2018 Formulary Drug List

For Federal Employee Health Benefits Program Employees

GlobalHealth, Inc. 701 NE 10th Street, Suite 300 MFEHBDF18 Lists Updated 11/2017 Oklahoma City, OK 73104-5403 www.GlobalHealth.com/fehb HELPFUL NUMBERS Plan Issuer: Medication Prior Authorizations: GlobalHealth, Inc. [email protected] PO Box 2393 918.878.7361 Oklahoma City, OK 73101-2393 Mail Claims to: GlobalHealth Customer Care, Language Magellan Rx Management, LLC Assistance, and Disease Management: PO Box 85042 [email protected] Richmond, VA 23261-5042 405.280.2989 (local) 1.877.280.2989 (toll-free) Mail Order Pharmacy: 711 (TTY) Magellan Rx Management, LLC Monday – Friday, 9 a.m. – 5 p.m. Central 1.800.424.1789 (toll-free) www.GlobalHealth.com/fehb 711 (TTY) P.O. Box 620968 Behavioral Health and Substance Use: Orlando, FL 32862 [email protected] 405.280.2989 (local) 24/7 Nurse Help Line: 1.877.280.2989 (toll-free) Information Line 711 (TTY) 1.877.280.2993 (toll-free) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/fehb GlobalHealth Compliance Officer: 1.877.280.5852 (toll-free) Pharmacy Benefits Manager: 405.280.5852 Magellan Rx Management, LLC [email protected] Customer Service 1.800.424.1789 (toll-free) GlobalHealth Privacy Officer: 711 (TTY) 405.280.5524 [email protected]

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IMPORTANT INFORMATION This formulary applies to Members who enrolled through the Federal Employees Health Benefits Program.

Member Materials Your Member materials are three booklets. Each one has a different purpose. These documents are important legal documents. Keep them in a safe place. Booklet Purpose FEHB Brochure  Tells you about your benefits. o What benefits are covered and how much you will pay. o How they are covered (including limitations and exclusions). o How to use them. Physicians and Health  Lists our Network of doctors, Facilities, and pharmacies. Providers Directory  Tells you if a Facility is preferred or not. (“Provider Directory”) Formulary Drug List  Lists drugs we cover. for Federal Employee  Tells you what Tier a drug is in. Health Benefits  Tells you if there are any rules to getting a drug. Program Employees (“Drug Formulary” or “Formulary”)

Member materials are available on our website. Contact Customer Care for printed copies at no charge. But, be aware that the most current Drug Formulary and Provider Directory lists are on the website.

When this document says “we”, “us”, or “our”, it means GlobalHealth, Inc.

For specific questions about your coverage, please call the phone number printed on your Member ID card.

Preferred Drugs Preferred drugs are listed in this Drug Formulary. Drugs on the list are selected based on quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to develop the Formulary, which includes generics and brand name drugs that are approved by the U. S. Food and Drug Administration (“FDA”).

For the Member: Generic drugs contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size.

For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.

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THIS DOCUMENT LIST IS EFFECTIVE AS OF THE DATE ON THE COVER. THIS LIST IS SUBJECT TO CHANGE. You may find the most current list, including any Utilization Management requirements, on our website. Contact Customer Care for printed copies.

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TIER DESCRIPTION

0 Health Care Reform

1 Generics

2 Preferred Brands

3 Non-Preferred Brands

4 Preferred Specialty

5 Specialty

TYPE DESCRIPTION

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

Your provider is required to get prior authorization before you fill PA Prior Authorization your prescription, which ensures appropriate use of the selected drug. Without prior approval, we may not cover this drug.

In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before you move up a “step” to other drug options.

GL Gender Limit This prescription drug is restricted for a single gender. .

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

C Custom This drug has unique restrictions.

Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions. Some examples of the diseases include; multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.

This medication is not on our drug list. Click on the THERAPEUTIC MED Medical Drug CLASS or sub class to find covered alternative medications. If you have questions, please contact member services.

PAGE 1 LAST UPDATED 10/2017 The Affordable Care Act (ACA) requires certain preventive generic HCR Health Care Reform Products products to be covered at zero dollar copay. This does not include plans that are grandfathered.

PS Preferred Specialty Preferred Specialty.

HCG High Cost Generic High Cost Generic.

Generic drugs available at the lowest cost. Please note the specific strengths and dosage forms; other strengths and/or dosage forms LCG Low Cost Generic of these products would be subject to the standard generic Cost- share.

PAGE 2 LAST UPDATED 10/2017 LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ADRENERGIC AGENTS

ALPHA AND BETA ADRENERGIC AGONIST(RESPR)

epinephrine 1 mg/ml ampul 1 HCG

epinephrine (0.15 mg auto-injct, 0.3 mg auto-inject) 1 QL 2 / fill

epinephrine (0.1 mg/ml syringe, 1 mg/ml vial) 1 SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR)

ADVAIR DISKUS 2 QL 2 / day

ADVAIR HFA 2 QL 0.4 / day

albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 ml sol, sulf 2 mg/5 ml syrup, sulfate er 4 mg tab, sulfate er 8 mg tab) 1 albuterol sulfate (2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, sulfate 2 mg tab, sulfate 4 mg tab, 5 mg/ml solution) 1 LCG

ANORO ELLIPTA 2 QL 2 / day

BREO ELLIPTA 2 QL 2 / day

COMBIVENT RESPIMAT 2 QL 0.267 / day

QL 0.04 / day fluticasone-salmeterol 1 AL At least 12 yrs old

ipratropium-albuterol 1

levalbuterol concentrate 3 HCG

levalbuterol hcl (0.31 mg/3 ml sol, 0.63 mg/3 ml sol, 1.25 mg/3 ml sol) 3 HCG metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syr, 20 mg tablet) 1

PROAIR HFA 2 QL .8 / day

QL 0.07 / day PROAIR RESPICLICK 2 AL At least 12 yrs old

SEREVENT DISKUS 2 QL 2 / day

PAGE 3 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL .144 / day STRIVERDI RESPIMAT 2 ST

SYMBICORT 2 QL 0.4 / day terbutaline sulfate (2.5 mg tab, 5 mg tab) 1 LCG terbutaline sulf 1 mg/ml vial 1

VENTOLIN HFA 2 QL 1.5 / day

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)

NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS doxazosin mesylate (1 mg tab, 2 mg tab, 4 mg tab, 8 mg tab) 1 prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) 1 terazosin hcl 1 NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS dihydroergotamine mesylate (1 mg/ml am, 1 mg/ml vl) 1

QL 8 / 30 days dihydroergotamine 4 mg/ml spry 3 HCG ergoloid mesylates 1 mg tab 1 ergotamine-caffeine 1 phenoxybenzamine hcl 10 mg cap 1 phentolamine 5 mg vial 1 phentolamine-alprostadil 1 SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT

QL 1 / day alfuzosin hcl er 1 GL Male carvedilol 1

QL 1 / day dutasteride-tamsulosin 1 GL Male

PAGE 4 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1

QL 1 / day RAPAFLO 2 GL Male tamsulosin hcl 1 QL 2 / day

ANALGESICS AND ANTIPYRETICS

ANALGESICS AND ANTIPYRETICS, MISC.

QL 10 / day acetamin-caff-dihydrocod 320.5 1 AL At least 18 yrs old acetamin-caff-dihydrocod 325 1 QL 10 / day acetaminophen-codeine (acetamin-codein 300-30 mg/12.5, QL 139 / day 1 acetaminop-codeine 120-12 mg/5) AL At least 18 yrs old

QL 22 / day acetaminophen-cod #2 tablet 1 AL At least 18 yrs old

QL 12 / day acetaminophen-cod #3 tablet 1 AL At least 12 yrs old

QL 6 / day acetaminophen-cod #4 tablet 1 AL At least 12 yrs old

QL 6 / day BUPAP 3 HCG butalb-acetaminoph-caff-codein 1 QL 6 / day butalb-caff-acetaminoph-codein 1 QL 6 / day

QL 6 / day butalbital-acetaminophn 50-300 3 HCG

QL 6 / day butalbit-acetaminophen-caff cp 3 HCG

PAGE 5 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS butalbital-acetaminophen-caffe (50-300-40, 50-325-40) 1 QL 6 / day

QL 6 / day CAPACET 3 HCG

QL 12 / day ENDOCET 1 AL At least 18 yrs old

QL 6 / day ESGIC CAPSULE 3 HCG gabapentin (100 mg capsule, 300 mg capsule, 400 mg capsule) 1 QL 9 / day gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) 1 QL 72 / day gabapentin 600 mg tablet 1 QL 6 / day gabapentin 800 mg tablet 1 QL 5 / day

QL 100 / day hydrocodone-acetamin 2.5-167/5 1 AL At least 2 yrs old hydrocodone-acetaminophen (hydrocodon-acetamin 7.5- QL 140 / day 325/15, hydrocodone-acetamin 2.5-108/5, hydrocodone- 1 acetamin 5-217/10) AL At least 2 yrs old

QL 20 / day hydrocodon-acetaminoph 2.5-325 1 AL At least 18 yrs old

QL 8 / day hydrocodon-acetaminoph 7.5-325 1 AL At least 18 yrs old

QL 6 / day hydrocodone-acetamin 7.5-325 1 AL At least 18 yrs old hydrocodone-acetaminophen (hydrocodon-acetaminoph 7.5- 300, hydrocodon-acetaminophen 5-300, hydrocodon- QL 13 / day 1 acetaminophn 10-300, hydrocodone-acetamin 7.5-300, AL At least 18 yrs old hydrocodone-acetamin 10-300 mg) hydrocodone-acetaminophen (hydrocodon-acetaminophen 5- QL 12 / day 325, hydrocodon-acetaminophn 10-325, hydrocodone- 1 acetamin 10-325 mg) AL At least 18 yrs old

PAGE 6 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS isomethept-caff-acetaminophen 1 isomethept-dichloralp-acetamin 1

QL 12 / day LORCET 1 AL At least 18 yrs old

QL 12 / day LORCET HD 1 AL At least 18 yrs old

QL 6 / day LORCET PLUS 1 AL At least 18 yrs old

LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MG QL 8 / day 1 TABLET) AL At least 18 yrs old

QL 6 / day MARGESIC 3 HCG

MARTEN-TAB 1 QL 6 / day

NODOLOR 1

QL 12 / day NORCO 5-325 TABLET 1 AL At least 18 yrs old

QL 62 / day oxycodone-acetaminophn 5-325/5 1 AL At least 18 yrs old

QL 4 / day oxycodon-acetaminophen 7.5-300 1 AL At least 18 yrs old oxycodone-acetaminophen (oxycodon-acetaminophen 2.5-325, QL 12 / day oxycodon-acetaminophen 7.5-325, oxycodone-acetaminophen 1 5-325, oxycodone-acetaminophen 10-325) AL At least 18 yrs old

QL 3 / day oxycodone-acetaminophen 10-300 1 AL At least 18 yrs old

QL 7 / day oxycodone-acetaminophen 5-300 1 AL At least 18 yrs old

PAGE 7 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

TENCON 1 QL 6 / day

QL 8 / day tramadol hcl-acetaminophen 1 AL At least 18 yrs old

QL 20 / day VERDROCET 1 AL At least 18 yrs old

QL 8 / day VICODIN 1 AL At least 18 yrs old

QL 13 / day VICODIN ES 1 AL At least 18 yrs old

QL 13 / day VICODIN HP 1 AL At least 18 yrs old

QL 6 / day ZEBUTAL 3 HCG

OPIATE AGONISTS alfentanil 500 mcg/ml ampul 1

QL 6 / day asa-butalb-caffeine-codeine 1 AL At least 18 yrs old

QL 6 / day ASCOMP WITH CODEINE 1 AL At least 18 yrs old

ASTRAMORPH-PF (1 MG/ML AMPUL, 10 MG/10 ML VIAL) 1 QL 50 / day

QL 100 / day ASTRAMORPH-PF (1 MG/2 ML AMPULE, 5 MG/10 ML VIAL) 3 HCG belladonna-opium 16.2-30 supp 1 QL 2 / day belladonna-opium 16.2-60 supp 1 QL 1 / day

QL 6 / day butalbital compound-codeine 1 AL At least 18 yrs old

PAGE 8 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carisoprodol compound-codeine 1 QL 21 / day carisoprodol-aspirin-codeine 1 QL 21 / day

QL 6 / day codeine sulfate 1 AL At least 18 yrs old

DURAMORPH 10 MG/10 ML AMPUL 1 QL 5 / day

QL 10 / day DURAMORPH 5 MG/10 ML AMPUL 3 HCG

QL 2 / day EMBEDA 2 PA fentanyl (12 mcg/hr patch, 25 mcg/hr patch, 50 mcg/hr patch, QL 0.5 / day 1 75 mcg/hr patch, 100 mcg/hr patch) PA

QL 0.5 / day fentanyl (37.5 mcg/hr patch, 62.5 mcg/hr patch, 87.5 mcg/hr patch) 3 PA HCG fentanyl citrate (0.05 mg/ml ampul, 100 mcg/2 ml ampul, 100 mcg/2 ml vial, 1,000 mcg/20 ml ampul, 1,000 mcg/20 ml vial) 1

QL 4 / day fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate 200 mcg, PA 3 citrate 400 mcg, citrate 600 mcg, citrate 800 mcg) AL At least 18 yrs old HCG fentanyl citrate (250 mcg/5 ml vial, 2,500 mcg/50 ml vial) 1 fentanyl-bup-ns 4 mcg/ml-0.1% 1 QL 96 / day fentanyl-bupivacaine-0.9% nacl (2 mcg-0.1%, 2 mcg-0.125%) 1 QL 192 / day fentanyl 2mcg-bupiv 0.0625%-ns 1 QL 192 / day fentanyl 2 mcg-ropiv 0.15%-ns 1 QL 192 / day

QL 20 / day hydrocod-cpm-pseudoephedrine 1 AL At least 18 yrs old

PAGE 9 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 5 / day hydrocodone-ibuprofen (2.5-200, 7.5-200, 10-200) 1 AL At least 16 yrs old

QL 6 / day hydrocodone-ibuprofen 5-200 mg 3 AL At least 16 yrs old HCG

QL 2 / day hydromorphone er 3 PA HCG hydromorphone hcl 1 mg/ml amp 1 QL 13 / day

QL 1 / day hydromorphone hcl 10 mg/ml amp 1 AL At least 18 yrs old

QL 13 / day hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 1 AL At least 18 yrs old hydromorphone 3 mg suppos 1 QL 4 / day

QL 50 / day hydromorphone 0.5 mg/0.5 ml 3 AL At least 18 yrs old HCG

QL 6 / day hydromorphone 2 mg/ml carpujct 1 AL At least 18 yrs old

QL 3 / day hydromorphone 4 mg/ml carpujct 1 AL At least 18 yrs old

QL 13 / day hydromorphone hcl (1 mg/ml carpujct, 1 mg/ml syringe) 1 AL At least 18 yrs old

QL 6 / day hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg tablet) 1 AL At least 18 yrs old hydromorphone hcl (10 mg/ml vial, hcl 10 mg/ml vl, 50 mg/5 1 / day ml vial, 500 mg/50 ml via) 1 QL

PAGE 10 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydromorphone hcl (2 mg/ml vial, hcl 2 mg/ml amp) 1 QL 6 / day

QL 6 / day IBUDONE 5-200 MG TABLET 3 AL At least 16 yrs old HCG

QL 4 / day levorphanol 2 mg tablet 1 AL At least 18 yrs old

QL 50 / day meperidine 10 mg/ml cartrdge 1 AL At least 18 yrs old

QL 50 / day meperidine 50 mg/5 ml solution 1 AL At least 18 yrs old

QL 5 / day meperidine 100 mg tablet 1 AL At least 18 yrs old

QL 10 / day meperidine 50 mg tablet 1 AL At least 18 yrs old

QL 5 / day meperidine 100 mg/ml vial 1 AL At least 18 yrs old

QL 20 / day meperidine 25 mg/ml vial 1 AL At least 18 yrs old

QL 10 / day meperidine 50 mg/ml vial 1 AL At least 18 yrs old

QL 8 / day methadone 10 mg/5 ml solution 1 PA

QL 18 / day methadone 5 mg/5 ml solution 1 PA

QL 2 / day methadone hcl (10 mg/ml oral conc, hcl 10 mg tablet) 1 PA

PAGE 11 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day methadone hcl 5 mg tablet 1 PA methadone hcl 10 mg/ml vial 1 QL 2 / day

QL 2 / day METHADONE INTENSOL 1 PA

QL 3 / day morphine sulf 10 mg/0.7 ml syr 3 PA HCG morphine sulf 10 mg/5 ml soln 1 QL 25 / day morphine sulf 20 mg/5 ml soln 1 QL 13 / day morphine sulf 10 mg suppos 1 QL 5 / day morphine sulf 30 mg suppos 1 QL 2 / day morphine sulf 5 mg suppos 1 QL 10 / day morphine sulfate (20 mg suppos, 100 mg/5 ml soln) 1 QL 3 / day

QL 5 / day morphine 10 mg/ml syringe 1 PA

QL 25 / day morphine 2 mg/ml syringe 1 PA

QL 13 / day morphine 4 mg/ml syringe 1 PA

QL 10 / day morphine 5 mg/ml syringe 1 PA

QL 3 / day morphine sulfate ir 15 mg tab 1 AL At least 18 yrs old

QL 2 / day morphine sulfate ir 30 mg tab 1 AL At least 18 yrs old

PAGE 12 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 100 / day morphine 0.5 mg/ml vial 3 PA HCG

QL 50 / day morphine 1 mg/ml vial p-f 1 PA

QL 3 / day morphine 15 mg/ml vial 1 PA

QL 6 / day morphine 8 mg/ml vial 1 PA morphine sulfate er (er 10 mg cap, er 20 mg cap, er 50 mg cap, QL 2 / day 1 er 100 mg cap) PA morphine sulfate er (er 30 mg cap, er 45 mg cap, er 60 mg cap, QL 1 / day 1 er 75 mg cap, er 80 mg cap, er 90 mg cap, er 120 mg cap) PA morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er 60 mg QL 3 / day 1 tablet, er 100 mg tablet, er 200 mg tablet) PA oxycodone hcl 100 mg/5 ml soln 1 QL 2 / day oxycodone hcl 5 mg/5 ml soln 1 QL 33 / day oxycodon 10 mg/0.5 ml oral syr 1 QL 4 / day oxycodone hcl (5 mg capsule, 5 mg tablet, 15 mg tablet, 20 mg QL 8 / day 1 tablet, 30 mg tablet) AL At least 18 yrs old oxycodone hcl 10 mg tablet 1 QL 8 / day

QL 3 / day oxycodone hcl er 3 PA HCG

QL 7 / day oxycodone hcl-aspirin 1 AL At least 18 yrs old

PAGE 13 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day oxycodone hcl-ibuprofen 1 AL At least 18 yrs old

QL 12 / day oxymorphone hcl 3 AL At least 18 yrs old HCG

QL 2 / day PA oxymorphone hcl er 3 AL At least 18 yrs old HCG

QL 30 / day promethazine vc-codeine 1 AL At least 6 yrs old

QL 30 / day promethazine-phenyleph-codeine 1 AL At least 6 yrs old

QL 5 / day REPREXAIN 10-200 MG TABLET 1 AL At least 16 yrs old

QL 8 / day tramadol hcl 50 mg tablet 1 AL At least 18 yrs old

QL 1 / day tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mg tablet, hcl er 100 mg capsule, hcl er 100 mg tablet, hcl er 150 PA 3 mg capsule, hcl er 200 mg capsule, hcl er 200 mg tablet, hcl er AL At least 18 yrs old 300 mg capsule, hcl er 300 mg tablet) HCG

XYLON 10 1 OPIATE PARTIAL AGONISTS buprenorphine hcl (0.3 mg/ml syring, 0.3 mg/ml vial) 1 QL 17 / day

QL 3 / day buprenorphine hcl (2 mg tablet, 8 mg tablet) 1 PA

QL 3 / day buprenorphine-naloxone 3 PA HCG

PAGE 14 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.3 / day butorphanol 10 mg/ml spray 1 AL At least 18 yrs old

QL 7 / day butorphanol 1 mg/ml vial 1 AL At least 18 yrs old

QL 4 / day butorphanol 2 mg/ml vial 1 AL At least 18 yrs old nalbuphine hcl (10 mg/ml ampul, 100 mg/10 ml vial) 1 QL 5 / day nalbuphine hcl (20 mg/ml ampul, 200 mg/10 ml vial) 1 QL 3 / day

QL 12 / day pentazocine-naloxone hcl 1 AL At least 12 yrs old

QL 3 / day SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 2 PA

QL 2 / day SUBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 2 PA

ANOREXIGENIC AGENTS

AMPHETAMINE DERIVATIVES

QL 3 / day diethylpropion 25 mg tablet 1 PA AL At least 16 yrs old

QL 1 / day diethylpropion hcl er 1 PA

QL 3 / day LOMAIRA 1 PA AL At least 17 yrs old

QL 1 / day phendimetrazine er 105 mg cap 1 PA

PAGE 15 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day phendimetrazine 35 mg tablet 1 PA

QL 1 / day phentermine hcl (15 mg capsule, 30 mg capsule) 1 PA

QL 2 / day phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1 PA AL At least 17 yrs old

ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS

AMPHETAMINES

QL 3 / day benzphetamine hcl 25 mg tablet 1 PA AL At least 12 yrs old

QL 3 / day benzphetamine hcl 50 mg tablet 1 PA

QL 6 / day DEXEDRINE 10 MG TABLET 3 HCG

QL 2 / day DEXEDRINE 5 MG TABLET 3 HCG

QL 60 / day dextroamphetamine 5 mg/5 ml 3 HCG

QL 6 / day dextroamphetamine 10 mg tab 3 HCG

QL 2 / day dextroamphetamine 5 mg tab 3 HCG

QL 5 / day d-amphetamine er 10 mg capsule 3 HCG

PAGE 16 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day d-amphetamine er 15 mg capsule 3 HCG

QL 2 / day d-amphetamine er 5 mg capsule 3 HCG dextroamphetamine-amphet er 1 QL 2 / day dextroamphetamine-amphetamine 1 QL 2 / day methamphetamine hcl 1 QL 5 / day

VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MG 2 QL 1 / day CAPSULE) VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 1 / day MG TABLET, 50 MG TABLET, 60 MG TABLET) 2 QL

QL 6 / day ZENZEDI 10 MG TABLET 3 HCG

QL 2 / day ZENZEDI 5 MG TABLET 3 HCG

RESPIRATORY AND CNS STIMULANTS caffeine and sodium benzoate 1 caffeine cit 60 mg/3 ml oral 1 dexmethylphenidate 10 mg tab 1 QL 2 / day dexmethylphenidate hcl (2.5 mg tab, 5 mg tab) 1 QL 3 / day

QL 2 / day dexmethylphenidate er 20 mg cp 3 HCG dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 15 mg QL 1 / day 3 cp, er 25 mg cp, er 30 mg cp, er 35 mg cp, er 40 mg cp) HCG

QL 3 / day METADATE ER 1 LCG

PAGE 17 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day methylphenidate er (er 20 mg cap, er 40 mg cap) 3 HCG

QL 2 / day methylphenidate er 30 mg cap 3 HCG

QL 2 / day methylphenidate er (er 18 mg tab, er 27 mg tab, er 36 mg tab) 3 HCG

QL 1 / day methylphenidate er 54 mg tab 3 HCG methylphenidate er 10 mg tab 1 QL 5 / day methylphenidate er 20 mg tab 1 QL 3 / day methylphenidate 10 mg/5 ml sol 1 QL 30 / day methylphenidate 5 mg/5 ml soln 1 QL 60 / day methylphenidate 2.5 mg chew tb 1

QL 5 / day methylphenidate 10 mg tablet 1 LCG

QL 3 / day methylphenidate 5 mg tablet 1 LCG methylphenidate hcl (5 mg chew tab, 10 mg chew tab, 20 mg 3 / day tablet) 1 QL

QL 1 / day methylphenidate hcl cd 3 HCG methylphenidate hcl er (er 10 mg cap, er 50 mg cap, er 60 mg QL 1 / day 3 cap) HCG

QL 1 / day methylphenidate la (20 mg cap, 40 mg cap) 3 HCG

QL 2 / day methylphenidate la 30 mg cap 3 HCG

PAGE 18 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methylphenidate la 60 mg cap 1 QL 1 / day

WAKEFULNESS-PROMOTING AGENTS

QL 1 / day armodafinil 3 PA HCG

QL 1 / day modafinil 1 PA

ANTI-INFECTIVE AGENTS

ANTHELMINTICS ivermectin 3 mg tablet 1 PA

URINARY ANTI-INFECTIVES

AZUPHEN MB 1 HYOPHEN 1

INDIOMIN MB 3 HCG me-naphos-mb-hyo 1 1 methenamine hippurate 1 methenamine mandelate (md 1 gm tablet, md 500 mg tablet) 1 nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr 50 mg cap, mcr 100 mg cap) 1 nitrofurantoin mono-macro 1 PHOSPHASAL 1 trimethoprim 100 mg tablet 1 UR N-C 1

URELLE 3 HCG

URETRON D-S 1

QL 4 / day URIBEL 3 HCG

PAGE 19 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS URIMAR-T 1 URIN D.S. 1

URO-458 3 HCG

URO-BLUE 1

URO-L 3 HCG

UROPHEN MB 1 URYL 1 USTELL 1 UTA 1 UTIRA-C 1 ANTI-INFECTIVES (EENT)

ANTIBACTERIALS (EENT)

AK-POLY-BAC 1 QL 0.434 / day bacitracin 500 unit/gm ophth 1 QL 0.434 / day bacitracin-polymyxin 1 QL 0.434 / day

BACTROBAN NASAL 2

CIPRODEX 2 QL 0.257 / day ciprofloxacin 0.2% otic soln 1 QL 0.567 / day ciprofloxacin 0.3% eye drop 1 QL 0.767 / day doxycycline hyclate 20 mg tab 1 erythromycin 0.5% eye ointment 1 QL 0.54 / day gatifloxacin 1 QL 0.36/day

GENTAK 1 QL 0.54 / day gentamicin sulfate (0.3% drops, 3 mg/ml drops) 1 QL 2.143 / day gentamicin 0.3% eye ointment 1 QL 0.54 / day

PAGE 20 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ILOTYCIN 1 QL 0.54 / day levofloxacin 0.5% eye drops 1 QL 0.767 / day

MOXEZA 2 QL 0.434 / day moxifloxacin 0.5% eye drops 1 QL 0.434 / day

NEO-POLYCIN 1 QL 0.124 / day

NEO-POLYCIN HC 1 QL 4 / fill neomycin-bacitracin-poly-hc 1 QL 4 / fill neomycin-bacitracin-polymyxin 1 QL 0.124 / day neomyc-polym-dexameth eye drop 1 QL 5 / fill neomyc-polym-dexamet eye ointm 1 QL 4 / fill neomycin-polymyxin-gramicidin 1 QL 1.47 / day neomycin-poly-hc eye drops 1 QL 10/ fill neomycin-polymyxin-hc ear susp 1 QL 10 / fill neomycin-polymyxin-hydrocort 1 QL 10 / fill ofloxacin 0.3% ear drops 1 QL 10 / 30 days ofloxacin 0.3% eye drops 1 QL 1.47 / day

POLYCIN 1 QL 0.434 / day polymyxin b sul-trimethoprim 1 QL 1.47 / day sulfacetamide 10% eye drops 1 QL 5 / fill sulfacetamide 10% eye ointment 1 QL 4 / fill sulfacetamide-prednisolone 1 QL 5 / fill tobramycin 0.3% eye drops 1 QL 2.143 / day tobramycin-dexamethasone 1 QL 5 / fill

PAGE 21 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VIGAMOX 2 QL 0.434 / day

ANTIVIRALS (EENT) trifluridine 1% eye drops 1 EENT ANTI-INFECTIVES, MISCELLANEOUS

ACETASOL HC 1 acetic acid 2% ear solution 1 acetic acid-aluminum 1 chlorhexidine 0.12% rinse 1 hydrocortisone-acetic acid 1 PAROEX 1 PERIOGARD 1 povidone iodine 5% eye drop 1 ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

CLEOCIN 100 MG VAGINAL OVULE 2 CLINDACIN ETZ 1% PLEDGET 1 CLINDACIN P 1 clindamax 1

QL 1.5 / day clindamycin phos-benzoyl perox 3 HCG

QL 2 / day clindamycin phos-tretinoin 3 HCG clindamycin phosphate 1% foam 1 QL 1.667 / day clindamycin ph 1% gel 1 QL 75 / 30 days clindamycin phosphate (ph 1% solution, phos 1% pledget, phosp 1% lotion, 2% vaginal cream) 1

PAGE 22 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clindamycin-benzoyl peroxide (clinda-benzoyl 1-5% pump, QL 1.667 / day 3 clindamycin-benzoyl 1-5%) HCG

ERY 1 erythromycin 2% gel 1 QL 1 / day erythromycin (pledgets, solution) 1

QL 1.60 / day erythromycin-benzoyl peroxide 3 HCG gentamicin sulfate (cream, ointment) 1 metronidazole (0.75% cream, 0.75% lotion, topical 0.75% gl, topical 1% gel) 3 HCG metronidazole (top 1% gel pump, vaginal 0.75% gl) 1 mupirocin (cream, ointment) 1

QL 1.5 / day NEUAC GEL 3 HCG

ROSADAN (CREAM, GEL) 3 HCG

VANDAZOLE 1 ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) acyclovir 5% ointment 3 HCG

QL 0.167 / day ZOVIRAX 5% CREAM 2 PA AL At least 12 yrs old

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

AVAR CLEANSER 3 HCG

AVAR-E 3 HCG

AVAR-E GREEN 3 HCG

BP 10-1 1

PAGE 23 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CLEANSING WASH 1 DERMAZENE 1 guaiacol 1 hydrocortisone-iodoquinol 1 hydrocortisone-iodoquinol-aloe 1 LUGOL'S STRONG IODINE SOLUTION 1 phenol liquified 1

ROSANIL 3 HCG

QL 12 / day SEB-PREV 3 HCG selenium sulfide (2.25% shampoo, 2.5% lotion) 1 silver nitrate (0.5% soln, 10% ointment, 25% solution, 50% solution) 1 silver sulfadiazine 1% cream 1 sodium sulfacetamide (sod sulfacetam clnsng gel, sodium QL 12 / day 3 sulfacetamide wash) HCG sod sulfacetamide 10% shampoo 1 QL 8 / day sod sulfacet-sulfur 10-5% clsr 3 HCG sodium sulf-sulfur cleanser 1 sulfacetamide-sulfur 10-5% crm 3 HCG

PAGE 24 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium sulfacetamide-sulfur (sod sulface-sulf 9.8-4.8% clsr, sod sulface-sulfur 9-4.5% wash, sod sulfacet-sulfur 10-2% clsr, sod sulfacet-sulfur 10-4% pad, sod sulfacet-sulfur 10-5% lotn, sod sulfacetamide-sulfur foam, sod sulfacetamide-sulfur lotn, sod 1 sulfacetamide-sulfur susp, sodium sulfacet-sulfur wash, sulfacetamide-sulfur 8-4% susp, sulfacetamide-sulfur 10-2% crm)

SSD 1

SSS 10-5 CREAM 3 HCG

SSS 10-5 FOAM 1 sulfacetamide sodium (sod top susp, sodium lotn) 1 QL 4 / day sulfacetamide sodium-sulfur 1

SULFACLEANSE 8-4 3 HCG

THERMAZENE 1 ZENCIA 1 SCABICIDES AND PEDICULICIDES lindane (lotion, shampoo) 1 malathion 3 HCG permethrin 5% cream 1 spinosad 3 HCG

ANTI-INFLAMMATORY AGENTS (EENT)

CORTICOSTEROIDS (EENT) budesonide 32 mcg nasal spray 1 QL 0.574 / day dexamethasone 0.1% eye drop 1 QL 10 / fill flunisolide 0.025% spray 1 QL .834 / day fluocinolone acetonide oil 3 HCG fluorometholone 1 QL 10 / fill

PAGE 25 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluticasone prop 50 mcg spray 1 QL 0.6 / day

QL 0.567 / day mometasone furoate 50 mcg spry 3 HCG prednisolone acetate 1 QL 21 / fill prednisolone sod 1% eye drop 1 triamcinolone 55 mcg nasal spr 1 QL 0.55 / day

EENT ANTI-INFLAMMATORY AGENTS, MISC.

