List of Covered Over-The-Counter Medications

LIST OF COVERED OVER-THE-COUNTER MEDICATIONS

DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

ADULT ASPIRIN REGIMEN BRAND 1 aspirin ASPIR 81 BRAND 1 aspirin ASPIR-LOW BRAND 1 aspirin ASPIRIN (600 MG SUPPOSITORY, GS 81 MG CHEWABLE TAB, 325 MG TABLET, SM 81 MG CHEWABLE TAB, QC 81 MG CHEWABLE TAB, HM 325 MG TABLET, HM 81 MG generic 1 CHEWABLE TAB, 300 MG SUPPOSITORY, SM 325 MG TABLET, GS 325 MG TABLET, 81 MG CHEWABLE TABLET, QC 325 MG TABLET) ASPIRIN EC (SM 81 MG, 500 MG, SM 325 MG, 81 MG, HM 81 MG, HM 325 MG, QC 81 generic 1 MG, QC 325 MG, 325 MG) CHILDREN'S ASPIRIN (SM 81 MG CHW, 81 generic 1 MG CHEW) ECPIRIN BRAND 1 aspirin

ANESTHETICS

LOCAL ANESTHETICS

lidocaine 3% cream generic 1

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

SMOKING CESSATION AGENTS

NICORETTE (2 MG, 4 MG) BRAND 1 AL At least 18 yrs old nicotine polacrilex NICOTINE GUM (HM 4 MG, 2 MG, 4 MG, SM generic 1 AL At least 18 yrs old 2 MG, SM 4 MG, HM 2 MG) NICOTINE LOZENGE (2 MG MINI, 4 MG MINI, SM 2 MG, HM 2 MG MINI, GS 2 MG MINI, GS generic 1 AL At least 18 yrs old 4 MG MINI, 4 MG, GS 4 MG, 2 MG, HM 2 MG, SM 4 MG, HM 4 MG)

NICOTINE PATCH (HM 7 MG/24HR PATCH, 7 generic 1 AL At least 18 yrs old

PAGE 1 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS MG/24HR PATCH, TRANSDERMAL SYSTEM, SM 7 MG/24HR PATCH, HM 14 MG/24HR PATCH, SM 14 MG/24HR PATCH, SM 21 MG/24HR PATCH, HM 21 MG/24HR PATCH, 14 MG/24HR PATCH, 21 MG/24HR PATCH)

ANTIFUNGALS

3 DAY VAGINAL BRAND 1 miconazole nitrate 3-DAY VAGINAL CREAM (SM, ) BRAND 1 clotrimazole

CLOTRIMAZOLE (SM VAG, VAGINAL) generic 1

clotrimazole-3 2% cream generic 1

miconazole 1 combination pack generic 1 MICONAZOLE 3 4% CREAM BRAND 1 miconazole nitrate MICONAZOLE 7 (SM 7 100 MG VAG SUP, SM generic 1 7 CREAM, 7 100 MG VAG SUPP, 7 CREAM) MICONAZOLE NITRATE (VAGINAL, SM generic 1 VAGINAL, TOPICAL)

qc miconazole-7 cream generic 1

BLOOD GLUCOSE REGULATORS

INSULINS

HUMULIN 70-30 insulin nph human isophane/insulin regular, BRAND 1 human HUMULIN 70/30 KWIKPEN insulin nph human isophane/insulin regular, BRAND 1 human HUMULIN N BRAND 1 insulin nph human isophane HUMULIN N KWIKPEN BRAND 1 insulin nph human isophane HUMULIN R BRAND 1 insulin regular, human NOVOLIN N BRAND 1 insulin nph human isophane NOVOLIN R BRAND 1 insulin regular, human

PAGE 2 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS CENTRAL NERVOUS SYSTEM AGENTS

CENTRAL NERVOUS SYSTEM, OTHER

8 HOUR ACETAMINOPHEN ER 650 MG BRAND 1 acetaminophen SM 8 HOUR PAIN RELIEF 650 MG BRAND 1 acetaminophen 8HR ARTHRITIS PAIN BRAND 1 acetaminophen 8HR MUSCLE ACHE-PAIN ER 650 MG BRAND 1 acetaminophen

acetaminophen 160 mg/5 ml liq generic 1 AL Up to 6 yrs old

acetaminophen er 650 mg caplet generic 1

acetaminophen er 650 mg tablet generic 1 GS ARTHRITIS PAIN ER 650 MG BRAND 1 acetaminophen ARTHRITIS PAIN RELIEF (RELF ER 650 MG, SM ER 650 MG, QC ER 650 MG) BRAND 1 acetaminophen ARTHRITIS PAIN RELIEF (SM ARTHRIT RLF ER 650 MG, ARTHRITIS ER 650 MG CAPLT, HM ARTHRITIS ER 650 MG, HM ARTHRIT BRAND 1 RLF ER 650 MG) acetaminophen CHILDREN'S ACETAMINOPHEN (HM CHILD generic 1 AL Up to 6 yrs old 160 MG, CHLD 160 MG/5 ML, CHILD 160 MG) CHILD'S MAPAP 160 MG TAB CHEW BRAND 1 AL Up to 6 yrs old acetaminophen CHILDREN'S PAIN RELIEF (160 ML SUS, QC 160 ML) BRAND 1 AL Up to 6 yrs old acetaminophen CHILD'S PAIN RELIEVER SUSP BRAND 1 AL Up to 6 yrs old acetaminophen CHILDREN'S PAIN-FEVER (GS CHLD 160 ML, SM CHLD 160 ML, HM CHLD 160 ML, BRAND 1 AL Up to 6 yrs old CHILD 160 ML) acetaminophen CHILDREN'S SILAPAP BRAND 1 AL Up to 6 yrs old acetaminophen ED-APAP BRAND 1 AL Up to 6 yrs old acetaminophen

PAGE 3 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS INFANT PAIN-FEVER 160 MG/5 ML BRAND AL Up to 6 yrs old acetaminophen

inf acetaminophen 160 mg/5 ml generic 1 AL Up to 6 yrs old

INFANT PAIN RELIEF 160 MG/5 ML BRAND 1 AL Up to 6 yrs old acetaminophen QC INFANT PAIN RLF 160 MG/5 ML BRAND 1 AL Up to 6 yrs old acetaminophen INFANTS' PAIN-FEVER (INFANTS 160 ML, GS INFANT 160, SM INFANT 160, HM BRAND 1 AL Up to 6 yrs old INFANT 160) acetaminophen JR. STR NON-ASPIRIN PAIN BRAND 1 AL Up to 6 yrs old acetaminophen M-PAP BRAND 1 AL Up to 6 yrs old acetaminophen MAPAP ARTHRITIS PAIN BRAND 1 acetaminophen PAIN RELIEF ER 650 MG CAPLET BRAND 1 acetaminophen PAIN RELIEVER JUNIOR STRENGTH BRAND 1 AL Up to 6 yrs old acetaminophen

DERMATOLOGICAL AGENTS

VANALICE BRAND 1 piperonyl butoxide/pyrethrins

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

CALCITRATE BRAND 1 calcium citrate

calcium 600 mg tablet generic 1

calcium carb 1,250 mg/5 ml sus generic 1

children's ferrous sulfate generic 1 FEOSOL (65 MG TABLET, 45 MG CAPLET) BRAND 1 ferrous sulfate FER-IN-SOL BRAND 1 ferrous sulfate FERATE BRAND 1 ferrous gluconate

FEROSUL 325 MG TABLET BRAND 1

PAGE 4 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS ferrous sulfate FERRIMIN 150 BRAND 1 ferrous fumarate FERRO-TIME BRAND 1 ferrous sulfate

ferrous fumarate 324 mg tab generic 1

ferrous gluconate 324 mg tab generic 1 FERROUS SULFATE (SULF 300 MG/5 ML LIQ, SULFATE 325 MG TABLET, SULF EC 325 MG TABLET, SULF 220 MG/5 ML ELIX, generic 1 SULF 44 MG IRON/5ML LQ, SULF EC 324 MG TABLET, SULF 15 MG IRON/ML DRP) FERROUSUL BRAND 1 ferrous sulfate HEMOCYTE BRAND 1 ferrous fumarate

IRON (45 MG, 65 MG) generic 1 OYSCO-500 BRAND 1 calcium carbonate

oyster shell calcium generic 1

hm slow release iron tablet generic 1 PHOSPHATE BINDERS

calcium acetate 668 mg tablet generic 1 VITAMINS

AQUADEKS PEDIATRIC LIQUID QL pediatric multivitamin no.40/phytonadione (vit BRAND 1 k1) AL Up to 3 yrs old AQUADEKS CHEWABLE TABLET multivitamin, minerals no.51/folic acid/vit BRAND 1 AL At least 4 yrs old k1/ubidecarenone CORVITA folic acid/multivitamin,ther and BRAND 1 minerals/lycopene/lutein POLY-VI-FLOR (0.25 MG DROPS, 0.5 MG TAB CHEW, 0.25 MG TAB CHEW, 1 MG TAB CHEW) BRAND 1 AL Up to 12 yrs old pediatric multivitamin no.33 with sodium fluoride POLY-VI-FLOR WITH IRON (0.25 MG, 0.5 MG) BRAND 1 AL Up to 12 yrs old pediatric multivitamin no.33/sodium fluoride/iron

PAGE 5 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS carbonyl TRI-VI-FLOR pediatric multivitamin a,c,and d3 no.38 with BRAND 1 AL Up to 12 yrs old sodium fluoride

GASTROINTESTINAL AGENTS

GASTROINTESTINAL AGENTS, OTHER

ANTACID (500 MG CHEW TABLET, GS 500 MG CHEWABLE TAB, HM 500 MG CHEW BRAND 1 TABLET) calcium carbonate ANTACID CALCIUM BRAND 1 calcium carbonate ANTACID EXTRA STRENGTH (HM EX-STR 750 MG CHWTB, XTRA STRENGTH CHEW BRAND 1 TAB, EX-STR 750 MG TAB CHEW) calcium carbonate ANTACID ULTRA STR 1,000 MG CHW BRAND 1 calcium carbonate CAL-GEST BRAND 1 calcium carbonate CALCIUM ANTACID (CALCIUM 750 MG TB CHEW, EX-STR TABLET CHEW, HM CAL 1000 MG CHEW TB, SM CAL 500 MG CHEW TAB, CALCIUM EX-STR TABLET, CALCIUM BRAND 1 500 MG CHW TAB, CALCIUM 1,000 MG TAB, GS CAL 500 MG CHEW TAB, HM CAL 750 MG CHEW TAB) calcium carbonate

calcium carbonate 648 mg tab generic 1 TUMS (TABLET CHEWABLE, E-X TABLET CHEWABLE, KIDS 300 MG (750) CHEWTAB) BRAND 1 calcium carbonate TUMS FRESHERS BRAND 1 calcium carbonate TUMS SMOOTHIES BRAND 1 calcium carbonate TUMS ULTRA BRAND 1 calcium carbonate TUMS ULTRA STRENGTH BRAND 1 calcium carbonate TUMS X-STR BRAND 1 calcium carbonate

PAGE 6 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS SM CALCIUM ANTACID TAB CHEW BRAND 1 calcium carbonate LAXATIVES

CLEARLAX POWDER BRAND 1 polyethylene glycol 3350 ENEMEEZ (, PLUS) BRAND 1 AL At least 12 yrs old docusate sodium

polyethylene glycol 3350 generic 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

PROGESTINS

AFTERA BRAND 1 AL At least 12 yrs old levonorgestrel ECONTRA EZ BRAND 1 AL At least 12 yrs old levonorgestrel ECONTRA ONE-STEP BRAND 1 AL At least 12 yrs old levonorgestrel

levonorgestrel generic 1 AL At least 12 yrs old

MY CHOICE BRAND 1 AL At least 12 yrs old levonorgestrel MY WAY BRAND 1 AL At least 12 yrs old levonorgestrel NEW DAY BRAND 1 AL At least 12 yrs old levonorgestrel OPCICON ONE-STEP BRAND 1 AL At least 12 yrs old levonorgestrel PLAN B ONE-STEP BRAND 1 AL At least 12 yrs old levonorgestrel TAKE ACTION BRAND 1 AL At least 12 yrs old levonorgestrel

MISCELLANEOUS THERAPEUTIC AGENTS

ANTACID 750 MG CHEWABLE TABLET BRAND 1 calcium carbonate

RESPIRATORY TRACT/PULMONARY AGENTS

ANTIHISTAMINES

ALL DAY ALLERGY (10 MG TABLET, QC 10 MG TAB, SM 10 MG TAB, HM 10 MG TAB) BRAND 1 cetirizine hcl

PAGE 7 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS ALLERGY (LORATADINE) 10 MG TAB BRAND 1 QL loratadine ALLERGY RELIEF 5 MG/5 ML SOLN BRAND 1 AL Up to 11 yrs old loratadine ALLERGY RELIEF (10 MG, GS 10 MG) BRAND 1 QL loratadine ALLERGY RELIEF (SM RELIEF 10 MG ODT, RELIEF 10 MG ODT, RLF (CETRZN) 10 MG BRAND 1 TAB) loratadine

cetirizine hcl 1 mg/ml soln generic 1 AL Up to 11 yrs old

CETIRIZINE HCL (5 MG, 10 MG) generic 1 CHILDREN'S ALL DAY ALLERGY (SM ER 1 MG/ML, GS ER 1 MG/ML, ERGY 1 MG/ML) BRAND 1 AL Up to 11 yrs old cetirizine hcl HM CHILD ALL DAY ALLER 1 MG/ML BRAND 1 AL Up to 11 yrs old cetirizine hcl CHILDREN'S ALLERGY (CHILD 5 MG/5 ML SOLN, QC CHILDREN'S 1 MG/ML) BRAND 1 AL Up to 11 yrs old loratadine SM CHILD ALLERGY 5 MG/5 ML SOL BRAND 1 AL Up to 11 yrs old loratadine CHILD ALLERGY RELIEF 1 MG/ML BRAND 1 AL Up to 11 yrs old cetirizine hcl CHILDREN'S CETIRIZINE HCL (HCL 1 generic 1 AL Up to 11 yrs old MG/ML, HM 1 MG/ML) CHILDREN'S LORATADINE (HM 5 ML, 5 ML generic 1 AL Up to 11 yrs old SYR, SM 5 ML, 5 ML SOL)

LORATADINE (5 ML, SM 5 ML) generic 1 AL Up to 11 yrs old

LORATADINE (HM 10 MG, SM 10 MG) generic 1

LORATADINE (QC 10 MG, 10 MG) generic 1 QL

loratadine allergy generic 1 AL Up to 11 yrs old

RESPIRATORY TRACT AGENTS, OTHER

ADULT TUSSIN CHEST CONGESTION BRAND 1 guaifenesin ADULT TUSSIN COUGH CONGEST DM BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr ALL DAY ALLERGY-D (, GNP, SM) BRAND 1 cetirizine hcl/pseudoephedrine hcl

PAGE 8 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS ALLERGY COMPLETE-D BRAND 1 cetirizine hcl/pseudoephedrine hcl ALLERGY RELIEF D-24HR TABLET BRAND 1 loratadine/pseudoephedrine sulfate ALLERGY RELIEF-NASAL DECONGEST BRAND 1 loratadine/pseudoephedrine sulfate ALLERGY-CONGESTION 12HR BRAND 1 loratadine/pseudoephedrine sulfate ALLERGY-CONGES RELF ER TABLET BRAND 1 loratadine/pseudoephedrine sulfate

cetirizine-pseudoephedrine er generic 1 CHEST CONGESTION RELIEF (HM CONGEST RLF 400 MG TB, CONGEST RLF 400 MG TAB, SM CONGESTION RELIEF BRAND 1 CAP) guaifenesin CHILD MUCINEX CHEST MINI-MELTS BRAND 1 guaifenesin CHILD MUCINEX COUGH MINI-MELTS BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr CHILD MUCUS-COUGH RELIEF BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr CHILDREN'S MUCUS RELIEF BRAND 1 guaifenesin COUGH DM BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr GUAIFENESIN (200 MG/10 ML, 300 MG/15 generic 1 ML, 100 MG/5 ML) GUAIFENESIN-DEXTROMETHORPHAN (GUAIFENESIN-DM 200-20 MG/10 ML, generic 1 AL Up to 20 yrs old GUAIFENESIN-DM 100-10 MG/5 ML, GUAIFENESIN DM SYRUP)

guaifenesin-dm er generic 1 AL Up to 20 yrs old

LIQUITUSS GG BRAND 1 guaifenesin LORATA-DINE D BRAND 1 loratadine/pseudoephedrine sulfate LORATADINE-D (24HR, SM 12 HOUR, QC 24HR, 12 HOUR) BRAND 1 loratadine/pseudoephedrine sulfate MUCINEX BRAND 1

PAGE 9 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS guaifenesin MUCINEX DM ER 600-30 MG TABLET BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr MUCOSA BRAND 1 guaifenesin MUCUS DM MAX ER 1,200-60 MG TB BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr MUCUS ER 600 MG TABLET BRAND 1 guaifenesin MUCUS RELIEF (QC 400 MG CAPLET, 400 MG TABLET) BRAND 1 guaifenesin MUCUS RELIEF CHEST CONGESTION BRAND 1 guaifenesin MUCUS RELIEF DM COUGH BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr MUCUS RLF DM ER 600-30 MG TAB BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr MUCUS RELIEF DM MAX LIQUID BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr MUCUS RELIEF DM MAX ER BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr MUCUS RELIEF ER (ER 600 MG TABLET, ER 1,200 MG TAB, QC ER 600 MG TAB, SM ER BRAND 1 600 MG TAB, QC ER 1,200 MG TB) guaifenesin MUCUS-CHEST CONGESTION BRAND 1 guaifenesin MUCUS-ER MAX (MG TABLET, SM MG TAB) BRAND 1 guaifenesin ROBAFEN 200 MG/10 ML SYRUP BRAND 1 guaifenesin ROBAFEN DM COUGH BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr ROBAFEN DM PEAK COLD BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr SILTUSSIN SA BRAND 1 guaifenesin TUSSIN (100 MG/5 ML SYRUP, 400 MG TABLET) BRAND 1 guaifenesin

PAGE 10 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS TUSSIN CHEST CONGESTION LIQUID BRAND 1 guaifenesin TUSSIN DM (400-20 MG/20 ML LIQ, SM 400- 20 MG/20 ML, LIQUID) BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr HM TUSSIN DM MAX LIQUID BRAND 1 AL Up to 20 yrs old guaifenesin/dextromethorphan hbr TUSSIN HONEY BRAND 1 guaifenesin TUSSIN MUCUS-CHEST CONGESTION (GS 200 MG/10, GS 100 MG/5, 200 MG/10, SM 200 BRAND 1 MG/10, QC 200 MG/10) guaifenesin

PAGE 11 LAST UPDATED 04/2020 LIST OF COVERED PRESCRIPTION MEDICATIONS

DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

butalb-aspirin-caffe 50-325-40 generic 1

celecoxib generic 1 DICLOFENAC SODIUM (DR 50 MG, DR 25 MG, DR 75 MG, EC 50 MG, EC 25 MG, EC 75 generic 1 MG)

ec-naproxen generic 1 IBU BRAND 1 ibuprofen IBUPROFEN (400 MG TABLET, 600 MG TABLET, 800 MG TABLET, 100 MG/5 ML generic 1 SUSP)

INDOMETHACIN (25 MG, 50 MG) generic 1 KETOROLAC TROMETHAMINE (30 MG/ML VIAL, 10 MG TABLET, 60 MG/2 ML SYRINGE, 15 MG/ML SYRINGE, 60 MG/2 ML generic 1 AL At least 17 yrs old CARPUJECT, 60 MG/2 ML VIAL, 30 MG/ML SYRINGE, 15 MG/ML VIAL, 30 MG/ML CARPUJECT)

meloxicam generic 1

nabumetone generic 1 NAPROXEN (250 MG, DR 375 MG, 375 MG, generic 1 500 MG, DR 500 MG)

salsalate generic 1 OPIOID ANALGESICS, LONG-ACTING

ARYMO ER PA BRAND 1 morphine sulfate AL At least 18 yrs old

FENTANYL (12, 25, 75, 50, 100) generic 1 AL At least 18 yrs old

HYSINGLA ER PA BRAND 1 hydrocodone bitartrate AL At least 18 yrs old

MORPHABOND ER PA BRAND 1 morphine sulfate AL At least 18 yrs old

morphine sulf er 30 mg tablet generic 1 AL At least 18 yrs old

PAGE 12 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS MORPHINE SULFATE ER (ER 200 MG, ER 60 generic 1 AL At least 18 yrs old MG, ER 100 MG, ER 15 MG)

SUBLOCADE PA BRAND 1 buprenorphine AL At least 18 yrs old

XTAMPZA ER PA BRAND 1 oxycodone myristate AL At least 18 yrs old

OPIOID ANALGESICS, SHORT-ACTING

ACETAMINOPHEN-CODEINE (ACETAMINOPHEN-COD #4 TABLET, ACETAMINOPHEN-COD #3 TABLET, generic 1 AL At least 12 yrs old ACETAMINOPHEN-COD #2 TABLET, ACETAMIN-CODEIN 300-30 MG/12.5, ACETAMINOP-CODEINE 120-12 MG/5)

belladonna-opium generic 1

butalb-caff-acetaminoph-codein generic 1 AL At least 12 yrs old

butalbital-asa-caffeine cap generic 1

codeine sulfate generic 1 AL At least 12 yrs old

HYDROCODONE-ACETAMINOPHEN (HYDROCODONE-ACETAMIN 5-217/10, HYDROCODONE-ACETAMIN 7.5-325, HYDROCODONE-ACETAMIN 10-325 MG, HYDROCODONE-ACETAMIN 2.5-108/5, generic 1 HYDROCODONE-ACETAMIN 5-300 MG, HYDROCODONE-ACETAMIN 5-325 MG, HYDROCODONE-ACETAMN 7.5-325/15, HYDROCODONE-ACETAMIN 7.5-300, HYDROCODONE-ACETAMIN 10-300 MG)

hydrocodone-ibuprofen generic 1 HYDROMORPHONE HCL (2 MG TABLET, 8 generic 1 MG TABLET, 4 MG TABLET, 0.5 MG/0.5 ML) MORPHINE SULFATE (SULFATE IR 30 MG TAB, SULF 100 MG/5 ML CONC, SULF 10 generic 1 MG/5 ML SOLN, SULFATE IR 15 MG TAB, SULF 20 MG/5 ML SOLN) OXYCODONE HCL (5 MG/5 ML SOLN, 10 MG TABLET, 20 MG TABLET, 5 MG TABLET, 30 generic 1 MG TABLET, 15 MG TABLET) OXYCODONE-ACETAMINOPHEN (OXYCODON-ACETAMINOPHEN 2.5-325, OXYCODONE-ACETAMINOPHEN 10-325, generic 1 OXYCODONE-ACETAMINOPHEN 5-325, OXYCODON-ACETAMINOPHEN 7.5-325)

PAGE 13 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

tramadol hcl 50 mg tablet generic 1 AL At least 12 yrs old

VICODIN HP BRAND 1 hydrocodone bitartrate/acetaminophen

ANESTHETICS

LOCAL ANESTHETICS

BUPIVACAINE HCL (0.25% VIAL, 0.5% (5 MG/ML) AMP, 0.75% VIAL, 0.25% (2.5 generic 1 MG/ML), 0.5% VIAL, 0.75% AMPUL)

bupivacaine hcl-epinephrine generic 1

lidocaine 5% patch generic 1 PA

lidocaine 5% ointment generic 1 LIDOCAINE HCL (HCL 4% SOLUTION, HCL 2% JEL UROJET AC, HCL 2% JELLY URO- JET, HCL 1% 20 MG/2 ML VL, HCL 1.5% AMPUL, 3% CREAM, HCL 2% AMPUL, HCL 2% 40 MG/2 ML, HCL 1% VIAL, HCL 0.5% generic 1 VIAL, HCL 1% 50 MG/5 ML, HCL 2% 100 MG/5 ML, HCL 2% 40 MG/2 ML VL, HCL 1% 20 MG/2 ML, HCL 1% 50 MG/5 ML VL, HCL 1% AMPUL, HCL 1% 300 MG/30 ML, HCL 4% AMPUL, HCL 2% VIAL, HCL 2% JELLY)

lidocaine hcl in 7.5% dextrose generic 1

lidocaine hcl viscous generic 1

lidocaine hcl-epinephrine generic 1

lidocaine-epinephrine generic 1

lidocaine-prilocaine generic 1 QL

ZTLIDO BRAND 1 PA lidocaine

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium generic 1

disulfiram generic 1

naltrexone hcl generic 1

VIVITROL PA BRAND 1 naltrexone microspheres AL At least 18 yrs old

OPIOID DEPENDENCE TREATMENTS

PAGE 14 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

PA BUPRENORPHINE HCL (2 MG, 8 MG) generic 1 AL At least 16 yrs old

BUPRENORPHINE-NALOXONE PA (BUPRENORPHIN-NALOXON 8-2 MG, generic 1 BUPRENORPHN-NALOXN 2-0.5 MG) AL At least 16 yrs old

SUBOXONE PA BRAND 1 buprenorphine hcl/naloxone hcl AL At least 16 yrs old

ZUBSOLV PA BRAND 1 buprenorphine hcl/naloxone hcl AL At least 16 yrs old

OPIOID REVERSAL AGENTS

NALOXONE HCL (2 MG/2 ML SYRINGE, 0.4 MG/ML CARPUJECT, 0.4 MG/ML VIAL, 4 generic 1 MG/10 ML VIAL) NARCAN BRAND 1 naloxone hcl SMOKING CESSATION AGENTS

bupropion hcl sr 150 mg tablet generic 1 AL At least 6 yrs old

CHANTIX (1 MG CONT MONTH BOX, 0.5 MG TABLET, 1 MG TABLET, STARTING MONTH BRAND 1 AL At least 18 yrs old BOX) varenicline tartrate

ANTIBACTERIALS

AMINOGLYCOSIDES

GENTAMICIN SULFATE (20 MG/2 ML VIAL, 80 MG/2 ML VIAL, 800 MG/20 ML VIAL, 3 generic 1 MG/ML EYE DROP, 0.1% CREAM, 40 MG/ML VIAL, 0.3% EYE DROP) GENTAMICIN SULFATE IN NS (ISOTON 80 MG/100 ML, 70 MG/NS 50 ML PB, ISO 120 MG/100 ML, ISOTON 60 MG/50 ML, ISOTON generic 1 80 MG/50 ML, ISOTON 100 MG/50 ML, ISO 100 MG/100 ML)

neomycin sulfate generic 1

tobramycin 0.3% eye drop generic 1 TOBRAMYCIN SULFATE (10 MG/ML, 80 MG/2 generic 1 ML, 40 MG/ML) ANTIBACTERIALS, OTHER

PAGE 15 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

acetic acid 0.25% irrig soln generic 1 CLEOCIN 100 MG VAGINAL OVULE BRAND 1 clindamycin phosphate CLEOCIN PHOSPHATE (300 MG/2 ML, 900 MG/6 ML, 600 MG/4 ML) BRAND 1 clindamycin phosphate

clindamycin hcl generic 1

clindamycin palmitate hcl generic 1 AL Up to 11 yrs old

clindamycin pediatric generic 1 AL Up to 11 yrs old

CLINDAMYCIN PHOSPHATE (PHOS generic 1 AL At least 12 yrs old PLEDGET, PH SOLUTION) CLINDAMYCIN PHOSPHATE (9 G/60 ML VIAL, 600 MG/4 ML VL, 300 MG/2 ML VL, 900 generic 1 MG/6 ML VL) CLINDESSE BRAND 1 clindamycin phosphate

colistimethate generic 1 FIRVANQ BRAND 1 vancomycin hcl

lincomycin hcl generic 1

linezolid 600 mg tablet generic 1

methenamine hippurate generic 1

methenamine mandelate generic 1 METRONIDAZOLE (250 MG TABLET, 500 MG/100 ML, VAGINAL 0.75% GL, 500 MG generic 1 TABLET)

mupirocin 2% ointment generic 1 NEOMYCIN-POLYMYXIN B (40 MG/ML AMP, generic 1 40 MG/ML VL) NITROFURANTOIN (25 MG/5 ML SUSP, MCR 25 MG CAP, MCR 50 MG CAP, MCR 100 MG generic 1 CAP)

nitrofurantoin mono-macro generic 1

polymyxin b sulfate generic 1

tinidazole generic 1

trimethoprim generic 1 VANCOMYCIN HCL (1 GM VIAL, 500 MG A-V generic 1 VIAL, HCL 250 MG CAPSULE, 1 GM ADD-

