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Your 2021 BCBSVT Formulary Effective July 1, 2021

For the most current list of covered medications or if you have questions: Call the pharmacy number on the back of your ID card

Visit bcbsvt.com/vermontbluerx to: • Find a participating retail pharmacy by ZIP code • Look up possible lower-cost medication alternatives • Compare medication pricing and options Understanding your formulary

What is a formulary? About this formulary A formulary is a list of prescribed medications or other When differences between this formulary and your pharmacy care products, services or supplies chosen benefit plan exist, the benefit plan documents rule. This for their safety, cost, and effectiveness. Medications are formulary may not be a complete list of medications that listed by categories or classes and are placed into cost are covered by your plan. Please review your benefit plan levels known as tiers. It includes both brand and generic for full details. prescription medications. To create the list, your plan is guided by the Pharmacy and When does the formulary change? Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how • Medications may move to a lower tier at any time. well the drugs work, as well as their safety and overall value. • Medications may move to a higher tier when a generic equal becomes available. How do I use my formulary? • Medications may move to a higher tier or be excluded from You and your doctor can use the formulary to help you coverage on January 1 or July 1 of each year. choose the most cost-effective prescription medications. If a medication changes tiers, you may have to pay a different This guide tells you if a medication is generic or brand, and amount for that medication. if special rules apply. If your medication is not listed here, please visit bcbsvt.com/vermontbluerx or call the pharmacy Why are some medications excluded number on the back of your ID card. from coverage? A medication may be excluded from coverage under your What are tiers? pharmacy benefit when it works the same as or is similar to Tiers are the different cost levels you pay for a medication another prescription or over-the-counter (OTC) medication. when you fill a prescription. What if I don’t agree with a decision about an excluded medication? You or your doctor can ask for a coverage request by calling the pharmacy number on the back of your ID card.

Medication tips

What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients as brand-name medications, but they often cost less. In some situations, brand-name medications could be lower in cost.

What if my doctor writes a brand-name prescription? If your doctor gives you a prescription for a brand-name medication, ask if a Over-the-counter lower-cost option could be right for you. medications (OTC) What if I am taking a specialty medication? Talk to your doctor about OTC options. Even though OTC Specialty medications are used to treat complex conditions and are generally medications may not be covered higher in cost. Please note, not all specialty medications are listed in the formulary. by your pharmacy benefit, Our specialty pharmacy can provide most of your specialty medications along with they may cost less than a helpful programs and services. Call and ask how you can have (855) 427-4682 prescription medication. your prescriptions delivered right to your home or doctor’s office. Reading your formulary

The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase (for example, clobetasol).

Tier information Using lower tier or preferred medications can help you lower your out-of-pocket cost. Your plan may have multiple or no tiers.

Drug Tier Includes Helpful Tips

Tier CM Oral Chemotherapy $0 copay/bypass deductible for oral chemotherapy drugs

Tier 1 $ Lower-cost Use Tier 1 drugs for the lowest out-of-pocket costs. generics and some brand name

Tier 2 $$ Mid-range cost Use Tier 2 drugs instead of Tier 3 to help reduce your preferred brand out-of-pocket costs. name

Tier 3 $$$ Higher-cost Many Tier 3 drugs have lower-cost options in Tier 1 or 2. brand name and Ask your doctor if they could work for you. some generics

Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

PA Prior Authorization – Your doctor is required to give your plan more information to determine coverage.

QL Quantity Limit – Medication may be limited to a certain quantity.

SP Specialty Medication – Medication is designated as specialty.

ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.

3P Tier 3 preferred Drug Name Drug Tier Requirements/Limits Analgesics - Drugs for Pain acetaminophen intravenous solution 1 ACETAMINOPHEN INTRAVENOUS 3 PA SOLUTION PREFILLED SYRINGE acetaminophen-codeine 1 QL acetaminophen-codeine #2 1 QL acetaminophen-codeine #3 1 QL acetaminophen-codeine #4 1 QL ACTIQ 3 PA; QL alfentanil hcl 1 ALLZITAL 3 PA APADAZ 3 QL apap-caff-dihydrocodeine oral capsule 1 QL apap-caff-dihydrocodeine oral tablet 1 PA; QL ascomp-codeine 1 bac 1 BELBUCA 2 PA; QL BENZHYDROCODONE-ACETAMINOPHEN 3 QL BUPRENEX 3 PA buprenorphine hcl injection 1 buprenorphine transdermal 1 PA; QL butalbital-acetaminophen capsule 50-300 mg 1 PA oral BUTALBITAL-ACETAMINOPHEN CAPSULE 3 PA 50-300 MG ORAL butalbital-acetaminophen oral tablet 25-325 mg, 1 PA 50-300 mg butalbital-acetaminophen oral tablet 50-325 mg 1 butalbital-apap-caff-cod 1 butalbital-apap-caffeine 1 butalbital-asa-caff-codeine 1 butalbital-aspirin-caffeine 1 butorphanol tartrate injection 1 butorphanol tartrate nasal 1 QL carisoprodol-aspirin-codeine 1 codeine sulfate 1 QL CONZIP 3 PA; QL DEMEROL INJECTION SOLUTION 100 3 MG/2ML, 75 MG/ML

Effective Date: 7/1/2021 1 Drug Name Drug Tier Requirements/Limits DEMEROL INJECTION SOLUTION 100 3 PA MG/ML, 25 MG/ML, 50 MG/ML DILAUDID INJECTION SOLUTION 0.2 MG/ML 3 DILAUDID INJECTION SOLUTION 1 MG/ML, 2 3 PA MG/ML DILAUDID ORAL 3 PA; QL DSUVIA 3 PA duramorph 1 endocet 1 QL ESGIC 3 PA 1 PA; QL fentanyl citrate buccal lozenge on a handle 1 PA; QL FENTANYL CITRATE BUCCAL TABLET 3 PA; M; QL FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 3 PA MCG/10ML, 20 MCG/2ML, 50 MCG/5ML, 500 MCG/50ML FENTANYL CITRATE-NACL INJECTION 3 PA FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 1.25-0.9 MG/250ML-%, 2-0.9 3 MG/100ML-% FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MCG/2ML-%, 10-0.9 MCG/ML-%, 1000-0.9 3 MCG/50ML-%, 5-0.9 MCG/ML-%, 550-0.9 MCG/55ML-% FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 100-0.9 3 PA MCG/10ML-% FENTANYL CITRATE-NACL SOLUTION 1-0.9 3 MG/100ML-% INTRAVENOUS FENTANYL CITRATE-NACL SOLUTION 1-0.9 3 PA MG/100ML-% INTRAVENOUS FENTANYL CITRATE-NACL SOLUTION 2.5- 3 0.9 MG/250ML-% INTRAVENOUS FENTANYL CITRATE-NACL SOLUTION 2.5- 3 PA 0.9 MG/250ML-% INTRAVENOUS FENTANYL CITRATE-NACL SOLUTION PREFILLED SYRINGE 500-0.9 MCG/50ML-% 3 INTRAVENOUS FENTANYL CITRATE-NACL SOLUTION PREFILLED SYRINGE 500-0.9 MCG/50ML-% 3 PA INTRAVENOUS

Effective Date: 7/1/2021 2 Drug Name Drug Tier Requirements/Limits FENTANYL-BUPIVACAINE-NACL INJECTION 3 PA FENTORA 3 PA; QL FIORICET 3 PA FIORICET/CODEINE 3 PA hydrocodone bitartrate er oral capsule extended 1 PA; QL release 12 hour hydrocodone bitartrate er oral tablet er 24 hour 1 ST; QL abuse-deterrent hydrocodone-acetaminophen 1 QL hydrocodone-ibuprofen 1 QL hydromorphone hcl er 1 PA; QL HYDROMORPHONE HCL INJECTION 3 SOLUTION 0.2 MG/ML hydromorphone hcl injection solution 4 mg/ml 1 HYDROMORPHONE HCL INTRAVENOUS 3 hydromorphone hcl oral 1 QL hydromorphone hcl pf 1 hydromorphone hcl rectal 1 PA; QL HYDROMORPHONE HCL SOLUTION 1 3 MG/ML INJECTION hydromorphone hcl solution 1 mg/ml injection 1 hydromorphone hcl solution 2 mg/ml injection 1 hydromorphone hcl solution 2 mg/ml injection 1 PA HYDROMORPHONE HCL-NACL INJECTION 3 HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 20-0.9 MG/100ML- 3 %, 25-0.9 MG/50ML-%, 30-0.9 MG/30ML-%, 50- 0.9 MG/50ML-%, 6-0.9 MG/30ML-% HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.2-0.9 MG/0.2ML-%, 0.5-0.9 MG/0.5ML-%, 1-0.9 MG/5ML-%, 1-0.9 MG/ML- 3 %, 10-0.9 MG/50ML-%, 15-0.9 MG/30ML-%, 2- 0.9 MG/ML-%, 30-0.9 MG/30ML-%, 5-0.9 MG/25ML-%, 55-0.9 MG/55ML-%, 6-0.9 MG/30ML-% HYDROMORPHONE HCL-NACL SOLUTION 3 10-0.9 MG/50ML-% INTRAVENOUS HYDROMORPHONE HCL-NACL SOLUTION 3 PA 10-0.9 MG/50ML-% INTRAVENOUS HYDROMORPHONE HCL-NACL SOLUTION PREFILLED SYRINGE 25-0.9 MG/50ML-% 3 INTRAVENOUS Effective Date: 7/1/2021 3 Drug Name Drug Tier Requirements/Limits HYDROMORPHONE HCL-NACL SOLUTION PREFILLED SYRINGE 25-0.9 MG/50ML-% 3 PA INTRAVENOUS HYDROMORPHONE HCL-NACL SOLUTION PREFILLED SYRINGE 50-0.9 MG/50ML-% 3 INTRAVENOUS HYDROMORPHONE HCL-NACL SOLUTION PREFILLED SYRINGE 50-0.9 MG/50ML-% 3 PA INTRAVENOUS HYSINGLA ER 2 ST; QL INFUMORPH 200 3 PA INFUMORPH 500 3 PA LAZANDA 3 PA; QL levorphanol tartrate oral 1 PA; QL LORTAB 3 QL meperidine hcl injection 1 meperidine hcl oral solution 1 QL meperidine hcl oral tablet 1 PA; QL methadone hcl injection 1 methadone hcl intensol 1 methadone hcl oral concentrate 1 methadone hcl oral solution 1 methadone hcl oral tablet 1 PA methadone hcl oral tablet soluble 1 METHADONE HCL-NACL 3 methadose oral concentrate 10 mg/ml 1 methadose oral tablet soluble 1 methadose sugar-free 1 mitigo 1 morphine sulfate (concentrate) oral solution 100 1 QL mg/5ml, 20 mg/ml morphine sulfate (pf) 1 morphine sulfate er 1 PA; QL morphine sulfate er beads 1 PA; QL MORPHINE SULFATE INJECTION SOLUTION 3 1 MG/ML morphine sulfate injection solution 2 mg/ml, 4 1 mg/ml MORPHINE SULFATE INTRAVENOUS 3 SOLUTION 0.5 MG/ML morphine sulfate intravenous solution 50 mg/ml 1 PA Effective Date: 7/1/2021 4 Drug Name Drug Tier Requirements/Limits morphine sulfate oral 1 QL morphine sulfate rectal 1 PA; QL MORPHINE SULFATE SOLUTION 1 MG/ML 3 INTRAVENOUS morphine sulfate solution 1 mg/ml intravenous 1 PA MORPHINE SULFATE-NACL INJECTION 3 MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION 50-0.9 MG/50ML-%, 500-0.9 3 MG/100ML-% MORPHINE SULFATE-NACL INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE MORPHINE SULFATE-NACL SOLUTION 100- 3 0.9 MG/100ML-% INTRAVENOUS MORPHINE SULFATE-NACL SOLUTION 100- 3 PA 0.9 MG/100ML-% INTRAVENOUS MS CONTIN 3 PA; QL nalbuphine hcl injection 1 NALOCET 3 PA; QL NUCYNTA 3 QL NUCYNTA ER 3 PA; QL OLINVYK 3 PA OXAYDO 3 PA; QL OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG, 30 MG, 3 PA; M; QL 60 MG, 80 MG OXYCODONE HCL ER TABLET ER 12 HOUR 3 PA; QL ABUSE-DETERRENT 10 MG ORAL OXYCODONE HCL ER TABLET ER 12 HOUR 3 PA; M; QL ABUSE-DETERRENT 10 MG ORAL OXYCODONE HCL ER TABLET ER 12 HOUR 3 PA; QL ABUSE-DETERRENT 20 MG ORAL OXYCODONE HCL ER TABLET ER 12 HOUR 3 PA; M; QL ABUSE-DETERRENT 20 MG ORAL OXYCODONE HCL ER TABLET ER 12 HOUR 3 PA; QL ABUSE-DETERRENT 40 MG ORAL OXYCODONE HCL ER TABLET ER 12 HOUR 3 PA; M; QL ABUSE-DETERRENT 40 MG ORAL oxycodone hcl oral capsule 1 QL oxycodone hcl oral concentrate 100 mg/5ml 1 QL oxycodone hcl oral solution 1 QL oxycodone hcl oral tablet 1 QL

Effective Date: 7/1/2021 5 Drug Name Drug Tier Requirements/Limits OXYCODONE-ACETAMINOPHEN ORAL 3 PA; QL SOLUTION OXYCODONE-ACETAMINOPHEN ORAL 3 PA; QL TABLET 10-300 MG, 2.5-300 MG, 5-300 MG oxycodone-acetaminophen oral tablet 10-325 1 QL mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin 1 QL OXYCONTIN 2 PA; QL oxymorphone hcl 1 QL oxymorphone hcl er 1 PA; QL pentazocine-naloxone hcl 1 QL PROBUPHINE IMPLANT KIT 3 PROLATE 3 PA; QL QDOLO 3 PA; QL remifentanil hcl 1 SUBSYS 3 PA; QL TENCON 3 PA hcl er 1 QL tramadol hcl er (biphasic) 1 QL tramadol hcl ir 1 QL tramadol-acetaminophen 1 QL TREZIX 3 PA; QL ULTIVA 3 PA ULTRACET 3 PA; QL VTOL LQ 3 PA XTAMPZA ER 2 PA; QL ZEBUTAL 3 PA Analgesics - Drugs for Pain and Inflammation ACTIVE INJECTION KET-L 3 PA ACTIVE INJECTION KETMARC-L 3 PA ANJESO 3 PA ARTHROTEC 3 PA CALDOLOR 3 CAMBIA 3 ST celecoxib oral 1 QL DAYPRO 3 PA DFS DR/MS/MENTH/CAP PAK 3 PA DFS/MS/MENTH/CAP PAK 3 PA

Effective Date: 7/1/2021 6 Drug Name Drug Tier Requirements/Limits DICLOFENAC 3 ST; M DICLOFENAC EPOLAMINE 3 PA; M; QL diclofenac potassium 1 diclofenac sodium er 1 diclofenac sodium external gel 1 % 1 QL diclofenac sodium external solution 1 PA diclofenac sodium oral 1 diclofenac-misoprostol 1 DICLOFONO GEL 1.6 % EXTERNAL 3 DICLOFONO GEL 1.6 % EXTERNAL 3 PA DICLOPR 3 PA DICLOVIX 3 PA diflunisal oral 1 DUEXIS 3 PA; QL EC-NAPROSYN 3 PA ec-naproxen 1 etodolac 1 etodolac er 1 FELDENE 3 PA fenoprofen oral 1 PA fenortho 1 PA FLECTOR 3 PA; QL flurbiprofen oral 1 IBUPAK 3 PA ibuprofen 1 ibuprofen lysine 1 ibuprofen oral suspension 1 INDOCIN 3 ST indomethacin er 1 INDOMETHACIN ORAL CAPSULE 20 MG 3 ST indomethacin oral capsule 25 mg, 50 mg 1 indomethacin sodium 1 ketoprofen er 1 PA ketoprofen oral capsule 25 mg 1 PA ketoprofen oral capsule 50 mg, 75 mg 1 KETOROCAINE-L 3 PA KETOROCAINE-LM 3 PA

Effective Date: 7/1/2021 7 Drug Name Drug Tier Requirements/Limits ketorolac tromethamine injection solution 15 1 mg/ml ketorolac tromethamine intramuscular 1 KETOROLAC TROMETHAMINE NASAL 3 PA; M; QL ketorolac tromethamine oral 1 QL ketorolac tromethamine solution 30 mg/ml 1 injection KETOROLAC TROMETHAMINE SOLUTION 30 3 MG/ML INJECTION KETOROLAC-BUPIV-KETAMINE 3 PA KETOROLAC-ROPIV-KETAMINE 3 PA LICART 3 PA LODINE 3 PA meclofenamate sodium oral 1 PA mefenamic acid oral 1 PA meloxicam oral capsule 1 PA meloxicam oral tablet 1 MOBIC 3 PA nabumetone oral 1 NAPRELAN ORAL TABLET EXTENDED 3 PA RELEASE 24 HOUR 750 MG naproxen oral suspension 1 PA naproxen oral tablet 1 naproxen oral tablet delayed release 1 naproxen sodium er oral tablet extended release 1 PA 24 hour 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg 1 naproxen-esomeprazole 1 PA; QL NEOPROFEN 3 PA NUDROXIPAK DSDR-50 3 PA NUDROXIPAK DSDR-75 3 PA NUDROXIPAK E-400 3 PA NUDROXIPAK I-800 3 PA NUDROXIPAK M-15 3 PA NUDROXIPAK N-500 3 PA ORMECA 3 PA oxaprozin 1 PENNSAID 3 PA piroxicam oral 1

Effective Date: 7/1/2021 8 Drug Name Drug Tier Requirements/Limits PRASTERA 3 PA QMIIZ ODT 3 PA READYSHARP ANESTH + KETOROLAC 3 PA RELAFEN 3 PA RELAFEN DS 3 ST salsalate oral 1 PA SPRIX 3 PA; QL sulindac oral 1 TIVORBEX 3 ST tolmetin sodium 1 TORONOVA II SUIK 3 PA TORONOVA SUIK 3 PA VAROPHEN 3 PA VENNGEL ONE 3 PA VOLTAREN 3 QL ZIPSOR 3 PA ZORVOLEX 3 ST Anesthetics 1ST MEDX-PATCH/ LIDOCAINE EXTERNAL 3 PA PATCH 4-0.0375-5-20 % 7T LIDO 3 PA ACCUCAINE 3 PA ACTIVE INJECTION LM-2 3 PA AGONEAZE 3 PA ANODYNE LPT 3 PA APRIZIO PAK 3 PA APRIZIO PAK II 3 PA ARTICADENT DENTAL 3 ASTERO 3 PA BENZO-LIDOCAINE-TETRACAINE 3 PA bupivacaine fisiopharma 1 bupivacaine hcl (pf) 1 BUPIVACAINE HCL INJECTION SOLUTION 3 PA 0.125 % bupivacaine hcl injection solution 0.25 %, 0.5 % 1 BUPIVACAINE HCL INJECTION SOLUTION 3 PA PREFILLED SYRINGE bupivacaine-epinephrine 1 bupivacaine-epinephrine (pf) 1

Effective Date: 7/1/2021 9 Drug Name Drug Tier Requirements/Limits CADIRAMD 3 PA CARBOCAINE 3 PA CARBOCAINE PRESERVATIVE-FREE 3 PA chloroprocaine hcl (pf) 1 CITANEST FORTE DENTAL 3 CITANEST PLAIN DENTAL 3 COCAINE HCL NASAL 3 PA DERMACINRX EMPRICAINE 3 PA DERMACINRX PRIZOPAK 3 PA EHA 3 PA EMPRICAINE-II 3 PA ENZNONUTY 3 ethyl chloride 1 EXPAREL 3 FLEXIN 3 PA GEBAUERS PAIN EASE 3 GEBAUERS SPRAY AND STRETCH 3 GEN7T 3 PA GEN7T PLUS 3 PA glydo 1 GOPRELTO 3 PA L.E.T. 3 LDO PLUS 3 PA LEVATIO 3 PA LIDO BDK 3 PA lidocaine external patch 5 % 1 LIDOCAINE HCL (CARDIAC) INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 3 MG/10ML lidocaine hcl (cardiac) intravenous solution 1 prefilled syringe 50 mg/5ml lidocaine hcl (cardiac) pf 1 lidocaine hcl (cardiac) solution prefilled syringe 1 100 mg/5ml intravenous LIDOCAINE HCL (CARDIAC) SOLUTION PREFILLED SYRINGE 100 MG/5ML 3 INTRAVENOUS lidocaine hcl (pf) 1 lidocaine hcl external cream 3 % 1 PA LIDOCAINE HCL EXTERNAL CREAM 4.12 % 3 PA Effective Date: 7/1/2021 10 Drug Name Drug Tier Requirements/Limits lidocaine hcl external lotion 1 PA lidocaine hcl external solution 1 lidocaine hcl injection solution 0.5 % 1 LIDOCAINE HCL INJECTION SOLUTION 3 PREFILLED SYRINGE LIDOCAINE HCL SOLUTION 1 % INJECTION 3 lidocaine hcl solution 1 % injection 1 LIDOCAINE HCL SOLUTION 2 % INJECTION 3 lidocaine hcl solution 2 % injection 1 lidocaine hcl urethral/mucosal 1 LIDOCAINE IN D5W INTRAVENOUS 3 SOLUTION 2-5 MG/ML-% lidocaine in d5w intravenous solution 4-5 mg/ml- 1 %, 8-5 mg/ml-% LIDOCAINE IN DEXTROSE 3 lidocaine ointment 5 % external 1 lidocaine ointment 5 % external 1 PA lidocaine-epinephrine injection 1 lidocaine-prilocaine external cream 1 lidocaine-prilocaine external kit 1 PA LIDOCAINE-SODIUM BICARBONATE 3 LIDOCAINE-TETRACAINE 3 PA LIDOCANNA 3 PA LIDO-EPINEPHRINE-TETRACAINE SOLUTION 3 4-0.05-0.5 % EXTERNAL LIDO-EPINEPHRINE-TETRACAINE SOLUTION 3 PA 4-0.05-0.5 % EXTERNAL LIDOMAR 3 PA LIDOMARK 2/5 3 PA LIDOPAC 3 PA lidopin external cream 3 % 1 PA LIDOPIN EXTERNAL CREAM 3.25 % 3 PA LIDOPRIL 3 PA LIDOPRIL XR 3 PA LIDO-PRILO CAINE PACK 3 PA LIDOPURE PATCH 3 PA LIDORX 3 PA LIDO-SORB 3 PA LIDOSTREAM 3 PA

Effective Date: 7/1/2021 11 Drug Name Drug Tier Requirements/Limits LIDOTHOL 3 PA LIDOTRAL 3 PA LIDOVIX L 3 PA LIVIXIL PAK 3 PA LMR PLUS 3 PA LYDEXA 3 PA MARCAINE 3 PA MARCAINE PRESERVATIVE FREE 3 PA MARCAINE/EPINEPHRINE 3 PA MARCAINE/EPINEPHRINE PF 3 PA marlido 1 PA MARLIDO-25 3 PA MARVONA SUIK 3 PA NAROPIN 3 PA NESACAINE 3 NESACAINE-MPF SOLUTION 2 % INJECTION 3 NESACAINE-MPF SOLUTION 2 % INJECTION 3 PA NESACAINE-MPF SOLUTION 3 % INJECTION 3 NESACAINE-MPF SOLUTION 3 % INJECTION 3 PA NUMBRINO 3 PA NUVAKAAN 3 PA NUVAKAAN-II 3 PA ORABLOC 3 PAINGO KFT 3 PA PLIAGLIS 3 PA POINT OF CARE LM-2.2 3 PA POINT OF CARE LM-2.5 3 PA polocaine 1 polocaine-mpf 1 premium lidocaine 1 PA PREMIUM SCAR 3 PA PREPIV SUPPLY 3 PRILO PATCH 3 PA PRILO PATCH II 3 PA PRILOLID 3 PA PRILOVIX 3 PA PRILOVIX LITE 3 PA PRILOVIX LITE PLUS 3 PA

Effective Date: 7/1/2021 12 Drug Name Drug Tier Requirements/Limits PRILOVIX PLUS 3 PA PRILOVIX ULTRALITE 3 PA PRILOVIX ULTRALITE PLUS 3 PA PRILOVIXIL 3 PA PRIZOPAK II 3 PA PRIZOTRAL 3 PA PRIZOTRAL-II 3 PA READYSHARP-A 3 PA RECK 3 PA RELADOR PAK 3 PA RELADOR PAK PLUS 3 PA ropivacaine hcl injection solution 10 mg/ml, 5 1 mg/ml, 7.5 mg/ml ROPIVACAINE HCL INJECTION SOLUTION 3 PA PREFILLED SYRINGE ropivacaine hcl solution 2 mg/ml injection 1 ROPIVACAINE HCL SOLUTION 2 MG/ML 3 PA INJECTION ROPIVACAINE HCL-NACL INJECTION 3 PA ROPIV-CLONIDINE-KETOROLAC 3 PA SENSORCAINE 3 SENSORCAINE/EPINEPHRINE 3 SENSORCAINE-MPF INJECTION SOLUTION 3 0.75 % sensorcaine-mpf solution 0.25 % injection 1 SENSORCAINE-MPF SOLUTION 0.25 % 3 INJECTION sensorcaine-mpf solution 0.5 % injection 1 SENSORCAINE-MPF SOLUTION 0.5 % 3 INJECTION SENSORCAINE-MPF/EPINEPHRINE 3 SKYADERM-LP 3 PA SOOTHEE 3 PA STERILE TOPICAL L.E.T. GEL 3 SX1 MEDICATED POST-OPERATIVE 3 PA SYNERA 3 PA tetracaine hcl injection 1 PA VENIPUNCTURE PX1 PHLEBOTOMY 3 VEXATROL 3 PA XARACOLL 3 PA Effective Date: 7/1/2021 13 Drug Name Drug Tier Requirements/Limits XYLOCAINE 3 PA xylocaine dental 1 XYLOCAINE/EPINEPHRINE 3 PA XYLOCAINE-MPF 3 PA XYLOCAINE-MPF/EPINEPHRINE INJECTION 3 SOLUTION 1 %-1:200000 XYLOCAINE-MPF/EPINEPHRINE INJECTION 3 PA SOLUTION 1.5 %-1:200000, 2 %-1:200000 ZERUVIA 3 PA ZIONODIL 3 PA ZIONODIL 100 3 PA ZTLIDO 3 PA Anti-Addiction / Substance Abuse Treatment Agents acamprosate calcium 1 BUNAVAIL 3 QL buprenorphine hcl sublingual 1 QL buprenorphine hcl-naloxone hcl 1 QL bupropion hcl er (smoking det) 1 QL CHANTIX 3 QL CHANTIX CONTINUING MONTH PAK 3 QL CHANTIX STARTING MONTH PAK 3 QL disulfiram oral 1 LIFEMS NALOXONE 3 PA LUCEMYRA 3 ST; QL naloxone hcl injection 1 naltrexone hcl oral 1 NALTREXONE SUBCUTANEOUS 3 PA NARCAN 2 NICOTROL 3 QL NICOTROL NS 3 QL SUBLOCADE 3 SP SUBOXONE 3 PA; QL VIVITROL 3 SP ZUBSOLV 2 QL Antibacterials AEMCOLO 3 PA; QL ALTABAX 3 amikacin sulfate injection 1 QL

Effective Date: 7/1/2021 14 Drug Name Drug Tier Requirements/Limits amoxicillin 1 QL amoxicillin-potassium clavulanate er 1 QL amoxicillin-potassium clavulanate oral 1 QL ampicillin 1 QL ampicillin sodium 1 QL ampicillin-sulbactam sodium 1 QL ARIKAYCE 3 SP; QL AUGMENTIN ES-600 3 PA; QL AUGMENTIN ORAL SUSPENSION 3 QL RECONSTITUTED 125-31.25 MG/5ML AUGMENTIN ORAL SUSPENSION 3 PA; QL RECONSTITUTED 250-62.5 MG/5ML AUGMENTIN ORAL TABLET 3 PA; QL avidoxy 1 QL AVIDOXY DK 3 PA; QL AVYCAZ 3 QL AZACTAM 3 PA; QL azithromycin intravenous 1 QL azithromycin oral 1 QL aztreonam 1 QL bacitracin intramuscular 1 QL BACTRIM 3 PA; QL BACTRIM DS 3 PA; QL BAXDELA 3 QL benzalkonium chloride external solution 1 BICILLIN C-R 3 QL BICILLIN C-R 900/300 3 QL BICILLIN L-A 3 QL cefaclor 1 QL cefaclor er 1 QL cefadroxil 1 QL CEFAZOLIN IN SODIUM CHLORIDE 3 QL cefazolin sodium injection 1 QL CEFAZOLIN SODIUM INTRAVENOUS 3 QL SOLUTION PREFILLED SYRINGE cefazolin sodium intravenous solution 1 QL reconstituted cefazolin sodium-dextrose intravenous solution 1 QL 1-4 gm/50ml-%, 2-4 gm/100ml-%

Effective Date: 7/1/2021 15 Drug Name Drug Tier Requirements/Limits CEFAZOLIN SODIUM-DEXTROSE 3 QL INTRAVENOUS SOLUTION 2-5 GM/100ML-% cefazolin sodium-dextrose intravenous solution 1 QL reconstituted cefdinir 1 QL cefepime hcl injection 1 QL cefepime hcl intravenous solution 1 QL cefepime hcl intravenous solution reconstituted 1 PA; QL cefepime-dextrose 1 QL cefixime 1 QL CEFOTAN 3 PA; QL cefotaxime sodium 1 QL cefotetan disodium 1 QL cefotetan disodium-dextrose 1 QL cefoxitin sodium 1 QL CEFOXITIN SODIUM-DEXTROSE 3 QL cefpodoxime proxetil 1 QL cefprozil 1 QL ceftazidime and dextrose 1 QL ceftazidime injection 1 QL ceftriaxone sodium in dextrose 1 QL ceftriaxone sodium injection 1 QL ceftriaxone sodium intravenous 1 QL ceftriaxone sodium-dextrose 1 QL cefuroxime axetil 1 QL cefuroxime sodium 1 QL CENTANY 3 PA CENTANY AT 3 PA cephalexin 1 QL chloramphenicol sod succinate 1 QL CIPRO ORAL SUSPENSION 3 QL RECONSTITUTED CIPRO ORAL TABLET 3 PA; QL ciprofloxacin hcl oral 1 QL ciprofloxacin in d5w 1 QL clarithromycin er 1 QL clarithromycin oral 1 QL CLEOCIN ORAL 3 PA; QL CLEOCIN PHOSPHATE 3 PA; QL

Effective Date: 7/1/2021 16 Drug Name Drug Tier Requirements/Limits CLEOCIN VAGINAL CREAM 3 PA CLEOCIN VAGINAL SUPPOSITORY 2 clindamycin hcl oral 1 QL clindamycin palmitate hcl 1 QL clindamycin phosphate in d5w 1 QL CLINDAMYCIN PHOSPHATE IN NACL 3 QL clindamycin phosphate injection 1 QL clindamycin phosphate vaginal 1 CLINDESSE 3 colistimethate sodium (cba) 1 QL COLY-MYCIN M 3 PA; QL coremino 1 PA; QL DALVANCE 3 QL daptomycin 1 QL demeclocycline hcl 1 QL dicloxacillin sodium 1 QL DIFICID 3 QL DORYX MPC 3 ST; QL DORYX ORAL TABLET DELAYED RELEASE 3 ST; QL 80 MG doxy 100 1 QL doxycycline hyclate intravenous 1 QL doxycycline hyclate oral capsule 1 QL doxycycline hyclate oral tablet 100 mg, 20 mg 1 QL doxycycline hyclate oral tablet 150 mg, 50 mg, 1 PA; QL 75 mg doxycycline hyclate oral tablet delayed release 1 PA; QL 100 mg, 150 mg, 200 mg, 50 mg, 75 mg DOXYCYCLINE HYCLATE ORAL TABLET 3 ST; QL DELAYED RELEASE 80 MG doxycycline monohydrate oral capsule 100 mg, 1 QL 50 mg doxycycline monohydrate oral capsule 150 mg, 1 PA; QL 75 mg doxycycline monohydrate oral suspension 1 QL reconstituted doxycycline monohydrate oral tablet 1 QL E.E.S. GRANULES 3 PA; QL ertapenem sodium 1 QL ERYPED 200 3 PA; QL

Effective Date: 7/1/2021 17 Drug Name Drug Tier Requirements/Limits ERYPED 400 3 PA; QL ERY-TAB 3 PA; QL ERYTHROCIN LACTOBIONATE 3 QL ERYTHROCIN STEARATE 3 QL erythromycin base 1 QL erythromycin ethylsuccinate oral 1 QL erythromycin oral 1 QL FETROJA 3 QL FIRVANQ 3 QL FLAGYL 3 PA; QL FORTAZ INJECTION SOLUTION 3 PA; QL RECONSTITUTED 1 GM FORTAZ INJECTION SOLUTION 3 QL RECONSTITUTED 500 MG FORTAZ INTRAVENOUS 3 QL fosfomycin tromethamine 1 QL gentamicin in saline 1 QL gentamicin sulfate external 1 gentamicin sulfate injection 1 QL HIPREX 3 PA; QL hydrogen peroxide 1 imipenem-cilastatin 1 QL INVANZ 3 PA; QL KEFLEX 3 PA; QL levofloxacin in d5w 1 QL levofloxacin intravenous 1 QL levofloxacin oral 1 QL LINCOCIN 3 PA; QL lincomycin hcl injection 1 QL linezolid 1 QL linezolid in sodium chloride 1 QL LUGOLS STRONG IODINE 3 MACROBID 3 PA; QL MACRODANTIN 3 PA; QL mafenide acetate external 1 meropenem 1 QL MEROPENEM-SODIUM CHLORIDE 3 QL MERREM 3 PA; QL methenamine hippurate 1 QL Effective Date: 7/1/2021 18 Drug Name Drug Tier Requirements/Limits methenamine mandelate oral 1 PA; QL metronidazole in nacl 1 QL metronidazole oral 1 QL metronidazole vaginal 1 MINOCIN INTRAVENOUS 3 QL MINOCYCLINE HCL ER ORAL CAPSULE 3 QL EXTENDED RELEASE 24 HOUR minocycline hcl er oral tablet extended release 1 PA; QL 24 hour minocycline hcl oral 1 QL MINOLIRA 3 ST; QL mondoxyne nl oral capsule 100 mg 1 QL mondoxyne nl oral capsule 75 mg 1 PA; QL MONUROL 3 PA; QL MORGIDOX COMBINATION 3 PA; QL morgidox oral 1 QL moxifloxacin hcl in nacl 1 QL MOXIFLOXACIN HCL INTRAVENOUS 3 QL moxifloxacin hcl oral 1 QL mupirocin calcium 1 PA mupirocin external 1 nafcillin sodium 1 QL NAFCILLIN SODIUM IN DEXTROSE 3 QL neomycin sulfate oral 1 QL neomycin-polymyxin b gu 1 nitrofurantoin 1 QL nitrofurantoin macrocrystal 1 QL nitrofurantoin monohydrate macrocrystals 1 QL NUTRIDOX 3 PA; QL NUVESSA 3 PA NUZYRA 3 QL ofloxacin oral 1 QL ORBACTIV 3 QL oxacillin sodium 1 QL OXACILLIN SODIUM IN DEXTROSE 3 QL paromomycin sulfate oral 1 QL PENICILLIN G POT IN DEXTROSE 3 QL penicillin g potassium 1 QL penicillin g procaine 1 QL Effective Date: 7/1/2021 19 Drug Name Drug Tier Requirements/Limits penicillin g sodium 1 QL penicillin v potassium 1 QL PFIZERPEN 3 PA; QL piperacillin sod-tazobactam so 1 QL polymyxin b sulfate injection 1 QL PRIMAXIN IV 3 PA; QL PRIMSOL 3 QL RECARBRIO 3 QL SEYSARA 3 ST; QL SILVADENE 3 PA silver nitrate external 1 PA silver sulfadiazine external 1 SIVEXTRO INTRAVENOUS 3 QL SIVEXTRO ORAL 3 PA; QL SOLOSEC 3 ssd 1 streptomycin sulfate intramuscular 1 QL sulfadiazine oral 1 QL sulfamethoxazole-trimethoprim 1 QL SULFAMYLON 3 PA sulfatrim pediatric 1 QL SUPRAX ORAL CAPSULE 3 PA; QL SUPRAX ORAL SUSPENSION 3 PA; QL RECONSTITUTED 100 MG/5ML, 200 MG/5ML SUPRAX ORAL SUSPENSION 3 QL RECONSTITUTED 500 MG/5ML SUPRAX ORAL TABLET CHEWABLE 3 QL SYNERCID 3 QL tazicef injection 1 QL TAZICEF INTRAVENOUS SOLUTION 3 QL tazicef intravenous solution reconstituted 1 QL TEFLARO 3 QL tetracycline hcl oral 1 QL tigecycline 1 QL tinidazole oral 1 QL tobramycin sulfate injection 1 QL trimethoprim oral 1 QL TYGACIL 3 PA; QL UNASYN 3 PA; QL Effective Date: 7/1/2021 20 Drug Name Drug Tier Requirements/Limits VABOMERE 3 QL VANCOCIN 3 PA; QL VANCOCIN HCL 3 PA; QL VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1.25-5 GM/250ML- 3 QL %, 1.5-5 GM/250ML-% vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 1 QL mg/150ml-% VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1.5-0.9 GM/500ML-%, 1.75-0.9 3 QL GM/250ML-% vancomycin hcl in nacl intravenous solution 1- 1 QL 0.9 gm/200ml-%, 500-0.9 mg/100ml-% VANCOMYCIN HCL IN NACL SOLUTION 1.25- 3 QL 0.9 GM/250ML-% INTRAVENOUS VANCOMYCIN HCL IN NACL SOLUTION 1.25- 3 PA; QL 0.9 GM/250ML-% INTRAVENOUS VANCOMYCIN HCL IN NACL SOLUTION 1.5- 3 QL 0.9 GM/250ML-% INTRAVENOUS VANCOMYCIN HCL IN NACL SOLUTION 1.5- 3 PA; QL 0.9 GM/250ML-% INTRAVENOUS VANCOMYCIN HCL IN NACL SOLUTION 1-0.9 3 QL GM/250ML-% INTRAVENOUS VANCOMYCIN HCL IN NACL SOLUTION 1-0.9 3 PA; QL GM/250ML-% INTRAVENOUS VANCOMYCIN HCL IN NACL SOLUTION 2-0.9 3 QL GM/500ML-% INTRAVENOUS VANCOMYCIN HCL IN NACL SOLUTION 2-0.9 3 PA; QL GM/500ML-% INTRAVENOUS VANCOMYCIN HCL IN NACL SOLUTION 750- 3 QL 0.9 MG/150ML-% INTRAVENOUS vancomycin hcl in nacl solution 750-0.9 1 QL mg/150ml-% intravenous vancomycin hcl intravenous 1 QL vancomycin hcl oral 1 QL vandazole 1 VIBATIV 3 QL VIBRAMYCIN ORAL CAPSULE 3 PA; QL VIBRAMYCIN ORAL SUSPENSION 3 PA; QL RECONSTITUTED VIBRAMYCIN ORAL SYRUP 3 ST; QL XENLETA 3 QL Effective Date: 7/1/2021 21 Drug Name Drug Tier Requirements/Limits XEPI 3 XERAVA 3 QL XIFAXAN 3 PA; QL XIMINO 3 QL ZEMDRI 3 QL ZERBAXA 3 QL ZITHROMAX INTRAVENOUS 3 PA; QL ZITHROMAX ORAL PACKET 3 QL ZITHROMAX ORAL SUSPENSION 3 PA; QL RECONSTITUTED ZITHROMAX ORAL TABLET 3 PA; QL ZITHROMAX TRI-PAK 3 PA; QL ZITHROMAX Z-PAK 3 PA; QL ZOSYN 3 QL ZYVOX INTRAVENOUS SOLUTION 200 3 QL MG/100ML ZYVOX INTRAVENOUS SOLUTION 600 3 PA; QL MG/300ML ZYVOX ORAL SUSPENSION 3 PA; QL RECONSTITUTED Anticoagulants ACD FORMULA A 3 ACD-A NOCLOT-50 3 ACTIVASE 3 PA ANGIOMAX 3 PA ANTICOAGULANT SODIUM CITRATE 3 argatroban 1 argatroban in sodium chloride 1 PA ARIXTRA 3 PA; SP; QL BIVALIRUDIN RTU 3 PA bivalirudin trifluoroacetate 1 BIVALIRUDIN-SODIUM CHLORIDE 3 PA CATHFLO ACTIVASE 3 PA ELIQUIS 2 QL ELIQUIS DVT/PE STARTER PACK 2 QL enoxaparin sodium 1 SP; QL fondaparinux sodium 1 SP; QL FRAGMIN 3 SP; QL heparin (porcine) in nacl intravenous solution 1

Effective Date: 7/1/2021 22 Drug Name Drug Tier Requirements/Limits HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 2500-0.9 UT/500ML-%, 30000-0.9 UNIT/L-%, 500-0.9 3 UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 UT/500ML-% heparin sod (porcine) in d5w 1 heparin sodium (porcine) 1 heparin sodium (porcine) pf 1 jantoven 1 LOVENOX 3 PA; SP; QL PRADAXA 2 QL REGIOCIT 3 PA RETAVASE 3 RETAVASE HALF-KIT 3 SAVAYSA 3 QL SODIUM CITRATE IN VITRO 3 SODIUM CITRATE LOCK FLUSH 3 SODIUM CITRATE-GENTAMICIN SULF 3 SOLUTION 4-320 %-MCG/ML INTRAVENOUS SODIUM CITRATE-GENTAMICIN SULF 3 PA SOLUTION 4-320 %-MCG/ML INTRAVENOUS TNKASE 3 TRICITRASOL 3 warfarin sodium oral 1 XARELTO 2 QL XARELTO STARTER PACK 2 QL Anticonvulsants - Drugs for Seizures APTIOM 3 BANZEL 3 PA BRIVIACT INTRAVENOUS 3 BRIVIACT ORAL 3 ST carbamazepine er 1 carbamazepine oral 1 CARBATROL 3 PA CELONTIN 3 CEREBYX 3 PA clobazam 1 PA DIACOMIT 3 PA; SP DIASTAT ACUDIAL 3 PA; QL DIASTAT PEDIATRIC 3 PA; QL Effective Date: 7/1/2021 23 Drug Name Drug Tier Requirements/Limits diazepam rectal 1 QL DILANTIN ORAL CAPSULE 30 MG 3 divalproex sodium er 1 divalproex sodium oral 1 EPIDIOLEX 3 PA; SP epitol 1 ethosuximide oral 1 felbamate 1 FINTEPLA 3 PA; SP fosphenytoin sodium 1 FYCOMPA 3 gabapentin oral 1 GABITRIL 3 PA KEPPRA INTRAVENOUS 3 PA KEPPRA ORAL SOLUTION 3 PA LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 3 ST 50 MG, 42 X 50 MG & 14X100 MG LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG 3 PA LAMICTAL STARTER 3 PA LAMICTAL XR ORAL KIT 3 ST lamotrigine er 1 lamotrigine oral 1 lamotrigine starter kit-blue 1 lamotrigine starter kit-green 1 lamotrigine starter kit-orange 1 levetiracetam er 1 levetiracetam in nacl 1 levetiracetam intravenous 1 levetiracetam oral 1 NAYZILAM 3 QL NEMBUTAL 3 PA NEURONTIN ORAL SOLUTION 3 PA oxcarbazepine 1 OXTELLAR XR 3 ST pentobarbital sodium injection 1 phenobarbital oral 1 phenobarbital sodium injection 1 PHENYTEK 3 PA

Effective Date: 7/1/2021 24 Drug Name Drug Tier Requirements/Limits phenytoin infatabs 1 phenytoin oral 1 phenytoin sodium extended 1 phenytoin sodium injection 1 primidone oral 1 QUDEXY XR 3 PA roweepra 1 rufinamide 1 PA SPRITAM 3 PA subvenite 1 subvenite starter kit-blue 1 subvenite starter kit-green 1 subvenite starter kit-orange 1 SYMPAZAN 3 PA tiagabine hcl 1 er 1 topiramate oral 1 TROKENDI XR 3 ST sodium intravenous 1 valproic acid oral 1 VALTOCO 3 QL vigabatrin 1 PA; SP vigadrone 1 PA; SP VIMPAT 3 XCOPRI 3 ST ZARONTIN 3 PA zonisamide oral 1 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia ARICEPT 3 PA donepezil hcl 1 EXELON 3 PA galantamine hydrobromide 1 galantamine hydrobromide er 1 memantine hcl er 1 QL memantine hcl oral 1 NAMENDA 3 PA NAMENDA TITRATION PAK 3 PA

Effective Date: 7/1/2021 25 Drug Name Drug Tier Requirements/Limits NAMENDA XR 3 PA; QL NAMENDA XR TITRATION PACK 3 QL NAMZARIC 2 QL RAZADYNE ER 3 PA rivastigmine 1 rivastigmine tartrate 1 Antidepressants amitriptyline hcl oral 1 amoxapine 1 APLENZIN 3 ST; QL BRISDELLE 3 PA; QL bupropion hcl er (sr) 1 QL bupropion hcl er (xl) oral tablet extended release 1 QL 24 hour 150 mg, 300 mg BUPROPION HCL ER (XL) ORAL TABLET 3 ST; M; QL EXTENDED RELEASE 24 HOUR 450 MG bupropion hcl oral 1 chlordiazepoxide-amitriptyline 1 citalopram hydrobromide 1 clomipramine hcl oral 1 desipramine hcl oral 1 DESVENLAFAXINE ER 3 ST; QL desvenlafaxine succinate er 1 QL doxepin hcl oral capsule 1 doxepin hcl oral concentrate 1 DRIZALMA SPRINKLE 3 ST; QL hcl oral 1 QL EMSAM 3 QL escitalopram oxalate 1 FETZIMA 3 ST; QL FETZIMA TITRATION 3 ST; QL hcl (pmdd) 1 fluoxetine hcl oral capsule 1 fluoxetine hcl oral capsule delayed release 1 QL fluoxetine hcl oral solution 1 fluoxetine hcl oral tablet 10 mg, 60 mg 1 fluoxetine hcl oral tablet 20 mg 1 PA fluvoxamine maleate 1 fluvoxamine maleate er 1 QL Effective Date: 7/1/2021 26 Drug Name Drug Tier Requirements/Limits FORFIVO XL 3 ST; QL imipramine hcl oral 1 imipramine pamoate 1 maprotiline hcl 1 MARPLAN 3 mirtazapine oral 1 NARDIL 3 PA nefazodone hcl 1 NORPRAMIN 3 PA nortriptyline hcl oral 1 -fluoxetine hcl 1 QL PARNATE 3 PA paroxetine hcl 1 paroxetine hcl er 1 paroxetine mesylate 1 QL PAXIL CR 3 PA PAXIL ORAL SUSPENSION 2 ST PAXIL ORAL TABLET 3 PA perphenazine-amitriptyline 1 PEXEVA 3 PA; QL phenelzine sulfate oral 1 protriptyline hcl 1 REMERON 3 PA REMERON SOLTAB 3 PA sertraline hcl oral 1 SPRAVATO (56 MG DOSE) 3 PA; SP SPRAVATO (84 MG DOSE) 3 PA; SP SYMBYAX 3 PA; QL tranylcypromine sulfate 1 trazodone hcl oral 1 trimipramine maleate oral 1 TRINTELLIX 3 ST; QL venlafaxine hcl 1 venlafaxine hcl er oral capsule extended release 1 24 hour venlafaxine hcl er oral tablet extended release 1 PA 24 hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 1 24 hour 225 mg

Effective Date: 7/1/2021 27 Drug Name Drug Tier Requirements/Limits VIIBRYD 3 QL VIIBRYD STARTER PACK 3 QL ZULRESSO 3 PA; SP Antiemetics - Drugs for Nausea and Vomiting AKYNZEO INTRAVENOUS 3 AKYNZEO ORAL 3 QL ALOXI 3 PA ANZEMET 3 QL aprepitant 1 QL BARHEMSYS 3 BONJESTA 3 PA; QL CINVANTI 3 compro 1 DICLEGIS 3 PA; QL dimenhydrinate injection 1 doxylamine-pyridoxine 1 PA; QL dronabinol 1 PA; QL droperidol injection 1 DROPERIDOL INTRAVENOUS 3 PA EMEND INTRAVENOUS 3 PA EMEND ORAL CAPSULE 3 PA; QL EMEND ORAL SUSPENSION 3 QL RECONSTITUTED EMEND TRI-PACK 3 PA; QL fosaprepitant dimeglumine 1 GIMOTI 3 PA granisetron hcl intravenous 1 granisetron hcl oral 1 QL MARINOL 3 PA; QL meclizine hcl oral 1 metoclopramide hcl injection 1 metoclopramide hcl oral 1 ondansetron hcl injection 1 ondansetron hcl oral solution 1 QL ondansetron hcl oral tablet 24 mg 1 QL ondansetron hcl oral tablet 4 mg, 8 mg 1 ondansetron odt 1 palonosetron hcl 1

Effective Date: 7/1/2021 28 Drug Name Drug Tier Requirements/Limits perphenazine oral 1 prochlorperazine 1 prochlorperazine edisylate injection 1 prochlorperazine maleate oral 1 REGLAN 3 PA SANCUSO 3 PA; QL scopolamine 1 SUSTOL 3 QL SYNDROS 3 PA; QL TIGAN INTRAMUSCULAR 3 TIGAN ORAL 3 PA TRANSDERM SCOP (1.5 MG) 3 PA TRANSDERM-SCOP (1.5 MG) 3 PA trimethobenzamide hcl oral 1 VARUBI (180 MG DOSE) 3 QL ZUPLENZ 3 PA; QL Antifungals ABELCET 3 AMBISOME 3 ANCOBON 3 PA BIO-STATIN ORAL CAPSULE 3 bio-statin oral powder 1 PA CANCIDAS 3 PA caspofungin acetate 1 ciclodan 1 ciclopirox external 1 ciclopirox olamine external 1 ciclopirox treatment 1 PA clotrimazole external 1 clotrimazole mouth/throat 1 clotrimazole-betamethasone 1 CRESEMBA 3 DIFLUCAN 3 PA DIFMETIOXRIME 3 PA ECONASIL 3 PA econazole nitrate external 1 ECONAZOLE NITRATE-NIACINAMIDE 3 PA ECOZA 3 PA

Effective Date: 7/1/2021 29 Drug Name Drug Tier Requirements/Limits ERAXIS 3 ERTACZO 3 PA EXELDERM 3 PA EXODERM EXTERNAL LOTION 3 fluconazole in sodium chloride 1 fluconazole oral 1 FLUCON-IBUPROF-ITRACON-TERBINA 3 PA flucytosine oral 1 FUNGIMEZ 3 PA griseofulvin microsize oral 1 griseofulvin ultramicrosize 1 GYNAZOLE-1 3 HIXDEFRIMA 3 IMIOXIA 3 PA IODOQUINOL-HC- 3 PA oral 1 PA JUBLIA 3 PA KERYDIN 3 PA ketoconazole cream 2 % external 1 ketoconazole cream 2 % external 1 PA ketoconazole external foam 1 PA ketoconazole external shampoo 1 ketoconazole oral 1 KETOCONAZOLE-HYDROCORTISONE 3 PA ketodan external foam 1 PA KETODAN EXTERNAL KIT 3 PA LOPROX 3 PA LULICONAZOLE 3 PA LUZU 3 PA MENTAX 3 PA micafungin sodium 1 miconazole 3 1 MICONAZOLE- OXIDE-PETROLAT 3 PA MYCAMINE 3 PA naftifine hcl 1 NAFTIN EXTERNAL GEL 1 % 3 PA NAFTIN EXTERNAL GEL 2 % 3 NOXAFIL INTRAVENOUS 3

Effective Date: 7/1/2021 30 Drug Name Drug Tier Requirements/Limits NOXAFIL ORAL SUSPENSION 3 NOXAFIL ORAL TABLET DELAYED RELEASE 3 PA nyamyc 1 nystatin external 1 nystatin mouth/throat 1 nystatin oral 1 nystatin-triamcinolone 1 nystop 1 ONYCHO-MED 3 PA ORAVIG 3 PA oxiconazole nitrate 1 PA OXISTAT EXTERNAL LOTION 3 PA PHEODOYO 3 PA PHEYO 3 PA posaconazole 1 RECURA 3 PA SPORANOX 3 PA SPORANOX PULSEPAK 3 PA SULCONAZOLE NITRATE 3 PA tavaborole 1 PA terbinafine hcl oral 1 QL 1 TOLSURA 3 PA VFEND IV 3 PA VFEND ORAL SUSPENSION 3 PA RECONSTITUTED voriconazole intravenous 1 voriconazole oral 1 VUSION 3 PA XOLEGEL 3 PA XOLEGEL COREPAK 3 PA XOLEGEL DUO/HEAD & SHOULDERS 3 PA XOLEGEL DUO/XOLEX 3 PA ZOLPAK 3 PA Antigout Agents allopurinol oral 1 allopurinol sodium 1 ALOPRIM 3 PA

