYR 4

SODIUM CITRATE LOCK FLUSH 4

SOLU-PREF 4

WARFARIN SODIUM POWDER 4 warfarin sodium (1 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab, 10 mg tab) 1

XARELTO (10 MG TAB, 20 MG TAB) 3 QL 30 / 30 Days

XARELTO 15 MG TAB 3 QL 60 / 30 Days

XARELTO 2.5 MG TAB 4

XARELTO STARTER PACK 3 QL 51 / 365 Days

HEMATOLOGICAL AGENTS - MISC.

ACTIVASE 3

LA Limited Access ADVATE 5 S

LA Limited Access ADYNOVATE 5 S

LA Limited Access AFSTYLA 6 S

AGGRENOX 4 QL 60 / 30 Days

AGRYLIN 4

albuked 25 1

albuked 5 1

albumin human 1

albumin-zlb 1

PAGE 229 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

albuminar-25 1

albuminar-5 1

ALBUMINEX 3

alburx 1

albutein 1

LA Limited Access ALPHANATE/VWF COMPLEX/HUMAN 5 S

LA Limited Access ALPHANINE SD 5 S

LA Limited Access ALPROLIX 5 S

anagrelide hcl 1

aspirin-dipyridamole er 1 QL 60 / 30 Days

LA Limited Access BEBULIN 5 S

LA Limited Access BENEFIX 5 S

BERINERT 5 LA Limited Access

BRILINTA 3 QL 60 / 30 Days

buminate 1

QL 58 Vials / 58 Days

PA CABLIVI 6 LA Limited Access

CATHFLO ACTIVASE 3

LA Limited Access CEPROTIN 5 S

cilostazol 1

PAGE 230 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CINRYZE 5 LA Limited Access

clopidogrel bisulfate (75 mg tab, 300 mg tab) 1

LA Limited Access COAGADEX 5 S

LA Limited Access CORIFACT 5 S

dipyridamole (25 mg tab, 50 mg tab, 75 mg tab) 1

EFFIENT 4 QL 30 / 30 Days

LA Limited Access ELOCTATE 5 S

eptifibatide 1

LA Limited Access FEIBA 5 S

LA Limited Access FIBRYGA 5 S

FIRAZYR 6 LA Limited Access

flexbumin 1

GIVLAARI 6 LA Limited Access

HAEGARDA 6 LA Limited Access

LA Limited Access HELIXATE FS 5 S

HEMLIBRA 5 LA Limited Access

PAGE 231 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HEMOFIL M (250 RECON SOLN, 500 RECON SOLN, 1000 LA Limited Access 6 RECON SOLN) S

LA Limited Access HEMOFIL M (801-1500 RECON SOLN, 1700 RECON SOLN) 5 S

hetastarch-nacl 1

human albumin grifols 1

LA Limited Access HUMATE-P 5 S

PA icatibant acetate 5 S

LA Limited Access IDELVION 6 S

LA Limited Access IXINITY 5 S

JIVI 6 LA Limited Access

KALBITOR 5 LA Limited Access

LA Limited Access KCENTRA 6 S

kedbumin 1

KINLYTIC 4

LA Limited Access KOATE 6 S

LA Limited Access KOATE-DVI 5 S

LA Limited Access KOGENATE FS 5 S

PAGE 232 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LA Limited Access KOGENATE FS BIO-SET 5 S

LA Limited Access KOVALTRY 5 S

LA Limited Access MONOCLATE-P 5 S

LA Limited Access MONONINE 5 S

NOVOEIGHT (250 RECON SOLN, 500 RECON SOLN, 1000 LA Limited Access 5 RECON SOLN, 2000 RECON SOLN, 3000 RECON SOLN) S

LA Limited Access NOVOEIGHT 1500 UNIT RECON SOLN 6 S

LA Limited Access NOVOSEVEN RT 5 S

LA Limited Access NUWIQ 6 S

LA Limited Access OBIZUR 5 S

PANHEMATIN 313 MG RECON SOLN 3

PANHEMATIN 350 MG RECON SOLN 4

pentoxifylline er 1

PERSANTINE 4

plasbumin-25 1

plasbumin-5 1

PLAVIX 4

PLETAL 4

prasugrel hcl 1 QL 30 / 30 Days

LA Limited Access PROFILNINE 5 S

PAGE 233 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LA Limited Access PROFILNINE SD 5 S

PROTAMINE SULFATE 10 MG/ML SOLUTION 3

LA Limited Access REBINYN 6 S

LA Limited Access RECOMBINATE 5 S

REOPRO 3

RETAVASE 4

RETAVASE HALF-KIT 4

LA Limited Access RIASTAP 5 S

LA Limited Access RIXUBIS 6 S

RUCONEST 6 LA Limited Access

SOLIRIS 5 LA Limited Access

QL 2 Vials / 28 Days

PA TAKHZYRO 6 LA Limited Access

QL 60 / 30 Days

PA TAVALISSE 6 LA Limited Access

THROMBATE III 6 S

ticlopidine hcl 1

PAGE 234 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LA Limited Access TRETTEN 5 S

QL 12 Vials / 56 Days

ULTOMIRIS 5 PA

LA Limited Access VONVENDI 5 S

LA Limited Access WILATE 5 S

LA Limited Access XYNTHA 5 S

LA Limited Access XYNTHA SOLOFUSE 5 S

ZONTIVITY 3 QL 30 / 30 Days

HEMATOPOIETIC AGENTS

abaneu-sl 1

ACTIVE FE 4

ADAKVEO 6 LA Limited Access

airavite 1

ANIMI-3 3

ANIMI-3/VITAMIN D 3

PA ARANESP (ALBUMIN FREE) 6 S

av-vite fb 1

AXIFOL 4

B-12 3

B-12 COMPLIANCE INJECTION 3

B-SERENE 4

PAGE 235 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BIFERARX 3

BP VIT 3 3

BP VIT 3 PLUS 3

CENFOL 4

CENTRATEX 4

QL 60 / 30 Days

PA CERDELGA 5 LA Limited Access

CEREZYME 5 LA Limited Access

CIFEREX 3

CIFRAZOL 3

corvita 150 1

CORVITE 150 (150 TAB, 150 150-1.25 MG TAB) 4

CORVITE FE 4

cyanocobalamin 1000 mcg/ml solution 1

CYANOCOBALAMIN 2000 MCG/ML SOLUTION 3

CYFOLEX 4

DERMACINRX PUREFOLIX 4

dexferrum 1

DIVISTA 4

QL 15 / 90 Days

PA DOPTELET 6 LA Limited Access

DROXIA 3

DURACHOL 3

ED CYTE F 4

ELELYSO 5 LA Limited Access

PAGE 236 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 180 / 30 Days

PA ENDARI 6 LA Limited Access

PA EPOGEN 6 S

fa-vitamin b-6-vitamin b-12 1

fabb 1

FERAHEME 3

FERIVA 4

FERIVA 21/7 4

FERIVAFA 4

ferocon 1

ferotrinsic 1

FERRALET 90 3

FERRAPLUS 90 3

FERRO-PLEX HEMATINIC 4

ferrocite plus 1

FERROTRIN 4

FERROUS SULFATE 4

FOCALGIN DSS 3

folbee 1

FOLENE 4

FOLGARD RX 4

FOLI-D 4

FOLIC ACID POWDER 4

folic acid 1 mg tab 1

FOLIC ACID 5 MG/ML SOLUTION 3

FOLIKA-D 4

FOLIVANE-F 3

PAGE 237 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FOLIVANE-PLUS 3

FOLIXAPURE 4

folplex 2.2 1

FOLTRATE 4

foltrin 1

folvite-d 2

QL 1 Syringe / 14 Days

FULPHILA 5 PA

GENICIN VITA-D 2

GRANIX (300 MCG/0.5ML SOLN PRSYR, 480 MCG/0.8ML PA 5 SOLN PRSYR) S

GRANIX (300 MCG/ML SOLUTION, 480 MCG/1.6ML S SOLUTION) 5

hematinic plus vit/minerals 1

hematinic/folic acid 1

hematogen 1

HEMATOGEN FA 3

hematogen forte 1

HEMETAB 3

HEMOCYTE PLUS 4

hemocyte-f 324-1 mg tab 1

hemocyte-plus 1

HYDROXOCOBALAMIN ACETATE 4

iferex 150 forte 1

INFED 4

PA INJECTAFER 6 S

INTEGRA F 3

INTEGRA PLUS 3

k-tan plus 1

PAGE 238 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA LEUKINE 5 S

LIPO-B 4

MAXFE 4 METHYLCOBALAMIN (10000 MCG RECON SOLN, 50000 MCG RECON SOLN) 4

QL 90 / 30 Days

miglustat 5 LA Limited Access

PA MIRCERA 6 S

QL 8 Vials / 180 Days

PA MOZOBIL 5 LA Limited Access

QL 7 / 365 Days

MULPLETA 5 PA

MULTIGEN 3

MULTIGEN FOLIC 3

MULTIGEN PLUS 3

myferon 150 forte 1

na ferric gluc cplx in sucrose 1

NEPHRON FA 4

PA NEULASTA 5 S

PA NEULASTA ONPRO 5 S

NEUMEGA 5 S

PA NEUPOGEN 5 S

PAGE 239 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NEURIN-SL 4

NIFEREX 4

PA NIVESTYM 6 S

NOXIFOL-D 4

PA NPLATE (125 MCG RECON SOLN, 250 MCG RECON SOLN, LA Limited Access 500 MCG RECON SOLN) 5 S

NUFERA 4

nufol 1

OMONTYS 10 MG/ML SOLUTION 5 S

OMONTYS 20 MG/2ML SOLUTION 6 S

ORTHO D 3

ORTHO DF 3

ORTHO-FOLIC 4

QL 90 / 30 day(s)

OXBRYTA 6 AL1 At least 12 yrs old

LA Limited Access

PHYSICIANS EZ USE B-12 3

poly-iron 150 forte 1

polysaccharide iron forte 1

PRE-FOLIC 4 PROCRIT (2000 UNIT/ML SOLUTION, 3000 UNIT/ML SOLUTION, 4000 UNIT/ML SOLUTION, 10000 UNIT/ML PA 5 SOLUTION, 20000 UNIT/ML SOLUTION, 40000 UNIT/ML S SOLUTION)

QL 30 / 30 Days

PA PROMACTA (12.5 MG TAB, 25 MG TAB) 5 LA Limited Access

PAGE 240 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 / 30 Days

PA PROMACTA (50 MG TAB, 75 MG TAB) 5 LA Limited Access

QL 30 / 30 day(s)

PA PROMACTA 12.5 MG PACKET 5 LA Limited Access

PUREFE PLUS 4

purevit dualfe plus 1

PA REBLOZYL 6 S

PA RETACRIT 6 S

REVESTA 3

ROXIFOL-D 4

se-tan plus 1

SIKLOS 4

TALIVA 3

TANDEM F 3

TANDEM PLUS 4

TARON FORTE 3

tl gard rx 1

tl icon 1

tl-hem 150 1

tricon 1

TRIFERIC 27.2 MG/5ML SOLUTION 4

trigels-f forte 1

QL 1 Syringe / 14 Days

UDENYCA 5 PA

PAGE 241 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VENOFER 3

VIRT-FEFA PLUS 3

virt-gard 1

virt-vite 1

VIT B12-METHIONINE-INOS-CHOL 4

VITAMEZ 3

VITAMIN DEFICIENCY SYSTEM-B12 3

VPRIV 5 LA Limited Access

westab one 1

PA ZARXIO 5 S

ZAVARA 3

QL 90 / 30 Days

PA ZAVESCA 6 LA Limited Access

PA ZIEXTENZO 5 S

ZOLATE 3 HEMOSTATICS

AMICAR (0.25 GM/ML SOLUTION, 500 MG TAB, 1000 MG TAB) 4 aminocaproic acid (0.25 gm/ml solution, 25 % syrup, 250 mg/ml solution, 500 mg tab, 1000 mg tab) 1

AMINOCAPROIC ACID 1000 MG TAB 4

ASTRINGYN 4

EVICEL 5 ML KIT 4

EVITHROM 4

LYSTEDA 4 QL 30 / 28 Days

PAGE 242 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MONSELS FERRIC SUBSULFATE 3

RAPLIXA 4

RECOTHROM 4

RECOTHROM SPRAY KIT 4

THROMBI-PAD 4

THROMBIN-JMI 4

THROMBIN-JMI EPISTAXIS 4

THROMBOGEN 4

tranexamic acid 1000 mg/10ml solution 1

tranexamic acid 650 mg tab 1 QL 30 / 28 Days

TRANEXAMIC ACID-NACL 4 MISCELLANEOUS PRODUCTS

ALTERNATIVE MEDICINES

ALPHA-LIPOIC ACID 25 MG/ML SOLUTION 4

COENZYME Q-10 4

ISCAR MALI 4

QUINZYME 4

RESERVAPAK 4

RESERVAPAK PLUS 4 ANTIDOTES AND SPECIFIC ANTAGONISTS

ACETADOTE 4

acetylcysteine 200 mg/ml solution 1

LA Limited Access ANDEXXA 6 S

ANTIZOL 4

PA BRIDION 6 S

CETYLEV 4

CHARCOAL ACTIVATED 4

CHEMET 3

PAGE 243 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CYANOKIT 4

deferasirox (90 mg tab, 125 mg tab sol, 180 mg tab, 250 mg tab PA 5 sol, 360 mg tab, 500 mg tab sol) S

PA deferoxamine mesylate 5 S

PA DESFERAL 6 S

DUODOTE 4

EDETATE CALCIUM DISODIUM 4

PA EXJADE 6 S

FERRIPROX (100 MG/ML SOLUTION, 500 MG TAB) 5 LA Limited Access

AL1 At least 18 yrs old FERRIPROX 1000 MG TAB 5 LA Limited Access

flumazenil (0.5 mg/5ml solution, 1 mg/10ml solution) 1

fomepizole 1

PA JADENU 6 S

PA JADENU SPRINKLE 5 S

METHYLENE BLUE 1 % SOLUTION 4 NALOXONE HCL (0.4 MG/ML SOLN CART, 2 MG/2ML SOLN PRSYR) 4

naloxone hcl (0.4 mg/ml solution, 4 mg/10ml solution) 1

NALTREXONE 200-6.5 MG IMPLANT 4

naltrexone hcl 50 mg tab 1 QL 60 / 30 day(s)

PAGE 244 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NARCAN 3

PENTETATE CALCIUM TRISODIUM 4

PENTETATE ZINC TRISODIUM 4

PHYSOSTIGMINE SALICYLATE 3

PRALIDOXIME CHLORIDE 600 MG/2ML SOLN A-INJ 4

PRAXBIND 4 QL 2 Vials / 365 Days

REVIA 4 QL 60 / 30 day(s)

SODIUM THIOSULFATE 10 % SOLUTION 3

sodium thiosulfate 25 % solution 1

QL 20 / 365 Days

PA VISTOGARD 5 LA Limited Access

PA VIVITROL 5 S

ANTISEPTICS & DISINFECTANTS

BENZALKONIUM CHLORIDE 3

CETYLCIDE-G 4

CHLORHEXIDINE GLUCONATE 20 % SOLUTION 4

formadon 1

FORMALDEHYDE 10 % SOLUTION 3

formaldehyde 10 % solution 1

KENDALL WET SKIN SCRUB PREP 4

PHENOL (89 % LIQUID, CRYSTALS, LIQUID) 4

SILVER PROTEIN MILD 4

THIMEROSAL 4

TRIPLE DYE 4 CHEMICALS

2-DEOXY-D-GLUCOSE 4

2-METHOXYESTRADIOL 4

PAGE 245 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

4-AMINOBUTYRIC ACID 4

4-AMINOPYRIDINE 4

4-METHYLPYRAZOLE 4

5-FLUOROURACIL 4

5-HTP 4

5-HYDROXY-L-TRYPTOPHAN 4

5-METHYLTETRAHYDROFOLATE CALC 4

7-KETO DHEA 4

9-AMINOACRIDINE HCL 4

AC DERMAPEPTIDE 4

ACARBOSE POWDER 4

ACEPROMAZINE MALEATE 4

ACESULFAME POTASSIUM 4

ACETAMINOPHEN 4

ACETARSONE 4

ACETAZOLAMIDE POWDER 4

ACETIC ACID 5 % SOLUTION 4

ACETIC ACID GLACIAL 4

ACETONE 4

ACETYL DIPEPTIDE-1 CETYL ESTER 4

ACETYL HEXAPEPTIDE-8 (POWDER, SOLUTION) 4

ACETYL-D-GLUCOSAMINE 4

ACETYL-L-CARNITINE HCL 4

ACETYLCHOLINE CHLORIDE 4

ACIDOPHILUS LACTOBACILLUS 4

ACTIPHYTE OF ALGAE GL 4

ACTIPHYTE OF CUCUMBER 4

ACTIPHYTE OF IVY 4

ACTIPHYTE OF LEMONGRASS 4

ACYCLOVIR POWDER 4

PAGE 246 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ADEMETIONINE DISULF TOSYLATE 4

ADENOSINE POWDER 4

ADRENOCHROME SEMICARBAZONE 4

ADRENOCORTICOTROPHIC HORMONE 4

AGAR 4

ALASKAN RED ALGAE 4

ALBENDAZOLE POWDER 4

ALCOHOL, USP 4

ALDOSTERONE 4

ALGINIC ACID 4

ALKYL BENZOATE C12-15 4

ALLANTOIN 4

ALLOPURINOL POWDER 4

ALMOND OIL (SWEET) 4

ALOE VERA (OIL, POWDER) 4

ALOE VERA FREEZE DRIED 4

ALOE VERA LEAF 4

ALPHA-GPC 50% 4

ALPHA-KETOGLUTARIC ACID 4

ALPHA-LIPOIC ACID POWDER 4

ALPHA-TOCOPHEROL 4

ALPRAZOLAM POWDER 4

ALPROSTADIL POWDER 4

ALTRENOGEST 4

ALUMINUM ACETATE BASIC 4

ALUMINUM CHLOROHYDRATE 4

ALUMINUM HYDROXIDE DRIED GEL 4

ALUMINUM POTASSIUM SULFATE 4

ALUMINUM SULFATE 4

AMANTADINE HCL POWDER 4

PAGE 247 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AMERICAN GINSENG 4

AMINOCAPROIC ACID POWDER 4

AMINOLEVULINIC ACID HCL 4

AMINOPROPYL RACEMENTHYL PHOS 4

AMITRIPTYLINE HCL POWDER 4

AMLODIPINE BESYLATE POWDER 4

AMMONIUM BROMIDE 4

AMMONIUM CHLORIDE 4

AMMONIUM HYDROXIDE 4

AMMONIUM LACTATE 70 % SOLUTION 4

AMMONIUM LAURYL SULFATE 4

AMMONIUM MOLYBDATE TETRAHYD 4

AMMONIUM PHOSPHATE DIBASIC 4

AMMONIUM SULFATE 4

AMOXICILLIN-POT CLAVULANATE POWDER 4

ANASTROZOLE POWDER 4

ANDROSTENEDIONE 4

ANISINDIONE 4

ANTIMONY POTASSIUM TARTRATE 4

ANTIMONY TRICHLORIDE 4

ANTIMONY TRISULFIDE 4

ANTIPYRINE 4

APOMORPHINE HCL 4

ARBUTIN ALPHA 4

ARGININE HCL POWDER 4

ARLACEL 165 4

ARSENIC TRIOXIDE POWDER 4

ASCORBIC ACID (GRANULES, POWDER) 4

ASCORBIC ACID CASSAVE 4

ASCORBIC ACID FINE 4

PAGE 248 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ASCORBYL PALMITATE 4

ASPARAGINE MONOHYDRATE 4

ATORVASTATIN CALCIUM POWDER 4

ATOVAQUONE POWDER 4

ATTAPULGITE 4

AVICEL PH 101 MICRO CELLULOSE 4

AVICEL PH 105 MICRO CELLULOSE 4

AVIPTADIL ACETATE 4

AVOCADO OIL 4

AZELAIC ACID FLAKES 4

AZELASTINE HCL POWDER 4

AZITHROMYCIN POWDER 4

AZITHROMYCIN DIHYDRATE 4

BACITRACIN MICRONIZED 4

BASE G ALMOND OIL (SWEET) 4

BASIC FUCHSIN HCL 4

BAY OIL 4

BECLOMETHASONE DIPROPIONATE 4

BELLADONNA 4

BELLADONNA EXTRACT 4

BELLADONNA LEAF EXTRACT 4

BENACTYZINE HCL 4

BENAZEPRIL HCL POWDER 4

BENFOTIAMINE 4

BENZETHONIUM CHLORIDE 4

BENZOCAINE 4

BENZOIN GUM 4

BENZOQUINONE (PARA) 4

BENZYL BENZOATE 4

BETA CAROTENE 4

PAGE 249 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BETA CYCLODEXTRIN 4

BETA GLUCAN 4

BETAHISTINE DIHYDROCHLORIDE 4

BETAHISTINE HCL 4

BETAINE ANHYDROUS 4

BETAINE HCL 4

BETAMETHASONE 4

BETAMETHASONE ACETATE 4

BETANAPHTHOL 4

BETHANECHOL CHLORIDE POWDER 4

BHA 4

BHT 4

BIMATOPROST POWDER 4

BIORE HYDRATING MOISTURIZER 4

BIOTIN 4

BISABOLOL, ALPHA-L 4

BISMUTH CITRATE 4

BISMUTH SUBCARBONATE 4

BISMUTH SUBNITRATE 4

BISMUTH SUBSALICYLATE 4

BITTER ORANGE 4

BLUE AGAVE ORGANIC 4

BORIC ACID (CRYSTALS, POWDER) 4

BORON AMORPHOUS FINE 4

BORON CITRATE 4

BOSWELLIA SERRATA EXTRACT 4

BRIJ 35 4

BRIJ 700 4

BRIJ 93 4

BRILLIANT GREEN 4

PAGE 250 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BRIMONIDINE TARTRATE POWDER 4

BROMFENAC SODIUM (MISC, POWDER) 4

BUDESONIDE POWDER 4

BUFLOMEDIL HCL 4

BUPRENORPHINE HCL POWDER 4

BUPROPION HCL POWDER 4

BUSPIRONE HCL POWDER 4

BUTALBITAL 4

BUTORPHANOL TARTRATE POWDER 4

BUTYL ALCOHOL 4

BUTYLATED HYDROXYANISOLE 4

BUTYLATED HYDROXYTOLUENE 4

BUTYLENE GLYCOL 4

C INDICUM & C SINESIS LEAF EXT 4

CALCIPOTRIENE POWDER 4

CALCIPOTRIENE MONOHYDRATE 4

CALCIPOTRIOL 4

CALCITRIOL POWDER 4

CALCITRIOL IN ALMOND OIL 4

CALCIUM ACETATE POWDER 4

CALCIUM ALGINATE 4

CALCIUM AMINO ACID CHELATE 4

CALCIUM CHLORIDE ANHYDROUS POWDER 4

CALCIUM CITRATE 4

CALCIUM CITRATE TETRAHYDRATE 4

CALCIUM FOLINATE 4

CALCIUM FRUCTOBORATE 4

CALCIUM GLUBIONATE 4

CALCIUM GLYCEROPHOSPHATE 4

CALCIUM HYDROXIDE 4

PAGE 251 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CALCIUM HYDROXYAPATITE 4

CALCIUM LEVULINATE DIHYDRATE 4

CALCIUM PROPIONATE 4

CALCIUM PYRUVATE 4

CALCIUM SACCHARIN 4

CALCIUM STEARATE 4

CALCIUM SULFATE 4

CALCIUM SULFATE HEMIHYDRATE 4

CALCIUM THIOGLYCOLATE 4

CANADIAN BALSAM 4

CAPRYLIC ACID 4

CAPRYLIC CAPRIC TRIGLYCERIDE 4

CAPSAICIN PALMITATE 4

CAPSICUM OLEORESIN 4

CAPTOPRIL POWDER 4

CARBACHOL 4

CARBAMIDE PEROXIDE 4

CARBAZOCHROME 4

CARBIDOPA POWDER 4

CARBIDOPA ANHYDROUS 4

CARBIMAZOLE 4

CARBOMER 934P 4

CARBOMER 934P RESIN 4

CARBOMER 940 4

CARBOMER 941 4

CARBOPOL 940 4

CARBOPOL 940 NF 4

CARBOXYMETHYLCELLULOSE SODIUM 4

CARMINE 4

CARNAUBA WAX 4

PAGE 252 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CARNITINE (L) 4

CARNOSINE L 4

CASTOR OIL 4

CEDAR LEAF OIL 4

CEFTAZIDIME POWDER 4

CEFTAZIDIME WITH SOD CARBONATE 4

CEFTRIAXONE SODIUM POWDER 4

CELECOXIB POWDER 4

CELLULASE 4

CELLULOSE 4

CELLULOSE CARMELLOSE SODIUM 4

CERAPHYL SLK 4

CERESIN WAX 4

CESIUM CHLORIDE 4

CETEARYL ALCOHOL-CETEARETH 20 4

CETOSTEARYL ALCOHOL 4

CETYL ESTERS WAX 4

CETYL MYRISTOLEATE 4

CETYLPYRIDINIUM CHLORIDE 4

CHICKEN PROTEIN 4

CHLORAMBUCIL 4

CHLORAMPHENICOL 4

CHLORAMPHENICOL PALMITATE 4

CHLORHEXIDINE DIACETATE 4

CHLORHEXIDINE GLUCONATE SOLUTION 4

CHLOROFORM 4

CHLOROPHYLLIN SODIUM COPPER 4

CHLOROXINE 4

CHLOROXYLENOL 4

CHLORPROMAZINE HCL POWDER 4

PAGE 253 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CHOLECALCIFEROL 4

CHOLESTEROL 4

CHOLESTYRAMINE POWDER 4

CHOLINE CHLORIDE 4

CHOLINE MAG TRISALICYLATE 4

CHONDROITIN SULFATE SODIUM 4

CHORIONIC GONADOTROPIN POWDER 4

CHROMIC CHLORIDE CRYSTALS 4

CHROMIUM CHLORIDE 4

CHROMIUM K SULFATE DODECAHYD 4

CHROMIUM PICOLINATE 4

CHROMIUM POLYNICOTINATE 4

CHRYSIN 4

CIDOFOVIR POWDER 4

CINNAMON BARK 4

CIPROFLOXACIN POWDER 4

CIPROFLOXACIN HCL POWDER 4

CISAPRIDE 4

CISPLATIN POWDER 4

CITRIC ACID 4

CITRIC ACID ANHYDROUS 4

CITRIC ACID MONOHYDRATE 4

CITRONELLA OIL 4

CITRUS BIOFLAVONOIDS 4

CLARITHROMYCIN POWDER 4

CLEMIZOLE HCL 4

CLIDINIUM BROMIDE 4

CLINDAMYCIN HCL POWDER 4

CLINDAMYCIN HCL MONOHYDRATE 4

CLINDAMYCIN PHOSPHATE POWDER 4

PAGE 254 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CLOFAZIMINE 4

CLOMIPRAMINE HCL POWDER 4

CLONAZEPAM POWDER 4

CLOPIDOGREL BISULFATE POWDER 4

CLORSULON 4

CLOVE OIL 4 COAL TAR (TAR SOLUTION, TAR TAR, TAR 20 % SOLUTION) 4

COAL TAR EXTRACT 4

COBALT GLUCONATE 4

COBAMAMIDE 4

COCAMIDE DEA 4

COCONUT OIL 4

COENZYME Q10 4

COLHIBIN 4

COLISTIMETHATE SODIUM 4

COLLAGEN HYDROLYSATE 4

COPASIL 4

COPPER GLUCONATE 4

COPPER GLYCINATE 4

COPPER PEPTIDE 4

CORAL CALCIUM 4

CORN OIL 4

CORN STARCH 4

CORTICOTROPIN 4

COSMOCIL CQ 4

COTTONSEED OIL 4

COUMARIN 4

CRANBERRY 4

CREATINE 4

CREATINE MONOHYDRATE 4

PAGE 255 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CREATININE 4

CRESOL 4

CROSCARMELLOSE SODIUM 4

CROTAMITON 4

CROTON OIL 4

CRYOSERV 4

CUCUMBER MELON 4

CUPRIC CHLORIDE DIHYDRATE 4

CUPUACU BUTTER 4

CURCUMIN 4

CURCUMIN EXTRACT 4

CYANOCOBALAMIN (CRYSTALS, POWDER) 4

CYCLANDELATE 4

CYCLOBENZAPRINE 4

CYCLOBENZAPRINE HCL POWDER 4

CYCLODEXTRIN-BETA 4

CYCLOMETHICONE 4

CYCLOPENTASILOX-PEG/PPG DIMETH 4

CYCLOPENTOLATE HCL POWDER 4

CYCLOPHOSPHAMIDE POWDER 4

CYCLOSERINE POWDER 4

CYCLOSPORINE POWDER 4

CYCLOSPORINE A 4

CYPROHEPTADINE HCL POWDER 4

CYSTEAMINE HCL 4

D-MANNOSE 4

D-RIBOSE 4

DANTROLENE SODIUM POWDER 4

DAPIPRAZOLE HCL 4

DAPSONE POWDER 4

PAGE 256 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DEHYDROCHOLIC ACID 4

DEHYDROEPIANDROSTERONE 4

DEHYDROEPIANDROSTERONE MICRO 4

DEMECARIUM BROMIDE 4

DENATONIUM BENZOATE 4

DEOXYCHOLIC ACID 4

DEOXYCHOLIC ACID SODIUM 4

DERMACINRX ETHOXY DIGLYCOL 4

DESICCATED BEEF LIVER 4

DESMOPRESSIN ACETATE POWDER 4

DESOXIMETASONE POWDER 4

DESOXYCORTICOSTERONE ACETATE 4

DEVILS CLAW 4

DEXAMETHASONE POWDER 4

DEXAMETHASONE ACETATE 4

DEXAMETHASONE BASE 4

DEXAMETHASONE ISONICOTINATE 4

DEXAMETHASONE SODIUM PHOSPHATE POWDER 4

DEXCHLORPHENIRAMINE MALEATE POWDER 4

DEXPANTHENOL (LIQUID, POWDER) 4

DEXTRAN 40000 4

DEXTRAN 75000 4

DEXTROMETHORPHAN 4

DHEA 4

DHEA MICRONIZED 4

DIAMINOPYRIDINE 4

DIAZEPAM POWDER 4

DIAZOXIDE 4

DIBUCAINE 4

DIBUCAINE HCL 4

PAGE 257 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DIBUTYL SQUARATE 4

DICHLORALPHENAZONE 4

DICHLOROACETIC ACID 4

DICLAZURIL 4

DICLOFENAC SODIUM POWDER 4

DICUMAROL 4

DICYCLOMINE HCL POWDER 4

DIETHANOLAMINE 4

DIETHYL PHTHALATE 4

DIETHYL TOLUAMIDE 4

DIETHYLCARBAMAZINE CITRATE 4

DIETHYLENE GLYCOL MONOETHYL ET 4

DIETHYLPROPION HCL POWDER 4

DIETHYLSTILBESTROL 4

DIGOXIN POWDER 4

DIGOXIN MICRONIZED 4

DIHYDROCODEINE BITARTRATE 4

DIHYDROXYACETONE (1,3) DIMER 4

DIINDOLYLMETHANE 4

DIIODO-L-THYRONINE 3,5 4

DILTIAZEM HCL POWDER 4

DIMENHYDRINATE POWDER 4

DIMERCAPTOPROPANE-SULFONATE NA 4

DIMERCAPTOSUCCINIC ACID 4

DIMETHYL FUMARATE 4

DIMETHYL SILOXANE HYDROXYALKYL 4

DIMETHYL SULFONE 4

DIMETHYL SULFOXIDE 4

DIMETHYLACETAMIDE 4

DIMETHYLAMINOETHANOL 4

PAGE 258 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DIMETHYLGLYCINE HCL 4

DINITROCHLOROBENZENE 4

DIOSGENIN 4

DIOSMIN 4

DIOXYBENZONE 4

DIPHENIDOL HCL 4

DIPHENYLCYCLOPROPENONE 4

DIPYRIDAMOLE POWDER 4

DISOPHENOL 4

DISULFIRAM POWDER 4

DIVALPROEX SODIUM POWDER 4

DL-3-HYDROXYBUTYRIC ACID SOD 4

DL-ALPHA LIPOIC ACID 4

DL-PANTHENOL 4

DL-PANTHENOL ALCOHOL 4

DMAE BITARTRATE 4

DOCOSANOL 4

DOCUSATE SODIUM-SOD BENZOATE 4

DOPAMINE HCL POWDER 4

DORZOLAMIDE HCL POWDER 4

DOW CORNING 1501 FLUID 4

DOW CORNING 200 4

DOXAZOSIN MESYLATE POWDER 4

DOXEPIN HCL POWDER 4

DOXYCYCLINE MONOHYDRATE POWDER 4

DRAKKAR NOIR 4

DULOXETINE HCL (PASTE, POWDER) 4

DUTASTERIDE POWDER 4

DYCLONINE HCL 4

DYPHYLLINE 4

PAGE 259 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ECONAZOLE NITRATE POWDER 4

EDETATE ACID 4

EDETATE DISODIUM POWDER 4

EDETATE DISODIUM DIHYDRATE 4

EDETATE SODIUM 4

EDETIC ACID 4

EDROPHONIUM CHLORIDE 4

EGCG 4

EMU OIL 4

ENALAPRIL MALEATE POWDER 4

ENOVARX-AMITRIPTYLINE 4

ENROFLOXACIN 4

EPINEPHRINE POWDER 4

EPINEPHRINE BASE 4

EPINEPHRINE BITARTRATE 4

ERGOLOID MESYLATES POWDER 4

ERYTHROMYCIN ESTOLATE 4

ESTRADIOL (10 % CREAM, POWDER) 4

ESTRADIOL BENZOATE 4

ESTRADIOL CYPIONATE 4

ESTRADIOL HEMIHYDRATE (BULK) 4

ESTRADIOL MICRONIZED 4

ESTRADIOL VALERATE (CRYSTALS, POWDER) 4

ESTRIOL (10 % CREAM, POWDER) 4

ESTRIOL MICRONIZED 4

ESTRONE 4

ETHER 4

ETHOSUXIMIDE POWDER 4

ETHOXY DIGLYCOL 4

ETHYL ALCOHOL 95 % SOLUTION 4

PAGE 260 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ETHYL OLEATE 4

ETHYL VANILLIN 4

ETHYLCELLULOSE 4

ETHYLENEDIAMINE 4

ETHYLPARABEN 4

ETOMIDATE POWDER 4

ETOPOSIDE POWDER 4

EUCALYPTOL 4

EUCALYPTUS OIL 4

EUGENOL 4

FAMOTIDINE POWDER 4

FENBENDAZOLE 4

FENOFIBRATE POWDER 4

FERRIC AMMONIUM CITRATE 4

FERRIC CHLORIDE HEXAHYDRATE 4

FERRIC PYROPHOSPHATE 4

FERRIC SUBSULFATE 4

FERRIC SULFATE 4

FERROUS BISGLYCINATE CHELATE 4

FERROUS FUMARATE 4

FERROUS GLUCONATE 4

FERROUS GLUCONATE DIHYDRATE 4

FERULIC ACID 4

FEVERFEW 4

FEXOFENADINE HCL 4

FINASTERIDE (CRYSTALS, POWDER) 4

FLIBANSERIN 4

FLOXURIDINE POWDER 4

FLUCONAZOLE POWDER 4

FLUCYTOSINE POWDER 4

PAGE 261 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FLUMAZENIL POWDER 4

FLUNIXIN MEGLUMINE 4

FLUORESCEIN 4

FLUORESCEIN SODIUM 4

FLUOROURACIL POWDER 4

FLUOXETINE HCL POWDER 4

FLUPHENAZINE DECANOATE (LIQUID, POWDER) 4

FLUTICASONE PROPIONATE POWDER 4

FORMOTEROL FUMARATE 4

FORMOTEROL FUMARATE DIHYDRATE 4

FORSKOLIN 4

FREEDOM ESTERDERM 4

FRESH LINEN FRAGRANCE 4

FULLERS EARTH 4

FUMARIC ACID 4

FURAZOLIDONE 4

GABAPENTIN POWDER 4

GALACTOSE 4

GAMMA-AMINOBUTYRIC ACID 4

GARDENIA FRAGRANCE 4

GATIFLOXACIN POWDER 4

GENISTEIN 4

GERANIUM OIL 4

GERMALL PLUS 4

GERMANIUM SESQUIOXIDE 4

GINGER OIL 4

GINGER ROOT 4

GINSENG ROOT 4

GLUCONOLACTONE 4

GLUCOSAMINE HCL 4

PAGE 262 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GLUCOSAMINE SULFATE 4

GLUCOSAMINE SULFATE NACL 4

GLUCOSAMINE SULFATE POTASSIUM 4

GLUTARALDEHYDE IN WATER 4

GLYCERIN 4

GLYCERINE 4

GLYCEROL FORMAL 4

GLYCEROL MONOOLEATE 4

GLYCERYL MONOSTEARATE 4

GLYCINE SOYA PROTEIN 4

GLYCOFUROL 4

GLYCOLIC ACID (CRYSTALS, GRANULES) 4

GLYCOPYRROLATE POWDER 4

GLYCOSAMINOGLYCANS 4

GLYCYRRHIZIC ACID 4

GOLD SODIUM THIOMALATE 4

GRAMICIDIN D 4

GRAPE SEED 4

GREEN SOAP 4

GREEN TEA (95 % POWDER, POWDER) 4

GREEN TEA OIL FRAGRANCE 4

GRISEOFULVIN MICRONIZED 4

GRISEOFULVIN MICROSIZE POWDER 4

GUAIACOL 4

GUANABENZ ACETATE 4

GUANETHIDINE SULFATE 4

GUANIDINEACETIC ACID 4

GUAR GUM 4

GUARANA SEED EXTRACT 4

GYMNEMA SYLVESTRIS LEAF 4

PAGE 263 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HALOPERIDOL POWDER 4

HALOPERIDOL DECANOATE POWDER 4

HAWTHORN BERRY 4

HEMATOXYLIN 4

HEPARIN SODIUM 4

HEPES 4

HEPTAMINOL 4

HISTAMINE PHOSPHATE 4

HOMATROPINE METHYLBROMIDE 4

HONEY ALMOND FRAGRANCE 4

HUPERZINE SERRATE A 4

HYALURONATE SODIUM 4

HYALURONIC ACID 4

HYALURONIC ACID SODIUM 4

HYALURONIDASE 4

HYDRALAZINE HCL POWDER 4

HYDRAZINE SULFATE 4

HYDROCHLORIC ACID 4

HYDROCODONE BITARTRATE 4

HYDROCORTISONE HEMISUCCINATE 4

HYDROFLUORIC ACID 4

HYDROXOCOBALAMIN 4

HYDROXOCOBALAMIN HCL 4

HYDROXYAMPHETAMINE HBR 4

HYDROXYCHLOROQUINE SULFATE POWDER 4

HYDROXYETHYL CELLULOSE POWDER 4

HYDROXYETHYL METHACRYLATE 4

HYDROXYPROGESTERONE CAPROATE POWDER 4

HYDROXYPROPYL CELLULOSE 4

HYDROXYPROPYL METHYLCELLULOSE 4

PAGE 264 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HYDROXYPROPYL-BETA-CYCLODEXT 4

HYDROXYQUINOLINE SULFATE 4

HYDROXYTRYPTOPHAN 4

HYDROXYTRYPTOPHAN L-5 4

HYDROXYUREA POWDER 4

HYDROXYZINE HCL POWDER 4

HYPROMELLOSE 4

HYPROMELLOSE METHOCEL K100M 4

IDEBENONE 4

IDOXURIDINE 4

IMIDUREA 4

IMIQUIMOD POWDER 4

INDOCYANINE GREEN POWDER 4

INDOLE-3-CARBINOL 4

INOSITOL 4

INOSITOL HEXANICOTINATE 4

IODINE 4

IODINE RESUBLIMED 4

IODINE STRONG (LUGOL'S) 4

IODOFORM 4

IOPANOIC ACID 4

ISOMETHEPTENE MUCATE 4

ISOPROPYL ALCOHOL SOLUTION 4

isopropyl alcohol 99 % solution 2

ISOPROPYL MYRISTATE 4

ISOPROPYL PALMITATE 4

ISOPROTERENOL HCL POWDER 4

ISOSORBIDE 4

ISOTRETINOIN POWDER 4

ISOXSUPRINE HCL POWDER 4

PAGE 265 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ITRACONAZOLE POWDER 4

IVERMECTIN POWDER 4

JASMINE FRAGRANCE 4

JOJOBA OIL 4

JUNIPER TAR 4

KANAMYCIN SULFATE 4

KETAMINE HCL POWDER 4

KETOCONAZOLE POWDER 4

KETOPROFEN POWDER 4

KETOROLAC TROMETHAMINE POWDER 4

KETOTIFEN FUMARATE 4

KETOTIFEN HYDROGEN FUMARATE 4

KINETIN 4

KIWI FRAGRANCE 4

KOJIC ACID 4

KUDZU 4

L-ARGININE HCL 4

L-ASPARAGINE 4

L-ASPARTIC ACID 4

L-CARNITINE 4

L-CARNOSINE 4

L-CITRULLINE 4

L-CYSTEINE 4

L-CYSTEINE HCL POWDER 4

L-GLUTAMIC ACID MONOSOD SALT 4

L-LYSINE HCL 4

L-MENTHOL 4

L-METHYLFOLATE CALCIUM POWDER 4

L-ORNITHINE HYDROCHLORIDE 4

L-SELENOMETHIONINE 4

PAGE 266 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

L-SELENOMETHIONINE BLEND 4

L-SERINE 4

LABETALOL HCL POWDER 4

LACTASE 5000 4

LACTIC ACID (88 % SOLUTION, SOLUTION) 4

LAMOTRIGINE POWDER 4

LANSOPRAZOLE POWDER 4

LATANOPROST POWDER 4

LAURETH-9 POLIDOCANOL 4

LAURIC ACID 4

LAVENDER OIL 4

LEAD ACETATE TRIHYDRATE 4

LEAD TETROXIDE 4

LECITHIN 4

LECITHIN SOYA 4

LEFLUNOMIDE POWDER 4

LETROZOLE POWDER 4

LEUCOVORIN CALCIUM POWDER 4

LEUPROLIDE ACETATE POWDER 6

LEVALBUTEROL HCL POWDER 4

LEVETIRACETAM POWDER 4

LEVOCARNITINE POWDER 4

LEVOCETIRIZINE DIHYDROCHLORIDE POWDER 4

LEVOFLOXACIN POWDER 4

LEVOFLOXACIN HEMIHYDRATE 4

LEVOMEFOLATE CALCIUM 4

LEVOMEFOLATE GLUCOSAMINE 4

LEVORPHANOL TARTRATE POWDER 4

LEVOTHYROXINE SODIUM POWDER 4

LICORICE DEGLYCYRRHIZINATED 4

PAGE 267 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LICORICE ROOT 4

LIDOCAINE (CRYSTALS, POWDER) 4

LIDOCAINE HCL POWDER 4

LIDOCAINE HCL MONOHYDRATE 4

LIME OIL 4

LIMONENE 4

LINCOMYCIN HCL POWDER 4

LINOLEIC ACID 4

LINSEED OIL 4

LIOTHYRONINE 4

LIOTHYRONINE SODIUM POWDER 4

LIPACTIVE INCA INCHI WO 4

LIPOIC ACID 4

LISINOPRIL POWDER 4

LITHIUM CITRATE TETRAHYDRATE 4

LOCUST BEAN GUM 4

LORATADINE 4

LORAZEPAM POWDER 4

LUTEIN 4

LYSINE HCL GRANULES 4

MACA ROOT 4

MACADAMIA NUT OIL 4

MAFENIDE ACETATE POWDER 4

MAGNASWEET 110 4

MAGNASWEET 135 4

MAGNESIUM ALUMINUM SILICATE 4

MAGNESIUM AMINO ACID CHELATE 4

MAGNESIUM ASCORBATE 4

MAGNESIUM BISGLYCINATE DIHYD 4

MAGNESIUM CITRATE 4

PAGE 268 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MAGNESIUM GLUCONATE 4

MAGNESIUM GLYCINATE 4

MAGNESIUM HYDROXIDE 4

MAGNESIUM MALATE 4

MAGNESIUM PHOSPHATE 4

MAGNESIUM SALICYLATE 4

MALEIC ACID 4

MALIC ACID 4

MALTODEXTRIN 4

MANDELIC ACID 4

MANGANESE CHLORIDE TETRAHYD 4

MANGANESE GLUCONATE 4

MANGANESE SULFATE POWDER 4

MANNITOL POWDER 4

MECAMYLAMINE HCL 4

MECHLORETHAMINE HCL 4

MECLOFENOXATE HCL 4

MEDIUM CHAIN TRIGLYCERIDES 4

MEDROXYPROGESTERONE ACE MICRO 4

MEDROXYPROGESTERONE ACETATE POWDER 4

MEDROXYPROGESTERONE MICRONIZED 4

MEGLUMINE 4

MELATONIN 4

MELOXICAM POWDER 4

MEMANTINE HCL POWDER 4

MENADIONE 4

MENADIONE SODIUM BISULFITE 4

MENTHOL 4

MEQUINOL 4

MERCAPTOPURINE POWDER 4

PAGE 269 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MERCAPTOPURINE MONOHYDRATE 4

METACRESOL ACETATE 4

METFORMIN HCL POWDER 4

METHACHOLINE CHLORIDE 4

METHACRYLIC ACID COPOLYMER A 4

METHANESULFONIC ACID 4

METHANOL 4

METHENAMINE 4

METHENAMINE MANDELATE POWDER 4

METHOCARBAMOL POWDER 4

METHOCEL E4M 4

METHOCEL E4M PREMIUM 4

METHOCEL E4M PREMIUM CR 4

METHOCEL K100 PREMIUM 4

METHOCEL K100M PREMIUM 4

METHOXYAMINE HYDROCHLORIDE 4

METHOXYETHANOL 4

METHSCOPOLAMINE BROMIDE POWDER 4

METHSCOPOLAMINE NITRATE 4

METHYL FOLATE 4

METHYL METHACRYLATE CROSSPOLY 4

METHYL SULFONE 4

METHYLCOBALAMIN POWDER 4

METHYLCOBALAMIN PREMIUM 4

METHYLENE BLUE POWDER 4

METHYLMETHACRYL CROSSPOLYMER 4

METHYLPHENIDATE HCL POWDER 4

METHYLSULFONYLMETHANE 4

METHYSERGIDE MALEATE 4

METRONIDAZOLE POWDER 4

PAGE 270 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

METRONIDAZOLE BENZOATE 4

MEXILETINE HCL POWDER 4

MIDAZOLAM 4

MILK THISTLE 4

MINOXIDIL POWDER 4

MIRTAZAPINE POWDER 4

MISOPROSTOL 1 % POWDER 4

MISOPROSTOL DISPERSION (HPMC) 4

MISOPROSTOL-HPMC 4

MITOMYCIN POWDER 4

MITOTANE 4

MOLYBDENUM 4

MOMETASONE FUROATE POWDER 4

MONOBENZONE 4

MONOETHANOLAMINE 4

MONTELUKAST SODIUM POWDER 4

MORANTEL TARTRATE 4

MOXIFLOXACIN HCL POWDER 4

MOXISYLYTE HCL 4

MUPIROCIN POWDER 4

N-ACETYL-L-CARNOSINE 4

NABUMETONE POWDER 4

NADH 4

NADH DISODIUM 4

NALBUPHINE HCL POWDER 4

NALOXONE HCL POWDER 4

NALOXONE HCL DIHYDRATE 4

NALTREXONE POWDER 4

NALTREXONE HCL POWDER 4

NALTREXONE HCL ANHYDROUS 4

PAGE 271 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NANDROLONE DECANOATE POWDER 4