RESTASIS 2 PA

RESTASIS MULTIDOSE 2 PA

EENT NONSTEROIDAL ANTI-INFLAM. AGENTS

ACUVAIL 2 QL 1 / day bromfenac sodium 0.09% eye drp 1 QL 8 / rx diclofenac 0.1% eye drops 1 QL 5 / fill flurbiprofen sodium 1 QL 3/ fill ketorolac 0.4% ophth solution 1 QL 5 / fill ketorolac 0.5% ophth solution 1 QL 15 / 30 days

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)

LEUKOTRIENE MODIFIERS montelukast sodium (4 mg granules, 4 mg tab chew, 5 mg tab 1 / day chew, 10 mg tablet) 1 QL zafirlukast 1 QL 2 / day

MAST-CELL STABILIZERS cromolyn 20 mg/2 ml neb soln 1 cromolyn 4% eye drops 1 QL 10 / fill

PAGE 26 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cromolyn 100 mg/5 ml oral conc 1 ANTIANEMIA DRUGS

IRON PREPARATIONS

FEROCON 1 FEROTRINSIC 1 FERROCITE PLUS 1 HEMATINIC PLUS 1

HEMATINIC WITH FOLIC ACID 3 HCG

HEMAX 3 HCG

HEMOCYTE-F 3 HCG

INFED 5 S multivitamin-iron-fluoride 1

GL Female OBSTETRIX ONE 1 HCG

POLYSACCHARIDE IRON FORTE 1

TRIFERIC 272 MG POWDER PACKET 5 S

VYNATAL-FA 1 GL Female

ANTIARRHYTHMIC AGENTS

ANTIARRHYTHMICS, MISCELLANEOUS

DIGITEK 1 DIGOX 1 digoxin (0.25 mg/ml syringe, 500 mcg/2 ml ampule) 1 digoxin (0.05 mg/ml solution, 0.125 mg tablet, 0.25 mg tablet, 125 mcg tablet, 250 mcg tablet) 1

LANOXIN 500 MCG/2 ML AMPULE 2 LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG TABLET, 250 MCG TABLET) 2

PAGE 27 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LANOXIN PEDIATRIC 2 magnesium sulfate (syringe, vial) 1 CLASS IA ANTIARRHYTHMICS disopyramide phosphate 1 NORPACE CR 100 MG CAPSULE 2 procainamide 500 mg/ml vial 1 quinidine gluc er 324 mg tab 1 quinidine gluc 80 mg/ml vial 1 quinidine sulfate (sulf er 300 mg tab, sulfate 200 mg tab, sulfate 300 mg tab) 1 CLASS IB ANTIARRHYTHMICS

DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2 DILANTIN-125 2 lidocaine hcl (1% syringe, 2% vial) 1 MED Medical Drug lidocaine hcl (2% 100 mg/5 ml, 2% 40 mg/2 ml, 2% 40 mg/2 ml vl, 30 mg/3 ml syr, 100 mg/10 ml syr) 1 mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule) 1

PHENYTEK 2 phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4 ml susp, 125 mg/5 ml susp) 1 phenytoin sodium extended 1 CLASS IC ANTIARRHYTHMICS flecainide acetate 1 propafenone hcl 1 propafenone hcl er 3 HCG

CLASS II ANTIARRHYTHMICS acebutolol hcl (200 mg capsule, 400 mg capsule) 1

PAGE 28 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS atenolol (25 mg tablet, 50 mg tablet) 1 LCG atenolol 100 mg tablet 1 atenolol-chlorthalidone 1 betaxolol hcl (10 mg tablet, 20 mg tablet) 1 bisoprolol fumarate 1 bisoprolol-hydrochlorothiazide 1 LCG

HEMANGEOL 5 S metoprolol succinate 1 metoprolol tartrate (25 mg tab, 50 mg tab) 1 LCG metoprolol tartrate (37.5 mg tb, 75 mg tab) 1 metoprolol tartrate 100 mg tab 1 metoprolol-hydrochlorothiazide 1 nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) 1 nadolol-bendroflumethiazide 1 pindolol 1 propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml soln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mg tablet) 1 propranolol hcl er 1 propranolol-hydrochlorothiazid 1 SORINE 1 sotalol 1 sotalol af 1 timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 CLASS III ANTIARRHYTHMICS amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1 CORDARONE 2 dofetilide 5 S

PAGE 29 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PACERONE 1

TIKOSYN 5 S

CLASS IV ANTIARRHYTHMICS

CARTIA XT 1 QL 1 / day

DILT XR 120 MG CAPSULE 1 QL 1 / day

DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) 1 diltiazem 12hr er 1 diltiazem 24hr cd (24hr 180 mg cap, 24hr 240 mg cap, 24hr 300 mg cap, 24hr 360 mg cap) 1 diltiazem 24hr cd 120 mg cap 1 QL 1 / day diltiazem 24hr er (24hr er 240 mg cap, 24hr er 300 mg cap, 24hr er 360 mg cap, 24hr er 420 mg cap) 1 diltiazem 24hr er (24hr er 120 mg cap, 24hr er 180 mg cap, 1 / day 24hr er 300 mg tab, 24hr er 360 mg tab, 24hr er 420 mg tab) 1 QL diltiazem 24hr er 180 mg tab 1 QL 3 / day diltiazem 24hr er 240 mg tab 1 QL 2 / day diltiazem er (er 120 mg capsule, er 180 mg capsule) 1 QL 1 / day diltiazem er 240 mg capsule 1 diltiazem 90 mg tablet 1 diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg tablet) 1 QL 4 / day

MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MG TABLET) 1 QL 1 / day

MATZIM LA 180 MG TABLET 1 QL 3 / day

MATZIM LA 240 MG TABLET 1 QL 2 / day

TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE) 1 QL 1 / day

TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 MG CAPSULE) 1

PAGE 30 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS verapamil er (er 120 mg capsule, er 120 mg tablet, er 180 mg 1 / day capsule, er 180 mg tablet, er 240 mg capsule, er 240 mg tablet) 1 QL verapamil er pm 1 QL 1 / day verapamil 360 mg cap pellet 1 QL 1 / day verapamil 40 mg tablet 1 verapamil hcl (80 mg tablet, 120 mg tablet) 1 QL 3 / day verapamil sr 1 QL 1 / day

ANTIBACTERIALS

AMINOGLYCOSIDES amikacin sulfate (1 gram/4 ml vial, 500 mg/2 ml vial, 1,000 mg/4 ml vl) 1

PA BETHKIS 4 S PS gentamicin sulfate (20 mg/2 ml vial, ped 20 mg/2 ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 800 mg/20 ml vial) 1

PA KITABIS PAK 5 S neomycin 500 mg tablet 1 paromomycin 250 mg capsule 1 streptomycin sulf 1 gm vial 1

PA TOBI 5 S

PA TOBI PODHALER 5 S

PA tobramycin (300 mg/5 ml ampule, pak 300 mg/5 ml) 5 S

PAGE 31 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tobramycin sulfate (1.2 gm vial, 1.2 gram/30 ml vial, 10 mg/ml vial, 40 mg/ml vial, 80 mg/2 ml vial, 1,200 mg/30 ml vial) 1 MACROLIDES

ERYPED 200 2 erythromycin (dr 250 mg cap, ec 250 mg cap) 1 erythromycin (250 mg, 500 mg) 3 HCG erythromycin 200 mg/5 ml gran 1 erythromycin es 400 mg tab 3 HCG

QUINOLONES ciprofloxacin 250 mg/5 ml susp 1 QL 7 / day ciprofloxacin 500 mg/5 ml susp 1 QL 10 / day ciprofloxacin er 1,000 mg tab 1 QL 14 / 1 rx ciprofloxacin er 500 mg tablet 1 QL 28 / fill ciprofloxacin hcl (100 mg tab, 250 mg tab, 750 mg tab) 1 QL 2 / day

QL 2 / day ciprofloxacin hcl 500 mg tab 1 LCG levofloxacin (25 mg/ml solution, 250 mg/10 ml soln, 500 mg/20 ml soln) 1 levofloxacin (250 mg tablet, 500 mg tablet, 750 mg tablet) 1 QL 30 / fill moxifloxacin hcl 400 mg tablet 1 QL 21 / fill ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill

SULFONAMIDES (SYSTEMIC) sulfadiazine 500 mg tablet 1 sulfamethoxazole-tmp ds tablet 1 LCG sulfamethoxazole-trimethoprim (ss tablet, susp) 1

PAGE 32 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfasalazine 500 mg tablet 1 sulfasalazine dr 1 SULFATRIM 1 TETRACYCLINES

AVIDOXY 1 demeclocycline hcl 1 doxycycline hyclate (50 mg cap, 100 mg cap, 100 mg tab) 1

QL 7/ rx doxycycline hyc dr 200 mg tab 3 HCG doxycycline hyclate (dr 50 mg tab, dr 75 mg tab, dr 100 mg tab, dr 150 mg tab) 3 HCG doxycycline ir-dr 1 QL 1 / day doxycycline mono 150 mg cap 1 QL 30 / fill doxycycline monohydrate (25 mg/5 ml susp, mono 50 mg cap, mono 50 mg tablet, mono 75 mg capsule, mono 75 mg tablet, 1 mono 100 mg cap, mono 100 mg tablet, mono 150 mg tablet) minocycline hcl (50 mg capsule, hcl 50 mg tablet, 75 mg capsule, hcl 75 mg tablet, 100 mg capsule, hcl 100 mg tablet) 1

QL 3 / day minocycline er 45 mg tablet 3 HCG

QL 1 / day minocycline hcl er (er 90 mg tablet, er 135 mg tablet) 3 HCG

MONDOXYNE NL 1 MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1

PYLERA 2 QL 120 / 365 days

HCG tetracycline hcl (250 mg capsule, 500 mg capsule) 3 LCG

PAGE 33 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIBACTERIALS, MISCELLANEOUS

BACITRACINS

BACIIM 1 bacitracin (unit vial, units vial) 1 GLYCOPEPTIDES vancomycin hcl (125 mg capsule, 250 mg capsule) 3 HCG vancomycin 125 mg/2.5 ml oral 1 LINCOMYCINS clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg 4 / day capsule) 1 QL clindamycin palmitate hcl 1 QL 70/ day clindamycin pediatric 1 QL 70/ day clindamycin phosphate (9 g/60 ml vial, 300 mg/2 ml vl, 600 mg/4 ml vl, 900 mg/6 ml vl) 1 lincomycin hcl (3 gm/10 ml vial, 600 mg/2 ml vl) 1 QL 10 / day

OXAZOLIDINONES linezolid 100 mg/5 ml susp 1 QL 900 / rx linezolid 600 mg tablet 1 QL 2 / day

POLYMYXINS colistimethate 1 polymyxin b sulfate vial 1 RIFAMYCINS rifabutin 1 rifampin (150 mg capsule, 300 mg capsule) 1

PAGE 34 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTICHOLINERGIC AGENTS

ANTIMUSCARINICS/ANTISPASMODICS atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml abboject, 0.1 mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml vial, 8 mg/20 ml vial) 1

B-DONNA 1 belladonna-phenobarbital 1 chlordiazepoxide-clidinium 1 dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mg tablet) 1 LCG dicyclomine 20 mg/2 ml vial 1 diphenoxylate-atropine (diphenoxylat-atrop 2.5-0.025/5, diphenoxylate-atrop 2.5-0.025) 1

ED-SPAZ 3 HCG glycopyrrolate (1 mg tablet, 2 mg tablet) 1

QL 30 / day hydrocodone-homatropine mbr (soln, syrup) 1 AL At least 2 yrs old

QL 6 / day hydrocod-homatrop 5-1.5 mg tab 1 AL At least 6 yrs old

QL 30 / day HYDROMET 1 AL At least 2 yrs old hyoscyamine sulfate (0.125 mg tab sl, 0.125 mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab) 1 hyoscyamine 0.125 mg odt 3 HCG hyoscyamine sulfate er 1 hyoscyamine sulfate sr 1 HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1

INCRUSE ELLIPTA 2 QL 1 / day ipratropium br 0.02% soln 1 QL 12.5 / day

PAGE 35 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS methscopolamine bromide (2.5 mg tb, 5 mg tab) 1

NULEV 3 HCG

OSCIMIN 0.125 MG TABLET 1

OSCIMIN 0.125 MG ODT 3 HCG

OSCIMIN SL 1 OSCIMIN SR 1 PHENOHYTRO 1 propantheline 15 mg tablet 1 scopolamine 0.4 mg/ml vial 1

SPIRIVA 2 QL 1 / day

SPIRIVA RESPIMAT 2 QL 1 / day

STIOLTO RESPIMAT 2 QL 0.134 / day

SYMAX 3 HCG

SYMAX-SL 1 SYMAX-SR 1

QL 6 / day TUSSIGON 1 AL At least 6 yrs old

ANTIPARKINSONIAN AGENTS benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mg tablet) 1 benztropine mesylate (2 mg/2 ml ampule, 2 mg/2 ml vial) 1 trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elx, 5 mg tablet) 1 ANTICOAGULANTS

ANTICOAGULANTS, MISCELLANEOUS sodium citrate 4% soln 1 sodium citrate (lock flush, syringe) 1

PAGE 36 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COUMARIN DERIVATIVES

COUMADIN 2 JANTOVEN (1 MG TABLET, 2.5 MG TABLET, 3 MG TABLET, 4 MG TABLET, 5 MG TABLET) 1 LCG JANTOVEN (2 MG TABLET, 6 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 1 warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1 LCG warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mg tablet) 1 DIRECT FACTOR XA INHIBITORS

ARIXTRA (2.5 MG/0.5 ML SYRINGE, 5 MG/0.4 ML SYRINGE) 5 S

ARIXTRA (7.5 MG/0.6 ML SYRINGE, 10 MG/0.8 ML SYRINGE) 5 S fondaparinux 5 mg/0.4 ml syr 5 S fondaparinux sodium (2.5 mg/0.5 ml syr, 7.5 mg/0.6 ml syr, 10 mg/0.8 ml syr) 5 S

XARELTO STARTER PACK 2

XARELTO (10 MG TABLET, 20 MG TABLET) 2 QL 1 / day

XARELTO 15 MG TABLET 2 QL 2 / day

DIRECT THROMBIN INHIBITORS

IPRIVASK 5 S

PRADAXA 2 QL 2 / day

HEPARINS enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr, 60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe, 120 5 S mg/0.8 ml syr, 150 mg/ml syringe, 300 mg/3 ml vial)

PAGE 37 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 5 S 95,000 UNITS/3.8 ML VL) heparin sodium (2,000 unit/2 ml vial, 40,000 units/4 ml vial, 50,000 units/10 ml vl, 50,000 units/5 ml vial) 1 heparin sodium (5,000 unit/ 0.5 ml, 5,000 unit/0.5 ml, 5,000 unit/ml syr, 20,000 unit/ml vl) 1 LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300 5 S MG/3 ML VIAL) ANTICONVULSANTS

ANTICONVULSANTS, MISCELLANEOUS carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200 mg tablet) 1 carbamazepine er (er 100 mg cap, er 200 mg cap, er 300 mg cap) 1 carbamazepine er (er 100 mg tablet, er 200 mg tablet, er 400 mg tablet) 3 HCG

CARBATROL 2 DEPAKOTE ER 2 DEPAKOTE SPRINKLE 2 divalproex sodium (dr 125 mg cap sprnk, sod dr 125 mg tab, sod dr 250 mg tab, sod dr 500 mg tab) 1 divalproex sodium er 3 HCG

EPITOL 1 felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 ml susp) 1 GABITRIL (12 MG TABLET, 16 MG TABLET) 2 lamotrigine (5 mg disper tablet, 25 mg disper tab, 25 mg tablet, 25 mg tb start kit, 100 mg tablet, 150 mg tablet, 200 mg tablet) 1 lamotrigine (blue) 1

PAGE 38 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS lamotrigine (green) 1 lamotrigine (orange) 1 lamotrigine er 3 HCG lamotrigine odt 1 lamotrigine odt (blue) 1 lamotrigine odt (green) 1 lamotrigine odt (orange) 1 levetiracetam 500 mg/5 ml soln 1 QL 946 / 30 days levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mg tablet, 750 mg tablet, 1,000 mg tablet) 1 levetiracetam er 1 magnesium chl 200 mg/ml vial 1 oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5 ml susp, 600 mg tablet) 1

ROWEEPRA 1

QL 6 / day SABRIL (500 MG POWDER PACKET, 500 MG TABLET) 5 PA S

TEGRETOL XR 2 tiagabine hcl 1 TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 2 topiramate 15 mg sprinkle cap 1 LCG topiramate (25 mg sprinkle cap, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1 topiramate er 3 HCG valproic acid (250 mg capsule, 250 mg/5 ml soln, 500 mg/10 ml sol) 1

QL 6 / day vigabatrin 5 PA S

PAGE 39 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ZONEGRAN 2 zonisamide (25 mg capsule, 100 mg capsule) 1 zonisamide 50 mg capsule 1 LCG

BARBITURATES (ANTICONVULSANTS) phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elix, 20 mg/5 ml soln, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 1 64.8 mg tablet, 97.2 mg tablet, 100 mg tablet) phenobarbital sodium 1 primidone (50 mg tablet, 250 mg tablet) 1 BENZODIAZEPINES (ANTICONVULSANTS)

ATIVAN 4 MG/ML VIAL 1 clonazepam (2 mg odt, 2 mg tablet) 1 QL 10 / day clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mg odt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet, 1 mg dis tablet, 1 mg 1 QL 3 / day odt, 1 mg tablet) clorazepate 15 mg tablet 1 QL 6 / day clorazepate 3.75 mg tablet 1 QL 24 / day clorazepate 7.5 mg tablet 1 QL 12 / day diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20 mg 0.07 / day rectal gel syst) 1 QL diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml oral soln, 5 mg/5 ml solution, 5 mg/ml oral conc, 5 mg/ml vial, 10 mg tablet, 10 mg/2 ml carpuject, 10 mg/2 ml isecure, 10 mg/2 ml syringe, 50 1 mg/10 ml vial) lorazepam (2 mg tablet, 2 mg/ml oral concent) 1 QL 5 / day lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 3 / day lorazepam (2 mg/ml carpuject, 2 mg/ml syringe, 2 mg/ml vial, 4 mg/ml carpuject, 4 mg/ml vial, 20 mg/10 ml vial, 40 mg/10 ml 1 vial)

LORAZEPAM INTENSOL 1 QL 5 / day

PAGE 40 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET) 5 S

SUCCINIMIDES ethosuximide (250 mg capsule, 250 mg/5 ml soln) 1 ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 2 ANTIDEPRESSANTS

ANTIDEPRESSANTS, MISCELLANEOUS

QL 2 / day BUPROBAN 0 HCR bupropion hcl 100 mg tablet 1 QL 5 / day bupropion hcl 75 mg tablet 1 QL 6 / day bupropion hcl sr 100 mg tablet 1 QL 4 / day

QL 2 / day bupropion hcl sr 150 mg tablet 1 HCR bupropion hcl sr 200 mg tablet 1 QL 2 / day bupropion hcl xl 150 mg tablet 1 QL 3 / day bupropion hcl xl 300 mg tablet 1 QL 1 / day mirtazapine 7.5 mg tablet 1 QL 2 / day mirtazapine (15 mg odt, 15 mg tablet, 30 mg odt, 30 mg tablet, 1 / day 45 mg odt, 45 mg tablet) 1 QL MONOAMINE OXIDASE INHIBITORS phenelzine sulfate 15 mg tab 1 QL 6 / day rasagiline mesylate (0.5 mg tab, 1 mg tab) 1 selegiline hcl (5 mg capsule, 5 mg tablet) 1 tranylcypromine sulfate 1 QL 6 / day

PAGE 41 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR

QL 1 / day desvenlafaxine er (er 50 mg tab, er 50 mg tablet) 3 HCG

QL 1 / day desvenlafaxine er 100 mg tab 3 HCG

QL 1 / day desvenlafaxine fumarate er 3 HCG

QL 1 / day desvenlafaxine succinate er 3 HCG duloxetine hcl (dr 20 mg cap, dr 30 mg cap) 1 QL 1 / day duloxetine hcl (dr 40 mg cap, dr 60 mg cap) 1 QL 2 / day venlafaxine hcl (37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet) 1 venlafaxine hcl 25 mg tablet 1 LCG venlafaxine hcl er 75 mg cap 1 QL 3 / day venlafaxine hcl er (er 37.5 mg cap, er 37.5 mg tab, er 75 mg tab, 1 / day er 150 mg cap, er 150 mg tab, er 225 mg tab) 1 QL SELECTIVE-SEROTONIN REUPTAKE INHIBITORS citalopram hbr 10 mg/5 ml soln 1 QL 20 / day

QL 1 / day citalopram hbr (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 LCG escitalopram oxalate 5 mg/5 ml 1 QL 20 / day escitalopram 20 mg tablet 1 QL 1 / day escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day fluoxetine dr 1 QL 0.142 / day

QL 1 / day fluoxetine hcl 10 mg capsule 1 LCG

PAGE 42 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day fluoxetine hcl 20 mg capsule 1 LCG fluoxetine hcl 40 mg capsule 1 QL 2 / day fluoxetine 20 mg/5 ml solution 1 QL 20 / day

QL 1.5 / day fluoxetine hcl 10 mg tablet 1 LCG fluoxetine hcl 20 mg tablet 1 QL 4 / day

QL 1.5 / day fluoxetine hcl 60 mg tablet 3 HCG fluvoxamine maleate (25 mg tab, 50 mg tab) 1 QL 1 / day fluvoxamine maleate 100 mg tab 1 QL 3 / day

QL 2 / day fluvoxamine maleate er 3 HCG

QL 1 / day olanzapine-fluoxetine hcl 3 AL At least 10 yrs old HCG paroxetine cr (cr 25 mg tablet, cr 37.5 mg tablet) 1 QL 2 / day paroxetine cr 12.5 mg tablet 1 QL 1 / day paroxetine er (er 25 mg tablet, er 37.5 mg tablet) 1 QL 2 / day paroxetine er 12.5 mg tablet 1 QL 1 / day

QL 1.5 / day paroxetine hcl 10 mg tablet 1 LCG

QL 1 / day paroxetine hcl 20 mg tablet 1 LCG paroxetine hcl 30 mg tablet 1 QL 2 / day

PAGE 43 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS paroxetine hcl 40 mg tablet 1 QL 1 / day paroxetine mesylate 1 QL 1 / day sertraline 20 mg/ml oral conc 1 QL 10 / day

QL 1.5 / day sertraline hcl (25 mg tablet, 50 mg tablet) 1 LCG

QL 2 / day sertraline hcl 100 mg tablet 1 LCG

SEROTONIN MODULATORS nefazodone hcl 100 mg tablet 1 QL 6 / day nefazodone hcl 150 mg tablet 1 QL 4 / day nefazodone hcl 200 mg tablet 1 QL 3 / day nefazodone hcl 250 mg tablet 1 QL 2.5 / day nefazodone hcl 50 mg tablet 1 QL 12 / day

QL 4 / day trazodone 100 mg tablet 1 LCG

QL 2 / day trazodone 150 mg tablet 1 LCG trazodone 300 mg tablet 1 QL 1 / day

QL 3 / day trazodone 50 mg tablet 1 LCG

TRICYCLICS, OTHER NOREPI-RU INHIBITORS amitriptyline hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 100 mg tab, 150 mg tab) 1 LCG amoxapine 1 chlordiazepoxide-amitriptyline 1

PAGE 44 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) 3 HCG desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) 3 HCG doxepin hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 100 mg capsule) 1 LCG doxepin hcl (10 mg/ml oral conc, 75 mg capsule, 150 mg capsule) 1 imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1 LCG imipramine pamoate 3 HCG maprotiline hcl 1 nortriptyline hcl (10 mg/5 ml sol, hcl 10 mg cap, hcl 25 mg cap, hcl 50 mg cap, hcl 75 mg cap) 1 perphenazine-amitriptyline 1 protriptyline hcl 1 trimipramine maleate 1 ANTIDIABETIC AGENTS

ALPHA-GLUCOSIDASE INHIBITORS acarbose 100 mg tablet 1 QL 3 / day acarbose 25 mg tablet 1 QL 12 / day acarbose 50 mg tablet 1 QL 6 / day miglitol 1 QL 3 / day

AMYLINOMIMETICS

SYMLINPEN 120 2 QL 0.4 / day

SYMLINPEN 60 2 QL 0.2 / day

ANTIDIABETIC AGENTS, MISCELLANEOUS

PA KORLYM 5 S

PAGE 45 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

WELCHOL 3.75G PACKET 2 QL 1 / day

WELCHOL 625 MG TABLET 2 QL 6 / day

BIGUANIDES

QL 3 / day ACTOPLUS MET XR 15-1,000 MG TB 2 ST

QL 1 / day ACTOPLUS MET XR 30-1,000 MG TB 2 ST

QL 2 / day AVANDAMET 2 PA glipizide-metformin (2.5-500 mg, 5-500 mg) 1 QL 4 / day glipizide-metformin 2.5-250 mg 1 QL 8 / day

QL 8 / day glyburid-metformin 1.25-250 mg 1 LCG glyburide-metformin hcl (2.5-500 mg, 5-500 mg) 1 QL 4 / day

QL 2 / day INVOKAMET 2 ST

QL 2 / day INVOKAMET XR 2 ST

QL 2 / day JANUMET 2 ST

QL 2 / day JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET) 2 ST

QL 1 / day JANUMET XR 100-1,000 MG TABLET 2 ST

QL 2 / day JENTADUETO 2 ST

PAGE 46 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day JENTADUETO XR 2 ST

QL 2.5 / day metformin hcl 1,000 mg tablet 1 LCG

QL 5 / day metformin hcl 500 mg tablet 1 LCG

QL 3 / day metformin hcl 850 mg tablet 1 LCG

QL 5 / day metformin hcl er 500 mg tablet 1 C Only Glucophage ER generic covered LCG

QL 3 / day metformin hcl er 750 mg tablet 1 C Only Glucophage ER generic covered

QL 3 / day pioglitazone-metformin 3 HCG repaglinide-metformin hcl 1 QL 5 / day

QL 2 / day SYNJARDY 2 ST

SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5- QL 2 / day 2 1,000 MG TAB) ST

