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Home , Phenazopyridine

Drug Formulary

The information is up to date as of January 1, 2018. For questions regarding the PDL, please contact NLH at 844-807-9734 or [email protected] . To receive updates regarding the PDL, please email [email protected].

A healthier you. A healthier community.

Pharmacy Program NextLevel Health Partners (NLH) wants you to receive all the services you need. We work with communities, providers, and members to improve our members’ health. NLH is committed to providing appropriate, high quality, and cost effective drug therapy to all NLH members. NLH works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. NLH covers prescription medications and certain over-the-counter (OTC) medications when ordered by a practitioner. NLH does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

Preferred Drug List The NLH Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The NLH PDL is continually evaluated by the Utilization Review/Pharmacy Care Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the NLH Medical Director, Pharmacy Director, and several Illinois physicians, pharmacists, and other healthcare professionals.

Pharmacy Benefit Manager NLH works with Envolve Pharmacy Solutions (EPS) to process pharmacy claims for prescribed drugs. Some drugs on the NLH PDL may require PA, and Envolve Pharmacy Solutions is responsible for administering this process. EPS is our Pharmacy Benefit Manager (PBM).

Specialty Drugs NLH contracts with a number of specialty pharmacies, such as AcariaHealth Specialty Pharmacy, to ensure members have adequate access to the specialty drugs they require. All specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by NLH. PA requirements are programmed specific to the drug.

Dispensing Limits Drugs may be dispensed up to a maximum of thirty-four (34) day supply for each new prescription or refill. A total of 85% of the day supply must have elapsed before the prescription can be refilled for non- controlled-substance PDL drugs except for ophthalmic drugs.

Appropriate Use and Safety Edits The health and safety of the member are top priorities for NLH. One of the ways we address member safety is through point-of sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

Prior Authorizations Some medications listed on the NLH PDL may require PA. The information should be submitted by the practitioner to Envolve Pharmacy Solutions on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document can be found on the NLH website. NLH will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the NLH Utilization Review/Pharmacy Care Committee. If the request is approved, NLH notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, NLH will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Step Therapy Some medications listed on the NLH PDL may require specific medications to be used before the member can receive the step therapy medication. If NLH has a record that the required medication was tried first the step therapy medications are automatically covered. If NLH does not have a record that the required medication was tried, the member’s practitioner may be required to provide additional information. If authorization is not granted, NLH will notify the member and their practitioner and provide information regarding the appeal process.

Quantity Limits NLH may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If NLH does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Age Limits Some medications on the NLH PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Non-Preferred NLH incorporates a Preferred Drug List. ! notation of ‘Non-Formulary’ corresponds to drugs identified on the NLH PDL indicating the trial and failure of preferred alternatives. The number of preferred drugs that must be tried prior to approval of non-formulary drugs varies by therapeutic drug class. To request the approval of a non-formulary drug please submit rationale via prior authorization request form to Envolve Pharmacy Solutions (fax 1-866-399-0929).

Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member’s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions.

For a MN request NLH requires: - Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or - Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or - Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. These requests are reviewed by a licensed clinical pharmacist using the criteria established by the NLH Utilization Review/Pharmacy Care Committee. If the request is approved, Envolve Pharmacy Solutions will notify the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, the member and their practitioner will be notified of alternatives and provide information regarding the appeal process.

72 Hour Emergency Supply Policy State and Federal law require that a pharmacy dispense a 72-hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. A provision of a 72-hour supply does not guarantee that the medication will be approved after a PA review. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72-hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call Envolve Pharmacy Solutions at 1-866-399-0928 for a prescription override to submit the 72-hour medication supply for payment.

Newly Approved Products NLH reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If NLH does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Over-the-Counter Medications NLH covers a variety of OTC medications. These medications can be found throughout the NLH PDL. NLH covers OTC products listed on the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

Drug Efficacy Study and Implementation (DESI) Drugs DESI products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by NLH.

Filling a Prescription A member can have prescriptions filled at a NLH network pharmacy. If the member decides to have a prescription filled at a network pharmacy, they can locate a pharmacy near them by NLH Member services. At the pharmacy, the member will need to provide the pharmacist with the prescription and their NLH ID card.

Glossary of terms The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column.

Legend Description

AL Age Limit Drug is limited to specific age.

Prior PA Prior Authorization required before prescription can be filled. Authorization There is a limit on the amount of drug covered per prescription, or within a QL Quantity Limit specific time frame. Rx/OTC Rx/OTC Product has both Rx and OTC National Drug Codes.

SP Specialty This is a Specialty drug

Requires trial and failure of one or more preferred products prior to ST Step Therapy coverage.

Tier Definitions

Legend Description F Formulary Preferred drugs NF Non-formulary Non-preferred drugs

Copays There are no member copays for covered medications.

Contact Information

For more information regarding specific medication(s): Next Level Health Phone: 1-844-807-9734 Website: www.nextlevelhealthil.com Envolve Pharmacy Solutions PA Phone: 1-866-399-0928 Discrepancies

To reports discrepancies with the PDL, please contact NLH at 844-807-9734 or [email protected] .

Disclosure

The information is up to date as of April 1, 2018. For questions regarding the PDL, please contact NLH at NLH at 844-807-9734 or [email protected] . To receive updates regarding the PDL, please email [email protected]

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- VYVANSE CAPS 10 MG, QL(1 ea daily) OBESITY/ANOREXIANTS 20 MG, 30 MG, 40 MG, 50 F MG, 60 MG, 70 MG Amphetamines Analeptics ADDERALL TABS (Use QL(2 ea daily); QL(45 ml per Amphetamine- NF AL; At least 3 caffeine citrate soln or 20 Dextroamphetamine) yrs old F fill retail); AL; mg/ml, 60 mg/3ml Up to 18 yrs old ADDERALL XR CP24 (Use QL(1 ea daily); Amphetamine- NF AL; At least 6 Attention-Deficit/Hyperactivity Disorder (ADHD) Dextroamphetamine) yrs old clonidine hcl (adhd) tb12 F amphetamine- QL(1 ea daily); dextroamphetamine cp24 AL; At least 6 QL(1 ea daily); 5mg-5mg-5mg-5mg, yrs old guanfacine hcl (adhd) tb24 F AL; At least 6 2.5mg-2.5mg-2.5mg- yrs old 2.5mg, 7.5mg-7.5mg- F QL(1 ea daily); 7.5mg-7.5mg, 1.25mg- INTUNIV TB24 (Use NF )) AL; At least 6 1.25mg-1.25mg-1.25mg, Guanfacine HCl (ADHD yrs old 3.75mg-3.75mg-3.75mg- 3.75mg, 6.25mg-6.25mg- KAPVAY TB12 (Use NF 6.25mg-6.25mg Clonidine HCl (ADHD)) amphetamine- QL(2 ea daily); Stimulants - Misc. dextroamphetamine tabs AL; At least 3 CONCERTA TBCR 18 MG, QL(1 ea daily); 5mg-5mg-5mg-5mg, yrs old 27 MG, 54 MG (Use NF AL; At least 6 2.5mg-2.5mg-2.5mg- Methylphenidate HCl) yrs old 2.5mg, 7.5mg-7.5mg- QL(2 ea daily); 7.5mg-7.5mg, 1.25mg- CONCERTA TBCR 36 MG NF ) AL; At least 6 1.25mg-1.25mg-1.25mg, F (Use Methylphenidate HCl yrs old 3.75mg-3.75mg-3.75mg- 3.75mg, 1.875mg- QL(2 ea daily); dexmethylphenidate hcl F AL; At least 6 1.875mg-1.875mg- tabs 5 mg, 10 mg, 2.5 mg 1.875mg, 3.125mg- yrs old 3.125mg-3.125mg- QL(2 ea daily); FOCALIN TABS (Use NF 3.125mg Dexmethylphenidate HCl) AL; At least 6 DEXEDRINE CP24 10 MG, QL(2 ea daily); yrs old 15 MG (Use AL; At least 6 QL(1 ea daily); NF METADATE CD CPCR NF AL; At least 6 Dextroamphetamine yrs old (Use Methylphenidate HCl) Sulfate) yrs old DEXEDRINE CP24 5 MG QL(1 ea daily); methylphenidate hcl cpcr QL(1 ea daily); (Use Dextroamphetamine NF AL; At least 6 10 mg, 20 mg, 30 mg, 40 F AL; At least 6 Sulfate) yrs old mg, 50 mg, 60 mg yrs old QL(2 ea daily); METHYLPHENIDATE HCL QL(1 ea daily); dextroamphetamine sulfate F AL; At least 6 ER TB24 18 MG, 27 MG, F AL; At least 6 cp24 10 mg, 15 mg yrs old 54 MG yrs old QL(1 ea daily); QL(2 ea daily); dextroamphetamine sulfate METHYLPHENIDATE HCL F F AL; At least 6 ER TB24 36 MG AL; At least 6 cp24 5 mg yrs old yrs old QL(3 ea daily); QL(1 ea daily); dextroamphetamine sulfate METHYLPHENIDATE HCL F F AL; At least 3 ER TBCR 18 MG AL; At least 6 tabs 5 mg, 10 mg yrs old yrs old

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3 ea daily); methylphenidate hcl tabs HUMIRA PEN-CROHNS F PA; SP F AL; At least 3 DISEASESTARTER PNKT 10 mg, 20 mg yrs old HUMIRA PEN-PSORIASIS F PA; SP QL(6 ea daily); STARTER PNKT methylphenidate hcl tabs 5 F AL; At least 3 mg HUMIRA PSKT 20 F PA; SP yrs old MG/0.4ML, 40 MG/0.8ML QL(2 ea daily); methylphenidate hcl tbcr 10 F AL; At least 6 Antirheumatic Antimetabolites mg, 36 mg yrs old RHEUMATREX TABS F QL(1 ea daily); methylphenidate hcl tbcr 18 F AL; At least 6 Nonsteroidal Anti-inflammatory Agents (NSAIDs) mg, 20 mg, 27 mg, 54 mg yrs old ADVIL TABS (Use NF RITALIN TABS 10 MG, 20 QL(3 ea daily); ) MG (Use Methylphenidate NF AL; At least 3 ALEVE ARTHRITIS TABS NF QL(2 ea daily) HCl) yrs old (Use Sodium) QL(6 ea daily); ALEVE TABS (Use QL(2 ea daily) RITALIN TABS 5 MG (Use NF NF ) AL; At least 3 Naproxen Sodium) Methylphenidate HCl yrs old ANAPROX DS TABS (Use NF AMINOGLYCOSIDES Naproxen Sodium) CELEBREX CAPS (Use NF PA; QL(2 ea Aminoglycosides ) daily) PA; SP KITABIS PAK NEBU F F PA; QL(2 ea celecoxib caps daily) neomycin sulfate tabs F CHILDRENS ADVIL SUSP NF RX/OTC (Use Ibuprofen) TOBI NEBU (Use PA; SP NF CHILDRENS MOTRIN NF RX/OTC Tobramycin) SUSP (Use Ibuprofen) TOBRAMYCIN NEBU F PA; SP DAYPRO TABS (Use NF Oxaprozin) tobramycin nebu F PA; SP potassium tabs F TOBRAMYCIN SULFATE PA SOLN 10 MG/ML, 40 F diclofenac sodium tb24 or F MG/ML 100 mg tobramycin sulfate soln 40 PA diclofenac sodium tbec or F mg/ml, 80 mg/2ml, 1.2 F 25 mg, 50 mg, 75 mg gm/30ml EC-NAPROSYN TBEC NF QL(2 ea daily) (Use Naproxen) tobramycin sulfate solr 1.2 F PA gm caps F - ANTI-INFLAMMATORY etodolac tabs F Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC PA; SP etodolac tb24 F CROHNS DISEASE F FELDENE CAPS (Use NF STARTER PACK PSKT Piroxicam) PA; SP HUMIRA PEN PNKT F tabs F

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ibuprofen chew 100 mg F naproxen tbec 375 mg, 500 F QL(2 ea daily) mg RX/OTC ibuprofen susp 100 mg/5ml F oxaprozin tabs F ibuprofen susp 40 mg/ml, F 50 mg/1.25ml piroxicam caps F ibuprofen tabs 200 mg, 400 F sulindac tabs F mg, 600 mg, 800 mg tolmetin sodium caps 400 F indomethacin caps F mg indomethacin cpcr F TOLMETIN SODIUM F CAPS 400 MG INFANTS ADVIL SUSP NF TOLMETIN SODIUM TABS F (Use Ibuprofen) 200 MG, 600 MG caps 50 mg, 75 F Pyrimidine Synthesis Inhibitors mg ARAVA TABS (Use NF QL(1 ea daily) KETOPROFEN CAPS 50 F Leflunomide) MG, 75 MG leflunomide tabs F QL(1 ea daily) KETOPROFEN ER CP24 F Soluble Tumor Necrosis Factor Receptor Agents tromethamine F AL; At least 17 tabs or 10 mg yrs old ENBREL SOLR 25 MG F SP LODINE TABS (Use NF Etodolac) ENBREL SOSY 50 MG/ML, F PA; SP 25 MG/0.5ML meloxicam tabs F ENBREL SURECLICK F PA; SP SOAJ MOBIC TABS 15 MG, 7.5 NF MG (Use Meloxicam) ANALGESICS - NonNarcotic MOTRIN INFANTS DROPS SUSP (Use NF Combinations Ibuprofen) butalbital-acetaminophen F nabumetone tabs F tabs 325mg-50mg butalbital-acetaminophen- QL(4 ea daily) NAPROSYN SUSP (Use NF caffeine caps 325mg- F Naproxen) 50mg-40mg NAPROSYN TABS (Use NF butalbital-acetaminophen- QL(4 ea daily) Naproxen) caffeine tabs 325mg-50mg- F 40mg naproxen sodium tabs 220 F QL(2 ea daily) mg butalbital--caffeine F QL(4 ea daily) caps naproxen sodium tabs 275 F mg, 550 mg ESGIC TABS (Use QL(4 ea daily) Butalbital-Acetaminophen- NF naproxen susp 125 mg/5ml F Caffeine) NAPROXEN SUSP 125 F FIORINAL CAPS (Use NF QL(4 ea daily) MG/5ML Butalbital-Aspirin-Caffeine) naproxen tabs 250 mg, 375 F TENCON TABS F mg, 500 mg

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Analgesics Other choline & mag salicylate F liqd acetaminophen chew or 80 F mg tabs F acetaminophen liqd or 160 F mg/5ml DISALCID TABS (Use NF Salsalate) acetaminophen soln or 160 mg/5ml, 650 mg/20.3ml, F ECOTRIN REGULAR 325 mg/10.15ml STRENGTH TBEC (Use NF Aspirin) acetaminophen supp re F 120 mg, 325 mg, 650 mg salsalate tabs F acetaminophen susp or 160 mg/5ml, 80 mg/0.8ml, F ANALGESICS - 80 mg/2.5ml Opioid Agonists acetaminophen tabs or 325 F mg, 500 mg sulfate tabs 15 mg, F QL(2 ea daily) 30 mg, 60 mg NORTEMP INFANTS F SUSP CODEINE SULFATE TABS QL(2 ea daily) 15 MG, 30 MG, 60 MG NF TYLENOL CHILDRENS (Use Codeine Sulfate) SUSP (Use NF Acetaminophen) DEMEROL TABS OR 50 MG, 100 MG (Use NF TYLENOL EXTRA Meperidine HCl) STRENGTH TABS (Use NF Acetaminophen) DILAUDID TABS OR 2 MG, 4 MG, 8 MG (Use NF TYLENOL INFANTS HCl) PAIN+ SUSP (Use NF Acetaminophen) DOLOPHINE TABS 10 MG NF QL(10 ea daily) (Use HCl) TYLENOL INFANTS SUSP NF (Use Acetaminophen) DOLOPHINE TABS 5 MG NF QL(4 ea daily) (Use Methadone HCl) TYLENOL TABS (Use NF Acetaminophen) DURAGESIC PT72 (Use NF QL(0.34 ea ) daily) Salicylates fentanyl pt72 12 mcg/hr, 25 QL(0.34 ea aspirin buffered (cal carb- F mcg/hr, 50 mcg/hr, 75 F daily) mag carb-mag oxide) tabs mcg/hr, 100 mcg/hr aspirin chew or 81 mg F HYDROMORPHONE HCL F QL(12 ea per SUPP RE 3 MG fill retail) aspirin supp re 300 mg, F hydromorphone hcl tabs or F 600 mg 2 mg, 4 mg, 8 mg ASPIRIN SUPP RE 300 F KADIAN CP24 10 MG, 20 MG, 600 MG MG, 30 MG, 50 MG, 60 NF aspirin tabs or 325 mg F MG, 80 MG, 100 MG (Use Sulfate) aspirin tbec or 81 mg, 324 F mg, 325 mg KADIAN CP24 200 MG F BUFFERIN TABS (Use MEPERIDINE HCL SOLN F QL(500 ml per Aspirin Buffered (Cal Carb- NF OR 50 MG/5ML fill retail) Mag Carb-Mag Oxide))

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits meperidine hcl tabs or 50 F ULTRAM TABS (Use NF QL(8 ea daily) mg, 100 mg HCl) methadone hcl tabs or 10 F QL(10 ea daily) Opioid Combinations mg acetaminophen w/ codeine F QL(30 ml daily) methadone hcl tabs or 5 F QL(4 ea daily) soln 120mg/5ml-12mg/5ml mg acetaminophen w/ codeine morphine sulfate cp24 or tabs 300mg-15mg, 300mg- F 10 mg, 20 mg, 30 mg, 50 F 30mg, 300mg-60mg mg, 60 mg, 80 mg, 100 mg butalbital-acetaminophen- QL(4 ea daily) morphine sulfate soln or 10 F caffeine w/ codeine caps F mg/5ml, 20 mg/5ml 325mg-50mg-40mg-30mg morphine sulfate soln or 20 QL(240 ml per F butalbital-aspirin-caffeine F QL(4 ea daily) mg/ml, 100 mg/5ml fill retail) w/cod caps MORPHINE SULFATE QL(24 ea per FIORINAL/CODEINE #3 QL(4 ea daily) SUPP RE 5 MG, 10 MG, F fill retail) CAPS (Use Butalbital- NF 20 MG, 30 MG Aspirin-Caffeine w/Cod) MORPHINE SULFATE F HYCET SOLN (Use QL(180 ml TABS OR 15 MG, 30 MG - NF daily) morphine sulfate tbcr or 15 QL(3 ea daily) Acetaminophen) mg, 30 mg, 60 mg, 100 mg, F hydrocodone- QL(180 ml 200 mg acetaminophen soln daily) 2.5mg/5ml-108mg/5ml, F MS CONTIN TBCR (Use NF QL(3 ea daily) Morphine Sulfate) 5mg/10ml-217mg/10ml, 7.5mg/15ml-325mg/15ml hcl caps 5 mg F hydrocodone- acetaminophen tabs 5mg- oxycodone hcl conc 100 F QL(6 ml daily) F mg/5ml 325mg, 10mg-325mg, 7.5mg-325mg OXYCODONE HCL ER F QL(2 ea daily) T12A NORCO TABS (Use Hydrocodone- NF oxycodone hcl soln 5 F mg/5ml Acetaminophen) oxycodone hcl tabs 5 mg, oxycodone w/ 10 mg, 15 mg, 20 mg, 30 F acetaminophen tabs 5mg- F mg 325mg, 10mg-325mg, 7.5mg-325mg OXYCONTIN T12A F QL(2 ea daily) oxycodone-aspirin tabs F QL(6 ea daily) hcl tb12 5 mg, 10 mg, 15 mg, 20 mg, F OXYCODONE/ACETAMIN F QL(30 ml daily) 30 mg, 40 mg, 7.5 mg OPHEN SOLN OXYMORPHONE PERCOCET TABS 5MG- HYDROCHLORIDE ER F 325MG, 10MG-325MG, TB12 7.5MG-325MG (Use NF Oxycodone w/ ROXICODONE TABS (Use NF Acetaminophen) Oxycodone HCl) tramadol-acetaminophen F QL(4 ea daily) tramadol hcl tabs 50 mg F QL(8 ea daily) tabs

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYLENOL/CODEINE #3 phenylephrine-cocoa butter F TABS (Use Acetaminophen NF supp 88.44%-0.25% w/ Codeine) phenylephrine-shark liver F TYLENOL/CODEINE #4 oil-cocoa butter supp TABS (Use Acetaminophen NF phenylephrine-shark liver w/ Codeine) oil-mineral oil-petrolatum F ULTRACET TABS (Use NF QL(4 ea daily) oint Tramadol-Acetaminophen) Rectal Local Anesthetics Opioid Partial Agonists QL(15 gm per pramoxine hcl (rectal) foam F BUNAVAIL FILM F fill retail) PROCTOFOAM FOAM QL(15 gm per hcl subl sl 2 F (Use Pramoxine HCl NF fill retail) mg, 8 mg (Rectal)) buprenorphine hcl- F Rectal Steroids naloxone hcl dihydrate subl ANUSOL-HC CREA (Use NF QL(30 gm per SUBOXONE FILM F Hydrocortisone (Rectal)) fill retail) ZUBSOLV SUBL 5.7MG- hydrocortisone (rectal) crea F QL(30 gm per 2.5 % fill retail) 1.4MG, 8.6MG-2.1MG, F 1.4MG-0.36MG, 11.4MG- ANTACIDS 2.9MG, 2.9MG-0.71MG Antacid Combinations ANDROGENS-ANABOLIC alum & mag hydrox- Androgens simethicone liqd F QL(1 ea daily) 200mg/5ml-20mg/5ml- ANDRODERM PT24 F 200mg/5ml alum & mag hydrox- ANDROXY TABS F simethicone susp DEPO-TESTOSTERONE 200mg/5ml-20mg/5ml- SOLN 200 MG/ML (Use NF 200mg/5ml, 200mg/5ml- F Testosterone Cypionate) 200mg/5ml-20mg/5ml- 20mg/5ml-200mg/5ml- METHITEST TABS F 200mg/5ml Antacids - Aluminum Salts testosterone cypionate soln F 200 mg/ml ALUMINUM HYDROXIDE F SUSP OR ANORECTAL AGENTS Antacids - Bicarbonate Intrarectal Steroids sodium bicarbonate F CORTENEMA ENEM (Use QL(420 ml per (antacid) tabs Hydrocortisone NF fill retail) (Intrarectal)) Antacids - Calcium Salts calcium carbonate (antacid) hydrocortisone (intrarectal) F QL(420 ml per F enem fill retail) chew 500 mg calcium carbonate (antacid) F Rectal Combinations susp 1250 mg/5ml ANALPRAM-HC LOTN F QL(60 ml per 1%-2.5% fill retail)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUMS CHEW (Use BACTRIM TABS (Use Calcium Carbonate NF Sulfamethoxazole- NF (Antacid)) Trimethoprim) TUMS LASTING EFFECTS sulfamethoxazole- CHEW (Use Calcium NF trimethoprim susp or F Carbonate (Antacid)) 40mg/5ml-200mg/5ml Antacids - Magnesium Salts sulfamethoxazole- trimethoprim tabs or 80mg- F magnesium oxide tabs 400 F mg 400mg, 160mg-800mg Leprostatics ANTHELMINTICS dapsone tabs F Anthelmintics Lincosamides EMVERM CHEW F CLEOCIN CAPS OR 150 MG, 300 MG (Use NF ANTI-INFECTIVE AGENTS - MISC. Clindamycin HCl) Anti-infective Agents - Misc. CLEOCIN PEDIATRIC QL(300 ml per GRANULES SOLR (Use fill retail) FIRST-VANCOMYCIN 25 F NF SOLN Clindamycin Palmitate Hydrochloride) FIRST-VANCOMYCIN 50 F SOLN clindamycin hcl caps 150 F mg, 300 mg FLAGYL TABS 250 MG, 500 MG (Use NF clindamycin palmitate F QL(300 ml per Metronidazole) hydrochloride solr fill retail) Oxazolidinones metronidazole tabs or 250 F mg, 500 mg F PA; QL(6 ea SIVEXTRO TABS OR per fill retail) trimethoprim tabs F VANCOCIN HCL CAPS QL(4 ea daily) ANTIANGINAL AGENTS 125 MG (Use Vancomycin NF Nitrates HCl) ISORDIL TITRADOSE VANCOCIN HCL CAPS QL(8 ea daily) TABS 5 MG (Use NF 250 MG (Use Vancomycin NF Isosorbide Dinitrate) HCl) ISOSORBIDE DINITRATE F vancomycin hcl caps or F QL(4 ea daily) ER TBCR 125 mg isosorbide dinitrate tabs F vancomycin hcl caps or F QL(8 ea daily) 250 mg isosorbide mononitrate tabs F QL(2 ea daily) vancomycin hcl solr iv 1000 F QL(14 ea per 10 mg, 20 mg mg fill retail) isosorbide mononitrate F QL(1 ea daily) vancomycin hcl solr iv 500 F tb24 30 mg, 60 mg, 120 mg mg NITRO-BID OINT F Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole- NF Trimethoprim) Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NITRO-DUR PT24 0.1 clorazepate dipotassium F QL(3 ea daily) MG/HR, 0.2 MG/HR, 0.4 NF tabs MG/HR, 0.6 MG/HR (Use DIAZEPAM SOLN OR 1 F QL(500 ml per Nitroglycerin) MG/ML fill retail) nitroglycerin cpcr or 9 mg, F diazepam tabs or 2 mg, 5 F QL(4 ea daily) 2.5 mg, 6.5 mg mg, 10 mg nitroglycerin pt24 td 0.1 lorazepam soln ij 2 mg/ml, F QL(3 ml daily) mg/hr, 0.2 mg/hr, 0.4 F 20 mg/10ml mg/hr, 0.6 mg/hr lorazepam tabs or 0.5 mg, F QL(3 ea daily) nitroglycerin subl sl 0.3 mg, F 2 mg 0.4 mg, 0.6 mg lorazepam tabs or 1 mg F QL(4 ea daily) NITROSTAT SUBL (Use NF Nitroglycerin) oxazepam caps F QL(4 ea daily) ANTIANXIETY AGENTS TRANXENE T TABS (Use NF QL(3 ea daily) Antianxiety Agents - Misc. Clorazepate Dipotassium) QL(4 ea daily) VALIUM TABS (Use NF QL(4 ea daily) buspirone hcl tabs 15 mg F Diazepam) buspirone hcl tabs 30 mg, QL(3 ea daily) F XANAX TABS (Use NF QL(4 ea daily) 7.5 mg Alprazolam) buspirone hcl tabs 5 mg, F QL(6 ea daily) 10 mg ANTIARRHYTHMICS hydroxyzine hcl syrp or 10 F Antiarrhythmics Type I-A mg/5ml disopyramide phosphate F hydroxyzine hcl tabs or 10 F caps mg, 25 mg, 50 mg NORPACE CAPS (Use F HYDROXYZINE F Disopyramide Phosphate) PAMOATE CAPS 100 MG NORPACE CR CP12 150 F hydroxyzine pamoate caps F MG 25 mg, 50 mg quinidine gluconate tbcr or F meprobamate tabs F 324 mg QUINIDINE SULFATE F VISTARIL CAPS (Use NF TABS Hydroxyzine Pamoate) Antiarrhythmics Type I-B Benzodiazepines hcl caps F alprazolam tabs 0.25 mg, F QL(4 ea daily) 0.5 mg, 1 mg, 2 mg Antiarrhythmics Type I-C ATIVAN SOLN IJ 2 MG/ML NF QL(3 ml daily) (Use Lorazepam) flecainide acetate tabs F ATIVAN TABS OR 0.5 MG, NF QL(3 ea daily) 2 MG (Use Lorazepam) propafenone hcl cp12 F ATIVAN TABS OR 1 MG NF QL(4 ea daily) (Use Lorazepam) propafenone hcl tabs F QL(4 ea daily) chlordiazepoxide hcl caps F RYTHMOL SR CP12 (Use NF Propafenone HCl)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RYTHMOL TABS (Use NF FLOVENT DISKUS AEPB QL(2 ea daily) Propafenone HCl) 100 MCG/BLIST, 250 F MCG/BLIST Antiarrhythmics Type III FLOVENT DISKUS AEPB QL(60 ea per amiodarone hcl tabs or 200 F F mg 50 MCG/BLIST fill retail) FLOVENT HFA AERO 110 F QL(12 gm per dofetilide caps F MCG/ACT, 220 MCG/ACT fill retail) FLOVENT HFA AERO 44 QL(11 gm per TIKOSYN CAPS (Use NF F Dofetilide) MCG/ACT fill retail) PULMICORT FLEXHALER F ANTIASTHMATIC AND BRONCHODILATOR AEPB AGENTS AL; At least 1 Anti-Inflammatory Agents PULMICORT SUSP (Use NF Budesonide (Inhalation)) yrs old - Up to cromolyn sodium nebu F 8 yrs old Sympathomimetics Bronchodilators - ALBUTEROL SULFATE F ATROVENT HFA AERS F ER TB12 albuterol sulfate nebu in 0.5 F QL(2 ml daily) F QL(30 ea per % INCRUSE ELLIPTA AEPB fill retail) albuterol sulfate nebu in ipratropium bromide soln F 0.63 mg/3ml, 0.083 %, 1.25 F mg/3ml TUDORZA PRESSAIR F AEPB albuterol sulfate syrp or 2 F mg/5ml Leukotriene Modulators albuterol sulfate tabs or 2 F montelukast sodium chew F QL(1 ea daily) mg, 4 mg albuterol sulfate tb12 or 4 F montelukast sodium pack F QL(1 ea daily) mg, 8 mg COMBIVENT RESPIMAT F montelukast sodium tabs F QL(1 ea daily) AERS QL(13 gm per SINGULAIR CHEW (Use NF QL(1 ea daily) DULERA AERO F Montelukast Sodium) fill retail) ipratropium-albuterol soln F QL(12 ml daily) SINGULAIR PACK (Use NF QL(1 ea daily) Montelukast Sodium) METAPROTERENOL QL(30 ml daily) SINGULAIR TABS (Use NF QL(1 ea daily) SULFATE SYRP 10 F Montelukast Sodium) MG/5ML Steroid Inhalants METAPROTERENOL QL(0.3 gm SULFATE TABS 10 MG, F AEROSPAN AERS F daily,8.9 gm 20 MG per fill retail) SEREVENT DISKUS F QL(2 ea daily) AL; At least 1 AEPB budesonide (inhalation) F yrs old - Up to susp F QL(11 gm per 8 yrs old SYMBICORT AERO fill retail) terbutaline sulfate tabs or 5 F mg, 2.5 mg

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(36 gm per enoxaparin sodium soln sc F QL(12 ml per VENTOLIN HFA AERS fill retail) 80 mg/0.8ml, 120 mg/0.8ml fill retail); SP F QL(16 gm per heparin sodium (porcine) F VENTOLIN HFA AERS fill retail) soln VOSPIRE ER TB12 (Use NF LOVENOX SOLN IJ 300 QL(42 ml per Albuterol Sulfate) MG/3ML (Use Enoxaparin NF fill retail); SP Sodium) Xanthines LOVENOX SOLN SC 100 QL(14 ml per ELIXOPHYLLIN ELIX F MG/ML, 150 MG/ML (Use NF fill retail); SP Enoxaparin Sodium) THEO-24 CP24 F LOVENOX SOLN SC 30 QL(5 ml per fill MG/0.3ML (Use NF retail); SP theophylline soln 80 F QL(475 ml per mg/15ml fill retail) Enoxaparin Sodium) LOVENOX SOLN SC 40 QL(6 ml per fill theophylline tb12 100 mg, F 200 mg, 300 mg, 450 mg MG/0.4ML (Use NF retail); SP Enoxaparin Sodium) theophylline tb24 400 mg, F 600 mg LOVENOX SOLN SC 60 QL(9 ml per fill MG/0.6ML (Use NF retail); SP ANTICOAGULANTS Enoxaparin Sodium) LOVENOX SOLN SC 80 QL(12 ml per Coumarin Anticoagulants MG/0.8ML, 120 MG/0.8ML NF fill retail); SP COUMADIN TABS (Use F (Use Enoxaparin Sodium) Warfarin Sodium) ANTICONVULSANTS warfarin sodium tabs F Anticonvulsants - Benzodiazepines Direct Factor Xa Inhibitors clonazepam tabs 0.5 mg, 1 F QL(4 ea daily) ELIQUIS STARTER PACK F QL(4 ea daily) mg, 2 mg TABS QL(1 ea per fill ELIQUIS TABS F QL(4 ea daily) DIASTAT ACUDIAL GEL F retail); AL; At least 2 yrs old XARELTO TABS 10 MG, F QL(1 ea daily) QL(1 ea per fill 20 MG DIASTAT PEDIATRIC GEL F retail); AL; At XARELTO TABS 15 MG F QL(2 ea daily) least 2 yrs old QL(1 ea per fill DIAZEPAM GEL RE 10 F Heparins And Heparinoid-Like Agents MG, 20 MG, 2.5 MG retail); AL; At least 2 yrs old enoxaparin sodium soln ij F QL(42 ml per 300 mg/3ml fill retail); SP QL(1 ea per fill DIAZEPAM RECTAL GEL F retail); AL; At enoxaparin sodium soln sc F QL(14 ml per GEL 100 mg/ml, 150 mg/ml fill retail); SP least 2 yrs old KLONOPIN TABS (Use QL(4 ea daily) enoxaparin sodium soln sc F QL(5 ml per fill NF 30 mg/0.3ml retail); SP Clonazepam) Anticonvulsants - Misc. enoxaparin sodium soln sc F QL(6 ml per fill 40 mg/0.4ml retail); SP carbamazepine chew F enoxaparin sodium soln sc F QL(9 ml per fill 60 mg/0.6ml retail); SP carbamazepine cp12 F

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carbamazepine susp F NEURONTIN TABS 600 NF QL(6 ea daily) MG (Use Gabapentin) carbamazepine tabs F NEURONTIN TABS 800 NF QL(4 ea daily) MG (Use Gabapentin) carbamazepine tb12 F oxcarbazepine susp F CARBATROL CP12 (Use F Carbamazepine) oxcarbazepine tabs F gabapentin caps 100 mg, F QL(9 ea daily) 300 mg, 400 mg primidone tabs F gabapentin soln 250 F TEGRETOL SUSP (Use F mg/5ml, 300 mg/6ml Carbamazepine) gabapentin tabs 600 mg F QL(6 ea daily) TEGRETOL TABS (Use F Carbamazepine) QL(4 ea daily) gabapentin tabs 800 mg F TEGRETOL-XR TB12 (Use F Carbamazepine) KEPPRA SOLN OR 100 QL(30 ml daily) TOPAMAX SPRINKLE QL(6 ea daily) MG/ML (Use NF CPSP 15 MG (Use NF Levetiracetam) Topiramate) KEPPRA TABS OR 250 QL(4 ea daily) TOPAMAX SPRINKLE QL(8 ea daily) MG, 750 MG (Use NF CPSP 25 MG (Use NF Levetiracetam) Topiramate) KEPPRA TABS OR 500 QL(6 ea daily) NF TOPAMAX TABS 100 MG NF QL(4 ea daily) MG (Use Levetiracetam) (Use Topiramate) LAMICTAL CHEWABLE TOPAMAX TABS 200 MG NF QL(2 ea daily) DISPERSIBLE CHEW (Use NF (Use Topiramate) Lamotrigine) TOPAMAX TABS 25 MG, NF QL(6 ea daily) LAMICTAL TABS (Use NF 50 MG (Use Topiramate) Lamotrigine) topiramate cpsp 15 mg F QL(6 ea daily) lamotrigine chew 5 mg, 25 F mg topiramate cpsp 25 mg F QL(8 ea daily) lamotrigine tabs 25 mg, F 100 mg, 150 mg, 200 mg topiramate tabs 100 mg F QL(4 ea daily) levetiracetam soln or 100 F QL(30 ml daily) mg/ml, 500 mg/5ml topiramate tabs 200 mg F QL(2 ea daily) levetiracetam tabs or 250 F QL(4 ea daily) mg, 750 mg topiramate tabs 25 mg, 50 F QL(6 ea daily) mg levetiracetam tabs or 500 F QL(6 ea daily) mg TRILEPTAL SUSP (Use NF Oxcarbazepine) MYSOLINE TABS (Use NF Primidone) TRILEPTAL TABS (Use NF NEURONTIN CAPS 100 QL(9 ea daily) Oxcarbazepine) MG, 300 MG, 400 MG (Use NF ZONEGRAN CAPS (Use NF Gabapentin) Zonisamide) NEURONTIN SOLN 250 NF zonisamide caps F MG/5ML (Use Gabapentin) Carbamates

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits felbamate susp F DEPACON SOLN (Use NF Valproate Sodium) felbamate tabs F DEPAKENE CAPS (Use F Valproic Acid) FELBATOL SUSP (Use NF DEPAKENE SOLN (Use F Felbamate) Valproate Sodium) FELBATOL TABS (Use NF DEPAKOTE ER TB24 (Use NF Felbamate) Divalproex Sodium) GABA Modulators DEPAKOTE SPRINKLES CSDR (Use Divalproex NF GABITRIL TABS (Use NF Tiagabine HCl) Sodium) DEPAKOTE TBEC (Use NF tiagabine hcl tabs F Divalproex Sodium) Hydantoins divalproex sodium csdr or F 125 mg CEREBYX SOLN (Use NF Fosphenytoin Sodium) divalproex sodium tb24 or F DILANTIN CAPS 100 MG 250 mg, 500 mg (Use Phenytoin Sodium F divalproex sodium tbec or F Extended) 125 mg, 250 mg, 500 mg DILANTIN CAPS 30 MG F valproate sodium soln F

DILANTIN INFATABS F valproic acid caps F CHEW (Use Phenytoin) DILANTIN-125 SUSP (Use F ANTIDEPRESSANTS Phenytoin) Alpha-2 Receptor Antagonists (Tetracyclics) fosphenytoin sodium soln F mirtazapine tabs 15 mg F QL(3 ea daily) PHENYTEK CAPS (Use QL(1.5 ea Phenytoin Sodium F mirtazapine tabs 30 mg F Extended) daily) phenytoin chew F mirtazapine tabs 45 mg, F QL(1 ea daily) 7.5 mg phenytoin sodium extended F QL(3 ea daily) caps mirtazapine tbdp 15 mg F phenytoin susp F F QL(1.5 ea mirtazapine tbdp 30 mg daily) mirtazapine tbdp 45 mg F QL(1 ea daily) ethosuximide caps F REMERON SOLTAB TBDP NF QL(3 ea daily) 15 MG (Use Mirtazapine) ethosuximide soln F REMERON SOLTAB TBDP NF QL(1.5 ea 30 MG (Use Mirtazapine) daily) ZARONTIN CAPS (Use F Ethosuximide) REMERON SOLTAB TBDP NF QL(1 ea daily) 45 MG (Use Mirtazapine) ZARONTIN SOLN (Use F Ethosuximide) REMERON TABS 15 MG NF QL(3 ea daily) Valproic Acid (Use Mirtazapine)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REMERON TABS 30 MG NF QL(1.5 ea CELEXA TABS 10 MG QL(4 ea daily) (Use Mirtazapine) daily) (Use Citalopram NF Hydrobromide) REMERON TABS 45 MG NF QL(1 ea daily) (Use Mirtazapine) CELEXA TABS 20 MG QL(2 ea daily) (Use Citalopram NF Antidepressants - Misc. Hydrobromide) bupropion hcl tabs 75 mg, F QL(3 ea daily) 100 mg CELEXA TABS 40 MG QL(1 ea daily) (Use Citalopram NF bupropion hcl tb12 100 mg F QL(4 ea daily) Hydrobromide) citalopram hydrobromide F bupropion hcl tb12 150 mg F QL(3 ea daily) soln 10 mg/5ml QL(2 ea daily) citalopram hydrobromide F QL(4 ea daily) bupropion hcl tb12 200 mg F tabs 10 mg QL(3 ea daily) citalopram hydrobromide F QL(2 ea daily) bupropion hcl tb24 150 mg F tabs 20 mg bupropion hcl tb24 300 mg F QL(1 ea daily) citalopram hydrobromide F QL(1 ea daily) tabs 40 mg MAPROTILINE HCL TABS F escitalopram oxalate tabs F QL(2 ea daily) 10 mg WELLBUTRIN SR TB12 QL(4 ea daily) escitalopram oxalate tabs F QL(1 ea daily) 100 MG (Use Bupropion NF 20 mg HCl) escitalopram oxalate tabs 5 F QL(4 ea daily) WELLBUTRIN SR TB12 QL(3 ea daily) mg 150 MG (Use Bupropion NF HCl) fluoxetine hcl caps 10 mg, F QL(4 ea daily) 20 mg WELLBUTRIN SR TB12 QL(2 ea daily) 200 MG (Use Bupropion NF QL(4 ea daily); HCl) fluoxetine hcl caps 40 mg F AL; At least 7 yrs old WELLBUTRIN TABS (Use NF QL(3 ea daily) Bupropion HCl) QL(20 ml fluoxetine hcl soln 20 F daily); AL; At WELLBUTRIN XL TB24 QL(3 ea daily) mg/5ml least 7 yrs old 150 MG (Use Bupropion NF HCl) QL(1 ea daily); fluoxetine hcl tabs 10 mg F AL; At least 7 WELLBUTRIN XL TB24 QL(1 ea daily) yrs old 300 MG (Use Bupropion NF HCl) fluvoxamine maleate tabs F QL(3 ea daily) 100 mg Monoamine Oxidase Inhibitors (MAOIs) fluvoxamine maleate tabs F QL(2 ea daily) NARDIL TABS (Use NF 25 mg, 50 mg Phenelzine Sulfate) LEXAPRO TABS 10 MG NF QL(2 ea daily) PARNATE TABS (Use NF (Use Escitalopram Oxalate) Tranylcypromine Sulfate) LEXAPRO TABS 20 MG NF QL(1 ea daily) phenelzine sulfate tabs F (Use Escitalopram Oxalate) LEXAPRO TABS 5 MG NF QL(4 ea daily) tranylcypromine sulfate F (Use Escitalopram Oxalate) tabs paroxetine hcl tabs 10 mg F QL(6 ea daily) Selective Serotonin Reuptake Inhibitors (SSRIs)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits paroxetine hcl tabs 20 mg F QL(3 ea daily) Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use NF QL(1 ea daily) paroxetine hcl tabs 30 mg, F QL(2 ea daily) Duloxetine HCl) 40 mg desvenlafaxine succinate F QL(4 ea daily) PAXIL SUSP 10 MG/5ML F QL(40 ml daily) tb24 100 mg desvenlafaxine succinate QL(1 ea daily) PAXIL TABS 10 MG (Use NF QL(6 ea daily) F Paroxetine HCl) tb24 25 mg, 50 mg duloxetine hcl cpep 20 mg, QL(1 ea daily) PAXIL TABS 20 MG (Use NF QL(3 ea daily) F Paroxetine HCl) 30 mg, 60 mg EFFEXOR XR CP24 150 QL(2 ea daily) PAXIL TABS 30 MG, 40 NF QL(2 ea daily) NF MG (Use Paroxetine HCl) MG (Use Venlafaxine HCl) EFFEXOR XR CP24 37.5 QL(4 ea daily) PROZAC CAPS 10 MG, 20 NF QL(4 ea daily) NF MG (Use Fluoxetine HCl) MG (Use Venlafaxine HCl) QL(4 ea daily); EFFEXOR XR CP24 75 NF QL(5 ea daily) PROZAC CAPS 40 MG NF MG (Use Venlafaxine HCl) ) AL; At least 7 (Use Fluoxetine HCl yrs old PRISTIQ TB24 100 MG QL(4 ea daily) (Use Desvenlafaxine NF sertraline hcl conc 20 F QL(10 ml daily) mg/ml Succinate) QL(2 ea daily) PRISTIQ TB24 25 MG, 50 QL(1 ea daily) sertraline hcl tabs 100 mg F MG (Use Desvenlafaxine NF Succinate) sertraline hcl tabs 25 mg, F QL(4 ea daily) 50 mg venlafaxine hcl cp24 150 F QL(2 ea daily) mg ZOLOFT CONC 20 MG/ML NF QL(10 ml daily) (Use Sertraline HCl) venlafaxine hcl cp24 37.5 F QL(4 ea daily) mg ZOLOFT TABS 100 MG NF QL(2 ea daily) (Use Sertraline HCl) venlafaxine hcl cp24 75 mg F QL(5 ea daily) ZOLOFT TABS 25 MG, 50 NF QL(4 ea daily) MG (Use Sertraline HCl) VENLAFAXINE HCL ER QL(2 ea daily) TB24 150 MG (Use NF Serotonin Modulators Venlafaxine HCl) QL(1 ea daily); VENLAFAXINE HCL ER F QL(1 ea daily) BRINTELLIX TABS F AL; At least 18 TB24 225 MG yrs old VENLAFAXINE HCL ER QL(1 ea daily) NEFAZODONE HCL TABS F TB24 37.5 MG (Use NF 100 MG, 150 MG, 200 MG Venlafaxine HCl) nefazodone hcl tabs 50 F VENLAFAXINE HCL ER mg, 250 mg TB24 75 MG (Use NF Venlafaxine HCl) trazodone hcl tabs 300 mg F QL(2 ea daily) venlafaxine hcl tabs 25 mg, trazodone hcl tabs 50 mg, F 50 mg, 75 mg, 100 mg, F 100 mg, 150 mg 37.5 mg QL(1 ea daily); venlafaxine hcl tb24 150 F QL(2 ea daily) TRINTELLIX TABS F AL; At least 18 mg yrs old venlafaxine hcl tb24 225 F QL(1 ea daily) F PA; QL(1 ea mg, 37.5 mg VIIBRYD TABS daily)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits venlafaxine hcl tb24 75 mg F ACTOPLUS MET TABS QL(2 ea daily) (Use Pioglitazone HCl- NF Tricyclic Agents Metformin HCl) ALOGLIPTIN/METFORMIN F PA; QL(1 ea amitriptyline hcl tabs F HCL TABS daily) ALOGLIPTIN/PIOGLITAZO F PA; QL(1 ea AMOXAPINE TABS F NE TABS daily) ANAFRANIL CAPS 50 MG, glipizide-metformin hcl tabs F 75 MG (Use Clomipramine NF HCl) GLUCOVANCE TABS (Use NF Glyburide-Metformin) clomipramine hcl caps 50 F mg, 75 mg glyburide-metformin tabs F desipramine hcl tabs 10 mg, 50 mg, 75 mg, 100 mg, F PA; QL(2 ea 150 mg JENTADUETO TABS F daily); AL; At least 18 yrs old desipramine hcl tabs 25 mg F QL(2 ea daily) F PA; QL(1 ea KAZANO TABS daily) doxepin hcl caps F OSENI TABS F PA; QL(1 ea doxepin hcl conc F daily) pioglitazone hcl-metformin F QL(2 ea daily) ELAVIL TABS (Use NF hcl tabs Amitriptyline HCl) Biguanides imipramine hcl tabs F GLUCOPHAGE TABS QL(2 ea daily) NORPRAMIN TABS 10 1000 MG (Use Metformin NF HCl) MG, 50 MG, 75 MG, 100 NF MG, 150 MG (Use GLUCOPHAGE TABS 500 NF QL(5 ea daily) Desipramine HCl) MG (Use Metformin HCl) GLUCOPHAGE TABS 850 QL(3 ea daily) NORPRAMIN TABS 25 MG NF QL(2 ea daily) NF (Use Desipramine HCl) MG (Use Metformin HCl) GLUCOPHAGE XR TB24 QL(4 ea daily) nortriptyline hcl caps 10 F mg, 25 mg, 50 mg, 75 mg 500 MG (Use Metformin NF HCl) NORTRIPTYLINE HCL F QL(20 ml daily) SOLN 10 MG/5ML GLUCOPHAGE XR TB24 QL(2 ea daily) 750 MG (Use Metformin NF PAMELOR CAPS (Use NF Nortriptyline HCl) HCl) metformin hcl tabs 1000 QL(2 ea daily) TOFRANIL TABS (Use NF F Imipramine HCl) mg QL(5 ea daily) ANTIDIABETICS metformin hcl tabs 500 mg F QL(3 ea daily) Antidiabetic - Amylin Analogs metformin hcl tabs 850 mg F PA; SYMLINPEN 120 SOPN F metformin hcl tb24 500 mg F QL(4 ea daily) PA; SYMLINPEN 60 SOPN F metformin hcl tb24 750 mg F QL(2 ea daily) Antidiabetic Combinations Diabetic Other Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD GLUCOSE CHEW F pioglitazone hcl tabs F QL(1 ea daily)

CVS GLUCOSE CHEW 4 F Insulin GM ADMELOG SOLN F DEX4 QUICK DISSOLVE F GLUCOSE CHEW ADMELOG SOLOSTAR F GLUCAGEN HYPOKIT F SOPN SOLR APIDRA SOLN F GLUCAGON F QL(1 ea per fill EMERGENCY KIT KIT retail) APIDRA SOLOSTAR F SOPN GLUCOSE CHEW 4 GM F BASAGLAR KWIKPEN F GNP GLUCOSE CHEW 4 F SOPN GM FIASP FLEXTOUCH F GNP QUICK DISSOLVE F SOPN GLUCOSE CHEW FIASP SOLN F LEADER QUICK DISSOLVE GLUCOSE F HUMALOG JUNIOR F CHEW KWIKPEN SOPN SM GLUCOSE CHEW 4 F HUMALOG KWIKPEN F GM SOPN 100 UNIT/ML WALGREENS GLUCOSE F HUMALOG MIX 50/50 F CHEW 4 GM KWIKPEN SUPN Dipeptidyl Peptidase-4 (DPP-4) Inhibitors HUMALOG MIX 50/50 F SUSP ALOGLIPTIN TABS F PA; QL(1 ea daily) HUMALOG MIX 75/25 F KWIKPEN SUPN NESINA TABS F PA; QL(1 ea daily) HUMALOG MIX 75/25 F PA; QL(1 ea SUSP TRADJENTA TABS F daily); AL; At HUMALOG SOCT F least 18 yrs old Incretin Mimetic Agents (GLP-1 Receptor HUMALOG SOLN F PA; AL; At BYDUREON PEN PEN F HUMULIN 70/30 KWIKPEN F least 18 yrs old SUPN F PA; AL; At BYDUREON SRER least 18 yrs old HUMULIN 70/30 SUSP F PA; AL; At BYETTA SOPN F HUMULIN N KWIKPEN F least 18 yrs old SUPN F QL(0.3 ml VICTOZA SOPN daily) HUMULIN N SUSP F Insulin Sensitizing Agents HUMULIN R SOLN F ACTOS TABS (Use QL(1 ea daily) NF NOVOLIN 70/30 RELION F Pioglitazone HCl) SUSP F QL(1 ea daily) AVANDIA TABS NOVOLIN 70/30 SUSP F

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVOLIN N RELION F glyburide tabs F SUSP GLYNASE TABS (Use NF NOVOLIN N SUSP F Glyburide Micronized) NOVOLIN R RELION F SOLN ANTIDIARRHEAL/PROBIOTIC AGENTS NOVOLIN R SOLN F Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew F NOVOLOG FLEXPEN F 262 mg SOPN bismuth subsalicylate susp F NOVOLOG MIX 70/30 525 mg/15ml F PREFILLED FLEXPEN PEPTO-BISMOL CHEW SUPN 262 MG (Use Bismuth NF NOVOLOG MIX 70/30 F Subsalicylate) SUSP PEPTO-BISMOL NOVOLOG PENFILL F INSTACOOL CHEW (Use NF SOCT Bismuth Subsalicylate) NOVOLOG SOLN F PEPTO-BISMOL MAX STRENGTH SUSP (Use NF Meglitinide Analogues Bismuth Subsalicylate) nateglinide tabs F QL(3 ea daily) PEPTO-BISMOL TO-GO CHEW (Use Bismuth NF Subsalicylate) STARLIX TABS (Use NF QL(3 ea daily) Nateglinide) Antiperistaltic Agents Sodium-Glucose Co-Transporter 2 (SGLT2) diphenoxylate w/ atropine F tabs F PA; QL(1 ea JARDIANCE TABS daily) DIPHENOXYLATE/ATROP F Sulfonylureas INE LIQD IMODIUM A-D CAPS 2 MG RX/OTC AMARYL TABS 1 MG, 2 NF QL(4 ea daily) NF MG (Use Glimepiride) (Use Loperamide HCl) IMODIUM A-D TABS 2 MG QL(2 ea daily) AMARYL TABS 4 MG (Use NF QL(2 ea daily) NF Glimepiride) (Use Loperamide HCl) LOMOTIL TABS (Use glimepiride tabs 1 mg, 2 F QL(4 ea daily) NF mg Diphenoxylate w/ Atropine) RX/OTC glimepiride tabs 4 mg F QL(2 ea daily) loperamide hcl caps 2 mg F loperamide hcl liqd 1 F glipizide tabs F mg/5ml QL(2 ea daily) glipizide tb24 F loperamide hcl tabs 2 mg F

GLUCOTROL TABS (Use NF PAREGORIC TINC F Glipizide) GLUCOTROL XL TB24 NF ANTIDOTES AND SPECIFIC ANTAGONISTS (Use Glipizide) Antidotes - Chelating Agents glyburide micronized tabs F

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHEMET CAPS F meclizine hcl tabs 25 mg, F RX/OTC 12.5 mg PA; SP JADENU TABS F ANTIFUNGALS Antidotes and Specific Antagonists Antifungals VISTOGARD PACK F GRIS-PEG TABS (Use NF Griseofulvin Ultramicrosize) Opioid Antagonists griseofulvin microsize susp F EVZIO SOAJ 0.4 F MG/0.4ML griseofulvin microsize tabs F naloxone hcl soln 0.4 F mg/ml, 4 mg/10ml griseofulvin ultramicrosize F tabs NALOXONE HCL SOSY 2 F MG/2ML LAMISIL TABS 250 MG NF QL(1 ea daily) (Use Terbinafine HCl) naltrexone hcl tabs F nystatin tabs F QL(6 ea daily) NARCAN LIQD F terbinafine hcl tabs F QL(1 ea daily) VIVITROL SUSR F Imidazole-Related Antifungals ANTIEMETICS DIFLUCAN SUSR 10 QL(70 ml per MG/ML, 40 MG/ML (Use NF fill retail) 5-HT3 Receptor Antagonists Fluconazole) DIFLUCAN TABS 100 MG QL(1 ea daily) ondansetron hcl soln or 4 F QL(50 ml per NF mg/5ml fill retail) (Use Fluconazole) QL(2 ea DIFLUCAN TABS 150 MG NF QL(2 ea per fill ondansetron hcl tabs or 4 F daily,20 ea per (Use Fluconazole) retail) mg, 8 mg 30 days retail) DIFLUCAN TABS 200 MG NF QL(2 ea daily) QL(2 ea (Use Fluconazole) ondansetron tbdp F daily,20 ea per DIFLUCAN TABS 50 MG NF QL(7 ea per fill 30 days retail) (Use Fluconazole) retail) QL(2 ea fluconazole susr 10 mg/ml, QL(70 ml per ZOFRAN ODT TBDP (Use NF F ) daily,20 ea per 40 mg/ml fill retail) Ondansetron 30 days retail) fluconazole tabs 100 mg F QL(1 ea daily) ZOFRAN SOLN 4 MG/5ML NF QL(50 ml per (Use Ondansetron HCl) fill retail) QL(2 ea per fill fluconazole tabs 150 mg F ZOFRAN TABS 4 MG, 8 QL(2 ea retail) MG (Use Ondansetron NF daily,20 ea per QL(2 ea daily) HCl) 30 days retail) fluconazole tabs 200 mg F Antiemetics - F QL(7 ea per fill fluconazole tabs 50 mg retail) dimenhydrinate tabs or 50 F QL(24 ea per mg fill retail) F PA; QL(1 ea itraconazole caps daily) DRAMAMINE TABS (Use NF QL(24 ea per Dimenhydrinate) fill retail) SPORANOX CAPS 100 NF PA; QL(1 ea MG (Use Itraconazole) daily) meclizine hcl chew 25 mg F

