2020 Pharmacy Drug Guide - Advanced Control Plan

Plan for your best health

Advanced Control Plan

Aetna.com Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Pharmacy Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefits portion of your health plan and has no financial responsibility therefor. 2020 Pharmacy Drug Guide - Advanced Control Plan

Table of Contents

INFORMATIONAL SECTION...... 6 *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 16 *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS...... 19 *ALTERNATIVE MEDICINES* - VITAMINS AND MINERALS...... 19 *AMEBICIDES* - DRUGS FOR INFECTIONS...... 19 *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS...... 19 *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER...... 20 *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER...... 25 *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER...... 26 *ANDROGENS-ANABOLIC* - HORMONES...... 31 *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS...... 33 *ANTACIDS* - DRUGS FOR THE STOMACH...... 33 *ANTHELMINTICS* - DRUGS FOR INFECTIONS...... 33 *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART...... 34 *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 34 *ANTIARRHYTHMICS* - DRUGS FOR THE HEART...... 35 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS...... 36 *ANTICOAGULANTS* - DRUGS FOR THE BLOOD...... 40 *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 42 *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM...... 46 *ANTIDIABETICS* - HORMONES...... 49 *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH...... 57 *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING...57 *ANTIEMETICS* - DRUGS FOR THE STOMACH...... 58 *ANTIFUNGALS* - DRUGS FOR INFECTIONS...... 59 *ANTIHISTAMINES* - DRUGS FOR THE LUNGS...... 60 *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART...... 61 *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART...... 63 *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS...... 66 *ANTIMALARIALS* - DRUGS FOR INFECTIONS...... 68 *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 69 *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS...... 69 *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER...... 70 *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 78 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 79 *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS...... 82 *ANTIVIRALS* - DRUGS FOR INFECTIONS...... 83 *BETA BLOCKERS* - DRUGS FOR THE HEART...... 87 *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART...... 89 *CARDIOTONICS* - DRUGS FOR THE HEART...... 90 *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART...... 90 *CEPHALOSPORINS* - DRUGS FOR INFECTIONS...... 92 *CHEMICALS*...... 93 *CONTRACEPTIVES* - DRUGS FOR WOMEN...... 94 *CORTICOSTEROIDS* - HORMONES...... 104 TOC-3 *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS...... 106 *DERMATOLOGICALS* - DRUGS FOR THE SKIN...... 108 *DIAGNOSTIC PRODUCTS*...... 132 ...... *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* - DRUGS FOR NUTRITION . 142 *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH...... 144 *DIURETICS* - DRUGS FOR THE HEART...... 144 *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES...... 145 *ESTROGENS* - HORMONES...... 150 *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS...... 152 *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH...... 152 *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER...... 154 *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM 155 *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER...... 156 *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD...... 157 *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION...... 160 *HEMOSTATICS* - DRUGS FOR THE BLOOD...... 164 *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM...... 165 *LAXATIVES* - DRUGS FOR THE STOMACH...... 166 *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER...... 168 *MACROLIDES* - DRUGS FOR INFECTIONS...... 168 *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT...... 169 *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM...... 214 *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION...... 216 *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS...... 218 *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT...... 220 *MULTIVITAMINS* - DRUGS FOR NUTRITION...... 222 *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES...... 231 *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE...... 232 *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES...... 233 *NUTRIENTS* - DRUGS FOR NUTRITION...... 234 *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE...... 235 *OTIC AGENTS* - DRUGS FOR THE EAR...... 241 *OXYTOCICS* - HORMONES...... 242 *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS...... 242 *PENICILLINS* - DRUGS FOR INFECTIONS...... 243 *PHARMACEUTICAL ADJUVANTS*...... 244 *PROGESTINS* - HORMONES...... 246 *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM...... 247 *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS...... 253 *SULFONAMIDES* - DRUGS FOR INFECTIONS...... 254 *TETRACYCLINES* - DRUGS FOR INFECTIONS...... 254 *THYROID AGENTS* - HORMONES...... 255 *ULCER...... DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH . 256 *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM...... 259 *VACCINES* - BIOLOGICAL AGENTS...... 260 *VAGINALTOC-4 AND RELATED PRODUCTS* - DRUGS FOR WOMEN...... 260 *VASOPRESSORS* - DRUGS FOR THE HEART...... 261 *VITAMINS* - DRUGS FOR NUTRITION...... 262

TOC-5 How to use this guide

Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.

Your plan includes You’re covered for all types of medicine — some more expensive, and some less. • Brand and generic drugs that are hand-picked for their quality and effectiveness • Generic: the lowest cost • A specialty pharmacy that fills specialty prescriptions • Preferred brand: a slightly higher cost (ones that are injected, infused or taken by mouth) — • Non-preferred brand: a higher cost and provides services that include personal • Preferred Specialty: lower cost for specialty drugs support, helpful resources and training, and free secure home delivery • Non-preferred Specialty: higher cost for non-preferred specialty drugs • A home delivery pharmacy that delivers maintenance drugs to your home or wherever Your pharmacy plan may not have all the coverage levels you choose (for drugs that are taken regularly to listed above so check your plan documents to see how treat conditions like diabetes or asthma) much you will pay.

What you can expect to pay For your exact coverage and cost, and to learn more about your plan With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or Visit the website that’s on your member ID card. a percentage of the drug’s/medicine’s price. Then log in to your account, where you can:

Each drug is grouped as a generic, a brand or a • Find out the coverage* and estimate of cost for specialty drug. The preferred drugs within these specific drugs groups will generally save you money compared • View your deductibles and plan limits to a non-preferred drug. Typically, generic drugs • Order medications are less expensive than brands. • Check your pharmacy order status Specialty prescription drugs typically include higher-cost • Get a member ID card drugs that require special handling, special storage or • View your claims, Explanation of Benefits and more. monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.

* Check your plan documents for coverage information. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking cessation.

1 Have more questions about your CVS Caremark Mail Service Pharmacy™ pharmacy benefits? You can have maintenance drugs sent right to your home We’re here to help. There are several ways you can or anywhere else you choose by CVS Caremark Mail learn more about your benefits: Service Pharmacy. These are drugs that are taken regularly for chronic conditions like diabetes or asthma. • Check your Plan Design and Benefits Summary in Depending on your plan, you can get up to a 90-day your enrollment kit. supply of medicine for less cost. It’s fast and convenient, • Call the toll-free number on your member ID card. and standard shipping is always free. • Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on Get started right away your member ID card to search for the “Pharmacy FAQ.” You can submit your order using one of these options:

Specialty Pharmacy Network 1. Online — Visit your secure member website and An in-network specialty pharmacy can fill your sign in to your account. There you can add or prescriptions for specialty drugs. These are the types remove your prescriptions. of drugs that may be injected, infused or taken by mouth. 2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. They often need special storage and handling. And they If you need the help of a telephone device for the need to be delivered quickly. A nurse or pharmacist may hard of hearing, call 1-877-833-2779. monitor you during your treatment, if needed. With this type of pharmacy, you can get 3. Mail — Get a new prescription from your doctor. Then this medicine sent right to your home. mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form. How to get started with a specialty pharmacy

Ordering your prescriptions through our specialty Your doctor can submit your order using one of pharmacy is easy. And we typically offer a 30-day these options: medicine supply. 1. Online — They can submit your prescriptions using • To transfer your prescription, just call us toll-free the e-prescribe services on our provider website. at 1-866-353-1892. 2. Fax — They can fax your prescription to • For a new prescription, your doctor can send it to 1-877-270-3317. Make sure they include your member us in one of four ways: ID number, date of birth and mailing address on the 1. Electronically: Through e-prescribe fax cover sheet. Only a doctor may fax a prescription. 2. Fax: 1-866-329-2779

3. Phone: 1-866-782-2779, option 2

If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that’s on your member ID card, to search for the “Patient Profile Form.”

2 Frequently asked questions

How can I save on prescriptions? What is step therapy?

Here are some tips to pay less out of pocket for your Some drugs require step therapy. This means that prescription drugs: you must try one or more prerequisite drug(s) before a step therapy drug is covered. • Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary). The prerequisite drugs have U.S. Food and Drug • Ask your doctor to consider prescribing generic Administration (FDA) approval and may cost less. They drugs instead of brand-name drugs. treat the same condition as the step therapy drug. • Our home delivery pharmacy may save you money. If you don’t try the appropriate prerequisite drug first, you For more information, visit the website on your may need to pay full cost for the step-therapy drug. member ID card and log in to your account. What are quantity limits? What are generic drugs? Quantity limits help your doctor and pharmacist make Generic drugs are proven to be just as safe and effective sure that you use your drug correctly and safely. We use as brand-name drugs. They contain the same active medical guidelines and FDA-approved recommendations ingredients in the same amounts as the brand-name from drug makers to set these coverage limits. The drugs and work the same way. So they have the same quantity limit program includes: risks and benefits as brand-name drugs. However, they • Dose efficiency edits — Limits prescription coverage typically cost less. to one dose per day for drugs that have approval for When appropriate, your doctor may decide to prescribe once-daily dosing a generic drug or allow the pharmacist to substitute a • Maximum daily dose — If a prescription is lower than generic drug. the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy What is precertification? • Quantity limits over time — Limits prescription Precertification is one way that we can help you and your coverage to a specific number of units over a specific doctor find safe, appropriate drugs and keep costs down. amount of time Precertification means that you or your doctor need to get approval from the plan before certain drugs will be What if I need a drug that requires an exception covered. Generally, precertification applies to drugs that: to the precertification, step therapy or quantity • Are often taken in the wrong way limits requirements? Or what if I need a drug that’s not covered under my plan? • Should only be used for certain conditions • Often cost more than other drugs that are proven In certain cases, you or your prescriber can request a to be just as effective medical exception to the precertification, step therapy or quantity limits requirements or for a drug that’s not Keep in mind that your doctor must contact us to request covered on your plan. You can ask for your request to be approval of coverage for these drugs. expedited. Expedited coverage decisions are made within 24 hours.

We’ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design.

3 How can your provider request a medical Can the formulary change during the year? exception? The formulary can change throughout the year. • Submit their request through our secure provider Some reasons why it can change include: website on NaviNet®. • New drugs are approved. • Call the Aetna Pharmacy Precertification Unit: • Existing drugs are removed from the market. Non-Specialty 1-800-294-5979 or Specialty 1-866-814-5506. • Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs • Fax the completed request form to: are not generally covered in a formulary. Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155. • Brand-name drugs lose patent protection and generic versions become available. When this happens, the • Mail the completed request form to: generic drug will be covered in place of the brand- Aetna Pharmacy Management name drug. The brand-name drug is likely to become 1300 East Campbell Road non-formulary or covered at a higher cost. See the Richardson, TX 75081 “What are generic drugs?” section above for more information. Pharmacy and Therapeutics (P&T) committee

The services of an independent National Pharmacy and Therapeutics Committee (“P&T Committee”) are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee’s voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Voting members of the P&T Committee are not employees of CVS Caremark and must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

4 Commercial 1557 Nondiscrimination Notice

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and their affiliates (Aetna).

5

Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.

Please note that if your prescription drug benefits plan changes, the information here may no longer apply. Medications on the Aetna Drug Guide, precertification, step-therapy and quantity limits lists are subject to change. A copayment is a flat fee. Coinsurance is a percentage of the rate that Aetna negotiates with the plan sponsor for covered prescriptions except as required by law to be otherwise. Some drugs on the Pharmacy Drug Guide (formulary) may be subject to manufacturer rebates. Coinsurance is calculated before any rebates are subtracted. That means it may be possible for your cost of a preferred drug to be higher than your cost of a non-preferred drug. Louisiana members: depending on your specific plan and the prescription medication in question, you may in some instances be subject to an excess consumer cost burden for prescription drugs as defined by your state. Not all health services are covered. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking cessation. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna or its affiliate(s) may receive rebates from drug manufacturers. Rebates may reduce the amount a member pays the pharmacy for covered prescriptions. Information is subject to change. The drugs on the Pharmacy Drug Guide (formulary), Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and step therapy drug coverage review programs are not available in all service areas. However, these programs are available to self-funded plans. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug Guide (formulary), Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law, certain fully insured commercial California members (except Federal Employee Health Benefit Plan members) who obtained approval from an Aetna plan for coverage of drugs that are later added to the Preauthorization or Step Therapy Lists or removed from the Pharmacy Drug Guide will continue to have those drugs covered, for as long as the treating in-network provider continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. Aetna reserves the right to periodically request clinical information from your provider to assess your medical condition and the appropriateness of your ongoing treatment. Failure to provide clinical information could result in subsequent denial of coverage for this medication. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered for as long as the prescriber prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change. CVS Caremark Mail Service Pharmacy is part of the CVS Health family of companies.

Aetna.com

©2020 Aetna Inc. Drug Tier CE = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations may apply. Drug Notes G = Generics IBC = Indication Based Coverage NF = Non-formulary, not covered LGC = Lowest Generic Copay unless exception request granted Applies NPB = Non-Preferred Brands N8 = Drug Specific Coverage NPSB = Non-Preferred Specialty SPC = Select Plan Coverage: lowercase italics = Generic drugs Brands Only available for select plans. UPPERCASE = Brand name PB = Preferred Brands Refer to member plan documents drugs PSB = Preferred Specialty Brands for coverage. Prescription Drug Name Drug Tier Drug Notes *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* - DRUGS FOR THE NERVOUS SYSTEM ADDERALL XR ORAL CAPSULE EXTENDED N8 (Listing does not include RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 NPB certain NDCs) MG, 5 MG (amphetamine-dextroamphetamine) ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 MG, 45 MG, 55 MG, 70 NF MG, 85 MG (methylphenidate hcl) ADZENYS ER ORAL SUSPENSION EXTENDED NPB RELEASE 1.25 MG/ML (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 12.5 MG, 15.7 MG, 18.8 MG, 3.1 NF MG, 6.3 MG, 9.4 MG (amphetamine) amphetamine sulfate oral tablet 10 mg, 5 mg G amphetamine-dextroamphet er oral capsule extended release 24 N8 (Listing does not include G hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg certain NDCs) amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, G 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, NF 60 MG (methylphenidate hcl) armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg G atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 G mg, 60 mg, 80 mg

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

16 Prescription Drug Name Drug Tier Drug Notes caffeine citrate oral solution 20 mg/ml, 60 mg/3ml G clonidine hcl er oral tablet extended release 12 hour 0.1 mg G CONCERTA ORAL TABLET EXTENDED RELEASE 18 N8 (Listing does not include NPB MG, 27 MG, 36 MG, 54 MG (methylphenidate hcl) certain NDCs) CONTRAVE ORAL TABLET EXTENDED RELEASE 12 SPC (Only available for NF HOUR 8-90 MG (naltrexone-bupropion hcl) select plans) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG NF (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 NPB MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate) dexmethylphenidate hcl er oral capsule extended release 24 hour G 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg G dextroamphetamine sulfate er oral capsule extended release 24 G hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral solution 5 mg/5ml G dextroamphetamine sulfate oral tablet 10 mg, 5 mg G DYANAVEL XR ORAL SUSPENSION EXTENDED NPB RELEASE 2.5 MG/ML (amphetamine) EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15 NF MG, 20 MG, 5 MG (amphetamine sulfate) EVEKEO ORAL TABLET 10 MG, 5 MG (amphetamine NF sulfate) guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 G mg, 3 mg, 4 mg INTUNIV ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1 MG, 2 MG, 3 MG, 4 MG (guanfacine hcl) JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG NF (methylphenidate hcl) KAPVAY ORAL TABLET EXTENDED RELEASE 12 NF HOUR 0.1 MG (clonidine hcl) LOMAIRA ORAL TABLET 8 MG (phentermine hcl) NF methylphenidate hcl (Metadate Er Oral Tablet Extended G Release 20 Mg) methamphetamine hcl oral tablet 5 mg G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

17 Prescription Drug Name Drug Tier Drug Notes methylphenidate hcl er (cd) oral capsule extended release 10 G mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 G hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 20 G mg methylphenidate hcl er oral tablet extended release 18 mg, 27 N8 (Listing does not include G mg, 36 mg, 54 mg certain NDCs) methylphenidate hcl er oral tablet extended release 24 hour 18 G mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 72 mg NPB methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml G methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg G methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg G modafinil oral tablet 100 mg, 200 mg G MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine- PB dextroamphetamine) NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 NF MG (armodafinil) PROVIGIL ORAL TABLET 100 MG, 200 MG (modafinil) NF QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG NF (phentermine-topiramate) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG NPB (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION NPB RECONSTITUTED ER 25 MG/5ML (methylphenidate hcl) RELEXXII ORAL TABLET EXTENDED RELEASE 72 NF MG (methylphenidate hcl) SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) NF VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 PB MG, 50 MG, 60 MG, 70 MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, PB 30 MG, 40 MG, 50 MG, 60 MG (lisdexamfetamine dimesylate) XENICAL ORAL CAPSULE 120 MG (orlistat) NF 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

18 Prescription Drug Name Drug Tier Drug Notes dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Mg) G ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 G MG, 7.5 MG (dextroamphetamine sulfate) *ALLERGENIC EXTRACTS/BIOLOGICALS MISC* - BIOLOGICAL AGENTS GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 PB BAU (timothy grass pollen allergen) ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 NPB SQ-HDM (dust mite mixed allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 PB IR (grass mix pollens allergen ext) RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 PB AMB A 1-U (short ragweed pollen ext) sorrel/dock mix subcutaneous solution 1:20 NF *ALTERNATIVE MEDICINES* - VITAMINS AND MINERALS CYTO RALA ORAL POWDER 800 MG/GM (alpha-lipoic NF acid) EC-RX DHEA EXTERNAL CREAM 10 %, 4 % (prasterone NF (dhea)) NEOKE RA LIPOIC ORAL POWDER 800 MG/GM (alpha- NF lipoic acid) *AMEBICIDES* - DRUGS FOR INFECTIONS SOLOSEC ORAL PACKET 2 GM (secnidazole) NF *AMINOGLYCOSIDES* - DRUGS FOR INFECTIONS ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML NPB (amikacin sulfate liposome) BETHKIS INHALATION NEBULIZATION SOLUTION PSB 300 MG/4ML (tobramycin) KITABIS PAK INHALATION NEBULIZATION NPSB SOLUTION 300 MG/5ML (tobramycin) neomycin sulfate oral tablet 500 mg G paromomycin sulfate oral capsule 250 mg G TOBI PODHALER INHALATION CAPSULE 28 MG NF (tobramycin) tobramycin inhalation nebulization solution 300 mg/5ml G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

19 Prescription Drug Name Drug Tier Drug Notes *ANALGESICS - ANTI-INFLAMMATORY* - DRUGS FOR PAIN AND FEVER ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION NF AUTO-INJECTOR 162 MG/0.9ML (tocilizumab) ARCALYST SUBCUTANEOUS SOLUTION NPSB RECONSTITUTED 220 MG (rilonacept) ARTHROTEC ORAL TABLET DELAYED RELEASE 50- NF 0.2 MG, 75-0.2 MG (diclofenac-misoprostol) CALDOLOR INTRAVENOUS SOLUTION 800 NPB MG/200ML (ibuprofen) CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, NF 50 MG (celecoxib) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg G dermacinrx analgesic combopak combination kit 75 mg NF dfs dr/ms/menth/cap pak combination kit 75 mg NF diclofenac potassium oral tablet 50 mg G diclofenac sodium er oral tablet extended release 24 hour 100 G mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 G mg diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75- G 0.2 mg DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen- NPB famotidine) ENBREL MINI SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSB CARTRIDGE 50 MG/ML (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML PSB (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for all PSB SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSB RECONSTITUTED 25 MG (etanercept) conditions except Psoriasis) ENBREL SURECLICK SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSB AUTO-INJECTOR 50 MG/ML (etanercept) conditions except Psoriasis) equapax/ibuprofen/minrex oral therapy pack 800 mg NF etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, G 600 mg 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

20 Prescription Drug Name Drug Tier Drug Notes etodolac oral capsule 200 mg, 300 mg G etodolac oral tablet 400 mg, 500 mg G fenoprofen calcium oral capsule 200 mg, 400 mg NF fenoprofen calcium oral tablet 600 mg NF flurbiprofen oral tablet 100 mg, 50 mg G HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 PSB MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PSB 40 MG/0.4ML, 40 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML PSB (adalimumab) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PSB (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 PSB MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML (adalimumab) ibuprofen (Ibu Oral Tablet 400 Mg, 600 Mg, 800 Mg) G ibuprofen oral suspension 100 mg/5ml G ibuprofen oral tablet 400 mg, 600 mg, 800 mg G ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML NPSB (canakinumab) INDOCIN ORAL SUSPENSION 25 MG/5ML NF (indomethacin) INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) NF indomethacin er oral capsule extended release 75 mg G indomethacin oral capsule 20 mg NF indomethacin oral capsule 25 mg, 50 mg G diclofenac sodium-capsaicin (Inflammacin Combination NF Therapy Pack 75 & 0.025 Mg-%) INFLATHERM COMBINATION THERAPY PACK 75 & NF 3-3 MG & % (diclofenac-menthol-camphor) ketoprofen er oral capsule extended release 24 hour 200 mg NF ketoprofen oral capsule 25 mg NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

21 Prescription Drug Name Drug Tier Drug Notes ketorolac tromethamine oral tablet 10 mg G KEVZARA SUBCUTANEOUS SOLUTION AUTO- PSB INJECTOR 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) KEVZARA SUBCUTANEOUS SOLUTION PREFILLED PSB SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) leflunomide oral tablet 10 mg, 20 mg G LODINE ORAL TABLET 400 MG (etodolac) NF meclofenamate sodium oral capsule 100 mg, 50 mg G mefenamic acid oral capsule 250 mg NF meloxicam oral tablet 15 mg, 7.5 mg G nabumetone oral tablet 500 mg, 750 mg G NALFON ORAL CAPSULE 400 MG (fenoprofen calcium) NPB NAPRELAN ORAL TABLET EXTENDED RELEASE 24 NF HOUR 375 MG, 500 MG, 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION 125 MG/5ML NF (naproxen) naproxen dr oral tablet delayed release 375 mg, 500 mg G naproxen oral tablet 250 mg, 375 mg, 500 mg G naproxen sodium er oral tablet extended release 24 hour 375 mg, NF 500 mg naproxen sodium oral tablet 275 mg, 550 mg G naproxen-esomeprazole oral tablet delayed release 375-20 mg, NF 500-20 mg diclofenac sodium-capsaicin (Nudiclo Tabpak Combination NF Therapy Pack 75 & 0.025 Mg-%) NUDROXIPAK COMBINATION THERAPY PACK 200 NF MG (celecoxib-capsaic-men-methsal) NUDROXIPAK DSDR-50 COMBINATION KIT 50 MG NF (diclofenac sodium-liniment) NUDROXIPAK DSDR-75 COMBINATION KIT 75 MG NF (diclofenac sodium-liniment) NUDROXIPAK E-400 COMBINATION KIT 400 MG NF (etodolac-liniment) NUDROXIPAK I-800 COMBINATION KIT 800 MG NF (ibuprofen-liniment)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

22 Prescription Drug Name Drug Tier Drug Notes NUDROXIPAK M-15 COMBINATION KIT 15 MG NF (meloxicam-liniment) NUDROXIPAK N-500 COMBINATION KIT 500 MG NF (nabumetone-liniment) OLUMIANT ORAL TABLET 1 MG (baricitinib) NF IBC (Preferred agent for ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION Rheumatoid Arthritis. Not PSB AUTO-INJECTOR 125 MG/ML (abatacept) covered for other conditions) IBC (Preferred agent for ORENCIA SUBCUTANEOUS SOLUTION PREFILLED Rheumatoid Arthritis. Not SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML PSB covered for other (abatacept) conditions) IBC (Preferred agent for OTEZLA ORAL TABLET 30 MG (apremilast) PSB Psoriasis and Psoriatic Arthritis) IBC (Preferred agent for OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 PSB Psoriasis and Psoriatic MG (apremilast) Arthritis) oxaprozin oral tablet 600 mg G piroxicam oral capsule 10 mg, 20 mg G PREVIDOLRX ANALGESIC COMBINATION THERAPY PACK 75-20-0.025 MG-MG-% (diclofenac- NF omeprazole-capsicum) QMIIZ ODT ORAL TABLET DISPERSIBLE 15 MG, 7.5 NF MG (meloxicam) RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 PSB MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) READYSHARP ANESTH + KETOROLAC INJECTION KIT 15 & 0.5 & 1 MG/ML-%-% (ketorolac & bupivacaine & NF lido) READYSHARP KETOROLAC INJECTION KIT 15 NF MG/ML (ketorolac tromethamine) RIDAURA ORAL CAPSULE 3 MG (auranofin) NPB RINVOQ ORAL TABLET EXTENDED RELEASE 24 IBC (Preferred agent for PSB HOUR 15 MG (upadacitinib) Rheumatoid Arthritis) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

23 Prescription Drug Name Drug Tier Drug Notes SIMPONI ARIA INTRAVENOUS SOLUTION 50 PSB MG/4ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION AUTO- NPSB INJECTOR 100 MG/ML, 50 MG/0.5ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED NPSB SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab) SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac NF tromethamine) sulindac oral tablet 150 mg, 200 mg G TIVORBEX ORAL CAPSULE 20 MG (indomethacin) NF tolmetin sodium oral capsule 400 mg G tolmetin sodium oral tablet 600 mg G TORONOVA II SUIK COMBINATION KIT 30 MG/ML NF (ketorolac trometh & anesthetic) TORONOVA SUIK COMBINATION KIT 30 MG/ML NF (ketorolac trometh & anesthetic) VIMOVO ORAL TABLET DELAYED RELEASE 375-20 NPB MG, 500-20 MG (naproxen-esomeprazole) VIVLODEX ORAL CAPSULE 10 MG, 5 MG (meloxicam) NF IBC (Preferred agent for XELJANZ ORAL TABLET 10 MG (tofacitinib citrate) PSB Ulcerative Colitis (after failure of Humira)) IBC (Preferred agent for Rheumatoid Arthritis and Ulcerative Colitis (after XELJANZ ORAL TABLET 5 MG (tofacitinib citrate) PSB failure of Humira). Not covered for Psoriatic Arthritis.) IBC (Preferred agent for XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 Rheumatoid Arthritis. Not PSB HOUR 11 MG (tofacitinib citrate) covered for Psoriatic Arthritis.) IBC (Preferred agent for XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 PSB Ulcerative Colitis (after HOUR 22 MG (tofacitinib citrate) failure of Humira)) ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) NF ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

24 Prescription Drug Name Drug Tier Drug Notes *ANALGESICS - NONNARCOTIC* - DRUGS FOR PAIN AND FEVER ALLZITAL ORAL TABLET 25-325 MG (butalbital- NF acetaminophen) aspirin adult low dose oral tablet delayed release 81 mg CE aspirin ec low strength oral tablet delayed release 81 mg CE aspirin low dose oral tablet chewable 81 mg CE aspirin low dose oral tablet delayed release 81 mg CE aspirin oral tablet chewable 81 mg CE aspirin oral tablet delayed release 81 mg CE ASPIR-LOW ORAL TABLET DELAYED RELEASE 81 CE MG (aspirin) BAYER ASPIRIN EC LOW DOSE ORAL TABLET CE DELAYED RELEASE 81 MG (aspirin) BAYER LOW DOSE ORAL TABLET CHEWABLE 81 MG CE (aspirin) BAYER LOW DOSE ORAL TABLET DELAYED CE RELEASE 81 MG (aspirin) butalbital-acetaminophen (Bupap Oral Tablet 50-300 Mg) NF butalbital-acetaminophen oral capsule 50-300 mg G butalbital-acetaminophen oral tablet 50-300 mg NF butalbital-acetaminophen oral tablet 50-325 mg G butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 NF mg butalbital-apap-caffeine oral tablet 50-325-40 mg G butalbital-aspirin-caffeine oral capsule 50-325-40 mg G childrens aspirin low strength oral tablet chewable 81 mg CE childrens aspirin oral tablet chewable 81 mg CE cvs aspirin low dose oral tablet delayed release 81 mg CE cvs aspirin low strength oral tablet delayed release 81 mg CE diflunisal oral tablet 500 mg G ECOTRIN LOW STRENGTH ORAL TABLET DELAYED CE RELEASE 81 MG (aspirin) eq childrens aspirin oral tablet chewable 81 mg CE eql aspirin low dose oral tablet chewable 81 mg CE

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

25 Prescription Drug Name Drug Tier Drug Notes butalbital-apap-caffeine (Esgic Oral Capsule 50-325-40 Mg) NF FIORICET ORAL CAPSULE 50-300-40 MG (butalbital- NF apap-caffeine) gnp adult aspirin low strength oral tablet chewable 81 mg CE gnp aspirin oral tablet delayed release 81 mg CE h-e-b aspirin oral tablet delayed release 81 mg CE hm aspirin oral tablet chewable 81 mg CE kls aspirin low dose oral tablet delayed release 81 mg CE kp aspirin oral tablet delayed release 81 mg CE MINIPRIN LOW DOSE ORAL TABLET DELAYED CE RELEASE 81 MG (aspirin) px aspirin oral tablet chewable 81 mg CE px enteric aspirin oral tablet delayed release 81 mg CE qc childrens aspirin oral tablet chewable 81 mg CE ra aspirin adult low dose oral tablet chewable 81 mg CE ra aspirin childrens oral tablet chewable 81 mg CE ra aspirin ec adult low st oral tablet delayed release 81 mg CE ra childrens aspirin oral tablet chewable 81 mg CE salsalate oral tablet 500 mg, 750 mg G sb childrens aspirin oral tablet chewable 81 mg CE sm aspirin adult low strength oral tablet chewable 81 mg CE sm aspirin adult low strength oral tablet delayed release 81 mg CE sm childrens aspirin oral tablet chewable 81 mg CE ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE 81 CE MG (aspirin) TENCON ORAL TABLET 50-325 MG (butalbital- G acetaminophen) butalbital-apap-caffeine (Vanatol Lq Oral Solution 50-325-40 NF Mg/15Ml) butalbital-apap-caffeine (Zebutal Oral Capsule 50-325-40 Mg) NF *ANALGESICS - OPIOID* - DRUGS FOR PAIN AND FEVER acetaminophen-codeine #3 oral tablet 300-30 mg G acetaminophen-codeine oral solution 120-12 mg/5ml G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

26 Prescription Drug Name Drug Tier Drug Notes acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg G ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG NPB (fentanyl citrate) APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, NF 8.16-325 MG (benzhydrocodone-acetaminophen) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg G ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG, 30 MG, 60 MG (morphine NF sulfate) butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- G 325-40-30 Mg) BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG PB (buprenorphine hcl) BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 NF MG (buprenorphine hcl-naloxone hcl) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg G buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 G mg, 4-1 mg, 8-2 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2- G 0.5 mg, 8-2 mg butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- G 40-30 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg G butorphanol tartrate nasal solution 10 mg/ml G BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 NF MCG/HR (buprenorphine) codeine sulfate oral tablet 60 mg NPB CONZIP ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 100 MG, 200 MG, 300 MG (tramadol hcl) DILAUDID INJECTION SOLUTION 1 MG/ML, 2 NF MG/ML (hydromorphone hcl) DILAUDID ORAL LIQUID 1 MG/ML (hydromorphone hcl) NPB DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG NPB (hydromorphone hcl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

27 Prescription Drug Name Drug Tier Drug Notes DOLOPHINE ORAL TABLET 10 MG, 5 MG (methadone NPB hcl) DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 NPB MCG (sufentanil citrate) DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR NPB 100 MCG/HR (fentanyl) DURAGESIC-12 TRANSDERMAL PATCH 72 HOUR 12 NPB MCG/HR (fentanyl) DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR 25 NPB MCG/HR (fentanyl) DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR 50 NPB MCG/HR (fentanyl) DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR 75 NPB MCG/HR (fentanyl) oxycodone-acetaminophen (Endocet Oral Tablet 10-325 Mg, G 2.5-325 Mg, 5-325 Mg, 7.5-325 Mg) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, G 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate buccal tablet 200 mcg, 400 mcg, 600 mcg, 800 G mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 G mcg/hr FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 NF MCG, 600 MCG, 800 MCG (fentanyl citrate) hydrocodone bitartrate er oral capsule extended release 12 hour NF 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg hydrocodone-acetaminophen oral solution 5-217 mg/10ml G hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, G 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 G mg hydromorphone hcl er oral tablet extended release 24 hour 12 G mg, 16 mg, 32 mg, 8 mg hydromorphone hcl oral liquid 1 mg/ml G hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg G hydromorphone hcl rectal suppository 3 mg NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

28 Prescription Drug Name Drug Tier Drug Notes HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE- DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, NF 60 MG, 80 MG (hydrocodone bitartrate) KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, NF 50 MG, 60 MG, 80 MG (morphine sulfate) LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 NF MCG/ACT, 400 MCG/ACT (fentanyl citrate) levorphanol tartrate oral tablet 2 mg, 3 mg NF LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- NPB acetaminophen) meperidine hcl oral solution 50 mg/5ml NF meperidine hcl oral tablet 50 mg NF methadone hcl injection solution 10 mg/ml G methadone hcl (Methadone Hcl Intensol Oral Concentrate 10 G Mg/Ml) methadone hcl oral concentrate 10 mg/ml G methadone hcl oral solution 10 mg/5ml, 5 mg/5ml G methadone hcl oral tablet 10 mg, 5 mg G methadone hcl oral tablet soluble 40 mg G methadone hcl-nacl intravenous solution prefilled syringe 1-0.9 NPB mg/ml-% METHADOSE ORAL CONCENTRATE 10 MG/ML NPB (methadone hcl) methadone hcl (Methadose Oral Tablet Soluble 40 Mg) G METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 NPB MG/ML (methadone hcl) morphine sulfate (concentrate) oral solution 20 mg/ml, 5 G mg/0.25ml morphine sulfate er beads oral capsule extended release 24 hour G 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 10 mg, G 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 100 mg, 15 mg, G 200 mg, 30 mg, 60 mg morphine sulfate intravenous solution 1 mg/ml NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

29 Prescription Drug Name Drug Tier Drug Notes morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml G morphine sulfate oral tablet 15 mg, 30 mg G morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg G MS CONTIN ORAL TABLET EXTENDED RELEASE 100 NPB MG, 15 MG, 200 MG, 30 MG, 60 MG (morphine sulfate) nalocet oral tablet 2.5-300 mg NF NORCO ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 NPB MG (hydrocodone-acetaminophen) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG PB (tapentadol hcl) NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG PB (tapentadol hcl) OPANA ORAL TABLET 10 MG (oxymorphone hcl) NPB OXAYDO ORAL TABLET 5 MG, 7.5 MG (oxycodone hcl) NF oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, G 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg oxycodone hcl oral capsule 5 mg G oxycodone hcl oral concentrate 100 mg/5ml G oxycodone hcl oral solution 5 mg/5ml G oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg G oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5- G 325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 4.8355-325 mg G OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 NF MG, 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 10 mg, G 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg oxymorphone hcl oral tablet 10 mg, 5 mg G pentazocine-naloxone hcl oral tablet 50-0.5 mg G PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5- NF 325 MG, 7.5-325 MG (oxycodone-acetaminophen) PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 NF MG (oxycodone-acetaminophen)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

30 Prescription Drug Name Drug Tier Drug Notes PROBUPHINE IMPLANT KIT SUBCUTANEOUS NF IMPLANT 74.2 MG (buprenorphine hcl) ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG NPB (oxycodone hcl) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML NPB (buprenorphine) SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4- NF 1 MG, 8-2 MG (buprenorphine hcl-naloxone hcl) SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 PB MCG, 800 MCG (fentanyl) SYNAPRYN FUSEPAQ ORAL SUSPENSION NF RECONSTITUTED 10 MG/ML (tramadol hcl) tramadol hcl er (biphasic) oral tablet extended release 24 hour G 100 mg, 200 mg, 300 mg tramadol hcl er oral capsule extended release 24 hour 100 mg, G 150 mg, 200 mg, 300 mg tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 G mg, 300 mg tramadol hcl oral tablet 100 mg NF tramadol hcl oral tablet 50 mg G tramadol-acetaminophen oral tablet 37.5-325 mg G ULTRACET ORAL TABLET 37.5-325 MG (tramadol- NPB acetaminophen) ULTRAM ORAL TABLET 50 MG (tramadol hcl) NPB XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG PB (oxycodone) ZOHYDRO ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG NF (hydrocodone bitartrate) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7- 0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 PB MG, 8.6-2.1 MG (buprenorphine hcl-naloxone hcl) *ANDROGENS-ANABOLIC* - HORMONES ANADROL-50 ORAL TABLET 50 MG (oxymetholone) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

31 Prescription Drug Name Drug Tier Drug Notes ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 PB MG/24HR, 4 MG/24HR (testosterone) ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%), NF 50 MG/5GM (1%) (testosterone) danazol oral capsule 100 mg, 200 mg, 50 mg G DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML (testosterone NPB cypionate) ec-rx testosterone transdermal cream 0.2 %, 0.4 %, 10 %, 20 % NF FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%) NF (testosterone) methitest oral tablet 10 mg NPB methyltestosterone oral capsule 10 mg G NATESTO NASAL GEL 5.5 MG/ACT (testosterone) NF oxandrolone oral tablet 10 mg, 2.5 mg G TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML NF (testosterone cypionate) TESTOPEL IMPLANT PELLET 75 MG (testosterone) NPB testosterone compounding kit transdermal cream 20 % NF testosterone cypionate intramuscular solution 100 mg/ml, 200 G mg/ml testosterone enanthate intramuscular solution 200 mg/ml G testosterone gel 12.5 mg/act (1%) transdermal 12.5 mg/act G (1%) testosterone gel 12.5 mg/act (1%) transdermal 12.5 mg/act NF (1%) testosterone gel 50 mg/5gm (1%) transdermal 50 mg/5gm (1%) G testosterone gel 50 mg/5gm (1%) transdermal 50 mg/5gm (1%) NF testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm G (1.62%) testosterone transdermal solution 30 mg/act G VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT NF (1%) (testosterone)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

32 Prescription Drug Name Drug Tier Drug Notes VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) XYOSTED SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML NF (testosterone enanthate) *ANORECTAL AND RELATED PRODUCTS* - RECTAL PREPARATIONS CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone PB acetate) hydrocortisone (perianal) external cream 1 %, 2.5 % G hydrocortisone ace-pramoxine external cream 1-1 % G hydrocortisone rectal enema 100 mg/60ml G PROCORT EXTERNAL CREAM 1.85-1.15 % NF (hydrocortisone ace-pramoxine) PROCTOCORT EXTERNAL CREAM 1 % (hydrocortisone) NF PROCTOCORT RECTAL SUPPOSITORY 30 MG NF (hydrocortisone acetate) PROCTOFOAM HC EXTERNAL FOAM 1-1 % PB (hydrocortisone ace-pramoxine) hydrocortisone (Procto-Med Hc External Cream 2.5 %) G hydrocortisone (Procto-Pak External Cream 1 %) G hydrocortisone (Proctozone-Hc External Cream 2.5 %) G RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) NPB UCERIS RECTAL FOAM 2 MG/ACT (budesonide) NF *ANTACIDS* - DRUGS FOR THE STOMACH sodium bicarbonate oral powder NPB *ANTHELMINTICS* - DRUGS FOR INFECTIONS albendazole oral tablet 200 mg G benznidazole oral tablet 100 mg, 12.5 mg NPB EMVERM ORAL TABLET CHEWABLE 100 MG NPB (mebendazole) ivermectin oral tablet 3 mg G praziquantel oral tablet 600 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

33 Prescription Drug Name Drug Tier Drug Notes *ANTIANGINAL AGENTS* - DRUGS FOR THE HEART DILATRATE-SR ORAL CAPSULE EXTENDED NPB RELEASE 40 MG (isosorbide dinitrate) GONITRO SUBLINGUAL PACKET 400 MCG NF (nitroglycerin) ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG NF (isosorbide dinitrate) isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg G isosorbide mononitrate er oral tablet extended release 24 hour G 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg G nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 G Mg/Hr, 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) NITRO-BID TRANSDERMAL OINTMENT 2 % NPB (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 NPB MG/HR, 0.8 MG/HR (nitroglycerin) nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg G nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, G 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray G NITROMIST TRANSLINGUAL AEROSOL SOLUTION NF 400 MCG/SPRAY (nitroglycerin) ranolazine er oral tablet extended release 12 hour 1000 mg, 500 G mg *ANTIANXIETY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, G 2 mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 NPB MG/ML (alprazolam) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg G alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg G alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, G 2 mg, 3 mg ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML NF (lorazepam) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

34 Prescription Drug Name Drug Tier Drug Notes ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG NF (lorazepam) buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg G chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg G clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg G diazepam injection solution 5 mg/ml NPB diazepam oral concentrate 5 mg/ml G diazepam oral solution 5 mg/5ml G diazepam oral tablet 10 mg, 2 mg, 5 mg G hydroxyzine hcl oral syrup 10 mg/5ml G hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg G hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg G lorazepam oral concentrate 2 mg/ml G lorazepam oral tablet 0.5 mg, 1 mg, 2 mg G meprobamate oral tablet 200 mg, 400 mg G oxazepam oral capsule 10 mg, 15 mg, 30 mg G XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG NF (alprazolam) XANAX XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 0.5 MG, 1 MG, 2 MG, 3 MG (alprazolam) *ANTIARRHYTHMICS* - DRUGS FOR THE HEART amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg G disopyramide phosphate oral capsule 100 mg, 150 mg G dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg G flecainide acetate oral tablet 100 mg, 150 mg, 50 mg G mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg NPB MULTAQ ORAL TABLET 400 MG (dronedarone hcl) PB NORPACE CR ORAL CAPSULE EXTENDED RELEASE NPB 12 HOUR 100 MG, 150 MG (disopyramide phosphate) amiodarone hcl (Pacerone Oral Tablet 100 Mg, 200 Mg, 400 G Mg) propafenone hcl er oral capsule extended release 12 hour 225 G mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

35 Prescription Drug Name Drug Tier Drug Notes quinidine gluconate er oral tablet extended release 324 mg G quinidine sulfate oral tablet 200 mg, 300 mg G TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 NPSB MCG (dofetilide) *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* - DRUGS FOR THE LUNGS ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT PB (fluticasone-salmeterol) AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT NF (fluticasone-salmeterol) albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 G mg albuterol sulfate hfa inhalation aerosol solution 108 (90 base) G mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 G mg/0.5ml albuterol sulfate oral syrup 2 mg/5ml G albuterol sulfate oral tablet 2 mg, 4 mg G ALVESCO INHALATION AEROSOL SOLUTION 160 NF MCG/ACT, 80 MCG/ACT (ciclesonide) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- PB vilanterol) ARCAPTA NEOHALER INHALATION CAPSULE 75 NF MCG (indacaterol maleate) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 PB MCG/ACT, 50 MCG/ACT (fluticasone furoate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

36 Prescription Drug Name Drug Tier Drug Notes ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NPB MCG/INH (mometasone furoate) ASMANEX (14 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NPB MCG/INH (mometasone furoate) ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 NPB MCG/INH, 220 MCG/INH (mometasone furoate) ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NPB MCG/INH (mometasone furoate) ASMANEX (7 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 NPB MCG/INH (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 100 NPB MCG/ACT, 200 MCG/ACT (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 50 NF MCG/ACT (mometasone furoate) ATROVENT HFA INHALATION AEROSOL SOLUTION NF 17 MCG/ACT (ipratropium bromide hfa) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 PB MCG/ACT (glycopyrrolate-formoterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 PB MCG/INH (fluticasone furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160- NPB 9-4.8 MCG/ACT (budeson-glycopyrrol-formoterol) BROVANA INHALATION NEBULIZATION SOLUTION NF 15 MCG/2ML (arformoterol tartrate) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 G mg/2ml COMBIVENT RESPIMAT INHALATION AEROSOL NPB SOLUTION 20-100 MCG/ACT (ipratropium-albuterol) cromolyn sodium inhalation nebulization solution 20 mg/2ml G DALIRESP ORAL TABLET 250 MCG, 500 MCG PB (roflumilast)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

37 Prescription Drug Name Drug Tier Drug Notes DIFIL-G FORTE ORAL LIQUID 100-100 MG/5ML G (dyphylline-guaifenesin) DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT (mometasone furo- NF formoterol fum) ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML NPB (theophylline) FASENRA PEN SUBCUTANEOUS SOLUTION AUTO- PSB INJECTOR 30 MG/ML (benralizumab) FASENRA SUBCUTANEOUS SOLUTION PREFILLED PSB SYRINGE 30 MG/ML (benralizumab) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 PB MCG/BLIST, 50 MCG/BLIST (fluticasone propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT (fluticasone PB propionate hfa) fluticasone-salmeterol inhalation aerosol powder breath NF activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH (umeclidinium PB bromide) ipratropium bromide inhalation solution 0.02 % G ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml G levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, G 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml levalbuterol tartrate inhalation aerosol 45 mcg/act G LONHALA MAGNAIR REFILL KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) montelukast sodium oral packet 4 mg G montelukast sodium oral tablet 10 mg G montelukast sodium oral tablet chewable 4 mg, 5 mg G NUCALA SUBCUTANEOUS SOLUTION PSB RECONSTITUTED 100 MG (mepolizumab)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

38 Prescription Drug Name Drug Tier Drug Notes PERFOROMIST INHALATION NEBULIZATION PB SOLUTION 20 MCG/2ML (formoterol fumarate) PROAIR HFA INHALATION AEROSOL SOLUTION 108 NPB (90 BASE) MCG/ACT (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) NPB MCG/ACT (albuterol sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION NF 108 (90 BASE) MCG/ACT (albuterol sulfate) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 PB MCG/ACT (budesonide) PULMICORT INHALATION SUSPENSION 0.25 NF MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone PB diprop hfa) SEEBRI NEOHALER INHALATION CAPSULE 15.6 NF MCG (glycopyrrolate) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE NF (salmeterol xinafoate) SINGULAIR ORAL PACKET 4 MG (montelukast sodium) NF SINGULAIR ORAL TABLET 10 MG (montelukast sodium) NF SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG NF (montelukast sodium) SPIRIVA HANDIHALER INHALATION CAPSULE 18 PB MCG (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT (tiotropium PB bromide monohydrate) STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT (tiotropium bromide- PB olodaterol) STRIVERDI RESPIMAT INHALATION AEROSOL PB SOLUTION 2.5 MCG/ACT (olodaterol hcl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

39 Prescription Drug Name Drug Tier Drug Notes SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT (budesonide-formoterol PB fumarate) terbutaline sulfate oral tablet 2.5 mg, 5 mg G THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 G mg theophylline er oral tablet extended release 24 hour 400 mg, 600 G mg theophylline oral solution 80 mg/15ml G TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, PB 200-62.5-25 MCG/INH (fluticasone-umeclidin-vilant) TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT NF (aclidinium bromide) UTIBRON NEOHALER INHALATION CAPSULE 27.5- NF 15.6 MCG (indacaterol-glycopyrrolate) VENTOLIN HFA INHALATION AEROSOL SOLUTION NF 108 (90 BASE) MCG/ACT (albuterol sulfate) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED PSB SYRINGE 150 MG/ML, 75 MG/0.5ML (omalizumab) XOLAIR SUBCUTANEOUS SOLUTION PSB RECONSTITUTED 150 MG (omalizumab) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT NF (levalbuterol tartrate) YUPELRI INHALATION SOLUTION 175 MCG/3ML PB (revefenacin) zafirlukast oral tablet 10 mg, 20 mg G zileuton er oral tablet extended release 12 hour 600 mg G ZYFLO ORAL TABLET 600 MG (zileuton) NPB *ANTICOAGULANTS* - DRUGS FOR THE BLOOD acd formula a in vitro solution 0.73-2.45-2.2 gm/100ml NPB ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 NPB GM/100ML (anticoagulant cit dext soln a)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

40 Prescription Drug Name Drug Tier Drug Notes anticoagulant cit dext soln a in vitro solution 0.8-2.45-2.2 NPB gm/100ml anticoagulant sodium citrate in vitro solution 4 gm/100ml NPB bivalirudin rtu intravenous solution 250 mg/50ml NPB ELIQUIS DVT/PE STARTER PACK ORAL TABLET PB THERAPY PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) PB enoxaparin sodium injection solution 300 mg/3ml G enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, G 80 mg/0.8ml fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 G mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 NF UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML (dalteparin sodium) heparin sodium (porcine) injection solution 1000 unit/ml, 10000 G unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml G hepmed combination kit 100&0.9&2.5-2.5 ut/ml&% NF warfarin sodium (Jantoven Oral Tablet 1 Mg, 10 Mg, 2 Mg, 2.5 G LGC Mg, 3 Mg, 4 Mg, 5 Mg, 6 Mg, 7.5 Mg) PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG NF (dabigatran etexilate mesylate) REGIOCIT IN VITRO SOLUTION 0.529 % (anticoagulant NPB na cit (crrt)) SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG NF (edoxaban tosylate) TRICITRASOL IN VITRO CONCENTRATE 46.7 % NPB (anticoagulant sodium citrate) warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 G LGC mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 PB MG (rivaroxaban) XARELTO STARTER PACK ORAL TABLET THERAPY PB PACK 15 & 20 MG (rivaroxaban)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

41 Prescription Drug Name Drug Tier Drug Notes *ANTICONVULSANTS* - DRUGS FOR THE NERVOUS SYSTEM APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 NF MG (eslicarbazepine acetate) BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) NPB BANZEL ORAL TABLET 200 MG, 400 MG (rufinamide) NPB BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) NPB BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 NPB MG, 75 MG (brivaracetam) carbamazepine er oral capsule extended release 12 hour 100 mg, G 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 mg, G 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml G carbamazepine oral tablet 200 mg G carbamazepine oral tablet chewable 100 mg G CELONTIN ORAL CAPSULE 300 MG (methsuximide) NPB clobazam oral suspension 2.5 mg/ml G clobazam oral tablet 10 mg, 20 mg G clonazepam oral tablet 0.5 mg, 1 mg, 2 mg G clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 G mg, 2 mg DIACOMIT ORAL CAPSULE 250 MG, 500 MG NPB (stiripentol) DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) NPB DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG NF (diazepam) DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) NF diazepam rectal gel 10 mg, 2.5 mg, 20 mg G DILANTIN INFATABS ORAL TABLET CHEWABLE 50 NF MG (phenytoin) DILANTIN ORAL CAPSULE 100 MG, 30 MG (phenytoin NF sodium extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) NF divalproex sodium er oral tablet extended release 24 hour 250 G mg, 500 mg 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

42 Prescription Drug Name Drug Tier Drug Notes divalproex sodium oral capsule delayed release sprinkle 125 mg G divalproex sodium oral tablet delayed release 125 mg, 250 mg, G 500 mg EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) NPSB carbamazepine (Epitol Oral Tablet 200 Mg) G ethosuximide oral capsule 250 mg G ethosuximide oral solution 250 mg/5ml G FANATREX FUSEPAQ ORAL SUSPENSION 25 MG/ML NF (gabapentin) felbamate oral suspension 600 mg/5ml G felbamate oral tablet 400 mg, 600 mg G FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine NPB hcl) FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) PB FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, PB 6 MG, 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg G gabapentin oral solution 250 mg/5ml, 300 mg/6ml G gabapentin oral tablet 600 mg, 800 mg G KEPPRA ORAL SOLUTION 100 MG/ML (levetiracetam) NF KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 NF MG (levetiracetam) KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 500 MG, 750 MG (levetiracetam) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, NF 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 NF MG, 200 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, NF 25 MG (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG NF (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 NF MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 NF & 50 & 100 MG, 50 & 100 & 200 MG (lamotrigine)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

43 Prescription Drug Name Drug Tier Drug Notes LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 NF MG (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 G mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg G lamotrigine oral tablet chewable 25 mg, 5 mg G lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 G mg lamotrigine starter kit-blue oral kit 35 x 25 mg G lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg G lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg G levetiracetam er oral tablet extended release 24 hour 500 mg, G 750 mg levetiracetam oral solution 100 mg/ml G levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg G LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 NPB MG, 25 MG, 300 MG, 50 MG, 75 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) NPB NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam NPB (anticonvulsant)) ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) NF ONFI ORAL TABLET 10 MG, 20 MG (clobazam) NF oxcarbazepine oral suspension 300 mg/5ml G oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg G OXTELLAR XR ORAL TABLET EXTENDED RELEASE PB 24 HOUR 150 MG, 300 MG, 600 MG (oxcarbazepine) phenytoin oral suspension 125 mg/5ml G phenytoin oral tablet chewable 50 mg G phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 G mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 G mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml G primidone oral tablet 250 mg, 50 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

44 Prescription Drug Name Drug Tier Drug Notes levetiracetam (Roweepra Oral Tablet 500 Mg) G SABRIL ORAL PACKET 500 MG (vigabatrin) NPSB SABRIL ORAL TABLET 500 MG (vigabatrin) NPSB SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG NF (levetiracetam) lamotrigine (Subvenite Oral Tablet 100 Mg, 150 Mg, 200 Mg, G 25 Mg) lamotrigine (Subvenite Starter Kit-Blue Oral Kit 35 X 25 Mg) G lamotrigine (Subvenite Starter Kit-Green Oral Kit 84 X 25 Mg G & 14X100 Mg) lamotrigine (Subvenite Starter Kit-Orange Oral Kit 42 X 25 G Mg & 7 X 100 Mg) SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG NF (clobazam) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg G topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, G 200 mg, 25 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 25 mg G topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg G TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG PB (topiramate) valproic acid oral capsule 250 mg G valproic acid oral solution 250 mg/5ml G VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML NPB (diazepam) VALTOCO 15 MG DOSE NASAL LIQUID THERAPY NPB PACK 7.5 MG/0.1ML (diazepam) VALTOCO 20 MG DOSE NASAL LIQUID THERAPY NPB PACK 10 MG/0.1ML (diazepam) VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML NPB (diazepam) vigabatrin oral packet 500 mg G vigabatrin oral tablet 500 mg G vigabatrin (Vigadrone Oral Packet 500 Mg) G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

45 Prescription Drug Name Drug Tier Drug Notes VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) PB VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 PB MG (lacosamide) XCOPRI (250 MG DAILY DOSE) ORAL TABLET NPB THERAPY PACK 50 & 200 MG (cenobamate) XCOPRI (350 MG DAILY DOSE) ORAL TABLET NPB THERAPY PACK 150 & 200 MG (cenobamate) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 NPB MG (cenobamate) XCOPRI ORAL TABLET THERAPY PACK 14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 MG & NPB 14 X100 MG (cenobamate) ZONEGRAN ORAL CAPSULE 100 MG, 25 MG NF (zonisamide) zonisamide oral capsule 100 mg, 25 mg, 50 mg G *ANTIDEPRESSANTS* - DRUGS FOR THE NERVOUS SYSTEM amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 G mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg G APLENZIN ORAL TABLET EXTENDED RELEASE 24 NF HOUR 174 MG, 348 MG, 522 MG (bupropion hbr) bupropion hcl er (sr) oral tablet extended release 12 hour 100 G mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 G mg, 300 mg bupropion hcl er (xl) oral tablet extended release 24 hour 450 NF mg bupropion hcl oral tablet 100 mg, 75 mg G citalopram hydrobromide oral solution 10 mg/5ml G citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg G LGC clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg G CYMBALTA ORAL CAPSULE DELAYED RELEASE NF PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl) desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 G mg, 75 mg

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

46 Prescription Drug Name Drug Tier Drug Notes desvenlafaxine succinate er oral tablet extended release 24 hour G 100 mg, 25 mg, 50 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, G 75 mg doxepin hcl oral concentrate 10 mg/ml G duloxetine hcl oral capsule delayed release particles 20 mg, 30 G mg, 40 mg, 60 mg EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 150 MG, 37.5 MG, 75 MG (venlafaxine hcl) EMSAM TRANSDERMAL PATCH 24 HOUR 12 NPB MG/24HR, 6 MG/24HR, 9 MG/24HR (selegiline) escitalopram oxalate oral solution 5 mg/5ml G escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg G FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran NF hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR NF THERAPY PACK 20 & 40 MG (levomilnacipran hcl) fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg G LGC fluoxetine hcl oral capsule delayed release 90 mg G fluoxetine hcl oral solution 20 mg/5ml G fluoxetine hcl oral tablet 10 mg, 20 mg G fluoxetine hcl oral tablet 60 mg NF fluvoxamine maleate er oral capsule extended release 24 hour G 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg G imipramine hcl oral tablet 10 mg, 25 mg, 50 mg G imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 G mg LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG NF (escitalopram oxalate) maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg G MARPLAN ORAL TABLET 10 MG (isocarboxazid) NPB mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg G mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

47 Prescription Drug Name Drug Tier Drug Notes nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 G mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg G nortriptyline hcl oral solution 10 mg/5ml G paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, G 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg G LGC PAXIL CR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 12.5 MG, 25 MG, 37.5 MG (paroxetine hcl) PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) NF PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine hcl) PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine mesylate) phenelzine sulfate oral tablet 15 mg G PRISTIQ ORAL TABLET EXTENDED RELEASE 24 NF HOUR 100 MG, 25 MG, 50 MG (desvenlafaxine succinate) protriptyline hcl oral tablet 10 mg, 5 mg G PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG NF (fluoxetine hcl) sertraline hcl oral concentrate 20 mg/ml G sertraline hcl oral tablet 100 mg, 25 mg, 50 mg G LGC SPRAVATO (56 MG DOSE) NASAL SOLUTION NPSB THERAPY PACK 28 MG/DEVICE (esketamine hcl) SPRAVATO (84 MG DOSE) NASAL SOLUTION NPSB THERAPY PACK 28 MG/DEVICE (esketamine hcl) tranylcypromine sulfate oral tablet 10 mg G trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg G trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg G TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG PB (vortioxetine hbr) venlafaxine hcl er oral capsule extended release 24 hour 150 mg, G 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 mg, NF 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 225 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

48 Prescription Drug Name Drug Tier Drug Notes venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 G mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG PB (vilazodone hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG PB (vilazodone hcl) ZULRESSO INTRAVENOUS SOLUTION 100 MG/20ML NF (brexanolone) *ANTIDIABETICS* - HORMONES acarbose oral tablet 100 mg, 25 mg, 50 mg G ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG NF (pioglitazone hcl) ADLYXIN STARTER PACK SUBCUTANEOUS PEN- NF INJECTOR KIT 10 & 20 MCG/0.2ML (lixisenatide) ADLYXIN SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 20 MCG/0.2ML (lixisenatide) ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin lispro) ADMELOG SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin lispro) AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 NF UNIT & 90X12 UNIT (insulin regular human) alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg NF alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg NF alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5- NF 45 mg, 25-15 mg, 25-30 mg, 25-45 mg APIDRA INJECTION SOLUTION 100 UNIT/ML (insulin NF glulisine) APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin glulisine) AVANDIA ORAL TABLET 2 MG, 4 MG (rosiglitazone NPB maleate) BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE PB (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE PB (glucagon)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

49 Prescription Drug Name Drug Tier Drug Notes BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin glargine) BYDUREON BCISE SUBCUTANEOUS AUTO- NF INJECTOR 2 MG/0.85ML (exenatide) BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG NF (exenatide) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 10 MCG/0.04ML (exenatide) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 5 MCG/0.02ML (exenatide) cvs glucose oral tablet chewable 4-6 gm-mg NPB CYCLOSET ORAL TABLET 0.8 MG (bromocriptine NF mesylate) DEX4 NATURALS ORAL TABLET CHEWABLE 4-6 GM- NPB MG (glucose-vitamin c) DEX4 ORAL TABLET CHEWABLE 4-6 GM-MG (glucose- NPB vitamin c) DEX4 POUCH PACK ORAL TABLET CHEWABLE 4-6 NPB GM-MG (glucose-vitamin c) FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin PB propanediol) FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin aspart PB (w/niacinamide)) FIASP PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin aspart (w/niacinamide)) FORTAMET ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 500 MG (metformin hcl) glimepiride oral tablet 1 mg, 2 mg, 4 mg G LGC glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 G LGC mg glipizide oral tablet 10 mg, 5 mg G LGC glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 G LGC mg

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

50 Prescription Drug Name Drug Tier Drug Notes glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5- G LGC 500 mg GLUCAGEN HYPOKIT INJECTION SOLUTION PB RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency injection kit 1 mg PB glucose instant energy oral tablet chewable 4-6 gm-mg, 6-4 mg- NPB gm glucose oral tablet chewable 4-6 gm-mg NPB GLUMETZA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 500 MG (metformin hcl) glyburide micronized oral tablet 1.5 mg G glyburide micronized oral tablet 3 mg, 6 mg G LGC glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg G LGC glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 G LGC mg GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG PB (empagliflozin-linagliptin) gnp glucose oral tablet chewable 4-6 gm-mg NPB goodsense glucose oral tablet chewable 4-6 gm-mg NPB GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 PB MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 PB MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) hm glucose oral tablet chewable 4-6 gm-mg NPB HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin NF lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML NF (insulin lispro prot & lispro) HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION NF (50-50) 100 UNIT/ML (insulin lispro prot & lispro)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

51 Prescription Drug Name Drug Tier Drug Notes HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML NF (insulin lispro prot & lispro) HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION NF (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin lispro) HUMALOG SUBCUTANEOUS SOLUTION NF CARTRIDGE 100 UNIT/ML (insulin lispro) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NF (insulin nph isophane & regular) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70- NF 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph NF human (isophane)) HUMULIN N SUBCUTANEOUS SUSPENSION 100 NF UNIT/ML (insulin nph human (isophane)) HUMULIN R INJECTION SOLUTION 100 UNIT/ML NF (insulin regular human) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML (insulin PB regular human) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML (insulin regular PB human) INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, NF 50-1000 MG, 50-500 MG (canagliflozin-metformin hcl) INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 NF MG, 50-500 MG (canagliflozin-metformin hcl) INVOKANA ORAL TABLET 100 MG, 300 MG NF (canagliflozin) JANUMET ORAL TABLET 50-1000 MG, 50-500 MG PB (sitagliptin-metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG PB (sitagliptin-metformin hcl) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

52 Prescription Drug Name Drug Tier Drug Notes JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG PB (sitagliptin phosphate) JARDIANCE ORAL TABLET 10 MG, 25 MG PB (empagliflozin) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, NF 2.5-850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG (linagliptin- NF metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG NF (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG NF (saxagliptin-metformin) KORLYM ORAL TABLET 300 MG (mifepristone) NPB kroger glucose oral tablet chewable 4-6 gm-mg NPB LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin glargine) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NF (insulin glargine) LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin detemir) LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin detemir) meijer glucose oral tablet chewable 4-6 gm-mg NPB metformin hcl er (mod) oral tablet extended release 24 hour NF 1000 mg, 500 mg metformin hcl er (osm) oral tablet extended release 24 hour NF 1000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 mg G LGC metformin hcl er oral tablet extended release 24 hour 750 mg G metformin hcl oral solution 500 mg/5ml NPB metformin hcl oral tablet 1000 mg, 500 mg, 850 mg G LGC miglitol oral tablet 100 mg, 25 mg, 50 mg G nateglinide oral tablet 120 mg, 60 mg G LGC NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG NF (alogliptin benzoate) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

53 Prescription Drug Name Drug Tier Drug Notes NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NF (insulin nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML PB (insulin nph isophane & regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML (insulin nph isophane & NF regular) NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) PB 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph PB human (isophane)) NOVOLIN N RELION SUBCUTANEOUS SUSPENSION NF 100 UNIT/ML (insulin nph human (isophane)) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 PB UNIT/ML (insulin nph human (isophane)) NOVOLIN R FLEXPEN INJECTION SOLUTION PEN- PB INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin regular NF human) NOVOLIN R INJECTION SOLUTION 100 UNIT/ML PB (insulin regular human) NOVOLIN R RELION INJECTION SOLUTION 100 NF UNIT/ML (insulin regular human) NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML PB (insulin aspart prot & aspart) NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION PB (70-30) 100 UNIT/ML (insulin aspart prot & aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE 100 UNIT/ML (insulin aspart) NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin aspart)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

54 Prescription Drug Name Drug Tier Drug Notes ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) NF OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG (alogliptin- NF pioglitazone) OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS PB SOLUTION PEN-INJECTOR 2 MG/1.5ML (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 2 MG/1.5ML (semaglutide) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg G LGC pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg G pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg G LGC PROGLYCEM ORAL SUSPENSION 50 MG/ML NPB (diazoxide) px glucose oral tablet chewable 4-6 gm-mg NPB QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin- NPB saxagliptin) ra glucose oral tablet chewable 4-6 gm-mg, 6-4 mg-gm NPB RELION GLUCOSE ORAL TABLET CHEWABLE 4-6 NPB GM-MG (glucose-vitamin c) repaglinide oral tablet 0.5 mg, 1 mg, 2 mg G LGC RIOMET ORAL SOLUTION 500 MG/5ML (metformin hcl) NF RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG PB (semaglutide) SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 NF MG, 7.5-1000 MG, 7.5-500 MG (ertugliflozin-metformin hcl) sm glucose oral tablet chewable 4-6 gm-mg NPB SMART SENSE GLUCOSE ORAL TABLET CHEWABLE NPB 4-6 GM-MG (glucose-vitamin c) SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-33 UNT-MCG/ML (insulin glargine- PB lixisenatide) STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin NF l-pyroglutamicac) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG NF (ertugliflozin-sitagliptin) SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 2700 MCG/2.7ML (pramlintide acetate) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

55 Prescription Drug Name Drug Tier Drug Notes SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 1500 MCG/1.5ML (pramlintide acetate) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, PB 5-1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 PB MG (empagliflozin-metformin hcl) tgt glucose oral tablet chewable 4-6 gm-mg NPB tolbutamide oral tablet 500 mg G TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML (insulin NF glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 300 UNIT/ML (insulin glargine) TRADJENTA ORAL TABLET 5 MG (linagliptin) NF TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin PB degludec) TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin degludec) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, PB 5-2.5-1000 MG (empagliflozin-linaglip-metform) TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, PB 4.5 MG/0.5ML (dulaglutide) up & up glucose oral tablet chewable 4-6 gm-mg NPB value plus glucose oral tablet chewable 4-6 gm-mg NPB VICTOZA SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 18 MG/3ML (liraglutide) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, PB 5-500 MG (dapagliflozin-metformin hcl) XULTOPHY SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML (insulin degludec- PB liraglutide)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

56 Prescription Drug Name Drug Tier Drug Notes *ANTIDIARRHEAL/PROBIOTIC AGENTS* - DRUGS FOR THE STOMACH diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml G diphenoxylate-atropine oral tablet 2.5-0.025 mg G EVIVO ORAL LIQUID (bifidobacterium longum inf-mct) NF loperamide hcl oral capsule 2 mg G MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin- NF atropine) MYTESI ORAL TABLET DELAYED RELEASE 125 MG NF (crofelemer) opium oral tincture 10 mg/ml (1%) G probichew oral tablet chewable NF prodigen oral capsule NF RESTORA RX ORAL CAPSULE 60-1.25 MG (lactobacillus NF casei-folic acid) VSL#3 DS ORAL PACKET (probiotic product) NPB zelac oral capsule NF *ANTIDOTES AND SPECIFIC ANTAGONISTS* - DRUGS FOR OVERDOSE OR POISONING BRIDION INTRAVENOUS SOLUTION 200 MG/2ML, 500 NF MG/5ML (sugammadex sodium) CHEMET ORAL CAPSULE 100 MG (succimer) NPB deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg G deferoxamine mesylate injection solution reconstituted 2 gm NPSB DESFERAL INJECTION SOLUTION RECONSTITUTED NPSB 500 MG (deferoxamine mesylate) EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, NPSB 500 MG (deferasirox) FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) NF FERRIPROX ORAL TABLET 1000 MG, 500 MG NPB (deferiprone) FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG NPSB (deferiprone) JADENU ORAL TABLET 180 MG, 360 MG, 90 MG NPSB (deferasirox)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

