Preferred Drug List

The SilverSummit Healthplan Formulary includes a list of drugs covered by your prescription benefit. The formulary is updated often and may change. To get the most up-to-date information, you may view the latest formulary on our website at silversummithealthplan.com or call us at 1-844-366-2880 (TTY/TDD: 1-844-804-6086).

Preferred Drug List Medication Locator Instructions: 1. With the PDF open, click on the Edit menu, then click Find 2. In the Find box type the name of the medication you want to locate 3. Click the Next button until you find the medication(s) you are looking for SilverSummit Healthplan Pharmacy Program SilverSummit Healthplan, Inc. (SilverSummit) is committed to providing appropriate, high quality, and cost effective drug therapy to all SilverSummit members. SilverSummit works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. SilverSummit covers prescription medications and certain over- the-counter (OTC) medications when ordered by a physician/clinician. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. This section provides an overview of the SilverSummit pharmacy program. For more detailed information, please visit our website at www.silversummithealthplan.com.

Plan Preferred Drug List and Prior Authorization List The SilverSummit Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the program. All drugs covered under the Nevada Medicaid program are available for SilverSummit members. The PDL includes all drugs available without PA and those agents that have the restrictions of Step Therapy (ST). The PA list includes those drugs that require PA for coverage. The PDL applies to drugs you receive at retail pharmacies. The PDL is continually evaluated by the SilverSummit Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the SilverSummit Medical Director, SilverSummit Pharmacy Director, and several Nevada primary care physicians, pharmacists, and specialists. The PDL does not: Require or prohibit the prescribing or dispensing of any medication Substitute for the independent professional judgment of the physician/clinician or pharmacist, or Relieve the physician/clinician or pharmacist of any obligation to the patient or others

Envolve Pharmacy Solutions With the exceptions of biopharmaceuticals and specialty drugs, SilverSummit works with Envolve Pharmacy Solutions to process all pharmacy claims for prescribed drugs. Some drugs on the SilverSummit PDL and PA list require a PA and Envolve Pharmacy Solutions is responsible for administering this process. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager. Follow these guidelines for efficient processing of your authorization requests: 1. Complete the SilverSummit Healthplan/Envolve Pharmacy Solutions form: Medication Prior Authorization Request Form. 2. Fax to Envolve Pharmacy Solutions at 1-866-399-0929. 3. Once approved, Envolve Pharmacy Solutions notifies the prescriber by fax. 4. If the clinical information provided does not explain the medical necessity for the requested PA medication, Envolve Pharmacy Solutions will deny the request and offer PDL alternatives to the prescriber by fax. 5. For urgent or after-hours requests, a pharmacy can provide up to a 96-hour emergency supply of medication by calling 1-844-214-2606. Prior Authorization Process The SilverSummit PDL includes a broad spectrum of brand name and generic drugs. Clinicians are encouraged to prescribe from the SilverSummit PDL for their patients who are members of SilverSummit. Some drugs will require PA and are listed on the PA list. In addition, all name brand drugs not listed on either the PDL or PA list will require prior authorization. If a request for authorization is needed the information should be submitted by your physician/clinician to Envolve Pharmacy Solutions on the SilverSummit Healthplan/Envolve Pharmacy Solutions form: Medication Prior Authorization Request Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document is located on the SilverSummit website at www.silversummithealthplan.com. SilverSummit will cover the medication if it is determined that: 1. There is a medical reason you need the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. All reviews are performed by a licensed clinical pharmacist using the criteria established by the SilverSummit P&T Committee. Once approved, Envolve Pharmacy Solutions notifies the physician/clinician by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, SilverSummit will notify you and your physician/clinician of alternatives and provide information, regarding the appeal process. The P&T committee has reviewed and approved, with input from its members and in consideration of medical evidence, the list of drugs requiring prior authorization. This PDL attempts to provide appropriate and cost-effective drug therapy to all members covered under the SilverSummit pharmacy program. If a patient requires a brand name medication that does not appear on the PDL, the physician/clinician can make a PA request for the brand name medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the SilverSummit pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA, the pharmacist should attempt to contact the clinician to request a change to a product included on the PDL.

Phone Numbers for SilverSummit Healthplan Member Services The phone and fax lines listed in the Prior Authorization Process section are dedicated to clinicians requesting PA medication items only. Members cannot be assisted if they call the PA toll-free number. SilverSummit Member Services may be reached at 1-844-366-2880 (TTY 1-844-804-6086). Transition Period SilverSummit members new to managed care will be able to receive their prescription drugs with no new PA requirements for 2 fills not to exceed 68 total day’s supply in the first 90 days of eligibility.. Please note, the timeframe for PA requirements on controlled medications may be shorter than 90 days. This will allow you and your doctor time to consider other medications that do not require PA and to learn the proper steps for obtaining a PA. SilverSummit’s PDL and PA List identify the drugs that will require PA once you have been a managed care member for 90 days. If you are not sure when you will need to have your medications prior authorized or you have other questions about continuing to get your medications, call member services at 1-844-366-2880(TTY1- 844-804-6086).

96- Hour Emergency Supply Policy State and federal law requires that a pharmacy dispense a 96-hour (4-day) supply of medication to any patient awaiting a PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 96-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 96-hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call the Envolve Pharmacy Solutions Pharmacy Help Desk at 1-844-214-2606 for a prescription override to submit the 96-hour medication supply for payment.

Step Therapy Some medications listed on the SilverSummit PDL may require specific medications to be used before you can receive the step therapy medication. If SilverSummit has a record that the required medication was tried first the ST medications are automatically covered. If SilverSummit does not have a record that the required medication was tried, you or your physician/clinician may be required to provide additional information. If SilverSummit does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process.

Dispensing Limits, Quantity Limits, and Age Limits Drugs may be dispensed up to a maximum 34 day supply for each new or refill non-controlled substance. A total of 80 percent (80%) of the days supplied must have elapsed before the prescription can be refilled. Dispensing outside the quantity limit (QL) or age limits (AL) requires PA. SilverSummit may limit how much of a medication you can get at one time. If the physician/clinician feels you have a medical reason for getting a larger amount, he or she can ask for PA. If SilverSummit does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process. Some medications on the SilverSummit PDL may have AL. These are set for certain drugs based on Food and Drug Administration (FDA) approved labeling, for safety concerns and quality standards of care. The AL aligns with current FDA alerts for the appropriate use of pharmaceuticals. Medical Necessity Requests If you require a medication that does not appear on the PDL, you or your physician/clinician can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. SilverSummit requires: Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. All reviews are performed by a licensed clinical pharmacist using the criteria established by the SilverSummit P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication, SilverSummit will notify you and your physician/clinician of alternatives and provide information regarding the appeal process.

Appropriate Use and Safety Edits Your health and safety is a priority for SilverSummit. One of the ways we address your safety is through Point-of-Sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

DUR (Drug Utilization Review) Programs SilverSummit will monitor ongoing prescribing of medications for clinical appropriateness. SilverSummit reviews prescribing retrospectively to review for both safety and efficacy. SilverSummit will work with Envolve Pharmacy Solutions to review for such things as disease management, fraud and abuse (i.e. Coordinated Services Program), and prescriber profiling. Prescriber or member outreach may occur based on prescribing/dispensing patterns. SilverSummit will continue to monitor for issues going forward and take action as needed. Mandatory Generic Substitution When generic drugs are available, the brand name drug will not be covered without SilverSummit PA. Generic drugs have the same active ingredient and work the same as brand name drugs. If you or your physician/clinician feels a brand name drug is medically necessary, the physician/clinician can ask for PA.

We will cover the brand name drug according to our clinical guidelines if there is a medical reason you need the particular brand name drug. If SilverSummit does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process.

Over-The-Counter Medications The pharmacy program covers a large selection of OTC medications. All covered OTC medications appear in the PDL. All OTC medications must be written on a valid prescription by a licensed physician/clinician in order to be reimbursed.

Filling a Prescription You can have prescriptions filled at a SilverSummit network pharmacy. If you decide to have a prescription filled at a network pharmacy you can locate a pharmacy near you by contacting a SilverSummit Member Services Representative. At the pharmacy, you will need to provide the pharmacist with your prescription and your SilverSummit ID card. Please visit the SilverSummit website at www.silversummithealthplan.com to access the SilverSummit PDL, SilverSummit PA lists, important forms, and provider/member information 24 hours a day, seven days a week.

Maintenance Medications SilverSummit Healthplan offers up to 100 day supply of maintenance medications. These drugs are used to treat long-term conditions or illnesses. Please contact a SilverSummit Member Service Representative if you have any questions.

SilverSummit Healthplan Pharmacy Program - Additional Information

Working with Our Pharmacy Benefit Managers SilverSummit works with two Pharmacy Benefit Managers (PBMs). Acaria Health is the preferred provider of biopharmaceuticals and injectables for SilverSummit. Envolve Pharmacy Solutions administers all other prescribed drugs. Certain drugs require PA to be approved for payment by SilverSummit. These include: Some SilverSummit drugs listed on the PA list Most injectables including Procrit, Neulasta and Neupogen.

AcariaHealth – Biopharmaceuticals and Injectables AcariaHealth is the provider of biopharmaceuticals and injectables for SilverSummit. Most injectables require PA to be approved for payment. Our Medical Director oversees the clinical review. SilverSummit provides a number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals and injectables require a PA to be approved for payment by SilverSummit; however, PA requirements are programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program document located on the SilverSummit website at www.silversummithealthplan.com. Follow these guidelines for the most efficient processing of your authorization requests. Providers can request that AcariaHealth deliver the specialty drug to the office/member. If you want AcariaHealth to deliver the specialty drug to the office/member: 1. Fax the AcariaHealth PA form to 1-855-217-0926 for PA. 2. If approved, AcariaHealth will contact the provider or member for delivery confirmation.

Pharmacy and Therapeutics Committee The SilverSummit Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic classes included in the PDL. The Committee is composed of the SilverSummit Medical Director, SilverSummit Pharmacy Director, and several community based primary care physicians and specialists. The primary purpose of the Committee is to assist in developing and monitoring the SilverSummit PDL and to establish programs and procedures that promote the appropriate and cost-effective use of medications. The P&T Committee schedules meetings at least quarterly and coordinates reviews with a national P&T Committee which meets at least 4 times a year. Changes to the SilverSummit PDL are done in conjunction with the approval of the State of Nevada. SilverSummit will meet with the State quarterly to review any proposed changes and update the PDL and PA lists accordingly based on the results of both the SilverSummit P&T Committee and the requirements from the State of Nevada. SilverSummit will follow all State policies regarding member notification when changes are made to the PA list. Unapproved Use of Preferred Medication Medication coverage under this program is limited to non-experimental indications as approved by the FDA. Other indications may also be covered if they are accepted as safe and effective using current medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for specific non-approved indications will be made by SilverSummit. Experimental drugs and investigational drugs are not eligible for coverage.

Benefit Exclusions The following drug categories are not part of the SilverSummit PDL and are not covered by the 96-hour emergency supplypolicy: - Fertility enhancing drugs - Anorexia, weight loss, or weight gain drugs - Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective

- Drugs and other agents used for cosmetic purposes or for hair growth - Erectile dysfunction drugs prescribed to treat impotence - Bulk powders, because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established.

Newly Approved Products We review new drugs for safety and effectiveness for the first 12 months before adding them to the SilverSummit PDL. During this period, access to these medications will be considered through the PA review process. If SilverSummit does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process.

Medical Benefits The following drugs and medical services are a part of the SilverSummit medical benefit and are not available at the retail pharmacy: 1. Botox is a medical benefit that is covered for non-cosmetic purposes only, it requires a PA from SilverSummit. 2. Blood and blood products. 3. Those specialty injectable drugs available as a medical benefit. Most injectables require PA from SilverSummit.

Prescribers who request medical prior authorizations at Envolve Pharmacy Solutions will be redirected to contact SilverSummit Healthplan as applicable.

DME/Home Health Benefits The following medical services are a part of the SilverSummit medical benefit and are not available at the retail pharmacy: 1. Enteral products 2. Nebulizers 3. Medical supplies

Injectable Drugs Injections that are self-administered by the member and/or a family member and appear on the PDL are covered by the SilverSummit pharmacy program. Insulin vials, Glucagon Kit, Epinephrine, Imitrex, and Depo-Provera IM are covered by SilverSummit and do not require a PA.. All other injectables require PA.

We help keep you informed The SilverSummit Pharmacy Director, a registered pharmacist, compiles current pharmacological policy and information about important seasonal topics such as Respiratory Syncytial Virus (RSV) and influenza. The information is consistent with published guidelines and is mailed to network providers as a service. The most current SilverSummit PDL and PA List can be downloaded from our website at www.silversummithealthplan.com.

Contacts for Pharmacy Appeals/Grievances Members: In the event that a member disagrees with the decision regarding coverage of a medication, the member may file an appeal with SilverSummit by calling SilverSummit Member Services at 1-844-366-2880 (TTY 1-844-804-6086). Physicians / Clinicians: In the event that a clinician disagrees with the decision regarding coverage of a medication, the clinician may request an appeal by submitting additional information to SilverSummit in writing to the Appeals Department at the following address:

SilverSummit Healthplan AppealDepartment 2500 North Buffalo Drive Las Vegas, NV 89128 Fax:1- 855-742-0125

A decision will be rendered and the clinician will be notified with a mailed response. An expedited appeal may be requested at any time ifthe provider believes the adverse determination might seriously jeopardize the life or health of a member by calling SilverSummit Healthplan at 1-844- 366-2880 ext. 24084 (TTY 1-844-804-6086). A response will be rendered the same day as receipt of complete information. In circumstances that require research, a same day response may not be possible.

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

AL: Age Limit PA: Prior Authorization QL: Quantity Limit ST: Step Therapy SP: Specialty Drugs*

*Specialty Drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia and may be limited to a specific pharmacy.

Drug Tier Definitions

F: Formulary These drugs are covered on the drug list NF: Non-Formulary These drugs are not covered on the drug list Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea ADHD/ANTI-NARCOLEPSY/ANTI- VYVANSE CAPS F OBESITY/ANOREXIANTS - Drugs to Treat daily) ADHD, Sleep and Eating Disorders Analeptics Amphetamines caffeine citrate soln or 20 F QL(45 ml per ADDERALL TABS (Use QL(2 ea daily); mg/ml, 60 mg/3ml fill retail) Amphetamine- NF AL(At least 3 Attention-Deficit/Hyperactivity Disorder (ADHD) Dextroamphetamine) yrs old) ST; AL(At least atomoxetine hcl caps F ADDERALL XR CP24 (Use QL(1 ea daily); 6 yrs old) Amphetamine- NF AL(At least 6 Dextroamphetamine) yrs old) guanfacine hcl (adhd) tb24 F QL(1 ea daily) amphetamine- QL(1 ea daily); INTUNIV TB24 (Use NF QL(1 ea daily) dextroamphetamine cp24 AL(At least 6 Guanfacine HCl (ADHD)) 5mg-5mg-5mg-5mg, yrs old) 2.5mg-2.5mg-2.5mg- STRATTERA CAPS (Use NF ST; AL(At least Atomoxetine HCl) 6 yrs old) 2.5mg, 7.5mg-7.5mg- F 7.5mg-7.5mg, 1.25mg- Stimulants - Misc. 1.25mg-1.25mg-1.25mg, PA 3.75mg-3.75mg-3.75mg- armodafinil tabs F 3.75mg, 6.25mg-6.25mg- CONCERTA TBCR 18 MG, QL(1 ea daily); 6.25mg-6.25mg 27 MG, 54 MG (Use NF AL(At least 6 amphetamine- QL(2 ea daily); Methylphenidate HCl) yrs old) dextroamphetamine tabs AL(At least 3 QL(2 ea daily); 5mg-5mg-5mg-5mg, yrs old) CONCERTA TBCR 36 MG NF AL(At least 6 (Use Methylphenidate HCl) 2.5mg-2.5mg-2.5mg- yrs old) 2.5mg, 7.5mg-7.5mg- 7.5mg-7.5mg, 1.25mg- dexmethylphenidate hcl F QL(2 ea daily) 1.25mg-1.25mg-1.25mg, F tabs 5 mg, 10 mg, 2.5 mg 3.75mg-3.75mg-3.75mg- FOCALIN TABS (Use NF QL(2 ea daily) 3.75mg, 1.875mg- Dexmethylphenidate HCl) 1.875mg-1.875mg- QL(1 ea daily); 1.875mg, 3.125mg- METADATE CD CPCR NF AL(At least 6 (Use Methylphenidate HCl) 3.125mg-3.125mg- yrs old) 3.125mg methylphenidate hcl cpcr QL(1 ea daily); DEXEDRINE CP24 10 MG, QL(2 ea daily); 10 mg, 20 mg, 30 mg, 40 F AL(At least 6 15 MG (Use NF AL(At least 6 mg, 50 mg, 60 mg yrs old) Dextroamphetamine yrs old) Sulfate) QL(1 ea daily); METHYLPHENIDATE HCL F ER TBCR AL(At least 6 DEXEDRINE CP24 5 MG QL(1 ea daily); yrs old) (Use Dextroamphetamine NF AL(At least 6 Sulfate) yrs old) QL(3 ea daily); methylphenidate hcl tabs F AL(At least 3 10 mg, 20 mg QL(2 ea daily); yrs old) dextroamphetamine sulfate F AL(At least 6 cp24 10 mg, 15 mg yrs old) QL(6 ea daily); methylphenidate hcl tabs 5 F AL(At least 3 mg QL(1 ea daily); yrs old) dextroamphetamine sulfate F AL(At least 6 cp24 5 mg yrs old) QL(2 ea daily); methylphenidate hcl tbcr 10 F AL(At least 6 mg, 36 mg QL(3 ea daily); yrs old) dextroamphetamine sulfate F AL(At least 3 tabs 5 mg, 10 mg yrs old) NV Silver Summit Updated September 1, 2018

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); methylphenidate hcl tbcr 18 F PA; QL(1 ml F AL(At least 6 BETHKIS NEBU daily); SP mg, 20 mg, 27 mg, 54 mg yrs old) PA; QL(1 ml KITABIS PAK NEBU F NUVIGIL TABS (Use NF PA daily); SP Armodafinil) neomycin sulfate tabs F RITALIN TABS 10 MG, 20 QL(3 ea daily); MG (Use Methylphenidate NF AL(At least 3 TOBI NEBU (Use NF PA; QL(1 ml HCl) yrs old) Tobramycin) daily); SP QL(6 ea daily); PA; QL(2 ea RITALIN TABS 5 MG (Use NF TOBI PODHALER CAPS F Methylphenidate HCl) AL(At least 3 daily); SP yrs old) PA; QL(1 ml TOBRAMYCIN NEBU F ALLERGENIC EXTRACTS/BIOLOGICALS MISC daily); SP PA; QL(1 ml tobramycin nebu F Allergenic Extracts daily); SP QL(1 ea daily); TOBRAMYCIN SULFATE GRASTEK SUBL 2800 F AL(At least 5 SOLN 10 MG/ML, 40 F BAU yrs old - Up to MG/ML 65 yrs old) tobramycin sulfate soln 40 QL(1 ea daily); mg/ml, 80 mg/2ml, 1.2 F ORALAIR ADULT SAMPLE F AL(At least 10 gm/30ml KIT SUBL yrs old - Up to tobramycin sulfate solr 1.2 F 65 yrs old) gm QL(1 ea daily); ANALGESICS - ANTI-INFLAMMATORY - Drugs ORALAIR ADULT F AL(At least 10 STARTER PACK SUBL yrs old - Up to to Treat Pain, Swelling, Muscle and Joint 65 yrs old) Conditions QL(3 ea daily); Anti-TNF-alpha - Monoclonal Antibodies ORALAIR F AL(At least 10 HUMIRA PEDIATRIC PA; SP CHILDREN/ADOLESCENT yrs old - Up to S STARTER PACK SUBL CROHNS DISEASE F 65 yrs old) STARTER PACK PSKT 40 QL(1 ea daily); MG/0.8ML AL(At least 10 ORALAIR SUBL F HUMIRA PEN PNKT 40 F PA; SP yrs old - Up to MG/0.8ML 65 yrs old) HUMIRA PEN-CD/UC/HS PA; SP QL(1 ea daily); STARTER PNKT 40 F RAGWITEK SUBL 12 AMB F AL(At least 18 MG/0.8ML A 1-U yrs old - Up to HUMIRA PEN-PS/UV F PA; SP 65 yrs old) STARTER PNKT ALTERNATIVE MEDICINES HUMIRA PSKT 10 PA; SP MG/0.2ML, 20 MG/0.4ML, F Alternative Medicine - M's 40 MG/0.8ML melatonin tabs or 3 mg, 5 F QL(1 ea daily) Antirheumatic Antimetabolites mg OTREXUP SOAJ F SP AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections RASUVO SOAJ F SP Aminoglycosides

NV Silver Summit Updated September 1, 2018

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RHEUMATREX TABS F flurbiprofen tabs F

Interleukin-1 Receptor Antagonist (IL-1Ra) ibuprofen chew 100 mg F KINERET SOSY F PA; SP ibuprofen susp 100 mg/5ml F RX/OTC Nonsteroidal Anti-inflammatory Agents (NSAIDs) ibuprofen susp 40 mg/ml, F ADVIL TABS (Use NF 50 mg/1.25ml Ibuprofen) ibuprofen tabs 200 mg, 400 F ALEVE ARTHRITIS TABS NF QL(2 ea daily) mg, 600 mg, 800 mg (Use Naproxen Sodium) indomethacin caps F ALEVE TABS (Use NF QL(2 ea daily) Naproxen Sodium) indomethacin cpcr F ANAPROX DS TABS (Use NF Naproxen Sodium) INFANTS ADVIL SUSP NF (Use Ibuprofen) CELEBREX CAPS 400 MG NF PA; QL(2 ea (Use Celecoxib) daily) KETOPROFEN CAPS 50 F CELEBREX CAPS 50 MG, PA; QL(1 ea MG, 75 MG 100 MG, 200 MG (Use NF daily) ketoprofen caps 50 mg, 75 F Celecoxib) mg PA; QL(2 ea celecoxib caps 400 mg F KETOPROFEN ER CP24 F daily) QL(20 ea per celecoxib caps 50 mg, 100 F PA; QL(1 ea mg, 200 mg daily) ketorolac tromethamine F 30 days retail); tabs or 10 mg AL(At least 17 CHILDRENS ADVIL SUSP NF RX/OTC (Use Ibuprofen) yrs old) LODINE TABS (Use CHILDRENS MOTRIN NF RX/OTC NF SUSP (Use Ibuprofen) Etodolac) meloxicam tabs F DAYPRO TABS (Use NF Oxaprozin) MOBIC TABS (Use NF diclofenac potassium tabs F Meloxicam) 50 mg MOTRIN INFANTS diclofenac sodium tb24 or F DROPS SUSP (Use NF 100 mg Ibuprofen) diclofenac sodium tbec or F 25 mg, 50 mg, 75 mg nabumetone tabs F EC-NAPROSYN TBEC QL(2 ea daily) NF NAPROSYN SUSP (Use NF (Use Naproxen) Naproxen) etodolac caps F NAPROSYN TABS (Use NF Naproxen) etodolac tabs F naproxen sodium tabs 220 F QL(2 ea daily) mg etodolac tb24 F naproxen sodium tabs 275 F mg, 550 mg FELDENE CAPS (Use NF Piroxicam) naproxen susp 125 mg/5ml F

NV Silver Summit Updated September 1, 2018

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits naproxen tabs 250 mg, 375 F acetaminophen chew or 80 F mg, 500 mg mg, 160 mg naproxen tbec 375 mg, 500 F QL(2 ea daily) acetaminophen liqd or 160 F mg mg/5ml oxaprozin tabs 600 mg F acetaminophen soln or 160 mg/5ml, 650 mg/20.3ml, F piroxicam caps F 325 mg/10.15ml acetaminophen supp re F QL(12 ea per sulindac tabs F 120 mg, 325 mg, 650 mg fill retail) acetaminophen susp or TOLMETIN SODIUM F 160 mg/5ml, 80 mg/0.8ml, F CAPS 400 MG 80 mg/2.5ml tolmetin sodium caps 400 F acetaminophen tabs or 325 F mg mg, 500 mg TOLMETIN SODIUM TABS F FEVERALL INFANTS F 200 MG, 600 MG SUPP Soluble Tumor Necrosis Factor Receptor Agents NORTEMP INFANTS F SUSP ENBREL SOLR F PA; SP TYLENOL CHILDRENS ENBREL SOSY F PA; SP CHEWABLES/PAIN + NF FEVER CHEW (Use Acetaminophen) ENBREL SURECLICK F PA; SP SOAJ TYLENOL CHILDRENS ANALGESICS - NonNarcotic - Drugs to Treat SUSP (Use NF Pain, Muscle and Joint Conditions Acetaminophen) TYLENOL EXTRA Analgesic Combinations STRENGTH TABS (Use NF butalbital-acetaminophen F Acetaminophen) tabs 325mg-50mg TYLENOL INFANTS butalbital-acetaminophen- QL(4 ea daily) PAIN+FEVER SUSP (Use NF caffeine caps 325mg- F Acetaminophen) 50mg-40mg TYLENOL INFANTS SUSP NF butalbital-acetaminophen- QL(4 ea daily) (Use Acetaminophen) caffeine tabs 325mg-50mg- F TYLENOL TABS (Use NF 40mg Acetaminophen) butalbital-aspirin-caffeine F QL(4 ea daily) caps 50mg-40mg-325mg Salicylates ESGIC TABS (Use QL(4 ea daily) aspirin buffered (cal carb- F Butalbital-Acetaminophen- NF mag carb-mag oxide) tabs Caffeine) aspirin chew or 81 mg F FIORINAL CAPS (Use NF QL(4 ea daily) Butalbital-Aspirin-Caffeine) ASPIRIN SUPP RE 120 QL(12 ea per MG, 200 MG, 300 MG, 600 F fill retail) TENCON TABS 325MG- F MG 50MG aspirin supp re 300 mg, F QL(12 ea per Analgesics Other 600 mg fill retail) acetaminophen caps or F 500 mg aspirin tabs or 325 mg F NV Silver Summit Updated September 1, 2018

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits aspirin tbec or 81 mg, 324 F hydromorphone hcl tabs or F QL(8 ea daily) mg, 325 mg 2 mg, 4 mg, 8 mg BUFFERIN TABS (Use HYSINGLA ER T24A F Aspirin Buffered (Cal Carb- NF Mag Carb-Mag Oxide)) MEPERIDINE HCL SOLN F QL(500 ml per OR 50 MG/5ML fill retail) choline & mag salicylate F liqd meperidine hcl tabs or 50 F QL(6 ea daily) mg, 100 mg diflunisal tabs F methadone hcl tabs or 10 F QL(10 ea daily) DISALCID TABS (Use NF mg Salsalate) methadone hcl tabs or 5 F QL(4 ea daily) ECOTRIN REGULAR mg STRENGTH TBEC (Use NF morphine sulfate soln or 10 F QL(16.67 ml Aspirin) mg/5ml, 20 mg/5ml daily) salsalate tabs F morphine sulfate soln or 20 F QL(240 ml per mg/ml, 100 mg/5ml fill retail) ANALGESICS - OPIOID - Drugs to Treat Pain, MORPHINE SULFATE QL(24 ea per Muscle and Joint Conditions SUPP RE 5 MG, 10 MG, F fill retail) Opioid Agonists 20 MG, 30 MG QL(2 ea daily); MORPHINE SULFATE F QL(6 ea daily) codeine sulfate tabs 15 mg, F AL(At least 12 TABS OR 15 MG, 30 MG 30 mg, 60 mg yrs old) morphine sulfate tbcr or 15 QL(3 ea daily) CODEINE SULFATE TABS QL(2 ea daily); mg, 30 mg, 60 mg, 100 mg, F 15 MG, 30 MG, 60 MG NF AL(At least 12 200 mg (Use Codeine Sulfate) yrs old) MS CONTIN TBCR (Use NF QL(3 ea daily) Morphine Sulfate) DEMEROL TABS OR 100 NF QL(6 ea daily) MG (Use Meperidine HCl) oxycodone hcl caps 5 mg F QL(6 ea daily) DILAUDID TABS OR 2 QL(8 ea daily) MG, 4 MG, 8 MG (Use NF oxycodone hcl conc 100 F QL(6 ml daily) Hydromorphone HCl) mg/5ml oxycodone hcl soln 5 DOLOPHINE TABS 10 MG NF QL(10 ea daily) F (Use Methadone HCl) mg/5ml oxycodone hcl tabs 5 mg, QL(6 ea daily) DOLOPHINE TABS 5 MG NF QL(4 ea daily) (Use Methadone HCl) 10 mg, 15 mg, 20 mg, 30 F Limit 10 mg ROXICODONE TABS (Use QL(6 ea daily) DURAGESIC PT72 (Use NF patches per NF Fentanyl) month;QL(0.34 Oxycodone HCl) ea daily) QL(8 ea daily); tramadol hcl tabs 50 mg F AL(At least 18 EMBEDA CPCR F yrs old) Limit 10 ULTRAM TABS ( QL(8 ea daily); fentanyl pt72 12 mcg/hr, 25 Use NF AL(At least 18 F patches per Tramadol HCl) mcg/hr, 50 mcg/hr, 75 month;QL(0.34 yrs old) mcg/hr, 100 mcg/hr ea daily) Opioid Combinations HYDROMORPHONE HCL F QL(12 ea per SUPP RE 3 MG fill retail)

NV Silver Summit Updated September 1, 2018

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(30 ml PERCOCET TABS 5MG- QL(6 ea daily) acetaminophen w/ codeine F daily); AL(At 325MG, 10MG-325MG, soln 120mg/5ml-12mg/5ml least 12 yrs 7.5MG-325MG (Use NF old) Oxycodone w/ acetaminophen w/ codeine QL(6 ea daily); Acetaminophen) F AL(At least 12 QL(4 ea daily); tabs 300mg-15mg, 300mg- tramadol-acetaminophen 30mg, 300mg-60mg yrs old) F AL(At least 18 tabs 37.5mg-325mg butalbital-acetaminophen- QL(4 ea daily); yrs old) caffeine w/ codeine caps F AL(At least 12 TYLENOL/CODEINE #3 QL(6 ea daily); 325mg-50mg-40mg-30mg yrs old) TABS (Use Acetaminophen NF AL(At least 12 butalbital-aspirin-caffeine QL(4 ea daily); w/ Codeine) yrs old) w/cod caps 50mg-40mg- F AL(At least 12 TYLENOL/CODEINE #4 QL(6 ea daily); 30mg-325mg yrs old) TABS (Use Acetaminophen NF AL(At least 12 FIORINAL/CODEINE #3 QL(4 ea daily); w/ Codeine) yrs old) CAPS (Use Butalbital- NF AL(At least 12 QL(4 ea daily); ) ULTRACET TABS (Use NF Aspirin-Caffeine w/Cod yrs old) Tramadol-Acetaminophen) AL(At least 18 hydrocodone- QL(180 ml yrs old) acetaminophen soln daily) Opioid Partial Agonists 2.5mg/5ml-108mg/5ml, F buprenorphine hcl subl sl 2 F PA 5mg/10ml-217mg/10ml, mg, 8 mg 7.5mg/15ml-325mg/15ml buprenorphine hcl- PA hydrocodone- QL(6 ea daily) F acetaminophen tabs 10mg- F naloxone hcl dihydrate film 325mg buprenorphine hcl- F PA naloxone hcl dihydrate subl hydrocodone- QL(12 ea daily) acetaminophen tabs 5mg- F SUBOXONE FILM F PA 325mg hydrocodone- QL(8 ea daily) ANDROGENS-ANABOLIC - Drugs to Regulate acetaminophen tabs F Hormones 7.5mg-325mg Androgens NORCO TABS 10MG- QL(6 ea daily) QL(1 ea daily) 325MG (Use Hydrocodone- NF ANDRODERM PT24 F Acetaminophen) NORCO TABS 5MG- QL(12 ea daily) ANDROXY TABS F 325MG (Use Hydrocodone- NF DEPO-TESTOSTERONE Limit 4mls per Acetaminophen) SOLN 200 MG/ML (Use NF month;QL(0.14 NORCO TABS 7.5MG- QL(8 ea daily) Testosterone Cypionate) 29 ml daily) 325MG (Use Hydrocodone- NF Acetaminophen) METHITEST TABS 10 MG F oxycodone w/ QL(6 ea daily) Limit 4mls per acetaminophen tabs 5mg- testosterone cypionate soln F month;QL(0.14 F 200 mg/ml 325mg, 10mg-325mg, 29 ml daily) 7.5mg-325mg ANORECTAL AGENTS - Rectal Drugs to Treat oxycodone-aspirin tabs F QL(6 ea daily) Pain, Swelling and Itching Intrarectal Steroids OXYCODONE/ACETAMIN F QL(30 ml daily) OPHEN SOLN

NV Silver Summit Updated September 1, 2018

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORTENEMA ENEM (Use QL(420 ml per alum & mag hydrox- Hydrocortisone NF fill retail) simethicone susp (Intrarectal)) 400mg/5ml-40mg/5ml- 400mg/5ml, 400mg/5ml- F hydrocortisone (intrarectal) F QL(420 ml per enem 100 mg/60ml fill retail) 400mg/5ml-40mg/5ml- 40mg/5ml-400mg/5ml- Rectal Combinations 400mg/5ml phenylephrine-shark liver F QL(12 ea per GELUSIL CHEW 200MG- oil-cocoa butter supp fill retail) 25MG-200MG (Use Alum & NF phenylephrine-shark liver QL(30 gm per Mag Hydrox-Simethicone) oil-mineral oil-petrolatum F fill retail) HYVEE ADVANCED oint ANTACID MAXIMUM Rectal Local Anesthetics STRENGTH SUSP (Use NF Alum & Mag Hydrox- pramoxine hcl (rectal) foam F QL(15 gm per Simethicone) 1 % fill retail) PROCTOFOAM FOAM QL(15 gm per Antacids - Aluminum Salts (Use Pramoxine HCl NF fill retail) ALUMINUM HYDROXIDE F (Rectal)) SUSP OR Rectal Steroids Antacids - Bicarbonate ANUSOL-HC CREA (Use QL(30 gm per Limit 496 per NF sodium bicarbonate F month;QL(16.5 Hydrocortisone (Rectal)) fill retail) (antacid) tabs 4 ea daily) hydrocortisone (rectal) crea F QL(30 gm per 2.5 % fill retail) Antacids - Calcium Salts ANTACIDS calcium carbonate (antacid) chew 500 mg, 750 mg, F Antacid Combinations 1000 mg alum & mag hydrox- TUMS CHEW (Use simethicone chew 200mg- F Calcium Carbonate NF 25mg-200mg (Antacid)) alum & mag hydrox- QL(24 ml daily) TUMS CHEWY BITES CHEW (Use Calcium NF simethicone liqd F 200mg/5ml-20mg/5ml- Carbonate (Antacid)) 200mg/5ml TUMS E-X 750 CHEW alum & mag hydrox- (Use Calcium Carbonate NF (Antacid)) simethicone liqd F 400mg/5ml-40mg/5ml- TUMS EXTRA STRENGTH 400mg/5ml 750 CHEW (Use Calcium NF alum & mag hydrox- QL(24 ml daily) Carbonate (Antacid)) simethicone susp TUMS KIDS CHEW (Use 200mg/5ml-20mg/5ml- Calcium Carbonate NF 200mg/5ml, 200mg/5ml- F (Antacid)) 200mg/5ml-20mg/5ml- TUMS LASTING EFFECTS 20mg/5ml-200mg/5ml- CHEW (Use Calcium NF 200mg/5ml Carbonate (Antacid)) TUMS SMOOTHIES CHEW (Use Calcium NF Carbonate (Antacid))

NV Silver Summit Updated September 1, 2018

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUMS ULTRA 1000 CHEW Leprostatics (Use Calcium Carbonate NF (Antacid)) dapsone tabs F Antacids - Magnesium Salts Lincosamides magnesium oxide tabs 400 F CLEOCIN CAPS OR 150 mg MG, 300 MG (Use NF ANTI-INFECTIVE AGENTS - MISC. - Drugs to Clindamycin HCl) Treat Bacterial Infections CLEOCIN PEDIATRIC Limit 1 package Anti-infective Agents - Misc. GRANULES SOLR (Use NF per Clindamycin Palmitate claim;QL(100 FIRVANQ SOLR F QL(300 ml per Hydrochloride) ml per fill retail) fill retail) clindamycin hcl caps 150 F FLAGYL TABS 250 MG, mg, 300 mg 500 MG (Use NF Limit 1 package Metronidazole) clindamycin palmitate F per metronidazole tabs or 250 hydrochloride solr 75 claim;QL(100 F mg/5ml mg, 500 mg ml per fill retail) trimethoprim tabs F Oxazolidinones VANCOCIN HCL CAPS QL(4 ea daily) SIVEXTRO TABS OR 200 F PA; QL(6 ea 125 MG (Use Vancomycin NF MG per fill retail) HCl) ANTIANGINAL AGENTS - Drugs to Treat Chest VANCOCIN HCL CAPS QL(8 ea daily) Pain 250 MG (Use Vancomycin NF Nitrates HCl) ISORDIL TITRADOSE vancomycin hcl caps or F QL(4 ea daily) TABS 5 MG (Use NF 125 mg Isosorbide Dinitrate) vancomycin hcl caps or QL(8 ea daily) F ISOSORBIDE DINITRATE F 250 mg ER TBCR vancomycin hcl solr iv 1000 F QL(14 ea per mg fill retail) isosorbide dinitrate tabs F Limit 14 per isosorbide mononitrate tabs QL(2 ea daily) vancomycin hcl solr iv 500 F month;QL(0.46 F mg 10 mg, 20 mg 7 ea daily) isosorbide mononitrate F QL(1 ea daily) Anti-infective Misc. - Combinations tb24 30 mg, 60 mg, 120 mg BACTRIM DS TABS (Use NITRO-BID OINT F Sulfamethoxazole- NF Trimethoprim) NITRO-DUR PT24 0.1 BACTRIM TABS (Use MG/HR, 0.2 MG/HR, 0.4 NF Sulfamethoxazole- NF MG/HR, 0.6 MG/HR (Use Trimethoprim) Nitroglycerin) sulfamethoxazole- nitroglycerin cpcr or 9 mg, F trimethoprim susp or F 2.5 mg, 6.5 mg 40mg/5ml-200mg/5ml nitroglycerin pt24 td 0.1 sulfamethoxazole- mg/hr, 0.2 mg/hr, 0.4 F trimethoprim tabs or 80mg- F mg/hr, 0.6 mg/hr 400mg, 160mg-800mg NV Silver Summit Updated September 1, 2018

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nitroglycerin subl sl 0.3 mg, F DIAZEPAM SOLN IJ 5 F 0.4 mg, 0.6 mg MG/ML NITROSTAT SUBL (Use NF DIAZEPAM SOLN OR 5 F QL(500 ml per Nitroglycerin) MG/5ML fill retail) diazepam tabs or 2 mg, 5 F QL(4 ea daily) ANTIANXIETY AGENTS - Drugs to Treat Anxiety mg, 10 mg Antianxiety Agents - Misc. lorazepam conc or 2 mg/ml F buspirone hcl tabs 15 mg F QL(4 ea daily) lorazepam soln ij 2 mg/ml, F 4 mg/ml, 20 mg/10ml buspirone hcl tabs 30 mg, F QL(3 ea daily) 7.5 mg lorazepam tabs or 0.5 mg, F QL(3 ea daily) 2 mg buspirone hcl tabs 5 mg, F QL(6 ea daily) 10 mg lorazepam tabs or 1 mg F QL(4 ea daily) droperidol soln F oxazepam caps 10 mg, 15 F QL(4 ea daily) mg, 30 mg HYDROXYZINE HCL F SOLN IM 25 MG/ML OXAZEPAM CAPS 30 MG F QL(4 ea daily) hydroxyzine hcl soln im 50 F mg/ml TRANXENE T TABS (Use NF QL(3 ea daily) Clorazepate Dipotassium) hydroxyzine hcl syrp or 10 F mg/5ml VALIUM TABS (Use NF QL(4 ea daily) Diazepam) hydroxyzine hcl tabs or 10 F mg, 25 mg, 50 mg XANAX TABS (Use NF QL(4 ea daily) Alprazolam) HYDROXYZINE F PAMOATE CAPS 100 MG ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms hydroxyzine pamoate caps F 25 mg, 50 mg Antiarrhythmics Type I-A meprobamate tabs F disopyramide phosphate F caps VISTARIL CAPS (Use NF NORPACE CAPS (Use NF Hydroxyzine Pamoate) Disopyramide Phosphate) Benzodiazepines NORPACE CR CP12 150 F MG alprazolam tabs 0.25 mg, F QL(4 ea daily) 0.5 mg, 1 mg, 2 mg quinidine gluconate tbcr or F ATIVAN SOLN IJ 2 324 mg MG/ML, 4 MG/ML (Use NF QUINIDINE SULFATE F Lorazepam) TABS ATIVAN TABS OR 0.5 MG, NF QL(3 ea daily) Antiarrhythmics Type I-B 2 MG (Use Lorazepam) mexiletine hcl caps F ATIVAN TABS OR 1 MG NF QL(4 ea daily) (Use Lorazepam) Antiarrhythmics Type I-C chlordiazepoxide hcl caps F QL(4 ea daily) flecainide acetate tabs F clorazepate dipotassium F QL(3 ea daily) tabs propafenone hcl tabs 150 F mg, 225 mg, 300 mg

NV Silver Summit Updated September 1, 2018

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RYTHMOL TABS (Use NF Steroid Inhalants Propafenone HCl) Limit 1 package Antiarrhythmics Type III F per AEROSPAN AERS month;QL(0.3 amiodarone hcl tabs or 200 F mg gm daily) QL(4 ml daily); dofetilide caps F budesonide (inhalation) F AL(Up to 6 yrs susp old ) TIKOSYN CAPS (Use NF Dofetilide) FLOVENT DISKUS AEPB F QL(2 ea daily) ANTIASTHMATIC AND BRONCHODILATOR Limit 1 package AGENTS - Drugs to Treat Lung Conditions FLOVENT HFA AERO 110 F per Anti-Inflammatory Agents MCG/ACT, 220 MCG/ACT month;QL(0.4 gm daily) cromolyn sodium nebu F QL(8 ml daily) Limit 1 package Bronchodilators - Anticholinergics FLOVENT HFA AERO 44 F per MCG/ACT month;QL(0.36 Limit 1 7 gm daily) F package per ATROVENT HFA AERS month;QL(0.87 Limit 1 package gm daily) PULMICORT FLEXHALER F per AEPB month;QL(0.04 INCRUSE ELLIPTA AEPB F QL(1 ea daily) ea daily) Limit 1 PULMICORT SUSP ( QL(4 ml daily); Use NF AL(Up to 6 yrs F package per Budesonide (Inhalation)) ipratropium bromide soln month;QL(12.5 old ) ml daily) Sympathomimetics Limit 1 ALBUTEROL SULFATE F TUDORZA PRESSAIR F package per ER TB12 AEPB month;QL(0.03 albuterol sulfate nebu in 0.5 F QL(2 ml daily) 4 ea daily) % Leukotriene Modulators albuterol sulfate nebu in QL(12.5 ml QL(1 ea daily) 0.63 mg/3ml, 0.083 %, 1.25 F daily) montelukast sodium chew F mg/3ml QL(1 ea daily) montelukast sodium pack F albuterol sulfate syrp or 2 F mg/5ml QL(1 ea daily) montelukast sodium tabs F albuterol sulfate tabs or 2 F mg, 4 mg SINGULAIR CHEW (Use QL(1 ea daily) NF albuterol sulfate tb12 or 4 F Montelukast Sodium) mg, 8 mg SINGULAIR PACK (Use NF QL(1 ea daily) PA Montelukast Sodium) ANORO ELLIPTA AEPB F SINGULAIR TABS (Use NF QL(1 ea daily) Limit 1 package Montelukast Sodium) COMBIVENT RESPIMAT F per Selective Phosphodiesterase 4 (PDE4) Inhibitors AERS month;QL(0.13 4 gm daily) DALIRESP TABS 500 F PA MCG

NV Silver Summit Updated September 1, 2018

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 Coumarin Anticoagulants package per DULERA AERO F COUMADIN TABS (Use NF month;QL(0.43 Warfarin Sodium) 4 gm daily) warfarin sodium tabs F ipratropium-albuterol soln F QL(12 ml daily) METAPROTERENOL QL(30 ml daily) Direct Factor Xa Inhibitors F SULFATE SYRP 10 ELIQUIS STARTER PACK F QL(4 ea daily) MG/5ML TABS METAPROTERENOL ELIQUIS TABS F QL(4 ea daily) SULFATE TABS 10 MG, F 20 MG QL(1 ea XARELTO TABS 10 MG F daily,35 ea per SEREVENT DISKUS F QL(2 ea daily) AEPB 180 days retail) QL(2 ea daily) STIOLTO RESPIMAT F PA XARELTO TABS 15 MG F AERS Limit 1 XARELTO TABS 20 MG F QL(1 ea daily) F package per SYMBICORT AERO month;QL(0.36 Heparins And Heparinoid-Like Agents 7 gm daily) enoxaparin sodium soln ij F QL(42 ml per 7 300 mg/3ml days retail); SP terbutaline sulfate tabs or 5 F mg, 2.5 mg enoxaparin sodium soln sc F QL(14 ml per 7 Limit 2 100 mg/ml, 150 mg/ml days retail); SP packages per enoxaparin sodium soln sc F QL(5 ml per 7 VENTOLIN HFA AERS F month;QL(0.54 30 mg/0.3ml days retail); SP gm daily,8 gm enoxaparin sodium soln sc F QL(6 ml per 7 per fill retail) 40 mg/0.4ml days retail); SP Limit 2 enoxaparin sodium soln sc F QL(9 ml per 7 packages per 60 mg/0.6ml days retail); SP VENTOLIN HFA AERS F month;QL(1.2 gm daily,18 gm enoxaparin sodium soln sc F QL(12 ml per 7 per fill retail) 80 mg/0.8ml, 120 mg/0.8ml days retail); SP heparin sodium (porcine) VOSPIRE ER TB12 (Use NF F Albuterol Sulfate) soln Xanthines LOVENOX SOLN IJ 300 QL(42 ml per 7 MG/3ML (Use Enoxaparin NF days retail); SP ELIXOPHYLLIN ELIX F Sodium) LOVENOX SOLN SC 100 QL(14 ml per 7 THEO-24 CP24 F MG/ML, 150 MG/ML (Use NF days retail); SP Enoxaparin Sodium) theophylline soln 80 F QL(475 ml per mg/15ml fill retail) LOVENOX SOLN SC 30 QL(5 ml per 7 MG/0.3ML (Use NF days retail); SP theophylline tb12 100 mg, F Enoxaparin Sodium) 200 mg, 300 mg, 450 mg LOVENOX SOLN SC 40 QL(6 ml per 7 theophylline tb24 400 mg, F MG/0.4ML (Use NF days retail); SP 600 mg Enoxaparin Sodium) ANTICOAGULANTS - Blood Thinners

NV Silver Summit Updated September 1, 2018

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOVENOX SOLN SC 60 QL(9 ml per 7 gabapentin soln 250 F MG/0.6ML (Use NF days retail); SP mg/5ml, 300 mg/6ml Enoxaparin Sodium) gabapentin tabs 600 mg F QL(6 ea daily) LOVENOX SOLN SC 80 QL(12 ml per 7 NF MG/0.8ML, 120 MG/0.8ML days retail); SP gabapentin tabs 800 mg F QL(4 ea daily) (Use Enoxaparin Sodium) KEPPRA SOLN IV 500 ANTICONVULSANTS - Drugs to Treat Seizures MG/5ML (Use NF Anticonvulsants - Benzodiazepines Levetiracetam) KEPPRA SOLN OR 100 QL(30 ml daily) clonazepam tabs 0.5 mg, 1 F QL(4 ea daily) mg, 2 mg MG/ML (Use NF Levetiracetam) QL(1 ea per fill DIASTAT ACUDIAL GEL F retail); AL(Up to KEPPRA TABS OR 1000 NF 21 yrs old ) MG (Use Levetiracetam) QL(1 ea per fill KEPPRA TABS OR 250 QL(4 ea daily) DIASTAT PEDIATRIC GEL F retail); AL(Up to MG, 750 MG (Use NF 21 yrs old ) Levetiracetam) QL(1 ea per fill KEPPRA TABS OR 500 NF QL(6 ea daily) DIAZEPAM GEL RE 10 F retail); AL(Up to MG (Use Levetiracetam) MG, 20 MG, 2.5 MG 21 yrs old ) KEPPRA XR TB24 (Use NF QL(1 ea per fill Levetiracetam) DIAZEPAM RECTAL GEL F LAMICTAL CHEWABLE GEL retail); AL(Up to 21 yrs old ) DISPERSIBLE CHEW (Use NF Lamotrigine) KLONOPIN TABS (Use NF QL(4 ea daily) Clonazepam) LAMICTAL TABS (Use NF Lamotrigine) Anticonvulsants - Misc. LAMICTAL XR TB24 25 ST APTIOM TABS F MG, 50 MG, 100 MG, 200 NF MG, 250 MG, 300 MG (Use BANZEL SUSP F Lamotrigine) lamotrigine chew 5 mg, 25 F BANZEL TABS F mg lamotrigine tabs 25 mg, F carbamazepine chew F 100 mg, 150 mg, 200 mg lamotrigine tb24 25 mg, 50 ST carbamazepine cp12 F mg, 100 mg, 200 mg, 250 F mg, 300 mg carbamazepine susp F levetiracetam soln iv 500 F carbamazepine tabs F mg/5ml levetiracetam soln or 100 F QL(30 ml daily) carbamazepine tb12 F mg/ml, 500 mg/5ml levetiracetam tabs or 1000 F CARBATROL CP12 (Use NF mg Carbamazepine) levetiracetam tabs or 250 F QL(4 ea daily) gabapentin caps 100 mg, F QL(9 ea daily) mg, 750 mg 300 mg, 400 mg levetiracetam tabs or 500 F QL(6 ea daily) mg

NV Silver Summit Updated September 1, 2018

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits levetiracetam tb24 or 500 F topiramate tabs 25 mg, 50 F QL(6 ea daily) mg, 750 mg mg MYSOLINE TABS (Use NF TRILEPTAL SUSP (Use NF Primidone) Oxcarbazepine) NEURONTIN CAPS 100 QL(9 ea daily) TRILEPTAL TABS (Use NF MG, 300 MG, 400 MG (Use NF Oxcarbazepine) Gabapentin) VIMPAT SOLN OR 10 F NEURONTIN SOLN 250 NF MG/ML MG/5ML (Use Gabapentin) VIMPAT TABS OR 50 MG, F NEURONTIN TABS 600 NF QL(6 ea daily) 100 MG, 150 MG, 200 MG MG (Use Gabapentin) ZONEGRAN CAPS (Use NF NEURONTIN TABS 800 NF QL(4 ea daily) Zonisamide) MG (Use Gabapentin) zonisamide caps F oxcarbazepine susp F Carbamates oxcarbazepine tabs F felbamate susp F POTIGA TABS F felbamate tabs F primidone tabs F FELBATOL SUSP (Use NF Felbamate) TEGRETOL SUSP (Use NF Carbamazepine) FELBATOL TABS (Use NF Felbamate) TEGRETOL TABS (Use NF Carbamazepine) GABA Modulators GABITRIL TABS (Use TEGRETOL-XR TB12 (Use NF NF Carbamazepine) Tiagabine HCl) TOPAMAX SPRINKLE QL(6 ea daily) tiagabine hcl tabs F CPSP 15 MG (Use NF Topiramate) Hydantoins TOPAMAX SPRINKLE QL(8 ea daily) DILANTIN CAPS 100 MG CPSP 25 MG (Use NF (Use Phenytoin Sodium NF Topiramate) Extended) TOPAMAX TABS 100 MG NF QL(4 ea daily) (Use Topiramate) DILANTIN CAPS 30 MG F TOPAMAX TABS 200 MG QL(3 ea daily) NF DILANTIN INFATABS NF (Use Topiramate) CHEW (Use Phenytoin) TOPAMAX TABS 25 MG, QL(6 ea daily) NF DILANTIN-125 SUSP (Use NF 50 MG (Use Topiramate) Phenytoin) topiramate cpsp 15 mg F QL(6 ea daily) PEGANONE TABS F topiramate cpsp 25 mg F QL(8 ea daily) phenytoin chew F QL(4 ea daily) topiramate tabs 100 mg F phenytoin sodium extended F caps 100 mg QL(3 ea daily) topiramate tabs 200 mg F phenytoin susp F

NV Silver Summit Updated September 1, 2018

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1.5 ea Succinimides mirtazapine tbdp 30 mg F daily) CELONTIN CAPS F mirtazapine tbdp 45 mg F QL(1 ea daily) ethosuximide caps F REMERON SOLTAB TBDP NF QL(3 ea daily) 15 MG (Use Mirtazapine) ethosuximide soln F REMERON SOLTAB TBDP NF QL(1.5 ea 30 MG (Use Mirtazapine) daily) ZARONTIN CAPS (Use NF Ethosuximide) REMERON SOLTAB TBDP NF QL(1 ea daily) 45 MG (Use Mirtazapine) ZARONTIN SOLN (Use NF Ethosuximide) REMERON TABS 15 MG NF QL(3 ea daily) Valproic Acid (Use Mirtazapine) REMERON TABS 30 MG QL(1.5 ea DEPACON SOLN (Use NF NF Valproate Sodium) (Use Mirtazapine) daily) REMERON TABS 45 MG QL(1 ea daily) DEPAKENE CAPS (Use NF NF Valproic Acid) (Use Mirtazapine) Antidepressants - Misc. DEPAKENE SOLN (Use NF Valproate Sodium) APLENZIN TB24 F DEPAKOTE ER TB24 (Use NF Divalproex Sodium) bupropion hcl tabs 75 mg, F QL(3 ea daily) DEPAKOTE SPRINKLES 100 mg CSDR (Use Divalproex NF bupropion hcl tb12 100 mg F QL(4 ea daily) Sodium) QL(3 ea daily) DEPAKOTE TBEC (Use NF bupropion hcl tb12 150 mg F Divalproex Sodium) QL(2 ea daily) divalproex sodium csdr F bupropion hcl tb12 200 mg F QL(3 ea daily) divalproex sodium tb24 F bupropion hcl tb24 150 mg F QL(1 ea daily) divalproex sodium tbec F bupropion hcl tb24 300 mg F valproate sodium soln F FORFIVO XL TB24 F valproic acid caps 250 mg F MAPROTILINE HCL TABS F WELLBUTRIN SR TB12 QL(4 ea daily) ANTIDEPRESSANTS - Drugs to Treat 100 MG (Use Bupropion NF Depression HCl) Alpha-2 Receptor Antagonists (Tetracyclics) WELLBUTRIN SR TB12 QL(3 ea daily) QL(3 ea daily) 150 MG (Use Bupropion NF mirtazapine tabs 15 mg F HCl) QL(1.5 ea mirtazapine tabs 30 mg F WELLBUTRIN SR TB12 QL(2 ea daily) daily) 200 MG (Use Bupropion NF HCl) mirtazapine tabs 45 mg, F QL(1 ea daily) 7.5 mg WELLBUTRIN XL TB24 QL(3 ea daily) QL(3 ea daily) 150 MG (Use Bupropion NF mirtazapine tbdp 15 mg F HCl)

NV Silver Summit Updated September 1, 2018

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WELLBUTRIN XL TB24 QL(1 ea daily) fluoxetine hcl caps 40 mg F QL(2 ea daily) 300 MG (Use Bupropion NF HCl) QL(20 ml Monoamine Oxidase Inhibitors (MAOIs) fluoxetine hcl soln 20 F daily,30 day(s) mg/5ml limit); AL(At EMSAM PT24 F least 7 yrs old) QL(1 ea daily); MARPLAN TABS F fluoxetine hcl tabs 10 mg F AL(At least 13 yrs old) NARDIL TABS (Use NF Phenelzine Sulfate) fluoxetine hcl tabs 20 mg F QL(4 ea daily) PARNATE TABS (Use NF Tranylcypromine Sulfate) fluoxetine hcl tabs 60 mg F phenelzine sulfate tabs 15 F FLUOXETINE F mg HYDROCHLORIDE TABS tranylcypromine sulfate F FLUOXETINE tabs 10 mg HYDROCHLORIDE TABS NF Selective Serotonin Reuptake Inhibitors (SSRIs) (Use Fluoxetine HCl) CELEXA TABS 10 MG QL(4 ea daily) fluvoxamine maleate cp24 F (Use Citalopram NF 100 mg, 150 mg Hydrobromide) fluvoxamine maleate tabs F QL(3 ea daily) CELEXA TABS 20 MG QL(2 ea daily) 100 mg (Use Citalopram NF fluvoxamine maleate tabs F QL(2 ea daily) Hydrobromide) 25 mg, 50 mg CELEXA TABS 40 MG QL(1 ea daily) LEXAPRO SOLN 5 (Use Citalopram NF MG/5ML (Use Escitalopram NF Hydrobromide) Oxalate) citalopram hydrobromide QL(8 ml daily) F LEXAPRO TABS 10 MG NF QL(2 ea daily) soln 10 mg/5ml (Use Escitalopram Oxalate) citalopram hydrobromide QL(4 ea daily) F LEXAPRO TABS 20 MG NF QL(1 ea daily) tabs 10 mg (Use Escitalopram Oxalate) citalopram hydrobromide QL(2 ea daily) F LEXAPRO TABS 5 MG NF QL(4 ea daily) tabs 20 mg (Use Escitalopram Oxalate) citalopram hydrobromide F QL(1 ea daily) paroxetine hcl tabs 10 mg F QL(6 ea daily) tabs 40 mg QL(3 ea daily) escitalopram oxalate soln 5 F paroxetine hcl tabs 20 mg F mg/5ml paroxetine hcl tabs 30 mg, QL(2 ea daily) escitalopram oxalate tabs F QL(2 ea daily) F 10 mg 40 mg paroxetine hcl tb24 25 mg, escitalopram oxalate tabs F QL(1 ea daily) F 20 mg 12.5 mg, 37.5 mg PAXIL CR TB24 (Use escitalopram oxalate tabs 5 F QL(4 ea daily) NF mg Paroxetine HCl) QL(40 ml daily) FLUOXETINE DR CPDR F PAXIL SUSP 10 MG/5ML F PAXIL TABS 10 MG (Use QL(6 ea daily) fluoxetine hcl caps 10 mg, F QL(4 ea daily) NF 20 mg Paroxetine HCl)

NV Silver Summit Updated September 1, 2018

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PAXIL TABS 20 MG (Use NF QL(3 ea daily) duloxetine hcl cpep 40 mg F Paroxetine HCl) EFFEXOR XR CP24 150 QL(2 ea daily) PAXIL TABS 30 MG, 40 NF QL(2 ea daily) NF MG (Use Paroxetine HCl) MG (Use Venlafaxine HCl) EFFEXOR XR CP24 37.5 NF QL(4 ea daily) PEXEVA TABS F MG (Use Venlafaxine HCl) PROZAC CAPS 10 MG, 20 NF QL(4 ea daily) EFFEXOR XR CP24 75 NF QL(5 ea daily) MG (Use Fluoxetine HCl) MG (Use Venlafaxine HCl) PROZAC CAPS 40 MG NF QL(2 ea daily) FETZIMA CP24 F (Use Fluoxetine HCl) FETZIMA TITRATION sertraline hcl conc 20 F QL(10 ml daily) F mg/ml PACK C4PK sertraline hcl tabs 100 mg F QL(2 ea daily) KHEDEZLA TB24 F PRISTIQ TB24 (Use sertraline hcl tabs 25 mg, F QL(4 ea daily) NF 50 mg Desvenlafaxine Succinate) venlafaxine hcl cp24 150 QL(2 ea daily) ZOLOFT CONC 20 MG/ML NF QL(10 ml daily) F (Use Sertraline HCl) mg venlafaxine hcl cp24 37.5 QL(4 ea daily) ZOLOFT TABS 100 MG NF QL(2 ea daily) F (Use Sertraline HCl) mg QL(5 ea daily) ZOLOFT TABS 25 MG, 50 NF QL(4 ea daily) venlafaxine hcl cp24 75 mg F MG (Use Sertraline HCl) VENLAFAXINE HCL ER F QL(1 ea daily) Serotonin Modulators TB24 225 MG NEFAZODONE HCL TABS F VENLAFAXINE HCL ER QL(1 ea daily) 100 MG, 150 MG, 200 MG TB24 75 MG, 150 MG, 37.5 NF nefazodone hcl tabs 50 F MG (Use Venlafaxine HCl) mg, 250 mg venlafaxine hcl tabs 25 mg, trazodone hcl tabs or 300 F QL(2 ea daily) 50 mg, 75 mg, 100 mg, F mg 37.5 mg trazodone hcl tabs or 50 F venlafaxine hcl tb24 75 mg, F QL(1 ea daily) mg, 100 mg, 150 mg 150 mg, 225 mg, 37.5 mg TRINTELLIX TABS F PA Tricyclic Agents amitriptyline hcl tabs F VIIBRYD STARTER PACK F PA KIT AMOXAPINE TABS F VIIBRYD TABS F PA; QL(1 ea daily) ANAFRANIL CAPS (Use NF Serotonin-Norepinephrine Reuptake Inhibitors Clomipramine HCl) CYMBALTA CPEP (Use NF QL(1 ea daily) clomipramine hcl caps F Duloxetine HCl) desipramine hcl tabs or 10 DESVENLAFAXINE ER F TB24 50 MG, 100 MG mg, 50 mg, 75 mg, 100 mg, F 150 mg desvenlafaxine succinate F tb24 desipramine hcl tabs or 25 F QL(2 ea daily) mg duloxetine hcl cpep 20 mg, F QL(1 ea daily) 30 mg, 60 mg NV Silver Summit Updated September 1, 2018

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxepin hcl caps or 10 mg, Limit 4 pens 25 mg, 50 mg, 75 mg, 100 F per mg, 150 mg SYMLINPEN 60 SOPN F month;QL(0.2 ml daily,100 doxepin hcl conc or 10 F mg/ml day(s) limit) Antidiabetic Combinations ELAVIL TABS (Use NF Amitriptyline HCl) ACTOPLUS MET TABS QL(2 ea daily) (Use Pioglitazone HCl- NF imipramine hcl tabs or 10 F mg, 25 mg, 50 mg Metformin HCl) imipramine pamoate caps F ACTOPLUS MET XR TB24 F QL(2 ea daily) alogliptin-metformin hcl QL(1 ea daily) NORPRAMIN TABS 10 MG NF F (Use Desipramine HCl) tabs QL(1 ea daily) NORPRAMIN TABS 25 MG NF QL(2 ea daily) alogliptin-pioglitazone tabs F (Use Desipramine HCl) DUETACT TABS (Use QL(1 ea daily) nortriptyline hcl caps or 10 F mg, 25 mg, 50 mg, 75 mg Pioglitazone HCl- NF Glimepiride) nortriptyline hcl soln or 10 F QL(20 ml daily) mg/5ml glipizide-metformin hcl tabs F PAMELOR CAPS (Use NF Nortriptyline HCl) GLUCOVANCE TABS (Use NF Glyburide-Metformin) protriptyline hcl tabs F glyburide-metformin tabs F SURMONTIL CAPS (Use NF Trimipramine Maleate) GLYXAMBI TABS F QL(1 ea daily) TOFRANIL TABS (Use NF INVOKAMET TABS 50MG- F QL(2 ea daily) Imipramine HCl) 1000MG, 150MG-1000MG trimipramine maleate caps F INVOKAMET TABS 50MG- F QL(4 ea daily) or 25 mg, 50 mg, 100 mg 500MG, 150MG-500MG ANTIDIABETICS - Drugs to Regulate Blood INVOKAMET XR TB24 QL(2 ea daily) Sugar 50MG-1000MG, 150MG- F Alpha-Glucosidase Inhibitors 1000MG INVOKAMET XR TB24 QL(4 ea daily) acarbose tabs F 50MG-500MG, 150MG- F 500MG GLYSET TABS 50 MG NF (Use Miglitol) QL(2 ea JANUMET TABS 50MG- F 1000MG daily,100 miglitol tabs 50 mg F day(s) limit) PRECOSE TABS (Use QL(4 ea NF JANUMET TABS 50MG- F Acarbose) 500MG daily,100 day(s) limit) Antidiabetic - Amylin Analogs JANUMET XR TB24 QL(2 ea Limit 4 pens 50MG-1000MG, 100MG- F daily,100 per 1000MG day(s) limit) SYMLINPEN 120 SOPN F month;QL(0.36 ml daily,100 QL(4 ea JANUMET XR TB24 F daily,100 day(s) limit) 50MG-500MG day(s) limit) NV Silver Summit Updated September 1, 2018

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JENTADUETO TABS F QL(2 ea daily) GLUCOPHAGE TABS 850 NF QL(3 ea daily) MG (Use Metformin HCl) QL(2 ea GLUCOPHAGE XR TB24 QL(4 ea daily) JENTADUETO XR TB24 F daily,100 500 MG (Use Metformin NF day(s) limit) HCl) KAZANO TABS (Use NF QL(1 ea daily) GLUCOPHAGE XR TB24 QL(2 ea daily) Alogliptin-Metformin HCl) 750 MG (Use Metformin NF KOMBIGLYZE XR TB24 QL(2 ea HCl) 5MG-1000MG, 2.5MG- F daily,100 GLUMETZA TB24 1000 NF QL(2 ea daily) 1000MG day(s) limit) MG (Use Metformin HCl) QL(4 ea GLUMETZA TB24 500 MG QL(4 ea daily) KOMBIGLYZE XR TB24 F NF 5MG-500MG daily,100 (Use Metformin HCl) day(s) limit) metformin hcl tabs 1000 F QL(2 ea daily) OSENI TABS (Use NF QL(1 ea daily) mg Alogliptin-Pioglitazone) metformin hcl tabs 500 mg F QL(5 ea daily) pioglitazone hcl-glimepiride F QL(1 ea daily) tabs metformin hcl tabs 850 mg F QL(3 ea daily) pioglitazone hcl-metformin F QL(2 ea daily) hcl tabs metformin hcl tb24 500 mg F QL(4 ea daily) QTERN TABS F metformin hcl tb24 750 mg, F QL(2 ea daily) REPAGLINIDE/METFORM QL(4 ea daily) 1000 mg IN HYDROCHLORIDE F METFORMIN F TABS HYDROCHLORIDE SOLN SOLIQUA 100/33 SOPN F RIOMET SOLN F

SYNJARDY TABS 5MG- F QL(2 ea daily) Diabetic Other 1000MG, 12.5MG-1000MG Limit 50 per SYNJARDY TABS 5MG- QL(4 ea daily) CVS GLUCOSE CHEW 4 F F GM month;QL(1.67 500MG, 12.5MG-500MG ea daily) SYNJARDY XR TB24 F Limit 50 per DEX4 QUICK DISSOLVE F month;QL(1.67 GLUCOSE CHEW XIGDUO XR TB24 5MG- F QL(2 ea daily) ea daily) 1000MG, 10MG-1000MG dextrose (diabetic use) gel F XIGDUO XR TB24 5MG- F QL(4 ea daily) 40 %, 15 gm/38gm 500MG, 10MG-500MG GLUCAGEN HYPOKIT F QL(1 ea per fill Biguanides SOLR retail) FORTAMET TB24 1000 NF QL(2 ea daily) GLUCAGON F QL(1 ea per fill MG (Use Metformin HCl) EMERGENCY KIT KIT retail) FORTAMET TB24 500 MG NF QL(4 ea daily) Limit 50 per (Use Metformin HCl) GLUCOSE CHEW 4 GM F month;QL(1.67 GLUCOPHAGE TABS QL(2 ea daily) ea daily) 1000 MG (Use Metformin NF Limit 50 per HCl) GNP GLUCOSE CHEW 4 F GM month;QL(1.67 ea daily) GLUCOPHAGE TABS 500 NF QL(5 ea daily) MG (Use Metformin HCl)

NV Silver Summit Updated September 1, 2018

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP QUICK DISSOLVE Limit 50 per Limit 1 syringe F month;QL(1.67 BYETTA SOPN 5 per GLUCOSE CHEW F ea daily) MCG/0.02ML month;QL(0.04 QL(100 day(s) ml daily) KORLYM TABS F limit) OZEMPIC SOPN F LEADER QUICK Limit 50 per DISSOLVE GLUCOSE F month;QL(1.67 TANZEUM PEN F CHEW ea daily) PROGLYCEM SUSP F QL(100 day(s) TRULICITY SOPN F limit) Limit 3 syringes Limit 50 per per SM GLUCOSE CHEW 4 F month;QL(1.67 VICTOZA SOPN F GM month;QL(0.3 ea daily) ml daily) Limit 50 per WALGREENS GLUCOSE F month;QL(1.67 Insulin Sensitizing Agents CHEW 4 GM ea daily) ACTOS TABS (Use NF QL(1 ea daily) Pioglitazone HCl) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors AVANDIA TABS F QL(1 ea daily) alogliptin benzoate tabs F QL(1 ea daily) pioglitazone hcl tabs F QL(1 ea daily) JANUVIA TABS F QL(1 ea daily) Insulin NESINA TABS (Use NF QL(1 ea daily) Alogliptin Benzoate) Limit 40mls per QL(1 ea daily) ADMELOG SOLN F month;QL(1.34 ONGLYZA TABS F ml daily) QL(1 ea daily); ADMELOG SOLOSTAR F QL(1 ml daily) TRADJENTA TABS F AL(At least 18 SOPN yrs old) AFREZZA POWD F Incretin Mimetic Agents (GLP-1 Receptor Limit 30mls per ADLYXIN SOPN F APIDRA SOLN F month;QL(1 ml daily) ADLYXIN STARTER PACK F PNKT APIDRA SOLOSTAR F QL(1 ml daily) SOPN Limit 1 syringe BASAGLAR KWIKPEN QL(1 ml daily) F per F BYDUREON PEN PEN month;QL(0.14 SOPN 3 ea daily) FIASP FLEXTOUCH F QL(1 ml daily) Limit 1 syringe SOPN Limit 30mls per F per BYDUREON SRER month;QL(0.14 FIASP SOLN F month;QL(1 ml 3 ea daily) daily) Limit 1 syringe HUMALOG JUNIOR F QL(1 ml daily) KWIKPEN SOPN BYETTA SOPN 10 F per MCG/0.04ML month;QL(0.08 HUMALOG KWIKPEN F QL(1 ml daily) ml daily) SOPN HUMALOG MIX 50/50 F QL(1 ml daily) KWIKPEN SUPN

NV Silver Summit Updated September 1, 2018

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 40mls per Limit 40mls per HUMALOG MIX 50/50 F NOVOLIN N RELION F SUSP month;QL(1.34 SUSP month;QL(1.34 ml daily) ml daily) HUMALOG MIX 75/25 F QL(1 ml daily) Limit 40mls per KWIKPEN SUPN NOVOLIN N SUSP F month;QL(1.34 Limit 40mls per ml daily) HUMALOG MIX 75/25 F month;QL(1.34 Limit 40mls per SUSP NOVOLIN R RELION F ml daily) SOLN month;QL(1.34 ml daily) HUMALOG SOCT F QL(1 ml daily) Limit 40mls per Limit 40mls per NOVOLIN R SOLN F month;QL(1.34 HUMALOG SOLN F month;QL(1.34 ml daily) ml daily) NOVOLOG FLEXPEN F QL(1 ml daily) SOPN HUMULIN 70/30 KWIKPEN F QL(1 ml daily) SUPN NOVOLOG MIX 70/30 QL(1 ml daily) Limit 40mls per PREFILLED FLEXPEN F HUMULIN 70/30 SUSP F month;QL(1.34 SUPN ml daily) Limit 40mls per NOVOLOG MIX 70/30 F month;QL(1.34 HUMULIN N KWIKPEN F QL(1 ml daily) SUSP SUPN ml daily) Limit 40mls per NOVOLOG PENFILL F QL(1 ml daily) HUMULIN N SUSP F month;QL(1.34 SOCT ml daily) Limit 30mls per Limit 40mls per NOVOLOG SOLN F month;QL(1 ml HUMULIN R SOLN F month;QL(1.34 daily) ml daily) TOUJEO MAX SOLOSTAR F SOPN HUMULIN R U-500 F QL(1.34 ml (CONCENTRATED) SOLN daily) TOUJEO SOLOSTAR F SOPN HUMULIN R U-500 F QL(1.34 ml KWIKPEN SOPN daily) TRESIBA FLEXTOUCH F Limit 30mls per SOPN LANTUS SOLN F month;QL(1 ml Meglitinide Analogues daily) nateglinide tabs F QL(3 ea daily) LANTUS SOLOSTAR F QL(1 ml daily) SOPN PRANDIN TABS (Use NF LEVEMIR FLEXTOUCH F Repaglinide) SOPN repaglinide tabs F LEVEMIR SOLN F STARLIX TABS (Use NF QL(3 ea daily) Limit 40mls per Nateglinide) NOVOLIN 70/30 RELION F SUSP month;QL(1.34 ml daily) Sodium-Glucose Co-Transporter 2 (SGLT2) Limit 40mls per FARXIGA TABS F NOVOLIN 70/30 SUSP F month;QL(1.34 ml daily) INVOKANA TABS F

NV Silver Summit Updated September 1, 2018

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea PEPTO-BISMOL JARDIANCE TABS F daily,100 INSTACOOL CHEW (Use NF day(s) limit) Bismuth Subsalicylate) Sulfonylureas PEPTO-BISMOL MAX STRENGTH SUSP (Use NF AMARYL TABS 1 MG, 2 NF QL(4 ea daily) Bismuth Subsalicylate) MG (Use Glimepiride) PEPTO-BISMOL SUSP AMARYL TABS 4 MG (Use NF QL(2 ea daily) NF ) 262 MG/15ML (Use Glimepiride Bismuth Subsalicylate) CHLORPROPAMIDE F PEPTO-BISMOL TO-GO TABS CHEW (Use Bismuth NF glimepiride tabs 1 mg, 2 F QL(4 ea daily) Subsalicylate) mg Antiperistaltic Agents glimepiride tabs 4 mg F QL(2 ea daily) diphenoxylate w/ atropine F tabs glipizide tabs F DIPHENOXYLATE/ATROP F INE LIQD glipizide tb24 F IMODIUM A-D CAPS 2 MG NF QL(8 ea daily); GLUCOTROL TABS (Use NF (Use Loperamide HCl) RX/OTC Glipizide) IMODIUM A-D TABS 2 MG NF QL(8 ea daily) GLUCOTROL XL TB24 NF (Use Loperamide HCl) (Use Glipizide) LOMOTIL TABS (Use NF glyburide micronized tabs F Diphenoxylate w/ Atropine) QL(8 ea daily); loperamide hcl caps 2 mg F glyburide tabs F RX/OTC loperamide hcl liqd 1 F QL(40 ml daily) GLYNASE TABS (Use NF mg/5ml Glyburide Micronized) loperamide hcl tabs 2 mg F QL(8 ea daily) TOLAZAMIDE TABS F