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPORANOX PULSEPAK NF PA; QL(1 ea TAVIST ALLERGY TABS NF QL(2 ea daily) CAPS (Use Itraconazole) daily) (Use Clemastine Fumarate) ANTIHISTAMINES Antihistamines - Non-Sedating ALLEGRA ALLERGY QL(1 ea daily) Antihistamines - Alkylamines TABS 180 MG (Use NF CHLOR-TRIMETON SYRP QL(60 ml daily) Fexofenadine HCl) 2 MG/5ML (Use NF ALLEGRA ALLERGY QL(2 ea daily) Chlorpheniramine Maleate) TABS 60 MG (Use NF CHLOR-TRIMETON TABS QL(120 ea per Fexofenadine HCl) 4 MG (Use NF fill retail) cetirizine hcl chew 5 mg, 10 F QL(1 ea daily) Chlorpheniramine Maleate) mg chlorpheniramine maleate F QL(60 ml daily) QL(480 ml per syrp 2 mg/5ml cetirizine hcl soln 1 mg/ml, F fill retail); 5 mg/5ml RX/OTC chlorpheniramine maleate F QL(120 ea per tabs 4 mg fill retail) QL(480 ml per cetirizine hcl syrp 1 mg/ml, Antihistamines - Ethanolamines F fill retail); 5 mg/5ml RX/OTC BENADRYL ALLERGY QL(4 ea daily) CAPS (Use NF cetirizine hcl tabs 5 mg, 10 F QL(1 ea daily) Diphenhydramine HCl) mg BENADRYL ALLERGY QL(240 ml per CLARITIN ALLERGY QL(240 ml per CHILDRENS SYRP (Use NF fill retail) CHILDRENS LIQD 12.5 NF fill retail) MG/5ML (Use Loratadine) Diphenhydramine HCl) CLARITIN REDITABS BENADRYL ALLERGY QL(4 ea daily) TBDP 10 MG (Use NF TABS (Use NF Loratadine) Diphenhydramine HCl) CLARITIN SYRP 5 NF QL(240 ml per MG/5ML (Use Loratadine) fill retail) clemastine fumarate tabs F QL(2 ea daily) 1.34 mg CLARITIN TABS 10 MG NF (Use Loratadine) diphenhydramine hcl caps F QL(4 ea daily) or 25 mg fexofenadine hcl tabs 180 F QL(1 ea daily) mg diphenhydramine hcl caps F QL(4 ea daily); or 50 mg RX/OTC fexofenadine hcl tabs 60 F QL(2 ea daily) QL(240 ml per mg diphenhydramine hcl elix or QL(240 ml per F fill retail); loratadine soln 5 mg/5ml F 12.5 mg/5ml RX/OTC fill retail) QL(240 ml per diphenhydramine hcl liqd or QL(240 ml per loratadine syrp 5 mg/5ml F 25 mg/10ml, 50 mg/20ml, F fill retail) fill retail) 12.5 mg/5ml loratadine tabs 10 mg F diphenhydramine hcl syrp F QL(240 ml per or 12.5 mg/5ml fill retail) loratadine tbdp 10 mg F diphenhydramine hcl tabs F QL(4 ea daily) or 25 mg ZYRTEC ALLERGY TABS NF QL(1 ea daily) (Use Cetirizine HCl) F QL(240 ml per SILPHEN COUGH SYRP fill retail) ZYRTEC CHILDRENS QL(480 ml per ALLERGY SYRP (Use NF fill retail); Cetirizine HCl) RX/OTC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antihistamines - Phenothiazines fenofibrate micronized caps F QL(1 ea daily) QL(240 ml per 134 mg, 200 mg promethazine hcl soln or F fill retail); AL; At fenofibrate micronized caps F QL(2 ea daily) 6.25 mg/5ml least 2 yrs old 67 mg QL(12 ea per fenofibrate tabs 160 mg F QL(1 ea daily) promethazine hcl supp re F fill retail); AL; At 25 mg, 50 mg, 12.5 mg least 2 yrs old fenofibrate tabs 54 mg F QL(3 ea daily) QL(240 ml per promethazine hcl syrp or F fill retail); AL; At gemfibrozil tabs F QL(2 ea daily) 6.25 mg/5ml least 2 yrs old LOFIBRA CAPS 134 MG, QL(1 ea daily) promethazine hcl tabs or F AL; At least 2 200 MG (Use Fenofibrate NF 25 mg, 50 mg, 12.5 mg yrs old Micronized) Antihistamines - Piperidines LOFIBRA CAPS 67 MG QL(2 ea daily) cyproheptadine hcl syrp F (Use Fenofibrate NF Micronized) cyproheptadine hcl tabs F LOFIBRA TABS 160 MG NF QL(1 ea daily) (Use Fenofibrate) ANTIHYPERLIPIDEMICS LOFIBRA TABS 54 MG NF QL(3 ea daily) (Use Fenofibrate) Bile Acid Sequestrants LOPID TABS (Use NF QL(2 ea daily) cholestyramine light pack F Gemfibrozil) TRIGLIDE TABS F QL(1 ea daily) cholestyramine light powd F HMG CoA Reductase Inhibitors cholestyramine pack F atorvastatin calcium tabs F QL(1 ea daily) cholestyramine powd F CRESTOR TABS (Use NF ST COLESTID FLAVORED Rosuvastatin Calcium) GRAN 5 GM (Use NF LIPITOR TABS (Use NF QL(1 ea daily) Colestipol HCl) Atorvastatin Calcium) lovastatin tabs 10 mg, 20 QL(1 ea daily) COLESTID GRAN 5 GM NF F (Use Colestipol HCl) mg QL(2 ea daily) COLESTID TABS 1 GM NF lovastatin tabs 40 mg F (Use Colestipol HCl) MEVACOR TABS (Use NF QL(2 ea daily) colestipol hcl gran 5 gm F Lovastatin) colestipol hcl tabs 1 gm F PRAVACHOL TABS (Use NF QL(1 ea daily) Pravastatin Sodium) QUESTRAN LIGHT POWD NF QL(1 ea daily) (Use Cholestyramine Light) pravastatin sodium tabs F ST QUESTRAN PACK (Use NF rosuvastatin calcium tabs F Cholestyramine) simvastatin tabs 5 mg, 10 QL(1 ea daily) QUESTRAN POWD (Use NF F Cholestyramine) mg, 20 mg, 40 mg F PA; QL(1 ea Fibric Acid Derivatives simvastatin tabs 80 mg daily)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOCOR TABS 5 MG, 10 QL(1 ea daily) trandolapril tabs 4 mg F QL(2 ea daily) MG, 20 MG, 40 MG (Use NF Simvastatin) VASOTEC TABS (Use NF QL(2 ea daily) Enalapril Maleate) ZOCOR TABS 80 MG (Use NF PA; QL(1 ea Simvastatin) daily) ZESTRIL TABS (Use NF Nicotinic Acid Derivatives Lisinopril) Angiotensin II Receptor Antagonists niacin (antihyperlipidemic) F tbcr AVAPRO TABS (Use NF QL(1 ea daily) Irbesartan) NIACOR TABS F COZAAR TABS (Use NF QL(1 ea daily) NIASPAN TBCR (Use NF Losartan Potassium) Niacin (Antihyperlipidemic)) DIOVAN TABS (Use NF QL(1 ea daily) Valsartan) ANTIHYPERTENSIVES irbesartan tabs F QL(1 ea daily) ACE Inhibitors QL(1 ea daily) ACCUPRIL TABS (Use NF QL(1 ea daily) losartan potassium tabs F Quinapril HCl) MICARDIS TABS (Use QL(1 ea daily) ALTACE CAPS (Use NF QL(2 ea daily) NF Ramipril) Telmisartan) QL(1 ea daily) benazepril hcl tabs 40 mg F QL(2 ea daily) telmisartan tabs F valsartan tabs F QL(1 ea daily) benazepril hcl tabs 5 mg, F QL(1 ea daily) 10 mg, 20 mg Antiadrenergic Antihypertensives captopril tabs F QL(3 ea daily) CARDURA TABS (Use NF Doxazosin Mesylate) enalapril maleate tabs F QL(2 ea daily) CATAPRES TABS (Use NF EPANED SOLR F Clonidine HCl) clonidine hcl tabs or 0.1 F fosinopril sodium tabs F QL(1 ea daily) mg, 0.2 mg, 0.3 mg doxazosin mesylate tabs F lisinopril tabs F guanfacine hcl tabs F LOTENSIN TABS 20 MG NF QL(1 ea daily) (Use Benazepril HCl) methyldopa tabs F LOTENSIN TABS 40 MG NF QL(2 ea daily) (Use Benazepril HCl) MINIPRESS CAPS (Use NF MAVIK TABS (Use NF QL(1 ea daily) Prazosin HCl) Trandolapril) prazosin hcl caps F PRINIVIL TABS (Use NF Lisinopril) RESERPINE TABS F quinapril hcl tabs F QL(1 ea daily) TENEX TABS (Use NF Guanfacine HCl) ramipril caps F QL(2 ea daily) terazosin hcl caps F trandolapril tabs 1 mg, 2 F QL(1 ea daily) mg Antihypertensive Combinations Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACCURETIC TABS 10MG- QL(3 ea daily) LOTREL CAPS (Use QL(1 ea daily) 12.5MG (Use Quinapril- NF Amlodipine Besylate- NF Hydrochlorothiazide) Benazepril HCl) ACCURETIC TABS 20MG- QL(4 ea daily) metoprolol & F QL(2 ea daily) 12.5MG (Use Quinapril- NF hydrochlorothiazide tabs Hydrochlorothiazide) METOPROLOL QL(1 ea daily) ACCURETIC TABS 20MG- QL(2 ea daily) SUCCINATE F 25MG (Use Quinapril- NF ER/HYDROCHLOROTHIA Hydrochlorothiazide) ZIDE TB24 amlodipine besylate- F QL(1 ea daily) METOPROLOL/HYDROCH F QL(2 ea daily) benazepril hcl caps LOROTHIAZIDE TABS atenolol & chlorthalidone F QL(1 ea daily) MICARDIS HCT TABS QL(1 ea daily) tabs (Use Telmisartan- NF AVALIDE TABS (Use QL(1 ea daily) Hydrochlorothiazide) NF Irbesartan- PROPRANOLOL/HYDROC F QL(2 ea daily) Hydrochlorothiazide) HLOROTHIAZIDE TABS benazepril & F QL(1 ea daily) quinapril- QL(3 ea daily) hydrochlorothiazide tabs hydrochlorothiazide tabs F 10mg-12.5mg bisoprolol & F QL(1 ea daily) hydrochlorothiazide tabs quinapril- QL(4 ea daily) hydrochlorothiazide tabs F CAPTOPRIL/HYDROCHL F QL(2 ea daily) OROTHIAZIDE TABS 20mg-12.5mg DIOVAN HCT TABS (Use QL(1 ea daily) quinapril- QL(2 ea daily) Valsartan- NF hydrochlorothiazide tabs F Hydrochlorothiazide) 20mg-25mg QL(1 ea daily) TARKA TBCR (Use DUTOPROL TB24 F Trandolapril-Verapamil NF HCl) enalapril maleate & F QL(2 ea daily) hydrochlorothiazide tabs telmisartan-amlodipine tabs F fosinopril sodium & F QL(1 ea daily) hydrochlorothiazide tabs telmisartan- F QL(1 ea daily) hydrochlorothiazide tabs HYZAAR TABS (Use QL(1 ea daily) Losartan Potassium & NF TENORETIC 100 TABS QL(1 ea daily) Hydrochlorothiazide) (Use Atenolol & NF Chlorthalidone) irbesartan- F QL(1 ea daily) hydrochlorothiazide tabs TENORETIC 50 TABS QL(1 ea daily) (Use Atenolol & NF lisinopril & F Chlorthalidone) hydrochlorothiazide tabs trandolapril-verapamil hcl F LOPRESSOR HCT TABS QL(2 ea daily) tbcr (Use Metoprolol & NF Hydrochlorothiazide) TRANDOLAPRIL/VERAPA F MIL HCL ER TBCR losartan potassium & F QL(1 ea daily) hydrochlorothiazide tabs TWYNSTA TABS (Use NF Telmisartan-Amlodipine) LOTENSIN HCT TABS QL(1 ea daily) (Use Benazepril & NF valsartan- F QL(1 ea daily) Hydrochlorothiazide) hydrochlorothiazide tabs

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VASERETIC TABS (Use QL(2 ea daily) pyridostigmine bromide tbcr F Enalapril Maleate & NF Hydrochlorothiazide) ANTIMYCOBACTERIAL AGENTS ZESTORETIC TABS (Use Lisinopril & NF Antimycobacterial Agents Hydrochlorothiazide) ethambutol hcl tabs F ZIAC TABS (Use Bisoprolol NF QL(1 ea daily) & Hydrochlorothiazide) ISONIAZID SYRP OR 50 F Vasodilators MG/5ML isoniazid tabs or 100 mg, hydralazine hcl tabs or 10 F F mg, 25 mg, 50 mg, 100 mg 300 mg MYAMBUTOL TABS (Use NF minoxidil tabs F Ethambutol HCl) ANTIMALARIALS pyrazinamide tabs F Antimalarial Combinations RIFADIN CAPS OR 150 MG, 300 MG (Use NF F QL(24 ea per Rifampin) COARTEM TABS fill retail) rifampin caps or 150 mg, F Antimalarials 300 mg CHLOROQUINE QL(2 ea daily) PHOSPHATE TABS 250 F TRECATOR TABS F MG ANTINEOPLASTICS AND ADJUNCTIVE chloroquine phosphate F THERAPIES tabs 500 mg Alkylating Agents hydroxychloroquine sulfate F tabs ALKERAN TABS OR 2 MG NF (Use Melphalan) MEFLOQUINE HCL TABS F LEUKERAN TABS F mefloquine hcl tabs F melphalan tabs F PLAQUENIL TABS (Use Hydroxychloroquine NF MYLERAN TABS F Sulfate) TEMODAR CAPS OR 180 PA; QL(2 ea PRIMAQUINE F PHOSPHATE TABS MG, 250 MG (Use NF daily); SP Temozolomide) ANTIMYASTHENIC/CHOLINERGIC AGENTS temozolomide caps 180 F PA; QL(2 ea mg, 250 mg daily); SP Antimyasthenic/Cholinergic Agents Antimetabolites MESTINON TABS 60 MG (Use Pyridostigmine NF mercaptopurine tabs F Bromide) MESTINON TIMESPAN methotrexate sodium soln ij TBCR (Use Pyridostigmine NF 1 gm/40ml, 50 mg/2ml, 100 F Bromide) mg/4ml, 200 mg/8ml, 250 mg/10ml pyridostigmine bromide F tabs

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHOTREXATE hydroxyurea caps F SODIUM SOLN IJ 250 F MG/10ML Chemotherapy Rescue/Antidote Agents methotrexate sodium tabs F LEUCOVORIN CALCIUM F or 2.5 mg TABS OR 10 MG, 15 MG PURIXAN SUSP F leucovorin calcium tabs or F 5 mg, 25 mg TREXALL TABS F ANTIPARKINSON AND RELATED THERAPY AGENTS Antineoplastic - Hormonal and Related Agents Antiparkinson Adjuvants anastrozole tabs F carbidopa tabs F ARIMIDEX TABS (Use NF Anastrozole) LODOSYN TABS (Use NF Carbidopa) AROMASIN TABS (Use NF SP Exemestane) Antiparkinson Anticholinergics QL(1 ea daily) bicalutamide tabs F benztropine mesylate tabs F or 0.5 mg, 1 mg, 2 mg CASODEX TABS (Use NF QL(1 ea daily) Bicalutamide) trihexyphenidyl hcl elix F SP exemestane tabs F trihexyphenidyl hcl tabs F FARESTON TABS F PA Antiparkinson Dopaminergics amantadine hcl caps 100 FEMARA TABS (Use NF F Letrozole) mg amantadine hcl syrp 50 F flutamide caps F mg/5ml bromocriptine mesylate F letrozole tabs F caps bromocriptine mesylate MEGACE ORAL SUSP NF F (Use Megestrol Acetate) tabs megestrol acetate susp F carbidopa-levodopa tabs 10mg-100mg, 25mg- F 100mg, 25mg-250mg megestrol acetate tabs F carbidopa-levodopa tbcr tamoxifen citrate tabs F 25mg-100mg, 50mg- F 200mg Antineoplastic Enzyme Inhibitors MIRAPEX TABS (Use QL(3 ea daily); PA; SP NF AL; At least 18 COTELLIC TABS F Dihydrochloride) yrs old NINLARO CAPS F PA; SP PARLODEL CAPS (Use NF Bromocriptine Mesylate) Antineoplastics Misc. PARLODEL TABS (Use NF Bromocriptine Mesylate) HYDREA CAPS (Use NF Hydroxyurea)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pramipexole QL(3 ea daily); NUPLAZID TABS F PA; QL(2 ea dihydrochloride tabs 0.125 F AL; At least 18 daily) mg, 0.25 mg, 0.75 mg, 0.5 yrs old QL(2 ea daily); mg, 1 mg, 1.5 mg ziprasidone hcl caps F AL; At least 18 REQUIP TABS 0.25 MG, 3 QL(6 ea daily) yrs old MG, 4 MG (Use Ropinirole NF Hydrochloride) Benzisoxazoles QL(2 ea daily); REQUIP TABS 0.5 MG, 1 QL(3 ea daily) RISPERDAL M-TAB TBDP NF AL; At least 5 MG, 2 MG, 5 MG (Use NF (Use Risperidone) Ropinirole Hydrochloride) yrs old QL(4 ml daily); ropinirole hydrochloride F QL(6 ea daily) RISPERDAL SOLN 1 NF ) AL; At least 5 tabs 0.25 mg, 3 mg, 4 mg MG/ML (Use Risperidone yrs old ropinirole hydrochloride QL(3 ea daily) tabs 0.5 mg, 1 mg, 2 mg, 5 F RISPERDAL TABS 0.25 QL(4 ea daily); mg MG, 0.5 MG, 1 MG, 2 MG, NF AL; At least 5 3 MG, 4 MG (Use yrs old SINEMET CR TBCR (Use NF Risperidone) Carbidopa-Levodopa) QL(2 ea daily); SINEMET TABS (Use NF RISPERIDONE ODT TBDP F AL; At least 5 Carbidopa-Levodopa) yrs old Antiparkinson Monoamine Oxidase Inhibitors QL(4 ml daily); risperidone soln 1 mg/ml F AL; At least 5 ELDEPRYL CAPS (Use NF Selegiline HCl) yrs old risperidone tabs 0.25 mg, QL(4 ea daily); selegiline hcl caps F 0.5 mg, 1 mg, 2 mg, 3 mg, F AL; At least 5 4 mg yrs old selegiline hcl tabs F risperidone tbdp 0.25 mg, QL(2 ea daily); 0.5 mg, 1 mg, 2 mg, 3 mg, F AL; At least 5 ANTIPSYCHOTICS/ANTIMANIC AGENTS 4 mg yrs old Antimanic Agents Butyrophenones lithium carbonate caps 150 F HALDOL DECANOATE mg, 300 mg, 600 mg 100 SOLN (Use NF LITHIUM CARBONATE Haloperidol Decanoate) CAPS 150 MG, 600 MG F HALDOL DECANOATE 50 (Use Lithium Carbonate) SOLN (Use Haloperidol NF Decanoate) lithium carbonate tabs 300 F mg HALDOL SOLN (Use NF QL(6 ml daily) Haloperidol Lactate) lithium carbonate tbcr 300 F mg, 450 mg haloperidol decanoate soln F LITHIUM SOLN F haloperidol lactate conc or F 2 mg/ml LITHOBID TBCR (Use F Lithium Carbonate) haloperidol lactate soln ij 5 F QL(6 ml daily) Antipsychotics - Misc. mg/ml GEODON CAPS OR 20 QL(2 ea daily); haloperidol tabs 0.5 mg, 1 F QL(3 ea daily) MG, 40 MG, 60 MG, 80 MG NF AL; At least 18 mg, 10 mg (Use Ziprasidone HCl) yrs old haloperidol tabs 2 mg, 5 F mg, 20 mg Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Dibenzapines MOLINDONE F QL(4 ea daily) QL(9 ea daily); HYDROCHLORIDE TABS clozapine tabs 100 mg F AL; At least 18 Phenothiazines yrs old CHLORPROMAZINE HCL QL(12 ml daily) QL(3 ea daily); F clozapine tabs 25 mg, 50 SOLN IJ 25 MG/ML, 50 F AL; At least 18 MG/2ML mg, 200 mg yrs old chlorpromazine hcl tabs or F QL(10 ea daily) QL(9 ea daily); 10 mg CLOZARIL TABS 100 MG NF (Use Clozapine) AL; At least 18 chlorpromazine hcl tabs or QL(3 ea daily) yrs old 25 mg, 50 mg, 100 mg, 200 F QL(3 ea daily); mg CLOZARIL TABS 25 MG NF AL; At least 18 (Use Clozapine) fluphenazine decanoate F yrs old soln QL(4 ea daily) loxapine succinate caps F fluphenazine hcl tabs or 1 F mg, 5 mg, 10 mg, 2.5 mg QL(2 ea daily); QL(4 ea daily) olanzapine tabs or 10 mg, F AL; At least 10 perphenazine tabs F 7.5 mg yrs old prochlorperazine maleate F QL(1 ea daily); tabs olanzapine tabs or 15 mg, F AL; At least 10 20 mg yrs old prochlorperazine supp F QL(4 ea daily); QL(3 ea daily) olanzapine tabs or 5 mg, F AL; At least 10 thioridazine hcl tabs F 2.5 mg yrs old QL(3 ea daily) quetiapine fumarate tabs QL(4 ea daily); trifluoperazine hcl tabs F F 25 mg, 50 mg, 100 mg, 200 AL; At least 10 Quinolinone Derivatives mg yrs old PA; QL(1 ea QL(2 ea daily); ABILIFY TABS (Use NF quetiapine fumarate tabs ) daily); AL; At F AL; At least 10 Aripiprazole least 6 yrs old 300 mg, 400 mg yrs old F PA; AL; At SEROQUEL TABS 25 MG, QL(4 ea daily); aripiprazole soln 1 mg/ml least 6 yrs old 50 MG, 100 MG, 200 MG NF AL; At least 10 (Use Quetiapine Fumarate) yrs old aripiprazole tabs 2 mg, 5 PA; QL(1 ea mg, 10 mg, 15 mg, 20 mg, F daily); AL; At SEROQUEL TABS 300 QL(2 ea daily); 30 mg least 6 yrs old MG, 400 MG (Use NF AL; At least 10 Quetiapine Fumarate) yrs old PA; QL(1 ea aripiprazole tbdp 10 mg, 15 F daily); AL; At ZYPREXA TABS OR 10 QL(2 ea daily); mg least 6 yrs old MG, 7.5 MG (Use NF AL; At least 10 Olanzapine) yrs old Thioxanthenes ZYPREXA TABS OR 15 QL(1 ea daily); thiothixene caps F QL(3 ea daily) MG, 20 MG (Use NF AL; At least 10 Olanzapine) yrs old ANTISEPTICS & DISINFECTANTS ZYPREXA TABS OR 5 QL(4 ea daily); MG, 2.5 MG (Use NF AL; At least 10 Antiseptics & Disinfectants Olanzapine) yrs old formaldehyde soln 10%, 10 F QL(90 ml per Dihydroindolones % fill retail) Chlorine Antiseptics Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits chlorhexidine gluconate F EPIVIR SOLN 10 MG/ML NF QL(30 ml daily) liqd ex 4 % (Use Lamivudine) HIBICLENS LIQD (Use NF EPIVIR TABS 150 MG NF QL(2 ea daily) Chlorhexidine Gluconate) (Use Lamivudine) EPIVIR TABS 300 MG NF QL(1 ea daily) ANTIVIRALS (Use Lamivudine) Antiretrovirals EPZICOM TABS (Use QL(1 ea daily) Abacavir Sulfate- NF abacavir sulfate soln 20 F QL(30 ml daily) mg/ml Lamivudine) QL(1 ea daily) abacavir sulfate tabs 300 F QL(2 ea daily) EVOTAZ TABS F mg fosamprenavir calcium tabs F QL(4 ea daily) abacavir sulfate-lamivudine F QL(1 ea daily) tabs GENVOYA TABS F QL(1 ea daily) abacavir sulfate- F QL(2 ea daily) lamivudine-zidovudine tabs INTELENCE TABS 200 F QL(2 ea daily) APTIVUS CAPS 250 MG F QL(4 ea daily) MG INTELENCE TABS 25 MG, F QL(4 ea daily) APTIVUS SOLN 100 F QL(10 ml daily) 100 MG MG/ML INVIRASE CAPS 200 MG F QL(10 ea daily) atazanavir sulfate caps F QL(2 ea daily) INVIRASE TABS 500 MG F QL(4 ea daily) ATRIPLA TABS F QL(1 ea daily) ISENTRESS CHEW 100 F QL(6 ea daily) COMBIVIR TABS (Use NF QL(2 ea daily) MG Lamivudine-Zidovudine) ISENTRESS CHEW 25 MG F QL(12 ea daily) COMPLERA TABS F QL(1 ea daily) ISENTRESS PACK 100 F QL(2 ea daily) CRIXIVAN CAPS 200 MG F QL(9 ea daily) MG ISENTRESS TABS 400 F QL(2 ea daily) CRIXIVAN CAPS 400 MG F QL(6 ea daily) MG QL(1 ea daily) KALETRA SOLN QL(10.67 ml DESCOVY TABS F 400MG/5ML-100MG/5ML NF daily) (Use Lopinavir-Ritonavir) didanosine cpdr F QL(1 ea daily) KALETRA TABS 100MG- F QL(4 ea daily) 25MG EDURANT TABS F QL(1 ea daily) KALETRA TABS 200MG- F QL(6 ea daily) efavirenz caps 200 mg F QL(1 ea daily) 50MG lamivudine soln 10 mg/ml F QL(30 ml daily) efavirenz caps 50 mg F QL(2 ea daily) lamivudine tabs 150 mg F QL(2 ea daily) efavirenz tabs 600 mg F QL(1 ea daily) lamivudine tabs 300 mg F QL(1 ea daily) EMTRIVA CAPS 200 MG F QL(1 ea daily) lamivudine-zidovudine tabs F QL(2 ea daily) EMTRIVA SOLN 10 F QL(24 ml daily) MG/ML LEXIVA SUSP 50 MG/ML F QL(56 ml daily)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEXIVA TABS 700 MG QL(4 ea daily) stavudine caps F QL(2 ea daily) (Use Fosamprenavir NF Calcium) STRIBILD TABS F QL(1 ea daily) QL(10.67 ml lopinavir-ritonavir soln F daily) SUSTIVA CAPS 200 MG NF QL(1 ea daily) (Use Efavirenz) nevirapine tabs 200 mg F QL(2 ea daily) SUSTIVA CAPS 50 MG NF QL(2 ea daily) (Use Efavirenz) nevirapine tb24 100 mg F QL(3 ea daily) SUSTIVA TABS 600 MG NF QL(1 ea daily) nevirapine tb24 400 mg F QL(1 ea daily) (Use Efavirenz) tenofovir disoproxil F QL(1 ea daily) NORVIR CAPS 100 MG F QL(12 ea daily) fumarate tabs TIVICAY TABS F NORVIR SOLN 80 MG/ML F QL(15 ml daily) TRIUMEQ TABS F NORVIR TABS 100 MG NF QL(12 ea daily) (Use Ritonavir) TRIZIVIR TABS (Use QL(2 ea daily) ODEFSEY TABS F Abacavir Sulfate- NF Lamivudine-Zidovudine) QL(1 ea daily) PREZCOBIX TABS F TRUVADA TABS 300MG- F QL(1 ea daily) 200MG PREZISTA SUSP 100 F QL(12 ml daily) MG/ML TYBOST TABS F QL(1 ea daily) QL(3 ea daily) PREZISTA TABS 150 MG F VIDEX EC CPDR 125 MG F QL(1 ea daily) PREZISTA TABS 75 MG, F QL(2 ea daily) VIDEX EC CPDR 200 MG, QL(1 ea daily) 600 MG 250 MG, 400 MG (Use NF PREZISTA TABS 800 MG F QL(1 ea daily) Didanosine) VIDEXPEDIATRIC SOLR F QL(20 ml daily) RESCRIPTOR TABS 100 F QL(12 ea daily) MG VIRACEPT TABS 250 MG F QL(9 ea daily) RESCRIPTOR TABS 200 F QL(6 ea daily) MG VIRACEPT TABS 625 MG F QL(4 ea daily) RETROVIR CAPS 100 MG NF QL(6 ea daily) (Use Zidovudine) VIRAMUNE SUSP 50 F QL(40 ml daily) MG/5ML RETROVIR SYRP 50 NF QL(60 ml daily) MG/5ML (Use Zidovudine) VIRAMUNE TABS 200 MG NF QL(2 ea daily) REYATAZ CAPS 150 MG, QL(2 ea daily) (Use Nevirapine) 200 MG, 300 MG (Use NF VIRAMUNE XR TB24 100 NF QL(3 ea daily) Atazanavir Sulfate) MG (Use Nevirapine) REYATAZ PACK 50 MG F QL(6 ea daily) VIRAMUNE XR TB24 400 NF QL(1 ea daily) MG (Use Nevirapine) QL(12 ea daily) ritonavir tabs F VIREAD POWD 40 MG/GM F QL(8 gm daily) SELZENTRY TABS 25 QL(2 ea daily) F VIREAD TABS 150 MG, F QL(1 ea daily) MG, 75 MG, 150 MG 200 MG, 250 MG SELZENTRY TABS 300 F QL(4 ea daily) MG Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIREAD TABS 300 MG QL(1 ea daily) VALTREX TABS 500 MG NF QL(2 ea daily) (Use Tenofovir Disoproxil NF (Use Valacyclovir HCl) Fumarate) ZOVIRAX CAPS OR 200 NF ZERIT CAPS 15 MG, 20 QL(2 ea daily) MG (Use Acyclovir) MG, 30 MG, 40 MG (Use NF ZOVIRAX SUSP OR 200 NF Stavudine) MG/5ML (Use Acyclovir) QL(80 ml daily) ZERIT SOLR 1 MG/ML F ZOVIRAX TABS OR 400 NF QL(3 ea daily) MG (Use Acyclovir) ZIAGEN SOLN 20 MG/ML QL(30 ml daily) NF ZOVIRAX TABS OR 800 NF (Use Abacavir Sulfate) MG (Use Acyclovir) ZIAGEN TABS 300 MG NF QL(2 ea daily) (Use Abacavir Sulfate) Influenza Agents QL(6 ea daily) oseltamivir phosphate caps F zidovudine caps 100 mg F 30 mg, 45 mg QL(60 ml daily) QL(10 ea per zidovudine syrp 50 mg/5ml F 30 days retail)1 oseltamivir phosphate caps QL(2 ea daily) F rtl MAX fill,180 zidovudine tabs 300 mg F 75 mg rtl day(s) supply, CMV Agents oseltamivir phosphate susr F VALCYTE TABS 450 MG NF QL(2 ea daily) 6 mg/ml (Use Valganciclovir HCl) RELENZA DISKHALER QL(20 ea per valganciclovir hcl tabs 450 F QL(2 ea daily) F fill retail); AL; At mg AEPB least 5 yrs old Hepatitis Agents TAMIFLU CAPS 30 MG, 45 MG (Use Oseltamivir NF F PA; QL(3 ea MAVYRET TABS daily); SP Phosphate) SOVALDI TABS F PA; SP QL(10 ea per TAMIFLU CAPS 75 MG 30 days retail)1 Herpes Agents (Use Oseltamivir NF rtl MAX fill,180 Phosphate) rtl day(s) acyclovir caps 200 mg F supply, TAMIFLU SUSR 6 MG/ML acyclovir susp 200 mg/5ml F (Use Oseltamivir NF Phosphate) acyclovir tabs 400 mg F QL(3 ea daily) BETA BLOCKERS acyclovir tabs 800 mg F Alpha-Beta Blockers famciclovir tabs F carvedilol phosphate cp24 F QL(1 ea daily) FAMVIR TABS (Use NF carvedilol tabs 12.5 mg, F QL(3 ea daily) Famciclovir) 6.25 mg, 3.125 mg valacyclovir hcl tabs 1 gm, F QL(42 ea per QL(4 ea daily) 1000 mg 21 days retail) carvedilol tabs 25 mg F valacyclovir hcl tabs 500 F QL(2 ea daily) COREG CR CP24 (Use NF QL(1 ea daily) mg Carvedilol Phosphate) VALTREX TABS 1 GM NF QL(42 ea per (Use Valacyclovir HCl) 21 days retail) Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COREG TABS 12.5 MG, QL(3 ea daily) BETAPACE TABS (Use NF QL(2 ea daily) 6.25 MG, 3.125 MG (Use NF Sotalol HCl) Carvedilol) CORGARD TABS (Use NF QL(2 ea daily) COREG TABS 25 MG (Use NF QL(4 ea daily) Nadolol) Carvedilol) HEMANGEOL SOLN F PA labetalol hcl tabs or 100 mg F QL(3 ea daily) INDERAL LA CP24 (Use NF QL(2 ea daily) labetalol hcl tabs or 200 mg F QL(6 ea daily) Propranolol HCl) nadolol tabs F QL(2 ea daily) labetalol hcl tabs or 300 mg F QL(8 ea daily) pindolol tabs F Beta Blockers Cardio-Selective propranolol hcl cp24 or 60 QL(2 ea daily) acebutolol hcl caps F mg, 80 mg, 120 mg, 160 F mg atenolol tabs F QL(2 ea daily) PROPRANOLOL HCL QL(1 ea daily) SOLN OR 20 MG/5ML, 40 F bisoprolol fumarate tabs F MG/5ML LOPRESSOR TABS 100 QL(4.5 ea propranolol hcl tabs or 10 MG (Use Metoprolol NF daily) mg, 20 mg, 40 mg, 60 mg, F Tartrate) 80 mg LOPRESSOR TABS 50 QL(4 ea daily) sotalol hcl (afib/afl) tabs F QL(2 ea daily) MG (Use Metoprolol NF Tartrate) sotalol hcl tabs 240 mg F metoprolol succinate tb24 F QL(2 ea daily) 200 mg sotalol hcl tabs 80 mg, 120 F QL(2 ea daily) mg, 160 mg metoprolol succinate tb24 F QL(4 ea daily) 25 mg, 50 mg, 100 mg TIMOLOL MALEATE TABS F metoprolol tartrate tabs or F QL(4.5 ea 100 mg daily) CALCIUM CHANNEL BLOCKERS metoprolol tartrate tabs or F QL(4 ea daily) 25 mg, 50 mg Calcium Channel Blockers ADALAT CC TB24 30 MG, QL(1 ea daily) SECTRAL CAPS (Use NF NF Acebutolol HCl) 90 MG (Use Nifedipine) ADALAT CC TB24 60 MG QL(2 ea daily) TENORMIN TABS (Use NF QL(2 ea daily) NF Atenolol) (Use Nifedipine) QL(1 ea daily) TOPROL XL TB24 200 MG NF QL(2 ea daily) amlodipine besylate tabs F (Use Metoprolol Succinate) TOPROL XL TB24 25 MG, QL(4 ea daily) CALAN SR TBCR (Use NF QL(2 ea daily) 50 MG, 100 MG (Use NF Verapamil HCl) Metoprolol Succinate) CALAN TABS (Use NF QL(3 ea daily) Verapamil HCl) ZEBETA TABS (Use NF QL(1 ea daily) Bisoprolol Fumarate) CARDIZEM CD CP24 120 QL(1 ea daily) MG, 180 MG (Use NF Beta Blockers Non-Selective Diltiazem HCl Coated BETAPACE AF TABS (Use NF QL(2 ea daily) Beads) Sotalol HCl (AFIB/AFL))

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARDIZEM CD CP24 240 QL(2 ea daily) verapamil hcl tabs or 40 F QL(3 ea daily) MG (Use Diltiazem HCl NF mg, 80 mg, 120 mg Coated Beads) verapamil hcl tbcr or 120 F QL(2 ea daily) CARDIZEM TABS (Use NF QL(3 ea daily) mg, 180 mg, 240 mg Diltiazem HCl) VERELAN CP24 120 MG, QL(2 ea daily) diltiazem hcl coated beads QL(1 ea daily) 180 MG, 240 MG (Use NF cp24 120 mg, 180 mg, 300 F Verapamil HCl) mg VERELAN CP24 360 MG NF QL(1 ea daily) diltiazem hcl coated beads F QL(2 ea daily) (Use Verapamil HCl) cp24 240 mg VERELAN PM CP24 100 QL(2 ea daily) diltiazem hcl cp12 or 60 F QL(2 ea daily) MG, 200 MG (Use NF mg, 90 mg, 120 mg Verapamil HCl) diltiazem hcl cp24 or 120 F QL(1 ea daily) VERELAN PM CP24 300 NF QL(1 ea daily) mg, 180 mg MG (Use Verapamil HCl) diltiazem hcl cp24 or 240 F QL(2 ea daily) mg CARDIOTONICS diltiazem hcl extended F QL(1 ea daily) Cardiac Glycosides release beads cp24 DIGOXIN SOLN OR 0.05 F diltiazem hcl tabs or 30 mg, F QL(3 ea daily) MG/ML 60 mg, 90 mg, 120 mg digoxin tabs or 0.125 mg, felodipine tb24 F QL(1 ea daily) 0.25 mg, 125 mcg, 250 F mcg nicardipine hcl caps or 20 F LANOXIN TABS OR 125 mg, 30 mg MCG, 250 MCG (Use F Digoxin) nifedipine caps 10 mg, 20 F QL(4 ea daily) mg CEPHALOSPORINS nifedipine tb24 30 mg, 90 F QL(1 ea daily) mg Cephalosporins - 1st Generation QL(2 ea daily) nifedipine tb24 60 mg F cefadroxil caps F NORVASC TABS (Use NF QL(1 ea daily) Amlodipine Besylate) cefadroxil susr F PROCARDIA CAPS (Use NF QL(4 ea daily) cefadroxil tabs F Nifedipine) PROCARDIA XL TB24 30 QL(1 ea daily) cephalexin caps 250 mg, F MG, 90 MG (Use NF 500 mg Nifedipine) cephalexin susr 125 F mg/5ml, 250 mg/5ml PROCARDIA XL TB24 60 NF QL(2 ea daily) MG (Use Nifedipine) KEFLEX CAPS 250 MG, NF TIAZAC CP24 (Use QL(1 ea daily) 500 MG (Use Cephalexin) Diltiazem HCl Extended NF Cephalosporins - 2nd Generation Release Beads) cefaclor caps 250 mg, 500 F verapamil hcl cp24 or 100 QL(2 ea daily) mg mg, 120 mg, 180 mg, 200 F mg, 240 mg CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML, F verapamil hcl cp24 or 300 F QL(1 ea daily) 375 MG/5ML mg, 360 mg Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(200 ml per ESTROSTEP FE TABS F cefprozil susr 125 mg/5ml fill retail); AL; (Use Norethindrone NF Up to 12 yrs old Acetate-Ethinyl Estradiol- QL(100 ml per Fe) cefprozil susr 250 mg/5ml F fill retail); AL; ethynodiol diacet & eth F QL(1 ea daily) Up to 12 yrs old estrad tabs 1mg-35mcg cefprozil tabs 250 mg, 500 F QL(20 ea per ethynodiol diacet & eth F mg fill retail) estrad tabs 1mg-50mcg QL(100 ml per FEMCON FE CHEW (Use CEFTIN SUSR 125 F fill retail); AL; Norethindrone & Ethinyl NF MG/5ML, 250 MG/5ML Up to 12 yrs old Estradiol-Fe) CEFTIN TABS 250 MG, QL(20 ea per GENERESS FE CHEW 500 MG (Use Cefuroxime NF fill retail) (Use Norethindrone & NF Axetil) Ethinyl Estradiol-Fe) F QL(20 ea per levonorgestrel & eth F QL(1 ea daily) cefuroxime axetil tabs fill retail) estradiol tabs Cephalosporins - 3rd Generation levonorgestrel-eth estradiol F QL(1 ea daily) QL(20 ea per (triphasic) tabs cefdinir caps 300 mg F fill retail) levonorgestrel-ethinyl F QL(1 ea daily) estradiol (91-day) tabs cefdinir susr 125 mg/5ml, F QL(100 ml per 250 mg/5ml fill retail) LOESTRIN 1.5/30-21 QL(1 ea daily) TABS (Use Norethindrone NF ceftriaxone sodium solr ij 1 F QL(3 ea per fill ) gm, 250 mg, 500 mg retail) Acet & Eth Estra LOESTRIN 1/20-21 TABS QL(1 ea daily) CONTRACEPTIVES (Use Norethindrone Acet & NF Eth Estra) Combination Contraceptives - Oral LOESTRIN FE 1.5/30 QL(1 ea daily) BREVICON-28 TABS (Use QL(1 ea daily) TABS (Use Norethin Acet & NF Norethindrone & Eth NF Estrad-Fe) Estradiol) LOESTRIN FE 1/20 TABS QL(1 ea daily) CYCLESSA TABS (Use QL(1 ea daily) (Use Norethin Acet & NF Desogestrel-Ethinyl NF Estrad-Fe) Estradiol (Triphasic)) MIRCETTE TABS (Use QL(1 ea daily) DESOGEN TABS (Use QL(1 ea daily) Desogestrel-Ethinyl NF Desogestrel & Ethinyl NF Estradiol (Biphasic)) Estradiol) MODICON TABS (Use QL(1 ea daily) desogestrel & ethinyl F QL(1 ea daily) Norethindrone & Eth NF estradiol tabs Estradiol) desogestrel-ethinyl F QL(1 ea daily) QL(1 ea daily) estradiol (biphasic) tabs NECON 1/50-28 TABS F desogestrel-ethinyl F QL(1 ea daily) NECON 10/11-28 TABS F QL(1 ea daily) estradiol (triphasic) tabs norethin acet & estrad-fe QL(1 ea daily) drospirenone-ethinyl F QL(1 ea daily) estradiol tabs tabs 75mg-20mcg-1mg, F 75mg-30mcg-1.5mg norethindrone & eth F QL(1 ea daily) estradiol tabs

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norethindrone & ethinyl F TRI-NORINYL 28 TABS QL(1 ea daily) estradiol-fe chew (Use Norethindrone-Eth NF Estradiol (Triphasic)) norethindrone acet & eth F QL(1 ea daily) estra tabs YASMIN 28 TABS (Use QL(1 ea daily) Drospirenone-Ethinyl NF norethindrone acetate- F ethinyl estradiol-fe tabs Estradiol) YAZ TABS (Use QL(1 ea daily) norethindrone-eth estradiol F QL(1 ea daily) (triphasic) tabs Drospirenone-Ethinyl NF Estradiol) norgestimate-ethinyl F estradiol (triphasic) tabs Combination Contraceptives - Transdermal norgestimate-ethinyl F QL(1 ea daily) XULANE PTWK F estradiol (triphasic) tabs norgestimate-ethinyl F QL(1 ea daily) Combination Contraceptives - Vaginal estradiol tabs NUVARING RING F norgestrel & ethinyl F QL(2 ea daily) estradiol tabs Emergency Contraceptives NORINYL 1+35 TABS (Use QL(1 ea daily) Norethindrone & Eth NF ELLA TABS F Estradiol) levonorgestrel (emergency F NORINYL 1+50 TABS F QL(1 ea daily) oc) tabs PLAN B ONE-STEP TABS OGESTREL TABS F QL(1 ea daily) (Use Levonorgestrel NF (Emergency OC)) ORTHO TRI-CYCLEN LO Progestin Contraceptives - Injectable TABS (Use Norgestimate- NF Ethinyl Estradiol DEPO-PROVERA QL(1 ml per fill (Triphasic)) CONTRACEPTIVE SUSP NF retail) ORTHO TRI-CYCLEN QL(1 ea daily) (Use Medroxyprogesterone Acetate (Contraceptive)) TABS (Use Norgestimate- NF Ethinyl Estradiol DEPO-PROVERA (Triphasic)) CONTRACEPTIVE SUSY NF ORTHO-CYCLEN TABS QL(1 ea daily) (Use Medroxyprogesterone (Use Norgestimate-Ethinyl NF Acetate (Contraceptive)) Estradiol) DEPO-SUBQ PROVERA F ORTHO-NOVUM 1/35 QL(1 ea daily) 104 SUSY TABS (Use Norethindrone NF medroxyprogesterone QL(1 ml per fill & Eth Estradiol) acetate (contraceptive) F retail) ORTHO-NOVUM 7/7/7 QL(1 ea daily) susp TABS (Use Norethindrone- NF medroxyprogesterone Eth Estradiol (Triphasic)) acetate (contraceptive) F OVCON-35 TABS (Use QL(1 ea daily) susy Norethindrone & Eth NF Progestin Contraceptives - Oral Estradiol) NOR-QD TABS (Use QL(1 ea daily) SEASONIQUE TABS (Use QL(1 ea daily) Norethindrone NF Levonorgestrel-Ethinyl NF (Contraceptive)) Estradiol (91-Day)) norethindrone F QL(1 ea daily) (contraceptive) tabs

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORTHO MICRONOR QL(1 ea daily) prednisolone sodium TABS (Use Norethindrone NF phosphate soln or 5 F (Contraceptive)) mg/5ml, 6.7 mg/5ml CORTICOSTEROIDS prednisolone soln F Glucocorticosteroids prednisolone syrp F CORTEF TABS (Use NF Hydrocortisone) PREDNISONE INTENSOL F CONC CORTISONE ACETATE F TABS PREDNISONE SOLN 5 F MG/5ML dexamethasone elix 0.5 F mg/5ml prednisone tabs 1 mg, 5 F mg, 10 mg, 20 mg, 2.5 mg DEXAMETHASONE F INTENSOL CONC PREDNISONE TABS 50 F MG dexamethasone sodium phosphate soln ij 4 mg/ml, F PREDNISONE TBPK 5 F 20 mg/5ml, 120 mg/30ml MG, 10 MG VERIPRED 20 SOLN (Use QL(150 ml per DEXAMETHASONE SOLN F 0.5 MG/5ML Prednisolone Sodium NF fill retail) Phosphate) dexamethasone tabs 0.75 mg, 0.5 mg, 4 mg, 6 mg, F Mineralocorticoids 1.5 mg fludrocortisone acetate tabs F DEXAMETHASONE TABS F 1 MG, 2 MG COUGH/COLD/ALLERGY hydrocortisone tabs F Antitussives MEDROL DOSEPAK TBPK NF benzonatate caps 100 mg, F AL; At least 10 (Use Methylprednisolone) 200 mg yrs old MEDROL TABS 4 MG, 8 DELSYM COUGH MG (Use NF CHILDRENS SUER (Use NF Methylprednisolone) Dextromethorphan Polistirex) methylprednisolone tabs or F 4 mg, 8 mg DELSYM SUER (Use Dextromethorphan NF methylprednisolone tbpk or F 4 mg Polistirex) dextromethorphan F MILLIPRED TABS 5 MG F polistirex suer PEDIAPRED SOLN (Use hydrocodone w/ Prednisolone Sodium NF homatropine syrp 5mg/5ml- F Phosphate) 1.5mg/5ml prednisolone sodium QL(240 ml per TESSALON PERLES NF AL; At least 10 phosphate soln or 15 F fill retail) CAPS (Use Benzonatate) yrs old mg/5ml Cough/Cold/Allergy Combinations prednisolone sodium QL(150 ml per phosphate soln or 20 F fill retail) mg/5ml

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVIL COLD & SINUS dextromethorphan- TABS (Use NF doxylamine-acetaminophen Pseudoephedrine- liqd 6.25mg/15ml- Ibuprofen) 15mg/15ml-500mg/15ml, brompheniramine & QL(120 ml per 12.5mg/30ml-30mg/30ml- F phenyleph elix 1mg/5ml- fill retail) 1000mg/30ml, 2.5mg/5ml, 1mg/5ml- F 6.25mg/15ml-6.25mg/15ml- 1mg/5ml-2.5mg/5ml- 15mg/15ml-15mg/15ml- 2.5mg/5ml 500mg/15ml-500mg/15ml- 10% brompheniramine & F QL(120 ml per pseudoeph elix fill retail) dextromethorphan- QL(240 ml per guaifenesin liqd 5mg/5ml- fill retail) brompheniramine & F QL(120 ml per 100mg/5ml, 10mg/5ml- pseudoeph liqd fill retail) 100mg/5ml, 10mg/5ml- QL(240 ml per BROTAPP DM LIQD F 200mg/5ml, 20mg/10ml- F fill retail) 200mg/10ml, 20mg/20ml- 400mg/20ml, 15mg/7.5ml- cetirizine-pseudoephedrine F QL(2 ea daily) tb12 150mg/7.5ml, 10mg/5ml- CHERACOL PLUS LIQD QL(240 ml per 10mg/5ml-100mg/5ml- (Use Dextromethorphan- NF fill retail) 100mg/5ml Guaifenesin) dextromethorphan- QL(240 ml per CHERACOL-D COUGH QL(240 ml per guaifenesin soln 10mg/5ml- F fill retail) 100mg/5ml, 20mg/10ml- LIQD (Use NF fill retail) Dextromethorphan- 200mg/10ml Guaifenesin) dextromethorphan- QL(240 ml per CLARITIN-D 12 HOUR QL(2 ea daily) guaifenesin syrp 10mg/5ml- fill retail) TB12 (Use Loratadine & NF 100mg/5ml, 10mg/5ml- F Pseudoephedrine) 10mg/5ml-100mg/5ml- 100mg/5ml CLARITIN-D 24 HOUR QL(1 ea daily) TB24 (Use Loratadine & NF dextromethorphan- Pseudoephedrine) phenylephrine- acetaminophen caps F CLEAR COUGH PM 10mg-325mg-5mg, 10mg- MULTI-SYMPTOM LIQD 10mg-325mg-325mg-5mg- (Use Dextromethorphan- NF 5mg Doxylamine- Acetaminophen) DIMETAPP COLD & QL(120 ml per ALLERGY ELIX 1MG/5ML- fill retail) DAY TIME MULTI- 2.5MG/5ML (Use NF SYMPTOM COLD/FLU Brompheniramine & RELIEF CAPS (Use NF Phenyleph) Dextromethorphan- Phenylephrine- DIMETAPP LONG ACTING QL(240 ml per Acetaminophen) COUGH PLUS COLD F fill retail) SYRP ED BRON GP LIQD F

guaifenesin-codeine liqd F 100mg/5ml-10mg/5ml guaifenesin-codeine soln F 100mg/5ml-10mg/5ml

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits guaifenesin-codeine syrp F ROBITUSSIN DM SYRP QL(240 ml per 100mg/5ml-10mg/5ml (Use Dextromethorphan- NF fill retail) Guaifenesin) LOHIST-D LIQD F QL(240 ml per fill retail) ROBITUSSIN PEAK COLD QL(240 ml per loratadine & QL(2 ea daily) COUGH+ CHEST fill retail) pseudoephedrine tb12 F CONGESTION DM MAX NF 5mg-120mg STRENGTH LIQD (Use Dextromethorphan- loratadine & QL(1 ea daily) Guaifenesin) pseudoephedrine tb24 F 10mg-240mg, 10mg-10mg- ROBITUSSIN PEAK COLD QL(240 ml per 240mg-240mg DM SYRP (Use NF fill retail) Dextromethorphan- F QL(240 ml per Guaifenesin) phenylephrine-dm liqd fill retail) TRIAMINIC COLD & QL(240 ml per QL(240 ml per phenylephrine-dm soln F COUGH DAY TIME F fill retail) fill retail) CHILDRENS SOLN phenylephrine-guaifenesin F TRIAMINIC COLD & QL(240 ml per liqd 100mg/5ml-5mg/5ml COUGH DAY TIME F fill retail) promethazine & F CHILDRENS SYRP phenylephrine soln ZYRTEC-D QL(2 ea daily) promethazine & F ALLERGY/CONGESTION NF phenylephrine syrp TB12 (Use Cetirizine- QL(240 ml per Pseudoephedrine) promethazine w/codeine F fill retail); AL; At Expectorants syrp least 6 yrs old guaifenesin liqd 100 F QL(240 ml per F QL(240 ml per mg/5ml, 400 mg/20ml fill retail) promethazine-dm syrp fill retail) guaifenesin soln 100 QL(240 ml per promethazine- QL(240 ml per mg/5ml, 200 mg/10ml, 300 F fill retail) phenylephrine-codeine F fill retail); AL; At mg/15ml syrp least 6 yrs old guaifenesin syrp 100 F QL(240 ml per PROMETHAZINE/PHENYL F mg/5ml, 200 mg/10ml fill retail) EPHRINE SYRP QL(40 ea per guaifenesin tb12 600 mg F pseudoephed-bromphen- F QL(240 ml per fill retail) dm elix fill retail) MUCINEX TB12 (Use NF QL(40 ea per pseudoephed-bromphen- F QL(240 ml per Guaifenesin) fill retail) dm syrp fill retail) Misc. Respiratory Inhalants pseudoephedrine w/ F QL(240 ml per codeine-gg soln fill retail) sodium chloride (inhalant) F pseudoephedrine- QL(240 ml per nebu 0.9 % chlorphen-dm liqd F fill retail) Mucolytics 15mg/5ml-5mg/5ml- 1mg/5ml acetylcysteine soln F pseudoephedrine-ibuprofen F tabs DERMATOLOGICALS RESCON-GG LIQD (Use Acne Products Phenylephrine- NF Guaifenesin)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); QL(2 ea daily); ABSORICA CAPS 10 MG, F isotretinoin caps 10 mg, 20 F AL; At least 12 AL; At least 12 mg, 40 mg 20 MG, 40 MG yrs old yrs old ACNE MEDICATION 10 F KLARON LOTN (Use QL(120 ml per LOTN Sulfacetamide Sodium NF fill retail) (Acne)) ACNE MEDICATION 5 F LOTN QL(20 gm per RETIN-A CREA 0.025 % NF fill retail); AL; BENZAC AC WASH LIQD NF RX/OTC (Use Tretinoin) (Use Benzoyl Peroxide) Up to 35 yrs old RX/OTC RETIN-A CREA 0.05 %, NF AL; Up to 35 benzoyl peroxide gel 10 % F 0.1 % (Use Tretinoin) yrs old BENZOYL PEROXIDE QL(45 gm per F RETIN-A GEL 0.025 %, NF GEL 2.5 % ) fill retail); AL; 0.01 % (Use Tretinoin Up to 35 yrs old benzoyl peroxide gel 5 % F sulfacetamide sodium F QL(120 ml per (acne) lotn fill retail) benzoyl peroxide liqd 5 %, F RX/OTC 10 % sulfacetamide sodium F QL(120 ml per CLEAN & CLEAR (acne) susp fill retail) ADVANTAGE 3-IN-1 F QL(20 gm per EXFOLIATING CLEANSER tretinoin crea 0.025 % F fill retail); AL; LOTN Up to 35 yrs old CLEOCIN-T GEL (Use QL(75 ml per F AL; Up to 35 Clindamycin Phosphate NF fill retail) tretinoin crea 0.05 %, 0.1 % yrs old (Topical)) QL(45 gm per CLEOCIN-T LOTN (Use QL(60 ml per tretinoin gel 0.025 %, 0.01 F fill retail); AL; Clindamycin Phosphate NF fill retail) % Up to 35 yrs old (Topical)) Anti-inflammatory Agents - Topical CLEOCIN-T SOLN (Use Clindamycin Phosphate NF diclofenac sodium (topical) F QL(6.68 gm (Topical)) gel 1 % daily) VOLTAREN GEL (Use QL(6.68 gm F QL(75 ml per CLINDAGEL GEL fill retail) Diclofenac Sodium NF daily) (Topical)) clindamycin phosphate F QL(75 ml per (topical) gel fill retail) Antibiotics - Topical BACIGUENT OINT (Use QL(30 gm per clindamycin phosphate F QL(60 ml per NF (topical) lotn fill retail) Bacitracin (Topical)) fill retail) QL(30 gm per clindamycin phosphate F bacitracin (topical) oint F (topical) soln fill retail) QL(30 gm per DESQUAM-X WASH LIQD NF RX/OTC bacitracin zinc oint F (Use Benzoyl Peroxide) fill retail) BACTROBAN CREA (Use QL(30 gm per ERYGEL GEL (Use NF QL(60 gm per Erythromycin (Acne Aid)) fill retail) Mupirocin Calcium NF fill retail) QL(60 gm per (Topical)) erythromycin (acne aid) gel F fill retail) BACTROBAN OINT (Use NF QL(2160 gm Mupirocin) per fill retail) erythromycin (acne aid) F soln F QL(2160 gm CENTANY OINT per fill retail)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits gentamicin sulfate (topical) F QL(30 gm per LOTRIMIN AF FOR HER QL(113 gm per crea fill retail) CREA (Use Clotrimazole NF fill retail); (Topical)) RX/OTC gentamicin sulfate (topical) F QL(30 gm per oint fill retail) LOTRIMIN AF JOCK ITCH QL(113 gm per CREA (Use Clotrimazole NF fill retail); mupirocin calcium (topical) F QL(30 gm per crea fill retail) (Topical)) RX/OTC LOTRISONE CREA (Use QL(45 gm per F QL(2160 gm mupirocin oint per fill retail) Clotrimazole w/ NF fill retail) Betamethasone) neomycin-bacitracin- F QL(454 gm per polymyxin oint fill retail) MICATIN CREA (Use QL(60 ml per Miconazole Nitrate NF fill retail) neomycin-polymyxin w/ F QL(28.3 gm per (Topical)) pramoxine crea fill retail) miconazole nitrate (topical) F QL(60 ml per NEOSPORIN ORIGINAL QL(454 gm per crea fill retail) OINT (Use Neomycin- NF fill retail) Bacitracin-Polymyxin) NIZORAL SHAM (Use NF QL(120 ml per Ketoconazole (Topical)) fill retail) NEOSPORIN PLUS PAIN QL(28.3 gm per QL(30 gm per RELIEF MAXIMUM fill retail) nystatin (topical) crea F STRENGTH CREA (Use NF fill retail) Neomycin-Polymyxin w/ F QL(30 gm per Pramoxine) nystatin (topical) oint fill retail) QL(60 gm per Antifungals - Topical nystatin (topical) powd F QL(113 gm per fill retail) QL(60 gm per clotrimazole (topical) crea F fill retail); nystatin-triamcinolone crea F RX/OTC fill retail) QL(60 gm per QL(60 ml per nystatin-triamcinolone oint F clotrimazole (topical) soln F fill retail); fill retail) RX/OTC F QL(42 gm per terbinafine hcl (topical) crea fill retail) clotrimazole w/ F QL(45 gm per betamethasone crea fill retail) TINACTIN CREA (Use NF QL(30 gm per Tolnaftate) fill retail) clotrimazole w/ F QL(30 ml per betamethasone lotn fill retail) TINACTIN JOCK ITCH NF QL(30 gm per QL(30 gm per CREA (Use Tolnaftate) fill retail) econazole nitrate crea F fill retail) QL(30 gm per tolnaftate crea F QL(60 gm per fill retail) ketoconazole (topical) crea F fill retail) Antineoplastic or Premalignant Lesion Agents - ketoconazole (topical) QL(120 ml per F F QL(30 gm per sham fill retail) CARAC CREA fill retail) LAMISIL AT CREA (Use QL(42 gm per NF EFUDEX CREA (Use NF QL(40 gm per Terbinafine HCl (Topical)) fill retail) Fluorouracil (Topical)) fill retail) LAMISIL AT JOCK ITCH QL(42 gm per fluorouracil (topical) crea 5 F QL(40 gm per CREA (Use Terbinafine NF fill retail) % fill retail) HCl (Topical)) fluorouracil (topical) soln 2 F QL(10 ml per LOTRIMIN AF CREA 1 % QL(113 gm per % fill retail) (Use Clotrimazole NF fill retail); (Topical)) RX/OTC FLUOROURACIL CREA F QL(30 gm per EX 0.5 % fill retail)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUOROURACIL SOLN F QL(10 ml per sulfacetamide sodium liqd F QL(480 ml per EX 2 %, 5 % fill retail) ex fill retail) Antipruritics - Topical Antivirals - Topical camphor & lotn F QL(222 ml per acyclovir topical oint F 0.5%-0.5% fill retail) QL(5 gm per fill SARNA LOTN (Use NF QL(222 ml per ZOVIRAX CREA EX 5 % F Camphor & Menthol) fill retail) retail) Antipsoriatics ZOVIRAX OINT EX 5 % NF (Use Acyclovir Topical) F QL(60 gm per calcipotriene crea fill retail) Burn Products SILVADENE CREA (Use QL(1000 gm F QL(60 ml per NF calcipotriene soln fill retail) Silver Sulfadiazine) per fill retail) QL(1000 gm DOVONEX CREA (Use NF QL(60 gm per silver sulfadiazine crea F Calcipotriene) fill retail) per fill retail) F QL(60 gm per Corticosteroids - Topical tazarotene crea fill retail) APEXICON E CREA F QL(60 gm per TAZORAC CREA 0.05 % F QL(100 gm per fill retail) fill retail) betamethasone QL(45 gm per TAZORAC CREA 0.1 % NF QL(60 gm per dipropionate augmented F fill retail) (Use Tazarotene) fill retail) crea TAZORAC GEL 0.05 %, QL(100 gm per F betamethasone valerate F QL(45 gm per 0.1 % fill retail) crea 0.1 % fill retail) Antiseborrheic Products betamethasone valerate F QL(60 ml per OVACE PLUS WASH LIQD QL(480 ml per lotn 0.1 % fill retail) (Use Sulfacetamide NF fill retail) betamethasone valerate F QL(45 gm per Sodium) oint 0.1 % fill retail) QL(60 gm per OVACE WASH LIQD (Use NF QL(480 ml per clobetasol propionate crea F Sulfacetamide Sodium) fill retail) fill retail) clobetasol propionate QL(60 gm per F QL(240 ml per F selenium sulfide lotn 1 % fill retail) emollient base crea fill retail) QL(60 gm per F QL(120 ml per clobetasol propionate gel F selenium sulfide lotn 2.5 % fill retail) fill retail) QL(60 gm per F QL(240 ml per clobetasol propionate oint F selenium sulfide sham 1 % fill retail) fill retail) QL(50 ml per SELSUN BLUE DAILY QL(240 ml per clobetasol propionate soln F LOTN (Use Selenium NF fill retail) fill retail) Sulfide) CUTIVATE CREA (Use NF QL(60 gm per Fluticasone Propionate) fill retail) SELSUN BLUE LOTN (Use NF QL(240 ml per Selenium Sulfide) fill retail) DERMATOP CREA (Use NF QL(60 gm per SELSUN BLUE QL(240 ml per Prednicarbate) fill retail) MEDICATED LOTN (Use NF fill retail) desoximetasone crea 0.05 F QL(300 gm per Selenium Sulfide) % fill retail) SELSUN BLUE QL(240 ml per DIFLORASONE F QL(60 gm per MOISTURIZING LOTN NF fill retail) DIACETATE CREA fill retail) (Use Selenium Sulfide)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIFLORASONE F QL(100 gm per LOCOID SOLN (Use NF QL(60 ml per DIACETATE OINT fill retail) Hydrocortisone Butyrate) fill retail) QL(50 gm per DIPROLENE AF CREA QL(45 gm per mometasone furoate crea F (Use Betamethasone NF fill retail) fill retail) Dipropionate Augmented) QL(45 gm per mometasone furoate oint F ELOCON CREA (Use NF QL(50 gm per fill retail) Mometasone Furoate) fill retail) QL(60 ml per mometasone furoate soln F ELOCON OINT (Use NF QL(45 gm per fill retail) Mometasone Furoate) fill retail) MONISTAT SOOTHING QL(454 gm per EPIFOAM FOAM F CARE ITCH RELIEF CREA NF fill retail); (Use Hydrocortisone RX/OTC (Topical)) F QL(60 gm per fluocinonide crea 0.05 % fill retail) F QL(60 gm per PREDNICARBATE CREA fill retail) fluocinonide emulsified F QL(60 gm per base crea fill retail) F QL(60 gm per prednicarbate crea fill retail) F QL(60 gm per fluocinonide gel 0.05 % fill retail) F QL(60 gm per PREDNICARBATE OINT fill retail) F QL(60 gm per fluocinonide oint 0.05 % fill retail) F QL(60 gm per PSORCON CREA fill retail) F QL(60 ml per fluocinonide soln 0.05 % fill retail) TEMOVATE CREA (Use NF QL(60 gm per Clobetasol Propionate) fill retail) fluticasone propionate crea F QL(60 gm per 0.05 % fill retail) TEMOVATE E CREA (Use QL(60 gm per Clobetasol Propionate NF fill retail) fluticasone propionate oint F QL(60 gm per 0.005 % fill retail) Emollient Base) TEMOVATE GEL (Use QL(60 gm per hydrocortisone (topical) F NF crea 0.5 % Clobetasol Propionate) fill retail) QL(454 gm per TEMOVATE OINT (Use NF QL(60 gm per hydrocortisone (topical) F fill retail); Clobetasol Propionate) fill retail) crea 1%, 1 % RX/OTC TEMOVATE SOLN (Use NF QL(50 ml per Clobetasol Propionate) fill retail) hydrocortisone (topical) F QL(454 gm per crea 2.5 % fill retail) TOPICORT CREA 0.05 % NF QL(300 gm per (Use Desoximetasone) fill retail) hydrocortisone (topical) F QL(120 ml per lotn 1 % fill retail) triamcinolone acetonide F QL(908 gm per (topical) crea 0.025 % fill retail) hydrocortisone (topical) F QL(118 ml per lotn 2.5 % fill retail) triamcinolone acetonide F QL(454 gm per QL(454 gm per (topical) crea 0.1 % fill retail) hydrocortisone (topical) F fill retail); oint 1 % triamcinolone acetonide F QL(15 gm per RX/OTC (topical) crea 0.5 % fill retail) hydrocortisone (topical) F QL(454 gm per triamcinolone acetonide QL(60 ml per oint 2.5 % fill retail) (topical) lotn 0.025 %, 0.1 F fill retail) % hydrocortisone butyrate F QL(60 ml per soln fill retail) triamcinolone acetonide F QL(454 gm per (topical) oint 0.025 % fill retail) hydrocortisone-aloe vera F QL(30 gm per crea 1% fill retail) triamcinolone acetonide F QL(60 gm per (topical) oint 0.1 % fill retail)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits triamcinolone acetonide F QL(15 gm per ARTHRITIS PAIN F QL(60 gm per (topical) oint 0.5 % fill retail) RELIEVING CREA fill retail) Emollient/Keratolytic Agents crea 0.025 % F QL(200 gm per crea 40 % F fill retail) F QL(60 gm per capsaicin crea 0.075 % fill retail) QL(325 ml per urea lotn 40 % F fill retail) F QL(43 gm per capsaicin crea 0.1 % fill retail) Emollients CAPZASIN-HP CREA (Use NF QL(43 gm per LAC-HYDRIN CREA (Use QL(385 gm per Capsaicin) fill retail) Lactic Acid (Ammonium NF fill retail); F QL(30 gm per Lactate)) RX/OTC dibucaine oint fill retail) LAC-HYDRIN LOTN (Use QL(1368 ml per EMLA CREA (Use NF QL(30 gm per Lactic Acid (Ammonium NF fill retail); Lidocaine-Prilocaine) fill retail) Lactate)) RX/OTC QL(1 gm daily) LAC-HYDRIN TWELVE QL(1368 ml per lidocaine crea 4 % F LOTN (Use Lactic Acid NF fill retail); (Ammonium Lactate)) RX/OTC lidocaine hcl crea ex 3 % F QL(385 gm per QL(1 ml daily) lactic acid (ammonium F fill retail); lidocaine hcl crea ex 4 % F lactate) crea 12 % RX/OTC QL(30 ml per QL(1368 ml per lidocaine hcl gel ex 2 % F fill retail); lactic acid (ammonium F fill retail); lactate) lotn 12 % RX/OTC RX/OTC QL(30 gm per lidocaine-prilocaine crea F Immunomodulating Agents - Topical fill retail) LMX 4 CREA (Use QL(1 gm daily) ALDARA CREA (Use NF NF Imiquimod) Lidocaine) PREDATOR CREA (Use NF QL(1 ml daily) imiquimod crea F Lidocaine HCl) Immunosuppressive Agents - Topical ZOSTRIX DIABETIC FOOT QL(60 gm per PAIN CREA (Use NF fill retail) F PA; AL; At ELIDEL CREA least 2 yrs old Capsaicin) Misc. Topical PROTOPIC OINT 0.03 % NF PA; AL; At (Use Tacrolimus (Topical)) least 2 yrs old F QL(60 ml per DRYSOL SOLN fill retail) PROTOPIC OINT 0.1 % NF PA; AL; At (Use Tacrolimus (Topical)) least 16 yrs old F QL(170 gm per OFF DEEP WOODS AERO fill retail) tacrolimus (topical) oint F PA; AL; At 0.03 % least 2 yrs old OFF DEEP WOODS DRY F QL(113 gm per AERO fill retail) tacrolimus (topical) oint 0.1 F PA; AL; At % least 16 yrs old ULTRATHON INSECT F QL(170 gm per Keratolytic/Antimitotic Agents REPELLENT 8 AERO fill retail) ULTRATHON INSECT QL(57 gm per CONDYLOX SOLN (Use NF QL(4 ml per fill F Podofilox) retail) REPELLENT LOTN fill retail) zinc oxide (topical) oint 20 QL(500 gm per F QL(4 ml per fill F podofilox soln retail) % fill retail) Local Anesthetics - Topical Pigmenting-Depigmenting Agents Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(56.8 ml per hydroquinone crea F RID COMPLETE LICE fill retail) ELIMINATION KIT (Use Pyrethrins-Piperonyl NF Rosacea Agents Butoxide-Permethrin-Nit METROCREAM CREA QL(45 gm per Remover) (Use Metronidazole NF fill retail) )) RID LIQD EX 0.33%-4% QL(240 ml per (Topical (Use Pyrethrins-Piperonyl NF fill retail) METROLOTION LOTN Butoxide) (Use Metronidazole NF (Topical)) SPINOSAD SUSP F metronidazole (topical) F QL(45 gm per crea 0.75 % fill retail) Tar Products coal tar extract sham 0.5 % F metronidazole (topical) gel F QL(45 gm per 0.75 % fill retail) DHS TAR GEL SHAM (Use NF metronidazole (topical) lotn F Coal Tar Extract) 0.75 % DHS TAR SHAM (Use Coal NF Scabicides & Pediculicides Tar Extract) ELIMITE CREA (Use NF QL(60 gm per NEUTROGENA T/GEL Permethrin) fill retail) SHAM (Use Coal Tar NF Extract) EURAX CREA F QL(60 gm per fill retail) NEUTROGENA T/GEL STUBBORN ITCH F QL(454 gm per NF EURAX LOTN fill retail) CONTROL SHAM (Use QL(59 ml per Coal Tar Extract) malathion lotn F fill retail) DIAGNOSTIC PRODUCTS NATROBA SUSP F Diagnostic Tests NIX CREME RINSE LIQD NF CHEK-STIX COMBO PAK (Use Permethrin) URINALYSIS CONTROL F STRP OVIDE LOTN (Use NF QL(59 ml per Malathion) fill retail) CHEK-STIX CONTROL F QL(60 gm per STRP permethrin crea ex 5 % F fill retail) CHEMSTRIP-K STRP F permethrin liqd ex 1 % F KETOCARE STRP F QL(120 ml per permethrin lotn ex 1 % F fill retail) KETONE TEST STRIPS F STRP pyrethrins-piperonyl F QL(240 ml per butoxide liqd 0.33%-4% fill retail) KETOSTIX STRP F pyrethrins-piperonyl butoxide sham 0.3%- F NOVA MAX PLUS 0.33%-4%, 0.33%-4% KETONE TESTSTRIPS F STRP pyrethrins-piperonyl F QL(240 ml per butoxide sham 0.33%-4% fill retail) PRECISION XTRA STRP F VI pyrethrins-piperonyl butoxide-permethrin-nit F PTS PANELS KETONE F remover kit TEST STRP