NAPHAZOLINE HCL POWDER 4

NATAPRES 4

NATURAL MIXED TOCOPHEROLS 4

NEOSTIGMINE METHYLSULFATE POWDER 4

NEPAFENAC 4

NETTLE LEAF 4

NIAOULI 4

NICLOSAMIDE 4

NICOTINAMIDE ADENINE DINUCLEO 4

NICOTINAMIDE RIBOSIDE CHLORIDE 4

NICOTINE POLACRILEX 4

NICOTINE TARTRATE 4

NIMODIPINE POWDER 4

NITRIC ACID 4

NITROFURANTOIN ANHYDROUS 4

NONOXYNOL-9 4

NOREPINEPHRINE BITARTRATE POWDER 4

NORETHINDRONE POWDER 4

NOURISIL 4

NYSTATIN POWDER 4

OCTINOXATE 4

OCTYL STEARATE 4

OLIVE OIL 4

OLMESARTAN MEDOXOMIL POWDER 4

OMEPRAZOLE POWDER 4

ONDANSETRON HCL POWDER 4

ORIGANUM OIL 4

ORLISTAT 4

ORNITHINE HCL 4

PAGE 272 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

OSELTAMIVIR PHOSPHATE POWDER 4

OXALIC ACID DIHYDRATE 4

OXANDROLONE POWDER 4

OXYBENZONE 4

OXYBUTYNIN CHLORIDE POWDER 4

OXYMETAZOLINE HCL 4

OXYMETHOLONE 4

OXYTETRACYCLINE DIHYDRATE 4

OXYTOCIN POWDER 4

PALMAROSA 4

PALMIDROL 4

PALMITOYL PENTAPEPTIDE-3 4

PALMITOYL TRIPEPTIDE-3 4

PANCREATIN 4

PANTHENOL 4

PANTOPRAZOLE SODIUM POWDER 4

PAPAIN 4

PARACHLOROPHENOL 4

PARAFORMALDEHYDE 4

PAROMOMYCIN SULFATE POWDER 4

PCCA DMAE COMPLEX 4

PCCA T3 SODIUM 4

PCCA T4 SODIUM 4

PEANUT OIL 4

PEG 400 MONOSTEARATE 4

PEG-40 CASTOR OIL 4

PENICILLAMINE POWDER 4

PENNYROYAL OIL 4

PENTOSAN POLYSULFATE SODIUM 4

PENTOXIFYLLINE 4

PAGE 273 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PENTYLENE GLYCOL 4

PENTYLENETETRAZOLE 4

PEPPERMINT OIL 4

PERFLUORODECALIN 4

PERGOLIDE MESYLATE 4

PERMETHRIN LIQUID 4

PERPHENAZINE POWDER 4

PERUVIAN BALSAM 4

PEUCEDANUM OSTRUTHIUM EXTRACT 4

PHENELZINE SULFATE POWDER 4

PHENINDIONE 4

PHENIRAMINE MALEATE 4

PHENOLSULFONIC ACID 4

PHENOXYBENZAMINE HCL POWDER 4

PHENOXYETHANOL 4

PHENTERMINE HCL POWDER 4

PHENTOLAMINE MESYLATE POWDER 4

PHENYL SALICYLATE 4

PHENYLETHYL ALCOHOL 4

PHENYLETHYLAMINE HCL 4

PHENYLMERCURIC ACETATE 4

PHENYLMERCURIC NITRATE 4

PHENYLTOLOXAMINE CITRATE 4

PHENYTOIN POWDER 4

PHOSPHATIDYLCHOLINE 4

PHOSPHATIDYLSERINE 4

PHOSPHORIC ACID 4

PHYTIC ACID IN WATER 4

PHYTONADIONE (CRYSTALS, LIQUID) 4

PILOCARPINE HCL POWDER 4

PAGE 274 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PILOCARPINE NITRATE 4

PIMOBENDAN 4

PINE BARK EXTRACT 4

PINE NEEDLE OIL 4

PINE OIL 4

PINE TAR 4

PINEAPPLE EXTRACT 4

PINENE (L-ALPHA) 4

PIPERINE 4

PIRACETAM 4

PMX-1184 SILICONE 4

PODOFILOX POWDER 4

POLYETHYLENE GLYCOL 600 4

POLYHEXAMETHYLENE BIGUANIDE 4

POLYOX WSR-301 4

POLYSORBATE 20 4

POLYSORBATE 40 4

POLYSORBATE 60 4

POLYSORBATE 80 4

POLYVINYL ALCOHOL 4

POLYVINYLPYRROLIDONE K-30 4

POLYVINYLPYRROLIDONE K-90 4

POMEGRANATE SEED 4

PONAZURIL 4

POTASH SULFURATED LUMP 4

POTASSIUM ACETATE (CRYSTALS, POWDER) 4

POTASSIUM ASPARTATE 4

POTASSIUM AZELAOYL DIGLYCINATE 4

POTASSIUM BENZOATE 4

POTASSIUM BITARTRATE 4

PAGE 275 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

POTASSIUM BROMIDE 4

POTASSIUM CARBONATE 4

POTASSIUM GLUCONATE ANHYDROUS 4 POTASSIUM HYDROXIDE (5 % SOLUTION, 45 % SOLUTION, PELLET) 4

POTASSIUM IODIDE 4

POTASSIUM METABISULFITE 4

POTASSIUM NITRATE 4

POTASSIUM PERCHLORATE 4

POTASSIUM PERMANGANATE 4

POTASSIUM PHOSPHATE DIBASIC GRANULES 4

POTASSIUM PHOSPHATE MONOBASIC CRYSTALS 4

POTASSIUM SODIUM TARTRATE 4

POTASSIUM SULFATE 4

POVIDONE 4

POVIDONE K-30 4

POVIDONE-IODINE (FLAKES, POWDER) 4

POWDER SCENT FRAGRANCE 4

PRALIDOXIME CHLORIDE POWDER 4

PRASTERONE MICRONIZED 4

PRAZIQUANTEL POWDER 4

PREGABALIN POWDER 4

PREGNENOLONE 4

PREGNENOLONE MICRONIZED 4

PRILOCAINE 4

PRILOCAINE HCL 4

PRIMIDONE POWDER 4

PROCARBAZINE HCL 4

PROCHLORPERAZINE EDISYLATE POWDER 4

PROFLAVINE HEMISULFATE 4

PROGESTERONE (40 % CREAM, POWDER) 4

PAGE 276 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PROGESTERONE MICRONIZED POWDER 4

PROGESTERONE MILLED 4

PROGESTERONE ULTRA MICRONIZED 4

PROGESTERONE WETTABLE 4

PROMAZINE HCL 4

PROMETHAZINE HCL POWDER 4

PROPANEDIOL 4

PROPARACAINE HCL POWDER 4

PROPYL GALLATE 4

PROPYLENE GLYCOL LIQUID 4

PROPYLENE GLYCOL MONOSTEARATE 4

PROPYLTHIOURACIL POWDER 4

PROSTAGLANDIN E1 4

PROSTAGLANDIN E2 4

PROTAMINE SULFATE POWDER 4

PROTEASE 4

PSYLLIUM HUSK 4

PULLULAN 4

PUMICE (FLOUR) 4

PYRANTEL PAMOATE 4

PYRAZINAMIDE POWDER 4

PYRIDOSTIGMINE BROMIDE POWDER 4

PYRIDOXAL-5 PHOSPHATE 4

PYRIDOXAL-5-PHOSPHATE 4

PYRIMETHAMINE 4

PYROGALLOL 4

PYRUVIC ACID 4

QUATERNIUM-15 4

QUERCETIN DIHYDRATE 4

QUINIDINE SULFATE DIHYDRATE 4

PAGE 277 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QUININE HCL DIHYDRATE 4

RACEPINEPHRINE HCL 4

RANITIDINE HCL POWDER 4

RAPESEED OIL 4

RASAGILINE MESYLATE POWDER 4

RAUWOLFIA SERPENTINA 4

RED YEAST RICE POWDER 4

RENOVAGE 4

RESORCINOL 4

RESVERATROL 4

RETINAL 4

RETINOL MOLECULAR FILM 4

RIBAVIRIN POWDER 4

RIBOFLAVIN 4

RIBOFLAVIN 5-PHOSPHATE SODIUM 4

RIBOFLAVIN-5-PHOSPHATE SODIUM 4

RIBOSE (D) 4

RIFAMPIN POWDER 4

RIFAXIMIN 4

ROCURONIUM BROMIDE POWDER 4

RONIDAZOLE 4

ROPIVACAINE HCL POWDER 4

ROSE BENGAL B 4

ROSE OIL 4

ROSEMARY OIL 4

ROSIN 4

RUBIDIUM CHLORIDE 4

RUTIN 4

SACCHARIN CALCIUM 4

SAFFLOWER OIL 4

PAGE 278 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SAGE LEAF 4

SALICYLIC ACID (50 % SOLUTION, CRYSTALS, POWDER) 4

SALSALATE POWDER 4

SASSAFRAS OIL 4

SAW PALMETTO 4

SAW PALMETTO BERRY 4

SCARLET RED 4

SECRETIN-MANNITOL 4

SELENIUM SULFIDE POWDER 4

SELENIUM YEAST 4

SENNA 4

SEPICALM VG 4

SERMORELIN ACETATE 4

SEROTONIN HCL 4

SERTRALINE HCL POWDER 4

SESAME OIL 4

SHARK CARTILAGE 4

SHOWER FRESH FRAGRANCE 4

SIBERIAN GINSENG 4

SILDENAFIL CITRATE POWDER 4

SILICA 4

SILICON DIOXIDE 4

SILICON DIOXIDE (SYLOID 244FP) 4

SILICONE BLEND CUSTOM 4

SILICONE ELASTOMER BLEND 4

SILICONE FLUID 556 4

SILVER SULFADIAZINE POWDER 4

SIMVASTATIN POWDER 4

SINCALIDE IN MANNITOL 4

SIROLIMUS POWDER 4

PAGE 279 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SODIUM 4-AMINOSALICYLATE 4

SODIUM ACETATE TRIHYDRATE 4

SODIUM ALGINATE 4

SODIUM ASCORBYL PHOS DIHYDRATE 4

SODIUM ASPARTATE 4

SODIUM ASPARTATE MONOHYDRATE 4

SODIUM BICARBONATE POWDER 4

SODIUM BICARBONATE-NACL 4

SODIUM BISULFITE 4

SODIUM BITARTRATE MONOHYDRATE 4

SODIUM BORATE DECAHYDRATE 4

SODIUM BROMIDE 4

SODIUM BUTYRATE 4

SODIUM CACODYLATE 4

SODIUM CAPRATE 4

SODIUM CAPRYLATE 4

SODIUM CARBONATE ANHYDROUS 4

SODIUM CARBONATE MONOHYDRATE 4

SODIUM CHLORITE 4

SODIUM CITRATE DIHYDRATE 4

SODIUM COCOYL GLUTAMATE 4

SODIUM DEHYDROACETATE 4

SODIUM DEOXYCHOLATE 4

SODIUM DIACETATE 4

SODIUM DICHLOROACETATE 4

SODIUM FLUORIDE POWDER 4

SODIUM FLUOROPHOSPHATE 4

SODIUM GLUCONATE 4

SODIUM HYALURONATE POWDER 4

SODIUM HYDROXIDE PELLET 4

PAGE 280 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SODIUM HYDROXIDE 10 % SOLUTION 3

SODIUM IODIDE 4

SODIUM LACTATE 60 % SOLUTION 4

SODIUM LAURETH SULFATE 4

SODIUM METABISULFITE 4

SODIUM MOLYBDATE 4

SODIUM MONOFLUOROPHOSPHATE 4

SODIUM NITRATE 4

SODIUM NITRITE GRANULES 4

SODIUM OLEATE 4

SODIUM PERBORATE 4

SODIUM PHENYLBUTYRATE POWDER 4

SODIUM PHOSPHATE DIBASIC 4

SODIUM PHOSPHATE DIBASIC HEPTA 4

SODIUM PHOSPHATE MONOBASIC 4

SODIUM PHOSPHATE TRIBASIC 4

SODIUM PIDOLATE 4

SODIUM PROPIONATE 4

SODIUM PYROPHOSPHATE 4

SODIUM SELENITE 4

SODIUM STEARATE 4

SODIUM STEARYL FUMARATE 4

SODIUM SUCCINATE 4

SODIUM SULFATE 4

SODIUM SULFITE 4

SODIUM TARTRATE DIHYDRATE 4 SODIUM TETRADECYL SULFATE (27 % SOLUTION, POWDER) 4

SODIUM THIOSALICYLATE 4

SODIUM VALPROATE 4

SORBITAN MONOLAURATE 4

PAGE 281 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SORBITAN MONOOLEATE 4

SORBITAN MONOPALMITATE 4

SORBITAN MONOSTEARATE 4

SORBITOL POWDER 4

SOYABEAN CASEIN DIGEST MEDIUM 4

SOYBEAN LECITHIN 4

SOYBEAN OIL 4

SPEARMINT OIL 4

SPIRULINA 4

SQUALANE 4

SQUARIC ACID 4

ST JOHNS WORT 4

STANNOUS CHLORIDE DIHYDRATE 4

STANNOUS FLUORIDE POWDER 4

STANOZOLOL 4

STARCH RICE 4

STEVIA EXTRACT 4

STEVIOL GLYCOSIDES 4

STEVIOSIDE 15 % FL EXTRACT 4

STRONTIUM CHLORIDE CRYSTALS 4

STRONTIUM NITRATE 4

SUCCIMER DMSA 4

SUCCINIC ACID 4

SUCCINYLCHOLINE CHLORIDE POWDER 4

SUCROSE 4

SUCROSE OCTAACETATE 4

SUFENTANIL CITRATE POWDER 4

SULFACETAMIDE 4

SULFADIMETHOXINE 4

SULFAMERAZINE 4

PAGE 282 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SULFANILAMIDE 4

SULFOSALICYLIC ACID DIHYDRATE 4

SULFUR 4

SULFUR PRECIPITATED 4

SULFUR SUBLIMED 4

SULFURIC ACID 4

SULPIRIDE 4

SUMATRIPTAN POWDER 4

SUMATRIPTAN SUCCINATE POWDER 4

SUPEROXIDE DISMUTASE (POWDER, SOLUTION) 4

SYN-AKE 4

TACROLIMUS POWDER 4

TADALAFIL POWDER 4

TALC 4

TAMOXIFEN CITRATE POWDER 4

TARTARIC ACID 4

TAZAROTENE POWDER 4

TEA COCOYL GLUTAMINE 4

TEA TREE OIL 4

TERBINAFINE HCL POWDER 4

TESTOSTERONE (20 % CREAM, POWDER) 4

TESTOSTERONE CYPIONATE POWDER 4

TESTOSTERONE ENANTHATE POWDER 4

TESTOSTERONE MICRONIZED 4

TESTOSTERONE PROPIONATE POWDER 4

TETRACAINE 4

TETRACAINE HCL POWDER 4

TETRAHYDROBIOPTERIN DIHCL 4

TETRAHYDROCURCUMIN 4

TETRAHYDROZOLINE HCL 4

PAGE 283 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

THEANINE 4

THEOBROMINE 4

THEOPHYLLINE ANHYDROUS 4

THIOGUANINE 4

THIORIDAZINE HCL POWDER 4

THIOTEPA POWDER 4

THYMOL 4

THYMOL IODIDE 4

THYMUS 4

THYROID (PORCINE) 4

THYROID 3X (PORCINE) 4

TICARCILLIN-POT CLAVULANATE 4

TINIDAZOLE POWDER 4

TINOGARD TL 4

TIOPRONIN 4

TITANIUM DIOXIDE 4

TIZANIDINE HCL POWDER 4

TOBRAMYCIN POWDER 4

TOCOPHERYL ACID SUCC D-ALPHA 4

TOCOTRIENOLS 4

TOFACITINIB CITRATE 6 S

TOLAZOLINE HCL 4

TOLTRAZURIL 4

TOLU BALSAM 4

TOLUIDINE BLUE O 4

TOPIRAMATE POWDER 4

TRAMADOL HCL POWDER 4

TRANEXAMIC ACID POWDER 4

TRANILAST 4

TRIACETIN 4

PAGE 284 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TRIAMCINOLONE 4

TRIAMCINOLONE HEXACETONIDE 4

TRICHLORMETHIAZIDE 4

TRICHLOROACETIC ACID 4

TRICLOSAN 4

TRIETHANOLAMINE LAURYL SULFATE 4

TRIETHYL CITRATE 4

TRILOSTANE 4

TRIMEPRAZINE TARTRATE 4

TRIMETHOBENZAMIDE HCL POWDER 4

TRIOXSALEN 4

TRIPROLIDINE HCL 4

TRITON X-100 4

TROMETHAMINE 4

TROPOLONE 4

TRYPSIN 4

TURMERIC 4

TURMERIC ROOT 4

TYLOSIN TARTRATE 4

TYLOXAPOL 4

UBIDECARENONE 4

UBIQUINOL 4

UNDECYLENIC ACID 4

UREA (BEADS, POWDER) 4

URIDINE 4

URSODIOL POWDER 4

VALACYCLOVIR HCL POWDER 4

VALERIAN ROOT 4

VALPROATE SODIUM POWDER 4

VALPROIC ACID POWDER 4

PAGE 285 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VANADIUM 4

VANADYL SULFATE HYDRATE 4

VANCOMYCIN HCL POWDER 4

VANILLIN 4

VICTORIAS SECRET VANILLA LACE 4

VIDARABINE 4

VINPOCETINE 4

VITAMIN A 4

VITAMIN A ACETATE 4

VITAMIN A PALMITATE 4 VITAMIN D3 (2400 UNIT/ML LIQUID, 100000 UNIT/GM POWDER, 1000000 UNIT/GM LIQUID, LIQUID, POWDER) 4

VITAMIN E LIQUID 4 VITAMIN E ACETATE (ACTAT LIQUID, ACTAT1 UNIT/MG LIQUID, ACTAT125 UNIT/ML LIQUID) 4

VITAMIN E SUCCINATE 4

VITAMIN K2 4

VORICONAZOLE POWDER 4

WHEY PROTEIN ISOLATE 4

WHITE KIDNEY BEAN EXTRACT 4

WHITE WILLOW BARK 4

WITCH HAZEL 4

XYLAZINE HCL 4

XYLITOL 4

XYLOMETAZOLINE HCL 4

YEAST EXTRACT 4

YLANG-YLANG OIL FRAGRANCE 4

YOHIMBINE HCL 4

ZEAXANTHIN 4

ZINC ACETATE POWDER 4

ZINC CHLORIDE GRANULES 4

PAGE 286 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ZINC CITRATE 4

ZINC GLUCONATE POWDER 4

ZINC MONOMETHIONINE 4

ZINC OXIDE 4

ZINC PICOLINATE 4

ZINC PYRITHIONE 4

ZINC UNDECYLENATE 4

ZIRCONIUM OXIDE 4

ZOLMITRIPTAN POWDER 4

ZONISAMIDE POWDER 4 DIAGNOSTIC PRODUCTS

ABLAVAR 4

adenosine (diagnostic) 1

adenosine 3 mg/ml solution 1

ARIDOL 4

ASPERGILLUS FUMIGATUS 1:500 SOLUTION 4

candida albicans skn tst antgn 1

CANDIN 4

CONRAY 30 4

CONSTANT TRICHOPHYTON 4

CORTROSYN 4

cosyntropin 1

CUSHING SYNDROME DIAGNOSTIC 4

CYSVIEW 4

DIAGNOSTIC 4

DMSA 4

DOTAREM 2.5 MMOL/5ML SOLUTION 4

DRAX IMAGE DTPA 4

E-Z-DISK 4

E-Z-DOSE 4

PAGE 287 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GASTROGRAFIN 4

GLEOLAN 4

GLOFIL-125 4

GLUCAGEN DIAGNOSTIC 3 QL 2 kits / 365 Days

GLUCAGON HCL (DIAGNOSTIC) 4

HYMENOPTRA TESTS 4

HYSKON 4

INDIGO CARMINE 4

indocyanine green 25 mg recon soln 1

INULIN 4

isosulfan blue 1

KINEVAC 3

LEXISCAN 3

QL 1 / Lifetime

PA MACRILEN 6 LA Limited Access

MD-76 R 3

md-gastroview 1

METOPIRONE 4

OMNIPAQUE (9 MG/ML SOLUTION, 12 MG/ML SOLUTION) 4

OPTIMARK 4

PROSTASCINT 4

PROVOCHOLINE 4

R-GENE 10 3

SERMORELIN ACETATE DIAGNOSTIC 4

SINOGRAFIN 4

T.R.U.E. TEST 4

THALLOUS CHLORIDE TL 201 1 MCI/ML SOLUTION 3

THYROGEN 5 LA Limited Access

PAGE 288 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TRICHOPHYTON 1000 PNU/ML INJECTABLE 4

ULTRAVIST 31 % SOLUTION 4 MEDICAL DEVICES AND SUPPLIES

ADULT MASK DEVICE 3

AEROCHAMBER MINI CHAMBER 3

AEROCHAMBER MV 3

AEROCHAMBER PLUS FLO-VU 3

AEROCHAMBER PLUS FLO-VU LARGE 3

AEROCHAMBER PLUS FLO-VU MEDIUM 3

AEROCHAMBER PLUS FLO-VU SMALL 3

AEROCHAMBER PLUS FLO-VU W/MASK 3

AEROCHAMBER PLUS FLOW VU 3

AEROCHAMBER W/FLOWSIGNAL 3

AEROCHAMBER Z-STAT PLUS 3

AEROCHAMBER Z-STAT PLUS CHAMBR 3

AEROCHAMBER Z-STAT PLUS/LARGE 3

AEROCHAMBER Z-STAT PLUS/MEDIUM 3

AEROCHAMBER Z-STAT PLUS/SMALL 3

AEROVENT PLUS 3

AIRS DISPOSABLE NEBULIZER 3

ASSURE ID INSULIN SAFETY SYR 3

BD INSULIN SYRINGE U-500 3

BD PEN NEEDLE NANO U/F 3

BD SAFETYGLIDE INSULIN SYRINGE 3

BREATHE EASE LARGE 3

BREATHE EASE MEDIUM 3

BREATHE EASE SMALL 3

BREATHERITE 3

BREATHERITE COLL SPACER ADULT 3

BREATHERITE COLL SPACER CHILD 3

PAGE 289 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BREATHERITE COLL SPACER INFANT 3

BREATHERITE RIGID SPACER/MASK 3

BREATHERITE SPACER NEONATE 3

BREATHERITE SPACER SMALL CHILD 3

BREATHERITE/LARGE MASK 3

BREATHERITE/MEDIUM MASK 3

BREATHERITE/SMALL MASK 3

CAYA 3

CLEVER CHOICE HOLDING CHAMBER 3

COMPACT SPACE CHAMBER 3

COMPACT SPACE CHAMBER/LG MASK 3

COMPACT SPACE CHAMBER/MED MASK 3

COMPACT SPACE CHAMBER/SM MASK 3

DEXCOM G4 PLAT PED RCV/SHARE 3

DEXCOM G4 PLAT PED RECEIVER 3

DEXCOM G4 PLATINUM RCV/SHARE 3

DEXCOM G4 PLATINUM RECEIVER 3

DEXCOM G4 PLATINUM TRANSMITTER 3

DEXCOM G4 SENSOR 3

DEXCOM G5 MOB/G4 PLAT SENSOR 3

DEXCOM G5 MOBILE RECEIVER 3

DEXCOM G5 MOBILE TRANSMITTER 3

DEXCOM G6 RECEIVER 3

DEXCOM G6 SENSOR 3

DEXCOM G6 TRANSMITTER 3

DEXCOM RECEIVER KIT 3

E-Z SPACER 3

E-Z SPACER THE BODY GUARDS PK 3

EASIVENT 3

EASIVENT MASK LARGE 3

PAGE 290 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

EASIVENT MASK MEDIUM 3

EASIVENT MASK SMALL 3

FEMCAP 3

FLEXICHAMBER 3

FREESTYLE LIBRE 14 DAY READER 3

FREESTYLE LIBRE 14 DAY SENSOR 3

FREESTYLE LIBRE READER 3

FREESTYLE LIBRE SENSOR SYSTEM 3

INSPIRACHAMBER/LARGE 3

INSPIRACHAMBER/MEDIUM 3

INSPIRACHAMBER/MOUTHPIECE 3

INSPIRACHAMBER/SMALL 3

INSPIREASE 3

INSPIREASE RESERVOIR BAGS 4

LITEAIRE 3

MAGELLAN INSULIN SAFETY SYR 3

MARATHON MEDICAL PENTIPS 3

MICROCHAMBER 3

MICROSPACER 3

MINIMED 670G INSULIN PUMP 3

MONOJECT BLOOD COLLECTION NDL 20G X 1-1/2" MISC 4 MONOJECT BLUNT CANNULA (15G 1-1/2" MISC, 17G 1-1/2" MISC) 4 MONOJECT HYPODERMIC NEEDLE (15G 1-1/2" MISC, 23G 1/2" MISC) 4

PAGE 291 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MONOJECT INSULIN SYRINGE (SYRINGE 27G X 1/2" 1 ML MISC, SYRINGE 28G X 1/2" 0.5 ML MISC, SYRINGE 28G X 1/2" 1 ML MISC, SYRINGE 29G X 1/2" 0.3 ML MISC, SYRINGE 29G X 1/2" 0.5 ML MISC, SYRINGE 29G X 1/2" 1 3 ML MISC, SYRINGE 30G X 5/16" 0.3 ML MISC, SYRINGE 30G X 5/16" 0.5 ML MISC, SYRINGE 30G X 5/16" 1 ML MISC, SYRINGE U-100 1 ML MISC)

MONOJECT LIFESHIELD SYRINGE 18G X 1" 1 ML MISC 4

MONOJECT SAFETY SYRINGE/SHIELD 22G X 1" 3 ML MISC 4

MONOJECT ULTRA COMFORT SYRINGE 3

OMNIFLEX DIAPHRAGM 3

OPTICHAMBER ADVANTAGE-LG MASK 3

OPTICHAMBER ADVANTAGE-MED MASK 3

OPTICHAMBER ADVANTAGE-SM MASK 3

OPTICHAMBER DIAMOND 3

OPTICHAMBER DIAMOND-LG MASK 3

OPTICHAMBER DIAMOND-MD MASK 3

OPTICHAMBER DIAMOND-SM MASK 3

OPTIHALER 3

PARI LC PLUS NEBULIZER 3

PARI TREK S COMBO PACK 3

PARI TREK S W/12V DC ADAPTOR 3

PENTIPS 3

POCKET CHAMBER 3

POCKET SPACER 3

PRO COMFORT PEN NEEDLES 3

RESPERATE 1.0 4

RESPERATE 1.1 4

RITEFLO 3

SURE-T INFUSION SET 18" 3

SURE-T INFUSION SET 23" 3

SURE-T INFUSION SET 32" 3

T:SLIM INSULIN DELIVERY SYSTEM 3

PAGE 292 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

T:SLIM INSULIN PUMP 3

T:SLIM X2 INS PUMP/CONTROL-IQ 3

T:SLIM X2/CONTROL-IQ/REFURB 3

TRUEPLUS 5-BEVEL PEN NEEDLES 3

TRUZONE PEAK FLOW METER 3 QL 1 Fill / 365 Days

ULTICARE INSULIN SAFETY SYR 3

ULTILET INSULIN SYRINGE 3

V-GO 20 3

V-GO 30 3

V-GO 40 3

VALVED HOLDING CHAMBER 3

VORTEX VALVED HOLDING CHAMBER 3

WATCHHALER 3

WIDE-SEAL DIAPHRAGM 60 3

WIDE-SEAL DIAPHRAGM 65 3

WIDE-SEAL DIAPHRAGM 70 3

WIDE-SEAL DIAPHRAGM 75 3

WIDE-SEAL DIAPHRAGM 80 3

WIDE-SEAL DIAPHRAGM 85 3

WIDE-SEAL DIAPHRAGM 90 3

WIDE-SEAL DIAPHRAGM 95 3

ZOEY OPTICHAMBER ADVANTAGE 3 MISCELLANEOUS THERAPEUTIC CLASSES

ADENOSINE-5-MONOPHOSPHATE 4

ADENOSINE-5-TRIPHOSPHATE 4

alprostadil 500 mcg/ml solution 1

AMPHADASE 4

argyle sterile water 1

ASTAGRAF XL 4

ATGAM 3

PAGE 293 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AZASAN 3

AZATHIOPRINE POWDER 4

azathioprine 50 mg tab 1

AZATHIOPRINE SODIUM 3

BENLYSTA (120 MG RECON SOLN, 400 MG RECON SOLN) 5 LA Limited Access

QL 4 Auto-Injectors / 28 Days PA BENLYSTA 200 MG/ML SOLN A-INJ 5 LA Limited Access

QL 4 Syringes / 28 Days

PA BENLYSTA 200 MG/ML SOLN PRSYR 5 LA Limited Access

BROMELAIN 4 CELLCEPT (200 MG/ML RECON SUSP, 250 MG CAP, 500 MG TAB) 4

CELLCEPT INTRAVENOUS 4

CHYMOTRYPSIN (ALPHA) 4

QL 240 / 30 Days clovique 5 S

QL 180 / 30 day(s)

CUPRIMINE 6 PA

cyclosporine (25 mg cap, 50 mg/ml solution, 100 mg cap) 1 cyclosporine modified (25 mg cap, 100 mg cap, 100 mg/ml solution) 1

CYCLOSPORINE MODIFIED 50 MG CAP 4

D-PENAMINE 5 S

DELFLEX-SM/4.25% DEXTROSE 4

PAGE 294 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DEPEN TITRATABS 4

EDETATE DISODIUM 150 MG/ML SOLUTION 4

ENVARSUS XR 4

GAMIFANT 5 LA Limited Access

gengraf (25 mg cap, 50 mg cap, 100 mg cap, 100 mg/ml solution) 1

HYALURONIDASE BOVINE 150 UNIT/ML SOLUTION 4

HYLENEX 4

IMURAN 4

KAYEXALATE 4

kionex (15 gm/60ml suspension, powder) 1

LOKELMA 10 GM PACKET 4 QL 30 / 30 Days

LOKELMA 5 GM PACKET 4 QL 90 / 30 Days

morrhuate sodium 1 mycophenolate mofetil (200 mg/ml recon susp, 250 mg cap, 500 mg tab) 1

mycophenolate mofetil hcl 1

mycophenolate sodium 1

MYFORTIC 4

NEORAL (25 MG CAP, 100 MG CAP, 100 MG/ML SOLUTION) 4

LA Limited Access NULOJIX 5 S

QL 180 / 30 day(s)

penicillamine 250 mg cap 6 PA

penicillamine 250 mg tab 1

PHOXILLUM B22K4/0 4

PHOXILLUM BK4/2.5 4

physiolyte 1

PAGE 295 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

physiosol irrigation 1

POLIDOCANOL 4

PRISMASOL B22GK 2/0 4

PROGRAF (0.2 MG PACKET, 1 MG PACKET) 4 PROGRAF (0.5 MG CAP, 1 MG CAP, 5 MG CAP, 5 MG/ML SOLUTION) 3

PROSTIN VR 4 RAPAMUNE (0.5 MG TAB, 1 MG TAB, 1 MG/ML SOLUTION, 2 MG TAB) 4

QL 21 / 28 Days

PA REVLIMID 5 LA Limited Access

SANDIMMUNE (25 MG CAP, 100 MG CAP) 4

SANDIMMUNE 100 MG/ML SOLUTION 3

SARAPIN 4

SIMULECT 3

sirolimus (0.5 mg tab, 1 mg tab, 1 mg/ml solution, 2 mg tab) 1 sodium polystyrene sulfonate (15 gm/60ml suspension, 30 gm/120ml suspension, 50 gm/200ml suspension, powder) 1

PA SOLESTA 6 S

sps 1

sterile water for irrigation 1

SYLVANT 5 LA Limited Access

QL 240 / 30 Days SYPRINE 6 S

tacrolimus (0.5 mg cap, 1 mg cap, 5 mg cap) 1

THALOMID 5 LA Limited Access

PAGE 296 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

THYMOGLOBULIN 3

QL 240 / 30 Days trientine hcl 5 S

TRISODIUM CITRATE/CRRT 4

VARITHENA 4

VELTASSA 3 QL 30 / 30 Days

VITRASE 4

water for irrigation, sterile 1

XIAFLEX 5 LA Limited Access

ZORTRESS (0.25 MG TAB, 0.5 MG TAB, 0.75 MG TAB) 3

ZORTRESS 1 MG TAB 4 PHARMACEUTICAL ADJUVANTS

ACACIA POWDER 4

ALFALFA FLAVOR 4

ALKYL ACRYLATE CROSSPOLYMER 4

ALMOND OIL BITTER FLAVOR 4

AMARANTH 4

ANHYDROUS GEL BASE 4

ANISE EXTRACT 4

ANISE FLAVOR 4

APPLE FLAVOR (LIQUID, POWDER) 4

APRICOT FLAVOR (LIQUID, POWDER) 4

ASTRAGALUS ROOT 4

AUXIPRO PLASTICIZED 4

BACOCALMINE 4

BACON FLAVOR 4

BACTERIOSTATIC WATER(BENZ ALC) 3

BACTERIOSTATIC WATER(PARABENS) 3

PAGE 297 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BANANA CONCENTRATE 4

BANANA CREAM FLAVOR 4

BANANA CREME FLAVOR 4

BANANA FLAVOR 4

BASE A POLYETHYLENE GLYCOL 4

BASE C POLYETHYLENE GLYCOL 300 4

BASE D POLYETHYLENE GLYCOL 4

BASE FOR SALTS 4

BASE FOR WOUNDS 4

BASE GELATIN GUMMY TROCHE 4

BASE X 4

BEEF FLAVOR (LIQUID, POWDER) 4

BEEF TYPE FLAVOR NATURAL 4

BEEF-ADE 4

BEES WAX 4

BEESWAX 4

BEESWAX (YELLOW) 4

BENTONITE 4

BENZYL ALCOHOL 4

BHRT BASE 4

BITTER DRUG 4

BITTER STOP FLAVOR 4

BITTERNESS MASK FLAVOR 4

BITTERNESS REDUCING AGENT 4

BITTERNESS SUPPRESSOR FLAVOR 4

BLACKBERRY FLAVOR 4

BLUEBERRY FLAVOR 4

BRILLIANT BLUE G 4

BUBBLE GUM CONCENTRATE 4

BUBBLE GUM FLAVOR 4

PAGE 298 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BUTTER FLAVOR 4

BUTTER RUM FLAVOR 4

BUTTERSCOTCH FLAVOR 4

CAPSUBLEND-H 4

CAPSUBLEND-P 4

CAPSUBLEND-S 4

CARAMEL FLAVOR 4

CARRAGEENAN 4

CETYL ALCOHOL 4

CHEESE-ADE FLAVOR 4

CHEESECAKE FLAVOR 4

CHEMSIL K-12 4

CHEMSIL K-51 4

CHERRY FLAVOR 4

CHERRY-ADE FLAVOR 4

CHEW-HESIVE 4

CHICKEN BROTH FLAVOR 4

CHICKEN FLAVOR 4

CHICKEN FLAVOR OIL SOLUBLE 4

CHICKEN FLAVOR WATER MISCIBLE 4

CHLOROBUTANOL 4

CHLOROBUTANOL ANHYDROUS 4

CHOCOLATE FLAVOR (LIQUID, POWDER) 4

CHOCOLATE HAZELNUT FLAVOR 4

CINNAMON FLAVOR 4

CLOVAGEL 4

COCOA BUTTER 4

COCONUT FLAVOR 4

COFFEE FLAVOR 4

COLA FLAVOR 4

PAGE 299 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

COLLASIL OSA 4

COLLODION 4

COTTON CANDY FLAVOR 4

CRAN-RASPBERRY FLAVOR 4

CREME DEMENTHE FLAVOR 4

CUSTOM LIPOTHENE 110 4

CUSTOM LIPOTHENE 133 4

CUSTOM POLYGLYCOL TROCHE BASE 4

DERMASHIELD HYDROGEL 4

DILUENT FOR LEFAMULIN 3

DILUENT FOR TREPROSTINIL 4

EFFERVESCENT BASE 4

EMULGADE CM 4

EMULSIFYING WAX 4

EMULSION CONCENTRATE 4

ENGLISH TOFFEE FLAVOR 4

ETHYL ACETATE 4

ETHYL ALCOHOL 100 % SOLUTION 4

EUCALYPTUS FLAVOR 4

EUGENOL FLAVOR 4

EVANS BLUE 4

EXQUISITE HRT 4

F-MELT 4

FAGRON CAPFILL PRO 4

FAGRON DISPERSAPRO 4

FD&C YELLOW #5 4

FD&C YELLOW #6 ALUMINUM LAKE 4

FDC BLUE 1 4

FDC BLUE 2 4

FDC GREEN #3 4

PAGE 300 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FDC RED #3 4

FDC RED 40 4

FDC YELLOW 6 4

FISH FLAVOR 4

FIXED OIL SUSPENSION 4

FIZZMIX BASE 4

FLAVOR CONC-CHLORHEXIDINE 4

FLAVOR SWEET 3

FLAVOR SWEET-SF 3

FOOD COLOR BLACK 4

FOOD COLOR BLUE POWDER 4

FOOD COLOR BROWN 4

FOOD COLOR GREEN (LIQUID, POWDER) 4

FOOD COLOR LIME GREEN 4

FOOD COLOR ORANGE 4

FOOD COLOR PINK 4

FOOD COLOR RED (LIQUID, POWDER) 4

FOOD COLOR VIOLET 4

FOOD COLOR WHITE 4

FOOD COLOR YELLOW (LIQUID, POWDER) 4

FP CEPA 4

FP DERM GEL 4

FP NATURAL LOTION 4

FP SILO 4

FREEDOM ADAPTADERM GEL 4

FREEDOM CEPAPRO 4

FREEDOM LOLLIPOP BASE 4

FREEDOM ODT BASE 4

FREEDOM PEG TROCHE BASE 4

FREEDOM POLOXITOL 4

PAGE 301 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FREEDOM POLYMATRIX 4

FREEDOM SET-GEL 4

FREEDOM SILOMAC ANHYDROUS 4

FREEDOM SILOMAC ULTRA 4

FREEDOM SIMPLECAP 4

FREEDOM TRIBLEND BASE 4

GELATIN 4

GRAPE FLAVOR 4

GRAPEFRUIT FLAVOR 4

GUAVA FLAVOR 4

GUM ARABIC 4

GUM BASE (GELATIN) 4

H20 GEL BASE 4

HAM FLAVOR 4

HONEY FLAVOR 4

HORMONE CREAM BASE 4

HRT BASE 4

HRT BASE (MEN) 4

HRT BOTANICAL 4

HRT CREAM 4

HRT CREAM BASE 4

HRT CREAM BASE WOMEN 4

HRT ESSENTIAL 4

HRT HEAVY 4

HRT NATURAL 4

HRT NATURAL BASE 4

HRT NATURAL CREAM BASE 4

HRT SUPREME CREAM BASE 4

HSA STERILE DILUENT 4

ISOMALT LOLLIPOP BASE 4

PAGE 302 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

IV STABILIZER FOR LUMOXITI 3

KAHLUA FLAVOR 4

KARAYA GUM GUM 4

KRIS-ESTER 236 4

KRISGEL 100 3

LACTOSE 4

LACTOSE ANHYDROUS 4

LACTOSE MONOHYDRATE 4

lanolin ointment 1

LANOLIN ALCOHOL 4

LECITHIN-ISOPROPYL PALMITATE 4

LEMON EXTRACT 4

LEMON FLAVOR 4

LEMONADE FLAVOR 4

LICORICE FLAVOR 4

LIDOCAINE-PRILOCAINE (BULK) 2-2 % CREAM 4

LIME FLAVOR 4

LIPMAX 4

LIPOGEL CR BASE 4

LIPOPEN ANHYDROUS LOTION 4

LIQUIGEL COMPLEX 4

LISSAMINE GREEN B 4

LIVER FLAVOR (LIQUID, POWDER) 4

LOXORAL BASE 4

LUBRAJEL NP 4

MAGNESIUM STEARATE 4

MANGO FLAVOR (LIQUID, POWDER) 4

MANGO FLAVOR SWEETENED 4

MAPLE FLAVOR 4

MARSHMALLOW FLAVOR 4

PAGE 303 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MEDI-RDT 4

MEDI-RDT BASE 4

MEDIBASE C 4

METER BUFFER 4

METHYLCELLULOSE (1 % GEL, POWDER) 4

METHYLPARABEN 4

METHYLPARABEN SODIUM 4

MINT CHOCOLATE CHIP FLAVOR 4

MOLASSES FLAVOR 4

MUCOLOX 4

MYRJ 53 4

OINTMENT BASE (EMULSIFYING) 4

OLEABASE PLASTICIZED 4

OLEIC ACID 4

ORA-SWEET 3

ORA-SWEET SF 3

ORANGE CREAM FLAVOR 4

ORANGE FLAVOR (LIQUID, POWDER) 4

ORANGE OIL FLAVOR 4

PARAFFIN 4

PASSION FRUIT FLAVOR 4

PASSION FRUIT FLAVOR SWEETENED 4

PCCA EMULSIFIX-205 BASE 4

PCCA FIXED OIL BASE 4

PCCA GELATIN BASE 4

PCCA LECITHIN ISOPROPYL PALM 4

PCCA LIPODERM HMW 4

PCCA LOXASPERSE BASE 4

PCCA OCCLUSADERM 4

PCCA PLASTICIZED BASE 4

PAGE 304 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PCCA PLURONIC F127 BASE 4

PCCA POLOXAMER 407 4

PCCA POLYGLYCOL TROCHE 4

PCCA PRACAMAC BASE 4

PCCA RAPID DISSOLVE TABLET 4

PCCA SORBITOL LOLLIPOP BASE 4

PCCA SPIRA-WASH BASE 4

PCCA SWEET-SF 3

PCCA SWEETNESS ENHANCER 4

PCCA SYRUP VEHICLE 3

PCCA XYLIFOS BASE 4

PEACH FLAVOR 4

PEANUT BUTTER FLAVOR 4

PEG 300 4

PEPPERMINT FLAVOR 4

PH BUFFER 4

PINA COLADA FLAVOR 4

PINEAPPLE FLAVOR 4

PLASTIBASE 4

PLASTICIZED BASE 4

PLURONIC 4

PLURONIC F127 (20 % GEL, 30 % GEL, POWDER) 4

PLURONIC L64 4

POLOXAMER 188 4

POLOXAMER 407 4

POLYETHYLENE GLYCOL 4

POLYETHYLENE GLYCOL 1000 4

POLYETHYLENE GLYCOL 1450 4

POLYETHYLENE GLYCOL 1500 4

POLYETHYLENE GLYCOL 300 4

PAGE 305 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS POLYETHYLENE GLYCOL 3350 (3350 GRANULES, 3350 POWDER) 4

POLYETHYLENE GLYCOL 400 4

POLYETHYLENE GLYCOL 4500 4

POLYETHYLENE GLYCOL 8000 OINTMENT 3 POLYETHYLENE GLYCOL 8000 (8000 GRANULES, 8000 POWDER) 4

POLYMAC PROGEL 4

POLYOXYL 40 STEARATE 4

POLYPEG 4

POTASSIUM SORBATE 4

PRALINES AND CREAM FLAVOR 4

PROPYLPARABEN 4

PROPYLPARABEN SODIUM 4

PUMPKIN FLAVOR 4

QUINIZARIN GREEN SS 4

RASPBERRY CONCENTRATE 4

RASPBERRY FLAVOR (LIQUID, POWDER) 4

RDT-PLUS 4

REGENT ALCOHOL 4

RENEWCREAM HRT 4

ROOT BEER FLAVOR 4

saline bacteriostatic 1

SEPINEO P 600 4

SHEA BUTTER 4

SHEA BUTTER ORGANIC 4

SHRIMP FLAVOR 4

SIMPLE SYRUP 3

SIMPLGEL 30 4

SODIUM BENZOATE 4

sodium chloride bacteriostatic 1

PAGE 306 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SODIUM LAURYL SULFATE 4

SODIUM THIOSULFATE (CRYSTALS, POWDER) 4

SOLU-K 4

SOLVATECH SWEET SF 3

SORBIC ACID 4

SORBITOL (70 % SOLUTION, SOLUTION) 4

SORBITOL CANDY BASE 4

SPEARMINT FLAVOR 4

SPG SUPPOSI-BASE 4

STEARIC ACID 4

STEARYL ALCOHOL 4

STERILE DILUENT FOR REMODULIN 4

sterile diluent/epoprostenol 1

sterile water for injection 1

STERILE WATER FOR INJECTION SOLUTION 3

STEVIA GLYCERITE EXTRACT 4

STRAWBERRY FLAVOR 4

SULPHAN BLUE 4

SUPER SYNERSWEET FLAVOR 4

SUPPOSITORY BLEND 4

SWEET CORN FLAVOR 4

SWEETENING ENHANCER 4

SYNAPSIN 4

SYRPALTA (85 % SYRUP, SYRUP) 3

SYRPALTA (RED) 3

SYRUP VEHICLE 3

SYRUP VEHICLE SF 3

TANGERINE FLAVOR 4

TANGERINE FLAVOR SWEETENED 4

TEABERRY FLAVOR 4

PAGE 307 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TOMMY GEL 4

TRAGACANTH 4

TROCHE BASE 4

TROLAMINE 4

TROPICAL PUNCH FLAVOR 4

TRYPAN BLUE 4

TUNA FLAVOR 4

TUTTI FRUTTI FLAVOR 4

TUTTI-FRUTTI FLAVOR 4

UCARE POLYMER JR-400 4

VANILLA BUTTERNUT FLAVOR 4

VANILLA FLAVOR 4

VANILLIN FLAVOR 4

vaseline 2

VERSABASE (CREAM, FOAM, GEL, LOTION, SHAMPOO) 4

VERSAFREE 3

VERSAPLUS 3

VERSAPRO (GEL, LOTION) 4

WATERMELON FLAVOR 4

WAX, WHITE 4

WHITE BEES WAX 4

white petrolatum gel 2

WILD CHERRY FLAVOR 4

WILEY BASIC ELEMENTS BHRT BASE 4

WITEPSOL 4

WOUND WASH BASE 4

XANTHAN GUM 4

ZOSIL 4

PAGE 308 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NEUROMUSCULAR AGENTS

ANTICONVULSANTS

APTIOM (200 MG TAB, 400 MG TAB) 4 QL 30 / 30 Days

APTIOM (600 MG TAB, 800 MG TAB) 4 QL 60 / 30 Days

BANZEL (200 MG TAB, 400 MG TAB) 3 QL 240 / 30 Days

BANZEL 40 MG/ML SUSPENSION 3 QL 3220 Milliliters / 30 Days BRIVIACT (25 MG TAB, 50 MG TAB, 75 MG TAB, 100 MG QL 60 / 30 Days TAB) 4

BRIVIACT 10 MG TAB 4 QL 120 / 30 Days

BRIVIACT 10 MG/ML SOLUTION 4 QL 600 Milliliters / 30 Days

BRIVIACT 50 MG/5ML SOLUTION 4

CARBAMAZEPINE POWDER 4 carbamazepine (100 mg chew tab, 100 mg/5ml suspension, 200 mg tab) 1

carbamazepine er 1

CARBATROL 4

CELONTIN 3

clobazam (2.5 mg/ml suspension, 10 mg tab, 20 mg tab) 1 clonazepam (0.125 mg tab disp, 0.25 mg tab disp, 0.5 mg tab, 0.5 mg tab disp, 1 mg tab, 1 mg tab disp, 2 mg tab, 2 mg tab 1 disp)

DEPACON 4

DEPAKENE (250 MG CAP, 250 MG/5ML SOLUTION) 4

DEPAKOTE 4

DEPAKOTE ER 4

DEPAKOTE SPRINKLES 4

QL 180 / 30 day(s)

DIACOMIT (250 MG CAP, 250 MG PACKET, 500 MG CAP, PA 5 500 MG PACKET) LA Limited Access