57 Prescription Drug Name Drug Tier Drug Notes JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, NPSB 90 MG (deferasirox) naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml G naloxone hcl injection solution auto-injector 2 mg/0.4ml NF naloxone hcl injection solution cartridge 0.4 mg/ml G naloxone hcl injection solution prefilled syringe 2 mg/2ml G naltrexone hcl oral tablet 50 mg G NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) PB PROVAYBLUE INTRAVENOUS SOLUTION 50 NF MG/10ML (methylene blue (antidote)) RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue NPB insoluble) sodium thiosulfate intravenous solution 25 % NPB VISTOGARD ORAL PACKET 10 GM (uridine triacetate) PB VIVITROL INTRAMUSCULAR SUSPENSION NPSB RECONSTITUTED 380 MG (naltrexone) *ANTIEMETICS* - DRUGS FOR THE STOMACH AKYNZEO INTRAVENOUS SOLUTION 235-0.25 NPB MG/20ML (fosnetupitant-palonosetron) AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- NPB palonosetron) ANZEMET ORAL TABLET 100 MG, 50 MG (dolasetron NPB mesylate) aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg G BONJESTA ORAL TABLET EXTENDED RELEASE 20- NF 20 MG (doxylamine-pyridoxine) CINVANTI INTRAVENOUS EMULSION 130 MG/18ML NF (aprepitant) doxylamine-pyridoxine oral tablet delayed release 10-10 mg G dronabinol oral capsule 10 mg, 2.5 mg, 5 mg G EMEND ORAL SUSPENSION RECONSTITUTED 125 NPB MG/5ML (aprepitant) granisetron hcl oral tablet 1 mg G meclizine hcl oral tablet 12.5 mg, 25 mg G ondansetron hcl oral solution 4 mg/5ml G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

58 Prescription Drug Name Drug Tier Drug Notes ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg G ondansetron oral tablet dispersible 4 mg, 8 mg G SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR NF (granisetron) scopolamine transdermal patch 72 hour 1 mg/3days G SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 NF MG/0.4ML (granisetron) SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) NF TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH NF 72 HOUR 1 MG/3DAYS (scopolamine base) trimethobenzamide hcl oral capsule 300 mg G VARUBI (180 MG DOSE) ORAL TABLET THERAPY PB PACK 2 X 90 MG (rolapitant hcl) ZUPLENZ ORAL FILM 4 MG, 8 MG (ondansetron) NF *ANTIFUNGALS* - DRUGS FOR INFECTIONS bio-statin oral capsule 1000000 unit, 500000 unit NPB bio-statin oral powder G CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium NPB sulfate) fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml G fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg G flucytosine oral capsule 250 mg G flucytosine oral capsule 500 mg NF griseofulvin microsize oral suspension 125 mg/5ml G griseofulvin microsize oral tablet 500 mg G griseofulvin ultramicrosize oral tablet 125 mg, 250 mg G itraconazole oral capsule 100 mg G itraconazole oral solution 10 mg/ml G ketoconazole oral tablet 200 mg G NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7ML NF (posaconazole) NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) NF NOXAFIL ORAL TABLET DELAYED RELEASE 100 NF MG (posaconazole) nystatin oral tablet 500000 unit G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

59 Prescription Drug Name Drug Tier Drug Notes posaconazole oral tablet delayed release 100 mg NF SPORANOX ORAL CAPSULE 100 MG (itraconazole) NF SPORANOX ORAL SOLUTION 10 MG/ML (itraconazole) NF SPORANOX PULSEPAK ORAL CAPSULE 100 MG NF (itraconazole) terbinafine hcl oral tablet 250 mg G tolsura oral capsule 65 mg NF voriconazole oral suspension reconstituted 40 mg/ml G voriconazole oral tablet 200 mg, 50 mg G *ANTIHISTAMINES* - DRUGS FOR THE LUNGS carbinoxamine maleate oral solution 4 mg/5ml G carbinoxamine maleate oral tablet 4 mg G carbinoxamine maleate oral tablet 6 mg NF cetirizine hcl oral solution 1 mg/ml G clemastine fumarate oral tablet 2.68 mg G cyproheptadine hcl oral syrup 2 mg/5ml G cyproheptadine hcl oral tablet 4 mg G desloratadine oral tablet 5 mg G desloratadine oral tablet dispersible 2.5 mg, 5 mg G dexchlorpheniramine maleate oral solution 2 mg/5ml NF diphen oral elixir 12.5 mg/5ml NF diphenhydramine hcl oral elixir 12.5 mg/5ml G KARBINAL ER ORAL SUSPENSION EXTENDED NPB RELEASE 4 MG/5ML (carbinoxamine maleate) levocetirizine dihydrochloride oral solution 2.5 mg/5ml G levocetirizine dihydrochloride oral tablet 5 mg G promethazine hcl oral syrup 6.25 mg/5ml G promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg G promethazine hcl rectal suppository 12.5 mg, 25 mg G promethazine hcl (Promethegan Rectal Suppository 12.5 Mg, G 25 Mg) PROMETHEGAN RECTAL SUPPOSITORY 50 MG G (promethazine hcl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

60 Prescription Drug Name Drug Tier Drug Notes RYCLORA ORAL SOLUTION 2 MG/5ML NF (dexchlorpheniramine maleate) RYVENT ORAL TABLET 6 MG (carbinoxamine maleate) G *ANTIHYPERLIPIDEMICS* - DRUGS FOR THE HEART ALTOPREV ORAL TABLET EXTENDED RELEASE 24 NF HOUR 20 MG, 40 MG, 60 MG (lovastatin) ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate NPB micronized) atorvastatin calcium oral tablet 10 mg, 20 mg CE LGC atorvastatin calcium oral tablet 40 mg, 80 mg G LGC cholestyramine light oral packet 4 gm G cholestyramine light oral powder 4 gm/dose G cholestyramine oral packet 4 gm G cholestyramine oral powder 4 gm/dose G colesevelam hcl oral packet 3.75 gm G colesevelam hcl oral tablet 625 mg G colestipol hcl oral granules 5 gm G colestipol hcl oral packet 5 gm G colestipol hcl oral tablet 1 gm G CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG NF (rosuvastatin calcium) equapax/atorvastatin/coq10 oral therapy pack 20 & 100 mg NF EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 NF MG, 20 MG, 40 MG, 5 MG (rosuvastatin calcium) ezetimibe oral tablet 10 mg G ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, G 10-80 mg fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 G mg, 67 mg fenofibrate oral capsule 150 mg, 50 mg G fenofibrate oral tablet 120 mg NF fenofibrate oral tablet 145 mg, 160 mg, 40 mg, 48 mg, 54 mg G fenofibric acid oral capsule delayed release 135 mg, 45 mg G fenofibric acid oral tablet 105 mg G FENOGLIDE ORAL TABLET 120 MG (fenofibrate) NF 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

61 Prescription Drug Name Drug Tier Drug Notes FIBRICOR ORAL TABLET 105 MG, 35 MG (fenofibric NPB acid) flolipid oral suspension 20 mg/5ml, 40 mg/5ml NF fluvastatin sodium er oral tablet extended release 24 hour 80 mg G fluvastatin sodium oral capsule 20 mg, 40 mg G gemfibrozil oral tablet 600 mg G LGC JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 NPSB MG (lomitapide mesylate) LESCOL XL ORAL TABLET EXTENDED RELEASE 24 NF HOUR 80 MG (fluvastatin sodium) LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG NF (atorvastatin calcium) LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin NF calcium) lovastatin oral tablet 10 mg, 20 mg, 40 mg G LGC NEXLETOL ORAL TABLET 180 MG (bempedoic acid) NPB NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- NPB ezetimibe) niacin (antihyperlipidemic) oral tablet 500 mg NF niacin er (antihyperlipidemic) oral tablet extended release 1000 G mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG (niacin NF (antihyperlipidemic)) omega-3 rx complete oral therapy pack 1 gm NF OMEGA-3/D-3 WELLNESS PACK ORAL KIT 1 & 1000 NF GM & UNIT (omega-3-acid ethyl esters & d3) omega-3-acid ethyl esters oral capsule 1 gm G PRALUENT SUBCUTANEOUS SOLUTION AUTO- PSB INJECTOR 150 MG/ML, 75 MG/ML (alirocumab) pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg G LGC cholestyramine light (Prevalite Oral Packet 4 Gm) G cholestyramine light (Prevalite Oral Powder 4 Gm/Dose) G REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS NF SOLUTION CARTRIDGE 420 MG/3.5ML (evolocumab) REPATHA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 140 MG/ML (evolocumab)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

62 Prescription Drug Name Drug Tier Drug Notes REPATHA SURECLICK SUBCUTANEOUS SOLUTION NF AUTO-INJECTOR 140 MG/ML (evolocumab) rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg CE LGC simvastatin oral tablet 80 mg G LGC sure result o3d3 system oral kit 1 & 1000 gm & unit NF TRICOR ORAL TABLET 145 MG, 48 MG (fenofibrate) NF VASCEPA ORAL CAPSULE 0.5 GM, 1 GM (icosapent PB ethyl) ZETIA ORAL TABLET 10 MG (ezetimibe) NF ZYPITAMAG ORAL TABLET 2 MG, 4 MG (pitavastatin NF magnesium) *ANTIHYPERTENSIVES* - DRUGS FOR THE HEART aliskiren fumarate oral tablet 150 mg, 300 mg G amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, G LGC 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, G LGC 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, G LGC 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 G LGC mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 NF MG, 32-25 MG (candesartan cilexetil-hctz) ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG NF (candesartan cilexetil) atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg G benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg, 5-6.25 mg BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, NF 40-25 MG (olmesartan medoxomil-hctz) BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG NF (olmesartan medoxomil) bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 G LGC mg, 5-6.25 mg

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

63 Prescription Drug Name Drug Tier Drug Notes candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg G LGC candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, G LGC 32-25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg G LGC captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, G 50-15 mg, 50-25 mg clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg G LGC clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, G 0.3 mg/24hr DEMSER ORAL CAPSULE 250 MG (metyrosine) NPB DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- NF hydrochlorothiazide) DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 NF MG (valsartan) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg G DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- NF hydrochlorothiazide) EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan NF medoxomil) EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG NF (azilsartan-chlorthalidone) enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg G LGC enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg G LGC EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) NPB eplerenone oral tablet 25 mg, 50 mg G EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160- 25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG NF (amlodipine-valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 NF MG, 5-320 MG (amlodipine besylate-valsartan) fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg G LGC fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg G LGC guanfacine hcl oral tablet 1 mg, 2 mg G hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

64 Prescription Drug Name Drug Tier Drug Notes hydralazine hcl oral tablet 25 mg G LGC irbesartan oral tablet 150 mg, 300 mg, 75 mg G LGC irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- G LGC 12.5 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg G LGC lisinopril oral tablet 30 mg, 40 mg G lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg losartan potassium oral tablet 100 mg, 25 mg, 50 mg G LGC losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50- G LGC 12.5 mg methyldopa oral tablet 250 mg, 500 mg G methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 G mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 G mg, 50-25 mg minoxidil oral tablet 10 mg, 2.5 mg G moexipril hcl oral tablet 15 mg, 7.5 mg G NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 50-0.9 MG/100ML-% (nitroprusside sodium- NF nacl) olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg G LGC olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, G LGC 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- G LGC 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg G LGC phenoxybenzamine hcl oral capsule 10 mg G prazosin hcl oral capsule 1 mg, 2 mg, 5 mg G PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 NF MG (perindopril arg-amlodipine) propranolol-hctz oral tablet 40-25 mg, 80-25 mg G QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) NPB quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

65 Prescription Drug Name Drug Tier Drug Notes ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg G LGC TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 PB MG, 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG (aliskiren NPB fumarate) telmisartan oral tablet 20 mg, 40 mg, 80 mg G LGC telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 G LGC mg, 80-5 mg telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg G LGC terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg G LGC trandolapril oral tablet 1 mg, 2 mg, 4 mg G LGC trandolapril-verapamil hcl er oral tablet extended release 1-240 G mg, 2-180 mg, 2-240 mg, 4-240 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg G LGC valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 G LGC mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) NPB *ANTI-INFECTIVE AGENTS - MISC.* - DRUGS FOR INFECTIONS AEMCOLO ORAL TABLET DELAYED RELEASE 194 NPB MG (rifamycin sodium) ALINIA ORAL SUSPENSION RECONSTITUTED 100 NPB MG/5ML (nitazoxanide) ALINIA ORAL TABLET 500 MG (nitazoxanide) NPB atovaquone oral suspension 750 mg/5ml G CAYSTON INHALATION SOLUTION NPB RECONSTITUTED 75 MG (aztreonam lysine) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg G clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml G dapsone oral tablet 100 mg, 25 mg G FIRST-METRONIDAZOLE ORAL SUSPENSION NF RECONSTITUTED 50 MG/ML (metronidazole benzoate) FIRVANQ ORAL SOLUTION RECONSTITUTED 25 NF MG/ML, 50 MG/ML (vancomycin hcl) HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz G acd-ph sal)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

66 Prescription Drug Name Drug Tier Drug Notes IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) NPB LAMPIT ORAL TABLET 120 MG, 30 MG (nifurtimox) NPB linezolid oral suspension reconstituted 100 mg/5ml G linezolid oral tablet 600 mg G MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 NF MG (nitrofurantoin macrocrystal) me/naphos/mb/hyo1 oral tablet 81.6 mg G methenamine hippurate oral tablet 1 gm G methenamine mandelate oral tablet 0.5 gm, 1 gm G METRONIDAZOLE BENZO+SYRSPEND ORAL SUSPENSION RECONSTITUTED 50 MG/ML NF (metronidazole benzoate) metronidazole oral capsule 375 mg G metronidazole oral tablet 250 mg, 500 mg G MONUROL ORAL PACKET 3 GM (fosfomycin NPB tromethamine) NEBUPENT INHALATION SOLUTION NPB RECONSTITUTED 300 MG (pentamidine isethionate) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg G nitrofurantoin monohyd macro oral capsule 100 mg G nitrofurantoin oral suspension 25 mg/5ml G meth-hyo-m bl-na phos-ph sal (Phosphasal Oral Tablet 81.6 G Mg) PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim NPB hcl) RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM (imipenem-cilastatin- NPB relebactam) SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) NPB sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml G sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 G mg sulfamethoxazole-trimethoprim (Sulfatrim Pediatric Oral G Suspension 200-40 Mg/5Ml) tinidazole oral tablet 250 mg, 500 mg G trimethoprim oral tablet 100 mg G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

67 Prescription Drug Name Drug Tier Drug Notes meth-hyo-m bl-na phos-ph sal (Uretron D/S Oral Tablet 81.6 G Mg) meth-hyo-m bl-na phos-ph sal (Uribel Oral Capsule 118 Mg) G URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na G phos-ph sal) urin ds oral tablet 81.6 mg G uro-458 oral tablet 81 mg G uro-mp oral capsule 118 mg G meth-hyo-m bl-na phos-ph sal (Ustell Oral Capsule 120 Mg) G uticap oral capsule 120 mg G meth-hyo-m bl-na phos-ph sal (Utira-C Oral Tablet 81.6 Mg) G meth-hyo-m bl-na phos-ph sal (Utrona-C Oral Tablet 81.6 Mg) G vancomycin hcl intravenous solution 1250 mg/250ml, 1750 NPB mg/350ml, 500 mg/100ml, 750 mg/150ml vancomycin hcl oral capsule 125 mg, 250 mg G VANCOMYCIN+SYRSPEND SF ORAL SUSPENSION 50 NF MG/ML (vancomycin hcl) meth-hyo-m bl-na phos-ph sal (Vilamit Mb Oral Capsule 118 G Mg) meth-hyo-m bl-na phos-ph sal (Vilevev Mb Oral Tablet 81 Mg) G XENLETA ORAL TABLET 600 MG (lefamulin acetate) NPB XIFAXAN ORAL TABLET 200 MG (rifaximin) NF XIFAXAN ORAL TABLET 550 MG (rifaximin) PB ZYVOX ORAL SUSPENSION RECONSTITUTED 100 NF MG/5ML (linezolid) ZYVOX ORAL TABLET 600 MG (linezolid) NF *ANTIMALARIALS* - DRUGS FOR INFECTIONS ARAKODA ORAL TABLET 100 MG (tafenoquine NF succinate) atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg G chloroquine phosphate oral tablet 250 mg, 500 mg G COARTEM ORAL TABLET 20-120 MG (artemether- NPB lumefantrine) DARAPRIM ORAL TABLET 25 MG (pyrimethamine) NPB hydroxychloroquine sulfate oral tablet 200 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

68 Prescription Drug Name Drug Tier Drug Notes KRINTAFEL ORAL TABLET 150 MG (tafenoquine NF succinate) mefloquine hcl oral tablet 250 mg G primaquine phosphate oral tablet 26.3 mg G quinine sulfate oral capsule 324 mg G *ANTIMYASTHENIC/CHOLINERGIC AGENTS* - DRUGS FOR NERVES AND MUSCLES FIRDAPSE ORAL TABLET 10 MG (amifampridine NPB phosphate) guanidine hcl oral tablet 125 mg NPB MESTINON ORAL SOLUTION 60 MG/5ML NF (pyridostigmine bromide) MESTINON ORAL TABLET 60 MG (pyridostigmine NF bromide) pyridostigmine bromide er oral tablet extended release 180 mg G pyridostigmine bromide oral solution 60 mg/5ml G pyridostigmine bromide oral tablet 60 mg G RUZURGI ORAL TABLET 10 MG (amifampridine) NPB *ANTIMYCOBACTERIAL AGENTS* - DRUGS FOR INFECTIONS cycloserine oral capsule 250 mg G ethambutol hcl oral tablet 100 mg, 400 mg G isoniazid oral syrup 50 mg/5ml G isoniazid oral tablet 100 mg, 300 mg G PASER ORAL PACKET 4 GM (aminosalicylic acid) NPB pretomanid oral tablet 200 mg NPB PRIFTIN ORAL TABLET 150 MG (rifapentine) NPB pyrazinamide oral tablet 500 mg G rifabutin oral capsule 150 mg G rifampin oral capsule 150 mg, 300 mg G SIRTURO ORAL TABLET 100 MG, 20 MG (bedaquiline NPB fumarate) TRECATOR ORAL TABLET 250 MG (ethionamide) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

69 Prescription Drug Name Drug Tier Drug Notes *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* - DRUGS FOR CANCER abiraterone acetate oral tablet 250 mg G ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 NPSB UNIT/0.5ML (interferon gamma-1b) AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 PSB MG, 5 MG (everolimus) AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 PSB MG (everolimus) ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) NPSB ALIQOPA INTRAVENOUS SOLUTION NF RECONSTITUTED 60 MG (copanlisib hcl) ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG NPSB (brigatinib) ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 NPSB MG (brigatinib) anastrozole oral tablet 1 mg G ASPARLAS INTRAVENOUS SOLUTION 3750 NPB UNIT/5ML (calaspargase pegol-mknl) BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG NPB (erdafitinib) BELRAPZO INTRAVENOUS SOLUTION 100 MG/4ML NF (bendamustine hcl) bexarotene oral capsule 75 mg G bicalutamide oral tablet 50 mg G BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG PSB (bosutinib) BRAFTOVI ORAL CAPSULE 75 MG (encorafenib) NPB BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) NPB CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PSB (cabozantinib s-malate) CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) NPB capecitabine oral tablet 150 mg, 500 mg G CAPRELSA ORAL TABLET 100 MG, 300 MG (vandetanib) NPB COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 NPSB MG (cabozantinib s-malate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

70 Prescription Drug Name Drug Tier Drug Notes COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 NPSB MG & 80 MG (cabozantinib s-malate) COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG NPSB (cabozantinib s-malate) COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) PSB COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) NPSB cyclophosphamide intravenous solution 1 gm/5ml, 500 mg/2.5ml NPB cyclophosphamide oral capsule 25 mg, 50 mg G CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, NPB 500 MG/50ML (ramucirumab) DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib NF maleate) ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide PSB acetate (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide PSB acetate (4 month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide PSB acetate (6 month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide PSB acetate) EMCYT ORAL CAPSULE 140 MG (estramustine phosphate NPB sodium) ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) NPSB ERLEADA ORAL TABLET 60 MG (apalutamide) PSB erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg G ERWINAZE INJECTION SOLUTION RECONSTITUTED NPB 10000 UNIT (asparaginase erwinia chrysanth) etoposide oral capsule 50 mg G EVOMELA INTRAVENOUS SOLUTION NF RECONSTITUTED 50 MG (melphalan hcl) exemestane oral tablet 25 mg G FARYDAK ORAL CAPSULE 10 MG, 20 MG (panobinostat NF lactate) FASLODEX INTRAMUSCULAR SOLUTION 250 NPB MG/5ML (fulvestrant)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

71 Prescription Drug Name Drug Tier Drug Notes FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG/VIAL (degarelix NPSB acetate) FIRMAGON SUBCUTANEOUS SOLUTION NPSB RECONSTITUTED 80 MG (degarelix acetate) flutamide oral capsule 125 mg G GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG NPB (afatinib dimaleate) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG NPB (lomustine) GLIADEL WAFER IMPLANT WAFER 7.7 MG NPB (carmustine in polifeprosan) HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION NF 600-10000 MG-UNT/5ML (trastuzumab-hyaluronidase-oysk) HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan NPSB hcl) hydroxyurea oral capsule 500 mg G IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PSB (palbociclib) IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PSB (palbociclib) ICLUSIG ORAL TABLET 15 MG, 45 MG (ponatinib hcl) NPB IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib NPSB mesylate) imatinib mesylate oral tablet 100 mg, 400 mg G IMBRUVICA ORAL CAPSULE 140 MG, 70 MG (ibrutinib) NPB IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, NPB 560 MG (ibrutinib) IMLYGIC INTRALESIONAL SUSPENSION 1000000 NPSB UNIT/ML, 100000000 UNIT/ML (talimogene laherparepvec) INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML-%, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 NF MG/160ML-%, 1700-0.9 MG/170ML-%, 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-% (gemcitabine hcl-nacl) INLYTA ORAL TABLET 1 MG, 5 MG (axitinib) NPSB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

72 Prescription Drug Name Drug Tier Drug Notes INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) NF INTRON A INJECTION SOLUTION 10000000 UNIT/ML, NPSB 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon NPSB alfa-2b) IRESSA ORAL TABLET 250 MG (gefitinib) PSB JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 NPSB MG (ruxolitinib phosphate) KANJINTI INTRAVENOUS SOLUTION NF RECONSTITUTED 420 MG (trastuzumab-anns) KHAPZORY INTRAVENOUS SOLUTION NF RECONSTITUTED 175 MG, 300 MG (levoleucovorin) KISQALI (200 MG DOSE) ORAL TABLET THERAPY PSB PACK 200 MG (ribociclib succinate) KISQALI (400 MG DOSE) ORAL TABLET THERAPY PSB PACK 200 MG (ribociclib succinate) KISQALI (600 MG DOSE) ORAL TABLET THERAPY PSB PACK 200 MG (ribociclib succinate) KISQALI FEMARA (400 MG DOSE) ORAL TABLET PSB THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KISQALI FEMARA (600 MG DOSE) ORAL TABLET PSB THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KISQALI FEMARA(200 MG DOSE) ORAL TABLET PSB THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KOSELUGO ORAL CAPSULE 10 MG, 25 MG (selumetinib NPB sulfate) LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE NPSB THERAPY PACK 10 MG (lenvatinib mesylate) LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE NPSB THERAPY PACK 3 X 4 MG (lenvatinib mesylate) LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE NPSB THERAPY PACK 10 & 4 MG (lenvatinib mesylate) LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE NPSB THERAPY PACK 10 MG & 2 X 4 MG (lenvatinib mesylate) LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE NPSB THERAPY PACK 2 X 10 MG (lenvatinib mesylate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

73 Prescription Drug Name Drug Tier Drug Notes LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE NPSB THERAPY PACK 2 X 10 MG & 4 MG (lenvatinib mesylate) LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE NPSB THERAPY PACK 4 MG (lenvatinib mesylate) LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE NPSB THERAPY PACK 2 X 4 MG (lenvatinib mesylate) letrozole oral tablet 2.5 mg G leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg G LEUKERAN ORAL TABLET 2 MG (chlorambucil) PB leuprolide acetate injection kit 1 mg/0.2ml G LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG NPSB (trifluridine-tipiracil) LORBRENA ORAL TABLET 100 MG, 25 MG (lorlatinib) NPSB LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT NPSB 3.75 MG (leuprolide acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT NPSB 11.25 MG (leuprolide acetate (3 month)) LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) PSB LYSODREN ORAL TABLET 500 MG (mitotane) PB MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) PB megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml G megestrol acetate oral tablet 20 mg, 40 mg G MEKINIST ORAL TABLET 0.5 MG, 2 MG (trametinib NPSB dimethyl sulfoxide) MEKTOVI ORAL TABLET 15 MG (binimetinib) NPB melphalan oral tablet 2 mg G mercaptopurine oral tablet 50 mg G MESNEX ORAL TABLET 400 MG (mesna) NPB methotrexate sodium (pf) injection solution 1 gm/40ml, 250 G mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml G methotrexate sodium injection solution reconstituted 1 gm G methotrexate sodium oral tablet 2.5 mg G MVASI INTRAVENOUS SOLUTION 100 MG/4ML, 400 NF MG/16ML (bevacizumab-awwb)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

74 Prescription Drug Name Drug Tier Drug Notes MYLERAN ORAL TABLET 2 MG (busulfan) PB NERLYNX ORAL TABLET 40 MG (neratinib maleate) NPSB NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) NPSB NILANDRON ORAL TABLET 150 MG (nilutamide) NF nilutamide oral tablet 150 mg G NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG NPSB (ixazomib citrate) NUBEQA ORAL TABLET 300 MG (darolutamide) PSB ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) PSB oxaliplatin intravenous solution 200 mg/40ml NPB PARAPLATIN INTRAVENOUS SOLUTION 1000 NPB MG/100ML (carboplatin) PIQRAY (200 MG DAILY DOSE) ORAL TABLET NF THERAPY PACK 200 MG (alpelisib) PIQRAY (250 MG DAILY DOSE) ORAL TABLET NF THERAPY PACK 200 & 50 MG (alpelisib) PIQRAY (300 MG DAILY DOSE) ORAL TABLET NF THERAPY PACK 2 X 150 MG (alpelisib) POLIVY INTRAVENOUS SOLUTION NF RECONSTITUTED 140 MG (polatuzumab vedotin-piiq) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG NPSB (pomalidomide) PORTRAZZA INTRAVENOUS SOLUTION 800 NPB MG/50ML (necitumumab) PURIXAN ORAL SUSPENSION 2000 MG/100ML NPSB (mercaptopurine) romidepsin intravenous solution 27.5 mg/5.5ml NPSB ROZLYTREK ORAL CAPSULE 100 MG, 200 MG NPSB (entrectinib) RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PSB (rucaparib camsylate) RYDAPT ORAL CAPSULE 25 MG (midostaurin) PSB SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen NPB citrate) SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 PSB MG, 70 MG, 80 MG (dasatinib)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

75 Prescription Drug Name Drug Tier Drug Notes STIVARGA ORAL TABLET 40 MG (regorafenib) NPSB SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 PSB MG (sunitinib malate) SYNRIBO SUBCUTANEOUS SOLUTION NPB RECONSTITUTED 3.5 MG (omacetaxine mepesuccinate) TABLOID ORAL TABLET 40 MG (thioguanine) PB TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib NPSB mesylate) TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib NPSB mesylate) TALZENNA ORAL CAPSULE 0.25 MG, 1 MG (talazoparib NF tosylate) tamoxifen citrate oral tablet 10 mg, 20 mg CE TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG NPSB (erlotinib hcl) TARGRETIN ORAL CAPSULE 75 MG (bexarotene) NPSB TEMODAR INTRAVENOUS SOLUTION NPSB RECONSTITUTED 100 MG (temozolomide) TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, NPSB 20 MG, 250 MG, 5 MG (temozolomide) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 G mg, 5 mg TIBSOVO ORAL TABLET 250 MG (ivosidenib) NPB TICE BCG INTRAVESICAL SUSPENSION NPB RECONSTITUTED 50 MG (bcg live) toremifene citrate oral tablet 60 mg G TREANDA INTRAVENOUS SOLUTION NPSB RECONSTITUTED 100 MG, 25 MG (bendamustine hcl) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, NPSB 3.75 MG (triptorelin pamoate) tretinoin oral capsule 10 mg G TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG PB (methotrexate sodium) TRODELVY INTRAVENOUS SOLUTION NPB RECONSTITUTED 180 MG (sacituzumab govitecan-hziy) TUKYSA ORAL TABLET 150 MG, 50 MG (tucatinib) NPB 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

76 Prescription Drug Name Drug Tier Drug Notes TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) NF TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) PSB VANTAS SUBCUTANEOUS KIT 50 MG (histrelin acetate) NPSB VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG NPB (venetoclax) VENCLEXTA STARTING PACK ORAL TABLET NPB THERAPY PACK 10 & 50 & 100 MG (venetoclax) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 NPSB MG (abemaciclib) VITRAKVI ORAL CAPSULE 100 MG, 25 MG (larotrectinib NPSB sulfate) VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib NPSB sulfate) VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG NF (dacomitinib) VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) PSB XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) NPSB XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) NPB XELODA ORAL TABLET 150 MG, 500 MG (capecitabine) NPSB XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML NF (radium ra 223 dichloride) XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) NF XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) XTANDI ORAL CAPSULE 40 MG (enzalutamide) PSB YONSA ORAL TABLET 125 MG (abiraterone acetate) PSB ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) PSB ZELBORAF ORAL TABLET 240 MG (vemurafenib) NPSB ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 NPSB MG (goserelin acetate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

77 Prescription Drug Name Drug Tier Drug Notes ZOLINZA ORAL CAPSULE 100 MG (vorinostat) PSB ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) NF ZYKADIA ORAL TABLET 150 MG (ceritinib) NPSB *ANTIPARKINSON AND RELATED THERAPY AGENTS* - DRUGS FOR THE NERVOUS SYSTEM amantadine hcl oral capsule 100 mg G amantadine hcl oral syrup 50 mg/5ml G amantadine hcl oral tablet 100 mg G APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE NPSB 30 MG/3ML (apomorphine hcl) benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg G bromocriptine mesylate oral capsule 5 mg G bromocriptine mesylate oral tablet 2.5 mg G carbidopa oral tablet 25 mg G carbidopa-levodopa er oral tablet extended release 25-100 mg, G 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 G mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 G mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150- G 200 mg, 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML NPB (carbidopa-levodopa) entacapone oral tablet 200 mg G GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 137 MG, 68.5 MG (amantadine hcl) INBRIJA INHALATION CAPSULE 42 MG (levodopa) NPSB NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 PB MG/24HR, 8 MG/24HR (rotigotine) OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY NF PACK 129 & 193 MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE NF 24 HOUR 129 MG, 193 MG, 258 MG (amantadine hcl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

78 Prescription Drug Name Drug Tier Drug Notes pramipexole dihydrochloride er oral tablet extended release 24 G hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 G mg, 0.75 mg, 1 mg, 1.5 mg rasagiline mesylate oral tablet 0.5 mg, 1 mg G ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 G mg, 4 mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 G mg, 5 mg RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG NPB (carbidopa-levodopa) selegiline hcl oral capsule 5 mg G selegiline hcl oral tablet 5 mg G tolcapone oral tablet 100 mg G trihexyphenidyl hcl oral solution 0.4 mg/ml G trihexyphenidyl hcl oral tablet 2 mg, 5 mg G XADAGO ORAL TABLET 100 MG, 50 MG (safinamide NF mesylate) ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG NF (selegiline hcl) *ANTIPSYCHOTICS/ANTIMANIC AGENTS* - DRUGS FOR THE NERVOUS SYSTEM ABILIFY MAINTENA INTRAMUSCULAR PREFILLED NPB SYRINGE 300 MG, 400 MG (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG NPB (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, NF 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, NF 30 MG, 5 MG (aripiprazole) ADASUVE INHALATION AEROSOL POWDER NPB BREATH ACTIVATED 10 MG (loxapine) aripiprazole oral solution 1 mg/ml G aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg G aripiprazole oral tablet dispersible 10 mg, 15 mg G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

79 Prescription Drug Name Drug Tier Drug Notes ARISTADA INITIO INTRAMUSCULAR PREFILLED PB SYRINGE 675 MG/2.4ML (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 PB MG/3.2ML (aripiprazole lauroxil) chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml NPB chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, G 50 mg clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg G clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg G clozapine oral tablet dispersible 150 mg, 200 mg NPB CLOZARIL ORAL TABLET 200 MG, 50 MG (clozapine) NPB prochlorperazine (Compro Rectal Suppository 25 Mg) G EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG (carbamazepine NPB (antipsychotic)) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 NF MG, 6 MG, 8 MG (iloperidone) FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & NF 6 MG (iloperidone) fluphenazine decanoate injection solution 25 mg/ml G fluphenazine hcl injection solution 2.5 mg/ml G fluphenazine hcl oral concentrate 5 mg/ml G fluphenazine hcl oral elixir 2.5 mg/5ml G fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg G GEODON INTRAMUSCULAR SOLUTION NF RECONSTITUTED 20 MG (ziprasidone mesylate) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 NF MG (ziprasidone hcl) haloperidol decanoate intramuscular solution 100 mg/ml, 50 G mg/ml haloperidol lactate injection solution 5 mg/ml G haloperidol lactate oral concentrate 2 mg/ml G haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

80 Prescription Drug Name Drug Tier Drug Notes INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, NPB 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML (paliperidone palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 NF MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML (paliperidone palmitate) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 NF MG, 80 MG (lurasidone hcl) lithium carbonate er oral tablet extended release 300 mg, 450 G mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg G lithium carbonate oral tablet 300 mg G lithium oral solution 8 meq/5ml NPB loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg G molindone hcl oral tablet 10 mg, 25 mg, 5 mg G NUPLAZID ORAL CAPSULE 34 MG (pimavanserin NPSB tartrate) NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) NPSB olanzapine intramuscular solution reconstituted 10 mg G olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 G mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg G paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 G mg, 6 mg, 9 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg G PERSERIS SUBCUTANEOUS PREFILLED SYRINGE NF 120 MG, 90 MG (risperidone) prochlorperazine edisylate injection solution 10 mg/2ml, 50 G mg/10ml prochlorperazine maleate oral tablet 10 mg, 5 mg G prochlorperazine rectal suppository 25 mg G quetiapine fumarate er oral tablet extended release 24 hour 150 G mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, G 400 mg, 50 mg 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

81 Prescription Drug Name Drug Tier Drug Notes REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 NPB MG, 3 MG, 4 MG (brexpiprazole) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, NPB 37.5 MG, 50 MG (risperidone microspheres) risperidone oral solution 1 mg/ml G risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg G risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 G mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 NPB MG, 2.5 MG, 5 MG (asenapine maleate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG NF (quetiapine fumarate) thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg G thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg G trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg G VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) NPB VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 PB MG (cariprazine hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 PB MG (cariprazine hcl) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg G ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 NPB MG (olanzapine pamoate) *ANTISEPTICS & DISINFECTANTS* - ANTISEPTICS AND DISINFECTANTS ANASEPT EXTERNAL LIQUID 0.057 % (sodium NF hypochlorite) benzalkonium chloride external solution , 50 % NPB chlorhexidine gluconate solution 20 % NPB formaldehyde external solution 10 % G formaldehyde external solution 37 % NPB glutaraldehyde external solution 25 % NPB hydrogen peroxide solution 30 % G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

82 Prescription Drug Name Drug Tier Drug Notes iodine tincture external tincture 2 % NPB *ANTIVIRALS* - DRUGS FOR INFECTIONS abacavir sulfate oral solution 20 mg/ml G abacavir sulfate oral tablet 300 mg G abacavir sulfate-lamivudine oral tablet 600-300 mg G abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg G acyclovir oral capsule 200 mg G acyclovir oral suspension 200 mg/5ml G acyclovir oral tablet 400 mg, 800 mg G adefovir dipivoxil oral tablet 10 mg G APTIVUS ORAL CAPSULE 250 MG (tipranavir) NPSB APTIVUS ORAL SOLUTION 100 MG/ML (tipranavir) NPSB atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg G ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz- PSB emtricitab-tenofovir) BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) PSB BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- PSB emtricitab-tenofov) CIMDUO ORAL TABLET 300-300 MG (lamivudine- PSB tenofovir) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- NF rilpivir-tenofovir) CRIXIVAN ORAL CAPSULE 200 MG, 400 MG (indinavir NPSB sulfate) DESCOVY ORAL TABLET 200-25 MG (emtricitabine- PSB tenofovir af) didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg G DOVATO ORAL TABLET 50-300 MG (dolutegravir- PSB lamivudine) EDURANT ORAL TABLET 25 MG (rilpivirine hcl) PSB efavirenz oral capsule 200 mg, 50 mg G efavirenz oral tablet 600 mg G EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) PSB EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) PSB entecavir oral tablet 0.5 mg, 1 mg G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

83 Prescription Drug Name Drug Tier Drug Notes EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir- PSB velpatasvir) EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir- IBC (Preferred for all PSB velpatasvir) genotypes) EVOTAZ ORAL TABLET 300-150 MG (atazanavir- PSB cobicistat) famciclovir oral tablet 125 mg, 250 mg, 500 mg G favipiravir oral tablet 200 mg NPB fosamprenavir calcium oral tablet 700 mg G FUZEON SUBCUTANEOUS SOLUTION PSB RECONSTITUTED 90 MG (enfuvirtide) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg- PSB cobic-emtricit-tenofaf) HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG PSB (ledipasvir-sofosbuvir) HARVONI ORAL TABLET 45-200 MG, 90-400 MG IBC (Preferred for PSB (ledipasvir-sofosbuvir) genotypes 1,4,5,6) INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG PSB (etravirine) INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) NPSB ISENTRESS HD ORAL TABLET 600 MG (raltegravir PSB potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir PSB potassium) ISENTRESS ORAL TABLET 400 MG (raltegravir PSB potassium) ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 PSB MG (raltegravir potassium) JULUCA ORAL TABLET 50-25 MG (dolutegravir- NPSB rilpivirine) KALETRA ORAL TABLET 100-25 MG, 200-50 MG PSB (lopinavir-ritonavir) lamivudine oral solution 10 mg/ml G lamivudine oral tablet 100 mg, 150 mg, 300 mg G lamivudine-zidovudine oral tablet 150-300 mg G LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir NPSB calcium) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

84 Prescription Drug Name Drug Tier Drug Notes lopinavir-ritonavir oral solution 400-100 mg/5ml G nevirapine er oral tablet extended release 24 hour 100 mg, 400 G mg nevirapine oral suspension 50 mg/5ml G nevirapine oral tablet 200 mg G NORVIR ORAL PACKET 100 MG (ritonavir) PSB NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) PSB ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab- PSB rilpivir-tenofov af) oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg G oseltamivir phosphate oral suspension reconstituted 6 mg/ml G PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML NPSB (peginterferon alfa-2b) PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) NPB PREZCOBIX ORAL TABLET 800-150 MG (darunavir- PSB cobicistat) PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir PSB ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 PSB MG (darunavir ethanolate) RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER PB (zanamivir) remdesivir intravenous solution reconstituted 150 mg NPB REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG NPSB (atazanavir sulfate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) NPSB ribavirin inhalation solution reconstituted 6 gm G ribavirin oral capsule 200 mg G ribavirin oral tablet 200 mg G rimantadine hcl oral tablet 100 mg G ritonavir oral tablet 100 mg G SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) NPSB SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, NPSB 75 MG (maraviroc)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

85 Prescription Drug Name Drug Tier Drug Notes SITAVIG BUCCAL TABLET 50 MG (acyclovir) NPB SOVALDI ORAL PACKET 150 MG, 200 MG (sofosbuvir) NPSB SOVALDI ORAL TABLET 200 MG, 400 MG (sofosbuvir) NPSB stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg G STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- NF cobic-emtricit-tenofdf) SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- PSB lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- PSB lamivudine-tenofovir) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun- PSB cobic-emtricit-tenofaf) TEMIXYS ORAL TABLET 300-300 MG (lamivudine- PSB tenofovir) tenofovir disoproxil fumarate oral tablet 300 mg G TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG PSB (dolutegravir sodium) TIVICAY PD ORAL TABLET SOLUBLE 5 MG PSB (dolutegravir sodium) TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- PSB dolutegravir-lamivud) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, PSB 167-250 MG, 200-300 MG (emtricitabine-tenofovir df) TYBOST ORAL TABLET 150 MG (cobicistat) NPSB valacyclovir hcl oral tablet 1 gm, 500 mg G VALCYTE ORAL SOLUTION RECONSTITUTED 50 NF MG/ML (valganciclovir hcl) VALCYTE ORAL TABLET 450 MG (valganciclovir hcl) NF valganciclovir hcl oral solution reconstituted 50 mg/ml G valganciclovir hcl oral tablet 450 mg G VALTREX ORAL TABLET 1 GM, 500 MG (valacyclovir NF hcl) VEKLURY INTRAVENOUS SOLUTION 100 MG/20ML NPB (remdesivir) VEKLURY INTRAVENOUS SOLUTION NPB RECONSTITUTED 100 MG (remdesivir)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

86 Prescription Drug Name Drug Tier Drug Notes VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide NPB fumarate) VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir NPSB mesylate) VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil NPSB fumarate) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 NPSB MG (tenofovir disoproxil fumarate) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- IBC (Preferred for all PSB velpatasv-voxilaprev) genotypes) XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY NF PACK 2 X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY NF PACK 2 X 40 MG (baloxavir marboxil) zidovudine oral capsule 100 mg G zidovudine oral syrup 50 mg/5ml G zidovudine oral tablet 300 mg G ZOVIRAX ORAL SUSPENSION 200 MG/5ML (acyclovir) NF *BETA BLOCKERS* - DRUGS FOR THE HEART acebutolol hcl oral capsule 200 mg, 400 mg G atenolol oral tablet 100 mg, 25 mg, 50 mg G LGC BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl) betaxolol hcl oral tablet 10 mg, 20 mg G bisoprolol fumarate oral tablet 10 mg, 5 mg G BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG NF (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg G LGC carvedilol phosphate er oral capsule extended release 24 hour 10 G mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) HEMANGEOL ORAL SOLUTION 4.28 MG/ML NPB (propranolol hcl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

87 Prescription Drug Name Drug Tier Drug Notes INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol NF hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG (propranolol hcl sr NF beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG NF (metoprolol succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg G metoprolol succinate er oral tablet extended release 24 hour 100 G mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg G LGC metoprolol tartrate oral tablet 37.5 mg, 75 mg G nadolol oral tablet 20 mg, 40 mg, 80 mg G pindolol oral tablet 10 mg, 5 mg G propranolol hcl er oral capsule extended release 24 hour 120 mg, G 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml G propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg G LGC propranolol hcl oral tablet 60 mg G sotalol hcl (Sorine Oral Tablet 120 Mg, 80 Mg) G LGC sotalol hcl (Sorine Oral Tablet 160 Mg, 240 Mg) G sotalol hcl (af) oral tablet 120 mg G LGC sotalol hcl (af) oral tablet 160 mg, 80 mg G sotalol hcl oral tablet 120 mg, 80 mg G LGC sotalol hcl oral tablet 160 mg, 240 mg G SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) NPB timolol maleate oral tablet 10 mg, 20 mg, 5 mg G TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG (metoprolol NF succinate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

88 Prescription Drug Name Drug Tier Drug Notes *CALCIUM CHANNEL BLOCKERS* - DRUGS FOR THE HEART amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg G LGC CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, NF 360 MG (diltiazem hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 NF MG (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG NF (diltiazem hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended G Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 NF MG (amlodipine besylate-celecoxib) diltiazem hcl er beads oral capsule extended release 24 hour 120 G mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 G hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 NF hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, G 60 mg, 90 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg G LGC dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, G 240 mg felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, G 5 mg isradipine oral capsule 2.5 mg, 5 mg G KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine NF benzoate) diltiazem hcl coated beads (Matzim La Oral Tablet Extended NF Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) nicardipine hcl oral capsule 20 mg, 30 mg G nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, G 90 mg

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

89 Prescription Drug Name Drug Tier Drug Notes nifedipine er osmotic release oral tablet extended release 24 hour G 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg G nimodipine oral capsule 30 mg G nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, G 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG NF (amlodipine besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) NPB diltiazem hcl er beads (Taztia Xt Oral Capsule Extended G Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) verapamil hcl er oral capsule extended release 24 hour 100 mg, G 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg G LGC verapamil hcl er oral tablet extended release 180 mg, 240 mg G verapamil hcl oral tablet 120 mg, 40 mg, 80 mg G LGC *CARDIOTONICS* - DRUGS FOR THE HEART digoxin (Digitek Oral Tablet 125 Mcg, 250 Mcg) G digoxin (Digox Oral Tablet 125 Mcg, 250 Mcg) G digoxin oral solution 0.05 mg/ml G digoxin oral tablet 125 mcg, 250 mcg G LANOXIN ORAL TABLET 125 MCG, 250 MCG (digoxin) NF LANOXIN ORAL TABLET 62.5 MCG (digoxin) NPB *CARDIOVASCULAR AGENTS - MISC.* - DRUGS FOR THE HEART ABLYSINOL INTRA-ARTERIAL SOLUTION (dehydrated NF alcohol) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, PSB 2.5 MG (riociguat) tadalafil (pah) (Alyq Oral Tablet 20 Mg) G ambrisentan oral tablet 10 mg, 5 mg G amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 G LGC mg, 5-40 mg, 5-80 mg BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- PB hydralazine) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

90 Prescription Drug Name Drug Tier Drug Notes SPC (Only available for bi-mix intracavernosal solution reconstituted 150-5 mg NF select plans) bosentan oral tablet 125 mg, 62.5 mg G cardioplegic perfusion solution G CIALIS ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG SPC (Only available for NF (tadalafil) select plans) CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine NPB hcl) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine PB hcl) ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 PB MG (sacubitril-valsartan) epoprostenol sodium intravenous solution reconstituted 0.5 mg, G 1.5 mg FLOLAN INTRAVENOUS SOLUTION NPSB RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium) LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) NF LEVITRA ORAL TABLET 10 MG, 20 MG (vardenafil hcl) NF OPSUMIT ORAL TABLET 10 MG (macitentan) PSB ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil PSB diolamine) quad-mix intracavernosal solution reconstituted 150-10-0.1-1 NF mg REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 NPSB MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) sildenafil citrate oral suspension reconstituted 10 mg/ml NF sildenafil citrate oral tablet 20 mg G STAXYN ORAL TABLET DISPERSIBLE 10 MG NF (vardenafil hcl) STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG SPC (Only available for NF (avanafil) select plans) SPC (Only available for super bi-mix intracavernosal solution reconstituted 150-10 mg NF select plans) super quad-mix intracavernosal solution reconstituted 150-20- SPC (Only available for NF 0.2-2 mg select plans)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

91 Prescription Drug Name Drug Tier Drug Notes super tri-mix intracavernosal solution reconstituted 150-10-100 SPC (Only available for NF mg-mg-mcg select plans) tadalafil (pah) oral tablet 20 mg G TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) NPSB TRACLEER ORAL TABLET SOLUBLE 32 MG (bosentan) NPSB treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 G mg/20ml, 50 mg/20ml tri-mix intracavernosal solution reconstituted 150-5-50 mg-mg- NF mcg TYVASO INHALATION SOLUTION 0.6 MG/ML NPSB (treprostinil) TYVASO REFILL INHALATION SOLUTION 0.6 NPSB MG/ML (treprostinil) TYVASO STARTER INHALATION SOLUTION 0.6 NPSB MG/ML (treprostinil) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 PSB MCG (selexipag) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 PSB MCG (selexipag) VELETRI INTRAVENOUS SOLUTION NPSB RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium) VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 NPSB MCG/ML (iloprost) VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG SPC (Only available for NF (sildenafil citrate) select plans) VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) NPSB VYNDAQEL ORAL CAPSULE 20 MG (tafamidis NF meglumine (cardiac)) *CEPHALOSPORINS* - DRUGS FOR INFECTIONS cefaclor er oral tablet extended release 12 hour 500 mg NPB cefaclor oral capsule 250 mg, 500 mg G cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, G 375 mg/5ml cefadroxil oral capsule 500 mg G cefadroxil oral suspension reconstituted 250 mg/5ml, 500 G mg/5ml 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

92 Prescription Drug Name Drug Tier Drug Notes cefadroxil oral tablet 1 gm G cefdinir oral capsule 300 mg G cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml G cefixime oral capsule 400 mg G cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml G cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, G 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg G cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml G cefprozil oral tablet 250 mg, 500 mg G cefuroxime axetil oral tablet 250 mg, 500 mg G cephalexin oral capsule 250 mg, 500 mg, 750 mg G cephalexin oral suspension reconstituted 125 mg/5ml, 250 G mg/5ml cephalexin oral tablet 250 mg, 500 mg G FETROJA INTRAVENOUS SOLUTION NPB RECONSTITUTED 1 GM (cefiderocol sulfate tosylate) FORTAZ INJECTION SOLUTION RECONSTITUTED 1 NPB GM, 500 MG (ceftazidime) FORTAZ INTRAVENOUS SOLUTION NPB RECONSTITUTED 2 GM (ceftazidime) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 PB MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG PB (cefixime) *CHEMICALS* almond oil (sweet) oil NPB base g almond oil (sweet) oil NPB benzyl benzoate liquid NPB calcium folinate powder NPB castor oil oil NPB coconut oil oil NPB cottonseed oil oil NPB glycine soya protein solution NPB hydroxyprogesterone caproate powder NPB 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

93 Prescription Drug Name Drug Tier Drug Notes leucovorin calcium powder NPB linseed oil oil NPB macadamia nut oil oil NPB olive oil oil NPB peanut oil oil NPB pyrimethamine powder NPB safflower oil oil NPB sesame oil oil NPB soybean oil oil NPB *CONTRACEPTIVES* - DRUGS FOR WOMEN levonorgestrel-ethinyl estrad (Afirmelle Oral Tablet 0.1-20 Mg- CE Mcg) AFTERA ORAL TABLET 1.5 MG (levonorgestrel) CE levonorgestrel-ethinyl estrad (Altavera Oral Tablet 0.15-30 Mg- CE Mcg) alyacen 1/35 oral tablet 1-35 mg-mcg CE alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg CE levonorgest-eth estrad 91-day (Amethia Lo Oral Tablet 0.1- CE 0.02 & 0.01 Mg) levonorgest-eth estrad 91-day (Amethia Oral Tablet 0.15-0.03 CE &0.01 Mg) levonorgestrel-ethinyl estrad (Amethyst Oral Tablet 90-20 CE Mcg) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR NPB (segesterone-ethinyl estradiol) desogestrel-ethinyl estradiol (Apri Oral Tablet 0.15-30 Mg- CE Mcg) norethin-eth estrad triphasic (Aranelle Oral Tablet 0.5/1/0.5-35 CE Mg-Mcg) levonorgest-eth estrad 91-day (Ashlyna Oral Tablet 0.15-0.03 CE &0.01 Mg) levonorgestrel-ethinyl estrad (Aubra Eq Oral Tablet 0.1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Aubra Oral Tablet 0.1-20 Mg- CE Mcg)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

94 Prescription Drug Name Drug Tier Drug Notes norethindrone acet-ethinyl est (Aurovela 1.5/30 Oral Tablet 1.5- CE 30 Mg-Mcg) norethindrone acet-ethinyl est (Aurovela 1/20 Oral Tablet 1-20 CE Mg-Mcg) norethin ace-eth estrad-fe (Aurovela 24 Fe Oral Tablet 1-20 CE Mg-Mcg(24)) norethin ace-eth estrad-fe (Aurovela Fe 1.5/30 Oral Tablet 1.5- CE 30 Mg-Mcg) norethin ace-eth estrad-fe (Aurovela Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Aviane Oral Tablet 0.1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Ayuna Oral Tablet 0.15-30 Mg- CE Mcg) desogestrel-ethinyl estradiol (Azurette Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) NPB (levonorgest-eth estrad-fe bisg) norethindrone-eth estradiol (Balziva Oral Tablet 0.4-35 Mg- CE Mcg) desogestrel-ethinyl estradiol (Bekyree Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth NF estrad-levomefol) norethin ace-eth estrad-fe (Blisovi 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Blisovi Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Blisovi Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) briellyn oral tablet 0.4-35 mg-mcg CE norethindrone (Camila Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Camrese Lo Oral Tablet 0.1- CE 0.02 & 0.01 Mg) levonorgest-eth estrad 91-day (Camrese Oral Tablet 0.15-0.03 CE &0.01 Mg)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

95 Prescription Drug Name Drug Tier Drug Notes desogestrel-ethinyl estradiol (Caziant Oral Tablet CE 0.1/0.125/0.15 -0.025 Mg) levonorgestrel-ethinyl estrad (Chateal Eq Oral Tablet 0.15-30 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Chateal Oral Tablet 0.15-30 Mg- CE Mcg) norgestrel-ethinyl estradiol (Cryselle-28 Oral Tablet 0.3-30 Mg- CE Mcg) norethindrone-eth estradiol (Cyclafem 1/35 Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Cyclafem 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Eq Oral Tablet 0.15-30 CE Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone-eth estradiol (Dasetta 1/35 Oral Tablet 1-35 Mg- CE Mcg) norethin-eth estrad triphasic (Dasetta 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) levonorgest-eth estrad 91-day (Daysee Oral Tablet 0.15-0.03 CE &0.01 Mg) norethindrone (Deblitane Oral Tablet 0.35 Mg) CE levonorgestrel-ethinyl estrad (Delyla Oral Tablet 0.1-20 Mg- CE Mcg) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML NPB (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg CE (21/5) drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- CE 0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg CE ECONTRA EZ ORAL TABLET 1.5 MG (levonorgestrel) CE ECONTRA ONE-STEP ORAL TABLET 1.5 MG CE (levonorgestrel)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

96 Prescription Drug Name Drug Tier Drug Notes norgestrel-ethinyl estradiol (Elinest Oral Tablet 0.3-30 Mg- CE Mcg) ELLA ORAL TABLET 30 MG (ulipristal acetate) CE etonogestrel-ethinyl estradiol (Eluryng Vaginal Ring 0.12-0.015 CE Mg/24Hr) desogestrel-ethinyl estradiol (Emoquette Oral Tablet 0.15-30 CE Mg-Mcg) levonorg-eth estrad triphasic (Enpresse-28 Oral Tablet 50- CE 30/75-40/ 125-30 Mcg) desogestrel-ethinyl estradiol (Enskyce Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone (Errin Oral Tablet 0.35 Mg) CE norgestimate-eth estradiol (Estarylla Oral Tablet 0.25-35 Mg- CE Mcg) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg- CE mcg etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24hr CE levonorgestrel-ethinyl estrad (Falmina Oral Tablet 0.1-20 Mg- CE Mcg) levonorgest-eth estrad 91-day (Fayosim Oral Tablet 42-21-21-7 CE Days) norgestimate-eth estradiol (Femynor Oral Tablet 0.25-35 Mg- CE Mcg) drospirenone-ethinyl estradiol (Gianvi Oral Tablet 3-0.02 Mg) CE norethindrone acet-ethinyl est (Hailey 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Hailey 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethindrone (Heather Oral Tablet 0.35 Mg) CE norethindrone (Incassia Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Introvale Oral Tablet 0.15-0.03 CE Mg) desogestrel-ethinyl estradiol (Isibloom Oral Tablet 0.15-30 Mg- CE Mcg) drospirenone-ethinyl estradiol (Jasmiel Oral Tablet 3-0.02 Mg) CE norethindrone (Jencycla Oral Tablet 0.35 Mg) CE

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

97 Prescription Drug Name Drug Tier Drug Notes levonorgest-eth estrad 91-day (Jolessa Oral Tablet 0.15-0.03 CE Mg) desogestrel-ethinyl estradiol (Juleber Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone acet-ethinyl est (Junel 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethindrone acet-ethinyl est (Junel 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Junel Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Junel Fe 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Junel Fe 24 Oral Tablet 1-20 Mg- CE Mcg(24)) norethin-eth estradiol-fe (Kaitlib Fe Oral Tablet Chewable 0.8- CE 25 Mg-Mcg) desogestrel-ethinyl estradiol (Kalliga Oral Tablet 0.15-30 Mg- CE Mcg) desogestrel-ethinyl estradiol (Kariva Oral Tablet 0.15-0.02/0.01 CE Mg (21/5)) ethynodiol diac-eth estradiol (Kelnor 1/35 Oral Tablet 1-35 CE Mg-Mcg) ethynodiol diac-eth estradiol (Kelnor 1/50 Oral Tablet 1-50 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Kurvelo Oral Tablet 0.15-30 Mg- CE Mcg) KYLEENA INTRAUTERINE INTRAUTERINE DEVICE CE 19.5 MG (levonorgestrel) norethindrone acet-ethinyl est (Larin 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethindrone acet-ethinyl est (Larin 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Larin 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Larin Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Larin Fe 1/20 Oral Tablet 1-20 Mg- CE Mcg) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

98 Prescription Drug Name Drug Tier Drug Notes levonorgestrel-ethinyl estrad (Larissia Oral Tablet 0.1-20 Mg- CE Mcg) norethin-eth estradiol-fe (Layolis Fe Oral Tablet Chewable 0.8- CE 25 Mg-Mcg) norethin-eth estrad triphasic (Leena Oral Tablet 0.5/1/0.5-35 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Lessina Oral Tablet 0.1-20 Mg- CE Mcg) levonorg-eth estrad triphasic (Levonest Oral Tablet 50-30/75- CE 40/ 125-30 Mcg) levonorgest-eth est & eth est oral tablet 42-21-21-7 days CE levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, CE 0.15-0.03 &0.01 mg, 0.15-0.03 mg levonorgestrel oral tablet 1.5 mg CE levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 CE mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 CE mcg levonorgestrel-ethinyl estrad (Levora 0.15/30 (28) Oral Tablet CE 0.15-30 Mg-Mcg) levonorgestrel-ethinyl estrad (Lillow Oral Tablet 0.15-30 Mg- CE Mcg) LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 CE MCG (norethin-eth estrad-fe biphas) drospirenone-ethinyl estradiol (Loryna Oral Tablet 3-0.02 Mg) CE norgestrel-ethinyl estradiol (Low-Ogestrel Oral Tablet 0.3-30 CE Mg-Mcg) drospirenone-ethinyl estradiol (Lo-Zumandimine Oral Tablet CE 3-0.02 Mg) levonorgestrel-ethinyl estrad (Lutera Oral Tablet 0.1-20 Mg- CE Mcg) norethindrone (Lyza Oral Tablet 0.35 Mg) CE marlissa oral tablet 0.15-30 mg-mcg CE medroxyprogesterone acetate intramuscular suspension 150 CE mg/ml medroxyprogesterone acetate intramuscular suspension prefilled CE syringe 150 mg/ml 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

99 Prescription Drug Name Drug Tier Drug Notes norethin ace-eth estrad-fe (Melodetta 24 Fe Oral Tablet CE Chewable 1-20 Mg-Mcg(24)) norethin ace-eth estrad-fe (Mibelas 24 Fe Oral Tablet CE Chewable 1-20 Mg-Mcg(24)) norethindrone acet-ethinyl est (Microgestin 1.5/30 Oral Tablet CE 1.5-30 Mg-Mcg) norethindrone acet-ethinyl est (Microgestin 1/20 Oral Tablet 1- CE 20 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1.5/30 Oral Tablet CE 1.5-30 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1/20 Oral Tablet 1- CE 20 Mg-Mcg) norgestimate-eth estradiol (Mili Oral Tablet 0.25-35 Mg-Mcg) CE MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 NF MG-MCG(24) (norethin ace-eth estrad-fe) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE CE DEVICE 20 MCG/24HR (levonorgestrel) norgestimate-eth estradiol (Mono-Linyah Oral Tablet 0.25-35 CE Mg-Mcg) MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) CE MY WAY ORAL TABLET 1.5 MG (levonorgestrel) CE NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol NF valerate-dienogest) norethindrone-eth estradiol (Necon 0.5/35 (28) Oral Tablet 0.5- CE 35 Mg-Mcg) NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) CE NEXPLANON SUBCUTANEOUS IMPLANT 68 MG CE (etonogestrel) drospirenone-ethinyl estradiol (Nikki Oral Tablet 3-0.02 Mg) CE norethindrone (Nora-Be Oral Tablet 0.35 Mg) CE norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg CE norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- CE mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg CE norethindrone oral tablet 0.35 mg CE

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

100 Prescription Drug Name Drug Tier Drug Notes norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, CE 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg CE norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25 CE mcg, 0.18/0.215/0.25 mg-35 mcg norethindrone (Norlyda Oral Tablet 0.35 Mg) CE norethindrone (Norlyroc Oral Tablet 0.35 Mg) CE norethindrone-eth estradiol (Nortrel 0.5/35 (28) Oral Tablet CE 0.5-35 Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (21) Oral Tablet 1-35 CE Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (28) Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Nortrel 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) NUVARING VAGINAL RING 0.12-0.015 MG/24HR NPB (etonogestrel-ethinyl estradiol) drospirenone-ethinyl estradiol (Ocella Oral Tablet 3-0.03 Mg) CE OPCICON ONE-STEP ORAL TABLET 1.5 MG CE (levonorgestrel) OPTION 2 ORAL TABLET 1.5 MG (levonorgestrel) CE levonorgestrel-ethinyl estrad (Orsythia Oral Tablet 0.1-20 Mg- CE Mcg) ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.215/0.25 NF MG-25 MCG (norgestim-eth estrad triphasic) PARAGARD INTRAUTERINE COPPER CE INTRAUTERINE INTRAUTERINE DEVICE (copper) norethindrone-eth estradiol (Philith Oral Tablet 0.4-35 Mg- CE Mcg) desogestrel-ethinyl estradiol (Pimtrea Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) norethindrone-eth estradiol (Pirmella 1/35 Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Pirmella 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) levonorgestrel-ethinyl estrad (Portia-28 Oral Tablet 0.15-30 CE Mg-Mcg) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

101 Prescription Drug Name Drug Tier Drug Notes PREVENTEZA ORAL TABLET 1.5 MG (levonorgestrel) CE norgestimate-eth estradiol (Previfem Oral Tablet 0.25-35 Mg- CE Mcg) QUARTETTE ORAL TABLET 42-21-21-7 DAYS NF (levonorgest-eth estrad 91-day) REACT ORAL TABLET 1.5 MG (levonorgestrel) CE desogestrel-ethinyl estradiol (Reclipsen Oral Tablet 0.15-30 CE Mg-Mcg) levonorgest-eth estrad 91-day (Rivelsa Oral Tablet 42-21-21-7 CE Days) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth NPB estrad-levomefol) levonorgest-eth estrad 91-day (Setlakin Oral Tablet 0.15-0.03 CE Mg) norethindrone (Sharobel Oral Tablet 0.35 Mg) CE desogestrel-ethinyl estradiol (Simliya Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) levonorgest-eth estrad 91-day (Simpesse Oral Tablet 0.15-0.03 CE &0.01 Mg) SKYLA INTRAUTERINE INTRAUTERINE DEVICE CE 13.5 MG (levonorgestrel) SLYND ORAL TABLET 4 MG (drospirenone) NF norgestimate-eth estradiol (Sprintec 28 Oral Tablet 0.25-35 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Sronyx Oral Tablet 0.1-20 Mg- CE Mcg) drospirenone-ethinyl estradiol (Syeda Oral Tablet 3-0.03 Mg) CE TAKE ACTION ORAL TABLET 1.5 MG (levonorgestrel) CE norethin ace-eth estrad-fe (Tarina 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Tarina Fe 1/20 Eq Oral Tablet 1-20 CE Mg-Mcg) norethin ace-eth estrad-fe (Tarina Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) NF (norethin ace-eth estrad-fe)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

102 Prescription Drug Name Drug Tier Drug Notes norethindron-ethinyl estrad-fe (Tilia Fe Oral Tablet 1-20/1- CE 30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri Femynor Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Estarylla Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norethindron-ethinyl estrad-fe (Tri-Legest Fe Oral Tablet 1- CE 20/1-30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri-Linyah Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Estarylla Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Marzia Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Mili Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Sprintec Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Mili Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Previfem Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Sprintec Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) levonorg-eth estrad triphasic (Trivora (28) Oral Tablet 50- CE 30/75-40/ 125-30 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Lo Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norethindrone (Tulana Oral Tablet 0.35 Mg) CE drospiren-eth estrad-levomefol (Tydemy Oral Tablet 3-0.03- CE 0.451 Mg) desogestrel-ethinyl estradiol (Velivet Oral Tablet 0.1/0.125/0.15 CE -0.025 Mg) levonorgestrel-ethinyl estrad (Vienva Oral Tablet 0.1-20 Mg- CE Mcg)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

103 Prescription Drug Name Drug Tier Drug Notes viorele oral tablet 0.15-0.02/0.01 mg (21/5) CE norethindrone-eth estradiol (Vyfemla Oral Tablet 0.4-35 Mg- CE Mcg) norgestimate-eth estradiol (Vylibra Oral Tablet 0.25-35 Mg- CE Mcg) norethindrone-eth estradiol (Wera Oral Tablet 0.5-35 Mg-Mcg) CE norethin-eth estradiol-fe (Wymzya Fe Oral Tablet Chewable CE 0.4-35 Mg-Mcg) XULANE TRANSDERMAL PATCH WEEKLY 150-35 CE MCG/24HR (norelgestromin-eth estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl NF estradiol) drospirenone-ethinyl estradiol (Zarah Oral Tablet 3-0.03 Mg) CE ethynodiol diac-eth estradiol (Zovia 1/35E (28) Oral Tablet 1- CE 35 Mg-Mcg) drospirenone-ethinyl estradiol (Zumandimine Oral Tablet 3- CE 0.03 Mg) *CORTICOSTEROIDS* - HORMONES beta 1 kit injection kit 30 mg/5ml NF betamethasone combo injection suspension 6 (3-3) mg/ml, 7 (4- NF 3) mg/ml budesonide er oral tablet extended release 24 hour 9 mg G budesonide oral capsule delayed release particles 3 mg G CELESTONE SOLUSPAN INJECTION SUSPENSION 6 NF (3-3) MG/ML (betamethasone sod phos & acet) CONTRAST ALLERGY PREMED PACK ORAL KIT 3 X NF 50 MG & 1 X 50 MG (prednisone-diphenhydramine hcl) cortisone acetate oral tablet 25 mg G dexamethasone (Decadron Oral Tablet 0.5 Mg, 0.75 Mg, 4 G Mg, 6 Mg) dexamethasone (la) injection suspension 8 mg/ml NF DEXAMETHASONE INTENSOL ORAL NPB CONCENTRATE 1 MG/ML (dexamethasone) dexamethasone oral elixir 0.5 mg/5ml G dexamethasone oral solution 0.5 mg/5ml G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

104 Prescription Drug Name Drug Tier Drug Notes dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, G 4 mg, 6 mg dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg G (35), 1.5 mg (51) dexamethasone sodium phosphate injection solution 10 mg/ml, 4 NPB mg/ml DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 NF MG/5ML (dexamethasone sodium phosphate) DMT SUIK COMBINATION KIT 10 MG/ML (dexameth NF sod phos & anesthetic) DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5 NF MG (dexamethasone) EMFLAZA ORAL SUSPENSION 22.75 MG/ML NF (deflazacort) EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG NF (deflazacort) fludrocortisone acetate oral tablet 0.1 mg G dexamethasone (Hidex 6-Day Oral Tablet Therapy Pack 1.5 G Mg (21)) hydrocortisone oral tablet 10 mg, 20 mg, 5 mg G lidocidex i injection solution 5-10 mg/1.5ml NF MEDROL ORAL TABLET 2 MG (methylprednisolone) NPB MEDROLOAN II SUIK COMBINATION KIT 40 MG/ML NF (methylprednisolone & anesth) MEDROLOAN SUIK COMBINATION KIT 40 MG/ML NF (methylprednisolone & anesth) methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg G methylprednisolone oral tablet therapy pack 4 mg G MILLIPRED DP 12-DAY ORAL TABLET THERAPY NF PACK 5 MG (48) (prednisolone) MILLIPRED ORAL TABLET 5 MG (prednisolone) NF pod-care 100c injection kit 30 mg/5ml NF prednisolone oral solution 15 mg/5ml G prednisolone sodium phosphate oral solution 10 mg/5ml, 15 G mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

105 Prescription Drug Name Drug Tier Drug Notes prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 G mg, 30 mg PREDNISONE INTENSOL ORAL CONCENTRATE 5 NPB MG/ML (prednisone) prednisone oral solution 5 mg/5ml G prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg G prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 G mg (21), 5 mg (48) PRO-C-DURE 6 INJECTION KIT 3 X 40 MG/ML NF (triamcinolone acetonide) RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2 NF MG, 5 MG (prednisone) READYSHARP ANESTH + DEXAMETH INJECTION KIT 10 & 0.5 & 1 MG/ML-%-% (dexameth sod phos-bupiv- NF lido) READYSHARP ANESTH + METHYLPRED INJECTION KIT 80 & 0.5 & 1 MG/ML-%-% (methylprednisol & bupiv & NF lido) READYSHARP BETAMETHASONE INJECTION KIT 30 NF MG/5ML (betamethasone sod phos & acet) READYSHARP DEXAMETHASONE INJECTION KIT 10 NF MG/ML (dexamethasone sodium phosphate) ROPIDEX INJECTION KIT 10-0.5 MG/ML-% (dexamet sod NF phos pf & ropiv pf) TAPERDEX 12-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (49) (dexamethasone) dexamethasone (Taperdex 6-Day Oral Tablet Therapy Pack NF 1.5 Mg) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (27) (dexamethasone) UCERIS ORAL TABLET EXTENDED RELEASE 24 NF HOUR 9 MG (budesonide) ZILRETTA INTRA-ARTICULAR SUSPENSION NF RECONSTITUTED ER 32 MG (triamcinolone acetonide) *COUGH/COLD/ALLERGY* - DRUGS FOR THE LUNGS acetylcysteine inhalation solution 10 %, 20 % G benzonatate oral capsule 100 mg, 200 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