QL 1 / day SYNJARDY XR 25-1,000 MG TABLET 2 ST

DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

QL 1 / day JANUVIA 2 ST

PAGE 47 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day TRADJENTA 2 ST

INCRETIN MIMETICS

QL 0.15 / day BYDUREON 2 ST

QL .15 / day BYDUREON PEN 2 ST

QL 0.8 / day BYETTA 10 MCG DOSE PEN INJ 2 ST

QL 0.04 / day BYETTA 5 MCG DOSE PEN INJ 2 ST

QL 0.6 / day SOLIQUA 100-33 2 PA

QL 0.08 / day TRULICITY 2 ST

QL 0.3 / day VICTOZA 2-PAK 2 ST

QL 0.3 / day VICTOZA 3-PAK 2 ST

INSULINS

HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL) 2 HUMALOG KWIKPEN U-100 2 HUMALOG KWIKPEN U-200 2 HUMALOG MIX 50-50 2 HUMALOG MIX 50-50 KWIKPEN 2 HUMALOG MIX 75-25 2

PAGE 48 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HUMALOG MIX 75-25 KWIKPEN 2 HUMULIN R U-500 2 HUMULIN R U-500 KWIKPEN 2 LANTUS 2 LANTUS SOLOSTAR 2 TOUJEO SOLOSTAR 2 MEGLITINIDES nateglinide 1 QL 3 / day repaglinide (0.5 mg tablet, 1 mg tablet) 1 QL 4 / day repaglinide 2 mg tablet 1 QL 8 / day

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

QL 1 / day INVOKANA 2 ST

QL 1 / day JARDIANCE 2 ST

SULFONYLUREAS chlorpropamide 100 mg tablet 1 chlorpropamide 250 mg tablet 1 QL 3 / day glimepiride 1 LCG glipizide (5 mg tablet, 10 mg tablet) 1 LCG glipizide er 1 LCG glipizide xl 1 LCG glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet) 1 LCG glyburide micronized 1 LCG pioglitazone-glimepiride 1 QL 1 / day

PAGE 49 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS tolazamide 250 mg tablet 1 QL 4 / day tolazamide 500 mg tablet 1 QL 2 / day tolbutamide 1 QL 6 / day

THIAZOLIDINEDIONES

QL 3 / day AVANDIA 2 MG TABLET 2 PA

QL 2 / day AVANDIA 4 MG TABLET 2 PA

QL 1 / day AVANDIA 8 MG TABLET 2 PA pioglitazone hcl 1 QL 1 / day

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

QL 0.15 / day AKYNZEO 5 PA S granisetron hcl 1 mg tablet 1 QL 6 / 30 days ondansetron hcl (4 mg/2 ml isecure, hcl 4 mg/2 ml amp, hcl 4 mg/2 ml syr, hcl 4 mg/2 ml vial) 5 S ondansetron 4 mg/5 ml solution 1 QL 20 / day

QL 24 / 30 days ondansetron hcl (4 mg tablet, 8 mg tablet) 1 Max allowable- 3/day C with max of 24 / 30 days ondansetron hcl 24 mg tablet 1 QL 3 days

QL 24 / 30 days ondansetron odt 1 Max allowable- 3/day C with max of 24 / 30 days

PAGE 50 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.144 / day SANCUSO 5 S

ANTIEMETICS, MISCELLANEOUS aprepitant 125-80-80 mg pack 1 QL 3/ fill aprepitant (40 mg capsule, 125 mg capsule) 1 QL 0.08 / day aprepitant 80 mg capsule 1 QL 0.15 / day

QL 0.67 / day CESAMET 5 PA S

QL 5 / day dronabinol 3 HCG scopolamine 1 TRANSDERM-SCOP 2

QL 0.15 / day VARUBI 5 PA S

ANTIHISTAMINES (GI DRUGS)

COMPAZINE 25 MG SUPPOSITORY 3 HCG

COMPRO 3 HCG dimenhydrinate 50 mg/ml vial 1 meclizine hcl (12.5 mg tablet, 25 mg tablet) 1 prochlorperazine 3 HCG prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vl) 1 prochlorperazine maleate (5 mg tablet, 10 mg tab) 1 trimethobenzamide 300 mg cap 1

PAGE 51 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIFUNGAL (SYSTEMIC)

ALLYLAMINES terbinafine hcl 250 mg tablet 1 ANTIFUNGALS, MISCELLANEOUS griseofulvin (125 mg/5 ml susp, micro 500 mg tab) 3 HCG griseofulvin ultramicrosize 1 LUGOL'S SOLUTION 1 strong iodine 1 triacetin 1 AZOLES fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet, 100 mg tablet, 200 mg tablet) 1

QL 0.4 / day fluconazole 150 mg tablet 1 LCG itraconazole 100 mg capsule 1 ketoconazole 200 mg tablet 1

QL 20 / day voriconazole 40 mg/ml susp 3 HCG

QL 4 / day voriconazole (50 mg tablet, 200 mg tablet) 3 HCG

POLYENES amphotericin b 50 mg vial 1 nystatin (100,000 unit/ml susp, 500,000 unit oral tab, 500,000 unit/5 ml sus, 50,000,000 units pwd, 150,000,000 units pwd, 1 500,000,000 units pwd) PYRIMIDINES flucytosine (250 mg capsule, 500 mg capsule) 1

PAGE 52 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)

ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) naftifine hcl 1 ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC

EXODERM 1 AZOLES (SKIN AND MUCOUS MEMBRANE) clotrimazole (1% cream, 1% solution, 10 mg troche) 1 clotrimazole-betamethasone (crm, lot) 1 econazole nitrate 1% cream 3 HCG ketoconazole (cream, foam, shampoo) 1 oxiconazole nitrate 3 HCG

QL 1.5 / day terconazole (0.4% cream, 0.8% cream, 80 mg suppository) 1 GL Female

QL 1.5 / day zazole 1 GL Female

HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)

CICLODAN 0.77% CREAM 1

CICLODAN 8% SOLUTION 1 QL 0.22 / day ciclopirox (0.77% cream, 0.77% gel, 0.77% topical susp, 1% shampoo) 1 ciclopirox 8% solution 1 QL 0.22 / day

POLYENES (SKIN AND MUCOUS MEMBRANE)

NYAMYC 1 NYATA 100,000 UNIT/GM POWDER 1 nystatin (unit/gm cream, unit/gm powd, units/gm oint) 1 nystatin-triamcinolone (cream, ointm) 3 HCG

PAGE 53 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NYSTOP 1 ANTIGLAUCOMA AGENTS

ALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P 0.1% DROPS 2 QL 0.4 / day brimonidine tartrate (tartrate 0.15% drp, 0.2% eye drop) 1 QL 0.4 / day

COMBIGAN 2 QL 0.334 / day

BETA-ADRENERGIC BLOCKING AGENTS (EENT) betaxolol hcl 0.5% eye drop 1 QL 0.54 / day carteolol hcl 1 QL 0.334 / day dorzolamide-timolol 1 QL 0.334 / day levobunolol hcl 1 QL 0.4 / day metipranolol 1 QL 0.334 / day timolol 0.5% eye drops 1 QL 0.334 / day timolol maleate (0.25% eye drops, 0.25% gel-solution, 0.25% 0.286 / day gfs gel-solution, 0.5% gel-solution, 0.5% gfs gel-solution) 1 QL CARBONIC ANHYDRASE INHIBITORS (EENT) acetazolamide er 500 mg cap 3 HCG acetazolamide (125 mg tablet, 250 mg tablet) 1 acetazolamide sodium 1

AZOPT 2 QL 0.334 / day dorzolamide hcl 1 QL 0.4 / day methazolamide (25 mg tablet, 50 mg tablet) 1 MIOTICS pilocarpine hcl (1% drops, 2% drops, 4% drops) 1 QL 0.54 / day

PAGE 54 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROSTAGLANDIN ANALOGS bimatoprost 0.03% eye drops 1 QL 0.13 / day bimatoprost 0.03% eyelash soln 1 latanoprost 0.005% eye drops 1 QL 0.13 / day

LUMIGAN 2 QL 0.13 / day

TRAVATAN Z 2 QL 0.167 / day travoprost 1 QL 0.167 / day

ANTIHEMORRHAGIC AGENTS

HEMOSTATICS desmopressin acetate (0.01% solution, 0.01% spray, 0.1 mg/ml sol, acetate 0.1 mg tb, acetate 0.2 mg tb) 1 desmopressin acetate (ac 4 mcg/ml ampul, ac 4 mcg/ml vial, 40 mcg/10 ml vial) 1

RECOTHROM (5,000 UNIT VIAL, 20,000 UNIT VIAL) 5 S

STIMATE 5 S

QL 6 / day tranexamic acid 650 mg tablet 1 GL Female

ANTIHISTAMINE DRUGS

FIRST GENERATION ANTIHISTAMINES

ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1 AL At least 2 yrs old carbinoxamine maleate (4 mg/5 ml liquid, maleate 4 mg tab) 1 AL At least 2 yrs old clemastine fum 2.68 mg tab 1 AL At least 2 yrs old cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 mg/10 ml At least 2 yrs old syrp) 1 AL diphenhydramine hcl (12.5 mg/5 ml, 25 mg/10 ml) 1 diphenhydramine hcl (50 mg/ml syrng, 50 mg/ml vial) 1

PAGE 55 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SECOND GENERATION ANTIHISTAMINES cetirizine hcl 1 QL 10 / day desloratadine (2.5 mg odt, 5 mg odt, 5 mg tablet) 1 QL 1 / day fexofenadine hcl 180 mg tablet 1 QL 1 / day fexofenadine hcl 30 mg tablet 1 fexofenadine hcl 60 mg tablet 1 QL 2 / day levocetirizine 2.5 mg/5 ml sol 1 QL 30 / day levocetirizine 5 mg tablet 1 QL 1 / day

ANTIHISTAMINES (RESPIRATORY TRACT AGNTS)

FIRST GENERATION ANTIHIST.(RESPIR TRACT)

AL At least 2 yrs old BROMFED DM 3 HCG

AL At least 2 yrs old brompheniramine-pseudoephed-dm 3 HCG

CENTERGY 1 CENTERGY DM 1

QL 10 / day hydrocodone-chlorpheniramne er 1 AL At least 6 yrs old

AL At least 2 yrs old promethazine 25 mg tablet 1 LCG promethazine hcl (6.25 mg/5 ml syrp, 12.5 mg tablet, 50 mg At least 2 yrs old tablet) 1 AL promethazine hcl (25 mg/ml ampul, 25 mg/ml syringe, 25 At least 2 yrs old mg/ml vial, 50 mg/ml ampul, 50 mg/ml vial) 1 AL promethazine vc 1 promethazine-codeine 1

PAGE 56 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 2 yrs old promethazine-dm 1 LCG promethazine-phenylephrine 1 SECOND GENERATION ANTIHIST(RESPIR TRACT)

DYMISTA 2 QL 0.8 / day

ANTIHYPOGLYCEMIC AGENTS

GLYCOGENOLYTIC AGENTS

GLUCAGEN 2 GLUCAGON EMERGENCY KIT 2 glucagon hcl 3 HCG

ANTILIPEMIC AGENTS

ANTILIPEMIC AGENTS, MISCELLANEOUS

QL 1 / day JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) 5 PA S

QL 2 / day JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) 5 PA S

QL 0.15 / day KYNAMRO 5 PA S

QL 2 / day niacin er (er 750 mg tablet, er 1,000 mg tablet) 3 HCG

QL 3 / day niacin er 500 mg tablet 3 HCG

QL 4 / day omega-3 acid ethyl esters 3 HCG

PAGE 57 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day TRIKLO 3 HCG

BILE ACID SEQUESTRANTS cholestyramine powder 1 QL 24 / day cholestyramine packet 1 QL 4 / day

QL 24 / day cholestyramine light powder 3 HCG

QL 4 / day cholestyramine light packet 3 HCG colestipol hcl (granules, granules packet) 1 QL 6 / day colestipol hcl (hcl 1 gm tablet, micronized 1 gm tab) 1 QL 4 / day

QL 24 / day PREVALITE POWDER 3 HCG

QL 4 / day PREVALITE PACKET 3 HCG

CHOLESTEROL ABSORPTION INHIBITORS ezetimibe 1 QL 1 / day ezetimibe-simvastatin 1 QL 1 / day

FIBRIC ACID DERIVATIVES

QL 1 / day fenofibrate 150 mg capsule 3 HCG

QL 2 / day fenofibrate 50 mg capsule 3 HCG fenofibrate (43 mg capsule, 48 mg tablet, 54 mg tablet) 1 QL 2 / day

PAGE 58 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fenofibrate (67 mg capsule, 130 mg capsule, 134 mg capsule, 1 / day 145 mg tablet, 160 mg tablet, 200 mg capsule) 1 QL fenofibrate 120 mg tablet 1 QL 1 / day fenofibrate 40 mg tablet 1 QL 2 / day fenofibric acid (105 mg tablet, dr 135 mg cap) 1 QL 1 / day fenofibric acid (35 mg tablet, dr 45 mg cap) 1 QL 2 / day gemfibrozil 600 mg tablet 1 QL 2 / day

HMG-COA REDUCTASE INHIBITORS

QL 1 / day amlodipine-atorvastatin 3 HCG atorvastatin calcium 1 QL 1 / day fluvastatin er 1 QL 1 / day fluvastatin sodium 20 mg cap 1 QL 1 / day fluvastatin sodium 40 mg cap 1 QL 2 / day lovastatin (10 mg tablet, 20 mg tablet) 1 QL 1 / day lovastatin 40 mg tablet 1 QL 2 / day

QL 1 / day pravastatin sodium (10 mg tab, 20 mg tab, 40 mg tab) 1 LCG pravastatin sodium 80 mg tab 1 rosuvastatin calcium 1 QL 1 / day

QL 1.5 / day simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 LCG

QL 1 / day simvastatin 5 mg tablet 1 LCG

QL 1 / day simvastatin 80 mg tablet 1 PA

PAGE 59 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PCSK9 INHIBITORS

QL 0.08 / day PA PRALUENT PEN 4 S PS

QL 0.08 / day PA PRALUENT SYRINGE 4 S PS

QL 0.13 / day PA REPATHA PUSHTRONEX 4 S PS

QL 0.08 / day PA REPATHA SURECLICK 4 S PS

QL 0.08 / day PA REPATHA SYRINGE 4 S PS

ANTIMIGRAINE AGENTS

SELECTIVE SEROTONIN AGONISTS

QL 0.4 / day almotriptan malate 3 HCG

QL 0.4 / day eletriptan hbr 3 HCG

PAGE 60 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.6 / day frovatriptan succinate 3 HCG naratriptan 1 QL 0.6 / day naratriptan hcl 1 QL 0.6 / day rizatriptan (5 mg odt, 5 mg tablet, 10 mg odt, 10 mg tablet) 1 QL 0.6 / day

QL 6 / 30 days sumatriptan (5 mg nasal spray, 20 mg nasal spray) 3 HCG sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 ml inject, 6 QL 0.167 / day 3 mg/0.5 ml inject, 6 mg/0.5 ml refill, 6 mg/0.5 ml vial) HCG sumatriptan 6 mg/0.5 ml syrng 1 QL 0.167 / day sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg 0.3 / day tablet) 1 QL zolmitriptan (2.5 mg tablet, 5 mg tablet) 1 QL 0.2 / day

QL 0.2 / day zolmitriptan odt 3 HCG

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 2 QL 0.2 / day

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, MISCELLANEOUS dapsone (25 mg tablet, 100 mg tablet) 1 ANTITUBERCULOSIS AGENTS clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250 mg/5 ml sus, 500 mg tablet) 1 clarithromycin er 1 cycloserine 250 mg capsule 3 HCG ethambutol hcl 1 isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1

PAGE 61 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS isoniazid 100 mg/ml vial 1 pyrazinamide 500 mg tablet 1 ANTIPARKINSONIAN AGENTS (CNS)

ADAMANTANES (CNS) amantadine (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet, 100 mg/10 ml soln) 1 CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. carbidopa-levodopa-entacapone 1 entacapone 1 tolcapone 1 DOPAMINE PRECURSORS carbidopa-levodopa (carbidopa-levo 10-100 mg odt, carbidopa- levo 25-100 mg odt, carbidopa-levo 25-250 mg odt, carbidopa- levodopa 10-100 tab, carbidopa-levodopa 25-100 tab, 1 carbidopa-levodopa 25-250 tab) carbidopa-levodopa er 1

QL 1 / day DUOPA 5 PA S

ANTIPROTOZOALS

AMEBICIDES metronidazole (250 mg tablet, 375 mg capsule, 500 mg tablet) 1 ANTIMALARIALS atovaquone-proguanil hcl 1 PA chloroquine phosphate (250 mg tablet, 500 mg tablet) 1 hydroxychloroquine 200 mg tab 1 mefloquine hcl 1 primaquine 1

PAGE 62 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 42 / 365 days quinine sulfate 324 mg capsule 1 PA

ANTIPROTOZOALS, MISCELLANEOUS atovaquone 1 PA

IMPAVIDO 5 S tinidazole (250 mg tablet, 500 mg tablet) 1 ANTIPSYCHOTIC AGENTS

ANTIPSYCHOTICS, MISCELLANEOUS loxapine 1 AL At least 18 yrs old molindone hcl 1 pimozide 1 ATYPICAL ANTIPSYCHOTICS

QL 30 / day aripiprazole 1 mg/ml solution 3 AL At least 6 yrs old HCG

QL 1 / day aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg At least 6 yrs old tablet, 20 mg tablet, 30 mg tablet) 3 AL HCG

QL 1 / day aripiprazole odt 1 AL At least 6 yrs old

QL 9 / day clozapine 100 mg tablet 1 AL At least 18 yrs old

QL 4 / day clozapine 200 mg tablet 1 AL At least 18 yrs old

QL 18 / day clozapine 25 mg tablet 1 AL At least 18 yrs old

PAGE 63 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day clozapine 50 mg tablet 1 AL At least 18 yrs old

QL 3 / day clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet) 1 AL At least 18 yrs old

AL At least 18 yrs old clozapine odt (odt 150 mg tablet, odt 200 mg tablet) 3 HCG

QL 9 / day clozapine odt 100 mg tablet 1 AL At least 18 yrs old

QL 2 / day NUPLAZID 5 PA S olanzapine (2.5 mg tablet, 5 mg tablet) 1 QL 6 / day olanzapine 10 mg tablet 1 QL 3 / day olanzapine 15 mg tablet 1 QL 2 / day olanzapine 20 mg tablet 1 QL 1 / day olanzapine 7.5 mg tablet 1 QL 4 / day olanzapine 10 mg vial 1

QL 3 / day olanzapine odt 10 mg tablet 3 HCG

QL 2 / day olanzapine odt 15 mg tablet 3 HCG

QL 1 / day olanzapine odt 20 mg tablet 3 HCG

QL 6 / day olanzapine odt 5 mg tablet 3 HCG

AL At least 12 yrs old paliperidone er 3 HCG

PAGE 64 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 6 / day quetiapine fumarate (25 mg tab, 50 mg tab) 1 AL At least 10 yrs old

QL 3 / day quetiapine fumarate 100 mg tab 1 AL At least 10 yrs old

QL 1.5 / day quetiapine fumarate 200 mg tab 1 AL At least 10 yrs old

QL 1 / day quetiapine fumarate 300 mg tab 1 AL At least 10 yrs old

QL 2 / day quetiapine fumarate 400 mg tab 1 AL At least 10 yrs old

QL 5 / day quetiapine er 150 mg tablet 3 AL At least 10 yrs old HCG

QL 4 / day quetiapine er 200 mg tablet 3 AL At least 10 yrs old HCG

QL 6 / day quetiapine er 50 mg tablet 3 AL At least 10 yrs old HCG

QL 2 / day quetiapine fumarate er (er 300 mg tablet, er 400 mg tablet) 3 AL At least 10 yrs old HCG

QL 16/day risperidone 1 mg/ml solution 1 AL At least 5 yrs old risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg QL 8 / day 1 tablet) AL At least 5 yrs old

QL 5 / day risperidone 3 mg tablet 1 AL At least 5 yrs old

PAGE 65 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day risperidone 4 mg tablet 1 AL At least 5 yrs old

QL 5 / day risperidone 3 mg odt 3 AL At least 5 yrs old HCG

QL 4 / day risperidone 4 mg odt 3 AL At least 5 yrs old HCG

QL 8 / day risperidone odt (0.25 mg odt, 0.5 mg odt, 1 mg odt, 2 mg odt) 3 AL At least 5 yrs old HCG

SEROQUEL XR SAMPLE KIT 2 AL At least 10 yrs old

QL 2 / day SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 2 AL At least 10 yrs old

QL 5 / day SEROQUEL XR 150 MG TABLET 2 AL At least 10 yrs old

QL 4 / day SEROQUEL XR 200 MG TABLET 2 AL At least 10 yrs old

QL 6 / day SEROQUEL XR 50 MG TABLET 2 AL At least 10 yrs old

QL 2 / day ziprasidone hcl 1 AL At least 18 yrs old

BUTYROPHENONES haloperidol 5 mg/ml ampul 1 haloperidol (0.5 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) 1 haloperidol 1 mg tablet 1 LCG

PAGE 66 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS haloperidol decan 50 mg/ml amp 1 haloperidol decanoate (50 mg/ml vial, 100 mg/ml vial) 1 haloperidol decanoate 100 1 haloperidol lac 2 mg/ml conc 1 haloperidol lactate (5 mg/ml vial, 50 mg/10 ml vl) 1 PHENOTHIAZINES chlorpromazine 25 mg/ml amp 1 chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 3 HCG fluphenazine dec 125 mg/5 ml 1 fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5 ml elix, 5 mg tablet, 5 mg/ml conc, 10 mg tablet) 1 fluphenazine 2.5 mg/ml vial 1 perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mg At least 18 yrs old tablet) 1 AL thioridazine hcl 1 trifluoperazine hcl 1 THIOXANTHENES thiothixene 1 ANTIRETROVIRALS

HIV ENTRY AND FUSION INHIBITORS

QL 2 / day FUZEON 5 S

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75 MG S 4 TABLET, 150 MG TABLET, 300 MG TABLET) PS

HIV INTEGRASE INHIBITORS

GENVOYA 5 S

PAGE 67 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

S ISENTRESS 100 MG POWDER PACKET 4 PS

ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400 S 4 MG TABLET) PS

S ISENTRESS HD 4 PS

STRIBILD 5 S

TIVICAY 5 S

TRIUMEQ 5 S

HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.

S ATRIPLA 4 PS

S COMPLERA 4 PS

S EDURANT 4 PS

S INTELENCE 4 PS nevirapine (50 mg/5 ml susp, 200 mg tablet) 5 S nevirapine er 5 S

ODEFSEY 5 S

RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 5 S

SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET) 5 S

VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 5 S

VIRAMUNE XR 5 S

PAGE 68 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS abacavir (20 mg/ml solution, 300 mg tablet) 5 S abacavir-lamivudine 5 S abacavir-lamivudine-zidovudine 5 S

COMBIVIR 5 S

QL 1 / day DESCOVY 5 S didanosine 5 S

S EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 4 PS

EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 5 S

EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 5 S

EPZICOM 5 S lamivudine 10 mg/ml oral soln 5 S lamivudine (100 mg tablet, 150 mg tablet, 300 mg tablet) 5 S lamivudine hbv 5 S lamivudine-zidovudine 5 S

RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 5 S stavudine (1 mg/ml solution, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) 5 S

TRIZIVIR 5 S

S TRUVADA 4 PS

S VIDEX 4 PS

PAGE 69 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VIDEX EC 5 S

VIREAD POWDER 5 S

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 S 4 MG TABLET) PS

ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE) 5 S

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 5 S zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mg tablet) 5 S

HIV PROTEASE INHIBITORS

S APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 4 PS

S CRIXIVAN 4 PS

EVOTAZ 5 S fosamprenavir calcium 5 S

S INVIRASE (200 MG CAPSULE, 500 MG TABLET) 4 PS

KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50 MG TABLET) 5 S

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 5 S

S lopinavir-ritonavir 4 PS

NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGEL CAP, 100 MG TABLET) 5 S

PREZCOBIX 5 S

PAGE 70 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG S 4 TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) PS

REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MG S 4 CAPSULE) PS

S REYATAZ 50 MG POWDER PACKET 4 PS

QL 2 / day TECHNIVIE 5 PA S

QL 4 / day VIEKIRA PAK 5 PA S

QL 3 / day VIEKIRA XR 5 PA S

S VIRACEPT 4 PS

ANTITHROMBOTIC AGENTS

PLATELET-AGGREGATION INHIBITORS

QL 10 / day aspirin-caffeine-dihydrocodein 1 AL At least 18 yrs old

QL 2 / day aspirin-dipyridamole er 3 HCG

BRILINTA 2 QL 2 / day butalbital-asa-caffeine cap 1 QL 6 / day cilostazol 1 QL 2 / day

PAGE 71 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS clopidogrel 1 QL 1 / day dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1 QL 4 / day prasugrel hcl 1 QL 1 / day ticlopidine hcl 1 QL 2 / day

PLATELET-REDUCING AGENTS anagrelide hcl 1 QL 4 / day

THROMBOLYTIC AGENTS

CATHFLO ACTIVASE 5 S

ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES

ANTITOXINS AND IMMUNE GLOBULINS antivenin latrodectus mactans 1 antivenin micrurus fulvius 1

PA CUVITRU 5 S

PA GAMMAGARD LIQUID 5 S

PA GAMMAKED 5 S

PA GAMUNEX-C 5 S

PA HIZENTRA 5 S

HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) 5 S

HYPERRAB S-D 5 S

HYPERTET S-D 5 S

PAGE 72 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA HYQVIA 5 S

PA HYQVIA IG COMPONENT 5 S

IMOGAM RABIES-HT 5 S

NABI-HB 5 S

VARIZIG (125 UNIT VIAL, 125 UNIT/1.2 ML VIAL) 5 S

TOXOIDS

ADACEL TDAP (SYRINGE, VIAL) 0 HCR

BOOSTRIX TDAP (SYRINGE, VIAL) 0 HCR

DAPTACEL DTAP 0 HCR diphtheria-tetanus toxoids-ped 1 INFANRIX DTAP (SYRINGE, VIAL) 2 PEDIARIX 2

TENIVAC (SYRINGE, VIAL) 0 HCR tetanus diphtheria toxoids 0 HCR

VACCINES

ACTHIB VACCINE WITH DILUENT 2

AFLURIA 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR

AFLURIA QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR

BEXSERO 2 BIOTHRAX 2

CERVARIX 0 HCR

ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 0 HCR

PAGE 73 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL, PEDI 10 MCG/0.5 SYRN) 0 HCR

EZ FLU 16-17 (FLUZON QUAD PED) 0 HCR

EZ FLU 2016-2017 (AFLURIA) 0 HCR

EZ FLU 2016-2017 (FLUVIRIN) 0 HCR

FLUAD 2016-2017 0 HCR

FLUARIX QUAD 2016-2017 0 HCR

FLUBLOK 2016-2017 0 HCR

FLUCELVAX QUAD 2016-2017 0 HCR

FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016-2017 VIAL) 0 HCR

FLUVIRIN 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR

FLUZONE HIGH-DOSE 2016-2017 0 HCR

FLUZONE INTRADERM QUAD 2016-17 0 HCR

FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR

FLUZONE QUAD PEDI 2016-2017 0 HCR

GARDASIL (SYRINGE, VIAL) 0 HCR

GARDASIL 9 (9 SYRINGE, 9 VIAL) 0 HCR

HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML VIAL, 1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) 0 HCR

HIBERIX VACCINE WITH DILUENT 2 IMOVAX RABIES VACCINE 2 IPOL VIAL 2 IXIARO 2 KINRIX (TIP-LOK SYRINGE, VIAL) 2

PAGE 74 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

M-M-R II VACCINE 0 HCR

MENACTRA 0 HCR

MENHIBRIX 2

MENOMUNE-A-C-Y-W-135 0 HCR

MENVEO A-C-Y-W-135-DIP 0 HCR

MENVEO MENA COMPONENT 2 MENVEO MENCYW-135 COMPONENT 2 PEDVAXHIB 2 PENTACEL 2 PENTACEL DTAP-IPV COMPONENT 2

PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 0 HCR

PREVNAR 13 0 HCR

PROQUAD 2 QUADRACEL DTAP-IPV 2 RABAVERT 2 RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10 MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 0 HCR

ROTARIX 2 ROTATEQ 2 STAMARIL 2

THERACYS 5 S

TWINRIX (SYRINGE, VIAL) 0 HCR

TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2 VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML VIAL, 50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 0 HCR

VARIVAX VACCINE 0 HCR

PAGE 75 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VAXCHORA ACTIVE COMPONENT 2 VAXCHORA VACCINE 2 VIVOTIF 2 VIVOTIF BERNA 2 YF-VAX 2

ZOSTAVAX 0 HCR

ANTIULCER AGENTS AND ACID SUPPRESSANTS

HISTAMINE H2-ANTAGONISTS cimetidine (200 mg tablet, 300 mg tablet, 300 mg/5 ml soln, 400 mg tablet, 800 mg tablet) 1 famotidine (20 mg tablet, 40 mg tablet, 40 mg/5 ml susp) 1 nizatidine (15 mg/ml solution, 300 mg capsule) 1 nizatidine 150 mg capsule 1 QL 2 / day ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 150 mg/10 ml syrup, 300 mg capsule, 300 mg tablet) 1 ranitidine hcl (50 mg/2 ml vial, 150 mg/6 ml vl) 1 PROSTAGLANDINS diclofenac sodium-misoprostol 1 misoprostol (100 mcg tablet, 200 mcg tablet) 1 PROTECTANTS

CARAFATE 1 GM/10 ML SUSP 2 sucralfate 1 gm tablet 1 PROTON-PUMP INHIBITORS esomeprazole mag dr 20 mg cap 1 QL 1 / day