TOLBUTAMIDE TABS F ANTIDOTES AND SPECIFIC ANTAGONISTS Antidotes - Chelating Agents ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea CHEMET CAPS F Antidiarrheal/Probiotic Agents - Misc. JADENU TABS F PA; SP bismuth subsalicylate chew F Antidotes and Specific Antagonists bismuth subsalicylate susp F SM IPECAC SYRUP SYRP F bismuth subsalicylate tabs F Opioid Antagonists PEPTO BISMOL TABS naloxone hcl soln 0.4 F QL(2 ml per 90 (Use Bismuth NF mg/ml days retail) Subsalicylate) naltrexone hcl tabs F PEPTO-BISMOL CHEW 262 MG (Use Bismuth NF NARCAN LIQD F Subsalicylate)

NV Silver Summit Updated September 1, 2018

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIVITROL SUSR F PA; SP QL(1 ea LAMISIL TABS (Use NF Terbinafine HCl) daily,90 ea per ANTIEMETICS - Drugs to Treat Nausea and 120 days retail) Vomiting nystatin tabs 500000 unit F QL(6 ea daily) 5-HT3 Receptor Antagonists QL(1 ea ondansetron hcl soln ij 4 F terbinafine hcl tabs 250 mg F daily,90 ea per mg/2ml, 40 mg/20ml 120 days retail) QL(50 ml per ondansetron hcl soln or 4 F Imidazole-Related Antifungals mg/5ml fill retail) Limit 1 package DIFLUCAN SUSR 10 ondansetron hcl tabs or 24 F QL(1 ea per 14 per mg days retail) MG/ML, 40 MG/ML (Use NF Fluconazole) claim;QL(70 ml ondansetron hcl tabs or 4 F QL(2 ea daily) per fill retail) mg, 8 mg DIFLUCAN TABS 100 MG NF QL(1 ea daily) ONDANSETRON F (Use Fluconazole) HYDROCHLORIDE SOLN DIFLUCAN TABS 150 MG NF QL(2 ea per fill ondansetron tbdp F QL(2 ea daily) (Use Fluconazole) retail) DIFLUCAN TABS 200 MG NF QL(2 ea daily) ZOFRAN ODT TBDP (Use NF QL(2 ea daily) (Use Fluconazole) Ondansetron) DIFLUCAN TABS 50 MG NF QL(7 ea per fill ZOFRAN SOLN 4 MG/5ML NF QL(50 ml per (Use Fluconazole) retail) (Use Ondansetron HCl) fill retail) Limit 1 package ZOFRAN TABS 4 MG, 8 QL(2 ea daily) fluconazole susr 10 mg/ml, F per MG (Use Ondansetron NF 40 mg/ml claim;QL(70 ml HCl) per fill retail) Antiemetics - Anticholinergic fluconazole tabs 100 mg F QL(1 ea daily) dimenhydrinate tabs or 50 F QL(2 ea per fill mg fluconazole tabs 150 mg F retail) DRAMAMINE TABS (Use NF Dimenhydrinate) fluconazole tabs 200 mg F QL(2 ea daily) meclizine hcl chew 25 mg F QL(7 ea per fill fluconazole tabs 50 mg F meclizine hcl tabs 25 mg, RX/OTC retail) F PA; QL(1 ea 12.5 mg itraconazole caps 100 mg F daily) ANTIFUNGALS - Drugs to Treat Fungal Infections SPORANOX CAPS 100 NF PA; QL(1 ea Antifungals MG (Use Itraconazole) daily) SPORANOX PULSEPAK PA; QL(1 ea GRIS-PEG TABS (Use NF NF Griseofulvin Ultramicrosize) CAPS (Use Itraconazole) daily) griseofulvin microsize susp F ANTIHISTAMINES - Drugs to Treat Allergies griseofulvin microsize tabs F Antihistamines - Alkylamines CHLOR-TRIMETON SYRP QL(60 ml daily) griseofulvin ultramicrosize F 2 MG/5ML (Use NF tabs Chlorpheniramine Maleate)

NV Silver Summit Updated September 1, 2018

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHLOR-TRIMETON TABS QL(120 ea per cetirizine hcl chew 5 mg, 10 F QL(1 ea daily) 4 MG (Use NF fill retail) mg Chlorpheniramine Maleate) QL(240 ml per chlorpheniramine maleate F QL(60 ml daily) cetirizine hcl soln 1 mg/ml, F fill retail); syrp 2 mg/5ml 5 mg/5ml AL(Up to 12 yrs old ); RX/OTC chlorpheniramine maleate F QL(120 ea per tabs 4 mg fill retail) QL(240 ml per cetirizine hcl syrp 1 mg/ml, F fill retail); Antihistamines - Ethanolamines 5 mg/5ml AL(Up to 12 yrs BENADRYL ALLERGY QL(4 ea daily) old ); RX/OTC NF CAPS (Use QL(1 ea daily) Diphenhydramine HCl) cetirizine hcl tabs 5 mg, 10 F mg BENADRYL ALLERGY QL(240 ml per CLARITIN ALLERGY QL(240 ml per CHILDRENS LIQD 12.5 fill retail) NF CHILDRENS SYRP (Use NF fill retail) MG/5ML (Use ) Diphenhydramine HCl) Loratadine CLARITIN REDITABS BENADRYL ALLERGY QL(4 ea daily) NF TBDP 10 MG (Use NF TABS (Use ) Diphenhydramine HCl) Loratadine QL(2 ea daily) CLARITIN SYRP 5 NF QL(240 ml per clemastine fumarate tabs F MG/5ML (Use Loratadine) fill retail) 1.34 mg diphenhydramine hcl caps QL(4 ea daily) CLARITIN TABS 10 MG NF F (Use Loratadine) or 25 mg QL(4 ea daily); fexofenadine hcl tabs 180 F QL(1 ea daily) diphenhydramine hcl caps F mg or 50 mg RX/OTC QL(240 ml per fexofenadine hcl tabs 60 F QL(2 ea daily) diphenhydramine hcl elix or F fill retail); mg 12.5 mg/5ml RX/OTC levocetirizine F RX/OTC diphenhydramine hcl liqd or QL(240 ml per dihydrochloride tabs 5 mg QL(240 ml per 25 mg/10ml, 50 mg/20ml, F fill retail) loratadine soln 5 mg/5ml F 12.5 mg/5ml fill retail) QL(240 ml per diphenhydramine hcl syrp F QL(240 ml per loratadine syrp 5 mg/5ml F or 12.5 mg/5ml fill retail) fill retail) diphenhydramine hcl tabs F QL(4 ea daily) loratadine tabs 10 mg F or 25 mg QL(240 ml per loratadine tbdp 10 mg F SILPHEN COUGH SYRP F fill retail) XYZAL ALLERGY 24HR RX/OTC TAVIST ALLERGY TABS QL(2 ea daily) TABS (Use Levocetirizine NF (Use Clemastine NF Dihydrochloride) Fumarate) XYZAL TABS 5 MG (Use RX/OTC Antihistamines - Non-Sedating Levocetirizine NF ALLEGRA ALLERGY QL(1 ea daily) Dihydrochloride) TABS 180 MG (Use NF ZYRTEC ALLERGY TABS NF QL(1 ea daily) Fexofenadine HCl) (Use Cetirizine HCl) ALLEGRA ALLERGY QL(2 ea daily) TABS 60 MG (Use NF Fexofenadine HCl)

NV Silver Summit Updated September 1, 2018

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(240 ml per ZYRTEC CHILDRENS colestipol hcl tabs 1 gm F NF fill retail); ALLERGY SOLN (Use AL(Up to 12 yrs Cetirizine HCl) QUESTRAN LIGHT POWD NF old ); RX/OTC (Use Cholestyramine Light) Antihistamines - Phenothiazines QUESTRAN PACK (Use NF QL(240 ml per Cholestyramine) promethazine hcl soln or F fill retail); AL(At QUESTRAN POWD (Use 6.25 mg/5ml NF least 2 yrs old) Cholestyramine) QL(12 ea per Fibric Acid Derivatives promethazine hcl supp re F fill retail); AL(At 25 mg, 50 mg, 12.5 mg fenofibrate micronized caps F QL(1 ea daily) least 2 yrs old) 134 mg, 200 mg QL(240 ml per fenofibrate micronized caps QL(2 ea daily) promethazine hcl syrp or F fill retail); AL(At F 6.25 mg/5ml 67 mg least 2 yrs old) fenofibrate tabs 160 mg F QL(1 ea daily) promethazine hcl tabs or F AL(At least 2 25 mg, 50 mg, 12.5 mg yrs old) fenofibrate tabs 54 mg F QL(3 ea daily) Antihistamines - Piperidines QL(2 ea daily) cyproheptadine hcl syrp F gemfibrozil tabs 600 mg F LOFIBRA CAPS 134 MG, QL(1 ea daily) cyproheptadine hcl tabs F 200 MG (Use Fenofibrate NF Micronized) ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol LOFIBRA CAPS 67 MG QL(2 ea daily) (Use Fenofibrate NF Antihyperlipidemics - Combinations Micronized) PA ezetimibe-simvastatin tabs F LOFIBRA TABS 160 MG NF QL(1 ea daily) (Use Fenofibrate) VYTORIN TABS (Use PA NF LOFIBRA TABS 54 MG NF QL(3 ea daily) Ezetimibe-Simvastatin) (Use Fenofibrate) Bile Acid Sequestrants LOPID TABS (Use NF QL(2 ea daily) Gemfibrozil) cholestyramine light pack F TRIGLIDE TABS F QL(1 ea daily) cholestyramine light powd F HMG CoA Reductase Inhibitors cholestyramine pack F atorvastatin calcium tabs F QL(1 ea daily) cholestyramine powd F CRESTOR TABS (Use NF ST; QL(1 ea Rosuvastatin Calcium) daily) COLESTID FLAVORED GRAN 5 GM (Use NF LIPITOR TABS (Use NF QL(1 ea daily) Colestipol HCl) Atorvastatin Calcium) lovastatin tabs 10 mg, 20 QL(1 ea daily) COLESTID GRAN 5 GM NF F (Use Colestipol HCl) mg QL(2 ea daily) COLESTID TABS 1 GM NF lovastatin tabs 40 mg F (Use Colestipol HCl) MEVACOR TABS (Use NF QL(2 ea daily) colestipol hcl gran 5 gm F Lovastatin)

NV Silver Summit Updated September 1, 2018

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRAVACHOL TABS (Use NF QL(1 ea daily) lisinopril tabs 2.5 mg F QL(1 ea daily) Pravastatin Sodium) QL(1 ea daily) lisinopril tabs 5 mg, 10 mg, F QL(2 ea daily) pravastatin sodium tabs F 20 mg, 30 mg, 40 mg ST; QL(1 ea rosuvastatin calcium tabs F LOTENSIN TABS 10 MG, QL(1 ea daily) daily) 20 MG (Use Benazepril NF HCl) simvastatin tabs 5 mg, 10 F QL(1 ea daily) mg, 20 mg, 40 mg LOTENSIN TABS 40 MG NF QL(2 ea daily) (Use Benazepril HCl) simvastatin tabs 80 mg F MAVIK TABS (Use NF QL(1 ea daily) ZOCOR TABS 5 MG, 10 QL(1 ea daily) Trandolapril) MG, 20 MG, 40 MG (Use NF PRINIVIL TABS (Use NF QL(2 ea daily) Simvastatin) Lisinopril) ZOCOR TABS 80 MG (Use NF QL(1 ea daily) Simvastatin) quinapril hcl tabs F Intestinal Cholesterol Absorption Inhibitors ramipril caps F QL(2 ea daily) ezetimibe tabs 10 mg F PA trandolapril tabs 1 mg, 2 F QL(1 ea daily) mg ZETIA TABS (Use NF PA Ezetimibe) trandolapril tabs 4 mg F QL(2 ea daily) Nicotinic Acid Derivatives VASOTEC TABS (Use NF QL(2 ea daily) niacin (antihyperlipidemic) F Enalapril Maleate) tbcr ZESTRIL TABS 2.5 MG NF QL(1 ea daily) NIACOR TABS F (Use Lisinopril) ZESTRIL TABS 5 MG, 10 QL(2 ea daily) NIASPAN TBCR (Use NF MG, 20 MG, 30 MG, 40 MG NF Niacin (Antihyperlipidemic)) (Use Lisinopril) ANTIHYPERTENSIVES - Drugs to Treat High Angiotensin II Receptor Antagonists Blood Pressure ATACAND TABS (Use NF ACE Inhibitors Candesartan Cilexetil) ACCUPRIL TABS (Use QL(1 ea daily) NF AVAPRO TABS (Use NF QL(1 ea daily) Quinapril HCl) Irbesartan) ALTACE CAPS (Use QL(2 ea daily) NF BENICAR TABS (Use NF ST Ramipril) Olmesartan Medoxomil) benazepril hcl tabs 40 mg F QL(2 ea daily) candesartan cilexetil tabs F benazepril hcl tabs 5 mg, QL(1 ea daily) F COZAAR TABS (Use NF QL(1 ea daily) 10 mg, 20 mg Losartan Potassium) QL(3 ea daily) captopril tabs F DIOVAN TABS (Use NF QL(1 ea daily) Valsartan) QL(2 ea daily) enalapril maleate tabs F irbesartan tabs F QL(1 ea daily) EPANED SOLR F AL(Up to 8 yrs QL(1 ea daily) old ) losartan potassium tabs F QL(1 ea daily) fosinopril sodium tabs F MICARDIS TABS (Use NF QL(1 ea daily) Telmisartan) NV Silver Summit Updated September 1, 2018

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olmesartan medoxomil tabs F ST amlodipine besylate- QL(1 ea daily) benazepril hcl caps 5mg- F telmisartan tabs F QL(1 ea daily) 10mg, 5mg-20mg, 10mg- 20mg, 2.5mg-10mg QL(1 ea daily) valsartan tabs F amlodipine besylate- F ST olmesartan medoxomil tabs Antiadrenergic Antihypertensives amlodipine besylate- F ST valsartan tabs CARDURA TABS (Use NF Doxazosin Mesylate) amlodipine-valsartan- F ST hydrochlorothiazide tabs CATAPRES TABS (Use NF Clonidine HCl) ATACAND HCT TABS (Use Candesartan Cilexetil- NF CATAPRES-TTS-1 PTWK NF (Use Clonidine HCl) Hydrochlorothiazide) atenolol & chlorthalidone QL(1 ea daily) CATAPRES-TTS-2 PTWK NF F (Use Clonidine HCl) tabs AVALIDE TABS (Use QL(1 ea daily) CATAPRES-TTS-3 PTWK NF (Use Clonidine HCl) Irbesartan- NF Hydrochlorothiazide) clonidine hcl ptwk F AZOR TABS (Use ST Amlodipine Besylate- NF clonidine hcl tabs F Olmesartan Medoxomil) benazepril & QL(1 ea daily) doxazosin mesylate tabs or F F 1 mg, 2 mg, 4 mg, 8 mg hydrochlorothiazide tabs BENICAR HCT TABS (Use ST guanfacine hcl tabs F Olmesartan Medoxomil- NF Hydrochlorothiazide) methyldopa tabs F bisoprolol & QL(1 ea daily) MINIPRESS CAPS (Use NF hydrochlorothiazide tabs F Prazosin HCl) 5mg-6.25mg, 10mg- 6.25mg prazosin hcl caps F candesartan cilexetil- F hydrochlorothiazide tabs TENEX TABS (Use NF Guanfacine HCl) CAPTOPRIL/HYDROCHL F QL(2 ea daily) terazosin hcl caps F OROTHIAZIDE TABS DIOVAN HCT TABS (Use QL(1 ea daily) Antihypertensive Combinations Valsartan- NF ACCURETIC TABS 10MG- QL(3 ea daily) Hydrochlorothiazide) 12.5MG (Use Quinapril- NF DUTOPROL TB24 F QL(1 ea daily) Hydrochlorothiazide) ACCURETIC TABS 20MG- QL(4 ea daily) enalapril maleate & F QL(2 ea daily) 12.5MG (Use Quinapril- NF hydrochlorothiazide tabs Hydrochlorothiazide) EXFORGE HCT TABS ST ACCURETIC TABS 20MG- QL(2 ea daily) (Use Amlodipine-Valsartan- NF 25MG (Use Quinapril- NF Hydrochlorothiazide) Hydrochlorothiazide) EXFORGE TABS (Use ST Amlodipine Besylate- NF Valsartan)

NV Silver Summit Updated September 1, 2018

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fosinopril sodium & F QL(1 ea daily) quinapril- QL(4 ea daily) hydrochlorothiazide tabs hydrochlorothiazide tabs F HYZAAR TABS (Use QL(1 ea daily) 20mg-12.5mg Losartan Potassium & NF quinapril- QL(2 ea daily) Hydrochlorothiazide) hydrochlorothiazide tabs F 20mg-25mg irbesartan- F QL(1 ea daily) hydrochlorothiazide tabs TEKTURNA HCT TABS F lisinopril & QL(2 ea daily) hydrochlorothiazide tabs F telmisartan-amlodipine tabs F 10mg-12.5mg, 20mg- 12.5mg telmisartan- F QL(1 ea daily) lisinopril & QL(1 ea daily) hydrochlorothiazide tabs hydrochlorothiazide tabs F TENORETIC 100 TABS QL(1 ea daily) 20mg-25mg (Use Atenolol & NF LOPRESSOR HCT TABS QL(2 ea daily) Chlorthalidone) (Use Metoprolol & NF TENORETIC 50 TABS QL(1 ea daily) Hydrochlorothiazide) (Use Atenolol & NF Chlorthalidone) losartan potassium & F QL(1 ea daily) hydrochlorothiazide tabs TRIBENZOR TABS (Use ST LOTENSIN HCT TABS QL(1 ea daily) Olmesartan Medoxomil- NF (Use Benazepril & NF Amlodipine- Hydrochlorothiazide) Hydrochlorothiazide) LOTREL CAPS 5MG- QL(1 ea daily) TWYNSTA TABS (Use NF Telmisartan-Amlodipine) 10MG, 5MG-20MG, 10MG- NF 20MG (Use Amlodipine valsartan- F QL(1 ea daily) Besylate-Benazepril HCl) hydrochlorothiazide tabs VASERETIC TABS (Use QL(2 ea daily) metoprolol & F QL(2 ea daily) hydrochlorothiazide tabs Enalapril Maleate & NF METOPROLOL QL(1 ea daily) Hydrochlorothiazide) ZESTORETIC TABS QL(2 ea daily) SUCCINATE F ER/HYDROCHLOROTHIA 10MG-12.5MG, 20MG- NF ZIDE TB24 12.5MG (Use Lisinopril & Hydrochlorothiazide) METOPROLOL/HYDROCH F QL(2 ea daily) LOROTHIAZIDE TABS ZESTORETIC TABS QL(1 ea daily) MICARDIS HCT TABS QL(1 ea daily) 20MG-25MG (Use NF (Use Telmisartan- NF Lisinopril & Hydrochlorothiazide) Hydrochlorothiazide) olmesartan medoxomil- ST ZIAC TABS 5MG-6.25MG, QL(1 ea daily) amlodipine- F 10MG-6.25MG (Use NF hydrochlorothiazide tabs Bisoprolol & Hydrochlorothiazide) olmesartan medoxomil- F ST hydrochlorothiazide tabs Direct Renin Inhibitors PROPRANOLOL/HYDROC F TEKTURNA TABS F HLOROTHIAZIDE TABS quinapril- QL(3 ea daily) Vasodilators hydrochlorothiazide tabs F hydralazine hcl tabs or 10 F 10mg-12.5mg mg, 25 mg, 50 mg, 100 mg

NV Silver Summit Updated September 1, 2018

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits minoxidil tabs F isoniazid tabs or 100 mg, F 300 mg ANTIMALARIALS - Drugs to Treat Malaria MYAMBUTOL TABS (Use NF (Parasitic Infections) Ethambutol HCl) Antimalarial Combinations pyrazinamide tabs F COARTEM TABS F QL(24 ea per fill retail) RIFADIN CAPS OR 150 MG, 300 MG (Use NF Antimalarials Rifampin) CHLOROQUINE QL(2 ea daily) rifampin caps or 150 mg, F PHOSPHATE TABS 250 F 300 mg MG TRECATOR TABS F chloroquine phosphate F QL(8 ea per 56 tabs 500 mg days retail) ANTINEOPLASTICS AND ADJUNCTIVE hydroxychloroquine sulfate F THERAPIES - Drugs to Treat Cancer tabs 200 mg Alkylating Agents mefloquine hcl tabs F ALKERAN TABS OR 2 MG NF (Use Melphalan) MEFLOQUINE HCL TABS F cyclophosphamide caps or F PLAQUENIL TABS (Use 25 mg, 50 mg Hydroxychloroquine NF CYCLOPHOSPHAMIDE Sulfate) CAPS OR 25 MG, 50 MG NF (Use Cyclophosphamide) PRIMAQUINE F PA PHOSPHATE TABS LEUKERAN TABS F ANTIMYASTHENIC/CHOLINERGIC AGENTS melphalan tabs 2 mg F Antimyasthenic/Cholinergic Agents MESTINON TABS 60 MG MYLERAN TABS 2 MG F (Use Pyridostigmine NF TEMODAR CAPS OR 5 PA; SP Bromide) MG, 20 MG, 100 MG, 140 NF MESTINON TIMESPAN MG, 180 MG, 250 MG (Use TBCR (Use Pyridostigmine NF Temozolomide) Bromide) TEMODAR SOLR IV 100 F PA; SP pyridostigmine bromide F MG tabs temozolomide caps F PA; SP pyridostigmine bromide F tbcr Antimetabolites ANTIMYCOBACTERIAL AGENTS - Drugs to PA; SP Treat Tuberculosis (Bacterial Infections) capecitabine tabs F Antimycobacterial Agents mercaptopurine tabs F ethambutol hcl tabs F methotrexate sodium soln ij 1 gm/40ml, 50 mg/2ml, 200 F ISONIAZID SYRP OR 50 F mg/8ml, 250 mg/10ml MG/5ML

NV Silver Summit Updated September 1, 2018

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHOTREXATE flutamide caps F SODIUM SOLN IJ 250 F MG/10ML PA; Limit 5ml per methotrexate sodium tabs F HYDROXYPROGESTERO or 2.5 mg F month;QL(0.16 NE CAPROATE SOLN 7 ml daily); PURIXAN SUSP F AL(Up to 8 yrs 1.25 GM/5ML old ) AL(At least 16 yrs old); SP TREXALL TABS F ST; Try anastrozole or letrozole tabs 2.5 mg F XELODA TABS (Use NF PA; SP exemastane Capecitabine) first Antineoplastic - Hedgehog Pathway Inhibitors leuprolide acetate kit F PA; SP ERIVEDGE CAPS F PA; SP LUPRON DEPOT (1- F PA; SP ODOMZO CAPS F PA; SP MONTH) KIT LUPRON DEPOT (3- F PA; SP Antineoplastic - Hormonal and Related Agents MONTH) KIT anastrozole tabs 1 mg F LUPRON DEPOT (4- F PA; SP MONTH) KIT ARIMIDEX TABS (Use NF LUPRON DEPOT (6- F PA; SP Anastrozole) MONTH) KIT ST; Try LYSODREN TABS F SP AROMASIN TABS (Use NF anastrozole or Exemestane) letrozole MEGACE ORAL SUSP NF first;SP (Use Megestrol Acetate) QL(1 ea daily) bicalutamide tabs 50 mg F megestrol acetate susp or F 40 mg/ml, 400 mg/10ml CASODEX TABS (Use QL(1 ea daily) NF megestrol acetate tabs or F Bicalutamide) 20 mg, 40 mg PA; SP ELIGARD KIT F tamoxifen citrate tabs F SP EMCYT CAPS F TRELSTAR MIXJECT F PA; SP SUSR ERLEADA TABS F PA TRELSTAR SUSR F PA; SP ST; Try anastrozole or VANTAS KIT F PA; SP exemestane tabs 25 mg F letrozole first;SP XTANDI CAPS F PA; SP PA FARESTON TABS F ZOLADEX IMPL F PA; SP ST; Try ZYTIGA TABS 250 MG F PA; SP FEMARA TABS (Use NF anastrozole or Letrozole) exemastane first Antineoplastic - Immunomodulators PA; SP FIRMAGON SOLR F PA; SP POMALYST CAPS F

NV Silver Summit Updated September 1, 2018

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antineoplastic Enzyme Inhibitors TYKERB TABS F PA; SP AFINITOR DISPERZ TBSO F PA; SP VOTRIENT TABS F PA; SP AFINITOR TABS F PA; SP XALKORI CAPS F PA; SP BOSULIF TABS F PA; SP ZELBORAF TABS F PA; SP COTELLIC TABS F PA; SP ZOLINZA CAPS F PA; SP FARYDAK CAPS F PA; SP ZYKADIA CAPS F PA; SP PA; SP GILOTRIF TABS F Antineoplastics Misc. GLEEVEC TABS (Use NF PA; SP bexarotene caps 75 mg F PA; SP Imatinib Mesylate) PA; SP HYDREA CAPS (Use NF IBRANCE CAPS F Hydroxyurea) ICLUSIG TABS F PA; SP hydroxyurea caps 500 mg F imatinib mesylate tabs F PA; SP MATULANE CAPS F SP

INLYTA TABS F PA; SP TARGRETIN CAPS OR 75 NF PA; SP MG (Use Bexarotene) ISTODAX (OVERFILL) PA; SP F tretinoin (chemotherapy) F SP SOLR caps ISTODAX SOLR F PA; SP Chemotherapy Rescue/Antidote Agents PA; SP LEUCOVORIN CALCIUM F JAKAFI TABS F TABS OR 10 MG, 15 MG PA; SP leucovorin calcium tabs or F MEKINIST TABS F 5 mg, 25 mg NEXAVAR TABS F PA; SP MESNEX TABS OR 400 F SP MG NINLARO CAPS F PA; SP Mitotic Inhibitors PA; SP ETOPOSIDE CAPS OR 50 F SP ROMIDEPSIN SOLR F MG SPRYCEL TABS F PA; SP Topoisomerase I Inhibitors HYCAMTIN CAPS OR 0.25 F PA; SP STIVARGA TABS F PA; SP MG, 1 MG PA; SP ANTIPARKINSON AND RELATED THERAPY SUTENT CAPS F AGENTS - Drugs to Treat Parkinson's Disease TAFINLAR CAPS F PA; SP Antiparkinson Adjuvants carbidopa tabs 25 mg F TARCEVA TABS F PA; SP LODOSYN TABS (Use NF TASIGNA CAPS 150 MG, F PA; SP Carbidopa) 200 MG

NV Silver Summit Updated September 1, 2018

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antiparkinson Anticholinergics ropinirole hydrochloride QL(3 ea daily) tabs 0.5 mg, 1 mg, 2 mg, 5 F benztropine mesylate soln F mg SINEMET CR TBCR (Use NF benztropine mesylate tabs F Carbidopa-Levodopa) SINEMET TABS (Use COGENTIN SOLN (Use NF NF Benztropine Mesylate) Carbidopa-Levodopa) trihexyphenidyl hcl elix 0.4 F QL(16.67 ml Antiparkinson Monoamine Oxidase Inhibitors mg/ml daily) ELDEPRYL CAPS (Use NF trihexyphenidyl hcl tabs 2 F Selegiline HCl) mg, 5 mg selegiline hcl caps 5 mg F Antiparkinson Dopaminergics amantadine hcl caps 100 F selegiline hcl tabs 5 mg F mg ANTIPSYCHOTICS/ANTIMANIC AGENTS - amantadine hcl syrp 50 F mg/5ml Drugs to Treat Mood Disorders bromocriptine mesylate F Antimanic Agents caps lithium carbonate caps or F 150 mg, 300 mg, 600 mg bromocriptine mesylate F tabs LITHIUM CARBONATE carbidopa-levodopa tabs CAPS OR 150 MG, 600 NF 10mg-100mg, 25mg- F MG (Use Lithium 100mg, 25mg-250mg Carbonate) carbidopa-levodopa tbcr lithium carbonate tabs or F 25mg-100mg, 50mg- F 300 mg 200mg lithium carbonate tbcr or F MIRAPEX TABS (Use QL(3 ea daily) 300 mg, 450 mg Pramipexole NF Dihydrochloride) LITHIUM SOLN F PARLODEL CAPS (Use NF LITHOBID TBCR (Use NF Bromocriptine Mesylate) Lithium Carbonate) PARLODEL TABS (Use NF Antipsychotics - Misc. Bromocriptine Mesylate) pramipexole QL(3 ea daily) EQUETRO CP12 F dihydrochloride tabs 0.125 F GEODON CAPS OR 20 QL(2 ea daily); mg, 0.25 mg, 0.75 mg, 0.5 MG, 40 MG, 60 MG, 80 MG NF AL(At least 18 mg, 1 mg, 1.5 mg (Use Ziprasidone HCl) yrs old) REQUIP TABS 0.25 MG, 3 QL(6 ea daily) SP MG, 4 MG (Use Ropinirole NF GEODON SOLR IM 20 MG F Hydrochloride) LATUDA TABS 20 MG, 40 F REQUIP TABS 0.5 MG, 1 QL(3 ea daily) MG, 80 MG, 120 MG MG, 2 MG, 5 MG (Use NF QL(2 ea daily) Ropinirole Hydrochloride) NUPLAZID TABS 17 MG F ropinirole hydrochloride QL(6 ea daily) F VRAYLAR CAPS 3 MG, 6 F tabs 0.25 mg, 3 mg, 4 mg MG, 1.5 MG, 4.5 MG

NV Silver Summit Updated September 1, 2018

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); PA; Limit 2 F ziprasidone hcl caps AL(At least 18 RISPERDAL CONSTA F vials per yrs old) SUSR month;QL(0.07 2 ea daily); SP Benzisoxazoles QL(2 ea daily); FANAPT TABS F RISPERDAL M-TAB TBDP NF AL(At least 5 (Use Risperidone) yrs old) FANAPT TITRATION F PACK TABS QL(4 ml daily); RISPERDAL SOLN 1 NF AL(At least 5 MG/ML (Use Risperidone) PA; Limit 1 yrs old) INVEGA SUSTENNA F syringe per SUSP 117 MG/0.75ML month;QL(0.02 RISPERDAL TABS 0.25 QL(4 ea daily); 7 ml daily); SP MG, 0.5 MG, 1 MG, 2 MG, NF AL(At least 5 3 MG, 4 MG (Use yrs old) PA; Limit 1 Risperidone) INVEGA SUSTENNA F syringe per SUSP 156 MG/ML month;QL(0.03 QL(1 ea daily); 6 ml daily); SP RISPERIDONE ODT TBDP F AL(At least 5 yrs old) PA; Limit 1 QL(4 ml daily); INVEGA SUSTENNA F syringe per SUSP 234 MG/1.5ML month;QL(0.05 risperidone soln 1 mg/ml F AL(At least 5 4 ml daily); SP yrs old) PA; Limit 1 risperidone tabs 0.25 mg, QL(4 ea daily); 0.5 mg, 1 mg, 2 mg, 3 mg, F AL(At least 5 INVEGA SUSTENNA F syringe per SUSP 39 MG/0.25ML month;QL(0.00 4 mg yrs old) 9 ml daily); SP QL(1 ea daily); PA; Limit 1 risperidone tbdp 0.25 mg F AL(At least 5 yrs old) INVEGA SUSTENNA F syringe per SUSP 78 MG/0.5ML month;QL(0.01 QL(2 ea daily); risperidone tbdp 0.5 mg, 1 F AL(At least 5 8 ml daily); SP mg, 2 mg, 3 mg, 4 mg yrs old) INVEGA TB24 (Use NF Paliperidone) Butyrophenones PA; Limit 1 HALDOL DECANOATE INVEGA TRINZA SUSP syringe every 3 100 SOLN (Use NF 273 MG/0.875ML, 410 F months;QL(1 Haloperidol Decanoate) MG/1.315ML ml per 84 days HALDOL DECANOATE 50 retail); SP SOLN (Use Haloperidol NF PA; Limit 1 Decanoate) syringe every 3 INVEGA TRINZA SUSP HALDOL SOLN (Use NF F months;QL(2 Haloperidol Lactate) 546 MG/1.75ML ml per 84 days retail); SP haloperidol decanoate soln F PA; Limit 1 syringe every 3 haloperidol lactate conc F INVEGA TRINZA SUSP F months;QL(3 819 MG/2.625ML ml per 84 days haloperidol lactate soln F retail); SP haloperidol tabs 0.5 mg, 1 F QL(3 ea daily) paliperidone tb24 F mg, 10 mg

NV Silver Summit Updated September 1, 2018

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits haloperidol tabs 2 mg, 5 F quetiapine fumarate tabs F QL(2 ea daily) mg, 20 mg 300 mg, 400 mg Dibenzapines quetiapine fumarate tb24 F QL(3 ea daily) 50 mg, 150 mg, 200 mg, CLOZAPINE ODT TBDP F 300 mg, 400 mg QL(9 ea daily); SAPHRIS SUBL F clozapine tabs 100 mg F AL(At least 18 yrs old) SEROQUEL TABS 25 MG, QL(4 ea daily) 50 MG, 100 MG, 200 MG NF QL(3 ea daily); ) clozapine tabs 25 mg, 50 F AL(At least 18 (Use Quetiapine Fumarate mg, 200 mg yrs old) SEROQUEL TABS 300 QL(2 ea daily) NF QL(9 ea daily) MG, 400 MG (Use clozapine tbdp 100 mg F Quetiapine Fumarate) SEROQUEL XR TB24 (Use clozapine tbdp 25 mg, 12.5 F QL(3 ea daily) NF mg Quetiapine Fumarate) QL(9 ea daily); VERSACLOZ SUSP F CLOZARIL TABS 100 MG NF AL(At least 18 (Use Clozapine) yrs old) PA; Limit 2 QL(3 ea daily); ZYPREXA RELPREVV F vials per CLOZARIL TABS 25 MG NF SUSR month;QL(0.07 (Use Clozapine) AL(At least 18 2 ea daily); SP yrs old) ZYPREXA SOLR IM 10 NF FAZACLO TBDP 100 MG NF QL(9 ea daily) Use Olanzapine) (Use Clozapine) MG ( ZYPREXA TABS OR 10 QL(2 ea daily); FAZACLO TBDP 150 MG, F QL(3 ea daily) MG, 7.5 MG (Use NF AL(At least 13 200 MG Olanzapine) yrs old) QL(3 ea daily) FAZACLO TBDP 25 MG, NF ZYPREXA TABS OR 15 QL(1 ea daily); 12.5 MG (Use Clozapine) MG, 20 MG (Use NF AL(At least 13 loxapine succinate caps F QL(4 ea daily) Olanzapine) yrs old) ZYPREXA TABS OR 5 QL(4 ea daily); olanzapine solr im 10 mg F MG, 2.5 MG (Use NF AL(At least 13 Olanzapine) yrs old) QL(2 ea daily); olanzapine tabs or 10 mg, F AL(At least 13 QL(1 ea daily); 7.5 mg ZYPREXA ZYDIS TBDP NF yrs old) (Use Olanzapine) AL(At least 13 yrs old) QL(1 ea daily); olanzapine tabs or 15 mg, F AL(At least 13 Dihydroindolones 20 mg yrs old) MOLINDONE F QL(4 ea daily); HYDROCHLORIDE TABS olanzapine tabs or 5 mg, F AL(At least 13 2.5 mg Phenothiazines yrs old) CHLORPROMAZINE HCL F QL(1 ea daily); SOLN IJ 25 MG/ML olanzapine tbdp or 5 mg, F AL(At least 13 10 mg, 15 mg, 20 mg yrs old) chlorpromazine hcl tabs or F QL(10 ea daily) 10 mg quetiapine fumarate tabs QL(4 ea daily) 25 mg, 50 mg, 100 mg, 200 F chlorpromazine hcl tabs or QL(3 ea daily) mg 25 mg, 50 mg, 100 mg, 200 F mg

NV Silver Summit Updated September 1, 2018

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluphenazine decanoate F Thioxanthenes soln thiothixene caps F QL(3 ea daily) FLUPHENAZINE HCL F CONC OR 5 MG/ML ANTISEPTICS & DISINFECTANTS FLUPHENAZINE HCL F ELIX OR 2.5 MG/5ML Antiseptics & Disinfectants FLUPHENAZINE HCL F formaldehyde soln 10%, 10 F QL(90 ml per SOLN IJ 2.5 MG/ML % fill retail) fluphenazine hcl tabs or 1 F mg, 5 mg, 10 mg, 2.5 mg Chlorine Antiseptics QL(4 ea daily) chlorhexidine gluconate F perphenazine tabs F liqd 4 % prochlorperazine edisylate F dakin's solution soln F soln DAKINS SOLUTION prochlorperazine maleate F tabs or 5 mg, 10 mg QUARTER STRENGTH NF SOLN (Use Dakin's prochlorperazine supp F Solution) HIBICLENS LIQD (Use NF thioridazine hcl tabs F QL(3 ea daily) Chlorhexidine Gluconate) trifluoperazine hcl tabs F QL(3 ea daily) Iodine Antiseptics BETADINE SOLN 10 % NF Quinolinone Derivatives (Use Povidone-Iodine) ABILIFY TABS (Use NF QL(1 ea daily) povidone-iodine soln 10 % F Aripiprazole) QL(25 ml ANTIVIRALS - Drugs to Treat Viral Infections aripiprazole soln 1 mg/ml F daily); AL(At least 6 yrs old) Antiretrovirals aripiprazole tabs 2 mg, 5 QL(1 ea daily) abacavir sulfate soln 20 F QL(30 ml daily) mg, 10 mg, 15 mg, 20 mg, F mg/ml 30 mg abacavir sulfate tabs 300 F QL(2 ea daily) aripiprazole tbdp 10 mg, 15 F QL(1 ea daily) mg mg abacavir sulfate-lamivudine F QL(1 ea daily) PA; Limit 1 tabs 600mg-300mg ARISTADA PRSY 441 F syringe per abacavir sulfate- QL(2 ea daily) MG/1.6ML month;QL(0.05 lamivudine-zidovudine tabs F 7 ml daily); SP 300mg-150mg-300mg PA; Limit 1 APTIVUS CAPS 250 MG F QL(4 ea daily) ARISTADA PRSY 662 F syringe per MG/2.4ML month;QL(0.08 APTIVUS SOLN 100 F QL(10 ml daily) 6 ml daily); SP MG/ML PA; Limit 1 atazanavir sulfate caps F QL(2 ea daily) ARISTADA PRSY 882 F syringe per MG/3.2ML month;QL(0.11 QL(1 ea daily) 4 ml daily); SP ATRIPLA TABS F

REXULTI TABS F COMBIVIR TABS (Use NF QL(2 ea daily) Lamivudine-Zidovudine) NV Silver Summit Updated September 1, 2018

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMPLERA TABS F QL(1 ea daily) ISENTRESS CHEW 100 F QL(6 ea daily) MG QL(9 ea daily) CRIXIVAN CAPS 200 MG F ISENTRESS CHEW 25 MG F QL(12 ea daily) QL(6 ea daily) CRIXIVAN CAPS 400 MG F ISENTRESS PACK 100 F QL(2 ea daily) MG QL(1 ea daily) DESCOVY TABS F ISENTRESS TABS 400 F QL(2 ea daily) MG QL(1 ea daily) didanosine cpdr F Limit 1 package KALETRA SOLN per EDURANT TABS F QL(1 ea daily) 400MG/5ML-100MG/5ML NF (Use Lopinavir-Ritonavir) claim;QL(160 ml per fill retail) efavirenz caps 200 mg F QL(1 ea daily) KALETRA TABS 100MG- F QL(4 ea daily) 25MG efavirenz caps 50 mg F QL(2 ea daily) KALETRA TABS 200MG- F QL(6 ea daily) 50MG efavirenz tabs 600 mg F QL(1 ea daily) lamivudine soln 10 mg/ml F QL(30 ml daily) EMTRIVA CAPS 200 MG F QL(1 ea daily) lamivudine tabs 150 mg F QL(2 ea daily) EMTRIVA SOLN 10 F QL(24 ml daily) MG/ML lamivudine tabs 300 mg F QL(1 ea daily) EPIVIR SOLN 10 MG/ML NF QL(30 ml daily) (Use Lamivudine) lamivudine-zidovudine tabs F QL(2 ea daily) 150mg-300mg EPIVIR TABS 150 MG NF QL(2 ea daily) (Use Lamivudine) LEXIVA SUSP 50 MG/ML F QL(56 ml daily) EPIVIR TABS 300 MG NF QL(1 ea daily) (Use Lamivudine) LEXIVA TABS 700 MG QL(4 ea daily) (Use Fosamprenavir NF EPZICOM TABS (Use QL(1 ea daily) Calcium) Abacavir Sulfate- NF Lamivudine) Limit 1 package per lopinavir-ritonavir soln F EVOTAZ TABS F QL(1 ea daily) claim;QL(160 ml per fill retail) fosamprenavir calcium tabs F QL(4 ea daily) nevirapine susp 50 mg/5ml F QL(40 ml daily) FUZEON SOLR F SP nevirapine tabs 200 mg F QL(2 ea daily) GENVOYA TABS F QL(1 ea daily) nevirapine tb24 100 mg F QL(3 ea daily) INTELENCE TABS 200 F QL(2 ea daily) MG nevirapine tb24 400 mg F QL(1 ea daily) INTELENCE TABS 25 MG, F QL(4 ea daily) QL(12 ea daily) 100 MG NORVIR CAPS 100 MG F QL(10 ea daily) INVIRASE CAPS 200 MG F NORVIR SOLN 80 MG/ML F QL(15 ml daily) QL(4 ea daily) INVIRASE TABS 500 MG F NORVIR TABS 100 MG NF QL(12 ea daily) (Use Ritonavir)

NV Silver Summit Updated September 1, 2018

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREZCOBIX TABS F TIVICAY TABS 50 MG F

PREZISTA SUSP 100 F QL(12 ml daily) TRIUMEQ TABS F QL(1 ea daily) MG/ML QL(3 ea daily) TRIZIVIR TABS (Use QL(2 ea daily) PREZISTA TABS 150 MG F Abacavir Sulfate- NF Lamivudine-Zidovudine) PREZISTA TABS 75 MG, F QL(2 ea daily) 600 MG TRUVADA TABS F QL(1 ea daily) PREZISTA TABS 800 MG F QL(1 ea daily) TYBOST TABS F QL(1 ea daily) RESCRIPTOR TABS 100 F QL(12 ea daily) MG VIDEX EC CPDR 125 MG F QL(1 ea daily) RESCRIPTOR TABS 200 F QL(6 ea daily) MG VIDEX EC CPDR 200 MG, QL(1 ea daily) 250 MG, 400 MG (Use NF RETROVIR CAPS 100 MG NF QL(6 ea daily) Didanosine) (Use Zidovudine) VIDEXPEDIATRIC SOLR F QL(20 ml daily) RETROVIR IV INFUSION F SOLN VIRACEPT TABS 250 MG F QL(9 ea daily) RETROVIR SYRP 50 NF QL(60 ml daily) MG/5ML (Use Zidovudine) VIRACEPT TABS 625 MG F QL(4 ea daily) REYATAZ CAPS 150 MG, QL(2 ea daily) 200 MG, 300 MG (Use NF VIRAMUNE SUSP 50 NF QL(40 ml daily) Atazanavir Sulfate) MG/5ML (Use Nevirapine) QL(6 ea daily) REYATAZ PACK 50 MG F VIRAMUNE TABS 200 MG NF QL(2 ea daily) (Use Nevirapine) QL(12 ea daily) ritonavir tabs F VIRAMUNE XR TB24 100 NF QL(3 ea daily) MG (Use Nevirapine) SELZENTRY TABS 150 QL(2 ea daily) F VIRAMUNE XR TB24 400 NF QL(1 ea daily) MG MG (Use Nevirapine) QL 2 per QL(8 gm daily) SELZENTRY TABS 25 F VIREAD POWD 40 MG/GM F MG, 75 MG day;SL(2 ea daily) VIREAD TABS 150 MG, F QL(1 ea daily) SELZENTRY TABS 300 F QL(4 ea daily) 200 MG, 250 MG MG VIREAD TABS 300 MG QL(1 ea daily) stavudine caps F QL(2 ea daily) (Use Tenofovir Disoproxil NF Fumarate) QL(1 ea daily) STRIBILD TABS F VITEKTA TABS F QL(1 ea daily) SUSTIVA CAPS 200 MG NF QL(1 ea daily) ZERIT CAPS 15 MG, 20 QL(2 ea daily) (Use Efavirenz) MG, 30 MG, 40 MG (Use NF SUSTIVA CAPS 50 MG NF QL(2 ea daily) Stavudine) (Use Efavirenz) ZERIT SOLR 1 MG/ML F QL(80 ml daily) SUSTIVA TABS 600 MG NF QL(1 ea daily) (Use Efavirenz) ZIAGEN SOLN 20 MG/ML NF QL(30 ml daily) (Use Abacavir Sulfate) tenofovir disoproxil F QL(1 ea daily) fumarate tabs ZIAGEN TABS 300 MG NF QL(2 ea daily) (Use Abacavir Sulfate)

NV Silver Summit Updated September 1, 2018

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits zidovudine caps 100 mg F QL(6 ea daily) Limit 400ml per ZOVIRAX SUSP OR 200 NF month;QL(13.3 MG/5ML (Use Acyclovir) zidovudine syrp 50 mg/5ml F QL(60 ml daily) 4 ml daily) ZOVIRAX TABS OR 400 NF QL(3 ea daily) zidovudine tabs 300 mg F QL(2 ea daily) MG (Use Acyclovir) Limit 50 per CMV Agents ZOVIRAX TABS OR 800 NF month;QL(1.67 MG (Use Acyclovir) ea daily) VALCYTE TABS 450 MG NF QL(2 ea daily) (Use Valganciclovir HCl) Influenza Agents valganciclovir hcl tabs 450 QL(2 ea daily) F oseltamivir phosphate caps F QL(20 ea per mg or 30 mg 30 days retail) Hepatitis Agents oseltamivir phosphate caps F QL(10 ea per or 45 mg, 75 mg 30 days retail) adefovir dipivoxil tabs 10 F mg oseltamivir phosphate susr F QL(120 ml per or 6 mg/ml 30 days retail) BARACLUDE TABS 0.5 NF MG, 1 MG (Use Entecavir) Limit 1 package per entecavir tabs F RELENZA DISKHALER F month;QL(0.67 AEPB ea daily); AL(At HEPSERA TABS (Use NF Adefovir Dipivoxil) least 6 yrs old) TAMIFLU CAPS 30 MG QL(20 ea per Herpes Agents (Use Oseltamivir NF 30 days retail) Limit 50 per Phosphate) acyclovir caps 200 mg F month;QL(1.67 TAMIFLU CAPS 45 MG, 75 QL(10 ea per ea daily) MG (Use Oseltamivir NF 30 days retail) Limit 400ml per Phosphate) acyclovir susp 200 mg/5ml F month;QL(13.3 TAMIFLU SUSR 6 MG/ML QL(120 ml per 4 ml daily) (Use Oseltamivir NF 30 days retail) acyclovir tabs 400 mg F QL(3 ea daily) Phosphate) Limit 50 per BETA BLOCKERS - Drugs to Treat High Blood acyclovir tabs 800 mg F month;QL(1.67 Pressure ea daily) Alpha-Beta Blockers Limit 21 per carvedilol phosphate cp24 F QL(1 ea daily) valacyclovir hcl tabs 1 gm, F Month;QL(42 1000 mg ea per 21 days carvedilol tabs 12.5 mg, F QL(3 ea daily) retail) 6.25 mg, 3.125 mg valacyclovir hcl tabs 500 F QL(2 ea daily) QL(4 ea daily) mg carvedilol tabs 25 mg F Limit 21 per COREG CR CP24 (Use NF QL(1 ea daily) VALTREX TABS 1 GM NF Month;QL(42 Carvedilol Phosphate) (Use Valacyclovir HCl) ea per 21 days COREG TABS 12.5 MG, QL(3 ea daily) retail) 6.25 MG, 3.125 MG (Use NF VALTREX TABS 500 MG NF QL(2 ea daily) Carvedilol) (Use Valacyclovir HCl) COREG TABS 25 MG (Use NF QL(4 ea daily) Limit 50 per Carvedilol) ZOVIRAX CAPS OR 200 NF month;QL(1.67 MG (Use Acyclovir) ea daily) NV Silver Summit Updated September 1, 2018

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

NV Silver Summit Updated September 1, 2018

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diltiazem hcl coated beads QL(1 ea daily) VERELAN CP24 120 MG, QL(2 ea daily) cp24 120 mg, 180 mg, 300 F 180 MG, 240 MG (Use NF mg Verapamil HCl) diltiazem hcl coated beads F QL(2 ea daily) VERELAN CP24 360 MG F QL(1 ea daily) cp24 240 mg diltiazem hcl cp12 or 60 F QL(2 ea daily) CARDIOTONICS - Drugs to Treat Heart Failure mg, 90 mg, 120 mg and Abnormal Heart Rhythm diltiazem hcl cp24 or 120 F QL(1 ea daily) Cardiac Glycosides mg, 180 mg DIGOXIN SOLN OR 0.05 F diltiazem hcl cp24 or 240 F QL(2 ea daily) MG/ML mg digoxin tabs or 0.125 mg, diltiazem hcl extended F QL(1 ea daily) 0.25 mg, 125 mcg, 250 F release beads cp24 mcg diltiazem hcl tabs or 30 mg, F QL(3 ea daily) LANOXIN TABS OR 125 60 mg, 90 mg, 120 mg MCG, 250 MCG (Use NF felodipine tb24 F QL(1 ea daily) Digoxin) CARDIOVASCULAR AGENTS - MISC. - Drugs to nicardipine hcl caps or 20 F Treat Heart and Circulation Conditions mg, 30 mg Peripheral Vasodilators nifedipine caps 10 mg, 20 F QL(4 ea daily) mg isoxsuprine hcl tabs 10 mg F nifedipine tb24 30 mg, 90 F QL(1 ea daily) mg Prostaglandin Vasodilators nifedipine tb24 60 mg F QL(2 ea daily) TYVASO REFILL SOLN F PA

NORVASC TABS (Use NF QL(1 ea daily) TYVASO SOLN F PA Amlodipine Besylate) PA PROCARDIA CAPS (Use NF QL(4 ea daily) TYVASO STARTER SOLN F Nifedipine) PROCARDIA XL TB24 30 QL(1 ea daily) VENTAVIS SOLN F PA MG, 90 MG (Use NF Nifedipine) Pulmonary Hypertension - Endothelin Receptor PA; SP PROCARDIA XL TB24 60 NF QL(2 ea daily) LETAIRIS TABS F MG (Use Nifedipine) TIAZAC CP24 (Use QL(1 ea daily) TRACLEER TABS 125 F PA; SP Diltiazem HCl Extended NF MG, 62.5 MG Release Beads) TRACLEER TBSO 32 MG F PA verapamil hcl cp24 or 120 F QL(2 ea daily) mg, 180 mg, 240 mg Pulmonary Hypertension - Phosphodiesterase VERAPAMIL HCL SR F QL(1 ea daily) REVATIO SOLN IV 10 PA; SP CP24 MG/12.5ML (Use Sildenafil NF Citrate (Pulmonary verapamil hcl tabs or 40 F QL(3 ea daily) mg, 80 mg, 120 mg Hypertension)) REVATIO SUSR OR 10 PA; SP verapamil hcl tbcr or 120 F QL(2 ea daily) F mg, 180 mg, 240 mg MG/ML

NV Silver Summit Updated September 1, 2018

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REVATIO TABS OR 20 PA; SP Cephalosporins - 3rd Generation NF MG (Use Sildenafil Citrate QL(20 ea per (Pulmonary Hypertension)) cefdinir caps 300 mg F fill retail) sildenafil citrate (pulmonary PA; SP F Limit 1 package hypertension) soln cefdinir susr 125 mg/5ml, F per sildenafil citrate (pulmonary F PA; SP 250 mg/5ml claim;QL(100 hypertension) tabs ml per fill retail) CEPHALOSPORINS - Drugs to Treat Bacterial ceftriaxone sodium solr ij 1 F Infections gm, 500 mg Cephalosporins - 1st Generation ceftriaxone sodium solr ij F QL(3 ea per fill 250 mg retail) cefadroxil caps F ceftriaxone sodium solr iv 1 F gm cefadroxil susr F CONTRACEPTIVES - Drugs to Prevent cefadroxil tabs F Pregnancy Combination Contraceptives - Oral cephalexin caps 250 mg, F 500 mg BREVICON-28 TABS (Use QL(1 ea daily) Norethindrone & Eth NF cephalexin susr 125 F mg/5ml, 250 mg/5ml Estradiol) CYCLESSA TABS (Use QL(1 ea daily) KEFLEX CAPS 250 MG, NF 500 MG (Use Cephalexin) Desogestrel-Ethinyl NF Estradiol (Triphasic)) Cephalosporins - 2nd Generation DESOGEN TABS (Use QL(1 ea daily) cefaclor caps 250 mg, 500 F Desogestrel & Ethinyl NF mg Estradiol) CEFACLOR SUSR 125 desogestrel & ethinyl F QL(1 ea daily) MG/5ML, 250 MG/5ML, F estradiol tabs 375 MG/5ML desogestrel-ethinyl F QL(1 ea daily) Limit 1 estradiol (biphasic) tabs package per desogestrel-ethinyl F QL(1 ea daily) cefprozil susr 125 mg/5ml, F claim;QL(100 estradiol (triphasic) tabs 250 mg/5ml ml per fill retail); AL(Up to drospirenone-ethinyl F QL(1 ea daily) 12 yrs old ) estradiol tabs ESTROSTEP FE TABS cefprozil tabs 250 mg, 500 F QL(20 ea per mg fill retail) (Use Norethindrone NF Acetate-Ethinyl Estradiol- Limit 1 Fe) package per ethynodiol diacet & eth QL(1 ea daily) CEFTIN SUSR 125 F claim;QL(100 F MG/5ML, 250 MG/5ML ml per fill estrad tabs retail); AL(Up to FEMCON FE CHEW (Use 12 yrs old ) Norethindrone & Ethinyl NF Estradiol-Fe) CEFTIN TABS 500 MG NF QL(20 ea per (Use Cefuroxime Axetil) fill retail) GENERESS FE CHEW QL(20 ea per (Use Norethindrone & NF cefuroxime axetil tabs F fill retail) Ethinyl Estradiol-Fe)

NV Silver Summit Updated September 1, 2018

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits levonorgestrel & eth F QL(1 ea daily) norgestrel & ethinyl F QL(1 ea daily) estradiol tabs estradiol tabs levonorgestrel-eth estradiol F QL(1 ea daily) NORINYL 1+35 TABS (Use QL(1 ea daily) (triphasic) tabs Norethindrone & Eth NF Estradiol) levonorgestrel-ethinyl F QL(1 ea daily) estradiol (91-day) tabs OGESTREL TABS F QL(1 ea daily) LOESTRIN 1.5/30-21 QL(1 ea daily) TABS (Use Norethindrone NF ORTHO TRI-CYCLEN LO QL(1 ea daily) Acet & Eth Estra) TABS (Use Norgestimate- NF LOESTRIN 1/20-21 TABS QL(1 ea daily) Ethinyl Estradiol (Use Norethindrone Acet & NF (Triphasic)) Eth Estra) ORTHO TRI-CYCLEN QL(1 ea daily) LOESTRIN FE 1.5/30 QL(1 ea daily) TABS (Use Norgestimate- NF TABS (Use Norethin Acet & NF Ethinyl Estradiol Estrad-Fe) (Triphasic)) LOESTRIN FE 1/20 TABS QL(1 ea daily) ORTHO-CYCLEN TABS QL(1 ea daily) (Use Norethin Acet & NF (Use Norgestimate-Ethinyl NF Estrad-Fe) Estradiol) MIRCETTE TABS (Use QL(1 ea daily) ORTHO-NOVUM 1/35 QL(1 ea daily) Desogestrel-Ethinyl NF TABS (Use Norethindrone NF Estradiol (Biphasic)) & Eth Estradiol) MODICON TABS (Use QL(1 ea daily) ORTHO-NOVUM 7/7/7 QL(1 ea daily) Norethindrone & Eth NF TABS (Use Norethindrone- NF Estradiol) Eth Estradiol (Triphasic)) QL(1 ea daily) OVCON-35 TABS (Use QL(1 ea daily) NECON 1/50-28 TABS F Norethindrone & Eth NF Estradiol) QL(1 ea daily) NECON 10/11-28 TABS F SEASONIQUE TABS (Use QL(1 ea daily) norethin acet & estrad-fe QL(1 ea daily) Levonorgestrel-Ethinyl NF tabs 75mg-20mcg-1mg, F Estradiol (91-Day)) 75mg-30mcg-1.5mg TRI-NORINYL 28 TABS QL(1 ea daily) (Use Norethindrone-Eth NF norethindrone & eth F QL(1 ea daily) estradiol tabs Estradiol (Triphasic)) YASMIN 28 TABS (Use QL(1 ea daily) norethindrone & ethinyl F estradiol-fe chew Drospirenone-Ethinyl NF Estradiol) norethindrone acet & eth F QL(1 ea daily) estra tabs YAZ TABS (Use QL(1 ea daily) Drospirenone-Ethinyl NF norethindrone acetate- Estradiol) ethinyl estradiol-fe tabs F 75mg-1mg Combination Contraceptives - Transdermal Limit 3 patches norethindrone-eth estradiol F QL(1 ea daily) (triphasic) tabs F per XULANE PTWK month;QL(0.11 norgestimate-ethinyl F QL(1 ea daily) estradiol (triphasic) tabs ea daily) norgestimate-ethinyl QL(1 ea daily) Combination Contraceptives - Vaginal estradiol tabs 0.25mg- F NUVARING RING F QL(1 ea per fill 35mcg retail)

NV Silver Summit Updated September 1, 2018

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Emergency Contraceptives CORTEF TABS (Use NF Hydrocortisone) QL(4 ea per ELLA TABS F 365 days retail) CORTISONE ACETATE F TABS levonorgestrel (emergency F QL(1 ea per 21 oc) tabs 1.5 mg days retail) dexamethasone elix 0.5 F mg/5ml PLAN B ONE-STEP TABS QL(1 ea per 21 (Use Levonorgestrel NF days retail) DEXAMETHASONE F (Emergency OC)) INTENSOL CONC Progestin Contraceptives - IUD dexamethasone sodium QL(5 ml daily) phosphate soln ij 4 mg/ml, F SKYLA IUD 13.5 MG F SP 20 mg/5ml, 120 mg/30ml DEXAMETHASONE SOLN F Progestin Contraceptives - Implants 0.5 MG/5ML NEXPLANON IMPL F dexamethasone tabs 0.75 mg, 0.5 mg, 4 mg, 6 mg, F Progestin Contraceptives - Injectable 1.5 mg DEPO-PROVERA QL(1 ml per fill DEXAMETHASONE TABS F 1 MG, 2 MG CONTRACEPTIVE SUSP NF retail) (Use Medroxyprogesterone Acetate (Contraceptive)) hydrocortisone tabs F DEPO-PROVERA QL(1 ml per fill MEDROL DOSEPAK TBPK NF CONTRACEPTIVE SUSY NF retail) (Use Methylprednisolone) (Use Medroxyprogesterone MEDROL TABS 4 MG, 8 Acetate (Contraceptive)) MG (Use NF DEPO-SUBQ PROVERA F QL(1 ml per fill Methylprednisolone) 104 SUSY retail) methylprednisolone tabs or F medroxyprogesterone QL(1 ml per fill 4 mg, 8 mg acetate (contraceptive) F retail) methylprednisolone tbpk or F susp 4 mg medroxyprogesterone QL(1 ml per fill acetate (contraceptive) F retail) MILLIPRED TABS 5 MG F susy prednisolone sodium QL(240 ml per Progestin Contraceptives - Oral phosphate soln or 15 F fill retail) NOR-QD TABS (Use QL(1 ea daily) mg/5ml Norethindrone NF prednisolone sodium QL(150 ml per (Contraceptive)) phosphate soln or 20 F fill retail) norethindrone QL(1 ea daily) mg/5ml (contraceptive) tabs 0.35 F prednisolone sodium mg phosphate soln or 5 F ORTHO MICRONOR QL(1 ea daily) mg/5ml TABS (Use Norethindrone NF PREDNISOLONE SOLN F (Contraceptive)) CORTICOSTEROIDS - Steroid Hormone Drugs to prednisolone soln F Treat Systemic Swelling Conditions prednisolone syrp F Glucocorticosteroids

NV Silver Summit Updated September 1, 2018

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREDNISONE INTENSOL F ADVIL COLD & SINUS CONC TABS (Use NF Pseudoephedrine- PREDNISONE SOLN 5 F MG/5ML Ibuprofen) brompheniramine & QL(120 ml per prednisone tabs 1 mg, 5 F mg, 10 mg, 20 mg, 2.5 mg phenyleph elix 1mg/5ml- fill retail) 2.5mg/5ml, 1mg/5ml- F PREDNISONE TABS 50 F 1mg/5ml-2.5mg/5ml- MG 2.5mg/5ml PREDNISONE TBPK 5 F brompheniramine & QL(120 ml per MG, 10 MG pseudoeph elix 1mg/5ml- F fill retail) VERIPRED 20 SOLN (Use QL(150 ml per 15mg/5ml Prednisolone Sodium NF fill retail) brompheniramine & QL(120 ml per Phosphate) pseudoeph liqd 1mg/5ml- F fill retail) Mineralocorticoids 15mg/5ml fludrocortisone acetate F BROTAPP DM LIQD F tabs COUGH/COLD/ALLERGY - Drugs to Treat cetirizine-pseudoephedrine F QL(2 ea daily) Cough, Cold and Allergy Symptoms tb12 CHERACOL PLUS LIQD Antitussives (Use Dextromethorphan- NF AL(At least 10 benzonatate caps 100 mg F Guaifenesin) yrs old) CHERACOL-D COUGH QL(1 ea daily); LIQD (Use NF benzonatate caps 200 mg F AL(At least 10 Dextromethorphan- yrs old) Guaifenesin) DELSYM COUGH CLARITIN-D 12 HOUR QL(2 ea daily) CHILDRENS SUER (Use NF TB12 (Use Loratadine & NF Dextromethorphan Pseudoephedrine) Polistirex) CLARITIN-D 24 HOUR QL(1 ea daily) DELSYM SUER (Use TB24 (Use Loratadine & NF Dextromethorphan NF Pseudoephedrine) Polistirex) CLEAR COUGH PM dextromethorphan F MULTI-SYMPTOM LIQD polistirex suer 30 mg/5ml (Use Dextromethorphan- NF hydrocodone w/ AL(At least 18 Doxylamine- homatropine syrp 5mg/5ml- F yrs old) Acetaminophen) 1.5mg/5ml DAY TIME MULTI- SYMPTOM COLD/FLU TESSALON PERLES NF AL(At least 10 CAPS (Use Benzonatate) yrs old) RELIEF CAPS (Use NF Dextromethorphan- Cough/Cold/Allergy Combinations Phenylephrine- acetaminophen w/ dm liqd Acetaminophen) 5mg/5ml-160mg/5ml, F 5mg/5ml-5mg/5ml- 160mg/5ml-160mg/5ml

NV Silver Summit Updated September 1, 2018

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextromethorphan- guaifenesin-codeine liqd F QL(240 ml per doxylamine-acetaminophen 100mg/5ml-10mg/5ml fill retail) liqd 6.25mg/15ml- guaifenesin-codeine soln F QL(240 ml per 15mg/15ml-500mg/15ml, 100mg/5ml-10mg/5ml fill retail) 12.5mg/30ml-30mg/30ml- F 1000mg/30ml, guaifenesin-codeine syrp F QL(240 ml per 6.25mg/15ml-6.25mg/15ml- 100mg/5ml-10mg/5ml fill retail) 15mg/15ml-15mg/15ml- LOHIST-D LIQD F 500mg/15ml-500mg/15ml- 30MG/5ML-2MG/5ML 10% loratadine & QL(2 ea daily) dextromethorphan- pseudoephedrine tb12 F guaifenesin liqd 5mg/5ml- 5mg-120mg 100mg/5ml, 10mg/5ml- loratadine & QL(1 ea daily) 100mg/5ml, 10mg/5ml- pseudoephedrine tb24 F 200mg/5ml, 20mg/10ml- 10mg-240mg, 10mg-10mg- 200mg/10ml, 20mg/10ml- F 240mg-240mg 400mg/10ml, 20mg/20ml- MUCINEX D MAXIMUM 400mg/20ml, 15mg/7.5ml- STRENGTH TB12 (Use NF 150mg/7.5ml, 10mg/5ml- Pseudoephedrine- 10mg/5ml-100mg/5ml- Guaifenesin) 100mg/5ml MUCINEX D TB12 (Use dextromethorphan- Pseudoephedrine- NF guaifenesin soln 10mg/5ml- F Guaifenesin) 100mg/5ml, 20mg/10ml- 200mg/10ml MUCINEX DM TB12 (Use Dextromethorphan- NF dextromethorphan- Guaifenesin) guaifenesin syrp 10mg/5ml-100mg/5ml, F phenylephrine-chlorphen- 10mg/5ml-10mg/5ml- dm liqd 15mg/5ml- F 100mg/5ml-100mg/5ml 4mg/5ml-10mg/5ml QL(240 ml per dextromethorphan- phenylephrine-dm liqd F guaifenesin tabs 20mg- fill retail) F QL(240 ml per 400mg, 20mg-20mg- phenylephrine-dm soln F 400mg-400mg fill retail) dextromethorphan- QL(240 ml per promethazine & F fill retail); AL(At guaifenesin tb12 30mg- F phenylephrine soln 600mg least 2 yrs old) dextromethorphan- QL(240 ml per promethazine & F fill retail); AL(At phenylephrine- phenylephrine syrp least 2 yrs old) acetaminophen caps F 10mg-325mg-5mg, 10mg- QL(240 ml per 10mg-325mg-325mg-5mg- promethazine w/codeine F fill retail); AL(At 5mg soln least 18 yrs DIMETAPP COLD & QL(120 ml per old) ALLERGY ELIX 1MG/5ML- fill retail) QL(240 ml per 2.5MG/5ML (Use NF promethazine w/codeine F fill retail); AL(At Brompheniramine & syrp least 18 yrs Phenyleph) old) ED BRON GP LIQD F 100MG/5ML-5MG/5ML NV Silver Summit Updated September 1, 2018

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(240 ml per promethazine-dm syrp F guaifenesin liqd 100 fill retail) mg/5ml, 200 mg/10ml, 400 F QL(240 ml per mg/20ml promethazine- F fill retail); AL(At guaifenesin soln 100 phenylephrine-codeine least 18 yrs F syrp mg/5ml, 200 mg/10ml, 300 old) mg/15ml QL(240 ml per guaifenesin syrp 100 F PROMETHAZINE/PHENYL F EPHRINE SYRP fill retail); AL(At mg/5ml, 200 mg/10ml least 2 yrs old) guaifenesin tb12 600 mg, F pseudoephed-bromphen- F 1200 mg dm elix MUCINEX MAXIMUM pseudoephed-bromphen- F STRENGTH TB12 (Use NF dm syrp Guaifenesin) pseudoephedrine w/ QL(240 ml per MUCINEX TB12 (Use NF codeine-gg soln 30mg/5ml- F fill retail) Guaifenesin) 100mg/5ml-10mg/5ml Misc. Respiratory Inhalants pseudoephedrine- F chlorphen-dm liqd sodium chloride (inhalant) F nebu 0.9 %, 3 %, 10 % pseudoephedrine- guaifenesin tb12 60mg- F Mucolytics 600mg, 120mg-1200mg acetylcysteine soln F pseudoephedrine-ibuprofen F tabs 200mg-30mg DERMATOLOGICALS - Drugs to Treat Skin ROBITUSSIN DM SYRP Conditions (Use Dextromethorphan- NF Acne Products Guaifenesin) ACNE MEDICATION 10 F ROBITUSSIN PEAK COLD LOTN COUGH+ CHEST ACNE MEDICATION 5 CONGESTION DM MAX NF F STRENGTH LIQD (Use LOTN Dextromethorphan- BENZAC AC WASH LIQD NF RX/OTC Guaifenesin) (Use Benzoyl Peroxide) ROBITUSSIN PEAK COLD benzoyl peroxide bar 10 % F DM SYRP (Use NF Dextromethorphan- BENZOYL PEROXIDE F Guaifenesin) CLEANSER LOTN 6 % TRIAMINIC COLD & benzoyl peroxide crea 10 F COUGH DAY TIME F % CHILDRENS SOLN benzoyl peroxide gel 10 % F RX/OTC TRIAMINIC COLD & COUGH DAY TIME F BENZOYL PEROXIDE F CHILDRENS SYRP GEL 2.5 % ZYRTEC-D QL(2 ea daily) benzoyl peroxide gel 5 % F ALLERGY/CONGESTION NF TB12 (Use Cetirizine- benzoyl peroxide liqd 4 % F Pseudoephedrine) Expectorants benzoyl peroxide liqd 5 %, F RX/OTC 10 % NV Silver Summit Updated September 1, 2018

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benzoyl peroxide lotn 6 % F QL(20 gm per RETIN-A GEL 0.025 % NF fill retail); CLEAN & CLEAR (Use Tretinoin) AL(Up to 21 yrs old ) ADVANTAGE 3-IN-1 F EXFOLIATING CLEANSER SODIUM QL(60 gm per LOTN SULFACETAMIDE/SULFU F fill retail) CLEOCIN-T GEL (Use R LOTN 5%-10% Clindamycin Phosphate NF SODIUM QL(30 gm per (Topical)) SULFACETAMIDE/SULFU F fill retail) CLEOCIN-T LOTN (Use QL(60 ml per R SUSP 5%-10% Clindamycin Phosphate NF fill retail) sulfacetamide sodium F QL(120 ml per (Topical)) (acne) lotn 10 % fill retail) CLEOCIN-T SOLN (Use QL(20 gm per Clindamycin Phosphate NF tretinoin crea 0.025 %, 0.05 F fill retail); (Topical)) %, 0.1 % AL(Up to 21 yrs old ) clindamycin phosphate F (topical) gel 1 % QL(15 gm per fill retail); clindamycin phosphate F QL(60 ml per tretinoin gel 0.01 % F (topical) lotn 1 % fill retail) AL(Up to 21 yrs old ) clindamycin phosphate F (topical) soln 1 % QL(20 gm per fill retail); DESQUAM-X WASH LIQD NF RX/OTC tretinoin gel 0.025 % F (Use Benzoyl Peroxide) AL(Up to 21 yrs old ) ERYGEL GEL (Use NF QL(60 gm per Erythromycin (Acne Aid)) fill retail) Antibiotics - Topical BACIGUENT OINT (Use QL(30 gm per erythromycin (acne aid) gel F QL(60 gm per NF 2 % fill retail) Bacitracin (Topical)) fill retail) bacitracin (topical) oint 500 QL(30 gm per erythromycin (acne aid) F F soln 2 % unit/gm fill retail) QL(30 gm per PA; QL(2 ea bacitracin zinc oint F daily); AL(At fill retail) isotretinoin caps 10 mg, 20 F least 12 yrs old mg, 40 mg - Up to 22 yrs bacitracin-polymyxin b oint F old) BACTROBAN CREA (Use QL(30 gm per KLARON LOTN (Use QL(120 ml per Mupirocin Calcium NF fill retail) Sulfacetamide Sodium NF fill retail) (Topical)) (Acne)) QL(30 gm per CENTANY OINT 2 % F PANOXYL-4 CREAMY fill retail) WASH LIQD (Use Benzoyl NF gentamicin sulfate (topical) F QL(30 gm per Peroxide) crea fill retail) QL(20 gm per gentamicin sulfate (topical) QL(30 gm per RETIN-A CREA 0.025 %, fill retail); F 0.05 %, 0.1 % (Use NF oint fill retail) ) AL(Up to 21 yrs QL(30 gm per Tretinoin old ) mupirocin calcium (topical) F crea 2 % fill retail) QL(15 gm per F QL(30 gm per RETIN-A GEL 0.01 % (Use NF fill retail); mupirocin oint 2 % fill retail) Tretinoin) AL(Up to 21 yrs old ) NV Silver Summit Updated September 1, 2018

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits neomycin-bacitracin- F QL(30 gm per LOTRIMIN AF FOR HER QL(30 gm per polymyxin oint fill retail) CREA (Use Clotrimazole NF fill retail); neomycin-polymyxin w/ QL(30 gm per (Topical)) RX/OTC pramoxine crea F fill retail) LOTRIMIN AF JOCK ITCH QL(30 gm per 10000unit/gm-3.5mg/gm- CREA (Use Clotrimazole NF fill retail); 10mg/gm (Topical)) RX/OTC NEOSPORIN ORIGINAL QL(30 gm per LOTRISONE CREA (Use QL(45 gm per OINT (Use Neomycin- NF fill retail) Clotrimazole w/ NF fill retail) Bacitracin-Polymyxin) Betamethasone) NEOSPORIN PLUS PAIN QL(30 gm per MICATIN CREA (Use QL(45 ml per RELIEF MAXIMUM fill retail) Miconazole Nitrate NF fill retail) STRENGTH CREA (Use NF (Topical)) Neomycin-Polymyxin w/ miconazole nitrate (topical) F QL(45 ml per Pramoxine) crea 2 % fill retail) POLYSPORIN OINT (Use NF NIZORAL SHAM (Use NF QL(120 ml per Bacitracin-Polymyxin B) Ketoconazole (Topical)) fill retail) Antifungals - Topical QL(30 gm per nystatin (topical) crea F QL(30 gm per fill retail) clotrimazole (topical) crea 1 F fill retail); QL(30 gm per % nystatin (topical) oint F RX/OTC fill retail) QL(30 ml per QL(60 gm per clotrimazole (topical) soln 1 F fill retail); nystatin (topical) powd F % fill retail) RX/OTC QL(30 gm per nystatin-triamcinolone crea F clotrimazole w/ QL(45 gm per fill retail) betamethasone crea 1%- F fill retail) QL(30 gm per nystatin-triamcinolone oint F 0.05% fill retail) clotrimazole w/ QL(30 ml per terbinafine hcl (topical) crea F QL(30 gm per betamethasone lotn 1%- F fill retail) 1 % fill retail) 0.05% TINACTIN CREA (Use QL(30 gm per QL(30 gm per NF econazole nitrate crea 1 % F Tolnaftate) fill retail) fill retail) TINACTIN JOCK ITCH NF QL(30 gm per Limit 1 CREA (Use Tolnaftate) fill retail) package per ketoconazole (topical) crea QL(30 gm per F claim;QL(60 tolnaftate crea 1 % F 2 % gm per fill fill retail) retail) Antihistamines-Topical ketoconazole (topical) QL(120 ml per F diphenhydramine hcl F sham 2 % fill retail) (topical) crea 2 % LAMISIL AT CREA (Use NF QL(30 gm per Antineoplastic or Premalignant Lesion Agents - Terbinafine HCl (Topical)) fill retail) CARAC CREA F QL(30 gm per LAMISIL AT JOCK ITCH QL(30 gm per fill retail) CREA (Use Terbinafine NF fill retail) HCl (Topical)) EFUDEX CREA (Use NF QL(40 gm per Fluorouracil (Topical)) fill retail) LOTRIMIN AF CREA 1 % QL(30 gm per QL(40 gm per (Use Clotrimazole NF fill retail); fluorouracil (topical) crea F (Topical)) RX/OTC fill retail) FLUOROURACIL CREA F QL(30 gm per EX 0.5 % fill retail) NV Silver Summit Updated September 1, 2018