PAGE 309 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC 3

DIAZEPAM (2.5 MG GEL, 10 MG GEL, 20 MG GEL) 3

DILANTIN (100 MG CAP, 125 MG/5ML SUSPENSION) 4

DILANTIN 30 MG CAP 3

DILANTIN INFATABS 4 divalproex sodium (125 mg cap dr, 125 mg tab dr, 250 mg tab dr, 500 mg tab dr) 1

divalproex sodium er 1

EPIDIOLEX 6 LA Limited Access

epitol 1

ethosuximide (250 mg cap, 250 mg/5ml solution) 1

felbamate (400 mg tab, 600 mg tab, 600 mg/5ml suspension) 1 FELBATOL (400 MG TAB, 600 MG TAB, 600 MG/5ML SUSPENSION) 4

fosphenytoin sodium 1 FYCOMPA (2 MG TAB, 4 MG TAB, 6 MG TAB, 8 MG TAB, 10 QL 30 / 30 Days MG TAB, 12 MG TAB) 3

FYCOMPA 0.5 MG/ML SUSPENSION 3 QL 1020 Milliliters / 30 Days gabapentin (100 mg cap, 250 mg/5ml solution, 300 mg cap, 300 mg/6ml solution, 400 mg cap, 600 mg tab, 800 mg tab) 1

GABITRIL 4 KEPPRA (100 MG/ML SOLUTION, 250 MG TAB, 500 MG TAB, 500 MG/5ML SOLUTION, 750 MG TAB, 1000 MG TAB) 4

KEPPRA XR 4

KLONOPIN 4

LAMICTAL 4 LAMICTAL ODT (ODT 25 & 50 & 100 MG KIT, ODT 25 (21)-50 QL 1 kit / 180 days (7) MG KIT, ODT 50 (42)-100(14) MG KIT) 4 LAMICTAL ODT (ODT 25 MG TAB DISP, ODT 50 MG TAB QL 60 / 30 Days DISP, ODT 100 MG TAB DISP, ODT 200 MG TAB DISP) 4

PAGE 310 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LAMICTAL STARTER 25 (35) MG KIT 4 QL 35 / 180 Days

LAMICTAL STARTER 25 (42)-100 (7) MG KIT 4 QL 49 / 180 Days

LAMICTAL STARTER 25 (84)-100(14) MG KIT 4 QL 98 / 180 Days

LAMICTAL XR (25 50 100 MG KIT, 50 100 200 MG KIT) 3 QL 35 / 180 Days

LAMICTAL XR (25 MG TAB ER 24H, 50 MG TAB ER 24H, 100 MG TAB ER 24H, 200 MG TAB ER 24H, 250 MG TAB ER 24H, 4 300 MG TAB ER 24H)

LAMICTAL XR 25 (21)-50 (7) MG KIT 3 QL 28 / 180 Days

lamotrigine (25 mg tab disp, 50 mg tab disp, 100 mg tab disp, QL 60 / 30 Days 200 mg tab disp) 1 lamotrigine (5 mg chew tab, 25 & 50 & 100 mg kit, 25 (21)-50 (7) mg kit, 25 mg chew tab, 25 mg tab, 50 (42)-100(14) mg kit, 1 100 mg tab, 150 mg tab, 200 mg tab)

lamotrigine er 1

lamotrigine starter kit-blue 1 QL 35 / 180 Days

lamotrigine starter kit-green 1 QL 98 / 180 Days

lamotrigine starter kit-orange 1 QL 49 / 180 Days

levetiracetam (100 mg/ml solution, 250 mg tab, 500 mg tab, 500 mg/5ml solution, 750 mg tab, 1000 mg tab) 1

levetiracetam er 1

levetiracetam in nacl 1 LYRICA (25 MG CAP, 50 MG CAP, 75 MG CAP, 100 MG CAP, QL 90 / 30 day(s) 150 MG CAP, 200 MG CAP, 225 MG CAP) 4

LYRICA 20 MG/ML SOLUTION 4 QL 600 / 30 day(s)

LYRICA 300 MG CAP 4 QL 60 / 30 day(s)

MYSOLINE 4

QL 5 / 30 day(s) NAYZILAM 4 PA

NEURONTIN (100 MG CAP, 250 MG/5ML SOLUTION, 300 MG CAP, 400 MG CAP, 600 MG TAB, 800 MG TAB) 4

ONFI (2.5 MG/ML SUSPENSION, 10 MG TAB, 20 MG TAB) 4 oxcarbazepine (150 mg tab, 300 mg tab, 300 mg/5ml suspension, 600 mg tab) 1

PAGE 311 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

OXTELLAR XR 4

PEGANONE 3

PHENYTEK 4

phenytoin (50 mg chew tab, 125 mg/5ml suspension) 1

phenytoin infatabs 1

PHENYTOIN SODIUM POWDER 4

phenytoin sodium 50 mg/ml solution 1

phenytoin sodium extended 1

POTIGA 3 pregabalin (25 mg cap, 50 mg cap, 75 mg cap, 100 mg cap, QL 90 / 30 day(s) 150 mg cap, 200 mg cap, 225 mg cap) 1

QL 600 / 30 day(s) pregabalin 20 mg/ml solution 1 ST

pregabalin 300 mg cap 1 QL 60 / 30 day(s)

primidone (50 mg tab, 250 mg tab) 1

QUDEXY XR 3 QL 60 / 30 Days

roweepra 1

roweepra xr 1

QL 180 / 30 Days

PA SABRIL 6 LA Limited Access

SPRITAM 4 QL 60 / 30 Days

STAVZOR 4

subvenite 1

subvenite starter kit-blue 1 QL 35 / 180 Days

subvenite starter kit-green 1 QL 98 / 180 Days

subvenite starter kit-orange 1 QL 49 / 180 Days

SYMPAZAN 4

TEGRETOL (100 MG/5ML SUSPENSION, 200 MG TAB) 4

PAGE 312 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TEGRETOL-XR 4

tiagabine hcl 1

TOPAMAX 4

TOPAMAX SPRINKLE 4

topiragen 1 topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) 1

TOPIRAMATE ER 3 QL 60 / 30 Days

TRILEPTAL (150 MG TAB, 300 MG TAB, 300 MG/5ML SUSPENSION, 600 MG TAB) 4 TROKENDI XR (25 MG CAP ER 24H, 50 MG CAP ER 24H, QL 60 / 30 Days 200 MG CAP ER 24H) 4

TROKENDI XR 100 MG CAP ER 24H 4 QL 90 / 30 Days

valproate sodium (100 mg/ml solution, 250 mg/5ml solution, 500 mg/5ml solution) 1

valproic acid (250 mg cap, 250 mg/5ml solution) 1

QL 180 / 30 Days

PA vigabatrin 500 mg packet 5 LA Limited Access

vigabatrin 500 mg tab 5 LA Limited Access

QL 180 / 30 Days

PA vigadrone 5 LA Limited Access

VIMPAT (10 MG/ML SOLUTION, 200 MG/20ML SOLUTION) 3 VIMPAT (50 MG TAB, 100 MG TAB, 150 MG TAB, 200 MG QL 60 / 30 Days TAB) 3

ZARONTIN (250 MG CAP, 250 MG/5ML SOLUTION) 4

ZONEGRAN 4

PAGE 313 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

zonisamide (25 mg cap, 50 mg cap, 100 mg cap) 1 ANTIMYASTHENIC/CHOLINERGIC AGENTS

ENLON 3

ENLON-PLUS 4

QL 240 / 30 day(s)

PA FIRDAPSE 5 LA Limited Access

GUANIDINE HCL 3

MESTINON (60 MG TAB, 180 MG TAB ER) 4

MESTINON 60 MG/5ML SOLUTION 3 neostigmine methylsulfate (0.5 mg/ml solution, 1 mg/ml solution, 5 mg/10ml solution, 10 mg/10ml solution) 1 NEOSTIGMINE METHYLSULFATE (1 MG/ML SOLUTION, 5 MG/5ML SOLN PRSYR) 3 NEOSTIGMINE METHYLSULFATE (2 MG/2ML SOLN PRSYR, 3 MG/3ML SOLN PRSYR, 3 MG/3ML SOLUTION, 4 MG/4ML 4 SOLN PRSYR, 5 MG/5ML SOLUTION)

pyridostigmine bromide (60 mg tab, 60 mg/5ml solution) 1

PYRIDOSTIGMINE BROMIDE 30 MG TAB 4

pyridostigmine bromide er 1

QL 300 / 30 day(s)

RUZURGI 6 AL1 6 to 17 yrs old

LA Limited Access

ANTIPARKINSON AND RELATED THERAPY AGENTS

amantadine hcl (50 mg/5ml syrup, 100 mg cap, 100 mg tab) 1

QL 2 Boxes / 28 Days

PA APOKYN 5 LA Limited Access

PAGE 314 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AZILECT 4 QL 30 / 30 Days

benztropine mesylate (0.5 mg tab, 1 mg tab, 1 mg/ml solution, 2 mg tab) 1

BROMOCRIPTINE MESYLATE POWDER 4

bromocriptine mesylate (2.5 mg tab, 5 mg cap) 1

carbidopa 25 mg tab 1

carbidopa-levodopa 1

carbidopa-levodopa er 1 CARBIDOPA-LEVODOPA-ENTACAPONE (12.5-50-200 MG TAB, 18.75-75-200 MG TAB, 25-100-200 MG TAB, 31.25-125- 3 QL 240 / 30 Days 200 MG TAB, 37.5-150-200 MG TAB) CARBIDOPA-LEVODOPA-ENTACAPONE 50-200-200 MG QL 180 / 30 Days TAB 3

COGENTIN 4

COMTAN 4

LA Limited Access DUOPA 6 S

ELDEPRYL 4

entacapone 1

QL 60 / 30 Days

GOCOVRI 4 PA

LA Limited Access

QL 1 Inhaler / 30 Days

PA INBRIJA 6 LA Limited Access

LEVODOPA 4

LODOSYN 4

MIRAPEX 4

MIRAPEX ER 4 QL 30 / 30 Days

NEUPRO 4 QL 1 Box / 30 Days

PAGE 315 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 / 30 day(s)

NOURIANZ 4 AL1 At least 18 yrs old

LA Limited Access

QL 30 / 30 Days OSMOLEX ER 4 PA

PARLODEL 4

pramipexole dihydrochloride 1

pramipexole dihydrochloride er 1 QL 30 / 30 Days

rasagiline mesylate (0.5 mg tab, 1 mg tab) 1 QL 30 / 30 Days

REQUIP 4 REQUIP XL (2 MG TAB ER 24H, 4 MG TAB ER 24H, 6 MG QL 30 / 30 Days TAB ER 24H, 8 MG TAB ER 24H) 4

REQUIP XL 12 MG TAB ER 24H 4 QL 60 / 30 Days

ropinirole hcl 1 ropinirole hcl er (er 2 mg tab er 24h, er 4 mg tab er 24h, er 6 mg QL 30 / 30 Days tab er 24h, er 8 mg tab er 24h) 1

ropinirole hcl er 12 mg tab er 24h 1 QL 60 / 30 Days

RYTARY 23.75-95 MG CAP ER 4 QL 270 / 30 Days

RYTARY 36.25-145 MG CAP ER 4 QL 180 / 30 Days

RYTARY 48.75-195 MG CAP ER 4 QL 360 / 30 day(s)

RYTARY 61.25-245 MG CAP ER 4 QL 300 / 30 day(s)

SELEGILINE HCL POWDER 4

selegiline hcl (5 mg cap, 5 mg tab) 1

SELEGILINE HCL 5 MG TAB 3

SINEMET 4

SINEMET CR 4

STALEVO 100 3 QL 240 / 30 Days

STALEVO 125 3 QL 240 / 30 Days

PAGE 316 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

STALEVO 150 3 QL 240 / 30 Days

STALEVO 200 3 QL 180 / 30 Days

STALEVO 50 3 QL 240 / 30 Days

STALEVO 75 3 QL 240 / 30 Days

TASMAR 4

tolcapone 1

trihexyphenidyl hcl (0.4 mg/ml solution, 2 mg tab, 5 mg tab) 1

QL 30 / 30 Days XADAGO 4 PA

ZELAPAR 4 MUSCULOSKELETAL THERAPY AGENTS

ACTIVE-CYCLOBENZAPRINE 4

BACLOFEN POWDER 4

baclofen (10 mg tab, 20 mg tab) 1 baclofen (10 mg/20ml solution, 40 mg/20ml solution, 20000 S mcg/20ml solution) 5

BACLOFEN 5 MG TAB 3

CARISOPRODOL POWDER 4

carisoprodol (250 mg tab, 350 mg tab) 1

carisoprodol-aspirin 1

carisoprodol-aspirin-codeine 1 chlorzoxazone (250 mg tab, 375 mg tab, 500 mg tab, 750 mg tab) 2

CYCLOBENZAPRINE COMFORT PAC 4

cyclobenzaprine hcl (5 mg tab, 10 mg tab) 1

CYCLOBENZAPRINEPAX 4

CYCLOPHENE RAPIDPAQ 4

DANTRIUM (25 MG CAP, 50 MG CAP) 4 dantrolene sodium (20 mg recon soln, 25 mg cap, 50 mg cap, 100 mg cap) 1

PA DUROLANE 6 S

PAGE 317 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ENOVARX-CYCLOBENZAPRINE HCL 4

QL 6 Syringes / 180 Days

EUFLEXXA 5 PA

FIRST-BACLOFEN 4

FLEXEPAX 4 GABLOFEN (10000 MCG/20ML SOLUTION, 20000 S MCG/20ML SOLUTION, 40000 MCG/20ML SOLUTION) 6 GABLOFEN (50 MCG/ML SOLN PRSYR, 10000 MCG/20ML SOLN PRSYR, 20000 MCG/20ML SOLN PRSYR, 40000 5 S MCG/20ML SOLN PRSYR)

QL 6 Syringes / 180 Days

PA GELSYN-3 6 LA Limited Access

LIORESAL (0.05 MG/ML SOLUTION, 10 MG/5ML SOLUTION) 5 S

LIORESAL (10 MG/20ML SOLUTION, 40 MG/20ML S SOLUTION) 6

lorzone 2

metaxall 1

METAXALONE 400 MG TAB 3

metaxalone 800 mg tab 1 methocarbamol (500 mg tab, 750 mg tab, 1000 mg/10ml solution) 1

QL 2 Syringes / 180 Days

MONOVISC 5 PA

NORGESIC FORTE 3

ORPHENADRINE CITRATE POWDER 4

orphenadrine citrate 30 mg/ml solution 1

orphenadrine citrate er 1

ORPHENADRINE-ASPIRIN-CAFFEINE 3

PAGE 318 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ORPHENGESIC FORTE 3

QL 8 Syringes / 180 Days

ORTHOVISC 5 PA

OZOBAX 3 QL 2400 / 30 day(s)

PARAFON FORTE DSC 4

revonto 1

ROBAXIN (500 MG TAB, 1000 MG/10ML SOLUTION) 4

ROBAXIN-750 4

SKELAXIN 4

SOD HYALURONATE-LIDOCAINE 4

SOMA 4

TABRADOL RAPIDPAQ 4

tizanidine hcl (2 mg cap, 2 mg tab, 4 mg cap, 6 mg cap) 1 QL 120 / 30 Days

tizanidine hcl 4 mg tab 1 QL 180 / 30 Days

ZANAFLEX (2 MG CAP, 4 MG CAP, 6 MG CAP) 4 QL 120 / 30 Days

ZANAFLEX 4 MG TAB 4 QL 180 / 30 Days

atracurium besylate 1

PA BOTOX 5 S

cisatracurium besylate (10 mg/ml solution, 20 mg/10ml solution, 200 mg/20ml solution) 1

cisatracurium besylate (pf) 1

CISATRACURIUM BESYLATE 2 MG/ML SOLUTION 4

DYSPORT 6 LA Limited Access

EXONDYS 51 6 LA Limited Access

PAGE 319 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA MYOBLOC 5 S

pancuronium bromide (1 mg/ml solution, 2 mg/ml solution) 1

QUELICIN 4

RADICAVA 5 LA Limited Access

RILUTEK 4

riluzole 1

rocuronium bromide (50 mg/5ml solution, 100 mg/10ml solution) 1

ROCURONIUM BROMIDE 75 MG/7.5ML SOLN PRSYR 4

SPINRAZA 5 LA Limited Access

SUCCINYLCHOLINE CHLORIDE (100 MG/5ML SOLN PRSYR, 140 MG/7ML SOLN PRSYR, 200 MG/10ML SOLN 4 PRSYR)

succinylcholine chloride 20 mg/ml solution 1

QL 600 Milliliters / 30 Days TIGLUTIK 4 LA Limited Access

vecuronium bromide (10 mg recon soln, 20 mg recon soln) 1

VYONDYS 53 6 LA Limited Access

XEOMIN 6 LA Limited Access

ZEMURON 4

PAGE 320 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NUTRITIONAL PRODUCTS

DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS

2-fucosyllact-lacto-n-neotetra 1

ASPARTAME 4

ASPARTAME (NUTRASWEET) 4

ASTAMED MYO 4

AVAILNEX 4

CEREFOLIN 3

CEREFOLIN NAC 4

DEPLIN 15 4

DEPLIN 7.5 4

DERMANIC 4

ELFOLATE 3

ELFOLATE PLUS 4

FOLBIC 3

FOLBIC RF 4

FOLTANX 3

FOLTANX RF 4

FOLTX 4

GLYGEST 4

L-METHYL-MC 3

L-METHYL-MC NAC 3

L-METHYLFOLATE 3

L-METHYLFOLATE CA ME-CBL NAC 4

L-METHYLFOLATE CALCIUM (7.5 MG TAB, 15 MG TAB) 3

L-METHYLFOLATE FORMULA 15 4

L-METHYLFOLATE FORMULA 7.5 4

L-METHYLFOLATE FORTE 4

L-METHYLFOLATE-ALGAE 4

L-METHYLFOLATE-ALGAE-B12-B6 4

PAGE 321 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

L-METHYLFOLATE-B6-B12 1.13-25-2 MG TAB 4

L-METHYLFOLATE-B6-B12 3-35-2 MG TAB 3

LIMBREL 4

LIMBREL250 4

LIMBREL500 4

LUKAID GLA 4

METAFOLBIC 3

METAFOLBIC PLUS 3

METAFOLBIC PLUS RF 4

METANX 4

METHYLFOL-ALGAE-B12-ACETYLCYST 4

niva-fol 1

OLLIZAC 4

PODIAPN 4

PURALOR CI 4

SACCHARIN 4

VAYACOG 4

VAYARIN 4

VAYAROL 4

virt-vite forte 1

VITA-RESPA 4

VP-PRECIP 1000-500-40 MG CAP 1

WESTAB MAX 3

XAQUIL XR 4 MINERALS & ELECTROLYTES

ADDAMEL N 3

AMMONIUM MOLYBDATE 3

bd posiflush 1

CALCIFOL 4

CALCIUM CARBONATE 4

PAGE 322 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CALCIUM CARBONATE LIGHT 4

calcium chloride 1

CALCIUM CHLORIDE ANHYDROUS GRANULES 4

CALCIUM CHLORIDE DIHYDRATE 4

CALCIUM GLUCONATE POWDER 4

CALCIUM GLUCONATE 10 % SOLUTION 3

calcium gluconate 10 % solution 1

CALCIUM GLUCONATE ANHYDROUS 4

CALCIUM GLUCONATE MONOHYDRATE 4 CALCIUM GLUCONATE-NACL (1-0.675 GM/50ML-% SOLUTION, 2-0.675 GM/100ML-% SOLUTION) 4

CALCIUM LACTATE PENTAHYDRATE 4

CALCIUM PHOSPHATE DIBASIC 4

CALCIUM PHOSPHATE TRIBASIC 4

chloromag 1

COPPER SULFATE 3

CUPRIC SULFATE 4

dextrose in lactated ringers 1 DEXTROSE-NACL (10-0.2 % SOLUTION, 10-0.45 % SOLUTION) 3 dextrose-nacl (2.5-0.45 % solution, 5-0.2 % solution, 5-0.33 % solution, 5-0.45 % solution, 5-0.9 % solution) 1

EFFER-K (10 EFFER TAB, 20 EFFER TAB) 4

effer-k 25 meq effer tab 1

effervescent pot chloride 1

FLORIVA 0.25-400 MG-UNIT/ML LIQUID 4 FLUOR-A-DAY (0.25 MG CHEW TAB, 0.5 MG CHEW TAB, 1 MG CHEW TAB) 3

fluor-a-day 0.275 (0.125 f) mg/drop solution 1

FLUORABON 4 fluoritab (0.275 (0.125 mg/drop solution, 0.55 (0.25 mg chew tab, 1.1 (0.5 mg chew tab, 2.2 (1 mg chew tab) 1

PAGE 323 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

flura-drops 0.275 (0.125 f) mg/drop solution 1

FLURA-DROPS 0.55 (0.25 F) MG/DROP SOLUTION 4

GLYCOPHOS 3

HYPERLYTE-CR 3

IODINE STRONG 3

IODOPEN 3

IONOSOL-B IN D5W 3

IONOSOL-MB IN D5W 3

k-effervescent 1

K-PHOS 3

K-PHOS-NEUTRAL 4

k-prime 1

k-sol 1

K-TAB (8 TAB ER, 20 TAB ER) 3

K-TAB 10 MEQ TAB ER 4

k-vescent 1

karidium 1 KCL (IN NACL 0.9%) (10 MEQ/500ML SOLUTION, 40 MEQ/500ML SOLUTION) 4 kcl in dextrose-nacl (10-5-0.45 meq/l-%-% solution, 20-5-0.2 meq/l-%-% solution, 20-5-0.33 meq/l-%-% solution, 20-5-0.45 meq/l-%-% solution, 20-5-0.9 meq/l-%-% solution, 30-5-0.45 1 meq/l-%-% solution, 40-5-0.45 meq/l-%-% solution)

KCL IN DEXTROSE-NACL 20-5-0.33 MEQ/L-%-% SOLUTION 3

KCL IN LACTATED RINGERS 4

KCL-LIDOCAINE IN NACL 4

kendall sodium chloride flush 1

klor-con (8 tab er, 20 packet) 1

klor-con 10 1

klor-con m10 1

KLOR-CON M15 3

klor-con m20 1

PAGE 324 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

klor-con sprinkle 1

klor-con/ef 1

lactated ringers 1

LIQUIVIDA HYDRATION 3

LOZI-FLUR 4

ludent 1

LURIDE 4

MAGNEBIND 400 4

MAGNESIUM CARBONATE 4

MAGNESIUM CARBONATE HEAVY 4 MAGNESIUM CHLORIDE (200 MG/ML SOLUTION, CRYSTALS, POWDER) 4

magnesium chloride 200 mg/ml solution 1 magnesium sulfate (2 gm/50ml solution, 4 gm/100ml solution, 4 gm/50ml solution, 20 gm/500ml solution, 40 gm/1000ml 1 solution, 50 % solution) MAGNESIUM SULFATE (50 % SOLUTION, 1000 MG/1.6ML SOLUTION, 2000 MG/3.2ML SOLUTION, 3000 MG/4.8ML 4 SOLUTION, 4000 MG/6.4ML SOLUTION) MAGNESIUM SULFATE IN D5W (10-5 GM/500ML-% SOLUTION, 25-5 GM/250ML-% SOLUTION) 4

magnesium sulfate in d5w 1-5 gm/100ml-% solution 1

MANGANESE SULFATE 0.1 MG/ML SOLUTION 3

MICRO-K 4

monoject flush syringe 1

monoject sodium chloride flush 1

multitrace-4 concentrate 1

multitrace-5 concentrate 1

nafrinse 1

nafrinse drops 1

NEUT 3

normal saline flush 1

nutrilyte 1

PAGE 325 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

nutrilyte ii 1

PEDITRACE 3

phospha 250 neutral 1

phospho-trin 250 neutral 1

phosphorous 1

PLASMA-LYTE-56 IN D5W 3

POT BICARB-POT CHLORIDE 3

potassium acetate (2 meq/ml solution, 4 meq/ml solution) 1

POTASSIUM ACETATE 2 MEQ/ML SOLUTION 4

POTASSIUM ACETATE-NACL 4

POTASSIUM BICARBONATE (GRANULES, POWDER) 4

potassium bicarbonate 25 meq effer tab 1 POTASSIUM CHLORIDE (0.4 MEQ/ML SOLUTION, 10 MEQ/100ML SOLUTION, 10 MEQ/50ML SOLUTION, 20 MEQ/100ML SOLUTION, 20 MEQ/50ML SOLUTION, 40 3 MEQ/100ML SOLUTION) potassium chloride (2 meq/ml solution, 10 meq/100ml solution, 20 meq packet, 20 meq/100ml solution, 20 meq/15ml (10%) 1 solution, 40 meq/15ml (20%) solution) POTASSIUM CHLORIDE (2 MEQ/ML SOLUTION, GRANULES, POWDER) 4

potassium chloride crys er 1 potassium chloride er (er 8 cap er, er 8 tab er, er 10 cap er, er 10 tab er) 1

POTASSIUM CHLORIDE ER (ER 8 TAB ER, ER 20 TAB ER) 3 POTASSIUM CHLORIDE IN D5W (10 MEQ/500ML SOLUTION, 40 MEQ/250ML SOLUTION, 40 MEQ/500ML 3 SOLUTION)

POTASSIUM CHLORIDE IN D5W 20 MEQ/250ML SOLUTION 4

potassium chloride in dextrose 20-5 meq/l-% solution 1 potassium chloride in nacl (20-0.45 meq/l-% solution, 20-0.9 meq/l-% solution, 40-0.9 meq/l-% solution) 1

potassium chloride proamp 1

potassium phosphates 45 mmole/15ml solution 1

PAGE 326 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

POTASSIUM PHOSPHATES-DEXTROSE 4 POTASSIUM PHOSPHATES-NACL (5 MMOL/250ML SOLUTION, 7 MMOL/100ML SOLUTION, 7.5 MMOL/100ML SOLUTION, 9 MMOL/100ML SOLUTION, 20 MMOL/100ML 3 SOLUTION, 22 MMOL/500ML SOLUTION, 40 MMOL/250ML SOLUTION)

ringers 1

saline flush 1

saline flush zr 1

SELENIOUS ACID 3

SELENIUM 3

sodium acetate (2 meq/ml solution, 4 meq/ml solution) 1

SODIUM ACETATE (CRYSTALS, GRANULES, POWDER) 4 sodium bicarbonate (4.2 % solution, 7.5 % solution, 8.4 % solution) 1

SODIUM BICARBONATE 8.4 % SOLUTION 4 sodium chloride (0.45 % solution, 2.5 meq/ml solution, 3 % solution, 4 meq/ml solution, 5 % solution) 1 SODIUM CHLORIDE (23.4 % SOLUTION, GRANULES, POWDER) 4

sodium chloride (pf) 1

sodium chloride flush 1 sodium fluoride (0.55 (0.25 mg chew tab, 1.1 (0.5 mg chew tab, 1.1 (0.5 mg/ml solution, 2.2 (1 mg chew tab) 1

SODIUM FLUORIDE (1.1 (0.5 MG TAB, 2.2 (1 MG TAB) 3

SODIUM LACTATE 5 MEQ/ML SOLUTION 3 SODIUM PHOSPHATE-NACL (9 MMOL/50ML SOLUTION, 10 MMOL/100ML SOLUTION) 4 sodium phosphates (45 mmole/15ml solution, 150 mmole/50ml solution) 1

SODIUM PHOSPHATES 15 MMOLE/5ML SOLUTION 4 SODIUM PHOSPHATES-DEXTROSE 15 MMOL/100ML SOLUTION 4

swabflush saline flush 1

THAM 4

PAGE 327 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

virt-phos 250 neutral 1

ZINC GLUCONATE 10 MG/10ML SOLUTION 4

ZINC SULFATE (1 MG/ML SOLUTION, 5 MG/ML SOLUTION) 3

ZINC SULFATE (GRANULES, POWDER) 4

ZINC SULFATE HEPTAHYDRATE 4

ZINC SULFATE MONOHYDRATE 4 MULTIVITAMINS

ACTIVE OB 4

activite 1

adc/f (0.5mg/ml) 1

ADVANCED AM/PM 3

ATABEX EC 4

ATABEX OB 3

AZESCO 4

b complex vitamins 1

B-COMPLEX 4

b-plex 1

b-plex plus 1

BAL-CARE DHA 3

biocel 1

BP FOLINATAL PLUS B 3

BP MULTINATAL PLUS 30-1 MG TAB 4

C-NATE DHA 3

CALCIUM PNV 3

CITRANATAL 90 DHA 3

CITRANATAL ASSURE 3

CITRANATAL B-CALM 4

CITRANATAL BLOOM 4

CITRANATAL BLOOM DHA 3

CITRANATAL DHA 3

PAGE 328 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CITRANATAL HARMONY 3

CITRANATAL MEDLEY 3

CITRANATAL RX 3

CO-NATAL FA 3

COMPLETE NATAL DHA 3

COMPLETENATE 3

CONCEPT DHA 3

CONCEPT OB 3

CORVITA 4

CORVITE 4

corvite free 1

dexifol 1

dialyvite 1

DIALYVITE 3000 4

DIALYVITE 5000 4

DIALYVITE SUPREME D 4

DIALYVITE/ZINC 3

DOTHELLE DHA 3

DUET DHA 400 4

DUET DHA BALANCED 4

ELITE-OB 3

ENBRACE HR 4

ESCAVITE 3

ESCAVITE D 4

ESCAVITE LQ 4

EXTRA-VIRT PLUS DHA 4 FLORIVA (0.25 MG CHEW TAB, 0.5 MG CHEW TAB, 1 MG CHEW TAB) 4

FOCALGIN 90 DHA 3

FOCALGIN CA 3

folbee plus 1

PAGE 329 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

FOLBEE PLUS CZ 4

FOLCAL DHA 3

FOLCAPS OMEGA 3 3

FOLET DHA 4

FOLET ONE 4

FOLGARD OS 3

folika-t 1

FOLIKA-V 4

FOLIVANE-OB 3

GENICIN VITA-Q 4

genicin vita-s 1

HEMENATAL OB 3

HEMENATAL OB + DHA 3

hylavite 1

INATAL ADVANCE 3

INATAL GT 3

INATAL ULTRA 3

INFANATE BALANCE 3

KOSHER PRENATAL PLUS IRON 4

LEVOMEFOLATE DHA 4

lorid 1

lysiplex plus 1

M-NATAL PLUS 3

M-VIT 3

MACNATAL CN DHA 3

MARNATAL-F 4

multi vitamin/fluoride 1

multi-vit/fluoride 0.5 mg/ml solution 1

multi-vit/fluoride/iron 1

multi-vit/iron/fluoride 1

PAGE 330 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS multi-vitamin/fluoride (multi-vitamin/fluoride 0.5 mg chew tab, multi-vitamin/fluoride 0.5 mg/ml solution) 1

multi-vitamin/fluoride/iron 1 MULTIVITAMIN/FLUORIDE (MULTIVITAMIN/FLUORIDE 0.25 MG CHEW TAB, MULTIVITAMIN/FLUORIDE 0.25-0.3 MG CHEW TAB, MULTIVITAMIN/FLUORIDE 0.5 MG CHEW TAB, MULTIVITAMIN/FLUORIDE 0.5-0.3 MG CHEW TAB, 4 MULTIVITAMIN/FLUORIDE 1 MG CHEW TAB, MULTIVITAMIN/FLUORIDE 1-0.3 MG CHEW TAB) multivitamin/fluoride (multivitamin/fluoride 0.25 mg chew tab, multivitamin/fluoride 0.5 mg chew tab, multivitamin/fluoride 0.5 1 mg/ml solution, multivitamin/fluoride 1 mg chew tab)

multivitamin/fluoride/iron 1

multivitamins/fluoride 1

mvc-fluoride 1

MYKIDZ IRON FL 4

MYNATAL (90-1 MG TAB, CAP) 3

MYNATAL ADVANCE 3

MYNATAL PLUS 3

MYNATAL-Z 3

MYNATE 90 PLUS 3

mynephrocaps 1

mynephron 1

NATACHEW 4

NATALVIT 4

NATELLE ONE 3

NEEVO DHA 4

NEONATAL COMPLETE 3

NEONATAL PLUS 3

NEPHPLEX RX 3

NEPHRO-VITE RX 4

NEPHROCAPS 4

NEPHROCAPS QT 4

nephronex 1

PAGE 331 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NESTABS 3

NESTABS ABC 4

NESTABS DHA 3

NESTABS ONE 4

NEWGEN 3

NEXA PLUS 4

NICOMIDE (750-25-1.5-0.5 MG TAB, 750-27-2-0.5 MG TAB) 4

NIVA-PLUS 3

nutrifac zx 1

NUTRIVIT 3

O-CAL FA 3

O-CAL PRENATAL 4

OB COMPLETE 3

OB COMPLETE ADVANCED 3

OB COMPLETE GOLD 4

OB COMPLETE ONE 4

OB COMPLETE PETITE 4

OB COMPLETE PREMIER 4

OB COMPLETE/DHA 4

OBSTETRIX DHA 3

OBSTETRIX EC 3

OBSTETRIX ONE 4

ONEVITE 4

PNV FE FUM/DOCUSATE/FOLIC ACID 3

PNV FOLIC ACID + IRON 3

PNV OB+DHA 3

PNV PRENATAL PLUS MULTIVIT+DHA 4

PNV PRENATAL PLUS MULTIVITAMIN 3

PNV TABS 29-1 3

PNV-DHA 3

PAGE 332 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PNV-DHA+DOCUSATE 3

PNV-OMEGA 3

PNV-SELECT 3

PNV-TOTAL 3

PNV-VP-U 3 POLY-VI-FLOR (0.25 MG CHEW TAB, 0.25 MG/ML SUSPENSION, 0.5 MG CHEW TAB, 1 MG CHEW TAB) 4

POLY-VI-FLOR FS 4 POLY-VI-FLOR/IRON (POLY-VI-FLOR/IRON 0.25-7 MG/ML SUSPENSION, POLY-VI-FLOR/IRON 0.5-10 MG CHEW TAB) 4

PR NATAL 400 3

PR NATAL 400 EC 3

PR NATAL 430 3

PR NATAL 430 EC 3

PREFERA OB 4

PREFERAOB +DHA 4

PREFERAOB ONE 3

PREMESISRX 4

PRENA 1 TRUE 3

PRENA1 3

PRENA1 PEARL 3

PRENAISSANCE 3

PRENAISSANCE BALANCE 3

PRENAISSANCE HARMONY DHA 3

PRENAISSANCE NEXT 3

PRENAISSANCE NEXT-B 4

PRENAISSANCE PLUS 3

PRENATA 4

PRENATABS FA 3

PRENATABS RX 3

PRENATAL 3

PAGE 333 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PRENATAL + DHA 4 PRENATAL 19 (19 CHEW TAB, 19 TAB, 19 29-1 MG CHEW TAB, 19 29-1 MG TAB) 3

PRENATAL PLUS 3

PRENATAL PLUS IRON 3

PRENATAL VITAMIN PLUS LOW IRON 3

PRENATAL-U 3

PRENATE 4

PRENATE AM 4 PRENATE DHA (18-0.6-0.4-300 MG CAP, 28-0.6-0.4-300 MG CAP) 4

PRENATE ELITE (20-0.6-0.4 MG TAB, 26-0.6-0.4 MG TAB) 4

PRENATE ENHANCE 4 PRENATE ESSENTIAL (18-0.6-0.4-300 MG CAP, 29-0.6-0.4- 340 MG CAP) 4 PRENATE MINI (18-0.6-0.4-350 MG CAP, 29-0.6-0.4-350 MG CAP) 4

PRENATE PIXIE 4

PRENATE RESTORE 4

PRENATE STAR 4

PREPLUS 3

PREQUE 10 4

PRETAB 3

PRIMACARE 4

PROVIDA DHA 4

PROVIDA OB 4

PUREFE OB PLUS 4

QUFLORA FE 4

QUFLORA FE PEDIATRIC 4

QUFLORA GUMMIES 4 QUFLORA PEDIATRIC (0.25 MG CHEW TAB, 0.5 MG CHEW TAB, 0.5 MG/ML SOLUTION, 1 MG CHEW TAB) 4

PAGE 334 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

R-NATAL OB 4

RELNATE DHA 3

renal 1

RENATABS 4

RENATABS WITH IRON 4

reno caps 1

RULAVITE DHA 3

SE-NATAL 19 (19 MG CHEW TAB, 19 MG TAB) 3

SE-TAN DHA 3 SELECT-OB (29-0.6-0.4 MG CHEW TAB, 29-1 MG CHEW TAB) 4

SELECT-OB+DHA 3

STROVITE FORTE SYRUP 4

SUPERVITE 4

SUPERVITE EC 4

TARON-BC 3

TARON-C DHA 3

TARON-PREX 3

TEXAVITE LQ 4

THRIVITE 19 3

THRIVITE RX 3

TL FOLATE 4

TL G-FOL OS 3

TL-CARE DHA 3

TL-FLUORIVITE 3

TL-SELECT 3

TRI-TABS DHA 3

TRI-VI-FLOR 4

TRI-VI-FLORO 4

tri-vit/fluoride 1

TRI-VIT/FLUORIDE/IRON 4

PAGE 335 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

tri-vitamin/fluoride 1

tri-vite/fluoride 1

TRIADVANCE 3

TRICARE 3

TRICARE PRENATAL 1 4

TRICARE PRENATAL 4.5-1 MG CHEW TAB 4

TRICARE PRENATAL COMPLEAT 4

TRICARE PRENATAL DHA ONE 0.8 MG CAP 4

TRICARE PRENATAL DHA ONE 27-1-500 MG CAP 3

TRINATAL GT 3

TRINATAL RX 1 3

TRINATE 3

TRINAZ 4

triphrocaps 1

triple-vitamin/fluoride 1

TRISTART DHA 4

TRISTART ONE 4

TRIVEEN-DUO DHA 3

TRIVEEN-PRX RNF 3

tronvite 1

UDAMIN SP 4

ULTIMATECARE ONE 3

ULTIMATECARE ONE NF 3

urosex 1

VEMAVITE-PRX 2 3

VENA-BAL DHA 3

VIL-RX 3

VINATE DHA RF 4

VINATE II 3

VINATE M 3

PAGE 336 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VINATE ONE 3

VIRT NATE 3

VIRT-ADVANCE 3

VIRT-C DHA 3

virt-caps 1

VIRT-NATE DHA 3

VIRT-PN 3

VIRT-PN DHA 3

VIRT-PN PLUS 3

VIRT-SELECT 3

VIRT-VITE GT 3

virt-vite plus 1

VIRTPREX 3

vit b3-azelac-turm-fa-b6-zn-cu 1

vita s forte 1

VITA-PREN 4

vitacel 1

VITAFOL (1 MG FILM, TAB) 4 VITAFOL FE+ (90-0.6-0.4-200 MG CAP, 90-1-200 & 50 MG CAP THPK) 4

VITAFOL GUMMIES 4

VITAFOL ULTRA 4

VITAFOL-NANO 4

VITAFOL-OB 3

VITAFOL-OB+DHA 3

VITAFOL-ONE 3

VITAL-D RX 4

vitamax pediatric 1

VITAMEDMD ONE RX/QUATREFOLIC 3

VITAMEDMD PLUS RX/QUATREFOLIC 3

VITAMEDMD REDICHEW RX 3

PAGE 337 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

vitamin b complex 100 1

vitamin b-complex 100 1

vitamins acd-fluoride 1

VITAPEARL 3

vitasure 1

VITATHELY WITH GINGER 3

VITATRUE 3

VITAXYME 4

VIVA DHA 3

vol-care rx 1

VOL-NATE 3

VOL-PLUS 3

VOL-TAB RX 3

VP-CH PLUS 3

VP-CH-PNV 3

VP-GGR-B6 PRENATAL 3

VP-HEME OB 3

VP-HEME OB + DHA 3

VP-HEME ONE 3

VP-PNV-DHA 4

vp-vite rx 1

xvite 1

ZALVIT 4

ZATEAN-CH 3

ZATEAN-PN DHA 3

ZATEAN-PN PLUS 3 NUTRIENTS

ALANINE 4

alcohol 98 % solution 1

aminoamrms 1

PAGE 338 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

aminoreliefrms 1

aminosyn ii/electrolytes 1

AMINOSYN/ELECTROLYTES 8.5 % SOLUTION 1

ARGININE HCL 6 GM/30ML SOLUTION 4

BCAA 4

CALM 4

CARDIOVID PLUS 4

CHOLINE BITARTRATE 4

clinisol sf 1

CLINOLIPID 4

dehydrated alcohol 1

DEXTROSE POWDER 4 dextrose (5 % solution, 10 % solution, 50 % solution, 70 % solution) 1

DEXTROSE ANHYDROUS 4

DL-ALANINE 4

DL-LEUCINE 4

DL-METHIONINE 4

DL-PHENYLALANINE 4

ELCYS 4

FRUCTOSE 4

GABA 4

glucose 1

GLUTAMINE 4 GLUTATHIONE (6 GM/30ML SOLUTION, 200 MG/ML SOLUTION, POWDER) 4

GLUTATHIONE-L 4

GLUTATHIONE-L REDUCED 4

GLYCINE 50 MG/ML SOLUTION 4

INTRALIPID 20 % EMULSION 4

L-ALANINE 4

PAGE 339 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

L-ARGININE 4

L-CYSTEINE HCL 50 MG/ML SOLUTION 4

L-CYSTINE 4

L-GLUTAMIC ACID 4

L-GLUTAMINE 4

L-HISTIDINE MONOHYDROCHLORIDE 4

L-ISOLEUCINE 4

L-LEUCINE 4

L-METHIONINE 4

L-PHENYLALANINE 4

L-PROLINE 4

L-THREONINE 4

L-TRYPTOPHAN 4

L-TYROSINE 4

L-VALINE 4

LEUCINE 4

LIPO 4

LIPO-C 4

LYSINE HCL 100 MG/ML SOLUTION 3

METHIONINE 4

MIC COMBO 4

n-acetyl-l-cysteine 600 mg cap 1

NUTRILIPID 4

OMEGAVEN 3

plenamine 1

premasol 6 % solution 1

TAURINE (50 MG/ML SOLUTION, LIQUID, POWDER) 4

THREONINE 4

TRI-AMINO 4

TROPHAMINE 6 % SOLUTION 3

PAGE 340 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TRYPTOPHAN POWDER 4

VALINE 4 VITAMINS

AMINOBENZOATE POTASSIUM 4

AMINOBENZOIC ACID 4

ASCORBIC ACID 15000 MG/30ML SOLUTION 3

ascorbic acid 500 mg/ml solution 1

CALCIUM ASCORBATE 4

CALCIUM PANTOTHENATE 4

CALCIUM-D-PANTOTHENATE 4

DRISDOL 4

ERGOCAL 4

ERGOCALCIFEROL POWDER 4

ergocalciferol 50000 unit cap 1

mega-c/a plus 1

MEPHYTON 4

NIACIN 4

NIACINAMIDE 4

NICOTINAMIDE 4

ortho-cs 250 1

PARA-AMINOBENZOIC ACID 4 phytonadione (1 mg/0.5ml solution, 5 mg tab, 10 mg/ml solution) 1

POTABA 4

POTASSIUM AMINOBENZOATE 4

PYRIDOXINE HCL (100 MG/ML SOLUTION, POWDER) 4

pyridoxine hcl 100 mg/ml solution 1

SODIUM ASCORBATE (GRANULES, POWDER) 4

sodium ascorbate 250 mg/ml solution 1

THIAMINE HCL POWDER 4

thiamine hcl 100 mg/ml solution 1

PAGE 341 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

THIAMINE MONONITRATE 4

vitamin d (ergocalciferol) 1

VITAMIN E (500 UNIT/GM POWDR, POWDR) 4

vitamin k1 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISCELLANEOUS

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

acamprosate calcium 1 QL 180 / 30 Days

QL 30 / 30 Days ADDYI 4 PA

QL 60 / 30 Days

PA AMPYRA 6 LA Limited Access

ANTABUSE 4 QL 30 / 30 Days

ARICEPT (5 MG TAB, 10 MG TAB) 4

ARICEPT 23 MG TAB 4 QL 30 / 30 Days

ARICEPT ODT 4

QL 30 / 30 Days

PA AUBAGIO 5 LA Limited Access

QL 120 / 30 Days

PA AUSTEDO 12 MG TAB 5 LA Limited Access

QL 240 / 30 Days

PA AUSTEDO 6 MG TAB 5 LA Limited Access

PAGE 342 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Box / 28 Days

AVONEX 6 PA

QL 1 Box / 28 Days

AVONEX PEN 6 PA

QL 1 Box / 28 Days

AVONEX PREFILLED 6 PA

QL 1 Box / 28 Days

BETASERON 5 PA

BRISDELLE 4 QL 30 / 30 Days

buproban 1 QL 60 / 30 Days

bupropion hcl er (smoking det) 1 QL 60 / 30 Days

CHANTIX 3 QL 60 / 30 Days

CHANTIX CONTINUING MONTH PAK 3 QL 60 / 30 Days

CHANTIX STARTING MONTH PAK 3 QL 2 / 365 Days

CHLORDIAZEPOXIDE-AMITRIPTYLINE 10-25 MG TAB 3

CHLORDIAZEPOXIDE-AMITRIPTYLINE 5-12.5 MG TAB 4

QL 60 / 30 Days

PA dalfampridine er 5 LA Limited Access

disulfiram (250 mg tab, 500 mg tab) 1 QL 30 / 30 Days

donepezil hcl (5 mg tab disp, 10 mg tab disp, 23 mg tab) 1 QL 30 / 30 Days

donepezil hcl (5 mg tab, 10 mg tab) 1

ERGOLOID MESYLATES 1 MG TAB 4

EXELON (1.5 MG CAP, 3 MG CAP, 4.5 MG CAP, 6 MG CAP) 4

PAGE 343 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EXELON (4.6 MG/24HR PATCH 24HR, 9.5 MG/24HR PATCH QL 1 Box / 30 Days 24HR, 13.3 MG/24HR PATCH 24HR) 4

FLUOXETINE HCL (PMDD) (10 MG CAP, 20 MG CAP) 4

fluoxetine hcl (pmdd) (10 mg tab, 20 mg tab) 1

galantamine hydrobromide (4 mg tab, 8 mg tab, 12 mg tab) 1 QL 60 / 30 Days

GALANTAMINE HYDROBROMIDE 4 MG/ML SOLUTION 4 QL 300 Milliliters / 30 Days

galantamine hydrobromide er 1 QL 30 / 30 Days

QL 30 / 30 Days

GILENYA 5 PA

QL 1 Box / 28 Days

glatiramer acetate 5 PA

QL 1 Box / 28 Days

glatopa 5 PA

QL 1 / 365 day(s)

PA INGREZZA 40 & 80 MG CAP THPK 6 LA Limited Access

QL 60 / 30 Days

PA INGREZZA 40 MG CAP 6 LA Limited Access

QL 30 / 30 Days

PA INGREZZA 80 MG CAP 6 LA Limited Access

QL 8 Vials / 365 Days

PA LEMTRADA 5 LA Limited Access

PAGE 344 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 224 / 14 Days LUCEMYRA 4 PA

QL 90 / 30 Days LYRICA CR (82.5 MG TAB ER 24H, 165 MG TAB ER 24H) 4 ST

QL 60 / 30 Days LYRICA CR 330 MG TAB ER 24H 4 ST

QL 2 / 365 day(s)

PA MAVENCLAD (10 TABS) 6 LA Limited Access

QL 2 / 365 day(s)

PA MAVENCLAD (4 TABS) 6 LA Limited Access

QL 2 / 365 day(s)

PA MAVENCLAD (5 TABS) 6 LA Limited Access

QL 2 / 365 day(s)

PA MAVENCLAD (6 TABS) 6 LA Limited Access

QL 2 / 365 day(s)

PA MAVENCLAD (7 TABS) 6 LA Limited Access

QL 2 / 365 day(s)

PA MAVENCLAD (8 TABS) 6 LA Limited Access

PAGE 345 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 112 / 28 day(s)