Effective Date: 7/1/2021 31 Drug Name Drug Tier Requirements/Limits COLCHICINE ORAL CAPSULE 3 ST; M colchicine oral tablet 1 colchicine-probenecid 1 COLCRYS 3 PA febuxostat 1 ST GLOPERBA 3 ST KRYSTEXXA 3 PA; SP MITIGARE 3 ST probenecid 1 ULORIC 3 PA ZYLOPRIM 3 PA Anti-inflammatory Agents EMFLAZA 3 PA; SP Antimigraine Agents AIMOVIG SUBCUTANEOUS SOLUTION 2 PA; QL AUTO-INJECTOR 140 MG/ML, 70 MG/ML AJOVY 3 PA; QL almotriptan malate 1 QL AMERGE 3 PA; QL CAFERGOT 3 PA D.H.E. 45 3 PA; QL dihydroergotamine mesylate injection 1 PA; QL dihydroergotamine mesylate nasal 1 PA; QL eletriptan hydrobromide 1 QL EMGALITY 2 PA; QL EMGALITY (300 MG DOSE) 2 PA; QL ERGOMAR 3 ergotamine-caffeine 1 frovatriptan succinate 1 PA; QL IMITREX NASAL 3 PA; QL IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE 4 3 PA; QL MG/0.5ML IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO- 3 PA; QL INJECTOR 4 MG/0.5ML IMITREX SUBCUTANEOUS 3 PA; QL MIGERGOT 3 MIGRANAL 3 PA; QL

Effective Date: 7/1/2021 32 Drug Name Drug Tier Requirements/Limits naratriptan hcl 1 QL NURTEC 2 PA; QL ONZETRA XSAIL 3 ST; QL REYVOW 3 PA; QL rizatriptan benzoate 1 QL SUMANSETRON 3 PA sumatriptan nasal 1 QL sumatriptan succinate oral 1 QL sumatriptan succinate refill 1 QL sumatriptan succinate subcutaneous 1 QL sumatriptan-naproxen sodium 1 PA; QL TOSYMRA 3 ST; QL UBRELVY 2 PA; QL VYEPTI 3 PA; QL ZEMBRACE SYMTOUCH 3 ST; QL ZOLMITRIPTAN NASAL 3 ST; QL zolmitriptan oral 1 QL ZOMIG NASAL 3 ST; QL Antimyasthenic Agents BLOXIVERZ 3 PA GUANIDINE HCL 3 MESTINON ORAL SOLUTION 3 PA MESTINON ORAL TABLET EXTENDED 3 PA RELEASE neostigmine methylsulfate intravenous solution 1 10 mg/10ml, 5 mg/10ml NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION 3 MG/3ML, 5 3 MG/5ML NEOSTIGMINE METHYLSULFATE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 2 MG/2ML, 3 MG/3ML NEOSTIGMINE METHYLSULFATE SOLUTION PREFILLED SYRINGE 4 MG/4ML 3 INTRAVENOUS NEOSTIGMINE METHYLSULFATE SOLUTION PREFILLED SYRINGE 4 MG/4ML 3 PA INTRAVENOUS NEOSTIGMINE METHYLSULFATE SOLUTION PREFILLED SYRINGE 5 MG/5ML 3 INTRAVENOUS

Effective Date: 7/1/2021 33 Drug Name Drug Tier Requirements/Limits NEOSTIGMINE METHYLSULFATE SOLUTION PREFILLED SYRINGE 5 MG/5ML 3 PA INTRAVENOUS pyridostigmine bromide er 1 pyridostigmine bromide oral 1 REGONOL 3 Antimycobacterials CAPASTAT SULFATE 3 QL cycloserine oral 1 QL dapsone oral 1 QL ethambutol hcl oral 1 QL isoniazid injection 1 QL isoniazid oral 1 QL MYAMBUTOL 3 PA; QL MYCOBUTIN 3 PA; QL PASER 3 QL PRETOMANID 3 QL PRIFTIN 3 QL pyrazinamide oral 1 QL rifabutin 1 QL RIFADIN 3 PA; QL rifampin intravenous 1 QL rifampin oral 1 QL SIRTURO 3 QL TRECATOR 3 QL Antineoplastics - Drugs for Cancer CM PA; SP ABRAXANE 2 SP ADCETRIS 2 PA; SP adriamycin 1 SP AFINITOR DISPERZ CM PA; SP AFINITOR ORAL TABLET 10 MG CM PA; SP; QL ALECENSA CM PA; SP ALIMTA 2 SP ALIQOPA 3 PA; SP ALKERAN INTRAVENOUS 3 PA; SP ALKERAN ORAL CM PA; SP ALUNBRIG CM PA; SP; QL anastrozole oral CM Effective Date: 7/1/2021 34 Drug Name Drug Tier Requirements/Limits AROMASIN CM PA ARRANON 2 SP arsenic trioxide intravenous 1 SP ARZERRA 2 PA; SP ASPARLAS 3 SP AVASTIN 3 PA; SP AYVAKIT CM PA; SP; QL azacitidine 1 SP AZEDRA DOSIMETRIC 3 PA AZEDRA THERAPEUTIC 3 PA BALVERSA CM PA; SP BAVENCIO 3 PA; SP BELEODAQ 3 PA; SP BELRAPZO 3 PA; SP BENDEKA 3 PA; SP BESPONSA 3 PA; SP bexarotene CM PA; SP CM BICNU 3 PA; SP BLENREP 3 PA; SP bleomycin sulfate 1 SP BLINCYTO 3 PA; SP BORTEZOMIB 3 PA; SP BOSULIF CM PA; SP BRAFTOVI CM PA; SP BRUKINSA CM PA; SP busulfan 1 SP BUSULFEX 3 PA; SP CABOMETYX CM PA; SP CALQUENCE CM PA; SP CAMPATH 2 SP CAMPTOSAR 3 PA; SP capecitabine CM PA; SP CAPRELSA ORAL TABLET 100 MG CM PA; SP; QL CAPRELSA ORAL TABLET 300 MG CM PA; SP carboplatin 1 SP carmustine 1 SP CASODEX CM PA

Effective Date: 7/1/2021 35 Drug Name Drug Tier Requirements/Limits cisplatin intravenous solution 1 SP CISPLATIN INTRAVENOUS SOLUTION 3 SP RECONSTITUTED cladribine 1 SP clofarabine 1 SP CLOLAR 3 PA; SP COMETRIQ CM PA; SP COPIKTRA CM PA; SP COSMEGEN 3 PA; SP COTELLIC CM PA; SP cyclophosphamide injection 1 SP CYCLOPHOSPHAMIDE INTRAVENOUS 3 SP cyclophosphamide oral capsule CM CYRAMZA 3 PA; SP cytarabine 1 SP cytarabine (pf) 1 SP dacarbazine 1 SP DACOGEN 3 PA; SP dactinomycin 1 SP DANYELZA 3 PA; SP DARZALEX 3 PA; SP DARZALEX FASPRO 3 PA; SP daunorubicin hcl 1 SP DAURISMO CM PA; SP decitabine 1 PA; SP dexrazoxane hcl 1 SP docetaxel 1 SP DOXIL 3 PA; SP doxorubicin hcl 1 SP doxorubicin hcl liposomal 1 SP DROXIA 3 ELITEK 3 SP ELLENCE 3 PA; SP ELZONRIS 3 PA; SP EMCYT CM EMPLICITI 3 PA; SP ENHERTU 3 PA; SP epirubicin hcl 1 SP

Effective Date: 7/1/2021 36 Drug Name Drug Tier Requirements/Limits ERBITUX 2 PA; SP ERIVEDGE CM PA; SP ERLEADA CM PA; SP erlotinib hcl oral tablet 100 mg, 150 mg CM PA; SP erlotinib hcl oral tablet 25 mg CM PA; SP; QL ERWINAZE 3 SP ETHYOL 3 ETOPOPHOS 3 SP etoposide intravenous 1 SP etoposide oral CM SP everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg CM PA; SP; QL EVOMELA 3 SP CM FARESTON CM PA FARYDAK CM PA; SP FASLODEX 3 PA; SP FEMARA CM PA floxuridine injection 1 SP fludarabine phosphate 1 SP fluorouracil intravenous 1 SP CM FOLOTYN 2 PA; SP fulvestrant 1 SP GAVRETO CM PA; SP GAZYVA 3 PA; SP hcl 1 SP GILOTRIF CM PA; SP; QL GLEOSTINE CM SP GLIADEL WAFER 3 HALAVEN 2 PA; SP HERCEPTIN 3 PA; SP HERCEPTIN HYLECTA 3 PA; SP HERZUMA 3 PA; SP HYCAMTIN INTRAVENOUS 3 PA; SP HYCAMTIN ORAL CM SP HYDREA CM PA hydroxyurea oral CM IBRANCE CM PA; SP

Effective Date: 7/1/2021 37 Drug Name Drug Tier Requirements/Limits ICLUSIG ORAL TABLET 10 MG, 15 MG CM PA; SP; QL ICLUSIG ORAL TABLET 30 MG, 45 MG CM PA; SP IDAMYCIN PFS 3 PA; SP idarubicin hcl 1 SP IDHIFA CM PA; SP; QL IFEX 3 PA; SP ifosfamide 1 SP imatinib mesylate CM PA; SP IMBRUVICA CM PA; SP IMFINZI 3 PA; SP IMLYGIC 3 SP INFUGEM 3 SP INLYTA CM PA; SP INQOVI CM PA; SP INREBIC CM PA; SP IRESSA CM PA; SP irinotecan hcl 1 SP ISTODAX (OVERFILL) 3 PA; SP IXEMPRA KIT 2 SP JAKAFI ORAL TABLET 10 MG CM PA; SP; QL JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, CM PA; SP 5 MG JELMYTO 3 PA; SP JEVTANA 2 PA; SP KADCYLA 3 PA; SP KANJINTI 2 PA; SP KEYTRUDA 3 PA; SP KHAPZORY 3 ST; SP KISQALI FEMARA CM PA; SP KISQALI ORAL TABLET THERAPY PACK 200 CM PA; SP MG KOSELUGO CM PA; SP KYPROLIS 2 PA; SP lapatinib ditosylate CM PA; SP LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 10 MG, 10 MG & 2 X 4 MG, 2 X 10 CM PA; SP MG, 2 X 10 MG & 4 MG, 2 X 4 MG, 3 X 4 MG, 4 MG letrozole oral CM

Effective Date: 7/1/2021 38 Drug Name Drug Tier Requirements/Limits leucovorin calcium injection 1 leucovorin calcium oral CM LEUKERAN CM levoleucovorin calcium 1 SP levoleucovorin calcium pf 1 SP LIBTAYO 3 PA; SP LONSURF CM PA; SP LORBRENA CM PA; SP LUMOXITI 3 PA; SP LUTATHERA 3 PA LYNPARZA CM PA; SP LYSODREN CM MARQIBO 3 SP MATULANE CM SP MEKINIST CM PA; SP MEKTOVI CM PA; SP melphalan CM SP melphalan hcl 1 SP mercaptopurine oral CM mesna 1 SP MESNEX INTRAVENOUS 3 PA; SP MESNEX ORAL CM SP mitomycin intravenous 1 SP MITOMYCIN INTRAVESICAL 3 PA; SP mitoxantrone hcl 1 PA; SP MONJUVI 3 PA; SP mutamycin 1 SP MVASI 2 PA; SP MYLERAN CM MYLOTARG 3 PA; SP NAVELBINE 3 SP NERLYNX CM PA; SP; QL NEXAVAR CM PA; SP NILANDRON CM PA; SP CM SP NINLARO CM PA; SP NIPENT 3 SP NUBEQA CM PA; SP

Effective Date: 7/1/2021 39 Drug Name Drug Tier Requirements/Limits ODOMZO CM PA; SP OGIVRI 3 PA; SP ONCASPAR 2 SP ONIVYDE 3 SP ONTRUZANT 3 PA; SP ONUREG CM PA; SP OPDIVO 3 PA; SP ORGOVYX CM PA; SP oxaliplatin 1 SP paclitaxel 1 SP PADCEV 3 PA; SP PANRETIN 3 paraplatin 1 SP PEMAZYRE CM PA; SP; QL PERJETA 2 PA; SP PHESGO 2 PA; SP PHOTOFRIN 3 SP PIQRAY CM PA; SP POLIVY 3 PA; SP POMALYST CM PA; SP PORTRAZZA 3 PA; SP POTELIGEO 3 PA; SP PROLEUKIN 2 SP PURIXAN CM SP QINLOCK CM PA; SP QUADRAMET 3 RETEVMO CM PA; SP REVLIMID CM PA; SP RIABNI 3 PA; SP RITUXAN 3 PA; SP RITUXAN HYCELA 3 PA; SP ROMIDEPSIN 3 PA; SP ROZLYTREK CM PA; SP RUBRACA CM PA; SP RUXIENCE 2 PA; SP RYDAPT CM PA; SP SARCLISA 3 PA; SP SIKLOS 3 PA

Effective Date: 7/1/2021 40 Drug Name Drug Tier Requirements/Limits SOLTAMOX CM SPRYCEL CM PA; SP STIVARGA CM PA; SP CHLORIDE SR-89 3 PA SUTENT CM PA; SP SYLVANT 3 PA; SP SYNRIBO 3 PA; SP TABLOID CM SP TABRECTA CM PA; SP TAFINLAR CM PA; SP TAGRISSO ORAL TABLET 40 MG CM PA; SP; QL TAGRISSO ORAL TABLET 80 MG CM PA; SP TALZENNA CM PA; SP tamoxifen citrate oral CM TARGRETIN EXTERNAL 3 PA; SP TASIGNA CM PA; SP TAZVERIK CM PA; SP TECARTUS 3 PA; SP TECENTRIQ 3 PA; SP TEMODAR INTRAVENOUS 2 SP TEMODAR ORAL CM PA; SP temozolomide CM PA; SP teniposide 1 SP TEPADINA 3 PA; SP THALOMID CM PA; SP thiotepa injection 1 SP TIBSOVO CM PA; SP toposar 1 SP topotecan hcl 1 SP toremifene citrate CM TOTECT 3 SP TRAZIMERA 2 PA; SP TREANDA 3 PA; SP tretinoin oral CM SP TRISENOX 3 PA; SP TRODELVY 3 PA; SP TRUXIMA 3 PA; SP TUKYSA CM PA; SP

Effective Date: 7/1/2021 41 Drug Name Drug Tier Requirements/Limits TURALIO CM PA; SP TYKERB CM PA; SP UNITUXIN 3 PA; SP VALCHLOR 3 PA; SP valrubicin 1 SP VALSTAR 3 PA; SP VECTIBIX 3 SP VELCADE 2 PA; SP VENCLEXTA CM PA; SP VENCLEXTA STARTING PACK CM PA; SP VERZENIO CM PA; SP VIDAZA 3 PA; SP vinblastine sulfate 1 SP vincristine sulfate 1 SP vinorelbine tartrate 1 SP VITRAKVI CM PA; SP VIZIMPRO CM PA; SP VORAXAZE 3 VOTRIENT CM PA; SP VYXEOS 3 PA; SP XALKORI CM PA; SP XOFIGO 2 XOSPATA CM PA; SP XPOVIO (100 MG ONCE WEEKLY) CM PA; SP XPOVIO (40 MG ONCE WEEKLY) CM PA; SP XPOVIO (40 MG TWICE WEEKLY) CM PA; SP XPOVIO (60 MG ONCE WEEKLY) CM PA; SP XPOVIO (60 MG TWICE WEEKLY) CM PA; SP XPOVIO (80 MG ONCE WEEKLY) CM PA; SP XPOVIO (80 MG TWICE WEEKLY) CM PA; SP XTANDI ORAL CAPSULE CM PA; SP XTANDI ORAL TABLET CM SP YERVOY 2 PA; SP YESCARTA 3 PA; SP YONDELIS 3 SP YONSA CM PA; SP ZALTRAP 2 PA; SP ZANOSAR 2 SP

Effective Date: 7/1/2021 42 Drug Name Drug Tier Requirements/Limits ZEJULA CM PA; SP ZELBORAF CM PA; SP ZEPZELCA 3 PA; SP ZEVALIN Y-90 3 SP ZIRABEV 2 PA; SP ZOLINZA CM PA; SP ZYDELIG CM PA; SP ZYKADIA CM PA; SP Antiparasitics albendazole oral 1 PA ALINIA ORAL SUSPENSION 2 RECONSTITUTED ALINIA ORAL TABLET 3 PA ARAKODA 3 atovaquone oral 1 atovaquone-proguanil hcl 1 BENZNIDAZOLE 3 BILTRICIDE 3 PA chloroquine phosphate oral 1 COARTEM 3 crotan 1 DARAPRIM 3 PA; SP EGATEN 3 ELIMITE 3 PA EMVERM 2 hydroxychloroquine sulfate oral 1 IMPAVIDO 3 QL ivermectin external 1 ivermectin oral 1 KRINTAFEL 3 LAMPIT 3 lindane 1 MALARONE 3 PA malathion 1 mefloquine hcl 1 MEPRON 3 PA NATROBA 3 PA NEBUPENT 3 PA; QL

Effective Date: 7/1/2021 43 Drug Name Drug Tier Requirements/Limits nitazoxanide 1 OVIDE 3 PA PENTAM 3 PA; QL pentamidine isethionate 1 QL permethrin external 1 praziquantel oral 1 primaquine phosphate 1 pyrimethamine oral 1 PA; SP PYRIMETHAMINE-LEUCOVORIN 3 QUALAQUIN 3 PA quinine sulfate oral 1 PA SKLICE 3 PA spinosad 1 STROMECTOL 3 PA sulfurated lime 1 Antiparkinson Agents amantadine hcl oral 1 APOKYN 3 PA; SP; QL AZILECT 3 PA benztropine mesylate 1 bromocriptine mesylate oral 1 carbidopa oral 1 carbidopa-levodopa 1 carbidopa-levodopa er 1 carbidopa-levodopa-entacapone 1 COGENTIN 3 PA COMTAN 3 PA DUOPA 3 PA entacapone 1 GOCOVRI 3 PA INBRIJA 3 PA; SP KYNMOBI 3 PA; SP; QL KYNMOBI TITRATION KIT 3 PA; SP; QL MIRAPEX 3 PA MIRAPEX ER 3 PA NEUPRO 3 ST NOURIANZ 3 PA ONGENTYS 3 ST

Effective Date: 7/1/2021 44 Drug Name Drug Tier Requirements/Limits OSMOLEX ER 3 PA PARLODEL 3 PA pramipexole dihydrochloride 1 pramipexole dihydrochloride er 1 rasagiline mesylate oral 1 ropinirole hcl 1 ropinirole hcl er 1 RYTARY 3 ST selegiline hcl oral 1 SINEMET 3 PA STALEVO 100 3 PA STALEVO 125 3 PA STALEVO 150 3 PA STALEVO 200 3 PA STALEVO 50 3 PA STALEVO 75 3 PA TASMAR 3 PA tolcapone 1 trihexyphenidyl hcl 1 XADAGO 3 ST; QL ZELAPAR 3 Antiplatelets AGGRASTAT 3 aspirin-dipyridamole er 1 ASPIRIN-OMEPRAZOLE 3 PA; M; QL BRILINTA 2 CABLIVI 3 PA; SP; QL cilostazol 1 clopidogrel bisulfate oral 1 DEFITELIO 3 PA dipyridamole oral 1 DURLAZA 3 PA EFFIENT 3 PA eptifibatide 1 INTEGRILIN 3 PA KENGREAL 3 PLAVIX 3 PA prasugrel hcl 1

Effective Date: 7/1/2021 45 Drug Name Drug Tier Requirements/Limits YOSPRALA 3 PA; QL ZONTIVITY 3 Antipsychotics - Drugs for Mood Disorders ABILIFY MAINTENA 3 ABILIFY MYCITE 3 ST; QL ADASUVE 3 PA aripiprazole 1 QL ARISTADA 3 ARISTADA INITIO 3 asenapine maleate 1 QL CAPLYTA 3 ST; QL chlorpromazine hcl injection 1 chlorpromazine hcl oral 1 clozapine 1 QL CLOZARIL 3 PA; QL FANAPT 3 ST; QL FANAPT TITRATION PACK 3 ST; QL fluphenazine decanoate injection 1 fluphenazine hcl 1 GEODON INTRAMUSCULAR 3 PA HALDOL 3 PA HALDOL DECANOATE 3 PA decanoate intramuscular 1 haloperidol lactate 1 haloperidol oral 1 INVEGA 3 PA; QL INVEGA SUSTENNA 3 INVEGA TRINZA 3 LATUDA 3 QL loxapine succinate 1 molindone hcl 1 NUPLAZID 3 PA olanzapine intramuscular 1 olanzapine oral 1 QL er 1 QL PERSERIS 3 pimozide 1 quetiapine fumarate 1 QL

Effective Date: 7/1/2021 46 Drug Name Drug Tier Requirements/Limits quetiapine fumarate er 1 QL REXULTI 3 QL RISPERDAL CONSTA 3 RISPERDAL ORAL SOLUTION 3 PA; QL 1 QL SAPHRIS 3 PA; QL SECUADO 3 ST; QL thioridazine hcl oral 1 thiothixene 1 trifluoperazine hcl 1 VERSACLOZ 3 QL VRAYLAR 3 ST; QL ziprasidone hcl 1 QL ziprasidone mesylate 1 ZYPREXA INTRAMUSCULAR 3 PA ZYPREXA RELPREVV 3 ZYPREXA ZYDIS 3 PA; QL Antivirals abacavir sulfate 1 abacavir sulfate-lamivudine 1 abacavir-lamivudine-zidovudine 1 acyclovir external cream 1 PA acyclovir external ointment 1 acyclovir oral 1 acyclovir sodium 1 adefovir dipivoxil 1 SP APTIVUS 2 atazanavir sulfate 1 ATRIPLA 3 PA BARACLUDE ORAL SOLUTION 3 SP; QL BIKTARVY 3 cidofovir intravenous 1 CIMDUO 2 COMBIVIR 3 PA COMPLERA 2 CRIXIVAN 2 DELSTRIGO 3 DENAVIR 3 PA

Effective Date: 7/1/2021 47 Drug Name Drug Tier Requirements/Limits DESCOVY 3 PA DOVATO 2 EDURANT 2 efavirenz 1 efavirenz-emtricitab-tenofovir 1 efavirenz-lamivudine-tenofovir 1 emtricitabine 1 emtricitabine-tenofovir df 1 EMTRIVA ORAL CAPSULE 3 PA EMTRIVA ORAL SOLUTION 2 entecavir 1 SP; QL EPCLUSA 2 PA; SP; QL EPIVIR 3 PA EPIVIR HBV ORAL SOLUTION 2 SP EPIVIR HBV ORAL TABLET 3 PA; SP EPZICOM 3 PA EVOTAZ 2 famciclovir oral 1 FAVIPIRAVIR 3 fosamprenavir calcium 1 foscarnet sodium 1 FOSCAVIR 3 PA FUZEON 2 GANCICLOVIR 3 ganciclovir sodium 1 GENVOYA 3 HARVONI 2 PA; SP; QL HEPSERA 3 PA; SP INTELENCE 2 INTRON A 3 PA; SP INVIRASE 2 ISENTRESS 2 ISENTRESS HD 2 JULUCA 2 KALETRA ORAL SOLUTION 3 PA KALETRA ORAL TABLET 2 lamivudine oral solution 1 lamivudine oral tablet 100 mg 1 SP

Effective Date: 7/1/2021 48 Drug Name Drug Tier Requirements/Limits lamivudine oral tablet 150 mg, 300 mg 1 lamivudine-zidovudine 1 LEDIPASVIR-SOFOSBUVIR 3 PA; M; SP; QL LEXIVA ORAL SUSPENSION 2 LEXIVA ORAL TABLET 3 PA lopinavir-ritonavir 1 MAVYRET 2 PA; SP; QL nevirapine 1 nevirapine er 1 NORVIR ORAL PACKET 2 NORVIR ORAL SOLUTION 2 NORVIR ORAL TABLET 3 PA ODEFSEY 3 oseltamivir phosphate oral 1 QL PEGASYS 2 PA; SP PEGINTRON 3 PA; SP PIFELTRO 3 PREVYMIS 3 SP PREZCOBIX 2 PREZISTA 2 RAPIVAB 3 RELENZA DISKHALER 3 QL RETROVIR INTRAVENOUS 2 RETROVIR ORAL 3 PA REYATAZ ORAL CAPSULE 3 PA REYATAZ ORAL PACKET 2 ribavirin inhalation 1 ribavirin oral 1 SP rimantadine hcl 1 ritonavir 1 RUKOBIA 3 SELZENTRY 2 PA SITAVIG 3 PA; QL SOFOSBUVIR-VELPATASVIR 3 PA; M; SP; QL SOVALDI 3 PA; SP; QL stavudine 1 STRIBILD 3 SUSTIVA 3 PA

Effective Date: 7/1/2021 49 Drug Name Drug Tier Requirements/Limits SYMFI 2 PA SYMFI LO 2 PA SYMTUZA 3 TAMIFLU ORAL SUSPENSION 3 PA; QL RECONSTITUTED TEMIXYS 3 ST tenofovir disoproxil fumarate 1 TIVICAY 2 TIVICAY PD 2 TRIUMEQ 2 TRIZIVIR 3 PA TROGARZO 3 PA TRUVADA 3 PA TYBOST 2 valacyclovir hcl oral 1 QL valganciclovir hcl 1 VEMLIDY 3 SP VIEKIRA PAK 3 PA; SP; QL VIRACEPT 2 VIRAMUNE 3 PA VIRAMUNE XR 3 PA VIRAZOLE 3 PA VIREAD ORAL POWDER 2 VIREAD ORAL TABLET 150 MG, 200 MG, 250 2 MG VOSEVI 2 PA; SP XERESE 3 PA XOFLUZA (40 MG DOSE) 3 QL XOFLUZA (80 MG DOSE) 3 QL ZEPATIER 3 PA; SP; QL ZIAGEN 3 PA zidovudine 1 Anxiolytics - Drugs for Anxiety alprazolam er 1 QL alprazolam intensol 1 QL alprazolam oral tablet 1 QL alprazolam oral tablet dispersible 1 PA; QL alprazolam xr 1 QL ATIVAN INJECTION 3 PA Effective Date: 7/1/2021 50 Drug Name Drug Tier Requirements/Limits buspirone hcl oral 1 chlordiazepoxide hcl 1 QL clonazepam oral 1 QL clorazepate dipotassium 1 QL diazepam intensol 1 diazepam intramuscular 1 diazepam oral 1 diazepam solution 5 mg/ml injection 1 DIAZEPAM SOLUTION 5 MG/ML INJECTION 3 DORAL 3 PA; QL estazolam 1 QL HALCION 3 PA; QL hydroxyzine hcl intramuscular 1 hydroxyzine hcl oral 1 hydroxyzine pamoate oral 1 lorazepam injection 1 lorazepam intensol 1 QL lorazepam oral concentrate 2 mg/ml 1 QL lorazepam oral tablet 1 QL meprobamate 1 oxazepam 1 QL quazepam 1 QL TRANXENE-T 3 PA; QL triazolam 1 QL VISTARIL 3 PA Bipolar Agents - Drugs for Mood Disorders EQUETRO 3 lithium 1 lithium carbonate er 1 lithium carbonate oral 1 LITHOBID 3 PA Blood Products and Modifiers - Drugs for Blood Disorders ADVATE 2 SP ADYNOVATE 3 SP AFSTYLA 3 SP AGRYLIN 3 PA ALPHANATE 2 SP

Effective Date: 7/1/2021 51 Drug Name Drug Tier Requirements/Limits ALPHANINE SD 2 SP ALPROLIX 3 SP AMICAR 3 PA aminocaproic acid intravenous 1 aminocaproic acid oral 1 anagrelide hcl 1 ARANESP (ALBUMIN FREE) 2 PA; SP ASTRINGYN SOLUTION 259 MG/GM 3 EXTERNAL ASTRINGYN SOLUTION 259 MG/GM 3 PA EXTERNAL BENEFIX 2 SP COAGADEX 3 SP CORIFACT 2 SP CYKLOKAPRON 3 PA DOPTELET 3 PA; SP ELOCTATE 3 SP EPOGEN 3 PA; SP ESPEROCT 3 SP FEIBA 2 SP FIBRYGA 2 SP FULPHILA 3 PA; SP GRANIX 3 PA; SP HEMLIBRA 3 SP HEMOFIL M 3 SP HESPAN 3 hetastarch-nacl 1 HEXTEND 3 HUMATE-P 2 SP IDELVION 3 SP IXINITY 3 SP JIVI 3 SP KCENTRA 3 KOATE 2 SP KOATE-DVI 2 SP KOGENATE FS 3 SP KOVALTRY 3 SP LEUKINE 3 PA; SP LMD IN D5W 3 Effective Date: 7/1/2021 52 Drug Name Drug Tier Requirements/Limits LMD IN NACL 3 LYSTEDA 3 PA MIRCERA 3 PA; SP MONONINE 2 SP MONSELS FERRIC SUBSULFATE 3 PA MOZOBIL 2 PA; SP; QL MULPLETA 2 PA; SP NEULASTA 3 PA; SP NEULASTA ONPRO 3 PA; SP NEUPOGEN 3 PA; SP NIVESTYM 2 PA; SP NOVOEIGHT 2 SP NOVOSEVEN RT 2 SP NPLATE 3 PA; SP NUWIQ 2 SP NYVEPRIA 3 PA; SP OBIZUR 3 SP PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 3 PA; SP UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION 40000 2 PA; SP UNIT/ML PROFILNINE 2 SP PROMACTA 3 PA; SP protamine sulfate intravenous 1 REBINYN 3 SP REBLOZYL 3 PA; SP RECOMBINATE 2 SP RECOTHROM 3 RECOTHROM SPRAY KIT 3 RETACRIT 2 PA; SP RIASTAP 2 SP RIXUBIS 3 SP SEVENFACT 3 SP SOLIRIS 3 PA; SP TAVALISSE 3 PA; SP THROMBIN-JMI 3 THROMBIN-JMI EPISTAXIS 3 THROMBOGEN 3

Effective Date: 7/1/2021 53 Drug Name Drug Tier Requirements/Limits tranexamic acid intravenous 1 tranexamic acid oral 1 TRANEXAMIC ACID-NACL 3 TRETTEN 3 SP UDENYCA 3 PA; SP ULTOMIRIS 3 PA; SP VONVENDI 3 SP WILATE 2 SP XYNTHA 2 SP XYNTHA SOLOFUSE 2 SP ZARXIO 2 PA; SP ZIEXTENZO 3 PA; SP Cardiovascular Agents - Drugs for Heart and Circulation Conditions ACCUPRIL 3 PA ACCURETIC 3 PA acebutolol hcl oral 1 acetazolamide sodium 1 ADENOCARD 3 PA adenosine intravenous solution 12 mg/4ml, 6 1 mg/2ml AKOVAZ 3 PA ALDACTAZIDE ORAL TABLET 25-25 MG 3 PA ALDACTAZIDE ORAL TABLET 50-50 MG 3 ALDACTONE 3 PA aliskiren fumarate 1 alprostadil injection 1 ALTACE 3 PA ALTOPREV 3 ST amiloride hcl oral 1 amiloride-hydrochlorothiazide 1 amiodarone hcl 1 AMIODARONE HCL IN DEXTROSE 3 PA amlodipine besylate oral 1 amlodipine besylate-benazepril hcl 1 amlodipine besylate-valsartan 1 amlodipine-atorvastatin 1 amlodipine-olmesartan 1 amlodipine-valsartan-hctz 1 Effective Date: 7/1/2021 54 Drug Name Drug Tier Requirements/Limits ANTARA 3 PA ASCLERA 3 ATACAND 3 PA ATACAND HCT 3 PA atenolol oral 1 atenolol-chlorthalidone 1 atorvastatin calcium oral 1 AVALIDE 3 PA AVAPRO 3 PA benazepril hcl oral 1 benazepril-hydrochlorothiazide 1 BETAPACE AF 3 PA betaxolol hcl oral 1 BIDIL 3 BIORPHEN 3 bisoprolol fumarate oral 1 bisoprolol-hydrochlorothiazide 1 BRETYLIUM TOSYLATE 3 PA BREVIBLOC 3 PA BREVIBLOC IN NACL 3 PA BREVIBLOC PREMIXED 3 PA BREVIBLOC PREMIXED DS 3 PA bumetanide 1 BUMEX 3 PA BYSTOLIC 2 CALAN SR 3 PA candesartan cilexetil 1 candesartan cilexetil-hctz 1 captopril oral 1 captopril-hydrochlorothiazide 1 CARDENE IV 3 CARDIZEM 3 PA CARDIZEM LA ORAL TABLET EXTENDED 3 ST RELEASE 24 HOUR 120 MG CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 3 PA MG, 360 MG, 420 MG CARDURA 3 PA CAROSPIR 3

Effective Date: 7/1/2021 55 Drug Name Drug Tier Requirements/Limits cartia xt 1 carvedilol 1 carvedilol phosphate er 1 CATAPRES-TTS-1 3 PA CATAPRES-TTS-2 3 PA CATAPRES-TTS-3 3 PA chlorothiazide sodium 1 chlorthalidone 1 cholestyramine light 1 cholestyramine oral 1 CLEVIPREX 3 clonidine 1 clonidine hcl oral 1 colesevelam hcl oral packet 1 PA colesevelam hcl oral tablet 1 COLESTID 3 PA COLESTID FLAVORED 3 PA colestipol hcl 1 CONJUPRI 3 PA CONSENSI 3 ST; QL COREG 3 PA COREG CR 3 PA CORLANOR 3 PA; QL CORLOPAM 3 CORVERT 3 PA DEMSER 3 DIBENZYLINE 3 PA digitek 1 digox 1 digoxin injection 1 digoxin oral 1 DILATRATE-SR 3 diltiazem hcl er 1 diltiazem hcl er beads 1 diltiazem hcl er coated beads 1 diltiazem hcl intravenous 1 diltiazem hcl oral 1

Effective Date: 7/1/2021 56 Drug Name Drug Tier Requirements/Limits DILTIAZEM HCL-DEXTROSE SOLUTION 125- 3 PA 5 MG/125ML-% INTRAVENOUS DILTIAZEM HCL-DEXTROSE SOLUTION 125- 3 5 MG/125ML-% INTRAVENOUS DILTIAZEM HCL-SODIUM CHLORIDE 3 dilt-xr 1 disopyramide phosphate 1 DIURIL 3 dobutamine hcl 1 dobutamine in d5w 1 dofetilide 1 dopamine hcl intravenous 1 dopamine in d5w 1 doxazosin mesylate oral 1 droxidopa 1 PA; SP DUTOPROL 3 PA DYRENIUM 3 PA EDARBI 3 ST EDARBYCLOR 3 ST EDECRIN 3 PA EMERPHED 3 PA enalapril maleate oral 1 enalaprilat 1 enalapril-hydrochlorothiazide 1 ENTRESTO 2 QL EPANED 3 PA EPHEDRINE SULFATE (PRESSORS) INJECTION SOLUTION PREFILLED SYRINGE 3 PA 50 MG/10ML EPHEDRINE SULFATE (PRESSORS) SOLUTION PREFILLED SYRINGE 25 MG/5ML 3 INJECTION EPHEDRINE SULFATE (PRESSORS) SOLUTION PREFILLED SYRINGE 25 MG/5ML 3 PA INJECTION EPHEDRINE SULFATE (PRESSORS) SOLUTION PREFILLED SYRINGE 50 MG/5ML 3 INJECTION EPHEDRINE SULFATE (PRESSORS) SOLUTION PREFILLED SYRINGE 50 MG/5ML 3 PA INJECTION

Effective Date: 7/1/2021 57 Drug Name Drug Tier Requirements/Limits ephedrine sulfate injection 1 PA ephedrine sulfate intravenous solution 1 EPHEDRINE SULFATE INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 3 MG/ML-%, 100-0.9 MG/10ML-% EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 25-0.9 MG/5ML-% 3 INTRAVENOUS EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 25-0.9 MG/5ML-% 3 PA INTRAVENOUS EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-0.9 MG/10ML-% 3 INTRAVENOUS EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-0.9 MG/10ML-% 3 PA INTRAVENOUS EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-0.9 MG/5ML-% 3 INTRAVENOUS EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-0.9 MG/5ML-% 3 PA INTRAVENOUS EPINEPHRINE HCL-DEXTROSE 3 EPINEPHRINE HCL-NACL 3 EPINEPHRINE INTRAVENOUS SOLUTION 3 EPINEPHRINE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 0.1 MG/10ML epinephrine intravenous solution prefilled 1 syringe 1 mg/10ml epinephrine pf 1 epinephrine solution prefilled syringe 1 mg/10ml 1 PA injection EPINEPHRINE SOLUTION PREFILLED 3 SYRINGE 1 MG/10ML INJECTION EPINEPHRINE-DEXTROSE 3 EPINEPHRINE-NACL INTRAVENOUS 3 SOLUTION 2-0.9 MG/250ML-% EPINEPHRINE-NACL INTRAVENOUS 3 PA SOLUTION 5-0.9 MG/250ML-% EPINEPHRINE-NACL INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE Effective Date: 7/1/2021 58 Drug Name Drug Tier Requirements/Limits eplerenone 1 esmolol hcl intravenous solution 100 mg/10ml 1 ESMOLOL HCL INTRAVENOUS SOLUTION 3 2000 MG/100ML, 2500 MG/250ML ESMOLOL HCL INTRAVENOUS SOLUTION 3 PA PREFILLED SYRINGE esmolol hcl-sodium chloride 1 ethacrynate sodium 1 ethacrynic acid 1 ETHAMOLIN 3 EXFORGE 3 PA EXFORGE HCT 3 PA EZALLOR SPRINKLE 3 ST ezetimibe 1 ezetimibe-simvastatin 1 felodipine er 1 fenofibrate micronized oral capsule 130 mg 1 PA fenofibrate micronized oral capsule 134 mg, 200 1 mg, 43 mg, 67 mg fenofibrate oral capsule 1 fenofibrate oral tablet 120 mg, 40 mg 1 PA fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 1 54 mg fenofibric acid oral capsule delayed release 1 fenofibric acid oral tablet 1 PA FIBRICOR 3 ST flecainide acetate 1 FLOLIPID 3 ST fluvastatin sodium 1 PA fluvastatin sodium er 1 PA fosinopril sodium 1 fosinopril sodium-hctz 1 FUROSEMIDE IN SODIUM CHLORIDE 3 furosemide injection 1 furosemide oral 1 gemfibrozil oral 1 GIAPREZA 3 PA GONITRO 3 guanfacine hcl 1

Effective Date: 7/1/2021 59 Drug Name Drug Tier Requirements/Limits HEMANGEOL 3 hydralazine hcl injection 1 hydralazine hcl oral 1 hydrochlorothiazide oral 1 HYZAAR 3 PA ibutilide fumarate 1 icosapent ethyl 1 PA indapamide 1 INDERAL XL 3 ST INNOPRAN XL 3 ST INSPRA 3 PA irbesartan 1 irbesartan-hydrochlorothiazide 1 ISORDIL TITRADOSE 3 PA isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 1 mg, 5 mg isosorbide dinitrate oral tablet 40 mg 1 PA isosorbide mononitrate 1 isosorbide mononitrate er 1 isradipine 1 JUXTAPID 3 PA; SP; QL KAPSPARGO SPRINKLE 3 ST KATERZIA 3 ST LABETALOL HCL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE labetalol hcl oral 1 labetalol hcl solution 5 mg/ml intravenous 1 LABETALOL HCL SOLUTION 5 MG/ML 3 INTRAVENOUS LANOXIN INJECTION 3 PA LANOXIN ORAL TABLET 125 MCG, 250 MCG 2 PA LANOXIN ORAL TABLET 62.5 MCG 2 LANOXIN PEDIATRIC 3 LASIX 3 PA LEVOPHED 3 PA LIPOFEN 3 lisinopril oral 1 lisinopril-hydrochlorothiazide 1 LIVALO 3 ST

Effective Date: 7/1/2021 60 Drug Name Drug Tier Requirements/Limits LOPID 3 PA LOPRESSOR 3 PA losartan potassium oral 1 losartan potassium-hctz 1 LOTENSIN 3 PA LOTENSIN HCT 3 PA lovastatin oral 1 mannitol intravenous 1 matzim la 1 MAXZIDE 3 PA MAXZIDE-25 3 PA methyldopa 1 methyldopa-hydrochlorothiazide 1 metolazone 1 metoprolol succinate er 1 metoprolol tartrate intravenous 1 metoprolol tartrate oral 1 metoprolol-hydrochlorothiazide 1 metyrosine 1 mexiletine hcl oral 1 MICARDIS 3 PA MICARDIS HCT 3 PA midodrine hcl 1 milrinone lactate 1 milrinone lactate in dextrose 1 MINIPRESS 3 PA minitran 1 PA oral 1 moexipril hcl 1 MULTAQ 3 nadolol oral 1 PA NEXLETOL 2 PA; QL NEXLIZET 2 PA; QL NEXTERONE 3 niacin (antihyperlipidemic) 1 PA niacin er (antihyperlipidemic) 1 niacor 1 PA NIASPAN 3 PA

Effective Date: 7/1/2021 61 Drug Name Drug Tier Requirements/Limits nicardipine hcl 1 NICARDIPINE HCL IN NACL 3 nifedipine er 1 nifedipine er osmotic release 1 nifedipine oral 1 nimodipine oral 1 NIPRIDE RTU 3 PA nisoldipine er 1 NITRO-BID 3 NITRO-DUR 3 nitroglycerin 1 nitroglycerin in d5w 1 NITROLINGUAL 3 PA NITROMIST 3 nitroprusside sodium solution 25 mg/ml 1 intravenous nitroprusside sodium solution 25 mg/ml 1 PA intravenous NITROSTAT 3 PA NITRO-TIME 3 PA NOREPINEPHRINE (BASE)-DEXTROSE 3 norepinephrine bitartrate intravenous 1 NOREPINEPHRINE-DEXTROSE 3 INTRAVENOUS SOLUTION 8-5 MG/500ML-% NOREPINEPHRINE-DEXTROSE SOLUTION 4- 3 5 MG/250ML-% INTRAVENOUS NOREPINEPHRINE-DEXTROSE SOLUTION 4- 3 PA 5 MG/250ML-% INTRAVENOUS NOREPINEPHRINE-DEXTROSE SOLUTION 8- 3 5 MG/250ML-% INTRAVENOUS NOREPINEPHRINE-DEXTROSE SOLUTION 8- 3 PA 5 MG/250ML-% INTRAVENOUS NOREPINEPHRINE-SODIUM CHLORIDE INTRAVENOUS SOLUTION 8-0.9 MG/500ML- 3 PA % NOREPINEPHRINE-SODIUM CHLORIDE SOLUTION 16-0.9 MG/250ML-% 3 INTRAVENOUS NOREPINEPHRINE-SODIUM CHLORIDE SOLUTION 16-0.9 MG/250ML-% 3 PA INTRAVENOUS

Effective Date: 7/1/2021 62 Drug Name Drug Tier Requirements/Limits NOREPINEPHRINE-SODIUM CHLORIDE SOLUTION 4-0.9 MG/250ML-% 3 INTRAVENOUS NOREPINEPHRINE-SODIUM CHLORIDE SOLUTION 4-0.9 MG/250ML-% 3 PA INTRAVENOUS NOREPINEPHRINE-SODIUM CHLORIDE SOLUTION 8-0.9 MG/250ML-% 3 INTRAVENOUS NOREPINEPHRINE-SODIUM CHLORIDE SOLUTION 8-0.9 MG/250ML-% 3 PA INTRAVENOUS NORPACE 3 PA NORPACE CR 2 NORTHERA 3 PA; SP NYMALIZE 3 olmesartan medoxomil oral 1 olmesartan medoxomil-hctz 1 olmesartan-amlodipine-hctz 1 omega-3-acid ethyl esters 1 PA OSMITROL 3 PACERONE 3 PA papaverine hcl injection 1 PA pentoxifylline er 1 perindopril erbumine 1 phenoxybenzamine hcl oral 1 phentolamine mesylate injection 1 PHENYLEPHRINE HCL (PRESSORS) 3 PHENYLEPHRINE HCL INTRAVENOUS 3 SOLUTION 1 MG/10ML PHENYLEPHRINE HCL INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE phenylephrine hcl solution 10 mg/ml intravenous 1 phenylephrine hcl solution 10 mg/ml intravenous 1 PA PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 10-0.9 MG/250ML-%, 100-0.9 3 PA MG/250ML-%, 25-0.9 MG/250ML-% PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 20-0.9 MG/250ML-%, 40-0.9 3 MG/250ML-%, 80-0.9 MG/250ML-%

Effective Date: 7/1/2021 63 Drug Name Drug Tier Requirements/Limits PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.4-0.9 3 PA MG/10ML-% PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 0.5-0.9 MG/5ML-%, 0.8-0.9 MG/10ML-%, 1-0.9 3 MG/10ML-%, 100-0.9 MCG/10ML-%, 20-0.9 MG/50ML-% PHENYLEPHRINE HCL-NACL SOLUTION 50- 3 0.9 MG/250ML-% INTRAVENOUS PHENYLEPHRINE HCL-NACL SOLUTION 50- 3 PA 0.9 MG/250ML-% INTRAVENOUS pindolol 1 POLIDOCANOL 3 PA PRALUENT 2 PA; QL pravastatin sodium 1 prazosin hcl oral 1 PRESTALIA 3 prevalite 1 procainamide hcl injection 1 PROCARDIA 3 PA PROCARDIA XL 3 PA propafenone hcl 1 propafenone hcl er 1 propranolol hcl er 1 propranolol hcl intravenous 1 propranolol hcl oral 1 propranolol-hctz 1 PROSTIN VR 3 PA QBRELIS 3 PA QUESTRAN 3 PA QUESTRAN LIGHT 3 PA quinapril hcl 1 quinapril-hydrochlorothiazide 1 quinidine gluconate er 1 quinidine sulfate 1 ramipril 1 ranolazine er 1 RECTIV 3 REPATHA 2 PA; QL

Effective Date: 7/1/2021 64 Drug Name Drug Tier Requirements/Limits REPATHA PUSHTRONEX SYSTEM 2 PA; QL REPATHA SURECLICK 2 PA; QL rosuvastatin calcium 1 RYTHMOL SR 3 PA simvastatin oral 1 SODIUM DIURIL 3 PA SODIUM EDECRIN 3 PA sodium nitroprusside 1 sodium tetradecyl sulfate intravenous 1 PA sorine 1 sotalol hcl (af) 1 SOTALOL HCL INTRAVENOUS 3 sotalol hcl oral 1 SOTRADECOL 3 PA SOTYLIZE 3 oral 1 spironolactone-hctz 1 SULAR 3 PA SURE RESULT O3D3 SYSTEM 3 PA TARKA 3 PA taztia xt 1 TEKTURNA 2 PA TEKTURNA HCT 2 ST telmisartan 1 telmisartan-amlodipine 1 telmisartan-hctz 1 TENORETIC 100 3 PA TENORETIC 50 3 PA tiadylt er 1 TIAZAC 3 PA TIKOSYN 3 PA timolol maleate oral 1 torsemide 1 trandolapril 1 trandolapril-verapamil hcl er 1 triamterene oral 1 triamterene-hctz 1 TRICOR 3 PA

Effective Date: 7/1/2021 65 Drug Name Drug Tier Requirements/Limits TRILIPIX 3 PA TWYNSTA 3 PA valsartan 1 valsartan-hydrochlorothiazide 1 VARITHENA 3 VASCEPA 2 PA VASERETIC 3 PA VAZCULEP 3 PA VECAMYL 3 verapamil hcl er 1 verapamil hcl intravenous 1 verapamil hcl oral 1 VERELAN 3 PA VERELAN PM 3 PA VYNDAMAX 3 PA; SP; QL VYNDAQEL 3 PA; SP; QL ZIAC 3 PA ZYPITAMAG 3 ST Central Nervous System Agents - Drugs for Attention Deficit Disorder ADHANSIA XR 3 ST; QL ADZENYS ER 3 ST; QL ADZENYS XR-ODT 3 ST; QL AMPHETAMINE ER 3 ST; QL amphetamine sulfate 1 PA; QL amphetamine-dextroamphetamine 1 PA; QL amphetamine-dextroamphetamine er 1 PA; QL APTENSIO XR 3 PA; QL hcl 1 QL clonidine hcl er 1 COTEMPLA XR-ODT 3 ST; QL DAYTRANA 3 ST; QL dexmethylphenidate hcl 1 PA; QL dexmethylphenidate hcl er 1 PA; QL dextroamphetamine sulfate 1 PA; QL dextroamphetamine sulfate er 1 PA; QL DYANAVEL XR 3 ST; QL EVEKEO 3 PA; QL

Effective Date: 7/1/2021 66 Drug Name Drug Tier Requirements/Limits EVEKEO ODT 3 PA; QL FOCALIN 3 PA; QL guanfacine hcl er 1 INTUNIV 3 PA JORNAY PM 3 ST; QL KAPVAY 3 PA methamphetamine hcl 1 PA; QL METHYLIN 3 PA; QL hcl er 1 PA; QL methylphenidate hcl er (cd) 1 PA; QL methylphenidate hcl er (la) oral capsule 1 ST; QL extended release 24 hour 10 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 1 PA; QL 60 mg methylphenidate hcl er (xr) 1 PA; QL methylphenidate hcl oral 1 PA; QL MYDAYIS 3 ST; QL PROCENTRA 3 PA; QL QUILLICHEW ER 3 ST; QL QUILLIVANT XR 3 ST; QL relexxii 1 PA; QL RITALIN 3 PA; QL RITALIN LA 3 PA; QL VYVANSE 2 PA; QL ZENZEDI ORAL TABLET 10 MG, 5 MG 3 PA; QL ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 3 ST; QL MG, 30 MG, 7.5 MG Central Nervous System Agents - Drugs for Multiple Sclerosis AMPYRA 3 PA; SP; QL AUBAGIO 3 PA; 3P; SP; QL AVONEX PEN 2 PA; SP; QL AVONEX PREFILLED 2 PA; SP; QL BAFIERTAM 2 PA; SP; QL BETASERON 2 PA; SP; QL COPAXONE 2 PA; SP; QL dalfampridine er 1 PA; SP; QL dimethyl fumarate oral 1 PA; SP; QL

Effective Date: 7/1/2021 67 Drug Name Drug Tier Requirements/Limits dimethyl fumarate starter pack 1 PA; SP; QL EXTAVIA 3 PA; SP; QL GILENYA 3 PA; 3P; SP; QL glatiramer acetate 1 PA; SP; QL glatopa 1 PA; SP; QL KESIMPTA 2 PA; SP; QL LEMTRADA 3 PA; SP MAVENCLAD 3 PA; 3P; SP MAYZENT 3 PA; 3P; SP; QL MAYZENT STARTER PACK 3 PA; 3P; SP; QL OCREVUS 3 PA; SP; QL PLEGRIDY 3 PA; SP; QL PLEGRIDY STARTER PACK 3 PA; SP; QL REBIF 3 PA; SP; QL REBIF REBIDOSE 3 PA; SP; QL REBIF REBIDOSE TITRATION PACK 3 PA; SP; QL REBIF TITRATION PACK 3 PA; SP; QL TECFIDERA 3 PA; SP; QL TYSABRI 3 PA; SP; QL VUMERITY 2 PA; SP; QL ZEPOSIA 3 PA; 3P; SP; QL ZEPOSIA 7-DAY STARTER PACK 3 PA; 3P; SP; QL ZEPOSIA STARTER KIT 3 PA; 3P; SP; QL Central Nervous System Agents - Miscellaneous ADIPEX-P 3 PA ANECTINE 3 PA atracurium besylate 1 AUSTEDO 3 PA; SP; QL benzphetamine hcl 1 PA CAFCIT 3 PA caffeine citrate 1 CAFFEINE-SODIUM BENZOATE SOLUTION 3 125-125 MG/ML INJECTION CAFFEINE-SODIUM BENZOATE SOLUTION 3 PA 125-125 MG/ML INJECTION cisatracurium besylate 1 cisatracurium besylate (pf) intravenous solution 1 10 mg/5ml