106 Prescription Drug Name Drug Tier Drug Notes pseudoeph-bromphen-dm (Bromfed Dm Oral Syrup 30-2-10 G Mg/5Ml) CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR 2.5-120 MG (desloratadine- NPB pseudoephedrine) g tussin ac oral solution 100-10 mg/5ml G GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- NPB guaifenesin) GILTUSS TR ORAL TABLET 10-28-388 MG NPB (phenylephrine-dm-gg) guaiatussin ac oral syrup 100-10 mg/5ml G guaifenesin-codeine oral solution 100-10 mg/5ml G hydrocod polst-cpm polst er oral suspension extended release 10- G 8 mg/5ml hydrocodone-homatropine oral syrup 5-1.5 mg/5ml G hydrocodone-homatropine oral tablet 5-1.5 mg G hydromet oral syrup 5-1.5 mg/5ml G HYPERSAL INHALATION NEBULIZATION NPB SOLUTION 3.5 % (sodium chloride) NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML NPB (phenylephrine-chlorphen-dm) promethazine-codeine oral solution 6.25-10 mg/5ml G promethazine-codeine oral syrup 6.25-10 mg/5ml G promethazine-dm oral syrup 6.25-15 mg/5ml G promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml G promethazine-phenylephrine oral syrup 6.25-5 mg/5ml G pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml G SEMPREX-D ORAL CAPSULE 8-60 MG (acrivastine- NPB pseudoephedrine) sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 G %, 7 % TUSNEL C ORAL SYRUP 30-10-100 MG/5ML NPB (pseudoephedrine-codeine-gg) TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 NPB HOUR 10-8 MG (hydrocod polst-chlorphen polst)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

107 Prescription Drug Name Drug Tier Drug Notes TUXARIN ER ORAL TABLET EXTENDED RELEASE NF 12 HOUR 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED NF RELEASE 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) virtussin a/c oral solution 100-10 mg/5ml G virtussin dac oral solution 30-10-100 mg/5ml G *DERMATOLOGICALS* - DRUGS FOR THE SKIN 1st relief spray external liquid 4-1 % NF lidocaine hcl (7T Lido External Gel 2 %) G A.A.G.C. KIT IN TERODERM EXTERNAL CREAM 8-4- NF 10-4 % (amantad-amitrip-gabap-cycloben) ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 NPB MG, 35 MG, 40 MG (isotretinoin) ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- NF benzoyl perox) ACCUCAINE COMBINATION KIT 1 % (lido-pentaf- NF tetrafl-ultrasound) aceso ag external pad 4"x4" NF acitretin oral capsule 10 mg, 17.5 mg, 25 mg G ACTICOAT 7 EXTERNAL PAD 2"X2" , 4"X5" (silver) NPB ACTICOAT ABSORBENT EXTERNAL PAD 4"X5" (silver) NPB ACTICOAT ANTIMICROBIAL EXTERNAL PAD 2"X2" , NPB 4"X4" (silver) ACTICOAT FLEX 3 4"X4" EXTERNAL PAD (wound NPB dressings) active-prep kit i external cream NF active-prep kit ii external cream NF active-prep kit iii external cream NF active-prep kit iv external cream NF active-prep kit v external cream NF ACUICYN EXTERNAL SOLUTION (eyelid cleansers) NF acyclovir external cream 5 % NF acyclovir external ointment 5 % G ACZONE EXTERNAL GEL 7.5 % (dapsone) NPB adapalene external cream 0.1 % G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

108 Prescription Drug Name Drug Tier Drug Notes adapalene external gel 0.1 %, 0.3 % G adapalene external pad 0.1 % NF adapalene-benzoyl peroxide external gel 0.1-2.5 % G ADVANCED ALLERGY COLLECTION EXTERNAL NF KIT 2.5 % (hydrocortisone) ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) NPB ala-cort external cream 1 %, 2.5 % G ALA-QUIN EXTERNAL CREAM 3-0.5 % (clioquinol-hc) NF alclometasone dipropionate external cream 0.05 % G alclometasone dipropionate external ointment 0.05 % G ALCORTIN A EXTERNAL GEL 1-2-1 % (iodoquinol-hc- NF aloe polysacch) ALDARA EXTERNAL CREAM 5 % (imiquimod) NF alevamax external cream NPB ALEVICYN ANTIPRURITIC EXTERNAL GEL NF (dermatological products, misc.) ALEVICYN ANTIPRURITIC SG EXTERNAL GEL NF (dermatological products, misc.) ALEVICYN DERMAL SPRAY EXTERNAL SOLUTION NF (wound cleansers) ALLEVYN AG ADHESIVE EXTERNAL PAD NPB 12.5X12.5CM , 17.5X17.5CM , 7.5X7.5CM (silver) ALLEVYN AG NON-ADHESIVE EXTERNAL PAD NPB 2"X2" , 4"X4" , 6"X6" , 8"X8" (silver) ALLEVYN AG SACRUM 6-3/4" EXTERNAL (silver) NPB ALLEVYN AG SACRUM 9"X9" EXTERNAL (silver) NPB ALLEVYN GENTLE EXTERNAL PAD (wound dressings) NPB ALOCANE EMERGENCY BURN MAX STR NF EXTERNAL GEL 4 % (lidocaine hcl) ALTABAX EXTERNAL OINTMENT 1 % (retapamulin) NPB ALTRENO EXTERNAL LOTION 0.05 % (tretinoin) NF amcinonide external cream 0.1 % G amcinonide external lotion 0.1 % G amcinonide external ointment 0.1 % NPB AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

109 Prescription Drug Name Drug Tier Drug Notes ammonium lactate external cream 12 % G ammonium lactate external lotion 12 % G isotretinoin (Amnesteem Oral Capsule 10 Mg, 20 Mg, 40 Mg) G ANACAINE EXTERNAL OINTMENT 10 % (benzocaine) NPB APEXICON E EXTERNAL CREAM 0.05 % (diflorasone NF diacet emoll base) APRIZIO PAK EXTERNAL KIT 2.5-2.5 % (lidocaine- NF prilocaine-dressing) AQUACEL AG BURN EXTERNAL PAD 4"X5" (silver- NF carboxymethylcellulose) ARAZLO EXTERNAL LOTION 0.045 % (tazarotene) NPB arnica flower tincture NPB ASTERO EXTERNAL GEL 4 % (lidocaine hcl) NF atopaderm external cream NF ATOPICLAIR EXTERNAL CREAM (dermatological NPB products, misc.) ATRALIN EXTERNAL GEL 0.05 % (tretinoin) NF ATRAPRO HYDROGEL EXTERNAL GEL (wound NF dressings) AVENOVA EXTERNAL SOLUTION 0.01 % (eyelid NF cleansers) tretinoin (Avita External Cream 0.025 %) G tretinoin (Avita External Gel 0.025 %) G azelaic acid external gel 15 % G AZELEX EXTERNAL CREAM 20 % (azelaic acid) NF balsam peru-castor oil external ointment NF beau rx external gel NF bensal hp external ointment 3-6 % NF BENZACLIN EXTERNAL GEL 1-5 % (clindamycin phos- NF benzoyl perox) BENZACLIN WITH PUMP EXTERNAL GEL 1-5 % NF (clindamycin phos-benzoyl perox) benzoyl peroxide (Benzepro External Foam 5.3 %) G benzoyl peroxide (Benzepro Short Contact External Foam 9.8 G %)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

110 Prescription Drug Name Drug Tier Drug Notes benzoin external tincture NPB benzoyl perox-hydrocortisone external lotion 5-0.5 % G benzoyl peroxide external foam 9.8 % G benzoyl peroxide-erythromycin external gel 5-3 % G BESER EXTERNAL KIT 0.05 % (fluticasone-emollient) NF fluticasone propionate (Beser External Lotion 0.05 %) G betamethasone dipropionate aug external cream 0.05 % G betamethasone dipropionate aug external gel 0.05 % G betamethasone dipropionate aug external lotion 0.05 % G betamethasone dipropionate aug external ointment 0.05 % G betamethasone dipropionate external cream 0.05 % G betamethasone dipropionate external lotion 0.05 % G betamethasone dipropionate external ointment 0.05 % G betamethasone valerate external cream 0.1 % G betamethasone valerate external foam 0.12 % G betamethasone valerate external lotion 0.1 % G betamethasone valerate external ointment 0.1 % G BIONECT EXTERNAL FOAM 0.2 % (hyaluronate sodium) NF boric acid external granules NPB bp wash external liquid 2.5 %, 7 % G bpco external ointment NF BRYHALI EXTERNAL LOTION 0.01 % (halobetasol PB propionate) CADIRAMD EXTERNAL KIT 2.5-2.5 % (lido-prilocaine- NF blood collect) calcipotriene external cream 0.005 % NF calcipotriene external ointment 0.005 % G calcipotriene external solution 0.005 % G calcipotriene-betameth diprop external ointment 0.005-0.064 % G calcipotriene (Calcitrene External Ointment 0.005 %) G calcitriol external ointment 3 mcg/gm NF CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone NF acetonide) CARAC EXTERNAL CREAM 0.5 % (fluorouracil) NF 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

111 Prescription Drug Name Drug Tier Drug Notes scar treatment products (Celacyn External Gel) G CENTANY EXTERNAL OINTMENT 2 % (mupirocin) NPB CERACADE EXTERNAL EMULSION (dermatological NF products, misc.) CETACAINE EXTERNAL LIQUID 2-2-14 % (butamben- NF tetracaine-benzocaine) ciclopirox (Ciclodan External Solution 8 %) G ciclopirox external gel 0.77 % G ciclopirox external shampoo 1 % G ciclopirox external solution 8 % G ciclopirox olamine external cream 0.77 % G ciclopirox olamine external suspension 0.77 % G isotretinoin (Claravis Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) clindamycin phosphate (Clindacin Etz External Swab 1 %) G clindamycin phosphate (Clindacin-P External Swab 1 %) G CLINDAGEL EXTERNAL GEL 1 % (clindamycin NF phosphate) clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, G 1.2-5 % clindamycin phosphate external foam 1 % G clindamycin phosphate external gel 1 % NF clindamycin phosphate external lotion 1 % G clindamycin phosphate external solution 1 % G clindamycin phosphate external swab 1 % G clindamycin-tretinoin external gel 1.2-0.025 % G CLINOIN EXTERNAL CREAM 1.25-0.025-1 % NF (clindamycin-tretinoin-cholesty) clobetasol prop emollient base external cream 0.05 % G clobetasol propionate e external cream 0.05 % G clobetasol propionate emulsion external foam 0.05 % G clobetasol propionate external cream 0.05 % G clobetasol propionate external foam 0.05 % G clobetasol propionate external gel 0.05 % G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

112 Prescription Drug Name Drug Tier Drug Notes clobetasol propionate external liquid 0.05 % NF clobetasol propionate external lotion 0.05 % G clobetasol propionate external ointment 0.05 % G clobetasol propionate external shampoo 0.05 % G clobetasol propionate external solution 0.05 % G CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol NF propionate) CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & NF cleanser) clobetasol propionate (Clodan External Shampoo 0.05 %) G CLODERM EXTERNAL CREAM 0.1 % (clocortolone NPB pivalate) clotrimazole external cream 1 % G clotrimazole external solution 1 % G clotrimazole-betamethasone external cream 1-0.05 % G clotrimazole-betamethasone external lotion 1-0.05 % G coal tar external solution 20 % G COLLATYL EXTERNAL GEL (silver) NF CONDYLOX EXTERNAL GEL 0.5 % (podofilox) NPB COPASIL EXTERNAL GEL (scar treatment products) NPB CORDRAN EXTERNAL CREAM 0.025 % (flurandrenolide) NPB CORDRAN EXTERNAL OINTMENT 0.05 % NF (flurandrenolide) CORDRAN EXTERNAL TAPE 4 MCG/SQCM NF (flurandrenolide) CORTISPORIN EXTERNAL CREAM 3.5-10000-0.5 NPB (neomycin-polymyxin-hc) CORTISPORIN EXTERNAL OINTMENT 1 % (bacit-poly- NPB neo hc) IBC (Preferred agent for COSENTYX (300 MG DOSE) SUBCUTANEOUS Ankylosing Spondylitis and SOLUTION PREFILLED SYRINGE 150 MG/ML PSB Psoriatic Arthritis. Not (secukinumab) covered for Psoriasis)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

113 Prescription Drug Name Drug Tier Drug Notes IBC (Preferred agent for COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS Ankylosing Spondylitis and PSB SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis) IBC (Preferred agent for COSENTYX SENSOREADY PEN SUBCUTANEOUS Ankylosing Spondylitis and PSB SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis.) IBC (Preferred agent for COSENTYX SUBCUTANEOUS SOLUTION PREFILLED Ankylosing Spondylitis and PSB SYRINGE 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis) CROTAN EXTERNAL LOTION 10 % (crotamiton) G CURITY HYPERTONIC NACL STRIP EXTERNAL NPB (wound dressings) CURITY NACL DRESSING 6"X6-3/4" EXTERNAL PAD NPB (wound dressings) dapsone external gel 5 % G DENAVIR EXTERNAL CREAM 1 % (penciclovir) NF DERMACINRX CLORHEXACIN EXTERNAL KIT 4 & 2 NF & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) DERMACINRX DUOPATCH PHARMAPAK EXTERNAL THERAPY PACK 5 & 3-10 % (methyl NF salicylate-lido-menthol) DERMACINRX LEXITRAL PHARMAPAK COMBINATION THERAPY PACK 1.5 & 0.025 % NF (diclofenac sodium-capsaicin) DERMACINRX NEUROTRAL PHARMAPAK EXTERNAL THERAPY PACK 5 & 0.025 % (lidocaine- NF capsaicin) DERMACINRX PHN EXTERNAL THERAPY PACK 5 & NF 5 % (lidocaine-dimethicone) dermacinrx surgical combopak combination kit NF DERMACINRX SURGICAL PHARMAPAK EXTERNAL NF KIT 4 & 2 & 5 % (CREAM) (chlorhex-mupir-dimeth-silicone) DERMACINRX THERAZOLE PAK EXTERNAL THERAPY PACK 1-0.05 & 20 % (clotrimazole-betameth & zn NF ox)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

114 Prescription Drug Name Drug Tier Drug Notes DERMACINRX ZRM EXTERNAL THERAPY PACK 5 % NF (lidocaine-emollient) dermovix external patch 2-30 % NF DERMULCERA EXTERNAL OINTMENT (balsam peru- NF castor oil) DESONATE EXTERNAL GEL 0.05 % (desonide) NPB desonide external cream 0.05 % G desonide external lotion 0.05 % G desonide external ointment 0.05 % G desoximetasone external cream 0.05 %, 0.25 % G desoximetasone external gel 0.05 % G desoximetasone external liquid 0.25 % G desoximetasone external ointment 0.05 %, 0.25 % G DEXERYL EXTERNAL CREAM (dermatological products, NPB misc.) dfs/ms/menth/cap pak combination kit 1.5 % NF DIAB EXTERNAL GEL (wound dressings) NPB DIAB F.D.G. FREEZE-DRIED EXTERNAL GEL (wound NPB dressings) diclofenac epolamine external patch 1.3 % G diclofenac sodium external gel 3 % G diclofenac sodium external solution 1.5 % G DICLOFONO EXTERNAL GEL 1.6 % (diclofenac sodium) NF diclopr external kit 1 & 10-30 % NF diclosaicin combination therapy pack 1.5 & 0.025 % NF diclovix combination kit 1.5 & 2-2.5-4 % NF diclozor external therapy pack 1 % NF diflorasone diacetate external cream 0.05 % NF diflorasone diacetate external ointment 0.05 % NF dimentho external therapy pack 1.5 & 10 % NF doxepin hcl external cream 5 % NF doxycycline oral capsule delayed release 40 mg G DRYSOL EXTERNAL SOLUTION 20 % (aluminum NPB chloride)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

115 Prescription Drug Name Drug Tier Drug Notes dual complex formula 1 kit external cream NF DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol NPB prop-tazarotene) DUPIXENT SUBCUTANEOUS SOLUTION PEN- PSB INJECTOR 300 MG/2ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED PSB SYRINGE 200 MG/1.14ML, 300 MG/2ML (dupilumab) econazole nitrate external cream 1 % G ECOZA EXTERNAL FOAM 1 % (econazole nitrate) NF ELETONE EXTERNAL CREAM (dermatological products, NPB misc.) ELIDEL EXTERNAL CREAM 1 % (pimecrolimus) NPB ELLZIA PAK EXTERNAL THERAPY PACK 0.1 & 5 % NF (triamcinolone acet-dimethicone) EMULSION SB EXTERNAL EMULSION (dermatological NPB products, misc.) enovarx-diclofenac sodium external cream 2.5 % NF ENSTILAR EXTERNAL FOAM 0.005-0.064 % NPB (calcipotriene-betameth diprop) ENTTY SPRAY EXTERNAL EMULSION (dermatological NF products, misc.) EPICERAM EXTERNAL EMULSION (dermatological NF products, misc.) EPICYN EXTERNAL SOLUTION (hypochlorous acid) NF EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- PB benzoyl peroxide) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) NPB ERTACZO EXTERNAL CREAM 2 % (sertaconazole nitrate) NF ery external pad 2 % G erythromycin external gel 2 % G erythromycin external solution 2 % G ESKATA EXTERNAL SOLUTION 40 % (hydrogen NF peroxide) essentra wipes 9x9" external 70 % NPB EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) PB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

116 Prescription Drug Name Drug Tier Drug Notes EXELDERM EXTERNAL CREAM 1 % (sulconazole NPB nitrate) EXELDERM EXTERNAL SOLUTION 1 % (sulconazole NPB nitrate) EXODERM EXTERNAL LOTION 25-1 % (sod thiosulfate- NPB salicylic acd) EXTINA EXTERNAL FOAM 2 % (ketoconazole) NPB FABIOR EXTERNAL FOAM 0.1 % (tazarotene) NF FINACEA EXTERNAL FOAM 15 % (azelaic acid) PB FINACEA EXTERNAL GEL 15 % (azelaic acid) NF FLECTOR EXTERNAL PATCH 1.3 % (diclofenac NF epolamine) fluocinolone acetonide body external oil 0.01 % G fluocinolone acetonide external cream 0.01 %, 0.025 % G fluocinolone acetonide external ointment 0.025 % G fluocinolone acetonide external solution 0.01 % G fluocinolone acetonide scalp external oil 0.01 % G fluocinonide emulsified base external cream 0.05 % G fluocinonide external cream 0.05 % G fluocinonide external cream 0.1 % NF fluocinonide external gel 0.05 % G fluocinonide external ointment 0.05 % G fluocinonide external solution 0.05 % G FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) NF fluorouracil external cream 0.5 % NF fluorouracil external cream 5 % G fluorouracil external solution 2 %, 5 % G fluovix external therapy pack 0.1 % NF flurandrenolide external cream 0.05 % G flurandrenolide external lotion 0.05 % NF flurandrenolide external ointment 0.05 % NF fluticasone propionate external cream 0.05 % G fluticasone propionate external lotion 0.05 % G fluticasone propionate external ointment 0.005 % G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

117 Prescription Drug Name Drug Tier Drug Notes fungimez external solution NF GEBAUERS PAIN EASE EXTERNAL AEROSOL NPB (pentafluoroprop-tetrafluoroeth) GEBAUERS SPRAY AND STRETCH EXTERNAL NPB AEROSOL (pentafluoroprop-tetrafluoroeth) GENADUR EXTERNAL LIQUID (dermatological products, NPB misc.) gentamicin sulfate external cream 0.1 % G gentamicin sulfate external ointment 0.1 % G glycolic acid solution 70 % NPB lidocaine hcl (Glydo External Prefilled Syringe 2 %) G g-myco nail external solution NF GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % NPB (salicylic acid-lactic acid) halcinonide external cream 0.1 % G halobetasol propionate external cream 0.05 % G halobetasol propionate external foam 0.05 % NF halobetasol propionate external ointment 0.05 % G HALOG EXTERNAL CREAM 0.1 % (halcinonide) NF HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) NF HALOG EXTERNAL SOLUTION 0.1 % (halcinonide) NF HPR PLUS EXTERNAL CREAM (dermatological products, NPB misc.) HPR PLUS EXTERNAL FOAM (dermatological products, NPB misc.) HPR PLUS HYDROGEL EXTERNAL KIT (dermatological NPB products, misc.) hyalucil-4 transdermal cream 2-4 % NF HYCLODEX EXTERNAL SOLUTION 0.012 % NF (hypochlorous acid) hydrocortisone butyr lipo base external cream 0.1 % NF hydrocortisone butyrate external cream 0.1 % NF hydrocortisone butyrate external lotion 0.1 % G hydrocortisone butyrate external ointment 0.1 % G hydrocortisone butyrate external solution 0.1 % G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

118 Prescription Drug Name Drug Tier Drug Notes hydrocortisone external cream 1 %, 2.5 % G hydrocortisone external lotion 2.5 % G hydrocortisone external ointment 1 %, 2.5 % G hydrocortisone valerate external cream 0.2 % G hydrocortisone valerate external ointment 0.2 % G HYDROFERA BLUE 6"X6" EXTERNAL PAD (wound NPB dressings) HYDROFERA BLUE FOAM DRESSING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE FOAM/TUNNELING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE MRF DRESSING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE READY FOAM EXTERNAL PAD NPB (wound dressings) hygel external gel 2.5 % NF HYLATOPIC PLUS EXTERNAL CREAM (dermatological NPB products, misc.) HYPOCYN EXTERNAL SOLUTION (eyelid cleansers) NF ICY HOT PM EXTERNAL PATCH 0.025-5 % (capsaicin- NF menthol) imiquimod external cream 5 % G imiquimod pump external cream 3.75 % G IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol NF propionate) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg G JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) NF KAMDOY EXTERNAL EMULSION (dermatological NF products, misc.) KELARX EXTERNAL GEL (scar treatment products) NF KENALOG EXTERNAL AEROSOL SOLUTION 0.147 NF MG/GM (triamcinolone acetonide) KENDALL ALGINATE 12" ROPE EXTERNAL (wound NPB dressings) KENDALL ALGINATE DRESS 2"X2" EXTERNAL PAD NPB (wound dressings)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

119 Prescription Drug Name Drug Tier Drug Notes KENDALL ALGINATE DRESS 4"X4" EXTERNAL PAD NPB (hydroactive dressings) KENDALL ALGINATE DRESS 4"X8" EXTERNAL PAD NPB (wound dressings) KENDALL AMORPHOUS WOUND EXTERNAL GEL NPB (wound dressings) KENDALL HYDROGEL GAUZE 2"X2" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL GAUZE 4"X4" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL GAUZE 4"X8" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL WOUND DRESS EXTERNAL NPB (hydroactive dressings) KERAGEL EXTERNAL GEL (wound dressings) NPB KERAGELT EXTERNAL GEL (wound dressings) NPB KERAMATRIX REPLICINE 10CMX10CM EXTERNAL NPB SHEET (wound dressings) KERAMATRIX REPLICINE 5CMX5CM EXTERNAL NPB SHEET (wound dressings) KERYDIN EXTERNAL SOLUTION 5 % (tavaborole) NF ketoconazole external cream 2 % G ketoconazole external foam 2 % NF ketoconazole external shampoo 2 % G ketoconazole (Ketodan External Foam 2 %) NF KETOPHENE RAPIDPAQ EXTERNAL CREAM 20 % NF (ketoprofen) KIVIK EXTERNAL EMULSION (dermatological products, NF misc.) L.E.T. EXTERNAL GEL 4-0.05-0.5 % (lido-epinephrine- NF tetracaine) lactic acid e external cream 10-3500 %-unt/30gm G lactic acid external lotion 10 % G LDO PLUS EXTERNAL GEL 4 % (lidocaine hcl) NF LEVICYN EXTERNAL GEL (dermatological products, NF misc.)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

120 Prescription Drug Name Drug Tier Drug Notes LEVULAN KERASTICK EXTERNAL SOLUTION NPB RECONSTITUTED 20 % (aminolevulinic acid hcl) LEXETTE EXTERNAL FOAM 0.05 % (halobetasol NF propionate) lidocaine external ointment 5 % G lidocaine external patch 5 % G lidocaine hcl external solution 4 % G lidocaine hcl urethral/mucosal external gel 2 % G lidocaine hcl urethral/mucosal external prefilled syringe 2 % G lidocaine-prilocaine external cream 2.5-2.5 % G lidocaine-tetracaine external cream 23-7 % NF lidocaine-tetracaine external cream 7-7 % NF LIDOCARE ARM/NECK/LEG EXTERNAL PATCH 4 % NF (lidocaine) LIDOCARE BACK/SHOULDER EXTERNAL PATCH 4 NF % (lidocaine) LIDODERM EXTERNAL PATCH 5 % (lidocaine) NPB lidopac external kit 5 % NF lidopin external cream 3.25 % NF LIDOPURE PATCH EXTERNAL KIT 5 % (lidocaine- NF adhesive sheets) LIDOTHOL EXTERNAL GEL 4.5-5 % (lidocaine-menthol) NF LIDOTHOL EXTERNAL PATCH 4.5-5 % (lidocaine- NF menthol) LIDOTRAL EXTERNAL CREAM 3.88 % (lidocaine hcl) NF LIDOTREX EXTERNAL GEL 2 % (lidocaine-collagen-aloe NF vera) lindane external shampoo 1 % G LMR PLUS EXTERNAL KIT 5 & 0.5-0.5 % (lidocaine- NF camphor-menthol) LOPROX EXTERNAL CREAM 0.77 % (ciclopirox olamine) NF LOPROX EXTERNAL KIT 0.77 % (SUSP) (ciclopirox NF olamine-cleanser) LOPROX EXTERNAL SUSPENSION 0.77 % (ciclopirox NF olamine)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

121 Prescription Drug Name Drug Tier Drug Notes LOYON EXTERNAL SOLUTION (dermatological products, NPB misc.) luliconazole external cream 1 % G LUXAMEND EXTERNAL CREAM (wound dressings) NPB LUXIQ EXTERNAL FOAM 0.12 % (betamethasone valerate) NF LUZU EXTERNAL CREAM 1 % (luliconazole) NF mafenide acetate external packet 5 % G malathion external lotion 0.5 % G MENTAX EXTERNAL CREAM 1 % (butenafine hcl) NPB methoxsalen rapid oral capsule 10 mg G METROGEL EXTERNAL GEL 1 % (metronidazole) NF metronidazole external cream 0.75 % G metronidazole external gel 0.75 %, 1 % G metronidazole external lotion 0.75 % G miconazole-zinc oxide-petrolat external ointment 0.25-15-81.35 G % MICROCYN EXTERNAL LIQUID 0.023 % (wound NPB cleansers) MIMYX EXTERNAL CREAM (dermatological products, NPB misc.) MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) NPB mometasone furoate external cream 0.1 % G mometasone furoate external ointment 0.1 % G mometasone furoate external solution 0.1 % G mupirocin calcium external cream 2 % NF mupirocin external ointment 2 % G MYCO NAIL EXTERNAL SOLUTION , 25 % (misc NF antifungal combo products) isotretinoin (Myorisan Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) naftifine hcl external cream 1 %, 2 % G NAFTIN EXTERNAL CREAM 2 % (naftifine hcl) NF NAFTIN EXTERNAL GEL 1 %, 2 % (naftifine hcl) NF NEOCERA EXTERNAL CREAM (dermatological products, NPB misc.) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

122 Prescription Drug Name Drug Tier Drug Notes NEOSALUS CP EXTERNAL CREAM (dermatological NPB products, misc.) NEOSALUS EXTERNAL CREAM (dermatological NPB products, misc.) NEOSALUS EXTERNAL FOAM (dermatological products, NPB misc.) NEOSALUS EXTERNAL LOTION (dermatological NPB products, misc.) NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % NF (neomycin-fluocinolone) NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % (neo- NF fluocinolone & emollient) clindamycin-benzoyl per (refr) (Neuac External Gel 1.2-5 %) G NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- NF moist) NIVATOPIC PLUS EXTERNAL CREAM (dermatological NPB products, misc.) flurandrenolide (Nolix External Cream 0.05 %) G flurandrenolide (Nolix External Lotion 0.05 %) G NORITATE EXTERNAL CREAM 1 % (metronidazole) NF NOVACORT EXTERNAL GEL 1-2 % (pramoxine-hc) NF NUCARACLINPAK EXTERNAL KIT 1 % (clindamycin NF phos- moisturizer) NUCARARXPAK EXTERNAL KIT 1-2.5 % (clindamycin- NF benzoyl per-moist) NUDERMRXPAK 120 EXTERNAL THERAPY PACK NF 0.005-5 % (calcipotriene-dimethicone) NUDERMRXPAK 60 EXTERNAL THERAPY PACK NF 0.005-5 % (calcipotriene-dimethicone) diclofenac sodium-capsaicin (Nudiclo Solupak Combination NF Therapy Pack 1.5 & 0.025 %) NUSURGEPAK SURGICAL PREP/CARE EXTERNAL NF KIT 4 & 2 & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) NUTRASEB EXTERNAL CREAM (antiseborrheic products, NPB misc.) NUVAIL EXTERNAL SOLUTION (dermatological NPB products, misc.) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

123 Prescription Drug Name Drug Tier Drug Notes nystatin (Nyamyc External Powder 100000 Unit/Gm) G nystatin external cream 100000 unit/gm G nystatin external ointment 100000 unit/gm G nystatin external powder 100000 unit/gm G nystatin-triamcinolone external cream 100000-0.1 unit/gm-% G nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% G nystatin (Nystop External Powder 100000 Unit/Gm) G OLUX-E EXTERNAL FOAM 0.05 % (clobetasol propionate NF emulsion) ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- PB benzoyl perox) ORMECA COMBINATION KIT 3 & 46-0.4-1.1 %-MG NF (diclofenac-b6-fa-b12) OVACE PLUS EXTERNAL FOAM 9.8 % (sulfacetamide NF sodium) oxiconazole nitrate external cream 1 % NF OXISTAT EXTERNAL CREAM 1 % (oxiconazole nitrate) NF OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) NF OXSORALEN ULTRA ORAL CAPSULE 10 MG NF (methoxsalen rapid) paingo kft external kit 2.5-2.5-10-30 % NF PALMERS SCAR SERUM EXTERNAL LIQUID (scar NF treatment products) PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone NPB probutate) PANRETIN EXTERNAL GEL 0.1 % (alitretinoin) NPB PENLEN EXTERNAL EMULSION (dermatological NF products, misc.) PENNSAID EXTERNAL SOLUTION 2 % (diclofenac NF sodium) permethrin external cream 5 % G PHLAG SPRAY EXTERNAL EMULSION (dermatological NPB products, misc.) PICATO EXTERNAL GEL 0.015 %, 0.05 % (ingenol NF mebutate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

124 Prescription Drug Name Drug Tier Drug Notes PICO WOUND THERAPY SYSTEM EXTERNAL KIT NPB (wound dressings) pimecrolimus external cream 1 % G PLIAGLIS EXTERNAL CREAM 7-7 % (lidocaine- NF tetracaine) podofilox external solution 0.5 % G PR BENZOYL PEROXIDE EXTERNAL LIQUID 6.9 % NPB (benzoyl peroxide) benzoyl peroxide (Pr Benzoyl Peroxide Wash External Liquid 7 G %) PR CREAM EXTERNAL KIT (dermatological products, NPB misc.) PRE & POST SX POUCH EXTERNAL THERAPY PACK NF 4 & 2 & 5 % (chlorhex-mupirocin-dimethicone) prednicarbate external cream 0.1 % G prednicarbate external ointment 0.1 % G premium scar external patch 2-4-30 % NF prepiv supply combination kit 2.5-2.5 & 0.9 % NF PRESERA EXTERNAL FOAM (dermatological products, NPB misc.) PRIZOTRAL EXTERNAL KIT 2.5-2.5 & 3.88 % (lidocaine- NF prilocaine) PROMISEB EXTERNAL CREAM (antiseborrheic products, NPB misc.) PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % NPB (tacrolimus) PROTYL AG EXTERNAL GEL 1 % (silver) NF PRUCLAIR EXTERNAL CREAM (dermatological products, NPB misc.) PRUMYX EXTERNAL CREAM (dermatological products, NPB misc.) psorcon external cream 0.05 % NF pyrogallic acid external ointment 25-2 % NPB QBREXZA EXTERNAL PAD 2.4 % (glycopyrronium NPB tosylate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

125 Prescription Drug Name Drug Tier Drug Notes QUINJA EXTERNAL GEL 1.25-1 % (iodoquinol-aloe NF polysaccharide) QUTENZA (2 PATCH) EXTERNAL KIT 8 % (capsaicin- NPB cleansing gel) QUTENZA EXTERNAL KIT 8 % (capsaicin-cleansing gel) NPB RADIAGEL EXTERNAL GEL (wound dressings) NPB RECEDO EXTERNAL GEL (scar treatment products) NF RECURA EXTERNAL CREAM (misc antifungal combo NF products) REGENECARE EXTERNAL GEL 2 % (lidocaine-collagen- NPB aloe vera) REGRANEX EXTERNAL GEL 0.01 % (becaplermin) NPB remigen external cream NPB resorcinol-sulfur external lotion 2-5 % G RESTORE SILVER DRESSING EXTERNAL PAD 2"X2" , NPB 4"X4.75" (calcium alginate-silver) RESTORE SILVER DRESSING EXTERNAL PAD 4"X4" , NPB 4"X5" , 6"X8" (silver) RETIN-A MICRO EXTERNAL GEL 0.04 %, 0.1 % NPB (tretinoin microsphere) RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.06 NPB %, 0.08 %, 0.1 % (tretinoin microsphere) rexaphenac external cream 1 % NF REXASIL PATCH & VITAMIN E LIQ EXTERNAL KIT NF (silicone-vitamin e) RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) NPB RIAX EXTERNAL FOAM 5.5 %, 9.5 % (benzoyl peroxide) NPB metronidazole (Rosadan External Cream 0.75 %) G metronidazole (Rosadan External Gel 0.75 %) G RTD WOUND CARE DRESSING EXTERNAL PAD NPB (wound dressings) salimez external cream 6 % G salimez forte external cream 10 % NPB SANTYL EXTERNAL OINTMENT 250 UNIT/GM NPB (collagenase) scarcin external gel NPB 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

126 Prescription Drug Name Drug Tier Drug Notes scarcin external liquid NF scarsilk external gel NF SCARZEN SKIN REPAIR EXTERNAL KIT 0.1 & 5 % NF (LOTION) (triamcinolone-dimeth-silicone) SEBUDERM EXTERNAL GEL (dermatological products, NPB misc.) selenium sulfide external lotion 2.5 % G SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone NPB dipropionate) silipac external kit NF SILIQ SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 210 MG/1.5ML (brodalumab) silver sulfadiazine external cream 1 % G SKLICE EXTERNAL LOTION 0.5 % (ivermectin) NPB SKYRIZI (150 MG DOSE) SUBCUTANEOUS IBC (Preferred agent for PREFILLED SYRINGE KIT 75 MG/0.83ML (risankizumab- PSB Psoriasis) rzaa) sodium hyaluronate external gel 0.2 % G sodium sulfacetamide wash external liquid 10 % NPB SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) NPB SORIATANE ORAL CAPSULE 10 MG, 25 MG (acitretin) NPB SORILUX EXTERNAL FOAM 0.005 % (calcipotriene) NF spinosad external suspension 0.9 % G silver sulfadiazine (Ssd External Cream 1 %) G IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML PSB Ulcerative Colitis after (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

127 Prescription Drug Name Drug Tier Drug Notes IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA SUBCUTANEOUS SOLUTION PREFILLED PSB Ulcerative Colitis after SYRINGE 45 MG/0.5ML, 90 MG/ML (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) sulfacetamide sodium (acne) external lotion 10 % G sulfacetamide sodium-sulfur external pad 10-4 % G sulfamez wash external emulsion 10-1 % G SULFAMYLON EXTERNAL CREAM 85 MG/GM NPB (mafenide acetate) sulfurated lime external solution NPB suvicort external emulsion NF SX1 MEDICATED POST-OPERATIVE EXTERNAL KIT NF 2 % (lidocaine hcl & post-op system) SYNERA EXTERNAL PATCH 70-70 MG (lidocaine- NPB tetracaine) SYNERDERM EXTERNAL EMULSION (dermatological NF products, misc.) synvexia tc external cream 4-1 % NF TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % NPB (calcipotriene-betameth diprop) tacrolimus external ointment 0.03 %, 0.1 % G IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION AUTO- Psoriasis. Not covered for PSB INJECTOR 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION PREFILLED Psoriasis. Not covered for PSB SYRINGE 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) TARGRETIN EXTERNAL GEL 1 % (bexarotene) NPSB tazarotene external cream 0.1 % G TAZORAC EXTERNAL CREAM 0.05 % (tazarotene) PB TAZORAC EXTERNAL GEL 0.05 %, 0.1 % (tazarotene) PB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

128 Prescription Drug Name Drug Tier Drug Notes TEGADERM AG MESH EXTERNAL PAD 2"X2" , 4"X5" , NPB 4"X8" , 8"X8" (silver) TETRIX EXTERNAL CREAM (dermatological products, NPB misc.) TEXACORT EXTERNAL SOLUTION 2.5 % NPB (hydrocortisone) THERAHONEY EXTERNAL GEL (wound dressings) NPB THERAHONEY EXTERNAL SHEET (wound dressings) NPB TOLAK EXTERNAL CREAM 4 % (fluorouracil) PB TREMFYA SUBCUTANEOUS SOLUTION PEN- IBC (Preferred agent for PSB INJECTOR 100 MG/ML (guselkumab) Psoriasis) TREMFYA SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for PSB SYRINGE 100 MG/ML (guselkumab) Psoriasis) tretinoin external cream 0.025 %, 0.05 %, 0.1 % G tretinoin external gel 0.01 %, 0.025 %, 0.05 % G tretinoin microsphere external gel 0.04 %, 0.1 % G tretinoin microsphere pump external gel 0.04 % G triamcinolone acetonide external aerosol solution 0.147 mg/gm NF triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % G triamcinolone acetonide external lotion 0.025 %, 0.1 % G triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 G % TRIAMSIL COMBIPAK EXTERNAL THERAPY PACK NF 0.1 & 5 % (triamcinolone acet-silicone) triamsil multipak external therapy pack 0.1 & 5 % NF triamcinolone acetonide (Trianex External Ointment 0.05 %) NF triamcinolone acetonide (Triderm External Cream 0.1 %, 0.5 G %) triple complex formula 3 kit external cream 20-2-10 % NF turpentine external spirit NPB ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol NF propionate) urea (Uredeb External Cream 39 %) G URESOL EXTERNAL CREAM 42.5 % (urea) NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

129 Prescription Drug Name Drug Tier Drug Notes VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine NPB hcl (topical)) VANOS EXTERNAL CREAM 0.1 % (fluocinonide) NF benzoyl perox-hydrocortisone (Vanoxide-Hc External Lotion 5- NF 0.5 %) VAROPHEN EXTERNAL KIT 1.5-10-15 % (diclofenac& NF menthol-methyl sal) VECTICAL EXTERNAL OINTMENT 3 MCG/GM NF (calcitriol) VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin- NF tretinoin) VENELEX EXTERNAL OINTMENT (balsam peru-castor NPB oil) VENIPUNCTURE PX1 PHLEBOTOMY EXTERNAL KIT NF 2 % (lidocaine hcl-blood collection) VERDESO EXTERNAL FOAM 0.05 % (desonide) NF VEREGEN EXTERNAL OINTMENT 15 % (sinecatechins) NF vexasyn external gel NF VOLTAREN EXTERNAL GEL 1 % (diclofenac sodium) NPB vp fc kit external cream NF VUSION EXTERNAL OINTMENT 0.25-15-81.35 % NF (miconazole-zinc oxide-petrolat) wpr plus wound healing system external therapy pack 4 & 10-30 NF % XALIX EXTERNAL SOLUTION 28 % (salicylic acid) NF XEPI EXTERNAL CREAM 1 % (ozenoxacin) NPB XERAC AC EXTERNAL SOLUTION 6.25 % (aluminum NPB chloride in alcohol) XERALUX EXTERNAL CREAM (dermatological products, NPB misc.) XERESE EXTERNAL CREAM 5-1 % (acyclovir- NF hydrocortisone) XEROFORM OIL EMULSION 2"X2" EXTERNAL PAD NPB (bismuth tribromoph-petrolatum) XEROFORM OIL EMULSION GAUZE EXTERNAL NPB PAD (bismuth tribromoph-petrolatum)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

130 Prescription Drug Name Drug Tier Drug Notes XEROFORM OIL EMULSION STRIP EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM OIL ROLL 4"X9' EXTERNAL 3 % (bismuth NPB tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM PETROLAT PATCH 2"X2" EXTERNAL NPB PAD (bismuth tribromoph-petrolatum) XEROFORM PETROLAT PATCH 4"X4" EXTERNAL NPB PAD (bismuth tribromoph-petrolatum) XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL NPB (bismuth tribromoph-petrolatum) XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % NF (ketoconazole-hydrocortisone) XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL NF KIT 2 & 1 % (ketoconazole & pyrithione zinc) XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % NF (ketoconazole & pyrithione zinc) XOLEGEL EXTERNAL GEL 2 % (ketoconazole) NF XRYLIX EXTERNAL THERAPY PACK 1.5 % (diclofenac NF sod-adhesive sheet) zaclir cleansing external lotion 8 % NPB zanabin hydrogel external gel NPB isotretinoin (Zenatane Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) ZIANA EXTERNAL GEL 1.2-0.025 % (clindamycin- NF tretinoin) ZILACAINE PATCH EXTERNAL THERAPY PACK 5 % NF (lidocaine-silicone) ZOVIRAX EXTERNAL CREAM 5 % (acyclovir) NF ZOVIRAX EXTERNAL OINTMENT 5 % (acyclovir) NF ZTLIDO EXTERNAL PATCH 1.8 % (lidocaine) NF ZYCLARA EXTERNAL CREAM 3.75 % (imiquimod) NF ZYCLARA PUMP EXTERNAL CREAM 2.5 %, 3.75 % NF (imiquimod) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

131 Prescription Drug Name Drug Tier Drug Notes *DIAGNOSTIC PRODUCTS* 12-PANEL POC TOXICOLOGY SYSTEM IN VITRO KIT NPB (drug assay (urine)) ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose PB blood) ACCU-CHEK COMPACT PLUS IN VITRO STRIP (glucose PB blood) ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) NPB ACCU-CHEK SMARTVIEW IN VITRO STRIP (glucose PB blood) ACCUTREND GLUCOSE IN VITRO STRIP (glucose NF blood) ADVANCE INTUITION TEST IN VITRO STRIP (glucose NF blood) ADVANCE MICRO-DRAW TEST IN VITRO STRIP NF (glucose blood) ADVOCATE REDI-CODE IN VITRO STRIP (glucose NF blood) ADVOCATE REDI-CODE+ TEST IN VITRO STRIP NF (glucose blood) ADVOCATE TEST IN VITRO STRIP (glucose blood) NF AGAMATRIX AMP TEST IN VITRO STRIP (glucose NF blood) AGAMATRIX JAZZ TEST IN VITRO STRIP (glucose NF blood) AGAMATRIX KEYNOTE TEST IN VITRO STRIP NF (glucose blood) AGAMATRIX PRESTO TEST IN VITRO STRIP (glucose NF blood) ASSURE 3 TEST IN VITRO STRIP (glucose blood) NF ASSURE 4 TEST IN VITRO STRIP (glucose blood) NF ASSURE II CHECK IN VITRO STRIP (glucose blood) NF ASSURE II IN VITRO STRIP (glucose blood) NF ASSURE PLATINUM IN VITRO STRIP (glucose blood) NF ASSURE PRISM MULTI TEST IN VITRO STRIP (glucose NF blood)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

132 Prescription Drug Name Drug Tier Drug Notes ASSURE PRO TEST IN VITRO STRIP (glucose blood) NF barium sulfate powder NPB BIOSCANNER GLUCOSE TEST IN VITRO STRIP NF (glucose blood) blood glucose test in vitro strip NF CAREONE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) CARESENS N GLUCOSE TEST IN VITRO STRIP (glucose NF blood) CARETOUCH TEST IN VITRO STRIP (glucose blood) NF cervical specimen collection swab NPB CHEMSTRIP K IN VITRO STRIP (acetone (urine) test) NPB CHEMSTRIP UGK IN VITRO STRIP (urine glucose-ketones NPB test) CLEVER CHEK AUTO-CODE TEST IN VITRO STRIP NF (glucose blood) CLEVER CHEK AUTO-CODE VOICE IN VITRO STRIP NF (glucose blood) CLEVER CHEK TEST IN VITRO STRIP (glucose blood) NF CLEVER CHOICE AUTO-CODE TEST IN VITRO STRIP NF (glucose blood) CLEVER CHOICE MICRO TEST IN VITRO STRIP NF (glucose blood) CLEVER CHOICE NO CODING IN VITRO STRIP NF (glucose blood) CLEVER CHOICE TALK SYSTEM IN VITRO STRIP NF (glucose blood) CONTOUR NEXT TEST IN VITRO STRIP (glucose blood) NF CONTOUR TEST IN VITRO STRIP (glucose blood) NF COOL BLOOD GLUCOSE TEST STRIPS IN VITRO NF STRIP (glucose blood) CVS ADVANCED GLUCOSE TEST IN VITRO STRIP NF (glucose blood) cvs glucose meter test strips in vitro strip NF CVS KETONE CARE IN VITRO STRIP (urine glucose- NPB ketones test)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

133 Prescription Drug Name Drug Tier Drug Notes CYSTOGRAFIN URETHRAL SOLUTION 30 % NPB (diatrizoate meglumine) CYSTOGRAFIN-DILUTE URETHRAL SOLUTION 18 % NPB (diatrizoate meglumine) CYSVIEW INTRAVESICAL SOLUTION NPB RECONSTITUTED 100 MG (hexaminolevulinate hcl) D-CARE BLOOD GLUCOSE IN VITRO STRIP (glucose NF blood) DIASTIX IN VITRO STRIP (glucose urine test-glucose ox) NPB DIATHRIVE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) DIATHRIVE GLUCOSE TEST IN VITRO STRIP (glucose NF blood) DIATHRIVE+ GLUCOSE TEST IN VITRO STRIP (glucose NF blood) diatrue plus test in vitro strip NF DUO-CARE TEST IN VITRO STRIP (glucose blood) NF d-xylose powder NPB easy plus ii glucose test in vitro strip NF EASY STEP TEST IN VITRO STRIP (glucose blood) NF easy talk blood glucose test in vitro strip NF EASY TOUCH TEST IN VITRO STRIP (glucose blood) NF easy trak blood glucose test in vitro strip NF easy trak ii glucose test in vitro strip NF EASYGLUCO IN VITRO STRIP (glucose blood) NF EASYMAX 15 TEST IN VITRO STRIP (glucose blood) NF EASYMAX TEST IN VITRO STRIP (glucose blood) NF EASYPRO BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EASYPRO PLUS IN VITRO STRIP (glucose blood) NF element compact test in vitro strip NF ELEMENT TEST IN VITRO STRIP (glucose blood) NF EMBRACE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

134 Prescription Drug Name Drug Tier Drug Notes EMBRACE EVO BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) EMBRACE PRO GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EMBRACE TALK GLUCOSE TEST IN VITRO STRIP NF (glucose blood) eq blood glucose test in vitro strip NF EVENCARE + BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) EVENCARE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EVENCARE G2 TEST IN VITRO STRIP (glucose blood) NF EVENCARE G3 TEST IN VITRO STRIP (glucose blood) NF EVENCARE MINI GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EVENCARE PROVIEW GLUCOSE TEST IN VITRO NF STRIP (glucose blood) EVOLUTION AUTOCODE IN VITRO STRIP (glucose NF blood) EXACTECH R-S-G TEST IN VITRO STRIP (glucose blood) NF EXACTECH TEST IN VITRO STRIP (glucose blood) NF EZ SMART BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EZ SMART PLUS GLUCOSE TEST IN VITRO STRIP NF (glucose blood) E-Z-HD ORAL SUSPENSION RECONSTITUTED 98 % NPB (barium sulfate) E-Z-PAQUE ORAL SUSPENSION RECONSTITUTED 96 NPB % (barium sulfate) FIFTY50 GLUCOSE TEST 2.0 IN VITRO STRIP (glucose NF blood) FORA 6 CONNECT IN VITRO STRIP (glucose blood) NF FORA BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D15G BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

135 Prescription Drug Name Drug Tier Drug Notes FORA D20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D40/G31 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) FORA G20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA G30/PREM V10 GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GD20 TEST IN VITRO STRIP (glucose blood) NF FORA GD50 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GTEL BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GTEL BLOOD KETONE TEST IN VITRO STRIP NPB (ketone blood test) FORA TN'G/TN'G VOICE IN VITRO STRIP (glucose NF blood) FORA V10 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V12 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V30A BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORACARE GD40 TEST IN VITRO STRIP (glucose blood) NF FORACARE PREMIUM V10 TEST IN VITRO STRIP NF (glucose blood) FORACARE TEST N GO TEST IN VITRO STRIP (glucose NF blood) FORTISCARE TEST IN VITRO STRIP (glucose blood) NF FREESTYLE INSULINX TEST IN VITRO STRIP (glucose NF blood) FREESTYLE LITE TEST IN VITRO STRIP (glucose blood) NF FREESTYLE PRECISION NEO TEST IN VITRO STRIP NF (glucose blood) FREESTYLE TEST IN VITRO STRIP (glucose blood) NF 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

136 Prescription Drug Name Drug Tier Drug Notes ge100 blood glucose test in vitro strip NF GENULTIMATE TEST IN VITRO STRIP (glucose blood) NPB ght test in vitro strip NF GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 NPB GM (aminolevulinic acid hcl) GLUCO PERFECT 3 TEST IN VITRO STRIP (glucose NF blood) GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP NF (glucose blood) GLUCOCARD EXPRESSION TEST IN VITRO STRIP NF (glucose blood) GLUCOCARD SHINE TEST IN VITRO STRIP (glucose NPB blood) GLUCOCARD VITAL TEST IN VITRO STRIP (glucose NF blood) GLUCOCARD X-SENSOR IN VITRO STRIP (glucose NF blood) GLUCOCOM TEST IN VITRO STRIP (glucose blood) NF GLUCONAVII BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) glucose meter test in vitro strip NF gnp easy touch glucose test in vitro strip NF GOJJI BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) GOJJI BLOOD TEST STRIP/LANCETS IN VITRO STRIP NF (glucose blood) goodsense blood glucose in vitro strip NF HARMONY BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) HW EMBRACE PRO GLUCOSE TEST IN VITRO STRIP NF (glucose blood) HW EMBRACE TALK GLUCOSE TEST IN VITRO NF STRIP (glucose blood) IGLUCOSE TEST STRIPS IN VITRO STRIP (glucose NF blood) IN TOUCH BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

137 Prescription Drug Name Drug Tier Drug Notes INFINITY BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) INFINITY VOICE IN VITRO STRIP (glucose blood) NF KETO-DIASTIX IN VITRO STRIP (urine glucose-ketones NPB test) ketone test in vitro strip NPB KETOSTIX IN VITRO STRIP (acetone (urine) test) NPB kroger blood glucose test in vitro strip NF KROGER HEALTHPRO GLUCOSE TEST IN VITRO NF STRIP (glucose blood) kroger premium glucose test in vitro strip NF kroger test in vitro strip NF LEU TECHNELITE COMBINATION KIT (technet tc 99m NF pertechnetate) LIBERTY NEXT GENERATION TEST IN VITRO STRIP NF (glucose blood) liberty test in vitro strip NF LIQUID E-Z-PAQUE ORAL SUSPENSION 60 % (barium NPB sulfate) MACRILEN ORAL PACKET 60 MG (macimorelin acetate) NF diatrizoate meglumine & sodium (Md-Gastroview Oral G Solution 66-10 %) meijer blood glucose test in vitro strip NF meijer essential glucose test in vitro strip NF meijer premium glucose test in vitro strip NF MEIJER TRUETEST TEST IN VITRO STRIP (glucose NF blood) MEIJER TRUETRACK TEST IN VITRO STRIP (glucose NF blood) METOPIRONE ORAL CAPSULE 250 MG (metyrapone) NPB MICRODOT TEST IN VITRO STRIP (glucose blood) NF MM EASY TOUCH GLUCOSE IN VITRO STRIP (glucose NF blood) MYGLUCOHEALTH TEST IN VITRO STRIP (glucose NF blood) NEUTEK 2TEK TEST IN VITRO STRIP (glucose blood) NF 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

138 Prescription Drug Name Drug Tier Drug Notes NOVA MAX GLUCOSE TEST IN VITRO STRIP (glucose NF blood) NOVA MAX PLUS KETONE TEST IN VITRO STRIP NPB (ketone blood test) OMNIPAQUE ORAL SOLUTION 12 MG/ML, 9 MG/ML NPB (iohexol) one drop test in vitro strip NF ONETOUCH ULTRA IN VITRO STRIP (glucose blood) NF ONETOUCH VERIO IN VITRO STRIP (glucose blood) NF OPTIUM TEST IN VITRO STRIP (glucose blood) NF OPTIUMEZ TEST IN VITRO STRIP (glucose blood) NF ph strips in vitro diagnostic test NPB PHARMACIST CHOICE AUTOCODE IN VITRO STRIP NF (glucose blood) pharmacist choice no coding in vitro strip NF POCKETCHEM EZ TEST IN VITRO STRIP (glucose blood) NF PRECISION PCX IN VITRO STRIP (glucose blood) NF PRECISION PCX PLUS TEST IN VITRO STRIP (glucose NF blood) PRECISION POINT OF CARE TEST IN VITRO STRIP NF (glucose blood) PRECISION QID TEST IN VITRO STRIP (glucose blood) NF PRECISION SOF-TACT TEST IN VITRO STRIP (glucose NF blood) PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) PRECISION XTRA KETONE IN VITRO STRIP (ketone NPB blood test) premium blood glucose test in vitro strip NF pro voice v8/v9 glucose in vitro strip NF PRODIGY NO CODING BLOOD GLUC IN VITRO NF STRIP (glucose blood) PROVOCHOLINE INHALATION SOLUTION NPB RECONSTITUTED 100 MG (methacholine chloride) PTS PANELS GLUCOSE TEST IN VITRO STRIP (glucose NF blood)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

139 Prescription Drug Name Drug Tier Drug Notes PTS PANELS KETONE TEST IN VITRO STRIP (ketone NPB blood test) QUICKTEK TEST IN VITRO STRIP (glucose blood) NF QUINTET AC BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) QUINTET BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RA TRUETEST TEST IN VITRO STRIP (glucose blood) NF READI-CAT 2 ORAL SUSPENSION 2 % (barium sulfate) NPB REFUAH PLUS BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) RELION BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RELION CONFIRM/MICRO TEST IN VITRO STRIP NF (glucose blood) RELION KETONE IN VITRO STRIP (acetone (urine) test) NPB RELION KETONE TEST IN VITRO STRIP (acetone NPB (urine) test) RELION PRIME TEST IN VITRO STRIP (glucose blood) NF RELION ULTIMA TEST IN VITRO STRIP (glucose blood) NF REXALL BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RIGHTEST GS100 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) RIGHTEST GS300 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) RIGHTEST GS550 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) SITZMARKS COMBO PACKAGE ORAL CAPSULE NPB THERAPY PACK (barium sulfate) SITZMARKS ORAL CAPSULE (barium sulfate) NPB SMART SENSE PREMIUM TEST IN VITRO STRIP NF (glucose blood) SMART SENSE VALUE TEST IN VITRO STRIP (glucose NF blood) SMARTEST BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

140 Prescription Drug Name Drug Tier Drug Notes SOLUS V2 TEST IN VITRO STRIP (glucose blood) NF SPHERUSOL INTRADERMAL SOLUTION 127 NF MCG/0.1ML (coccidioides immitis) SUPREME TEST IN VITRO STRIP (glucose blood) NF SURE EDGE TEST IN VITRO STRIP (glucose blood) NF SURECHEK BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) SURE-TEST EASYPLUS MINI TEST IN VITRO STRIP NF (glucose blood) TAGITOL V ORAL SUSPENSION 40 % (barium sulfate) NPB TECHNELITE COMBINATION KIT (technet tc 99m NF pertechnetate) TELCARE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) tgt blood glucose test in vitro strip NF TOXICOLOGY MED COLLECTION SYS IN VITRO KIT NPB (drug assay (urine)) true focus blood glucose strip in vitro strip NF TRUE METRIX BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) TRUETEST TEST IN VITRO STRIP (glucose blood) NF TRUETRACK TEST IN VITRO STRIP (glucose blood) NF ULTIMA TEST IN VITRO STRIP (glucose blood) NF ULTRATRAK PRO TEST IN VITRO STRIP (glucose blood) NF ULTRATRAK ULTIMATE TEST IN VITRO STRIP NF (glucose blood) UNISTRIP1 GENERIC IN VITRO STRIP (glucose blood) NF VARIBAR HONEY ORAL SUSPENSION 40 % (barium NPB sulfate) VARIBAR NECTAR ORAL SUSPENSION 40 % (barium NPB sulfate) VARIBAR PUDDING ORAL PASTE 40 % (barium sulfate) NPB VARIBAR THIN HONEY ORAL SUSPENSION 40 % NPB (barium sulfate) VARIBAR THIN LIQUID ORAL SUSPENSION NPB RECONSTITUTED 40 % (barium sulfate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

141 Prescription Drug Name Drug Tier Drug Notes verasens blood glucose test in vitro strip NF VIVAGUARD INO TEST STRIPS IN VITRO STRIP NF (glucose blood) VOCAL POINT BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) xenon xe 133 inhalation gas 10 mci, 20 mci NPB *DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS* - DRUGS FOR NUTRITION AMINOPMRMS ORAL CAPSULE (nutritional supplements) NPB APP SLIM RMS ORAL CAPSULE (nutritional supp - diet NPB aids) nutritional supplements (Asilnasalrms Oral Capsule) G ASTAMED MYO ORAL CAPSULE (astaxanthin- NF tocotrienol-zn-d3) CAMINO PRO COMPLETE/GLYTACTIN ORAL BAR NPB (nutritional supplements) CHOLEXMAX ORAL POWDER (dietary management NF product) CHOLEXTRA T/F ORAL POWDER (dietary management NF product) ELIGEN B12 ORAL TABLET 1000-100 MCG-MG NF (cyanocobalamin-salcaprozate) ENTERAGAM ORAL PACKET 5 GM (sbi/protein isolate) NF FOSTEUM ORAL CAPSULE 27-20-200 MG-MG-UNIT NF (genistein-zn chelate-vit d) FOSTEUM PLUS ORAL CAPSULE (dietary management NF product) GALAXTRA ORAL POWDER (galactose) NF GLYTACTIN BUILD 10PE ORAL PACKET (nutritional NPB supplements) GLYTACTIN COMPLETE 10PE ORAL BAR (nutritional NPB supplements) GLYTACTIN SWIRL 15PE ORAL PACKET (nutritional NPB supplements) HCU EASY ORAL TABLET (nutritional supplements) NF KETOVIE ORAL LIQUID (nutritional supplements) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

142 Prescription Drug Name Drug Tier Drug Notes KETOVIE PEPTIDE ORAL LIQUID (nutritional NPB supplements) LDL CARE ORAL POWDER (dietary management product) NF MSUD EASY ORAL TABLET (nutritional supplements) NF NEOKE BCAA4 ORAL POWDER (dietary management NF product) neoke bhb oral powder NF NICAPRIN ORAL TABLET (dietary management product) NF nicazyme oral tablet NF NOURISH ORAL LIQUID (nutritional supplements) NPB omnivex oral tablet NF PKU EASY MICROTABS ORAL TABLET DELAYED NF RELEASE (nutritional supplements) PKU EASY ORAL TABLET (nutritional supplements) NF PROMACTIN AA PLUS 20PE ORAL SUSPENSION NF (nutritional supplements) RHEUMATE ORAL CAPSULE (dietary management NF product) ribozel oral capsule NF sodium saccharin granules NPB sodium saccharin powder NPB thrivacin 30 oral liquid NPB thrivacin detox oral liquid NPB TOBAKIENT ORAL CAPSULE (dietary management NF product) TYLACTIN COMPLETE 15 PE ORAL BAR (nutritional NPB supplements) TYR EASY ORAL TABLET (nutritional supplements) NF VASCULERA ORAL TABLET (dietary management NF product) vb6 p5p oral powder NF XAQUIL XR ORAL TABLET EXTENDED RELEASE 30 NF MG (levomefolate glucosamine) xyzbac oral tablet NF zyvit oral tablet NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

143 Prescription Drug Name Drug Tier Drug Notes *DIGESTIVE AIDS* - DRUGS FOR THE STOMACH CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 PB UNIT, 36000 UNIT, 6000 UNIT (pancrelipase (lip-prot- amyl)) enzadyne oral capsule NF PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 NF UNIT, 4200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 24000-86250 UNIT, 4000 UNIT, NF 8000 UNIT (pancrelipase (lip-prot-amyl)) SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) NPB VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT PB (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000- PB 126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot- amyl)) *DIURETICS* - DRUGS FOR THE HEART acetazolamide er oral capsule extended release 12 hour 500 mg G acetazolamide oral tablet 125 mg, 250 mg G ALDACTAZIDE ORAL TABLET 50-50 MG NPB (spironolactone-hctz) amiloride hcl oral tablet 5 mg G amiloride-hydrochlorothiazide oral tablet 5-50 mg G LGC bumetanide oral tablet 0.5 mg, 1 mg, 2 mg G CAROSPIR ORAL SUSPENSION 25 MG/5ML NF (spironolactone) chlorthalidone oral tablet 25 mg, 50 mg G DIURIL ORAL SUSPENSION 250 MG/5ML NPB (chlorothiazide) DYRENIUM ORAL CAPSULE 100 MG, 50 MG NF (triamterene) ethacrynic acid oral tablet 25 mg G furosemide oral solution 10 mg/ml, 8 mg/ml G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

144 Prescription Drug Name Drug Tier Drug Notes furosemide oral tablet 20 mg, 40 mg, 80 mg G LGC hydrochlorothiazide oral capsule 12.5 mg G LGC hydrochlorothiazide oral tablet 12.5 mg G hydrochlorothiazide oral tablet 25 mg, 50 mg G LGC indapamide oral tablet 1.25 mg, 2.5 mg G KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) NPB methazolamide oral tablet 25 mg, 50 mg G metolazone oral tablet 10 mg, 2.5 mg, 5 mg G spironolactone oral tablet 100 mg, 50 mg G spironolactone oral tablet 25 mg G LGC spironolactone-hctz oral tablet 25-25 mg G torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg G triamterene oral capsule 100 mg, 50 mg G triamterene-hctz oral capsule 37.5-25 mg G LGC triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg G LGC *ENDOCRINE AND METABOLIC AGENTS - MISC.* - HORMONES ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) NPSB ALDURAZYME INTRAVENOUS SOLUTION 2.9 NPSB MG/5ML (laronidase) alendronate sodium oral solution 70 mg/75ml G alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg G BINOSTO ORAL TABLET EFFERVESCENT 70 MG NPB (alendronate sodium) cabergoline oral tablet 0.5 mg G calcitonin (salmon) nasal solution 200 unit/act G calcitriol oral capsule 0.25 mcg, 0.5 mcg G calcitriol oral solution 1 mcg/ml G CARBAGLU ORAL TABLET 200 MG (carglumic acid) NPB CARNITOR ORAL SOLUTION 1 GM/10ML (levocarnitine) NF CARNITOR ORAL TABLET 330 MG (levocarnitine) NF CARNITOR SF ORAL SOLUTION 1 GM/10ML NF (levocarnitine)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

145 Prescription Drug Name Drug Tier Drug Notes CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix SPC (Only available for PSB acetate) select plans) cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg G SPC (Only available for clomiphene citrate oral tablet 50 mg G select plans) CYSTADANE ORAL POWDER (betaine) NPB DDAVP RHINAL TUBE NASAL SOLUTION 0.01 % NPB (desmopressin ace refrigerated) desmopressin ace spray refrig nasal solution 0.01 % G desmopressin acetate oral tablet 0.1 mg, 0.2 mg G desmopressin acetate spray nasal solution 0.01 % G doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg G ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML NPSB (idursulfase) EVENITY SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 105 MG/1.17ML (romosozumab-aqqg) FABRAZYME INTRAVENOUS SOLUTION NPSB RECONSTITUTED 35 MG, 5 MG (agalsidase beta) FENSOLVI (6 MONTH) SUBCUTANEOUS KIT 45 MG NPB (PED) (leuprolide acetate (6 month)) FORTEO SUBCUTANEOUS SOLUTION PEN- PSB INJECTOR 600 MCG/2.4ML (teriparatide (recombinant)) FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, NPB 70-5600 MG-UNIT (alendronate-cholecalciferol) GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) NPB ganirelix acetate subcutaneous solution prefilled syringe 250 NPSB mcg/0.5ml GONAL-F INJECTION SOLUTION RECONSTITUTED SPC (Only available for PSB 1050 UNIT, 450 UNIT (follitropin alfa) select plans) GONAL-F RFF REDIJECT SUBCUTANEOUS SPC (Only available for SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 PSB select plans) UNIT/1.5ML (follitropin alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION SPC (Only available for PSB RECONSTITUTED 75 UNIT (follitropin alfa) select plans) HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG PSB (somatropin) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

146 Prescription Drug Name Drug Tier Drug Notes ibandronate sodium oral tablet 150 mg G INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML NPSB (mecasermin) JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) NPB JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 30 & 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG NPB (tolvaptan) KANUMA INTRAVENOUS SOLUTION 20 MG/10ML NPSB (sebelipase alfa) KUVAN ORAL PACKET 100 MG, 500 MG (sapropterin NPSB dihydrochloride) KUVAN ORAL TABLET SOLUBLE 100 MG (sapropterin NPSB dihydrochloride) levocarnitine oral solution 1 gm/10ml G levocarnitine oral tablet 330 mg G LUMIZYME INTRAVENOUS SOLUTION NPSB RECONSTITUTED 50 MG (alglucosidase alfa) LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, NPSB 3.75 & 5 MG (leuprolide & norethindrone) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR NPSB KIT 11.25 MG, 15 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED), 30 MG (PED) (leuprolide acetate (3 NPSB month)) MENOPUR SUBCUTANEOUS SOLUTION SPC (Only available for NPSB RECONSTITUTED 75 UNIT (menotropins) select plans) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NF (calcitonin (salmon)) MIACALCIN NASAL SOLUTION 200 UNIT/ACT NF (calcitonin (salmon)) MYALEPT SUBCUTANEOUS SOLUTION NPB RECONSTITUTED 11.3 MG (metreleptin) NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML NPSB (galsulfase) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, SPC (Only available for NPSB 25 MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) select plans) NITYR ORAL TABLET 10 MG, 2 MG, 5 MG (nitisinone) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

147 Prescription Drug Name Drug Tier Drug Notes NOCDURNA SUBLINGUAL TABLET SUBLINGUAL NPB 27.7 MCG, 55.3 MCG (desmopressin acetate) octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, G 200 mcg/ml, 50 mcg/ml, 500 mcg/ml ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG PSB (nitisinone) ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) PSB ORILISSA ORAL TABLET 150 MG, 200 MG (elagolix PB sodium) OSPHENA ORAL TABLET 60 MG (ospemifene) PB OVIDREL SUBCUTANEOUS INJECTABLE 250 SPC (Only available for PSB MCG/0.5ML (choriogonadotropin alfa) select plans) paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg G PROLIA SUBCUTANEOUS SOLUTION PREFILLED SPC (Only available for PSB SYRINGE 60 MG/ML (denosumab) select plans) raloxifene hcl oral tablet 60 mg CE RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 NPB MCG (calcifediol) RECLAST INTRAVENOUS SOLUTION 5 MG/100ML NPSB (zoledronic acid) risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg G risedronate sodium oral tablet delayed release 35 mg G SAMSCA ORAL TABLET 15 MG, 30 MG (tolvaptan) NPSB SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, NPSB 50 MCG/ML, 500 MCG/ML (octreotide acetate) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG NPSB (cinacalcet hcl) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG (somatropin (non- NPSB refrigerated)) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 20 MG, 30 MG (pasireotide NPB pamoate) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 40 MG, 60 MG (pasireotide NPSB pamoate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