PA MAYZENT 0.25 MG TAB 6 LA Limited Access

QL 30 / 30 day(s)

PA MAYZENT 2 MG TAB 6 LA Limited Access

MAYZENT STARTER PACK 6 LA Limited Access

memantine hcl (2 mg/ml solution, 10 mg/5ml solution) 1 QL 360 Milliliters / 30 Days

memantine hcl (5 mg tab, 10 mg tab) 1 QL 60 / 30 Days

memantine hcl 5 (28)-10 (21) mg tab 1 QL 49 / 365 Days

QL 30 / 30 Days memantine hcl er 1 ST

NAMENDA (5 MG TAB, 10 MG TAB) 4 QL 60 / 30 Days

NAMENDA 10 MG/5ML SOLUTION 4

NAMENDA TITRATION PAK 4 QL 49 / 365 Days

NAMENDA XR 4 QL 30 / 30 Days

NAMENDA XR TITRATION PACK 3 QL 28 / 365 Days

NAMZARIC (7-10 MG CAP ER 24H, 14-10 MG CAP ER 24H, QL 30 / 30 Days 3 21-10 MG CAP ER 24H, 28-10 MG CAP ER 24H) ST

NAMZARIC 7 & 14 & 21 &28 -10 MG CP24 THPK 3 QL 28 / 365 Days

NICOTROL 4

NICOTROL NS 4

QL 60 / 30 Days NUEDEXTA 3 PA

PAGE 346 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

olanzapine-fluoxetine hcl 1 QL 30 / 30 Days

ONPATTRO 5 LA Limited Access

ORAP 4

paroxetine mesylate 1 QL 30 / 30 Days

PERPHENAZINE-AMITRIPTYLINE 3

PIMOZIDE 1

QL 4 Auto-Injectors / 28 Days PA PLEGRIDY 125 MCG/0.5ML SOLN PEN 6 LA Limited Access

QL 1 Box / 28 Days

PA PLEGRIDY 125 MCG/0.5ML SOLN PRSYR 6 LA Limited Access

QL 1 Box / 365 Days

PA PLEGRIDY STARTER PACK 6 LA Limited Access

RAZADYNE 4 QL 60 / 30 Days

RAZADYNE ER 4 QL 30 / 30 Days

QL 12 Syringes / 28 Days

REBIF 5 PA

QL 12 Auto-Injectors / 28 Days REBIF REBIDOSE 5 PA

QL 1 Box / 365 Days

REBIF REBIDOSE TITRATION PACK 5 PA

PAGE 347 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 Box / 365 Days

REBIF TITRATION PACK 5 PA

QL 1 Box / 30 Days rivastigmine 1 ST

rivastigmine tartrate 1 QL 60 / 30 Days

SARAFEM 4

SAVELLA 3 QL 60 / 30 Days

SAVELLA TITRATION PACK 3

SYMBYAX 4 QL 30 / 30 Days

QL 60 / 365 Days

PA TECFIDERA 120 & 240 MG MISC 5 LA Limited Access

QL 14 / 365 Days

PA TECFIDERA 120 MG CAP DR 5 LA Limited Access

QL 60 / 30 Days

PA TECFIDERA 240 MG CAP DR 5 LA Limited Access

TEGSEDI 6 LA Limited Access

QL 120 / 30 Days

PA tetrabenazine 5 LA Limited Access

PAGE 348 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 120 / 30 day(s)

VUMERITY 6 AL1 At least 18 yrs old

LA Limited Access

QL 1 / 365 day(s)

VUMERITY (STARTER) 6 AL1 At least 18 yrs old

LA Limited Access

QL 8 / 30 day(s)

VYLEESI 6 AL1 At least 18 yrs old

LA Limited Access

QL 120 / 30 Days

XENAZINE 6 LA Limited Access

QL 540 Milliliters / 30 Days

PA XYREM 5 LA Limited Access

ZINBRYTA 6 LA Limited Access

ZYBAN 4 QL 60 / 30 Days

VACCINES/TOXOIDS/PASSIVE IMMUNIZING/ALLERGENIC EXTRACTS/MISC

ALLERGENIC EXTRACTS/BIOLOGICALS MISC

ADAGEN 5 LA Limited Access

PAGE 349 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ALK SQ CAT HAIR 4

ASPERGILLUS FUMIGATUS 10000 PNU/ML SOLUTION 4

GRASTEK 4 QL 30 / 30 Days

HONEY BEE TREATMENT 4

HONEY BEE VENOM 1000 MCG RECON SOLN 4 MIXED VESPID VENOM PROTEIN (100-100-100 MCG KIT, 1000-1000-1000 MCG KIT) 4

QL 30 / 30 Days ORALAIR 4 LA Limited Access

QL 30 / 30 Days ORALAIR ADULT SAMPLE KIT 4 LA Limited Access

QL 30 / 30 Days ORALAIR ADULT STARTER PACK 4 LA Limited Access

QL 9 / 365 Days ORALAIR CHILDRENS SAMPLE KIT 3 LA Limited Access

QL 3 / 365 Days ORALAIR CHILDRENS STARTER PACK 4 LA Limited Access

RAGWITEK 4 QL 30 / 30 Days

WASP VENOM PROTEIN (100 MCG KIT, 1000 MCG RECON SOLN) 4

WHITE FACED HORNET VENOM PROT 4 YELLOW HORNET VENOM PROTEIN (100 MCG KIT, 1000 MCG RECON SOLN) 4 YELLOW JACKET VENOM PROTEIN (100 MCG KIT, 1000 MCG RECON SOLN) 4 PASSIVE IMMUNIZING AND TREATMENT AGENTS

ANAVIP 4

ANTIVENIN LATRODECTUS MACTANS 4

ASCENIV 6 LA Limited Access

PAGE 350 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA BIVIGAM 6 S

PA CARIMUNE NF 12 GM RECON SOLN 6 S

PA CARIMUNE NF 6 GM RECON SOLN 5 S

PA CUTAQUIG (1 GM/6ML SOLUTION, 1.65 GM/10ML SOLUTION, 2 GM/12ML SOLUTION, 3.3 GM/20ML 6 LA Limited Access SOLUTION, 4 GM/24ML SOLUTION, 8 GM/48ML SOLUTION) S

CUVITRU 6 LA Limited Access

CYTOGAM 5 S

PA FLEBOGAMMA DIF 6 S

PA GAMASTAN 6 S

PA GAMASTAN S/D 6 S

PA GAMMAGARD 5 S

PA GAMMAGARD S/D LESS IGA 5 S

PA GAMMAKED 6 S

PA GAMMAPLEX 6 S

PA GAMUNEX-C 5 S

PAGE 351 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

HEPAGAM B 3

HIZENTRA (1 GM/5ML SOLUTION, 10 GM/50ML SOLUTION) 6 LA Limited Access

HIZENTRA (2 GM/10ML SOLUTION, 4 GM/20ML SOLUTION) 5 LA Limited Access

HYPERHEP B S/D 3

HYPERRAB 4

HYPERRAB S/D 4

HYPERRHO S/D 5 S

HYPERTET S/D 3

HYQVIA 6 LA Limited Access

IMOGAM RABIES-HT 4

KEDRAB 4

MICRHOGAM ULTRA-FILTERED PLUS 6 S

NABI-HB 3 OCTAGAM (1 GM/20ML SOLUTION, 2 GM/20ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 5 PA GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 10 6 GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 25 S GM/500ML SOLUTION, 30 GM/300ML SOLUTION)

PANZYGA (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, PA 5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 20 6 GM/200ML SOLUTION, 30 GM/300ML SOLUTION) S

PA PRIVIGEN 5 S

RHOGAM ULTRA-FILTERED PLUS 6 S

RHOPHYLAC 6 S

SYNAGIS 5 LA Limited Access

PAGE 352 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VARIZIG (125 UNIT RECON SOLN, 125 UNIT/1.2ML SOLUTION) 3

WINRHO SDF 6 S

XEMBIFY 6 LA Limited Access

QL 1 / 365 Days

ZINPLAVA 6 PA

TOXOIDS

ADACEL 3

BOOSTRIX 3

DAPTACEL 3

DIPHTHERIA-TETANUS TOXOIDS DT 3

INFANRIX 3

KINRIX 3

PEDIARIX 3

PENTACEL 3

QUADRACEL 3

TDVAX 4

TENIVAC 3

TETANUS-DIPHTHERIA TOXOIDS TD 4 VACCINES

ACTHIB 3

AFLURIA 3

AFLURIA PRESERVATIVE FREE 3

AFLURIA QUADRIVALENT 3

BCG VACCINE 3

BEXSERO 3

BIOTHRAX 4

PAGE 353 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

CERVARIX 3

COMVAX 3

ENGERIX-B 3

EZ FLU SHOT-FLUCELVAX 3

EZ FLU SHOT-FLUVIRIN 3

FLUAD 3

FLUARIX 3

FLUARIX QUADRIVALENT 3

FLUBLOK 3

FLUBLOK QUADRIVALENT 3

FLUCELVAX 3

FLUCELVAX QUADRIVALENT 3

FLULAVAL 3

FLULAVAL QUADRIVALENT 3

FLUMIST QUADRIVALENT 3

FLUVIRIN 3

FLUVIRIN PRESERVATIVE FREE 3

FLUZONE 3

FLUZONE HIGH-DOSE 3

FLUZONE PRESERVATIVE FREE 3

FLUZONE QUADRIVALENT 3

GARDASIL 3

GARDASIL 9 3 QL 3 Injections / Lifetime

HAVRIX 3

HEPLISAV-B 3

HIBERIX 3

IMOVAX RABIES 4

IPOL 3

M-M-R II 3

MEDICAL PROVIDER EZ AFLURIA PF 3

PAGE 354 LAST UPDATED 01/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

MEDICAL PROVIDER EZ FLU 3

MEDICAL PROVIDER EZ FLU PF 3

MEDICAL PROVIDER EZ FLU SHOT 3

MEDICAL PROVIDER EZ FLUVIRIN 3

MENACTRA 3

MENHIBRIX 3

MENOMUNE 3

MENVEO 3

PEDVAX HIB 3

PNEUMOVAX 23 3

PREVNAR 13 3

PROQUAD 3

RABAVERT 4

RECOMBIVAX HB 3

ROTARIX 3

ROTATEQ 3

SHINGRIX 3 QL 2 injections / Lifetime

STAMARIL 3

TRUMENBA 3

TWINRIX 3

TYPHIM VI 4

VAQTA 3

VARIVAX 3

VAXCHORA 4

VIVOTIF 3

YF-VAX 3

ZOSTAVAX 3

PAGE 355 LAST UPDATED 01/2020 Index of covered drugs ABRAXANE 70 1 AC DERMAPEPTIDE 246 1ST MEDX-PATCH/ LIDOCAINE 139 ACACIA 297 acamprosate calcium 342 2 acarbose 178 2-DEOXY-D-GLUCOSE 245 ACARBOSE 246 2-fucosyllact-lacto-n-neotetra 321 ACCOLATE 60 2-METHOXYESTRADIOL 245 ACCUPRIL 108 ACCURETIC 108 4 ACEBUTOLOL HCL 113 4-AMINOBUTYRIC ACID 246 acebutolol hcl 113 4-AMINOPYRIDINE 246 ACEON 108 4-METHYLPYRAZOLE 246 ACEPROMAZINE MALEATE 246 ACESULFAME POTASSIUM 246 5 ACETADOTE 243 5-FLUOROURACIL 246 ACETAMINOPHEN 246 5-HTP 246 acetaminophen-codeine 16 5-HYDROXY-L-TRYPTOPHAN 246 acetaminophen-codeine #2 16 5-METHYLTETRAHYDROFOLATE CALC 246 acetaminophen-codeine #3 16 acetaminophen-codeine #4 16 7 ACETARSONE 246 7-KETO DHEA 246 acetasol hc 175 7t lido 139 acetazolamide 123 ACETAZOLAMIDE 246 8 acetazolamide er 123 8-MOP 139 acetazolamide sodium 123 acetic acid 175,221 9 ACETIC ACID 246 9-AMINOACRIDINE HCL 246 ACETIC ACID GLACIAL 246 ACETIC ACID-ALUMINUM ACETATE 175 A ACETONE 246 abacavir sulfate 39 ACETYL DIPEPTIDE-1 CETYL ESTER 246 abacavir sulfate-lamivudine 39 ACETYL HEXAPEPTIDE-8 246 abacavir-lamivudine-zidovudine 39 ACETYL SALICYLIC ACID 15 abaneu-sl 235 ACETYL-D-GLUCOSAMINE 246 ABELCET 36 ACETYL-L-CARNITINE HCL 246 ABILIFY 132 ACETYLCHOLINE CHLORIDE 246 ABILIFY MAINTENA 132 ACETYLCYSTEINE 65 abiraterone acetate 70 acetylcysteine 65,243 ABLAVAR 287 ACIDOPHILUS LACTOBACILLUS 246 ABLYSINOL 118 ACIPHEX 217

PAGE 356 LAST UPDATED 01/2020 ACIPHEX SPRINKLE 217,218 ADALAT CC 115 acitretin 139 adapalene 139 ACLARO 139 ADAPALENE 140 ACLOVATE 139 adapalene-benzoyl peroxide 140 ACTEMRA 9 ADASUVE 132 ACTEMRA ACTPEN 9 adc/f (0.5mg/ml) 328 ACTHIB 353 ADCETRIS 70 ACTICOAT 139 ADCIRCA 118 ACTICOAT 7 139 ADDAMEL N 322 ACTICOAT FLEX 3 139 ADDERALL 2 ACTICOAT FLEX 7 139 ADDERALL XR 2 ACTICOAT MOISTURE CONTROL 139 ADDYI 342 ACTICOAT SITE 139 adefovir dipivoxil 39 ACTICOAT SURGICAL 139 ADEMETIONINE DISULF TOSYLATE 247 ACTIGALL 212 ADEMPAS 118 ACTIMMUNE 70 adenosine 102,287 ACTIPHYTE OF ALGAE GL 246 ADENOSINE 247 ACTIPHYTE OF CUCUMBER 246 adenosine (diagnostic) 287 ACTIPHYTE OF IVY 246 ADENOSINE-5-MONOPHOSPHATE 293 ACTIPHYTE OF LEMONGRASS 246 ADENOSINE-5-TRIPHOSPHATE 293 ACTIQ 16 ADHANSIA XR 2 ACTIVASE 229 ADIPEX-P 2 ACTIVE FE 235 ADLYXIN 178 ACTIVE OB 328 ADLYXIN STARTER PACK 178 ACTIVE-CYCLOBENZAPRINE 317 ADOXA 58 ACTIVELLA 204 ADOXA PAK 1/100 58 activite 328 ADOXA PAK 1/150 58 ACTONEL 194 ADOXA PAK 2/100 58 ACTOPLUS MET 178 ADRENACLICK 125 ACTOPLUS MET XR 178 ADRENALIN 67,125 ACTOS 178 ADRENOCHROME SEMICARBAZONE 247 ACULAR 165 ADRENOCORTICOTROPHIC HORMONE 247 ACULAR LS 165 ADRIAMYCIN 71 acyclovir 39,139 adrucil 71 ACYCLOVIR 246 ADULT MASK 289 ACYCLOVIR SODIUM 39 ADVAIR DISKUS 60 acyclovir sodium 39 ADVAIR HFA 60 ACZONE 139 ADVANCED ALLERGY COLLECTION 140 ADACEL 353 ADVANCED AM/PM 328 ADAGEN 349 ADVATE 229 ADAKVEO 235 ADVICOR 103

PAGE 357 LAST UPDATED 01/2020 ADYNOVATE 229 AKTIPAK 140 ADZENYS ER 2 AKYNZEO 210 ADZENYS XR-ODT 2 ALA SCALP 140 AEMCOLO 32 ala-cort 140 aero otic hc 175 ALANINE 338 AEROCHAMBER MINI CHAMBER 289 ALASKAN RED ALGAE 247 AEROCHAMBER MV 289 ALBATUSSIN 65 AEROCHAMBER PLUS FLO-VU 289 ALBATUSSIN NN 65 AEROCHAMBER PLUS FLO-VU LARGE 289 albendazole 31 AEROCHAMBER PLUS FLO-VU MEDIUM 289 ALBENDAZOLE 247 AEROCHAMBER PLUS FLO-VU SMALL 289 ALBENZA 31 AEROCHAMBER PLUS FLO-VU W/MASK 289 albuked 25 229 AEROCHAMBER PLUS FLOW VU 289 albuked 5 229 AEROCHAMBER W/FLOWSIGNAL 289 albumin human 229 AEROCHAMBER Z-STAT PLUS 289 albumin-zlb 229 AEROCHAMBER Z-STAT PLUS CHAMBR 289 albuminar-25 230 AEROCHAMBER Z-STAT PLUS/LARGE 289 albuminar-5 230 AEROCHAMBER Z-STAT PLUS/MEDIUM 289 ALBUMINEX 230 AEROCHAMBER Z-STAT PLUS/SMALL 289 alburx 230 AEROVENT PLUS 289 albutein 230 afeditab cr 115 ALBUTEROL SULFATE 60 AFINITOR 71 albuterol sulfate 60 AFINITOR DISPERZ 71 albuterol sulfate er 60 afirmelle 183 ALBUTEROL SULFATE ER 60 AFLURIA 353 ALCAINE 165 AFLURIA PRESERVATIVE FREE 353 alclometasone dipropionate 140 AFLURIA QUADRIVALENT 353 alcohol 338 AFREZZA 179 ALCOHOL, USP 247 AFSTYLA 229 ALDACTAZIDE 123 AGAR 247 ALDACTONE 123 AGGRENOX 229 ALDARA 140 AGRYLIN 229 ALDOSTERONE 247 AIMOVIG 27 ALDURAZYME 194 AIMOVIG (140 MG DOSE) 27 ALECENSA 71 airavite 235 alendronate sodium 194 AIRS DISPOSABLE NEBULIZER 289 ALENDRONATE SODIUM 195 AJOVY 27 alevicyn dermal spray 140 ak-fluor 165 ALFALFA FLAVOR 297 ak-poly-bac 165 alfentanil hcl 16 AKLIEF 140 ALFENTANIL HCL 16 AKTEN 165 ALFERON N 71

PAGE 358 LAST UPDATED 01/2020 alfuzosin hcl er 221 ALPROLIX 230 ALGINIC ACID 247 ALPROSTADIL 247 ALIMTA 71 alprostadil 293 ALINIA 32 ALREX 165 ALIQOPA 71 altacaine 165 aliskiren fumarate 108 ALTACE 108 ALK SQ CAT HAIR 350 altafluor 165 ALKERAN 71 altafluor benox 165 ALKYL ACRYLATE CROSSPOLYMER 297 altafrin 165 ALKYL BENZOATE C12-15 247 altavera 183 ALLANTOIN 247 ALTOPREV 104 ALLEVYN AG GENTLE 140 ALTRENO 140 ALLO-PAX 140 ALTRENOGEST 247 allopurinol 25 ALUMINUM ACETATE BASIC 247 ALLOPURINOL 247 ALUMINUM CHLORIDE ANHYDROUS 140 allopurinol sodium 25 ALUMINUM CHLORIDE HEXAHYDRATE 140 ALMOND OIL (SWEET) 247 ALUMINUM CHLOROHYDRATE 247 ALMOND OIL BITTER FLAVOR 297 ALUMINUM HYDROXIDE DRIED GEL 247 almotriptan malate 27 ALUMINUM POTASSIUM SULFATE 247 ALOCRIL 165 ALUMINUM SULFATE 247 ALODOX CONVENIENCE 58 ALUNBRIG 72 ALOE VERA 247 ALUVEA 140 ALOE VERA FREEZE DRIED 247 alyacen 1/35 183 ALOE VERA LEAF 247 alyacen 7/7/7 183 ALOMIDE 165 alyq 118 ALORA 204 amabelz 204 alosetron hcl 212 AMANTADINE HCL 247 ALOXI 210 amantadine hcl 314 ALPHA-GPC 50% 247 AMARANTH 297 ALPHA-KETOGLUTARIC ACID 247 AMARYL 179 ALPHA-LIPOIC ACID 243,247 AMBIEN 136 ALPHA-TOCOPHEROL 247 AMBIEN CR 136 ALPHAGAN P 165 AMBISOME 36 ALPHANATE/VWF COMPLEX/HUMAN 230 ambrisentan 118 ALPHANINE SD 230 AMCINONIDE 140 alphaquin hp 140 AMELUZ 140 alprazolam 127 AMERGE 28 ALPRAZOLAM 247 AMERICAN GINSENG 248 alprazolam er 127 amethia 183 ALPRAZOLAM INTENSOL 127 amethia lo 183 alprazolam xr 127 amethyst 183

PAGE 359 LAST UPDATED 01/2020 AMICAR 242 AMMONIUM LAURYL SULFATE 248 amifostine 72 AMMONIUM MOLYBDATE 322 AMIKACIN SULFATE 30 AMMONIUM MOLYBDATE TETRAHYD 248 amikacin sulfate 30 AMMONIUM PHOSPHATE DIBASIC 248 AMILORIDE HCL 123 AMMONIUM SULFATE 248 amiloride hcl 123 amnesteem 140 amiloride-hydrochlorothiazide 123 AMOXAPINE 128 aminoacetic acid 221 amoxicill-clarithro-lansopraz 218 aminoamrms 338 AMOXICILLIN 56 AMINOBENZOATE POTASSIUM 341 amoxicillin 56 AMINOBENZOIC ACID 341 AMOXICILLIN ER 56 aminocaproic acid 242 AMOXICILLIN TRIHYDRATE 56 AMINOCAPROIC ACID 242,248 amoxicillin-pot clavulanate 56 AMINOLEVULINIC ACID HCL 248 AMOXICILLIN-POT CLAVULANATE 56,248 AMINOPHYLLINE 60 amoxicillin-pot clavulanate er 56 aminophylline 60 AMPHADASE 293 AMINOPHYLLINE ANHYDROUS 60 AMPHETAMINE ER 2 AMINOPROPYL RACEMENTHYL PHOS 248 amphetamine sulfate 2 aminoreliefrms 339 amphetamine-dextroamphet er 2 AMINOSALICYLIC ACID-4 38 amphetamine-dextroamphetamine 2 AMINOSALICYLIC ACID-5 212 AMPHOTEC 36 aminosyn ii/electrolytes 339 AMPHOTERICIN B 36,162 AMINOSYN/ELECTROLYTES 339 AMPICILLIN 56 amiodarone hcl 102 ampicillin 56 AMIODARONE HCL IN DEXTROSE 102 AMPICILLIN SODIUM 57 AMITIZA 212 ampicillin sodium 57 amitriptyline hcl 128 ampicillin-sulbactam sodium 57 AMITRIPTYLINE HCL 248 AMPICILLIN-SULBACTAM SODIUM 57 AMLODIPINE BES+SYRSPEND SF 115 AMPYRA 342 amlodipine besy-benazepril hcl 108 AMTURNIDE 108 amlodipine besylate 115 AMVISC 165 AMLODIPINE BESYLATE 248 AMVISC PLUS 165 amlodipine besylate-valsartan 108 AMYTAL SODIUM 136 amlodipine-atorvastatin 118 ana-lex 138 amlodipine-olmesartan 108 ANACAINE 140 amlodipine-valsartan-hctz 108 ANADROL-50 176 AMMONIUM BROMIDE 248 ANAFRANIL 128 AMMONIUM CHLORIDE 248 anagrelide hcl 230 AMMONIUM HYDROXIDE 248 ANALPRAM ADVANCED 138 ammonium lactate 140 ANALPRAM E 138 AMMONIUM LACTATE 248 ANALPRAM HC 138

PAGE 360 LAST UPDATED 01/2020 ANALPRAM HC SINGLES 138 ANUSOL-HC 138 ANALPRAM-HC 138 anusol-hc 138 ANAPROX DS 9 ANZEMET 210 ANASPAZ 218 APADAZ 16 ANASTIA 140 APAP-CAFF-DIHYDROCODEINE 16 anastrozole 72 APEXICON E 141 ANASTROZOLE 248 APOKYN 314 ANAVIP 350 APOMORPHINE HCL 248 ANCOBON 36 APPLE FLAVOR 297 ANDEXXA 243 apraclonidine hcl 165 ANDRODERM 176 aprepitant 210 ANDROGEL 176 apri 183 ANDROGEL PUMP 177 APRICOT FLAVOR 297 ANDROID 177 APRISO 213 ANDROSTENEDIONE 248 APTENSIO XR 2 ANDROXY 177 APTIOM 309 ANGELIQ 204 APTIVUS 39,40 ANGIOMAX 227 AQUACEL AG BURN 141 ANHYDROUS GEL BASE 297 AQUORAL 162 ANIMI-3 235 ARAKODA 37 ANIMI-3/VITAMIN D 235 ARALAST NP 68 ANISE EXTRACT 297 aranelle 183 ANISE FLAVOR 297 ARANESP (ALBUMIN FREE) 235 ANISINDIONE 248 ARAVA 9 ANNOVERA 183 arbinoxa 64 ANODYNE ILE 9 ARBUTIN ALPHA 248 anodynz 140 ARCALYST 9 ANORO ELLIPTA 60 ARCAPTA NEOHALER 60 ANTABUSE 342 ARESTIN 162 ANTARA 104 argatroban 227 ANTHRALIN 141 ARGATROBAN 227 ANTICOAGULANT CIT DEXT SOLN A 227 ARGATROBAN IN SODIUM CHLORIDE 227 ANTIMONY POTASSIUM TARTRATE 248 ARGININE HCL 248,339 ANTIMONY TRICHLORIDE 248 argyle sterile saline 221 ANTIMONY TRISULFIDE 248 argyle sterile water 293 ANTIPYRINE 248 ARICEPT 342 antipyrine-benzocaine 175 ARICEPT ODT 342 ANTIPYRINE-BENZOCAINE 175 ARIDOL 287 ANTIVENIN LATRODECTUS MACTANS 350 ARIKAYCE 30 ANTIZOL 243 ARIMIDEX 72 anucort-hc 138 aripiprazole 132

PAGE 361 LAST UPDATED 01/2020 ARISTADA 132,133 ASPIRIN-CAFF-DIHYDROCODEINE 17 ARISTADA INITIO 133 aspirin-dipyridamole er 230 ARISTOSPAN INTRA-ARTICULAR 191 ASSURE ID INSULIN SAFETY SYR 289 ARIXTRA 227 ASTAGRAF XL 293 ARLACEL 165 248 ASTAMED MYO 321 armodafinil 2 ASTEPRO 67 ARMONAIR RESPICLICK 113 60 ASTERO 141 ARMONAIR RESPICLICK 232 60 ASTRAGALUS ROOT 297 ARMONAIR RESPICLICK 55 60 ASTRINGYN 242 ARMOUR THYROID 208 ATABEX EC 328 ARNUITY ELLIPTA 60 ATABEX OB 328 AROMASIN 72 ATACAND 108 ARRANON 72 ATACAND HCT 108 arsenic trioxide 72 atazanavir sulfate 40 ARSENIC TRIOXIDE 248 ATELVIA 195 ARTHROTEC 9 ATENOLOL 113 articadent dental 26 atenolol 113 ARYMO ER 17 ATENOLOL+SYRSPEND SF 113 ARZERRA 72 atenolol-chlorthalidone 108 arzol silver nit applicators 141 ATGAM 293 ASACOL HD 213 ATIVAN 127 ASCENIV 350 atomoxetine hcl 2,3 ascomp-codeine 17 atorvastatin calcium 104 ASCORBIC ACID 248,341 ATORVASTATIN CALCIUM 249 ascorbic acid 341 atovaquone 32 ASCORBIC ACID CASSAVE 248 ATOVAQUONE 249 ASCORBIC ACID FINE 248 atovaquone-proguanil hcl 37 ASCORBYL PALMITATE 249 atracurium besylate 319 ashlyna 183 ATRALIN 141 ASMANEX 120 METERED DOSES 60 ATRIPLA 40 ASMANEX 14 METERED DOSES 60 ATROPEN 218 ASMANEX 30 METERED DOSES 60 ATROPINE SULFATE 165,218 ASMANEX 60 METERED DOSES 60 atropine sulfate 165,218 ASMANEX 7 METERED DOSES 60 ATROPINE SULFATE (PF) 218 ASMANEX HFA 60 ATROPINE SULFATE MONOHYDRATE 218 ASPARAGINE MONOHYDRATE 249 ATROPINE SULFATE-NACL 165 ASPARLAS 72 ATROVENT 67 ASPARTAME 321 ATROVENT HFA 60 ASPARTAME (NUTRASWEET) 321 ATTAPULGITE 249 ASPERGILLUS FUMIGATUS 287,350 AUBAGIO 342 ASPIRIN 15 aubra 183

PAGE 362 LAST UPDATED 01/2020 aubra eq 183 AVONEX PEN 343 AUGMENTIN 57 AVONEX PREFILLED 343 AUGMENTIN ES-600 57 AVYCAZ 52 AUGMENTIN XR 57 AXERT 28 aurovela 1.5/30 183 AXIFOL 235 aurovela 1/20 183 AYGESTIN 207 aurovela 24 fe 183 ayuna 183 aurovela fe 1.5/30 183 azacitidine 72 aurovela fe 1/20 183 AZACTAM 32 AURYXIA 213 AZACTAM IN DEXTROSE 32 AUSTEDO 342,343 AZASAN 294 AUXIPRO PLASTICIZED 297 AZASITE 165 av-vite fb 235 AZATHIOPRINE 294 AVAILNEX 321 azathioprine 294 AVALIDE 108 AZATHIOPRINE SODIUM 294 AVANDAMET 179 AZEDRA DOSIMETRIC 72 AVANDARYL 179 AZEDRA THERAPEUTIC 72 AVANDIA 179 azelaic acid 141 AVAPRO 108 AZELAIC ACID 249 AVAR 141 azelastine hcl 67,165 avar cleanser 141 AZELASTINE HCL 249 AVAR LS 141 AZELEX 141 AVAR LS CLEANSER 141 AZESCO 328 avar-e emollient 141 AZILECT 315 avar-e green 141 azithromycin 55 AVAR-E LS 141 AZITHROMYCIN 55,249 AVASTIN 72 AZITHROMYCIN DIHYDRATE 249 AVC VAGINAL 226 AZOPT 165 AVEED 177 AZOR 108 AVELOX 54 aztreonam 32 AVELOX ABC PACK 54 AZULFIDINE 213 aviane 183 AZULFIDINE EN-TABS 213 AVICEL PH 101 MICRO CELLULOSE 249 azuphen mb 223 AVICEL PH 105 MICRO CELLULOSE 249 azurette 183 avidoxy 58 AVINZA 17 B AVIPTADIL ACETATE 249 b complex vitamins 328 avita 141 B-12 235 AVOCADO OIL 249 B-12 COMPLIANCE INJECTION 235 AVODART 221 B-COMPLEX 328 AVONEX 343 b-plex 328

PAGE 363 LAST UPDATED 01/2020 b-plex plus 328 BASIC FUCHSIN HCL 249 B-SERENE 235 BAVENCIO 73 baciim 32 BAXDELA 54 bacitra-neomycin-polymyxin-hc 165 BAY OIL 249 bacitracin 32 baycadron 191 BACITRACIN 141,165 BCAA 339 BACITRACIN MICRONIZED 249 BCG VACCINE 353 BACITRACIN ZINC 141 BD INSULIN SYRINGE U-500 289 bacitracin-polymyxin b 165 BD PEN NEEDLE NANO U/F 289 BACLOFEN 317 bd posiflush 322 baclofen 317 BD SAFETYGLIDE INSULIN SYRINGE 289 BACOCALMINE 297 BEBULIN 230 BACON FLAVOR 297 BECLOMETHASONE DIPROPIONATE 249 BACTERIOSTATIC WATER(BENZ ALC) 297 BECONASE AQ 67 BACTERIOSTATIC WATER(PARABENS) 297 BEEF FLAVOR 298 BACTRIM 32 BEEF TYPE FLAVOR NATURAL 298 BACTRIM DS 32 BEEF-ADE 298 BACTROBAN 141 BEES WAX 298 BACTROBAN NASAL 67 BEESWAX 298 BAL-CARE DHA 328 BEESWAX (YELLOW) 298 balanced salt 166 bekyree 183 BALCOLTRA 183 BELBUCA 17 balsalazide disodium 213 BELEODAQ 73 BALVERSA 73 BELLADONNA 249 balziva 183 BELLADONNA ALKALOIDS-OPIUM 218 BANANA CONCENTRATE 298 BELLADONNA EXTRACT 249 BANANA CREAM FLAVOR 298 BELLADONNA LEAF EXTRACT 249 BANANA CREME FLAVOR 298 BELRAPZO 73 BANANA FLAVOR 298 BELVIQ 3 BANZEL 309 BELVIQ XR 3 BAQSIMI ONE PACK 179 BENACTYZINE HCL 249 BAQSIMI TWO PACK 179 benazepril hcl 108 BARACLUDE 40 BENAZEPRIL HCL 249 BASE A POLYETHYLENE GLYCOL 298 benazepril-hydrochlorothiazide 108 BASE C POLYETHYLENE GLYCOL 300 298 BENDAMUSTINE HCL 73 BASE D POLYETHYLENE GLYCOL 298 BENDEKA 73 BASE FOR SALTS 298 BENEFIX 230 BASE FOR WOUNDS 298 BENFOTIAMINE 249 BASE G ALMOND OIL (SWEET) 249 BENICAR 108 BASE GELATIN GUMMY TROCHE 298 BENICAR HCT 108 BASE X 298 BENLYSTA 294

PAGE 364 LAST UPDATED 01/2020 BENSAL HP 141 BESPONSA 73 BENTONITE 298 BETA CAROTENE 249 BENTYL 218 BETA CYCLODEXTRIN 250 BENZAC AC WASH 141 BETA GLUCAN 250 BENZACLIN 141 BETADINE OPHTHALMIC PREP 166 BENZACLIN WITH PUMP 141 BETAGAN 166 BENZALKONIUM CHLORIDE 245 BETAHISTINE DIHYDROCHLORIDE 250 BENZAMYCIN 141 BETAHISTINE HCL 250 BENZEFOAM 141 BETAINE ANHYDROUS 250 BENZEFOAMULTRA 141 BETAINE HCL 250 benzepro 141 BETAMETHASONE 250 benzepro creamy wash 142 BETAMETHASONE ACETATE 250 benzepro foaming cloths 142 BETAMETHASONE COMBO 191 benzepro short contact 142 BETAMETHASONE DIPROPIONATE 142 BENZETHONIUM CHLORIDE 249 betamethasone dipropionate 142 BENZHYDROCODONE-ACETAMINOPHEN 17 betamethasone dipropionate aug 142 BENZIQ 142 BETAMETHASONE DIPROPIONATE AUG 142 BENZIQ LS 142 BETAMETHASONE SOD PHOS & ACET 191 BENZIQ WASH 142 betamethasone sod phos & acet 191 BENZNIDAZOLE 31 BETAMETHASONE SOD PHOSPHATE 191 BENZOCAINE 249 BETAMETHASONE SODIUM PHOSPHATE 191 BENZOIC ACID 142 BETAMETHASONE VALERATE 142 BENZOIN GUM 249 betamethasone valerate 142 benzonatate 65 BETANAPHTHOL 250 BENZOQUINONE (PARA) 249 BETAPACE 113 benzoyl peroxide 142 BETAPACE AF 113 BENZOYL PEROXIDE 142 BETASERON 343 BENZOYL PEROXIDE FORTE- HC 142 betaxolol hcl 113,166 BENZOYL PEROXIDE HYDROUS 142 bethanechol chloride 225 benzoyl peroxide short contact 142 BETHANECHOL CHLORIDE 250 benzoyl peroxide-erythromycin 142 BETHKIS 30 BENZPHETAMINE HCL 3 BETIMOL 166 benzphetamine hcl 3 BETOPTIC-S 166 benztropine mesylate 315 BEVACIZUMAB 166 BENZYL ALCOHOL 298 BEVESPI AEROSPHERE 61 BENZYL BENZOATE 249 BEVYXXA 227 BEOVU 166 bexarotene 73 BEPREVE 166 BEXSERO 353 BERINERT 230 BEYAZ 183 beser 142 BHA 250 BESIVANCE 166 BHRT BASE 298

PAGE 365 LAST UPDATED 01/2020 BHT 250 BITTERNESS MASK FLAVOR 298 BI-EST 50:50 204 BITTERNESS REDUCING AGENT 298 BI-EST 80:20 PROGESTERONE 204 BITTERNESS SUPPRESSOR FLAVOR 298 BI-EST PROGEST-TESTOSTERONE 204 bivalirudin trifluoroacetate 227 BIAFINE 142 BIVALIRUDIN-SODIUM CHLORIDE 227 BIAXIN 55 BIVIGAM 351 bicalutamide 74 BL INJECTION 26 BICILLIN C-R 57 BLACKBERRY FLAVOR 298 BICILLIN C-R 900/300 57 blanche 142 BICILLIN L-A 57 BLEO 15K 74 BICNU 74 bleomycin sulfate 74 BIDIL 118 BLEPH-10 166 BIEST/PROGESTERONE 204 BLEPHAMIDE 166 BIFERARX 236 BLEPHAMIDE S.O.P. 166 BIJUVA 205 BLINCYTO 74 BIKTARVY 40 blisovi 24 fe 183 BILTRICIDE 31 blisovi fe 1.5/30 184 bimatoprost 142 blisovi fe 1/20 184 BIMATOPROST 250 BLUE AGAVE ORGANIC 250 bio glo 166 BLUEBERRY FLAVOR 298 bio-statin 36 BONIVA 195 BIO-STATIN 36 BONTRIL PDM 3 biocel 328 BOOSTRIX 353 BIOLON 166 BORIC ACID 250 BIONECT 142 BORON AMORPHOUS FINE 250 BIORE HYDRATING MOISTURIZER 250 BORON CITRATE 250 BIOTHRAX 353 BORTEZOMIB 74 BIOTIN 250 bosentan 118 biotuss pediatric 65 BOSULIF 74 BISABOLOL, ALPHA-L 250 BOSWELLIA SERRATA EXTRACT 250 BISACODYL 216 BOTOX 319 BISMUTH CITRATE 250 BOTOX COSMETIC 142 BISMUTH SUBCARBONATE 250 bp 10-1 142 BISMUTH SUBGALLATE 209 BP CLEANSING WASH 143 BISMUTH SUBNITRATE 250 bp foam 143 BISMUTH SUBSALICYLATE 250 bp foaming wash 143 bisoprolol fumarate 113 BP FOLINATAL PLUS B 328 bisoprolol-hydrochlorothiazide 109 BP MULTINATAL PLUS 328 BITTER DRUG 298 BP VIT 3 236 BITTER ORANGE 250 BP VIT 3 PLUS 236 BITTER STOP FLAVOR 298 bp wash 143

PAGE 366 LAST UPDATED 01/2020 BPO 143 bromfenac sodium (once-daily) 167 bpo foaming cloths 143 BROMHEXINE HCL 65 BRAFTOVI 74 BROMOCRIPTINE MESYLATE 315 BREATHE EASE LARGE 289 bromocriptine mesylate 315 BREATHE EASE MEDIUM 289 BROMPHENIRAMINE MALEATE 64 BREATHE EASE SMALL 289 BROMPHENIRAMINE TANNATE 64 BREATHERITE 289 BROMSITE 167 BREATHERITE COLL SPACER ADULT 289 BROVANA 61 BREATHERITE COLL SPACER CHILD 289 BRUKINSA 74 BREATHERITE COLL SPACER INFANT 290 BUBBLE GUM CONCENTRATE 298 BREATHERITE RIGID SPACER/MASK 290 BUBBLE GUM FLAVOR 298 BREATHERITE SPACER NEONATE 290 budesonide 61,67,191 BREATHERITE SPACER SMALL CHILD 290 BUDESONIDE 251 BREATHERITE/LARGE MASK 290 budesonide er 191 BREATHERITE/MEDIUM MASK 290 BUFLOMEDIL HCL 251 BREATHERITE/SMALL MASK 290 bumetanide 123 BREO ELLIPTA 61 BUMEX 123 BREVIBLOC 113 buminate 230 BREVIBLOC IN NACL 113 BUNAVAIL 17 BREVIBLOC PREMIXED 113 BUPHENYL 195 BREVIBLOC PREMIXED DS 113 BUPIVACAINE FISIOPHARMA 26 BREVICON (28) 184 bupivacaine hcl 26 BREVITAL SODIUM 24 BUPIVACAINE HCL 26 BRIDION 243 bupivacaine hcl (pf) 26 briellyn 184 BUPIVACAINE HCL-NACL 26 BRIJ 35 250 bupivacaine in dextrose 26 BRIJ 700 250 bupivacaine spinal 26 BRIJ 93 250 bupivacaine-epinephrine 26 BRILINTA 230 BUPIVACAINE-EPINEPHRINE 26 BRILLIANT BLUE G 298 bupivacaine-epinephrine (pf) 26 BRILLIANT GREEN 250 BUPRENEX 17 brimonidine tartrate 166 buprenorphine 17 BRIMONIDINE TARTRATE 251 BUPRENORPHINE 17 BRIMONIDINE-DORZOLAMIDE 167 buprenorphine hcl 17 BRINEURA 195 BUPRENORPHINE HCL 251 BRINTELLIX 128 buprenorphine hcl-naloxone hcl 17 BRISDELLE 343 buproban 343 BRIVIACT 309 bupropion hcl 128 BROMELAIN 294 BUPROPION HCL 251 bromfed dm 65 bupropion hcl er (smoking det) 343 BROMFENAC SODIUM 167,251 bupropion hcl er (sr) 128

PAGE 367 LAST UPDATED 01/2020 bupropion hcl er (xl) 128 CAFFEINE-SODIUM BENZOATE 3 buspirone hcl 127 CALAMINE 143 BUSPIRONE HCL 251 CALAN 115 busulfan 74 CALAN SR 115 BUSULFEX 75 CALCIFOL 322 BUTALBITAL 251 calcipotriene 143 butalbital-acetaminophen 15 CALCIPOTRIENE 251 butalbital-apap 15 CALCIPOTRIENE MONOHYDRATE 251 butalbital-apap-caff-cod 17 calcipotriene-betameth diprop 143 butalbital-apap-caffeine 15 CALCIPOTRIOL 251 butalbital-asa-caff-codeine 17 calcitonin (salmon) 195 butalbital-asa-caffeine 15 calcitrene 143 butalbital-aspirin-caffeine 15 CALCITRIOL 143,195,251 BUTALBITAL-ASPIRIN-CAFFEINE 15 calcitriol 195 BUTISOL SODIUM 136 CALCITRIOL IN ALMOND OIL 251 BUTORPHANOL TARTRATE 17,251 calcium acetate 213 butorphanol tartrate 17 CALCIUM ACETATE 251 BUTRANS 17,18 calcium acetate (phos binder) 213 BUTTER FLAVOR 299 CALCIUM ALGINATE 251 BUTTER RUM FLAVOR 299 CALCIUM AMINO ACID CHELATE 251 BUTTERSCOTCH FLAVOR 299 CALCIUM ASCORBATE 341 BUTYL ALCOHOL 251 CALCIUM CARBONATE 322 BUTYLATED HYDROXYANISOLE 251 CALCIUM CARBONATE LIGHT 323 BUTYLATED HYDROXYTOLUENE 251 calcium chloride 323 BUTYLENE GLYCOL 251 CALCIUM CHLORIDE ANHYDROUS 251,323 BYSTOLIC 113 CALCIUM CHLORIDE DIHYDRATE 323 BYVALSON 109 CALCIUM CITRATE 251 CALCIUM CITRATE TETRAHYDRATE 251 C CALCIUM FOLINATE 251 C INDICUM & C SINESIS LEAF EXT 251 CALCIUM FRUCTOBORATE 251 C-NATE DHA 328 CALCIUM GLUBIONATE 251 cabergoline 195 CALCIUM GLUCONATE 323 CABLIVI 230 calcium gluconate 323 CABOMETYX 75 CALCIUM GLUCONATE ANHYDROUS 323 CADUET 118 CALCIUM GLUCONATE MONOHYDRATE 323 CAFCIT 3 CALCIUM GLUCONATE-NACL 323 CAFERGOT 28 CALCIUM GLYCEROPHOSPHATE 251 CAFFEINE 3 CALCIUM HYDROXIDE 251 CAFFEINE ANHYDROUS 3 CALCIUM HYDROXYAPATITE 252 caffeine citrate 3 CALCIUM LACTATE PENTAHYDRATE 323 CAFFEINE CITRATED 3 CALCIUM LEVULINATE DIHYDRATE 252

PAGE 368 LAST UPDATED 01/2020 CALCIUM PANTOTHENATE 341 CAPSUBLEND-S 299 CALCIUM PHOSPHATE DIBASIC 323 captopril 109 CALCIUM PHOSPHATE TRIBASIC 323 CAPTOPRIL 252 CALCIUM PNV 328 CAPTOPRIL-HYDROCHLOROTHIAZIDE 109 CALCIUM PROPIONATE 252 CARAFATE 218 CALCIUM PYRUVATE 252 CARAMEL FLAVOR 299 CALCIUM SACCHARIN 252 carb-o-philic/40 143 CALCIUM STEARATE 252 CARBACHOL 252 CALCIUM SULFATE 252 CARBAGLU 195 CALCIUM SULFATE HEMIHYDRATE 252 CARBAMAZEPINE 309 CALCIUM THIOGLYCOLATE 252 carbamazepine 309 CALCIUM-D-PANTOTHENATE 341 carbamazepine er 309 CALM 339 CARBAMIDE PEROXIDE 252 CALQUENCE 75 CARBAPHEN 12 65 camila 184 CARBAPHEN 12 PED 65 CAMPATH 75 CARBATROL 309 CAMPHOR 143 CARBAZOCHROME 252 CAMPTOSAR 75 CARBIDOPA 252 camrese 184 carbidopa 315 camrese lo 184 CARBIDOPA ANHYDROUS 252 CANADIAN BALSAM 252 carbidopa-levodopa 315 CANASA 213 carbidopa-levodopa er 315 CANCIDAS 36 CARBIDOPA-LEVODOPA-ENTACAPONE 315 candesartan cilexetil 109 CARBIMAZOLE 252 candesartan cilexetil-hctz 109 carbinoxamine maleate 64 candida albicans skn tst antgn 287 CARBOMER 934P 252 CANDIN 287 CARBOMER 934P RESIN 252 CANTHARIDIN 143 CARBOMER 940 252 CANTIL 218 CARBOMER 941 252 capacet 15 carboplatin 75 capecitabine 75 CARBOPOL 940 252 CAPEX 143 CARBOPOL 940 NF 252 CAPITAL/CODEINE 18 carboprost tromethamine 207 CAPRELSA 75 CARBOXYMETHYLCELLULOSE SODIUM 252 CAPRYLIC ACID 252 CARDENE IV 115 CAPRYLIC CAPRIC TRIGLYCERIDE 252 cardioplegic 118 CAPSAICIN 143 CARDIOVID PLUS 339 CAPSAICIN PALMITATE 252 CARDIZEM 115 CAPSICUM OLEORESIN 252 CARDIZEM CD 115 CAPSUBLEND-H 299 CARDIZEM LA 115 CAPSUBLEND-P 299 CARDURA 109