QL 1 / day esomeprazole mag dr 40 mg cap 3 HCG

QL 1 / day esomeprazole strontium 3 HCG

PAGE 76 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 112 / 365 days lansoprazol-amoxicil-clarithro 3 HCG lansoprazole dr 15 mg capsule 1 lansoprazole dr 30 mg capsule 1 QL 1 / day omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40 mg 1 / day capsule) 1 QL omeprazole-bicarb 40-1,100 cap 3 HCG omeprazole-sodium bicarbonate (20-1,100 cap, 20-1,680 pkt, 40-1,680 pkt) 1

QL 1 / day pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 1 LCG rabeprazole sodium 1 QL 2 / day

ANTIVIRALS (SYSTEMIC)

ADAMANTANES rimantadine hcl 1 INTERFERONS

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 PA MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS 5 VIL) S

PA PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 5 S

PA PEGASYS PROCLICK 5 S

PA PEGINTRON 4 S PS

PA PEGINTRON REDIPEN 4 S PS

PAGE 77 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA SYLATRON 5 S

NEURAMINIDASE INHIBITORS oseltamivir phosphate 1 QL 20 / 365 days

NUCLEOSIDES AND NUCLEOTIDES acyclovir (200 mg capsule, 200 mg/5 ml susp, 400 mg tablet, 800 mg tablet) 1 adefovir dipivoxil 5 S

QL 20 / day BARACLUDE 0.05 MG/ML SOLUTION 5 PA S

QL 1 / day BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 5 PA S

QL 6 / day COPEGUS 5 PA S

QL 1 / day entecavir 5 S famciclovir 3 HCG

QL 1 / day HEPSERA 5 PA S

QL 2 / day MODERIBA (200-400 MG DOSEPACK, 400-400 MG DOSEPACK, 600-400 MG DOSEPACK, 600-600 MG DOSEPACK) 5 PA S

QL 6 / day MODERIBA 200 MG TABLET 5 PA S

PAGE 78 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 6 / day REBETOL 200 MG CAPSULE 5 PA S

QL 30 / day REBETOL 40 MG/ML SOLUTION 5 PA S

QL 6 / day RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 5 PA S

QL 3 / day RIBASPHERE 400 MG TABLET 5 PA S

QL 2 / day RIBASPHERE 600 MG TABLET 5 PA S

QL 2 / day RIBASPHERE RIBAPAK 5 PA S

QL 2 / day RIBATAB 5 PA S

QL 6 / day ribavirin (200 mg capsule, 200 mg tablet) 5 PA S ribavirin 6 gm inhalation vial 1

QL 1 / day TYZEKA 5 PA S

PAGE 79 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS valacyclovir 3 HCG valganciclovir hcl 50 mg/ml 1 valganciclovir 450 mg tablet 1 QL 4 / day

QL 1 / day PA VEMLIDY 5 AL At least 18 yrs old S

ANXIOLYTICS, SEDATIVES AND HYPNOTICS

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet) 1 droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 1 eszopiclone (1 mg tablet, 2 mg tablet) 1 QL 1 / day

QL 1 / day eszopiclone 3 mg tablet 1 AL Up to 65 yrs old

QL 1 / day HETLIOZ 5 PA S hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, hcl 10 mg At least 2 yrs old tablet, hcl 25 mg tablet, 50 mg/25 ml syrup, hcl 50 mg tablet) 1 AL hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial, 100 mg/2 ml At least 2 yrs old vial, 500 mg/10 ml vial) 1 AL hydroxyzine pam 100 mg cap 1 hydroxyzine pamoate (25 mg cap, 50 mg cap) 1 AL At least 2 yrs old meprobamate 1

PHENADOZ 1 AL At least 2 yrs old

PHENERGAN (12.5 MG, 25 MG, 50 MG) 1 AL At least 2 yrs old

PAGE 80 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS promethazine hcl (12.5 mg suppos, 25 mg suppository, 50 mg At least 2 yrs old suppository) 1 AL

PROMETHEGAN 1 AL At least 2 yrs old zaleplon 1 QL 1 / day zolpidem tartrate (tart 1.75 mg tab sl, tart 3.5 mg tablet sl, 1 / day tartrate 5 mg tablet, tartrate 10 mg tablet) 1 QL zolpidem tartrate er 1 QL 1 / day

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) pentobarbital 1,000 mg/20 ml 1 BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 1 QL 4 / day alprazolam 2 mg tablet 1 QL 5 / day alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 1 QL 1 / day alprazolam er 2 mg tablet 1 QL 5 / day alprazolam er 3 mg tablet 1 QL 3 / day alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab, odt 1 mg tab) 1 QL 4 / day alprazolam odt 2 mg tab 1 QL 5 / day alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 QL 1 / day alprazolam xr 2 mg tablet 1 QL 5 / day alprazolam xr 3 mg tablet 1 QL 3 / day chlordiazepoxide 10 mg capsule 1 QL 30 / day chlordiazepoxide 25 mg capsule 1 QL 12 / day chlordiazepoxide 5 mg capsule 1 QL 4 / day estazolam 1 QL 1 / day flurazepam hcl 1 QL 1 / day

PAGE 81 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS midazolam hcl 2 mg/ml syrup 1 midazolam hcl (hcl 1 mg/ml vial, 2 mg/2 ml syringe, hcl 2 mg/2 ml vial, 5 mg/ml isecure syr, 5 mg/ml syringe, hcl 5 mg/5 ml vial, hcl 5 mg/ml vial, hcl 10 mg/10 ml vial, hcl 10 mg/2 ml vial, 1 hcl 25 mg/5 ml vial, hcl 50 mg/10 ml vial) oxazepam 1 QL 4 / day quazepam 1 QL 1 / day temazepam 1 QL 1 / day triazolam 0.125 mg tablet 1 QL 1 / day triazolam 0.25 mg tablet 1 QL 2 / day

AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX STARTING MONTH BOX 0 HCR

CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG QL 2 / day 0 TABLET) HCR

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet) 1 cevimeline hcl 3 HCG donepezil hcl 1 AL At least 40 yrs old donepezil hcl odt 1 AL At least 40 yrs old galantamine er 3 HCG galantamine hbr 1 galantamine hydrobromide 1 guanidine hcl 1 MESTINON 60 MG/5 ML SYRUP 2

PAGE 82 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS physostigmine salicylate 1 pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1 pyridostigmine br 60 mg tablet 1 pyridostigmine bromide er 1 rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hr patch, 13.3 mg/24hr 1 AL At least 40 yrs old ptch) BETA-3-ADRENERGIC AGONISTS

SELECTIVE BETA-3-ADRENERGIC AGONISTS

MYRBETRIQ 2 QL 1 / day

BETA-ADRENERGIC BLOCKING AGENTS(SYMPATH)

NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS

BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2 QL 3 / day

BYSTOLIC 2.5 MG TABLET 2 QL 1 / day

BYSTOLIC 20 MG TABLET 2 QL 2 / day

BYVALSON 2 QL 1 / day

BLOOD FORMATION, COAGULATION, THROMBOSIS

HEMATOPOIETIC AGENTS

ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML PA SYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150 4 S MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 PS MCG/1 ML SYRINGE)

PA EPOGEN 5 S

PA GRANIX 5 S

PAGE 83 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA LEUKINE 5 S

PA MIRCERA 5 S

PA MOZOBIL 5 S

PA NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6 MG/0.6 ML KIT) 4 S PS

PA NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 4 S PS

PA PROCRIT 4 S PS

PA PROMACTA 5 S

QL 90 / 30 days ZARXIO 5 PA S

HEMORRHEOLOGIC AGENTS pentoxifylline er 400 mg tab 1 BRONCHODILATORS

XANTHINE DERIVATIVES

THEOCHRON 1 theophylline (80 mg/15 ml soln, er 400 mg tablet, er 600 mg tablet) 1

PAGE 84 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS theophylline anhydrous (er 100 mg tablet, er 200 mg tablet, er 300 mg tab, er 450 mg tab) 1 CALCIUM-CHANNEL BLOCKING AGENTS

DIHYDROPYRIDINES felodipine er 1 QL 1 / day isradipine 1 QL 2 / day

QL 1 / day nisoldipine 3 HCG

CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)

CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN) trandolapril-verapamil er 1 DIHYDROPYRIDINES (HYPOTENSIVE AGENTS)

AFEDITAB CR 30 MG TABLET 1 QL 1 / day

AFEDITAB CR 60 MG TABLET 1 QL 2 / day amlodipine besylate (2.5 mg tab, 5 mg tab, 10 mg tab) 1 QL 1 / day amlodipine besylate-benazepril 1 QL 1 / day

QL 1 / day amlodipine-olmesartan 3 HCG amlodipine-valsartan (5-320 mg, 10-160 mg, 10-320 mg) 1 QL 1 / day amlodipine-valsartan 5-160 mg 1 QL 2 / day

QL 1 / day amlodipine-valsartan-hctz 3 HCG nicardipine hcl (20 mg capsule, 30 mg capsule) 3 HCG

NIFEDICAL XL 1 QL 1 / day nifedipine (10 mg capsule, 20 mg capsule) 1 QL 4 / day

PAGE 85 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS nifedipine er (er 30 mg tablet, er 90 mg tablet) 1 QL 1 / day nifedipine er 60 mg tablet 1 QL 2 / day nimodipine 30 mg capsule 1 CARDIAC DRUGS

CARDIAC DRUGS, MISCELLANEOUS

QL 2 / day CORLANOR 2 ST

RANEXA 2 QL 2 / day

CARDIOVASCULAR DRUGS

CALCIUM-CHANNEL BLOCKING AGENTS telmisartan-amlodipine 1 QL 1 / day

CENTRAL NERVOUS SYSTEM AGENTS

ANTIMANIC AGENTS lithium 1 lithium carbonate (150 mg cap, 300 mg cap, 300 mg tab, 600 mg cap) 1 lithium carbonate er 1 CENTRAL NERVOUS SYSTEM AGENTS, MISC. acamprosate calcium 3 HCG

QL 2 / day atomoxetine hcl 1 AL At least 6 yrs old

QL 4 / day PA AUSTEDO 5 AL At least 18 yrs old S carbidopa 25 mg tablet 1

PAGE 86 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS guanfacine hcl 1 guanfacine hcl er 1

QL 2 / day PA INGREZZA 40 MG CAPSULE 5 AL At least 18 yrs old S

QL 360 / 30 days memantine hcl 2 mg/ml solution 1 AL At least 40 yrs old

AL At least 40 yrs old memantine 5-10 mg titration pk 3 HCG

QL 2 / day memantine hcl 10 mg tablet 1 AL At least 40 yrs old

QL 3 / day memantine hcl 5 mg tablet 1 AL At least 40 yrs old

NUEDEXTA 2 PA riluzole 1

PA tetrabenazine 5 S

PA XENAZINE 5 S

QL 18 / day XYREM 5 PA S

OPIATE ANTAGONISTS

DEPADE 1 naloxone hcl (0.4 mg/ml carpuject, 0.4 mg/ml vial, 2 mg/2 ml syringe, 4 mg/10 ml vial) 1

PAGE 87 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS naltrexone 50 mg tablet 1

PA VIVITROL 380 MG VIAL 5 S

CEPHALOSPORINS

FIRST GENERATION CEPHALOSPORINS cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg/5 ml susp) 1 cefazolin sodium (10 gm vial, 20 gm bulk vial, sod 100 gm bulk bag, sod 300 gm bulk bag, 500 mg vial) 1 cephalexin (125 mg/5 ml susp, 250 mg capsule, 250 mg tablet, 250 mg/5 ml susp, 500 mg capsule, 500 mg tablet, 750 mg 1 capsule) FOURTH GENERATION CEPHALOSPORINS cefepime hcl 1 SECOND GENERATION CEPHALOSPORINS cefaclor (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 375 mg/5 ml suspen, 500 mg capsule) 1 cefaclor er 1 QL 20 / 30 days cefotetan (1 gm vial, 2 gm vial) 1 cefprozil (125 mg/5 ml susp, 250 mg tablet, 250 mg/5 ml susp, 500 mg tablet) 1

CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML ORAL SUSP) 2 cefuroxime 1 cefuroxime sod 750 mg vial 1 THIRD GENERATION CEPHALOSPORINS cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mg capsule) 1 cefditoren pivoxil 1

QL 1200 / 90 days cefixime 3 HCG

PAGE 88 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cefotaxime sodium 1 cefpodoxime proxetil (50 mg/5 ml susp, 100 mg tablet, 100 mg/5 ml susp, 200 mg tablet) 1 ceftazidime (1 gm vial, 2 gm vial, 6 gm vial) 3 HCG ceftibuten (180 mg/5 ml susp, 400 mg capsule) 3 HCG ceftriaxone 100 gram bulk bag 3 HCG ceftriaxone (2 gm vial, 10 gm vial, 250 mg vial, 500 mg vial) 1 ceftriaxone 1 gm vial 1 MED Medical Drug

TAZICEF (1 VIAL, 2 VIAL, 6 VIAL) 3 HCG

CORTICOSTEROIDS (RESPIRATORY TRACT)

ORALLY INHALED PREPARATIONS (STEROIDS)

AEROSPAN 2 QL 0.334 / day

ARNUITY ELLIPTA 100 MCG INH 2 QL 2 / day

ARNUITY ELLIPTA 200 MCG INH 2 QL 1 / day budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1 mg/2 ml inh susp) 1

FLOVENT 250 MCG DISKUS 2 QL 8 / day

FLOVENT DISKUS (50 MCG, 100 MCG) 2 QL 4 / day

FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCG INHALER) 2 QL 0.8 / day

FLOVENT HFA 44 MCG INHALER 2 QL 0.767 / day

PULMICORT FLEXHALER 2 QL 0.07 / day

CYSTIC FIBROSIS (CFTR) MODULATORS

CYSTIC FIBROSIS (CFTR) CORRECTORS

QL 4 / day ORKAMBI 5 PA S

PAGE 89 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CYSTIC FIBROSIS (CFTR) POTENTIATORS

QL 2 / day KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULES PACKET, 150 MG TABLET) 5 PA S

DEPIGMENTING AND PIGMENTING AGENTS

DEPIGMENTING AGENTS

ALPHAQUIN HP 1 BLANCHE 1 hydroquinone (cream, tl cream, tr cream) 1 MELPAQUE HP 1 PIGMENTING AGENTS methoxsalen (10 mg capsule, 10 mg softgel) 1

UVADEX 5 S

DIAGNOSTIC AGENTS

ADRENOCORTICAL INSUFFICIENCY cosyntropin 0.25 mg vial 1

PA H.P. ACTHAR 5 S

CARDIAC FUNCTION indocyanine green 1 KIDNEY FUNCTION

INDIGO CARMINE 1 indigotindisulfonate sod-water 1 OCULAR DISORDERS

BIOGLO 1 FLUCAINE 1

PAGE 90 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FLUOR-I-STRIP AT 1 fluorescein-proparacaine 1 FUL-GLO 1 MG OPTH STRIPS 1 ROENTGENOGRAPHY

MD-GASTROVIEW 1 DIURETICS

LOOP DIURETICS bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1 bumetanide (0.25 mg/ml vial, 1 mg/4 ml vial, 2.5 mg/10 ml vial) 1 ethacrynic acid 1 furosemide (20 mg/2 ml vial, 40 mg/4 ml syringe, 40 mg/4 ml vial, 100 mg/10 ml syring, 100 mg/10 ml vial) 1 furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40 mg/5 ml soln, 80 mg tablet) 1 torsemide 1 OSMOTIC DIURETICS sorbitol-mannitol 3 HCG

POTASSIUM-SPARING DIURETICS amiloride hcl 1 amiloride-hydrochlorothiazide 1 triamterene-hydrochlorothiazid (37.5-25 mg cp, 37.5-25 mg tb, 50-25 mg cap, 75-50 mg tab) 1 THIAZIDE DIURETICS chlorothiazide 1 hydrochlorothiazide (12.5 mg cp, 12.5 mg tb, 50 mg tab) 1 hydrochlorothiazide 25 mg tab 1 LCG methyclothiazide 1

PAGE 91 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS THIAZIDE-LIKE DIURETICS chlorthalidone 1 indapamide 1 metolazone 1 VASOPRESSIN ANTAGONISTS

QL 1 / day SAMSCA 15 MG TABLET 5 PA S

QL 2 / day SAMSCA 30 MG TABLET 5 PA S

DIURETICS (HYPOTENSIVE AGENTS)

POTASSIUM-SPARING DIURETICS (HYPOTEN) eplerenone 3 HCG spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet) 1 spironolactone-hctz 1 THIAZIDE DIURETICS(HYPOTENSIVE AGENTS) benazepril-hydrochlorothiazide 1 QL 1 / day candesartan-hctz 16-12.5 mg tb 1 QL 2 / day candesartan-hydrochlorothiazid (32-12.5 mg tb, 32-25 mg tab) 1 QL 1 / day captopril-hydrochlorothiazide 1 QL 2 / day enalapril-hctz 10-25 mg tablet 1 QL 2 / day enalapril-hctz 5-12.5 mg tab 1 fosinopril-hydrochlorothiazide 1 QL 2 / day irbesartan-hctz 150-12.5 mg tb 1 QL 2 / day

PAGE 92 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS irbesartan-hctz 300-12.5 mg tb 1 QL 1 / day

QL 2 / day lisinopril-hctz 20-25 mg tab 1 LCG lisinopril-hydrochlorothiazide (10-12.5 mg tab, 20-12.5 mg 2 / day tab) 1 QL losartan-hctz 50-12.5 mg tab 1 QL 2 / day losartan-hydrochlorothiazide (100-12.5 mg tab, 100-25 mg 1 / day tab) 1 QL methyldopa-hydrochlorothiazide 1 moexipril-hydrochlorothiazide 1 QL 2 / day

QL 1 / day olmesartan-amlodipine-hctz 3 HCG olmesartan-hydrochlorothiazide 1 QL 1 / day quinapril-hctz 20-25 mg tab 1 QL 1 / day quinapril-hydrochlorothiazide (10-12.5 mg tab, 20-12.5 mg 2 / day tab) 1 QL

QL 2 / day telmisartan-hctz 80-12.5 mg tb 3 HCG

QL 1 / day telmisartan-hydrochlorothiazid (40-12.5 mg tb, 80-25 mg tab) 3 HCG valsartan-hydrochlorothiazide (320-12.5 mg tab, 320-25 mg 1 / day tab) 1 QL valsartan-hydrochlorothiazide (80-12.5 mg tab, 160-12.5 mg 2 / day tab, 160-25 mg tab) 1 QL DOPAMINE RECEPTOR AGONISTS

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1 cabergoline 1

PAGE 93 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

PA APOKYN 5 S pramipexole dihydrochloride 1 pramipexole er 3 HCG ropinirole er 1 QL 1 / day ropinirole hcl 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AGENTS

PHOSPHA 250 NEUTRAL 1 VIRT-PHOS 250 NEUTRAL 1 ALKALINIZING AGENTS

CYTRA-2 1 CYTRA-K (CRYSTALS PACKET, ORAL SOLUTION) 1 potass cit-sod cit-citric acid 1 potassium citrate er 1 potassium cit-citric acid soln 1 sodium citrate-citric acid 1 TARON-CRYSTALS 1 TRICITRATES 1 VIRTRATE-2 1 VIRTRATE-3 1 VIRTRATE-K 1 AMMONIA DETOXICANTS

BUPHENYL (500 MG TABLET, POWDER) 5 S

CARBAGLU 5 S

PAGE 94 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CONSTULOSE 1 ENULOSE 1 GENERLAC 1 KRISTALOSE 1 lactulose 1

QL 20 / day RAVICTI 5 PA S sodium phenylbutyrate (500mg tb, powder) 5 S

CALORIC AGENTS

ACD 1 LYSIPLEX PLUS 1 REPLACEMENT PREPARATIONS cardioplegic 1 EFFER-K 25 MEQ TABLET EFF 1 K EFFERVESCENT 1 K-SOL 1 KLOR-CON 20 MEQ PACKET 1 KLOR-CON 10 1 KLOR-CON 8 1 KLOR-CON M10 1 KLOR-CON M15 1 KLOR-CON M20 1 KLOR-CON SPRINKLE 1 KLOR-CON-EF 1 MONOJECT 0.9% SODIUM CHLORIDE 1 MONOJECT PREFILL 0.9% FLUSH 1

PAGE 95 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MONOJECT PREFILL ADVANCED 1 NEBUSAL 3% VIAL 1 normal saline flush 1 potassium bicarbonate 1 potassium chloride (er 8 meq capsule, er 8 meq tablet, 10% (20 meq/15 ml, 10% (40 meq/30 ml, er 10 meq capsule, er 10 meq tablet, 20 meq packet, 20% (40 meq/15 ml, er 20 meq tablet, 1 25 meq tab eff)

PULMOSAL 1 sodium chloride (bacteriostatic saline vial, sodium chloride 0.9% vial) 1 sodium chloride (0.9% inhal vl, 0.9% syringe, 0.9% zr syr, 3% vial, 7% vial, 10% vial) 1

SYREX 1 SALT AND SUGAR SUBSTITUTES saccharin 1 URICOSURIC AGENTS probenecid 1 QL 4 / day probenecid-colchicine 1 QL 2 / day

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

BASIC LOTIONS AND LINIMENTS ammonium lactate 12% lotion 1 lactic acid 10% lotion 1 BASIC OILS AND OTHER SOLVENTS

LUXAMEND 1 BASIC OINTMENTS AND PROTECTANTS ammonium lactate 12% cream 1 lactic acid 10% e cream 1

PAGE 96 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ESTROGENS AND ANTIESTROGENS

ESTROGEN AGONIST-ANTAGONISTS clomiphene citrate 50 mg tab 1 GL Female

DUAVEE 2 raloxifene hcl 0 HCR

SEROPHENE 1 GL Female

ESTROGENS

QL 1 / day AMABELZ 1 GL Female

QL 0.15 / day CLIMARA PRO 2 GL Female

COVARYX 1 GL Female

COVARYX H.S. 1 GL Female

DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1 MG GEL Female PACKET) 2 GL

EEMT 1 GL Female

EEMT H.S. 1 GL Female

QL 1 / day ENJUVIA 2 GL Female

ESTRACE 0.01% CREAM 2 GL Female estradiol (0.025 mg patch, 0.0375 mg patch, 0.05 mg patch, QL 0.29 / day 1 0.075 mg patch, 0.1 mg patch) GL Female estradiol (tds 0.025 mg/day, 0.0375 mg/day patch, tds 0.0375 QL 0.15 / day mg/day, tds 0.05 mg/day, tds 0.06 mg/day, 0.075 mg/day 1 patch, tds 0.075 mg/day, tds 0.1 mg/day) GL Female

QL .15 / day estradiol 0.06 mg/day patch 1 GL Female

PAGE 97 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day estradiol (0.5 mg tablet, 1 mg tablet) 1 GL Female LCG estradiol 10 mcg vaginal insrt 1 GL Female

QL 1 / day estradiol 2 mg tablet 1 GL Female estradiol valerate (20 mg/ml vl, 40 mg/ml vl) 1 GL Female

QL 1 / day estradiol-norethindrone acetat 1 GL Female

QL 90 days ESTRING 2 GL Female estrogen-methyltestosterone 1 GL Female

QL 1 / day estropipate 1 GL Female LCG

FYAVOLV 1 GL Female

QL 1 / day JINTELI 0 GL Female HCR

QL 1 / day LOPREEZA 1 GL Female

QL 1 / day MENEST 0.3 MG TABLET 2 GL Female

QL 1 / day MIMVEY 1 GL Female

MIMVEY LO 1

PAGE 98 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS norethindron-ethinyl estradiol (norethin-eth 1 mg-5 mcg, norethind-eth 0.5-2.5) 0 HCR

PREMARIN VAGINAL CREAM-APPL 2 GL Female

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, QL 1 / day 2 0.9 MG TABLET, 1.25 MG TABLET) GL Female

PREMARIN 25 MG VIAL 2

QL 1 / day PREMPHASE 2 GL Female

QL 1 / day PREMPRO 2 GL Female

YUVAFEM 1 GL Female

EYE, EAR, NOSE AND THROAT (EENT) PREPS.

ANTIALLERGIC AGENTS azelastine hcl 0.05% drops 1 QL 0.267 / day azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) 1 QL 2 / day epinastine hcl 1 QL 0.286 / day

QL 0.286 / day olopatadine hcl 0.1% eye drops 3 HCG olopatadine hcl 0.2% eye drop 1 QL 0.286 / day

QL 31 / 30 days olopatadine 665 mcg nasal spry 3 HCG

EENT DRUGS, MISCELLANEOUS acetylcysteine-water 1 QL 10 / 30 days apraclonidine hcl 1 QL 0.8 / day balanced salt 1

PAGE 99 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BSS 1

PA CYSTARAN 5 S ipratropium bromide (0.03% spray, 0.06% spray) 1 QL 2 / day

QL 0.04 / day LUCENTIS (0.3 MG/0.05 ML VIAL, 0.5 MG/0.05 ML SYRING, 0.5 MG/0.05 ML VIAL) 5 PA S

OCUCOAT 1 LOCAL ANESTHETICS (EENT)

ALTACAINE 1 ALTAFLUOR 1 cocaine 4% solution 1 cyclopentolate-lidoc-pe-tropic 1 fluorescein-benoxinate 1 FLUROX 1 GLYDO 1 lidocaine hcl (2% jelly, 4% solution) 1 lidocaine hcl viscous 1 proparacaine 0.5% eye drops 1 TETCAINE 1 tetracaine hcl (eye drops, steri-unit sol) 1

TETRAVISC 3 HCG

TETRAVISC FORTE 1 MYDRIATICS atropine sulfate (drops, ointment) 1 atropine 0.01%-ns eye drops 1 cyclopentolate hcl (0.5% eye drops, 1% eye drops, hcl 2% drops) 1

PAGE 100 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cyclopentolate-tropicamide-pe 1 HOMATROPAIRE 1 homatropine hydrobromide 1 tropicamide (0.5% drops, 1% drops) 1 VASOCONSTRICTORS naphazoline hcl 1 phenylephrine hcl (2.5% drop, 10% drops) 1 GASTROINTESTINAL DRUGS

ANTI-INFLAMMATORY AGENTS (GI DRUGS)

GL Female alosetron hcl 1 AL At least 18 yrs old

APRISO 2 balsalazide disodium 1 CANASA 2 LIALDA 2 mesalamine (4 gm/60 ml enema, 4 gm/60 ml kit) 1 mesalamine dr 1.2 gm tablet 3 HCG

ANTIDIARRHEA AGENTS

FULYZAQ 5 S loperamide 2 mg capsule 1

MYTESI 5 S opium tincture 1 QL 5 / day paregoric 1

PA XERMELO 5 AL At least 18 yrs old S

PAGE 101 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CATHARTICS AND LAXATIVES

QL 2 / day AMITIZA 2 AL At least 18 yrs old

GAVILYTE-C 0 HCR

GAVILYTE-G 0 HCR

GAVILYTE-N 0 HCR

GOLYTELY PACKET 0 HCR

MOVIPREP 0 HCR peg 3350-electrolyte (3350 electrolyte soln, 3350-electrolyte solution) 0 HCR peg-3350 and electrolytes 0 HCR peg-3350 with flavor packs 0 HCR

PEG-PREP 1 polyethylene glycol 3350 0 HCR sorbitol 70% solution 1

TRILYTE WITH FLAVOR PACKETS 0 HCR

CHOLELITHOLYTIC AGENTS

CHENODAL 5 S ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1 DIGESTANTS

CREON 2 PANCRELIPASE 5,000 1 ZENPEP 2 GI DRUGS, MISCELLANEOUS

QL 7 / day CHOLBAM 250 MG CAPSULE 5 PA S

PAGE 102 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day CHOLBAM 50 MG CAPSULE 5 PA S

QL 0.08 / day CIMZIA (200 MG VIAL KIT, 200 MG/ML SYRINGE KIT) 5 PA S

QL 3/ fill CIMZIA 200 MG/ML STARTER KIT 5 PA S

PA GATTEX 5 S

QL 0.22 / day PA HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE) 4 S PS

QL 0.15 / day PA HUMIRA 10 MG/0.2 ML SYRINGE 4 S PS

QL 0.22 / day PA HUMIRA PEDIATRIC CROHN'S 4 S PS

QL 0.22 / day PA HUMIRA PEN 4 S PS

QL 0.22 / day PA HUMIRA PEN CROHN-UC-HS STARTER 4 S PS

PAGE 103 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.22 / day PA HUMIRA PEN PSORIASIS-UVEITIS 4 S PS

QL 1 / day LINZESS 2 ST

QL 1 / day OCALIVA 5 PA S

QL 2 / day VIBERZI 2 PA

PROKINETIC AGENTS metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mg tablet, 10 mg/10 ml sol) 1 LCG metoclopramide 10 mg/2 ml syr 1 metoclopramide 10 mg/2 ml vial 1 LCG metoclopramide hcl odt 1 GENERAL ANESTHETICS

GENERAL ANESTHETICS, MISCELLANEOUS ketamine hcl (100 mg/ml vial, 200 mg/20 ml vial, 500 mg/10 ml vial, 500 mg/5 ml vial, 1,000 mg/10 ml vial) 1 INHALATION ANESTHETICS

COMPOUND 347 1 isoflurane 1 sevoflurane 1 SOJOURN 1 TERRELL 1

PAGE 104 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GENITOURINARY SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