148 Prescription Drug Name Drug Tier Drug Notes SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, NPB 0.6 MG/ML, 0.9 MG/ML (pasireotide diaspartate) sodium phenylbutyrate oral powder 3 gm/tsp G sodium phenylbutyrate oral tablet 500 mg G SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide PSB acetate) SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG PSB (pegvisomant) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin NPSB acetate) STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML NPB (asfotase alfa) SUPPRELIN LA SUBCUTANEOUS KIT 50 MG (histrelin NPSB acetate (cpp)) SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin NPB acetate) TEPEZZA INTRAVENOUS SOLUTION NPSB RECONSTITUTED 500 MG (teprotumumab-trbw) TRIPTODUR INTRAMUSCULAR SUSPENSION NF RECONSTITUTED ER 22.5 MG (triptorelin pamoate) TYMLOS SUBCUTANEOUS SOLUTION PEN- PSB INJECTOR 3120 MCG/1.56ML (abaloparatide) VASOSTRICT INTRAVENOUS SOLUTION 20 UNIT/ML NF (vasopressin) VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML NPSB (elosulfase alfa) XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML SPC (Only available for NPSB (denosumab) select plans) XURIDEN ORAL PACKET 2 GM (uridine triacetate) NPB zoledronic acid intravenous concentrate 4 mg/5ml G zoledronic acid intravenous solution 4 mg/100ml NPSB zoledronic acid intravenous solution 5 mg/100ml G ZORBTIVE SUBCUTANEOUS SOLUTION NPSB RECONSTITUTED 8.8 MG (somatropin (non-refrigerated))

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

149 Prescription Drug Name Drug Tier Drug Notes *ESTROGENS* - HORMONES ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 NF MG/24HR (estradiol) estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg, G 1-0.5 Mg) ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG NF (drospirenone-estradiol) bi-est 80:20 progesterone transdermal cream NF BIEST/PROGESTERONE TRANSDERMAL CREAM NF (estradiol-estriol-progesterone) BIJUVA ORAL CAPSULE 1-100 MG (estradiol- NPB progesterone) CLIMARA PRO TRANSDERMAL PATCH WEEKLY PB 0.045-0.015 MG/DAY (estradiol-levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY NF (estradiol-norethindrone acet) DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML NPB (estradiol valerate) DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML NPB (estradiol cypionate) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 PB MG/1.25GM (estradiol) estradiol (Dotti Transdermal Patch Twice Weekly 0.025 Mg/24Hr, 0.0375 Mg/24Hr, 0.05 Mg/24Hr, 0.075 Mg/24Hr, G 0.1 Mg/24Hr) DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- PB bazedoxifene) ec-rx estradiol transdermal cream 0.4 %, 0.6 % NF ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM NF (0.06%) (estradiol) estradiol oral tablet 0.5 mg, 1 mg, 2 mg G estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 G mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

150 Prescription Drug Name Drug Tier Drug Notes estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 G mg/24hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml G estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg G ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM NF (0.06%) (estradiol) EVAMIST TRANSDERMAL SOLUTION 1.53 PB MG/SPRAY (estradiol) FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG NF (norethindrone-eth estradiol) norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg- G Mcg, 1-5 Mg-Mcg) norethindrone-eth estradiol (Jinteli Oral Tablet 1-5 Mg-Mcg) G MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG NF (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 NF MCG/24HR (estradiol) estradiol-norethindrone acet (Mimvey Oral Tablet 1-0.5 Mg) G MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 NF MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol) norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg- G mcg ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 PB & 300 MG (elagolix-estradiol-norethind) PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- NF norgestimate) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, PB 0.9 MG, 1.25 MG (estrogens conjugated) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- PB medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, PB 0.625-2.5 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) VIVELLE-DOT TRANSDERMAL PATCH TWICE NF WEEKLY 0.0375 MG/24HR (estradiol)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

151 Prescription Drug Name Drug Tier Drug Notes *FLUOROQUINOLONES* - DRUGS FOR INFECTIONS BAXDELA ORAL TABLET 450 MG (delafloxacin NPB meglumine) CIPRO ORAL SUSPENSION RECONSTITUTED 250 NPB MG/5ML (5%) (ciprofloxacin) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg G levofloxacin oral solution 25 mg/ml G levofloxacin oral tablet 250 mg, 500 mg, 750 mg G moxifloxacin hcl oral tablet 400 mg G ofloxacin oral tablet 300 mg, 400 mg G *GASTROINTESTINAL AGENTS - MISC.* - DRUGS FOR THE STOMACH alosetron hcl oral tablet 0.5 mg, 1 mg G AMITIZA ORAL CAPSULE 24 MCG, 8 MCG PB (lubiprostone) APRISO ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 0.375 GM (mesalamine) ASACOL HD ORAL TABLET DELAYED RELEASE 800 NF MG (mesalamine) AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric NPB citrate) balsalazide disodium oral capsule 750 mg G calcium acetate (phos binder) oral capsule 667 mg G calcium acetate (phos binder) oral tablet 667 mg G CANASA RECTAL SUPPOSITORY 1000 MG (mesalamine) NF CHENODAL ORAL TABLET 250 MG (chenodiol) NPB CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) NPSB COLAZAL ORAL CAPSULE 750 MG (balsalazide disodium) NF cromolyn sodium oral concentrate 100 mg/5ml G DELZICOL ORAL CAPSULE DELAYED RELEASE 400 NF MG (mesalamine) DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) NPB ENTEREG ORAL CAPSULE 12 MG (alvimopan) NPB ENTYVIO INTRAVENOUS SOLUTION NF RECONSTITUTED 300 MG (vedolizumab)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

152 Prescription Drug Name Drug Tier Drug Notes enulose oral solution 10 gm/15ml G FOSRENOL ORAL PACKET 1000 MG, 750 MG NF (lanthanum carbonate) FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 NF MG, 750 MG (lanthanum carbonate) GATTEX SUBCUTANEOUS KIT 5 MG (teduglutide NPSB (rdna)) generlac oral solution 10 gm/15ml G lactulose encephalopathy oral solution 10 gm/15ml G lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 NF mg LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM NF (mesalamine) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG PB (linaclotide) LOTRONEX ORAL TABLET 0.5 MG, 1 MG (alosetron hcl) NPB mesalamine oral capsule delayed release 400 mg G mesalamine oral tablet delayed release 1.2 gm, 800 mg G mesalamine rectal enema 4 gm G mesalamine rectal suppository 1000 mg G mesalamine-cleanser rectal kit 4 gm G metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml G metoclopramide hcl oral tablet 10 mg, 5 mg G metoclopramide hcl oral tablet dispersible 10 mg NPB metoclopramide hcl oral tablet dispersible 5 mg G MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride NF succinate) MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol PB oxalate) OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) NPSB PENTASA ORAL CAPSULE EXTENDED RELEASE 250 PB MG, 500 MG (mesalamine) PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium PB acetate (phos binder)) RELISTOR ORAL TABLET 150 MG (methylnaltrexone NPB bromide) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

153 Prescription Drug Name Drug Tier Drug Notes RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, NPB 8 MG/0.4ML (methylnaltrexone bromide) REMICADE INTRAVENOUS SOLUTION PSB RECONSTITUTED 100 MG (infliximab) ROWASA RECTAL KIT 4 GM (mesalamine-cleanser) NF sevelamer carbonate oral packet 0.8 gm, 2.4 gm G sevelamer carbonate oral tablet 800 mg G sevelamer hcl oral tablet 400 mg, 800 mg G SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) NF IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA INTRAVENOUS SOLUTION 130 MG/26ML PSB Ulcerative Colitis after (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) sulfasalazine oral tablet 500 mg G sulfasalazine oral tablet delayed release 500 mg G SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) PB TRULANCE ORAL TABLET 3 MG (plecanatide) NPB ursodiol oral capsule 300 mg G ursodiol oral tablet 250 mg, 500 mg G VELPHORO ORAL TABLET CHEWABLE 500 MG PB (sucroferric oxyhydroxide) VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) PB XERMELO ORAL TABLET 250 MG (telotristat etiprate) NPB ZELNORM ORAL TABLET 6 MG (tegaserod maleate) NF *GENERAL ANESTHETICS* - DRUGS FOR PAIN AND FEVER anesthesia s/i-40a intravenous kit 200 mg/20ml NF anesthesia s/i-40h intravenous kit 200 mg/20ml NF anesthesia s/i-40s intravenous kit 200 mg/20ml NF desflurane inhalation solution G isoflurane inhalation solution G sevoflurane inhalation solution G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

154 Prescription Drug Name Drug Tier Drug Notes isoflurane (Terrell Inhalation Solution) G *GENITOURINARY AGENTS - MISCELLANEOUS* - DRUGS FOR THE URINARY SYSTEM acetic acid irrigation solution 0.25 % G alfuzosin hcl er oral tablet extended release 24 hour 10 mg G aminoacetic acid irrigation solution 1.5 % G sodium chloride (gu irrigant) (Argyle Sterile Saline Irrigation G Solution 0.9 %) CARDURA XL ORAL TABLET EXTENDED RELEASE NPB 24 HOUR 4 MG, 8 MG (doxazosin mesylate) sodium chloride (gu irrigant) (Curity Sterile Saline Irrigation G Solution 0.9 %) CYSTAGON ORAL CAPSULE 150 MG, 50 MG PSB (cysteamine bitartrate) cytra k crystals oral packet 3300-1002 mg G dutasteride oral capsule 0.5 mg G dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg G ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate NPB sodium) finasteride oral tablet 5 mg G glycine irrigation solution 1.5 % G JALYN ORAL CAPSULE 0.5-0.4 MG (dutasteride- NF tamsulosin hcl) K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac NPB phosphates) LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic NPB acid) neomycin-polymyxin b gu irrigation solution 40-200000 G ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate- NPB citric acid) phenazopyridine hcl (Phenazo Oral Tablet 200 Mg) G pot & sod cit-cit ac oral solution 550-500-334 mg/5ml G potassium citrate er oral tablet extended release 10 meq (1080 G mg), 15 meq (1620 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 1100-334 mg/5ml G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

155 Prescription Drug Name Drug Tier Drug Notes PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine NF bitartrate) RAPAFLO ORAL CAPSULE 4 MG, 8 MG (silodosin) NF RENACIDIN IRRIGATION SOLUTION (citric ac- NPB gluconolact-mg carb) RESECTISOL IRRIGATION SOLUTION 5 % (mannitol NPB (gu irrigant)) RIMSO-50 INTRAVESICAL SOLUTION 50 % (dimethyl NF sulfoxide) silodosin oral capsule 4 mg, 8 mg G sod citrate-citric acid oral solution 500-334 mg/5ml G sodium chloride irrigation solution 0.9 % G sorbitol irrigation solution 3 %, 3.3 % NPB sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml NPB tamsulosin hcl oral capsule 0.4 mg G potassium citrate-citric acid (Taron-Crystals Oral Packet 3300- G 1002 Mg) THIOLA EC ORAL TABLET DELAYED RELEASE 100 NPB MG, 300 MG (tiopronin) THIOLA ORAL TABLET 100 MG (tiopronin) NPB tricitrates oral solution 550-500-334 mg/5ml G UROXATRAL ORAL TABLET EXTENDED RELEASE NF 24 HOUR 10 MG (alfuzosin hcl) *GOUT AGENTS* - DRUGS FOR PAIN AND FEVER allopurinol oral tablet 100 mg, 300 mg G colchicine oral capsule 0.6 mg G colchicine oral tablet 0.6 mg G colchicine-probenecid oral tablet 0.5-500 mg G COLCRYS ORAL TABLET 0.6 MG (colchicine) NF febuxostat oral tablet 40 mg, 80 mg G KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML NPSB (pegloticase) probenecid oral tablet 500 mg G ULORIC ORAL TABLET 40 MG, 80 MG (febuxostat) NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

156 Prescription Drug Name Drug Tier Drug Notes *HEMATOLOGICAL AGENTS - MISC.* - DRUGS FOR THE BLOOD ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NPSB 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) adynovate intravenous solution reconstituted 1000 unit, 1500 PSB unit, 2000 unit, 250 unit, 3000 unit, 500 unit, 750 unit AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT NPSB (antihemophil fact single chain) AGGRASTAT INTRAVENOUS CONCENTRATE 3.75 NF MG/15ML (tirofiban hcl) ALBUMINEX INTRAVENOUS SOLUTION 25 %, 5 % NF (albumin human-kjda) ALPHANATE/VWF COMPLEX/HUMAN INTRAVENOUS SOLUTION RECONSTITUTED 1000 NPSB UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT NPSB (coagulation factor ix) anagrelide hcl oral capsule 0.5 mg, 1 mg G aspirin-dipyridamole er oral capsule extended release 12 hour G 25-200 mg BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix NPSB (recomb)) BRILINTA ORAL TABLET 60 MG, 90 MG (ticagrelor) PB CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) NF cilostazol oral tablet 100 mg, 50 mg G CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT (c1 esterase inhibitor NPSB (human)) clopidogrel bisulfate oral tablet 300 mg, 75 mg G COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT (coagulation NPSB factor x (human))

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

157 Prescription Drug Name Drug Tier Drug Notes DEFITELIO INTRAVENOUS SOLUTION 200 MG/2.5ML NF (defibrotide sodium) dipyridamole oral tablet 25 mg, 50 mg, 75 mg G DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 162.5 MG (aspirin) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant NPSB cmplx) FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML PSB (icatibant acetate) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT (c1 esterase NPSB inhibitor (human)) HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML NPSB (emicizumab-kxwh) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 NPSB UNIT (antihemophilic factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500- NPSB 1200 UNIT (antihemophilic factor-vwf) icatibant acetate subcutaneous solution 30 mg/3ml G IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, NPSB 3500 UNIT, 500 UNIT (coagulation factor ix (rix-fp)) IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NPSB 250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix (recomb)) JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT (ahf (bdd- PSB rfviii peg-aucl)) KENGREAL INTRAVENOUS SOLUTION NF RECONSTITUTED 50 MG (cangrelor tetrasodium) KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT NPSB (antihemophilic factor)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

158 Prescription Drug Name Drug Tier Drug Notes KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT NPSB (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihemophilic PSB factor (recomb)) KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, PSB 3000 UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) MONONINE INTRAVENOUS SOLUTION NPSB RECONSTITUTED 1000 UNIT (coagulation factor ix) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSB 250 UNIT, 3000 UNIT, 500 UNIT (antihemophil fact bd truncated) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation NPSB factor viia recomb) NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT PSB (antihem fact (bdd-rfviii,sim)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, PSB 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihem fact (bdd-rfviii,sim)) pentoxifylline er oral tablet extended release 400 mg G PLAVIX ORAL TABLET 75 MG (clopidogrel bisulfate) NF prasugrel hcl oral tablet 10 mg, 5 mg G PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT NPSB (factor ix complex) REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT PSB (coagulation factor ix glycopeg) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, NPSB 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT (antihemophilic factor (recomb))

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

159 Prescription Drug Name Drug Tier Drug Notes RETAVASE HALF-KIT INTRAVENOUS KIT 1 X 10 NF UNIT (reteplase) RETAVASE INTRAVENOUS KIT 2 X 10 UNIT (reteplase) NF rixubis intravenous solution reconstituted 1000 unit, 2000 unit, NPSB 250 unit, 3000 unit, 500 unit RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT (c1 esterase inhibitor PSB (recomb)) SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML NPSB (eculizumab) TAKHZYRO SUBCUTANEOUS SOLUTION 300 PSB MG/2ML (lanadelumab-flyo) TAVALISSE ORAL TABLET 100 MG, 150 MG NF (fostamatinib disodium) ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/30ML NF (ravulizumab-cwvz) WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 NPSB UNIT (antihemophilic factor-vwf) XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, NPSB 250 UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem fact NPSB (bdd-rfviii,mor)) YOSPRALA ORAL TABLET DELAYED RELEASE 325- NF 40 MG, 81-40 MG (aspirin-omeprazole) ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) NF *HEMATOPOIETIC AGENTS* - DRUGS FOR NUTRITION cyanocobalamin-methylcobalamin (Abaneu-Sl Sublingual G Tablet Sublingual 600-600 Mcg) active fe oral tablet 75-1.25 mg NPB ADAKVEO INTRAVENOUS SOLUTION 100 MG/10ML NPB (crizanlizumab-tmca) folic acid-vit b6-vit b12 (Airavite Oral Tablet 2.5-25-1 Mg) G ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, PSB 40 MCG/ML, 60 MCG/ML (darbepoetin alfa)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

160 Prescription Drug Name Drug Tier Drug Notes ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 PSB MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML (darbepoetin alfa) b-6 folic acid oral capsule 8.333-100-1 mg NPB bp vit 3 oral capsule 1 mg NPB CENFOL ORAL TABLET 2.3-24.5-2 MG (folic acid-vit b6- NPB vit b12) CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) PSB CEREZYME INTRAVENOUS SOLUTION PSB RECONSTITUTED 400 UNIT (imiglucerase) CIFEREX ORAL CAPSULE 1-3775 MG-UNIT (folic acid- NF cholecalciferol) iron-folic acid-c-b6-b12-zinc (Corvita 150 Oral Tablet 150-1.25 G Mg) CORVITE 150 ORAL TABLET (iron combinations) NPB corvite fe oral tablet NPB cvs folic acid oral tablet 800 mcg CE cyanocobalamin injection solution 1000 mcg/ml G DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG NPB (hydroxyurea) durachol oral capsule 1-3775 mg-unit NF ENDARI ORAL PACKET 5 GM (glutamine (sickle cell)) NPB FA-8 ORAL CAPSULE 0.8 MG (folic acid) CE FA-8 ORAL TABLET 800 MCG (folic acid) CE fabb oral tablet 2.2-25-1 mg G fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg G FERIVA 21/7 ORAL TABLET 75-1 MG (feasp-b12-fa-c-dss- NF succac-zn) ferocon oral capsule G ferotrinsic oral capsule G ferraplus 90 oral tablet 90-1 mg NPB fe fum-fa-b cmp-c-zn-mg-mn-cu (Ferrocite Plus Oral Tablet G 106-1 Mg)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

161 Prescription Drug Name Drug Tier Drug Notes FERRO-PLEX HEMATINIC ORAL TABLET 115-1 MG NPB (fe fum-dss-c-e-b12-if-fa) FERROTRIN ORAL CAPSULE (iron-b12-vit c-fa-ifc) NPB folbee oral tablet 2.5-25-1 mg G folic acid injection solution 5 mg/ml G folic acid oral capsule 0.8 mg CE folic acid oral tablet 1 mg CE FOLI-D ORAL TABLET 1-2000 MG-UNIT (folic acid- NF cholecalciferol) folite oral tablet NF FOLIVANE-F ORAL CAPSULE 125-1 MG (fe fum-fepoly- NPB fa-vit c-vit b3) FOLIVANE-PLUS ORAL CAPSULE (fefum-fepoly-fa-b NPB cmp-c-biot) folplex 2.2 oral tablet 2.2-25-0.5 mg G foltrin oral capsule G folic acid-cholecalciferol (Folvite-D Oral Tablet 1-3775 Mg- NF Unit) FUSION PLUS ORAL CAPSULE (iron-fa-b cmp-c-biot- NPB probiotic) GENICIN VITA-D ORAL TABLET 1-3775 MG-UNIT NF (folic acid-cholecalciferol) hematinic plus vit/minerals oral tablet 106-1 mg G hematinic/folic acid oral tablet 324-1 mg G HEMOCYTE PLUS ORAL CAPSULE 106-1 MG (fe fum-fa- NPB b cmp-c-zn-mg-mn-cu) ferrous fumarate-folic acid (Hemocyte-F Oral Tablet 324-1 G Mg) hemocyte-plus oral tablet 106-1 mg G hydroxocobalamin acetate intramuscular solution 1000 mcg/ml G ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG (iron- NF vit c-vit b12-folic acid) iron polysacch cmplx-b12-fa (Iferex 150 Forte Oral Capsule G 150-25-1 Mg-Mcg-Mg) INTEGRA F ORAL CAPSULE 125-1 MG (fe fum-fepoly-fa- NPB vit c-vit b3)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

162 Prescription Drug Name Drug Tier Drug Notes INTEGRA PLUS ORAL CAPSULE (fefum-fepoly-fa-b cmp- NPB c-biot) fefum-fepo-fa-b cmp-c-zn-mn-cu (K-Tan Plus Oral Capsule G 162-115.2-1 Mg) LEUKINE INJECTION SOLUTION RECONSTITUTED NPSB 250 MCG (sargramostim) miglustat oral capsule 100 mg G MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 NF MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML (methoxy peg-epoetin beta) MULPLETA ORAL TABLET 3 MG (lusutrombopag) PSB MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe NPB asp gly-succ-c-thre-b12-fa) MULTIGEN ORAL TABLET 70 MG (fe-succ-c-thre-b12-des NPB stomach) MULTIGEN PLUS ORAL TABLET 50-101-1 MG (feasp- NPB fefum -suc-c-thre-b12-fa) NASCOBAL NASAL SOLUTION 500 MCG/0.1ML NPB (cyanocobalamin) NEULASTA ONPRO SUBCUTANEOUS PREFILLED PSB SYRINGE KIT 6 MG/0.6ML (pegfilgrastim) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED PSB SYRINGE 6 MG/0.6ML (pegfilgrastim) NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 PSB MCG/1.6ML (filgrastim-aafi) NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim- PSB aafi) NPLATE SUBCUTANEOUS SOLUTION NPSB RECONSTITUTED 250 MCG, 500 MCG (romiplostim) NUFERA ORAL TABLET (iron combinations) NPB folic acid-vit b6-vit b12 (Nufol Oral Tablet 2.5-25-1 Mg) G ortho df oral capsule 1-3775 mg-unit NF poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg G polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

163 Prescription Drug Name Drug Tier Drug Notes PROMACTA ORAL PACKET 12.5 MG, 25 MG NPSB (eltrombopag olamine) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 NPSB MG (eltrombopag olamine) RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 PSB UNIT/ML (epoetin alfa-epbx) revesta oral capsule 1-5750 mg-unit NF SIKLOS ORAL TABLET 100 MG, 1000 MG (hydroxyurea) NPB sm folic acid oral tablet 400 mcg CE TALIVA ORAL CAPSULE 1 MG (fa-b6-b12-omega 3- NF phytosterols) taron forte oral capsule NPB tl-hem 150 oral tablet 150-1 mg G fe fumarate-b12-vit c-fa-ifc (Tricon Oral Capsule) G TRIFERIC HEMODIALYSIS PACKET 272 MG (ferric NF pyrophosphate citrate) TRIFERIC HEMODIALYSIS SOLUTION 27.2 MG/5ML NF (ferric pyrophosphate citrate) trigels-f forte oral capsule 460-60-0.01-1 mg G UDENYCA SUBCUTANEOUS SOLUTION PREFILLED PSB SYRINGE 6 MG/0.6ML (pegfilgrastim-cbqv) virt-fefa plus oral capsule NF folic acid-vit b6-vit b12 (Virt-Gard Oral Tablet 2.2-25-1 Mg) G VITAMEZ ORAL CAPSULE 1 MG (fa-b6-b12-omega 3- NPB phytosterols) VPRIV INTRAVENOUS SOLUTION RECONSTITUTED NPSB 400 UNIT (velaglucerase alfa) yl folic acid oral tablet 400 mcg CE ZAVESCA ORAL CAPSULE 100 MG (miglustat) NPB *HEMOSTATICS* - DRUGS FOR THE BLOOD AMICAR ORAL SOLUTION 0.25 GM/ML (aminocaproic NF acid) aminocaproic acid oral tablet 1000 mg, 500 mg G ARTISS EXTERNAL SOLUTION (fibrin sealant component) NPB GEL-FLOW EXTERNAL KIT (gelatin absorb-thrombin) NF 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

164 Prescription Drug Name Drug Tier Drug Notes GELFOAM-JMI POWDER EXTERNAL KIT (gelatin NF absorb-thrombin) GELFOAM-JMI SPONGE EXTERNAL KIT (gelatin NF absorb-thrombin) RECOTHROM EXTERNAL SOLUTION NPB RECONSTITUTED 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION NPB RECONSTITUTED 20000 UNIT (thrombin (recombinant)) THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 NPB UNIT (thrombin) THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 NPB UNIT (thrombin) THROMBIN-JMI EXTERNAL SOLUTION NPB RECONSTITUTED 20000 UNIT, 5000 UNIT (thrombin) THROMBOGEN EXTERNAL KIT 10000 UNIT (thrombin) NPB THROMBOGEN EXTERNAL SOLUTION NPB RECONSTITUTED 1000 UNIT, 10000 UNIT (thrombin) TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML (fibrin NPB sealant component) TISSEEL EXTERNAL SOLUTION (fibrin sealant NPB component) tranexamic acid oral tablet 650 mg G *HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS* - DRUGS FOR THE NERVOUS SYSTEM BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 NF MG (suvorexant) EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 NF MG, 5 MG (zolpidem tartrate) estazolam oral tablet 1 mg, 2 mg G eszopiclone oral tablet 1 mg, 2 mg, 3 mg G flurazepam hcl oral capsule 15 mg, 30 mg G HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) NPB INTERMEZZO SUBLINGUAL TABLET SUBLINGUAL NF 1.75 MG (zolpidem tartrate) LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG NF (eszopiclone) midazolam hcl oral syrup 2 mg/ml G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

165 Prescription Drug Name Drug Tier Drug Notes mko melt dose pack mouth/throat troche 3-25-2 mg NF phenobarbital oral elixir 20 mg/5ml G phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 G mg, 60 mg, 64.8 mg, 97.2 mg PRECEDEX INTRAVENOUS SOLUTION 1000 NPB MCG/250ML (dexmedetomidine hcl in nacl) quazepam oral tablet 15 mg NF ramelteon oral tablet 8 mg G ROZEREM ORAL TABLET 8 MG (ramelteon) NF SECONAL ORAL CAPSULE 100 MG (secobarbital sodium) NPB SILENOR ORAL TABLET 3 MG, 6 MG (doxepin hcl) NF temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg G triazolam oral tablet 0.125 mg, 0.25 mg G zaleplon oral capsule 10 mg, 5 mg G zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 G mg zolpidem tartrate oral tablet 10 mg, 5 mg G zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg G ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem NF tartrate) *LAXATIVES* - DRUGS FOR THE STOMACH ALOPHEN ORAL TABLET DELAYED RELEASE 5 MG CE (bisacodyl) bisacodyl ec oral tablet delayed release 5 mg CE bisacodyl rectal suppository 10 mg CE cascara sagrada oral fluid extract 1 gm/ml NPB CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM - NF GM/160ML (sod picosulfate-mag ox-cit acd) constulose oral solution 10 gm/15ml G correct oral tablet delayed release 5 mg CE CORRECTOL ORAL TABLET DELAYED RELEASE 5 CE MG (bisacodyl) cvs c-lax laxative oral tablet delayed release 5 mg CE ducodyl oral tablet delayed release 5 mg CE eq womens laxative oral tablet delayed release 5 mg CE 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

166 Prescription Drug Name Drug Tier Drug Notes eql gentle laxative oral tablet delayed release 5 mg CE eql laxative oral tablet delayed release 5 mg CE FEENAMINT ORAL TABLET DELAYED RELEASE 5 CE MG (bisacodyl) GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 CE GM (peg 3350-kcl-nabcb-nacl-nasulf) peg 3350-kcl-nabcb-nacl-nasulf (Gavilyte-G Oral Solution CE Reconstituted 236 Gm) bisacodyl-peg-kcl-nabicar-nacl (Gavilyte-H Oral Kit 5-210 Mg- CE Gm) peg 3350-kcl-na bicarb-nacl (Gavilyte-N With Flavor Pack CE Oral Solution Reconstituted 420 Gm) gentle laxative oral tablet delayed release 5 mg CE GIALAX ORAL KIT (polyethylene glycol 3350) NF GNP BISA-LAX ORAL TABLET DELAYED RELEASE 5 CE MG (bisacodyl) gnp gentle laxative oral tablet delayed release 5 mg CE gnp gentle laxative rectal suppository 10 mg CE gnp laxative rectal suppository 10 mg CE gnp womens gentle laxative oral tablet delayed release 5 mg CE hm laxative oral tablet delayed release 5 mg CE hm laxative rectal suppository 10 mg CE kp bisacodyl oral tablet delayed release 5 mg CE KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) NPB lactulose oral packet 10 gm NF lactulose oral solution 10 gm/15ml, 20 gm/30ml G laxative oral tablet delayed release 5 mg CE laxative rectal suppository 10 mg CE mineral oil heavy oral oil G MOVIPREP ORAL SOLUTION RECONSTITUTED 100 NF GM (peg-kcl-nacl-nasulf-na asc-c) OSMOPREP ORAL TABLET 1.102-0.398 GM (sod phos NF mono-sod phos dibasic) PCP 100 COMBINATION KIT (mgcit-bisacod-pet-peg- NF metoclop)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

167 Prescription Drug Name Drug Tier Drug Notes peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm CE peg-3350/electrolytes oral solution reconstituted 236 gm CE bisacodyl-peg-kcl-nabicar-nacl (Peg-Prep Oral Kit 5-210 Mg- CE Gm) PLENVU ORAL SOLUTION RECONSTITUTED 140 GM NF (peg-kcl-nacl-nasulf-na asc-c) qc gentle laxative oral tablet delayed release 5 mg CE qc gentle laxative rectal suppository 10 mg CE ra fast relief laxative rectal suppository 10 mg CE ra laxative oral tablet delayed release 5 mg CE ra stimulant laxative rectal suppository 10 mg CE sb bisacodyl laxative ec oral tablet delayed release 5 mg CE sb laxative rectal suppository 10 mg CE sm gentle laxative oral tablet delayed release 5 mg CE sm laxative rectal suppository 10 mg CE SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13- CE 1.6 GM/177ML (na sulfate-k sulfate-mg sulf) THE MAGIC BULLET RECTAL SUPPOSITORY 10 MG CE (bisacodyl) peg 3350-kcl-na bicarb-nacl (Trilyte Oral Solution CE Reconstituted 420 Gm) veracolate oral tablet delayed release 5 mg CE womans laxative oral tablet delayed release 5 mg CE *LOCAL ANESTHETICS-PARENTERAL* - DRUGS FOR PAIN AND FEVER bupivacaine hcl injection solution 0.125 % NPB lidocaine in dextrose solution 5-7.5 % NPB lidomark 2/5 injection kit 2 % NPB READYSHARP-A INJECTION KIT 1 & 0.5 % (lidocaine NF hcl-bupivacaine hcl) reck solution prefilled syringe 123-0.25-0.04- 15 mg/50ml NF ZINGO INTRADERMAL JET-INJECTOR 0.5 MG NF (lidocaine hcl) *MACROLIDES* - DRUGS FOR INFECTIONS azithromycin oral packet 1 gm G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

168 Prescription Drug Name Drug Tier Drug Notes azithromycin oral suspension reconstituted 100 mg/5ml, 200 G mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg G clarithromycin er oral tablet extended release 24 hour 500 mg G clarithromycin oral suspension reconstituted 125 mg/5ml, 250 G mg/5ml clarithromycin oral tablet 250 mg, 500 mg G DIFICID ORAL TABLET 200 MG (fidaxomicin) PB E.E.S. 400 ORAL TABLET 400 MG (erythromycin G ethylsuccinate) E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML (erythromycin NF ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED NF 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 400 ORAL SUSPENSION RECONSTITUTED NF 400 MG/5ML (erythromycin ethylsuccinate) erythromycin base (Ery-Tab Oral Tablet Delayed Release 250 G Mg, 333 Mg, 500 Mg) ERYTHROCIN STEARATE ORAL TABLET 250 MG G (erythromycin stearate) erythromycin base oral capsule delayed release particles 250 mg G erythromycin base oral tablet 250 mg, 500 mg G erythromycin ethylsuccinate oral suspension reconstituted 200 G mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg G erythromycin oral tablet delayed release 250 mg, 333 mg, 500 G mg *MEDICAL DEVICES AND SUPPLIES* - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT 1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , NF 31g x 8 mm , 32g x 4 mm , 32g x 6 mm , 33g x 4 mm 1st tier unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm , 33g x 4 mm 1st tier unilet comfortouch NPB ABOUTTIME PEN NEEDLE 30G X 8 MM , 31G X 5 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

169 Prescription Drug Name Drug Tier Drug Notes ACCU-CHEK AVIVA CONNECT KIT W/DEVICE (blood PB glucose monitoring suppl) ACCU-CHEK AVIVA DEVICE (blood glucose monitoring PB suppl) ACCU-CHEK AVIVA PLUS KIT W/DEVICE (blood PB glucose monitoring suppl) ACCU-CHEK COMBO KIT (insulin infusion pump) NF ACCU-CHEK COMPACT PLUS CARE KIT (blood glucose PB monitoring suppl) ACCU-CHEK FASTCLIX LANCET KIT (lancets misc.) PB ACCU-CHEK FASTCLIX LANCETS (lancets) PB ACCU-CHEK FLEXLINK PLUS 10MM (insulin infusion NPB pump supplies) ACCU-CHEK FLEXLINK PLUS 6MM (insulin infusion NPB pump supplies) ACCU-CHEK FLEXLINK PLUS 8MM (insulin infusion NPB pump supplies) ACCU-CHEK GUIDE KIT W/DEVICE (blood glucose PB monitoring suppl) ACCU-CHEK GUIDE ME KIT W/DEVICE (blood glucose PB monitoring suppl) ACCU-CHEK LINKASSIST (insulin pump accessories) NPB ACCU-CHEK MULTICLIX LANCET DEV KIT (lancets PB misc.) ACCU-CHEK MULTICLIX LANCETS (lancets) PB ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE PB (blood glucose monitoring suppl) ACCU-CHEK PLASTIC CARTRIDGE (insulin infusion NPB pump supplies) ACCU-CHEK RAPID-D INFUSION SET (insulin infusion NPB pump supplies) ACCU-CHEK RAPID-D LINK (insulin infusion pump NPB supplies) ACCU-CHEK SAFE-T PRO LANCETS (lancets) NPB ACCU-CHEK SOFTCLIX LANCET DEV KIT (lancets PB misc.) ACCU-CHEK SOFTCLIX LANCETS (lancets) PB 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

170 Prescription Drug Name Drug Tier Drug Notes ACCU-CHEK SPIRIT BATTERY KIT (insulin pump NPB accessories) ACCU-CHEK SPIRIT INSULIN PUMP KIT (insulin NF infusion pump) ACCU-CHEK TENDER II SET 24" (insulin infusion pump NPB supplies) ACCU-CHEK TENDER II SET 31" (insulin infusion pump NPB supplies) ACCU-CHEK TENDER II SET 43" (insulin infusion pump NPB supplies) ACCU-CHEK ULTRAFLEX INF SET (insulin infusion NPB pump supplies) ACCU-CHEK ULTRAFLEX-1 INF SET (insulin infusion NPB pump supplies) acti-lance 28g NPB acti-lance lite lancets 28g NPB acti-lance special lancets 17g NPB acti-lance universal 23g NPB adjustable lancing device NPB ADVANCE INTUITION METER DEVICE (blood glucose NF monitoring suppl) ADVANCE INTUITION MONITOR KIT (blood glucose NF monitoring suppl) ADVANCE MICRO-DRAW METER DEVICE (blood NF glucose monitoring suppl) ADVOCATE BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) ADVOCATE BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) ADVOCATE INSULIN PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 33G X 4 MM (insulin pen NF needle) ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

171 Prescription Drug Name Drug Tier Drug Notes ADVOCATE LANCETS 30G (lancets) NPB ADVOCATE LANCING DEVICE (lancet devices) NPB ADVOCATE RAPID-SAFE LANCING (lancet devices) NPB ADVOCATE REDI-CODE DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE KIT W/DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE+ DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE+ TALKING KIT W/DEVICE NF (blood glucose monitoring suppl) ADVOCATE SAFETY LANCETS (lancets) NPB ADVOCATE SAFETY LANCETS 26G (lancets) NPB AGAMATRIX AMP DEVICE (blood glucose monitoring NF suppl) AGAMATRIX JAZZ WIRELESS 2 KIT W/DEVICE (blood NF glucose monitoring suppl) AGAMATRIX PRESTO KIT W/DEVICE (blood glucose NF monitoring suppl) AGAMATRIX PRESTO PRO METER DEVICE (blood NF glucose monitoring suppl) AGAMATRIX ULTRA-THIN LANCETS (lancets) NPB aimsco twist lancets 32g NPB AIMSCO TWIST LANCETS 33G (lancets) NPB ALCOH-GLOVE CONTOURED WIPE PAD (alcohol NPB swabs) alcohol pads pad 70 % NPB alcohol prep pad NPB alcohol prep pad 70 % NPB alcohol swabs pad NPB ALCOHOL SWABSTICK PAD 70 % (alcohol swabs) NPB alcohol wipes pad 70 % NPB alcoh-wipe sheet NPB alternate site lancing device NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

172 Prescription Drug Name Drug Tier Drug Notes AMD FOAM DRESSING PAD 3-1/2"X3" , 4"X4" , 6"X6" NPB (gauze pads & dressings) APLICARE ALCOHOL SWABSTICK PAD 70 % (alcohol NPB swabs) AQUALANCE LANCETS 30G (lancets) NPB ASSURE 3 METER KIT (blood glucose monitoring suppl) NF ASSURE 4 METER DEVICE (blood glucose monitoring NF suppl) assure comfort lancets 28g NPB ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) ASSURE ID SAFETY PEN NEEDLES 30G X 5 MM , 30G NF X 8 MM , 31G X 5 MM (insulin pen needle) ASSURE LANCETS (lancets) NPB ASSURE PLATINUM METER DEVICE (blood glucose NF monitoring suppl) ASSURE PRO BLOOD GLUCOSE METER DEVICE NF (blood glucose monitoring suppl) aurora lancet super thin 30g NPB aurora lancet thin 23g NPB aurora pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF aurora unifine pentips 31g x 5 mm , 32g x 4 mm NF AUTO-LANCET (lancet devices) NPB AUTO-LANCET MINI (lancet devices) NPB AUTOLET II CLINISAFE KIT (lancets misc.) NPB AUTOLET LITE CLINISAFE KIT (lancets misc.) NPB AUTOLET LITE STARTER PACK KIT (lancets misc.) NPB AUTOLET MINI (lancet devices) NPB AUTOLET PLATFORMS (lancets misc.) NPB AUTOLET PLUS (lancet devices) NPB autopen device NPB AUTOSOFT 30 INFUSION SET (insulin infusion pump NPB supplies) AUTOSOFT 90 INFUSION SET (insulin infusion pump NPB supplies)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

173 Prescription Drug Name Drug Tier Drug Notes AUTOSOFT XC INFUSION SET (insulin infusion pump NPB supplies) BD AUTOSHIELD 29G X 5MM , 29G X 8MM (insulin pen PB needle) BD AUTOSHIELD DUO 30G X 5 MM (insulin pen needle) PB BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 29G PB X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (insulin syringe-needle PB u-100) BD INSULIN SYRINGE U/F 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 1 ML (insulin PB syringe-needle u-100) BD INSULIN SYRINGE U-100 1 ML (insulin syringes PB (disposable)) BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML PB (insulin syringe/needle u-500) BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 PB ML (insulin syringe-needle u-100) BD LANCET ULTRAFINE 30G (lancets) NPB BD LANCET ULTRAFINE 33G (lancets) NPB BD LATITUDE DIABETES KIT (blood glucose monitoring NF suppl) BD LATITUDE DIABETES SYSTEM KIT (blood glucose NF monitoring suppl) BD LOGIC BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) BD MICROTAINER LANCETS (lancets) NPB BD PEN (injection device for insulin) NPB BD PEN MINI (injection device for insulin) NPB BD PEN NEEDLE MICRO U/F 32G X 6 MM (insulin pen PB needle) BD PEN NEEDLE MINI U/F 31G X 5 MM (insulin pen PB needle)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

174 Prescription Drug Name Drug Tier Drug Notes BD PEN NEEDLE NANO 2ND GEN 32G X 4 MM (insulin PB pen needle) BD PEN NEEDLE NANO U/F 32G X 4 MM (insulin pen PB needle) BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM (insulin PB pen needle) BD PEN NEEDLE SHORT U/F 31G X 8 MM (insulin pen PB needle) BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X PB 15/64" 1 ML (insulin syringe-needle u-100) BD SWABS SINGLE USE BUTTERFLY PAD (alcohol NPB swabs) BD VEO INSULIN SYR U/F 1/2UNIT 31G X 15/64" 0.3 ML PB (insulin syringe-needle u-100) BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML PB (insulin syringe-needle u-100) BIOFREQUENCY INSOLES (foot care products) NPB BIOGUARD GAUZE SPONGES PAD 2"X2" , 4"X4" (gauze NPB pads & dressings) BIOGUARD ISLAND DRESSINGS PAD 4"X10" , 4"X14" , NPB 4"X5" (gauze pads & dressings) BIOGUARD NON-ADHERENT DRESSING PAD 3"X4" , NPB 3"X8" (gauze pads & dressings) BIOTEL CARE BLOOD GLUCOSE SYST KIT W/DEVICE NF (blood glucose monitoring suppl) blood glucose monitor system kit w/device NF blood glucose system pak kit NF bullseye mini safety lancets NPB BULLSEYE SAFETY LANCETS (lancets) NPB CARDIOCOM LANCING DEVICE (lancet devices) NPB CAREFINE PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , NF 32G X 6 MM (insulin pen needle) careone advanced lancing dev NPB CAREONE BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

175 Prescription Drug Name Drug Tier Drug Notes careone insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" NF 1 ml careone lancet thin 23g NPB careone lancet ultra thin 28g NPB careone unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , NF 31g x 8 mm , 32g x 4 mm careone unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm CARESENS N GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) CARESENS N VOICE SYSTEM DEVICE (blood glucose NF monitoring suppl) CARETOUCH ALCOHOL PREP PAD 70 % (alcohol swabs) NPB CARETOUCH INSULIN SYRINGE 28G X 5/16" 1 ML, NF 29G X 5/16" 1 ML (insulin syringe-needle u-100) CARETOUCH LANCING/EJECTOR (lancet devices) NPB CARETOUCH MONITOR SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) CARETOUCH PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM (insulin NF pen needle) CARETOUCH SAFETY LANCETS (lancets) NPB CARETOUCH SAFETY LANCETS 26G (lancets) NPB CARETOUCH TWIST LANCETS 28G (lancets) NPB CARETOUCH TWIST LANCETS 30G (lancets) NPB CARETOUCH TWIST LANCETS 33G (lancets) NPB CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) CE CEQUR SIMPLICITY INSERTER (injection device for NPB insulin) CHOICE DM DIABETES RISK TEST KIT (blood glucose NF monitoring suppl) cicatrace pad sheet NF CLEANLET LANCETS 28G (lancets) NPB CLEVER CHEK AUTO-CODE SYSTEM DEVICE (blood NF glucose monitoring suppl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

176 Prescription Drug Name Drug Tier Drug Notes CLEVER CHEK AUTO-CODE VOICE DEVICE (blood NF glucose monitoring suppl) CLEVER CHEK LANCETS (lancets) NPB CLEVER CHEK SYSTEM KIT W/DEVICE (blood glucose NF monitoring suppl) CLEVER CHOICE AUTO-CODE SYSTEM DEVICE NF (blood glucose monitoring suppl) CLEVER CHOICE COMFORT EZ 29G X 12MM , 33G X 4 NF MM (insulin pen needle) CLEVER CHOICE LANCETS 21G (lancets) NPB CLEVER CHOICE LANCETS 23G (lancets) NPB CLEVER CHOICE LANCETS 28G (lancets) NPB CLEVER CHOICE MICRO SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) CLEVER CHOICE MINI SYSTEM DEVICE (blood glucose NF monitoring suppl) CLEVER CHOICE TALK SYSTEM DEVICE (blood glucose NF monitoring suppl) CLICKFINE PEN NEEDLES 31G X 5 MM (insulin pen NF needle) clickfine pen needles 31g x 6 mm , 31g x 8 mm , 32g x 4 mm NF COAGUCHEK LANCETS (lancets) NPB COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" NF 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) comfort assured lancets 28g NPB comfort assured lancets 33g NPB COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, NF 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) COMFORT EZ MICRO PEN NEEDLES 32G X 4 MM NF (insulin pen needle)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

177 Prescription Drug Name Drug Tier Drug Notes COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 NF MM , 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM , 33G X 8 MM (insulin pen needle) COMFORT EZ SHORT PEN NEEDLES 31G X 8 MM NF (insulin pen needle) comfort lancets NPB COMFORT SHORT INF SET 23"/13MM (insulin infusion NPB pump supplies) COMFORT SHORT INF SET 31"/13MM (insulin infusion NPB pump supplies) COMFORT SHORT INF SET 43"/13MM (insulin infusion NPB pump supplies) CONTOUR MONITOR DEVICE (blood glucose monitoring NF suppl) CONTOUR NEXT EZ KIT W/DEVICE (blood glucose NF monitoring suppl) CONTOUR NEXT LINK KIT W/DEVICE (blood glucose NF monitoring suppl) CONTOUR NEXT MONITOR KIT W/DEVICE (blood NF glucose monitoring suppl) CONTOUR NEXT ONE KIT (blood glucose monitoring NF suppl) COOL MONITOR DEVICE (blood glucose monitoring suppl) NF COOL MONITOR KIT KIT W/DEVICE (blood glucose NF monitoring suppl) CURITY ALCOHOL PREPS PAD 70 % (alcohol swabs) NPB CURITY ALCOHOL SWABS PAD (alcohol swabs) NPB CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4" NPB (gauze pads & dressings) CURITY AMD ANTIMICROBIAL STRIP (gauze pads & NPB dressings) CURITY IODOFORM PACKING STRIP (gauze pads & NPB dressings) CURITY WOUND CLOSURE 1/2"X4" (adhesive bandages) NPB CURITY WOUND CLOSURE 1/4"X1.5" (adhesive NPB bandages)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

178 Prescription Drug Name Drug Tier Drug Notes CURITY WOUND CLOSURE 1/4"X3" (adhesive bandages) NPB CURITY WOUND CLOSURE 1/4"X4" (adhesive bandages) NPB CURITY WOUND CLOSURE 1/8"X3" (adhesive bandages) NPB CVS BLOOD GLUCOSE METER KIT W/DEVICE (blood NF glucose monitoring suppl) cvs lancets 21g NPB cvs lancets micro thin 33g NPB cvs lancets original NPB cvs lancets thin 26g NPB cvs lancets ultra thin 30g NPB cvs lancets ultra-thin 30g NPB cvs lancing device NPB cvs prep pad 70 % NPB cvs ultra thin lancets NPB D-CARE GLUCOMETER KIT W/DEVICE (blood glucose NF monitoring suppl) DELTEC COZMO CLEO SET 42" 6MM (insulin infusion NPB pump supplies) DELTEC COZMO CLEO SET 42" 9MM (insulin infusion NPB pump supplies) DEXCOM G4 PLAT PED RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G4 PLATINUM RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous PB blood gluc transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) PB DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood PB gluc sensor) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous PB blood gluc receiver)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

179 Prescription Drug Name Drug Tier Drug Notes DEXCOM G5 MOBILE TRANSMITTER (continuous blood PB gluc transmit) DEXCOM G5 RECEIVER KIT DEVICE (continuous blood PB gluc receiver) DEXCOM G6 RECEIVER DEVICE (continuous blood gluc PB receiver) DEXCOM G6 SENSOR (continuous blood gluc sensor) PB DEXCOM G6 TRANSMITTER (continuous blood gluc PB transmit) DIATHRIVE BLOOD GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) DIATHRIVE LANCET ULTRA THIN 30 (lancets) NPB DIATHRIVE LANCETS (lancets) NPB DIATHRIVE LANCING DEVICE (lancet devices) NPB DIATHRIVE PEN NEEDLE 31G X 5 MM , 31G X 6 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) DIATHRIVE+ GLUCOSE MONITOR DEVICE (blood NF glucose monitoring suppl) diatrue plus blood glucose device NF DROPLET INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G NF X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) DROPLET LANCETS ULTRA THIN 30G (lancets) NPB DROPLET LANCING DEVICE (lancet devices) NPB DROPLET MICRON 34G X 3.5 MM (insulin pen needle) NF DROPLET PEN NEEDLES 29G X 10MM , 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , NF 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 32G X 8 MM (insulin pen needle) dropsafe safety pen needles 31g x 6 mm , 31g x 8 mm NF drug mart lancets thin 26g NPB DRUG MART ON-THE-GO LANCET 30G (lancets) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

180 Prescription Drug Name Drug Tier Drug Notes drug mart unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm drug mart unifine pentips plus 32g x 4 mm NF easy comfort alcohol pads pad NPB easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.5 ml, 31g x NF 5/16" 1 ml, 32g x 5/16" 0.5 ml, 32g x 5/16" 1 ml easy comfort lancets NPB easy comfort lancets twist top NPB easy comfort pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm NF , 32g x 4 mm , 33g x 4 mm , 33g x 5 mm , 33g x 6 mm easy glide pen needles 33g x 4 mm NF easy mini eject lancing device NPB easy mini lancing device NPB easy plus ii glucose system device NF EASY STEP GLUCOSE MONITOR DEVICE (blood glucose NF monitoring suppl) easy talk blood glucose system device NF EASY TOUCH ALCOHOL PREP MEDIUM PAD 70 % NPB (alcohol swabs) EASY TOUCH FLIPLOCK INSULIN SY 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) EASY TOUCH GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 NF ML (insulin syringe-needle u-100) EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X NF 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u- 100) EASY TOUCH LANCETS 21G (lancets) NPB EASY TOUCH LANCETS 23G (lancets) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

181 Prescription Drug Name Drug Tier Drug Notes EASY TOUCH LANCETS 28G (lancets) NPB EASY TOUCH LANCETS 30G (lancets) NPB EASY TOUCH LANCETS 32G (lancets) NPB EASY TOUCH LANCING DEVICE (lancet devices) NPB EASY TOUCH PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 NF MM , 32G X 5 MM , 32G X 6 MM (insulin pen needle) EASY TOUCH SAFETY PEN NEEDLES 29G X 5MM , NF 29G X 8MM , 30G X 8 MM (insulin pen needle) EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) easy trak blood glucose system device NF easy trak ii blood glucose sys device NF EASYGLUCO KIT (blood glucose monitoring suppl) NF EASYMAX NG BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) EASYMAX NG BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) EASYMAX V BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) EASYMAX V BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) EASYPRO BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) EASYPRO PLUS KIT W/DEVICE (blood glucose monitoring NF suppl) ELEMENT AUTOCODE SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) element compact glucose system device NF element compact v glucose sys device NF ELEMENT PLUS DEVICE (blood glucose monitoring suppl) NF EMBRACE BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) EMBRACE EVO GLUCOSE MONITORING KIT NF W/DEVICE (blood glucose monitoring suppl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

182 Prescription Drug Name Drug Tier Drug Notes EMBRACE LANCETS ULTRA THIN 30G (lancets) NPB EMBRACE PRO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) EMBRACE TALK BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) EMBRACE TALK MONITORING SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) NF ENLITE SERTER (insulin infusion pump supplies) NPB eql alcohol swabs pad 70 % NPB eql color lancets 21g NPB eql color lancets micro 33g NPB eql insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 NF ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml eql super thin lancets 30g NPB eql thin lancets 26g NPB EROS-CTD DEVICE (clitoral vacuum device) NPB EVENCARE G2 MONITOR DEVICE (blood glucose NF monitoring suppl) EVENCARE G3 MONITOR DEVICE (blood glucose NF monitoring suppl) EVENCARE GLUCOSE MONITORING KIT (blood NF glucose monitoring suppl) EVENCARE MINI MONITOR DEVICE (blood glucose NF monitoring suppl) EVERSENSE SENSOR/HOLDER (continuous blood gluc NF sensor) EVERSENSE SMART TRANSMITTER (continuous blood NF gluc transmit) EVOLUTION AUTOCODE DEVICE (blood glucose NF monitoring suppl) EXCILON AMD DRAIN SPONGES PAD 4"X4" (gauze NPB pads & dressings)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

183 Prescription Drug Name Drug Tier Drug Notes EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 NF ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) EXEL COMFORT POINT PEN NEEDLE 29G X 12MM , 31G X 4 MM , 31G X 6 MM , 31G X 8 MM (insulin pen NF needle) E-Z JECT LANCET MICRO-THIN 33G (lancets) NPB E-Z JECT LANCET SUPER THIN 30G (lancets) NPB E-Z JECT LANCETS (lancets) NPB E-Z JECT LANCETS 21G (lancets) NPB E-Z JECT LANCETS THIN 26G (lancets) NPB EZ SMART BLOOD GLUCOSE LANCETS (lancets) NPB EZ SMART MONITORING SYSTEM DEVICE (blood NF glucose monitoring suppl) EZ SMART PLUS MONITORING SYS DEVICE (blood NF glucose monitoring suppl) EZ-LETS LANCETS 21G (lancets) NPB EZ-LETS LANCETS 26G (lancets) NPB EZ-LETS LANCETS 28G (lancets) NPB EZ-LETS LANCETS 30G (lancets) NPB FC FEMALE CONDOM (condoms - female) CE FC2 FEMALE CONDOM (condoms - female) CE FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM CE (cervical caps) FIFTY50 GLUCOSE METER 2.0 KIT W/DEVICE (blood NF glucose monitoring suppl) FIFTY50 PEN NEEDLES 31G X 5 MM , 31G X 8 MM , NF 32G X 4 MM , 32G X 6 MM (insulin pen needle) FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- NF needle u-100) FIFTY50 UNILET LANCETS 33G (lancets) NPB FINGERSTIX LANCETS (lancets) NPB FORA D40 GLUCOSE/PRESSURE DEVICE (blood NF glucose-bp monitor)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

184 Prescription Drug Name Drug Tier Drug Notes FORA D40G GLUCOSE/PRESSURE DEVICE (blood NF glucose-bp monitor) FORA G20 BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FORA G30A BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GD20 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GD50 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GTEL BLOOD GLUCOSE SYSTEM DEVICE NF (blood glucose monitoring suppl) FORA LANCETS (lancets) NPB FORA LANCING DEVICE (lancet devices) NPB FORA PREMIUM V10 BLE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA TEST N' GO MONITOR DEVICE (blood glucose NF monitoring suppl) FORA TN'G VOICE KIT W/DEVICE (blood glucose NF monitoring suppl) FORA V10 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V12 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V20 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V30A BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V30A BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) FORACARE GD40 MONITOR DEVICE (blood glucose NF monitoring suppl) FORACARE PREMIUM V10 DEVICE (blood glucose NF monitoring suppl) FORACARE TEST N GO MONITOR DEVICE (blood NF glucose monitoring suppl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

185 Prescription Drug Name Drug Tier Drug Notes FORTISCARE GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORTISCARE GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FORTISCARE T1 GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) freds pharmacy autolet lancing NPB freds pharmacy unifine pentip+ 31g x 5 mm , 31g x 8 mm NF freds pharmacy unifine pentips 32g x 4 mm NF FREESTYLE FLASH SYSTEM KIT (blood glucose NF monitoring suppl) FREESTYLE FREEDOM KIT (blood glucose monitoring NF suppl) FREESTYLE FREEDOM LITE KIT W/DEVICE (blood NF glucose monitoring suppl) FREESTYLE INSULINX SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) FREESTYLE LIBRE 14 DAY READER DEVICE NF (continuous blood gluc receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood NF gluc sensor) FREESTYLE LIBRE 2 READER SYSTM DEVICE NF (continuous blood gluc receiver) FREESTYLE LIBRE 2 SENSOR SYSTM (continuous blood NF gluc sensor) FREESTYLE LIBRE READER DEVICE (continuous blood NF gluc receiver) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood NF gluc sensor) FREESTYLE LITE DEVICE (blood glucose monitoring suppl) NF FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) FREESTYLE PRECISION NEO SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FREESTYLE SIDEKICK II KIT (blood glucose monitoring NF suppl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

186 Prescription Drug Name Drug Tier Drug Notes FREESTYLE SYSTEM KIT (blood glucose monitoring suppl) NF FREESTYLE UNISTICK II LANCETS (lancets) NPB GAMMACORE DEVICE (nerve stimulator) NF GAMMACORE SAPPHIRE 31-DAY DEVICE (nerve NF stimulator) GAMMACORE SAPPHIRE REFILL KIT (nerve stimulator) NF ge100 blood glucose system device NF ge100 blood glucose system kit w/device NF GENTEEL BUTTERFLY TOUCH LANCET (lancets) NPB GENTEEL CONTACT TIPS (BLUE) (lancets misc.) NPB GENTEEL CONTACT TIPS (CLEAR) (lancets misc.) NPB GENTEEL CONTACT TIPS (GREEN) (lancets misc.) NPB GENTEEL CONTACT TIPS (ORANGE) (lancets misc.) NPB GENTEEL CONTACT TIPS (RAINBOW) (lancets misc.) NPB GENTEEL CONTACT TIPS (VIOLET) (lancets misc.) NPB GENTEEL CONTACT TIPS (YELLOW) (lancets misc.) NPB GENTEEL LANCING DEVICE (BLACK) (lancet devices) NPB GENTEEL LANCING DEVICE (BLUE) (lancet devices) NPB GENTEEL LANCING DEVICE (PINK) (lancet devices) NPB GENTEEL LANCING DEVICE (WHITE) (lancet devices) NPB GENTEEL LANCING DEVICE(PURPLE) (lancet devices) NPB GENTEEL LANCING KIT (BLUE) KIT (lancets misc.) NPB GENTEEL NOZZLES (lancets misc.) NPB GENTLE-LET GP LANCETS (lancets) NPB GENTLE-LET LANCETS (lancets) NPB GENTLE-LET PLATFORMS (lancets misc.) NPB ght blood glucose monitor kit w/device NF global alcohol prep ease pad 70 % NPB global ease inject pen needles 29g x 12mm , 31g x 5 mm , 31g x NF 8 mm , 32g x 4 mm global easy glide insulin syr 31g x 15/64" 0.3 ml, 31g x 15/64" NF 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml global easy glide pen needles 32g x 4 mm NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

187 Prescription Drug Name Drug Tier Drug Notes global inject ease insulin syr 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml global inject ease lancets 28g NPB global inject ease lancets 30g NPB global insulin syringes 30g x 1/2" 0.3 ml, 30g x 5/16" 0.3 ml NF global lancing device NPB GLUCO PERFECT 3 METER DEVICE (blood glucose NF monitoring suppl) GLUCOCARD 01 BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) GLUCOCARD 01 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOCARD 01-MINI GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOCARD EXPRESSION MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) GLUCOCARD SHINE CONNEX KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD SHINE EXPRESS KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD SHINE XL DEVICE (blood glucose NF monitoring suppl) GLUCOCARD VITAL MONITOR KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD X-METER KIT W/DEVICE (blood glucose NF monitoring suppl) GLUCOCOM BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) GLUCOCOM LANCETS 28G (lancets) NPB GLUCOCOM LANCETS 30G (lancets) NPB GLUCOCOM LANCETS 33G (lancets) NPB GLUCOCOM MONITOR KIT W/DEVICE (blood glucose NF monitoring suppl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

188 Prescription Drug Name Drug Tier Drug Notes GLUCONAVII BLOOD GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) GLUCOPRO SYR RES 3ML 22GX3/8" (insulin infusion NPB pump supplies) gnp alcohol swabs pad 70 % NPB gnp clickfine pen needles 31g x 6 mm , 31g x 8 mm NF GNP EASY TOUCH GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) gnp insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml gnp lancets NPB gnp lancets 21g NPB gnp lancets micro thin 33g NPB gnp lancets thin NPB gnp lancets thin 26g NPB gnp micro thin lancets 33g NPB gnp super thin lancets 30g NPB gnp ulticare pen needles 31g x 8 mm , 32g x 4 mm , 32g x 6 mm NF gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml GOJJI STERILE LANCETS (lancets) NPB goodsense blood glucose kit w/device NF goodsense clickfine pen needle 31g x 5 mm NF goodsense lancets 26g univ NPB goodsense lancets 30g univ NPB goodsense lancets 33g univ NPB goodsense lancing device NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

189 Prescription Drug Name Drug Tier Drug Notes GOODSENSE PEN NEEDLE PENFINE 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM (insulin pen NF needle) GUARDIAN CONNECT TRANSMITTER (continuous NF blood gluc transmit) GUARDIAN LINK 3 TRANSMITTER (continuous blood NF gluc transmit) GUARDIAN REAL-TIME CHARGER (continuous glucose NPB monitor sup) GUARDIAN REAL-TIME REPLACE PED DEVICE NPB (continuous blood gluc receiver) GUARDIAN REAL-TIME TEST PLUG (continuous glucose NPB monitor sup) GUARDIAN SENSOR (3) (continuous blood gluc sensor) NF HEALTH CARE LANCING DEVICE (lancet devices) NPB healthwise insulin syr/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g NF x 5/16" 1 ml healthwise micron pen needles 32g x 4 mm NF healthwise mini pen needles 31g x 6 mm NF healthwise pen needles 29g x 12mm NF healthwise short pen needles 31g x 5 mm , 31g x 8 mm NF healthwise unifine pentips 32g x 4 mm NF healthy accents lancing device NPB healthy accents unifine pentip 29g x 12mm , 31g x 5 mm , 31g x NF 6 mm , 31g x 8 mm , 32g x 4 mm healthy accents unilet lancets NPB h-e-b incontrol adv lancing NPB h-e-b incontrol alcohol pad NPB h-e-b incontrol lancets 28g NPB h-e-b incontrol lancets 30g NPB h-e-b incontrol lancets 33g NPB h-e-b incontrol pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm H-E-B INCONTROL UNIFINE PENTIP 32G X 4 MM NF (insulin pen needle)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

190 Prescription Drug Name Drug Tier Drug Notes HM EMBRACE TALK SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) hm sterile alcohol prep pad NPB HM ULTICARE INSULIN SYRINGE 30G X 1/2" 1 ML, NF 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) HM ULTICARE SHORT PEN NEEDLES 31G X 8 MM NF (insulin pen needle) HURRISEAL DENTAL SOLUTION (dental desensitizing NF product) HURRISEAL SNAP-N-GO DENTAL SWAB (dental NF desensitizing product) HW EMBRACE PRO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) HW EMBRACE TALK BLOOD GLUCOSE DEVICE NF (blood glucose monitoring suppl) HY-VEE LANCETS (lancets) NPB hy-vee thin lancets NPB IBG STAR BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) IGLUCOSE MONITORING SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) IN TOUCH DEVICE (blood glucose monitoring suppl) NF IN TOUCH LANCING DEVICE (lancet devices) NPB IN TOUCH STERILE LANCETS 30G (lancets) NPB INFINITY BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) INFINITY VOICE KIT W/DEVICE (blood glucose NF monitoring suppl) infusion catheter soft 23" NPB infusion catheter soft 31" NPB infusion catheter soft 43" NPB INPEN 100-BLUE-LILLY DEVICE (injection device for NPB insulin) INPEN 100-BLUE-NOVO DEVICE (injection device for NPB insulin)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

191 Prescription Drug Name Drug Tier Drug Notes INPEN 100-GRAY-LILLY DEVICE (injection device for NPB insulin) INPEN 100-GREY-NOVO DEVICE (injection device for NPB insulin) INPEN 100-PINK-LILLY DEVICE (injection device for NPB insulin) INPEN 100-PINK-NOVO DEVICE (injection device for NPB insulin) insulin cartridge 3ml NPB insulin syringe 27g x 1/2" 0.5 ml, 27g x 1/2" 1 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, NF 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 0.5 ml, 28g x NF 1/2" 1 ml insulin syringe-needle u-100 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x NF 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insupen pen needles 29g x 12mm , 31g x 5 mm , 31g x 8 mm , NF 32g x 4 mm , 33g x 4 mm INSUPEN SENSITIVE 32G X 6 MM , 32G X 8 MM (insulin NF pen needle) INSUPEN ULTRAFIN 30G X 8 MM , 31G X 6 MM , 31G NF X 8 MM (insulin pen needle) KERLIX AMD ANTIMICROBIAL (gauze pads & dressings) NPB KERLIX AMD SUPER SPONGES PAD 6"X6-3/4" (gauze NPB pads & dressings) kinney lancets NPB kinney thin lancets NPB kinray insulin syringe 29g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g NF x 5/16" 0.5 ml, 31g x 5/16" 1 ml kmart valu insulin syringe 29g u-100 0.5 ml, u-100 1 ml NF kmart valu insulin syringe 30g u-100 0.3 ml, u-100 0.5 ml, u-100 NF 1 ml kroger blood glucose kit , w/device NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

192 Prescription Drug Name Drug Tier Drug Notes kroger insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 NF ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml kroger lancets NPB kroger lancets super thin NPB kroger lancets thin NPB kroger pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g NF x 8 mm , 32g x 4 mm , 33g x 4 mm kroger premium blood glucose kit w/device NF lancet device NPB lancet device with ejector NPB lancet transporter case NPB lancets NPB lancets 30g NPB lancets micro thin 33g NPB lancets thin NPB LANCETS ULTRA FINE (lancets) NPB lancets ultra thin 30g NPB lancing device NPB LANZO (lancet devices) NPB ldr blood glucose truetest kit w/device NF leader insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 NF ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml LEADER UNIFINE PENTIPS 31G X 5 MM , 32G X 4 MM NF (insulin pen needle) LEADER UNIFINE PENTIPS PLUS 31G X 5 MM , 31G X NF 8 MM , 32G X 4 MM (insulin pen needle) liberty blood glucose meter device NF LIBERTY NXT GENERATION MONITOR DEVICE NF (blood glucose monitoring suppl) LIFESCAN UNISTIK 2 (lancets) NPB LIFESCAN UNISTIK II LANCETS (lancets) NPB lite touch lancets NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

193 Prescription Drug Name Drug Tier Drug Notes LITE TOUCH LANCING PEN (lancet devices) NPB LITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, NF 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) LITETOUCH LANCETS (lancets) NPB LITETOUCH PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM (insulin NF pen needle) live better adv lancing device NPB live better lancet ultra thin NPB longs insulin syringe 31g x 5/16" 0.5 ml NF longs lancets standard NPB longs lancets thin NPB longs lancets ultra thin NPB MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, NF 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) MARATHON MEDICAL PENTIPS 29G X 12MM , 31G X NF 5 MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) MAXICOMFORT II PEN NEEDLE 31G X 6 MM (insulin NF pen needle) MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 NF ML, 28G X 1/2" 1 ML (insulin syringe-needle u-100) MAXI-COMFORT SAFETY PEN NEEDLE 29G X 5MM , NF 29G X 8MM (insulin pen needle) MAXICOMFORT SYR 27G X 1/2" 27G X 1/2" 0.5 ML, 27G NF X 1/2" 1 ML (insulin syringe-needle u-100) medic insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml NF medichoice safety lancet extra NPB medicine shoppe pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 NF mm MEDISENSE THIN LANCETS (lancets) NPB MEDLANCE PLUS EXTRA 21G (lancets) NPB MEDLANCE PLUS LANCETS (lancets) NPB 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

194 Prescription Drug Name Drug Tier Drug Notes MEDLANCE PLUS LITE 25G (lancets) NPB MEDLANCE PLUS SPECIAL 0.8MM (lancets) NPB MEDLANCE PLUS SUPERLITE 30G (lancets) NPB MEDLANCE PLUS UNIVERSAL 21G (lancets) NPB meijer blood glucose kit w/device NF meijer essential blood glucose kit w/device NF MEIJER LANCETS THIN (lancets) NPB MEIJER LANCETS UNIVERSAL 21G (lancets) NPB MEIJER LANCETS UNIVERSAL 30G (lancets) NPB MEIJER LANCETS UNIVERSAL 33G (lancets) NPB meijer pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF meijer premium blood glucose kit w/device NF MEIJER SUPER THIN LANCETS (lancets) NPB MEIJER TRUE2GO BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUERESULT GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUETRACK GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) MI PASTE DENTAL PASTE (dentifrices) NPB MI PASTE PLUS DENTAL PASTE (dentifrices) NPB MICRODOT BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) MICRODOT PEN NEEDLE 31G X 6 MM , 32G X 4 MM , NF 33G X 4 MM (insulin pen needle) MICROLET LANCETS (lancets) NPB MICROLET NEXT LANCING DEVICE (lancet devices) NPB mini lancing device NPB MINILINK REAL-TIME TRANSMITTER (insulin pump NF accessories) MINIMED 630G GUARDIAN PRESS (insulin pump NPB accessories) MINIMED GUARDIAN LINK 3 (insulin pump accessories) NF MINIMED GUARDIAN SENSOR 3 (continuous blood gluc NF sensor)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