Effective Date: 7/1/2021 68 Drug Name Drug Tier Requirements/Limits cisatracurium besylate (pf) solution 200 mg/20ml 1 intravenous cisatracurium besylate (pf) solution 200 mg/20ml 1 PA intravenous CONTRAVE 3 PA diethylpropion hcl er 1 PA diethylpropion hcl oral 1 PA DOPRAM 3 GRALISE ORAL 3 GRALISE ORAL TABLET 3 ST; QL HORIZANT 3 PA; QL IMCIVREE 3 PA; SP; QL INGREZZA 3 PA; SP; QL LOMAIRA 3 PA LYRICA CR 3 ST; QL LYRICA ORAL SOLUTION 3 PA; QL NIMBEX 3 PA NUEDEXTA 3 PA ONPATTRO 3 PA; SP pancuronium bromide 1 phendimetrazine tartrate 1 PA phendimetrazine tartrate er 1 PA phentermine hcl oral 1 PA pregabalin oral 1 QL QSYMIA 3 PA QUELICIN 3 PA RADICAVA 3 PA; SP RILUTEK 3 PA; QL riluzole 1 PA; QL rocuronium bromide intravenous solution 1 ROCURONIUM BROMIDE INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE SAVELLA 3 ST; QL SAVELLA TITRATION PACK 3 ST; QL SAXENDA 3 PA SUCCINYLCHOLINE CHLORIDE INJECTION 3 SOLUTION PREFILLED SYRINGE SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 140 MG/7ML Effective Date: 7/1/2021 69 Drug Name Drug Tier Requirements/Limits succinylcholine chloride solution 20 mg/ml 1 injection SUCCINYLCHOLINE CHLORIDE SOLUTION 3 20 MG/ML INJECTION SUCCINYLCHOLINE CHLORIDE SOLUTION PREFILLED SYRINGE 100 MG/5ML 3 INTRAVENOUS SUCCINYLCHOLINE CHLORIDE SOLUTION PREFILLED SYRINGE 100 MG/5ML 3 PA INTRAVENOUS SUCCINYLCHOLINE CHLORIDE SOLUTION PREFILLED SYRINGE 200 MG/10ML 3 INTRAVENOUS SUCCINYLCHOLINE CHLORIDE SOLUTION PREFILLED SYRINGE 200 MG/10ML 3 PA INTRAVENOUS TEGSEDI 3 PA; SP tetrabenazine 1 PA; SP TIGLUTIK 3 PA; SP; QL VECURONIUM BROMIDE INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE vecuronium bromide intravenous solution 1 reconstituted XENICAL 3 PA Dental and Oral Agents - Drugs for Mouth and Throat Conditions ARESTIN 3 PA BOCASAL 3 PA cavarest 1 cevimeline hcl 1 chlorhexidine gluconate mouth/throat 1 CLINPRO 5000 3 DEBACTEROL SOLUTION 30-50 % 3 MOUTH/THROAT DEBACTEROL SOLUTION 30-50 % 3 PA MOUTH/THROAT DENTA 5000 PLUS 3 DENTAGEL 3 DERMACINRX CLORHEXACIN 3 PA DERMACINRX SURGICAL PHARMAPAK 3 PA easygel 1 EVOXAC 3 PA

Effective Date: 7/1/2021 70 Drug Name Drug Tier Requirements/Limits FLUORIDEX 3 fluoridex daily renewal 1 FLUORIDEX ENHANCED WHITENING 3 FLUORIDEX SENSITIVITY RELIEF 3 KEPIVANCE 2 SP lidocaine hcl mouth/throat 1 lidocaine viscous hcl 1 MI PASTE 3 MI PASTE PLUS 3 MUCOSITISRX 3 PA NAFRINSE DAILY ACIDULATED 3 NAFRINSE DAILY/NEUTRAL 3 NAFRINSE WEEKLY 3 NEUTRASAL 3 PA NUMOISYN MOUTH/THROAT LOZENGE 3 PA NUSURGEPAK SURGICAL PREP/CARE 3 PA oralone 1 PERIDEX 3 PA periogard 1 pilocarpine hcl oral 1 PREVIDENT 5000 BOOSTER PLUS 3 PREVIDENT 5000 DRY MOUTH 3 PREVIDENT 5000 ENAMEL PROTECT 3 PREVIDENT 5000 ORTHO DEFENSE 3 PREVIDENT 5000 PLUS 3 PREVIDENT 5000 SENSITIVE 3 PREVIDENT DENTAL 3 prevident mouth/throat 1 REMESENSE 3 SALAGEN 3 PA SALIVAMAX 3 PA sf 1 sf 5000 plus 1 sodium fluoride 5000 enamel 1 sodium fluoride 5000 plus 1 sodium fluoride 5000 ppm 1 sodium fluoride 5000 sensitive 1 sodium fluoride dental 1

Effective Date: 7/1/2021 71 Drug Name Drug Tier Requirements/Limits TOPEX TOPICAL ANESTHETIC 3 triamcinolone acetonide mouth/throat 1 XEROSTOMIA RELIEF SPRAY 3 PA Dermatological Agents - Drugs for Skin Conditions ABSORICA 3 PA ABSORICA LD 3 PA ACANYA 3 PA accutane 1 PA ACIOXIAY 3 acitretin 1 ACZONE EXTERNAL GEL 7.5 % 2 ADAINZDE 3 ADAINZOXIA 3 adapalene external cream 1 PA adapalene external gel 1 PA ADAPALENE EXTERNAL PAD 3 PA ADAPALENE EXTERNAL SOLUTION 3 PA ADAPALENE-BENZOYL PER-CLINDAMY 3 PA ADAPALENE-BENZOYL PER-NIACINAM 3 PA adapalene-benzoyl peroxide external gel 1 ADAPALENE-BENZOYL PEROXIDE 3 PA EXTERNAL PAD ADVANCED ALLERGY COLLECTION 3 PA AKLIEF 3 PA ALA SCALP 3 PA ala-cort 1 alclometasone dipropionate 1 ALCOHOL PREP PADS EXTERNAL 70 % 3 ALEVAMAX 3 PA ALEVICYN ANTIPRURITIC 3 PA ALEVICYN ANTIPRURITIC SG 3 PA ALEVICYN DERMAL SPRAY 3 PA ALTRENO 3 PA amcinonide external cream 1 PA amcinonide external lotion 1 amcinonide external ointment 1 PA AMELUZ 3 PA ammonium lactate external 1 Effective Date: 7/1/2021 72 Drug Name Drug Tier Requirements/Limits amnesteem 1 PA AMZEEQ 3 ANACAINE 3 PA APEXICON E 3 PA AQUACEL AG BURN 3 ARAZLO 3 PA ARZOL SILVER NIT APPLICATORS 3 PA ATOPADERM 3 PA ATOPICLAIR 3 PA ATRALIN 3 PA AVAR CLEANSER 3 PA AVAR LS CLEANSER 3 PA AVAR-E EMOLLIENT 3 PA AVAR-E GREEN 3 PA AVAR-E LS 3 PA AVEIDAOXIA 3 PA AVITA 3 PA external 1 AZELAIC ACID-NIACINAMIDE 3 PA AZELEX 3 balsam peru-castor oil 1 BENSAL HP 3 PA BENZ PER-CLIND-NIACIN-TRETIN 3 PA BENZAC AC WASH 3 PA BENZAMYCIN 3 PA BENZEPRO CREAMY WASH 3 PA BENZEPRO EXTERNAL 3 PA BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 % 3 PA benzepro external foam 5.3 % 1 PA BENZEPRO EXTERNAL LIQUID 3 PA BENZEPRO FOAMING CLOTHS 3 PA BENZEPRO SHORT CONTACT 3 PA BENZOYL PEROX-HYDROCORTISONE 3 PA benzoyl peroxide external foam 1 PA BENZOYL PEROXIDE EXTERNAL GEL 6.5 % 3 PA BENZOYL PEROXIDE FORTE- HC 3 PA benzoyl peroxide-erythromycin 1 BESER EXTERNAL KIT 3 PA

Effective Date: 7/1/2021 73 Drug Name Drug Tier Requirements/Limits beser external lotion 1 betamethasone dipropionate aug 1 betamethasone dipropionate external 1 BETAMETHASONE DIPROP-MINOXIDIL 3 PA betamethasone valerate external 1 bp 10-1 1 PA bp cleansing wash 1 PA bp wash external liquid 2.5 %, 7 % 1 PA BPCO 3 BRYHALI 3 PA calcipotriene external cream 1 calcipotriene external ointment 1 calcipotriene external solution 1 CALCIPOTRIENE FOAM 0.005 % EXTERNAL 3 ST CALCIPOTRIENE FOAM 0.005 % EXTERNAL 3 ST; M calcipotriene-betameth diprop external ointment 1 PA; QL calcipotriene-betameth diprop external 1 QL suspension CALCIPOTRIENE-CLOBETASOL PROP 3 PA CALCITRENE 3 PA calcitriol external 1 CANTHARIDIN EXTERNAL 3 PA CAPEX 3 PA CARAC 3 CEM-UREA 3 PA CERACADE 3 PA CERAMAX 3 PA cerovel 1 PA CHLOOXIA 3 PA CICLOPIROX-CLOBETASOL 3 PA CICLOPIROX-CLOBETASOL-SAL ACID 3 PA CICLOPIROX-SALICYLIC ACID 3 PA -LIDO-SALICYLIC ACID 3 PA claravis 1 PA CLEOCIN-T 3 PA CLINDACIN ETZ EXTERNAL KIT 3 PA clindacin etz external swab 1 CLINDACIN PAC 3 PA

Effective Date: 7/1/2021 74 Drug Name Drug Tier Requirements/Limits clindacin-p 1 CLINDAGEL 3 ST CLINDAMY-BENZOYL PER-NIACINAM 3 PA clindamycin phosphate-benzoyl peroxide 1 CLINDAMYCIN PHOS-NIACINAMIDE 3 PA clindamycin phosphate external foam 1 clindamycin phosphate external lotion 1 clindamycin phosphate external solution 1 clindamycin phosphate external swab 1 CLINDAMYCIN PHOSPHATE GEL 1 % 3 ST; M EXTERNAL clindamycin phosphate gel 1 % external 1 CLINDAMYCIN-NIACIN-TRETINOIN 3 PA clindamycin-tretinoin 1 CLIND-NIACIN-SPIRONOLAC-TRETIN 3 PA clobetasol prop emollient base 1 clobetasol propionate e 1 clobetasol propionate emulsion 1 clobetasol propionate external 1 CLOBETASOL PROP-LEVOCETIRIZINE 3 PA CLOBETASOL PROP-NIACINAMIDE 3 PA CLOBETAVIX 3 PA CLOBEX 3 PA CLOBEX SPRAY 3 PA clocortolone pivalate 1 CLODAN EXTERNAL KIT 3 PA clodan external shampoo 1 coal tar external 1 CONDYLOX 3 CORDRAN EXTERNAL CREAM 0.025 % 3 PA CORTISPORIN 3 CUTIVATE 3 PA dapsone external gel 5 % 1 PA dapsone gel 7.5 % external 1 DAPSONE GEL 7.5 % EXTERNAL 3 M DAPSONE-NIACINAMIDE 3 PA DAPSONE-NIACINAMIDE-SPIRONOLAC 3 PA DELUO 3 PA

Effective Date: 7/1/2021 75 Drug Name Drug Tier Requirements/Limits DEOXIA 3 PA DERMACINRX SURGICAL COMBOPAK 3 PA DERMA-SMOOTHE/FS BODY 3 PA DERMA-SMOOTHE/FS SCALP 3 PA DERMULCERA 3 DERPIXA 3 PA desonide external cream 1 desonide external gel 1 PA desonide external lotion 1 desonide external ointment 1 DESOWEN 3 PA desoximetasone external cream 0.05 % 1 PA desoximetasone external cream 0.25 % 1 desoximetasone external gel 1 desoximetasone external liquid 1 desoximetasone external ointment 0.05 % 1 PA desoximetasone external ointment 0.25 % 1 DEXERYL 3 PA DIADIMAXIA 3 PA DIAOXIA 3 PA DIASDIMAXIA 3 PA DIASOXIA 3 PA diclofenac sodium external gel 3 % 1 ST; QL DICLOFENAC-NA HYALURON-NIACIN 3 PA DIFFERIN EXTERNAL CREAM 3 PA DIFFERIN EXTERNAL GEL 0.3 % 3 PA DIFFERIN EXTERNAL LOTION 3 PA diflorasone diacetate 1 PA DIMOXIA 3 PA DIOCHLOY 3 DIPROLENE 3 PA DIPROLENE AF 3 PA DOVONEX 3 PA doxepin hcl external 1 PA doxycycline 1 PA DRAXACE 3 PA DRAXACE LOTION CLEANSER 3 PA DRITHO-CREME HP 3 PA

Effective Date: 7/1/2021 76 Drug Name Drug Tier Requirements/Limits DRIXECE 3 PA DRYSOL 3 DUOBRII 3 PA DUPIXENT 2 PA; SP; QL ECEOXIA 3 PA EFUDEX 3 PA ELETONE 3 PA EMULSION SB 3 PA ENSTILAR 3 PA; QL ENTTY SPRAY 3 PA ENZOCLEAR 3 PA EPICERAM 3 PA EPICYN 3 PA EPIDUO FORTE 3 EPIFOAM 3 ery 1 ERYGEL 3 PA erythromycin external 1 ESKATA 3 PA ETHOXIA 3 PA EUCRISA 2 ST EVOCLIN 3 PA FABIOR 3 PA FINACEA EXTERNAL FOAM 3 FINACEA EXTERNAL GEL 3 PA FINAPOD 3 FINASTERIDE-MINOXIDIL 3 PA FLUOCINOLONE ACET-NIACINAMIDE 3 PA fluocinolone acetonide body 1 fluocinolone acetonide external 1 fluocinolone acetonide scalp 1 fluocinonide emulsified base 1 fluocinonide external 1 FLUOPAR 3 PA FLUOROPLEX 3 FLUOROURACIL EXTERNAL CREAM 0.5 % 2 fluorouracil external cream 5 % 1 fluorouracil external solution 1

Effective Date: 7/1/2021 77 Drug Name Drug Tier Requirements/Limits flurandrenolide 1 PA fluticasone propionate external 1 GEAMETDRAY 3 GENADUR 3 PA glycolic acid solution 1 PA GORDOFILM 3 GUANENDRUX 3 halcinonide 1 PA halobetasol propionate external cream 1 HALOBETASOL PROPIONATE EXTERNAL 3 PA; M FOAM halobetasol propionate external ointment 1 HALOG EXTERNAL OINTMENT 3 PA HALOG EXTERNAL SOLUTION 3 PA HALUCORT 3 PA HAXCHLO 3 HPR PLUS 3 PA HPR PLUS HYDROGEL 3 PA HYALURONATE-NIACINAM-TRETINOIN 3 PA HYALURONATE-NIACIN-TACROLIMUS 3 PA HYDRO 40 3 PA hydrocortisone butyr lipo base 1 PA hydrocortisone butyrate external cream 1 hydrocortisone butyrate external lotion 1 PA hydrocortisone butyrate external ointment 1 hydrocortisone butyrate external solution 1 hydrocortisone external cream 1 %, 2.5 % 1 hydrocortisone external lotion 2.5 % 1 hydrocortisone external ointment 1 %, 2.5 % 1 hydrocortisone valerate 1 HYLAGUARD 3 PA HYLATOPIC PLUS 3 PA ILIDERM 3 PA imiquimod external 1 IMIQUIMOD PUMP 3 ST; M IMIQUIMOD-LEVOCETIRIZIN-NIACIN 3 PA IMIQUIMOD-LEVOCET-TRETINOIN 3 PA IMPEKLO 3 PA

Effective Date: 7/1/2021 78 Drug Name Drug Tier Requirements/Limits IMPOYZ 3 PA INOVA 3 PA INOVA 4/1 ACNE CONTROL THERAPY 3 PA INOVA 8/2 ACNE CONTROL THERAPY 3 PA isotretinoin oral 1 PA ITHOXIA 3 PA IVERMECTIN-METRONIDAZOL-NIACIN 3 PA KAMDOY 3 PA KERAGEL 3 PA KERALAC 3 PA KERALYT EXTERNAL GEL 6 % 3 PA KERALYT EXTERNAL SHAMPOO 3 KERALYT SCALP 3 PA KERAMATRIX REPLICINE 5CMX5CM 3 KIVIK 3 PA KLARON 3 PA lactic acid e 1 lactic acid external 1 LACTIC ACID-NIACINAMIDE 3 PA LAVARE WOUND WASH 3 PA LEVICYN 3 PA LEVICYN DERMAL SPRAY 3 PA LEVULAN KERASTICK 3 LEXETTE 3 PA LIDOCAINE (ANORECTAL) RECTAL 3 PA LIDOCAINE-HYDROCORTISONE ACE 3 PA EXTERNAL LIDOTREX (ALOE VERA) 3 PA LOYON 3 PA LUXIQ 3 PA methoxsalen rapid 1 methyl salicylate external liquid 1 PA METROCREAM 3 PA METROGEL 3 PA METROLOTION 3 PA metronidazole external 1 MICROCYN EXTERNAL GEL 3 PA MICROCYN EXTERNAL LIQUID 3

Effective Date: 7/1/2021 79 Drug Name Drug Tier Requirements/Limits MICROCYN SKIN AND WOUND 3 PA MIMYX 3 PA MINOXIDIL-PROGEST-TRETINOIN 3 PA MIRVASO 3 mometasone furoate external 1 myorisan 1 PA NEOSALUS 3 PA NEO-SYNALAR EXTERNAL CREAM 3 NEO-SYNALAR EXTERNAL KIT 3 PA neuac external gel 1 NEUAC EXTERNAL KIT 3 PA NIACINAMIDE-SPIRONOLACTONE 3 PA NIACINAMIDE-SULFACETAMIDE 3 PA NIACINAMIDE-TACROLIMUS 3 PA NIACINAMIDE-TAZAROTENE 3 PA NIACINAMIDE-TRETINOIN 3 PA NIACINAMIDE-TRIAMCINOLONE ACET 3 PA NIACIN-SPIRONOLACTON-TRETINOIN 3 PA nolix 1 PA NORITATE 3 ST NUCARACLINPAK 3 PA NUCARARXPAK 3 PA NUCORT 3 PA NUTRASEB 3 PA NUTRIARX CREAMPAK 3 PA NUVAIL 3 PA OLUX 3 PA OLUX-E 3 PA ONEXTON 3 ONZDEOXIA 3 OVACE PLUS 3 PA OVACE PLUS WASH 3 PA OVACE WASH 3 PA OXIANUJO 3 OXIATAR 3 OXIAVARRY 3 OXIAZAR 3 OXOPOD 3

Effective Date: 7/1/2021 80 Drug Name Drug Tier Requirements/Limits OXSORALEN ULTRA 3 PA PANDEL 3 PA PENLEN 3 PA PHLAG SPRAY 3 PA PICATO 3 ST pimecrolimus 1 PLEXION 3 PA PLEXION CLEANSER 3 PA PLEXION CLEANSING CLOTH 3 PA podocon 1 PA podofilox external 1 PODPROG 3 PR BENZOYL PEROXIDE 3 PA PR BENZOYL PEROXIDE WASH 3 PA PR CREAM 3 PA pramox 1 PA prednicarbate 1 PRESERA 3 PA PROGESTERONE-MINOXIDIL 3 PA PROMISEB 3 PA PROSILK EXTERNAL 3 PA PROTEXA 3 PA PROTOPIC 3 PA PRUCLAIR 3 PA PRUMYX 3 PA PSORCON 3 PA PYROGALLIC ACID 3 QBREXZA 3 QL QUIHOXVAR 3 QUTENZA 3 PA; QL QUTENZA (2 PATCH) 3 PA; QL RADIAGEL 3 PA RADIAPLEXRX GEL EXTERNAL 3 RADIAPLEXRX GEL EXTERNAL 3 PA REGENECARE 3 REGRANEX 3 PA REMIGEN 3 PA RESORCINOL-SULFUR 3 PA

Effective Date: 7/1/2021 81 Drug Name Drug Tier Requirements/Limits RETIN-A 3 PA RETIN-A MICRO PUMP EXTERNAL GEL 0.06 2 PA %, 0.08 % REXASIL PATCH & VITAMIN E LIQ 3 PA RHOFADE 3 RIAX 3 PA ROAOXIA 3 rosadan external cream 1 rosadan external gel 1 ROSADAN EXTERNAL KIT 3 PA SALEX 3 PA salicylic acid er 1 PA salicylic acid external 1 PA salicylic acid wart remover 1 PA salicylic acid-cleanser 1 PA SALICYLIC ACID-SULFACETAMIDE 3 PA salimez 1 PA SALIMEZ FORTE 3 PA SALVAX 3 PA SALVAX DUO PLUS 3 PA SANADERMRX SKIN REPAIR 3 PA SANTYL 3 SCALACORT DK 3 PA SCARCARE GEL-PAD KIT/LARGE 3 PA SCARZEN SKIN REPAIR 3 PA SCENESSE 3 PA; SP SEBUDERM 3 PA selenium sulfide external lotion 1 selenium sulfide external shampoo 1 PA SELRX 3 PA SERNIVO 3 SILIPAC 3 PA sodium sulfacetamide 1 PA sodium sulfacetamide wash 1 PA SODIUM SULFACETAMIDE-BAKUCHIOL 3 PA SOOLANTRA 3 SORIATANE 3 PA SORILUX 3 ST

Effective Date: 7/1/2021 82 Drug Name Drug Tier Requirements/Limits sss 10-5 1 PA STRATA CTX 3 PA STRATA GRT 3 PA STRATA MARK 3 PA STRATA XRT 3 PA sulfacetamide sodium (acne) 1 sulfacetamide sodium external 1 PA sulfacetamide sodium-sulfur emulsion 10-5 % 1 external sulfacetamide sodium-sulfur emulsion 10-5 % 1 PA external sulfacetamide sodium-sulfur external cream 1 PA sulfacetamide sodium-sulfur external liquid 1 PA sulfacetamide sodium-sulfur external lotion 1 PA sulfacetamide sodium-sulfur external pad 1 PA sulfacetamide sodium-sulfur external 1 PA suspension sulfacetamide sod-sulfur wash 1 PA sulfacetamide-sulfur in urea 1 PA SULFACLEANSE 8/4 3 PA sulfamez wash 1 PA SUMADAN 3 PA SUMADAN WASH 3 PA SUMADAN XLT 3 PA SUMAXIN 3 PA SUMAXIN CP 3 PA SUMAXIN WASH 3 PA SUVICORT 3 PA SYNALAR 3 PA SYNALAR (CREAM) 3 PA SYNALAR (OINTMENT) 3 PA SYNALAR TS 3 PA SYNERDERM 3 PA TACLONEX EXTERNAL SUSPENSION 3 PA; QL TACROLIMUS EXTERNAL CREAM 3 PA tacrolimus external ointment 1 TARDEOXIA 3 PA TARDIMAXIA 3 PA TAROXIA 3 PA

Effective Date: 7/1/2021 83 Drug Name Drug Tier Requirements/Limits TASOPROL 3 PA tazarotene external 1 PA TAZORAC EXTERNAL CREAM 0.05 % 3 PA TAZORAC EXTERNAL GEL 3 PA TEMOVATE 3 PA TETRIX 3 PA TEXACORT 3 THERAHONEY EXTERNAL SHEET 3 TOPICORT EXTERNAL CREAM 0.25 % 3 PA TOPICORT EXTERNAL GEL 3 PA TOPICORT EXTERNAL OINTMENT 3 PA TOPICORT SPRAY 3 PA tovet external foam 1 TOVET EXTERNAL KIT 3 PA tretinoin external 1 PA tretinoin microsphere 1 PA tretinoin microsphere pump 1 PA triamcinolone acetonide external aerosol 1 PA solution triamcinolone acetonide external cream 1 triamcinolone acetonide external lotion 1 triamcinolone acetonide external ointment 0.025 1 %, 0.1 %, 0.5 % triamcinolone acetonide external ointment 0.05 1 PA % TRIANEX 3 PA TRI-CHLOR 3 triderm 1 TRIDESILON 3 PA TRILOCICLO 3 PA TRIVIX 3 PA turpentine external 1 PA ULTRASAL-ER 3 PA ULTRAVATE 3 PA UMECTA MOUSSE 3 PA URAMAXIN 3 PA urea external cream 1 PA UREA EXTERNAL FOAM 3 PA urea external lotion 1 PA

Effective Date: 7/1/2021 84 Drug Name Drug Tier Requirements/Limits urea hydrating 1 PA urea nail 1 PA uredeb 1 PA UREMEZ-40 3 PA URESOL 3 PA UREVAZ EXTERNAL CREAM 44 % 3 PA UTOPIC 3 PA VANOXIDE-HC 3 PA VARDIMAXIA 3 PA VAROXIA 3 PA VASHE CLEANSING 3 VECTICAL 3 PA VELTIN 3 ST VENELEX 3 VERDESO 3 PA VEREGEN 3 PA VEXASYN 3 PA VIRASAL 3 PA WINLEVI 3 PA WYNZORA 3 PA; QL XALIX 3 PA XERAC AC 3 XERALUX 3 PA XEROFORM OIL EMULSION 2"X2" 3 XEROFORM OIL EMULSION GAUZE 3 XEROFORM OIL EMULSION STRIP 3 XEROFORM OIL ROLL 4"X9' 3 XEROFORM PETROLAT GAUZE 1"X8" 3 XEROFORM PETROLAT GAUZE 5"X9" 3 XEROFORM PETROLAT PATCH 2"X2" 3 XEROFORM PETROLAT PATCH 4"X4" 3 XEROFORM PETROLATUM ROLL 4"X9' 3 xurea 1 PA ZACARE 3 PA zaclir cleansing 1 PA zenatane 1 PA ZILXI 3 ST ZITHRANOL 3 PA

Effective Date: 7/1/2021 85 Drug Name Drug Tier Requirements/Limits ZYCLARA 3 PA ZYCLARA PUMP 3 ST Diabetes - Antidiabetic Agents acarbose oral 1 ACTOPLUS MET 3 PA ADLYXIN 3 ST; QL ADLYXIN STARTER PACK 3 ST; QL ALOGLIPTIN BENZOATE 3 ST; M ALOGLIPTIN- HCL 3 ST; M ALOGLIPTIN-PIOGLITAZONE 3 ST; M AMARYL 3 PA AVANDIA 3 ST BYDUREON BCISE AUTOINJECTOR 2 ST; QL BYETTA 10 MCG PEN 2 ST; QL BYETTA 5 MCG PEN 2 ST; QL CYCLOSET 3 ST DUETACT 3 PA FARXIGA 2 ST glimepiride 1 glipizide er 1 glipizide ir 1 glipizide xl 1 glipizide-metformin hcl 1 GLUCOTROL 3 PA GLUCOTROL XL 3 PA glyburide micronized 1 glyburide oral 1 glyburide-metformin 1 GLYNASE 3 PA GLYXAMBI 2 ST INVOKAMET 3 ST INVOKAMET XR 3 ST INVOKANA 3 ST JANUMET 2 ST JANUMET XR 2 ST JANUVIA 2 ST JARDIANCE 2 ST JENTADUETO 2 ST

Effective Date: 7/1/2021 86 Drug Name Drug Tier Requirements/Limits JENTADUETO XR 2 ST KAZANO 3 ST KOMBIGLYZE XR ORAL TABLET EXTENDED 3 RELEASE 24 HOUR 2.5-1000 MG KOMBIGLYZE XR ORAL TABLET EXTENDED 3 ST RELEASE 24 HOUR 5-1000 MG, 5-500 MG metformin hcl er 1 metformin hcl er (mod) 1 PA metformin hcl er (osm) 1 PA metformin hcl ir 1 miglitol 1 nateglinide 1 NESINA 3 ST ONGLYZA 3 ST OSENI 3 ST OZEMPIC 2 ST; QL pioglitazone hcl 1 pioglitazone hcl-glimepiride 1 pioglitazone hcl-metformin hcl 1 PRECOSE 3 PA QTERN 3 ST repaglinide 1 RIOMET 3 PA RYBELSUS 2 ST; QL SEGLUROMET 3 ST SOLIQUA 2 ST; QL STARLIX 3 PA STEGLATRO 3 ST STEGLUJAN 3 ST SYMLINPEN 120 3 PA SYMLINPEN 60 3 PA SYNJARDY 2 ST SYNJARDY XR 2 ST tolbutamide 1 TRADJENTA 2 ST TRIJARDY XR 2 ST TRULICITY 2 ST; QL VICTOZA 2 ST; QL XIGDUO XR 2 ST Effective Date: 7/1/2021 87 Drug Name Drug Tier Requirements/Limits XULTOPHY 3 ST; QL Diabetes - Glucose Monitoring ACCU-CHEK AVIVA DEVICE 3 ACCU-CHEK AVIVA PLUS KIT W/DEVICE 3 ST ACCU-CHEK AVIVA PLUS TEST STRIPS 3 ST; QL ACCU-CHEK COMPACT PLUS CONTROL 3 ACCU-CHEK COMPACT PLUS TEST STRIPS 3 ST; QL ACCU-CHEK FASTCLIX LANCET KIT 2 ACCU-CHEK GUIDE TEST STRIPS 3 ST ACCU-CHEK GUIDE CONTROL 3 ACCU-CHEK GUIDE TEST STRIPS 3 ST; QL ACCU-CHEK GUIDE KIT W/DEVICE 3 ST ACCU-CHEK SMARTVIEW CONTROL 3 ACCU-CHEK SMARTVIEW TEST STRIPS 3 ST; QL ACCU-CHEK SOFTCLIX LANCET DEVICE KIT 2 AGAMATRIX CONTROL LEVEL 2 3 AGAMATRIX CONTROL LEVEL 4 3 AGAMATRIX PRESTO TEST 3 ST; QL ASSURE PLATINUM 3 QL AUTOLET LANCING DEVICE 3 BIOTEL CARE BLOOD GLUCOSE 3 BIOTEL CARE BLOOD GLUCOSE SYST 3 ST BLOOD GLUCOSE TEST 3 ST; QL CARETOUCH CONTROL SOL LEVEL 2 3 CARETOUCH LANCING/EJECTOR 3 CARETOUCH TEST 3 ST; QL CEQUR SIMPLICITY 2U 3 CEQUR SIMPLICITY STARTER 3 CHEMSTRIP UGK 3 CONTOUR CONTROL SOLUTION 2 CONTOUR MONITOR DEVICE 2 CONTOUR MONITOR KIT W/DEVICE 2 CONTOUR NEXT CONTROL SOLUTION 2 CONTOUR NEXT EZ KIT W/DEVICE 2 CONTOUR NEXT LINK 2 CONTOUR NEXT MONITOR KIT W/DEVICE 2 CONTOUR NEXT ONE KIT 2 CONTOUR NEXT TEST STRIPS 2 QL

Effective Date: 7/1/2021 88 Drug Name Drug Tier Requirements/Limits CONTOUR TEST STRIPS 2 QL DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING 2 PLATINUM, PLATINUM PEDIATRIC) DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING 2 PLATINUM, PLATINUM PEDIATRIC) DEVICE DIATHRIVE BLOOD GLUCOSE METER 3 ST DIATHRIVE BLOOD GLUCOSE TEST 3 ST; QL DIATHRIVE GLUCOSE CONTROL SOLN 3 DIATHRIVE GLUCOSE TEST 3 ST; QL DIATHRIVE LANCING DEVICE 3 DIATHRIVE+ GLUCOSE MONITOR 3 ST; QL DIATHRIVE+ GLUCOSE TEST 3 ST; QL DROPLET GENTEEL LANCING DEVICE 3 EASY TRAK II BLOOD GLUCOSE SYS 3 ST EASY TRAK II CONTROL 3 EASY TRAK II GLUCOSE TEST 3 ST; QL EASYMAX 15 LEVEL 2-3 CONTROL 3 EASYMAX CONTROL 3 GLUCOSE CONTROL SOLUTIONS 3 EMBRACE LANCING DEVICE/EJECTOR 3 EMBRACE TALK BLOOD GLUCOSE 3 ST EMBRACE TALK GLUCOSE CONTROL 3 EMBRACE TALK GLUCOSE TEST 3 ST; QL EMBRACE TALK MONITORING SYSTEM 3 ST ENLITE GLUCOSE SENSOR 3 EVENCARE PROVIEW GLUCOSE TEST 3 ST; QL EVERSENSE SENSOR/HOLDER 3 EVERSENSE SMART TRANSMITTER 3 FORA 6 CONNECT 3 ST; QL FORA GTEL BLOOD GLUCOSE SYSTEM 3 ST FORA GTEL BLOOD GLUCOSE TEST 3 ST; QL FORTISCARE CONTROL 3 FORTISCARE GLUCOSE SYSTEM DEVICE 3 ST FORTISCARE T1 GLUCOSE SYSTEM 3 ST FREESTYLE FREEDOM LITE 3 FREESTYLE INSULINX SYSTEM 3 FREESTYLE INSULINX TEST 3 ST; QL

Effective Date: 7/1/2021 89 Drug Name Drug Tier Requirements/Limits FREESTYLE LIBRE 14 DAY READER 2 FREESTYLE LIBRE 14 DAY SENSOR 2 FREESTYLE LIBRE 2 READER 2 FREESTYLE LIBRE 2 SENSOR 2 FREESTYLE LIBRE READER 2 FREESTYLE LIBRE SENSOR SYSTEM 2 FREESTYLE LITE TEST 3 ST; QL FREESTYLE PRECISION NEO TEST 3 QL FREESTYLE TEST 3 ST; QL GENTEEL LANCING KIT (BLUE) 3 GLUCOCARD 01 SENSOR PLUS 3 ST; QL GLUCOCARD EXPRESSION TEST 3 ST; QL GLUCOCARD SHINE CONNEX 3 GLUCOCARD SHINE EXPRESS 3 GLUCOCARD SHINE TEST 3 ST; QL GLUCOCARD VITAL TEST 3 ST; QL GOJJI BLOOD GLUCOSE TEST 3 QL GOJJI BLOOD TEST STRIP/LANCETS 3 QL GOJJI CONTROL 3 GOJJI LANCING DEVICE/CLEAR CAP 3 GUARDIAN CONNECT TRANSMITTER 3 GUARDIAN LINK 3 TRANSMITTER 3 GUARDIAN SENSOR (3) 3 GUARDIAN SENSOR 3 3 HARMONY BLOOD GLUCOSE TEST 3 ST; QL HW EMBRACE PRO GLUCOSE METER 3 ST HW EMBRACE PRO GLUCOSE TEST 3 ST; QL HW EMBRACE TALK BLOOD GLUCOSE 3 ST HW EMBRACE TALK GLUCOSE TEST 3 ST; QL INFINITY BLOOD GLUCOSE TEST 3 ST; QL INPEN 100-BLUE-LILLY 3 INPEN 100-BLUE-NOVO 3 INPEN 100-GRAY-LILLY 3 INPEN 100-GREY-NOVO 3 INPEN 100-PINK-LILLY 3 INPEN 100-PINK-NOVO 3 KETOSTIX 3 KROGER HEALTHPRO GLUCOSE TEST 3 QL

Effective Date: 7/1/2021 90 Drug Name Drug Tier Requirements/Limits LANCETS 2 LANCETS 3 LANCETS KIT 3 MICRODOT TEST 3 ST; QL MICROLET NEXT LANCING DEVICE 3 NOVOPEN ECHO 3 OMNIPOD DASH SYSTEM 3 OMNIPOD STARTER 3 ONE DROP BLOOD GLUCOSE MONITOR 3 ST ONE DROP TEST 3 ST; QL ONETOUCH DELICA LANCING DEV 3 ONETOUCH DELICA PLUS LANCING 3 ONETOUCH ULTRA 3 ST; QL ONETOUCH ULTRA 2 KIT W/DEVICE 3 ST ONETOUCH ULTRA MINI KIT W/DEVICE 3 ST ONETOUCH VERIO KIT W/DEVICE 3 ST ONETOUCH VERIO FLEX SYSTEM KIT 3 ST W/DEVICE ONETOUCH VERIO IN VITRO SOLUTION 3 HIGH ONETOUCH VERIO TEST STRIPS 3 ST; QL ONETOUCH VERIO IQ SYSTEM 3 ST ONETOUCH VERIO REFLECT 3 ST ONETOUCH VERIO SYNC SYSTEM KIT 3 ST W/DEVICE PRECISION LINK 3 PRECISION PCX PLUS TEST 3 ST; QL PRECISION QID MONITOR 3 PRECISION QID TEST 3 ST; QL PRECISION SOF-TACT MONITOR 3 PRECISION SOF-TACT TEST 3 ST; QL PRECISION XTRA BLOOD GLUCOSE 3 ST; QL PRECISION XTRA DEVICE 3 PRECISION XTRA KIT 3 PRECISION XTRA MONITOR 3 PRODIGY NO CODING BLOOD GLUC 3 ST RELION BLOOD GLUCOSE TEST 3 ST; QL RELION PREMIER CLASSIC 3 ST RELION PREMIER TEST 3 ST; QL

Effective Date: 7/1/2021 91 Drug Name Drug Tier Requirements/Limits SURESTEP PRO HIGH GLUCOSE 3 SURESTEP PRO LOW GLUCOSE 3 SURESTEP PRO NORMAL GLUCOSE 3 TRUE FOCUS BLOOD GLUCOSE METER 3 TRUE METRIX BLOOD GLUCOSE TEST 3 ST; QL TRUE METRIX PRO BLOOD GLUCOSE 3 ST; QL UNISTRIP CONTROL IN VITRO SOLUTION 3 LOW V-GO 20 2 V-GO 30 2 V-GO 40 2 VIVAGUARD INO CONTROL SOLUTION 3 VIVAGUARD INO GLUCOSE METER 3 ST VIVAGUARD INO TEST STRIPS 3 ST; QL VIVAGUARD LANCING DEVICE 3 Diabetes - Glycemic Agents BAQSIMI ONE PACK 2 BAQSIMI TWO PACK 2 diazoxide oral 1 GLUCAGEN HYPOKIT 3 ST emergency kit 1 mg injection 1 mg 1 GLUCAGON EMERGENCY KIT 1 MG 3 PA INJECTION 1 MG GLUCAGON EMERGENCY KIT 2 GVOKE HYPOPEN 1-PACK 2 GVOKE HYPOPEN 2-PACK 2 GVOKE PFS 2 PROGLYCEM 3 PA Diabetes - Insulins ADMELOG 3 ST ADMELOG SOLOSTAR 3 ST AFREZZA 3 PA APIDRA SOLOSTAR 3 ST APIDRA VIAL 3 ST BASAGLAR KWIKPEN 3 ST BD AUTOSHIELD DUO PEN NEEDLES 2 BD ULTRA-FINE SYRINGES 2 BD ULTRA-FINE PEN NEEDLES 2 BD VEO INSULIN SYR U/F 1/2UNIT 2 Effective Date: 7/1/2021 92 Drug Name Drug Tier Requirements/Limits DROPLET MICRON 2 FIASP 3 ST FIASP FLEXTOUCH 3 ST FIASP PENFILL 3 ST HUMALOG KWIKPEN 2 HUMALOG MIX 50/50 KWIKPEN 2 HUMALOG MIX 50/50 VIAL 2 HUMALOG MIX 75/25 KWIKPEN 2 HUMALOG MIX 75/25 VIAL 2 HUMALOG U-100 JUNIOR KWIKPEN 2 HUMALOG VIAL 2 HUMULIN 70/30 KWIKPEN 2 HUMULIN 70/30 VIAL 2 HUMULIN N KWIKPEN 2 HUMULIN N VIAL 2 HUMULIN R U-500 KWIKPEN 2 HUMULIN R U-500 VIAL 2 HUMULIN R VIAL 2 INSULIN ASP PROT & ASP FLEXPEN 2 ST; M INSULIN ASPART 2 ST; M INSULIN ASPART FLEXPEN 2 ST; M INSULIN ASPART PENFILL 2 ST; M INSULIN ASPART PROT & ASPART 2 ST; M 2 ST; M INSULIN LISPRO (1 UNIT DIAL) 2 ST; M INSULIN LISPRO JUNIOR KWIKPEN 2 ST; M INSULIN LISPRO PROT & LISPRO 2 ST; M INSULIN PEN NEEDLES 2 INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 2 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML, 32G X 5/16" 0.5 ML, 32G X 5/16" 1 ML LANTUS SOLOSTAR 2 LANTUS U-100 VIAL 2 LEVEMIR U-100 FLEXTOUCH 2

Effective Date: 7/1/2021 93 Drug Name Drug Tier Requirements/Limits LEVEMIR U-100 VIAL 2 LYUMJEV KWIKPEN 2 ST LYUMJEV VIAL 2 ST MAXICOMFORT SYR 27G X 1/2" 2 MYXREDLIN 3 NOVOFINE AUTOCOVER PEN NEEDLE 2 NOVOFINE PEN NEEDLE 2 NOVOFINE PLUS PEN NEEDLE 2 NOVOLIN 70/30 FLEXPEN 2 NOVOLIN 70/30 FLEXPEN RELION 2 NOVOLIN 70/30 RELION 2 NOVOLIN 70/30 VIAL 2 NOVOLIN N FLEXPEN 2 NOVOLIN N FLEXPEN RELION 2 NOVOLIN N RELION 2 NOVOLIN N VIAL 2 NOVOLIN R FLEXPEN 2 NOVOLIN R FLEXPEN RELION 2 NOVOLIN R RELION 2 NOVOLIN R VIAL 2 NOVOLOG FLEXPEN 2 NOVOLOG MIX 70/30 FLEXPEN 2 NOVOLOG MIX 70/30 VIAL 2 NOVOLOG PENFILL 2 NOVOLOG U-100 VIAL 2 NOVOTWIST PEN NEEDLE 2 SEMGLEE 3 ST TOUJEO MAX SOLOSTAR 2 TOUJEO SOLOSTAR 2 TRESIBA 2 TRESIBA FLEXTOUCH 2 TRUE COMFORT PRO INSULIN SYR 32G X 2 5/16" 0.5 ML TRUE COMFORT PRO PEN NEEDLES 31G X 8 MM , 32G X 5 MM , 32G X 6 MM , 33G X 4 2 MM , 33G X 5 MM , 33G X 6 MM ULTIGUARD SAFEPACK SYR/NEEDLE 2 Electrolytes / Minerals / Metals / Vitamins ACTIVE FE 3

Effective Date: 7/1/2021 94 Drug Name Drug Tier Requirements/Limits adc/f (0.5mg/ml) 1 AMINO ACID 3 aminoamrms 1 PA AMINOPROTECT 3 aminoreliefrms 1 PA AMINOSYN II 3 AMINOSYN-PF 3 AQUASOL A 3 ARGININE HCL INJECTION 3 argyle sterile saline 1 argyle sterile water 1 ASCOR 3 PA ASCORBIC ACID INTRAVENOUS 3 PA ASCORBIC ACID SOLUTION 500 MG/ML 3 PA INJECTION ascorbic acid solution 500 mg/ml injection 1 PA ATABEX OB 2 AZESCHEW PRENATAL/POSTNATAL 3 PA AZESCO 3 PA B-12 COMPLIANCE INJECTION 3 PA CALCIFOL 3 CALCIUM CHLORIDE SOLUTION 10 % 3 INTRAVENOUS calcium chloride solution 10 % intravenous 1 calcium chloride solution 10 % intravenous 1 PA calcium gluconate solution 10 % intravenous 1 CALCIUM GLUCONATE SOLUTION 10 % 3 INTRAVENOUS CALCIUM GLUCONATE-NACL INTRAVENOUS 3 SOLUTION 1-0.675 GM/50ML-% CALCIUM GLUCONATE-NACL INTRAVENOUS SOLUTION 1-0.9 GM/100ML-%, 2-0.9 3 GM/100ML-% CALCIUM GLUCONATE-NACL INTRAVENOUS 3 PA SOLUTION 2-0.675 GM/100ML-% calcium-folic acid plus d 1 PA CARBAGLU 2 SP CARNITOR INTRAVENOUS 3 CARNITOR ORAL 3 PA CARNITOR SF 3 PA

Effective Date: 7/1/2021 95 Drug Name Drug Tier Requirements/Limits CENTRATEX 3 CHEMET 3 CHOLECAL DF 3 PA CHROMAGEN 3 chromic chloride intravenous 1 CIFEREX 3 PA CITRANATAL BLOOM 3 PA CITRANATAL MEDLEY 3 PA CLINIMIX E/DEXTROSE (2.75/5) 3 CLINIMIX E/DEXTROSE (4.25/10) 3 CLINIMIX E/DEXTROSE (4.25/5) 3 CLINIMIX E/DEXTROSE (5/15) 3 CLINIMIX E/DEXTROSE (5/20) 3 CLINIMIX E/DEXTROSE (8/10) 3 CLINIMIX E/DEXTROSE (8/14) 3 CLINIMIX/DEXTROSE (4.25/10) 3 CLINIMIX/DEXTROSE (4.25/5) 3 CLINIMIX/DEXTROSE (5/15) 3 CLINIMIX/DEXTROSE (5/20) 3 CLINIMIX/DEXTROSE (6/5) 3 CLINIMIX/DEXTROSE (8/10) 3 CLINIMIX/DEXTROSE (8/14) 3 CLINISOL SF 3 CLINOLIPID 3 clovique 1 PA; SP CORVITE 150 ORAL TABLET 3 PA CORVITE 150 ORAL TABLET 150-1.25 MG 2 CORVITE FE 3 PA CUPRIC CHLORIDE 3 curity sterile saline 1 cyanocobalamin injection solution 1000 mcg/ml 1 CYANOCOBALAMIN INJECTION SOLUTION 3 2000 MCG/ML cytra k crystals 1 PA deferasirox 1 PA deferasirox granules 1 PA deferiprone 1 PA DERMACINRX PUREFOLIX 3 PA

Effective Date: 7/1/2021 96 Drug Name Drug Tier Requirements/Limits DEXPANTHENOL INJECTION 3 dextrose intravenous solution 10 %, 20 %, 30 %, 1 40 %, 5 %, 70 % DEXTROSE SOLUTION 250 MG/ML 3 INTRAVENOUS dextrose solution 250 mg/ml intravenous 1 DEXTROSE SOLUTION 50 % INTRAVENOUS 3 dextrose solution 50 % intravenous 1 DILUENT FOR LEFAMULIN 3 DRISDOL 3 PA EDETATE DISODIUM INTRAVENOUS 3 EFFER-K ORAL TABLET EFFERVESCENT 10 3 MEQ, 20 MEQ effer-k tablet effervescent 25 meq oral 1 effer-k tablet effervescent 25 meq oral 1 PA ENBRACE HR 3 PA ERGOCAL 3 PA ergocalciferol oral capsule 1 EXJADE 3 PA FEONYX 3 PA FERAHEME 3 FERIVA 21/7 3 PA FERIVAFA 3 PA ferocon 1 ferotrinsic 1 FERRALET 90 3 ferraplus 90 1 FERRIPROX 3 PA FERRIPROX TWICE-A-DAY 3 PA FERRLECIT 3 PA ferrocite plus 1 FERRO-PLEX HEMATINIC 3 FERROTRIN 3 FLORIVA 3 PA FLORIVA PLUS 3 PA fluoritab oral tablet chewable 0.55 (0.25 f) mg, 1 1.1 (0.5 f) mg, 2.2 (1 f) mg folic acid injection 1 folic acid oral tablet 1 mg 1

Effective Date: 7/1/2021 97 Drug Name Drug Tier Requirements/Limits FOLIC D3 3 PA FOLI-D 3 PA FOLITE 3 PA FOLIXAPURE 3 PA FOLTREXYL 3 PA foltrin 1 FOLVITE-D 3 PA FREAMINE HBC 3 FREAMINE III 3 FUSION PLUS 3 GALZIN 3 GENICIN VITA-D 3 PA GLUTATHIONE INJECTION SOLUTION 200 3 MG/ML GLUTATHIONE INJECTION SOLUTION 6 3 PA GM/30ML GLUTATHIONE INTRAVENOUS 3 GLYCINE INJECTION 3 GLYCOPHOS 3 hematinic plus vit/minerals 1 hematinic/folic acid 1 HEMATOGEN FA 3 HEMATRON-AF 3 HEMETAB 3 PA HEMOCYTE PLUS 3 hemocyte-f 1 HEPATAMINE 3 hydroxocobalamin acetate 1 ICAR-C PLUS 2 iferex 150 forte 1 INFED 3 INJECTAFER 3 INTEGRA F 3 INTEGRA PLUS 3 INTRALIPID 3 iodine strong oral 1 IROSPAN 24/6 3 PA JADENU SPRINKLE 3 PA JENLIVA PRENATAL/POSTNATAL 3 PA Effective Date: 7/1/2021 98 Drug Name Drug Tier Requirements/Limits JYNARQUE 3 SP; QL KABIVEN 3 klor-con 1 klor-con 10 1 klor-con m10 1 KLOR-CON M15 3 klor-con m20 1 klor-con/ef 1 K-PHOS NO 2 3 PA K-PHOS TABLET 500 MG ORAL 3 K-PHOS TABLET 500 MG ORAL 3 PA K-PHOS-NEUTRAL 3 PA k-prime 1 K-TAB 3 PA k-tan plus 1 lactated ringers irrigation 1 LEVOCARNITINE INJECTION 3 levocarnitine oral solution 1 levocarnitine oral tablet 1 levocarnitine sf 1 LIPO 3 LIPO-C 3 LOKELMA 3 LYSINE HCL INJECTION 3 MAGNEBIND 400 3 chloride injection 1 magnesium sulfate in d5w 1 magnesium sulfate intravenous 1 MAGNESIUM SULFATE SOLUTION 50 % 3 INJECTION magnesium sulfate solution 50 % injection 1 MAGNESIUM SULFATE-NACL 3 MANGANESE CHLORIDE 3 MEPHYTON 3 PA METHYLCOBALAMIN INJECTION SOLUTION 3 PA METHYLCOBALAMIN INJECTION SOLUTION 3 RECONSTITUTED MIC-L-CARNITINE 3 PA M-NATAL PLUS 2 Effective Date: 7/1/2021 99 Drug Name Drug Tier Requirements/Limits MONOFERRIC 3 monoject flush syringe 1 monoject sodium chloride flush 1 MULTIGEN 3 MULTIGEN FOLIC 3 MULTIGEN PLUS 3 multitrace-4 neonatal 1 PA MULTITRACE-4 PEDIATRIC 3 PA multi-vit/iron/fluoride 1 multi-vitamin/fluoride 1 multivitamin/fluoride oral solution 1 multivitamin/fluoride oral tablet chewable 0.25 1 mg, 0.5 mg, 1 mg MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 0.25-0.3 MG, 0.5-0.3 MG, 1-0.3 3 MG multi-vitamin/fluoride/iron 1 myferon 150 forte 1 na ferric gluc cplx in 1 n-acetyl-l-cysteine oral 1 nafrinse 1 nafrinse drops 1 NASCOBAL 3 NEOKE ALCAR 3 NEONATAL + DHA 3 PA NEONATAL COMPLETE 3 PA NEONATAL FE 3 PA NEONATAL PLUS 2 NEPHRAMINE 3 NEPHRON FA 3 NESTABS 2 NESTABS ONE 3 PA NIFEREX 3 PA normal saline flush 1 NUFERA 3 PA nutrilipid 1 NUTRIVIT 3 OMEGAVEN 3 PA ONE VITE WOMENS PLUS 2

Effective Date: 7/1/2021 100 Drug Name Drug Tier Requirements/Limits ORACIT SOLUTION 490-640 MG/5ML ORAL 3 ORACIT SOLUTION 490-640 MG/5ML ORAL 3 PA ORTHO DF 3 PA PERIKABIVEN 3 PHOSPHA 250 NEUTRAL 3 phosphorous 1 phospho-trin 250 neutral 1 PHOXILLUM B22K4/0 3 PA PHOXILLUM BK4/2.5 3 PA PHYSICIANS EZ USE B-12 3 PA PHYSIOLYTE 3 PHYSIOSOL IRRIGATION 3 phytonadione injection 1 phytonadione oral 1 PLENAMINE 3 PNV TABS 20-1 3 PA poly-iron 150 forte 1 polysaccharide iron forte 1 POLY-VI-FLOR ORAL SUSPENSION 2 POLY-VI-FLOR ORAL TABLET CHEWABLE 2 PA POLY-VI-FLOR/IRON ORAL SUSPENSION 2 POLY-VI-FLOR/IRON ORAL TABLET 2 PA CHEWABLE potassium acetate intravenous 1 potassium chloride crys er 1 potassium chloride er 1 potassium chloride intravenous 1 potassium chloride oral 1 potassium citrate er 1 potassium citrate-citric acid 1 PA potassium phosphates 1 PA potassium phosphates(66 meq k) 1 PA potassium phosphates(71 meq k) 1 PREGEN DHA 3 PA PREGENNA 3 PA PREMASOL 3 PRENAISSANCE 3 PA PRENARA 3 PA