PAGE 16 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS VAN VIAL, HCL 1.5 GRAM VIAL, 500 MG VIAL, HCL 125 MG CAPSULE, HCL 250 MG VIAL, HCL 5 GM VIAL, HCL 10 GM VIAL, HCL 750 MG VIAL, HCL 1.25 GRAM VIAL) VANCOMYCIN HCL-0.9% NACL (VANCO 500 MG/100 ML-0.9%, VANCO 750 MG/150 ML- generic 1 0.9%, VANCOMYCIN 1 G/200ML-0.9%)

vancomycin-d5w 500 mg/100 ml generic 1 BETA-LACTAM, CEPHALOSPORINS

CEFACLOR (500 MG, 250 MG) generic 1

cefadroxil 500 mg capsule generic 1 CEFAZOLIN SODIUM (1 GM ADD-VAN, 20 generic 1 GM BULK, 1 GM, 500 MG, 10 GM) CEFDINIR (250 MG/5 ML SUSP, 300 MG generic 1 CAPSULE, 125 MG/5 ML SUSP)

CEFEPIME HCL (2 GRAM, 1 GM) generic 1

cefixime 400 mg capsule generic 1

cefotaxime sodium 1 gm vial generic 1

cefotetan generic 1

cefotetan & dextrose generic 1

cefoxitin generic 1

cefoxitin sodium generic 1 CEFPROZIL (250 MG/5 ML SUSP, 125 MG/5 generic 1 ML SUSP, 250 MG TABLET, 500 MG TABLET) CEFTRIAXONE (1 GM-D5W BAG, 1 GM ADD- VANT VIAL, 1 GM PIGGYBACK, 250 MG VIAL, generic 1 2 GM PIGGYBACK, 2 GM-D5W BAG, 2 GM ADD VIAL) CEFTRIAXONE (500 MG, 10 GM, 1 GM, 2 generic 1 GM)

cefuroxime generic 1

cefuroxime sodium generic 1 CEPHALEXIN (125 MG/5 ML SUSP, 250 MG CAPSULE, 750 MG CAPSULE, 250 MG/5 ML generic 1 SUSP, 500 MG CAPSULE) BETA-LACTAM, OTHER

AZACTAM BRAND 1 aztreonam

PAGE 17 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

imipenem-cilastatin sodium generic 1

meropenem generic 1

meropenem-0.9% nacl generic 1 BETA-LACTAM, PENICILLINS

AMOXICILLIN (250 MG CAPSULE, 500 MG TABLET, 500 MG CAPSULE, 125 MG/5 ML generic 1 SUSP, 200 MG/5 ML SUSP, 875 MG TABLET, 250 MG/5 ML SUSP, 400 MG/5 ML SUSP)

AMOXICILLIN (125 MG, 250 MG) generic 1 AMOXICILLIN-CLAVULANATE POTASS (600- 42.9 MG/5 ML SUS, 875-125 MG TABLET, 400-57 MG/5 ML SUSP, 500-125 MG TABLET, generic 1 250-62.5 MG/5 ML SUS, 250-125 MG TABLET, 200-28.5 MG/5 ML SUS) AMPICILLIN SODIUM (10 GM VIAL, 2 GM ADD-VANTAGE VL, 500 MG VIAL, 250 MG VIAL, 1 GM ADD-VANTAGE VL, 10 GM generic 1 BOTTLE, 125 MG VIAL, 2 GM VIAL, 1 GM VIAL)

ampicillin 500 mg capsule generic 1 AMPICILLIN-SULBACTAM (AMPICILLIN-SULB 3 GM ADD VIAL, AMPICILLIN-SULB 1.5 G ADD VIAL, AMPICILLIN-SULBACTAM 15 GM generic 1 VL, AMPICILLIN-SULBACTAM 3 GM VIAL, AMPICILLIN-SULBACTAM 1.5 GM VL) BICILLIN C-R 1.2 MILLION UNIT BRAND 1 penicillin g benzathine/penicillin g procaine BICILLIN C-R 900-300 SYRINGE BRAND 1 penicillin g benzathine/penicillin g procaine BICILLIN L-A (600,000 UNIT/ML, 1,200,000 UNITS) BRAND 1 penicillin g benzathine BICILLIN L-A 2,400,000 UNITS BRAND 1 penicillin g benzathine

dicloxacillin sodium generic 1

pen g 1.2 million unit/2 ml generic 1

penicillin g 600,000 unit/1 ml generic 1

penicillin g sodium generic 1 PENICILLIN V POTASSIUM (250 MG TABLET, 250 MG/5 ML SOLN, 125 MG/5 ML SOLN, 500 generic 1 MG TABLET)

PAGE 18 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS PIPERACILLIN-TAZOBACTAM (PIPERACIL- TAZOBACT 2.25 GM VL, PIPERACIL-TAZO 3.375 GM ADD VL, PIPERACIL-TAZOBACT 4.5 GM VIAL, PIPERACIL-TAZO 4.5 GM ADD generic 1 VIAL, PIPERACIL-TAZOBACT 3.375 GM VL, PIPERACIL-TAZOBACT 13.5 GM VL, PIPERACIL-TAZOBACT 40.5 GRAM, PIPERACIL-TAZO 2.25 GM ADD VL) MACROLIDES

AZITHROMYCIN (200 MG/5 ML SUSP, I.V. generic 1 500 MG VIAL, 100 MG/5 ML SUSP) AZITHROMYCIN (500 MG ADD-VAN VL, 500 MG TABLET, 600 MG TABLET, 1 GM PWD generic 1 PACKET, 250 MG TABLET)

CLARITHROMYCIN (125 ML, 250 ML) generic 1 AL Up to 11 yrs old

CLARITHROMYCIN (500 MG, 250 MG) generic 1

clarithromycin er generic 1 E.E.S. 200 BRAND 1 erythromycin ethylsuccinate

erythromycin 0.5% eye ointment generic 1 QUINOLONES

CIPRO (5%, 10%) BRAND 1 AL Up to 11 yrs old ciprofloxacin

ciprofloxacin 0.3% eye drop generic 1 CIPROFLOXACIN HCL (500 MG, 100 MG, 750 generic 1 AL At least 12 yrs old MG, 250 MG)

ciprofloxacin-d5w generic 1

LEVOFLOXACIN (500 MG, 750 MG, 250 MG) generic 1 AL At least 12 yrs old

levofloxacin-d5w generic 1

moxifloxacin 0.5% eye drops generic 1

OFLOXACIN (EYE, EAR) generic 1 SULFONAMIDES

silver sulfadiazine generic 1 SULFAMETHOXAZOLE-TRIMETHOPRIM (SS generic 1 TABLET, SUSP, DS TABLET) TETRACYCLINES

PAGE 19 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS DOXYCYCLINE HYCLATE (75 MG TAB, 50 MG CAP, 100 MG TAB, 150 MG TAB, 100 MG generic 1 CAP)

doxycycline hyclate 20 mg tab generic 1

MINOCYCLINE HCL (100 MG, 50 MG, 75 MG) generic 1

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT (50 MG TABLET, 10 MG/ML ORAL SOLN, 100 MG TABLET, 25 MG TABLET, 10 PA BRAND 1 MG TABLET, 75 MG TABLET) AL At least 4 yrs old brivaracetam

BRIVIACT 50 MG/5 ML VIAL PA BRAND 1 brivaracetam AL At least 16 yrs old

KEPPRA (750 MG TABLET, 250 MG TABLET, 100 MG/ML ORAL SOLN, 1,000 MG TABLET, BRAND 1 PA 500 MG TABLET) levetiracetam KEPPRA XR BRAND 1 PA levetiracetam LEVETIRACETAM (100 MG/ML SOLN, 500 MG/5 ML VIAL, 500 MG TABLET, 750 MG generic 1 TABLET, 250 MG TABLET, 1,000 MG TABLET, 500 MG/5 ML SOLN)

levetiracetam er generic 1 ROWEEPRA BRAND 1 PA levetiracetam CALCIUM CHANNEL MODIFYING AGENTS

ETHOSUXIMIDE (250 MG/5 ML SOLN, 250 generic 1 MG CAPSULE) ZARONTIN 250 MG CAPSULE BRAND 1 PA ethosuximide

zonisamide generic 1 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

CLOBAZAM (10 MG TABLET, 2.5 MG/ML generic 1 AL At least 2 yrs old SUSPENSION, 20 MG TABLET) DEPAKOTE BRAND 1 PA divalproex sodium DEPAKOTE ER BRAND 1 PA divalproex sodium

PAGE 20 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS DEPAKOTE SPRINKLE BRAND 1 PA divalproex sodium

DIASTAT PA BRAND 1 diazepam AL Up to 18 yrs old

DIASTAT ACUDIAL PA BRAND 1 diazepam AL Up to 18 yrs old

DIAZEPAM (2.5 MG SYS, 20 MG SYST, 10 generic 1 AL Up to 18 yrs old MG SYST) DIVALPROEX SODIUM (SOD 250 MG TAB, SOD 500 MG TAB, 125 MG CAP SPRNK, SOD generic 1 125 MG TAB)

divalproex sodium er generic 1 GABAPENTIN (300 MG/6 ML SOLN, 250 MG/5 ML SOLN, 800 MG TABLET, 100 MG generic 1 CAPSULE, 300 MG CAPSULE, 600 MG TABLET, 400 MG CAPSULE) GABITRIL BRAND 1 PA tiagabine hcl MYSOLINE BRAND 1 PA primidone NEURONTIN (800 MG TABLET, 100 MG CAPSULE, 300 MG CAPSULE, 400 MG CAPSULE, 600 MG TABLET, 250 MG/5 ML BRAND 1 PA SOLUTION) gabapentin

ONFI (2.5 MG/ML SUSPENSION, 20 MG PA TABLET, 10 MG TABLET) BRAND 1 clobazam AL At least 2 yrs old PHENOBARBITAL (60 MG TABLET, 97.2 MG TABLET, 100 MG TABLET, 15 MG TABLET, 64.8 MG TABLET, 20 MG/5 ML SOLN, 30 MG generic 1 TABLET, 16.2 MG TABLET, 20 MG/5 ML ELIX, 32.4 MG TABLET)

primidone generic 1 SABRIL (500 MG TABLET, 500 MG POWDER PACKET) BRAND 1 PA vigabatrin

SYMPAZAN PA BRAND 1 clobazam AL At least 2 yrs old

tiagabine hcl generic 1

PAGE 21 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS VALPROIC ACID (500 MG/10 ML SOL, 250 generic MG CAPSULE, 250 MG/5 ML SOLN) VIGABATRIN (500 MG POWDER PACKT, 500 generic 1 MG TABLET) VIGADRONE BRAND 1 PA vigabatrin GLUTAMATE REDUCING AGENTS

FELBAMATE (400 MG TABLET, 600 MG generic 1 TABLET, 600 MG/5 ML SUSP) FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP) BRAND 1 PA felbamate FYCOMPA (10 MG TABLET, 6 MG TABLET, 12 MG TABLET, 2 MG TABLET, 8 MG PA TABLET, 0.5 MG/ML ORAL SUSP, 4 MG BRAND 1 TABLET) AL At least 4 yrs old perampanel LAMICTAL (200 MG, 25 MG DISPER, 5 MG DISPER, 150 MG, 100 MG, 25 MG) BRAND 1 PA lamotrigine LAMICTAL (BLUE) BRAND 1 lamotrigine LAMICTAL (GREEN) BRAND 1 lamotrigine LAMICTAL (ORANGE) BRAND 1 lamotrigine LAMICTAL ODT BRAND 1 lamotrigine LAMICTAL ODT (BLUE) BRAND 1 PA lamotrigine LAMICTAL ODT (GREEN) BRAND 1 PA lamotrigine LAMICTAL ODT (ORANGE) BRAND 1 PA lamotrigine

LAMICTAL XR PA BRAND 1 lamotrigine AL At least 13 yrs old

LAMICTAL XR (BLUE) PA BRAND 1 lamotrigine AL At least 13 yrs old

LAMICTAL XR (GREEN) PA BRAND 1 lamotrigine AL At least 13 yrs old

PAGE 22 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

LAMICTAL XR (ORANGE) PA BRAND 1 lamotrigine AL At least 13 yrs old

LAMOTRIGINE (5 MG DISPER TABLET, 200 MG TABLET, 150 MG TABLET, 25 MG generic 1 DISPER TAB, 100 MG TABLET, 25 MG TABLET)

lamotrigine (blue) generic 1 PA

lamotrigine (green) generic 1 PA

lamotrigine (orange) generic 1 PA

lamotrigine er generic 1 AL At least 13 yrs old

lamotrigine odt generic 1 PA

lamotrigine odt (blue) generic 1

lamotrigine odt (green) generic 1

lamotrigine odt (orange) generic 1 QUDEXY XR BRAND 1 PA topiramate SUBVENITE BRAND 1 PA lamotrigine SUBVENITE (BLUE) BRAND 1 PA lamotrigine SUBVENITE (GREEN) BRAND 1 PA lamotrigine SUBVENITE (ORANGE) BRAND 1 PA lamotrigine TOPAMAX (100 MG TABLET, 50 MG TABLET, 25 MG SPRINKLE CAP, 25 MG TABLET, 200 BRAND 1 PA MG TABLET, 15 MG SPRINKLE CAP) topiramate TOPIRAMATE (25 MG SPRINKLE CAP, 15 MG SPRINKLE CAP, 200 MG TABLET, 50 MG generic 1 TABLET, 25 MG TABLET, 100 MG TABLET)

topiramate er generic 1

TROKENDI XR PA BRAND 1 topiramate AL At least 6 yrs old

SODIUM CHANNEL AGENTS

PAGE 23 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

APTIOM PA BRAND 1 eslicarbazepine acetate AL At least 4 yrs old

BANZEL (400 MG TABLET, 40 MG/ML PA SUSPENSION, 200 MG TABLET) BRAND 1 rufinamide AL At least 1 yrs old CARBAMAZEPINE (200 MG TABLET, 100 MG generic 1 TAB CHEW, 100 MG/5 ML SUSP) CARBAMAZEPINE ER (ER 100 MG CAP, ER 400 MG TABLET, ER 300 MG CAP, ER 200 generic 1 MG TABLET, ER 200 MG CAP, ER 100 MG TABLET) CARBATROL BRAND 1 PA carbamazepine DILANTIN (30 MG, 100 MG) BRAND 1 PA phenytoin sodium extended DILANTIN-125 BRAND 1 PA phenytoin EPITOL BRAND 1 PA carbamazepine OXCARBAZEPINE (150 MG TABLET, 300 MG/5 ML SUSP, 300 MG TABLET, 600 MG generic 1 TABLET)

OXTELLAR XR PA BRAND 1 oxcarbazepine AL At least 6 yrs old

PHENYTOIN (125 MG/5 ML SUSP, 50 MG INFATAB, 50 MG TABLET CHEW, 100 MG/4 generic 1 ML SUSP)

phenytoin sodium extended generic 1 TEGRETOL (200 MG TABLET, 100 MG/5 ML SUSP) BRAND 1 PA carbamazepine TEGRETOL XR BRAND 1 PA carbamazepine TRILEPTAL (600 MG TABLET, 300 MG/5 ML SUSP, 300 MG TABLET, 150 MG TABLET) BRAND 1 PA oxcarbazepine VIMPAT (10 MG/ML SOLUTION, 150 MG TABLET, 100 MG TABLET, 200 MG TABLET, BRAND 1 PA 50 MG TABLET, STARTER KIT) lacosamide

ANTIDEMENTIA AGENTS

PAGE 24 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS CHOLINESTERASE INHIBITORS

DONEPEZIL HCL (10 MG, 5 MG) generic 1 AL At least 18 yrs old

donepezil hcl odt generic 1 AL At least 18 yrs old

EXELON BRAND 1 AL At least 18 yrs old rivastigmine N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

MEMANTINE HCL (10 MG, 5 MG) generic 1 AL At least 18 yrs old

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

bupropion hcl generic 1 AL At least 6 yrs old

BUPROPION HCL SR (200 MG, 100 MG) generic 1 AL At least 6 yrs old

bupropion hcl xl 450 mg tablet generic 1 AL At least 18 yrs old

BUPROPION XL (300 MG, 150 MG) generic 1 AL At least 6 yrs old

chlordiazepoxide-amitriptyline generic 1 AL At least 18 yrs old

MIRTAZAPINE (15 MG TABLET, 45 MG TABLET, 45 MG ODT, 7.5 MG TABLET, 30 generic 1 AL At least 6 yrs old MG TABLET, 15 MG ODT, 30 MG ODT)

perphenazine-amitriptyline generic 1 AL At least 18 yrs old

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

CITALOPRAM HBR (10 MG/5 ML SOLN, 20 generic 1 AL 6.0 to 11.0 yrs old MG/10 ML SOL)

CITALOPRAM HBR (20 MG, 10 MG, 40 MG) generic 1 AL At least 6 yrs old

desvenlafaxine succinate er generic 1 AL At least 18 yrs old

ESCITALOPRAM OXALATE (10 MG, 5 MG, 20 generic 1 AL At least 6 yrs old MG)

FLUOXETINE HCL (40 MG, 10 MG, 20 MG) generic 1 AL At least 6 yrs old

fluoxetine 20 mg/5 ml solution generic 1 AL 6.0 to 11.0 yrs old

fluvoxamine maleate generic 1 AL At least 6 yrs old

paroxetine hcl generic 1 AL At least 6 yrs old

sertraline 20 mg/ml oral conc generic 1 AL 6.0 to 11.0 yrs old

PAGE 25 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

SERTRALINE HCL (50 MG, 25 MG, 100 MG) generic 1 AL At least 6 yrs old

trazodone hcl generic 1 AL At least 6 yrs old

TRINTELLIX PA BRAND 1 vortioxetine hydrobromide AL At least 18 yrs old

venlafaxine hcl generic 1 AL At least 6 yrs old

VENLAFAXINE HCL ER (ER 37.5 MG, ER 75 generic 1 AL At least 6 yrs old MG, ER 150 MG) VIIBRYD (10 MG, 20 MG, 40 MG) BRAND 1 AL At least 18 yrs old vilazodone hcl TRICYCLICS

amitriptyline hcl generic 1 AL At least 12 yrs old

amoxapine generic 1 AL At least 16 yrs old

PA clomipramine hcl generic 1 AL At least 10 yrs old

desipramine hcl generic 1 AL At least 13 yrs old

DOXEPIN HCL (25 MG CAPSULE, 150 MG CAPSULE, 10 MG/ML ORAL CONC, 100 MG generic 1 AL At least 12 yrs old CAPSULE, 50 MG CAPSULE, 10 MG CAPSULE, 75 MG CAPSULE)

imipramine hcl generic 1 AL At least 6 yrs old

NORTRIPTYLINE HCL (HCL 75 MG CAP, HCL 10 MG CAP, HCL 25 MG CAP, HCL 50 MG generic 1 AL At least 13 yrs old CAP, 10 MG/5 ML SOLN)

ANTIEMETICS

ANTIEMETICS, OTHER

DICLEGIS BRAND 1 AL At least 18 yrs old doxylamine succinate/pyridoxine hcl (b6)

meclizine hcl generic 1 METOCLOPRAMIDE HCL (10 MG TABLET, 5 MG TABLET, 10 MG/10 ML SOL, 5 MG/5 ML generic 1 SOLN)

perphenazine generic 1 AL At least 6 yrs old

prochlorperazine maleate generic 1 PROMETHAZINE HCL (25 MG generic 1

PAGE 26 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS SUPPOSITORY, 12.5 MG TABLET, 12.5 MG SUPPOS, 50 MG TABLET, 25 MG TABLET) PROMETHEGAN BRAND 1 promethazine hcl

TRANSDERM-SCOP PA BRAND 1 scopolamine AL At least 18 yrs old

EMETOGENIC THERAPY ADJUNCTS

APREPITANT (125 MG, 40 MG, 80 MG) generic 1 GRANISETRON HCL (1 MG TABLET, 0.1 generic 1 MG/ML VIAL, 1 MG/ML VIAL) ONDANSETRON HCL (4 MG/5 ML SOLUTION, HCL 4 MG/2 ML VIAL, HCL 8 MG generic 1 TABLET, HCL 4 MG TABLET, 40 MG/20 ML VIAL, HCL 4 MG/2 ML SYR)

ondansetron odt generic 1

ANTIFUNGALS

amphotericin b generic 1 CICLOPIROX (0.77% CREAM, 0.77% generic 1 TOPICAL SUSP, 8% SOLUTION) CLOTRIMAZOLE (1% SOLUTION, 10 MG generic 1 TROCHE, 1% TOPICAL CREAM)

econazole nitrate generic 1 ERAXIS (WATER DILUENT) BRAND 1 anidulafungin FLUCONAZOLE (150 MG TABLET, 40 MG/ML generic 1 SUSP, 10 MG/ML SUSP)

FLUCONAZOLE (50 MG, 200 MG, 100 MG) generic 1 FLUCONAZOLE-NACL (200 MG/100 ML, 400 generic 1 MG/200 ML) GRISEOFULVIN (125 MG/5 ML SUSP, MICRO generic 1 500 MG TAB) GYNAZOLE 1 BRAND 1 butoconazole nitrate

KETOCONAZOLE (SHAMPOO, CREAM) generic 1

miconazole 3 generic 1 NYSTATIN (100,000 UNIT/GM CREAM, 500,000 UNIT ORAL TAB, 500,000 UNIT/5 ML generic 1 SUS, 100,000 UNIT/ML SUSP, 100,000

PAGE 27 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS UNIT/GM OINT, 100,000 UNIT/GM POWD) NYSTATIN-TRIAMCINOLONE (CREAM, generic 1 OINTM)

terbinafine hcl generic 1

terconazole 0.4% cream generic 1 QL

terconazole 0.8% cream generic 1 QL

ANTIGOUT AGENTS

allopurinol generic 1

colchicine 0.6 mg capsule generic 1 AL At least 18 yrs old

colchicine 0.6 mg tablet generic 1 AL At least 4 yrs old

probenecid generic 1

probenecid-colchicine generic 1

ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS, OTHER

EMGALITY PEN BRAND 1 AL At least 18 yrs old galcanezumab-gnlm EMGALITY SYRINGE BRAND 1 AL At least 18 yrs old galcanezumab-gnlm SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

RIZATRIPTAN (10 MG ODT, 10 MG TABLET, generic 1 AL At least 6 yrs old 5 MG TABLET, 5 MG ODT)

sumatriptan generic 1 AL At least 18 yrs old

SUMATRIPTAN SUCCINATE (SUCC 50 MG TABLET, 6 MG/0.5 ML VIAL, SUCC 25 MG generic 1 AL At least 18 yrs old TABLET, SUCC 100 MG TABLET)

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

guanidine hcl generic 1 MESTINON 60 MG/5 ML SYRUP BRAND 1 pyridostigmine bromide PYRIDOSTIGMINE BROMIDE (BR 30 MG TABLET, BR 60 MG TABLET, 60 MG/5 ML generic 1 SOLN)

PAGE 28 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS pyridostigmine bromide er generic

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

DAPSONE (100 MG, 25 MG) generic 1

rifabutin generic 1 ANTITUBERCULARS

ethambutol hcl generic 1 ISONIAZID (50 MG/5 ML SOLUTION, 300 MG generic 1 TABLET, 100 MG TABLET)

pyrazinamide generic 1 RIFAMPIN (150 MG CAPSULE, IV 600 MG generic 1 VIAL, 300 MG CAPSULE)

ANTINEOPLASTICS

ALKYLATING AGENTS

ALKERAN 2 MG TABLET BRAND 1 AL At least 18 yrs old melphalan BICNU BRAND 1 carmustine

cisplatin 50 mg vial generic 1 CYCLOPHOSPHAMIDE (25 MG CAPSULE, 50 MG CAPSULE, 1 GM VIAL, 500 MG VIAL, 2 generic 1 GM VIAL)

ifosfamide generic 1 LEUKERAN BRAND 1 chlorambucil MATULANE BRAND 1 procarbazine hcl

melphalan hcl generic 1 MYLERAN BRAND 1 busulfan TEMODAR 100 MG VIAL BRAND 1 temozolomide

temozolomide generic 1

thiotepa 100 mg vial generic 1 TREANDA BRAND 1 bendamustine hcl

PAGE 29 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ANTIANDROGENS

bicalutamide generic 1 AL At least 18 yrs old

flutamide generic 1 AL At least 18 yrs old

XTANDI BRAND 1 AL At least 18 yrs old enzalutamide ZYTIGA BRAND 1 AL At least 18 yrs old abiraterone acetate ANTIANGIOGENIC AGENTS

POMALYST BRAND 1 AL At least 18 yrs old pomalidomide REVLIMID BRAND 1 AL At least 18 yrs old lenalidomide ANTIESTROGENS/MODIFIERS

tamoxifen citrate generic 1 AL At least 18 yrs old

ANTIMETABOLITES

ALIMTA BRAND 1 pemetrexed disodium

cladribine generic 1

cytarabine generic 1

floxuridine generic 1 FLUOROURACIL (5,000 MG/100 ML, 2.5 GM/50 ML BTL, 2.5 GM/50 ML VIAL, 500 MG/10 ML VIAL, 2,500 MG/50 ML VL, 2% generic 1 TOPICAL SOLN, 5% CREAM, 5 GM/100 ML BTL, 5 GM/100 ML VIAL, 1,000 MG/20 ML VL, 5% TOPICAL SOLN)

gemcitabine hcl generic 1

hydroxyurea generic 1

mercaptopurine generic 1 XELODA BRAND 1 AL At least 18 yrs old capecitabine ANTINEOPLASTICS, OTHER

azacitidine generic 1

bleomycin sulfate generic 1

bortezomib generic 1

CARBOPLATIN (150 MG/15 ML, 50 MG/5 ML, generic 1

PAGE 30 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS 450 MG/45 ML, 600 MG/60 ML) CISPLATIN (100 MG/100 ML, 50 MG/50 ML, generic 1 200 MG/200 ML)

dacarbazine generic 1

daunorubicin hcl generic 1

decitabine generic 1

dexrazoxane generic 1 AL At least 18 yrs old

docetaxel generic 1 AL At least 18 yrs old

DOXORUBICIN HCL (50 MG, 150 MG/75 ML, 20 MG/10 ML, 10 MG/5 ML, 50 MG/25 ML, 200 generic 1 MG/100 ML)

doxorubicin hcl liposome generic 1 EPIRUBICIN HCL (HCL 200 MG, 200 MG/100 generic 1 ML, 50 MG/25 ML)

fludarabine phosphate generic 1

idarubicin hcl generic 1 IRINOTECAN HCL (100 MG/5 ML VL, 40 MG/2 generic 1 ML VIAL, 500 MG/25 ML VL) LEUCOVORIN CALCIUM (CALCIUM 100 MG VIAL, CALCIUM 10 MG TAB, CALCIUM 5 MG TAB, CALCIUM 25 MG TAB, CALCIUM 200 MG VIAL, CALCIUM 50 MG VIAL, CALCIUM generic 1 350 MG VIAL, CALCIUM 15 MG TAB, CALCIUM 500 MG VL, CAL 100 MG/10 ML VL, CAL 500 MG/50 ML VL)

mitomycin generic 1

mitoxantrone hcl generic 1 AL At least 18 yrs old

MUTAMYCIN BRAND 1 mitomycin ONCASPAR BRAND 1 pegaspargase

oxaliplatin generic 1

paclitaxel generic 1 PARAPLATIN BRAND 1 carboplatin

thiotepa 15 mg vial generic 1 VALSTAR BRAND 1 valrubicin

PAGE 31 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

vinblastine sulfate generic 1

vincristine sulfate generic 1

vinorelbine tartrate generic 1

ZOLADEX PA BRAND 1 goserelin acetate AL At least 18 yrs old

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole generic 1 AL At least 18 yrs old

exemestane generic 1 AL At least 18 yrs old

letrozole generic 1 AL At least 18 yrs old

ENZYME INHIBITORS

ETOPOSIDE (1,000 MG/50 ML, 500 MG/25 generic 1 ML, 100 MG/5 ML)

topotecan hcl 4 mg vial generic 1 AL At least 6 yrs old

topotecan hcl 4 mg/4 ml vial generic 1 MOLECULAR TARGET INHIBITORS

imatinib mesylate generic 1 AL At least 1 yrs old

IRESSA BRAND 1 AL At least 18 yrs old gefitinib SUTENT BRAND 1 AL At least 18 yrs old sunitinib malate VOTRIENT BRAND 1 AL At least 18 yrs old pazopanib hcl MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE

ARZERRA BRAND 1 ofatumumab CAMPATH BRAND 1 alemtuzumab RITUXAN BRAND 1 rituximab RETINOIDS

PANRETIN BRAND 1 PA alitretinoin

tretinoin 10 mg capsule generic 1 AL At least 1 yrs old

TREATMENT ADJUNCTS

PAGE 32 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

mesna generic 1

ANTIPARASITICS

ANTIHELMINTHICS

albendazole generic 1 BILTRICIDE BRAND 1 praziquantel

ivermectin 3 mg tablet generic 1 ANTIPROTOZOALS

atovaquone generic 1

chloroquine phosphate generic 1

hydroxychloroquine sulfate generic 1

mefloquine hcl generic 1 NEBUPENT BRAND 1 pentamidine isethionate

primaquine generic 1 PEDICULICIDES/SCABICIDES

permethrin generic 1

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

BENZTROPINE MESYLATE (1 MG TABLET, 2 generic 1 AL At least 3 yrs old MG TABLET, 0.5 MG TAB) TRIHEXYPHENIDYL HCL (5 MG TABLET, 2 generic 1 AL At least 18 yrs old MG TABLET, 2 MG/5 ML ELX) ANTIPARKINSON AGENTS, OTHER

AMANTADINE (50 MG/5 ML SOLUTION, 100 MG TABLET, 100 MG/10 ML SOLN, 100 MG generic 1 AL At least 1 yrs old CAPSULE)

carbidopa-levodopa-entacapone generic 1 AL At least 18 yrs old

DOPAMINE AGONISTS

pramipexole dihydrochloride generic 1 AL At least 18 yrs old

ropinirole hcl generic 1 AL At least 18 yrs old

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

PAGE 33 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS CARBIDOPA-LEVODOPA (25-250, 10-100, 25- generic 1 AL At least 18 yrs old 100)

carbidopa-levodopa er generic 1 AL At least 18 yrs old

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

SELEGILINE HCL (5 MG TABLET, 5 MG generic 1 AL At least 18 yrs old CAPSULE)

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

chlorpromazine 25 mg/ml amp generic 1 AL At least 18 yrs old

CHLORPROMAZINE HCL (50 MG, 200 MG, generic 1 AL At least 18 yrs old 100 MG, 10 MG, 25 MG) DROPERIDOL (2.5 MG/ML AMPUL, 5 MG/2 generic 1 AL At least 18 yrs old ML VIAL)

fluphenazine decanoate generic 1 AL At least 18 yrs old

FLUPHENAZINE HCL (10 MG TABLET, 5 MG/ML CONC, 5 MG TABLET, 2.5 MG/5 ML generic 1 AL At least 6 yrs old ELIX, 2.5 MG TABLET, 1 MG TABLET)

fluphenazine 2.5 mg/ml vial generic 1 AL At least 18 yrs old

haloperidol generic 1 AL At least 6 yrs old

HALOPERIDOL DECANOATE (DECAN 50 MG/ML AMP, DEC 50 MG/ML VIAL, DEC 500 generic 1 AL At least 18 yrs old MG/5 ML VL, DEC 100 MG/ML VIAL, DEC 250 MG/5 ML VL, DEC 100 MG/ML AMP)

haloperidol decanoate 100 generic 1 AL At least 18 yrs old

HALOPERIDOL LACTATE (50 MG/10 ML VL, generic 1 AL At least 18 yrs old 5 MG/ML AMPUL, 5 MG/ML VIAL)

haloperidol lac 2 mg/ml conc generic 1 AL At least 6 yrs old

loxapine generic 1 AL At least 18 yrs old

pimozide generic 1 AL At least 18 yrs old

thioridazine hcl generic 1 AL At least 18 yrs old

thiothixene generic 1 AL At least 18 yrs old

trifluoperazine hcl generic 1 AL At least 18 yrs old

2ND GENERATION/ATYPICAL

PAGE 34 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

ABILIFY MAINTENA (ER 300 MG SYR, ER PA 300 MG VL, ER 400 MG VL, ER 400 MG SYR) BRAND 1 aripiprazole AL At least 18 yrs old ARIPIPRAZOLE (15 MG TABLET, 1 MG/ML SOLUTION, 10 MG TABLET, 30 MG TABLET, generic 1 AL At least 6 yrs old 5 MG TABLET, 20 MG TABLET, 2 MG TABLET)

ARISTADA PA BRAND 1 aripiprazole lauroxil AL At least 18 yrs old

ARISTADA INITIO PA BRAND 1 aripiprazole lauroxil, submicronized AL At least 18 yrs old

FANAPT (10 MG, 1 MG, 2 MG, 6 MG, 8 MG, 4 MG, 12 MG) BRAND 1 AL At least 18 yrs old iloperidone

INVEGA SUSTENNA PA BRAND 1 paliperidone palmitate AL At least 18 yrs old

INVEGA TRINZA PA BRAND 1 paliperidone palmitate AL At least 18 yrs old

LATUDA BRAND 1 AL At least 10 yrs old lurasidone hcl OLANZAPINE (20 MG, 10 MG, 5 MG, 2.5 MG, generic 1 AL At least 6 yrs old 7.5 MG, 15 MG)

olanzapine odt generic 1 AL At least 6 yrs old

PERSERIS PA BRAND 1 risperidone AL At least 18 yrs old

quetiapine fumarate generic 1 AL At least 6 yrs old

quetiapine fumarate er generic 1 AL At least 6 yrs old

RISPERDAL CONSTA PA BRAND 1 risperidone microspheres AL At least 18 yrs old

RISPERIDONE (2 MG TABLET, 4 MG TABLET, 0.25 MG TABLET, 1 MG/ML generic 1 AL At least 6 yrs old SOLUTION, 1 MG TABLET, 3 MG TABLET, 0.5 MG TABLET)

risperidone odt generic 1 AL At least 6 yrs old

ziprasidone hcl generic 1 AL At least 6 yrs old

PAGE 35 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS TREATMENT-RESISTANT

clozapine generic 1 AL At least 6 yrs old

CLOZARIL BRAND 1 AL At least 6 yrs old clozapine

ANTISPASTICITY AGENTS

BACLOFEN (10 MG, 20 MG, 5 MG) generic 1

TIZANIDINE HCL (4 MG, 2 MG) generic 1

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

ganciclovir sodium generic 1 VALGANCICLOVIR HCL (450 MG TABLET, generic 1 HCL 50 MG/ML) ANTI-HEPATITIS B (HBV) AGENTS

entecavir generic 1 EPIVIR HBV 25 MG/5 ML SOLN BRAND 1 AL Up to 11 yrs old lamivudine

lamivudine hbv generic 1 ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

MAVYRET PA BRAND 1 glecaprevir/pibrentasvir AL At least 12 yrs old

PA sofosbuvir-velpatasvir generic 1 AL At least 18 yrs old

VOSEVI PA BRAND 1 sofosbuvir/velpatasvir/voxilaprevir AL At least 18 yrs old

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

INTRON A BRAND 1 interferon alfa-2b,recomb.

PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 PA ML SYRINGE) BRAND 1 peginterferon alfa-2a AL At least 3 yrs old

PEGINTRON PA BRAND 1 peginterferon alfa-2b AL At least 3 yrs old

RIBAVIRIN (200 MG CAPSULE, 200 MG generic 1 PA

PAGE 36 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

TABLET) AL At least 5 yrs old

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

BIKTARVY PA bictegravir sodium/emtricitabine/tenofovir BRAND 1 alafenamide fumar AL At least 6 yrs old

GENVOYA PA elvitegravir/cobicistat/emtricitabine/tenofovir BRAND 1 alafenamide AL At least 12 yrs old ISENTRESS (100 MG POWDER PACKET, 25 MG TABLET CHEW, 400 MG TABLET, 100 BRAND 1 PA MG TABLET CHEW) raltegravir potassium ISENTRESS HD BRAND 1 PA raltegravir potassium

STRIBILD PA elvitegravir/cobicistat/emtricitabine/tenofovir BRAND 1 disoproxil AL At least 12 yrs old TIVICAY BRAND 1 PA dolutegravir sodium ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA PA efavirenz/emtricitabine/tenofovir disoproxil BRAND 1 fumarate AL At least 12 yrs old

COMPLERA PA emtricitabine/rilpivirine hcl/tenofovir disoproxil BRAND 1 fumarate AL At least 12 yrs old

DELSTRIGO PA doravirine/lamivudine/tenofovir disoproxil BRAND 1 fumarate AL At least 18 yrs old

EDURANT PA BRAND 1 rilpivirine hcl AL At least 12 yrs old

INTELENCE BRAND 1 PA etravirine NEVIRAPINE (50 MG/5 ML SUSP, 200 MG generic 1 PA TABLET)

nevirapine er generic 1 PA

ODEFSEY PA emtricitabine/rilpivirine hcl/tenofovir BRAND 1 alafenamide fumarate AL At least 12 yrs old PIFELTRO BRAND 1 PA

PAGE 37 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

doravirine AL At least 18 yrs old

SUSTIVA (200 MG CAPSULE, 600 MG TABLET, 50 MG CAPSULE) BRAND 1 PA efavirenz SYMFI efavirenz/lamivudine/tenofovir disoproxil BRAND 1 PA fumarate SYMFI LO efavirenz/lamivudine/tenofovir disoproxil BRAND 1 PA fumarate VIRAMUNE 50 MG/5 ML SUSP BRAND 1 PA nevirapine ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir 300 mg tablet generic 1 PA

abacavir-lamivudine generic 1 PA

CIMDUO BRAND 1 PA lamivudine/tenofovir disoproxil fumarate

DIDANOSINE (400 MG, 250 MG) generic 1 PA

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) BRAND 1 PA emtricitabine EPIVIR 10 MG/ML ORAL SOLN BRAND 1 PA lamivudine LAMIVUDINE (300 MG TABLET, 150 MG generic 1 PA TABLET, 10 MG/ML ORAL SOLN)

lamivudine-zidovudine generic 1 PA

RETROVIR 200 MG/20 ML VIAL BRAND 1 PA zidovudine

stavudine generic 1 PA

TEMIXYS BRAND 1 PA lamivudine/tenofovir disoproxil fumarate

tenofovir disoproxil fumarate generic 1 TRIZIVIR BRAND 1 PA abacavir sulfate/lamivudine/zidovudine TRUVADA BRAND 1 PA emtricitabine/tenofovir disoproxil fumarate VIDEX 2 GM PEDIATRIC SOLN BRAND 1 PA didanosine

PAGE 38 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS VIREAD (POWDER, 200 MG TABLET, 150 MG TABLET, 250 MG TABLET) BRAND 1 tenofovir disoproxil fumarate ZIAGEN 20 MG/ML SOLUTION BRAND 1 PA abacavir sulfate ZIDOVUDINE (50 MG/5 ML SYRUP, 300 MG generic 1 PA TABLET, 100 MG CAPSULE) ANTI-HIV AGENTS, OTHER

DESCOVY BRAND 1 PA emtricitabine/tenofovir alafenamide fumarate

DOVATO PA BRAND 1 dolutegravir sodium/lamivudine AL At least 18 yrs old

FUZEON PA BRAND 1 enfuvirtide AL At least 6 yrs old

JULUCA PA BRAND 1 dolutegravir sodium/rilpivirine hcl AL At least 18 yrs old

SELZENTRY (20 MG/ML ORAL SOLN, 300 MG TABLET, 25 MG TABLET, 150 MG PA BRAND 1 TABLET, 75 MG TABLET) AL At least 16 yrs old maraviroc

TRIUMEQ PA BRAND 1 abacavir sulfate/dolutegravir sodium/lamivudine AL At least 18 yrs old

TROGARZO PA BRAND 1 ibalizumab-uiyk AL At least 18 yrs old

TYBOST PA BRAND 1 cobicistat AL At least 12 yrs old

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) BRAND 1 PA tipranavir/vitamin e tpgs CRIXIVAN BRAND 1 PA indinavir sulfate

EVOTAZ PA BRAND 1 atazanavir sulfate/cobicistat AL At least 18 yrs old

INVIRASE 500 MG TABLET BRAND 1 PA saquinavir mesylate

PAGE 39 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS KALETRA (100-25 MG TABLET, 80 MG-20 MG/ML SOLN, 200-50 MG TABLET) BRAND PA lopinavir/ritonavir LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) BRAND 1 PA fosamprenavir calcium NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100 MG POWDER PACKET) BRAND 1 PA ritonavir

PREZCOBIX PA BRAND 1 darunavir ethanolate/cobicistat AL At least 18 yrs old

PREZISTA (600 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 75 MG BRAND 1 PA TABLET, 800 MG TABLET) darunavir ethanolate REYATAZ (200 MG CAPSULE, 50 MG POWDER PACKET, 300 MG CAPSULE, 150 BRAND 1 PA MG CAPSULE) atazanavir sulfate SYMTUZA darunavir eth/cobicistat/emtricitabine/tenofovir BRAND 1 PA alafenamide VIRACEPT BRAND 1 PA nelfinavir mesylate ANTI-INFLUENZA AGENTS

OSELTAMIVIR PHOSPHATE (30 MG, 75 MG, generic 1 45 MG)

oseltamivir 6 mg/ml suspension generic 1 AL Up to 12 yrs old

ANTIHERPETIC AGENTS

acyclovir 200 mg/5 ml susp generic 1 AL Up to 17 yrs old

ACYCLOVIR (200 MG CAPSULE, 400 MG generic 1 TABLET, 800 MG TABLET) DENAVIR BRAND 1 penciclovir

trifluridine generic 1

valacyclovir generic 1 ZOVIRAX (OINTMENT, CREAM) BRAND 1 AL At least 12 yrs old acyclovir

ANXIOLYTICS

PAGE 40 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ANXIOLYTICS, OTHER

buspirone hcl generic 1 BENZODIAZEPINES

alprazolam generic 1 AL At least 7 yrs old

chlordiazepoxide hcl generic 1 AL At least 6 yrs old

CLONAZEPAM (0.5 MG DIS TABLET, 0.25 MG ODT, 0.5 MG TABLET, 0.5 MG ODT, 2 MG ODT, 0.125 MG ODT, 1 MG ODT, 1 MG generic 1 TABLET, 1 MG DIS TABLET, 2 MG TABLET, 0.125 MG DIS TAB)

clorazepate dipotassium generic 1 AL At least 9 yrs old

DIAZEPAM (2 MG TABLET, 10 MG TABLET, 5 generic 1 MG/5 ML SOLUTION, 5 MG TABLET) KLONOPIN BRAND 1 PA clonazepam

lisinopril 5 mg tablet generic 1 LORAZEPAM (4 MG/ML CARPUJECT, 2 MG/ML ORAL CONCENT, 0.5 MG TABLET, 4 MG/ML VIAL, 2 MG/ML VIAL, 1 MG TABLET, 2 generic 1 MG/ML CARPUJECT, 20 MG/10 ML VIAL, 2 MG TABLET) LORAZEPAM INTENSOL BRAND 1 lorazepam

oxazepam generic 1 AL At least 6 yrs old

BIPOLAR AGENTS

MOOD STABILIZERS

EQUETRO PA BRAND 1 carbamazepine AL At least 6 yrs old

LITHIUM CARBONATE (300 MG TAB, 600 MG generic 1 AL At least 6 yrs old CAP, 150 MG CAP, 300 MG CAP)

lithium carbonate er generic 1 AL At least 6 yrs old

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS

acarbose generic 1

BYDUREON PEN BRAND 1

PAGE 41 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS exenatide microspheres BYETTA BRAND 1 exenatide FARXIGA BRAND 1 dapagliflozin propanediol FORTAMET BRAND 1 metformin hcl

glimepiride generic 1

glipizide generic 1

glipizide er generic 1

glipizide xl generic 1

glipizide-metformin generic 1 GLUMETZA BRAND 1 metformin hcl

glyburide generic 1

glyburide micronized generic 1

glyburide-metformin hcl generic 1 GLYSET BRAND 1 miglitol GLYXAMBI BRAND 1 AL At least 18 yrs old empagliflozin/linagliptin INVOKAMET BRAND 1 canagliflozin/metformin hcl INVOKANA BRAND 1 canagliflozin JANUMET BRAND 1 AL At least 18 yrs old sitagliptin phosphate/metformin hcl JANUMET XR BRAND 1 AL At least 18 yrs old sitagliptin phosphate/metformin hcl JANUVIA BRAND 1 AL At least 18 yrs old sitagliptin phosphate JARDIANCE BRAND 1 empagliflozin JENTADUETO BRAND 1 AL At least 18 yrs old linagliptin/metformin hcl KOMBIGLYZE XR BRAND 1 AL At least 18 yrs old saxagliptin hcl/metformin hcl

metformin er gastric generic 1

PAGE 42 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

metformin er osmotic generic 1 METFORMIN HCL (1,000 MG, 850 MG, 500 generic 1 MG)

metformin hcl er generic 1 ONGLYZA BRAND 1 AL At least 18 yrs old saxagliptin hcl

pioglitazone hcl generic 1

repaglinide generic 1 TRADJENTA BRAND 1 AL At least 18 yrs old linagliptin GLYCEMIC AGENTS

GLUCAGEN 1 MG HYPOKIT BRAND 1 QL glucagon,human recombinant GLUCAGEN DIAGNOSTIC 1 MG VIAL BRAND 1 glucagon,human recombinant GLUCAGON EMERGENCY KIT BRAND 1 glucagon hcl

glucagon hcl generic 1 PROGLYCEM BRAND 1 diazoxide INSULINS

BASAGLAR KWIKPEN U-100 BRAND 1 insulin glargine,human recombinant analog HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNIT/ML VIAL) BRAND 1 insulin lispro HUMALOG KWIKPEN U-100 BRAND 1 insulin lispro HUMALOG MIX 50-50 BRAND 1 insulin lispro protamine and insulin lispro HUMALOG MIX 50-50 KWIKPEN BRAND 1 insulin lispro protamine and insulin lispro HUMALOG MIX 75-25 BRAND 1 insulin lispro protamine and insulin lispro HUMALOG MIX 75-25 KWIKPEN BRAND 1 insulin lispro protamine and insulin lispro LANTUS BRAND 1 insulin glargine,human recombinant analog

LANTUS SOLOSTAR BRAND 1

PAGE 43 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS insulin glargine,human recombinant analog LEVEMIR BRAND 1 insulin detemir LEVEMIR FLEXTOUCH BRAND 1 insulin detemir NOVOLOG (100 CARTRIDGE, 100 VIAL) BRAND 1 insulin aspart NOVOLOG FLEXPEN BRAND 1 insulin aspart NOVOLOG MIX 70-30 BRAND 1 insulin aspart protamine human/insulin aspart NOVOLOG MIX 70-30 FLEXPEN BRAND 1 insulin aspart protamine human/insulin aspart

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

CATHFLO ACTIVASE BRAND 1 alteplase COUMADIN BRAND 1 warfarin sodium ELIQUIS (5 MG TABLET, 2.5 MG TABLET, DVT-PE TREAT START 5MG) BRAND 1 AL At least 18 yrs old apixaban ENOXAPARIN SODIUM (150 MG/ML SYRINGE, 80 MG/0.8 ML SYR, 300 MG/3 ML VIAL, 120 MG/0.8 ML SYR, 30 MG/0.3 ML generic 1 SYR, 60 MG/0.6 ML SYR, 100 MG/ML SYRINGE, 40 MG/0.4 ML SYR)

heparin 500 unit/5 ml (100/ml) generic 1 HEPARIN SODIUM (SOD 5,000 UNIT/0.5 ML, 2,000 UNIT/2 ML VIAL, 5,000 UNIT/ML CARPUJCT, SOD 1,000 UNIT/ML VIAL, SOD generic 1 10,000 UNIT/ML VL, SOD 5,000 UNIT/ML VIAL, SOD 5,000 UNIT/ML SYRG, SOD 20,000 UNIT/ML VL, SOD 5,000 UNIT/ 0.5 ML)

heparin 1,000 unit/500 ml-ns generic 1 JANTOVEN BRAND 1 warfarin sodium PRADAXA BRAND 1 AL At least 18 yrs old dabigatran etexilate mesylate

warfarin sodium generic 1

PAGE 44 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS XARELTO (2.5 MG TABLET, 15 MG TABLET, 20 MG TABLET, STARTER PACK, 10 MG BRAND AL At least 18 yrs old TABLET) rivaroxaban BLOOD FORMATION MODIFIERS

anagrelide hcl generic 1 ARANESP (500 MCG/1 ML SYRINGE, 150 MCG/0.3 ML SYRINGE, 100 MCG/ML VIAL, 60 MCG/0.3 ML SYRINGE, 25 MCG/ML VIAL, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 300 MCG/0.6 ML SYRINGE, 10 MCG/0.4 ML BRAND 1 PA SYRINGE, 300 MCG/ML VIAL, 200 MCG/0.4 ML SYRINGE, 100 MCG/0.5 ML SYRINGE, 25 MCG/0.42 ML SYRING, 200 MCG/ML VIAL, 60 MCG/ML VIAL) darbepoetin alfa in polysorbate 80 GRANIX (300 MCG/ML VIAL, 300 MCG/0.5 ML SYRINGE, 300 MCG/0.5 ML SAFE SYR, 480 MCG/0.8 ML SYRINGE, 480 MCG/0.8 ML BRAND 1 PA SAFE SYR, 480 MCG/1.6 ML VIAL) tbo-filgrastim LEUKINE BRAND 1 PA sargramostim NEULASTA (6 ML SYRINGE, ONPRO 6 ML KIT) BRAND 1 PA pegfilgrastim NEUPOGEN (300 MCG/ML VIAL, 300 MCG/0.5 ML SYR, 480 MCG/1.6 ML VIAL, 480 BRAND 1 PA MCG/0.8 ML SYR) filgrastim PROCRIT BRAND 1 PA epoetin alfa HEMOSTASIS AGENTS

ADVATE antihemophilic factor (fviii) recombinant,full BRAND 1 length ADYNOVATE antihemophilic factor (fviii) recombinant, full BRAND 1 length, peg AFSTYLA antihemophilic factor viii recomb,single-chn,b- BRAND 1 dom truncated ALPHANATE antihemophilic factor, human/von willebrand BRAND 1 factor,human

PAGE 45 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ALPHANINE SD BRAND 1 factor ix ALPROLIX BRAND 1 factor ix recombinant, fc fusion protein AMICAR (500 MG TABLET, 1,000 MG TABLET, 0.25 GRAM/ML ORAL SOLN) BRAND 1 aminocaproic acid

aminocaproic acid 5 g/20 ml vl generic 1 BENEFIX BRAND 1 factor ix human recombinant COAGADEX BRAND 1 coagulation factor x CORIFACT BRAND 1 factor xiii ELOCTATE antihemophilic factor (fviii) recombinant, fc BRAND 1 fusion protein ESPEROCT antihemophilic factor (fviii) rec, b-dom truncated BRAND 1 peg-exei FEIBA NF BRAND 1 anti-inhibitor coagulant complex HEMLIBRA BRAND 1 emicizumab-kxwh HEMOFIL M BRAND 1 antihemophilic factor, human HUMATE-P antihemophilic factor, human/von willebrand BRAND 1 factor,human IDELVION BRAND 1 factor ix recombinant,albumin fusion protein IXINITY (3,000, 2,000, 250) BRAND 1 factor ix human recombinant, threonine 148 JIVI antihemophilic factor (fviii) rec, b-domain BRAND 1 AL At least 12 yrs old deleted peg-aucl KOATE BRAND 1 antihemophilic factor, human KOGENATE FS antihemophilic factor (fviii) recombinant,full BRAND 1 length

KOVALTRY BRAND 1

PAGE 46 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS antihemophilic factor (fviii) recombinant,full length MEPHYTON BRAND 1 phytonadione (vit k1) MONONINE BRAND 1 factor ix NOVOEIGHT antihemophilic factor viii recombinant, b-domain BRAND 1 truncated NOVOSEVEN RT BRAND 1 coagulation factor viia (recombinant) NUWIQ antihemophilic factor viii rec hek cell, b-domain BRAND 1 deleted OBIZUR antihemophilic factor viii, recombinant porcine BRAND 1 sequence PHYTONADIONE (1 MG/0.5 ML SYR, 10 generic 1 MG/ML AMPUL) PROFILNINE factor ix complex, prothrombin cplx conc(pcc) BRAND 1 no.4, 3-factor REBINYN BRAND 1 factor ix (human) recombinant, pegylated RECOMBINATE BRAND 1 antihemophilic factor viii, human recombinant RIXUBIS BRAND 1 factor ix human recombinant TRANEXAMIC ACID (650 MG TABLET, 1,000 generic 1 MG/10 ML)

tranexamic acid-nacl generic 1 TRETTEN BRAND 1 factor xiii a-subunit, recombinant

vitamin k1 generic 1 VONVENDI BRAND 1 von willebrand factor (recombinant) WILATE (500-500, 1,000-1,000) antihemophilic factor, human/von willebrand BRAND 1 factor,human XYNTHA antihemophilic factor (factor viii) recomb,b- BRAND 1 domain deleted

PAGE 47 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b- BRAND 1 domain deleted PLATELET MODIFYING AGENTS

AGGRENOX BRAND 1 aspirin/dipyridamole BRILINTA BRAND 1 ticagrelor

cilostazol generic 1

clopidogrel 75 mg tablet generic 1

DIPYRIDAMOLE (75 MG, 25 MG, 50 MG) generic 1

prasugrel hcl generic 1

CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

CATAPRES-TTS 1 BRAND 1 clonidine CATAPRES-TTS 2 BRAND 1 clonidine CATAPRES-TTS 3 BRAND 1 clonidine

CLONIDINE HCL (0.3 MG, 0.2 MG, 0.1 MG) generic 1

guanfacine hcl generic 1

methyldopa generic 1

midodrine hcl generic 1 ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate generic 1

prazosin hcl generic 1

terazosin hcl generic 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS

irbesartan generic 1

losartan potassium generic 1

olmesartan medoxomil generic 1 ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

benazepril hcl generic 1

PAGE 48 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS enalapril maleate generic

fosinopril sodium generic 1 LISINOPRIL (10 MG, 30 MG, 40 MG, 2.5 MG, generic 1 20 MG)

quinapril hcl generic 1

ramipril generic 1 ANTIARRHYTHMICS

AMIODARONE HCL (200 MG, 100 MG) generic 1

flecainide acetate generic 1

mexiletine hcl generic 1

propafenone hcl generic 1

quinidine sulfate generic 1

sotalol generic 1

sotalol af generic 1 TIKOSYN BRAND 1 dofetilide BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl generic 1

atenolol generic 1

bisoprolol fumarate generic 1

carvedilol generic 1

LABETALOL HCL (100 MG, 200 MG, 300 MG) generic 1

metoprolol succinate generic 1 METOPROLOL TARTRATE (50 MG, 100 MG, generic 1 25 MG) PROPRANOLOL HCL (20 MG/5 ML SOLN, 40 MG TABLET, 10 MG TABLET, 20 MG generic 1 TABLET, 40 MG/5 ML SOLN, 60 MG TABLET, 80 MG TABLET)

propranolol hcl er generic 1 CALCIUM CHANNEL BLOCKING AGENTS

amlodipine besylate generic 1

diltiazem 12hr er generic 1

diltiazem 24hr er generic 1

PAGE 49 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS diltiazem 24hr er (cd) generic DILTIAZEM HCL (90 MG, 30 MG, 60 MG, 120 generic 1 MG)

felodipine er generic 1

nifedipine generic 1

nifedipine er generic 1

nimodipine generic 1 AL At least 18 yrs old

VERAPAMIL ER (ER 240 MG CAPSULE, ER 240 MG TABLET, ER 120 MG CAPSULE, ER generic 1 120 MG TABLET, ER 180 MG TABLET, ER 180 MG CAPSULE) VERAPAMIL HCL (80 MG TABLET, 40 MG TABLET, 360 MG CAP PELLET, 120 MG generic 1 TABLET)

verapamil sr generic 1 CARDIOVASCULAR AGENTS, OTHER

amiloride-hydrochlorothiazide generic 1

amlodipine besylate-benazepril generic 1

amlodipine-olmesartan generic 1

amlodipine-valsartan generic 1

atenolol-chlorthalidone generic 1

bisoprolol-hydrochlorothiazide generic 1 DIGOXIN (0.05 MG/ML SOLUTION, 125 MCG TABLET, 0.125 MG TABLET, 250 MCG generic 1 TABLET, 0.25 MG TABLET)

dobutamine 250 mg/20 ml vial generic 1

dobutamine hcl in dextrose generic 1

enalapril-hydrochlorothiazide generic 1 ENTRESTO BRAND 1 sacubitril/valsartan

fosinopril-hydrochlorothiazide generic 1

lisinopril-hydrochlorothiazide generic 1

losartan-hydrochlorothiazide generic 1

milrinone in 5% dextrose generic 1

milrinone lactate generic 1

pentoxifylline generic 1

PAGE 50 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

quinapril-hydrochlorothiazide generic 1 RANEXA BRAND 1 ranolazine

spironolactone-hctz generic 1 TRIAMTERENE-HYDROCHLOROTHIAZID (75-50 MG TAB, 37.5-25 MG CP, 37.5-25 MG generic 1 TB) DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide generic 1

acetazolamide er generic 1 DIURETICS, LOOP

BUMETANIDE (1 MG/4 ML VIAL, 1 MG TABLET, 0.5 MG TABLET, 2.5 MG/10 ML generic 1 VIAL, 2 MG TABLET) FUROSEMIDE (100 MG/10 ML SYRING, 80 MG TABLET, 20 MG TABLET, 40 MG/4 ML VIAL, 40 MG/4 ML SYRINGE, 40 MG/5 ML generic 1 SOLN, 10 MG/ML SOLUTION, 40 MG TABLET, 100 MG/10 ML VIAL, 20 MG/2 ML VIAL)

torsemide generic 1 DIURETICS, POTASSIUM-SPARING

amiloride hcl generic 1

eplerenone generic 1

spironolactone generic 1 DIURETICS, THIAZIDE

chlorthalidone generic 1 DIURIL BRAND 1 AL Up to 11 yrs old chlorothiazide HYDROCHLOROTHIAZIDE (12.5 MG TB, 50 generic 1 MG TAB, 12.5 MG CP, 25 MG TAB)

indapamide generic 1

metolazone generic 1 DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

FENOFIBRATE (145 MG, 48 MG) generic 1

gemfibrozil generic 1 DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

PAGE 51 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

atorvastatin calcium generic 1

lovastatin generic 1

pravastatin sodium generic 1

rosuvastatin calcium generic 1 SIMVASTATIN (20 MG, 40 MG, 5 MG, 80 MG, generic 1 10 MG) DYSLIPIDEMICS, OTHER