195 Prescription Drug Name Drug Tier Drug Notes MINIMED PUMP RESERVOIR 3ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 1.8ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 3ML (insulin infusion pump NPB supplies) MIO INFUSION SET 18" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 23" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 9MM (insulin infusion pump NPB supplies) MM EASY TOUCH GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl) mm insulin syringe/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g NF x 5/16" 1 ml MM PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 NF MM , 32G X 4 MM (insulin pen needle) MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" NF 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) MONOJECT INSULIN SYRINGE U-100 1 ML (insulin NF syringes (disposable)) MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" NF 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u-100) MONOLET LANCETS (lancets) NPB MONOLET OPD LANCETS (lancets) NPB MONOLETTOR SAFETY LANCETS (lancets) NPB mpd safety lancet 21g NPB mpd safety lancet 23g NPB 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

196 Prescription Drug Name Drug Tier Drug Notes mpd safety lancet 28g NPB mpd safety lancet 30g NPB ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x NF 5/16" 1 ml MULTI-LANCET DEVICE 2 KIT (lancets misc.) NPB MYGLUCOHEALTH BLOOD GLUCOSE KIT NF W/DEVICE (blood glucose monitoring suppl) MYGLUCOHEALTH LANCETS 30G (lancets) NPB NOVA MAX BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) NOVA MAX BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) NOVA SAFETY LANCETS 23G (lancets) NPB NOVA SAFETY LANCETS 28G (lancets) NPB NOVA SUREFLEX LANCETS (lancets) NPB NOVA SUREFLEX LANCING DEVICE (lancet devices) NPB NOVOFINE 32G X 6 MM (insulin pen needle) NF NOVOFINE AUTOCOVER 30G X 8 MM (insulin pen NF needle) NOVOFINE PLUS 32G X 4 MM (insulin pen needle) NF NOVOPEN ECHO DEVICE (injection device for insulin) NPB NOVOTWIST 32G X 5 MM (insulin pen needle) NF OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM CE (diaphragms) OMNIPOD 5 PACK (insulin disposable pump) NF OMNIPOD DASH 5 PACK PODS (insulin disposable pump) NF OMNIPOD STARTER KIT (insulin disposable pump) NF one drop blood glucose monitor kit w/device NF ONETOUCH CLUB LANCETS FINE PT (lancets) NPB ONETOUCH DELICA LANCETS 30G (lancets) NPB ONETOUCH DELICA LANCETS 33G (lancets) NPB ONETOUCH DELICA LANCING DEV (lancet devices) NPB ONETOUCH DELICA PLUS LANCET30G (lancets) NPB ONETOUCH DELICA PLUS LANCET33G (lancets) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

197 Prescription Drug Name Drug Tier Drug Notes ONETOUCH DELICA PLUS LANCING (lancet devices) NPB ONETOUCH SURESOFT LANCING DEV (lancets misc.) NPB ONETOUCH ULTRA 2 KIT W/DEVICE (blood glucose NF monitoring suppl) ONETOUCH ULTRA MINI KIT W/DEVICE (blood glucose NF monitoring suppl) ONETOUCH ULTRALINK KIT W/DEVICE (blood glucose NF monitoring suppl) ONETOUCH ULTRASOFT LANCETS (lancets) NPB ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE (blood NPB glucose monitoring suppl) ONETOUCH VERIO KIT W/DEVICE (blood glucose NF monitoring suppl) ONETOUCH VERIO REFLECT KIT W/DEVICE (blood NF glucose monitoring suppl) ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) OPTIUM BLOOD GLUCOSE MONITOR KIT W/DEVICE NF (blood glucose monitoring suppl) OPTIUM GLUCOSE MONITOR SYSTEM DEVICE (blood NF glucose monitoring suppl) PARADIGM PUMP RESERVOIR 1.8ML (insulin infusion NPB pump supplies) PARADIGM PUMP RESERVOIR 3ML (insulin infusion NPB pump supplies) PARADIGM QUICK-SET 18" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 23" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 23" 9MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 32" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 32" 9MM (insulin infusion pump NPB supplies)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

198 Prescription Drug Name Drug Tier Drug Notes PARADIGM QUICK-SET 43" 6MM (insulin infusion pump NPB supplies) PARADIGM QUICK-SET 43" 9MM (insulin infusion pump NPB supplies) PARADIGM REAL-TIME TRANSMITTER (insulin pump NPB accessories) PARADIGM SILHOUETTE 18" 13MM (insulin infusion NPB pump supplies) PARADIGM SILHOUETTE 32" 17MM (insulin infusion NPB pump supplies) PARADIGM SILHOUETTE COMBO 23" (insulin infusion NPB pump supplies) PARADIGM SILHOUETTE FULL 23" (insulin infusion NPB pump supplies) PARADIGM SURE-T 23" 6MM (insulin infusion pump NPB supplies) PARADIGM SURE-T 23" 8MM (insulin infusion pump NPB supplies) pc lancets super thin 30g NPB pc unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g NF x 8 mm pen needles 1/2" 29g x 12mm NF pen needles 29g x 12mm , 30g x 5 mm , 30g x 8 mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g NF x 6 mm , 33g x 4 mm pen needles 3/16" 31g x 5 mm NF pen needles 5/16" 30g x 8 mm , 31g x 8 mm NF PENLET II BLOOD SAMPLER KIT (lancets misc.) NPB PENLET II REPLACEMENT CAP (lancets misc.) NPB PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G NF X 8 MM , 32G X 4 MM (insulin pen needle) PERFECT LANCETS 28G (lancets) NPB PERFECT LANCETS 30G (lancets) NPB PHARMACIST CHOICE AUTOCODE SYS KIT NF W/DEVICE (blood glucose monitoring suppl) PHARMACIST CHOICE LANCETS (lancets) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

199 Prescription Drug Name Drug Tier Drug Notes PHARMACIST CHOICE MINI SYSTEM DEVICE (blood NF glucose monitoring suppl) PHARMACY COUNTER LANCETS (lancets) NPB pip lancets 28g NPB pip lancets 30g NPB POCKETCHEM EZ SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) polytoza patch sheet NF PRECISION LINK KIT (blood glucose monitoring suppl) NF PRECISION QID MONITOR DEVICE (blood glucose NF monitoring suppl) PRECISION SOF-TACT MONITOR DEVICE (blood NF glucose monitoring suppl) PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X 3/8" 0.5 ML, NF 30G X 5/16" 0.3 ML (insulin syringe-needle u-100) PRECISION XTRA DEVICE (blood glucose monitoring NF suppl) PRECISION XTRA KIT , W/DEVICE (blood glucose NF monitoring suppl) PRECISION XTRA MONITOR DEVICE (blood glucose NF monitoring suppl) preferred plus insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml preferred plus lancets colored NPB preferred plus lancets thin NPB preferred plus unifine pentips 29g x 12mm , 31g x 5 mm , 31g x NF 6 mm , 31g x 8 mm , 32g x 4 mm pressure activat safety lancet NPB PREVENT SAFETY PEN NEEDLES 31G X 6 MM , 31G X NF 8 MM (insulin pen needle) pro comfort alcohol pad 70 % NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

200 Prescription Drug Name Drug Tier Drug Notes PRO COMFORT INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) pro comfort lancets 30g NPB pro comfort lancets 31g NPB pro comfort pen needles 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , NF 32g x 6 mm pro voice v8 glucose system device NF pro voice v9 glucose system device NF PRODIGY AUTOCODE BLOOD GLUCOSE DEVICE NF (blood glucose monitoring suppl) PRODIGY AUTOCODE BLOOD GLUCOSE KIT NF W/DEVICE (blood glucose monitoring suppl) PRODIGY INSULIN SYRINGE 28G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u- NF 100) PRODIGY LANCETS 28G (lancets) NPB PRODIGY LANCING DEVICE (lancet devices) NPB PRODIGY POCKET BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) PRODIGY SAFETY LANCETS 26G (lancets) NPB PRODIGY VOICE BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) PSS SELECT GP LANCETS (lancets) NPB PSS SELECT PLATFORMS (lancets misc.) NPB PSS SELECT SAFETY LANCETS (lancets) NPB push button safety lancets NPB push button safety lancets 28g NPB px extra short pen needles 31g x 6 mm NF px insulin syringe 30g x 1/2" 0.5 ml NF px lancet auto injector NPB px lancets ultra thin NPB px mini pen needles 31g x 5 mm NF px pen needle 29g x 12mm , 31g x 8 mm NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

201 Prescription Drug Name Drug Tier Drug Notes px shortlength pen needles 31g x 8 mm NF qc advanced lancing device NPB qc alcohol swabs pad 70 % NPB qc lancets super thin 30g NPB qc lancets ultra thin NPB qc pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF qc unifine pentips 32g x 4 mm NF qc unilet lancets 28g NPB qc unilet lancets micro thin NPB QUICKTEK KIT (blood glucose monitoring suppl) NF QUICKTEK/METER KIT (blood glucose monitoring suppl) NF QUINTET AC BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) QUINTET BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) ra alcohol swabs pad 70 % NPB ra blood glucose monitor device NF RA E-ZJECT COLOR LANCETS 33G (lancets) NPB RA E-ZJECT LANCETS 28G (lancets) NPB RA E-ZJECT LANCETS THIN 26G (lancets) NPB RA E-ZJECT LANCETS THIN 28G (lancets) NPB RA E-ZJECT LANCETS ULTRA THIN (lancets) NPB ra insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" NF 0.5 ml, 30g x 5/16" 1 ml ra pen needles 31g x 5 mm , 31g x 8 mm NF RA TRUE2GO BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) RA TRUERESULT BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RAPPORT RLS KIT (impotence aid device) NPB RAPPORT VTD KIT (impotence aid device) NPB READYLANCE SAFETY LANCETS (lancets) NPB reality insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x NF 1/2" 0.5 ml, 29g x 1/2" 1 ml

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

202 Prescription Drug Name Drug Tier Drug Notes reality lancets NPB reality swabs pad NPB reality trigger lancets NPB REFUAH PLUS MONITORING SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) RELION CONFIRM GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) RELI-ON INSULIN SYRINGE 29G 0.3 ML, 29G 0.5 ML, 29G X 1/2" 1 ML, 30G 0.3 ML, 30G 0.5 ML, 30G 1 ML NF (insulin syringe-needle u-100) RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G NF X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) RELION LANCET DEVICES 30G (lancet devices) NPB RELION LANCETS MICRO-THIN 33G (lancets) NPB RELION LANCETS STANDARD 21G (lancets) NPB RELION LANCETS THIN 26G (lancets) NPB RELION LANCETS ULTRA-THIN 30G (lancets) NPB RELION LANCING DEVICE (lancet devices) NPB RELION LANCING DEVICE KIT (lancets misc.) NPB RELION MICRO KIT W/DEVICE (blood glucose monitoring NF suppl) RELION MINI PEN NEEDLES 31G X 6 MM (insulin pen NF needle) RELION PEN NEEDLES 29G X 12MM , 31G X 6 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) RELION PREMIER BLU MONITOR DEVICE (blood NF glucose monitoring suppl) RELION PREMIER COMPACT SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) RELION PREMIER VOICE MONITOR DEVICE (blood NF glucose monitoring suppl) RELION PRIME MONITOR DEVICE (blood glucose NF monitoring suppl) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

203 Prescription Drug Name Drug Tier Drug Notes RELION SHORT PEN NEEDLES 31G X 8 MM (insulin pen NF needle) RELION ULTIMA GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) RELION ULTRA THIN LANCETS 30G (lancets) NPB RELION ULTRA THIN PLUS LANCETS (lancets) NPB REMESENSE DENTAL 3 % (dental desensitizing product) NPB REXALL BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST ALTERNATE SITE ADAPT (lancets misc.) NPB RIGHTEST GD500 LANCING DEVICE (lancet devices) NPB RIGHTEST GL300 LANCETS (lancets) NPB RIGHTEST GM100 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GM300 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GM550 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) SAFESNAP INSULIN SYRINGE 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X NF 5/16" 0.5 ML (insulin syringe-needle u-100) SAFE-T-LANCE (lancets) NPB SAFE-T-LANCE PLUS (lancets) NPB safety insulin syringes 27g x 1/2" 1 ml, 29g x 1/2" 0.5 ml, 29g x NF 1/2" 1 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml safety lancet 23g/pressure act NPB safety lancet 30g/pressure act NPB SAFETY LET LANCETS (lancets) NPB SAFETY SEAL LANCETS (lancets) NPB saps care alcohol prep pad 70 % NPB saps health care alcohol prep pad 70 % NPB saps health twist top lancets NPB saps twist top lancets NPB sapscare twist top lancets NPB sb alcohol prep pad 70 % NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

204 Prescription Drug Name Drug Tier Drug Notes sb insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" NF 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 1 ml sb lancets thin NPB sb lancets ultra thin NPB scarsilk sheet NF SECURESAFE INSULIN SYRINGE 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) select-lite lancing device NPB SHOPKO ALCOHOL SWABS PAD 70 % (alcohol swabs) NPB SHOPKO AUTOLET LANCING DEVICE (lancet devices) NPB SHOPKO UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM NF , 31G X 8 MM , 32G X 4 MM (insulin pen needle) SHOPKO UNIFINE PENTIPS PLUS 29G X 12MM , 31G X NF 5 MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) side button safety lancet NPB SILHOUETTE 13MM (insulin infusion pump supplies) NPB SILHOUETTE 17MM (insulin infusion pump supplies) NPB SILHOUETTE INFUSION SET 23" (insulin infusion pump NPB supplies) SILHOUETTE INFUSION SET 43" (insulin infusion pump NPB supplies) silivex sheet NF SILTREX SHEET (occlusive silicone sheets) NF SIMPLE DIAGNOSTICS LANCING DEV (lancet devices) NPB SINGLE-LET (lancets) NPB sm alcohol prep pad 70 % NPB sm lancets 33g NPB SM TRUEDRAW LANCING DEVICE (lancet devices) NPB SMART DIABETES VANTAGE LANCING (lancet devices) NPB SMART SENSE COLOR LANCETS 33G (lancets) NPB SMART SENSE PREMIUM SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) SMART SENSE STANDARD LANCETS (lancets) NPB SMART SENSE SUPER THIN LANCETS (lancets) NPB SMART SENSE THIN LANCETS 26G (lancets) NPB 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

205 Prescription Drug Name Drug Tier Drug Notes SMART SENSE VALUE GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) SMARTEST EJECT DEVICE (blood glucose monitoring NF suppl) SMARTEST EJECT STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST LANCETS 28G (lancets) NPB SMARTEST PERSONA STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST PRONTO STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST PROTEGE DEVICE (blood glucose monitoring NF suppl) SMARTEST PROTEGE STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SOLUS V2 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) SOLUS V2 BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) SOLUS V2 LANCETS 28G (lancets) NPB SOLUS V2 LANCING DEVICE (lancet devices) NPB SOLUS V2 TWIST LANCETS 30G (lancets) NPB STERILANCE PA (lancets misc.) NPB STERILANCE TL (lancets) NPB super thin lancets NPB sure comfort alcohol prep pad 70 % NPB sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml sure comfort lancets 18g NPB sure comfort lancets 21g NPB sure comfort lancets 23g NPB sure comfort lancets 30g NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

206 Prescription Drug Name Drug Tier Drug Notes sure comfort lancing pen NPB sure comfort pen needles 29g x 12.7mm , 30g x 8 mm , 31g x 5 NF mm , 31g x 8 mm , 32g x 6 mm SURE EDGE GLUCOSE MONITOR DEVICE (blood NF glucose monitoring suppl) SURECHEK BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) SURECHEK BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) SURE-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 NF MM , 31G X 8 MM (insulin pen needle) SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) SURE-LANCE FLAT LANCETS (lancets) NPB SURE-LANCE LANCETS 26G (lancets) NPB SURELITE LANCETS (lancets) NPB SURE-PEN (lancet devices) NPB SURE-T INFUSION SET 18" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 23" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 32" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 6MM (insulin infusion pump NPB supplies) SURE-T INFUSION SET 8MM (insulin infusion pump NPB supplies) SURE-TEST EASYPLUS MINI METER DEVICE (blood NF glucose monitoring suppl) SURE-TOUCH LANCETS UNIVERSAL (lancets) NPB T:FLEX T:LOCK CARTRIDGE 4.8ML (insulin infusion NPB pump supplies) T:SLIM T:LOCK INSULIN CART 3ML (insulin infusion NPB pump supplies)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

207 Prescription Drug Name Drug Tier Drug Notes techlite insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g NF x 15/64" 0.3 ml, 31g x 15/64" 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml TECHLITE PEN NEEDLES 29G X 10MM , 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , NF 32G X 6 MM , 32G X 8 MM (insulin pen needle) TELCARE BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) TELFA AMD ISLAND DRESSING PAD 4"X5" , 4"X8" NPB (gauze pads & dressings) TELFA AMD NON-ADHERENT PAD 3"X8" (gauze pads & NPB dressings) tgt blood glucose monitoring kit w/device NF tgt lancet micro thin 33g NPB tgt lancet thin 26g NPB tgt lancet ultra thin 30g NPB tgt lancing device NPB THINLETS GP LANCETS (lancets) NPB todays health mini pen needles 31g x 6 mm NF todays health pen needles 29g x 12mm NF todays health short pen needle 31g x 8 mm NF topcare clickfine pen needles 31g x 6 mm , 31g x 8 mm NF topcare lancets micro-thin 33g NPB topcare ultra comfort ins syr 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g NF x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml travel lancets NPB TRAVEL LANCETS ADVANCED 28G (lancets) NPB true comfort insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml NF true comfort pen needles 31g x 5 mm , 31g x 6 mm , 32g x 4 mm NF true comfort twist top lancets NPB TRUE FOCUS BLOOD GLUCOSE METER DEVICE NF (blood glucose monitoring suppl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

208 Prescription Drug Name Drug Tier Drug Notes TRUE METRIX AIR GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) TRUE METRIX AIR GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl) TRUE METRIX GO GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl) TRUE METRIX METER DEVICE (blood glucose monitoring NF suppl) TRUE METRIX METER KIT W/DEVICE (blood glucose NF monitoring suppl) TRUEDRAW LANCING DEVICE (lancet devices) NPB TRUEPLUS 5-BEVEL PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM NF (insulin pen needle) TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) TRUEPLUS LANCETS 26G (lancets) NPB TRUEPLUS LANCETS 28G (lancets) NPB TRUEPLUS LANCETS 30G (lancets) NPB TRUEPLUS LANCETS 33G (lancets) NPB TRUEPLUS PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM (insulin pen NF needle) TRUEPLUS SAFETY LANCETS 28G (lancets) NPB TRUERESULT BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) TRUETRACK BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) TRUETRACK BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) TRUETRACK SMART SYSTEM KIT (blood glucose NF monitoring suppl) TRUSTEEL INFUSION SET (insulin infusion pump supplies) NPB ULTICARE ALCOHOL SWABS PAD (alcohol swabs) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

209 Prescription Drug Name Drug Tier Drug Notes ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 0.5 ML, 31G X 1/4" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTICARE MICRO PEN NEEDLES 31G X 6 MM , 31G X NF 8 MM , 32G X 4 MM (insulin pen needle) ULTICARE MINI PEN NEEDLES 31G X 6 MM , 32G X 6 NF MM (insulin pen needle) ULTICARE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM NF (insulin pen needle) ULTICARE SHORT PEN NEEDLES 31G X 8 MM (insulin NF pen needle) ultiguard safepack pen needle 31g x 5 mm , 31g x 6 mm , 31g x NF 8 mm , 32g x 4 mm , 32g x 6 mm ULTI-LANCE AUTOMATIC (lancet devices) NPB ultilet alcohol swabs pad NPB ULTILET CLASSIC LANCETS (lancets) NPB ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 1 ML, 31G X NF 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTILET INSULIN SYRINGE SHORT 30G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" NF 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTILET LANCETS (lancets) NPB ULTILET PEN NEEDLE 29G X 12.7MM , 31G X 5 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) ULTILET SAFETY LANCETS (lancets) NPB ULTILET SAFETY LANCETS 23G (lancets) NPB ULTIMA KIT (blood glucose monitoring suppl) NF ultra comfort insulin syringe 30g x 5/16" 0.3 ml NF 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

210 Prescription Drug Name Drug Tier Drug Notes ultra thin lancets 31g NPB ULTRA THIN PEN NEEDLES 32G X 4 MM (insulin pen NF needle) ULTRA TRAK PRO BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) ultracare insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" NF 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ultra-care lancets 30g NPB ultracare pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , NF 32g x 4 mm , 32g x 5 mm , 32g x 6 mm , 33g x 4 mm ultra-comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ULTRALANCE (lancets misc.) NPB ULTRA-THIN II AUTO LANCET (lancets) NPB ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 NF ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- needle u-100) ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) ULTRA-THIN II LANCETS (lancets) NPB ULTRA-THIN II MINI PEN NEEDLE 31G X 5 MM NF (insulin pen needle) ULTRA-THIN II PEN NEEDLE SHORT 31G X 8 MM NF (insulin pen needle) ULTRA-THIN II PEN NEEDLES 29G X 12.7MM (insulin NF pen needle) ULTRATRAK ACTIVE DEVICE (blood glucose monitoring NF suppl) ULTRATRAK PRO DEVICE (blood glucose monitoring NF suppl) ULTRATRAK ULTIMATE MONITOR DEVICE (blood NF glucose monitoring suppl)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

211 Prescription Drug Name Drug Tier Drug Notes UNIFINE PENTIPS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 NF MM , 33G X 4 MM (insulin pen needle) UNIFINE PENTIPS PLUS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , NF 33G X 4 MM (insulin pen needle) UNIFINE SAFECONTROL PEN NEEDLE 30G X 5 MM , NF 30G X 8 MM (insulin pen needle) UNILET COMFORTOUCH LANCET (lancets) NPB UNILET EXCELITE (lancets) NPB UNILET EXCELITE II (lancets) NPB UNILET G.P. LANCET (lancets) NPB UNILET G.P. SUPERLITE LANCET (lancets) NPB UNILET GP 28 ULTRA THIN (lancets) NPB UNILET LANCET (lancets) NPB UNILET MICRO-THIN 33G (lancets) NPB UNILET SUPERLITE LANCET (lancets) NPB UNILET SUPER-THIN 30G (lancets) NPB UNILET ULTRA-THIN 28G (lancets) NPB UNISTIK 1 (lancets misc.) NPB UNISTIK 2 (lancets misc.) NPB UNISTIK 2 COMFORT (lancets misc.) NPB UNISTIK 2 EXTRA (lancets misc.) NPB UNISTIK 2 NEONATAL (lancets misc.) NPB UNISTIK 2 NORMAL (lancets misc.) NPB UNISTIK 2 SUPER (lancets misc.) NPB UNISTIK 3 (lancets misc.) NPB UNISTIK 3 COMFORT (lancets misc.) NPB UNISTIK 3 EXTRA (lancets misc.) NPB UNISTIK 3 GENTLE (lancets) NPB UNISTIK 3 NEONATAL (lancets misc.) NPB UNISTIK 3 NORMAL (lancets misc.) NPB UNISTIK CZT COMFORT (lancets misc.) NPB UNISTIK CZT NORMAL (lancets misc.) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

212 Prescription Drug Name Drug Tier Drug Notes UNISTIK PRO SAFETY LANCET (lancets) NPB UNISTIK SAFETY LANCETS 28G (lancets) NPB UNISTIK SAFETY LANCETS 30G (lancets) NPB UNISTIK TOUCH SAFETY LANC 21G (lancets) NPB UNISTIK TOUCH SAFETY LANC 23G (lancets) NPB UNISTIK TOUCH SAFETY LANC 28G (lancets) NPB UNISTIK TOUCH SAFETY LANC 30G (lancets) NPB UNIVERSAL 1 LANCETS THIN 26G (lancets) NPB UNIVERSAL 1 LANCETS THIN 33G (lancets) NPB UNIVERSAL 1 LANCETS ULTRA THIN (lancets) NPB value health insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml NF value plus lancet standard 21g NPB value plus lancets super thin NPB valumark lancet ultra thin 28g NPB valumark pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 30G X 1/2" 0.5 ML, 30G X 3/16" 0.5 ML, NF 30G X 3/16" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) VARISOFT INFUSION SET (insulin infusion pump supplies) NPB verasens blood glucose meter device NF verasens blood glucose system kit w/device NF V-GO 20 KIT (insulin disposable pump) PB V-GO 30 KIT (insulin disposable pump) PB V-GO 40 KIT (insulin disposable pump) PB VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 NF MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) VIVAGUARD INO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) VIVAGUARD LANCETS (lancets) NPB VIVAGUARD LANCING DEVICE (lancet devices) NPB VOCAL POINT BLOOD GLUCOSE SYS DEVICE (blood NF glucose monitoring suppl) vp insulin syringe 29g x 1/2" 0.3 ml NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

213 Prescription Drug Name Drug Tier Drug Notes walgreens adv travel lancets NPB WALGREENS LANCETS (lancets) NPB walgreens lancets micro thin NPB walgreens lancets super thin NPB WALGREENS THIN LANCETS (lancets) NPB WALGREENS ULTRA THIN LANCETS (lancets) NPB WAVESENSE AMP KIT W/DEVICE (blood glucose NF monitoring suppl) WEBCOL ALCOHOL PREP LARGE PAD 70 % (alcohol NPB swabs) WEBCOL ALCOHOL PREP MEDIUM PAD 70 % (alcohol NPB swabs) wegmans unifine pentips plus 31g x 5 mm , 31g x 6 mm , 31g x 8 NF mm , 32g x 4 mm WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) *MIGRAINE PRODUCTS* - DRUGS FOR THE NERVOUS SYSTEM AIMOVIG SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe) AJOVY SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 225 MG/1.5ML (fremanezumab-vfrm)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

214 Prescription Drug Name Drug Tier Drug Notes AJOVY SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 225 MG/1.5ML (fremanezumab-vfrm) almotriptan malate oral tablet 12.5 mg, 6.25 mg G CAFERGOT ORAL TABLET 1-100 MG (ergotamine- NF caffeine) CAMBIA ORAL PACKET 50 MG (diclofenac NF potassium(migraine)) dihydroergotamine mesylate injection solution 1 mg/ml G dihydroergotamine mesylate nasal solution 4 mg/ml NF eletriptan hydrobromide oral tablet 20 mg, 40 mg G EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML PB (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 120 MG/ML (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 120 MG/ML (galcanezumab-gnlm) ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 NPB MG (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg NF frovatriptan succinate oral tablet 2.5 mg G MIGERGOT RECTAL SUPPOSITORY 2-100 MG NF (ergotamine-caffeine) MIGRAINE PACK COMBINATION THERAPY PACK 50 NF MG (sumatriptan-homeopathic prod) MIGRANAL NASAL SOLUTION 4 MG/ML NF (dihydroergotamine mesylate) MIGRANOW COMBINATION THERAPY PACK 50 & 4- NF 10 MG & % (sumatriptan & camphor-menthol) naratriptan hcl oral tablet 1 mg, 2.5 mg G NURTEC ORAL TABLET DISPERSIBLE 75 MG PB (rimegepant sulfate) ONZETRA XSAIL NASAL EXHALER POWDER 11 NPB MG/NOSEPC (sumatriptan succinate) REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan PB succinate) rizatriptan benzoate oral tablet 10 mg, 5 mg G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

215 Prescription Drug Name Drug Tier Drug Notes rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg G sumatriptan nasal solution 20 mg/act, 5 mg/act G sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg G sumatriptan succinate refill subcutaneous solution cartridge 4 G mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml G sumatriptan succinate subcutaneous solution auto-injector 4 G mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 G mg/0.5ml sumatriptan-naproxen sodium oral tablet 85-500 mg NF TREXIMET ORAL TABLET 85-500 MG (sumatriptan- NF naproxen sodium) UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) PB ZEMBRACE SYMTOUCH SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 MG/0.5ML (sumatriptan NPB succinate) zolmitriptan oral tablet 2.5 mg, 5 mg G zolmitriptan oral tablet dispersible 2.5 mg, 5 mg G ZOMIG NASAL SOLUTION 2.5 MG, 5 MG (zolmitriptan) PB *MINERALS & ELECTROLYTES* - DRUGS FOR NUTRITION CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6- NPB b12-boron-mg) calcium gluconate intravenous solution 10 % NPB dextrose-sodium chloride intravenous solution 5-0.225 % NPB EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 NPB MEQ (potassium bicarb-citric acid) potassium bicarbonate (Effer-K Oral Tablet Effervescent 25 G Meq) FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium NF fluoride-vitamin d) FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML CE (sodium fluoride) fluoritab oral solution 0.275 (0.125 f) mg/drop CE

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

216 Prescription Drug Name Drug Tier Drug Notes fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg, CE 2.2 (1 f) mg FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) CE MG/DROP (sodium fluoride) GALZIN ORAL CAPSULE 25 MG, 50 MG (zinc acetate NPB (oral)) iodine strong oral solution 5 % G potassium chloride (Klor-Con 10 Oral Tablet Extended G Release 10 Meq) potassium chloride crys er (Klor-Con M10 Oral Tablet G Extended Release 10 Meq) KLOR-CON M15 ORAL TABLET EXTENDED G RELEASE 15 MEQ (potassium chloride crys er) potassium chloride crys er (Klor-Con M20 Oral Tablet G Extended Release 20 Meq) potassium chloride (Klor-Con Oral Packet 20 Meq) G potassium chloride (Klor-Con Oral Tablet Extended Release 8 G Meq) potassium chloride (Klor-Con Sprinkle Oral Capsule Extended G Release 10 Meq, 8 Meq) potassium bicarbonate (Klor-Con/Ef Oral Tablet Effervescent G 25 Meq) K-PHOS ORAL TABLET 500 MG (potassium phosphate NPB monobasic) potassium bicarbonate (K-Prime Oral Tablet Effervescent 25 G Meq) sodium fluoride (Nafrinse Drops Oral Solution 0.275 (0.125 F) CE Mg/Drop) sodium fluoride (Nafrinse Oral Tablet Chewable 2.2 (1 F) Mg) CE k phos mono-sod phos di & mono (Phospha 250 Neutral Oral G Tablet 155-852-130 Mg) phosphorous oral tablet 155-852-130 mg G k phos mono-sod phos di & mono (Phospho-Trin 250 Neutral G Oral Tablet 155-852-130 Mg) potassium chloride crys er oral tablet extended release 10 meq, G 20 meq

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

217 Prescription Drug Name Drug Tier Drug Notes potassium chloride er oral capsule extended release 10 meq, 8 G meq potassium chloride er oral tablet extended release 10 meq, 20 G meq, 8 meq potassium chloride oral packet 20 meq G potassium chloride oral solution 20 meq/15ml (10%), 40 G meq/15ml (20%) sodium bicarbonate intravenous solution 7.5 %, 8.4 % NPB sodium fluoride oral solution 1.1 (0.5 f) mg/ml CE sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg CE sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 CE f) mg, 2.2 (1 f) mg THE LIQUILIFT TRACE INTRAVENOUS KIT 10-1000- NF 500-60 MCG/ML (trace minerals cr-cu-mn-se-zn) virt-phos 250 neutral oral tablet 155-852-130 mg G zinc sulfate intravenous solution 3 mg/ml NPB *MISCELLANEOUS THERAPEUTIC CLASSES* - VITAMINS AND MINERALS AMPHADASE INJECTION SOLUTION 150 UNIT/ML NF (hyaluronidase bovine) water for irrigation, sterile (Argyle Sterile Water Irrigation G Solution) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) NPB azathioprine oral tablet 50 mg G BENLYSTA INTRAVENOUS SOLUTION NPSB RECONSTITUTED 120 MG, 400 MG (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION AUTO- NPSB INJECTOR 200 MG/ML (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED NPSB SYRINGE 200 MG/ML (belimumab) COLD-EEZE PLUS DEFENSE ORAL TABLET NF CHEWABLE (homeopathic products) CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) NF cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg G cyclosporine modified oral solution 100 mg/ml G cyclosporine oral capsule 100 mg, 25 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

218 Prescription Drug Name Drug Tier Drug Notes DEPEN TITRATABS ORAL TABLET 250 MG NPB (penicillamine) cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg) G cyclosporine modified (Gengraf Oral Solution 100 Mg/Ml) G sodium polystyrene sulfonate (Kionex Oral Suspension 15 G Gm/60Ml) lactated ringers irrigation solution G LOKELMA ORAL PACKET 10 GM, 5 GM (sodium PB zirconium cyclosilicate) mycophenolate mofetil oral capsule 250 mg G mycophenolate mofetil oral suspension reconstituted 200 mg/ml G mycophenolate mofetil oral tablet 500 mg G mycophenolate sodium oral tablet delayed release 180 mg, 360 G mg penicillamine oral capsule 250 mg G irrigation solns physiological (Physiolyte Irrigation Solution) G irrigation solns physiological (Physiosol Irrigation Irrigation G Solution) REBOOST COLD/FLU RELIEF ORAL TABLET NF CHEWABLE (homeopathic products) RESET FOR IOS OR ANDROID APP (digital therapy) NF RESET-O FOR IOS OR ANDROID APP (digital therapy) NF REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 PSB MG, 25 MG, 5 MG (lenalidomide) ringers irrigation irrigation solution G SANDIMMUNE ORAL SOLUTION 100 MG/ML NPSB (cyclosporine) sirolimus oral solution 1 mg/ml G sirolimus oral tablet 0.5 mg, 1 mg, 2 mg G sodium polystyrene sulfonate oral powder G sodium polystyrene sulfonate oral suspension 15 gm/60ml G sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 G gm/200ml sodium polystyrene sulfonate (Sps Oral Suspension 15 G Gm/60Ml)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

219 Prescription Drug Name Drug Tier Drug Notes sterile water for irrigation irrigation solution G SYLVANT INTRAVENOUS SOLUTION NPB RECONSTITUTED 100 MG, 400 MG (siltuximab) SYPRINE ORAL CAPSULE 250 MG (trientine hcl) NF tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg G THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, PSB 50 MG (thalidomide) ringers irrigation (Tis-U-Sol Irrigation Solution) G T-RELIEF ARTHRITIS MOBILITY ORAL TABLET NF CHEWABLE (homeopathic products) T-RELIEF EXTRA STRENGTH ORAL TABLET NF CHEWABLE (homeopathic products) T-RELIEF SAFE RELIEF ORAL TABLET CHEWABLE NF (homeopathic products) trientine hcl oral capsule 250 mg G VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM PB (patiromer sorbitex calcium) WELLMIND MENTAL FOCUS ORAL TABLET NF CHEWABLE (homeopathic products) WELLMIND VERTIGO ORAL TABLET (homeopathic NPB products) *MOUTH/THROAT/DENTAL AGENTS* - DRUGS FOR THE MOUTH AND THROAT AQUORAL MOUTH/THROAT SOLUTION (artificial NPB saliva) BOCASAL MOUTH/THROAT PACKET (artificial saliva) NPB CAPHOSOL MOUTH/THROAT SOLUTION (artificial NPB saliva) sodium fluoride (Cavarest Dental Gel 1.1 %) CE cevimeline hcl oral capsule 30 mg G chlorhexidine gluconate mouth/throat solution 0.12 % G sodium fluoride (Clinpro 5000 Dental Paste 1.1 %) CE clotrimazole mouth/throat troche 10 mg G sodium fluoride (Denta 5000 Plus Dental Cream 1.1 %) CE sodium fluoride (Dentagel Dental Gel 1.1 %) CE EASYGEL DENTAL GEL 0.4 % (stannous fluoride) CE 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

220 Prescription Drug Name Drug Tier Drug Notes stannous fluoride (Fluoridex Daily Renewal Mouth/Throat CE Concentrate 0.63 %) sodium fluoride (Fluoridex Enhanced Whitening Dental Paste CE 1.1 %) sod fluoride-potassium nitrate (Fluoridex Sensitivity Relief CE Dental Paste 1.1-5 %) GELCLAIR MOUTH/THROAT GEL (povidone-nahyaluron- NPB glycyrrhet) lidocaine hcl mouth/throat solution 4 % G lidocaine viscous hcl mouth/throat solution 2 % G NAFRINSE DAILY ACIDULATED MOUTH/THROAT SOLUTION RECONSTITUTED 1 MG/5ML (sodium CE fluoride-phosphoric acd) NAFRINSE DAILY/NEUTRAL MOUTH/THROAT CE SOLUTION RECONSTITUTED 0.05 % (sodium fluoride) NAFRINSE WEEKLY MOUTH/THROAT SOLUTION CE RECONSTITUTED 0.2 % (sodium fluoride) NEUTRASAL MOUTH/THROAT PACKET (artificial NPB saliva) NUMOISYN MOUTH/THROAT LIQUID (artificial saliva) NPB nystatin mouth/throat suspension 100000 unit/ml G ORAFATE MOUTH/THROAT PASTE 10 % (sucralfate- NPB malate) triamcinolone acetonide (Oralone Mouth/Throat Paste 0.1 %) G ORAVIG BUCCAL TABLET 50 MG (miconazole) NPB chlorhexidine gluconate (Paroex Mouth/Throat Solution 0.12 G %) chlorhexidine gluconate (Periogard Mouth/Throat Solution G 0.12 %) pilocarpine hcl oral tablet 5 mg, 7.5 mg G PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 NF % (sodium fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % NF (sodium fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE NF 1.1-5 % (sod fluoride-potassium nitrate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

221 Prescription Drug Name Drug Tier Drug Notes PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE NF 1.1 % (sodium fluoride) PREVIDENT 5000 PLUS DENTAL CREAM 1.1 % (sodium NF fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % NF (sod fluoride-potassium nitrate) PREVIDENT DENTAL GEL 1.1 % (sodium fluoride) NF PREVIDENT MOUTH/THROAT SOLUTION 0.2 % NF (sodium fluoride) PROTHELIAL MOUTH/THROAT PASTE 10 % NPB (sucralfate-malate) SALIVAMAX MOUTH/THROAT PACKET (artificial NPB saliva) sf 5000 plus dental cream 1.1 % CE sf dental gel 1.1 % CE triamcinolone acetonide mouth/throat paste 0.1 % G XEROSTOMIA RELIEF SPRAY MOUTH/THROAT NPB SOLUTION (artificial saliva) *MULTIVITAMINS* - DRUGS FOR NUTRITION activite oral tablet 1 mg NF adc/f (0.5mg/ml) oral solution 0.5 mg/ml G ADRENAL C FORMULA ORAL TABLET (bioflavonoid NPB products) ATABEX EC ORAL TABLET DELAYED RELEASE 29-1 NPB MG (prenatal vit-dss-fe cbn-fa) ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe NPB bisg-fa) azesco oral tablet 13-1 mg NF biocel oral tablet G b-plex oral tablet G b-plex plus oral tablet G CITRANATAL 90 DHA ORAL 90-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha) CITRANATAL ASSURE ORAL 35-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

222 Prescription Drug Name Drug Tier Drug Notes CITRANATAL B-CALM ORAL 20-1 MG & 2 X 25 MG PB (prenat w/o a fecbnfeglu-fa &b6) CITRANATAL BLOOM DHA ORAL 90-1 & 300 MG PB (prenat w/o a-fecbgl-dss-fa-dha) CITRANATAL BLOOM ORAL TABLET 90-1 MG PB (prenatal-dss-fecb-fegl-fa) CITRANATAL DHA ORAL 27-1 & 250 MG (prenat w/o a- PB fecbgl-dss-fa-dha) CITRANATAL HARMONY ORAL CAPSULE 27-1-260 PB MG (prenat-fefmcb-dss-fa-dha w/o a) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG PB (prenat-fecb-fefum-fa-dha w/o a) CITRANATAL RX ORAL TABLET 27-1 MG (prenat w/o a- PB fecb-fegl-dss-fa) c-nate dha oral capsule 28-1-200 mg NPB cod liver oil oral oil NPB complete natal dha oral 29-1-200 & 250 mg NPB completenate oral tablet chewable 29-1 mg NPB CO-NATAL FA ORAL TABLET (prenatal vit-fe fumarate- NPB fa) CONCEPT DHA ORAL CAPSULE 53.5-38-1 MG (prenat- NPB fefum-fepo-fa-omega 3) CONCEPT OB ORAL CAPSULE 130-92.4-1 MG (prenat w/o NPB a vit-fefum-fepo-fa) CORVITA ORAL TABLET 1.25 MG (multiple vitamins- G minerals-fa) b complex-c-folic acid (Dexifol Oral Tablet 5 Mg) NF DUET DHA 400 ORAL 25-1 & 400 MG (prenat-fepoly-fered- NPB fa-omega 3) DUET DHA BALANCED ORAL 25-1 & 267 MG (prenat- NPB fepoly-fered-fa-omega 3) ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron G carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- NF omega) FLORIVA ORAL TABLET CHEWABLE 0.25 MG (ped NPB multiple vit-minerals-fl) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

223 Prescription Drug Name Drug Tier Drug Notes FLORIVA ORAL TABLET CHEWABLE 0.5 MG, 1 MG NF (ped multiple vit-minerals-fl) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML NPB (pediatric multivitamins-fl) FOLBEE PLUS CZ ORAL TABLET 5 MG (b-complex-c- G biotin-minerals-fa) folbee plus oral tablet G FOLGARD OS ORAL TABLET 500-1.1 MG (multiple vit- NPB min-calcium-fa) folic-k oral capsule 1 mg NF FOLIVANE-OB ORAL CAPSULE 130-92.4-1 MG (prenat NPB w/o a vit-fefum-fepo-fa) GENICIN VITA-Q ORAL TABLET 1 MG (multiple vitamins NF with fa) b complex-c-folic acid (Genicin Vita-S Oral Tablet 1 Mg) NF hylavite oral tablet NF INATAL GT ORAL TABLET (prenatal vit-dss-fe cbn-fa) G INFUVITE ADULT INTRAVENOUS INJECTABLE NPB (multiple vitamin) INFUVITE PEDIATRIC INTRAVENOUS SOLUTION NPB (pediatric multiple vitamins) kosher prenatal plus iron oral tablet 30-1 mg NF lorid oral tablet 1 mg NF multiple vitamins-minerals (Lysiplex Plus Oral Tablet) G M.V.I. ADULT INTRAVENOUS INJECTABLE (multiple NPB vitamin) M.V.I. PEDIATRIC INTRAVENOUS SOLUTION NPB RECONSTITUTED (pediatric multiple vitamins) MARNATAL-F ORAL CAPSULE 60-1 MG (prenat w/o a-fe NPB poly cmplx-fa) m-natal plus oral tablet 27-1 mg NF multipro oral capsule NF multi-vit/iron/fluoride oral solution 0.25-10 mg/ml G multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml G multi-vitamin/fluoride oral solution 0.5 mg/ml G multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

224 Prescription Drug Name Drug Tier Drug Notes multivitamin/fluoride oral tablet chewable 0.25-0.3 mg, 0.5-0.3 NF mg, 1-0.3 mg multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml G MYNATAL ORAL CAPSULE (prenatal multivit-min-fe-fa) NPB mynatal plus oral tablet NPB mynatal-z oral tablet NPB NATACHEW ORAL TABLET CHEWABLE 28-1 MG NPB (prenatal vit-fe fum-fe bisg-fa) NATALVIT ORAL TABLET (prenatal vit-fe fumarate-fa) NPB NEEVO DHA ORAL CAPSULE 27-1.13 MG (prenat w/oa- NPB fefum-methf-omegas) NEONATAL PLUS ORAL TABLET 27-1 MG (prenatal vit- NPB fe fumarate-fa) b complex-c-folic acid (Nephronex Oral Tablet) G NESTABS DHA ORAL 32-1 MG (prenat-w/oa-fe bisgly-fa- NPB omega) NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- NF methylfol-dha w/o a) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o NPB vit a) NICADAN ORAL TABLET (multiple vitamins-minerals) NF NICAZEL FORTE ORAL TABLET (multiple vitamins- NF minerals) NICAZEL ORAL TABLET (multiple vitamins-minerals) NF NICOMIDE ORAL TABLET 750-27-2-0.5 MG (niacinamide- NF zn-cu-methfo-se-cr) NIVA-PLUS ORAL TABLET 27-1 MG (prenatal vit-fe NF fumarate-fa) NUTRICAP ORAL TABLET (multiple vitamins-minerals) NPB multiple vitamins-minerals (Nutrifac Zx Oral Tablet) G NUTRIVIT ORAL LIQUID (b complex-lysine-min-fe-fa) NPB OB COMPLETE ONE ORAL CAPSULE 50-1-476 MG NPB (prenat-fecbn-feaspgl-fa-fish) OB COMPLETE ORAL TABLET 50-1.25 MG (prenatal vit- NPB iron carbonyl-fa)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

225 Prescription Drug Name Drug Tier Drug Notes OB COMPLETE PETITE ORAL CAPSULE 35-5-1-200 MG NPB (prenat-fecbn-feaspgl-fa-omega) OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG NPB (prenatal-fe cbn-fe asp gly-fa) OB COMPLETE/DHA ORAL CAPSULE 30-10-1-200 MG NPB (prenat-fecbn-feaspgl-fa-omega) OBSTETRIX DHA ORAL 29-1 & 387 MG (prenatal-fecbn- NPB fa-dss-omega 3) OBSTETRIX EC ORAL TABLET 29-1 MG (prenatal vit-dss- NPB fe cbn-fa) O-CAL PRENATAL ORAL TABLET (prenatal vit-fe NPB fumarate-fa) OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins- NF minerals-fa) onevite oral tablet 1 mg NPB pnv prenatal plus multivitamin oral tablet 27-1 mg NPB pnv tabs 29-1 oral tablet 29-1 mg NF pnv-dha oral capsule 27-0.6-0.4-300 mg G pnv-dha+docusate oral capsule 27-1.25-300 mg NPB pnv-omega oral capsule 28-0.6-0.4-340 mg NPB pnv-select oral tablet 27-0.6-0.4 mg G POLY-VI-FLOR FS ORAL STRIP 0.25 MG, 0.5 MG NF (pediatric multivitamins-fl) POLY-VI-FLOR FS ORAL STRIP 1 MG (pediatric NPB multivitamins-fl) POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML NPB (pediatric multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, NPB 0.5 MG, 1 MG (pediatric multivitamins-fl) POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 NPB MG/ML (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5- NPB 10 MG (ped multivitamins-fl-iron) PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12- NPB fa-ginger) prena 1 true oral 30-1.4 & 300 mg NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

226 Prescription Drug Name Drug Tier Drug Notes prena1 oral tablet chewable 1.4 mg NPB prena1 pearl oral capsule extended release 30-1.4-200 mg NPB prenaissance oral capsule 29-1.25-325 mg NPB prenaissance plus oral capsule 28-1-250 mg NPB PRENATABS RX ORAL TABLET 29-1 MG (prenatal vit- G iron carbonyl-fa) prenatal 19 oral tablet G prenatal 19 oral tablet 29-1 mg NPB prenatal 19 oral tablet chewable G prenatal 19 oral tablet chewable 29-1 mg NPB prenatal oral tablet 27-1 mg NPB prenatal plus iron oral tablet 29-1 mg NPB prenatal plus oral tablet 27-1 mg NPB prenatal vitamin plus low iron oral tablet 27-1 mg NPB PRENATAL-U ORAL CAPSULE 106.5-1 MG (prenatal w/o NPB a vit-fe fum-fa) PRENATE AM ORAL TABLET 1 MG (prenatal ca-b6-b12- NPB fa-ginger) PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG NPB (prenat-feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG NPB (prenatal-feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 NPB MG (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 NPB MG (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG NPB (prenat-fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG NPB (prenat mv-min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG NPB (prenat-feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 NPB MG (prenat w/o a-fe-methfol-fa-dha) preplus oral tablet 27-1 mg NPB pretab oral tablet 29-1 mg NF 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

227 Prescription Drug Name Drug Tier Drug Notes PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe- NF meth-fa-omeg w/o a) PROVIDA OB ORAL CAPSULE 20-20-1.25 MG (prenat w/o NPB a vit-fefum-fepo-fa) QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG NF (multi vit-min-fluoride-fe-fa) QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5 NF MG/ML (ped multivitamins-fl-iron) QUFLORA GUMMIES ORAL TABLET CHEWABLE NF 0.125 MG (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, NPB 0.5 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE NPB 0.25 MG, 0.5 MG, 1 MG (pediatric multivitamins-fl) relnate dha oral capsule 28-1-200 mg NPB REMEDIENT ORAL CAPSULE 1 MG (multiple vitamins- NF minerals-fa) RENATABS ORAL TABLET 1 MG (b complex-c-biotin-e-fa) NPB RENATABS WITH IRON ORAL 1 & 100 MG (b complex-c- NPB biotin-e-fa-fe cbn) reno caps oral capsule 1 mg G REQ 49+ ORAL TABLET (multiple vitamins-minerals) NPB SELECT-OB ORAL TABLET CHEWABLE 29-0.6-0.4 MG NPB (prenat vit-fepoly-methylfol-fa) SELECT-OB ORAL TABLET CHEWABLE 29-1 MG NPB (prenatal vit-fe psac cmplx-fa) SELECT-OB+DHA ORAL 29-1 & 250 MG (prenatal vit- NPB fepoly-fa-dha) se-natal 19 oral tablet 29-1 mg NPB se-natal 19 oral tablet chewable 29-1 mg NPB SIDEROL ORAL TABLET (multiple vitamins-minerals) NPB STROVITE FORTE ORAL SYRUP (multiple vitamins- NPB minerals-fa) SUPERVITE ORAL LIQUID (b complex-lysine-zn-fa) NPB support oral liquid NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

228 Prescription Drug Name Drug Tier Drug Notes SUPPORT-500 ORAL CAPSULE (specialty vitamins NPB products) SYNAGEX ORAL CAPSULE 1.25 MG (multiple vitamins- NPB minerals-fa) TARON-C DHA ORAL CAPSULE 53.5-38-1 MG (prenat- NPB fefum-fepo-fa-omega 3) TARON-PREX ORAL CAPSULE 30-1.2-265 MG (prenat- NPB fefum-dss-fa-dha w/o a) THERANATAL CORE NUTRITION ORAL TABLET 27-1 NPB MG (prenatal vit-fe fumarate-fa) thrivite 19 oral tablet 1 mg NPB thrivite rx oral tablet 29-1 mg NPB TRICARE ORAL TABLET (prenatal vit-fe fumarate-fa) NPB TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1- NPB 500 MG (prenatal-fefum-fa-dss-fish oil) trinatal rx 1 oral tablet 60-1 mg NPB TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) G triphrocaps oral capsule 1 mg G tristart dha oral capsule 31-0.6-0.4-200 mg NF TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat NF w/o a-fecbn-meth-fa-dha) tri-tabs dha oral 32-1 mg NPB TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 NPB MG/ML (ped vit a-c-d-methylfolate-fl) tri-vi-floro oral suspension 0.25 mg/ml, 0.5 mg/ml NPB tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml G tronvite oral tablet 1 mg NF UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- NPB minerals-fa) urosex oral tablet G v-c forte oral capsule G multiple vitamins-minerals (Vic-Forte Oral Capsule) G VINATE DHA RF ORAL CAPSULE 27-1.13 MG (prenat NPB w/oa-fefum-methf-omegas) VINATE II ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- NPB fa) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

229 Prescription Drug Name Drug Tier Drug Notes VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe NPB fumarate-fa) virt-c dha oral capsule 53.5-38-1 mg NF virt-caps oral capsule 1 mg G virt-nate dha oral capsule 28-1-200 mg NPB virt-pn dha oral capsule 27-0.6-0.4-300 mg NPB virt-pn plus oral capsule 28-0.6-0.4-340 mg NPB multiple vitamins-minerals (Vita S Forte Oral Tablet) G multiple vitamins-minerals (Vitacel Oral Tablet) G VITAFOL GUMMIES ORAL TABLET CHEWABLE 3.33- NF 0.333-34.8 MG (prenatal vit-fe phos-fa-omega) VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3- NF folic acid) VITAFOL ULTRA ORAL CAPSULE 29-0.6-0.4-200 MG NPB (prenat-fe poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal- NPB fe fum-methf-fa w/o a) VITAFOL-OB ORAL TABLET (prenatal vit-fe fumarate-fa) NPB VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv- NPB min-fe fum-fa-dha) VITAFOL-ONE ORAL CAPSULE 29-1-200 MG (prenatal NPB vit-fepoly-fa-dha) pediatric multivit-minerals-c (Vitamax Pediatric Oral Solution) G VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG (prenat w/o a-fe-methfol-fa- NPB dha) VITAMEDMD REDICHEW RX ORAL TABLET NPB CHEWABLE 1.4 MG (prenat-b2-b6-b12-d3-fa) vita-min oral capsule G vitamins acd-fluoride oral solution 0.25 mg/ml G VITAPEARL ORAL CAPSULE EXTENDED RELEASE NPB 30-1.4-200 MG (prenat-fefum-fered-fa-dha w/oa) vitasure oral tablet 1 mg NF VITATRUE ORAL 30-1.4 & 300 MG (prenat-fechel-fa-dha NPB w/o vit a)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

230 Prescription Drug Name Drug Tier Drug Notes VIVA DHA ORAL CAPSULE 28-1-200 MG (prenatal vit-fe NPB fum-fa-omega) vol-plus oral tablet 27-1 mg NPB vol-tab rx oral tablet 29-1 mg NPB vp-heme ob + dha oral 28-6-1 & 203 mg NPB vp-pnv-dha oral capsule 28-1-215.8 mg NPB vp-vite rx oral tablet 1 mg G xvite oral tablet 1 mg NF zalvit oral tablet 13-1 mg NF ZATEAN-PN DHA ORAL CAPSULE 27-0.6-0.4-300 MG NPB (prenat w/o a-fe-methfol-fa-dha) ZATEAN-PN PLUS ORAL CAPSULE 28-0.6-0.4-340 MG NPB (prenat w/o a-fe-methf-fa-omega) *MUSCULOSKELETAL THERAPY AGENTS* - DRUGS FOR MUSCLES, LIGAMENTS, TENDONS, AND BONES AMRIX ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 15 MG, 30 MG (cyclobenzaprine hcl) baclofen oral tablet 10 mg, 20 mg, 5 mg G carisoprodol oral tablet 250 mg, 350 mg G carisoprodol-aspirin-codeine oral tablet 200-325-16 mg G chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg NF cyclo/gaba 10/300 oral therapy pack 10-300 mg NF cyclobenzaprine hcl er oral capsule extended release 24 hour 15 NF mg, 30 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg G cyclobenzaprine hcl oral tablet 7.5 mg NF dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg G DUROLANE INTRA-ARTICULAR PREFILLED NPSB SYRINGE 60 MG/3ML (sodium hyaluronate (viscosup)) FEXMID ORAL TABLET 7.5 MG (cyclobenzaprine hcl) NF FIRST-BACLOFEN ORAL SUSPENSION 1 MG/ML, 5 NF MG/ML (baclofen) GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE PSB 30 MG/3ML (cross-linked hyaluronate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

231 Prescription Drug Name Drug Tier Drug Notes GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16.8 MG/2ML (sodium hyaluronate PSB (viscosup)) chlorzoxazone (Lorzone Oral Tablet 375 Mg, 750 Mg) NF MACI INTRA-ARTICULAR SHEET (autolog cult chond NF coll membr) METAXALL CP COMBINATION KIT 800 & 0.025 MG & NF % (metaxalone-capsaicin) metaxalone oral tablet 800 mg G methocarbamol oral tablet 750 mg NF norgesic forte oral tablet 50-770-60 mg NF orphenadrine citrate er oral tablet extended release 12 hour 100 G mg orphenadrine-asa-caffeine oral tablet 50-770-60 mg NF orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet NF 50-770-60 Mg) SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML (sodium hyaluronate PSB (viscosup)) TABRADOL FUSEPAQ ORAL SUSPENSION 1 MG/ML NF (cyclobenzaprine hcl-msm) TABRADOL RAPIDPAQ ORAL SUSPENSION 1 MG/ML NF (cyclobenzaprine hcl-msm) tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg G tizanidine hcl oral tablet 2 mg, 4 mg G VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED PSB SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) *NASAL AGENTS - SYSTEMIC AND TOPICAL* - DRUGS FOR THE NOSE ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl NPB (nasal)) ALZAIR ALLERGY NASAL SPRAY NASAL POWDER NF (hypromellose) azelastine hcl nasal solution 0.15 %, 137 mcg/spray G BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY NF (beclomethasone diprop monohyd)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

232 Prescription Drug Name Drug Tier Drug Notes DERMACINRX AZENASE PAK NASAL THERAPY NF PACK 137 & 50 MCG/ACT (azelastine-fluticasone) DERMACINRX TICANASE PAK NASAL THERAPY NF PACK 50-2.7 MCG/ACT-% (fluticasone-sodium chloride) DYMISTA NASAL SUSPENSION 137-50 MCG/ACT PB (azelastine-fluticasone) flunisolide nasal solution 25 mcg/act (0.025%) G fluticasone propionate nasal suspension 50 mcg/act G goprelto nasal solution 40 mg/ml NF ipratropium bromide nasal solution 0.03 %, 0.06 % G mometasone furoate nasal suspension 50 mcg/act G olopatadine hcl nasal solution 0.6 % G OMNARIS NASAL SUSPENSION 50 MCG/ACT NF (ciclesonide) QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 NF MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT NF (beclomethasone diprop (nasal)) SINUVA NASAL IMPLANT 1350 MCG (mometasone NF furoate) XHANCE NASAL EXHALER SUSPENSION 93 NPB MCG/ACT (fluticasone propionate) ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT NF (ciclesonide) *NEUROMUSCULAR AGENTS* - DRUGS FOR NERVES AND MUSCLES BOTOX INJECTION SOLUTION RECONSTITUTED 100 NPSB UNIT, 200 UNIT (onabotulinumtoxina) DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT NPSB (abobotulinumtoxina) EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 NPB MG/ML (risdiplam) riluzole oral tablet 50 mg G TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

233 Prescription Drug Name Drug Tier Drug Notes XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT NPSB (incobotulinumtoxina) *NUTRIENTS* - DRUGS FOR NUTRITION amino acids (Aminoamrms Oral Capsule) G AMINOPROTECT INTRAVENOUS SOLUTION 5 % NF (amino acid infusion) amino acids (Aminoreliefrms Oral Capsule) G CARDIOVID PLUS ORAL CAPSULE (dha-epa-vit b6-b12- NPB folic acid) clinimix e/dextrose (8/10) intravenous solution 8 % NPB clinimix e/dextrose (8/14) intravenous solution 8 % NPB clinimix/dextrose (6/5) intravenous solution 6 % NPB clinimix/dextrose (8/10) intravenous solution 8 % NPB clinimix/dextrose (8/14) intravenous solution 8 % NPB CLINOLIPID INTRAVENOUS EMULSION 20 % (fat NF emulsion plant based) CYTO CARN ORAL POWDER (acetylcarnitine) NF dextrose intravenous solution 50 % NPB ELCYS INTRAVENOUS SOLUTION 50 MG/ML (cysteine NF hcl) INTRALIPID INTRAVENOUS EMULSION 20 % (fat NF emulsion plant based) lecithin oral granules NPB lipo-c intramuscular solution NF n-acetyl-l-cysteine oral capsule 600 mg G NEOKE ALCAR ORAL POWDER (acetylcarnitine) NF NEOKE MCT70 ORAL POWDER 70 GM/100GM (medium NF chain triglycerides) NUTRILIPID INTRAVENOUS EMULSION 20 % (fat NF emulsion plant based) OMEGAVEN INTRAVENOUS EMULSION 10 NF GM/100ML, 5 GM/50ML (fish oil triglyceride based) tri-amino injection solution 100-100-100 mg/ml NF tryptophan oral capsule 500 mg NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

234 Prescription Drug Name Drug Tier Drug Notes *OPHTHALMIC AGENTS* - DRUGS FOR THE EYE ak-poly-bac ophthalmic ointment 500-10000 unit/gm G AKTEN OPHTHALMIC GEL 3.5 % (lidocaine hcl) NPB ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil NPB sodium) ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide NPB tromethamine) ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % PB (brimonidine tartrate) ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol NPB etabonate) tetracaine hcl (Altacaine Ophthalmic Solution 0.5 %) G altafluor benox ophthalmic solution 0.25-0.4 % G phenylephrine hcl (Altafrin Ophthalmic Solution 10 %, 2.5 %) G apraclonidine hcl ophthalmic solution 0.5 % G atropine sulfate ophthalmic ointment 1 % NPB atropine sulfate ophthalmic solution 1 % NPB AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) NF azelastine hcl ophthalmic solution 0.05 % G AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) PB bacitracin ophthalmic ointment 500 unit/gm G bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm G bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % G BEPREVE OPHTHALMIC SOLUTION 1.5 % (bepotastine NF besilate) BESIVANCE OPHTHALMIC SUSPENSION 0.6 % PB (besifloxacin hcl) BETADINE OPHTHALMIC PREP OPHTHALMIC NPB SOLUTION 5 % (povidone-iodine) betaxolol hcl ophthalmic solution 0.5 % G BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % PB (timolol hemihydrate) BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % PB (betaxolol hcl) bimatoprost ophthalmic solution 0.03 % NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

235 Prescription Drug Name Drug Tier Drug Notes BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % NPB (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 NPB % (sulfacetamide-prednisolone) brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % G bromfenac sodium (once-daily) ophthalmic solution 0.09 % G BROMSITE OPHTHALMIC SOLUTION 0.075 % NPB (bromfenac sodium) carteolol hcl ophthalmic solution 1 % G CEQUA OPHTHALMIC SOLUTION 0.09 % (cyclosporine) NF CILOXAN OPHTHALMIC OINTMENT 0.3 % NPB (ciprofloxacin hcl) ciprofloxacin hcl ophthalmic solution 0.3 % G COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % PB (brimonidine tartrate-timolol) COSOPT PF OPHTHALMIC SOLUTION 2-0.5 % NF (dorzolamide hcl-timolol mal) cromolyn sodium ophthalmic solution 4 % G CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % NPB (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % G CYCLOSPORINE IN KLARITY OPHTHALMIC NF EMULSION 0.1 % (cyclosporine) CYSTARAN OPHTHALMIC SOLUTION 0.44 % NPB (cysteamine hcl) dexamethasone sodium phosphate ophthalmic solution 0.1 % G DEXTENZA OPHTHALMIC INSERT 0.4 MG NF (dexamethasone) DEXYCU INTRAOCULAR SUSPENSION 9 % NF (dexamethasone) diclofenac sodium ophthalmic solution 0.1 % G dorzolamide hcl ophthalmic solution 2 % G dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml G dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % G double pm ophthalmic solution reconstituted 1-0.5 % NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

236 Prescription Drug Name Drug Tier Drug Notes DUREZOL OPHTHALMIC EMULSION 0.05 % NF (difluprednate) epinastine hcl ophthalmic solution 0.05 % G erythromycin ophthalmic ointment 5 mg/gm G EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML PSB (aflibercept) EYLEA INTRAVITREAL SOLUTION PREFILLED PSB SYRINGE 2 MG/0.05ML (aflibercept) FLAREX OPHTHALMIC SUSPENSION 0.1 % NF (fluorometholone acetate) fluorescein-benoxinate ophthalmic solution 0.25-0.4 % G fluorescein sodium (Fluor-I-Strips A.T. Ophthalmic Strip 1 G Mg) fluorometholone ophthalmic suspension 0.1 % G FLURA-SAFE OPHTHALMIC SOLUTION 0.35-0.4 % NPB (fluorexon-benoxinate) flurbiprofen sodium ophthalmic solution 0.03 % G FML FORTE OPHTHALMIC SUSPENSION 0.25 % NF (fluorometholone) FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 % NF (fluorometholone) FML OPHTHALMIC OINTMENT 0.1 % (fluorometholone) PB gatifloxacin ophthalmic solution 0.5 % G GELFILM OPHTHALMIC FILM (gelatin adsorbable) NPB GENTAK OPHTHALMIC OINTMENT 0.3 % (gentamicin G sulfate) gentamicin sulfate ophthalmic solution 0.3 % G ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) NF INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol NPB etabonate) IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine NPB hcl) ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % NPB (atropine sulfate) ISTALOL OPHTHALMIC SOLUTION 0.5 % (timolol NF maleate)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

237 Prescription Drug Name Drug Tier Drug Notes ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % G KLARITY-L OPHTHALMIC EMULSION 0.2 %, 0.5 % NF (loteprednol etabonate) LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear NPB insert) LASTACAFT OPHTHALMIC SOLUTION 0.25 % NF (alcaftadine) latanoprost ophthalmic solution 0.005 % G levobunolol hcl ophthalmic solution 0.5 % G levofloxacin ophthalmic solution 0.5 % G lissamine green ophthalmic strip 1.5 mg G LOTEMAX OPHTHALMIC GEL 0.5 % (loteprednol NPB etabonate) LOTEMAX OPHTHALMIC OINTMENT 0.5 % (loteprednol NPB etabonate) LOTEMAX OPHTHALMIC SUSPENSION 0.5 % NPB (loteprednol etabonate) LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol NF etabonate) loteprednol etabonate ophthalmic suspension 0.5 % G LUCENTIS INTRAVITREAL SOLUTION 0.3 PSB MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) LUCENTIS INTRAVITREAL SOLUTION PREFILLED PSB SYRINGE 0.3 MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) LUMIGAN OPHTHALMIC SOLUTION 0.01 % NF (bimatoprost) MAXIDEX OPHTHALMIC SUSPENSION 0.1 % NPB (dexamethasone) MITOSOL OPHTHALMIC KIT 0.2 MG (mitomycin) NPB MOXEZA OPHTHALMIC SOLUTION 0.5 % (moxifloxacin NPB hcl) moxifloxacin hcl ophthalmic solution 0.5 % G NATACYN OPHTHALMIC SUSPENSION 5 % NPB (natamycin) neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400- G 10000 , 5-400-10000

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

238 Prescription Drug Name Drug Tier Drug Notes neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000- G 0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- G 10000-0.1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- G 10000-.025 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 G bacitracin-polymyx-neo-hc (Neo-Polycin Hc Ophthalmic G Ointment 1 %) neomycin-bacitracin zn-polymyx (Neo-Polycin Ophthalmic G Ointment 3.5-400-10000) NEVANAC OPHTHALMIC SUSPENSION 0.1 % NF (nepafenac) ofloxacin ophthalmic solution 0.3 % G olopatadine hcl ophthalmic solution 0.1 %, 0.2 % G OZURDEX INTRAVITREAL IMPLANT 0.7 MG NPSB (dexamethasone) PAREMYD OPHTHALMIC SOLUTION 1-0.25 % NPB (hydroxyamphetamine-tropicamide) PAZEO OPHTHALMIC SOLUTION 0.7 % (olopatadine hcl) NPB phenylephrine hcl ophthalmic solution 10 %, 2.5 % G PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION NPB RECONSTITUTED 0.125 % (echothiophate iodide) PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146-20 % (riboflavin 5-phosphate- NF dextran) PHOTREXA-PHOTREXA VISCOUS KIT OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146 &0.146-20 % NF (riboflav5 & riboflav5-dextran) pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % G bacitracin-polymyxin b (Polycin Ophthalmic Ointment 500- G 10000 Unit/Gm) polymyxin b-trimethoprim ophthalmic solution 10000-0.1 G unit/ml-% povidone-iodine ophthalmic solution 5 % NPB PRED FORTE OPHTHALMIC SUSPENSION 1 % NF (prednisolone acetate) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

239 Prescription Drug Name Drug Tier Drug Notes PRED MILD OPHTHALMIC SUSPENSION 0.12 % NF (prednisolone acetate) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % NPB (gentamicin-prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % NPB (gentamicin-prednisolone acet) prednisolone acetate ophthalmic suspension 1 % G prednisolone acetate p-f ophthalmic suspension 1 % NF prednisolone sodium phosphate ophthalmic solution 1 % NPB prednisolone-gatifloxacin ophthalmic suspension 1-0.5 % NF PROLENSA OPHTHALMIC SOLUTION 0.07 % PB (bromfenac sodium) proparacaine hcl ophthalmic solution 0.5 % G proparacaine-fluorescein ophthalmic solution 0.5-0.25 % G RESTASIS MULTIDOSE OPHTHALMIC EMULSION NF 0.05 % (cyclosporine) RESTASIS OPHTHALMIC EMULSION 0.05 % NF (cyclosporine) RHOPRESSA OPHTHALMIC SOLUTION 0.02 % PB (netarsudil dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % NF (netarsudil-latanoprost) ROSE GLO OPHTHALMIC STRIP 1.5 MG (rose bengal) NPB SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % NPB (brinzolamide-brimonidine) sulfacetamide sodium ophthalmic ointment 10 % G sulfacetamide sodium ophthalmic solution 10 % G sulfacetamide-prednisolone ophthalmic solution 10-0.23 % G tetracaine hcl ophthalmic solution 0.5 % G timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % G timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % G (daily) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 NF %, 0.5 % (timolol maleate) TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % PB (tobramycin-dexamethasone)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