Effective Date: 7/1/2021 101 Drug Name Drug Tier Requirements/Limits prenatal plus iron 1 prenatal tablet 27-1 mg oral 1 prenatal tablet 27-1 mg oral 1 PA prenatal vitamin plus low iron 1 PRENATE DHA 3 PA PRENATE ELITE 3 PA PRENATE ENHANCE 3 PA PRENATE ESSENTIAL 3 PA PRENATE MINI 3 PA PRENATE PIXIE 3 PA PRENATE RESTORE 3 PA PRENATRIX 3 PA PRENATRYL 3 PA PRENATVITE COMPLETE 3 PA PRENATVITE PLUS 2 PRENATVITE RX 2 preplus 1 PRETAB 2 PRIMACARE 3 PA PRISMASOL B22GK 4/0 3 PRISMASOL BGK 0/2.5 3 PRISMASOL BGK 2/0 3 PRISMASOL BGK 2/3.5 3 PRISMASOL BGK 4/0/1.2 3 PA PRISMASOL BGK 4/2.5 3 PRISMASOL BK 0/0/1.2 3 PROCALAMINE 3 PROSOL 3 purevit dualfe plus 1 PYRIDOXAL-5 PHOSPHATE INJECTION 3 PA pyridoxine hcl solution 100 mg/ml injection 1 PYRIDOXINE HCL SOLUTION 100 MG/ML 3 INJECTION QUFLORA FE 3 QUFLORA FE PEDIATRIC 3 PA QUFLORA GUMMIES 3 PA QUFLORA PEDIATRIC 3 PA RELNATE DHA 2

Effective Date: 7/1/2021 102 Drug Name Drug Tier Requirements/Limits RENATABS WITH IRON 3 REVESTA 3 PA ringers irrigation 1 saline bacteriostatic 1 saline flush 1 saline flush zr 1 SALINE-PHENOL 3 SAMSCA ORAL TABLET 15 MG 3 SP; QL SAMSCA ORAL TABLET 30 MG 3 PA; SP; QL SELECT-OB ORAL TABLET CHEWABLE 29-1 2 PA MG SELENIOUS ACID 3 PA SELENIUM INTRAVENOUS 3 PA se-tan plus 1 SMOFLIPID 3 sod citrate-citric acid solution 500-334 mg/5ml 1 oral sod citrate-citric acid solution 500-334 mg/5ml 1 PA oral sodium acetate intravenous solution 2 meq/ml 1 sodium acetate solution 4 meq/ml intravenous 1 sodium acetate solution 4 meq/ml intravenous 1 PA sodium bicarbonate intravenous solution 7.5 % 1 sodium bicarbonate solution 4.2 % intravenous 1 sodium bicarbonate solution 4.2 % intravenous 1 PA sodium bicarbonate solution 8.4 % intravenous 1 SODIUM BICARBONATE SOLUTION 8.4 % 3 INTRAVENOUS SODIUM BICARBONATE SOLUTION 8.4 % 3 PA INTRAVENOUS sodium bicarbonate solution 8.4 % intravenous 1 PA SODIUM BICARBONATE-DEXTROSE 3 PA sodium chloride (pf) solution 0.9 % injection 1 sodium chloride (pf) solution 0.9 % injection 1 PA sodium chloride bacteriostatic 1 sodium chloride flush 1 sodium chloride injection 1 sodium chloride intravenous solution 0.45 %, 0.9 1 %, 3 %, 5 % sodium chloride irrigation 1 Effective Date: 7/1/2021 103 Drug Name Drug Tier Requirements/Limits sodium chloride solution 4 meq/ml intravenous 1 sodium chloride solution 4 meq/ml intravenous 1 PA sodium fluoride oral 1 sodium phosphates 1 PA sodium polystyrene sulfonate 1 sps 1 sterile water for irrigation 1 swabflush saline flush 1 TAURINE INJECTION 3 THAM 3 THE LIQUILIFT TRACE 3 thiamine hcl injection 1 tis-u-sol 1 tl-hem 150 1 TOLVAPTAN ORAL TABLET 15 MG 3 SP; QL tolvaptan oral tablet 30 mg 1 SP; QL TRACE ELEMENTS 4/PEDIATRIC 3 PA TRALEMENT 3 TRAVASOL 3 TRI-AMINO 3 TRICARE PRENATAL DHA ONE 2 tricitrates 1 PA TRICON 3 trientine hcl 1 PA; SP TRIFERIC 3 TRINATE 2 TRINAZ 3 PA TRISODIUM CITRATE/CRRT 3 TRISTART DHA 3 PA TRISTART FREE 3 PA TRISTART ONE 3 PA TRI-VI-FLOR 2 TRI-VI-FLORO 2 tri-vite/fluoride 1 TROPHAMINE 3 tryptophan oral 1 PA UROCIT-K 10 3 PA UROCIT-K 15 3 PA

Effective Date: 7/1/2021 104 Drug Name Drug Tier Requirements/Limits UROCIT-K 5 3 PA VELTASSA 3 VENOFER 3 VINATE ONE 2 VIRT-FEFA PLUS 3 virt-phos 250 neutral 1 VITAFOL 3 PA VITAFOL FE+ 3 PA VITAFOL-OB+DHA 3 PA vitamin d (ergocalciferol) oral capsule 1.25 mg 1 (50000 ut) VITAMIN DEFICIENCY SYSTEM-B12 3 PA vitamin k1 injection 1 vitamins acd-fluoride 1 VITATHELY WITH GINGER 3 PA vp-pnv-dha 1 water for irrigation, sterile 1 WESTAB PLUS 2 WESTGEL DHA 3 PA wheat germ oil 1 PA WILZIN 3 ZALVIT 3 PA ZINC CHLORIDE INTRAVENOUS 3 ZINC SULFATE INTRAVENOUS SOLUTION 1 3 PA MG/ML, 3 MG/ML ZINC SULFATE INTRAVENOUS SOLUTION 5 3 MG/ML Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ACIPHEX SPRINKLE 3 ST; QL CARAFATE ORAL SUSPENSION 3 PA cimetidine hcl 1 cimetidine oral 1 CYTOTEC 3 PA DEXILANT 2 QL ESOMEP-EZS 3 PA esomeprazole magnesium 1 QL esomeprazole sodium 1 ESOMEPRAZOLE STRONTIUM 3 ST; QL

Effective Date: 7/1/2021 105 Drug Name Drug Tier Requirements/Limits intravenous 1 famotidine oral suspension reconstituted 1 famotidine oral tablet 20 mg, 40 mg 1 famotidine premixed 1 FIRST-LANSOPRAZOLE 3 ST FIRST-OMEPRAZOLE 3 ST lansoprazole oral capsule delayed release 1 QL lansoprazole oral tablet delayed release 1 ST; QL dispersible misoprostol oral 1 NEXIUM I.V. 3 PA NEXIUM ORAL PACKET 10 MG, 20 MG, 40 3 PA; QL MG NEXIUM ORAL PACKET 2.5 MG, 5 MG 3 QL nizatidine 1 omeprazole oral capsule delayed release 1 QL OMEPRAZOLE+SYRSPEND SF ALKA 3 ST omeprazole-sodium bicarbonate 1 PA; QL pantoprazole sodium intravenous 1 QL pantoprazole sodium oral 1 QL PRILOSEC 3 ST; QL PROTONIX INTRAVENOUS 3 PA; QL PROTONIX ORAL PACKET 3 PA; QL RABEPRAZOLE SODIUM ORAL CAPSULE 3 ST; M; QL SPRINKLE rabeprazole sodium oral tablet delayed release 1 QL sucralfate oral 1 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions alosetron hcl 1 PA alvimopan 1 AMITIZA 3 ST; QL amoxicill-clarithro-lansopraz 1 ANASPAZ 3 ATROPEN 3 atropine sulfate injection solution 0.4 mg/ml, 1 1 PA mg/ml atropine sulfate injection solution prefilled 1 syringe 0.25 mg/5ml atropine sulfate intravenous solution 1 Effective Date: 7/1/2021 106 Drug Name Drug Tier Requirements/Limits ATROPINE SULFATE INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE atropine sulfate solution 8 mg/20ml injection 1 atropine sulfate solution 8 mg/20ml injection 1 PA atropine sulfate solution prefilled syringe 0.5 1 mg/5ml injection atropine sulfate solution prefilled syringe 0.5 1 PA mg/5ml injection atropine sulfate solution prefilled syringe 1 1 mg/10ml injection atropine sulfate solution prefilled syringe 1 1 PA mg/10ml injection belladonna alkaloids-opium 1 PA BENTYL 3 PA cascara sagrada oral fluid extract 1 CHENODAL 3 PA; SP chlordiazepoxide-clidinium 1 CLENPIQ 3 constulose 1 cromolyn sodium oral 1 CUVPOSA 3 dicyclomine hcl intramuscular 1 dicyclomine hcl oral 1 diphenoxylate-atropine 1 ED-SPAZ 3 ENTEREG 3 PA enulose 1 GASTROCROM 3 PA GATTEX 3 PA; SP gavilyte-c 1 gavilyte-g 1 gavilyte-h 1 gavilyte-n with flavor pack 1 generlac 1 GIALAX 3 PA GLYCATE 3 PA glycopyrrolate injection solution 1 GLYCOPYRROLATE INJECTION SOLUTION 3 PREFILLED SYRINGE 0.6 MG/3ML glycopyrrolate oral tablet 1 mg, 2 mg 1 Effective Date: 7/1/2021 107 Drug Name Drug Tier Requirements/Limits GLYCOPYRROLATE ORAL TABLET 1.5 MG 3 PA glycopyrrolate pf 1 GLYCOPYRROLATE SOLUTION PREFILLED 3 SYRINGE 0.6 MG/3ML INTRAVENOUS GLYCOPYRROLATE SOLUTION PREFILLED 3 PA SYRINGE 0.6 MG/3ML INTRAVENOUS GLYCOPYRROLATE SOLUTION PREFILLED 3 SYRINGE 1 MG/5ML INJECTION GLYCOPYRROLATE SOLUTION PREFILLED 3 PA SYRINGE 1 MG/5ML INJECTION GLYCOPYRROLATE SOLUTION PREFILLED 3 SYRINGE 1 MG/5ML INTRAVENOUS GLYCOPYRROLATE SOLUTION PREFILLED 3 PA SYRINGE 1 MG/5ML INTRAVENOUS GLYRX-PF 3 GOLYTELY 3 PA HELIDAC THERAPY 3 hyoscyamine sulfate er 1 PA hyoscyamine sulfate injection 1 PA hyoscyamine sulfate oral elixir 1 hyoscyamine sulfate oral tablet 1 hyoscyamine sulfate oral tablet dispersible 1 hyoscyamine sulfate sl 1 hyoscyamine sulfate solution 0.125 mg/ml oral 1 PA hyoscyamine sulfate solution 0.125 mg/ml oral 1 hyoscyamine sulfate tablet sublingual 0.125 mg 1 sublingual hyoscyamine sulfate tablet sublingual 0.125 mg 1 PA sublingual KRISTALOSE 3 PA LACTEROL 3 LACTOJEN 3 PA lactulose encephalopathy 1 lactulose oral packet 1 PA lactulose oral solution 1 LEVBID 3 PA LEVSIN 3 PA LEVSIN/SL 3 PA LINZESS 2 ST; QL LOMOTIL 3 PA

Effective Date: 7/1/2021 108 Drug Name Drug Tier Requirements/Limits hcl oral capsule 1 LUBIPROSTONE 3 ST; M; QL methscopolamine bromide oral 1 mineral oil heavy oral 1 MOTEGRITY 3 ST; QL MOTOFEN 3 PA MOVANTIK 2 ST; QL MOVIPREP 3 PA MYTESI 3 QL NULEV 3 NULYTELY LEMON-LIME 3 PA NULYTELY WITH FLAVOR PACKS ORAL 3 PA SOLUTION RECONSTITUTED 420 GM OMECLAMOX-PAK 2 oscimin 1 oscimin sr 1 PA OSMOPREP 3 ST PCP 100 3 PA peg 3350-kcl-na bicarb-nacl 1 peg-3350/electrolytes 1 peg-3350/electrolytes/ascorbat 1 peg-kcl-nacl-nasulf-na asc-c 1 peg-prep 1 PLENVU 3 ST PROBICHEW 3 PA PRODIGEN 3 PA PROMELLA IN PREBIOTIC 3 PA PYLERA 2 RELISTOR 3 ST; QL RELTONE 3 PA RESTORA RX 3 SEROSTIM 3 PA; SP sodium bicarbonate oral powder 1 SUPREP BOWEL PREP KIT 3 SUTAB 3 ST SYMAX DUOTAB 3 PA SYMAX-SR 3 PA SYMPROIC 2 ST; QL

Effective Date: 7/1/2021 109 Drug Name Drug Tier Requirements/Limits TALICIA 3 TRULANCE 3 ST; QL URSO 250 3 PA URSO FORTE 3 PA ursodiol oral 1 VIBERZI 3 PA; QL XERMELO 3 PA; SP; QL ZELAC 3 PA ZELNORM 3 QL ZORBTIVE 3 PA; SP Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment ALDURAZYME 2 PA; SP AMMONUL 3 PA BRINEURA 3 PA; SP BUPHENYL 3 PA; SP CERDELGA 3 PA; SP CEREZYME 2 PA; SP CHOLBAM 3 PA; SP CREON 2 CRYSVITA 3 PA; SP CYSTADANE 3 SP CYSTAGON 3 SP ELAPRASE 2 PA; SP ELELYSO 3 PA; SP ENZADYNE 3 PA EVRYSDI 3 PA; SP; QL EXONDYS 51 3 PA; SP FABRAZYME 2 PA; SP GALAFOLD 3 PA; SP; QL KANUMA 3 PA; SP KUVAN 3 PA; SP LUMIZYME 2 PA; SP MEPSEVII 3 PA; SP miglustat 1 PA; SP MYALEPT 3 PA; SP NAGLAZYME 2 PA; SP nitisinone 1 PA; SP

Effective Date: 7/1/2021 110 Drug Name Drug Tier Requirements/Limits NITYR 3 PA; SP OCALIVA 3 PA; SP; QL ORFADIN 3 PA; SP PALYNZIQ 3 PA; SP; QL PANCREAZE 3 ST PERTZYE 3 ST PROCYSBI 3 PA; SP RAVICTI 3 PA; SP REVCOVI 3 PA; SP sapropterin dihydrochloride 1 PA; SP sod benz-sod phenylacet 1 sodium phenylbutyrate oral 1 SP STRENSIQ 2 PA; SP SUCRAID 3 SP VIMIZIM 3 PA; SP VIOKACE 3 ST VPRIV 3 PA; SP VYONDYS 53 3 PA; SP XURIDEN 3 PA; SP; QL ZAVESCA 3 PA; SP ZENPEP 2 ZOLGENSMA 3 PA; SP Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions acetic acid irrigation 1 aminoacetic acid 1 AURYXIA 3 bethanechol chloride oral 1 calcium acetate (phos binder) 1 calcium acetate oral tablet 667 mg 1 CUPRIMINE 3 PA; SP darifenacin hydrobromide er 1 DEPEN TITRATABS 2 PA; SP DETROL 3 PA DETROL LA 3 PA DITROPAN XL 3 PA ELMIRON 3 ENABLEX ORAL TABLET EXTENDED 3 PA RELEASE 24 HOUR 7.5 MG Effective Date: 7/1/2021 111 Drug Name Drug Tier Requirements/Limits flavoxate hcl 1 FOSRENOL ORAL PACKET 3 FOSRENOL ORAL TABLET CHEWABLE 3 PA GELNIQUE 3 ST glycine irrigation 1 glycine urologic 1 HYOPHEN 3 PA; QL INTRAROSA 3 ST lanthanum carbonate 1 LITHOSTAT 3 me/naphos/mb/hyo1 1 PA; QL MYRBETRIQ 2 OXLUMO 3 PA; SP oxybutynin chloride er 1 oxybutynin chloride oral 1 OXYTROL 3 ST; QL penicillamine oral capsule 1 PA; SP penicillamine oral tablet 1 SP PENTOSAN POLYSULFATE SODIUM ORAL 3 PA phenazo oral tablet 200 mg 1 phenazopyridine hcl oral tablet 100 mg, 200 mg 1 PHOSLYRA 3 PHOSPHASAL 3 PA; QL PYRIDIUM 3 PA RENACIDIN 3 RENAGEL 3 PA RIMSO-50 3 sevelamer carbonate 1 sevelamer hcl 1 solifenacin succinate 1 oral tablet 2.5 mg, 5 mg 1 QL THIOLA EC 3 SP tolterodine tartrate 1 tolterodine tartrate er 1 TOVIAZ 3 trospium chloride 1 trospium chloride er 1 uretron d/s 1 QL

Effective Date: 7/1/2021 112 Drug Name Drug Tier Requirements/Limits URIBEL 3 PA; QL URIMAR-T 3 PA; QL urin ds 1 QL URO-458 3 PA; QL UROGESIC-BLUE 3 PA; QL uro-mp 1 PA; QL USTELL 3 PA; QL UTIRA-C 3 PA; QL VELPHORO 3 VILAMIT MB 3 PA; QL VILEVEV MB 3 PA; QL Genitourinary Agents - Drugs for Prostate Conditions alfuzosin hcl er 1 AVODART 3 PA CARDURA XL 3 ST dutasteride oral 1 dutasteride-tamsulosin hcl 1 finasteride oral tablet 5 mg 1 JALYN 3 PA PROSCAR 3 PA RAPAFLO 3 PA silodosin 1 tamsulosin hcl 1 terazosin hcl 1 Hormonal Agents - Adrenal ACTIVE INJECTION BLM-1 3 PA ACTIVE INJECTION BM 3 PA ACTIVE INJECTION D 3 PA ACTIVE INJECTION DL 3 PA ACTIVE INJECTION DLM 3 PA ACTIVE INJECTION KIT L 3 PA ACTIVE INJECTION KL-3 3 PA ACTIVE INJECTION KM 3 PA ACTIVE INJECTION LM-DEP-2 3 PA ACTIVE INJECTION M-1 3 PA ALKINDI SPRINKLE 3 PA BETA 1 KIT 3 PA

Effective Date: 7/1/2021 113 Drug Name Drug Tier Requirements/Limits BETALIDO 3 PA BETALOAN SUIK 3 PA BETAMETHASONE COMBO 3 PA BETAMETHASONE SOD PHOS & ACET 3 PA INJECTION SUSPENSION 7 (4-3) MG/ML BETAMETHASONE SOD PHOS & ACET 3 PA SUSPENSION 6 (3-3) MG/ML INJECTION betamethasone sod phos & acet suspension 6 1 (3-3) mg/ml injection BETAMETHASONE SODIUM PHOSPHATE 3 PA INJECTION BSP 0820 3 PA BUPIVILOG 3 PA CELESTONE SOLUSPAN 3 PA CONTRAST ALLERGY PREMED PACK 3 PA CORTEF 3 PA DECADRON 3 PA DEPO-MEDROL INJECTION SUSPENSION 20 3 MG/ML DEPO-MEDROL INJECTION SUSPENSION 40 3 PA MG/ML, 80 MG/ML DEXABLISS 3 PA DEXAMETH SOD PHOS-BUPIV-EPIN 3 PA DEXAMETHASONE (LA) 3 DEXAMETHASONE ACE & SOD PHOS 3 PA dexamethasone intensol 1 dexamethasone oral 1 DEXAMETHASONE SOD PHOS-BUPIV 3 PA DEXAMETHASONE SOD PHOS-NACL 3 dexamethasone sod phosphate pf 1 dexamethasone sodium phosphate injection 1 solution 100 mg/10ml, 120 mg/30ml, 20 mg/5ml DEXAMETHASONE SODIUM PHOSPHATE 3 SOLUTION 10 MG/ML INJECTION dexamethasone sodium phosphate solution 10 1 mg/ml injection dexamethasone sodium phosphate solution 4 1 mg/ml injection DEXAMETHASONE SODIUM PHOSPHATE 3 SOLUTION 4 MG/ML INJECTION DEXLIDO 3 PA

Effective Date: 7/1/2021 114 Drug Name Drug Tier Requirements/Limits DEXLIDO-M 3 PA DEXONTO 0.4% 3 DMT SUIK 3 PA DOUBLEDEX 3 PA DXEVO 11-DAY 3 PA DYURAL-40 3 PA DYURAL-80 3 PA DYURAL-L 3 PA DYURAL-LM 3 PA fludrocortisone acetate oral 1 HEMADY 3 PA HIDEX 6-DAY 3 PA hydrocortisone oral 1 KENALOG INJECTION SUSPENSION 10 3 ST MG/ML KENALOG INJECTION SUSPENSION 40 3 PA MG/ML KENALOG-80 3 ST LIDOCIDEX I 3 PA lidolog 1 PA MARBETA-25 3 PA MARBETA-L 3 PA MARDEX-25 3 PA MAS CARE-PAK 3 PA MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 3 PA 8 MG MEDROL ORAL TABLET 2 MG 2 MEDROL ORAL TABLET THERAPY PACK 3 PA MEDROLOAN II SUIK 3 PA MEDROLOAN SUIK 3 PA METHYLPREDNISOLONE ACE-LIDO 3 PA METHYLPREDNISOLONE ACETATE 3 INJECTION SUSPENSION 50 MG/ML methylprednisolone acetate suspension 40 1 mg/ml injection METHYLPREDNISOLONE ACETATE 3 SUSPENSION 40 MG/ML INJECTION methylprednisolone acetate suspension 80 1 mg/ml injection

Effective Date: 7/1/2021 115 Drug Name Drug Tier Requirements/Limits METHYLPREDNISOLONE ACETATE 3 SUSPENSION 80 MG/ML INJECTION methylprednisolone oral 1 methylprednisolone sodium succ 1 METHYLPREDNISOLONE-BUPIVACAINE 3 MILLIPRED 2 PA MULTI-SPECIALTY 3 PA ORAPRED ODT 3 PA P-CARE K40 3 PA P-CARE K40G 3 PA P-CARE K40MX 3 PA P-CARE K80 3 PA P-CARE K80G 3 PA P-CARE K80MX 3 PA PEDIAPRED 3 PA PHYSICIANS EZ USE JOINT/TUNNEL 3 PA PHYSICIANS EZ USE M-PRED 3 PA POD-CARE 100K 3 PA POINT OF CARE KM 3 PA POINT OF CARE L.2 3 PA POINT OF CARE L.5 3 PA POINT OF CARE LM DEP 2 3 PA prednisolone oral solution 1 prednisolone sodium phosphate oral 1 prednisone intensol 1 prednisone oral 1 PRO-C-DURE 5 3 PA PRO-C-DURE 6 3 PA RAYOS 3 ST READYSHARP ANESTH + BETAMETH 3 PA READYSHARP ANESTH + DEXAMETH 3 PA READYSHARP ANESTH + METHYLPRED 3 PA READYSHARP BETAMETHASONE 3 PA READYSHARP DEXAMETHASONE 3 PA ROPIDEX 3 PA SOLU-CORTEF 3 SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 1000 MG, 125 MG, 40 MG, 3 PA 500 MG

Effective Date: 7/1/2021 116 Drug Name Drug Tier Requirements/Limits SOLU-MEDROL INJECTION SOLUTION 3 RECONSTITUTED 2 GM TAPERDEX 12-DAY 3 PA TAPERDEX 6-DAY 3 PA TAPERDEX 7-DAY 3 PA TOPIDEX 3 PA TRIAMCINOLONE ACETONIDE INJECTION 3 ST SUSPENSION 50 MG/ML TRIAMCINOLONE ACETONIDE SUSPENSION 3 ST 40 MG/ML INJECTION triamcinolone acetonide suspension 40 mg/ml 1 injection TRIAMCINOLONE DIACETATE INJECTION 3 PA SUSPENSION 40 MG/ML TRIAMCINOLONE DIACETATE INJECTION 3 SUSPENSION 80 MG/ML TRIAMCINOLONE DIACETATE PF INJECTION 3 PA SUSPENSION 80 MG/2ML TRIAMCINOLONE-BUPIVACAINE 3 TRILOAN II SUIK 3 PA TRILOAN SUIK 3 PA ZCORT 7-DAY 3 PA ZILRETTA 3 PA Hormonal Agents - Men's Health ANDRODERM 2 PA ANDROGEL TRANSDERMAL GEL 40.5 3 PA MG/2.5GM (1.62%) AVEED 3 PA oral 1 FORTESTA 3 PA JATENZO 3 PA METHITEST 3 PA oral 1 PA NATESTO 3 PA oral 1 PA; QL TESTONE CIK 3 PA TESTOPEL 3 PA CYPIONATE INJECTION 3 PA intramuscular 1 PA intramuscular 1 PA

Effective Date: 7/1/2021 117 Drug Name Drug Tier Requirements/Limits TESTOSTERONE IMPLANT 3 PA testosterone transdermal 1 PA XYOSTED 3 PA Hormonal Agents - EVISTA 3 PA OSPHENA 3 hcl 1 Hormonal Agents - Pituitary ACTHAR 2 PA; SP BYNFEZIA PEN 3 PA; SP cabergoline 1 CETROTIDE 3 PA; SP chorionic gonadotropin intramuscular 1 PA; SP clomiphene citrate oral 1 DDAVP 3 PA DDAVP RHINAL TUBE 2 desmopressin ace spray refrig 1 desmopressin acetate injection 1 desmopressin acetate oral 1 desmopressin acetate spray 1 EGRIFTA SV 3 PA; SP; QL ELIGARD 3 PA; SP; QL FENSOLVI (6 MONTH) 3 PA; SP; QL FIRMAGON 3 PA; SP; QL FIRMAGON (240 MG DOSE) 3 PA; SP; QL FOLLISTIM AQ 2 PA; SP ganirelix acetate 1 PA; SP GENOTROPIN 3 PA; SP GENOTROPIN MINIQUICK 3 PA; SP GONAL-F 3 PA; SP GONAL-F RFF 3 PA; SP GONAL-F RFF REDIJECT 3 PA; SP HUMATROPE 3 PA; SP INCRELEX 2 PA; SP ISTURISA 3 PA; SP leuprolide acetate injection 1 PA; SP LEUPROLIDE ACETATE-BUPIVACAINE 3 LUPANETA PACK 3 PA; SP; QL

Effective Date: 7/1/2021 118 Drug Name Drug Tier Requirements/Limits LUPRON DEPOT (1-MONTH) 3 PA; SP INTRAMUSCULAR KIT 3.75 MG LUPRON DEPOT (1-MONTH) 2 PA; SP INTRAMUSCULAR KIT 7.5 MG LUPRON DEPOT (3-MONTH) 3 PA; SP INTRAMUSCULAR KIT 11.25 MG LUPRON DEPOT (3-MONTH) 2 PA; SP INTRAMUSCULAR KIT 22.5 MG LUPRON DEPOT (4-MONTH) 2 PA; SP INTRAMUSCULAR KIT 30MG LUPRON DEPOT (6-MONTH) 2 PA; SP INTRAMUSCULAR KIT 45MG LUPRON DEPOT-PED (1-MONTH) 3 PA; SP INTRAMUSCULAR KIT 11.25 MG LUPRON DEPOT-PED (1-MONTH) 2 PA; SP INTRAMUSCULAR KIT 15 MG, 7.5 MG LUPRON DEPOT-PED (3-MONTH) 3 PA; SP INTRAMUSCULAR KIT 11.25 MG (PED) LUPRON DEPOT-PED (3-MONTH) 2 PA; SP INTRAMUSCULAR KIT 30 MG (PED) MENOPUR 3 PA; SP MYCAPSSA 3 PA; SP NOCDURNA 3 NORDITROPIN FLEXPRO 2 PA; SP novarel intramuscular solution reconstituted 1 PA; SP 10000 unit NOVAREL INTRAMUSCULAR SOLUTION 3 PA; SP RECONSTITUTED 5000 UNIT NUTROPIN AQ NUSPIN 10 2 PA; SP NUTROPIN AQ NUSPIN 20 2 PA; SP NUTROPIN AQ NUSPIN 5 2 PA; SP octreotide acetate 1 PA; SP OMNITROPE 3 PA; SP ORILISSA 2 PA; QL OVIDREL 3 PA; SP oxytocin injection 1 OXYTOCIN-LACTATED RINGERS 3 OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 15-0.9 UT/250ML- 3 %, 20-0.9 UNIT/L-%, 20-0.9 UNT/L-% OXYTOCIN-SODIUM CHLORIDE SOLUTION 3 30-0.9 UT/500ML-% INTRAVENOUS

Effective Date: 7/1/2021 119 Drug Name Drug Tier Requirements/Limits OXYTOCIN-SODIUM CHLORIDE SOLUTION 3 PA 30-0.9 UT/500ML-% INTRAVENOUS PITOCIN 3 PA pregnyl 1 PA; SP SAIZEN 3 PA; SP SAIZENPREP 3 PA; SP SANDOSTATIN LAR DEPOT 3 PA; SP SIGNIFOR 3 PA; SP; QL SIGNIFOR LAR 3 PA; SP; QL SOMATULINE DEPOT 3 PA; SP SOMAVERT 3 PA; SP STIMATE 3 SUPPRELIN LA 2 PA; SP; QL SYNAREL 2 TEPEZZA 3 PA; SP TRELSTAR MIXJECT 3 PA; SP; QL TRIPTODUR 3 PA; SP; QL VANTAS 3 PA; SP; QL VAPRISOL 3 VASOSTRICT 3 ZOLADEX SUBCUTANEOUS IMPLANT 10.8 3 SP; QL MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG 2 SP; QL ZOMACTON 3 PA; SP ZOMACTON (FOR ZOMA-JET 10) 3 PA; SP Hormonal Agents - Prostaglandins KORLYM 3 PA; SP; QL Hormonal Agents - Sex Hormones and Birth Control ACTIVELLA 3 PA afirmelle 1 ALORA 3 ST altavera 1 alyacen 1/35 1 alyacen 7/7/7 1 amabelz 1 amethia 1 QL amethia lo 1 QL amethyst 1

Effective Date: 7/1/2021 120 Drug Name Drug Tier Requirements/Limits ANGELIQ 3 ANNOVERA 3 ST; QL apri 1 aranelle 1 ashlyna 1 QL aubra 1 aubra eq 1 aurovela 1.5/30 1 aurovela 1/20 1 aurovela 24 fe 1 aurovela fe 1.5/30 1 aurovela fe 1/20 1 aviane 1 AYGESTIN 3 PA ayuna 1 azurette 1 BALCOLTRA 3 PA balziva 1 bekyree 1 BIJUVA 3 blisovi 24 fe 1 blisovi fe 1.5/30 1 blisovi fe 1/20 1 briellyn 1 camila 1 camrese 1 QL camrese lo 1 QL caziant 1 charlotte 24 fe 1 chateal 1 chateal eq 1 CLIMARA 3 PA CLIMARA PRO 2 COMBIPATCH 3 CRINONE 3 QL cryselle-28 1 cyclafem 1/35 1 cyclafem 7/7/7 1

Effective Date: 7/1/2021 121 Drug Name Drug Tier Requirements/Limits cyred 1 cyred eq 1 dasetta 1/35 1 dasetta 7/7/7 1 daysee 1 QL deblitane 1 DELESTROGEN INTRAMUSCULAR OIL 10 3 ST MG/ML DELESTROGEN INTRAMUSCULAR OIL 20 3 PA MG/ML, 40 MG/ML delyla 1 DEPO- 3 DEPO-PROVERA 3 PA; QL DEPO-SUBQ PROVERA 104 3 QL -ethinyl estradiol 1 DIVIGEL 3 dotti 1 drospiren-eth estrad-levomefol 1 -ethinyl estradiol 1 DUAVEE 2 ELESTRIN 3 elinest 1 ELLA 3 eluryng 1 emoquette 1 ENDOMETRIN 2 enpresse-28 1 enskyce 1 errin 1 estarylla 1 ESTRACE 3 PA ESTRADIOL IMPLANT 3 PA estradiol oral 1 estradiol transdermal 1 estradiol vaginal 1 estradiol valerate intramuscular 1 estradiol-norethindrone acet 1 ESTRING 3 QL ESTROGEL 3 Effective Date: 7/1/2021 122 Drug Name Drug Tier Requirements/Limits ESTROSTEP FE 3 PA ethynodiol diac-eth estradiol 1 -ethinyl estradiol 1 EVAMIST 3 FALESSA 3 PA falmina 1 fayosim 1 QL FEMHRT LOW DOSE 3 PA FEMRING 3 ST; QL femynor 1 fyavolv 1 gemmily 1 GENERESS FE 3 PA hailey 1.5/30 1 hailey 24 fe 1 hailey fe 1.5/30 1 hailey fe 1/20 1 heather 1 hydroxyprogesterone caproate intramuscular 1 PA; SP iclevia 1 QL IMVEXXY MAINTENANCE PACK 3 IMVEXXY STARTER PACK 3 incassia 1 introvale 1 QL isibloom 1 jaimiess 1 QL jasmiel 1 jencycla 1 jinteli 1 jolessa 1 QL juleber 1 junel 1.5/30 1 junel 1/20 1 junel fe 1.5/30 1 junel fe 1/20 1 junel fe 24 1 kaitlib fe 1 kalliga 1

Effective Date: 7/1/2021 123 Drug Name Drug Tier Requirements/Limits kariva 1 kelnor 1/35 1 kelnor 1/50 1 kurvelo 1 KYLEENA 3 larin 1.5/30 1 larin 1/20 1 larin 24 fe 1 larin fe 1.5/30 1 larin fe 1/20 1 larissia 1 layolis fe 1 leena 1 lessina 1 levonest 1 levonorgest-eth est & eth est 1 QL levonorgest-eth estrad 91-day 1 QL -ethinyl estrad 1 levonorg-eth estrad triphasic 1 levora 0.15/30 (28) 1 LILETTA (52 MG) 3 lillow 1 LO LOESTRIN FE 3 LOESTRIN 1.5/30 (21) 3 PA LOESTRIN 1/20 (21) 3 PA LOESTRIN FE 1.5/30 3 PA LOESTRIN FE 1/20 3 PA lojaimiess 1 QL loryna 1 LOSEASONIQUE 3 PA; QL low-ogestrel 1 lo-zumandimine 1 lutera 1 lyleq 1 lyllana 1 lyza 1 MAKENA 2 PA; SP marlissa 1

Effective Date: 7/1/2021 124 Drug Name Drug Tier Requirements/Limits medroxyprogesterone acetate intramuscular 1 QL medroxyprogesterone acetate oral 1 oral suspension 40 mg/ml, CM 400 mg/10ml megestrol acetate oral suspension 625 mg/5ml 1 megestrol acetate oral tablet CM melodetta 24 fe 1 MENEST 2 MENOSTAR 3 ST merzee 1 mibelas 24 fe 1 microgestin 1.5/30 1 microgestin 1/20 1 microgestin 24 fe 1 microgestin fe 1.5/30 1 microgestin fe 1/20 1 mili 1 mimvey 1 MINIVELLE 3 PA MIRCETTE 3 PA MIRENA (52 MG) 3 mono-linyah 1 NATAZIA 2 necon 0.5/35 (28) 1 NEXPLANON 3 nikki 1 nora-be 1 norethin ace-eth estrad-fe 1 norethindrone acetate oral 1 norethindrone acet-ethinyl est 1 norethindrone oral 1 norethindrone-eth estradiol 1 norethin-eth estradiol-fe 1 -eth estradiol 1 norgestimate-ethinyl estradiol triphasic 1 norlyda 1 norlyroc 1 nortrel 0.5/35 (28) 1

Effective Date: 7/1/2021 125 Drug Name Drug Tier Requirements/Limits nortrel 1/35 (21) 1 nortrel 1/35 (28) 1 nortrel 7/7/7 1 NUVARING 3 PA nylia 7/7/7 1 nymyo 1 ocella 1 ORIAHNN 2 PA; QL orsythia 1 ORTHO MICRONOR 3 PA PARAGARD INTRAUTERINE COPPER 3 philith 1 pimtrea 1 pirmella 1/35 1 pirmella 7/7/7 1 portia-28 1 PREFEST 3 PREMARIN INJECTION 3 PREMARIN ORAL 2 PREMARIN VAGINAL 2 PREMPHASE 2 PREMPRO 2 previfem 1 progesterone intramuscular 1 progesterone micronized oral 1 PROVERA 3 PA QUARTETTE 3 PA; QL reclipsen 1 rivelsa 1 QL SAFYRAL 3 PA SEASONIQUE 3 PA; QL setlakin 1 QL sharobel 1 simliya 1 simpesse 1 QL SKYLA 3 SLYND 3 ST sprintec 28 1

Effective Date: 7/1/2021 126 Drug Name Drug Tier Requirements/Limits sronyx 1 syeda 1 tarina 24 fe 1 tarina fe 1/20 1 tarina fe 1/20 eq 1 TAYTULLA 3 PA tilia fe 1 tri femynor 1 tri-estarylla 1 tri-legest fe 1 tri-linyah 1 tri-lo-estarylla 1 tri-lo-marzia 1 tri-lo-mili 1 tri-lo-sprintec 1 tri-mili 1 tri-nymyo 1 tri-previfem 1 tri-sprintec 1 trivora (28) 1 tri-vylibra 1 tri-vylibra lo 1 tulana 1 TWIRLA 3 PA tyblume 1 tydemy 1 velivet 1 vestura 1 vienva 1 viorele 1 volnea 1 vyfemla 1 vylibra 1 wera 1 wymzya fe 1 xulane 1 YASMIN 28 3 PA yuvafem 1

Effective Date: 7/1/2021 127 Drug Name Drug Tier Requirements/Limits zafemy 1 zarah 1 zovia 1/35 (28) 1 zovia 1/35e (28) 1 zumandimine 1 Hormonal Agents - Thyroid ARMOUR THYROID 3 ST euthyrox 1 levo-t 1 levothyroxine sodium intravenous 1 LEVOTHYROXINE SODIUM ORAL CAPSULE 3 ST; M levothyroxine sodium oral tablet 1 levoxyl 1 liothyronine sodium intravenous 1 liothyronine sodium oral 1 methimazole oral 1 NATURE-THROID 3 ST np thyroid 1 propylthiouracil oral 1 SYNTHROID 3 PA TAPAZOLE 3 PA THYQUIDITY 3 ST TIROSINT 3 TIROSINT-SOL 3 TRIOSTAT 3 PA unithroid 1 WESTHROID 3 ST WP THYROID 3 ST Immunological Agents - Drugs for Immune System Stimulation or Suppression ACTEMRA 3 PA; 3P; SP ACTEMRA ACTPEN 3 PA; 3P; SP ACTIMMUNE 2 PA; SP ALFERON N 2 SP ARCALYST 3 PA; SP ASCENIV 3 PA; SP ASTAGRAF XL 3 SP ATGAM 2 SP

Effective Date: 7/1/2021 128 Drug Name Drug Tier Requirements/Limits AVSOLA 2 PA; SP AZASAN 3 azathioprine oral 1 azathioprine sodium 1 BAMLANIVIMAB 3 BENLYSTA 3 PA; SP BERINERT 3 PA; SP; QL BIVIGAM 3 PA; SP CARIMUNE NF 3 PA; SP CASIRIVIMAB 3 CELLCEPT 3 PA; SP CELLCEPT INTRAVENOUS 3 PA; SP CIMZIA 2 PA; SP CIMZIA PREFILLED KIT 2 PA; SP CIMZIA STARTER KIT 2 PA; SP CINRYZE 3 PA; SP COSENTYX (300 MG DOSE) 3 PA; SP COSENTYX 150 MG/ML 3 PA; SP COSENTYX SENSOREADY (300 MG) 3 PA; SP COSENTYX SENSOREADY PEN 3 PA; SP CUTAQUIG 3 PA; SP CUVITRU 3 PA; SP cyclosporine intravenous 1 SP cyclosporine modified 1 SP cyclosporine oral 1 SP CYTOGAM 2 PA; SP ENBREL 3 PA; SP ENBREL MINI 3 PA; SP ENBREL SURECLICK 3 PA; SP ENSPRYNG 3 PA; SP ENTYVIO 3 PA; SP ENVARSUS XR 3 SP ETESEVIMAB 3 everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg 1 SP FIRAZYR 3 PA; SP; QL FLEBOGAMMA DIF 3 PA; SP GAMASTAN 2 PA; SP GAMIFANT 3 PA; SP

Effective Date: 7/1/2021 129 Drug Name Drug Tier Requirements/Limits GAMMAGARD 3 PA; SP GAMMAGARD S/D LESS IGA 3 PA; SP GAMMAKED 3 PA; SP GAMMAPLEX 3 PA; SP GAMUNEX-C 3 PA; SP gengraf 1 SP HAEGARDA 3 PA; SP HEPAGAM B 3 HIZENTRA 3 PA; SP HUMIRA 2 PA; SP HUMIRA PEDIATRIC CROHNS START 2 PA; SP HUMIRA PEN 2 PA; SP HUMIRA PEN-CD/UC/HS STARTER 2 PA; SP HUMIRA PEN-PEDIATRIC UC START 2 PA; SP HUMIRA PEN-PS/UV/ADOL HS START 2 PA; SP HUMIRA PEN-PSOR/UVEIT STARTER 2 PA; SP HYPERHEP B 3 HYPERRAB 3 PA HYPERRAB S/D 3 PA HYPERRHO S/D 2 SP HYPERTET S/D 3 HYQVIA 3 PA; SP icatibant acetate 1 PA; SP; QL ILARIS 2 PA; SP; QL ILUMYA 3 PA; SP IMDEVIMAB 3 IMOGAM RABIES-HT 3 PA IMURAN 3 PA INFLECTRA 2 PA; SP KALBITOR 3 PA; SP; QL KEDRAB 3 PA KEVZARA 3 PA; SP KINERET 3 PA; SP KYMRIAH 3 PA; SP leflunomide oral 1 methotrexate oral CM methotrexate sodium (pf) 1 methotrexate sodium injection 1

Effective Date: 7/1/2021 130 Drug Name Drug Tier Requirements/Limits methotrexate sodium oral CM MICRHOGAM ULTRA-FILTERED PLUS 2 SP mycophenolate mofetil hcl 1 SP mycophenolate mofetil oral 1 SP mycophenolate sodium 1 SP MYFORTIC 3 PA; SP NABI-HB 3 NEORAL 3 PA; SP NULOJIX 3 SP OCTAGAM 3 PA; SP OLUMIANT 3 PA; SP ORENCIA 3 PA; 3P; SP ORENCIA CLICKJECT 3 PA; 3P; SP ORLADEYO 3 PA; SP; QL OTEZLA 2 PA; SP OTREXUP 3 PA; QL PANZYGA 3 PA; SP PRIVIGEN 3 PA; SP PROGRAF INTRAVENOUS 3 SP PROGRAF ORAL CAPSULE 3 PA; SP PROGRAF ORAL PACKET 3 SP PROVENGE 2 PA; SP RAPAMUNE 3 PA; SP RASUVO 2 PA; QL REDITREX 3 PA; QL REMICADE 3 PA; SP RENFLEXIS 3 PA; SP RHOGAM ULTRA-FILTERED PLUS 2 SP RHOPHYLAC 2 RIDAURA 3 SP RINVOQ 2 PA; SP RUCONEST 3 PA; SP; QL SANDIMMUNE INTRAVENOUS 2 PA; SP SANDIMMUNE ORAL CAPSULE 3 PA; SP SANDIMMUNE ORAL SOLUTION 2 SP SILIQ 3 PA; SP SIMPONI 2 PA; SP SIMPONI ARIA 2 PA; SP

Effective Date: 7/1/2021 131 Drug Name Drug Tier Requirements/Limits SIMULECT 3 sirolimus oral 1 SP SKYRIZI (150 MG DOSE) 2 PA; SP; QL STELARA INTRAVENOUS 2 PA; SP STELARA SUBCUTANEOUS 2 PA; SP; QL SYNAGIS 2 PA; SP tacrolimus oral 1 SP TAKHZYRO 3 PA; SP TALTZ 3 PA; 3P; SP temsirolimus 1 SP THYMOGLOBULIN 3 TICE BCG 2 SP TORISEL 3 PA; SP TREMFYA 2 PA; SP TREXALL CM UPLIZNA 3 PA; SP VARIZIG 3 PA WINRHO SDF 2 SP XATMEP CM XELJANZ ORAL SOLUTION 3 PA; SP XELJANZ ORAL TABLET 2 PA; SP XELJANZ XR 2 PA; SP XEMBIFY 3 PA; SP ZINPLAVA 3 ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 3 PA; SP 0.75 MG ZORTRESS ORAL TABLET 1 MG 3 SP Immunological Agents - Drugs for Vaccination ACTHIB 3 ADACEL 3 AFLURIA QUADRIVALENT 3 ASTRAZENECA COVID-19 VACCINE 3 BCG VACCINE 3 BEXSERO 3 BIOTHRAX 3 BOOSTRIX 3 DAPTACEL 3 DIPHTHERIA-TETANUS TOXOIDS DT 3 Effective Date: 7/1/2021 132 Drug Name Drug Tier Requirements/Limits ENGERIX-B 3 FLUAD 3 FLUAD QUADRIVALENT 3 FLUARIX QUADRIVALENT 3 FLUBLOK QUADRIVALENT 3 FLUCELVAX QUADRIVALENT 3 FLULAVAL QUADRIVALENT 3 FLUMIST QUADRIVALENT 3 FLUZONE HIGH-DOSE QUADRIVALENT 3 FLUZONE QUADRIVALENT 3 GARDASIL 9 3 HAVRIX 3 HEPLISAV-B 3 HIBERIX 3 IMOVAX RABIES 3 INFANRIX 3 IPOL 3 IXIARO 3 JANSSEN COVID-19 VACCINE 3 KINRIX 3 MENACTRA 3 MENQUADFI 3 MENVEO 3 M-M-R II 3 MODERNA COVID-19 VACCINE 3 PEDIARIX 3 PEDVAX HIB 3 PENTACEL 3 PFIZER-BIONTECH COVID-19 VACC 3 PNEUMOVAX 23 3 PREVNAR 13 3 PROQUAD 3 QUADRACEL 3 RABAVERT 3 RECOMBIVAX HB 3 ROTARIX 3 ROTATEQ 3 SHINGRIX 3

Effective Date: 7/1/2021 133 Drug Name Drug Tier Requirements/Limits STAMARIL 3 TDVAX 3 TENIVAC 3 TETANUS-DIPHTHERIA TOXOIDS TD 3 TRUMENBA 3 TWINRIX 3 TYPHIM VI 3 VAQTA 3 VARIVAX 3 VAXCHORA 3 VAXELIS 3 VIVOTIF 3 YF-VAX 3 Inflammatory Bowel Disease Agents ana-lex 1 PA ANUSOL-HC EXTERNAL 3 PA APRISO 2 PA AZULFIDINE 3 PA AZULFIDINE EN-TABS 3 PA balsalazide disodium 1 budesonide er 1 budesonide oral 1 CORTENEMA 3 PA CORTIFOAM 3 DELZICOL 3 PA DIPENTUM 3 ENTOCORT EC 3 PA hydrocortisone (perianal) 1 hydrocortisone ace-pramoxine external cream 1- 1 1 % hydrocortisone rectal 1 lidocaine-hydrocort (perianal) 1 PA LIDOCAINE-HYDROCORTISONE ACE 3 PA RECTAL GEL lidocaine-hydrocortisone ace rectal kit 1 PA LIDOCORT 3 PA mesalamine er oral capsule 0.375 gm 1 mesalamine oral 1 mesalamine rectal 1 Effective Date: 7/1/2021 134 Drug Name Drug Tier Requirements/Limits mesalamine-cleanser 1 ORTIKOS ORAL CAPSULE EXTENDED 3 ST; QL RELEASE 24 HOUR 6 MG PENTASA 3 PROCTOFOAM HC 2 procto-med hc 1 procto-pak 1 proctozone-hc 1 ROWASA 3 PA SFROWASA 2 sulfasalazine oral 1 UCERIS ORAL 3 PA UCERIS RECTAL 3 Metabolic Bone Disease Agents - Drugs for Osteoporosis ACTONEL 3 PA; QL alendronate sodium oral solution 1 alendronate sodium oral tablet 10 mg, 5 mg 1 alendronate sodium oral tablet 35 mg, 70 mg 1 QL ATELVIA 3 PA; QL BINOSTO 3 QL BONIVA 3 PA; QL calcitonin (salmon) 1 QL EVENITY 3 PA; SP; QL FORTEO 3 PA; SP FOSAMAX 3 PA; QL FOSAMAX PLUS D 3 PA; QL ibandronate sodium 1 QL MIACALCIN INJECTION 3 pamidronate disodium 1 SP PROLIA 2 PA; SP; QL RAYALDEE 3 RECLAST 3 PA; SP risedronate sodium oral tablet 150 mg, 35 mg 1 QL risedronate sodium oral tablet 30 mg, 5 mg 1 risedronate sodium oral tablet delayed release 1 QL (RECOMBINANT) 2 PA; SP TYMLOS 2 PA; SP XGEVA 2 PA; SP Effective Date: 7/1/2021 135 Drug Name Drug Tier Requirements/Limits zoledronic acid 1 SP Metabolic Bone Disease Agents - Other calcitriol intravenous 1 calcitriol oral 1 cinacalcet hcl 1 PA doxercalciferol intravenous 1 doxercalciferol oral 1 PA HECTOROL INTRAVENOUS SOLUTION 2 3 MCG/ML HECTOROL INTRAVENOUS SOLUTION 4 3 PA MCG/2ML NATPARA 3 PA; SP; QL paricalcitol 1 PARSABIV 3 SP ROCALTROL 3 PA ZEMPLAR 3 PA Miscellaneous Therapeutic Agents ACACIA SUBCUTANEOUS 3 PA ACCU-CHEK ULTRAFLEX INF SET 3 ACETADOTE 3 PA acetylcysteine intravenous 1 ACREMONIUM 3 PA ADAKVEO 3 PA; SP ALCOHOL PREP PADS PAD 3 ALCOHOL PREP PADS PAD 70 % 3 ALDER 3 PA ALPHA-LIPOIC ACID INJECTION 3 ALTERNARIA 3 PA AMD FOAM DRESSING 3 AMD FOAM DRESSING TOPSHEET 3 AMERICAN BEECH 3 PA AMERICAN COCKROACH 3 PA AMERICAN ELM 3 PA AMINOPMRMS 3 PA AMPHADASE 3 ANASCORP 3 ANAVIP 3 ANDEXXA 3 PA ANTIVENIN LATRODECTUS MACTANS 3 Effective Date: 7/1/2021 136 Drug Name Drug Tier Requirements/Limits ANTIVENIN MICRURUS FULVIUS 3 APP SLIM RMS 3 PA ARIZONA CYPRESS 3 PA ARTISS 3 asilnasalrms 1 PA ASPERGILLUS FUMIGATUS INJECTION 3 PA AUREOBASIDIUM 3 PA AUREOBASIDIUM PULLULANS INJECTION 3 PA AUSTRALIAN PINE 3 PA AUTOSOFT 30 INFUSION SET 3 AUTOSOFT 90 INFUSION SET 3 AUTOSOFT XC INFUSION SET 3 BACTERIOSTATIC WATER(BENZ ALC) 3 BAHIA 3 PA bal in oil 1 BALD CYPRESS 3 PA BAYBERRY (WAX MYRTLE) 3 PA BERMUDA GRASS 3 PA BIOFREQUENCY INSOLES 3 PA BIOGUARD GAUZE SPONGES PAD 4"X4" 3 BIOGUARD ISLAND DRESSINGS 3 BIOGUARD NON-ADHERENT DRESSING 3 BLACK WILLOW 3 PA BOTOX 2 PA; SP BOTRYTIS 3 PA BREATHE EASE LARGE 2 BREATHE EASE MEDIUM 2 BREATHE EASE SMALL 2 BRIDION INTRAVENOUS SOLUTION 500 3 PA MG/5ML BRIDION SOLUTION 200 MG/2ML 3 INTRAVENOUS BRIDION SOLUTION 200 MG/2ML 3 PA INTRAVENOUS BROME 3 PA CALCIUM DISODIUM VERSENATE 3 CALIFORNIA PEPPER TREE 3 PA CANDIDA ALBICANS EXTRACT 3 PA CARDIOVID PLUS 3 PA

Effective Date: 7/1/2021 137 Drug Name Drug Tier Requirements/Limits CARTICEL 3 CAT HAIR EXTRACT 3 PA CATTLE EPITHELIUM 3 PA CAYA 3 CEDAR ELM 3 PA CHLORHEXIDINE GLUCONATE SOLUTION 20 3 % CLADOSPORIUM CLADOSPORIOIDES 3 PA INJECTION CLADOSPORIUM CLADOSPORIOIDES 3 PA SUBCUTANEOUS CLADOSPORIUM SPHAEROSPERMUM 3 PA CLEVER CHOICE HOLDING CHAMBER 2 COCKLEBUR 3 PA COENZYME Q-10 INJECTION 3 PA COMFORT TOUCH ALCOHOL PREP 3 COMPACT SPACE CHAMBER/LG MASK 2 COMPACT SPACE CHAMBER/MED MASK 2 COMPACT SPACE CHAMBER/SM MASK 2 CORN POLLEN 3 PA CROFAB 3 CURITY AMD ANTIMICROBIAL SPNGE PAD 3 4"X4" CURITY AMD ANTIMICROBIAL STRIP 3 CURITY IODOFORM PACKING STRIP 3 CURVULARIA 3 PA CYANOKIT 3 CYTOTINE ORAL POWDER 3 DANDELION 3 PA deferoxamine mesylate 1 DESFERAL 3 PA dexmedetomidine hcl in nacl intravenous 1 solution 200-0.9 mcg/50ml-% DEXMEDETOMIDINE HCL IN NACL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE dexmedetomidine hcl in nacl solution 200 1 mcg/50ml intravenous dexmedetomidine hcl in nacl solution 200 1 PA mcg/50ml intravenous