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION KETONE STRP F INSULIN USERS LIMITED TO RELION KETONE TEST F STRIPS STRP 150 PER 30 INSULIN TRUETEST STRIPS STRP F DAYS, NON- USERS INSULIN LIMITED TO USERS 150 PER 30 LIMITED TO TRUE METRIX BLOOD 100 PER 90 F DAYS, NON- GLUCOSETEST STRIPS INSULIN DAYS;RX/OTC STRP USERS INSULIN LIMITED TO USERS 100 PER 90 LIMITED TO DAYS;RX/OTC 150 PER 30 INSULIN TRUETRACK BLOOD F DAYS, NON- USERS GLUCOSE TEST STRP INSULIN LIMITED TO USERS 150 PER 30 LIMITED TO TRUE METRIX SELF 100 PER 90 F DAYS, NON- MONITORING BLOOD INSULIN DAYS;RX/OTC GLUCOSE STRIPS STRP USERS INSULIN LIMITED TO USERS 100 PER 90 LIMITED TO DAYS;RX/OTC 150 PER 30 INSULIN TRUETRACK TEST STRP F DAYS, NON- USERS INSULIN LIMITED TO USERS 150 PER 30 LIMITED TO TRUETEST BLOOD DAYS, NON- 100 PER 90 GLUCOSE TEST STRIPS F DAYS;RX/OTC STRP INSULIN USERS DIGESTIVE AIDS LIMITED TO 100 PER 90 Digestive Enzymes DAYS;RX/OTC INSULIN CREON CPEP F USERS PANCREAZE CPEP LIMITED TO 14200UNIT-4200UNIT- 150 PER 30 24600UNIT, 35500UNIT- TRUETEST BLOOD F DAYS, NON- 10500UNIT-61500UNIT, F GLUCOSE TEST STRP INSULIN 54700UNIT-21000UNIT- USERS 83900UNIT, 56800UNIT- LIMITED TO 16800UNIT-98400UNIT 100 PER 90 DAYS;RX/OTC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZENPEP CPEP Loop Diuretics 10000UNIT-3000UNIT- bumetanide tabs or 0.5 mg, F 16000UNIT, 17000UNIT- 1 mg, 2 mg 5000UNIT-27000UNIT, BUMEX TABS (Use 34000UNIT-10000UNIT- F NF 55000UNIT, 51000UNIT- Bumetanide) 15000UNIT-82000UNIT, DEMADEX TABS 20 MG NF 68000UNIT-20000UNIT- (Use Torsemide) 109000UNIT, 85000UNIT- DEMADEX TABS 5 MG, 10 NF QL(1 ea daily) 25000UNIT-136000UNIT MG (Use Torsemide) DIURETICS furosemide soln or 10 F mg/ml Carbonic Anhydrase Inhibitors FUROSEMIDE SOLN OR 8 F acetazolamide cp12 F MG/ML furosemide tabs or 20 mg, F acetazolamide tabs F 40 mg, 80 mg LASIX TABS (Use NF DIAMOX CP12 (Use NF Furosemide) Acetazolamide) torsemide tabs 20 mg F methazolamide tabs F torsemide tabs 5 mg, 10 F QL(1 ea daily) NEPTAZANE TABS (Use NF mg, 100 mg Methazolamide) Potassium Sparing Diuretics Diuretic Combinations ALDACTONE TABS (Use NF ALDACTAZIDE TABS Spironolactone) 25MG-25MG (Use NF Spironolactone & amiloride hcl tabs F QL(4 ea daily) Hydrochlorothiazide) spironolactone tabs F amiloride & F QL(1 ea daily) hydrochlorothiazide tabs DYAZIDE CAPS (Use QL(1 ea daily) Thiazides and Thiazide-Like Diuretics Triamterene & NF CHLOROTHIAZIDE TABS F QL(2 ea daily) Hydrochlorothiazide) 250 MG MAXZIDE TABS (Use QL(1 ea daily) chlorothiazide tabs 500 mg F QL(4 ea daily) Triamterene & NF Hydrochlorothiazide) chlorthalidone tabs F MAXZIDE-25 TABS (Use QL(1 ea daily) Triamterene & NF hydrochlorothiazide caps F Hydrochlorothiazide) 12.5 mg hydrochlorothiazide tabs 25 spironolactone & F F hydrochlorothiazide tabs mg, 50 mg triamterene & F QL(1 ea daily) indapamide tabs F hydrochlorothiazide caps metolazone tabs F triamterene & F QL(1 ea daily) hydrochlorothiazide tabs MICROZIDE CAPS (Use NF TRIAMTERENE/HYDROC F QL(1 ea daily) Hydrochlorothiazide) HLOROTHIAZIDE CAPS

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENDOCRINE AND METABOLIC AGENTS - raloxifene hcl tabs F QL(1 ea daily) MISC. Bone Density Regulators Metabolic Modifiers calcitriol caps or 0.25 mcg, ACTONEL TABS 35 MG NF PA; F (Use Risedronate Sodium) 0.5 mcg ACTONEL TABS 5 MG, 30 PA; QL(1 ea CARNITOR SF SOLN (Use QL(30 ml daily) MG (Use Risedronate NF daily) Levocarnitine (Metabolic NF Sodium) Modifiers)) CARNITOR SOLN OR 1 QL(30 ml daily) ALENDRONATE SODIUM F QL(10.8 ml SOLN 70 MG/75ML daily) GM/10ML (Use NF Levocarnitine (Metabolic alendronate sodium tabs F QL(0.15 ea Modifiers)) 35 mg, 70 mg daily) CARNITOR TABS OR 330 QL(3 ea daily); ALENDRONATE SODIUM F QL(1 ea daily) MG (Use Levocarnitine NF RX/OTC TABS 40 MG (Metabolic Modifiers)) alendronate sodium tabs 5 QL(1 ea daily) F levocarnitine (metabolic F QL(30 ml daily) mg, 10 mg modifiers) soln 1 gm/10ml calcitonin (salmon) soln F levocarnitine (metabolic F QL(3 ea daily); modifiers) tabs 330 mg RX/OTC FORTICAL SOLN F ROCALTROL CAPS 0.25 MCG, 0.5 MCG (Use NF FOSAMAX TABS (Use NF QL(0.15 ea Calcitriol) Alendronate Sodium) daily) Posterior Pituitary Hormones MIACALCIN SOLN IJ 200 F UNIT/ML DDAVP SOLN NA 0.01 % F QL(5 ml per fill MIACALCIN SOLN NA 200 retail) UNIT/ACT (Use Calcitonin NF DDAVP SOLN NA 0.01 % QL(1 ml daily,5 (Salmon)) (Use Desmopressin NF ml per fill retail) Acetate Spray) risedronate sodium tabs 35 F PA; mg DDAVP TABS OR 0.1 MG, QL(6 ea daily) 0.2 MG (Use NF risedronate sodium tabs 5 F PA; QL(1 ea mg, 30 mg daily) Desmopressin Acetate) desmopressin acetate F QL(5 ml per fill Growth Hormones refrigerated soln retail) NORDITROPIN FLEXPRO SP F desmopressin acetate F QL(1 ml daily,5 SOLN 10 MG/1.5ML spray refrigerated soln ml per fill retail) NORDITROPIN FLEXPRO PA; SP desmopressin acetate F QL(1 ml daily,5 SOLN 30 MG/3ML, 5 F spray soln ml per fill retail) MG/1.5ML, 15 MG/1.5ML desmopressin acetate tabs F QL(6 ea daily) OMNITROPE SOLN 10 F SP or 0.1 mg, 0.2 mg MG/1.5ML ESTROGENS OMNITROPE SOLN 5 F PA; SP MG/1.5ML Estrogen Combinations Hormone Receptor Modulators ACTIVELLA TABS (Use QL(1 ea daily) EVISTA TABS (Use NF QL(1 ea daily) Estradiol & Norethindrone NF Raloxifene HCl) Acetate)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMBIPATCH PTTW F QL(0.286 ea PREMARIN TABS OR QL(1 ea daily) daily) 0.625 MG, 0.45 MG, 0.3 F MG, 0.9 MG, 1.25 MG esterified estrogens & F QL(1 ea daily) methyltestosterone tabs VIVELLE-DOT PTTW (Use NF QL(0.29 ea Estradiol) daily) estradiol & norethindrone F QL(1 ea daily) acetate tabs FLUOROQUINOLONES FEMHRT LOW DOSE TABS (Use Norethindrone NF Fluoroquinolones Acetate-Ethinyl Estradiol) CIPRO TABS 250 MG, 500 norethindrone acetate- MG (Use Ciprofloxacin NF ethinyl estradiol tabs F HCl) 2.5mcg-0.5mg CIPROFLOXACIN HCL F QL(6 ea per fill PREMPHASE TABS F QL(1 ea daily) TABS 100 MG retail) ciprofloxacin hcl tabs 250 F PREMPRO TABS F QL(1 ea daily) mg, 500 mg, 750 mg QL(1 ea Estrogens LEVAQUIN TABS (Use NF ) daily,14 ea per Levofloxacin fill retail) ALORA PTTW F QL(0.29 ea daily) QL(1 ea levofloxacin tabs or 250 F daily,14 ea per CLIMARA PTWK 0.025 NF mg, 500 mg, 750 mg MG/24HR (Use Estradiol) fill retail) QL(56 ea per CLIMARA PTWK 0.075 Limit 4 per ofloxacin tabs 400 mg F MG/24HR, 0.05 MG/24HR, month;QL(0.13 fill retail) 0.06 MG/24HR, 0.1 NF 4 ea daily) MG/24HR, 37.5 GASTROINTESTINAL AGENTS - MISC. MCG/24HR (Use Estradiol) Antiflatulents ESTRACE TABS (Use NF ) GAS-X CHEW (Use NF Estradiol Simethicone) estradiol pttw td 0.0375 QL(0.29 ea daily) MYLICON INFANTS GAS mg/24hr, 0.025 mg/24hr, F RELIEF SUSP (Use NF 0.075 mg/24hr, 0.05 ) mg/24hr, 0.1 mg/24hr Simethicone MYLICON SUSP (Use NF estradiol ptwk td 0.025 F ) mg/24hr Simethicone estradiol ptwk td 0.075 Limit 4 per simethicone chew 80 mg F mg/24hr, 0.05 mg/24hr, F month;QL(0.13 0.06 mg/24hr, 0.1 mg/24hr, 4 ea daily) simethicone liqd 20 F 37.5 mcg/24hr mg/0.3ml, 40 mg/0.6ml simethicone susp 20 estradiol tabs or 0.5 mg, 1 F F mg, 2 mg mg/0.3ml, 40 mg/0.6ml Bile Acid Synthesis Disorder Agents ESTROPIPATE TABS 0.75 F QL(1 ea daily) MG, 1.5 MG F PA; QL(5 ea CHOLBAM CAPS daily); SP ESTROPIPATE TABS 3 F QL(2 ea daily) MG Gallstone Solubilizing Agents QL(0.29 ea MINIVELLE PTTW F ACTIGALL CAPS (Use NF QL(3 ea daily) daily) Ursodiol)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits URSO 250 TABS (Use NF QL(7 ea daily) potassium citrate Ursodiol) (alkalinizer) tbcr 540 mg, F 1080 mg ursodiol caps 300 mg F QL(3 ea daily) potassium citrate-citric acid F ursodiol tabs 250 mg F QL(7 ea daily) pack 3300mg-1002mg SHOHLS SOLUTION RX/OTC Gastrointestinal Stimulants MODIFIED SOLN (Use NF Sodium Citrate & Citric metoclopramide hcl soln or F 5 mg/5ml, 10 mg/10ml Acid) sodium citrate & citric acid RX/OTC metoclopramide hcl tabs or F F 5 mg, 10 mg soln UROCIT-K 10 TBCR (Use REGLAN TABS (Use NF Metoclopramide HCl) Potassium Citrate NF (Alkalinizer)) Inflammatory Bowel Agents UROCIT-K 5 TBCR (Use ASACOL HD TBEC F QL(3 ea daily) Potassium Citrate NF (Alkalinizer)) AZULFIDINE EN-TABS NF TBEC (Use Sulfasalazine) Genitourinary Irrigants sodium chloride (gu AZULFIDINE TABS (Use NF F Sulfasalazine) irrigant) soln Interstitial Cystitis Agents balsalazide disodium caps F QL(9 ea daily) ELMIRON CAPS F QL(3 ea daily) COLAZAL CAPS (Use NF QL(9 ea daily) Balsalazide Disodium) Prostatic Hypertrophy Agents QL(6 ea daily) DELZICOL CPDR F finasteride tabs F QL(1 ea daily) QL(3 ea daily) MESALAMINE DR TBEC F FLOMAX CAPS (Use NF QL(2 ea daily) Tamsulosin HCl) mesalamine enem re 4 gm F QL(60 ml daily) PROSCAR TABS (Use NF QL(1 ea daily) Finasteride) SFROWASA ENEM F tamsulosin hcl caps F QL(2 ea daily) sulfasalazine tabs F Urinary Analgesics sulfasalazine tbec F phenazopyridine hcl tabs F 100 mg, 200 mg Intestinal PYRIDIUM TABS (Use NF Phenazopyridine HCl) lactulose (encephalopathy) F soln GOUT AGENTS Phosphate Binder Agents Gout Agent Combinations calcium acetate (phosphate F binder) caps colchicine w/ probenecid F tabs GENITOURINARY AGENTS - MISCELLANEOUS Gout Agents Alkalinizers allopurinol tabs F

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(6 ea per fill ZARXIO SOSY F PA; SP COLCHICINE TABS retail) F QL(6 ea per fill Iron COLCRYS TABS retail) FERRETTS TABS F QL(2 ea daily) ZYLOPRIM TABS (Use NF Allopurinol) ferrous fumarate tabs F QL(2 ea daily) Uricosurics ferrous sulfate elix 220 F QL(16 ml daily) probenecid tabs F mg/5ml ferrous sulfate tabs 65 mg, F HEMATOLOGICAL AGENTS - MISC. 325 mg Hematorheologic Agents HEMOCYTE TABS (Use NF QL(2 ea daily) Ferrous Fumarate) pentoxifylline tbcr F polysaccharide iron F QL(1 ea daily) complex caps Platelet Aggregation Inhibitors HEMOSTATICS BRILINTA TABS F QL(2 ea daily) Hemostatics - Systemic cilostazol tabs F QL(2 ea daily) F QL(24 ea per AMICAR TABS 500 MG fill retail); SP clopidogrel bisulfate tabs or F QL(1 ea daily) 75 mg LYSTEDA TABS (Use NF AL; At least 12 Tranexamic Acid) yrs old dipyridamole tabs F tranexamic acid tabs or 650 F AL; At least 12 mg yrs old EFFIENT TABS (Use NF QL(1 ea daily) Prasugrel HCl) HYPNOTICS/SEDATIVES/SLEEP DISORDER PERSANTINE TABS (Use NF AGENTS Dipyridamole) Antihistamine Hypnotics PLAVIX TABS 75 MG (Use NF QL(1 ea daily) Clopidogrel Bisulfate) diphenhydramine hcl F (sleep) caps 50 mg prasugrel hcl tabs F QL(1 ea daily) diphenhydramine hcl F QL(1 ea daily) (sleep) tabs 25 mg HEMATOPOIETIC AGENTS diphenhydramine hcl F (sleep) tabs 50 mg Agents for Sickle Cell Anemia doxylamine succinate F DROXIA CAPS F (sleep) tabs NYTOL MAXIMUM Cobalamins STRENGTH TABS (Use NF cyanocobalamin soln F Diphenhydramine HCl (Sleep)) Folic Acid/Folates UNISOM SLEEPGELS RX/OTC CAPS (Use NF folic acid tabs 1 mg F Diphenhydramine HCl (Sleep)) folic acid tabs 400 mcg, F QL(1 ea daily) 800 mcg UNISOM TABS (Use Hematopoietic Growth Factors Doxylamine Succinate NF (Sleep)) Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Barbiturate Hypnotics METAMUCIL CAPS 0.52 NF GM (Use Psyllium) phenobarbital elix 20 F mg/5ml METAMUCIL ORIGINAL TEXTURE POWD (Use NF phenobarbital soln 20 F ) mg/5ml Psyllium METAMUCIL POWD 48.57 NF PHENOBARBITAL TABS ) 15 MG, 30 MG, 60 MG, F % (Use Psyllium 100 MG psyllium caps 0.52 gm, 520 F phenobarbital tabs 16.2 mg mg, 32.4 mg, 64.8 mg, 97.2 F psyllium powd 28.3 %, 30.9 F mg %, 58.6 %, 48.57 % Non-Barbiturate Hypnotics Laxative Combinations COLYTE-FLAVOR PACKS QL(4000 ml per AMBIEN TABS (Use NF QL(1 ea daily) Zolpidem Tartrate) SOLR (Use PEG 3350-KCl- NF fill retail) QL(1 ea daily) Sod Bicarb-Sod Chloride- FLURAZEPAM HCL CAPS F Sod Sulfate) GOLYTELY SOLR 236GM- QL(4000 ml per HALCION TABS (Use NF QL(1 ea daily) Triazolam) 22.74GM-5.86GM-2.97GM- fill retail) 6.74GM (Use PEG 3350- NF midazolam hcl soln F KCl-Sod Bicarb-Sod Chloride-Sod Sulfate) QL(1 ea daily); RESTORIL CAPS 15 MG, NF NULYTELY/FLAVOR QL(4000 ml per ) AL; At least 18 30 MG (Use Temazepam yrs old PACKS SOLR (Use PEG fill retail) 3350-Potassium Chloride- NF QL(1 ea daily); Sod Bicarbonate-Sod SONATA CAPS (Use NF ) AL; At least 18 Chloride) Zaleplon yrs old peg 3350-kcl-sod bicarb- QL(4000 ml per QL(1 ea daily); temazepam caps 15 mg, sod chloride-sod sulfate F fill retail) F AL; At least 18 solr 30 mg yrs old peg 3350-potassium QL(4000 ml per TRIAZOLAM TABS 0.125 F QL(1 ea daily) chloride-sod bicarbonate- F fill retail) MG sod chloride solr QL(1 ea daily) triazolam tabs 0.25 mg F sennosides-docusate F QL(4 ea daily) sodium tabs QL(1 ea daily); zaleplon caps F AL; At least 18 SENOKOT S TABS (Use QL(4 ea daily) yrs old Sennosides-Docusate NF Sodium) zolpidem tartrate tabs or 5 F QL(1 ea daily) mg, 10 mg Laxatives - Miscellaneous glycerin (laxative) supp 2 F LAXATIVES gm Bulk Laxatives GLYCERIN ADULT SUPP NF (Use Glycerin (Laxative)) calcium polycarbophil tabs F QL(10 ea daily) lactulose soln F FIBERCON TABS (Use NF QL(10 ea daily) Calcium Polycarbophil) MIRALAX PACK (Use NF RX/OTC Polyethylene Glycol 3350)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MIRALAX POWD (Use NF QL(34 gm docusate sodium syrp or 60 F Polyethylene Glycol 3350) daily); RX/OTC mg/15ml polyethylene glycol 3350 F RX/OTC docusate sodium tabs or F QL(3 ea daily) pack 100 mg polyethylene glycol 3350 F QL(34 gm powd daily); RX/OTC MACROLIDES Saline Laxatives Azithromycin AZITHROMYCIN PACK QL(2 ea per fill FLEET ENEMA ENEM NF F (Use Sodium Phosphates) OR 1 GM retail) FLEET ENEMA SIX PACK azithromycin susr or 100 F QL(15 ml per ENEM (Use Sodium NF mg/5ml fill retail) Phosphates) azithromycin susr or 200 F QL(60 ml per mg/5ml fill retail) FLEET PEDIATRIC ENEM NF (Use Sodium Phosphates) azithromycin tabs or 250 F QL(6 ea per fill magnesium citrate soln mg retail) 1.745gm/30ml, 1.745 F azithromycin tabs or 500 F QL(4 ea daily) gm/30ml, mg susp azithromycin tabs or 600 F 7.75 %, 400 mg/5ml, 1200 F mg mg/15ml, ZITHROMAX PACK OR 1 F QL(2 ea per fill sodium phosphates enem GM retail) re 16gm/133ml-6gm/133ml, ZITHROMAX SUSR OR QL(15 ml per 19gm/118ml-7gm/118ml, F 100 MG/5ML (Use NF fill retail) 9.5gm/59ml-3.5gm/59ml, Azithromycin) 19gm/118ml-19gm/118ml- 7gm/118ml-7gm/118ml ZITHROMAX SUSR OR QL(60 ml per 200 MG/5ML (Use NF fill retail) Stimulant Laxatives Azithromycin) QL(12 ea per bisacodyl supp re 10 mg F ZITHROMAX TABS OR NF QL(6 ea per fill fill retail) 250 MG (Use Azithromycin) retail) QL(1 ea daily) bisacodyl tbec or 5 mg F ZITHROMAX TABS OR NF QL(4 ea daily) 500 MG (Use Azithromycin) DULCOLAX SUPP RE 10 QL(12 ea per NF ZITHROMAX TABS OR NF MG (Use Bisacodyl) fill retail) 600 MG (Use Azithromycin) DULCOLAX TBEC OR 5 QL(1 ea daily) NF ZITHROMAX TRI-PAK NF QL(4 ea daily) MG (Use Bisacodyl) TABS (Use Azithromycin) sennosides tabs 8.6 mg F ZITHROMAX Z-PAK TABS NF QL(6 ea per fill (Use Azithromycin) retail) SENOKOT TABS (Use NF Sennosides) Clarithromycin BIAXIN SUSR 250 QL(200 ml per Surfactant Laxatives MG/5ML (Use NF fill retail) COLACE CAPS (Use NF QL(3 ea daily) Clarithromycin) Docusate Sodium) BIAXIN TABS 250 MG, 500 NF QL(28 ea per docusate sodium caps or F QL(3 ea daily) MG (Use Clarithromycin) fill retail) 100 mg, 250 mg clarithromycin susr 125 F QL(100 ml per docusate sodium liqd or 50 F mg/5ml fill retail) mg/5ml, 150 mg/15ml

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLARITHROMYCIN SUSR F QL(100 ml per AMD FOAM RX/OTC 125 MG/5ML fill retail) DRESSING/TOPSHEET F 4"X4" PADS CLARITHROMYCIN SUSR F QL(200 ml per 250 MG/5ML fill retail) BAND-AID GAUZE PADS F RX/OTC LARGE4" X 4" PADS clarithromycin susr 250 F QL(200 ml per mg/5ml fill retail) BAND-AID GAUZE PADS F MEDIUM 3" X 3" PADS clarithromycin tabs 250 mg, F QL(28 ea per 500 mg fill retail) BAND-AID GAUZE PADS F RX/OTC QL(14 ea per SMALL2" X 2" PADS clarithromycin tb24 500 mg F fill retail) BAND-AID MIRASORB RX/OTC GAUZE SPONGES F Erythromycins LARGE 4" X 4" PADS E.E.S. 400 TABS F BIATAIN ADHESIVE RX/OTC FOAM DRESSING 4"X4" F E.E.S. GRANULES SUSR PADS (Use Erythromycin NF Ethylsuccinate) BIATAIN FOAM F RX/OTC DRESSING 4"X4" PADS ERY-TAB TBEC F BIOGUARD GAUZE RX/OTC ERYPED 200 SUSR (Use SPONGE 2"X2" 8 PLY F Erythromycin NF PADS Ethylsuccinate) BIOGUARD GAUZE RX/OTC SPONGES 4"X4" 12 PLY F ERYPED 400 SUSR F PADS BORDERED GAUZE RX/OTC ERYTHROCIN STEARATE F F TABS PADS CARRASMART FOAM RX/OTC erythromycin base cpep F F 250 mg PADS RX/OTC erythromycin base tabs F CARRASMART PADS XX F 500 mg erythromycin COPA ISLAND RX/OTC ethylsuccinate susr 200 F BORDERED FOAM F mg/5ml DRESSING 4"X4" PADS ERYTHROMYCIN COPA PLUS RX/OTC ETHYLSUCCINATE TABS F HYDROPHILIC FOAM F 400 MG DRESSING 4"X4" PADS COVRSITE COVER F RX/OTC PCE TBEC F DRESSING PADS COVRSITE PLUS RX/OTC MEDICAL DEVICES AND SUPPLIES COMPOSITE DRESSING F PADS Bandages-Dressings-Tape CUREX ALL-PURPOSE RX/OTC ALLEVYN PLUS CAVITY F RX/OTC SPONGES 4"X4" 4 PLY F PADS XX PADS ALLEVYN THIN PADS F RX/OTC CURITY ALL PURPOSE RX/OTC SPONGES 2"X2" 4PLY F AMD FOAM DRESSING F RX/OTC PADS 4"X4" PADS

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY ALL PURPOSE F RX/OTC CURITY GAUZE SPONGE F RX/OTC SPONGES 2"X2" PADS 4"X4" 12 PLY PADS CURITY ALL PURPOSE CURITY GAUZE SPONGE F RX/OTC SPONGES 3"X3" 4PLY F 4"X4" 16 PLY PADS PADS CURITY GAUZE SPONGE F RX/OTC CURITY ALL PURPOSE F RX/OTC 4"X4" 8 PLY PADS SPONGES 4 PLY PADS CURITY GAUZE SPONGE F RX/OTC CURITY ALL PURPOSE RX/OTC 4"X4"16 PLY PADS SPONGES 4"X4" 4PLY F CURITY GAUZE RX/OTC PADS SPONGES 4"X4" 12 PLY F CURITY ALL PURPOSE RX/OTC PADS SPONGES 4"X4" F CURITY GAUZE RX/OTC 4PLY/SOFT POUCH PADS SPONGES 4"X4" 8 PLY F CURITY ALL PURPOSE F RX/OTC PADS SPONGES 4"X4" PADS CURITY NON-ADHERENT F CURITY AMD RX/OTC STRIPS 3"X3" PADS ANTIMICROBIALGAUZE F CURITY RX/OTC SPONGES 2"X2" 8 PLY SPONGES/CELLULOSEFI F PADS LLED/2"X2" PADS CURITY AMD RX/OTC CURITY RX/OTC ANTIMICROBIALGAUZE F SPONGES/CELLULOSEFI F SPONGES 4"X4" 12 PLY LLED/4"X4" PADS PADS CVS GAUZE PADS 2"X2" F RX/OTC CURITY COVER SPONGE F RX/OTC 12-PLY PADS 4"X4" PADS CVS GAUZE PADS 4"X4" F RX/OTC CURITY COVER F 12-PLY PADS SPONGES 3"X3" PADS CVS GAUZE PADS RX/OTC CURITY COVER F RX/OTC STERILE 4"X4" 12-PLY F SPONGES 4"X4" PADS PADS CURITY DRESSING RX/OTC DERMACEA DRAIN F RX/OTC SPONGES 4"X4" 6 PLY F SPONGES 4"X4" PADS PADS DERMACEA GAUZE RX/OTC CURITY GAUZE PADS F RX/OTC SPONGE 2"X2" 12 PLY F 2"X2" 12 PLY PADS PADS CURITY GAUZE PADS F RX/OTC DERMACEA GAUZE RX/OTC 2"X2" PADS SPONGE 2"X2" 8 PLY F CURITY GAUZE PADS F PADS 3"X3" PADS DERMACEA GAUZE CURITY GAUZE PADS F RX/OTC SPONGE 3"X3" 12 PLY F 4"X4" 12 PLY PADS PADS CURITY GAUZE SPONGE F RX/OTC DERMACEA GAUZE 2"X2" 8 PLY PADS SPONGE 3"X3" 8 PLY F PADS CURITY GAUZE SPONGE F RX/OTC 2"X2"12 PLY PADS DERMACEA GAUZE RX/OTC SPONGE 4"X4" 12 PLY F CURITY GAUZE SPONGE F 3"X3" 12 PLY PADS PADS

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA GAUZE RX/OTC DERMALEVIN ADHESIVE RX/OTC SPONGE 4"X4" 16 PLY F FOAMDRESSING 4"X4" F PADS PADS DERMACEA GAUZE RX/OTC DRESSING SPONGES F RX/OTC SPONGE 4"X4" 8 PLY F 4"X4" PADS PADS DRYMAX EXTRA PADS F RX/OTC DERMACEA I.V. DRAIN F RX/OTC SPONGES 2"X2" PADS EQL GAUZE PADS F RX/OTC 2"X2"/SMALL PADS DERMACEA I.V. DRAIN F RX/OTC SPONGES 4"X4" PADS EQL GAUZE PADS F RX/OTC 4"X4"/LARGE PADS DERMACEA I.V. F RX/OTC SPONGES 2"X2" PADS EQL GAUZE PADS DERMACEA NON-WOVEN RX/OTC STERILE 3"X3"/MEDIUM F SPONGES 2"X2" 4 PLY F PADS PADS EQL GAUZE STERILE F DERMACEA NON-WOVEN PADS 3"X3" PADS SPONGES 3"X3" 4 PLY F EXCILON AMD RX/OTC PADS ANTIMICROBIALDRAIN F DERMACEA NON-WOVEN RX/OTC SPONGES 4"X4" 6 PLY SPONGES 4"X4" 4 PLY F PADS PADS EXCILON AMD RX/OTC DERMACEA NON-WOVEN RX/OTC ANTIMICROBIALNON- F SPONGES 4"X4" 6 PLY F WOVEN SPONGES 4"X4" PADS 6 PLY PADS DERMACEA TYPE VII RX/OTC EXCILON DRAIN F RX/OTC GAUZE 2"X2" 12 PLY F SPONGE 4"X4" PADS PADS EXCILON DRAIN RX/OTC SPONGES 4"X4" 6 PLY F DERMACEA TYPE VII F RX/OTC GAUZE 2"X2" 8 PLY PADS PADS DERMACEA TYPE VII EXCILON I.V. SPONGES F RX/OTC GAUZE 3"X3" 12 PLY F 2"X2" 6 PLY PADS PADS FLEXZAN 4 X 4 PADS F RX/OTC DERMACEA TYPE VII GAUZE 3"X3" 12PLY F GAUZE DRESSING 4"X4" F RX/OTC PADS PADS DERMACEA TYPE VII RX/OTC GAUZE PADS 2"X2" PADS F RX/OTC GAUZE 4"X4" 12 PLY F PADS GAUZE PADS 3"X3" PADS F DERMACEA TYPE VII RX/OTC GAUZE 4"X4" 16 PLY F GAUZE PADS 4"X4" 12 F RX/OTC PADS PLY PADS RX/OTC DERMACEA TYPE VII F RX/OTC GAUZE PADS 4"X4" PADS F GAUZE 4"X4" 8 PLY PADS DERMACEA X-RAY RX/OTC GAUZE SPONGE TYPE RX/OTC SPONGES 4"X4" 16 PLY F VII MEDI-PAK 2"X2" 8PLY F PADS PADS

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GAUZE SPONGES 4"X4" F RX/OTC MIRASORB SPONGES 2" F RX/OTC 12 PLY PADS X 2" MISC GAUZE SPONGES 4"X4" F RX/OTC MIRASORB SPONGES 4" F RX/OTC PADS X 4" MISC GNP STERILE PADS F NU GAUZE 4PLY 4"X4" F RX/OTC 3"X3" PADS PADS HM STERILE PADS 2"X2" F RX/OTC NU GAUZE GENERAL- RX/OTC PADS USE SPONGES 4"X4" 4 F PLY MISC HM STERILE PADS PADS F RX/OTC OPTIFOAM PADS F RX/OTC HYDROCELL ADHESIVE F RX/OTC DRESSING 4"X4" PADS POLYMEM DRESSING/3" F X 3" PADS HYDROCELL DRESSING F RX/OTC 4"X4" PADS POLYMEM DRESSING/4" F RX/OTC X 4" PADS J & J GAUZE 2"X2" 8 PLY F RX/OTC PADS QC ALL PURPOSE F RX/OTC DRESSINGS4"X4" PADS J & J GAUZE 4"X4" 12 PLY F RX/OTC PADS QC BORDER ISLAND F RX/OTC GAUZE PAD 2"X2" PADS J & J GAUZE 4"X4" 8 PLY F RX/OTC PADS QC STERILE PADS PADS F J & J GAUZE SPONGES F RX/OTC 12-PLY 4" X 4" MISC QC STERILE PADS PADS F RX/OTC J & J GAUZE SPONGES F RX/OTC 16-PLY 4" X 4" MISC RA ALL PURPOSE F RX/OTC DRESSINGS4"X4" PADS J & J GAUZE SPONGES F RX/OTC 8-PLY4" X 4" MISC RA DRESSING SPONGES F RX/OTC 4"X4" PADS KENDALL HYDROPHILIC RX/OTC FOAMDRESSING 2"X2" F RA GAUZE SPONGES F RX/OTC PADS 4"X4" PADS KENDALL HYDROPHILIC RA STERILE PADS 2"X2" F RX/OTC FOAMDRESSING 3"X3" F PADS PADS RA STERILE PADS 3"X3" F KENDALL HYDROPHILIC RX/OTC PADS FOAMDRESSING 4"X4" F RA STERILE PADS 4"X4" F RX/OTC PADS PADS KENDALL HYDROPHILIC RX/OTC RAY-TEC X-RAY RX/OTC FOAMPLUS DRESSING F DETECTABLESPONGES F 2"X2" PADS 4" X 4" 16 PLY MISC KENDALL HYDROPHILIC RESTORE CONTACT RX/OTC FOAMPLUS DRESSING F LAYER/NON-ADHERENT F 3"X3" PADS 2"X2" PADS RESTORE FOAM RX/OTC KERLIX SPONGES 4" X 4" F RX/OTC 12 PLY PADS DRESSING BORDERED F 4"X4" PADS KERLIX SPONGES 4" X 4" F RX/OTC 16 PLY PADS RESTORE FOAM RX/OTC DRESSING NON- F BORDERED 4"X4" PADS Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RESTORE ODOR RX/OTC VISTEC X-RAY RX/OTC ABSORBING DRESSING F DETECTABLE SPONGES F 4"X4" PADS 4"X4" 16 PLY PADS RESTORE TRIO Contraceptives ABSORBENT DRESSING F AIMSCO LUBRICATED F QL(36 ea per 3"X3" PADS MISC fill retail) SM GAUZE PADS 2"X2" F RX/OTC PADS ATLAS COLORED QL(36 ea per CONDOM/SPERMICIDE F fill retail) SM GAUZE PADS 3"X3" F DEVI PADS ATLAS COLORED QL(36 ea per SM GAUZE PADS 4"X4" F RX/OTC LUBRICATEDCONDOM F fill retail) PADS DEVI SM STERILE PADS 2"X2" RX/OTC F ATLAS LUBRICATED F QL(36 ea per PADS CONDOM DEVI fill retail) SM STERILE PADS PADS F RX/OTC ATLAS LUBRICATED QL(36 ea per CONDOM/SPERMICIDE F fill retail) SOF-WICK 4"X4" PADS F RX/OTC DEVI CLASS ACT LUBRICATED F QL(36 ea per STERILE GAUZE PADS F RX/OTC MISC fill retail) 2"X2" PADS DUREX EXTRA F QL(36 ea per STERILE GAUZE PADS F SENSITIVE DEVI fill retail) 3"X3" PADS ELEXA NATURAL FEEL F QL(36 ea per STERILE PADS 2"X2" F RX/OTC MISC fill retail) PADS ELEXA STIMULATING F QL(36 ea per STERILE PADS 3"X3" F MISC fill retail) PADS ELEXA ULTRA SENSITIVE F QL(36 ea per STERILE PADS 4"X4" F RX/OTC MISC fill retail) PADS EXTRA SENSITIVE F QL(36 ea per SURGICAL GAUZE F RX/OTC SPERMICIDAL DEVI fill retail) SPONGE PADS FANTASY LUBRICATED F QL(36 ea per TEGADERM FOAM F RX/OTC MISC fill retail) DRESSING 2"X2" PADS FANTASY QL(36 ea per TEGADERM FOAM F RX/OTC LUBRICATED/SPERMICID F fill retail) DRESSING 4"X4" PADS E MISC RX/OTC THERAGAUZE PADS F HIGH SENSATION F QL(36 ea per SPERMICIDAL DEVI fill retail) TOPPER DRESSING F RX/OTC SPONGES 4"X4" MISC INTENSE SENSATION F QL(36 ea per DEVI fill retail) VERSIVA XC 3" X 3" KAMELEON LUBRICATED QL(36 ea per FOAM F F DRESSING/HYDROFIBER MISC fill retail) TECHNOLOGY PADS KIMONO COLORS DEVI F QL(36 ea per VERSIVA XC 4" X 4" RX/OTC fill retail) KIMONO LUBRICATED QL(36 ea per FOAM F F DRESSING/HYDROFIBER MISC fill retail) TECHNOLOGY PADS KIMONO MICRO THIN F QL(36 ea per MISC fill retail)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO MICRO THIN QL(36 ea per F QL(36 ea per PLUS SPERMICIDE F fill retail) TROJAN MISC fill retail) LUBRICATED MISC TROJAN PLEASURE QL(36 ea per KIMONO PLUS QL(36 ea per MESH/SPERMICIDAL F fill retail) SPERMICIDE F fill retail) DEVI LUBRICATED MISC F QL(36 ea per KIMONO PLUS QL(36 ea per TROJAN PLUS MISC fill retail) SPERMICIDE/LUBRICATE F fill retail) F QL(36 ea per D MISC TROJAN REGULAR MISC fill retail) KIMONO PS LUBRICATED QL(36 ea per F F QL(36 ea per MISC fill retail) TROJAN RIBBED MISC fill retail) KIMONO PS PLUS QL(36 ea per TROJAN RIBBED F QL(36 ea per SPERMICIDE/LUBRICATE F fill retail) W/SPERMICIDAL MISC fill retail) D MISC TROJAN SHARED QL(36 ea per KIMONO SENSATION F QL(36 ea per SENSATION/LUBRICATE F fill retail) LUBRICATED MISC fill retail) D DEVI KIMONO SENSATION QL(36 ea per TROJAN SUPRAS F QL(36 ea per PLUS SPERMICIDE F fill retail) SPERMICIDAL DEVI fill retail) LUBRICATED MISC TROJAN TWISTED F QL(36 ea per F QL(36 ea per PLEASURE DEVI fill retail) KIMONO SPECIAL DEVI fill retail) TROJAN ULTRA QL(36 ea per MAXX LUBRICATED MISC F QL(36 ea per PLEASURE/LUBRICATED F fill retail) fill retail) DEVI MAXX PLUS SPERMICIDE F QL(36 ea per TROJAN VERY QL(36 ea per LUBRICATED MISC fill retail) SENSITIVE LUBRICATED F fill retail) PREMIUM CONDOMS F QL(36 ea per MISC LUBRICATED MISC fill retail) TROJAN VERY QL(36 ea per REALITY LATEX QL(36 ea per SENSITIVE SPERMICIDAL F fill retail) CONDOMS/LUBRICATED F fill retail) LUBRICANT MISC MISC TROJAN VERY THIN F QL(36 ea per REALITY LATEX/ULTRA F QL(36 ea per LUBRICATED MISC fill retail) TEXTURED DEVI fill retail) TROJAN VERY THIN QL(36 ea per REALITY LATEX/ULTRA F QL(36 ea per SPERMICIDAL F fill retail) THIN DEVI fill retail) LUBRICANT MISC TROJAN ASSORTMENT F QL(36 ea per TROJAN-ENZ LUBRICANT F QL(36 ea per PACK MISC fill retail) MISC fill retail) TROJAN EXTENDED QL(36 ea per TROJAN-ENZ F QL(36 ea per PLEASURE/LUBRICATED F fill retail) LUBRICATED MISC fill retail) DEVI TROJAN-ENZ F QL(36 ea per TROJAN EXTRA F QL(36 ea per W/SPERMICIDAL MISC fill retail) STRENGTH MISC fill retail) TRUSTEX COLOR F QL(36 ea per F QL(36 ea per CONDOMS + LUBE MISC fill retail) TROJAN MAGNUM MISC fill retail) TRUSTEX LUBRICATED F QL(36 ea per TROJAN MAGNUM WARM F QL(36 ea per EXTRALARGE MISC fill retail) SENSATIONS DEVI fill retail) TRUSTEX LUBRICATED F QL(36 ea per TROJAN MAGNUM XL F QL(36 ea per EXTRASTRENGTH MISC fill retail) LUBRICATED DEVI fill retail) Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX LUBRICATED F QL(36 ea per 1ST TIER UNILET MISC fill retail) COMFORTOUCH F TRUSTEX QL(36 ea per LANCETS 30G MISC LUBRICATED/RIBBED/ST F fill retail) ADJUSTABLE LANCING F UDDED MISC DEVICE MISC TRUSTEX QL(36 ea per ADVOCATE LANCING F LUBRICATED/SPERMICID F fill retail) DEVICE MISC E EXTRA LARGE MISC ADVOCATE RAPID-SAFE F TRUSTEX QL(36 ea per LANCING DEVICE MISC LUBRICATED/SPERMICID fill retail) F AGAMATRIX ULTRA-THIN F E EXTRA STRENGTH LANCETS 33G MISC MISC ALTERNATE SITE F TRUSTEX QL(36 ea per LANCING DEVICE MISC LUBRICATED/SPERMICID F fill retail) E MISC AQUA LANCE ADJUSTABLE LANCING F TRUSTEX NATURAL QL(36 ea per DEVICE DEVI CONDOMS F fill retail) +LUBE/LUBRICATED AURORA LANCET SUPER F MISC THIN30G MISC AURORA LANCET THIN TRUSTEX NON- F QL(36 ea per F LUBRICATED MISC fill retail) 23G MISC TRUSTEX WITH QL(36 ea per AUTO-LANCET MINI MISC F NONOXYNOL- F fill retail) 9/RIBBED/STUDDED AUTO-LANCET MISC F MISC AUTOLET IMPRESSION F TRUSTEX/RIA F QL(36 ea per LANCING DEVICE MISC LUBRICATED MISC fill retail) AUTOLET LANCING F TRUSTEX/RIA QL(36 ea per DEVICE MISC LUBRICATED F fill retail) SPERMICIDE MISC AUTOLET MINI MISC F TRUSTEX/RIA QL(36 ea per LUBRICATED/SPERMICID F fill retail) AUTOLET PLUS MISC F E MISC BAYER MICROLET 2 F TRUSTEX/RIA NON- F QL(36 ea per LANCING DEVICE MISC LUBRICATED MISC fill retail) BD LANCET DEVICE F F QL(36 ea per MISC ULTIMATE FEELING DEVI fill retail) BD LANCET ULTRAFINE F Diabetic Supplies 30G MISC 1ST CHOICE LANCETS F CARDIOCOM LANCING F SUPERTHIN MISC DEVICE MISC 1ST CHOICE LANCETS F CAREONE ADVANCED F THIN MISC LANCINGDEVICE MISC 1ST CHOICE LANCETS F CAREONE LANCET THIN F ULTRATHIN MISC MISC 1ST TIER UNILET CAREONE LANCET F COMFORTOUCH F ULTRA THIN MISC LANCETS 28G MISC Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARETOUCH LANCING DRUG MART UNILET DEVICEWITH EJECTOR F LANCETSULTRA THIN F MISC 28G MISC CLEANLET LANCETS 28G F DUANE READE LANCET MISC ALTERNATE SITE 26G F MISC CLOSERCARE MISC F DUANE READE LANCET F COMFORT ASSURED SUPERTHIN 30G MISC LANCETS MICRO THIN F DUANE READE LANCET F 33G MISC ULTRATHIN 28G MISC COMFORT ASSURED E-Z JECT LANCETS 21G F LANCETS SUPER THIN F MISC 28G MISC E-Z JECT LANCETS F COMFORT LANCETS F COLOR MISC MISC E-Z JECT LANCETS MISC F CVS LANCETS 21G MISC F E-Z JECT LANCETS F CVS LANCETS MICRO F SUPER THIN 30G MISC THIN 33G MISC E-Z JECT LANCETS THIN F CVS LANCETS MICRO- F 26G MISC THIN 33G MISC E-ZJECT LANCETS F CVS LANCETS ORIGINAL F MICRO-THIN 33G MISC MISC EASY MINI EJECT F CVS LANCETS THIN 26G F LANCING DEVICE MISC MISC EASY MINI LANCING F CVS LANCETS ULTRA F DEVICE MISC THIN 30G MISC EASY TOUCH LANCETS F CVS LANCETS ULTRA- F 26G/PULL-TOP MISC THIN 30G MISC EASY TOUCH LANCETS F CVS LANCING DEVICE F 26G/TWIST MISC MISC EASY TOUCH LANCETS F CVS ULTRA THIN F 28G/PULL-TOP MISC LANCETS MISC EASY TOUCH LANCETS F DROPLET LANCETS F 28G/TWIST MISC ULTRA THIN 30G MISC EASY TOUCH LANCETS F DROPLET LANCING F 30G/PULL-TOP MISC DEVICE MISC EASY TOUCH LANCETS F DRUG MART 30G/TWIST MISC ADJUSTABLE LANCING F EASY TOUCH LANCETS F DEVICE MISC 32G/PULL-TOP MISC DRUG MART LANCETS F EASY TOUCH LANCETS F THIN MISC 32G/TWIST MISC DRUG MART UNILET EASY TOUCH LANCETS F LANCETSSUPER THIN F 33G/TWIST MISC 30G MISC EASY TOUCH LANCING F DEVICE/EJECTOR MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASYTEST II LANCETS F GENTLE-LET LANCETS MISC GENERAL PURPOSE F STYLE/FINE POINT MISC EASYTEST LANCETS F MISC GENTLE-LET LANCETS GENERAL PURPOSE EQL COLOR LANCETS F F 21G MISC STYLE/MEDIUM POINT MISC EQL COLOR LANCETS F MICRO THIN 33G MISC GENTLE-LET LANCETS SAFETY STYLE/FINE F EQL SUPER THIN F POINT MISC LANCETS 30G MISC GENTLE-LET LANCETS EQL THIN LANCETS 26G F SAFETY STYLE/MEDIUM F MISC POINT MISC EZ SMART BLOOD GLOBAL LANCING F GLUCOSE LANCETS F DEVICE MISC MISC GLUCOCOM LANCETS F EZ-LETS LANCETS 23G F 28G MISC MISC GLUCOCOM LANCETS F EZ-LETS LANCETS 26G F 30G MISC SUPER-SOFT MISC GLUCOLET 2 EZ-LETS LANCETS 28G F AUTOMATIC LANCING F ULTRA-SOFT MISC DEVICE MISC EZ-LETS LANCETS 30G F GLUCOSOURCE LANCET F MISC DEVICE MISC FIFTY50 LANCING F GLUCOSOURCE F DEVICE MISC LANCETS MISC FIFTY50 UNILET F LANCETS 33G MISC GNP LANCETS 21G MISC F