CHOLESTYRAMINE (POWDER, PACKET) generic 1 CHOLESTYRAMINE LIGHT (POWDER, generic 1 PACKET) COLESTID (PACKET, FLAVORED, ) BRAND 1 colestipol hcl COLESTIPOL HCL (HCL GRANULES, MICRONIZED 1 GM TAB, HCL GRANULES generic 1 PACKET, HCL 1 GM TABLET)

ezetimibe generic 1 AL At least 10 yrs old

niacin er generic 1 VASODILATORS, DIRECT-ACTING ARTERIAL

HYDRALAZINE HCL (25 MG, 10 MG, 100 MG, generic 1 50 MG)

minoxidil generic 1 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

isosorbide dinitrate generic 1

isosorbide mononitrate generic 1

isosorbide mononitrate er generic 1

NITROGLYCERIN (0.6 MG, 0.3 MG, 0.4 MG) generic 1

nitroglycerin patch generic 1

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

DEXTROAMPHETAMINE SULFATE (10 MG, 5 generic 1 MG)

dextroamphetamine-amphet er generic 1 AL At least 6 yrs old

dextroamphetamine-amphetamine generic 1 AL At least 3 yrs old

DYANAVEL XR BRAND 1 AL At least 6 yrs old

PAGE 52 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS amphetamine VYVANSE (10 MG CHEWABLE TABLET, 60 MG CAPSULE, 60 MG CHEWABLE TABLET, 20 MG CAPSULE, 50 MG CAPSULE, 30 MG CAPSULE, 20 MG CHEWABLE TABLET, 10 MG CAPSULE, 30 MG CHEWABLE TABLET, BRAND 1 AL At least 6 yrs old 40 MG CHEWABLE TABLET, 70 MG CAPSULE, 40 MG CAPSULE, 50 MG CHEWABLE TABLET) lisdexamfetamine dimesylate ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

APTENSIO XR BRAND 1 AL At least 6 yrs old methylphenidate hcl

atomoxetine hcl generic 1 AL At least 6 yrs old

DAYTRANA BRAND 1 AL At least 6 yrs old methylphenidate

dexmethylphenidate hcl generic 1 FOCALIN XR BRAND 1 AL At least 6 yrs old dexmethylphenidate hcl

guanfacine hcl er generic 1 METHYLPHENIDATE ER (ER 20 MG, ER 10 generic 1 AL At least 6 yrs old MG) METHYLPHENIDATE HCL (5 MG, 20 MG, 10 generic 1 MG)

methylphenidate hcl cd generic 1 AL At least 6 yrs old

methylphenidate hcl er (cd) generic 1 AL At least 6 yrs old

QUILLICHEW ER BRAND 1 AL At least 6 yrs old methylphenidate hcl QUILLIVANT XR BRAND 1 AL At least 6 yrs old methylphenidate hcl CENTRAL NERVOUS SYSTEM, OTHER

AUSTEDO PA BRAND 1 deutetrabenazine AL At least 18 yrs old

BUTALBITAL-ACETAMINOPHEN (50-325, 50- generic 1 300)

butalbital-acetaminophen-caffe generic 1

INGREZZA PA BRAND 1 valbenazine tosylate AL At least 18 yrs old

PAGE 53 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS NUEDEXTA BRAND 1 AL At least 18 yrs old dextromethorphan hbr/quinidine sulfate

riluzole generic 1

PA tetrabenazine generic 1 AL At least 18 yrs old

FIBROMYALGIA AGENTS

duloxetine hcl generic 1 AL At least 6 yrs old

PREGABALIN (200 MG, 100 MG, 225 MG, 75 generic 1 MG, 25 MG, 150 MG, 50 MG, 300 MG) MULTIPLE SCLEROSIS AGENTS

AUBAGIO BRAND 1 AL At least 18 yrs old teriflunomide AVONEX PREFILLED SYR 30 MCG KT BRAND 1 AL At least 18 yrs old interferon beta-1a AVONEX PEN BRAND 1 AL At least 18 yrs old interferon beta-1a BETASERON (0.3 MG VIAL, 0.3 MG KIT) BRAND 1 AL At least 18 yrs old interferon beta-1b COPAXONE 20 MG/ML SYRINGE BRAND 1 AL At least 18 yrs old glatiramer acetate

dalfampridine er generic 1 AL At least 18 yrs old

GILENYA BRAND 1 AL At least 10 yrs old fingolimod hcl REBIF BRAND 1 interferon beta-1a/albumin human REBIF REBIDOSE BRAND 1 interferon beta-1a/albumin human TECFIDERA BRAND 1 AL At least 18 yrs old dimethyl fumarate

DENTAL AND ORAL AGENTS

chlorhexidine gluconate generic 1

PILOCARPINE HCL (7.5 MG, 5 MG) generic 1

sodium fluoride 1.1% gel generic 1

triamcinolone 0.1% paste generic 1

DERMATOLOGICAL AGENTS

PAGE 54 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

acitretin generic 1 ALA-QUIN BRAND 1 clioquinol/hydrocortisone

AMMONIUM LACTATE (CREAM, LOTION) generic 1 AMNESTEEM BRAND 1 AL At least 12 yrs old isotretinoin AVITA 0.025% CREAM BRAND 1 AL At least 12 yrs old tretinoin

PA CALCIPOTRIENE (CREAM, OINTMENT) generic 1 AL At least 18 yrs old

calcitriol 3 mcg/g ointment generic 1 CLARAVIS BRAND 1 AL At least 12 yrs old isotretinoin

clinda-benzoyl perox 1-5% pump generic 1 AL At least 12 yrs old

clotrimazole-betamethasone crm generic 1 CORTISPORIN (CREAM, OINTMENT) neomycin/bacitracin/polymyxin BRAND 1 b/hydrocortisone

COSENTYX (2 SYRINGES) PA BRAND 1 secukinumab AL At least 18 yrs old

COSENTYX PEN PA BRAND 1 secukinumab AL At least 18 yrs old

COSENTYX PEN (2 PENS) PA BRAND 1 secukinumab AL At least 18 yrs old

COSENTYX SYRINGE PA BRAND 1 secukinumab AL At least 18 yrs old

diclofenac sodium 1% gel generic 1

PA diclofenac sodium 3% gel generic 1 AL At least 18 yrs old

DIFFERIN (LOTION, CREAM) BRAND 1 AL At least 12 yrs old adapalene

PA doxepin 5% cream generic 1 AL At least 18 yrs old

ELIDEL BRAND 1 pimecrolimus

PAGE 55 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS EUCRISA BRAND 1 AL At least 2 yrs old crisaborole FINACEA 15% GEL BRAND 1 azelaic acid

imiquimod 5% cream packet generic 1 AL At least 12 yrs old

isotretinoin generic 1 AL At least 12 yrs old

LIDOCAINE-HYDROCORTISONE (2.8-0.55% generic 1 GEL, 3-0.5% CREAM)

lidocaine-hc 3-2.5% gel kit generic 1 QL

METRONIDAZOLE (0.75% CREAM, TOPICAL 0.75% GL, TOPICAL 1% GEL, TOP 1% GEL generic 1 PUMP) MYORISAN BRAND 1 AL At least 12 yrs old isotretinoin NATROBA BRAND 1 spinosad

podofilox generic 1 PROCTOFOAM-HC BRAND 1 hydrocortisone acetate/pramoxine hcl PROTOPIC 0.03% OINTMENT BRAND 1 tacrolimus PROTOPIC 0.1% OINTMENT BRAND 1 AL At least 16 yrs old tacrolimus RETIN-A (0.025%, 0.05%, 0.1%) BRAND 1 AL At least 12 yrs old tretinoin

salicylic acid 6% cream generic 1 SANTYL BRAND 1 collagenase clostridium histolyticum SELENIUM SULFIDE (2.25% SHAMPOO, generic 1 2.5% LOTION)

silver nitrate 0.5% soln generic 1

UREA (CREAM, LOTION) generic 1 ZENATANE BRAND 1 AL At least 12 yrs old isotretinoin

ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

PAGE 56 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS AMINOSYN (8.5%, 10%) BRAND 1 parenteral amino acid 10 % combination no.2 AMINOSYN II (15%, 7%, 8.5%, 10%) BRAND 1 parenteral amino acid 7 % combination no.2 AMINOSYN II WITH ELECTROLYTES BRAND 1 amino acids 8.5 %/electrolyte-tpn soln AMINOSYN M BRAND 1 amino acids 3.5 %/electrolyte-m solution AMINOSYN WITH ELECTROLYTES (8.5%- ELECTROLYTES, 7%-ELECTROLYTE) BRAND 1 amino acids 8.5 %/electrolyte-tpn soln AMINOSYN-HBC BRAND 1 amino acids 7 % AMINOSYN-PF (10%, 7%) parenteral amino acid 7 % combination no.1 BRAND 1 (pediatric) AMINOSYN-RF parenteral amino acid 5.2 % combination no.1 BRAND 1 (renal)

calcium chloride 10% vial generic 1 CALCIUM GLUCONATE (10,000 MG/100 ML, generic 1 5,000 MG/50 ML VL, 1,000 MG/10 ML VL) CENTRATEX ferrous fumarate/folic acid/multivitamin- BRAND 1 minerals no.15

chromium generic 1 CLINIMIX (5%-20%, 4.25%-5%, 4.25%-10%, 5%-15%) BRAND 1 amino acids 4.25 %/dextrose 10 % in water CLINIMIX E (5%-15%, 4.25%-10%, 2.75%-5%, 4.25%-5%, 5%-20%) BRAND 1 amino acids 5 %/calcium/electrolyte-tpn soln/dextrose 20 % CLINISOL BRAND 1 parenteral amino acid 15% combination no.5

copper chloride generic 1 DELFLEX WITH 1.5% DEXTROSE peritoneal dialysis solution no.19 and dextrose BRAND 1 1.5 %

dextrose 10%-0.2% nacl generic 1

dextrose 10%-0.45% nacl generic 1

PAGE 57 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

dextrose 2.5%-0.45% nacl generic 1

dextrose 5%-0.2% nacl generic 1

dextrose 5%-0.2% nacl-kcl generic 1

dextrose 5%-0.225% nacl generic 1

dextrose 5%-0.225% nacl-kcl generic 1

dextrose 5%-0.3% nacl generic 1

dextrose 5%-0.3% nacl-kcl generic 1

dextrose 5%-0.33% nacl generic 1

dextrose 5%-0.45% nacl generic 1

dextrose 5%-0.45% nacl-kcl generic 1

dextrose 5%-0.9% nacl generic 1

dextrose 5%-1/2ns-kcl generic 1

dextrose 5%-1/4ns-kcl generic 1

dextrose 5%-electrolyte #48 generic 1

dextrose 5%-ns-kcl generic 1

dextrose 5%-potassium chloride generic 1

dextrose in lactated ringers generic 1 DEXTROSE IN WATER (10%-WATER IV SOLUTION, 20%-WATER IV SOLN, 70%- WATER IV SOLN, 5%-WATER VIAL, 50%- WATER IV SOLN, 50%-WATER ABBOJECT, generic 1 50%-WATER VIAL, 50%-WATER SYRINGE, 40%-WATER IV SOLN, 5%-WATER 50 ML, 25%-WATER SYRINGE, 5%-WATER 100 ML, 30%-WATER IV SOLN, 5%-WATER IV SOLN) EFFER-K BRAND 1 potassium bicarbonate/citric acid

fluoride generic 1 FREAMINE III BRAND 1 parenteral amino acid 10 % combination no.4 FUSION PLUS iron fum,polysac comp/folic acid/vit b compc BRAND 1 no.18/l. casei

glucose in water generic 1 HEMATOGEN FA ferrous fumarate/ascorbic BRAND 1 acid/cyanocobalamin/folic acid

HEMOCYTE PLUS BRAND 1

PAGE 58 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS ferrous fumarate/folic acid/multivitamin- minerals no.15 HEMOCYTE-F BRAND 1 ferrous fumarate/folic acid HEPATAMINE BRAND 1 amino acids 8 % HYPERLYTE CR sodium/potassium/magnesium/calcium/chloride BRAND 1 /acetate IFEREX 150 FORTE iron polysaccharide BRAND 1 complex/cyanocobalamin/folic acid INTEGRA F iron fumarate,polysac comp/folic acid/vitamin BRAND 1 c/niacinamide INTEGRA PLUS iron fumarate,polysac cplex/folic acid/vitb comp BRAND 1 with c no.9 INTRALIPID BRAND 1 fat emulsions IODOPEN BRAND 1 sodium iodide IONOSOL B WITH DEXTROSE 5% BRAND 1 electrolyte-b solution/dextrose 5 % in water IONOSOL MB-DEXTROSE 5% BRAND 1 electrolyte-mb solution/dextrose 5 % in water ISOLYTE P WITH DEXTROSE BRAND 1 electrolyte-p solution/dextrose 5 % in water ISOLYTE S (OLUTION-EXCEL, OLN PH7.4) BRAND 1 electrolyte-s solution KLOR-CON BRAND 1 potassium chloride KLOR-CON 10 BRAND 1 potassium chloride KLOR-CON 8 BRAND 1 potassium chloride KLOR-CON M10 BRAND 1 potassium chloride KLOR-CON M15 BRAND 1 potassium chloride KLOR-CON M20 BRAND 1 potassium chloride

PAGE 59 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS KLOR-CON-EF BRAND 1 potassium bicarbonate/citric acid LACTATED RINGERS (IRRIGATION, generic 1 INJECTION) LEVOCARNITINE (1 G/10 ML SOLN, 330 MG generic 1 TABLET)

magnesium chloride generic 1 MAGNESIUM SULFATE (SULF 2 G/50 ML BAG, SULF 40 G/1,000 ML, SULF 4 G/100 ML generic 1 BAG, SULFATE 50% VIAL, SULF 4 G/50 ML BAG, SULF 20 G/500 ML BAG)

manganese chloride generic 1

manganese sulfate generic 1 MULTITRACE-4 zinc sulfate/cupric sulfate/manganese BRAND 1 sulf/chromic chloride MULTITRACE-5 zinc sulfate/copper BRAND 1 sulfate/manganese/chromium/selenium NEPHRAMINE BRAND 1 amino acids 5.4 % NORMOSOL-M AND DEXTROSE BRAND 1 electrolyte-m solution/dextrose 5 % in water NORMOSOL-R BRAND 1 electrolyte-r solution NORMOSOL-R AND DEXTROSE BRAND 1 electrolyte-r solution/dextrose 5 % in water NORMOSOL-R PH 7.4 BRAND 1 electrolyte-r (ph 7.4) NUTRILIPID BRAND 1 fat emulsions PLASMA-LYTE 148 BRAND 1 electrolyte-148 solution PLASMA-LYTE A PH 7.4 BRAND 1 electrolyte-a solution PLENAMINE BRAND 1 parenteral amino acid 15% combination no.1

potassium acetate generic 1

potassium chl-normal saline generic 1 POTASSIUM CHLORIDE (ER 10 MEQ generic 1

PAGE 60 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS TABLET, 20 MEQ PACKET, 40 MEQ/20 ML CONC, 60 MEQ/30 ML CONC, 10% (20 MEQ/15ML), 20 MEQ/10 ML CONC, 10 MEQ/50 ML SOL, ER 8 MEQ CAPSULE, 20 MEQ/50 ML SOL, ER 8 MEQ TABLET, 10 MEQ/100 ML SOL, ER 10 MEQ CAPSULE, 2 MEQ/ML CONC, 20% (40 MEQ/15ML), 30 MEQ/100 ML SOL, 10% (40 MEQ/30ML), 40 MEQ/100 ML SOL, 10 MEQ/5 ML CONC, ER 20 MEQ TABLET, 20 MEQ/100 ML SOL)

potassium chloride in d5lr generic 1

potassium chloride-nacl generic 1

potassium phosp 45 mmol/15 ml generic 1

potassium phosphates generic 1 PREMASOL 10% IV SOLUTION BRAND 1 parenteral amino acid 10% combination no.7 PROCALAMINE BRAND 1 amino acids 3 %/electrolyte-tpn soln/glycerin PROSOL BRAND 1 parenteral amino acid 20 % combination no.1 PUREVIT DUALFE PLUS iron fumarate-iron polysacch cplex/folic BRAND 1 acid/multivit no.18

ringers injection generic 1

ringers irrigation generic 1 SE-TAN PLUS iron fumarate-iron polysacch cplex/folic BRAND 1 acid/multivit no.18 SODIUM ACETATE (400 MEQ/100 ML, 200 MEQ/100 ML, 100 MEQ/50 ML, 40 MEQ/20 ML generic 1 VL)

sodium bicarbonate 4.2% vial generic 1 SODIUM CHLORIDE (SODIUM CHLORIDE 5% IV SOLN, SODIUM CHLORIDE 0.9% 50 ML, SODIUM CHLORIDE 0.9% IRRIG., SODIUM CHLORIDE 4 MEQ/ML VL, SODIUM CHLORIDE 3% IV SOLN, SODIUM CHLORIDE 0.9% PRCSS SOL, SODIUM CHLORIDE 50 MEQ/20 ML, SALINE 0.45% SOLN-EXCEL generic 1 CON, SODIUM CHLORIDE 0.9% SOLN, SODIUM CHLORIDE 0.9% 500 ML, SODIUM CHLORIDE 0.9% 1,000 ML, SODIUM CHLORIDE 0.9% SOL-EXCEL, SODIUM CHLORIDE 0.9% VIAL, SODIUM CHLORIDE

PAGE 61 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS 0.9% SOLUTION, SODIUM CHLORIDE 0.45% SOLN, SODIUM CHLORIDE 0.9% IRRIG, SODIUM CHLORIDE 100 MEQ/40 ML, SODIUM CHLORIDE 0.9% 100 ML)

sodium fluoride 0.5 mg/ml drop generic 1

sodium phosphate generic 1 SYNTHAMIN 17 WITHOUT ELTYE BRAND 1 parenteral amino acid 10 % combination no.6 TANDEM PLUS iron fumarate-iron polysacch cplex/folic BRAND 1 acid/multivit no.18 TIS-U-SOL PENTALYTE sodium chloride/pot chloride/mag sul/sod BRAND 1 phos,db/pot phos,mb TPN ELECTROLYTES sodium/potassium/magnesium/calcium/chloride BRAND 1 /acetate TPN ELECTROLYTES II sodium/potassium/magnesium/calcium/chloride BRAND 1 /acetate TRAVASOL BRAND 1 parenteral amino acid 10 % combination no.6 TRICON BRAND 1 ferrous fumarate/ascorbic acid/b12-if/folic acid TROPHAMINE 10% IV SOLUTION BRAND 1 amino acids 10 %

zinc chloride generic 1

ZINC SULFATE (30 MG/10 ML, 25 MG/5 ML) generic 1 ELECTROLYTE/MINERAL/METAL MODIFIERS

deferoxamine mesylate generic 1 SODIUM POLYSTYRENE SULFONATE (SODIUM POLYSTYRENE POWDER, SOD generic 1 POLYSTYREN 15 G/60 ML) SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA SUSP) BRAND 1 sodium polystyrene sulfonate/sorbitol solution PHOSPHATE BINDERS

CALCIUM ACETATE (667 MG CAPSULE, 667 generic 1 MG GELCAP) RENVELA (0.8, 2.4) BRAND 1 AL Up to 11 yrs old sevelamer carbonate

PAGE 62 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

sevelamer hcl generic 1 VITAMINS

ascorbic acid generic 1 BACMIN BRAND 1 multivitamin with minerals no.20/iron/folic acid CITRANATAL B-CALM prenatal vitamin BRAND 1 AL At least 12 yrs old no.48/iron,carbonyl,gluconate/folic acid/b6 COMPLETE NATAL DHA prenatal vit no.2/iron bg chel,succ-prot/folic BRAND 1 AL At least 12 yrs old acid/omega-3 CONCEPT DHA mv-min 75/ferrous fum/iron ps cplx/folic BRAND 1 AL At least 12 yrs old ac/omega-3/dha/epa CONCEPT OB mv-mins no.74/ferrous fumarate/iron ps BRAND 1 AL At least 12 yrs old cplx/folic acid

cyanocobalamin injection generic 1 DIALYVITE BRAND 1 folic acid/vitamin b complex and vitamin c DIALYVITE 3000 folic acid/vitamin b comp and BRAND 1 c/selenium/minerals/zinc DIALYVITE 5000 BRAND 1 multivitamins with minerals no.11/folic acid DIALYVITE SUPREME D multivitamin-minerals no.25/folic acid/vitamin BRAND 1 d3 DIALYVITE ZINC vitamin b complex no.11/folic acid/vit BRAND 1 c/biotin/zinc oxide

FOLIC ACID (5 MG/ML VIAL, 1 MG TABLET) generic 1 FOLIVANE-OB mv-mins no.74/ferrous fumarate/iron ps BRAND 1 AL At least 12 yrs old cplx/folic acid FOLTRATE BRAND 1 cyanocobalamin/folic acid INFUVITE ADULT VIAL BRAND 1 multivitamin infusion, adult no.4 with vitamin k INFUVITE PEDIATRIC multivitamin infusion, pediatric no.1 with vitamin BRAND 1

PAGE 63 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS k KABIVEN amino acid 3.31 % no.1/d9.8w/fat BRAND 1 emulsions/electrolyte no.10 M-NATAL PLUS prenatal vits with calcium no.72/ferrous BRAND 1 AL At least 12 yrs old fumarate/folic acid M.V.I. ADULT BRAND 1 multivitamin infusion, adult no.1 with witamin k M.V.I. PEDIATRIC multivitamin infusion, pediatric no.2 with vitamin BRAND 1 k MULTIVITAMIN WITH FLUORIDE (MULTIVIT- FLUOR 0.25 MG CHW, MULTIVIT-FLUOR 0.5 generic 1 AL Up to 12 yrs old MG CHEW, MULTIVIT-FLUORIDE 1 MG CHW) NEPHPLEX RX vit b complex no.3/folic acid/ascorbic BRAND 1 acid/biotin/zinc oxid NEPHRO-VITE RX vitamin b complex no.3/folic acid/ascorbic BRAND 1 acid(vitc)/biotin PERIKABIVEN amino acid 2.36 % no.1/d6.8w/fat BRAND 1 emulsions/electrolytes no.9 PNV 29-1 prenatal vitamin with calcium BRAND 1 AL At least 12 yrs old no.76/iron,carbonyl/folic acid

prenatal vitamin plus low iron generic 1 AL At least 12 yrs old

PREPLUS prenatal vits with calcium no.72/ferrous BRAND 1 AL At least 12 yrs old fumarate/folic acid

pyridoxine hcl generic 1 SE-NATAL 19 prenatal vits with calcium 118/ferrous BRAND 1 AL At least 12 yrs old fumarate/folic acid SELECT-OB prenatal vit no.128/iron polysaccharide BRAND 1 AL At least 12 yrs old complex/folic acid SELECT-OB + DHA prenatal vitamins no.33/iron polysach BRAND 1 AL At least 12 yrs old complex/folic acid/dha

STROVITE ONE BRAND 1

PAGE 64 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS multivit with mins10/folic acid/vit d3/a lipoic acid/lutein TARON-C DHA mv-min 75/ferrous fum/iron ps cplx/folic BRAND 1 AL At least 12 yrs old ac/omega-3/dha/epa

thiamine hcl generic 1 THRIVITE RX prenatal vitamin with calcium BRAND 1 AL At least 12 yrs old no.76/iron,carbonyl/folic acid TRINATAL RX 1 prenatal vitamin 27 with calcium/ferrous BRAND 1 AL At least 12 yrs old fumarate/folic acid TRIVEEN-DUO DHA prenatal vit with calcium 53/iron bis,s-p/folic BRAND 1 AL At least 12 yrs old acid/omega-3 TRUST NATAL DHA prenatal vit no.2/iron bg chel,succ-prot/folic BRAND 1 AL At least 12 yrs old acid/omega-3 VIRT-C DHA mv-min 75/ferrous fum/iron ps cplx/folic BRAND 1 AL At least 12 yrs old ac/omega-3/dha/epa VIRT-FEFA PLUS iron fumarate,polysac cplex/folic acid/vitb comp BRAND 1 with c no.9 VITAFOL GUMMIES prenatal vit no.112/iron phosph/folic BRAND 1 AL At least 12 yrs old acid/omega-3s/dha/epa VITAFOL ULTRA prenatal vit no.67/iron polysaccharides/folate BRAND 1 AL At least 12 yrs old comb.no.1/dha VITAFOL-OB prenatal vits with calcium no.10/ferrous BRAND 1 AL At least 12 yrs old fumarate/folic acid VITAFOL-OB+DHA prenatal vits with calcium no.10/ferrous BRAND 1 AL At least 12 yrs old fum/folic acid/dha VITAFOL-ONE prenatal vits no.26/iron polysaccharide BRAND 1 AL At least 12 yrs old cplex/folic acid/dha VITAL-D RX vit b complex no.4/vit d3/ascorbic acid/folic BRAND 1 acid/zinc oxid VP-VITE RX BRAND 1 vitamin b complex no.3/folic acid/ascorbic

PAGE 65 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS acid(vitc)/biotin

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

belladonna-phenobarbital generic 1 DICYCLOMINE HCL (20 MG TABLET, 10 MG generic 1 CAPSULE, 10 MG/5 ML SOLN)

GLYCOPYRROLATE (1 MG, 2 MG) generic 1 GLYRX-PF BRAND 1 glycopyrrolate/pf HYOSCYAMINE SULFATE (0.125 MG ODT, SULF 0.125 MG TAB, 0.125 MG TAB SL, generic 1 0.125 MG/5 ML ELIX, 0.125 MG/ML DROP)

hyoscyamine sulfate er generic 1

propantheline bromide generic 1 GASTROINTESTINAL AGENTS, OTHER

cromolyn 100 mg/5 ml oral conc generic 1

diphenoxylate-atrop 2.5-0.025 generic 1

loperamide generic 1 MOVANTIK BRAND 1 PA naloxegol oxalate PYLERA colloidal bismuth BRAND 1 subcitrate/metronidazole/tetracycline hcl URSODIOL (250 MG TABLET, 300 MG generic 1 CAPSULE, 500 MG TABLET) HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

FAMOTIDINE (40 MG/4 ML VIAL, 20 MG TABLET, 20 MG PIGGYBACK, 40 MG generic 1 TABLET, 20 MG/2 ML VIAL)

famotidine 200 mg/20 ml vial generic 1 IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl generic 1