Effective Date: 7/1/2021 138 Drug Name Drug Tier Requirements/Limits dexmedetomidine hcl in nacl solution 400 1 mcg/100ml intravenous dexmedetomidine hcl in nacl solution 400 1 PA mcg/100ml intravenous dexmedetomidine hcl in nacl solution 80 1 mcg/20ml intravenous dexmedetomidine hcl in nacl solution 80 1 PA mcg/20ml intravenous DEXMEDETOMIDINE HCL INTRAVENOUS 3 SOLUTION 1000 MCG/10ML, 400 MCG/4ML dexmedetomidine hcl intravenous solution 200 1 mcg/2ml DEXMEDETOMIDINE HCL-DEXTROSE 3 DIGIFAB 3 diluent for treprostinil 1 DIMERCAPTOPROPANE-SULFONATE 3 PA DOG EPITHELIUM 3 PA DOG FENNEL 3 PA DOJOLVI 3 PA DRECHSLERA 3 PA DUODOTE 3 DUROLANE 2 PA; SP DUST MITE MIXED ALLERGEN EXT 3 PA DYSPORT 3 PA; SP EASIVENT 2 EASTERN COTTONWOOD 3 PA ELCYS 3 PA ENDARI 3 PA ENU PRO3 PLUS 3 PA EPICOCCUM 3 PA EPICOCCUM NIGRUM 3 PA EQUACARE JR 3 PA ergoloid mesylates oral 1 ESSENTIAL CARE JR 3 PA EUFLEXXA 2 PA; SP EXCILON AMD DRAIN SPONGES 3 FEMCAP 3 FIBERSOURCE HN 3 PA FIRDAPSE 3 PA; SP FIRE ANT 3 PA Effective Date: 7/1/2021 139 Drug Name Drug Tier Requirements/Limits FLEXICHAMBER ADULT MASK/SMALL 2 FLEXICHAMBER CHILD MASK/LARGE 2 FLEXICHAMBER CHILD MASK/SMALL 2 flumazenil intravenous 1 fomepizole 1 FORA D40G GLUCOSE/PRESSURE 3 formaldehyde external solution 10 % 1 PA formaldehyde solution 37 % external (rx) 1 formaldehyde solution 37 % external (rx) 1 PA FUSARIUM 3 PA GELCLAIR 3 PA GEL-FLOW 3 PA GELFOAM-JMI POWDER 3 PA GELFOAM-JMI SPONGE 3 PA GEL-ONE 3 PA; SP GELSYN-3 2 PA; SP GENVISC 850 3 PA; SP GERMAN COCKROACH 3 PA GIVLAARI 3 PA; SP glutaraldehyde external 1 GLYTACTIN BETTERMILK 15 3 PA GLYTACTIN BETTERMILK DE-LITE 3 PA GLYTACTIN BUILD 10PE 3 PA GLYTACTIN BUILD 20/20 3 PA GLYTACTIN BUILD 20/20 PKU 3 PA GLYTACTIN BURST 3 PA GLYTACTIN RESTORE 10 3 PA GLYTACTIN RESTORE 5 3 PA GLYTACTIN RESTORE LITE 10 3 PA GLYTACTIN RESTORE LITE 10PE 3 PA GLYTACTIN RTD 10 3 PA GLYTACTIN RTD 15 3 PA GLYTACTIN RTD LITE 15 3 PA GLYTACTIN SWIRL 15PE 3 PA GOLDENROD 3 PA GRASS POLLEN(K-O-R-T-SWT VERN) 3 PA GRASTEK 3 PA; QL HACKBERRY 3 PA

Effective Date: 7/1/2021 140 Drug Name Drug Tier Requirements/Limits HCU EASY 3 PA heparin lock flush 1 heparin sodium lock flush 1 HEPMED 3 PA HOMACTIN AA PLUS 3 PA HONEY BEE VENOM 3 PA HONEY BEE VENOM PROTEIN 3 PA HORSE EPITHELIUM 3 PA HYALGAN 3 PA; SP HYLENEX 3 HYMOVIS 3 PA; SP HYRONAN 3 PA INSPIREASE RESERVOIR BAGS 2 ISOVACTIN AA PLUS 3 PA IV STABILIZER FOR LUMOXITI 3 JOHNSON GRASS 3 PA J-TIP KIT W/VIAL ADAPTERS 3 JUNE GRASS POLLEN STANDARDIZED 3 PA KAPOK 3 PA KERLIX AMD ANTIMICROBIAL 3 KERLIX AMD SUPER SPONGES 3 KETOVIE 3 PA KETOVIE PEPTIDE 3 PA KOCHIA 3 PA LENSCALE 3 PA MACI 3 PA MEADOW FESCUE GRASS POLLEN 3 PA MELALEUCA 3 PA MESQUITE 3 PA methergine 1 QL methylene blue injection 1 PA methylergonovine maleate injection 1 methylergonovine maleate oral 1 QL MICROCHAMBER 2 MINIMED 770G INSULIN PUMP SYS 3 MINIMED MIO ADVANCE INFUSE SET 3 MINIMED PUMP RESERVOIR 3ML 3 MINIMED QUICK SET INF SET 18" 3

Effective Date: 7/1/2021 141 Drug Name Drug Tier Requirements/Limits MINIMED QUICK SET INF SET 23" 3 MINIMED QUICK SET INF SET 32" 3 MINIMED QUICK SET INF SET 43" 3 MINIMED SILHOUETTE INF SET 32" 3 MINIMED SILHOUETTE INF SET 43" 3 MITE (D. FARINAE) 3 PA MITE (D. PTERONYSSINUS) 3 PA MIXED ASPERGILLUS 3 PA MIXED FEATHERS 3 PA MIXED RAGWEED 3 PA MIXED VESPID VENOM PROTEIN INJECTION 3 PA mixed vespid venom protein subcutaneous 1 PA solution reconstituted 1100-1100-1100 mcg MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 PA RECONSTITUTED 120-120-120 MCG mlk f1 1 PA mlk f2 1 PA mlk f3 1 PA MLK F4 3 PA MONOVISC 3 PA; SP MOUNTAIN CEDAR 3 PA MOUSE EPITHELIUM 3 PA MSUD EASY 3 PA MUCOR INJECTION 3 PA MUCOR SUBCUTANEOUS 3 PA MUGWORT 3 PA MYOBLOC 3 PA; SP NEOKE RA LIPOIC 3 NEXAVIR 3 NITHIODOTE 3 NOURISH 3 PA NOZIN NASAL SANITIZER POPSWAB 3 ODACTRA 3 PA; QL OLIVE TREE 3 PA OMNIPOD 5 PACK 3 OMNIPOD DASH 5 PACK PODS 3 ORAFATE 3 PA ORALAIR 3 PA; QL

Effective Date: 7/1/2021 142 Drug Name Drug Tier Requirements/Limits ORALAIR ADULT STARTER PACK 3 PA; QL ORALAIR CHILDRENS STARTER PACK 3 PA; QL ORCHARD GRASS POLLEN 3 PA ORTHOVISC 3 PA; SP OXBRYTA 3 PA; SP; QL PALFORZIA 3 PA; SP PANDA MASK LARGE 2 PANDA MASK MEDIUM 2 PANDA MASK SMALL 2 PARADIGM QUICK-SET 23" 9MM 3 PEDIATRIC PANDA MASK 2 PENICILLIUM NOTATUM INJECTION 3 PA PENICILLIUM NOTATUM SUBCUTANEOUS 3 PA PENTETATE CALCIUM TRISODIUM 3 PENTETATE ZINC TRISODIUM 3 PERENNIAL RYE GRASS POLLEN 3 PA PHENACTIN AA PLUS 3 PA PHENOL INJECTION 3 PA PHEXXI 3 PHOMA EXIGUA 3 PA PHOTREXA VISCOUS 3 PHOTREXA-PHOTREXA VISCOUS KIT 3 PHYSOSTIGMINE SALICYLATE 3 PA PKU EASY 3 PA PKU EASY MICROTABS 3 PA PKU GO 3 PA POCKET SPACER 2 PRAXBIND 3 PA PRECEDEX 3 PA PRIVET 3 PA PRO COMFORT SPACER ADULT 2 PRO COMFORT SPACER CHILD 2 PRO COMFORT SPACER INFANT 2 PROCARE SPACER/ADULT MASK 2 PROCARE SPACER/CHILD MASK 2 PROMACTIN AA PLUS 20PE 3 PA PROTHELIAL 3 PA PROTOPAM CHLORIDE 3

Effective Date: 7/1/2021 143 Drug Name Drug Tier Requirements/Limits PROVAYBLUE 3 QUEEN PALM 3 PA RABBIT EPITHELIUM 3 PA RADIOGARDASE 3 RAGWITEK 3 PA; QL RAPPORT RLS 3 RAPPORT VTD 3 RED MAPLE 3 PA RED MULBERRY 3 PA RED TOP GRASS POLLEN 3 PA RHIZOPUS 3 PA ROUGH MARSH ELDER 3 PA RUSSIAN THISTLE 3 PA RUZURGI 3 PA; SP SACCHAROMYCES CEREVISIAE INJECTION 3 PA SACCHAROMYCES CEREVISIAE 3 PA SUBCUTANEOUS SHAGBARK HICKORY 3 PA SHEEP SORREL 3 PA SHORT RAGWEED POLLEN EXT 3 PA SILHOUETTE 23" INFUSION SET 3 SILHOUETTE 43" INFUSION SET 3 SILHOUETTE INFUSION SET 18" 3 sodium nitrite intravenous 1 sodium saccharin powder 1 SODIUM THIOSULFATE SOLUTION 25 % 3 PA INTRAVENOUS sodium thiosulfate solution 25 % intravenous 1 SORBITOL IRRIGATION SOLUTION 3 % 3 sorbitol irrigation solution 3.3 % 1 sorbitol-mannitol 1 SORREL/DOCK MIX 3 PA SPINY PIGWEED 3 PA STEMPHYLIUM 3 PA STERILE DILUENT FLOLAN PH 12 3 sterile diluent/epoprostenol 1 sterile water for injection intravenous 1 sterile water for injection solution injection 1 sterile water for injection solution injection 1 PA Effective Date: 7/1/2021 144 Drug Name Drug Tier Requirements/Limits SUPARTZ FX 3 PA; SP SURE T INFUSION SET 18"/6MM 3 SURE T INFUSION SET 23"/10MM 3 SURE T INFUSION SET 23"/6MM 3 SURE T INFUSION SET 23"/8MM 3 SURE T INFUSION SET 32"/10MM 3 SURE T INFUSION SET 32"/6MM 3 SURE T INFUSION SET 32"/8MM 3 SWEET GUM 3 PA SWEET VERNAL GRASS POLLEN 3 PA SYNVISC 3 PA; SP SYNVISC ONE 3 PA; SP T: SLIM X2 INS PMP/CONTROL 7.4 3 T:SLIM X2 INS PUMP/CONTROL-IQ 3 T:SLIM X2 INSULIN PMP BASAL IQ 3 T:SLIM X2 INSULIN PMP BASAL6.4 3 T:SLIM X2 INSULIN PMP/RFURB IQ 3 T:SLIM X2/CONTROL-IQ/REFURB 3 TACHOSIL 3 TALL RAGWEED 3 PA TELFA AMD ISLAND DRESSING 3 TELFA AMD NON-ADHERENT 3 THRIVACIN 30 3 PA THRIVACIN DETOX 3 PA TIMOTHY GRASS POLLEN ALLERGEN 3 PA TISSEEL 3 TRICHOPHYTON 3 PA TRICHOPHYTON MENTAGROPHYTES 3 PA TRILURON 3 PA; SP TRIVISC 3 PA; SP TRUE COMFORT PRO ALCOHOL PREP 3 TRUSTEEL INFUSION SET 3 TYLACTIN BUILD 20PE TYR 3 PA TYLACTIN RESTORE 10 3 PA TYLACTIN RESTORE 5PE 3 PA TYLACTIN RTD 15 3 PA TYR EASY 3 PA VARISOFT INFUSION SET 3

Effective Date: 7/1/2021 145 Drug Name Drug Tier Requirements/Limits VENOMIL HONEY BEE VENOM 3 PA VENOMIL MIXED VESPID VENOM 3 PA VENOMIL WASP VENOM 3 PA VENOMIL WHITE FACED HORNET 3 PA VENOMIL YELLOW HORNET VENOM 3 PA VENOMIL YELLOW JACKET VENOM 3 PA VILACTIN AA PLUS 3 PA VILTEPSO 3 PA; SP VISCO-3 3 PA; SP VISTOGARD 3 VITRASE 3 WASP VENOM PROTEIN 3 PA WESTERN JUNIPER 3 PA WHITE BIRCH 3 PA WHITE FACED HORNET VENOM 3 PA WHITE MULBERRY 3 PA WHITE OAK 3 PA WHITE PINE 3 PA WHITE-FACED HORNET VENOM 3 PA WIDE-SEAL DIAPHRAGM 60 3 WIDE-SEAL DIAPHRAGM 65 3 WIDE-SEAL DIAPHRAGM 70 3 WIDE-SEAL DIAPHRAGM 75 3 WIDE-SEAL DIAPHRAGM 80 3 WIDE-SEAL DIAPHRAGM 85 3 WIDE-SEAL DIAPHRAGM 90 3 WIDE-SEAL DIAPHRAGM 95 3 XEOMIN 3 PA; SP XIAFLEX 2 PA; SP YELLOW DOCK 3 PA YELLOW HORNET VENOM PROTEIN 3 PA YELLOW JACKET VENOM PROTEIN 3 PA ZOKINVY 3 PA; SP; QL Ophthalmic Agents - Drugs for Eye Allergy, and Inflammation ACULAR 3 PA ACULAR LS 3 PA ACUVAIL 3 PA

Effective Date: 7/1/2021 146 Drug Name Drug Tier Requirements/Limits ALOCRIL 3 PA ALOMIDE 3 ALREX 3 PA AZASITE 3 azelastine hcl ophthalmic 1 bacitracin ophthalmic 1 BEPREVE 3 ST BESIVANCE 3 BETADINE OPHTHALMIC PREP 3 BLEPH-10 3 PA bromfenac sodium (once-daily) 1 QL BROMSITE 3 ST; QL CILOXAN OPHTHALMIC OINTMENT 3 CILOXAN OPHTHALMIC SOLUTION 3 PA ciprofloxacin hcl ophthalmic 1 cromolyn sodium ophthalmic 1 dexamethasone sodium phosphate ophthalmic 1 DEXTENZA 3 PA; SP DEXYCU 3 diclofenac sodium ophthalmic 1 DUREZOL 3 PA epinastine hcl 1 erythromycin ophthalmic 1 EYSUVIS 3 PA FLAREX 3 fluorometholone 1 flurbiprofen sodium 1 FML 2 FML FORTE 3 FML LIQUIFILM 3 PA gatifloxacin ophthalmic 1 gentak 1 gentamicin sulfate ophthalmic 1 ILEVRO 3 ST; QL ILUVIEN 3 PA; SP INVELTYS 3 ketorolac tromethamine ophthalmic 1 KLARITY-A 3 PA

Effective Date: 7/1/2021 147 Drug Name Drug Tier Requirements/Limits KLARITY-L 3 PA levofloxacin ophthalmic 1 LOTEMAX OPHTHALMIC GEL 3 PA; QL LOTEMAX OPHTHALMIC OINTMENT 3 PA; QL LOTEMAX OPHTHALMIC SUSPENSION 3 PA LOTEMAX SM 3 loteprednol etabonate ophthalmic gel 1 QL loteprednol etabonate ophthalmic suspension 1 MAXIDEX 3 MITOMYCIN INTRAOCULAR 3 PA MITOSOL 3 MOXEZA 2 PA moxifloxacin hcl (2x day) 1 MOXIFLOXACIN HCL INTRAOCULAR 3 PA SOLUTION MOXIFLOXACIN HCL INTRAOCULAR 3 SOLUTION PREFILLED SYRINGE 0.16 % MOXIFLOXACIN HCL INTRAOCULAR SOLUTION PREFILLED SYRINGE 0.3 3 PA MG/0.3ML moxifloxacin hcl ophthalmic solution 1 MOXIFLOXACIN HCL OPHTHALMIC 3 PA SOLUTION PREFILLED SYRINGE NATACYN 2 NEVANAC 3 ST; QL OCUFLOX 3 PA ofloxacin ophthalmic 1 olopatadine hcl ophthalmic 1 OZURDEX 3 PA; SP POVIDONE-IODINE OPHTHALMIC 3 PRED FORTE 3 PA PRED MILD 3 PREDNISOL ACE-MOXIFLOX-BROMFEN 3 PA prednisolone acetate ophthalmic 1 prednisolone acetate p-f 1 PA prednisolone sodium phosphate ophthalmic 1 PREDNISOLON-MOXIFLOX-NEPAFENAC 3 PA PROLENSA 2 QL RETISERT 3 PA; SP

Effective Date: 7/1/2021 148 Drug Name Drug Tier Requirements/Limits sulfacetamide sodium ophthalmic 1 tobramycin ophthalmic 1 TOBREX OPHTHALMIC OINTMENT 3 TOBREX OPHTHALMIC SOLUTION 3 PA TRIESENCE 3 trifluridine 1 UPNEEQ 3 PA VANCOMYCIN HCL OPHTHALMIC 3 VIGAMOX 3 PA YUTIQ 3 PA; SP ZERVIATE 3 ST ZIRGAN 3 ZYMAXID 3 PA Ophthalmic Agents - Drugs for Glaucoma acetazolamide er 1 acetazolamide oral 1 ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % 2 apraclonidine hcl 1 AZOPT 2 PA betaxolol hcl ophthalmic 1 BETIMOL 3 BETOPTIC-S 3 bimatoprost ophthalmic 1 QL brimonidine tartrate ophthalmic 1 BRIMONIDINE-DORZOLAMIDE 3 PA brinzolamide 1 carteolol hcl 1 COMBIGAN 2 COSOPT 3 PA COSOPT PF 3 PA dorzolamide hcl solution 2 % ophthalmic 1 DORZOLAMIDE HCL SOLUTION 2 % 3 OPHTHALMIC dorzolamide hcl-timolol mal 1 dorzolamide hcl-timolol mal pf 1 DURYSTA 3 PA EPINEPHRINE HCL 3 IOPIDINE 3

Effective Date: 7/1/2021 149 Drug Name Drug Tier Requirements/Limits ISOPTO CARPINE 3 PA ISTALOL 3 PA KEVEYIS 3 PA; SP; QL latanoprost ophthalmic 1 LATANOPROST-TIMOLOL MALEATE 3 PA levobunolol hcl 1 LUMIGAN 2 QL methazolamide oral 1 PHOSPHOLINE IODIDE 2 pilocarpine hcl ophthalmic 1 RHOPRESSA 3 QL ROCKLATAN 3 QL SIMBRINZA 2 timolol maleate ophthalmic gel forming solution 1 PA timolol maleate ophthalmic solution 1 timolol maleate pf 1 TIMOLOL-BRIMON-DORZOL-LATANOPR 3 PA TIMOLOL-BRIMONIDINE-DORZOLAMID 3 PA TIMOLOL-DORZOLAMID-LATANOPROST 3 PA TIMOPTIC 3 PA TIMOPTIC OCUDOSE OPHTHALMIC 3 ST SOLUTION 0.25 % TIMOPTIC OCUDOSE OPHTHALMIC 3 PA SOLUTION 0.5 % TRAVATAN Z 3 PA; QL travoprost (bak free) 1 QL TRUSOPT 3 PA VYZULTA 3 ST; QL XELPROS 3 ST; QL ZIOPTAN 3 QL Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ACUICYN 3 PA ak-poly-bac 1 AKTEN 3 ALCAINE 3 PA ALTACAINE 3 altafrin 1 AMVISC 3

Effective Date: 7/1/2021 150 Drug Name Drug Tier Requirements/Limits AMVISC PLUS 3 atropine sulfate ophthalmic ointment 1 ATROPINE SULFATE OPHTHALMIC 3 PA SOLUTION 0.01 % atropine sulfate ophthalmic solution 1 % 1 AVENOVA 3 PA bacitracin-polymyxin b ophthalmic 1 bacitra-neomycin-polymyxin-hc 1 balanced salt 1 BEOVU 3 PA; SP BEVACIZUMAB 3 SP BIOLON 3 BLEPHAMIDE 3 BLEPHAMIDE S.O.P. 3 BSS 3 bss plus solution intraocular 1 BSS PLUS SOLUTION INTRAOCULAR 3 CEQUA 3 PA CHONDROITIN SULFATE OPHTHALMIC 3 PA CYCLOGYL 3 PA CYCLOMYDRIL 3 cyclopentolate hcl ophthalmic 1 CYCLOSPORINE IN KLARITY 3 PA CYSTADROPS 3 PA; SP; QL CYSTARAN 3 PA; SP; QL DEXAMETHASONE-MOXIFLOXACIN 3 PA DEXAMETH-MOXIFLOX-KETOROLAC 3 PA EYLEA 3 PA; SP GELFILM OPHTHALMIC 3 PA HEALON 3 HEALON GV 3 HEALON PRO 3 PA HEALON5 3 HEALON5 PRO 3 PA homatropaire 1 HYALURONIDASE (INTRAOCULAR) 3 HYPOCYN 3 PA ISOPTO ATROPINE 3

Effective Date: 7/1/2021 151 Drug Name Drug Tier Requirements/Limits LACRISERT 3 LASTACAFT 3 ST LIDOCAINE-EPINEPHRINE INTRAOCULAR 3 PA LIDOCAINE-PHENYLEPHRINE 3 PA LIDOCAINE-PHENYLEPHRINE-BSS 3 PA LUCENTIS 2 PA; SP LUXTURNA 3 PA; SP MAXITROL 3 PA MEMBRANEBLUE 3 MIOCHOL-E 3 MIOSTAT 3 MOXIFLOXACIN HCL-BSS 3 PA neomycin-bacitracin zn-polymyx 1 neomycin-polymyxin-dexameth ophthalmic 1 ointment neomycin-polymyxin-dexameth ophthalmic 1 suspension 3.5-10000-0.1 neomycin-polymyxin-gramicidin 1 neomycin-polymyxin-hc ophthalmic 1 neo-polycin 1 neo-polycin hc 1 OMIDRIA 3 OXERVATE 3 PA; SP; QL PHENYLEPHRINE HCL INTRAOCULAR 3 phenylephrine hcl ophthalmic 1 polycin 1 polymyxin b-trimethoprim 1 POLYTRIM 3 PA PRED-G 3 PRED-G S.O.P. 3 PREDNISOLONE ACETATE-NEPAFENAC 3 PA PREDNISOLONE ACET-MOXIFLOXACIN 3 PA PREDNISOLONE-BROMFENAC 3 PA PREDNISOLONE-GATIFLOXACIN 3 PA PREDNISOLONE-MOXIFLOXACIN 3 PA PREDNISOLON-GATIFLOX-BROMFENAC 3 PA PREDNISOLON-MOXIFLOX-BROMFENAC 3 PA proparacaine hcl ophthalmic 1 PROVISC 3 Effective Date: 7/1/2021 152 Drug Name Drug Tier Requirements/Limits RESTASIS 2 PA RESTASIS MULTIDOSE 2 PA sulfacetamide-prednisolone ophthalmic solution 1 tetracaine hcl ophthalmic 1 TOBRADEX OPHTHALMIC OINTMENT 3 TOBRADEX ST 3 tobramycin-dexamethasone 1 TRIAMCINOLONE-MOXIFLOXACIN 3 PA TROPICAMIDE-CYCLOPENTOLATE-PE 3 SOLUTION 1-1-2.5 % OPHTHALMIC TROPICAMIDE-CYCLOPENTOLATE-PE 3 PA SOLUTION 1-1-2.5 % OPHTHALMIC TROPICAMIDE-PHENYLEPHRINE 3 PA TROPIC-CYCLOPENT-PE-KETOROLAC 3 PA TROPIC-CYCLOP-PE-KETO-PROPAR 3 PA TROPIC-PROPARACA-PE-KETOROLAC 3 PA VISIONBLUE 3 VISUDYNE 3 SP XIIDRA 2 PA ZYLET 3 Otic Agents - Drugs for Ear Conditions acetic acid otic 1 CETRAXAL 3 PA CIPRO HC 3 ciprofloxacin hcl otic 1 ST ciprofloxacin-dexamethasone 1 CIPROFLOXACIN-FLUOCINOLONE PF 3 PA CORTISPORIN-TC 3 DERMOTIC 3 PA flac 1 fluocinolone acetonide otic 1 hydrocortisone-acetic acid 1 neomycin-polymyxin-hc otic 1 ofloxacin otic 1 OTIPRIO 3 PA OTOVEL 3 PA PRAMOTIC 3

Effective Date: 7/1/2021 153 Drug Name Drug Tier Requirements/Limits Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ADRENALIN NASAL 3 PA azelastine hcl nasal 1 QL azelastine-fluticasone 1 QL BECONASE AQ 3 QL benzonatate 1 BROMPHENIRAMINE MALEATE 3 PA INTRAMUSCULAR carbinoxamine maleate oral solution 1 carbinoxamine maleate oral tablet 4 mg 1 carbinoxamine maleate oral tablet 6 mg 1 PA cetirizine hcl oral solution 1 CINQAIR 3 PA; SP CLARINEX 3 PA CLARINEX-D 12 HOUR 3 PA clemastine fumarate oral tablet 2.68 mg 1 CUROSURF 3 hcl oral 1 desloratadine 1 dexchlorpheniramine maleate oral 1 PA DI-PHEN 3 PA diphen oral elixir 1 diphenhydramine hcl injection 1 diphenhydramine hcl oral elixir 1 DYMISTA 2 PA; QL FASENRA 2 PA; SP FASENRA PEN 2 PA; SP flunisolide nasal 1 QL fluticasone propionate nasal 1 GILPHEX TR 3 PA HYCODAN 3 PA; QL hydrocodone polst-chlorphen polst er susp 1 PA; QL hydrocodone-homatropine 1 PA; QL hydromet 1 PA; QL HYPERSAL 3 INFASURF 3 ipratropium bromide nasal 1 KARBINAL ER 3 PA Effective Date: 7/1/2021 154 Drug Name Drug Tier Requirements/Limits levocetirizine dihydrochloride oral 1 mometasone furoate nasal 1 QL NEOTUSS PLUS 3 PA NUCALA 2 PA; SP; QL olopatadine hcl nasal 1 QL OMNARIS 3 QL PATANASE 3 PA; QL PHENERGAN 3 PA promethazine hcl injection 1 promethazine hcl oral 1 promethazine hcl rectal 1 promethazine vc 1 promethazine vc/codeine 1 PA; QL promethazine-codeine 1 PA; QL promethazine-dm 1 promethazine-phenyleph-codeine 1 PA; QL promethazine-phenylephrine 1 promethegan 1 -bromphen-dm 1 QNASL 3 QL QNASL CHILDRENS 3 QL QUZYTTIR 3 PA RYCLORA 3 PA ryvent 1 SINUVA 3 PA sodium chloride inhalation 1 SSKI 3 PA SURVANTA 3 TESSALON PERLES 3 PA TUSSICAPS 3 PA; QL TUXARIN ER 3 PA; QL TUZISTRA XR 3 PA; QL XHANCE 3 ST; QL XOLAIR 2 PA; SP ZETONNA 3 QL Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions ACCOLATE 3 PA Effective Date: 7/1/2021 155 Drug Name Drug Tier Requirements/Limits acetylcysteine inhalation 1 ADRENALIN INJECTION SOLUTION 1 MG/ML 3 ADRENALIN INJECTION SOLUTION 30 3 PA MG/30ML ADVAIR DISKUS 2 PA; QL ADVAIR HFA 2 QL ADYPHREN 3 PA ADYPHREN AMP 3 PA ADYPHREN AMP II 3 PA ADYPHREN II 3 PA AIRDUO DIGIHALER 3 ST; QL AIRDUO RESPICLICK 113/14 3 ST; QL AIRDUO RESPICLICK 232/14 3 ST; QL AIRDUO RESPICLICK 55/14 3 ST; QL albuterol sulfate er 1 albuterol sulfate hfa aerosol solution 108 (90 1 QL base) mcg/act inhalation ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT 3 ST; M; QL INHALATION albuterol sulfate inhalation nebulization solution 1 QL (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate inhalation nebulization solution 1 2.5 mg/0.5ml ALBUTEROL SULFATE NEBULIZATION 2 PA SOLUTION (5 MG/ML) 0.5% INHALATION albuterol sulfate nebulization solution (5 mg/ml) 1 0.5% inhalation albuterol sulfate oral 1 ALVESCO 3 ST; QL aminophylline intravenous 1 ANORO ELLIPTA 2 QL ARALAST NP 3 PA; SP ARMONAIR DIGIHALER 3 ST; QL ARNUITY ELLIPTA 2 QL ASMANEX (120 METERED DOSES) 3 ST; QL ASMANEX (14 METERED DOSES) 3 ST; QL ASMANEX (30 METERED DOSES) 3 ST; QL ASMANEX (60 METERED DOSES) 3 ST; QL ASMANEX (7 METERED DOSES) 3 ST; QL

Effective Date: 7/1/2021 156 Drug Name Drug Tier Requirements/Limits ASMANEX HFA 3 ST; QL ATROVENT HFA 3 QL AUVI-Q INJECTION SOLUTION AUTO- 3 QL INJECTOR 0.1 MG/0.1ML AUVI-Q INJECTION SOLUTION AUTO- 3 ST INJECTOR 0.15 MG/0.15ML, 0.3 MG/0.3ML BEVESPI AEROSPHERE 3 ST; QL BREO ELLIPTA 2 QL BREZTRI AEROSPHERE 2 QL BROVANA 3 QL budesonide inhalation 1 QL BUDESONIDE-FORMOTEROL FUMARATE 3 PA; M; QL COMBIVENT RESPIMAT 2 QL cromolyn sodium inhalation 1 DALIRESP 3 PA DUAKLIR PRESSAIR 3 ST; QL DULERA 3 ST; QL ELIXOPHYLLIN 2 epinephrine (anaphylaxis) 1 epinephrine injection solution auto-injector 1 EPINEPHRINE PROFESSIONAL 3 PA EPINEPHRINESNAP-EMS 3 PA EPINEPHRINESNAP-V 3 PA EPIPEN 2-PAK 3 PA EPIPEN JR 2-PAK 3 PA EPISNAP 3 PA ESBRIET 3 PA; SP FLOVENT DISKUS 2 QL FLOVENT HFA 2 QL fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 1 QL mcg/dose, 500-50 mcg/dose FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 1 QL 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT GLASSIA 3 PA; SP INCRUSE ELLIPTA 3 ST; QL ipratropium bromide inhalation 1 QL ipratropium-albuterol 1 QL

Effective Date: 7/1/2021 157 Drug Name Drug Tier Requirements/Limits isoproterenol hcl injection 1 ISOPROTERENOL-SODIUM CHLORIDE 3 PA ISUPREL 3 PA levalbuterol hcl inhalation 1 QL LEVALBUTEROL HFA INHALATION AEROSOL 3 ST; M; QL 45 MCG/ACT LONHALA MAGNAIR REFILL KIT 3 QL LONHALA MAGNAIR STARTER KIT 3 QL montelukast sodium oral 1 OFEV 3 PA; SP PERFOROMIST 3 QL PROAIR DIGIHALER 3 ST; QL PROAIR HFA 2 QL PROAIR RESPICLICK 2 QL PROLASTIN-C 3 PA; SP PROVENTIL HFA 3 ST; QL PULMICORT FLEXHALER 2 QL QVAR REDIHALER 2 QL SCLEROSOL INTRAPLEURAL 3 SEEBRI NEOHALER 3 ST; QL SEREVENT DISKUS 2 QL SPIRIVA HANDIHALER 2 QL SPIRIVA RESPIMAT 2 QL STERILE TALC POWDER 3 STERITALC 3 STIOLTO RESPIMAT 2 QL STRIVERDI RESPIMAT 2 QL SYMBICORT 2 QL SYMJEPI 3 terbutaline sulfate injection 1 terbutaline sulfate oral 1 THEO-24 3 theophylline 1 theophylline er 1 theophylline in d5w 1 TRELEGY ELLIPTA 2 QL TUDORZA PRESSAIR 3 ST; QL UTIBRON NEOHALER 3 ST; QL

Effective Date: 7/1/2021 158 Drug Name Drug Tier Requirements/Limits VENTOLIN HFA 2 QL wixela inhub 1 QL XOPENEX NEB 3 PA; QL XOPENEX CONCENTRATE 3 PA; QL XOPENEX HFA 3 ST; QL YUPELRI 3 QL zafirlukast 1 ZEMAIRA 3 PA; SP zileuton er 1 ST ZYFLO 3 ST Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis BETHKIS 3 PA; SP; QL CAYSTON 3 PA; SP; QL KALYDECO 3 PA; SP KITABIS PAK 3 ST; SP; QL ORKAMBI 3 PA; SP; QL PULMOZYME 2 PA; SP SYMDEKO 3 PA; SP; QL TOBI PODHALER 3 SP; QL tobramycin inhalation nebulization solution 300 1 SP; QL mg/4ml tobramycin nebulization solution 300 mg/5ml 1 ST; SP; QL inhalation TOBRAMYCIN NEBULIZATION SOLUTION 3 ST; M; SP; QL 300 MG/5ML INHALATION TRIKAFTA 3 PA; SP; QL Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ADEMPAS 2 PA; SP; QL alyq 1 PA; SP; QL ambrisentan 1 PA; SP; QL 1 PA; SP; QL epoprostenol sodium 1 PA; SP FLOLAN 3 PA; SP OPSUMIT 2 PA; SP; QL ORENITRAM 3 PA; SP REMODULIN 3 PA; SP REVATIO INTRAVENOUS 3 PA; SP

Effective Date: 7/1/2021 159 Drug Name Drug Tier Requirements/Limits sildenafil citrate intravenous 1 PA; SP sildenafil citrate oral suspension reconstituted 1 PA; SP; QL sildenafil citrate oral tablet 20 mg 1 PA; SP; QL tadalafil (pah) 1 PA; SP; QL TRACLEER 32 MG 3 PA; SP; QL treprostinil 1 PA; SP TYVASO 3 PA; SP; QL TYVASO REFILL 3 PA; SP; QL TYVASO STARTER 3 PA; SP; QL UPTRAVI 3 PA; SP; QL VELETRI 3 PA; SP VENTAVIS 3 PA; SP; QL Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm baclofen oral 1 carisoprodol oral 1 chlorzoxazone oral tablet 250 mg, 375 mg, 750 1 PA mg chlorzoxazone oral tablet 500 mg 1 cyclobenzaprine hcl er 1 PA cyclobenzaprine hcl oral tablet 5 mg 1 cyclobenzaprine hcl oral tablet 7.5 mg 1 PA cyclobenzaprine hcl tablet 10 mg oral 1 cyclobenzaprine hcl tablet 10 mg oral 1 PA DANTRIUM 3 PA dantrolene sodium intravenous 1 dantrolene sodium oral 1 METAXALL CP 3 PA metaxalone 1 methocarbamol injection 1 methocarbamol oral 1 NORGESIC FORTE 3 PA orphenadrine citrate er 1 orphenadrine citrate injection 1 orphenadrine-asa-caffeine 1 PA ORPHENGESIC FORTE 3 PA; M OZOBAX 3 ST revonto 1 ROBAXIN 3 PA Effective Date: 7/1/2021 160 Drug Name Drug Tier Requirements/Limits ROBAXIN-750 3 PA RYANODEX 3 SKELAXIN 3 PA tizanidine hcl oral 1 ZANAFLEX 3 PA Sleep Disorder Agents AMYTAL SODIUM 3 PA armodafinil 1 PA; QL BELSOMRA 3 ST; QL DAYVIGO 3 ST; QL doxepin hcl oral tablet 1 QL EDLUAR 3 ST; QL eszopiclone 1 QL flurazepam hcl 1 PA; QL HETLIOZ 3 PA; SP; QL modafinil 1 PA; QL ramelteon 1 QL ROZEREM 3 PA; QL SILENOR 3 PA; QL SUNOSI 2 PA; QL temazepam 1 QL WAKIX 3 PA; SP; QL XYREM 3 PA; SP; QL XYWAV 3 PA; SP; QL zaleplon 1 QL zolpidem tartrate er 1 QL zolpidem tartrate oral 1 QL zolpidem tartrate sublingual 1 PA; QL ZOLPIMIST 3 ST; QL

Effective Date: 7/1/2021 161 Index of Drugs 1ST MEDX-PATCH/ acetaminophen-codeine...... 1 ADAPALENE-BENZOYL PER- LIDOCAINE...... 9 acetaminophen-codeine #2...... 1 CLINDAMY...... 72 7T LIDO...... 9 acetaminophen-codeine #3...... 1 ADAPALENE-BENZOYL PER- abacavir sulfate...... 47 acetaminophen-codeine #4...... 1 NIACINAM...... 72 abacavir sulfate-lamivudine...... 47 acetazolamide...... 149 adapalene-benzoyl peroxide.....72 abacavir-lamivudine- acetazolamide er...... 149 ADAPALENE-BENZOYL zidovudine...... 47 acetazolamide sodium...... 54 PEROXIDE...... 72 ABELCET...... 29 acetic acid...... 111, 153 ADASUVE...... 46 ABILIFY MAINTENA...... 46 acetylcysteine...... 136, 156 adc/f (0.5mg/ml)...... 95 ABILIFY MYCITE...... 46 ACIOXIAY...... 72 ADCETRIS...... 34 abiraterone acetate...... 34 ACIPHEX SPRINKLE...... 105 adefovir dipivoxil...... 47 ABRAXANE...... 34 acitretin...... 72 ADEMPAS...... 159 ABSORICA...... 72 ACREMONIUM...... 136 ADENOCARD...... 54 ABSORICA LD...... 72 ACTEMRA...... 128 adenosine...... 54 ACACIA...... 136 ACTEMRA ACTPEN...... 128 ADHANSIA XR...... 66 acamprosate calcium...... 14 ACTHAR...... 118 ADIPEX-P...... 68 ACANYA...... 72 ACTHIB...... 132 ADLYXIN...... 86 acarbose...... 86 ACTIMMUNE...... 128 ADLYXIN STARTER PACK...... 86 ACCOLATE...... 155 ACTIQ...... 1 ADMELOG...... 92 ACCUCAINE...... 9 ACTIVASE...... 22 ADMELOG SOLOSTAR...... 92 ACCU-CHEK AVIVA DEVICE...88 ACTIVE FE...... 94 ADRENALIN...... 154, 156 ACCU-CHEK AVIVA PLUS ACTIVE INJECTION BLM-1... 113 adriamycin...... 34 KIT W/DEVICE...... 88 ACTIVE INJECTION BM...... 113 ADVAIR DISKUS...... 156 ACCU-CHEK COMPACT ACTIVE INJECTION D...... 113 ADVAIR HFA...... 156 PLUS CONTROL...... 88 ACTIVE INJECTION DL...... 113 ADVANCED ALLERGY ACCU-CHEK COMPACT ACTIVE INJECTION DLM...... 113 COLLECTION...... 72 PLUS TEST STRIPS...... 88 ACTIVE INJECTION KET-L...... 6 ADVATE...... 51 ACCU-CHEK FASTCLIX ACTIVE INJECTION ADYNOVATE...... 51 LANCET KIT...... 88 KETMARC-L...... 6 ADYPHREN...... 156 ACCU-CHEK GUIDE ACTIVE INJECTION KIT L..... 113 ADYPHREN AMP...... 156 CONTROL...... 88 ACTIVE INJECTION KL-3...... 113 ADYPHREN AMP II...... 156 ACCU-CHEK GUIDE KIT ACTIVE INJECTION KM...... 113 ADYPHREN II...... 156 W/DEVICE...... 88 ACTIVE INJECTION LM-2...... 9 ADZENYS ER...... 66 ACCU-CHEK GUIDE TEST ACTIVE INJECTION LM-DEP- ADZENYS XR-ODT...... 66 STRIPS...... 88 2...... 113 AEMCOLO...... 14 ACCU-CHEK SMARTVIEW ACTIVE INJECTION M-1...... 113 AFINITOR...... 34 CONTROL...... 88 ACTIVELLA...... 120 AFINITOR DISPERZ...... 34 ACCU-CHEK SMARTVIEW ACTONEL...... 135 afirmelle...... 120 TEST STRIPS...... 88 ACTOPLUS MET...... 86 AFLURIA QUADRIVALENT....132 ACCU-CHEK SOFTCLIX ACUICYN...... 150 AFREZZA...... 92 LANCET DEVICE KIT...... 88 ACULAR...... 146 AFSTYLA...... 51 ACCU-CHEK ULTRAFLEX ACULAR LS...... 146 AGAMATRIX CONTROL INF SET...... 136 ACUVAIL...... 146 LEVEL 2...... 88 ACCUPRIL...... 54 acyclovir...... 47 AGAMATRIX CONTROL ACCURETIC...... 54 acyclovir sodium...... 47 LEVEL 4...... 88 accutane...... 72 ACZONE...... 72 AGAMATRIX PRESTO TEST...88 ACD FORMULA A...... 22 ADACEL...... 132 AGGRASTAT...... 45 ACD-A NOCLOT-50...... 22 ADAINZDE...... 72 AGONEAZE...... 9 acebutolol hcl...... 54 ADAINZOXIA...... 72 AGRYLIN...... 51 ACETADOTE...... 136 ADAKVEO...... 136 AIMOVIG...... 32 acetaminophen...... 1 adapalene...... 72 AIRDUO DIGIHALER...... 156 ACETAMINOPHEN...... 1 ADAPALENE...... 72 AIRDUO RESPICLICK 113/14 156

162 AIRDUO RESPICLICK 232/14 156 ALPHAGAN P...... 149 aminoreliefrms...... 95 AIRDUO RESPICLICK 55/14..156 ALPHA-LIPOIC ACID...... 136 AMINOSYN II...... 95 AJOVY...... 32 ALPHANATE...... 51 AMINOSYN-PF...... 95 AKLIEF...... 72 ALPHANINE SD...... 52 amiodarone hcl...... 54 AKOVAZ...... 54 alprazolam...... 50 AMIODARONE HCL IN ak-poly-bac...... 150 alprazolam er...... 50 DEXTROSE...... 54 AKTEN...... 150 alprazolam intensol...... 50 AMITIZA...... 106 AKYNZEO...... 28 alprazolam xr...... 50 amitriptyline hcl...... 26 ALA SCALP...... 72 ALPROLIX...... 52 amlodipine besylate...... 54 ala-cort...... 72 alprostadil...... 54 amlodipine besylate-benazepril albendazole...... 43 ALREX...... 147 hcl...... 54 albuterol sulfate...... 156 ALTABAX...... 14 amlodipine besylate-valsartan.. 54 ALBUTEROL SULFATE...... 156 ALTACAINE...... 150 amlodipine-atorvastatin...... 54 albuterol sulfate er...... 156 ALTACE...... 54 amlodipine-olmesartan...... 54 albuterol sulfate hfa...... 156 altafrin...... 150 amlodipine-valsartan-hctz...... 54 ALBUTEROL SULFATE HFA. 156 altavera...... 120 ammonium lactate...... 72 ALCAINE...... 150 ALTERNARIA...... 136 AMMONUL...... 110 alclometasone dipropionate...... 72 ALTOPREV...... 54 amnesteem...... 73 ALCOHOL PREP PADS... 72, 136 ALTRENO...... 72 amoxapine...... 26 ALDACTAZIDE...... 54 ALUNBRIG...... 34 amoxicill-clarithro-lansopraz... 106 ALDACTONE...... 54 ALVESCO...... 156 amoxicillin...... 15 ALDER...... 136 alvimopan...... 106 amoxicillin-potassium ALDURAZYME...... 110 alyacen 1/35...... 120 clavulanate...... 15 ALECENSA...... 34 alyacen 7/7/7...... 120 amoxicillin-potassium alendronate sodium...... 135 alyq...... 159 clavulanate er...... 15 ALEVAMAX...... 72 amabelz...... 120 AMPHADASE...... 136 ALEVICYN ANTIPRURITIC...... 72 amantadine hcl...... 44 AMPHETAMINE ER...... 66 ALEVICYN ANTIPRURITIC AMARYL...... 86 amphetamine sulfate...... 66 SG...... 72 AMBISOME...... 29 amphetamine- ALEVICYN DERMAL SPRAY... 72 ambrisentan...... 159 dextroamphetamine...... 66 alfentanil hcl...... 1 amcinonide...... 72 amphetamine- ALFERON N...... 128 AMD FOAM DRESSING...... 136 dextroamphetamine er...... 66 alfuzosin hcl er...... 113 AMD FOAM DRESSING ampicillin...... 15 ALIMTA...... 34 TOPSHEET...... 136 ampicillin sodium...... 15 ALINIA...... 43 AMELUZ...... 72 ampicillin-sulbactam sodium..... 15 ALIQOPA...... 34 AMERGE...... 32 AMPYRA...... 67 aliskiren fumarate...... 54 AMERICAN BEECH...... 136 AMVISC...... 150 ALKERAN...... 34 AMERICAN COCKROACH.....136 AMVISC PLUS...... 151 ALKINDI SPRINKLE...... 113 AMERICAN ELM...... 136 AMYTAL SODIUM...... 161 allopurinol...... 31 amethia...... 120 AMZEEQ...... 73 allopurinol sodium...... 31 amethia lo...... 120 ANACAINE...... 73 ALLZITAL...... 1 amethyst...... 120 anagrelide hcl...... 52 almotriptan malate...... 32 AMICAR...... 52 ana-lex...... 134 ALOCRIL...... 147 amikacin sulfate...... 14 ANASCORP...... 136 ALOGLIPTIN BENZOATE...... 86 amiloride hcl...... 54 ANASPAZ...... 106 ALOGLIPTIN-METFORMIN amiloride-hydrochlorothiazide... 54 anastrozole...... 34 HCL...... 86 AMINO ACID...... 95 ANAVIP...... 136 ALOGLIPTIN-PIOGLITAZONE. 86 aminoacetic acid...... 111 ANCOBON...... 29 ALOMIDE...... 147 aminoamrms...... 95 ANDEXXA...... 136 ALOPRIM...... 31 aminocaproic acid...... 52 ANDRODERM...... 117 ALORA...... 120 aminophylline...... 156 ANDROGEL...... 117 alosetron hcl...... 106 AMINOPMRMS...... 136 ANECTINE...... 68 ALOXI...... 28 AMINOPROTECT...... 95 ANGELIQ...... 121

163 ANGIOMAX...... 22 ARMONAIR DIGIHALER...... 156 ATOPICLAIR...... 73 ANJESO...... 6 ARMOUR THYROID...... 128 atorvastatin calcium...... 55 ANNOVERA...... 121 ARNUITY ELLIPTA...... 156 atovaquone...... 43 ANODYNE LPT...... 9 AROMASIN...... 35 atovaquone-proguanil hcl...... 43 ANORO ELLIPTA...... 156 ARRANON...... 35 atracurium besylate...... 68 ANTARA...... 55 arsenic trioxide...... 35 ATRALIN...... 73 ANTICOAGULANT SODIUM ARTHROTEC...... 6 ATRIPLA...... 47 CITRATE...... 22 ARTICADENT DENTAL...... 9 ATROPEN...... 106 ANTIVENIN LATRODECTUS ARTISS...... 137 atropine sulfate...... 106, 107, 151 MACTANS...... 136 ARZERRA...... 35 ATROPINE SULFATE.... 107, 151 ANTIVENIN MICRURUS ARZOL SILVER NIT ATROVENT HFA...... 157 FULVIUS...... 137 APPLICATORS...... 73 AUBAGIO...... 67 ANUSOL-HC...... 134 ASCENIV...... 128 aubra...... 121 ANZEMET...... 28 ASCLERA...... 55 aubra eq...... 121 APADAZ...... 1 ascomp-codeine...... 1 AUGMENTIN...... 15 apap-caff-dihydrocodeine...... 1 ASCOR...... 95 AUGMENTIN ES-600...... 15 APEXICON E...... 73 ASCORBIC ACID...... 95 AUREOBASIDIUM...... 137 APIDRA SOLOSTAR...... 92 ascorbic acid...... 95 AUREOBASIDIUM APIDRA VIAL...... 92 asenapine maleate...... 46 PULLULANS...... 137 APLENZIN...... 26 ashlyna...... 121 aurovela 1.5/30...... 121 APOKYN...... 44 asilnasalrms...... 137 aurovela 1/20...... 121 APP SLIM RMS...... 137 ASMANEX (120 METERED aurovela 24 fe...... 121 apraclonidine hcl...... 149 DOSES)...... 156 aurovela fe 1.5/30...... 121 aprepitant...... 28 ASMANEX (14 METERED aurovela fe 1/20...... 121 apri...... 121 DOSES)...... 156 AURYXIA...... 111 APRISO...... 134 ASMANEX (30 METERED AUSTEDO...... 68 APRIZIO PAK...... 9 DOSES)...... 156 AUSTRALIAN PINE...... 137 APRIZIO PAK II...... 9 ASMANEX (60 METERED AUTOLET LANCING DEVICE.. 88 APTENSIO XR...... 66 DOSES)...... 156 AUTOSOFT 30 INFUSION APTIOM...... 23 ASMANEX (7 METERED SET...... 137 APTIVUS...... 47 DOSES)...... 156 AUTOSOFT 90 INFUSION AQUACEL AG BURN...... 73 ASMANEX HFA...... 157 SET...... 137 AQUASOL A...... 95 ASPARLAS...... 35 AUTOSOFT XC INFUSION ARAKODA...... 43 ASPERGILLUS FUMIGATUS.137 SET...... 137 ARALAST NP...... 156 aspirin-dipyridamole er...... 45 AUVI-Q...... 157 aranelle...... 121 ASPIRIN-OMEPRAZOLE...... 45 AVALIDE...... 55 ARANESP (ALBUMIN FREE)...52 ASSURE PLATINUM...... 88 AVANDIA...... 86 ARAZLO...... 73 ASTAGRAF XL...... 128 AVAPRO...... 55 ARCALYST...... 128 ASTERO...... 9 AVAR CLEANSER...... 73 ARESTIN...... 70 ASTRAZENECA COVID-19 AVAR LS CLEANSER...... 73 argatroban...... 22 VACCINE...... 132 AVAR-E EMOLLIENT...... 73 argatroban in sodium chloride...22 ASTRINGYN...... 52 AVAR-E GREEN...... 73 ARGININE HCL...... 95 ATABEX OB...... 95 AVAR-E LS...... 73 argyle sterile saline...... 95 ATACAND...... 55 AVASTIN...... 35 argyle sterile water...... 95 ATACAND HCT...... 55 AVEED...... 117 ARICEPT...... 25 atazanavir sulfate...... 47 AVEIDAOXIA...... 73 ARIKAYCE...... 15 ATELVIA...... 135 AVENOVA...... 151 aripiprazole...... 46 atenolol...... 55 aviane...... 121 ARISTADA...... 46 atenolol-chlorthalidone...... 55 avidoxy...... 15 ARISTADA INITIO...... 46 ATGAM...... 128 AVIDOXY DK...... 15 ARIXTRA...... 22 ATIVAN...... 50 AVITA...... 73 ARIZONA CYPRESS...... 137 atomoxetine hcl...... 66 AVODART...... 113 armodafinil...... 161 ATOPADERM...... 73 AVONEX PEN...... 67