FORA LANCETS MISC F GNP LANCETS MICRO F THIN 33G MISC FORA LANCING DEVICE F MISC GNP LANCETS MISC F FORA LANCING F GNP LANCETS SUPER F DEVICE/CLEARCAP MISC THIN 30G MISC FREDS PHARMACY GNP LANCETS THIN 26G F AUTOLET LANCING F MISC DEVICE MISC GNP LANCETS THIN F FREDS PHARMACY MISC UNILET LANCETS SUPER F THIN 30G MISC GNP MICRO THIN F LANCETS 33G MISC FREDS PHARMACY UNILET LANCETS ULTRA F GNP SUPER THIN F THIN 28G MISC LANCETS/30G MISC GOODSENSE LANCING GENTLE-LET GP F F LANCETS MISC DEVICE MISC H-E-B INCONTROL ADVANCEDLANCING F DEVICE MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B INCONTROL LANCET DEVICE WITH F LANCETS MICRO THIN F EJECTOR MISC 33G MISC LANCETS 26G TWIST F H-E-B INCONTROL TOP MISC LANCETS SUPER THIN F 30G MISC LANCETS 28G MISC F H-E-B INCONTROL LANCETS 30G MISC F LANCETS ULTRA THIN F 28G MISC LANCETS MISC F HEALTH CARE LANCING F DEVICE MISC LANCETS SAFETY SEAL F 21G MISC HEALTHWISE LANCING F PEN MISC LANCETS SAFETY SEAL F HEALTHY ACCENTS 26G MISC AUTOLET IMPRESSION F LANCETS SAFETY SEAL F LANCING DEVICE MISC 28G MISC HEALTHY ACCENTS LANCETS THIN MISC F UNILET LANCETS SUPER F THIN 30G MISC LANCETS ULTRA THIN F MISC HY-VEE LANCETS MISC F LANCING DEVICE F ADJUSTABLE MISC HY-VEE THIN LANCETS F MISC LANCING DEVICE MISC F IN TOUCH LANCING F DEVICE MISC LANZO MISC F KINNEY LANCETS MISC F LEADER ADVANCED F LANCING DEVICE MISC KINNEY THIN LANCETS F MISC LIBERTY MINI LANCING F DEVICE MISC KROGER LANCETS 21G F MISC LITE TOUCH LANCING F DEVICE MISC KROGER LANCETS F MICRO THIN33G MISC LITE TOUCH LANCING F PEN MISC KROGER LANCETS MISC F LIVE BETTER ADVANCED F LANCING DEVICE MISC KROGER LANCETS F SUPER THIN MISC LIVE BETTER LANCET F SUPERTHIN 30G MISC KROGER LANCETS THIN F 26G MISC LIVE BETTER LANCET F ULTRATHIN 28G MISC KROGER LANCETS THIN F MISC LONGS LANCETS F STANDARD MISC KROGER LANCETS F ULTRATHIN30G MISC LONGS LANCETS THIN F MISC KROGER LANCING F DEVICE MISC MEDISENSE THIN F LANCETS MISC LANCET DEVICE F ADJUSTABLE MISC Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEIJER COLOR PRECISION THINS GP F LANCETS UNIVERSAL F LANCET MISC 33G MISC PRECISION ULTRA F MEIJER LANCETS MISC F LANCET MISC PREFERRED PLUS MEIJER LANCETS THIN F LANCETS COLORED 21G F MISC MISC MEIJER LANCETS F PREFERRED PLUS UNIVERSAL21G MISC LANCETS SUPER THIN F 30G MISC MEIJER LANCETS F UNIVERSAL30G MISC PREFERRED PLUS F LANCETS THIN 26G MISC MEIJER LANCETS F UNIVERSAL33G MISC PRODIGY LANCING F DEVICE MISC MEIJER SUPER THIN F LANCETS MISC PRODIGY TWIST TOP F MICROLET NEXT MISC F LANCETS MISC PSS SELECT GP F MINI LANCING DEVICE F LANCETS MISC MISC PSS SELECT SAFETY F MM LANCING DEVICE F LANCETS MISC MISC PX ADVANCED LANCING F MONOLET LANCETS F DEVICE MISC MISC PX LANCET AUTO F MONOLET OPD LANCETS F INJECTOR MISC MISC PX LANCETS ULTRA F MULTI-LANCET DEVICE F THIN MISC MISC QC ADVANCED LANCING F NOVA SUREFLEX F DEVICE MISC LANCETS MISC QC LANCETS SUPER F NOVA SUREFLEX F THIN MISC LANCING DEVICE MISC QC LANCETS ULTRA F ON CALL LANCING F THIN MISC DEVICE MISC QC UNILET LANCETS F ON CALL PLUS LANCING F 33G/MICRO THIN MISC DEVICE MISC RA E-ZJECT COLOR ONETOUCH DELICA F LANCETSMICRO-THIN F LANCING DEVICE MISC 33G MISC PC LANCETS SUPER F RA E-ZJECT LANCETS F THIN 30G MISC 28G MISC PERFECT LANCETS 30G F RA E-ZJECT LANCETS F MISC THIN 26G MISC PHARMACY COUNTER F RA E-ZJECT LANCETS F LANCETS MISC THIN 28G MISC PRECISION THIN F RA E-ZJECT LANCETS F LANCETS MISC ULTRATHIN 30G MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA LANCING DEVICE F SHOPKO UNILET MISC LANCETS SUPER THIN F 30G MISC REALITY LANCETS MISC F SHOPKO UNILET LANCETS ULTRA THIN F RELION 2-IN-1 LANCING F DEVICE 25G MISC 28G MISC SIDE BUTTON SAFETY RELION 2-IN-1 LANCING F F DEVICE 30G MISC LANCET21G MISC SIMPLE DIAGNOSTICS RELION LANCETS F F MICRO-THIN33G MISC LANCING DEVICE MISC SM MICRO THIN RELION LANCETS F F STANDARD 21G MISC LANCETS 33G MISC SM TRUEDRAW LANCING RELION LANCETS THIN F F 26G MISC DEVICE MISC SMART DIABETES RELION LANCETS F ULTRA-THIN30G MISC VANTAGE LANCING F DEVICE MISC RELION LANCING F DEVICE MISC SMART SENSE COLOR LANCETS UNIVERSAL F RELION ULTRA THIN F LANCETS30G MISC 33G MISC RELION ULTRA THIN SMART SENSE PLUS LANCETS 32G F STANDARD LANCETS F MISC UNIVERSAL 21G MISC RELION ULTRA THIN SMART SENSE SUPER PLUS LANCETS 33G F THIN LANCETS F MISC UNIVERSAL 30G MISC SMART SENSE THIN REXALL LANCETS ULTRA F THIN MISC LANCETSUNIVERSAL F 26G MISC RIGHTEST GD500 F LANCING DEVICE MISC SOLUS V2 LANCING F DEVICE MISC RIGHTEST GL300 F LANCETS MISC STERILANCE TL MISC F SAFETY SEAL LANCETS F SUPER THIN LANCETS F 28G MISC MISC SAFETY SEAL LANCETS F SURE COMFORT F 30G MISC LANCING PEN MISC SB LANCETS THIN MISC F SURE-PEN MISC F SB LANCETS ULTRA F SURELITE LANCETS F THIN MISC MISC SELECT-LITE LANCING F TECHLITE AST LANCETS F DEVICE MISC MISC SHOPKO AUTOLET F TECHLITE LANCETS 30G F LANCING DEVICE MISC MISC TECHLITE LANCETS F MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TGT ADVANCED F TRUEPLUS LANCETS F LANCING DEVICE MISC 26G MISC TGT LANCET F TRUEPLUS LANCETS F ALTERNATE SITE MISC 28G MISC TGT LANCET MICRO F TRUEPLUS LANCETS F THIN 33G MISC 28G SUPER THIN MISC TGT LANCET SUPER F TRUEPLUS LANCETS F THIN 30G MISC 30G MISC TGT LANCET THIN 23G F TRUEPLUS LANCETS F MISC 30G ULTRA THIN MISC TGT LANCET THIN 26G F TRUEPLUS LANCETS F MISC 33G MISC TGT LANCET ULTRA F TRUETEST GLUCOSE F THIN 28G MISC CONTROLLEVEL 1 LIQD TGT LANCET ULTRA F TRUETEST GLUCOSE F THIN 30G MISC CONTROLLEVEL 2 LIQD TGT LANCING DEVICE F TRUETEST GLUCOSE F MISC CONTROLLEVEL 3 LIQD THINLETS GP LANCETS F ULTI-LANCE AUTOMATIC/ F MISC CLEAR TIP MISC THINLETS LANCET MISC F ULTILET CLASSIC F LANCETS MISC TODAYS HEALTH ULTRA THIN LANCETS F ADVANCED LANCING F 28G MISC DEVICE MISC ULTRA THIN LANCETS F TODAYS HEALTH SUPER F 30G MISC THINLANCETS 30G MISC UNILET COMFORTOUCH F TODAYS HEALTH ULTRA F LANCET MISC THINLANCETS 28G MISC TRUE METRIX CONTROL UNILET EXCELITE II MISC F SOLUTION LEVEL 1 F SOLN UNILET EXCELITE MISC F TRUE METRIX CONTROL UNILET G.P. LANCET F SOLUTION LEVEL 2 F MISC SOLN UNILET G.P. SUPERLITE F TRUE METRIX CONTROL LANCET MISC SOLUTION LEVEL 3 F UNILET GP 28 ULTRA F SOLN THIN MISC TRUECONTROL GLUCOSE CONTROL F UNILET LANCET MISC F LEVEL 0 LIQD UNILET LANCETS F TRUECONTROL MICRO-THIN33G MISC GLUCOSE CONTROL F UNILET LANCETS F LEVEL 1 LIQD SUPER-THIN30G MISC TRUEDRAW LANCING F UNILET LANCETS F DEVICE MISC ULTRA-THIN 28G MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNILET SUPERLITE F Misc. Devices LANCET MISC PREP PADS F RX/OTC UNISTIK TOUCH SAFETY F PADS LANCETS 21G MISC ALCOHOL PREPS PADS F RX/OTC UNISTIK TOUCH SAFETY F LANCETS 23G MISC ALCOHOL SWABS PADS F RX/OTC UNISTIK TOUCH SAFETY F LANCETS 28G MISC ALCOHOL WIPES PADS F RX/OTC UNISTIK TOUCH SAFETY F LANCETS 30G MISC BD SWABS SINGLE USE F RX/OTC BUTTERFLY PADS UNIVERSAL 1 LANCETS F THIN26G MISC BD SWABS SINGLE USE F RX/OTC PADS UNIVERSAL 1 LANCETS F ULTRA THIN 30G MISC CURITY ALCOHOL RX/OTC PREPS/MEDIUM 2 PLY F VALUE PLUS LANCETS F STANDARD 21G MISC PADS CURITY ALCOHOL RX/OTC VALUE PLUS LANCETS F F SUPERTHIN 30G MISC SWABS PADS CVS ALCOHOL PREP RX/OTC VALUE PLUS LANCETS F F THIN 26G MISC SWABS PADS CVS ALCOHOL SWABS RX/OTC VALUE PLUS LANCING F F DEVICE MISC PADS RX/OTC VALUMARK LANCET F CVS PREP PADS PADS F SUPER THIN 30G MISC EASY TOUCH ALCOHOL RX/OTC VALUMARK LANCET F PREP PADS/MEDIUM F ULTRA THIN 28G MISC PADS VIDA MIA AUTOLET F EQL ALCOHOL SWABS F RX/OTC LANCINGDEVICE MISC PADS VIDA MIA UNILET FIFTY50 ALCOHOL PREP F RX/OTC LANCETS SUPER THIN F PADS PADS 30G MISC GNP ALCOHOL SWABS F RX/OTC VIDA MIA UNILET PADS LANCETS ULTRA THIN F 28G MISC H-E-B INCONTROL F RX/OTC ALCOHOL PADS PADS W&F LANCETS 26G MISC F MEIJER ALCOHOL RX/OTC SWABS EXTRA-THICK F W&F LANCETS F COLORED 21G MISC PADS WALGREENS COMFORT QC ALCOHOL SWABS F RX/OTC ASSUREDLANCETS F PADS MICRO THIN/33G MISC RA ALCOHOL SWABS F RX/OTC WALGREENS COMFORT PADS ASSUREDLANCETS F REALITY SWABS PADS F RX/OTC SUPER THIN/28G MISC RELION ALCOHOL RX/OTC WALGREENS THIN F F LANCETS MISC SWABS PADS

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SB ALCOHOL PREP F RX/OTC ADVOCATE INSULIN QL(5 ea daily) PADS PADS SYRINGE/U- F 100/0.5ML/31GX5/16" SHOPKO ALCOHOL F RX/OTC SWABS PADS MISC ADVOCATE INSULIN QL(5 ea daily); SM ALCOHOL PREP F RX/OTC PADS PADS SYRINGE/U- F RX/OTC 100/1ML/29GX1/2" MISC TGT ALCOHOL SWABS F RX/OTC PADS ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC ULTICARE ALCOHOL F RX/OTC 100/1ML/30GX5/16" MISC SWABS PADS ADVOCATE INSULIN QL(5 ea daily) ULTILET ALCOHOL F RX/OTC SYRINGE/U- F SWABS PADS 100/1ML/31GX5/16" MISC WEBCOL ALCOHOL RX/OTC ANTI-STICK INSULIN QL(5 ea daily); PREP LARGE 1 PLY F SYRINGE/U- F RX/OTC PADS 100/0.5ML/28G X 1/2" WEBCOL ALCOHOL RX/OTC MISC PREP LARGE 2 PLY F ANTI-STICK INSULIN QL(5 ea daily); PADS SYRINGE/U- F RX/OTC WEBCOL ALCOHOL RX/OTC 100/0.5ML/29G X 1/2" PREP MEDIUM 2 PLY F MISC PADS ANTI-STICK INSULIN QL(5 ea daily); Parenteral Therapy Supplies SYRINGE/U-100/1ML/29G F RX/OTC 1ST TIER UNIFINE QL(5 ea daily); X 1/2" MISC PENTIPS29GX12MM F RX/OTC ASSURE ID INSULIN QL(5 ea daily); MISC SAFETYSYRINGE/U- F RX/OTC 1ST TIER UNIFINE QL(5 ea daily); 100/0.5ML/29G X 1/2" PENTIPSPLUS/ORIGINAL/ F RX/OTC MISC 29GX12MM MISC ASSURE ID INSULIN QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); SAFETYSYRINGE/U- F RX/OTC SYRINGE/U- F RX/OTC 100/1ML/29G X 1/2" MISC 100/0.3ML/29GX1/2" MISC AURORA PEN NEEDLES F QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); 29GX12MM MISC RX/OTC B-D INSULIN SYRINGE QL(5 ea daily) SYRINGE/U- F RX/OTC 100/0.3ML/30GX5/16" ULTRAFINE II/0.3ML/31G F MISC X 5/16" MISC ADVOCATE INSULIN QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/0.5ML/31G F SYRINGE/U- F 100/0.3ML/31GX5/16" X 5/16" MISC MISC B-D INSULIN SYRINGE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); ULTRAFINE II/1ML/31G X F SYRINGE/U- F RX/OTC 5/16" MISC 100/0.5ML/29GX1/2" MISC B-D INSULIN SYRINGE QL(5 ea daily) ADVOCATE INSULIN QL(5 ea daily); ULTRAFINE/0.3ML/30G X F 1/2" MISC SYRINGE/U- F RX/OTC 100/0.5ML/30GX5/16" B-D INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE/0.5ML/30G X F 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD LO-DOSE INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) SYRINGE MICROFINE F RX/OTC ULTRAFINE HALF- F IV/0.5ML/28G X 1/2" MISC UNIT/0.3ML/31G X 5/16" MISC BD AUTOSHIELD 29G X F QL(5 ea daily) 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE F LUER-LOK/U-100/1ML F RX/OTC II/SHORT/0.5ML/31G X MISC 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE MICROFINE IV/U- F F 100/0.3ML/28G X 1/2" II/SHORT/1ML/31G X 5/16" MISC MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.3ML/30G X F MICROFINE IV/U- F RX/OTC 100/0.5ML/28G X 1/2" 1/2" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.3ML/31G X F MICROFINE IV/U- F 5/16" MISC 100/1ML/27G X 5/8" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/0.5ML/30G X F MICROFINE IV/U- F RX/OTC 1/2" MISC 100/1ML/28G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/31G X F 5/16" MISC MICROFINE/U- F 100/0.3ML/28G X 1/2" BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE/1ML/30G X F BD INSULIN SYRINGE QL(5 ea daily); 1/2" MISC MICROFINE/U- F RX/OTC BD INSULIN SYRINGE QL(5 ea daily) 100/0.5ML/28G X 1/2" ULTRAFINE/1ML/31G X F MISC 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); MICROFINE/U- F ULTRAFINE/U- F RX/OTC 100/1ML/27G X 5/8" MISC 100/0.3ML/29G X 1/2" BD INSULIN SYRINGE QL(5 ea daily); MISC MICROFINE/U- F RX/OTC BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/28G X 1/2" MISC ULTRAFINE/U- F BD INSULIN SYRINGE QL(5 ea daily); 100/0.3ML/30G X 1/2" SAFETYGLIDE/0.5ML/29G F RX/OTC MISC X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/U- F SAFETYGLIDE/1ML/29G X F RX/OTC 100/0.3ML/31G X 5/16" 1/2" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/U- RX/OTC SAFETYGLIDE/U- F F 100/0.3ML/31G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC BD INSULIN SYRINGE F QL(5 ea daily); SLIP TIP/U-100/1ML MISC RX/OTC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily) BD INTEGRA QL(5 ea daily) ULTRAFINE/U- F SYRINGE/RETRACTING F 100/0.5ML/30G X 1/2" NEEDLE/1ML/25G X 1" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD SAFETY-GLIDE QL(5 ea daily); ULTRAFINE/U- F INSULIN F RX/OTC 100/0.5ML/31G X 5/16" SYRINGE/0.5ML/29G X MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); BD SAFETY-LOK INSULIN QL(5 ea daily); F ULTRAFINE/U- RX/OTC SYRINGE/PERM F RX/OTC 100/1ML/29G X 1/2" MISC NEEDLE/UF/1ML/29G X BD INSULIN SYRINGE QL(5 ea daily) 1/2" MISC ULTRAFINE/U- F BD SAFETYGLIDE QL(5 ea daily); 100/1ML/30G X 1/2" MISC INSULIN F RX/OTC BD INSULIN SYRINGE SYSYRINGE/0.5ML/30G X 5/16" MISC ULTRAFINE/U- F 100/1ML/31G X 15/64" CAREFINE PEN F QL(5 ea daily); MISC NEEDLES 29GX1/2" MISC RX/OTC BD INSULIN SYRINGE QL(5 ea daily) CAREFINE PEN QL(5 ea daily); ULTRAFINE/U- F NEEDLES 30GX5/16" F RX/OTC 100/1ML/31G X 5/16" MISC MISC CAREFINE PEN QL(5 ea daily); BD INSULIN QL(5 ea daily) NEEDLES 32GX5MM F RX/OTC SYRINGE/DETACHABLE F MISC NEEDLE/U-100/1ML/25G CAREONE INSULIN QL(5 ea daily) X 1" MISC SYRINGES/0.3ML/30G X F BD INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/DETACHABLE F CAREONE INSULIN QL(5 ea daily) NEEDLE/U-100/1ML/25G SYRINGES/0.3ML/31G X F X 5/8" MISC 5/16" MISC BD INSULIN QL(5 ea daily) CAREONE INSULIN QL(5 ea daily) SYRINGE/DETACHABLE F SYRINGES/0.5ML/30G X F NEEDLE/U-100/1ML/26G 1/2" MISC X 1/2" MISC CAREONE INSULIN QL(5 ea daily) BD INSULIN SYRINGE/U- QL(5 ea daily) SYRINGES/0.5ML/31G X F 100/0.5ML/30G X 1/2" F 5/16" MISC MISC CAREONE INSULIN QL(5 ea daily) BD INSULIN SYRINGE/U- F QL(5 ea daily); SYRINGES/1ML/30G X F 100/1ML/27G X 1/2" MISC RX/OTC 1/2" MISC BD INSULIN SYRINGE/U- F QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) 100/1ML/28G X 1/2" MISC RX/OTC SYRINGES/1ML/31GX5/16 F BD INSULIN SYRINGE/U- QL(5 ea daily) " MISC 100/2ML/27.5G X 5/8" F CAREONE UNIFINE QL(5 ea daily); MISC PENTIPS 29GX12MM F RX/OTC BD INTEGRA INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G F RX/OTC X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); PENTIPS PLUS PEN F RX/OTC COMFORT EZINSULIN F RX/OTC NEEDLES 29GX12MM SYRINGE/1ML/28G X 1/2" MISC MISC CARETOUCH PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); F NEEDLES 32GX 5MM RX/OTC COMFORT EZINSULIN F RX/OTC MISC SYRINGE/1ML/29G X 1/2" CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN F RX/OTC CLEVER CHOICE QL(5 ea daily); SYRINGE/0.3ML/29G X COMFORT EZINSULIN F RX/OTC 1/2" MISC SYRINGE/1ML/30G X CLEVER CHOICE QL(5 ea daily) 5/16" MISC COMFORT EZINSULIN F CLEVER CHOICE QL(5 ea daily) SYRINGE/0.3ML/30G X COMFORT EZINSULIN F 1/2" MISC SYRINGE/U- CLEVER CHOICE QL(5 ea daily); 100/1ML/31GX5/16" MISC COMFORT EZINSULIN F RX/OTC CLEVER CHOICE QL(5 ea daily); SYRINGE/0.3ML/30G X COMFORT EZPEN F RX/OTC 5/16" MISC NEEDLES 29GX12MM CLEVER CHOICE QL(5 ea daily) MISC COMFORT EZINSULIN F CLEVER CHOICE QL(5 ea daily); SYRINGE/0.3ML/31G X COMFORT EZPEN F RX/OTC 5/16" MISC NEEDLES 32GX5MM CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN F RX/OTC COMFORT ASSIST QL(5 ea daily); SYRINGE/0.5ML/28G X INSULIN SYRINGE F RX/OTC 1/2" MISC 0.3ML/29G X 1/2" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); COMFORT EZINSULIN F RX/OTC INSULIN F RX/OTC SYRINGE/0.5ML/29G X SYRINGE/0.3ML/30G X 1/2" MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily) COMFORT EZINSULIN F INSULIN F SYRINGE/0.5ML/30G X SYRINGE/0.3ML/31G X 1/2" MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); COMFORT EZINSULIN F RX/OTC INSULIN F RX/OTC SYRINGE/0.5ML/30G X SYRINGE/0.5ML/29G X 5/16" MISC 1/2" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); COMFORT EZINSULIN F INSULIN F RX/OTC SYRINGE/0.5ML/31G X SYRINGE/0.5ML/30G X 5/16" MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily) COMFORT EZINSULIN F INSULIN F SYRINGE/1.0ML/30G X SYRINGE/0.5ML/31G X 1/2" MISC 5/16" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily); INSULIN F RX/OTC SAFETY INSULIN F RX/OTC SYRINGE/1ML/29G X 1/2" SYRINGE 1ML/29GX1/2" MISC MISC COMFORT ASSIST QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily) INSULIN F RX/OTC SAFETY INSULIN F SYRINGE/1ML/30G X SYRINGE 1ML/30GX1/2" 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily) EASY TOUCH FLIPLOCK QL(5 ea daily); INSULIN F SAFETY INSULIN F RX/OTC SYRINGE/1ML/31G X SYRINGE 1ML/30GX5/16" 5/16" MISC MISC DROPLET PEN NEEDLES F QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily) 29GX12MM MISC RX/OTC SAFETY INSULIN F SYRINGE 1ML/31GX5/16" DROPLET PEN NEEDLES F QL(5 ea daily); 32G X 3/16" MISC RX/OTC MISC EASY TOUCH INSULIN QL(5 ea daily); DROPLET PEN NEEDLES F QL(5 ea daily); 32GX5MM MISC RX/OTC SYRINGE/0.3ML/30G X F RX/OTC 5/16" MISC DRUG MART UNIFINE QL(5 ea daily); PENTIPS29G X 12MM F RX/OTC EASY TOUCH INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X F 5/16" MISC DUANE READE UNIFINE QL(5 ea daily); PENTIPS 29G X 12MM F RX/OTC EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/29G X F RX/OTC 1/2" MISC EASY COMFORT INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X F RX/OTC EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC EASY COMFORT INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/30G X F RX/OTC 5/16" MISC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/SAFETY/U- F RX/OTC 100/0.5ML/29G X 1/2" EASY COMFORT INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X F RX/OTC 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/SAFETY/U- F RX/OTC EASY COMFORT INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/1ML/31G X F MISC 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/SAFETY/U- F RX/OTC SYRINGE/U- F 100/1ML/29G X 1/2" MISC 100/0.5ML/30G X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/SAFETY/U- F EASY COMFORT INSULIN QL(5 ea daily) 100/1ML/30G X 1/2" MISC SYRINGE/U-100/1ML/30G F X 1/2" MISC EASY TOUCH 32GX5MM F QL(5 ea daily); MISC RX/OTC Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH QL(5 ea daily); SYRINGE/U- F SHEATHLOCK SAFETY F RX/OTC 100/0.3ML/30G X 1/2" INSULIN SYRINGE MISC 1ML/30GX5/16" MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH QL(5 ea daily) SYRINGE/U- F SHEATHLOCK SAFETY F 100/0.5ML/27G X 1/2" INSULIN SYRINGE MISC 1ML/31GX5/16" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH QL(5 ea daily) SYRINGE/U- F RX/OTC SHEATHLOCK SAFETY F 100/0.5ML/28G X 1/2" SYRINGE 1ML/30GX1/2" MISC MISC EASY TOUCH INSULIN QL(5 ea daily) ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/U- F SYRINGE/0.3ML/31G X F 100/0.5ML/30G X 1/2" 5/16" MISC MISC ELITE-THIN INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X F RX/OTC SYRINGE/U- F 1/2" MISC 100/0.5ML/31G X 5/16" ELITE-THIN INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X F RX/OTC EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U-100/1ML/27G F RX/OTC ELITE-THIN INSULIN QL(5 ea daily) X 1/2" MISC SYRINGE/1ML/29G X F EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U-100/1ML/28G F RX/OTC ELITE-THIN INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/1ML/30G X F RX/OTC EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U-100/1ML/29G F RX/OTC ELITE-THIN INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/U- F RX/OTC EASY TOUCH INSULIN QL(5 ea daily) 100/0.5ML/28G X 1/2" SYRINGE/U-100/1ML/30G F MISC X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/U- F SYRINGE/U-100/1ML/31G F 100/0.5ML/29G X 5/16" X 5/16" MISC MISC EASY TOUCH PEN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) F NEEDLE 30G X 5/16" RX/OTC SYRINGE/U- F MISC 100/0.5ML/31G X 5/16" MISC EASY TOUCH PEN F QL(5 ea daily); NEEDLES 29GX1/2" MISC RX/OTC ELITE-THIN INSULIN QL(5 ea daily); EASY TOUCH PEN QL(5 ea daily); SYRINGE/U-100/1ML/28G F RX/OTC NEEDLES 32GX3/16" F RX/OTC X 1/2" MISC MISC ELITE-THIN INSULIN QL(5 ea daily) EASY TOUCH QL(5 ea daily); SYRINGE/U-100/1ML/28G F X 5/16" MISC SHEATHLOCK SAFETY F RX/OTC INSULIN SYRINGE ELITE-THIN INSULIN QL(5 ea daily); 1ML/29GX1/2" MISC SYRINGE/U-100/1ML/29G F RX/OTC X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELITE-THIN INSULIN QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily); SYRINGE/U-100/1ML/31G F INSULIN PEN NEEDLES F RX/OTC X 5/16" MISC 29G X 12MM MISC EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/0.3ML/29G X F RX/OTC INSULIN F RX/OTC 1/2" MISC SYRINGE/0.3ML/29G X EQL INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/30G X F RX/OTC EXEL COMFORT POINT QL(5 ea daily); 5/16" MISC INSULIN F RX/OTC EQL INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X SYRINGE/0.3ML/31G X F 5/16" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); EQL INSULIN QL(5 ea daily); INSULIN F RX/OTC SYRINGE/0.5ML/29G X F RX/OTC SYRINGE/0.5ML/28G X 1/2" MISC 1/2" MISC EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC INSULIN F RX/OTC 5/16" MISC SYRINGE/0.5ML/29G X 1/2" MISC EQL INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F EXEL COMFORT POINT QL(5 ea daily); 5/16" MISC INSULIN F RX/OTC SYRINGE/0.5ML/30G X EQL INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/29G X 1/2" F RX/OTC MISC EXEL COMFORT POINT QL(5 ea daily); INSULIN F RX/OTC EQL INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" SYRINGE/1ML/30G X F RX/OTC MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); EQL INSULIN QL(5 ea daily) INSULIN F RX/OTC SYRINGE/1ML/31G X F SYRINGE/1ML/29G X 1/2" 5/16" MISC MISC EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); SYRINGE/U- RX/OTC F INSULIN F RX/OTC 100/0.3ML/29G X 1/2" SYRINGE/1ML/30G X MISC 5/16" MISC EQL INSULIN QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) SYRINGE/U- RX/OTC F COMFORTINSULIN F 100/0.5ML/29G X 1/2" SYRINGE/0.3ML/31G X MISC 5/16" MISC EQL INSULIN QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) SYRINGE/U-100/1ML/29G F RX/OTC COMFORTINSULIN F X 1/2" MISC SYRINGE/0.5ML/31G X EQL ULTRA COMFORT QL(5 ea daily) 5/16" MISC INSULINSYRINGE/0.3ML/ F FIFTY50 SUPERIOR QL(5 ea daily) 31G X 5/16" MISC COMFORTINSULIN F EQL ULTRA COMFORT QL(5 ea daily); SYRINGE/1ML/31G X INSULINSYRINGE/1ML/30 F RX/OTC 5/16" MISC G X 5/16" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREESTYLE PRECISION QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily) INSULIN SYRINGE/U- F RX/OTC INSULIN SYRINGE/U- F 100/0.5ML/30G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC FREESTYLE PRECISION QL(5 ea daily) GLOBAL INJECT EASE QL(5 ea daily); INSULIN SYRINGE/U- F INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/31G X 5/16" 100/0.5ML/30G X 5/16" MISC MISC FREESTYLE PRECISION QL(5 ea daily) GLOBAL INJECT EASE QL(5 ea daily) INSULIN SYRINGE/U- F INSULIN SYRINGE/U- F 100/1ML/31G X 5/16" 100/0.5ML/31G X 5/16" MISC MISC FREESTYLE PRECISION QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); INSULIN SYRINGES/U- F RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/1ML/30G X 5/16" 100/1ML/28G X 1/2" MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC PEN NEEDLES F RX/OTC 100/1ML/29G X 1/2" MISC 29GX12MM MISC GLOBAL INJECT EASE QL(5 ea daily) GLOBAL EASY GLIDE QL(5 ea daily) INSULIN SYRINGE/U- F INSULINSYRINGE/U- F 100/1ML/30G X 1/2" MISC 100/0.3ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC GLOBAL INJECT EASE QL(5 ea daily); 100/1ML/30G X 5/16" INSULIN SYRINGE/U- F RX/OTC MISC 100/0.3ML/29G X 1/2" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- F GLOBAL INJECT EASE QL(5 ea daily) 100/1ML/31G X 5/16" INSULIN SYRINGE/U- F MISC 100/0.3ML/30G X 1/2" GLOBAL INSULIN QL(5 ea daily) MISC SYRINGE/U- F GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 1/2" INSULIN SYRINGE/U- F RX/OTC MISC 100/0.3ML/30G X 5/16" GLOBAL INSULIN QL(5 ea daily); MISC SYRINGES/U- F RX/OTC GLOBAL INJECT EASE QL(5 ea daily) 100/0.3ML/30GX5/16" INSULIN SYRINGE/U- F MISC 100/0.3ML/31G X 5/16" GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U- F GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 1/2" INSULIN SYRINGE/U- F RX/OTC MISC 100/0.5ML/28G X 1/2" GLUCOPRO INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 5/16" INSULIN SYRINGE/U- F RX/OTC MISC 100/0.5ML/29G X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPRO INSULIN QL(5 ea daily) GNP INSULIN QL(5 ea daily); SYRINGE/U- F SYRINGE/1ML/28G X 1/2" F RX/OTC 100/0.3ML/31G X 5/16" MISC MISC GNP INSULIN QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/U- F MISC 100/0.5ML/30G X 1/2" GNP INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X F RX/OTC GLUCOPRO INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- F RX/OTC GNP INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/1ML/31G X F MISC 5/16" MISC GLUCOPRO INSULIN QL(5 ea daily) GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/U- F INSULIN F RX/OTC 100/0.5ML/31G X 5/16" SYRINGE/0.3ML/29G X MISC 1/2" MISC GLUCOPRO INSULIN QL(5 ea daily) GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/U-100/1ML/30G F INSULIN F RX/OTC X 1/2" MISC SYRINGE/0.3ML/30G X GLUCOPRO INSULIN QL(5 ea daily); 5/16" SHORT MISC SYRINGE/U-100/1ML/30G F RX/OTC GNP ULTRA COMFORT QL(5 ea daily) X 5/16" MISC INSULIN F GLUCOPRO INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X SYRINGE/U-100/1ML/31G F 5/16" SHORT MISC X 5/16" MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN F RX/OTC SYRINGE/0.3ML/29G X F RX/OTC SYRINGE/0.5ML/28G X 1/2" MISC 1/2" MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); F SYRINGE/0.3ML/30G X RX/OTC INSULIN F RX/OTC 5/16" MISC SYRINGE/0.5ML/29G X GNP INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/0.3ML/31G X F GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN F RX/OTC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X SYRINGE/0.5ML/28G X F RX/OTC 5/16" SHORT MISC 1/2" MISC GNP ULTRA COMFORT QL(5 ea daily) GNP INSULIN QL(5 ea daily); INSULIN F SYRINGE/0.5ML/29G X F RX/OTC SYRINGE/0.5ML/31G X 1/2" MISC 5/16" SHORT MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC INSULIN F RX/OTC 5/16" MISC SYRINGE/1ML/28G X 1/2" MISC GNP INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN F RX/OTC SYRINGE/1ML/29G X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP ULTRA COMFORT QL(5 ea daily); INSULIN QL(5 ea daily); INSULIN F RX/OTC SYRINGE/1ML/28G X 1/2" F RX/OTC SYRINGE/1ML/30G X MISC 5/16" SHORT MISC INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily) SYRINGE/1ML/29G X 1/2" F RX/OTC INSULIN F MISC SYRINGE/1ML/31G X INSULIN QL(5 ea daily); 5/16" SHORT MISC SYRINGE/1ML/30G X F RX/OTC H-E-B INCONTROL PEN QL(5 ea daily); 5/16" MISC NEEDLES 29GX12MM F RX/OTC INSULIN QL(5 ea daily) MISC SYRINGE/1ML/31G X F HEALTHWISE PEN QL(5 ea daily); 5/16" MISC NEEDLES 29GX12MM F RX/OTC INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/0.3ML/29G X 1/2" F RX/OTC HEALTHY ACCENTS QL(5 ea daily); MISC UNIFINE PENTIPS PEN F RX/OTC INSULIN SYRINGE/U- QL(5 ea daily); NEEDLES 29GX12MM 100/0.5ML/28G X 1/2" F RX/OTC MISC MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.3ML/29G X 1" F 100/0.5ML/29G X 1/2" F RX/OTC MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F QL(5 ea daily); SYRINGE/0.3ML/29G X F RX/OTC 100/1ML/28G X 1/2" MISC RX/OTC 1/2" MISC INSULIN SYRINGE/U- F QL(5 ea daily); INSULIN QL(5 ea daily); 100/1ML/29G X 1/2" MISC RX/OTC SYRINGE/0.3ML/30G X F RX/OTC 5/16" MISC INSULIN SYRINGE/U- QL(5 ea daily); 100/1ML/30G X 5/16" F RX/OTC INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X F 5/16" MISC INSULIN SYRINGE/U- QL(5 ea daily) 100/1ML/31G X 5/16" F INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/27G X F 1/2" MISC INSULIN QL(5 ea daily) SYRINGES/0.5ML/27GX1/ F INSULIN QL(5 ea daily); 2" MISC SYRINGE/0.5ML/28G X F RX/OTC 1/2" MISC INSULIN QL(5 ea daily); SYRINGES/0.5ML/28GX1/ F RX/OTC INSULIN QL(5 ea daily); 2" MISC SYRINGE/0.5ML/29G X F RX/OTC 1/2" MISC INSULIN QL(5 ea daily); SYRINGES/0.5ML/29GX1/ F RX/OTC INSULIN QL(5 ea daily) 2" MISC SYRINGE/0.5ML/30G X F 1/2" MISC INSULIN QL(5 ea daily); SYRINGES/0.5ML/30GX5/ F RX/OTC INSULIN QL(5 ea daily); 16" MISC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC INSULIN QL(5 ea daily) SYRINGES/0.5ML/31GX F INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/0.5ML/31G X F 5/16" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily); SYRINGES/0.5ML/31GX5/ F SYRINGE/0.3ML/29G X F RX/OTC 16" MISC 1/2" MISC INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/27GX/1/2" F RX/OTC SYRINGE/0.3ML/30G X F RX/OTC MISC 5/16" MISC INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily) SYRINGES/1ML/27GX1/2" F RX/OTC SYRINGE/0.3ML/31G X F MISC 5/16" MISC INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/28GX1/2" F RX/OTC SYRINGE/0.5ML/29G X F RX/OTC MISC 1/2" MISC INSULIN QL(5 ea daily); KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/29GX1/2" F RX/OTC SYRINGE/0.5ML/30G X F RX/OTC MISC 5/16" MISC INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily) SYRINGES/1ML/30GX1/2" F SYRINGE/0.5ML/31G X F MISC 5/16" MISC INSULIN QL(5 ea daily) KROGER INSULIN QL(5 ea daily); SYRINGES/1ML/31GX5/16 F SYRINGE/1ML/29G X 1/2" F RX/OTC " MISC MISC INSUPEN 29G X 12MM F QL(5 ea daily); KROGER INSULIN QL(5 ea daily); MISC RX/OTC SYRINGE/1ML/30G X F RX/OTC 5/16" MISC INSUPEN ULTRAFIN F QL(5 ea daily); 29GX12MM MISC RX/OTC KROGER INSULIN QL(5 ea daily) SYRINGE/1ML/31G X F INSUPEN ULTRAFIN F QL(5 ea daily); 30GX8MM MISC RX/OTC 5/16" MISC KINRAY INSULIN QL(5 ea daily) KROGER PEN NEEDLES F QL(5 ea daily); 29G X12MM MISC RX/OTC SYRINGE PREFERRED F PLUS/0.3ML/31G X 5/16" LEADER INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/29G X F RX/OTC KINRAY INSULIN QL(5 ea daily) 1/2" MISC SYRINGE PREFERRED F LEADER INSULIN QL(5 ea daily); PLUS/0.5ML/31G X 5/16" SYRINGE/0.3ML/30G X F RX/OTC MISC 5/16" MISC KINRAY INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily) SYRINGE PREFERRED F SYRINGE/0.3ML/31G X F PLUS/1ML/31G X 5/16" 5/16" MISC MISC LEADER INSULIN QL(5 ea daily); KINRAY INSULIN QL(5 ea daily); SYRINGE/0.5ML/28G X F RX/OTC SYRINGE/0.5ML/29G X F RX/OTC 1/2" MISC 1/2" MISC LEADER INSULIN QL(5 ea daily); KMART VALU PLUS QL(5 ea daily); SYRINGE/0.5ML/29G X F RX/OTC INSULIN F RX/OTC 1/2" MISC SYRINGE/1ML/29G MISC LEADER INSULIN QL(5 ea daily); KMART VALU PLUS QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC INSULIN F RX/OTC 5/16" MISC SYRINGE/1ML/30G MISC Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F SYRINGE/U-100/1ML/31G F 5/16" MISC X 5/16" MISC LEADER INSULIN QL(5 ea daily); LIVE BETTER PEN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" F RX/OTC NEEDLES 29G X 12MM F RX/OTC MISC MISC LEADER INSULIN QL(5 ea daily); LONGS INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/0.5ML/31G X F MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); SYRINGE/1ML/30G X F RX/OTC SAFETY SYRINGE/U- F RX/OTC 5/16" MISC 100/0.3ML/29G X 1/2" LEADER INSULIN QL(5 ea daily) MISC SYRINGE/1ML/31G X F MAGELLAN INSULIN QL(5 ea daily); 5/16" MISC SAFETY SYRINGE/U- F RX/OTC LITETOUCH INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" SYRINGE/0.3ML/29G X F RX/OTC MISC 1/2" MISC MAGELLAN INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SAFETY SYRINGE/U- F RX/OTC SYRINGE/0.3ML/30G X F RX/OTC 100/0.5ML/29G X 1/2" 5/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily) MAGELLAN INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X F SAFETY SYRINGE/U- F RX/OTC 5/16" MISC 100/0.5ML/30G X 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC MAGELLAN INSULIN QL(5 ea daily); 5/16" MISC SAFETY SYRINGE/U- F RX/OTC 100/1ML/29G X 1/2" MISC LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F MAGELLAN INSULIN QL(5 ea daily); 5/16" MISC SAFETY SYRINGE/U- F RX/OTC 100/1ML/30G X 5/16" LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X F RX/OTC 5/16" MISC MARATHON MEDICAL QL(5 ea daily); PENTIPS29GX12MM F RX/OTC LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" MAXI-COMFORT INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC 100/0.5ML/28GX1/2" MISC LITETOUCH INSULIN QL(5 ea daily); MAXI-COMFORT INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" SYRINGE/U- F RX/OTC MISC 100/1ML/28GX1/2" MISC LITETOUCH INSULIN QL(5 ea daily); MEDIC INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G F RX/OTC SYRINGE/0.3ML/30G X F RX/OTC X 1/2" MISC 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); MEDIC INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G F RX/OTC SYRINGE/0.5ML/30G X F RX/OTC X 1/2" MISC 5/16" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDICINE SHOPPE PEN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); NEEDLES 29G X 12MM F RX/OTC SYRINGE/SAFETY/PERM F RX/OTC MISC NEEDLE/0.3ML/29GX1/2" MISC MEIJER PEN NEEDLES F QL(5 ea daily); 29G X12MM MISC RX/OTC MONOJECT INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/SAFETY/PERM F RX/OTC 100/0.3ML/30G X 5/16" F RX/OTC NEEDLE/0.5ML/29G X 1/2" MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); 100/0.3ML/31G X 5/16" F SYRINGE/SAFETY/PERM F RX/OTC MISC NEEDLE/1ML/29G X 1/2" MISC MM INSULIN SYRINGE/U- QL(5 ea daily); 100/1/2ML/30G X 5/16" F RX/OTC MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/SOFTPACK/1M F RX/OTC L/27G X 1/2" MISC MM INSULIN SYRINGE/U- QL(5 ea daily) 100/1/2ML/31G X 5/16" F MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/SOFTPACK/U- F RX/OTC 100/0.5ML/28G X 1/2" MM INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/1ML/30G X 5/16" F RX/OTC MISC MONOJECT INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC MM INSULIN SYRINGE/U- QL(5 ea daily) 100/0.3ML/30G X 5/16" 100/1ML/31G X 5/16" F MISC MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); F SYRINGE/U- F RX/OTC SYRINGE/1ML MISC RX/OTC 100/0.5ML/28G X 1/2" MONOJECT INSULIN QL(5 ea daily) MISC SYRINGE/1ML/31G X F MONOJECT INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- F RX/OTC MONOJECT INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/DETACH F MISC NEEDLE/1ML/25G X 5/8" MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/28G F RX/OTC MONOJECT INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/DETACH F RX/OTC MONOJECT INSULIN QL(5 ea daily); NEEDLE/1ML/27G X 1/2" SYRINGE/U-100/1ML/30G F RX/OTC MISC X 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGE/PERM F RX/OTC SYRINGEREGULAR LUER F RX/OTC NEEDLE/1ML/28G X 1/2" TIP/SOFTPACK/1ML MISC MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN F RX/OTC SYRINGE/PERM F RX/OTC SYRINGE/0.3ML/29G X NEEDLE/U-100/0.5ML/28G 1/2" MISC X 1/2" MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN F RX/OTC SYRINGE/SAFETY/PERM F RX/OTC SYRINGE/0.3ML/30G X NEEDLE/0.3ML/29G X 1/2" 5/16" MISC MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(5 ea daily) MS INSULIN QL(5 ea daily) COMFORT INSULIN F SYRINGE/0.3ML/31G X F SYRINGE/0.3ML/31G X 5/16" MISC 5/16" MISC MS INSULIN QL(5 ea daily) MONOJECT ULTRA QL(5 ea daily); SYRINGE/0.5ML/31G X F COMFORT INSULIN F RX/OTC 5/16" MISC SYRINGE/0.5ML/28G X MS INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/1ML/31G X F MONOJECT ULTRA QL(5 ea daily); 5/16" MISC COMFORT INSULIN RX/OTC F NOVOFINE 30GX8MM F QL(5 ea daily); SYRINGE/0.5ML/29G X MISC RX/OTC 1/2" MISC NOVOFINE AUTOCOVER F QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 30GX8MM MISC RX/OTC COMFORT INSULIN F RX/OTC SYRINGE/0.5ML/30G X NOVOTWIST 30GX8MM F QL(5 ea daily); 5/16" MISC MISC RX/OTC MONOJECT ULTRA QL(5 ea daily) NOVOTWIST 32GX5MM F QL(5 ea daily); MISC RX/OTC COMFORT INSULIN F SYRINGE/0.5ML/31G X PC UNIFINE PENTIPS F QL(5 ea daily); 5/16" MISC 29G X1/2" MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 29G X F QL(5 ea daily); 12MM MISC RX/OTC COMFORT INSULIN F RX/OTC SYRINGE/1ML/28G X 1/2" PEN NEEDLES 29GX1/2" F QL(5 ea daily); MISC MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 30GX5/16" F QL(5 ea daily); COMFORT INSULIN F RX/OTC MISC RX/OTC SYRINGE/1ML/29G X 1/2" PEN NEEDLES 30GX8MM F QL(5 ea daily); MISC MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 32G X F QL(5 ea daily); COMFORT INSULIN F RX/OTC 5MM MISC RX/OTC SYRINGE/1ML/30G X 5/16" MISC PENTIPS 29G X 12MM F QL(5 ea daily); MISC RX/OTC MOORE MED MONOJECT QL(5 ea daily); PENTIPS 29GX12MM QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC F 100/0.5ML/28G X 1/2" MISC RX/OTC MISC PRECISION SURE-DOSE QL(5 ea daily); MOORE MED MONOJECT QL(5 ea daily); INSULIN F RX/OTC SYRINGE/0.3ML/30G X INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" 5/16" MISC MISC PRECISION SURE-DOSE QL(5 ea daily); MOORE MED MONOJECT QL(5 ea daily); INSULIN F RX/OTC INSULIN SYRINGE/U- F RX/OTC SYRINGE/0.5ML/28G X 100/1ML/28G X 1/2" MISC 1/2" MISC MOORE MED MONOJECT QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC INSULIN F RX/OTC 100/1ML/29G X 1/2" MISC SYRINGE/0.5ML/29G X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRECISION SURE-DOSE QL(5 ea daily) PREFERRED PLUS QL(5 ea daily); INSULIN F UNIFINE PENTIPS 29G X F RX/OTC SYRINGE/0.5ML/30G X 12MM MISC 3/8" MISC PRO COMFORT INSULIN QL(5 ea daily) PRECISION SURE-DOSE QL(5 ea daily); SYRINGES/0.5ML/30G X F INSULIN F RX/OTC 1/2" MISC SYRINGE/1ML/28G X 1/2" PRO COMFORT INSULIN QL(5 ea daily); MISC SYRINGES/0.5ML/30G X F RX/OTC PRECISION SURE-DOSE QL(5 ea daily); 5/16" MISC PLUSINSULIN F RX/OTC PRO COMFORT INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X SYRINGES/0.5ML/31G X F 1/2" MISC 5/16" MISC PRECISION SURE-DOSE QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily) PLUSINSULIN F RX/OTC SYRINGES/1ML/30G X F SYRINGE/1ML/29G X 1/2" 1/2" MISC MISC PRO COMFORT INSULIN QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); SYRINGES/1ML/30G X F RX/OTC INSULIN SYRINGE/U- F RX/OTC 5/16" MISC 100/0.3ML/29G X 1/2" MISC PRO COMFORT INSULIN QL(5 ea daily) SYRINGES/1ML/31G X F PREFERRED PLUS QL(5 ea daily); 5/16" MISC INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" PRO COMFORT PEN QL(5 ea daily); MISC NEEDLES/32G X 5MM F RX/OTC MISC PREFERRED PLUS QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily) INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" SYRING/U-100/0.3ML/31G F MISC X 5/16" MISC PREFERRED PLUS QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily) SYRINGE/1/2ML/31G X F INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" 5/16" MISC MISC PRODIGY INSULIN QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); SYRINGE/1ML/28G X 1/2" F RX/OTC MISC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" PX INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/0.3ML/30G X 1/2" F PREFERRED PLUS QL(5 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC PX INSULIN SYRINGE/U- QL(5 ea daily) 100/1ML/28G X 1/2" MISC 100/0.3ML/31G X 5/16" F PREFERRED PLUS QL(5 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC PX INSULIN SYRINGE/U- QL(5 ea daily) 100/1ML/29G X 1/2" MISC 100/0.5ML/30G X 1/2" F PREFERRED PLUS QL(5 ea daily); MISC PX INSULIN SYRINGE/U- QL(5 ea daily) INSULIN SYRINGE/U- F RX/OTC 100/1ML/30G X 5/16" 100/0.5ML/31G X 5/16" F MISC MISC PX INSULIN SYRINGE/U- F QL(5 ea daily) 100/1ML/30G X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PX INSULIN SYRINGE/U- QL(5 ea daily) RELION INSULIN QL(5 ea daily) F 100/1ML/31G X 5/16" SYRINGE/U- F MISC 100/0.3ML/31G X 5/16" MISC PX PEN NEEDLE F QL(5 ea daily); 29GX12MM MISC RX/OTC RELION INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC QC PEN NEEDLES 29G X F QL(5 ea daily); F 12MM MISC RX/OTC 100/0.5ML/29G X 1/2" MISC RA INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X F RX/OTC RELION INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" RA INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" F RX/OTC MISC RELION INSULIN QL(5 ea daily) SYRINGE/U- F RA INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/31G X 5/16" 100/0.5ML/30G X 5/16" F RX/OTC MISC MISC RELION INSULIN QL(5 ea daily); RA INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/U-100/1ML/30G F RX/OTC 100/1 ML/30G X 5/16" F RX/OTC X 5/16" MISC MISC RELION INSULIN REALITY INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G F SYRINGE/U- F RX/OTC X 15/64" MISC 100/0.5ML/28G X 1/2" MISC RELION INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G F REALITY INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" RELION PEN NEEDLES F QL(5 ea daily); MISC 29GX12MM MISC RX/OTC REALITY INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G F RX/OTC SYRINGE/0.3ML/30G X F RX/OTC X 1/2" MISC 5/16" MISC REALITY INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G F RX/OTC SYRINGE/0.5ML/29G X F RX/OTC X 1/2" MISC 1/2" MISC RELION INSULIN SAFESNAP INSULIN QL(5 ea daily); SYRINGE F SYRINGE/0.5ML/30G X F RX/OTC 1ML/31GX15/64" MISC 5/16" MISC RELION INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/U-00/1ML/29G F RX/OTC SYRINGE/1ML/28G X 1/2" F RX/OTC X 1/2" MISC MISC RELION INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" MISC MISC SAFETY INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGES F RX/OTC 0.5ML/29GX1/2" MISC SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" SAFETY INSULIN QL(5 ea daily); MISC SYRINGES F RX/OTC 0.5ML/30GX5/16" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily); F SYRINGES 1ML/27GX1/2" RX/OTC INSULIN SYRINGE/U- F RX/OTC MISC 100/0.3ML/29G X 1/2" SAFETY INSULIN QL(5 ea daily); MISC SYRINGES 1ML/29GX1/2" F RX/OTC SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- F SAFETY INSULIN QL(5 ea daily) 100/0.3ML/30G X 1/2" SYRINGES 1ML/30GX1/2" F MISC MISC SURE COMFORT QL(5 ea daily); SAFETY-GLIDE INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC SYRINGE/0.3ML/29G X F RX/OTC 100/0.3ML/30G X 5/16" 1/2" MISC MISC SB INSULIN SYRINGE/U- QL(5 ea daily); SURE COMFORT QL(5 ea daily) 100/0.5ML/29G X 1/2" F RX/OTC INSULIN SYRINGE/U- F MISC 100/0.3ML/31G X 5/16 MISC SB INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/30G X 5/16" F RX/OTC SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- F 100/0.3ML/31G X 5/16" SB INSULIN SYRINGE/U- F QL(5 ea daily); MISC 100/1ML/29G X 1/2" MISC RX/OTC SURE COMFORT QL(5 ea daily); SB INSULIN SYRINGE/U- QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC 100/1ML/30G X 5/16" F RX/OTC 100/0.5ML/28G X 1/2" MISC MISC SB INSULIN SYRINGE/U- QL(5 ea daily) SURE COMFORT QL(5 ea daily); 100/1ML/31G X 5/16" F INSULIN SYRINGE/U- F RX/OTC MISC 100/0.5ML/29G X 1/2" SCHNUCKS INSULIN QL(5 ea daily); MISC SYRINGEULTI-FINE/U- F RX/OTC SURE COMFORT QL(5 ea daily) 100/0.5ML/29G X 1/2" INSULIN SYRINGE/U- F MISC 100/0.5ML/30G X 1/2" SCHNUCKS INSULIN QL(5 ea daily); MISC SYRINGEULTI-FINE/U- F RX/OTC SURE COMFORT QL(5 ea daily); 100/0.5ML/30G X 5/16" INSULIN SYRINGE/U- F RX/OTC MISC 100/0.5ML/30G X 5/16" SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PEN F RX/OTC SURE COMFORT QL(5 ea daily) NEEDLES/ORIGINAL/29G INSULIN SYRINGE/U- F X12MM MISC 100/0.5ML/31G X 5/16 SHOPKO UNIFINE QL(5 ea daily); MISC PENTIPS PLUS PEN F RX/OTC SURE COMFORT QL(5 ea daily); NEEDLES/REMOVER/29G INSULIN SYRINGE/U- F RX/OTC X12MM MISC 100/1ML/28G X 1/2" MISC SM INSULIN QL(5 ea daily) SURE COMFORT QL(5 ea daily); SYRINGE/1ML/31G X F INSULIN SYRINGE/U- F RX/OTC 5/16" MISC 100/1ML/29G X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F SYRINGE/U-100/1ML/30G F RX/OTC 100/1ML/30G X 1/2" MISC X 5/16" MISC SURE COMFORT QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily) INSULIN SYRINGE/U- F RX/OTC SYRINGE/U-100/1ML/31G F 100/1ML/30G X 5/16" X 5/16" MISC MISC TECHLITE INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily) SYRINGEU- F RX/OTC INSULIN SYRINGE/U- F 100/0.3ML/29G X 1/2" 100/1ML/31G X 5/16" MISC MISC TECHLITE INSULIN QL(5 ea daily) SURE COMFORT PEN QL(5 ea daily); SYRINGEU- F NEEDLES30GX5/16" F RX/OTC 100/0.3ML/30G X 1/2" SHORT MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC F SYRINGEU- F RX/OTC 100/0.3ML/29G X 1/2" 100/0.3ML/30G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- F RX/OTC SYRINGEU- F 100/0.3ML/30G X 5/16" 100/0.3ML/31G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- F SYRINGEU- F RX/OTC 100/0.3ML/31G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- F RX/OTC SYRINGEU- F 100/0.5ML/28G X 1/2" 100/0.5ML/30G X 1/2" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC SYRINGEU- F RX/OTC 100/0.5ML/29G X 1/2" 100/0.5ML/30G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) SYRINGE/U- F RX/OTC SYRINGEU- F 100/0.5ML/30G X 5/16" 100/0.5ML/31G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); SYRINGE/U- F SYRINGEU-100/1ML/29G F RX/OTC 100/0.5ML/31G X 5/16" X 1/2" MISC MISC TECHLITE INSULIN QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G F SYRINGE/U-100/1ML/28G F RX/OTC X 1/2" MISC X 1/2" MISC TECHLITE INSULIN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G F RX/OTC SYRINGE/U-100/1ML/29G F RX/OTC X 5/16" MISC X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE INSULIN TOPCARE ULTRA QL(5 ea daily); F SYRINGEU-100/1ML/31G COMFORT INSULIN F RX/OTC X 15/64" MISC SYRINGE/U-100/1ML/29G TECHLITE INSULIN QL(5 ea daily) X 1/2" MISC SYRINGEU-100/1ML/31G F TOPCO INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" TECHLITE PEN NEEDLES F QL(5 ea daily); 29GX 12 MM MISC RX/OTC MISC TODAYS HEALTH QL(5 ea daily); TOPCO INSULIN QL(5 ea daily); ORIGINAL PEN NEEDLES F RX/OTC SYRINGE/U- F RX/OTC 29G X 1/2" MISC 100/0.5ML/28G X 1/2" MISC TOPCARE ULTRA QL(5 ea daily); TOPCO INSULIN QL(5 ea daily); COMFORT INSULIN F RX/OTC SYRINGE/0.3ML/30G X SYRINGE/U- F RX/OTC 5/16" MISC 100/0.5ML/29G X 1/2" MISC TOPCARE ULTRA QL(5 ea daily) TOPCO INSULIN QL(5 ea daily); COMFORT INSULIN F SYRINGE/0.3ML/31G X SYRINGE/U-100/1ML/28G F RX/OTC 5/16" MISC X 1/2" MISC TOPCARE ULTRA QL(5 ea daily); TOPCO INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G F RX/OTC COMFORT INSULIN F RX/OTC SYRINGE/0.5ML/30G X X 1/2" MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily) SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" COMFORT INSULIN F SYRINGE/0.5ML/31G X MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" COMFORT INSULIN F RX/OTC SYRINGE/1ML/30G X MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily) SYRINGE/U- F 100/0.3ML/31G X 5/16" COMFORT INSULIN F SYRINGE/1ML/31G X MISC 5/16" MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- F RX/OTC COMFORT INSULIN RX/OTC 100/0.5ML/28G X 1/2" SYRINGE/U- F MISC 100/0.3ML/29G X 1/2" TRUEPLUS INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC TOPCARE ULTRA QL(5 ea daily); 100/0.5ML/29G X 1/2" COMFORT INSULIN RX/OTC MISC SYRINGE/U- F TRUEPLUS INSULIN QL(5 ea daily); 100/0.5ML/29G X 1/2" SYRINGE/U- F RX/OTC MISC 100/0.5ML/30G X 5/16" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- F SYRINGE/1ML/28G X 1/2" F RX/OTC 100/0.5ML/31G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/U-100/1ML/28G F RX/OTC MISC X 1/2" MISC ULTICARE INSULIN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1/2" F SYRINGE/U-100/1ML/29G F RX/OTC MISC X 1/2" MISC ULTICARE INSULIN QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/1ML/30G X F RX/OTC SYRINGE/U-100/1ML/30G F RX/OTC 5/16" MISC X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily) SYRINGE/SHORT/0.3ML/3 F RX/OTC SYRINGE/U-100/1ML/31G F 0G X 5/16" MISC X 5/16" MISC ULTICARE INSULIN QL(5 ea daily) TRUEPLUS PEN QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 F NEEDLES 29GX12MM F RX/OTC 1G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 F RX/OTC SAFETY F RX/OTC 0G X 5/16" MISC SYRINGE/0.5ML/29G X ULTICARE INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/SHORT/0.5ML/3 F ULTICARE INSULIN QL(5 ea daily); 1G X 5/16" MISC SAFETY F RX/OTC ULTICARE INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" SYRINGE/SHORT/1ML/30 F RX/OTC MISC G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X F RX/OTC SYRINGE/SHORT/1ML/31 F 1/2" MISC G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X F SYRINGE/U- F RX/OTC 1/2" MISC 100/0.3ML/29G X 1/2" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X F RX/OTC ULTICARE INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U- F ULTICARE INSULIN QL(5 ea daily); 100/0.3ML/30G X 1/2" SYRINGE/0.5ML/28G X F RX/OTC MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC SYRINGE/0.5ML/29G X F RX/OTC 100/0.3ML/30G X 5/16" 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X F SYRINGE/U- F 1/2" MISC 100/0.3ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) SYRINGE/U- F RX/OTC SYRINGE/0.3ML/31G X F 100/0.5ML/29G X 1/2" 8MM MISC MISC ULTILET INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/U- F 8MM MISC 100/0.5ML/30G X 1/2" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X F RX/OTC ULTICARE INSULIN QL(5 ea daily); 8MM MISC SYRINGE/U- F RX/OTC ULTILET INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/1ML/31G X F MISC 8MM MISC ULTICARE INSULIN QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) SYRINGE/U- F SYRINGE/SHORT/0.3ML/3 F 100/0.5ML/31G X 5/16" 0G X 12.7MM MISC MISC ULTILET INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 F RX/OTC SYRINGE/U-100/1ML/29G F RX/OTC 0G X 5/16" MISC X 1/2" MISC ULTILET INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGE/SHORT/0.3ML/3 F SYRINGE/U-100/1ML/30G F 1G X 5/16" MISC X 1/2" MISC ULTILET INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 F RX/OTC SYRINGE/U-100/1ML/30G F RX/OTC 0G X 5/16" MISC X 5/16" MISC ULTILET INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGE/SHORT/0.5ML/3 F SYRINGE/U-100/1ML/31G F 1G X 5/16" MISC X 5/16" MISC ULTILET INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/SHORT/1ML/30 F RX/OTC SYRINGEULTRAFINE U- F G X 5/16" MISC 100/0.3ML/31G X 5/16" MISC ULTILET INSULIN QL(5 ea daily) SYRINGE/SHORT/1ML/31 F ULTICARE INSULIN QL(5 ea daily) G X 5/16" MISC SYRINGEULTRAFINE U- F 100/0.5ML/31G X 5/16" ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/U- F 100/0.5ML/30G X 1/2" ULTICARE INSULIN QL(5 ea daily) MISC SYRINGEULTRAFINE U- F 100/1ML/31G X 5/16" ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/30G F X 1/2" MISC ULTICARE ORIGINAL QL(5 ea daily); PEN NEEDLES ULTI-FINE F RX/OTC ULTRA COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/30G X F RX/OTC 8MM MISC ULTRA-COMFORT QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC SYRINGE SHORT/U- F RX/OTC 100/0.3ML/30G X 5/16" 100/0.5ML/30GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily) INSULIN SYRINGE/U- F SYRINGE SHORT/U- F 100/0.3ML/31G X 5/16" 100/0.5ML/31GX5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC SYRINGE SHORT/U- F RX/OTC 100/0.5ML/28G X 1/2" 100/1ML/30GX5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE SHORT/U- F INSULIN SYRINGE/U- F RX/OTC 100/1ML/31GX5/16" MISC 100/0.5ML/29G X 1/2" ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC ULTRA-COMFORT QL(5 ea daily); 100/0.3ML/29GX1/2" MISC INSULIN SYRINGE/U- F RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/U- F RX/OTC MISC 100/0.5ML/29GX1/2" MISC ULTRA-COMFORT QL(5 ea daily) ULTRA-THIN II INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F SYRINGE/U- F RX/OTC 100/0.5ML/31G X 5/16" 100/1ML/29GX1/2" MISC MISC UNIFINE PENTIPS F QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily); 29GX12MM MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/1ML/28G X 1/2" MISC UNIFINE PENTIPS PLUS F QL(5 ea daily); 29GX12MM MISC RX/OTC ULTRA-COMFORT QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC V-R MONOJECT INSULIN QL(5 ea daily); 100/1ML/29G X 1/2" MISC SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" ULTRA-COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC 100/1ML/30G X 5/16" V-R MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" ULTRA-COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- F 100/1ML/31G X 5/16" V-R MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE SHORT/U- F RX/OTC 100/0.3ML/30GX5/16" V-R MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/28G F RX/OTC X 1/2" MISC ULTRA-THIN II INSULIN QL(5 ea daily) V-R MONOJECT INSULIN QL(5 ea daily); SYRINGE SHORT/U- F 100/0.3ML/31GX5/16" SYRINGE/U-100/1ML/29G F RX/OTC MISC X 1/2" MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VALUE HEALTH INSULIN QL(5 ea daily); AEROCHAMBER MINI RX/OTC SYRINGE/U- F RX/OTC AEROSOLCHAMBER F 100/0.5ML/29G X 1/2" DEVI MISC AEROCHAMBER MV F RX/OTC VALUE HEALTH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G F RX/OTC AEROCHAMBER PLUS F RX/OTC X 1/2" MISC FLOW VU MISC VALUMARK PEN QL(5 ea daily); AEROCHAMBER PLUS F RX/OTC NEEDLES 29GX12MM F RX/OTC FLOW-VU MISC MISC AEROCHAMBER PLUS RX/OTC VANISHPOINT INSULIN QL(5 ea daily) FLOW-VU/LARGE MASK F SYRINGE/0.5ML/30G X F MISC 1/2" MISC AEROCHAMBER PLUS F RX/OTC VANISHPOINT INSULIN QL(5 ea daily); FLOW-VU/MASK MISC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC AEROCHAMBER PLUS RX/OTC FLOW-VU/MEDIUM MASK F VANISHPOINT INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" F RX/OTC MISC AEROCHAMBER PLUS RX/OTC FLOW-VU/SMALL MASK F VANISHPOINT INSULIN QL(5 ea daily) MISC SYRINGE/1ML/29G X F 5/16" MISC AEROCHAMBER Z-STAT RX/OTC PLUS VALVED HOLDING F VANISHPOINT INSULIN QL(5 ea daily); CHAMBER W/FLOW VU SYRINGE/1ML/30G X F RX/OTC MISC 5/16" MISC AEROCHAMBER Z-STAT F RX/OTC VIDA MIA UNIFINE QL(5 ea daily); PLUS/FLOWSIGNAL MISC PENTIPSORIGINAL F RX/OTC 29GX12MM MISC AEROCHAMBER Z-STAT F RX/OTC PLUS/LARGE MASK MISC VP INSULIN SYRINGE/U- QL(5 ea daily); 100/0.3ML/29G X 1/2" F RX/OTC AEROCHAMBER Z-STAT RX/OTC MISC PLUS/MEDIUM MASK F MISC Respiratory Therapy Supplies AEROCHAMBER Z-STAT F RX/OTC ACE AEROSOL CLOUD F RX/OTC PLUS/SMALL MASK MISC ENHANCER MISC AEROCHAMBER/FLOWSI F RX/OTC ACTIVITY POUCH MISC F RX/OTC GNAL MISC RX/OTC ADAPTER PED RX/OTC AEROTRACH PLUS MISC F DISPOSABLE F AEROVENT PLUS RX/OTC MOUTHPIECE MISC HOLDING F ADULT AEROSOL MASK F RX/OTC CHAMBER/COLLAPSIBLE MISC DEVI ADULT DISPOSABLE RX/OTC F AIRS PEDIATRIC F RX/OTC MOUTHPIECE MISC AEROSOL MASK MISC ADULT MASK LARGE F RX/OTC ALL FLOW 1000 RX/OTC MISC PULMONARY FUNCTION F FILTER MISC ADULT MASK MISC F RX/OTC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARIAL CHAMBER DEVI F RX/OTC COMPACT SPACE RX/OTC CHAMBER/ANTI-STATIC F BREATHERITE RX/OTC DEVI COLLAPSIBLEADULT F COMPACT SPACE RX/OTC SPACER W/MASK MISC CHAMBER/ANTI- F BREATHERITE RX/OTC STATIC/LARGE MASK COLLAPSIBLECHILD F DEVI SPACER W/MASK MISC COMPACT SPACE RX/OTC BREATHERITE RX/OTC CHAMBER/ANTI- F COLLAPSIBLEINFANT F STATIC/MEDIUM MASK SPACER W/MASK MISC DEVI BREATHERITE RX/OTC COMPACT SPACE RX/OTC CHAMBER/ANTI- COLLAPSIBLESMALL F F CHILD SPACER W/MASK STATIC/SMALL MASK MISC DEVI BREATHERITE RX/OTC CONE MASK MISC F RX/OTC COLLAPSIBLESPACER F W/ NEONATE MASK MISC DISPOSABLE RX/OTC RX/OTC MOUTHPIECE FULL F BREATHERITE MISC F RANGE MISC DISPOSABLE RX/OTC BREATHERITE RIGID F RX/OTC SPACERW/MASK MISC MOUTHPIECE F LOWRANGE/PEDIATRIC BREATHERITE W/LARGE F RX/OTC MASK MISC MISC DISPOSABLE RX/OTC BREATHERITE F RX/OTC W/MEDIUM MASK MISC MOUTHPIECE/LOW F RANGE MISC BREATHERITE W/SMALL F RX/OTC MASK MISC DISPOSABLE RX/OTC MOUTHPIECE/UNIVERSA F BUBBLES THE FISH II RX/OTC L RANGE MISC PEDIATRIC MASK/PVC F MISC DISPOSABLE PAPER F RX/OTC MOUTHPIECE MISC CLEVER CHOICE ANTI- RX/OTC STATICVALVED E-Z SPACER DEVI F RX/OTC HOLDING F CHAMBER/ADULT LARGE E-Z SPACER THE BODY F RX/OTC DEVI GUARDS PACK DEVI CLEVER CHOICE ANTI- RX/OTC EARLOOP MASK MISC F RX/OTC STATICVALVED F HOLDING EASIVENT MISC F RX/OTC CHAMBER/MEDIUM DEVI CLEVER CHOICE ANTI- RX/OTC EASIVENT/MASK-LARGE F RX/OTC MISC STATICVALVED F HOLDING EASIVENT/MASK- F RX/OTC CHAMBER/SMALL DEVI MEDIUM MISC CO MONITOR RX/OTC EASIVENT/MASK-SMALL F RX/OTC REPLACEMENT TPIECES F MISC MISC EBASE CONTROLLER KIT F RX/OTC MISC Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EFLOW SCF AEROSOL F RX/OTC LITEAIRE DEVI F RX/OTC HEAD MISC LITETOUCH MASK RX/OTC ELITE DC AUTO F RX/OTC F ADAPTER MISC LARGE MISC LITETOUCH MASK RX/OTC EXPIRATORY F RX/OTC F MOUTHPIECE MISC MEDIUM MISC RX/OTC LITETOUCH MASK F RX/OTC FILTER AIR PP MISC F SMALL MISC FLEXICHAMBER DEVI F RX/OTC MICROCHAMBER MISC F RX/OTC