PAGE 369 LAST UPDATED 01/2020 CARDURA XL 221 cefadroxil 52 CARIMUNE NF 351 CEFAZOLIN IN SODIUM CHLORIDE 52 CARISOPRODOL 317 cefazolin sodium 52 carisoprodol 317 CEFAZOLIN SODIUM 52 carisoprodol-aspirin 317 CEFAZOLIN SODIUM-DEXTROSE 52 carisoprodol-aspirin-codeine 317 CEFAZOLIN SODIUM-NACL 52 CARMINE 252 cefdinir 52 carmustine 75 CEFDITOREN PIVOXIL 52 CARNAUBA WAX 252 cefepime hcl 52 CARNITINE (L) 253 CEFEPIME HCL 52 CARNITOR 195 cefixime 52 CARNITOR SF 195 CEFOTAN 52 CARNOSINE L 253 CEFOTAXIME SODIUM 53 CAROSPIR 123 cefotaxime sodium 53 CARRAGEENAN 299 cefotetan disodium 53 CARTEOLOL HCL 167 CEFOTETAN DISODIUM 53 carteolol hcl 167 cefoxitin sodium 53 cartia xt 115 CEFOXITIN SODIUM-DEXTROSE 53 carvedilol 113 cefpodoxime proxetil 53 carvedilol phosphate er 113 cefprozil 53 CASODEX 75 ceftazidime 53 caspofungin acetate 36 CEFTAZIDIME 253 CASPOFUNGIN ACETATE 36 CEFTAZIDIME AND DEXTROSE 53 CASTOR OIL 253 CEFTAZIDIME WITH SOD CARBONATE 253 CATAPRES 109 CEFTIBUTEN 53 CATAPRES-TTS-1 109 CEFTIN 53 CATAPRES-TTS-2 109 CEFTRI-IM 53 CATAPRES-TTS-3 109 ceftriaxone sodium 53 CATHFLO ACTIVASE 230 CEFTRIAXONE SODIUM 253 cavarest 163 CEFTRIAXONE SODIUM IN DEXTROSE 53 CAVERJECT 118 CEFTRIAXONE SODIUM-DEXTROSE 53 CAVERJECT IMPULSE 118 CEFTRISOL PLUS 53 cavirinse 163 cefuroxime axetil 53 CAYA 290 cefuroxime sodium 53 CAYSTON 32 CEFUROXIME SODIUM-NACL 167 caziant 184 celacyn 143 CEDAR LEAF OIL 253 CELEBREX 9 CEDAX 52 celecoxib 9 CEFACLOR 52 CELECOXIB 253 cefaclor 52 CELESTONE SOLUSPAN 191 CEFACLOR ER 52 CELEXA 128

PAGE 370 LAST UPDATED 01/2020 CELLCEPT 294 CHANTIX CONTINUING MONTH PAK 343 CELLCEPT INTRAVENOUS 294 CHANTIX STARTING MONTH PAK 343 CELLUGEL 167 CHARCOAL ACTIVATED 243 CELLULASE 253 chateal 184 CELLULOSE 253 chateal eq 184 CELLULOSE CARMELLOSE SODIUM 253 CHEESE-ADE FLAVOR 299 CELONTIN 309 CHEESECAKE FLAVOR 299 CEM-UREA 143 CHEMET 243 CENFOL 236 CHEMSIL K-12 299 CENOVIA 143 CHEMSIL K-51 299 CENTANY 143 CHENODAL 213 CENTANY AT 143 CHERRY FLAVOR 299 CENTRATEX 236 CHERRY-ADE FLAVOR 299 cephalexin 53 CHEW-HESIVE 299 CEPHALEXIN 53 CHICKEN BROTH FLAVOR 299 CEPROTIN 230 CHICKEN FLAVOR 299 CEQUA 167 CHICKEN FLAVOR OIL SOLUBLE 299 CERAPHYL SLK 253 CHICKEN FLAVOR WATER MISCIBLE 299 CERDELGA 236 CHICKEN PROTEIN 253 CEREFOLIN 321 CHLORAL HYDRATE 136 CEREFOLIN NAC 321 CHLORAMBUCIL 253 CERESIN WAX 253 CHLORAMPHENICOL 253 CEREZYME 236 CHLORAMPHENICOL PALMITATE 253 cerisa wash 143 chlordiazepoxide hcl 127 cerovel 143 CHLORDIAZEPOXIDE-AMITRIPTYLINE 343 CERVARIX 354 chlordiazepoxide-clidinium 218 CERVIDIL 207 CHLORHEXIDINE DIACETATE 253 CESAMET 210 chlorhexidine gluconate 163 CESIUM CHLORIDE 253 CHLORHEXIDINE GLUCONATE 245,253 CETEARYL ALCOHOL-CETEARETH 20 253 CHLOROACETIC ACID 143 cetirizine hcl 64 CHLOROBUTANOL 299 CETOSTEARYL ALCOHOL 253 CHLOROBUTANOL ANHYDROUS 299 CETROTIDE 195 CHLOROFORM 253 CETYL ALCOHOL 299 chloromag 323 CETYL ESTERS WAX 253 CHLOROPHYLLIN SODIUM COPPER 253 CETYL MYRISTOLEATE 253 chloroprocaine hcl (pf) 26 CETYLCIDE-G 245 chloroquine phosphate 37 CETYLEV 243 CHLOROQUINE PHOSPHATE 37 CETYLPYRIDINIUM CHLORIDE 253 CHLOROTHIAZIDE 123 cevimeline hcl 163 chlorothiazide 123 CHANTIX 343 chlorothiazide sodium 123

PAGE 371 LAST UPDATED 01/2020 CHLOROXINE 253 CIDOFOVIR 254 CHLOROXYLENOL 253 CIFEREX 236 CHLORPHENIRAMINE MALEATE 64 CIFRAZOL 236 chlorpromazine hcl 133 cilostazol 230 CHLORPROMAZINE HCL 133,253 CILOXAN 167 CHLORPROPAMIDE 179 CIMDUO 40 chlorthalidone 123 CIMETIDINE 218 CHLORTHALIDONE 123 cimetidine 218 chlorzoxazone 317 CIMETIDINE HCL 218 CHOCOLATE FLAVOR 299 cimetidine hcl 218 CHOCOLATE HAZELNUT FLAVOR 299 CIMZIA 213 CHOLBAM 213 CIMZIA PREFILLED 213 CHOLECALCIFEROL 254 CIMZIA STARTER KIT 213 CHOLESTEROL 254 cinacalcet hcl 195 cholestyramine 104 CINNAMON BARK 254 CHOLESTYRAMINE 254 CINNAMON FLAVOR 299 cholestyramine light 104 CINQAIR 61 CHOLINE & MAG TRISALICYLATE 15 CINRYZE 231 CHOLINE BITARTRATE 339 CINVANTI 210 CHOLINE CHLORIDE 254 CIPRO 54 CHOLINE MAG TRISALICYLATE 254 CIPRO HC 176 choline-mag trisalicylate 15 CIPRO XR 54 CHONDROITIN SULFATE 167 CIPRODEX 176 CHONDROITIN SULFATE SODIUM 254 CIPROFLOXACIN 54,254 CHORIONIC GONADOTROPIN 195,254 ciprofloxacin 54 CHROMIC CHLORIDE 254 ciprofloxacin hcl 54,167 CHROMIUM CHLORIDE 254 CIPROFLOXACIN HCL 54,254 CHROMIUM K SULFATE DODECAHYD 254 ciprofloxacin in d5w 54 CHROMIUM PICOLINATE 254 CIPROFLOXACIN-CIPROFLOX HCL ER 55 CHROMIUM POLYNICOTINATE 254 CIPROFLOXACIN-FLUOCINOLONE PF 176 CHRYSIN 254 CISAPRIDE 254 CHYMOTRYPSIN (ALPHA) 294 cisatracurium besylate 319 CIALIS 118,119 CISATRACURIUM BESYLATE 319 ciclodan 143 cisatracurium besylate (pf) 319 CICLODAN SOLUTION 143 cisplatin 75 ciclopirox 143 CISPLATIN 254 CICLOPIROX OLAMINE 143 citalopram hydrobromide 128 ciclopirox olamine 143 CITRANATAL 90 DHA 328 ciclopirox treatment 144 CITRANATAL ASSURE 328 cidaleaze 144 CITRANATAL B-CALM 328 cidofovir 40 CITRANATAL BLOOM 328

PAGE 372 LAST UPDATED 01/2020 CITRANATAL BLOOM DHA 328 clindamycin phos-benzoyl perox 144 CITRANATAL DHA 328 clindamycin phosphate 32,144,226 CITRANATAL HARMONY 329 CLINDAMYCIN PHOSPHATE 144,254 CITRANATAL MEDLEY 329 clindamycin phosphate in d5w 32 CITRANATAL RX 329 CLINDAP-T 144 CITRIC ACID 254 CLINDESSE 226 CITRIC ACID ANHYDROUS 254 clinisol sf 339 CITRIC ACID MONOHYDRATE 254 CLINOLIPID 339 CITRONELLA OIL 254 clinpro 5000 163 CITRUS BIOFLAVONOIDS 254 CLIOQUINOL 144 cladribine 75 clobazam 309 CLAFORAN 53 CLOBETASOL 17 PROPIONATE 144 CLAFORAN IN D5W 53 clobetasol prop emollient base 144 claravis 144 CLOBETASOL PROPIONATE 144 CLARIFOAM EF 144 clobetasol propionate 144 CLARINEX 64 clobetasol propionate e 144 CLARINEX-D 12 HOUR 65 clobetasol propionate emulsion 144 clarithromycin 55 CLOBEX 144 CLARITHROMYCIN 55,254 CLOBEX SPRAY 144 clarithromycin er 55 CLOCORTOLONE PIVALATE 144 CLARYS 144 CLOCORTOLONE PIVALATE PUMP 144 clearplex x 144 clodan 144 CLEMASTINE FUMARATE 64 CLODERM 145 clemastine fumarate 64 CLODERM PUMP 145 CLEMIZOLE HCL 254 clofarabine 76 CLENPIQ 216 CLOFAZIMINE 255 CLEOCIN 32,226 CLOLAR 76 CLEOCIN PHOSPHATE 32 CLOMIPHENE CITRATE 195 CLEOCIN-T 144 clomiphene citrate 195 CLEVER CHOICE HOLDING CHAMBER 290 clomipramine hcl 128 CLIDINIUM BROMIDE 254 CLOMIPRAMINE HCL 255 CLIMARA 205 CLONAZEPAM 255 CLIMARA PRO 205 clonazepam 309 clindacin etz 144 clonidine 109 clindacin-p 144 CLONIDINE HCL 109 CLINDAGEL 144 clonidine hcl 109 clindamax 144 clonidine hcl (analgesia) 15 clindamycin hcl 32 clonidine hcl er 3 CLINDAMYCIN HCL 254 clopidogrel bisulfate 231 CLINDAMYCIN HCL MONOHYDRATE 254 CLOPIDOGREL BISULFATE 255 clindamycin palmitate hcl 32 clorazepate dipotassium 127

PAGE 373 LAST UPDATED 01/2020 CLORPRES 109 colestipol hcl 104 CLORSULON 255 COLHIBIN 255 clotrimazole 145,163 COLISTIMETHATE SODIUM 255 CLOTRIMAZOLE 145 colistimethate sodium (cba) 32 clotrimazole-betamethasone 145 COLLAGEN HYDROLYSATE 255 CLOVAGEL 299 COLLAGENASE 145 CLOVE OIL 255 COLLASIL OSA 300 clovique 294 COLLIGINIX 145 CLOZAPINE 133 COLLODION 300 clozapine 133 colocort 138 CLOZARIL 133 COLY-MYCIN M 33 CNL8 NAIL 145 COLYTE WITH FLAVOR PACKS 216 CO-NATAL FA 329 COMBIGAN 167 COAGADEX 231 COMBIPATCH 205 COAL TAR 255 COMBIVENT RESPIMAT 61 COAL TAR EXTRACT 255 COMBIVIR 40 COARTEM 38 COMETRIQ (100 MG DAILY DOSE) 76 COBALT GLUCONATE 255 COMETRIQ (140 MG DAILY DOSE) 76 COBAMAMIDE 255 COMETRIQ (60 MG DAILY DOSE) 76 COCAINE HCL 145 COMPACT SPACE CHAMBER 290 COCAMIDE DEA 255 COMPACT SPACE CHAMBER/LG MASK 290 COCOA BUTTER 299 COMPACT SPACE CHAMBER/MED MASK 290 COCONUT FLAVOR 299 COMPACT SPACE CHAMBER/SM MASK 290 COCONUT OIL 255 COMPLERA 40 CODAR AR 65 COMPLETE NATAL DHA 329 CODEINE PHOSPHATE 18 COMPLETENATE 329 CODEINE SULFATE 18 compro 133 codeine sulfate 18 COMTAN 315 COENZYME Q-10 243 COMVAX 354 COENZYME Q10 255 CONCEPT DHA 329 COFFEE FLAVOR 299 CONCEPT OB 329 COGENTIN 315 CONCERTA 3 COLA FLAVOR 299 CONDYLOX 145 COLAZAL 213 CONRAY 30 287 COLCHICINE 25 CONSTANT TRICHOPHYTON 287 colchicine 25 constulose 216 colchicine-probenecid 25 CONTRAST ALLERGY PREMED PACK 191 COLCRYS 25 CONTRAVE 3 colesevelam hcl 104 controlrx 163 COLESTID 104 CONZIP 18 COLESTID FLAVORED 104 COPASIL 255

PAGE 374 LAST UPDATED 01/2020 COPEGUS 40 COSMOCIL CQ 255 COPIKTRA 76 COSOPT 167 COPPER GLUCONATE 255 COSOPT PF 167 COPPER GLYCINATE 255 cosyntropin 287 COPPER PEPTIDE 255 COTELLIC 76 COPPER SULFATE 323 COTEMPLA XR-ODT 3 CORAL CALCIUM 255 COTTON CANDY FLAVOR 300 CORDARONE 102 COTTONSEED OIL 255 CORDRAN 145 COUMADIN 227 COREG 113 COUMARIN 255 COREG CR 113 covaryx 205 coremino 58 covaryx hs 205 CORGARD 114 COZAAR 109 CORIFACT 231 CPB WC 65 CORLANOR 119 CRAN-RASPBERRY FLAVOR 300 cormax scalp application 145 CRANBERRY 255 CORN OIL 255 CREATINE 255 CORN STARCH 255 CREATINE MONOHYDRATE 255 CORTANE-B 145,176 CREATININE 256 CORTANE-B AQUEOUS 176 CREME DEMENTHE FLAVOR 300 CORTEF 191 CREON 212 CORTENEMA 138 CRESEMBA 36 cortic-nd 176 CRESOL 256 CORTICOTROPIN 255 CRESTOR 104 CORTIFOAM 138 CRINONE 226 CORTISONE ACETATE 191,192 CRIXIVAN 40 CORTISPORIN 145 CROMOLYN SODIUM 61 CORTROSYN 287 cromolyn sodium 61,167,213 CORVERT 102 CROSCARMELLOSE SODIUM 256 CORVITA 329 CROTAMITON 256 corvita 150 236 crotan 145 CORVITE 329 CROTON OIL 256 CORVITE 150 236 CRYOSERV 256 CORVITE FE 236 cryselle-28 184 corvite free 329 CRYSVITA 196 CORZIDE 109 CUBICIN 33 COSENTYX 145 CUBICIN RF 33 COSENTYX (300 MG DOSE) 145 CUCUMBER MELON 256 COSENTYX SENSOREADY (300 MG) 145 CUPRIC CHLORIDE DIHYDRATE 256 COSENTYX SENSOREADY PEN 145 CUPRIC SULFATE 323 COSMEGEN 76 CUPRIMINE 294

PAGE 375 LAST UPDATED 01/2020 CUPUACU BUTTER 256 cyclosporine modified 294 CURCUMIN 256 CYCLOSPORINE MODIFIED 294 CURCUMIN EXTRACT 256 CYFOLEX 236 curity sterile saline 221 CYMBALTA 128 CUSHING SYNDROME DIAGNOSTIC 287 cyotic 176 CUSTOM LIPOTHENE 110 300 cyproheptadine hcl 64 CUSTOM LIPOTHENE 133 300 CYPROHEPTADINE HCL 256 CUSTOM POLYGLYCOL TROCHE BASE 300 CYRAMZA 76 CUTAQUIG 351 cyred 184 CUTIVATE 145 cyred eq 184 CUVITRU 351 CYSTADANE 196 CUVPOSA 218 CYSTAGON 221 cyanocobalamin 236 CYSTARAN 167 CYANOCOBALAMIN 236,256 CYSTEAMINE HCL 256 CYANOKIT 244 CYSVIEW 287 cyclafem 1/35 184 CYTARABINE 76 cyclafem 7/7/7 184 cytarabine (pf) 77 CYCLANDELATE 256 CYTOGAM 351 CYCLESSA 184 CYTOMEL 208 CYCLOBENZAPRINE 256 CYTOTEC 218 CYCLOBENZAPRINE COMFORT PAC 317 CYTOVENE 41 CYCLOBENZAPRINE HCL 256 cytra k crystals 222 cyclobenzaprine hcl 317 CYCLOBENZAPRINEPAX 317 D CYCLODEXTRIN-BETA 256 D-MANNOSE 256 CYCLOGYL 167 D-PENAMINE 294 CYCLOMETHICONE 256 D-RIBOSE 256 CYCLOMYDRIL 167 D.H.E. 45 28 CYCLOPENTASILOX-PEG/PPG DIMETH 256 DACARBAZINE 77 cyclopentolate hcl 167 DACOGEN 77 CYCLOPENTOLATE HCL 256 dactinomycin 77 CYCLOPHENE RAPIDPAQ 317 dalfampridine er 343 cyclophosphamide 76 DALIRESP 61 CYCLOPHOSPHAMIDE 76,256 DANAZOL 177 cycloserine 38 danazol 177 CYCLOSERINE 256 DANTRIUM 317 CYCLOSET 179 DANTROLENE SODIUM 256 CYCLOSPORINE 256 dantrolene sodium 317 cyclosporine 294 DAPIPRAZOLE HCL 256 CYCLOSPORINE A 256 dapsone 33,145 CYCLOSPORINE IN KLARITY 167 DAPSONE 146,256

PAGE 376 LAST UPDATED 01/2020 DAPTACEL 353 DEMEROL 18 DAPTOMYCIN 33 DEMSER 109 daptomycin 33 DENATONIUM BENZOATE 257 DARAPRIM 38 denta 5000 plus 163 darifenacin hydrobromide er 225 dentagel 163 DARZALEX 77 DEOXYCHOLIC ACID 257 dasetta 1/35 184 DEOXYCHOLIC ACID SODIUM 257 dasetta 7/7/7 184 DEPACON 309 DAUNORUBICIN HCL 77 DEPAKENE 309 DAUNOXOME 77 DEPAKOTE 309 DAURISMO 77 DEPAKOTE ER 309 DAXBIA 53 DEPAKOTE SPRINKLES 309 DAYPRO 9 DEPEN TITRATABS 295 daysee 184 DEPLIN 15 321 DAYTRANA 4 DEPLIN 7.5 321 DDAVP 196 DEPO-ESTRADIOL 205 DDAVP RHINAL TUBE 196 DEPO-MEDROL 192 DEBACTEROL 163 DEPO-PROVERA 77,184 deblitane 184 DEPO-SUBQ PROVERA 104 184 decadron 192 DEPO-TESTOSTERONE 177 decitabine 77 DEPOCYT 77 DECON-A 65 DEPRIZINE FUSEPAQ 218 DECON-G 65 DEPRIZINE RAPIDPAQ 218 deferasirox 244 DERMA-SMOOTHE/FS BODY 146 deferoxamine mesylate 244 DERMA-SMOOTHE/FS SCALP 146 DEFITELIO 227 DERMACINRX ETHOXY DIGLYCOL 257 DEFLUX 222 DERMACINRX PUREFOLIX 236 dehydrated alcohol 339 DERMANIC 321 DEHYDROCHOLIC ACID 257 DERMAPAK PLUS 146 DEHYDROEPIANDROSTERONE 257 DERMASHIELD HYDROGEL 300 DEHYDROEPIANDROSTERONE MICRO 257 DERMATOP 146 DELESTROGEN 205 DERMAWERX SURGICAL PLUS PAK 146 DELFLEX-SM/4.25% DEXTROSE 294 dermazene 146 DELSTRIGO 41 DERMAZONE 146 deltasone 192 DERMOTIC 176 deluo 146 DESCOVY 41 delyla 184 DESFERAL 244 DELZICOL 213 desflurane 24 DEMADEX 123 DESICCATED BEEF LIVER 257 DEMECARIUM BROMIDE 257 DESIPRAMINE HCL 128 demeclocycline hcl 58 desipramine hcl 128

PAGE 377 LAST UPDATED 01/2020 DESLORATADINE 64 DEXAMETHASONE-MOXIFLOXACIN 167 desloratadine 64 DEXCHLORPHENIRAMINE MALEATE 64,257 desmopressin ace rhinal tube 196 DEXCOM G4 PLAT PED RCV/SHARE 290 desmopressin ace spray refrig 196 DEXCOM G4 PLAT PED RECEIVER 290 desmopressin acetate 196 DEXCOM G4 PLATINUM RCV/SHARE 290 DESMOPRESSIN ACETATE 257 DEXCOM G4 PLATINUM RECEIVER 290 desmopressin acetate spray 196 DEXCOM G4 PLATINUM TRANSMITTER 290 DESOGEN 184 DEXCOM G4 SENSOR 290 desogestrel-ethinyl estradiol 184 DEXCOM G5 MOB/G4 PLAT SENSOR 290 DESONATE 146 DEXCOM G5 MOBILE RECEIVER 290 DESONIDE 146 DEXCOM G5 MOBILE TRANSMITTER 290 desonide 146 DEXCOM G6 RECEIVER 290 DESOWEN 146 DEXCOM G6 SENSOR 290 desoximetasone 146 DEXCOM G6 TRANSMITTER 290 DESOXIMETASONE 257 DEXCOM RECEIVER KIT 290 DESOXYCORTICOSTERONE ACETATE 257 DEXEDRINE 4 DESOXYN 4 dexedrine 4 DESVENLAFAXINE ER 128,129 dexferrum 236 DESVENLAFAXINE FUMARATE ER 129 dexifol 329 desvenlafaxine succinate er 129 dexmedetomidine hcl 136 DETROL 225 dexmedetomidine hcl in nacl 136 DETROL LA 225 dexmethylphenidate hcl 4 DEVILS CLAW 257 dexmethylphenidate hcl er 4 DEX COMBO 192 DEXONTO 0.4% 192 DEX LA 8 192 DEXOPIN 192 DEXAMETH-MOXIFLOX-KETOROLAC 167 DEXPANTHENOL 213,257 dexamethasone 192 dexrazoxane hcl 77 DEXAMETHASONE 192,257 DEXTENZA 168 DEXAMETHASONE (LA) 192 DEXTRAN 40000 257 DEXAMETHASONE ACE & SOD PHOS 192 DEXTRAN 75000 257 DEXAMETHASONE ACETATE 257 dextroamphetamine sulfate 4 DEXAMETHASONE BASE 257 dextroamphetamine sulfate er 4 DEXAMETHASONE INTENSOL 192 DEXTROMETHORPHAN 257 DEXAMETHASONE ISONICOTINATE 257 DEXTROMETHORPHAN HBR 65 DEXAMETHASONE SOD PHOS IN D5W 192 DEXTROMETHORPHAN HBR MONOHYD 65 DEXAMETHASONE SOD PHOS-BUPIV 192 DEXTROSE 339 DEXAMETHASONE SOD PHOSPHATE PF 192 dextrose 339 dexamethasone sod phosphate pf 192 DEXTROSE ANHYDROUS 339 dexamethasone sodium phosphate 167,192 dextrose in lactated ringers 323 DEXAMETHASONE SODIUM DEXTROSE-NACL 323 PHOSPHATE 167,192,257 dextrose-nacl 323

PAGE 378 LAST UPDATED 01/2020 DEXYCU 168 DIETHYLCARBAMAZINE CITRATE 258 DHEA 257 DIETHYLENE GLYCOL MONOETHYL ET 258 DHEA MICRONIZED 257 diethylpropion hcl 4 DIABETA 179 DIETHYLPROPION HCL 4,258 DIACOMIT 309 DIETHYLPROPION HCL ER 4 DIAGNOSTIC 287 diethylpropion hcl er 4 dialyvite 329 DIETHYLSTILBESTROL 258 DIALYVITE 3000 329 DIFFERIN 146 DIALYVITE 5000 329 DIFICID 55 DIALYVITE SUPREME D 329 difil-g forte 61 DIALYVITE/ZINC 329 DIFLORASONE DIACETATE 146 DIAMINOPYRIDINE 257 diflorasone diacetate 146 DIAMOX SEQUELS 123 DIFLUCAN 36 DIASTAT ACUDIAL 310 DIFLUNISAL 15 DIASTAT PEDIATRIC 310 diflunisal 15 diazepam 127 digitek 117 DIAZEPAM 127,257,310 digox 117 diazepam intensol 127 digoxin 117 DIAZOXIDE 257 DIGOXIN 117,258 DIBENZYLINE 109 DIGOXIN MICRONIZED 258 DIBUCAINE 257 DIHYDROCODEINE BITARTRATE 258 DIBUCAINE HCL 257 DIHYDROERGOTAMINE MESYLATE 28 DIBUTYL SQUARATE 258 dihydroergotamine mesylate 28 DICHLORALPHENAZONE 258 DIHYDROXYACETONE (1,3) DIMER 258 DICHLOROACETIC ACID 258 DIINDOLYLMETHANE 258 DICLAZURIL 258 DIIODO-L-THYRONINE 3,5 258 DICLOFENAC EPOLAMINE 146 DILANTIN 310 diclofenac potassium 9 DILANTIN INFATABS 310 diclofenac sodium 9,146,168 DILATRATE-SR 101 DICLOFENAC SODIUM 258 DILAUDID 18 diclofenac sodium er 9 DILAUDID-HP 18 diclofenac-misoprostol 9 DILT-XR 115,116 dicloxacillin sodium 57 diltiazem cd 116 DICOPANOL RAPIDPAQ 64 DILTIAZEM HCL 116,258 DICUMAROL 258 diltiazem hcl 116 dicyclomine hcl 218 diltiazem hcl er 116 DICYCLOMINE HCL 258 diltiazem hcl er beads 116 didanosine 41 diltiazem hcl er coated beads 116 DIETHANOLAMINE 258 DILTIAZEM HCL-SODIUM CHLORIDE 116 DIETHYL PHTHALATE 258 DILUENT FOR LEFAMULIN 300 DIETHYL TOLUAMIDE 258 DILUENT FOR TREPROSTINIL 300

PAGE 379 LAST UPDATED 01/2020 DIMENHYDRINATE 210,258 DIVIGEL 205 DIMERCAPTOPROPANE-SULFONATE NA 258 DIVISTA 236 DIMERCAPTOSUCCINIC ACID 258 DL-3-HYDROXYBUTYRIC ACID SOD 259 DIMETHYL FUMARATE 258 DL-ALANINE 339 DIMETHYL SILOXANE HYDROXYALKYL 258 DL-ALPHA LIPOIC ACID 259 DIMETHYL SULFONE 258 DL-LEUCINE 339 DIMETHYL SULFOXIDE 258 DL-METHIONINE 339 DIMETHYLACETAMIDE 258 DL-PANTHENOL 259 DIMETHYLAMINOETHANOL 258 DL-PANTHENOL ALCOHOL 259 DIMETHYLGLYCINE HCL 259 DL-PHENYLALANINE 339 DINITROCHLOROBENZENE 259 DMAE BITARTRATE 259 DIOSGENIN 259 DMSA 287 DIOSMIN 259 dobutamine hcl 125 DIOVAN 109 dobutamine in d5w 125 DIOVAN HCT 109 DOCEFREZ 77 DIOXYBENZONE 259 DOCETAXEL 78 DIPENTUM 213 DOCETAXEL (NON-ALCOHOL) 78 diphen 64 DOCOSANOL 259 DIPHENHYDRAMINE HCL 64 DOCUSATE SODIUM 216 diphenhydramine hcl 64 DOCUSATE SODIUM-SOD BENZOATE 259 DIPHENIDOL HCL 259 dofetilide 102 diphenoxylate-atropine 209 DOLOPHINE 18 DIPHENOXYLATE-ATROPINE 209 DOLOTRANZ 146 DIPHENYLCYCLOPROPENONE 259 donepezil hcl 343 DIPHTHERIA-TETANUS TOXOIDS DT 353 DONNATAL 218 DIPRIVAN 24 DONNATAL EXTENTABS 218 DIPROLENE 146 DOPAMINE HCL 125,259 DIPROLENE AF 146 dopamine hcl 125 dipyridamole 231 dopamine in d5w 125 DIPYRIDAMOLE 259 DOPTELET 236 DISALCID 15 DORAL 136 DISCOVISC 168 DORIBAX 33 DISOPHENOL 259 DORIPENEM 33 disopyramide phosphate 102 dorzolamide hcl 168 DISULFIRAM 259 DORZOLAMIDE HCL 168,259 disulfiram 343 dorzolamide hcl-timolol mal 168 DITROPAN XL 225 dorzolamide hcl-timolol mal pf 168 DIURIL 123 DOTAREM 287 DIVALPROEX SODIUM 259 DOTHELLE DHA 329 divalproex sodium 310 dotti 205 divalproex sodium er 310 DOUBLE PM 168

PAGE 380 LAST UPDATED 01/2020 DOVATO 41 DUOVISC 168 DOVONEX 146 DUPIXENT 147 DOW CORNING 1501 FLUID 259 DURACHOL 236 DOW CORNING 200 259 DURACLON 15 doxazosin mesylate 109 DURAFIBER 147 DOXAZOSIN MESYLATE 259 DURAFIBER AG 147 doxepin hcl 129 DURAGESIC-100 18 DOXEPIN HCL 129,146,259 DURAGESIC-12 18 doxercalciferol 196 DURAGESIC-25 18 DOXIL 78 DURAGESIC-50 18 doxorubicin hcl 78 DURAGESIC-75 18 doxorubicin hcl liposomal 78 duramorph 18 doxy 100 58 DURAXIN 15 DOXYCYCLINE 146 DUROLANE 317 DOXYCYCLINE HYCLATE 58 dutasteride 222 doxycycline hyclate 58,59 DUTASTERIDE 259 doxycycline monohydrate 59 dutasteride-tamsulosin hcl 222 DOXYCYCLINE MONOHYDRATE 259 DVORAH 18 DOXYLAMINE SUCCINATE 64 DYANAVEL XR 4 DRAKKAR NOIR 259 DYAZIDE 123 DRAX IMAGE DTPA 287 DYCLONINE HCL 259 DRISDOL 341 DYLOJECT 10 DRITHO-CREME HP 146 DYMISTA 67 DRIZALMA SPRINKLE 129 DYPHYLLINE 259 dronabinol 210 DYRENIUM 123 DROPERIDOL 127 DYSPORT 319 droperidol 127 drospiren-eth estrad-levomefol 184 E drospirenone-ethinyl estradiol 184 E-Z SPACER 290 DROXIA 236 E-Z SPACER THE BODY GUARDS PK 290 DRYSOL 146 E-Z-DISK 287 DSUVIA 18 E-Z-DOSE 287 DUAC 146 E.E.S. 400 55 DUAVEE 205 E.E.S. GRANULES 55 DUET DHA 400 329 EASIVENT 290 DUET DHA BALANCED 329 EASIVENT MASK LARGE 290 DUETACT 179 EASIVENT MASK MEDIUM 291 duloxetine hcl 129 EASIVENT MASK SMALL 291 DULOXETINE HCL 259 easygel 163 DUODOTE 244 EC-NAPROSYN 10 DUOPA 315 EC-NAPROXEN 10

PAGE 381 LAST UPDATED 01/2020 EC-RX ESTRADIOL 205 ELESTRIN 205 EC-RX PROGESTERONE 207 eletriptan hydrobromide 28 EC-RX TESTOSTERONE 177 ELFOLATE 321 econazole nitrate 147 ELFOLATE PLUS 321 ECONAZOLE NITRATE 260 ELIDEL 147 ECOZA 147 ELIGARD 78 ED CYTE F 236 ELIMITE 147 ed-spaz 219 elinest 184 EDARBI 109 ELIQUIS 227 EDARBYCLOR 109 ELIQUIS STARTER PACK 227 EDECRIN 123 ELITE-OB 329 EDETATE ACID 260 ELITEK 78 EDETATE CALCIUM DISODIUM 244 ELIXOPHYLLIN 61 EDETATE DISODIUM 260,295 ELLA 185 EDETATE DISODIUM DIHYDRATE 260 ELLENCE 78 EDETATE SODIUM 260 ELMIRON 222 EDETIC ACID 260 ELOCON 147 EDEX 119 ELOCTATE 231 EDLUAR 136 eluryng 185 EDROPHONIUM CHLORIDE 260 ELZONRIS 78 EDURANT 41 EMADINE 168 eemt 205 EMBEDA 18 eemt hs 205 EMCYT 78 efavirenz 41 EMEND 210,211 EFFER-K 323 EMEND TRI-PACK 211 effer-k 323 EMFLAZA 192 EFFERVESCENT BASE 300 EMGALITY 28 effervescent pot chloride 323 EMLA 147 EFFEXOR XR 129 emoquette 185 EFFIENT 231 EMPLICITI 78 EFUDEX 147 EMSAM 129 EGATEN 31 EMTRIVA 41 EGCG 260 EMU OIL 260 EGRIFTA 196 EMULGADE CM 300 EGRIFTA SV 196 EMULSIFYING WAX 300 ELAPRASE 196 EMULSION CONCENTRATE 300 ELAVIL 129 EMVERM 31 ELCYS 339 ENABLEX 225 ELDEPRYL 315 enalapril maleate 109 ELELYSO 236 ENALAPRIL MALEATE 260 ELESTAT 168 enalapril-hydrochlorothiazide 110

PAGE 382 LAST UPDATED 01/2020 enalaprilat 110 EPIDUO 147 ENBRACE HR 329 EPIDUO FORTE 147 ENBREL 10 EPIFOAM 147 ENBREL MINI 10 epinastine hcl 168 ENBREL SURECLICK 10 EPINEPHRINE 125,260 ENDARI 237 epinephrine 125 endocet 18 EPINEPHRINE BASE 260 endodan 18 EPINEPHRINE BITARTRATE 260 ENDOMETRIN 226 EPINEPHRINE HCL-DEXTROSE 125 ENGERIX-B 354 EPINEPHRINE HCL-NACL 125 ENGLISH TOFFEE FLAVOR 300 epinephrine pf 125 ENHERTU 79 EPINEPHRINE PF 125 ENJUVIA 205 EPINEPHRINESNAP-V 125 ENLON 314 EPIPEN 2-PAK 125 ENLON-PLUS 314 EPIPEN JR 2-PAK 126 ENOVARX-AMITRIPTYLINE 260 EPIQUIN MICRO 147 ENOVARX-BACLOFEN 147 epirubicin hcl 79 ENOVARX-CYCLOBENZAPRINE HCL 318 EPISNAP 126 ENOVARX-NAPROXEN 147 epitol 310 ENOVARX-TRAMADOL 147 EPIVIR 41 enoxaparin sodium 227 EPIVIR HBV 42 enpresse-28 185 eplerenone 110 ENROFLOXACIN 260 EPOGEN 237 enskyce 185 epoprostenol sodium 119 ENSTILAR 147 EPROSARTAN MESYLATE 110 entacapone 315 eptifibatide 231 entecavir 41 EPZICOM 42 ENTEREG 213 EQUETRO 133 ENTOCORT EC 192 EQUIPTO-NAPROXEN 147 ENTRESTO 119 ERAXIS 36 ENTYVIO 214 ERBITUX 79 enulose 214 ERGOCAL 341 ENVARSUS XR 295 ERGOCALCIFEROL 341 enzoclear 147 ergocalciferol 341 EPANED 110 ERGOLOID MESYLATES 260,343 EPHEDRINE HCL 61 ERGOMAR 28 EPHEDRINE SULFATE 61,125 ERGOTAMINE TARTRATE 28 ephedrine sulfate 125 ergotamine-caffeine 28 EPHEDRINE SULFATE (PRESSORS) 125 ERIVEDGE 79 EPICYN 147 ERLEADA 79 EPIDIOLEX 310 erlotinib hcl 79

PAGE 383 LAST UPDATED 01/2020 errin 185 estradiol valerate 206 ERTACZO 147 ESTRADIOL VALERATE 260 ertapenem sodium 33 estradiol-norethindrone acet 206 ERWINAZE 79 ESTRING 226 ERY 147 ESTRIOL 260 ery-tab 55 ESTRIOL MICRONIZED 260 ERYGEL 148 ESTRIOL-PROGESTERONE MICRO 206 ERYPED 200 55 ESTROGEL 206 ERYPED 400 55 ESTRONE 260 ERYTHROCIN LACTOBIONATE 55 ESTROPIPATE 206 ERYTHROCIN STEARATE 55 ESTROSTEP FE 185 ERYTHROMYCIN 55 eszopiclone 136 erythromycin 56,148,168 ethacrynate sodium 123 erythromycin base 56 ethacrynic acid 123 ERYTHROMYCIN ESTOLATE 260 ETHAMBUTOL HCL 38 ERYTHROMYCIN ETHYLSUCCINATE 56 ethambutol hcl 38 erythromycin ethylsuccinate 56 ETHER 260 ESBRIET 68,69 ETHINYL ESTRADIOL 206 ESCAVITE 329 ETHOSUXIMIDE 260 ESCAVITE D 329 ethosuximide 310 ESCAVITE LQ 329 ETHOXY DIGLYCOL 260 escitalopram oxalate 129 ETHYL ACETATE 300 esgic 15 ETHYL ALCOHOL 260,300 ESGIC 15 ETHYL OLEATE 261 esmolol hcl 114 ETHYL VANILLIN 261 esmolol hcl-sodium chloride 114 ETHYLCELLULOSE 261 esomeprazole magnesium 219 ETHYLENEDIAMINE 261 esomeprazole sodium 219 ETHYLPARABEN 261 ESOMEPRAZOLE STRONTIUM 219 ethynodiol diac-eth estradiol 185 est estrogens-methyltest 205 ETHYOL 79 est estrogens-methyltest ds 205 ETIDRONATE DISODIUM 196 est estrogens-methyltest hs 205 etodolac 10 estarylla 185 etodolac er 10 estazolam 136 etomidate 24 ESTRACE 205,226 ETOMIDATE 261 estradiol 205,206,226 etonogestrel-ethinyl estradiol 185 ESTRADIOL 206,260 ETOPOPHOS 79 ESTRADIOL BENZOATE 260 ETOPOSIDE 79,261 ESTRADIOL CYPIONATE 260 EUCALYPTOL 261 ESTRADIOL HEMIHYDRATE (BULK) 260 EUCALYPTUS FLAVOR 300 ESTRADIOL MICRONIZED 260 EUCALYPTUS OIL 261

PAGE 384 LAST UPDATED 01/2020 EUCRISA 148 fa-vitamin b-6-vitamin b-12 237 EUFLEXXA 318 fabb 237 EUGENOL 261 FABIOR 148 EUGENOL FLAVOR 300 FABRAZYME 196 EURAX 148 FACTIVE 55 euthyrox 208 FAGRON CAPFILL PRO 300 EVAMIST 206 FAGRON DISPERSAPRO 300 EVANS BLUE 300 FALESSA 185 EVEKEO 4,5 falmina 185 EVEKEO ODT 5 famciclovir 42 EVENITY 196 famotidine 219 everolimus 79 FAMOTIDINE 261 EVICEL 242 FAMVIR 42 EVISTA 196 FANAPT 133 EVITHROM 242 FANAPT TITRATION PACK 133 EVOCLIN 148 FARESTON 80 EVOMELA 79 FARXIGA 179 EVOTAZ 42 FARYDAK 80 EVOXAC 163 FASENRA 61 EXALGO 18 FASENRA PEN 61 EXELDERM 148 FASLODEX 80 EXELON 343,344 fayosim 185 exemestane 80 FAZACLO 133 EXFORGE 110 FD&C YELLOW #5 300 EXFORGE HCT 110 FD&C YELLOW #6 ALUMINUM LAKE 300 EXJADE 244 FDC BLUE 1 300 EXODERM 148 FDC BLUE 2 300 EXONDYS 51 319 FDC GREEN #3 300 exotic-hc 176 FDC RED #3 301 EXQUISITE HRT 300 FDC RED 40 301 EXTINA 148 FDC YELLOW 6 301 EXTRA-VIRT PLUS DHA 329 febuxostat 25 EYLEA 168 FEIBA 231 EZ FLU SHOT-FLUCELVAX 354 felbamate 310 EZ FLU SHOT-FLUVIRIN 354 FELBATOL 310 EZALLOR SPRINKLE 104 FELDENE 10 ezetimibe 104 felodipine er 116 ezetimibe-simvastatin 104 FEM PH 226 FEMARA 80 F FEMCAP 291 F-MELT 300 FEMCON FE 185

PAGE 385 LAST UPDATED 01/2020 FEMHRT LOW DOSE 206 FERROUS SULFATE 237 FEMRING 226 FERULIC ACID 261 femynor 185 FETZIMA 129 FENBENDAZOLE 261 FETZIMA TITRATION 129 fenofibrate 104,105 FEVERFEW 261 FENOFIBRATE 104,105,261 FEXOFENADINE HCL 261 fenofibrate micronized 105 FIASP 179 fenofibric acid 105 FIASP FLEXTOUCH 179 FENOFIBRIC ACID 105 FIASP PENFILL 179 FENOGLIDE 105 FIBRICOR 105 FENOPROFEN CALCIUM 10 FIBRYGA 231 fenoprofen calcium 10 FINACEA 148 FENORTHO 10 finasteride 148,222 fentanyl 18 FINASTERIDE 261 FENTANYL CIT-ROPIVACAINE-NACL 18 FIORICET 15 FENTANYL CITRATE 19 FIORICET/CODEINE 19 fentanyl citrate 19 FIORINAL 16 fentanyl citrate (pf) 19 FIORINAL/CODEINE #3 19 FENTANYL CITRATE (PF) 19 FIRAZYR 231 FENTANYL CITRATE-NACL 19 FIRDAPSE 314 FERAHEME 237 FIRMAGON 80 FERIVA 237 FIRST - METOPROLOL 114 FERIVA 21/7 237 FIRST-ATENOLOL 114 FERIVAFA 237 FIRST-BACLOFEN 318 ferocon 237 FIRST-BXN MOUTHWASH 163 ferotrinsic 237 FIRST-DUKES MOUTHWASH 163 FERRALET 90 237 FIRST-HYDROCORTISONE 148 FERRAPLUS 90 237 FIRST-LANSOPRAZOLE 219 FERRIC AMMONIUM CITRATE 261 FIRST-MARYS MOUTHWASH 163 FERRIC CHLORIDE HEXAHYDRATE 261 FIRST-METRONIDAZOLE 33 FERRIC PYROPHOSPHATE 261 FIRST-MOUTHWASH BLM 163 FERRIC SUBSULFATE 261 FIRST-OMEPRAZOLE 219 FERRIC SULFATE 261 FIRST-PROGESTERONE VGS 226 FERRIPROX 244 FIRST-TESTOSTERONE 177 FERRO-PLEX HEMATINIC 237 FIRST-TESTOSTERONE MC 177 ferrocite plus 237 FIRST-VANCOMYCIN 33 FERROTRIN 237 FIRVANQ 33 FERROUS BISGLYCINATE CHELATE 261 FISH FLAVOR 301 FERROUS FUMARATE 261 FIXED OIL SUSPENSION 301 FERROUS GLUCONATE 261 FIZZMIX BASE 301 FERROUS GLUCONATE DIHYDRATE 261 flac 176

PAGE 386 LAST UPDATED 01/2020 FLAGYL 33 FLULAVAL QUADRIVALENT 354 FLAREX 168 FLUMADINE 42 FLAVOR CONC-CHLORHEXIDINE 301 flumazenil 244 FLAVOR SWEET 301 FLUMAZENIL 262 FLAVOR SWEET-SF 301 FLUMIST QUADRIVALENT 354 flavoxate hcl 225 FLUNISOLIDE 61,67 FLEBOGAMMA DIF 351 FLUNIXIN MEGLUMINE 262 flecainide acetate 102 FLUOCINOLONE ACETONIDE 148 FLECTOR 148 fluocinolone acetonide 148,176 flexbumin 231 fluocinolone acetonide body 148 FLEXEPAX 318 fluocinolone acetonide scalp 148 FLEXICHAMBER 291 FLUOCINONIDE 148 FLIBANSERIN 261 fluocinonide 148 FLOLAN 119 fluocinonide emulsified base 148 FLOLIPID 105 FLUOR-A-DAY 323 FLOMAX 222 fluor-a-day 323 FLORIVA 323,329 fluor-i-strips a.t. 168 FLOVENT DISKUS 61 FLUORABON 323 FLOVENT HFA 61 FLUORAC 148 FLOWTUSS 65 FLUORESCEIN 262 FLOXIN OTIC 176 FLUORESCEIN SODIUM 262 floxuridine 80 fluorescein-benoxinate 168 FLOXURIDINE 261 FLUORESCITE 168 FLUAD 354 fluoridex 163 FLUARIX 354 fluoridex daily defense 163 FLUARIX QUADRIVALENT 354 fluoridex daily renewal 163 FLUBLOK 354 fluoridex enhanced whitening 163 FLUBLOK QUADRIVALENT 354 FLUORIDEX SENSITIVITY RELIEF 163 flucaine 168 fluoridex sensitivity relief 163 FLUCELVAX 354 fluoritab 323 FLUCELVAX QUADRIVALENT 354 fluorometholone 168 fluconazole 36 FLUOROPLEX 148 FLUCONAZOLE 261 fluorouracil 80,148 FLUCONAZOLE IN DEXTROSE 36 FLUOROURACIL 148,262 fluconazole in sodium chloride 36 fluoxetine hcl 129 flucytosine 37 FLUOXETINE HCL 130,262 FLUCYTOSINE 261 FLUOXETINE HCL (PMDD) 344 fludarabine phosphate 80 fluoxetine hcl (pmdd) 344 FLUDROCORTISONE ACETATE 192 fluphenazine decanoate 133 fludrocortisone acetate 193 FLUPHENAZINE DECANOATE 262 FLULAVAL 354 FLUPHENAZINE HCL 133

PAGE 387 LAST UPDATED 01/2020 fluphenazine hcl 133 FOLET DHA 330 flura-drops 324 FOLET ONE 330 FLURA-DROPS 324 FOLGARD OS 330 FLURA-SAFE 168 FOLGARD RX 237 flurandrenolide 148 FOLI-D 237 FLURAZEPAM HCL 136 FOLIC ACID 237 FLURBIPROFEN 10 folic acid 237 flurbiprofen 10 FOLIKA-D 237 FLURBIPROFEN SODIUM 168 folika-t 330 flurbiprofen sodium 168 FOLIKA-V 330 flurox 168 FOLIVANE-F 237 flutamide 80 FOLIVANE-OB 330 fluticasone propionate 67,148 FOLIVANE-PLUS 238 FLUTICASONE PROPIONATE 262 FOLIXAPURE 238 fluticasone-salmeterol 62 FOLOTYN 80 fluvastatin sodium 105 folplex 2.2 238 fluvastatin sodium er 105 FOLTANX 321 FLUVIRIN 354 FOLTANX RF 321 FLUVIRIN PRESERVATIVE FREE 354 FOLTRATE 238 fluvoxamine maleate 130 foltrin 238 fluvoxamine maleate er 130 FOLTX 321 FLUZONE 354 folvite-d 238 FLUZONE HIGH-DOSE 354 fomepizole 244 FLUZONE PRESERVATIVE FREE 354 fondaparinux sodium 227 FLUZONE QUADRIVALENT 354 FOOD COLOR BLACK 301 FML 169 FOOD COLOR BLUE 301 FML FORTE 169 FOOD COLOR BROWN 301 FML LIQUIFILM 169 FOOD COLOR GREEN 301 FOCALGIN 90 DHA 329 FOOD COLOR LIME GREEN 301 FOCALGIN CA 329 FOOD COLOR ORANGE 301 FOCALGIN DSS 237 FOOD COLOR PINK 301 FOCALIN 5 FOOD COLOR RED 301 FOCALIN XR 5 FOOD COLOR VIOLET 301 folbee 237 FOOD COLOR WHITE 301 folbee plus 329 FOOD COLOR YELLOW 301 FOLBEE PLUS CZ 330 FORADIL AEROLIZER 62 FOLBIC 321 FORANE 24 FOLBIC RF 321 formadon 245 FOLCAL DHA 330 FORMALDEHYDE 245 FOLCAPS OMEGA 3 330 formaldehyde 245 FOLENE 237 FORMOTEROL FUMARATE 262