QL 1 / day darifenacin er 3 HCG flavoxate hcl 1 oxybutynin 5 mg/5 ml syrup 1 QL 20 / day oxybutynin 5 mg tablet 1 QL 4 / day oxybutynin chloride er (er 10 mg tablet, er 15 mg tablet) 1 QL 2 / day oxybutynin cl er 5 mg tablet 1 QL 1 / day tolterodine tartrate 1 QL 2 / day

QL 1 / day tolterodine tartrate er 3 HCG

QL 2 / day trospium chloride 3 HCG

QL 1 / day trospium chloride er 3 HCG

VESICARE 2 QL 1 / day

HCV ANTIVIRALS

HCV POLYMERASE INHIBITORS

QL 1 / day PA EPCLUSA 4 S PS

QL 1 / day PA HARVONI 4 S PS

PAGE 105 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day PA SOVALDI 4 S PS

HCV PROTEASE INHIBITORS

QL 1 / day OLYSIO 5 PA S

QL 1 / day ZEPATIER 5 PA S

HCV REPLICATION COMPLEX INHIBITORS

QL 1 / day DAKLINZA 5 PA S

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

A-METHAPRED 1 betamethasone acetate-sod phos 1 budesonide ec 3 HCG cortisone 25 mg tablet 1 DELTASONE 1 dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5 mg/5 ml liq, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg 1 tablet, 6 mg tablet)

DEXAMETHASONE INTENSOL 2

PA EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL At least 5 yrs old SUSP, 30 MG TABLET, 36 MG TABLET) 5 AL S

PAGE 106 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fludrocortisone 0.1 mg tablet 1 hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 MEDROL 2 MG TABLET 2 methylprednisolone (4 mg dosepk, 4 mg tablet, 8 mg tab, 16 mg tab, 32 mg tab) 1 methylprednisolone acetate 1 methylprednisolone sodium succ (40 mg vl, 125 mg) 1 prednisolone (15 mg/5 ml soln, 15 mg/5 ml syrup) 1 prednisolone sodium phos odt 1 prednisolone sodium phosphate (5 mg/5 ml soln, 10 mg/5 ml soln, 20 mg/5 ml soln, sod ph 25 mg/5 ml) 1 prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dose pack, 5 mg tablet, 5 mg/5 ml solution, 10 mg tab dose pack, 10 mg 1 tablet, 20 mg tablet, 50 mg tablet)

PREDNISONE INTENSOL 2 triamcinolone acetonide (40mg/ml vl, 50mg/5ml vl) 1 ANDROGENS

QL 1 / day ANDRODERM 2 PA GL Male

QL 5 / day ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT, 1.62%(2.5G) GEL PCKT) 2 PA GL Male danazol (50 mg capsule, 100 mg capsule, 200 mg capsule) 1 methyltestosterone 10 mg cap 1

PA oxandrolone (2.5 mg tablet, 10 mg tablet) 1 GL Male testosterone cypionate (testosteron 1,000 mg/10 ml, testosteron 2,000 mg/10 ml, testosterone 100 mg/ml, 1 GL Male testosterone 200 mg/ml)

PAGE 107 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS testosterone enanthate (testosteron 1,000 mg/5 ml, PA 1 testosterone 200 mg/ml) GL Male

CONTRACEPTIVES

QL 1 / day ALTAVERA 0 GL Female HCR

GL Female ALYACEN 0 HCR

QL 91 days AMETHIA 0 GL Female HCR

QL 91 days AMETHIA LO 0 GL Female HCR

QL 1 / day AMETHYST 0 GL Female HCR

GL Female APRI 0 HCR

GL Female ARANELLE 0 HCR

GL Female ASHLYNA 0 HCR

QL 1 / day AUBRA 0 GL Female HCR

QL 1 / day AVIANE 0 GL Female HCR

PAGE 108 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female AZURETTE 0 HCR

GL Female BALZIVA 0 HCR

GL Female BEKYREE 0 HCR

GL Female BLISOVI 24 FE 0 HCR

GL Female BLISOVI FE 0 HCR

GL Female BRIELLYN 0 HCR

GL Female CAMILA 0 HCR

QL 91 days CAMRESE 0 GL Female HCR

QL 91 days CAMRESE LO 0 GL Female HCR

GL Female CAZIANT 0 HCR

QL 1 / day CHATEAL 0 GL Female HCR

GL Female CRYSELLE 0 HCR

PAGE 109 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female CYCLAFEM 0 HCR

GL Female CYRED 0 HCR

GL Female DASETTA 0 HCR

QL 91 days DAYSEE 0 GL Female HCR

GL Female DEBLITANE 0 HCR

QL 1 / day DELYLA 0 GL Female HCR

GL Female desogestr-eth estrad eth estra 0 HCR

GL Female desogestrel-ethinyl estradiol 0 HCR

GL Female drospirenone-eth estra-levomef 0 HCR

GL Female drospirenone-ethinyl estradiol 0 HCR

GL Female ELINEST 0 HCR

QL 1 / day ELLA 0 GL Female HCR

PAGE 110 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female EMOQUETTE 0 HCR

GL Female ENPRESSE 0 HCR

GL Female ENSKYCE 0 HCR

GL Female ERRIN 0 HCR

GL Female ESTARYLLA 0 HCR

GL Female ethynodiol-ethinyl estradiol 0 HCR

QL 1 / day FALMINA 0 GL Female HCR

QL 91 days FAYOSIM 0 GL Female HCR

GL Female FEMYNOR 0 HCR

GL Female GIANVI 0 HCR

GL Female GILDAGIA 0 HCR

GL Female GILDESS 0 HCR

PAGE 111 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female GILDESS 24 FE 0 HCR

GL Female GILDESS FE 0 HCR

GL Female HEATHER 0 HCR

QL 91 days INTROVALE 0 GL Female HCR

GL Female ISIBLOOM 0 HCR

GL Female JENCYCLA 0 HCR

QL 91 days JOLESSA 0 GL Female HCR

GL Female JOLIVETTE 0 HCR

GL Female JULEBER 0 HCR

GL Female JUNEL 0 HCR

GL Female JUNEL FE 0 HCR

GL Female JUNEL FE 24 0 HCR

PAGE 112 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female KAITLIB FE 0 HCR

GL Female KARIVA 0 HCR

GL Female KELNOR 1-35 0 HCR

GL Female KIMIDESS 0 HCR

QL 1 / day KURVELO 0 GL Female HCR

GL Female LARIN 0 HCR

GL Female LARIN 24 FE 0 HCR

GL Female LARIN FE 0 HCR

QL 1 / day LARISSIA 0 GL Female HCR

GL Female LAYOLIS FE 0 HCR

GL Female LEENA 0 HCR

QL 1 / day LESSINA 0 GL Female HCR

PAGE 113 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female LEVONEST 0 HCR

GL Female levono-e estrad 0.15-0.03-0.01 0 HCR

QL 91 days levonorg-eth estrad eth estrad (levono-e estrad 0.10-0.02-0.01, Female levonorg 0.15mg-ee 20-25-30mcg) 0 GL HCR

QL 0.07 / day levonorgestrel 0 GL Female HCR

QL 91 days levonor-eth estrad 0.15-0.03 0 GL Female HCR

GL Female levonor-eth estrad triphasic 0 HCR

QL 1 / day levonorgestrel-eth estradiol (estra 0.09-0.02 mg, estrad 0.1- Female 0.02 mg) 0 GL HCR

QL 1 / day LEVORA-28 0 GL Female HCR

QL 1 / day LILLOW 0 GL Female HCR

GL Female LO LOESTRIN FE 0 HCR

GL Female LOESTRIN FE 1.5-30 TABLET 0 HCR

PAGE 114 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female LOMEDIA 24 FE 0 HCR

GL Female LORYNA 0 HCR

GL Female LOW-OGESTREL 0 HCR

QL 1 / day LUTERA 0 GL Female HCR

GL Female LYZA 0 HCR

QL 1 / day MARLISSA 0 GL Female HCR

GL Female MELODETTA 24 FE 0 HCR

GL Female MIBELAS 24 FE 0 HCR

GL Female MICROGESTIN 0 HCR

GL Female MICROGESTIN 24 FE 0 HCR

GL Female MICROGESTIN FE 0 HCR

GL Female MONO-LINYAH 0 HCR

PAGE 115 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female MONONESSA 0 HCR

GL Female MYZILRA 0 HCR

NATAZIA 2 GL Female

NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 1-50-28 TABLET, GL Female 0 10-11-28 TABLET) HCR

QL 1 / day NECON 7-7-7-28 TABLET 1 GL Female HCR

GL Female NIKKI 0 HCR

GL Female NORA-BE 0 HCR norethin-eth estra-ferrous fum (noret-estr-fe 0.4-0.035(21)-75, GL Female noreth-estrad-fe 1-0.02(21)-75, noreth-estrad-fe 1-0.02(24)- 0 75, norethin-estra-fe 0.8-0.025 mg) HCR

GL Female norethind-eth estrad 1-0.02 mg 0 HCR

GL Female norethindrone 0.35 mg tablet 0 HCR

GL Female norgestimate-ethinyl estradiol 0 HCR

GL Female NORINYL 1+50 0 HCR

GL Female NORLYDA 0 HCR

PAGE 116 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female NORLYROC 0 HCR

GL Female NORTREL 0 HCR

GL Female NUVARING 0 HCR

GL Female OCELLA 0 HCR

QL 1 / day OGESTREL 0 GL Female HCR

QL 1 / day ORSYTHIA 0 GL Female HCR

GL Female PHILITH 0 HCR

GL Female PIMTREA 0 HCR

GL Female PIRMELLA 0 HCR

QL 1 / day PORTIA 0 GL Female HCR

GL Female PREVIFEM 0 HCR

QL 91 days QUASENSE 0 GL Female HCR

PAGE 117 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female RAJANI 0 HCR

GL Female RECLIPSEN 0 HCR

QL 91 days RIVELSA 0 GL Female HCR

QL 91 days SETLAKIN 0 GL Female HCR

GL Female SHAROBEL 0 HCR

GL Female SPRINTEC 0 HCR

QL 1 / day SRONYX 0 GL Female HCR

GL Female SYEDA 0 HCR

GL Female TARINA FE 0 HCR

GL Female TAYTULLA 0 HCR

GL Female TILIA FE 0 HCR

GL Female TRI FEMYNOR 0 HCR

PAGE 118 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

GL Female TRI-ESTARYLLA 0 HCR

GL Female TRI-LEGEST FE 0 HCR

GL Female TRI-LINYAH 0 HCR

GL Female TRI-LO-ESTARYLLA 0 HCR

GL Female TRI-LO-MARZIA 0 HCR

GL Female TRI-LO-SPRINTEC 0 HCR

GL Female TRI-PREVIFEM 0 HCR

GL Female TRI-SPRINTEC 0 HCR

GL Female TRINESSA 0 HCR

GL Female TRINESSA LO 0 HCR

GL Female TRIVORA-28 0 HCR

GL Female VELIVET 0 HCR

GL Female VESTURA 0 HCR

PAGE 119 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day VIENVA 0 GL Female HCR

GL Female VIORELE 0 HCR

GL Female VYFEMLA 0 HCR

GL Female WERA 0 HCR

GL Female WYMZYA FE 0 HCR

QL 0.12 / day XULANE 0 GL Female HCR

GL Female ZARAH 0 HCR

GL Female ZENCHENT 0 HCR

GL Female ZENCHENT FE 0 HCR

GL Female ZEOSA 0 HCR

GL Female ZOVIA 1-35E 0 HCR

GL Female ZOVIA 1-50E 0 HCR

PAGE 120 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GONADOTROPINS

PA GL Female BRAVELLE 4 S PS chorionic gonadotropin (1 million unit, 2 million unit, 5 million unit, 10mm unit, 10,000 unit vl) 5 S

PA ELIGARD 5 S

FOLLISTIM AQ (75 UNIT VIAL, 300 UNIT CARTRIDG, 600 UNIT PA 5 CARTRIDG, 900 UNIT CARTRIDG) S

PA GONAL-F 4 S PS

PA GL Female GONAL-F RFF 4 S PS

PA GL Female GONAL-F RFF REDI-JECT 4 S PS

PA leuprolide acetate (1 mg/0.2 ml vial, 2wk 1 mg/0.2 ml kit) 5 S

PA leuprolide acetate (14 mg/2.8 ml kt, 14 mg/2.8 ml vl) 5 S

LUPANETA PACK 5 S

PAGE 121 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 7.5 MG KIT, PA DEPOT 11.25 MG 3MO KIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45 5 MG 6MO KIT) S

PA LUPRON DEPOT 3.75 MG KIT 5 S

PA LUPRON DEPO 11.25MG (LUPANETA) 5 S

PA LUPRON DEPOT 3.75MG (LUPANETA) 5 S

LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 MG PA 5 KIT, 15 MG KIT, 30 MG 3MO KIT) S

PA GL Female MENOPUR 4 S PS

PA NOVAREL 10,000 UNITS VIAL 5 S

PA OVIDREL 4 S PS

PA PREGNYL 5 S

PA SYNAREL 5 S

LEPTINS

PA MYALEPT 5 S

PAGE 122 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PARATHYROID calcitonin-salmon 1 QL 0.13 / day

PA FORTEO 5 S

MIACALCIN 400 UNIT/2 ML VIAL 5 S

PA NATPARA 5 S

QL 1.60 / day PA TYMLOS 5 AL At least 18 yrs old S

PITUITARY desmopressin 10 mcg/0.1 ml spr 1 GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG, PA MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, 5 MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MG S CARTRIDGE)

HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE, PA 5 24 MG CARTRIDGE) S

PA NORDITROPIN FLEXPRO 4 S PS

PA NUTROPIN AQ 5 S

PA NUTROPIN AQ NUSPIN 5 S

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML PA 5 CRTG) S

PAGE 123 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8 MG VIAL) 5 S

PA SAIZEN-SAIZENPREP 5 S

QL 1 / day SEROSTIM 5 PA S vasopressin 1

PA ZOMACTON 5 S

QL 1 / day ZORBTIVE 5 PA S

PROGESTINS

QL 90 days DEPO-SUBQ PROVERA 104 0 GL Female HCR

GL Female ENDOMETRIN 4 S PS

PA hydroxyprogesterone 1.25 g/5ml 5 GL Female S

PA GL Female MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) 4 S PS

PAGE 124 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.04 / day medroxyprogesterone 150 mg/ml 0 GL Female HCR

GL Female medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10 mg tab) 1 LCG norethindrone ac (lupaneta) 1 GL Female norethindrone 5 mg tablet 1 GL Female progesterone (100 mg capsule, 200 mg capsule) 1 GL Female progesterone oil 50 mg/ml vl 1 GL Female progesterone in oil 1 GL Female

HYPOTENSIVE AGENTS

CENTRAL ALPHA-AGONISTS

QL 0.29 / day clonidine (0.2 mg/day patch, 0.3 mg/day patch) 3 HCG

QL 0.15 / day clonidine 0.1 mg/day patch 3 HCG clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 LCG

QL 4 / day clonidine hcl er 3 HCG methyldopa 1 DIRECT VASODILATORS hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1 hydralazine 20 mg/ml vial 1 minoxidil (2.5 mg tablet, 10 mg tablet) 1

PAGE 125 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HYPOTENSIVE AGENTS, MISCELLANEOUS

PA VECAMYL 5 S

PERIPHERAL ADRENERGIC INHIBITORS reserpine (0.1 mg tablet, 0.25 mg tablet) 1 ION-REMOVING AGENTS

PHOSPHATE-REMOVING AGENTS calcium acetate (667 mg capsule, 667 mg gelcap, 667 mg tablet) 1 FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MG TABLET CHEW) 2 lanthanum carbonate 1 RENVELA 800 MG TABLET 2 sevelamer carbonate (0.8 gm powder packet, 2.4 gm powder packet, carbonate 800 mg tab) 3 HCG POTASSIUM-REMOVING AGENTS

KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1 sps 50 gm/200 ml enema 3 HCG sodium polystyrene sulfonate (sod polystyren sulf 15 g/60 ml, sodium polystyrene sulf powder, sps 15 gm/60 ml suspension, 1 sps 30 gm/120 ml enema)

SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA) 1 MACROLIDES

OTHER MACROLIDES azithromycin (1 gm pwd packet, 100 mg/5 ml susp, 200 mg/5 ml susp, 500 mg tablet, 600 mg tablet) 1 azithromycin 250 mg tablet 1 QL 6 / 5 days

ZMAX 2 QL 60 / fill

PAGE 126 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MISCELLANEOUS B-LACTAM ANTIBIOTICS

MONOBACTAMS aztreonam 1

PA CAYSTON 5 S

MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

QL 1 / day dutasteride 3 GL Male HCG

QL 1 / day finasteride 5 mg tablet 1 GL Male

ALCOHOL DETERRENTS disulfiram (250 mg tablet, 500 mg tablet) 1 ANTIDOTES amyl nitrite 1 calcium disodium versenate 1 deferoxamine mesylate 1 leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25 mg tab) 1 leucovorin calcium (50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500 mg vl) 5 S

MEPHYTON 2 phytonadione 1 mg/0.5 ml syr 1 pralidoxime chloride 300 mg/ml 1

VISTOGARD 5 S vitamin k1 1

PAGE 127 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIGOUT AGENTS

QL 3 / day allopurinol 100 mg tablet 1 LCG

QL 2 / day allopurinol 300 mg tablet 1 LCG colchicine 0.6 mg capsule 1 QL 2 / day colchicine 0.6 mg tablet 1 QL 4 / day

COLCRYS 2 QL 4 / day indomethacin 25 mg capsule 1 LCG indomethacin 50 mg capsule 1 indomethacin er 1 naproxen (125 mg/5 ml suspen, 375 mg tablet, 500 mg kit, 500 mg tablet) 1 LCG naproxen (250 mg tablet, dr 375 mg tablet, dr 500 mg tablet, ec 375 mg tablet, ec 500 mg tablet) 1 naproxen sodium (275 mg tab, 550 mg tab) 1 naproxen sodium cr 3 HCG naproxen sodium ds 1 naproxen sod er 375 mg tablet 3 HCG

QL 1 / day ULORIC 2 ST

BONE RESORPTION INHIBITORS alendronate sodium (5 mg tablet, 10 mg tab) 1 QL 1 / day alendronate sodium (sod 70 mg/75 ml, sodium 35 mg tab, .15 / day sodium 40 mg tab, sodium 70 mg tab) 1 QL etidronate disodium 1 ibandronate sodium 150 mg tab 1 QL 0.04 / day

PAGE 128 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.04 / day risedronate sodium 150 mg tab 3 HCG risedronate sodium 30 mg tab 3 HCG

QL 0.15 / day risedronate sodium 35 mg tab 3 HCG

QL 1 / day risedronate sodium 5 mg tablet 3 HCG risedronate sodium dr 1 CARIOSTATIC AGENTS

CLINPRO 5000 1 DENTA 5000 PLUS 1 DENTAGEL 1

HCR FLUOR-A-DAY 2.5 MG/ML DROPS 0 HCG fluoride 0 HCR

FLUORIDEX 1 FLUORIDEX DAILY DEFENSE 1 FLUORIDEX SENSITIVITY RELIEF 1

HCR FLUORITAB 0.125 MG/DRP DROPS 0 HCG

FLUORITAB (0.5 MG TABLET CHEW, 1 MG TABLET CHEW) 0 HCR

FLURA-DROPS 0 HCR

LUDENT FLUORIDE 0 HCR multivitamin with fluoride (0.25 mg/ml drop, 0.5 mg/ml drop) 1 SF 1 SF 5000 PLUS 1

PAGE 129 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS neutral sodium fluoride 1 sodium fluoride (0.5 mg(1.1 mg), 0.5 mg/ml drop, 1 mg (2.2 mg)) 0 HCR COMPLEMENT INHIBITORS

PA FIRAZYR 5 S

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

QL 0.15 / day ACTEMRA 162 MG/0.9 ML SYRINGE 5 PA S azathioprine 50 mg tablet 1 azathioprine sodium 1 cyclosporine (25 mg capsule, 100 mg capsule, 100 mg/ml soln) 5 S cyclosporine modified 5 S

DEPEN 2

QL 0.15 / day PA ENBREL 50 MG/ML SURECLICK SYR 4 S PS

QL 0.29 / day ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML PA 4 SYRINGE) S PS

GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 100 MG/ML SOLUTION) 5 S

QL 0.1 / day PA KEVZARA 5 AL At least 18 yrs old S

PAGE 130 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS leflunomide 1 methotrexate (1 gm vial, 2.5 mg tablet, 50 mg/2 ml vial, 250 mg/10 ml vial) 1 methotrexate sodium 1 NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATIN CAPSULE, 100 MG/ML SOLUTION) 5 S

QL 0.15 / day ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML SYRINGE, 125 MG/ML SYRINGE) 5 PA S

QL 0.15 / day ORENCIA CLICKJECT 5 PA S

QL 2 / day OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTER PACK) 5 PA S

RIDAURA 2

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE) 5 S

S SANDIMMUNE 100 MG/ML SOLN 4 PS

QL 0.04 / day SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE, 100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE) 5 PA S

QL 0.08 / day STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90 MG/ML SYRINGE) 5 PA S

TREXALL 2

QL 2 / day XELJANZ 5 PA S

PAGE 131 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day XELJANZ XR 5 PA S

GONADOTROPIN-RELEASING HORMONE ANTAGNTS

PA GL Female CETROTIDE 4 S PS

PA FIRMAGON 120 MG VIAL 5 S

GL Female ganirelix acetate 5 S

IMMUNOMODULATORY AGENTS

ACTIMMUNE 5 S

QL 1 / day PA AUBAGIO 4 S PS

QL 0.15 / day AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG, PREFILLED PA 4 SYR 30 MCG KT) S PS

QL 0.15 / day PA AVONEX PEN (PEN 30 MCG/0.5 ML, PEN 30 MCG/0.5 ML KIT) 4 S PS

QL 0.5 / day BETASERON (0.3 MG KIT, 0.3 MG VIAL) 5 PA S

PAGE 132 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day PA COPAXONE 4 S PS

QL 0.5 / day EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 5 PA S

QL 1 / day PA GILENYA 4 S PS

QL 1 / day GLATOPA 5 PA S

QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML SYRING 4 S PS

QL 1 / lifetime PA PLEGRIDY SYRINGE STARTER PACK 4 S PS

QL 0.04 / day PA PLEGRIDY 125 MCG/0.5 ML PEN 4 S PS

QL 1 / lifetime PA PLEGRIDY PEN INJ STARTER PACK 4 S PS

PAGE 133 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day POMALYST 5 PA S

QL 0.22 / day REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE) 5 PA S

QL 4.2 / 365 days REBIF TITRATION PACK 5 PA S

QL 0.22 / day REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 5 PA S

QL 4.2 / 365 days REBIF REBIDOSE TITRATION PACK 5 PA S

QL 1 / day REVLIMID 5 PA S

QL 2 / day PA TECFIDERA 4 S PS

QL 2 / day THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 5 PA S

QL 1 / day THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 5 PA S

PAGE 134 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day ZINBRYTA 5 PA S

IMMUNOSUPPRESSIVE AGENTS

QL 15 / day ASTAGRAF XL 0.5 MG CAPSULE 5 PA S

QL 30 / day ASTAGRAF XL 1 MG CAPSULE 5 PA S

QL 6 / day ASTAGRAF XL 5 MG CAPSULE 5 PA S

CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET) 5 S cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PA

QL 2.5 / day ELIDEL 2 ST AL At least 2 yrs old

QL 1 / day ENVARSUS XR 5 PA S mercaptopurine 50 mg tablet 1 mycophenolate 200 mg/ml susp 5 S mycophenolate mofetil (250 mg capsule, 500 mg tablet) 5 S mycophenolic acid 5 S

MYFORTIC 5 S

PAGE 135 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 5 S

PA PURIXAN 5 S

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MG TABLET) 5 S sirolimus (1 mg tablet, 2 mg tablet) 5 S sirolimus 0.5 mg tablet 5 S

QL 2 / day tacrolimus 0.5 mg capsule 5 S

QL 8 / day tacrolimus 1 mg capsule 5 S

QL 4 / day tacrolimus 5 mg capsule 5 S

PA ZORTRESS 5 S

OTHER MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine (10% vial, 20% vial) 1 alcohol,dehydrated (ampule, vial) 1

QL 2 / day PA AMPYRA 4 S PS

PA ARCALYST 5 S

PA BOTOX COSMETIC 5 S

PAGE 136 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day CERDELGA 5 PA S

CYSTADANE 5 S

CYSTAGON 5 S

QL 0.04 / day ILARIS 150 MG/ML VIAL 5 PA S

QL 4 / day KEVEYIS 5 PA S

KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500 MG PA 5 POWDER PACKET) S levocarnitine (1 g/10 ml soln, 330 mg tablet) 1

ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULT SAMPLE KT, PA 5 300 IR STARTER PACK, 300 IR SUBLINGUAL TAB) S

ORALAIR 100 IR STARTER PACK 5 S

ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG PA 5 CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) S

PROCYSBI 5 S

QL 2 / day SENSIPAR (30 MG TABLET, 60 MG TABLET) 5 PA S

QL 4 / day SENSIPAR 90 MG TABLET 5 PA S

PAGE 137 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

S TYBOST 4 PS

XURIDEN 5 S

PA ZAVESCA 5 S

PROTECTIVE AGENTS

MESNEX 400 MG TABLET 5 S

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CYCLOOXYGENASE-2 (COX-2) INHIBITORS celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day celecoxib 100 mg capsule 1 QL 3 / day celecoxib 400 mg capsule 1 QL 1 / day

OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS diclofenac potassium 1 diclofenac 1.5% topical soln 3 HCG

QL 1000/ 30 days diclofenac sodium 1% gel 3 HCG diclofenac sodium (dr 25 mg tab, dr 50 mg tab, dr 75 mg tab, ec 25 mg tab, ec 50 mg tab, ec 75 mg tab) 1 diclofenac sodium er 1 diflunisal 1 etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet, 500 mg tablet) 1 etodolac er 1 fenoprofen calcium (200 mg capsule, 400 mg capsule) 3 HCG fenoprofen 600 mg tablet 1

PAGE 138 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS flurbiprofen (50 mg tablet, 100 mg tablet) 1 ibuprofen 100 mg/5 ml susp 1 ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1 LCG ketoprofen (75 mg capsule, er 200 mg capsule) 3 HCG

HCG ketoprofen 50 mg capsule 3 LCG ketorolac tromethamine (15 mg/ml carpuject, 15 mg/ml isecure 40 / 23 days syr, 15 mg/ml vial) 1 QL ketorolac tromethamine (30 mg/ml carpuject, 60 mg/2 ml QL 20 / 30 days 1 carpuject, 60 mg/2 ml vial) LCG ketorolac tromethamine (30 mg/ml isecure syr, 30 mg/ml 20 / 23 days syringe) 1 QL

QL 21 / fill ketorolac 10 mg tablet 1 LCG

QL 20 / 23 days ketorolac 30 mg/ml vial 1 LCG ketorolac tromethamine (60 mg/2 ml syringe, 300 mg/10 ml 20 / 30 days vial) 1 QL

KLOFENSAID II 3 HCG meclofenamate sodium (50 mg capsule, 100 mg capsule) 1

QL 5 / day mefenamic acid 250 mg capsule 3 HCG meloxicam 7.5 mg/5 ml susp 1 QL 10 / day

QL 1 / day meloxicam (7.5 mg tablet, 15 mg tablet) 1 LCG nabumetone (500 mg tablet, 750 mg tablet) 1 oxaprozin 3 HCG

PAGE 139 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS piroxicam (10 mg capsule, 20 mg capsule) 1 AL Up to 75 yrs old sulindac (150 mg tablet, 200 mg tablet) 1 tolmetin sodium (200 mg tab, 400 mg cap, 600 mg tab) 1 SALICYLATES carisoprodol compound 1 carisoprodol-aspirin 1 choline mag trisalicylate 1 salsalate (500 mg tablet, 750 mg tablet) 1 PENICILLINS

AMINOPENICILLINS amoxicillin (125 mg/5 ml susp, 200 mg/5 ml susp, 250 mg capsule, 400 mg/5 ml susp, 875 mg tablet) 1 LCG amoxicillin (125 mg tab chew, 250 mg tab chew, 250 mg/5 ml susp, 500 mg capsule, 500 mg tablet) 1 amoxicillin er 3 HCG amoxicillin-clavulanate pot er 3 HCG amoxicillin-clavulanate potass (200-28.5 mg tab chew, 200- 28.5 mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5 ml sus, 400-57 mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 1 600-42.9 mg/5 ml sus, 875-125 mg tablet) ampicillin sodium (1 gm vial, 2 gm vial, 10 gm vial, 125 mg vial, 250 mg vial, 500 mg vial) 1 ampicillin trihydrate (125 mg/5 ml susp, 250 mg capsule, 250 mg/5 ml susp, 500 mg capsule) 1 ampicillin-sulbactam (3 gm vial, 15 gm vl) 1 ampicillin-sulbactam 1.5 gm vl 1 MED Medical Drug

AUGMENTIN 125-31.25 MG/5 ML 2

PAGE 140 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NATURAL PENICILLINS penicillin g potassium 1 penicillin g procaine 1 penicillin g sodium 1 penicillin v potassium (125 mg/5 ml soln, 250 mg tablet, 250 mg/5 ml soln, 500 mg tablet) 1 LCG PENICILLINASE-RESISTANT PENICILLINS dicloxacillin 250 mg capsule 1 dicloxacillin 500 mg capsule 1 LCG nafcillin sodium (1 gm vial, 2 gm vial, 10 gm bulk vial, 10 gm vial) 1 oxacillin sodium (1 gm vial, 2 gm vial, 10 gm vial) 1 RENIN-ANGIOTENSIN-ALDOSTER.INHIB(HYPOTN)

ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN) candesartan cilexetil 1 QL 1 / day eprosartan mesylate 1 QL 1 / day irbesartan 1 QL 1 / day

QL 2 / day losartan potassium (25 mg tab, 50 mg tab) 1 LCG

QL 1 / day losartan potassium 100 mg tab 1 LCG olmesartan medoxomil 1 QL 3 / day telmisartan 1 QL 1 / day valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1 QL 2 / day valsartan 320 mg tablet 1 QL 1 / day

PAGE 141 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN) benazepril hcl (10 mg tablet, 40 mg tablet) 1 QL 2 / day benazepril hcl 20 mg tablet 1 QL 4 / day benazepril hcl 5 mg tablet 1 QL 3 / day captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg 4 / day tablet) 1 QL enalapril maleate (2.5 mg tab, 5 mg tablet, 10 mg tab, 20 mg 2 / day tab) 1 QL fosinopril sodium 1 QL 2 / day

QL 1 / day lisinopril (2.5 mg tablet, 10 mg tablet, 20 mg tablet) 1 LCG lisinopril (5 mg tablet, 30 mg tablet) 1 QL 1 / day lisinopril 40 mg tablet 1 QL 2 / day moexipril hcl 1 QL 1 / day perindopril erbumine 1 QL 1 / day quinapril hcl 1 QL 2 / day ramipril 1 QL 2 / day trandolapril 1 QL 2 / day

RESPIRATORY TRACT AGENTS

ANTIFIBROTIC AGENTS

QL 9 / day ESBRIET (267 MG CAPSULE, 267 MG TABLET) 5 PA S

QL 3 / day ESBRIET 801 MG TABLET 5 PA S

PAGE 142 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day OFEV 5 PA S

ANTITUSSIVES benzonatate 1 AL At least 11 yrs old

MUCOLYTIC AGENTS

QL 5 / day PULMOZYME 5 PA S

VASODILATING AGENTS (RESPIRATORY TRACT)

QL 2 / day ADCIRCA 5 PA S

QL 3 / day ADEMPAS 5 PA S

QL 1 / day PA LETAIRIS 4 S PS

QL 1 / day OPSUMIT 5 PA S

QL 3 / day ORENITRAM ER 5 PA S

PA REMODULIN 5 S

PAGE 143 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 6 / day PA REVATIO 10 MG/ML ORAL SUSP 5 AL At least 18 yrs old S

QL 3 / day PA REVATIO 20 MG TABLET 5 AL At least 18 yrs old S

QL 3 / day sildenafil 5 PA S

QL 2 / day PA TRACLEER 4 S PS

QL 1 / day TYVASO 5 PA S

QL 1 / day TYVASO INSTITUTIONAL START KIT 5 PA S

QL 1 / day TYVASO REFILL KIT 5 PA S

QL 1 / day TYVASO STARTER KIT 5 PA S

PA UPTRAVI 200-800 TITRATION PACK 5 AL At least 18 yrs old S

PAGE 144 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 / day UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG PA TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG 5 TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) AL At least 18 yrs old S

SKELETAL MUSCLE RELAXANTS

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT carisoprodol (250 mg tablet, 350 mg tablet) 1 chlorzoxazone 500 mg tablet 1 cyclobenzaprine 10 mg tablet 1 LCG cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet) 1 LORZONE 750 MG TABLET 1

METAXALL 3 HCG metaxalone 3 HCG methocarbamol (500 mg tablet, 750 mg tablet) 1 methocarbamol 1,000 mg/10 ml 1 tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg capsule, 4 mg tablet, 6 mg capsule) 1 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS dantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 1 GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT baclofen (10 mg tablet, 20 mg tablet) 1 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS orphenadrine er 100 mg tablet 1 orphenadrine citrate (30 mg/ml vial, 60 mg/2 ml ampule, 60 mg/2 ml vial) 1

PAGE 145 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

ALA-CORT 1 alclometasone dipropionate (dipr oint, dipro crm) 1 amcinonide (cream, lotion, ointment) 1 ANUCORT-HC 1 ANUSOL-HC 25 MG SUPPOSITORY 1 betamethasone dipropionate (aug crm, aug gel, aug lot, aug oin, crm, lot, oint) 1 betamethasone valerate (va 0.1% cream, va 0.1% lotion, valer 0.1% ointm, valer 0.12% foam) 1 calcipotriene-betamethasone dp 1 QL 3 / day clobetasol emollient (emollient crm, emollnt foam) 1 clobetasol emulsion 1 clobetasol propionate (cream, gel, ointment, prop foam, prop spray, shampoo, solution, topical lotn) 1 clocortolone pivalate 3 HCG

CLODAN 0.05% SHAMPOO 1 COLOCORT 1 CORMAX 1 desonide (cream, lotion, ointment) 3 HCG desoximetasone (0.05% cream, 0.05% gel, 0.05% ointment, 0.25% cream, 0.25% ointment) 3 HCG diflorasone diacetate (cream, ointment) 1

QL 2.143 / day EUCRISA 2 ST AL At least 2 yrs old fluocinolone acetonide (0.01% body oil, 0.01% cream, 0.01% scalp oil, 0.025% cream, 0.025% ointment) 3 HCG

PAGE 146 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fluocinolone 0.01% solution 1 fluocinonide (0.05% cream, 0.05% gel, 0.05% ointment, 0.05% solution, 0.1% cream) 1 fluocinonide-e 1 fluticasone propionate (0.005% oint, 0.05% cream, 0.05% lotion) 1 halobetasol propionate (cream, ointmnt) 3 HCG

HEMMOREX-HC 1 hydrocortisone (1% absorbase, 1% cream, 1% ointment, 2.5% cream, 2.5% lotion, 2.5% ointment, 100 mg/60 ml) 1 hydrocortisone acetate (25 mg, 30 mg) 1 hydrocortisone butyrate (hydrocort buty lipid crm, hydrocort buty lipo cream, hydrocortisone buty cream, hydrocortisone 1 butyr oint, hydrocortisone butyr soln) hydrocortisone valerate (cream, ointmt) 1 hydrocortisone-pramoxine (1%-1% crm, 2.5%-1% cm, 2.5-1% crm) 1 hydrocortisone-pramoxine hcl 1 lidocaine-hc 2.8-0.55% gel 1 lidocaine-hydrocortisone (lidocaine-hc 3-0.5% cream, lidocaine-hydrocort 3-2.5% gel) 3 HCG lokara 3 HCG mometasone furoate (cream, oint, soln) 1 ORALONE 1 PRAMCORT 1 prednicarbate (cream, ointment) 1 PROCTO-MED HC 1 PROCTO-PAK 1 PROCTOFOAM-HC 2 PROCTOSOL-HC 1

PAGE 147 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROCTOZONE-HC 1

SANADERMRX 3 HCG

SCALACORT 1 triamcinolone acetonide (0.025% cream, 0.025% lotion, 0.025% oint, 0.1% cream, 0.1% lotion, 0.1% ointment, 0.1% 1 paste, 0.147 mg/g spray, 0.5% cream, 0.5% ointment)

TRIANEX 1 TRIDERM 1

TRIDESILON 3 HCG

ANTIPRURITICS AND LOCAL ANESTHETICS

CIDALEAZE 1 doxepin 5% cream 1 ethyl chloride 1

QL 3 / day lidocaine 5% patch 3 HCG lidocaine 5% ointment 1 lidocaine hcl (cream, hcl lotion) 1 lidocaine-prilocaine 1 lidocaine-tetracaine 3 HCG

LIDOPIN 3% CREAM 1 LIDOPRIL 1

QL 1 / day LIDORX 2 PA

LP LITE PAK 1 phenazopyridine hcl (100 mg tab, 200 mg tab) 1 CELL STIMULANTS AND PROLIFERANTS

AVITA 0.025% CREAM 1

PAGE 148 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AVITA 0.025% GEL 3 HCG tretinoin (0.01% gel, 0.025% cream, 0.05% cream, 0.05% gel, 0.1% cream) 1 tretinoin 0.05% emollient crm 1 tretinoin 0.025% gel 3 HCG tretinoin microsphere (gel 0.04% pump, gel 0.04% tube, gel QL 1.667 / day 3 0.1% pump, gel 0.1% tube) HCG

KERATOLYTIC AGENTS

BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) 1 pr benzoyl peroxide 7% wash 1 BP-50% UREA 1

BPO 6% FOAMING CLOTHS 1 QL 2 / day

LATRIX 1 PACNEX 1 potassium hydroxide 5% soln 3 HCG

PR BENZOYL PEROXIDE 1 REA LO 40 (40 CM, 40 TION) 1 REMEVEN 1 SALACYN (CREAM, LOTION) 1 salicylic acid (6% cream, 6% foam, 6% gel, 6% lotion, 6% shampoo, 26% liquid, 27.5% liquid) 1 salicylic acid er 1 silver nitrate 10% solution 1 grafco silver nit applicator 1 UMECTA 40% MOUSSE 1 URE-K 1

PAGE 149 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS urea (35% foam, 39% cream, 40% cream, 40% gel, 40% lotion, 40% nail film susp, 45% cream, 45% lotion, 45% nail 1 gel, 47% cream, 50% cream) KERATOPLASTIC AGENTS coal tar topical solution 1 SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

QL 2 / day acitretin (17.5 mg capsule, 25 mg capsule) 3 HCG

QL 4 / day acitretin 10 mg capsule 3 HCG

QL 1.5 / day adapalene (0.1% cream, 0.3% gel, 0.3% gel pump) 3 HCG adapalene 0.1% gel 1 QL 1.5 / day

QL 2 / day adapalene 0.1% lotion 3 HCG

PA AMNESTEEM 3 HCG

QL 2 / day calcipotriene (cream, ointment) 3 HCG calcipotriene 0.005% solution 1 QL 2 / day

QL 2 / day CALCITRENE 3 HCG calcitriol 3 mcg/g ointment 1 QL 3.334 / day

CARAC 2

PA CLARAVIS 3 HCG

QL 0.357 / day COSENTYX (2 SYRINGES) 5 PA S

PAGE 150 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.357 / day COSENTYX PEN 5 PA S

QL 0.357 / day COSENTYX PEN (2 PENS) 5 PA S

QL 0.357 / day COSENTYX SYRINGE 5 PA S dapsone 5% gel 1 QL 3 / day diclofenac sodium 3% gel 1 QL 100 / 30 days

QL 0.15 / day PA DUPIXENT 5 AL At least 18 yrs old S finasteride 1 mg tablet 1 FLUOROPLEX 2 fluorouracil (0.5% cream, 2% topical soln, 5% cream, 5% topical soln) 1

FORMADON 1 formaldehyde 1

QL 0.434 / day imiquimod 5% cream packet 1 AL At least 12 yrs old

MIRVASO (GEL, GEL PUMP) 2 QL 1 / day

PA MYORISAN 3 HCG podofilox 0.5% topical soln 1

PAGE 151 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PYROGALLIC ACID 1

SOOLANTRA 2 QL 1.5 / day

QL 100 / 30 days tacrolimus (0.03% ointment, 0.1% ointment) 3 ST HCG

QL 0.15 / day TALTZ AUTOINJECTOR 5 PA S

QL 0.15 / day TALTZ AUTOINJECTOR (2 PACK) 5 PA S

QL 0.15 / day TALTZ AUTOINJECTOR (3 PACK) 5 PA S

QL 0.15 / day TALTZ SYRINGE 5 PA S

QL 0.15 / day TALTZ SYRINGE (2 PACK) 5 PA S

QL 0.15 / day TALTZ SYRINGE (3 PACK) 5 PA S

PA TARGRETIN 1% GEL 5 S

QL 1.47 / day tazarotene 0.1% cream 3 HCG

PAGE 152 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS trichloroacetic acid (25%, 75%) 1

QL 3 / day VALCHLOR 5 PA S

PA ZENATANE 3 HCG

SOMATOSTATIN AGONISTS AND ANTAGONISTS

SOMATOSTATIN AGONISTS octreotide acetate (acet 0.05 mg/ml vl, acet 50 mcg/ml amp, acet 50 mcg/ml syr, acet 50 mcg/ml vial, acet 100 mcg/ml amp, acet 100 mcg/ml syr, acet 100 mcg/ml vl, acet 200 mcg/ml vl, PA 5 acet 500 mcg/ml amp, acet 500 mcg/ml syr, acet 500 mcg/ml S vl, 1,000 mcg/5 ml vial, 1,000 mcg/ml vial, 5,000 mcg/5 ml vial)

QL 30 / day SANDOSTATIN 0.05 MG/ML AMPUL 5 PA S

QL 15 / day SANDOSTATIN 0.1 MG/ML AMPUL 5 PA S

QL 3 / day SANDOSTATIN 0.5 MG/ML AMPUL 5 PA S

QL 8 / day SANDOSTATIN 0.2 MG/ML VIAL 5 PA S

QL 1.5 / day SANDOSTATIN 1 MG/ML VIAL 5 PA S

PAGE 153 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 0.04 / day SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MG KT, 30 MG VL) 5 PA S

QL 0.07 / day SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 5 PA S

PA SIGNIFOR 5 S

QL 0.1 / day SIGNIFOR LAR (20 MG KIT, 20 MG VIAL) 5 PA S

QL 0.067 / day SIGNIFOR LAR (40 MG KIT, 40 MG VIAL) 5 PA S

QL 0.04 / day SIGNIFOR LAR (60 MG KIT, 60 MG VIAL) 5 PA S

SOMATOTROPIN AGONISTS AND ANTAGONISTS

SOMATOTROPIN AGONISTS

QL 2 / day EGRIFTA 5 PA S

PA INCRELEX 5 S

SOMATOTROPIN ANTAGONISTS

SOMAVERT 5 S

PAGE 154 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ALPHA- AND BETA-ADRENERGIC AGONISTS bupivacaine hcl-epinephrine 1 lidocaine hcl-epinephrine 1 lidocaine-epinephrine 1

QL 84 / 14 days NORTHERA 5 PA S

SENSORCAINE-EPINEPHRINE 1 SENSORCAINE-MPF EPINEPHRINE (SENSORC MPF 0.25%-EPI, SENSORCN-MPF 0.5%-EPI) 1

XYLOCAINE DENTAL-EPINEPHRINE 1 ALPHA-ADRENERGIC AGONISTS midodrine hcl 1 phenylephrine 10 mg/ml vial 1 THYROID AND ANTITHYROID AGENTS

ANTITHYROID AGENTS methimazole (5 mg tablet, 10 mg tablet) 1 propylthiouracil 50 mg tablet 1 THYROID AGENTS

LEVO-T 3 HCG levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 100 mcg HCG tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 3 mcg tablet, 175 mcg tablet) LCG levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 200 mcg tablet, 300 mcg tablet) 3 HCG

HCG LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 100 MCG TABLET) 3 LCG

PAGE 155 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LEVOXYL (75 MCG TABLET, 88 MCG TABLET, 112 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175 3 HCG MCG TABLET, 200 MCG TABLET) liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 1 NP THYROID 1 SYNTHROID 2

UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 MCG HCG 3 TABLET, 112 MCG TABLET) LCG

UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175 MCG TABLET, 3 HCG 200 MCG TABLET, 300 MCG TABLET) Uncategorized

Unclassified acticoat (4"x48", 4"x8", 8"x16", 16"x16") 1 acticoat surgical 1 aerochamber mini 2 aerochamber mv 2 aerochamber plus flow-vu 2 aerochamber with flowsignal 2 aerochamber z-stat plus 2

QL 2 / day AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 5 PA S

QL 1 / day AFINITOR 2.5 MG TABLET 5 PA S

PA AFINITOR DISPERZ 5 S

AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR

PAGE 156 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AFLURIA QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR air filter 1

QL 8 / day PA ALECENSA 5 AL At least 18 yrs old S allevyn 1 allevyn adhesive 1 allevyn ag 1 allevyn ag gentle 1 allevyn heel 1 allevyn life (5 1/16"x5 1/16", 6 1/16"x 6 1/16", 8 1/4"x8 1/4") 1

QL 6 / day PA ALUNBRIG 5 AL At least 18 yrs old S anastrozole 1 mg tablet 1 apogee hc intermittent 1 azacitidine 5 S

B-PLEX PLUS 1

PA BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 5 S

PA bexarotene 5 S bicalutamide 1

BLEO 15K 5 S

PAGE 157 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS bleomycin sulfate 5 S

QL 4 / day PA BOSULIF 100 MG TABLET 4 S PS

QL 1 / day PA BOSULIF 500 MG TABLET 4 S PS bupivacaine hcl (0.25% ampul, 0.5% ampul, 0.75% ampul) 1 bupivacaine-dextrose 1 butalb-aspirin-caffe 50-325-40 1 QL 6 / day

QL 4 / day CABOMETYX 20 MG TABLET 5 PA S

QL 2 / day CABOMETYX 40 MG TABLET 5 PA S

QL 1.5 / day CABOMETYX 60 MG TABLET 5 PA S capecitabine 5 S

QL 2 / day CAPRELSA 100 MG TABLET 5 PA S

QL 1 / day CAPRELSA 300 MG TABLET 5 PA S

PAGE 158 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS carrasyn hydrogel wound 1 catheter 1

CERAMAX 3 HCG chloroprocaine hcl 1 chlorzoxazone 250 mg tablet 1

QL 2 / day COMETRIQ 100 MG DAILY-DOSE PK 5 PA S

QL 4 / day COMETRIQ 140 MG DAILY-DOSE PK 5 PA S

QL 3 / day COMETRIQ 60 MG DAILY-DOSE PACK 5 PA S conception 1

QL 2.5 / day PA COTELLIC 5 AL At least 18 yrs old S cytarabine 5 S dexchlorpheniramine maleate 1 ear popper 1

EMCYT 5 S

EPISIL 3 HCG

QL 1 / day ERIVEDGE 5 PA S

PAGE 159 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ERWINAZE 5 S ethyl acetate 1 etoposide 50 mg capsule 5 S exemestane 1

PA EXJADE 5 S

FARESTON 2

PA FARYDAK 5 S female self catheter 1 femcap 22 mm cervical cap 0 HCR

PA FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 5 S fexofenadine-pse er 1 QL 1 / day floxuridine 500 mg vial 5 S

AL At least 65 yrs old FLUAD 2017-2018 0 HCR

FLUARIX QUAD 2017-2018 0 HCR

FLUBLOK 2017-2018 0 HCR

FLUBLOK QUAD 2017-2018 0 HCR

FLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 0 HCR FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017-2018 VIAL) 0 HCR flutamide 1

FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR

PAGE 160 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

AL At least 65 yrs old FLUZONE HIGH-DOSE 2017-2018 0 HCR

FLUZONE INTRADERM QUAD 2017-18 0 HCR

FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR

FLUZONE QUAD PEDI 2017-2018 0 HCR

QL 1 / day GILOTRIF 5 PA S

QL 8 / day PA GLEEVEC 100 MG TABLET 4 S PS

QL 2 / day PA GLEEVEC 400 MG TABLET 4 S PS glutaraldehyde 1 glycopyrrolate 1.5 mg tablet 1

PA HEXALEN 5 S

HUMALOG JUNIOR KWIKPEN 2

PA HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 5 S hydrofera blue ready 1 hydroxyurea 500 mg capsule 1

PA HYQVIA HY COMPONENT 5 S

PAGE 161 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1.25 / day IBRANCE 100 MG CAPSULE 5 PA S

QL 1 / day IBRANCE 125 MG CAPSULE 5 PA S

QL 1.667 / day IBRANCE 75 MG CAPSULE 5 PA S

QL 2 / day ICLUSIG 15 MG TABLET 5 PA S

QL 1 / day ICLUSIG 45 MG TABLET 5 PA S

QL 4 / day IMBRUVICA 5 PA S

QL 1 / day PA INGREZZA 80 MG CAPSULE 5 AL At least 18 yrs old S

QL 4 / day PA INLYTA 4 S PS inspiration elite filter 1

PAGE 162 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS insulin syringe (insulin syrin 0.5 ml 30gx1/2", insulin syrin 0.5 ml 30gx5/16", insulin syringe 1 ml 30gx1/2", insulin syringe 1 ml 30gx5/16", ulticare ins safety 1ml 29x1/2, ulticare safety 0.5 2 ml 29gx1/2) insulin syringe u-500 2 IPOL SINGLE DOSE SYRINGE 2

QL 1 / day IRESSA 5 PA S isoproterenol hcl (0.2 mg/ml vial, 1 mg/5 ml vial) 1

PA JADENU 5 S

PA JADENU SPRINKLE 5 S

QL 2 / day JAKAFI 5 PA S kendall 0.9% nacl with cap 3 HCG

QL 3 / day PA KISQALI 200 MG DAILY DOSE 5 AL At least 18 yrs old S

QL 1.5 / day PA KISQALI 400 MG DAILY DOSE 5 AL At least 18 yrs old S

QL 1 / day PA KISQALI 600 MG DAILY DOSE 5 AL At least 18 yrs old S

PAGE 163 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day PA KISQALI FEMARA 200 MG CO-PACK 5 AL At least 18 yrs old S

QL 1.5 / day PA KISQALI FEMARA 400 MG CO-PACK 5 AL At least 18 yrs old S

QL 1 / day PA KISQALI FEMARA 600 MG CO-PACK 5 AL At least 18 yrs old S pari lc plus nebulizer set 1

QL 3 / day LENVIMA 5 PA S letrozole 2.5 mg tablet 1 lidocaine hcl (1% 20 mg/2 ml, 1% 20 mg/2 ml vl, 1% 300 mg/30 ml, 1% 50 mg/5 ml, 1% 50 mg/5 ml vl, 1% vial, 1.5% 1 ampul, 10 mg/ml syringe, 50 mg/5 ml syrng, 200 mg/10 ml syr) lidocaine hcl 0.5% vial 1 MED Medical Drug lidocaine hcl 100 mg/10 ml-ns 1 lomustine 1

QL 2.15 / day LONSURF 15 MG-6.14 MG TABLET 5 PA S

QL 3 / day LONSURF 20 MG-8.19 MG TABLET 5 PA S

PAGE 164 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA LYNPARZA (50 MG CAPSULE, 100 MG TABLET, 150 MG TABLET) 5 S

LYSODREN 5 S magellan insulin safety syrng (syr 0.3 ml, syr 0.5 ml, syringe 1 ml) 2 magellan insulin syringe (syringe 0.3 ml, syringe 0.5 ml) 2

MATULANE 5 S

QL 3 / day PA MAVYRET 4 AL At least 18 yrs old S PS megestrol acetate (acet 40 mg/ml susp, acet 400 mg/10 ml, 625 mg/5 ml susp) 1 megestrol acetate (20 mg tablet, 40 mg tablet) 1

QL 4 / day MEKINIST 0.5 MG TABLET 5 PA S

QL 1 / day MEKINIST 2 MG TABLET 5 PA S melphalan 1 mepivacaine hcl 1

QL 2 / day methadone 5 mg/0.5 ml syringe 1 PA

METHERGINE 1 methylergonovine 0.2 mg tablet 1 methylergonovine maleate (0.2 mg/ml amp, 0.2 mg/ml vl) 1

PAGE 165 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS monoject 0.5 ml syrn 28gx1/2" 2 monoject insulin syringe (insulin syr 0.3 ml, insulin syr 0.5 ml, 1 ml syrn 28gx1/2", insulin syr 1 ml, insulin syr u-100, syringe 1 2 ml)

MUSTARGEN 5 S

MYLERAN 5 S

QL 4 / day NEXAVAR 5 PA S

NILANDRON 5 S

PA nilutamide 5 S

QL 0.124 / day PA NINLARO 5 AL At least 18 yrs old S

PA NOVAREL 5,000 UNIT VIAL 5 S

QL 1 / day ODOMZO 5 PA S

ONCASPAR 5 S optichamber 1

ORAFATE 5 S oxytocin 10 units/ml vial 1 pen needle 2 pillow mask for children 1

PAGE 166 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS POLOCAINE (1% VIAL, 2% VIAL, 3% CARTRIDGE) 1 POLOCAINE-MPF 1

PROTHELIAL 5 S replicare (4"x4", 6"x6", 8"x8") 1 replicare ultra 6"x6" dressing 1 reusable nebulizer kit 1 ropivacaine hcl (20 mg/10 ml, autofuser pmp) 1 ropivacaine hcl (0.2% 40 mg/20 ml, 0.5% 150 mg/30 ml, 0.75% 150 mg/20 ml, 1% 100 mg/10 ml vl, 1% 200 mg/20 ml 1 vl) ropivacaine-ns 0.1% on-q pump 1 rubber mouthpiece 2

QL 2 / day PA RUBRACA (200 MG TABLET, 250 MG TABLET) 5 AL At least 18 yrs old S

QL 2 / day PA RUBRACA 300 MG TABLET 5 AL At least 18 yrs old S

QL 2 / day PA RYDAPT 5 AL At least 18 yrs old S

SENSORCAINE 1 SENSORCAINE WITH DEXTROSE 1 SENSORCAINE-MPF (0.25% AMPUL, 0.25% VIAL, 0.5% AMPUL, 0.5% VIAL, 0.75% AMPUL, 0.75% VIAL) 1 silicone mask (mask-adult, mask-infant, mask-pediatric) 1

PAGE 167 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sodium succinate 1

QL 1 / day SPRYCEL (100 MG TABLET, 140 MG TABLET) 5 PA S

QL 2 / day SPRYCEL (70 MG TABLET, 80 MG TABLET) 5 PA S

QL 9 / day SPRYCEL 20 MG TABLET 5 PA S

QL 3 / day SPRYCEL 50 MG TABLET 5 PA S

QL 4 / day STIVARGA 5 PA S

PA AL Up to 18 yrs old STRENSIQ 4 S PS

SUCRAID 5 S sunrise compressor-nebulizer 1

QL 1 / day PA SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 4 S PS

QL 7 / day PA SUTENT 12.5 MG CAPSULE 4 S PS

PAGE 168 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 3 / day PA SUTENT 25 MG CAPSULE 4 S PS

SWABFLUSH 3 HCG

PA SYNRIBO 5 S

PA SYPRINE 5 S

QL 6 / day TAFINLAR 50 MG CAPSULE 5 PA S

QL 4 / day TAFINLAR 75 MG CAPSULE 5 PA S

QL 1 / day PA TAGRISSO 4 AL At least 18 yrs old S PS tamoxifen citrate (10 mg tablet, 20 mg tablet) 0 HCR

QL 1 / day TARCEVA (100 MG TABLET, 150 MG TABLET) 5 PA S

QL 6 / day TARCEVA 25 MG TABLET 5 PA S

PAGE 169 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA TARGRETIN 75 MG CAPSULE 5 S

QL 4 / day PA TASIGNA 4 S PS

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, PA 5 140 MG CAPSULE, 180 MG CAPSULE, 250 MG CAPSULE) S

PA temozolomide 5 S tetracaine hcl 1% ampul 1 thiotepa 15 mg vial 5 S toomey syringe 1

QL 90 / 365 days tretinoin 10 mg capsule 5 S

QL 6 / day PA TYKERB 4 S PS unistik 2 normal 2

VALSTAR 5 S

VAXCHORA BUFFER COMPONENT 2

QL 4 / day VENCLEXTA 5 PA S

QL 1.5 / day VENCLEXTA STARTING PACK 5 PA S

PAGE 170 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 / day PA VOSEVI 4 AL At least 18 yrs old S PS

QL 4 / day VOTRIENT 5 PA S water (bacteriostatic vial, for injection ampul, for injection vial) 1 wide seal diaphragm 0 HCR

QL 2 / day XALKORI 5 PA S

QL 4 / day XELODA 5 PA S xeroform petrol 5"x9" dressing 1

QL 4 / day XTANDI 5 PA S yohimbine 5.4 mg tablet 1

QL 3 / day PA ZEJULA 5 AL At least 18 yrs old S

QL 8 / day ZELBORAF 5 PA S

PAGE 171 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 4 / day ZOLINZA 5 PA S

QL 2 / day ZYDELIG 5 PA S

QL 8 / day PA ZYKADIA 5 AL At least 18 yrs old S

QL 4 / day PA ZYTIGA 250 MG TABLET 4 S PS

QL 2 / day PA ZYTIGA 500 MG TABLET 4 S PS

VASODILATING AGENTS

NITRATES AND NITRITES

QL 4 / day ISOCHRON 3 HCG isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 12 / day mg tablet) 1 QL

QL 4 / day isosorbide dn er 40 mg tablet 3 HCG isosorbide mononitrate 1 QL 2 / day

PAGE 172 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS isosorbide mononitrate er 1 QL 2 / day

QL 1 / day MINITRAN 3 HCG

NITRO-BID 2 QL 4 / day

NITRO-TIME 1 QL 4 / day nitroglycerin (er 2.5 mg cap, er 6.5 mg cap, er 9 mg capsule) 1 QL 4 / day

QL 0.3 / day nitroglycerin 400 mcg spray 3 HCG

QL 0.8 / day nitroglycerin lingual 0.4 mg 3 HCG nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 1 QL 6 / day

QL 1 / day nitroglycerin patch 3 HCG

PHOSPHODIESTERASE TYPE 5 INHIBITORS

QL 0.2 / day CIALIS (10 MG TABLET, 20 MG TABLET) 2 GL Male

QL 1 / day CIALIS (2.5 MG TABLET, 5 MG TABLET) 2 GL Male

QL 0.2 / day VIAGRA 2 GL Male AL At least 18 yrs old

VASODILATING AGENTS, MISCELLANEOUS alprostadil 500 mcg/ml vial 1 isoxsuprine hcl (10 mg tablet, 20 mg tablet) 1 papaverine 60 mg/2 ml vial 1 papaverine-alprostadil 1