FULL KIT NEBULIZER F RX/OTC MICROELITE FILTER F RX/OTC SET MISC REPLACEMENTS MISC HEALTHY LIVING RX/OTC MICROELITE RX/OTC REPLACEMENT FILTERS F RECHARGEABLE F MISC BATTERY MISC HEALTHY LIVING RX/OTC MICROSPACER MISC F RX/OTC REPLACEMENT KIT FOR F NEBULIZER MISC MINIELITE FILTER F RX/OTC HEALTHY LIVING RX/OTC REPLACEMENTS MISC REPLACEMENT MASKS F MINIELITE RX/OTC MISC RECHARGEABLE F HUDSON RCI SEE-THRU RX/OTC BATTERY MISC AEROSOL MASK F NEBULIZER AIR F RX/OTC ELONGATED/ADULT TUBE/PLUGS MISC MISC NEBULIZER PEDIATRIC F RX/OTC INNOSPIRE RX/OTC MASK MISC REPLACEMENT FILTER F RX/OTC MISC NOSE CLIP MISC F INSPIRACHAMBER/ANTI- RX/OTC ONE FLOW TESTER RX/OTC STATIC F TUBE MOUTHPIECE F VALVED/MOUTHPIECE MISC DEVI ONE-WAY VALVED RX/OTC INSPIRACHAMBER/LARG F RX/OTC EXPIRATORYMOUTHPIE F E DEVI CE/DISPOSABLE MISC INSPIRACHAMBER/SOOT RX/OTC ONE-WAY VALVED RX/OTC HERMASK/INSPIRAMASK F INSPIRATORY F /MEDIUM DEVI MOUTHPIECE/DISPOSAB INSPIRACHAMBER/SOOT RX/OTC LE MISC HERMASK/INSPIRAMASK F OPTICHAMBER RX/OTC /SMALL DEVI ADVANTAGE/LARGE F MASK MISC INSPIREASE DRUG F RX/OTC DELIVERYSYSTEM MISC OPTICHAMBER RX/OTC ADVANTAGE/MEDIUM F INSPIREASE RESERVOIR F BAGS MISC FACE MASK MISC KOKO PEAK PRO RX/OTC OPTICHAMBER RX/OTC REPLACEMENTPLASTIC F ADVANTAGE/SMALL F MOUTHPIECE MISC FACE MASK MISC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPTICHAMBER F RX/OTC PFLEX MISC F RX/OTC DIAMOND MISC OPTICHAMBER RX/OTC PILLOW MASK/ADULT F RX/OTC DIAMOND/LARGEFACE F MISC MASK DEVI PILLOW MASK/CHILD F RX/OTC OPTICHAMBER RX/OTC MISC DIAMOND/MEDIUM FACE F PILLOW F RX/OTC MASK MISC MASK/PEDIATRIC MISC OPTICHAMBER RX/OTC POCKET CHAMBER DEVI F RX/OTC DIAMOND/SMALLFACE F MASK MISC POCKET SPACER DEVI F RX/OTC OPTICHAMBER FACE F RX/OTC MASK/LARGE MISC REPLACEMENT AIR F RX/OTC FILTER MISC OPTICHAMBER FACE F RX/OTC MASK/MEDIUM MISC REPLACEMENT FILTERS F RX/OTC MISC OPTICHAMBER FACE F RX/OTC MASK/SMALL MISC RITEFLO DEVI F RX/OTC OPTIHALER MDI DRUG F RX/OTC DELIVERY SYSTEM DEVI SAMI THE SEAL RX/OTC RX/OTC REPLACEMENTFILTERS F OPTIHALER MISC F MISC PARI ALTERA RX/OTC SIDESTREAM ADULT F RX/OTC NEBULIZER HANDSET F FACE MASK MISC MISC SIDESTREAM PEDIATRIC F RX/OTC FACEMASK MISC PARI BABY CONVERSION F RX/OTC KITSIZE 1 MISC SIDESTREAM PEDIATRIC RX/OTC FACEMASK/SAMI THE F PARI BABY CONVERSION F RX/OTC KITSIZE 2 MISC SEAL MISC SIDESTREAM PEDIATRIC RX/OTC PARI BABY CONVERSION F RX/OTC KITSIZE 3 MISC FACEMASK/TUCKER THE F TURTLE MISC PARI ERAPID NEBULIZER F RX/OTC HANDSET MISC SIDESTREAM PLUS F RX/OTC ADULT FACE MASK MISC PARI EXPIRATORY F RX/OTC FILTER VALVE SET DEVI SILICONE MASK FOR RX/OTC BREATHERITE F PARI MASK SET MISC F RX/OTC CHAMBER/ADULT MISC SILICONE MASK FOR RX/OTC PARI SOFT PLASTIC F RX/OTC ADULT MASK MISC BREATHERITE F CHAMBER/INFANT MISC PARI SOFT PLASTIC F RX/OTC PEDIATRIC MASK MISC SILICONE MASK FOR RX/OTC BREATHERITE F PEDIATRIC AEROSOL F RX/OTC CHAMBER/PEDIATRIC MASK MISC MISC PEDIATRIC DISPOSABLE F RX/OTC SILICONE MASK FOR RX/OTC MOUTPIECE MISC BREATHRITE F PEDIATRIC RX/OTC CHAMBER/ADULT MISC MOUTHPIECE/DISPOSAB F LE MISC Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOOTHENEB NBL 100 F RX/OTC IMITREX SOLN (Use NF AL; At least 12 CHILD MASK MISC Sumatriptan) yrs old SOOTHENEB NBL 100 F RX/OTC IMITREX STATDOSE AL; At least 12 MEDICATION CUP MISC REFILL SOCT 6 MG/0.5ML NF yrs old (Use Sumatriptan SOOTHENEB NBL 100 F RX/OTC MESH CAP MISC Succinate) IMITREX STATDOSE AL; At least 12 SOOTHENEB NBL100 F RX/OTC ADULT MASK MISC SYSTEM SOAJ 6 NF yrs old MG/0.5ML (Use THRESHOLD IMT MISC F RX/OTC Sumatriptan Succinate) RX/OTC IMITREX TABS (Use NF AL; At least 12 TUBING/WING TIP MISC F Sumatriptan Succinate) yrs old MAXALT TABS (Use AL; At least 6 VALVED HOLDING F RX/OTC NF CHAMBER DEVI Rizatriptan Benzoate) yrs old AL; At least 18 VORTEX VALVED RX/OTC naratriptan hcl tabs F HOLDING CHAMBER F yrs old DEVI RELPAX TABS (Use NF Eletriptan Hydrobromide) WATCHHALER DEVI F RX/OTC rizatriptan benzoate tabs 5 F AL; At least 6 WINDMILL TRAINER F RX/OTC mg, 10 mg yrs old MISC F AL; At least 12 sumatriptan soln yrs old MIGRAINE PRODUCTS sumatriptan succinate soaj F AL; At least 12 Migraine Combinations sc 6 mg/0.5ml yrs old sumatriptan succinate soct AL; At least 12 CAFERGOT TABS (Use NF F Ergotamine w/ Caffeine) sc 6 mg/0.5ml yrs old ergotamine w/ caffeine tabs F sumatriptan succinate soln F AL; At least 12 sc 6 mg/0.5ml yrs old Migraine Products SUMATRIPTAN AL; At least 12 D.H.E. 45 SOLN (Use SUCCINATE SOSY SC 6 F yrs old Dihydroergotamine NF MG/0.5ML Mesylate) sumatriptan succinate tabs F AL; At least 12 or 25 mg, 50 mg, 100 mg yrs old dihydroergotamine F mesylate soln ij 1 mg/ml zolmitriptan tabs F DIHYDROERGOTAMINE MESYLATE SOLN NA 4 F zolmitriptan tbdp F MG/ML F AL; At least 12 MIGRANAL SOLN F ZOMIG SOLN NA 5 MG yrs old Serotonin Agonists ZOMIG TABS OR 5 MG, NF 2.5 MG (Use Zolmitriptan) AMERGE TABS (Use NF AL; At least 18 Naratriptan HCl) yrs old ZOMIG ZMT TBDP (Use NF Zolmitriptan) eletriptan hydrobromide F tabs MINERALS & ELECTROLYTES IMITREX SOLN (Use NF AL; At least 12 Sumatriptan Succinate) yrs old Electrolyte Mixtures

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CERASPORT EX1 SOLN F K-TAB TBCR 8 MEQ F

CERASPORT SOLN KLOR-CON M15 TBCR F 4MEQ/L-18MEQ/L- F 20MEQ/L-6MEQ/L KLOR-CON/25 PACK F ENFAMIL ENFALYTE F SOLN MICRO-K CPCR 10 MEQ NF (Use Potassium Chloride) oral electrolytes soln F MICRO-K CPCR 8 MEQ NF QL(1 ea daily) PEDIALYTE FREEZER (Use Potassium Chloride) POPS SOLN (Use Oral NF potassium bicarbonate tbef F Electrolytes) PEDIALYTE SOLN potassium chloride cpcr or F 20MEQ/L-45MEQ/L- 10 meq 35MEQ/L-5GM/L-20GM/L, potassium chloride cpcr or F QL(1 ea daily) 20MEQ/L-45MEQ/L- NF 8 meq 35MEQ/L-30MEQ/L- POTASSIUM CHLORIDE F 25GM/L (Use Oral ER TBCR 8 MEQ Electrolytes) potassium chloride Fluoride microencapsulated crystals F er tbcr LURIDE SOLN (Use NF Sodium Fluoride) potassium chloride pack or F sodium fluoride chew 0.25 20 meq mg, 0.5 mg, 1 mg, 1.1 mg, F potassium chloride soln or F 2.2 mg 10 %, 20 % sodium fluoride soln 0.125 F POTASSIUM CHLORIDE F mg/drop, 0.5 mg/ml SOLN OR 20 % Magnesium potassium chloride tbcr or 8 F meq, 10 meq magnesium oxide (mg F supplement) tabs 241.3 mg MISCELLANEOUS THERAPEUTIC CLASSES MAGOX 400 TABS (Use Magnesium Oxide (Mg NF Chelating Agents Supplement)) DEPEN TITRATABS TABS F Phosphate K-PHOS NEUTRAL TABS QL(8 ea daily) Immunosuppressive Agents (Use Pot Phosphate QL(3 ea daily) Monobasic w/ Sod NF AZASAN TABS F Phosphate Dibasic & Monobasic) azathioprine tabs or 50 mg F pot phosphate monobasic QL(8 ea daily) CELLCEPT CAPS 250 MG QL(2 ea daily); w/ sod phosphate dibasic & F (Use Mycophenolate NF SP monobasic tabs Mofetil) Potassium CELLCEPT SUSR 200 QL(15 ml MG/ML (Use NF daily); SP K-TAB TBCR 10 MEQ (Use NF ) Potassium Chloride) Mycophenolate Mofetil

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELLCEPT TABS 500 MG QL(4 ea daily); RAPAMUNE TABS 0.5 SP (Use Mycophenolate NF SP MG, 1 MG, 2 MG (Use NF Mofetil) Sirolimus) cyclosporine caps or 25 F SP SANDIMMUNE CAPS OR SP mg, 100 mg 25 MG, 100 MG (Use NF cyclosporine modified (for QL(4 ea daily); Cyclosporine) F microemulsion) caps 25 SP SANDIMMUNE SOLN OR F SP mg, 50 mg, 100 mg 100 MG/ML cyclosporine modified (for QL(8 ml daily); sirolimus tabs F SP microemulsion) soln 100 F SP mg/ml QL(3 ea daily); tacrolimus caps F CYCLOSPORINE QL(4 ea daily); SP MODIFIED CAPS (Use NF SP Potassium Removing Agents Cyclosporine Modified (For Microemulsion)) KAYEXALATE POWD (Use QL(454 gm per Sodium Polystyrene NF fill retail) IMURAN TABS (Use NF Sulfonate) Azathioprine) sodium polystyrene F QL(454 gm per mycophenolate mofetil F QL(2 ea daily); sulfonate powd or fill retail) caps 250 mg SP sodium polystyrene mycophenolate mofetil susr F QL(15 ml sulfonate susp or 15 F 200 mg/ml daily); SP gm/60ml mycophenolate mofetil tabs F QL(4 ea daily); 500 mg SP MOUTH/THROAT/DENTAL AGENTS mycophenolate sodium F QL(2 ea daily); Anesthetics Topical Oral tbec 180 mg SP lidocaine hcl (mouth-throat) F QL(100 ml per mycophenolate sodium F QL(4 ea daily); soln fill retail) tbec 360 mg SP MYFORTIC TBEC 180 MG QL(2 ea daily); Anti-infectives - Throat (Use Mycophenolate NF SP nystatin (mouth-throat) F QL(120 ml per Sodium) susp fill retail) MYFORTIC TBEC 360 MG QL(4 ea daily); Antiseptics - Mouth/Throat (Use Mycophenolate NF SP chlorhexidine gluconate F Sodium) (mouth-throat) soln NEORAL CAPS 25 MG, QL(4 ea daily); PERIDEX SOLN (Use 100 MG (Use Cyclosporine NF SP Chlorhexidine Gluconate NF Modified (For (Mouth-Throat)) Microemulsion)) NEORAL SOLN 100 QL(8 ml daily); Dental Products GEL-KAM ORAL CARE RX/OTC MG/ML (Use Cyclosporine NF SP Modified (For RINSE CONC (Use NF Microemulsion)) Stannous Fluoride) PROGRAF CAPS OR 0.5 QL(3 ea daily); PREVIDENT 5000 DRY QL(672 ml per MG, 1 MG, 5 MG (Use NF SP MOUTH GEL (Use Sodium NF fill retail) Tacrolimus) Fluoride (Dental)) PREVIDENT 5000 PLUS QL(102 gm per RAPAMUNE SOLN 1 F SP MG/ML CREA (Use Sodium NF fill retail) Fluoride (Dental))

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREVIDENT FLUORIDE QL(672 ml per NEPHRO-VITE RX TABS QL(1 ea daily) GEL (Use Sodium Fluoride NF fill retail) 1.5MG-10MG-20MG- (Dental)) 1.7MG-6MCG-1MG- NF 300MCG-10MG-60MG PREVIDENT SOLN (Use NF Sodium Fluoride (Dental)) (Use B-Complex w/ C & Folic Acid) sodium fluoride (dental) F QL(102 gm per crea dt 1.1 % fill retail) NEPHROCAPS CAPS QL(1 ea daily); (Use B-Complex w/ C & NF RX/OTC sodium fluoride (dental) gel F QL(672 ml per Folic Acid) dt 1.1 % fill retail) Multiple Vitamins w/ Minerals sodium fluoride (dental) F soln mt 0.2 % ADVANCED DIABETIC QL(1 ea daily); MULTIVITAMIN FORMULA F RX/OTC stannous fluoride conc mt F RX/OTC 0.63 % TABS QL(1 ea daily); THERA-FLUR-N GEL (Use NF QL(672 ml per ALIVE ENERGY 50+ TABS F Sodium Fluoride (Dental)) fill retail) RX/OTC ALIVE MENS ENERGY F QL(1 ea daily); Steroids - Mouth/Throat TABS RX/OTC triamcinolone acetonide F QL(5 gm per fill ALIVE ONCE DAILY QL(1 ea daily); (mouth) pste retail) WOMENS 50+ ULTRA F RX/OTC Throat Products - Misc. POTENCY TABS ALIVE ONCE DAILY QL(1 ea daily); pilocarpine hcl (oral) tabs 5 F QL(6 ea daily) mg WOMENS ULTRA F RX/OTC SALAGEN TABS 5 MG QL(6 ea daily) POTENCY TABS (Use Pilocarpine HCl NF ALIVE WOMENS 50+ F QL(1 ea daily); (Oral)) TABS RX/OTC ALIVE WOMENS ENERGY F QL(1 ea daily); MULTIVITAMINS TABS RX/OTC B-Complex w/ Folic Acid ANTIOXIDANT FORTE F QL(1 ea daily); b-complex w/ c & folic acid QL(1 ea daily); TABS RX/OTC caps 1.5mg-5mg-20mg- RX/OTC F QL(1 ea daily); AP-ZEL TABS RX/OTC 1.7mg-6mcg-1mg-150mcg- F 10mg-100mg, 5mg-1.7mg- F QL(1 ea daily); 6mcg-20mg-1.5mg-1mg- BACMIN TABS RX/OTC 150mcg-10mg-100mg F QL(1 ea daily); b-complex w/ c & folic acid QL(1 ea daily) BASIC AM TABS RX/OTC tabs 1.5mg-10mg-20mg- F QL(1 ea daily); 1.7mg-6mcg-1mg-300mcg- BASIC PM TABS RX/OTC 10mg-60mg, 1.5mg-1.7mg- 10mg-0.01mcg-20mg-1mg- F CAL-DAY 1000 TABS F QL(1 ea daily); 300mcg-10mg-60mg, RX/OTC 20mg-1.7mg-10mg- CENTRAVITES 50 PLUS F QL(1 ea daily); 0.006mg-1.5mg-1mg- TABS RX/OTC 0.3mg-10mg-100mg CENTRAVITES ADULTS F QL(1 ea daily); TABS RX/OTC CENTRUM ADULTS TABS QL(1 ea daily); (Use Multiple Vitamins w/ NF RX/OTC Minerals)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTRUM CARDIO TABS F QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); RX/OTC ULTRA WOMENS F RX/OTC HEALTH SENIOR TABS CENTRUM MEN TABS F QL(1 ea daily); RX/OTC CVS SPECTRAVITE QL(1 ea daily); ULTRA WOMENS F RX/OTC CENTRUM SILVER F QL(1 ea daily); ULTRA MENS TABS RX/OTC HEALTH TABS QL(1 ea daily); CENTRUM SILVER F QL(1 ea daily); DERMAVITE TABS F ULTRA WOMENS TABS RX/OTC RX/OTC EQ COMPLETE QL(1 ea daily); CENTRUM SPECIALIST F QL(1 ea daily); HEART TABS RX/OTC MULTIVITAMINADULTS F RX/OTC UNDER 50 TABS CENTRUM SPECIALIST F QL(1 ea daily); IMMUNE SUPPORT TABS RX/OTC EQ ONE DAILY MENS 50+ F QL(1 ea daily); TABS RX/OTC CENTRUM SPECIALIST F QL(1 ea daily); VISION TABS RX/OTC EQ ONE DAILY MENS F QL(1 ea daily); HEALTH TABS RX/OTC CENTRUM ULTRA F QL(1 ea daily); WOMENS TABS RX/OTC EQ ONE DAILY WOMENS F QL(1 ea daily); 50+ TABS RX/OTC CERTAVITE QL(1 ea daily); SENIOR/ANTIOXIDANT F RX/OTC EQ ONE DAILY WOMENS F QL(1 ea daily); NUTRIENTS TABS HEALTH TABS RX/OTC EQL CENTURY MATURE QL(1 ea daily); CLINICAL NUTRIENTS 45- F QL(1 ea daily); F PLUS WOMEN TABS RX/OTC ADULTS50+ TABS RX/OTC EQL CENTURY MENS QL(1 ea daily); CLINICAL NUTRIENTS 50- F QL(1 ea daily); F PLUS MEN TABS RX/OTC TABS RX/OTC CLINICAL NUTRIENTS QL(1 ea daily); EQL CENTURY WOMENS F QL(1 ea daily); FOR FEMALE TEENS F RX/OTC TABS RX/OTC TABS EQL MEGA SELECT F QL(1 ea daily); MENS TABS RX/OTC CLINICAL NUTRIENTS F QL(1 ea daily); FOR MALE TEENS TABS RX/OTC EQL MEGA SELECT F QL(1 ea daily); WOMENS TABS RX/OTC CLINICAL NUTRIENTS F QL(1 ea daily); FOR MEN TABS RX/OTC EQL ONE DAILY DIET F QL(1 ea daily); SUPPORT TABS RX/OTC CLINICAL NUTRIENTS F QL(1 ea daily); FOR WOMEN TABS RX/OTC EQL ONE DAILY MENS F QL(1 ea daily); 50+ ADVANCED TABS RX/OTC CVS ONE DAILY MENS F QL(1 ea daily); 50+ ADVANCED TABS RX/OTC EQL ONE DAILY MENS F QL(1 ea daily); TABS RX/OTC CVS SPECTRAVITE F QL(1 ea daily); ADULT 50+ TABS RX/OTC FITNESS TABS FOR MEN F QL(1 ea daily); AM/PM/LYCOPENE TABS RX/OTC CVS SPECTRAVITE F QL(1 ea daily); ULTRA MEN50+ TABS RX/OTC FITNESS TABS FOR QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); WOMEN F RX/OTC ULTRA MENS HEALTH F RX/OTC AM/PM/LYCOPENE TABS SENIOR TABS FREEDAVITE TABS F QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); RX/OTC F ULTRA MENS HEALTH RX/OTC GERI-FREEDA SENIOR F QL(1 ea daily); TABS FORMULA TABS RX/OTC CVS SPECTRAVITE F QL(1 ea daily); F QL(1 ea daily); ULTRA WOMEN TABS RX/OTC HAIR-VITES TABS RX/OTC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(1 ea daily); multiple vitamins w/ F QL(1 ea daily); HAIR//NAILS TABS RX/OTC minerals tabs RX/OTC HM COMPLETE 50+ F QL(1 ea daily); MULTIVITAL PLATINUM F QL(1 ea daily); MENS ULTIMATE TABS RX/OTC TABS RX/OTC HM COMPLETE 50+ QL(1 ea daily); MULTIVITAMIN ADULTS F QL(1 ea daily); WOMENS ULTIMATE F RX/OTC TABS RX/OTC TABS MULTIVITAMIN MEN F QL(1 ea daily); F QL(1 ea daily); TABS RX/OTC HM COMPLETE TABS RX/OTC NAT-RUL THERAVITE- F QL(1 ea daily); HM HAIR/SKIN/NAILS F QL(1 ea daily); M/HIGHPOTENCY TABS RX/OTC TABS RX/OTC NATRUL-MEGA-75 TABS F QL(1 ea daily); HM ONE DAILY MENS F QL(1 ea daily); RX/OTC TABS RX/OTC NATRUL-VITES TABS F QL(1 ea daily); HM ONE DAILY WOMENS F QL(1 ea daily); RX/OTC TABS RX/OTC NICADAN TABS F QL(1 ea daily); F QL(1 ea daily); RX/OTC HYALEX TABS RX/OTC NICADAN ZX TABS F QL(1 ea daily); ICAPS AREDS FORMULA F QL(1 ea daily); RX/OTC TABS RX/OTC NICAZEL FORTE TABS F QL(1 ea daily); F QL(1 ea daily); RX/OTC ICAPS PLUS TABS RX/OTC NICAZEL TABS F QL(1 ea daily); K-PAX IMMUNE QL(1 ea daily); RX/OTC SUPPORT FORMULA F RX/OTC NO IRON MULTIPLE QL(1 ea daily); PROFESSIONAL VITAMIN/MINERALS F RX/OTC STRENGTH TABS TABS MACULAR VITAMIN QL(1 ea daily); F F QL(1 ea daily); BENEFIT TABS RX/OTC NUTRICAP TABS RX/OTC MEGA MULTIVITAMIN QL(1 ea daily); F F QL(1 ea daily); FOR MEN TABS RX/OTC ONCOVITE TABS RX/OTC MEGA MULTIVITAMIN F QL(1 ea daily); ONE DAILY MENS QL(1 ea daily); FOR WOMEN TABS RX/OTC FORMULA W/O IRON F RX/OTC MEGAVITE FRUITS & F QL(1 ea daily); TABS VEGGIES TABS RX/OTC ONE DAILY PLUS IRON F QL(1 ea daily); MEGAVITE GOLDEN F QL(1 ea daily); TABS RX/OTC YEARS 55+ TABS RX/OTC ONE-A-DAY ENERGY F QL(1 ea daily); MENS 50+ MULTI QL(1 ea daily); TABS RX/OTC VITAMIN &MINERAL F RX/OTC ONE-A-DAY MENOPAUSE F QL(1 ea daily); FORMULA TABS FORMULA TABS RX/OTC MENS MULTI VITAMIN & QL(1 ea daily); ONE-A-DAY MENS 50+ F QL(1 ea daily); MINERAL FORMULA F RX/OTC ADVANTAGE TABS RX/OTC TABS ONE-A-DAY MENS F QL(1 ea daily); MULTI-BETIC DIABETES F QL(1 ea daily); HEALTH FORMULA TABS RX/OTC TABS RX/OTC ONE-A-DAY MENS PRO F QL(1 ea daily); MULTI-VITAMIN F QL(1 ea daily); EDGE TABS RX/OTC MONOCAPS TABS RX/OTC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONE-A-DAY TEEN QL(1 ea daily); SM ONE DAILY MENS F QL(1 ea daily); ADVANTAGEFOR HIM F RX/OTC TABS RX/OTC TABS SM ONE DAILY WOMENS F QL(1 ea daily); F QL(1 ea daily); TABS RX/OTC OPTI-WOMAN TABS RX/OTC SOLO TABS F QL(1 ea daily); F QL(1 ea daily); RX/OTC OPURITY TABS RX/OTC STROVITE ONE TABS F QL(1 ea daily); PARVLEX TABS F QL(1 ea daily); RX/OTC RX/OTC QL(1 ea daily); SUPERB NAILS TABS F F QL(1 ea daily); RX/OTC PHYTOMULTI TABS RX/OTC T-VITES TABS F QL(1 ea daily); PRESERVISION AREDS F QL(1 ea daily); RX/OTC TABS RX/OTC THERA M PLUS TABS F QL(1 ea daily); F QL(1 ea daily); RX/OTC PRO-CAL TABS RX/OTC THERA-M TABS F QL(1 ea daily); F QL(1 ea daily); RX/OTC PROCERV HP TABS RX/OTC THERA-TABS M TABS F QL(1 ea daily); F QL(1 ea daily); RX/OTC PRORENAL+D TABS RX/OTC THERABETIC MULTI- F QL(1 ea daily); PROVIT TABS F QL(1 ea daily); VITAMIN TABS RX/OTC RX/OTC THERAGRAN-M QL(1 ea daily); F QUENCH TABS F QL(1 ea daily); ADVANCED 50 PLUS RX/OTC RX/OTC TABS QUIN B STRONG TABS F QL(1 ea daily); THERAGRAN-M F QL(1 ea daily); RX/OTC ADVANCED TABS RX/OTC QUINTABS-M TABS F QL(1 ea daily); THERAGRAN-M PREMIER F QL(1 ea daily); RX/OTC 50 PLUS TABS RX/OTC RA CENTRAL-VITE TABS F QL(1 ea daily); THERAGRAN-M PREMIER F QL(1 ea daily); RX/OTC TABS RX/OTC RA CENTRAL-VITE F QL(1 ea daily); F QL(1 ea daily); UNDER 50MENS TABS RX/OTC THERAGRAN-M TABS RX/OTC RA CENTRAL-VITE QL(1 ea daily); F QL(1 ea daily); UNDER 50WOMENS F RX/OTC THEREMS-H TABS RX/OTC TABS THEREMS-M TABS F QL(1 ea daily); F QL(1 ea daily); RX/OTC RENAPLEX-D TABS RX/OTC UNICOMPLEX-M TABS F QL(1 ea daily); F QL(1 ea daily); RX/OTC REQ 49+ TABS RX/OTC VITALINE TOTAL F QL(1 ea daily); F QL(1 ea daily); FORMULA 2 TABS RX/OTC SENTRY SENIOR TABS RX/OTC VITALINE TOTAL F QL(1 ea daily); SENTRY SENIOR/LUTEIN F QL(1 ea daily); FORMULA 3 TABS RX/OTC TABS RX/OTC VITAMIN D3 COMPLETE F QL(1 ea daily); F QL(1 ea daily); TABS RX/OTC SENTRY TABS RX/OTC VITASANA TABS F QL(1 ea daily); F QL(1 ea daily); RX/OTC SIDEROL TABS RX/OTC

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(1 ea daily); pediatric multivitamins w/fl QL(1 ea daily); VITATRUM TABS RX/OTC chew 0.25mg-15unit- AL; Up to 13 1.2mg-2500unit-4.5mcg- yrs old VITRUM 50+ SENIOR F QL(1 ea daily); MULTI TABS RX/OTC 400unit-1.05mg-13.5mg- 1.05mg-0.3mg-60mg, VP-ZEL TABS F QL(1 ea daily); 0.25mg-15unit-400unit- RX/OTC 2500unit-1.2mg-4.5mcg- WHOLE FOOD F QL(1 ea daily); 13.5mg-1.05mg-0.3mg- MULTIVITAMIN TABS RX/OTC 1.05mg-60mg, 0.5mg- WOMENS 50+ MULTI QL(1 ea daily); 15unit-1.2mg-2500unit- VITAMIN& MINERAL F RX/OTC 4.5mcg-400unit-1.05mg- FORMULA TABS 13.5mg-1.05mg-0.3mg- 60mg, 0.5mg-15unit- WOMENS BIOMULTIPLE F QL(1 ea daily); TABS RX/OTC 400unit-2500unit-1.2mg- 4.5mcg-13.5mg-1.05mg- WOMENS MULTI VITAMIN QL(1 ea daily); 0.3mg-1.05mg-60mg, & MINERAL FORMULA F RX/OTC 0.5mg-2500unit-13.5mg- TABS 1.2mg-4.5mcg-400unit- YELETS TEENAGE F QL(1 ea daily); 1.05mg-0.3mg-15unit- FORMULA TABS RX/OTC 1.05mg-60mg, 15unit-1mg- Ped MV w/ Fluoride 2500unit-13.5mg-1.2mg- F 4.5mcg-400unit-1.05mg- QL(50 ml per 0.3mg-1.05mg-60mg, 1mg- FLORIVA PLUS SOLN F fill retail); AL; 15unit-1.2mg-2500unit- Up to 13 yrs old 4.5mcg-400unit-1.05mg- ; RX/OTC 13.5mg-1.05mg-0.3mg- QL(1 ea daily); 60mg, 1mg-15unit-400unit- MULTIVITAMIN/FLUORID F E CHEW AL; Up to 13 2500unit-1.2mg-4.5mcg- yrs old 13.5mg-1.05mg-0.3mg- 1.05mg-60mg, 15unit- 0.5mg-1.05mg-13.5mg- 1.2mg-2500unit-4.5mcg- 400unit-0.3mg-1.05mg- 60mg, 15unit-0.5mg- 2500unit-13.5mg-1.2mg- 4.5mcg-400unit-1.05mg- 0.3mg-1.05mg-60mg, 15unit-0.25mg-2500unit- 13.5mg-1.2mg-4.5mcg- 400unit-1.05mg-0.3mg- 1.05mg-60mg

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pediatric multivitamins w/fl QL(50 ml per QUFLORA PEDIATRIC QL(1 ea daily); soln 0.25mg/ml-0.6mg/ml- fill retail); AL; CHEW 108MCG-1MG- AL; Up to 13 8mg/ml-1500unit/ml- Up to 13 yrs old 15UNIT-1MG-15MG- yrs old 2mcg/ml-400unit/ml- ; RX/OTC 1200UNIT-5MG-1.3MG- 0.5mg/ml-5unit/ml- 4MCG-400UNIT-1.2MG- 0.4mg/ml-35mg/ml, 100MCG-1.5MG-60MG, 0.25mg/ml-5unit/ml- 108MCG-1MG-15UNIT- 0.6mg/ml-8mg/ml- 0.5MG-15MG-1200UNIT- F 1500unit/ml-2mcg/ml- 5MG-1.3MG-4MCG- 400unit/ml-0.5mg/ml- 400UNIT-1.2MG-100MCG- 0.4mg/ml-35mg/ml, F 1.5MG-60MG, 108MCG- 0.25mg/ml-5unit/ml- 1MG-15UNIT-0.25MG- 8mg/ml-0.6mg/ml- 15MG-1200UNIT-5MG- 1500unit/ml-2mcg/ml- 1.3MG-4MCG-400UNIT- 400unit/ml-0.5mg/ml- 1.2MG-100MCG-1.5MG- 0.4mg/ml-35mg/ml, 60MG 5unit/ml-0.25mg/ml- QUFLORA PEDIATRIC QL(50 ml per 0.6mg/ml-8mg/ml- SOLN 150MCG/ML- fill retail); AL; 1500unit/ml-2mcg/ml- 1MG/ML-0.5MG/ML- Up to 13 yrs old 400unit/ml-0.5mg/ml- 12MG/ML-1100UNIT/ML- 0.4mg/ml-35mg/ml 2MG/ML-1MG/ML- F pediatric multivitamins w/fl QL(50 ml per 3MCG/ML-400UNIT/ML- soln 0.5mg/ml-0.6mg/ml- fill retail); AL; 1MG/ML-81MCG/ML- 8mg/ml-1500unit/ml- Up to 13 yrs old 12UNIT/ML-1MG/ML- 2mcg/ml-400unit/ml- 45MG/ML 0.5mg/ml-5unit/ml- QUFLORA PEDIATRIC QL(50 ml per 0.4mg/ml-35mg/ml, SOLN 65MCG/ML- fill retail); AL; 0.5mg/ml-5unit/ml- 1MG/ML-0.25MG/ML- Up to 13 yrs old 0.6mg/ml-8mg/ml- 10MG/ML-1000UNIT/ML- ; RX/OTC 1500unit/ml-2mcg/ml- 0.8MG/ML-0.6MG/ML- F 400unit/ml-0.5mg/ml- 2MCG/ML-400UNIT/ML- 0.4mg/ml-35mg/ml, 0.5MG/ML-35MCG/ML- 0.5mg/ml-5unit/ml-8mg/ml- 5UNIT/ML-0.4MG/ML- 0.6mg/ml-1500unit/ml- F 35MG/ML 2mcg/ml-400unit/ml- 0.5mg/ml-0.4mg/ml- Ped MV w/ Iron 35mg/ml, 5unit/ml- QL(50 ml per 0.5mg/ml-0.6mg/ml- pediatric multiple vitamins F fill retail); AL; 8mg/ml-1500unit/ml- w/ iron soln Up to 13 yrs old 2mcg/ml-400unit/ml- 0.5mg/ml-0.4mg/ml- Ped Multi Vitamins w/Fl & FE 35mg/ml, 5unit/ml- QL(50 ml per ped multivitamins w/fl & F fill retail); AL; 0.5mg/ml-8mg/ml- iron soln 0.6mg/ml-1500unit/ml- Up to 13 yrs old 2mcg/ml-400unit/ml- QL(50 ml per 0.5mg/ml-0.4mg/ml- TRI-VIT/FLUORIDE/IRON F fill retail); AL; 35mg/ml SOLN Up to 13 yrs old QL(50 ml per Pediatric Multiple Vitamins pediatric vitamins acd w/ F fill retail); AL; fluoride soln Up to 13 yrs old QL(1 ea daily); pediatric multiple vitamin w/ F AL; Up to 13 c & fa chew yrs old Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(50 ml per pediatric multiple vitamin w/ MYNATAL ULTRACAPLET F QL(1 ea daily) F fill retail); AL; TABS c soln Up to 13 yrs old MYNATAL-Z TABS F QL(1 ea daily) Pediatric Vitamins QL(50 ml per MYNATE 90 PLUS TBCR F QL(1 ea daily) BPROTECTED PEDIA F TRI-VITE SOLN fill retail); AL; Up to 13 yrs old NAT-RUL PRENATAL F VITAMINS TABS QL(50 ml per pediatric vitamins adc soln F fill retail); AL; NATALVIT TABS F Up to 13 yrs old RX/OTC Prenatal Vitamins NIVA-PLUS TABS F CLASSIC PRENATAL F NUTRICION PORVIDA F QL(1 ea daily) TABS TABS CO-NATAL FA TABS F O-CAL FA TABS F RX/OTC

COMPLETENATE CHEW F O-CAL PRENATAL TABS F

CVS PRENATAL TABS F OB COMPLETE F ADVANCED CAPS EQL PRENATAL F FORMULA TABS PERRY PRENATAL CAPS F GNP PRENATAL TABS F PNV FERROUS QL(1 ea daily) FUMARATE/DOCUSATE/F F OLIC ACID TABS GOODSENSE PRENATAL F VITAMINS TABS PNV FOLIC ACID + IRON F RX/OTC HM PRENATAL TABS F MULTIVITAMIN TABS PNV PRENATAL PLUS F RX/OTC INATAL ADVANCE TABS F QL(1 ea daily) MULTIVITAMIN TABS PNV TABS 29-1 TABS F QL(1 ea daily) INATAL GT TABS F QL(1 ea daily) PRE-NATAL FORMULA F INATAL ULTRA TABS F QL(1 ea daily) TABS PRENATABS FA TABS F KP PRENATAL F MULTIVITAMINS TABS PRENATABS RX TABS F QL(1 ea daily) KPN PRENATAL TABS F PRENATAL 19 CHEW M-VIT TABS F RX/OTC 30UNIT-1000UNIT-20MG- 3MG-200MG-29MG-7MG- MULTI PRENATAL TABS F 15MG-3MG-12MCG- 400UNIT-1MG-20MG- F MYNATAL ADVANCE F QL(1 ea daily) 100MG, 1000UNIT- TABS 400UNIT-20MG-25MG- MYNATAL CAPS F QL(1 ea daily) 3MG-200MG-29MG-7MG- 6MG-3MG-12MCG-1MG- 30UNIT-20MG-100MG MYNATAL PLUS TABS F QL(1 ea daily)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL 19 TABS QL(1 ea daily) PRENATAL TABS 11UNIT- 1000UNIT-30UNIT-20MG- 263MG-25MG-1.5MG- 25MG-3MG-200MG-29MG- 27MG-4000UNIT-18MG- 15MG-3MG-7MG-12MCG- 1.7MG-4MCG-400UNIT- 400UNIT-20MG-1MG- 0.8MG-2.6MG-100MG, 100MG, 30UNIT- F 30UNIT-4000UNIT-25MG- 1000UNIT-20MG-25MG- 1.8MG-200MG-28MG- 3MG-200MG-29MG-7MG- 20MG-1.7MG-8MCG- 15MG-3MG-12MCG- 400UNIT-0.8MG-2.6MG- 400UNIT-1MG-20MG- 120MG, 30UNIT-25MG- 100MG 1.8MG-200MG-28MG- 20MG-1.7MG-4000UNIT- PRENATAL AND IRON F TABS 8MCG-400UNIT-800MCG- 2.6MG-120MG, 30UNIT- PRENATAL FORMULA F 4000UNIT-25MG-1.8MG- TABS 200MG-28MG-20MG- F PRENATAL FORTE TABS F 1.7MG-8MCG-400UNIT- 800MCG-2.6MG-120MG, PRENATAL LOW IRON F 4000UNIT-30UNIT-200MG- TABS 25MG-1.8MG-28MG- 20MG-1.7MG-8MCG- PRENATAL F MULTIVITAMIN TABS 400UNIT-800MCG-2.6MG- 120MG, 4000UNIT- PRENATAL ONE DAILY F TABS 30UNIT-25MG-1.8MG- 200MG-28MG-20MG- PRENATAL PLUS IRON F QL(1 ea daily) 1.7MG-8MCG-400UNIT- TABS 800MCG-2.6MG-120MG, PRENATAL PLUS TABS F RX/OTC 160MG-11UNIT-200MG- 25MG-1.84MG-27MG- 4000UNIT-18MG-1.7MG- 4MCG-400UNIT-800MCG- 2.6MG-100MG PRENATAL TABS 22MG- RX/OTC 2MG-25MG-1.84MG- 200MG-27MG-4000UNIT- F 20MG-3MG-12MCG- 400UNIT-1MG-10MG- 120MG PRENATAL TABS 4000UNIT-200MG-11UNIT- 27MG-25MG-1.84MG- F 18MG-1.7MG-4MCG- 400UNIT-0.8MG-2.6MG- 100MG PRENATAL VITAMIN & F MINERAL TABS PRENATAL VITAMIN F TABS PRENATAL F VITAMIN/IRON TABS

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL VITAMINS F RX/OTC VINATE ONE TABS F QL(1 ea daily) PLUS LOW IRON TABS QL(1 ea daily) PRENATAL VITAMINS F VIRT-ADVANCE TABS F TABS QL(1 ea daily) PREPLUS TABS F RX/OTC VIRT-VITE GT TABS F QL(1 ea daily) PRETAB TABS F VITAFOL-OB TABS F RX/OTC PX PRENATAL F VOL-PLUS TABS F MULTIVITAMINS TABS VOL-TAB RX TABS F QL(1 ea daily) QC PRENATAL TABS F RA PRENATAL MUSCULOSKELETAL THERAPY AGENTS FORMULA/FOLICACID F TABS Central Muscle Relaxants baclofen tabs or 10 mg, 20 F RA PRENATAL TABS F mg CHLORZOXAZONE TABS RIGHT STEP PRENATAL F F TABS 500 MG SE-NATAL 19 CHEW cyclobenzaprine hcl tabs 5 F QL(3 ea daily) 30UNIT-1000UNIT- mg, 10 mg 100MG-20MG-3MG- F methocarbamol tabs or 500 F 200MG-29MG-7MG-15MG- mg, 750 mg 3MG-12MCG-400UNIT- citrate tb12 or F QL(2 ea daily) 1MG-20MG 100 mg SE-NATAL 19 TABS QL(1 ea daily) ROBAXIN TABS OR 500 NF 30UNIT-1000UNIT-20MG- MG (Use Methocarbamol) 25MG-200MG-29MG-7MG- F 15MG-3MG-12MCG- ROBAXIN-750 TABS (Use NF 400UNIT-3MG-20MG- Methocarbamol) 1MG-100MG tizanidine hcl tabs 2 mg, 4 F mg SM PRENATAL VITAMINS F TABS ZANAFLEX TABS 4 MG NF (Use Tizanidine HCl) THERANATAL CORE F RX/OTC NUTRITION TABS NASAL AGENTS - SYSTEMIC AND TOPICAL THRIVITE 19 TABS F QL(1 ea daily) Nasal Agents - Misc. QL(1 ea daily) THRIVITE RX TABS F OCEAN NASAL SPRAY NF QL(480 ml per SOLN (Use Saline) fill retail) TRIADVANCE TABS F QL(1 ea daily) saline soln na 0.65%- F QL(480 ml per 0.002%, 0.65 %, 0.65% fill retail) RX/OTC TRICARE TABS F Nasal Anti-infectives QL(1 ea daily) TRINATAL GT TABS F BACTROBAN NASAL F OINT TRINATAL RX 1 TABS F QL(1 ea daily) Nasal Antiallergy QL(1 ea daily) ASTEPRO SOLN (Use NF VINATE M TABS F Azelastine HCl) Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits azelastine hcl soln 0.1 %, F QL(1 ml daily) SUDAFED CHILDRENS 137 mcg/spray LIQD (Use NF Pseudoephedrine HCl) azelastine hcl soln 0.15 % F SUDAFED CONGESTION TABS (Use NF cromolyn sodium (nasal) F QL(26 ml per aers fill retail) Pseudoephedrine HCl) SUDAFED NASAL NASALCROM AERS (Use NF QL(26 ml per Cromolyn Sodium (Nasal)) fill retail) DECONGESTANT MAXIMUM STRENGTH NF Nasal Anticholinergics TABS (Use ATROVENT SOLN 0.03 % QL(30 ml per Pseudoephedrine HCl) (Use Ipratropium Bromide NF fill retail) SUDAFED PE QL(24 ea per (Nasal)) CONGESTION TABS (Use NF fill retail) ATROVENT SOLN 0.06 % QL(25 ml per Phenylephrine HCl (Oral)) (Use Ipratropium Bromide NF fill retail) (Nasal)) NUTRIENTS ipratropium bromide (nasal) F QL(30 ml per Carbohydrates soln 0.03 % fill retail) QL(124 ml per POLYCOSE LIQD F ipratropium bromide (nasal) F QL(25 ml per fill retail) soln 0.06 % fill retail) F QL(350 gm per Nasal Steroids POLYCOSE POWD fill retail) FLONASE ALLERGY QL(16 ml per OPHTHALMIC AGENTS RELIEF CHILDRENS NF fill retail); SUSP (Use Fluticasone RX/OTC Propionate (Nasal)) Artificial Tears and Lubricants FLONASE ALLERGY QL(16 ml per F QL(4 gm per fill artificial tear ointment oint retail) RELIEF SUSP (Use NF fill retail); Fluticasone Propionate RX/OTC ARTIFICIAL TEARS SOLN F QL(15 ml per (Nasal)) fill retail) QL(30 ml per F QL(25 ml per HYPOTEARS SOLN F FLUNISOLIDE SOLN fill retail) fill retail) QL(15 ml per QL(16 ml per polyvinyl alcohol soln F fluticasone propionate F fill retail); fill retail) (nasal) susp RX/OTC TEARS NATURALE PM QL(42 gm per Sympathomimetic Decongestants OINT (Use White NF fill retail) Petrolatum-Mineral Oil) NASAL DECONGESTANT F LIQD white petrolatum-mineral oil F QL(42 gm per oint fill retail) NASAL DECONGESTANT F SYRP Beta-blockers - Ophthalmic BETAGAN SOLN (Use QL(15 ml per phenylephrine hcl (oral) F QL(24 ea per NF tabs fill retail) Levobunolol HCl) fill retail) QL(15 ml per pseudoephedrine hcl liqd F betaxolol hcl (ophth) soln F 15 mg/5ml fill retail) QL(15 ml per pseudoephedrine hcl tabs F BETOPTIC-S SUSP F 30 mg, 60 mg fill retail) pseudoephedrine hcl tb12 F QL(2 ea daily) carteolol hcl (ophth) soln F 120 mg Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARTEOLOL HCL SOLN F brimonidine tartrate soln F QL(15 ml per 0.2 % fill retail) COSOPT SOLN (Use QL(10 ml per IOPIDINE SOLN 0.5 % NF Dorzolamide HCl-Timolol NF fill retail) (Use Apraclonidine HCl) Maleate) IOPIDINE SOLN 1 % F dorzolamide hcl-timolol F QL(10 ml per maleate soln fill retail) Ophthalmic Anti-infectives F QL(15 ml per levobunolol hcl soln fill retail) BACITRACIN OINT OP F QL(4 gm per fill 500 UNIT/GM retail) METIPRANOLOL SOLN F bacitracin-polymyxin b F QL(4 gm per fill (ophth) oint retail) timolol maleate (ophth) F QL(5 ml per fill solg 0.5 % retail) BLEPH-10 SOLN (Use QL(15 ml per Sulfacetamide Sodium NF fill retail) timolol maleate (ophth) F QL(15 ml per (Ophth)) soln 0.25 %, 0.5 % fill retail) F QL(4 gm per fill TIMOLOL MALEATE QL(5 ml per fill CILOXAN OINT retail) OPHTHALMIC GEL F retail) FORMING SOLG 0.5 % CILOXAN SOLN (Use NF QL(10 ml per Ciprofloxacin HCl (Ophth)) fill retail) TIMOPTIC OCUDOSE F QL(60 ea per SOLN fill retail) ciprofloxacin hcl (ophth) F QL(10 ml per soln fill retail) TIMOPTIC SOLN (Use NF QL(15 ml per Timolol Maleate (Ophth)) fill retail) F QL(4 gm per fill erythromycin (ophth) oint retail) TIMOPTIC-XE SOLG 0.5 F QL(5 ml per fill % retail) F QL(4 gm per fill GENTAK OINT retail) Cycloplegic Mydriatics gentamicin sulfate (ophth) F QL(4 gm per fill ATROPINE SULFATE F QL(4 gm per fill oint retail) OINT OP 1 % retail) gentamicin sulfate (ophth) F QL(15 ml per ATROPINE SULFATE F QL(15 ml per soln fill retail) SOLN OP 1 % fill retail) moxifloxacin hcl (ophth) F QL(3 ml per fill CYCLOGYL SOLN 1 %, 2 QL(15 ml per soln retail) % (Use Cyclopentolate NF fill retail) neomycin-bacitracin zn- F QL(4 gm per fill HCl) polymyxin oint retail) cyclopentolate hcl soln 1 QL(15 ml per F neomycin-polymyxin- F QL(10 ml per %, 2 % fill retail) gramicidin soln fill retail) MYDRIACYL SOLN (Use NF QL(15 ml per NEOSPORIN SOLN (Use QL(10 ml per Tropicamide) fill retail) Neomycin-Polymyxin- NF fill retail) F QL(15 ml per Gramicidin) tropicamide soln fill retail) OCUFLOX SOLN (Use NF QL(10 ml per Miotics Ofloxacin (Ophth)) fill retail) QL(10 ml per ISOPTO CARPINE SOLN NF ofloxacin (ophth) soln F (Use Pilocarpine HCl) fill retail) pilocarpine hcl soln F polymyxin b-trimethoprim F QL(10 ml per soln fill retail) Ophthalmic Adrenergic Agents POLYTRIM SOLN (Use NF QL(10 ml per Polymyxin B-Trimethoprim) fill retail) apraclonidine hcl soln F

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sulfacetamide sodium F QL(15 ml per MAXITROL OINT QL(4 gm per fill (ophth) soln fill retail) 10000UNIT/GM- retail) 3.5MG/GM-0.1% (Use NF SULFACETAMIDE F QL(4 gm per fill SODIUM OINT OP retail) Neomycin-Polymy- Dexameth) F QL(5 ml per fill tobramycin (ophth) soln retail) MAXITROL SUSP QL(5 ml per fill 10000UNIT/ML-3.5MG/ML- NF retail) TOBREX OINT F QL(4 gm per fill 0.1% (Use Neomycin- retail) Polymy-Dexameth) TOBREX SOLN (Use NF QL(5 ml per fill neomycin-polymy- QL(4 gm per fill Tobramycin (Ophth)) retail) dexameth oint retail) QL(8 ml per fill F trifluridine soln F 10000unit/gm-3.5mg/gm- retail) 0.1% VIGAMOX SOLN (Use NF QL(3 ml per fill neomycin-polymy- QL(5 ml per fill Moxifloxacin HCl (Ophth)) retail) dexameth susp F retail) 10000unit/ml-3.5mg/ml- VIROPTIC SOLN (Use NF QL(8 ml per fill Trifluridine) retail) 0.1% Ophthalmic Decongestants NEOMYCIN/POLYMYXIN/ QL(8 ml per fill HYDROCORTISONE F retail) NAPHAZOLINE HCL F QL(15 ml per SUSP SOLN fill retail) OMNIPRED SUSP (Use QL(15 ml per phenylephrine hcl (ophth) F QL(30 ml per Prednisolone Acetate NF fill retail) soln 2.5 % fill retail) (Ophth)) tetrahydrozoline hcl (ophth) F QL(1 ml daily) PRED FORTE SUSP (Use QL(15 ml per soln Prednisolone Acetate NF fill retail) VISINE EXTRA SOLN (Use QL(1 ml daily) (Ophth)) Tetrahydrozoline HCl NF F QL(10 ml per (Ophth)) PRED MILD SUSP fill retail) VISINE SOLN (Use QL(1 ml daily) QL(0.167 ml Tetrahydrozoline HCl NF PRED-G SUSP F daily,5 ml per (Ophth)) fill retail) Ophthalmic Steroids prednisolone acetate F QL(15 ml per (ophth) susp fill retail) BLEPHAMIDE S.O.P. F QL(4 gm per fill OINT retail) PREDNISOLONE F QL(15 ml per ACETATE P-F SUSP fill retail) BLEPHAMIDE SUSP F QL(10 ml per fill retail) PREDNISOLONE SODIUM QL(15 ml per DEXAMETHASONE QL(5 ml per fill PHOSPHATE SOLN OP 1 F fill retail) SODIUM PHOSPHATE F retail) % SOLN OP 0.1 % sulfacetamide sod- F QL(10 ml per prednisolone soln fill retail) fluorometholone (ophth) F QL(15 ml per susp fill retail) TOBRADEX OINT F QL(4 gm per fill FML LIQUIFILM SUSP QL(15 ml per retail) (Use Fluorometholone NF fill retail) TOBRADEX SUSP (Use QL(10 ml per (Ophth)) Tobramycin- NF fill retail) Dexamethasone) F QL(4 gm per fill FML OINT retail) tobramycin- F QL(10 ml per dexamethasone susp fill retail)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(10 ml per VEXOL SUSP fill retail) OTIC AGENTS Ophthalmics - Misc. Otic Agents - Miscellaneous QL(15 ml per ACULAR LS SOLN (Use acetic acid (otic) soln F Ketorolac Tromethamine NF fill retail) (Ophth)) carbamide peroxide (otic) F QL(15 ml per ACULAR SOLN (Use QL(10 ml per soln fill retail) Ketorolac Tromethamine NF fill retail) DEBROX SOLN (Use NF QL(15 ml per (Ophth)) Carbamide Peroxide (Otic)) fill retail) F QL(5 ml per fill Otic Anti-infectives ALOCRIL SOLN retail) FLOXIN OTIC SOLN (Use NF QL(10 ml per F QL(10 ml per Ofloxacin (Otic)) fill retail) ALOMIDE SOLN fill retail) QL(10 ml per ofloxacin (otic) soln F F QL(6 ml per fill fill retail) azelastine hcl (ophth) soln retail) Otic Combinations F QL(15 ml per AZOPT SUSP fill retail) CORTANE-B-OTIC SOLN QL(0.5 ml (Use Pramoxine-HC- NF daily,15 ml per cromolyn sodium (ophth) F QL(10 ml per soln fill retail) Chloroxylenol) fill retail) neomycin-polymyxin-hc QL(10 ml per diclofenac sodium (ophth) F QL(5 ml per fill F soln retail) (otic) soln fill retail) neomycin-polymyxin-hc QL(10 ml per F QL(10 ml per F dorzolamide hcl soln fill retail) (otic) susp fill retail) OTICIN HC NR SOLN (Use QL(0.5 ml FLURBIPROFEN SODIUM F QL(3 ml per fill SOLN retail) Pramoxine-HC- NF daily,15 ml per Chloroxylenol) fill retail) F QL(3 ml per fill flurbiprofen sodium soln retail) QL(0.5 ml pramoxine-hc-chloroxylenol F daily,15 ml per soln ketorolac tromethamine F fill retail) (ophth) soln 0.4 % Otic Steroids ketorolac tromethamine F QL(10 ml per (ophth) soln 0.5 % fill retail) DERMOTIC OIL (Use QL(20 ml per Fluocinolone Acetonide NF fill retail) ketotifen fumarate (ophth) F QL(240 ml per (Otic)) soln fill retail) fluocinolone acetonide F QL(20 ml per OCUFEN SOLN (Use NF QL(3 ml per fill (otic) oil fill retail) Flurbiprofen Sodium) retail) hydrocortisone w/acetic F QL(10 ml per TRUSOPT SOLN (Use NF QL(10 ml per acid soln fill retail) Dorzolamide HCl) fill retail) ZADITOR SOLN (Use QL(240 ml per OXYTOCICS Ketotifen Fumarate NF fill retail) (Ophth)) Oxytocics - Ophthalmic METHERGINE TABS F QL(3 ml per fill latanoprost soln F methylergonovine maleate F retail) tabs or 0.2 mg XALATAN SOLN (Use NF QL(3 ml per fill Latanoprost) retail) PASSIVE IMMUNIZING AND TREATMENT AGENTS