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUOROURACIL SOLN F QL(10 ml per SELSUN BLUE DAILY QL(240 ml per EX 2 %, 5 % fill retail) LOTN (Use Selenium NF fill retail) Sulfide) VALCHLOR GEL F PA; SP SELSUN BLUE LOTN (Use NF QL(240 ml per Antipruritics - Topical Selenium Sulfide) fill retail) SELSUN BLUE QL(240 ml per camphor & menthol lotn F QL(222 ml per 0.5%-0.5% fill retail) MEDICATED LOTN (Use NF fill retail) Selenium Sulfide) SARNA LOTN (Use NF QL(222 ml per Camphor & Menthol) fill retail) SELSUN BLUE QL(240 ml per MOISTURIZING LOTN NF fill retail) Antipsoriatics (Use Selenium Sulfide) QL(60 gm per calcipotriene crea 0.005 % F sulfacetamide sodium liqd F QL(360 ml per fill retail) ex 10 % fill retail) QL(60 ml per calcipotriene soln 0.005 % F Antivirals - Topical fill retail) Limit 1 package DOVONEX CREA (Use NF QL(60 gm per acyclovir topical oint 5 % F per month;QL(1 Calcipotriene) fill retail) gm daily) PA; QL(60 gm QL(5 gm per fill ZOVIRAX CREA EX 5 % F F per fill retail); retail) tazarotene crea AL(Up to 21 yrs old ) Limit 1 package ZOVIRAX OINT EX 5 % NF per month;QL(1 (Use Acyclovir Topical) PA; QL(60 gm gm daily) F per fill retail); TAZORAC CREA 0.05 % AL(Up to 21 yrs Burn Products old ) SILVADENE CREA (Use NF QL(50 gm per PA; QL(60 gm Silver Sulfadiazine) fill retail) TAZORAC CREA 0.1 % per fill retail); QL(50 gm per NF silver sulfadiazine crea 1 % F (Use Tazarotene) AL(Up to 21 yrs fill retail) old ) Corticosteroids - Topical PA; QL(60 gm QL(60 gm per TAZORAC GEL 0.05 %, F per fill retail); APEXICON E CREA F 0.1 % AL(Up to 21 yrs fill retail) old ) betamethasone 1 rtl pack lmt dipropionate (topical) crea F per fill, Antiseborrheic Products 0.05 % OVACE PLUS WASH LIQD QL(360 ml per betamethasone QL(50 gm per (Use Sulfacetamide NF fill retail) dipropionate augmented F fill retail) Sodium) crea 0.05 % OVACE WASH LIQD (Use QL(360 ml per NF betamethasone valerate F QL(45 gm per Sulfacetamide Sodium) fill retail) crea 0.1 % fill retail) QL(240 ml per selenium sulfide lotn 1 % F betamethasone valerate F QL(60 ml per fill retail) lotn 0.1 % fill retail) QL(120 ml per selenium sulfide lotn 2.5 % F betamethasone valerate F QL(45 gm per fill retail) oint 0.1 % fill retail) QL(240 ml per selenium sulfide sham 1 % F clobetasol propionate crea F QL(45 gm per fill retail) 0.05 % fill retail) clobetasol propionate F QL(60 gm per emollient base crea 0.05 % fill retail) NV Silver Summit Updated September 1, 2018

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clobetasol propionate gel F QL(60 gm per hydrocortisone (topical) F QL(30 gm per 0.05 % fill retail) crea 0.5 %, 2.5 % fill retail) clobetasol propionate oint F QL(60 gm per QL(60 gm per fill retail) hydrocortisone (topical) F fill retail); 0.05 % crea 1%, 1 % RX/OTC clobetasol propionate soln F QL(25 ml per 0.05 % fill retail) hydrocortisone (topical) lotn F QL(60 ml per 1 %, 2.5 % fill retail) DERMATOP CREA (Use NF QL(60 gm per Prednicarbate) fill retail) hydrocortisone (topical) oint F 1 rtl pack lmt 0.5 % desonide crea 0.05 % F per fill, Limit 1 package 1 rtl pack lmt hydrocortisone (topical) oint per month;QL(2 desonide oint 0.05 % F F per fill, 1 % gm daily); RX/OTC DESOWEN CREA (Use NF 1 rtl pack lmt Desonide) per fill, Limit 1 package hydrocortisone (topical) oint F per month;QL(1 2.5 % desoximetasone crea 0.05 F QL(60 gm per gm daily) % fill retail) hydrocortisone butyrate F QL(60 ml per DIFLORASONE F QL(60 gm per soln 0.1 % fill retail) DIACETATE CREA fill retail) hydrocortisone-aloe vera QL(60 gm per QL(60 gm per F diflorasone diacetate oint F crea 1% fill retail) fill retail) LOCOID SOLN (Use NF QL(60 ml per DIPROLENE AF CREA QL(50 gm per Hydrocortisone Butyrate) fill retail) (Use Betamethasone NF fill retail) Dipropionate Augmented) mometasone furoate crea F QL(45 gm per 0.1 % fill retail) ELOCON CREA (Use NF QL(45 gm per Mometasone Furoate) fill retail) mometasone furoate oint F QL(45 gm per 0.1 % fill retail) ELOCON OINT (Use NF QL(45 gm per Mometasone Furoate) fill retail) mometasone furoate soln F QL(60 ml per 0.1 % fill retail) EPIFOAM FOAM 1%-1% F MONISTAT SOOTHING QL(60 gm per QL(60 gm per CARE ITCH RELIEF CREA fill retail); fluocinonide crea 0.05 % F NF fill retail) (Use Hydrocortisone RX/OTC (Topical)) fluocinonide emulsified F QL(60 gm per base crea fill retail) PREDNICARBATE CREA F QL(60 gm per 0.1 % fill retail) QL(60 gm per fluocinonide gel 0.05 % F QL(60 gm per fill retail) prednicarbate crea 0.1 % F fill retail) QL(60 gm per fluocinonide oint 0.05 % F fill retail) PREDNICARBATE OINT F QL(60 gm per 0.1 % fill retail) QL(60 ml per fluocinonide soln 0.05 % F fill retail) PSORCON CREA F QL(60 gm per fill retail) Limit 1 TEMOVATE CREA (Use QL(45 gm per fluticasone propionate crea F package per NF 0.05 % month;QL(2 gm Clobetasol Propionate) fill retail) daily) TEMOVATE E CREA (Use QL(60 gm per Clobetasol Propionate NF fill retail) fluticasone propionate oint F QL(60 gm per 0.005 % fill retail) Emollient Base) TEMOVATE OINT (Use NF QL(60 gm per Clobetasol Propionate) fill retail) NV Silver Summit Updated September 1, 2018

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPICORT CREA 0.05 % NF QL(60 gm per LAC-HYDRIN CREA (Use QL(140 gm per (Use Desoximetasone) fill retail) Lactic Acid (Ammonium NF fill retail); Lactate)) RX/OTC triamcinolone acetonide F QL(454 gm per (topical) crea 0.025 % fill retail) Limit 1 package LAC-HYDRIN LOTN (Use per triamcinolone acetonide F QL(30 gm per (topical) crea 0.1 % fill retail) Lactic Acid (Ammonium NF month;QL(13.3 Lactate)) 4 ml daily); triamcinolone acetonide F QL(15 gm per RX/OTC (topical) crea 0.5 % fill retail) Limit 1 package triamcinolone acetonide QL(60 ml per LAC-HYDRIN TWELVE per (topical) lotn 0.025 %, 0.1 F fill retail) LOTN (Use Lactic Acid NF month;QL(13.3 % (Ammonium Lactate)) 4 ml daily); triamcinolone acetonide QL(80 gm per RX/OTC (topical) oint 0.025 %, 0.1 F fill retail) QL(140 gm per % lactic acid (ammonium F fill retail); lactate) crea 12 % triamcinolone acetonide F QL(15 gm per RX/OTC (topical) oint 0.5 % fill retail) Limit 1 package TRIDESILON CREA (Use NF 1 rtl pack lmt per Desonide) per fill, lactic acid (ammonium F month;QL(13.3 lactate) lotn 12 % Diaper Rash Products 4 ml daily); RX/OTC diaper rash products oint F LANAPHILIC OINT F Emollient/Keratolytic Agents QL(210 gm per OINTMENT BASE OINT F urea crea 40 % F fill retail); RA ADVANCED HEALING F RX/OTC OINT QL(240 ml per urea lotn 40 % F fill retail) Immunomodulating Agents - Topical ALDARA CREA (Use NF QL(48 ea per Emollients Imiquimod) 180 days retail) QL(48 ea per AQUAPHILIC OINT F imiquimod crea 5 % F 180 days retail) AQUAPHOR ADVANCED F THERAPY OINT Immunosuppressive Agents - Topical PA; Limit 1 AQUAPHOR OINT F package per ELIDEL CREA F BOUDREAUXS BABY month;QL(1 gm BUTT SMOOTH DRY SKIN F daily) OINT PA; Limit 1 PROTOPIC OINT (Use package per DAILY CONDITIONING F NF TREATMENT OINT Tacrolimus (Topical)) month;QL(1 gm daily) emollient oint 0.16gm/30gm- PA; Limit 1 F package per 300mg/30gm- tacrolimus (topical) oint F 100unit/30gm, 41 %, 52 %, month;QL(1 gm daily) GOLD BOND ULTIMATE F HEALING OINT Keratolytic/Antimitotic Agents

NV Silver Summit Updated September 1, 2018

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONDYLOX SOLN (Use NF QL(4 ml per fill NEUTRAPHORUS REX F Podofilox) retail) CREA 1 % KERALYT GEL 6 % (Use NF QL(40 gm per PROSHIELD PLUS SKIN F Salicylic Acid) fill retail) PROTECTANT CREA 1 % QL(4 ml per fill podofilox soln 0.5 % F REMEDY NUTRASHIELD F retail) CREA 1 % QL(40 gm per QL(60 gm per salicylic acid gel ex 6 % F zinc oxide (topical) oint 20 F fill retail) % fill retail) Local Anesthetics - Topical Rosacea Agents ARTHRITIS PAIN F QL(60 gm per METROCREAM CREA QL(45 gm per RELIEVING CREA fill retail) (Use Metronidazole NF fill retail) (Topical)) capsaicin crea 0.025 % F METROLOTION LOTN QL(60 gm per (Use Metronidazole NF capsaicin crea 0.075 % F fill retail) (Topical)) QL(42.5 gm per metronidazole (topical) QL(45 gm per capsaicin crea 0.1 % F F fill retail) crea 0.75 % fill retail) metronidazole (topical) gel QL(45 gm per CAPZASIN-HP CREA (Use NF QL(42.5 gm per F Capsaicin) fill retail) 0.75 % fill retail) QL(30 gm per metronidazole (topical) lotn dibucaine oint F F fill retail) 0.75 % QL(30 gm per lidocaine crea 4 % F Scabicides & Pediculicides fill retail) QL(60 gm per crotamiton lotn 10 % F QL(30 gm per fill retail) lidocaine hcl crea ex 3 % F fill retail); ELIMITE CREA (Use NF QL(60 gm per RX/OTC Permethrin) fill retail) QL(65 ml per lidocaine hcl crea ex 4 % F EURAX CREA 10 % F QL(60 gm per fill retail) fill retail) QL(30 ml per EURAX LOTN (Use NF QL(60 gm per lidocaine hcl gel ex 2 % F fill retail); Crotamiton) fill retail) RX/OTC QL(59 ml per malathion lotn 0.5 % F lidocaine-prilocaine crea F QL(30 gm per fill retail) 2.5%-2.5% fill retail) QL(120 ml per LMX 4 CREA (Use NF QL(30 gm per NATROBA SUSP F fill retail); AL(At Lidocaine) fill retail) least 1 yrs old) PREDATOR CREA (Use QL(65 ml per NF NIX CREME RINSE LIQD NF Lidocaine HCl) fill retail) (Use Permethrin) Misc. Topical OVIDE LOTN (Use NF QL(59 ml per 4-N-1 CREA 1 % F Malathion) fill retail) QL(60 gm per permethrin crea 5 % F COOL BOTTOMS CREA 1 F fill retail) % QL(60 ml per permethrin liqd 1 % F DRYSOL SOLN F fill retail) QL(120 ml per permethrin lotn 1 % F NEUTRAPHOR CREA 1 % F fill retail)

NV Silver Summit Updated September 1, 2018

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pyrethrins-piperonyl F QL(60 ml per AVEENO POSITIVELY butoxide liqd 0.33%-4% fill retail) RADIANTDAILY F pyrethrins-piperonyl MOISTURIZER SPF15 butoxide sham 0.3%- F LOTN 0.33%-4%, 0.33%-4% AVEENO POSITIVELY RADIANTDAILY pyrethrins-piperonyl F QL(60 ml per F butoxide sham 0.33%-4% fill retail) MOISTURIZER SPF30 LOTN pyrethrins-piperonyl AVEENO POSITIVELY butoxide-permethrin-nit F remover kit 0.5%-0.33%- RADIANTTINTED F 4% MOISTURIZER SPF30 FAIR/LIGHT LOTN RID COMPLETE LICE ELIMINATION KIT (Use AVEENO POSITIVELY Pyrethrins-Piperonyl NF RADIANTTINTED F Butoxide-Permethrin-Nit MOISTURIZER SPF30 Remover) MEDIUM LOTN AVEENO PROTECT + RID LIQD (Use Pyrethrins- NF QL(60 ml per F Piperonyl Butoxide) fill retail) HYDRATESPF 50 LOTN QL(120 ml per AVEENO PROTECT + F SPINOSAD SUSP F fill retail); AL(At HYDRATESPF 70 LOTN least 1 yrs old) AVEENO SMART ESSENTIALS DAILY Sunscreens NOURISHING F ANTHELIOS 60 MELT-IN F MOISTURIZER SPF30 SUNSCREEN LOTN LOTN AVEENO ABSOLUTELY AVEENO ULTRA- AGELESSLEAVE-ON DAY F CALMING DAILY F MASK SPF 30 LOTN MOISTURIZER SPF15 AVEENO ACTIVE LOTN NATURALS F AVEENO ULTRA- PROTECT+HYDRATE/SP CALMING DAILY F F 30 LOTN MOISTURIZER SPF30 AVEENO BABY LOTN CONTINUOUS F BULL FROG PROTECTION LOTN SUPERBLOCK SPF50 F AVEENO BABY LOTN CONTINUOUS F BULL FROG ULTIMATE PROTECTION SHEERPROTECTION F SUNBLOCK SPF55 LOTN FACE SUNBLOCK SPF 30 AVEENO BABY NATURAL LOTN PROTECTION SPF 50 F BULL FROG ULTIMATE LOTN SHEERPROTECTION F AVEENO NATURAL SUNBLOCK SPF 30 LOTN PROTECTIONSPF 50 F BULL FROG WATER LOTN ARMOR SPORT FACE F SPF 30 LOTN CERAVE SUNSCREEN F FACE/SPF50 LOTN

NV Silver Summit Updated September 1, 2018

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CERAVE NEUTROGENA ULTRA SUNSCREEN/BODY F SHEER DRY-TOUCH SPF F LOTN 45 LOTN CERAVE F NEUTROGENA ULTRA SUNSCREEN/FACE LOTN SHEER DRY-TOUCH F WITH HELIOPLEX SPF CHANTAL SUN SCREEN F SPF 30 LOTN 100 LOTN NEUTROGENA ULTRA COTZ LOTN F SHEER DRY-TOUCH F DIABETIDERM WITH HELIOPLEX SPF 55 SUNSCREEN SPF15 F LOTN LOTN NEUTROGENA ULTRA SHEER DRY-TOUCH F FACE COTZ LOTN F WITH HELIOPLEX SPF 70 HUGGIES LITTLE LOTN SWIMMERS SPF50 LOTN F NIVEA HAND THERAPY F 1%-5%-0.8%-7.5%-5% LOTN NIVEA VISAGE UV CARE KERI AGE DEFY & F F PROTECT LOTN DAILY FACIAL LOTN LUBRIDERM DAILY PRE SUN KIDS LOTN F MOISTURE/SUNSCREEN F SPF 15 LOTN PURE & FREE BABY NEUTROGENA AGE SUNSCREEN BROAD F SHIELD FACE SPECTRUM SPF 60+ SUNBLOCK WITH F LOTN HELIOPLEX SPF110 RA RX SUNCARE LOTN ADVANCED F NEUTROGENA AGE PROTECTION SPF50 LOTN SHIELD FACE F SUNBLOCK WITH ROC MULTI CORREXION HELIOPLEX SPF70 LOTN 5 IN1 DAILY F NEUTROGENA COOLDRY MOISTURIZER SPF 30 SPORTWITH HELIOPLEX F LOTN SPF 30 LOTN ROC RETINOL NEUTROGENA HEALTHY CORREXION SPF30 F LOTN DEFENSE DAILY F MOISTURIZER SHADE SUNBLOCK SPF PURESCREEN LOTN 45 LOTN (Use NF Sunscreens) NEUTROGENA MEN SPF F 20 LOTN SHADE UVAGUARD SPF NEUTROGENA 15 LOTN (Use NF MOISTURE F Sunscreens) SPF15UNTINTED LOTN SOLBAR AVO LOTN F NEUTROGENA SPORT FACE SUNBLOCK WITH F SOLBAR PF SPF15 LOTN F HELIOPLEX SPF70 LOTN 7.5%-6%

NV Silver Summit Updated September 1, 2018

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sunscreens lotn 4%-5%, CHEMSTRIP-K STRP F 9.1 %, 5%-10%, 1%-0.5%, 5.5%-8%, 4.9%-4.7%, KETOCARE STRP F 7.5%-4.5%, 7.5%-3%-5%, 2%-1%-1%-4%, 3%-7%- KETONE TEST STRIPS F 4%-13%, 2%-7.5%-6%-3%, STRP 5%-7.5%-4%-9%, 5%-9%- 7.5%-6%, 2%-5%-2%-2%- KETOSTIX STRP F 2%, 2%-5%-4%-5%-8%, NOVA MAX PLUS QL(1 ea daily) 2%-2%-4%-5%-13%, 2%- F 2%-5%-2%-10%, 2%-5%- KETONE TESTSTRIPS F 2%-2%-10%, 2%-5%-2%- STRP 4%-13%, 3%-5%-6%-5%- PRECISION XTRA STRP F QL(1 ea daily) 13%, 3%-7%-4%-5%-13%, VI 3%-10%-6%-5%-15%, 5%- PTS PANELS KETONE F QL(1 ea daily) 2%-7.5%-6%-8%, 5%-3%- TEST STRP 7.5%-6%-9%, 2%-2%-2%- 5%-10.5%, 2%-5%-7.5%- RELION KETONE STRP F 6%-12%, 2%-5%-1%- RELION KETONE TEST F 7.5%-6%-15%, STRIPS STRP TOTAL BLOCK SPF 60 F INSULIN COVERUP LOTN USERS TOTAL BLOCK SPF 65 F LIMITED TO CLEAR LOTN 150 PER 30 TRUE METRIX BLOOD DAYS, NON- WATER BABIES SPF 30 NF GLUCOSETEST STRIPS F LOTN (Use Sunscreens) STRP INSULIN USERS Tar Products LIMITED TO coal tar extract sham 0.5 % F 100 PER 90 DAYS;RX/OTC DHS TAR GEL SHAM (Use NF INSULIN Coal Tar Extract) USERS DHS TAR SHAM (Use Coal NF LIMITED TO Tar Extract) 150 PER 30 TRUE METRIX SELF NEUTROGENA T/GEL F DAYS, NON- MONITORING BLOOD INSULIN SHAM (Use Coal Tar NF GLUCOSE STRIPS STRP Extract) USERS LIMITED TO NEUTROGENA T/GEL 100 PER 90 STUBBORN ITCH NF DAYS;RX/OTC CONTROL SHAM (Use Coal Tar Extract) INSULIN USERS DIAGNOSTIC PRODUCTS LIMITED TO 150 PER 30 Diagnostic Tests TRUETEST BLOOD F DAYS, NON- GLUCOSE TEST STRIPS INSULIN CHEK-STIX COMBO PAK STRP URINALYSIS CONTROL F USERS STRP LIMITED TO 100 PER 90 CHEK-STIX CONTROL F STRP DAYS;RX/OTC

NV Silver Summit Updated September 1, 2018

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN L-METHYLFOLATE CA/S- F USERS ALGAL CAPS LIMITED TO L-METHYLFOLATE F 150 PER 30 CALCIUM TABS TRUETEST BLOOD F DAYS, NON- GLUCOSE TEST STRP INSULIN L-METHYLFOLATE F USERS FORMULA 15 CAPS LIMITED TO L-METHYLFOLATE F 100 PER 90 FORMULA 7.5 CAPS DAYS;RX/OTC L-METHYLFOLATE F INSULIN FORTE CAPS USERS L-METHYLFOLATE TABS F LIMITED TO 150 PER 30 LEVOMEFOLATE DAYS, NON- TRUETEST STRIPS STRP F CALCIUM ALGAL F INSULIN POWDER CAPS USERS LIMITED TO DIGESTIVE AIDS - Drugs to Treat Low Digestive 100 PER 90 Enzymes DAYS;RX/OTC Digestive Enzymes INSULIN CREON CPEP USERS 19000UNIT-6000UNIT- LIMITED TO 30000UNIT, 38000UNIT- F 150 PER 30 12000UNIT-60000UNIT, TRUETRACK BLOOD F DAYS, NON- 76000UNIT-24000UNIT- GLUCOSE TEST STRP INSULIN 120000UNIT USERS PANCREAZE CPEP LIMITED TO 14200UNIT-4200UNIT- 100 PER 90 24600UNIT, 35500UNIT- DAYS;RX/OTC 10500UNIT-61500UNIT, F INSULIN 54700UNIT-21000UNIT- USERS 83900UNIT, 56800UNIT- LIMITED TO 16800UNIT-98400UNIT 150 PER 30 DIURETICS - Drugs to Treat Heart, Circulation TRUETRACK TEST STRP F DAYS, NON- INSULIN Conditions and Blood Pressure USERS Carbonic Anhydrase Inhibitors LIMITED TO 100 PER 90 acetazolamide cp12 F DAYS;RX/OTC acetazolamide tabs F DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS DIAMOX CP12 (Use NF Dietary Management Products Acetazolamide) DEPLIN 15 CAPS F methazolamide tabs F NEPTAZANE TABS (Use NF DEPLIN 7.5 CAPS F Methazolamide) ELFOLATE TABS F Diuretic Combinations

NV Silver Summit Updated September 1, 2018

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALDACTAZIDE TABS amiloride hcl tabs F QL(4 ea daily) 25MG-25MG (Use NF Spironolactone & spironolactone tabs F Hydrochlorothiazide) amiloride & F QL(1 ea daily) Thiazides and Thiazide-Like Diuretics hydrochlorothiazide tabs CHLOROTHIAZIDE TABS F QL(2 ea daily) DYAZIDE CAPS (Use QL(1 ea daily) 250 MG Triamterene & NF QL(4 ea daily) Hydrochlorothiazide) chlorothiazide tabs 500 mg F MAXZIDE TABS (Use QL(1 ea daily) Triamterene & NF chlorthalidone tabs F Hydrochlorothiazide) hydrochlorothiazide caps F MAXZIDE-25 TABS (Use QL(1 ea daily) Triamterene & NF Hydrochlorothiazide) hydrochlorothiazide tabs F spironolactone & indapamide tabs F hydrochlorothiazide tabs F 25mg-25mg metolazone tabs F triamterene & F QL(1 ea daily) hydrochlorothiazide caps MICROZIDE CAPS (Use NF Hydrochlorothiazide) triamterene & F QL(1 ea daily) hydrochlorothiazide tabs ENDOCRINE AND METABOLIC AGENTS - MISC. - Drugs to Treat Bone Disease and TRIAMTERENE/HYDROC F QL(1 ea daily) HLOROTHIAZIDE CAPS Regulate Hormones Loop Diuretics Bone Density Regulators bumetanide tabs or 0.5 mg, PA; Limit 4 per F ACTONEL TABS 35 MG NF month;QL(0.13 1 mg, 2 mg (Use Risedronate Sodium) 4 ea daily) BUMEX TABS (Use NF Bumetanide) ACTONEL TABS 5 MG, 30 PA; QL(1 ea MG (Use Risedronate NF daily) DEMADEX TABS (Use NF QL(1 ea daily) Torsemide) Sodium) ALENDRONATE SODIUM F PA; QL(10.8 ml furosemide soln ij 10 mg/ml F SOLN 70 MG/75ML daily) furosemide soln or 10 PA; Limit 4 per F alendronate sodium tabs F month;QL(0.13 mg/ml 35 mg, 70 mg 4 ea daily) FUROSEMIDE SOLN OR 8 F MG/ML ALENDRONATE SODIUM F PA; QL(1 ea TABS 40 MG daily) furosemide tabs or 20 mg, F 40 mg, 80 mg alendronate sodium tabs 5 F PA; QL(1 ea mg, 10 mg daily) LASIX TABS (Use NF Furosemide) ATELVIA TBEC (Use NF PA; QL(0.15 ea Risedronate Sodium) daily) QL(1 ea daily) torsemide tabs F QL(0.143 ml calcitonin (salmon) soln F daily) Potassium Sparing Diuretics QL(0.143 ml FORTICAL SOLN F ALDACTONE TABS (Use NF daily) Spironolactone)

NV Silver Summit Updated September 1, 2018

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Limit 4 per CARNITOR SOLN OR 1 QL(30 ml daily) FOSAMAX TABS (Use NF Alendronate Sodium) month;QL(0.13 GM/10ML (Use NF 4 ea daily) Levocarnitine (Metabolic Limit 1 Modifiers)) QL(3 ea daily); MIACALCIN SOLN IJ 200 package per CARNITOR TABS OR 330 F month;QL(0.06 MG (Use Levocarnitine NF RX/OTC UNIT/ML 7 ml daily,2 ml (Metabolic Modifiers)) per fill retail) FABRAZYME SOLR F PA; SP MIACALCIN SOLN NA 200 QL(0.143 ml UNIT/ACT (Use Calcitonin NF daily) levocarnitine (metabolic F QL(30 ml daily) (Salmon)) modifiers) soln 1 gm/10ml PA; Limit 4 per levocarnitine (metabolic QL(3 ea daily); risedronate sodium tabs 35 F month;QL(0.13 F mg modifiers) tabs 330 mg RX/OTC 4 ea daily) ROCALTROL CAPS 0.25 risedronate sodium tabs 5 F PA; QL(1 ea MCG, 0.5 MCG (Use NF mg, 30 mg daily) Calcitriol) risedronate sodium tbec 35 F PA; QL(0.15 ea Posterior Pituitary Hormones mg daily) DDAVP SOLN IJ 4 PA; SP Growth Hormones MCG/ML (Use NF Desmopressin Acetate) NORDITROPIN FLEXPRO F PA; SP SOLN DDAVP SOLN NA 0.01 % F QL(5 ml per fill retail) SAIZEN CLICK.EASY F PA; SP SOLR DDAVP SOLN NA 0.01 % PA; QL(5 ml PA; SP (Use Desmopressin NF per fill retail) SAIZEN SOLR F Acetate Spray) SAIZENPREP PA; SP DDAVP TABS OR 0.1 MG, QL(3 ea daily) RECONSTITUTIONKIT F 0.2 MG (Use NF SOLR Desmopressin Acetate) SEROSTIM SOLR F PA; SP desmopressin acetate soln F PA; SP ij 4 mcg/ml PA; SP ZORBTIVE SOLR F desmopressin acetate F QL(5 ml per fill spray refrigerated soln retail) Hormone Receptor Modulators desmopressin acetate F PA; QL(5 ml spray soln 0.01 % per fill retail) EVISTA TABS (Use NF QL(1 ea daily) Raloxifene HCl) desmopressin acetate tabs F QL(3 ea daily) or 0.1 mg, 0.2 mg raloxifene hcl tabs 60 mg F QL(1 ea daily) ESTROGENS - Hormone Replacement/Modifying LHRH/GnRH Agonist Analog Pituitary Drugs SYNAREL SOLN F PA; SP Estrogen Combinations ACTIVELLA TABS (Use QL(1 ea daily) Metabolic Modifiers Estradiol & Norethindrone NF calcitriol caps or 0.25 mcg, F Acetate) 0.5 mcg Limit 8 patches CARNITOR SF SOLN (Use QL(30 ml daily) F per Levocarnitine (Metabolic NF COMBIPATCH PTTW month;QL(0.29 Modifiers)) ea daily)

NV Silver Summit Updated September 1, 2018

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits estradiol & norethindrone F QL(1 ea daily) PREMARIN TABS OR QL(1 ea daily) acetate tabs 0.625 MG, 0.45 MG, 0.3 F FEMHRT LOW DOSE MG, 0.9 MG, 1.25 MG TABS (Use Norethindrone NF VIVELLE-DOT PTTW Limit 8 patches Acetate-Ethinyl Estradiol) 0.025 MG/24HR, 0.075 per MG/24HR, 0.05 MG/24HR, NF month;QL(0.29 norethindrone acetate- F ethinyl estradiol tabs 0.1 MG/24HR (Use ea daily) Estradiol) QL(1 ea daily) PREMPHASE TABS F VIVELLE-DOT PTTW QL(0.29 ea QL(1 ea daily) 0.0375 MG/24HR (Use NF daily) PREMPRO TABS F Estradiol) Estrogens FLUOROQUINOLONES - Drugs to Treat Bacterial Limit 8 patches Infections per ALORA PTTW F Fluoroquinolones month;QL(0.29 CIPRO TABS 250 MG, 500 ea daily) MG (Use Ciprofloxacin NF Limit 4 patches HCl) CLIMARA PTWK (Use per NF CIPROFLOXACIN HCL F QL(6 ea per fill Estradiol) month;QL(0.14 TABS 100 MG retail) 3 ea daily) ciprofloxacin hcl tabs 250 F ESTRACE TABS OR 0.5 mg, 500 mg, 750 mg MG, 1 MG, 2 MG (Use NF Estradiol) QL(1 ea LEVAQUIN TABS (Use NF daily,14 ea per Limit 8 patches Levofloxacin) estradiol pttw td 0.025 fill retail) F per mg/24hr, 0.075 mg/24hr, month;QL(0.29 QL(1 ea 0.05 mg/24hr, 0.1 mg/24hr levofloxacin tabs or 250 F daily,14 ea per ea daily) mg, 500 mg, 750 mg fill retail) estradiol pttw td 0.0375 F QL(0.29 ea mg/24hr daily) OFLOXACIN TABS 300 F QL(56 ea per MG fill retail) estradiol ptwk td 0.025 Limit 4 patches QL(56 ea per mg/24hr, 0.075 mg/24hr, per ofloxacin tabs 400 mg F 0.05 mg/24hr, 0.06 F month;QL(0.14 fill retail) mg/24hr, 0.1 mg/24hr, 37.5 3 ea daily) GASTROINTESTINAL AGENTS - MISC. - mcg/24hr Miscellaneous Gastrointestinal Drugs estradiol tabs or 0.5 mg, 1 F Antiflatulents mg, 2 mg GAS-X CHEW (Use NF ESTROPIPATE TABS 0.75 F QL(1 ea daily) Simethicone) MG, 1.5 MG MYLICON INFANTS GAS QL(30 ml per ESTROPIPATE TABS 3 F QL(2 ea daily) RELIEF SUSP (Use NF fill retail) MG Simethicone) MINIVELLE PTTW 0.025 Limit 8 patches MYLICON SUSP (Use NF QL(30 ml per MG/24HR, 0.075 F per Simethicone) fill retail) MG/24HR, 0.05 MG/24HR, month;QL(0.29 0.1 MG/24HR ea daily) simethicone chew 80 mg F MINIVELLE PTTW 0.0375 QL(0.29 ea F simethicone susp 20 F QL(30 ml per MG/24HR daily) mg/0.3ml, 40 mg/0.6ml fill retail) Bile Acid Synthesis Disorder Agents NV Silver Summit Updated September 1, 2018

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHOLBAM CAPS F PA; SP lactulose (encephalopathy) F soln Gallstone Solubilizing Agents Phosphate Binder Agents ACTIGALL CAPS (Use QL(3 ea daily) NF calcium acetate (phosphate F Ursodiol) binder) caps 667 mg URSO 250 TABS (Use NF QL(7 ea daily) GENITOURINARY AGENTS - MISCELLANEOUS Ursodiol) - Miscellaneous Drugs to Treat Reproductive ursodiol caps 300 mg F QL(3 ea daily) Organs and Urinary System QL(7 ea daily) Alkalinizers ursodiol tabs 250 mg F potassium citrate Gastrointestinal Stimulants (alkalinizer) tbcr 540 mg, F 1080 mg metoclopramide hcl soln or F 5 mg/5ml, 10 mg/10ml potassium citrate-citric acid F pack 3300mg-1002mg metoclopramide hcl tabs or F 5 mg, 10 mg Limit 1 package SHOHLS SOLUTION per MODIFIED SOLN (Use REGLAN TABS (Use NF NF month;QL(16.6 Metoclopramide HCl) Sodium Citrate & Citric 7 ml daily); Acid) Inflammatory Bowel Agents RX/OTC Limit 1 package ASACOL HD TBEC F ST; QL(3 ea daily) per sodium citrate & citric acid F month;QL(16.6 ASACOL HD TBEC (Use F ST; QL(3 ea soln 7 ml daily); Mesalamine) daily) RX/OTC AZULFIDINE EN-TABS NF UROCIT-K 10 TBCR (Use TBEC (Use Sulfasalazine) Potassium Citrate NF AZULFIDINE TABS (Use NF (Alkalinizer)) Sulfasalazine) UROCIT-K 5 TBCR (Use balsalazide disodium caps F QL(9 ea daily) Potassium Citrate NF 750 mg (Alkalinizer)) COLAZAL CAPS (Use NF QL(9 ea daily) Genitourinary Irrigants Balsalazide Disodium) sodium chloride (gu F LIALDA TBEC (Use NF irrigant) soln Mesalamine) Interstitial Cystitis Agents mesalamine enem re 4 gm F QL(60 ml daily) ELMIRON CAPS F QL(3 ea daily) mesalamine tbec or 1.2 gm F Prostatic Hypertrophy Agents mesalamine tbec or 800 F ST; QL(3 ea QL(1 ea daily) mg daily) finasteride tabs 5 mg F SFROWASA ENEM F FLOMAX CAPS (Use NF QL(2 ea daily) Tamsulosin HCl) sulfasalazine tabs 500 mg F PROSCAR TABS (Use NF QL(1 ea daily) Finasteride) sulfasalazine tbec 500 mg F tamsulosin hcl caps 0.4 mg F QL(2 ea daily) Intestinal Acidifiers NV Silver Summit Updated September 1, 2018

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Urinary Analgesics ALPROLIX SOLR 4000 F UNIT phenazopyridine hcl tabs F 95 mg, 100 mg, 200 mg BEBULIN SOLR F SP PYRIDIUM TABS (Use NF Phenazopyridine HCl) BENEFIX KIT F SP

GOUT AGENTS - Drugs to Treat Gout CORIFACT KIT F SP Gout Agent Combinations ELOCTATE SOLR F SP colchicine w/ probenecid F tabs FEIBA SOLR F SP Gout Agents FIBRYGA SOLR F SP allopurinol tabs F SP PA; Limit 6 per HELIXATE FS KIT F COLCHICINE TABS 0.6 F MG claim;QL(6 ea SP per fill retail) HEMOFIL M SOLR F PA; Limit 6 per SP COLCRYS TABS 0.6 MG F claim;QL(6 ea HUMATE-P SOLR F per fill retail) IDELVION SOLR 250 SP UNIT, 500 UNIT, 1000 F ZYLOPRIM TABS (Use NF Allopurinol) UNIT, 2000 UNIT Uricosurics IXINITY SOLR F SP probenecid tabs F KOATE SOLR F SP HEMATOLOGICAL AGENTS - MISC. - Drugs to SP Treat Blood Disorders KOATE-DVI SOLR F Antihemophilic Products KOGENATE FS BIO-SET F SP KIT ADVATE SOLR F SP KOGENATE FS KIT F SP ADYNOVATE SOLR 250 SP UNIT, 500 UNIT, 1000 F KOVALTRY SOLR F SP UNIT, 2000 UNIT ADYNOVATE SOLR 750 MONOCLATE-P KIT F SP UNIT, 1500 UNIT, 3000 F UNIT MONONINE SOLR F SP AFSTYLA KIT 1500 UNIT, F 2500 UNIT NOVOEIGHT SOLR F SP ALPHANATE/VON SP SP WILLEBRANDFACTOR F NOVOSEVEN RT SOLR F COMPLEX/HUMAN SOLR NUWIQ SOLR 250 UNIT, ALPHANINE SD SOLR F SP 500 UNIT, 1000 UNIT, F 2000 UNIT ALPROLIX SOLR 250 SP OBIZUR SOLR F SP UNIT, 500 UNIT, 1000 F UNIT, 2000 UNIT, 3000 UNIT NV Silver Summit Updated September 1, 2018

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROFILNINE SD SOLR F SP miglustat caps 100 mg F PA; SP

PROFILNINE SOLR F SP VPRIV SOLR F PA; SP

RECOMBINATE SOLR F SP ZAVESCA CAPS (Use NF PA; SP Miglustat) RIASTAP SOLR F SP Agents for Sickle Cell Anemia

RIXUBIS SOLR F SP DROXIA CAPS F Cobalamins TRETTEN SOLR F SP cyanocobalamin soln ij F WILATE KIT F SP 1000 mcg/ml Folic Acid/Folates XYNTHA KIT F SP folic acid tabs or 1 mg F RX/OTC XYNTHA SOLOFUSE KIT F SP folic acid tabs or 400 mcg, F QL(1 ea daily) 800 mcg Hematorheologic Agents Hematopoietic Growth Factors pentoxifylline tbcr F ARANESP ALBUMIN F PA; SP Platelet Aggregation Inhibitors FREE SOLN ARANESP ALBUMIN PA; SP AGRYLIN CAPS (Use NF F Anagrelide HCl) FREE SOSY PA; SP anagrelide hcl caps F EPOGEN SOLN F PA; SP BRILINTA TABS F QL(2 ea daily) MIRCERA SOSY F PA; SP cilostazol tabs F QL(2 ea daily) NPLATE SOLR F PROCRIT SOLN 2000 PA; SP clopidogrel bisulfate tabs F QL(1 ea daily) 75 mg UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 10000 F dipyridamole tabs F UNIT/ML, 20000 UNIT/ML, 40000 UNIT/ML EFFIENT TABS (Use NF QL(1 ea daily) Prasugrel HCl) PROMACTA TABS F PA; SP PLAVIX TABS 75 MG (Use NF QL(1 ea daily) PA; SP Clopidogrel Bisulfate) ZARXIO SOSY F prasugrel hcl tabs F QL(1 ea daily) Hematopoietic Mixtures ferrous fumarate-fa-b QL(1 ea daily) HEMATOPOIETIC AGENTS - Drugs to Treat complex-c-zn-mg-mn-cu F Blood Disorders tabs Agents for Gaucher Disease Iron CERDELGA CAPS F PA; SP 100 / 30 days FER-IN-SOL SOLN (Use NF Ferrous Sulfate) QL(3.4 ml CEREZYME SOLR F PA; SP daily)

NV Silver Summit Updated September 1, 2018

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FERRETTS TABS F QL(2 ea daily) QL(30 ea per 5 days retail); tranexamic acid tabs or 650 F AL(At least 12 ferrous fumarate tabs 324 F mg mg yrs old - Up to 49 yrs old) ferrous gluconate tabs 27 F mg, 240 mg HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS FERROUS GLUCONATE F AL(Up to 50 yrs TABS 324 MG old ) Antihistamine Hypnotics ferrous sulfate dried tbcr F diphenhydramine hcl F 160 mg (sleep) caps 25 mg, 50 mg ferrous sulfate elix 220 QL(16 ml daily) F diphenhydramine hcl F mg/5ml (sleep) liqd 50 mg/30ml FERROUS SULFATE LIQD F diphenhydramine hcl F QL(1 ea daily) 220 MG/5ML (sleep) tabs 25 mg 100 / 30 days diphenhydramine hcl ferrous sulfate soln 15 F QL(3.4 ml F mg/ml (sleep) tabs 50 mg daily) doxylamine succinate F ferrous sulfate tabs 65 mg, F (sleep) tabs 25 mg 325 mg NYTOL MAXIMUM FERROUS SULFATE F STRENGTH TABS (Use NF TBEC 324 MG Diphenhydramine HCl ferrous sulfate tbec 325 mg F (Sleep)) UNISOM SLEEPGELS HEMOCYTE TABS (Use NF CAPS (Use NF Ferrous Fumarate) Diphenhydramine HCl IRON CHEWS PEDIATRIC F (Sleep)) CHEW 15 MG UNISOM TABS (Use polysaccharide iron F QL(1 ea daily) Doxylamine Succinate NF complex caps 150 mg (Sleep)) Stem Cell Mobilizers ZZZQUIL CAPS (Use PA; SP Diphenhydramine HCl NF MOZOBIL SOLN F (Sleep)) ZZZQUIL LIQD (Use HEMOSTATICS - Drugs to Stop Bleeding/Treat Diphenhydramine HCl NF Blood Disorders (Sleep)) Hemostatics - Systemic Barbiturate Hypnotics AMICAR TABS 500 MG F QL(24 ea per fill retail); SP AMYTAL SODIUM SOLR F QL(30 ea per 5 days retail); BUTISOL SODIUM TABS F LYSTEDA TABS (Use NF AL(At least 12 Tranexamic Acid) phenobarbital elix or 20 F yrs old - Up to mg/5ml 49 yrs old) PHENOBARBITAL F SODIUM SOLN phenobarbital soln or 20 F mg/5ml

NV Silver Summit Updated September 1, 2018

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PHENOBARBITAL TABS QL(2 ea daily); OR 15 MG, 30 MG, 60 MG, F temazepam caps 30 mg F AL(At least 18 100 MG yrs old) phenobarbital tabs or 16.2 ST; Try 2 F temazepam caps 7.5 mg, F preferred mg, 32.4 mg, 64.8 mg, 97.2 22.5 mg mg hypnotics first SECONAL SODIUM CAPS F TRIAZOLAM TABS 0.125 F QL(1 ea daily) MG Hypnotics - Tricyclic Agents triazolam tabs 0.25 mg F QL(1 ea daily) ST; Try 2 SILENOR TABS F preferred QL(1 ea daily); hypnotics first zaleplon caps F AL(At least 18 yrs old) Non-Barbiturate Hypnotics zolpidem tartrate tabs or 5 F QL(1 ea daily) AMBIEN TABS (Use NF QL(1 ea daily) mg, 10 mg Zolpidem Tartrate) LAXATIVES - Bowel Treatment Drugs estazolam tabs F ST; Try 2 Bulk Laxatives eszopiclone tabs F preferred calcium polycarbophil tabs F QL(10 ea daily) hypnotics first 625 mg QL(1 ea daily) EVAC POWD (Use NF FLURAZEPAM HCL CAPS F Psyllium) FIBERCON TABS (Use QL(10 ea daily) HALCION TABS (Use NF QL(1 ea daily) NF Triazolam) Calcium Polycarbophil) ST; Try 2 KONSYL PACK 100 % F LUNESTA TABS (Use NF Eszopiclone) preferred hypnotics first KONSYL POWD 100 % NF (Use Psyllium) midazolam hcl soln F METAMUCIL CAPS 0.52 NF midazolam hcl syrp F GM (Use Psyllium) METAMUCIL ORIGINAL QL(1 ea daily); TEXTURE POWD (Use NF RESTORIL CAPS 15 MG NF (Use Temazepam) AL(At least 18 Psyllium) yrs old) METAMUCIL POWD 48.57 NF QL(2 ea daily); % (Use Psyllium) RESTORIL CAPS 30 MG NF AL(At least 18 (Use Temazepam) psyllium caps 0.52 gm, 520 F yrs old) mg RESTORIL CAPS 7.5 MG, ST; Try 2 psyllium powd 30 %, 33 %, 22.5 MG (Use NF preferred 100 %, 28.3 %, 30.9 %, F Temazepam) hypnotics first 58.6 %, 48.57 %, QL(1 ea daily); SONATA CAPS (Use NF Laxative Combinations Zaleplon) AL(At least 18 yrs old) COLYTE-FLAVOR PACKS QL(4000 ml per QL(1 ea daily); SOLR (Use PEG 3350-KCl- NF fill retail) temazepam caps 15 mg F AL(At least 18 Sod Bicarb-Sod Chloride- yrs old) Sod Sulfate)

NV Silver Summit Updated September 1, 2018

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GOLYTELY SOLR 236GM- QL(4000 ml per FLEET PEDIATRIC ENEM NF 22.74GM-5.86GM-2.97GM- fill retail) (Use Sodium Phosphates) 6.74GM (Use PEG 3350- NF magnesium citrate soln KCl-Sod Bicarb-Sod 1.745gm/30ml, 1.745 F Chloride-Sod Sulfate) gm/30ml, NULYTELY/FLAVOR QL(4000 ml per QL(33 ml daily) PACKS SOLR (Use PEG fill retail) magnesium hydroxide susp F 3350-Potassium Chloride- NF MILK OF MAGNESIA F Sod Bicarbonate-Sod CONCENTRATE SUSP Chloride) sodium phosphates enem peg 3350-kcl-sod bicarb- QL(4000 ml per re 16gm/133ml-6gm/133ml, sod chloride-sod sulfate F fill retail) 19gm/118ml-7gm/118ml, F solr 9.5gm/59ml-3.5gm/59ml, peg 3350-potassium QL(4000 ml per 19gm/118ml-19gm/118ml- chloride-sod bicarbonate- F fill retail) 7gm/118ml-7gm/118ml sod chloride solr 420gm- 11.2gm-1.48gm-5.72gm Stimulant Laxatives QL(12 ea per sennosides-docusate F QL(4 ea daily) bisacodyl supp re 10 mg F sodium tabs fill retail) SENOKOT S TABS (Use QL(4 ea daily) bisacodyl tbec or 5 mg F QL(1 ea daily) Sennosides-Docusate NF Sodium) DULCOLAX SUPP RE 10 NF QL(12 ea per MG (Use Bisacodyl) fill retail) Laxatives - Miscellaneous DULCOLAX TBEC OR 5 NF QL(1 ea daily) glycerin (laxative) supp 2 F MG (Use Bisacodyl) gm, 1.2 gm, 2.1 gm EX-LAX TABS (Use NF GLYCERIN ADULT SUPP NF Sennosides) (Use Glycerin (Laxative)) SENNA SYRP 176 F lactulose soln F MG/5ML sennosides liqd 8.8 mg/5ml F MIRALAX PACK (Use NF RX/OTC Polyethylene Glycol 3350) sennosides syrp 8.8 F MIRALAX POWD (Use NF QL(34 gm mg/5ml Polyethylene Glycol 3350) daily); RX/OTC sennosides tabs 15 mg, 8.6 F PEDIA-LAX SUPP RE 2.8 F mg, 17.2 mg GM SENOKOT TABS (Use NF polyethylene glycol 3350 F RX/OTC Sennosides) pack SENOKOT XTRA TABS NF polyethylene glycol 3350 F QL(34 gm (Use Sennosides) powd daily); RX/OTC Surfactant Laxatives SORBITOL SOLN OR 70 F % COLACE CAPS (Use NF QL(3 ea daily) Docusate Sodium) Saline Laxatives docusate calcium caps F FLEET ENEMA ENEM NF (Use Sodium Phosphates) docusate sodium caps or F QL(3 ea daily) FLEET ENEMA SIX PACK 100 mg, 250 mg ENEM (Use Sodium NF Phosphates) NV Silver Summit Updated September 1, 2018

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits docusate sodium liqd or 50 F ZITHROMAX Z-PAK TABS NF QL(6 ea per fill mg/5ml, 150 mg/15ml (Use Azithromycin) retail) docusate sodium syrp or F Clarithromycin 60 mg/15ml BIAXIN SUSR 250 docusate sodium tabs or F MG/5ML (Use NF 100 mg Clarithromycin) MACROLIDES - Drugs to Treat Bacterial BIAXIN TABS 250 MG, 500 NF QL(28 ea per Infections MG (Use Clarithromycin) fill retail) Azithromycin Limit 1 package clarithromycin susr 125 F per AZITHROMYCIN PACK F QL(2 ea per fill mg/5ml claim;QL(100 OR 1 GM retail) ml per fill retail) Limit 1 Limit 1 package azithromycin susr or 100 package per F CLARITHROMYCIN SUSR F per mg/5ml claim;QL(15 ml 125 MG/5ML claim;QL(100 per fill retail) ml per fill retail) Limit 1 CLARITHROMYCIN SUSR F azithromycin susr or 200 F package per 250 MG/5ML mg/5ml claim;QL(30 ml per fill retail) clarithromycin susr 250 F mg/5ml azithromycin tabs or 250 F QL(6 ea per fill mg retail) clarithromycin tabs 250 mg, F QL(28 ea per 500 mg fill retail) azithromycin tabs or 500 QL(4 ea daily) F QL(14 ea per mg clarithromycin tb24 500 mg F fill retail) Limit 8 per 28 azithromycin tabs or 600 F days;QL(0.286 mg Erythromycins ea daily) E.E.S. 400 TABS F ZITHROMAX PACK OR 1 F QL(2 ea per fill GM retail) E.E.S. GRANULES SUSR (Use Erythromycin NF ZITHROMAX SUSR OR Limit 1 package per Ethylsuccinate) 100 MG/5ML (Use NF Azithromycin) claim;QL(15 ml ERY-TAB TBEC F per fill retail) Limit 1 ERYPED 200 SUSR (Use ZITHROMAX SUSR OR package per Erythromycin NF 200 MG/5ML (Use NF Ethylsuccinate) Azithromycin) claim;QL(30 ml per fill retail) ERYPED 400 SUSR F ZITHROMAX TABS OR QL(6 ea per fill 250 MG (Use NF retail) ERYTHROCIN STEARATE F Azithromycin) TABS ZITHROMAX TABS OR QL(4 ea daily) erythromycin base cpep F 500 MG (Use NF Azithromycin) erythromycin base tabs F ZITHROMAX TABS OR Limit 8 per 28 600 MG (Use NF days;QL(0.286 erythromycin Azithromycin) ea daily) ethylsuccinate susr 200 F mg/5ml ZITHROMAX TRI-PAK NF QL(4 ea daily) TABS (Use Azithromycin) NV Silver Summit Updated September 1, 2018

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ERYTHROMYCIN COPA PLUS RX/OTC ETHYLSUCCINATE TABS F HYDROPHILIC FOAM F 400 MG DRESSING 4"X4" PADS PCE TBEC F COVRSITE COVER F RX/OTC DRESSING PADS MEDICAL DEVICES AND SUPPLIES COVRSITE PLUS RX/OTC COMPOSITE DRESSING F Bandages-Dressings-Tape PADS CUREX ALL-PURPOSE RX/OTC ALLEVYN PLUS CAVITY F RX/OTC PADS SPONGES 4"X4" 4 PLY F RX/OTC PADS ALLEVYN THIN PADS F CURITY ALL PURPOSE RX/OTC SPONGES 2"X2" 4PLY F AMD FOAM DRESSING F RX/OTC 4"X4" PADS PADS AMD FOAM RX/OTC CURITY ALL PURPOSE F RX/OTC DRESSING/TOPSHEET F SPONGES 2"X2" PADS 4"X4" PADS CURITY ALL PURPOSE SPONGES 3"X3" 4PLY F BAND-AID GAUZE PADS F RX/OTC LARGE4" X 4" PADS PADS CURITY ALL PURPOSE RX/OTC BAND-AID GAUZE PADS F F MEDIUM 3" X 3" PADS SPONGES 4 PLY PADS CURITY ALL PURPOSE RX/OTC BAND-AID GAUZE PADS F RX/OTC SMALL2" X 2" PADS SPONGES 4"X4" 4PLY F BAND-AID MIRASORB RX/OTC PADS GAUZE SPONGES F CURITY ALL PURPOSE RX/OTC LARGE 4" X 4" PADS SPONGES 4"X4" F BIATAIN ADHESIVE RX/OTC 4PLY/SOFT POUCH PADS FOAM DRESSING 4"X4" F CURITY ALL PURPOSE F RX/OTC PADS SPONGES 4"X4" PADS CURITY AMD RX/OTC BIATAIN FOAM F RX/OTC DRESSING 4"X4" PADS ANTIMICROBIALGAUZE F BIOGUARD GAUZE RX/OTC SPONGES 2"X2" 8 PLY SPONGE 2"X2" 8 PLY F PADS PADS CURITY AMD RX/OTC BIOGUARD GAUZE RX/OTC ANTIMICROBIALGAUZE F SPONGES 4"X4" 12 PLY F SPONGES 4"X4" 12 PLY PADS PADS CURITY COVER SPONGE RX/OTC BORDERED GAUZE F RX/OTC F PADS 4"X4" PADS CURITY COVER CARRASMART FOAM F RX/OTC F PADS SPONGES 3"X3" PADS RX/OTC CURITY COVER F RX/OTC CARRASMART PADS XX F SPONGES 4"X4" PADS COPA ISLAND RX/OTC CURITY DRESSING RX/OTC BORDERED FOAM F SPONGES 4"X4" 6 PLY F DRESSING 4"X4" PADS PADS

NV Silver Summit Updated September 1, 2018

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY GAUZE PADS F RX/OTC DERMACEA DRAIN F RX/OTC 2"X2" 12 PLY PADS SPONGES 4"X4" PADS CURITY GAUZE PADS F RX/OTC DERMACEA GAUZE RX/OTC 2"X2" PADS SPONGE 2"X2" 12 PLY F PADS CURITY GAUZE PADS F 3"X3" PADS DERMACEA GAUZE RX/OTC SPONGE 2"X2" 8 PLY F CURITY GAUZE PADS F RX/OTC 4"X4" 12 PLY PADS PADS DERMACEA GAUZE CURITY GAUZE SPONGE F RX/OTC 2"X2" 8 PLY PADS SPONGE 3"X3" 12 PLY F PADS CURITY GAUZE SPONGE F RX/OTC 2"X2"12 PLY PADS DERMACEA GAUZE SPONGE 3"X3" 8 PLY F CURITY GAUZE SPONGE F PADS 3"X3" 12 PLY PADS DERMACEA GAUZE RX/OTC CURITY GAUZE SPONGE F RX/OTC SPONGE 4"X4" 12 PLY F 4"X4" 12 PLY PADS PADS CURITY GAUZE SPONGE F RX/OTC DERMACEA GAUZE RX/OTC 4"X4" 16 PLY PADS SPONGE 4"X4" 16 PLY F CURITY GAUZE SPONGE F RX/OTC PADS 4"X4" 8 PLY PADS DERMACEA GAUZE RX/OTC CURITY GAUZE SPONGE F RX/OTC SPONGE 4"X4" 8 PLY F 4"X4"16 PLY PADS PADS CURITY GAUZE RX/OTC DERMACEA I.V. DRAIN F RX/OTC SPONGES 4"X4" 12 PLY F SPONGES 2"X2" PADS PADS DERMACEA I.V. DRAIN F RX/OTC CURITY GAUZE RX/OTC SPONGES 4"X4" PADS SPONGES 4"X4" 8 PLY F DERMACEA I.V. F RX/OTC PADS SPONGES 2"X2" PADS CURITY NON-ADHERENT F DERMACEA NON-WOVEN RX/OTC STRIPS 3"X3" PADS SPONGES 2"X2" 4 PLY F CURITY RX/OTC PADS SPONGES/CELLULOSEFI F DERMACEA NON-WOVEN LLED/2"X2" PADS SPONGES 3"X3" 4 PLY F CURITY RX/OTC PADS SPONGES/CELLULOSEFI F DERMACEA NON-WOVEN RX/OTC LLED/4"X4" PADS SPONGES 4"X4" 4 PLY F CVS GAUZE PAD 3"X3" F PADS PADS DERMACEA NON-WOVEN RX/OTC CVS GAUZE PADS 2"X2" F RX/OTC SPONGES 4"X4" 6 PLY F 12-PLY PADS PADS CVS GAUZE PADS 4"X4" F RX/OTC DERMACEA TYPE VII RX/OTC 12-PLY PADS GAUZE 2"X2" 12 PLY F CVS GAUZE PADS RX/OTC PADS STERILE 4"X4" 12-PLY F DERMACEA TYPE VII F RX/OTC PADS GAUZE 2"X2" 8 PLY PADS

NV Silver Summit Updated September 1, 2018

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA TYPE VII GAUZE PADS 3"X3" PADS F GAUZE 3"X3" 12 PLY F PADS GAUZE PADS 4"X4" 12 F RX/OTC DERMACEA TYPE VII PLY PADS F GAUZE 3"X3" 12PLY GAUZE PADS 4"X4" PADS F RX/OTC PADS DERMACEA TYPE VII RX/OTC GAUZE SPONGE TYPE RX/OTC GAUZE 4"X4" 12 PLY F VII MEDI-PAK 2"X2" 8PLY F PADS PADS DERMACEA TYPE VII RX/OTC GAUZE SPONGES 4"X4" F RX/OTC GAUZE 4"X4" 16 PLY F 12 PLY PADS PADS GNP STERILE PADS F 3"X3" PADS DERMACEA TYPE VII F RX/OTC GAUZE 4"X4" 8 PLY PADS HM STERILE PADS 2"X2" F RX/OTC DERMACEA X-RAY RX/OTC PADS SPONGES 4"X4" 16 PLY F RX/OTC PADS HM STERILE PADS PADS F DERMALEVIN ADHESIVE RX/OTC HYDROCELL ADHESIVE F RX/OTC FOAMDRESSING 4"X4" F DRESSING 4"X4" PADS PADS HYDROCELL DRESSING F RX/OTC DRYMAX EXTRA PADS F RX/OTC 4"X4" PADS J & J GAUZE 2"X2" 8 PLY F RX/OTC EQL GAUZE PADS F RX/OTC PADS 2"X2"/SMALL PADS J & J GAUZE 4"X4" 12 PLY F RX/OTC EQL GAUZE PADS F RX/OTC PADS 4"X4"/LARGE PADS J & J GAUZE 4"X4" 8 PLY F RX/OTC EQL GAUZE STERILE F PADS PADS 3"X3" PADS J & J GAUZE SPONGES F RX/OTC EXCILON AMD RX/OTC 12-PLY 4" X 4" MISC ANTIMICROBIALDRAIN F J & J GAUZE SPONGES F RX/OTC SPONGES 4"X4" 6 PLY 16-PLY 4" X 4" MISC PADS J & J GAUZE SPONGES F RX/OTC EXCILON AMD RX/OTC 8-PLY4" X 4" MISC ANTIMICROBIALNON- F WOVEN SPONGES 4"X4" KENDALL HYDROPHILIC RX/OTC 6 PLY PADS FOAMDRESSING 2"X2" F PADS EXCILON DRAIN F RX/OTC SPONGE 4"X4" PADS KENDALL HYDROPHILIC FOAMDRESSING 3"X3" F EXCILON DRAIN RX/OTC PADS SPONGES 4"X4" 6 PLY F PADS KENDALL HYDROPHILIC RX/OTC FOAMDRESSING 4"X4" F EXCILON I.V. SPONGES F RX/OTC PADS 2"X2" 6 PLY PADS KENDALL HYDROPHILIC RX/OTC GAUZE DRESSING 4"X4" F RX/OTC FOAMPLUS DRESSING F PADS 2"X2" PADS GAUZE PADS 2"X2" PADS F RX/OTC

NV Silver Summit Updated September 1, 2018

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KENDALL HYDROPHILIC RESTORE CONTACT RX/OTC FOAMPLUS DRESSING F LAYER/NON-ADHERENT F 3"X3" PADS 2"X2" PADS KERLIX SPONGES 4" X 4" F RX/OTC RESTORE FOAM RX/OTC 12 PLY PADS DRESSING BORDERED F 4"X4" PADS KERLIX SPONGES 4" X 4" F RX/OTC 16 PLY PADS RESTORE FOAM RX/OTC DRESSING NON- F MIRASORB SPONGES 2" F RX/OTC X 2" MISC BORDERED 4"X4" PADS RESTORE ODOR RX/OTC MIRASORB SPONGES 4" F RX/OTC X 4" MISC ABSORBING DRESSING F 4"X4" PADS NU GAUZE 4PLY 4"X4" F RX/OTC PADS RESTORE TRIO ABSORBENT DRESSING F NU GAUZE GENERAL- RX/OTC 3"X3" PADS USE SPONGES 4"X4" 4 F PLY MISC SM GAUZE PADS 2"X2" F RX/OTC PADS OPTIFOAM PADS F RX/OTC SM GAUZE PADS 3"X3" F PADS POLYMEM DRESSING/3" F X 3" PADS SM GAUZE PADS 4"X4" F RX/OTC PADS POLYMEM DRESSING/4" F RX/OTC X 4" PADS SM STERILE PADS 2"X2" F RX/OTC PADS QC ALL PURPOSE F RX/OTC DRESSINGS4"X4" PADS SM STERILE PADS PADS F RX/OTC QC BORDER ISLAND F RX/OTC GAUZE PAD 2"X2" PADS SOF-WICK 4"X4" PADS F RX/OTC QC STERILE PADS PADS F STERILE GAUZE PADS F RX/OTC 2"X2" PADS QC STERILE PADS PADS F RX/OTC STERILE GAUZE PADS F 3"X3" PADS RA ALL PURPOSE F RX/OTC DRESSINGS4"X4" PADS STERILE PADS 2"X2" F RX/OTC PADS RA DRESSING SPONGES F RX/OTC 4"X4" PADS STERILE PADS 3"X3" F PADS RA GAUZE SPONGES F RX/OTC 4"X4" PADS STERILE PADS 4"X4" F RX/OTC PADS RA STERILE PADS 2"X2" F RX/OTC PADS SURGICAL GAUZE F RX/OTC SPONGE PADS RA STERILE PADS 3"X3" F PADS TEGADERM FOAM F RX/OTC DRESSING 2"X2" PADS RA STERILE PADS 4"X4" F RX/OTC PADS TEGADERM FOAM F RX/OTC RAY-TEC X-RAY RX/OTC DRESSING 4"X4" PADS DETECTABLESPONGES F THERAGAUZE PADS F RX/OTC 4" X 4" 16 PLY MISC TOPPER DRESSING F RX/OTC SPONGES 4"X4" MISC NV Silver Summit Updated September 1, 2018

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VERSIVA XC 3" X 3" QL(36 ea per KIMONO COLORS DEVI F FOAM F fill retail) DRESSING/HYDROFIBER KIMONO LUBRICATED F QL(36 ea per TECHNOLOGY PADS MISC fill retail) VERSIVA XC 4" X 4" RX/OTC KIMONO MICRO THIN QL(36 ea per FOAM F PLUS SPERMICIDE F fill retail) DRESSING/HYDROFIBER LUBRICATED MISC TECHNOLOGY PADS KIMONO PLUS QL(36 ea per VISTEC X-RAY RX/OTC SPERMICIDE F fill retail) DETECTABLE SPONGES F LUBRICATED MISC 4"X4" 16 PLY PADS KIMONO PLUS QL(36 ea per Contraceptives SPERMICIDE/LUBRICATE F fill retail) D MISC AIMSCO LUBRICATED F QL(36 ea per MISC fill retail) KIMONO PS LUBRICATED F QL(36 ea per ATLAS COLORED QL(36 ea per MISC fill retail) LUBRICATEDCONDOM F fill retail) KIMONO PS PLUS QL(36 ea per DEVI SPERMICIDE/LUBRICATE F fill retail) D MISC ATLAS LUBRICATED F QL(36 ea per CONDOM DEVI fill retail) KIMONO SENSATION F QL(36 ea per ATLAS LUBRICATED QL(36 ea per LUBRICATED MISC fill retail) CONDOM/SPERMICIDE F fill retail) KIMONO SENSATION QL(36 ea per DEVI PLUS SPERMICIDE F fill retail) LUBRICATED MISC CLASS ACT LUBRICATED F QL(36 ea per MISC fill retail) KIMONO SPECIAL DEVI F QL(36 ea per fill retail) DUREX EXTRA F QL(36 ea per SENSITIVE DEVI fill retail) MAXX LUBRICATED MISC F QL(36 ea per fill retail) ELEXA NATURAL FEEL F QL(36 ea per MISC fill retail) MAXX PLUS SPERMICIDE F QL(36 ea per LUBRICATED MISC fill retail) ELEXA STIMULATING F QL(36 ea per MISC fill retail) PREMIUM CONDOMS F QL(36 ea per LUBRICATED MISC fill retail) ELEXA ULTRA SENSITIVE F QL(36 ea per MISC fill retail) REALITY LATEX QL(36 ea per CONDOMS/LUBRICATED F fill retail) EXTRA SENSITIVE F QL(36 ea per SPERMICIDAL DEVI fill retail) MISC REALITY LATEX/ULTRA QL(36 ea per FANTASY LUBRICATED F QL(36 ea per F MISC fill retail) TEXTURED DEVI fill retail) FANTASY QL(36 ea per REALITY LATEX/ULTRA F QL(36 ea per LUBRICATED/SPERMICID F fill retail) THIN DEVI fill retail) E MISC TROJAN EXTENDED QL(36 ea per PLEASURE/LUBRICATED F fill retail) HIGH SENSATION F QL(36 ea per SPERMICIDAL DEVI fill retail) DEVI QL(36 ea per INTENSE SENSATION F QL(36 ea per TROJAN MAGNUM MISC F DEVI fill retail) fill retail) TROJAN MAGNUM WARM QL(36 ea per KAMELEON LUBRICATED F QL(36 ea per F MISC fill retail) SENSATIONS DEVI fill retail) TROJAN MAGNUM XL F QL(36 ea per LUBRICATED DEVI fill retail) NV Silver Summit Updated September 1, 2018

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TROJAN PLEASURE QL(36 ea per TRUSTEX QL(36 ea per F MESH/SPERMICIDAL fill retail) LUBRICATED/SPERMICID F fill retail) DEVI E EXTRA STRENGTH MISC TROJAN RIBBED F QL(36 ea per W/SPERMICIDAL MISC fill retail) TRUSTEX QL(36 ea per TROJAN SHARED QL(36 ea per LUBRICATED/SPERMICID F fill retail) SENSATION/LUBRICATE F fill retail) E MISC D DEVI TRUSTEX NATURAL QL(36 ea per CONDOMS fill retail) TROJAN SUPRAS F QL(36 ea per F SPERMICIDAL DEVI fill retail) +LUBE/LUBRICATED MISC TROJAN TWISTED F QL(36 ea per PLEASURE DEVI fill retail) TRUSTEX WITH QL(36 ea per NONOXYNOL- F fill retail) TROJAN ULTRA QL(36 ea per 9/RIBBED/STUDDED PLEASURE/LUBRICATED F fill retail) MISC DEVI TRUSTEX/RIA F QL(36 ea per TROJAN VERY QL(36 ea per LUBRICATED MISC fill retail) SENSITIVE LUBRICATED F fill retail) MISC TRUSTEX/RIA QL(36 ea per LUBRICATED F fill retail) TROJAN VERY QL(36 ea per SPERMICIDE MISC SENSITIVE SPERMICIDAL F fill retail) LUBRICANT MISC TRUSTEX/RIA QL(36 ea per LUBRICATED/SPERMICID F fill retail) TROJAN VERY THIN F QL(36 ea per E MISC LUBRICATED MISC fill retail) ULTIMATE FEELING DEVI F QL(36 ea per TROJAN VERY THIN QL(36 ea per fill retail) SPERMICIDAL F fill retail) LUBRICANT MISC Diabetic Supplies 1ST CHOICE LANCETS QL(5 ea daily) TROJAN-ENZ LUBRICANT F QL(36 ea per F MISC fill retail) SUPERTHIN MISC 1ST CHOICE LANCETS QL(5 ea daily) TROJAN-ENZ F QL(36 ea per F LUBRICATED MISC fill retail) THIN MISC 1ST CHOICE LANCETS QL(5 ea daily) TROJAN-ENZ F QL(36 ea per F W/SPERMICIDAL MISC fill retail) ULTRATHIN MISC 1ST TIER UNILET QL(5 ea daily) TRUSTEX COLOR F QL(36 ea per CONDOMS + LUBE MISC fill retail) COMFORTOUCH F LANCETS 28G MISC TRUSTEX LUBRICATED F QL(36 ea per EXTRALARGE MISC fill retail) 1ST TIER UNILET QL(5 ea daily) COMFORTOUCH F TRUSTEX LUBRICATED F QL(36 ea per EXTRASTRENGTH MISC fill retail) LANCETS 30G MISC ACCU-CHEK FASTCLIX QL(5 ea daily) TRUSTEX LUBRICATED F QL(36 ea per F MISC fill retail) LANCETS MISC TRUSTEX QL(36 ea per ACCU-CHEK SOFTCLIX F QL(5 ea daily) LUBRICATED/RIBBED/ST F fill retail) LANCETS MISC UDDED MISC ACTI-LANCE LANCETS F QL(5 ea daily) TRUSTEX QL(36 ea per 28G MISC LUBRICATED/SPERMICID F fill retail) ACTI-LANCE LITE QL(5 ea daily) E EXTRA LARGE MISC SAFETY LANCETS 28G F MISC NV Silver Summit Updated September 1, 2018

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTI-LANCE SPECIAL QL(5 ea daily) AT LAST LANCETS MISC F QL(5 ea daily) SAFETY LANCETS 17G F MISC AURORA LANCET SUPER F QL(5 ea daily) ACTI-LANCE UNIVERSAL QL(5 ea daily) THIN30G MISC SAFETY LANCETS 23G F AURORA LANCET THIN F QL(5 ea daily) MISC 23G MISC ADJUSTABLE LANCING QL(1 ea per F AUTO-LANCET MINI MISC F QL(1 ea per DEVICE MISC 180 days retail) 180 days retail) ADVOCATE LANCING QL(1 ea per F AUTO-LANCET MISC F QL(1 ea per DEVICE MISC 180 days retail) 180 days retail) ADVOCATE RAPID-SAFE QL(1 ea per F AUTOLET IMPRESSION F QL(1 ea per LANCING DEVICE MISC 180 days retail) LANCING DEVICE MISC 180 days retail) AGAMATRIX ULTRA-THIN QL(5 ea daily) F AUTOLET LANCING F QL(1 ea per LANCETS 33G MISC DEVICE MISC 180 days retail) ALTERNATE SITE QL(1 ea per F AUTOLET MINI MISC F QL(1 ea per LANCING DEVICE MISC 180 days retail) 180 days retail) AQUA LANCE QL(1 ea per AUTOLET PLUS MISC F QL(1 ea per ADJUSTABLE LANCING F 180 days retail) 180 days retail) DEVICE DEVI BAYER MICROLET 2 F QL(1 ea per ASSURE COMFORT QL(5 ea daily) LANCING DEVICE MISC 180 days retail) LANCETS ULTRA THIN F BAYER MICROLET F QL(5 ea daily) 28G MISC LANCETS MISC ASSURE HAEMOLANCE QL(5 ea daily) BD LANCET DEVICE F QL(1 ea per PLUS HIGH FLOW 18G F MISC 180 days retail) MISC BD LANCET ULTRAFINE F QL(5 ea daily) ASSURE HAEMOLANCE QL(5 ea daily) 30G MISC PLUS LOW FLOW 25G F MISC BD MICROTAINER F QL(5 ea daily) LANCETS MISC ASSURE HAEMOLANCE QL(5 ea daily) PLUS MICRO FLOW 28G F BULLSEYE MINI SAFETY F QL(5 ea daily) MISC LANCETS MISC ASSURE HAEMOLANCE QL(5 ea daily) BULLSEYE SAFETY F QL(5 ea daily) PLUS NORMAL FLOW F LANCETS MISC 21G MISC CARDIOCOM LANCING F QL(1 ea per ASSURE HAEMOLANCE QL(5 ea daily) DEVICE MISC 180 days retail) PLUS PEDIATRIC BLADE F CAREONE ADVANCED F QL(1 ea per MISC LANCINGDEVICE MISC 180 days retail) CAREONE LANCET THIN QL(5 ea daily) ASSURE LANCE F QL(5 ea daily) F LANCETS 21G MISC MISC CAREONE LANCET QL(5 ea daily) ASSURE LANCE F QL(5 ea daily) F LANCETS MISC ULTRA THIN MISC ASSURE LANCE PLUS QL(5 ea daily) CARETOUCH LANCING QL(1 ea per SAFETYLANCETS 25G F DEVICEWITH EJECTOR F 180 days retail) MISC MISC ASSURE LANCE PLUS QL(5 ea daily) CARETOUCH TWIST F QL(5 ea daily) SAFETYLANCETS 30G F LANCETS 30G MISC MISC