PAGE 388 LAST UPDATED 01/2020 FORMOTEROL FUMARATE DIHYDRATE 262 frovatriptan succinate 28 FORSKOLIN 262 FRUCTOSE 339 FORTAZ 53 ful-glo 169 FORTAZ IN D5W 53 FULLERS EARTH 262 FORTEO 197 FULPHILA 238 FORTICAL 197 FULVESTRANT 80 FOSAMAX 197 FULYZAQ 209 FOSAMAX PLUS D 197 FUMARIC ACID 262 fosamprenavir calcium 42 FURADANTIN 223 FOSAPREPITANT DIMEGLUMINE 211 FURAZOLIDONE 262 fosaprepitant dimeglumine 211 FUROSEMIDE 123 FOSCAVIR 42 furosemide 123 fosinopril sodium 110 FUSILEV 80 fosinopril sodium-hctz 110 FUZEON 42 fosphenytoin sodium 310 fyavolv 206 FOSRENOL 214 FYCOMPA 310 FP CEPA 301 FP DERM 301 G FP NATURAL 301 GABA 339 FP SILO 301 GABAPENTIN 262 FRAGMIN 227,228 gabapentin 310 FREEDOM ADAPTADERM 301 GABITRIL 310 FREEDOM CEPAPRO 301 GABLOFEN 318 FREEDOM ESTERDERM 262 GALACTOSE 262 FREEDOM LOLLIPOP BASE 301 GALAFOLD 197 FREEDOM ODT BASE 301 galantamine hydrobromide 344 FREEDOM PEG TROCHE BASE 301 GALANTAMINE HYDROBROMIDE 344 FREEDOM POLOXITOL 301 galantamine hydrobromide er 344 FREEDOM POLYMATRIX 302 GAMASTAN 351 FREEDOM SET-GEL 302 GAMASTAN S/D 351 FREEDOM SILOMAC ANHYDROUS 302 GAMIFANT 295 FREEDOM SILOMAC ULTRA 302 GAMMA-AMINOBUTYRIC ACID 262 FREEDOM SIMPLECAP 302 GAMMAGARD 351 FREEDOM TRIBLEND BASE 302 GAMMAGARD S/D LESS IGA 351 FREESTYLE LIBRE 14 DAY READER 291 GAMMAKED 351 FREESTYLE LIBRE 14 DAY SENSOR 291 GAMMAPLEX 351 FREESTYLE LIBRE READER 291 GAMUNEX-C 351 FREESTYLE LIBRE SENSOR SYSTEM 291 ganciclovir sodium 42 fresenius propoven 24 ganirelix acetate 197 FRESH LINEN FRAGRANCE 262 GARAMYCIN 169 FROVA 28 GARDASIL 354

PAGE 389 LAST UPDATED 01/2020 GARDASIL 9 354 GERANIUM OIL 262 GARDENIA FRAGRANCE 262 GERMALL PLUS 262 GASTROCROM 214 GERMANIUM SESQUIOXIDE 262 GASTROGRAFIN 288 gianvi 185 gatifloxacin 169 GIAZO 214 GATIFLOXACIN 262 gildagia 185 GATIFLOXACIN-DEXAMETHASONE 169 gildess 1.5/30 185 GATTEX 214 gildess 1/20 185 gavilyte-c 216 gildess 24 fe 185 gavilyte-g 217 gildess fe 1.5/30 185 gavilyte-h 217 gildess fe 1/20 185 gavilyte-n with flavor pack 217 GILENYA 344 GAZYVA 80 GILOTRIF 81 GELATIN 302 GILPHEX TR 66 GELCLAIR 163 giltuss pediatric 66 GELNIQUE 225 GILTUSS TR 66 GELNIQUE PUMP 225 GINGER OIL 262 GELSYN-3 318 GINGER ROOT 262 GELX 163 GINSENG ROOT 262 GEMCITABINE HCL 80 GIVLAARI 231 GEMFIBROZIL 105 GLASSIA 69 gemfibrozil 105 glatiramer acetate 344 GEMZAR 81 glatopa 344 GENERESS FE 185 GLEEVEC 81 generlac 214 GLEOLAN 288 gengraf 295 GLEOSTINE 81 GENICIN VITA-D 238 GLIADEL WAFER 81 GENICIN VITA-Q 330 glimepiride 179 genicin vita-s 330 GLIPIZIDE 179 GENISTEIN 262 glipizide 179 GENOTROPIN 197 glipizide er 179 GENOTROPIN MINIQUICK 197 glipizide xl 179 gentak 169 glipizide-metformin hcl 179 GENTAK 169 GLOFIL-125 288 GENTAMICIN IN SALINE 30 glostrips 169 gentamicin in saline 30 GLUCAGEN DIAGNOSTIC 288 gentamicin sulfate 30,149,169 GLUCAGEN HYPOKIT 179 GENTAMICIN SULFATE 149 GLUCAGON EMERGENCY 179 GENTIAN VIOLET 149 GLUCAGON HCL (DIAGNOSTIC) 288 GENVOYA 42 GLUCONOLACTONE 262 GEODON 133 GLUCOPHAGE 179

PAGE 390 LAST UPDATED 01/2020 GLUCOPHAGE XR 180 GLYXAMBI 180 GLUCOSAMINE HCL 262 GOCOVRI 315 GLUCOSAMINE SULFATE 263 GOLD SODIUM THIOMALATE 263 GLUCOSAMINE SULFATE NACL 263 GOLYTELY 217 GLUCOSAMINE SULFATE POTASSIUM 263 GONAL-F 197 glucose 339 GONAL-F RFF 197 GLUCOTROL 180 GONAL-F RFF REDIJECT 197 GLUCOTROL XL 180 GONITRO 101 GLUCOVANCE 180 GORDOFILM 149 GLUTAMINE 339 GORDONS UREA 149 GLUTARALDEHYDE IN WATER 263 grafco silver nit applicator 149 GLUTATHIONE 339 GRAMICIDIN D 263 GLUTATHIONE-L 339 granisetron hcl 211 GLUTATHIONE-L REDUCED 339 GRANISETRON HCL 211 glyburide 180 GRANIX 238 GLYBURIDE 180 GRAPE FLAVOR 302 glyburide micronized 180 GRAPE SEED 263 glyburide-metformin 180 GRAPEFRUIT FLAVOR 302 GLYCATE 219 GRASTEK 350 GLYCERIN 263 green glo lissamine green 169 GLYCERINE 263 GREEN SOAP 263 GLYCEROL FORMAL 263 GREEN TEA 263 GLYCEROL MONOOLEATE 263 GREEN TEA OIL FRAGRANCE 263 GLYCERYL MONOSTEARATE 263 GRIFULVIN V 37 GLYCINE 222,339 GRIS-PEG 37 glycine 222 GRISEOFULVIN MICRONIZED 263 GLYCINE SOYA PROTEIN 263 griseofulvin microsize 37 glycine urologic 222 GRISEOFULVIN MICROSIZE 263 GLYCOFUROL 263 griseofulvin ultramicrosize 37 GLYCOLIC ACID 149,263 grx hicort 25 138 GLYCOPHOS 324 GUAIACOL 263 glycopyrrolate 219 GUAIFENESIN 66 GLYCOPYRROLATE 263 GUANABENZ ACETATE 263 GLYCOPYRROLATE PF 219 GUANETHIDINE SULFATE 263 GLYCOSAMINOGLYCANS 263 guanfacine hcl 110 GLYCYRRHIZIC ACID 263 guanfacine hcl er 5 glydo 149 GUANIDINE HCL 314 GLYGEST 321 GUANIDINEACETIC ACID 263 GLYNASE 180 GUAR GUM 263 GLYRX-PF 219 GUARANA SEED EXTRACT 263 GLYSET 180 GUAVA FLAVOR 302

PAGE 391 LAST UPDATED 01/2020 GUM ARABIC 302 hematogen forte 238 GUM BASE (GELATIN) 302 HEMATOXYLIN 264 GVOKE PFS 180 HEMENATAL OB 330 GYMNEMA SYLVESTRIS LEAF 263 HEMENATAL OB + DHA 330 GYNAZOLE-1 226 HEMETAB 238 HEMLIBRA 231 H hemmorex-hc 138 H20 GEL BASE 302 HEMOCYTE PLUS 238 HAEGARDA 231 hemocyte-f 238 hailey 1.5/30 185 hemocyte-plus 238 hailey 24 fe 185 HEMOFIL M 232 HALAVEN 81 HEPAGAM B 352 halcinonide 149 heparin (porcine) in nacl 228 HALCION 137 HEPARIN (PORCINE) IN NACL 228 HALDOL 133 heparin lock flush 228 HALDOL DECANOATE 133 HEPARIN LOCK FLUSH 228 halobetasol propionate 149 HEPARIN SOD (PORCINE) IN D5W 228 HALOBETASOL PROPIONATE 149 heparin sod (porcine) in d5w 228 HALOG 149 HEPARIN SOD (PORCINE)-D10 228 haloperidol 133 HEPARIN SODIUM 264 HALOPERIDOL 264 heparin sodium (porcine) 228 haloperidol decanoate 133 HEPARIN SODIUM (PORCINE) 228 HALOPERIDOL DECANOATE 264 heparin sodium (porcine) pf 228 haloperidol lactate 133 heparin sodium flush 228 HALOTIN 149 heparin sodium lock flush 228 HAM FLAVOR 302 HEPES 264 HAVRIX 354 HEPLISAV-B 354 HAWTHORN BERRY 264 HEPMED 228 HCG 197 HEPSERA 42 HEALON 169 HEPTAMINOL 264 HEALON GV 169 HERCEPTIN 81 HEALON5 169 HERCEPTIN HYLECTA 81 heather 185 hetastarch-nacl 232 HECTOROL 197 HETLIOZ 137 HELIXATE FS 231 HEXALEN 81 HEMABATE 207 HIBERIX 354 HEMANGEOL 114 HIPREX 223 hematinic plus vit/minerals 238 HISTAMINE PHOSPHATE 264 hematinic/folic acid 238 HIZENTRA 352 hematogen 238 homatropaire 169 HEMATOGEN FA 238 homatropine hbr 169

PAGE 392 LAST UPDATED 01/2020 HOMATROPINE METHYLBROMIDE 264 HYDRAZINE SULFATE 264 HONEY ALMOND FRAGRANCE 264 HYDREA 81 HONEY BEE TREATMENT 350 HYDRO 35 149 HONEY BEE VENOM 350 HYDRO 40 149 HONEY FLAVOR 302 HYDROCHLORIC ACID 264 HORMONE CREAM BASE 302 HYDROCHLOROTHIAZIDE 124 HP ACTHAR 197 hydrochlorothiazide 124 HRT BASE 302 hydrocod polst-cpm polst er 66 HRT BASE (MEN) 302 HYDROCODONE BITARTRATE 264 HRT BOTANICAL 302 HYDROCODONE BITARTRATE ER 19 HRT CREAM 302 hydrocodone-acetaminophen 19 HRT CREAM BASE 302 HYDROCODONE-ACETAMINOPHEN 19 HRT CREAM BASE WOMEN 302 HYDROCODONE-GUAIFENESIN 66 HRT ESSENTIAL 302 hydrocodone-homatropine 66 HRT HEAVY 302 hydrocodone-ibuprofen 19 HRT NATURAL 302 hydrocortisone 138,149,193 HRT NATURAL BASE 302 HYDROCORTISONE 149 HRT NATURAL CREAM BASE 302 hydrocortisone ace-pramoxine 138 HRT SUPREME CREAM BASE 302 hydrocortisone acetate 138 HSA STERILE DILUENT 302 HYDROCORTISONE ACETATE 149 human albumin grifols 232 hydrocortisone butyr lipo base 149 HUMATE-P 232 hydrocortisone butyrate 149 HUMIRA 10 HYDROCORTISONE HEMISUCCINATE 264 HUMIRA PEDIATRIC CROHNS START 10 hydrocortisone in absorbase 149 HUMIRA PEN 10 HYDROCORTISONE MICRONIZED 149 HUMIRA PEN-CD/UC/HS STARTER 11 hydrocortisone valerate 149 HUMIRA PEN-PS/UV/ADOL HS START 11 hydrocortisone-acetic acid 176 HUMULIN R U-500 (CONCENTRATED) 180 hydrocortisone-iodoquinol 149 HUMULIN R U-500 KWIKPEN 180 HYDROFLUORIC ACID 264 HUPERZINE SERRATE A 264 hydromet 66 HYALURONATE SODIUM 264 HYDROMORPHONE HCL 19 HYALURONIC ACID 264 hydromorphone hcl 19 HYALURONIC ACID SODIUM 264 hydromorphone hcl er 19 HYALURONIDASE 264 hydromorphone hcl pf 19 HYALURONIDASE (INTRAOCULAR) 169 HYDROMORPHONE HCL PF 19 HYALURONIDASE BOVINE 295 HYDROMORPHONE HCL-NACL 20 HYCAMTIN 81 HYDROQUINONE 149 HYCET 19 hydroquinone 149 HYCOFENIX 66 HYDROXOCOBALAMIN 264 hydralazine hcl 110 HYDROXOCOBALAMIN ACETATE 238 HYDRALAZINE HCL 264 HYDROXOCOBALAMIN HCL 264

PAGE 393 LAST UPDATED 01/2020 HYDROXYAMPHETAMINE HBR 264 HYQVIA 352 hydroxychloroquine sulfate 38 HYSINGLA ER 20 HYDROXYCHLOROQUINE SULFATE 264 HYSKON 288 HYDROXYETHYL CELLULOSE 264 HYZAAR 110 HYDROXYETHYL METHACRYLATE 264 HYDROXYPROGESTERONE CAPROATE 81,264 I hydroxyprogesterone caproate 207 ibandronate sodium 197 HYDROXYPROPYL CELLULOSE 264 IBRANCE 81 HYDROXYPROPYL METHYLCELLULOSE 264 ibu 11 HYDROXYPROPYL-BETA-CYCLODEXT 265 IBUDONE 20 HYDROXYQUINOLINE SULFATE 265 ibudone 20 HYDROXYTRYPTOPHAN 265 IBUPROFEN 11 HYDROXYTRYPTOPHAN L-5 265 ibuprofen 11 hydroxyurea 81 ibuprofen lysine 11 HYDROXYUREA 265 ibutilide fumarate 103 hydroxyzine hcl 127 icatibant acetate 232 HYDROXYZINE HCL 127,265 ICHTHAMMOL 149 HYDROXYZINE PAMOATE 127 ICLUSIG 82 hydroxyzine pamoate 127 IDAMYCIN PFS 82 HYGEL 149 idarubicin hcl 82 hylavite 330 IDEBENONE 265 HYLENEX 295 IDELVION 232 HYLIRA 149 IDHIFA 82 HYMENOPTRA TESTS 288 IDOXURIDINE 265 hyolev mb 223 IFE-PG20 119 HYOPHEN 224 iferex 150 forte 238 HYOSCYAMINE SULFATE 219 IFEX 82 hyoscyamine sulfate 219 ifosfamide 82 hyoscyamine sulfate er 219 ILARIS 11 hyoscyamine sulfate sl 219 ILEVRO 169 hyosyne 219 ilotycin 169 hypercare 149 ILUMYA 150 HYPERHEP B S/D 352 ILUVIEN 169 HYPERLYTE-CR 324 imatinib mesylate 82 HYPERRAB 352 IMBRUVICA 82,83 HYPERRAB S/D 352 IMFINZI 83 HYPERRHO S/D 352 IMIDUREA 265 HYPERSAL 66 imipenem-cilastatin 33 HYPERTET S/D 352 IMIPRAMINE HCL 130 HYPROMELLOSE 265 imipramine hcl 130 HYPROMELLOSE METHOCEL K100M 265 imipramine pamoate 130

PAGE 394 LAST UPDATED 01/2020 imiquimod 150 INOSITOL 265 IMIQUIMOD 265 INOSITOL HEXANICOTINATE 265 IMITREX 28 INREBIC 83 IMITREX STATDOSE REFILL 29 INSPIRACHAMBER/LARGE 291 IMITREX STATDOSE SYSTEM 29 INSPIRACHAMBER/MEDIUM 291 IMLYGIC 83 INSPIRACHAMBER/MOUTHPIECE 291 IMOGAM RABIES-HT 352 INSPIRACHAMBER/SMALL 291 IMOVAX RABIES 354 INSPIREASE 291 IMPAVIDO 33 INSPIREASE RESERVOIR BAGS 291 IMPOYZ 150 INSPRA 110 IMURAN 295 INSULIN ASP PROT & ASP FLEXPEN 180 IMVEXXY MAINTENANCE PACK 226 INSULIN ASPART 180 IMVEXXY STARTER PACK 226 INSULIN ASPART FLEXPEN 180 INATAL ADVANCE 330 INSULIN ASPART PENFILL 180 INATAL GT 330 INSULIN ASPART PROT & ASPART 180 INATAL ULTRA 330 INTEGRA F 238 INBRIJA 315 INTEGRA PLUS 238 incassia 185 INTELENCE 42 INCRELEX 198 INTRALIPID 339 indapamide 124 INTRAROSA 226 INDERAL LA 114 INTRON A 83 INDERAL XL 114 introvale 185 INDIGO CARMINE 288 INTUNIV 5 indiomin mb 224 INULIN 288 INDOCIN 11 INVANZ 33 INDOCYANINE GREEN 265 INVEGA 134 indocyanine green 288 INVEGA SUSTENNA 134 INDOLE-3-CARBINOL 265 INVEGA TRINZA 134 INDOMETHACIN 11 INVELTYS 169 indomethacin 11 INVIRASE 42 indomethacin er 11 IODINE 265 indomethacin sodium 11 IODINE RESUBLIMED 265 INFANATE BALANCE 330 IODINE STRONG 324 INFANRIX 353 IODINE STRONG (LUGOL'S) 265 INFED 238 IODOFORM 265 INFLECTRA 214 IODOPEN 324 INFUGEM 83 IODOQUINOL 30 INGREZZA 344 IONOSOL-B IN D5W 324 INJECTAFER 238 IONOSOL-MB IN D5W 324 INLYTA 83 IONSYS 20 INNOPRAN XL 114 IOPANOIC ACID 265

PAGE 395 LAST UPDATED 01/2020 IOPIDINE 169 isoxsuprine hcl 119 IPOL 354 ISOXSUPRINE HCL 265 IPRATROPIUM BROMIDE 62 isradipine 116 ipratropium bromide 62,67 ISTALOL 170 ipratropium-albuterol 62 ISTODAX 84 IPRIVASK 228 ISTODAX (OVERFILL) 84 irbesartan 110 ISUPREL 62 irbesartan-hydrochlorothiazide 110 itraconazole 37 IRESSA 83 ITRACONAZOLE 266 irinotecan hcl 84 IV STABILIZER FOR LUMOXITI 303 ISCAR MALI 243 ivermectin 31 ISENTRESS 43 IVERMECTIN 266 ISENTRESS HD 43 IXEMPRA KIT 84 isibloom 185 IXINITY 232 isoflurane 24 ISOMALT LOLLIPOP BASE 302 J ISOMETHEPTENE MUCATE 265 JADENU 244 ISOMETHEPTENE-CAFFEINE-APAP 29 JADENU SPRINKLE 244 isometheptene-caffeine-apap 29 JAKAFI 84 ISOMETHEPTENE-DICHLORAL-APAP 29 JALYN 222 isometheptene-dichloral-apap 29 jantoven 229 ISONIAZID 38 JANUMET 180 isoniazid 38 JANUMET XR 180 ISOPROPAMIDE IODIDE 219 JANUVIA 180 ISOPROPYL ALCOHOL 265 JARDIANCE 180 isopropyl alcohol 265 jasmiel 185 ISOPROPYL MYRISTATE 265 JASMINE FRAGRANCE 266 ISOPROPYL PALMITATE 265 JATENZO 177 isoproterenol hcl 62 jencycla 186 ISOPROTERENOL HCL 265 JETREA 170 ISOPTO ATROPINE 170 jevantique lo 206 ISOPTO CARPINE 170 JEVTANA 84 ISORDIL TITRADOSE 101 jinteli 206 ISOSORBIDE 265 JIVI 232 isosorbide dinitrate 101 JOJOBA OIL 266 ISOSORBIDE DINITRATE ER 101 jolessa 186 isosorbide mononitrate 101 jolivette 186 isosorbide mononitrate er 102 juleber 186 isosulfan blue 288 JULUCA 43 isotretinoin 150 junel 1.5/30 186 ISOTRETINOIN 265 junel 1/20 186

PAGE 396 LAST UPDATED 01/2020 junel fe 1.5/30 186 kcl in dextrose-nacl 324 junel fe 1/20 186 KCL IN DEXTROSE-NACL 324 junel fe 24 186 KCL IN LACTATED RINGERS 324 JUNIPER TAR 266 KCL-LIDOCAINE IN NACL 324 JUXTAPID 105 kedbumin 232 JYNARQUE 198 KEDRAB 352 KEFLEX 54 K kelnor 1/35 186 k-effervescent 324 kelnor 1/50 186 K-PHOS 324 KENALOG 150,193 K-PHOS NO 2 222 KENALOG-80 193 K-PHOS-NEUTRAL 324 kendall sodium chloride flush 324 k-prime 324 KENDALL WET SKIN SCRUB PREP 245 k-sol 324 KEPIVANCE 84 K-TAB 324 KEPPRA 310 k-tan plus 238 KEPPRA XR 310 k-vescent 324 KERALYT 150 KADCYLA 84 KERALYT SCALP 150 KADIAN 20 KETALAR 25 KAHLUA FLAVOR 303 KETAMINE HCL 25,266 kaitlib fe 186 ketamine hcl 25 KALBITOR 232 KETAMINE HCL-SODIUM CHLORIDE 25 KALETRA 43 KETEK 33 kalliga 186 ketoconazole 37,150 KALYDECO 69 KETOCONAZOLE 266 KANAMYCIN SULFATE 266 ketodan 150 KANJINTI 84 KETODAN 150 KANUMA 198 KETOPHENE RAPIDPAQ 150 KAOLIN 209 KETOPROFEN 11,266 KAPSPARGO SPRINKLE 114 KETOPROFEN ER 11 KAPVAY 5 ketorolac tromethamine 11,12,170 KARAYA GUM 303 KETOROLAC TROMETHAMINE 11,150,266 KARBINAL ER 64 KETOROLAC-ROPIV-KETAMINE 12 karidium 324 KETOTIFEN FUMARATE 266 karigel 163 KETOTIFEN HYDROGEN FUMARATE 266 karigel-n 163 KEVEYIS 124 kariva 186 KEVZARA 12 KATERZIA 116 KEYTRUDA 84 KAYEXALATE 295 KHAPZORY 84 KCENTRA 232 KHEDEZLA 130 KCL (IN NACL 0.9%) 324 kimidess 186

PAGE 397 LAST UPDATED 01/2020 KINERET 12 KYLEENA 186 KINETIN 266 KYMRIAH 85 KINEVAC 288 KYNAMRO 105 KINLYTIC 232 KYPROLIS 85 KINRIX 353 kionex 295 L KISQALI 200 DOSE 84 L-ALANINE 339 KISQALI 400 DOSE 84 L-ARGININE 340 KISQALI 600 DOSE 85 L-ARGININE HCL 266 KISQALI FEMARA 200 DOSE 85 L-ASPARAGINE 266 KISQALI FEMARA 400 DOSE 85 L-ASPARTIC ACID 266 KISQALI FEMARA 600 DOSE 85 L-CARNITINE 266 KITABIS PAK 30 L-CARNOSINE 266 KIWI FRAGRANCE 266 L-CITRULLINE 266 KLARITY-A 170 L-CYSTEINE 266 KLARON 150 L-CYSTEINE HCL 266,340 klofensaid ii 150 L-CYSTINE 340 KLONOPIN 310 L-GLUTAMIC ACID 340 klor-con 324 L-GLUTAMIC ACID HCL 212 klor-con 10 324 L-GLUTAMIC ACID MONOSOD SALT 266 klor-con m10 324 L-GLUTAMINE 340 KLOR-CON M15 324 L-HISTIDINE MONOHYDROCHLORIDE 340 klor-con m20 324 L-ISOLEUCINE 340 klor-con sprinkle 325 L-LEUCINE 340 klor-con/ef 325 L-LYSINE HCL 266 KOATE 232 L-MENTHOL 266 KOATE-DVI 232 L-METHIONINE 340 KOGENATE FS 232 L-METHYL-MC 321 KOGENATE FS BIO-SET 233 L-METHYL-MC NAC 321 KOJIC ACID 266 L-METHYLFOLATE 321 KORLYM 180 L-METHYLFOLATE CA ME-CBL NAC 321 KOSHER PRENATAL PLUS IRON 330 L-METHYLFOLATE CALCIUM 266,321 KOVALTRY 233 L-METHYLFOLATE FORMULA 15 321 KRINTAFEL 38 L-METHYLFOLATE FORMULA 7.5 321 KRIS-ESTER 236 303 L-METHYLFOLATE FORTE 321 KRISGEL 100 303 L-METHYLFOLATE-ALGAE 321 KRYSTEXXA 25 L-METHYLFOLATE-ALGAE-B12-B6 321 KUDZU 266 L-METHYLFOLATE-B6-B12 322 kurvelo 186 L-ORNITHINE HYDROCHLORIDE 266 KUVAN 198 L-PHENYLALANINE 340 KYBELLA 150 L-PROLINE 340

PAGE 398 LAST UPDATED 01/2020 L-SELENOMETHIONINE 266 lanthanum carbonate 214 L-SELENOMETHIONINE BLEND 267 LANTUS 181 L-SERINE 267 LANTUS SOLOSTAR 181 L-THREONINE 340 larin 1.5/30 186 L-TRYPTOPHAN 340 larin 1/20 186 L-TYROSINE 340 larin 24 fe 186 L-VALINE 340 larin fe 1.5/30 186 L.E.T. 150 larin fe 1/20 186 labetalol hcl 114 larissia 186 LABETALOL HCL 114,267 LARTRUVO 85 LABETALOL HCL-DEXTROSE 114 LASIX 124 LABETALOL HCL-SODIUM CHLORIDE 114 latanoprost 170 LAC-HYDRIN 150 LATANOPROST 170,267 LACTASE 5000 267 LATISSE 150 lactated ringers 325 LATRIX XM 150 lactic acid 150 LATUDA 134 LACTIC ACID 267 LAURETH-9 POLIDOCANOL 267 LACTOSE 303 LAURIC ACID 267 LACTOSE ANHYDROUS 303 LAVENDER OIL 267 LACTOSE MONOHYDRATE 303 layolis fe 186 lactulose 217 LAZANDA 20 lactulose encephalopathy 214 LDO PLUS 150 LAMICTAL 310 LEAD ACETATE TRIHYDRATE 267 LAMICTAL ODT 310 LEAD TETROXIDE 267 LAMICTAL STARTER 311 LECITHIN 267 LAMICTAL XR 311 LECITHIN SOYA 267 LAMISIL 37 LECITHIN-ISOPROPYL PALMITATE 303 lamivudine 43 leena 186 lamivudine-zidovudine 43 leflunomide 12 LAMOTRIGINE 267 LEFLUNOMIDE 267 lamotrigine 311 LEMON EXTRACT 303 lamotrigine er 311 LEMON FLAVOR 303 lamotrigine starter kit-blue 311 LEMONADE FLAVOR 303 lamotrigine starter kit-green 311 LEMTRADA 344 lamotrigine starter kit-orange 311 LENVIMA 10 MG DAILY DOSE 85 lanolin 303 LENVIMA 12 MG DAILY DOSE 85 LANOLIN ALCOHOL 303 LENVIMA 14 MG DAILY DOSE 86 LANOXIN 117 LENVIMA 18 MG DAILY DOSE 86 LANOXIN PEDIATRIC 117 LENVIMA 20 MG DAILY DOSE 86 lansoprazole 219 LENVIMA 24 MG DAILY DOSE 86 LANSOPRAZOLE 267 LENVIMA 4 MG DAILY DOSE 86

PAGE 399 LAST UPDATED 01/2020 LENVIMA 8 MG DAILY DOSE 86 LEVOLEUCOVORIN CALCIUM 87 LESCOL 106 levoleucovorin calcium 87 LESCOL XL 106 levoleucovorin calcium pf 87 lessina 186 LEVOMEFOLATE CALCIUM 267 LETAIRIS 119 LEVOMEFOLATE DHA 330 letrozole 86 LEVOMEFOLATE GLUCOSAMINE 267 LETROZOLE 267 levonest 186 LEUCINE 340 levonorg-eth estrad triphasic 186 LEUCOVORIN CALCIUM 86,267 levonorgest-eth est & eth est 186 leucovorin calcium 86 levonorgest-eth estrad 91-day 186 LEUKERAN 86 levonorgestrel-ethinyl estrad 187 LEUKINE 239 LEVOPHED 126 leuprolide acetate 86 levora 0.15/30 (28) 187 LEUPROLIDE ACETATE 267 LEVORPHANOL TARTRATE 267 LEVACET 16 LEVOTHYROXINE SODIUM 208,267 levalbuterol hcl 62 levothyroxine sodium 208 LEVALBUTEROL HCL 267 levoxyl 208 LEVALBUTEROL TARTRATE 62 LEVSIN 219 LEVAMISOLE HCL 86 LEVSIN/SL 219 LEVAQUIN 55 LEVULAN KERASTICK 150 LEVBID 219 LEXAPRO 130 LEVEMIR 181 LEXETTE 150 LEVEMIR FLEXTOUCH 181 LEXISCAN 288 LEVETIRACETAM 267 LEXIVA 43 levetiracetam 311 LIALDA 214 levetiracetam er 311 LIBRAX 219 levetiracetam in nacl 311 LIBTAYO 87 levicyn dermal spray 150 LICORICE DEGLYCYRRHIZINATED 267 LEVITRA 119 LICORICE FLAVOR 303 levo-t 208 LICORICE ROOT 268 levobunolol hcl 170 lidazone hc 138 levocarnitine 198 lido-k 150 LEVOCARNITINE 198,267 lido-sorb 150 levocarnitine sf 198 lidocaine 151 levocetirizine dihydrochloride 64 LIDOCAINE 268 LEVOCETIRIZINE DIHYDROCHLORIDE 267 lidocaine hcl 26,151 LEVODOPA 315 LIDOCAINE HCL 26,151,268 levofloxacin 55,170 lidocaine hcl (cardiac) 103 LEVOFLOXACIN 267 LIDOCAINE HCL (CARDIAC) 103 LEVOFLOXACIN HEMIHYDRATE 267 LIDOCAINE HCL (CARDIAC) PF 103 levofloxacin in d5w 55 lidocaine hcl (pf) 26

PAGE 400 LAST UPDATED 01/2020 LIDOCAINE HCL (PF) 26 lindane 151 LIDOCAINE HCL MONOHYDRATE 268 LINDANE 151 lidocaine hcl urethral/mucosal 151 linezolid 33 lidocaine in d5w 103 LINOLEIC ACID 268 LIDOCAINE IN D5W 103 LINSEED OIL 268 lidocaine pak 151 LINZESS 214 lidocaine viscous 163 LIORESAL 318 lidocaine viscous hcl 163 LIOTHYRONINE 268 lidocaine-epinephrine 26 liothyronine sodium 208 LIDOCAINE-EPINEPHRINE 170 LIOTHYRONINE SODIUM 268 lidocaine-hydrocortisone ace 138 LIPACTIVE INCA INCHI WO 268 LIDOCAINE-HYDROCORTISONE ACE 139,151 LIPITOR 106 LIDOCAINE-PHENYLEPHRINE 170 LIPMAX 303 lidocaine-prilocaine 151 LIPO 340 LIDOCAINE-PRILOCAINE (BULK) 303 LIPO-B 239 LIDOCAINE-TETRACAINE 151 LIPO-C 340 LIDOCIDEX I 193 lipodox 87 LIDOCILONE I 193 lipodox 50 87 LIDOCIN 151 LIPOFEN 106 LIDODERM 151 LIPOGEL CR BASE 303 lidopin 151 LIPOIC ACID 268 LIDOPIN 151 LIPOPEN ANHYDROUS 303 LIDORX 151 LIQUIGEL COMPLEX 303 LIDOSOL-HC 151 LIQUIVIDA HYDRATION 325 LIDOTRAL 151 lisinopril 110 LIDOTREX 151 LISINOPRIL 268 LIDOVEX 151 lisinopril-hydrochlorothiazide 110 LIDOVIN 151 lissamine green 170 lidozion 151 LISSAMINE GREEN B 303 LIDOZOL 151 LITEAIRE 291 LILETTA (52 MG) 187 LITHIUM 134 lillow 187 lithium carbonate 134 LIMBREL 322 LITHIUM CARBONATE 134 LIMBREL250 322 lithium carbonate er 134 LIMBREL500 322 LITHIUM CITRATE TETRAHYDRATE 268 LIME FLAVOR 303 LITHOBID 134 LIME OIL 268 LITHOSTAT 222 LIMONENE 268 LIVALO 106 LINCOCIN 33 LIVER FLAVOR 303 lincomycin hcl 33 LO LOESTRIN FE 187 LINCOMYCIN HCL 268 lo-zumandimine 187

PAGE 401 LAST UPDATED 01/2020 LOCOID 151 losartan potassium 110 LOCOID LIPOCREAM 151 losartan potassium-hctz 110 LOCUST BEAN GUM 268 LOSEASONIQUE 187 LODINE 12 LOTEMAX 170 LODOSYN 315 LOTEMAX SM 170 LOESTRIN 1.5/30 (21) 187 LOTENSIN 110 LOESTRIN 1/20 (21) 187 LOTENSIN HCT 110 LOESTRIN FE 1.5/30 187 loteprednol etabonate 170 LOESTRIN FE 1/20 187 LOTREL 110 LOFIBRA 106 LOTRISONE 152 lokara 151 LOTRONEX 214 LOKELMA 295 lovastatin 106 LOMAIRA 5 LOVAZA 106 lomedia 24 fe 187 LOVENOX 229 LOMOTIL 209 low-ogestrel 187 LOMUSTINE 87 loxapine succinate 134 LONHALA MAGNAIR REFILL KIT 62 LOXORAL BASE 303 LONHALA MAGNAIR STARTER KIT 62 LOZI-FLUR 325 LONSURF 87 LUBRAJEL NP 303 LOPERAMIDE HCL 209 LUCEMYRA 345 loperamide hcl 210 LUCENTIS 170 LOPID 106 ludent 325 lopinavir-ritonavir 43 LUFYLLIN 62 lopreeza 206 LUKAID GLA 322 LOPRESSOR 114 LUMIGAN 170 LOPRESSOR HCT 110 LUMIZYME 198 LOPROX 151 LUMOXITI 87 LORATADINE 268 LUNESTA 137 lorazepam 127 LUPANETA PACK 198 LORAZEPAM 268 LUPRON DEPOT (1-MONTH) 87 lorazepam intensol 127 LUPRON DEPOT (3-MONTH) 87 LORAZEPAM-SODIUM CHLORIDE 127 LUPRON DEPOT (4-MONTH) 88 LORBRENA 87 LUPRON DEPOT (6-MONTH) 88 lorcet 20 LUPRON DEPOT-PED (1-MONTH) 199 lorcet hd 20 LUPRON DEPOT-PED (3-MONTH) 199 lorcet plus 20 LURADROX 152 lorid 330 LURIDE 325 lortab 20 LUTEIN 268 LORTAB 20 lutera 187 loryna 187 LUXIQ 152 lorzone 318 LUXTURNA 170

PAGE 402 LAST UPDATED 01/2020 LYNPARZA 88 MAGNESIUM SALICYLATE 269 LYRICA 311 MAGNESIUM STEARATE 303 LYRICA CR 345 MAGNESIUM SULFATE 217,325 LYSINE HCL 268,340 magnesium sulfate 325 lysiplex plus 330 MAGNESIUM SULFATE IN D5W 325 LYSODREN 88 magnesium sulfate in d5w 325 LYSTEDA 242 MAGNESIUM TRISILICATE 209 lyza 187 MAKENA 207 MALARONE 38 M malathion 152 M-M-R II 354 MALEIC ACID 269 M-NATAL PLUS 330 MALIC ACID 269 M-VIT 330 MALTODEXTRIN 269 MACA ROOT 268 MANDELIC ACID 269 MACADAMIA NUT OIL 268 MANGANESE CHLORIDE TETRAHYD 269 MACNATAL CN DHA 330 MANGANESE GLUCONATE 269 MACRILEN 288 MANGANESE SULFATE 269,325 MACROBID 224 MANGO FLAVOR 303 MACRODANTIN 224 MANGO FLAVOR SWEETENED 303 MACUGEN 170 mannitol 124 mafenide acetate 152 MANNITOL 269 MAFENIDE ACETATE 268 MAPLE FLAVOR 303 MAGELLAN INSULIN SAFETY SYR 291 MAPROTILINE HCL 130 MAGNASWEET 110 268 MARATHON MEDICAL PENTIPS 291 MAGNASWEET 135 268 margesic 16 MAGNEBIND 400 325 MARINOL 211 MAGNESIUM ALUMINUM SILICATE 268 marlissa 187 MAGNESIUM AMINO ACID CHELATE 268 MARNATAL-F 330 MAGNESIUM ASCORBATE 268 MARPLAN 130 MAGNESIUM BISGLYCINATE DIHYD 268 MARQIBO 88 MAGNESIUM CARBONATE 325 MARSHMALLOW FLAVOR 303 MAGNESIUM CARBONATE HEAVY 325 marten-tab 16 MAGNESIUM CHLORIDE 325 MATULANE 88 magnesium chloride 325 matzim la 116 MAGNESIUM CITRATE 268 MAVENCLAD (10 TABS) 345 MAGNESIUM GLUCONATE 269 MAVENCLAD (4 TABS) 345 MAGNESIUM GLYCINATE 269 MAVENCLAD (5 TABS) 345 MAGNESIUM HYDROXIDE 269 MAVENCLAD (6 TABS) 345 MAGNESIUM MALATE 269 MAVENCLAD (7 TABS) 345 MAGNESIUM OXIDE 209 MAVENCLAD (8 TABS) 345 MAGNESIUM PHOSPHATE 269 MAVENCLAD (9 TABS) 346

PAGE 403 LAST UPDATED 01/2020 MAVIK 110 mega-c/a plus 341 MAVYRET 44 MEGACE ES 208 MAXALT 29 MEGACE ORAL 88 MAXALT-MLT 29 MEGESTROL ACETATE 88 MAXFE 239 megestrol acetate 88,208 MAXIDEX 171 MEGLUMINE 269 MAXIPIME 54 MEKINIST 88 MAXITROL 171 MEKTOVI 89 MAXZIDE 124 MELATONIN 269 MAXZIDE-25 124 melodetta 24 fe 187 MAYZENT 346 meloxicam 12 MAYZENT STARTER PACK 346 MELOXICAM 12,269 MD-76 R 288 melphalan 89 md-gastroview 288 melphalan hcl 89 me/naphos/mb/hyo1 224 MELQUIN 3 152 MEBENDAZOLE 31 MEMANTINE HCL 269 MECAMYLAMINE HCL 269 memantine hcl 346 MECHLORETHAMINE HCL 269 memantine hcl er 346 MECLIZINE HCL 211 MENACTRA 355 meclizine hcl 211 MENADIONE 269 MECLOFENAMATE SODIUM 12 MENADIONE SODIUM BISULFITE 269 MECLOFENOXATE HCL 269 MENEST 206 MEDI-RDT 304 MENHIBRIX 355 MEDI-RDT BASE 304 MENOMUNE 355 MEDIBASE C 304 MENOPUR 199 MEDICAL PROVIDER EZ AFLURIA PF 354 MENOSTAR 206 MEDICAL PROVIDER EZ FLU 355 MENTHOCIN WITH LIDOCAINE 152 MEDICAL PROVIDER EZ FLU PF 355 MENTHOL 269 MEDICAL PROVIDER EZ FLU SHOT 355 MENVEO 355 MEDICAL PROVIDER EZ FLUVIRIN 355 MEPERIDINE HCL 20 MEDIUM CHAIN TRIGLYCERIDES 269 meperidine hcl 20 MEDROL 193 MEPERIDINE-PROMETHAZINE 20 MEDROXYPROGESTERONE ACE MICRO 269 MEPHYTON 341 MEDROXYPROGESTERONE ACE-LIDO 208 MEPIVACAINE HCL 26 medroxyprogesterone acetate 187,208 meprobamate 127 MEDROXYPROGESTERONE ACETATE 269 MEPRON 33 MEDROXYPROGESTERONE MICRONIZED 269 MEPSEVII 199 MEFENAMIC ACID 12 MEQUINOL 269 mefenamic acid 12 mercaptopurine 89 MEFLOQUINE HCL 38 MERCAPTOPURINE 269 mefloquine hcl 38 MERCAPTOPURINE MONOHYDRATE 270

PAGE 404 LAST UPDATED 01/2020 meropenem 33 methenamine mandelate 224 MEROPENEM-SODIUM CHLORIDE 33 METHENAMINE MANDELATE 270 MERREM 34 methergine 207 MESALAMINE 214 METHIMAZOLE 208 mesalamine 214 methimazole 208 mesalamine er 214 METHIONINE 340 mesalamine-cleanser 214 METHITEST 177 mesna 89 METHOCARBAMOL 270 MESNEX 89 methocarbamol 318 MESTINON 314 METHOCEL E4M 270 METACRESOL ACETATE 270 METHOCEL E4M PREMIUM 270 METADATE CD 5 METHOCEL E4M PREMIUM CR 270 metadate er 5 METHOCEL K100 PREMIUM 270 METAFOLBIC 322 METHOCEL K100M PREMIUM 270 METAFOLBIC PLUS 322 METHOTREXATE 89 METAFOLBIC PLUS RF 322 methotrexate 89 METANX 322 METHOTREXATE (ANTI-RHEUMATIC) 12 METAPROTERENOL SULFATE 62 methotrexate sodium 89 METASTRON 89 METHOTREXATE SODIUM 89 metaxall 318 methotrexate sodium (pf) 89 METAXALONE 318 METHOXSALEN 152 metaxalone 318 methoxsalen rapid 152 METER BUFFER 304 METHOXYAMINE HYDROCHLORIDE 270 metformin hcl 181 METHOXYETHANOL 270 METFORMIN HCL 181,270 methscopolamine bromide 219 metformin hcl er 181 METHSCOPOLAMINE BROMIDE 270 METHACHOLINE CHLORIDE 270 METHSCOPOLAMINE NITRATE 270 METHACRYLIC ACID COPOLYMER A 270 METHYCLOTHIAZIDE 124 methadone hcl 20 METHYL FOLATE 270 METHADONE HCL 20 METHYL METHACRYLATE CROSSPOLY 270 methadone hcl intensol 20 METHYL SULFONE 270 METHADOSE 20 METHYLCELLULOSE 304 methadose 20 METHYLCOBALAMIN 239,270 METHADOSE SUGAR-FREE 21 METHYLCOBALAMIN PREMIUM 270 methamphetamine hcl 5 methyldopa 110 METHANESULFONIC ACID 270 METHYLDOPA-HYDROCHLOROTHIAZIDE 110 METHANOL 270 METHYLDOPATE HCL 111 METHAZOLAMIDE 124 METHYLENE BLUE 244,270 methazolamide 124 methylergonovine maleate 207 METHENAMINE 270 METHYLFOL-ALGAE-B12-ACETYLCYST 322 methenamine hippurate 224 METHYLIN 5

PAGE 405 LAST UPDATED 01/2020 METHYLMETHACRYL CROSSPOLYMER 270 MEXILETINE HCL 103,271 METHYLPARABEN 304 MIACALCIN 199 METHYLPARABEN SODIUM 304 mibelas 24 fe 187 methylphenidate hcl 5,6 MIC COMBO 340 METHYLPHENIDATE HCL 270 MICARDIS 111 methylphenidate hcl er 6 MICARDIS HCT 111 METHYLPHENIDATE HCL ER 6 MICONAZOLE 37 methylphenidate hcl er (cd) 6 MICONAZOLE 3 226 methylphenidate hcl er (la) 6 MICONAZOLE NITRATE 152 METHYLPREDNISOLONE 193 MICORT-HC 152 methylprednisolone 193 MICRHOGAM ULTRA-FILTERED PLUS 352 METHYLPREDNISOLONE ACE-LIDO 193 MICRO-K 325 METHYLPREDNISOLONE ACETATE 193 MICROCHAMBER 291 methylprednisolone acetate 193 microgestin 1.5/30 187 methylprednisolone sodium succ 193 microgestin 1/20 187 METHYLSULFONYLMETHANE 270 microgestin 24 fe 187 METHYLTESTOSTERONE 177 microgestin fe 1.5/30 187 METHYSERGIDE MALEATE 270 microgestin fe 1/20 187 METIPRANOLOL 171 MICROSPACER 291 METOCLOPRAMIDE HCL 214 MICROZIDE 124 metoclopramide hcl 214 MIDAZOLAM 271 METOCLOPRAMIDE HCL MONOHYDRATE 215 midazolam hcl 137 metolazone 124 MIDAZOLAM HCL 137 METOPIRONE 288 midazolam hcl (pf) 137 metoprolol succinate er 114 MIDAZOLAM HCL-SODIUM CHLORIDE 137 METOPROLOL TARTRATE 114 MIDAZOLAM+SYRSPEND SF 137 metoprolol tartrate 114 MIDAZOLAM-KETAMINE-ONDANSETRON 137 metoprolol-hydrochlorothiazide 111 MIDAZOLAM-SODIUM CHLORIDE 137 METOPROLOL-HYDROCHLOROTHIAZIDE 111 midodrine hcl 126 METOZOLV ODT 215 MIFEPREX 199 METROCREAM 152 mifepristone 199 METROGEL 152 MIGERGOT 29 METROGEL-VAGINAL 226 miglitol 181 METROLOTION 152 miglustat 239 metronidazole 34,152 MIGRAL 29 METRONIDAZOLE 270 MIGRALAM 29 METRONIDAZOLE BENZO+SYRSPEND 34 MIGRANAL 29 METRONIDAZOLE BENZOATE 271 migryl 152 metronidazole in nacl 34 mili 187 METRONIDAZOLE IN NACL 34 MILK THISTLE 271 MEVACOR 106 MILLIPRED 193

PAGE 406 LAST UPDATED 01/2020 milrinone lactate 117 MKO MELT DOSE PACK 137 milrinone lactate in dextrose 117 MLD 26 mimvey 206 MOBIC 12 mimvey lo 206 modafinil 6 MINASTRIN 24 FE 187 moderiba 44 MINERAL OIL 217 MODERIBA (1000 MG PACK) 44 mineral oil heavy 217 MODERIBA (1200 MG PACK) 44 MINERAL OIL HEAVY 217 MODERIBA (600 MG PACK) 44 MINERAL OIL LIGHT 217 MODERIBA (800 MG PACK) 44 MINIMED 670G INSULIN PUMP 291 MODICON (28) 188 MINIPRESS 111 moexipril hcl 111 minitran 102 moexipril-hydrochlorothiazide 111 MINIVELLE 206 MOLASSES FLAVOR 304 MINOCIN 59 MOLINDONE HCL 134 MINOCYCLINE HCL 59 MOLYBDENUM 271 minocycline hcl 59 mometasone furoate 68,152 minocycline hcl er 59 MOMETASONE FUROATE 271 minoxidil 111 mondoxyne nl 59 MINOXIDIL 271 mono-linyah 188 MINT CHOCOLATE CHIP FLAVOR 304 MONOBENZONE 271 MIOCHOL-E 171 MONOCLATE-P 233 MIOSTAT 171 MONODOX 59 MIRAPEX 315 MONOETHANOLAMINE 271 MIRAPEX ER 315 MONOJECT BLOOD COLLECTION NDL 291 MIRCERA 239 MONOJECT BLUNT CANNULA 291 MIRCETTE 187 monoject flush syr/hep lock 229 MIRENA (52 MG) 188 monoject flush syringe 325 mirtazapine 130 MONOJECT HYPODERMIC NEEDLE 291 MIRTAZAPINE 271 MONOJECT INSULIN SYRINGE 292 MIRVASO 152 MONOJECT LIFESHIELD SYRINGE 292 misoprostol 219 monoject prefill adv heparin 229 MISOPROSTOL 271 MONOJECT SAFETY SYRINGE/SHIELD 292 MISOPROSTOL DISPERSION (HPMC) 271 monoject sodium chloride flush 325 MISOPROSTOL-HPMC 271 MONOJECT ULTRA COMFORT SYRINGE 292 mitigo 21 mononessa 188 mitomycin 89 MONONINE 233 MITOMYCIN 271 MONOVISC 318 MITOSOL 171 MONSELS FERRIC SUBSULFATE 243 MITOTANE 271 montelukast sodium 62 mitoxantrone hcl 89 MONTELUKAST SODIUM 271 MIXED VESPID VENOM PROTEIN 350 MONUROL 224