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Immune Serums amoxicillin & pot QL(30 ea per clavulanate tabs 250mg- F fill retail) HYPERRHO S/D SOSY F SP 125mg amoxicillin & pot QL(20 ea per RHOGAM ULTRA- F SP FILTERED PLUS SOSY clavulanate tabs 500mg- F fill retail) 125mg, 875mg-125mg PENICILLINS amoxicillin & pot clavulanate tb12 1000mg- F Aminopenicillins 62.5mg amoxicillin caps 250 mg, F AMOXICILLIN/CLAVULAN F QL(20 ea per 500 mg ATE POTASSIUM CHEW fill retail) AMOXICILLIN CHEW 125 F AUGMENTIN ES-600 QL(400 ml per MG, 250 MG SUSR (Use Amoxicillin & NF fill retail) amoxicillin susr 125 Pot Clavulanate) mg/5ml, 200 mg/5ml, 250 F AUGMENTIN SUSR QL(150 ml per mg/5ml, 400 mg/5ml 250MG/5ML-62.5MG/5ML NF fill retail) amoxicillin tabs 875 mg F (Use Amoxicillin & Pot Clavulanate) ampicillin caps 250 mg, F AUGMENTIN TABS QL(20 ea per 500 mg 500MG-125MG, 875MG- NF fill retail) AMPICILLIN CAPS 500 F 125MG (Use Amoxicillin & MG Pot Clavulanate) AMPICILLIN SUSR 125 F AUGMENTIN XR TB12 MG/5ML, 250 MG/5ML (Use Amoxicillin & Pot NF ) Natural Penicillins Clavulanate Penicillinase-Resistant Penicillins penicillin v potassium solr F 125 mg/5ml, 250 mg/5ml dicloxacillin sodium caps F PENICILLIN V POTASSIUM SOLR 125 F PROGESTINS MG/5ML, 250 MG/5ML Progestins penicillin v potassium tabs F 250 mg, 500 mg AYGESTIN TABS (Use NF Penicillin Combinations Norethindrone Acetate) amoxicillin & pot QL(100 ml per medroxyprogesterone F clavulanate susr F fill retail) acetate tabs 200mg/5ml-28.5mg/5ml norethindrone acetate tabs F amoxicillin & pot QL(150 ml per clavulanate susr F fill retail) progesterone micronized F QL(1 ea daily) 250mg/5ml-62.5mg/5ml caps 100 mg amoxicillin & pot QL(200 ml per progesterone micronized F clavulanate susr F fill retail) caps 200 mg 400mg/5ml-57mg/5ml PROMETRIUM CAPS 100 QL(1 ea daily) amoxicillin & pot QL(400 ml per MG (Use Progesterone NF clavulanate susr F fill retail) Micronized) 600mg/5ml-42.9mg/5ml PROMETRIUM CAPS 200 MG (Use Progesterone NF Micronized)

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROVERA TABS (Use rivastigmine pt24 4.6 F PA; QL(1 ea Medroxyprogesterone NF mg/24hr, 9.5 mg/24hr daily) Acetate) PA; QL(2 ea rivastigmine tartrate caps F PSYCHOTHERAPEUTIC AND NEUROLOGICAL daily) AGENTS - MISC. Combination Psychotherapeutics Agents for Chemical Dependency PERPHENAZINE/AMITRIP F QL(4 ea daily) TYLINE TABS acamprosate calcium tbec F Fibromyalgia Agents ANTABUSE TABS (Use NF F PA; QL(2 ea Disulfiram) SAVELLA TABS daily) disulfiram tabs F SAVELLA TITRATION F PA; PACK MISC Antidementia Agents Multiple Sclerosis Agents ARICEPT TABS 5 MG, 10 QL(1 ea daily) MG (Use Donepezil NF AVONEX KIT F PA; SP Hydrochloride) AVONEX PEN AJKT F PA; SP donepezil hydrochloride F QL(1 ea daily) tabs 5 mg, 10 mg PA; SP EXELON CAPS OR 3 MG, PA; QL(2 ea AVONEX PSKT F 6 MG, 1.5 MG, 4.5 MG NF daily) COPAXONE SOSY (Use NF PA; SP (Use Rivastigmine Tartrate) Glatiramer Acetate) EXELON PT24 TD 4.6 PA; QL(1 ea PA; SP MG/24HR, 9.5 MG/24HR NF daily) GILENYA CAPS F (Use Rivastigmine) glatiramer acetate sosy F PA; SP galantamine hydrobromide F QL(1 ea daily) cp24 8 mg, 16 mg, 24 mg PLEGRIDY SOPN F PA; SP GALANTAMINE QL(6 ml daily) HYDROBROMIDE SOLN 4 F PLEGRIDY SOSY F PA; SP MG/ML PLEGRIDY STARTER PA; SP galantamine hydrobromide F QL(2 ea daily) F tabs 4 mg, 8 mg, 12 mg PACK SOPN PLEGRIDY STARTER PA; SP F PA; QL(49 ea F memantine hcl tabs per fill retail) PACK SOSY PA; SP memantine hcl tabs 5 mg, F PA; QL(2 ea TECFIDERA CPDR F 10 mg daily) TECFIDERA STARTER PA; SP NAMENDA TABS 5 MG, 10 NF PA; QL(2 ea F MG (Use Memantine HCl) daily) PACK MISC NAMENDA TITRATION PA; QL(49 ea Psychotherapeutic and Neurological Agents - PAK TABS (Use NF per fill retail) ERGOLOID MESYLATES F Memantine HCl) TABS RAZADYNE ER CP24 (Use QL(1 ea daily) Smoking Deterrents Galantamine NF Hydrobromide) bupropion hcl (smoking F QL(2 ea daily) deterrent) tb12 RAZADYNE TABS (Use QL(2 ea daily) Galantamine NF CHANTIX CONTINUING F QL(2 ea daily) Hydrobromide) MONTHPAK TABS

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHANTIX STARTING F QL(53 ea per MONTH PAK TABS fill retail) TETRACYCLINES CHANTIX TABS F QL(2 ea daily) Tetracyclines doxycycline hyclate caps or F NICODERM CQ PT24 14 QL(1 ea daily) 50 mg, 100 mg MG/24HR, 21 MG/24HR NF ( ) doxycycline hyclate tabs or F Use Nicotine 100 mg NICODERM CQ PT24 7 NF ) MINOCIN CAPS OR 50 MG/24HR (Use Nicotine MG, 75 MG, 100 MG (Use NF NICORETTE GUM 2 MG, 4 QL(24 ea daily) Minocycline HCl) MG (Use Nicotine NF ) minocycline hcl caps 50 F Polacrilex mg, 75 mg, 100 mg NICORETTE LOZG 2 MG, QL(20 ea daily) VIBRAMYCIN CAPS 100 4 MG (Use Nicotine NF NF ) MG (Use Doxycycline Polacrilex Hyclate) NICORETTE MINI LOZG NF QL(20 ea daily) (Use Nicotine Polacrilex) THYROID AGENTS NICORETTE STARTER QL(24 ea daily) KIT GUM (Use Nicotine NF Antithyroid Agents Polacrilex) methimazole tabs F nicotine polacrilex gum 2 F QL(24 ea daily) mg, 4 mg propylthiouracil tabs F nicotine polacrilex lozg 2 QL(20 ea daily) F TAPAZOLE TABS (Use NF mg, 4 mg Methimazole) nicotine pt24 14 mg/24hr, F QL(1 ea daily) 21 mg/24hr Thyroid Hormones ARMOUR THYROID TABS nicotine pt24 7 mg/24hr F 15 MG, 30 MG, 60 MG, 90 F NICOTINE QL(56 ea per MG, 120 MG (Use Thyroid) TRANSDERMAL SYSTEM F fill retail) ARMOUR THYROID TABS F KIT 180 MG, 240 MG, 300 MG CYTOMEL TABS (Use NICOTROL INHALER F QL(504 ea per NF INHA fill retail) Liothyronine Sodium) levothyroxine sodium tabs F QL(120 ml per NICOTROL NS SOLN fill retail) or 25 mcg, 50 mcg, 75 ZYBAN TB12 (Use QL(2 ea daily) mcg, 88 mcg, 100 mcg, F Bupropion HCl (Smoking NF 112 mcg, 125 mcg, 137 Deterrent)) mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg RESPIRATORY AGENTS - MISC. liothyronine sodium tabs or F 5 mcg, 25 mcg, 50 mcg Cystic Fibrosis Agents SYNTHROID TABS (Use F KALYDECO PACK F PA; SP Levothyroxine Sodium) thyroid tabs F KALYDECO TABS F PA; SP THYROLAR-1 TABS F ORKAMBI TABS 200MG- F PA; SP 125MG

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THYROLAR-1/2 TABS F DONNATAL TABS 0.1037MG-0.0065MG- THYROLAR-1/4 TABS F 0.0194MG-16.2MG (Use NF Phenobarbital- Hyoscyamine-Atropine- THYROLAR-2 TABS F Scopolamine) THYROLAR-3 TABS F glycopyrrolate tabs or 1 F QL(4 ea daily) mg, 2 mg TOXOIDS hyoscyamine sulfate elix or F 0.125 mg/5ml Toxoid Combinations hyoscyamine sulfate soln F or 0.125 mg/ml F AL; At least 19 ADACEL SUSP yrs old hyoscyamine sulfate subl sl F 0.125 mg F AL; At least 19 BOOSTRIX SUSP yrs old hyoscyamine sulfate tabs F DIPHTHERIA/TETANUS AL; At least 19 or 0.125 mg TOXOIDS ADSORBED F yrs old hyoscyamine sulfate tb12 F QL(4 ea daily) PEDIATRIC SUSP or 0.375 mg AL; At least 19 INFANRIX SUSP F hyoscyamine sulfate tbdp F yrs old or 0.125 mg AL; At least 19 TENIVAC INJ F LEVBID TB12 (Use NF QL(4 ea daily) yrs old Hyoscyamine Sulfate) TETANUS/DIPHTHERIA AL; At least 19 LEVSIN TABS OR 0.125 TOXOIDS-ADSORBED F yrs old MG (Use Hyoscyamine NF SUSP Sulfate) ULCER DRUGS LEVSIN/SL SUBL (Use NF Hyoscyamine Sulfate) phenobarbital- hyoscyamine-atropine- F ANASPAZ TBDP (Use NF Hyoscyamine Sulfate) scopolamine tabs ROBINUL FORTE TABS QL(4 ea daily) BENTYL CAPS OR 10 MG NF NF (Use Dicyclomine HCl) (Use Glycopyrrolate) ROBINUL TABS OR 1 MG QL(4 ea daily) BENTYL TABS OR 20 MG NF NF (Use Dicyclomine HCl) (Use Glycopyrrolate) dicyclomine hcl caps or 10 F H-2 Antagonists mg CIMETIDINE HCL SOLN F QL(27 ml daily) dicyclomine hcl soln or 10 F QL(40 ml daily) mg/5ml cimetidine tabs 200 mg F RX/OTC dicyclomine hcl tabs or 20 F mg cimetidine tabs 300 mg, F DONNATAL ELIX 400 mg, 800 mg 0.1037MG/5ML- famotidine tabs or 10 mg, F 0.0065MG/5ML- F 40 mg 0.0194MG/5ML- RX/OTC 16.2MG/5ML famotidine tabs or 20 mg F

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEPCID AC MAXIMUM RX/OTC NEXIUM 24HR CLEAR QL(2 ea daily); STRENGTH TABS (Use NF MINIS CPDR (Use NF RX/OTC Famotidine) Esomeprazole Magnesium) PEPCID AC TABS (Use NF NEXIUM 24HR CPDR (Use NF QL(2 ea daily); Famotidine) Esomeprazole Magnesium) RX/OTC PEPCID TABS 20 MG (Use NF RX/OTC NEXIUM CPDR 20 MG QL(2 ea daily); Famotidine) (Use Esomeprazole NF RX/OTC Magnesium) PEPCID TABS 40 MG (Use NF Famotidine) F QL(2 ea daily); omeprazole cpdr 20 mg RX/OTC ranitidine hcl caps or 150 F QL(2 ea daily) mg omeprazole cpdr 40 mg F QL(2 ea daily) ranitidine hcl caps or 300 F QL(1 ea daily) mg pantoprazole sodium tbec F QL(1 ea daily) ranitidine hcl syrp or 15 QL(40 ml daily) or 20 mg mg/ml, 75 mg/5ml, 150 F pantoprazole sodium tbec F QL(2 ea daily) mg/10ml or 40 mg PREVACID 24HR CPDR QL(4 ea daily); ranitidine hcl tabs or 150 F QL(2 ea daily); NF mg RX/OTC (Use Lansoprazole) RX/OTC PREVACID CPDR 15 MG QL(4 ea daily); ranitidine hcl tabs or 75 F QL(2 ea daily) NF mg, 300 mg (Use Lansoprazole) RX/OTC PRILOSEC CPDR 20 MG QL(2 ea daily); TAGAMET HB TABS (Use NF RX/OTC NF Cimetidine) (Use Omeprazole) RX/OTC ZANTAC 150 MAXIMUM QL(2 ea daily); PRILOSEC CPDR 40 MG NF QL(2 ea daily) STRENGTH TABS (Use NF RX/OTC (Use Omeprazole) Ranitidine HCl) PRILOSEC OTC TBEC F QL(1 ea daily) ZANTAC 75 TABS (Use NF QL(2 ea daily) Ranitidine HCl) PROTONIX TBEC OR 20 QL(1 ea daily) MG (Use Pantoprazole NF ZANTAC TABS OR 150 NF QL(2 ea daily); MG (Use Ranitidine HCl) RX/OTC Sodium) PROTONIX TBEC OR 40 QL(2 ea daily) ZANTAC TABS OR 300 NF QL(2 ea daily) MG (Use Ranitidine HCl) MG (Use Pantoprazole NF Sodium) Misc. Anti-Ulcer Ulcer Drugs - Prostaglandins CARAFATE SUSP 1 F QL(420 ml per GM/10ML fill retail) CYTOTEC TABS (Use NF Misoprostol) CARAFATE TABS 1 GM NF QL(4 ea daily) (Use Sucralfate) misoprostol tabs F sucralfate tabs F QL(4 ea daily) URINARY ANTI-INFECTIVES Proton Pump Inhibitors Urinary Anti-infective Combinations DEXILANT CPDR F methenamine-hyosc- methylene blue-sod phos- esomeprazole magnesium QL(2 ea daily); F phenyl sal tabs 40.8mg- F cpdr 20 mg RX/OTC 0.12mg-36.2mg-81.6mg- QL(4 ea daily); lansoprazole cpdr 15 mg F 10.8mg, 40.8mg-36.2mg- RX/OTC 0.12mg-81.6mg-10.8mg

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Urinary Anti-infectives URECHOLINE TABS (Use NF Chloride) FURADANTIN SUSP (Use NF QL(40 ml daily) Nitrofurantoin) Urinary Antispasmodics - Direct Muscle Relaxants MACROBID CAPS (Use hcl tabs F Nitrofurantoin Monohyd NF Macro) VACCINES MACRODANTIN CAPS 50 MG, 100 MG (Use NF Bacterial Vaccines Nitrofurantoin F AL; At least 19 Macrocrystal) BEXSERO SUSY yrs old METHENAMINE F AL; At least 19 MANDELATE TABS 0.5 F MENACTRA INJ yrs old GM MENOMUNE-A/C/Y/W-135 F AL; At least 19 methenamine mandelate F INJ yrs old tabs 1 gm AL; At least 19 MENVEO SOLR F nitrofurantoin macrocrystal F yrs old caps 50 mg, 100 mg PNEUMOVAX 23 INJ F AL; At least 19 nitrofurantoin monohyd F yrs old macro caps PNEUMOVAX 23/1 DOSE F AL; At least 19 nitrofurantoin susp F QL(40 ml daily) INJ yrs old F AL; At least 19 URINARY ANTISPASMODICS PREVNAR 13 SUSP yrs old Urinary - Antimuscarinics F AL; At least 19 TRUMENBA SUSY yrs old DETROL LA CP24 (Use NF QL(1 ea daily) Tartrate) Viral Vaccines AFLURIA PF 2015-2016 AL; At least 13 DETROL TABS (Use NF QL(2 ea daily) F Tolterodine Tartrate) SUSY yrs old AFLURIA PF 2016-2017 AL; At least 13 DITROPAN XL TB24 (Use NF QL(2 ea daily) F Chloride) SUSY yrs old AFLURIA PF 2017-2018 AL; At least 13 oxybutynin chloride syrp 5 F F mg/5ml SUSY yrs old AFLURIA QUADRIVALENT AL; At least 13 oxybutynin chloride tabs 5 F QL(3 ea daily) F mg 2016-2017 SUSY yrs old AFLURIA QUADRIVALENT AL; At least 13 oxybutynin chloride tb24 5 F QL(2 ea daily) F mg, 10 mg, 15 mg 2017-2018 SUSP yrs old AFLURIA QUADRIVALENT AL; At least 13 tolterodine tartrate cp24 2 F QL(1 ea daily) F mg, 4 mg 2017-2018 SUSY yrs old AL; At least 19 tolterodine tartrate tabs 1 F QL(2 ea daily) CERVARIX SUSP F mg, 2 mg yrs old AL; At least 19 tabs 20 F QL(2 ea daily) ENGERIX-B INJ F mg yrs old Urinary Antispasmodics - Cholinergic Agonists F AL; At least 19 ENGERIX-B SUSP yrs old bethanechol chloride tabs F FLUARIX QUADRIVALENT F AL; At least 13 2015-2016 SUSY yrs old

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUARIX QUADRIVALENT F AL; At least 13 FLUZONE HIGH-DOSE PF F AL; At least 13 2016-2017 SUSY yrs old 2015-2016 SUSY yrs old FLUARIX QUADRIVALENT F AL; At least 13 FLUZONE HIGH-DOSE PF F AL; At least 13 2017-2018 SUSY yrs old 2016-2017 SUSY yrs old FLUBLOK 2015-2016 F AL; At least 13 FLUZONE HIGH-DOSE PF F AL; At least 13 SOLN yrs old 2017-2018 SUSY yrs old FLUBLOK 2016-2017 F AL; At least 13 FLUZONE INTRADERMAL AL; At least 13 SOLN yrs old QUADRIVALENT 2015- F yrs old 2016 SUPN FLUBLOK 2017-2018 F AL; At least 13 SOLN yrs old FLUZONE INTRADERMAL AL; At least 13 QUADRIVALENT 2016- F yrs old FLUCELVAX 2015-2016 F AL; At least 13 SUSY yrs old 2017 SUPN FLUCELVAX AL; At least 13 FLUZONE INTRADERMAL AL; At least 13 QUADRIVALENT 2017- F yrs old QUADRIVALENT 2017- F yrs old 2018 SUSP 2018 SUPN FLULAVAL AL; At least 13 FLUZONE AL; At least 13 QUADRIVALENT 2014- F yrs old QUADRIVALENT 2015- F yrs old 2015 SUSY 2016 SUSP FLULAVAL AL; At least 13 FLUZONE AL; At least 13 QUADRIVALENT 2015- F yrs old QUADRIVALENT 2015- F yrs old 2016 SUSP 2016 SUSY FLULAVAL AL; At least 13 FLUZONE AL; At least 13 QUADRIVALENT 2016- F yrs old QUADRIVALENT 2016- F yrs old 2017 SUSP 2017 SUSP FLULAVAL AL; At least 13 FLUZONE AL; At least 13 QUADRIVALENT 2016- F yrs old QUADRIVALENT 2016- F yrs old 2017 SUSY 2017 SUSY FLULAVAL AL; At least 13 FLUZONE AL; At least 13 QUADRIVALENT 2017- F yrs old QUADRIVALENT 2017- F yrs old 2018 SUSP 2018 SUSP FLULAVAL AL; At least 13 FLUZONE AL; At least 13 QUADRIVALENT 2017- F yrs old QUADRIVALENT 2017- F yrs old 2018 SUSY 2018 SUSY AL; At least 19 FLUMIST F AL; At least 13 GARDASIL 9 SUSP F QUADRIVALENT SUSP yrs old yrs old AL; At least 19 FLUVIRIN 2015-2016 F AL; At least 13 GARDASIL 9 SUSY F SUSP yrs old yrs old AL; At least 19 FLUVIRIN 2015-2016 F AL; At least 13 GARDASIL SUSP F SUSY yrs old yrs old AL; At least 19 FLUVIRIN 2016-2017 F AL; At least 13 HAVRIX SUSP F SUSP yrs old yrs old AL; At least 19 FLUVIRIN 2016-2017 F AL; At least 13 M-M-R II INJ F SUSY yrs old yrs old MEDICAL PROVIDER EZ AL; At least 13 FLUVIRIN 2017-2018 F AL; At least 13 SUSP yrs old FLU SHOT 2015-2016 F yrs old PSKT FLUVIRIN 2017-2018 F AL; At least 13 SUSY yrs old Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDICAL PROVIDER EZ AL; At least 13 MONISTAT 3 QL(24 gm per FLU SHOT PF 2014-2015 F yrs old COMBINATION PACK KIT NF fill retail) PSKT (Use Miconazole Nitrate MEDICAL PROVIDER AL; At least 13 Vaginal) SINGLE USE EZ FLU F yrs old MONISTAT 3 CREA (Use NF QL(45 gm per SHOT PSKT Miconazole Nitrate Vaginal) fill retail) F AL; At least 19 MONISTAT 7 SIMPLY QL(45 gm per RECOMBIVAX HB SUSP yrs old CURE CREA (Use NF fill retail) Miconazole Nitrate Vaginal) VAQTA SUSP F AL; At least 19 yrs old TERAZOL 3 CREA (Use NF QL(20 gm per AL; At least 19 Terconazole Vaginal) fill retail) VARIVAX INJ F yrs old TERAZOL 7 CREA (Use NF QL(45 gm per Terconazole Vaginal) fill retail) ZOSTAVAX SUSR F AL; At least 19 yrs old F QL(20 gm per TERCONAZOLE CREA fill retail) VAGINAL PRODUCTS terconazole vaginal crea F QL(45 gm per Vaginal Anti-infectives 0.4 % fill retail) CLEOCIN CREA VA 2 % QL(40 gm per terconazole vaginal crea F QL(20 gm per (Use Clindamycin NF fill retail) 0.8 % fill retail) Phosphate Vaginal) terconazole vaginal supp F QL(3 ea per fill 80 mg retail) clindamycin phosphate F QL(40 gm per vaginal crea fill retail) F QL(5 gm per fill tioconazole vaginal oint retail) clotrimazole vaginal crea 1 F QL(45 gm per % fill retail) VAGISTAT-1 OINT (Use NF QL(5 gm per fill Tioconazole Vaginal) retail) clotrimazole vaginal crea 2 F QL(30 gm per % fill retail) Vaginal Estrogens GYNAZOLE-1 CREA F ESTRACE CREA (Use NF Estradiol Vaginal) GYNE-LOTRIMIN 3 CREA QL(30 gm per NF estradiol vaginal crea 0.1 F (Use Clotrimazole Vaginal) fill retail) mg/gm GYNE-LOTRIMIN CREA QL(45 gm per NF PREMARIN CREA VA F (Use Clotrimazole Vaginal) fill retail) 0.625 MG/GM METROGEL-VAGINAL QL(70 gm per GEL (Use Metronidazole NF fill retail) VASOPRESSORS Vaginal) Anaphylaxis Therapy Agents QL(70 gm per metronidazole vaginal gel F fill retail) ADRENACLICK SOAJ F QL(3 ea per fill MICONAZOLE 3 SUPP F epinephrine (anaphylaxis) F retail) soaj miconazole nitrate vaginal F QL(45 gm per crea 2 %, 4 % fill retail) Vasopressors miconazole nitrate vaginal F QL(24 gm per midodrine hcl tabs F kit fill retail) miconazole nitrate vaginal F QL(7 ea per fill VITAMINS supp 100 mg retail) Oil Soluble Vitamins

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

114 Drug Requirements/ Drug Name Tier Limits DRISDOL CAPS (Use NF Ergocalciferol) ergocalciferol caps F

MEPHYTON TABS F Water Soluble Vitamins niacin cpcr F

Updated April 1, 2018\ F-Preferred drug, NF-Non-formulary, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, ST-Step Therapy

115 Index 1ST CHOICE LANCETS ADDERALL XR 1 AEROCHAMBER PLUS FLOW- SUPERTHIN 57 ADJUSTABLE LANCING VU/MASK 87 1ST CHOICE LANCETS THIN DEVICE 57 AEROCHAMBER PLUS FLOW- 57 ADMELOG 16 VU/MEDIUM MASK 87 1ST CHOICE LANCETS AEROCHAMBER PLUS FLOW- ULTRATHIN 57 ADMELOG SOLOSTAR 16 VU/SMALL MASK 87 1ST TIER UNIFINE ADRENACLICK 114 AEROCHAMBER Z-STAT PLUS PENTIPS29GX12MM 65 ADULT AEROSOL MASK 87 VALVED HOLDING CHAMBER 1ST TIER UNIFINE ADULT DISPOSABLE W/FLOW VU 87 PENTIPSPLUS/ORIGINAL/29GX MOUTHPIECE 87 AEROCHAMBER Z-STAT 12MM 65 PLUS/FLOWSIGNAL 87 1ST TIER UNILET ADULT MASK 87 AEROCHAMBER Z-STAT COMFORTOUCH LANCETS ADULT MASK LARGE 87 PLUS/LARGE MASK 87 28G 57 ADVANCED DIABETIC AEROCHAMBER Z-STAT 1ST TIER UNILET MULTIVITAMIN PLUS/MEDIUM MASK 87 COMFORTOUCH LANCETS FORMULA 94 AEROCHAMBER Z-STAT 30G 57 ADVIL 2 PLUS/SMALL MASK 87 abacavir sulfate 27 ADVIL COLD & SINUS 35 AEROCHAMBER/FLOWSIGNAL 87 abacavir sulfate-lamivudine 27 ADVOCATE INSULIN abacavir sulfate-lamivudine- SYRINGE/U- AEROSPAN 9 zidovudine 27 100/0.3ML/29GX1/2" 65 AEROTRACH PLUS 87 ABILIFY 26 ADVOCATE INSULIN AEROVENT PLUS HOLDING ABSORICA 37 SYRINGE/U- CHAMBER/COLLAPSIBLE 87 100/0.3ML/30GX5/16" 65 AFLURIA PF 2015-2016 112 acamprosate calcium 108 ADVOCATE INSULIN AFLURIA PF 2016-2017 112 ACCUPRIL 21 SYRINGE/U- AFLURIA PF 2017-2018 112 ACCURETIC 22 100/0.3ML/31GX5/16" 65 ADVOCATE INSULIN AFLURIA QUADRIVALENT ACE AEROSOL CLOUD 2016-2017 112 ENHANCER 87 SYRINGE/U- 100/0.5ML/29GX1/2" 65 AFLURIA QUADRIVALENT acebutolol hcl 30 ADVOCATE INSULIN 2017-2018 112 acetaminophen 4 SYRINGE/U- AGAMATRIX ULTRA-THIN acetaminophen w/ codeine 5 100/0.5ML/30GX5/16" 65 LANCETS 33G 57 acetazolamide 44 ADVOCATE INSULIN AIMSCO LUBRICATED 55 SYRINGE/U- AIRS PEDIATRIC AEROSOL acetic acid (otic) 106 100/0.5ML/31GX5/16" 65 MASK 87 acetylcysteine 36 ADVOCATE INSULIN albuterol sulfate 9 ACNE MEDICATION 10 37 SYRINGE/U- ALBUTEROL SULFATE ER 9 ACNE MEDICATION 5 37 100/1ML/29GX1/2" 65 ADVOCATE INSULIN ALCOHOL PREP PADS 64 ACTIGALL 46 SYRINGE/U- ALCOHOL PREPS 64 ACTIVELLA 45 100/1ML/30GX5/16" 65 ALCOHOL SWABS 64 ACTIVITY POUCH 87 ADVOCATE INSULIN ALCOHOL WIPES 64 SYRINGE/U- ACTONEL 45 100/1ML/31GX5/16" 65 ALDACTAZIDE 44 ACTOPLUS MET 15 ADVOCATE LANCING ALDACTONE 44 ACTOS 16 DEVICE 57 ALDARA 41 ACULAR 106 ADVOCATE RAPID-SAFE LANCING DEVICE 57 ALENDRONATE SODIUM 45 ACULAR LS 106 AEROCHAMBER MINI alendronate sodium 45 acyclovir 29 AEROSOLCHAMBER 87 ALENDRONATE SODIUM 45 acyclovir topical 39 AEROCHAMBER MV 87 alendronate sodium 45 ADACEL 110 AEROCHAMBER PLUS FLOW ALEVE 2 VU 87 ADALAT CC 30 AEROCHAMBER PLUS ALEVE ARTHRITIS 2 ADAPTER PED DISPOSABLE FLOW-VU 87 ALIVE ENERGY 50+ 94 MOUTHPIECE 87 AEROCHAMBER PLUS ALIVE MENS ENERGY 94 ADDERALL 1 FLOW-VU/LARGE MASK 87

Index 1 ALIVE ONCE DAILY WOMENS AMOXICILLIN/CLAVULANATE ASSURE ID INSULIN 50+ ULTRA POTENCY 94 POTASSIUM 107 SAFETYSYRINGE/U- ALIVE ONCE DAILY WOMENS amphetamine- 100/0.5ML/29G X 1/2" 65 ULTRA POTENCY 94 dextroamphetamine 1 ASSURE ID INSULIN ALIVE WOMENS 50+ 94 ampicillin 107 SAFETYSYRINGE/U- ALIVE WOMENS ENERGY 94 AMPICILLIN 107 100/1ML/29G X 1/2" 65 ASTEPRO 102 ALKERAN 23 ANAFRANIL 15 atazanavir sulfate 27 ALL FLOW 1000 PULMONARY ANALPRAM-HC 6 atenolol 30 FUNCTION FILTER 87 ANAPROX DS 2 ALLEGRA ALLERGY 19 atenolol & chlorthalidone 22 ANASPAZ 110 ALLEVYN PLUS CAVITY 51 ATIVAN 8 anastrozole 24 ALLEVYN THIN 51 ATLAS COLORED ANDRODERM 6 allopurinol 47 CONDOM/SPERMICIDE 55 ANDROXY 6 ATLAS COLORED ALOCRIL 106 ANTABUSE 108 LUBRICATEDCONDOM 55 ALOGLIPTIN 16 ANTI-STICK INSULIN ATLAS LUBRICATED ALOGLIPTIN/METFORMIN SYRINGE/U-100/0.5ML/28G X CONDOM 55 HCL 15 1/2" 65 ATLAS LUBRICATED ALOGLIPTIN/PIOGLITAZONE ANTI-STICK INSULIN CONDOM/SPERMICIDE 55 15 SYRINGE/U-100/0.5ML/29G X atorvastatin calcium 20 ALOMIDE 106 1/2" 65 ATRIPLA 27 ALORA 46 ANTI-STICK INSULIN ATROPINE SULFATE 104 alprazolam 8 SYRINGE/U-100/1ML/29G X 1/2" 65 ATROVENT 103 21 ALTACE ANTIOXIDANT FORTE 94 ATROVENT HFA 9 ALTERNATE SITE LANCING AUGMENTIN 107 DEVICE 57 ANUSOL-HC 6 alum & mag hydrox- AP-ZEL 94 AUGMENTIN ES-600 107 simethicone 6 APEXICON E 39 AUGMENTIN XR 107 ALUMINUM HYDROXIDE 6 APIDRA 16 AURORA LANCET SUPER amantadine hcl 24 THIN30G 57 APIDRA SOLOSTAR 16 AURORA LANCET THIN AMARYL 17 apraclonidine hcl 104 23G 57 AMBIEN 49 APTIVUS 27 AURORA PEN NEEDLES AMD FOAM DRESSING AQUA LANCE ADJUSTABLE 29GX12MM 65 4"X4" 51 LANCING DEVICE 57 AUTO-LANCET 57 AMD FOAM AUTO-LANCET MINI 57 DRESSING/TOPSHEET ARAVA 3 ARIAL CHAMBER 88 AUTOLET IMPRESSION 4"X4" 51 LANCING DEVICE 57 AMERGE 91 ARICEPT 108 AUTOLET LANCING AMICAR 48 ARIMIDEX 24 DEVICE 57 amiloride & aripiprazole 26 AUTOLET MINI 57 hydrochlorothiazide 44 ARMOUR THYROID 109 AUTOLET PLUS 57 amiloride hcl 44 AROMASIN 24 AVALIDE 22 amiodarone hcl 9 ARTHRITIS PAIN AVANDIA 16 amitriptyline hcl 15 RELIEVING 41 AVAPRO 21 artificial tear ointment 103 amlodipine besylate 30 AVONEX 108 amlodipine besylate-benazepril ARTIFICIAL TEARS 103 AVONEX PEN 108 hcl 22 ASACOL HD 47 AYGESTIN 107 AMOXAPINE 15 aspirin 4 AZASAN 92 amoxicillin 107 ASPIRIN 4 azathioprine 92 AMOXICILLIN 107 aspirin 4 azelastine hcl 103 amoxicillin 107 aspirin buffered (cal carb-mag amoxicillin & pot carb-mag oxide) 4 azelastine hcl (ophth) 106 clavulanate 107

Index 2 AZITHROMYCIN 50 BD INSULIN SYRINGE LUER- BD INSULIN SYRINGE azithromycin 50 LOK/U-100/1ML 66 ULTRAFINE/0.5ML/31G X BD INSULIN SYRINGE 5/16" 66 AZOPT 106 MICROFINE IV/U- BD INSULIN SYRINGE AZULFIDINE 47 100/0.3ML/28G X 1/2" 66 ULTRAFINE/1ML/30G X AZULFIDINE EN-TABS 47 BD INSULIN SYRINGE 1/2" 66 MICROFINE IV/U- BD INSULIN SYRINGE b-complex w/ c & folic acid 94 100/0.5ML/28G X 1/2" 66 ULTRAFINE/1ML/31G X B-D INSULIN SYRINGE BD INSULIN SYRINGE 5/16" 66 ULTRAFINE II/0.3ML/31G X MICROFINE IV/U- BD INSULIN SYRINGE 5/16" 65 100/1ML/27G X 5/8" 66 ULTRAFINE/U-100/0.3ML/29G X B-D INSULIN SYRINGE BD INSULIN SYRINGE 1/2" 66 ULTRAFINE II/0.5ML/31G X MICROFINE IV/U- BD INSULIN SYRINGE 5/16" 65 100/1ML/28G X 1/2" 66 ULTRAFINE/U-100/0.3ML/30G X B-D INSULIN SYRINGE BD INSULIN SYRINGE 1/2" 66 ULTRAFINE II/1ML/31G X MICROFINE/U-100/0.3ML/28G BD INSULIN SYRINGE 5/16" 65 X 1/2" 66 ULTRAFINE/U-100/0.3ML/31G X B-D INSULIN SYRINGE BD INSULIN SYRINGE 5/16" 66 ULTRAFINE/0.3ML/30G X MICROFINE/U-100/0.5ML/28G BD INSULIN SYRINGE 1/2" 65 X 1/2" 66 ULTRAFINE/U-100/0.5ML/29G X B-D INSULIN SYRINGE BD INSULIN SYRINGE 1/2" 66 ULTRAFINE/0.5ML/30G X MICROFINE/U-100/1ML/27G X BD INSULIN SYRINGE 1/2" 65 5/8" 66 ULTRAFINE/U-100/0.5ML/30G X BACIGUENT 37 BD INSULIN SYRINGE 1/2" 67 BACITRACIN 104 MICROFINE/U-100/1ML/28G X BD INSULIN SYRINGE bacitracin (topical) 37 1/2" 66 ULTRAFINE/U-100/0.5ML/31G X BD INSULIN SYRINGE 5/16" 67 bacitracin zinc 37 SAFETYGLIDE/0.5ML/29G X BD INSULIN SYRINGE bacitracin-polymyxin b 1/2" 66 ULTRAFINE/U-100/1ML/29G X (ophth) 104 BD INSULIN SYRINGE 1/2" 67 baclofen 102 SAFETYGLIDE/1ML/29G X BD INSULIN SYRINGE BACMIN 94 1/2" 66 ULTRAFINE/U-100/1ML/30G X BACTRIM 7 BD INSULIN SYRINGE 1/2" 67 SAFETYGLIDE/U- BD INSULIN SYRINGE BACTRIM DS 7 100/0.3ML/31G X 5/16" 66 ULTRAFINE/U-100/1ML/31G X BACTROBAN 37 BD INSULIN SYRINGE SLIP 15/64" 67 BACTROBAN NASAL 102 TIP/U-100/1ML 66 BD INSULIN SYRINGE BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X balsalazide disodium 47 ULTRAFINE HALF- 5/16" 67 BAND-AID GAUZE PADS UNIT/0.3ML/31G X 5/16" 66 BD INSULIN LARGE4" X 4" 51 BD INSULIN SYRINGE SYRINGE/DETACHABLE BAND-AID GAUZE PADS ULTRAFINE NEEDLE/U-100/1ML/25G X MEDIUM 3" X 3" 51 II/SHORT/0.5ML/31G X 1" 67 BAND-AID GAUZE PADS 5/16" 66 BD INSULIN SMALL2" X 2" 51 BD INSULIN SYRINGE SYRINGE/DETACHABLE BAND-AID MIRASORB GAUZE ULTRAFINE NEEDLE/U-100/1ML/25G X SPONGES LARGE 4" X 4" 51 II/SHORT/1ML/31G X 5/8" 67 BASAGLAR KWIKPEN 16 5/16" 66 BD INSULIN BASIC AM 94 BD INSULIN SYRINGE SYRINGE/DETACHABLE BASIC PM 94 ULTRAFINE/0.3ML/30G X NEEDLE/U-100/1ML/26G X BAYER MICROLET 2 LANCING 1/2" 66 1/2" 67 DEVICE 57 BD INSULIN SYRINGE BD INSULIN SYRINGE/U- BD LO-DOSE INSULIN ULTRAFINE/0.3ML/31G X 100/0.5ML/30G X 1/2" 67 SYRINGE MICROFINE 5/16" 66 BD INSULIN SYRINGE/U- IV/0.5ML/28G X 1/2" 66 BD INSULIN SYRINGE 100/1ML/27G X 1/2" 67 BD AUTOSHIELD 29G X ULTRAFINE/0.5ML/30G X BD INSULIN SYRINGE/U- 5/16" 66 1/2" 66 100/1ML/28G X 1/2" 67 BD INSULIN SYRINGE/U- BD GLUCOSE 16 100/2ML/27.5G X 5/8" 67

Index 3 BD INTEGRA INSULIN BIOGUARD GAUZE BUNAVAIL 6 SYRINGE/U-100/1ML/29G X SPONGES 4"X4" 12 PLY 51 buprenorphine hcl 6 1/2" 67 bisacodyl 50 BD INTEGRA buprenorphine hcl-naloxone hcl bismuth subsalicylate 17 dihydrate 6 SYRINGE/RETRACTING bisoprolol & NEEDLE/1ML/25G X 1" 67 bupropion hcl 13 hydrochlorothiazide 22 bupropion hcl (smoking BD LANCET DEVICE 57 bisoprolol fumarate 30 BD LANCET ULTRAFINE deterrent) 108 30G 57 BLEPH-10 104 buspirone hcl 8 BD SAFETY-GLIDE INSULIN BLEPHAMIDE 105 butalbital-acetaminophen 3 SYRINGE/0.5ML/29G X 1/2" 67 BLEPHAMIDE S.O.P. 105 butalbital-acetaminophen- BD SAFETY-LOK INSULIN BOOSTRIX 110 caffeine 3 SYRINGE/PERM butalbital-acetaminophen- NEEDLE/UF/1ML/29G X BORDERED GAUZE 51 caffeine w/ codeine 5 1/2" 67 BPROTECTED PEDIA TRI- butalbital-aspirin-caffeine 3 BD SAFETYGLIDE INSULIN VITE 100 butalbital-aspirin-caffeine SYSYRINGE/0.5ML/30G X BREATHERITE 88 w/cod 5 5/16" 67 BREATHERITE BYDUREON 16 BD SWABS SINGLE USE 64 COLLAPSIBLEADULT BYDUREON PEN 16 BD SWABS SINGLE USE SPACER W/MASK 88 BUTTERFLY 64 BREATHERITE BYETTA 16 BENADRYL ALLERGY 19 COLLAPSIBLECHILD SPACER CAFERGOT 91 BENADRYL ALLERGY W/MASK 88 caffeine citrate 1 BREATHERITE CHILDRENS 19 CAL-DAY 1000 94 benazepril & COLLAPSIBLEINFANT hydrochlorothiazide 22 SPACER W/MASK 88 CALAN 30 benazepril hcl 21 BREATHERITE CALAN SR 30 COLLAPSIBLESMALL CHILD calcipotriene 39 BENTYL 110 SPACER W/MASK 88 BENZAC AC WASH 37 BREATHERITE calcitonin (salmon) 45 benzonatate 34 COLLAPSIBLESPACER W/ calcitriol 45 NEONATE MASK 88 benzoyl peroxide 37 calcium acetate (phosphate BREATHERITE RIGID binder) 47 BENZOYL PEROXIDE 37 SPACERW/MASK 88 calcium carbonate (antacid) 6 BREATHERITE W/LARGE benzoyl peroxide 37 calcium polycarbophil 49 benztropine mesylate 24 MASK 88 BREATHERITE W/MEDIUM camphor & menthol 39 BETAGAN 103 MASK 88 capsaicin 41 betamethasone dipropionate BREATHERITE W/SMALL captopril 21 augmented 39 MASK 88 betamethasone valerate 39 CAPTOPRIL/HYDROCHLOROT BREVICON-28 32 HIAZIDE 22 BETAPACE 30 BRILINTA 48 CAPZASIN-HP 41 BETAPACE AF 30 brimonidine tartrate 104 CARAC 38 betaxolol hcl (ophth) 103 BRINTELLIX 14 CARAFATE 111 bethanechol chloride 112 bromocriptine mesylate 24 carbamazepine 10 BETOPTIC-S 103 brompheniramine & carbamide peroxide (otic) 106 phenyleph 35 BEXSERO 112 CARBATROL 11 BIATAIN ADHESIVE FOAM brompheniramine & DRESSING 4"X4" 51 pseudoeph 35 carbidopa 24 BIATAIN FOAM DRESSING BROTAPP DM 35 carbidopa-levodopa 24 4"X4" 51 BUBBLES THE FISH II CARDIOCOM LANCING BIAXIN 50 PEDIATRIC MASK/PVC 88 DEVICE 57 bicalutamide 24 budesonide (inhalation) 9 CARDIZEM 31 BIOGUARD GAUZE SPONGE BUFFERIN 4 CARDIZEM CD 30,31 2"X2" 8 PLY 51 bumetanide 44 CARDURA 21 BUMEX 44

Index 4 CAREFINE PEN NEEDLES CELEBREX 2 CHLOROQUINE 29GX1/2" 67 celecoxib 2 PHOSPHATE 23 CAREFINE PEN NEEDLES chloroquine phosphate 23 CELEXA 13 30GX5/16" 67 CHLOROTHIAZIDE 44 CAREFINE PEN NEEDLES CELLCEPT 92,93 chlorothiazide 44 32GX5MM 67 CENTANY 37 CAREONE ADVANCED chlorpheniramine maleate 19 CENTRAVITES 50 PLUS 94 LANCINGDEVICE 57 CHLORPROMAZINE HCL 26 CAREONE INSULIN CENTRAVITES ADULTS 94 chlorpromazine hcl 26 SYRINGES/0.3ML/30G X CENTRUM ADULTS 94 chlorthalidone 44 1/2" 67 CENTRUM CARDIO 95 CAREONE INSULIN CHLORZOXAZONE 102 CENTRUM MEN 95 SYRINGES/0.3ML/31G X CHOLBAM 46 5/16" 67 CENTRUM SILVER ULTRA CAREONE INSULIN MENS 95 cholestyramine 20 SYRINGES/0.5ML/30G X CENTRUM SILVER ULTRA cholestyramine light 20 1/2" 67 WOMENS 95 choline & mag salicylate 4 CAREONE INSULIN CENTRUM SPECIALIST SYRINGES/0.5ML/31G X HEART 95 cilostazol 48 5/16" 67 CENTRUM SPECIALIST CILOXAN 104 CAREONE INSULIN IMMUNE SUPPORT 95 cimetidine 110 CENTRUM SPECIALIST SYRINGES/1ML/30G X 1/2" 67 CIMETIDINE HCL 110 CAREONE INSULIN VISION 95 SYRINGES/1ML/31GX5/16" 67 CENTRUM ULTRA CIPRO 46 CAREONE LANCET THIN 57 WOMENS 95 CIPROFLOXACIN HCL 46 CAREONE LANCET ULTRA cephalexin 31 ciprofloxacin hcl 46 THIN 57 CERASPORT 92 ciprofloxacin hcl (ophth) 104 CAREONE UNIFINE PENTIPS CERASPORT EX1 92 29GX12MM 67 citalopram hydrobromide 13 CAREONE UNIFINE PENTIPS CEREBYX 12 clarithromycin 50 PLUS PEN NEEDLES CERTAVITE CLARITHROMYCIN 51 SENIOR/ANTIOXIDANT 29GX12MM 68 clarithromycin 51 CARETOUCH LANCING NUTRIENTS 95 DEVICEWITH EJECTOR 58 CERVARIX 112 CLARITIN 19 CARETOUCH PEN NEEDLES cetirizine hcl 19 CLARITIN ALLERGY 32GX 5MM 68 cetirizine-pseudoephedrine CHILDRENS 19 CARNITOR 45 35 CLARITIN REDITABS 19 CARNITOR SF 45 CHANTIX 109 CLARITIN-D 12 HOUR 35 CARRASMART 51 CHANTIX CONTINUING CLARITIN-D 24 HOUR 35 MONTHPAK 108 CLASS ACT LUBRICATED 55 CARRASMART FOAM 51 CHANTIX STARTING MONTH CARTEOLOL HCL 104 PAK 109 CLASSIC PRENATAL 100 carteolol hcl (ophth) 103 CHEK-STIX COMBO PAK CLEAN & CLEAR ADVANTAGE 3-IN-1 EXFOLIATING carvedilol 29 URINALYSIS CONTROL 42 CHEK-STIX CONTROL 42 CLEANSER 37 carvedilol phosphate 29 CLEANLET LANCETS 28G 58 CHEMET 18 CASODEX 24 CLEAR COUGH PM MULTI- CHEMSTRIP-K 42 CATAPRES 21 SYMPTOM 35 CHERACOL PLUS 35 cefaclor 31 clemastine fumarate 19 CHERACOL-D COUGH 35 CEFACLOR 31 CLEOCIN 7,114 CHILDRENS ADVIL 2 cefadroxil 31 CLEOCIN PEDIATRIC CHILDRENS MOTRIN 2 GRANULES 7 cefdinir 32 CHLOR-TRIMETON 19 CLEOCIN-T 37 cefprozil 32 CLEVER CHOICE ANTI- chlordiazepoxide hcl 8 CEFTIN 32 STATICVALVED HOLDING chlorhexidine gluconate 27 ceftriaxone sodium 32 CHAMBER/ADULT LARGE 88 chlorhexidine gluconate cefuroxime axetil 32 (mouth-throat) 93

Index 5 CLEVER CHOICE ANTI- CLIMARA 46 colestipol hcl 20 STATICVALVED HOLDING CLINDAGEL 37 COLYTE-FLAVOR PACKS 49 CHAMBER/MEDIUM 88 CLEVER CHOICE ANTI- clindamycin hcl 7 COMBIPATCH 46 STATICVALVED HOLDING clindamycin palmitate COMBIVENT RESPIMAT 9 CHAMBER/SMALL 88 hydrochloride 7 COMBIVIR 27 clindamycin phosphate CLEVER CHOICE COMFORT COMFORT ASSIST INSULIN EZINSULIN (topical) 37 clindamycin phosphate SYRINGE 0.3ML/29G X 1/2" 68 SYRINGE/0.3ML/29G X 1/2" 68 COMFORT ASSIST INSULIN CLEVER CHOICE COMFORT vaginal 114 CLINICAL NUTRIENTS 45- SYRINGE/0.3ML/30G X EZINSULIN 5/16" 68 SYRINGE/0.3ML/30G X 1/2" 68 PLUS WOMEN 95 CLINICAL NUTRIENTS 50- COMFORT ASSIST INSULIN CLEVER CHOICE COMFORT SYRINGE/0.3ML/31G X EZINSULIN PLUS MEN 95 CLINICAL NUTRIENTS FOR 5/16" 68 SYRINGE/0.3ML/30G X COMFORT ASSIST INSULIN 5/16" 68 FEMALE TEENS 95 CLINICAL NUTRIENTS FOR SYRINGE/0.5ML/29G X 1/2" 68 CLEVER CHOICE COMFORT COMFORT ASSIST INSULIN EZINSULIN MALE TEENS 95 CLINICAL NUTRIENTS FOR SYRINGE/0.5ML/30G X SYRINGE/0.3ML/31G X 5/16" 68 5/16" 68 MEN 95 CLINICAL NUTRIENTS FOR COMFORT ASSIST INSULIN CLEVER CHOICE COMFORT SYRINGE/0.5ML/31G X EZINSULIN WOMEN 95 clobetasol propionate 39 5/16" 68 SYRINGE/0.5ML/28G X 1/2" 68 COMFORT ASSIST INSULIN CLEVER CHOICE COMFORT clobetasol propionate emollient SYRINGE/1ML/29G X 1/2" 69 EZINSULIN base 39 COMFORT ASSIST INSULIN SYRINGE/0.5ML/29G X 1/2" 68 clomipramine hcl 15 SYRINGE/1ML/30G X 5/16" 69 CLEVER CHOICE COMFORT clonazepam 10 COMFORT ASSIST INSULIN EZINSULIN clonidine hcl 21 SYRINGE/1ML/31G X 5/16" 69 SYRINGE/0.5ML/30G X 1/2" 68 COMFORT ASSURED CLEVER CHOICE COMFORT clonidine hcl (adhd) 1 LANCETS MICRO THIN EZINSULIN clopidogrel bisulfate 48 33G 58 SYRINGE/0.5ML/30G X clorazepate dipotassium 8 COMFORT ASSURED 5/16" 68 CLOSERCARE 58 LANCETS SUPER THIN CLEVER CHOICE COMFORT 28G 58 EZINSULIN clotrimazole (topical) 38 COMFORT LANCETS 58 SYRINGE/0.5ML/31G X clotrimazole vaginal 114 COMPACT SPACE 5/16" 68 clotrimazole w/ CHAMBER/ANTI-STATIC 88 CLEVER CHOICE COMFORT betamethasone 38 COMPACT SPACE EZINSULIN clozapine 26 CHAMBER/ANTI- SYRINGE/1.0ML/30G X 1/2" 68 CLOZARIL 26 STATIC/LARGE MASK 88 CLEVER CHOICE COMFORT COMPACT SPACE EZINSULIN SYRINGE/1ML/28G CO MONITOR REPLACEMENT TPIECES88 CHAMBER/ANTI- X 1/2" 68 STATIC/MEDIUM MASK 88 CLEVER CHOICE COMFORT CO-NATAL FA 100 COMPACT SPACE EZINSULIN SYRINGE/1ML/29G coal tar extract 42 CHAMBER/ANTI-STATIC/SMALL X 1/2" 68 MASK 88 CLEVER CHOICE COMFORT COARTEM 23 EZINSULIN SYRINGE/1ML/30G codeine sulfate 4 COMPLERA 27 X 5/16" 68 CODEINE SULFATE 4 COMPLETENATE 100 CLEVER CHOICE COMFORT COLACE 50 CONCERTA 1 EZINSULIN SYRINGE/U- CONDYLOX 41 100/1ML/31GX5/16" 68 COLAZAL 47 CLEVER CHOICE COMFORT COLCHICINE 48 CONE MASK 88 EZPEN NEEDLES colchicine w/ probenecid 47 COPA ISLAND BORDERED FOAM DRESSING 4"X4" 51 29GX12MM 68 COLCRYS 48 CLEVER CHOICE COMFORT COPA PLUS HYDROPHILIC EZPEN NEEDLES COLESTID 20 FOAM DRESSING 4"X4" 51 32GX5MM 68 COLESTID FLAVORED 20 COPAXONE 108

Index 6 COREG 30 CURITY DRESSING CVS LANCING DEVICE 58 COREG CR 29 SPONGES 4"X4" 6 PLY 52 CVS ONE DAILY MENS 50+ CURITY GAUZE PADS CORGARD 30 ADVANCED 95 2"X2" 52 CVS PRENATAL 100 CORTANE-B-OTIC 106 CURITY GAUZE PADS 2"X2" CVS PREP PADS 64 CORTEF 34 12 PLY 52 CURITY GAUZE PADS CVS SPECTRAVITE ADULT CORTENEMA 6 3"X3" 52 50+ 95 CORTISONE ACETATE 34 CURITY GAUZE PADS 4"X4" CVS SPECTRAVITE ULTRA COSOPT 104 12 PLY 52 MEN50+ 95 CVS SPECTRAVITE ULTRA COTELLIC 24 CURITY GAUZE SPONGE 2"X2" 8 PLY 52 MENS HEALTH 95 COUMADIN 10 CURITY GAUZE SPONGE CVS SPECTRAVITE ULTRA COVRSITE COVER 2"X2"12 PLY 52 MENS HEALTH SENIOR 95 DRESSING 51 CURITY GAUZE SPONGE CVS SPECTRAVITE ULTRA COVRSITE PLUS COMPOSITE 3"X3" 12 PLY 52 WOMEN 95 DRESSING 51 CURITY GAUZE SPONGE CVS SPECTRAVITE ULTRA COZAAR 21 4"X4" 12 PLY 52 WOMENS HEALTH 95 CREON 43 CURITY GAUZE SPONGE CVS SPECTRAVITE ULTRA 4"X4" 16 PLY 52 WOMENS HEALTH CRESTOR 20 CURITY GAUZE SPONGE SENIOR 95 CRIXIVAN 27 4"X4" 8 PLY 52 CVS ULTRA THIN cromolyn sodium 9 CURITY GAUZE SPONGE LANCETS 58 cromolyn sodium (nasal) 103 4"X4"16 PLY 52 cyanocobalamin 48 CURITY GAUZE SPONGES CYCLESSA 32 cromolyn sodium (ophth) 106 4"X4" 12 PLY 52 CUREX ALL-PURPOSE CURITY GAUZE SPONGES cyclobenzaprine hcl 102 SPONGES 4"X4" 4 PLY 51 4"X4" 8 PLY 52 CYCLOGYL 104 CURITY ALCOHOL CURITY NON-ADHERENT cyclopentolate hcl 104 PREPS/MEDIUM 2 PLY 64 STRIPS 3"X3" 52 cyclosporine 93 CURITY ALCOHOL SWABS 64 CURITY SPONGES/CELLULOSEFILLE CYCLOSPORINE CURITY ALL PURPOSE MODIFIED 93 SPONGES 2"X2" 52 D/2"X2" 52 CURITY cyclosporine modified (for CURITY ALL PURPOSE microemulsion) 93 SPONGES 2"X2" 4PLY 51 SPONGES/CELLULOSEFILLE CURITY ALL PURPOSE D/4"X4" 52 CYMBALTA 14 SPONGES 3"X3" 4PLY 52 CUTIVATE 39 cyproheptadine hcl 20 CURITY ALL PURPOSE CVS ALCOHOL PREP CYTOMEL 109 SPONGES 4 PLY 52 SWABS 64 CYTOTEC 111 CURITY ALL PURPOSE CVS ALCOHOL SWABS 64 D.H.E. 45 91 SPONGES 4"X4" 52 CVS GAUZE PADS 2"X2" 12- CURITY ALL PURPOSE PLY 52 dapsone 7 SPONGES 4"X4" 4PLY 52 CVS GAUZE PADS 4"X4" 12- DAY TIME MULTI-SYMPTOM CURITY ALL PURPOSE PLY 52 COLD/FLU RELIEF 35 SPONGES 4"X4" 4PLY/SOFT CVS GAUZE PADS STERILE DAYPRO 2 POUCH 52 4"X4" 12-PLY 52 CURITY AMD DDAVP 45 ANTIMICROBIALGAUZE CVS GLUCOSE 16 DEBROX 106 SPONGES 2"X2" 8 PLY 52 CVS LANCETS 21G 58 DELSYM 34 CURITY AMD CVS LANCETS MICRO THIN DELSYM COUGH ANTIMICROBIALGAUZE 33G 58 CHILDRENS 34 SPONGES 4"X4" 12 PLY 52 CVS LANCETS MICRO-THIN DELZICOL 47 CURITY COVER SPONGE 33G 58 4"X4" 52 CVS LANCETS ORIGINAL58 DEMADEX 44 CURITY COVER SPONGES CVS LANCETS THIN 26G 58 DEMEROL 4 3"X3" 52 CVS LANCETS ULTRA THIN DEPACON 12 CURITY COVER SPONGES 58 4"X4" 52 30G DEPAKENE 12 CVS LANCETS ULTRA-THIN DEPAKOTE 12 30G 58

Index 7 DEPAKOTE ER 12 DERMOTIC 106 DIAZEPAM 8 DEPAKOTE SPRINKLES 12 DESCOVY 27 diazepam 8 DEPEN TITRATABS 92 desipramine hcl 15 DIAZEPAM 10 DEPO-PROVERA desmopressin acetate 45 DIAZEPAM RECTAL GEL 10 CONTRACEPTIVE 33 desmopressin acetate dibucaine 41 DEPO-SUBQ PROVERA refrigerated 45 diclofenac potassium 2 104 33 desmopressin acetate DEPO-TESTOSTERONE 6 spray 45 diclofenac sodium 2 DERMACEA DRAIN SPONGES desmopressin acetate spray diclofenac sodium (ophth) 106 4"X4" 52 refrigerated 45 diclofenac sodium (topical) 37 DERMACEA GAUZE SPONGE DESOGEN 32 dicloxacillin sodium 107 2"X2" 12 PLY 52 desogestrel & ethinyl DERMACEA GAUZE SPONGE estradiol 32 dicyclomine hcl 110 2"X2" 8 PLY 52 desogestrel-ethinyl estradiol didanosine 27 DERMACEA GAUZE SPONGE (biphasic) 32 DIFLORASONE 3"X3" 12 PLY 52 desogestrel-ethinyl estradiol DIACETATE 39 DERMACEA GAUZE SPONGE (triphasic) 32 DIFLUCAN 18 3"X3" 8 PLY 52 desoximetasone 39 DERMACEA GAUZE SPONGE diflunisal 4 4"X4" 12 PLY 52 DESQUAM-X WASH 37 DIGOXIN 31 DERMACEA GAUZE SPONGE desvenlafaxine succinate 14 digoxin 31 4"X4" 16 PLY 53 DETROL 112 DERMACEA GAUZE SPONGE dihydroergotamine mesylate 91 4"X4" 8 PLY 53 DETROL LA 112 DIHYDROERGOTAMINE DERMACEA I.V. DRAIN DEX4 QUICK DISSOLVE MESYLATE 91 SPONGES 2"X2" 53 GLUCOSE 16 DILANTIN 12 DERMACEA I.V. DRAIN dexamethasone 34 DILANTIN INFATABS 12 SPONGES 4"X4" 53 DEXAMETHASONE 34 DILANTIN-125 12 DERMACEA I.V. SPONGES dexamethasone 34 2"X2" 53 DILAUDID 4 DERMACEA NON-WOVEN DEXAMETHASONE 34 diltiazem hcl 31 SPONGES 2"X2" 4 PLY 53 DEXAMETHASONE diltiazem hcl coated beads 31 INTENSOL 34 DERMACEA NON-WOVEN diltiazem hcl extended release SPONGES 3"X3" 4 PLY 53 dexamethasone sodium DERMACEA NON-WOVEN phosphate 34 beads 31 SPONGES 4"X4" 4 PLY 53 DEXAMETHASONE SODIUM dimenhydrinate 18 DERMACEA NON-WOVEN PHOSPHATE 105 DIMETAPP COLD & SPONGES 4"X4" 6 PLY 53 DEXEDRINE 1 ALLERGY 35 DIMETAPP LONG ACTING DERMACEA TYPE VII GAUZE DEXILANT 111 2"X2" 12 PLY 53 COUGH PLUS COLD 35 DERMACEA TYPE VII GAUZE dexmethylphenidate hcl 1 DIOVAN 21 2"X2" 8 PLY 53 dextroamphetamine sulfate 1 DIOVAN HCT 22 DERMACEA TYPE VII GAUZE dextromethorphan diphenhydramine hcl 19 3"X3" 12 PLY 53 polistirex 34 DERMACEA TYPE VII GAUZE dextromethorphan-doxylamine- diphenhydramine hcl (sleep) 48 3"X3" 12PLY 53 acetaminophen 35 diphenoxylate w/ atropine 17 DERMACEA TYPE VII GAUZE dextromethorphan-guaifenesin DIPHENOXYLATE/ATROPINE 4"X4" 12 PLY 53 35 17 DERMACEA TYPE VII GAUZE dextromethorphan- DIPHTHERIA/TETANUS 4"X4" 16 PLY 53 phenylephrine-acetaminophen TOXOIDS ADSORBED DERMACEA TYPE VII GAUZE 35 PEDIATRIC 110 4"X4" 8 PLY 53 DHS TAR 42 DIPROLENE AF 40 DERMACEA X-RAY SPONGES 4"X4" 16 PLY 53 DHS TAR GEL 42 dipyridamole 48 DERMALEVIN ADHESIVE DIAMOX 44 DISALCID 4 FOAMDRESSING 4"X4" 53 DIASTAT ACUDIAL 10 disopyramide phosphate 8 DERMATOP 39 DIASTAT PEDIATRIC 10 DISPOSABLE MOUTHPIECE DERMAVITE 95 FULL RANGE 88