NV Silver Summit Updated September 1, 2018

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEANLET LANCETS 28G F QL(5 ea daily) DRUG MART UNILET QL(5 ea daily) MISC LANCETSULTRA THIN F QL(1 ea per 28G MISC CLOSERCARE MISC F 180 days retail) DUANE READE LANCET QL(5 ea daily) COMFORT ASSURED QL(5 ea daily) ALTERNATE SITE 26G F LANCETS MICRO THIN F MISC 33G MISC DUANE READE LANCET F QL(5 ea daily) COMFORT ASSURED QL(5 ea daily) SUPERTHIN 30G MISC LANCETS SUPER THIN F DUANE READE LANCET F QL(5 ea daily) 28G MISC ULTRATHIN 28G MISC COMFORT LANCETS QL(5 ea daily) F E-Z JECT LANCETS 21G F QL(5 ea daily) MISC MISC QL(5 ea daily) CVS LANCETS 21G MISC F E-Z JECT LANCETS F QL(5 ea daily) COLOR MISC CVS LANCETS MICRO F QL(5 ea daily) QL(5 ea daily) THIN 33G MISC E-Z JECT LANCETS MISC F CVS LANCETS MICRO- QL(5 ea daily) F E-Z JECT LANCETS F QL(5 ea daily) THIN 33G MISC SUPER THIN 30G MISC CVS LANCETS ORIGINAL QL(5 ea daily) F E-Z JECT LANCETS THIN F QL(5 ea daily) MISC 26G MISC CVS LANCETS THIN 26G QL(5 ea daily) F E-ZJECT LANCETS F QL(5 ea daily) MISC MICRO-THIN 33G MISC CVS LANCETS ULTRA QL(5 ea daily) F EASY MINI EJECT F QL(1 ea per THIN 30G MISC LANCING DEVICE MISC 180 days retail) CVS LANCETS ULTRA- QL(5 ea daily) F EASY MINI LANCING F QL(1 ea per THIN 30G MISC DEVICE MISC 180 days retail) CVS LANCING DEVICE QL(1 ea per F EASY TOUCH LANCETS F QL(5 ea daily) MISC 180 days retail) 26G/PULL-TOP MISC CVS ULTRA THIN QL(5 ea daily) F EASY TOUCH LANCETS F QL(5 ea daily) LANCETS MISC 26G/TWIST MISC DROPLET LANCETS QL(5 ea daily) F EASY TOUCH LANCETS F QL(5 ea daily) ULTRA THIN 30G MISC 28G/PULL-TOP MISC DROPLET LANCING QL(1 ea per F EASY TOUCH LANCETS F QL(5 ea daily) DEVICE MISC 180 days retail) 28G/TWIST MISC DRUG MART QL(1 ea per EASY TOUCH LANCETS QL(5 ea daily) ADJUSTABLE LANCING F 180 days retail) 30G/BUTTON-ACTIVATED F DEVICE MISC MISC DRUG MART LANCETS QL(5 ea daily) F EASY TOUCH LANCETS F QL(5 ea daily) THIN MISC 30G/PULL-TOP MISC DRUG MART ON-THE-GO QL(5 ea daily) EASY TOUCH LANCETS F QL(5 ea daily) LANCETS GENTLE 30G F 30G/TWIST MISC MISC EASY TOUCH LANCETS QL(5 ea daily) DRUG MART UNILET QL(5 ea daily) 32G/PRESSURE F LANCETSSUPER THIN F ACTIVATED MISC 30G MISC EASY TOUCH LANCETS F QL(5 ea daily) 32G/PULL-TOP MISC

NV Silver Summit Updated September 1, 2018

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS F QL(5 ea daily) FINE 30 MISC F QL(5 ea daily) 32G/TWIST MISC FINGERSTIX LANCETS QL(5 ea daily) EASY TOUCH LANCETS F QL(5 ea daily) F 33G/TWIST MISC MISC QL(5 ea daily) EASY TOUCH LANCING F QL(1 ea per FORA LANCETS MISC F DEVICE/EJECTOR MISC 180 days retail) EASY TOUCH SAFETY QL(5 ea daily) FORA LANCING DEVICE F QL(1 ea per LANCETS21G/PRESSURE F MISC 180 days retail) ACTIVATED MISC FORA LANCING F QL(1 ea per EASY TOUCH SAFETY QL(5 ea daily) DEVICE/CLEARCAP MISC 180 days retail) LANCETS28G/BUTTON F FREDS PHARMACY QL(1 ea per ACTIVATED MISC AUTOLET LANCING F 180 days retail) DEVICE MISC EASY TWIST & CAP F QL(5 ea daily) LANCETS MISC FREDS PHARMACY QL(5 ea daily) UNILET LANCETS SUPER F EASYTEST II LANCETS F QL(5 ea daily) MISC THIN 30G MISC FREDS PHARMACY QL(5 ea daily) EASYTEST LANCETS F QL(5 ea daily) MISC UNILET LANCETS ULTRA F THIN 28G MISC EQL COLOR LANCETS F QL(5 ea daily) 21G MISC GENTEEL LANCING QL(1 ea per DEVICE/BUFF BLACK F 180 days retail) EQL COLOR LANCETS F QL(5 ea daily) MISC MICRO THIN 33G MISC GENTEEL LANCING QL(1 ea per EQL SUPER THIN F QL(5 ea daily) DEVICE/BUTTERFLY F 180 days retail) LANCETS 30G MISC BLUE MISC EQL THIN LANCETS 26G F QL(5 ea daily) GENTEEL LANCING QL(1 ea per MISC DEVICE/GLORIOUS F 180 days retail) EZ SMART BLOOD QL(5 ea daily) GOLD MISC GLUCOSE LANCETS F GENTEEL LANCING QL(1 ea per MISC DEVICE/PLAYFUL F 180 days retail) EZ-LETS LANCETS 21G F QL(5 ea daily) PURPLE MISC MISC GENTEEL LANCING QL(1 ea per EZ-LETS LANCETS 23G F QL(5 ea daily) DEVICE/PRECIOUS F 180 days retail) MISC PLATINUM MISC EZ-LETS LANCETS 26G F QL(5 ea daily) GENTEEL LANCING QL(1 ea per SUPER-SOFT MISC DEVICE/PRINCESS PINK F 180 days retail) MISC EZ-LETS LANCETS 28G F QL(5 ea daily) ULTRA-SOFT MISC GENTEEL LANCING QL(1 ea per DEVICE/STATELY SILVER F 180 days retail) EZ-LETS LANCETS 30G F QL(5 ea daily) MISC MISC GENTEEL LANCING QL(1 ea per FIFTY50 LANCING F QL(1 ea per DEVICE MISC 180 days retail) DEVICE/WILLOWY WHITE F 180 days retail) MISC FIFTY50 SAFETY SEAL F QL(5 ea daily) LANCETS 32G MISC GENTLE-LET GP F QL(5 ea daily) LANCETS MISC FIFTY50 UNILET F QL(5 ea daily) LANCETS 33G MISC

NV Silver Summit Updated September 1, 2018

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTLE-LET LANCETS QL(5 ea daily) H-E-B INCONTROL QL(5 ea daily) GENERAL PURPOSE F LANCETS MICRO THIN F STYLE/FINE POINT MISC 33G MISC GENTLE-LET LANCETS QL(5 ea daily) H-E-B INCONTROL QL(5 ea daily) GENERAL PURPOSE F LANCETS SUPER THIN F STYLE/MEDIUM POINT 30G MISC MISC H-E-B INCONTROL QL(5 ea daily) GENTLE-LET LANCETS QL(5 ea daily) LANCETS ULTRA THIN F SAFETY STYLE/FINE F 28G MISC POINT MISC HAEMOLANCE LOW F QL(5 ea daily) GENTLE-LET LANCETS QL(5 ea daily) FLOW LANCETS MISC SAFETY STYLE/MEDIUM F QL(5 ea daily) POINT MISC HAEMOLANCE MISC F GLOBAL LANCING QL(1 ea per F HAEMOLANCE PLUS F QL(5 ea daily) DEVICE MISC 180 days retail) LOW FLOW MISC GLUCOCOM LANCETS QL(5 ea daily) F HAEMOLANCE PLUS F QL(5 ea daily) 33G MISC MISC GLUCOSOURCE LANCET QL(1 ea per F HEALTH CARE LANCING F QL(1 ea per DEVICE MISC 180 days retail) DEVICE MISC 180 days retail) GLUCOSOURCE QL(5 ea daily) F HEALTHWISE LANCING F QL(1 ea per LANCETS MISC PEN MISC 180 days retail) GNP LANCETS 21G MISC F QL(5 ea daily) HEALTHY ACCENTS QL(1 ea per AUTOLET IMPRESSION F 180 days retail) GNP LANCETS MICRO F QL(5 ea daily) LANCING DEVICE MISC THIN 33G MISC HEALTHY ACCENTS QL(5 ea daily) GNP LANCETS MISC F QL(5 ea daily) UNILET LANCETS SUPER F THIN 30G MISC GNP LANCETS SUPER F QL(5 ea daily) QL(5 ea daily) THIN 30G MISC HY-VEE LANCETS MISC F GNP LANCETS THIN 26G QL(5 ea daily) F HY-VEE THIN LANCETS F QL(5 ea daily) MISC MISC GNP LANCETS THIN QL(5 ea daily) F IN TOUCH LANCING F QL(1 ea per MISC DEVICE MISC 180 days retail) GNP MICRO THIN F QL(5 ea daily) KINNEY LANCETS MISC F QL(5 ea daily) LANCETS 33G MISC KINNEY THIN LANCETS QL(5 ea daily) GNP SUPER THIN F QL(5 ea daily) F LANCETS/30G MISC MISC KROGER LANCETS 21G QL(5 ea daily) GOODSENSE LANCETS F QL(5 ea daily) F MICRO-THIN 33G MISC MISC KROGER LANCETS QL(5 ea daily) GOODSENSE LANCETS F QL(5 ea daily) F ULTRA-THIN 30G MISC MICRO THIN33G MISC QL(5 ea daily) GOODSENSE LANCING F QL(1 ea per KROGER LANCETS MISC F DEVICE MISC 180 days retail) H-E-B INCONTROL QL(1 ea per KROGER LANCETS F QL(5 ea daily) ADVANCEDLANCING F 180 days retail) SUPER THIN MISC DEVICE MISC KROGER LANCETS THIN F QL(5 ea daily) 26G MISC

NV Silver Summit Updated September 1, 2018

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KROGER LANCETS THIN QL(5 ea daily) F LANZO MISC F QL(1 ea per MISC 180 days retail) KROGER LANCETS F QL(5 ea daily) LEADER ADVANCED F QL(1 ea per ULTRATHIN30G MISC LANCING DEVICE MISC 180 days retail) KROGER LANCING F QL(1 ea per LIBERTY MEDICAL F QL(5 ea daily) DEVICE MISC 180 days retail) LANCETS 30G MISC LANCET DEVICE F QL(1 ea per LIBERTY MINI LANCING F QL(1 ea per ADJUSTABLE MISC 180 days retail) DEVICE MISC 180 days retail) LANCET DEVICE WITH F QL(1 ea per LIFESCAN UNISTIK 2 QL(5 ea daily) EJECTOR MISC 180 days retail) DEEP PENETRATION F MISC LANCETS 26G TWIST F QL(5 ea daily) TOP MISC LIFESCAN UNISTIK II F QL(5 ea daily) LANCETS MISC LANCETS 28G MISC F QL(5 ea daily) LITE TOUCH LANCETS F QL(5 ea daily) LANCETS 30G MISC F QL(5 ea daily) MISC LITE TOUCH LANCING F QL(1 ea per LANCETS 31G TWIST F QL(5 ea daily) PEN MISC 180 days retail) TOP MISC LITETOUCH LANCETS F QL(5 ea daily) LANCETS MICRO THIN F QL(5 ea daily) MICRO THIN 33G MISC 33G MISC LIVE BETTER ADVANCED F QL(1 ea per LANCETS MISC F QL(5 ea daily) LANCING DEVICE MISC 180 days retail) LIVE BETTER LANCET F QL(5 ea daily) LANCETS SAFETY SEAL F QL(5 ea daily) SUPERTHIN 30G MISC 21G MISC LIVE BETTER LANCET F QL(5 ea daily) LANCETS SAFETY SEAL F QL(5 ea daily) ULTRATHIN 28G MISC 26G MISC LONGS LANCETS F QL(5 ea daily) LANCETS SAFETY SEAL F QL(5 ea daily) STANDARD MISC 28G MISC LONGS LANCETS THIN F QL(5 ea daily) LANCETS SAFETY SEAL F QL(5 ea daily) MISC 30G MISC LONGS LANCETS ULTRA F QL(5 ea daily) LANCETS SUPER THIN F QL(5 ea daily) THIN MISC 28G MISC MEDICHOICE PRE-SET QL(5 ea daily) LANCETS THIN MISC F QL(5 ea daily) SAFETY LANCET DUAL F USE MISC LANCETS ULTRA FINE F QL(5 ea daily) MEDICHOICE PRE-SET QL(5 ea daily) MISC SAFETY LANCET LOW F LANCETS ULTRA THIN F QL(5 ea daily) FLOW MISC 30G MISC MEDICHOICE PRE-SET QL(5 ea daily) LANCETS ULTRA THIN F QL(5 ea daily) SAFETY LANCET F MISC MEDIUM FLOW MISC LANCETSBULLSEYE F QL(5 ea daily) MEDICHOICE PRE-SET QL(5 ea daily) SAFETY MISC SAFETY LANCET F MODERATE FLOW MISC LANCING DEVICE F QL(1 ea per ADJUSTABLE MISC 180 days retail) QL(5 ea daily) MEDICHOICE SAFETY F LANCETEXTRA MISC LANCING DEVICE MISC F QL(1 ea per 180 days retail)

NV Silver Summit Updated September 1, 2018

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDICHOICE SAFETY QL(5 ea daily) F MINI LANCING DEVICE F QL(1 ea per LANCETNORMAL MISC MISC 180 days retail) MEDISENSE THIN QL(5 ea daily) F MM LANCING DEVICE F QL(1 ea per LANCETS MISC MISC 180 days retail) MEDLANCE PLUS EXTRA QL(5 ea daily) F MONOLET LANCETS F QL(5 ea daily) LANCETS 21G MISC MISC MEDLANCE PLUS QL(5 ea daily) F MONOLET OPD LANCETS F QL(5 ea daily) LANCETS LITE 25G MISC MISC MEDLANCE PLUS QL(5 ea daily) F MONOLETTOR SAFETY F QL(5 ea daily) LANCETS MISC LANCETS MISC MEDLANCE PLUS LITE QL(5 ea daily) F MULTI-LANCET DEVICE F QL(1 ea per LANCETS 25G MISC MISC 180 days retail) MEDLANCE PLUS QL(5 ea daily) NOVA SUREFLEX F QL(5 ea daily) SPECIAL LANCETS F LANCETS MISC 0.8MM MISC NOVA SUREFLEX F QL(1 ea per MEDLANCE PLUS QL(5 ea daily) LANCING DEVICE MISC 180 days retail) SUPERLITE F ON CALL LANCING F QL(1 ea per 30G/COMFORT MAX DEVICE MISC 180 days retail) MISC ON CALL PLUS LANCING F QL(1 ea per MEDLANCE PLUS QL(5 ea daily) DEVICE MISC 180 days retail) UNIVERSAL LANCETS F 21G MISC ONETOUCH CLUB QL(5 ea daily) LANCETS FINE POINT F MEDLANCE/EXTRA MISC F QL(5 ea daily) MISC ONETOUCH COMBO F QL(5 ea daily) MEDLANCE/LITE MISC F QL(5 ea daily) PACK MISC ONETOUCH DELICA QL(5 ea daily) MEDLANCE/UNIVERSAL F QL(5 ea daily) MISC LANCETS EXTRA FINE F 33G MISC MEIJER COLOR QL(5 ea daily) LANCETS UNIVERSAL F ONETOUCH DELICA F QL(5 ea daily) 33G MISC LANCETS FINE 30G MISC QL(5 ea daily) ONETOUCH DELICA F QL(1 ea per MEIJER LANCETS MISC F LANCING DEVICE MISC 180 days retail) ONETOUCH ULTRASOFT QL(5 ea daily) MEIJER LANCETS THIN F QL(5 ea daily) F MISC LANCETS MISC PC LANCETS SUPER QL(5 ea daily) MEIJER LANCETS F QL(5 ea daily) F UNIVERSAL21G MISC THIN 30G MISC PERFECT LANCETS 30G QL(5 ea daily) MEIJER LANCETS F QL(5 ea daily) F UNIVERSAL30G MISC MISC PHARMACY COUNTER QL(5 ea daily) MEIJER LANCETS F QL(5 ea daily) F UNIVERSAL33G MISC LANCETS MISC PRECISION THIN QL(5 ea daily) MEIJER SUPER THIN F QL(5 ea daily) F LANCETS MISC LANCETS MISC PRECISION THINS GP QL(5 ea daily) MICROLET LANCETS F QL(5 ea daily) F MISC LANCET MISC PRECISION ULTRA QL(5 ea daily) MICROLET NEXT MISC F QL(1 ea per F 180 days retail) LANCET MISC NV Silver Summit Updated September 1, 2018

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREFERRED PLUS QL(5 ea daily) RA E-ZJECT LANCETS F QL(5 ea daily) LANCETS COLORED 21G F THIN 28G MISC MISC RA E-ZJECT LANCETS F QL(5 ea daily) PREFERRED PLUS QL(5 ea daily) ULTRATHIN 30G MISC LANCETS SUPER THIN F RA LANCING DEVICE F QL(1 ea per 30G MISC MISC 180 days retail) PREFERRED PLUS F QL(5 ea daily) QL(5 ea daily) LANCETS THIN 26G MISC REALITY LANCETS MISC F PRESSURE ACTIVATED QL(5 ea daily) RELION 2-IN-1 LANCING F QL(1 ea per SAFETYLANCET 21G F DEVICE 25G MISC 180 days retail) MISC RELION 2-IN-1 LANCING F QL(1 ea per PRODIGY LANCING F QL(1 ea per DEVICE 30G MISC 180 days retail) DEVICE MISC 180 days retail) RELION LANCETS F QL(5 ea daily) PRODIGY TWIST TOP F QL(5 ea daily) MICRO-THIN33G MISC LANCETS MISC RELION LANCETS F QL(5 ea daily) PSS SELECT GP F QL(5 ea daily) STANDARD 21G MISC LANCETS MISC RELION LANCETS THIN F QL(5 ea daily) PSS SELECT SAFETY F QL(5 ea daily) 26G MISC LANCETS MISC RELION LANCETS F QL(5 ea daily) PUSH BUTTON SAFETY F QL(5 ea daily) ULTRA-THIN30G MISC LANCETS 21G MISC RELION LANCING F QL(1 ea per PUSH BUTTON SAFETY F QL(5 ea daily) DEVICE MISC 180 days retail) LANCETS 28G MISC RELION ULTRA THIN F QL(5 ea daily) PX ADVANCED LANCING F QL(1 ea per LANCETS30G MISC DEVICE MISC 180 days retail) RELION ULTRA THIN QL(5 ea daily) PX LANCET AUTO F QL(1 ea per PLUS LANCETS 32G F INJECTOR MISC 180 days retail) MISC PX LANCETS ULTRA F QL(5 ea daily) RELION ULTRA THIN QL(5 ea daily) THIN MISC PLUS LANCETS 33G F MISC QC ADVANCED LANCING F QL(1 ea per DEVICE MISC 180 days retail) REXALL LANCETS ULTRA F QL(5 ea daily) THIN MISC QC LANCETS SUPER F QL(5 ea daily) THIN MISC RIGHTEST GD500 F QL(1 ea per LANCING DEVICE MISC 180 days retail) QC LANCETS ULTRA F QL(5 ea daily) THIN MISC RIGHTEST GL300 F QL(5 ea daily) LANCETS MISC QC UNILET LANCETS F QL(5 ea daily) 28G/ULTRA THIN MISC SAFE-T-LANCE LOW F QL(5 ea daily) FLOW 25G MISC QC UNILET LANCETS F QL(5 ea daily) 33G/MICRO THIN MISC SAFE-T-LANCE NORMAL F QL(5 ea daily) RA E-ZJECT COLOR QL(5 ea daily) FLOW21G MISC LANCETSMICRO-THIN F SAFE-T-LANCE PLUS QL(5 ea daily) 33G MISC SAFETYLANCET LOW F FLOW MISC RA E-ZJECT LANCETS F QL(5 ea daily) 28G MISC SAFE-T-LANCE PLUS QL(5 ea daily) SAFETYLANCET F RA E-ZJECT LANCETS F QL(5 ea daily) THIN 26G MISC NORMAL FLOW MISC

NV Silver Summit Updated September 1, 2018

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY LANCETS 28G F QL(5 ea daily) SMART SENSE THIN QL(5 ea daily) MISC LANCETSUNIVERSAL F 26G MISC SAFETY LET LANCETS F QL(5 ea daily) MISC SMARTEST LANCETS F QL(5 ea daily) 28G MISC SAFETY SEAL LANCETS F QL(5 ea daily) 28G MISC SOLUS V2 LANCING F QL(1 ea per DEVICE MISC 180 days retail) SAFETY SEAL LANCETS F QL(5 ea daily) 30G MISC STERILANCE TL MISC F QL(5 ea daily) SB LANCETS THIN MISC F QL(5 ea daily) SUPER THIN LANCETS F QL(5 ea daily) MISC SB LANCETS ULTRA F QL(5 ea daily) THIN MISC SURE COMFORT F QL(1 ea per LANCING PEN MISC 180 days retail) SELECT-LITE LANCING F QL(1 ea per DEVICE MISC 180 days retail) SURE-LANCE THIN F QL(5 ea daily) LANCETS 28G MISC SHOPKO AUTOLET F QL(1 ea per LANCING DEVICE MISC 180 days retail) SURE-LANCE ULTRA F QL(5 ea daily) SHOPKO ON-THE-GO QL(5 ea daily) THIN LANCETS MISC COMFORTLANCETS 30G F SURE-PEN MISC F QL(1 ea per MISC 180 days retail) SHOPKO UNILET QL(5 ea daily) SURE-TOUCH LANCETS F QL(5 ea daily) LANCETS SUPER THIN F UNIVERSAL MISC 30G MISC SURELITE LANCETS F QL(5 ea daily) SHOPKO UNILET QL(5 ea daily) MISC LANCETS ULTRA THIN F TECHLITE AST LANCETS F QL(5 ea daily) 28G MISC MISC SIDE BUTTON SAFETY QL(5 ea daily) F TECHLITE LANCETS 30G F QL(5 ea daily) LANCET21G MISC MISC SIMPLE DIAGNOSTICS QL(1 ea per F TECHLITE LANCETS F QL(5 ea daily) LANCING DEVICE MISC 180 days retail) MISC QL(5 ea daily) SINGLE-LET MISC F TGT ADVANCED F QL(1 ea per LANCING DEVICE MISC 180 days retail) SM MICRO THIN QL(5 ea daily) F TGT LANCET F QL(5 ea daily) LANCETS 33G MISC ALTERNATE SITE MISC SM TRUEDRAW LANCING QL(1 ea per F TGT LANCET MICRO F QL(5 ea daily) DEVICE MISC 180 days retail) THIN 33G MISC SMART DIABETES QL(1 ea per TGT LANCET SUPER F QL(5 ea daily) VANTAGE LANCING F 180 days retail) THIN 30G MISC DEVICE MISC TGT LANCET THIN 23G F QL(5 ea daily) SMART SENSE COLOR QL(5 ea daily) MISC LANCETS UNIVERSAL F 33G MISC TGT LANCET THIN 26G F QL(5 ea daily) MISC SMART SENSE QL(5 ea daily) STANDARD LANCETS F TGT LANCET ULTRA F QL(5 ea daily) UNIVERSAL 21G MISC THIN 28G MISC SMART SENSE SUPER QL(5 ea daily) TGT LANCET ULTRA F QL(5 ea daily) THIN LANCETS F THIN 30G MISC UNIVERSAL 30G MISC

NV Silver Summit Updated September 1, 2018

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TGT LANCING DEVICE F QL(1 ea per TRUEPLUS LANCETS F QL(5 ea daily) MISC 180 days retail) 33G MISC THINLETS GP LANCETS F QL(5 ea daily) TRUEPLUS SAFETY F QL(5 ea daily) MISC LANCETS 28G MISC THINLETS LANCET MISC F QL(5 ea daily) TRUETEST GLUCOSE F CONTROLLEVEL 1 LIQD TODAYS HEALTH QL(1 ea per TRUETEST GLUCOSE F ADVANCED LANCING F 180 days retail) CONTROLLEVEL 2 LIQD DEVICE MISC TRUETEST GLUCOSE F TODAYS HEALTH SUPER F QL(5 ea daily) CONTROLLEVEL 3 LIQD THINLANCETS 30G MISC ULTI-LANCE AUTOMATIC/ F QL(1 ea per TODAYS HEALTH ULTRA F QL(5 ea daily) CLEAR TIP MISC 180 days retail) THINLANCETS 28G MISC ULTICARE THIN F QL(5 ea daily) TOPCARE LANCETS F QL(5 ea daily) LANCETS 30G MISC MICRO-THIN 33G MISC ULTILET CLASSIC F QL(5 ea daily) TRAVEL LANCETS 30G F QL(5 ea daily) LANCETS MISC MISC ULTILET LANCETS 33G F QL(5 ea daily) TRAVEL LANCETS F QL(5 ea daily) MISC ADVANCED 28G MISC QL(5 ea daily) TRUE METRIX CONTROL ULTILET LANCETS MISC F SOLUTION LEVEL 1 F ULTRA THIN LANCETS F QL(5 ea daily) SOLN 28G MISC TRUE METRIX CONTROL UNILET COMFORTOUCH F QL(5 ea daily) SOLUTION LEVEL 2 F LANCET MISC SOLN QL(5 ea daily) TRUE METRIX CONTROL UNILET EXCELITE II MISC F SOLUTION LEVEL 3 F QL(5 ea daily) SOLN UNILET EXCELITE MISC F TRUECONTROL UNILET G.P. LANCET F QL(5 ea daily) GLUCOSE CONTROL F MISC LEVEL 0 LIQD UNILET G.P. SUPERLITE F QL(5 ea daily) TRUECONTROL LANCET MISC GLUCOSE CONTROL F UNILET GP 28 ULTRA F QL(5 ea daily) LEVEL 1 LIQD THIN MISC TRUEDRAW LANCING F QL(1 ea per QL(5 ea daily) DEVICE MISC 180 days retail) UNILET LANCET MISC F TRUEPLUS LANCETS QL(5 ea daily) F UNILET LANCETS F QL(5 ea daily) 26G MISC MICRO-THIN33G MISC TRUEPLUS LANCETS QL(5 ea daily) F UNILET LANCETS F QL(5 ea daily) 28G MISC SUPER-THIN30G MISC TRUEPLUS LANCETS QL(5 ea daily) F UNILET LANCETS F QL(5 ea daily) 28G SUPER THIN MISC ULTRA-THIN 28G MISC TRUEPLUS LANCETS QL(5 ea daily) F UNILET SUPERLITE F QL(5 ea daily) 30G MISC LANCET MISC TRUEPLUS LANCETS QL(5 ea daily) F UNISTIK TOUCH SAFETY F QL(5 ea daily) 30G ULTRA THIN MISC LANCETS 23G MISC

NV Silver Summit Updated September 1, 2018

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNIVERSAL 1 LANCETS F QL(5 ea daily) QL(400 ea per THIN26G MISC ALCOHOL PREP PADS F PADS fill retail); RX/OTC UNIVERSAL 1 LANCETS F QL(5 ea daily) ULTRA THIN 30G MISC QL(400 ea per UNIVERSAL 1 QL(5 ea daily) ALCOHOL PREPS PADS F fill retail); LANCETS/33G/MICRO- F RX/OTC THIN MISC QL(400 ea per ALCOHOL SWABS PADS F fill retail); VALUE PLUS LANCETS F QL(5 ea daily) STANDARD 21G MISC RX/OTC VALUE PLUS LANCETS QL(5 ea daily) QL(400 ea per F ALCOHOL SWABSTICK F SUPERTHIN 30G MISC PADS fill retail); RX/OTC VALUE PLUS LANCETS F QL(5 ea daily) THIN 26G MISC QL(400 ea per ALCOHOL WIPES PADS F fill retail); VALUE PLUS LANCING F QL(1 ea per RX/OTC DEVICE MISC 180 days retail) QL(400 ea per VALUMARK LANCET QL(5 ea daily) APLICARE ALCOHOL F F SWABSTICK PADS fill retail); SUPER THIN 30G MISC RX/OTC VALUMARK LANCET F QL(5 ea daily) QL(400 ea per ULTRA THIN 28G MISC BD SWABS SINGLE USE F fill retail); BUTTERFLY PADS VIDA MIA AUTOLET F QL(1 ea per RX/OTC LANCINGDEVICE MISC 180 days retail) QL(400 ea per VIDA MIA UNILET QL(5 ea daily) BD SWABS SINGLE USE F PADS fill retail); LANCETS SUPER THIN F RX/OTC 30G MISC QL(400 ea per VIDA MIA UNILET QL(5 ea daily) CARETOUCH ALCOHOL F PREP PADS PADS fill retail); LANCETS ULTRA THIN F RX/OTC 28G MISC CURITY ALCOHOL QL(400 ea per VITALET PRO PLUS F QL(5 ea daily) PREPS/MEDIUM 2 PLY F fill retail); LANCETS MISC PADS RX/OTC W&F LANCETS 26G MISC F QL(5 ea daily) QL(400 ea per CURITY ALCOHOL F fill retail); SWABS PADS W&F LANCETS F QL(5 ea daily) RX/OTC COLORED 21G MISC QL(400 ea per WALGREENS COMFORT QL(5 ea daily) CVS ALCOHOL PREP F SWABS PADS fill retail); ASSUREDLANCETS F RX/OTC MICRO THIN/33G MISC QL(400 ea per WALGREENS COMFORT QL(5 ea daily) CVS PREP PADS PADS F fill retail); ASSUREDLANCETS F RX/OTC SUPER THIN/28G MISC EASY TOUCH ALCOHOL QL(400 ea per WALGREENS LANCETS F QL(5 ea daily) PREP PADS/MEDIUM F fill retail); MISC PADS RX/OTC WALGREENS THIN F QL(5 ea daily) QL(400 ea per LANCETS MISC EQL ALCOHOL SWABS F PADS fill retail); RX/OTC WALGREENS ULTRA F QL(5 ea daily) THIN LANCETS MISC QL(400 ea per FIFTY50 ALCOHOL PREP F fill retail); Misc. Devices PADS PADS RX/OTC NV Silver Summit Updated September 1, 2018

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP ALCOHOL SWABS QL(400 ea per WEBCOL ALCOHOL QL(400 ea per F fill retail); PREP MEDIUM 2 PLY F fill retail); PADS RX/OTC PADS RX/OTC QL(400 ea per Parenteral Therapy Supplies H-E-B INCONTROL F fill retail); ALCOHOL PADS PADS 1ST TIER UNIFINE QL(5 ea daily); RX/OTC PENTIPS/MINI/31GX5MM F RX/OTC QL(400 ea per MISC HM STERILE ALCOHOL F fill retail); PREP PADS PADS 1ST TIER UNIFINE QL(5 ea daily); RX/OTC PENTIPS29GX12MM F RX/OTC MEIJER ALCOHOL QL(400 ea per MISC SWABS EXTRA-THICK F fill retail); 1ST TIER UNIFINE QL(5 ea daily) PADS RX/OTC F PENTIPS31GX6MM MISC QL(400 ea per PRO COMFORT F fill retail); 1ST TIER UNIFINE F QL(5 ea daily); ALCOHOL PADS PADS PENTIPS31GX8MM MISC RX/OTC RX/OTC QL(400 ea per 1ST TIER UNIFINE F QL(5 ea daily); QC ALCOHOL SWABS F PENTIPS32GX4MM MISC RX/OTC PADS fill retail); RX/OTC 1ST TIER UNIFINE QL(5 ea daily); F QL(400 ea per PENTIPSPLUS 31GX8MM RX/OTC RA ALCOHOL SWABS F MISC PADS fill retail); RX/OTC 1ST TIER UNIFINE QL(5 ea daily); F QL(400 ea per PENTIPSPLUS 32GX4MM RX/OTC MISC REALITY SWABS PADS F fill retail); RX/OTC 1ST TIER UNIFINE QL(5 ea daily); F QL(400 ea per PENTIPSPLUS/MINI/31GX RX/OTC RELION ALCOHOL F 5MM MISC SWABS PADS fill retail); RX/OTC 1ST TIER UNIFINE QL(5 ea daily); F QL(400 ea per PENTIPSPLUS/ORIGINAL/ RX/OTC SB ALCOHOL PREP F 29GX12MM MISC PADS PADS fill retail); RX/OTC 1ST TIER UNIFINE QL(5 ea daily) F QL(400 ea per PENTIPSPLUS/ULTRA SHOPKO ALCOHOL F SHORT/31GX6MM MISC SWABS PADS fill retail); RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily) F QL(400 ea per NEEDLES 29GX12.7MM SM ALCOHOL PREP F MISC PADS PADS fill retail); RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily); F QL(400 ea per NEEDLES 31GX5MM RX/OTC TGT ALCOHOL SWABS F MISC PADS fill retail); RX/OTC ADVOCATE INSULIN PEN QL(5 ea daily); F QL(400 ea per NEEDLES 31GX8MM RX/OTC ULTICARE ALCOHOL F MISC SWABS PADS fill retail); RX/OTC ADVOCATE INSULIN QL(5 ea daily); F WEBCOL ALCOHOL QL(400 ea per SYRINGE/U- RX/OTC 100/0.3ML/29GX1/2" MISC PREP LARGE 1 PLY F fill retail); PADS RX/OTC ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC WEBCOL ALCOHOL QL(400 ea per F PREP LARGE 2 PLY F fill retail); 100/0.3ML/30GX5/16" MISC PADS RX/OTC NV Silver Summit Updated September 1, 2018

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVOCATE INSULIN QL(5 ea daily) AURORA PEN NEEDLES F QL(5 ea daily); SYRINGE/U- F 29GX12MM MISC RX/OTC 100/0.3ML/31GX5/16" AURORA PEN NEEDLES F QL(5 ea daily) MISC 31G X6MM MISC ADVOCATE INSULIN QL(5 ea daily); AURORA PEN NEEDLES F QL(5 ea daily); SYRINGE/U- F RX/OTC 31G X8MM MISC RX/OTC 100/0.5ML/29GX1/2" MISC AURORA UNIFINE F QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); PENTIPS/32GX5/32" MISC RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/30GX5/16" AURORA UNIFINE QL(5 ea daily); MISC PENTIPS/MINI/31GX3/16" F RX/OTC MISC ADVOCATE INSULIN QL(5 ea daily) QL(1 ea per SYRINGE/U- F 100/0.5ML/31GX5/16" AUTOPEN DEVI F 180 days MISC retail); RX/OTC ADVOCATE INSULIN QL(5 ea daily); B-D INSULIN SYRINGE QL(5 ea daily) SYRINGE/U- F RX/OTC ULTRAFINE II/0.3ML/31G F 100/1ML/29GX1/2" MISC X 5/16" MISC ADVOCATE INSULIN QL(5 ea daily); B-D INSULIN SYRINGE QL(5 ea daily) SYRINGE/U- F RX/OTC ULTRAFINE II/0.5ML/31G F 100/1ML/30GX5/16" MISC X 5/16" MISC ADVOCATE INSULIN QL(5 ea daily) B-D INSULIN SYRINGE QL(5 ea daily) SYRINGE/U- F ULTRAFINE II/1ML/31G X F 100/1ML/31GX5/16" MISC 5/16" MISC ANTI-STICK INSULIN QL(5 ea daily); B-D INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.3ML/30G X F SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" 1/2" MISC MISC B-D INSULIN SYRINGE QL(5 ea daily) ANTI-STICK INSULIN QL(5 ea daily); ULTRAFINE/0.5ML/30G X F 1/2" MISC SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" BD LO-DOSE INSULIN QL(5 ea daily); MISC SYRINGE MICROFINE F RX/OTC ANTI-STICK INSULIN QL(5 ea daily); IV/0.5ML/28G X 1/2" MISC SYRINGE/U-100/1ML/29G F RX/OTC BD AUTOSHIELD 29G X F QL(5 ea daily) X 1/2" MISC 5/16" MISC ASSURE ID INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- SAFETYSYRINGE/U- F RX/OTC F 100/0.5ML/29G X 1/2" 100/0.3ML/28G X 1/2" MISC MISC ASSURE ID INSULIN QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily); SAFETYSYRINGE/U- F RX/OTC MICROFINE IV/U- F RX/OTC 100/1ML/29G X 1/2" MISC 100/0.5ML/28G X 1/2" ASSURE ID SAFETY PEN QL(5 ea daily); MISC NEEDLES 30G X 5/16" F RX/OTC BD INSULIN SYRINGE QL(5 ea daily) MISC MICROFINE IV/U- F ASSURE ID SAFETY PEN QL(5 ea daily); 100/1ML/27G X 5/8" MISC NEEDLES 31G X 3/16" F RX/OTC MISC

NV Silver Summit Updated September 1, 2018

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) MICROFINE IV/U- F RX/OTC ULTRAFINE/0.3ML/30G X F 100/1ML/28G X 1/2" MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) MICROFINE/U- F ULTRAFINE/0.3ML/31G X F 100/0.3ML/28G X 1/2" 5/16" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/0.5ML/30G X F MICROFINE/U- F RX/OTC 1/2" MISC 100/0.5ML/28G X 1/2" BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE/0.5ML/31G X F BD INSULIN SYRINGE QL(5 ea daily) 5/16" MISC MICROFINE/U- F BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/27G X 5/8" MISC ULTRAFINE/1ML/30G X F BD INSULIN SYRINGE QL(5 ea daily); 1/2" MISC MICROFINE/U- F RX/OTC BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/28G X 1/2" MISC ULTRAFINE/1ML/31G X F BD INSULIN SYRINGE QL(5 ea daily); 5/16" MISC SAFETYGLIDE/0.5ML/29G F RX/OTC BD INSULIN SYRINGE QL(5 ea daily); X 1/2" MISC ULTRAFINE/U- F RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/0.3ML/29G X 1/2" SAFETYGLIDE/1ML/29G X F RX/OTC MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/U- F SAFETYGLIDE/U- F 100/0.3ML/30G X 1/2" 100/0.3ML/31G X 5/16" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/U- F SAFETYGLIDE/U- F 100/0.3ML/31G X 5/16" 100/1ML/31G X 15/64" MISC MISC BD INSULIN SYRINGE QL(5 ea daily); BD INSULIN SYRINGE U- QL(5 ea daily); ULTRAFINE/U- F RX/OTC 100/0.3ML/29G X 1/2" F RX/OTC 100/0.5ML/29G X 1/2" MISC MISC BD INSULIN SYRINGE U- F QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/29G X 1/2" MISC RX/OTC ULTRAFINE/U- F BD INSULIN SYRINGE QL(5 ea daily) 100/0.5ML/30G X 1/2" MISC ULTRAFINE HALF- F UNIT/0.3ML/31G X 5/16" BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE/U- F BD INSULIN SYRINGE QL(5 ea daily) 100/0.5ML/31G X 5/16" MISC ULTRAFINE F II/SHORT/0.5ML/31G X BD INSULIN SYRINGE QL(5 ea daily); 5/16" MISC ULTRAFINE/U- F RX/OTC BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/29G X 1/2" MISC ULTRAFINE F BD INSULIN SYRINGE QL(5 ea daily) II/SHORT/1ML/31G X 5/16" ULTRAFINE/U- F MISC 100/1ML/30G X 1/2" MISC

NV Silver Summit Updated September 1, 2018

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily) BD PEN QL(5 ea daily); ULTRAFINE/U- F NEEDLE/SHORT/ULTRAFI F RX/OTC 100/1ML/31G X 15/64" NE/31G X 5/16" MISC MISC BD PEN QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) NEEDLE/ULTRAFINE/29G F ULTRAFINE/U- F X 12.7MM MISC 100/1ML/31G X 5/16" BD PEN QL(5 ea daily) MISC NEEDLE/ULTRAFINE/29G F BD INSULIN QL(5 ea daily) X1/2" 12.7MM MISC SYRINGE/DETACHABLE F BD PEN NEEDLES QL(5 ea daily); NEEDLE/U-100/1ML/25G SHORT/ULTRAFINE/31G F RX/OTC X 1" MISC X 5/16" MISC BD INSULIN QL(5 ea daily) BD SAFETY-GLIDE QL(5 ea daily); SYRINGE/DETACHABLE F INSULIN F RX/OTC NEEDLE/U-100/1ML/25G SYRINGE/0.5ML/29G X X 5/8" MISC 1/2" MISC BD INSULIN QL(5 ea daily) BD SAFETY-LOK INSULIN QL(5 ea daily); SYRINGE/DETACHABLE F SYRINGE/PERM F RX/OTC NEEDLE/U-100/1ML/26G NEEDLE/UF/1ML/29G X X 1/2" MISC 1/2" MISC BD INSULIN SYRINGE/U- QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily); 100/0.5ML/30G X 1/2" F INSULIN F RX/OTC MISC SYSYRINGE/0.5ML/30G X BD INSULIN SYRINGE/U- F QL(5 ea daily); 5/16" MISC 100/1ML/27G X 1/2" MISC RX/OTC BD ULTRA-FINE MICRO QL(5 ea daily) BD INSULIN SYRINGE/U- F QL(5 ea daily); PEN NEEDLES 6MM X F 100/1ML/28G X 1/2" MISC RX/OTC 32G MISC BD INTEGRA INSULIN QL(5 ea daily); BD VEO INSULIN QL(5 ea daily) F SYRINGE/U-100/1ML/29G RX/OTC SYRINGE ULTRAFINE/U- F X 1/2" MISC 100/1ML/31G X 15/64" BD INTEGRA QL(5 ea daily) MISC SYRINGE/RETRACTING F CAREFINE PEN NEEDLE F QL(5 ea daily); NEEDLE/1ML/25G X 1" 32GX4MM MISC RX/OTC MISC CAREFINE PEN F QL(5 ea daily); QL(1 ea per NEEDLES 29GX1/2" MISC RX/OTC BD PEN MINI MISC F 180 days CAREFINE PEN QL(5 ea daily); retail); RX/OTC NEEDLES 30GX5/16" F RX/OTC QL(1 ea per MISC BD PEN MISC F 180 days CAREFINE PEN QL(5 ea daily) retail); RX/OTC NEEDLES 31GX6MM F BD PEN QL(5 ea daily); MISC NEEDLE/MINI/ULTRAFINE F RX/OTC CAREFINE PEN QL(5 ea daily); /31G X 3/16" MISC NEEDLES 31GX8MM F RX/OTC BD PEN QL(5 ea daily); MISC NEEDLE/NANO/ULTRAFI F RX/OTC CAREFINE PEN QL(5 ea daily); NE/32G X 4MM MISC NEEDLES 32GX5MM F RX/OTC MISC

NV Silver Summit Updated September 1, 2018

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREFINE PEN QL(5 ea daily) CAREONE UNIFINE QL(5 ea daily); NEEDLES 32GX6MM F PENTIPS PLUS PEN F RX/OTC MISC NEEDLES 31GX8MM CAREONE INSULIN QL(5 ea daily) MISC SYRINGES/0.3ML/30G X F CAREONE UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS PLUS PEN F RX/OTC CAREONE INSULIN QL(5 ea daily) NEEDLES 32GX4MM SYRINGES/0.3ML/31G X F MISC 5/16" MISC CARETOUCH PEN QL(5 ea daily) CAREONE INSULIN QL(5 ea daily) NEEDLES 31G X 6 MM F SYRINGES/0.5ML/30G X F MISC 1/2" MISC CARETOUCH PEN QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) NEEDLES 31GX 5MM F RX/OTC SYRINGES/0.5ML/31G X F MISC 5/16" MISC CARETOUCH PEN QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) NEEDLES 31GX 8MM F RX/OTC SYRINGES/1ML/30G X F MISC 1/2" MISC CARETOUCH PEN QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) NEEDLES 32GX 4MM F RX/OTC SYRINGES/1ML/31GX5/16 F MISC " MISC CARETOUCH PEN QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily); NEEDLES 32GX 5MM F RX/OTC PENTIPS 29GX12MM F RX/OTC MISC MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN RX/OTC CAREONE UNIFINE F QL(5 ea daily); F PENTIPS 31GX5MM MISC RX/OTC PEN NEEDLES 31GX8MM MISC CAREONE UNIFINE F QL(5 ea daily) PENTIPS 31GX6MM MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN F RX/OTC CAREONE UNIFINE F QL(5 ea daily); SYRINGE/0.3ML/29G X PENTIPS 31GX8MM MISC RX/OTC 1/2" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) PENTIPS PEN NEEDLES F RX/OTC COMFORT EZINSULIN F 32GX4MM MISC SYRINGE/0.3ML/30G X CAREONE UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS PLUS PEN F RX/OTC CLEVER CHOICE QL(5 ea daily); NEEDLES 29GX12MM COMFORT EZINSULIN F RX/OTC MISC SYRINGE/0.3ML/30G X CAREONE UNIFINE QL(5 ea daily); 5/16" MISC PENTIPS PLUS PEN F RX/OTC CLEVER CHOICE QL(5 ea daily) NEEDLES 31GX5MM COMFORT EZINSULIN F MISC SYRINGE/0.3ML/31G X CAREONE UNIFINE QL(5 ea daily) 5/16" MISC PENTIPS PLUS PEN F CLEVER CHOICE QL(5 ea daily); NEEDLES 31GX6MM COMFORT EZINSULIN F RX/OTC MISC SYRINGE/0.5ML/28G X 1/2" MISC

NV Silver Summit Updated September 1, 2018

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN F RX/OTC COMFORT EZPEN F RX/OTC SYRINGE/0.5ML/29G X NEEDLES 31GX8MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN F COMFORT EZPEN F RX/OTC SYRINGE/0.5ML/30G X NEEDLES 32GX4MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN F RX/OTC COMFORT EZPEN F RX/OTC SYRINGE/0.5ML/30G X NEEDLES 32GX5MM 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN F COMFORT EZPEN F SYRINGE/0.5ML/31G X NEEDLES 32GX6MM 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLICKFINE PEN NEEDLE F QL(5 ea daily); COMFORT EZINSULIN F 32GX5/32" MISC RX/OTC SYRINGE/1.0ML/30G X CLICKFINE PEN NEEDLE QL(5 ea daily) 1/2" MISC UNIVERSAL/31GX1/4" F CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN F RX/OTC CLICKFINE PEN NEEDLE QL(5 ea daily); SYRINGE/1ML/28G X 1/2" UNIVERSAL/31GX5/16" F RX/OTC MISC MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN F QL(5 ea daily) COMFORT EZINSULIN F RX/OTC NEEDLES/31GX1/4" MISC SYRINGE/1ML/29G X 1/2" MISC CLICKFINE PEN QL(5 ea daily); NEEDLES/31GX5/16" F RX/OTC CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN F RX/OTC SYRINGE/1ML/30G X CLICKFINE UNIVERSAL QL(5 ea daily); 5/16" MISC PEN NEEDLES 31GX5/16" F RX/OTC MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); COMFORT EZINSULIN F SYRINGE/U- INSULIN SYRINGE F RX/OTC 100/1ML/31GX5/16" MISC 0.3ML/29G X 1/2" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); INSULIN RX/OTC COMFORT EZPEN F RX/OTC F NEEDLES 29GX12MM SYRINGE/0.3ML/30G X MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) INSULIN COMFORT EZPEN F RX/OTC F NEEDLES 31GX5MM SYRINGE/0.3ML/31G X MISC 5/16" MISC CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); INSULIN RX/OTC COMFORT EZPEN F F NEEDLES 31GX6MM SYRINGE/0.5ML/29G X MISC 1/2" MISC

NV Silver Summit Updated September 1, 2018

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST QL(5 ea daily); DRUG MART UNIFINE F QL(5 ea daily); INSULIN F RX/OTC PENTIPS 31GX5MM MISC RX/OTC SYRINGE/0.5ML/30G X DRUG MART UNIFINE QL(5 ea daily); 5/16" MISC PENTIPS29G X 12MM F RX/OTC COMFORT ASSIST QL(5 ea daily) MISC INSULIN F DRUG MART UNIFINE F QL(5 ea daily) SYRINGE/0.5ML/31G X PENTIPS31GX6MM MISC 5/16" MISC DRUG MART UNIFINE F QL(5 ea daily); COMFORT ASSIST QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC INSULIN F RX/OTC SYRINGE/1ML/29G X 1/2" DRUG MART UNIFINE F QL(5 ea daily); MISC PENTIPS32GX4MM MISC RX/OTC COMFORT ASSIST QL(5 ea daily); DRUG MART UNIFINE QL(5 ea daily); PENTIPSPLUS 32GX4MM F RX/OTC INSULIN F RX/OTC SYRINGE/1ML/30G X MISC 5/16" MISC DUANE READE UNIFINE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) PENTIPS 29G X 12MM F RX/OTC MISC INSULIN F SYRINGE/1ML/31G X DUANE READE UNIFINE QL(5 ea daily) 5/16" MISC PENTIPS 31G X 6MM F ULTRA SHORT MISC DROPLET PEN NEEDLES F QL(5 ea daily); 29GX12MM MISC RX/OTC DUANE READE UNIFINE QL(5 ea daily); PENTIPS 31G X 8MM F RX/OTC DROPLET PEN NEEDLES F QL(5 ea daily); 31GX5MM MISC RX/OTC SHORT MISC EASY COMFORT INSULIN QL(5 ea daily); DROPLET PEN NEEDLES F QL(5 ea daily) 31GX6MM MISC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC DROPLET PEN NEEDLES F QL(5 ea daily); 31GX8MM MISC RX/OTC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F DROPLET PEN NEEDLES F QL(5 ea daily) 5/16" MISC 32G X 1/4" MISC EASY COMFORT INSULIN QL(5 ea daily); DROPLET PEN NEEDLES F QL(5 ea daily); SYRINGE/1ML/30G X F RX/OTC 32G X 3/16" MISC RX/OTC 5/16" MISC DROPLET PEN NEEDLES F QL(5 ea daily); EASY COMFORT INSULIN QL(5 ea daily) 32G X 5/32" MISC RX/OTC SYRINGE/1ML/31G X F DROPLET PEN NEEDLES F QL(5 ea daily); 5/16" MISC 32GX4MM MISC RX/OTC EASY COMFORT INSULIN QL(5 ea daily) DROPLET PEN NEEDLES F QL(5 ea daily); SYRINGE/U- F 32GX5MM MISC RX/OTC 100/0.5ML/30G X 1/2" MISC DROPLET PEN NEEDLES F QL(5 ea daily) 32GX6MM MISC EASY COMFORT INSULIN QL(5 ea daily) DROPSAFE SAFETY PEN QL(5 ea daily); SYRINGE/U-100/1ML/30G F NEEDLES/31G X 5/16" F RX/OTC X 1/2" MISC MISC EASY COMFORT PEN F QL(5 ea daily) DROPSAFE SAFTEY PEN QL(5 ea daily) NEEDLES31GX1/4" MISC F NEEDLES/31G X 1/4" EASY COMFORT PEN F QL(5 ea daily); MISC NEEDLES31GX3/16" MISC RX/OTC

NV Silver Summit Updated September 1, 2018

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY COMFORT PEN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); F NEEDLES31GX5/16" RX/OTC SYRINGE/SAFETY/U- F RX/OTC MISC 100/0.5ML/30G X 5/16" EASY COMFORT PEN QL(5 ea daily); MISC NEEDLES32GX5/32" F RX/OTC EASY TOUCH INSULIN QL(5 ea daily); MISC SYRINGE/SAFETY/U- F RX/OTC 100/1ML/29G X 1/2" MISC EASY TOUCH 32GX5MM F QL(5 ea daily); MISC RX/OTC EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/SAFETY/U- F EASY TOUCH 32GX6MM F QL(5 ea daily) MISC 100/1ML/30G X 1/2" MISC EASY TOUCH FLIPLOCK QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/U- SAFETY INSULIN F RX/OTC F SYRINGE 1ML/29GX1/2" 100/0.3ML/30G X 1/2" MISC MISC EASY TOUCH FLIPLOCK QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/U- SAFETY INSULIN F F SYRINGE 1ML/30GX1/2" 100/0.5ML/27G X 1/2" MISC MISC EASY TOUCH FLIPLOCK QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC SAFETY INSULIN F RX/OTC F SYRINGE 1ML/30GX5/16" 100/0.5ML/28G X 1/2" MISC MISC EASY TOUCH FLIPLOCK QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/U- SAFETY INSULIN F F SYRINGE 1ML/31GX5/16" 100/0.5ML/30G X 1/2" MISC MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X F RX/OTC SYRINGE/U- F 5/16" MISC 100/0.5ML/31G X 5/16" MISC EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X F EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U-100/1ML/27G F RX/OTC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X F RX/OTC EASY TOUCH INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/U-100/1ML/28G F RX/OTC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U-100/1ML/29G F RX/OTC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/30G X F RX/OTC EASY TOUCH INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/U-100/1ML/30G F X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/SAFETY/U- F RX/OTC 100/0.5ML/29G X 1/2" SYRINGE/U-100/1ML/31G F MISC X 5/16" MISC EASY TOUCH PEN QL(5 ea daily); NEEDLE 30G X 5/16" F RX/OTC MISC

NV Silver Summit Updated September 1, 2018

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH PEN F QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); NEEDLES 29GX1/2" MISC RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" EASY TOUCH PEN F QL(5 ea daily) NEEDLES 31GX1/4" MISC MISC EASY TOUCH PEN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) NEEDLES 31GX5/16" F RX/OTC SYRINGE/U- F MISC 100/0.5ML/31G X 5/16" MISC EASY TOUCH PEN F QL(5 ea daily) NEEDLES 32GX1/4" MISC ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G F RX/OTC EASY TOUCH PEN QL(5 ea daily); X 1/2" MISC NEEDLES 32GX3/16" F RX/OTC MISC ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G F RX/OTC EASY TOUCH PEN QL(5 ea daily); X 1/2" MISC NEEDLES 32GX5/32" F RX/OTC MISC ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G F EASY TOUCH PEN QL(5 ea daily); X 5/16" MISC NEEDLES/31G X 3/16" F RX/OTC MISC EQL INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X F RX/OTC EASY TOUCH QL(5 ea daily); 1/2" MISC SHEATHLOCK SAFETY F RX/OTC INSULIN SYRINGE EQL INSULIN QL(5 ea daily); 1ML/29GX1/2" MISC SYRINGE/0.3ML/30G X F RX/OTC 5/16" MISC EASY TOUCH QL(5 ea daily); EQL INSULIN QL(5 ea daily) SHEATHLOCK SAFETY F RX/OTC INSULIN SYRINGE SYRINGE/0.3ML/31G X F 1ML/30GX5/16" MISC 5/16" MISC EASY TOUCH QL(5 ea daily) EQL INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X F RX/OTC SHEATHLOCK SAFETY F INSULIN SYRINGE 1/2" MISC 1ML/31GX5/16" MISC EQL INSULIN QL(5 ea daily); EASY TOUCH QL(5 ea daily) SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC SHEATHLOCK SAFETY F SYRINGE 1ML/30GX1/2" EQL INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X F ELITE-THIN INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/0.3ML/31G X F EQL INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/29G X 1/2" F RX/OTC ELITE-THIN INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/29G X F RX/OTC EQL INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/1ML/30G X F RX/OTC ELITE-THIN INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/0.5ML/30G X F RX/OTC EQL INSULIN QL(5 ea daily) 5/16" MISC SYRINGE/1ML/31G X F ELITE-THIN INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/1ML/30G X F RX/OTC EQL SHORT PEN QL(5 ea daily); 5/16" MISC NEEDLES 31G X 8MM F RX/OTC MISC

NV Silver Summit Updated September 1, 2018

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EQL ULTRA SHORT PEN QL(5 ea daily) FIFTY50 PEN NEEDLES F QL(5 ea daily); NEEDLES 31G X 6MM F 31GX5MM MISC RX/OTC MISC FIFTY50 PEN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); NEEDLES/31GX8MM F RX/OTC INSULIN PEN NEEDLES F RX/OTC MISC 29G X 12MM MISC FIFTY50 PEN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily) NEEDLES/32GX4MM F RX/OTC INSULIN PEN NEEDLES F MISC 31G X 6MM MISC FIFTY50 PEN QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily); NEEDLES/32GX6MM F INSULIN PEN NEEDLES F RX/OTC MISC 31G X 8MM MISC FIFTY50 SUPERIOR QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily); COMFORTINSULIN F INSULIN F RX/OTC SYRINGE/0.3ML/31G X SYRINGE/0.3ML/29G X 5/16" MISC 1/2" MISC FIFTY50 SUPERIOR QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily); COMFORTINSULIN F INSULIN F RX/OTC SYRINGE/0.5ML/31G X SYRINGE/0.3ML/30G X 5/16" MISC 5/16" MISC FIFTY50 SUPERIOR QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily); COMFORTINSULIN F INSULIN F RX/OTC SYRINGE/1ML/31G X SYRINGE/0.5ML/28G X 5/16" MISC 1/2" MISC FREDS PHARMACY QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); UNIFINE PENTIPS PEN F RX/OTC INSULIN F RX/OTC NEEDLES 32GX4MM SYRINGE/0.5ML/29G X MISC 1/2" MISC FREDS PHARMACY QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); UNIFINE PENTIPS PLUS F RX/OTC INSULIN F RX/OTC 31GX5MM MISC SYRINGE/0.5ML/30G X FREDS PHARMACY QL(5 ea daily); 5/16" MISC UNIFINE PENTIPS PLUS F RX/OTC EXEL COMFORT POINT QL(5 ea daily); 31GX8MM MISC INSULIN F RX/OTC FREESTYLE PRECISION QL(5 ea daily); SYRINGE/1ML/28G X 1/2" INSULIN SYRINGE/U- F RX/OTC MISC 100/0.5ML/30G X 5/16" EXEL COMFORT POINT QL(5 ea daily); MISC INSULIN F RX/OTC FREESTYLE PRECISION QL(5 ea daily) SYRINGE/1ML/29G X 1/2" INSULIN SYRINGE/U- F MISC 100/0.5ML/31G X 5/16" EXEL COMFORT POINT QL(5 ea daily); MISC INSULIN F RX/OTC FREESTYLE PRECISION QL(5 ea daily) SYRINGE/1ML/30G X INSULIN SYRINGE/U- F 5/16" MISC 100/1ML/31G X 5/16" FIFTY50 PEN NEEDLES F QL(5 ea daily); MISC 31G X3/16" (5MM) MISC RX/OTC FIFTY50 PEN NEEDLES F QL(5 ea daily); 31G X5/16" (8MM) MISC RX/OTC

NV Silver Summit Updated September 1, 2018

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREESTYLE PRECISION QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily) INSULIN SYRINGES/U- F RX/OTC INSULIN SYRINGE/U- F 100/1ML/30G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC GLOBAL EASE INJECT QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); F PEN NEEDLES RX/OTC INSULIN SYRINGE/U- F RX/OTC 29GX12MM MISC 100/0.5ML/30G X 5/16" GLOBAL EASE INJECT QL(5 ea daily); MISC PEN NEEDLES 31GX8MM F RX/OTC GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- F GLOBAL EASE INJECT QL(5 ea daily); 100/0.5ML/31G X 5/16" PEN NEEDLES 32GX4MM F RX/OTC MISC MISC GLOBAL INJECT EASE QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC PEN NEEEDLES F RX/OTC 100/1ML/28G X 1/2" MISC 31GX5MM MISC GLOBAL INJECT EASE QL(5 ea daily); GLOBAL EASY GLIDE QL(5 ea daily) INSULIN SYRINGE/U- F RX/OTC 100/1ML/29G X 1/2" MISC INSULINSYRINGE/U- F 100/0.3ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- F GLOBAL EASY GLIDE QL(5 ea daily); 100/1ML/30G X 1/2" MISC PEN NEEDLES 32GX4MM F RX/OTC GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC GLOBAL INJECT EASE QL(5 ea daily); 100/1ML/30G X 5/16" MISC INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- F GLOBAL INJECT EASE QL(5 ea daily) 100/1ML/31G X 5/16" MISC INSULIN SYRINGE/U- F 100/0.3ML/30G X 1/2" GLOBAL INSULIN QL(5 ea daily) MISC SYRINGE/U- F GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 1/2" MISC INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" GLOBAL INSULIN QL(5 ea daily); MISC SYRINGES/U- F RX/OTC GLOBAL INJECT EASE QL(5 ea daily) 100/0.3ML/30GX5/16" MISC INSULIN SYRINGE/U- F 100/0.3ML/31G X 5/16" GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U- F GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 1/2" MISC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" GLUCOPRO INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC GLOBAL INJECT EASE QL(5 ea daily); 100/0.3ML/30G X 5/16" MISC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" MISC

NV Silver Summit Updated September 1, 2018

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPRO INSULIN QL(5 ea daily) GNP INSULIN QL(5 ea daily); SYRINGE/U- F SYRINGE/0.5ML/29G X F RX/OTC 100/0.3ML/31G X 5/16" 1/2" MISC MISC GNP INSULIN QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/U- F 5/16" MISC 100/0.5ML/30G X 1/2" GNP INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X F GLUCOPRO INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- F RX/OTC GNP INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/1ML/28G X 1/2" F RX/OTC MISC MISC GLUCOPRO INSULIN QL(5 ea daily) GNP INSULIN QL(5 ea daily); SYRINGE/U- F SYRINGE/1ML/29G X 1/2" F RX/OTC 100/0.5ML/31G X 5/16" MISC MISC GNP INSULIN QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) SYRINGE/1ML/30G X F RX/OTC SYRINGE/U-100/1ML/30G F 5/16" MISC X 1/2" MISC GNP INSULIN QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily); SYRINGE/1ML/31G X F SYRINGE/U-100/1ML/30G F RX/OTC 5/16" MISC X 5/16" MISC GNP ULTRA COMFORT QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily) INSULIN F RX/OTC SYRINGE/U-100/1ML/31G F SYRINGE/0.3ML/29G X X 5/16" MISC 1/2" MISC GNP CLICKFINE PEN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); NEEDLEUNIVERSAL/31G F RX/OTC INSULIN F RX/OTC X5/16" MISC SYRINGE/0.3ML/30G X GNP CLICKFINE QL(5 ea daily) 5/16" SHORT MISC UNIVERSAL PEN F GNP ULTRA COMFORT QL(5 ea daily) NEEDLES 31GX1/4" MISC INSULIN F GNP CLICKFINE QL(5 ea daily); SYRINGE/0.3ML/31G X UNIVERSAL PEN F RX/OTC 5/16" SHORT MISC NEEDLES 31GX5/16" GNP ULTRA COMFORT QL(5 ea daily); MISC INSULIN F RX/OTC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/28G X SYRINGE/0.3ML/29G X F RX/OTC 1/2" MISC 1/2" MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN F RX/OTC SYRINGE/0.3ML/30G X F RX/OTC SYRINGE/0.5ML/29G X 5/16" MISC 1/2" MISC GNP INSULIN QL(5 ea daily) GNP ULTRA COMFORT QL(5 ea daily); F SYRINGE/0.3ML/31G X INSULIN F RX/OTC 5/16" MISC SYRINGE/0.5ML/30G X GNP INSULIN QL(5 ea daily); 5/16" SHORT MISC SYRINGE/0.5ML/28G X F RX/OTC 1/2" MISC

NV Silver Summit Updated September 1, 2018

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP ULTRA COMFORT QL(5 ea daily) HEALTHWISE SHORT QL(5 ea daily); INSULIN F PEN NEEDLES 31GX8MM F RX/OTC SYRINGE/0.5ML/31G X MISC 5/16" SHORT MISC HEALTHWISE UNIFINE QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); PENTIPS PEN NEEDLES F RX/OTC INSULIN F RX/OTC 32GX4MM MISC SYRINGE/1ML/28G X 1/2" HEALTHY ACCENTS QL(5 ea daily); MISC UNIFINE PENTIPS PEN F RX/OTC GNP ULTRA COMFORT QL(5 ea daily); NEEDLES 29GX12MM INSULIN F RX/OTC MISC SYRINGE/1ML/29G X 1/2" HEALTHY ACCENTS QL(5 ea daily); MISC UNIFINE PENTIPS PEN F RX/OTC GNP ULTRA COMFORT QL(5 ea daily); NEEDLES 31GX5MM INSULIN F RX/OTC MISC SYRINGE/1ML/30G X HEALTHY ACCENTS QL(5 ea daily) 5/16" SHORT MISC UNIFINE PENTIPS PEN F GNP ULTRA COMFORT QL(5 ea daily) NEEDLES 31GX6MM INSULIN F MISC SYRINGE/1ML/31G X HEALTHY ACCENTS QL(5 ea daily); 5/16" SHORT MISC UNIFINE PENTIPS PEN F RX/OTC H-E-B IN CONTROL PEN QL(5 ea daily); NEEDLES 31GX8MM NEEDLES 31GX5MM F RX/OTC MISC MISC HEALTHY ACCENTS QL(5 ea daily); H-E-B IN CONTROL PEN QL(5 ea daily) UNIFINE PENTIPS PEN F RX/OTC NEEDLES 31GX6MM F NEEDLES 32GX4MM MISC MISC H-E-B IN CONTROL PEN QL(5 ea daily); QL(1 ea per NEEDLES 31GX8MM F RX/OTC HUMAPEN LUXURA HD F DEVI 180 days MISC retail); RX/OTC H-E-B IN CONTROL PEN QL(5 ea daily); QL(1 ea per NEEDLES/NANO/32GX4M F RX/OTC INPEN 100/BLUE/LILLY F DEVI 180 days M MISC retail); RX/OTC H-E-B IN CONTROL QL(5 ea daily); QL(1 ea per UNIFINEPENTIPS PLUS F RX/OTC INPEN 100/BLUE/NOVO F DEVI 180 days 31GX5MM MISC retail); RX/OTC H-E-B IN CONTROL QL(5 ea daily); QL(1 ea per UNIFINEPENTIPS PLUS F RX/OTC INPEN 100/GRAY/LILLY F DEVI 180 days 32GX4MM MISC retail); RX/OTC H-E-B INCONTROL PEN QL(5 ea daily); QL(1 ea per NEEDLES 29GX12MM F RX/OTC INPEN 100/GREY/NOVO F DEVI 180 days MISC retail); RX/OTC HEALTHWISE MINI PEN QL(5 ea daily) QL(1 ea per NEEDLES 31GX6MM F INPEN 100/PINK/LILLY F DEVI 180 days MISC retail); RX/OTC HEALTHWISE PEN QL(5 ea daily); QL(1 ea per NEEDLES 29GX12MM F RX/OTC INPEN 100/PINK/NOVO F DEVI 180 days MISC retail); RX/OTC

NV Silver Summit Updated September 1, 2018

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X 1" F SYRINGE/NEEDLE F MISC 0.5ML/31G X 5/16" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X F RX/OTC SYRINGE/NEEDLE F RX/OTC 1/2" MISC 1ML/29G X 1/2" MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X F RX/OTC SYRINGE/NEEDLE F RX/OTC 5/16" MISC 1ML/30G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X F SYRINGE/NEEDLE F 5/16" MISC 1ML/31G X 5/16" MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/27G X F 100/0.3ML/29G X 1/2" F RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/28G X F RX/OTC 100/0.5ML/28G X 1/2" F RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily) INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/0.5ML/30G X F 100/0.5ML/29G X 1/2" F RX/OTC 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC 100/1ML/28G X 1/2" MISC RX/OTC 5/16" MISC INSULIN SYRINGE/U- F QL(5 ea daily); INSULIN QL(5 ea daily) 100/1ML/29G X 1/2" MISC RX/OTC SYRINGE/0.5ML/31G X F INSULIN SYRINGE/U- QL(5 ea daily); 5/16" MISC 100/1ML/30G X 5/16" F RX/OTC INSULIN QL(5 ea daily); MISC SYRINGE/1ML/28G X 1/2" F RX/OTC INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" F INSULIN QL(5 ea daily); MISC SYRINGE/1ML/29G X 1/2" F RX/OTC INSULIN QL(5 ea daily) MISC SYRINGES/0.5ML/27GX1/ F INSULIN QL(5 ea daily); 2" MISC SYRINGE/1ML/30G X F RX/OTC INSULIN QL(5 ea daily); 5/16" MISC SYRINGES/0.5ML/28GX1/ F RX/OTC INSULIN QL(5 ea daily); 2" MISC SYRINGE/NEEDLE F RX/OTC INSULIN QL(5 ea daily); 0.3ML/30G X 5/16" MISC SYRINGES/0.5ML/29GX1/ F RX/OTC INSULIN QL(5 ea daily) 2" MISC SYRINGE/NEEDLE F INSULIN QL(5 ea daily); 0.3ML/31G X 5/16" MISC SYRINGES/0.5ML/30GX5/ F RX/OTC INSULIN QL(5 ea daily); 16" MISC SYRINGE/NEEDLE F RX/OTC INSULIN QL(5 ea daily) 0.5ML/29G X 1/2" MISC SYRINGES/0.5ML/31GX F INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/NEEDLE F RX/OTC 0.5ML/30G X 5/16" MISC NV Silver Summit Updated September 1, 2018

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily) KINRAY INSULIN QL(5 ea daily) SYRINGES/0.5ML/31GX5/ F SYRINGE PREFERRED F 16" MISC PLUS/0.5ML/31G X 5/16" INSULIN QL(5 ea daily); MISC SYRINGES/1ML/27GX/1/2" F RX/OTC KINRAY INSULIN QL(5 ea daily) MISC SYRINGE PREFERRED F INSULIN QL(5 ea daily); PLUS/1ML/31G X 5/16" SYRINGES/1ML/27GX1/2" F RX/OTC MISC MISC KINRAY INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X F RX/OTC SYRINGES/1ML/28GX1/2" F RX/OTC 1/2" MISC MISC KROGER INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X F RX/OTC SYRINGES/1ML/29GX1/2" F RX/OTC 1/2" MISC MISC KROGER INSULIN QL(5 ea daily); INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X F RX/OTC SYRINGES/1ML/30GX1/2" F 5/16" MISC MISC KROGER INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X F SYRINGES/1ML/31GX5/16 F 5/16" MISC " MISC KROGER INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X F RX/OTC INSUPEN 29G X 12MM F QL(5 ea daily); MISC RX/OTC 1/2" MISC KROGER INSULIN QL(5 ea daily); INSUPEN 31G X 5MM F QL(5 ea daily); MISC RX/OTC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC INSUPEN 31G X 8MM F QL(5 ea daily); MISC RX/OTC KROGER INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F INSUPEN 32G X 4MM F QL(5 ea daily); 5/16" MISC MISC RX/OTC KROGER INSULIN QL(5 ea daily); INSUPEN PEN NEEDLES F QL(5 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC 32G X4MM MISC RX/OTC MISC INSUPEN SENSITIVE F QL(5 ea daily) KROGER INSULIN QL(5 ea daily); 32GX6MM MISC SYRINGE/1ML/30G X F RX/OTC INSUPEN ULTRAFIN F QL(5 ea daily); 5/16" MISC 29GX12MM MISC RX/OTC KROGER INSULIN QL(5 ea daily) INSUPEN ULTRAFIN F QL(5 ea daily); SYRINGE/1ML/31G X F 30GX8MM MISC RX/OTC 5/16" MISC INSUPEN ULTRAFIN QL(5 ea daily) F KROGER PEN NEEDLES F QL(5 ea daily); 31GX6MM MISC 29G X12MM MISC RX/OTC INSUPEN ULTRAFIN QL(5 ea daily); F KROGER PEN NEEDLES F QL(5 ea daily); 31GX8MM MISC RX/OTC 31G X8MM MISC RX/OTC KINRAY INSULIN QL(5 ea daily) KROGER PEN NEEDLES F QL(5 ea daily) SYRINGE PREFERRED F 31GX1/4" MISC PLUS/0.3ML/31G X 5/16" LEADER INSULIN QL(5 ea daily); MISC SYRINGE/0.3ML/29G X F RX/OTC 1/2" MISC

NV Silver Summit Updated September 1, 2018

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER INSULIN QL(5 ea daily); LITE TOUCH PEN QL(5 ea daily); SYRINGE/0.3ML/30G X F RX/OTC NEEDLES/31G X 3/16" F RX/OTC 5/16" MISC MISC LEADER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X F SYRINGE/0.3ML/29G X F RX/OTC 5/16" MISC 1/2" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/28G X F RX/OTC SYRINGE/0.3ML/30G X F RX/OTC 1/2" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X F RX/OTC SYRINGE/0.3ML/31G X F 1/2" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X F RX/OTC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X F SYRINGE/0.5ML/31G X F 5/16" MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/28G X 1/2" F RX/OTC SYRINGE/1ML/30G X F RX/OTC MISC 5/16" MISC LEADER INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/U- F RX/OTC MISC 100/0.5ML/28G X 1/2" LEADER INSULIN QL(5 ea daily); MISC SYRINGE/1ML/30G X F RX/OTC LITETOUCH INSULIN QL(5 ea daily); 5/16" MISC SYRINGE/U- F RX/OTC LEADER INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" SYRINGE/1ML/31G X F MISC 5/16" MISC LITETOUCH INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily); SYRINGE/U-100/1ML/28G F RX/OTC X 1/2" MISC PENTIPS F RX/OTC PLUS/MINI/31GX3/16" LITETOUCH INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G F RX/OTC LEADER UNIFINE QL(5 ea daily); X 1/2" MISC PENTIPS F RX/OTC LITETOUCH INSULIN QL(5 ea daily) PLUS/SHORT/31GX5/16" SYRINGE/U-100/1ML/31G F MISC X 5/16" MISC LEADER UNIFINE QL(5 ea daily); LITETOUCH PEN QL(5 ea daily) PENTIPS/MINI/31GX3/16" F RX/OTC NEEDLES 29GX12.7MM F MISC MISC LEADER UNIFINE QL(5 ea daily); LITETOUCH PEN QL(5 ea daily) PENTIPS/NANO/32GX5/32 F RX/OTC NEEDLES 31G X 6MM F " MISC MISC LEADER UNIFINE QL(5 ea daily); LITETOUCH PEN QL(5 ea daily); PENTIPS/PLUS/32GX5/32 F RX/OTC NEEDLES 31GX8MM F RX/OTC " MISC SHORT MISC