LINZESS PA BRAND 1 linaclotide AL At least 18 yrs old

LOTRONEX BRAND 1 alosetron hcl

PAGE 66 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS LAXATIVES

CLENPIQ BRAND 1 AL At least 9 yrs old sodium picosulfate/magnesium oxide/citric acid GOLYTELY PACKET peg 3350/sod sulf/sod bicarb/sod BRAND 1 QL chloride/potassium chloride GOLYTELY SOLUTION peg 3350/sod sulf/sod bicarb/sod BRAND 1 QL chloride/potassium chloride

LACTULOSE (20 GM/30 ML, 10 GM/15 ML) generic 1

peg 3350-electrolyte solution generic 1

peg-3350 and electrolytes generic 1 TRILYTE WITH FLAVOR PACKETS sodium chloride/sodium bicarbonate/potassium BRAND 1 chloride/peg PROTECTANTS

misoprostol generic 1 SUCRALFATE (1 GM TABLET, 1 GM/10 ML generic 1 SUSP) PROTON PUMP INHIBITORS

NEXIUM (20 MG, 2.5 MG, 10 MG, 40 MG, 5 MG) BRAND 1 AL Up to 11 yrs old esomeprazole magnesium

omeprazole generic 1 AL At least 1 yrs old

PANTOPRAZOLE SODIUM (40 MG, 20 MG) generic 1 AL At least 5 yrs old

PREVACID (30 MG, 15 MG) BRAND 1 AL 1.0 to 11.0 yrs old lansoprazole PROTONIX 40 MG SUSPENSION BRAND 1 AL 5.0 to 11.0 yrs old pantoprazole sodium

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

ARALAST NP PA BRAND 1 alpha-1-proteinase inhibitor AL At least 18 yrs old

CREON BRAND 1 PA lipase/protease/amylase CYSTADANE BRAND 1 betaine

CYSTAGON BRAND 1

PAGE 67 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS cysteamine bitartrate

ELELYSO PA BRAND 1 taliglucerase alfa AL At least 4 yrs old

FABRAZYME PA BRAND 1 agalsidase beta AL At least 8 yrs old

GLASSIA PA BRAND 1 alpha-1-proteinase inhibitor AL At least 18 yrs old

PANCREAZE BRAND 1 PA lipase/protease/amylase PERTZYE (4,000, 8,000, 16,000) BRAND 1 PA lipase/protease/amylase PERTZYE DR 24,000 UNIT CAPSULE BRAND 1 PA lipase/protease/amylase

PROLASTIN C PA BRAND 1 alpha-1-proteinase inhibitor AL At least 18 yrs old

VIOKACE PA BRAND 1 lipase/protease/amylase AL At least 18 yrs old

ZAVESCA PA BRAND 1 miglustat AL At least 18 yrs old

ZEMAIRA PA BRAND 1 alpha-1-proteinase inhibitor AL At least 18 yrs old

ZENPEP (10,000, 20,000, 25,000, 5,000) BRAND 1 PA lipase/protease/amylase ZENPEP (15,000, 3,000, 40,000) BRAND 1 PA lipase/protease/amylase

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

OXYBUTYNIN CHLORIDE (5 MG/5 ML generic 1 SYRUP, 5 MG TABLET)

oxybutynin chloride er generic 1

solifenacin succinate generic 1 AL At least 18 yrs old

TOVIAZ BRAND 1 AL At least 18 yrs old fesoterodine fumarate BENIGN PROSTATIC HYPERTROPHY AGENTS

PAGE 68 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

alfuzosin hcl er generic 1

dutasteride generic 1

finasteride 5 mg tablet generic 1

tamsulosin hcl generic 1 GENITOURINARY AGENTS, OTHER

bethanechol chloride generic 1 K-PHOS NEUTRAL sodium phosphate,dibasic/pot phos,monob/sod BRAND 1 phosphate mono K-PHOS NO.2 sodium phosphate,monobasic/potassium BRAND 1 phosphate,monobasic K-PHOS ORIGINAL BRAND 1 potassium phosphate,monobasic ORACIT BRAND 1 citric acid/sodium citrate

phenazopyridine hcl generic 1 PHOSPHA 250 NEUTRAL sodium phosphate,dibasic/pot phos,monob/sod BRAND 1 phosphate mono

potass cit-sod cit-citric acid generic 1

potassium citrate er generic 1

potassium citrate-citric acid generic 1 RENACIDIN citric acid/gluconolactone/magnesium BRAND 1 carbonate

sodium citrate-citric acid generic 1 THIOLA BRAND 1 tiopronin TRICITRATES sodium/potassium/potassium citrate/sodium BRAND 1 citrate/cit ac VIRT-PHOS 250 NEUTRAL sodium phosphate,dibasic/pot phos,monob/sod BRAND 1 phosphate mono VIRTRATE-3 sodium/potassium/potassium citrate/sodium BRAND 1 citrate/cit ac VIRTRATE-K BRAND 1

PAGE 69 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS potassium citrate/citric acid

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ACTHAR BRAND 1 PA corticotropin

betamethasone dp aug 0.05% crm generic 1

betamethasone sod phos-acetate generic 1

betamethasone va 0.1% cream generic 1 CELESTONE betamethasone acetate/betamethasone sodium BRAND 1 phosphate

clobetasol emollient 0.05% crm generic 1 CLOBETASOL PROPIONATE (OINTMENT, generic 1 GEL, CREAM, SOLUTION) DERMA-SMOOTHE-FS (SCALP, BODY) BRAND 1 fluocinolone acetonide DEXAMETHASONE (6 MG TABLET, 0.5 MG TABLET, 2 MG TABLET, 0.75 MG TABLET, generic 1 0.5 MG/5 ML ELX, 4 MG TABLET, 1.5 MG TABLET, 1 MG TABLET, 0.5 MG/5 ML LIQ) DEXAMETHASONE SODIUM PHOSPHATE (10 MG/ML SYRING, 4 MG/ML VIAL, 120 generic 1 MG/30 ML VL, 20 MG/5 ML VIAL, 10 MG/ML VIAL, 100 MG/10 ML VL, 4 MG/ML SYRINGE)

fludrocortisone acetate generic 1 FLUTICASONE PROPIONATE (0.05% generic 1 CREAM, 0.005% OINT) HALOBETASOL PROPIONATE (CREAM, generic 1 OINTMNT) HYDROCORTISONE (5 MG TABLET, 1% OINTMENT, 10 MG TABLET, 2.5% CREAM, generic 1 20 MG TABLET, 1% CREAM, 2.5% OINTMENT) METHYLPREDNISOLONE (4 MG TABLET, 32 generic 1 MG TAB, 4 MG DOSEPK, 8 MG TAB) METHYLPREDNISOLONE ACETATE (40 generic 1 MG/ML, 80 MG/ML)

methylprednisolone sodium succ generic 1 MOMETASONE FUROATE (OINT, CREAM, generic 1 SOLN)

prednisolone 15 mg/5 ml soln generic 1

PAGE 70 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

prednisolone sodium phos odt generic 1 AL Up to 11 yrs old

PREDNISOLONE SODIUM PHOSPHATE generic 1 (SOD PH 25 ML, 5 ML SOLN) PREDNISONE (5 MG TAB DOSE PACK, 2.5 MG TABLET, 1 MG TABLET, 10 MG TAB DOSE PACK, 5 MG TABLET, 50 MG TABLET, generic 1 5 MG/5 ML SOLUTION, 20 MG TABLET, 10 MG TABLET) SOLU-CORTEF (100 MG ACT-O-VIAL, 250 MG ACT-O-VIAL, 500 MG ACT-O-VIAL, 100 BRAND 1 MG VIAL, 1,000 MG ACT-O-VL) hydrocortisone sodium succinate/pf TRIAMCINOLONE ACETONIDE (0.025% OINT, 0.1% OINTMENT, 0.5% OINTMENT, generic 1 0.1% CREAM, 0.5% CREAM, 0.025% CREAM, 0.05% OINTMENT) TRIDERM 0.1% CREAM BRAND 1 triamcinolone acetonide

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

DESMOPRESSIN ACETATE (ACETATE 0.2 MG TB, AC 4 MCG/ML VIAL, 40 MCG/10 ML generic 1 VIAL, ACETATE 0.1 MG TB, 10 MCG/0.1 ML SPR, AC 4 MCG/ML AMPUL) GENOTROPIN (MINIQUICK 2 MG, 5 MG CARTRIDGE, MINIQUICK 1.6 MG, MINIQUICK 1.2 MG, MINIQUICK 0.4 MG, MINIQUICK 1.8 PA MG, MINIQUICK 0.6 MG, MINIQUICK 1 MG, BRAND 1 MINIQUICK 0.8 MG, MINIQUICK 1.4 MG, 12 AL Up to 16 yrs old MG CARTRIDGE, MINIQUICK 0.2 MG) somatropin

NORDITROPIN FLEXPRO PA BRAND 1 somatropin AL Up to 16 yrs old

STIMATE BRAND 1 desmopressin acetate

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANDROGENS

ANDRODERM PA BRAND 1 testosterone AL At least 18 yrs old

ANDROGEL (1.62%(1.25G) PCKT, 1.62% PA PUMP, 1.62%(2.5G) PCKT, 1%(5G) PACKET, BRAND 1 1%(2.5G) PACKET) AL At least 18 yrs old

PAGE 71 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS testosterone

danazol generic 1 TESTOSTERONE CYPIONATE (TESTOSTERON 2,000 MG/10 ML, TESTOSTERONE 100 MG/ML, generic 1 TESTOSTERONE 200 MG/ML, TESTOSTERON 1,000 MG/10 ML)

testosterone enanthate generic 1 ESTROGENS

AFIRMELLE BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol ALTAVERA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol ALYACEN BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol AMETHIA levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol AMETHIA LO levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol AMETHYST BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol ANNOVERA BRAND 1 AL At least 12 yrs old segesterone acetate/ethinyl estradiol APRI BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol ARANELLE BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol ASHLYNA levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol AUBRA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol AUBRA EQ BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol AUROVELA BRAND 1 AL At least 12 yrs old norethindrone acetate-ethinyl estradiol AUROVELA 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate

PAGE 72 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS AUROVELA FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate AVIANE BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol AYUNA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol AZURETTE BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol/ethinyl estradiol BALCOLTRA levonorgestrel/ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old bisglycinate BALZIVA BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol BEKYREE BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol/ethinyl estradiol BEYAZ drospirenone/ethinyl estradiol/levomefolate BRAND 1 AL At least 12 yrs old calcium BLISOVI 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate BLISOVI FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate BRIELLYN BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol CAMRESE levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol CAMRESE LO levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol CAZIANT BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol CHATEAL BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol CHATEAL EQ BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol CLIMARA PRO BRAND 1 estradiol/levonorgestrel COMBIPATCH BRAND 1

PAGE 73 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS estradiol/norethindrone acetate CRYSELLE BRAND 1 AL At least 12 yrs old norgestrel-ethinyl estradiol CYCLAFEM BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol CYRED BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol CYRED EQ BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol DASETTA BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol DAYSEE levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol

desogestr-eth estrad eth estra generic 1 AL At least 12 yrs old

desogestrel-ethinyl estradiol generic 1 AL At least 12 yrs old

drospirenone-eth estra-levomef generic 1 AL At least 12 yrs old

drospirenone-ethinyl estradiol generic 1 AL At least 12 yrs old

ELINEST BRAND 1 AL At least 12 yrs old norgestrel-ethinyl estradiol ELURYNG BRAND 1 AL At least 12 yrs old etonogestrel/ethinyl estradiol EMOQUETTE BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol ENPRESSE BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol ENSKYCE BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol ESTARYLLA BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol ESTRADIOL (TDS 0.075 MG/DAY, 0.5 MG TABLET, 0.0375 MG/DAY PATCH, TDS 0.0375 MG/DAY, 0.06 MG/DAY PATCH, 1 MG generic 1 TABLET, TDS 0.05 MG/DAY, 0.075 MG/DAY PATCH, 2 MG TABLET, TDS 0.06 MG/DAY, TDS 0.025 MG/DAY, TDS 0.1 MG/DAY)

estradiol valerate generic 1

estradiol-norethindrone acetat generic 1 AL At least 18 yrs old

ESTRING BRAND 1

PAGE 74 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS estradiol

estrogen-methyltestosterone generic 1 ESTROSTEP FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate

ethynodiol-ethinyl estradiol generic 1 AL At least 12 yrs old

etonogestrel-ethinyl estradiol generic 1 AL At least 12 yrs old

FALMINA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol FAYOSIM levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol FEMHRT BRAND 1 norethindrone acetate-ethinyl estradiol FEMYNOR BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol GENERESS FE BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol/ferrous fumarate GIANVI BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone HAILEY BRAND 1 AL At least 12 yrs old norethindrone acetate-ethinyl estradiol HAILEY 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate INTROVALE BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol ISIBLOOM BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol JAIMIESS levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol JASMIEL BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone JOLESSA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol JULEBER BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol JUNEL BRAND 1 AL At least 12 yrs old norethindrone acetate-ethinyl estradiol

PAGE 75 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS JUNEL FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate JUNEL FE 24 norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate KAITLIB FE BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol/ferrous fumarate KALLIGA BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol KARIVA BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol/ethinyl estradiol KELNOR 1-35 BRAND 1 AL At least 12 yrs old ethynodiol diacetate-ethinyl estradiol KELNOR 1-50 BRAND 1 AL At least 12 yrs old ethynodiol diacetate-ethinyl estradiol KURVELO BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol LARIN BRAND 1 AL At least 12 yrs old norethindrone acetate-ethinyl estradiol LARIN 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate LARIN FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate LARISSIA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol LAYOLIS FE BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol/ferrous fumarate LEENA BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol LESSINA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol LEVONEST BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol

levonorg-eth estrad eth estrad generic 1 AL At least 12 yrs old

levonorgestrel-eth estradiol generic 1 AL At least 12 yrs old

LEVORA-28 BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol

PAGE 76 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS LILLOW BRAND AL At least 12 yrs old levonorgestrel/ethinyl estradiol LO LOESTRIN FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate LO-ZUMANDIMINE BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone LOESTRIN BRAND 1 AL At least 12 yrs old norethindrone acetate-ethinyl estradiol LOESTRIN FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate LOJAIMIESS levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol LORYNA BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone LOSEASONIQUE levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol LOW-OGESTREL BRAND 1 AL At least 12 yrs old norgestrel-ethinyl estradiol LUTERA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol MARLISSA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol MELODETTA 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate MIBELAS 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate MICROGESTIN FE 1.5-30 TAB norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate MILI BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol MINASTRIN 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate MIRCETTE BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol/ethinyl estradiol

PAGE 77 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS MONO-LINYAH BRAND AL At least 12 yrs old norgestimate-ethinyl estradiol NATAZIA BRAND 1 AL At least 12 yrs old estradiol valerate/dienogest NECON 0.5-35-28 TABLET BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol NIKKI BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone NORETHIN-ETH ESTRA-FERROUS FUM (NORET-ESTR-FE 0.4-0.035(21)-75, NORETH-ESTRAD-FE 1-0.02(21)-75, generic 1 AL At least 12 yrs old NORETH-ESTRAD-FE 1-0.02(24)-75, NORETHIN-ESTRA-FE 0.8-0.025 MG) NORETHINDRON-ETHINYL ESTRADIOL (NORETHIN-ETH 1 MG-5 MCG, NORETHIND- generic 1 ETH 0.5-2.5) NORETHINDRON-ETHINYL ESTRADIOL (NORETHIND-ETH ESTRAD 1-0.02 MG, generic 1 AL At least 12 yrs old NORETHIN-EE 1.5-0.03 MG(21) TB)

norethindrone-eth estradiol-fe generic 1 AL At least 12 yrs old

norgestimate-ethinyl estradiol generic 1 AL At least 12 yrs old

NORTREL BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol NUVARING BRAND 1 AL At least 12 yrs old etonogestrel/ethinyl estradiol OCELLA BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone OGESTREL BRAND 1 AL At least 12 yrs old norgestrel-ethinyl estradiol ORSYTHIA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol ORTHO TRI-CYCLEN BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol ORTHO-NOVUM BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol PHILITH BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol PIMTREA BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol/ethinyl estradiol PIRMELLA (7-7-7-28, 1-35 28) BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol

PAGE 78 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS PORTIA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol PREMARIN VAGINAL CREAM-APPL BRAND 1 estrogens, conjugated PREMARIN (1.25 MG, 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG) BRAND 1 estrogens, conjugated PREMPHASE estrogens, conjugated/medroxyprogesterone BRAND 1 acetate PREMPRO estrogens, conjugated/medroxyprogesterone BRAND 1 acetate PREVIFEM BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol QUARTETTE levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol RECLIPSEN BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol RIVELSA levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol SAFYRAL drospirenone/ethinyl estradiol/levomefolate BRAND 1 AL At least 12 yrs old calcium SEASONIQUE levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol SETLAKIN BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol SIMLIYA BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol/ethinyl estradiol SIMPESSE levonorgestrel/ethinyl estradiol and ethinyl BRAND 1 AL At least 12 yrs old estradiol SPRINTEC BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol SRONYX BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol SYEDA BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone

PAGE 79 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS TARINA 24 FE norethindrone acetate-ethinyl estradiol/ferrous BRAND AL At least 12 yrs old fumarate TARINA FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate TARINA FE 1-20 EQ norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate TAYTULLA norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate TILIA FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate TRI FEMYNOR BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-ESTARYLLA BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-LEGEST FE norethindrone acetate-ethinyl estradiol/ferrous BRAND 1 AL At least 12 yrs old fumarate TRI-LINYAH BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-LO-ESTARYLLA BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-LO-MARZIA BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-LO-MILI BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-LO-SPRINTEC BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-MILI BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-PREVIFEM BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-SPRINTEC BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-VYLIBRA BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol TRI-VYLIBRA LO BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol

PAGE 80 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS TRIVORA-28 BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol TYDEMY drospirenone/ethinyl estradiol/levomefolate BRAND 1 AL At least 12 yrs old calcium VAGIFEM BRAND 1 QL estradiol VELIVET BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol VIENVA BRAND 1 AL At least 12 yrs old levonorgestrel/ethinyl estradiol VIORELE BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol/ethinyl estradiol VOLNEA BRAND 1 AL At least 12 yrs old desogestrel-ethinyl estradiol/ethinyl estradiol VYFEMLA BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol VYLIBRA BRAND 1 AL At least 12 yrs old norgestimate-ethinyl estradiol WERA BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol WYMZYA FE BRAND 1 AL At least 12 yrs old norethindrone-ethinyl estradiol/ferrous fumarate XULANE BRAND 1 AL At least 12 yrs old norelgestromin/ethinyl estradiol YASMIN 28 BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone YAZ BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone ZARAH BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone ZOVIA 1-35E BRAND 1 AL At least 12 yrs old ethynodiol diacetate-ethinyl estradiol ZUMANDIMINE BRAND 1 AL At least 12 yrs old ethinyl estradiol/drospirenone PROGESTERONE AGONISTS/ANTAGONISTS

ELLA BRAND 1 AL At least 12 yrs old ulipristal acetate PROGESTINS

PAGE 81 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS CAMILA BRAND 1 AL At least 12 yrs old norethindrone DEBLITANE BRAND 1 AL At least 12 yrs old norethindrone DEPO-PROVERA (150 MG/ML SYRINGE, 150 MG/ML VIAL) BRAND 1 AL At least 12 yrs old medroxyprogesterone acetate DEPO-SUBQ PROVERA 104 BRAND 1 AL At least 12 yrs old medroxyprogesterone acetate ERRIN BRAND 1 AL At least 12 yrs old norethindrone HEATHER BRAND 1 AL At least 12 yrs old norethindrone

PA hydroxyprogest 250 mg/ml vial generic 1 AL At least 16 yrs old

INCASSIA BRAND 1 AL At least 12 yrs old norethindrone JENCYCLA BRAND 1 AL At least 12 yrs old norethindrone KYLEENA BRAND 1 QL levonorgestrel LILETTA BRAND 1 QL levonorgestrel LYZA BRAND 1 AL At least 12 yrs old norethindrone

MAKENA (275 MG/1.1 ML AUTOINJCT, 250 PA MG/ML VIAL) BRAND 1 hydroxyprogesterone caproate/pf AL At least 16 yrs old

medroxyprogesterone 150 mg/ml generic 1 AL At least 12 yrs old

MEDROXYPROGESTERONE ACETATE (2.5 generic 1 MG, 10 MG, 5 MG) MEGESTROL ACETATE (ACET 40 MG/ML SUSP, 40 MG TABLET, 625 MG/5 ML SUSP, generic 1 ACET 400 MG/10 ML, 20 MG TABLET) MIRENA BRAND 1 QL levonorgestrel NEXPLANON BRAND 1 QL etonogestrel NORA-BE BRAND 1 AL At least 12 yrs old norethindrone

PAGE 82 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

norethindrone generic 1 AL At least 12 yrs old

PA norethindrone ac (lupaneta) generic 1 AL At least 18 yrs old

norethindrone acetate generic 1 NORLYDA BRAND 1 AL At least 12 yrs old norethindrone ORTHO MICRONOR BRAND 1 AL At least 12 yrs old norethindrone PROGESTERONE (500 MG/10 ML VIAL, 200 generic 1 MG CAPSULE, 100 MG CAPSULE) PROMETRIUM BRAND 1 progesterone, micronized SHAROBEL BRAND 1 AL At least 12 yrs old norethindrone SKYLA BRAND 1 QL levonorgestrel SLYND BRAND 1 AL At least 12 yrs old drospirenone TULANA BRAND 1 AL At least 12 yrs old norethindrone

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID BRAND 1 thyroid,pork LEVOTHYROXINE SODIUM (150 MCG TABLET, 200 MCG TABLET, 500 MCG/5 ML VL, 112 MCG TABLET, 200 MCG/5 ML VL, 300 MCG TABLET, 125 MCG TABLET, 50 generic 1 MCG TABLET, 88 MCG TABLET, 175 MCG TABLET, 100 MCG/5 ML VL, 100 MCG TABLET, 25 MCG TABLET, 75 MCG TABLET, 137 MCG TABLET) LEVOXYL BRAND 1 levothyroxine sodium LIOTHYRONINE SODIUM (50 MCG, 5 MCG, generic 1 25 MCG) NP THYROID BRAND 1 thyroid,pork THYROID (30 MG, 15 MG, 90 MG, 120 MG, 60 MG) BRAND 1 thyroid,pork

PAGE 83 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS THYROLAR-1 BRAND 1 liotrix THYROLAR-1/2 BRAND 1 liotrix THYROLAR-1/4 BRAND 1 liotrix THYROLAR-2 BRAND 1 liotrix THYROLAR-3 BRAND 1 liotrix UNITHROID BRAND 1 levothyroxine sodium

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline generic 1 LEUPROLIDE ACETATE (14 MG/2.8 ML VL, 1 generic 1 PA MG/0.2 ML KIT, 14 MG/2.8 ML KT)

LUPANETA PACK PA BRAND 1 leuprolide acetate/norethindrone acetate AL At least 18 yrs old

LUPRON DEPOT PA BRAND 1 leuprolide acetate AL At least 18 yrs old

LUPRON DEPOT (LUPANETA) PA BRAND 1 leuprolide acetate AL At least 18 yrs old

LUPRON DEPOT-PED (11.25 MG 3MO, 30 MG 3MO KIT, 7.5 MG KIT, 11.25 MG KIT, 15 PA BRAND 1 MG KIT) AL 2.0 to 12.0 yrs old leuprolide acetate OCTREOTIDE ACETATE (ACET 0.05 MG/ML VL, ACET 50 MCG/ML AMP, 1,000 MCG/5 ML VIAL, 5,000 MCG/5 ML VIAL, ACET 100 MCG/ML AMP, ACET 500 MCG/ML AMP, 1,000 MCG/ML VIAL, ACET 50 MCG/ML SYR, generic 1 ACET 100 MCG/ML VL, ACET 500 MCG/ML SYR, ACET 500 MCG/ML VL, ACET 50 MCG/ML VIAL, ACET 200 MCG/ML VL, ACET 100 MCG/ML SYR) ORILISSA BRAND 1 PA elagolix sodium SYNAREL BRAND 1 PA nafarelin acetate

TRIPTODUR BRAND 1 PA

PAGE 84 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

triptorelin pamoate AL 2.0 to 12.0 yrs old

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole generic 1

propylthiouracil generic 1

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT (500 VIAL, 500 KIT) PA BRAND 1 c1 esterase inhibitor AL At least 12 yrs old

FIRAZYR PA BRAND 1 icatibant acetate AL At least 18 yrs old

IMMUNE SUPPRESSANTS

azathioprine generic 1 CELLCEPT 200 MG/ML ORAL SUSP BRAND 1 AL Up to 11 yrs old mycophenolate mofetil CELLCEPT 500 MG VIAL BRAND 1 mycophenolate mofetil hcl

cyclosporine 250 mg/5 ml ampul generic 1 CYCLOSPORINE MODIFIED (50 MG, 25 MG, generic 1 100 MG)

cyclosporine modified 100mg/ml generic 1 AL Up to 11 yrs old

ENBREL (50 MG/ML SYRINGE, 25 MG KIT, 25 PA MG/0.5 ML SYRINGE) BRAND 1 etanercept AL At least 2 yrs old

ENBREL MINI PA BRAND 1 etanercept AL At least 2 yrs old

ENBREL SURECLICK PA BRAND 1 etanercept AL At least 2 yrs old

HUMIRA BRAND 1 PA adalimumab HUMIRA PEN BRAND 1 PA adalimumab

PAGE 85 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS HUMIRA PEN CROHN'S-UC-HS BRAND PA adalimumab HUMIRA PEN PSOR-UVEITS-ADOL HS BRAND 1 PA adalimumab HUMIRA(CF) BRAND 1 PA adalimumab HUMIRA(CF) PEDIATRIC CROHN'S BRAND 1 PA adalimumab HUMIRA(CF) PEN BRAND 1 PA adalimumab HUMIRA(CF) PEN CROHN'S-UC-HS BRAND 1 PA adalimumab HUMIRA(CF) PEN PSOR-UV-ADOL HS BRAND 1 PA adalimumab METHOTREXATE (250 MG/10 ML VIAL, 50 generic 1 MG/2 ML VIAL, 2.5 MG TABLET, 1 GM VIAL)

methotrexate sodium generic 1 MYCOPHENOLATE MOFETIL (500 MG VIAL, generic 1 250 MG CAPSULE, 500 MG TABLET) RAPAMUNE 1 MG/ML ORAL SOLN BRAND 1 sirolimus SANDIMMUNE 50 MG/ML AMPUL BRAND 1 cyclosporine

SIROLIMUS (1 MG, 2 MG, 0.5 MG) generic 1

TACROLIMUS (1 MG, 5 MG, 0.5 MG) generic 1

XELJANZ PA BRAND 1 tofacitinib citrate AL At least 18 yrs old

IMMUNIZING AGENTS, PASSIVE

BIVIGAM 10% VIAL immune globulin,gamm(igg)/glycine/iga greater BRAND 1 PA than 50 mcg/ml GAMMAGARD S-D immune globulin,gamm(igg)/glycine/glucose/iga BRAND 1 PA 0 to 50 mcg/ml HYPERRHO S-D BRAND 1 rho(d) immune globulin IMMUNOMODULATORS

ACTIMMUNE BRAND 1 interferon gamma-1b,recomb.