PAGE 407 LAST UPDATED 01/2020 MORANTEL TARTRATE 271 multivitamin/fluoride/iron 331 morgidox 59 multivitamins/fluoride 331 MORPHABOND ER 21 mupirocin 152 morphine sulfate 21 MUPIROCIN 271 MORPHINE SULFATE 21 mupirocin calcium 152 morphine sulfate (concentrate) 21 MUPIROCIN CALCIUM 152 morphine sulfate (pf) 21 MURI-LUBE 217 MORPHINE SULFATE (PF) 21 MUSE 119 morphine sulfate er 21 MUSTARGEN 89 MORPHINE SULFATE ER BEADS 21 mutamycin 89 MORPHINE SULFATE-NACL 21 MVASI 89 morrhuate sodium 295 mvc-fluoride 331 MOTEGRITY 215 MYALEPT 199 MOTOFEN 210 MYAMBUTOL 38 MOVANTIK 215 MYCAMINE 37 MOVIPREP 217 MYCOBUTIN 38 MOXATAG 57 mycophenolate mofetil 295 MOXEZA 171 mycophenolate mofetil hcl 295 moxifloxacin hcl 55,171 mycophenolate sodium 295 MOXIFLOXACIN HCL 55,171,271 MYDAYIS 6 moxifloxacin hcl in nacl 55 MYDRIACYL 171 MOXIFLOXACIN HCL-BSS 171 myferon 150 forte 239 MOXISYLYTE HCL 271 MYFORTIC 295 MOZOBIL 239 MYKIDZ IRON FL 331 MS CONTIN 21 MYLERAN 89 MUCOLOX 304 MYLOTARG 89 MULPLETA 239 MYNATAL 331 MULTAQ 103 MYNATAL ADVANCE 331 multi vitamin/fluoride 330 MYNATAL PLUS 331 multi-vit/fluoride 330 MYNATAL-Z 331 multi-vit/fluoride/iron 330 MYNATE 90 PLUS 331 multi-vit/iron/fluoride 330 mynephrocaps 331 multi-vitamin/fluoride 331 mynephron 331 multi-vitamin/fluoride/iron 331 MYOBLOC 320 MULTIGEN 239 myorisan 152 MULTIGEN FOLIC 239 MYRBETRIQ 225 MULTIGEN PLUS 239 MYRJ 53 304 multitrace-4 concentrate 325 MYSOLINE 311 multitrace-5 concentrate 325 MYTESI 210 MULTIVITAMIN/FLUORIDE 331 MYXREDLIN 181 multivitamin/fluoride 331 myzilra 188

PAGE 408 LAST UPDATED 01/2020 NAMENDA XR TITRATION PACK 346 N NAMZARIC 346 N-ACETYL-L-CARNOSINE 271 NANDROLONE DECANOATE 177,272 N-ACETYL-L-CYSTEINE 66 NANDROLONE-TESTOSTERONE CYP&EN 177 n-acetyl-l-cysteine 340 NAPHAZOLINE HCL 171,272 na ferric gluc cplx in sucrose 239 NAPROSYN 12 NABI-HB 352 NAPROXEN 12 nabumetone 12 naproxen 13 NABUMETONE 271 naproxen dr 13 NADH 271 naproxen kit 13 NADH DISODIUM 271 NAPROXEN SODIUM 13 NADOLOL 114 naproxen sodium 13 nadolol 114 naratriptan hcl 29 NADOLOL-BENDROFLUMETHIAZIDE 111 NARCAN 245 nadolol-bendroflumethiazide 111 NARDIL 130 nafcillin sodium 57 NASONEX 68 NAFCILLIN SODIUM 57 NATACHEW 331 NAFCILLIN SODIUM IN DEXTROSE 57 NATACYN 171 nafrinse 325 NATALVIT 331 NAFRINSE DAILY ACIDULATED 163 NATAPRES 272 NAFRINSE DAILY/NEUTRAL 163 NATAZIA 188 nafrinse drops 325 nateglinide 181 NAFRINSE WEEKLY 164 NATELLE ONE 331 naftifine hcl 152 NATPARA 199 NAFTIN 152 NATROBA 152 NAGLAZYME 199 NATURAL MIXED TOCOPHEROLS 272 nalbuphine hcl 21 NATURE-THROID 209 NALBUPHINE HCL 271 NAVELBINE 90 NALFON 12 NAYZILAM 311 NALIDIXIC ACID 224 NAZIREX 152 NALOCET 21 NEBUPENT 34 NALOXONE HCL 244,271 nebusal 66 naloxone hcl 244 NEBUSAL 66 NALOXONE HCL DIHYDRATE 271 necon 0.5/35 (28) 188 NALTREXONE 244,271 necon 1/35 (28) 188 naltrexone hcl 244 NECON 1/50 (28) 188 NALTREXONE HCL 271 NECON 10/11 (28) 188 NALTREXONE HCL ANHYDROUS 271 necon 7/7/7 188 NAMENDA 346 NEEVO DHA 331 NAMENDA TITRATION PAK 346 NEFAZODONE HCL 130 NAMENDA XR 346 nefazodone hcl 130

PAGE 409 LAST UPDATED 01/2020 neo-polycin 171 NEUPOGEN 239 neo-polycin hc 171 NEUPRO 315 NEO-SYNALAR 152 NEURIN-SL 240 neofrin 171 NEURONTIN 311 neomycin sulfate 31 NEUT 325 NEOMYCIN SULFATE 153 neutragard advanced 164 neomycin-bacitracin zn-polymyx 171 neutral sodium fluoride 164 NEOMYCIN-POLYMYXIN B GU 222 NEVANAC 171 neomycin-polymyxin b gu 222 nevirapine 44 neomycin-polymyxin-dexameth 171 nevirapine er 44 NEOMYCIN-POLYMYXIN-GRAMICIDIN 171 NEWGEN 332 NEOMYCIN-POLYMYXIN-HC 171 NEXA PLUS 332 neomycin-polymyxin-hc 176 NEXAVAR 90 NEONATAL COMPLETE 331 NEXIUM 220 NEONATAL PLUS 331 NEXPLANON 188 NEORAL 295 NEXTERONE 103 NEOSPORIN 171 NIACIN 341 NEOSPORIN GU IRRIGANT 222 NIACIN (ANTIHYPERLIPIDEMIC) 106 NEOSTIGMINE METHYLSULFATE 272,314 niacin er (antihyperlipidemic) 106 neostigmine methylsulfate 314 NIACINAMIDE 341 NEOTUSS PLUS 66 NIACOR 106 NEPAFENAC 272 NIAOULI 272 NEPHPLEX RX 331 NIASPAN 106 NEPHRO-VITE RX 331 nicardipine hcl 116 NEPHROCAPS 331 NICARDIPINE HCL IN NACL 116 NEPHROCAPS QT 331 NICLOSAMIDE 272 NEPHRON FA 239 NICOMIDE 332 nephronex 331 NICOTINAMIDE 341 NEPTAZANE 124 NICOTINAMIDE ADENINE DINUCLEO 272 NERLYNX 90 NICOTINAMIDE RIBOSIDE CHLORIDE 272 NESACAINE 26 NICOTINE POLACRILEX 272 NESACAINE-MPF 26 NICOTINE TARTRATE 272 NESTABS 332 NICOTROL 346 NESTABS ABC 332 NICOTROL NS 346 NESTABS DHA 332 nifedical xl 116 NESTABS ONE 332 NIFEDIPINE 116 NETTLE LEAF 272 nifedipine 116 neuac 153 nifedipine er 116 NEULASTA 239 nifedipine er osmotic release 116 NEULASTA ONPRO 239 NIFEREX 240 NEUMEGA 239 nikki 188

PAGE 410 LAST UPDATED 01/2020 NILANDRON 90 nora-be 188 nilutamide 90 NORCO 21 nimodipine 116 norepinephrine bitartrate 126 NIMODIPINE 272 NOREPINEPHRINE BITARTRATE 272 NINLARO 90 NOREPINEPHRINE-DEXTROSE 126 NIPENT 90 NOREPINEPHRINE-SODIUM CHLORIDE 126 NISOLDIPINE ER 116,117 norethin ace-eth estrad-fe 188 nisoldipine er 116 norethin-eth estradiol-fe 188 nitisinone 199 norethindrone 188 NITRIC ACID 272 NORETHINDRONE 272 NITRO-BID 102 norethindrone acet-ethinyl est 188 NITRO-DUR 102 NORETHINDRONE ACETATE 208 NITRO-TIME 102 norethindrone acetate 208 nitrofurantoin 224 norethindrone-eth estradiol 206 NITROFURANTOIN ANHYDROUS 272 NORGESIC FORTE 318 NITROFURANTOIN MACROCRYSTAL 224 norgestim-eth estrad triphasic 188 nitrofurantoin macrocrystal 224 norgestimate-eth estradiol 188 nitrofurantoin monohyd macro 224 NORINYL 1+35 (28) 188 NITROFURAZONE 153 NORINYL 1+50 (28) 188 nitroglycerin 102 NORITATE 153 NITROGLYCERIN 102 norlyda 188 nitroglycerin er 102 norlyroc 188 nitroglycerin in d5w 102 normal saline flush 325 NITROLINGUAL 102 NORPACE 103 NITROMIST 102 NORPACE CR 103 NITRONAL 102 NORPRAMIN 130 NITROPRESS 111 NORTHERA 126 nitroprusside sodium 111 nortrel 0.5/35 (28) 188 NITROSTAT 102 nortrel 1/35 (21) 188 NITYR 199 nortrel 1/35 (28) 188 niva-fol 322 nortrel 7/7/7 188 NIVA-PLUS 332 NORTRIPTYLINE HCL 130 NIVESTYM 240 nortriptyline hcl 130 nizatidine 220 nortuss-de 66 NIZATIDINE 220 NORTUSS-EX 66 NIZORAL 153 NORVASC 117 NOCTIVA 200 NORVIR 44,45 nodolor 29 NOURIANZ 316 nolix 153 NOURISIL 272 NONOXYNOL-9 272 NOVAREL 200 NOR-QD 188 NOVOEIGHT 233

PAGE 411 LAST UPDATED 01/2020 NOVOLOG 181 NOVOLOG FLEXPEN 181 O NOVOLOG MIX 70/30 181 O-CAL FA 332 NOVOLOG MIX 70/30 FLEXPEN 181 O-CAL PRENATAL 332 NOVOLOG PENFILL 181 OB COMPLETE 332 NOVOSEVEN RT 233 OB COMPLETE ADVANCED 332 NOXAFIL 37 OB COMPLETE GOLD 332 NOXIFOL-D 240 OB COMPLETE ONE 332 np thyroid 209 OB COMPLETE PETITE 332 NPLATE 240 OB COMPLETE PREMIER 332 NUBEQA 90 OB COMPLETE/DHA 332 NUCALA 62 OBIZUR 233 NUCORT 153 OBREDON 66 NUCYNTA 21 OBSTETRIX DHA 332 NUCYNTA ER 22 OBSTETRIX EC 332 NUEDEXTA 346 OBSTETRIX ONE 332 NUFERA 240 OCALIVA 215 nufol 240 ocella 189 nulev 220 OCREVUS 347 NULOJIX 295 OCTAGAM 352 NULYTELY WITH FLAVOR PACKS 217 OCTINOXATE 272 NUMBONEX 153 OCTREOTIDE ACETATE 200 NUPLAZID 134 octreotide acetate 200 nutrifac zx 332 OCTYL STEARATE 272 NUTRILIPID 340 ocucoat viscoadherent 171 nutrilyte 325 OCUDOX 59 nutrilyte ii 326 OCUFEN 171 NUTRIVIT 332 OCUFLOX 171 NUVARING 189 ODEFSEY 45 NUVESSA 226 ODOMZO 90 NUVIGIL 6 OFEV 69 NUWIQ 233 OFIRMEV 16 NUZYRA 59 OFLOXACIN 55 nyamyc 153 ofloxacin 55,171 nyata 153 OGESTREL 189 NYLIDRIN HCL 119 OGIVRI 90 NYMALIZE 117 OINTMENT BASE (EMULSIFYING) 304 nystatin 37,153,164 okebo 59 NYSTATIN 272 olanzapine 134 nystatin-triamcinolone 153 olanzapine-fluoxetine hcl 347 nystop 153 OLEABASE PLASTICIZED 304

PAGE 412 LAST UPDATED 01/2020 OLEIC ACID 304 OPTICHAMBER ADVANTAGE-MED MASK 292 OLIVE OIL 272 OPTICHAMBER ADVANTAGE-SM MASK 292 OLLIZAC 322 OPTICHAMBER DIAMOND 292 olmesartan medoxomil 111 OPTICHAMBER DIAMOND-LG MASK 292 OLMESARTAN MEDOXOMIL 272 OPTICHAMBER DIAMOND-MD MASK 292 olmesartan medoxomil-hctz 111 OPTICHAMBER DIAMOND-SM MASK 292 olmesartan-amlodipine-hctz 111 OPTIHALER 292 olopatadine hcl 68,171 OPTIMARK 288 OLUMIANT 13 OPTIVAR 172 OLUX 153 ORA-SWEET 304 OLUX-E 153 ORA-SWEET SF 304 OMECLAMOX-PAK 220 ORACEA 153 omega-3-acid ethyl esters 106 ORACIT 222 OMEGA-3/D-3 WELLNESS PACK 106 ORALAIR 350 OMEGAVEN 340 ORALAIR ADULT SAMPLE KIT 350 omeprazole 220 ORALAIR ADULT STARTER PACK 350 OMEPRAZOLE 272 ORALAIR CHILDRENS SAMPLE KIT 350 OMEPRAZOLE+SYRSPEND SF ALKA 220 ORALAIR CHILDRENS STARTER PACK 350 OMIDRIA 171 oralone 164 OMNARIS 68 ORANGE CREAM FLAVOR 304 OMNIFLEX DIAPHRAGM 292 ORANGE FLAVOR 304 OMNIPAQUE 288 ORANGE OIL FLAVOR 304 OMNIPRED 171 ORAP 347 OMONTYS 240 ORAPEUTIC 164 ONCASPAR 90 ORAPRED ODT 193 ondansetron 211 ORAVIG 164 ondansetron hcl 211 ORBACTIV 34 ONDANSETRON HCL 211,272 ORENCIA 13 ONDANSETRON HCL-NACL 211 ORENCIA CLICKJECT 13 ONEVITE 332 ORENITRAM 120 ONFI 311 ORFADIN 200 ONIVYDE 90 ORIGANUM OIL 272 ONMEL 37 ORILISSA 200 ONPATTRO 347 ORKAMBI 69 ONZETRA XSAIL 29 ORLISTAT 272 OPANA 22 ORNITHINE HCL 272 OPANA ER 22 ORPHENADRINE CITRATE 318 OPDIVO 91 orphenadrine citrate 318 opium 210 orphenadrine citrate er 318 OPSUMIT 119 ORPHENADRINE-ASPIRIN-CAFFEINE 318 OPTICHAMBER ADVANTAGE-LG MASK 292 ORPHENGESIC FORTE 319

PAGE 413 LAST UPDATED 01/2020 orsythia 189 oxaliplatin 91 ORTHO D 240 OXANDRIN 177 ORTHO DF 240 oxandrolone 177 ORTHO MICRONOR 189 OXANDROLONE 273 ORTHO TRI-CYCLEN (28) 189 oxaprozin 14 ORTHO TRI-CYCLEN LO 189 OXAYDO 22 ortho-cs 250 341 oxazepam 127 ORTHO-CYCLEN (28) 189 OXAZEPAM 127,128 ortho-est 0.625 206 OXBRYTA 240 ortho-est 1.25 206 oxcarbazepine 311 ORTHO-FOLIC 240 OXERVATE 172 ORTHO-NOVUM 1/35 (28) 189 OXISTAT 153 ORTHO-NOVUM 7/7/7 (28) 189 OXSORALEN 153 ORTHOVISC 319 OXSORALEN ULTRA 153 oscimin 220 OXTELLAR XR 312 oscimin sr 220 OXYBENZONE 273 oseltamivir phosphate 45 oxybutynin chloride 225 OSELTAMIVIR PHOSPHATE 273 OXYBUTYNIN CHLORIDE 273 osmitrol 124 oxybutynin chloride er 225 OSMOLEX ER 316 OXYCODONE HCL 22 OSMOPREP 217 oxycodone hcl 22 OSPHENA 200 OXYCODONE HCL ER 22 OTEZLA 13 oxycodone-acetaminophen 22 otic care 176 OXYCODONE-ACETAMINOPHEN 22 oticin 176 OXYCODONE-ASPIRIN 22 OTICIN HC NR 176 oxycodone-aspirin 22 OTIPRIO 176 OXYCODONE-IBUPROFEN 22 oto-end 10 176 OXYCONTIN 22 otomax-hc 176 OXYMETAZOLINE HCL 273 OTOVEL 176 OXYMETHOLONE 273 OTOZIN 176 oxymorphone hcl 22 OTREXUP 13,14 OXYMORPHONE HCL ER 22 OVACE PLUS 153 oxymorphone hcl er 22 OVACE PLUS WASH 153 OXYTETRACYCLINE DIHYDRATE 273 OVACE WASH 153 OXYTETRACYCLINE HCL 59 OVCON-35 (28) 189 oxytocin 207 OVIDE 153 OXYTOCIN 273 OVIDREL 200 OXYTOCIN-DEXTROSE 207 oxacillin sodium 57 OXYTOCIN-DEXTROSE-LACT RINGERS 207 OXACILLIN SODIUM IN DEXTROSE 57 OXYTOCIN-LACTATED RINGERS 207 OXALIC ACID DIHYDRATE 273 OXYTROL 225

PAGE 414 LAST UPDATED 01/2020 OZEMPIC 181 PARAFON FORTE DSC 319 OZOBAX 319 PARAFORMALDEHYDE 273 OZURDEX 172 PARAGARD INTRAUTERINE COPPER 189 parcaine 172 P PAREGORIC 210 pacerone 103 PAREMYD 172 paclitaxel 91 PARI LC PLUS NEBULIZER 292 PADCEV 91 PARI TREK S COMBO PACK 292 paliperidone er 134 PARI TREK S W/12V DC ADAPTOR 292 PALMAROSA 273 paricalcitol 201 PALMIDROL 273 PARLODEL 316 PALMITOYL PENTAPEPTIDE-3 273 PARNATE 130 PALMITOYL TRIPEPTIDE-3 273 paroex 164 palonosetron hcl 211 PAROMOMYCIN SULFATE 31,273 PALONOSETRON HCL 211 paromomycin sulfate 31 PALYNZIQ 200 paroxetine hcl 130 PAMELOR 130 paroxetine hcl er 130 PAMIDRONATE DISODIUM 201 paroxetine mesylate 347 PAMINE 220 PARSABIV 201 PAMINE FORTE 220 PASER 38 PAMINE FQ 220 PASSION FRUIT FLAVOR 304 PANCREATIN 273 PASSION FRUIT FLAVOR SWEETENED 304 PANCRELIPASE (LIP-PROT-AMYL) 212 PATADAY 172 pancuronium bromide 320 PATANASE 68 PANDEL 153 PATANOL 172 PANHEMATIN 233 PAXIL 130 panlor 22 PAXIL CR 130 PANRETIN 153 PAZEO 172 PANTHENOL 273 pb-hyoscy-atropine-scopolamine 220 pantoprazole sodium 220 PCCA DMAE COMPLEX 273 PANTOPRAZOLE SODIUM 273 PCCA EMULSIFIX-205 BASE 304 PANZYGA 352 PCCA FIXED OIL BASE 304 PAPAIN 273 PCCA GELATIN BASE 304 PAPAV-PHENTOLAMINE-ALPROSTADIL 120 PCCA LECITHIN ISOPROPYL PALM 304 PAPAVERINE HCL 120 PCCA LIPODERM HMW 304 papaverine hcl 120 PCCA LOXASPERSE BASE 304 PAPAVERINE-ALPROSTADIL 120 PCCA OCCLUSADERM 304 PAPAVERINE-PHENTOLAMINE 120 PCCA PLASTICIZED BASE 304 PARA-AMINOBENZOIC ACID 341 PCCA PLURONIC F127 BASE 305 PARACHLOROPHENOL 273 PCCA POLOXAMER 407 305 PARAFFIN 304 PCCA POLYGLYCOL TROCHE 305

PAGE 415 LAST UPDATED 01/2020 PCCA PRACAMAC BASE 305 PENICILLIN G SODIUM 57 PCCA RAPID DISSOLVE TABLET 305 penicillin v potassium 57 PCCA SORBITOL LOLLIPOP BASE 305 PENICILLIN V POTASSIUM 57 PCCA SPIRA-WASH BASE 305 PENLAC 153 PCCA SWEET-SF 305 PENNSAID 154 PCCA SWEETNESS ENHANCER 305 PENNYROYAL OIL 273 PCCA SYRUP VEHICLE 305 PENTACEL 353 PCCA T3 SODIUM 273 PENTAM 34 PCCA T4 SODIUM 273 pentamidine isethionate 34 PCCA XYLIFOS BASE 305 PENTASA 215 PCE 56 pentazocine-naloxone hcl 22 PEACH FLAVOR 305 PENTETATE CALCIUM TRISODIUM 245 PEANUT BUTTER FLAVOR 305 PENTETATE ZINC TRISODIUM 245 PEANUT OIL 273 PENTIPS 292 PECTIN 210 PENTOBARBITAL SODIUM 137 PEDIADERM AF COMPLETE 153 pentobarbital sodium 137 PEDIADERM HC 153 PENTOSAN POLYSULFATE SODIUM 273 PEDIAPRED 193 PENTOXIFYLLINE 273 PEDIARIX 353 pentoxifylline er 233 PEDITRACE 326 PENTYLENE GLYCOL 274 PEDVAX HIB 355 PENTYLENETETRAZOLE 274 PEG 300 305 PEPCID 220 peg 3350-kcl-na bicarb-nacl 217 PEPPERMINT FLAVOR 305 peg 3350/electrolytes 217 PEPPERMINT OIL 274 PEG 400 MONOSTEARATE 273 PEPSIN 212 peg-3350/electrolytes 217 PERCOCET 22 PEG-40 CASTOR OIL 273 PERCODAN 22 PEG-INTRON 45 PERFLUORODECALIN 274 PEG-INTRON REDIPEN 45 PERFOROMIST 62 PEG-INTRON REDIPEN PAK 4 45 PERGOLIDE MESYLATE 274 peg-prep 217 PERIDEX 164 PEGANONE 312 perindopril erbumine 111 PEGASYS 45 periogard 164 PEGASYS PROCLICK 46 PERJETA 91 PEGINTRON 46 PERLANE 154 pegylax 217 PERLANE-L 154 PENICILLAMINE 273 permethrin 154 penicillamine 295 PERMETHRIN 274 PENICILLIN G POT IN DEXTROSE 57 perphenazine 134 penicillin g potassium 57 PERPHENAZINE 274 PENICILLIN G PROCAINE 57 PERPHENAZINE-AMITRIPTYLINE 347

PAGE 416 LAST UPDATED 01/2020 PERSANTINE 233 PHENYLEPHRINE-GUAIFENESIN 66 PERSERIS 134 PHENYLETHYL ALCOHOL 274 PERUVIAN BALSAM 274 PHENYLETHYLAMINE HCL 274 PEUCEDANUM OSTRUTHIUM EXTRACT 274 PHENYLMERCURIC ACETATE 274 PEXEVA 131 PHENYLMERCURIC NITRATE 274 PFIZERPEN 57 PHENYLPROPANOLAMINE HCL 68 PH BUFFER 305 PHENYLTOLOXAMINE CITRATE 274 phenadoz 64 PHENYTEK 312 phenazo 222 PHENYTOIN 274 PHENAZOPYRIDINE HCL 222 phenytoin 312 phenazopyridine hcl 222 phenytoin infatabs 312 phendimetrazine tartrate 7 PHENYTOIN SODIUM 312 PHENDIMETRAZINE TARTRATE ER 7 phenytoin sodium 312 phenelzine sulfate 131 phenytoin sodium extended 312 PHENELZINE SULFATE 274 philith 189 phenergan 65 phos-flur 164 PHENERGAN 65 PHOSLO 215 PHENINDIONE 274 PHOSLYRA 215 PHENIRAMINE MALEATE 274 phospha 250 neutral 326 PHENOBARBITAL 137 phosphasal 224 phenobarbital 137 PHOSPHATIDYLCHOLINE 274 PHENOBARBITAL SODIUM 137 PHOSPHATIDYLSERINE 274 phenobarbital-belladonna alk 220 phospho-trin 250 neutral 326 phenohytro 220 PHOSPHOLINE IODIDE 172 PHENOL 245 PHOSPHORIC ACID 274 PHENOLSULFONIC ACID 274 phosphorous 326 phenoxybenzamine hcl 111 PHOTOFRIN 91 PHENOXYBENZAMINE HCL 274 PHOTREXA VISCOUS 172 PHENOXYETHANOL 274 PHOTREXA-PHOTREXA VISCOUS KIT 172 phentermine hcl 7 PHOXILLUM B22K4/0 295 PHENTERMINE HCL 274 PHOXILLUM BK4/2.5 295 phentolamine mesylate 111 phrenilin forte 16 PHENTOLAMINE MESYLATE 111,274 PHYSICIANS EZ USE B-12 240 PHENTOLAMINE-ALPROSTADIL 120 physiolyte 295 PHENYL SALICYLATE 274 physiosol irrigation 296 PHENYLBUTAZONE 14 PHYSOSTIGMINE SALICYLATE 245 PHENYLEPHRINE HCL 68,120,126 PHYTIC ACID IN WATER 274 phenylephrine hcl 126,172 PHYTONADIONE 274 PHENYLEPHRINE HCL (PRESSORS) 126 phytonadione 341 PHENYLEPHRINE HCL-DEXTROSE 126 PICATO 154 PHENYLEPHRINE HCL-NACL 126 PIFELTRO 46

PAGE 417 LAST UPDATED 01/2020 pilocarpine hcl 164,172 PLENVU 217 PILOCARPINE HCL 274 PLETAL 233 PILOCARPINE NITRATE 275 PLEXION 154 pimecrolimus 154 PLEXION CLEANSER 154 PIMOBENDAN 275 PLEXION CLEANSING CLOTH 154 PIMOZIDE 347 PLIAGLIS 154 pimtrea 189 PLIXDA 154 PINA COLADA FLAVOR 305 PLURONIC 305 pindolol 114 PLURONIC F127 305 PINE BARK EXTRACT 275 PLURONIC L64 305 PINE NEEDLE OIL 275 PMX-1184 SILICONE 275 PINE OIL 275 PNEUMOVAX 23 355 PINE TAR 275 PNV FE FUM/DOCUSATE/FOLIC ACID 332 PINEAPPLE EXTRACT 275 PNV FOLIC ACID + IRON 332 PINEAPPLE FLAVOR 305 PNV OB+DHA 332 PINENE (L-ALPHA) 275 PNV PRENATAL PLUS MULTIVIT+DHA 332 PINNACAINE OTIC 176 PNV PRENATAL PLUS MULTIVITAMIN 332 pioglitazone hcl 181 PNV TABS 29-1 332 pioglitazone hcl-glimepiride 181 PNV-DHA 332 pioglitazone hcl-metformin hcl 181 PNV-DHA+DOCUSATE 333 piperacillin sod-tazobactam so 58 PNV-OMEGA 333 PIPERAZINE CITRATE 31 PNV-SELECT 333 PIPERINE 275 PNV-TOTAL 333 PIQRAY 200MG DAILY DOSE 91 PNV-VP-U 333 PIQRAY 250MG DAILY DOSE 91 POCKET CHAMBER 292 PIQRAY 300MG DAILY DOSE 91 POCKET SPACER 292 PIRACETAM 275 PODIAPN 322 pirmella 1/35 189 PODOCON 154 pirmella 7/7/7 189 podofilox 154 PIROXICAM 14 PODOFILOX 275 piroxicam 14 PODOPHYLLUM RESIN 154 PLAQUENIL 38 POLIDOCANOL 296 plasbumin-25 233 POLIVY 91 plasbumin-5 233 polocaine 26 PLASMA-LYTE-56 IN D5W 326 polocaine-mpf 27 PLASTIBASE 305 POLOXAMER 188 305 PLASTICIZED BASE 305 POLOXAMER 407 305 PLAVIX 233 poly-dex 172 PLEGRIDY 347 poly-iron 150 forte 240 PLEGRIDY STARTER PACK 347 POLY-PREP 217 plenamine 340 POLY-VI-FLOR 333

PAGE 418 LAST UPDATED 01/2020 POLY-VI-FLOR FS 333 POTABA 341 POLY-VI-FLOR/IRON 333 POTASH SULFURATED LUMP 275 polycin 172 POTASSIUM ACETATE 275,326 polycin b 172 potassium acetate 326 POLYETHYLENE GLYCOL 305 POTASSIUM ACETATE-NACL 326 POLYETHYLENE GLYCOL 1000 305 POTASSIUM AMINOBENZOATE 341 POLYETHYLENE GLYCOL 1450 305 POTASSIUM ASPARTATE 275 POLYETHYLENE GLYCOL 1500 305 POTASSIUM AZELAOYL DIGLYCINATE 275 POLYETHYLENE GLYCOL 300 305 POTASSIUM BENZOATE 275 polyethylene glycol 3350 217 POTASSIUM BICARBONATE 326 POLYETHYLENE GLYCOL 3350 306 potassium bicarbonate 326 POLYETHYLENE GLYCOL 400 306 POTASSIUM BITARTRATE 275 POLYETHYLENE GLYCOL 4500 306 POTASSIUM BROMIDE 276 POLYETHYLENE GLYCOL 600 275 POTASSIUM CARBONATE 276 POLYETHYLENE GLYCOL 8000 306 POTASSIUM CHLORIDE 326 POLYHEXAMETHYLENE BIGUANIDE 275 potassium chloride 326 POLYMAC PROGEL 306 potassium chloride crys er 326 POLYMYXIN B SULFATE 34 potassium chloride er 326 polymyxin b sulfate 34 POTASSIUM CHLORIDE ER 326 polymyxin b-trimethoprim 172 POTASSIUM CHLORIDE IN D5W 326 POLYOX WSR-301 275 potassium chloride in dextrose 326 POLYOXYL 40 STEARATE 306 potassium chloride in nacl 326 POLYPEG 306 potassium chloride proamp 326 polysaccharide iron forte 240 POTASSIUM CITRATE 222 POLYSORBATE 20 275 potassium citrate er 222 POLYSORBATE 40 275 POTASSIUM CITRATE MONOHYDRATE 222 POLYSORBATE 60 275 potassium citrate-citric acid 222 POLYSORBATE 80 275 POTASSIUM GLUCONATE ANHYDROUS 276 POLYTRIM 172 POTASSIUM HYDROXIDE 276 POLYVINYL ALCOHOL 275 POTASSIUM IODIDE 276 POLYVINYLPYRROLIDONE K-30 275 POTASSIUM METABISULFITE 276 POLYVINYLPYRROLIDONE K-90 275 POTASSIUM NITRATE 276 POMALYST 91 POTASSIUM PERCHLORATE 276 POMEGRANATE SEED 275 POTASSIUM PERMANGANATE 276 PONAZURIL 275 POTASSIUM PHOSPHATE DIBASIC 276 PONSTEL 14 POTASSIUM PHOSPHATE MONOBASIC 276 portia-28 189 potassium phosphates 326 PORTRAZZA 91 POTASSIUM PHOSPHATES-DEXTROSE 327 posaconazole 37 POTASSIUM PHOSPHATES-NACL 327 pot & sod cit-cit ac 222 POTASSIUM SODIUM TARTRATE 276 POT BICARB-POT CHLORIDE 326 POTASSIUM SORBATE 306

PAGE 419 LAST UPDATED 01/2020 POTASSIUM SULFATE 276 PRED-G S.O.P. 172 POTELIGEO 92 prednicarbate 154 POTIGA 312 PREDNICARBATE 154 POVIDONE 276 PREDNISOL ACE-MOXIFLOX-BROMFEN 173 POVIDONE K-30 276 PREDNISOLON-GATIFLOX-BROMFENAC 173 POVIDONE-IODINE 172,276 PREDNISOLON-MOXIFLOX-BROMFENAC 173 POWDER SCENT FRAGRANCE 276 PREDNISOLON-MOXIFLOX-KETOROLAC 173 pr benzoyl peroxide wash 154 prednisolone 193 PR NATAL 400 333 PREDNISOLONE 193 PR NATAL 400 EC 333 PREDNISOLONE ACETATE 173,193 PR NATAL 430 333 PREDNISOLONE ACETATE P-F 173 PR NATAL 430 EC 333 PREDNISOLONE ANHYDROUS 193 PRALIDOXIME CHLORIDE 245,276 PREDNISOLONE SODIUM PHOSPHATE 173,193 PRALINES AND CREAM FLAVOR 306 prednisolone sodium phosphate 193 PRALUENT 106 PREDNISOLONE-BROMFENAC 173 pramcort 139 PREDNISOLONE-GATIFLOXACIN 173 pramipexole dihydrochloride 316 PREDNISOLONE-MOXIFLOXACIN 173 pramipexole dihydrochloride er 316 PREDNISONE 193,194 PRAMLYTE 131 prednisone 194 PRAMOSONE 154 PREDNISONE INTENSOL 194 PRAMOSONE E 154 PREFERA OB 333 PRAMOTIC 176 PREFERAOB +DHA 333 pramox 154 PREFERAOB ONE 333 PRAMOXINE HCL 154 PREFEST 206 PRANDIMET 181 PREGABALIN 276 PRANDIN 181 pregabalin 312 PRASTERONE MICRONIZED 276 PREGNENOLONE 276 prasugrel hcl 233 PREGNENOLONE MICRONIZED 276 PRAVACHOL 106 PREGNYL 201 pravastatin sodium 106 PREMARIN 207,226 PRAXBIND 245 premasol 340 praziquantel 32 PREMESISRX 333 PRAZIQUANTEL 276 premium lidocaine 154 PRAZOSIN HCL 111 PREMPHASE 207 prazosin hcl 111 PREMPRO 207 PRE-FOLIC 240 PRENA 1 TRUE 333 PRECEDEX 137 PRENA1 333 PRECOSE 181 PRENA1 PEARL 333 PRED FORTE 172 PRENAISSANCE 333 PRED MILD 172 PRENAISSANCE BALANCE 333 PRED-G 172 PRENAISSANCE HARMONY DHA 333

PAGE 420 LAST UPDATED 01/2020 PRENAISSANCE NEXT 333 PREVPAC 220 PRENAISSANCE NEXT-B 333 PREVYMIS 46 PRENAISSANCE PLUS 333 PREZCOBIX 46 PRENATA 333 PREZISTA 46 PRENATABS FA 333 PRIALT 16 PRENATABS RX 333 PRIFTIN 39 PRENATAL 333 PRILOCAINE 276 PRENATAL + DHA 334 PRILOCAINE HCL 276 PRENATAL 19 334 PRILOSEC 220 PRENATAL PLUS 334 PRIMACARE 334 PRENATAL PLUS IRON 334 primaquine phosphate 38 PRENATAL VITAMIN PLUS LOW IRON 334 PRIMAQUINE PHOSPHATE 38 PRENATAL-U 334 PRIMAXIN IV 34 PRENATE 334 PRIMIDONE 276 PRENATE AM 334 primidone 312 PRENATE DHA 334 PRIMLEV 22 PRENATE ELITE 334 PRIMSOL 34 PRENATE ENHANCE 334 PRINIVIL 111 PRENATE ESSENTIAL 334 PRISMASOL B22GK 2/0 296 PRENATE MINI 334 PRISTIQ 131 PRENATE PIXIE 334 PRIVIGEN 352 PRENATE RESTORE 334 PRIZOTRAL 154 PRENATE STAR 334 PRO COMFORT PEN NEEDLES 292 PREPLUS 334 PROAIR HFA 62 PREPOPIK 217 PROAIR RESPICLICK 62 PREQUE 10 334 probenecid 25 PRETAB 334 PROBUPHINE IMPLANT KIT 22 PRETOMANID 38 PROCAINAMIDE HCL 103 PREVACID 220 procainamide hcl 103 PREVACID SOLUTAB 220 PROCAINE HCL 27 prevalite 107 PROCARBAZINE HCL 276 PREVIDENT 164 PROCARDIA 117 PREVIDENT 5000 BOOSTER 164 PROCARDIA XL 117 PREVIDENT 5000 BOOSTER PLUS 164 PROCENTRA 7 PREVIDENT 5000 DRY MOUTH 164 prochlorperazine 135 PREVIDENT 5000 ENAMEL PROTECT 164 prochlorperazine edisylate 135 PREVIDENT 5000 ORTHO DEFENSE 164 PROCHLORPERAZINE EDISYLATE 276 PREVIDENT 5000 PLUS 164 PROCHLORPERAZINE MALEATE 135 PREVIDENT 5000 SENSITIVE 164 prochlorperazine maleate 135 previfem 189 PROCORT 139 PREVNAR 13 355 PROCRIT 240

PAGE 421 LAST UPDATED 01/2020 procto-med hc 139 propafenone hcl er 103 procto-pak 139 PROPANEDIOL 277 PROCTOCORT 139 PROPANTHELINE BROMIDE 220 PROCTOFOAM HC 139 proparacaine hcl 173 proctosol hc 139 PROPARACAINE HCL 277 proctozone-hc 139 proparacaine-fluorescein 173 PROCYSBI 222 PROPECIA 154 PRODRIN 29 PROPEL 68 profeno 14 PROPEL MINI 68 PROFILNINE 233 propofol 25 PROFILNINE SD 234 PROPOFOL 25 PROFLAVINE HEMISULFATE 276 propranolol hcl 114 progesterone 208 PROPRANOLOL HCL 114,115 PROGESTERONE 276 propranolol hcl er 115 PROGESTERONE COMPOUNDING KIT 208 PROPRANOLOL-HCTZ 111 progesterone micronized 208 PROPYL GALLATE 277 PROGESTERONE MICRONIZED 208,277 PROPYLENE GLYCOL 277 PROGESTERONE MILLED 277 PROPYLENE GLYCOL MONOSTEARATE 277 PROGESTERONE ULTRA MICRONIZED 277 PROPYLPARABEN 306 PROGESTERONE WETTABLE 277 PROPYLPARABEN SODIUM 306 PROGLYCEM 181 propylthiouracil 209 PROGRAF 296 PROPYLTHIOURACIL 277 PROLASTIN-C 69 PROQUAD 355 PROLENSA 173 PROSCAR 222 PROLEUKIN 92 PROSTAGLANDIN E1 277 PROLIA 201 PROSTAGLANDIN E2 277 PROMACTA 240,241 PROSTASCINT 288 PROMAZINE HCL 277 PROSTIN E2 207 promethazine hcl 65 PROSTIN VR 296 PROMETHAZINE HCL 277 PROTAMINE SULFATE 234,277 promethazine vc plain 66 PROTEASE 277 promethazine vc/codeine 66 PROTONIX 220 promethazine-codeine 66 PROTOPIC 154 PROMETHAZINE-DM 66 protriptyline hcl 131 promethazine-dm 66 PROVENGE 92 promethazine-phenyleph-codeine 66 PROVERA 208 PROMETHAZINE-PHENYLEPHRINE 66 PROVIDA DHA 334 promethegan 65 PROVIDA OB 334 PROMETHEGAN 65 PROVIGIL 7 PROMETRIUM 208 PROVISC 173 propafenone hcl 103 PROVOCHOLINE 288

PAGE 422 LAST UPDATED 01/2020 PROZAC 131 QBREXZA 155 PROZAC WEEKLY 131 QNASL 68 PRUDOXIN 154 QNASL CHILDRENS 68 pseudoeph-bromphen-dm 66 QSYMIA 7 pseudoeph-chlorphen-hydrocod 66 QUADRACEL 353 PSEUDOEPH-CHLORPHEN-HYDROCOD 66 QUALAQUIN 38 PSEUDOEPHEDRINE HCL 68 QUARTETTE 189 PSORCON 155 quasense 189 PSYLLIUM HUSK 277 QUATERNIUM-15 277 PULLULAN 277 QUAZEPAM 137 PULMICORT 62 QUDEXY XR 312 PULMICORT FLEXHALER 62 QUELICIN 320 pulmosal 66 QUERCETIN DIHYDRATE 277 PULMOZYME 70 QUESTRAN 107 PUMICE (FLOUR) 277 QUESTRAN LIGHT 107 PUMPKIN FLAVOR 306 quetiapine fumarate 135 PURALOR CI 322 quetiapine fumarate er 135 PUREFE OB PLUS 334 QUFLORA FE 334 PUREFE PLUS 241 QUFLORA FE PEDIATRIC 334 purevit dualfe plus 241 QUFLORA GUMMIES 334 PURIXAN 92 QUFLORA PEDIATRIC 334 PYLERA 221 QUILLICHEW ER 7 PYRANTEL PAMOATE 277 QUILLIVANT XR 7 pyrazinamide 39 QUINACRINE HCL 38 PYRAZINAMIDE 277 quinapril hcl 111 PYRIDIUM 223 quinapril-hydrochlorothiazide 111 PYRIDOSTIGMINE BROMIDE 277,314 QUINIDINE GLUCONATE 103 pyridostigmine bromide 314 quinidine gluconate er 103 pyridostigmine bromide er 314 QUINIDINE SULFATE 103 PYRIDOXAL-5 PHOSPHATE 277 QUINIDINE SULFATE DIHYDRATE 277 PYRIDOXAL-5-PHOSPHATE 277 QUINIDINE SULFATE ER 103 PYRIDOXINE HCL 341 QUININE HCL DIHYDRATE 278 pyridoxine hcl 341 QUININE SULFATE 38 PYRILAMINE MALEATE 65 quinine sulfate 38 PYRIMETHAMINE 277 QUININE SULFATE DIHYDRATE 38 PYROGALLIC ACID 155 QUINIZARIN GREEN SS 306 PYROGALLOL 277 QUINZYME 243 PYRUVIC ACID 277 QVAR 62 QVAR REDIHALER 63 Q QBRELIS 111

PAGE 423 LAST UPDATED 01/2020 REBINYN 234 R REBLOZYL 241 R-GENE 10 288 RECLAST 201 R-NATAL OB 335 reclipsen 189 RABAVERT 355 RECOMBINATE 234 RABEPRAZOLE SODIUM 221 RECOMBIVAX HB 355 rabeprazole sodium 221 RECOTHROM 243 RACEPINEPHRINE HCL 278 RECOTHROM SPRAY KIT 243 RADICAVA 320 rectacort-hc 139 RAGWITEK 350 RECTIV 139 rajani 189 RED YEAST RICE 278 raloxifene hcl 201 REGENT ALCOHOL 306 ramelteon 137 REGIMEX 7 ramipril 112 REGLAN 215 RANEXA 102 REGRANEX 155 ranitidine hcl 221 RELAFEN DS 14 RANITIDINE HCL 221,278 RELAGARD 226 ranolazine er 102 RELENZA DISKHALER 47 RAPAFLO 223 RELEXXII 7 RAPAMUNE 296 RELHIST 66 RAPESEED OIL 278 RELISTOR 215 RAPIVAB 46 RELNATE DHA 335 RAPLIXA 243 RELPAX 29 RASAGILINE MESYLATE 278 RELYYKS 155 rasagiline mesylate 316 remergent hq 155 RASPBERRY CONCENTRATE 306 REMERON 131 RASPBERRY FLAVOR 306 REMERON SOLTAB 131 RASUVO 14 remeven 155 RAUWOLFIA SERPENTINA 278 REMICADE 215 RAVICTI 201 remifentanil hcl 23 RAYALDEE 201 REMODULIN 120 RAZADYNE 347 RENAGEL 215 RAZADYNE ER 347 renal 335 RDT-PLUS 306 RENATABS 335 rea lo 39 155 RENATABS WITH IRON 335 rea lo 40 155 RENEWCREAM HRT 306 REBETOL 46 RENFLEXIS 215 REBIF 347 reno caps 335 REBIF REBIDOSE 347 RENOVAGE 278 REBIF REBIDOSE TITRATION PACK 347 RENOVO LIDO5 155 REBIF TITRATION PACK 348 RENUU NL 155

PAGE 424 LAST UPDATED 01/2020 RENVELA 215 REVCOVI 201 REOPRO 234 REVESTA 241 repaglinide 181 REVIA 245 REPAGLINIDE-METFORMIN HCL 182 REVLIMID 296 REPATHA 107 revonto 319 REPATHA PUSHTRONEX SYSTEM 107 REXAPHENAC 155 REPATHA SURECLICK 107 REXULTI 135 reprexain 23 REYATAZ 47 REPREXAIN 23 REZESOL 155 REQUIP 316 REZIRA 67 REQUIP XL 316 RHEUMATREX 14 RESCON-JR 67 RHOGAM ULTRA-FILTERED PLUS 352 RESCRIPTOR 47 RHOPHYLAC 352 RESCULA 173 RHOPRESSA 173 RESECTISOL 223 RIASTAP 234 RESERPINE 112 RIAX 155 RESERVAPAK 243 ribasphere 47 RESERVAPAK PLUS 243 RIBASPHERE 47 RESORCINOL 278 RIBASPHERE RIBAPAK (1000 PACK) 47 RESPA-BR 65 RIBASPHERE RIBAPAK (1200 PACK) 47 RESPERATE 1.0 292 RIBASPHERE RIBAPAK (600 PACK) 48 RESPERATE 1.1 292 RIBASPHERE RIBAPAK (800 PACK) 48 RESTASIS 173 RIBATAB (1000 MG PACK) 48 RESTASIS MULTIDOSE 173 RIBATAB (1200 MG PACK) 48 restizan 155 RIBATAB (800 MG PACK) 48 RESTORIL 137 ribavirin 48 RESTYLANE 155 RIBAVIRIN 278 RESTYLANE-L 155 RIBOFLAVIN 278 RESVERATROL 278 RIBOFLAVIN 5-PHOSPHATE SODIUM 278 RETACRIT 241 RIBOFLAVIN-5-PHOSPHATE SODIUM 278 RETAVASE 234 RIBOSE (D) 278 RETAVASE HALF-KIT 234 RIDAURA 14 RETIN-A 155 rifabutin 39 RETIN-A MICRO 155 RIFADIN 39 RETIN-A MICRO PUMP 155 RIFAMATE 39 RETINAL 278 rifampin 39 RETINOIC ACID 155 RIFAMPIN 278 RETINOL MOLECULAR FILM 278 RIFAMPIN+SYRSPEND SF 39 RETISERT 173 RIFATER 39 RETROVIR 47 RIFAXIMIN 278 REVATIO 120 RILUTEK 320