164 AVONEX PREFILLED...... 67 BAQSIMI ONE PACK...... 92 BENZOYL PEROXIDE AVSOLA...... 129 BAQSIMI TWO PACK...... 92 FORTE- HC...... 73 AVYCAZ...... 15 BARACLUDE...... 47 benzoyl peroxide-erythromycin. 73 AYGESTIN...... 121 BARHEMSYS...... 28 benzphetamine hcl...... 68 ayuna...... 121 BASAGLAR KWIKPEN...... 92 benztropine mesylate...... 44 AYVAKIT...... 35 BAVENCIO...... 35 BEOVU...... 151 azacitidine...... 35 BAXDELA...... 15 BEPREVE...... 147 AZACTAM...... 15 BAYBERRY (WAX MYRTLE). 137 BERINERT...... 129 AZASAN...... 129 BCG VACCINE...... 132 BERMUDA GRASS...... 137 AZASITE...... 147 BD AUTOSHIELD DUO PEN BESER...... 73 azathioprine...... 129 NEEDLES...... 92 beser...... 74 azathioprine sodium...... 129 BD ULTRA-FINE INSULIN BESIVANCE...... 147 AZEDRA DOSIMETRIC...... 35 SYRINGES...... 92 BESPONSA...... 35 AZEDRA THERAPEUTIC...... 35 BD ULTRA-FINE PEN BETA 1 KIT...... 113 azelaic acid...... 73 NEEDLES...... 92 BETADINE OPHTHALMIC AZELAIC ACID-NIACINAMIDE.73 BD VEO INSULIN SYR U/F PREP...... 147 azelastine hcl...... 147, 154 1/2UNIT...... 92 BETALIDO...... 114 azelastine-fluticasone...... 154 BECONASE AQ...... 154 BETALOAN SUIK...... 114 AZELEX...... 73 bekyree...... 121 BETAMETHASONE COMBO. 114 AZESCHEW BELBUCA...... 1 betamethasone dipropionate.... 74 PRENATAL/POSTNATAL...... 95 BELEODAQ...... 35 betamethasone dipropionate AZESCO...... 95 belladonna alkaloids-opium.... 107 aug...... 74 AZILECT...... 44 BELRAPZO...... 35 BETAMETHASONE DIPROP- azithromycin...... 15 BELSOMRA...... 161 MINOXIDIL...... 74 AZOPT...... 149 benazepril hcl...... 55 BETAMETHASONE SOD aztreonam...... 15 benazepril-hydrochlorothiazide. 55 PHOS & ACET...... 114 AZULFIDINE...... 134 BENDEKA...... 35 betamethasone sod phos & AZULFIDINE EN-TABS...... 134 BENEFIX...... 52 acet...... 114 azurette...... 121 BENLYSTA...... 129 BETAMETHASONE SODIUM B-12 COMPLIANCE BENSAL HP...... 73 PHOSPHATE...... 114 INJECTION...... 95 BENTYL...... 107 betamethasone valerate...... 74 bac...... 1 BENZ PER-CLIND-NIACIN- BETAPACE AF...... 55 bacitracin...... 15, 147 TRETIN...... 73 BETASERON...... 67 bacitracin-polymyxin b...... 151 BENZAC AC WASH...... 73 betaxolol hcl...... 55, 149 bacitra-neomycin-polymyxin-hc benzalkonium chloride...... 15 bethanechol chloride...... 111 ...... 151 BENZAMYCIN...... 73 BETHKIS...... 159 baclofen...... 160 BENZEPRO...... 73 BETIMOL...... 149 BACTERIOSTATIC benzepro...... 73 BETOPTIC-S...... 149 WATER(BENZ ALC)...... 137 BENZEPRO CREAMY WASH.. 73 BEVACIZUMAB...... 151 BACTRIM...... 15 BENZEPRO FOAMING BEVESPI AEROSPHERE...... 157 BACTRIM DS...... 15 CLOTHS...... 73 bexarotene...... 35 BAFIERTAM...... 67 BENZEPRO SHORT BEXSERO...... 132 BAHIA...... 137 CONTACT...... 73 bicalutamide...... 35 bal in oil...... 137 BENZHYDROCODONE- BICILLIN C-R...... 15 balanced salt...... 151 ACETAMINOPHEN...... 1 BICILLIN C-R 900/300...... 15 BALCOLTRA...... 121 BENZNIDAZOLE...... 43 BICILLIN L-A...... 15 BALD CYPRESS...... 137 BENZO-LIDOCAINE- BICNU...... 35 balsalazide disodium...... 134 TETRACAINE...... 9 BIDIL...... 55 balsam peru-castor oil...... 73 benzonatate...... 154 BIJUVA...... 121 BALVERSA...... 35 BENZOYL PEROX- BIKTARVY...... 47 balziva...... 121 HYDROCORTISONE...... 73 BILTRICIDE...... 43 BAMLANIVIMAB...... 129 benzoyl peroxide...... 73 bimatoprost...... 149 BANZEL...... 23 BENZOYL PEROXIDE...... 73 BINOSTO...... 135

165 BIOFREQUENCY INSOLES...137 BRETYLIUM TOSYLATE...... 55 bupropion hcl er (xl)...... 26 BIOGUARD GAUZE BREVIBLOC...... 55 BUPROPION HCL ER (XL)...... 26 SPONGES...... 137 BREVIBLOC IN NACL...... 55 buspirone hcl...... 51 BIOGUARD ISLAND BREVIBLOC PREMIXED...... 55 busulfan...... 35 DRESSINGS...... 137 BREVIBLOC PREMIXED DS....55 BUSULFEX...... 35 BIOGUARD NON-ADHERENT BREZTRI AEROSPHERE...... 157 butalbital-acetaminophen...... 1 DRESSING...... 137 BRIDION...... 137 BUTALBITAL- BIOLON...... 151 briellyn...... 121 ACETAMINOPHEN...... 1 BIORPHEN...... 55 BRILINTA...... 45 butalbital-apap-caff-cod...... 1 BIO-STATIN...... 29 brimonidine tartrate...... 149 butalbital-apap-caffeine...... 1 bio-statin...... 29 BRIMONIDINE- butalbital-asa-caff-codeine...... 1 BIOTEL CARE BLOOD DORZOLAMIDE...... 149 butalbital-aspirin-caffeine...... 1 GLUCOSE...... 88 BRINEURA...... 110 butorphanol tartrate...... 1 BIOTEL CARE BLOOD brinzolamide...... 149 BYDUREON BCISE GLUCOSE SYST...... 88 BRISDELLE...... 26 AUTOINJECTOR...... 86 BIOTHRAX...... 132 BRIVIACT...... 23 BYETTA 10 MCG PEN...... 86 bisoprolol fumarate...... 55 BROME...... 137 BYETTA 5 MCG PEN...... 86 bisoprolol-hydrochlorothiazide.. 55 bromfenac sodium (once-daily) BYNFEZIA PEN...... 118 BIVALIRUDIN RTU...... 22 ...... 147 BYSTOLIC...... 55 bivalirudin trifluoroacetate...... 22 bromocriptine mesylate...... 44 cabergoline...... 118 BIVALIRUDIN-SODIUM BROMPHENIRAMINE CABLIVI...... 45 CHLORIDE...... 22 MALEATE...... 154 CABOMETYX...... 35 BIVIGAM...... 129 BROMSITE...... 147 CADIRAMD...... 10 BLACK WILLOW...... 137 BROVANA...... 157 CAFCIT...... 68 BLENREP...... 35 BRUKINSA...... 35 CAFERGOT...... 32 bleomycin sulfate...... 35 BRYHALI...... 74 caffeine citrate...... 68 BLEPH-10...... 147 BSP 0820...... 114 CAFFEINE-SODIUM BLEPHAMIDE...... 151 BSS...... 151 BENZOATE...... 68 BLEPHAMIDE S.O.P...... 151 bss plus...... 151 CALAN SR...... 55 BLINCYTO...... 35 BSS PLUS...... 151 CALCIFOL...... 95 blisovi 24 fe...... 121 budesonide...... 134, 157 calcipotriene...... 74 blisovi fe 1.5/30...... 121 budesonide er...... 134 CALCIPOTRIENE...... 74 blisovi fe 1/20...... 121 BUDESONIDE- calcipotriene-betameth diprop...74 BLOOD GLUCOSE TEST...... 88 FORMOTEROL FUMARATE..157 CALCIPOTRIENE- BLOXIVERZ...... 33 bumetanide...... 55 CLOBETASOL PROP...... 74 BOCASAL...... 70 BUMEX...... 55 calcitonin (salmon)...... 135 BONIVA...... 135 BUNAVAIL...... 14 CALCITRENE...... 74 BONJESTA...... 28 BUPHENYL...... 110 calcitriol...... 74, 136 BOOSTRIX...... 132 bupivacaine fisiopharma...... 9 calcium acetate...... 111 BORTEZOMIB...... 35 BUPIVACAINE HCL...... 9 calcium acetate (phos binder).111 bosentan...... 159 bupivacaine hcl...... 9 CALCIUM CHLORIDE...... 95 BOSULIF...... 35 bupivacaine hcl (pf)...... 9 calcium chloride...... 95 BOTOX...... 137 bupivacaine-epinephrine...... 9 CALCIUM DISODIUM BOTRYTIS...... 137 bupivacaine-epinephrine (pf)...... 9 VERSENATE...... 137 bp 10-1...... 74 BUPIVILOG...... 114 calcium gluconate...... 95 bp cleansing wash...... 74 BUPRENEX...... 1 CALCIUM GLUCONATE...... 95 bp wash...... 74 buprenorphine...... 1 CALCIUM GLUCONATE- BPCO...... 74 buprenorphine hcl...... 1, 14 NACL...... 95 BRAFTOVI...... 35 buprenorphine hcl-naloxone calcium-folic acid plus d...... 95 BREATHE EASE LARGE...... 137 hcl...... 14 CALDOLOR...... 6 BREATHE EASE MEDIUM.....137 bupropion hcl...... 26 CALIFORNIA PEPPER TREE 137 BREATHE EASE SMALL...... 137 bupropion hcl er (smoking det). 14 CALQUENCE...... 35 BREO ELLIPTA...... 157 bupropion hcl er (sr)...... 26 CAMBIA...... 6

166 camila...... 121 cartia xt...... 56 CELONTIN...... 23 CAMPATH...... 35 CARTICEL...... 138 CEM-UREA...... 74 CAMPTOSAR...... 35 carvedilol...... 56 CENTANY...... 16 camrese...... 121 carvedilol phosphate er...... 56 CENTANY AT...... 16 camrese lo...... 121 cascara sagrada...... 107 CENTRATEX...... 96 CANCIDAS...... 29 CASIRIVIMAB...... 129 cephalexin...... 16 candesartan cilexetil...... 55 CASODEX...... 35 CEQUA...... 151 candesartan cilexetil-hctz...... 55 caspofungin acetate...... 29 CEQUR SIMPLICITY 2U...... 88 CANDIDA ALBICANS CAT HAIR EXTRACT...... 138 CEQUR SIMPLICITY EXTRACT...... 137 CATAPRES-TTS-1...... 56 STARTER...... 88 CANTHARIDIN...... 74 CATAPRES-TTS-2...... 56 CERACADE...... 74 CAPASTAT SULFATE...... 34 CATAPRES-TTS-3...... 56 CERAMAX...... 74 capecitabine...... 35 CATHFLO ACTIVASE...... 22 CERDELGA...... 110 CAPEX...... 74 CATTLE EPITHELIUM...... 138 CEREBYX...... 23 CAPLYTA...... 46 cavarest...... 70 CEREZYME...... 110 CAPRELSA...... 35 CAYA...... 138 cerovel...... 74 captopril...... 55 CAYSTON...... 159 cetirizine hcl...... 154 captopril-hydrochlorothiazide.... 55 caziant...... 121 CETRAXAL...... 153 CARAC...... 74 CEDAR ELM...... 138 CETROTIDE...... 118 CARAFATE...... 105 cefaclor...... 15 cevimeline hcl...... 70 CARBAGLU...... 95 cefaclor er...... 15 CHANTIX...... 14 carbamazepine...... 23 cefadroxil...... 15 CHANTIX CONTINUING carbamazepine er...... 23 CEFAZOLIN IN SODIUM MONTH PAK...... 14 CARBATROL...... 23 CHLORIDE...... 15 CHANTIX STARTING MONTH carbidopa...... 44 cefazolin sodium...... 15 PAK...... 14 carbidopa-levodopa...... 44 CEFAZOLIN SODIUM...... 15 charlotte 24 fe...... 121 carbidopa-levodopa er...... 44 cefazolin sodium-dextrose.. 15, 16 chateal...... 121 carbidopa-levodopa- CEFAZOLIN SODIUM- chateal eq...... 121 entacapone...... 44 DEXTROSE...... 16 CHEMET...... 96 carbinoxamine maleate...... 154 cefdinir...... 16 CHEMSTRIP UGK...... 88 CARBOCAINE...... 10 cefepime hcl...... 16 CHENODAL...... 107 CARBOCAINE cefepime-dextrose...... 16 CHLOOXIA...... 74 PRESERVATIVE-FREE...... 10 cefixime...... 16 chloramphenicol sod succinate.16 carboplatin...... 35 CEFOTAN...... 16 chlordiazepoxide hcl...... 51 CARDENE IV...... 55 cefotaxime sodium...... 16 chlordiazepoxide-amitriptyline...26 CARDIOVID PLUS...... 137 cefotetan disodium...... 16 chlordiazepoxide-clidinium...... 107 CARDIZEM...... 55 cefotetan disodium-dextrose.....16 chlorhexidine gluconate...... 70 CARDIZEM LA...... 55 cefoxitin sodium...... 16 CHLORHEXIDINE CARDURA...... 55 CEFOXITIN SODIUM- GLUCONATE...... 138 CARDURA XL...... 113 DEXTROSE...... 16 chloroprocaine hcl (pf)...... 10 CARETOUCH CONTROL SOL cefpodoxime proxetil...... 16 chloroquine phosphate...... 43 LEVEL 2...... 88 cefprozil...... 16 chlorothiazide sodium...... 56 CARETOUCH ceftazidime...... 16 chlorpromazine hcl...... 46 LANCING/EJECTOR...... 88 ceftazidime and dextrose...... 16 chlorthalidone...... 56 CARETOUCH TEST...... 88 ceftriaxone sodium...... 16 chlorzoxazone...... 160 CARIMUNE NF...... 129 ceftriaxone sodium in dextrose. 16 CHOLBAM...... 110 carisoprodol...... 160 ceftriaxone sodium-dextrose.....16 CHOLECAL DF...... 96 carisoprodol-aspirin-codeine...... 1 cefuroxime axetil...... 16 cholestyramine...... 56 carmustine...... 35 cefuroxime sodium...... 16 cholestyramine light...... 56 CARNITOR...... 95 celecoxib...... 6 CHONDROITIN SULFATE..... 151 CARNITOR SF...... 95 CELESTONE SOLUSPAN...... 114 chorionic gonadotropin...... 118 CAROSPIR...... 55 CELLCEPT...... 129 CHROMAGEN...... 96 carteolol hcl...... 149 CELLCEPT INTRAVENOUS.. 129 chromic chloride...... 96

167 ciclodan...... 29 CLEOCIN...... 16, 17 CLINIMIX/DEXTROSE (8/14)... 96 ciclopirox...... 29 CLEOCIN PHOSPHATE...... 16 CLINISOL SF...... 96 ciclopirox olamine...... 29 CLEOCIN-T...... 74 CLINOLIPID...... 96 ciclopirox treatment...... 29 CLEVER CHOICE HOLDING CLINPRO 5000...... 70 CICLOPIROX-CLOBETASOL...74 CHAMBER...... 138 clobazam...... 23 CICLOPIROX-CLOBETASOL- CLEVIPREX...... 56 clobetasol prop emollient base. 75 SAL ACID...... 74 CLIMARA...... 121 clobetasol propionate...... 75 CICLOPIROX-SALICYLIC CLIMARA PRO...... 121 clobetasol propionate e...... 75 ACID...... 74 CLINDACIN ETZ...... 74 clobetasol propionate emulsion 75 cidofovir...... 47 clindacin etz...... 74 CLOBETASOL PROP- CIFEREX...... 96 CLINDACIN PAC...... 74 LEVOCETIRIZINE...... 75 cilostazol...... 45 clindacin-p...... 75 CLOBETASOL PROP- CILOXAN...... 147 CLINDAGEL...... 75 NIACINAMIDE...... 75 CIMDUO...... 47 CLINDAMY-BENZOYL PER- CLOBETAVIX...... 75 cimetidine...... 105 NIACINAM...... 75 CLOBEX...... 75 cimetidine hcl...... 105 clindamycin hcl...... 17 CLOBEX SPRAY...... 75 CIMETIDINE-LIDO- clindamycin palmitate hcl...... 17 clocortolone pivalate...... 75 SALICYLIC ACID...... 74 CLINDAMYCIN PHOS- CLODAN...... 75 CIMZIA...... 129 NIACINAMIDE...... 75 clodan...... 75 CIMZIA PREFILLED KIT...... 129 clindamycin phosphate...... 17, 75 clofarabine...... 36 CIMZIA STARTER KIT...... 129 CLINDAMYCIN PHOSPHATE.. 75 CLOLAR...... 36 cinacalcet hcl...... 136 clindamycin phosphate in d5w.. 17 clomiphene citrate...... 118 CINQAIR...... 154 CLINDAMYCIN PHOSPHATE clomipramine hcl...... 26 CINRYZE...... 129 IN NACL...... 17 clonazepam...... 51 CINVANTI...... 28 clindamycin phosphate- clonidine...... 56 CIPRO...... 16 benzoyl peroxide...... 75 clonidine hcl...... 56 CIPRO HC...... 153 CLINDAMYCIN-NIACIN- clonidine hcl er...... 66 ciprofloxacin hcl...... 16, 147, 153 TRETINOIN...... 75 clopidogrel bisulfate...... 45 ciprofloxacin in d5w...... 16 clindamycin-tretinoin...... 75 clorazepate dipotassium...... 51 ciprofloxacin-dexamethasone. 153 CLINDESSE...... 17 clotrimazole...... 29 CIPROFLOXACIN- CLIND-NIACIN- clotrimazole-betamethasone.....29 FLUOCINOLONE PF...... 153 SPIRONOLAC-TRETIN...... 75 clovique...... 96 cisatracurium besylate...... 68 CLINIMIX E/DEXTROSE clozapine...... 46 cisatracurium besylate (pf)..68, 69 (2.75/5)...... 96 CLOZARIL...... 46 cisplatin...... 36 CLINIMIX E/DEXTROSE COAGADEX...... 52 CISPLATIN...... 36 (4.25/10)...... 96 coal tar...... 75 citalopram hydrobromide...... 26 CLINIMIX E/DEXTROSE COARTEM...... 43 CITANEST FORTE DENTAL....10 (4.25/5)...... 96 COCAINE HCL...... 10 CITANEST PLAIN DENTAL...... 10 CLINIMIX E/DEXTROSE COCKLEBUR...... 138 CITRANATAL BLOOM...... 96 (5/15)...... 96 codeine sulfate...... 1 CITRANATAL MEDLEY...... 96 CLINIMIX E/DEXTROSE COENZYME Q-10...... 138 CLADOSPORIUM (5/20)...... 96 COGENTIN...... 44 CLADOSPORIOIDES...... 138 CLINIMIX E/DEXTROSE COLCHICINE...... 32 CLADOSPORIUM (8/10)...... 96 colchicine...... 32 SPHAEROSPERMUM...... 138 CLINIMIX E/DEXTROSE colchicine-probenecid...... 32 cladribine...... 36 (8/14)...... 96 COLCRYS...... 32 claravis...... 74 CLINIMIX/DEXTROSE colesevelam hcl...... 56 CLARINEX...... 154 (4.25/10)...... 96 COLESTID...... 56 CLARINEX-D 12 HOUR...... 154 CLINIMIX/DEXTROSE (4.25/5) 96 COLESTID FLAVORED...... 56 clarithromycin...... 16 CLINIMIX/DEXTROSE (5/15)... 96 colestipol hcl...... 56 clarithromycin er...... 16 CLINIMIX/DEXTROSE (5/20)... 96 colistimethate sodium (cba)...... 17 clemastine fumarate...... 154 CLINIMIX/DEXTROSE (6/5)..... 96 COLY-MYCIN M...... 17 CLENPIQ...... 107 CLINIMIX/DEXTROSE (8/10)... 96 COMBIGAN...... 149

168 COMBIPATCH...... 121 CORTISPORIN...... 75 CYCLOSET...... 86 COMBIVENT RESPIMAT...... 157 CORTISPORIN-TC...... 153 cyclosporine...... 129 COMBIVIR...... 47 CORVERT...... 56 CYCLOSPORINE IN KLARITY COMETRIQ...... 36 CORVITE 150...... 96 ...... 151 COMFORT TOUCH CORVITE FE...... 96 cyclosporine modified...... 129 ALCOHOL PREP...... 138 COSENTYX (300 MG DOSE).129 CYKLOKAPRON...... 52 COMPACT SPACE COSENTYX 150 MG/ML...... 129 cyproheptadine hcl...... 154 CHAMBER/LG MASK...... 138 COSENTYX SENSOREADY CYRAMZA...... 36 COMPACT SPACE (300 MG)...... 129 cyred...... 122 CHAMBER/MED MASK...... 138 COSENTYX SENSOREADY cyred eq...... 122 COMPACT SPACE PEN...... 129 CYSTADANE...... 110 CHAMBER/SM MASK...... 138 COSMEGEN...... 36 CYSTADROPS...... 151 COMPLERA...... 47 COSOPT...... 149 CYSTAGON...... 110 compro...... 28 COSOPT PF...... 149 CYSTARAN...... 151 COMTAN...... 44 COTELLIC...... 36 cytarabine...... 36 CONDYLOX...... 75 COTEMPLA XR-ODT...... 66 cytarabine (pf)...... 36 CONJUPRI...... 56 CREON...... 110 CYTOGAM...... 129 CONSENSI...... 56 CRESEMBA...... 29 CYTOTEC...... 105 constulose...... 107 CRINONE...... 121 CYTOTINE...... 138 CONTOUR CONTROL CRIXIVAN...... 47 cytra k crystals...... 96 SOLUTION...... 88 CROFAB...... 138 D.H.E. 45...... 32 CONTOUR MONITOR cromolyn sodium.....107, 147, 157 dacarbazine...... 36 DEVICE...... 88 crotan...... 43 DACOGEN...... 36 CONTOUR MONITOR KIT cryselle-28...... 121 dactinomycin...... 36 W/DEVICE...... 88 CRYSVITA...... 110 dalfampridine er...... 67 CONTOUR NEXT CONTROL CUPRIC CHLORIDE...... 96 DALIRESP...... 157 SOLUTION...... 88 CUPRIMINE...... 111 DALVANCE...... 17 CONTOUR NEXT EZ KIT CURITY AMD danazol...... 117 W/DEVICE...... 88 ANTIMICROBIAL SPNGE...... 138 DANDELION...... 138 CONTOUR NEXT LINK...... 88 CURITY AMD DANTRIUM...... 160 CONTOUR NEXT MONITOR ANTIMICROBIAL STRIP...... 138 dantrolene sodium...... 160 KIT W/DEVICE...... 88 CURITY IODOFORM DANYELZA...... 36 CONTOUR NEXT ONE KIT...... 88 PACKING STRIP...... 138 dapsone...... 34, 75 CONTOUR NEXT TEST curity sterile saline...... 96 DAPSONE...... 75 STRIPS...... 88 CUROSURF...... 154 DAPSONE-NIACINAMIDE...... 75 CONTOUR TEST STRIPS...... 89 CURVULARIA...... 138 DAPSONE-NIACINAMIDE- CONTRAST ALLERGY CUTAQUIG...... 129 SPIRONOLAC...... 75 PREMED PACK...... 114 CUTIVATE...... 75 DAPTACEL...... 132 CONTRAVE...... 69 CUVITRU...... 129 daptomycin...... 17 CONZIP...... 1 CUVPOSA...... 107 DARAPRIM...... 43 COPAXONE...... 67 cyanocobalamin...... 96 darifenacin hydrobromide er... 111 COPIKTRA...... 36 CYANOCOBALAMIN...... 96 DARZALEX...... 36 CORDRAN...... 75 CYANOKIT...... 138 DARZALEX FASPRO...... 36 COREG...... 56 cyclafem 1/35...... 121 dasetta 1/35...... 122 COREG CR...... 56 cyclafem 7/7/7...... 121 dasetta 7/7/7...... 122 coremino...... 17 cyclobenzaprine hcl...... 160 daunorubicin hcl...... 36 CORIFACT...... 52 cyclobenzaprine hcl er...... 160 DAURISMO...... 36 CORLANOR...... 56 CYCLOGYL...... 151 DAYPRO...... 6 CORLOPAM...... 56 CYCLOMYDRIL...... 151 daysee...... 122 CORN POLLEN...... 138 cyclopentolate hcl...... 151 DAYTRANA...... 66 CORTEF...... 114 cyclophosphamide...... 36 DAYVIGO...... 161 CORTENEMA...... 134 CYCLOPHOSPHAMIDE...... 36 DDAVP...... 118 CORTIFOAM...... 134 cycloserine...... 34 DDAVP RHINAL TUBE...... 118

169 DEBACTEROL...... 70 desvenlafaxine succinate er...... 26 DEXYCU...... 147 deblitane...... 122 DETROL...... 111 DFS DR/MS/MENTH/CAP DECADRON...... 114 DETROL LA...... 111 PAK...... 6 decitabine...... 36 DEXABLISS...... 114 DFS/MS/MENTH/CAP PAK...... 6 deferasirox...... 96 DEXAMETH SOD PHOS- DIACOMIT...... 23 deferasirox granules...... 96 BUPIV-EPIN...... 114 DIADIMAXIA...... 76 deferiprone...... 96 dexamethasone...... 114 DIAOXIA...... 76 deferoxamine mesylate...... 138 DEXAMETHASONE (LA)...... 114 DIASDIMAXIA...... 76 DEFITELIO...... 45 DEXAMETHASONE ACE & DIASOXIA...... 76 DELESTROGEN...... 122 SOD PHOS...... 114 DIASTAT ACUDIAL...... 23 DELSTRIGO...... 47 dexamethasone intensol...... 114 DIASTAT PEDIATRIC...... 23 DELUO...... 75 DEXAMETHASONE SOD DIATHRIVE BLOOD delyla...... 122 PHOS-BUPIV...... 114 GLUCOSE METER...... 89 DELZICOL...... 134 DEXAMETHASONE SOD DIATHRIVE BLOOD demeclocycline hcl...... 17 PHOS-NACL...... 114 GLUCOSE TEST...... 89 DEMEROL...... 1, 2 dexamethasone sod DIATHRIVE GLUCOSE DEMSER...... 56 phosphate pf...... 114 CONTROL SOLN...... 89 DENAVIR...... 47 dexamethasone sodium DIATHRIVE GLUCOSE TEST.. 89 DENTA 5000 PLUS...... 70 phosphate...... 114, 147 DIATHRIVE LANCING DENTAGEL...... 70 DEXAMETHASONE SODIUM DEVICE...... 89 DEOXIA...... 76 PHOSPHATE...... 114 DIATHRIVE+ GLUCOSE DEPEN TITRATABS...... 111 DEXAMETHASONE- MONITOR...... 89 DEPO-ESTRADIOL...... 122 MOXIFLOXACIN...... 151 DIATHRIVE+ GLUCOSE DEPO-MEDROL...... 114 DEXAMETH-MOXIFLOX- TEST...... 89 DEPO-PROVERA...... 122 KETOROLAC...... 151 diazepam...... 24, 51 DEPO-SUBQ PROVERA 104.122 dexchlorpheniramine maleate.154 DIAZEPAM...... 51 DERMACINRX DEXCOM G4 / G5 / G6 diazepam intensol...... 51 CLORHEXACIN...... 70 RECEIVER, TRANSMITTER, diazoxide...... 92 DERMACINRX EMPRICAINE.. 10 SENSOR (INCLUDING DIBENZYLINE...... 56 DERMACINRX PRIZOPAK...... 10 PLATINUM, PLATINUM DICLEGIS...... 28 DERMACINRX PUREFOLIX.... 96 PEDIATRIC)...... 89 DICLOFENAC...... 7 DERMACINRX SURGICAL DEXERYL...... 76 DICLOFENAC EPOLAMINE...... 7 COMBOPAK...... 76 DEXILANT...... 105 diclofenac potassium...... 7 DERMACINRX SURGICAL DEXLIDO...... 114 diclofenac sodium...... 7, 76, 147 PHARMAPAK...... 70 DEXLIDO-M...... 115 diclofenac sodium er...... 7 DERMA-SMOOTHE/FS BODY.76 DEXMEDETOMIDINE HCL.... 139 diclofenac-misoprostol...... 7 DERMA-SMOOTHE/FS dexmedetomidine hcl...... 139 DICLOFENAC-NA SCALP...... 76 dexmedetomidine hcl in nacl HYALURON-NIACIN...... 76 DERMOTIC...... 153 ...... 138, 139 DICLOFONO...... 7 DERMULCERA...... 76 DEXMEDETOMIDINE HCL IN DICLOPR...... 7 DERPIXA...... 76 NACL...... 138 DICLOVIX...... 7 DESCOVY...... 48 DEXMEDETOMIDINE HCL- dicloxacillin sodium...... 17 DESFERAL...... 138 DEXTROSE...... 139 dicyclomine hcl...... 107 desipramine hcl...... 26 dexmethylphenidate hcl...... 66 diethylpropion hcl...... 69 desloratadine...... 154 dexmethylphenidate hcl er...... 66 diethylpropion hcl er...... 69 desmopressin ace spray refrig 118 DEXONTO 0.4%...... 115 DIFFERIN...... 76 desmopressin acetate...... 118 DEXPANTHENOL...... 97 DIFICID...... 17 desmopressin acetate spray... 118 dexrazoxane hcl...... 36 diflorasone diacetate...... 76 desogestrel-ethinyl estradiol... 122 DEXTENZA...... 147 DIFLUCAN...... 29 desonide...... 76 dextroamphetamine sulfate...... 66 diflunisal...... 7 DESOWEN...... 76 dextroamphetamine sulfate er.. 66 DIFMETIOXRIME...... 29 desoximetasone...... 76 dextrose...... 97 DIGIFAB...... 139 DESVENLAFAXINE ER...... 26 DEXTROSE...... 97 digitek...... 56

170 digox...... 56 DORAL...... 51 duramorph...... 2 digoxin...... 56 DORYX...... 17 DUREZOL...... 147 dihydroergotamine mesylate.....32 DORYX MPC...... 17 DURLAZA...... 45 DILANTIN...... 24 dorzolamide hcl...... 149 DUROLANE...... 139 DILATRATE-SR...... 56 DORZOLAMIDE HCL...... 149 DURYSTA...... 149 DILAUDID...... 2 dorzolamide hcl-timolol mal.... 149 DUST MITE MIXED diltiazem hcl...... 56 dorzolamide hcl-timolol mal pf 149 ALLERGEN EXT...... 139 diltiazem hcl er...... 56 dotti...... 122 dutasteride...... 113 diltiazem hcl er beads...... 56 DOUBLEDEX...... 115 dutasteride-tamsulosin hcl...... 113 diltiazem hcl er coated beads... 56 DOVATO...... 48 DUTOPROL...... 57 DILTIAZEM HCL-DEXTROSE.. 57 DOVONEX...... 76 DXEVO 11-DAY...... 115 DILTIAZEM HCL-SODIUM doxazosin mesylate...... 57 DYANAVEL XR...... 66 CHLORIDE...... 57 doxepin hcl...... 26, 76, 161 DYMISTA...... 154 dilt-xr...... 57 doxercalciferol...... 136 DYRENIUM...... 57 DILUENT FOR LEFAMULIN.....97 DOXIL...... 36 DYSPORT...... 139 diluent for treprostinil...... 139 doxorubicin hcl...... 36 DYURAL-40...... 115 dimenhydrinate...... 28 doxorubicin hcl liposomal...... 36 DYURAL-80...... 115 DIMERCAPTOPROPANE- doxy 100...... 17 DYURAL-L...... 115 SULFONATE...... 139 doxycycline...... 76 DYURAL-LM...... 115 dimethyl fumarate...... 67 doxycycline hyclate...... 17 E.E.S. GRANULES...... 17 dimethyl fumarate starter pack..68 DOXYCYCLINE HYCLATE...... 17 EASIVENT...... 139 DIMOXIA...... 76 doxycycline monohydrate...... 17 EASTERN COTTONWOOD... 139 DIOCHLOY...... 76 doxylamine-pyridoxine...... 28 EASY TRAK II BLOOD DIPENTUM...... 134 DRAXACE...... 76 GLUCOSE SYS...... 89 diphen...... 154 DRAXACE LOTION EASY TRAK II CONTROL...... 89 DI-PHEN...... 154 CLEANSER...... 76 EASY TRAK II GLUCOSE diphenhydramine hcl...... 154 DRECHSLERA...... 139 TEST...... 89 diphenoxylate-atropine...... 107 DRISDOL...... 97 easygel...... 70 DIPHTHERIA-TETANUS DRITHO-CREME HP...... 76 EASYMAX 15 LEVEL 2-3 TOXOIDS DT...... 132 DRIXECE...... 77 CONTROL...... 89 DIPROLENE...... 76 DRIZALMA SPRINKLE...... 26 EASYMAX CONTROL...... 89 DIPROLENE AF...... 76 dronabinol...... 28 ECEOXIA...... 77 dipyridamole...... 45 droperidol...... 28 EC-NAPROSYN...... 7 disopyramide phosphate...... 57 DROPERIDOL...... 28 ec-naproxen...... 7 disulfiram...... 14 DROPLET GENTEEL ECONASIL...... 29 DITROPAN XL...... 111 LANCING DEVICE...... 89 econazole nitrate...... 29 DIURIL...... 57 DROPLET MICRON...... 93 ECONAZOLE NITRATE- divalproex sodium...... 24 drospiren-eth estrad-levomefol122 NIACINAMIDE...... 29 divalproex sodium er...... 24 drospirenone-ethinyl estradiol.122 ECOZA...... 29 DIVIGEL...... 122 DROXIA...... 36 EDARBI...... 57 DMT SUIK...... 115 droxidopa...... 57 EDARBYCLOR...... 57 dobutamine hcl...... 57 DRYSOL...... 77 EDECRIN...... 57 dobutamine in d5w...... 57 DSUVIA...... 2 EDETATE DISODIUM...... 97 docetaxel...... 36 DUAKLIR PRESSAIR...... 157 EDLUAR...... 161 dofetilide...... 57 DUAVEE...... 122 ED-SPAZ...... 107 DOG EPITHELIUM...... 139 DUETACT...... 86 EDURANT...... 48 DOG FENNEL...... 139 DUEXIS...... 7 efavirenz...... 48 DOJOLVI...... 139 DULERA...... 157 efavirenz-emtricitab-tenofovir....48 donepezil hcl...... 25 duloxetine hcl...... 26 efavirenz-lamivudine-tenofovir.. 48 dopamine hcl...... 57 DUOBRII...... 77 EFFER-K...... 97 dopamine in d5w...... 57 DUODOTE...... 139 effer-k...... 97 DOPRAM...... 69 DUOPA...... 44 EFFIENT...... 45 DOPTELET...... 52 DUPIXENT...... 77 EFUDEX...... 77

171 EGATEN...... 43 ENBRACE HR...... 97 EPINEPHRINE-DEXTROSE.....58 EGRIFTA SV...... 118 ENBREL...... 129 EPINEPHRINE-NACL...... 58 EHA...... 10 ENBREL MINI...... 129 EPINEPHRINESNAP-EMS.....157 ELAPRASE...... 110 ENBREL SURECLICK...... 129 EPINEPHRINESNAP-V...... 157 ELCYS...... 139 ENDARI...... 139 EPIPEN 2-PAK...... 157 ELELYSO...... 110 endocet...... 2 EPIPEN JR 2-PAK...... 157 ELESTRIN...... 122 ENDOMETRIN...... 122 epirubicin hcl...... 36 ELETONE...... 77 ENGERIX-B...... 133 EPISNAP...... 157 eletriptan hydrobromide...... 32 ENHERTU...... 36 epitol...... 24 ELIGARD...... 118 ENLITE GLUCOSE SENSOR...89 EPIVIR...... 48 ELIMITE...... 43 enoxaparin sodium...... 22 EPIVIR HBV...... 48 elinest...... 122 enpresse-28...... 122 eplerenone...... 59 ELIQUIS...... 22 enskyce...... 122 EPOGEN...... 52 ELIQUIS DVT/PE STARTER ENSPRYNG...... 129 epoprostenol sodium...... 159 PACK...... 22 ENSTILAR...... 77 eptifibatide...... 45 ELITEK...... 36 entacapone...... 44 EPZICOM...... 48 ELIXOPHYLLIN...... 157 entecavir...... 48 EQUACARE JR...... 139 ELLA...... 122 ENTEREG...... 107 EQUETRO...... 51 ELLENCE...... 36 ENTOCORT EC...... 134 ERAXIS...... 30 ELMIRON...... 111 ENTRESTO...... 57 ERBITUX...... 37 ELOCTATE...... 52 ENTTY SPRAY...... 77 ERGOCAL...... 97 eluryng...... 122 ENTYVIO...... 129 ergocalciferol...... 97 ELZONRIS...... 36 ENU PRO3 PLUS...... 139 ergoloid mesylates...... 139 EMBRACE LANCING enulose...... 107 ERGOMAR...... 32 DEVICE/EJECTOR...... 89 ENVARSUS XR...... 129 ergotamine-caffeine...... 32 EMBRACE TALK BLOOD ENZADYNE...... 110 ERIVEDGE...... 37 GLUCOSE...... 89 ENZNONUTY...... 10 ERLEADA...... 37 EMBRACE TALK GLUCOSE ENZOCLEAR...... 77 erlotinib hcl...... 37 CONTROL...... 89 EPANED...... 57 errin...... 122 EMBRACE TALK GLUCOSE EPCLUSA...... 48 ERTACZO...... 30 TEST...... 89 ephedrine sulfate...... 58 ertapenem sodium...... 17 EMBRACE TALK EPHEDRINE SULFATE...... 58 ERWINAZE...... 37 MONITORING SYSTEM...... 89 EPHEDRINE SULFATE ery...... 77 EMCYT...... 36 (PRESSORS)...... 57 ERYGEL...... 77 EMEND...... 28 EPHEDRINE SULFATE-NACL. 58 ERYPED 200...... 17 EMEND TRI-PACK...... 28 EPICERAM...... 77 ERYPED 400...... 18 EMERPHED...... 57 EPICOCCUM...... 139 ERY-TAB...... 18 EMFLAZA...... 32 EPICOCCUM NIGRUM...... 139 ERYTHROCIN EMGALITY...... 32 EPICYN...... 77 LACTOBIONATE...... 18 EMGALITY (300 MG DOSE).... 32 EPIDIOLEX...... 24 ERYTHROCIN STEARATE...... 18 emoquette...... 122 EPIDUO FORTE...... 77 erythromycin...... 18, 77, 147 EMPLICITI...... 36 EPIFOAM...... 77 erythromycin base...... 18 EMPRICAINE-II...... 10 epinastine hcl...... 147 erythromycin ethylsuccinate...... 18 EMSAM...... 26 EPINEPHRINE...... 58 ESBRIET...... 157 emtricitabine...... 48 epinephrine...... 58, 157 escitalopram oxalate...... 26 emtricitabine-tenofovir df...... 48 epinephrine (anaphylaxis)...... 157 ESGIC...... 2 EMTRIVA...... 48 EPINEPHRINE HCL...... 149 ESKATA...... 77 EMULSION SB...... 77 EPINEPHRINE HCL- esmolol hcl...... 59 EMVERM...... 43 DEXTROSE...... 58 ESMOLOL HCL...... 59 ENABLEX...... 111 EPINEPHRINE HCL-NACL...... 58 esmolol hcl-sodium chloride...... 59 enalapril maleate...... 57 epinephrine pf...... 58 ESOMEP-EZS...... 105 enalaprilat...... 57 EPINEPHRINE esomeprazole magnesium...... 105 enalapril-hydrochlorothiazide.... 57 PROFESSIONAL...... 157 esomeprazole sodium...... 105

172 ESOMEPRAZOLE EXELON...... 25 FENTORA...... 3 STRONTIUM...... 105 exemestane...... 37 FEONYX...... 97 ESPEROCT...... 52 EXFORGE...... 59 FERAHEME...... 97 ESSENTIAL CARE JR...... 139 EXFORGE HCT...... 59 FERIVA 21/7...... 97 estarylla...... 122 EXJADE...... 97 FERIVAFA...... 97 estazolam...... 51 EXODERM...... 30 ferocon...... 97 ESTRACE...... 122 EXONDYS 51...... 110 ferotrinsic...... 97 ESTRADIOL...... 122 EXPAREL...... 10 FERRALET 90...... 97 estradiol...... 122 EXTAVIA...... 68 ferraplus 90...... 97 estradiol valerate...... 122 EYLEA...... 151 FERRIPROX...... 97 estradiol-norethindrone acet... 122 EYSUVIS...... 147 FERRIPROX TWICE-A-DAY.... 97 ESTRING...... 122 EZALLOR SPRINKLE...... 59 FERRLECIT...... 97 ESTROGEL...... 122 ezetimibe...... 59 ferrocite plus...... 97 ESTROSTEP FE...... 123 ezetimibe-simvastatin...... 59 FERRO-PLEX HEMATINIC...... 97 eszopiclone...... 161 FABIOR...... 77 FERROTRIN...... 97 ETESEVIMAB...... 129 FABRAZYME...... 110 FETROJA...... 18 ethacrynate sodium...... 59 FALESSA...... 123 FETZIMA...... 26 ethacrynic acid...... 59 falmina...... 123 FETZIMA TITRATION...... 26 ethambutol hcl...... 34 famciclovir...... 48 FIASP...... 93 ETHAMOLIN...... 59 famotidine...... 106 FIASP FLEXTOUCH...... 93 ethosuximide...... 24 famotidine premixed...... 106 FIASP PENFILL...... 93 ETHOXIA...... 77 FANAPT...... 46 FIBERSOURCE HN...... 139 ethyl chloride...... 10 FANAPT TITRATION PACK..... 46 FIBRICOR...... 59 ethynodiol diac-eth estradiol... 123 FARESTON...... 37 FIBRYGA...... 52 ETHYOL...... 37 FARXIGA...... 86 FINACEA...... 77 etodolac...... 7 FARYDAK...... 37 FINAPOD...... 77 etodolac er...... 7 FASENRA...... 154 finasteride...... 113 etonogestrel-ethinyl estradiol.. 123 FASENRA PEN...... 154 FINASTERIDE-MINOXIDIL...... 77 ETOPOPHOS...... 37 FASLODEX...... 37 FINTEPLA...... 24 etoposide...... 37 FAVIPIRAVIR...... 48 FIORICET...... 3 EUCRISA...... 77 fayosim...... 123 FIORICET/CODEINE...... 3 EUFLEXXA...... 139 febuxostat...... 32 FIRAZYR...... 129 euthyrox...... 128 FEIBA...... 52 FIRDAPSE...... 139 EVAMIST...... 123 felbamate...... 24 FIRE ANT...... 139 EVEKEO...... 66 FELDENE...... 7 FIRMAGON...... 118 EVEKEO ODT...... 67 felodipine er...... 59 FIRMAGON (240 MG DOSE). 118 EVENCARE PROVIEW FEMARA...... 37 FIRST-LANSOPRAZOLE...... 106 GLUCOSE TEST...... 89 FEMCAP...... 139 FIRST-OMEPRAZOLE...... 106 EVENITY...... 135 FEMHRT LOW DOSE...... 123 FIRVANQ...... 18 everolimus...... 37, 129 FEMRING...... 123 flac...... 153 EVERSENSE femynor...... 123 FLAGYL...... 18 SENSOR/HOLDER...... 89 fenofibrate...... 59 FLAREX...... 147 EVERSENSE SMART fenofibrate micronized...... 59 flavoxate hcl...... 112 TRANSMITTER...... 89 fenofibric acid...... 59 FLEBOGAMMA DIF...... 129 EVISTA...... 118 fenoprofen calcium...... 7 flecainide acetate...... 59 EVOCLIN...... 77 fenortho...... 7 FLECTOR...... 7 EVOMELA...... 37 FENSOLVI (6 MONTH)...... 118 FLEXICHAMBER ADULT EVOTAZ...... 48 fentanyl...... 2 MASK/SMALL...... 140 EVOXAC...... 70 fentanyl citrate...... 2 FLEXICHAMBER CHILD EVRYSDI...... 110 FENTANYL CITRATE...... 2 MASK/LARGE...... 140 EXCILON AMD DRAIN FENTANYL CITRATE-NACL...... 2 FLEXICHAMBER CHILD SPONGES...... 139 FENTANYL-BUPIVACAINE- MASK/SMALL...... 140 EXELDERM...... 30 NACL...... 3 FLEXIN...... 10

173 FLOLAN...... 159 fluticasone-salmeterol...... 157 FOSRENOL...... 112 FLOLIPID...... 59 FLUTICASONE- FRAGMIN...... 22 FLORIVA...... 97 SALMETEROL...... 157 FREAMINE HBC...... 98 FLORIVA PLUS...... 97 fluvastatin sodium...... 59 FREAMINE III...... 98 FLOVENT DISKUS...... 157 fluvastatin sodium er...... 59 FREESTYLE FREEDOM LITE. 89 FLOVENT HFA...... 157 fluvoxamine maleate...... 26 FREESTYLE INSULINX floxuridine...... 37 fluvoxamine maleate er...... 26 SYSTEM...... 89 FLUAD...... 133 FLUZONE HIGH-DOSE FREESTYLE INSULINX TEST. 89 FLUAD QUADRIVALENT...... 133 QUADRIVALENT...... 133 FREESTYLE LIBRE 14 DAY FLUARIX QUADRIVALENT....133 FLUZONE QUADRIVALENT.. 133 READER...... 90 FLUBLOK QUADRIVALENT...133 FML...... 147 FREESTYLE LIBRE 14 DAY FLUCELVAX FML FORTE...... 147 SENSOR...... 90 QUADRIVALENT...... 133 FML LIQUIFILM...... 147 FREESTYLE LIBRE 2 fluconazole...... 30 FOCALIN...... 67 READER...... 90 fluconazole in sodium chloride..30 folic acid...... 97 FREESTYLE LIBRE 2 FLUCON-IBUPROF- FOLIC D3...... 98 SENSOR...... 90 ITRACON-TERBINA...... 30 FOLI-D...... 98 FREESTYLE LIBRE READER..90 flucytosine...... 30 FOLITE...... 98 FREESTYLE LIBRE SENSOR fludarabine phosphate...... 37 FOLIXAPURE...... 98 SYSTEM...... 90 fludrocortisone acetate...... 115 FOLLISTIM AQ...... 118 FREESTYLE LITE TEST...... 90 FLULAVAL QUADRIVALENT. 133 FOLOTYN...... 37 FREESTYLE PRECISION flumazenil...... 140 FOLTREXYL...... 98 NEO TEST...... 90 FLUMIST QUADRIVALENT....133 foltrin...... 98 FREESTYLE TEST...... 90 flunisolide...... 154 FOLVITE-D...... 98 frovatriptan succinate...... 32 FLUOCINOLONE ACET- fomepizole...... 140 FULPHILA...... 52 NIACINAMIDE...... 77 fondaparinux sodium...... 22 fulvestrant...... 37 fluocinolone acetonide...... 77, 153 FORA 6 CONNECT...... 89 FUNGIMEZ...... 30 fluocinolone acetonide body..... 77 FORA D40G furosemide...... 59 fluocinolone acetonide scalp.....77 GLUCOSE/PRESSURE...... 140 FUROSEMIDE IN SODIUM fluocinonide...... 77 FORA GTEL BLOOD CHLORIDE...... 59 fluocinonide emulsified base.....77 GLUCOSE SYSTEM...... 89 FUSARIUM...... 140 FLUOPAR...... 77 FORA GTEL BLOOD FUSION PLUS...... 98 FLUORIDEX...... 71 GLUCOSE TEST...... 89 FUZEON...... 48 fluoridex daily renewal...... 71 FORFIVO XL...... 27 fyavolv...... 123 FLUORIDEX ENHANCED formaldehyde...... 140 FYCOMPA...... 24 WHITENING...... 71 FORTAZ...... 18 gabapentin...... 24 FLUORIDEX SENSITIVITY FORTEO...... 135 GABITRIL...... 24 RELIEF...... 71 FORTESTA...... 117 GALAFOLD...... 110 fluoritab...... 97 FORTISCARE CONTROL...... 89 galantamine hydrobromide...... 25 fluorometholone...... 147 FORTISCARE GLUCOSE galantamine hydrobromide er... 25 FLUOROPLEX...... 77 SYSTEM...... 89 GALZIN...... 98 fluorouracil...... 37, 77 FORTISCARE T1 GLUCOSE GAMASTAN...... 129 FLUOROURACIL...... 77 SYSTEM...... 89 GAMIFANT...... 129 fluoxetine hcl...... 26 FOSAMAX...... 135 GAMMAGARD...... 130 fluoxetine hcl (pmdd)...... 26 FOSAMAX PLUS D...... 135 GAMMAGARD S/D LESS IGA 130 fluphenazine decanoate...... 46 fosamprenavir calcium...... 48 GAMMAKED...... 130 fluphenazine hcl...... 46 fosaprepitant dimeglumine...... 28 GAMMAPLEX...... 130 flurandrenolide...... 78 foscarnet sodium...... 48 GAMUNEX-C...... 130 flurazepam hcl...... 161 FOSCAVIR...... 48 GANCICLOVIR...... 48 flurbiprofen...... 7 fosfomycin tromethamine...... 18 ganciclovir sodium...... 48 flurbiprofen sodium...... 147 fosinopril sodium...... 59 ganirelix acetate...... 118 flutamide...... 37 fosinopril sodium-hctz...... 59 GARDASIL 9...... 133 fluticasone propionate...... 78, 154 fosphenytoin sodium...... 24 GASTROCROM...... 107

174 gatifloxacin...... 147 glimepiride...... 86 GLYTACTIN RESTORE LITE GATTEX...... 107 glipizide er...... 86 10PE...... 140 gavilyte-c...... 107 glipizide ir...... 86 GLYTACTIN RTD 10...... 140 gavilyte-g...... 107 glipizide xl...... 86 GLYTACTIN RTD 15...... 140 gavilyte-h...... 107 glipizide-metformin hcl...... 86 GLYTACTIN RTD LITE 15...... 140 gavilyte-n with flavor pack...... 107 GLOPERBA...... 32 GLYTACTIN SWIRL 15PE...... 140 GAVRETO...... 37 GLUCAGEN HYPOKIT...... 92 GLYXAMBI...... 86 GAZYVA...... 37 glucagon emergency kit...... 92 GOCOVRI...... 44 GEAMETDRAY...... 78 GLUCAGON EMERGENCY GOJJI BLOOD GLUCOSE GEBAUERS PAIN EASE...... 10 KIT...... 92 TEST...... 90 GEBAUERS SPRAY AND GLUCOCARD 01 SENSOR GOJJI BLOOD TEST STRETCH...... 10 PLUS...... 90 STRIP/LANCETS...... 90 GELCLAIR...... 140 GLUCOCARD EXPRESSION GOJJI CONTROL...... 90 GELFILM...... 151 TEST...... 90 GOJJI LANCING GEL-FLOW...... 140 GLUCOCARD SHINE DEVICE/CLEAR CAP...... 90 GELFOAM-JMI POWDER...... 140 CONNEX...... 90 GOLDENROD...... 140 GELFOAM-JMI SPONGE...... 140 GLUCOCARD SHINE GOLYTELY...... 108 GELNIQUE...... 112 EXPRESS...... 90 GONAL-F...... 118 GEL-ONE...... 140 GLUCOCARD SHINE TEST.....90 GONAL-F RFF...... 118 GELSYN-3...... 140 GLUCOCARD VITAL TEST...... 90 GONAL-F RFF REDIJECT..... 118 gemcitabine hcl...... 37 GLUCOSE CONTROL GONITRO...... 59 gemfibrozil...... 59 SOLUTIONS...... 89 GOPRELTO...... 10 gemmily...... 123 GLUCOTROL...... 86 GORDOFILM...... 78 GEN7T...... 10 GLUCOTROL XL...... 86 GRALISE...... 69 GEN7T PLUS...... 10 glutaraldehyde...... 140 granisetron hcl...... 28 GENADUR...... 78 GLUTATHIONE...... 98 GRANIX...... 52 GENERESS FE...... 123 glyburide...... 86 GRASS POLLEN(K-O-R-T- generlac...... 107 glyburide micronized...... 86 SWT VERN)...... 140 gengraf...... 130 glyburide-metformin...... 86 GRASTEK...... 140 GENICIN VITA-D...... 98 GLYCATE...... 107 griseofulvin microsize...... 30 GENOTROPIN...... 118 GLYCINE...... 98 griseofulvin ultramicrosize...... 30 GENOTROPIN MINIQUICK....118 glycine...... 112 GUANENDRUX...... 78 gentak...... 147 glycine urologic...... 112 guanfacine hcl...... 59 gentamicin in saline...... 18 glycolic acid...... 78 guanfacine hcl er...... 67 gentamicin sulfate...... 18, 147 GLYCOPHOS...... 98 GUANIDINE HCL...... 33 GENTEEL LANCING KIT glycopyrrolate...... 107 GUARDIAN CONNECT (BLUE)...... 90 GLYCOPYRROLATE...... 107, 108 TRANSMITTER...... 90 GENVISC 850...... 140 glycopyrrolate pf...... 108 GUARDIAN LINK 3 GENVOYA...... 48 glydo...... 10 TRANSMITTER...... 90 GEODON...... 46 GLYNASE...... 86 GUARDIAN SENSOR (3)...... 90 GERMAN COCKROACH...... 140 GLYRX-PF...... 108 GUARDIAN SENSOR 3...... 90 GIALAX...... 107 GLYTACTIN BETTERMILK 15140 GVOKE HYPOPEN 1-PACK.....92 GIAPREZA...... 59 GLYTACTIN BETTERMILK GVOKE HYPOPEN 2-PACK.....92 GILENYA...... 68 DE-LITE...... 140 GVOKE PFS...... 92 GILOTRIF...... 37 GLYTACTIN BUILD 10PE...... 140 GYNAZOLE-1...... 30 GILPHEX TR...... 154 GLYTACTIN BUILD 20/20...... 140 HACKBERRY...... 140 GIMOTI...... 28 GLYTACTIN BUILD 20/20 HAEGARDA...... 130 GIVLAARI...... 140 PKU...... 140 hailey 1.5/30...... 123 GLASSIA...... 157 GLYTACTIN BURST...... 140 hailey 24 fe...... 123 glatiramer acetate...... 68 GLYTACTIN RESTORE 10.... 140 hailey fe 1.5/30...... 123 glatopa...... 68 GLYTACTIN RESTORE 5...... 140 hailey fe 1/20...... 123 GLEOSTINE...... 37 GLYTACTIN RESTORE LITE HALAVEN...... 37 GLIADEL WAFER...... 37 10...... 140 halcinonide...... 78