PAGE 86 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

leflunomide generic 1 VACCINES

ADACEL TDAP (VIAL, SYRINGE) diphtheria,pertussis(acellular),tetanus BRAND 1 vaccine/pf BOOSTRIX TDAP (VIAL, SYRINGE) BRAND 1 diphtheria,pertussis(acellular),tetanus vaccine DAPTACEL DTAP diphtheria, pertussis (acell), tetanus pediatric BRAND 1 vaccine/pf HAVRIX (1,440 UNITS/ML VIAL, 720 UNITS/0.5 ML VIAL, 720 UNIT/0.5 ML BRAND 1 AL At least 21 yrs old SYRINGE, 1,440 UNITS/ML SYRINGE) hepatitis a virus vaccine/pf INFANRIX DTAP (SYRINGE, VIAL) diphtheria, pertussis (acell), tetanus pediatric BRAND 1 vaccine/pf SHINGRIX varicella-zoster virus glycoprotein e,rec/as01b BRAND 1 AL At least 50 yrs old adjuvant/pf SHINGRIX ADJUVANT COMPONENT vaccine adjuvant system, as01b/pf, component BRAND 1 AL At least 50 yrs old vial 1 of 2 SHINGRIX GE ANTIGEN COMPONENT varicella-zoster virus glycoprotein BRAND 1 AL At least 50 yrs old e,rec,component 2 of 2 VAQTA (50 UNITS/ML SYRINGE, 25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML BRAND 1 AL At least 21 yrs old VIAL, 50 UNITS/ML VIAL) hepatitis a virus vaccine/pf

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO BRAND 1 mesalamine

balsalazide disodium generic 1

mesalamine 1,000 mg supp generic 1

mesalamine dr generic 1 GLUCOCORTICOIDS

ANUSOL-HC 2.5% CREAM BRAND 1 hydrocortisone

PAGE 87 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

budesonide ec generic 1

hydrocortisone 100 mg/60 ml generic 1 PROCTO-MED HC BRAND 1 hydrocortisone PROCTOSOL-HC BRAND 1 hydrocortisone PROCTOZONE-HC BRAND 1 hydrocortisone SULFONAMIDES

sulfasalazine generic 1

sulfasalazine dr generic 1

METABOLIC BONE DISEASE AGENTS

ALENDRONATE SODIUM (10 MG TAB, 70 generic 1 MG TAB, 35 MG TAB, 5 MG TABLET)

calcitonin-salmon generic 1 AL At least 18 yrs old

CALCITRIOL (1 MCG/ML SOLUTION, 0.5 MCG CAPSULE, 0.25 MCG CAPSULE, 1 generic 1 MCG/ML AMPUL) DOXERCALCIFEROL (1 MCG CAPSULE, 4 generic 1 MCG/2 ML VL, 0.5 MCG CAP, 2.5 MCG CAP)

pamidronate disodium generic 1 PARICALCITOL (2 MCG/ML VIAL, 2 MCG CAPSULE, 5 MCG/ML VIAL, 10 MCG/2 ML generic 1 VIAL, 4 MCG CAPSULE, 1 MCG CAPSULE)

vitamin d2 generic 1 ZOLEDRONIC ACID (4 MG/5 ML VIAL, 4 MG generic 1 VIAL, 4 MG/100 ML, 5 MG/100 ML)

MISCELLANEOUS THERAPEUTIC AGENTS

acetylcysteine 6 gram/30 ml vl generic 1

methylergonovine 0.2 mg tablet generic 1 PARAGARD T 380-A BRAND 1 QL copper

bacteriostatic saline vial generic 1

sorbitol generic 1

sorbitol-mannitol generic 1

STERILE WATER FOR IC-GREEN BRAND 1

PAGE 88 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS water for injection,sterile STERILE WATER FOR KCENTRA BRAND 1 water for injection,sterile

sterile water for irrigation generic 1 WATER (FOR INJECTION VIAL, STERILE generic 1 FOR INJECTION, BACTERIOSTATIC VIAL)

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

AK-POLY-BAC BRAND 1 bacitracin/polymyxin b sulfate

ATROPINE SULFATE (DROPS, OINTMENT) generic 1

bacitracin-polymyxin generic 1

balanced salt generic 1 CYCLOPENTOLATE HCL (0.5% EYE, 1% generic 1 EYE, HCL 2%) CYSTARAN BRAND 1 cysteamine hcl

neomycin-bacitracin-poly-hc generic 1

neomycin-bacitracin-polymyxin generic 1 NEOMYCIN-POLYMYXIN-DEXAMETH (NEOMYC-POLYM-DEXAMETH DROP, generic 1 NEOMYC-POLYM-DEXAMET OINTM) PHENYLEPHRINE HCL (10% DROPS, 2.5% generic 1 DROP) POLYCIN BRAND 1 bacitracin/polymyxin b sulfate

polymyxin b sul-trimethoprim generic 1 RESTASIS BRAND 1 cyclosporine RESTASIS MULTIDOSE BRAND 1 cyclosporine

sulfacetamide-prednisolone generic 1 TOBRADEX (DROPS, OINTMENT) BRAND 1 tobramycin/dexamethasone ZYLET BRAND 1 tobramycin/loteprednol etabonate OPHTHALMIC ANTI-ALLERGY AGENTS

PAGE 89 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

cromolyn 4% eye drops generic 1

olopatadine hcl 0.1% eye drops generic 1 PAZEO BRAND 1 olopatadine hcl OPHTHALMIC ANTI-INFLAMMATORIES

ALREX BRAND 1 loteprednol etabonate

dexamethasone 0.1% eye drop generic 1

diclofenac 0.1% eye drops generic 1 DUREZOL BRAND 1 difluprednate FLAREX BRAND 1 fluorometholone acetate FML FORTE BRAND 1 fluorometholone FML S.O.P. BRAND 1 fluorometholone ILEVRO BRAND 1 nepafenac

ketorolac 0.5% ophth solution generic 1 LOTEMAX 0.5% EYE DROPS BRAND 1 loteprednol etabonate MAXIDEX BRAND 1 dexamethasone

prednisolone ac 1% eye drop generic 1 OPHTHALMIC ANTIGLAUCOMA AGENTS

brimonidine 0.2% eye drop generic 1

carteolol hcl generic 1 COMBIGAN BRAND 1 brimonidine tartrate/timolol maleate

dorzolamide hcl generic 1

dorzolamide-timolol eye drops generic 1

levobunolol hcl generic 1

methazolamide generic 1 RHOPRESSA BRAND 1 AL At least 18 yrs old netarsudil mesylate

ROCKLATAN BRAND 1 AL At least 18 yrs old

PAGE 90 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

netarsudil mesylate/latanoprost

TIMOLOL MALEATE (0.25% GFS GEL- SOLUTION, 0.5% EYE DROP, 0.5% GFS GEL-SOLUTION, 0.5% GEL-SOLUTION, generic 1 MALEATE 0.5% EYE DROPS, 0.25% GEL- SOLUTION, MALEATE 0.25% EYE DROP) OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

latanoprost 0.005% eye drops generic 1 TRAVATAN Z BRAND 1 travoprost

OTIC AGENTS

acetic acid 2% ear solution generic 1 CIPRODEX BRAND 1 ciprofloxacin hcl/dexamethasone DERMOTIC BRAND 1 fluocinolone acetonide oil

neomycin-polymyxin-hc ear susp generic 1

neomycin-polymyxin-hydrocort generic 1

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ASMANEX (TWISTHALER 220 MCG #60, TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #14, TWISTHALR 220 MCG #120, BRAND 1 AL At least 4 yrs old TWISTHALER 220 MCG #30) mometasone furoate

budesonide generic 1 AL 1.0 to 8.0 yrs old

FLOVENT HFA BRAND 1 fluticasone propionate

fluticasone prop 50 mcg spray generic 1 ANTIHISTAMINES

AZELASTINE HCL (0.1% (137 MCG) SPRY, generic 1 0.15% NASAL SPRAY) CARBINOXAMINE MALEATE (4 MG/5 ML generic 1 LIQUID, MALEATE 4 MG TAB)

cetirizine hcl generic 1 AL Up to 11 yrs old

clemastine fumarate generic 1

PAGE 91 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS CYPROHEPTADINE HCL (2 MG/5 ML SYRUP, 4 MG TABLET, 2 MG/5 ML SOLN, 4 MG/10 ML generic SYRP) DIPHENHYDRAMINE HCL (50 MG/ML SYRNG, 50 MG/ML VIAL, 50 MG/ML CRPJT, generic 1 25 MG/10 ML, 12.5 MG/5 ML) HYDROXYZINE HCL (HCL 10 MG TABLET, 50 MG/ML VIAL, 10 MG/5 ML SYRUP, 100 MG/2 generic 1 ML VIAL, HCL 50 MG TABLET, 10 MG/5 ML SOLN, 25 MG/ML VIAL, HCL 25 MG TABLET)

hydroxyzine pamoate generic 1

levocetirizine 5 mg tablet generic 1 PROMETHAZINE HCL (50 MG/ML VIAL, 50 MG/ML AMPUL, 6.25 MG/5 ML SYRP, 25 generic 1 MG/ML VIAL, 6.25 MG/5 ML SOLN, 25 MG/ML AMPUL) ANTILEUKOTRIENES

MONTELUKAST SODIUM (4 MG TAB CHEW, generic 1 10 MG TABLET, 5 MG TAB CHEW) BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA BRAND 1 ipratropium bromide

ipratropium br 0.02% soln generic 1 SPIRIVA BRAND 1 AL At least 18 yrs old tiotropium bromide BRONCHODILATORS, SYMPATHOMIMETIC

ALBUTEROL SULFATE (SUL 1.25 MG/3 ML SOL, SULF 2 MG/5 ML SYRUP, 5 MG/ML generic 1 SOLUTION) ALBUTEROL SULFATE (SUL 0.63 MG/3 ML SOL, SUL 2.5 MG/3 ML SOLN, 2.5 MG/0.5 ML generic 1 SOL) EPINEPHRINE (0.15 MG AUTO-INJCT, 0.3 generic 1 MG AUTO-INJECT) PROAIR HFA BRAND 1 albuterol sulfate PROVENTIL HFA BRAND 1 albuterol sulfate

SEREVENT DISKUS QL BRAND 1 salmeterol xinafoate AL At least 4 yrs old

PAGE 92 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

terbutaline sulf 1 mg/ml vial generic 1 CYSTIC FIBROSIS AGENTS

BETHKIS BRAND 1 PA tobramycin KITABIS PAK BRAND 1 PA tobramycin/nebulizer

QL PULMOZYME BRAND 1 PA dornase alfa AL Up to 65 yrs old

MAST CELL STABILIZERS

cromolyn 20 mg/2 ml neb soln generic 1 PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

CAFFEINE CITRATE (60 ML VIAL, 60 ML generic 1 ORAL) ELIXOPHYLLIN BRAND 1 theophylline anhydrous THEO-24 BRAND 1 theophylline anhydrous THEOPHYLLINE (80 MG/15 ML SOLN, ER generic 1 400 MG TABLET, ER 600 MG TABLET) THEOPHYLLINE ANHYDROUS (ER 450 MG generic 1 TAB, ER 300 MG TAB, ER 100 MG TABLET)

theophylline er 200 mg tablet generic 1 PULMONARY ANTIHYPERTENSIVES

epoprostenol sodium generic 1 LETAIRIS BRAND 1 PA ambrisentan SILDENAFIL CITRATE (20 MG TABLET, 10 generic 1 PA MG/ML ORAL SUSP)

tadalafil 20 mg tablet generic 1 PA

TRACLEER (125 MG, 62.5 MG) BRAND 1 PA bosentan VENTAVIS BRAND 1 PA iloprost tromethamine RESPIRATORY TRACT AGENTS, OTHER

ACETYLCYSTEINE (20%, 10%) generic 1

PAGE 93 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

ADVAIR DISKUS QL BRAND 1 fluticasone propionate/salmeterol xinafoate AL At least 4 yrs old

ADVAIR HFA QL BRAND 1 fluticasone propionate/salmeterol xinafoate AL At least 5 yrs old

benzonatate generic 1 AL Up to 20 yrs old

BEVESPI AEROSPHERE BRAND 1 glycopyrrolate/formoterol fumarate

brompheniramine-pseudoephed-dm generic 1 AL Up to 20 yrs old

COMBIVENT RESPIMAT BRAND 1 ipratropium bromide/albuterol sulfate

DULERA (200 MCG, 100 MCG) QL BRAND 1 mometasone furoate/formoterol fumarate AL At least 5 yrs old

DULERA 50 MCG-5 MCG INHALER BRAND 1 AL At least 5 yrs old mometasone furoate/formoterol fumarate HYDROCODONE-HOMATROPINE MBR generic 1 AL 18.0 to 20.0 yrs old (SOLN, SYRUP)

ipratropium-albuterol generic 1

promethazine-dm generic 1 AL Up to 20 yrs old

promethazine-phenylephrine generic 1 AL Up to 20 yrs old

PA ribavirin 6 gm inhalation vial generic 1 AL At least 5 yrs old

sodium chloride 0.9% inhal vl generic 1

sodium chloride 10% vial generic 1 PA

STIOLTO RESPIMAT BRAND 1 tiotropium bromide/olodaterol hcl

SYMBICORT 160-4.5 MCG INHALER QL BRAND 1 budesonide/formoterol fumarate AL At least 5 yrs old

SYMBICORT 80-4.5 MCG INHALER QL BRAND 1 budesonide/formoterol fumarate AL At least 5 yrs old

UTIBRON NEOHALER BRAND 1 indacaterol maleate/glycopyrrolate

SKELETAL MUSCLE RELAXANTS

chlorzoxazone 500 mg tablet generic 1

PAGE 94 LAST UPDATED 04/2020 DRUG DESCRIPTION (RX) BRAND/GEN TIER LIMITS & RESTRICTIONS

CYCLOBENZAPRINE HCL (10 MG, 5 MG) generic 1

METHOCARBAMOL (750 MG, 500 MG) generic 1

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

TEMAZEPAM (15 MG, 30 MG) generic 1 AL At least 18 yrs old

zaleplon generic 1 AL At least 18 yrs old

PA zolpidem tartrate 10 mg tablet generic 1 AL At least 18 yrs old

zolpidem tartrate 5 mg tablet generic 1 AL At least 18 yrs old

SLEEP DISORDERS, OTHER

PA modafinil generic 1 AL At least 18 yrs old

ROZEREM BRAND 1 AL At least 65 yrs old ramelteon

PAGE 95 LAST UPDATED 04/2020 Index of covered drugs AFIRMELLE72 3 AFSTYLA45 3 DAY VAGINAL2 AFTERA7 3-DAY VAGINAL CREAM2 AGALSIDASE BETA68 AGGRENOX48 8 AK-POLY-BAC89 8 HOUR ACETAMINOPHEN2 ALA-QUIN55 8 HOUR PAIN RELIEF3 ALBENDAZOLE33 8HR ARTHRITIS PAIN3 ALBUTEROL SULFATE92 8HR MUSCLE ACHES-PAIN3 ALEMTUZUMAB32 ALENDRONATE SODIUM88 A ALFUZOSIN HCL68 ABACAVIR SULFATE39 ALIMTA30 ABACAVIR SULFATE/DOLUTEGRAVIR ALITRETINOIN32 SODIUM/LAMIVUDINE39 ALKERAN29 ABACAVIR SULFATE/LAMIVUDINE38 ALL DAY ALLERGY7 ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE38 ALL DAY ALLERGY-D8 ABILIFY MAINTENA34 ALLERGY7 ABIRATERONE ACETATE30 ALLERGY COMPLETE-D8 ACAMPROSATE CALCIUM14 ALLERGY RELIEF8 ACARBOSE41 ALLERGY RELIEF D-24HR9 ACEBUTOLOL HCL49 ALLERGY RELIEF-NASAL DECONGEST9 ACETAMINOPHEN4 ALLERGY-CONGESTION 12HR9 ACETAMINOPHEN WITH CODEINE PHOSPHATE13 ALLERGY-CONGESTION RELIEF9 ACETAZOLAMIDE51 ALLOPURINOL28 ACETIC ACID91 ALOSETRON HCL66 ACETYLCYSTEINE93 ALPHA-1-PROTEINASE INHIBITOR68 ACITRETIN54 ALPHANATE45 ACTHAR70 ALPHANINE SD45 ACTIMMUNE86 ALPRAZOLAM41 ACYCLOVIR40 ALPROLIX46 ADACEL TDAP87 ALREX90 ADALIMUMAB86 ALTAVERA72 ADAPALENE55 ALTEPLASE44 ADULT ASPIRIN REGIMEN1 ALYACEN72 ADULT TUSSIN CHEST CONGESTION8 AMANTADINE HCL33 ADULT TUSSIN COUGH CONGEST DM8 AMBRISENTAN93 ADVAIR DISKUS93 AMETHIA72 ADVAIR HFA94 AMETHIA LO72 ADVATE45 AMETHYST72 ADYNOVATE45 AMICAR46

PAGE 96 LAST UPDATED 04/2020 AMILORIDE HCL51 AMPHETAMINE52 AMILORIDE HCL/HYDROCHLOROTHIAZIDE50 AMPHOTERICIN B27 AMINO ACID 2.36 % NO.1/D6.8W/FAT AMPICILLIN SODIUM18 EMULSIONS/ELECTROLYTES NO.964 AMPICILLIN SODIUM/SULBACTAM SODIUM18 AMINO ACID 3.31 % NO.1/D9.8W/FAT AMPICILLIN TRIHYDRATE18 EMULSIONS/ELECTROLYTE NO.1064 ANAGRELIDE HCL45 AMINO ACIDS 10 %62 ANASTROZOLE32 AMINO ACIDS 3 %/ELECTROLYTE-TPN ANDRODERM71 SOLN/GLYCERIN61 ANDROGEL71 AMINO ACIDS 3.5 %/ELECTROLYTE-M ANIDULAFUNGIN27 SOLUTION57 ANNOVERA72 AMINO ACIDS 4.25 %/DEXTROSE 10 % IN ANTACID7 WATER57 ANTACID CALCIUM6 AMINO ACIDS 5 %/CALCIUM/ELECTROLYTE-TPN ANTACID EXTRA STRENGTH6 SOLN/DEXTROSE 20 %57 ANTACID ULTRA STRENGTH6 AMINO ACIDS 5.4 %60 ANTI-INHIBITOR COAGULANT COMPLEX46 AMINO ACIDS 7 %57 ANTIHEMOPHILIC FACTOR (FACTOR VIII) AMINO ACIDS 8 %59 RECOMB,B-DOMAIN DELETED47 AMINO ACIDS 8.5 %/ELECTROLYTE-TPN SOLN57 ANTIHEMOPHILIC FACTOR (FVIII) REC, B-DOM AMINOCAPROIC ACID46 TRUNCATED PEG-EXEI46 AMINOSYN56 ANTIHEMOPHILIC FACTOR (FVIII) REC, B-DOMAIN AMINOSYN II57 DELETED PEG-AUCL46 AMINOSYN II WITH ELECTROLYTES57 ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, AMINOSYN M57 FC FUSION PROTEIN46 AMINOSYN WITH ELECTROLYTES57 ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, AMINOSYN-HBC57 FULL LENGTH, PEG45 AMINOSYN-PF57 ANTIHEMOPHILIC FACTOR (FVIII) AMINOSYN-RF57 RECOMBINANT,FULL LENGTH46 AMIODARONE HCL49 ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B- AMITRIPTYLINE HCL26 DOMAIN DELETED47 AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE25 ANTIHEMOPHILIC FACTOR VIII RECOMB,SINGLE- AMLODIPINE BESYLATE49 CHN,B-DOM TRUNCATED45 AMLODIPINE BESYLATE/BENAZEPRIL HCL50 ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B- AMLODIPINE BESYLATE/OLMESARTAN DOMAIN TRUNCATED47 MEDOXOMIL50 ANTIHEMOPHILIC FACTOR VIII, HUMAN AMLODIPINE BESYLATE/VALSARTAN50 RECOMBINANT47 AMMONIUM LACTATE55 ANTIHEMOPHILIC FACTOR VIII, RECOMBINANT AMNESTEEM55 PORCINE SEQUENCE47 AMOXAPINE26 ANTIHEMOPHILIC FACTOR, HUMAN46 AMOXICILLIN18 ANTIHEMOPHILIC FACTOR, HUMAN/VON AMOXICILLIN/POTASSIUM CLAVULANATE18 WILLEBRAND FACTOR,HUMAN47

PAGE 97 LAST UPDATED 04/2020 ANUSOL-HC87 AUBRA EQ72 APIXABAN44 AUROVELA72 APREPITANT27 AUROVELA 24 FE72 APRI72 AUROVELA FE72 APRISO87 AUSTEDO53 APTENSIO XR53 AVIANE73 APTIOM23 AVITA55 APTIVUS39 AVONEX54 AQUADEKS5 AVONEX PEN54 ARALAST NP67 AYUNA73 ARANELLE72 AZACITIDINE30 ARANESP45 AZACTAM17 ARIPIPRAZOLE35 AZATHIOPRINE85 ARIPIPRAZOLE LAUROXIL35 AZELAIC ACID56 ARIPIPRAZOLE LAUROXIL, SUBMICRONIZED35 AZELASTINE HCL91 ARISTADA35 AZITHROMYCIN19 ARISTADA INITIO35 AZTREONAM17 ARMOUR THYROID83 AZURETTE73 ARTHRITIS PAIN3 ARTHRITIS PAIN RELIEF3 B ARYMO ER12 BACITRACIN/POLYMYXIN B SULFATE89 ARZERRA32 BACLOFEN36 ASCORBIC ACID63 BACMIN63 ASHLYNA72 BACTERIOSTATIC SODIUM CHLORIDE88 ASMANEX91 BALANCED SALT IRRIG SOLN NO.289 ASPIR 811 BALCOLTRA73 ASPIR-LOW1 BALSALAZIDE DISODIUM87 ASPIRIN1 BALZIVA73 ASPIRIN/DIPYRIDAMOLE48 BANZEL24 ATAZANAVIR SULFATE40 BASAGLAR KWIKPEN U-10043 ATAZANAVIR SULFATE/COBICISTAT39 BEKYREE73 ATENOLOL49 BENAZEPRIL HCL48 ATENOLOL/CHLORTHALIDONE50 BENDAMUSTINE HCL29 ATOMOXETINE HCL53 BENEFIX46 ATORVASTATIN CALCIUM51 BENZONATATE94 ATOVAQUONE33 BENZTROPINE MESYLATE33 ATRIPLA37 BERINERT85 ATROPINE SULFATE89 BETAINE67 ATROVENT HFA92 BETAMETHASONE ACETATE/BETAMETHASONE AUBAGIO54 SODIUM PHOSPHATE70 AUBRA72

PAGE 98 LAST UPDATED 04/2020 BETAMETHASONE DIPROPIONATE/PROPYLENE BUPRENORPHINE13 GLYCOL70 BUPRENORPHINE HCL14 BETAMETHASONE VALERATE70 BUPRENORPHINE HCL/NALOXONE HCL15 BETASERON54 BUPROPION HCL25 BETHANECHOL CHLORIDE69 BUSPIRONE HCL40 BETHKIS93 BUSULFAN29 BEVESPI AEROSPHERE94 BUTALBITAL/ACETAMINOPHEN53 BEYAZ73 BUTALBITAL/ACETAMINOPHEN/CAFFEINE53 BICALUTAMIDE29 BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN BICILLIN C-R18 E PHOSPHATE13 BICILLIN L-A18 BUTALBITAL/ASPIRIN/CAFFEINE13 BICNU29 BUTOCONAZOLE NITRATE27 BICTEGRAVIR BYDUREON PEN41 SODIUM/EMTRICITABINE/TENOFOVIR BYETTA42 ALAFENAMIDE FUMAR37 BIKTARVY37 C BILTRICIDE33 C1 ESTERASE INHIBITOR85 BISOPROLOL FUMARATE49 CABERGOLINE84 BISOPROLOL CAFFEINE CITRATE93 FUMARATE/HYDROCHLOROTHIAZIDE50 CAL-GEST6 BIVIGAM86 CALCIPOTRIENE55 BLEOMYCIN SULFATE30 CALCITONIN,SALMON,SYNTHETIC88 BLISOVI 24 FE73 CALCITRATE4 BLISOVI FE73 CALCITRIOL88 BOOSTRIX TDAP87 CALCIUM ACETATE62 BORTEZOMIB30 CALCIUM ANTACID6 BOSENTAN93 CALCIUM CARBONATE7 BRIELLYN73 CALCIUM CHLORIDE57 BRILINTA48 CALCIUM CITRATE4 BRIMONIDINE TARTRATE90 CALCIUM GLUCONATE57 BRIMONIDINE TARTRATE/TIMOLOL MALEATE90 CAMILA81 BRIVARACETAM20 CAMPATH32 BRIVIACT20 CAMRESE73 BROMPHENIRAMINE CAMRESE LO73 MALEATE/PSEUDOEPHEDRINE CANAGLIFLOZIN42 HCL/DEXTROMETHORPHAN94 CANAGLIFLOZIN/METFORMIN HCL42 BUDESONIDE91 CAPECITABINE30 BUDESONIDE/FORMOTEROL FUMARATE94 CARBAMAZEPINE41 BUMETANIDE51 CARBATROL24 BUPIVACAINE HCL/EPINEPHRINE14 CARBIDOPA/LEVODOPA34 BUPIVACAINE HCL/PF14 CARBIDOPA/LEVODOPA/ENTACAPONE33

PAGE 99 LAST UPDATED 04/2020 CARBINOXAMINE MALEATE91 CHILD MUCUS-COUGH RELIEF9 CARBOPLATIN31 CHILDREN'S ALL DAY ALLERGY8 CARMUSTINE29 CHILDREN'S ALLERGY8 CARTEOLOL HCL90 CHILDREN'S ALLERGY RELIEF8 CARVEDILOL49 CHILDREN'S MAPAP3 CATAPRES-TTS 148 CHILDREN'S MUCUS RELIEF9 CATAPRES-TTS 248 CHILDREN'S PAIN RELIEF3 CATAPRES-TTS 348 CHILDREN'S PAIN RELIEVER3 CATHFLO ACTIVASE44 CHILDREN'S PAIN-FEVER3 CAZIANT73 CHILDREN'S SILAPAP3 CEFACLOR17 CHLORAMBUCIL29 CEFADROXIL17 CHLORDIAZEPOXIDE HCL41 CEFAZOLIN SODIUM17 CHLORHEXIDINE GLUCONATE54 CEFDINIR17 CHLOROQUINE PHOSPHATE33 CEFEPIME HCL17 CHLOROTHIAZIDE51 CEFIXIME17 CHLORPROMAZINE HCL34 CEFOTAXIME SODIUM17 CHLORTHALIDONE51 CEFOTETAN DISODIUM17 CHLORZOXAZONE94 CEFOTETAN DISODIUM IN ISO-OSMOTIC CHOLESTYRAMINE (WITH SUGAR)52 DEXTROSE17 CHOLESTYRAMINE/ASPARTAME52 CEFOXITIN SODIUM17 CHROMIC CHLORIDE57 CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC17 CICLOPIROX27 CEFPROZIL17 CILOSTAZOL48 CEFTRIAXONE SODIUM17 CIMDUO38 CEFTRIAXONE SODIUM IN ISO-OSMOTIC CIPRO19 DEXTROSE17 CIPRODEX91 CEFUROXIME AXETIL17 CIPROFLOXACIN19 CEFUROXIME SODIUM17 CIPROFLOXACIN HCL19 CELECOXIB12 CIPROFLOXACIN HCL/DEXAMETHASONE91 CELESTONE70 CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN CELLCEPT85 WATER19 CENTRATEX57 CISPLATIN31 CEPHALEXIN17 CITALOPRAM HYDROBROMIDE25 CETIRIZINE HCL91 CITRANATAL B-CALM63 CETIRIZINE HCL/PSEUDOEPHEDRINE HCL9 CITRIC ACID/GLUCONOLACTONE/MAGNESIUM CHANTIX15 CARBONATE69 CHATEAL73 CITRIC ACID/SODIUM CITRATE69 CHATEAL EQ73 CLADRIBINE30 CHEST CONGESTION RELIEF9 CLARAVIS55 CHILD MUCINEX CHEST MINI-MELTS9 CLARITHROMYCIN19 CHILD MUCINEX COUGH MINI-MELTS9 CLEARLAX7