PAGE 173 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMINS

MULTIVITAMIN PREPARATIONS

ELDERCAPS 3 HCG

MATERNITY 1 GL Female multivitamins-a,b,d,e,k,zn (pediatric drops, softgels) 3 HCG multivitamins chewables tablet 1 THERAPEUTIC VITAMIN W-MINERALS 1 V-C FORTE 1 VIC-FORTE 1 VITAMIN A vitamins a,c,d and fluoride 1 VITAMIN B COMPLEX

B-12 KIT 1 b-complex 1 cyanocobalamin injection 1 FOLBEE 1 FOLBEE PLUS CZ 1 folic acid 1 mg tablet 1 folic acid 5 mg/ml vial 1 folic acid-vit b6-vit b12 1 FOLPLEX 2.2 1 hydroxocobalamin 1,000 mcg/ml 1 pyridoxine 100 mg/ml vial 1 RENA-VITE RX 1 thiamine 200 mg/2 ml vial 1 VIRT-CAPS SOFTGEL 1

PAGE 174 LAST UPDATED 10/2017 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VIRT-GARD 1 VIRT-VITE 1

VIRT-VITE PLUS 3 HCG

VP-VITE RX 1 ZOLATE 1 VITAMIN C ascorbic acid 500 mg/ml vial 1 VITAMIN D calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1 doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcg cap) 5 S

HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE) 5 S paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 5 S