NV Silver Summit Updated September 1, 2018

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIVE BETTER PEN QL(5 ea daily); MAXI-COMFORT INSULIN QL(5 ea daily); NEEDLES 29G X 12MM F RX/OTC SYRINGE/U- F RX/OTC MISC 100/1ML/28GX1/2" MISC LIVE BETTER PEN QL(5 ea daily); MEDIC INSULIN QL(5 ea daily); NEEDLES 31G X 12MM F RX/OTC SYRINGE/0.3ML/30G X F RX/OTC MISC 5/16" MISC LIVE BETTER PEN QL(5 ea daily) MEDIC INSULIN QL(5 ea daily); NEEDLES 31G X 6MM F SYRINGE/0.5ML/30G X F RX/OTC MISC 5/16" MISC LONGS INSULIN QL(5 ea daily) MEDICINE SHOPPE PEN QL(5 ea daily); SYRINGE/0.5ML/31G X F NEEDLES 29G X 12MM F RX/OTC 5/16" MISC MISC MAGELLAN INSULIN QL(5 ea daily); MEDICINE SHOPPE PEN QL(5 ea daily) SAFETY SYRINGE/U- F RX/OTC NEEDLES 31G X 6MM F 100/0.3ML/29G X 1/2" MISC MISC MEDICINE SHOPPE PEN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); NEEDLES 31G X 8MM F RX/OTC SAFETY SYRINGE/U- F RX/OTC MISC 100/0.3ML/30G X 5/16" MEIJER PEN NEEDLES F QL(5 ea daily); MISC 29G X12MM MISC RX/OTC MAGELLAN INSULIN QL(5 ea daily); MEIJER PEN NEEDLES F QL(5 ea daily) SAFETY SYRINGE/U- F RX/OTC 31G X6MM MISC 100/0.5ML/29G X 1/2" MISC MEIJER PEN NEEDLES F QL(5 ea daily); 31G X8MM MISC RX/OTC MAGELLAN INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily); SAFETY SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" 100/0.3ML/30G X 5/16" F RX/OTC MISC MISC MAGELLAN INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily) SAFETY SYRINGE/U- F RX/OTC 100/0.3ML/31G X 5/16" F 100/1ML/29G X 1/2" MISC MISC MAGELLAN INSULIN QL(5 ea daily); MM INSULIN SYRINGE/U- QL(5 ea daily); 100/1/2ML/30G X 5/16" F RX/OTC SAFETY SYRINGE/U- F RX/OTC 100/1ML/30G X 5/16" MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MARATHON MEDICAL QL(5 ea daily); 100/1/2ML/31G X 5/16" F PENTIPS29GX12MM F RX/OTC MISC MISC MM INSULIN SYRINGE/U- QL(5 ea daily); 100/1ML/30G X 5/16" F RX/OTC MARATHON MEDICAL F QL(5 ea daily); PENTIPS31GX5MM MISC RX/OTC MISC MM INSULIN SYRINGE/U- QL(5 ea daily) MARATHON MEDICAL F QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC 100/1ML/31G X 5/16" F MISC MARATHON MEDICAL F QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC MM PEN NEEDLES 31G X F QL(5 ea daily) 1/4" MISC MAXI-COMFORT INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC MM PEN NEEDLES 31G X F QL(5 ea daily); 100/0.5ML/28GX1/2" MISC 3/16" MISC RX/OTC

NV Silver Summit Updated September 1, 2018

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MM PEN NEEDLES 31G X F QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); 5/16" MISC RX/OTC SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" MM PEN NEEDLES 32G X F QL(5 ea daily); 5/32" MISC RX/OTC MISC MONOJECT INSULIN QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); SYRINGE/1ML/31G X F SYRINGE/U- F RX/OTC 5/16" MISC 100/0.5ML/28G X 1/2" MISC MONOJECT INSULIN QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); SYRINGE/DETACH F NEEDLE/1ML/25G X 5/8" SYRINGE/U- F RX/OTC MISC 100/0.5ML/30G X 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGE/DETACH F RX/OTC NEEDLE/1ML/27G X 1/2" SYRINGE/U-100/1ML/28G F RX/OTC MISC X 1/2" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G F RX/OTC SYRINGE/PERM F RX/OTC NEEDLE/1ML/28G X 1/2" X 5/16" MISC MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN F RX/OTC SYRINGE/0.3ML/29G X SYRINGE/PERM F RX/OTC NEEDLE/U-100/0.5ML/28G 1/2" MISC X 1/2" MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN F RX/OTC SYRINGE/0.3ML/30G X SYRINGE/SAFETY/PERM F RX/OTC NEEDLE/0.3ML/29G X 1/2" 5/16" MISC MISC MONOJECT ULTRA QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN F SYRINGE/0.3ML/31G X SYRINGE/SAFETY/PERM F RX/OTC NEEDLE/0.3ML/29GX1/2" 5/16" MISC MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN F RX/OTC SYRINGE/0.5ML/28G X SYRINGE/SAFETY/PERM F RX/OTC NEEDLE/0.5ML/29G X 1/2" 1/2" MISC MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN F RX/OTC SYRINGE/0.5ML/29G X SYRINGE/SAFETY/PERM F RX/OTC NEEDLE/1ML/29G X 1/2" 1/2" MISC MISC MONOJECT ULTRA QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); COMFORT INSULIN F RX/OTC SYRINGE/SOFTPACK/1M F RX/OTC SYRINGE/0.5ML/30G X L/27G X 1/2" MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily) COMFORT INSULIN SYRINGE/SOFTPACK/U- F RX/OTC F 100/0.5ML/28G X 1/2" SYRINGE/0.5ML/31G X MISC 5/16" MISC

NV Silver Summit Updated September 1, 2018

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(5 ea daily); NOVOTWIST 32GX5MM F QL(5 ea daily); COMFORT INSULIN F RX/OTC MISC RX/OTC SYRINGE/1ML/28G X 1/2" PC UNIFINE PENTIPS F QL(5 ea daily); MISC 29G X1/2" MISC RX/OTC MONOJECT ULTRA QL(5 ea daily); PC UNIFINE PENTIPS F QL(5 ea daily); COMFORT INSULIN F RX/OTC 31G X5MM MINI MISC RX/OTC SYRINGE/1ML/29G X 1/2" MISC PC UNIFINE PENTIPS QL(5 ea daily) 31G X6MM ULTRA F MONOJECT ULTRA QL(5 ea daily); SHORT MISC COMFORT INSULIN F RX/OTC SYRINGE/1ML/30G X PC UNIFINE PENTIPS F QL(5 ea daily); 5/16" MISC 31G X8MM SHORT MISC RX/OTC MOORE MED MONOJECT QL(5 ea daily); PEN NEEDLES 29G X F QL(5 ea daily); 12MM MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" PEN NEEDLES 29GX1/2" F QL(5 ea daily); MISC MISC RX/OTC MOORE MED MONOJECT QL(5 ea daily); PEN NEEDLES 30GX5/16" F QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" PEN NEEDLES 30GX8MM F QL(5 ea daily); MISC MISC RX/OTC MOORE MED MONOJECT QL(5 ea daily); PEN NEEDLES 31G X 1/4" F QL(5 ea daily) INSULIN SYRINGE/U- F RX/OTC SHORT MISC 100/1ML/28G X 1/2" MISC PEN NEEDLES 31G X F QL(5 ea daily); MOORE MED MONOJECT QL(5 ea daily); 3/16" MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC PEN NEEDLES 31G X F QL(5 ea daily); 100/1ML/29G X 1/2" MISC 5MM MISC RX/OTC MS INSULIN QL(5 ea daily) PEN NEEDLES 31G X F QL(5 ea daily) SYRINGE/0.3ML/31G X F 6MM MISC 5/16" MISC PEN NEEDLES 31G X F QL(5 ea daily); MS INSULIN QL(5 ea daily) 8MM MISC RX/OTC SYRINGE/0.5ML/31G X F 5/16" MISC PEN NEEDLES 31GX5/16" F QL(5 ea daily); MISC RX/OTC MS INSULIN QL(5 ea daily) SYRINGE/1ML/31G X F PEN NEEDLES 31GX6MM F QL(5 ea daily) 5/16" MISC (1/4") MISC PEN NEEDLES 31GX8MM QL(5 ea daily); NOVOFINE 30GX8MM F QL(5 ea daily); F MISC RX/OTC (5/16") MISC RX/OTC PEN NEEDLES 31GX8MM QL(5 ea daily); NOVOFINE 32GX6MM F QL(5 ea daily) F MISC MISC RX/OTC PEN NEEDLES 32G X QL(5 ea daily); NOVOFINE AUTOCOVER F QL(5 ea daily); F 30GX8MM MISC RX/OTC 4MM MISC RX/OTC PEN NEEDLES 32G X QL(5 ea daily); NOVOFINE PLUS F QL(5 ea daily); F 32GX4MM MISC RX/OTC 5MM MISC RX/OTC QL(1 ea per PEN NEEDLES 32G X F QL(5 ea daily) NOVOPEN ECHO DEVI F 180 days 6MM MISC retail); RX/OTC PEN NEEDLES 32GX4MM F QL(5 ea daily); MISC RX/OTC NOVOTWIST 30GX8MM F QL(5 ea daily); MISC RX/OTC NV Silver Summit Updated September 1, 2018

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENTIPS 29G X 12MM F QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" PENTIPS 29GX12MM F QL(5 ea daily); MISC RX/OTC MISC PREFERRED PLUS QL(5 ea daily); PENTIPS 31G X 5MM F QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" PENTIPS 31G X 8MM F QL(5 ea daily); MISC MISC RX/OTC PREFERRED PLUS QL(5 ea daily); QL(5 ea daily); PENTIPS 31GX5MM MISC F INSULIN SYRINGE/U- F RX/OTC RX/OTC 100/0.5ML/28G X 1/2" PENTIPS 31GX6MM MISC F QL(5 ea daily) MISC PREFERRED PLUS QL(5 ea daily); QL(5 ea daily); PENTIPS 31GX8MM MISC F INSULIN SYRINGE/U- F RX/OTC RX/OTC 100/0.5ML/29G X 1/2" PENTIPS 32G X 4MM F QL(5 ea daily); MISC MISC RX/OTC PREFERRED PLUS QL(5 ea daily); QL(5 ea daily); PENTIPS 32GX4MM MISC F INSULIN SYRINGE/U- F RX/OTC RX/OTC 100/0.5ML/30G X 5/16" PRECISION SURE-DOSE QL(5 ea daily); MISC INSULIN F RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/0.3ML/30G X INSULIN SYRINGE/U- F RX/OTC 5/16" MISC 100/1ML/28G X 1/2" MISC PRECISION SURE-DOSE QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); INSULIN F RX/OTC INSULIN SYRINGE/U- F RX/OTC SYRINGE/0.5ML/28G X 100/1ML/29G X 1/2" MISC 1/2" MISC PREFERRED PLUS QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC INSULIN F RX/OTC 100/1ML/30G X 5/16" SYRINGE/0.5ML/29G X MISC 1/2" MISC PREFERRED PLUS QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily) UNIFINE PENTIPS 29G X F RX/OTC INSULIN F 12MM MISC SYRINGE/0.5ML/30G X PREFERRED PLUS QL(5 ea daily) 3/8" MISC UNIFINE PENTIPS 31G X F PRECISION SURE-DOSE QL(5 ea daily); 6MM ULTRA SHORT INSULIN F RX/OTC MISC SYRINGE/1ML/28G X 1/2" PREFERRED PLUS QL(5 ea daily); MISC UNIFINE PENTIPS 31G X F RX/OTC PRECISION SURE-DOSE QL(5 ea daily); 8MM SHORT MISC PLUSINSULIN F RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/0.3ML/29G X UNIFINE PENTIPS F RX/OTC 1/2" MISC 32GX4MM MISC PRECISION SURE-DOSE QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); PLUSINSULIN RX/OTC F UNIFINE F RX/OTC SYRINGE/1ML/29G X 1/2" PENTIPS/MINI/31GX5MM MISC MISC

NV Silver Summit Updated September 1, 2018

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT INSULIN QL(5 ea daily) PX INSULIN SYRINGE/U- QL(5 ea daily) SYRINGES/0.5ML/30G X F 100/0.5ML/30G X 1/2" F 1/2" MISC MISC PRO COMFORT INSULIN QL(5 ea daily); PX INSULIN SYRINGE/U- QL(5 ea daily) SYRINGES/0.5ML/30G X F RX/OTC 100/0.5ML/31G X 5/16" F 5/16" MISC MISC PRO COMFORT INSULIN QL(5 ea daily) PX INSULIN SYRINGE/U- F QL(5 ea daily) SYRINGES/0.5ML/31G X F 100/1ML/30G X 1/2" MISC 5/16" MISC PX INSULIN SYRINGE/U- QL(5 ea daily) PRO COMFORT INSULIN QL(5 ea daily) 100/1ML/31G X 5/16" F SYRINGES/1ML/30G X F MISC 1/2" MISC PX MINI PEN NEEDLES F QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily); 31GX5MM MISC RX/OTC SYRINGES/1ML/30G X F RX/OTC PX PEN NEEDLE F QL(5 ea daily); 5/16" MISC 29GX12MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily) PX PEN NEEDLE F QL(5 ea daily); SYRINGES/1ML/31G X F 31GX8MM MISC RX/OTC 5/16" MISC PX SHORTLENGTH PEN QL(5 ea daily); PRO COMFORT PEN QL(5 ea daily); NEEDLES/31GX8MM F RX/OTC NEEDLES/31G X 8MM F RX/OTC MISC MISC QC PEN NEEDLES 29G X F QL(5 ea daily); PRO COMFORT PEN QL(5 ea daily); 12MM MISC RX/OTC NEEDLES/32G X 4MM F RX/OTC MISC QC PEN NEEDLES 31G X F QL(5 ea daily) 6MM MISC PRO COMFORT PEN QL(5 ea daily); NEEDLES/32G X 5MM F RX/OTC QC PEN NEEDLES 31G X F QL(5 ea daily); MISC 8MM MISC RX/OTC PRO COMFORT PEN QL(5 ea daily) QC UNIFINE PENTIPS F QL(5 ea daily); NEEDLES/32G X 6MM F 32GX4MM MISC RX/OTC MISC RA INSULIN QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X F RX/OTC SYRING/U-100/0.3ML/31G F 1/2" MISC X 5/16" MISC RA INSULIN QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/1/2ML/31G X F MISC 5/16" MISC RA INSULIN SYRINGE/U- QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" F RX/OTC SYRINGE/1ML/28G X 1/2" F RX/OTC MISC MISC RA INSULIN SYRINGE/U- QL(5 ea daily); PX EXTRA SHORT PEN QL(5 ea daily) 100/1 ML/30G X 5/16" F RX/OTC NEEDLES 31GX6MM F MISC MISC RA PEN NEEDLES 31G X F QL(5 ea daily); PX INSULIN SYRINGE/U- QL(5 ea daily) 5MM3/16" MISC RX/OTC 100/0.3ML/30G X 1/2" F RA PEN NEEDLES 31G X F QL(5 ea daily); MISC 8MM5/16" MISC RX/OTC PX INSULIN SYRINGE/U- QL(5 ea daily) 100/0.3ML/31G X 5/16" F MISC NV Silver Summit Updated September 1, 2018

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REALITY INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily) SYRINGE/U- F RX/OTC SYRINGE/U-100/1ML/31G F 100/0.5ML/28G X 1/2" X 15/64" MISC MISC RELION INSULIN QL(5 ea daily) REALITY INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G F SYRINGE/U- F RX/OTC X 5/16" MISC 100/0.5ML/29G X 1/2" RELION MINI PEN QL(5 ea daily) MISC NEEDLES 31GX6MM F REALITY INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/28G F RX/OTC RELION PEN NEEDLES F QL(5 ea daily); X 1/2" MISC 29GX12MM MISC RX/OTC REALITY INSULIN QL(5 ea daily); RELION PEN NEEDLES F QL(5 ea daily) SYRINGE/U-100/1ML/29G F RX/OTC 31GX6MM MISC X 1/2" MISC RELION PEN NEEDLES F QL(5 ea daily); RELION INSULIN QL(5 ea daily) 31GX8MM MISC RX/OTC SYRINGE F 1ML/31GX15/64" MISC RELION PEN NEEDLES F QL(5 ea daily); 32GX4MM MISC RX/OTC RELION INSULIN QL(5 ea daily); SYRINGE/U-00/1ML/29G F RX/OTC RELION SHORT PEN F QL(5 ea daily); X 1/2" MISC NEEDLES31GX8MM MISC RX/OTC RELION INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X F RX/OTC SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" 5/16" MISC MISC SAFESNAP INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X F RX/OTC 1/2" MISC SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" SAFESNAP INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X F RX/OTC RELION INSULIN QL(5 ea daily) 5/16" MISC SAFESNAP INSULIN QL(5 ea daily); SYRINGE/U- F 100/0.3ML/31G X 5/16" SYRINGE/1ML/28G X 1/2" F RX/OTC MISC MISC RELION INSULIN QL(5 ea daily); SAFESNAP INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" MISC MISC SAFETY INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGES F RX/OTC 0.5ML/29GX1/2" MISC SYRINGE/U- F RX/OTC 100/0.5ML/30G X 5/16" SAFETY INSULIN QL(5 ea daily); MISC SYRINGES F RX/OTC RELION INSULIN QL(5 ea daily) 0.5ML/30GX5/16" MISC SYRINGE/U- F SAFETY INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGES 1ML/27GX1/2" F RX/OTC MISC MISC RELION INSULIN QL(5 ea daily); SAFETY INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G F RX/OTC SYRINGES 1ML/29GX1/2" F RX/OTC X 5/16" MISC MISC

NV Silver Summit Updated September 1, 2018

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY INSULIN QL(5 ea daily) SHOPKO UNIFINE QL(5 ea daily); F SYRINGES 1ML/30GX1/2" PENTIPS PLUS PEN F RX/OTC MISC NEEDLES/MINI/REMOVE SAFETY-GLIDE INSULIN QL(5 ea daily); R/31GX5MM MISC SYRINGE/0.3ML/29G X F RX/OTC SHOPKO UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS PLUS PEN F RX/OTC SB INSULIN SYRINGE/U- QL(5 ea daily); NEEDLES/REMOVER/29G 100/0.5ML/29G X 1/2" F RX/OTC X12MM MISC MISC SHOPKO UNIFINE QL(5 ea daily); SB INSULIN SYRINGE/U- QL(5 ea daily); PENTIPS PLUS PEN F RX/OTC 100/0.5ML/30G X 5/16" F RX/OTC NEEDLES/SHORT/REMO MISC VR/31GX8MM MISC SM INSULIN QL(5 ea daily) SB INSULIN SYRINGE/U- F QL(5 ea daily); 100/1ML/29G X 1/2" MISC RX/OTC SYRINGE/1ML/31G X F 5/16" MISC SB INSULIN SYRINGE/U- QL(5 ea daily); 100/1ML/30G X 5/16" F RX/OTC SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" SB INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" F MISC SURE COMFORT QL(5 ea daily) INSULIN SYRINGE/U- F SCHNUCKS INSULIN QL(5 ea daily); 100/0.3ML/30G X 1/2" SYRINGEULTI-FINE/U- F RX/OTC MISC 100/0.5ML/29G X 1/2" MISC SURE COMFORT QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC SCHNUCKS INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" SYRINGEULTI-FINE/U- F RX/OTC MISC 100/0.5ML/30G X 5/16" MISC SURE COMFORT QL(5 ea daily) INSULIN SYRINGE/U- F SHOPKO UNIFINE QL(5 ea daily); 100/0.3ML/31G X 5/16 PENTIPS PEN F RX/OTC MISC NEEDLES/MICRO/32GX4 MM MISC SURE COMFORT QL(5 ea daily) INSULIN SYRINGE/U- F SHOPKO UNIFINE QL(5 ea daily); 100/0.3ML/31G X 5/16" PENTIPS PEN F RX/OTC MISC NEEDLES/MINI/31GX5MM MISC SURE COMFORT QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC SHOPKO UNIFINE QL(5 ea daily); 100/0.5ML/28G X 1/2" PENTIPS PEN F RX/OTC MISC NEEDLES/ORIGINAL/29G X12MM MISC SURE COMFORT QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC SHOPKO UNIFINE QL(5 ea daily); 100/0.5ML/29G X 1/2" PENTIPS PEN F RX/OTC MISC NEEDLES/SHORT/31GX8 MM MISC SURE COMFORT QL(5 ea daily) INSULIN SYRINGE/U- F SHOPKO UNIFINE QL(5 ea daily); 100/0.5ML/30G X 1/2" PENTIPS PLUS PEN F RX/OTC MISC NEEDLES/MICRO/REMOV R/32GX4MM MISC

NV Silver Summit Updated September 1, 2018

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT QL(5 ea daily); SURE-FINE PEN QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC NEEDLES 31GX5/16" 8MM F RX/OTC 100/0.5ML/30G X 5/16" MISC MISC SURE-JECT INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily) SYRINGE/U- F RX/OTC INSULIN SYRINGE/U- F 100/0.3ML/29G X 1/2" 100/0.5ML/31G X 5/16 MISC MISC SURE-JECT INSULIN QL(5 ea daily); SURE COMFORT QL(5 ea daily); SYRINGE/U- F RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" 100/1ML/28G X 1/2" MISC MISC SURE COMFORT QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily) F INSULIN SYRINGE/U- RX/OTC SYRINGE/U- F 100/1ML/29G X 1/2" MISC 100/0.3ML/31G X 5/16" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- F SURE-JECT INSULIN QL(5 ea daily); 100/1ML/30G X 1/2" MISC SYRINGE/U- F RX/OTC SURE COMFORT QL(5 ea daily); 100/0.5ML/28G X 1/2" MISC INSULIN SYRINGE/U- F RX/OTC 100/1ML/30G X 5/16" SURE-JECT INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC SURE COMFORT QL(5 ea daily) 100/0.5ML/29G X 1/2" MISC INSULIN SYRINGE/U- F 100/1ML/31G X 5/16" SURE-JECT INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC SURE COMFORT PEN QL(5 ea daily) 100/0.5ML/30G X 5/16" NEEDLES29GX1/2" F MISC 12.7MM MISC SURE-JECT INSULIN QL(5 ea daily) SURE COMFORT PEN QL(5 ea daily); SYRINGE/U- F NEEDLES30GX5/16" F RX/OTC 100/0.5ML/31G X 5/16" SHORT MISC MISC SURE COMFORT PEN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); NEEDLES31GX3/16" F RX/OTC SYRINGE/U-100/1ML/28G F RX/OTC (5MM) MISC X 1/2" MISC SURE COMFORT PEN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); NEEDLES31GX5/16" F RX/OTC SYRINGE/U-100/1ML/29G F RX/OTC (8MM) MISC X 1/2" MISC SURE COMFORT PEN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); NEEDLES32GX5/32" F RX/OTC SYRINGE/U-100/1ML/30G F RX/OTC MISC X 5/16" MISC SURE-JECT INSULIN QL(5 ea daily) SURE COMFORT PEN F QL(5 ea daily) NEEDLES32GX6MM MISC SYRINGE/U-100/1ML/31G F X 5/16" MISC SURE-FINE PEN QL(5 ea daily) NEEDLES 29GX1/2" F TECHLITE INSULIN QL(5 ea daily); 12.7MM MISC SYRINGEU- F RX/OTC 100/0.3ML/29G X 1/2" SURE-FINE PEN QL(5 ea daily); MISC NEEDLES 31GX3/16" F RX/OTC 5MM MISC

NV Silver Summit Updated September 1, 2018

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE INSULIN QL(5 ea daily) TECHLITE PEN QL(5 ea daily); SYRINGEU- F NEEDLES/31GX 5MM F RX/OTC 100/0.3ML/30G X 1/2" MISC MISC TECHLITE PEN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily); NEEDLES/31GX 6 MM F SYRINGEU- F RX/OTC MISC 100/0.3ML/30G X 5/16" TECHLITE PEN QL(5 ea daily); MISC NEEDLES/31GX 8MM F RX/OTC TECHLITE INSULIN QL(5 ea daily) MISC SYRINGEU- F TECHLITE PEN QL(5 ea daily); 100/0.3ML/31G X 5/16" NEEDLES/32GX 4MM F RX/OTC MISC MISC TECHLITE INSULIN QL(5 ea daily); TECHLITE PEN QL(5 ea daily) SYRINGEU- F RX/OTC NEEDLES/32GX 6MM F 100/0.5ML/29G X 1/2" MISC MISC TODAYS HEALTH MINI QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily) PEN NEEDLES 31G X 1/4" F SYRINGEU- F MISC 100/0.5ML/30G X 1/2" MISC TODAYS HEALTH QL(5 ea daily); ORIGINAL PEN NEEDLES F RX/OTC TECHLITE INSULIN QL(5 ea daily); 29G X 1/2" MISC SYRINGEU- F RX/OTC 100/0.5ML/30G X 5/16" TODAYS HEALTH SHORT QL(5 ea daily); MISC PEN NEEDLES 31G X F RX/OTC 5/16" MISC TECHLITE INSULIN QL(5 ea daily) TOPCARE CLICKFINE QL(5 ea daily) SYRINGEU- F 100/0.5ML/31G X 5/16" UNIVERSAL PEN EEDLES F MISC 31GX1/4" MISC TECHLITE INSULIN QL(5 ea daily); TOPCARE CLICKFINE QL(5 ea daily); SYRINGEU-100/1ML/29G F RX/OTC UNIVERSAL PEN EEDLES F RX/OTC X 1/2" MISC 31GX5/16" MISC TECHLITE INSULIN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily); SYRINGEU-100/1ML/30G F COMFORT INSULIN F RX/OTC X 1/2" MISC SYRINGE/0.3ML/30G X 5/16" MISC TECHLITE INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G F RX/OTC TOPCARE ULTRA QL(5 ea daily) X 5/16" MISC COMFORT INSULIN F SYRINGE/0.3ML/31G X TECHLITE INSULIN QL(5 ea daily) 5/16" MISC SYRINGEU-100/1ML/31G F X 15/64" MISC TOPCARE ULTRA QL(5 ea daily); COMFORT INSULIN F RX/OTC TECHLITE INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X SYRINGEU-100/1ML/31G F 5/16" MISC X 5/16" MISC TOPCARE ULTRA QL(5 ea daily) TECHLITE PEN NEEDLES QL(5 ea daily); F COMFORT INSULIN F 29GX 12 MM MISC RX/OTC SYRINGE/0.5ML/31G X TECHLITE PEN NEEDLES F QL(5 ea daily); 5/16" MISC 31GX 5MM MISC RX/OTC

NV Silver Summit Updated September 1, 2018

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPCARE ULTRA QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily) COMFORT INSULIN F RX/OTC SYRINGE/U- F SYRINGE/1ML/30G X 100/0.3ML/31G X 5/16" 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); COMFORT INSULIN F SYRINGE/U- F RX/OTC SYRINGE/1ML/31G X 100/0.5ML/28G X 1/2" 5/16" MISC MISC TOPCARE ULTRA QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); COMFORT INSULIN RX/OTC SYRINGE/U- F RX/OTC SYRINGE/U- F 100/0.5ML/29G X 1/2" 100/0.3ML/29G X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- F RX/OTC COMFORT INSULIN RX/OTC 100/0.5ML/30G X 5/16" SYRINGE/U- F MISC 100/0.5ML/29G X 1/2" TRUEPLUS INSULIN QL(5 ea daily) MISC SYRINGE/U- F TOPCARE ULTRA QL(5 ea daily); 100/0.5ML/31G X 5/16" COMFORT INSULIN F RX/OTC MISC SYRINGE/U-100/1ML/29G TRUEPLUS INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/U-100/1ML/28G F RX/OTC TOPCO INSULIN QL(5 ea daily); X 1/2" MISC SYRINGE/U- F RX/OTC TRUEPLUS INSULIN QL(5 ea daily); 100/0.3ML/29G X 1/2" SYRINGE/U-100/1ML/29G F RX/OTC MISC X 1/2" MISC TOPCO INSULIN QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily); SYRINGE/U- F RX/OTC SYRINGE/U-100/1ML/30G F RX/OTC 100/0.5ML/28G X 1/2" X 5/16" MISC MISC TRUEPLUS INSULIN QL(5 ea daily) TOPCO INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G F SYRINGE/U- F RX/OTC X 5/16" MISC 100/0.5ML/29G X 1/2" MISC TRUEPLUS PEN QL(5 ea daily); NEEDLES 29GX12MM F RX/OTC TOPCO INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/28G F RX/OTC X 1/2" MISC TRUEPLUS PEN QL(5 ea daily); NEEDLES 31GX5MM F RX/OTC TOPCO INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G F RX/OTC X 1/2" MISC TRUEPLUS PEN QL(5 ea daily) NEEDLES 31GX6MM F TRUEPLUS INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC 100/0.3ML/29G X 1/2" TRUEPLUS PEN QL(5 ea daily); MISC NEEDLES 31GX8MM F RX/OTC MISC TRUEPLUS INSULIN QL(5 ea daily); TRUEPLUS PEN QL(5 ea daily); SYRINGE/U- F RX/OTC 100/0.3ML/30G X 5/16" NEEDLES 32GX4MM F RX/OTC MISC MISC

NV Silver Summit Updated September 1, 2018

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

NV Silver Summit Updated September 1, 2018

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily) ULTICARE PEN QL(5 ea daily) SYRINGE/U-100/1ML/30G F NEEDLES/29GX 12.7MM F X 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE SHORT PEN QL(5 ea daily); SYRINGE/U-100/1ML/30G F RX/OTC NEEDLES 31GX8MM F RX/OTC X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE SHORT PEN QL(5 ea daily); SYRINGE/U-100/1ML/31G F NEEDLES ULTI-FINE IV F RX/OTC X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE SHORT PEN QL(5 ea daily); SYRINGEULTRAFINE U- F NEEDLES/31G X 8MM F RX/OTC 100/0.3ML/31G X 5/16" MISC MISC ULTILET INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X F RX/OTC SYRINGEULTRAFINE U- F 8MM MISC 100/0.5ML/31G X 5/16" ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X F ULTICARE INSULIN QL(5 ea daily) 8MM MISC SYRINGEULTRAFINE U- F ULTILET INSULIN QL(5 ea daily); 100/1ML/31G X 5/16" SYRINGE/0.5ML/30G X F RX/OTC MISC 8MM MISC ULTICARE MICRO PEN QL(5 ea daily); ULTILET INSULIN QL(5 ea daily); NEEDLES 31G X 8MM F RX/OTC SYRINGE/1ML/30G X F RX/OTC MISC 8MM MISC ULTICARE MICRO PEN QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) NEEDLES 32G X 4MM F RX/OTC SYRINGE/1ML/31G X F MISC 8MM MISC ULTICARE MICRO PEN QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) NEEDLES/32G X 4MM F RX/OTC SYRINGE/SHORT/0.3ML/3 F MISC 0G X 12.7MM MISC ULTICARE MINI PEN QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); NEEDLES 31GX6MM F SYRINGE/SHORT/0.3ML/3 F RX/OTC MISC 0G X 5/16" MISC ULTICARE MINI PEN QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) NEEDLES ULTI-FINE IV F SYRINGE/SHORT/0.3ML/3 F MISC 1G X 5/16" MISC ULTICARE MINI PEN QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); NEEDLES/31G X 6MM F SYRINGE/SHORT/0.5ML/3 F RX/OTC MISC 0G X 5/16" MISC ULTICARE MINI PEN F QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) NEEDLES31GX6MM MISC SYRINGE/SHORT/0.5ML/3 F ULTICARE ORIGINAL QL(5 ea daily); 1G X 5/16" MISC PEN NEEDLES ULTI-FINE F RX/OTC ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/1ML/30 F RX/OTC ULTICARE PEN NEEDLES F QL(5 ea daily); G X 5/16" MISC 31GX 5MM/MINI MISC RX/OTC ULTILET INSULIN QL(5 ea daily) SYRINGE/SHORT/1ML/31 F G X 5/16" MISC NV Silver Summit Updated September 1, 2018

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE/U- F INSULIN SYRINGE/U- F RX/OTC 100/0.5ML/30G X 1/2" 100/0.5ML/30G X 5/16" MISC MISC ULTILET INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily) F SYRINGE/U-100/1ML/30G INSULIN SYRINGE/U- F X 1/2" MISC 100/0.5ML/31G X 5/16" MISC ULTILET PEN NEEDLE F QL(5 ea daily) 29GX12.7MM MISC ULTRA-COMFORT QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC ULTILET PEN NEEDLE F QL(5 ea daily); 31GX5MM MISC RX/OTC 100/1ML/28G X 1/2" MISC ULTRA-COMFORT QL(5 ea daily); ULTILET PEN NEEDLE F QL(5 ea daily); 31GX8MM MISC RX/OTC INSULIN SYRINGE/U- F RX/OTC 100/1ML/29G X 1/2" MISC ULTILET PEN NEEDLE F QL(5 ea daily); 32GX4MM MISC RX/OTC ULTRA-COMFORT QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC ULTILET PEN NEEDLE F QL(5 ea daily); 100/1ML/30G X 5/16" 32GX4MM/SHORT MISC RX/OTC MISC ULTILET SHORT PEN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily) NEEDLES 31GX5/16" F RX/OTC INSULIN SYRINGE/U- F MISC 100/1ML/31G X 5/16" ULTILET SHORT PEN QL(5 ea daily); MISC NEEDLES31GX3/16" F RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE SHORT/U- F RX/OTC ULTRA COMFORT QL(5 ea daily); 100/0.3ML/30GX5/16" INSULIN SYRINGE/U- F RX/OTC MISC 100/0.3ML/30G X 5/16" ULTRA-THIN II INSULIN QL(5 ea daily) MISC SYRINGE SHORT/U- F ULTRA-COMFORT QL(5 ea daily); 100/0.3ML/31GX5/16" INSULIN SYRINGE/U- F RX/OTC MISC 100/0.3ML/29G X 1/2" ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE SHORT/U- F RX/OTC ULTRA-COMFORT QL(5 ea daily); 100/0.5ML/30GX5/16" INSULIN SYRINGE/U- F RX/OTC MISC 100/0.3ML/30G X 5/16" ULTRA-THIN II INSULIN QL(5 ea daily) MISC SYRINGE SHORT/U- F ULTRA-COMFORT QL(5 ea daily) 100/0.5ML/31GX5/16" INSULIN SYRINGE/U- F MISC 100/0.3ML/31G X 5/16" ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE SHORT/U- F RX/OTC ULTRA-COMFORT QL(5 ea daily); 100/1ML/30GX5/16" MISC INSULIN SYRINGE/U- F RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily) 100/0.5ML/28G X 1/2" SYRINGE SHORT/U- F MISC 100/1ML/31GX5/16" MISC ULTRA-COMFORT QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily); INSULIN SYRINGE/U- F RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/29G X 1/2" 100/0.3ML/29GX1/2" MISC MISC

NV Silver Summit Updated September 1, 2018

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-THIN II INSULIN QL(5 ea daily); V-R MONOJECT INSULIN QL(5 ea daily); F SYRINGE/U- RX/OTC SYRINGE/U- F RX/OTC 100/0.5ML/29GX1/2" MISC 100/0.5ML/29G X 1/2" ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE/U- F RX/OTC V-R MONOJECT INSULIN QL(5 ea daily); 100/1ML/29GX1/2" MISC SYRINGE/U-100/1ML/28G F RX/OTC ULTRA-THIN II MINI PEN QL(5 ea daily); X 1/2" MISC NEEEDLES/31GX3/16" F RX/OTC V-R MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/29G F RX/OTC X 1/2" MISC ULTRA-THIN II PEN F QL(5 ea daily) NEEDLES 29GX1/2" MISC VALUE HEALTH INSULIN QL(5 ea daily); ULTRA-THIN II PEN QL(5 ea daily); SYRINGE/U- F RX/OTC NEEDLES/SHORT/31GX5/ F RX/OTC 100/0.5ML/29G X 1/2" 16" MISC MISC VALUE HEALTH INSULIN QL(5 ea daily); UNIFINE PENTIPS F QL(5 ea daily); 29GX12MM MISC RX/OTC SYRINGE/U-100/1ML/29G F RX/OTC X 1/2" MISC UNIFINE PENTIPS 31G X F QL(5 ea daily); 3/16" MISC RX/OTC VALUMARK PEN QL(5 ea daily); NEEDLES 29GX12MM F RX/OTC UNIFINE PENTIPS F QL(5 ea daily); MISC 31GX5MM MISC RX/OTC VALUMARK PEN QL(5 ea daily) UNIFINE PENTIPS F QL(5 ea daily) NEEDLES 31GX 6MM F 31GX6MM MISC MISC UNIFINE PENTIPS F QL(5 ea daily); VALUMARK PEN QL(5 ea daily); 31GX8MM MISC RX/OTC NEEDLES 31GX 8MM F RX/OTC UNIFINE PENTIPS F QL(5 ea daily); MISC 32GX4MM MISC RX/OTC VANISHPOINT INSULIN QL(5 ea daily) UNIFINE PENTIPS PLUS F QL(5 ea daily); SYRINGE/0.5ML/30G X F 29GX12MM MISC RX/OTC 1/2" MISC UNIFINE PENTIPS PLUS F QL(5 ea daily); VANISHPOINT INSULIN QL(5 ea daily); 31GX5MM MISC RX/OTC SYRINGE/0.5ML/30G X F RX/OTC 5/16" MISC UNIFINE PENTIPS PLUS F QL(5 ea daily) 31GX6MM MISC VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2" F RX/OTC UNIFINE PENTIPS PLUS F QL(5 ea daily); 31GX8MM MISC RX/OTC MISC VANISHPOINT INSULIN QL(5 ea daily); UNIFINE PENTIPS PLUS F QL(5 ea daily); 32GX4MM MISC RX/OTC SYRINGE/1ML/30G X F RX/OTC V-R MONOJECT INSULIN QL(5 ea daily); 5/16" MISC VIDA MIA UNIFINE QL(5 ea daily); SYRINGE/U- F RX/OTC F 100/0.3ML/29G X 1/2" PENTIPS32GX4MM MISC RX/OTC MISC VIDA MIA UNIFINE QL(5 ea daily) V-R MONOJECT INSULIN QL(5 ea daily); PENTIPSMINI 31GX6MM F MISC SYRINGE/U- F RX/OTC 100/0.5ML/28G X 1/2" VIDA MIA UNIFINE QL(5 ea daily); MISC PENTIPSORIGINAL F RX/OTC 29GX12MM MISC

NV Silver Summit Updated September 1, 2018

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDA MIA UNIPFINE QL(5 ea daily); AEROCHAMBER Z-STAT QL(2 ea per F PENTIPSSHORT RX/OTC PLUS VALVED HOLDING F 360 days 31GX8MM MISC CHAMBER W/FLOW VU retail); RX/OTC VP INSULIN SYRINGE/U- QL(5 ea daily); MISC 100/0.3ML/29G X 1/2" F RX/OTC AEROCHAMBER Z-STAT QL(2 ea per MISC F 360 days PLUS/FLOWSIGNAL MISC WEGMANS UNIFINE QL(5 ea daily); retail); RX/OTC PENTIPS PLUS 32GX4MM F RX/OTC AEROCHAMBER Z-STAT QL(2 ea per MISC F 360 days PLUS/LARGE MASK MISC WEGMANS UNIFINE QL(5 ea daily); retail); RX/OTC PENTIPS F RX/OTC AEROCHAMBER Z-STAT QL(2 ea per PLUS/MINI/31GX5MM PLUS/MEDIUM MASK F 360 days MISC MISC retail); RX/OTC WEGMANS UNIFINE QL(5 ea daily); QL(2 ea per PENTIPS RX/OTC AEROCHAMBER Z-STAT F F PLUS/SMALL MASK MISC 360 days PLUS/SHORT/31GX8MM retail); RX/OTC MISC QL(2 ea per WEGMANS UNIFINE QL(5 ea daily) AEROCHAMBER/FLOWSI F GNAL MISC 360 days PENTIPS PLUS/ULTRA F retail); RX/OTC SHORT/31GX6MM MISC AEROVENT PLUS QL(2 ea per Respiratory Therapy Supplies HOLDING F 360 days AEROCHAMBER MINI QL(2 ea per CHAMBER/COLLAPSIBLE retail); RX/OTC DEVI AEROSOLCHAMBER F 360 days DEVI retail); RX/OTC QL(2 ea per F QL(2 ea per ARIAL CHAMBER DEVI 360 days AEROCHAMBER MV F retail); RX/OTC MISC 360 days retail); RX/OTC BREATHERITE QL(2 ea per F QL(2 ea per COLLAPSIBLEADULT 360 days AEROCHAMBER PLUS F SPACER W/MASK MISC retail); RX/OTC FLOW VU MISC 360 days retail); RX/OTC BREATHERITE QL(2 ea per F QL(2 ea per COLLAPSIBLECHILD 360 days AEROCHAMBER PLUS F SPACER W/MASK MISC retail); RX/OTC FLOW-VU MISC 360 days retail); RX/OTC BREATHERITE QL(2 ea per COLLAPSIBLEINFANT F 360 days AEROCHAMBER PLUS QL(2 ea per FLOW-VU/LARGE MASK F 360 days SPACER W/MASK MISC retail); RX/OTC MISC retail); RX/OTC BREATHERITE QL(2 ea per QL(2 ea per COLLAPSIBLESMALL F 360 days AEROCHAMBER PLUS F 360 days CHILD SPACER W/MASK retail); RX/OTC FLOW-VU/MASK MISC MISC retail); RX/OTC BREATHERITE QL(2 ea per AEROCHAMBER PLUS QL(2 ea per F FLOW-VU/MEDIUM MASK F 360 days COLLAPSIBLESPACER 360 days W/ NEONATE MASK MISC retail); RX/OTC MISC retail); RX/OTC QL(2 ea per AEROCHAMBER PLUS QL(2 ea per F FLOW-VU/SMALL MASK F 360 days BREATHERITE MISC 360 days retail); RX/OTC MISC retail); RX/OTC QL(2 ea per BREATHERITE RIGID F SPACERW/MASK MISC 360 days retail); RX/OTC

NV Silver Summit Updated September 1, 2018

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREATHERITE W/LARGE QL(2 ea per QL(2 ea per F 360 days EASIVENT/MASK-LARGE F 360 days MASK MISC MISC retail); RX/OTC retail); RX/OTC BREATHERITE QL(2 ea per QL(2 ea per F 360 days EASIVENT/MASK- F 360 days W/MEDIUM MASK MISC MEDIUM MISC retail); RX/OTC retail); RX/OTC BREATHERITE W/SMALL QL(2 ea per QL(2 ea per F 360 days EASIVENT/MASK-SMALL F 360 days MASK MISC MISC retail); RX/OTC retail); RX/OTC CLEVER CHOICE ANTI- QL(2 ea per QL(2 ea per STATICVALVED 360 days FLEXICHAMBER DEVI F 360 days HOLDING F retail); RX/OTC retail); RX/OTC CHAMBER/ADULT LARGE INSPIRACHAMBER/ANTI- QL(2 ea per DEVI STATIC F 360 days CLEVER CHOICE ANTI- QL(2 ea per VALVED/MOUTHPIECE retail); RX/OTC STATICVALVED F 360 days DEVI HOLDING retail); RX/OTC QL(2 ea per CHAMBER/MEDIUM DEVI INSPIRACHAMBER/LARG F E DEVI 360 days CLEVER CHOICE ANTI- QL(2 ea per retail); RX/OTC STATICVALVED F 360 days INSPIRACHAMBER/SOOT QL(2 ea per HOLDING retail); RX/OTC HERMASK/INSPIRAMASK F 360 days CHAMBER/SMALL DEVI /MEDIUM DEVI retail); RX/OTC COMPACT SPACE QL(2 ea per INSPIRACHAMBER/SOOT QL(2 ea per CHAMBER/ANTI-STATIC F 360 days HERMASK/INSPIRAMASK F 360 days DEVI retail); RX/OTC /SMALL DEVI retail); RX/OTC COMPACT SPACE QL(2 ea per QL(2 ea per CHAMBER/ANTI- 360 days INSPIREASE DRUG F F DELIVERYSYSTEM MISC 360 days STATIC/LARGE MASK retail); RX/OTC retail); RX/OTC DEVI INSPIREASE RESERVOIR F QL(3 ea per COMPACT SPACE QL(2 ea per BAGS MISC 180 days retail) CHAMBER/ANTI- F 360 days STATIC/MEDIUM MASK retail); RX/OTC QL(2 ea per DEVI LITEAIRE DEVI F 360 days retail); RX/OTC COMPACT SPACE QL(2 ea per QL(2 ea per CHAMBER/ANTI- F 360 days STATIC/SMALL MASK retail); RX/OTC MICROCHAMBER MISC F 360 days DEVI retail); RX/OTC QL(2 ea per QL(2 ea per E-Z SPACER DEVI F 360 days MICROSPACER MISC F 360 days retail); RX/OTC retail); RX/OTC QL(2 ea per OPTICHAMBER QL(2 ea per E-Z SPACER THE BODY F ADVANTAGE/LARGE F 360 days GUARDS PACK DEVI 360 days retail); RX/OTC MASK MISC retail); RX/OTC QL(2 ea per OPTICHAMBER QL(2 ea per EASIVENT MISC F 360 days ADVANTAGE/MEDIUM F 360 days retail); RX/OTC FACE MASK MISC retail); RX/OTC OPTICHAMBER QL(2 ea per ADVANTAGE/SMALL F 360 days FACE MASK MISC retail); RX/OTC NV Silver Summit Updated September 1, 2018

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea per Migraine Products OPTICHAMBER F 360 days Use AL(At least 18 DIAMOND MISC retail); RX/OTC D.H.E. 45 SOLN ( Dihydroergotamine NF yrs old) OPTICHAMBER QL(2 ea per Mesylate) F DIAMOND/LARGEFACE 360 days dihydroergotamine AL(At least 18 MASK DEVI retail); RX/OTC F mesylate soln ij 1 mg/ml yrs old) OPTICHAMBER QL(2 ea per F DIHYDROERGOTAMINE AL(At least 18 DIAMOND/MEDIUM FACE 360 days MESYLATE SOLN NA 4 F yrs old) MASK MISC retail); RX/OTC MG/ML OPTICHAMBER QL(2 ea per AL(At least 18 DIAMOND/SMALLFACE F 360 days MIGRANAL SOLN F yrs old) MASK MISC retail); RX/OTC QL(2 ea per Serotonin Agonists OPTICHAMBER FACE F Limit 9 per MASK/LARGE MISC 360 days retail); RX/OTC month;QL(0.3 AMERGE TABS (Use NF QL(2 ea per Naratriptan HCl) ea daily); AL(At OPTICHAMBER FACE F least 18 yrs MASK/MEDIUM MISC 360 days retail); RX/OTC old) QL(2 ea per Limit 6 per OPTICHAMBER FACE F month;QL(0.2 MASK/SMALL MISC 360 days eletriptan hydrobromide retail); RX/OTC F ea daily); AL(At tabs least 18 yrs QL(2 ea per old) OPTIHALER MDI DRUG F DELIVERY SYSTEM DEVI 360 days retail); RX/OTC Limit 6 per IMITREX SOLN NA 5 month;QL(0.2 QL(2 ea per MG/ACT, 20 MG/ACT (Use NF ea daily); AL(At OPTIHALER MISC F 360 days Sumatriptan) least 12 yrs retail); RX/OTC old) QL(2 ea per QL(2.5 ml per POCKET CHAMBER DEVI F 360 days IMITREX SOLN SC 6 30 days retail); retail); RX/OTC MG/0.5ML (Use NF Sumatriptan Succinate) AL(At least 12 QL(2 ea per yrs old) POCKET SPACER DEVI F 360 days Limit 2 per retail); RX/OTC IMITREX STATDOSE month;QL(0.06 QL(2 ea per REFILL SOCT 6 MG/0.5ML NF 7 ml daily); RITEFLO DEVI F 360 days (Use Sumatriptan Succinate) AL(At least 12 retail); RX/OTC yrs old) QL(2 ea per Limit 2 syringes VALVED HOLDING F CHAMBER DEVI 360 days IMITREX STATDOSE per retail); RX/OTC SYSTEM SOAJ 6 NF month;QL(0.06 VORTEX VALVED QL(2 ea per MG/0.5ML (Use 7 ml daily); HOLDING CHAMBER F 360 days Sumatriptan Succinate) AL(At least 12 DEVI retail); RX/OTC yrs old) QL(2 ea per Limit 9 per WATCHHALER DEVI F 360 days IMITREX TABS OR 25 MG, month;QL(0.3 retail); RX/OTC 50 MG, 100 MG (Use NF ea daily); AL(At Sumatriptan Succinate) least 12 yrs MIGRAINE PRODUCTS - Drugs to Treat Migraine old) Headaches

NV Silver Summit Updated September 1, 2018

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 12 per Limit 9 per MAXALT TABS (Use NF month;QL(0.4 month;QL(0.3 ) sumatriptan succinate tabs F ea daily); AL(At Rizatriptan Benzoate ea daily); AL(At or 25 mg, 50 mg, 100 mg least 6 yrs old) least 12 yrs old) MAXALT-MLT TBDP (Use NF QL(0.4 ea Rizatriptan Benzoate) daily) Limit 6 per Limit 9 per month;QL(0.2 month;QL(0.3 zolmitriptan tabs F ea daily); AL(At naratriptan hcl tabs F ea daily); AL(At least 18 yrs least 18 yrs old) old) Limit 6 per Limit 6 per month;QL(0.2 month;QL(0.2 zolmitriptan tbdp F ea daily); AL(At RELPAX TABS (Use NF least 18 yrs ) ea daily); AL(At Eletriptan Hydrobromide least 18 yrs old) old) Limit 6 per Limit 12 per month;QL(0.2 ZOMIG SOLN NA 5 MG F ea daily); AL(At rizatriptan benzoate tabs 5 F month;QL(0.4 mg, 10 mg ea daily); AL(At least 12 yrs least 6 yrs old) old) Limit 6 per rizatriptan benzoate tbdp 5 F QL(0.4 ea mg, 10 mg daily) month;QL(0.2 ZOMIG TABS OR 5 MG, NF ) ea daily); AL(At Limit 6 per 2.5 MG (Use Zolmitriptan least 18 yrs month;QL(0.2 old) sumatriptan soln F ea daily); AL(At least 12 yrs Limit 6 per old) month;QL(0.2 ZOMIG ZMT TBDP (Use NF ) ea daily); AL(At Limit 2 syringes Zolmitriptan least 18 yrs per old) sumatriptan succinate soaj F month;QL(0.06 sc 6 mg/0.5ml 7 ml daily); MINERALS & ELECTROLYTES AL(At least 12 yrs old) Calcium Limit 2 per CALCI-CHEW CHEW F month;QL(0.06 sumatriptan succinate soct F 7 ml daily); sc 6 mg/0.5ml calcium carbonate tabs 500 F AL(At least 12 mg, 1250 mg yrs old) calcium carbonate- QL(2.5 ml per cholecalciferol chew F sumatriptan succinate soln F 30 days retail); 500mg-100unit, 500mg- sc 6 mg/0.5ml AL(At least 12 400unit yrs old) calcium carbonate- Limit 2 syringes cholecalciferol tabs 500mg- per SUMATRIPTAN 200unit, 500mg-400unit, F month;QL(0.06 600mg-200unit, 600mg- SUCCINATE SOSY SC 6 7 ml daily); F MG/0.5ML 400unit, 600mg-800unit, AL(At least 12 500mg-500mg-400unit- yrs old) 400unit, 600mg-600mg- 800unit-400unit NV Silver Summit Updated September 1, 2018

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcium carbonate-vitamin PEDIALYTE SOLN d tabs 125unit-250mg, 20MEQ/L-45MEQ/L- 125unit-500mg, 200unit- 35MEQ/L-5GM/L-20GM/L, 500mg, 250mg-125unit, F 20MEQ/L-45MEQ/L- NF 500mg-125unit, 500mg- 35MEQ/L-30MEQ/L- 200unit, 500mg-500mg- 25GM/L (Use Oral 200unit-200unit Electrolytes) calcium carbonate-vitamin QL(2 ea daily) Fluoride d tabs 200unit-600mg, F LURIDE SOLN (Use NF AL(Up to 15 yrs 400unit-600mg, 600mg- Sodium Fluoride) old ) 200unit, 600mg-400unit sodium fluoride chew 0.25 AL(Up to 15 yrs calcium citrate tabs 200 F F old ) mg, 950 mg mg, 0.5 mg, 1 mg, 1.1 mg, 2.2 mg CALCIUM TABS 600MG- F AL(Up to 15 yrs 200UNIT sodium fluoride soln 0.125 F mg/drop, 0.5 mg/ml old ) calcium w/ vitamin d tabs F 600mg-200unit Magnesium CALTRATE 600+D TABS magnesium oxide (mg (Use Calcium Carbonate- NF supplement) tabs 400 mg, F Cholecalciferol) 241.3 mg MAGOX 400 TABS (Use oyster shell tabs F Magnesium Oxide (Mg NF Supplement)) PARVA-CAL TABS F 500MG-200UNIT Phosphate Electrolyte Mixtures K-PHOS NEUTRAL TABS QL(8 ea daily) (Use Pot Phosphate CERASPORT EX1 SOLN F Monobasic w/ Sod NF CERASPORT SOLN Phosphate Dibasic & 4MEQ/L-18MEQ/L- F Monobasic) 20MEQ/L-6MEQ/L pot phosphate monobasic QL(8 ea daily) w/ sod phosphate dibasic & ENFAMIL ENFALYTE F F SOLN monobasic tabs 130mg- 155mg-852mg HYDRALYTE FREEZER F POPS SOLN Potassium HYDRALYTE SOLN K-TAB TBCR 10 MEQ (Use NF 270MG/250ML- Potassium Chloride) 210MG/250ML, 45MEQ/L- F K-TAB TBCR 8 MEQ, 20 F 45MEQ/L-20MEQ/L- MEQ 90MEQ/L-16GM/L KLOR-CON M15 TBCR F oral electrolytes soln F MICRO-K CPCR 10 MEQ NF PEDIALYTE FREEZER (Use Potassium Chloride) POPS SOLN (Use Oral NF MICRO-K CPCR 8 MEQ NF QL(1 ea daily) Electrolytes) (Use Potassium Chloride) potassium bicarbonate tbef F

NV Silver Summit Updated September 1, 2018

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride cpcr or F CELLCEPT SUSR 200 QL(15 ml daily) 10 meq MG/ML (Use NF Mycophenolate Mofetil) potassium chloride cpcr or F QL(1 ea daily) 8 meq CELLCEPT TABS 500 MG QL(4 ea daily) (Use Mycophenolate NF POTASSIUM CHLORIDE F ER TBCR Mofetil) potassium chloride cyclosporine caps or 25 F QL(4 ea daily) microencapsulated crystals F mg, 100 mg er tbcr cyclosporine modified (for QL(4 ea daily) microemulsion) caps 25 F potassium chloride pack or F 20 meq mg, 50 mg, 100 mg cyclosporine modified (for QL(8 ml daily) potassium chloride soln or F 10 %, 20 % microemulsion) soln 100 F mg/ml potassium chloride tbcr or F 8 meq, 10 meq CYCLOSPORINE F QL(4 ea daily) MODIFIED CAPS Sodium CYCLOSPORINE QL(4 ea daily) sodium chloride soln ij 0.9 F MODIFIED CAPS (Use NF % Cyclosporine Modified (For Microemulsion)) SODIUM CHLORIDE F SOLN IJ 0.9 % cyclosporine soln iv 50 F mg/ml sodium chloride soln iv 0.9 F % IMURAN TABS (Use NF Azathioprine) SODIUM CHLORIDE F SOLN IV 0.9 % mycophenolate mofetil F QL(2 ea daily) Zinc caps 250 mg mycophenolate mofetil hcl F zinc sulfate caps or 220 mg F solr 500 mg mycophenolate mofetil susr F QL(15 ml daily) MISCELLANEOUS THERAPEUTIC CLASSES 200 mg/ml Chelating Agents mycophenolate mofetil tabs F QL(4 ea daily) 500 mg DEPEN TITRATABS TABS F 250 MG mycophenolate sodium F QL(2 ea daily) tbec 180 mg Immunosuppressive Agents mycophenolate sodium F QL(4 ea daily) AZASAN TABS F QL(3 ea daily) tbec 360 mg MYFORTIC TBEC 180 MG QL(2 ea daily) azathioprine tabs or 50 mg F (Use Mycophenolate NF Sodium) CELLCEPT CAPS 250 MG QL(2 ea daily) (Use Mycophenolate NF MYFORTIC TBEC 360 MG QL(4 ea daily) Mofetil) (Use Mycophenolate NF Sodium) CELLCEPT NEORAL CAPS 25 MG, QL(4 ea daily) INTRAVENOUS SOLR NF (Use Mycophenolate 100 MG (Use Cyclosporine NF Mofetil HCl) Modified (For Microemulsion))

NV Silver Summit Updated September 1, 2018

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEORAL SOLN 100 QL(8 ml daily) chlorhexidine gluconate F MG/ML (Use Cyclosporine NF (mouth-throat) soln 0.12 % Modified (For PERIDEX SOLN (Use Microemulsion)) Chlorhexidine Gluconate NF PROGRAF CAPS OR 0.5 QL(3 ea daily) (Mouth-Throat)) MG, 1 MG, 5 MG (Use NF Tacrolimus) Dental Products PREVIDENT 5000 DRY QL(60 ml per PROGRAF SOLN IV 5 F MOUTH GEL (Use Sodium NF fill retail) MG/ML Fluoride (Dental)) RAPAMUNE SOLN 1 F MG/ML PREVIDENT 5000 PLUS QL(60 gm per CREA (Use Sodium NF fill retail) RAPAMUNE TABS 0.5 Fluoride (Dental)) MG, 1 MG, 2 MG (Use NF Sirolimus) PREVIDENT FLUORIDE QL(60 ml per GEL (Use Sodium Fluoride NF fill retail) SANDIMMUNE CAPS OR QL(4 ea daily) (Dental)) NF 25 MG, 100 MG (Use QL(60 gm per Cyclosporine) sodium fluoride (dental) F crea dt 1.1 % fill retail) SANDIMMUNE SOLN IV NF sodium fluoride (dental) gel F QL(60 ml per 50 MG/ML (Use fill retail) Cyclosporine) dt 1.1 % sodium fluoride (dental) F SANDIMMUNE SOLN OR F QL(8 ml daily) soln mt 0.2 % 100 MG/ML THERA-FLUR-N GEL (Use NF QL(60 ml per sirolimus tabs F Sodium Fluoride (Dental)) fill retail) tacrolimus caps F QL(3 ea daily) Steroids - Mouth/Throat triamcinolone acetonide F QL(5 gm per fill ZORTRESS TABS F (mouth) pste retail) Throat Products - Misc. Potassium Removing Agents QL(900 ml per KAYEXALATE POWD (Use QL(454 gm per AQUORAL SOLN F fill retail); Sodium Polystyrene NF fill retail) RX/OTC Sulfonate) BIOTENE DRY MOUTH QL(900 ml per sodium polystyrene F QL(454 gm per MOISTURIZING SPRAY F fill retail); sulfonate powd or fill retail) SOLN RX/OTC sodium polystyrene QL(900 ml per sulfonate susp or 15 F CAPHOSOL SOLN F fill retail); gm/60ml RX/OTC MOUTH/THROAT/DENTAL AGENTS QL(900 ml per CVS DRY MOUTH SPRAY F fill retail); SOLN Anesthetics Topical Oral RX/OTC lidocaine hcl (mouth-throat) QL(100 ml per QL(900 ml per F EQL DRY MOUTH ORAL F soln 2 % fill retail) RINSE SOLN fill retail); RX/OTC Anti-infectives - Throat QL(900 ml per nystatin (mouth-throat) F QL(120 ml per MOI-STIR SOLN F fill retail); susp fill retail) RX/OTC Antiseptics - Mouth/Throat

NV Silver Summit Updated September 1, 2018

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(900 ml per b-complex w/ c & folic acid QL(1 ea daily); MOUTHKOTE SOLN F fill retail); caps 1.5mg-5mg-20mg- RX/OTC RX/OTC 1.7mg-6mcg-1mg-150mcg- F QL(900 ml per 10mg-100mg, 5mg-1.7mg- NUMOISYN LIQD F fill retail); 6mcg-20mg-1.5mg-1mg- RX/OTC 150mcg-10mg-100mg ORAL RELIEF SPRAY QL(900 ml per NEPHROCAPS CAPS QL(1 ea daily); FOR DRYMOUTH & F fill retail); (Use B-Complex w/ C & NF RX/OTC DISCOMFORT SOLN RX/OTC Folic Acid) Multiple Vitamins w/ Minerals pilocarpine hcl (oral) tabs 5 F QL(6 ea daily) mg ACTIVESSENTIALS PACK F QL(900 ml per RA DRY MOUTH SOLN F fill retail); AIRBORNE LOZG F RX/OTC SALAGEN TABS 5 MG QL(6 ea daily) ANTIOXIDANT FORMULA F (Use Pilocarpine HCl NF SG CPCR (Oral)) BIOVOL SYRP F MULTIVITAMINS C-BUFF POWD F B-Complex Vitamins CENTRUM b-complex vitamins caps or QL(1 ea daily) MULTIVITAMIN FLAVOR F 70mg-100mg-1mg-10mg- BURST DRINK PACK 2mg-1.5mg-100mcg, 60mg-60mg-3mg-5mg- F CONCEPTIONXR 20mg-3mg-1mcg-0.5mg, MOTILITY SUPPORT F 60mg-60mg-5mg-20mg- FORMULA MISC 3mg-1mcg-3mg-0.5mg CORVITE TABS (Use b-complex vitamins tabs or QL(1 ea daily) Multiple Vitamins w/ NF 0.1mg-20mg-2mg-5mcg- Minerals & Folic Acid) 3mg-1mg, 10mg-10mg- CVS DIABETES HEALTH F 2mg-1.5mg-0.2mg, 10mg- SUPPORT MISC 14mg-25mcg-7mg-4.5mg, DAILY HEART HEALTH F 15mg-2mg-5mg-2mcg- SUPPORT MISC 2mg-2mg, 3mg-10mg- 20mg-3mg-6mcg-2mg, DAILY PAK MAXIMUM 3mg-20mg-3mg-10mg- MULTIVITAMIN/ASIAN F GINSENG EXTRACT 6mcg-2mg, 83mg-3mg- F 20mg-2mg-5mcg-1mg, MISC 100mg-50mg-40mg-10mg- DIABETES HEALTH PACK F 20mg-5mg-4.6mg-1mcg- MISC 5mg-1mg, 3mg-3mg-20mg- DIABETES SUPPORT F 20mg-3mg-3mg-10mg- PACK MISC 10mg-6mcg-6mcg-2mg- 2mg, 30mg-50mg-50mg- ELDERTONIC ELIX F 50mg-50mg-50mg-50mcg- 50mg-100mcg-50mcg- ELLIS TONIC ELIX F 50mg EMERGEN-C BLUE PACK F B-Complex w/ Folic Acid

NV Silver Summit Updated September 1, 2018

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMERGEN-C FIVE PACK F MH MACULAR HEALTH F MISC EMERGEN-C HEART F HEALTH PACK MULTI FOR HER PACK F EMERGEN-C IMMUNE F MULTI FOR HIM PACK F PACK multiple vitamins w/ EMERGEN-C IMMUNE F F PLUS PACK minerals & folic acid tabs PA MENS 50 PLUS EMERGEN-C IMMUNE+ F F WARMERS PACK VITAPAK MISC EMERGEN-C JOINT F PA MENS VITAPAK MISC F HEALTH PACK PA WOMENS 50 PLUS F EMERGEN-C KIDZ PACK F VITAPAK MISC PA WOMENS VITAPAK EMERGEN-C MSM LITE F F PACK MISC EMERGEN-C PINK PACK F PHLEXY-VITS POWD F PREMIUM PACKETS EMERGEN-C SUPER F F FRUIT PACK MISC PRESCRIPTIVE EMERGEN-C VITAMIN C F LITE PACK FORMULAS OPTIMAL F VITAMIN PACKS MENS EMERGEN-C VITAMIN C F PACK MISC PRESCRIPTIVE EMERGEN-C VITAMIN D F & CALCIUM PACK FORMULAS OPTIMAL F VITAMIN PACKS END FATIGUE DAILY WOMENS MISC ENERGYENFUSION F POWD RA ESSENCE-C PACK F ENERGY BOOSTER F SKIN BEAUTY & F PACK WELLNESS PACK IMMUNE SUPPORT F VITAMIN C PACK STROVITE FORTE SYRP F KP MENS DAILY PACK F MISC SUPER NU-THERA POWD F KP WOMENS DAILY F SYNAGEX CAPS F PACK MISC LIFE PACK MENS MISC F SYNATEK CAPS F THERANATAL LIFE PACK WOMENS F MISC LACTATION COMPLETE F MISC MAXIMIN PACK PACK F ULTRA MENS PACK MISC F MEGA MULTIVITAMIN F POWD ULTRA WOMENS PACK F MISC MENS PACK MISC F

NV Silver Summit Updated September 1, 2018

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITAMENT PACK F CVS PRENATAL GUMMY/DHA/FOLIC ACID F VITAMIN C CHEW EFFERVESCENT BLEND F QL(1 ea daily); PACK CVS PRENATAL TABS F AL(Up to 45 yrs old ) VITAMIN F C/ELECTROLYTES PACK QL(1 ea daily); EQL PRENATAL F AL(Up to 45 yrs VITAMINS TO GO F FORMULA TABS MAXIMUM MISC old ) QL(1 ea daily); VITAMINS TO GO MEN F MISC GNP PRENATAL TABS F AL(Up to 45 yrs old ) VITAMINS TO GO F WOMEN MISC QL(1 ea daily); GOODSENSE PRENATAL F VITAMINS TABS AL(Up to 45 yrs WOMENS PACK MISC F old ) ZINC LOZG OR 50MG- QL(1 ea daily); 15MG-500UNIT-100MG, HM PRENATAL TABS F AL(Up to 45 yrs old ) 50MG-15MG-10MG- F 500UNIT-100MG, 10MG- QL(1 ea daily); 5MG-10MG-10MG-15MG- KP PRENATAL F MULTIVITAMINS TABS AL(Up to 45 yrs 500UNIT-60MG old ) Ped MV w/ Fluoride QL(1 ea daily); QL(50 ml per KPN PRENATAL TABS F AL(Up to 45 yrs old ) pediatric vitamins acd w/ F fill retail); fluoride soln AL(Up to 13 yrs QL(1 ea daily); old ) M-VIT TABS F AL(Up to 45 yrs old ); RX/OTC Ped Multi Vitamins w/Fl & FE QL(1 ea daily); QL(50 ml per MULTI PRENATAL TABS F AL(Up to 45 yrs ped multivitamins w/fl & F fill retail); old ) iron soln AL(Up to 13 yrs old ) QL(1 ea daily); MYNATAL CAPS F AL(Up to 45 yrs TRI-VIT/FLUORIDE/IRON QL(50 ml per old ) SOLN 0.25MG/ML- F fill retail); 1500UNIT/ML-10MG/ML- AL(Up to 13 yrs QL(1 ea daily); NAT-RUL PRENATAL F 400UNIT/ML-35MG/ML old ) VITAMINS TABS AL(Up to 45 yrs old ) Pediatric Multiple Vitamins QL(1 ea daily); pediatric multiple vitamins F NIVA-PLUS TABS F AL(Up to 45 yrs liqd old ); RX/OTC Pediatric Vitamins QL(1 ea daily); pediatric vitamins adc soln QL(50 ml per O-CAL FA TABS F AL(Up to 45 yrs 1500unit/ml-400unit/ml- F fill retail) old ); RX/OTC 35mg/ml QL(1 ea daily); PNV FOLIC ACID + IRON F MULTIVITAMIN TABS AL(Up to 45 yrs Prenatal Vitamins old ); RX/OTC QL(1 ea daily); CLASSIC PRENATAL QL(1 ea daily); F AL(Up to 45 yrs PNV PRENATAL PLUS F AL(Up to 45 yrs TABS MULTIVITAMIN TABS old ) old ); RX/OTC NV Silver Summit Updated September 1, 2018

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); PRENATAL TABS 11UNIT- QL(1 ea daily); PRE-NATAL FORMULA F TABS AL(Up to 45 yrs 263MG-25MG-1.5MG- AL(Up to 45 yrs old ) 27MG-4000UNIT-18MG- old ) QL(1 ea daily); 1.7MG-4MCG-400UNIT- PRENATAL AND IRON F 0.8MG-2.6MG-100MG, TABS AL(Up to 45 yrs old ) 30UNIT-4000UNIT-25MG- 1.8MG-200MG-28MG- PRENATAL FORMULA 20MG-1.7MG-8MCG- CAPS 35MG-30UNIT- 400UNIT-0.8MG-2.6MG- 4000UNIT-200MG-25MG- 120MG, 30UNIT-25MG- 1.8MG-200MG-28MG- F 1.8MG-200MG-28MG- 20MG-1.7MG-8MCG- 20MG-1.7MG-4000UNIT- 400UNIT-800MCG-2.6MG- 8MCG-400UNIT-800MCG- 120MG 2.6MG-120MG, 30UNIT- QL(1 ea daily); 4000UNIT-25MG-1.8MG- PRENATAL FORTE TABS F AL(Up to 45 yrs 200MG-28MG-20MG- F old ) 1.7MG-8MCG-400UNIT- QL(1 ea daily); 800MCG-2.6MG-120MG, PRENATAL LOW IRON F 4000UNIT-30UNIT-200MG- TABS AL(Up to 45 yrs old ) 25MG-1.8MG-28MG- QL(1 ea daily); 20MG-1.7MG-8MCG- PRENATAL F 400UNIT-800MCG-2.6MG- MULTIVITAMIN TABS AL(Up to 45 yrs old ) 120MG, 4000UNIT- 30UNIT-25MG-1.8MG- QL(1 ea daily); 200MG-28MG-20MG- PRENATAL ONE DAILY F AL(Up to 45 yrs TABS 1.7MG-8MCG-400UNIT- old ) 800MCG-2.6MG-120MG, QL(1 ea daily); 160MG-11UNIT-200MG- PRENATAL PLUS TABS F AL(Up to 45 yrs 25MG-1.84MG-27MG- old ); RX/OTC 4000UNIT-18MG-1.7MG- 4MCG-400UNIT-800MCG- 2.6MG-100MG PRENATAL TABS 22MG- QL(1 ea daily); 2MG-25MG-1.84MG- AL(Up to 45 yrs 200MG-27MG-4000UNIT- F old ); RX/OTC 20MG-3MG-12MCG- 400UNIT-1MG-10MG- 120MG PRENATAL TABS QL(1 ea daily); 4000UNIT-200MG-11UNIT- AL(Up to 45 yrs 27MG-25MG-1.84MG- F old ) 18MG-1.7MG-4MCG- 400UNIT-0.8MG-2.6MG- 100MG QL(1 ea daily); PRENATAL VITAMIN & F MINERAL TABS AL(Up to 45 yrs old ) QL(1 ea daily); PRENATAL VITAMIN F TABS AL(Up to 45 yrs old )

NV Silver Summit Updated September 1, 2018

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); vitamins w/ lipotropics caps QL(1 ea daily) PRENATAL F 50mg-50mg-50mg-50mg- VITAMIN/IRON TABS AL(Up to 45 yrs old ) 50mcg-50mcg-50mcg- QL(1 ea daily); 50mg, 86mg-2mg-10mg- PRENATAL VITAMINS F 83mg-240mg-3mg-2mcg- PLUS LOW IRON TABS AL(Up to 45 yrs old ); RX/OTC 3mg-110mg-1.65mg, 50mg-50mg-50mg-50mg- QL(1 ea daily); 50mg-50mg-50mg-50mcg- PRENATAL VITAMINS F AL(Up to 45 yrs TABS 100mcg-50mcg-50mg, F old ) 75mg-30mg-2unit- QL(1 ea daily); 10000unit-40mg-15mg- PREPLUS TABS F AL(Up to 45 yrs 31mg-2.5mg-4mg-2mcg- old ); RX/OTC 75mg-400unit, 10000unit- QL(1 ea daily); 3mg-0.5mg-2mg-75mg- PX PRENATAL F 58mg-30mg-2unit-0.5mg- MULTIVITAMINS TABS AL(Up to 45 yrs old ) 4mg-40mg-15mg-31.4mg- QL(1 ea daily); 2.5mg-2mcg-5mg-1mg- QC PRENATAL TABS F AL(Up to 45 yrs 75mg-400unit old ) MUSCULOSKELETAL THERAPY AGENTS - RA PRENATAL QL(1 ea daily); Drugs to Treat Spasms FORMULA/FOLICACID F AL(Up to 45 yrs Central Muscle Relaxants TABS old ) baclofen tabs or 10 mg, 20 F QL(1 ea daily); mg RA PRENATAL TABS F AL(Up to 45 yrs old ) CHLORZOXAZONE TABS F 500 MG QL(1 ea daily); RIGHT STEP PRENATAL F cyclobenzaprine hcl tabs 5 QL(3 ea daily) TABS AL(Up to 45 yrs F old ) mg, 10 mg QL(1 ea daily); methocarbamol tabs or 500 F SM PRENATAL VITAMINS F AL(Up to 45 yrs mg, 750 mg TABS old ) ROBAXIN TABS OR 500 NF QL(1 ea daily); MG (Use Methocarbamol) THERANATAL CORE F ROBAXIN-750 TABS (Use NUTRITION TABS AL(Up to 45 yrs NF old ); RX/OTC Methocarbamol) QL(1 ea daily); tizanidine hcl tabs 2 mg, 4 F TRICARE TABS F AL(Up to 45 yrs mg old ); RX/OTC ZANAFLEX TABS 4 MG NF QL(1 ea daily); (Use Tizanidine HCl) VOL-PLUS TABS F AL(Up to 45 yrs NASAL AGENTS - SYSTEMIC AND TOPICAL - old ); RX/OTC Drugs to treat the Nose or Sinus Vitamins w/ Lipotropics Nasal Agents - Misc. OCEAN NASAL SPRAY NF QL(90 ml per SOLN (Use Saline) fill retail) saline soln 0.65%-0.002%, F QL(90 ml per 0.65 %, 0.65% fill retail) Nasal Anti-infectives