175 HALCION...... 51 hetastarch-nacl...... 52 HW EMBRACE TALK BLOOD HALDOL...... 46 HETLIOZ...... 161 GLUCOSE...... 90 HALDOL DECANOATE...... 46 HEXTEND...... 52 HW EMBRACE TALK halobetasol propionate...... 78 HIBERIX...... 133 GLUCOSE TEST...... 90 HALOBETASOL HIDEX 6-DAY...... 115 HYALGAN...... 141 PROPIONATE...... 78 HIPREX...... 18 HYALURONATE-NIACINAM- HALOG...... 78 HIXDEFRIMA...... 30 TRETINOIN...... 78 haloperidol...... 46 HIZENTRA...... 130 HYALURONATE-NIACIN- haloperidol decanoate...... 46 HOMACTIN AA PLUS...... 141 TACROLIMUS...... 78 haloperidol lactate...... 46 homatropaire...... 151 HYALURONIDASE HALUCORT...... 78 HONEY BEE VENOM...... 141 (INTRAOCULAR)...... 151 HARMONY BLOOD HONEY BEE VENOM HYCAMTIN...... 37 GLUCOSE TEST...... 90 PROTEIN...... 141 HYCODAN...... 154 HARVONI...... 48 HORIZANT...... 69 hydralazine hcl...... 60 HAVRIX...... 133 HORSE EPITHELIUM...... 141 HYDREA...... 37 HAXCHLO...... 78 HPR PLUS...... 78 HYDRO 40...... 78 HCU EASY...... 141 HPR PLUS HYDROGEL...... 78 hydrochlorothiazide...... 60 HEALON...... 151 HUMALOG KWIKPEN...... 93 hydrocodone bitartrate er...... 3 HEALON GV...... 151 HUMALOG MIX 50/50 hydrocodone polst-chlorphen HEALON PRO...... 151 KWIKPEN...... 93 polst er susp...... 154 HEALON5...... 151 HUMALOG MIX 50/50 VIAL...... 93 hydrocodone-acetaminophen..... 3 HEALON5 PRO...... 151 HUMALOG MIX 75/25 hydrocodone-homatropine...... 154 heather...... 123 KWIKPEN...... 93 hydrocodone-ibuprofen...... 3 HECTOROL...... 136 HUMALOG MIX 75/25 VIAL...... 93 hydrocortisone...... 78, 115, 134 HELIDAC THERAPY...... 108 HUMALOG U-100 JUNIOR hydrocortisone (perianal)...... 134 HEMADY...... 115 KWIKPEN...... 93 hydrocortisone ace-pramoxine 134 HEMANGEOL...... 60 HUMALOG VIAL...... 93 hydrocortisone butyr lipo base.. 78 hematinic plus vit/minerals...... 98 HUMATE-P...... 52 hydrocortisone butyrate...... 78 hematinic/folic acid...... 98 HUMATROPE...... 118 hydrocortisone valerate...... 78 HEMATOGEN FA...... 98 HUMIRA...... 130 hydrocortisone-acetic acid...... 153 HEMATRON-AF...... 98 HUMIRA PEDIATRIC hydrogen peroxide...... 18 HEMETAB...... 98 CROHNS START...... 130 hydromet...... 154 HEMLIBRA...... 52 HUMIRA PEN...... 130 HYDROMORPHONE HCL...... 3 HEMOCYTE PLUS...... 98 HUMIRA PEN-CD/UC/HS hydromorphone hcl...... 3 hemocyte-f...... 98 STARTER...... 130 hydromorphone hcl er...... 3 HEMOFIL M...... 52 HUMIRA PEN-PEDIATRIC UC hydromorphone hcl pf...... 3 HEPAGAM B...... 130 START...... 130 HYDROMORPHONE HCL- heparin (porcine) in nacl...... 22 HUMIRA PEN-PS/UV/ADOL NACL...... 3, 4 HEPARIN (PORCINE) IN HS START...... 130 hydroxocobalamin acetate...... 98 NACL...... 23 HUMIRA PEN-PSOR/UVEIT hydroxychloroquine sulfate...... 43 heparin lock flush...... 141 STARTER...... 130 hydroxyprogesterone caproate123 heparin sod (porcine) in d5w.....23 HUMULIN 70/30 KWIKPEN...... 93 hydroxyurea...... 37 heparin sodium (porcine)...... 23 HUMULIN 70/30 VIAL...... 93 hydroxyzine hcl...... 51 heparin sodium (porcine) pf...... 23 HUMULIN N KWIKPEN...... 93 hydroxyzine pamoate...... 51 heparin sodium lock flush...... 141 HUMULIN N VIAL...... 93 HYLAGUARD...... 78 HEPATAMINE...... 98 HUMULIN R U-500 KWIKPEN..93 HYLATOPIC PLUS...... 78 HEPLISAV-B...... 133 HUMULIN R U-500 VIAL...... 93 HYLENEX...... 141 HEPMED...... 141 HUMULIN R VIAL...... 93 HYMOVIS...... 141 HEPSERA...... 48 HW EMBRACE PRO HYOPHEN...... 112 HERCEPTIN...... 37 GLUCOSE METER...... 90 hyoscyamine sulfate...... 108 HERCEPTIN HYLECTA...... 37 HW EMBRACE PRO hyoscyamine sulfate er...... 108 HERZUMA...... 37 GLUCOSE TEST...... 90 hyoscyamine sulfate sl...... 108 HESPAN...... 52 HYPERHEP B...... 130

176 HYPERRAB...... 130 IMOGAM RABIES-HT...... 130 INSULIN ASPART PENFILL.....93 HYPERRAB S/D...... 130 IMOVAX RABIES...... 133 INSULIN ASPART PROT & HYPERRHO S/D...... 130 IMPAVIDO...... 43 ASPART...... 93 HYPERSAL...... 154 IMPEKLO...... 78 INSULIN LISPRO...... 93 HYPERTET S/D...... 130 IMPOYZ...... 79 INSULIN LISPRO (1 UNIT HYPOCYN...... 151 IMURAN...... 130 DIAL)...... 93 HYQVIA...... 130 IMVEXXY MAINTENANCE INSULIN LISPRO JUNIOR HYRONAN...... 141 PACK...... 123 KWIKPEN...... 93 HYSINGLA ER...... 4 IMVEXXY STARTER PACK... 123 INSULIN LISPRO PROT & HYZAAR...... 60 INBRIJA...... 44 LISPRO...... 93 ibandronate sodium...... 135 incassia...... 123 INSULIN PEN NEEDLES...... 93 IBRANCE...... 37 INCRELEX...... 118 INSULIN SYRINGES...... 93 IBUPAK...... 7 INCRUSE ELLIPTA...... 157 INTEGRA F...... 98 ibuprofen...... 7 indapamide...... 60 INTEGRA PLUS...... 98 ibuprofen lysine...... 7 INDERAL XL...... 60 INTEGRILIN...... 45 ibutilide fumarate...... 60 INDOCIN...... 7 INTELENCE...... 48 ICAR-C PLUS...... 98 INDOMETHACIN...... 7 INTRALIPID...... 98 icatibant acetate...... 130 indomethacin...... 7 INTRAROSA...... 112 iclevia...... 123 indomethacin er...... 7 INTRON A...... 48 ICLUSIG...... 38 indomethacin sodium...... 7 introvale...... 123 icosapent ethyl...... 60 INFANRIX...... 133 INTUNIV...... 67 IDAMYCIN PFS...... 38 INFASURF...... 154 INVANZ...... 18 idarubicin hcl...... 38 INFED...... 98 INVEGA...... 46 IDELVION...... 52 INFINITY BLOOD GLUCOSE INVEGA SUSTENNA...... 46 IDHIFA...... 38 TEST...... 90 INVEGA TRINZA...... 46 iferex 150 forte...... 98 INFLECTRA...... 130 INVELTYS...... 147 IFEX...... 38 INFUGEM...... 38 INVIRASE...... 48 ifosfamide...... 38 INFUMORPH 200...... 4 INVOKAMET...... 86 ILARIS...... 130 INFUMORPH 500...... 4 INVOKAMET XR...... 86 ILEVRO...... 147 INGREZZA...... 69 INVOKANA...... 86 ILIDERM...... 78 INJECTAFER...... 98 iodine strong...... 98 ILUMYA...... 130 INLYTA...... 38 IODOQUINOL-HC- ILUVIEN...... 147 INNOPRAN XL...... 60 KETOCONAZOLE...... 30 imatinib mesylate...... 38 INOVA...... 79 IOPIDINE...... 149 IMBRUVICA...... 38 INOVA 4/1 ACNE CONTROL IPOL...... 133 IMCIVREE...... 69 THERAPY...... 79 ipratropium bromide...... 154, 157 IMDEVIMAB...... 130 INOVA 8/2 ACNE CONTROL ipratropium-albuterol...... 157 IMFINZI...... 38 THERAPY...... 79 irbesartan...... 60 IMIOXIA...... 30 INPEN 100-BLUE-LILLY...... 90 irbesartan-hydrochlorothiazide..60 imipenem-cilastatin...... 18 INPEN 100-BLUE-NOVO...... 90 IRESSA...... 38 imipramine hcl...... 27 INPEN 100-GRAY-LILLY...... 90 irinotecan hcl...... 38 imipramine pamoate...... 27 INPEN 100-GREY-NOVO...... 90 IROSPAN 24/6...... 98 imiquimod...... 78 INPEN 100-PINK-LILLY...... 90 ISENTRESS...... 48 IMIQUIMOD PUMP...... 78 INPEN 100-PINK-NOVO...... 90 ISENTRESS HD...... 48 IMIQUIMOD-LEVOCETIRIZIN- INQOVI...... 38 isibloom...... 123 NIACIN...... 78 INREBIC...... 38 isoniazid...... 34 IMIQUIMOD-LEVOCET- INSPIREASE RESERVOIR isoproterenol hcl...... 158 TRETINOIN...... 78 BAGS...... 141 ISOPROTERENOL-SODIUM IMITREX...... 32 INSPRA...... 60 CHLORIDE...... 158 IMITREX STATDOSE REFILL..32 INSULIN ASP PROT & ASP ISOPTO ATROPINE...... 151 IMITREX STATDOSE FLEXPEN...... 93 ISOPTO CARPINE...... 150 SYSTEM...... 32 INSULIN ASPART...... 93 ISORDIL TITRADOSE...... 60 IMLYGIC...... 38 INSULIN ASPART FLEXPEN... 93 isosorbide dinitrate...... 60

177 isosorbide mononitrate...... 60 junel fe 1/20...... 123 KETOROLAC isosorbide mononitrate er...... 60 junel fe 24...... 123 TROMETHAMINE...... 8 isotretinoin...... 79 JUXTAPID...... 60 KETOROLAC-BUPIV- ISOVACTIN AA PLUS...... 141 JYNARQUE...... 99 KETAMINE...... 8 isradipine...... 60 KABIVEN...... 99 KETOROLAC-ROPIV- ISTALOL...... 150 KADCYLA...... 38 KETAMINE...... 8 ISTODAX (OVERFILL)...... 38 kaitlib fe...... 123 KETOSTIX...... 90 ISTURISA...... 118 KALBITOR...... 130 KETOVIE...... 141 ISUPREL...... 158 KALETRA...... 48 KETOVIE PEPTIDE...... 141 ITHOXIA...... 79 kalliga...... 123 KEVEYIS...... 150 itraconazole...... 30 KALYDECO...... 159 KEVZARA...... 130 IV STABILIZER FOR KAMDOY...... 79 KEYTRUDA...... 38 LUMOXITI...... 141 KANJINTI...... 38 KHAPZORY...... 38 ivermectin...... 43 KANUMA...... 110 KINERET...... 130 IVERMECTIN- KAPOK...... 141 KINRIX...... 133 METRONIDAZOL-NIACIN...... 79 KAPSPARGO SPRINKLE...... 60 KISQALI...... 38 IXEMPRA KIT...... 38 KAPVAY...... 67 KISQALI FEMARA...... 38 IXIARO...... 133 KARBINAL ER...... 154 KITABIS PAK...... 159 IXINITY...... 52 kariva...... 124 KIVIK...... 79 JADENU SPRINKLE...... 98 KATERZIA...... 60 KLARITY-A...... 147 jaimiess...... 123 KAZANO...... 87 KLARITY-L...... 148 JAKAFI...... 38 KCENTRA...... 52 KLARON...... 79 JALYN...... 113 KEDRAB...... 130 klor-con...... 99 JANSSEN COVID-19 KEFLEX...... 18 klor-con 10...... 99 VACCINE...... 133 kelnor 1/35...... 124 klor-con m10...... 99 jantoven...... 23 kelnor 1/50...... 124 KLOR-CON M15...... 99 JANUMET...... 86 KENALOG...... 115 klor-con m20...... 99 JANUMET XR...... 86 KENALOG-80...... 115 klor-con/ef...... 99 JANUVIA...... 86 KENGREAL...... 45 KOATE...... 52 JARDIANCE...... 86 KEPIVANCE...... 71 KOATE-DVI...... 52 jasmiel...... 123 KEPPRA...... 24 KOCHIA...... 141 JATENZO...... 117 KERAGEL...... 79 KOGENATE FS...... 52 JELMYTO...... 38 KERALAC...... 79 KOMBIGLYZE XR...... 87 jencycla...... 123 KERALYT...... 79 KORLYM...... 120 JENLIVA KERALYT SCALP...... 79 KOSELUGO...... 38 PRENATAL/POSTNATAL...... 98 KERAMATRIX REPLICINE KOVALTRY...... 52 JENTADUETO...... 86 5CMX5CM...... 79 K-PHOS...... 99 JENTADUETO XR...... 87 KERLIX AMD K-PHOS NO 2...... 99 JEVTANA...... 38 ANTIMICROBIAL...... 141 K-PHOS-NEUTRAL...... 99 jinteli...... 123 KERLIX AMD SUPER k-prime...... 99 JIVI...... 52 SPONGES...... 141 KRINTAFEL...... 43 JOHNSON GRASS...... 141 KERYDIN...... 30 KRISTALOSE...... 108 jolessa...... 123 KESIMPTA...... 68 KROGER HEALTHPRO JORNAY PM...... 67 ketoconazole...... 30 GLUCOSE TEST...... 90 J-TIP KIT W/VIAL ADAPTERS141 KETOCONAZOLE- KRYSTEXXA...... 32 JUBLIA...... 30 HYDROCORTISONE...... 30 K-TAB...... 99 juleber...... 123 ketodan...... 30 k-tan plus...... 99 JULUCA...... 48 KETODAN...... 30 kurvelo...... 124 JUNE GRASS POLLEN ketoprofen...... 7 KUVAN...... 110 STANDARDIZED...... 141 ketoprofen er...... 7 KYLEENA...... 124 junel 1.5/30...... 123 KETOROCAINE-L...... 7 KYMRIAH...... 130 junel 1/20...... 123 KETOROCAINE-LM...... 7 KYNMOBI...... 44 junel fe 1.5/30...... 123 ketorolac tromethamine...... 8, 147 KYNMOBI TITRATION KIT...... 44

178 KYPROLIS...... 38 LENVIMA...... 38 LIDOCAINE HCL (CARDIAC)...10 L.E.T...... 10 lessina...... 124 lidocaine hcl (cardiac)...... 10 LABETALOL HCL...... 60 letrozole...... 38 lidocaine hcl (cardiac) pf...... 10 labetalol hcl...... 60 leucovorin calcium...... 39 lidocaine hcl (pf)...... 10 LACRISERT...... 152 LEUKERAN...... 39 lidocaine hcl urethral/mucosal...11 lactated ringers...... 99 LEUKINE...... 52 LIDOCAINE IN D5W...... 11 LACTEROL...... 108 leuprolide acetate...... 118 lidocaine in d5w...... 11 lactic acid...... 79 LEUPROLIDE ACETATE- LIDOCAINE IN DEXTROSE..... 11 lactic acid e...... 79 BUPIVACAINE...... 118 lidocaine viscous hcl...... 71 LACTIC ACID-NIACINAMIDE...79 levalbuterol hcl...... 158 lidocaine-epinephrine...... 11 LACTOJEN...... 108 LEVALBUTEROL HFA...... 158 LIDOCAINE-EPINEPHRINE... 152 lactulose...... 108 LEVATIO...... 10 lidocaine-hydrocort (perianal). 134 lactulose encephalopathy...... 108 LEVBID...... 108 LIDOCAINE- LAMICTAL ODT...... 24 LEVEMIR U-100 FLEXTOUCH.93 HYDROCORTISONE ACE79, 134 LAMICTAL STARTER...... 24 LEVEMIR U-100 VIAL...... 94 lidocaine-hydrocortisone ace.. 134 LAMICTAL XR...... 24 levetiracetam...... 24 LIDOCAINE- lamivudine...... 48, 49 levetiracetam er...... 24 PHENYLEPHRINE...... 152 lamivudine-zidovudine...... 49 levetiracetam in nacl...... 24 LIDOCAINE- lamotrigine...... 24 LEVICYN...... 79 PHENYLEPHRINE-BSS...... 152 lamotrigine er...... 24 LEVICYN DERMAL SPRAY..... 79 lidocaine-prilocaine...... 11 lamotrigine starter kit-blue...... 24 levobunolol hcl...... 150 LIDOCAINE-SODIUM lamotrigine starter kit-green...... 24 LEVOCARNITINE...... 99 BICARBONATE...... 11 lamotrigine starter kit-orange.... 24 levocarnitine...... 99 LIDOCAINE-TETRACAINE...... 11 LAMPIT...... 43 levocarnitine sf...... 99 LIDOCANNA...... 11 LANCETS...... 91 levocetirizine dihydrochloride..155 LIDOCIDEX I...... 115 LANOXIN...... 60 levofloxacin...... 18, 148 LIDOCORT...... 134 LANOXIN PEDIATRIC...... 60 levofloxacin in d5w...... 18 LIDO-EPINEPHRINE- lansoprazole...... 106 levoleucovorin calcium...... 39 TETRACAINE...... 11 lanthanum carbonate...... 112 levoleucovorin calcium pf...... 39 lidolog...... 115 LANTUS SOLOSTAR...... 93 levonest...... 124 LIDOMAR...... 11 LANTUS U-100 VIAL...... 93 levonorgest-eth est & eth est.. 124 LIDOMARK 2/5...... 11 lapatinib ditosylate...... 38 levonorgest-eth estrad 91-day 124 LIDOPAC...... 11 larin 1.5/30...... 124 levonorgestrel-ethinyl estrad...124 lidopin...... 11 larin 1/20...... 124 levonorg-eth estrad triphasic...124 LIDOPIN...... 11 larin 24 fe...... 124 LEVOPHED...... 60 LIDOPRIL...... 11 larin fe 1.5/30...... 124 levora 0.15/30 (28)...... 124 LIDOPRIL XR...... 11 larin fe 1/20...... 124 levorphanol tartrate...... 4 LIDO-PRILO CAINE PACK...... 11 larissia...... 124 levo-t...... 128 LIDOPURE PATCH...... 11 LASIX...... 60 levothyroxine sodium...... 128 LIDORX...... 11 LASTACAFT...... 152 LEVOTHYROXINE SODIUM.. 128 LIDO-SORB...... 11 latanoprost...... 150 levoxyl...... 128 LIDOSTREAM...... 11 LATANOPROST-TIMOLOL LEVSIN...... 108 LIDOTHOL...... 12 MALEATE...... 150 LEVSIN/SL...... 108 LIDOTRAL...... 12 LATUDA...... 46 LEVULAN KERASTICK...... 79 LIDOTREX (ALOE VERA)...... 79 LAVARE WOUND WASH...... 79 LEXETTE...... 79 LIDOVIX L...... 12 layolis fe...... 124 LEXIVA...... 49 LIFEMS NALOXONE...... 14 LAZANDA...... 4 LIBTAYO...... 39 LILETTA (52 MG)...... 124 LDO PLUS...... 10 LICART...... 8 lillow...... 124 LEDIPASVIR-SOFOSBUVIR.... 49 LIDO BDK...... 10 LINCOCIN...... 18 leena...... 124 lidocaine...... 10, 11 lincomycin hcl...... 18 leflunomide...... 130 LIDOCAINE (ANORECTAL)..... 79 lindane...... 43 LEMTRADA...... 68 lidocaine hcl...... 10, 11, 71 linezolid...... 18 LENSCALE...... 141 LIDOCAINE HCL...... 10, 11 linezolid in sodium chloride...... 18

179 LINZESS...... 108 loxapine succinate...... 46 MANGANESE CHLORIDE...... 99 liothyronine sodium...... 128 LOYON...... 79 mannitol...... 61 LIPO...... 99 lo-zumandimine...... 124 maprotiline hcl...... 27 LIPO-C...... 99 LUBIPROSTONE...... 109 MARBETA-25...... 115 LIPOFEN...... 60 LUCEMYRA...... 14 MARBETA-L...... 115 lisinopril...... 60 LUCENTIS...... 152 MARCAINE...... 12 lisinopril-hydrochlorothiazide.....60 LUGOLS STRONG IODINE...... 18 MARCAINE PRESERVATIVE lithium...... 51 LULICONAZOLE...... 30 FREE...... 12 lithium carbonate...... 51 LUMIGAN...... 150 MARCAINE/EPINEPHRINE...... 12 lithium carbonate er...... 51 LUMIZYME...... 110 MARCAINE/EPINEPHRINE LITHOBID...... 51 LUMOXITI...... 39 PF...... 12 LITHOSTAT...... 112 LUPANETA PACK...... 118 MARDEX-25...... 115 LIVALO...... 60 LUPRON DEPOT (1-MONTH) 119 MARINOL...... 28 LIVIXIL PAK...... 12 LUPRON DEPOT (3-MONTH) 119 marlido...... 12 LMD IN D5W...... 52 LUPRON DEPOT (4-MONTH) MARLIDO-25...... 12 LMD IN NACL...... 53 INTRAMUSCULAR KIT 30MG 119 marlissa...... 124 LMR PLUS...... 12 LUPRON DEPOT (6-MONTH) MARPLAN...... 27 LO LOESTRIN FE...... 124 INTRAMUSCULAR KIT 45MG 119 MARQIBO...... 39 LODINE...... 8 LUPRON DEPOT-PED (1- MARVONA SUIK...... 12 LOESTRIN 1.5/30 (21)...... 124 MONTH)...... 119 MAS CARE-PAK...... 115 LOESTRIN 1/20 (21)...... 124 LUPRON DEPOT-PED (3- MATULANE...... 39 LOESTRIN FE 1.5/30...... 124 MONTH)...... 119 matzim la...... 61 LOESTRIN FE 1/20...... 124 LUTATHERA...... 39 MAVENCLAD...... 68 lojaimiess...... 124 lutera...... 124 MAVYRET...... 49 LOKELMA...... 99 LUXIQ...... 79 MAXICOMFORT SYR 27G X LOMAIRA...... 69 LUXTURNA...... 152 1/2"...... 94 LOMOTIL...... 108 LUZU...... 30 MAXIDEX...... 148 LONHALA MAGNAIR REFILL LYDEXA...... 12 MAXITROL...... 152 KIT...... 158 lyleq...... 124 MAXZIDE...... 61 LONHALA MAGNAIR lyllana...... 124 MAXZIDE-25...... 61 STARTER KIT...... 158 LYNPARZA...... 39 MAYZENT...... 68 LONSURF...... 39 LYRICA...... 69 MAYZENT STARTER PACK.... 68 loperamide hcl...... 109 LYRICA CR...... 69 me/naphos/mb/hyo1...... 112 LOPID...... 61 LYSINE HCL...... 99 MEADOW FESCUE GRASS lopinavir-ritonavir...... 49 LYSODREN...... 39 POLLEN...... 141 LOPRESSOR...... 61 LYSTEDA...... 53 meclizine hcl...... 28 LOPROX...... 30 LYUMJEV KWIKPEN...... 94 meclofenamate sodium...... 8 lorazepam...... 51 LYUMJEV VIAL...... 94 MEDROL...... 115 lorazepam intensol...... 51 lyza...... 124 MEDROLOAN II SUIK...... 115 LORBRENA...... 39 MACI...... 141 MEDROLOAN SUIK...... 115 LORTAB...... 4 MACROBID...... 18 medroxyprogesterone acetate 125 loryna...... 124 MACRODANTIN...... 18 mefenamic acid...... 8 losartan potassium...... 61 mafenide acetate...... 18 mefloquine hcl...... 43 losartan potassium-hctz...... 61 MAGNEBIND 400...... 99 megestrol acetate...... 125 LOSEASONIQUE...... 124 magnesium chloride...... 99 MEKINIST...... 39 LOTEMAX...... 148 magnesium sulfate...... 99 MEKTOVI...... 39 LOTEMAX SM...... 148 MAGNESIUM SULFATE...... 99 MELALEUCA...... 141 LOTENSIN...... 61 magnesium sulfate in d5w...... 99 melodetta 24 fe...... 125 LOTENSIN HCT...... 61 MAGNESIUM SULFATE- meloxicam...... 8 loteprednol etabonate...... 148 NACL...... 99 melphalan...... 39 lovastatin...... 61 MAKENA...... 124 melphalan hcl...... 39 LOVENOX...... 23 MALARONE...... 43 memantine hcl...... 25 low-ogestrel...... 124 malathion...... 43 memantine hcl er...... 25

180 MEMBRANEBLUE...... 152 methyldopa...... 61 microgestin 1/20...... 125 MENACTRA...... 133 methyldopa- microgestin 24 fe...... 125 MENEST...... 125 hydrochlorothiazide...... 61 microgestin fe 1.5/30...... 125 MENOPUR...... 119 methylene blue...... 141 microgestin fe 1/20...... 125 MENOSTAR...... 125 methylergonovine maleate...... 141 MICROLET NEXT LANCING MENQUADFI...... 133 METHYLIN...... 67 DEVICE...... 91 MENTAX...... 30 methylphenidate hcl...... 67 midodrine hcl...... 61 MENVEO...... 133 methylphenidate hcl er...... 67 MIGERGOT...... 32 meperidine hcl...... 4 methylphenidate hcl er (cd)...... 67 miglitol...... 87 MEPHYTON...... 99 methylphenidate hcl er (la)...... 67 miglustat...... 110 meprobamate...... 51 methylphenidate hcl er (xr)...... 67 MIGRANAL...... 32 MEPRON...... 43 methylprednisolone...... 116 mili...... 125 MEPSEVII...... 110 METHYLPREDNISOLONE MILLIPRED...... 116 mercaptopurine...... 39 ACE-LIDO...... 115 milrinone lactate...... 61 meropenem...... 18 METHYLPREDNISOLONE milrinone lactate in dextrose..... 61 MEROPENEM-SODIUM ACETATE...... 115, 116 mimvey...... 125 CHLORIDE...... 18 methylprednisolone acetate.... 115 MIMYX...... 80 MERREM...... 18 methylprednisolone sodium mineral oil heavy...... 109 merzee...... 125 succ...... 116 MINIMED 770G INSULIN mesalamine...... 134 METHYLPREDNISOLONE- PUMP SYS...... 141 mesalamine er oral capsule BUPIVACAINE...... 116 MINIMED MIO ADVANCE 0.375 gm...... 134 methyltestosterone...... 117 INFUSE SET...... 141 mesalamine-cleanser...... 135 metoclopramide hcl...... 28 MINIMED PUMP RESERVOIR mesna...... 39 metolazone...... 61 3ML...... 141 MESNEX...... 39 metoprolol succinate er...... 61 MINIMED QUICK SET INF MESQUITE...... 141 metoprolol tartrate...... 61 SET 18"...... 141 MESTINON...... 33 metoprolol-hydrochlorothiazide.61 MINIMED QUICK SET INF METAXALL CP...... 160 METROCREAM...... 79 SET 23"...... 142 metaxalone...... 160 METROGEL...... 79 MINIMED QUICK SET INF metformin hcl er...... 87 METROLOTION...... 79 SET 32"...... 142 metformin hcl er (mod)...... 87 metronidazole...... 19, 79 MINIMED QUICK SET INF metformin hcl er (osm)...... 87 metronidazole in nacl...... 19 SET 43"...... 142 metformin hcl ir...... 87 metyrosine...... 61 MINIMED SILHOUETTE INF methadone hcl...... 4 mexiletine hcl...... 61 SET 32"...... 142 methadone hcl intensol...... 4 MI PASTE...... 71 MINIMED SILHOUETTE INF METHADONE HCL-NACL...... 4 MI PASTE PLUS...... 71 SET 43"...... 142 methadose...... 4 MIACALCIN...... 135 MINIPRESS...... 61 methadose sugar-free...... 4 mibelas 24 fe...... 125 minitran...... 61 methamphetamine hcl...... 67 micafungin sodium...... 30 MINIVELLE...... 125 methazolamide...... 150 MICARDIS...... 61 MINOCIN...... 19 methenamine hippurate...... 18 MICARDIS HCT...... 61 minocycline hcl...... 19 methenamine mandelate...... 19 MIC-L-CARNITINE...... 99 MINOCYCLINE HCL ER...... 19 methergine...... 141 miconazole 3...... 30 minocycline hcl er...... 19 methimazole...... 128 MICONAZOLE-ZINC OXIDE- MINOLIRA...... 19 METHITEST...... 117 PETROLAT...... 30 minoxidil...... 61 methocarbamol...... 160 MICRHOGAM ULTRA- MINOXIDIL-PROGEST- methotrexate...... 130 FILTERED PLUS...... 131 TRETINOIN...... 80 methotrexate sodium...... 130, 131 MICROCHAMBER...... 141 MIOCHOL-E...... 152 methotrexate sodium (pf)...... 130 MICROCYN...... 79 MIOSTAT...... 152 methoxsalen rapid...... 79 MICROCYN SKIN AND MIRAPEX...... 44 methscopolamine bromide...... 109 WOUND...... 80 MIRAPEX ER...... 44 methyl salicylate...... 79 MICRODOT TEST...... 91 MIRCERA...... 53 METHYLCOBALAMIN...... 99 microgestin 1.5/30...... 125 MIRCETTE...... 125

181 MIRENA (52 MG)...... 125 MOTEGRITY...... 109 na ferric gluc cplx in sucrose...100 mirtazapine...... 27 MOTOFEN...... 109 NABI-HB...... 131 MIRVASO...... 80 MOUNTAIN CEDAR...... 142 nabumetone...... 8 misoprostol...... 106 MOUSE EPITHELIUM...... 142 n-acetyl-l-cysteine...... 100 MITE (D. FARINAE)...... 142 MOVANTIK...... 109 nadolol...... 61 MITE (D. PTERONYSSINUS).142 MOVIPREP...... 109 nafcillin sodium...... 19 MITIGARE...... 32 MOXEZA...... 148 NAFCILLIN SODIUM IN mitigo...... 4 MOXIFLOXACIN HCL...... 19, 148 DEXTROSE...... 19 mitomycin...... 39 moxifloxacin hcl...... 19, 148 nafrinse...... 100 MITOMYCIN...... 39, 148 moxifloxacin hcl (2x day)...... 148 NAFRINSE DAILY MITOSOL...... 148 moxifloxacin hcl in nacl...... 19 ACIDULATED...... 71 mitoxantrone hcl...... 39 MOXIFLOXACIN HCL-BSS.... 152 NAFRINSE DAILY/NEUTRAL...71 MIXED ASPERGILLUS...... 142 MOZOBIL...... 53 nafrinse drops...... 100 MIXED FEATHERS...... 142 MS CONTIN...... 5 NAFRINSE WEEKLY...... 71 MIXED RAGWEED...... 142 MSUD EASY...... 142 naftifine hcl...... 30 MIXED VESPID VENOM MUCOR...... 142 NAFTIN...... 30 PROTEIN...... 142 MUCOSITISRX...... 71 NAGLAZYME...... 110 mixed vespid venom protein... 142 MUGWORT...... 142 nalbuphine hcl...... 5 mlk f1...... 142 MULPLETA...... 53 NALOCET...... 5 mlk f2...... 142 MULTAQ...... 61 naloxone hcl...... 14 mlk f3...... 142 MULTIGEN...... 100 NALTREXONE...... 14 MLK F4...... 142 MULTIGEN FOLIC...... 100 naltrexone hcl...... 14 M-M-R II...... 133 MULTIGEN PLUS...... 100 NAMENDA...... 25 M-NATAL PLUS...... 99 MULTI-SPECIALTY...... 116 NAMENDA TITRATION PAK....25 MOBIC...... 8 multitrace-4 neonatal...... 100 NAMENDA XR...... 26 modafinil...... 161 MULTITRACE-4 PEDIATRIC..100 NAMENDA XR TITRATION MODERNA COVID-19 multi-vit/iron/fluoride...... 100 PACK...... 26 VACCINE...... 133 multivitamin/fluoride...... 100 NAMZARIC...... 26 moexipril hcl...... 61 MULTIVITAMIN/FLUORIDE... 100 NAPRELAN...... 8 molindone hcl...... 46 multi-vitamin/fluoride...... 100 naproxen...... 8 mometasone furoate...... 80, 155 multi-vitamin/fluoride/iron...... 100 naproxen sodium...... 8 mondoxyne nl...... 19 mupirocin...... 19 naproxen sodium er...... 8 MONJUVI...... 39 mupirocin calcium...... 19 naproxen-esomeprazole...... 8 MONOFERRIC...... 100 mutamycin...... 39 naratriptan hcl...... 33 monoject flush syringe...... 100 MVASI...... 39 NARCAN...... 14 monoject sodium chloride flush MYALEPT...... 110 NARDIL...... 27 ...... 100 MYAMBUTOL...... 34 NAROPIN...... 12 mono-linyah...... 125 MYCAMINE...... 30 NASCOBAL...... 100 MONONINE...... 53 MYCAPSSA...... 119 NATACYN...... 148 MONOVISC...... 142 MYCOBUTIN...... 34 NATAZIA...... 125 MONSELS FERRIC mycophenolate mofetil...... 131 nateglinide...... 87 SUBSULFATE...... 53 mycophenolate mofetil hcl...... 131 NATESTO...... 117 montelukast sodium...... 158 mycophenolate sodium...... 131 NATPARA...... 136 MONUROL...... 19 MYDAYIS...... 67 NATROBA...... 43 MORGIDOX...... 19 myferon 150 forte...... 100 NATURE-THROID...... 128 morgidox...... 19 MYFORTIC...... 131 NAVELBINE...... 39 MORPHINE SULFATE...... 4, 5 MYLERAN...... 39 NAYZILAM...... 24 morphine sulfate...... 4, 5 MYLOTARG...... 39 NEBUPENT...... 43 morphine sulfate (concentrate)... 4 MYOBLOC...... 142 necon 0.5/35 (28)...... 125 morphine sulfate (pf)...... 4 myorisan...... 80 nefazodone hcl...... 27 morphine sulfate er...... 4 MYRBETRIQ...... 112 NEMBUTAL...... 24 morphine sulfate er beads...... 4 MYTESI...... 109 NEOKE ALCAR...... 100 MORPHINE SULFATE-NACL.....5 MYXREDLIN...... 94 NEOKE RA LIPOIC...... 142

182 neomycin sulfate...... 19 NIACINAMIDE- NOREPINEPHRINE (BASE)- neomycin-bacitracin zn- SPIRONOLACTONE...... 80 DEXTROSE...... 62 polymyx...... 152 NIACINAMIDE- norepinephrine bitartrate...... 62 neomycin-polymyxin b gu...... 19 SULFACETAMIDE...... 80 NOREPINEPHRINE- neomycin-polymyxin-dexameth NIACINAMIDE-TACROLIMUS..80 DEXTROSE...... 62 ...... 152 NIACINAMIDE-TAZAROTENE. 80 NOREPINEPHRINE-SODIUM neomycin-polymyxin- NIACINAMIDE-TRETINOIN...... 80 CHLORIDE...... 62, 63 gramicidin...... 152 NIACINAMIDE- norethin ace-eth estrad-fe...... 125 neomycin-polymyxin-hc.. 152, 153 TRIAMCINOLONE ACET...... 80 norethindrone...... 125 NEONATAL + DHA...... 100 NIACIN-SPIRONOLACTON- norethindrone acetate...... 125 NEONATAL COMPLETE...... 100 TRETINOIN...... 80 norethindrone acet-ethinyl est.125 NEONATAL FE...... 100 niacor...... 61 norethindrone-eth estradiol..... 125 NEONATAL PLUS...... 100 NIASPAN...... 61 norethin-eth estradiol-fe...... 125 neo-polycin...... 152 nicardipine hcl...... 62 NORGESIC FORTE...... 160 neo-polycin hc...... 152 NICARDIPINE HCL IN NACL... 62 norgestimate-eth estradiol...... 125 NEOPROFEN...... 8 NICOTROL...... 14 norgestimate-ethinyl estradiol NEORAL...... 131 NICOTROL NS...... 14 triphasic...... 125 NEOSALUS...... 80 nifedipine...... 62 NORITATE...... 80 neostigmine methylsulfate...... 33 nifedipine er...... 62 norlyda...... 125 NEOSTIGMINE nifedipine er osmotic release.... 62 norlyroc...... 125 METHYLSULFATE...... 33, 34 NIFEREX...... 100 normal saline flush...... 100 NEO-SYNALAR...... 80 nikki...... 125 NORPACE...... 63 NEOTUSS PLUS...... 155 NILANDRON...... 39 NORPACE CR...... 63 NEPHRAMINE...... 100 nilutamide...... 39 NORPRAMIN...... 27 NEPHRON FA...... 100 NIMBEX...... 69 NORTHERA...... 63 NERLYNX...... 39 nimodipine...... 62 nortrel 0.5/35 (28)...... 125 NESACAINE...... 12 NINLARO...... 39 nortrel 1/35 (21)...... 126 NESACAINE-MPF...... 12 NIPENT...... 39 nortrel 1/35 (28)...... 126 NESINA...... 87 NIPRIDE RTU...... 62 nortrel 7/7/7...... 126 NESTABS...... 100 nisoldipine er...... 62 nortriptyline hcl...... 27 NESTABS ONE...... 100 nitazoxanide...... 44 NORVIR...... 49 neuac...... 80 NITHIODOTE...... 142 NOURIANZ...... 44 NEUAC...... 80 nitisinone...... 110 NOURISH...... 142 NEULASTA...... 53 NITRO-BID...... 62 novarel...... 119 NEULASTA ONPRO...... 53 NITRO-DUR...... 62 NOVAREL...... 119 NEUPOGEN...... 53 nitrofurantoin...... 19 NOVOEIGHT...... 53 NEUPRO...... 44 nitrofurantoin macrocrystal...... 19 NOVOFINE AUTOCOVER NEURONTIN...... 24 nitrofurantoin monohydrate PEN NEEDLE...... 94 NEUTRASAL...... 71 macrocrystals...... 19 NOVOFINE PEN NEEDLE...... 94 NEVANAC...... 148 nitroglycerin...... 62 NOVOFINE PLUS PEN nevirapine...... 49 nitroglycerin in d5w...... 62 NEEDLE...... 94 nevirapine er...... 49 NITROLINGUAL...... 62 NOVOLIN 70/30 FLEXPEN...... 94 NEXAVAR...... 39 NITROMIST...... 62 NOVOLIN 70/30 FLEXPEN NEXAVIR...... 142 nitroprusside sodium...... 62 RELION...... 94 NEXIUM...... 106 NITROSTAT...... 62 NOVOLIN 70/30 RELION...... 94 NEXIUM I.V...... 106 NITRO-TIME...... 62 NOVOLIN 70/30 VIAL...... 94 NEXLETOL...... 61 NITYR...... 111 NOVOLIN N FLEXPEN...... 94 NEXLIZET...... 61 NIVESTYM...... 53 NOVOLIN N FLEXPEN NEXPLANON...... 125 nizatidine...... 106 RELION...... 94 NEXTERONE...... 61 NOCDURNA...... 119 NOVOLIN N RELION...... 94 niacin (antihyperlipidemic)...... 61 nolix...... 80 NOVOLIN N VIAL...... 94 niacin er (antihyperlipidemic).... 61 nora-be...... 125 NOVOLIN R FLEXPEN...... 94 NORDITROPIN FLEXPRO..... 119

183 NOVOLIN R FLEXPEN NUVAKAAN...... 12 OMNITROPE...... 119 RELION...... 94 NUVAKAAN-II...... 12 ONCASPAR...... 40 NOVOLIN R RELION...... 94 NUVARING...... 126 ondansetron hcl...... 28 NOVOLIN R VIAL...... 94 NUVESSA...... 19 ondansetron odt...... 28 NOVOLOG FLEXPEN...... 94 NUWIQ...... 53 ONE DROP BLOOD NOVOLOG MIX 70/30 NUZYRA...... 19 GLUCOSE MONITOR...... 91 FLEXPEN...... 94 nyamyc...... 31 ONE DROP TEST...... 91 NOVOLOG MIX 70/30 VIAL...... 94 nylia 7/7/7...... 126 ONE VITE WOMENS PLUS... 100 NOVOLOG PENFILL...... 94 NYMALIZE...... 63 ONETOUCH DELICA NOVOLOG U-100 VIAL...... 94 nymyo...... 126 LANCING DEV...... 91 NOVOPEN ECHO...... 91 nystatin...... 31 ONETOUCH DELICA PLUS NOVOSEVEN RT...... 53 nystatin-triamcinolone...... 31 LANCING...... 91 NOVOTWIST PEN NEEDLE.... 94 nystop...... 31 ONETOUCH ULTRA...... 91 NOXAFIL...... 30, 31 NYVEPRIA...... 53 ONETOUCH ULTRA 2 KIT NOZIN NASAL SANITIZER OBIZUR...... 53 W/DEVICE...... 91 POPSWAB...... 142 OCALIVA...... 111 ONETOUCH ULTRA MINI KIT np thyroid...... 128 ocella...... 126 W/DEVICE...... 91 NPLATE...... 53 OCREVUS...... 68 ONETOUCH VERIO FLEX NUBEQA...... 39 OCTAGAM...... 131 SYSTEM KIT W/DEVICE...... 91 NUCALA...... 155 octreotide acetate...... 119 ONETOUCH VERIO IQ NUCARACLINPAK...... 80 OCUFLOX...... 148 SYSTEM...... 91 NUCARARXPAK...... 80 ODACTRA...... 142 ONETOUCH VERIO KIT NUCORT...... 80 ODEFSEY...... 49 W/DEVICE...... 91 NUCYNTA...... 5 ODOMZO...... 40 ONETOUCH VERIO NUCYNTA ER...... 5 OFEV...... 158 REFLECT...... 91 NUDROXIPAK DSDR-50...... 8 ofloxacin...... 19, 148, 153 ONETOUCH VERIO SYNC NUDROXIPAK DSDR-75...... 8 OGIVRI...... 40 SYSTEM KIT W/DEVICE...... 91 NUDROXIPAK E-400...... 8 olanzapine...... 46 ONEXTON...... 80 NUDROXIPAK I-800...... 8 olanzapine-fluoxetine hcl...... 27 ONGENTYS...... 44 NUDROXIPAK M-15...... 8 OLINVYK...... 5 ONGLYZA...... 87 NUDROXIPAK N-500...... 8 OLIVE TREE...... 142 ONIVYDE...... 40 NUEDEXTA...... 69 olmesartan medoxomil...... 63 ONPATTRO...... 69 NUFERA...... 100 olmesartan medoxomil-hctz...... 63 ONTRUZANT...... 40 NULEV...... 109 olmesartan-amlodipine-hctz...... 63 ONUREG...... 40 NULOJIX...... 131 olopatadine hcl...... 148, 155 ONYCHO-MED...... 31 NULYTELY LEMON-LIME...... 109 OLUMIANT...... 131 ONZDEOXIA...... 80 NULYTELY WITH FLAVOR OLUX...... 80 ONZETRA XSAIL...... 33 PACKS...... 109 OLUX-E...... 80 OPDIVO...... 40 NUMBRINO...... 12 OMECLAMOX-PAK...... 109 OPSUMIT...... 159 NUMOISYN...... 71 omega-3-acid ethyl esters...... 63 ORABLOC...... 12 NUPLAZID...... 46 OMEGAVEN...... 100 ORACIT...... 101 NURTEC...... 33 omeprazole...... 106 ORAFATE...... 142 NUSURGEPAK SURGICAL OMEPRAZOLE+SYRSPEND ORALAIR...... 142 PREP/CARE...... 71 SF ALKA...... 106 ORALAIR ADULT STARTER NUTRASEB...... 80 omeprazole-sodium PACK...... 143 NUTRIARX CREAMPAK...... 80 bicarbonate...... 106 ORALAIR CHILDRENS NUTRIDOX...... 19 OMIDRIA...... 152 STARTER PACK...... 143 nutrilipid...... 100 OMNARIS...... 155 oralone...... 71 NUTRIVIT...... 100 OMNIPOD 5 PACK...... 142 ORAPRED ODT...... 116 NUTROPIN AQ NUSPIN 10... 119 OMNIPOD DASH 5 PACK ORAVIG...... 31 NUTROPIN AQ NUSPIN 20... 119 PODS...... 142 ORBACTIV...... 19 NUTROPIN AQ NUSPIN 5..... 119 OMNIPOD DASH SYSTEM...... 91 ORCHARD GRASS POLLEN. 143 NUVAIL...... 80 OMNIPOD STARTER...... 91 ORENCIA...... 131

184 ORENCIA CLICKJECT...... 131 OXOPOD...... 80 paroxetine mesylate...... 27 ORENITRAM...... 159 OXSORALEN ULTRA...... 81 PARSABIV...... 136 ORFADIN...... 111 OXTELLAR XR...... 24 PASER...... 34 ORGOVYX...... 40 oxybutynin chloride...... 112 PATANASE...... 155 ORIAHNN...... 126 oxybutynin chloride er...... 112 PAXIL...... 27 ORILISSA...... 119 oxycodone hcl...... 5 PAXIL CR...... 27 ORKAMBI...... 159 OXYCODONE HCL ER...... 5 P-CARE K40...... 116 ORLADEYO...... 131 OXYCODONE- P-CARE K40G...... 116 ORMECA...... 8 ACETAMINOPHEN...... 6 P-CARE K40MX...... 116 orphenadrine citrate...... 160 oxycodone-acetaminophen...... 6 P-CARE K80...... 116 orphenadrine citrate er...... 160 oxycodone-aspirin...... 6 P-CARE K80G...... 116 orphenadrine-asa-caffeine...... 160 OXYCONTIN...... 6 P-CARE K80MX...... 116 ORPHENGESIC FORTE...... 160 oxymorphone hcl...... 6 PCP 100...... 109 orsythia...... 126 oxymorphone hcl er...... 6 PEDIAPRED...... 116 ORTHO DF...... 101 oxytocin...... 119 PEDIARIX...... 133 ORTHO MICRONOR...... 126 OXYTOCIN-LACTATED PEDIATRIC PANDA MASK.... 143 ORTHOVISC...... 143 RINGERS...... 119 PEDVAX HIB...... 133 ORTIKOS...... 135 OXYTOCIN-SODIUM peg 3350-kcl-na bicarb-nacl....109 oscimin...... 109 CHLORIDE...... 119, 120 peg-3350/electrolytes...... 109 oscimin sr...... 109 OXYTROL...... 112 peg-3350/electrolytes/ascorbat oseltamivir phosphate...... 49 OZEMPIC...... 87 ...... 109 OSENI...... 87 OZOBAX...... 160 PEGASYS...... 49 OSMITROL...... 63 OZURDEX...... 148 PEGINTRON...... 49 OSMOLEX ER...... 45 PACERONE...... 63 peg-kcl-nacl-nasulf-na asc-c... 109 OSMOPREP...... 109 paclitaxel...... 40 peg-prep...... 109 OSPHENA...... 118 PADCEV...... 40 PEMAZYRE...... 40 OTEZLA...... 131 PAINGO KFT...... 12 penicillamine...... 112 OTIPRIO...... 153 PALFORZIA...... 143 PENICILLIN G POT IN OTOVEL...... 153 paliperidone er...... 46 DEXTROSE...... 19 OTREXUP...... 131 palonosetron hcl...... 28 penicillin g potassium...... 19 OVACE PLUS...... 80 PALYNZIQ...... 111 penicillin g procaine...... 19 OVACE PLUS WASH...... 80 pamidronate disodium...... 135 penicillin g sodium...... 20 OVACE WASH...... 80 PANCREAZE...... 111 penicillin v potassium...... 20 OVIDE...... 44 pancuronium bromide...... 69 PENICILLIUM NOTATUM...... 143 OVIDREL...... 119 PANDA MASK LARGE...... 143 PENLEN...... 81 oxacillin sodium...... 19 PANDA MASK MEDIUM...... 143 PENNSAID...... 8 OXACILLIN SODIUM IN PANDA MASK SMALL...... 143 PENTACEL...... 133 DEXTROSE...... 19 PANDEL...... 81 PENTAM...... 44 oxaliplatin...... 40 PANRETIN...... 40 pentamidine isethionate...... 44 oxandrolone...... 117 pantoprazole sodium...... 106 PENTASA...... 135 oxaprozin...... 8 PANZYGA...... 131 pentazocine-naloxone hcl...... 6 OXAYDO...... 5 papaverine hcl...... 63 PENTETATE CALCIUM oxazepam...... 51 PARADIGM QUICK-SET 23" TRISODIUM...... 143 OXBRYTA...... 143 9MM...... 143 PENTETATE ZINC oxcarbazepine...... 24 PARAGARD INTRAUTERINE TRISODIUM...... 143 OXERVATE...... 152 COPPER...... 126 pentobarbital sodium...... 24 OXIANUJO...... 80 paraplatin...... 40 PENTOSAN POLYSULFATE OXIATAR...... 80 paricalcitol...... 136 SODIUM...... 112 OXIAVARRY...... 80 PARLODEL...... 45 pentoxifylline er...... 63 OXIAZAR...... 80 PARNATE...... 27 PERENNIAL RYE GRASS oxiconazole nitrate...... 31 paromomycin sulfate...... 19 POLLEN...... 143 OXISTAT...... 31 paroxetine hcl...... 27 PERFOROMIST...... 158 OXLUMO...... 112 paroxetine hcl er...... 27 PERIDEX...... 71