240 Prescription Drug Name Drug Tier Drug Notes TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % PB (tobramycin-dexamethasone) tobramycin ophthalmic solution 0.3 % G tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % G TOBREX OPHTHALMIC OINTMENT 0.3 % (tobramycin) NPB TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % NPB (travoprost) trifluridine ophthalmic solution 1 % G triple pmb ophthalmic solution reconstituted 1-0.5-0.09 % NF triple pmk ophthalmic solution reconstituted 1-0.5-0.5 % NF tropicamide ophthalmic solution 0.5 %, 1 % G VYZULTA OPHTHALMIC SOLUTION 0.024 % NF (latanoprostene bunod) XELPROS OPHTHALMIC EMULSION 0.005 % NF (latanoprost) XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) PB YUTIQ INTRAVITREAL IMPLANT 0.18 MG (fluocinolone NF acetonide) ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % PB (tafluprost) ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) NPB ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % NPB (loteprednol-tobramycin) ZYMAXID OPHTHALMIC SOLUTION 0.5 % NF (gatifloxacin) *OTIC AGENTS* - DRUGS FOR THE EAR acetic acid otic solution 2 % G CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- NPB hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- PB dexamethasone) ciprofloxacin hcl otic solution 0.2 % G ciprofloxacin-fluocinolone pf otic solution 0.3-0.025 % NF CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 NPB MG/ML (neomycin-colist-hc-thonzonium) fluocinolone acetonide (Flac Otic Oil 0.01 %) G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

241 Prescription Drug Name Drug Tier Drug Notes fluocinolone acetonide otic oil 0.01 % G hydrocortisone-acetic acid otic solution 1-2 % G neomycin-polymyxin-hc otic solution 3.5-10000-1 G neomycin-polymyxin-hc otic suspension 3.5-10000-1 G ofloxacin otic solution 0.3 % G OTIPRIO INTRATYMPANIC SUSPENSION 6 % NF (ciprofloxacin) OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- NF fluocinolone) *OXYTOCICS* - HORMONES CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) NPB methylergonovine maleate (Methergine Oral Tablet 0.2 Mg) G methylergonovine maleate oral tablet 0.2 mg G PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) NPB PROSTIN E2 VAGINAL SUPPOSITORY 20 MG NPB (dinoprostone) *PASSIVE IMMUNIZING AND TREATMENT AGENTS* - BIOLOGICAL AGENTS BIVIGAM INTRAVENOUS SOLUTION 5 GM/50ML NPSB (immune globulin (human)) CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM (immune globulin NPSB (human)) CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 NF GM/48ML (immune globulin (human)-hipp) CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML (immune NF globulin (human)) FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, NPSB 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NPSB 5 GM/50ML (immune globulin (human))

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

242 Prescription Drug Name Drug Tier Drug Notes GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM (immune NPSB globulin (human)) GAMMAKED INJECTION SOLUTION 10 GM/100ML, 20 NPSB GM/200ML, 5 GM/50ML (immune globulin (human)) GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, NPSB 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML NPSB (immune globulin (human)) GAMUNEX-C INJECTION SOLUTION 40 GM/400ML NF (immune globulin (human)) HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin NPSB (human)) HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML (immune NPSB globulin (human)) HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML NF (immune globulin-hyaluronidase) OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 NPSB GM/200ML, 25 GM/500ML, 30 GM/300ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NF 5 GM/50ML (immune globulin (human)-ifas) PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML (immune NPSB globulin (human)) SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, NPSB 50 MG/0.5ML (palivizumab) ZINPLAVA INTRAVENOUS SOLUTION 1000 MG/40ML NF (bezlotoxumab) *PENICILLINS* - DRUGS FOR INFECTIONS amoxicillin oral capsule 250 mg, 500 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

243 Prescription Drug Name Drug Tier Drug Notes amoxicillin oral suspension reconstituted 125 mg/5ml, 200 G mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg G amoxicillin oral tablet chewable 125 mg, 250 mg G amoxicillin-pot clavulanate er oral tablet extended release 12 G hour 1000-62.5 mg amoxicillin-pot clavulanate oral suspension reconstituted 200- 28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 G mg/5ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, G 875-125 mg amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, G 400-57 mg ampicillin oral capsule 500 mg G ampicillin-sulbactam sodium intravenous solution reconstituted NPB 1.5 (1-0.5) gm, 3 (2-1) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED NPB 125-31.25 MG/5ML (amoxicillin-pot clavulanate) dicloxacillin sodium oral capsule 250 mg, 500 mg G penicillin v potassium oral solution reconstituted 125 mg/5ml, G 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg G PFIZERPEN INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT NF (penicillin g potassium) *PHARMACEUTICAL ADJUVANTS* base x flakes NPB benzyl alcohol liquid NPB capsule 0 clear dr capsule NPB capsule coni-snap #0 clear capsule NPB capsule coni-snap #0 purple capsule NPB capsule coni-snap #00 white capsule NPB capsule coni-snap #000 clear capsule NPB capsule coni-snap #1 red/blue capsule NPB capsule coni-snap #1 veggie capsule NPB capsule coni-snap #2 white capsule NPB 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

244 Prescription Drug Name Drug Tier Drug Notes capsule coni-snap #3 clear capsule NPB capsule coni-snap #3 yellow capsule NPB capsule coni-snap #4 white capsule NPB capsule ezeefit #0 clear capsule NPB capsule ezeefit #00 clear capsule NPB cherry oral syrup NPB cocoa butter NPB corn (syrup) oral syrup NPB DRCAPS SIZE 0 CAPSULE (gelatin capsules (empty)) NPB DRCAPS SIZE 00 CAPSULE (gelatin capsules (empty)) NPB DRCAPS SIZE 1 CAPSULE (gelatin capsules (empty)) NPB empty capsule size 0 white/opa capsule NPB empty capsule size 00 clear capsule NPB empty capsule size 1 clear capsule NPB empty capsule size 1 veg clear capsule NPB empty capsule size 2 clear capsule NPB empty capsule size 3 clear capsule NPB empty capsule size 4 clear capsule NPB empty capsule size 5 clear capsule NPB empty capsule size 7 clear capsule NPB FLAVOR BLEND ORAL SUSPENSION (oral vehicles) NPB flavor plus oral liquid NPB flavor sweet oral syrup NPB flavor sweet-sf oral syrup NPB mouth wash-gp oral liquid NPB mouthwash-af oral liquid NPB mouthwash-om oral liquid NPB ORA-BLEND ORAL SUSPENSION (oral vehicles) NPB ORA-BLEND SF ORAL SUSPENSION (oral vehicles) NPB ORA-PLUS ORAL LIQUID (oral vehicles) NPB ORA-SWEET ORAL SYRUP (oral vehicles) NPB ORA-SWEET SF ORAL SYRUP (oral vehicles) NPB PCCA SWEET-SF ORAL SYRUP (oral vehicles) NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

245 Prescription Drug Name Drug Tier Drug Notes PCCA SYRUP VEHICLE ORAL SYRUP (oral vehicles) NPB PCCA-PLUS ORAL SUSPENSION (oral vehicles) NPB polypeg NPB purified water oral liquid NPB simple syrup oral syrup NPB sorbitol solution , 70 % NPB spg supposi-base pellet NPB suppository blend pellet NPB SUSPENDRX W/BITTERBLOC SWEET ORAL NPB SUSPENSION (oral vehicles) SUSPENDRX W/BITTERBLOC UNSWEET ORAL NPB SUSPENSION (oral vehicles) suspension vehicle oral suspension NPB SYRPALTA (RED) ORAL SYRUP (oral vehicles) NPB syrpalta oral syrup 85 % NPB SYRSPEND SF ORAL LIQUID (oral vehicles) NPB SYRSPEND SF PH4 ORAL SUSPENSION NPB RECONSTITUTED (oral vehicles) syrup vehicle oral syrup NPB syrup vehicle sf oral syrup NPB vegetable capsule #0 green capsule NPB vegetable capsule #0 white capsule NPB vegetable capsule #00 white capsule NPB vegetable capsule #1 white capsule NPB vegetable capsule #2 white capsule NPB vegetable capsule #3 white capsule NPB vegetable capsule #4 white capsule NPB VERSAFREE ORAL SYRUP (oral vehicles) NPB VERSAPLUS ORAL SYRUP (oral vehicles) NPB WITEPSOL PELLET (hydrogenated vegetable oil) NPB WITEPSOL WAX (hydrogenated vegetable oil) NPB *PROGESTINS* - HORMONES ec-rx progesterone transdermal cream 20 % NF hydroxyprogesterone caproate intramuscular oil 250 mg/ml G 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

246 Prescription Drug Name Drug Tier Drug Notes MAKENA INTRAMUSCULAR OIL 250 MG/ML NPSB (hydroxyprogesterone caproate) MAKENA SUBCUTANEOUS SOLUTION AUTO- NPSB INJECTOR 275 MG/1.1ML (hydroxyprogesterone caproate) medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg G megestrol acetate oral suspension 625 mg/5ml G norethindrone acetate oral tablet 5 mg G progesterone compounding kit transdermal cream 20 % NF progesterone intramuscular oil 50 mg/ml G progesterone micronized oral capsule 100 mg, 200 mg G *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* - DRUGS FOR THE NERVOUS SYSTEM acamprosate calcium oral tablet delayed release 333 mg G ADDYI ORAL TABLET 100 MG (flibanserin) NF AMPYRA ORAL TABLET EXTENDED RELEASE 12 NPSB HOUR 10 MG (dalfampridine) AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) PSB AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG PSB (deutetrabenazine) AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR NF KIT 30 MCG/0.5ML (interferon beta-1a) AVONEX PREFILLED INTRAMUSCULAR PREFILLED NF SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a) BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon PSB beta-1b) bupropion hcl er (smoking det) oral tablet extended release 12 CE hour 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET CE 1 MG (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline CE tartrate) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 CE MG X 11 & 1 MG X 42 (varenicline tartrate) chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

247 Prescription Drug Name Drug Tier Drug Notes CONVENIENCE PAK COMBINATION THERAPY NF PACK 600 & 5 MG & % (gabapentin & lidocaine) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML PSB (glatiramer acetate) cvs nicotine mouth/throat gum 2 mg, 4 mg CE cvs nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE cvs nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE cvs nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr dalfampridine er oral tablet extended release 12 hour 10 mg G disulfiram oral tablet 250 mg, 500 mg G donepezil hcl oral tablet 10 mg, 23 mg, 5 mg G donepezil hcl oral tablet dispersible 10 mg, 5 mg G eq nicotine mouth/throat gum 4 mg CE eq nicotine mouth/throat lozenge 4 mg CE eq nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE eq nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE eq nicotine step 3 transdermal patch 24 hour 7 mg/24hr CE eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr CE eql nicotine polacrilex mouth/throat gum 2 mg CE eql nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE ergoloid mesylates oral tablet 1 mg G EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta- NF 1b) fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg NF galantamine hydrobromide er oral capsule extended release 24 G hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml G galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg G GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) PSB glatiramer acetate subcutaneous solution prefilled syringe 20 G mg/ml, 40 mg/ml glatiramer acetate (Glatopa Subcutaneous Solution Prefilled G Syringe 20 Mg/Ml, 40 Mg/Ml)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

248 Prescription Drug Name Drug Tier Drug Notes gnp nicotine mini mouth/throat lozenge 2 mg CE gnp nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE gnp nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE gnp nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr CE goodsense nicotine mouth/throat gum 4 mg CE goodsense nicotine mouth/throat lozenge 4 mg CE GRALISE ORAL TABLET 300 MG, 600 MG (gabapentin PB (once-daily)) hm nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE hm nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE hm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr HORIZANT ORAL TABLET EXTENDED RELEASE 300 NF MG, 600 MG (gabapentin enacarbil) INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine PSB tosylate) INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 PSB MG (valbenazine tosylate) KESIMPTA SUBCUTANEOUS SOLUTION AUTO- PSB INJECTOR 20 MG/0.4ML (ofatumumab) KLS QUIT2 MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) KLS QUIT2 MOUTH/THROAT LOZENGE 2 MG (nicotine CE polacrilex) KLS QUIT4 MOUTH/THROAT GUM 4 MG (nicotine CE polacrilex) KLS QUIT4 MOUTH/THROAT LOZENGE 4 MG (nicotine CE polacrilex) LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) NF LYRICA CR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 165 MG, 330 MG, 82.5 MG (pregabalin) MAVENCLAD (10 TABS) ORAL TABLET THERAPY NPSB PACK 10 MG (cladribine) MAVENCLAD (4 TABS) ORAL TABLET THERAPY NPSB PACK 10 MG (cladribine)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

249 Prescription Drug Name Drug Tier Drug Notes MAVENCLAD (5 TABS) ORAL TABLET THERAPY NPSB PACK 10 MG (cladribine) MAVENCLAD (6 TABS) ORAL TABLET THERAPY NPSB PACK 10 MG (cladribine) MAVENCLAD (7 TABS) ORAL TABLET THERAPY NPSB PACK 10 MG (cladribine) MAVENCLAD (8 TABS) ORAL TABLET THERAPY NPSB PACK 10 MG (cladribine) MAVENCLAD (9 TABS) ORAL TABLET THERAPY NPSB PACK 10 MG (cladribine) MAYZENT ORAL TABLET 0.25 MG, 2 MG (siponimod PSB fumarate) MAYZENT STARTER PACK ORAL TABLET THERAPY PSB PACK 0.25 MG (siponimod fumarate) memantine hcl er oral capsule extended release 24 hour 14 mg, G 21 mg, 28 mg, 7 mg memantine hcl oral solution 10 mg/5ml, 2 mg/ml G memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg G NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG NF (memantine hcl) NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG NF (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PB PACK 7 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG PB (memantine hcl-donepezil hcl) NICORELIEF MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) nicotine mini mouth/throat lozenge 2 mg CE nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE nicotine step 1 transdermal patch 24 hour 21 mg/24hr CE nicotine step 2 transdermal patch 24 hour 14 mg/24hr CE nicotine step 3 transdermal patch 24 hour 7 mg/24hr CE 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

250 Prescription Drug Name Drug Tier Drug Notes nicotine transdermal patch 24 hour 21 mg/24hr CE nicotine transdermal patch 24 hour 7 mg/24hr G NICOTROL INHALATION INHALER 10 MG (nicotine) CE NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) CE NUEDEXTA ORAL CAPSULE 20-10 MG NPB (dextromethorphan-quinidine) olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 G mg, 6-25 mg, 6-50 mg paroxetine mesylate oral capsule 7.5 mg G perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 G mg, 4-25 mg, 4-50 mg pimozide oral tablet 1 mg, 2 mg G PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML NF (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML NF (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 125 MCG/0.5ML (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) ra mini nicotine mouth/throat lozenge 2 mg, 4 mg CE ra nicotine mouth/throat gum 2 mg, 4 mg CE ra nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE ra nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML PSB (interferon beta-1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 PSB & 6X22 MCG (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta- PSB 1a)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

251 Prescription Drug Name Drug Tier Drug Notes REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG PSB (interferon beta-1a) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg G rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 G mg/24hr, 9.5 mg/24hr SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 NPB MG (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG NPB (milnacipran hcl) sm nicotine mouth/throat gum 4 mg CE sm nicotine mouth/throat lozenge 2 mg CE sm nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE sm nicotine polacrilex mouth/throat lozenge 4 mg CE sm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr sr nicotine mouth/throat gum 2 mg CE TECFIDERA ORAL 120 & 240 MG (dimethyl fumarate) PSB TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 PSB MG, 240 MG (dimethyl fumarate) TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED PSB SYRINGE 284 MG/1.5ML (inotersen sodium) tetrabenazine oral tablet 12.5 mg, 25 mg G THRIVE MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) TYSABRI INTRAVENOUS CONCENTRATE 300 PSB MG/15ML (natalizumab) VUMERITY ORAL CAPSULE DELAYED RELEASE 231 PSB MG (diroximel fumarate) VYLEESI SUBCUTANEOUS SOLUTION AUTO- NF INJECTOR 1.75 MG/0.3ML (bremelanotide acetate) XYREM ORAL SOLUTION 500 MG/ML (sodium oxybate) NPB ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod PSB hcl) ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) PSB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

252 Prescription Drug Name Drug Tier Drug Notes ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PSB PACK 0.23MG & 0.46MG & 0.92MG (ozanimod hcl) *RESPIRATORY AGENTS - MISC.* - DRUGS FOR THE LUNGS ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG (alpha1-proteinase NPSB inhibitor) CUROSURF INTRATRACHEAL SUSPENSION 120 NPB MG/1.5ML, 240 MG/3ML (poractant alfa) ESBRIET ORAL CAPSULE 267 MG (pirfenidone) PSB ESBRIET ORAL TABLET 267 MG, 801 MG (pirfenidone) PSB GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML NPSB (alpha1-proteinase inhibitor) INFASURF INTRATRACHEAL SUSPENSION 35-0.9 NPB MG/ML-% (calfactant in nacl) KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG NPB (ivacaftor) KALYDECO ORAL TABLET 150 MG (ivacaftor) NPB OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib PSB esylate) ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG NPB (lumacaftor-ivacaftor) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG NPB (lumacaftor-ivacaftor) PROLASTIN-C INTRAVENOUS SOLUTION 1000 PSB MG/20ML (alpha1-proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION PSB RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor) PULMOZYME INHALATION SOLUTION 1 MG/ML NPSB (dornase alfa) SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 NPB MG/ML-% (beractant in nacl) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & NPB 150 MG, 50-75 & 75 MG (tezacaftor-ivacaftor) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 NPB & 150 MG (elexacaftor-tezacaftor-ivacaft)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

253 Prescription Drug Name Drug Tier Drug Notes ZEMAIRA INTRAVENOUS SOLUTION NF RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor) *SULFONAMIDES* - DRUGS FOR INFECTIONS sulfadiazine oral tablet 500 mg NPB *TETRACYCLINES* - DRUGS FOR INFECTIONS ACTICLATE ORAL TABLET 150 MG, 75 MG (doxycycline NF hyclate) avidoxy oral tablet 100 mg G BENZODOX COMBINATION THERAPY PACK 30 X 100 MG & 4.4%, 60 X 100 MG & 4.4% (doxycycline-benzoyl NF peroxide) minocycline hcl (Coremino Oral Tablet Extended Release 24 NF Hour 135 Mg, 45 Mg, 90 Mg) demeclocycline hcl oral tablet 150 mg, 300 mg G DORYX MPC ORAL TABLET DELAYED RELEASE 120 NF MG (doxycycline hyclate) DORYX ORAL TABLET DELAYED RELEASE 200 MG, NF 50 MG, 80 MG (doxycycline hyclate) doxycycline hyclate oral capsule 100 mg, 50 mg G doxycycline hyclate oral tablet 100 mg, 20 mg G doxycycline hyclate oral tablet 150 mg, 50 mg, 75 mg NF doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, G 50 mg, 75 mg doxycycline hyclate oral tablet delayed release 200 mg NF doxycycline monohydrate oral capsule 100 mg, 50 mg G doxycycline monohydrate oral capsule 150 mg, 75 mg NF doxycycline monohydrate oral suspension reconstituted 25 G mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 G mg MINOCIN ORAL CAPSULE 100 MG (minocycline hcl) NF minocycline hcl er oral capsule extended release 24 hour 135 mg, NF 45 mg, 90 mg minocycline hcl er oral tablet extended release 24 hour 105 mg, NF 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

254 Prescription Drug Name Drug Tier Drug Notes minocycline hcl oral tablet 100 mg, 50 mg, 75 mg G MINOLIRA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 105 MG, 135 MG (minocycline hcl) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 100 G Mg) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 75 NF Mg) doxycycline hyclate (Morgidox Oral Capsule 100 Mg) G NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) NPB SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG NF (sarecycline hcl) SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG NF (minocycline hcl) TARGADOX ORAL TABLET 50 MG (doxycycline hyclate) NF tetracycline hcl oral capsule 250 mg, 500 mg G tigecycline intravenous solution reconstituted 50 mg NF VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline NPB calcium) XERAVA INTRAVENOUS SOLUTION NPB RECONSTITUTED 100 MG (eravacycline dihydrochloride) XIMINO ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 135 MG, 45 MG, 90 MG (minocycline hcl) *THYROID AGENTS* - HORMONES ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, NPB 300 MG (thyroid) levothyroxine sodium (Euthyrox Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 G Mcg, 50 Mcg, 75 Mcg, 88 Mcg) levothyroxine sodium (Levo-T Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 300 G Mcg, 50 Mcg, 75 Mcg, 88 Mcg) levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, G 75 mcg, 88 mcg

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

255 Prescription Drug Name Drug Tier Drug Notes levothyroxine sodium (Levoxyl Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 50 G Mcg, 75 Mcg, 88 Mcg) liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg G methimazole oral tablet 10 mg, 5 mg G NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 NPB MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg G propylthiouracil oral tablet 50 mg G TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, NF 25 MCG, 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium) TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 NF MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) levothyroxine sodium (Unithroid Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 G Mcg, 300 Mcg, 50 Mcg, 75 Mcg, 88 Mcg) WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, NPB 65 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG NPB (thyroid) *ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS* - DRUGS FOR THE STOMACH ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG NF (rabeprazole sodium) ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 NF MG, 5 MG (rabeprazole sodium) amoxicill-clarithro-lansopraz oral G belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2- NPB 60 mg CARAFATE ORAL SUSPENSION 1 GM/10ML (sucralfate) NF

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

256 Prescription Drug Name Drug Tier Drug Notes CARAFATE ORAL TABLET 1 GM (sucralfate) NF chlordiazepoxide-clidinium oral capsule 5-2.5 mg NF cimetidine hcl oral solution 300 mg/5ml G cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg G CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) NPB DEXILANT ORAL CAPSULE DELAYED RELEASE 30 PB MG, 60 MG (dexlansoprazole) dicyclomine hcl oral capsule 10 mg G dicyclomine hcl oral solution 10 mg/5ml G dicyclomine hcl oral tablet 20 mg G ed-spaz oral tablet dispersible 0.125 mg G eq famotidine max st oral tablet 20 mg G ESOMEP-EZS ORAL KIT 20 MG (esomeprazole magnesium) NF esomeprazole magnesium oral capsule delayed release 20 mg, 40 G mg famotidine oral suspension reconstituted 40 mg/5ml G famotidine oral tablet 20 mg, 40 mg G GLYCATE ORAL TABLET 1.5 MG (glycopyrrolate) NF glycopyrrolate oral tablet 1 mg, 2 mg G GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 NF MG/2ML (glycopyrrolate) hyoscyamine sulfate er oral tablet extended release 12 hour G 0.375 mg hyoscyamine sulfate oral elixir 0.125 mg/5ml G hyoscyamine sulfate oral solution 0.125 mg/ml G hyoscyamine sulfate oral tablet 0.125 mg G hyoscyamine sulfate oral tablet dispersible 0.125 mg G hyoscyamine sulfate sublingual tablet sublingual 0.125 mg G lansoprazole oral capsule delayed release 15 mg, 30 mg G lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg G methscopolamine bromide oral tablet 2.5 mg, 5 mg G misoprostol oral tablet 100 mcg, 200 mcg G NEXIUM 24HR CLEAR MINIS ORAL CAPSULE NF DELAYED RELEASE 20 MG (esomeprazole magnesium)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

257 Prescription Drug Name Drug Tier Drug Notes NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE NF 20 MG (esomeprazole magnesium) NEXIUM ORAL CAPSULE DELAYED RELEASE 20 NF MG, 40 MG (esomeprazole magnesium) NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40 NF MG, 5 MG (esomeprazole magnesium) nizatidine oral capsule 150 mg, 300 mg G nizatidine oral solution 15 mg/ml G hyoscyamine sulfate (Nulev Oral Tablet Dispersible 0.125 Mg) G OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- NPB clarithro-omeprazole) omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg G omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40- NF 1100 mg omeprazole-sodium bicarbonate oral packet 20-1680 mg, 40- NF 1680 mg oscimin oral tablet 0.125 mg G oscimin sr oral tablet extended release 12 hour 0.375 mg G oscimin sublingual tablet sublingual 0.125 mg G pantoprazole sodium oral tablet delayed release 20 mg, 40 mg G PREVACID 24HR ORAL CAPSULE DELAYED NF RELEASE 15 MG (lansoprazole) PREVACID ORAL CAPSULE DELAYED RELEASE 15 NF MG, 30 MG (lansoprazole) PREVACID SOLUTAB ORAL TABLET DELAYED NF RELEASE DISPERSIBLE 15 MG, 30 MG (lansoprazole) PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole NPB magnesium) propantheline bromide oral tablet 15 mg G PROTONIX ORAL PACKET 40 MG (pantoprazole sodium) NF PROTONIX ORAL TABLET DELAYED RELEASE 20 NF MG, 40 MG (pantoprazole sodium) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- PB metronid-tetracyc) rabeprazole sodium oral capsule sprinkle 10 mg NPB rabeprazole sodium oral tablet delayed release 20 mg G

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

258 Prescription Drug Name Drug Tier Drug Notes sucralfate oral suspension 1 gm/10ml NF sucralfate oral tablet 1 gm G SYMAX DUOTAB ORAL TABLET EXTENDED NPB RELEASE 0.375 MG (hyoscyamine sulfate) hyoscyamine sulfate (Symax-Sr Oral Tablet Extended Release G 12 Hour 0.375 Mg) TALICIA ORAL CAPSULE DELAYED RELEASE 250- NPB 12.5-10 MG (amoxicill-rifabutin-omeprazole) ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG NF (omeprazole-sodium bicarbonate) ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG NF (omeprazole-sodium bicarbonate) *URINARY ANTISPASMODICS* - DRUGS FOR THE URINARY SYSTEM bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg G darifenacin hydrobromide er oral tablet extended release 24 G hour 15 mg, 7.5 mg DETROL LA ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 2 MG, 4 MG (tolterodine tartrate) ENABLEX ORAL TABLET EXTENDED RELEASE 24 NF HOUR 15 MG, 7.5 MG (darifenacin hydrobromide) flavoxate hcl oral tablet 100 mg G GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin NF chloride) MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 25 MG, 50 MG (mirabegron) oxybutynin chloride er oral tablet extended release 24 hour 10 G mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml G oxybutynin chloride oral tablet 5 mg G OXYTROL FOR WOMEN TRANSDERMAL PATCH NF TWICE WEEKLY 3.9 MG/24HR (oxybutynin) OXYTROL TRANSDERMAL PATCH TWICE WEEKLY NF 3.9 MG/24HR (oxybutynin) solifenacin succinate oral tablet 10 mg, 5 mg G tolterodine tartrate er oral capsule extended release 24 hour 2 G mg, 4 mg 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

259 Prescription Drug Name Drug Tier Drug Notes tolterodine tartrate oral tablet 1 mg, 2 mg G TOVIAZ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 4 MG, 8 MG (fesoterodine fumarate) trospium chloride er oral capsule extended release 24 hour 60 G mg trospium chloride oral tablet 20 mg G VESICARE ORAL TABLET 10 MG, 5 MG (solifenacin NF succinate) *VACCINES* - BIOLOGICAL AGENTS FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 0.5 ML (influenza vac a&b sa adj NPB quad) FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED NPB SYRINGE 0.7 ML (influenza vac high-dose quad) MENQUADFI INTRAMUSCULAR INJECTABLE NPB (meningococcal a c y&w-135 conj) ROTARIX ORAL SUSPENSION RECONSTITUTED NPB (rotavirus vaccine live oral) ROTATEQ ORAL SOLUTION (rotavirus vac live NPB pentavalent) VAXCHORA ORAL SUSPENSION RECONSTITUTED NPB (cholera vac live attenuated) VIVOTIF ORAL CAPSULE DELAYED RELEASE NPB (typhoid vaccine) *VAGINAL AND RELATED PRODUCTS* - DRUGS FOR WOMEN CLEOCIN VAGINAL SUPPOSITORY 100 MG NPB (clindamycin phosphate) clindamycin phosphate vaginal cream 2 % G CLINDESSE VAGINAL CREAM 2 % (clindamycin NPB phosphate (1 dose)) CRINONE VAGINAL GEL 4 %, 8 % (progesterone) NF ENCARE VAGINAL SUPPOSITORY 100 MG (nonoxynol- CE 9) ENDOMETRIN VAGINAL INSERT 100 MG PB (progesterone)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

260 Prescription Drug Name Drug Tier Drug Notes estradiol vaginal cream 0.1 mg/gm G estradiol vaginal tablet 10 mcg G ESTRING VAGINAL RING 2 MG (estradiol) NF FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 NF MG/24HR (estradiol acetate) GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole NPB nitrate (1 dose)) IMVEXXY MAINTENANCE PACK VAGINAL INSERT NPB 10 MCG, 4 MCG (estradiol) IMVEXXY STARTER PACK VAGINAL INSERT 10 NPB MCG, 4 MCG (estradiol) INTRAROSA VAGINAL INSERT 6.5 MG (prasterone) NPB metronidazole vaginal gel 0.75 % G miconazole 3 vaginal suppository 200 mg G NUVESSA VAGINAL GEL 1.3 % (metronidazole) NF OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL CE 3 % (nonoxynol-9) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, PB conjugated) SHUR-SEAL CONTRACEPTIVE VAGINAL GEL 2 % CE (nonoxynol-9) terconazole vaginal cream 0.4 %, 0.8 % G terconazole vaginal suppository 80 mg G TRIMO-SAN VAGINAL GEL 0.025-0.01 % (oxyquinoline- NF sod lauryl sulf) metronidazole (Vandazole Vaginal Gel 0.75 %) G VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 CE % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM CE 12.5 % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL GEL 4 % CE (nonoxynol-9) estradiol (Yuvafem Vaginal Tablet 10 Mcg) G *VASOPRESSORS* - DRUGS FOR THE HEART ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 NPB MG/30ML (epinephrine)

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

261 Prescription Drug Name Drug Tier Drug Notes ADYPHREN AMP II INJECTION KIT 1 MG/ML NF (epinephrine) ADYPHREN AMP INJECTION KIT 1 MG/ML NF (epinephrine) ADYPHREN II INJECTION KIT 1 MG/ML (epinephrine) NF ADYPHREN INJECTION KIT 1 MG/ML (epinephrine) NF AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML NF (ephedrine sulfate (pressors)) AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 NF MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine) epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 G mg/0.3ml, 0.3 mg/0.3ml epinephrine intravenous solution prefilled syringe 0.1 mg/10ml NPB epinephrine professional injection kit 1 mg/ml NF EPINEPHRINESNAP-EMS INJECTION KIT 1 MG/ML NF (epinephrine) EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML NF (epinephrine) EPISNAP INJECTION KIT 1 MG/ML (epinephrine) NF GIAPREZA INTRAVENOUS SOLUTION 2.5 MG/ML NF (angiotensin ii acetate) midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg G phenylephrine hcl (pressors) intravenous solution 0.8 mg/10ml NPB phenylephrine hcl intravenous solution 1 mg/10ml NPB SYMJEPI INJECTION SOLUTION PREFILLED PB SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML (epinephrine) *VITAMINS* - DRUGS FOR NUTRITION aminobenzoate potassium oral packet 2 gm G ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML NF (ascorbic acid) ergocal oral capsule 62.5 mcg (2500 ut) NF ergocalciferol oral capsule 1.25 mg (50000 ut) G phytonadione injection solution 1 mg/0.5ml, 10 mg/ml G phytonadione oral tablet 5 mg G POTABA ORAL CAPSULE 500 MG (potassium NPB aminobenzoate) 2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

262 Prescription Drug Name Drug Tier Drug Notes pyridoxine hcl injection solution 100 mg/ml G thiamine hcl injection solution 100 mg/ml G vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) G vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml G wheat germ oil oral oil NPB