PAGE 100 LAST UPDATED 04/2020 CLEMASTINE FUMARATE91 COLLOIDAL BISMUTH CLENPIQ66 SUBCITRATE/METRONIDAZOLE/TETRACYCLINE CLEOCIN16 HCL66 CLEOCIN PHOSPHATE16 COMBIGAN90 CLIMARA PRO73 COMBIPATCH73 CLINDAMYCIN HCL16 COMBIVENT RESPIMAT94 CLINDAMYCIN PALMITATE HCL16 COMPLERA37 CLINDAMYCIN PHOSPHATE16 COMPLETE NATAL DHA63 CLINDAMYCIN PHOSPHATE/BENZOYL CONCEPT DHA63 PEROXIDE55 CONCEPT OB63 CLINDESSE16 COPAXONE54 CLINIMIX57 COPPER88 CLINIMIX E57 CORIFACT46 CLINISOL57 CORTICOTROPIN70 CLIOQUINOL/HYDROCORTISONE55 CORTISPORIN55 CLOBAZAM21 CORVITA5 CLOBETASOL PROPIONATE70 COSENTYX (2 SYRINGES)55 CLOBETASOL PROPIONATE/EMOLLIENT BASE70 COSENTYX PEN55 CLOMIPRAMINE HCL26 COSENTYX PEN (2 PENS)55 CLONAZEPAM41 COSENTYX SYRINGE55 CLONIDINE48 COUGH DM9 CLONIDINE HCL48 COUMADIN44 CLOPIDOGREL BISULFATE48 CREON67 CLORAZEPATE DIPOTASSIUM41 CRISABOROLE55 CLOTRIMAZOLE27 CRIXIVAN39 CLOTRIMAZOLE/BETAMETHASONE CROMOLYN SODIUM93 DIPROPIONATE55 CRYSELLE74 CLOZAPINE36 CUPRIC CHLORIDE57 CLOZARIL36 CYANOCOBALAMIN (VITAMIN B-12)63 COAGADEX46 CYANOCOBALAMIN/FOLIC ACID63 COAGULATION FACTOR VIIA (RECOMBINANT)47 CYCLAFEM74 COAGULATION FACTOR X46 CYCLOBENZAPRINE HCL94 COBICISTAT39 CYCLOPENTOLATE HCL89 CODEINE SULFATE13 CYCLOPHOSPHAMIDE29 COLCHICINE28 CYCLOSPORINE89 COLESTID52 CYCLOSPORINE, MODIFIED85 COLESTIPOL HCL52 CYPROHEPTADINE HCL91 COLISTIN (AS COLISTIMETHATE SODIUM)16 CYRED74 COLLAGENASE CLOSTRIDIUM HISTOLYTICUM56 CYRED EQ74 CYSTADANE67 CYSTAGON67

PAGE 101 LAST UPDATED 04/2020 CYSTARAN89 DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL CYSTEAMINE BITARTRATE67 ESTRADIOL81 CYSTEAMINE HCL89 DESVENLAFAXINE SUCCINATE25 CYTARABINE/PF30 DEUTETRABENAZINE53 DEXAMETHASONE90 D DEXAMETHASONE SODIUM PHOSPHATE90 DABIGATRAN ETEXILATE MESYLATE44 DEXMETHYLPHENIDATE HCL53 DACARBAZINE31 DEXRAZOXANE HCL31 DALFAMPRIDINE54 DEXTROAMPHETAMINE SULF- DANAZOL72 SACCHARATE/AMPHETAMINE SULF- DAPAGLIFLOZIN PROPANEDIOL42 ASPARTATE52 DAPSONE29 DEXTROAMPHETAMINE SULFATE52 DAPTACEL DTAP87 DEXTROMETHORPHAN HBR/QUINIDINE DARBEPOETIN ALFA IN POLYSORBATE 8045 SULFATE53 DARUNAVIR DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE57 ETH/COBICISTAT/EMTRICITABINE/TENOFOVIR DEXTROSE 10 % AND 0.45 % SODIUM ALAFENAMIDE40 CHLORIDE57 DARUNAVIR ETHANOLATE40 DEXTROSE 2.5 % AND 0.45 % SODIUM DARUNAVIR ETHANOLATE/COBICISTAT40 CHLORIDE57 DASETTA74 DEXTROSE 30 % IN WATER58 DAUNORUBICIN HCL31 DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE58 DAYSEE74 DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE58 DAYTRANA53 DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE58 DEBLITANE82 DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE58 DECITABINE31 DEXTROSE 5 % IN LACTATED RINGERS58 DEFEROXAMINE MESYLATE62 DEXTROSE 5 % IN WATER58 DELFLEX WITH 1.5% DEXTROSE57 DIALYVITE63 DELSTRIGO37 DIALYVITE 300063 DENAVIR40 DIALYVITE 500063 DEPAKOTE20 DIALYVITE SUPREME D63 DEPAKOTE ER20 DIALYVITE ZINC63 DEPAKOTE SPRINKLE20 DIASTAT21 DEPO-PROVERA82 DIASTAT ACUDIAL21 DEPO-SUBQ PROVERA 10482 DIAZEPAM41 DERMA-SMOOTHE-FS70 DIAZOXIDE43 DERMOTIC91 DICLEGIS26 DESCOVY39 DICLOFENAC SODIUM90 DESIPRAMINE HCL26 DICLOXACILLIN SODIUM18 DESMOPRESSIN ACETATE71 DICYCLOMINE HCL66 DESOGESTREL-ETHINYL ESTRADIOL81 DIDANOSINE38 DIFFERIN55

PAGE 102 LAST UPDATED 04/2020 DIFLUPREDNATE90 DOXYLAMINE SUCCINATE/PYRIDOXINE HCL DIGOXIN50 (B6)26 DILANTIN24 DROPERIDOL34 DILANTIN-12524 DROSPIRENONE83 DILTIAZEM HCL50 DROSPIRENONE/ETHINYL DIMETHYL FUMARATE54 ESTRADIOL/LEVOMEFOLATE CALCIUM81 DIPHENHYDRAMINE HCL92 DULERA94 DIPHENOXYLATE HCL/ATROPINE SULFATE66 DULOXETINE HCL54 DIPHTHERIA, PERTUSSIS (ACELL), TETANUS DUREZOL90 PEDIATRIC VACCINE/PF87 DUTASTERIDE69 DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS DYANAVEL XR52 VACCINE87 DIPHTHERIA,PERTUSSIS(ACELLULAR),TETANUS E VACCINE/PF87 E.E.S. 20019 DIPYRIDAMOLE48 ECONAZOLE NITRATE27 DISULFIRAM14 ECONTRA EZ7 DIURIL51 ECONTRA ONE-STEP7 DIVALPROEX SODIUM21 ECPIRIN1 DOBUTAMINE HCL50 ED-APAP3 DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER50 EDURANT37 DOCETAXEL31 EFAVIRENZ38 DOCUSATE SODIUM7 EFAVIRENZ/EMTRICITABINE/TENOFOVIR DOFETILIDE49 DISOPROXIL FUMARATE37 DOLUTEGRAVIR SODIUM37 EFAVIRENZ/LAMIVUDINE/TENOFOVIR DOLUTEGRAVIR SODIUM/LAMIVUDINE39 DISOPROXIL FUMARATE38 DOLUTEGRAVIR SODIUM/RILPIVIRINE HCL39 EFFER-K58 DONEPEZIL HCL25 ELAGOLIX SODIUM84 DORAVIRINE37 ELECTROLYTE-148 SOLUTION60 DORAVIRINE/LAMIVUDINE/TENOFOVIR ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN DISOPROXIL FUMARATE37 WATER58 DORNASE ALFA93 ELECTROLYTE-A SOLUTION60 DORZOLAMIDE HCL90 ELECTROLYTE-B SOLUTION/DEXTROSE 5 % IN DORZOLAMIDE HCL/TIMOLOL MALEATE90 WATER59 DOVATO39 ELECTROLYTE-M SOLUTION/DEXTROSE 5 % IN DOXAZOSIN MESYLATE48 WATER60 DOXEPIN HCL55 ELECTROLYTE-MB SOLUTION/DEXTROSE 5 % IN DOXERCALCIFEROL88 WATER59 DOXORUBICIN HCL31 ELECTROLYTE-P SOLUTION/DEXTROSE 5 % IN DOXORUBICIN HCL PEGYLATED LIPOSOMAL31 WATER59 DOXYCYCLINE HYCLATE20 ELECTROLYTE-R (PH 7.4)60 ELECTROLYTE-R SOLUTION60

PAGE 103 LAST UPDATED 04/2020 ELECTROLYTE-R SOLUTION/DEXTROSE 5 % IN ENTECAVIR36 WATER60 ENTRESTO50 ELECTROLYTE-S SOLUTION59 ENZALUTAMIDE30 ELELYSO68 EPINEPHRINE92 ELIDEL55 EPIRUBICIN HCL31 ELINEST74 EPITOL24 ELIQUIS44 EPIVIR38 ELIXOPHYLLIN93 EPIVIR HBV36 ELLA81 EPLERENONE51 ELOCTATE46 EPOETIN ALFA45 ELURYNG74 EPOPROSTENOL SODIUM (GLYCINE)93 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN EQUETRO41 OFOVIR ALAFENAMIDE37 ERAXIS (WATER DILUENT)27 ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN ERGOCALCIFEROL (VITAMIN D2)88 OFOVIR DISOPROXIL37 ERRIN82 EMGALITY PEN28 ERYTHROMYCIN BASE19 EMGALITY SYRINGE28 ERYTHROMYCIN ETHYLSUCCINATE19 EMICIZUMAB-KXWH46 ESCITALOPRAM OXALATE25 EMOQUETTE74 ESLICARBAZEPINE ACETATE23 EMPAGLIFLOZIN42 ESOMEPRAZOLE MAGNESIUM67 EMPAGLIFLOZIN/LINAGLIPTIN42 ESPEROCT46 EMTRICITABINE38 ESTARYLLA74 EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR ESTRADIOL81 ALAFENAMIDE FUMARATE37 ESTRADIOL VALERATE74 EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR ESTRADIOL VALERATE/DIENOGEST78 DISOPROXIL FUMARATE37 ESTRADIOL/LEVONORGESTREL73 EMTRICITABINE/TENOFOVIR ALAFENAMIDE ESTRADIOL/NORETHINDRONE ACETATE74 FUMARATE39 ESTRING74 EMTRICITABINE/TENOFOVIR DISOPROXIL ESTROGENS, CONJUGATED79 FUMARATE38 ESTROGENS, EMTRIVA38 CONJUGATED/MEDROXYPROGESTERONE ENALAPRIL MALEATE48 ACETATE79 ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE50 ESTROGENS,ESTERIFIED/METHYLTESTOSTERON ENBREL85 E75 ENBREL MINI85 ESTROSTEP FE75 ENBREL SURECLICK85 ETANERCEPT85 ENEMEEZ7 ETHAMBUTOL HCL29 ENFUVIRTIDE39 ETHINYL ESTRADIOL/DROSPIRENONE81 ENOXAPARIN SODIUM44 ETHOSUXIMIDE20 ENPRESSE74 ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL81 ENSKYCE74 ETONOGESTREL82

PAGE 104 LAST UPDATED 04/2020 ETONOGESTREL/ETHINYL ESTRADIOL78 FENTANYL12 ETOPOSIDE32 FEOSOL4 ETRAVIRINE37 FER-IN-SOL4 EUCRISA55 FERATE4 EVOTAZ39 FEROSUL4 EXELON25 FERRIMIN 1505 EXEMESTANE32 FERRO-TIME5 EXENATIDE42 FERROUS FUMARATE5 EXENATIDE MICROSPHERES41 FERROUS FUMARATE/ASCORBIC ACID/B12- EZETIMIBE52 IF/FOLIC ACID62 FERROUS FUMARATE/ASCORBIC F ACID/CYANOCOBALAMIN/FOLIC ACID58 FABRAZYME68 FERROUS FUMARATE/FOLIC ACID59 FACTOR IX47 FERROUS FUMARATE/FOLIC ACID/MULTIVITAMIN- FACTOR IX (HUMAN) RECOMBINANT, MINERALS NO.1558 PEGYLATED47 FERROUS GLUCONATE5 FACTOR IX COMPLEX, PROTHROMBIN CPLX FERROUS SULFATE5 CONC(PCC) NO.4, 3-FACTOR47 FERROUSUL5 FACTOR IX HUMAN RECOMBINANT47 FESOTERODINE FUMARATE68 FACTOR IX HUMAN RECOMBINANT, THREONINE FILGRASTIM45 14846 FINACEA56 FACTOR IX RECOMBINANT, FC FUSION FINASTERIDE69 PROTEIN46 FINGOLIMOD HCL54 FACTOR IX RECOMBINANT,ALBUMIN FUSION FIRAZYR85 PROTEIN46 FIRVANQ16 FACTOR XIII46 FLAREX90 FACTOR XIII A-SUBUNIT, RECOMBINANT47 FLECAINIDE ACETATE49 FALMINA75 FLOVENT HFA91 FAMOTIDINE66 FLOXURIDINE30 FAMOTIDINE/PF66 FLUCONAZOLE27 FANAPT35 FLUCONAZOLE IN SODIUM CHLORIDE, ISO- FARXIGA42 OSMOTIC27 FAT EMULSIONS60 FLUDARABINE PHOSPHATE31 FAYOSIM75 FLUDROCORTISONE ACETATE70 FEIBA NF46 FLUOCINOLONE ACETONIDE70 FELBAMATE22 FLUOCINOLONE ACETONIDE OIL91 FELBATOL22 FLUORIDE (SODIUM)62 FELODIPINE50 FLUOROMETHOLONE90 FEMHRT75 FLUOROMETHOLONE ACETATE90 FEMYNOR75 FLUOROURACIL30 FENOFIBRATE NANOCRYSTALLIZED51 FLUOXETINE HCL25

PAGE 105 LAST UPDATED 04/2020 FLUPHENAZINE DECANOATE34 GENTAMICIN SULFATE IN SODIUM CHLORIDE, FLUPHENAZINE HCL34 ISO-OSMOTIC15 FLUTAMIDE30 GENVOYA37 FLUTICASONE PROPIONATE91 GIANVI75 FLUTICASONE PROPIONATE/SALMETEROL GILENYA54 XINAFOATE94 GLASSIA68 FLUVOXAMINE MALEATE25 GLATIRAMER ACETATE54 FML FORTE90 GLECAPREVIR/PIBRENTASVIR36 FML S.O.P.90 GLIMEPIRIDE42 FOCALIN XR53 GLIPIZIDE42 FOLIC ACID63 GLIPIZIDE/METFORMIN HCL42 FOLIC ACID/MULTIVITAMIN,THER AND GLUCAGEN43 MINERALS/LYCOPENE/LUTEIN5 GLUCAGON EMERGENCY KIT43 FOLIC ACID/VITAMIN B COMP AND GLUCAGON HCL43 C/SELENIUM/MINERALS/ZINC63 GLUCAGON,HUMAN RECOMBINANT43 FOLIC ACID/VITAMIN B COMPLEX AND VITAMIN GLUMETZA42 C63 GLYBURIDE42 FOLIVANE-OB63 GLYBURIDE,MICRONIZED42 FOLTRATE63 GLYBURIDE/METFORMIN HCL42 FORTAMET42 GLYCOPYRROLATE66 FOSAMPRENAVIR CALCIUM40 GLYCOPYRROLATE/FORMOTEROL FUMARATE94 FOSINOPRIL SODIUM49 GLYCOPYRROLATE/PF66 FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE50 GLYRX-PF66 FREAMINE III58 GLYSET42 FUROSEMIDE51 GLYXAMBI42 FUSION PLUS58 GOLYTELY67 FUZEON39 GOSERELIN ACETATE32 FYCOMPA22 GRANISETRON HCL/PF27 GRANIX45 G GRISEOFULVIN, MICROSIZE27 GABAPENTIN21 GUAIFENESIN11 GABITRIL21 GUAIFENESIN/DEXTROMETHORPHAN HBR11 GALCANEZUMAB-GNLM28 GUANFACINE HCL53 GAMMAGARD S-D86 GUANIDINE HCL28 GANCICLOVIR SODIUM36 GYNAZOLE 127 GEFITINIB32 GEMCITABINE HCL30 H GEMFIBROZIL51 HAILEY75 GENERESS FE75 HAILEY 24 FE75 GENOTROPIN71 HALOBETASOL PROPIONATE70 GENTAMICIN SULFATE15 HALOPERIDOL34

PAGE 106 LAST UPDATED 04/2020 HALOPERIDOL DECANOATE34 HYDROCODONE HALOPERIDOL LACTATE34 BITARTRATE/ACETAMINOPHEN14 HAVRIX87 HYDROCODONE BITARTRATE/HOMATROPINE HEATHER82 METHYLBROMIDE94 HEMATOGEN FA58 HYDROCODONE/IBUPROFEN13 HEMLIBRA46 HYDROCORTISONE88 HEMOCYTE5 HYDROCORTISONE ACETATE/LIDOCAINE HEMOCYTE PLUS58 HCL/ALOE VERA56 HEMOCYTE-F59 HYDROCORTISONE ACETATE/PRAMOXINE HCL56 HEMOFIL M46 HYDROCORTISONE SODIUM SUCCINATE/PF71 HEPARIN SODIUM,PORCINE44 HYDROMORPHONE HCL13 HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM HYDROXYCHLOROQUINE SULFATE33 CHLORIDE/PF44 HYDROXYPROGESTERONE CAPROATE/PF82 HEPARIN SODIUM,PORCINE/PF44 HYDROXYUREA30 HEPATAMINE59 HYDROXYZINE HCL92 HEPATITIS A VIRUS VACCINE/PF87 HYDROXYZINE PAMOATE92 HUMALOG43 HYOSCYAMINE SULFATE66 HUMALOG KWIKPEN U-10043 HYPERLYTE CR59 HUMALOG MIX 50-5043 HYPERRHO S-D86 HUMALOG MIX 50-50 KWIKPEN43 HYSINGLA ER12 HUMALOG MIX 75-2543 HUMALOG MIX 75-25 KWIKPEN43 I HUMATE-P46 IBALIZUMAB-UIYK39 HUMIRA85 IBU12 HUMIRA PEN85 IBUPROFEN12 HUMIRA PEN CROHN'S-UC-HS85 ICATIBANT ACETATE85 HUMIRA PEN PSOR-UVEITS-ADOL HS86 IDARUBICIN HCL31 HUMIRA(CF)86 IDELVION46 HUMIRA(CF) PEDIATRIC CROHN'S86 IFEREX 150 FORTE59 HUMIRA(CF) PEN86 IFOSFAMIDE29 HUMIRA(CF) PEN CROHN'S-UC-HS86 ILEVRO90 HUMIRA(CF) PEN PSOR-UV-ADOL HS86 ILOPERIDONE35 HUMULIN 70-302 ILOPROST TROMETHAMINE93 HUMULIN 70/30 KWIKPEN2 IMATINIB MESYLATE32 HUMULIN N2 IMIPENEM/CILASTATIN SODIUM17 HUMULIN N KWIKPEN2 IMIPRAMINE HCL26 HUMULIN R2 IMIQUIMOD56 HYDRALAZINE HCL52 IMMUNE HYDROCHLOROTHIAZIDE51 GLOBULIN,GAMM(IGG)/GLYCINE/GLUCOSE/IGA 0 HYDROCODONE BITARTRATE12 TO 50 MCG/ML86

PAGE 107 LAST UPDATED 04/2020 IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA INVOKAMET42 GREATER THAN 50 MCG/ML86 INVOKANA42 INCASSIA82 IODOPEN59 INDACATEROL MALEATE/GLYCOPYRROLATE94 IONOSOL B WITH DEXTROSE 5%59 INDAPAMIDE51 IONOSOL MB-DEXTROSE 5%59 INDINAVIR SULFATE39 IPRATROPIUM BROMIDE92 INDOMETHACIN12 IPRATROPIUM BROMIDE/ALBUTEROL SULFATE94 INFANRIX DTAP87 IRBESARTAN48 INFANT PAIN-FEVER3 IRESSA32 INFANTS' PAIN RELIEF4 IRINOTECAN HCL31 INFANTS' PAIN-FEVER4 IRON FUM,POLYSAC COMP/FOLIC ACID/VIT B INFUVITE ADULT63 COMPC NO.18/L. CASEI58 INFUVITE PEDIATRIC63 IRON FUMARATE,POLYSAC COMP/FOLIC INGREZZA53 ACID/VITAMIN C/NIACINAMIDE59 INSULIN ASPART44 IRON FUMARATE,POLYSAC CPLEX/FOLIC INSULIN ASPART PROTAMINE HUMAN/INSULIN ACID/VITB COMP WITH C NO.965 ASPART44 IRON FUMARATE-IRON POLYSACCH CPLEX/FOLIC INSULIN DETEMIR44 ACID/MULTIVIT NO.1862 INSULIN GLARGINE,HUMAN RECOMBINANT IRON POLYSACCHARIDE ANALOG43 COMPLEX/CYANOCOBALAMIN/FOLIC ACID59 INSULIN LISPRO43 ISENTRESS37 INSULIN LISPRO PROTAMINE AND INSULIN ISENTRESS HD37 LISPRO43 ISIBLOOM75 INSULIN NPH HUMAN ISOPHANE2 ISOLYTE P WITH DEXTROSE59 INSULIN NPH HUMAN ISOPHANE/INSULIN ISOLYTE S59 REGULAR, HUMAN2 ISONIAZID29 INSULIN REGULAR, HUMAN2 ISOSORBIDE DINITRATE52 INTEGRA F59 ISOSORBIDE MONONITRATE52 INTEGRA PLUS59 ISOTRETINOIN56 INTELENCE37 IVERMECTIN33 INTERFERON ALFA-2B,RECOMB.36 IXINITY46 INTERFERON BETA-1A54 INTERFERON BETA-1A/ALBUMIN HUMAN54 J INTERFERON BETA-1B54 JAIMIESS75 INTERFERON GAMMA-1B,RECOMB.86 JANTOVEN44 INTRALIPID59 JANUMET42 INTRON A36 JANUMET XR42 INTROVALE75 JANUVIA42 INVEGA SUSTENNA35 JARDIANCE42 INVEGA TRINZA35 JASMIEL75 INVIRASE39 JENCYCLA82

PAGE 108 LAST UPDATED 04/2020 JENTADUETO42 JIVI46 L JOLESSA75 LABETALOL HCL49 JR. STR NON-ASPIRIN PAIN4 LACOSAMIDE24 JULEBER75 LACTULOSE67 JULUCA39 LAMICTAL22 JUNEL75 LAMICTAL (BLUE)22 JUNEL FE75 LAMICTAL (GREEN)22 JUNEL FE 2476 LAMICTAL (ORANGE)22 LAMICTAL ODT22 K LAMICTAL ODT (BLUE)22 K-PHOS NEUTRAL69 LAMICTAL ODT (GREEN)22 K-PHOS NO.269 LAMICTAL ODT (ORANGE)22 K-PHOS ORIGINAL69 LAMICTAL XR22 KABIVEN64 LAMICTAL XR (BLUE)22 KAITLIB FE76 LAMICTAL XR (GREEN)22 KALETRA39 LAMICTAL XR (ORANGE)22 KALLIGA76 LAMIVUDINE38 KARIVA76 LAMIVUDINE/TENOFOVIR DISOPROXIL KELNOR 1-3576 FUMARATE38 KELNOR 1-5076 LAMIVUDINE/ZIDOVUDINE38 KEPPRA20 LAMOTRIGINE23 KEPPRA XR20 LANSOPRAZOLE67 KETOCONAZOLE27 LANTUS43 KETOROLAC TROMETHAMINE90 LANTUS SOLOSTAR43 KITABIS PAK93 LARIN76 KLONOPIN41 LARIN 24 FE76 KLOR-CON59 LARIN FE76 KLOR-CON 1059 LARISSIA76 KLOR-CON 859 LATANOPROST91 KLOR-CON M1059 LATUDA35 KLOR-CON M1559 LAYOLIS FE76 KLOR-CON M2059 LEENA76 KLOR-CON-EF59 LEFLUNOMIDE86 KOATE46 LENALIDOMIDE30 KOGENATE FS46 LESSINA76 KOMBIGLYZE XR42 LETAIRIS93 KOVALTRY46 LETROZOLE32 KURVELO76 LEUCOVORIN CALCIUM31 KYLEENA82 LEUKERAN29 LEUKINE45

PAGE 109 LAST UPDATED 04/2020 LEUPROLIDE ACETATE84 LIQUITUSS GG9 LEUPROLIDE ACETATE/NORETHINDRONE LISDEXAMFETAMINE DIMESYLATE53 ACETATE84 LISINOPRIL49 LEVEMIR44 LISINOPRIL/HYDROCHLOROTHIAZIDE50 LEVEMIR FLEXTOUCH44 LITHIUM CARBONATE41 LEVETIRACETAM20 LO LOESTRIN FE77 LEVOBUNOLOL HCL90 LO-ZUMANDIMINE77 LEVOCARNITINE (WITH SUGAR)60 LOESTRIN77 LEVOCETIRIZINE DIHYDROCHLORIDE92 LOESTRIN FE77 LEVOFLOXACIN19 LOJAIMIESS77 LEVOFLOXACIN/DEXTROSE 5 % IN WATER19 LOPERAMIDE HCL66 LEVONEST76 LOPINAVIR/RITONAVIR39 LEVONORGESTREL83 LORATA-DINE D9 LEVONORGESTREL/ETHINYL ESTRADIOL81 LORATADINE8 LEVONORGESTREL/ETHINYL ESTRADIOL AND LORATADINE-D9 ETHINYL ESTRADIOL79 LORATADINE/PSEUDOEPHEDRINE SULFATE9 LEVONORGESTREL/ETHINYL LORAZEPAM41 ESTRADIOL/FERROUS BISGLYCINATE73 LORAZEPAM INTENSOL41 LEVORA-2876 LORYNA77 LEVOTHYROXINE SODIUM84 LOSARTAN POTASSIUM48 LEVOXYL83 LOSARTAN LEXIVA40 POTASSIUM/HYDROCHLOROTHIAZIDE50 LIDOCAINE14 LOSEASONIQUE77 LIDOCAINE HCL14 LOTEMAX90 LIDOCAINE HCL IN DEXTROSE 7.5 % IN LOTEPREDNOL ETABONATE90 WATER/PF14 LOTRONEX66 LIDOCAINE HCL/EPINEPHRINE14 LOVASTATIN52 LIDOCAINE HCL/EPINEPHRINE BITARTRATE14 LOW-OGESTREL77 LIDOCAINE HCL/PF14 LOXAPINE SUCCINATE34 LIDOCAINE/PRILOCAINE14 LUPANETA PACK84 LILETTA82 LUPRON DEPOT84 LILLOW76 LUPRON DEPOT (LUPANETA)84 LINACLOTIDE66 LUPRON DEPOT-PED84 LINAGLIPTIN43 LURASIDONE HCL35 LINAGLIPTIN/METFORMIN HCL42 LUTERA77 LINCOMYCIN HCL16 LYZA82 LINEZOLID16 LINZESS66 M LIOTHYRONINE SODIUM83 M-NATAL PLUS64 LIOTRIX84 M-PAP4 LIPASE/PROTEASE/AMYLASE68 M.V.I. ADULT64

PAGE 110 LAST UPDATED 04/2020 M.V.I. PEDIATRIC64 METHYLPREDNISOLONE70 MAGNESIUM CHLORIDE60 METHYLPREDNISOLONE ACETATE70 MAGNESIUM SULFATE IN STERILE WATER60 METHYLPREDNISOLONE SODIUM SUCCINATE70 MAKENA82 METOCLOPRAMIDE HCL26 MANGANESE CHLORIDE60 METOLAZONE51 MANGANESE SULFATE60 METOPROLOL SUCCINATE49 MANNITOL/SORBITOL SOLUTION88 METOPROLOL TARTRATE49 MAPAP ARTHRITIS PAIN4 METRONIDAZOLE56 MARAVIROC39 METRONIDAZOLE IN SODIUM CHLORIDE16 MARLISSA77 MEXILETINE HCL49 MATULANE29 MIBELAS 24 FE77 MAVYRET36 MICONAZOLE 32 MAXIDEX90 MICONAZOLE NITRATE27 MECLIZINE HCL26 MICROGESTIN FE77 MEDROXYPROGESTERONE ACETATE82 MIDODRINE HCL48 MEFLOQUINE HCL33 MIGLITOL42 MEGESTROL ACETATE82 MIGLUSTAT68 MELODETTA 24 FE77 MILI77 MELOXICAM12 MILRINONE LACTATE50 MELPHALAN29 MILRINONE LACTATE/DEXTROSE 5 % IN WATER50 MELPHALAN HCL29 MINASTRIN 24 FE77 MEMANTINE HCL25 MINOCYCLINE HCL20 MEPHYTON47 MINOXIDIL52 MERCAPTOPURINE30 MIRCETTE77 MEROPENEM18 MIRENA82 MEROPENEM IN 0.9 % SODIUM CHLORIDE18 MIRTAZAPINE25 MESALAMINE87 MISOPROSTOL67 MESNA32 MITOMYCIN31 MESTINON28 MITOXANTRONE HCL31 METFORMIN HCL43 MODAFINIL95 METHAZOLAMIDE90 MOMETASONE FUROATE91 METHENAMINE HIPPURATE16 MOMETASONE FUROATE/FORMOTEROL METHENAMINE MANDELATE16 FUMARATE94 METHIMAZOLE85 MONO-LINYAH77 METHOCARBAMOL95 MONONINE47 METHOTREXATE SODIUM86 MONTELUKAST SODIUM92 METHOTREXATE SODIUM/PF86 MORPHABOND ER12 METHYLDOPA48 MORPHINE SULFATE13 METHYLERGONOVINE MALEATE88 MOVANTIK66 METHYLPHENIDATE53 MOXIFLOXACIN HCL19 METHYLPHENIDATE HCL53 MUCINEX9