NV Silver Summit Updated September 1, 2018

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BACTROBAN NASAL F NASACORT ALLERGY QL(17 ml per OINT 24HR AERO 55 MCG/ACT F fill retail); AL(At (Use Triamcinolone least 2 yrs old); Nasal Antiallergy Acetonide (Nasal)) RX/OTC Limit 1 NASACORT ALLERGY QL(17 ml per ASTEPRO SOLN (Use NF package per ) 24HR CHILDRENS AERO fill retail); AL(At Azelastine HCl month;QL(1 ml F least 2 yrs old); daily) 55 MCG/ACT (Use Triamcinolone Acetonide RX/OTC Limit 1 (Nasal)) F package per azelastine hcl soln month;QL(1 ml NASONEX SUSP (Use QL(17 gm per Mometasone Furoate NF fill retail); AL(At daily) (Nasal)) least 2 yrs old) cromolyn sodium (nasal) F QL(26 ml per QL(17 ml per aers 5.2 mg/act fill retail) triamcinolone acetonide F fill retail); AL(At NASALCROM AERS (Use NF QL(26 ml per (nasal) aero 55 mcg/act least 2 yrs old); Cromolyn Sodium (Nasal)) fill retail) RX/OTC Nasal Anticholinergics Sympathomimetic Decongestants Limit 1 ADRENALIN SOLN NA 0.1 F ipratropium bromide (nasal) F package per % month;QL(1.2 soln 0.03 % NASAL DECONGESTANT ml daily) F LIQD Limit 1 package per NASAL DECONGESTANT F ipratropium bromide (nasal) F SYRP soln 0.06 % month;QL(0.5 ml daily) phenylephrine hcl (oral) F QL(24 ea per tabs 10 mg fill retail) Nasal Steroids pseudoephedrine hcl liqd F FLONASE ALLERGY QL(16 ml per 15 mg/5ml RELIEF CHILDRENS NF fill retail); SUSP (Use Fluticasone RX/OTC pseudoephedrine hcl tabs F Propionate (Nasal)) 30 mg, 60 mg FLONASE ALLERGY QL(16 ml per pseudoephedrine hcl tb12 F QL(2 ea daily) 120 mg RELIEF SUSP (Use NF fill retail); Fluticasone Propionate RX/OTC SUDAFED CHILDRENS (Nasal)) LIQD (Use NF Pseudoephedrine HCl) FLUNISOLIDE SOLN F QL(25 ml per fill retail) SUDAFED CONGESTION QL(16 ml per TABS (Use NF fluticasone propionate F fill retail); Pseudoephedrine HCl) (nasal) susp 50 mcg/act RX/OTC SUDAFED NASAL QL(17 gm per DECONGESTANT mometasone furoate F fill retail); AL(At MAXIMUM STRENGTH NF (nasal) susp 50 mcg/act least 2 yrs old) TABS (Use Pseudoephedrine HCl) QL(17 ml per SUDAFED PE QL(24 ea per NASACORT ALLERGY F fill retail); AL(At 24HR AERO 55 MCG/ACT least 2 yrs old); CONGESTION TABS (Use NF fill retail) RX/OTC Phenylephrine HCl (Oral)) NUTRIENTS

NV Silver Summit Updated September 1, 2018

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Misc. Nutritional Substances Proteins omega-3 fatty acids caps QL(6 ea daily) ARGININE TABS 500 MG F 1000mg, 1200mg, 1000 mg, 1200 mg, 180mg- arginine tabs 500 mg F 120mg, 1200mg-2unit, 300mg-1000mg, 350mg- L-TRYPTOPHAN TABS F 1000mg, 360mg-1200mg, OR 600mg-1000mg, 600mg- 1200mg, 180mg-120mg- OPHTHALMIC AGENTS - Drugs to Treat the Eye 5unit, 300mg-180mg- 120mg, 300mg-200mg- Artificial Tears and Lubricants 1unit, 1000mg-180mg- QL(4 gm per fill artificial tear ointment oint F 120mg, 160mg-1000mg- retail) 100mg, 180mg-1000mg- 120mg, 180mg-1200mg- artificial tear solution soln F 144mg, 216mg-1200mg- QL(15 ml per polyvinyl alcohol soln 1.4 % F 144mg, 270mg-1000mg- fill retail) 180mg, 300mg-1000mg- 1unit, 300mg-1000mg- TEARS NATURALE PM QL(4 gm per fill 200mg, 300mg-1unit- OINT (Use White NF retail) 1000mg, 336mg-1200mg- Petrolatum-Mineral Oil) 276mg, 350mg-1000mg- white petrolatum-mineral oil F QL(4 gm per fill 250mg, 400mg-1000mg- oint retail) 300mg, 500mg-1000mg- Beta-blockers - Ophthalmic 250mg, 180mg-120mg- BETAGAN SOLN (Use QL(10 ml per 1.8unit, 300mg-180mg- F NF 1gm-120mg, 1000mg- Levobunolol HCl) fill retail) 180mg-120mg-1mg, betaxolol hcl (ophth) soln F QL(10 ml per 210mg-1000mg-75mg- 0.5 % fill retail) 90mg, 60mg-180mg- Limit 1 package 1200mg-120mg, 60mg- F per 360mg-1200mg-300mg, carteolol hcl (ophth) soln month;QL(0.5 1000mg-180mg-120mg- ml daily) 1unit, 100mg-300mg- 1000mg-200mg, 180mg- Limit 1 package per 1000mg-120mg-1unit, CARTEOLOL HCL SOLN F 180mg-1unit-1000mg- month;QL(0.5 120mg, 300mg-1000mg- ml daily) 200mg-1unit, 300mg- COSOPT SOLN (Use QL(10 ml per 180mg-1000mg-120mg, Dorzolamide HCl-Timolol NF fill retail) 360mg-216mg-1200mg- Maleate) 144mg, 600mg-324mg- dorzolamide hcl-timolol QL(10 ml per 1200mg-216mg, 700mg- maleate soln 2%-0.5%, F fill retail) 350mg-1000mg-250mg, 22.3mg/ml-6.8mg/ml 900mg-455mg-1000mg- DORZOLAMIDE QL(10 ml per 360mg, 100mg-1000mg- HCL/TIMOLOL MALEATE F fill retail) 500mg-10unit, 216mg- SOLN 1200mg-144mg-15unit, QL(10 ml per 300mg-1000mg-1000mg- levobunolol hcl soln 0.5 % F 1unit, 340mg-180mg-1unit- fill retail) 1000mg-120mg METIPRANOLOL SOLN F

NV Silver Summit Updated September 1, 2018

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits timolol maleate (ophth) F QL(5 ml per fill apraclonidine hcl soln F solg 0.5 % retail) brimonidine tartrate soln QL(15 ml per timolol maleate (ophth) F QL(10 ml per F soln 0.25 % fill retail) 0.2 % fill retail) IOPIDINE SOLN 0.5 % timolol maleate (ophth) F QL(15 ml per NF soln 0.5 % fill retail) (Use Apraclonidine HCl) TIMOLOL MALEATE QL(5 ml per fill IOPIDINE SOLN 1 % F OPHTHALMIC GEL F retail) FORMING SOLG 0.5 % Ophthalmic Anti-infectives TIMOPTIC OCUDOSE QL(60 ea per F bacitracin-polymyxin b F QL(4 gm per fill SOLN fill retail) (ophth) oint retail) TIMOPTIC SOLN 0.25 % QL(10 ml per BLEPH-10 SOLN (Use QL(15 ml per (Use Timolol Maleate NF fill retail) Sulfacetamide Sodium NF fill retail) (Ophth)) (Ophth)) TIMOPTIC SOLN 0.5 % QL(15 ml per QL(4 gm per fill erythromycin (ophth) oint F (Use Timolol Maleate NF fill retail) retail) (Ophth)) QL(4 gm per fill GENTAK OINT F TIMOPTIC-XE SOLG 0.5 F QL(5 ml per fill retail) % retail) gentamicin sulfate (ophth) F QL(4 gm per fill Cycloplegic Mydriatics oint retail) gentamicin sulfate (ophth) QL(15 ml per ATROPINE SULFATE F QL(4 gm per fill F OINT OP 1 % retail) soln fill retail) moxifloxacin hcl (ophth) QL(3 ml per fill ATROPINE SULFATE F QL(15 ml per F SOLN OP 1 % fill retail) soln 0.5 % retail) CYCLOGYL SOLN 0.5 %, QL(15 ml per neomycin-bacitracin zn- F QL(4 gm per fill 1 % (Use Cyclopentolate NF fill retail) polymyxin oint retail) HCl) neomycin-polymyxin- QL(10 ml per gramicidin soln fill retail) CYCLOGYL SOLN 2 % NF F (Use Cyclopentolate HCl) 0.025mg/ml-10000unit/ml- 1.75mg/ml cyclopentolate hcl soln 0.5 F QL(15 ml per %, 1 % fill retail) NEOSPORIN SOLN (Use QL(10 ml per Neomycin-Polymyxin- NF fill retail) cyclopentolate hcl soln 2 % F Gramicidin) OCUFLOX SOLN (Use QL(10 ml per ISOPTO ATROPINE SOLN F QL(15 ml per NF fill retail) Ofloxacin (Ophth)) fill retail) ofloxacin (ophth) soln 0.3 QL(10 ml per MYDRIACYL SOLN (Use NF QL(15 ml per F Tropicamide) fill retail) % fill retail) QL(15 ml per polymyxin b-trimethoprim QL(10 ml per tropicamide soln F F fill retail) soln 0.1%-10000unit/ml fill retail) Miotics POLYTRIM SOLN (Use NF QL(10 ml per Polymyxin B-Trimethoprim) fill retail) ISOPTO CARPINE SOLN NF (Use Pilocarpine HCl) sulfacetamide sodium F QL(15 ml per (ophth) soln 10 % fill retail) pilocarpine hcl soln F SULFACETAMIDE F SODIUM OINT OP 10 % Ophthalmic Adrenergic Agents

NV Silver Summit Updated September 1, 2018

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tobramycin (ophth) soln 0.3 F QL(5 ml per fill MAXITROL OINT QL(4 gm per fill % retail) 10000UNIT/GM- retail) 3.5MG/GM-0.1% (Use NF TOBREX OINT 0.3 % F QL(4 gm per fill retail) Neomycin-Polymy- Dexameth) TOBREX SOLN (Use NF QL(5 ml per fill Tobramycin (Ophth)) retail) MAXITROL SUSP QL(5 ml per fill 10000UNIT/ML-3.5MG/ML- retail) QL(8 ml per fill NF trifluridine soln 1 % F 0.1% (Use Neomycin- retail) Polymy-Dexameth) VIGAMOX SOLN (Use NF QL(3 ml per fill neomycin-polymy- QL(4 gm per fill Moxifloxacin HCl (Ophth)) retail) dexameth oint F retail) VIROPTIC SOLN (Use NF QL(8 ml per fill 10000unit/gm-3.5mg/gm- Trifluridine) retail) 0.1% Ophthalmic Decongestants neomycin-polymy- QL(5 ml per fill dexameth susp retail) phenylephrine hcl (ophth) F QL(15 ml per F soln 2.5 % fill retail) 10000unit/ml-3.5mg/ml- 0.1% Limit 1 NEOMYCIN/POLYMYXIN/ QL(8 ml per fill tetrahydrozoline hcl (ophth) F package per soln 0.05 % month;QL(0.5 HYDROCORTISONE F retail) ml daily) SUSP Limit 1 OMNIPRED SUSP (Use QL(15 ml per VISINE EXTRA SOLN (Use package per Prednisolone Acetate NF fill retail) Tetrahydrozoline HCl NF (Ophth)) (Ophth)) month;QL(0.5 ml daily) PRED FORTE SUSP (Use QL(15 ml per Limit 1 Prednisolone Acetate NF fill retail) VISINE SOLN (Use package per (Ophth)) Tetrahydrozoline HCl NF QL(10 ml per (Ophth)) month;QL(0.5 PRED MILD SUSP F ml daily) fill retail) Ophthalmic Local Anesthetics PRED-G SUSP 0.3%-1% F QL(5 ml per fill retail) tetracaine hcl (ophth) soln F prednisolone acetate F QL(15 ml per (ophth) susp fill retail) Ophthalmic Steroids PREDNISOLONE F QL(15 ml per BLEPHAMIDE S.O.P. F QL(4 gm per fill ACETATE P-F SUSP fill retail) OINT retail) Limit 1 package QL(10 ml per PREDNISOLONE SODIUM BLEPHAMIDE SUSP F per fill retail) PHOSPHATE SOLN OP 1 F % month;QL(0.34 DEXAMETHASONE QL(5 ml per fill ml daily) SODIUM PHOSPHATE F retail) sulfacetamide sod- F QL(10 ml per SOLN OP 0.1 % prednisolone soln fill retail) fluorometholone (ophth) QL(15 ml per F TOBRADEX OINT 0.3%- F QL(4 gm per fill susp 0.1 % fill retail) 0.1% retail) FML LIQUIFILM SUSP QL(15 ml per TOBRADEX SUSP (Use QL(10 ml per (Use Fluorometholone NF fill retail) Tobramycin- NF fill retail) (Ophth)) Dexamethasone) QL(4 gm per fill FML OINT 0.1 % F tobramycin- QL(10 ml per retail) dexamethasone susp F fill retail) 0.3%-0.1% NV Silver Summit Updated September 1, 2018

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Use QL(10 ml per VEXOL SUSP F QL(10 ml per ZADITOR SOLN ( fill retail) Ketotifen Fumarate NF fill retail) (Ophth)) Ophthalmics - Misc. ACULAR LS SOLN (Use Prostaglandins - Ophthalmic NF Ketorolac Tromethamine LATANOPROST SOLN F QL(3 ml per fill (Ophth)) 0.005 % retail) QL(3 ml per fill ACULAR SOLN (Use QL(10 ml per latanoprost soln 0.005 % F Ketorolac Tromethamine NF fill retail) retail) (Ophth)) XALATAN SOLN (Use NF QL(3 ml per fill ST; Try Latanoprost) retail) F ketotifen ophth. ALOCRIL SOLN first;QL(5 ml OTIC AGENTS - Drugs to Treat the Ear per fill retail) Otic Agents - Miscellaneous ST; Try QL(15 ml per F ketotifen ophth. acetic acid (otic) soln F ALOMIDE SOLN first;QL(10 ml fill retail) per fill retail) Limit 1 package ST; Try carbamide peroxide (otic) F per soln 6.5 % month;QL(0.5 F ketotifen ophth. azelastine hcl (ophth) soln first;QL(6 ml ml daily) per fill retail) Limit 1 package DEBROX SOLN (Use per AZOPT SUSP F QL(15 ml per NF fill retail) Carbamide Peroxide (Otic)) month;QL(0.5 ml daily) cromolyn sodium (ophth) F QL(10 ml per soln fill retail) Otic Anti-infectives FLOXIN OTIC SOLN (Use QL(10 ml per diclofenac sodium (ophth) F QL(5 ml per fill NF soln retail) Ofloxacin (Otic)) fill retail) QL(10 ml per QL(10 ml per dorzolamide hcl soln 2 % F ofloxacin (otic) soln 0.3 % F fill retail) fill retail) DORZOLAMIDE HCL F QL(10 ml per Otic Combinations SOLN 2 % fill retail) QL(7.5 ml per CIPRODEX SUSP F flurbiprofen sodium soln F QL(3 ml per fill 30 days retail) 0.03 % retail) Limit 1 package CORTANE-B-OTIC SOLN ketorolac tromethamine F per (ophth) soln 0.4 % (Use Pramoxine-HC- NF Chloroxylenol) month;QL(0.34 ml daily) ketorolac tromethamine F QL(10 ml per (ophth) soln 0.5 % fill retail) neomycin-polymyxin-hc F QL(10 ml per (otic) soln fill retail) ketotifen fumarate (ophth) F QL(10 ml per soln 0.025 % fill retail) neomycin-polymyxin-hc F QL(10 ml per QL(3 ml per fill (otic) susp fill retail) NEVANAC SUSP 0.1 % F retail) Limit 1 package OTICIN HC NR SOLN (Use per OCUFEN SOLN (Use NF QL(3 ml per fill Pramoxine-HC- NF Flurbiprofen Sodium) retail) Chloroxylenol) month;QL(0.34 ml daily) TRUSOPT SOLN (Use NF QL(10 ml per Dorzolamide HCl) fill retail) PRAMOTIC LIQD F

NV Silver Summit Updated September 1, 2018

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 pramoxine-hc-chloroxylenol PENICILLIN V F package per POTASSIUM SOLR 125 F soln 10mg/ml-1mg/ml- month;QL(0.34 10mg/ml MG/5ML, 250 MG/5ML ml daily) penicillin v potassium solr F Otic Steroids 125 mg/5ml, 250 mg/5ml Limit 1 penicillin v potassium tabs F DERMOTIC OIL (Use package per 250 mg, 500 mg Fluocinolone Acetonide NF (Otic)) month;QL(0.67 Penicillin Combinations ml daily) Limit 1 package Limit 1 amoxicillin & pot F per fluocinolone acetonide package per clavulanate susr claim;QL(100 F 200mg/5ml-28.5mg/5ml (otic) oil 0.01 % month;QL(0.67 ml per fill retail) ml daily) Limit 1 package hydrocortisone w/acetic QL(10 ml per amoxicillin & pot F F per acid soln fill retail) clavulanate susr claim;QL(150 250mg/5ml-62.5mg/5ml OXYTOCICS - Drugs to Prevent/Control Uterine ml per fill retail) Bleeding amoxicillin & pot clavulanate susr F Oxytocics 400mg/5ml-57mg/5ml methylergonovine maleate F Limit 2 tabs or 0.2 mg amoxicillin & pot F packages per clavulanate susr claim;QL(400 PASSIVE IMMUNIZING AND TREATMENT 600mg/5ml-42.9mg/5ml AGENTS - Antibody Drugs to Treat Low Immune ml per fill retail) System amoxicillin & pot QL(30 ea per Monoclonal Antibodies clavulanate tabs 250mg- F fill retail) 125mg PA; SP SYNAGIS SOLN F amoxicillin & pot QL(20 ea per clavulanate tabs 500mg- F fill retail) PENICILLINS - Drugs to Treat Bacterial Infections 125mg, 875mg-125mg Aminopenicillins amoxicillin & pot Limit 40 per 30 clavulanate tb12 1000mg- F days;QL(1.34 amoxicillin caps 250 mg, F 62.5mg ea daily) 500 mg AMOXICILLIN/CLAVULAN F QL(20 ea per AMOXICILLIN CHEW 125 F ATE POTASSIUM CHEW fill retail) MG, 250 MG AUGMENTIN ES-600 Limit 2 amoxicillin susr 125 packages per mg/5ml, 200 mg/5ml, 250 F SUSR (Use Amoxicillin & NF Pot Clavulanate) claim;QL(400 mg/5ml, 400 mg/5ml ml per fill retail) amoxicillin tabs 875 mg F AUGMENTIN SUSR F 125MG/5ML-31.25MG/5ML ampicillin caps 250 mg, F 500 mg AUGMENTIN SUSR Limit 1 package 250MG/5ML-62.5MG/5ML NF per AMPICILLIN CAPS 500 F (Use Amoxicillin & Pot claim;QL(150 MG Clavulanate) ml per fill retail) AMPICILLIN SUSR 125 F MG/5ML, 250 MG/5ML Natural Penicillins

NV Silver Summit Updated September 1, 2018

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AUGMENTIN TABS QL(20 ea per PSYCHOTHERAPEUTIC AND NEUROLOGICAL 500MG-125MG, 875MG- NF fill retail) AGENTS - MISC. - Drugs to Treat Mental and 125MG (Use Amoxicillin & Emotional Conditions Pot Clavulanate) Agents for Chemical Dependency AUGMENTIN XR TB12 Limit 40 per 30 (Use Amoxicillin & Pot NF days;QL(1.34 ANTABUSE TABS 250 MG NF Clavulanate) ea daily) (Use Disulfiram) Penicillinase-Resistant Penicillins disulfiram tabs 250 mg F dicloxacillin sodium caps F Antidementia Agents ARICEPT TABS 5 MG, 10 QL(1 ea daily) PROGESTINS - Hormone Replacement/Modifying MG (Use Donepezil NF Drugs Hydrochloride) Progestins donepezil hydrochloride F QL(1 ea daily) AYGESTIN TABS (Use NF tabs 5 mg, 10 mg Norethindrone Acetate) EXELON CAPS OR 3 MG, PA; QL(2 ea hydroxyprogesterone F SP 6 MG, 1.5 MG, 4.5 MG NF daily) caproate oil 250 mg/ml (Use Rivastigmine Tartrate) MAKENA OIL IM 250 SP EXELON PT24 TD 4.6 PA; QL(1 ea MG/ML (Use NF MG/24HR, 9.5 MG/24HR, NF daily) Hydroxyprogesterone 13.3 MG/24HR (Use Caproate) Rivastigmine) MAKENA SOAJ SC 275 F galantamine hydrobromide F QL(1 ea daily) MG/1.1ML cp24 8 mg, 16 mg, 24 mg medroxyprogesterone F GALANTAMINE QL(6 ml daily) acetate tabs HYDROBROMIDE SOLN 4 F MEGACE ES SUSP (Use MG/ML Megestrol Acetate NF galantamine hydrobromide F QL(2 ea daily) (Appetite)) tabs 4 mg, 8 mg, 12 mg megestrol acetate F memantine hcl soln 2 F QL(10 ml daily) (appetite) susp 625 mg/5ml mg/ml norethindrone acetate tabs F Limit 1 package 5 mg F per 28 memantine hcl tabs days;QL(1.75 progesterone micronized F QL(1 ea daily) caps 100 mg ea daily) Limit 20 per memantine hcl tabs 5 mg, F QL(2 ea daily) progesterone micronized F month;QL(0.67 10 mg caps 200 mg ea daily) NAMENDA TABS 5 MG, 10 NF QL(2 ea daily) PROMETRIUM CAPS 100 QL(1 ea daily) MG (Use Memantine HCl) MG (Use Progesterone NF Limit 1 package Micronized) NAMENDA TITRATION per 28 PAK TABS (Use NF PROMETRIUM CAPS 200 Limit 20 per Memantine HCl) days;QL(1.75 MG (Use Progesterone NF month;QL(0.67 ea daily) Micronized) ea daily) RAZADYNE ER CP24 (Use QL(1 ea daily) PROVERA TABS (Use Galantamine NF Medroxyprogesterone NF Hydrobromide) Acetate)

NV Silver Summit Updated September 1, 2018

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RAZADYNE TABS (Use QL(2 ea daily) REBIF REBIDOSE F PA; SP Galantamine NF TITRATIONPACK SOAJ Hydrobromide) REBIF SOSY F PA; SP PA; QL(1 ea rivastigmine pt24 F daily) REBIF TITRATION PACK F PA; SP PA; QL(2 ea SOSY rivastigmine tartrate caps F daily) TECFIDERA CPDR F PA; SP Combination Psychotherapeutics TECFIDERA STARTER F PA; SP PERPHENAZINE/AMITRIP F QL(4 ea daily) PACK MISC TYLINE TABS PA; SP Fibromyalgia Agents TYSABRI CONC F PA; QL(2 ea PA; SP SAVELLA TABS F ZINBRYTA SOSY F daily) PA; QL(55 ea Premenstrual Dysphoric Disorder (PMDD) Agents SAVELLA TITRATION F PACK MISC per 365 days retail) FLUOXETINE CAPS F Multiple Sclerosis Agents Psychotherapeutic and Neurological Agents - PA; SP AMPYRA TB12 F ERGOLOID MESYLATES F TABS PA; SP AUBAGIO TABS F Smoking Deterrents PA; SP bupropion hcl (smoking F QL(2 ea daily) AVONEX KIT F deterrent) tb12 150 mg CHANTIX CONTINUING F PA; SP F AVONEX PEN AJKT MONTHPAK TABS PA; SP AVONEX PSKT F CHANTIX STARTING F MONTH PAK TABS PA; SP BETASERON KIT 0.3 MG F CHANTIX TABS F COPAXONE SOSY (Use PA; SP NF NICODERM CQ PT24 (Use NF Glatiramer Acetate) Nicotine) PA; SP GILENYA CAPS 0.5 MG F NICORETTE GUM (Use NF Nicotine Polacrilex) glatiramer acetate sosy F PA; SP NICORETTE LOZG (Use NF Nicotine Polacrilex) LEMTRADA SOLN F PA; SP NICORETTE MINI LOZG NF PA; SP (Use Nicotine Polacrilex) PLEGRIDY SOPN F NICORETTE STARTER PA; SP KIT GUM (Use Nicotine NF PLEGRIDY SOSY F Polacrilex) PLEGRIDY STARTER F PA; SP nicotine polacrilex gum F PACK SOPN PLEGRIDY STARTER F PA; SP nicotine polacrilex lozg F PACK SOSY REBIF REBIDOSE SOAJ F PA; SP nicotine pt24 F

NV Silver Summit Updated September 1, 2018

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NICOTINE MONODOX CAPS 100 MG TRANSDERMAL SYSTEM F (Use Doxycycline NF KIT (Monohydrate)) NICOTROL INHALER F VIBRAMYCIN CAPS 100 INHA MG (Use Doxycycline NF Hyclate) NICOTROL NS SOLN F THYROID AGENTS - Drugs to Regulate Thyroid ZYBAN TB12 (Use QL(2 ea daily) Hormones Bupropion HCl (Smoking NF Deterrent)) Antithyroid Agents RESPIRATORY AGENTS - MISC. - Drugs to methimazole tabs F Treat Lung Conditions propylthiouracil tabs F Cystic Fibrosis Agents PA; SP TAPAZOLE TABS (Use NF KALYDECO PACK F Methimazole) KALYDECO TABS F PA; SP Thyroid Hormones ARMOUR THYROID TABS ORKAMBI TABS 100MG- F PA; SP 15 MG, 30 MG, 60 MG, 90 NF 125MG, 200MG-125MG MG, 120 MG (Use Thyroid) PULMOZYME SOLN F PA; SP ARMOUR THYROID TABS F 180 MG, 240 MG, 300 MG TETRACYCLINES - Drugs to Treat Bacterial CYTOMEL TABS (Use NF Infections Liothyronine Sodium) Tetracyclines levothyroxine sodium tabs ADOXA PAK 1/100 TABS or 25 mcg, 50 mcg, 75 (Use Doxycycline NF mcg, 88 mcg, 100 mcg, F (Monohydrate)) 112 mcg, 125 mcg, 137 ADOXA PAK 2/100 TABS mcg, 150 mcg, 175 mcg, (Use Doxycycline NF 200 mcg, 300 mcg (Monohydrate)) liothyronine sodium tabs or F ADOXA TABS 50 MG, 100 5 mcg, 25 mcg, 50 mcg MG (Use Doxycycline NF SYNTHROID TABS (Use NF (Monohydrate)) Levothyroxine Sodium) doxycycline (monohydrate) F thyroid tabs F caps 50 mg, 100 mg doxycycline (monohydrate) F THYROLAR-1 TABS F tabs 50 mg, 100 mg THYROLAR-1/2 TABS F doxycycline hyclate caps or F 50 mg, 100 mg THYROLAR-1/4 TABS F doxycycline hyclate tabs or F 100 mg THYROLAR-2 TABS F MINOCIN CAPS OR 50 MG, 75 MG, 100 MG (Use NF Minocycline HCl) THYROLAR-3 TABS F minocycline hcl caps 50 F mg, 75 mg, 100 mg TOXOIDS

NV Silver Summit Updated September 1, 2018

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Toxoid Combinations cimetidine tabs 200 mg F RX/OTC AL(At least 19 ADACEL SUSP F yrs old) cimetidine tabs 300 mg, F 400 mg, 800 mg AL(At least 19 BOOSTRIX SUSP F yrs old) famotidine susr or 40 F mg/5ml AL(At least 19 TENIVAC INJ F yrs old) famotidine tabs or 10 mg, F 40 mg TETANUS/DIPHTHERIA AL(At least 19 TOXOIDS-ADSORBED F yrs old) famotidine tabs or 20 mg F RX/OTC SUSP PEPCID AC MAXIMUM RX/OTC ULCER DRUGS - Drugs to Treat Bowel, Intestine STRENGTH TABS (Use NF and Stomach Conditions Famotidine) Antispasmodics PEPCID AC TABS (Use NF Famotidine) ANASPAZ TBDP (Use NF Hyoscyamine Sulfate) PEPCID SUSR 40 MG/5ML NF (Use Famotidine) BENTYL CAPS OR 10 MG NF (Use Dicyclomine HCl) PEPCID TABS 20 MG (Use NF RX/OTC Famotidine) BENTYL TABS OR 20 MG NF (Use Dicyclomine HCl) PEPCID TABS 40 MG (Use NF Famotidine) dicyclomine hcl caps or 10 F mg ranitidine hcl caps or 150 F QL(2 ea daily) mg dicyclomine hcl soln or 10 F QL(40 ml daily) mg/5ml ranitidine hcl caps or 300 F QL(1 ea daily) mg dicyclomine hcl tabs or 20 F mg ranitidine hcl syrp or 15 QL(40 ml mg/ml, 75 mg/5ml, 150 F daily); AL(Up to glycopyrrolate tabs or 1 F QL(4 ea daily) mg, 2 mg mg/10ml 6 yrs old ) ranitidine hcl tabs or 150 QL(2 ea daily); hyoscyamine sulfate elix F F 0.125 mg/5ml mg RX/OTC ranitidine hcl tabs or 75 mg, QL(2 ea daily) hyoscyamine sulfate soln F F 0.125 mg/ml 300 mg TAGAMET HB TABS (Use RX/OTC hyoscyamine sulfate tb12 F QL(4 ea daily) NF 0.375 mg Cimetidine) ZANTAC 150 MAXIMUM QL(2 ea daily); hyoscyamine sulfate tbdp F 0.125 mg STRENGTH TABS (Use NF RX/OTC Ranitidine HCl) LEVBID TB12 (Use NF QL(4 ea daily) Hyoscyamine Sulfate) ZANTAC 75 TABS (Use NF QL(2 ea daily) Ranitidine HCl) ROBINUL FORTE TABS NF QL(4 ea daily) (Use Glycopyrrolate) ZANTAC TABS OR 150 NF QL(2 ea daily); MG (Use Ranitidine HCl) RX/OTC ROBINUL TABS OR 1 MG NF QL(4 ea daily) (Use Glycopyrrolate) ZANTAC TABS OR 300 NF QL(2 ea daily) MG (Use Ranitidine HCl) H-2 Antagonists Misc. Anti-Ulcer CIMETIDINE HCL SOLN F QL(27 ml daily)

NV Silver Summit Updated September 1, 2018

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(420 ml per PREVACID CPDR 15 MG NF QL(4 ea daily); CARAFATE SUSP 1 F fill retail); (Use Lansoprazole) RX/OTC GM/10ML AL(Up to 6 yrs PREVACID CPDR 30 MG NF old ) (Use Lansoprazole) CARAFATE TABS 1 GM QL(4 ea daily) NF PREVACID SOLUTAB NF (Use Sucralfate) TBDP (Use Lansoprazole) QL(4 ea daily) sucralfate tabs F PRILOSEC CPDR 10 MG NF (Use Omeprazole) Proton Pump Inhibitors PRILOSEC CPDR 20 MG NF QL(2 ea daily); CVS OMEPRAZOLE TBEC F QL(1 ea daily) (Use Omeprazole) RX/OTC PRILOSEC CPDR 40 MG NF QL(2 ea daily) EQ OMEPRAZOLE TBEC F QL(1 ea daily) (Use Omeprazole) PROTONIX TBEC OR 20 QL(1 ea daily) EQL OMEPRAZOLE TBEC F QL(1 ea daily) MG (Use Pantoprazole NF Sodium) esomeprazole magnesium F cpdr 40 mg PROTONIX TBEC OR 40 QL(2 ea daily) MG (Use Pantoprazole NF GNP OMEPRAZOLE F QL(1 ea daily) Sodium) TBEC PX OMEPRAZOLE TBEC F QL(1 ea daily) HM OMEPRAZOLE TBEC F QL(1 ea daily) RA OMEPRAZOLE TBEC F QL(1 ea daily) KLS OMEPRAZOLE TBEC F QL(1 ea daily) QL(1 ea daily) QL(4 ea daily); SB OMEPRAZOLE TBEC F lansoprazole cpdr 15 mg F RX/OTC SM OMEPRAZOLE TBEC F QL(1 ea daily) lansoprazole cpdr 30 mg F SW OMEPRAZOLE TBEC F QL(1 ea daily) lansoprazole tbdp 15 mg, F 30 mg TGT OMEPRAZOLE TBEC F QL(1 ea daily) NEXIUM CPDR 40 MG (Use Esomeprazole NF Ulcer Drugs - Prostaglandins Magnesium) CYTOTEC TABS (Use NF omeprazole cpdr 10 mg F Misoprostol) QL(2 ea daily); misoprostol tabs F omeprazole cpdr 20 mg F RX/OTC URINARY ANTI-INFECTIVES - Drugs to Treat omeprazole cpdr 40 mg F QL(2 ea daily) Bladder/Kidney Infections Urinary Anti-infective Combinations OMEPRAZOLE TBEC 20 F QL(1 ea daily) MG methenamine-hyosc- methylene blue-sod phos- pantoprazole sodium tbec F QL(1 ea daily) or 20 mg phenyl sal tabs 40.8mg- F 0.12mg-36.2mg-81.6mg- pantoprazole sodium tbec F QL(2 ea daily) or 40 mg 10.8mg, 40.8mg-36.2mg- 0.12mg-81.6mg-10.8mg PREVACID 24HR CPDR NF QL(4 ea daily); (Use Lansoprazole) RX/OTC Urinary Anti-infectives

NV Silver Summit Updated September 1, 2018

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(40 ml Urinary Antispasmodics - Direct Muscle Relaxants FURADANTIN SUSP (Use NF Nitrofurantoin) daily); AL(Up to 6 yrs old ) flavoxate hcl tabs F MACROBID CAPS (Use Nitrofurantoin Monohyd NF VACCINES Macro) Bacterial Vaccines MACRODANTIN CAPS 50 AL(At least 19 MG, 100 MG (Use NF ACTHIB SOLR F Nitrofurantoin yrs old) AL(At least 19 Macrocrystal) BEXSERO SUSY F methenamine mandelate yrs old) F AL(At least 19 tabs HIBERIX SOLR F nitrofurantoin macrocrystal yrs old) F AL(At least 19 caps 50 mg, 100 mg MENACTRA INJ F nitrofurantoin monohyd yrs old) F AL(At least 19 macro caps 100 mg MENVEO SOLR F QL(40 ml yrs old) nitrofurantoin susp 25 F daily); AL(Up to AL(At least 19 mg/5ml PEDVAX HIB SUSP F 6 yrs old ) yrs old) URINARY ANTISPASMODICS - Drugs to Treat One per Miscellaneous Bladder Spasms F lifetime; AL(At PNEUMOVAX 23 INJ least 65 yrs Urinary Antispasmodic - Antimuscarinics old) DETROL LA CP24 (Use NF QL(1 ea daily) One per Tolterodine Tartrate) PNEUMOVAX 23/1 DOSE F lifetime; AL(At INJ least 65 yrs DETROL TABS (Use NF QL(2 ea daily) Tolterodine Tartrate) old) One per DITROPAN XL TB24 (Use NF QL(2 ea daily) Oxybutynin Chloride) F lifetime; AL(At PREVNAR 13 SUSP least 65 yrs oxybutynin chloride syrp 5 F QL(16 ml daily) mg/5ml old) AL(At least 19 oxybutynin chloride tabs 5 F QL(3 ea daily) TRUMENBA SUSY F mg yrs old) Viral Vaccines oxybutynin chloride tb24 5 F QL(2 ea daily) mg, 10 mg, 15 mg AL(At least 19 ENGERIX-B INJ F yrs old) tolterodine tartrate cp24 2 F QL(1 ea daily) mg, 4 mg ENGERIX-B SUSP F AL(At least 19 yrs old) tolterodine tartrate tabs 1 F QL(2 ea daily) mg, 2 mg 1 rtl MAX fill,180 rtl trospium chloride tabs 20 F QL(2 ea daily) mg FLUMIST F day(s) supply,; QUADRIVALENT SUSP AL(At least 19 Urinary Antispasmodics - Cholinergic Agonists yrs old - Up to bethanechol chloride tabs F 49 yrs old) AL(At least 19 URECHOLINE TABS (Use NF GARDASIL 9 SUSP F yrs old - Up to Bethanechol Chloride) 26 yrs old)

NV Silver Summit Updated September 1, 2018

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 19 GYNE-LOTRIMIN CREA NF QL(45 gm per GARDASIL 9 SUSY F yrs old - Up to (Use Clotrimazole Vaginal) fill retail) 26 yrs old) METROGEL-VAGINAL QL(70 gm per AL(At least 19 GEL (Use Metronidazole NF fill retail) GARDASIL SUSP F yrs old - Up to Vaginal) 26 yrs old) metronidazole vaginal gel F QL(70 gm per AL(At least 19 0.75 % fill retail) HAVRIX SUSP F yrs old) QL(3 ea per fill MICONAZOLE 3 SUPP F IPOL INACTIVATED IPV F AL(At least 19 retail) INJ yrs old) miconazole nitrate vaginal F QL(45 gm per AL(At least 19 crea 2 % fill retail) M-M-R II INJ F yrs old) Limit 1 package miconazole nitrate vaginal per RECOMBIVAX HB SUSP F AL(At least 19 F yrs old) crea 4 % month;QL(1.5 QL(1 ea per gm daily) Seasonal Influenza F 180 days miconazole nitrate vaginal F QL(1 gm per fill Vaccine retail); AL: At kit retail) least 19 yrs old miconazole nitrate vaginal F kit SHINGRIX SUSR F AL(At least 50 yrs old) miconazole nitrate vaginal F QL(7 ea per fill AL(At least 19 supp 100 mg retail) STAMARIL SUSR F yrs old) MONISTAT 1 COMBO PACK KIT (Use Miconazole NF TWINRIX SUSP F AL(At least 19 yrs old) Nitrate Vaginal) AL(At least 19 MONISTAT 1 DAY OR VAQTA SUSP F yrs old) NIGHT COMBO PACK KIT NF (Use Miconazole Nitrate VARIVAX INJ F AL(At least 19 yrs old) Vaginal) AL(At least 60 MONISTAT 3 QL(1 gm per fill ZOSTAVAX SUSR F yrs old) COMBINATION PACK KIT NF retail) (Use Miconazole Nitrate VAGINAL PRODUCTS - Drugs to Treat Vaginal Vaginal) Infections and Low Hormones Limit 1 package Vaginal Anti-infectives MONISTAT 3 CREA (Use NF per CLEOCIN CREA VA 2 % QL(40 gm per Miconazole Nitrate Vaginal) month;QL(1.5 (Use Clindamycin NF fill retail) gm daily) Phosphate Vaginal) MONISTAT 7 SIMPLY QL(45 gm per CURE CREA (Use NF fill retail) clindamycin phosphate F QL(40 gm per vaginal crea 2 % fill retail) Miconazole Nitrate Vaginal) TERAZOL 3 CREA (Use QL(20 gm per clotrimazole vaginal crea 1 F QL(45 gm per NF % fill retail) Terconazole Vaginal) fill retail) TERAZOL 7 CREA (Use QL(45 gm per clotrimazole vaginal crea 2 F QL(20 gm per NF % fill retail) Terconazole Vaginal) fill retail) TERCONAZOLE CREA F QL(20 gm per GYNAZOLE-1 CREA F fill retail) terconazole vaginal crea QL(45 gm per GYNE-LOTRIMIN 3 CREA NF QL(20 gm per F (Use Clotrimazole Vaginal) fill retail) 0.4 % fill retail)

NV Silver Summit Updated September 1, 2018

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits terconazole vaginal crea F QL(20 gm per D-VI-SOL LIQD (Use NF 0.8 % fill retail) Cholecalciferol) terconazole vaginal supp F QL(3 ea per fill DRISDOL CAPS (Use NF 80 mg retail) Ergocalciferol) tioconazole vaginal oint 6.5 F QL(5 gm per fill ergocalciferol caps F % retail) VAGISTAT-1 OINT (Use NF QL(5 gm per fill ergocalciferol soln F Tioconazole Vaginal) retail) MEPHYTON TABS (Use NF Vaginal Estrogens Phytonadione) Limit 1 ESTRACE CREA VA 0.1 package per phytonadione tabs or 5 mg F MG/GM (Use Estradiol NF Vaginal) month;QL(1.5 gm daily) vitamin a caps 10000 unit F Limit 1 vitamin a tabs 10000 unit F estradiol vaginal crea 0.1 F package per mg/gm month;QL(1.5 vitamin e caps or 100 unit, F QL(2 ea daily) gm daily) 200 unit, 400 unit Limit 1 vitamin e soln or 15 F PREMARIN CREA VA F package per unit/0.3ml 0.625 MG/GM month;QL(1.5 gm daily) Water Soluble Vitamins VASOPRESSORS - Drugs to Treat Heart and ASCOCID POWD F Circulation Conditions ascorbic acid chew or Anaphylaxis Therapy Agents 500mg, 500 mg, 7.5mg- F 500mg epinephrine (anaphylaxis) F QL(4 ea per soaj 365 days retail) ASCORBIC ACID POWD F Vasopressors OR ascorbic acid tabs or 100 / 30 midodrine hcl tabs F 500mg, 1000mg, 250 mg, days;QL(100 500 mg, 1000 mg, 10mg- F ea per 34 days VITAMINS 500mg, 37mg-500mg, retail) 37mg-1000mg, 14mg- Oil Soluble Vitamins 25mg-500mg cholecalciferol caps 1000 F biotin caps or 5 mg, 5000 F unit, 2000 unit mcg cholecalciferol caps 5000 F QL(2 ea daily) unit niacin cpcr 250 mg, 500 mg F Limit 8 per niacin tabs 50 mg, 100 mg, cholecalciferol caps 50000 F month;QL(0.26 F unit 500 mg 7 ea daily) niacin tbcr 250 mg, 500 F cholecalciferol chew 400 F mg, 750 mg unit NIACIN TR TBCR F cholecalciferol liqd 400 F unit/ml pyridoxine hcl tabs or 25 mg, 50 mg, 100 mg, 250 F cholecalciferol tabs 400 F unit, 1000 unit mg

NV Silver Summit Updated September 1, 2018

137 Drug Requirements/ Drug Name Tier Limits 100 / 30 riboflavin tabs 50 mg, 100 F days;QL(100 mg ea per 34 days retail) SLO-NIACIN TBCR (Use NF Niacin) 100 / 30 thiamine hcl tabs or 50 mg, F days;QL(100 100 mg, 250 mg ea per 34 days retail) 100 / 30 thiamine mononitrate tabs F days;QL(100 100 mg ea per 34 days retail) VITAMIN C POWD F

VITAMIN C SYRP 500 F MG/5ML

NV Silver Summit Updated September 1, 2018

138 Index 1ST CHOICE LANCETS ACNE MEDICATION 10 45 ADVOCATE INSULIN SUPERTHIN 71 ACNE MEDICATION 5 45 SYRINGE/U- 1ST CHOICE LANCETS THIN 100/0.3ML/30GX5/16" 82 71 ACTHIB 135 ADVOCATE INSULIN 1ST CHOICE LANCETS ACTI-LANCE LANCETS SYRINGE/U- ULTRATHIN 71 28G 71 100/0.3ML/31GX5/16" 83 1ST TIER UNIFINE ACTI-LANCE LITE SAFETY ADVOCATE INSULIN PENTIPS/MINI/31GX5MM 82 LANCETS 28G 71 SYRINGE/U- 1ST TIER UNIFINE ACTI-LANCE SPECIAL 100/0.5ML/29GX1/2" 83 PENTIPS29GX12MM 82 SAFETY LANCETS 17G 72 ADVOCATE INSULIN 1ST TIER UNIFINE ACTI-LANCE UNIVERSAL SYRINGE/U- PENTIPS31GX6MM 82 SAFETY LANCETS 23G 72 100/0.5ML/30GX5/16" 83 1ST TIER UNIFINE ACTIGALL 59 ADVOCATE INSULIN PENTIPS31GX8MM 82 ACTIVELLA 57 SYRINGE/U- 1ST TIER UNIFINE ACTIVESSENTIALS 119 100/0.5ML/31GX5/16" 83 PENTIPS32GX4MM 82 ADVOCATE INSULIN 1ST TIER UNIFINE ACTONEL 56 SYRINGE/U-100/1ML/29GX1/2" PENTIPSPLUS 31GX8MM 82 ACTOPLUS MET 17 83 1ST TIER UNIFINE ACTOPLUS MET XR 17 ADVOCATE INSULIN PENTIPSPLUS 32GX4MM 82 SYRINGE/U-100/1ML/30GX5/16" 1ST TIER UNIFINE ACTOS 19 83 PENTIPSPLUS/MINI/31GX5MM ACULAR 128 ADVOCATE INSULIN 82 ACULAR LS 128 SYRINGE/U-100/1ML/31GX5/16" 1ST TIER UNIFINE acyclovir 37 83 PENTIPSPLUS/ORIGINAL/29GX ADVOCATE LANCING 12MM 82 acyclovir topical 48 DEVICE 72 1ST TIER UNIFINE ADACEL 133 ADVOCATE RAPID-SAFE PENTIPSPLUS/ULTRA ADALAT CC 38 LANCING DEVICE 72 SHORT/31GX6MM 82 ADDERALL 1 ADYNOVATE 60 1ST TIER UNILET AEROCHAMBER MINI COMFORTOUCH LANCETS ADDERALL XR 1 AEROSOLCHAMBER 112 28G 71 adefovir dipivoxil 37 AEROCHAMBER MV 112 1ST TIER UNILET ADJUSTABLE LANCING COMFORTOUCH LANCETS AEROCHAMBER PLUS FLOW DEVICE 72 VU 112 30G 71 ADLYXIN 19 4-N-1 51 AEROCHAMBER PLUS FLOW- ADLYXIN STARTER VU 112 abacavir sulfate 34 PACK 19 AEROCHAMBER PLUS FLOW- abacavir sulfate-lamivudine 34 ADMELOG 19 VU/LARGE MASK 112 abacavir sulfate-lamivudine- ADMELOG SOLOSTAR 19 AEROCHAMBER PLUS FLOW- VU/MASK 112 zidovudine 34 ADOXA 132 ABILIFY 34 AEROCHAMBER PLUS FLOW- ADOXA PAK 1/100 132 VU/MEDIUM MASK 112 acarbose 17 ADOXA PAK 2/100 132 AEROCHAMBER PLUS FLOW- ACCU-CHEK FASTCLIX VU/SMALL MASK 112 LANCETS 71 ADRENALIN 124 AEROCHAMBER Z-STAT PLUS ACCU-CHEK SOFTCLIX ADVATE 60 VALVED HOLDING CHAMBER LANCETS 71 ADVIL 3 W/FLOW VU 112 ACCUPRIL 25 ADVIL COLD & SINUS 43 AEROCHAMBER Z-STAT 112 ACCURETIC 26 ADVOCATE INSULIN PEN PLUS/FLOWSIGNAL acebutolol hcl 38 AEROCHAMBER Z-STAT NEEDLES 29GX12.7MM 82 PLUS/LARGE MASK 112 acetaminophen 4 ADVOCATE INSULIN PEN AEROCHAMBER Z-STAT NEEDLES 31GX5MM 82 112 acetaminophen w/ codeine 6 ADVOCATE INSULIN PEN PLUS/MEDIUM MASK acetaminophen w/ dm 43 AEROCHAMBER Z-STAT NEEDLES 31GX8MM 82 PLUS/SMALL MASK 112 acetazolamide 55 ADVOCATE INSULIN AEROCHAMBER/FLOWSIGNAL acetic acid (otic) 128 SYRINGE/U- 112 100/0.3ML/29GX1/2" 82 acetylcysteine 45 AEROSPAN 10

Index 1 AEROVENT PLUS HOLDING alum & mag hydrox- ANTI-STICK INSULIN CHAMBER/COLLAPSIBLE 112 simethicone 7 SYRINGE/U-100/0.5ML/28G X AFINITOR 30 ALUMINUM HYDROXIDE 7 1/2" 83 AFINITOR DISPERZ 30 amantadine hcl 31 ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/29G X AFREZZA 19 AMARYL 21 1/2" 83 AFSTYLA 60 AMBIEN 63 ANTI-STICK INSULIN AGAMATRIX ULTRA-THIN AMD FOAM DRESSING SYRINGE/U-100/1ML/29G X LANCETS 33G 72 4"X4" 66 1/2" 83 AGRYLIN 61 AMD FOAM ANTIOXIDANT FORMULA AIMSCO LUBRICATED 70 DRESSING/TOPSHEET SG 119 4"X4" 66 ANUSOL-HC 7 AIRBORNE 119 AMERGE 114 APEXICON E 48 albuterol sulfate 10 AMICAR 62 APIDRA 19 ALBUTEROL SULFATE ER 10 amiloride & APIDRA SOLOSTAR 19 ALCOHOL PREP PADS 81 hydrochlorothiazide 56 APLENZIN 14 amiloride hcl 56 ALCOHOL PREPS 81 APLICARE ALCOHOL ALCOHOL SWABS 81 amiodarone hcl 10 SWABSTICK 81 ALCOHOL SWABSTICK 81 amitriptyline hcl 16 apraclonidine hcl 126 ALCOHOL WIPES 81 amlodipine besylate 38 APTIOM 12 ALDACTAZIDE 56 amlodipine besylate-benazepril APTIVUS 34 hcl 26 ALDACTONE 56 AQUA LANCE ADJUSTABLE amlodipine besylate-olmesartan LANCING DEVICE 72 ALDARA 50 medoxomil 26 AQUAPHILIC 50 ALENDRONATE SODIUM 56 amlodipine besylate- AQUAPHOR 50 alendronate sodium 56 valsartan 26 amlodipine-valsartan- AQUAPHOR ADVANCED ALENDRONATE SODIUM 56 hydrochlorothiazide 26 THERAPY 50 alendronate sodium 56 AMOXAPINE 16 AQUORAL 118 ALEVE 3 amoxicillin 129 ARANESP ALBUMIN FREE 61 ALEVE ARTHRITIS 3 AMOXICILLIN 129 ARGININE 125 ALKERAN 28 amoxicillin 129 arginine 125 ALLEGRA ALLERGY 23 amoxicillin & pot ARIAL CHAMBER 112 ALLEVYN PLUS CAVITY 66 clavulanate 129 AMOXICILLIN/CLAVULANATE ARICEPT 130 ALLEVYN THIN 66 POTASSIUM 129 ARIMIDEX 29 allopurinol 60 amphetamine- aripiprazole 34 ALOCRIL 128 dextroamphetamine 1 ARISTADA 34 ampicillin 129 alogliptin benzoate 19 armodafinil 1 AMPICILLIN 129 alogliptin-metformin hcl 17 ARMOUR THYROID 132 AMPYRA 131 alogliptin-pioglitazone 17 AROMASIN 29 ALOMIDE 128 AMYTAL SODIUM 62 ARTHRITIS PAIN ALORA 58 ANAFRANIL 16 RELIEVING 51 ALPHANATE/VON anagrelide hcl 61 artificial tear ointment 125 WILLEBRANDFACTOR ANAPROX DS 3 artificial tear solution 125 COMPLEX/HUMAN 60 ANASPAZ 133 ASACOL HD 59 ALPHANINE SD 60 anastrozole 29 ASCOCID 137 alprazolam 9 ANDRODERM 6 ascorbic acid 137 ALPROLIX 60 ANDROXY 6 ASCORBIC ACID 137 ALTACE 25 ANORO ELLIPTA 10 ascorbic acid 137 ALTERNATE SITE LANCING DEVICE 72 ANTABUSE 130 aspirin 4 ANTHELIOS 60 MELT-IN ASPIRIN 4 SUNSCREEN 52

Index 2 aspirin 4,5 AUGMENTIN ES-600 129 AVEENO POSITIVELY aspirin buffered (cal carb-mag AUGMENTIN XR 130 RADIANTTINTED carb-mag oxide) 4 MOISTURIZER SPF30 AURORA LANCET SUPER MEDIUM 52 ASSURE COMFORT LANCETS THIN30G 72 ULTRA THIN 28G 72 AVEENO PROTECT + AURORA LANCET THIN HYDRATESPF 50 52 ASSURE HAEMOLANCE PLUS 23G 72 HIGH FLOW 18G 72 AVEENO PROTECT + AURORA PEN NEEDLES HYDRATESPF 70 52 ASSURE HAEMOLANCE PLUS 29GX12MM 83 LOW FLOW 25G 72 AVEENO SMART ESSENTIALS AURORA PEN NEEDLES 31G DAILY NOURISHING ASSURE HAEMOLANCE PLUS X6MM 83 MICRO FLOW 28G 72 MOISTURIZER SPF30 52 AURORA PEN NEEDLES 31G AVEENO ULTRA-CALMING ASSURE HAEMOLANCE PLUS X8MM 83 NORMAL FLOW 21G 72 AURORA UNIFINE DAILY MOISTURIZER ASSURE HAEMOLANCE PLUS PENTIPS/32GX5/32" 83 SPF15 52 PEDIATRIC BLADE 72 AURORA UNIFINE AVEENO ULTRA-CALMING ASSURE ID INSULIN PENTIPS/MINI/31GX3/16" DAILY MOISTURIZER SAFETYSYRINGE/U- 83 SPF30 52 100/0.5ML/29G X 1/2" 83 AUTO-LANCET 72 AVONEX 131 ASSURE ID INSULIN AVONEX PEN 131 SAFETYSYRINGE/U- AUTO-LANCET MINI 72 100/1ML/29G X 1/2" 83 AUTOLET IMPRESSION AYGESTIN 130 ASSURE ID SAFETY PEN LANCING DEVICE 72 AZASAN 117 NEEDLES 30G X 5/16" 83 AUTOLET LANCING azathioprine 117 DEVICE 72 ASSURE ID SAFETY PEN azelastine hcl 124 NEEDLES 31G X 3/16" 83 AUTOLET MINI 72 azelastine hcl (ophth) 128 ASSURE LANCE LANCETS 72 AUTOLET PLUS 72 AZITHROMYCIN 65 ASSURE LANCE LANCETS AUTOPEN 83 21G 72 azithromycin 65 AVALIDE 26 ASSURE LANCE PLUS AZOPT 128 SAFETYLANCETS 25G 72 AVANDIA 19 AZOR 26 ASSURE LANCE PLUS AVAPRO 25 SAFETYLANCETS 30G 72 AVEENO ABSOLUTELY AZULFIDINE 59 ASTEPRO 124 AGELESSLEAVE-ON DAY AZULFIDINE EN-TABS 59 AT LAST LANCETS 72 MASK SPF 30 52 b-complex vitamins 119 ATACAND 25 AVEENO ACTIVE NATURALS b-complex w/ c & folic acid 119 PROTECT+HYDRATE/SPF B-D INSULIN SYRINGE ATACAND HCT 26 30 52 atazanavir sulfate 34 AVEENO BABY CONTINUOUS ULTRAFINE II/0.3ML/31G X 5/16" 83 ATELVIA 56 PROTECTION 52 AVEENO BABY CONTINUOUS B-D INSULIN SYRINGE atenolol 38 PROTECTION SUNBLOCK ULTRAFINE II/0.5ML/31G X atenolol & chlorthalidone 26 SPF55 52 5/16" 83 AVEENO BABY NATURAL B-D INSULIN SYRINGE ATIVAN 9 ULTRAFINE II/1ML/31G X ATLAS COLORED PROTECTION SPF 50 52 AVEENO NATURAL 5/16" 83 LUBRICATEDCONDOM 70 B-D INSULIN SYRINGE ATLAS LUBRICATED PROTECTIONSPF 50 52 AVEENO POSITIVELY ULTRAFINE/0.3ML/30G X CONDOM 70 1/2" 83 ATLAS LUBRICATED RADIANTDAILY MOISTURIZER SPF15 52 B-D INSULIN SYRINGE CONDOM/SPERMICIDE 70 ULTRAFINE/0.5ML/30G X atomoxetine hcl 1 AVEENO POSITIVELY RADIANTDAILY 1/2" 83 atorvastatin calcium 24 MOISTURIZER SPF30 52 BACIGUENT 46 ATRIPLA 34 AVEENO POSITIVELY bacitracin (topical) 46 ATROPINE SULFATE 126 RADIANTTINTED bacitracin zinc 46 ATROVENT HFA 10 MOISTURIZER SPF30 FAIR/LIGHT 52 bacitracin-polymyxin b 46 AUBAGIO 131 bacitracin-polymyxin b AUGMENTIN 129,130 (ophth) 126

Index 3 baclofen 123 BD INSULIN SYRINGE BD INSULIN SYRINGE BACTRIM 8 SAFETYGLIDE/U- ULTRAFINE/U-100/1ML/29G X 100/0.3ML/31G X 5/16" 84 1/2" 84 BACTRIM DS 8 BD INSULIN SYRINGE BD INSULIN SYRINGE BACTROBAN 46 SAFETYGLIDE/U- ULTRAFINE/U-100/1ML/30G X BACTROBAN NASAL 124 100/1ML/31G X 15/64" 84 1/2" 84 BD INSULIN SYRINGE U- BD INSULIN SYRINGE balsalazide disodium 59 100/0.3ML/29G X 1/2" 84 ULTRAFINE/U-100/1ML/31G X BAND-AID GAUZE PADS BD INSULIN SYRINGE U- 15/64" 85 LARGE4" X 4" 66 100/1ML/29G X 1/2" 84 BD INSULIN SYRINGE BAND-AID GAUZE PADS BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X MEDIUM 3" X 3" 66 ULTRAFINE HALF- 5/16" 85 BAND-AID GAUZE PADS UNIT/0.3ML/31G X 5/16" 84 BD INSULIN SMALL2" X 2" 66 BD INSULIN SYRINGE SYRINGE/DETACHABLE BAND-AID MIRASORB GAUZE ULTRAFINE NEEDLE/U-100/1ML/25G X SPONGES LARGE 4" X 4" 66 II/SHORT/0.5ML/31G X 1" 85 BANZEL 12 5/16" 84 BD INSULIN BARACLUDE 37 BD INSULIN SYRINGE SYRINGE/DETACHABLE BASAGLAR KWIKPEN 19 ULTRAFINE NEEDLE/U-100/1ML/25G X BAYER MICROLET 2 LANCING II/SHORT/1ML/31G X 5/8" 85 DEVICE 72 5/16" 84 BD INSULIN BAYER MICROLET BD INSULIN SYRINGE SYRINGE/DETACHABLE LANCETS 72 ULTRAFINE/0.3ML/30G X NEEDLE/U-100/1ML/26G X BD LO-DOSE INSULIN 1/2" 84 1/2" 85 SYRINGE MICROFINE BD INSULIN SYRINGE BD INSULIN SYRINGE/U- IV/0.5ML/28G X 1/2" 83 ULTRAFINE/0.3ML/31G X 100/0.5ML/30G X 1/2" 85 BD AUTOSHIELD 29G X 5/16" 84 BD INSULIN SYRINGE/U- 5/16" 83 BD INSULIN SYRINGE 100/1ML/27G X 1/2" 85 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X BD INSULIN SYRINGE/U- MICROFINE IV/U- 1/2" 84 100/1ML/28G X 1/2" 85 100/0.3ML/28G X 1/2" 83 BD INSULIN SYRINGE BD INTEGRA INSULIN BD INSULIN SYRINGE ULTRAFINE/0.5ML/31G X SYRINGE/U-100/1ML/29G X MICROFINE IV/U- 5/16" 84 1/2" 85 100/0.5ML/28G X 1/2" 83 BD INSULIN SYRINGE BD INTEGRA BD INSULIN SYRINGE ULTRAFINE/1ML/30G X SYRINGE/RETRACTING MICROFINE IV/U-100/1ML/27G 1/2" 84 NEEDLE/1ML/25G X 1" 85 X 5/8" 83 BD INSULIN SYRINGE BD LANCET DEVICE 72 BD INSULIN SYRINGE ULTRAFINE/1ML/31G X BD LANCET ULTRAFINE MICROFINE IV/U-100/1ML/28G 5/16" 84 30G 72 X 1/2" 84 BD INSULIN SYRINGE BD MICROTAINER BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/29G LANCETS 72 MICROFINE/U-100/0.3ML/28G X X 1/2" 84 BD PEN 85 BD INSULIN SYRINGE 1/2" 84 BD PEN MINI 85 BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/30G X 1/2" 84 BD PEN MICROFINE/U-100/0.5ML/28G X NEEDLE/MINI/ULTRAFINE/31G 1/2" 84 BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/31G X 3/16" 85 BD INSULIN SYRINGE BD PEN MICROFINE/U-100/1ML/27G X X 5/16" 84 BD INSULIN SYRINGE NEEDLE/NANO/ULTRAFINE/32 5/8" 84 G X 4MM 85 BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/29G X 1/2" 84 BD PEN MICROFINE/U-100/1ML/28G X NEEDLE/SHORT/ULTRAFINE/31 1/2" 84 BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/30G G X 5/16" 85 BD INSULIN SYRINGE BD PEN SAFETYGLIDE/0.5ML/29G X X 1/2" 84 BD INSULIN SYRINGE NEEDLE/ULTRAFINE/29G X 1/2" 84 12.7MM 85 BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/31G X 5/16" 84 BD PEN SAFETYGLIDE/1ML/29G X NEEDLE/ULTRAFINE/29GX1/2" 1/2" 84 12.7MM 85

Index 4 BD PEN NEEDLES bexarotene 30 BRILINTA 61 SHORT/ULTRAFINE/31G X BEXSERO 135 brimonidine tartrate 126 5/16" 85 BD SAFETY-GLIDE INSULIN BIATAIN ADHESIVE FOAM bromocriptine mesylate 31 SYRINGE/0.5ML/29G X 1/2" 85 DRESSING 4"X4" 66 brompheniramine & BD SAFETY-LOK INSULIN BIATAIN FOAM DRESSING phenyleph 43 SYRINGE/PERM 4"X4" 66 brompheniramine & NEEDLE/UF/1ML/29G X BIAXIN 65 pseudoeph 43 1/2" 85 bicalutamide 29 BROTAPP DM 43 BD SAFETYGLIDE INSULIN BIOGUARD GAUZE SPONGE budesonide (inhalation) 10 SYSYRINGE/0.5ML/30G X 2"X2" 8 PLY 66 BUFFERIN 5 5/16" 85 BIOGUARD GAUZE SPONGES 4"X4" 12 PLY 66 BULL FROG SUPERBLOCK BD SWABS SINGLE USE 81 SPF50 52 BD SWABS SINGLE USE BIOTENE DRY MOUTH MOISTURIZING SPRAY 118 BULL FROG ULTIMATE BUTTERFLY 81 SHEERPROTECTION FACE BD ULTRA-FINE MICRO PEN biotin 137 SUNBLOCK SPF 30 52 NEEDLES 6MM X 32G 85 BIOVOL 119 BULL FROG ULTIMATE BD VEO INSULIN SYRINGE bisacodyl 64 SHEERPROTECTION ULTRAFINE/U-100/1ML/31G X bismuth subsalicylate 21 SUNBLOCK SPF 30 52 15/64" 85 BULL FROG WATER ARMOR bisoprolol & BEBULIN 60 SPORT FACE SPF 30 52 hydrochlorothiazide 26 BENADRYL ALLERGY 23 BULLSEYE MINI SAFETY bisoprolol fumarate 38 BENADRYL ALLERGY LANCETS 72 CHILDRENS 23 BLEPH-10 126 BULLSEYE SAFETY benazepril & BLEPHAMIDE 127 LANCETS 72 hydrochlorothiazide 26 BLEPHAMIDE S.O.P. 127 bumetanide 56 benazepril hcl 25 BOOSTRIX 133 BUMEX 56 BENEFIX 60 BORDERED GAUZE 66 buprenorphine hcl 6 buprenorphine hcl-naloxone hcl BENICAR 25 BOSULIF 30 BENICAR HCT 26 dihydrate 6 BOUDREAUXS BABY BUTT bupropion hcl 14 BENTYL 133 SMOOTH DRY SKIN 50 bupropion hcl (smoking BENZAC AC WASH 45 BREATHERITE 112 deterrent) 131 benzonatate 43 BREATHERITE buspirone hcl 9 COLLAPSIBLEADULT benzoyl peroxide 45 SPACER W/MASK 112 butalbital-acetaminophen 4 BENZOYL PEROXIDE 45 BREATHERITE butalbital-acetaminophen- benzoyl peroxide 45,46 COLLAPSIBLECHILD SPACER caffeine 4 BENZOYL PEROXIDE W/MASK 112 butalbital-acetaminophen- CLEANSER 45 BREATHERITE caffeine w/ codeine 6 benztropine mesylate 31 COLLAPSIBLEINFANT butalbital-aspirin-caffeine 4 SPACER W/MASK 112 butalbital-aspirin-caffeine BETADINE 34 BREATHERITE w/cod 6 BETAGAN 125 COLLAPSIBLESMALL CHILD BUTISOL SODIUM 62 betamethasone dipropionate SPACER W/MASK 112 BYDUREON 19 (topical) 48 BREATHERITE betamethasone dipropionate COLLAPSIBLESPACER W/ BYDUREON PEN 19 augmented 48 NEONATE MASK 112 BYETTA 19 betamethasone valerate 48 BREATHERITE RIGID C-BUFF 119 BETAPACE 38 SPACERW/MASK 112 BREATHERITE W/LARGE caffeine citrate 1 BETAPACE AF 38 MASK 113 CALAN 38 BETASERON 131 BREATHERITE W/MEDIUM CALAN SR 38 betaxolol hcl (ophth) 125 MASK 113 BREATHERITE W/SMALL CALCI-CHEW 115 bethanechol chloride 135 MASK 113 calcipotriene 48 BETHKIS 2 BREVICON-28 40 calcitonin (salmon) 56

Index 5 calcitriol 57 CAREONE ADVANCED CARETOUCH PEN NEEDLES CALCIUM 116 LANCINGDEVICE 72 32GX 4MM 86 CAREONE INSULIN CARETOUCH PEN NEEDLES calcium acetate (phosphate SYRINGES/0.3ML/30G X 32GX 5MM 86 binder) 59 1/2" 86 CARETOUCH TWIST LANCETS calcium carbonate 115 CAREONE INSULIN 30G 72 calcium carbonate (antacid) 7 SYRINGES/0.3ML/31G X CARNITOR 57 calcium carbonate- 5/16" 86 CARNITOR SF 57 cholecalciferol 115 CAREONE INSULIN calcium carbonate-vitamin SYRINGES/0.5ML/30G X CARRASMART 66 d 116 1/2" 86 CARRASMART FOAM 66 calcium citrate 116 CAREONE INSULIN CARTEOLOL HCL 125 calcium polycarbophil 63 SYRINGES/0.5ML/31G X carteolol hcl (ophth) 125 5/16" 86 calcium w/ vitamin d 116 CAREONE INSULIN carvedilol 37 CALTRATE 600+D 116 SYRINGES/1ML/30G X carvedilol phosphate 37 camphor & menthol 48 1/2" 86 CASODEX 29 CAREONE INSULIN candesartan cilexetil 25 SYRINGES/1ML/31GX5/16" CATAPRES 26 candesartan cilexetil- 86 CATAPRES-TTS-1 26 hydrochlorothiazide 26 CAREONE LANCET THIN 72 CATAPRES-TTS-2 26 capecitabine 28 CAREONE LANCET ULTRA CATAPRES-TTS-3 26 CAPHOSOL 118 THIN 72 cefaclor 40 capsaicin 51 CAREONE UNIFINE PENTIPS CEFACLOR 40 captopril 25 29GX12MM 86 CAREONE UNIFINE PENTIPS cefadroxil 40 CAPTOPRIL/HYDROCHLOROT 31GX5MM 86 cefdinir 40 HIAZIDE 26 CAREONE UNIFINE PENTIPS CAPZASIN-HP 51 31GX6MM 86 cefprozil 40 CARAC 47 CAREONE UNIFINE PENTIPS CEFTIN 40 CARAFATE 134 31GX8MM 86 ceftriaxone sodium 40 CAREONE UNIFINE PENTIPS cefuroxime axetil 40 carbamazepine 12 PEN NEEDLES 32GX4MM86 carbamide peroxide (otic) 128 CAREONE UNIFINE PENTIPS CELEBREX 3 CARBATROL 12 PLUS PEN NEEDLES celecoxib 3 carbidopa 30 29GX12MM 86 CELEXA 15 CAREONE UNIFINE PENTIPS carbidopa-levodopa 31 PLUS PEN NEEDLES CELLCEPT 117 CARDIOCOM LANCING 31GX5MM 86 CELLCEPT DEVICE 72 CAREONE UNIFINE PENTIPS INTRAVENOUS 117 CARDIZEM 38 PLUS PEN NEEDLES CELONTIN 14 CARDIZEM CD 38 31GX6MM 86 CENTANY 46 CAREONE UNIFINE PENTIPS CENTRUM MULTIVITAMIN CARDURA 26 PLUS PEN NEEDLES CAREFINE PEN NEEDLE FLAVOR BURST DRINK 119 31GX8MM 86 cephalexin 40 32GX4MM 85 CAREONE UNIFINE PENTIPS CAREFINE PEN NEEDLES PLUS PEN NEEDLES CERASPORT 116 29GX1/2" 85 32GX4MM 86 CERASPORT EX1 116 CAREFINE PEN NEEDLES CARETOUCH ALCOHOL CERAVE SUNSCREEN 30GX5/16" 85 PREP PADS 81 FACE/SPF50 52 CAREFINE PEN NEEDLES CARETOUCH LANCING CERAVE 31GX6MM 85 DEVICEWITH EJECTOR 72 SUNSCREEN/BODY 53 CAREFINE PEN NEEDLES CARETOUCH PEN NEEDLES CERAVE 31GX8MM 85 31G X 6 MM 86 SUNSCREEN/FACE 53 CAREFINE PEN NEEDLES CARETOUCH PEN NEEDLES CERDELGA 61 32GX5MM 85 31GX 5MM 86 CAREFINE PEN NEEDLES CARETOUCH PEN NEEDLES CEREZYME 61 32GX6MM 86 31GX 8MM 86 cetirizine hcl 23 cetirizine-pseudoephedrine 43

Index 6 CHANTAL SUN SCREEN SPF CLARITIN ALLERGY CLEVER CHOICE COMFORT 30 53 CHILDRENS 23 EZINSULIN CHANTIX 131 CLARITIN REDITABS 23 SYRINGE/0.5ML/29G X 1/2" 87 CHANTIX CONTINUING CLARITIN-D 12 HOUR 43 CLEVER CHOICE COMFORT EZINSULIN MONTHPAK 131 CLARITIN-D 24 HOUR 43 CHANTIX STARTING MONTH SYRINGE/0.5ML/30G X 1/2" 87 PAK 131 CLASS ACT CLEVER CHOICE COMFORT CHEK-STIX COMBO PAK LUBRICATED 70 EZINSULIN URINALYSIS CONTROL 54 CLASSIC PRENATAL 121 SYRINGE/0.5ML/30G X CHEK-STIX CONTROL 54 CLEAN & CLEAR 5/16" 87 ADVANTAGE 3-IN-1 CLEVER CHOICE COMFORT CHEMET 21 EXFOLIATING EZINSULIN CHEMSTRIP-K 54 CLEANSER 46 SYRINGE/0.5ML/31G X CHERACOL PLUS 43 CLEANLET LANCETS 5/16" 87 CHERACOL-D COUGH 43 28G 73 CLEVER CHOICE COMFORT CLEAR COUGH PM MULTI- EZINSULIN CHILDRENS ADVIL 3 SYMPTOM 43 SYRINGE/1.0ML/30G X 1/2" 87 CHILDRENS MOTRIN 3 clemastine fumarate 23 CLEVER CHOICE COMFORT CHLOR-TRIMETON 22,23 CLEOCIN 8,136 EZINSULIN SYRINGE/1ML/28G X 1/2" 87 chlordiazepoxide hcl 9 CLEOCIN PEDIATRIC CLEVER CHOICE COMFORT chlorhexidine gluconate 34 GRANULES 8 EZINSULIN SYRINGE/1ML/29G chlorhexidine gluconate (mouth- CLEOCIN-T 46 X 1/2" 87 throat) 118 CLEVER CHOICE ANTI- CLEVER CHOICE COMFORT CHLOROQUINE STATICVALVED HOLDING EZINSULIN SYRINGE/1ML/30G PHOSPHATE 28 CHAMBER/ADULT X 5/16" 87 chloroquine phosphate 28 LARGE 113 CLEVER CHOICE COMFORT CHLOROTHIAZIDE 56 CLEVER CHOICE ANTI- EZINSULIN SYRINGE/U- STATICVALVED HOLDING 100/1ML/31GX5/16" 87 chlorothiazide 56 CHAMBER/MEDIUM 113 CLEVER CHOICE COMFORT chlorpheniramine maleate 23 CLEVER CHOICE ANTI- EZPEN NEEDLES CHLORPROMAZINE HCL 33 STATICVALVED HOLDING 29GX12MM 87 CHAMBER/SMALL 113 chlorpromazine hcl 33 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT EZPEN NEEDLES CHLORPROPAMIDE 21 EZINSULIN PEN NEEDLES 31GX5MM 87 chlorthalidone 56 31GX8MM 86 CLEVER CHOICE COMFORT CHLORZOXAZONE 123 CLEVER CHOICE COMFORT EZPEN NEEDLES EZINSULIN 31GX6MM 87 CHOLBAM 59 SYRINGE/0.3ML/29G X CLEVER CHOICE COMFORT cholecalciferol 137 1/2" 86 EZPEN NEEDLES cholestyramine 24 CLEVER CHOICE COMFORT 31GX8MM 87 cholestyramine light 24 EZINSULIN CLEVER CHOICE COMFORT SYRINGE/0.3ML/30G X EZPEN NEEDLES choline & mag salicylate 5 1/2" 86 32GX4MM 87 cilostazol 61 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT cimetidine 133 EZINSULIN EZPEN NEEDLES SYRINGE/0.3ML/30G X CIMETIDINE HCL 133 32GX5MM 87 5/16" 86 CLEVER CHOICE COMFORT CIPRO 58 CLEVER CHOICE COMFORT EZPEN NEEDLES CIPRODEX 128 EZINSULIN 32GX6MM 87 CIPROFLOXACIN HCL 58 SYRINGE/0.3ML/31G X CLICKFINE PEN NEEDLE 5/16" 86 32GX5/32" 87 ciprofloxacin hcl 58 CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLE citalopram hydrobromide 15 EZINSULIN UNIVERSAL/31GX1/4" 87 clarithromycin 65 SYRINGE/0.5ML/28G X CLICKFINE PEN NEEDLE CLARITHROMYCIN 65 1/2" 86 UNIVERSAL/31GX5/16" 87 CLICKFINE PEN clarithromycin 65 NEEDLES/31GX1/4" 87 CLARITIN 23