2020 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month

12/01/2020

263 Index 12-PANEL POC ACCU-CHEK LINKASSIST acitretin...... 108 TOXICOLOGY SYSTEM....132 ...... 170 ACTEMRA ACTPEN...... 20 1st relief spray...... 108 ACCU-CHEK MULTICLIX ACTHAR...... 145 1st tier unifine pentips...... 169 LANCET DEV...... 170 ACTICLATE...... 254 1st tier unifine pentips plus...... 169 ACCU-CHEK MULTICLIX ACTICOAT 7...... 108 1st tier unilet comfortouch...... 169 LANCETS...... 170 ACTICOAT ABSORBENT..108 7T Lido...... 108 ACCU-CHEK NANO ACTICOAT A.A.G.C. KIT IN SMARTVIEW...... 170 ANTIMICROBIAL...... 108 TERODERM...... 108 ACCU-CHEK PLASTIC ACTICOAT FLEX 3 4"X4"..108 abacavir sulfate...... 83 CARTRIDGE...... 170 acti-lance 28g...... 171 abacavir sulfate-lamivudine...... 83 ACCU-CHEK RAPID-D acti-lance lite lancets 28g...... 171 abacavir-lamivudine-zidovudine 83 INFUSION SET...... 170 acti-lance special lancets 17g.. 171 Abaneu-Sl...... 160 ACCU-CHEK RAPID-D acti-lance universal 23g...... 171 ABILIFY...... 79 LINK...... 170 ACTIMMUNE...... 70 ABILIFY MAINTENA...... 79 ACCU-CHEK SAFE-T PRO ACTIQ...... 27 ABILIFY MYCITE...... 79 LANCETS...... 170 active fe...... 160 abiraterone acetate...... 70 ACCU-CHEK active-prep kit i...... 108 ABLYSINOL...... 90 SMARTVIEW...... 132 active-prep kit ii...... 108 ABOUTTIME PEN ACCU-CHEK SOFTCLIX active-prep kit iii...... 108 NEEDLE...... 169 LANCET DEV...... 170 active-prep kit iv...... 108 ABSORICA...... 108 ACCU-CHEK SOFTCLIX active-prep kit v...... 108 acamprosate calcium...... 247 LANCETS...... 170 activite...... 222 ACANYA...... 108 ACCU-CHEK SPIRIT ACTOS...... 49 acarbose...... 49 BATTERY KIT...... 171 ACUICYN...... 108 ACCUCAINE...... 108 ACCU-CHEK SPIRIT acyclovir...... 83, 108 ACCU-CHEK AVIVA...... 170 INSULIN PUMP...... 171 ACZONE...... 108 ACCU-CHEK AVIVA ACCU-CHEK TENDER II ADAKVEO...... 160 CONNECT...... 170 SET 24"...... 171 adapalene...... 108, 109 ACCU-CHEK AVIVA PLUS ACCU-CHEK TENDER II adapalene-benzoyl peroxide.... 109 ...... 132, 170 SET 31"...... 171 ADASUVE...... 79 ACCU-CHEK COMBO...... 170 ACCU-CHEK TENDER II adc/f (0.5mg/ml)...... 222 ACCU-CHEK COMPACT SET 43"...... 171 ADDERALL XR...... 16 PLUS...... 132 ACCU-CHEK ADDYI...... 247 ACCU-CHEK COMPACT ULTRAFLEX INF SET...... 171 adefovir dipivoxil...... 83 PLUS CARE...... 170 ACCU-CHEK ADEMPAS...... 90 ACCU-CHEK FASTCLIX ULTRAFLEX-1 INF SET....171 ADHANSIA XR...... 16 LANCET...... 170 ACCUTREND GLUCOSE..132 adjustable lancing device...... 171 ACCU-CHEK FASTCLIX acd formula a...... 40 ADLYXIN...... 49 LANCETS...... 170 ACD-A NOCLOT-50...... 40 ADLYXIN STARTER ACCU-CHEK FLEXLINK acebutolol hcl...... 87 PACK...... 49 PLUS 10MM...... 170 aceso ag...... 108 ADMELOG...... 49 ACCU-CHEK FLEXLINK acetaminophen-codeine...... 26, 27 ADMELOG SOLOSTAR...... 49 PLUS 6MM...... 170 acetaminophen-codeine #3...... 26 ADRENAL C FORMULA.. 222 ACCU-CHEK FLEXLINK acetazolamide...... 144 ADRENALIN...... 232, 261 PLUS 8MM...... 170 acetazolamide er...... 144 ADVAIR HFA...... 36 ACCU-CHEK GUIDE. 132, 170 acetic acid...... 155, 241 ADVANCE INTUITION ACCU-CHEK GUIDE ME..170 acetylcysteine...... 106 METER...... 171 ACIPHEX...... 256 ADVANCE INTUITION ACIPHEX SPRINKLE...... 256 MONITOR...... 171 264 ADVANCE INTUITION AGAMATRIX AMP TEST..132 ALDURAZYME...... 145 TEST...... 132 AGAMATRIX JAZZ TEST.132 ALECENSA...... 70 ADVANCE MICRO-DRAW AGAMATRIX JAZZ alendronate sodium...... 145 METER...... 171 WIRELESS 2...... 172 alevamax...... 109 ADVANCE MICRO-DRAW AGAMATRIX KEYNOTE ALEVICYN TEST...... 132 TEST...... 132 ANTIPRURITIC...... 109 ADVANCED ALLERGY AGAMATRIX PRESTO...... 172 ALEVICYN COLLECTION...... 109 AGAMATRIX PRESTO ANTIPRURITIC SG...... 109 ADVATE...... 157 PRO METER...... 172 ALEVICYN DERMAL ADVOCATE BLOOD AGAMATRIX PRESTO SPRAY...... 109 GLUCOSE MONITOR...... 171 TEST...... 132 alfuzosin hcl er...... 155 ADVOCATE BLOOD AGAMATRIX ULTRA- ALINIA...... 66 GLUCOSE SYSTEM...... 171 THIN LANCETS...... 172 ALIQOPA...... 70 ADVOCATE INSULIN PEN AGGRASTAT...... 157 aliskiren fumarate...... 63 NEEDLES...... 171 AIMOVIG...... 214 ALLEVYN AG ADHESIVE 109 ADVOCATE INSULIN aimsco twist lancets 32g...... 172 ALLEVYN AG NON- SYRINGE...... 171 AIMSCO TWIST LANCETS ADHESIVE...... 109 ADVOCATE LANCETS 33G...... 172 ALLEVYN AG SACRUM 6- 30G...... 172 Airavite...... 160 3/4"...... 109 ADVOCATE LANCING AIRDUO RESPICLICK ALLEVYN AG SACRUM DEVICE...... 172 113/14...... 36 9"X9"...... 109 ADVOCATE RAPID-SAFE AIRDUO RESPICLICK ALLEVYN GENTLE...... 109 LANCING...... 172 232/14...... 36 allopurinol...... 156 ADVOCATE REDI-CODE AIRDUO RESPICLICK ALLZITAL...... 25 ...... 132, 172 55/14...... 36 almond oil (sweet)...... 93 ADVOCATE REDI-CODE+172 AJOVY...... 214, 215 almotriptan malate...... 215 ADVOCATE REDI-CODE+ AKOVAZ...... 262 ALOCANE EMERGENCY TALKING...... 172 ak-poly-bac...... 235 BURN MAX STR...... 109 ADVOCATE REDI-CODE+ AKTEN...... 235 ALOCRIL...... 235 TEST...... 132 AKYNZEO...... 58 alogliptin benzoate...... 49 ADVOCATE SAFETY ALA SCALP...... 109 alogliptin-metformin hcl...... 49 LANCETS...... 172 ala-cort...... 109 alogliptin-pioglitazone...... 49 ADVOCATE SAFETY ALA-QUIN...... 109 ALOMIDE...... 235 LANCETS 26G...... 172 albendazole...... 33 ALOPHEN...... 166 ADVOCATE TEST...... 132 ALBUMINEX...... 157 ALORA...... 150 adynovate...... 157 albuterol sulfate...... 36 alosetron hcl...... 152 ADYPHREN...... 262 albuterol sulfate er...... 36 ALPHAGAN P...... 235 ADYPHREN AMP...... 262 albuterol sulfate hfa...... 36 ALPHANATE/VWF ADYPHREN AMP II...... 262 alclometasone dipropionate.....109 COMPLEX/HUMAN...... 157 ADYPHREN II...... 262 ALCOH-GLOVE ALPHANINE SD...... 157 ADZENYS ER...... 16 CONTOURED WIPE...... 172 alprazolam...... 34 ADZENYS XR-ODT...... 16 alcohol pads...... 172 alprazolam er...... 34 AEMCOLO...... 66 alcohol prep...... 172 ALPRAZOLAM INTENSOL 34 AFINITOR...... 70 alcohol swabs...... 172 alprazolam xr...... 34 AFINITOR DISPERZ...... 70 ALCOHOL SWABSTICK....172 ALREX...... 235 Afirmelle...... 94 alcohol wipes...... 172 ALTABAX...... 109 AFREZZA...... 49 alcoh-wipe...... 172 Altacaine...... 235 AFSTYLA...... 157 ALCORTIN A...... 109 altafluor benox...... 235 AFTERA...... 94 ALDACTAZIDE...... 144 Altafrin...... 235 AGAMATRIX AMP...... 172 ALDARA...... 109 Altavera...... 94 265 alternate site lancing device.... 172 ampicillin...... 244 ARCAPTA NEOHALER...... 36 ALTOPREV...... 61 ampicillin-sulbactam sodium...244 Argyle Sterile Saline...... 155 ALTRENO...... 109 AMPYRA...... 247 Argyle Sterile Water...... 218 ALUNBRIG...... 70 AMRIX...... 231 ARIKAYCE...... 19 ALVESCO...... 36 ANACAINE...... 110 aripiprazole...... 79 alyacen 1/35...... 94 ANADROL-50...... 31 ARISTADA...... 80 alyacen 7/7/7...... 94 anagrelide hcl...... 157 ARISTADA INITIO...... 80 Alyq...... 90 ANASEPT...... 82 armodafinil...... 16 ALZAIR ALLERGY anastrozole...... 70 ARMOUR THYROID...... 255 NASAL SPRAY...... 232 ANDRODERM...... 32 arnica flower...... 110 Amabelz...... 150 ANDROGEL...... 32 ARNUITY ELLIPTA...... 36 amantadine hcl...... 78 anesthesia s/i-40a...... 154 ARTHROTEC...... 20 ambrisentan...... 90 anesthesia s/i-40h...... 154 ARTISS...... 164 amcinonide...... 109 anesthesia s/i-40s...... 154 ARYMO ER...... 27 AMD FOAM DRESSING... 173 ANGELIQ...... 150 ASACOL HD...... 152 AMELUZ...... 109 ANNOVERA...... 94 Ascomp-Codeine...... 27 Amethia...... 94 ANORO ELLIPTA...... 36 ASCOR...... 262 Amethia Lo...... 94 ANTARA...... 61 Ashlyna...... 94 Amethyst...... 94 anticoagulant cit dext soln a..... 41 Asilnasalrms...... 142 AMICAR...... 164 anticoagulant sodium citrate.....41 ASMANEX (120 METERED amiloride hcl...... 144 ANZEMET...... 58 DOSES)...... 37 amiloride-hydrochlorothiazide 144 APADAZ...... 27 ASMANEX (14 METERED aminoacetic acid...... 155 apap-caff-dihydrocodeine...... 27 DOSES)...... 37 Aminoamrms...... 234 APEXICON E...... 110 ASMANEX (30 METERED aminobenzoate potassium...... 262 APIDRA...... 49 DOSES)...... 37 aminocaproic acid...... 164 APIDRA SOLOSTAR...... 49 ASMANEX (60 METERED AMINOPMRMS...... 142 APLENZIN...... 46 DOSES)...... 37 AMINOPROTECT...... 234 APLICARE ALCOHOL ASMANEX (7 METERED Aminoreliefrms...... 234 SWABSTICK...... 173 DOSES)...... 37 amiodarone hcl...... 35 APOKYN...... 78 ASMANEX HFA...... 37 AMITIZA...... 152 APP SLIM RMS...... 142 ASPARLAS...... 70 amitriptyline hcl...... 46 apraclonidine hcl...... 235 aspirin...... 25 amlodipine besy-benazepril hcl..63 aprepitant...... 58 aspirin adult low dose...... 25 amlodipine besylate...... 89 Apri...... 94 aspirin ec low strength...... 25 amlodipine besylate-valsartan...63 APRISO...... 152 aspirin low dose...... 25 amlodipine-atorvastatin...... 90 APRIZIO PAK...... 110 aspirin-dipyridamole er...... 157 amlodipine-olmesartan...... 63 APTENSIO XR...... 16 ASPIR-LOW...... 25 amlodipine-valsartan-hctz...... 63 APTIOM...... 42 ASSURE 3 METER...... 173 ammonium lactate...... 110 APTIVUS...... 83 ASSURE 3 TEST...... 132 Amnesteem...... 110 AQUACEL AG BURN...... 110 ASSURE 4 METER...... 173 amoxapine...... 46 AQUALANCE LANCETS ASSURE 4 TEST...... 132 amoxicill-clarithro-lansopraz..256 30G...... 173 assure comfort lancets 28g...... 173 amoxicillin...... 243, 244 AQUORAL...... 220 ASSURE ID INSULIN amoxicillin-pot clavulanate.....244 ARAKODA...... 68 SAFETY SYR...... 173 amoxicillin-pot clavulanate er. 244 ARALAST NP...... 253 ASSURE ID SAFETY PEN AMPHADASE...... 218 Aranelle...... 94 NEEDLES...... 173 amphetamine sulfate...... 16 ARANESP (ALBUMIN ASSURE II...... 132 amphetamine-dextroamphet er. 16 FREE)...... 160, 161 ASSURE II CHECK...... 132 amphetamine- ARAZLO...... 110 ASSURE LANCETS...... 173 dextroamphetamine...... 16 ARCALYST...... 20 ASSURE PLATINUM...... 132 266 ASSURE PLATINUM AUTOLET MINI...... 173 BAYER ASPIRIN EC LOW METER...... 173 AUTOLET PLATFORMS... 173 DOSE...... 25 ASSURE PRISM MULTI AUTOLET PLUS...... 173 BAYER LOW DOSE...... 25 TEST...... 132 autopen...... 173 BD AUTOSHIELD...... 174 ASSURE PRO BLOOD AUTOSOFT 30 INFUSION BD AUTOSHIELD DUO.... 174 GLUCOSE METER...... 173 SET...... 173 BD INSULIN SYRINGE.....174 ASSURE PRO TEST...... 133 AUTOSOFT 90 INFUSION BD INSULIN SYRINGE ASTAMED MYO...... 142 SET...... 173 MICROFINE...... 174 ASTERO...... 110 AUTOSOFT XC INFUSION BD INSULIN SYRINGE ATABEX EC...... 222 SET...... 174 U/F...... 174 ATABEX OB...... 222 AUVI-Q...... 262 BD INSULIN SYRINGE U- ATACAND...... 63 AVANDIA...... 49 500...... 174 ATACAND HCT...... 63 AVENOVA...... 110 BD INSULIN SYRINGE atazanavir sulfate...... 83 Aviane...... 95 ULTRAFINE...... 174 atenolol...... 87 avidoxy...... 254 BD LANCET ULTRAFINE atenolol-chlorthalidone...... 63 Avita...... 110 30G...... 174 ATIVAN...... 34, 35 AVONEX PEN...... 247 BD LANCET ULTRAFINE atomoxetine hcl...... 16 AVONEX PREFILLED...... 247 33G...... 174 atopaderm...... 110 Ayuna...... 95 BD LATITUDE DIABETES174 ATOPICLAIR...... 110 AZASAN...... 218 BD LATITUDE DIABETES atorvastatin calcium...... 61 AZASITE...... 235 SYSTEM...... 174 atovaquone...... 66 azathioprine...... 218 BD LOGIC BLOOD atovaquone-proguanil hcl...... 68 azelaic acid...... 110 GLUCOSE MONITOR...... 174 ATRALIN...... 110 azelastine hcl...... 232, 235 BD MICROTAINER ATRAPRO HYDROGEL....110 AZELEX...... 110 LANCETS...... 174 ATRIPLA...... 83 azesco...... 222 BD PEN...... 174 atropine sulfate...... 235 azithromycin...... 168, 169 BD PEN MINI...... 174 ATROVENT HFA...... 37 AZOPT...... 235 BD PEN NEEDLE MICRO AUBAGIO...... 247 Azurette...... 95 U/F...... 174 Aubra...... 94 b-6 folic acid...... 161 BD PEN NEEDLE MINI Aubra Eq...... 94 bacitracin...... 235 U/F...... 174 AUGMENTIN...... 244 bacitracin-polymyxin b...... 235 BD PEN NEEDLE NANO aurora lancet super thin 30g....173 bacitra-neomycin-polymyxin- 2ND GEN...... 175 aurora lancet thin 23g...... 173 hc...... 235 BD PEN NEEDLE NANO aurora pen needles...... 173 baclofen...... 231 U/F...... 175 aurora unifine pentips...... 173 BALCOLTRA...... 95 BD PEN NEEDLE Aurovela 1.5/30...... 95 balsalazide disodium...... 152 ORIGINAL U/F...... 175 Aurovela 1/20...... 95 balsam peru-castor oil...... 110 BD PEN NEEDLE SHORT Aurovela 24 Fe...... 95 BALVERSA...... 70 U/F...... 175 Aurovela Fe 1.5/30...... 95 Balziva...... 95 BD SAFETYGLIDE Aurovela Fe 1/20...... 95 BANZEL...... 42 INSULIN SYRINGE...... 175 AURYXIA...... 152 BAQSIMI ONE PACK...... 49 BD SWABS SINGLE USE AUSTEDO...... 247 BAQSIMI TWO PACK...... 49 BUTTERFLY...... 175 AUTO-LANCET...... 173 BARACLUDE...... 83 BD VEO INSULIN SYR U/F AUTO-LANCET MINI...... 173 barium sulfate...... 133 1/2UNIT...... 175 AUTOLET II CLINISAFE.. 173 BASAGLAR KWIKPEN...... 50 BD VEO INSULIN AUTOLET LITE base g almond oil (sweet)...... 93 SYRINGE U/F...... 175 CLINISAFE...... 173 base x...... 244 beau rx...... 110 AUTOLET LITE STARTER BAXDELA...... 152 BECONASE AQ...... 232 PACK...... 173 Bekyree...... 95 267 BELBUCA...... 27 bicalutamide...... 70 BREO ELLIPTA...... 37 belladonna alkaloids-opium.....256 BIDIL...... 90 BREZTRI AEROSPHERE.... 37 BELRAPZO...... 70 bi-est 80:20 progesterone...... 150 BRIDION...... 57 BELSOMRA...... 165 BIEST/PROGESTERONE...150 briellyn...... 95 benazepril hcl...... 63 BIJUVA...... 150 BRILINTA...... 157 benazepril-hydrochlorothiazide.63 BIKTARVY...... 83 brimonidine tartrate...... 236 BENEFIX...... 157 bimatoprost...... 235 BRIVIACT...... 42 BENICAR...... 63 bi-mix...... 91 Bromfed Dm...... 107 BENICAR HCT...... 63 BINOSTO...... 145 bromfenac sodium (once-daily) BENLYSTA...... 218 biocel...... 222 ...... 236 bensal hp...... 110 BIOFREQUENCY bromocriptine mesylate...... 78 BENZACLIN...... 110 INSOLES...... 175 BROMSITE...... 236 BENZACLIN WITH PUMP 110 BIOGUARD GAUZE BROVANA...... 37 benzalkonium chloride...... 82 SPONGES...... 175 BRUKINSA...... 70 Benzepro...... 110 BIOGUARD ISLAND BRYHALI...... 111 Benzepro Short Contact...... 110 DRESSINGS...... 175 budesonide...... 37, 104 benznidazole...... 33 BIOGUARD NON- budesonide er...... 104 BENZODOX...... 254 ADHERENT DRESSING... 175 bullseye mini safety lancets.....175 benzoin...... 111 BIONECT...... 111 BULLSEYE SAFETY benzonatate...... 106 BIOSCANNER GLUCOSE LANCETS...... 175 benzoyl perox-hydrocortisone. 111 TEST...... 133 bumetanide...... 144 benzoyl peroxide...... 111 bio-statin...... 59 BUNAVAIL...... 27 benzoyl peroxide-erythromycin BIOTEL CARE BLOOD Bupap...... 25 ...... 111 GLUCOSE SYST...... 175 bupivacaine hcl...... 168 benztropine mesylate...... 78 bisacodyl...... 166 buprenorphine hcl...... 27 benzyl alcohol...... 244 bisacodyl ec...... 166 buprenorphine hcl-naloxone hcl.27 benzyl benzoate...... 93 bisoprolol fumarate...... 87 bupropion hcl...... 46 BEPREVE...... 235 bisoprolol-hydrochlorothiazide..63 bupropion hcl er (smoking det) BESER...... 111 bivalirudin rtu...... 41 ...... 247 Beser...... 111 BIVIGAM...... 242 bupropion hcl er (sr)...... 46 BESIVANCE...... 235 BLEPHAMIDE...... 236 bupropion hcl er (xl)...... 46 beta 1 kit...... 104 BLEPHAMIDE S.O.P...... 236 buspirone hcl...... 35 BETADINE OPHTHALMIC Blisovi 24 Fe...... 95 butalbital-acetaminophen...... 25 PREP...... 235 Blisovi Fe 1.5/30...... 95 butalbital-apap-caff-cod...... 27 betamethasone combo...... 104 Blisovi Fe 1/20...... 95 butalbital-apap-caffeine...... 25 betamethasone dipropionate....111 blood glucose monitor system..175 butalbital-asa-caff-codeine...... 27 betamethasone dipropionate blood glucose system pak...... 175 butalbital-aspirin-caffeine...... 25 aug...... 111 blood glucose test...... 133 butorphanol tartrate...... 27 betamethasone valerate...... 111 BOCASAL...... 220 BUTRANS...... 27 BETAPACE...... 87 BONJESTA...... 58 BYDUREON...... 50 BETAPACE AF...... 87 boric acid...... 111 BYDUREON BCISE...... 50 BETASERON...... 247 bosentan...... 91 BYETTA 10 MCG PEN...... 50 betaxolol hcl...... 87, 235 BOSULIF...... 70 BYETTA 5 MCG PEN...... 50 bethanechol chloride...... 259 BOTOX...... 233 BYSTOLIC...... 87 BETHKIS...... 19 bp vit 3...... 161 cabergoline...... 145 BETIMOL...... 235 bp wash...... 111 CABLIVI...... 157 BETOPTIC-S...... 235 bpco...... 111 CABOMETYX...... 70 BEVESPI AEROSPHERE..... 37 b-plex...... 222 CADIRAMD...... 111 bexarotene...... 70 b-plex plus...... 222 CAFERGOT...... 215 BEYAZ...... 95 BRAFTOVI...... 70 caffeine citrate...... 17 268 CALCIFOL...... 216 CARDIOCOM LANCING CARNITOR...... 145 calcipotriene...... 111 DEVICE...... 175 CARNITOR SF...... 145 calcipotriene-betameth diprop.111 cardioplegic...... 91 CAROSPIR...... 144 calcitonin (salmon)...... 145 CARDIOVID PLUS...... 234 carteolol hcl...... 236 Calcitrene...... 111 CARDIZEM...... 89 Cartia Xt...... 89 calcitriol...... 111, 145 CARDIZEM CD...... 89 carvedilol...... 87 calcium acetate (phos binder).152 CARDIZEM LA...... 89 carvedilol phosphate er...... 87 calcium folinate...... 93 CARDURA XL...... 155 cascara sagrada...... 166 calcium gluconate...... 216 CAREFINE PEN NEEDLES castor oil...... 93 CALDOLOR...... 20 ...... 175 Cavarest...... 220 CALQUENCE...... 70 careone advanced lancing dev..175 CAYA...... 176 CAMBIA...... 215 CAREONE BLOOD CAYSTON...... 66 Camila...... 95 GLUCOSE SYSTEM...... 175 Caziant...... 96 CAMINO PRO CAREONE BLOOD cefaclor...... 92 COMPLETE/GLYTACTIN.142 GLUCOSE TEST...... 133 cefaclor er...... 92 Camrese...... 95 careone insulin syringe...... 176 cefadroxil...... 92, 93 Camrese Lo...... 95 careone lancet thin 23g...... 176 cefdinir...... 93 CANASA...... 152 careone lancet ultra thin 28g...176 cefixime...... 93 candesartan cilexetil...... 64 careone unifine pentips...... 176 cefpodoxime proxetil...... 93 candesartan cilexetil-hctz...... 64 careone unifine pentips plus.....176 cefprozil...... 93 capecitabine...... 70 CARESENS N GLUCOSE cefuroxime axetil...... 93 CAPEX...... 111 SYSTEM...... 176 Celacyn...... 112 CAPHOSOL...... 220 CARESENS N GLUCOSE CELEBREX...... 20 CAPRELSA...... 70 TEST...... 133 celecoxib...... 20 capsule 0 clear dr...... 244 CARESENS N VOICE CELESTONE SOLUSPAN.. 104 capsule coni-snap #0 clear...... 244 SYSTEM...... 176 CELONTIN...... 42 capsule coni-snap #0 purple.... 244 CARETOUCH ALCOHOL CENFOL...... 161 capsule coni-snap #00 white....244 PREP...... 176 CENTANY...... 112 capsule coni-snap #000 clear.. 244 CARETOUCH INSULIN cephalexin...... 93 capsule coni-snap #1 red/blue. 244 SYRINGE...... 176 CEQUA...... 236 capsule coni-snap #1 veggie.... 244 CARETOUCH CEQUR SIMPLICITY capsule coni-snap #2 white..... 244 LANCING/EJECTOR...... 176 INSERTER...... 176 capsule coni-snap #3 clear...... 245 CARETOUCH MONITOR CERACADE...... 112 capsule coni-snap #3 yellow....245 SYSTEM...... 176 CERDELGA...... 161 capsule coni-snap #4 white..... 245 CARETOUCH PEN CEREZYME...... 161 capsule ezeefit #0 clear...... 245 NEEDLES...... 176 cervical specimen collection.... 133 capsule ezeefit #00 clear...... 245 CARETOUCH SAFETY CERVIDIL...... 242 captopril...... 64 LANCETS...... 176 CETACAINE...... 112 captopril-hydrochlorothiazide...64 CARETOUCH SAFETY cetirizine hcl...... 60 CARAC...... 111 LANCETS 26G...... 176 CETROTIDE...... 146 CARAFATE...... 256, 257 CARETOUCH TEST...... 133 cevimeline hcl...... 220 CARBAGLU...... 145 CARETOUCH TWIST CHANTIX...... 247 carbamazepine...... 42 LANCETS 28G...... 176 CHANTIX CONTINUING carbamazepine er...... 42 CARETOUCH TWIST MONTH PAK...... 247 carbidopa...... 78 LANCETS 30G...... 176 CHANTIX STARTING carbidopa-levodopa...... 78 CARETOUCH TWIST MONTH PAK...... 247 carbidopa-levodopa er...... 78 LANCETS 33G...... 176 Chateal...... 96 carbidopa-levodopa-entacapone 78 CARIMUNE NF...... 242 Chateal Eq...... 96 carbinoxamine maleate...... 60 carisoprodol...... 231 CHEMET...... 57 carisoprodol-aspirin-codeine... 231 CHEMSTRIP K...... 133 269 CHEMSTRIP UGK...... 133 CITRANATAL RX...... 223 clindamycin phos-benzoyl CHENODAL...... 152 Claravis...... 112 perox...... 112 cherry...... 245 CLARINEX-D 12 HOUR.... 107 clindamycin phosphate.... 112, 260 childrens aspirin...... 25 clarithromycin...... 169 clindamycin-tretinoin...... 112 childrens aspirin low strength....25 clarithromycin er...... 169 CLINDESSE...... 260 chlordiazepoxide hcl...... 35 CLEANLET LANCETS 28G clinimix e/dextrose (8/10)...... 234 chlordiazepoxide-amitriptyline247 ...... 176 clinimix e/dextrose (8/14)...... 234 chlordiazepoxide-clidinium..... 257 clemastine fumarate...... 60 clinimix/dextrose (6/5)...... 234 chlorhexidine gluconate.....82, 220 CLENPIQ...... 166 clinimix/dextrose (8/10)...... 234 chloroquine phosphate...... 68 CLEOCIN...... 260 clinimix/dextrose (8/14)...... 234 chlorpromazine hcl...... 80 CLEVER CHEK AUTO- CLINOIN...... 112 chlorthalidone...... 144 CODE SYSTEM...... 176 CLINOLIPID...... 234 chlorzoxazone...... 231 CLEVER CHEK AUTO- Clinpro 5000...... 220 CHOICE DM DIABETES CODE TEST...... 133 clobazam...... 42 RISK TEST...... 176 CLEVER CHEK AUTO- clobetasol prop emollient base.112 CHOLBAM...... 152 CODE VOICE...... 133, 177 clobetasol propionate...... 112, 113 cholestyramine...... 61 CLEVER CHEK LANCETS 177 clobetasol propionate e...... 112 cholestyramine light...... 61 CLEVER CHEK SYSTEM.. 177 clobetasol propionate emulsion112 CHOLEXMAX...... 142 CLEVER CHEK TEST...... 133 CLOBEX SPRAY...... 113 CHOLEXTRA T/F...... 142 CLEVER CHOICE AUTO- CLODAN...... 113 CIALIS...... 91 CODE SYSTEM...... 177 Clodan...... 113 cicatrace pad...... 176 CLEVER CHOICE AUTO- CLODERM...... 113 Ciclodan...... 112 CODE TEST...... 133 clomiphene citrate...... 146 ciclopirox...... 112 CLEVER CHOICE clomipramine hcl...... 46 ciclopirox olamine...... 112 COMFORT EZ...... 177 clonazepam...... 42 CIFEREX...... 161 CLEVER CHOICE clonidine...... 64 cilostazol...... 157 LANCETS 21G...... 177 clonidine hcl...... 64 CILOXAN...... 236 CLEVER CHOICE clonidine hcl er...... 17 CIMDUO...... 83 LANCETS 23G...... 177 clopidogrel bisulfate...... 157 cimetidine...... 257 CLEVER CHOICE clorazepate dipotassium...... 35 cimetidine hcl...... 257 LANCETS 28G...... 177 clotrimazole...... 113, 220 cinacalcet hcl...... 146 CLEVER CHOICE MICRO clotrimazole-betamethasone....113 CINRYZE...... 157 SYSTEM...... 177 clozapine...... 80 CINVANTI...... 58 CLEVER CHOICE MICRO CLOZARIL...... 80 CIPRO...... 152 TEST...... 133 c-nate dha...... 223 CIPRO HC...... 241 CLEVER CHOICE MINI COAGADEX...... 157 CIPRODEX...... 241 SYSTEM...... 177 COAGUCHEK LANCETS..177 ciprofloxacin hcl...... 152, 236, 241 CLEVER CHOICE NO coal tar...... 113 ciprofloxacin-fluocinolone pf.. 241 CODING...... 133 COARTEM...... 68 citalopram hydrobromide...... 46 CLEVER CHOICE TALK cocoa butter...... 245 CITRANATAL 90 DHA...... 222 SYSTEM...... 133, 177 coconut oil...... 93 CITRANATAL ASSURE.... 222 CLICKFINE PEN cod liver oil...... 223 CITRANATAL B-CALM.... 223 NEEDLES...... 177 codeine sulfate...... 27 CITRANATAL BLOOM..... 223 clickfine pen needles...... 177 COLAZAL...... 152 CITRANATAL BLOOM CLIMARA PRO...... 150 colchicine...... 156 DHA...... 223 Clindacin Etz...... 112 colchicine-probenecid...... 156 CITRANATAL DHA...... 223 Clindacin-P...... 112 COLCRYS...... 156 CITRANATAL HARMONY CLINDAGEL...... 112 COLD-EEZE PLUS ...... 223 clindamycin hcl...... 66 DEFENSE...... 218 CITRANATAL MEDLEY...223 clindamycin palmitate hcl...... 66 colesevelam hcl...... 61 270 colestipol hcl...... 61 CONTRAST ALLERGY CURITY ALCOHOL COLLATYL...... 113 PREMED PACK...... 104 SWABS...... 178 COMBIGAN...... 236 CONTRAVE...... 17 CURITY AMD COMBIPATCH...... 150 CONVENIENCE PAK...... 248 ANTIMICROBIAL SPNGE 178 COMBIVENT RESPIMAT....37 CONZIP...... 27 CURITY AMD COMETRIQ (100 MG COOL BLOOD GLUCOSE ANTIMICROBIAL STRIP.. 178 DAILY DOSE)...... 70 TEST STRIPS...... 133 CURITY HYPERTONIC COMETRIQ (140 MG COOL MONITOR...... 178 NACL STRIP...... 114 DAILY DOSE)...... 71 COOL MONITOR KIT...... 178 CURITY IODOFORM COMETRIQ (60 MG DAILY COPASIL...... 113 PACKING STRIP...... 178 DOSE)...... 71 COPAXONE...... 248 CURITY NACL DRESSING COMFORT ASSIST COPIKTRA...... 71 6"X6-3/4"...... 114 INSULIN SYRINGE...... 177 CORDRAN...... 113 Curity Sterile Saline...... 155 comfort assured lancets 28g.... 177 COREG CR...... 87 CURITY WOUND comfort assured lancets 33g.... 177 Coremino...... 254 CLOSURE 1/2"X4"...... 178 COMFORT EZ INSULIN CORLANOR...... 91 CURITY WOUND SYRINGE...... 177 corn (syrup)...... 245 CLOSURE 1/4"X1.5"...... 178 COMFORT EZ MICRO correct...... 166 CURITY WOUND PEN NEEDLES...... 177 CORRECTOL...... 166 CLOSURE 1/4"X3"...... 179 COMFORT EZ PEN CORTIFOAM...... 33 CURITY WOUND NEEDLES...... 178 cortisone acetate...... 104 CLOSURE 1/4"X4"...... 179 COMFORT EZ SHORT CORTISPORIN...... 113 CURITY WOUND PEN NEEDLES...... 178 CORTISPORIN-TC...... 241 CLOSURE 1/8"X3"...... 179 comfort lancets...... 178 CORVITA...... 223 CUROSURF...... 253 COMFORT SHORT INF Corvita 150...... 161 CUTAQUIG...... 242 SET 23"/13MM...... 178 CORVITE 150...... 161 CUVITRU...... 242 COMFORT SHORT INF corvite fe...... 161 CUVPOSA...... 257 SET 31"/13MM...... 178 COSENTYX...... 114 CVS ADVANCED COMFORT SHORT INF COSENTYX (300 MG GLUCOSE TEST...... 133 SET 43"/13MM...... 178 DOSE)...... 113 cvs aspirin low dose...... 25 COMPLERA...... 83 COSENTYX cvs aspirin low strength...... 25 complete natal dha...... 223 SENSOREADY (300 MG)... 114 CVS BLOOD GLUCOSE completenate...... 223 COSENTYX METER...... 179 Compro...... 80 SENSOREADY PEN...... 114 cvs c-lax laxative...... 166 CO-NATAL FA...... 223 COSOPT PF...... 236 cvs folic acid...... 161 CONCEPT DHA...... 223 COTELLIC...... 71 cvs glucose...... 50 CONCEPT OB...... 223 COTEMPLA XR-ODT...... 17 cvs glucose meter test strips.... 133 CONCERTA...... 17 cottonseed oil...... 93 CVS KETONE CARE...... 133 CONDYLOX...... 113 CREON...... 144 cvs lancets 21g...... 179 CONSENSI...... 89 CRESEMBA...... 59 cvs lancets micro thin 33g...... 179 constulose...... 166 CRESTOR...... 61 cvs lancets original...... 179 CONTOUR MONITOR...... 178 CRINONE...... 260 cvs lancets thin 26g...... 179 CONTOUR NEXT EZ...... 178 CRIXIVAN...... 83 cvs lancets ultra thin 30g...... 179 CONTOUR NEXT LINK.... 178 cromolyn sodium...... 37, 152, 236 cvs lancets ultra-thin 30g...... 179 CONTOUR NEXT CROTAN...... 114 cvs lancing device...... 179 MONITOR...... 178 Cryselle-28...... 96 cvs nicotine...... 248 CONTOUR NEXT ONE...... 178 CUPRIMINE...... 218 cvs nicotine polacrilex...... 248 CONTOUR NEXT TEST.....133 CURITY ALCOHOL PREPS cvs prep...... 179 CONTOUR TEST...... 133 ...... 178 cvs ultra thin lancets...... 179 cyanocobalamin...... 161 271 Cyclafem 1/35...... 96 DELTEC COZMO CLEO DESONATE...... 115 Cyclafem 7/7/7...... 96 SET 42" 6MM...... 179 desonide...... 115 cyclo/gaba 10/300...... 231 DELTEC COZMO CLEO desoximetasone...... 115 cyclobenzaprine hcl...... 231 SET 42" 9MM...... 179 desvenlafaxine succinate er...... 47 cyclobenzaprine hcl er...... 231 Delyla...... 96 DETROL LA...... 259 CYCLOMYDRIL...... 236 DELZICOL...... 152 DEX4...... 50 cyclopentolate hcl...... 236 demeclocycline hcl...... 254 DEX4 NATURALS...... 50 cyclophosphamide...... 71 DEMSER...... 64 DEX4 POUCH PACK...... 50 cycloserine...... 69 DENAVIR...... 114 dexamethasone...... 104, 105 CYCLOSET...... 50 Denta 5000 Plus...... 220 dexamethasone (la)...... 104 cyclosporine...... 218 Dentagel...... 220 DEXAMETHASONE CYCLOSPORINE IN DEPEN TITRATABS...... 219 INTENSOL...... 104 KLARITY...... 236 DEPO-ESTRADIOL...... 150 dexamethasone sodium cyclosporine modified...... 218 DEPO-SUBQ PROVERA phosphate...... 105, 236 CYMBALTA...... 46 104...... 96 dexchlorpheniramine maleate... 60 cyproheptadine hcl...... 60 DEPO-TESTOSTERONE...... 32 DEXCOM G4 PLAT PED CYRAMZA...... 71 dermacinrx analgesic RCV/SHARE...... 179 Cyred...... 96 combopak...... 20 DEXCOM G4 PLAT PED Cyred Eq...... 96 DERMACINRX AZENASE RECEIVER...... 179 CYSTADANE...... 146 PAK...... 233 DEXCOM G4 PLATINUM CYSTAGON...... 155 DERMACINRX RCV/SHARE...... 179 CYSTARAN...... 236 CLORHEXACIN...... 114 DEXCOM G4 PLATINUM CYSTOGRAFIN...... 134 DERMACINRX RECEIVER...... 179 CYSTOGRAFIN-DILUTE..134 DUOPATCH DEXCOM G4 PLATINUM CYSVIEW...... 134 PHARMAPAK...... 114 TRANSMITTER...... 179 CYTO CARN...... 234 DERMACINRX DEXCOM G4 SENSOR...... 179 CYTO RALA...... 19 LEXITRAL PHARMAPAK 114 DEXCOM G5 MOB/G4 cytra k crystals...... 155 DERMACINRX PLAT SENSOR...... 179 dalfampridine er...... 248 NEUROTRAL DEXCOM G5 MOBILE DALIRESP...... 37 PHARMAPAK...... 114 RECEIVER...... 179 danazol...... 32 DERMACINRX PHN...... 114 DEXCOM G5 MOBILE dantrolene sodium...... 231 dermacinrx surgical combopak114 TRANSMITTER...... 180 dapsone...... 66, 114 DERMACINRX DEXCOM G5 RECEIVER DARAPRIM...... 68 SURGICAL PHARMAPAK114 KIT...... 180 darifenacin hydrobromide er... 259 DERMACINRX DEXCOM G6 RECEIVER.. 180 Dasetta 1/35...... 96 THERAZOLE PAK...... 114 DEXCOM G6 SENSOR...... 180 Dasetta 7/7/7...... 96 DERMACINRX DEXCOM G6 DAURISMO...... 71 TICANASE PAK...... 233 TRANSMITTER...... 180 Daysee...... 96 DERMACINRX ZRM...... 115 DEXERYL...... 115 DAYTRANA...... 17 dermovix...... 115 Dexifol...... 223 D-CARE BLOOD DERMULCERA...... 115 DEXILANT...... 257 GLUCOSE...... 134 DESCOVY...... 83 dexmethylphenidate hcl...... 17 D-CARE GLUCOMETER.. 179 DESFERAL...... 57 dexmethylphenidate hcl er...... 17 DDAVP RHINAL TUBE.....146 desflurane...... 154 DEXONTO 0.4%...... 105 Deblitane...... 96 desipramine hcl...... 46 DEXTENZA...... 236 Decadron...... 104 desloratadine...... 60 dextroamphetamine sulfate...... 17 deferasirox...... 57 desmopressin ace spray refrig. 146 dextroamphetamine sulfate er...17 deferoxamine mesylate...... 57 desmopressin acetate...... 146 dextrose...... 234 DEFITELIO...... 158 desmopressin acetate spray..... 146 dextrose-sodium chloride...... 216 DELESTROGEN...... 150 desogestrel-ethinyl estradiol...... 96 DEXYCU...... 236 272 dfs dr/ms/menth/cap pak...... 20 DILANTIN...... 42 DROPLET LANCING dfs/ms/menth/cap pak...... 115 DILANTIN INFATABS...... 42 DEVICE...... 180 DIAB...... 115 DILATRATE-SR...... 34 DROPLET MICRON...... 180 DIAB F.D.G. FREEZE- DILAUDID...... 27 DROPLET PEN NEEDLES 180 DRIED...... 115 diltiazem hcl...... 89 dropsafe safety pen needles..... 180 DIACOMIT...... 42 diltiazem hcl er...... 89 drospiren-eth estrad-levomefol..96 DIASTAT ACUDIAL...... 42 diltiazem hcl er beads...... 89 drospirenone-ethinyl estradiol...96 DIASTAT PEDIATRIC...... 42 diltiazem hcl er coated beads.... 89 DROXIA...... 161 DIASTIX...... 134 dilt-xr...... 89 drug mart lancets thin 26g...... 180 DIATHRIVE BLOOD dimentho...... 115 DRUG MART ON-THE-GO GLUCOSE METER...... 180 DIOVAN...... 64 LANCET 30G...... 180 DIATHRIVE BLOOD DIOVAN HCT...... 64 drug mart unifine pentips...... 181 GLUCOSE TEST...... 134 DIPENTUM...... 152 drug mart unifine pentips plus. 181 DIATHRIVE GLUCOSE diphen...... 60 DRYSOL...... 115 TEST...... 134 diphenhydramine hcl...... 60 DSUVIA...... 28 DIATHRIVE LANCET diphenoxylate-atropine...... 57 dual complex formula 1 kit..... 116 ULTRA THIN 30...... 180 dipyridamole...... 158 DUAVEE...... 150 DIATHRIVE LANCETS..... 180 disopyramide phosphate...... 35 ducodyl...... 166 DIATHRIVE LANCING disulfiram...... 248 DUET DHA 400...... 223 DEVICE...... 180 DIURIL...... 144 DUET DHA BALANCED...223 DIATHRIVE PEN NEEDLE divalproex sodium...... 43 DUEXIS...... 20 ...... 180 divalproex sodium er...... 42 DULERA...... 38 DIATHRIVE+ GLUCOSE DIVIGEL...... 150 duloxetine hcl...... 47 MONITOR...... 180 DMT SUIK...... 105 DUOBRII...... 116 DIATHRIVE+ GLUCOSE dofetilide...... 35 DUO-CARE TEST...... 134 TEST...... 134 DOLOPHINE...... 28 DUOPA...... 78 diatrue plus blood glucose...... 180 donepezil hcl...... 248 DUPIXENT...... 116 diatrue plus test...... 134 DORYX...... 254 durachol...... 161 diazepam...... 35, 42 DORYX MPC...... 254 DURAGESIC-100...... 28 diclofenac epolamine...... 115 dorzolamide hcl...... 236 DURAGESIC-12...... 28 diclofenac potassium...... 20 dorzolamide hcl-timolol mal....236 DURAGESIC-25...... 28 diclofenac sodium...... 20, 115, 236 dorzolamide hcl-timolol mal pf236 DURAGESIC-50...... 28 diclofenac sodium er...... 20 Dotti...... 150 DURAGESIC-75...... 28 diclofenac-misoprostol...... 20 double pm...... 236 DUREZOL...... 237 DICLOFONO...... 115 DOVATO...... 83 DURLAZA...... 158 diclopr...... 115 doxazosin mesylate...... 64 DUROLANE...... 231 diclosaicin...... 115 doxepin hcl...... 47, 115 dutasteride...... 155 diclovix...... 115 doxercalciferol...... 146 dutasteride-tamsulosin hcl...... 155 dicloxacillin sodium...... 244 doxycycline...... 115 DUTOPROL...... 64 diclozor...... 115 doxycycline hyclate...... 254 DXEVO 11-DAY...... 105 dicyclomine hcl...... 257 doxycycline monohydrate...... 254 d-xylose...... 134 didanosine...... 83 doxylamine-pyridoxine...... 58 DYANAVEL XR...... 17 DIFICID...... 169 DRCAPS SIZE 0...... 245 DYMISTA...... 233 DIFIL-G FORTE...... 38 DRCAPS SIZE 00...... 245 DYRENIUM...... 144 diflorasone diacetate...... 115 DRCAPS SIZE 1...... 245 DYSPORT...... 233 diflunisal...... 25 dronabinol...... 58 E.E.S. 400...... 169 Digitek...... 90 DROPLET INSULIN E.E.S. GRANULES...... 169 Digox...... 90 SYRINGE...... 180 easy comfort alcohol pads...... 181 digoxin...... 90 DROPLET LANCETS easy comfort insulin syringe....181 dihydroergotamine mesylate... 215 ULTRA THIN 30G...... 180 easy comfort lancets...... 181 273 easy comfort lancets twist top. 181 EASYMAX TEST...... 134 ELLZIA PAK...... 116 easy comfort pen needles...... 181 EASYMAX V BLOOD ELMIRON...... 155 easy glide pen needles...... 181 GLUCOSE...... 182 Eluryng...... 97 easy mini eject lancing device..181 EASYPRO BLOOD EMBRACE BLOOD easy mini lancing device...... 181 GLUCOSE MONITOR...... 182 GLUCOSE MONITOR...... 182 easy plus ii glucose system...... 181 EASYPRO BLOOD EMBRACE BLOOD easy plus ii glucose test...... 134 GLUCOSE TEST...... 134 GLUCOSE TEST...... 134 EASY STEP GLUCOSE EASYPRO PLUS...... 134, 182 EMBRACE EVO BLOOD MONITOR...... 181 econazole nitrate...... 116 GLUCOSE TEST...... 135 EASY STEP TEST...... 134 ECONTRA EZ...... 96 EMBRACE EVO GLUCOSE easy talk blood glucose system 181 ECONTRA ONE-STEP...... 96 MONITORING...... 182 easy talk blood glucose test.....134 ECOTRIN LOW EMBRACE LANCETS EASY TOUCH ALCOHOL STRENGTH...... 25 ULTRA THIN 30G...... 183 PREP MEDIUM...... 181 ECOZA...... 116 EMBRACE PRO GLUCOSE EASY TOUCH FLIPLOCK EC-RX DHEA...... 19 METER...... 183 INSULIN SY...... 181 ec-rx estradiol...... 150 EMBRACE PRO GLUCOSE EASY TOUCH GLUCOSE ec-rx progesterone...... 246 TEST...... 135 SYSTEM...... 181 ec-rx testosterone...... 32 EMBRACE TALK BLOOD EASY TOUCH INSULIN EDARBI...... 64 GLUCOSE...... 183 SAFETY SYR...... 181 EDARBYCLOR...... 64 EMBRACE TALK EASY TOUCH INSULIN EDLUAR...... 165 GLUCOSE TEST...... 135 SYRINGE...... 181 ed-spaz...... 257 EMBRACE TALK EASY TOUCH LANCETS EDURANT...... 83 MONITORING SYSTEM... 183 21G...... 181 efavirenz...... 83 EMCYT...... 71 EASY TOUCH LANCETS EFFER-K...... 216 EMEND...... 58 23G...... 181 Effer-K...... 216 EMFLAZA...... 105 EASY TOUCH LANCETS EFFEXOR XR...... 47 EMGALITY...... 215 28G...... 182 ELAPRASE...... 146 EMGALITY (300 MG EASY TOUCH LANCETS ELCYS...... 234 DOSE)...... 215 30G...... 182 ELEMENT AUTOCODE Emoquette...... 97 EASY TOUCH LANCETS SYSTEM...... 182 empty capsule size 0 white/opa 245 32G...... 182 element compact glucose empty capsule size 00 clear..... 245 EASY TOUCH LANCING system...... 182 empty capsule size 1 clear...... 245 DEVICE...... 182 element compact test...... 134 empty capsule size 1 veg clear. 245 EASY TOUCH PEN element compact v glucose sys.182 empty capsule size 2 clear...... 245 NEEDLES...... 182 ELEMENT PLUS...... 182 empty capsule size 3 clear...... 245 EASY TOUCH SAFETY ELEMENT TEST...... 134 empty capsule size 4 clear...... 245 PEN NEEDLES...... 182 ELESTRIN...... 150 empty capsule size 5 clear...... 245 EASY TOUCH ELETONE...... 116 empty capsule size 7 clear...... 245 SHEATHLOCK SYRINGE.182 eletriptan hydrobromide...... 215 EMSAM...... 47 EASY TOUCH TEST...... 134 ELIDEL...... 116 EMTRIVA...... 83 easy trak blood glucose system182 ELIGARD...... 71 EMULSION SB...... 116 easy trak blood glucose test.... 134 ELIGEN B12...... 142 EMVERM...... 33 easy trak ii blood glucose sys.. 182 Elinest...... 97 ENABLEX...... 259 easy trak ii glucose test...... 134 ELIQUIS...... 41 enalapril maleate...... 64 EASYGEL...... 220 ELIQUIS DVT/PE enalapril-hydrochlorothiazide... 64 EASYGLUCO...... 134, 182 STARTER PACK...... 41 ENBRACE HR...... 223 EASYMAX 15 TEST...... 134 ELITE-OB...... 223 ENBREL...... 20 EASYMAX NG BLOOD ELIXOPHYLLIN...... 38 ENBREL MINI...... 20 GLUCOSE...... 182 ELLA...... 97 ENBREL SURECLICK...... 20 274 ENCARE...... 260 eql laxative...... 167 etoposide...... 71 ENDARI...... 161 eql nicotine polacrilex...... 248 EUCRISA...... 116 Endocet...... 28 eql super thin lancets 30g...... 183 Euthyrox...... 255 ENDOMETRIN...... 260 eql thin lancets 26g...... 183 EVAMIST...... 151 ENLITE GLUCOSE equapax/atorvastatin/coq10...... 61 EVEKEO...... 17 SENSOR...... 183 equapax/ibuprofen/minrex...... 20 EVEKEO ODT...... 17 ENLITE SERTER...... 183 EQUETRO...... 80 EVENCARE + BLOOD enovarx-diclofenac sodium...... 116 ergocal...... 262 GLUCOSE TEST...... 135 enoxaparin sodium...... 41 ergocalciferol...... 262 EVENCARE BLOOD Enpresse-28...... 97 ergoloid mesylates...... 248 GLUCOSE TEST...... 135 Enskyce...... 97 ERGOMAR...... 215 EVENCARE G2 MONITOR ENSTILAR...... 116 ergotamine-caffeine...... 215 ...... 183 entacapone...... 78 ERIVEDGE...... 71 EVENCARE G2 TEST...... 135 entecavir...... 83 ERLEADA...... 71 EVENCARE G3 MONITOR ENTERAGAM...... 142 erlotinib hcl...... 71 ...... 183 ENTEREG...... 152 EROS-CTD...... 183 EVENCARE G3 TEST...... 135 ENTRESTO...... 91 Errin...... 97 EVENCARE GLUCOSE ENTTY SPRAY...... 116 ERTACZO...... 116 MONITORING...... 183 ENTYVIO...... 152 ERWINAZE...... 71 EVENCARE MINI enulose...... 153 ery...... 116 GLUCOSE TEST...... 135 enzadyne...... 144 ERYPED 200...... 169 EVENCARE MINI EPANED...... 64 ERYPED 400...... 169 MONITOR...... 183 EPCLUSA...... 84 Ery-Tab...... 169 EVENCARE PROVIEW EPICERAM...... 116 ERYTHROCIN STEARATE GLUCOSE TEST...... 135 EPICYN...... 116 ...... 169 EVENITY...... 146 EPIDIOLEX...... 43 erythromycin...... 116, 169, 237 EVERSENSE EPIDUO FORTE...... 116 erythromycin base...... 169 SENSOR/HOLDER...... 183 EPIFOAM...... 116 erythromycin ethylsuccinate....169 EVERSENSE SMART epinastine hcl...... 237 ESBRIET...... 253 TRANSMITTER...... 183 epinephrine...... 262 escitalopram oxalate...... 47 EVIVO...... 57 epinephrine professional...... 262 Esgic...... 26 EVOLUTION AUTOCODE EPINEPHRINESNAP-EMS 262 ESKATA...... 116 ...... 135, 183 EPINEPHRINESNAP-V...... 262 ESOMEP-EZS...... 257 EVOMELA...... 71 EPISNAP...... 262 esomeprazole magnesium...... 257 EVOTAZ...... 84 Epitol...... 43 essentra wipes 9x9"...... 116 EVRYSDI...... 233 eplerenone...... 64 Estarylla...... 97 EXACTECH R-S-G TEST... 135 epoprostenol sodium...... 91 estazolam...... 165 EXACTECH TEST...... 135 eq blood glucose test...... 135 estradiol...... 150, 151, 261 EXCILON AMD DRAIN eq childrens aspirin...... 25 estradiol valerate...... 151 SPONGES...... 183 eq famotidine max st...... 257 estradiol-norethindrone acet... 151 EXEL COMFORT POINT eq nicotine...... 248 ESTRING...... 261 INSULIN SYR...... 184 eq nicotine polacrilex...... 248 ESTROGEL...... 151 EXEL COMFORT POINT eq nicotine step 3...... 248 eszopiclone...... 165 PEN NEEDLE...... 184 eq womens laxative...... 166 ethacrynic acid...... 144 EXELDERM...... 117 eql alcohol swabs...... 183 ethambutol hcl...... 69 exemestane...... 71 eql aspirin low dose...... 25 ethosuximide...... 43 EXFORGE...... 64 eql color lancets 21g...... 183 ethynodiol diac-eth estradiol..... 97 EXFORGE HCT...... 64 eql color lancets micro 33g...... 183 etodolac...... 21 EXJADE...... 57 eql gentle laxative...... 167 etodolac er...... 20 EXODERM...... 117 eql insulin syringe...... 183 etonogestrel-ethinyl estradiol....97 EXTAVIA...... 248 275 EXTINA...... 117 febuxostat...... 156 FIORICET...... 26 EYLEA...... 237 FEENAMINT...... 167 FIRAZYR...... 158 E-Z JECT LANCET FEIBA...... 158 FIRDAPSE...... 69 MICRO-THIN 33G...... 184 felbamate...... 43 FIRMAGON...... 72 E-Z JECT LANCET SUPER felodipine er...... 89 FIRMAGON (240 MG THIN 30G...... 184 FEMCAP...... 184 DOSE)...... 72 E-Z JECT LANCETS...... 184 FEMHRT LOW DOSE...... 151 FIRST-BACLOFEN...... 231 E-Z JECT LANCETS 21G....184 FEMRING...... 261 FIRST-METRONIDAZOLE.66 E-Z JECT LANCETS THIN Femynor...... 97 FIRVANQ...... 66 26G...... 184 fenofibrate...... 61 Flac...... 241 EZ SMART BLOOD fenofibrate micronized...... 61 FLAREX...... 237 GLUCOSE LANCETS...... 184 fenofibric acid...... 61 FLAVOR BLEND...... 245 EZ SMART BLOOD FENOGLIDE...... 61 flavor plus...... 245 GLUCOSE TEST...... 135 fenoprofen calcium...... 21 flavor sweet...... 245 EZ SMART MONITORING FENSOLVI (6 MONTH)...... 146 flavor sweet-sf...... 245 SYSTEM...... 184 fentanyl...... 28 flavoxate hcl...... 259 EZ SMART PLUS fentanyl citrate...... 28 FLEBOGAMMA DIF...... 242 GLUCOSE TEST...... 135 FENTORA...... 28 flecainide acetate...... 35 EZ SMART PLUS FERIVA 21/7...... 161 FLECTOR...... 117 MONITORING SYS...... 184 ferocon...... 161 FLOLAN...... 91 EZALLOR SPRINKLE...... 61 ferotrinsic...... 161 flolipid...... 62 ezetimibe...... 61 ferraplus 90...... 161 FLORIVA...... 216, 223, 224 ezetimibe-simvastatin...... 61 FERRIPROX...... 57 FLORIVA PLUS...... 224 E-Z-HD...... 135 FERRIPROX TWICE-A- FLOVENT DISKUS...... 38 EZ-LETS LANCETS 21G.... 184 DAY...... 57 FLOVENT HFA...... 38 EZ-LETS LANCETS 26G.... 184 Ferrocite Plus...... 161 FLUAD QUADRIVALENT260 EZ-LETS LANCETS 28G.... 184 FERRO-PLEX fluconazole...... 59 EZ-LETS LANCETS 30G.... 184 HEMATINIC...... 162 flucytosine...... 59 E-Z-PAQUE...... 135 FERROTRIN...... 162 fludrocortisone acetate...... 105 FA-8...... 161 FETROJA...... 93 flunisolide...... 233 fabb...... 161 FETZIMA...... 47 fluocinolone acetonide..... 117, 242 FABIOR...... 117 FETZIMA TITRATION...... 47 fluocinolone acetonide body.... 117 FABRAZYME...... 146 FEXMID...... 231 fluocinolone acetonide scalp....117 Falmina...... 97 FIASP...... 50 fluocinonide...... 117 famciclovir...... 84 FIASP FLEXTOUCH...... 50 fluocinonide emulsified base....117 famotidine...... 257 FIASP PENFILL...... 50 FLUORABON...... 216 FANAPT...... 80 FIBRICOR...... 62 fluorescein-benoxinate...... 237 FANAPT TITRATION FIFTY50 GLUCOSE Fluoridex Daily Renewal...... 221 PACK...... 80 METER 2.0...... 184 Fluoridex Enhanced FANATREX FUSEPAQ...... 43 FIFTY50 GLUCOSE TEST Whitening...... 221 FARXIGA...... 50 2.0...... 135 Fluoridex Sensitivity Relief....221 FARYDAK...... 71 FIFTY50 PEN NEEDLES... 184 Fluor-I-Strips A.T...... 237 FASENRA...... 38 FIFTY50 SUPERIOR fluoritab...... 216, 217 FASENRA PEN...... 38 COMFORT SYR...... 184 fluorometholone...... 237 FASLODEX...... 71 FIFTY50 UNILET FLUOROPLEX...... 117 favipiravir...... 84 LANCETS 33G...... 184 fluorouracil...... 117 fa-vitamin b-6-vitamin b-12.....161 FINACEA...... 117 fluovix...... 117 Fayosim...... 97 finasteride...... 155 fluoxetine hcl...... 47 FC FEMALE CONDOM..... 184 FINGERSTIX LANCETS... 184 fluoxetine hcl (pmdd)...... 248 FC2 FEMALE CONDOM... 184 FINTEPLA...... 43 fluphenazine decanoate...... 80 276 fluphenazine hcl...... 80 FORA G20 BLOOD FORACARE TEST N GO FLURA-DROPS...... 217 GLUCOSE TEST...... 136 MONITOR...... 185 flurandrenolide...... 117 FORA G30/PREM V10 FORACARE TEST N GO FLURA-SAFE...... 237 GLUCOSE TEST...... 136 TEST...... 136 flurazepam hcl...... 165 FORA G30A BLOOD formaldehyde...... 82 flurbiprofen...... 21 GLUCOSE SYSTEM...... 185 FORTAMET...... 50 flurbiprofen sodium...... 237 FORA GD20 BLOOD FORTAZ...... 93 flutamide...... 72 GLUCOSE SYSTEM...... 185 FORTEO...... 146 fluticasone propionate..... 117, 233 FORA GD20 TEST...... 136 FORTESTA...... 32 fluticasone-salmeterol...... 38 FORA GD50 BLOOD FORTISCARE GLUCOSE fluvastatin sodium...... 62 GLUCOSE SYSTEM...... 185 SYSTEM...... 186 fluvastatin sodium er...... 62 FORA GD50 BLOOD FORTISCARE T1 fluvoxamine maleate...... 47 GLUCOSE TEST...... 136 GLUCOSE SYSTEM...... 186 fluvoxamine maleate er...... 47 FORA GTEL BLOOD FORTISCARE TEST...... 136 FLUZONE HIGH-DOSE GLUCOSE SYSTEM...... 185 FOSAMAX PLUS D...... 146 QUADRIVALENT...... 260 FORA GTEL BLOOD fosamprenavir calcium...... 84 FML...... 237 GLUCOSE TEST...... 136 fosinopril sodium...... 64 FML FORTE...... 237 FORA GTEL BLOOD fosinopril sodium-hctz...... 64 FML LIQUIFILM...... 237 KETONE TEST...... 136 FOSRENOL...... 153 folbee...... 162 FORA LANCETS...... 185 FOSTEUM...... 142 folbee plus...... 224 FORA LANCING DEVICE 185 FOSTEUM PLUS...... 142 FOLBEE PLUS CZ...... 224 FORA PREMIUM V10 BLE FRAGMIN...... 41 FOLGARD OS...... 224 SYSTEM...... 185 freds pharmacy autolet lancing186 folic acid...... 162 FORA TEST N' GO freds pharmacy unifine pentip+ folic-k...... 224 MONITOR...... 185 ...... 186 FOLI-D...... 162 FORA TN'G VOICE...... 185 freds pharmacy unifine pentips 186 folite...... 162 FORA TN'G/TN'G VOICE.. 136 FREESTYLE FLASH FOLIVANE-F...... 162 FORA V10 BLOOD SYSTEM...... 186 FOLIVANE-OB...... 224 GLUCOSE SYSTEM...... 185 FREESTYLE FREEDOM... 186 FOLIVANE-PLUS...... 162 FORA V10 BLOOD FREESTYLE FREEDOM folplex 2.2...... 162 GLUCOSE TEST...... 136 LITE...... 186 foltrin...... 162 FORA V12 BLOOD FREESTYLE INSULINX Folvite-D...... 162 GLUCOSE SYSTEM...... 185 SYSTEM...... 186 fondaparinux sodium...... 41 FORA V12 BLOOD FREESTYLE INSULINX FORA 6 CONNECT...... 135 GLUCOSE TEST...... 136 TEST...... 136 FORA BLOOD GLUCOSE FORA V20 BLOOD FREESTYLE LIBRE 14 TEST...... 135 GLUCOSE SYSTEM...... 185 DAY READER...... 186 FORA D15G BLOOD FORA V20 BLOOD FREESTYLE LIBRE 14 GLUCOSE TEST...... 135 GLUCOSE TEST...... 136 DAY SENSOR...... 186 FORA D20 BLOOD FORA V30A BLOOD FREESTYLE LIBRE 2 GLUCOSE TEST...... 136 GLUCOSE SYSTEM...... 185 READER SYSTM...... 186 FORA D40 FORA V30A BLOOD FREESTYLE LIBRE 2 GLUCOSE/PRESSURE...... 184 GLUCOSE TEST...... 136 SENSOR SYSTM...... 186 FORA D40/G31 BLOOD FORACARE GD40 FREESTYLE LIBRE GLUCOSE...... 136 MONITOR...... 185 READER...... 186 FORA D40G FORACARE GD40 TEST....136 FREESTYLE LIBRE GLUCOSE/PRESSURE...... 185 FORACARE PREMIUM SENSOR SYSTEM...... 186 FORA G20 BLOOD V10...... 185 FREESTYLE LITE...... 186 GLUCOSE SYSTEM...... 185 FORACARE PREMIUM FREESTYLE LITE TEST....136 V10 TEST...... 136 277 FREESTYLE PRECISION GEL-FLOW...... 164 GENULTIMATE TEST...... 137 INS SYR...... 186 GELFOAM-JMI POWDER.165 GENVOYA...... 84 FREESTYLE PRECISION GELFOAM-JMI SPONGE.. 165 GEODON...... 80 NEO SYSTEM...... 186 GELNIQUE...... 259 ght blood glucose monitor...... 187 FREESTYLE PRECISION GEL-ONE...... 231 ght test...... 137 NEO TEST...... 136 GELSYN-3...... 232 GIALAX...... 167 FREESTYLE SIDEKICK II 186 gemfibrozil...... 62 Gianvi...... 97 FREESTYLE SYSTEM...... 187 GENADUR...... 118 GIAPREZA...... 262 FREESTYLE TEST...... 136 generlac...... 153 GILENYA...... 248 FREESTYLE UNISTICK II Gengraf...... 219 GILOTRIF...... 72 LANCETS...... 187 GENICIN VITA-D...... 162 GILPHEX TR...... 107 frovatriptan succinate...... 215 GENICIN VITA-Q...... 224 GILTUSS TR...... 107 fungimez...... 118 Genicin Vita-S...... 224 GLASSIA...... 253 furosemide...... 144, 145 GENTAK...... 237 glatiramer acetate...... 248 FUSION PLUS...... 162 gentamicin sulfate...... 118, 237 Glatopa...... 248 FUZEON...... 84 GENTEEL BUTTERFLY GLEOLAN...... 137 Fyavolv...... 151 TOUCH LANCET...... 187 GLEOSTINE...... 72 FYCOMPA...... 43 GENTEEL CONTACT TIPS GLIADEL WAFER...... 72 g tussin ac...... 107 (BLUE)...... 187 glimepiride...... 50 gabapentin...... 43 GENTEEL CONTACT TIPS glipizide...... 50 GALAFOLD...... 146 (CLEAR)...... 187 glipizide er...... 50 galantamine hydrobromide..... 248 GENTEEL CONTACT TIPS glipizide xl...... 50 galantamine hydrobromide er..248 (GREEN)...... 187 glipizide-metformin hcl...... 51 GALAXTRA...... 142 GENTEEL CONTACT TIPS global alcohol prep ease...... 187 GALZIN...... 217 (ORANGE)...... 187 global ease inject pen needles.. 187 GAMMACORE...... 187 GENTEEL CONTACT TIPS global easy glide insulin syr.....187 GAMMACORE SAPPHIRE (RAINBOW)...... 187 global easy glide pen needles... 187 31-DAY...... 187 GENTEEL CONTACT TIPS global inject ease insulin syr....188 GAMMACORE SAPPHIRE (VIOLET)...... 187 global inject ease lancets 28g.. 188 REFILL KIT...... 187 GENTEEL CONTACT TIPS global inject ease lancets 30g.. 188 GAMMAGARD...... 242 (YELLOW)...... 187 global insulin syringes...... 188 GAMMAGARD S/D LESS GENTEEL LANCING global lancing device...... 188 IGA...... 243 DEVICE (BLACK)...... 187 GLUCAGEN HYPOKIT...... 51 GAMMAKED...... 243 GENTEEL LANCING glucagon emergency...... 51 GAMMAPLEX...... 243 DEVICE (BLUE)...... 187 GLUCO PERFECT 3 GAMUNEX-C...... 243 GENTEEL LANCING METER...... 188 ganirelix acetate...... 146 DEVICE (PINK)...... 187 GLUCO PERFECT 3 TEST.137 gatifloxacin...... 237 GENTEEL LANCING GLUCOCARD 01 BLOOD GATTEX...... 153 DEVICE (WHITE)...... 187 GLUCOSE...... 188 GAVILYTE-C...... 167 GENTEEL LANCING GLUCOCARD 01 SENSOR Gavilyte-G...... 167 DEVICE(PURPLE)...... 187 PLUS...... 137 Gavilyte-H...... 167 GENTEEL LANCING KIT GLUCOCARD 01-MINI Gavilyte-N With Flavor Pack167 (BLUE)...... 187 GLUCOSE...... 188 ge100 blood glucose system.....187 GENTEEL NOZZLES...... 187 GLUCOCARD ge100 blood glucose test...... 137 gentle laxative...... 167 EXPRESSION MONITOR.. 188 GEBAUERS PAIN EASE.... 118 GENTLE-LET GP GLUCOCARD GEBAUERS SPRAY AND LANCETS...... 187 EXPRESSION TEST...... 137 STRETCH...... 118 GENTLE-LET LANCETS...187 GLUCOCARD SHINE GELCLAIR...... 221 GENTLE-LET CONNEX...... 188 GELFILM...... 237 PLATFORMS...... 187 278 GLUCOCARD SHINE gnp adult aspirin low strength... 26 griseofulvin microsize...... 59 EXPRESS...... 188 gnp alcohol swabs...... 189 griseofulvin ultramicrosize...... 59 GLUCOCARD SHINE gnp aspirin...... 26 guaiatussin ac...... 107 TEST...... 137 GNP BISA-LAX...... 167 guaifenesin-codeine...... 107 GLUCOCARD SHINE XL..188 gnp clickfine pen needles...... 189 guanfacine hcl...... 64 GLUCOCARD VITAL GNP EASY TOUCH guanfacine hcl er...... 17 MONITOR...... 188 GLUCOSE METER...... 189 guanidine hcl...... 69 GLUCOCARD VITAL gnp easy touch glucose test..... 137 GUARDIAN CONNECT TEST...... 137 gnp gentle laxative...... 167 TRANSMITTER...... 190 GLUCOCARD X-METER.. 188 gnp glucose...... 51 GUARDIAN LINK 3 GLUCOCARD X-SENSOR.137 gnp insulin syringe...... 189 TRANSMITTER...... 190 GLUCOCOM BLOOD gnp lancets...... 189 GUARDIAN REAL-TIME GLUCOSE MONITOR...... 188 gnp lancets 21g...... 189 CHARGER...... 190 GLUCOCOM LANCETS gnp lancets micro thin 33g...... 189 GUARDIAN REAL-TIME 28G...... 188 gnp lancets thin...... 189 REPLACE PED...... 190 GLUCOCOM LANCETS gnp lancets thin 26g...... 189 GUARDIAN REAL-TIME 30G...... 188 gnp laxative...... 167 TEST PLUG...... 190 GLUCOCOM LANCETS gnp micro thin lancets 33g...... 189 GUARDIAN SENSOR (3)...190 33G...... 188 gnp nicotine...... 249 GVOKE HYPOPEN 1- GLUCOCOM MONITOR... 188 gnp nicotine mini...... 249 PACK...... 51 GLUCOCOM TEST...... 137 gnp nicotine polacrilex...... 249 GVOKE HYPOPEN 2- GLUCONAVII BLOOD gnp super thin lancets 30g...... 189 PACK...... 51 GLUCOSE SYS...... 189 gnp ulticare pen needles...... 189 GVOKE PFS...... 51 GLUCONAVII BLOOD gnp ultra com insulin syringe...189 GYNAZOLE-1...... 261 GLUCOSE TEST...... 137 gnp womens gentle laxative.....167 HAEGARDA...... 158 GLUCOPRO INSULIN GOCOVRI...... 78 Hailey 1.5/30...... 97 SYRINGE...... 189 GOJJI BLOOD GLUCOSE Hailey 24 Fe...... 97 GLUCOPRO SYR RES 3ML TEST...... 137 halcinonide...... 118 22GX3/8"...... 189 GOJJI BLOOD TEST halobetasol propionate...... 118 glucose...... 51 STRIP/LANCETS...... 137 HALOG...... 118 glucose instant energy...... 51 GOJJI STERILE LANCETS 189 haloperidol...... 80 glucose meter test...... 137 GONAL-F...... 146 haloperidol decanoate...... 80 GLUMETZA...... 51 GONAL-F RFF...... 146 haloperidol lactate...... 80 glutaraldehyde...... 82 GONAL-F RFF REDIJECT 146 HARMONY BLOOD glyburide...... 51 GONITRO...... 34 GLUCOSE TEST...... 137 glyburide micronized...... 51 goodsense blood glucose.. 137, 189 HARVONI...... 84 glyburide-metformin...... 51 goodsense clickfine pen needle.189 HCU EASY...... 142 GLYCATE...... 257 goodsense glucose...... 51 HEALTH CARE LANCING glycine...... 155 goodsense lancets 26g univ...... 189 DEVICE...... 190 glycine soya protein...... 93 goodsense lancets 30g univ...... 189 healthwise insulin syr/needle... 190 glycolic acid...... 118 goodsense lancets 33g univ...... 189 healthwise micron pen needles.190 glycopyrrolate...... 257 goodsense lancing device...... 189 healthwise mini pen needles.....190 Glydo...... 118 goodsense nicotine...... 249 healthwise pen needles...... 190 GLYRX-PF...... 257 GOODSENSE PEN healthwise short pen needles....190 GLYTACTIN BUILD 10PE.142 NEEDLE PENFINE...... 190 healthwise unifine pentips...... 190 GLYTACTIN COMPLETE goprelto...... 233 healthy accents lancing device.190 10PE...... 142 GORDOFILM...... 118 healthy accents unifine pentip. 190 GLYTACTIN SWIRL 15PE.142 GRALISE...... 249 healthy accents unilet lancets.. 190 GLYXAMBI...... 51 granisetron hcl...... 58 Heather...... 97 g-myco nail...... 118 GRASTEK...... 19 h-e-b aspirin...... 26 279 h-e-b incontrol adv lancing...... 190 HUMIRA PEDIATRIC HYDROFERA BLUE MRF h-e-b incontrol alcohol...... 190 CROHNS START...... 21 DRESSING...... 119 h-e-b incontrol lancets 28g...... 190 HUMIRA PEN...... 21 HYDROFERA BLUE h-e-b incontrol lancets 30g...... 190 HUMIRA PEN-CD/UC/HS READY FOAM...... 119 h-e-b incontrol lancets 33g...... 190 STARTER...... 21 hydrogen peroxide...... 82 h-e-b incontrol pen needles...... 190 HUMIRA PEN- hydromet...... 107 H-E-B INCONTROL PS/UV/ADOL HS START..... 21 hydromorphone hcl...... 28 UNIFINE PENTIP...... 190 HUMULIN 70/30...... 52 hydromorphone hcl er...... 28 HEMANGEOL...... 87 HUMULIN 70/30 hydroxocobalamin acetate...... 162 hematinic plus vit/minerals...... 162 KWIKPEN...... 52 hydroxychloroquine sulfate...... 68 hematinic/folic acid...... 162 HUMULIN N...... 52 hydroxyprogesterone caproate HEMLIBRA...... 158 HUMULIN N KWIKPEN.....52 ...... 93, 246 HEMOCYTE PLUS...... 162 HUMULIN R...... 52 hydroxyurea...... 72 Hemocyte-F...... 162 HUMULIN R U-500 hydroxyzine hcl...... 35 hemocyte-plus...... 162 (CONCENTRATED)...... 52 hydroxyzine pamoate...... 35 HEMOFIL M...... 158 HUMULIN R U-500 hygel...... 119 heparin sodium (porcine)...... 41 KWIKPEN...... 52 HYLATOPIC PLUS...... 119 heparin sodium (porcine) pf..... 41 HURRISEAL...... 191 hylavite...... 224 hepmed...... 41 HURRISEAL SNAP-N-GO.191 HYOPHEN...... 66 HERCEPTIN HYLECTA...... 72 HW EMBRACE PRO hyoscyamine sulfate...... 257 HETLIOZ...... 165 GLUCOSE METER...... 191 hyoscyamine sulfate er...... 257 Hidex 6-Day...... 105 HW EMBRACE PRO HYPERSAL...... 107 HIZENTRA...... 243 GLUCOSE TEST...... 137 HYPOCYN...... 119 hm aspirin...... 26 HW EMBRACE TALK HYQVIA...... 243 HM EMBRACE TALK BLOOD GLUCOSE...... 191 HYSINGLA ER...... 29 SYSTEM...... 191 HW EMBRACE TALK HY-VEE LANCETS...... 191 hm glucose...... 51 GLUCOSE TEST...... 137 hy-vee thin lancets...... 191 hm laxative...... 167 hyalucil-4...... 118 ibandronate sodium...... 147 hm nicotine...... 249 HYCAMTIN...... 72 IBG STAR BLOOD hm nicotine polacrilex...... 249 HYCLODEX...... 118 GLUCOSE SYSTEM...... 191 hm sterile alcohol prep...... 191 hydralazine hcl...... 64, 65 IBRANCE...... 72 HM ULTICARE INSULIN hydrochlorothiazide...... 145 Ibu...... 21 SYRINGE...... 191 hydrocod polst-cpm polst er.... 107 ibuprofen...... 21 HM ULTICARE SHORT hydrocodone bitartrate er...... 28 ICAR-C PLUS...... 162 PEN NEEDLES...... 191 hydrocodone-acetaminophen.....28 icatibant acetate...... 158 HORIZANT...... 249 hydrocodone-homatropine...... 107 ICLUSIG...... 72 HPR PLUS...... 118 hydrocodone-ibuprofen...... 28 ICY HOT PM...... 119 HPR PLUS HYDROGEL.... 118 hydrocortisone...... 33, 105, 119 IDELVION...... 158 HUMALOG...... 52 hydrocortisone (perianal)...... 33 IDHIFA...... 72 HUMALOG KWIKPEN...... 51 hydrocortisone ace-pramoxine.. 33 Iferex 150 Forte...... 162 HUMALOG MIX 50/50...... 51 hydrocortisone butyr lipo base 118 IGLUCOSE MONITORING HUMALOG MIX 50/50 hydrocortisone butyrate...... 118 SYSTEM...... 191 KWIKPEN...... 51 hydrocortisone valerate...... 119 IGLUCOSE TEST STRIPS.. 137 HUMALOG MIX 75/25...... 52 hydrocortisone-acetic acid...... 242 ILARIS...... 21 HUMALOG MIX 75/25 HYDROFERA BLUE 6"X6"119 ILEVRO...... 237 KWIKPEN...... 52 HYDROFERA BLUE imatinib mesylate...... 72 HUMATE-P...... 158 FOAM DRESSING...... 119 IMBRUVICA...... 72 HUMATROPE...... 146 HYDROFERA BLUE imipramine hcl...... 47 HUMIRA...... 21 FOAM/TUNNELING...... 119 imipramine pamoate...... 47 imiquimod...... 119 280 imiquimod pump...... 119 insulin cartridge 3ml...... 192 JALYN...... 155 IMLYGIC...... 72 insulin syringe...... 192 Jantoven...... 41 IMPAVIDO...... 67 insulin syringe/needle...... 192 JANUMET...... 52 IMPOYZ...... 119 insulin syringe-needle u-100.... 192 JANUMET XR...... 52 IMVEXXY insupen pen needles...... 192 JANUVIA...... 53 MAINTENANCE PACK.....261 INSUPEN SENSITIVE...... 192 JARDIANCE...... 53 IMVEXXY STARTER INSUPEN ULTRAFIN...... 192 Jasmiel...... 97 PACK...... 261 INTEGRA F...... 162 Jencycla...... 97 IN TOUCH...... 191 INTEGRA PLUS...... 163 JENTADUETO...... 53 IN TOUCH BLOOD INTELENCE...... 84 JENTADUETO XR...... 53 GLUCOSE TEST...... 137 INTERMEZZO...... 165 Jinteli...... 151 IN TOUCH LANCING INTRALIPID...... 234 JIVI...... 158 DEVICE...... 191 INTRAROSA...... 261 Jolessa...... 98 IN TOUCH STERILE INTRON A...... 73 JORNAY PM...... 17 LANCETS 30G...... 191 Introvale...... 97 JUBLIA...... 119 INATAL GT...... 224 INTUNIV...... 17 Juleber...... 98 INBRIJA...... 78 INVEGA SUSTENNA...... 81 JULUCA...... 84 Incassia...... 97 INVEGA TRINZA...... 81 Junel 1.5/30...... 98 INCRELEX...... 147 INVELTYS...... 237 Junel 1/20...... 98 INCRUSE ELLIPTA...... 38 INVIRASE...... 84 Junel Fe 1.5/30...... 98 indapamide...... 145 INVOKAMET...... 52 Junel Fe 1/20...... 98 INDERAL LA...... 88 INVOKAMET XR...... 52 Junel Fe 24...... 98 INDERAL XL...... 88 INVOKANA...... 52 JUXTAPID...... 62 INDOCIN...... 21 iodine strong...... 217 JYNARQUE...... 147 indomethacin...... 21 iodine tincture...... 83 KADIAN...... 29 indomethacin er...... 21 IOPIDINE...... 237 Kaitlib Fe...... 98 INFASURF...... 253 ipratropium bromide...... 38, 233 KALETRA...... 84 INFINITY BLOOD ipratropium-albuterol...... 38 Kalliga...... 98 GLUCOSE SYSTEM...... 191 irbesartan...... 65 KALYDECO...... 253 INFINITY BLOOD irbesartan-hydrochlorothiazide. 65 KAMDOY...... 119 GLUCOSE TEST...... 138 IRESSA...... 73 KANJINTI...... 73 INFINITY VOICE...... 138, 191 ISENTRESS...... 84 KANUMA...... 147 Inflammacin...... 21 ISENTRESS HD...... 84 KAPSPARGO SPRINKLE....88 INFLATHERM...... 21 Isibloom...... 97 KAPVAY...... 17 INFUGEM...... 72 isoflurane...... 154 KARBINAL ER...... 60 infusion catheter soft 23"...... 191 isoniazid...... 69 Kariva...... 98 infusion catheter soft 31"...... 191 ISOPTO ATROPINE...... 237 KATERZIA...... 89 infusion catheter soft 43"...... 191 ISORDIL TITRADOSE...... 34 KAZANO...... 53 INFUVITE ADULT...... 224 isosorbide dinitrate...... 34 KELARX...... 119 INFUVITE PEDIATRIC..... 224 isosorbide mononitrate...... 34 Kelnor 1/35...... 98 INGREZZA...... 249 isosorbide mononitrate er...... 34 Kelnor 1/50...... 98 INLYTA...... 72 isotretinoin...... 119 KENALOG...... 119 INNOPRAN XL...... 88 isradipine...... 89 KENDALL ALGINATE 12" INPEN 100-BLUE-LILLY... 191 ISTALOL...... 237 ROPE...... 119 INPEN 100-BLUE-NOVO... 191 itraconazole...... 59 KENDALL ALGINATE INPEN 100-GRAY-LILLY.. 192 ivermectin...... 33 DRESS 2"X2"...... 119 INPEN 100-GREY-NOVO...192 IXINITY...... 158 KENDALL ALGINATE INPEN 100-PINK-LILLY....192 JADENU...... 57 DRESS 4"X4"...... 120 INPEN 100-PINK-NOVO.... 192 JADENU SPRINKLE...... 58 KENDALL ALGINATE INREBIC...... 73 JAKAFI...... 73 DRESS 4"X8"...... 120 281 KENDALL AMORPHOUS KISQALI FEMARA(200 L.E.T...... 120 WOUND...... 120 MG DOSE)...... 73 labetalol hcl...... 88 KENDALL HYDROGEL KITABIS PAK...... 19 LACRISERT...... 238 GAUZE 2"X2"...... 120 KIVIK...... 120 lactated ringers...... 219 KENDALL HYDROGEL KLARITY-L...... 238 lactic acid...... 120 GAUZE 4"X4"...... 120 Klor-Con...... 217 lactic acid e...... 120 KENDALL HYDROGEL Klor-Con 10...... 217 lactulose...... 167 GAUZE 4"X8"...... 120 Klor-Con M10...... 217 lactulose encephalopathy...... 153 KENDALL HYDROGEL KLOR-CON M15...... 217 LAMICTAL...... 43 WOUND DRESS...... 120 Klor-Con M20...... 217 LAMICTAL ODT...... 43 KENGREAL...... 158 Klor-Con Sprinkle...... 217 LAMICTAL STARTER...... 43 KEPPRA...... 43 Klor-Con/Ef...... 217 LAMICTAL XR...... 43, 44 KEPPRA XR...... 43 kls aspirin low dose...... 26 lamivudine...... 84 KERAGEL...... 120 KLS QUIT2...... 249 lamivudine-zidovudine...... 84 KERAGELT...... 120 KLS QUIT4...... 249 lamotrigine...... 44 KERAMATRIX kmart valu insulin syringe 29g.192 lamotrigine er...... 44 REPLICINE 10CMX10CM..120 kmart valu insulin syringe 30g.192 lamotrigine starter kit-blue...... 44 KERAMATRIX KOATE...... 158 lamotrigine starter kit-green.....44 REPLICINE 5CMX5CM..... 120 KOATE-DVI...... 159 lamotrigine starter kit-orange...44 KERLIX AMD KOGENATE FS...... 159 LAMPIT...... 67 ANTIMICROBIAL...... 192 KOMBIGLYZE XR...... 53 lancet device...... 193 KERLIX AMD SUPER KORLYM...... 53 lancet device with ejector...... 193 SPONGES...... 192 KOSELUGO...... 73 lancet transporter case...... 193 KERYDIN...... 120 kosher prenatal plus iron...... 224 lancets...... 193 KESIMPTA...... 249 KOVALTRY...... 159 lancets 30g...... 193 ketoconazole...... 59, 120 kp aspirin...... 26 lancets micro thin 33g...... 193 Ketodan...... 120 kp bisacodyl...... 167 lancets thin...... 193 KETO-DIASTIX...... 138 K-PHOS...... 217 LANCETS ULTRA FINE....193 ketone test...... 138 K-PHOS NO 2...... 155 lancets ultra thin 30g...... 193 KETOPHENE RAPIDPAQ. 120 K-Prime...... 217 lancing device...... 193 ketoprofen...... 21 KRINTAFEL...... 69 LANOXIN...... 90 ketoprofen er...... 21 KRISTALOSE...... 167 lansoprazole...... 257 ketorolac tromethamine.... 22, 238 kroger blood glucose...... 192 lanthanum carbonate...... 153 KETOSTIX...... 138 kroger blood glucose test...... 138 LANTUS...... 53 KETOVIE...... 142 kroger glucose...... 53 LANTUS SOLOSTAR...... 53 KETOVIE PEPTIDE...... 143 KROGER HEALTHPRO LANZO...... 193 KEVEYIS...... 145 GLUCOSE TEST...... 138 Larin 1.5/30...... 98 KEVZARA...... 22 kroger insulin syringe...... 193 Larin 1/20...... 98 KHAPZORY...... 73 kroger lancets...... 193 Larin 24 Fe...... 98 kinney lancets...... 192 kroger lancets super thin...... 193 Larin Fe 1.5/30...... 98 kinney thin lancets...... 192 kroger lancets thin...... 193 Larin Fe 1/20...... 98 kinray insulin syringe...... 192 kroger pen needles...... 193 Larissia...... 99 Kionex...... 219 kroger premium blood glucose.193 LASTACAFT...... 238 KISQALI (200 MG DOSE).... 73 kroger premium glucose test... 138 latanoprost...... 238 KISQALI (400 MG DOSE).... 73 kroger test...... 138 LATUDA...... 81 KISQALI (600 MG DOSE).... 73 KRYSTEXXA...... 156 laxative...... 