PAGE 111 LAST UPDATED 04/2020 MUCINEX DM10 MYCOPHENOLATE MOFETIL86 MUCOSA10 MYCOPHENOLATE MOFETIL HCL85 MUCUS DM MAX ER10 MYLERAN29 MUCUS ER10 MYORISAN56 MUCUS RELIEF10 MYSOLINE21 MUCUS RELIEF CHEST CONGESTION10 MUCUS RELIEF DM COUGH10 N MUCUS RELIEF DM ER10 NABUMETONE12 MUCUS RELIEF DM MAX10 NAFARELIN ACETATE84 MUCUS RELIEF DM MAX ER10 NALOXEGOL OXALATE66 MUCUS RELIEF ER10 NALOXONE HCL15 MUCUS-CHEST CONGESTION10 NALTREXONE HCL14 MUCUS-ER MAX10 NALTREXONE MICROSPHERES14 MULTITRACE-460 NAPROXEN12 MULTITRACE-560 NARCAN15 MULTIVIT WITH MINS10/FOLIC ACID/VIT D3/A NATAZIA78 LIPOIC ACID/LUTEIN64 NATROBA56 MULTIVITAMIN INFUSION, ADULT NO.1 WITH NEBUPENT33 WITAMIN K64 NECON78 MULTIVITAMIN INFUSION, ADULT NO.4 WITH NELFINAVIR MESYLATE40 VITAMIN K63 NEOMYCIN SULFATE15 MULTIVITAMIN INFUSION, PEDIATRIC NO.1 WITH NEOMYCIN SULFATE/BACITRACIN VITAMIN K63 ZINC/POLYMYXIN B/HYDROCORTISONE89 MULTIVITAMIN INFUSION, PEDIATRIC NO.2 WITH NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN VITAMIN K64 B89 MULTIVITAMIN WITH MINERALS NO.20/IRON/FOLIC NEOMYCIN SULFATE/POLYMYXIN B SULFATE16 ACID63 NEOMYCIN SULFATE/POLYMYXIN B MULTIVITAMIN, MINERALS NO.51/FOLIC ACID/VIT SULFATE/HYDROCORTISONE91 K1/UBIDECARENONE5 NEOMYCIN/BACITRACIN/POLYMYXIN MULTIVITAMIN-MINERALS NO.25/FOLIC B/HYDROCORTISONE55 ACID/VITAMIN D363 NEOMYCIN/POLYMYXIN B MULTIVITAMINS WITH MINERALS NO.11/FOLIC SULFATE/DEXAMETHASONE89 ACID63 NEPAFENAC90 MUPIROCIN16 NEPHPLEX RX64 MUTAMYCIN31 NEPHRAMINE60 MV-MIN 75/FERROUS FUM/IRON PS CPLX/FOLIC NEPHRO-VITE RX64 AC/OMEGA-3/DHA/EPA65 NETARSUDIL MESYLATE90 MV-MINS NO.74/FERROUS FUMARATE/IRON PS NETARSUDIL MESYLATE/LATANOPROST90 CPLX/FOLIC ACID63 NEULASTA45 MY CHOICE7 NEUPOGEN45 MY WAY7 NEURONTIN21

PAGE 112 LAST UPDATED 04/2020 NEVIRAPINE38 NOVOLOG FLEXPEN44 NEW DAY7 NOVOLOG MIX 70-3044 NEXIUM67 NOVOLOG MIX 70-30 FLEXPEN44 NEXPLANON82 NOVOSEVEN RT47 NIACIN52 NP THYROID83 NICORETTE1 NUEDEXTA53 NICOTINE1 NUTRILIPID60 NICOTINE POLACRILEX1 NUVARING78 NIFEDIPINE50 NUWIQ47 NIKKI78 NYSTATIN27 NIMODIPINE50 NYSTATIN/TRIAMCINOLONE ACETONIDE28 NITROFURANTOIN MACROCRYSTAL16 NITROFURANTOIN O MONOHYDRATE/MACROCRYSTALS16 OBIZUR47 NITROGLYCERIN52 OCELLA78 NORA-BE82 OCTREOTIDE ACETATE84 NORDITROPIN FLEXPRO71 ODEFSEY37 NORELGESTROMIN/ETHINYL ESTRADIOL81 OFATUMUMAB32 NORETHINDRONE83 OFLOXACIN19 NORETHINDRONE ACETATE83 OGESTREL78 NORETHINDRONE ACETATE-ETHINYL OLANZAPINE35 ESTRADIOL78 OLMESARTAN MEDOXOMIL48 NORETHINDRONE ACETATE-ETHINYL OLOPATADINE HCL90 ESTRADIOL/FERROUS FUMARATE80 OMEPRAZOLE67 NORETHINDRONE-ETHINYL ESTRADIOL81 ONCASPAR31 NORETHINDRONE-ETHINYL ONDANSETRON27 ESTRADIOL/FERROUS FUMARATE81 ONDANSETRON HCL27 NORGESTIMATE-ETHINYL ESTRADIOL81 ONFI21 NORGESTREL-ETHINYL ESTRADIOL78 ONGLYZA43 NORLYDA83 OPCICON ONE-STEP7 NORMOSOL-M AND DEXTROSE60 OPIUM/BELLADONNA ALKALOIDS13 NORMOSOL-R60 ORACIT69 NORMOSOL-R AND DEXTROSE60 ORILISSA84 NORMOSOL-R PH 7.460 ORSYTHIA78 NORTREL78 ORTHO MICRONOR83 NORTRIPTYLINE HCL26 ORTHO TRI-CYCLEN78 NORVIR40 ORTHO-NOVUM78 NOVOEIGHT47 OSELTAMIVIR PHOSPHATE40 NOVOLIN N2 OXALIPLATIN31 NOVOLIN R2 OXAZEPAM41 NOVOLOG44 OXCARBAZEPINE24

PAGE 113 LAST UPDATED 04/2020 OXTELLAR XR24 PAZOPANIB HCL32 OXYBUTYNIN CHLORIDE68 PEDIATRIC MULTIVITAMIN A,C,AND D3 NO.38 OXYCODONE HCL13 WITH SODIUM FLUORIDE6 OXYCODONE HCL/ACETAMINOPHEN13 PEDIATRIC MULTIVITAMIN NO.33 WITH SODIUM OXYCODONE MYRISTATE13 FLUORIDE5 OYSCO-5005 PEDIATRIC MULTIVITAMIN NO.33/SODIUM FLUORIDE/IRON CARBONYL5 P PEDIATRIC MULTIVITAMIN NO.40/PHYTONADIONE PACLITAXEL31 (VIT K1)5 PAIN RELIEF4 PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUM PAIN RELIEVER JUNIOR STRENGTH4 FLUORIDE64 PALIPERIDONE PALMITATE35 PEG 3350/SOD SULF/SOD BICARB/SOD PAMIDRONATE DISODIUM88 CHLORIDE/POTASSIUM CHLORIDE67 PANCREAZE68 PEGASPARGASE31 PANRETIN32 PEGASYS36 PANTOPRAZOLE SODIUM67 PEGFILGRASTIM45 PARAGARD T 380-A88 PEGINTERFERON ALFA-2A36 PARAPLATIN31 PEGINTERFERON ALFA-2B36 PARENTERAL AMINO ACID 10 % COMBINATION PEGINTRON36 NO.256 PEMETREXED DISODIUM30 PARENTERAL AMINO ACID 10 % COMBINATION PENCICLOVIR40 NO.458 PENICILLIN G BENZATHINE18 PARENTERAL AMINO ACID 10 % COMBINATION PENICILLIN G BENZATHINE/PENICILLIN G NO.662 PROCAINE18 PARENTERAL AMINO ACID 10% COMBINATION PENICILLIN G PROCAINE18 NO.761 PENICILLIN G SODIUM18 PARENTERAL AMINO ACID 15% COMBINATION PENICILLIN V POTASSIUM18 NO.160 PENTAMIDINE ISETHIONATE33 PARENTERAL AMINO ACID 15% COMBINATION PENTOXIFYLLINE50 NO.557 PERAMPANEL22 PARENTERAL AMINO ACID 20 % COMBINATION PERIKABIVEN64 NO.161 PERITONEAL DIALYSIS SOLUTION NO.19 AND PARENTERAL AMINO ACID 5.2 % COMBINATION DEXTROSE 1.5 %57 NO.1 (RENAL)57 PERMETHRIN33 PARENTERAL AMINO ACID 7 % COMBINATION PERPHENAZINE26 NO.1 (PEDIATRIC)57 PERPHENAZINE/AMITRIPTYLINE HCL25 PARENTERAL AMINO ACID 7 % COMBINATION PERSERIS35 NO.257 PERTZYE68 PARICALCITOL88 PHENAZOPYRIDINE HCL69 PAROXETINE HCL25 PHENOBARBITAL21 PAZEO90

PAGE 114 LAST UPDATED 04/2020 PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE POTASSIUM CHLORIDE IN 5 % DEXTROSE IN SULF/SCOPOLAMINE HB66 WATER58 PHENYLEPHRINE HCL89 POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 PHENYLEPHRINE HCL/PROMETHAZINE HCL94 % SODIUM CHLORIDE58 PHENYTOIN24 POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % PHENYTOIN SODIUM EXTENDED24 SODIUM CHLORIDE58 PHILITH78 POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % PHOSPHA 250 NEUTRAL69 SODIUM CHLORIDE58 PHYTONADIONE (VIT K1)47 POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3 PIFELTRO37 % SODIUM CHLORIDE58 PILOCARPINE HCL54 POTASSIUM CHLORIDE IN LACTATED RINGERS PIMECROLIMUS55 AND 5 % DEXTROSE61 PIMOZIDE34 POTASSIUM CHLORIDE IN WATER FOR PIMTREA78 INJECTION, STERILE60 PIOGLITAZONE HCL43 POTASSIUM CITRATE69 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM18 POTASSIUM CITRATE/CITRIC ACID69 PIPERONYL BUTOXIDE/PYRETHRINS4 POTASSIUM PHOSPHATE,MONOBASIC69 PIRMELLA78 POTASSIUM PHOSPHATE,MONOBASIC-DIBASIC61 PLAN B ONE-STEP7 PRADAXA44 PLASMA-LYTE 14860 PRAMIPEXOLE DI-HCL33 PLASMA-LYTE A PH 7.460 PRASUGREL HCL48 PLENAMINE60 PRAVASTATIN SODIUM52 PNV 29-164 PRAZIQUANTEL33 PODOFILOX56 PRAZOSIN HCL48 POLY-VI-FLOR5 PREDNISOLONE70 POLY-VI-FLOR WITH IRON5 PREDNISOLONE ACETATE90 POLYCIN89 PREDNISOLONE SODIUM PHOSPHATE71 POLYETHYLENE GLYCOL 33507 PREDNISONE71 POLYMYXIN B SULFATE16 PREGABALIN54 POLYMYXIN B SULFATE/TRIMETHOPRIM89 PREMARIN79 POMALIDOMIDE30 PREMASOL61 POMALYST30 PREMPHASE79 PORTIA78 PREMPRO79 POTASSIUM ACETATE60 PRENATAL VIT NO.112/IRON PHOSPH/FOLIC POTASSIUM BICARBONATE/CITRIC ACID59 ACID/OMEGA-3S/DHA/EPA65 POTASSIUM CHLORIDE59 PRENATAL VIT NO.128/IRON POLYSACCHARIDE POTASSIUM CHLORIDE IN 0.45 % SODIUM COMPLEX/FOLIC ACID64 CHLORIDE61 PRENATAL VIT NO.2/IRON BG CHEL,SUCC- POTASSIUM CHLORIDE IN 0.9 % SODIUM PROT/FOLIC ACID/OMEGA-365 CHLORIDE60 PRENATAL VIT NO.67/IRON POLYSACCHARIDES/FOLATE COMB.NO.1/DHA65

PAGE 115 LAST UPDATED 04/2020 PRENATAL VIT WITH CALCIUM 53/IRON BIS,S- PROGESTERONE, MICRONIZED83 P/FOLIC ACID/OMEGA-365 PROGLYCEM43 PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS PROLASTIN C68 FUMARATE/FOLIC ACID65 PROMETHAZINE HCL92 PRENATAL VITAMIN PROMETHAZINE HCL/DEXTROMETHORPHAN NO.48/IRON,CARBONYL,GLUCONATE/FOLIC HBR94 ACID/B663 PROMETHEGAN27 PRENATAL VITAMIN WITH CALCIUM PROMETRIUM83 NO.76/IRON,CARBONYL/FOLIC ACID65 PROPAFENONE HCL49 PRENATAL VITAMINS NO.33/IRON POLYSACH PROPANTHELINE BROMIDE66 COMPLEX/FOLIC ACID/DHA64 PROPRANOLOL HCL49 PRENATAL VITS NO.26/IRON POLYSACCHARIDE PROPYLTHIOURACIL85 CPLEX/FOLIC ACID/DHA65 PROSOL61 PRENATAL VITS WITH CALCIUM 118/FERROUS PROTONIX67 FUMARATE/FOLIC ACID64 PROTOPIC56 PRENATAL VITS WITH CALCIUM NO.10/FERROUS PROVENTIL HFA92 FUM/FOLIC ACID/DHA65 PULMOZYME93 PRENATAL VITS WITH CALCIUM NO.10/FERROUS PUREVIT DUALFE PLUS61 FUMARATE/FOLIC ACID65 PYLERA66 PRENATAL VITS WITH CALCIUM NO.72/FERROUS PYRAZINAMIDE29 FUMARATE/FOLIC ACID64 PYRIDOSTIGMINE BROMIDE28 PREPLUS64 PYRIDOXINE HCL (VITAMIN B6)64 PREVACID67 PREVIFEM79 Q PREZCOBIX40 QUARTETTE79 PREZISTA40 QUDEXY XR23 PRIMAQUINE PHOSPHATE33 QUETIAPINE FUMARATE35 PRIMIDONE21 QUILLICHEW ER53 PROAIR HFA92 QUILLIVANT XR53 PROBENECID28 QUINAPRIL HCL49 PROBENECID/COLCHICINE28 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE50 PROCALAMINE61 QUINIDINE SULFATE49 PROCARBAZINE HCL29 PROCHLORPERAZINE MALEATE26 R PROCRIT45 RALTEGRAVIR POTASSIUM37 PROCTO-MED HC88 RAMELTEON95 PROCTOFOAM-HC56 RAMIPRIL49 PROCTOSOL-HC88 RANEXA51 PROCTOZONE-HC88 RANOLAZINE51 PROFILNINE47 RAPAMUNE86 PROGESTERONE83 REBIF54

PAGE 116 LAST UPDATED 04/2020 REBIF REBIDOSE54 RUFINAMIDE24 REBINYN47 RECLIPSEN79 S RECOMBINATE47 SABRIL21 RENACIDIN69 SACUBITRIL/VALSARTAN50 RENVELA62 SAFYRAL79 REPAGLINIDE43 SALICYLIC ACID56 RESTASIS89 SALMETEROL XINAFOATE92 RESTASIS MULTIDOSE89 SALSALATE12 RETIN-A56 SANDIMMUNE86 RETROVIR38 SANTYL56 REVLIMID30 SAQUINAVIR MESYLATE39 REYATAZ40 SARGRAMOSTIM45 RHO(D) IMMUNE GLOBULIN86 SAXAGLIPTIN HCL43 RHOPRESSA90 SAXAGLIPTIN HCL/METFORMIN HCL42 RIBAVIRIN94 SCOPOLAMINE27 RIFABUTIN29 SE-NATAL 1964 RIFAMPIN29 SE-TAN PLUS61 RILPIVIRINE HCL37 SEASONIQUE79 RILUZOLE54 SECUKINUMAB55 RINGER'S SOLUTION61 SEGESTERONE ACETATE/ETHINYL ESTRADIOL72 RINGER'S SOLUTION,LACTATED60 SELECT-OB64 RISPERDAL CONSTA35 SELECT-OB + DHA64 RISPERIDONE35 SELEGILINE HCL34 RISPERIDONE MICROSPHERES35 SELENIUM SULFIDE56 RITONAVIR40 SELZENTRY39 RITUXAN32 SEREVENT DISKUS92 RITUXIMAB32 SERTRALINE HCL25 RIVAROXABAN44 SETLAKIN79 RIVASTIGMINE25 SEVELAMER CARBONATE62 RIVELSA79 SEVELAMER HCL62 RIXUBIS47 SHAROBEL83 RIZATRIPTAN BENZOATE28 SHINGRIX87 ROBAFEN10 SHINGRIX ADJUVANT COMPONENT87 ROBAFEN DM COUGH10 SHINGRIX GE ANTIGEN COMPONENT87 ROBAFEN DM PEAK COLD10 SILDENAFIL CITRATE93 ROCKLATAN90 SILTUSSIN SA10 ROPINIROLE HCL33 SILVER NITRATE56 ROSUVASTATIN CALCIUM52 SILVER SULFADIAZINE19 ROWEEPRA20 SIMLIYA79 ROZEREM95 SIMPESSE79

PAGE 117 LAST UPDATED 04/2020 SIMVASTATIN52 SPS62 SIROLIMUS86 SRONYX79 SITAGLIPTIN PHOSPHATE42 STAVUDINE38 SITAGLIPTIN PHOSPHATE/METFORMIN HCL42 STERILE WATER FOR IC-GREEN88 SKYLA83 STERILE WATER FOR KCENTRA89 SLYND83 STIMATE71 SODIUM ACETATE61 STIOLTO RESPIMAT94 SODIUM BICARBONATE61 STRIBILD37 SODIUM CHLORIDE 0.45 %61 STROVITE ONE64 SODIUM CHLORIDE FOR INHALATION94 SUBLOCADE13 SODIUM CHLORIDE/POT CHLORIDE/MAG SUL/SOD SUBOXONE15 PHOS,DB/POT PHOS,MB62 SUBVENITE23 SODIUM CHLORIDE/SODIUM SUBVENITE (BLUE)23 BICARBONATE/POTASSIUM CHLORIDE/PEG67 SUBVENITE (GREEN)23 SODIUM IODIDE59 SUBVENITE (ORANGE)23 SODIUM PHOSPHATE,DIBASIC/POT SUCRALFATE67 PHOS,MONOB/SOD PHOSPHATE MONO69 SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE,MONOBASIC-DIBASIC62 SODIUM PHOSPHATE89 SODIUM PHOSPHATE,MONOBASIC/POTASSIUM SULFAMETHOXAZOLE/TRIMETHOPRIM19 PHOSPHATE,MONOBASIC69 SULFASALAZINE88 SODIUM PICOSULFATE/MAGNESIUM SUMATRIPTAN28 OXIDE/CITRIC ACID66 SUMATRIPTAN SUCCINATE28 SODIUM POLYSTYRENE SULFONATE62 SUNITINIB MALATE32 SODIUM POLYSTYRENE SULFONATE/SORBITOL SUSTIVA38 SOLUTION62 SUTENT32 SODIUM/POTASSIUM/MAGNESIUM/CALCIUM/CHLO SYEDA79 RIDE/ACETATE62 SYMBICORT94 SODIUM/POTASSIUM/POTASSIUM SYMFI38 CITRATE/SODIUM CITRATE/CIT AC69 SYMFI LO38 SOFOSBUVIR/VELPATASVIR36 SYMPAZAN21 SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR36 SYMTUZA40 SOLIFENACIN SUCCINATE68 SYNAREL84 SOLU-CORTEF71 SYNTHAMIN 17 WITHOUT ELTYE62 SOMATROPIN71 SORBITOL SOLUTION88 T SOTALOL HCL49 TACROLIMUS86 SPINOSAD56 TADALAFIL93 SPIRIVA92 TAKE ACTION7 SPIRONOLACTONE51 TALIGLUCERASE ALFA68 SPIRONOLACTONE/HYDROCHLOROTHIAZIDE51 TAMOXIFEN CITRATE30 SPRINTEC79 TAMSULOSIN HCL69

PAGE 118 LAST UPDATED 04/2020 TANDEM PLUS62 TIKOSYN49 TARINA 24 FE79 TILIA FE80 TARINA FE80 TIMOLOL MALEATE91 TARINA FE 1-20 EQ80 TINIDAZOLE16 TARON-C DHA65 TIOPRONIN69 TAYTULLA80 TIOTROPIUM BROMIDE92 TBO-FILGRASTIM45 TIOTROPIUM BROMIDE/OLODATEROL HCL94 TECFIDERA54 TIPRANAVIR/VITAMIN E TPGS39 TEGRETOL24 TIS-U-SOL PENTALYTE62 TEGRETOL XR24 TIVICAY37 TEMAZEPAM95 TIZANIDINE HCL36 TEMIXYS38 TOBRADEX89 TEMODAR29 TOBRAMYCIN93 TEMOZOLOMIDE29 TOBRAMYCIN SULFATE15 TENOFOVIR DISOPROXIL FUMARATE38 TOBRAMYCIN/DEXAMETHASONE89 TERAZOSIN HCL48 TOBRAMYCIN/LOTEPREDNOL ETABONATE89 TERBINAFINE HCL28 TOBRAMYCIN/NEBULIZER93 TERBUTALINE SULFATE92 TOFACITINIB CITRATE86 TERCONAZOLE28 TOPAMAX23 TERIFLUNOMIDE54 TOPIRAMATE23 TESTOSTERONE71 TOPOTECAN HCL32 TESTOSTERONE CYPIONATE72 TORSEMIDE51 TESTOSTERONE ENANTHATE72 TOVIAZ68 TETRABENAZINE54 TPN ELECTROLYTES62 THEO-2493 TPN ELECTROLYTES II62 THEOPHYLLINE ANHYDROUS93 TRACLEER93 THIAMINE HCL65 TRADJENTA43 THIOLA69 TRAMADOL HCL13 THIORIDAZINE HCL34 TRANEXAMIC ACID47 THIOTEPA31 TRANEXAMIC ACID IN SODIUM CHLORIDE,ISO- THIOTHIXENE34 OSMOTIC47 THRIVITE RX65 TRANSDERM-SCOP27 THYROID83 TRAVASOL62 THYROID,PORK83 TRAVATAN Z91 THYROLAR-183 TRAVOPROST91 THYROLAR-1/284 TRAZODONE HCL26 THYROLAR-1/484 TREANDA29 THYROLAR-284 TRETINOIN56 THYROLAR-384 TRETTEN47 TIAGABINE HCL21 TRI FEMYNOR80 TICAGRELOR48 TRI-ESTARYLLA80

PAGE 119 LAST UPDATED 04/2020 TRI-LEGEST FE80 TUMS ULTRA STRENGTH6 TRI-LINYAH80 TUMS X-STR6 TRI-LO-ESTARYLLA80 TUSSIN10 TRI-LO-MARZIA80 TUSSIN CHEST CONGESTION10 TRI-LO-MILI80 TUSSIN DM11 TRI-LO-SPRINTEC80 TUSSIN DM MAX11 TRI-MILI80 TUSSIN HONEY11 TRI-PREVIFEM80 TUSSIN MUCUS-CHEST CONGESTION11 TRI-SPRINTEC80 TYBOST39 TRI-VI-FLOR6 TYDEMY81 TRI-VYLIBRA80 TRI-VYLIBRA LO80 U TRIAMCINOLONE ACETONIDE71 ULIPRISTAL ACETATE81 TRIAMTERENE/HYDROCHLOROTHIAZIDE51 ULTRA STRENGTH ANTACID6 TRICITRATES69 UNITHROID84 TRICON62 UREA56 TRIDERM71 URSODIOL66 TRIFLUOPERAZINE HCL34 UTIBRON NEOHALER94 TRIFLURIDINE40 TRIHEXYPHENIDYL HCL33 V TRILEPTAL24 VACCINE ADJUVANT SYSTEM, AS01B/PF, TRILYTE WITH FLAVOR PACKETS67 COMPONENT VIAL 1 OF 287 TRIMETHOPRIM16 VAGIFEM81 TRINATAL RX 165 VALACYCLOVIR HCL40 TRINTELLIX26 VALBENAZINE TOSYLATE53 TRIPTODUR84 VALGANCICLOVIR HCL36 TRIPTORELIN PAMOATE84 VALPROIC ACID21 TRIUMEQ39 VALRUBICIN31 TRIVEEN-DUO DHA65 VALSTAR31 TRIVORA-2880 VANALICE4 TRIZIVIR38 VANCOMYCIN HCL16 TROGARZO39 VANCOMYCIN IN 0.9 % SODIUM CHLORIDE17 TROKENDI XR23 VANCOMYCIN IN 5 % DEXTROSE IN WATER17 TROPHAMINE62 VAQTA87 TRUST NATAL DHA65 VARENICLINE TARTRATE15 TRUVADA38 VARICELLA-ZOSTER VIRUS GLYCOPROTEIN TULANA83 E,REC,COMPONENT 2 OF 287 TUMS6 VARICELLA-ZOSTER VIRUS GLYCOPROTEIN TUMS FRESHERS6 E,REC/AS01B ADJUVANT/PF87 TUMS SMOOTHIES6 VELIVET81 TUMS ULTRA6 VENLAFAXINE HCL26

PAGE 120 LAST UPDATED 04/2020 VENTAVIS93 VORTIOXETINE HYDROBROMIDE26 VERAPAMIL HCL50 VOSEVI36 VICODIN HP14 VOTRIENT32 VIDEX38 VP-VITE RX65 VIENVA81 VYFEMLA81 VIGABATRIN22 VYLIBRA81 VIGADRONE22 VYVANSE53 VIIBRYD26 VILAZODONE HCL26 W VIMPAT24 WARFARIN SODIUM44 VINBLASTINE SULFATE31 WATER FOR INJECTION,STERILE89 VINCRISTINE SULFATE32 WATER FOR IRRIGATION,STERILE89 VINORELBINE TARTRATE32 WERA81 VIOKACE68 WILATE47 VIORELE81 WYMZYA FE81 VIRACEPT40 VIRAMUNE38 X VIREAD38 XARELTO44 VIRT-C DHA65 XELJANZ86 VIRT-FEFA PLUS65 XELODA30 VIRT-PHOS 250 NEUTRAL69 XTAMPZA ER13 VIRTRATE-369 XTANDI30 VIRTRATE-K69 XULANE81 VIT B COMPLEX NO.3/FOLIC ACID/ASCORBIC XYNTHA47 ACID/BIOTIN/ZINC OXID64 XYNTHA SOLOFUSE47 VIT B COMPLEX NO.4/VIT D3/ASCORBIC ACID/FOLIC ACID/ZINC OXID65 Y VITAFOL GUMMIES65 YASMIN 2881 VITAFOL ULTRA65 YAZ81 VITAFOL-OB65 VITAFOL-OB+DHA65 Z VITAFOL-ONE65 ZALEPLON95 VITAL-D RX65 ZARAH81 VITAMIN B COMPLEX NO.11/FOLIC ACID/VIT ZARONTIN20 C/BIOTIN/ZINC OXIDE63 ZAVESCA68 VITAMIN B COMPLEX NO.3/FOLIC ACID/ASCORBIC ZEMAIRA68 ACID(VITC)/BIOTIN65 ZENATANE56 VIVITROL14 ZENPEP68 VOLNEA81 ZIAGEN39 VON WILLEBRAND FACTOR (RECOMBINANT)47 ZIDOVUDINE39 VONVENDI47 ZINC CHLORIDE62

PAGE 121 LAST UPDATED 04/2020 ZINC SULFATE62 ZINC SULFATE/COPPER SULFATE/MANGANESE/CHROMIUM/SELENIUM60 ZINC SULFATE/CUPRIC SULFATE/MANGANESE SULF/CHROMIC CHLORIDE60 ZIPRASIDONE HCL35 ZOLADEX32 ZOLEDRONIC ACID IN MANNITOL AND WATER FOR INJECTION88 ZOLPIDEM TARTRATE95 ZONISAMIDE20 ZOVIA 1-35E81 ZOVIRAX40 ZTLIDO14 ZUBSOLV15 ZUMANDIMINE81 ZYLET89 ZYTIGA30

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