Index 7 CLICKFINE PEN COMFORT ASSIST INSULIN CORTENEMA 7 NEEDLES/31GX5/16" 87 SYRINGE/0.3ML/31G X CORTISONE ACETATE 42 CLICKFINE UNIVERSAL PEN 5/16" 87 NEEDLES 31GX5/16" 87 COMFORT ASSIST INSULIN CORVITE 119 CLIMARA 58 SYRINGE/0.5ML/29G X COSOPT 125 clindamycin hcl 8 1/2" 87 COTELLIC 30 COMFORT ASSIST INSULIN clindamycin palmitate SYRINGE/0.5ML/30G X COTZ 53 hydrochloride 8 COUMADIN 11 clindamycin phosphate 5/16" 88 COMFORT ASSIST INSULIN COVRSITE COVER (topical) 46 SYRINGE/0.5ML/31G X DRESSING 66 clindamycin phosphate COVRSITE PLUS COMPOSITE vaginal 136 5/16" 88 COMFORT ASSIST INSULIN DRESSING 66 clobetasol propionate 48 SYRINGE/1ML/29G X 1/2" 88 COZAAR 25 clobetasol propionate emollient COMFORT ASSIST INSULIN CREON 55 base 48 SYRINGE/1ML/30G X clomipramine hcl 16 5/16" 88 CRESTOR 24 clonazepam 12 COMFORT ASSIST INSULIN CRIXIVAN 35 clonidine hcl 26 SYRINGE/1ML/31G X cromolyn sodium 10 5/16" 88 cromolyn sodium (nasal) 124 clopidogrel bisulfate 61 COMFORT ASSURED clorazepate dipotassium 9 LANCETS MICRO THIN cromolyn sodium (ophth) 128 CLOSERCARE 73 33G 73 crotamiton 51 COMFORT ASSURED clotrimazole (topical) 47 CUREX ALL-PURPOSE LANCETS SUPER THIN SPONGES 4"X4" 4 PLY 66 clotrimazole vaginal 136 28G 73 CURITY ALCOHOL clotrimazole w/ COMFORT LANCETS 73 PREPS/MEDIUM 2 PLY 81 betamethasone 47 COMPACT SPACE CURITY ALCOHOL SWABS 81 clozapine 33 CHAMBER/ANTI-STATIC CURITY ALL PURPOSE CLOZAPINE ODT 33 113 SPONGES 2"X2" 66 CLOZARIL 33 COMPACT SPACE CURITY ALL PURPOSE CHAMBER/ANTI- SPONGES 2"X2" 4PLY 66 coal tar extract 54 STATIC/LARGE MASK 113 CURITY ALL PURPOSE COARTEM 28 COMPACT SPACE SPONGES 3"X3" 4PLY 66 codeine sulfate 5 CHAMBER/ANTI- CURITY ALL PURPOSE CODEINE SULFATE 5 STATIC/MEDIUM MASK 113 SPONGES 4 PLY 66 COMPACT SPACE CURITY ALL PURPOSE COGENTIN 31 CHAMBER/ANTI- SPONGES 4"X4" 66 COLACE 64 STATIC/SMALL MASK 113 CURITY ALL PURPOSE COLAZAL 59 COMPLERA 35 SPONGES 4"X4" 4PLY 66 CURITY ALL PURPOSE COLCHICINE 60 CONCEPTIONXR MOTILITY SUPPORT FORMULA 119 SPONGES 4"X4" 4PLY/SOFT colchicine w/ probenecid 60 CONCERTA 1 POUCH 66 COLCRYS 60 CURITY AMD CONDYLOX 51 COLESTID 24 ANTIMICROBIALGAUZE COOL BOTTOMS 51 SPONGES 2"X2" 8 PLY 66 COLESTID FLAVORED 24 COPA ISLAND BORDERED CURITY AMD colestipol hcl 24 FOAM DRESSING 4"X4" 66 ANTIMICROBIALGAUZE COLYTE-FLAVOR PACKS 63 COPA PLUS HYDROPHILIC SPONGES 4"X4" 12 PLY 66 CURITY COVER SPONGE COMBIPATCH 57 FOAM DRESSING 4"X4" 66 COPAXONE 131 4"X4" 66 COMBIVENT RESPIMAT 10 CURITY COVER SPONGES COREG 37 COMBIVIR 34 3"X3" 66 COMFORT ASSIST INSULIN COREG CR 37 CURITY COVER SPONGES SYRINGE 0.3ML/29G X 1/2" 87 CORGARD 38 4"X4" 66 COMFORT ASSIST INSULIN CORIFACT 60 CURITY DRESSING SPONGES 4"X4" 6 PLY 66 SYRINGE/0.3ML/30G X CORTANE-B-OTIC 128 5/16" 87 CURITY GAUZE PADS CORTEF 42 2"X2" 67

Index 8 CURITY GAUZE PADS 2"X2" 12 CVS OMEPRAZOLE 134 DEPAKOTE ER 14 PLY 67 CVS PRENATAL 121 DEPAKOTE SPRINKLES 14 CURITY GAUZE PADS 3"X3" 67 CVS PRENATAL DEPEN TITRATABS 117 CURITY GAUZE PADS 4"X4" 12 GUMMY/DHA/FOLIC DEPLIN 15 55 PLY 67 ACID 121 CVS PREP PADS 81 DEPLIN 7.5 55 CURITY GAUZE SPONGE 2"X2" DEPO-PROVERA 8 PLY 67 CVS ULTRA THIN LANCETS 73 CONTRACEPTIVE 42 CURITY GAUZE SPONGE DEPO-SUBQ PROVERA 2"X2"12 PLY 67 cyanocobalamin 61 104 42 CURITY GAUZE SPONGE 3"X3" CYCLESSA 40 12 PLY 67 DEPO-TESTOSTERONE 6 CURITY GAUZE SPONGE 4"X4" cyclobenzaprine hcl 123 DERMACEA DRAIN SPONGES 12 PLY 67 CYCLOGYL 126 4"X4" 67 CURITY GAUZE SPONGE 4"X4" cyclopentolate hcl 126 DERMACEA GAUZE SPONGE 16 PLY 67 2"X2" 12 PLY 67 CURITY GAUZE SPONGE 4"X4" cyclophosphamide 28 DERMACEA GAUZE SPONGE 8 PLY 67 CYCLOPHOSPHAMIDE 28 2"X2" 8 PLY 67 CURITY GAUZE SPONGE cyclosporine 117 DERMACEA GAUZE SPONGE 4"X4"16 PLY 67 CYCLOSPORINE 3"X3" 12 PLY 67 DERMACEA GAUZE SPONGE CURITY GAUZE SPONGES MODIFIED 117 4"X4" 12 PLY 67 3"X3" 8 PLY 67 cyclosporine modified (for DERMACEA GAUZE SPONGE CURITY GAUZE SPONGES microemulsion) 117 4"X4" 12 PLY 67 4"X4" 8 PLY 67 CYMBALTA 16 CURITY NON-ADHERENT DERMACEA GAUZE SPONGE STRIPS 3"X3" 67 cyproheptadine hcl 24 4"X4" 16 PLY 67 CURITY CYTOMEL 132 DERMACEA GAUZE SPONGE SPONGES/CELLULOSEFILLED/ CYTOTEC 134 4"X4" 8 PLY 67 2"X2" 67 DERMACEA I.V. DRAIN CURITY D-VI-SOL 137 SPONGES 2"X2" 67 SPONGES/CELLULOSEFILLED/ D.H.E. 45 114 DERMACEA I.V. DRAIN 4"X4" 67 DAILY CONDITIONING SPONGES 4"X4" 67 CVS ALCOHOL PREP TREATMENT 50 DERMACEA I.V. SPONGES SWABS 81 DAILY HEART HEALTH 2"X2" 67 CVS DIABETES HEALTH SUPPORT 119 DERMACEA NON-WOVEN SUPPORT 119 DAILY PAK MAXIMUM SPONGES 2"X2" 4 PLY 67 CVS DRY MOUTH SPRAY 118 MULTIVITAMIN/ASIAN DERMACEA NON-WOVEN SPONGES 3"X3" 4 PLY 67 CVS GAUZE PAD 3"X3" 67 GINSENG EXTRACT 119 dakin's solution 34 DERMACEA NON-WOVEN CVS GAUZE PADS 2"X2" 12- SPONGES 4"X4" 4 PLY 67 PLY 67 DAKINS SOLUTION DERMACEA NON-WOVEN CVS GAUZE PADS 4"X4" 12- QUARTER STRENGTH 34 SPONGES 4"X4" 6 PLY 67 PLY 67 DALIRESP 10 DERMACEA TYPE VII GAUZE CVS GAUZE PADS STERILE dapsone 8 2"X2" 12 PLY 67 4"X4" 12-PLY 67 DAY TIME MULTI-SYMPTOM DERMACEA TYPE VII GAUZE CVS GLUCOSE 18 COLD/FLU RELIEF 43 2"X2" 8 PLY 67 CVS LANCETS 21G 73 DAYPRO 3 DERMACEA TYPE VII GAUZE 3"X3" 12 PLY 68 CVS LANCETS MICRO THIN DDAVP 57 DERMACEA TYPE VII GAUZE 33G 73 DEBROX 128 3"X3" 12PLY 68 CVS LANCETS MICRO-THIN DERMACEA TYPE VII GAUZE 33G 73 DELSYM 43 4"X4" 12 PLY 68 CVS LANCETS ORIGINAL 73 DELSYM COUGH CHILDRENS 43 DERMACEA TYPE VII GAUZE CVS LANCETS THIN 26G 73 DEMADEX 56 4"X4" 16 PLY 68 CVS LANCETS ULTRA THIN DERMACEA TYPE VII GAUZE 30G 73 DEMEROL 5 4"X4" 8 PLY 68 CVS LANCETS ULTRA-THIN DEPACON 14 DERMACEA X-RAY SPONGES 30G 73 DEPAKENE 14 4"X4" 16 PLY 68 CVS LANCING DEVICE 73 DERMALEVIN ADHESIVE DEPAKOTE 14 FOAMDRESSING 4"X4" 68

Index 9 DERMATOP 49 DIABETIDERM SUNSCREEN dipyridamole 61 DERMOTIC 129 SPF15 53 DISALCID 5 DIAMOX 55 DESCOVY 35 disopyramide phosphate 9 diaper rash products 50 desipramine hcl 16 disulfiram 130 DIASTAT ACUDIAL 12 desmopressin acetate 57 DITROPAN XL 135 DIASTAT PEDIATRIC 12 desmopressin acetate spray 57 divalproex sodium 14 DIAZEPAM 9 desmopressin acetate spray docusate calcium 64 diazepam 9 refrigerated 57 docusate sodium 64,65 DESOGEN 40 DIAZEPAM 12 dofetilide 10 desogestrel & ethinyl DIAZEPAM RECTAL GEL 12 DOLOPHINE 5 estradiol 40 dibucaine 51 desogestrel-ethinyl estradiol donepezil hydrochloride 130 diclofenac potassium 3 (biphasic) 40 dorzolamide hcl 128 desogestrel-ethinyl estradiol diclofenac sodium 3 DORZOLAMIDE HCL 128 (triphasic) 40 diclofenac sodium (ophth)128 desonide 49 dorzolamide hcl-timolol dicloxacillin sodium 130 maleate 125 DESOWEN 49 dicyclomine hcl 133 DORZOLAMIDE HCL/TIMOLOL desoximetasone 49 didanosine 35 MALEATE 125 DESQUAM-X WASH 46 DIFLORASONE DOVONEX 48 DESVENLAFAXINE ER 16 DIACETATE 49 doxazosin mesylate 26 desvenlafaxine succinate 16 diflorasone diacetate 49 doxepin hcl 17 DETROL 135 DIFLUCAN 22 doxycycline (monohydrate) 132 DETROL LA 135 diflunisal 5 doxycycline hyclate 132 DEX4 QUICK DISSOLVE DIGOXIN 39 doxylamine succinate GLUCOSE 18 digoxin 39 (sleep) 62 dexamethasone 42 dihydroergotamine DRAMAMINE 22 DEXAMETHASONE 42 mesylate 114 DRISDOL 137 dexamethasone 42 DIHYDROERGOTAMINE droperidol 9 MESYLATE 114 DEXAMETHASONE 42 DROPLET LANCETS ULTRA DILANTIN 13 DEXAMETHASONE THIN 30G 73 INTENSOL 42 DILANTIN INFATABS 13 DROPLET LANCING dexamethasone sodium DILANTIN-125 13 DEVICE 73 DROPLET PEN NEEDLES phosphate 42 DILAUDID 5 DEXAMETHASONE SODIUM 29GX12MM 88 PHOSPHATE 127 diltiazem hcl 39 DROPLET PEN NEEDLES diltiazem hcl coated beads 39 31GX5MM 88 DEXEDRINE 1 DROPLET PEN NEEDLES dexmethylphenidate hcl 1 diltiazem hcl extended release beads 39 31GX6MM 88 DROPLET PEN NEEDLES dextroamphetamine sulfate 1 dimenhydrinate 22 dextromethorphan polistirex 43 31GX8MM 88 DIMETAPP COLD & DROPLET PEN NEEDLES 32G dextromethorphan-doxylamine- ALLERGY 44 X 1/4" 88 acetaminophen 44 DIOVAN 25 DROPLET PEN NEEDLES 32G dextromethorphan-guaifenesin X 3/16" 88 44 DIOVAN HCT 26 diphenhydramine hcl 23 DROPLET PEN NEEDLES 32G dextromethorphan- X 5/32" 88 phenylephrine-acetaminophen diphenhydramine hcl DROPLET PEN NEEDLES 44 (sleep) 62 32GX4MM 88 dextrose (diabetic use) 18 diphenhydramine hcl DROPLET PEN NEEDLES DHS TAR 54 (topical) 47 32GX5MM 88 diphenoxylate w/ atropine 21 DHS TAR GEL 54 DROPLET PEN NEEDLES DIPHENOXYLATE/ATROPINE 32GX6MM 88 DIABETES HEALTH PACK 119 21 DROPSAFE SAFETY PEN DIABETES SUPPORT DIPROLENE AF 49 NEEDLES/31G X 5/16" 88 PACK 119

Index 10 DROPSAFE SAFTEY PEN E-Z JECT LANCETS SUPER EASY TOUCH FLIPLOCK NEEDLES/31G X 1/4" 88 THIN 30G 73 SAFETY INSULIN SYRINGE drospirenone-ethinyl E-Z JECT LANCETS THIN 1ML/30GX1/2" 89 estradiol 40 26G 73 EASY TOUCH FLIPLOCK DROXIA 61 E-Z SPACER 113 SAFETY INSULIN SYRINGE DRUG MART ADJUSTABLE E-Z SPACER THE BODY 1ML/30GX5/16" 89 LANCING DEVICE 73 GUARDS PACK 113 EASY TOUCH FLIPLOCK DRUG MART LANCETS E-ZJECT LANCETS MICRO- SAFETY INSULIN SYRINGE THIN 73 THIN 33G 73 1ML/31GX5/16" 89 DRUG MART ON-THE-GO E.E.S. 400 65 EASY TOUCH INSULIN SYRINGE/0.3ML/30G X LANCETS GENTLE 30G 73 E.E.S. GRANULES 65 DRUG MART UNIFINE PENTIPS 5/16" 89 31GX5MM 88 EASIVENT 113 EASY TOUCH INSULIN DRUG MART UNIFINE EASIVENT/MASK-LARGE SYRINGE/0.3ML/31G X PENTIPS29G X 12MM 88 113 5/16" 89 DRUG MART UNIFINE EASIVENT/MASK-MEDIUM EASY TOUCH INSULIN PENTIPS31GX6MM 88 113 SYRINGE/0.5ML/29G X 1/2" 89 DRUG MART UNIFINE EASIVENT/MASK-SMALL EASY TOUCH INSULIN PENTIPS31GX8MM 88 113 SYRINGE/0.5ML/30G X DRUG MART UNIFINE EASY COMFORT INSULIN 5/16" 89 PENTIPS32GX4MM 88 SYRINGE/0.5ML/30G X EASY TOUCH INSULIN DRUG MART UNIFINE 5/16" 88 SYRINGE/1ML/30G X 5/16" 89 PENTIPSPLUS 32GX4MM 88 EASY COMFORT INSULIN EASY TOUCH INSULIN DRUG MART UNILET SYRINGE/0.5ML/31G X SYRINGE/SAFETY/U- LANCETSSUPER THIN 30G73 5/16" 88 100/0.5ML/29G X 1/2" 89 DRUG MART UNILET EASY COMFORT INSULIN EASY TOUCH INSULIN LANCETSULTRA THIN 28G 73 SYRINGE/1ML/30G X SYRINGE/SAFETY/U- DRYMAX EXTRA 68 5/16" 88 100/0.5ML/30G X 5/16" 89 DRYSOL 51 EASY COMFORT INSULIN EASY TOUCH INSULIN SYRINGE/1ML/31G X SYRINGE/SAFETY/U- DUANE READE LANCET 5/16" 88 100/1ML/29G X 1/2" 89 ALTERNATE SITE 26G 73 EASY COMFORT INSULIN EASY TOUCH INSULIN DUANE READE LANCET SYRINGE/U-100/0.5ML/30G X SYRINGE/SAFETY/U- SUPERTHIN 30G 73 1/2" 88 100/1ML/30G X 1/2" 89 DUANE READE LANCET EASY COMFORT INSULIN EASY TOUCH INSULIN ULTRATHIN 28G 73 SYRINGE/U-100/1ML/30G X SYRINGE/U-100/0.3ML/30G X DUANE READE UNIFINE 1/2" 88 1/2" 89 PENTIPS 29G X 12MM 88 EASY COMFORT PEN EASY TOUCH INSULIN DUANE READE UNIFINE NEEDLES31GX1/4" 88 SYRINGE/U-100/0.5ML/27G X PENTIPS 31G X 6MM ULTRA EASY COMFORT PEN 1/2" 89 SHORT 88 NEEDLES31GX3/16" 88 EASY TOUCH INSULIN DUANE READE UNIFINE EASY COMFORT PEN SYRINGE/U-100/0.5ML/28G X PENTIPS 31G X 8MM NEEDLES31GX5/16" 89 1/2" 89 SHORT 88 EASY COMFORT PEN EASY TOUCH INSULIN DUETACT 17 NEEDLES32GX5/32" 89 SYRINGE/U-100/0.5ML/30G X DULCOLAX 64 EASY MINI EJECT LANCING 1/2" 89 DULERA 11 DEVICE 73 EASY TOUCH INSULIN EASY MINI LANCING duloxetine hcl 16 SYRINGE/U-100/0.5ML/31G X DEVICE 73 5/16" 89 DURAGESIC 5 EASY TOUCH 32GX5MM 89 EASY TOUCH INSULIN DUREX EXTRA SENSITIVE 70 EASY TOUCH 32GX6MM 89 SYRINGE/U-100/1ML/27G X DUTOPROL 26 EASY TOUCH ALCOHOL 1/2" 89 PREP PADS/MEDIUM 81 EASY TOUCH INSULIN DYAZIDE 56 SYRINGE/U-100/1ML/28G X E-Z JECT LANCETS 73 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1/2" 89 E-Z JECT LANCETS 21G 73 1ML/29GX1/2" 89 EASY TOUCH INSULIN E-Z JECT LANCETS SYRINGE/U-100/1ML/29G X COLOR 73 1/2" 89

Index 11 EASY TOUCH INSULIN EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN SYRINGE/U-100/1ML/30G X SAFETY INSULIN SYRINGE SYRINGE/U-100/1ML/28G X 1/2" 89 1ML/31GX5/16" 90 1/2" 90 EASY TOUCH INSULIN EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN SYRINGE/U-100/1ML/31G X SAFETY SYRINGE SYRINGE/U-100/1ML/29G X 5/16" 89 1ML/30GX1/2" 90 1/2" 90 EASY TOUCH LANCETS EASY TWIST & CAP ELITE-THIN INSULIN 26G/PULL-TOP 73 LANCETS 74 SYRINGE/U-100/1ML/31G X EASY TOUCH LANCETS EASYTEST II LANCETS 74 5/16" 90 26G/TWIST 73 EASYTEST LANCETS 74 ELIXOPHYLLIN 11 EASY TOUCH LANCETS ELLA 42 28G/PULL-TOP 73 EC-NAPROSYN 3 EASY TOUCH LANCETS econazole nitrate 47 ELLIS TONIC 119 28G/TWIST 73 ECOTRIN REGULAR ELMIRON 59 EASY TOUCH LANCETS STRENGTH 5 ELOCON 49 30G/BUTTON-ACTIVATED 73 ED BRON GP 44 EASY TOUCH LANCETS ELOCTATE 60 30G/PULL-TOP 73 EDURANT 35 EMBEDA 5 EASY TOUCH LANCETS efavirenz 35 EMCYT 29 30G/TWIST 73 EFFEXOR XR 16 EMERGEN-C BLUE 119 EASY TOUCH LANCETS EFFIENT 61 32G/PRESSURE EMERGEN-C FIVE 120 ACTIVATED 73 EFUDEX 47 EMERGEN-C HEART EASY TOUCH LANCETS ELAVIL 17 HEALTH 120 32G/PULL-TOP 73 ELDEPRYL 31 EMERGEN-C IMMUNE 120 EASY TOUCH LANCETS ELDERTONIC 119 EMERGEN-C IMMUNE 32G/TWIST 74 PLUS 120 EASY TOUCH LANCETS eletriptan hydrobromide 114 EMERGEN-C IMMUNE+ 33G/TWIST 74 ELEXA NATURAL FEEL 70 WARMERS 120 EASY TOUCH LANCING ELEXA STIMULATING 70 EMERGEN-C JOINT DEVICE/EJECTOR 74 ELEXA ULTRA HEALTH 120 EASY TOUCH PEN NEEDLE EMERGEN-C KIDZ 120 30G X 5/16" 89 SENSITIVE 70 EASY TOUCH PEN NEEDLES ELFOLATE 55 EMERGEN-C MSM LITE 120 29GX1/2" 90 ELIDEL 50 EMERGEN-C PINK 120 EASY TOUCH PEN NEEDLES ELIGARD 29 EMERGEN-C SUPER 31GX1/4" 90 FRUIT 120 ELIMITE 51 EASY TOUCH PEN NEEDLES EMERGEN-C VITAMIN C 120 31GX5/16" 90 ELIQUIS 11 EMERGEN-C VITAMIN C EASY TOUCH PEN NEEDLES ELIQUIS STARTER PACK 11 LITE 120 32GX1/4" 90 ELITE-THIN INSULIN EMERGEN-C VITAMIN D & EASY TOUCH PEN NEEDLES SYRINGE/0.3ML/31G X CALCIUM 120 32GX3/16" 90 5/16" 90 EASY TOUCH PEN NEEDLES emollient 50 ELITE-THIN INSULIN EMSAM 15 32GX5/32" 90 SYRINGE/0.5ML/29G X EASY TOUCH PEN 1/2" 90 EMTRIVA 35 NEEDLES/31G X 3/16" 90 ELITE-THIN INSULIN enalapril maleate 25 EASY TOUCH SAFETY SYRINGE/0.5ML/30G X enalapril maleate & LANCETS21G/PRESSURE 5/16" 90 hydrochlorothiazide 26 ACTIVATED 74 ELITE-THIN INSULIN EASY TOUCH SAFETY ENBREL 4 SYRINGE/1ML/30G X ENBREL SURECLICK 4 LANCETS28G/BUTTON 5/16" 90 ACTIVATED 74 ELITE-THIN INSULIN END FATIGUE DAILY EASY TOUCH SHEATHLOCK SYRINGE/U-100/0.5ML/28G X ENERGYENFUSION 120 SAFETY INSULIN SYRINGE 1/2" 90 ENERGY BOOSTER 120 1ML/29GX1/2" 90 ELITE-THIN INSULIN ENFAMIL ENFALYTE 116 EASY TOUCH SHEATHLOCK SYRINGE/U-100/0.5ML/31G X ENGERIX-B 135 SAFETY INSULIN SYRINGE 5/16" 90 1ML/30GX5/16" 90 enoxaparin sodium 11

Index 12 entecavir 37 ERIVEDGE 29 EXEL COMFORT POINT EPANED 25 ERLEADA 29 INSULIN PEN NEEDLES 29G X 12MM 91 EPIFOAM 49 ERY-TAB 65 EXEL COMFORT POINT epinephrine (anaphylaxis) 137 ERYGEL 46 INSULIN PEN NEEDLES 31G X EPIVIR 35 ERYPED 200 65 6MM 91 EXEL COMFORT POINT EPOGEN 61 ERYPED 400 65 INSULIN PEN NEEDLES 31G X EPZICOM 35 ERYTHROCIN 8MM 91 EQ OMEPRAZOLE 134 STEARATE 65 EXEL COMFORT POINT erythromycin (acne aid) 46 EQL ALCOHOL SWABS 81 INSULIN SYRINGE/0.3ML/29G X erythromycin (ophth) 126 1/2" 91 EQL COLOR LANCETS 21G74 erythromycin base 65 EXEL COMFORT POINT EQL COLOR LANCETS MICRO INSULIN SYRINGE/0.3ML/30G X THIN 33G 74 erythromycin ethylsuccinate 65 5/16" 91 EQL DRY MOUTH ORAL EXEL COMFORT POINT RINSE 118 ERYTHROMYCIN ETHYLSUCCINATE 66 INSULIN SYRINGE/0.5ML/28G X EQL GAUZE PADS 1/2" 91 2"X2"/SMALL 68 escitalopram oxalate 15 EXEL COMFORT POINT EQL GAUZE PADS ESGIC 4 INSULIN SYRINGE/0.5ML/29G X 4"X4"/LARGE 68 esomeprazole 1/2" 91 EQL GAUZE STERILE PADS magnesium 134 EXEL COMFORT POINT 3"X3" 68 estazolam 63 INSULIN SYRINGE/0.5ML/30G X EQL INSULIN ESTRACE 58,137 5/16" 91 SYRINGE/0.3ML/29G X 1/2" 90 EXEL COMFORT POINT EQL INSULIN estradiol 58 INSULIN SYRINGE/1ML/28G X SYRINGE/0.3ML/30G X estradiol & norethindrone 1/2" 91 5/16" 90 acetate 58 EXEL COMFORT POINT EQL INSULIN estradiol vaginal 137 INSULIN SYRINGE/1ML/29G X SYRINGE/0.3ML/31G X 1/2" 91 5/16" 90 ESTROPIPATE 58 ESTROSTEP FE 40 EXEL COMFORT POINT EQL INSULIN INSULIN SYRINGE/1ML/30G X SYRINGE/0.5ML/29G X 1/2" 90 eszopiclone 63 5/16" 91 EQL INSULIN ethambutol hcl 28 SYRINGE/0.5ML/30G X EXELON 130 5/16" 90 ethosuximide 14 exemestane 29 EQL INSULIN ethynodiol diacet & eth EXFORGE 26 estrad 40 SYRINGE/0.5ML/31G X EXFORGE HCT 26 5/16" 90 etodolac 3 EQL INSULIN EXTRA SENSITIVE ETOPOSIDE 30 SPERMICIDAL 70 SYRINGE/1ML/29G X 1/2" 90 EURAX 51 EZ SMART BLOOD GLUCOSE EQL INSULIN LANCETS 74 SYRINGE/1ML/30G X 5/16" 90 EVAC 63 EQL INSULIN EVISTA 57 EZ-LETS LANCETS 21G 74 SYRINGE/1ML/31G X 5/16" 90 EVOTAZ 35 EZ-LETS LANCETS 23G 74 EQL OMEPRAZOLE 134 EZ-LETS LANCETS 26G EX-LAX 64 SUPER-SOFT 74 EQL PRENATAL EXCILON AMD FORMULA 121 EZ-LETS LANCETS 28G EQL SHORT PEN NEEDLES ANTIMICROBIALDRAIN ULTRA-SOFT 74 SPONGES 4"X4" 6 PLY 68 EZ-LETS LANCETS 30G 74 31G X 8MM 90 EXCILON AMD EQL SUPER THIN LANCETS ezetimibe 25 30G 74 ANTIMICROBIALNON-WOVEN SPONGES 4"X4" 6 PLY 68 ezetimibe-simvastatin 24 EQL THIN LANCETS 26G 74 EXCILON DRAIN SPONGE FABRAZYME 57 EQL ULTRA SHORT PEN 4"X4" 68 NEEDLES 31G X 6MM 91 EXCILON DRAIN SPONGES FACE COTZ 53 EQUETRO 31 4"X4" 6 PLY 68 famotidine 133 ergocalciferol 137 EXCILON I.V. SPONGES 2"X2" FANAPT 32 ERGOLOID MESYLATES 131 6 PLY 68 FANAPT TITRATION PACK 32

Index 13 FANTASY LUBRICATED 70 FIFTY50 PEN fluocinonide emulsified base 49 FANTASY NEEDLES/31GX8MM 91 fluorometholone (ophth) 127 FIFTY50 PEN LUBRICATED/SPERMICIDE FLUOROURACIL 47,48 70 NEEDLES/32GX4MM 91 FARESTON 29 FIFTY50 PEN fluorouracil (topical) 47 NEEDLES/32GX6MM 91 FLUOXETINE 131 FARXIGA 20 FIFTY50 SAFETY SEAL FARYDAK 30 LANCETS 32G 74 FLUOXETINE DR 15 FAZACLO 33 FIFTY50 SUPERIOR fluoxetine hcl 15 COMFORTINSULIN FLUOXETINE FEIBA 60 SYRINGE/0.3ML/31G X HYDROCHLORIDE 15 felbamate 13 5/16" 91 fluphenazine decanoate 34 FELBATOL 13 FIFTY50 SUPERIOR FLUPHENAZINE HCL 34 FELDENE 3 COMFORTINSULIN SYRINGE/0.5ML/31G X fluphenazine hcl 34 felodipine 39 5/16" 91 FLURAZEPAM HCL 63 FEMARA 29 FIFTY50 SUPERIOR flurbiprofen 3 FEMCON FE 40 COMFORTINSULIN flurbiprofen sodium 128 FEMHRT LOW DOSE 58 SYRINGE/1ML/31G X 5/16" 91 flutamide 29 fenofibrate 24 FIFTY50 UNILET LANCETS fluticasone propionate 49 fenofibrate micronized 24 33G 74 fluticasone propionate fentanyl 5 finasteride 59 (nasal) 124 FER-IN-SOL 61 FINE 30 74 fluvoxamine maleate 15 FERRETTS 62 FINGERSTIX LANCETS 74 FML 127 ferrous fumarate 62 FIORINAL 4 FML LIQUIFILM 127 ferrous fumarate-fa-b complex-c- FIORINAL/CODEINE #3 6 FOCALIN 1 zn-mg-mn-cu 61 FIRMAGON 29 folic acid 61 ferrous gluconate 62 FIRVANQ 8 FORA LANCETS 74 FERROUS GLUCONATE 62 FLAGYL 8 FORA LANCING DEVICE 74 ferrous sulfate 62 flavoxate hcl 135 FORA LANCING DEVICE/CLEARCAP 74 FERROUS SULFATE 62 flecainide acetate 9 FORFIVO XL 14 ferrous sulfate 62 FLEET ENEMA 64 formaldehyde 34 FERROUS SULFATE 62 FLEET ENEMA SIX PACK 64 FORTAMET 18 ferrous sulfate 62 FLEET PEDIATRIC 64 FORTICAL 56 ferrous sulfate dried 62 FLEXICHAMBER 113 FOSAMAX 57 FETZIMA 16 FLOMAX 59 fosamprenavir calcium 35 FETZIMA TITRATION PACK16 FLONASE ALLERGY FEVERALL INFANTS 4 RELIEF 124 fosinopril sodium 25 fexofenadine hcl 23 FLONASE ALLERGY RELIEF fosinopril sodium & CHILDRENS 124 hydrochlorothiazide 27 FIASP 19 FLOVENT DISKUS 10 FREDS PHARMACY AUTOLET FIASP FLEXTOUCH 19 LANCING DEVICE 74 FLOVENT HFA 10 FIBERCON 63 FREDS PHARMACY UNIFINE FLOXIN OTIC 128 PENTIPS PEN NEEDLES FIBRYGA 60 fluconazole 22 32GX4MM 91 FIFTY50 ALCOHOL PREP fludrocortisone acetate 43 FREDS PHARMACY UNIFINE PADS 81 PENTIPS PLUS 31GX5MM 91 FIFTY50 LANCING DEVICE 74 FLUMIST FREDS PHARMACY UNIFINE FIFTY50 PEN NEEDLES 31G QUADRIVALENT 135 PENTIPS PLUS 31GX8MM 91 X3/16" (5MM) 91 FLUNISOLIDE 124 FREDS PHARMACY UNILET FIFTY50 PEN NEEDLES 31G fluocinolone acetonide LANCETS SUPER THIN X5/16" (8MM) 91 (otic) 129 30G 74 FIFTY50 PEN NEEDLES fluocinonide 49 31GX5MM 91

Index 14 FREDS PHARMACY UNILET GENTEEL LANCING GLOBAL INJECT EASE INSULIN LANCETS ULTRA THIN DEVICE/PRECIOUS SYRINGE/U-100/0.3ML/31G X 28G 74 PLATINUM 74 5/16" 92 FREESTYLE PRECISION GENTEEL LANCING GLOBAL INJECT EASE INSULIN INSULIN SYRINGE/U- DEVICE/PRINCESS PINK 74 SYRINGE/U-100/0.5ML/28G X 100/0.5ML/30G X 5/16" 91 GENTEEL LANCING 1/2" 92 FREESTYLE PRECISION DEVICE/STATELY GLOBAL INJECT EASE INSULIN INSULIN SYRINGE/U- SILVER 74 SYRINGE/U-100/0.5ML/29G X 100/0.5ML/31G X 5/16" 91 GENTEEL LANCING 1/2" 92 FREESTYLE PRECISION DEVICE/WILLOWY GLOBAL INJECT EASE INSULIN INSULIN SYRINGE/U- WHITE 74 SYRINGE/U-100/0.5ML/30G X 100/1ML/31G X 5/16" 91 GENTLE-LET GP 1/2" 92 FREESTYLE PRECISION LANCETS 74 GLOBAL INJECT EASE INSULIN INSULIN SYRINGES/U- GENTLE-LET LANCETS SYRINGE/U-100/0.5ML/30G X 100/1ML/30G X 5/16" 92 GENERAL PURPOSE 5/16" 92 FURADANTIN 135 STYLE/FINE POINT 75 GLOBAL INJECT EASE INSULIN furosemide 56 GENTLE-LET LANCETS SYRINGE/U-100/0.5ML/31G X GENERAL PURPOSE 5/16" 92 FUROSEMIDE 56 STYLE/MEDIUM POINT 75 GLOBAL INJECT EASE INSULIN furosemide 56 GENTLE-LET LANCETS SYRINGE/U-100/1ML/28G X FUZEON 35 SAFETY STYLE/FINE 1/2" 92 POINT 75 GLOBAL INJECT EASE INSULIN gabapentin 12 GENTLE-LET LANCETS SYRINGE/U-100/1ML/29G X GABITRIL 13 SAFETY STYLE/MEDIUM 1/2" 92 galantamine hydrobromide 130 POINT 75 GLOBAL INJECT EASE INSULIN GALANTAMINE GENVOYA 35 SYRINGE/U-100/1ML/30G X HYDROBROMIDE 130 GEODON 31 1/2" 92 galantamine hydrobromide 130 GLOBAL INJECT EASE INSULIN GILENYA 131 SYRINGE/U-100/1ML/30G X GARDASIL 136 GILOTRIF 30 5/16" 92 GARDASIL 9 135 glatiramer acetate 131 GLOBAL INJECT EASE INSULIN GAS-X 58 GLEEVEC 30 SYRINGE/U-100/1ML/31G X GAUZE DRESSING 4"X4" 68 5/16" 92 glimepiride 21 GLOBAL INSULIN SYRINGE/U- GAUZE PADS 2"X2" 68 glipizide 21 100/0.3ML/30G X 1/2" 92 GAUZE PADS 3"X3" 68 glipizide-metformin hcl 17 GLOBAL INSULIN SYRINGES/U- GAUZE PADS 4"X4" 68 GLOBAL EASE INJECT PEN 100/0.3ML/30GX5/16" 92 GAUZE PADS 4"X4" 12 PLY 68 NEEDLES 29GX12MM 92 GLOBAL LANCING DEVICE 75 GAUZE SPONGE TYPE VII GLOBAL EASE INJECT PEN GLUCAGEN HYPOKIT 18 MEDI-PAK 2"X2" 8PLY 68 NEEDLES 31GX8MM 92 GLUCAGON EMERGENCY GAUZE SPONGES 4"X4" 12 GLOBAL EASE INJECT PEN KIT 18 PLY 68 NEEDLES 32GX4MM 92 GLUCOCOM LANCETS GELUSIL 7 GLOBAL EASE INJECT PEN 33G 75 NEEEDLES 31GX5MM 92 GLUCOPHAGE 18 gemfibrozil 24 GLOBAL EASY GLIDE GENERESS FE 40 INSULINSYRINGE/U- GLUCOPHAGE XR 18 GLUCOPRO INSULIN GENTAK 126 100/0.3ML/31G X 5/16" 92 GLOBAL EASY GLIDE PEN SYRINGE/U-100/0.3ML/30G X gentamicin sulfate (ophth) 126 NEEDLES 32GX4MM 92 1/2" 92 gentamicin sulfate (topical) 46 GLOBAL INJECT EASE GLUCOPRO INSULIN GENTEEL LANCING INSULIN SYRINGE/U- SYRINGE/U-100/0.3ML/30G X DEVICE/BUFF BLACK 74 100/0.3ML/29G X 1/2" 92 5/16" 92 GENTEEL LANCING GLOBAL INJECT EASE GLUCOPRO INSULIN DEVICE/BUTTERFLY BLUE 74 INSULIN SYRINGE/U- SYRINGE/U-100/0.3ML/31G X GENTEEL LANCING 100/0.3ML/30G X 1/2" 92 5/16" 93 DEVICE/GLORIOUS GOLD 74 GLOBAL INJECT EASE GLUCOPRO INSULIN GENTEEL LANCING INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/30G X DEVICE/PLAYFUL PURPLE 74 100/0.3ML/30G X 5/16" 92 1/2" 93

Index 15 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/0.5ML/30G X SYRINGE/0.5ML/30G X INSULIN SYRINGE/1ML/28G X 5/16" 93 5/16" 93 1/2" 94 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/0.5ML/31G X SYRINGE/0.5ML/31G X INSULIN SYRINGE/1ML/29G X 5/16" 93 5/16" 93 1/2" 94 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X SYRINGE/1ML/28G X 1/2" 93 INSULIN SYRINGE/1ML/30G X 1/2" 93 GNP INSULIN 5/16" SHORT 94 GLUCOPRO INSULIN SYRINGE/1ML/29G X 1/2" 93 GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X GNP INSULIN INSULIN SYRINGE/1ML/31G X 5/16" 93 SYRINGE/1ML/30G X 5/16" SHORT 94 GLUCOPRO INSULIN 5/16" 93 GOLD BOND ULTIMATE SYRINGE/U-100/1ML/31G X GNP INSULIN HEALING 50 5/16" 93 SYRINGE/1ML/31G X GOLYTELY 64 GLUCOSE 18 5/16" 93 GOODSENSE LANCETS GLUCOSOURCE LANCET GNP LANCETS 75 MICRO-THIN 33G 75 DEVICE 75 GNP LANCETS 21G 75 GOODSENSE LANCETS GLUCOSOURCE LANCETS 75 GNP LANCETS MICRO THIN ULTRA-THIN 30G 75 GLUCOTROL 21 33G 75 GOODSENSE LANCING DEVICE 75 GLUCOTROL XL 21 GNP LANCETS SUPER THIN 30G 75 GOODSENSE PRENATAL GLUCOVANCE 17 GNP LANCETS THIN 75 VITAMINS 121 GRASTEK 2 GLUMETZA 18 GNP LANCETS THIN 26G 75 glyburide 21 GNP MICRO THIN LANCETS GRIS-PEG 22 glyburide micronized 21 33G 75 griseofulvin microsize 22 glyburide-metformin 17 GNP OMEPRAZOLE 134 griseofulvin ultramicrosize 22 glycerin (laxative) 64 GNP PRENATAL 121 guaifenesin 45 GLYCERIN ADULT 64 GNP QUICK DISSOLVE guaifenesin-codeine 44 GLUCOSE 19 guanfacine hcl 26 glycopyrrolate 133 GNP STERILE PADS GLYNASE 21 3"X3" 68 guanfacine hcl (adhd) 1 GLYSET 17 GNP SUPER THIN GYNAZOLE-1 136 LANCETS/30G 75 GYNE-LOTRIMIN 136 GLYXAMBI 17 GNP ULTRA COMFORT GNP ALCOHOL SWABS 82 INSULIN SYRINGE/0.3ML/29G GYNE-LOTRIMIN 3 136 GNP CLICKFINE PEN X 1/2" 93 H-E-B IN CONTROL PEN NEEDLEUNIVERSAL/31GX5/16" GNP ULTRA COMFORT NEEDLES 31GX5MM 94 93 INSULIN SYRINGE/0.3ML/30G H-E-B IN CONTROL PEN GNP CLICKFINE UNIVERSAL X 5/16" SHORT 93 NEEDLES 31GX6MM 94 PEN NEEDLES 31GX1/4" 93 GNP ULTRA COMFORT H-E-B IN CONTROL PEN GNP CLICKFINE UNIVERSAL INSULIN SYRINGE/0.3ML/31G NEEDLES 31GX8MM 94 PEN NEEDLES 31GX5/16" 93 X 5/16" SHORT 93 H-E-B IN CONTROL PEN GNP GLUCOSE 18 GNP ULTRA COMFORT NEEDLES/NANO/32GX4MM GNP INSULIN INSULIN SYRINGE/0.5ML/28G 94 H-E-B IN CONTROL SYRINGE/0.3ML/29G X 1/2" 93 X 1/2" 93 GNP INSULIN GNP ULTRA COMFORT UNIFINEPENTIPS PLUS SYRINGE/0.3ML/30G X INSULIN SYRINGE/0.5ML/29G 31GX5MM 94 H-E-B IN CONTROL 5/16" 93 X 1/2" 93 GNP INSULIN GNP ULTRA COMFORT UNIFINEPENTIPS PLUS SYRINGE/0.3ML/31G X INSULIN SYRINGE/0.5ML/30G 32GX4MM 94 H-E-B INCONTROL 5/16" 93 X 5/16" SHORT 93 GNP INSULIN GNP ULTRA COMFORT ADVANCEDLANCING SYRINGE/0.5ML/28G X 1/2" 93 INSULIN SYRINGE/0.5ML/31G DEVICE 75 GNP INSULIN X 5/16" SHORT 94 H-E-B INCONTROL ALCOHOL SYRINGE/0.5ML/29G X 1/2" 93 PADS 82 H-E-B INCONTROL LANCETS MICRO THIN 33G 75

Index 16 H-E-B INCONTROL LANCETS HEMOCYTE 62 HYDRALYTE FREEZER SUPER THIN 30G 75 HEMOFIL M 60 POPS 116 H-E-B INCONTROL LANCETS HYDREA 30 heparin sodium (porcine) 11 ULTRA THIN 28G 75 HYDROCELL ADHESIVE H-E-B INCONTROL PEN HEPSERA 37 DRESSING 4"X4" 68 NEEDLES 29GX12MM 94 HIBERIX 135 HYDROCELL DRESSING HAEMOLANCE 75 HIBICLENS 34 4"X4" 68 HAEMOLANCE LOW FLOW HIGH SENSATION hydrochlorothiazide 56 LANCETS 75 SPERMICIDAL 70 hydrocodone w/ HAEMOLANCE PLUS 75 HM OMEPRAZOLE 134 homatropine 43 HAEMOLANCE PLUS LOW HM PRENATAL 121 hydrocodone-acetaminophen 6 FLOW 75 hydrocortisone 42 HALCION 63 HM STERILE ALCOHOL PREP PADS 82 hydrocortisone (intrarectal) 7 HALDOL 32 HM STERILE PADS 68 hydrocortisone (rectal) 7 HALDOL DECANOATE 100 32 HM STERILE PADS 2"X2" 68 hydrocortisone (topical) 49 HALDOL DECANOATE 50 32 HUGGIES LITTLE SWIMMERS hydrocortisone butyrate 49 haloperidol 32,33 SPF50 53 hydrocortisone w/acetic haloperidol decanoate 32 HUMALOG 20 acid 129 haloperidol lactate 32 HUMALOG JUNIOR hydrocortisone-aloe vera 49 KWIKPEN 19 HAVRIX 136 HYDROMORPHONE HCL 5 HUMALOG KWIKPEN 19 HEALTH CARE LANCING hydromorphone hcl 5 HUMALOG MIX 50/50 20 DEVICE 75 hydroxychloroquine sulfate 28 HEALTHWISE LANCING HUMALOG MIX 50/50 PEN 75 KWIKPEN 19 HYDROXYPROGESTERONE HEALTHWISE MINI PEN HUMALOG MIX 75/25 20 CAPROATE 29 NEEDLES 31GX6MM 94 hydroxyprogesterone HUMALOG MIX 75/25 caproate 130 HEALTHWISE PEN NEEDLES KWIKPEN 20 hydroxyurea 30 29GX12MM 94 HUMAPEN LUXURA HD 94 HEALTHWISE SHORT PEN HYDROXYZINE HCL 9 HUMATE-P 60 NEEDLES 31GX8MM 94 hydroxyzine hcl 9 HEALTHWISE UNIFINE HUMIRA 2 PENTIPS PEN NEEDLES HUMIRA PEDIATRIC CROHNS HYDROXYZINE PAMOATE 9 32GX4MM 94 DISEASE STARTER PACK 2 hydroxyzine pamoate 9 HEALTHY ACCENTS AUTOLET HUMIRA PEN 2 hyoscyamine sulfate 133 IMPRESSION LANCING HUMIRA PEN-CD/UC/HS HYSINGLA ER 5 DEVICE 75 STARTER 2 HYVEE ADVANCED ANTACID HEALTHY ACCENTS UNIFINE HUMIRA PEN-PS/UV PENTIPS PEN NEEDLES MAXIMUM STRENGTH 7 STARTER 2 HYZAAR 27 29GX12MM 94 HUMULIN 70/30 20 IBRANCE 30 HEALTHY ACCENTS UNIFINE HUMULIN 70/30 PENTIPS PEN NEEDLES KWIKPEN 20 ibuprofen 3 31GX5MM 94 HEALTHY ACCENTS UNIFINE HUMULIN N 20 ICLUSIG 30 PENTIPS PEN NEEDLES HUMULIN N KWIKPEN 20 IDELVION 60 31GX6MM 94 HUMULIN R 20 imatinib mesylate 30 HEALTHY ACCENTS UNIFINE HUMULIN R U-500 imipramine hcl 17 PENTIPS PEN NEEDLES (CONCENTRATED) 20 imipramine pamoate 17 31GX8MM 94 HUMULIN R U-500 HEALTHY ACCENTS UNIFINE KWIKPEN 20 imiquimod 50 PENTIPS PEN NEEDLES HY-VEE LANCETS 75 IMITREX 114 32GX4MM 94 HY-VEE THIN LANCETS 75 IMITREX STATDOSE HEALTHY ACCENTS UNILET REFILL 114 LANCETS SUPER THIN HYCAMTIN 30 IMITREX STATDOSE 30G 75 hydralazine hcl 27 SYSTEM 114 HELIXATE FS 60 HYDRALYTE 116 IMMUNE SUPPORT VITAMIN HEMANGEOL 38 C 120

Index 17 IMODIUM A-D 21 INSULIN SYRINGE/NEEDLE INSULIN IMURAN 117 0.3ML/30G X 5/16" 95 SYRINGES/1ML/29GX1/2" 96 INSULIN SYRINGE/NEEDLE INSULIN IN TOUCH LANCING 0.3ML/31G X 5/16" 95 SYRINGES/1ML/30GX1/2" 96 DEVICE 75 INSULIN SYRINGE/NEEDLE INSULIN INCRUSE ELLIPTA 10 0.5ML/29G X 1/2" 95 SYRINGES/1ML/31GX5/16" 96 indapamide 56 INSULIN SYRINGE/NEEDLE INSUPEN 29G X 12MM 96 INDERAL LA 38 0.5ML/30G X 5/16" 95 INSUPEN 31G X 5MM 96 INSULIN SYRINGE/NEEDLE indomethacin 3 0.5ML/31G X 5/16" 95 INSUPEN 31G X 8MM 96 INFANTS ADVIL 3 INSULIN SYRINGE/NEEDLE INSUPEN 32G X 4MM 96 INLYTA 30 1ML/29G X 1/2" 95 INSUPEN PEN NEEDLES 32G INPEN 100/BLUE/LILLY 94 INSULIN SYRINGE/NEEDLE X4MM 96 1ML/30G X 5/16" 95 INSUPEN SENSITIVE INPEN 100/BLUE/NOVO 94 INSULIN SYRINGE/NEEDLE 32GX6MM 96 INPEN 100/GRAY/LILLY 94 1ML/31G X 5/16" 95 INSUPEN ULTRAFIN INPEN 100/GREY/NOVO 94 INSULIN SYRINGE/U- 29GX12MM 96 100/0.3ML/29G X 1/2" 95 INPEN 100/PINK/LILLY 94 INSUPEN ULTRAFIN INSULIN SYRINGE/U- 30GX8MM 96 INPEN 100/PINK/NOVO 94 100/0.5ML/28G X 1/2" 95 INSUPEN ULTRAFIN INSPIRACHAMBER/ANTI- INSULIN SYRINGE/U- 31GX6MM 96 STATIC 100/0.5ML/29G X 1/2" 95 INSUPEN ULTRAFIN VALVED/MOUTHPIECE 113 INSULIN SYRINGE/U- 31GX8MM 96 INSPIRACHAMBER/LARGE 100/1ML/28G X 1/2" 95 INTELENCE 35 113 INSULIN SYRINGE/U- INSPIRACHAMBER/SOOTHER 100/1ML/29G X 1/2" 95 INTENSE SENSATION 70 MASK/INSPIRAMASK/MEDIUM INSULIN SYRINGE/U- INTUNIV 1 113 100/1ML/30G X 5/16" 95 INVEGA 32 INSPIRACHAMBER/SOOTHER INSULIN SYRINGE/U- INVEGA SUSTENNA 32 MASK/INSPIRAMASK/SMALL 100/1ML/31G X 5/16" 95 113 INSULIN INVEGA TRINZA 32 INSPIREASE DRUG SYRINGES/0.5ML/27GX1/2" INVIRASE 35 DELIVERYSYSTEM 113 95 INVOKAMET 17 INSULIN INSPIREASE RESERVOIR INVOKAMET XR 17 BAGS 113 SYRINGES/0.5ML/28GX1/2" INSULIN SYRINGE/0.3ML/29G X 95 INVOKANA 20 1" 95 INSULIN IOPIDINE 126 INSULIN SYRINGE/0.3ML/29G X SYRINGES/0.5ML/29GX1/2" IPOL INACTIVATED IPV 136 1/2" 95 95 INSULIN SYRINGE/0.3ML/30G X INSULIN ipratropium bromide 10 5/16" 95 SYRINGES/0.5ML/30GX5/16" ipratropium bromide (nasal)124 INSULIN SYRINGE/0.3ML/31G X 95 ipratropium-albuterol 11 5/16" 95 INSULIN INSULIN SYRINGE/0.5ML/27G X SYRINGES/0.5ML/31GX irbesartan 25 1/2" 95 5/16" 95 irbesartan-hydrochlorothiazide INSULIN SYRINGE/0.5ML/28G X INSULIN 27 1/2" 95 SYRINGES/0.5ML/31GX5/16" IRON CHEWS PEDIATRIC 62 INSULIN SYRINGE/0.5ML/30G X 96 ISENTRESS 35 1/2" 95 INSULIN ISONIAZID 28 INSULIN SYRINGE/0.5ML/30G X SYRINGES/1ML/27GX/1/2" 5/16" 95 96 isoniazid 28 INSULIN SYRINGE/0.5ML/31G X INSULIN ISOPTO ATROPINE 126 5/16" 95 SYRINGES/1ML/27GX1/2" ISOPTO CARPINE 126 INSULIN SYRINGE/1ML/28G X 96 ISORDIL TITRADOSE 8 1/2" 95 INSULIN INSULIN SYRINGE/1ML/29G X SYRINGES/1ML/28GX1/2" isosorbide dinitrate 8 1/2" 95 96 ISOSORBIDE DINITRATE ER8 INSULIN SYRINGE/1ML/30G X isosorbide mononitrate 8 5/16" 95

Index 18 isotretinoin 46 KERLIX SPONGES 4" X 4" 16 KLOR-CON M15 116 isoxsuprine hcl 39 PLY 69 KLS OMEPRAZOLE 134 KETOCARE 54 ISTODAX 30 KOATE 60 ketoconazole (topical) 47 ISTODAX (OVERFILL) 30 KOATE-DVI 60 KETONE TEST STRIPS 54 itraconazole 22 KOGENATE FS 60 KETOPROFEN 3 IXINITY 60 KOGENATE FS BIO-SET 60 ketoprofen 3 J & J GAUZE 2"X2" 8 PLY 68 KOMBIGLYZE XR 18 KETOPROFEN ER 3 J & J GAUZE 4"X4" 12 PLY 68 KONSYL 63 ketorolac tromethamine 3 J & J GAUZE 4"X4" 8 PLY 68 KORLYM 19 ketorolac tromethamine J & J GAUZE SPONGES 12-PLY (ophth) 128 KOVALTRY 60 4" X 4" 68 KP MENS DAILY PACK 120 J & J GAUZE SPONGES 16-PLY KETOSTIX 54 4" X 4" 68 ketotifen fumarate (ophth)128 KP PRENATAL MULTIVITAMINS 121 J & J GAUZE SPONGES 8- KHEDEZLA 16 PLY4" X 4" 68 KP WOMENS DAILY KIMONO COLORS 70 PACK 120 JADENU 21 KIMONO LUBRICATED 70 KPN PRENATAL 121 JAKAFI 30 KIMONO MICRO THIN PLUS KROGER INSULIN JANUMET 17 SPERMICIDE SYRINGE/0.3ML/29G X 1/2" 96 JANUMET XR 17 LUBRICATED 70 KROGER INSULIN JANUVIA 19 KIMONO PLUS SPERMICIDE SYRINGE/0.3ML/30G X LUBRICATED 70 5/16" 96 JARDIANCE 21 KIMONO PLUS KROGER INSULIN JENTADUETO 18 SPERMICIDE/LUBRICATED SYRINGE/0.3ML/31G X JENTADUETO XR 18 70 5/16" 96 KIMONO PS KROGER INSULIN K-PHOS NEUTRAL 116 LUBRICATED 70 SYRINGE/0.5ML/29G X 1/2" 96 K-TAB 116 KIMONO PS PLUS KROGER INSULIN KALETRA 35 SPERMICIDE/LUBRICATED SYRINGE/0.5ML/30G X KALYDECO 132 70 5/16" 96 KIMONO SENSATION KROGER INSULIN KAMELEON LUBRICATED 70 LUBRICATED 70 SYRINGE/0.5ML/31G X KAYEXALATE 118 KIMONO SENSATION PLUS 5/16" 96 KAZANO 18 SPERMICIDE KROGER INSULIN LUBRICATED 70 SYRINGE/1ML/29G X 1/2" 96 KEFLEX 40 KROGER INSULIN KENDALL HYDROPHILIC KIMONO SPECIAL 70 KINERET 3 SYRINGE/1ML/30G X 5/16" 96 FOAMDRESSING 2"X2" 68 KROGER INSULIN KENDALL HYDROPHILIC KINNEY LANCETS 75 SYRINGE/1ML/31G X 5/16" 96 FOAMDRESSING 3"X3" 68 KINNEY THIN LANCETS 75 KENDALL HYDROPHILIC KROGER LANCETS 75 KINRAY INSULIN SYRINGE FOAMDRESSING 4"X4" 68 KROGER LANCETS 21G 75 KENDALL HYDROPHILIC PREFERRED KROGER LANCETS MICRO FOAMPLUS DRESSING PLUS/0.3ML/31G X 5/16" 96 THIN33G 75 KINRAY INSULIN SYRINGE 2"X2" 68 KROGER LANCETS SUPER KENDALL HYDROPHILIC PREFERRED THIN 75 FOAMPLUS DRESSING PLUS/0.5ML/31G X 5/16" 96 KROGER LANCETS THIN 76 3"X3" 69 KINRAY INSULIN SYRINGE PREFERRED PLUS/1ML/31G KROGER LANCETS THIN KEPPRA 12 X 5/16" 96 26G 75 KEPPRA XR 12 KINRAY INSULIN KROGER LANCETS ULTRATHIN30G 76 KERALYT 51 SYRINGE/0.5ML/29G X 1/2" 96 KROGER LANCING KERI AGE DEFY & DEVICE 76 PROTECT 53 KITABIS PAK 2 KROGER PEN NEEDLES 29G KERLIX SPONGES 4" X 4" 12 KLARON 46 X12MM 96 PLY 69 KLONOPIN 12 KROGER PEN NEEDLES 31G X8MM 96

Index 19 KROGER PEN NEEDLES LANCETS ULTRA FINE 76 LEADER UNIFINE PENTIPS 31GX1/4" 96 LANCETS ULTRA THIN 76 PLUS/SHORT/31GX5/16" 97 LEADER UNIFINE L-METHYLFOLATE 55 LANCETS ULTRA THIN L-METHYLFOLATE CA/S- PENTIPS/MINI/31GX3/16" 97 30G 76 LEADER UNIFINE ALGAL 55 LANCETSBULLSEYE L-METHYLFOLATE PENTIPS/NANO/32GX5/32" 97 SAFETY 76 LEADER UNIFINE CALCIUM 55 LANCING DEVICE 76 L-METHYLFOLATE FORMULA PENTIPS/PLUS/32GX5/32" 97 15 55 LANCING DEVICE LEMTRADA 131 ADJUSTABLE 76 L-METHYLFOLATE FORMULA LETAIRIS 39 LANOXIN 39 7.5 55 letrozole 29 L-METHYLFOLATE FORTE 55 lansoprazole 134 LEUCOVORIN CALCIUM 30 L-TRYPTOPHAN 125 LANTUS 20 leucovorin calcium 30 labetalol hcl 38 LANTUS SOLOSTAR 20 LEUKERAN 28 LAC-HYDRIN 50 LANZO 76 leuprolide acetate 29 LAC-HYDRIN TWELVE 50 LASIX 56 LEVAQUIN 58 lactic acid (ammonium LATANOPROST 128 LEVBID 133 lactate) 50 latanoprost 128 LEVEMIR 20 lactulose 64 LATUDA 31 lactulose (encephalopathy) 59 LEADER ADVANCED LEVEMIR FLEXTOUCH 20 LAMICTAL 12 LANCING DEVICE 76 levetiracetam 12,13 LAMICTAL CHEWABLE LEADER INSULIN levobunolol hcl 125 DISPERSIBLE 12 SYRINGE/0.3ML/29G X levocarnitine (metabolic LAMICTAL XR 12 1/2" 96 modifiers) 57 LEADER INSULIN levocetirizine dihydrochloride23 LAMISIL 22 SYRINGE/0.3ML/30G X LAMISIL AT 47 5/16" 97 levofloxacin 58 LAMISIL AT JOCK ITCH 47 LEADER INSULIN LEVOMEFOLATE CALCIUM ALGAL POWDER 55 lamivudine 35 SYRINGE/0.3ML/31G X 5/16" 97 levonorgestrel & eth lamivudine-zidovudine 35 LEADER INSULIN estradiol 41 lamotrigine 12 SYRINGE/0.5ML/28G X levonorgestrel (emergency LANAPHILIC 50 1/2" 97 oc) 42 LEADER INSULIN levonorgestrel-eth estradiol LANCET DEVICE (triphasic) 41 ADJUSTABLE 76 SYRINGE/0.5ML/29G X 1/2" 97 levonorgestrel-ethinyl estradiol LANCET DEVICE WITH (91-day) 41 EJECTOR 76 LEADER INSULIN levothyroxine sodium 132 LANCETS 76 SYRINGE/0.5ML/30G X 5/16" 97 LEXAPRO 15 LANCETS 26G TWIST TOP 76 LEADER INSULIN LEXIVA 35 LANCETS 28G 76 SYRINGE/0.5ML/31G X LIALDA 59 LANCETS 30G 76 5/16" 97 LEADER INSULIN LIBERTY MEDICAL LANCETS LANCETS 31G TWIST TOP 76 SYRINGE/1ML/28G X 1/2" 97 30G 76 LANCETS MICRO THIN LEADER INSULIN LIBERTY MINI LANCING 33G 76 SYRINGE/1ML/29G X 1/2" 97 DEVICE 76 LANCETS SAFETY SEAL LEADER INSULIN lidocaine 51 21G 76 SYRINGE/1ML/30G X lidocaine hcl 51 LANCETS SAFETY SEAL 5/16" 97 26G 76 LEADER INSULIN lidocaine hcl (mouth-throat) 118 LANCETS SAFETY SEAL SYRINGE/1ML/31G X lidocaine-prilocaine 51 28G 76 5/16" 97 LIFE PACK MENS 120 LANCETS SAFETY SEAL LEADER QUICK DISSOLVE LIFE PACK WOMENS 120 30G 76 GLUCOSE 19 LANCETS SUPER THIN LIFESCAN UNISTIK 2 DEEP LEADER UNIFINE PENTIPS PENETRATION 76 28G 76 PLUS/MINI/31GX3/16" 97 LANCETS THIN 76

Index 20 LIFESCAN UNISTIK II LITHOBID 31 lovastatin 24 LANCETS 76 LIVE BETTER ADVANCED LOVENOX 11,12 liothyronine sodium 132 LANCING DEVICE 76 loxapine succinate 33 LIVE BETTER LANCET LIPITOR 24 LUBRIDERM DAILY lisinopril 25 SUPERTHIN 30G 76 LIVE BETTER LANCET MOISTURE/SUNSCREEN SPF lisinopril & ULTRATHIN 28G 76 15 53 hydrochlorothiazide 27 LIVE BETTER PEN NEEDLES LUNESTA 63 LITE TOUCH LANCETS 76 29G X 12MM 98 LUPRON DEPOT (1- LITE TOUCH LANCING LIVE BETTER PEN NEEDLES MONTH) 29 PEN 76 31G X 12MM 98 LUPRON DEPOT (3- LITE TOUCH PEN LIVE BETTER PEN NEEDLES MONTH) 29 NEEDLES/31G X 3/16" 97 31G X 6MM 98 LUPRON DEPOT (4- LITEAIRE 113 LMX 4 51 MONTH) 29 LUPRON DEPOT (6- LITETOUCH INSULIN LOCOID 49 SYRINGE/0.3ML/29G X 1/2" 97 MONTH) 29 LITETOUCH INSULIN LODINE 3 LURIDE 116 SYRINGE/0.3ML/30G X LODOSYN 30 LYSODREN 29 5/16" 97 LOESTRIN 1.5/30-21 41 LYSTEDA 62 LITETOUCH INSULIN LOESTRIN 1/20-21 41 SYRINGE/0.3ML/31G X M-M-R II 136 5/16" 97 LOESTRIN FE 1.5/30 41 M-VIT 121 LITETOUCH INSULIN LOESTRIN FE 1/20 41 MACROBID 135 SYRINGE/0.5ML/30G X LOFIBRA 24 5/16" 97 MACRODANTIN 135 LITETOUCH INSULIN LOHIST-D 44 MAGELLAN INSULIN SAFETY SYRINGE/0.5ML/31G X LOMOTIL 21 SYRINGE/U-100/0.3ML/29G X 5/16" 97 LONGS INSULIN 1/2" 98 LITETOUCH INSULIN SYRINGE/0.5ML/31G X MAGELLAN INSULIN SAFETY SYRINGE/1ML/30G X 5/16" 97 5/16" 98 SYRINGE/U-100/0.3ML/30G X LITETOUCH INSULIN LONGS LANCETS 5/16" 98 SYRINGE/U-100/0.5ML/28G X STANDARD 76 MAGELLAN INSULIN SAFETY 1/2" 97 LONGS LANCETS THIN 76 SYRINGE/U-100/0.5ML/29G X LITETOUCH INSULIN LONGS LANCETS ULTRA 1/2" 98 SYRINGE/U-100/0.5ML/29G X MAGELLAN INSULIN SAFETY THIN 76 SYRINGE/U-100/0.5ML/30G X 1/2" 97 loperamide hcl 21 LITETOUCH INSULIN 5/16" 98 SYRINGE/U-100/1ML/28G X LOPID 24 MAGELLAN INSULIN SAFETY 1/2" 97 lopinavir-ritonavir 35 SYRINGE/U-100/1ML/29G X LITETOUCH INSULIN LOPRESSOR 38 1/2" 98 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X LOPRESSOR HCT 27 1/2" 97 SYRINGE/U-100/1ML/30G X LITETOUCH INSULIN loratadine 23 5/16" 98 SYRINGE/U-100/1ML/31G X loratadine & magnesium citrate 64 5/16" 97 pseudoephedrine 44 magnesium hydroxide 64 LITETOUCH LANCETS MICRO lorazepam 9 magnesium oxide 8 THIN 33G 76 losartan potassium 25 LITETOUCH PEN NEEDLES magnesium oxide (mg losartan potassium & supplement) 116 29GX12.7MM 97 hydrochlorothiazide 27 LITETOUCH PEN NEEDLES MAGOX 400 116 31G X 6MM 97 LOTENSIN 25 MAKENA 130 LITETOUCH PEN NEEDLES LOTENSIN HCT 27 malathion 51 31GX8MM SHORT 97 LOTREL 27 MAPROTILINE HCL 14 LITHIUM 31 LOTRIMIN AF 47 MARATHON MEDICAL lithium carbonate 31 LOTRIMIN AF FOR HER 47 PENTIPS29GX12MM 98 LITHIUM CARBONATE 31 LOTRIMIN AF JOCK ITCH 47 MARATHON MEDICAL PENTIPS31GX5MM 98 lithium carbonate 31 LOTRISONE 47

Index 21 MARATHON MEDICAL MEDLANCE PLUS melphalan 28 PENTIPS31GX8MM 98 LANCETS 77 memantine hcl 130 MARATHON MEDICAL MEDLANCE PLUS LANCETS PENTIPS32GX4MM 98 LITE 25G 77 MENACTRA 135 MARPLAN 15 MEDLANCE PLUS LITE MENS PACK 120 MATULANE 30 LANCETS 25G 77 MENVEO 135 MEDLANCE PLUS SPECIAL MAVIK 25 LANCETS 0.8MM 77 MEPERIDINE HCL 5 MAXALT 115 MEDLANCE PLUS meperidine hcl 5 MAXALT-MLT 115 SUPERLITE 30G/COMFORT MEPHYTON 137 MAXI-COMFORT INSULIN MAX 77 meprobamate 9 MEDLANCE PLUS SYRINGE/U- mercaptopurine 28 100/0.5ML/28GX1/2" 98 UNIVERSAL LANCETS MAXI-COMFORT INSULIN 21G 77 mesalamine 59 SYRINGE/U-100/1ML/28GX1/2" MEDLANCE/EXTRA 77 MESNEX 30 98 MEDLANCE/LITE 77 MESTINON 28 MAXIMIN PACK 120 MEDLANCE/UNIVERSAL 77 MESTINON TIMESPAN 28 MAXITROL 127 MEDROL 42 METADATE CD 1 MAXX LUBRICATED 70 MEDROL DOSEPAK 42 METAMUCIL 63 MAXX PLUS SPERMICIDE medroxyprogesterone METAMUCIL ORIGINAL LUBRICATED 70 acetate 130 TEXTURE 63 MAXZIDE 56 medroxyprogesterone acetate METAPROTERENOL MAXZIDE-25 56 (contraceptive) 42 SULFATE 11 meclizine hcl 22 mefloquine hcl 28 metformin hcl 18 MEDIC INSULIN MEFLOQUINE HCL 28 METFORMIN SYRINGE/0.3ML/30G X MEGA MULTIVITAMIN 120 HYDROCHLORIDE 18 5/16" 98 MEGACE ES 130 methadone hcl 5 MEDIC INSULIN MEGACE ORAL 29 methazolamide 55 SYRINGE/0.5ML/30G X methenamine mandelate 135 5/16" 98 megestrol acetate 29 megestrol acetate methenamine-hyosc-methylene MEDICHOICE PRE-SET blue-sod phos-phenyl sal 134 SAFETY LANCET DUAL (appetite) 130 USE 76 MEIJER ALCOHOL SWABS methimazole 132 MEDICHOICE PRE-SET EXTRA-THICK 82 METHITEST 6 SAFETY LANCET LOW MEIJER COLOR LANCETS methocarbamol 123 UNIVERSAL 33G 77 FLOW 76 methotrexate sodium 28 MEDICHOICE PRE-SET MEIJER LANCETS 77 METHOTREXATE SODIUM 29 SAFETY LANCET MEDIUM MEIJER LANCETS THIN 77 FLOW 76 MEIJER LANCETS methotrexate sodium 29 MEDICHOICE PRE-SET UNIVERSAL21G 77 methyldopa 26 SAFETY LANCET MODERATE MEIJER LANCETS FLOW 76 methylergonovine maleate 129 UNIVERSAL30G 77 methylphenidate hcl 1,2 MEDICHOICE SAFETY MEIJER LANCETS LANCETEXTRA 76 UNIVERSAL33G 77 METHYLPHENIDATE HCL MEDICHOICE SAFETY MEIJER PEN NEEDLES 29G ER 1 LANCETNORMAL 77 X12MM 98 methylprednisolone 42 MEDICINE SHOPPE PEN MEIJER PEN NEEDLES 31G METIPRANOLOL 125 NEEDLES 29G X 12MM 98 X6MM 98 metoclopramide hcl 59 MEDICINE SHOPPE PEN MEIJER PEN NEEDLES 31G NEEDLES 31G X 6MM 98 X8MM 98 metolazone 56 MEDICINE SHOPPE PEN MEIJER SUPER THIN metoprolol & NEEDLES 31G X 8MM 98 LANCETS 77 hydrochlorothiazide 27 MEDISENSE THIN metoprolol succinate 38 LANCETS 77 MEKINIST 30 melatonin 2 METOPROLOL SUCCINATE MEDLANCE PLUS EXTRA ER/HYDROCHLOROTHIAZIDE LANCETS 21G 77 meloxicam 3 27

Index 22 metoprolol tartrate 38 misoprostol 134 MONOJECT INSULIN METOPROLOL/HYDROCHLOR MM INSULIN SYRINGE/U- SYRINGE/PERM NEEDLE/U- OTHIAZIDE 27 100/0.3ML/30G X 5/16" 98 100/0.5ML/28G X 1/2" 99 METROCREAM 51 MM INSULIN SYRINGE/U- MONOJECT INSULIN SYRINGE/SAFETY/PERM METROGEL-VAGINAL 136 100/0.3ML/31G X 5/16" 98 MM INSULIN SYRINGE/U- NEEDLE/0.3ML/29G X 1/2" 99 METROLOTION 51 100/1/2ML/30G X 5/16" 98 MONOJECT INSULIN metronidazole 8 MM INSULIN SYRINGE/U- SYRINGE/SAFETY/PERM metronidazole (topical) 51 100/1/2ML/31G X 5/16" 98 NEEDLE/0.3ML/29GX1/2" 99 MM INSULIN SYRINGE/U- MONOJECT INSULIN metronidazole vaginal 136 100/1ML/30G X 5/16" 98 SYRINGE/SAFETY/PERM MEVACOR 24 MM INSULIN SYRINGE/U- NEEDLE/0.5ML/29G X 1/2" 99 mexiletine hcl 9 100/1ML/31G X 5/16" 98 MONOJECT INSULIN MM LANCING DEVICE 77 SYRINGE/SAFETY/PERM MH MACULAR HEALTH 120 NEEDLE/1ML/29G X 1/2" 99 MIACALCIN 57 MM PEN NEEDLES 31G X 1/4" 98 MONOJECT INSULIN MICARDIS 25 MM PEN NEEDLES 31G X SYRINGE/SOFTPACK/1ML/27G MICARDIS HCT 27 3/16" 98 X 1/2" 99 MONOJECT INSULIN MICATIN 47 MM PEN NEEDLES 31G X 5/16" 99 SYRINGE/SOFTPACK/U- MICONAZOLE 3 136 MM PEN NEEDLES 32G X 100/0.5ML/28G X 1/2" 99 miconazole nitrate (topical) 47 5/32" 99 MONOJECT INSULIN MOBIC 3 SYRINGE/U-100/0.3ML/30G X miconazole nitrate vaginal 136 5/16" 99 MICRO-K 116 MODICON 41 MONOJECT INSULIN MICROCHAMBER 113 MOI-STIR 118 SYRINGE/U-100/0.5ML/28G X MICROLET LANCETS 77 MOLINDONE 1/2" 99 MONOJECT INSULIN MICROLET NEXT 77 HYDROCHLORIDE 33 mometasone furoate 49 SYRINGE/U-100/0.5ML/30G X MICROSPACER 113 mometasone furoate 5/16" 99 MICROZIDE 56 (nasal) 124 MONOJECT INSULIN midazolam hcl 63 MONISTAT 1 COMBO SYRINGE/U-100/1ML/28G X 1/2" 99 midodrine hcl 137 PACK 136 MONISTAT 1 DAY OR NIGHT MONOJECT INSULIN miglitol 17 COMBO PACK 136 SYRINGE/U-100/1ML/30G X miglustat 61 5/16" 99 MONISTAT 3 136 MONOJECT ULTRA COMFORT MIGRANAL 114 MONISTAT 3 COMBINATION INSULIN SYRINGE/0.3ML/29G X MILK OF MAGNESIA PACK 136 1/2" 99 CONCENTRATE 64 MONISTAT 7 SIMPLY MONOJECT ULTRA COMFORT MILLIPRED 42 CURE 136 INSULIN SYRINGE/0.3ML/30G X MONISTAT SOOTHING CARE 5/16" 99 MINI LANCING DEVICE 77 ITCH RELIEF 49 MINIPRESS 26 MONOJECT ULTRA COMFORT MONOCLATE-P 60 INSULIN SYRINGE/0.3ML/31G X MINIVELLE 58 MONODOX 132 5/16" 99 MINOCIN 132 MONOJECT INSULIN MONOJECT ULTRA COMFORT minocycline hcl 132 SYRINGE/1ML/31G X INSULIN SYRINGE/0.5ML/28G X minoxidil 28 5/16" 99 1/2" 99 MONOJECT INSULIN MONOJECT ULTRA COMFORT MIRALAX 64 SYRINGE/DETACH INSULIN SYRINGE/0.5ML/29G X MIRAPEX 31 NEEDLE/1ML/25G X 5/8" 99 1/2" 99 MIRASORB SPONGES 2" X MONOJECT INSULIN MONOJECT ULTRA COMFORT 2" 69 SYRINGE/DETACH INSULIN SYRINGE/0.5ML/30G X MIRASORB SPONGES 4" X NEEDLE/1ML/27G X 1/2" 99 5/16" 99 4" 69 MONOJECT INSULIN MONOJECT ULTRA COMFORT MIRCERA 61 SYRINGE/PERM INSULIN SYRINGE/0.5ML/31G X 5/16" 99 MIRCETTE 41 NEEDLE/1ML/28G X 1/2" 99 mirtazapine 14