185 PERIKABIVEN...... 101 PHOTREXA-PHOTREXA POINT OF CARE LM DEP 2...116 perindopril erbumine...... 63 VISCOUS KIT...... 143 POINT OF CARE LM-2.2...... 12 periogard...... 71 PHOXILLUM B22K4/0...... 101 POINT OF CARE LM-2.5...... 12 PERJETA...... 40 PHOXILLUM BK4/2.5...... 101 POLIDOCANOL...... 64 permethrin...... 44 PHYSICIANS EZ USE B-12....101 POLIVY...... 40 perphenazine...... 29 PHYSICIANS EZ USE polocaine...... 12 perphenazine-amitriptyline...... 27 JOINT/TUNNEL...... 116 polocaine-mpf...... 12 PERSERIS...... 46 PHYSICIANS EZ USE M- polycin...... 152 PERTZYE...... 111 PRED...... 116 poly-iron 150 forte...... 101 PEXEVA...... 27 PHYSIOLYTE...... 101 polymyxin b sulfate...... 20 PFIZER-BIONTECH COVID- PHYSIOSOL IRRIGATION..... 101 polymyxin b-trimethoprim...... 152 19 VACC...... 133 PHYSOSTIGMINE polysaccharide iron forte...... 101 PFIZERPEN...... 20 SALICYLATE...... 143 POLYTRIM...... 152 PHENACTIN AA PLUS...... 143 phytonadione...... 101 POLY-VI-FLOR...... 101 phenazo...... 112 PICATO...... 81 POLY-VI-FLOR/IRON...... 101 phenazopyridine hcl...... 112 PIFELTRO...... 49 POMALYST...... 40 phendimetrazine tartrate...... 69 pilocarpine hcl...... 71, 150 portia-28...... 126 phendimetrazine tartrate er...... 69 pimecrolimus...... 81 PORTRAZZA...... 40 phenelzine sulfate...... 27 pimozide...... 46 posaconazole...... 31 PHENERGAN...... 155 pimtrea...... 126 potassium acetate...... 101 phenobarbital...... 24 pindolol...... 64 potassium chloride...... 101 phenobarbital sodium...... 24 pioglitazone hcl...... 87 potassium chloride crys er...... 101 PHENOL...... 143 pioglitazone hcl-glimepiride...... 87 potassium chloride er...... 101 phenoxybenzamine hcl...... 63 pioglitazone hcl-metformin hcl.. 87 potassium citrate er...... 101 phentermine hcl...... 69 piperacillin sod-tazobactam so..20 potassium citrate-citric acid.....101 phentolamine mesylate...... 63 PIQRAY...... 40 potassium phosphates...... 101 PHENYLEPHRINE HCL... 63, 152 pirmella 1/35...... 126 potassium phosphates(66 meq phenylephrine hcl...... 63, 152 pirmella 7/7/7...... 126 k)...... 101 PHENYLEPHRINE HCL piroxicam...... 8 potassium phosphates(71 meq (PRESSORS)...... 63 PITOCIN...... 120 k)...... 101 PHENYLEPHRINE HCL-NACL PKU EASY...... 143 POTELIGEO...... 40 ...... 63, 64 PKU EASY MICROTABS...... 143 POVIDONE-IODINE...... 148 PHENYTEK...... 24 PKU GO...... 143 PR BENZOYL PEROXIDE...... 81 phenytoin...... 25 PLAVIX...... 45 PR BENZOYL PEROXIDE phenytoin infatabs...... 25 PLEGRIDY...... 68 WASH...... 81 phenytoin sodium...... 25 PLEGRIDY STARTER PACK... 68 PR CREAM...... 81 phenytoin sodium extended...... 25 PLENAMINE...... 101 PRADAXA...... 23 PHEODOYO...... 31 PLENVU...... 109 PRALUENT...... 64 PHESGO...... 40 PLEXION...... 81 pramipexole dihydrochloride..... 45 PHEXXI...... 143 PLEXION CLEANSER...... 81 pramipexole dihydrochloride er.45 PHEYO...... 31 PLEXION CLEANSING PRAMOTIC...... 153 philith...... 126 CLOTH...... 81 pramox...... 81 PHLAG SPRAY...... 81 PLIAGLIS...... 12 PRASTERA...... 9 PHOMA EXIGUA...... 143 PNEUMOVAX 23...... 133 prasugrel hcl...... 45 PHOSLYRA...... 112 PNV TABS 20-1...... 101 pravastatin sodium...... 64 PHOSPHA 250 NEUTRAL...... 101 POCKET SPACER...... 143 PRAXBIND...... 143 PHOSPHASAL...... 112 POD-CARE 100K...... 116 praziquantel...... 44 PHOSPHOLINE IODIDE...... 150 podocon...... 81 prazosin hcl...... 64 phosphorous...... 101 podofilox...... 81 PRECEDEX...... 143 phospho-trin 250 neutral...... 101 PODPROG...... 81 PRECISION LINK...... 91 PHOTOFRIN...... 40 POINT OF CARE KM...... 116 PRECISION PCX PLUS TEST. 91 PHOTREXA VISCOUS...... 143 POINT OF CARE L.2...... 116 PRECISION QID MONITOR.....91 POINT OF CARE L.5...... 116 PRECISION QID TEST...... 91

186 PRECISION SOF-TACT prenatal vitamin plus low iron..102 PRIMSOL...... 20 MONITOR...... 91 PRENATE DHA...... 102 PRISMASOL B22GK 4/0...... 102 PRECISION SOF-TACT TEST. 91 PRENATE ELITE...... 102 PRISMASOL BGK 0/2.5...... 102 PRECISION XTRA...... 91 PRENATE ENHANCE...... 102 PRISMASOL BGK 2/0...... 102 PRECISION XTRA BLOOD PRENATE ESSENTIAL...... 102 PRISMASOL BGK 2/3.5...... 102 GLUCOSE...... 91 PRENATE MINI...... 102 PRISMASOL BGK 4/0/1.2...... 102 PRECISION XTRA MONITOR..91 PRENATE PIXIE...... 102 PRISMASOL BGK 4/2.5...... 102 PRECOSE...... 87 PRENATE RESTORE...... 102 PRISMASOL BK 0/0/1.2...... 102 PRED FORTE...... 148 PRENATRIX...... 102 PRIVET...... 143 PRED MILD...... 148 PRENATRYL...... 102 PRIVIGEN...... 131 PRED-G...... 152 PRENATVITE COMPLETE.....102 PRIZOPAK II...... 13 PRED-G S.O.P...... 152 PRENATVITE PLUS...... 102 PRIZOTRAL...... 13 prednicarbate...... 81 PRENATVITE RX...... 102 PRIZOTRAL-II...... 13 PREDNISOL ACE- PREPIV SUPPLY...... 12 PRO COMFORT SPACER MOXIFLOX-BROMFEN...... 148 preplus...... 102 ADULT...... 143 prednisolone...... 116 PRESERA...... 81 PRO COMFORT SPACER prednisolone acetate...... 148 PRESTALIA...... 64 CHILD...... 143 prednisolone acetate p-f...... 148 PRETAB...... 102 PRO COMFORT SPACER PREDNISOLONE ACETATE- PRETOMANID...... 34 INFANT...... 143 NEPAFENAC...... 152 prevalite...... 64 PROAIR DIGIHALER...... 158 PREDNISOLONE ACET- PREVIDENT...... 71 PROAIR HFA...... 158 MOXIFLOXACIN...... 152 prevident...... 71 PROAIR RESPICLICK...... 158 prednisolone sodium PREVIDENT 5000 BOOSTER probenecid...... 32 phosphate...... 116, 148 PLUS...... 71 PROBICHEW...... 109 PREDNISOLONE- PREVIDENT 5000 DRY PROBUPHINE IMPLANT KIT..... 6 BROMFENAC...... 152 MOUTH...... 71 procainamide hcl...... 64 PREDNISOLONE- PREVIDENT 5000 ENAMEL PROCALAMINE...... 102 GATIFLOXACIN...... 152 PROTECT...... 71 PROCARDIA...... 64 PREDNISOLONE- PREVIDENT 5000 ORTHO PROCARDIA XL...... 64 MOXIFLOXACIN...... 152 DEFENSE...... 71 PROCARE SPACER/ADULT PREDNISOLON-GATIFLOX- PREVIDENT 5000 PLUS...... 71 MASK...... 143 BROMFENAC...... 152 PREVIDENT 5000 SENSITIVE.71 PROCARE SPACER/CHILD PREDNISOLON-MOXIFLOX- previfem...... 126 MASK...... 143 BROMFENAC...... 152 PREVNAR 13...... 133 PRO-C-DURE 5...... 116 PREDNISOLON-MOXIFLOX- PREVYMIS...... 49 PRO-C-DURE 6...... 116 NEPAFENAC...... 148 PREZCOBIX...... 49 PROCENTRA...... 67 prednisone...... 116 PREZISTA...... 49 prochlorperazine...... 29 prednisone intensol...... 116 PRIFTIN...... 34 prochlorperazine edisylate...... 29 PREFEST...... 126 PRILO PATCH...... 12 prochlorperazine maleate...... 29 pregabalin...... 69 PRILO PATCH II...... 12 PROCRIT...... 53 PREGEN DHA...... 101 PRILOLID...... 12 PROCTOFOAM HC...... 135 PREGENNA...... 101 PRILOSEC...... 106 procto-med hc...... 135 pregnyl...... 120 PRILOVIX...... 12 procto-pak...... 135 PREMARIN...... 126 PRILOVIX LITE...... 12 proctozone-hc...... 135 PREMASOL...... 101 PRILOVIX LITE PLUS...... 12 PROCYSBI...... 111 premium lidocaine...... 12 PRILOVIX PLUS...... 13 PRODIGEN...... 109 PREMIUM SCAR...... 12 PRILOVIX ULTRALITE...... 13 PRODIGY NO CODING PREMPHASE...... 126 PRILOVIX ULTRALITE PLUS...13 BLOOD GLUC...... 91 PREMPRO...... 126 PRILOVIXIL...... 13 PROFILNINE...... 53 PRENAISSANCE...... 101 PRIMACARE...... 102 progesterone...... 126 PRENARA...... 101 primaquine phosphate...... 44 progesterone micronized...... 126 prenatal...... 102 PRIMAXIN IV...... 20 PROGESTERONE- prenatal plus iron...... 102 primidone...... 25 MINOXIDIL...... 81

187 PROGLYCEM...... 92 PYLERA...... 109 RADIAGEL...... 81 PROGRAF...... 131 pyrazinamide...... 34 RADIAPLEXRX...... 81 PROLASTIN-C...... 158 PYRIDIUM...... 112 RADICAVA...... 69 PROLATE...... 6 pyridostigmine bromide...... 34 RADIOGARDASE...... 144 PROLENSA...... 148 pyridostigmine bromide er...... 34 RAGWITEK...... 144 PROLEUKIN...... 40 PYRIDOXAL-5 PHOSPHATE. 102 raloxifene hcl...... 118 PROLIA...... 135 pyridoxine hcl...... 102 ramelteon...... 161 PROMACTA...... 53 PYRIDOXINE HCL...... 102 ramipril...... 64 PROMACTIN AA PLUS 20PE 143 pyrimethamine...... 44 ranolazine er...... 64 PROMELLA IN PREBIOTIC... 109 PYRIMETHAMINE- RAPAFLO...... 113 promethazine hcl...... 155 LEUCOVORIN...... 44 RAPAMUNE...... 131 promethazine vc...... 155 PYROGALLIC ACID...... 81 RAPIVAB...... 49 promethazine vc/codeine...... 155 QBRELIS...... 64 RAPPORT RLS...... 144 promethazine-codeine...... 155 QBREXZA...... 81 RAPPORT VTD...... 144 promethazine-dm...... 155 QDOLO...... 6 rasagiline mesylate...... 45 promethazine-phenyleph- QINLOCK...... 40 RASUVO...... 131 codeine...... 155 QMIIZ ODT...... 9 RAVICTI...... 111 promethazine-phenylephrine.. 155 QNASL...... 155 RAYALDEE...... 135 promethegan...... 155 QNASL CHILDRENS...... 155 RAYOS...... 116 PROMISEB...... 81 QSYMIA...... 69 RAZADYNE ER...... 26 propafenone hcl...... 64 QTERN...... 87 READYSHARP ANESTH + propafenone hcl er...... 64 QUADRACEL...... 133 BETAMETH...... 116 proparacaine hcl...... 152 QUADRAMET...... 40 READYSHARP ANESTH + propranolol hcl...... 64 QUALAQUIN...... 44 DEXAMETH...... 116 propranolol hcl er...... 64 QUARTETTE...... 126 READYSHARP ANESTH + propranolol-hctz...... 64 quazepam...... 51 KETOROLAC...... 9 propylthiouracil...... 128 QUDEXY XR...... 25 READYSHARP ANESTH + PROQUAD...... 133 QUEEN PALM...... 144 METHYLPRED...... 116 PROSCAR...... 113 QUELICIN...... 69 READYSHARP PROSILK...... 81 QUESTRAN...... 64 BETAMETHASONE...... 116 PROSOL...... 102 QUESTRAN LIGHT...... 64 READYSHARP PROSTIN VR...... 64 quetiapine fumarate...... 46 DEXAMETHASONE...... 116 protamine sulfate...... 53 quetiapine fumarate er...... 47 READYSHARP-A...... 13 PROTEXA...... 81 QUFLORA FE...... 102 REBIF...... 68 PROTHELIAL...... 143 QUFLORA FE PEDIATRIC.....102 REBIF REBIDOSE...... 68 PROTONIX...... 106 QUFLORA GUMMIES...... 102 REBIF REBIDOSE PROTOPAM CHLORIDE...... 143 QUFLORA PEDIATRIC...... 102 TITRATION PACK...... 68 PROTOPIC...... 81 QUIHOXVAR...... 81 REBIF TITRATION PACK...... 68 protriptyline hcl...... 27 QUILLICHEW ER...... 67 REBINYN...... 53 PROVAYBLUE...... 144 QUILLIVANT XR...... 67 REBLOZYL...... 53 PROVENGE...... 131 quinapril hcl...... 64 RECARBRIO...... 20 PROVENTIL HFA...... 158 quinapril-hydrochlorothiazide.... 64 RECK...... 13 PROVERA...... 126 quinidine gluconate er...... 64 RECLAST...... 135 PROVISC...... 152 quinidine sulfate...... 64 reclipsen...... 126 PRUCLAIR...... 81 quinine sulfate...... 44 RECOMBINATE...... 53 PRUMYX...... 81 QUTENZA...... 81 RECOMBIVAX HB...... 133 pseudoephedrine-bromphen- QUTENZA (2 PATCH)...... 81 RECOTHROM...... 53 dm...... 155 QUZYTTIR...... 155 RECOTHROM SPRAY KIT...... 53 PSORCON...... 81 QVAR REDIHALER...... 158 RECTIV...... 64 PULMICORT FLEXHALER.....158 RABAVERT...... 133 RECURA...... 31 PULMOZYME...... 159 RABBIT EPITHELIUM...... 144 RED MAPLE...... 144 purevit dualfe plus...... 102 RABEPRAZOLE SODIUM...... 106 RED MULBERRY...... 144 PURIXAN...... 40 rabeprazole sodium...... 106 RED TOP GRASS POLLEN... 144

188 REDITREX...... 131 REXASIL PATCH & VITAMIN ROPIVACAINE HCL-NACL...... 13 REGENECARE...... 81 E LIQ...... 82 ROPIV-CLONIDINE- REGIOCIT...... 23 REXULTI...... 47 KETOROLAC...... 13 REGLAN...... 29 REYATAZ...... 49 rosadan...... 82 REGONOL...... 34 REYVOW...... 33 ROSADAN...... 82 REGRANEX...... 81 RHIZOPUS...... 144 rosuvastatin calcium...... 65 RELADOR PAK...... 13 RHOFADE...... 82 ROTARIX...... 133 RELADOR PAK PLUS...... 13 RHOGAM ULTRA-FILTERED ROTATEQ...... 133 RELAFEN...... 9 PLUS...... 131 ROUGH MARSH ELDER...... 144 RELAFEN DS...... 9 RHOPHYLAC...... 131 ROWASA...... 135 RELENZA DISKHALER...... 49 RHOPRESSA...... 150 roweepra...... 25 relexxii...... 67 RIABNI...... 40 ROZEREM...... 161 RELION BLOOD GLUCOSE RIASTAP...... 53 ROZLYTREK...... 40 TEST...... 91 RIAX...... 82 RUBRACA...... 40 RELION PREMIER CLASSIC...91 ribavirin...... 49 RUCONEST...... 131 RELION PREMIER TEST...... 91 RIDAURA...... 131 rufinamide...... 25 RELISTOR...... 109 rifabutin...... 34 RUKOBIA...... 49 RELNATE DHA...... 102 RIFADIN...... 34 RUSSIAN THISTLE...... 144 RELTONE...... 109 rifampin...... 34 RUXIENCE...... 40 REMERON...... 27 RILUTEK...... 69 RUZURGI...... 144 REMERON SOLTAB...... 27 riluzole...... 69 RYANODEX...... 161 REMESENSE...... 71 rimantadine hcl...... 49 RYBELSUS...... 87 REMICADE...... 131 RIMSO-50...... 112 RYCLORA...... 155 remifentanil hcl...... 6 ringers irrigation...... 103 RYDAPT...... 40 REMIGEN...... 81 RINVOQ...... 131 RYTARY...... 45 REMODULIN...... 159 RIOMET...... 87 RYTHMOL SR...... 65 RENACIDIN...... 112 risedronate sodium...... 135 ryvent...... 155 RENAGEL...... 112 RISPERDAL...... 47 SACCHAROMYCES RENATABS WITH IRON...... 103 RISPERDAL CONSTA...... 47 CEREVISIAE...... 144 RENFLEXIS...... 131 risperidone...... 47 SAFYRAL...... 126 repaglinide...... 87 RITALIN...... 67 SAIZEN...... 120 REPATHA...... 64 RITALIN LA...... 67 SAIZENPREP...... 120 REPATHA PUSHTRONEX ritonavir...... 49 SALAGEN...... 71 SYSTEM...... 65 RITUXAN...... 40 SALEX...... 82 REPATHA SURECLICK...... 65 RITUXAN HYCELA...... 40 salicylic acid...... 82 RESORCINOL-SULFUR...... 81 rivastigmine...... 26 salicylic acid er...... 82 RESTASIS...... 153 rivastigmine tartrate...... 26 salicylic acid wart remover...... 82 RESTASIS MULTIDOSE...... 153 rivelsa...... 126 salicylic acid-cleanser...... 82 RESTORA RX...... 109 RIXUBIS...... 53 SALICYLIC ACID- RETACRIT...... 53 rizatriptan benzoate...... 33 SULFACETAMIDE...... 82 RETAVASE...... 23 ROAOXIA...... 82 salimez...... 82 RETAVASE HALF-KIT...... 23 ROBAXIN...... 160 SALIMEZ FORTE...... 82 RETEVMO...... 40 ROBAXIN-750...... 161 saline bacteriostatic...... 103 RETIN-A...... 82 ROCALTROL...... 136 saline flush...... 103 RETIN-A MICRO PUMP...... 82 ROCKLATAN...... 150 saline flush zr...... 103 RETISERT...... 148 rocuronium bromide...... 69 SALINE-PHENOL...... 103 RETROVIR...... 49 ROCURONIUM BROMIDE...... 69 SALIVAMAX...... 71 REVATIO...... 159 ROMIDEPSIN...... 40 salsalate...... 9 REVCOVI...... 111 ROPIDEX...... 116 SALVAX...... 82 REVESTA...... 103 ropinirole hcl...... 45 SALVAX DUO PLUS...... 82 REVLIMID...... 40 ropinirole hcl er...... 45 SAMSCA...... 103 revonto...... 160 ropivacaine hcl...... 13 SANADERMRX SKIN REPAIR.82 ROPIVACAINE HCL...... 13 SANCUSO...... 29

189 SANDIMMUNE...... 131 SHEEP SORREL...... 144 SODIUM CITRATE LOCK SANDOSTATIN LAR DEPOT. 120 SHINGRIX...... 133 FLUSH...... 23 SANTYL...... 82 SHORT RAGWEED POLLEN SODIUM CITRATE- SAPHRIS...... 47 EXT...... 144 GENTAMICIN SULF...... 23 sapropterin dihydrochloride.....111 SIGNIFOR...... 120 SODIUM DIURIL...... 65 SARCLISA...... 40 SIGNIFOR LAR...... 120 SODIUM EDECRIN...... 65 SAVAYSA...... 23 SIKLOS...... 40 sodium fluoride...... 71, 104 SAVELLA...... 69 sildenafil citrate...... 160 sodium fluoride 5000 enamel....71 SAVELLA TITRATION PACK... 69 SILENOR...... 161 sodium fluoride 5000 plus...... 71 SAXENDA...... 69 SILHOUETTE 23" INFUSION sodium fluoride 5000 ppm...... 71 SCALACORT DK...... 82 SET...... 144 sodium fluoride 5000 sensitive..71 SCARCARE GEL-PAD SILHOUETTE 43" INFUSION sodium nitrite...... 144 KIT/LARGE...... 82 SET...... 144 sodium nitroprusside...... 65 SCARZEN SKIN REPAIR...... 82 SILHOUETTE INFUSION SET sodium phenylbutyrate...... 111 SCENESSE...... 82 18"...... 144 sodium phosphates...... 104 SCLEROSOL SILIPAC...... 82 sodium polystyrene sulfonate. 104 INTRAPLEURAL...... 158 SILIQ...... 131 sodium saccharin...... 144 scopolamine...... 29 silodosin...... 113 sodium sulfacetamide...... 82 SEASONIQUE...... 126 SILVADENE...... 20 sodium sulfacetamide wash...... 82 SEBUDERM...... 82 silver nitrate...... 20 SODIUM SULFACETAMIDE- SECUADO...... 47 silver sulfadiazine...... 20 BAKUCHIOL...... 82 SEEBRI NEOHALER...... 158 SIMBRINZA...... 150 sodium tetradecyl sulfate...... 65 SEGLUROMET...... 87 simliya...... 126 SODIUM THIOSULFATE...... 144 SELECT-OB...... 103 simpesse...... 126 sodium thiosulfate...... 144 selegiline hcl...... 45 SIMPONI...... 131 SOFOSBUVIR-VELPATASVIR.49 SELENIOUS ACID...... 103 SIMPONI ARIA...... 131 solifenacin succinate...... 112 SELENIUM...... 103 SIMULECT...... 132 SOLIQUA...... 87 selenium sulfide...... 82 simvastatin...... 65 SOLIRIS...... 53 SELRX...... 82 SINEMET...... 45 SOLOSEC...... 20 SELZENTRY...... 49 SINUVA...... 155 SOLTAMOX...... 41 SEMGLEE...... 94 sirolimus...... 132 SOLU-CORTEF...... 116 SENSORCAINE...... 13 SIRTURO...... 34 SOLU-MEDROL...... 116, 117 SENSORCAINE/EPINEPHRIN SITAVIG...... 49 SOMATULINE DEPOT...... 120 E...... 13 SIVEXTRO...... 20 SOMAVERT...... 120 SENSORCAINE-MPF...... 13 SKELAXIN...... 161 SOOLANTRA...... 82 sensorcaine-mpf...... 13 SKLICE...... 44 SOOTHEE...... 13 SENSORCAINE- SKYADERM-LP...... 13 SORBITOL...... 144 MPF/EPINEPHRINE...... 13 SKYLA...... 126 sorbitol...... 144 SEREVENT DISKUS...... 158 SKYRIZI (150 MG DOSE)...... 132 sorbitol-mannitol...... 144 SERNIVO...... 82 SLYND...... 126 SORIATANE...... 82 SEROSTIM...... 109 SMOFLIPID...... 103 SORILUX...... 82 sertraline hcl...... 27 sod benz-sod phenylacet...... 111 sorine...... 65 se-tan plus...... 103 sod citrate-citric acid...... 103 SORREL/DOCK MIX...... 144 setlakin...... 126 sodium acetate...... 103 SOTALOL HCL...... 65 sevelamer carbonate...... 112 sodium bicarbonate...... 103, 109 sotalol hcl...... 65 sevelamer hcl...... 112 SODIUM BICARBONATE...... 103 sotalol hcl (af)...... 65 SEVENFACT...... 53 SODIUM BICARBONATE- SOTRADECOL...... 65 SEYSARA...... 20 DEXTROSE...... 103 SOTYLIZE...... 65 sf...... 71 sodium chloride...... 103, 104, 155 SOVALDI...... 49 sf 5000 plus...... 71 sodium chloride (pf)...... 103 spinosad...... 44 SFROWASA...... 135 sodium chloride bacteriostatic.103 SPINY PIGWEED...... 144 SHAGBARK HICKORY...... 144 sodium chloride flush...... 103 SPIRIVA HANDIHALER...... 158 sharobel...... 126 SODIUM CITRATE...... 23 SPIRIVA RESPIMAT...... 158

190 spironolactone...... 65 SUBSYS...... 6 SURE T INFUSION SET spironolactone-hctz...... 65 subvenite...... 25 32"/10MM...... 145 SPORANOX...... 31 subvenite starter kit-blue...... 25 SURE T INFUSION SET SPORANOX PULSEPAK...... 31 subvenite starter kit-green...... 25 32"/6MM...... 145 SPRAVATO (56 MG DOSE)..... 27 subvenite starter kit-orange...... 25 SURE T INFUSION SET SPRAVATO (84 MG DOSE)..... 27 SUCCINYLCHOLINE 32"/8MM...... 145 sprintec 28...... 126 CHLORIDE...... 69, 70 SURESTEP PRO HIGH SPRITAM...... 25 succinylcholine chloride...... 70 GLUCOSE...... 92 SPRIX...... 9 SUCRAID...... 111 SURESTEP PRO LOW SPRYCEL...... 41 sucralfate...... 106 GLUCOSE...... 92 sps...... 104 SULAR...... 65 SURESTEP PRO NORMAL sronyx...... 127 SULCONAZOLE NITRATE...... 31 GLUCOSE...... 92 ssd...... 20 sulfacetamide sodium...... 83, 149 SURVANTA...... 155 SSKI...... 155 sulfacetamide sodium (acne).... 83 SUSTIVA...... 49 sss 10-5...... 83 sulfacetamide sodium-sulfur..... 83 SUSTOL...... 29 STALEVO 100...... 45 sulfacetamide sod-sulfur wash..83 SUTAB...... 109 STALEVO 125...... 45 sulfacetamide-prednisolone.... 153 SUTENT...... 41 STALEVO 150...... 45 sulfacetamide-sulfur in urea...... 83 SUVICORT...... 83 STALEVO 200...... 45 SULFACLEANSE 8/4...... 83 swabflush saline flush...... 104 STALEVO 50...... 45 sulfadiazine...... 20 SWEET GUM...... 145 STALEVO 75...... 45 sulfamethoxazole-trimethoprim.20 SWEET VERNAL GRASS STAMARIL...... 134 sulfamez wash...... 83 POLLEN...... 145 STARLIX...... 87 SULFAMYLON...... 20 SX1 MEDICATED POST- stavudine...... 49 sulfasalazine...... 135 OPERATIVE...... 13 STEGLATRO...... 87 sulfatrim pediatric...... 20 syeda...... 127 STEGLUJAN...... 87 sulfurated lime...... 44 SYLVANT...... 41 STELARA...... 132 sulindac...... 9 SYMAX DUOTAB...... 109 STEMPHYLIUM...... 144 SUMADAN...... 83 SYMAX-SR...... 109 STERILE DILUENT FLOLAN SUMADAN WASH...... 83 SYMBICORT...... 158 PH 12...... 144 SUMADAN XLT...... 83 SYMBYAX...... 27 sterile diluent/epoprostenol..... 144 SUMANSETRON...... 33 SYMDEKO...... 159 STERILE TALC POWDER...... 158 sumatriptan...... 33 SYMFI...... 50 STERILE TOPICAL L.E.T. sumatriptan succinate...... 33 SYMFI LO...... 50 GEL...... 13 sumatriptan succinate refill...... 33 SYMJEPI...... 158 sterile water for injection...... 144 sumatriptan-naproxen sodium.. 33 SYMLINPEN 120...... 87 sterile water for irrigation...... 104 SUMAXIN...... 83 SYMLINPEN 60...... 87 STERITALC...... 158 SUMAXIN CP...... 83 SYMPAZAN...... 25 STIMATE...... 120 SUMAXIN WASH...... 83 SYMPROIC...... 109 STIOLTO RESPIMAT...... 158 SUNOSI...... 161 SYMTUZA...... 50 STIVARGA...... 41 SUPARTZ FX...... 145 SYNAGIS...... 132 STRATA CTX...... 83 SUPPRELIN LA...... 120 SYNALAR...... 83 STRATA GRT...... 83 SUPRAX...... 20 SYNALAR (CREAM)...... 83 STRATA MARK...... 83 SUPREP BOWEL PREP KIT..109 SYNALAR (OINTMENT)...... 83 STRATA XRT...... 83 SURE RESULT O3D3 SYNALAR TS...... 83 STRENSIQ...... 111 SYSTEM...... 65 SYNAREL...... 120 streptomycin sulfate...... 20 SURE T INFUSION SET SYNDROS...... 29 STRIBILD...... 49 18"/6MM...... 145 SYNERA...... 13 STRIVERDI RESPIMAT...... 158 SURE T INFUSION SET SYNERCID...... 20 STROMECTOL...... 44 23"/10MM...... 145 SYNERDERM...... 83 STRONTIUM CHLORIDE SR- SURE T INFUSION SET SYNJARDY...... 87 89...... 41 23"/6MM...... 145 SYNJARDY XR...... 87 SUBLOCADE...... 14 SURE T INFUSION SET SYNRIBO...... 41 SUBOXONE...... 14 23"/8MM...... 145 SYNTHROID...... 128

191 SYNVISC...... 145 TAZICEF...... 20 TETRIX...... 84 SYNVISC ONE...... 145 TAZORAC...... 84 TEXACORT...... 84 T: SLIM X2 INS taztia xt...... 65 THALOMID...... 41 PMP/CONTROL 7.4...... 145 TAZVERIK...... 41 THAM...... 104 T:SLIM X2 INS TDVAX...... 134 THE LIQUILIFT TRACE...... 104 PUMP/CONTROL-IQ...... 145 TECARTUS...... 41 THEO-24...... 158 T:SLIM X2 INSULIN PMP TECENTRIQ...... 41 theophylline...... 158 BASAL IQ...... 145 TECFIDERA...... 68 theophylline er...... 158 T:SLIM X2 INSULIN PMP TEFLARO...... 20 theophylline in d5w...... 158 BASAL6.4...... 145 TEGSEDI...... 70 THERAHONEY...... 84 T:SLIM X2 INSULIN TEKTURNA...... 65 thiamine hcl...... 104 PMP/RFURB IQ...... 145 TEKTURNA HCT...... 65 THIOLA EC...... 112 T:SLIM X2/CONTROL- TELFA AMD ISLAND thioridazine hcl...... 47 IQ/REFURB...... 145 DRESSING...... 145 thiotepa...... 41 TABLOID...... 41 TELFA AMD NON- thiothixene...... 47 TABRECTA...... 41 ADHERENT...... 145 THRIVACIN 30...... 145 TACHOSIL...... 145 telmisartan...... 65 THRIVACIN DETOX...... 145 TACLONEX...... 83 telmisartan-amlodipine...... 65 THROMBIN-JMI...... 53 TACROLIMUS...... 83 telmisartan-hctz...... 65 THROMBIN-JMI EPISTAXIS.... 53 tacrolimus...... 83, 132 temazepam...... 161 THROMBOGEN...... 53 tadalafil...... 112 TEMIXYS...... 50 THYMOGLOBULIN...... 132 tadalafil (pah)...... 160 TEMODAR...... 41 THYQUIDITY...... 128 TAFINLAR...... 41 TEMOVATE...... 84 tiadylt er...... 65 TAGRISSO...... 41 temozolomide...... 41 tiagabine hcl...... 25 TAKHZYRO...... 132 temsirolimus...... 132 TIAZAC...... 65 TALICIA...... 110 TENCON...... 6 TIBSOVO...... 41 TALL RAGWEED...... 145 teniposide...... 41 TICE BCG...... 132 TALTZ...... 132 TENIVAC...... 134 TIGAN...... 29 TALZENNA...... 41 tenofovir disoproxil fumarate.....50 tigecycline...... 20 TAMIFLU...... 50 TENORETIC 100...... 65 TIGLUTIK...... 70 tamoxifen citrate...... 41 TENORETIC 50...... 65 TIKOSYN...... 65 tamsulosin hcl...... 113 TEPADINA...... 41 tilia fe...... 127 TAPAZOLE...... 128 TEPEZZA...... 120 timolol maleate...... 65, 150 TAPERDEX 12-DAY...... 117 terazosin hcl...... 113 timolol maleate pf...... 150 TAPERDEX 6-DAY...... 117 terbinafine hcl...... 31 TIMOLOL-BRIMON-DORZOL- TAPERDEX 7-DAY...... 117 terbutaline sulfate...... 158 LATANOPR...... 150 TARDEOXIA...... 83 terconazole...... 31 TIMOLOL-BRIMONIDINE- TARDIMAXIA...... 83 TERIPARATIDE DORZOLAMID...... 150 TARGRETIN...... 41 (RECOMBINANT)...... 135 TIMOLOL-DORZOLAMID- tarina 24 fe...... 127 TESSALON PERLES...... 155 LATANOPROST...... 150 tarina fe 1/20...... 127 TESTONE CIK...... 117 TIMOPTIC...... 150 tarina fe 1/20 eq...... 127 TESTOPEL...... 117 TIMOPTIC OCUDOSE...... 150 TARKA...... 65 TESTOSTERONE...... 118 TIMOTHY GRASS POLLEN TAROXIA...... 83 testosterone...... 118 ALLERGEN...... 145 TASIGNA...... 41 TESTOSTERONE tinidazole...... 20 TASMAR...... 45 CYPIONATE...... 117 TIROSINT...... 128 TASOPROL...... 84 testosterone cypionate...... 117 TIROSINT-SOL...... 128 TAURINE...... 104 testosterone enanthate...... 117 TISSEEL...... 145 tavaborole...... 31 TETANUS-DIPHTHERIA tis-u-sol...... 104 TAVALISSE...... 53 TOXOIDS TD...... 134 TIVICAY...... 50 TAYTULLA...... 127 tetrabenazine...... 70 TIVICAY PD...... 50 tazarotene...... 84 tetracaine hcl...... 13, 153 TIVORBEX...... 9 tazicef...... 20 tetracycline hcl...... 20 tizanidine hcl...... 161

192 tl-hem 150...... 104 TRANSDERM-SCOP (1.5 MG).29 TRIESENCE...... 149 TNKASE...... 23 TRANXENE-T...... 51 tri-estarylla...... 127 TOBI PODHALER...... 159 tranylcypromine sulfate...... 27 TRIFERIC...... 104 TOBRADEX...... 153 TRAVASOL...... 104 trifluoperazine hcl...... 47 TOBRADEX ST...... 153 TRAVATAN Z...... 150 trifluridine...... 149 tobramycin...... 149, 159 travoprost (bak free)...... 150 trihexyphenidyl hcl...... 45 TOBRAMYCIN...... 159 TRAZIMERA...... 41 TRIJARDY XR...... 87 tobramycin sulfate...... 20 trazodone hcl...... 27 TRIKAFTA...... 159 tobramycin-dexamethasone....153 TREANDA...... 41 tri-legest fe...... 127 TOBREX...... 149 TRECATOR...... 34 tri-linyah...... 127 tolbutamide...... 87 TRELEGY ELLIPTA...... 158 TRILIPIX...... 66 tolcapone...... 45 TRELSTAR MIXJECT...... 120 TRILOAN II SUIK...... 117 tolmetin sodium...... 9 TREMFYA...... 132 TRILOAN SUIK...... 117 TOLSURA...... 31 treprostinil...... 160 TRILOCICLO...... 84 tolterodine tartrate...... 112 TRESIBA...... 94 tri-lo-estarylla...... 127 tolterodine tartrate er...... 112 TRESIBA FLEXTOUCH...... 94 tri-lo-marzia...... 127 TOLVAPTAN...... 104 tretinoin...... 41, 84 tri-lo-mili...... 127 tolvaptan...... 104 tretinoin microsphere...... 84 tri-lo-sprintec...... 127 TOPEX TOPICAL tretinoin microsphere pump...... 84 TRILURON...... 145 ANESTHETIC...... 72 TRETTEN...... 54 trimethobenzamide hcl...... 29 TOPICORT...... 84 TREXALL...... 132 trimethoprim...... 20 TOPICORT SPRAY...... 84 TREZIX...... 6 tri-mili...... 127 TOPIDEX...... 117 tri femynor...... 127 trimipramine maleate...... 27 topiramate...... 25 triamcinolone acetonide TRINATE...... 104 topiramate er...... 25 ...... 72, 84, 117 TRINAZ...... 104 toposar...... 41 TRIAMCINOLONE TRINTELLIX...... 27 topotecan hcl...... 41 ACETONIDE...... 117 tri-nymyo...... 127 toremifene citrate...... 41 TRIAMCINOLONE TRIOSTAT...... 128 TORISEL...... 132 DIACETATE...... 117 tri-previfem...... 127 TORONOVA II SUIK...... 9 TRIAMCINOLONE TRIPTODUR...... 120 TORONOVA SUIK...... 9 DIACETATE PF...... 117 TRISENOX...... 41 torsemide...... 65 TRIAMCINOLONE- TRISODIUM CITRATE/CRRT 104 TOSYMRA...... 33 BUPIVACAINE...... 117 tri-sprintec...... 127 TOTECT...... 41 TRIAMCINOLONE- TRISTART DHA...... 104 TOUJEO MAX SOLOSTAR...... 94 MOXIFLOXACIN...... 153 TRISTART FREE...... 104 TOUJEO SOLOSTAR...... 94 TRI-AMINO...... 104 TRISTART ONE...... 104 tovet...... 84 triamterene...... 65 TRIUMEQ...... 50 TOVET...... 84 triamterene-hctz...... 65 TRI-VI-FLOR...... 104 TOVIAZ...... 112 TRIANEX...... 84 TRI-VI-FLORO...... 104 TRACE ELEMENTS triazolam...... 51 TRIVISC...... 145 4/PEDIATRIC...... 104 TRICARE PRENATAL DHA tri-vite/fluoride...... 104 TRACLEER...... 160 ONE...... 104 TRIVIX...... 84 TRADJENTA...... 87 TRI-CHLOR...... 84 trivora (28)...... 127 TRALEMENT...... 104 TRICHOPHYTON...... 145 tri-vylibra...... 127 tramadol hcl er...... 6 TRICHOPHYTON tri-vylibra lo...... 127 tramadol hcl er (biphasic)...... 6 MENTAGROPHYTES...... 145 TRIZIVIR...... 50 tramadol hcl ir...... 6 TRICITRASOL...... 23 TRODELVY...... 41 tramadol-acetaminophen...... 6 tricitrates...... 104 TROGARZO...... 50 trandolapril...... 65 TRICON...... 104 TROKENDI XR...... 25 trandolapril-verapamil hcl er...... 65 TRICOR...... 65 TROPHAMINE...... 104 tranexamic acid...... 54 triderm...... 84 TROPICAMIDE- TRANEXAMIC ACID-NACL...... 54 TRIDESILON...... 84 CYCLOPENTOLATE-PE...... 153 TRANSDERM SCOP (1.5 MG).29 trientine hcl...... 104

193 TROPICAMIDE- TYSABRI...... 68 valproate sodium...... 25 PHENYLEPHRINE...... 153 TYVASO...... 160 valproic acid...... 25 TROPIC-CYCLOPENT-PE- TYVASO REFILL...... 160 valrubicin...... 42 KETOROLAC...... 153 TYVASO STARTER...... 160 valsartan...... 66 TROPIC-CYCLOP-PE-KETO- UBRELVY...... 33 valsartan-hydrochlorothiazide... 66 PROPAR...... 153 UCERIS...... 135 VALSTAR...... 42 TROPIC-PROPARACA-PE- UDENYCA...... 54 VALTOCO...... 25 KETOROLAC...... 153 ULORIC...... 32 VANCOCIN...... 21 trospium chloride...... 112 ULTIGUARD SAFEPACK VANCOCIN HCL...... 21 trospium chloride er...... 112 SYR/NEEDLE...... 94 vancomycin hcl...... 21 TRUE COMFORT PRO ULTIVA...... 6 VANCOMYCIN HCL...... 149 ALCOHOL PREP...... 145 ULTOMIRIS...... 54 VANCOMYCIN HCL IN TRUE COMFORT PRO ULTRACET...... 6 DEXTROSE...... 21 INSULIN SYR...... 94 ULTRASAL-ER...... 84 vancomycin hcl in dextrose...... 21 TRUE COMFORT PRO PEN ULTRAVATE...... 84 VANCOMYCIN HCL IN NACL.. 21 NEEDLES...... 94 UMECTA MOUSSE...... 84 vancomycin hcl in nacl...... 21 TRUE FOCUS BLOOD UNASYN...... 20 vandazole...... 21 GLUCOSE METER...... 92 UNISTRIP CONTROL...... 92 VANOXIDE-HC...... 85 TRUE METRIX BLOOD unithroid...... 128 VANTAS...... 120 GLUCOSE TEST...... 92 UNITUXIN...... 42 VAPRISOL...... 120 TRUE METRIX PRO BLOOD UPLIZNA...... 132 VAQTA...... 134 GLUCOSE...... 92 UPNEEQ...... 149 VARDIMAXIA...... 85 TRULANCE...... 110 UPTRAVI...... 160 VARISOFT INFUSION SET....145 TRULICITY...... 87 URAMAXIN...... 84 VARITHENA...... 66 TRUMENBA...... 134 urea...... 84 VARIVAX...... 134 TRUSOPT...... 150 UREA...... 84 VARIZIG...... 132 TRUSTEEL INFUSION SET... 145 urea hydrating...... 85 VAROPHEN...... 9 TRUVADA...... 50 urea nail...... 85 VAROXIA...... 85 TRUXIMA...... 41 uredeb...... 85 VARUBI (180 MG DOSE)...... 29 tryptophan...... 104 UREMEZ-40...... 85 VASCEPA...... 66 TUDORZA PRESSAIR...... 158 URESOL...... 85 VASERETIC...... 66 TUKYSA...... 41 uretron d/s...... 112 VASHE CLEANSING...... 85 tulana...... 127 UREVAZ...... 85 VASOSTRICT...... 120 TURALIO...... 42 URIBEL...... 113 VAXCHORA...... 134 turpentine...... 84 URIMAR-T...... 113 VAXELIS...... 134 TUSSICAPS...... 155 urin ds...... 113 VAZCULEP...... 66 TUXARIN ER...... 155 URO-458...... 113 VECAMYL...... 66 TUZISTRA XR...... 155 UROCIT-K 10...... 104 VECTIBIX...... 42 TWINRIX...... 134 UROCIT-K 15...... 104 VECTICAL...... 85 TWIRLA...... 127 UROCIT-K 5...... 105 VECURONIUM BROMIDE...... 70 TWYNSTA...... 66 UROGESIC-BLUE...... 113 vecuronium bromide...... 70 tyblume...... 127 uro-mp...... 113 VELCADE...... 42 TYBOST...... 50 URSO 250...... 110 VELETRI...... 160 tydemy...... 127 URSO FORTE...... 110 velivet...... 127 TYGACIL...... 20 ursodiol...... 110 VELPHORO...... 113 TYKERB...... 42 USTELL...... 113 VELTASSA...... 105 TYLACTIN BUILD 20PE TYR. 145 UTIBRON NEOHALER...... 158 VELTIN...... 85 TYLACTIN RESTORE 10...... 145 UTIRA-C...... 113 VEMLIDY...... 50 TYLACTIN RESTORE 5PE.... 145 UTOPIC...... 85 VENCLEXTA...... 42 TYLACTIN RTD 15...... 145 VABOMERE...... 21 VENCLEXTA STARTING TYMLOS...... 135 valacyclovir hcl...... 50 PACK...... 42 TYPHIM VI...... 134 VALCHLOR...... 42 VENELEX...... 85 TYR EASY...... 145 valganciclovir hcl...... 50

194 VENIPUNCTURE PX1 VINATE ONE...... 105 VUSION...... 31 PHLEBOTOMY...... 13 vinblastine sulfate...... 42 VYEPTI...... 33 venlafaxine hcl...... 27 vincristine sulfate...... 42 vyfemla...... 127 venlafaxine hcl er...... 27 vinorelbine tartrate...... 42 vylibra...... 127 VENNGEL ONE...... 9 VIOKACE...... 111 VYNDAMAX...... 66 VENOFER...... 105 viorele...... 127 VYNDAQEL...... 66 VENOMIL HONEY BEE VIRACEPT...... 50 VYONDYS 53...... 111 VENOM...... 146 VIRAMUNE...... 50 VYVANSE...... 67 VENOMIL MIXED VESPID VIRAMUNE XR...... 50 VYXEOS...... 42 VENOM...... 146 VIRASAL...... 85 VYZULTA...... 150 VENOMIL WASP VENOM...... 146 VIRAZOLE...... 50 WAKIX...... 161 VENOMIL WHITE FACED VIREAD...... 50 warfarin sodium...... 23 HORNET...... 146 VIRT-FEFA PLUS...... 105 WASP VENOM PROTEIN...... 146 VENOMIL YELLOW HORNET virt-phos 250 neutral...... 105 water for irrigation, sterile...... 105 VENOM...... 146 VISCO-3...... 146 wera...... 127 VENOMIL YELLOW JACKET VISIONBLUE...... 153 WESTAB PLUS...... 105 VENOM...... 146 VISTARIL...... 51 WESTERN JUNIPER...... 146 VENTAVIS...... 160 VISTOGARD...... 146 WESTGEL DHA...... 105 VENTOLIN HFA...... 159 VISUDYNE...... 153 WESTHROID...... 128 verapamil hcl...... 66 VITAFOL...... 105 wheat germ oil...... 105 verapamil hcl er...... 66 VITAFOL FE+...... 105 WHITE BIRCH...... 146 VERDESO...... 85 VITAFOL-OB+DHA...... 105 WHITE FACED HORNET VEREGEN...... 85 vitamin d (ergocalciferol)...... 105 VENOM...... 146 VERELAN...... 66 VITAMIN DEFICIENCY WHITE MULBERRY...... 146 VERELAN PM...... 66 SYSTEM-B12...... 105 WHITE OAK...... 146 VERSACLOZ...... 47 vitamin k1...... 105 WHITE PINE...... 146 VERZENIO...... 42 vitamins acd-fluoride...... 105 WHITE-FACED HORNET vestura...... 127 VITATHELY WITH GINGER... 105 VENOM...... 146 VEXASYN...... 85 VITRAKVI...... 42 WIDE-SEAL DIAPHRAGM 60 146 VEXATROL...... 13 VITRASE...... 146 WIDE-SEAL DIAPHRAGM 65 146 VFEND...... 31 VIVAGUARD INO CONTROL WIDE-SEAL DIAPHRAGM 70 146 VFEND IV...... 31 SOLUTION...... 92 WIDE-SEAL DIAPHRAGM 75 146 V-GO 20...... 92 VIVAGUARD INO GLUCOSE WIDE-SEAL DIAPHRAGM 80 146 V-GO 30...... 92 METER...... 92 WIDE-SEAL DIAPHRAGM 85 146 V-GO 40...... 92 VIVAGUARD INO TEST WIDE-SEAL DIAPHRAGM 90 146 VIBATIV...... 21 STRIPS...... 92 WIDE-SEAL DIAPHRAGM 95 146 VIBERZI...... 110 VIVAGUARD LANCING WILATE...... 54 VIBRAMYCIN...... 21 DEVICE...... 92 WILZIN...... 105 VICTOZA...... 87 VIVITROL...... 14 WINLEVI...... 85 VIDAZA...... 42 VIVOTIF...... 134 WINRHO SDF...... 132 VIEKIRA PAK...... 50 VIZIMPRO...... 42 wixela inhub...... 159 vienva...... 127 volnea...... 127 WP THYROID...... 128 vigabatrin...... 25 VOLTAREN...... 9 wymzya fe...... 127 vigadrone...... 25 VONVENDI...... 54 WYNZORA...... 85 VIGAMOX...... 149 VORAXAZE...... 42 XADAGO...... 45 VIIBRYD...... 28 voriconazole...... 31 XALIX...... 85 VIIBRYD STARTER PACK...... 28 VOSEVI...... 50 XALKORI...... 42 VILACTIN AA PLUS...... 146 VOTRIENT...... 42 XARACOLL...... 13 VILAMIT MB...... 113 vp-pnv-dha...... 105 XARELTO...... 23 VILEVEV MB...... 113 VPRIV...... 111 XARELTO STARTER PACK.....23 VILTEPSO...... 146 VRAYLAR...... 47 XATMEP...... 132 VIMIZIM...... 111 VTOL LQ...... 6 XCOPRI...... 25 VIMPAT...... 25 VUMERITY...... 68 XELJANZ...... 132

195 XELJANZ XR...... 132 XPOVIO (40 MG ONCE zarah...... 128 XELPROS...... 150 WEEKLY)...... 42 ZARONTIN...... 25 XEMBIFY...... 132 XPOVIO (40 MG TWICE ZARXIO...... 54 XENICAL...... 70 WEEKLY)...... 42 ZAVESCA...... 111 XENLETA...... 21 XPOVIO (60 MG ONCE ZCORT 7-DAY...... 117 XEOMIN...... 146 WEEKLY)...... 42 ZEBUTAL...... 6 XEPI...... 22 XPOVIO (60 MG TWICE ZEJULA...... 43 XERAC AC...... 85 WEEKLY)...... 42 ZELAC...... 110 XERALUX...... 85 XPOVIO (80 MG ONCE ZELAPAR...... 45 XERAVA...... 22 WEEKLY)...... 42 ZELBORAF...... 43 XERESE...... 50 XPOVIO (80 MG TWICE ZELNORM...... 110 XERMELO...... 110 WEEKLY)...... 42 ZEMAIRA...... 159 XEROFORM OIL EMULSION XTAMPZA ER...... 6 ZEMBRACE SYMTOUCH...... 33 2"X2"...... 85 XTANDI...... 42 ZEMDRI...... 22 XEROFORM OIL EMULSION xulane...... 127 ZEMPLAR...... 136 GAUZE...... 85 XULTOPHY...... 88 zenatane...... 85 XEROFORM OIL EMULSION xurea...... 85 ZENPEP...... 111 STRIP...... 85 XURIDEN...... 111 ZENZEDI...... 67 XEROFORM OIL ROLL 4"X9'...85 XYLOCAINE...... 14 ZEPATIER...... 50 XEROFORM PETROLAT xylocaine dental...... 14 ZEPOSIA...... 68 GAUZE 1"X8"...... 85 XYLOCAINE/EPINEPHRINE.... 14 ZEPOSIA 7-DAY STARTER XEROFORM PETROLAT XYLOCAINE-MPF...... 14 PACK...... 68 GAUZE 5"X9"...... 85 XYLOCAINE- ZEPOSIA STARTER KIT...... 68 XEROFORM PETROLAT MPF/EPINEPHRINE...... 14 ZEPZELCA...... 43 PATCH 2"X2"...... 85 XYNTHA...... 54 ZERBAXA...... 22 XEROFORM PETROLAT XYNTHA SOLOFUSE...... 54 ZERUVIA...... 14 PATCH 4"X4"...... 85 XYOSTED...... 118 ZERVIATE...... 149 XEROFORM PETROLATUM XYREM...... 161 ZETONNA...... 155 ROLL 4"X9'...... 85 XYWAV...... 161 ZEVALIN Y-90...... 43 XEROSTOMIA RELIEF YASMIN 28...... 127 ZIAC...... 66 SPRAY...... 72 YELLOW DOCK...... 146 ZIAGEN...... 50 XGEVA...... 135 YELLOW HORNET VENOM zidovudine...... 50 XHANCE...... 155 PROTEIN...... 146 ZIEXTENZO...... 54 XIAFLEX...... 146 YELLOW JACKET VENOM zileuton er...... 159 XIFAXAN...... 22 PROTEIN...... 146 ZILRETTA...... 117 XIGDUO XR...... 87 YERVOY...... 42 ZILXI...... 85 XIIDRA...... 153 YESCARTA...... 42 ZINC CHLORIDE...... 105 XIMINO...... 22 YF-VAX...... 134 ZINC SULFATE...... 105 XOFIGO...... 42 YONDELIS...... 42 ZINPLAVA...... 132 XOFLUZA (40 MG DOSE)...... 50 YONSA...... 42 ZIONODIL...... 14 XOFLUZA (80 MG DOSE)...... 50 YOSPRALA...... 46 ZIONODIL 100...... 14 XOLAIR...... 155 YUPELRI...... 159 ZIOPTAN...... 150 XOLEGEL...... 31 YUTIQ...... 149 ziprasidone hcl...... 47 XOLEGEL COREPAK...... 31 yuvafem...... 127 ziprasidone mesylate...... 47 XOLEGEL DUO/HEAD & ZACARE...... 85 ZIPSOR...... 9 SHOULDERS...... 31 zaclir cleansing...... 85 ZIRABEV...... 43 XOLEGEL DUO/XOLEX...... 31 zafemy...... 128 ZIRGAN...... 149 XOPENEX CONCENTRATE.. 159 zafirlukast...... 159 ZITHRANOL...... 85 XOPENEX HFA...... 159 zaleplon...... 161 ZITHROMAX...... 22 XOPENEX NEB...... 159 ZALTRAP...... 42 ZITHROMAX TRI-PAK...... 22 XOSPATA...... 42 ZALVIT...... 105 ZITHROMAX Z-PAK...... 22 XPOVIO (100 MG ONCE ZANAFLEX...... 161 ZOKINVY...... 146 WEEKLY)...... 42 ZANOSAR...... 42 ZOLADEX...... 120

196 zoledronic acid...... 136 ZOLGENSMA...... 111 ZOLINZA...... 43 ZOLMITRIPTAN...... 33 zolmitriptan...... 33 ZOLPAK...... 31 zolpidem tartrate...... 161 zolpidem tartrate er...... 161 ZOLPIMIST...... 161 ZOMACTON...... 120 ZOMACTON (FOR ZOMA-JET 10)...... 120 ZOMIG...... 33 zonisamide...... 25 ZONTIVITY...... 46 ZORBTIVE...... 110 ZORTRESS...... 132 ZORVOLEX...... 9 ZOSYN...... 22 zovia 1/35 (28)...... 128 zovia 1/35e (28)...... 128 ZTLIDO...... 14 ZUBSOLV...... 14 ZULRESSO...... 28 zumandimine...... 128 ZUPLENZ...... 29 ZYCLARA...... 86 ZYCLARA PUMP...... 86 ZYDELIG...... 43 ZYFLO...... 159 ZYKADIA...... 43 ZYLET...... 153 ZYLOPRIM...... 32 ZYMAXID...... 149 ZYPITAMAG...... 66 ZYPREXA...... 47 ZYPREXA RELPREVV...... 47 ZYPREXA ZYDIS...... 47 ZYVOX...... 22

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