Index 8 DISPOSABLE MOUTHPIECE DRYMAX EXTRA 53 EASY COMFORT INSULIN LOWRANGE/PEDIATRIC 88 DRYSOL 41 SYRINGE/U-100/0.5ML/30G X DISPOSABLE 1/2" 69 MOUTHPIECE/LOW DUANE READE LANCET EASY COMFORT INSULIN RANGE 88 ALTERNATE SITE 26G 58 SYRINGE/U-100/1ML/30G X DISPOSABLE DUANE READE LANCET 1/2" 69 SUPERTHIN 30G 58 EASY MINI EJECT LANCING MOUTHPIECE/UNIVERSAL DUANE READE LANCET RANGE 88 DEVICE 58 DISPOSABLE PAPER ULTRATHIN 28G 58 EASY MINI LANCING 88 DUANE READE UNIFINE DEVICE 58 MOUTHPIECE PENTIPS 29G X 12MM 69 108 EASY TOUCH 32GX5MM 69 disulfiram DULCOLAX 50 112 EASY TOUCH ALCOHOL PREP DITROPAN XL DULERA 9 divalproex sodium 12 PADS/MEDIUM 64 duloxetine hcl 14 EASY TOUCH FLIPLOCK 50 docusate sodium DURAGESIC 4 SAFETY INSULIN SYRINGE dofetilide 9 DUREX EXTRA 1ML/29GX1/2" 69 DOLOPHINE 4 SENSITIVE 55 EASY TOUCH FLIPLOCK DUTOPROL 22 SAFETY INSULIN SYRINGE donepezil hydrochloride 108 1ML/30GX1/2" 69 DONNATAL 110 DYAZIDE 44 EASY TOUCH FLIPLOCK dorzolamide hcl 106 E-Z JECT LANCETS 58 SAFETY INSULIN SYRINGE dorzolamide hcl-timolol E-Z JECT LANCETS 21G 58 1ML/30GX5/16" 69 maleate 104 E-Z JECT LANCETS EASY TOUCH FLIPLOCK DOVONEX 39 COLOR 58 SAFETY INSULIN SYRINGE 1ML/31GX5/16" 69 doxazosin mesylate 21 E-Z JECT LANCETS SUPER THIN 30G 58 EASY TOUCH INSULIN doxepin hcl 15 E-Z JECT LANCETS THIN SYRINGE/0.3ML/30G X doxycycline hyclate 109 26G 58 5/16" 69 doxylamine succinate EASY TOUCH INSULIN E-Z SPACER 88 SYRINGE/0.3ML/31G X (sleep) 48 E-Z SPACER THE BODY DRAMAMINE 18 5/16" 69 GUARDS PACK 88 EASY TOUCH INSULIN DRESSING SPONGES E-ZJECT LANCETS MICRO- SYRINGE/0.5ML/29G X 1/2" 69 4"X4" 53 THIN 33G 58 EASY TOUCH INSULIN DRISDOL 115 E.E.S. 400 51 SYRINGE/0.5ML/30G X DROPLET LANCETS ULTRA E.E.S. GRANULES 51 5/16" 69 THIN 30G 58 EARLOOP MASK 88 EASY TOUCH INSULIN DROPLET LANCING SYRINGE/1ML/30G X 5/16" 69 DEVICE 58 EASIVENT 88 EASY TOUCH INSULIN DROPLET PEN NEEDLES EASIVENT/MASK-LARGE 88 SYRINGE/SAFETY/U- 29GX12MM 69 EASIVENT/MASK-MEDIUM 100/0.5ML/29G X 1/2" 69 DROPLET PEN NEEDLES 32G 88 EASY TOUCH INSULIN X 3/16" 69 EASIVENT/MASK-SMALL 88 SYRINGE/SAFETY/U- DROPLET PEN NEEDLES EASY COMFORT INSULIN 100/0.5ML/30G X 5/16" 69 32GX5MM 69 EASY TOUCH INSULIN drospirenone-ethinyl SYRINGE/0.3ML/30G X 5/16" 69 SYRINGE/SAFETY/U- estradiol 32 EASY COMFORT INSULIN 100/1ML/29G X 1/2" 69 DROXIA 48 SYRINGE/0.5ML/30G X EASY TOUCH INSULIN DRUG MART ADJUSTABLE 5/16" 69 SYRINGE/SAFETY/U- LANCING DEVICE 58 EASY COMFORT INSULIN 100/1ML/30G X 1/2" 69 DRUG MART LANCETS SYRINGE/0.5ML/31G X EASY TOUCH INSULIN THIN 58 5/16" 69 SYRINGE/U-100/0.3ML/30G X DRUG MART UNIFINE EASY COMFORT INSULIN 1/2" 70 PENTIPS29G X 12MM 69 SYRINGE/1ML/30G X EASY TOUCH INSULIN DRUG MART UNILET 5/16" 69 SYRINGE/U-100/0.5ML/27G X LANCETSSUPER THIN 30G58 EASY COMFORT INSULIN 1/2" 70 DRUG MART UNILET SYRINGE/1ML/31G X EASY TOUCH INSULIN LANCETSULTRA THIN 28G 58 5/16" 69 SYRINGE/U-100/0.5ML/28G X 1/2" 70

Index 9 EASY TOUCH INSULIN EASYTEST II LANCETS 59 ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/30G X EASYTEST LANCETS 59 SYRINGE/U-100/1ML/28G X 1/2" 70 1/2" 70 EASY TOUCH INSULIN EBASE CONTROLLER ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/31G X KIT 88 SYRINGE/U-100/1ML/28G X 5/16" 70 EC-NAPROSYN 2 5/16" 70 EASY TOUCH INSULIN econazole nitrate 38 ELITE-THIN INSULIN SYRINGE/U-100/1ML/27G X ECOTRIN REGULAR SYRINGE/U-100/1ML/29G X 1/2" 70 STRENGTH 4 1/2" 70 EASY TOUCH INSULIN ED BRON GP 35 ELITE-THIN INSULIN SYRINGE/U-100/1ML/28G X EDURANT 27 SYRINGE/U-100/1ML/31G X 1/2" 70 5/16" 71 EASY TOUCH INSULIN efavirenz 27 ELIXOPHYLLIN 10 SYRINGE/U-100/1ML/29G X EFFEXOR XR 14 ELLA 33 1/2" 70 EFFIENT 48 ELMIRON 47 EASY TOUCH INSULIN EFLOW SCF AEROSOL SYRINGE/U-100/1ML/30G X HEAD 89 ELOCON 40 1/2" 70 EMLA 41 EASY TOUCH INSULIN EFUDEX 38 SYRINGE/U-100/1ML/31G X ELAVIL 15 EMTRIVA 27 5/16" 70 ELDEPRYL 25 EMVERM 7 EASY TOUCH LANCETS eletriptan hydrobromide 91 enalapril maleate 21 26G/PULL-TOP 58 ELEXA NATURAL FEEL 55 enalapril maleate & EASY TOUCH LANCETS hydrochlorothiazide 22 26G/TWIST 58 ELEXA STIMULATING 55 ENBREL 3 EASY TOUCH LANCETS ELEXA ULTRA 28G/PULL-TOP 58 SENSITIVE 55 ENBREL SURECLICK 3 EASY TOUCH LANCETS ELIDEL 41 ENFAMIL ENFALYTE 92 28G/TWIST 58 ENGERIX-B 112 EASY TOUCH LANCETS ELIMITE 42 30G/PULL-TOP 58 ELIQUIS 10 enoxaparin sodium 10 EASY TOUCH LANCETS ELIQUIS STARTER PACK 10 EPANED 21 30G/TWIST 58 ELITE DC AUTO EPIFOAM 40 EASY TOUCH LANCETS ADAPTER 89 epinephrine (anaphylaxis) 114 32G/PULL-TOP 58 ELITE-THIN INSULIN EPIVIR 27 EASY TOUCH LANCETS SYRINGE/0.3ML/31G X 32G/TWIST 58 5/16" 70 EPZICOM 27 EASY TOUCH LANCETS ELITE-THIN INSULIN EQ COMPLETE 33G/TWIST 58 SYRINGE/0.5ML/29G X MULTIVITAMINADULTS UNDER EASY TOUCH LANCING 1/2" 70 50 95 DEVICE/EJECTOR 58 ELITE-THIN INSULIN EQ ONE DAILY MENS 50+ 95 EASY TOUCH PEN NEEDLE SYRINGE/0.5ML/30G X EQ ONE DAILY MENS 30G X 5/16" 70 5/16" 70 HEALTH 95 EASY TOUCH PEN NEEDLES ELITE-THIN INSULIN EQ ONE DAILY WOMENS 29GX1/2" 70 SYRINGE/1ML/29G X 50+ 95 EASY TOUCH PEN NEEDLES 5/16" 70 EQ ONE DAILY WOMENS 32GX3/16" 70 ELITE-THIN INSULIN HEALTH 95 EASY TOUCH SHEATHLOCK SYRINGE/1ML/30G X SAFETY INSULIN SYRINGE EQL ALCOHOL SWABS 64 5/16" 70 EQL CENTURY MATURE 1ML/29GX1/2" 70 ELITE-THIN INSULIN EASY TOUCH SHEATHLOCK ADULTS50+ 95 SYRINGE/U-100/0.5ML/28G X EQL CENTURY MENS 95 SAFETY INSULIN SYRINGE 1/2" 70 1ML/30GX5/16" 70 ELITE-THIN INSULIN EQL CENTURY WOMENS 95 EASY TOUCH SHEATHLOCK SYRINGE/U-100/0.5ML/29G X EQL COLOR LANCETS 21G59 SAFETY INSULIN SYRINGE 5/16" 70 EQL COLOR LANCETS MICRO 1ML/31GX5/16" 70 ELITE-THIN INSULIN THIN 33G 59 EASY TOUCH SHEATHLOCK SYRINGE/U-100/0.5ML/31G X EQL GAUZE PADS SAFETY SYRINGE 5/16" 70 2"X2"/SMALL 53 1ML/30GX1/2" 70

Index 10 EQL GAUZE PADS ERYGEL 37 EXEL COMFORT POINT 4"X4"/LARGE 53 ERYPED 200 51 INSULIN SYRINGE/0.3ML/30G X EQL GAUZE PADS STERILE 5/16" 71 3"X3"/MEDIUM 53 ERYPED 400 51 EXEL COMFORT POINT EQL GAUZE STERILE PADS ERYTHROCIN INSULIN SYRINGE/0.5ML/28G X 3"X3" 53 STEARATE 51 1/2" 71 EQL INSULIN erythromycin (acne aid) 37 EXEL COMFORT POINT SYRINGE/0.3ML/29G X 1/2" 71 erythromycin (ophth) 104 INSULIN SYRINGE/0.5ML/29G X EQL INSULIN 1/2" 71 SYRINGE/0.3ML/30G X erythromycin base 51 EXEL COMFORT POINT 5/16" 71 erythromycin INSULIN SYRINGE/0.5ML/30G X EQL INSULIN ethylsuccinate 51 5/16" 71 SYRINGE/0.3ML/31G X ERYTHROMYCIN EXEL COMFORT POINT 5/16" 71 ETHYLSUCCINATE 51 INSULIN SYRINGE/1ML/28G X EQL INSULIN escitalopram oxalate 13 1/2" 71 SYRINGE/0.5ML/29G X 1/2" 71 ESGIC 3 EXEL COMFORT POINT EQL INSULIN esomeprazole INSULIN SYRINGE/1ML/29G X SYRINGE/0.5ML/30G X magnesium 111 1/2" 71 5/16" 71 esterified estrogens & EXEL COMFORT POINT EQL INSULIN methyltestosterone 46 INSULIN SYRINGE/1ML/30G X SYRINGE/0.5ML/31G X ESTRACE 46 5/16" 71 5/16" 71 EXELON 108 EQL INSULIN estradiol 46 SYRINGE/1ML/29G X 1/2" 71 estradiol & norethindrone exemestane 24 EQL INSULIN acetate 46 EXPIRATORY SYRINGE/1ML/30G X 5/16" 71 estradiol vaginal 114 MOUTHPIECE 89 EXTRA SENSITIVE EQL INSULIN ESTROPIPATE 46 SYRINGE/1ML/31G X 5/16" 71 SPERMICIDAL 55 EQL INSULIN SYRINGE/U- ESTROSTEP FE 32 EZ SMART BLOOD GLUCOSE 100/0.3ML/29G X 1/2" 71 ethambutol hcl 23 LANCETS 59 EQL INSULIN SYRINGE/U- ethosuximide 12 EZ-LETS LANCETS 23G 59 100/0.5ML/29G X 1/2" 71 ethynodiol diacet & eth EZ-LETS LANCETS 26G EQL INSULIN SYRINGE/U- estrad 32 SUPER-SOFT 59 100/1ML/29G X 1/2" 71 etodolac 2 EZ-LETS LANCETS 28G 95 ULTRA-SOFT 59 EQL MEGA SELECT MENS EURAX 42 EQL MEGA SELECT EZ-LETS LANCETS 30G 59 WOMENS 95 EVISTA 45 famciclovir 29 EQL ONE DAILY DIET EVOTAZ 27 famotidine 110 SUPPORT 95 EVZIO 18 FAMVIR 29 EQL ONE DAILY MENS 95 EXCILON AMD EQL ONE DAILY MENS 50+ ANTIMICROBIALDRAIN FANTASY LUBRICATED 55 ADVANCED 95 SPONGES 4"X4" 6 PLY 53 FANTASY EQL PRENATAL EXCILON AMD LUBRICATED/SPERMICIDE FORMULA 100 ANTIMICROBIALNON-WOVEN 55 EQL SUPER THIN LANCETS SPONGES 4"X4" 6 PLY 53 FARESTON 24 30G 59 EXCILON DRAIN SPONGE felbamate 12 EQL THIN LANCETS 26G 59 4"X4" 53 FELBATOL 12 EQL ULTRA COMFORT EXCILON DRAIN SPONGES INSULINSYRINGE/0.3ML/31G X 4"X4" 6 PLY 53 FELDENE 2 5/16" 71 EXCILON I.V. SPONGES 2"X2" felodipine 31 EQL ULTRA COMFORT 6 PLY 53 FEMARA 24 EXEL COMFORT POINT INSULINSYRINGE/1ML/30G X FEMCON FE 32 5/16" 71 INSULIN PEN NEEDLES 29G ergocalciferol 115 X 12MM 71 FEMHRT LOW DOSE 46 EXEL COMFORT POINT ERGOLOID MESYLATES 108 fenofibrate 20 INSULIN SYRINGE/0.3ML/29G fenofibrate micronized 20 ergotamine w/ caffeine 91 X 1/2" 71 ERY-TAB 51 fentanyl 4

Index 11 FERRETTS 48 FLUARIX QUADRIVALENT FLUZONE HIGH-DOSE PF 2017- ferrous fumarate 48 2015-2016 112 2018 113 FLUARIX QUADRIVALENT FLUZONE INTRADERMAL ferrous sulfate 48 2016-2017 113 QUADRIVALENT 2015- fexofenadine hcl 19 FLUARIX QUADRIVALENT 2016 113 FIASP 16 2017-2018 113 FLUZONE INTRADERMAL QUADRIVALENT 2016- FIASP FLEXTOUCH 16 FLUBLOK 2015-2016 113 FLUBLOK 2016-2017 113 2017 113 FIBERCON 49 FLUZONE INTRADERMAL FIFTY50 ALCOHOL PREP FLUBLOK 2017-2018 113 QUADRIVALENT 2017- PADS 64 FLUCELVAX 2015-2016 113 2018 113 FIFTY50 LANCING DEVICE 59 FLUCELVAX QUADRIVALENT FLUZONE QUADRIVALENT FIFTY50 SUPERIOR 2017-2018 113 2015-2016 113 COMFORTINSULIN fluconazole 18 FLUZONE QUADRIVALENT SYRINGE/0.3ML/31G X fludrocortisone acetate 34 2016-2017 113 5/16" 71 FLUZONE QUADRIVALENT FLULAVAL QUADRIVALENT 2017-2018 113 FIFTY50 SUPERIOR 2014-2015 113 COMFORTINSULIN FLULAVAL QUADRIVALENT FML 105 SYRINGE/0.5ML/31G X 2015-2016 113 FML LIQUIFILM 105 5/16" 71 FLULAVAL QUADRIVALENT FOCALIN 1 FIFTY50 SUPERIOR 2016-2017 113 folic acid 48 COMFORTINSULIN FLULAVAL QUADRIVALENT SYRINGE/1ML/31G X 5/16" 71 2017-2018 113 FORA LANCETS 59 FIFTY50 UNILET LANCETS FLUMIST FORA LANCING DEVICE 59 33G 59 QUADRIVALENT 113 FORA LANCING FILTER AIR PP 89 FLUNISOLIDE 103 DEVICE/CLEARCAP 59 finasteride 47 fluocinolone acetonide formaldehyde 26 FIORINAL 3 (otic) 106 FORTICAL 45 FIORINAL/CODEINE #3 5 fluocinonide 40 FOSAMAX 45 FIRST-VANCOMYCIN 25 7 fluocinonide emulsified base 40 fosamprenavir calcium 27 FIRST-VANCOMYCIN 50 7 fluorometholone (ophth) 105 fosinopril sodium 21 FITNESS TABS FOR MEN FLUOROURACIL 38,39 fosinopril sodium & AM/PM/LYCOPENE 95 hydrochlorothiazide 22 FITNESS TABS FOR WOMEN fluorouracil (topical) 38 fosphenytoin sodium 12 AM/PM/LYCOPENE 95 fluoxetine hcl 13 FREDS PHARMACY AUTOLET FLAGYL 7 fluphenazine decanoate 26 LANCING DEVICE 59 flavoxate hcl 112 fluphenazine hcl 26 FREDS PHARMACY UNILET flecainide acetate 8 LANCETS SUPER THIN FLURAZEPAM HCL 49 30G 59 FLEET ENEMA 50 flurbiprofen 2 FREDS PHARMACY UNILET FLEET ENEMA SIX PACK 50 FLURBIPROFEN LANCETS ULTRA THIN FLEET PEDIATRIC 50 SODIUM 106 28G 59 FLEXICHAMBER 89 flurbiprofen sodium 106 FREEDAVITE 95 FLEXZAN 4 X 4 53 flutamide 24 FREESTYLE PRECISION fluticasone propionate 40 INSULIN SYRINGE/U- FLOMAX 47 100/0.5ML/30G X 5/16" 72 FLONASE ALLERGY fluticasone propionate FREESTYLE PRECISION RELIEF 103 (nasal) 103 INSULIN SYRINGE/U- FLONASE ALLERGY RELIEF FLUVIRIN 2015-2016 113 100/0.5ML/31G X 5/16" 72 CHILDRENS 103 FLUVIRIN 2016-2017 113 FREESTYLE PRECISION FLORIVA PLUS 98 FLUVIRIN 2017-2018 113 INSULIN SYRINGE/U- FLOVENT DISKUS 9 100/1ML/31G X 5/16" 72 fluvoxamine maleate 13 FREESTYLE PRECISION FLOVENT HFA 9 FLUZONE HIGH-DOSE PF INSULIN SYRINGES/U- FLOXIN OTIC 106 2015-2016 113 100/1ML/30G X 5/16" 72 FLUZONE HIGH-DOSE PF 2016-2017 113 FULL KIT NEBULIZER SET 89

Index 12 FURADANTIN 112 glipizide-metformin hcl 15 GLUCAGON EMERGENCY furosemide 44 GLOBAL EASE INJECT PEN KIT 16 GLUCOCOM LANCETS FUROSEMIDE 44 NEEDLES 29GX12MM 72 GLOBAL EASY GLIDE 28G 59 furosemide 44 INSULINSYRINGE/U- GLUCOCOM LANCETS gabapentin 11 100/0.3ML/31G X 5/16" 72 30G 59 GLUCOLET 2 AUTOMATIC GABITRIL 12 GLOBAL INJECT EASE INSULIN SYRINGE/U- LANCING DEVICE 59 galantamine hydrobromide 108 100/0.3ML/29G X 1/2" 72 GLUCOPHAGE 15 GALANTAMINE GLOBAL INJECT EASE GLUCOPHAGE XR 15 HYDROBROMIDE 108 INSULIN SYRINGE/U- GLUCOPRO INSULIN galantamine hydrobromide 108 100/0.3ML/30G X 1/2" 72 SYRINGE/U-100/0.3ML/30G X GARDASIL 113 GLOBAL INJECT EASE 1/2" 72 GARDASIL 9 113 INSULIN SYRINGE/U- GLUCOPRO INSULIN 100/0.3ML/30G X 5/16" 72 GAS-X 46 SYRINGE/U-100/0.3ML/30G X GLOBAL INJECT EASE 5/16" 72 GAUZE DRESSING 4"X4" 53 INSULIN SYRINGE/U- GLUCOPRO INSULIN GAUZE PADS 2"X2" 53 100/0.3ML/31G X 5/16" 72 SYRINGE/U-100/0.3ML/31G X GAUZE PADS 3"X3" 53 GLOBAL INJECT EASE 5/16" 73 INSULIN SYRINGE/U- GLUCOPRO INSULIN GAUZE PADS 4"X4" 53 100/0.5ML/28G X 1/2" 72 SYRINGE/U-100/0.5ML/30G X GAUZE PADS 4"X4" 12 PLY 53 GLOBAL INJECT EASE 1/2" 73 GAUZE SPONGE TYPE VII INSULIN SYRINGE/U- GLUCOPRO INSULIN MEDI-PAK 2"X2" 8PLY 53 100/0.5ML/29G X 1/2" 72 SYRINGE/U-100/0.5ML/30G X GAUZE SPONGES 4"X4" 54 GLOBAL INJECT EASE 5/16" 73 GAUZE SPONGES 4"X4" 12 INSULIN SYRINGE/U- GLUCOPRO INSULIN PLY 54 100/0.5ML/30G X 1/2" 72 SYRINGE/U-100/0.5ML/31G X GEL-KAM ORAL CARE GLOBAL INJECT EASE 5/16" 73 RINSE 93 INSULIN SYRINGE/U- GLUCOPRO INSULIN gemfibrozil 20 100/0.5ML/30G X 5/16" 72 SYRINGE/U-100/1ML/30G X GLOBAL INJECT EASE 1/2" 73 GENERESS FE 32 INSULIN SYRINGE/U- GLUCOPRO INSULIN GENTAK 104 100/0.5ML/31G X 5/16" 72 SYRINGE/U-100/1ML/30G X gentamicin sulfate (ophth) 104 GLOBAL INJECT EASE 5/16" 73 INSULIN SYRINGE/U- gentamicin sulfate (topical) 38 GLUCOPRO INSULIN 100/1ML/28G X 1/2" 72 SYRINGE/U-100/1ML/31G X GENTLE-LET GP LANCETS59 GLOBAL INJECT EASE 5/16" 73 GENTLE-LET LANCETS INSULIN SYRINGE/U- GLUCOSE 16 GENERAL PURPOSE 100/1ML/29G X 1/2" 72 GLUCOSOURCE LANCET STYLE/FINE POINT 59 GLOBAL INJECT EASE 59 GENTLE-LET LANCETS INSULIN SYRINGE/U- DEVICE GENERAL PURPOSE 100/1ML/30G X 1/2" 72 GLUCOSOURCE LANCETS 59 STYLE/MEDIUM POINT 59 GLOBAL INJECT EASE GLUCOTROL 17 GENTLE-LET LANCETS INSULIN SYRINGE/U- GLUCOTROL XL 17 SAFETY STYLE/FINE 100/1ML/30G X 5/16" 72 GLUCOVANCE 15 POINT 59 GLOBAL INJECT EASE GENTLE-LET LANCETS INSULIN SYRINGE/U- glyburide 17 SAFETY STYLE/MEDIUM 100/1ML/31G X 5/16" 72 glyburide micronized 17 POINT 59 GLOBAL INSULIN glyburide-metformin 15 SYRINGE/U-100/0.3ML/30G X GENVOYA 27 glycerin (laxative) 49 GEODON 25 1/2" 72 GLOBAL INSULIN GLYCERIN ADULT 49 GERI-FREEDA SENIOR SYRINGES/U- FORMULA 95 glycopyrrolate 110 100/0.3ML/30GX5/16" 72 GLYNASE 17 GILENYA 108 GLOBAL LANCING glatiramer acetate 108 DEVICE 59 GNP ALCOHOL SWABS 64 glimepiride 17 GLUCAGEN HYPOKIT 16 GNP GLUCOSE 16 glipizide 17 GNP INSULIN SYRINGE/0.3ML/29G X 1/2" 73

Index 13 GNP INSULIN GNP ULTRA COMFORT haloperidol decanoate 25 SYRINGE/0.3ML/30G X INSULIN SYRINGE/0.5ML/30G haloperidol lactate 25 5/16" 73 X 5/16" SHORT 73 GNP INSULIN GNP ULTRA COMFORT HAVRIX 113 SYRINGE/0.3ML/31G X INSULIN SYRINGE/0.5ML/31G HEALTH CARE LANCING 5/16" 73 X 5/16" SHORT 73 DEVICE 60 GNP INSULIN GNP ULTRA COMFORT HEALTHWISE LANCING SYRINGE/0.5ML/28G X 1/2" 73 INSULIN SYRINGE/1ML/28G X PEN 60 GNP INSULIN 1/2" 73 HEALTHWISE PEN NEEDLES SYRINGE/0.5ML/29G X 1/2" 73 GNP ULTRA COMFORT 29GX12MM 74 GNP INSULIN INSULIN SYRINGE/1ML/29G X HEALTHY ACCENTS AUTOLET SYRINGE/0.5ML/30G X 1/2" 73 IMPRESSION LANCING 5/16" 73 GNP ULTRA COMFORT DEVICE 60 GNP INSULIN INSULIN SYRINGE/1ML/30G X HEALTHY ACCENTS UNIFINE SYRINGE/0.5ML/31G X 5/16" SHORT 74 PENTIPS PEN NEEDLES 5/16" 73 GNP ULTRA COMFORT 29GX12MM 74 GNP INSULIN INSULIN SYRINGE/1ML/31G X HEALTHY ACCENTS UNILET SYRINGE/1ML/28G X 1/2" 73 5/16" SHORT 74 LANCETS SUPER THIN GNP INSULIN GOLYTELY 49 30G 60 SYRINGE/1ML/29G X 1/2" 73 HEALTHY LIVING GOODSENSE LANCING 89 GNP INSULIN DEVICE 59 REPLACEMENT FILTERS SYRINGE/1ML/30G X 5/16" 73 GOODSENSE PRENATAL HEALTHY LIVING GNP INSULIN 100 REPLACEMENT KIT FOR VITAMINS NEBULIZER 89 SYRINGE/1ML/31G X 5/16" 73 GRIS-PEG 18 GNP LANCETS 59 HEALTHY LIVING griseofulvin microsize 18 REPLACEMENT MASKS 89 GNP LANCETS 21G 59 HEMANGEOL 30 GNP LANCETS MICRO THIN griseofulvin ultramicrosize 18 33G 59 guaifenesin 36 HEMOCYTE 48 GNP LANCETS SUPER THIN guaifenesin-codeine 35 heparin sodium (porcine) 10 30G 59 guanfacine hcl 21 HIBICLENS 27 GNP LANCETS THIN 59 guanfacine hcl (adhd) 1 HIGH SENSATION GNP LANCETS THIN 26G 59 GYNAZOLE-1 114 SPERMICIDAL 55 GNP MICRO THIN LANCETS HM COMPLETE 96 33G 59 GYNE-LOTRIMIN 114 HM COMPLETE 50+ MENS GNP PRENATAL 100 GYNE-LOTRIMIN 3 114 ULTIMATE 96 GNP QUICK DISSOLVE H-E-B INCONTROL HM COMPLETE 50+ WOMENS GLUCOSE 16 ADVANCEDLANCING ULTIMATE 96 GNP STERILE PADS 3"X3" 54 DEVICE 59 HM HAIR/SKIN/NAILS 96 GNP SUPER THIN H-E-B INCONTROL ALCOHOL HM ONE DAILY MENS 96 PADS 64 LANCETS/30G 59 HM ONE DAILY WOMENS 96 GNP ULTRA COMFORT H-E-B INCONTROL LANCETS INSULIN SYRINGE/0.3ML/29G X MICRO THIN 33G 60 HM PRENATAL 100 73 H-E-B INCONTROL LANCETS HM STERILE PADS 54 1/2" SUPER THIN 30G 60 GNP ULTRA COMFORT H-E-B INCONTROL LANCETS HM STERILE PADS 2"X2" 54 INSULIN SYRINGE/0.3ML/30G X ULTRA THIN 28G 60 HUDSON RCI SEE-THRU 5/16" SHORT 73 H-E-B INCONTROL PEN AEROSOL MASK GNP ULTRA COMFORT NEEDLES 29GX12MM 74 ELONGATED/ADULT 89 INSULIN SYRINGE/0.3ML/31G X HUMALOG 16 5/16" SHORT 73 HAIR-VITES 95 GNP ULTRA COMFORT HAIR/SKIN/NAILS 96 HUMALOG JUNIOR KWIKPEN 16 INSULIN SYRINGE/0.5ML/28G X 49 HALCION HUMALOG KWIKPEN 16 1/2" 73 HALDOL 25 GNP ULTRA COMFORT HUMALOG MIX 50/50 16 INSULIN SYRINGE/0.5ML/29G X HALDOL DECANOATE 25 HUMALOG MIX 50/50 1/2" 73 100 KWIKPEN 16 25 HALDOL DECANOATE 50 HUMALOG MIX 75/25 16 haloperidol 25

Index 14 HUMALOG MIX 75/25 ICAPS AREDS FORMULA 96 INSULIN SYRINGE/0.5ML/30G X KWIKPEN 16 ICAPS PLUS 96 5/16" 74 HUMIRA 2 INSULIN SYRINGE/0.5ML/31G X imipramine hcl 15 HUMIRA PEDIATRIC CROHNS 5/16" 74 DISEASE STARTER PACK 2 imiquimod 41 INSULIN SYRINGE/1ML/28G X HUMIRA PEN 2 IMITREX 91 1/2" 74 INSULIN SYRINGE/1ML/29G X HUMIRA PEN-CROHNS IMITREX STATDOSE REFILL 91 1/2" 74 DISEASESTARTER 2 INSULIN SYRINGE/1ML/30G X HUMIRA PEN-PSORIASIS IMITREX STATDOSE SYSTEM 91 5/16" 74 STARTER 2 INSULIN SYRINGE/1ML/31G X HUMULIN 70/30 16 IMODIUM A-D 17 5/16" 74 HUMULIN 70/30 KWIKPEN 16 IMURAN 93 INSULIN SYRINGE/U- HUMULIN N 16 IN TOUCH LANCING 100/0.3ML/29G X 1/2" 74 DEVICE 60 INSULIN SYRINGE/U- HUMULIN N KWIKPEN 16 INATAL ADVANCE 100 100/0.5ML/28G X 1/2" 74 HUMULIN R 16 INATAL GT 100 INSULIN SYRINGE/U- HY-VEE LANCETS 60 100/0.5ML/29G X 1/2" 74 INATAL ULTRA 100 HY-VEE THIN LANCETS 60 INSULIN SYRINGE/U- INCRUSE ELLIPTA 9 100/1ML/28G X 1/2" 74 HYALEX 96 indapamide 44 INSULIN SYRINGE/U- HYCET 5 100/1ML/29G X 1/2" 74 INDERAL LA 30 hydralazine hcl 23 INSULIN SYRINGE/U- indomethacin 3 100/1ML/30G X 5/16" 74 HYDREA 24 INFANRIX 110 INSULIN SYRINGE/U- HYDROCELL ADHESIVE 100/1ML/31G X 5/16" 74 DRESSING 4"X4" 54 INFANTS ADVIL 3 INSULIN HYDROCELL DRESSING INNOSPIRE REPLACEMENT SYRINGES/0.5ML/27GX1/2" 4"X4" 54 FILTER 89 74 hydrochlorothiazide 44 INSPIRACHAMBER/ANTI- INSULIN hydrocodone w/ STATIC SYRINGES/0.5ML/28GX1/2" homatropine 34 VALVED/MOUTHPIECE 89 74 INSPIRACHAMBER/LARGE INSULIN hydrocodone-acetaminophen 5 89 hydrocortisone 34 SYRINGES/0.5ML/29GX1/2" INSPIRACHAMBER/SOOTHE 74 hydrocortisone (intrarectal) 6 RMASK/INSPIRAMASK/MEDIU INSULIN hydrocortisone (rectal) 6 M 89 SYRINGES/0.5ML/30GX5/16" INSPIRACHAMBER/SOOTHE hydrocortisone (topical) 40 74 RMASK/INSPIRAMASK/SMAL INSULIN hydrocortisone butyrate 40 L 89 SYRINGES/0.5ML/31GX hydrocortisone w/acetic INSPIREASE DRUG 5/16" 74 acid 106 DELIVERYSYSTEM 89 INSULIN hydrocortisone-aloe vera 40 INSPIREASE RESERVOIR SYRINGES/0.5ML/31GX5/16" BAGS 89 HYDROMORPHONE HCL 4 INSULIN SYRINGE/0.3ML/29G 75 hydromorphone hcl 4 INSULIN X 1" 74 SYRINGES/1ML/27GX/1/2" 75 hydroquinone 42 INSULIN SYRINGE/0.3ML/29G INSULIN hydroxychloroquine sulfate 23 X 1/2" 74 INSULIN SYRINGE/0.3ML/30G SYRINGES/1ML/27GX1/2" 75 hydroxyurea 24 INSULIN X 5/16" 74 SYRINGES/1ML/28GX1/2" 75 hydroxyzine hcl 8 INSULIN SYRINGE/0.3ML/31G INSULIN HYDROXYZINE PAMOATE 8 X 5/16" 74 SYRINGES/1ML/29GX1/2" 75 INSULIN SYRINGE/0.5ML/27G INSULIN hydroxyzine pamoate 8 X 1/2" 74 hyoscyamine sulfate 110 SYRINGES/1ML/30GX1/2" 75 INSULIN SYRINGE/0.5ML/28G INSULIN HYPERRHO S/D 107 X 1/2" 74 SYRINGES/1ML/31GX5/16" 75 HYPOTEARS 103 INSULIN SYRINGE/0.5ML/29G X 1/2" 74 INSUPEN 29G X 12MM 75 HYZAAR 22 INSULIN SYRINGE/0.5ML/30G INSUPEN ULTRAFIN ibuprofen 3 X 1/2" 74 29GX12MM 75

Index 15 INSUPEN ULTRAFIN KENDALL HYDROPHILIC KINRAY INSULIN SYRINGE 30GX8MM 75 FOAMDRESSING 2"X2" 54 PREFERRED PLUS/0.5ML/31G INTELENCE 27 KENDALL HYDROPHILIC X 5/16" 75 INTENSE SENSATION 55 FOAMDRESSING 3"X3" 54 KINRAY INSULIN SYRINGE KENDALL HYDROPHILIC PREFERRED PLUS/1ML/31G X INTUNIV 1 FOAMDRESSING 4"X4" 54 5/16" 75 INVIRASE 27 KENDALL HYDROPHILIC KINRAY INSULIN IOPIDINE 104 FOAMPLUS DRESSING SYRINGE/0.5ML/29G X 1/2" 75 2"X2" 54 ipratropium bromide 9 KITABIS PAK 2 KENDALL HYDROPHILIC KLARON 37 ipratropium bromide (nasal)103 FOAMPLUS DRESSING ipratropium-albuterol 9 3"X3" 54 KLONOPIN 10 irbesartan 21 KEPPRA 11 KLOR-CON M15 92 irbesartan-hydrochlorothiazide KERLIX SPONGES 4" X 4" 12 KLOR-CON/25 92 22 PLY 54 KMART VALU PLUS INSULIN ISENTRESS 27 KERLIX SPONGES 4" X 4" 16 SYRINGE/1ML/29G 75 PLY 54 KMART VALU PLUS INSULIN ISONIAZID 23 KETOCARE 42 SYRINGE/1ML/30G 75 isoniazid 23 ketoconazole (topical) 38 KOKO PEAK PRO REPLACEMENTPLASTIC ISOPTO CARPINE 104 KETONE TEST STRIPS 42 ISORDIL TITRADOSE 7 MOUTHPIECE 89 ketoprofen 3 KP PRENATAL isosorbide dinitrate 7 KETOPROFEN 3 MULTIVITAMINS 100 ISOSORBIDE DINITRATE ER7 KETOPROFEN ER 3 KPN PRENATAL 100 isosorbide mononitrate 7 ketorolac tromethamine 3 KROGER INSULIN isotretinoin 37 SYRINGE/0.3ML/29G X 1/2" 75 ketorolac tromethamine KROGER INSULIN itraconazole 18 (ophth) 106 SYRINGE/0.3ML/30G X J & J GAUZE 2"X2" 8 PLY 54 KETOSTIX 42 5/16" 75 J & J GAUZE 4"X4" 12 PLY 54 ketotifen fumarate (ophth)106 KROGER INSULIN J & J GAUZE 4"X4" 8 PLY 54 KIMONO COLORS 55 SYRINGE/0.3ML/31G X J & J GAUZE SPONGES 12-PLY KIMONO LUBRICATED 55 5/16" 75 4" X 4" 54 KROGER INSULIN KIMONO MICRO THIN 55 SYRINGE/0.5ML/29G X 1/2" 75 J & J GAUZE SPONGES 16-PLY KIMONO MICRO THIN PLUS 4" X 4" 54 KROGER INSULIN J & J GAUZE SPONGES 8- SPERMICIDE SYRINGE/0.5ML/30G X PLY4" X 4" 54 LUBRICATED 56 5/16" 75 KIMONO PLUS SPERMICIDE KROGER INSULIN JADENU 18 LUBRICATED 56 SYRINGE/0.5ML/31G X JARDIANCE 17 KIMONO PLUS 5/16" 75 JENTADUETO 15 SPERMICIDE/LUBRICATED KROGER INSULIN K-PAX IMMUNE SUPPORT 56 SYRINGE/1ML/29G X 1/2" 75 FORMULA PROFESSIONAL KIMONO PS KROGER INSULIN STRENGTH 96 LUBRICATED 56 SYRINGE/1ML/30G X 5/16" 75 KIMONO PS PLUS K-PHOS NEUTRAL 92 KROGER INSULIN SPERMICIDE/LUBRICATED SYRINGE/1ML/31G X 5/16" 75 K-TAB 92 56 KROGER LANCETS 60 KADIAN 4 KIMONO SENSATION KROGER LANCETS 21G 60 KALETRA 27 LUBRICATED 56 KIMONO SENSATION PLUS KROGER LANCETS MICRO KALYDECO 109 SPERMICIDE THIN33G 60 KAMELEON LUBRICATED 55 LUBRICATED 56 KROGER LANCETS SUPER THIN 60 KAPVAY 1 KIMONO SPECIAL 56 KROGER LANCETS THIN 60 KAYEXALATE 93 KINNEY LANCETS 60 KROGER LANCETS THIN KAZANO 15 KINNEY THIN LANCETS 60 26G 60 KEFLEX 31 KINRAY INSULIN SYRINGE KROGER LANCETS PREFERRED ULTRATHIN30G 60 PLUS/0.3ML/31G X 5/16" 75

Index 16 KROGER LANCING LEADER INSULIN lidocaine hcl 41 DEVICE 60 SYRINGE/0.3ML/31G X lidocaine hcl (mouth-throat) 93 KROGER PEN NEEDLES 29G 5/16" 75 X12MM 75 LEADER INSULIN lidocaine-prilocaine 41 labetalol hcl 30 SYRINGE/0.5ML/28G X liothyronine sodium 109 LAC-HYDRIN 41 1/2" 75 LIPITOR 20 LEADER INSULIN LAC-HYDRIN TWELVE 41 SYRINGE/0.5ML/29G X lisinopril 21 lactic acid (ammonium 1/2" 75 lisinopril & lactate) 41 LEADER INSULIN hydrochlorothiazide 22 lactulose 49 SYRINGE/0.5ML/30G X LITE TOUCH LANCING 5/16" 75 DEVICE 60 lactulose (encephalopathy) 47 LITE TOUCH LANCING LAMICTAL 11 LEADER INSULIN SYRINGE/0.5ML/31G X PEN 60 LAMICTAL CHEWABLE 5/16" 76 LITEAIRE 89 DISPERSIBLE 11 LEADER INSULIN LITETOUCH INSULIN LAMISIL 18 SYRINGE/1ML/28G X 1/2" 76 SYRINGE/0.3ML/29G X 1/2" 76 LAMISIL AT 38 LEADER INSULIN LITETOUCH INSULIN LAMISIL AT JOCK ITCH 38 SYRINGE/1ML/29G X 1/2" 76 SYRINGE/0.3ML/30G X LEADER INSULIN 5/16" 76 lamivudine 27 SYRINGE/1ML/30G X LITETOUCH INSULIN lamivudine-zidovudine 27 5/16" 76 SYRINGE/0.3ML/31G X lamotrigine 11 LEADER INSULIN 5/16" 76 LANCET DEVICE SYRINGE/1ML/31G X LITETOUCH INSULIN ADJUSTABLE 60 5/16" 76 SYRINGE/0.5ML/30G X LANCET DEVICE WITH LEADER QUICK DISSOLVE 5/16" 76 EJECTOR 60 GLUCOSE 16 LITETOUCH INSULIN LANCETS 60 leflunomide 3 SYRINGE/0.5ML/31G X 5/16" 76 LANCETS 26G TWIST TOP 60 letrozole 24 LITETOUCH INSULIN LANCETS 28G 60 LEUCOVORIN CALCIUM 24 SYRINGE/1ML/30G X 5/16" 76 LANCETS 30G 60 leucovorin calcium 24 LITETOUCH INSULIN LANCETS SAFETY SEAL LEUKERAN 23 SYRINGE/U-100/0.5ML/28G X 21G 60 1/2" 76 LEVAQUIN 46 LITETOUCH INSULIN LANCETS SAFETY SEAL LEVBID 110 26G 60 SYRINGE/U-100/0.5ML/29G X LANCETS SAFETY SEAL levetiracetam 11 1/2" 76 28G 60 levobunolol hcl 104 LITETOUCH INSULIN SYRINGE/U-100/1ML/28G X LANCETS THIN 60 levocarnitine (metabolic 1/2" 76 LANCETS ULTRA THIN 60 modifiers) 45 LITETOUCH INSULIN LANCING DEVICE 60 levofloxacin 46 SYRINGE/U-100/1ML/29G X LANCING DEVICE levonorgestrel & eth 1/2" 76 ADJUSTABLE 60 estradiol 32 LITETOUCH INSULIN levonorgestrel (emergency LANOXIN 31 SYRINGE/U-100/1ML/31G X oc) 33 5/16" 76 lansoprazole 111 levonorgestrel-eth estradiol LITETOUCH MASK LARGE 89 LANZO 60 (triphasic) 32 LITETOUCH MASK LASIX 44 levonorgestrel-ethinyl estradiol MEDIUM 89 (91-day) 32 89 latanoprost 106 levothyroxine sodium 109 LITETOUCH MASK SMALL LEADER ADVANCED LANCING LITHIUM 25 LEVSIN 110 DEVICE 60 lithium carbonate 25 LEADER INSULIN LEVSIN/SL 110 25 SYRINGE/0.3ML/29G X 1/2" 75 LEXAPRO 13 LITHIUM CARBONATE lithium carbonate 25 LEADER INSULIN LEXIVA 27,28 SYRINGE/0.3ML/30G X LITHOBID 25 5/16" 75 LIBERTY MINI LANCING DEVICE 60 LIVE BETTER ADVANCED lidocaine 41 LANCING DEVICE 60

Index 17 LIVE BETTER LANCET MACROBID 112 MEDICAL PROVIDER EZ FLU SUPERTHIN 30G 60 MACRODANTIN 112 SHOT 2015-2016 113 LIVE BETTER LANCET MEDICAL PROVIDER EZ FLU ULTRATHIN 28G 60 MACULAR VITAMIN SHOT PF 2014-2015 114 LIVE BETTER PEN NEEDLES BENEFIT 96 MEDICAL PROVIDER SINGLE 29G X 12MM 76 MAGELLAN INSULIN SAFETY USE EZ FLU SHOT 114 SYRINGE/U-100/0.3ML/29G X MEDICINE SHOPPE PEN LMX 4 41 1/2" 76 LOCOID 40 NEEDLES 29G X 12MM 77 MAGELLAN INSULIN SAFETY MEDISENSE THIN LODINE 3 SYRINGE/U-100/0.3ML/30G X LANCETS 60 LODOSYN 24 5/16" 76 MAGELLAN INSULIN SAFETY MEDROL 34 LOESTRIN 1.5/30-21 32 SYRINGE/U-100/0.5ML/29G X MEDROL DOSEPAK 34 LOESTRIN 1/20-21 32 1/2" 76 medroxyprogesterone LOESTRIN FE 1.5/30 32 MAGELLAN INSULIN SAFETY acetate 107 medroxyprogesterone acetate LOESTRIN FE 1/20 32 SYRINGE/U-100/0.5ML/30G X 5/16" 76 (contraceptive) 33 LOFIBRA 20 MAGELLAN INSULIN SAFETY MEFLOQUINE HCL 23 LOHIST-D 36 SYRINGE/U-100/1ML/29G X mefloquine hcl 23 LOMOTIL 17 1/2" 76 MEGA MULTIVITAMIN FOR LONGS INSULIN MAGELLAN INSULIN SAFETY MEN 96 SYRINGE/0.5ML/31G X SYRINGE/U-100/1ML/30G X MEGA MULTIVITAMIN FOR 5/16" 76 5/16" 76 WOMEN 96 LONGS LANCETS magnesium citrate 50 MEGACE ORAL 24 STANDARD 60 magnesium hydroxide 50 MEGAVITE FRUITS & LONGS LANCETS THIN 60 magnesium oxide 7 VEGGIES 96 loperamide hcl 17 magnesium oxide (mg MEGAVITE GOLDEN YEARS LOPID 20 supplement) 92 55+ 96 megestrol acetate 24 lopinavir-ritonavir 28 MAGOX 400 92 malathion 42 MEIJER ALCOHOL SWABS LOPRESSOR 30 EXTRA-THICK 64 LOPRESSOR HCT 22 MAPROTILINE HCL 13 MEIJER COLOR LANCETS MARATHON MEDICAL loratadine 19 UNIVERSAL 33G 61 PENTIPS29GX12MM 76 MEIJER LANCETS 61 loratadine & MAVIK 21 pseudoephedrine 36 MEIJER LANCETS THIN 61 lorazepam 8 MAVYRET 29 MEIJER LANCETS losartan potassium 21 MAXALT 91 UNIVERSAL21G 61 MAXI-COMFORT INSULIN MEIJER LANCETS losartan potassium & UNIVERSAL30G 61 hydrochlorothiazide 22 SYRINGE/U- 100/0.5ML/28GX1/2" 76 MEIJER LANCETS LOTENSIN 21 MAXI-COMFORT INSULIN UNIVERSAL33G 61 LOTENSIN HCT 22 SYRINGE/U- MEIJER PEN NEEDLES 29G LOTREL 22 100/1ML/28GX1/2" 76 X12MM 77 MAXITROL 105 MEIJER SUPER THIN LOTRIMIN AF 38 LANCETS 61 MAXX LUBRICATED 56 LOTRIMIN AF FOR HER 38 meloxicam 3 LOTRIMIN AF JOCK ITCH 38 MAXX PLUS SPERMICIDE LUBRICATED 56 melphalan 23 LOTRISONE 38 MAXZIDE 44 memantine hcl 108 lovastatin 20 MAXZIDE-25 44 MENACTRA 112 LOVENOX 10 meclizine hcl 18 MENOMUNE-A/C/Y/W-135 loxapine succinate 26 MEDIC INSULIN 112 LURIDE 92 SYRINGE/0.3ML/30G X MENS 50+ MULTI VITAMIN &MINERAL FORMULA 96 LYSTEDA 48 5/16" 76 MEDIC INSULIN MENS MULTI VITAMIN & M-M-R II 113 SYRINGE/0.5ML/30G X MINERAL FORMULA 96 M-VIT 100 5/16" 76 MENVEO 112

Index 18 MEPERIDINE HCL 4 METROLOTION 42 MM INSULIN SYRINGE/U- meperidine hcl 5 metronidazole 7 100/0.3ML/31G X 5/16" 77 MM INSULIN SYRINGE/U- MEPHYTON 115 metronidazole (topical) 42 100/1/2ML/30G X 5/16" 77 meprobamate 8 metronidazole vaginal 114 MM INSULIN SYRINGE/U- mercaptopurine 23 MEVACOR 20 100/1/2ML/31G X 5/16" 77 MM INSULIN SYRINGE/U- mesalamine 47 mexiletine hcl 8 100/1ML/30G X 5/16" 77 MESALAMINE DR 47 MIACALCIN 45 MM INSULIN SYRINGE/U- MESTINON 23 MICARDIS 21 100/1ML/31G X 5/16" 77 MESTINON TIMESPAN 23 MICARDIS HCT 22 MM LANCING DEVICE 61 METADATE CD 1 MICATIN 38 MOBIC 3 METAMUCIL 49 MICONAZOLE 3 114 MODICON 32 METAMUCIL ORIGINAL miconazole nitrate (topical)38 MOLINDONE HYDROCHLORIDE 26 TEXTURE 49 miconazole nitrate METAPROTERENOL vaginal 114 mometasone furoate 40 SULFATE 9 MICRO-K 92 MONISTAT 3 114 metformin hcl 15 MICROCHAMBER 89 MONISTAT 3 COMBINATION PACK 114 methadone hcl 5 MICROELITE FILTER methazolamide 44 MONISTAT 7 SIMPLY REPLACEMENTS 89 CURE 114 METHENAMINE MICROELITE MONISTAT SOOTHING CARE MANDELATE 112 RECHARGEABLE ITCH RELIEF 40 methenamine mandelate 112 BATTERY 89 MONOJECT INSULIN methenamine-hyosc-methylene MICROLET NEXT 61 SYRINGE/1ML 77 blue-sod phos-phenyl sal 111 MICROSPACER 89 MONOJECT INSULIN METHERGINE 106 MICROZIDE 44 SYRINGE/1ML/31G X 5/16" 77 methimazole 109 MONOJECT INSULIN midazolam hcl 49 SYRINGE/DETACH METHITEST 6 midodrine hcl 114 NEEDLE/1ML/25G X 5/8" 77 methocarbamol 102 MIGRANAL 91 MONOJECT INSULIN methotrexate sodium 23 MILLIPRED 34 SYRINGE/DETACH METHOTREXATE SODIUM 24 NEEDLE/1ML/27G X 1/2" 77 MINI LANCING DEVICE 61 MONOJECT INSULIN methotrexate sodium 24 MINIELITE FILTER SYRINGE/PERM methyldopa 21 REPLACEMENTS 89 NEEDLE/1ML/28G X 1/2" 77 methylergonovine maleate 106 MINIELITE RECHARGEABLE MONOJECT INSULIN BATTERY 89 SYRINGE/PERM NEEDLE/U- methylphenidate hcl 1,2 MINIPRESS 21 100/0.5ML/28G X 1/2" 77 METHYLPHENIDATE HCL MINIVELLE 46 MONOJECT INSULIN ER 1 SYRINGE/SAFETY/PERM methylprednisolone 34 MINOCIN 109 NEEDLE/0.3ML/29G X 1/2" 77 METIPRANOLOL 104 minocycline hcl 109 MONOJECT INSULIN metoclopramide hcl 47 minoxidil 23 SYRINGE/SAFETY/PERM MIRALAX 49 NEEDLE/0.3ML/29GX1/2" 77 metolazone 44 MONOJECT INSULIN metoprolol & MIRAPEX 24 SYRINGE/SAFETY/PERM hydrochlorothiazide 22 MIRASORB SPONGES 2" X NEEDLE/0.5ML/29G X 1/2" 77 metoprolol succinate 30 2" 54 MONOJECT INSULIN METOPROLOL SUCCINATE MIRASORB SPONGES 4" X SYRINGE/SAFETY/PERM ER/HYDROCHLOROTHIAZIDE 4" 54 NEEDLE/1ML/29G X 1/2" 77 22 MIRCETTE 32 MONOJECT INSULIN metoprolol tartrate 30 mirtazapine 12 SYRINGE/SOFTPACK/1ML/27G METOPROLOL/HYDROCHLOR misoprostol 111 X 1/2" 77 MONOJECT INSULIN OTHIAZIDE 22 MM INSULIN SYRINGE/U- METROCREAM 42 SYRINGE/SOFTPACK/U- 100/0.3ML/30G X 5/16" 77 100/0.5ML/28G X 1/2" 77 METROGEL-VAGINAL 114

Index 19 MONOJECT INSULIN MOORE MED MONOJECT MYNATE 90 PLUS 100 SYRINGE/U-100/0.3ML/30G X INSULIN SYRINGE/U- MYSOLINE 11 5/16" 77 100/1ML/28G X 1/2" 78 MONOJECT INSULIN MOORE MED MONOJECT nabumetone 3 SYRINGE/U-100/0.5ML/28G X INSULIN SYRINGE/U- nadolol 30 1/2" 77 100/1ML/29G X 1/2" 78 naloxone hcl 18 MONOJECT INSULIN morphine sulfate 5 NALOXONE HCL 18 SYRINGE/U-100/0.5ML/30G X MORPHINE SULFATE 5 5/16" 77 naltrexone hcl 18 MONOJECT INSULIN morphine sulfate 5 NAMENDA 108 SYRINGE/U-100/1ML/28G X MOTRIN INFANTS DROPS 3 NAMENDA TITRATION 1/2" 77 moxifloxacin hcl (ophth) 104 PAK 108 MONOJECT INSULIN NAPHAZOLINE HCL 105 SYRINGE/U-100/1ML/30G X MS CONTIN 5 5/16" 77 MS INSULIN NAPROSYN 3 MONOJECT INSULIN SYRINGE/0.3ML/31G X naproxen 3 SYRINGEREGULAR LUER 5/16" 78 MS INSULIN NAPROXEN 3 TIP/SOFTPACK/1ML 77 naproxen 3 MONOJECT ULTRA COMFORT SYRINGE/0.5ML/31G X INSULIN SYRINGE/0.3ML/29G X 5/16" 78 naproxen sodium 3 1/2" 77 MS INSULIN naratriptan hcl 91 SYRINGE/1ML/31G X MONOJECT ULTRA COMFORT NARCAN 18 INSULIN SYRINGE/0.3ML/30G X 5/16" 78 5/16" 77 MUCINEX 36 NARDIL 13 MONOJECT ULTRA COMFORT MULTI PRENATAL 100 NASAL DECONGESTANT 103 INSULIN SYRINGE/0.3ML/31G X MULTI-BETIC DIABETES 96 NASALCROM 103 5/16" 78 MULTI-LANCET DEVICE 61 NAT-RUL PRENATAL MONOJECT ULTRA COMFORT VITAMINS 100 INSULIN SYRINGE/0.5ML/28G X MULTI-VITAMIN NAT-RUL THERAVITE- 1/2" 78 MONOCAPS 96 M/HIGHPOTENCY 96 multiple vitamins w/ MONOJECT ULTRA COMFORT NATALVIT 100 INSULIN SYRINGE/0.5ML/29G X minerals 96 1/2" 78 MULTIVITAL PLATINUM 96 nateglinide 17 MONOJECT ULTRA COMFORT MULTIVITAMIN ADULTS 96 NATROBA 42 INSULIN SYRINGE/0.5ML/30G X MULTIVITAMIN MEN 96 NATRUL-MEGA-75 96 5/16" 78 NATRUL-VITES 96 MONOJECT ULTRA COMFORT MULTIVITAMIN/FLUORIDE INSULIN SYRINGE/0.5ML/31G X 98 NEBULIZER AIR 5/16" 78 mupirocin 38 TUBE/PLUGS 89 MONOJECT ULTRA COMFORT mupirocin calcium (topical) 38 NEBULIZER PEDIATRIC MASK 89 INSULIN SYRINGE/1ML/28G X MYAMBUTOL 23 1/2" 78 NECON 1/50-28 32 MONOJECT ULTRA COMFORT mycophenolate mofetil 93 NECON 10/11-28 32 INSULIN SYRINGE/1ML/29G X mycophenolate sodium 93 NEFAZODONE HCL 14 1/2" 78 MYDRIACYL 104 nefazodone hcl 14 MONOJECT ULTRA COMFORT MYFORTIC 93 INSULIN SYRINGE/1ML/30G X neomycin sulfate 2 5/16" 78 MYLERAN 23 neomycin-bacitracin zn- MONOLET LANCETS 61 MYLICON 46 polymyxin 104 neomycin-bacitracin-polymyxin MONOLET OPD LANCETS 61 MYLICON INFANTS GAS RELIEF 46 38 montelukast sodium 9 MYNATAL 100 neomycin-polymy- MOORE MED MONOJECT dexameth 105 INSULIN SYRINGE/U- MYNATAL ADVANCE 100 neomycin-polymyxin w/ 100/0.5ML/28G X 1/2" 78 MYNATAL PLUS 100 pramoxine 38 MOORE MED MONOJECT MYNATAL neomycin-polymyxin-gramicidin INSULIN SYRINGE/U- ULTRACAPLET 100 104 100/0.5ML/29G X 1/2" 78 MYNATAL-Z 100 neomycin-polymyxin-hc (otic) 106