Index 23 MONOJECT ULTRA COMFORT multiple vitamins w/ minerals & neomycin-bacitracin-polymyxin INSULIN SYRINGE/1ML/28G X folic acid 120 47 1/2" 100 mupirocin 46 neomycin-polymy- MONOJECT ULTRA COMFORT mupirocin calcium (topical) 46 dexameth 127 INSULIN SYRINGE/1ML/29G X neomycin-polymyxin w/ 1/2" 100 MYAMBUTOL 28 pramoxine 47 MONOJECT ULTRA COMFORT mycophenolate mofetil 117 neomycin-polymyxin-gramicidin INSULIN SYRINGE/1ML/30G X mycophenolate mofetil 126 5/16" 100 hcl 117 neomycin-polymyxin-hc MONOLET LANCETS 77 mycophenolate sodium 117 (otic) 128 NEOMYCIN/POLYMYXIN/HYDR MONOLET OPD LANCETS 77 MYDRIACYL 126 OCORTISONE 127 MONOLETTOR SAFETY MYFORTIC 117 NEORAL 117,118 LANCETS 77 MYLERAN 28 MONONINE 60 NEOSPORIN 126 MYLICON 58 NEOSPORIN ORIGINAL 47 montelukast sodium 10 MYLICON INFANTS GAS MOORE MED MONOJECT NEOSPORIN PLUS PAIN RELIEF 58 RELIEF MAXIMUM INSULIN SYRINGE/U- MYNATAL 121 100/0.5ML/28G X 1/2" 100 STRENGTH 47 MOORE MED MONOJECT MYSOLINE 13 NEPHROCAPS 119 INSULIN SYRINGE/U- nabumetone 3 NEPTAZANE 55 100/0.5ML/29G X 1/2" 100 nadolol 38 NESINA 19 MOORE MED MONOJECT INSULIN SYRINGE/U- naloxone hcl 21 NEURONTIN 13 100/1ML/28G X 1/2" 100 naltrexone hcl 21 NEUTRAPHOR 51 MOORE MED MONOJECT NAMENDA 130 NEUTRAPHORUS REX 51 INSULIN SYRINGE/U- NAMENDA TITRATION NEUTROGENA AGE SHIELD 100/1ML/29G X 1/2" 100 PAK 130 FACE SUNBLOCK WITH morphine sulfate 5 NAPROSYN 3 HELIOPLEX SPF110 53 MORPHINE SULFATE 5 naproxen 3,4 NEUTROGENA AGE SHIELD morphine sulfate 5 FACE SUNBLOCK WITH naproxen sodium 3 HELIOPLEX SPF70 53 MOTRIN INFANTS DROPS 3 naratriptan hcl 115 NEUTROGENA COOLDRY MOUTHKOTE 119 NARCAN 21 SPORTWITH HELIOPLEX SPF moxifloxacin hcl (ophth) 126 30 53 NARDIL 15 NEUTROGENA HEALTHY MOZOBIL 62 NASACORT ALLERGY DEFENSE DAILY MS CONTIN 5 24HR 124 MOISTURIZER MS INSULIN NASACORT ALLERGY 24HR PURESCREEN 53 SYRINGE/0.3ML/31G X CHILDRENS 124 NEUTROGENA MEN SPF 5/16" 100 NASAL 20 53 MS INSULIN DECONGESTANT 124 NEUTROGENA MOISTURE SYRINGE/0.5ML/31G X NASALCROM 124 SPF15UNTINTED 53 5/16" 100 NASONEX 124 NEUTROGENA SPORT FACE MS INSULIN SYRINGE/1ML/31G NAT-RUL PRENATAL SUNBLOCK WITH HELIOPLEX X 5/16" 100 VITAMINS 121 SPF70 53 MUCINEX 45 nateglinide 20 NEUTROGENA T/GEL 54 MUCINEX D 44 NATROBA 51 NEUTROGENA T/GEL STUBBORN ITCH MUCINEX D MAXIMUM NECON 1/50-28 41 STRENGTH 44 CONTROL 54 NECON 10/11-28 41 MUCINEX DM 44 NEUTROGENA ULTRA SHEER NEFAZODONE HCL 16 DRY-TOUCH SPF 45 53 MUCINEX MAXIMUM NEUTROGENA ULTRA SHEER STRENGTH 45 nefazodone hcl 16 DRY-TOUCH WITH HELIOPLEX MULTI FOR HER 120 neomycin sulfate 2 SPF 100 53 MULTI FOR HIM 120 neomycin-bacitracin zn- NEUTROGENA ULTRA SHEER MULTI PRENATAL 121 polymyxin 126 DRY-TOUCH WITH HELIOPLEX MULTI-LANCET DEVICE 77 SPF 55 53

Index 24 NEUTROGENA ULTRA SHEER norethindrone NOVOTWIST 30GX8MM 100 DRY-TOUCH WITH HELIOPLEX (contraceptive) 42 NOVOTWIST 32GX5MM 100 SPF 70 53 norethindrone acet & eth NEVANAC 128 estra 41 NPLATE 61 nevirapine 35 norethindrone acetate 130 NU GAUZE 4PLY 4"X4" 69 NU GAUZE GENERAL-USE NEXAVAR 30 norethindrone acetate-ethinyl estradiol 58 SPONGES 4"X4" 4 PLY 69 NEXIUM 134 norethindrone acetate-ethinyl NULYTELY/FLAVOR NEXPLANON 42 estradiol-fe 41 PACKS 64 niacin 137 norethindrone-eth estradiol NUMOISYN 119 (triphasic) 41 NUPLAZID 31 niacin (antihyperlipidemic) 25 norgestimate-ethinyl NIACIN TR 137 estradiol 41 NUVARING 41 NIACOR 25 norgestimate-ethinyl estradiol NUVIGIL 2 NIASPAN 25 (triphasic) 41 NUWIQ 60 norgestrel & ethinyl nystatin 22 nicardipine hcl 39 estradiol 41 NICODERM CQ 131 NORINYL 1+35 41 nystatin (mouth-throat) 118 NICORETTE 131 NORPACE 9 nystatin (topical) 47 NICORETTE MINI 131 NORPACE CR 9 nystatin-triamcinolone 47 NICORETTE STARTER NYTOL MAXIMUM NORPRAMIN 17 STRENGTH 62 KIT 131 NORTEMP INFANTS 4 nicotine 131 O-CAL FA 121 nortriptyline hcl 17 nicotine polacrilex 131 OBIZUR 60 NICOTINE TRANSDERMAL NORVASC 39 OCEAN NASAL SPRAY 123 SYSTEM 132 NORVIR 35 OCUFEN 128 NICOTROL INHALER 132 NOVA MAX PLUS KETONE OCUFLOX 126 TESTSTRIPS 54 NICOTROL NS 132 NOVA SUREFLEX ODOMZO 29 nifedipine 39 LANCETS 77 OFLOXACIN 58 NINLARO 30 NOVA SUREFLEX LANCING ofloxacin 58 DEVICE 77 NITRO-BID 8 ofloxacin (ophth) 126 NOVOEIGHT 60 NITRO-DUR 8 ofloxacin (otic) 128 NOVOFINE 30GX8MM 100 nitrofurantoin 135 OGESTREL 41 NOVOFINE 32GX6MM 100 nitrofurantoin macrocrystal 135 OINTMENT BASE 50 nitrofurantoin monohyd NOVOFINE AUTOCOVER 30GX8MM 100 olanzapine 33 macro 135 NOVOFINE PLUS nitroglycerin 8,9 olmesartan medoxomil 26 32GX4MM 100 olmesartan medoxomil- NITROSTAT 9 NOVOLIN 70/30 20 amlodipine-hydrochlorothiazide NIVA-PLUS 121 NOVOLIN 70/30 RELION 20 27 NIVEA HAND THERAPY 53 NOVOLIN N 20 olmesartan medoxomil- hydrochlorothiazide 27 NIVEA VISAGE UV CARE DAILY NOVOLIN N RELION 20 FACIAL 53 omega-3 fatty acids 125 20 NIX CREME RINSE 51 NOVOLIN R omeprazole 134 20 NIZORAL 47 NOVOLIN R RELION OMEPRAZOLE 134 20 NOR-QD 42 NOVOLOG OMNIPRED 127 20 NORCO 6 NOVOLOG FLEXPEN ON CALL LANCING 20 NORDITROPIN FLEXPRO 57 NOVOLOG MIX 70/30 DEVICE 77 NOVOLOG MIX 70/30 ON CALL PLUS LANCING norethin acet & estrad-fe 41 PREFILLED FLEXPEN 20 DEVICE 77 norethindrone & eth estradiol41 NOVOLOG PENFILL 20 ondansetron 22 norethindrone & ethinyl estradiol- NOVOPEN ECHO 100 ondansetron hcl 22 fe 41 NOVOSEVEN RT 60 ONDANSETRON HYDROCHLORIDE 22

Index 25 ONETOUCH CLUB LANCETS ORTHO TRI-CYCLEN LO 41 PC UNIFINE PENTIPS 31G FINE POINT 77 ORTHO-CYCLEN 41 X6MM ULTRA SHORT 100 ONETOUCH COMBO PACK 77 PC UNIFINE PENTIPS 31G ORTHO-NOVUM 1/35 41 ONETOUCH DELICA LANCETS X8MM SHORT 100 EXTRA FINE 33G 77 ORTHO-NOVUM 7/7/7 41 PCE 66 ONETOUCH DELICA LANCETS oseltamivir phosphate 37 ped multivitamins w/fl & FINE 30G 77 OSENI 18 iron 121 ONETOUCH DELICA LANCING OTICIN HC NR 128 PEDIA-LAX 64 DEVICE 77 PEDIALYTE 116 ONETOUCH ULTRASOFT OTREXUP 2 LANCETS 77 PEDIALYTE FREEZER OVACE PLUS WASH 48 POPS 116 ONGLYZA 19 OVACE WASH 48 pediatric multiple vitamins 121 OPTICHAMBER OVCON-35 41 ADVANTAGE/LARGE pediatric vitamins acd w/ MASK 113 OVIDE 51 fluoride 121 OPTICHAMBER oxaprozin 4 pediatric vitamins adc 121 ADVANTAGE/MEDIUM FACE oxazepam 9 PEDVAX HIB 135 MASK 113 OXAZEPAM 9 peg 3350-kcl-sod bicarb-sod OPTICHAMBER chloride-sod sulfate 64 ADVANTAGE/SMALL FACE oxcarbazepine 13 peg 3350-potassium chloride-sod MASK 113 oxybutynin chloride 135 bicarbonate-sod chloride 64 OPTICHAMBER DIAMOND114 oxycodone hcl 5 PEGANONE 13 OPTICHAMBER oxycodone w/ PEN NEEDLES 29G X DIAMOND/LARGEFACE acetaminophen 6 12MM 100 MASK 114 oxycodone-aspirin 6 PEN NEEDLES 29GX1/2" 100 OPTICHAMBER OXYCODONE/ACETAMINOPH PEN NEEDLES 30GX5/16" 100 DIAMOND/MEDIUM FACE EN 6 MASK 114 PEN NEEDLES 30GX8MM 100 OPTICHAMBER oyster shell 116 PEN NEEDLES 31G X 1/4" DIAMOND/SMALLFACE OZEMPIC 19 SHORT 100 MASK 114 PA MENS 50 PLUS PEN NEEDLES 31G X OPTICHAMBER FACE VITAPAK 120 3/16" 100 MASK/LARGE 114 PA MENS VITAPAK 120 PEN NEEDLES 31G X OPTICHAMBER FACE PA WOMENS 50 PLUS 5MM 100 MASK/MEDIUM 114 VITAPAK 120 PEN NEEDLES 31G X 6MM 100 OPTICHAMBER FACE PA WOMENS VITAPAK 120 MASK/SMALL 114 PEN NEEDLES 31G X OPTIFOAM 69 paliperidone 32 8MM 100 OPTIHALER 114 PAMELOR 17 PEN NEEDLES 31GX5/16" 100 OPTIHALER MDI DRUG PANCREAZE 55 PEN NEEDLES 31GX6MM DELIVERY SYSTEM 114 PANOXYL-4 CREAMY (1/4") 100 oral electrolytes 116 WASH 46 PEN NEEDLES 31GX8MM 100 ORAL RELIEF SPRAY FOR pantoprazole sodium 134 PEN NEEDLES 31GX8MM DRYMOUTH & PARLODEL 31 (5/16") 100 DISCOMFORT 119 PEN NEEDLES 32G X PARNATE 15 4MM 100 ORALAIR 2 paroxetine hcl 15 PEN NEEDLES 32G X ORALAIR ADULT SAMPLE PARVA-CAL 116 5MM 100 KIT 2 PEN NEEDLES 32G X ORALAIR ADULT STARTER PAXIL 15,16 6MM 100 PACK 2 PAXIL CR 15 PEN NEEDLES 32GX4MM 100 ORALAIR PC LANCETS SUPER THIN PENICILLIN V CHILDREN/ADOLESCENTS 30G 77 POTASSIUM 129 STARTER PACK 2 PC UNIFINE PENTIPS 29G penicillin v potassium 129 ORKAMBI 132 X1/2" 100 PENTIPS 29G X 12MM 101 ORTHO MICRONOR 42 PC UNIFINE PENTIPS 31G PENTIPS 29GX12MM 101 ORTHO TRI-CYCLEN 41 X5MM MINI 100 PENTIPS 31G X 5MM 101

Index 26 PENTIPS 31G X 8MM 101 pioglitazone hcl 19 pramoxine-hc-chloroxylenol PENTIPS 31GX5MM 101 pioglitazone hcl- 129 PRANDIN 20 PENTIPS 31GX6MM 101 glimepiride 18 pioglitazone hcl-metformin prasugrel hcl 61 PENTIPS 31GX8MM 101 hcl 18 PRAVACHOL 25 PENTIPS 32G X 4MM 101 piroxicam 4 pravastatin sodium 25 PENTIPS 32GX4MM 101 PLAN B ONE-STEP 42 prazosin hcl 26 pentoxifylline 61 PLAQUENIL 28 PRE SUN KIDS 53 PEPCID 133 PLAVIX 61 PRE-NATAL FORMULA 122 PEPCID AC 133 PLEGRIDY 131 PRECISION SURE-DOSE PEPCID AC MAXIMUM PLEGRIDY STARTER INSULIN SYRINGE/0.3ML/30G X STRENGTH 133 PACK 131 5/16" 101 PEPTO BISMOL 21 PNEUMOVAX 23 135 PRECISION SURE-DOSE PEPTO-BISMOL 21 PNEUMOVAX 23/1 INSULIN SYRINGE/0.5ML/28G X PEPTO-BISMOL DOSE 135 1/2" 101 INSTACOOL 21 PNV FOLIC ACID + IRON PRECISION SURE-DOSE PEPTO-BISMOL MAX MULTIVITAMIN 121 INSULIN SYRINGE/0.5ML/29G X STRENGTH 21 PNV PRENATAL PLUS 1/2" 101 PEPTO-BISMOL TO-GO 21 MULTIVITAMIN 121 PRECISION SURE-DOSE PERCOCET 6 POCKET CHAMBER 114 INSULIN SYRINGE/0.5ML/30G X POCKET SPACER 114 3/8" 101 PERFECT LANCETS 30G 77 PRECISION SURE-DOSE PERIDEX 118 podofilox 51 INSULIN SYRINGE/1ML/28G X permethrin 51 polyethylene glycol 3350 64 1/2" 101 POLYMEM DRESSING/3" X PRECISION SURE-DOSE perphenazine 34 3" 69 PLUSINSULIN PERPHENAZINE/AMITRIPTYLIN POLYMEM DRESSING/4" X SYRINGE/0.3ML/29G X E 131 4" 69 1/2" 101 PEXEVA 16 polymyxin b-trimethoprim 126 PRECISION SURE-DOSE PHARMACY COUNTER polysaccharide iron PLUSINSULIN LANCETS 77 complex 62 SYRINGE/1ML/29G X 1/2" 101 phenazopyridine hcl 60 POLYSPORIN 47 PRECISION THIN phenelzine sulfate 15 LANCETS 77 POLYTRIM 126 PRECISION THINS GP phenobarbital 62 polyvinyl alcohol 125 LANCET 77 PHENOBARBITAL 63 POMALYST 29 PRECISION ULTRA phenobarbital 63 pot phosphate monobasic w/ LANCET 77 PHENOBARBITAL SODIUM 62 sod phosphate dibasic & PRECISION XTRA 54 phenylephrine hcl (ophth) 127 monobasic 116 PRECOSE 17 potassium bicarbonate 116 phenylephrine hcl (oral) 124 PRED FORTE 127 phenylephrine-chlorphen-dm potassium chloride 117 PRED MILD 127 44 POTASSIUM CHLORIDE PRED-G 127 phenylephrine-dm 44 ER 117 potassium chloride PREDATOR 51 phenylephrine-shark liver oil- microencapsulated crystals PREDNICARBATE 49 cocoa butter 7 117 phenylephrine-shark liver oil- er prednicarbate 49 potassium citrate PREDNISOLONE 42 mineral oil-petrolatum 7 (alkalinizer) 59 phenytoin 13 potassium citrate-citric acid59 prednisolone 42 prednisolone acetate phenytoin sodium extended 13 POTIGA 13 PHLEXY-VITS 120 (ophth) 127 povidone-iodine 34 PREDNISOLONE ACETATE P- phytonadione 137 pramipexole F 127 pilocarpine hcl 126 dihydrochloride 31 prednisolone sodium pilocarpine hcl (oral) 119 PRAMOTIC 128 phosphate 42 pindolol 38 pramoxine hcl (rectal) 7

Index 27 PREDNISOLONE SODIUM PRENATAL FORMULA 122 PRO COMFORT INSULIN PHOSPHATE 127 PRENATAL FORTE 122 SYRINGES/1ML/30G X PREDNISONE 43 1/2" 102 PRENATAL LOW IRON 122 prednisone 43 PRO COMFORT INSULIN PRENATAL SYRINGES/1ML/30G X PREDNISONE 43 MULTIVITAMIN 122 5/16" 102 PREDNISONE INTENSOL 43 PRENATAL ONE DAILY 122 PRO COMFORT INSULIN PREFERRED PLUS INSULIN PRENATAL PLUS 122 SYRINGES/1ML/31G X SYRINGE/U-100/0.3ML/29G X PRENATAL VITAMIN 122 5/16" 102 1/2" 101 PRO COMFORT PEN PREFERRED PLUS INSULIN PRENATAL VITAMIN & NEEDLES/31G X 8MM 102 SYRINGE/U-100/0.3ML/30G X MINERAL 122 PRO COMFORT PEN PRENATAL 5/16" 101 NEEDLES/32G X 4MM 102 PREFERRED PLUS INSULIN VITAMIN/IRON 123 PRO COMFORT PEN SYRINGE/U-100/0.5ML/28G X PRENATAL VITAMINS 123 NEEDLES/32G X 5MM 102 1/2" 101 PRENATAL VITAMINS PLUS PRO COMFORT PEN PREFERRED PLUS INSULIN LOW IRON 123 NEEDLES/32G X 6MM 102 SYRINGE/U-100/0.5ML/29G X PREPLUS 123 probenecid 60 1/2" 101 PRESCRIPTIVE FORMULAS PROCARDIA 39 PREFERRED PLUS INSULIN OPTIMAL VITAMIN PACKS PROCARDIA XL 39 SYRINGE/U-100/0.5ML/30G X MENS 120 5/16" 101 PRESCRIPTIVE FORMULAS prochlorperazine 34 PREFERRED PLUS INSULIN OPTIMAL VITAMIN PACKS prochlorperazine edisylate 34 SYRINGE/U-100/1ML/28G X WOMENS 120 prochlorperazine maleate 34 1/2" 101 PRESSURE ACTIVATED PREFERRED PLUS INSULIN SAFETYLANCET 21G 78 PROCRIT 61 SYRINGE/U-100/1ML/29G X PREVACID 134 PROCTOFOAM 7 1/2" 101 PREVACID 24HR 134 PRODIGY INSULIN SYRING/U- PREFERRED PLUS INSULIN 100/0.3ML/31G X 5/16" 102 SYRINGE/U-100/1ML/30G X PREVACID SOLUTAB 134 PRODIGY INSULIN 5/16" 101 PREVIDENT 5000 DRY SYRINGE/1/2ML/31G X PREFERRED PLUS LANCETS MOUTH 118 5/16" 102 COLORED 21G 78 PREVIDENT 5000 PLUS 118 PRODIGY INSULIN PREFERRED PLUS LANCETS PREVIDENT FLUORIDE 118 SYRINGE/1ML/28G X 1/2" 102 SUPER THIN 30G 78 PRODIGY LANCING PREFERRED PLUS LANCETS PREVNAR 13 135 DEVICE 78 THIN 26G 78 PREZCOBIX 36 PRODIGY TWIST TOP PREFERRED PLUS UNIFINE PREZISTA 36 LANCETS 78 PENTIPS 29G X 12MM 101 PRILOSEC 134 PROFILNINE 61 PREFERRED PLUS UNIFINE PROFILNINE SD 61 PENTIPS 31G X 6MM ULTRA PRIMAQUINE SHORT 101 PHOSPHATE 28 progesterone micronized 130 PREFERRED PLUS UNIFINE primidone 13 PROGLYCEM 19 PENTIPS 31G X 8MM PRINIVIL 25 PROGRAF 118 SHORT 101 PRISTIQ 16 PREFERRED PLUS UNIFINE PROMACTA 61 PRO COMFORT ALCOHOL promethazine & PENTIPS 32GX4MM 101 PADS 82 PREFERRED PLUS UNIFINE phenylephrine 44 PRO COMFORT INSULIN promethazine hcl 24 PENTIPS/MINI/31GX5MM 101 SYRINGES/0.5ML/30G X PREMARIN 58,137 1/2" 102 promethazine w/codeine 44 PREMIUM CONDOMS PRO COMFORT INSULIN promethazine-dm 45 LUBRICATED 70 SYRINGES/0.5ML/30G X promethazine-phenylephrine- PREMIUM PACKETS 120 5/16" 102 codeine 45 PREMPHASE 58 PRO COMFORT INSULIN PROMETHAZINE/PHENYLEPHR SYRINGES/0.5ML/31G X PREMPRO 58 INE 45 5/16" 102 PROMETRIUM 130 PRENATAL 122 propafenone hcl 9 PRENATAL AND IRON 122 propranolol hcl 38

Index 28 PROPRANOLOL HCL 38 PX INSULIN SYRINGE/U- quinapril-hydrochlorothiazide propranolol hcl 38 100/1ML/31G X 5/16" 102 27 PX LANCET AUTO PROPRANOLOL/HYDROCHLOR quinidine gluconate 9 INJECTOR 78 QUINIDINE SULFATE 9 OTHIAZIDE 27 PX LANCETS ULTRA propylthiouracil 132 THIN 78 RA ADVANCED HEALING 50 PROSCAR 59 PX MINI PEN NEEDLES RA ALCOHOL SWABS 82 PROSHIELD PLUS SKIN 31GX5MM 102 RA ALL PURPOSE PROTECTANT 51 PX OMEPRAZOLE 134 DRESSINGS4"X4" 69 PROTONIX 134 PX PEN NEEDLE RA DRESSING SPONGES PROTOPIC 50 29GX12MM 102 4"X4" 69 PX PEN NEEDLE RA DRY MOUTH 119 protriptyline hcl 17 31GX8MM 102 RA E-ZJECT COLOR PROVERA 130 PX PRENATAL LANCETSMICRO-THIN 33G 78 PROZAC 16 MULTIVITAMINS 123 RA E-ZJECT LANCETS 28G78 pseudoephed-bromphen-dm 45 PX SHORTLENGTH PEN RA E-ZJECT LANCETS THIN NEEDLES/31GX8MM 102 26G 78 pseudoephedrine hcl 124 pyrazinamide 28 pseudoephedrine w/ codeine- RA E-ZJECT LANCETS THIN pyrethrins-piperonyl 28G 78 gg 45 butoxide 52 pseudoephedrine-chlorphen-dm RA E-ZJECT LANCETS pyrethrins-piperonyl butoxide- ULTRATHIN 30G 78 45 permethrin-nit remover 52 pseudoephedrine-guaifenesin RA ESSENCE-C 120 45 PYRIDIUM 60 RA GAUZE SPONGES pseudoephedrine-ibuprofen 45 pyridostigmine bromide 28 4"X4" 69 pyridoxine hcl 137 RA INSULIN PSORCON 49 SYRINGE/0.5ML/29G X PSS SELECT GP LANCETS 78 QC ADVANCED LANCING DEVICE 78 1/2" 102 PSS SELECT SAFETY RA INSULIN SYRINGE/1ML/29G LANCETS 78 QC ALCOHOL SWABS 82 X 1/2" 102 psyllium 63 QC ALL PURPOSE RA INSULIN SYRINGE/U- DRESSINGS4"X4" 69 PTS PANELS KETONE 100/0.5ML/30G X 5/16" 102 QC BORDER ISLAND GAUZE RA INSULIN SYRINGE/U-100/1 TEST 54 PAD 2"X2" 69 PULMICORT 10 ML/30G X 5/16" 102 QC LANCETS SUPER RA LANCING DEVICE 78 PULMICORT FLEXHALER 10 THIN 78 RA OMEPRAZOLE 134 PULMOZYME 132 QC LANCETS ULTRA THIN 78 RA PEN NEEDLES 31G X PURE & FREE BABY 5MM3/16" 102 SUNSCREEN BROAD QC PEN NEEDLES 29G X 12MM 102 RA PEN NEEDLES 31G X SPECTRUM SPF 60+ 53 QC PEN NEEDLES 31G X 8MM5/16" 102 PURIXAN 29 6MM 102 RA PRENATAL 123 PUSH BUTTON SAFETY QC PEN NEEDLES 31G X RA PRENATAL LANCETS 21G 78 8MM 102 FORMULA/FOLICACID 123 PUSH BUTTON SAFETY QC PRENATAL 123 RA RX SUNCARE ADVANCED LANCETS 28G 78 PROTECTION SPF50 53 PX ADVANCED LANCING QC STERILE PADS 69 DEVICE 78 QC UNIFINE PENTIPS RA STERILE PADS 2"X2" 69 PX EXTRA SHORT PEN 32GX4MM 102 RA STERILE PADS 3"X3" 69 NEEDLES 31GX6MM 102 QC UNILET LANCETS RA STERILE PADS 4"X4" 69 28G/ULTRA THIN 78 PX INSULIN SYRINGE/U- RAGWITEK 2 100/0.3ML/30G X 1/2" 102 QC UNILET LANCETS PX INSULIN SYRINGE/U- 33G/MICRO THIN 78 raloxifene hcl 57 100/0.3ML/31G X 5/16" 102 QTERN 18 ramipril 25 PX INSULIN SYRINGE/U- QUESTRAN 24 ranitidine hcl 133 100/0.5ML/30G X 1/2" 102 PX INSULIN SYRINGE/U- QUESTRAN LIGHT 24 RAPAMUNE 118 100/0.5ML/31G X 5/16" 102 quetiapine fumarate 33 RASUVO 2 PX INSULIN SYRINGE/U- quinapril hcl 25 100/1ML/30G X 1/2" 102

Index 29 RAY-TEC X-RAY RELION INSULIN SYRINGE/U- RETROVIR 36 DETECTABLESPONGES 4" X 4" 100/1ML/31G X 5/16" 103 RETROVIR IV INFUSION 36 16 PLY 69 RELION KETONE 54 REVATIO 39,40 RAZADYNE 131 RELION KETONE TEST REXALL LANCETS ULTRA RAZADYNE ER 130 STRIPS 54 RELION LANCETS MICRO- THIN 78 REALITY INSULIN SYRINGE/U- REXULTI 34 100/0.5ML/28G X 1/2" 103 THIN33G 78 REALITY INSULIN SYRINGE/U- RELION LANCETS REYATAZ 36 100/0.5ML/29G X 1/2" 103 STANDARD 21G 78 RHEUMATREX 3 RELION LANCETS THIN REALITY INSULIN SYRINGE/U- RIASTAP 61 100/1ML/28G X 1/2" 103 26G 78 REALITY INSULIN SYRINGE/U- RELION LANCETS ULTRA- riboflavin 138 100/1ML/29G X 1/2" 103 THIN30G 78 RID 52 REALITY LANCETS 78 RELION LANCING RID COMPLETE LICE DEVICE 78 REALITY LATEX ELIMINATION 52 RELION MINI PEN NEEDLES RIFADIN 28 CONDOMS/LUBRICATED 70 31GX6MM 103 REALITY LATEX/ULTRA RELION PEN NEEDLES rifampin 28 TEXTURED 70 29GX12MM 103 RIGHT STEP PRENATAL 123 REALITY LATEX/ULTRA RELION PEN NEEDLES THIN 70 RIGHTEST GD500 LANCING 31GX6MM 103 DEVICE 78 REALITY SWABS 82 RELION PEN NEEDLES RIGHTEST GL300 REBIF 131 31GX8MM 103 LANCETS 78 REBIF REBIDOSE 131 RELION PEN NEEDLES RIOMET 18 REBIF REBIDOSE 32GX4MM 103 RELION SHORT PEN risedronate sodium 57 TITRATIONPACK 131 NEEDLES31GX8MM 103 RISPERDAL 32 REBIF TITRATION PACK 131 RELION ULTRA THIN RISPERDAL CONSTA 32 RECOMBINATE 61 LANCETS30G 78 RISPERDAL M-TAB 32 RECOMBIVAX HB 136 RELION ULTRA THIN PLUS risperidone 32 REGLAN 59 LANCETS 32G 78 RELION ULTRA THIN PLUS RISPERIDONE ODT 32 RELENZA DISKHALER 37 LANCETS 33G 78 RITALIN 2 RELION 2-IN-1 LANCING RELPAX 115 DEVICE 25G 78 RITEFLO 114 RELION 2-IN-1 LANCING REMEDY NUTRASHIELD 51 ritonavir 36 DEVICE 30G 78 REMERON 14 rivastigmine 131 RELION ALCOHOL SWABS 82 REMERON SOLTAB 14 rivastigmine tartrate 131 RELION INSULIN SYRINGE repaglinide 20 RIXUBIS 61 1ML/31GX15/64" 103 REPAGLINIDE/METFORMIN RELION INSULIN SYRINGE/U- HYDROCHLORIDE 18 rizatriptan benzoate 115 00/1ML/29G X 1/2" 103 REQUIP 31 ROBAXIN 123 RELION INSULIN SYRINGE/U- ROBAXIN-750 123 100/0.3ML/29G X 1/2" 103 RESCRIPTOR 36 RELION INSULIN SYRINGE/U- RESTORE CONTACT ROBINUL 133 100/0.3ML/30G X 5/16" 103 LAYER/NON-ADHERENT ROBINUL FORTE 133 RELION INSULIN SYRINGE/U- 2"X2" 69 ROBITUSSIN DM 45 100/0.3ML/31G X 5/16" 103 RESTORE FOAM DRESSING BORDERED 4"X4" 69 ROBITUSSIN PEAK COLD RELION INSULIN SYRINGE/U- COUGH+ CHEST CONGESTION 100/0.5ML/29G X 1/2" 103 RESTORE FOAM DRESSING NON-BORDERED 4"X4" 69 DM MAX STRENGTH 45 RELION INSULIN SYRINGE/U- ROBITUSSIN PEAK COLD 100/0.5ML/30G X 5/16" 103 RESTORE ODOR ABSORBING DRESSING DM 45 RELION INSULIN SYRINGE/U- ROC MULTI CORREXION 5 IN1 100/0.5ML/31G X 5/16" 103 4"X4" 69 RELION INSULIN SYRINGE/U- RESTORE TRIO ABSORBENT DAILY MOISTURIZER SPF 100/1ML/30G X 5/16" 103 DRESSING 3"X3" 69 30 53 RELION INSULIN SYRINGE/U- RESTORIL 63 ROC RETINOL CORREXION 100/1ML/31G X 15/64" 103 SPF30 53 RETIN-A 46 ROCALTROL 57

Index 30 ROMIDEPSIN 30 SANDIMMUNE 118 SEROQUEL XR 33 ropinirole hydrochloride 31 SAPHRIS 33 SEROSTIM 57 rosuvastatin calcium 25 SARNA 48 sertraline hcl 16 ROXICODONE 5 SAVELLA 131 SFROWASA 59 RYTHMOL 10 SAVELLA TITRATION SHADE SUNBLOCK SPF 4553 SAFE-T-LANCE LOW FLOW PACK 131 SHADE UVAGUARD SPF 25G 78 SB ALCOHOL PREP 15 53 SAFE-T-LANCE NORMAL PADS 82 SHINGRIX 136 FLOW21G 78 SB INSULIN SYRINGE/U- 100/0.5ML/29G X 1/2" 104 SHOHLS SOLUTION SAFE-T-LANCE PLUS MODIFIED 59 SAFETYLANCET LOW SB INSULIN SYRINGE/U- 100/0.5ML/30G X 5/16" 104 SHOPKO ALCOHOL FLOW 78 SWABS 82 SAFE-T-LANCE PLUS SB INSULIN SYRINGE/U- 100/1ML/29G X 1/2" 104 SHOPKO AUTOLET LANCING SAFETYLANCET NORMAL DEVICE 79 FLOW 78 SB INSULIN SYRINGE/U- 100/1ML/30G X 5/16" 104 SHOPKO ON-THE-GO SAFESNAP INSULIN COMFORTLANCETS 30G 79 SYRINGE/0.3ML/30G X SB INSULIN SYRINGE/U- 100/1ML/31G X 5/16" 104 SHOPKO UNIFINE PENTIPS 5/16" 103 PEN SAFESNAP INSULIN SB LANCETS THIN 79 NEEDLES/MICRO/32GX4MM SYRINGE/0.5ML/29G X SB LANCETS ULTRA 104 1/2" 103 THIN 79 SHOPKO UNIFINE PENTIPS SAFESNAP INSULIN SB OMEPRAZOLE 134 PEN NEEDLES/MINI/31GX5MM SYRINGE/0.5ML/30G X SCHNUCKS INSULIN 104 5/16" 103 SYRINGEULTI-FINE/U- SHOPKO UNIFINE PENTIPS SAFESNAP INSULIN 100/0.5ML/29G X 1/2" 104 PEN SYRINGE/1ML/28G X 1/2" 103 SCHNUCKS INSULIN NEEDLES/ORIGINAL/29GX12M SAFESNAP INSULIN SYRINGEULTI-FINE/U- M 104 SYRINGE/1ML/29G X 1/2" 103 100/0.5ML/30G X 5/16" 104 SHOPKO UNIFINE PENTIPS SAFETY INSULIN SYRINGES Seasonal Influenza PEN 0.5ML/29GX1/2" 103 Vaccine 136 NEEDLES/SHORT/31GX8MM SAFETY INSULIN SYRINGES SEASONIQUE 41 104 0.5ML/30GX5/16" 103 SECONAL SODIUM 63 SHOPKO UNIFINE PENTIPS SAFETY INSULIN SYRINGES PLUS PEN 1ML/27GX1/2" 103 SECTRAL 38 NEEDLES/MICRO/REMOVR/32 SAFETY INSULIN SYRINGES SELECT-LITE LANCING GX4MM 104 1ML/29GX1/2" 103 DEVICE 79 SHOPKO UNIFINE PENTIPS SAFETY INSULIN SYRINGES selegiline hcl 31 PLUS PEN 1ML/30GX1/2" 104 selenium sulfide 48 NEEDLES/MINI/REMOVER/31G SAFETY LANCETS 28G 79 SELSUN BLUE 48 X5MM 104 SAFETY LET LANCETS 79 SHOPKO UNIFINE PENTIPS SAFETY SEAL LANCETS SELSUN BLUE DAILY 48 PLUS PEN 28G 79 SELSUN BLUE NEEDLES/REMOVER/29GX12M SAFETY SEAL LANCETS MEDICATED 48 M 104 30G 79 SELSUN BLUE SHOPKO UNIFINE PENTIPS SAFETY-GLIDE INSULIN MOISTURIZING 48 PLUS PEN SYRINGE/0.3ML/29G X SELZENTRY 36 NEEDLES/SHORT/REMOVR/31 1/2" 104 SENNA 64 GX8MM 104 SAIZEN 57 sennosides 64 SHOPKO UNILET LANCETS SAIZEN CLICK.EASY 57 SUPER THIN 30G 79 sennosides-docusate SHOPKO UNILET LANCETS sodium 64 SAIZENPREP ULTRA THIN 28G 79 RECONSTITUTIONKIT 57 SENOKOT 64 SIDE BUTTON SAFETY SALAGEN 119 SENOKOT S 64 LANCET21G 79 salicylic acid 51 SENOKOT XTRA 64 sildenafil citrate (pulmonary saline 123 SEREVENT DISKUS 11 hypertension) 40 SILENOR 63 salsalate 5 SEROQUEL 33 SILPHEN COUGH 23

Index 31 SILVADENE 48 sodium fluoride (dental) 118 sulfacetamide sod- silver sulfadiazine 48 sodium phosphates 64 prednisolone 127 sulfacetamide sodium 48 simethicone 58 sodium polystyrene sulfonate 118 SULFACETAMIDE SIMPLE DIAGNOSTICS SODIUM 126 LANCING DEVICE 79 SODIUM sulfacetamide sodium (acne)46 simvastatin 25 SULFACETAMIDE/SULFUR 46 sulfacetamide sodium SINEMET 31 SOF-WICK 4"X4" 69 (ophth) 126 SINEMET CR 31 SOLBAR AVO 53 sulfamethoxazole- trimethoprim 8 SINGLE-LET 79 SOLBAR PF SPF15 53 SINGULAIR 10 sulfasalazine 59 SOLIQUA 100/33 18 sulindac 4 sirolimus 118 SOLUS V2 LANCING SIVEXTRO 8 DEVICE 79 sumatriptan 115 SKIN BEAUTY & SONATA 63 sumatriptan succinate 115 WELLNESS 120 SORBITOL 64 SUMATRIPTAN SKYLA 42 SUCCINATE 115 sotalol hcl 38 sumatriptan succinate 115 SLO-NIACIN 138 sotalol hcl (afib/afl) 38 SM ALCOHOL PREP PADS 82 sunscreens 54 SPINOSAD 52 SUPER NU-THERA 120 SM GAUZE PADS 2"X2" 69 spironolactone 56 SM GAUZE PADS 3"X3" 69 SUPER THIN LANCETS 79 spironolactone & SURE COMFORT INSULIN SM GAUZE PADS 4"X4" 69 hydrochlorothiazide 56 SYRINGE/U-100/0.3ML/29G X SM GLUCOSE 19 SPORANOX 22 1/2" 104 SM INSULIN SYRINGE/1ML/31G SPORANOX PULSEPAK 22 SURE COMFORT INSULIN X 5/16" 104 SPRYCEL 30 SYRINGE/U-100/0.3ML/30G X 1/2" 104 SM IPECAC SYRUP 21 STAMARIL 136 SM MICRO THIN LANCETS SURE COMFORT INSULIN 33G 79 STARLIX 20 SYRINGE/U-100/0.3ML/30G X SM OMEPRAZOLE 134 stavudine 36 5/16" 104 SURE COMFORT INSULIN SM PRENATAL VITAMINS 123 STERILANCE TL 79 STERILE GAUZE PADS SYRINGE/U-100/0.3ML/31G X SM STERILE PADS 69 5/16 104 2"X2" 69 SM STERILE PADS 2"X2" 69 STERILE GAUZE PADS SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X SM TRUEDRAW LANCING 3"X3" 69 5/16" 104 DEVICE 79 STERILE PADS 2"X2" 69 SMART DIABETES VANTAGE SURE COMFORT INSULIN LANCING DEVICE 79 STERILE PADS 3"X3" 69 SYRINGE/U-100/0.5ML/28G X SMART SENSE COLOR STERILE PADS 4"X4" 69 1/2" 104 LANCETS UNIVERSAL 33G 79 STIOLTO RESPIMAT 11 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X SMART SENSE STANDARD STIVARGA 30 LANCETS UNIVERSAL 21G 79 1/2" 104 SMART SENSE SUPER THIN STRATTERA 1 SURE COMFORT INSULIN LANCETS UNIVERSAL 30G 79 STRIBILD 36 SYRINGE/U-100/0.5ML/30G X 1/2" 104 SMART SENSE THIN STROVITE FORTE 120 LANCETSUNIVERSAL 26G 79 SURE COMFORT INSULIN SUBOXONE 6 SMARTEST LANCETS 28G 79 SYRINGE/U-100/0.5ML/30G X sucralfate 134 5/16" 105 sodium bicarbonate (antacid) 7 SUDAFED CHILDRENS 124 SURE COMFORT INSULIN sodium chloride 117 SUDAFED SYRINGE/U-100/0.5ML/31G X 105 SODIUM CHLORIDE 117 CONGESTION 124 5/16 sodium chloride (gu irrigant) 59 SUDAFED NASAL SURE COMFORT INSULIN DECONGESTANT MAXIMUM SYRINGE/U-100/1ML/28G X sodium chloride (inhalant) 45 105 STRENGTH 124 1/2" sodium citrate & citric acid 59 SUDAFED PE SURE COMFORT INSULIN sodium fluoride 116 CONGESTION 124 SYRINGE/U-100/1ML/29G X 1/2" 105

Index 32 SURE COMFORT INSULIN SURE-JECT INSULIN TECFIDERA STARTER SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/29G X PACK 131 1/2" 105 1/2" 105 TECHLITE AST LANCETS 79 SURE COMFORT INSULIN SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/30G X 100/0.3ML/29G X 1/2" 105 5/16" 105 5/16" 105 TECHLITE INSULIN SYRINGEU- SURE COMFORT INSULIN SURE-JECT INSULIN 100/0.3ML/30G X 1/2" 106 SYRINGE/U-100/1ML/31G X SYRINGE/U-100/1ML/31G X TECHLITE INSULIN SYRINGEU- 5/16" 105 5/16" 105 100/0.3ML/30G X 5/16" 106 SURE COMFORT LANCING SURE-LANCE THIN LANCETS TECHLITE INSULIN SYRINGEU- PEN 79 28G 79 100/0.3ML/31G X 5/16" 106 SURE COMFORT PEN SURE-LANCE ULTRA THIN TECHLITE INSULIN SYRINGEU- NEEDLES29GX1/2" LANCETS 79 100/0.5ML/29G X 1/2" 106 12.7MM 105 SURE-PEN 79 TECHLITE INSULIN SYRINGEU- SURE COMFORT PEN SURE-TOUCH LANCETS 100/0.5ML/30G X 1/2" 106 NEEDLES30GX5/16" UNIVERSAL 79 TECHLITE INSULIN SYRINGEU- SHORT 105 SURELITE LANCETS 79 100/0.5ML/30G X 5/16" 106 SURE COMFORT PEN TECHLITE INSULIN SYRINGEU- NEEDLES31GX3/16" SURGICAL GAUZE SPONGE 69 100/0.5ML/31G X 5/16" 106 (5MM) 105 TECHLITE INSULIN SYRINGEU- SURE COMFORT PEN SURMONTIL 17 100/1ML/29G X 1/2" 106 NEEDLES31GX5/16" SUSTIVA 36 TECHLITE INSULIN SYRINGEU- (8MM) 105 SUTENT 30 100/1ML/30G X 1/2" 106 SURE COMFORT PEN SW OMEPRAZOLE 134 TECHLITE INSULIN SYRINGEU- NEEDLES32GX5/32" 105 100/1ML/30G X 5/16" 106 SURE COMFORT PEN SYMBICORT 11 TECHLITE INSULIN SYRINGEU- NEEDLES32GX6MM 105 SYMLINPEN 120 17 100/1ML/31G X 15/64" 106 SURE-FINE PEN NEEDLES SYMLINPEN 60 17 TECHLITE INSULIN SYRINGEU- 29GX1/2" 12.7MM 105 100/1ML/31G X 5/16" 106 SYNAGEX 120 SURE-FINE PEN NEEDLES TECHLITE LANCETS 79 SYNAGIS 129 31GX3/16" 5MM 105 TECHLITE LANCETS 30G 79 SURE-FINE PEN NEEDLES SYNAREL 57 31GX5/16" 8MM 105 TECHLITE PEN NEEDLES 29GX SURE-JECT INSULIN SYNATEK 120 12 MM 106 SYRINGE/U-100/0.3ML/29G X SYNJARDY 18 TECHLITE PEN NEEDLES 31GX 1/2" 105 SYNJARDY XR 18 5MM 106 TECHLITE PEN NEEDLES/31GX SURE-JECT INSULIN SYNTHROID 132 SYRINGE/U-100/0.3ML/30G X 5MM 106 5/16" 105 tacrolimus 118 TECHLITE PEN NEEDLES/31GX SURE-JECT INSULIN tacrolimus (topical) 50 6 MM 106 SYRINGE/U-100/0.3ML/31G X TECHLITE PEN NEEDLES/31GX TAFINLAR 30 8MM 106 5/16" 105 TAGAMET HB 133 SURE-JECT INSULIN TECHLITE PEN NEEDLES/32GX SYRINGE/U-100/0.5ML/28G X TAMIFLU 37 4MM 106 TECHLITE PEN NEEDLES/32GX 1/2" 105 tamoxifen citrate 29 6MM 106 SURE-JECT INSULIN tamsulosin hcl 59 SYRINGE/U-100/0.5ML/29G X TEGADERM FOAM DRESSING TANZEUM 19 2"X2" 69 1/2" 105 TEGADERM FOAM DRESSING SURE-JECT INSULIN TAPAZOLE 132 4"X4" 69 SYRINGE/U-100/0.5ML/30G X TARCEVA 30 TEGRETOL 13 5/16" 105 TARGRETIN 30 SURE-JECT INSULIN TEGRETOL-XR 13 TASIGNA 30 SYRINGE/U-100/0.5ML/31G X TEKTURNA 27 TAVIST ALLERGY 23 5/16" 105 TEKTURNA HCT 27 SURE-JECT INSULIN tazarotene 48 telmisartan 26 SYRINGE/U-100/1ML/28G X TAZORAC 48 1/2" 105 telmisartan-amlodipine 27 TEARS NATURALE PM 125 telmisartan-hydrochlorothiazide TECFIDERA 131 27

Index 33 temazepam 63 THERANATAL LACTATION TODAYS HEALTH SHORT PEN TEMODAR 28 COMPLETE 120 NEEDLES 31G X 5/16" 106 thiamine hcl 138 TODAYS HEALTH SUPER TEMOVATE 49 thiamine mononitrate 138 THINLANCETS 30G 80 TEMOVATE E 49 TODAYS HEALTH ULTRA THINLETS GP LANCETS 80 temozolomide 28 THINLANCETS 28G 80 THINLETS LANCET 80 TENCON 4 TOFRANIL 17 thioridazine hcl 34 TENEX 26 TOLAZAMIDE 21 thiothixene 34 TENIVAC 133 TOLBUTAMIDE 21 thyroid 132 tenofovir disoproxil fumarate 36 TOLMETIN SODIUM 4 THYROLAR-1 132 TENORETIC 100 27 tolmetin sodium 4 THYROLAR-1/2 132 TENORETIC 50 27 TOLMETIN SODIUM 4 THYROLAR-1/4 132 TENORMIN 38 tolnaftate 47 THYROLAR-2 132 TERAZOL 3 136 tolterodine tartrate 135 THYROLAR-3 132 TERAZOL 7 136 TOPAMAX 13 tiagabine hcl 13 terazosin hcl 26 TOPAMAX SPRINKLE 13 TIAZAC 39 TOPCARE CLICKFINE terbinafine hcl 22 TIKOSYN 10 UNIVERSAL PEN EEDLES terbinafine hcl (topical) 47 31GX1/4" 106 TIMOLOL MALEATE 38 terbutaline sulfate 11 TOPCARE CLICKFINE timolol maleate (ophth) 126 TERCONAZOLE 136 UNIVERSAL PEN EEDLES TIMOLOL MALEATE 31GX5/16" 106 terconazole vaginal 136,137 OPHTHALMIC GEL TOPCARE LANCETS MICRO- TESSALON PERLES 43 FORMING 126 THIN 33G 80 testosterone cypionate 6 TIMOPTIC 126 TOPCARE ULTRA COMFORT TETANUS/DIPHTHERIA TIMOPTIC OCUDOSE 126 INSULIN SYRINGE/0.3ML/30G X TOXOIDS-ADSORBED 133 5/16" 106 TIMOPTIC-XE 126 TOPCARE ULTRA COMFORT tetracaine hcl (ophth) 127 TINACTIN 47 INSULIN SYRINGE/0.3ML/31G X tetrahydrozoline hcl (ophth) 127 TINACTIN JOCK ITCH 47 5/16" 106 TGT ADVANCED LANCING TOPCARE ULTRA COMFORT DEVICE 79 tioconazole vaginal 137 INSULIN SYRINGE/0.5ML/30G X TGT ALCOHOL SWABS 82 TIVICAY 36 5/16" 106 TGT LANCET ALTERNATE tizanidine hcl 123 TOPCARE ULTRA COMFORT SITE 79 TOBI 2 INSULIN SYRINGE/0.5ML/31G X 5/16" 106 TGT LANCET MICRO THIN TOBI PODHALER 2 33G 79 TOPCARE ULTRA COMFORT TGT LANCET SUPER THIN TOBRADEX 127 INSULIN SYRINGE/1ML/30G X 30G 79 TOBRAMYCIN 2 5/16" 107 TGT LANCET THIN 23G 79 tobramycin 2 TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/31G X TGT LANCET THIN 26G 79 tobramycin (ophth) 127 5/16" 107 TGT LANCET ULTRA THIN TOBRAMYCIN SULFATE 2 TOPCARE ULTRA COMFORT 28G 79 tobramycin sulfate 2 INSULIN SYRINGE/U- TGT LANCET ULTRA THIN 100/0.3ML/29G X 1/2" 107 30G 79 tobramycin- dexamethasone 127 TOPCARE ULTRA COMFORT TGT LANCING DEVICE 80 INSULIN SYRINGE/U- TOBREX 127 TGT OMEPRAZOLE 134 100/0.5ML/29G X 1/2" 107 TODAYS HEALTH ADVANCED THEO-24 11 TOPCARE ULTRA COMFORT LANCING DEVICE 80 INSULIN SYRINGE/U- theophylline 11 TODAYS HEALTH MINI PEN 100/1ML/29G X 1/2" 107 THERA-FLUR-N 118 NEEDLES 31G X 1/4" 106 TOPCO INSULIN SYRINGE/U- TODAYS HEALTH ORIGINAL THERAGAUZE 69 100/0.3ML/29G X 1/2" 107 PEN NEEDLES 29G X TOPCO INSULIN SYRINGE/U- THERANATAL CORE 1/2" 106 NUTRITION 123 100/0.5ML/28G X 1/2" 107

Index 34 TOPCO INSULIN SYRINGE/U- TRIAZOLAM 63 trospium chloride 135 100/0.5ML/29G X 1/2" 107 triazolam 63 TRUE METRIX BLOOD TOPCO INSULIN SYRINGE/U- TRIBENZOR 27 GLUCOSETEST STRIPS 54 100/1ML/28G X 1/2" 107 TRUE METRIX CONTROL TOPCO INSULIN SYRINGE/U- TRICARE 123 SOLUTION LEVEL 1 80 100/1ML/29G X 1/2" 107 TRIDESILON 50 TRUE METRIX CONTROL TOPICORT 50 trifluoperazine hcl 34 SOLUTION LEVEL 2 80 TRUE METRIX CONTROL topiramate 13 trifluridine 127 TOPPER DRESSING SPONGES SOLUTION LEVEL 3 80 4"X4" 69 TRIGLIDE 24 TRUE METRIX SELF TOPROL XL 38 trihexyphenidyl hcl 31 MONITORING BLOOD TRILEPTAL 13 GLUCOSE STRIPS 54 torsemide 56 TRUECONTROL GLUCOSE TOTAL BLOCK SPF 60 trimethoprim 8 CONTROL LEVEL 0 80 COVERUP 54 trimipramine maleate 17 TRUECONTROL GLUCOSE TOTAL BLOCK SPF 65 TRINTELLIX 16 CONTROL LEVEL 1 80 CLEAR 54 TRUEDRAW LANCING TOUJEO MAX SOLOSTAR 20 TRIUMEQ 36 DEVICE 80 TOUJEO SOLOSTAR 20 TRIZIVIR 36 TRUEPLUS INSULIN TROJAN EXTENDED SYRINGE/U-100/0.3ML/29G X TRACLEER 39 PLEASURE/LUBRICATED 1/2" 107 TRADJENTA 19 70 TRUEPLUS INSULIN tramadol hcl 5 TROJAN MAGNUM 70 SYRINGE/U-100/0.3ML/30G X tramadol-acetaminophen 6 TROJAN MAGNUM WARM 5/16" 107 TRUEPLUS INSULIN trandolapril 25 SENSATIONS 70 TROJAN MAGNUM XL SYRINGE/U-100/0.3ML/31G X tranexamic acid 62 LUBRICATED 70 5/16" 107 TRANXENE T 9 TROJAN PLEASURE TRUEPLUS INSULIN tranylcypromine sulfate 15 MESH/SPERMICIDAL 71 SYRINGE/U-100/0.5ML/28G X TROJAN RIBBED 1/2" 107 TRAVEL LANCETS 30G 80 W/SPERMICIDAL 71 TRUEPLUS INSULIN TRAVEL LANCETS ADVANCED TROJAN SHARED SYRINGE/U-100/0.5ML/29G X 28G 80 SENSATION/LUBRICATED 1/2" 107 trazodone hcl 16 71 TRUEPLUS INSULIN TRECATOR 28 TROJAN SUPRAS SYRINGE/U-100/0.5ML/30G X 5/16" 107 TRELSTAR 29 SPERMICIDAL 71 TROJAN TWISTED TRUEPLUS INSULIN TRELSTAR MIXJECT 29 PLEASURE 71 SYRINGE/U-100/0.5ML/31G X TRESIBA FLEXTOUCH 20 TROJAN ULTRA 5/16" 107 tretinoin 46 PLEASURE/LUBRICATED TRUEPLUS INSULIN 71 SYRINGE/U-100/1ML/28G X tretinoin (chemotherapy) 30 TROJAN VERY SENSITIVE 1/2" 107 TRETTEN 61 LUBRICATED 71 TRUEPLUS INSULIN TREXALL 29 TROJAN VERY SENSITIVE SYRINGE/U-100/1ML/29G X TRI-NORINYL 28 41 SPERMICIDAL 1/2" 107 LUBRICANT 71 TRUEPLUS INSULIN TRI-VIT/FLUORIDE/IRON 121 TROJAN VERY THIN SYRINGE/U-100/1ML/30G X triamcinolone acetonide LUBRICATED 71 5/16" 107 (mouth) 118 TROJAN VERY THIN TRUEPLUS INSULIN triamcinolone acetonide SPERMICIDAL SYRINGE/U-100/1ML/31G X (nasal) 124 LUBRICANT 71 5/16" 107 triamcinolone acetonide TROJAN-ENZ TRUEPLUS LANCETS 26G 80 (topical) 50 LUBRICANT 71 TRUEPLUS LANCETS 28G 80 TRIAMINIC COLD & COUGH TROJAN-ENZ DAY TIME CHILDRENS 45 TRUEPLUS LANCETS 28G LUBRICATED 71 SUPER THIN 80 triamterene & TROJAN-ENZ hydrochlorothiazide 56 W/SPERMICIDAL 71 TRUEPLUS LANCETS 30G 80 TRIAMTERENE/HYDROCHLOR tropicamide 126 TRUEPLUS LANCETS 30G OTHIAZIDE 56 ULTRA THIN 80

Index 35 TRUEPLUS LANCETS 33G 80 TRUSTEX/RIA LUBRICATED ULTICARE INSULIN TRUEPLUS PEN NEEDLES SPERMICIDE 71 SYRINGE/0.3ML/30G X 29GX12MM 107 TRUSTEX/RIA 5/16" 108 TRUEPLUS PEN NEEDLES LUBRICATED/SPERMICIDE ULTICARE INSULIN 31GX5MM 107 71 SYRINGE/0.5ML/28G X TRUEPLUS PEN NEEDLES TRUVADA 36 1/2" 108 31GX6MM 107 TUDORZA PRESSAIR 10 ULTICARE INSULIN SYRINGE/0.5ML/29G X TRUEPLUS PEN NEEDLES TUMS 7 31GX8MM 107 1/2" 108 TRUEPLUS PEN NEEDLES TUMS CHEWY BITES 7 ULTICARE INSULIN 32GX4MM 107 TUMS E-X 750 7 SYRINGE/0.5ML/30G X TRUEPLUS SAFETY LANCETS TUMS EXTRA STRENGTH 1/2" 108 28G 80 750 7 ULTICARE INSULIN TRUETEST BLOOD GLUCOSE TUMS KIDS 7 SYRINGE/0.5ML/30G X TEST 55 5/16" 108 TRUETEST BLOOD GLUCOSE TUMS LASTING EFFECTS 7 ULTICARE INSULIN TEST STRIPS 54 TUMS SMOOTHIES 7 SYRINGE/1ML/28G X 1/2" 108 TRUETEST GLUCOSE TUMS ULTRA 1000 8 ULTICARE INSULIN CONTROLLEVEL 1 80 SYRINGE/1ML/29G X 1/2" 108 TRUETEST GLUCOSE TWINRIX 136 ULTICARE INSULIN CONTROLLEVEL 2 80 TWYNSTA 27 SYRINGE/1ML/30G X 1/2" 108 TRUETEST GLUCOSE TYBOST 36 ULTICARE INSULIN CONTROLLEVEL 3 80 TYKERB 30 SYRINGE/1ML/30G X 5/16" 108 TRUETEST STRIPS 55 TYLENOL 4 TRUETRACK BLOOD ULTICARE INSULIN GLUCOSE TEST 55 TYLENOL CHILDRENS 4 SYRINGE/SHORT/0.3ML/30G X TRUETRACK TEST 55 TYLENOL CHILDRENS 5/16" 108 CHEWABLES/PAIN + ULTICARE INSULIN TRULICITY 19 FEVER 4 SYRINGE/SHORT/0.3ML/31G X TRUMENBA 135 TYLENOL EXTRA 5/16" 108 TRUSOPT 128 STRENGTH 4 ULTICARE INSULIN TRUSTEX COLOR CONDOMS + TYLENOL INFANTS 4 SYRINGE/SHORT/0.5ML/30G X LUBE 71 TYLENOL INFANTS 5/16" 108 PAIN+FEVER 4 ULTICARE INSULIN TRUSTEX LUBRICATED 71 SYRINGE/SHORT/0.5ML/31G X TRUSTEX LUBRICATED TYLENOL/CODEINE #3 6 5/16" 108 EXTRALARGE 71 TYLENOL/CODEINE #4 6 ULTICARE INSULIN TRUSTEX LUBRICATED TYSABRI 131 SYRINGE/SHORT/1ML/30G X EXTRASTRENGTH 71 TYVASO 39 5/16" 108 TRUSTEX ULTICARE INSULIN LUBRICATED/RIBBED/STUDDE TYVASO REFILL 39 SYRINGE/SHORT/1ML/31G X D 71 TYVASO STARTER 39 5/16" 108 TRUSTEX ULTI-LANCE AUTOMATIC/ ULTICARE INSULIN LUBRICATED/SPERMICIDE CLEAR TIP 80 SYRINGE/U-100/0.3ML/29G X 71 ULTICARE ALCOHOL 1/2" 108 TRUSTEX SWABS 82 ULTICARE INSULIN LUBRICATED/SPERMICIDE ULTICARE INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X EXTRA LARGE 71 SYRINGE/0.5ML/29G X 1/2" 108 TRUSTEX 1/2" 108 ULTICARE INSULIN LUBRICATED/SPERMICIDE ULTICARE INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X EXTRA STRENGTH 71 SYRINGE/1ML/29G X 5/16" 108 TRUSTEX NATURAL 1/2" 108 ULTICARE INSULIN CONDOMS ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X +LUBE/LUBRICATED 71 SYRINGE/0.3ML/29G X 5/16" 108 TRUSTEX WITH NONOXYNOL- 1/2" 108 ULTICARE INSULIN 9/RIBBED/STUDDED 71 ULTICARE INSULIN SYRINGE/U-100/0.5ML/29G X TRUSTEX/RIA SYRINGE/0.3ML/30G X 1/2" 108 LUBRICATED 71 1/2" 108

Index 36 ULTICARE INSULIN ULTILET CLASSIC ULTILET SHORT PEN SYRINGE/U-100/0.5ML/30G X LANCETS 80 NEEDLES31GX3/16" 110 1/2" 108 ULTILET INSULIN ULTIMATE FEELING 71 ULTICARE INSULIN SYRINGE/0.3ML/30G X ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 8MM 109 SYRINGE/U-100/0.3ML/30G X 5/16" 108 ULTILET INSULIN 5/16" 110 ULTICARE INSULIN SYRINGE/0.3ML/31G X ULTRA MENS PACK 120 8MM 109 SYRINGE/U-100/0.5ML/31G X ULTRA THIN LANCETS 5/16" 108 ULTILET INSULIN ULTICARE INSULIN SYRINGE/0.5ML/30G X 28G 80 SYRINGE/U-100/1ML/29G X 8MM 109 ULTRA WOMENS PACK 120 1/2" 108 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE INSULIN SYRINGE/1ML/30G X SYRINGE/U-100/0.3ML/29G X SYRINGE/U-100/1ML/30G X 8MM 109 1/2" 110 1/2" 109 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE INSULIN SYRINGE/1ML/31G X SYRINGE/U-100/0.3ML/30G X SYRINGE/U-100/1ML/30G X 8MM 109 5/16" 110 5/16" 109 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30G SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/1ML/31G X X 12.7MM 109 5/16" 110 5/16" 109 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30G SYRINGE/U-100/0.5ML/28G X SYRINGEULTRAFINE U- X 5/16" 109 1/2" 110 100/0.3ML/31G X 5/16" 109 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE INSULIN SYRINGE/SHORT/0.3ML/31G SYRINGE/U-100/0.5ML/29G X SYRINGEULTRAFINE U- X 5/16" 109 1/2" 110 100/0.5ML/31G X 5/16" 109 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE INSULIN SYRINGE/SHORT/0.5ML/30G SYRINGE/U-100/0.5ML/30G X SYRINGEULTRAFINE U- X 5/16" 109 5/16" 110 100/1ML/31G X 5/16" 109 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE MICRO PEN SYRINGE/SHORT/0.5ML/31G SYRINGE/U-100/0.5ML/31G X NEEDLES 31G X 8MM 109 X 5/16" 109 5/16" 110 ULTICARE MICRO PEN ULTILET INSULIN ULTRA-COMFORT INSULIN NEEDLES 32G X 4MM 109 SYRINGE/SHORT/1ML/30G X SYRINGE/U-100/1ML/28G X ULTICARE MICRO PEN 5/16" 109 1/2" 110 NEEDLES/32G X 4MM 109 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE MINI PEN NEEDLES SYRINGE/SHORT/1ML/31G X SYRINGE/U-100/1ML/29G X 31GX6MM 109 5/16" 109 1/2" 110 ULTICARE MINI PEN NEEDLES ULTILET INSULIN ULTRA-COMFORT INSULIN ULTI-FINE IV 109 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/1ML/30G X ULTICARE MINI PEN 1/2" 110 5/16" 110 NEEDLES/31G X 6MM 109 ULTILET INSULIN ULTRA-COMFORT INSULIN ULTICARE MINI PEN SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/31G X NEEDLES31GX6MM 109 1/2" 110 5/16" 110 ULTICARE ORIGINAL PEN ULTILET LANCETS 80 ULTRA-THIN II INSULIN NEEDLES ULTI-FINE 109 SYRINGE SHORT/U- ULTICARE PEN NEEDLES ULTILET LANCETS 33G 80 100/0.3ML/30GX5/16" 110 31GX 5MM/MINI 109 ULTILET PEN NEEDLE ULTRA-THIN II INSULIN ULTICARE PEN 29GX12.7MM 110 SYRINGE SHORT/U- NEEDLES/29GX 12.7MM 109 ULTILET PEN NEEDLE 100/0.3ML/31GX5/16" 110 ULTICARE SHORT PEN 31GX5MM 110 ULTRA-THIN II INSULIN NEEDLES 31GX8MM 109 ULTILET PEN NEEDLE SYRINGE SHORT/U- ULTICARE SHORT PEN 31GX8MM 110 100/0.5ML/30GX5/16" 110 NEEDLES ULTI-FINE IV 109 ULTILET PEN NEEDLE ULTRA-THIN II INSULIN ULTICARE SHORT PEN 32GX4MM 110 SYRINGE SHORT/U- NEEDLES/31G X 8MM 109 ULTILET PEN NEEDLE 100/0.5ML/31GX5/16" 110 ULTICARE THIN LANCETS 32GX4MM/SHORT 110 ULTRA-THIN II INSULIN 30G 80 ULTILET SHORT PEN SYRINGE SHORT/U- NEEDLES 31GX5/16" 110 100/1ML/30GX5/16" 110

Index 37 ULTRA-THIN II INSULIN UNILET LANCETS ULTRA- VALUE PLUS LANCETS SYRINGE SHORT/U- THIN 28G 80 STANDARD 21G 81 100/1ML/31GX5/16" 110 UNILET SUPERLITE VALUE PLUS LANCETS ULTRA-THIN II INSULIN LANCET 80 SUPERTHIN 30G 81 SYRINGE/U- UNISOM 62 VALUE PLUS LANCETS THIN 100/0.3ML/29GX1/2" 110 UNISOM SLEEPGELS 62 26G 81 VALUE PLUS LANCING ULTRA-THIN II INSULIN UNISTIK TOUCH SAFETY SYRINGE/U- DEVICE 81 LANCETS 23G 80 VALUMARK LANCET SUPER 100/0.5ML/29GX1/2" 111 UNIVERSAL 1 LANCETS ULTRA-THIN II INSULIN THIN 30G 81 THIN26G 81 VALUMARK LANCET ULTRA SYRINGE/U-100/1ML/29GX1/2" UNIVERSAL 1 LANCETS 111 THIN 28G 81 ULTRA THIN 30G 81 VALUMARK PEN NEEDLES ULTRA-THIN II MINI PEN UNIVERSAL 1 NEEEDLES/31GX3/16" 111 29GX12MM 111 LANCETS/33G/MICRO-THIN VALUMARK PEN NEEDLES ULTRA-THIN II PEN NEEDLES 81 29GX1/2" 111 31GX 6MM 111 ULTRA-THIN II PEN urea 50 VALUMARK PEN NEEDLES NEEDLES/SHORT/31GX5/16" URECHOLINE 135 31GX 8MM 111 111 UROCIT-K 10 59 VALVED HOLDING CHAMBER 114 ULTRACET 6 UROCIT-K 5 59 VANCOCIN HCL 8 ULTRAM 5 URSO 250 59 vancomycin hcl 8 UNIFINE PENTIPS ursodiol 59 29GX12MM 111 VANISHPOINT INSULIN UNIFINE PENTIPS 31G X V-R MONOJECT INSULIN SYRINGE/0.5ML/30G X 3/16" 111 SYRINGE/U-100/0.3ML/29G X 1/2" 111 UNIFINE PENTIPS 1/2" 111 VANISHPOINT INSULIN 31GX5MM 111 V-R MONOJECT INSULIN SYRINGE/0.5ML/30G X UNIFINE PENTIPS SYRINGE/U-100/0.5ML/28G X 5/16" 111 31GX6MM 111 1/2" 111 VANISHPOINT INSULIN UNIFINE PENTIPS V-R MONOJECT INSULIN SYRINGE/1ML/29G X 1/2" 111 31GX8MM 111 SYRINGE/U-100/0.5ML/29G X VANISHPOINT INSULIN UNIFINE PENTIPS 1/2" 111 SYRINGE/1ML/30G X 32GX4MM 111 V-R MONOJECT INSULIN 5/16" 111 UNIFINE PENTIPS PLUS SYRINGE/U-100/1ML/28G X VANTAS 29 1/2" 111 29GX12MM 111 VAQTA 136 UNIFINE PENTIPS PLUS V-R MONOJECT INSULIN 31GX5MM 111 SYRINGE/U-100/1ML/29G X VARIVAX 136 UNIFINE PENTIPS PLUS 1/2" 111 VASERETIC 27 31GX6MM 111 VAGISTAT-1 137 VASOTEC 25 UNIFINE PENTIPS PLUS valacyclovir hcl 37 31GX8MM 111 venlafaxine hcl 16 UNIFINE PENTIPS PLUS VALCHLOR 48 VENLAFAXINE HCL ER 16 32GX4MM 111 VALCYTE 37 VENTAVIS 39 UNILET COMFORTOUCH valganciclovir hcl 37 VENTOLIN HFA 11 LANCET 80 VALIUM 9 verapamil hcl 39 UNILET EXCELITE 80 valproate sodium 14 UNILET EXCELITE II 80 VERAPAMIL HCL SR 39 valproic acid 14 VERELAN 39 UNILET G.P. LANCET 80 valsartan 26 UNILET G.P. SUPERLITE VERIPRED 20 43 valsartan-hydrochlorothiazide VERSACLOZ 33 LANCET 80 27 VERSIVA XC 3" X 3" FOAM UNILET GP 28 ULTRA THIN80 VALTREX 37 UNILET LANCET 80 DRESSING/HYDROFIBER VALUE HEALTH INSULIN TECHNOLOGY 70 UNILET LANCETS MICRO- SYRINGE/U-100/0.5ML/29G X THIN33G 80 VERSIVA XC 4" X 4" FOAM 1/2" 111 DRESSING/HYDROFIBER UNILET LANCETS SUPER- VALUE HEALTH INSULIN THIN30G 80 TECHNOLOGY 70 SYRINGE/U-100/1ML/29G X VEXOL 128 1/2" 111

Index 38 VIBRAMYCIN 132 VIVITROL 22 XANAX 9 VICTOZA 19 VOL-PLUS 123 XARELTO 11 VIDA MIA AUTOLET VORTEX VALVED HOLDING XELODA 29 LANCINGDEVICE 81 CHAMBER 114 XIGDUO XR 18 VIDA MIA UNIFINE VOSPIRE ER 11 XTANDI 29 PENTIPS32GX4MM 111 VOTRIENT 30 VIDA MIA UNIFINE XULANE 41 VP INSULIN SYRINGE/U- PENTIPSMINI 31GX6MM 111 XYNTHA 61 VIDA MIA UNIFINE 100/0.3ML/29G X 1/2" 112 PENTIPSORIGINAL VPRIV 61 XYNTHA SOLOFUSE 61 29GX12MM 111 VRAYLAR 31 XYZAL 23 VIDA MIA UNILET LANCETS VYTORIN 24 XYZAL ALLERGY 24HR 23 SUPER THIN 30G 81 YASMIN 28 41 VIDA MIA UNILET LANCETS VYVANSE 1 ULTRA THIN 28G 81 W&F LANCETS 26G 81 YAZ 41 VIDA MIA UNIPFINE W&F LANCETS COLORED ZADITOR 128 PENTIPSSHORT 21G 81 zaleplon 63 31GX8MM 112 WALGREENS COMFORT ZANAFLEX 123 VIDEX EC 36 ASSUREDLANCETS MICRO ZANTAC 133 VIDEXPEDIATRIC 36 THIN/33G 81 WALGREENS COMFORT ZANTAC 150 MAXIMUM VIGAMOX 127 ASSUREDLANCETS SUPER STRENGTH 133 VIIBRYD 16 THIN/28G 81 ZANTAC 75 133 VIIBRYD STARTER PACK 16 WALGREENS GLUCOSE 19 ZARONTIN 14 VIMPAT 13 WALGREENS LANCETS 81 ZARXIO 61 VIRACEPT 36 WALGREENS THIN ZAVESCA 61 LANCETS 81 VIRAMUNE 36 WALGREENS ULTRA THIN ZEBETA 38 VIRAMUNE XR 36 LANCETS 81 ZELBORAF 30 VIREAD 36 warfarin sodium 11 ZERIT 36 VIROPTIC 127 WATCHHALER 114 ZESTORETIC 27 VISINE 127 WATER BABIES SPF 30 54 ZESTRIL 25 VISINE EXTRA 127 WEBCOL ALCOHOL PREP ZETIA 25 VISTARIL 9 LARGE 1 PLY 82 WEBCOL ALCOHOL PREP ZIAC 27 VISTEC X-RAY DETECTABLE LARGE 2 PLY 82 ZIAGEN 36 SPONGES 4"X4" 16 PLY 70 WEBCOL ALCOHOL PREP VITALET PRO PLUS zidovudine 37 MEDIUM 2 PLY 82 ZINBRYTA 131 LANCETS 81 WEGMANS UNIFINE PENTIPS VITAMENT 121 PLUS 32GX4MM 112 ZINC 121 vitamin a 137 WEGMANS UNIFINE PENTIPS zinc oxide (topical) 51 VITAMIN C 138 PLUS/MINI/31GX5MM 112 zinc sulfate 117 VITAMIN C EFFERVESCENT WEGMANS UNIFINE PENTIPS PLUS/SHORT/31GX8MM112 ziprasidone hcl 32 BLEND 121 ZITHROMAX 65 VITAMIN WEGMANS UNIFINE PENTIPS C/ELECTROLYTES 121 PLUS/ULTRA ZITHROMAX TRI-PAK 65 SHORT/31GX6MM 112 vitamin e 137 ZITHROMAX Z-PAK 65 WELLBUTRIN SR 14 VITAMINS TO GO ZOCOR 25 WELLBUTRIN XL 14,15 MAXIMUM 121 ZOFRAN 22 white petrolatum-mineral VITAMINS TO GO MEN 121 ZOFRAN ODT 22 VITAMINS TO GO oil 125 WOMEN 121 WILATE 61 ZOLADEX 29 vitamins w/ lipotropics 123 WOMENS PACK 121 ZOLINZA 30 VITEKTA 36 XALATAN 128 zolmitriptan 115 VIVELLE-DOT 58 XALKORI 30 ZOLOFT 16

Index 39 zolpidem tartrate 63 ZOMIG 115 ZOMIG ZMT 115 ZONEGRAN 13 zonisamide 13 ZORBTIVE 57 ZORTRESS 118 ZOSTAVAX 136 ZOVIRAX 37,48 ZYBAN 132 ZYKADIA 30 ZYLOPRIM 60 ZYPREXA 33 ZYPREXA RELPREVV 33 ZYPREXA ZYDIS 33 ZYRTEC ALLERGY 23 ZYRTEC CHILDRENS ALLERGY 24 ZYRTEC-D ALLERGY/CONGESTION 45 ZYTIGA 29 ZZZQUIL 62

Index 40