167 KISQALI FEMARA (400 K-Tan Plus...... 163 Layolis Fe...... 99 MG DOSE)...... 73 Kurvelo...... 98 LAZANDA...... 29 KISQALI FEMARA (600 KUVAN...... 147 LDL CARE...... 143 MG DOSE)...... 73 KYLEENA...... 98 LDO PLUS...... 120 282 ldr blood glucose truetest...... 193 levonorgestrel-ethinyl estrad.....99 lisinopril...... 65 leader insulin syringe...... 193 levonorg-eth estrad triphasic.....99 lisinopril-hydrochlorothiazide... 65 LEADER UNIFINE Levora 0.15/30 (28)...... 99 lissamine green...... 238 PENTIPS...... 193 levorphanol tartrate...... 29 lite touch lancets...... 193 LEADER UNIFINE Levo-T...... 255 LITE TOUCH LANCING PENTIPS PLUS...... 193 levothyroxine sodium...... 255 PEN...... 194 lecithin...... 234 Levoxyl...... 256 LITETOUCH INSULIN Leena...... 99 LEVULAN KERASTICK....121 SYRINGE...... 194 leflunomide...... 22 LEXAPRO...... 47 LITETOUCH LANCETS.....194 LENVIMA (10 MG DAILY LEXETTE...... 121 LITETOUCH PEN DOSE)...... 73 LEXIVA...... 84 NEEDLES...... 194 LENVIMA (12 MG DAILY LIALDA...... 153 lithium...... 81 DOSE)...... 73 liberty blood glucose meter..... 193 lithium carbonate...... 81 LENVIMA (14 MG DAILY LIBERTY NEXT lithium carbonate er...... 81 DOSE)...... 73 GENERATION TEST...... 138 LITHOSTAT...... 155 LENVIMA (18 MG DAILY LIBERTY NXT LIVALO...... 62 DOSE)...... 73 GENERATION MONITOR 193 live better adv lancing device...194 LENVIMA (20 MG DAILY liberty test...... 138 live better lancet ultra thin...... 194 DOSE)...... 73 lidocaine...... 121 LMR PLUS...... 121 LENVIMA (24 MG DAILY lidocaine hcl...... 121, 221 LO LOESTRIN FE...... 99 DOSE)...... 74 lidocaine hcl urethral/mucosal.121 LODINE...... 22 LENVIMA (4 MG DAILY lidocaine in dextrose...... 168 LOKELMA...... 219 DOSE)...... 74 lidocaine viscous hcl...... 221 LOMAIRA...... 17 LENVIMA (8 MG DAILY lidocaine-prilocaine...... 121 longs insulin syringe...... 194 DOSE)...... 74 lidocaine-tetracaine...... 121 longs lancets standard...... 194 LESCOL XL...... 62 LIDOCARE longs lancets thin...... 194 Lessina...... 99 ARM/NECK/LEG...... 121 longs lancets ultra thin...... 194 LETAIRIS...... 91 LIDOCARE LONHALA MAGNAIR letrozole...... 74 BACK/SHOULDER...... 121 REFILL KIT...... 38 LEU TECHNELITE...... 138 lidocidex i...... 105 LONHALA MAGNAIR leucovorin calcium...... 74, 94 LIDODERM...... 121 STARTER KIT...... 38 LEUKERAN...... 74 lidomark 2/5...... 168 LONSURF...... 74 LEUKINE...... 163 lidopac...... 121 loperamide hcl...... 57 leuprolide acetate...... 74 lidopin...... 121 lopinavir-ritonavir...... 85 levalbuterol hcl...... 38 LIDOPURE PATCH...... 121 LOPROX...... 121 levalbuterol tartrate...... 38 LIDOTHOL...... 121 lorazepam...... 35 LEVEMIR...... 53 LIDOTRAL...... 121 LORBRENA...... 74 LEVEMIR FLEXTOUCH..... 53 LIDOTREX...... 121 lorid...... 224 levetiracetam...... 44 LIFESCAN UNISTIK 2...... 193 LORTAB...... 29 levetiracetam er...... 44 LIFESCAN UNISTIK II Loryna...... 99 LEVICYN...... 120 LANCETS...... 193 Lorzone...... 232 LEVITRA...... 91 Lillow...... 99 losartan potassium...... 65 levobunolol hcl...... 238 lindane...... 121 losartan potassium-hctz...... 65 levocarnitine...... 147 linezolid...... 67 LOTEMAX...... 238 levocetirizine dihydrochloride... 60 linseed oil...... 94 LOTEMAX SM...... 238 levofloxacin...... 152, 238 LINZESS...... 153 loteprednol etabonate...... 238 Levonest...... 99 liothyronine sodium...... 256 LOTRONEX...... 153 levonorgest-eth est & eth est..... 99 LIPITOR...... 62 lovastatin...... 62 levonorgest-eth estrad 91-day... 99 lipo-c...... 234 Low-Ogestrel...... 99 levonorgestrel...... 99 LIQUID E-Z-PAQUE...... 138 loxapine succinate...... 81 283 LOYON...... 122 MAVENCLAD (7 TABS).....250 MEIJER LANCETS Lo-Zumandimine...... 99 MAVENCLAD (8 TABS).....250 UNIVERSAL 21G...... 195 LUCEMYRA...... 249 MAVENCLAD (9 TABS).....250 MEIJER LANCETS LUCENTIS...... 238 MAXICOMFORT II PEN UNIVERSAL 30G...... 195 luliconazole...... 122 NEEDLE...... 194 MEIJER LANCETS LUMIGAN...... 238 MAXI-COMFORT UNIVERSAL 33G...... 195 LUMIZYME...... 147 INSULIN SYRINGE...... 194 meijer pen needles...... 195 LUNESTA...... 165 MAXI-COMFORT SAFETY meijer premium blood glucose. 195 LUPANETA PACK...... 147 PEN NEEDLE...... 194 meijer premium glucose test.... 138 LUPRON DEPOT (1- MAXICOMFORT SYR 27G MEIJER SUPER THIN MONTH)...... 74 X 1/2"...... 194 LANCETS...... 195 LUPRON DEPOT (3- MAXIDEX...... 238 MEIJER TRUE2GO MONTH)...... 74 MAYZENT...... 250 BLOOD GLUCOSE...... 195 LUPRON DEPOT-PED (1- MAYZENT STARTER MEIJER TRUERESULT MONTH)...... 147 PACK...... 250 GLUCOSE SYS...... 195 LUPRON DEPOT-PED (3- Md-Gastroview...... 138 MEIJER TRUETEST TEST 138 MONTH)...... 147 me/naphos/mb/hyo1...... 67 MEIJER TRUETRACK Lutera...... 99 meclizine hcl...... 58 GLUCOSE SYS...... 195 LUXAMEND...... 122 meclofenamate sodium...... 22 MEIJER TRUETRACK LUXIQ...... 122 medic insulin syringe...... 194 TEST...... 138 LUZU...... 122 medichoice safety lancet extra 194 MEKINIST...... 74 LYNPARZA...... 74 medicine shoppe pen needles....194 MEKTOVI...... 74 LYRICA...... 44 MEDISENSE THIN Melodetta 24 Fe...... 100 LYRICA CR...... 249 LANCETS...... 194 meloxicam...... 22 Lysiplex Plus...... 224 MEDLANCE PLUS EXTRA melphalan...... 74 LYSODREN...... 74 21G...... 194 memantine hcl...... 250 Lyza...... 99 MEDLANCE PLUS memantine hcl er...... 250 M.V.I. ADULT...... 224 LANCETS...... 194 MENEST...... 151 M.V.I. PEDIATRIC...... 224 MEDLANCE PLUS LITE MENOPUR...... 147 macadamia nut oil...... 94 25G...... 195 MENOSTAR...... 151 MACI...... 232 MEDLANCE PLUS MENQUADFI...... 260 MACRILEN...... 138 SPECIAL 0.8MM...... 195 MENTAX...... 122 MACRODANTIN...... 67 MEDLANCE PLUS meperidine hcl...... 29 mafenide acetate...... 122 SUPERLITE 30G...... 195 meprobamate...... 35 MAGELLAN INSULIN MEDLANCE PLUS mercaptopurine...... 74 SAFETY SYR...... 194 UNIVERSAL 21G...... 195 mesalamine...... 153 MAKENA...... 247 MEDROL...... 105 mesalamine-cleanser...... 153 malathion...... 122 MEDROLOAN II SUIK...... 105 MESNEX...... 74 maprotiline hcl...... 47 MEDROLOAN SUIK...... 105 MESTINON...... 69 MARATHON MEDICAL medroxyprogesterone acetate Metadate Er...... 17 PENTIPS...... 194 ...... 99, 247 METAXALL CP...... 232 marlissa...... 99 mefenamic acid...... 22 metaxalone...... 232 MARNATAL-F...... 224 mefloquine hcl...... 69 metformin hcl...... 53 MARPLAN...... 47 megestrol acetate...... 74, 247 metformin hcl er...... 53 MATULANE...... 74 meijer blood glucose...... 195 metformin hcl er (mod)...... 53 Matzim La...... 89 meijer blood glucose test...... 138 metformin hcl er (osm)...... 53 MAVENCLAD (10 TABS)...249 meijer essential blood glucose..195 methadone hcl...... 29 MAVENCLAD (4 TABS).....249 meijer essential glucose test.... 138 Methadone Hcl Intensol...... 29 MAVENCLAD (5 TABS).....250 meijer glucose...... 53 methadone hcl-nacl...... 29 MAVENCLAD (6 TABS).....250 MEIJER LANCETS THIN.. 195 METHADOSE...... 29 284 Methadose...... 29 Microgestin Fe 1.5/30...... 100 MIO INFUSION SET 32" METHADOSE SUGAR- Microgestin Fe 1/20...... 100 9MM...... 196 FREE...... 29 MICROLET LANCETS...... 195 MIRCERA...... 163 methamphetamine hcl...... 17 MICROLET NEXT MIRENA (52 MG)...... 100 methazolamide...... 145 LANCING DEVICE...... 195 mirtazapine...... 47 methenamine hippurate...... 67 midazolam hcl...... 165 MIRVASO...... 122 methenamine mandelate...... 67 midodrine hcl...... 262 misoprostol...... 257 Methergine...... 242 MIGERGOT...... 215 MITOSOL...... 238 methimazole...... 256 miglitol...... 53 mko melt dose pack...... 166 methitest...... 32 miglustat...... 163 MM EASY TOUCH methocarbamol...... 232 MIGRAINE PACK...... 215 GLUCOSE...... 138 methotrexate sodium...... 74 MIGRANAL...... 215 MM EASY TOUCH methotrexate sodium (pf)...... 74 MIGRANOW...... 215 GLUCOSE METER...... 196 methoxsalen rapid...... 122 Mili...... 100 mm insulin syringe/needle...... 196 methscopolamine bromide...... 257 MILLIPRED...... 105 MM PEN NEEDLES...... 196 methyldopa...... 65 MILLIPRED DP 12-DAY....105 m-natal plus...... 224 methyldopa- Mimvey...... 151 modafinil...... 18 hydrochlorothiazide...... 65 MIMYX...... 122 moexipril hcl...... 65 methylergonovine maleate...... 242 MINASTRIN 24 FE...... 100 molindone hcl...... 81 methylphenidate hcl...... 18 mineral oil heavy...... 167 mometasone furoate...... 122, 233 methylphenidate hcl er...... 18 mini lancing device...... 195 Mondoxyne Nl...... 255 methylphenidate hcl er (cd)...... 18 MINILINK REAL-TIME MONOJECT INSULIN methylphenidate hcl er (la)...... 18 TRANSMITTER...... 195 SYRINGE...... 196 methylprednisolone...... 105 MINIMED 630G MONOJECT ULTRA methyltestosterone...... 32 GUARDIAN PRESS...... 195 COMFORT SYRINGE...... 196 metoclopramide hcl...... 153 MINIMED GUARDIAN MONOLET LANCETS...... 196 metolazone...... 145 LINK 3...... 195 MONOLET OPD LANCETS METOPIRONE...... 138 MINIMED GUARDIAN ...... 196 metoprolol succinate er...... 88 SENSOR 3...... 195 MONOLETTOR SAFETY metoprolol tartrate...... 88 MINIMED PUMP LANCETS...... 196 metoprolol-hydrochlorothiazide 65 RESERVOIR 3ML...... 196 Mono-Linyah...... 100 METROGEL...... 122 MINIMED RESERVOIR MONONINE...... 159 metronidazole...... 67, 122, 261 1.8ML...... 196 montelukast sodium...... 38 METRONIDAZOLE MINIMED RESERVOIR MONUROL...... 67 BENZO+SYRSPEND...... 67 3ML...... 196 Morgidox...... 255 mexiletine hcl...... 35 MINIPRIN LOW DOSE...... 26 morphine sulfate...... 29, 30 MI PASTE...... 195 Minitran...... 34 morphine sulfate (concentrate).29 MI PASTE PLUS...... 195 MINIVELLE...... 151 morphine sulfate er...... 29 MIACALCIN...... 147 MINOCIN...... 254 morphine sulfate er beads...... 29 Mibelas 24 Fe...... 100 minocycline hcl...... 254, 255 MOTEGRITY...... 153 miconazole 3...... 261 minocycline hcl er...... 254 MOTOFEN...... 57 miconazole-zinc oxide-petrolat122 MINOLIRA...... 255 mouth wash-gp...... 245 MICROCYN...... 122 minoxidil...... 65 mouthwash-af...... 245 MICRODOT BLOOD MIO INFUSION SET 18" mouthwash-om...... 245 GLUCOSE SYSTEM...... 195 6MM...... 196 MOVANTIK...... 153 MICRODOT PEN NEEDLE MIO INFUSION SET 23" MOVIPREP...... 167 ...... 195 6MM...... 196 MOXEZA...... 238 MICRODOT TEST...... 138 MIO INFUSION SET 32" moxifloxacin hcl...... 152, 238 Microgestin 1.5/30...... 100 6MM...... 196 mpd safety lancet 21g...... 196 Microgestin 1/20...... 100 mpd safety lancet 23g...... 196 285 mpd safety lancet 28g...... 197 naftifine hcl...... 122 Neo-Polycin...... 239 mpd safety lancet 30g...... 197 NAFTIN...... 122 Neo-Polycin Hc...... 239 MS CONTIN...... 30 NAGLAZYME...... 147 NEOSALUS...... 123 ms insulin syringe...... 197 NALFON...... 22 NEOSALUS CP...... 123 MSUD EASY...... 143 nalocet...... 30 NEO-SYNALAR...... 123 MULPLETA...... 163 naloxone hcl...... 58 NEOTUSS PLUS...... 107 MULTAQ...... 35 naltrexone hcl...... 58 Nephronex...... 225 MULTIGEN...... 163 NAMENDA XR...... 250 NERLYNX...... 75 MULTIGEN FOLIC...... 163 NAMENDA XR NESINA...... 53 MULTIGEN PLUS...... 163 TITRATION PACK...... 250 NESTABS...... 225 MULTI-LANCET DEVICE NAMZARIC...... 250 NESTABS DHA...... 225 2...... 197 NAPRELAN...... 22 NESTABS ONE...... 225 multipro...... 224 NAPROSYN...... 22 Neuac...... 123 multi-vit/iron/fluoride...... 224 naproxen...... 22 NEUAC...... 123 multivitamin/fluoride...... 224, 225 naproxen dr...... 22 NEULASTA...... 163 multi-vitamin/fluoride...... 224 naproxen sodium...... 22 NEULASTA ONPRO...... 163 multi-vitamin/fluoride/iron...... 225 naproxen sodium er...... 22 NEUPRO...... 78 mupirocin...... 122 naproxen-esomeprazole...... 22 NEUTEK 2TEK TEST...... 138 mupirocin calcium...... 122 naratriptan hcl...... 215 NEUTRASAL...... 221 MVASI...... 74 NARCAN...... 58 NEVANAC...... 239 MY CHOICE...... 100 NASCOBAL...... 163 nevirapine...... 85 MY WAY...... 100 NATACHEW...... 225 nevirapine er...... 85 MYALEPT...... 147 NATACYN...... 238 NEW DAY...... 100 MYCO NAIL...... 122 NATALVIT...... 225 NEXAVAR...... 75 mycophenolate mofetil...... 219 NATAZIA...... 100 NEXIUM...... 258 mycophenolate sodium...... 219 nateglinide...... 53 NEXIUM 24HR...... 258 MYDAYIS...... 18 NATESTO...... 32 NEXIUM 24HR CLEAR MYGLUCOHEALTH NATPARA...... 147 MINIS...... 257 BLOOD GLUCOSE...... 197 NATURE-THROID...... 256 NEXLETOL...... 62 MYGLUCOHEALTH NAYZILAM...... 44 NEXLIZET...... 62 LANCETS 30G...... 197 NEBUPENT...... 67 NEXPLANON...... 100 MYGLUCOHEALTH TEST Necon 0.5/35 (28)...... 100 niacin (antihyperlipidemic)...... 62 ...... 138 NEEVO DHA...... 225 niacin er (antihyperlipidemic).. 62 MYLERAN...... 75 nefazodone hcl...... 48 NIACOR...... 62 MYNATAL...... 225 NEOCERA...... 122 NICADAN...... 225 mynatal plus...... 225 NEOKE ALCAR...... 234 NICAPRIN...... 143 mynatal-z...... 225 NEOKE BCAA4...... 143 nicardipine hcl...... 89 Myorisan...... 122 neoke bhb...... 143 NICAZEL...... 225 MYRBETRIQ...... 259 NEOKE MCT70...... 234 NICAZEL FORTE...... 225 MYTESI...... 57 NEOKE RA LIPOIC...... 19 nicazyme...... 143 nabumetone...... 22 neomycin sulfate...... 19 NICOMIDE...... 225 n-acetyl-l-cysteine...... 234 neomycin-bacitracin zn- NICORELIEF...... 250 nadolol...... 88 polymyx...... 238 nicotine...... 251 Nafrinse...... 217 neomycin-polymyxin b gu...... 155 nicotine mini...... 250 NAFRINSE DAILY neomycin-polymyxin-dexameth nicotine polacrilex...... 250 ACIDULATED...... 221 ...... 239 nicotine step 1...... 250 NAFRINSE neomycin-polymyxin- nicotine step 2...... 250 DAILY/NEUTRAL...... 221 gramicidin...... 239 nicotine step 3...... 250 Nafrinse Drops...... 217 neomycin-polymyxin-hc.. 239, 242 NICOTROL...... 251 NAFRINSE WEEKLY...... 221 NEONATAL PLUS...... 225 NICOTROL NS...... 251 286 nifedipine...... 90 NOVA MAX GLUCOSE Nudiclo Solupak...... 123 nifedipine er...... 89 TEST...... 139 Nudiclo Tabpak...... 22 nifedipine er osmotic release..... 90 NOVA MAX PLUS NUDROXIPAK...... 22 Nikki...... 100 KETONE TEST...... 139 NUDROXIPAK DSDR-50.... 22 NILANDRON...... 75 NOVA SAFETY LANCETS NUDROXIPAK DSDR-75.... 22 nilutamide...... 75 23G...... 197 NUDROXIPAK E-400...... 22 nimodipine...... 90 NOVA SAFETY LANCETS NUDROXIPAK I-800...... 22 NINLARO...... 75 28G...... 197 NUDROXIPAK M-15...... 23 NIPRIDE RTU...... 65 NOVA SUREFLEX NUDROXIPAK N-500...... 23 nisoldipine er...... 90 LANCETS...... 197 NUEDEXTA...... 251 NITRO-BID...... 34 NOVA SUREFLEX NUFERA...... 163 NITRO-DUR...... 34 LANCING DEVICE...... 197 Nufol...... 163 nitrofurantoin...... 67 NOVACORT...... 123 Nulev...... 258 nitrofurantoin macrocrystal...... 67 NOVOEIGHT...... 159 NUMOISYN...... 221 nitrofurantoin monohyd macro. 67 NOVOFINE...... 197 NUPLAZID...... 81 nitroglycerin...... 34 NOVOFINE AUTOCOVER 197 NURTEC...... 215 NITROMIST...... 34 NOVOFINE PLUS...... 197 NUSURGEPAK NITYR...... 147 NOVOLIN 70/30...... 54 SURGICAL PREP/CARE....123 NIVA-PLUS...... 225 NOVOLIN 70/30 FLEXPEN..54 NUTRASEB...... 123 NIVATOPIC PLUS...... 123 NOVOLIN 70/30 FLEXPEN NUTRICAP...... 225 NIVESTYM...... 163 RELION...... 54 Nutrifac Zx...... 225 nizatidine...... 258 NOVOLIN 70/30 RELION.....54 NUTRILIPID...... 234 NOCDURNA...... 148 NOVOLIN N...... 54 NUTRIVIT...... 225 Nolix...... 123 NOVOLIN N FLEXPEN...... 54 NUVAIL...... 123 Nora-Be...... 100 NOVOLIN N RELION...... 54 NUVARING...... 101 NORCO...... 30 NOVOLIN R...... 54 NUVESSA...... 261 norethin ace-eth estrad-fe...... 100 NOVOLIN R FLEXPEN...... 54 NUVIGIL...... 18 norethindrone...... 100 NOVOLIN R FLEXPEN NUWIQ...... 159 norethindrone acetate...... 247 RELION...... 54 NUZYRA...... 255 norethindrone acet-ethinyl est. 100 NOVOLIN R RELION...... 54 Nyamyc...... 124 norethindrone-eth estradiol..... 151 NOVOLOG...... 54 NYMALIZE...... 90 norethin-eth estradiol-fe...... 101 NOVOLOG FLEXPEN...... 54 nystatin...... 59, 124, 221 norgesic forte...... 232 NOVOLOG MIX 70/30...... 54 nystatin-triamcinolone...... 124 norgestimate-eth estradiol...... 101 NOVOLOG MIX 70/30 Nystop...... 124 norgestim-eth estrad triphasic.101 FLEXPEN...... 54 OB COMPLETE...... 225 NORITATE...... 123 NOVOLOG PENFILL...... 54 OB COMPLETE ONE...... 225 Norlyda...... 101 NOVOPEN ECHO...... 197 OB COMPLETE PETITE.... 226 Norlyroc...... 101 NOVOSEVEN RT...... 159 OB COMPLETE PREMIER 226 NORPACE CR...... 35 NOVOTWIST...... 197 OB COMPLETE/DHA...... 226 Nortrel 0.5/35 (28)...... 101 NOXAFIL...... 59 OBSTETRIX DHA...... 226 Nortrel 1/35 (21)...... 101 np thyroid...... 256 OBSTETRIX EC...... 226 Nortrel 1/35 (28)...... 101 NPLATE...... 163 O-CAL PRENATAL...... 226 Nortrel 7/7/7...... 101 NUBEQA...... 75 OCALIVA...... 153 nortriptyline hcl...... 48 NUCALA...... 38 Ocella...... 101 NORVASC...... 90 NUCARACLINPAK...... 123 OCTAGAM...... 243 NORVIR...... 85 NUCARARXPAK...... 123 octreotide acetate...... 148 NOURISH...... 143 NUCYNTA...... 30 OCUVEL...... 226 NOVA MAX BLOOD NUCYNTA ER...... 30 ODACTRA...... 19 GLUCOSE SYSTEM...... 197 NUDERMRXPAK 120...... 123 ODEFSEY...... 85 NUDERMRXPAK 60...... 123 ODOMZO...... 75 287 OFEV...... 253 ONETOUCH ULTRA 2...... 198 ORMECA...... 124 ofloxacin...... 152, 239, 242 ONETOUCH ULTRA MINI orphenadrine citrate er...... 232 olanzapine...... 81 ...... 198 orphenadrine-asa-caffeine...... 232 olanzapine-fluoxetine hcl...... 251 ONETOUCH ULTRALINK198 Orphengesic Forte...... 232 olive oil...... 94 ONETOUCH ULTRASOFT Orsythia...... 101 olmesartan medoxomil...... 65 LANCETS...... 198 ortho df...... 163 olmesartan medoxomil-hctz...... 65 ONETOUCH VERIO... 139, 198 ORTHO TRI-CYCLEN LO. 101 olmesartan-amlodipine-hctz...... 65 ONETOUCH VERIO FLEX oscimin...... 258 olopatadine hcl...... 233, 239 SYSTEM...... 198 oscimin sr...... 258 OLUMIANT...... 23 ONETOUCH VERIO IQ oseltamivir phosphate...... 85 OLUX-E...... 124 SYSTEM...... 198 OSENI...... 55 OMECLAMOX-PAK...... 258 ONETOUCH VERIO OSMOLEX ER...... 78 omega-3 rx complete...... 62 REFLECT...... 198 OSMOPREP...... 167 OMEGA-3/D-3 WELLNESS ONETOUCH VERIO SYNC OSPHENA...... 148 PACK...... 62 SYSTEM...... 198 OTEZLA...... 23 omega-3-acid ethyl esters...... 62 onevite...... 226 OTIPRIO...... 242 OMEGAVEN...... 234 ONEXTON...... 124 OTOVEL...... 242 omeprazole...... 258 ONFI...... 44 OVACE PLUS...... 124 omeprazole-sodium ONGLYZA...... 55 OVIDREL...... 148 bicarbonate...... 258 ONZETRA XSAIL...... 215 oxaliplatin...... 75 OMNARIS...... 233 OPANA...... 30 oxandrolone...... 32 OMNIFLEX DIAPHRAGM197 OPCICON ONE-STEP...... 101 oxaprozin...... 23 OMNIPAQUE...... 139 opium...... 57 OXAYDO...... 30 OMNIPOD 5 PACK...... 197 OPSUMIT...... 91 oxazepam...... 35 OMNIPOD DASH 5 PACK OPTION 2...... 101 oxcarbazepine...... 44 PODS...... 197 OPTIONS GYNOL II oxiconazole nitrate...... 124 OMNIPOD STARTER...... 197 CONTRACEPTIVE...... 261 OXISTAT...... 124 omnivex...... 143 OPTIUM BLOOD OXSORALEN ULTRA...... 124 ondansetron...... 59 GLUCOSE MONITOR...... 198 OXTELLAR XR...... 44 ondansetron hcl...... 58, 59 OPTIUM GLUCOSE oxybutynin chloride...... 259 one drop blood glucose monitor MONITOR SYSTEM...... 198 oxybutynin chloride er...... 259 ...... 197 OPTIUM TEST...... 139 oxycodone hcl...... 30 one drop test...... 139 OPTIUMEZ TEST...... 139 oxycodone hcl er...... 30 ONETOUCH CLUB ORA-BLEND...... 245 oxycodone-acetaminophen...... 30 LANCETS FINE PT...... 197 ORA-BLEND SF...... 245 oxycodone-aspirin...... 30 ONETOUCH DELICA ORACIT...... 155 OXYCONTIN...... 30 LANCETS 30G...... 197 ORAFATE...... 221 oxymorphone hcl...... 30 ONETOUCH DELICA ORALAIR...... 19 oxymorphone hcl er...... 30 LANCETS 33G...... 197 Oralone...... 221 OXYTROL...... 259 ONETOUCH DELICA ORA-PLUS...... 245 OXYTROL FOR WOMEN..259 LANCING DEV...... 197 ORA-SWEET...... 245 OZEMPIC (0.25 OR 0.5 ONETOUCH DELICA ORA-SWEET SF...... 245 MG/DOSE)...... 55 PLUS LANCET30G...... 197 ORAVIG...... 221 OZEMPIC (1 MG/DOSE)...... 55 ONETOUCH DELICA ORENCIA...... 23 OZURDEX...... 239 PLUS LANCET33G...... 197 ORENCIA CLICKJECT...... 23 Pacerone...... 35 ONETOUCH DELICA ORENITRAM...... 91 paingo kft...... 124 PLUS LANCING...... 198 ORFADIN...... 148 paliperidone er...... 81 ONETOUCH SURESOFT ORIAHNN...... 151 PALMERS SCAR SERUM..124 LANCING DEV...... 198 ORILISSA...... 148 PANCREAZE...... 144 ONETOUCH ULTRA...... 139 ORKAMBI...... 253 PANDEL...... 124 288 PANRETIN...... 124 pc unifine pentips...... 199 PHARMACY COUNTER pantoprazole sodium...... 258 PCCA SWEET-SF...... 245 LANCETS...... 200 PANZYGA...... 243 PCCA SYRUP VEHICLE.... 246 Phenazo...... 155 PARADIGM PUMP PCCA-PLUS...... 246 phenelzine sulfate...... 48 RESERVOIR 1.8ML...... 198 PCP 100...... 167 phenobarbital...... 166 PARADIGM PUMP peanut oil...... 94 phenoxybenzamine hcl...... 65 RESERVOIR 3ML...... 198 peg 3350-kcl-na bicarb-nacl.... 168 phenylephrine hcl...... 239, 262 PARADIGM QUICK-SET peg-3350/electrolytes...... 168 phenylephrine hcl (pressors)...262 18" 6MM...... 198 PEGINTRON...... 85 phenytoin...... 44 PARADIGM QUICK-SET Peg-Prep...... 168 phenytoin sodium extended...... 44 23" 6MM...... 198 pen needles...... 199 Philith...... 101 PARADIGM QUICK-SET pen needles 1/2"...... 199 PHLAG SPRAY...... 124 23" 9MM...... 198 pen needles 3/16"...... 199 PHOSLYRA...... 153 PARADIGM QUICK-SET pen needles 5/16"...... 199 Phospha 250 Neutral...... 217 32" 6MM...... 198 penicillamine...... 219 Phosphasal...... 67 PARADIGM QUICK-SET penicillin v potassium...... 244 PHOSPHOLINE IODIDE....239 32" 9MM...... 198 PENLEN...... 124 phosphorous...... 217 PARADIGM QUICK-SET PENLET II BLOOD Phospho-Trin 250 Neutral.....217 43" 6MM...... 199 SAMPLER...... 199 PHOTREXA VISCOUS...... 239 PARADIGM QUICK-SET PENLET II PHOTREXA-PHOTREXA 43" 9MM...... 199 REPLACEMENT CAP...... 199 VISCOUS KIT...... 239 PARADIGM REAL-TIME PENNSAID...... 124 Physiolyte...... 219 TRANSMITTER...... 199 PENTASA...... 153 Physiosol Irrigation...... 219 PARADIGM SILHOUETTE pentazocine-naloxone hcl...... 30 phytonadione...... 262 18" 13MM...... 199 PENTIPS...... 199 PICATO...... 124 PARADIGM SILHOUETTE pentoxifylline er...... 159 PICO WOUND THERAPY 32" 17MM...... 199 PERCOCET...... 30 SYSTEM...... 125 PARADIGM SILHOUETTE PERFECT LANCETS 28G.. 199 pilocarpine hcl...... 221, 239 COMBO 23"...... 199 PERFECT LANCETS 30G.. 199 pimecrolimus...... 125 PARADIGM SILHOUETTE PERFOROMIST...... 39 pimozide...... 251 FULL 23"...... 199 perindopril erbumine...... 65 Pimtrea...... 101 PARADIGM SURE-T 23" Periogard...... 221 pindolol...... 88 6MM...... 199 permethrin...... 124 pioglitazone hcl...... 55 PARADIGM SURE-T 23" perphenazine...... 81 pioglitazone hcl-glimepiride...... 55 8MM...... 199 perphenazine-amitriptyline..... 251 pioglitazone hcl-metformin hcl..55 PARAGARD PERSERIS...... 81 pip lancets 28g...... 200 INTRAUTERINE COPPER 101 PERTZYE...... 144 pip lancets 30g...... 200 PARAPLATIN...... 75 PEXEVA...... 48 PIQRAY (200 MG DAILY PAREMYD...... 239 PFIZERPEN...... 244 DOSE)...... 75 paricalcitol...... 148 ph strips...... 139 PIQRAY (250 MG DAILY Paroex...... 221 PHARMACIST CHOICE DOSE)...... 75 paromomycin sulfate...... 19 AUTOCODE...... 139 PIQRAY (300 MG DAILY paroxetine hcl...... 48 PHARMACIST CHOICE DOSE)...... 75 paroxetine hcl er...... 48 AUTOCODE SYS...... 199 Pirmella 1/35...... 101 paroxetine mesylate...... 251 PHARMACIST CHOICE Pirmella 7/7/7...... 101 PASER...... 69 LANCETS...... 199 piroxicam...... 23 PAXIL...... 48 PHARMACIST CHOICE PKU EASY...... 143 PAXIL CR...... 48 MINI SYSTEM...... 200 PKU EASY MICROTABS...143 PAZEO...... 239 pharmacist choice no coding... 139 PLAVIX...... 159 pc lancets super thin 30g...... 199 PLEGRIDY...... 251 289 PLEGRIDY STARTER PRECISION LINK...... 200 prena1...... 227 PACK...... 251 PRECISION PCX...... 139 prena1 pearl...... 227 PLENVU...... 168 PRECISION PCX PLUS prenaissance...... 227 PLIAGLIS...... 125 TEST...... 139 prenaissance plus...... 227 pnv prenatal plus multivitamin 226 PRECISION POINT OF PRENATABS RX...... 227 pnv tabs 29-1...... 226 CARE TEST...... 139 prenatal...... 227 pnv-dha...... 226 PRECISION QID prenatal 19...... 227 pnv-dha+docusate...... 226 MONITOR...... 200 prenatal plus...... 227 pnv-omega...... 226 PRECISION QID TEST...... 139 prenatal plus iron...... 227 pnv-select...... 226 PRECISION SOF-TACT prenatal vitamin plus low iron. 227 POCKETCHEM EZ MONITOR...... 200 PRENATAL-U...... 227 SYSTEM...... 200 PRECISION SOF-TACT PRENATE...... 227 POCKETCHEM EZ TEST...139 TEST...... 139 PRENATE AM...... 227 pod-care 100c...... 105 PRECISION SUREDOSE PRENATE DHA...... 227 podofilox...... 125 PLUS SYR...... 200 PRENATE ELITE...... 227 POLIVY...... 75 PRECISION SURE-DOSE PRENATE ENHANCE...... 227 Polycin...... 239 SYRINGE...... 200 PRENATE ESSENTIAL...... 227 poly-iron 150 forte...... 163 PRECISION XTRA...... 200 PRENATE MINI...... 227 polymyxin b-trimethoprim...... 239 PRECISION XTRA BLOOD PRENATE PIXIE...... 227 polypeg...... 246 GLUCOSE...... 139 PRENATE RESTORE...... 227 polysaccharide iron forte...... 163 PRECISION XTRA PREPIDIL...... 242 polytoza patch...... 200 KETONE...... 139 prepiv supply...... 125 POLY-VI-FLOR...... 226 PRECISION XTRA preplus...... 227 POLY-VI-FLOR FS...... 226 MONITOR...... 200 PRESERA...... 125 POLY-VI-FLOR/IRON...... 226 PRED FORTE...... 239 pressure activat safety lancet.. 200 POMALYST...... 75 PRED MILD...... 240 PRESTALIA...... 65 Portia-28...... 101 PRED-G...... 240 pretab...... 227 PORTRAZZA...... 75 PRED-G S.O.P...... 240 pretomanid...... 69 posaconazole...... 60 prednicarbate...... 125 PREVACID...... 258 pot & sod cit-cit ac...... 155 prednisolone...... 105 PREVACID 24HR...... 258 POTABA...... 262 prednisolone acetate...... 240 PREVACID SOLUTAB...... 258 potassium chloride...... 218 prednisolone acetate p-f...... 240 Prevalite...... 62 potassium chloride crys er...... 217 prednisolone sodium phosphate PREVENT SAFETY PEN potassium chloride er...... 218 ...... 105, 106, 240 NEEDLES...... 200 potassium citrate er...... 155 prednisolone-gatifloxacin...... 240 PREVENTEZA...... 102 potassium citrate-citric acid....155 prednisone...... 106 PREVIDENT...... 222 povidone-iodine...... 239 PREDNISONE INTENSOL 106 PREVIDENT 5000 PR BENZOYL PEROXIDE.125 preferred plus insulin syringe...200 BOOSTER PLUS...... 221 Pr Benzoyl Peroxide Wash.....125 preferred plus lancets colored..200 PREVIDENT 5000 DRY PR CREAM...... 125 preferred plus lancets thin...... 200 MOUTH...... 221 PRADAXA...... 41 preferred plus unifine pentips.. 200 PREVIDENT 5000 PRALUENT...... 62 PREFEST...... 151 ENAMEL PROTECT...... 221 pramipexole dihydrochloride.....79 pregabalin...... 44 PREVIDENT 5000 ORTHO pramipexole dihydrochloride er.79 PREMARIN...... 151, 261 DEFENSE...... 222 prasugrel hcl...... 159 PREMESISRX...... 226 PREVIDENT 5000 PLUS.....222 pravastatin sodium...... 62 premium blood glucose test..... 139 PREVIDENT 5000 praziquantel...... 33 premium scar...... 125 SENSITIVE...... 222 prazosin hcl...... 65 PREMPHASE...... 151 PREVIDOLRX PRE & POST SX POUCH.... 125 PREMPRO...... 151 ANALGESIC...... 23 PRECEDEX...... 166 prena 1 true...... 226 Previfem...... 102 290 PREVYMIS...... 85 PRODIGY POCKET psorcon...... 125 PREZCOBIX...... 85 BLOOD GLUCOSE...... 201 PSS SELECT GP LANCETS201 PREZISTA...... 85 PRODIGY SAFETY PSS SELECT PLATFORMS 201 PRIFTIN...... 69 LANCETS 26G...... 201 PSS SELECT SAFETY PRILOSEC...... 258 PRODIGY VOICE BLOOD LANCETS...... 201 PRIMACARE...... 228 GLUCOSE...... 201 PTS PANELS GLUCOSE primaquine phosphate...... 69 PROFILNINE...... 159 TEST...... 139 primidone...... 44 progesterone...... 247 PTS PANELS KETONE PRIMLEV...... 30 progesterone compounding kit.247 TEST...... 140 PRIMSOL...... 67 progesterone micronized...... 247 PULMICORT...... 39 PRISTIQ...... 48 PROGLYCEM...... 55 PULMICORT PRIVIGEN...... 243 PROLASTIN-C...... 253 FLEXHALER...... 39 PRIZOTRAL...... 125 PROLENSA...... 240 PULMOZYME...... 253 pro comfort alcohol...... 200 PROLIA...... 148 purified water...... 246 PRO COMFORT INSULIN PROMACTA...... 164 PURIXAN...... 75 SYRINGE...... 201 PROMACTIN AA PLUS push button safety lancets...... 201 pro comfort lancets 30g...... 201 20PE...... 143 push button safety lancets 28g.201 pro comfort lancets 31g...... 201 promethazine hcl...... 60 px aspirin...... 26 pro comfort pen needles...... 201 promethazine-codeine...... 107 px enteric aspirin...... 26 pro voice v8 glucose system.....201 promethazine-dm...... 107 px extra short pen needles...... 201 pro voice v8/v9 glucose...... 139 promethazine-phenyleph- px glucose...... 55 pro voice v9 glucose system.....201 codeine...... 107 px insulin syringe...... 201 PROAIR HFA...... 39 promethazine-phenylephrine... 107 px lancet auto injector...... 201 PROAIR RESPICLICK...... 39 Promethegan...... 60 px lancets ultra thin...... 201 probenecid...... 156 PROMETHEGAN...... 60 px mini pen needles...... 201 probichew...... 57 PROMISEB...... 125 px pen needle...... 201 PROBUPHINE IMPLANT propafenone hcl...... 35 px shortlength pen needles...... 202 KIT...... 31 propafenone hcl er...... 35 PYLERA...... 258 PRO-C-DURE 6...... 106 propantheline bromide...... 258 pyrazinamide...... 69 prochlorperazine...... 81 proparacaine hcl...... 240 pyridostigmine bromide...... 69 prochlorperazine edisylate...... 81 proparacaine-fluorescein...... 240 pyridostigmine bromide er...... 69 prochlorperazine maleate...... 81 propranolol hcl...... 88 pyridoxine hcl...... 263 PROCORT...... 33 propranolol hcl er...... 88 pyrimethamine...... 94 PROCTOCORT...... 33 propranolol-hctz...... 65 pyrogallic acid...... 125 PROCTOFOAM HC...... 33 propylthiouracil...... 256 QBRELIS...... 65 Procto-Med Hc...... 33 PROSTIN E2...... 242 QBREXZA...... 125 Procto-Pak...... 33 PROTHELIAL...... 222 qc advanced lancing device...... 202 Proctozone-Hc...... 33 PROTONIX...... 258 qc alcohol swabs...... 202 PROCYSBI...... 156 PROTOPIC...... 125 qc childrens aspirin...... 26 prodigen...... 57 protriptyline hcl...... 48 qc gentle laxative...... 168 PRODIGY AUTOCODE PROTYL AG...... 125 qc lancets super thin 30g...... 202 BLOOD GLUCOSE...... 201 PROVAYBLUE...... 58 qc lancets ultra thin...... 202 PRODIGY INSULIN PROVENTIL HFA...... 39 qc pen needles...... 202 SYRINGE...... 201 PROVIDA OB...... 228 qc unifine pentips...... 202 PRODIGY LANCETS 28G..201 PROVIGIL...... 18 qc unilet lancets 28g...... 202 PRODIGY LANCING PROVOCHOLINE...... 139 qc unilet lancets micro thin..... 202 DEVICE...... 201 PROZAC...... 48 QMIIZ ODT...... 23 PRODIGY NO CODING PRUCLAIR...... 125 QNASL...... 233 BLOOD GLUC...... 139 PRUMYX...... 125 QNASL CHILDRENS...... 233 pseudoeph-bromphen-dm...... 107 QSYMIA...... 18 291 QTERN...... 55 ra glucose...... 55 REBIF REBIDOSE...... 251 quad-mix...... 91 ra insulin syringe...... 202 REBIF REBIDOSE QUARTETTE...... 102 ra laxative...... 168 TITRATION PACK...... 251 quazepam...... 166 ra mini nicotine...... 251 REBIF TITRATION PACK 252 quetiapine fumarate...... 81 ra nicotine...... 251 REBINYN...... 159 quetiapine fumarate er...... 81 ra nicotine polacrilex...... 251 REBOOST COLD/FLU QUFLORA FE...... 228 ra pen needles...... 202 RELIEF...... 219 QUFLORA FE PEDIATRIC ra stimulant laxative...... 168 RECARBRIO...... 67 ...... 228 RA TRUE2GO BLOOD RECEDO...... 126 QUFLORA GUMMIES...... 228 GLUCOSE...... 202 reck...... 168 QUFLORA PEDIATRIC.....228 RA TRUERESULT BLOOD RECLAST...... 148 QUICKTEK...... 202 GLUCOSE...... 202 Reclipsen...... 102 QUICKTEK TEST...... 140 RA TRUETEST TEST...... 140 RECOMBINATE...... 159 QUICKTEK/METER...... 202 rabeprazole sodium...... 258 RECOTHROM...... 165 QUILLICHEW ER...... 18 RADIAGEL...... 126 RECOTHROM SPRAY KIT QUILLIVANT XR...... 18 RADIOGARDASE...... 58 ...... 165 quinapril hcl...... 65 RAGWITEK...... 19 RECTIV...... 33 quinapril-hydrochlorothiazide...65 raloxifene hcl...... 148 RECURA...... 126 quinidine gluconate er...... 36 ramelteon...... 166 REFUAH PLUS BLOOD quinidine sulfate...... 36 ramipril...... 66 GLUCOSE TEST...... 140 quinine sulfate...... 69 ranolazine er...... 34 REFUAH PLUS QUINJA...... 126 RAPAFLO...... 156 MONITORING SYSTEM... 203 QUINTET AC BLOOD RAPPORT RLS...... 202 REGENECARE...... 126 GLUCOSE...... 202 RAPPORT VTD...... 202 REGIOCIT...... 41 QUINTET AC BLOOD rasagiline mesylate...... 79 REGRANEX...... 126 GLUCOSE TEST...... 140 RASUVO...... 23 RELENZA DISKHALER...... 85 QUINTET BLOOD RAYALDEE...... 148 RELEXXII...... 18 GLUCOSE SYSTEM...... 202 RAYOS...... 106 RELION BLOOD QUINTET BLOOD REACT...... 102 GLUCOSE TEST...... 140 GLUCOSE TEST...... 140 READI-CAT 2...... 140 RELION CONFIRM QUTENZA...... 126 READYLANCE SAFETY GLUCOSE MONITOR...... 203 QUTENZA (2 PATCH)...... 126 LANCETS...... 202 RELION QVAR REDIHALER...... 39 READYSHARP ANESTH + CONFIRM/MICRO TEST...140 ra alcohol swabs...... 202 DEXAMETH...... 106 RELION GLUCOSE...... 55 ra aspirin adult low dose...... 26 READYSHARP ANESTH + RELION INSULIN ra aspirin childrens...... 26 KETOROLAC...... 23 SYRINGE...... 203 ra aspirin ec adult low st...... 26 READYSHARP ANESTH + RELI-ON INSULIN ra blood glucose monitor...... 202 METHYLPRED...... 106 SYRINGE...... 203 ra childrens aspirin...... 26 READYSHARP RELION KETONE...... 140 RA E-ZJECT COLOR BETAMETHASONE...... 106 RELION KETONE TEST....140 LANCETS 33G...... 202 READYSHARP RELION LANCET RA E-ZJECT LANCETS DEXAMETHASONE...... 106 DEVICES 30G...... 203 28G...... 202 READYSHARP RELION LANCETS RA E-ZJECT LANCETS KETOROLAC...... 23 MICRO-THIN 33G...... 203 THIN 26G...... 202 READYSHARP-A...... 168 RELION LANCETS RA E-ZJECT LANCETS reality insulin syringe...... 202 STANDARD 21G...... 203 THIN 28G...... 202 reality lancets...... 203 RELION LANCETS THIN RA E-ZJECT LANCETS reality swabs...... 203 26G...... 203 ULTRA THIN...... 202 reality trigger lancets...... 203 RELION LANCETS ra fast relief laxative...... 168 REBIF...... 251 ULTRA-THIN 30G...... 203 292 RELION LANCING RESTORA RX...... 57 ringers irrigation...... 219 DEVICE...... 203 RESTORE SILVER RINVOQ...... 23 RELION MICRO...... 203 DRESSING...... 126 RIOMET...... 55 RELION MINI PEN RETACRIT...... 164 risedronate sodium...... 148 NEEDLES...... 203 RETAVASE...... 160 RISPERDAL CONSTA...... 82 RELION PEN NEEDLES....203 RETAVASE HALF-KIT...... 160 risperidone...... 82 RELION PREMIER BLU RETIN-A MICRO...... 126 ritonavir...... 85 MONITOR...... 203 RETIN-A MICRO PUMP....126 rivastigmine...... 252 RELION PREMIER revesta...... 164 rivastigmine tartrate...... 252 COMPACT SYSTEM...... 203 REVLIMID...... 219 Rivelsa...... 102 RELION PREMIER VOICE REXALL BLOOD rixubis...... 160 MONITOR...... 203 GLUCOSE SYSTEM...... 204 rizatriptan benzoate...... 215, 216 RELION PRIME REXALL BLOOD ROCKLATAN...... 240 MONITOR...... 203 GLUCOSE TEST...... 140 romidepsin...... 75 RELION PRIME TEST...... 140 rexaphenac...... 126 ROPIDEX...... 106 RELION SHORT PEN REXASIL PATCH & ropinirole hcl...... 79 NEEDLES...... 204 VITAMIN E LIQ...... 126 ropinirole hcl er...... 79 RELION ULTIMA REXULTI...... 82 Rosadan...... 126 GLUCOSE SYSTEM...... 204 REYATAZ...... 85 ROSE GLO...... 240 RELION ULTIMA TEST.... 140 REYVOW...... 215 rosuvastatin calcium...... 63 RELION ULTRA THIN RHEUMATE...... 143 ROTARIX...... 260 LANCETS 30G...... 204 RHOFADE...... 126 ROTATEQ...... 260 RELION ULTRA THIN RHOPRESSA...... 240 ROWASA...... 154 PLUS LANCETS...... 204 RIAX...... 126 Roweepra...... 45 RELISTOR...... 153, 154 ribavirin...... 85 ROXICODONE...... 31 relnate dha...... 228 ribozel...... 143 ROZEREM...... 166 remdesivir...... 85 RIDAURA...... 23 ROZLYTREK...... 75 REMEDIENT...... 228 rifabutin...... 69 RTD WOUND CARE REMESENSE...... 204 rifampin...... 69 DRESSING...... 126 REMICADE...... 154 RIGHTEST ALTERNATE RUBRACA...... 75 remigen...... 126 SITE ADAPT...... 204 RUCONEST...... 160 REMODULIN...... 91 RIGHTEST GD500 RUZURGI...... 69 RENACIDIN...... 156 LANCING DEVICE...... 204 RYBELSUS...... 55 RENATABS...... 228 RIGHTEST GL300 RYCLORA...... 61 RENATABS WITH IRON...228 LANCETS...... 204 RYDAPT...... 75 reno caps...... 228 RIGHTEST GM100 BLOOD RYTARY...... 79 repaglinide...... 55 GLUCOSE...... 204 RYVENT...... 61 REPATHA...... 62 RIGHTEST GM300 BLOOD SABRIL...... 45 REPATHA PUSHTRONEX GLUCOSE...... 204 SAFESNAP INSULIN SYSTEM...... 62 RIGHTEST GM550 BLOOD SYRINGE...... 204 REPATHA SURECLICK...... 63 GLUCOSE...... 204 SAFE-T-LANCE...... 204 REQ 49+...... 228 RIGHTEST GS100 BLOOD SAFE-T-LANCE PLUS...... 204 RESECTISOL...... 156 GLUCOSE...... 140 safety insulin syringes...... 204 RESET FOR IOS OR RIGHTEST GS300 BLOOD safety lancet 23g/pressure act. 204 ANDROID APP...... 219 GLUCOSE...... 140 safety lancet 30g/pressure act. 204 RESET-O FOR IOS OR RIGHTEST GS550 BLOOD SAFETY LET LANCETS.... 204 ANDROID APP...... 219 GLUCOSE...... 140 SAFETY SEAL LANCETS..204 resorcinol-sulfur...... 126 riluzole...... 233 safflower oil...... 94 RESTASIS...... 240 rimantadine hcl...... 85 SAFYRAL...... 102 RESTASIS MULTIDOSE....240 RIMSO-50...... 156 salimez...... 126 293 salimez forte...... 126 Setlakin...... 102 sirolimus...... 219 SALIVAMAX...... 222 sevelamer carbonate...... 154 SIRTURO...... 69 salsalate...... 26 sevelamer hcl...... 154 SITAVIG...... 86 SAMSCA...... 148 sevoflurane...... 154 SITZMARKS...... 140 SANCUSO...... 59 SEYSARA...... 255 SITZMARKS COMBO SANDIMMUNE...... 219 sf...... 222 PACKAGE...... 140 SANDOSTATIN...... 148 sf 5000 plus...... 222 SIVEXTRO...... 67 SANTYL...... 126 SFROWASA...... 154 SKLICE...... 127 SAPHRIS...... 82 Sharobel...... 102 SKYLA...... 102 saps care alcohol prep...... 204 SHOPKO ALCOHOL SKYRIZI (150 MG DOSE).. 127 saps health care alcohol prep...204 SWABS...... 205 SLYND...... 102 saps health twist top lancets....204 SHOPKO AUTOLET sm alcohol prep...... 205 saps twist top lancets...... 204 LANCING DEVICE...... 205 sm aspirin adult low strength.... 26 sapscare twist top lancets...... 204 SHOPKO UNIFINE sm childrens aspirin...... 26 SAVAYSA...... 41 PENTIPS...... 205 sm folic acid...... 164 SAVELLA...... 252 SHOPKO UNIFINE sm gentle laxative...... 168 SAVELLA TITRATION PENTIPS PLUS...... 205 sm glucose...... 55 PACK...... 252 SHUR-SEAL sm lancets 33g...... 205 sb alcohol prep...... 204 CONTRACEPTIVE...... 261 sm laxative...... 168 sb bisacodyl laxative ec...... 168 side button safety lancet...... 205 sm nicotine...... 252 sb childrens aspirin...... 26 SIDEROL...... 228 sm nicotine polacrilex...... 252 sb insulin syringe...... 205 SIGNIFOR...... 149 SM TRUEDRAW sb lancets thin...... 205 SIGNIFOR LAR...... 148 LANCING DEVICE...... 205 sb lancets ultra thin...... 205 SIKLOS...... 164 SMART DIABETES sb laxative...... 168 sildenafil citrate...... 91 VANTAGE LANCING...... 205 scarcin...... 126, 127 SILENOR...... 166 SMART SENSE COLOR scarsilk...... 127, 205 SILHOUETTE 13MM...... 205 LANCETS 33G...... 205 SCARZEN SKIN REPAIR.. 127 SILHOUETTE 17MM...... 205 SMART SENSE GLUCOSE..55 scopolamine...... 59 SILHOUETTE INFUSION SMART SENSE PREMIUM SEBUDERM...... 127 SET 23"...... 205 SYSTEM...... 205 SECONAL...... 166 SILHOUETTE INFUSION SMART SENSE PREMIUM SECURESAFE INSULIN SET 43"...... 205 TEST...... 140 SYRINGE...... 205 silipac...... 127 SMART SENSE SEEBRI NEOHALER...... 39 SILIQ...... 127 STANDARD LANCETS..... 205 SEGLUROMET...... 55 silivex...... 205 SMART SENSE SUPER select-lite lancing device...... 205 silodosin...... 156 THIN LANCETS...... 205 SELECT-OB...... 228 SILTREX...... 205 SMART SENSE THIN SELECT-OB+DHA...... 228 silver sulfadiazine...... 127 LANCETS 26G...... 205 selegiline hcl...... 79 SIMBRINZA...... 240 SMART SENSE VALUE selenium sulfide...... 127 Simliya...... 102 GLUCOSE SYS...... 206 SELZENTRY...... 85 Simpesse...... 102 SMART SENSE VALUE SEMPREX-D...... 107 SIMPLE DIAGNOSTICS TEST...... 140 se-natal 19...... 228 LANCING DEV...... 205 SMARTEST BLOOD SENSIPAR...... 148 simple syrup...... 246 GLUCOSE TEST...... 140 SEREVENT DISKUS...... 39 SIMPONI...... 24 SMARTEST EJECT...... 206 SERNIVO...... 127 SIMPONI ARIA...... 24 SMARTEST EJECT SEROQUEL XR...... 82 simvastatin...... 63 STARTER...... 206 SEROSTIM...... 148 SINGLE-LET...... 205 SMARTEST LANCETS 28G sertraline hcl...... 48 SINGULAIR...... 39 ...... 206 sesame oil...... 94 SINUVA...... 233 294 SMARTEST PERSONA spironolactone...... 145 sulfurated lime...... 128 STARTER...... 206 spironolactone-hctz...... 145 sulindac...... 24 SMARTEST PRONTO SPORANOX...... 60 sumatriptan...... 216 STARTER...... 206 SPORANOX PULSEPAK..... 60 sumatriptan succinate...... 216 SMARTEST PROTEGE...... 206 SPRAVATO (56 MG DOSE). 48 sumatriptan succinate refill.....216 SMARTEST PROTEGE SPRAVATO (84 MG DOSE). 48 sumatriptan-naproxen sodium.216 STARTER...... 206 Sprintec 28...... 102 SUNOSI...... 18 sod citrate-citric acid...... 156 SPRITAM...... 45 SUPARTZ FX...... 232 sodium bicarbonate...... 33, 218 SPRIX...... 24 super bi-mix...... 91 sodium chloride...... 107, 156 SPRYCEL...... 75 super quad-mix...... 91 sodium fluoride...... 218 Sps...... 219 super thin lancets...... 206 sodium hyaluronate...... 127 sr nicotine...... 252 super tri-mix...... 92 sodium phenylbutyrate...... 149 Sronyx...... 102 SUPERVITE...... 228 sodium polystyrene sulfonate.. 219 Ssd...... 127 support...... 228 sodium saccharin...... 143 ST JOSEPH LOW DOSE...... 26 SUPPORT-500...... 229 sodium sulfacetamide wash..... 127 stavudine...... 86 suppository blend...... 246 sodium thiosulfate...... 58 STAXYN...... 91 SUPPRELIN LA...... 149 solifenacin succinate...... 259 STEGLATRO...... 55 SUPRAX...... 93 SOLIQUA...... 55 STEGLUJAN...... 55 SUPREME TEST...... 141 SOLIRIS...... 160 STELARA...... 127, 128, 154 SUPREP BOWEL PREP KIT SOLODYN...... 255 STENDRA...... 91 ...... 168 SOLOSEC...... 19 STERILANCE PA...... 206 sure comfort alcohol prep...... 206 SOLTAMOX...... 75 STERILANCE TL...... 206 sure comfort insulin syringe.... 206 SOLUS V2 BLOOD sterile water for irrigation...... 220 sure comfort lancets 18g...... 206 GLUCOSE SYSTEM...... 206 STIMATE...... 149 sure comfort lancets 21g...... 206 SOLUS V2 LANCETS 28G.. 206 STIOLTO RESPIMAT...... 39 sure comfort lancets 23g...... 206 SOLUS V2 LANCING STIVARGA...... 76 sure comfort lancets 30g...... 206 DEVICE...... 206 STRENSIQ...... 149 sure comfort lancing pen...... 207 SOLUS V2 TEST...... 141 STRIBILD...... 86 sure comfort pen needles...... 207 SOLUS V2 TWIST STRIVERDI RESPIMAT...... 39 SURE EDGE GLUCOSE LANCETS 30G...... 206 STROVITE FORTE...... 228 MONITOR...... 207 SOMATULINE DEPOT...... 149 SUBLOCADE...... 31 SURE EDGE TEST...... 141 SOMAVERT...... 149 SUBOXONE...... 31 sure result o3d3 system...... 63 SOOLANTRA...... 127 SUBSYS...... 31 SURECHEK BLOOD sorbitol...... 156, 246 Subvenite...... 45 GLUCOSE MONITOR...... 207 sorbitol-mannitol...... 156 Subvenite Starter Kit-Blue...... 45 SURECHEK BLOOD SORIATANE...... 127 Subvenite Starter Kit-Green....45 GLUCOSE TEST...... 141 SORILUX...... 127 Subvenite Starter Kit-Orange.. 45 SURE-FINE PEN Sorine...... 88 SUCRAID...... 144 NEEDLES...... 207 sorrel/dock mix...... 19 sucralfate...... 259 SURE-JECT INSULIN sotalol hcl...... 88 sulfacetamide sodium...... 240 SYRINGE...... 207 sotalol hcl (af)...... 88 sulfacetamide sodium (acne).. 128 SURE-LANCE FLAT SOTYLIZE...... 88 sulfacetamide sodium-sulfur....128 LANCETS...... 207 SOVALDI...... 86 sulfacetamide-prednisolone..... 240 SURE-LANCE LANCETS soybean oil...... 94 sulfadiazine...... 254 26G...... 207 spg supposi-base...... 246 sulfamethoxazole-trimethoprim 67 SURELITE LANCETS...... 207 SPHERUSOL...... 141 sulfamez wash...... 128 SURE-PEN...... 207 spinosad...... 127 SULFAMYLON...... 128 SURE-T INFUSION SET SPIRIVA HANDIHALER.....39 sulfasalazine...... 154 18"...... 207 SPIRIVA RESPIMAT...... 39 Sulfatrim Pediatric...... 67 295 SURE-T INFUSION SET synvexia tc...... 128 TECHNELITE...... 141 23"...... 207 SYPRINE...... 220 TEGADERM AG MESH.....129 SURE-T INFUSION SET syrpalta...... 246 TEGSEDI...... 252 32"...... 207 SYRPALTA (RED)...... 246 TEKTURNA...... 66 SURE-T INFUSION SET SYRSPEND SF...... 246 TEKTURNA HCT...... 66 6MM...... 207 SYRSPEND SF PH4...... 246 TELCARE BLOOD SURE-T INFUSION SET syrup vehicle...... 246 GLUCOSE SYSTEM...... 208 8MM...... 207 syrup vehicle sf...... 246 TELCARE BLOOD SURE-TEST EASYPLUS T:FLEX T:LOCK GLUCOSE TEST...... 141 MINI METER...... 207 CARTRIDGE 4.8ML...... 207 TELFA AMD ISLAND SURE-TEST EASYPLUS T:SLIM T:LOCK INSULIN DRESSING...... 208 MINI TEST...... 141 CART 3ML...... 207 TELFA AMD NON- SURE-TOUCH LANCETS TABLOID...... 76 ADHERENT...... 208 UNIVERSAL...... 207 TABRADOL FUSEPAQ...... 232 telmisartan...... 66 SURVANTA...... 253 TABRADOL RAPIDPAQ... 232 telmisartan-amlodipine...... 66 SUSPENDRX TACLONEX...... 128 telmisartan-hctz...... 66 W/BITTERBLOC SWEET... 246 tacrolimus...... 128, 220 temazepam...... 166 SUSPENDRX tadalafil (pah)...... 92 TEMIXYS...... 86 W/BITTERBLOC TAFINLAR...... 76 TEMODAR...... 76 UNSWEET...... 246 TAGITOL V...... 141 temozolomide...... 76 suspension vehicle...... 246 TAGRISSO...... 76 TENCON...... 26 SUSTOL...... 59 TAKE ACTION...... 102 tenofovir disoproxil fumarate....86 SUTENT...... 76 TAKHZYRO...... 160 TEPEZZA...... 149 suvicort...... 128 TALICIA...... 259 terazosin hcl...... 66 SX1 MEDICATED POST- TALIVA...... 164 terbinafine hcl...... 60 OPERATIVE...... 128 TALTZ...... 128 terbutaline sulfate...... 40 Syeda...... 102 TALZENNA...... 76 terconazole...... 261 SYLVANT...... 220 tamoxifen citrate...... 76 Terrell...... 155 SYMAX DUOTAB...... 259 tamsulosin hcl...... 156 TESTIM...... 32 Symax-Sr...... 259 TAPERDEX 12-DAY...... 106 TESTONE CIK...... 32 SYMBICORT...... 40 Taperdex 6-Day...... 106 TESTOPEL...... 32 SYMDEKO...... 253 TAPERDEX 7-DAY...... 106 testosterone...... 32 SYMFI...... 86 TARCEVA...... 76 testosterone compounding kit....32 SYMFI LO...... 86 TARGADOX...... 255 testosterone cypionate...... 32 SYMJEPI...... 262 TARGRETIN...... 76, 128 testosterone enanthate...... 32 SYMLINPEN 120...... 55 Tarina 24 Fe...... 102 tetrabenazine...... 252 SYMLINPEN 60...... 56 Tarina Fe 1/20...... 102 tetracaine hcl...... 240 SYMPAZAN...... 45 Tarina Fe 1/20 Eq...... 102 tetracycline hcl...... 255 SYMPROIC...... 154 taron forte...... 164 TETRIX...... 129 SYMTUZA...... 86 TARON-C DHA...... 229 TEXACORT...... 129 SYNAGEX...... 229 Taron-Crystals...... 156 tgt blood glucose monitoring... 208 SYNAGIS...... 243 TARON-PREX...... 229 tgt blood glucose test...... 141 SYNAPRYN FUSEPAQ...... 31 TAVALISSE...... 160 tgt glucose...... 56 SYNAREL...... 149 TAYTULLA...... 102 tgt lancet micro thin 33g...... 208 SYNDROS...... 59 tazarotene...... 128 tgt lancet thin 26g...... 208 SYNERA...... 128 TAZORAC...... 128 tgt lancet ultra thin 30g...... 208 SYNERDERM...... 128 Taztia Xt...... 90 tgt lancing device...... 208 SYNJARDY...... 56 TECFIDERA...... 252 THALOMID...... 220 SYNJARDY XR...... 56 techlite insulin syringe...... 208 THE LIQUILIFT TRACE... 218 SYNRIBO...... 76 TECHLITE PEN NEEDLES208 THE MAGIC BULLET...... 168 296 THEO-24...... 40 TOLAK...... 129 TRESIBA...... 56 theophylline...... 40 tolbutamide...... 56 TRESIBA FLEXTOUCH...... 56 theophylline er...... 40 tolcapone...... 79 tretinoin...... 76, 129 THERAHONEY...... 129 tolmetin sodium...... 24 tretinoin microsphere...... 129 THERANATAL CORE tolsura...... 60 tretinoin microsphere pump.....129 NUTRITION...... 229 tolterodine tartrate...... 260 TREXALL...... 76 thiamine hcl...... 263 tolterodine tartrate er...... 259 TREXIMET...... 216 THINLETS GP LANCETS..208 topcare clickfine pen needles... 208 Tri Femynor...... 103 THIOLA...... 156 topcare lancets micro-thin 33g 208 triamcinolone acetonide...129, 222 THIOLA EC...... 156 topcare ultra comfort ins syr...208 tri-amino...... 234 thioridazine hcl...... 82 topiramate...... 45 TRIAMSIL COMBIPAK..... 129 thiothixene...... 82 topiramate er...... 45 triamsil multipak...... 129 thrivacin 30...... 143 TOPROL XL...... 88 triamterene...... 145 thrivacin detox...... 143 toremifene citrate...... 76 triamterene-hctz...... 145 THRIVE...... 252 TORONOVA II SUIK...... 24 Trianex...... 129 thrivite 19...... 229 TORONOVA SUIK...... 24 triazolam...... 166 thrivite rx...... 229 torsemide...... 145 TRICARE...... 229 THROMBIN-JMI...... 165 TOUJEO MAX SOLOSTAR. 56 TRICARE PRENATAL THROMBIN-JMI TOUJEO SOLOSTAR...... 56 DHA ONE...... 229 EPISTAXIS...... 165 TOVIAZ...... 260 TRICITRASOL...... 41 THROMBOGEN...... 165 TOXICOLOGY MED tricitrates...... 156 tiagabine hcl...... 45 COLLECTION SYS...... 141 Tricon...... 164 TIBSOVO...... 76 TRACLEER...... 92 TRICOR...... 63 TICE BCG...... 76 TRADJENTA...... 56 Triderm...... 129 tigecycline...... 255 tramadol hcl...... 31 trientine hcl...... 220 TIGLUTIK...... 233 tramadol hcl er...... 31 Tri-Estarylla...... 103 TIKOSYN...... 36 tramadol hcl er (biphasic)...... 31 TRIFERIC...... 164 Tilia Fe...... 103 tramadol-acetaminophen...... 31 trifluoperazine hcl...... 82 timolol maleate...... 88, 240 trandolapril...... 66 trifluridine...... 241 TIMOPTIC OCUDOSE...... 240 trandolapril-verapamil hcl er.... 66 trigels-f forte...... 164 tinidazole...... 67 tranexamic acid...... 165 trihexyphenidyl hcl...... 79 TIROSINT...... 256 TRANSDERM-SCOP (1.5 TRIJARDY XR...... 56 TIROSINT-SOL...... 256 MG)...... 59 TRIKAFTA...... 253 TISSEEL...... 165 tranylcypromine sulfate...... 48 Tri-Legest Fe...... 103 Tis-U-Sol...... 220 TRAVATAN Z...... 241 Tri-Linyah...... 103 TIVICAY...... 86 travel lancets...... 208 Tri-Lo-Estarylla...... 103 TIVICAY PD...... 86 TRAVEL LANCETS Tri-Lo-Marzia...... 103 TIVORBEX...... 24 ADVANCED 28G...... 208 Tri-Lo-Mili...... 103 tizanidine hcl...... 232 trazodone hcl...... 48 Tri-Lo-Sprintec...... 103 tl-hem 150...... 164 TREANDA...... 76 Trilyte...... 168 TOBAKIENT...... 143 TRECATOR...... 69 trimethobenzamide hcl...... 59 TOBI PODHALER...... 19 TRELEGY ELLIPTA...... 40 trimethoprim...... 67 TOBRADEX...... 240 T-RELIEF ARTHRITIS Tri-Mili...... 103 TOBRADEX ST...... 241 MOBILITY...... 220 trimipramine maleate...... 48 tobramycin...... 19, 241 T-RELIEF EXTRA tri-mix...... 92 tobramycin-dexamethasone.... 241 STRENGTH...... 220 TRIMO-SAN...... 261 TOBREX...... 241 T-RELIEF SAFE RELIEF...220 trinatal rx 1...... 229 todays health mini pen needles 208 TRELSTAR MIXJECT...... 76 TRINATE...... 229 todays health pen needles...... 208 TREMFYA...... 129 TRINTELLIX...... 48 todays health short pen needle.208 treprostinil...... 92 triphrocaps...... 229 297 triple complex formula 3 kit....129 TRUERESULT BLOOD ULTICARE PEN NEEDLES triple pmb...... 241 GLUCOSE...... 209 ...... 210 triple pmk...... 241 TRUETEST TEST...... 141 ULTICARE SHORT PEN Tri-Previfem...... 103 TRUETRACK BLOOD NEEDLES...... 210 TRIPTODUR...... 149 GLUCOSE...... 209 ultiguard safepack pen needle..210 Tri-Sprintec...... 103 TRUETRACK SMART ULTI-LANCE tristart dha...... 229 SYSTEM...... 209 AUTOMATIC...... 210 TRISTART ONE...... 229 TRUETRACK TEST...... 141 ultilet alcohol swabs...... 210 tri-tabs dha...... 229 TRULANCE...... 154 ULTILET CLASSIC TRIUMEQ...... 86 TRULICITY...... 56 LANCETS...... 210 TRI-VI-FLOR...... 229 TRUSTEEL INFUSION ULTILET INSULIN tri-vi-floro...... 229 SET...... 209 SYRINGE...... 210 tri-vite/fluoride...... 229 TRUVADA...... 86 ULTILET INSULIN Trivora (28)...... 103 tryptophan...... 234 SYRINGE SHORT...... 210 Tri-Vylibra...... 103 TUDORZA PRESSAIR...... 40 ULTILET LANCETS...... 210 Tri-Vylibra Lo...... 103 TUKYSA...... 76 ULTILET PEN NEEDLE.... 210 TRODELVY...... 76 Tulana...... 103 ULTILET SAFETY TROKENDI XR...... 45 TURALIO...... 77 LANCETS...... 210 tronvite...... 229 turpentine...... 129 ULTILET SAFETY tropicamide...... 241 TUSNEL C...... 107 LANCETS 23G...... 210 trospium chloride...... 260 TUSSICAPS...... 107 ULTIMA...... 210 trospium chloride er...... 260 TUXARIN ER...... 108 ULTIMA TEST...... 141 true comfort insulin syringe.....208 TUZISTRA XR...... 108 ULTOMIRIS...... 160 true comfort pen needles...... 208 TYBOST...... 86 ultra comfort insulin syringe... 210 true comfort twist top lancets..208 Tydemy...... 103 ultra thin lancets 31g...... 211 TRUE FOCUS BLOOD TYKERB...... 77 ULTRA THIN PEN GLUCOSE METER...... 208 TYLACTIN COMPLETE 15 NEEDLES...... 211 true focus blood glucose strip.. 141 PE...... 143 ULTRA TRAK PRO TRUE METRIX AIR TYMLOS...... 149 BLOOD GLUCOSE...... 211 GLUCOSE METER...... 209 TYR EASY...... 143 ultracare insulin syringe...... 211 TRUE METRIX BLOOD TYSABRI...... 252 ultra-care lancets 30g...... 211 GLUCOSE TEST...... 141 TYVASO...... 92 ultracare pen needles...... 211 TRUE METRIX GO TYVASO REFILL...... 92 ULTRACET...... 31 GLUCOSE METER...... 209 TYVASO STARTER...... 92 ultra-comfort insulin syringe...211 TRUE METRIX METER.... 209 UBRELVY...... 216 ULTRALANCE...... 211 TRUEDRAW LANCING UCERIS...... 33, 106 ULTRAM...... 31 DEVICE...... 209 UDAMIN SP...... 229 ULTRA-THIN II AUTO TRUEPLUS 5-BEVEL PEN UDENYCA...... 164 LANCET...... 211 NEEDLES...... 209 ULORIC...... 156 ULTRA-THIN II INS SYR TRUEPLUS INSULIN ULTICARE ALCOHOL SHORT...... 211 SYRINGE...... 209 SWABS...... 209 ULTRA-THIN II INSULIN TRUEPLUS LANCETS 26G209 ULTICARE INSULIN SYRINGE...... 211 TRUEPLUS LANCETS 28G209 SAFETY SYR...... 210 ULTRA-THIN II LANCETS TRUEPLUS LANCETS 30G209 ULTICARE INSULIN ...... 211 TRUEPLUS LANCETS 33G209 SYRINGE...... 210 ULTRA-THIN II MINI PEN TRUEPLUS PEN NEEDLES ULTICARE MICRO PEN NEEDLE...... 211 ...... 209 NEEDLES...... 210 ULTRA-THIN II PEN TRUEPLUS SAFETY ULTICARE MINI PEN NEEDLE SHORT...... 211 LANCETS 28G...... 209 NEEDLES...... 210 ULTRA-THIN II PEN NEEDLES...... 211 298 ULTRATRAK ACTIVE...... 211 UNISTIK SAFETY value plus lancet standard 21g.213 ULTRATRAK PRO...... 211 LANCETS 30G...... 213 value plus lancets super thin.... 213 ULTRATRAK PRO TEST.. 141 UNISTIK TOUCH SAFETY valumark lancet ultra thin 28g 213 ULTRATRAK ULTIMATE LANC 21G...... 213 valumark pen needles...... 213 MONITOR...... 211 UNISTIK TOUCH SAFETY Vanatol Lq...... 26 ULTRATRAK ULTIMATE LANC 23G...... 213 vancomycin hcl...... 68 TEST...... 141 UNISTIK TOUCH SAFETY VANCOMYCIN+SYRSPEN ULTRAVATE...... 129 LANC 28G...... 213 D SF...... 68 UNIFINE PENTIPS...... 212 UNISTIK TOUCH SAFETY Vandazole...... 261 UNIFINE PENTIPS PLUS.. 212 LANC 30G...... 213 VANISHPOINT INSULIN UNIFINE SAFECONTROL UNISTRIP1 GENERIC...... 141 SYRINGE...... 213 PEN NEEDLE...... 212 Unithroid...... 256 VANOS...... 130 UNILET COMFORTOUCH UNIVERSAL 1 LANCETS Vanoxide-Hc...... 130 LANCET...... 212 THIN 26G...... 213 VANTAS...... 77 UNILET EXCELITE...... 212 UNIVERSAL 1 LANCETS VARIBAR HONEY...... 141 UNILET EXCELITE II...... 212 THIN 33G...... 213 VARIBAR NECTAR...... 141 UNILET G.P. LANCET...... 212 UNIVERSAL 1 LANCETS VARIBAR PUDDING...... 141 UNILET G.P. SUPERLITE ULTRA THIN...... 213 VARIBAR THIN HONEY.. 141 LANCET...... 212 up & up glucose...... 56 VARIBAR THIN LIQUID.. 141 UNILET GP 28 ULTRA UPTRAVI...... 92 VARISOFT INFUSION SET THIN...... 212 Uredeb...... 129 ...... 213 UNILET LANCET...... 212 URESOL...... 129 VAROPHEN...... 130 UNILET MICRO-THIN 33G Uretron D/S...... 68 VARUBI (180 MG DOSE)..... 59 ...... 212 Uribel...... 68 VASCEPA...... 63 UNILET SUPERLITE URIMAR-T...... 68 VASCULERA...... 143 LANCET...... 212 urin ds...... 68 VASOSTRICT...... 149 UNILET SUPER-THIN 30G uro-458...... 68 VAXCHORA...... 260 ...... 212 uro-mp...... 68 vb6 p5p...... 143 UNILET ULTRA-THIN urosex...... 229 v-c forte...... 229 28G...... 212 UROXATRAL...... 156 VCF VAGINAL UNISTIK 1...... 212 ursodiol...... 154 CONTRACEPTIVE...... 261 UNISTIK 2...... 212 Ustell...... 68 VECAMYL...... 66 UNISTIK 2 COMFORT...... 212 UTIBRON NEOHALER...... 40 VECTICAL...... 130 UNISTIK 2 EXTRA...... 212 uticap...... 68 vegetable capsule #0 green...... 246 UNISTIK 2 NEONATAL.... 212 Utira-C...... 68 vegetable capsule #0 white...... 246 UNISTIK 2 NORMAL...... 212 Utrona-C...... 68 vegetable capsule #00 white....246 UNISTIK 2 SUPER...... 212 valacyclovir hcl...... 86 vegetable capsule #1 white...... 246 UNISTIK 3...... 212 VALCHLOR...... 130 vegetable capsule #2 white...... 246 UNISTIK 3 COMFORT...... 212 VALCYTE...... 86 vegetable capsule #3 white...... 246 UNISTIK 3 EXTRA...... 212 valganciclovir hcl...... 86 vegetable capsule #4 white...... 246 UNISTIK 3 GENTLE...... 212 valproic acid...... 45 VEKLURY...... 86 UNISTIK 3 NEONATAL.... 212 valsartan...... 66 VELETRI...... 92 UNISTIK 3 NORMAL...... 212 valsartan-hydrochlorothiazide...66 Velivet...... 103 UNISTIK CZT COMFORT.212 VALTOCO 10 MG DOSE...... 45 VELPHORO...... 154 UNISTIK CZT NORMAL...212 VALTOCO 15 MG DOSE...... 45 VELTASSA...... 220 UNISTIK PRO SAFETY VALTOCO 20 MG DOSE...... 45 VELTIN...... 130 LANCET...... 213 VALTOCO 5 MG DOSE...... 45 VEMLIDY...... 87 UNISTIK SAFETY VALTREX...... 86 VENCLEXTA...... 77 LANCETS 28G...... 213 value health insulin syringe..... 213 VENCLEXTA STARTING value plus glucose...... 56 PACK...... 77 299 VENELEX...... 130 virt-fefa plus...... 164 VOGELXO...... 33 VENIPUNCTURE PX1 Virt-Gard...... 164 VOGELXO PUMP...... 32 PHLEBOTOMY...... 130 virt-nate dha...... 230 vol-plus...... 231 venlafaxine hcl...... 49 virt-phos 250 neutral...... 218 vol-tab rx...... 231 venlafaxine hcl er...... 48 virt-pn dha...... 230 VOLTAREN...... 130 VENTAVIS...... 92 virt-pn plus...... 230 voriconazole...... 60 VENTOLIN HFA...... 40 virtussin a/c...... 108 VOSEVI...... 87 veracolate...... 168 virtussin dac...... 108 VOTRIENT...... 77 verapamil hcl...... 90 VISCO-3...... 232 vp fc kit...... 130 verapamil hcl er...... 90 VISTOGARD...... 58 vp insulin syringe...... 213 verasens blood glucose meter...213 Vita S Forte...... 230 vp-heme ob + dha...... 231 verasens blood glucose system.213 Vitacel...... 230 vp-pnv-dha...... 231 verasens blood glucose test...... 142 VITAFOL GUMMIES...... 230 VPRIV...... 164 VERDESO...... 130 VITAFOL STRIPS...... 230 vp-vite rx...... 231 VEREGEN...... 130 VITAFOL ULTRA...... 230 VRAYLAR...... 82 VERSACLOZ...... 82 VITAFOL-NANO...... 230 VSL#3 DS...... 57 VERSAFREE...... 246 VITAFOL-OB...... 230 VUMERITY...... 252 VERSAPLUS...... 246 VITAFOL-OB+DHA...... 230 VUSION...... 130 VERZENIO...... 77 VITAFOL-ONE...... 230 Vyfemla...... 104 VESICARE...... 260 Vitamax Pediatric...... 230 VYLEESI...... 252 vexasyn...... 130 VITAMEDMD ONE Vylibra...... 104 V-GO 20...... 213 RX/QUATREFOLIC...... 230 VYNDAMAX...... 92 V-GO 30...... 213 VITAMEDMD REDICHEW VYNDAQEL...... 92 V-GO 40...... 213 RX...... 230 VYVANSE...... 18 VIAGRA...... 92 VITAMEZ...... 164 VYZULTA...... 241 VIBERZI...... 154 vita-min...... 230 walgreens adv travel lancets....214 VIBRAMYCIN...... 255 vitamin d (ergocalciferol)...... 263 WALGREENS LANCETS...214 Vic-Forte...... 229 vitamin k1...... 263 walgreens lancets micro thin... 214 VICTOZA...... 56 vitamins acd-fluoride...... 230 walgreens lancets super thin....214 VIDA MIA UNIFINE VITAPEARL...... 230 WALGREENS THIN PENTIPS...... 213 vitasure...... 230 LANCETS...... 214 Vienva...... 103 VITATRUE...... 230 WALGREENS ULTRA vigabatrin...... 45 VITRAKVI...... 77 THIN LANCETS...... 214 Vigadrone...... 45 VIVA DHA...... 231 warfarin sodium...... 41 VIIBRYD...... 49 VIVAGUARD INO WAVESENSE AMP...... 214 VIIBRYD STARTER PACK.49 GLUCOSE METER...... 213 WEBCOL ALCOHOL PREP Vilamit Mb...... 68 VIVAGUARD INO TEST LARGE...... 214 Vilevev Mb...... 68 STRIPS...... 142 WEBCOL ALCOHOL PREP VIMIZIM...... 149 VIVAGUARD LANCETS... 213 MEDIUM...... 214 VIMOVO...... 24 VIVAGUARD LANCING wegmans unifine pentips plus.. 214 VIMPAT...... 46 DEVICE...... 213 WELLMIND MENTAL VINATE DHA RF...... 229 VIVELLE-DOT...... 151 FOCUS...... 220 VINATE II...... 229 VIVITROL...... 58 WELLMIND VERTIGO...... 220 VINATE ONE...... 230 VIVLODEX...... 24 Wera...... 104 VIOKACE...... 144 VIVOTIF...... 260 WESTHROID...... 256 viorele...... 104 VIZIMPRO...... 77 wheat germ oil...... 263 VIRACEPT...... 87 VOCAL POINT BLOOD WIDE-SEAL DIAPHRAGM VIREAD...... 87 GLUCOSE SYS...... 213 60...... 214 virt-c dha...... 230 VOCAL POINT BLOOD WIDE-SEAL DIAPHRAGM virt-caps...... 230 GLUCOSE TEST...... 142 65...... 214 300 WIDE-SEAL DIAPHRAGM XEROFORM OIL xvite...... 231 70...... 214 EMULSION GAUZE...... 130 XYNTHA...... 160 WIDE-SEAL DIAPHRAGM XEROFORM OIL XYNTHA SOLOFUSE...... 160 75...... 214 EMULSION STRIP...... 131 XYOSTED...... 33 WIDE-SEAL DIAPHRAGM XEROFORM OIL ROLL XYREM...... 252 80...... 214 4"X9'...... 131 xyzbac...... 143 WIDE-SEAL DIAPHRAGM XEROFORM PETROLAT YAZ...... 104 85...... 214 GAUZE 1"X8"...... 131 yl folic acid...... 164 WIDE-SEAL DIAPHRAGM XEROFORM PETROLAT YONSA...... 77 90...... 214 GAUZE 5"X9"...... 131 YOSPRALA...... 160 WIDE-SEAL DIAPHRAGM XEROFORM PETROLAT YUPELRI...... 40 95...... 214 PATCH 2"X2"...... 131 YUTIQ...... 241 WILATE...... 160 XEROFORM PETROLAT Yuvafem...... 261 WITEPSOL...... 246 PATCH 4"X4"...... 131 zaclir cleansing...... 131 womans laxative...... 168 XEROFORM zafirlukast...... 40 WP THYROID...... 256 PETROLATUM ROLL zaleplon...... 166 wpr plus wound healing system130 4"X9'...... 131 zalvit...... 231 Wymzya Fe...... 104 XEROSTOMIA RELIEF zanabin hydrogel...... 131 XADAGO...... 79 SPRAY...... 222 Zarah...... 104 XALIX...... 130 XGEVA...... 149 ZATEAN-PN DHA...... 231 XALKORI...... 77 XHANCE...... 233 ZATEAN-PN PLUS...... 231 XANAX...... 35 XIFAXAN...... 68 ZAVESCA...... 164 XANAX XR...... 35 XIGDUO XR...... 56 Zebutal...... 26 XAQUIL XR...... 143 XIIDRA...... 241 ZEGERID...... 259 XARELTO...... 41 XIMINO...... 255 ZEJULA...... 77 XARELTO STARTER XOFIGO...... 77 zelac...... 57 PACK...... 41 XOFLUZA (40 MG DOSE)... 87 ZELAPAR...... 79 XATMEP...... 77 XOFLUZA (80 MG DOSE)... 87 ZELBORAF...... 77 XCOPRI...... 46 XOLAIR...... 40 ZELNORM...... 154 XCOPRI (250 MG DAILY XOLEGEL...... 131 ZEMAIRA...... 254 DOSE)...... 46 XOLEGEL COREPAK...... 131 ZEMBRACE SYMTOUCH. 216 XCOPRI (350 MG DAILY XOLEGEL DUO/HEAD & Zenatane...... 131 DOSE)...... 46 SHOULDERS...... 131 ZENPEP...... 144 XELJANZ...... 24 XOLEGEL DUO/XOLEX... 131 Zenzedi...... 19 XELJANZ XR...... 24 XOPENEX HFA...... 40 ZENZEDI...... 19 XELODA...... 77 XOSPATA...... 77 ZEPOSIA...... 252 XELPROS...... 241 XPOVIO (100 MG ONCE ZEPOSIA 7-DAY STARTER XENICAL...... 18 WEEKLY)...... 77 PACK...... 252 XENLETA...... 68 XPOVIO (60 MG ONCE ZEPOSIA STARTER KIT... 253 xenon xe 133...... 142 WEEKLY)...... 77 ZETIA...... 63 XEOMIN...... 234 XPOVIO (80 MG ONCE ZETONNA...... 233 XEPI...... 130 WEEKLY)...... 77 ZIANA...... 131 XERAC AC...... 130 XPOVIO (80 MG TWICE zidovudine...... 87 XERALUX...... 130 WEEKLY)...... 77 ZILACAINE PATCH...... 131 XERAVA...... 255 XRYLIX...... 131 zileuton er...... 40 XERESE...... 130 XTAMPZA ER...... 31 ZILRETTA...... 106 XERMELO...... 154 XTANDI...... 77 zinc sulfate...... 218 XEROFORM OIL XULANE...... 104 ZINGO...... 168 EMULSION 2"X2"...... 130 XULTOPHY...... 56 ZINPLAVA...... 243 XURIDEN...... 149 ZIOPTAN...... 241 301 ziprasidone hcl...... 82 ZIPSOR...... 24 ZIRGAN...... 241 ZOHYDRO ER...... 31 ZOLADEX...... 77 zoledronic acid...... 149 ZOLINZA...... 78 zolmitriptan...... 216 zolpidem tartrate...... 166 zolpidem tartrate er...... 166 ZOLPIMIST...... 166 ZOMIG...... 216 ZONEGRAN...... 46 zonisamide...... 46 ZONTIVITY...... 160 ZORBTIVE...... 149 ZORVOLEX...... 24 Zovia 1/35E (28)...... 104 ZOVIRAX...... 87, 131 ZTLIDO...... 131 ZUBSOLV...... 31 ZULRESSO...... 49 Zumandimine...... 104 ZUPLENZ...... 59 ZYCLARA...... 131 ZYCLARA PUMP...... 131 ZYDELIG...... 78 ZYFLO...... 40 ZYKADIA...... 78 ZYLET...... 241 ZYMAXID...... 241 ZYPITAMAG...... 63 ZYPREXA RELPREVV...... 82 zyvit...... 143 ZYVOX...... 68

302