Index 20 NEOMYCIN/POLYMYXIN/HYDR nitroglycerin 8 NOVOLIN 70/30 RELION 16 OCORTISONE 105 NITROSTAT 8 NOVOLIN N 17 NEORAL 93 NIVA-PLUS 100 NOVOLIN N RELION 17 NEOSPORIN 104 NIX CREME RINSE 42 NOVOLIN R 17 NEOSPORIN ORIGINAL 38 NIZORAL 38 NOVOLIN R RELION 17 NEOSPORIN PLUS PAIN RELIEF MAXIMUM NO IRON MULTIPLE NOVOLOG 17 STRENGTH 38 VITAMIN/MINERALS 96 NOVOLOG FLEXPEN 17 NOR-QD 33 NEPHRO-VITE RX 94 NOVOLOG MIX 70/30 17 NEPHROCAPS 94 NORCO 5 NOVOLOG MIX 70/30 NEPTAZANE 44 NORDITROPIN FLEXPRO45 PREFILLED FLEXPEN 17 NESINA 16 norethin acet & estrad-fe 32 NOVOLOG PENFILL 17 norethindrone & eth NEURONTIN 11 NOVOTWIST 30GX8MM 78 estradiol 32 NOVOTWIST 32GX5MM 78 NEUTROGENA T/GEL 42 norethindrone & ethinyl NEUTROGENA T/GEL estradiol-fe 33 NU GAUZE 4PLY 4"X4" 54 STUBBORN ITCH norethindrone NU GAUZE GENERAL-USE CONTROL 42 (contraceptive) 33 SPONGES 4"X4" 4 PLY 54 nevirapine 28 norethindrone acet & eth NULYTELY/FLAVOR PACKS 49 NEXIUM 111 estra 33 norethindrone acetate 107 NUPLAZID 25 NEXIUM 24HR 111 norethindrone acetate-ethinyl NUTRICAP 96 NEXIUM 24HR CLEAR estradiol 46 NUTRICION PORVIDA 100 MINIS 111 norethindrone acetate-ethinyl niacin 115 estradiol-fe 33 NUVARING 33 niacin (antihyperlipidemic) 21 norethindrone-eth estradiol nystatin 18 NIACOR 21 (triphasic) 33 nystatin (mouth-throat) 93 norgestimate-ethinyl nystatin (topical) 38 NIASPAN 21 estradiol 33 NICADAN 96 norgestimate-ethinyl estradiol nystatin-triamcinolone 38 NICADAN ZX 96 (triphasic) 33 NYTOL MAXIMUM norgestrel & ethinyl STRENGTH 48 31 nicardipine hcl estradiol 33 O-CAL FA 100 96 NICAZEL NORINYL 1+35 33 O-CAL PRENATAL 100 NICAZEL FORTE 96 NORINYL 1+50 33 OB COMPLETE NICODERM CQ 109 NORPACE 8 ADVANCED 100 NICORETTE 109 NORPACE CR 8 OCEAN NASAL SPRAY 102 NICORETTE MINI 109 NORPRAMIN 15 OCUFEN 106 NICORETTE STARTER NORTEMP INFANTS 4 OCUFLOX 104 KIT 109 ODEFSEY 28 109 nortriptyline hcl 15 nicotine OFF DEEP WOODS 41 109 NORTRIPTYLINE HCL 15 nicotine polacrilex OFF DEEP WOODS DRY 41 NICOTINE TRANSDERMAL NORVASC 31 SYSTEM 109 NORVIR 28 ofloxacin 46 NICOTROL INHALER 109 NOSE CLIP 89 ofloxacin (ophth) 104 NICOTROL NS 109 NOVA MAX PLUS KETONE ofloxacin (otic) 106 nifedipine 31 TESTSTRIPS 42 OGESTREL 33 NOVA SUREFLEX olanzapine 26 NINLARO 24 LANCETS 61 NITRO-BID 7 NOVA SUREFLEX LANCING omeprazole 111 NITRO-DUR 8 DEVICE 61 OMNIPRED 105 nitrofurantoin 112 NOVOFINE 30GX8MM 78 OMNITROPE 45 nitrofurantoin macrocrystal 112 NOVOFINE AUTOCOVER ON CALL LANCING nitrofurantoin monohyd 30GX8MM 78 DEVICE 61 macro 112 NOVOLIN 70/30 16

Index 21 ON CALL PLUS LANCING OPTIHALER 90 PARI EXPIRATORY FILTER DEVICE 61 OPTIHALER MDI DRUG VALVE SET 90 ONCOVITE 96 DELIVERY SYSTEM 90 PARI MASK SET 90 ondansetron 18 OPURITY 97 PARI SOFT PLASTIC ADULT ondansetron hcl 18 oral electrolytes 92 MASK 90 PARI SOFT PLASTIC ONE DAILY MENS FORMULA ORKAMBI 109 PEDIATRIC MASK 90 W/O IRON 96 orphenadrine citrate 102 PARLODEL 24 ONE DAILY PLUS IRON 96 ORTHO MICRONOR 34 ONE FLOW TESTER TUBE PARNATE 13 MOUTHPIECE 89 ORTHO TRI-CYCLEN 33 paroxetine hcl 13,14 ONE-A-DAY ENERGY 96 ORTHO TRI-CYCLEN LO 33 PARVLEX 97 ONE-A-DAY MENOPAUSE ORTHO-CYCLEN 33 PAXIL 14 FORMULA 96 ORTHO-NOVUM 1/35 33 PC LANCETS SUPER THIN ONE-A-DAY MENS 50+ ORTHO-NOVUM 7/7/7 33 30G 61 ADVANTAGE 96 PC UNIFINE PENTIPS 29G ONE-A-DAY MENS HEALTH oseltamivir phosphate 29 X1/2" 78 FORMULA 96 OSENI 15 PCE 51 ONE-A-DAY MENS PRO OTICIN HC NR 106 EDGE 96 ped multivitamins w/fl & iron 99 ONE-A-DAY TEEN OVACE PLUS WASH 39 PEDIALYTE 92 ADVANTAGEFOR HIM 97 OVACE WASH 39 PEDIALYTE FREEZER ONE-WAY VALVED OVCON-35 33 POPS 92 EXPIRATORYMOUTHPIECE/DI PEDIAPRED 34 SPOSABLE 89 OVIDE 42 oxaprozin 3 PEDIATRIC AEROSOL ONE-WAY VALVED MASK 90 INSPIRATORY oxazepam 8 PEDIATRIC DISPOSABLE MOUTHPIECE/DISPOSABLE oxcarbazepine 11 MOUTPIECE 90 89 oxybutynin chloride 112 PEDIATRIC ONETOUCH DELICA LANCING MOUTHPIECE/DISPOSABLE DEVICE 61 oxycodone hcl 5 90 OPTI-WOMAN 97 OXYCODONE HCL ER 5 pediatric multiple vitamin w/ OPTICHAMBER oxycodone w/ c 100 ADVANTAGE/LARGE acetaminophen 5 pediatric multiple vitamin w/ c & MASK 89 oxycodone-aspirin 5 fa 99 OPTICHAMBER OXYCODONE/ACETAMINOPH pediatric multiple vitamins w/ ADVANTAGE/MEDIUM FACE EN 5 iron 99 MASK 89 OXYCONTIN 5 pediatric multivitamins OPTICHAMBER w/fl 98,99 ADVANTAGE/SMALL FACE oxymorphone hcl 5 pediatric vitamins acd w/ MASK 89 OXYMORPHONE fluoride 99 OPTICHAMBER DIAMOND 90 HYDROCHLORIDE ER 5 pediatric vitamins adc 100 OPTICHAMBER PAMELOR 15 peg 3350-kcl-sod bicarb-sod DIAMOND/LARGEFACE PANCREAZE 43 chloride-sod sulfate 49 MASK 90 pantoprazole sodium 111 peg 3350-potassium chloride-sod OPTICHAMBER bicarbonate-sod chloride 49 DIAMOND/MEDIUM FACE PAREGORIC 17 PEN NEEDLES 29G X MASK 90 PARI ALTERA NEBULIZER 12MM 78 OPTICHAMBER HANDSET 90 PEN NEEDLES 29GX1/2" 78 PARI BABY CONVERSION DIAMOND/SMALLFACE PEN NEEDLES 30GX5/16" 78 MASK 90 KITSIZE 1 90 OPTICHAMBER FACE PARI BABY CONVERSION PEN NEEDLES 30GX8MM 78 MASK/LARGE 90 KITSIZE 2 90 PEN NEEDLES 32G X 5MM 78 OPTICHAMBER FACE PARI BABY CONVERSION KITSIZE 3 90 penicillin v potassium 107 MASK/MEDIUM 90 PENICILLIN V OPTICHAMBER FACE PARI ERAPID NEBULIZER HANDSET 90 POTASSIUM 107 MASK/SMALL 90 penicillin v potassium 107 OPTIFOAM 54

Index 22 PENTIPS 29G X 12MM 78 pindolol 30 pramoxine hcl (rectal) 6 PENTIPS 29GX12MM 78 pioglitazone hcl 16 pramoxine-hc-chloroxylenol pentoxifylline 48 pioglitazone hcl-metformin 106 prasugrel hcl 48 PEPCID 111 hcl 15 piroxicam 3 PRAVACHOL 20 PEPCID AC 111 PEPCID AC MAXIMUM PLAN B ONE-STEP 33 pravastatin sodium 20 STRENGTH 111 PLAQUENIL 23 prazosin hcl 21 PEPTO-BISMOL 17 PLAVIX 48 PRE-NATAL FORMULA 100 PEPTO-BISMOL PLEGRIDY 108 PRECISION SURE-DOSE INSTACOOL 17 PLEGRIDY STARTER INSULIN SYRINGE/0.3ML/30G X PEPTO-BISMOL MAX PACK 108 5/16" 78 STRENGTH 17 PNEUMOVAX 23 112 PRECISION SURE-DOSE INSULIN SYRINGE/0.5ML/28G X PEPTO-BISMOL TO-GO 17 PNEUMOVAX 23/1 PERCOCET 5 1/2" 78 DOSE 112 PRECISION SURE-DOSE PERFECT LANCETS 30G 61 PNV FERROUS INSULIN SYRINGE/0.5ML/29G X PERIDEX 93 FUMARATE/DOCUSATE/FOLI 1/2" 78 C ACID 100 PRECISION SURE-DOSE permethrin 42 PNV FOLIC ACID + IRON perphenazine 26 100 INSULIN SYRINGE/0.5ML/30G X MULTIVITAMIN 3/8" 79 PERPHENAZINE/AMITRIPTYLIN PNV PRENATAL PLUS 100 PRECISION SURE-DOSE E 108 MULTIVITAMIN INSULIN SYRINGE/1ML/28G X PERRY PRENATAL 100 PNV TABS 29-1 100 1/2" 79 PERSANTINE 48 POCKET CHAMBER 90 PRECISION SURE-DOSE PFLEX 90 POCKET SPACER 90 PLUSINSULIN PHARMACY COUNTER podofilox 41 SYRINGE/0.3ML/29G X 1/2" 79 LANCETS 61 PRECISION SURE-DOSE POLYCOSE 103 PLUSINSULIN phenazopyridine hcl 47 polyethylene glycol 3350 50 SYRINGE/1ML/29G X 1/2" 79 phenelzine sulfate 13 POLYMEM DRESSING/3" X PRECISION THIN phenobarbital 49 3" 54 LANCETS 61 PHENOBARBITAL 49 POLYMEM DRESSING/4" X PRECISION THINS GP 4" 54 LANCET 61 phenobarbital 49 polymyxin b-trimethoprim 104 PRECISION ULTRA phenobarbital-hyoscyamine- LANCET 61 atropine-scopolamine 110 polysaccharide iron complex 48 PRECISION XTRA 42 phenylephrine hcl (ophth) 105 POLYTRIM 104 PRED FORTE 105 phenylephrine hcl (oral) 103 polyvinyl alcohol 103 PRED MILD 105 phenylephrine-cocoa butter 6 pot phosphate monobasic w/ PRED-G 105 phenylephrine-dm 36 sod phosphate dibasic & PREDATOR 41 monobasic 92 phenylephrine-guaifenesin 36 PREDNICARBATE 40 phenylephrine-shark liver oil- potassium bicarbonate 92 prednicarbate 40 cocoa butter 6 potassium chloride 92 prednisolone 34 phenylephrine-shark liver oil- POTASSIUM CHLORIDE 92 mineral oil-petrolatum 6 prednisolone acetate PHENYTEK 12 potassium chloride 92 (ophth) 105 POTASSIUM CHLORIDE phenytoin 12 PREDNISOLONE ACETATE P- ER 92 F 105 phenytoin sodium extended 12 potassium chloride prednisolone sodium PHYTOMULTI 97 microencapsulated crystals phosphate 34 PILLOW MASK/ADULT 90 er 92 PREDNISOLONE SODIUM potassium citrate PHOSPHATE 105 PILLOW MASK/CHILD 90 (alkalinizer) 47 PREDNISONE 34 PILLOW MASK/PEDIATRIC 90 potassium citrate-citric acid47 prednisone 34 pilocarpine hcl 104 pramipexole PREDNISONE 34 pilocarpine hcl (oral) 94 dihydrochloride 25

Index 23 PREDNISONE INTENSOL 34 PRENATAL PROCTOFOAM 6 PREFERRED PLUS INSULIN VITAMIN/IRON 101 PRODIGY INSULIN SYRING/U- SYRINGE/U-100/0.3ML/29G X PRENATAL VITAMINS 102 100/0.3ML/31G X 5/16" 79 1/2" 79 PRENATAL VITAMINS PLUS PRODIGY INSULIN PREFERRED PLUS INSULIN LOW IRON 102 SYRINGE/1/2ML/31G X SYRINGE/U-100/0.3ML/30G X PREPLUS 102 5/16" 79 5/16" 79 PRESERVISION AREDS 97 PRODIGY INSULIN PREFERRED PLUS INSULIN SYRINGE/1ML/28G X 1/2" 79 SYRINGE/U-100/0.5ML/28G X PRETAB 102 PRODIGY LANCING 1/2" 79 PREVACID 111 DEVICE 61 PREFERRED PLUS INSULIN PREVACID 24HR 111 PRODIGY TWIST TOP LANCETS 61 SYRINGE/U-100/0.5ML/29G X PREVIDENT 94 1/2" 79 progesterone micronized 107 PREVIDENT 5000 DRY PREFERRED PLUS INSULIN PROGRAF 93 SYRINGE/U-100/0.5ML/30G X MOUTH 93 PREVIDENT 5000 PLUS 93 promethazine & 5/16" 79 phenylephrine 36 PREFERRED PLUS INSULIN PREVIDENT FLUORIDE 94 promethazine hcl 20 SYRINGE/U-100/1ML/28G X PREVNAR 13 112 1/2" 79 promethazine w/codeine 36 PREZCOBIX 28 PREFERRED PLUS INSULIN promethazine-dm 36 SYRINGE/U-100/1ML/29G X PREZISTA 28 promethazine-phenylephrine- 1/2" 79 PRILOSEC 111 codeine 36 PREFERRED PLUS INSULIN PRILOSEC OTC 111 PROMETHAZINE/PHENYLEPHR SYRINGE/U-100/1ML/30G X PRIMAQUINE INE 36 5/16" 79 PROMETRIUM 107 PREFERRED PLUS LANCETS PHOSPHATE 23 COLORED 21G 61 primidone 11 propafenone hcl 8 PREFERRED PLUS LANCETS PRINIVIL 21 propranolol hcl 30 SUPER THIN 30G 61 PRISTIQ 14 PROPRANOLOL HCL 30 PREFERRED PLUS LANCETS PRO COMFORT INSULIN THIN 26G 61 propranolol hcl 30 SYRINGES/0.5ML/30G X PROPRANOLOL/HYDROCHLOR PREFERRED PLUS UNIFINE 1/2" 79 PENTIPS 29G X 12MM 79 OTHIAZIDE 22 PRO COMFORT INSULIN propylthiouracil 109 PREMARIN 46,114 SYRINGES/0.5ML/30G X PREMIUM CONDOMS 5/16" 79 PRORENAL+D 97 LUBRICATED 56 PRO COMFORT INSULIN PROSCAR 47 PREMPHASE 46 SYRINGES/0.5ML/31G X PROTONIX 111 PREMPRO 46 5/16" 79 PRO COMFORT INSULIN PROTOPIC 41 PRENATABS FA 100 SYRINGES/1ML/30G X PROVERA 108 PRENATABS RX 100 1/2" 79 PROVIT 97 PRENATAL 101 PRO COMFORT INSULIN PROZAC 14 PRENATAL 19 100,101 SYRINGES/1ML/30G X 5/16" 79 pseudoephed-bromphen-dm 36 PRENATAL AND IRON 101 PRO COMFORT INSULIN pseudoephedrine hcl 103 PRENATAL FORMULA 101 SYRINGES/1ML/31G X pseudoephedrine w/ codeine- PRENATAL FORTE 101 5/16" 79 gg 36 PRENATAL LOW IRON 101 PRO COMFORT PEN pseudoephedrine-chlorphen-dm NEEDLES/32G X 5MM 79 36 PRENATAL MULTIVITAMIN 101 PRO-CAL 97 pseudoephedrine-ibuprofen 36 PRENATAL ONE DAILY 101 probenecid 48 PSORCON 40 PRENATAL PLUS 101 PROCARDIA 31 PSS SELECT GP LANCETS61 PRENATAL PLUS IRON 101 PROCARDIA XL 31 PSS SELECT SAFETY PROCERV HP 97 LANCETS 61 PRENATAL VITAMIN 101 psyllium 49 prochlorperazine 26 PRENATAL VITAMIN & PTS PANELS KETONE MINERAL 101 prochlorperazine maleate 26 TEST 42

Index 24 PULMICORT 9 quinidine gluconate 8 REALITY INSULIN SYRINGE/U- PULMICORT FLEXHALER 9 QUINIDINE SULFATE 8 100/0.5ML/29G X 1/2" 80 REALITY INSULIN SYRINGE/U- PURIXAN 24 QUINTABS-M 97 100/1ML/28G X 1/2" 80 PX ADVANCED LANCING RA ALCOHOL SWABS 64 REALITY INSULIN SYRINGE/U- DEVICE 61 RA ALL PURPOSE 100/1ML/29G X 1/2" 80 PX INSULIN SYRINGE/U- DRESSINGS4"X4" 54 REALITY LANCETS 62 100/0.3ML/30G X 1/2" 79 RA CENTRAL-VITE 97 REALITY LATEX PX INSULIN SYRINGE/U- CONDOMS/LUBRICATED 56 100/0.3ML/31G X 5/16" 79 RA CENTRAL-VITE UNDER 50MENS 97 REALITY LATEX/ULTRA PX INSULIN SYRINGE/U- TEXTURED 56 100/0.5ML/30G X 1/2" 79 RA CENTRAL-VITE UNDER 50WOMENS 97 REALITY LATEX/ULTRA PX INSULIN SYRINGE/U- THIN 56 100/0.5ML/31G X 5/16" 79 RA DRESSING SPONGES PX INSULIN SYRINGE/U- 4"X4" 54 REALITY SWABS 64 100/1ML/30G X 1/2" 79 RA E-ZJECT COLOR RECOMBIVAX HB 114 PX INSULIN SYRINGE/U- LANCETSMICRO-THIN 33G 61 REGLAN 47 100/1ML/31G X 5/16" 80 RELENZA DISKHALER 29 PX LANCET AUTO RA E-ZJECT LANCETS INJECTOR 61 28G 61 RELION 2-IN-1 LANCING RA E-ZJECT LANCETS THIN DEVICE 25G 62 PX LANCETS ULTRA THIN 61 26G 61 RELION 2-IN-1 LANCING PX PEN NEEDLE RA E-ZJECT LANCETS THIN DEVICE 30G 62 29GX12MM 80 28G 61 RELION ALCOHOL SWABS 64 PX PRENATAL RA E-ZJECT LANCETS MULTIVITAMINS 102 RELION INSULIN SYRINGE ULTRATHIN 30G 61 1ML/31GX15/64" 80 pyrazinamide 23 RA GAUZE SPONGES RELION INSULIN SYRINGE/U- pyrethrins-piperonyl butoxide42 4"X4" 54 00/1ML/29G X 1/2" 80 pyrethrins-piperonyl butoxide- RA INSULIN RELION INSULIN SYRINGE/U- permethrin-nit remover 42 SYRINGE/0.5ML/29G X 100/0.3ML/29G X 1/2" 80 PYRIDIUM 47 1/2" 80 RELION INSULIN SYRINGE/U- RA INSULIN pyridostigmine bromide 23 100/0.3ML/30G X 5/16" 80 SYRINGE/1ML/29G X 1/2" 80 RELION INSULIN SYRINGE/U- QC ADVANCED LANCING RA INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16" 80 DEVICE 61 100/0.5ML/30G X 5/16" 80 RELION INSULIN SYRINGE/U- QC ALCOHOL SWABS 64 RA INSULIN SYRINGE/U- 100/0.5ML/29G X 1/2" 80 QC ALL PURPOSE 100/1 ML/30G X 5/16" 80 RELION INSULIN SYRINGE/U- DRESSINGS4"X4" 54 RA LANCING DEVICE 62 100/0.5ML/30G X 5/16" 80 QC BORDER ISLAND GAUZE RA PRENATAL 102 RELION INSULIN SYRINGE/U- PAD 2"X2" 54 RA PRENATAL 100/0.5ML/31G X 5/16" 80 QC LANCETS SUPER THIN 61 FORMULA/FOLICACID 102 RELION INSULIN SYRINGE/U- QC LANCETS ULTRA THIN 61 100/1ML/30G X 5/16" 80 RA STERILE PADS 2"X2" 54 RELION INSULIN SYRINGE/U- QC PEN NEEDLES 29G X RA STERILE PADS 3"X3" 54 12MM 80 100/1ML/31G X 15/64" 80 RA STERILE PADS 4"X4" 54 RELION INSULIN SYRINGE/U- QC PRENATAL 102 raloxifene hcl 45 100/1ML/31G X 5/16" 80 QC STERILE PADS 54 RELION KETONE 43 ramipril 21 QC UNILET LANCETS RELION KETONE TEST 33G/MICRO THIN 61 ranitidine hcl 111 STRIPS 43 QUENCH 97 RAPAMUNE 93 RELION LANCETS MICRO- QUESTRAN 20 RAY-TEC X-RAY THIN33G 62 QUESTRAN LIGHT 20 DETECTABLESPONGES 4" X RELION LANCETS STANDARD 4" 16 PLY 54 21G 62 26 quetiapine fumarate RAZADYNE 108 RELION LANCETS THIN 99 26G 62 QUFLORA PEDIATRIC RAZADYNE ER 108 QUIN B STRONG 97 RELION LANCETS ULTRA- REALITY INSULIN THIN30G 62 quinapril hcl 21 SYRINGE/U-100/0.5ML/28G X RELION LANCING DEVICE 62 quinapril-hydrochlorothiazide 1/2" 80 22

Index 25 RELION PEN NEEDLES risperidone 25 SAFETY-GLIDE INSULIN 29GX12MM 80 RISPERIDONE ODT 25 SYRINGE/0.3ML/29G X 1/2" 81 RELION ULTRA THIN SALAGEN 94 RITALIN 2 LANCETS30G 62 saline 102 RELION ULTRA THIN PLUS RITEFLO 90 salsalate 4 LANCETS 32G 62 ritonavir 28 RELION ULTRA THIN PLUS SAMI THE SEAL LANCETS 33G 62 rivastigmine 108 REPLACEMENTFILTERS 90 RELPAX 91 rivastigmine tartrate 108 SANDIMMUNE 93 REMERON 12,13 rizatriptan benzoate 91 SARNA 39 REMERON SOLTAB 12 ROBAXIN 102 SAVELLA 108 RENAPLEX-D 97 ROBAXIN-750 102 SAVELLA TITRATION REPLACEMENT AIR ROBINUL 110 PACK 108 FILTER 90 ROBINUL FORTE 110 SB ALCOHOL PREP PADS 65 REPLACEMENT FILTERS 90 SB INSULIN SYRINGE/U- ROBITUSSIN DM 36 100/0.5ML/29G X 1/2" 81 REQ 49+ 97 ROBITUSSIN PEAK COLD SB INSULIN SYRINGE/U- REQUIP 25 COUGH+ CHEST 100/0.5ML/30G X 5/16" 81 RESCON-GG 36 CONGESTION DM MAX SB INSULIN SYRINGE/U- STRENGTH 36 RESCRIPTOR 28 100/1ML/29G X 1/2" 81 ROBITUSSIN PEAK COLD SB INSULIN SYRINGE/U- RESERPINE 21 DM 36 100/1ML/30G X 5/16" 81 RESTORE CONTACT ROCALTROL 45 SB INSULIN SYRINGE/U- LAYER/NON-ADHERENT ropinirole hydrochloride 25 100/1ML/31G X 5/16" 81 2"X2" 54 SB LANCETS THIN 62 RESTORE FOAM DRESSING rosuvastatin calcium 20 BORDERED 4"X4" 54 ROXICODONE 5 SB LANCETS ULTRA THIN 62 SCHNUCKS INSULIN RESTORE FOAM DRESSING RYTHMOL 9 NON-BORDERED 4"X4" 54 SYRINGEULTI-FINE/U- RESTORE ODOR ABSORBING RYTHMOL SR 8 100/0.5ML/29G X 1/2" 81 DRESSING 4"X4" 55 SAFESNAP INSULIN SCHNUCKS INSULIN RESTORE TRIO ABSORBENT SYRINGE/0.3ML/30G X SYRINGEULTI-FINE/U- DRESSING 3"X3" 55 5/16" 80 100/0.5ML/30G X 5/16" 81 RESTORIL 49 SAFESNAP INSULIN SE-NATAL 19 102 SYRINGE/0.5ML/29G X SEASONIQUE 33 RETIN-A 37 1/2" 80 RETROVIR 28 SAFESNAP INSULIN SECTRAL 30 REXALL LANCETS ULTRA SYRINGE/0.5ML/30G X SELECT-LITE LANCING THIN 62 5/16" 80 DEVICE 62 REYATAZ 28 SAFESNAP INSULIN selegiline hcl 25 SYRINGE/1ML/28G X 1/2" 80 selenium sulfide 39 RHEUMATREX 2 SAFESNAP INSULIN RHOGAM ULTRA-FILTERED SYRINGE/1ML/29G X 1/2" 80 SELSUN BLUE 39 PLUS 107 SAFETY INSULIN SYRINGES SELSUN BLUE DAILY 39 RID 42 0.5ML/29GX1/2" 80 SELSUN BLUE RID COMPLETE LICE SAFETY INSULIN SYRINGES MEDICATED 39 ELIMINATION 42 0.5ML/30GX5/16" 80 SELSUN BLUE RIFADIN 23 SAFETY INSULIN SYRINGES MOISTURIZING 39 rifampin 23 1ML/27GX1/2" 81 SELZENTRY 28 SAFETY INSULIN SYRINGES sennosides 50 RIGHT STEP PRENATAL 102 1ML/29GX1/2" 81 RIGHTEST GD500 LANCING SAFETY INSULIN SYRINGES sennosides-docusate DEVICE 62 1ML/30GX1/2" 81 sodium 49 RIGHTEST GL300 SAFETY SEAL LANCETS SENOKOT 50 LANCETS 62 28G 62 SENOKOT S 49 risedronate sodium 45 SAFETY SEAL LANCETS SENTRY 97 30G 62 RISPERDAL 25 SENTRY SENIOR 97 RISPERDAL M-TAB 25 SENTRY SENIOR/LUTEIN 97

Index 26 SEREVENT DISKUS 9 SINEMET 25 SONATA 49 SEROQUEL 26 SINEMET CR 25 SOOTHENEB NBL 100 CHILD sertraline hcl 14 SINGULAIR 9 MASK 91 SOOTHENEB NBL 100 SFROWASA 47 sirolimus 93 MEDICATION CUP 91 SHOHLS SOLUTION SIVEXTRO 7 SOOTHENEB NBL 100 MESH MODIFIED 47 SM ALCOHOL PREP CAP 91 SHOPKO ALCOHOL PADS 65 SOOTHENEB NBL100 ADULT SWABS 65 SM GAUZE PADS 2"X2" 55 MASK 91 SHOPKO AUTOLET LANCING sotalol hcl 30 DEVICE 62 SM GAUZE PADS 3"X3" 55 SHOPKO UNIFINE PENTIPS SM GAUZE PADS 4"X4" 55 sotalol hcl (afib/afl) 30 PEN SM GLUCOSE 16 SOVALDI 29 NEEDLES/ORIGINAL/29GX12M SM INSULIN SPINOSAD 42 M 81 SYRINGE/1ML/31G X spironolactone 44 SHOPKO UNIFINE PENTIPS 5/16" 81 spironolactone & PLUS PEN SM MICRO THIN LANCETS hydrochlorothiazide 44 NEEDLES/REMOVER/29GX12M 33G 62 M 81 SPORANOX 18 SHOPKO UNILET LANCETS SM ONE DAILY MENS 97 SPORANOX PULSEPAK 19 SUPER THIN 30G 62 SM ONE DAILY WOMENS97 stannous fluoride 94 SM PRENATAL SHOPKO UNILET LANCETS STARLIX 17 ULTRA THIN 28G 62 VITAMINS 102 SIDE BUTTON SAFETY SM STERILE PADS 55 stavudine 28 LANCET21G 62 SM STERILE PADS 2"X2" 55 STERILANCE TL 62 SIDEROL 97 SM TRUEDRAW LANCING STERILE GAUZE PADS SIDESTREAM ADULT FACE DEVICE 62 2"X2" 55 MASK 90 SMART DIABETES VANTAGE STERILE GAUZE PADS SIDESTREAM PEDIATRIC LANCING DEVICE 62 3"X3" 55 FACEMASK 90 SMART SENSE COLOR STERILE PADS 2"X2" 55 SIDESTREAM PEDIATRIC LANCETS UNIVERSAL STERILE PADS 3"X3" 55 FACEMASK/SAMI THE 33G 62 STERILE PADS 4"X4" 55 SEAL 90 SMART SENSE STANDARD SIDESTREAM PEDIATRIC LANCETS UNIVERSAL STRIBILD 28 FACEMASK/TUCKER THE 21G 62 STROVITE ONE 97 TURTLE 90 SMART SENSE SUPER THIN SUBOXONE 6 SIDESTREAM PLUS ADULT LANCETS UNIVERSAL sucralfate 111 FACE MASK 90 30G 62 SILICONE MASK FOR SMART SENSE THIN SUDAFED CHILDRENS 103 BREATHERITE LANCETSUNIVERSAL SUDAFED CONGESTION 103 CHAMBER/ADULT 90 26G 62 SUDAFED NASAL SILICONE MASK FOR sodium bicarbonate DECONGESTANT MAXIMUM BREATHERITE (antacid) 6 STRENGTH 103 CHAMBER/INFANT 90 sodium chloride (gu SUDAFED PE SILICONE MASK FOR irrigant) 47 CONGESTION 103 BREATHERITE sodium chloride (inhalant) 36 sulfacetamide sod- CHAMBER/PEDIATRIC 90 prednisolone 105 SILICONE MASK FOR sodium citrate & citric acid 47 BREATHRITE sodium fluoride 92 sulfacetamide sodium 39 SULFACETAMIDE CHAMBER/ADULT 90 sodium fluoride (dental) 94 SILPHEN COUGH 19 SODIUM 105 sodium phosphates 50 sulfacetamide sodium (acne)37 SILVADENE 39 sodium polystyrene sulfacetamide sodium silver sulfadiazine 39 sulfonate 93 (ophth) 105 simethicone 46 SOF-WICK 4"X4" 55 sulfamethoxazole- SIMPLE DIAGNOSTICS SOLO 97 trimethoprim 7 LANCING DEVICE 62 SOLUS V2 LANCING sulfasalazine 47 simvastatin 20 DEVICE 62 sulindac 3

Index 27 sumatriptan 91 SURE-JECT INSULIN TEARS NATURALE PM 103 sumatriptan succinate 91 SYRINGE/U-100/0.3ML/29G X TECFIDERA 108 1/2" 82 SUMATRIPTAN SURE-JECT INSULIN TECFIDERA STARTER SUCCINATE 91 SYRINGE/U-100/0.3ML/30G X PACK 108 sumatriptan succinate 91 5/16" 82 TECHLITE AST LANCETS 62 SUPER THIN LANCETS 62 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU- SUPERB NAILS 97 SYRINGE/U-100/0.3ML/31G X 100/0.3ML/29G X 1/2" 82 TECHLITE INSULIN SYRINGEU- SURE COMFORT INSULIN 5/16" 82 SURE-JECT INSULIN 100/0.3ML/30G X 1/2" 82 SYRINGE/U-100/0.3ML/29G X TECHLITE INSULIN SYRINGEU- 1/2" 81 SYRINGE/U-100/0.5ML/28G X 1/2" 82 100/0.3ML/30G X 5/16" 82 SURE COMFORT INSULIN TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.3ML/30G X SURE-JECT INSULIN SYRINGE/U-100/0.5ML/29G X 100/0.3ML/31G X 5/16" 82 1/2" 81 TECHLITE INSULIN SYRINGEU- SURE COMFORT INSULIN 1/2" 82 SURE-JECT INSULIN 100/0.5ML/29G X 1/2" 82 SYRINGE/U-100/0.3ML/30G X TECHLITE INSULIN SYRINGEU- 5/16" 81 SYRINGE/U-100/0.5ML/30G X 5/16" 82 100/0.5ML/30G X 1/2" 82 SURE COMFORT INSULIN TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.3ML/31G X SURE-JECT INSULIN SYRINGE/U-100/0.5ML/31G X 100/0.5ML/30G X 5/16" 82 5/16 81 TECHLITE INSULIN SYRINGEU- SURE COMFORT INSULIN 5/16" 82 SURE-JECT INSULIN 100/0.5ML/31G X 5/16" 82 SYRINGE/U-100/0.3ML/31G X TECHLITE INSULIN SYRINGEU- 5/16" 81 SYRINGE/U-100/1ML/28G X 1/2" 82 100/1ML/29G X 1/2" 82 SURE COMFORT INSULIN TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/28G X SURE-JECT INSULIN SYRINGE/U-100/1ML/29G X 100/1ML/30G X 1/2" 82 1/2" 81 TECHLITE INSULIN SYRINGEU- SURE COMFORT INSULIN 1/2" 82 SURE-JECT INSULIN 100/1ML/30G X 5/16" 82 SYRINGE/U-100/0.5ML/29G X TECHLITE INSULIN SYRINGEU- 1/2" 81 SYRINGE/U-100/1ML/30G X 82 100/1ML/31G X 15/64" 83 SURE COMFORT INSULIN 5/16" TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/30G X SURE-JECT INSULIN SYRINGE/U-100/1ML/31G X 100/1ML/31G X 5/16" 83 1/2" 81 TECHLITE LANCETS 62 SURE COMFORT INSULIN 5/16" 82 SYRINGE/U-100/0.5ML/30G X SURE-PEN 62 TECHLITE LANCETS 30G 62 5/16" 81 SURELITE LANCETS 62 TECHLITE PEN NEEDLES 29GX SURE COMFORT INSULIN SURGICAL GAUZE 12 MM 83 SYRINGE/U-100/0.5ML/31G X 55 TEGADERM FOAM DRESSING SPONGE 2"X2" 55 5/16 81 SUSTIVA 28 SURE COMFORT INSULIN TEGADERM FOAM DRESSING SYRINGE/U-100/1ML/28G X SYMBICORT 9 4"X4" 55 1/2" 81 SYMLINPEN 120 15 TEGRETOL 11 SURE COMFORT INSULIN SYMLINPEN 60 15 TEGRETOL-XR 11 SYRINGE/U-100/1ML/29G X SYNTHROID 109 telmisartan 21 1/2" 81 SURE COMFORT INSULIN T-VITES 97 telmisartan-amlodipine 22 SYRINGE/U-100/1ML/30G X tacrolimus 93 telmisartan-hydrochlorothiazide 1/2" 82 tacrolimus (topical) 41 22 SURE COMFORT INSULIN temazepam 49 TAGAMET HB 111 SYRINGE/U-100/1ML/30G X TEMODAR 23 TAMIFLU 29 5/16" 82 TEMOVATE 40 SURE COMFORT INSULIN tamoxifen citrate 24 TEMOVATE E 40 SYRINGE/U-100/1ML/31G X tamsulosin hcl 47 5/16" 82 temozolomide 23 TAPAZOLE 109 SURE COMFORT LANCING TENCON 3 PEN 62 TARKA 22 TENEX 21 SURE COMFORT PEN TAVIST ALLERGY 19 TENIVAC 110 NEEDLES30GX5/16" tazarotene 39 SHORT 82 tenofovir disoproxil fumarate 28 TAZORAC 39

Index 28 TENORETIC 100 22 THEREMS-H 97 TODAYS HEALTH ULTRA TENORETIC 50 22 THEREMS-M 97 THINLANCETS 28G 63 TOFRANIL 15 TENORMIN 30 THINLETS GP LANCETS 63 tolmetin sodium 3 TERAZOL 3 114 THINLETS LANCET 63 TOLMETIN SODIUM 3 TERAZOL 7 114 thioridazine hcl 26 tolnaftate 38 terazosin hcl 21 thiothixene 26 tolterodine tartrate 112 terbinafine hcl 18 THRESHOLD IMT 91 TOPAMAX 11 terbinafine hcl (topical) 38 THRIVITE 19 102 TOPAMAX SPRINKLE 11 terbutaline sulfate 9 THRIVITE RX 102 TOPCARE ULTRA COMFORT TERCONAZOLE 114 thyroid 109 INSULIN SYRINGE/0.3ML/30G X terconazole vaginal 114 THYROLAR-1 109 5/16" 83 TESSALON PERLES 34 THYROLAR-1/2 110 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X testosterone cypionate 6 THYROLAR-1/4 110 5/16" 83 TETANUS/DIPHTHERIA THYROLAR-2 110 TOPCARE ULTRA COMFORT TOXOIDS-ADSORBED 110 THYROLAR-3 110 INSULIN SYRINGE/0.5ML/30G X tetrahydrozoline hcl (ophth) 105 tiagabine hcl 12 5/16" 83 TGT ADVANCED LANCING TOPCARE ULTRA COMFORT DEVICE 63 TIAZAC 31 INSULIN SYRINGE/0.5ML/31G X TGT ALCOHOL SWABS 65 TIKOSYN 9 5/16" 83 TGT LANCET ALTERNATE TIMOLOL MALEATE 30 TOPCARE ULTRA COMFORT SITE 63 timolol maleate (ophth) 104 INSULIN SYRINGE/1ML/30G X 5/16" 83 TGT LANCET MICRO THIN TIMOLOL MALEATE 33G 63 TOPCARE ULTRA COMFORT OPHTHALMIC GEL INSULIN SYRINGE/1ML/31G X TGT LANCET SUPER THIN FORMING 104 30G 63 5/16" 83 TIMOPTIC 104 TGT LANCET THIN 23G 63 TOPCARE ULTRA COMFORT TIMOPTIC OCUDOSE 104 INSULIN SYRINGE/U- TGT LANCET THIN 26G 63 TIMOPTIC-XE 104 100/0.3ML/29G X 1/2" 83 TGT LANCET ULTRA THIN TOPCARE ULTRA COMFORT 28G 63 TINACTIN 38 INSULIN SYRINGE/U- TGT LANCET ULTRA THIN TINACTIN JOCK ITCH 38 100/0.5ML/29G X 1/2" 83 30G 63 tioconazole vaginal 114 TOPCARE ULTRA COMFORT TGT LANCING DEVICE 63 TIVICAY 28 INSULIN SYRINGE/U- THEO-24 10 100/1ML/29G X 1/2" 83 tizanidine hcl 102 theophylline 10 TOPCO INSULIN SYRINGE/U- TOBI 2 100/0.3ML/29G X 1/2" 83 THERA M PLUS 97 TOBRADEX 105 TOPCO INSULIN SYRINGE/U- THERA-FLUR-N 94 100/0.5ML/28G X 1/2" 83 TOBRAMYCIN 2 THERA-M 97 TOPCO INSULIN SYRINGE/U- tobramycin 2 100/0.5ML/29G X 1/2" 83 THERA-TABS M 97 TOPCO INSULIN SYRINGE/U- THERABETIC MULTI- tobramycin (ophth) 105 TOBRAMYCIN SULFATE 2 100/1ML/28G X 1/2" 83 VITAMIN 97 TOPCO INSULIN SYRINGE/U- THERAGAUZE 55 tobramycin sulfate 2 100/1ML/29G X 1/2" 83 THERAGRAN-M 97 tobramycin- TOPICORT 40 dexamethasone 105 THERAGRAN-M topiramate 11 TOBREX 105 ADVANCED 97 TOPPER DRESSING SPONGES THERAGRAN-M ADVANCED 50 TODAYS HEALTH ADVANCED 4"X4" 55 LANCING DEVICE 63 PLUS 97 TOPROL XL 30 THERAGRAN-M PREMIER 97 TODAYS HEALTH ORIGINAL THERAGRAN-M PREMIER 50 PEN NEEDLES 29G X torsemide 44 PLUS 97 1/2" 83 TRADJENTA 16 THERANATAL CORE TODAYS HEALTH SUPER tramadol hcl 5 THINLANCETS 30G 63 NUTRITION 102 tramadol-acetaminophen 5

Index 29 trandolapril 21 TROJAN PLEASURE TRUEPLUS INSULIN trandolapril-verapamil hcl 22 MESH/SPERMICIDAL 56 SYRINGE/U-100/0.3ML/31G X 5/16" 83 TRANDOLAPRIL/VERAPAMIL TROJAN PLUS 56 TROJAN REGULAR 56 TRUEPLUS INSULIN HCL ER 22 SYRINGE/U-100/0.5ML/28G X tranexamic acid 48 TROJAN RIBBED 56 1/2" 83 TRANXENE T 8 TROJAN RIBBED TRUEPLUS INSULIN tranylcypromine sulfate 13 W/SPERMICIDAL 56 SYRINGE/U-100/0.5ML/29G X TROJAN SHARED 1/2" 83 trazodone hcl 14 SENSATION/LUBRICATED TRUEPLUS INSULIN TRECATOR 23 56 SYRINGE/U-100/0.5ML/30G X tretinoin 37 TROJAN SUPRAS 5/16" 83 SPERMICIDAL 56 TREXALL 24 TRUEPLUS INSULIN TROJAN TWISTED SYRINGE/U-100/0.5ML/31G X TRI-NORINYL 28 33 PLEASURE 56 5/16" 84 TRI-VIT/FLUORIDE/IRON 99 TROJAN ULTRA TRUEPLUS INSULIN TRIADVANCE 102 PLEASURE/LUBRICATED SYRINGE/U-100/1ML/28G X 56 1/2" 84 triamcinolone acetonide TROJAN VERY SENSITIVE (mouth) 94 TRUEPLUS INSULIN LUBRICATED 56 SYRINGE/U-100/1ML/29G X triamcinolone acetonide TROJAN VERY SENSITIVE (topical) 40 1/2" 84 SPERMICIDAL TRUEPLUS INSULIN TRIAMINIC COLD & COUGH LUBRICANT 56 DAY TIME CHILDRENS 36 SYRINGE/U-100/1ML/30G X TROJAN VERY THIN 5/16" 84 triamterene & LUBRICATED 56 hydrochlorothiazide 44 TRUEPLUS INSULIN TROJAN VERY THIN SYRINGE/U-100/1ML/31G X TRIAMTERENE/HYDROCHLOR SPERMICIDAL OTHIAZIDE 44 5/16" 84 LUBRICANT 56 TRUEPLUS LANCETS 26G 63 TRIAZOLAM 49 TROJAN-ENZ triazolam 49 LUBRICANT 56 TRUEPLUS LANCETS 28G 63 TRICARE 102 TROJAN-ENZ TRUEPLUS LANCETS 28G LUBRICATED 56 SUPER THIN 63 trifluoperazine hcl 26 TROJAN-ENZ TRUEPLUS LANCETS 30G 63 trifluridine 105 W/SPERMICIDAL 56 TRUEPLUS LANCETS 30G TRIGLIDE 20 tropicamide 104 ULTRA THIN 63 trihexyphenidyl hcl 24 trospium chloride 112 TRUEPLUS LANCETS 33G 63 TRILEPTAL 11 TRUE METRIX BLOOD TRUEPLUS PEN NEEDLES trimethoprim 7 GLUCOSETEST STRIPS 43 29GX12MM 84 TRUE METRIX CONTROL TRUETEST BLOOD GLUCOSE TRINATAL GT 102 SOLUTION LEVEL 1 63 TEST 43 TRINATAL RX 1 102 TRUE METRIX CONTROL TRUETEST BLOOD GLUCOSE TRINTELLIX 14 SOLUTION LEVEL 2 63 TEST STRIPS 43 TRUE METRIX CONTROL TRUETEST GLUCOSE TRIUMEQ 28 SOLUTION LEVEL 3 63 CONTROLLEVEL 1 63 TRIZIVIR 28 TRUE METRIX SELF TRUETEST GLUCOSE TROJAN 56 MONITORING BLOOD CONTROLLEVEL 2 63 TROJAN ASSORTMENT GLUCOSE STRIPS 43 TRUETEST GLUCOSE PACK 56 TRUECONTROL GLUCOSE CONTROLLEVEL 3 63 TROJAN EXTENDED CONTROL LEVEL 0 63 TRUETEST STRIPS 43 PLEASURE/LUBRICATED 56 TRUECONTROL GLUCOSE TRUETRACK BLOOD TROJAN EXTRA CONTROL LEVEL 1 63 GLUCOSE TEST 43 STRENGTH 56 TRUEDRAW LANCING TRUETRACK TEST 43 TROJAN MAGNUM 56 DEVICE 63 TRUEPLUS INSULIN TRUMENBA 112 TROJAN MAGNUM WARM TRUSOPT 106 SENSATIONS 56 SYRINGE/U-100/0.3ML/29G X 1/2" 83 TRUSTEX COLOR CONDOMS + TROJAN MAGNUM XL LUBE 56 LUBRICATED 56 TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X TRUSTEX LUBRICATED 57 5/16" 83

Index 30 TRUSTEX LUBRICATED ULTICARE INSULIN ULTICARE INSULIN EXTRALARGE 56 SYRINGE/0.3ML/29G X SYRINGE/U-100/0.3ML/31G X TRUSTEX LUBRICATED 1/2" 84 5/16" 84 EXTRASTRENGTH 56 ULTICARE INSULIN ULTICARE INSULIN TRUSTEX SYRINGE/0.3ML/30G X SYRINGE/U-100/0.5ML/29G X LUBRICATED/RIBBED/STUDDE 1/2" 84 1/2" 85 D 57 ULTICARE INSULIN ULTICARE INSULIN TRUSTEX SYRINGE/0.3ML/30G X SYRINGE/U-100/0.5ML/30G X LUBRICATED/SPERMICIDE 5/16" 84 1/2" 85 57 ULTICARE INSULIN ULTICARE INSULIN TRUSTEX SYRINGE/0.5ML/28G X SYRINGE/U-100/0.5ML/30G X LUBRICATED/SPERMICIDE 1/2" 84 5/16" 85 EXTRA LARGE 57 ULTICARE INSULIN ULTICARE INSULIN TRUSTEX SYRINGE/0.5ML/29G X SYRINGE/U-100/0.5ML/31G X LUBRICATED/SPERMICIDE 1/2" 84 5/16" 85 EXTRA STRENGTH 57 ULTICARE INSULIN ULTICARE INSULIN TRUSTEX NATURAL SYRINGE/0.5ML/30G X SYRINGE/U-100/1ML/29G X CONDOMS 1/2" 84 1/2" 85 +LUBE/LUBRICATED 57 ULTICARE INSULIN ULTICARE INSULIN TRUSTEX NON- SYRINGE/0.5ML/30G X SYRINGE/U-100/1ML/30G X LUBRICATED 57 5/16" 84 1/2" 85 TRUSTEX WITH NONOXYNOL- ULTICARE INSULIN ULTICARE INSULIN 9/RIBBED/STUDDED 57 SYRINGE/1ML/28G X 1/2" 84 SYRINGE/U-100/1ML/30G X TRUSTEX/RIA ULTICARE INSULIN 5/16" 85 LUBRICATED 57 SYRINGE/1ML/29G X 1/2" 84 ULTICARE INSULIN TRUSTEX/RIA LUBRICATED ULTICARE INSULIN SYRINGE/U-100/1ML/31G X SPERMICIDE 57 SYRINGE/1ML/30G X 1/2" 84 5/16" 85 TRUSTEX/RIA ULTICARE INSULIN ULTICARE INSULIN LUBRICATED/SPERMICIDE SYRINGE/1ML/30G X SYRINGEULTRAFINE U- 57 5/16" 84 100/0.3ML/31G X 5/16" 85 TRUSTEX/RIA NON- ULTICARE INSULIN ULTICARE INSULIN LUBRICATED 57 SYRINGE/SHORT/0.3ML/30G SYRINGEULTRAFINE U- TRUVADA 28 X 5/16" 84 100/0.5ML/31G X 5/16" 85 TUBING/WING TIP 91 ULTICARE INSULIN ULTICARE INSULIN SYRINGE/SHORT/0.3ML/31G SYRINGEULTRAFINE U- TUDORZA PRESSAIR 9 X 5/16" 84 100/1ML/31G X 5/16" 85 TUMS 7 ULTICARE INSULIN ULTICARE ORIGINAL PEN TUMS LASTING EFFECTS 7 SYRINGE/SHORT/0.5ML/30G NEEDLES ULTI-FINE 85 TWYNSTA 22 X 5/16" 84 ULTILET ALCOHOL ULTICARE INSULIN SWABS 65 TYBOST 28 SYRINGE/SHORT/0.5ML/31G ULTILET CLASSIC TYLENOL 4 X 5/16" 84 LANCETS 63 TYLENOL CHILDRENS 4 ULTICARE INSULIN ULTILET INSULIN TYLENOL EXTRA SYRINGE/SHORT/1ML/30G X SYRINGE/0.3ML/30G X STRENGTH 4 5/16" 84 8MM 85 ULTICARE INSULIN ULTILET INSULIN TYLENOL INFANTS 4 SYRINGE/SHORT/1ML/31G X SYRINGE/0.3ML/31G X TYLENOL INFANTS 5/16" 84 8MM 85 PAIN+FEVER 4 ULTICARE INSULIN ULTILET INSULIN TYLENOL/CODEINE #3 6 SYRINGE/U-100/0.3ML/29G X SYRINGE/0.5ML/30G X TYLENOL/CODEINE #4 6 1/2" 84 8MM 85 ULTI-LANCE AUTOMATIC/ ULTICARE INSULIN ULTILET INSULIN CLEAR TIP 63 SYRINGE/U-100/0.3ML/30G X SYRINGE/1ML/30G X 8MM 85 ULTICARE ALCOHOL 1/2" 84 ULTILET INSULIN SWABS 65 ULTICARE INSULIN SYRINGE/1ML/31G X 8MM 85 ULTICARE INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X ULTILET INSULIN SYRINGE/0.5ML/29G X 1/2" 84 5/16" 84 SYRINGE/SHORT/0.3ML/30G X ULTICARE INSULIN SAFETY 12.7MM 85 SYRINGE/1ML/29G X 1/2" 84

Index 31 ULTILET INSULIN ULTRA-COMFORT INSULIN UNILET LANCETS SUPER- SYRINGE/SHORT/0.3ML/30G X SYRINGE/U-100/1ML/30G X THIN30G 63 5/16" 85 5/16" 86 UNILET LANCETS ULTRA-THIN ULTILET INSULIN ULTRA-COMFORT INSULIN 28G 63 SYRINGE/SHORT/0.3ML/31G X SYRINGE/U-100/1ML/31G X UNILET SUPERLITE 5/16" 85 5/16" 86 LANCET 64 ULTILET INSULIN ULTRA-THIN II INSULIN UNISOM 48 SYRINGE/SHORT/0.5ML/30G X SYRINGE SHORT/U- UNISOM SLEEPGELS 48 5/16" 85 100/0.3ML/30GX5/16" 86 UNISTIK TOUCH SAFETY ULTILET INSULIN ULTRA-THIN II INSULIN LANCETS 21G 64 SYRINGE/SHORT/0.5ML/31G X SYRINGE SHORT/U- UNISTIK TOUCH SAFETY 5/16" 85 100/0.3ML/31GX5/16" 86 LANCETS 23G 64 ULTILET INSULIN ULTRA-THIN II INSULIN UNISTIK TOUCH SAFETY SYRINGE/SHORT/1ML/30G X SYRINGE SHORT/U- LANCETS 28G 64 5/16" 85 100/0.5ML/30GX5/16" 86 UNISTIK TOUCH SAFETY ULTILET INSULIN ULTRA-THIN II INSULIN LANCETS 30G 64 SYRINGE/SHORT/1ML/31G X SYRINGE SHORT/U- UNIVERSAL 1 LANCETS 5/16" 85 100/0.5ML/31GX5/16" 86 THIN26G 64 ULTILET INSULIN SYRINGE/U- ULTRA-THIN II INSULIN UNIVERSAL 1 LANCETS ULTRA 100/0.5ML/30G X 1/2" 85 SYRINGE SHORT/U- THIN 30G 64 ULTILET INSULIN SYRINGE/U- 100/1ML/30GX5/16" 86 100/1ML/30G X 1/2" 85 ULTRA-THIN II INSULIN urea 41 ULTIMATE FEELING 57 SYRINGE SHORT/U- URECHOLINE 112 ULTRA COMFORT INSULIN 100/1ML/31GX5/16" 86 UROCIT-K 10 47 SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II INSULIN UROCIT-K 5 47 SYRINGE/U- 5/16" 85 URSO 250 47 ULTRA THIN LANCETS 100/0.3ML/29GX1/2" 86 28G 63 ULTRA-THIN II INSULIN ursodiol 47 ULTRA THIN LANCETS SYRINGE/U- V-R MONOJECT INSULIN 30G 63 100/0.5ML/29GX1/2" 86 SYRINGE/U-100/0.3ML/29G X ULTRA-COMFORT INSULIN ULTRA-THIN II INSULIN 1/2" 86 SYRINGE/U-100/0.3ML/29G X SYRINGE/U- V-R MONOJECT INSULIN 1/2" 85 100/1ML/29GX1/2" 86 SYRINGE/U-100/0.5ML/28G X ULTRA-COMFORT INSULIN ULTRACET 6 1/2" 86 SYRINGE/U-100/0.3ML/30G X ULTRAM 5 V-R MONOJECT INSULIN SYRINGE/U-100/0.5ML/29G X 5/16" 86 ULTRATHON INSECT ULTRA-COMFORT INSULIN 1/2" 86 REPELLENT 41 V-R MONOJECT INSULIN SYRINGE/U-100/0.3ML/31G X ULTRATHON INSECT 5/16" 86 SYRINGE/U-100/1ML/28G X REPELLENT 8 41 1/2" 86 ULTRA-COMFORT INSULIN UNICOMPLEX-M 97 SYRINGE/U-100/0.5ML/28G X V-R MONOJECT INSULIN 1/2" 86 UNIFINE PENTIPS SYRINGE/U-100/1ML/29G X ULTRA-COMFORT INSULIN 29GX12MM 86 1/2" 86 SYRINGE/U-100/0.5ML/29G X UNIFINE PENTIPS PLUS VAGISTAT-1 114 29GX12MM 86 1/2" 86 valacyclovir hcl 29 ULTRA-COMFORT INSULIN UNILET COMFORTOUCH SYRINGE/U-100/0.5ML/30G X LANCET 63 VALCYTE 29 5/16" 86 UNILET EXCELITE 63 valganciclovir hcl 29 ULTRA-COMFORT INSULIN UNILET EXCELITE II 63 VALIUM 8 SYRINGE/U-100/0.5ML/31G X UNILET G.P. LANCET 63 valproate sodium 12 5/16" 86 UNILET G.P. SUPERLITE valproic acid 12 ULTRA-COMFORT INSULIN LANCET 63 SYRINGE/U-100/1ML/28G X UNILET GP 28 ULTRA valsartan 21 1/2" 86 THIN 63 valsartan-hydrochlorothiazide ULTRA-COMFORT INSULIN UNILET LANCET 63 22 SYRINGE/U-100/1ML/29G X VALTREX 29 1/2" 86 UNILET LANCETS MICRO- THIN33G 63

Index 32 VALUE HEALTH INSULIN VIDA MIA AUTOLET W&F LANCETS COLORED SYRINGE/U-100/0.5ML/29G X LANCINGDEVICE 64 21G 64 1/2" 87 VIDA MIA UNIFINE WALGREENS COMFORT VALUE HEALTH INSULIN PENTIPSORIGINAL ASSUREDLANCETS MICRO SYRINGE/U-100/1ML/29G X 29GX12MM 87 THIN/33G 64 1/2" 87 VIDA MIA UNILET LANCETS WALGREENS COMFORT VALUE PLUS LANCETS SUPER THIN 30G 64 ASSUREDLANCETS SUPER STANDARD 21G 64 VIDA MIA UNILET LANCETS THIN/28G 64 VALUE PLUS LANCETS ULTRA THIN 28G 64 WALGREENS GLUCOSE 16 SUPERTHIN 30G 64 VIDEX EC 28 WALGREENS THIN VALUE PLUS LANCETS THIN VIDEXPEDIATRIC 28 LANCETS 64 26G 64 warfarin sodium 10 VALUE PLUS LANCING VIGAMOX 105 DEVICE 64 VIIBRYD 14 WATCHHALER 91 VALUMARK LANCET SUPER VINATE M 102 WEBCOL ALCOHOL PREP THIN 30G 64 LARGE 1 PLY 65 VALUMARK LANCET ULTRA VINATE ONE 102 WEBCOL ALCOHOL PREP THIN 28G 64 VIRACEPT 28 LARGE 2 PLY 65 VALUMARK PEN NEEDLES VIRAMUNE 28 WEBCOL ALCOHOL PREP MEDIUM 2 PLY 65 29GX12MM 87 VIRAMUNE XR 28 VALVED HOLDING WELLBUTRIN 13 VIREAD 28,29 CHAMBER 91 WELLBUTRIN SR 13 VIROPTIC 105 VANCOCIN HCL 7 WELLBUTRIN XL 13 VIRT-ADVANCE 102 vancomycin hcl 7 white petrolatum-mineral oil103 VANISHPOINT INSULIN VIRT-VITE GT 102 WHOLE FOOD SYRINGE/0.5ML/30G X 1/2" 87 VISINE 105 MULTIVITAMIN 98 VANISHPOINT INSULIN SYRINGE/0.5ML/30G X VISINE EXTRA 105 WINDMILL TRAINER 91 5/16" 87 VISTARIL 8 WOMENS 50+ MULTI VITAMIN& VANISHPOINT INSULIN VISTEC X-RAY DETECTABLE MINERAL FORMULA 98 SYRINGE/1ML/29G X 1/2" 87 SPONGES 4"X4" 16 PLY 55 WOMENS BIOMULTIPLE 98 VANISHPOINT INSULIN VISTOGARD 18 WOMENS MULTI VITAMIN & SYRINGE/1ML/29G X 5/16" 87 VITAFOL-OB 102 MINERAL FORMULA 98 VANISHPOINT INSULIN XALATAN 106 SYRINGE/1ML/30G X 5/16" 87 VITALINE TOTAL FORMULA 2 97 XANAX 8 VAQTA 114 VITALINE TOTAL FORMULA XARELTO 10 VARIVAX 114 3 97 XULANE 33 VASERETIC 23 VITAMIN D3 COMPLETE 97 YASMIN 28 33 VASOTEC 21 VITASANA 97 YAZ 33 venlafaxine hcl 14 VITATRUM 98 YELETS TEENAGE VENLAFAXINE HCL ER 14 VITRUM 50+ SENIOR FORMULA 98 VENTOLIN HFA 10 MULTI 98 ZADITOR 106 VIVELLE-DOT 46 verapamil hcl 31 zaleplon 49 VIVITROL 18 VERELAN 31 ZANAFLEX 102 VOL-PLUS 102 VERELAN PM 31 ZANTAC 111 VOL-TAB RX 102 VERIPRED 20 34 ZANTAC 150 MAXIMUM VERSIVA XC 3" X 3" FOAM VOLTAREN 37 STRENGTH 111 DRESSING/HYDROFIBER VORTEX VALVED HOLDING ZANTAC 75 111 TECHNOLOGY 55 CHAMBER 91 ZARONTIN 12 VOSPIRE ER 10 VERSIVA XC 4" X 4" FOAM ZARXIO 48 DRESSING/HYDROFIBER VP INSULIN SYRINGE/U- TECHNOLOGY 55 100/0.3ML/29G X 1/2" 87 ZEBETA 30 VEXOL 106 VP-ZEL 98 ZENPEP 44 VIBRAMYCIN 109 VYVANSE 1 ZERIT 29 VICTOZA 16 W&F LANCETS 26G 64 ZESTORETIC 23

Index 33 ZESTRIL 21 ZIAC 23 ZIAGEN 29 zidovudine 29 zinc oxide (topical) 41 ziprasidone hcl 25 ZITHROMAX 50 ZITHROMAX TRI-PAK 50 ZITHROMAX Z-PAK 50 ZOCOR 21 ZOFRAN 18 ZOFRAN ODT 18 zolmitriptan 91 ZOLOFT 14 zolpidem tartrate 49 ZOMIG 91 ZOMIG ZMT 91 ZONEGRAN 11 zonisamide 11 ZOSTAVAX 114 ZOSTRIX DIABETIC FOOT PAIN 41 ZOVIRAX 29,39 ZUBSOLV 6 ZYBAN 109 ZYLOPRIM 48 ZYPREXA 26 ZYRTEC ALLERGY 19 ZYRTEC CHILDRENS ALLERGY 19 ZYRTEC-D ALLERGY/CONGESTION 36

Index 34