RAYALDEE 5 S vitamin d2 1

PA ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 5 S

PAGE 175 LAST UPDATED 10/2017 Index of Covered Drugs AFEDITAB CR 85 A AFINITOR 156 A-METHAPRED 106 AFINITOR DISPERZ 156 abacavir 69 AFLURIA 2016-2017 73 abacavir-lamivudine 69 AFLURIA 2017-2018 156 abacavir-lamivudine-zidovudine 69 AFLURIA QUAD 2016-2017 73 acamprosate calcium 86 AFLURIA QUAD 2017-2018 157 acarbose 45 air filter 157 ACD 95 AK-POLY-BAC 20 acebutolol hcl 28 AKYNZEO 50 acetamin-caff-dihydrocodeine 5 ALA-CORT 146 acetaminophen-codeine 5 albuterol sulfate 3 ACETASOL HC 22 alclometasone dipropionate 146 acetazolamide 54 alcohol,dehydrated 136 acetazolamide sodium 54 ALECENSA 157 acetic acid 22 alendronate sodium 128 acetic acid-aluminum 22 alfentanil hcl 8 acetylcysteine 136 alfuzosin hcl er 4 acetylcysteine-water 99 allevyn 157 acitretin 150 allevyn adhesive 157 ACTEMRA 130 allevyn ag 157 ACTHIB 73 allevyn ag gentle 157 acticoat 156 allevyn heel 157 acticoat surgical 156 allevyn life 157 ACTIMMUNE 132 allopurinol 128 ACTOPLUS MET XR 46 almotriptan malate 60 ACUVAIL 26 alosetron hcl 101 acyclovir 23,78 ALPHAGAN P 54 ADACEL TDAP 73 ALPHAQUIN HP 90 adapalene 150 alprazolam 81 ADCIRCA 143 alprazolam er 81 adefovir dipivoxil 78 alprazolam odt 81 ADEMPAS 143 alprazolam xr 81 ADVAIR DISKUS 3 alprostadil 173 ADVAIR HFA 3 ALTACAINE 100 aerochamber mini 156 ALTAFLUOR 100 aerochamber mv 156 ALTAVERA 108 aerochamber plus flow-vu 156 ALUNBRIG 157 aerochamber with flowsignal 156 ALYACEN 108 aerochamber z-stat plus 156 AMABELZ 97 AEROSPAN 89 amantadine 62 amcinonide 146 aprepitant 51 AMETHIA 108 APRI 108 AMETHIA LO 108 APRISO 101 AMETHYST 108 APTIVUS 70 amikacin sulfate 31 ARANELLE 108 amiloride hcl 91 ARANESP 83 amiloride-hydrochlorothiazide 91 ARBINOXA 55 amiodarone hcl 29 ARCALYST 136 AMITIZA 102 aripiprazole 63 amitriptyline hcl 44 aripiprazole odt 63 amlodipine besylate 85 ARIXTRA 37 amlodipine besylate-benazepril 85 armodafinil 19 amlodipine-atorvastatin 59 ARNUITY ELLIPTA 89 amlodipine-olmesartan 85 asa-butalb-caffeine-codeine 8 amlodipine-valsartan 85 ASCOMP WITH CODEINE 8 amlodipine-valsartan-hctz 85 ascorbic acid 175 ammonium lactate 96 ASHLYNA 108 AMNESTEEM 150 aspirin-caffeine-dihydrocodein 71 amoxapine 44 aspirin-dipyridamole er 71 amoxicillin 140 ASTAGRAF XL 135 amoxicillin er 140 ASTRAMORPH-PF 8 amoxicillin-clavulanate pot er 140 atenolol 29 amoxicillin-clavulanate potass 140 atenolol-chlorthalidone 29 amphotericin b 52 ATIVAN 40 ampicillin sodium 140 atomoxetine hcl 86 ampicillin trihydrate 140 atorvastatin calcium 59 ampicillin-sulbactam 140 atovaquone 63 AMPYRA 136 atovaquone-proguanil hcl 62 amyl nitrite 127 ATRIPLA 68 anagrelide hcl 72 atropine sulfate 35,100 anastrozole 157 atropine sulfate-0.9% nacl 100 ANDRODERM 107 AUBAGIO 132 ANDROGEL 107 AUBRA 108 ANORO ELLIPTA 3 AUGMENTIN 140 antivenin latrodectus mactans 72 AUSTEDO 86 antivenin micrurus fulvius 72 AVANDAMET 46 ANUCORT-HC 146 AVANDIA 50 ANUSOL-HC 146 AVAR 23 apogee hc intermittent 157 AVAR-E 23 APOKYN 94 AVAR-E GREEN 23 apraclonidine hcl 99 AVIANE 108 AVIDOXY 33 betamethasone valerate 146 AVITA 148,149 BETASERON 132 AVONEX 132 betaxolol hcl 29,54 AVONEX PEN 132 bethanechol chloride 82 azacitidine 157 BETHKIS 31 azathioprine 130 bexarotene 157 azathioprine sodium 130 BEXSERO 73 azelastine hcl 99 bicalutamide 157 azithromycin 126 bimatoprost 55 AZOPT 54 BIOGLO 90 aztreonam 127 BIOTHRAX 73 AZUPHEN MB 19 bisoprolol fumarate 29 AZURETTE 109 bisoprolol-hydrochlorothiazide 29 BLANCHE 90 B BLEO 15K 157 B-12 KIT 174 bleomycin sulfate 158 b-complex 174 BLISOVI 24 FE 109 B-DONNA 35 BLISOVI FE 109 B-PLEX PLUS 157 BOOSTRIX TDAP 73 BACIIM 34 BOSULIF 158 bacitracin 20,34 BOTOX COSMETIC 136 bacitracin-polymyxin 20 BP 10-1 23 baclofen 145 BP-50% UREA 149 BACTROBAN NASAL 20 BPO 149 balanced salt 99 BRAVELLE 121 balsalazide disodium 101 BREO ELLIPTA 3 BALZIVA 109 BRIELLYN 109 BARACLUDE 78 BRILINTA 71 BEKYREE 109 brimonidine tartrate 54 belladonna-opium 8 BROMFED DM 56 belladonna-phenobarbital 35 bromfenac sodium 26 benazepril hcl 142 bromocriptine mesylate 93 benazepril-hydrochlorothiazide 92 brompheniramine-pseudoephed-dm 56 BENLYSTA 157 BSS 100 BENZEPRO 149 budesonide 25,89 benzonatate 143 budesonide ec 106 benzoyl peroxide 149 bumetanide 91 benzphetamine hcl 16 BUPAP 5 benztropine mesylate 36 BUPHENYL 94 betamethasone acetate-sod phos 106 bupivacaine hcl 158 betamethasone dipropionate 146 bupivacaine hcl-epinephrine 155 bupivacaine-dextrose 158 CAPRELSA 158 buprenorphine hcl 14 captopril 142 buprenorphine-naloxone 14 captopril-hydrochlorothiazide 92 BUPROBAN 41 CARAC 150 bupropion hcl 41 CARAFATE 76 bupropion hcl sr 41 CARBAGLU 94 bupropion xl 41 carbamazepine 38 buspirone hcl 80 carbamazepine er 38 butalb-acetaminoph-caff-codein 5 CARBATROL 38 butalb-caff-acetaminoph-codein 5 carbidopa 86 butalbital compound-codeine 8 carbidopa-levodopa 62 butalbital-acetaminophen 5 carbidopa-levodopa er 62 butalbital-acetaminophen-caffe 5,6 carbidopa-levodopa-entacapone 62 butalbital-aspirin-caffeine 71,158 carbinoxamine maleate 55 butorphanol tartrate 15 cardioplegic 95 BYDUREON 48 carisoprodol 145 BYDUREON PEN 48 carisoprodol compound 140 BYETTA 48 carisoprodol compound-codeine 9 BYSTOLIC 83 carisoprodol-aspirin 140 BYVALSON 83 carisoprodol-aspirin-codeine 9 carrasyn hydrogel wound 159 C carteolol hcl 54 cabergoline 93 CARTIA XT 30 CABOMETYX 158 carvedilol 4 caffeine and sodium benzoate 17 catheter 159 caffeine citrate 17 CATHFLO ACTIVASE 72 calcipotriene 150 CAYSTON 127 calcipotriene-betamethasone dp 146 CAZIANT 109 calcitonin-salmon 123 cefaclor 88 CALCITRENE 150 cefaclor er 88 calcitriol 150,175 cefadroxil 88 calcium acetate 126 cefazolin sodium 88 calcium disodium versenate 127 cefdinir 88 CAMILA 109 cefditoren pivoxil 88 CAMRESE 109 cefepime hcl 88 CAMRESE LO 109 cefixime 88 CANASA 101 cefotaxime sodium 89 candesartan cilexetil 141 cefotetan 88 candesartan-hydrochlorothiazid 92 cefpodoxime proxetil 89 CAPACET 6 cefprozil 88 capecitabine 158 ceftazidime 89 ceftibuten 89 cimetidine 76 CEFTIN 88 CIMZIA 103 ceftriaxone 89 CIPRODEX 20 cefuroxime 88 ciprofloxacin 32 cefuroxime sodium 88 ciprofloxacin er 32 celecoxib 138 ciprofloxacin hcl 20,32 CELLCEPT 135 citalopram hbr 42 CENTERGY 56 CLARAVIS 150 CENTERGY DM 56 clarithromycin 61 cephalexin 88 clarithromycin er 61 CERAMAX 159 CLEANSING WASH 24 CERDELGA 137 clemastine fumarate 55 CERVARIX 73 CLEOCIN 22 CESAMET 51 CLIMARA PRO 97 cetirizine hcl 56 CLINDACIN ETZ 22 CETROTIDE 132 CLINDACIN P 22 cevimeline hcl 82 clindamax 22 CHANTIX 82 clindamycin hcl 34 CHATEAL 109 clindamycin palmitate hcl 34 CHENODAL 102 clindamycin pediatric 34 chlordiazepoxide hcl 81 clindamycin phos-benzoyl perox 22 chlordiazepoxide-amitriptyline 44 clindamycin phos-tretinoin 22 chlordiazepoxide-clidinium 35 clindamycin phosphate 22,34 chlorhexidine gluconate 22 clindamycin-benzoyl peroxide 23 chloroprocaine hcl 159 CLINPRO 5000 129 chloroquine phosphate 62 clobetasol emollient 146 chlorothiazide 91 clobetasol emulsion 146 chlorpromazine hcl 67 clobetasol propionate 146 chlorpropamide 49 clocortolone pivalate 146 chlorthalidone 92 CLODAN 146 chlorzoxazone 145,159 clomiphene citrate 97 CHOLBAM 102,103 clomipramine hcl 45 cholestyramine 58 clonazepam 40 cholestyramine light 58 clonidine 125 choline mag trisalicylate 140 clonidine hcl 125 chorionic gonadotropin 121 clonidine hcl er 125 CIALIS 173 clopidogrel 72 CICLODAN 53 clorazepate dipotassium 40 ciclopirox 53 clotrimazole 53 CIDALEAZE 148 clotrimazole-betamethasone 53 cilostazol 71 clozapine 63,64 clozapine odt 64 cyclobenzaprine hcl 145 coal tar 150 cyclopentolate hcl 100 cocaine hcl 100 cyclopentolate-lidoc-pe-tropic 100 codeine sulfate 9 cyclopentolate-tropicamide-pe 101 colchicine 128 cyclophosphamide 135 COLCRYS 128 cycloserine 61 colestipol hcl 58 cyclosporine 130 colistimethate 34 cyclosporine modified 130 COLOCORT 146 cyproheptadine hcl 55 COMBIGAN 54 CYRED 110 COMBIVENT RESPIMAT 3 CYSTADANE 137 COMBIVIR 69 CYSTAGON 137 COMETRIQ 159 CYSTARAN 100 COMPAZINE 51 cytarabine 159 COMPLERA 68 CYTRA-2 94 COMPOUND 347 104 CYTRA-K 94 COMPRO 51 conception 159 D CONSTULOSE 95 DAKLINZA 106 COPAXONE 133 danazol 107 COPEGUS 78 dantrolene sodium 145 CORDARONE 29 dapsone 61,151 CORLANOR 86 DAPTACEL DTAP 73 CORMAX 146 darifenacin er 105 cortisone acetate 106 DASETTA 110 COSENTYX (2 SYRINGES) 150 DAYSEE 110 COSENTYX PEN 151 DEBLITANE 110 COSENTYX PEN (2 PENS) 151 deferoxamine mesylate 127 COSENTYX SYRINGE 151 DELTASONE 106 cosyntropin 90 DELYLA 110 COTELLIC 159 demeclocycline hcl 33 COUMADIN 37 DENTA 5000 PLUS 129 COVARYX 97 DENTAGEL 129 COVARYX H.S. 97 DEPADE 87 CREON 102 DEPAKOTE ER 38 CRIXIVAN 70 DEPAKOTE SPRINKLE 38 cromolyn sodium 26,27 DEPEN 130 CRYSELLE 109 DEPO-SUBQ PROVERA 104 124 CUVITRU 72 DERMAZENE 24 cyanocobalamin injection 174 DESCOVY 69 CYCLAFEM 110 desipramine hcl 45 desloratadine 56 diltiazem 24hr er 30 desmopressin acetate 55,123 diltiazem er 30 desogestr-eth estrad eth estra 110 diltiazem hcl 30 desogestrel-ethinyl estradiol 110 dimenhydrinate 51 desonide 146 diphenhydramine hcl 55 desoximetasone 146 diphenoxylate-atropine 35 desvenlafaxine er 42 diphtheria-tetanus toxoids-ped 73 desvenlafaxine fumarate er 42 dipyridamole 72 desvenlafaxine succinate er 42 disopyramide phosphate 28 dexamethasone 106 disulfiram 127 DEXAMETHASONE INTENSOL 106 divalproex sodium 38 dexamethasone sodium phosphate 25 divalproex sodium er 38 dexchlorpheniramine maleate 159 DIVIGEL 97 DEXEDRINE 16 dofetilide 29 dexmethylphenidate hcl 17 donepezil hcl 82 dexmethylphenidate hcl er 17 donepezil hcl odt 82 dextroamphetamine sulfate 16 dorzolamide hcl 54 dextroamphetamine sulfate er 16,17 dorzolamide-timolol 54 dextroamphetamine-amphet er 17 doxazosin mesylate 4 dextroamphetamine-amphetamine 17 doxepin hcl 45,148 diazepam 40 doxercalciferol 175 diclofenac potassium 138 doxycycline hyclate 20,33 diclofenac sodium 26,138,151 doxycycline ir-dr 33 diclofenac sodium er 138 doxycycline monohydrate 33 diclofenac sodium-misoprostol 76 dronabinol 51 dicloxacillin sodium 141 droperidol 80 dicyclomine hcl 35 drospirenone-eth estra-levomef 110 didanosine 69 drospirenone-ethinyl estradiol 110 diethylpropion hcl 15 DUAVEE 97 diethylpropion hcl er 15 duloxetine hcl 42 diflorasone diacetate 146 DUOPA 62 diflunisal 138 DUPIXENT 151 DIGITEK 27 DURAMORPH 9 DIGOX 27 dutasteride 127 digoxin 27 dutasteride-tamsulosin 4 dihydroergotamine mesylate 4 DYMISTA 57 DILANTIN 28 DILANTIN-125 28 E DILT-XR 30 ear popper 159 diltiazem 12hr er 30 econazole nitrate 53 diltiazem 24hr cd 30 ED-SPAZ 35 EDURANT 68 EPZICOM 69 EEMT 97 ergoloid mesylates 4 EEMT H.S. 97 ergotamine-caffeine 4 EFFER-K 95 ERIVEDGE 159 EGRIFTA 154 ERRIN 111 ELDERCAPS 174 ERWINAZE 160 eletriptan hbr 60 ERY 23 ELIDEL 135 ERYPED 200 32 ELIGARD 121 erythromycin 20,23,32 ELINEST 110 erythromycin ethylsuccinate 32 ELLA 110 erythromycin-benzoyl peroxide 23 EMBEDA 9 ESBRIET 142 EMCYT 159 escitalopram oxalate 42 EMFLAZA 106 ESGIC 6 EMOQUETTE 111 esomeprazole magnesium 76 EMTRIVA 69 esomeprazole strontium 76 enalapril maleate 142 ESTARYLLA 111 enalapril-hydrochlorothiazide 92 estazolam 81 ENBREL 130 ESTRACE 97 ENDOCET 6 estradiol 97,98 ENDOMETRIN 124 estradiol valerate 98 ENGERIX-B ADULT 73 estradiol-norethindrone acetat 98 ENGERIX-B PEDIATRIC-ADOLESCENT 74 ESTRING 98 ENJUVIA 97 estrogen-methyltestosterone 98 enoxaparin sodium 37 estropipate 98 ENPRESSE 111 eszopiclone 80 ENSKYCE 111 ethacrynic acid 91 entacapone 62 ethambutol hcl 61 entecavir 78 ethosuximide 41 ENULOSE 95 ethyl acetate 160 ENVARSUS XR 135 ethyl chloride 148 EPCLUSA 105 ethynodiol-ethinyl estradiol 111 epinastine hcl 99 etidronate disodium 128 epinephrine 3 etodolac 138 EPISIL 159 etodolac er 138 EPITOL 38 etoposide 160 EPIVIR 69 EUCRISA 146 EPIVIR HBV 69 EVOTAZ 70 eplerenone 92 exemestane 160 EPOGEN 83 EXJADE 160 eprosartan mesylate 141 EXODERM 53 EXTAVIA 133 FLUAD 2017-2018 160 EZ FLU 16-17 (FLUZON QUAD PED) 74 FLUARIX QUAD 2016-2017 74 EZ FLU 2016-2017 (AFLURIA) 74 FLUARIX QUAD 2017-2018 160 EZ FLU 2016-2017 (FLUVIRIN) 74 FLUBLOK 2016-2017 74 ezetimibe 58 FLUBLOK 2017-2018 160 ezetimibe-simvastatin 58 FLUBLOK QUAD 2017-2018 160 FLUCAINE 90 F FLUCELVAX QUAD 2016-2017 74 FALMINA 111 FLUCELVAX QUAD 2017-2018 160 famciclovir 78 fluconazole 52 famotidine 76 flucytosine 52 FARESTON 160 fludrocortisone acetate 107 FARYDAK 160 FLULAVAL QUAD 2016-2017 74 FAYOSIM 111 FLULAVAL QUAD 2017-2018 160 felbamate 38 flunisolide 25 felodipine er 85 fluocinolone acetonide 146,147 female self catheter 160 fluocinolone acetonide oil 25 femcap 160 fluocinonide 147 FEMYNOR 111 fluocinonide-e 147 fenofibrate 58,59 FLUOR-A-DAY 129 fenofibric acid 59 FLUOR-I-STRIP AT 91 fenoprofen calcium 138 fluorescein-benoxinate 100 fentanyl 9 fluorescein-proparacaine 91 fentanyl citrate 9 fluoride 129 fentanyl-bupivacaine-0.9% nacl 9 FLUORIDEX 129 fentanyl-ropivacaine-0.9% nacl 9 FLUORIDEX DAILY DEFENSE 129 FEROCON 27 FLUORIDEX SENSITIVITY RELIEF 129 FEROTRINSIC 27 FLUORITAB 129 FERRIPROX 160 fluorometholone 25 FERROCITE PLUS 27 FLUOROPLEX 151 fexofenadine hcl 56 fluorouracil 151 fexofenadine-pse er 160 fluoxetine dr 42 finasteride 127,151 fluoxetine hcl 42,43 FIRAZYR 130 fluphenazine decanoate 67 FIRMAGON 132 fluphenazine hcl 67 flavoxate hcl 105 FLURA-DROPS 129 flecainide acetate 28 flurazepam hcl 81 FLOVENT DISKUS 89 flurbiprofen 139 FLOVENT HFA 89 flurbiprofen sodium 26 floxuridine 160 FLUROX 100 FLUAD 2016-2017 74 flutamide 160 fluticasone propionate 26,147 galantamine er 82 fluticasone-salmeterol 3 galantamine hbr 82 fluvastatin er 59 galantamine hydrobromide 82 fluvastatin sodium 59 GAMMAGARD LIQUID 72 FLUVIRIN 2016-2017 74 GAMMAKED 72 FLUVIRIN 2017-2018 160 GAMUNEX-C 72 fluvoxamine maleate 43 ganirelix acetate 132 fluvoxamine maleate er 43 GARDASIL 74 FLUZONE HIGH-DOSE 2016-2017 74 GARDASIL 9 74 FLUZONE HIGH-DOSE 2017-2018 161 gatifloxacin 20 FLUZONE INTRADERM QUAD 2016-17 74 GATTEX 103 FLUZONE INTRADERM QUAD 2017-18 161 GAVILYTE-C 102 FLUZONE QUAD 2016-2017 74 GAVILYTE-G 102 FLUZONE QUAD 2017-2018 161 GAVILYTE-N 102 FLUZONE QUAD PEDI 2016-2017 74 gemfibrozil 59 FLUZONE QUAD PEDI 2017-2018 161 GENERLAC 95 FOLBEE 174 GENGRAF 130 FOLBEE PLUS CZ 174 GENOTROPIN 123 folic acid 174 GENTAK 20 folic acid-vit b6-vit b12 174 gentamicin sulfate 20,23,31 FOLLISTIM AQ 121 GENVOYA 67 FOLPLEX 2.2 174 GIANVI 111 fondaparinux sodium 37 GILDAGIA 111 FORMADON 151 GILDESS 111 formaldehyde 151 GILDESS 24 FE 112 FORTEO 123 GILDESS FE 112 fosamprenavir calcium 70 GILENYA 133 fosinopril sodium 142 GILOTRIF 161 fosinopril-hydrochlorothiazide 92 GLATOPA 133 FOSRENOL 126 GLEEVEC 161 FRAGMIN 38 glimepiride 49 frovatriptan succinate 61 glipizide 49 FUL-GLO 91 glipizide er 49 FULYZAQ 101 glipizide xl 49 furosemide 91 glipizide-metformin 46 FUZEON 67 GLUCAGEN 57 FYAVOLV 98 GLUCAGON EMERGENCY KIT 57 glucagon hcl 57 G glutaraldehyde 161 gabapentin 6 glyburide 49 GABITRIL 38 glyburide micronized 49 glyburide-metformin hcl 46 HUMALOG 48 glycopyrrolate 35,161 HUMALOG JUNIOR KWIKPEN 161 GLYDO 100 HUMALOG KWIKPEN U-100 48 GOLYTELY 102 HUMALOG KWIKPEN U-200 48 GONAL-F 121 HUMALOG MIX 50-50 48 GONAL-F RFF 121 HUMALOG MIX 50-50 KWIKPEN 48 GONAL-F RFF REDI-JECT 121 HUMALOG MIX 75-25 48 granisetron hcl 50 HUMALOG MIX 75-25 KWIKPEN 49 GRANIX 83 HUMATROPE 123 griseofulvin 52 HUMIRA 103 griseofulvin ultramicrosize 52 HUMIRA PEDIATRIC CROHN'S 103 guaiacol 24 HUMIRA PEN 103 guanfacine hcl 87 HUMIRA PEN CROHN-UC-HS STARTER 103 guanfacine hcl er 87 HUMIRA PEN PSORIASIS-UVEITIS 104 guanidine hcl 82 HUMULIN R U-500 49 HUMULIN R U-500 KWIKPEN 49 H HYCAMTIN 161 H.P. ACTHAR 90 hydralazine hcl 125 halobetasol propionate 147 hydrochlorothiazide 91 haloperidol 66 hydrocod-cpm-pseudoephedrine 9 haloperidol decanoate 67 hydrocodone-acetaminophen 6 haloperidol decanoate 100 67 hydrocodone-chlorpheniramne er 56 haloperidol lactate 67 hydrocodone-homatropine mbr 35 HARVONI 105 hydrocodone-ibuprofen 10 HAVRIX 74 hydrocortisone 107,147 HEATHER 112 hydrocortisone acetate 147 HECTOROL 175 hydrocortisone butyrate 147 HEMANGEOL 29 hydrocortisone valerate 147 HEMATINIC PLUS 27 hydrocortisone-acetic acid 22 HEMATINIC WITH FOLIC ACID 27 hydrocortisone-iodoquinol 24 HEMAX 27 hydrocortisone-iodoquinol-aloe 24 HEMMOREX-HC 147 hydrocortisone-pramoxine 147 HEMOCYTE-F 27 hydrocortisone-pramoxine hcl 147 heparin sodium 38 hydrofera blue ready 161 HEPSERA 78 HYDROMET 35 HETLIOZ 80 hydromorphone er 10 HEXALEN 161 hydromorphone hcl 10,11 HIBERIX 74 hydroquinone 90 HIZENTRA 72 hydroxocobalamin 174 HOMATROPAIRE 101 hydroxychloroquine sulfate 62 homatropine hydrobromide 101 hydroxyprogesterone caproate 124 hydroxyurea 161 INGREZZA 87,162 hydroxyzine hcl 80 INLYTA 162 hydroxyzine pamoate 80 inspiration elite filter 162 HYOPHEN 19 insulin syringe 163 hyoscyamine sulfate 35 insulin syringe u-500 163 hyoscyamine sulfate er 35 INTELENCE 68 hyoscyamine sulfate sr 35 INTRON A 77 HYOSYNE 35 INTROVALE 112 HYPERHEP B S-D 72 INVIRASE 70 HYPERRAB S-D 72 INVOKAMET 46 HYPERTET S-D 72 INVOKAMET XR 46 HYQVIA 73 INVOKANA 49 HYQVIA HY COMPONENT 161 IPOL 74,163 HYQVIA IG COMPONENT 73 ipratropium bromide 35,100 ipratropium-albuterol 3 I IPRIVASK 37 ibandronate sodium 128 irbesartan 141 IBRANCE 162 irbesartan-hydrochlorothiazide 92,93 IBUDONE 11 IRESSA 163 ibuprofen 139 ISENTRESS 68 ICLUSIG 162 ISENTRESS HD 68 ILARIS 137 ISIBLOOM 112 ILOTYCIN 21 ISOCHRON 172 IMBRUVICA 162 isoflurane 104 imipramine hcl 45 isomethept-caff-acetaminophen 7 imipramine pamoate 45 isomethept-dichloralp-acetamin 7 imiquimod 151 isoniazid 61,62 IMOGAM RABIES-HT 73 isoproterenol hcl 163 IMOVAX RABIES VACCINE 74 isosorbide dinitrate 172 IMPAVIDO 63 isosorbide mononitrate 172 INCRELEX 154 isosorbide mononitrate er 173 INCRUSE ELLIPTA 35 isoxsuprine hcl 173 indapamide 92 isradipine 85 INDIGO CARMINE 90 itraconazole 52 indigotindisulfonate sod-water 90 ivermectin 19 INDIOMIN MB 19 IXIARO 74 indocyanine green 90 indomethacin 128 J indomethacin er 128 JADENU 163 INFANRIX DTAP 73 JADENU SPRINKLE 163 INFED 27 JAKAFI 163 JANTOVEN 37 KLOR-CON 8 95 JANUMET 46 KLOR-CON M10 95 JANUMET XR 46 KLOR-CON M15 95 JANUVIA 47 KLOR-CON M20 95 JARDIANCE 49 KLOR-CON SPRINKLE 95 JENCYCLA 112 KLOR-CON-EF 95 JENTADUETO 46 KORLYM 45 JENTADUETO XR 47 KRISTALOSE 95 JINTELI 98 KURVELO 113 JOLESSA 112 KUVAN 137 JOLIVETTE 112 KYNAMRO 57 JULEBER 112 JUNEL 112 L JUNEL FE 112 labetalol hcl 5 JUNEL FE 24 112 lactic acid 96 JUXTAPID 57 lactulose 95 lamivudine 69 K lamivudine hbv 69 K EFFERVESCENT 95 lamivudine-zidovudine 69 K-SOL 95 lamotrigine 38 KAITLIB FE 113 lamotrigine (blue) 38 KALETRA 70 lamotrigine (green) 39 KALYDECO 90 lamotrigine (orange) 39 KARIVA 113 lamotrigine er 39 KELNOR 1-35 113 lamotrigine odt 39 kendall 0.9% nacl with cap 163 lamotrigine odt (blue) 39 ketamine hcl 104 lamotrigine odt (green) 39 ketoconazole 52,53 lamotrigine odt (orange) 39 ketoprofen 139 LANOXIN 27 ketorolac tromethamine 26,139 LANOXIN PEDIATRIC 28 KEVEYIS 137 lansoprazol-amoxicil-clarithro 77 KEVZARA 130 lansoprazole 77 KIMIDESS 113 lanthanum carbonate 126 KINRIX 74 LANTUS 49 KIONEX 126 LANTUS SOLOSTAR 49 KISQALI 163 LARIN 113 KISQALI FEMARA CO-PACK 164 LARIN 24 FE 113 KITABIS PAK 31 LARIN FE 113 KLOFENSAID II 139 LARISSIA 113 KLOR-CON 95 latanoprost 55 KLOR-CON 10 95 LATRIX 149 LAYOLIS FE 113 LIDORX 148 lc plus 164 LILLOW 114 LEENA 113 lincomycin hcl 34 leflunomide 131 lindane 25 LENVIMA 164 linezolid 34 LESSINA 113 LINZESS 104 LETAIRIS 143 liothyronine sodium 156 letrozole 164 lisinopril 142 leucovorin calcium 127 lisinopril-hydrochlorothiazide 93 LEUKINE 84 lithium 86 leuprolide acetate 121 lithium carbonate 86 levalbuterol concentrate 3 lithium carbonate er 86 levalbuterol hcl 3 LO LOESTRIN FE 114 levetiracetam 39 LOESTRIN FE 114 levetiracetam er 39 lokara 147 LEVO-T 155 LOMAIRA 15 levobunolol hcl 54 LOMEDIA 24 FE 115 levocarnitine 137 lomustine 164 levocetirizine dihydrochloride 56 LONSURF 164 levofloxacin 21,32 loperamide 101 LEVONEST 114 lopinavir-ritonavir 70 levonorg-eth estrad eth estrad 114 LOPREEZA 98 levonorgestrel 114 lorazepam 40 levonorgestrel-eth estradiol 114 LORAZEPAM INTENSOL 40 LEVORA-28 114 LORCET 7 levorphanol tartrate 11 LORCET HD 7 levothyroxine sodium 155 LORCET PLUS 7 LEVOXYL 155,156 LORTAB 7 LEXIVA 70 LORYNA 115 LIALDA 101 LORZONE 145 lidocaine 148 losartan potassium 141 lidocaine hcl 28,100,148,164 losartan-hydrochlorothiazide 93 lidocaine hcl viscous 100 lovastatin 59 lidocaine hcl-0.9% nacl 164 LOVENOX 38 lidocaine hcl-epinephrine 155 LOW-OGESTREL 115 lidocaine-epinephrine 155 loxapine 63 lidocaine-hydrocortisone 147 LP LITE PAK 148 lidocaine-prilocaine 148 LUCENTIS 100 lidocaine-tetracaine 148 LUDENT FLUORIDE 129 LIDOPIN 148 LUGOL'S 24,52 LIDOPRIL 148 LUMIGAN 55 LUPANETA PACK 121 memantine hcl 87 LUPRON DEPOT 122 MENACTRA 75 LUPRON DEPOT (LUPANETA) 122 MENEST 98 LUPRON DEPOT-PED 122 MENHIBRIX 75 LUTERA 115 MENOMUNE-A-C-Y-W-135 75 LUXAMEND 96 MENOPUR 122 LYNPARZA 165 MENVEO A-C-Y-W-135-DIP 75 LYSIPLEX PLUS 95 MENVEO MENA COMPONENT 75 LYSODREN 165 MENVEO MENCYW-135 COMPONENT 75 LYZA 115 meperidine hcl 11 MEPHYTON 127 M mepivacaine hcl 165 M-M-R II VACCINE 75 meprobamate 80 magellan insulin safety syrng 165 mercaptopurine 135 magellan insulin syringe 165 mesalamine 101 magnesium chloride 39 MESNEX 138 magnesium sulfate 28 MESTINON 82 MAKENA 124 METADATE ER 17 malathion 25 metaproterenol sulfate 3 maprotiline hcl 45 METAXALL 145 MARGESIC 7 metaxalone 145 MARLISSA 115 metformin hcl 47 MARTEN-TAB 7 metformin hcl er 47 MATERNITY 174 methadone hcl 11,12,165 MATULANE 165 METHADONE INTENSOL 12 MATZIM LA 30 methamphetamine hcl 17 MAVYRET 165 methazolamide 54 MD-GASTROVIEW 91 methenamine hippurate 19 me-naphos-mb-hyo 1 19 methenamine mandelate 19 meclizine hcl 51 METHERGINE 165 meclofenamate sodium 139 methimazole 155 MEDROL 107 methocarbamol 145 medroxyprogesterone acetate 125 methotrexate 131 mefenamic acid 139 methotrexate sodium 131 mefloquine hcl 62 methoxsalen 90 megestrol acetate 165 methscopolamine bromide 36 MEKINIST 165 methyclothiazide 91 MELODETTA 24 FE 115 methyldopa 125 meloxicam 139 methyldopa-hydrochlorothiazide 93 MELPAQUE HP 90 methylergonovine maleate 165 melphalan 165 methylphenidate er 18 methylphenidate hcl 18 MONDOXYNE NL 33 methylphenidate hcl cd 18 MONO-LINYAH 115 methylphenidate hcl er 18 monoject 166 methylphenidate la 18,19 MONOJECT 0.9% SODIUM CHLORIDE 95 methylprednisolone 107 monoject insulin syringe 166 methylprednisolone acetate 107 MONOJECT PREFILL 95 methylprednisolone sodium succ 107 MONOJECT PREFILL ADVANCED 96 methyltestosterone 107 MONONESSA 116 metipranolol 54 montelukast sodium 26 metoclopramide hcl 104 MORGIDOX 33 metoclopramide hcl odt 104 morphine sulfate 12,13 metolazone 92 morphine sulfate er 13 metoprolol succinate 29 MOVIPREP 102 metoprolol tartrate 29 MOXEZA 21 metoprolol-hydrochlorothiazide 29 moxifloxacin 21 metronidazole 23,62 moxifloxacin hcl 32 mexiletine hcl 28 MOZOBIL 84 MIACALCIN 123 multivitamin with fluoride 129 MIBELAS 24 FE 115 multivitamin-iron-fluoride 27 MICROGESTIN 115 multivitamins-a,b,d,e,k,zn 174 MICROGESTIN 24 FE 115 mupirocin 23 MICROGESTIN FE 115 MUSTARGEN 166 midazolam hcl 82 MYALEPT 122 midodrine hcl 155 mycophenolate mofetil 135 miglitol 45 mycophenolic acid 135 MIMVEY 98 MYFORTIC 135 MIMVEY LO 98 MYLERAN 166 MINITRAN 173 MYORISAN 151 minocycline hcl 33 MYRBETRIQ 83 minocycline hcl er 33 MYTESI 101 minoxidil 125 MYZILRA 116 MIRCERA 84 mirtazapine 41 N MIRVASO 151 NABI-HB 73 misoprostol 76 nabumetone 139 modafinil 19 nadolol 29 MODERIBA 78 nadolol-bendroflumethiazide 29 moexipril hcl 142 nafcillin sodium 141 moexipril-hydrochlorothiazide 93 naftifine hcl 53 molindone hcl 63 nalbuphine hcl 15 mometasone furoate 26,147 naloxone hcl 87 naltrexone hcl 88 nisoldipine 85 naphazoline hcl 101 NITRO-BID 173 naproxen 128 NITRO-TIME 173 naproxen sodium 128 nitrofurantoin 19 naproxen sodium cr 128 nitrofurantoin mono-macro 19 naproxen sodium ds 128 nitroglycerin 173 naproxen sodium er 128 nitroglycerin patch 173 naratriptan 61 nizatidine 76 naratriptan hcl 61 NODOLOR 7 NATAZIA 116 NORA-BE 116 nateglinide 49 NORCO 7 NATPARA 123 NORDITROPIN FLEXPRO 123 NEBUSAL 96 norethin-eth estra-ferrous fum 116 NECON 116 norethindron-ethinyl estradiol 99,116 nefazodone hcl 44 norethindrone 116 NEO-POLYCIN 21 norethindrone ac (lupaneta) 125 NEO-POLYCIN HC 21 norethindrone acetate 125 neomycin sulfate 31 norgestimate-ethinyl estradiol 116 neomycin-bacitracin-poly-hc 21 NORINYL 1+50 116 neomycin-bacitracin-polymyxin 21 NORLYDA 116 neomycin-polymyxin-dexameth 21 NORLYROC 117 neomycin-polymyxin-gramicidin 21 normal saline flush 96 neomycin-polymyxin-hc 21 NORPACE CR 28 neomycin-polymyxin-hydrocort 21 NORTHERA 155 NEORAL 131 NORTREL 117 NEUAC 23 nortriptyline hcl 45 NEULASTA 84 NORVIR 70 NEUPOGEN 84 NOVAREL 122,166 nevirapine 68 NP THYROID 156 nevirapine er 68 NUEDEXTA 87 NEXAVAR 166 NULEV 36 niacin er 57 NUPLAZID 64 nicardipine hcl 85 NUTROPIN AQ 123 NIFEDICAL XL 85 NUTROPIN AQ NUSPIN 123 nifedipine 85 NUVARING 117 nifedipine er 86 NYAMYC 53 NIKKI 116 NYATA 53 NILANDRON 166 nystatin 52,53 nilutamide 166 nystatin-triamcinolone 53 nimodipine 86 NYSTOP 54 NINLARO 166 OSCIMIN 36 O OSCIMIN SL 36 OBSTETRIX ONE 27 OSCIMIN SR 36 OCALIVA 104 oseltamivir phosphate 78 OCELLA 117 OTEZLA 131 octreotide acetate 153 OVIDREL 122 OCUCOAT 100 oxacillin sodium 141 ODEFSEY 68 oxandrolone 107 ODOMZO 166 oxaprozin 139 OFEV 143 oxazepam 82 ofloxacin 21,32 oxcarbazepine 39 OGESTREL 117 oxiconazole nitrate 53 olanzapine 64 oxybutynin chloride 105 olanzapine odt 64 oxybutynin chloride er 105 olanzapine-fluoxetine hcl 43 oxycodone hcl 13 olmesartan medoxomil 141 oxycodone hcl er 13 olmesartan-amlodipine-hctz 93 oxycodone hcl-aspirin 13 olmesartan-hydrochlorothiazide 93 oxycodone hcl-ibuprofen 14 olopatadine hcl 99 oxycodone-acetaminophen 7 OLYSIO 106 oxymorphone hcl 14 omega-3 acid ethyl esters 57 oxymorphone hcl er 14 omeprazole 77 oxytocin 166 omeprazole-sodium bicarbonate 77 OMNITROPE 123 P ONCASPAR 166 PACERONE 30 ondansetron hcl 50 PACNEX 149 ondansetron odt 50 paliperidone er 64 ONFI 41 PANCRELIPASE 5,000 102 opium tincture 101 pantoprazole sodium 77 OPSUMIT 143 papaverine hcl 173 optichamber 166 papaverine-alprostadil 173 ORAFATE 166 paregoric 101 ORALAIR 137 paricalcitol 175 ORALONE 147 PAROEX 22 ORENCIA 131 paromomycin sulfate 31 ORENCIA CLICKJECT 131 paroxetine cr 43 ORENITRAM ER 143 paroxetine er 43 ORFADIN 137 paroxetine hcl 43,44 ORKAMBI 89 paroxetine mesylate 44 orphenadrine citrate 145 PEDIARIX 73 ORSYTHIA 117 PEDVAXHIB 75 peg 3350-electrolyte 102 PHOSPHA 250 NEUTRAL 94 peg-3350 and electrolytes 102 PHOSPHASAL 19 peg-3350 with flavor packs 102 physostigmine salicylate 83 PEG-PREP 102 phytonadione 127 PEGASYS 77 pillow mask for children 166 PEGASYS PROCLICK 77 pilocarpine hcl 54,83 PEGINTRON 77 pimozide 63 PEGINTRON REDIPEN 77 PIMTREA 117 pen needle 166 pindolol 29 penicillin g potassium 141 pioglitazone hcl 50 penicillin g procaine 141 pioglitazone-glimepiride 49 penicillin g sodium 141 pioglitazone-metformin 47 penicillin v potassium 141 PIRMELLA 117 PENTACEL 75 piroxicam 140 PENTACEL DTAP-IPV COMPONENT 75 PLEGRIDY 133 pentazocine-naloxone hcl 15 PLEGRIDY PEN 133 pentobarbital sodium 81 PNEUMOVAX 23 75 pentoxifylline 84 podofilox 151 perindopril erbumine 142 POLOCAINE 167 PERIOGARD 22 POLOCAINE-MPF 167 permethrin 25 POLYCIN 21 perphenazine 67 polyethylene glycol 3350 102 perphenazine-amitriptyline 45 polymyxin b sul-trimethoprim 21 PHENADOZ 80 polymyxin b sulfate 34 phenazopyridine hcl 148 POLYSACCHARIDE IRON FORTE 27 phendimetrazine tartrate 15,16 POMALYST 134 phenelzine sulfate 41 PORTIA 117 PHENERGAN 80 potass cit-sod cit-citric acid 94 phenobarbital 40 potassium bicarbonate 96 phenobarbital sodium 40 potassium chloride 96 PHENOHYTRO 36 potassium citrate er 94 phenol 24 potassium citrate-citric acid 94 phenoxybenzamine hcl 4 potassium hydroxide 149 phentermine hcl 16 povidone iodine 22 phentolamine mesylate 4 PR BENZOYL PEROXIDE 149 phentolamine-alprostadil 4 PRADAXA 37 phenylephrine hcl 101,155 pralidoxime chloride 127 PHENYTEK 28 PRALUENT PEN 60 phenytoin 28 PRALUENT SYRINGE 60 phenytoin sodium extended 28 PRAMCORT 147 PHILITH 117 pramipexole dihydrochloride 94 pramipexole er 94 promethazine hcl 56,81 prasugrel hcl 72 promethazine vc 56 pravastatin sodium 59 promethazine vc-codeine 14 prazosin hcl 4 promethazine-codeine 56 prednicarbate 147 promethazine-dm 57 prednisolone 107 promethazine-phenyleph-codeine 14 prednisolone acetate 26 promethazine-phenylephrine 57 prednisolone sodium phos odt 107 PROMETHEGAN 81 prednisolone sodium phosphate 26,107 propafenone hcl 28 prednisone 107 propafenone hcl er 28 PREDNISONE INTENSOL 107 propantheline bromide 36 PREGNYL 122 proparacaine hcl 100 PREMARIN 99 propranolol hcl 29 PREMPHASE 99 propranolol hcl er 29 PREMPRO 99 propranolol-hydrochlorothiazid 29 PREVALITE 58 propylthiouracil 155 PREVIFEM 117 PROQUAD 75 PREVNAR 13 75 PROTHELIAL 167 PREZCOBIX 70 protriptyline hcl 45 PREZISTA 71 PULMICORT FLEXHALER 89 primaquine 62 PULMOSAL 96 primidone 40 PULMOZYME 143 PROAIR HFA 3 PURIXAN 136 PROAIR RESPICLICK 3 PYLERA 33 probenecid 96 pyrazinamide 62 probenecid-colchicine 96 pyridostigmine bromide 83 procainamide hcl 28 pyridostigmine bromide er 83 prochlorperazine 51 pyridoxine hcl 174 prochlorperazine edisylate 51 PYROGALLIC ACID 152 prochlorperazine maleate 51 PROCRIT 84 Q PROCTO-MED HC 147 QUADRACEL DTAP-IPV 75 PROCTO-PAK 147 QUASENSE 117 PROCTOFOAM-HC 147 quazepam 82 PROCTOSOL-HC 147 quetiapine fumarate 65 PROCTOZONE-HC 148 quetiapine fumarate er 65 PROCYSBI 137 quinapril hcl 142 progesterone 125 quinapril-hydrochlorothiazide 93 progesterone in oil 125 quinidine gluconate 28 PROGRAF 136 quinidine sulfate 28 PROMACTA 84 quinine sulfate 63 REYATAZ 71 R RIBASPHERE 79 RABAVERT 75 RIBASPHERE RIBAPAK 79 rabeprazole sodium 77 RIBATAB 79 RAJANI 118 ribavirin 79 raloxifene hcl 97 RIDAURA 131 ramipril 142 rifabutin 34 RANEXA 86 rifampin 34 ranitidine hcl 76 riluzole 87 RAPAFLO 5 rimantadine hcl 77 RAPAMUNE 136 risedronate sodium 129 rasagiline mesylate 41 risedronate sodium dr 129 RAVICTI 95 risperidone 65,66 RAYALDEE 175 risperidone odt 66 REA LO 40 149 rivastigmine 83 REBETOL 79 RIVELSA 118 REBIF 134 rizatriptan 61 REBIF REBIDOSE 134 ropinirole er 94 RECLIPSEN 118 ropinirole hcl 94 RECOMBIVAX HB 75 ropivacaine hcl 167 RECOTHROM 55 ropivacaine hcl-0.9% nacl 167 REMEVEN 149 ROSADAN 23 REMODULIN 143 ROSANIL 24 RENA-VITE RX 174 rosuvastatin calcium 59 RENVELA 126 ROTARIX 75 repaglinide 49 ROTATEQ 75 repaglinide-metformin hcl 47 ROWEEPRA 39 REPATHA PUSHTRONEX 60 rubber mouthpiece 167 REPATHA SURECLICK 60 RUBRACA 167 REPATHA SYRINGE 60 RYDAPT 167 replicare 167 replicare ultra 167 S REPREXAIN 14 SABRIL 39 RESCRIPTOR 68 saccharin 96 reserpine 126 SAIZEN 124 RESTASIS 26 SAIZEN-SAIZENPREP 124 RESTASIS MULTIDOSE 26 SALACYN 149 RETROVIR 69 salicylic acid 149 reusable nebulizer kit 167 salicylic acid er 149 REVATIO 144 salsalate 140 REVLIMID 134 SAMSCA 92 SANADERMRX 148 sodium citrate-citric acid 94 SANCUSO 51 sodium fluoride 130 SANDIMMUNE 131 sodium phenylbutyrate 95 SANDOSTATIN 153 sodium polystyrene sulfonate 126 SANDOSTATIN LAR DEPOT 154 sodium succinate 168 SCALACORT 148 sodium sulfacetamide 24 scopolamine 51 sodium sulfacetamide-sulfur 24,25 scopolamine hydrobromide 36 SOJOURN 104 SEB-PREV 24 SOLIQUA 100-33 48 selegiline hcl 41 SOMAVERT 154 selenium sulfide 24 SOOLANTRA 152 SELZENTRY 67 sorbitol 102 SENSIPAR 137 sorbitol-mannitol 91 SENSORCAINE 167 SORINE 29 SENSORCAINE WITH DEXTROSE 167 sotalol 29 SENSORCAINE-EPINEPHRINE 155 sotalol af 29 SENSORCAINE-MPF 167 SOVALDI 106 SENSORCAINE-MPF EPINEPHRINE 155 spinosad 25 SEREVENT DISKUS 3 SPIRIVA 36 SEROPHENE 97 SPIRIVA RESPIMAT 36 SEROQUEL XR 66 spironolactone 92 SEROSTIM 124 spironolactone-hctz 92 sertraline hcl 44 SPRINTEC 118 SETLAKIN 118 SPRYCEL 168 sevelamer carbonate 126 SPS 126 sevoflurane 104 SRONYX 118 SF 129 SSD 25 SF 5000 PLUS 129 SSS 10-5 25 SHAROBEL 118 STAMARIL 75 SIGNIFOR 154 stavudine 69 SIGNIFOR LAR 154 STELARA 131 sildenafil 144 STIMATE 55 silicone mask 167 STIOLTO RESPIMAT 36 silver nitrate 24,149 STIVARGA 168 silver nitrate applicator 149 STRENSIQ 168 silver sulfadiazine 24 streptomycin sulfate 31 SIMPONI 131 STRIBILD 68 simvastatin 59 STRIVERDI RESPIMAT 4 sirolimus 136 strong iodine 52 sodium chloride 96 SUBOXONE 15 sodium citrate 36 SUCRAID 168 sucralfate 76 TALTZ SYRINGE (2 PACK) 152 sulfacetamide sodium 21,25 TALTZ SYRINGE (3 PACK) 152 sulfacetamide sodium-sulfur 25 tamoxifen citrate 169 sulfacetamide-prednisolone 21 tamsulosin hcl 5 SULFACLEANSE 8-4 25 TARCEVA 169 sulfadiazine 32 TARGRETIN 152,170 sulfamethoxazole-trimethoprim 32 TARINA FE 118 sulfasalazine 33 TARON-CRYSTALS 94 sulfasalazine dr 33 TASIGNA 170 SULFATRIM 33 TAYTULLA 118 sulindac 140 tazarotene 152 sumatriptan 61 TAZICEF 89 sumatriptan succinate 61 TAZTIA XT 30 sunrise compressor-nebulizer 168 TECFIDERA 134 SUSTIVA 68 TECHNIVIE 71 SUTENT 168,169 TEGRETOL XR 39 SWABFLUSH 169 telmisartan 141 SYEDA 118 telmisartan-amlodipine 86 SYLATRON 78 telmisartan-hydrochlorothiazid 93 SYMAX 36 temazepam 82 SYMAX-SL 36 TEMODAR 170 SYMAX-SR 36 temozolomide 170 SYMBICORT 4 TENCON 8 SYMLINPEN 120 45 TENIVAC 73 SYMLINPEN 60 45 terazosin hcl 4 SYNAREL 122 terbinafine hcl 52 SYNJARDY 47 terbutaline sulfate 4 SYNJARDY XR 47 terconazole 53 SYNRIBO 169 TERRELL 104 SYNTHROID 156 testosterone cypionate 107 SYPRINE 169 testosterone enanthate 108 SYREX 96 tetanus diphtheria toxoids 73 TETCAINE 100 T tetrabenazine 87 tacrolimus 136,152 tetracaine hcl 100,170 TAFINLAR 169 tetracycline hcl 33 TAGRISSO 169 TETRAVISC 100 TALTZ AUTOINJECTOR 152 TETRAVISC FORTE 100 TALTZ AUTOINJECTOR (2 PACK) 152 THALOMID 134 TALTZ AUTOINJECTOR (3 PACK) 152 THEOCHRON 84 TALTZ SYRINGE 152 theophylline 84 theophylline anhydrous 85 TRANSDERM-SCOP 51 THERACYS 75 tranylcypromine sulfate 41 THERAPEUTIC VITAMIN W-MINERALS 174 TRAVATAN Z 55 THERMAZENE 25 travoprost 55 thiamine hcl 174 trazodone hcl 44 thioridazine hcl 67 tretinoin 149,170 thiotepa 170 tretinoin microsphere 149 thiothixene 67 TREXALL 131 tiagabine hcl 39 TRI FEMYNOR 118 ticlopidine hcl 72 TRI-ESTARYLLA 119 TIKOSYN 30 TRI-LEGEST FE 119 TILIA FE 118 TRI-LINYAH 119 timolol maleate 29,54 TRI-LO-ESTARYLLA 119 tinidazole 63 TRI-LO-MARZIA 119 TIVICAY 68 TRI-LO-SPRINTEC 119 tizanidine hcl 145 TRI-PREVIFEM 119 TOBI 31 TRI-SPRINTEC 119 TOBI PODHALER 31 triacetin 52 tobramycin 21,31 triamcinolone acetonide 26,107,148 tobramycin sulfate 32 triamterene-hydrochlorothiazid 91 tobramycin-dexamethasone 21 TRIANEX 148 tolazamide 50 triazolam 82 tolbutamide 50 trichloroacetic acid 153 tolcapone 62 TRICITRATES 94 tolmetin sodium 140 TRIDERM 148 tolterodine tartrate 105 TRIDESILON 148 tolterodine tartrate er 105 TRIFERIC 27 toomey syringe 170 trifluoperazine hcl 67 TOPAMAX 39 trifluridine 22 topiramate 39 trihexyphenidyl hcl 36 topiramate er 39 TRIKLO 58 torsemide 91 TRILYTE WITH FLAVOR PACKETS 102 TOUJEO SOLOSTAR 49 trimethobenzamide hcl 51 TRACLEER 144 trimethoprim 19 TRADJENTA 48 trimipramine maleate 45 tramadol hcl 14 TRINESSA 119 tramadol hcl er 14 TRINESSA LO 119 tramadol hcl-acetaminophen 8 TRIUMEQ 68 trandolapril 142 TRIVORA-28 119 trandolapril-verapamil er 85 TRIZIVIR 69 tranexamic acid 55 tropicamide 101 trospium chloride 105 trospium chloride er 105 V TRULICITY 48 V-C FORTE 174 TRUVADA 69 valacyclovir 80 TUSSIGON 36 VALCHLOR 153 TWINRIX 75 valganciclovir hcl 80 TYBOST 138 valproic acid 39 TYKERB 170 valsartan 141 TYMLOS 123 valsartan-hydrochlorothiazide 93 TYPHIM VI 75 VALSTAR 170 TYVASO 144 vancomycin hcl 34 TYVASO INSTITUTIONAL START KIT 144 VANDAZOLE 23 TYVASO REFILL KIT 144 VAQTA 75 TYVASO STARTER KIT 144 VARIVAX VACCINE 75 TYZEKA 79 VARIZIG 73 VARUBI 51 U vasopressin 124 ULORIC 128 VAXCHORA ACTIVE COMPONENT 76 UMECTA 149 VAXCHORA BUFFER COMPONENT 170 unistik 2 normal 170 VAXCHORA VACCINE 76 UNITHROID 156 VECAMYL 126 UPTRAVI 144,145 VELIVET 119 UR N-C 19 VEMLIDY 80 URE-K 149 VENCLEXTA 170 urea 150 VENCLEXTA STARTING PACK 170 URELLE 19 venlafaxine hcl 42 URETRON D-S 19 venlafaxine hcl er 42 URIBEL 19 VENTOLIN HFA 4 URIMAR-T 20 verapamil er 31 URIN D.S. 20 verapamil er pm 31 URO-458 20 verapamil hcl 31 URO-BLUE 20 verapamil sr 31 URO-L 20 VERDROCET 8 UROPHEN MB 20 VESICARE 105 ursodiol 102 VESTURA 119 URYL 20 VIAGRA 173 USTELL 20 VIBERZI 104 UTA 20 VIC-FORTE 174 UTIRA-C 20 VICODIN 8 UVADEX 90 VICODIN ES 8 VICODIN HP 8 VICTOZA 2-PAK 48 WERA 120 VICTOZA 3-PAK 48 wide seal diaphragm 171 VIDEX 69 WYMZYA FE 120 VIDEX EC 70 VIEKIRA PAK 71 X VIEKIRA XR 71 XALKORI 171 VIENVA 120 XARELTO 37 vigabatrin 39 XELJANZ 131 VIGAMOX 22 XELJANZ XR 132 VIORELE 120 XELODA 171 VIRACEPT 71 XENAZINE 87 VIRAMUNE 68 XERMELO 101 VIRAMUNE XR 68 xeroform petrolatum dressing 171 VIREAD 70 XTANDI 171 VIRT-CAPS 174 XULANE 120 VIRT-GARD 175 XURIDEN 138 VIRT-PHOS 250 NEUTRAL 94 XYLOCAINE DENTAL-EPINEPHRINE 155 VIRT-VITE 175 XYLON 10 14 VIRT-VITE PLUS 175 XYREM 87 VIRTRATE-2 94 VIRTRATE-3 94 Y VIRTRATE-K 94 YF-VAX 76 VISTOGARD 127 yohimbine hcl 171 vitamin d2 175 YUVAFEM 99 vitamin k1 127 vitamins a,c,d and fluoride 174 Z VIVITROL 88 zafirlukast 26 VIVOTIF 76 zaleplon 81 VIVOTIF BERNA 76 ZARAH 120 voriconazole 52 ZARONTIN 41 VOSEVI 171 ZARXIO 84 VOTRIENT 171 ZAVESCA 138 VP-VITE RX 175 zazole 53 VYFEMLA 120 ZEBUTAL 8 VYNATAL-FA 27 ZEJULA 171 VYVANSE 17 ZELBORAF 171 ZEMPLAR 175 W ZENATANE 153 warfarin sodium 37 ZENCHENT 120 water 171 ZENCHENT FE 120 WELCHOL 46 ZENCIA 25 ZENPEP 102 ZENZEDI 17 ZEOSA 120 ZEPATIER 106 ZERIT 70 ZIAGEN 70 zidovudine 70 ZINBRYTA 135 ziprasidone hcl 66 ZMAX 126 ZOLATE 175 ZOLINZA 172 zolmitriptan 61 zolmitriptan odt 61 zolpidem tartrate 81 zolpidem tartrate er 81 ZOMACTON 124 ZOMIG 61 ZONEGRAN 40 zonisamide 40 ZORBTIVE 124 ZORTRESS 136 ZOSTAVAX 76 ZOVIA 1-35E 120 ZOVIA 1-50E 120 ZOVIRAX 23 ZYDELIG 172 ZYKADIA 172 ZYTIGA 172 NOTICE ABOUT NON-DISCRIMINATION

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GlobalHealth, Inc. PO Box 2393 Oklahoma City, OK 73101-2393 www.GlobalHealth.com/fehb Effective: 2018 Lists Updated 11/2017

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