PAGE 425 LAST UPDATED 01/2020 riluzole 320 ropivacaine hcl 27 RIMANTADINE HCL 48 ROPIVACAINE HCL 278 RIMSO-50 223 ROPIVACAINE HCL-NACL 27 ringers 327 rosadan 155 RINVOQ 14 rosanil cleanser 155 RIOMET 182 ROSE BENGAL B 278 risedronate sodium 201 ROSE OIL 278 RISPERDAL 135 ROSEMARY OIL 278 RISPERDAL CONSTA 135 ROSIN 278 RISPERDAL M-TAB 135 ROSULA 155 risperidone 135 ROSULA WASH 155 RISPERIDONE 135 rosuvastatin calcium 107 risperidone m-tab 135 ROTARIX 355 RITALIN 7 ROTATEQ 355 RITALIN LA 7,8 ROWASA 215 RITEFLO 292 roweepra 312 ritonavir 48 roweepra xr 312 RITUXAN 92 ROXICET 23 RITUXAN HYCELA 92 ROXICODONE 23 rivastigmine 348 ROXIFOL-D 241 rivastigmine tartrate 348 ROXYBOND 23 rivelsa 189 ROZEREM 137 RIXUBIS 234 ROZLYTREK 92 rizatriptan benzoate 29 RUBIDIUM CHLORIDE 278 ROBAXIN 319 RUBRACA 92 ROBAXIN-750 319 RUCONEST 234 ROBINUL 221 RULAVITE DHA 335 ROBINUL-FORTE 221 RUTIN 278 ROCALTROL 201 RUZURGI 314 ROCEPHIN 54 RYBELSUS 182 ROCKLATAN 173 RYCLORA 65 ROCURONIUM BROMIDE 278,320 RYDAPT 93 rocuronium bromide 320 RYNODERM 155 ROMIDEPSIN 92 RYTARY 316 romycin 173 RYTHMOL 103 RONIDAZOLE 278 RYTHMOL SR 103 ROOT BEER FLAVOR 306 ROPIDEX 194 S ropinirole hcl 316 SABRIL 312 ropinirole hcl er 316 SACCHARIN 322 ROPIV-CLONIDINE-KETOROLAC 27 SACCHARIN CALCIUM 278

PAGE 426 LAST UPDATED 01/2020 SAFFLOWER OIL 278 SAXENDA 8 SAFYRAL 189 scalacort 156 SAGE LEAF 279 SCARLET RED 279 salacyn 155 SCLEROSOL INTRAPLEURAL 70 SALAGEN 164 scopolamine 212 SALEX 156 SCOPOLAMINE HBR 221 salicylic acid 156 SCULPTRA 156 SALICYLIC ACID 156,279 SE-NATAL 19 335 salicylic acid er 156 SE-TAN DHA 335 salicylic acid wart remover 156 se-tan plus 241 salicylic acid-cleanser 156 SEASONIQUE 189 salimez 156 seb-prev wash 156 SALIMEZ FORTE 156 SECONAL 138 saline bacteriostatic 306 SECRETIN-MANNITOL 279 saline flush 327 SECTRAL 115 saline flush zr 327 SECUADO 135 SALISOL 156 SEEBRI NEOHALER 63 salisol forte 156 SELECT-OB 335 SALITECH 156 SELECT-OB+DHA 335 salitech forte 156 SELEGILINE HCL 316 SALRIX 156 selegiline hcl 316 salsalate 16 SELENIOUS ACID 327 SALSALATE 279 SELENIUM 327 SALVAX 156 selenium sulfide 156 SALVAX DUO PLUS 156 SELENIUM SULFIDE 279 SAMSCA 202 SELENIUM YEAST 279 SANCUSO 211 SELRX 156 SANDIMMUNE 296 SELZENTRY 48 SANDOSTATIN 202 SEMPREX-D 67 SANDOSTATIN LAR DEPOT 202 SENNA 279 SANTYL 156 SENSIPAR 202 SAPHRIS 135 sensorcaine 27 SARAFEM 348 sensorcaine-mpf 27 SARAPIN 296 sensorcaine-mpf spinal 27 SASH KIT 229 sensorcaine-mpf/epinephrine 27 sash kit 229 sensorcaine/epinephrine 27 SASSAFRAS OIL 279 SEPICALM VG 279 SAVELLA 348 SEPINEO P 600 306 SAVELLA TITRATION PACK 348 SEREVENT DISKUS 63 SAW PALMETTO 279 SERMORELIN ACETATE 279 SAW PALMETTO BERRY 279 SERMORELIN ACETATE DIAGNOSTIC 288

PAGE 427 LAST UPDATED 01/2020 SERNIVO 156 SILVADENE 157 SEROQUEL 135 SILVER NITRATE 157 SEROQUEL XR 135 SILVER PROTEIN MILD 245 SEROSTIM 202 silver sulfadiazine 157 SEROTONIN HCL 279 SILVER SULFADIAZINE 279 sertraline hcl 131 SILVERSEAL HYDROGEL DRESSING 157 SERTRALINE HCL 279 SIMBRINZA 174 SESAME OIL 279 SIMCOR 107 setlakin 189 SIMETHICONE 215 sevelamer carbonate 215 simliya 189 SEVELAMER HCL 215 simpesse 189 sevelamer hcl 215 SIMPLE SYRUP 306 sevoflurane 25 SIMPLGEL 30 306 SEYSARA 59 SIMPONI 14 sf 164 SIMPONI ARIA 14 sf 5000 plus 164 SIMULECT 296 SFROWASA 215 simvastatin 107 SHARK CARTILAGE 279 SIMVASTATIN 279 sharobel 189 SINCALIDE IN MANNITOL 279 SHEA BUTTER 306 SINEMET 316 SHEA BUTTER ORGANIC 306 SINEMET CR 316 SHELLGEL 173 SINGULAIR 63 SHINGRIX 355 SINOGRAFIN 288 SHOWER FRESH FRAGRANCE 279 SINUVA 68 SHRIMP FLAVOR 306 SIROLIMUS 279 SIBERIAN GINSENG 279 sirolimus 296 SIGNIFOR 202 SIRTURO 39 SIGNIFOR LAR 202 SIVEXTRO 34 SIKLOS 241 SKELAXIN 319 SILAZONE PHARMAPAK 156 skin bleaching 157 SILAZONE-II 156 skin bleaching-sunscreen 157 sildenafil citrate 121 SKLICE 157 SILDENAFIL CITRATE 279 SKYLA 190 SILICA 279 SKYRIZI 150 DOSE 157 SILICON DIOXIDE 279 SLYND 190 SILICON DIOXIDE (SYLOID 244FP) 279 sod benz-sod phenylacet 202 SILICONE BLEND CUSTOM 279 sod citrate-citric acid 223 SILICONE ELASTOMER BLEND 279 SOD HYALURONATE-LIDOCAINE 319 SILICONE FLUID 556 279 SODIUM 4-AMINOSALICYLATE 280 SILIQ 156 sodium acetate 327 silodosin 223 SODIUM ACETATE 327

PAGE 428 LAST UPDATED 01/2020 SODIUM ACETATE TRIHYDRATE 280 SODIUM FLUOROPHOSPHATE 280 SODIUM ALGINATE 280 SODIUM GLUCONATE 280 SODIUM ASCORBATE 341 SODIUM HYALURONATE 157,280 sodium ascorbate 341 SODIUM HYDROXIDE 280,281 SODIUM ASCORBYL PHOS DIHYDRATE 280 SODIUM IODIDE 281 SODIUM ASPARTATE 280 SODIUM LACTATE 281,327 SODIUM ASPARTATE MONOHYDRATE 280 SODIUM LAURETH SULFATE 281 SODIUM BENZOATE 306 SODIUM LAURYL SULFATE 307 SODIUM BICARBONATE 280,327 SODIUM METABISULFITE 281 sodium bicarbonate 327 SODIUM MOLYBDATE 281 SODIUM BICARBONATE-NACL 280 SODIUM MONOFLUOROPHOSPHATE 281 SODIUM BISULFITE 280 SODIUM NITRATE 281 SODIUM BITARTRATE MONOHYDRATE 280 SODIUM NITRITE 281 SODIUM BORATE DECAHYDRATE 280 SODIUM OLEATE 281 SODIUM BROMIDE 280 SODIUM PERBORATE 281 SODIUM BUTYRATE 280 sodium phenylbutyrate 202 SODIUM CACODYLATE 280 SODIUM PHENYLBUTYRATE 281 SODIUM CAPRATE 280 SODIUM PHOSPHATE DIBASIC 281 SODIUM CAPRYLATE 280 SODIUM PHOSPHATE DIBASIC HEPTA 281 SODIUM CARBONATE ANHYDROUS 280 SODIUM PHOSPHATE MONOBASIC 281 SODIUM CARBONATE MONOHYDRATE 280 SODIUM PHOSPHATE TRIBASIC 281 sodium chloride 67,223,327 SODIUM PHOSPHATE-NACL 327 SODIUM CHLORIDE 327 sodium phosphates 327 sodium chloride (pf) 327 SODIUM PHOSPHATES 327 sodium chloride bacteriostatic 306 SODIUM PHOSPHATES-DEXTROSE 327 sodium chloride flush 327 SODIUM PIDOLATE 281 SODIUM CHLORITE 280 sodium polystyrene sulfonate 296 SODIUM CITRATE 223,229 SODIUM PROPIONATE 281 SODIUM CITRATE ANHYDROUS 223 SODIUM PYROPHOSPHATE 281 SODIUM CITRATE DIHYDRATE 280 SODIUM SALICYLATE 16 SODIUM CITRATE LOCK FLUSH 229 SODIUM SELENITE 281 SODIUM COCOYL GLUTAMATE 280 SODIUM STEARATE 281 SODIUM DEHYDROACETATE 280 SODIUM STEARYL FUMARATE 281 SODIUM DEOXYCHOLATE 280 SODIUM SUCCINATE 281 SODIUM DIACETATE 280 sodium sulfacetamide 157 SODIUM DICHLOROACETATE 280 SODIUM SULFACETAMIDE WASH 157 SODIUM DIURIL 124 sodium sulfacetamide wash 157 SODIUM EDECRIN 124 SODIUM SULFATE 281 sodium fluoride 164,327 SODIUM SULFITE 281 SODIUM FLUORIDE 280,327 SODIUM TARTRATE DIHYDRATE 281 sodium fluoride 5000 plus 164 SODIUM TETRADECYL SULFATE 281

PAGE 429 LAST UPDATED 01/2020 SODIUM THIOSALICYLATE 281 SPG SUPPOSI-BASE 307 SODIUM THIOSULFATE 245,307 SPINOSAD 157 sodium thiosulfate 245 SPINRAZA 320 SODIUM VALPROATE 281 SPIRIVA HANDIHALER 63 sojourn 25 SPIRIVA RESPIMAT 63 SOLESTA 296 SPIRONOLACTONE 124 solifenacin succinate 225 spironolactone 124 SOLIRIS 234 spironolactone-hctz 124 SOLOSEC 30 SPIRULINA 282 soloxide 59 SPORANOX 37 SOLTAMOX 93 SPORANOX PULSEPAK 37 SOLU-CORTEF 194 SPRAVATO (56 MG DOSE) 131 SOLU-K 307 SPRAVATO (84 MG DOSE) 131 SOLU-MEDROL 194 sprintec 28 190 SOLU-PREF 229 SPRITAM 312 SOLVATECH SWEET SF 307 SPRIX 14 SOMA 319 SPRYCEL 93 SOMATULINE DEPOT 203 sps 296 SOMAVERT 203 SQUALANE 282 SONATA 138 SQUARIC ACID 282 SORBIC ACID 307 sronyx 190 SORBITAN MONOLAURATE 281 ssd 157 SORBITAN MONOOLEATE 282 SSKI 67 SORBITAN MONOPALMITATE 282 sss 10-5 157 SORBITAN MONOSTEARATE 282 SSS 10-5 157 SORBITOL 282,307 ST JOHNS WORT 282 SORBITOL CANDY BASE 307 STALEVO 100 316 SORIATANE 157 STALEVO 125 316 SORILUX 157 STALEVO 150 317 sorine 115 STALEVO 200 317 sotalol hcl 115 STALEVO 50 317 SOTALOL HCL 115 STALEVO 75 317 sotalol hcl (af) 115 STAMARIL 355 sotalol hydrochloride 115 STANNOUS CHLORIDE DIHYDRATE 282 SOTYLIZE 115 stannous fluoride 164 SOYABEAN CASEIN DIGEST MEDIUM 282 STANNOUS FLUORIDE 282 SOYBEAN LECITHIN 282 STANOZOLOL 282 SOYBEAN OIL 282 STARCH RICE 282 SPEARMINT FLAVOR 307 STARLIX 182 SPEARMINT OIL 282 stavudine 49 SPECTRACEF 54 STAVZOR 312

PAGE 430 LAST UPDATED 01/2020 STEARIC ACID 307 SUCROSE OCTAACETATE 282 STEARYL ALCOHOL 307 sufentanil citrate 23 STELARA 157,216 SUFENTANIL CITRATE 282 STERILE DILUENT FOR REMODULIN 307 SULAR 117 sterile diluent/epoprostenol 307 SULCONAZOLE NITRATE 157 sterile water for injection 307 SULFACETAMIDE 282 STERILE WATER FOR INJECTION 307 sulfacetamide sod-sulfur wash 157 sterile water for irrigation 296 SULFACETAMIDE SODIUM 157,174 STEVIA EXTRACT 282 sulfacetamide sodium 157,174 STEVIA GLYCERITE EXTRACT 307 sulfacetamide sodium (acne) 157 STEVIOL GLYCOSIDES 282 sulfacetamide sodium-sulfur 157,158 STEVIOSIDE 282 SULFACETAMIDE SODIUM-SULFUR 158 STIMATE 203 SULFACETAMIDE-PREDNISOLONE 174 STIOLTO RESPIMAT 63 SULFACETAMIDE-SULFUR IN UREA 158 STIVARGA 93 sulfacetamide-sulfur-sunscreen 158 STRATTERA 8 sulfacleanse 8/4 158 STRAWBERRY FLAVOR 307 SULFADIAZINE 58 STRENSIQ 203 SULFADIAZINE SODIUM 58 STREPTOMYCIN SULFATE 31 SULFADIMETHOXINE 282 STRIBILD 49 SULFAMERAZINE 282 STRIVERDI RESPIMAT 63 SULFAMETHOXAZOLE 58 STROMECTOL 32 SULFAMETHOXAZOLE MICRO 58 STRONTIUM CHLORIDE 282 sulfamethoxazole-trimethoprim 34 STRONTIUM NITRATE 282 sulfamez wash 158 STROVITE FORTE 335 SULFAMYLON 158 SUBLIMAZE 23 SULFANILAMIDE 283 SUBLOCADE 23 SULFAPYRIDINE 58 SUBSYS 23 SULFASALAZINE 216 subvenite 312 sulfasalazine 216 subvenite starter kit-blue 312 SULFATHIAZOLE 58 subvenite starter kit-green 312 sulfatrim pediatric 34 subvenite starter kit-orange 312 SULFISOXIZOLE 58 SUCCIMER DMSA 282 SULFOSALICYLIC ACID DIHYDRATE 283 SUCCINIC ACID 282 SULFUR 283 SUCCINYLCHOLINE CHLORIDE 282,320 SULFUR PRECIPITATED 283 succinylcholine chloride 320 SULFUR SUBLIMED 283 SUCLEAR 217 SULFURIC ACID 283 SUCRAID 212 SULINDAC 14 SUCRALFATE 221 sulindac 14 sucralfate 221 SULPHAN BLUE 307 SUCROSE 282 SULPIRIDE 283

PAGE 431 LAST UPDATED 01/2020 SUMADAN 158 SYMBICORT 63 SUMADAN WASH 158 SYMBYAX 348 SUMADAN XLT 158 SYMDEKO 70 sumatriptan 29 SYMFI 49 SUMATRIPTAN 283 SYMFI LO 49 sumatriptan succinate 29 SYMJEPI 126 SUMATRIPTAN SUCCINATE 29,283 SYMLINPEN 120 182 sumatriptan succinate refill 29 SYMLINPEN 60 182 SUMAXIN 158 SYMPAZAN 312 SUMAXIN TS 158 SYMPROIC 216 SUMAXIN WASH 158 SYMTUZA 49 SUNOSI 8 SYN-AKE 283 SUPER SYNERSWEET FLAVOR 307 SYNAGIS 352 SUPEROXIDE DISMUTASE 283 SYNALAR 158 SUPERVITE 335 SYNALGOS-DC 23 SUPERVITE EC 335 SYNAPSIN 307 SUPPOSITORY BLEND 307 SYNAREL 203 SUPPRELIN LA 203 SYNDROS 212 SUPRACIL 158 SYNERCID 34 SUPRANE 25 SYNJARDY 182 SUPRAX 54 SYNJARDY XR 182 SUPRENZA 8 SYNRIBO 93 SUPREP BOWEL PREP KIT 217 SYNTHROID 209 SURE RESULT O3D3 SYSTEM 107 SYPRINE 296 SURE-T INFUSION SET 18" 292 SYRPALTA 307 SURE-T INFUSION SET 23" 292 SYRPALTA (RED) 307 SURE-T INFUSION SET 32" 292 SYRUP VEHICLE 307 SURFAXIN 70 SYRUP VEHICLE SF 307 SURVANTA 70 SUSTIVA 49 T SUSTOL 212 T.R.U.E. TEST 288 SUTENT 93 T:SLIM INSULIN DELIVERY SYSTEM 292 swabflush saline flush 327 T:SLIM INSULIN PUMP 293 SWEET CORN FLAVOR 307 T:SLIM X2 INS PUMP/CONTROL-IQ 293 SWEETENING ENHANCER 307 T:SLIM X2/CONTROL-IQ/REFURB 293 syeda 190 TABLOID 93 SYLATRON 93 TABRADOL RAPIDPAQ 319 SYLVANT 296 TACLONEX 158 SYMAX DUOTAB 221 tacrolimus 158,296 symax-sl 221 TACROLIMUS 283 symax-sr 221 tadalafil 121

PAGE 432 LAST UPDATED 01/2020 TADALAFIL 283 TAZAROTENE 283 tadalafil (pah) 121 TAZICEF 54 TAFINLAR 93 tazicef 54 TAGRISSO 94 TAZORAC 159 TAKHZYRO 234 taztia xt 117 TALC 283 TBC 159 TALICIA 221 TDVAX 353 TALIVA 241 TEA COCOYL GLUTAMINE 283 TALTZ 158,159 TEA TREE OIL 283 TALWIN 23 TEABERRY FLAVOR 307 TALZENNA 94 TECENTRIQ 94 TAMIFLU 49 TECFIDERA 348 tamoxifen citrate 94 TEFLARO 54 TAMOXIFEN CITRATE 283 TEGRETOL 312 tamsulosin hcl 223 TEGRETOL-XR 313 TANDEM F 241 TEGSEDI 348 TANDEM PLUS 241 TEKAMLO 112 TANGERINE FLAVOR 307 TEKTURNA 112 TANGERINE FLAVOR SWEETENED 307 TEKTURNA HCT 112 TANNIC ACID 159 telmisartan 112 TANZEUM 182 telmisartan-amlodipine 112 TAPAZOLE 209 telmisartan-hctz 112 TARCEVA 94 temazepam 138 TARGRETIN 94,159 TEMIXYS 49 tarina 24 fe 190 TEMODAR 95 tarina fe 1/20 190 TEMOVATE 159 tarina fe 1/20 eq 190 TEMOVATE E 159 TARKA 112 temozolomide 95 TARON FORTE 241 temsirolimus 95 TARON-BC 335 TENCON 16 TARON-C DHA 335 TENEX 112 taron-crystals 223 TENIPOSIDE 95 TARON-PREX 335 TENIVAC 353 TARTARIC ACID 283 tenofovir disoproxil fumarate 49 TASIGNA 94 TENORETIC 100 112 TASMAR 317 TENORETIC 50 112 TAURINE 340 TENORMIN 115 TAVALISSE 234 TEPADINA 95 TAXOTERE 94 TERAZOL 3 226 TAYTULLA 190 TERAZOL 7 226 tazarotene 159 terazosin hcl 112

PAGE 433 LAST UPDATED 01/2020 terbinafine hcl 37 TEVETEN 112 TERBINAFINE HCL 283 TEVETEN HCT 112 TERBUTALINE SULFATE 63 TEXACORT 159 terbutaline sulfate 63 TEXAVITE LQ 335 terconazole 227 THALLOUS CHLORIDE TL 201 288 TERCONAZOLE 227 THALOMID 296 TERPIN HYDRATE 67 THAM 327 TERPIN HYDRATE MONOHYDRATE 67 THEANINE 284 terrell 25 THEO-24 63 TERSI 159 THEOBROMINE 284 TESSALON PERLES 67 THEOCHRON 63 TESTIM 177 theochron 63 TESTONE CIK 177 theophylline 63 TESTOPEL 177 THEOPHYLLINE ANHYDROUS 284 testosterone 178 theophylline er 63 TESTOSTERONE 178,283 THEOPHYLLINE ER 63 TESTOSTERONE COMPOUNDING KIT 178 THEOPHYLLINE-ETHYLENEDIAMINE 63 testosterone cypionate 178 THERA-FLUR-N 164 TESTOSTERONE CYPIONATE 178,283 THERACYS 95 TESTOSTERONE CYPIONATE & PROP 178 THERAPEVO 159 TESTOSTERONE ENANTHATE 178,283 THIABENDAZOLE 32 testosterone enanthate 178 THIAMINE HCL 341 TESTOSTERONE EO-PRO-CYP 220 178 thiamine hcl 341 TESTOSTERONE MICRONIZED 283 THIAMINE MONONITRATE 342 TESTOSTERONE PROPIONATE 178,283 THIMEROSAL 245 TESTRED 178 THIOGUANINE 284 TETANUS-DIPHTHERIA TOXOIDS TD 353 THIOLA 223 tetcaine 174 THIOLA EC 223 tetrabenazine 348 thioridazine hcl 135 TETRACAINE 283 THIORIDAZINE HCL 284 tetracaine hcl 174 thiotepa 95 TETRACAINE HCL 283 THIOTEPA 284 tetracycline hcl 59 thiothixene 135 TETRACYCLINE HCL 159 THREONINE 340 TETRAHYDROBIOPTERIN DIHCL 283 THRIVITE 19 335 TETRAHYDROCURCUMIN 283 THRIVITE RX 335 TETRAHYDROZOLINE HCL 283 THROMBATE III 234 TETRAMEX 159 THROMBI-PAD 243 TETRAVEX 159 THROMBIN-JMI 243 tetravisc 174 THROMBIN-JMI EPISTAXIS 243 tetravisc forte 174 THROMBOGEN 243

PAGE 434 LAST UPDATED 01/2020 THYMOGLOBULIN 297 TL FOLATE 335 THYMOL 284 TL G-FOL OS 335 THYMOL IODIDE 284 tl gard rx 241 THYMUS 284 tl hydroquinone 159 THYROGEN 288 tl icon 241 THYROID 209 TL-CARE DHA 335 thyroid 209 TL-FLUORIVITE 335 THYROID (PORCINE) 284 tl-hem 150 241 THYROID 3X (PORCINE) 284 TL-SELECT 335 THYROLAR-1 209 TOBI 31 THYROLAR-1/2 209 TOBI PODHALER 31 THYROLAR-1/4 209 TOBRADEX 174 THYROLAR-2 209 TOBRADEX ST 174 THYROLAR-3 209 tobramycin 31,174 tiadylt er 117 TOBRAMYCIN 284 tiagabine hcl 313 tobramycin sulfate 31 TIAZAC 117 TOBRAMYCIN SULFATE 31 TIBSOVO 95 tobramycin-dexamethasone 174 TICARCILLIN-POT CLAVULANATE 284 TOBREX 174 TICE BCG 95 TOCOPHERYL ACID SUCC D-ALPHA 284 ticlopidine hcl 234 TOCOTRIENOLS 284 TIGAN 212 TOFACITINIB CITRATE 284 tigecycline 59 TOFRANIL 131 TIGECYCLINE 59 TOLAK 159 TIGLUTIK 320 TOLAZAMIDE 182 TIKOSYN 103 tolazamide 182 tilia fe 190 TOLAZOLINE HCL 284 TIMOLOL MALEATE 115,174 TOLBUTAMIDE 182 timolol maleate 115,174 tolcapone 317 TIMOPTIC 174 TOLMETIN SODIUM 14 TIMOPTIC OCUDOSE 174 TOLNAFTATE 159 TIMOPTIC-XE 174 TOLSURA 37 TINDAMAX 34 tolterodine tartrate 225 tinidazole 34 tolterodine tartrate er 225 TINIDAZOLE 284 TOLTRAZURIL 284 TINOGARD TL 284 TOLU BALSAM 284 TIOPRONIN 284 TOLUIDINE BLUE O 284 TITANIUM DIOXIDE 284 TOMMY GEL 308 TIVICAY 49 TOPAMAX 313 TIZANIDINE HCL 284 TOPAMAX SPRINKLE 313 tizanidine hcl 319 TOPICORT 159

PAGE 435 LAST UPDATED 01/2020 TOPICORT SPRAY 159 TRAZODONE HCL 131 topiragen 313 trazodone hcl 131 TOPIRAMATE 284 TREANDA 95 topiramate 313 TRECATOR 39 TOPIRAMATE ER 313 TRELEGY ELLIPTA 63 toposar 95 TRELSTAR 95,96 topotecan hcl 95 TRELSTAR MIXJECT 96 TOPOTECAN HCL 95 TREMFYA 159,160 TOPROL XL 115 treprostinil 121 toremifene citrate 95 TRESIBA 182 TORISEL 95 TRESIBA FLEXTOUCH 182 TORSEMIDE 124 TRETIN-X 160 torsemide 124 tretinoin 96,160 TOUJEO MAX SOLOSTAR 182 TRETINOIN 160 TOUJEO SOLOSTAR 182 tretinoin microsphere 160 tovet 159 tretinoin microsphere pump 160 TOVIAZ 225 TRETTEN 235 TRACLEER 121 TREXALL 96 TRAGACANTH 308 TREZIX 23 tramadol hcl 23 tri femynor 190 TRAMADOL HCL 284 TRI-AMINO 340 TRAMADOL HCL ER 23 TRI-CHLOR 160 tramadol hcl er 23 tri-estarylla 190 tramadol hcl er (biphasic) 23 tri-legest fe 190 tramadol-acetaminophen 23 tri-linyah 190 trandolapril 112 tri-lo-estarylla 190 trandolapril-verapamil hcl er 112 tri-lo-marzia 190 TRANDOLAPRIL-VERAPAMIL HCL ER 112 tri-lo-mili 190 tranexamic acid 243 tri-lo-sprintec 190 TRANEXAMIC ACID 284 tri-mili 190 TRANEXAMIC ACID-NACL 243 TRI-NORINYL (28) 190 TRANILAST 284 tri-previfem 190 TRANSCYTE 159 tri-sprintec 190 TRANSDERM SCOP (1.5 MG) 212 TRI-TABS DHA 335 TRANSDERM-SCOP (1.5 MG) 212 TRI-VI-FLOR 335 TRANXENE-T 128 TRI-VI-FLORO 335 tranylcypromine sulfate 131 tri-vit/fluoride 335 TRANZAREL 159 TRI-VIT/FLUORIDE/IRON 335 TRAVATAN Z 174 tri-vitamin/fluoride 336 TRAVOPROST 174 tri-vite/fluoride 336 travoprost (bak free) 174 tri-vylibra 190

PAGE 436 LAST UPDATED 01/2020 tri-vylibra lo 190 TRIGLIDE 107 TRIACETIN 284 trihexyphenidyl hcl 317 TRIADVANCE 336 TRIKAFTA 70 TRIAMCINOLONE 285 triklo 107 triamcinolone acetonide 68,160,164,194 TRILEPTAL 313 TRIAMCINOLONE ACETONIDE 160,194 TRILIPIX 107 TRIAMCINOLONE ACETONIDE-LIDO 194 TRILOSTANE 285 TRIAMCINOLONE DIACET MICRONIZE 194 trilyte 217 TRIAMCINOLONE DIACETATE 194 TRIMEPRAZINE TARTRATE 285 TRIAMCINOLONE HEXACETONIDE 285 trimethobenzamide hcl 212 TRIAMCINOLONE-MOXIFLOXACIN 174 TRIMETHOBENZAMIDE HCL 285 TRIAMTERENE 124 TRIMETHOPRIM 34 triamterene 124 trimethoprim 34 triamterene-hctz 124 TRIMIPRAMINE MALEATE 131 TRIAMTERENE-HCTZ 124 TRIMO-SAN 227 triazolam 138 TRIMPEX 34 TRIBENZOR 112 TRINATAL GT 336 TRICARE 336 TRINATAL RX 1 336 TRICARE PRENATAL 336 TRINATE 336 TRICARE PRENATAL 1 336 TRINAZ 336 TRICARE PRENATAL COMPLEAT 336 trinessa (28) 190 TRICARE PRENATAL DHA ONE 336 trinessa lo 190 TRICHLORMETHIAZIDE 285 TRINTELLIX 131 TRICHLOROACETIC ACID 285 TRIOXSALEN 285 TRICHOPHYTON 289 TRIPELENNAMINE HCL 65 tricitrates 223 triphrocaps 336 TRICLOSAN 285 TRIPLE DYE 245 tricon 241 TRIPLE PMB 174 TRICOR 107 TRIPLE PMK 174 triderm 160 triple-vitamin/fluoride 336 TRIDERMA FORTE 160 TRIPROLIDINE HCL 285 TRIDESILON 160 TRIPTODUR 203 trientine hcl 297 TRISENOX 96 TRIESENCE 174 TRISEON 160 TRIETHANOLAMINE LAURYL SULFATE 285 TRISODIUM CITRATE/CRRT 297 TRIETHYL CITRATE 285 TRISTART DHA 336 TRIFERIC 241 TRISTART ONE 336 trifluoperazine hcl 136 TRITON X-100 285 TRIFLURIDINE 174 TRIUMEQ 49 trifluridine 174 TRIVEEN-DUO DHA 336 trigels-f forte 241 TRIVEEN-PRX RNF 336

PAGE 437 LAST UPDATED 01/2020 trivora (28) 190 TWINRIX 355 TRIZIVIR 49 TWYNSTA 112 TROCHE BASE 308 TYBOST 50 TROGARZO 50 tydemy 190 TROKENDI XR 313 TYGACIL 59 TROLAMINE 308 TYKERB 96 TROMETHAMINE 285 TYLENOL WITH CODEINE #3 23 tronvite 336 TYLENOL WITH CODEINE #4 24 TROPHAMINE 340 TYLOSIN TARTRATE 285 TROPIC-PROPARACA-PE-KETOROLAC 174 TYLOXAPOL 285 TROPICAL PUNCH FLAVOR 308 TYMLOS 203 TROPICAMIDE 175 TYPHIM VI 355 tropicamide 175 TYSABRI 349 TROPICAMIDE-CYCLOPENTOLATE-PE 175 TYVASO 121 TROPICAMIDE-PHENYLEPHRINE 175 TYVASO REFILL 122 TROPOLONE 285 TYVASO STARTER 122 trospium chloride 226 TYZEKA 50 trospium chloride er 226 TYZINE 68 TRUEPLUS 5-BEVEL PEN NEEDLES 293 TRULANCE 216 U TRULICITY 182 UBIDECARENONE 285 TRUMENBA 355 UBIQUINOL 285 TRUSOPT 175 UCARE POLYMER JR-400 308 TRUVADA 50 UCERIS 139,194 TRUXIMA 96 UDAMIN SP 336 TRUZONE PEAK FLOW METER 293 UDENYCA 241 TRYPAN BLUE 308 ULESFIA 160 TRYPSIN 285 ULORIC 25 TRYPTOPHAN 341 ULTICARE INSULIN SAFETY SYR 293 tulana 190 ULTILET INSULIN SYRINGE 293 TUNA FLAVOR 308 ULTIMATECARE ONE 336 TURALIO 96 ULTIMATECARE ONE NF 336 TURMERIC 285 ULTOMIRIS 235 TURMERIC ROOT 285 ULTRACET 24 TUSSICAPS 67 ULTRAM 24 tussigon 67 ULTRAM ER 24 TUSSIONEX PENNKINETIC ER 67 ULTRASAL-ER 160 TUTTI FRUTTI FLAVOR 308 ULTRAVATE 160 TUTTI-FRUTTI FLAVOR 308 ULTRAVATE X (CREAM) 160 TUXARIN ER 67 ULTRAVATE X (OINTMENT) 160 TUZISTRA XR 67 ULTRAVIST 289

PAGE 438 LAST UPDATED 01/2020 ULTRESA 212 UROCIT-K 15 223 UMECTA 160 UROCIT-K 5 223 umecta mousse 160 UROGESIC-BLUE 224 UMECTA NAIL FILM 160 urolet mb 224 UMECTA PD 160 urophen mb 224 UNASYN 58 urosex 336 UNDECYLENIC ACID 285 UROXATRAL 223 unithroid 209 URSO 250 216 unithroid direct 209 URSO FORTE 216 UNITUXIN 96 ursodiol 216 UPTRAVI 122 URSODIOL 285 ur n-c 224 URSODIOL+SYRSPEND SF 216 URALISS 160 uryl 224 URAMAXIN 160 ustell 224 URAMAXIN GT 161 UTA 225 uramit mb 224 UTIBRON NEOHALER 63 URE-K 161 uticap 225 UREA 161,285 utira-c 225 urea 161 utrona-c 225 urea hydrating 161 UVADEX 96 UREA IN ZN UNDECYL-LACTIC ACID 161 UREA NAIL 161 V urea nail 161 V-GO 20 293 urea nail film 161 V-GO 30 293 urea-c40 161 V-GO 40 293 URECHOLINE 226 VABOMERE 34 uredeb 161 VAGIFEM 227 urelle 224 valacyclovir hcl 50 uremez-40 161 VALACYCLOVIR HCL 285 URESOL 161 VALCHLOR 161 uretron d/s 224 VALCYTE 50 UREVAZ 161 VALERIAN ROOT 285 uribel 224 valganciclovir hcl 50 URIDINE 285 VALIDERM 161 URIMAR-T 224 VALINE 341 urin ds 224 VALIUM 128 uro-458 224 VALPROATE SODIUM 285 uro-blue 224 valproate sodium 313 uro-l 224 VALPROIC ACID 285 uro-mp 224 valproic acid 313 UROCIT-K 10 223 valrubicin 96

PAGE 439 LAST UPDATED 01/2020 valsartan 112 VAZCULEP 126 valsartan-hydrochlorothiazide 112 VECAMYL 113 VALSTAR 96 VECTIBIX 97 VALTREX 50 VECTICAL 161 VALVED HOLDING CHAMBER 293 vecuronium bromide 320 VANADIUM 286 VELCADE 97 VANADYL SULFATE HYDRATE 286 VELETRI 122 VANATOL LQ 16 velivet 190 VANATOL S 16 VELPHORO 216 VANCOCIN 34 VELTASSA 297 VANCOCIN HCL 34 VEMAVITE-PRX 2 336 vancomycin hcl 35 VEMLIDY 50 VANCOMYCIN HCL 35,286 VENA-BAL DHA 336 VANCOMYCIN HCL IN DEXTROSE 35 VENCLEXTA 97 VANCOMYCIN HCL IN NACL 35 VENCLEXTA STARTING PACK 97 VANCOSOL PACK 35 VENIPUNCTURE CPI 161 vandazole 227 venlafaxine hcl 131 VANILLA BUTTERNUT FLAVOR 308 venlafaxine hcl er 132 VANILLA FLAVOR 308 VENLAFAXINE HCL ER 132 VANILLIN 286 VENOFER 242 VANILLIN FLAVOR 308 VENTAVIS 122 VANOS 161 VERAMYST 68 VANTAS 97 VERAPAMIL HCL 117 VAQTA 355 verapamil hcl 117 vardenafil hcl 122 verapamil hcl er 117 VARITHENA 297 VERAPAMIL HCL ER 117 VARIVAX 355 VERDESO 161 VARIZIG 353 VERDROCET 24 VARUBI 212 VEREGEN 161 VASCEPA 107 VERELAN 117 vaseline 308 VERELAN PM 117 VASERETIC 112 VERIPRED 20 194 vashe cleansing 161 VERRUNEX 161 vasolex 161 VERSABASE 308 vasopressin 203 VERSACLOZ 136 VASOPRESSIN-SODIUM CHLORIDE 203 VERSAFREE 308 VASOTEC 113 VERSAPLUS 308 VAXCHORA 355 VERSAPRO 308 VAYACOG 322 VERZENIO 97 VAYARIN 322 VESICARE 226 VAYAROL 322 vestura 191

PAGE 440 LAST UPDATED 01/2020 VEXOL 175 VIRAMUNE XR 51 VFEND 37 VIRASAL 161 VFEND IV 37 VIRAZOLE 51 VIAGRA 122 VIREAD 51 VIBATIV 35 VIROPTIC 175 VIBERZI 216 VIRT NATE 337 VIBRAMYCIN 59 VIRT-ADVANCE 337 vicodin 24 VIRT-C DHA 337 vicodin es 24 virt-caps 337 vicodin hp 24 VIRT-FEFA PLUS 242 VICOPROFEN 24 virt-gard 242 VICTORIAS SECRET VANILLA LACE 286 VIRT-NATE DHA 337 VICTOZA 182 virt-phos 250 neutral 328 VIDARABINE 286 VIRT-PN 337 VIDAZA 97 VIRT-PN DHA 337 VIDEX 50 VIRT-PN PLUS 337 VIDEX EC 50 VIRT-SELECT 337 vienva 191 virt-vite 242 vigabatrin 313 virt-vite forte 322 vigadrone 313 VIRT-VITE GT 337 VIGAMOX 175 virt-vite plus 337 VIIBRYD 132 virti-sulf 161 VIIBRYD STARTER PACK 132 VIRTPREX 337 VIL-RX 336 virtrate-2 223 vilamit mb 225 virtrate-3 223 vilevev mb 225 virtrate-k 223 VIMIZIM 203 VISCOAT 175 VIMPAT 313 VISTARIL 128 VINATE DHA RF 336 VISTOGARD 245 VINATE II 336 VISUDYNE 175 VINATE M 336 VIT B12-METHIONINE-INOS-CHOL 242 VINATE ONE 337 vit b3-azelac-turm-fa-b6-zn-cu 337 VINBLASTINE SULFATE 97 vita s forte 337 vincasar pfs 98 VITA-PREN 337 VINCRISTINE SULFATE 98 VITA-RESPA 322 vinorelbine tartrate 98 vitacel 337 VINPOCETINE 286 VITAFOL 337 VIOKACE 212 VITAFOL FE+ 337 viorele 191 VITAFOL GUMMIES 337 VIRACEPT 50 VITAFOL ULTRA 337 VIRAMUNE 50 VITAFOL-NANO 337

PAGE 441 LAST UPDATED 01/2020 VITAFOL-OB 337 VOL-TAB RX 338 VITAFOL-OB+DHA 337 VOLTAREN 161 VITAFOL-ONE 337 VOLTAREN-XR 14 VITAL-D RX 337 VONVENDI 235 vitamax pediatric 337 voriconazole 37 VITAMEDMD ONE RX/QUATREFOLIC 337 VORICONAZOLE 286 VITAMEDMD PLUS RX/QUATREFOLIC 337 VORTEX VALVED HOLDING CHAMBER 293 VITAMEDMD REDICHEW RX 337 VOSEVI 51 VITAMEZ 242 VOSPIRE ER 63 VITAMIN A 286 VOTRIENT 98 VITAMIN A ACETATE 286 VP-CH PLUS 338 VITAMIN A PALMITATE 286 VP-CH-PNV 338 vitamin b complex 100 338 VP-GGR-B6 PRENATAL 338 vitamin b-complex 100 338 VP-HEME OB 338 vitamin d (ergocalciferol) 342 VP-HEME OB + DHA 338 VITAMIN D3 286 VP-HEME ONE 338 VITAMIN DEFICIENCY SYSTEM-B12 242 VP-PNV-DHA 338 VITAMIN E 286,342 VP-PRECIP 322 VITAMIN E ACETATE 286 vp-vite rx 338 VITAMIN E SUCCINATE 286 VPRIV 242 vitamin k1 342 VRAYLAR 136 VITAMIN K2 286 VUMERITY 349 vitamins acd-fluoride 338 VUMERITY (STARTER) 349 VITAPEARL 338 vyfemla 191 vitasure 338 VYLEESI 349 VITATHELY WITH GINGER 338 vylibra 191 VITATRUE 338 VYNDAMAX 122 VITAXYME 338 VYNDAQEL 122 VITEKTA 51 VYONDYS 53 320 VITRAKVI 98 VYTORIN 107 VITRASE 297 VYVANSE 8 VITUZ 67 VYXEOS 98 VIVA DHA 338 VYZULTA 175 VIVELLE-DOT 207 VIVITROL 245 W VIVOTIF 355 WAKIX 8 VIZIMPRO 98 WARFARIN SODIUM 229 VOGELXO PUMP 178 warfarin sodium 229 vol-care rx 338 WASP VENOM PROTEIN 350 VOL-NATE 338 WATCHHALER 293 VOL-PLUS 338 water for irrigation, sterile 297

PAGE 442 LAST UPDATED 01/2020 WATERMELON FLAVOR 308 XADAGO 317 WAX, WHITE 308 XALATAN 175 WELCHOL 107 XALIX 162 WELLBUTRIN 132 XALKORI 98 WELLBUTRIN SR 132 XANAX 128 WELLBUTRIN XL 132 XANAX XR 128 wera 191 XANTHAN GUM 308 WESTAB MAX 322 XAQUIL XR 322 westab one 242 XARELTO 229 WESTCORT 161 XARELTO STARTER PACK 229 WESTHROID 209 XARTEMIS XR 24 WHEY PROTEIN ISOLATE 286 XATMEP 98 WHITE BEES WAX 308 XELJANZ 15 WHITE FACED HORNET VENOM PROT 350 XELJANZ XR 15 WHITE KIDNEY BEAN EXTRACT 286 XELODA 99 white petrolatum 308 XEMBIFY 353 WHITE WILLOW BARK 286 XENAZINE 349 WHYTEDERM SURGIPAK 162 XENICAL 8 WHYTEDERM TDPAK 162 XENLETA 35,36 WHYTEDERM TRILASIL PAK 162 XEOMIN 320 WIDE-SEAL DIAPHRAGM 60 293 XEPI 162 WIDE-SEAL DIAPHRAGM 65 293 XERAC AC 162 WIDE-SEAL DIAPHRAGM 70 293 XERAVA 59 WIDE-SEAL DIAPHRAGM 75 293 XERMELO 216 WIDE-SEAL DIAPHRAGM 80 293 XGEVA 204 WIDE-SEAL DIAPHRAGM 85 293 XIAFLEX 297 WIDE-SEAL DIAPHRAGM 90 293 XIFAXAN 36 WIDE-SEAL DIAPHRAGM 95 293 XIGDUO XR 182,183 WILATE 235 XIIDRA 175 WILD CHERRY FLAVOR 308 XODOL 24 WILEY BASIC ELEMENTS BHRT BASE 308 XOFIGO 99 WINRHO SDF 353 XOFLUZA 51 WITCH HAZEL 286 XOLAIR 63 WITEPSOL 308 XOLEGEL 162 wixela inhub 63 XOLEGEL COREPAK 162 WOUND WASH BASE 308 XOPENEX 64 WP THYROID 209 XOPENEX CONCENTRATE 64 wymzya fe 191 XOSPATA 99 XPOVIO (100 MG ONCE WEEKLY) 99 X XPOVIO (60 MG ONCE WEEKLY) 99 x-viate 162 XPOVIO (80 MG ONCE WEEKLY) 99

PAGE 443 LAST UPDATED 01/2020 XPOVIO (80 MG TWICE WEEKLY) 99 XTAMPZA ER 24 Z XTANDI 99 ZACARE 162 XULANE 191 ZACLIR CLEANSING 162 XULTOPHY 183 zafirlukast 64 xurea 162 zaleplon 138 XURIDEN 204 ZALTRAP 100 xvite 338 ZALVIT 338 XYLAZINE HCL 286 ZAMICET 24 XYLITOL 286 ZANAFLEX 319 XYLOCAINE 162 ZANOSAR 100 XYLOCAINE (CARDIAC) 103 ZANTAC 221 xylocaine dental 27 zarah 191 XYLOCAINE-MPF 27 ZARONTIN 313 XYLOMETAZOLINE HCL 286 ZARXIO 242 xylon 24 ZATEAN-CH 338 XYNTHA 235 ZATEAN-PN DHA 338 XYNTHA SOLOFUSE 235 ZATEAN-PN PLUS 338 XYOSTED 178 ZAVARA 242 xyphex 162 ZAVESCA 242 XYREM 349 zazole 227 XYZAL 65 ZEAXANTHIN 286 ZEBETA 115 Y zebutal 16 YASMIN 28 191 ZECUITY 29 YAZ 191 ZEJULA 100 YEAST EXTRACT 286 ZELAPAR 317 YELLOW HORNET VENOM PROTEIN 350 ZELBORAF 100 YELLOW JACKET VENOM PROTEIN 350 ZELNORM 216 YERVOY 99 ZEMAIRA 70 YESCARTA 100 ZEMBRACE SYMTOUCH 29 YF-VAX 355 ZEMDRI 31 YLANG-YLANG OIL FRAGRANCE 286 ZEMPLAR 204 YOHIMBINE HCL 286 ZEMURON 320 YONDELIS 100 zenatane 162 YONSA 100 zenchent 191 YUPELRI 64 zenchent fe 191 YUTIQ 175 zencia 162 yuvafem 227 ZENEVIX 162 ZENPEP 212 ZENZEDI 8

PAGE 444 LAST UPDATED 01/2020 zenzedi 8 ZOEY OPTICHAMBER ADVANTAGE 293 ZERBAXA 54 ZOFRAN 212 ZERIT 51 ZOFRAN ODT 212 ZESTORETIC 113 ZOHYDRO ER 24 ZESTRIL 113 ZOLADEX 100 ZETIA 107 ZOLATE 242 ZETONNA 68 ZOLEDRONIC ACID 204 ZIAC 113 zoledronic acid 204 ZIAGEN 51 ZOLINZA 101 zidovudine 51,52 zolmitriptan 30 ZIEXTENZO 242 ZOLMITRIPTAN 287 ZILRETTA 194 ZOLOFT 132 ZINACEF 54 zolpidem tartrate 138 ZINACEF IN STERILE WATER 54 zolpidem tartrate er 138 ZINBRYTA 349 ZOMETA 204 ZINC ACETATE 164,286 ZOMIG 30 ZINC CHLORIDE 286 ZOMIG ZMT 30 ZINC CITRATE 287 ZONALON 162 ZINC GLUCONATE 287,328 ZONATUSS 67 ZINC MONOMETHIONINE 287 ZONEGRAN 313 ZINC OXIDE 287 ZONISAMIDE 287 ZINC PICOLINATE 287 zonisamide 314 ZINC PYRITHIONE 287 ZONTIVITY 235 ZINC SULFATE 328 ZORBTIVE 204 ZINC SULFATE HEPTAHYDRATE 328 ZORTRESS 297 ZINC SULFATE MONOHYDRATE 328 ZOSIL 308 ZINC UNDECYLENATE 287 ZOSTAVAX 355 ZINECARD 100 ZOSYN 58 ZINGO 27 zovia 1/35e (28) 191 ZINPLAVA 353 zovia 1/50e (28) 191 zionodil 162 ZOVIRAX 52,162 ziprasidone hcl 136 ZTLIDO 162 ZIRABEV 100 ZUBSOLV 24 ZIRCONIUM OXIDE 287 ZULRESSO 132 ZIRGAN 175 zumandimine 191 ZITHRANOL-RR 162 ZUPLENZ 212 ZITHROMAX 56 ZUTRIPRO 67 ZITHROMAX TRI-PAK 56 ZYBAN 349 ZITHROMAX Z-PAK 56 ZYDELIG 101 ZMAX 56 ZYKADIA 101 ZOCOR 108 ZYLET 175

PAGE 445 LAST UPDATED 01/2020 ZYLOPRIM 25 ZYMAXID 175 ZYPITAMAG 108 ZYPREXA 136 ZYPREXA RELPREVV 136 ZYPREXA ZYDIS 136 ZYTIGA 101 ZYVOX 36

PAGE 446 LAST UPDATED 01/2020